Life-Threatening Non-Allergic Drug Hypersensitivity Reaction as a Very Rare Side Effect of Rivaroxaban Administration in the Netherlands

Background: Anticoagulant therapy is indicated for the prevention and treatment of thromboembolic disease. Direct oral anticoagulants (DOACs) are frequently prescribed and Rivaroxaban is the most frequently administered DOAC in the Netherlands. Most side effects relate to hemorrhagic complications, however, also non-hemorrhagic side effect may be potentially life threatening. Case presentation: A 74-year-old man presented at the emergency department with a ruptured infrarenal abdominal aortic aneurysm for which open aneurysm repair was performed. Postoperatively, the patient developed neurological deficit, respiratory and circulatory failure following rivaroxaban administration, initiated for atrial fibrillation. Even though, the clinical signs resembled an anaphylactic reaction, the skin-prick test was negative and complications most likely resulted from a non-allergic drug hypersensitivity reaction. Conclusion: This case report shows that non-allergic drug hypersensitivity reactions may mimic an anaphylactic reaction and can be potentially life threatening. In addition, severe non-hemorrhagic complications after rivaroxaban administration do occur and should be considered in case of acute clinical deterioration

Thoracic Endovascular Aneurysm Repair and Tracheal Stenting for Respiratory Failure due to a Thoracic Aortic Aneurysm: A Case Report

An 82-year-old male was referred to the emergency department for severe respiratory distress. Computed tomography angiography showed tracheal compression due to a large ruptured saccular aneurysm of the descending thoracic aorta. Emergency Thoracic Endovascular Aneurysm Repair (TEVAR) was performed. To reduce tracheal compression, an endotracheal stent was placed (silicone Dumon©). Following surgery, respiratory function improved. Two days after the surgery, the patient refused further invasive treatment, including mechanical mucus aspiration from the endotracheal stent, and palliative sedation was initiated. Conventional treatment to reduce tracheal compression by a saccular aortic aneurysm is open surgical aneurysm repair. If open repair is contraindicated because of patient age, comorbidity, or in case of severe hemodynamic instability following aneurysm rupture, TEVAR with endotracheal stent placement may serve as a bridge to definite surgery to reduce tracheal compression

Incidental finding of malignancy in patients preoperatively evaluated for aneurysm wall pathology using PET/CT.

Contains fulltext : 80256.pdf (publisher's version ) (Closed access)Preoperative positron emission tomography/computed tomography (PET/CT) was performed in 26 consecutive patients considered fit for aneurysm repair. Besides information on aneurysm wall pathology, PET/CT identified 6 patients with concomitant malignancy. As a result of this coincidental finding, the operation was postponed in 2 patients and cancelled in 1. Although previous studies have shown that PET/CT might affect patient selection based on aneurysm wall inflammation, our preliminary results show a big impact on patient management as a result of the sensitivity of PET/CT for detecting malignancy. Future larger studies are warranted to investigate the effect and cost effectiveness of routine PET/CT in abdominal aortic aneurysm (AAA) patients

Systematic review of circulating, biomechanical, and genetic markers for the prediction of abdominal aortic aneurysm growth and rupture

Background-—The natural course of abdominal aortic aneurysms (AAA) is growth and rupture if left untreated. Numerous markers have been investigated; however, none are broadly acknowledged. Our aim was to identify potential prognostic markers for AAA growth and rupture. Methods and Results-—Potential circulating, biomechanical, and genetic markers were studied. A comprehensive search was conducted in PubMed, Embase, and Cochrane Library in February 2017, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study selection, data extraction, and methodological quality assessment were conducted by 2 independent researchers. Plausibility of markers was based on the amount of publications regarding the marker (more than 3), pooled sample size (more than 100), bias risk and statistical significance of the studies. Eighty-two studies were included, which examined circulating (n=40), biomechanical (n=27), and genetic markers (n=7) and combinations of markers (n=8). Factors with an increased expansion risk included: AAA diameter (9 studies; n=1938; low bias risk), chlamydophila pneumonia (4 studies; n=311; medium bias risk), S-elastin peptides (3 studies; n=205; medium bias risk), fluorodeoxyglucose uptake (3 studies; n=104; medium bias risk), and intraluminal thrombus size (5 studies; n=758; medium bias risk). Factors with an increased rupture risk rupture included: peak wall stress (9 studies; n=579; medium bias risk) and AAA diameter (8 studies; n=354; medium bias risk). No meta-analysis was conducted because of clinical and methodological heterogeneity. Conclusions-—We identified 5 potential markers with a prognostic value for AAA growth and 2 for rupture. While interpreting these data, one must realize that conclusions are based on small sample sizes and clinical and methodological heterogeneity. Prospective and methodological consonant studies are strongly urged to further study these potential markers

Secondary Fill Minimizes Gutter Size in Chimney EVAS Configurations In Vitro

Purpose: To investigate in an in vitro model if secondary endobag filling can reduce gutter size during chimney endovascular aneurysm sealing (chEVAS). Materials and Methods: Nellix EVAS systems were deployed in 2 silicone juxtarenal aneurysm models with suprarenal aortic diameters of 19 and 24 mm. Four configurations were tested: EVAS with 6-mm balloon-expandable (BE) or self-expanding (SE) chimney grafts (CGs) in the renal branches of both models. Balloons were inflated simultaneously in the CGs and main endografts during primary and secondary endobag filling and polymer curing. Computed tomography (CT) was performed immediately after the primary and secondary fills. Cross-sectional lumen areas were measured on the CT images to calculate gutter volumes and percent change. CG compression was calculated as the reduction in lumen surface area measured perpendicular to the central lumen line. The largest gutter volume and highest compression were presented per CG configuration per model. Results: Secondary endobag filling reduced the largest gutter volumes from 99.4 to 73.1 mm3 (13.2% change) and 84.2 to 72.0 mm3 (27.6% change) in the BECG configurations and from 67.2 to 44.0 mm3 (34.5% change) and 92.7 to 82.3 mm3 (11.2% change) in the SECG configurations in the 19- and 24-mm models, respectively. Secondary endobag filling increased CG compression in 6 of 8 configurations. BECG compression changed by −0.2% and 5.4% and by −1.0% and 0.4% in the 19- and 24-mm models, respectively. SECG compression changed by 10.2% and 16.0% and by 7.2% and 7.3% in the 19- and 24-mm models, respectively. Conclusion: Secondary endobag filling reduced paragraft gutters; however, this technique did not obliterate them. Increased CG compression and prolonged renal ischemia time should be considered if secondary endobag filling is used

Anatomic Suitability for Branched Thoracic Endovascular Repair in Patients with Aortic Arch Pathological Features

Background Endovascular repair has become a viable alternative for aortic pathological features, including those located within the aortic arch. We investigated the anatomic suitability for branched thoracic endovascular repair in patients previously treated with conventional open surgery for aortic arch pathological features. Methods and Results Patients who underwent open surgery for aortic arch pathological features at our institution between 2000 and 2018 were included. Anatomic suitability was determined by strict compliance with the anatomic criteria within manufacturers' instructions for use for each of the following branched thoracic stent grafts: Relay Plus Double-Branched (Terumo-Aortic), TAG Thoracic Branch Endoprosthesis (W.L. Gore & Associates), Zenith Arch Branched Device (Cook-Medical), and Nexus Stent Graft System (Endospan Ltd/Jotec GmbH). Computed tomography angiography images were analyzed with outer luminal line measurements. A total of 377 patients (mean age, 64±14 years; 64% men) were identified, 153 of whom had suitable computed tomography angiography images for measurements. In total, 59 patients (15.6% of the total cohort and 38.6% of the measured cohort) were eligible for endovascular repair using at least one of the devices. Device suitability was 30.9% for thoracic aneurysms, 4.6% for type A dissections, 62.5% for type B dissections, and 28.6% for other pathological features. Conclusions The anatomic suitability for endovascular repair of all aortic arch pathological features was modest. The highest suitability rates were observed for thoracic aneurysms and for type B dissections, of which repair included part of the aortic arch. We suggest endovascular repair of arch pathological features should be reserved for high-volume centers with experience in endovascular arch repair

Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study

Objective: We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR. Summary of Background Data: Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volumeoutcome association exists in endovascular treatment of complex AAs (complex EVAR). Methods: All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories. Results: We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/ yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and 23 procedures/yr. The highest volume hospitals treated significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of <9, and 2.5% in hospitals with a volume of 13 (P = 0.008). After adjustment for confounders, an annual volume of 13 was associated with less perioperative mortality compared to hospitals with a volume of <9. Conclusions: Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates