Circulating biochemical marker levels of collagen metabolism are abnormal in patients with abdominal aortic aneurysm

Changes in extracellular matrix composition induced by abnormal collagen metabolism in the aortic wall may be an important factor in the progression of aortic structural changes. The authors have measured several types of biochemical marker for collagen metabolism in plasma: carboxyterminal propeptide of type Icollagen (PICP) for a pure collagen synthesis marker, matrix metalloproteinase-1 (MMP-1) for a degradation marker of collagen matrix, and tissue inhibitors of metalloproteinase-1 (TIMP-1) as a native inhibitor of MMP-1. Subjects of this study were 17 patients with abdominal aortic aneurysm (AAA), 14 patients with atherosclerosis obliterans (ASO), and 22 age/sex-matched healthy controls (HC). Blood samples were drawn from a forearm vein and measured by radioimmunoassay or enzyme-linked immunosorbent assay. Plasma concentrations of PICP in patients with AAA were significantly decreased compared to those in HC patients (82.0 +/- 16.4 vs 111.3 +/- 40.3 ng/mL; p < 0.01), but those in patients with ASO (105.4 +/- 55.4 ng/mL) were comparable to control concentrations. Although no differences in plasma concentrations of MMP-1 were observed among the three subject groups (HC, 20.0 +/- 5.6 ng/mL; ASO, 21.4 +/- 13.8 ng/mL; AAA, 24.5 +/- 11.7 ng/mL; NS), MMP-1/PICP ratio as an index of collagen degradation to collagen neosynthesis in AAA was significantly elevated compared to HC (0.32 +/- 0.18 vs 0.20 +/- 0.08; p < 0.01). Plasma concentrations of TIMP-1 in patients with AAA (293.8 +/- 61.2 ng/mL) or ASO (327.6 +/- 54.9 ng/mL) were significantly higher than in HC (227.3 +/- 60.2 ng/mL; both p < 0.01). In conclusion, these data suggest that although a compensatory mechanism such as increased TIMP-1 may be activated, collagen neosynthesis may decrease with relatively increased collagen degradation in patients with AAA.     

Raised plasma fibrinogen concentration in patients with abdominal aortic aneurysm

A feature associated with abdominal aortic aneurysms (AAA) is the presence of intraluminal thrombi (ILT). Elevated plasma fibrinogen concentrations predict a greater risk of thrombosis. Therefore, the authors assessed the relationship between fibrinogen levels, AAA size, and ILT. An age- and sex-matched case-control study was conducted. Demographic data and plasma samples were obtained from 110 patients with AAA and 110 controls. All subjects had an abdominal ultrasound scan to determine the size of the aneurysm and the percentage of the ILT occupying the lumen. Plasma fibrinogen concentrations were measured by the Clauss method. Fibrinogen concentrations were significantly higher in patients with AAA than in controls (median: 2.89 vs 2.53 g/L; p<0.01). Patients with AAA who were current smokers had a larger median AAA size (4.50 vs 4.30 cm; p<0.04) and greater percentage of the ILT (40% vs 30%) than those who did not smoke. Fibrinogen was positively correlated with AAA size (r =0.323; p<0.01) and the percentage of ILT occupying the lumen (r =0.358; p<0.05). Fibrinogen levels were higher in the AAA group. The authors also demonstrated positive correlations between the AAA size, ILT, and fibrinogen concentration. Smoking was associated with larger aneurysms and ILT. Fibrinogen may be a useful marker to monitor the progression of AAA.     

Proximal clamping levels in abdominal aortic aneurysm surgery

In the surgical treatment of abdominal aortic aneurysm, the single proximal cross-clamp can be placed at 3 alternative aortic levels: infrarenal, hiatal, and thoracic. We performed this retrospective study to evaluate the advantages and disadvantages of the 3 main aortic clamping locations. Eighty patients presented at our institution with abdominal aortic aneurysms from March 1993 through May 1998. Fifty of these patients had intact aneurysms and underwent elective surgery, and 30 had ruptured aneurysms that necessitated emergency surgery. Proximal aortic clamping was applied at the infrarenal level in 24 patients (22 from the intact aneurysm group, 2 from the ruptured group), at the hiatal level in 34 patients (22 intact, 12 ruptured), and at the thoracic level (descending aorta) via a limited left lateral thoracotomy in 22 patients (6 intact, 16 ruptured). Early mortality rates (within 30 days) were 4% (2 of 50 patients) among patients with intact aneurysms and 40% (12 of 30 patients) among those with ruptured aneurysms. In the 2 patients from the intact aneurysm group, proximal aortic clamps were applied at the hiatal level. In the ruptured aneurysm group, proximal aortic clamps were placed at the thoracic level in 10 patients, the infrarenal level in 1, and the hiatal level in 1. According to our study, the clinical status of the patient and the degree of operative urgency--as determined by the extent of the aneurysm--generally dictate the proximal clamp location. Patients who present with aneurysmal rupture or hypovolemic shock benefit from thoracic clamping, because it restores the blood pressure and allows time to replace the volume deficit. Infrarenal placement is advantageous in patients with intact aneurysms if there is sufficient space for the clamp between the renal arteries and the aortic aneurysm. In patients with juxtarenal aneurysms, hiatal clamping enables safe and easy anastomosis to the healthy aorta. Clamping at this level also helps prevent late anastomotic aneurysm formation, which is frequently encountered after inadvertent anastomosis of the graft to a diseased portion of the aorta. Further studies are needed in order to confirm these results.     

Acute phase reactants in patients with abdominal aortic aneurysm

BACKGROUND: There is increasing evidence that an inflammatory process is present in abdominal aortic aneurysms (AAAs) to varying degrees. The aim of this study was to compare acute phase reactants in patients with asymptomatic AAA, symptomatic AAA without rupture and ruptured AAA. METHOD: Two hundred and twenty-five consecutive patients treated because of AAA were included in this case-control study. Polynomial logistic regression analysis was applied to compare admission C-reactive protein (CRP) and white blood count (WBC) measured in 111 asymptomatic outpatients, 52 symptomatic patients without rupture and 62 patients with rupture of the aneurysm. We adjusted for the potentially confounding effect of age, sex, haemoglobin levels and aneurysm diameter. RESULTS: Patients with symptomatic AAA and patients with ruptured AAA had significantly elevated CRP (p=0.002) and WBC (p<0.0001) levels compared to asymptomatic patients. There was no statistically significant difference in CRP and WBC between patients with symptomatic AAA and ruptured AAA. Median CRP values of asymptomatic, symptomatic and ruptured AAA were <0.5 (interquartile range (IQR) <0.5-0.85), 1.1(IQR <0.5-4.0) and 2.4 mg/dl (IQR 0.65-8.6), respectively, and median WBC values were 6.5 (IQR 5.5-8.0), 8.7 (IQR 6.8-11.2) and 13.2 (IQR 10.5-17.0), respectively. CONCLUSION: A significant elevation of CRP and WBC could be found in patients who presented with symptoms or rupture of an AAA. These indicators of inflammation were not observed in asymptomatic patients with AAA.     

Coronary disease in patients with an abdominal aortic aneurysm]

The presence of coronary artery disease (CAD) evaluated with coronary angiography and eventual correction of CAD in abdominal aortic aneurysm (AAA) patients has been considered the main determinant of early and late outcome after AAA repair. This study reports our experience in CAD and AAA patients in terms of diagnosis and therapy of CAD. In a population of 126 patients (122 males, 4 females, mean age 67.5 years, range 37-81) who were candidates to elective repair for AAA with a diameter > or = 5 centimeters, we included coronary arteriography in 1) patients who were symptomatic for angina (15.9%); 2) patients with previous myocardial infarction (33.3%); 3) patients with previous coronary artery bypass (4%). We identified a group of 45 patients (35.7%) with significant CAD who had been treated before AAA surgery by coronary artery bypass grafting (CABG) in 37 cases or percutaneous coronary angioplasty (PTCA) in 8 cases. AAA repair was performed during the same hospital stay or at a later date. We did not report any morbidity and mortality related to cardiac or vascular procedures. We believe that among patients reporting cardiac symptoms (previous myocardial infarction, angina) the incidence of surgically-correctable CAD is not negligible (45/67, 67.2%). Therefore, invasive coronary study is strongly suggested in such cases to reveal and treat an eventual coronary artery stenosis prior to AAA repair. The absence of cardiac morbidity and mortality related to cardiac and vascular procedures supports this approach.     

血浆同型半胱氨酸水平与腹主动脉瘤的相关性研究

目的探讨血浆同型半胱氨酸(Hcy)水平与腹主动脉瘤的相关性。方法回顾性分析2011年7月²012年7月入住我院血管外科经CT诊断为腹主动脉瘤患者(病例组)58例,另选健康体检者63例为对照组。常规检测血生化指标,采用循环酶法检测Hcy水平。结果与对照组比较,病例组高同型半胱氨酸血症(HHcy)发生率明显升高(65.5%vs 27.0%,P<0.01),Hcy水平明显升高[(19.02±9.80)μmol/L vs(13.37±4.54)μmol/L,P<0.01]。多元logistic回归分析显示,HHcy较非HHcy发生腹主动脉瘤的风险增加4.12倍(OR=5.12,95%CI:2.332012年7月入住我院血管外科经CT诊断为腹主动脉瘤患者(病例组)58例,另选健康体检者63例为对照组。常规检测血生化指标,采用循环酶法检测Hcy水平。结果与对照组比较,病例组高同型半胱氨酸血症(HHcy)发生率明显升高(65.5%vs 27.0%,P<0.01),Hcy水平明显升高[(19.02±9.80)μmol/L vs(13.37±4.54)μmol/L,P<0.01]。多元logistic回归分析显示,HHcy较非HHcy发生腹主动脉瘤的风险增加4.12倍(OR=5.12,95%CI:2.33¹1.27,P=0.00)。调整相关危险因素后,未明显改变相关结果(OR=3.35,95%CI:1.1411.27,P=0.00)。调整相关危险因素后,未明显改变相关结果(OR=3.35,95%CI:1.14⁹.80,P=0.03)。病例组HHcy患者与Hcy水平正常者腹主动脉瘤最大直径比较,差异无统计学意义[(5.66±1.49)cmvs(5.11±0.98)cm,P=0.18],年龄与腹主动脉瘤最大直径不相关(r=0.09,P=0.48)。结论 HHcy患者发生腹主动脉瘤的风险更大。降低Hcy水平可能有助于减缓腹主动脉瘤的发展。     

The characteristics of screened patients with abdominal aortic aneurysm.

BACKGROUND: Screening for abdominal aortic aneurysm (AAA) has not yet been established in Japan. We therefore report the characteristics of a screened population and discuss the implications of screening using ultrasound in Japan. METHODS: The subjects in our screening group were composed of 4428 participants who were 60 years of age or older. Aneurysm was detected in 16 cases, 15 males and 1 female, the detection rate being 0.4% in total and 0.9% in the males. We compare the characteristics of screened patients (n = 16) with non-screened patients operated on for abdominal aortic aneurysm (n = 166). RESULTS: There were no significant differences in the mean age or in the female ratio between the screened and non-screened groups (71 vs 70 y/o, 6% vs 13%, respectively). Solitary iliac aneurysms were significantly (p < 0.05) more frequent in the screened than in the non-screened group (19% vs 3%). The size of aneurysm in the screened group was significantly (p < 0.05) smaller compared with the non-screened group. Sixty-three per cent of the screened group and only 8% of the non-screened group had an aneurysm less than 40 mm in size. Aneurysm was palpable in only 31% of those of the screened group. There were no significant differences between the groups in the frequency of arteriosclerotic risk factors such as hypertension, ischaemic heart disease, diabetes mellitus, peripheral vascular disease and smoking habits. Surgical treatment was selected in 7 out of 16 screened patients. The remaining 9 patients with small-sized abdominal aortic aneurysms have been carefully followed up. CONCLUSIONS: Screening for abdominal aortic aneurysm using ultrasound is advisable especially for male participants and for the detection of iliac aneurysms. This screening procedure is useful for early detection because the screened aneurysm is generally small-sized and impalpable.     

Critical aortic stenosis in a patient with a large saccular abdominal aortic aneurysm

Elderly patients with aortic stenosis are often deemed too high risk, and consequently turned down for conventional surgery. Transcatheter aortic valve implantation (TAVI) is a safe and an increasingly attractive option in this group of patients. Although TAVI has been shown to be successful and safe, the cardiovascular assessment of other co‐morbidities in this susceptible group of patients is critical to ensuring good clinical outcomes. The presence of a saccular abdominal aortic aneurysm (AAA) in our patient was an example of an important co‐morbidity which could have a significant impact on the outcome of TAVI, if not managed appropriately. The increased systolic pressure post successful TAVI will result in an increased strain within the wall of the saccular AAA with an increased risk of rupture. Therefore, a timely management strategy for the AAA was necessary. We believe that we report the first case of simultaneous TAVI and endovascular aneurysm repair (EVAR). The patient underwent uncomplicated transfemoral TAVI immediately followed by successful drive‐by percutaneous EVAR delivered over the same superstiff guidewire via the transfemoral route. Our case highlights the importance of a detailed assessment in all patients before consideration for TAVI, and the multi‐disciplinary team and a management strategy for both pathologies tailored to the patient. The case demonstrates the versatility of trans‐catheter techniques which has enabled the treatment of aortic stenosis and abdominal AAA in a single procedure. © 2012 Wiley Periodicals, Inc.     

Urinary neutrophil gelatinase associated lipocalin (NGAL), a marker of tubular damage, is increased in patients with chronic heart failure

Renal impairment, as measured by reduced glomerular filtration rate (GFR) and increased urinary albumin excretion (UAE), is prevalent in patients with chronic heart failure (CHF) and is associated with reduced survival. The prevalence of structural tubular damage in CHF is unknown. We investigated 90 CHF patients and 20 age and sex matched healthy controls, and determined estimated GFR, UAE, N terminal-pro brain natriuretic peptide (NT-proBNP) and urinary neutrophil gelatinase associated lipocalin (NGAL) as a marker for tubular damage. CHF patients had significantly lower averaged estimated GFR (64+/-17 vs 90+/-12 mL/min/1.73 m(2), P<0.0001), but higher NT-proBNP and UAE levels (both P<0.0001). Median urinary NGAL levels were markedly increased in CHF patients compared to controls (175 (70-346) vs 37 (6-58) microg/gCr, P<0.0001). Both serum creatinine (r=0.26, P=0.006) and eGFR (r=-0.29, P=0.002) were significantly associated with urinary NGAL levels as were NT-proBNP and UAE but to a lesser extent. In conclusion, renal impairment in CHF patients is not only characterised by decreased eGFR and increased UAE, but also by the presence of tubular damage, as measured by increased urinary NGAL concentrations.     

Relationship between aortic calcification and atherosclerotic disease in patients with abdominal aortic aneurysm.

BACKGROUND: Calcification of the aortic wall has been used as an index of the degree of complicated atherosclerotic plaque formation. Atherosclerosis in the abdominal aorta in patients with abdominal aortic aneurysm (AAA) was studied by measuring aortic calcification via computerised tomography. METHODS: Design: retrospective study. Patients: preoperative computer tomography (CT) in 129 male patients with a mean age of 68.6 years (range: 42 to 82) undergoing elective aneurysmectomy. Measurements: a conventional CT scanner was used. Aortic calcification was assessed at four levels: (A) the origin of the coeliac artery, (B) the left renal vein, (C) the maximum diameter of the aneurysm, and (D) the aortic bifurcation. Calcification was graded as: (0) no calcification, (1) calcification less than 40% of the aortic circumference, or (2) calcification more than 40% of the aortic circumference. The relationships between aortic calcification at each level and various factors related to atherosclerosis were analysed. RESULTS: Maximum calcification was seen at level D, followed by levels C, B and A, in that order. Calcification was less common in patients younger than 50 years old. Hypertension, coronary artery disease, and peripheral vascular occlusive disease correlated with the incidence of aortic calcification. CONCLUSIONS: A correlation between aortic calcification and atherosclerotic disease was demonstrated in patients with abdominal aortic aneurysm.     

Cholesterol embolism in a patient with inflammatory abdominal aortic aneurysm

A 66-year-old man whose renal function had progressively deteriorated had an elevated blood pressure and also was found to have an inflammatory abdominal aortic aneurysm (AAA). Blood examination revealed that he had eosinophilia. Livedo reticularis of the toes developed, and a skin biopsy specimen showed embolization of atheromatous plaques in the arterioles of the subcutaneous tissue. Progressive enlargement of inflammatory AAA may have dislodged the atheromatous plaques, resulting in cholesterol embolism.     

Angiopoietins,abdominal aortic aneurysm and atherosclerosis

Abdominal aortic aneurysm (AAA) and atherosclerosis are common causes of mortality and morbidity in an aging population. Angiogenesis is believed to contribute to the development and progression of these diseases. Angiopoietins (angpts) are known to be important regulators of angiogenesis. Angpts can also influence inflammation and have been shown to possess both pro-atherosclerotic and atheroprotective effects. This review explores the potential roles that the angpts play in the development and progression of AAA and atherosclerosis.     

腹主动脉瘤110例临床特点及预后分析

目的 探讨腹主动脉瘤的临床特点及影响预后的可能因素.方法 回顾性分析我院确诊的110例腹主动脉瘤患者的临床资料,其中肾下型109例,肾上型1例.应用Cox比例风险回归模型分析各相关因素与预后的关系.结果 110例患者中,男性84例（76.4％）,女性26例（23.6％）,男女比例为3.23：1,中位年龄74岁.11例（10.0％）患者以腹主动脉瘤破裂作为首发症状,其中男性10例,女性1例,男性中破裂率（11.9％）高于女性（3.8％）.Cox比例风险回归模型分析显示瘤体直径大的患者预后较差,手术治疗可改善患者预后.结论 早期诊断、密切随访、及时手术可改善腹主动脉瘤患者预后.     

Increased plasma thrombopoietin levels in patients with myelodysplastic syndrome: a reliable marker for a benign subset of bone marrow failure

Although myelodysplastic syndromes are heterogeneous disorders comprising a benign subset of bone marrow failure similar to aplastic anemia, no laboratory test has been established to distinguish it from bone marrow failures that can evolve into acute myeloid leukemia. Plasma thrombopoietin levels were measured in 120 patients who had myelodysplastic syndrome with thrombocytopenia (< 100 × 10⁹/L) to determine any correlation to markers associated with immune pathophysiology and outcome. Thrombopoietin levels were consistently low for patients with refractory anemia with excess of blasts, while patients with other myelodysplatic syndrome subsets had more variable results. Patients with thrombopoietin levels of 320 pg/mL and over had increased glycosylphosphatidylinositol-anchored protein-deficient blood cells (49.1% vs. 0%), were more likely to have a low International Prognostic Scoring System (IPSS) score (≤1.0, 100% vs. 65.5%), a higher response rate to immunosuppressive therapy (84.2% vs. 14.3%), and a better 5-year progression-free survival rate (94.1% vs. 63.6% for refractory cytopenia with unilineage dysplasia; 100.0% vs. 44.4% for refractory cytopenia with multilineage dysplasia). In conclusion, increased plasma thrombopoietin levels were associated with a favorable prognosis of bone marrow failure and could, therefore, represent a reliable marker for a benign subset of myelodysplastic syndrome.     

Mid-term results of endovascular repair for abdominal aortic aneurysm, with loco-regional anesthesia, in high-risk patients

BACKGROUND: Aim of this study was to evaluate the results of endovascular repair of abdominal aortic aneurysm (AAA) in patients considered not suitable for traditional open surgical repair because of the high anesthesiological risk. METHODS: We have retrospectively evaluated the result of the endovascular treatment of 11 patients with AAA of more than 6 cm diameter and high surgical risk due to cardiac hypokinesia and/or respiratory insufficiency. Patients were selected by a team composed of vascular surgeons and vascular radiologists who decided to implant the graft according to anatomical features of the AAA and of the iliac arteries. The treatment was performed in loco-regional anesthesia. The main end-points were: implantation success, mortality, morbidity, the absence of endoleak during the follow up that lasted two years. RESULTS: All the grafts were successfully implanted. There were no complications caused by anesthesiological manouvres. We had a minor intra-operative vascular complication and we performed three adjunctive endovascular procedures. A patient died of acute myocardial infarction, in the post operative period. Mean stay was six days. Pre-discharge scan showed 3 endoleaks (type I), two of these healed spontaneously and one sealed by percutaneous endovascular treatment. During follow-up (3-24 months) no patient died. One endoleak (type II) still persists. CONCLUSIONS The use of loco-regional anaesthesia allows us to treat high risk patients. Following strictly the criteria of patient selection, the surgical high risk seems not to influence significantly the mid term results that are almost equal to the ones obtained in low-risk patients.