The pathology of Kawasaki disease aortitis: a study of 37 cases.

BACKGROUND: Kawasaki disease (KD) is a systemic vasculitis syndrome that occurs most frequently in children. Most clinical and pathological studies have focused on its coronary artery lesions. To date, no detailed studies of the aorta have been conducted. We studied KD autopsy cases with the aims of clarifying the time-course of changes in aortic lesions, the differences in the inflammatory cells and degree of inflammation at various aortic sites, and the progression of the inflammation. MATERIALS AND METHODS: The study materials were aortic specimens taken from 37 KD autopsy cases (acute phase: 19; remote phase: 18). Twenty-seven of the cases also had coronary aneurysms. We chose 3 aortic sites, i.e., the thoracic aorta, aortic root and aortic bifurcation, and we histologically observed and compared those sites in regard to the changes with time, the kinds of infiltrating cells and the number of inflammatory cells. We also observed the relationship between the vasa vasorum and inflammatory cell localization in the tunica media, and examined the progression of inflammation in the tunica media. RESULTS: Destruction of the vascular architecture was not seen in any of the 37 cases, but inflammatory cell infiltration was observed in 90% of the acute-phase cases. The inflammatory cell infiltration involved the tunica intima and tunica adventitia of the aorta on the 6th disease-day, and all layers of the aorta on the 13th disease-day; the infiltration peaked on the 18th disease-day. The infiltration gradually disappeared thereafter, and no significant infiltration was seen in the remote phase. The infiltrating inflammatory cells consisted mainly of CD163-positive macrophages. Comparison of the 3 sites of the aorta showed that the inflammatory cell infiltration was more severe in the aortic root and aortic bifurcation than in the thoracic aorta. The progression of inflammation to the aortic tunica media from the adventitia showed 2 patterns: 1 in which macrophages were aggregated around the vasa vasorum; and a second in which there was no such aggregation around the vasa vasorum, but there was diffuse inflammatory cell infiltration of the tunica media. In addition to this, there were findings of direct infiltration of cells from the tunica intima into the tunica media. CONCLUSION: Inflammation in KD occurs in the aorta. The changes with time and the kinds of infiltrating cells were the same as reported to date for coronary arteries in KD. There were differences in the degree of inflammation among the 3 aortic sites. It can be thought that the inflammation from the adventitia to the media progresses via the vas vasorum, and also, there is a possibility of spreading directly. From the intima to the media, inflammation spreads directly. However, formation of aneurysms and destruction of the vascular architecture of the aorta were absent in this study, unlike in coronary arteries.

A strobe multicenter descriptive study of 55 infectious aortitis.

Infectious aortitis (IA) is a rare and severe disease. The treatment classically associates open surgery with prolonged antibiotic therapy. This study aimed to describe clinical characteristics, medical and surgical supports in a large and current series of IA.We conducted a retrospective multicenter study of native aorta IA, between 2000 and 2019. Inclusion criteria were the presence of a microorganism on blood culture, aortic sample or any other validated technique and structural anomaly in imaging.We included 55 patients (85% men), with a median age of 65. Microbiology data substantially differed from previous studies with 12 Gram-negative rods IA, of which only 3 due to Salmonella spp., 24 Gram-positive cocci IA of which 12 Streptococcus spp., and 18 IA due to intracellular growth and/or fastidious microorganisms, of which 8 Coxiella burnetii, 3 Treponema pallidum, and 5 tuberculosis suspicious cases. Fifteen patients (27%) presented with thoracic IA, 31 (56%) with abdominal IA, and 9 (16%) with thoraco-abdominal IA. Eight patients had no surgery, 41 underwent open surgery, only 4 endovascular aneurysm repair, and 2 a combination of these 2 techniques. Nine patients died before 1-month follow-up. There was no difference in the mortality rate between the different types of germ or localization of IA.The variety of germs involved in IA increases. Positron emission tomography-computed tomography scan is a very useful tool for diagnosis. Surgery is still mainly done in open approach and a prospective multicenter study seems necessary to better determine the place of endovascular aneurysm repair versus open surgery.

Giant cell arteritis-related aortitis with positive or negative temporal artery biopsy: a French multicentre study.

Objective: To compare the clinical presentation and outcome of giant cell arteritis (GCA)-related aortitis according to the results of temporal artery biopsy (TAB).Method: Patients with GCA-related aortitis diagnosed between 2000 and 2017, who underwent TAB, were retrospectively included from a French multicentre database. They all met at least three American College of Rheumatology criteria for the diagnosis of GCA. Aortitis was defined by aortic wall thickening > 2 mm on computed tomography scan and/or an aortic aneurysm, associated with an inflammatory syndrome. Patients were divided into two groups [positive and negative TAB (TAB+, TAB-)], which were compared regarding aortic imaging characteristics and aortic events, at aortitis diagnosis and during follow-up.Results: We included 56 patients with TAB+ (70%) and 24 with TAB- (30%). At aortitis diagnosis, patients with TAB- were significantly younger than those with TAB+ (67.7 ± 9 vs 72.3 ± 7 years, p = 0.022). Initial clinical signs of GCA, inflammatory parameters, and glucocorticoid therapy were similar in both groups. Coronary artery disease and/or lower limb peripheral arterial disease was more frequent in TAB- patients (25% vs 5.3%, p = 0.018). Aortic wall thickness and type of aortic involvement were not significantly different between groups. Diffuse arterial involvement from the aortic arch was more frequent in TAB- patients (29.1 vs 8.9%, p = 0.03). There were no differences between the groups regarding overall, aneurism-free, relapse-free, and aortic event-free survival.Conclusion: Among patients with GCA-related aortitis, those with TAB- are characterized by younger age and increased frequency of diffuse arterial involvement from the aortic arch compared to those with TAB+, without significant differences in terms of prognosis.

Endovascular Repair of Inflammatory Aortic Aneurysms: Experience in a Single Center.

BACKGROUND: Inflammatory abdominal aortic aneurysm (IAAA) remained a rare cause of aneurysmal aortic disease, with incidences between 5% and 10%. The current treatment for IAAA consists of open surgical repair and endovascular aneurysm repair (EVAR). Avoiding an inflamed, fibrotic retroperitoneum is the driving force behind the desire to repair IAAA endovascularly. The latest published works confirm the promising results after EVAR for IAAA, but there is still a paucity of data regarding hydroureter and hydronephrosis. In this article, we describe our experience with 5 patients diagnosed with IAAA and treated by EVAR, of whom 3 presented with associated hydronephrosis. METHODS: A retrospective review of our endovascular database identified five patients who underwent EVAR for IAAA. Unilateral ureteral involvement in the inflammatory process was seen in 3 patients, accompanied by secondary hydronephrosis. One patient presented retroperitoneal fibrosis with duodenal stenosis. Primary outcomes were primary technical success, aneurysm-related mortality, change in aneurysm size, perianeurysmal fibrosis (PAF), and hydronephrosis. Secondary outcomes were requirement for reintervention, progression/resolution of symptoms, and short-term clinical success. RESULTS: Follow-up duration ranged from 3 to 61 months. No patients were lost to follow-up. Primary technical success was obtained in all patients. One patient died three months after the operation due to persistence of the duodenal stenosis in spite of subsequent endoscopic treatments and corticotherapy. The aneurysm sac progressively reduced in 4 patients and remained unchanged in one patient. PAF regressed in 2 patients, reduced in two, and remained unchanged in one patient. Hydronephrosis persisted in all three patients preoperatively diagnosed with this condition. No patient required subsequent intervention. Four patients had complete resolution of their symptoms at a follow-up visit at 1 month. CONCLUSIONS: This series suggests that EVAR for IAAA is technically feasible, excludes the aneurysm effectively, and reduces PAF with an acceptable morbidity and mortality rate. EVAR does not seem to offer any benefits for hydronephrosis, and closer follow-up in patients presenting renal or ureter involvement treated by EVAR is necessary.

Long-term results after open repair of inflammatory infrarenal aortic aneurysms.

OBJECTIVE: The objective of this study was to investigate the long-term outcome after open repair of inflammatory infrarenal aortic aneurysms. METHODS: A total of 62 patients (mean age, 68.9 ± 8.8 years; 91.9% male) undergoing open surgery for inflammatory aortic aneurysm from 1995 until 2014 in a high-volume vascular center were retrospectively evaluated. The patients' demographics, preoperative and postoperative clinical characteristics, imaging measurements, and procedural data were collected. Study end points were preoperative and postoperative sac diameter, evolution of periaortic fibrosis and development of hydroureteronephrosis detected by computed tomography (CT) scan, and mortality and morbidity after 30 days and at the time of maximum follow-up. RESULTS: The mean abdominal aortic aneurysm diameter was 67.3 ± 16.7 mm. A total of 30 patients (48.4%) were asymptomatic, 27 patients (43.5%) were symptomatic, and 5 patients (8.1%) were treated for ruptured aneurysm. In 25 patients (40.3%), an aorta-aortic tube graft was implanted; in 37 patients (59.7%), an aortic bifurcation graft was used. Median operating time was 208 minutes (range, 83-519 minutes). Median aortic clamping time was 31 minutes (range, 14-90 minutes); in 25 patients (40.3%), suprarenal aortic cross-clamping was necessary. Hydroureteronephrosis was preoperatively diagnosed by CT scan in 16 patients (25.8%), with the need for a ureteral stent in 11 patients (17.7%). Aneurysm- and procedure-associated 30-day mortality was 11.3% (n = 7), with septic multiple organ failure in four patients and cardiac arrest in three patients. The overall perioperative complication rate was 33.9% (n = 21 patients). Median follow-up was 71.0 months (range, 0.2-231.6 months). At 1 year, 2 years, 4 years, and 6 years, overall survival was 83.4%, 79.6%, 79.6%, and 72.6%, respectively. Six patients (9.7%) required a reintervention during follow-up, predominantly aneurysm related and caused by aortoenteric fistula and graft infection (three of five patients). Median maximum thickness of preoperative perianeurysmal inflammation on CT was 10 mm (range, 2-22 mm), which decreased in 15 of 16 (94%) patients with available postoperative CT scans. Postoperative median thickness of perianeurysmal inflammation on CT was 6 mm (range, 0-13 mm). Hydroureteronephrosis persisted in two of nine (22.2%) patients at the end of follow-up. CONCLUSIONS: Surgery in patients with inflammatory abdominal aortic aneurysms is associated with a substantial amount of perioperative complications. After surgery, the perianeurysmal inflammation decreases in most patients on follow-up CT. However, because the inflammatory process does not totally resolve, patients require lifelong surveillance for hydroureteronephrosis and development of aortoenteric fistulas.

Redefining the histopathologic profile of acute aortic syndromes: Clinical and prognostic implications.

OBJECTIVES: The study objectives were to describe the aortic histopathologic substrates in patients with type A surgically treated acute aortic syndromes, to provide clinico-pathological correlations, and to identify the possible prognostic role of histology. METHODS: We assessed the aortic wall degenerative or inflammatory alterations of 158 patients according to the histopathologic consensus documents. Moreover, we correlated these histologic patterns with the patients' clinical data and long-term follow-up for mortality, major aorta-related events, and nonaorta-related events (including cardiovascular ones). RESULTS: We identified 2 histopathologic patterns: 122 patients (77%) with degenerative alterations and 36 patients (23%) with mixed degenerative-atherosclerotic lesions. Patients with mixed alterations were older (mean 69.6 ± 8.7 years vs 62.2 ± 12.4 years, P = .001) and more hypercholesterolemic (33.3% vs 13.9%, P = .017). The degenerative subgroup showed more intralamellar-mucoid extracellular matrix accumulation (86% vs 66.7%, P = .017) and a lower prevalence of translamellar collagen increase (9.8% vs 50%, P < .001). Patients with mixed degenerative-atherosclerotic abnormalities more frequently had long-term nonaorta-related events compared with those with degenerative abnormalities alone (P = .046); no differences were found between the groups with respect to mortality, major aorta-related events, and cardiovascular nonaorta-related events. CONCLUSIONS: Although degenerative lesions of the medial layer were present in all specimens, substantial atherosclerosis coexisted in approximately one quarter of cases. Patients with mixed degenerative-atherosclerotic abnormalities had a coherent clinical risk profile, a clinical presentation frequently mimicking acute coronary syndrome, and a higher incidence of nonaorta-related events during follow-up. Histopathologic characterization may improve the long-term prognostic stratification of patients after surgical treatment.

Outcomes after Open Surgery for Inflammatory Abdominal Aortic Aneurysm: A 10-Year Single-Center Experience.

BACKGROUND: Inflammatory abdominal aortic aneurysms (IAAAs) are rare clinical entities with an exaggerated inflammatory component. The aim of this study is to report outcomes of a single-center 10-year experience in open surgical management of IAAA and to compare the results with noninflammatory, atherosclerotic abdominal aortic aneurysms (non-IAAAs). METHODS: We retrospectively reviewed the medical records of 18 patients with IAAA selected out of patients with AAA who underwent open surgery in the Department of Vascular and Endovascular Surgery at the University Hospital Dusseldorf from January 2006 to December 2015. These patients were matched with controls, selected from a prospectively retained database of patients with AAA undergoing open surgery during the study period. A 1:2 case-control match regarding age, gender, and year of treatment was performed. We analyzed both groups for preoperative parameters, intraoperative findings, and early postoperative outcomes. RESULTS: The 2 groups showed considerable similarities with no significant differences in the clinical features. Both groups outlined comparable aneurysm size (62 vs. 56 mm); however, the mean preoperative C-reactive protein was found to be significantly elevated in the study group (mean value: 2.6 vs. 0.9 mg/dL, P < 0.05). Most patients were operated using a standard transperitoneal median laparotomy approach; only 1 patient of each group was operated using a left retroperitoneal approach. There was no significant difference in operation time (190 vs. 194 min) and 30-day mortality 0%. The in-hospital mortality was 11% in the study group and 0% in the control group. We found a significant higher complication rate in the study group 10 (56%) vs. 12 (33%). The major complications were also more frequent in the study group 4 (22%) vs. 6 (16.7%). IAAA showed a statistically significant longer length of intensive care unit and hospital stay when compared with non-IAAA (7 and 20 days vs. 2 and 14 days, P < 0.05). IAAAs outlined a significantly greater transfusion requirement for erythrocytes and fresh frozen plasma than non-IAAA. CONCLUSIONS: Open surgical treatment of IAAA guarantees a regression of the inflammatory process in most patients, which was detected through ultrasound in follow-up examination, although the approach to the surgical site is highly demanding. IAAA exhibits clear gender predominance and is associated with significantly higher transfusion requirement, early morbidity, and length of stay.

Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms: A Comparative Study and Meta-Analysis of the Literature.

OBJECTIVES: Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature. METHODS: Twenty-seven patients with an intact IAAA operated on during a 21-year period were included. RESULTS: Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units (P = .001), procedure duration (P < .001), and postoperative hospitalization (P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR (P = 1.00). CONCLUSIONS: Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.

Influence of aortitis on late outcomes after repair of ascending aortic aneurysms.

OBJECTIVE: To determine outcomes of repair of ascending aortic aneurysms in patients with histopathologic diagnoses of aortitis. METHODS: We reviewed histopathologic findings and outcomes of elective repair of ascending aortic aneurysms between January 1, 1955, and December 31, 2012. Noninfectious aortitis was identified in 186 patients, and we compared outcomes for these patients with outcomes for others operated on at the same time with diagnoses of medial degeneration (n = 317) or atherosclerosis (n = 232). RESULTS: Early mortality (<30 days postoperatively) for patients with aortitis was 2%, and overall 10-year survival was 45%, compared with 66% for patients with medial degeneration, and 45% for patients with atherosclerosis (P < .001 vs medial degeneration). In addition to histopathologic diagnosis, overall mortality was influenced by older age at operation (hazard ratio [HR]: 1.060; 95% confidence interval [CI], 1.046-1.077; P < .001), chronic obstructive pulmonary disease (HR: 1.560; 95% CI: 1.136-2.136; P = .006); concomitant coronary artery bypass grafting (HR: 1.980; 95% CI: 1.520-2.600; P < .001); and use of circulatory arrest (HR: 1.500; 95% CI: 1.148-1.960; P = .003). Risk of aortic reoperation at 10 years was 21% for aortitis patients, compared with 11% for those with medial degeneration, and 19% for patients with atherosclerosis (P = .028). CONCLUSIONS: Patients with repaired ascending aneurysms secondary to noninfectious aortitis have low early mortality, but late risks of death and aortic reoperation are increased, compared with these outcomes for patients with aneurysms that result from medial degeneration.

Early and mid-term postoperative outcome of inflammatory abdominal aortic aneurysms.

INTRODUCTION AND OBJECTIVES: The aim of this study is to report our experience on the postoperative outcome of surgical treatment of inflammatory abdominal aortic aneurysm (IAAA). MATERIALS AND METHODS: Between January 1997 and March 2014, 35 patients with IAAA underwent surgery. The mean age was 63 ± 18 years. Chronic renal failure was identified in 11 (31.4%) patients, and ischemic heart disease was confirmed in 15 (43%) patients. The mean aortic aneurysm diameter was 68 ± 25 mm. The abdominal aorta was clamped above the renal arteries in 6 (17%) patients. RESULTS: The hospital mortality was 5.7% (2 patients). Three patients developed an aortic pseudoaneurysm and underwent reoperation. Another patient developed a femoral anastomotic pseudoaneurysm 7 years after operation, which was treated surgically. The overall reoperation-free actuarial survival at 1, 5, and 7 years was 94, 62, and 50%, respectively. The Cox model revealed the delta erythrocyte sedimentation rate (p = 0.002), ischemic heart disease (p = 0.006), and renal failure (p = 0.036) as strong predictors for poor overall outcome. CONCLUSION: Early postoperative outcome in terms of mortality and morbidity seems acceptable; however, patients with IAAA have an increased risk for reoperation due to pseudoaneurysm formation. Strong predictors for poor overall outcome seem to be elevated erythrocyte sedimentation rate, ischemic heart disease, and chronic renal failure.

Surgical management of aortitis with early aneurysmal dilation.

BACKGROUND: Aortitis is a rare and serious condition that requires expedient surgical evaluation. Diagnosis is generally made by computed tomography (CT). Surgery is most often performed when significant aneurysmal changes have already occurred. Outcomes of early surgical management of aortitis with early aneurysmal dilation have not been reported previously. METHODS: A retrospective review of open abdominal aortic repairs performed from 1999 to 2009 at a single center was done from a prospectively collected database. Patients with a confirmed radiographic appearance of aortitis and treated surgically were selected. Demographic, clinical, and surgical data of patients with aortitis showing early aneurysmal changes (aortic diameter <4 cm) were then analyzed. All aortitis cases with >4-cm aortic diameters and with prosthetic aortic grafts were excluded. RESULTS: During the observation period, 421 open abdominal aortic repairs were performed. Of these, 10 (2.4%) were identified as having primary aortitis without significant aneurysmal changes. The mean age of the patients was 62 (range 48-77) years. There were 6 (60%) men and 4 (40%) women in the cohort. Four patients (40%) had culture-negative aortitis, whereas 6 (60%) had positive microbial cultures at the time of diagnosis. Paravisceral involvement was seen in 8 (80%) cases. All patients underwent in situ repair with aortic homografts. Mean operative time was 348 minutes and mean estimated blood loss was 2475 mL. Median follow-up time was 23.1 months with a range of 1.7-51.4 months. Operative mortality was 0%, and 1 late death occurred at 23 months postoperatively. There were 9 significant in-hospital (30-day) events occurring in 5 patients, including 3 cardiovascular events, 2 pulmonary events, 3 acute renal failures, and 1 deep surgical site infection. CONCLUSIONS: Aortitis is an uncommon indication for aortic repair. Infectious aortitis is most commonly confirmed by microbiologic studies, but a significant number of cases have no demonstrable microbial source. Outcomes after early surgical management for aortitis with small aneurysms demonstrated improved mortality when compared with series reviewing outcomes in aortitis patients with large mycotic aneurysms.

Influence of prosthesis type on long-term survival after re-replacement of aortic valve prosthesis.

BACKGROUND: The purpose of this study is to examine the influence of the prosthesis type on early mortality and long-term survival after re-replacement of aortic valve prosthesis, especially in patients over 60 years old. METHODS: Late outcome of 223 patients who underwent a reoperation on the aortic valve and received a mechanical (mechanical group) or biological (biological group) heart valve prosthesis at a single institution were analyzed for survival and major valve-related complications, including structural valve deterioration, thromboembolism, hemorrhage, further reoperation, and valve-related mortality. RESULTS: Preoperative New York Heart Association class IV (P = 0.001), emergency procedure (P = 0.002), and endocarditis (P = 0.025) were significant risk factors for 30-day mortality rates, which were 8.4 % and 12.5 %, respectively (mechanical versus biological group, P = 0.361). A subanalysis of elective patients revealed a low risk of 30-day mortality of 2.4 % and 1.8 %, respectively. Event-free survival was comparable at 5 years (73.9% ± 3.6% versus 70.5% ± 6.5%, mechanical versus biological group) and 10 year (49.7% ± 5.0% versus 35.3% ± 9.8%, mechanical versus biological group). In a propensity-matched subanalysis, survival and event-free survival were comparable at 5 and 10 years in both groups. CONCLUSION: The type of aortic valve prosthesis did not affect early outcome and late survival in patients who underwent valve replacement, and therefore, the current strategy favoring a biological aortic valve prosthesis for patients aged over 60 years in first-time operations could also be applied in re-replacement.

Giant cell arteritis with or without aortitis at diagnosis. A retrospective study of 22 patients with longterm followup.

OBJECTIVE: Studies have shown that aortitis may be present in half the patients with recent-onset giant cell arteritis (GCA). We assessed whether aortitis at diagnosis affects longterm outcome in patients with GCA. METHODS: We retrospectively analyzed the longterm outcome of a prospective cohort of 22 patients with biopsy-proven GCA who all had aortic computed tomography (CT) evaluation at the time of diagnosis of GCA between May 1998 and November 1999. Longterm outcome, especially vascular events such as aortic aneurysm, mortality, relapses of GCA, and requirement for steroids, was assessed in 2011 by chart review and patient/physician interviews. RESULTS: At disease onset, 10/22 patients had aortitis on CT scan. Patients with and without aortitis had similar baseline characteristics, including cardiovascular risk profile. At the time of the study, 12/22 (57%) patients had died. Vascular causes of death were more frequent in patients with aortitis (5/7 vs 0/5; p = 0.02). A higher number of vascular events was noted in patients with aortitis (mean events per patient 1.33 vs 0.25; p = 0.009). Stroke was more frequent in patients with aortitis. These patients seemed to exhibit a more chronic or relapsing disease course, and they were less likely to completely discontinue steroid therapy (p = 0.009, log-rank test). CONCLUSION: Our study suggests for the first time that inflammatory aortic involvement present at onset of GCA could predict a more chronic/relapsing course of GCA, with higher steroid requirements and an increased risk for vascular events in the long term.

Pneumococcal aortitis: an insidious diagnosis.

A patient with Streptococcus pneumoniae aortitis is presented. Because of nonspecific symptoms (fever and back pain) there was a long diagnostic delay. In addition, the aortitis was located near the renal arteries which severely hampered early surgical treatment. Although emergency surgery was performed when aortic rupture occurred, the patient did not survive. Infectious arteritis of large vessels is a diagnosis often made late and associated with high mortality.

Inflammatory abdominal aortic aneurysms (IAAA): past and present.

AIM: The aim of the study is to determine whether presentation and outcomes of inflammatory abdominal aortic aneurysms (IAAA) have changed over the last five decades. METHODS: Comparison of current outcomes (January 2001 to December 2007) with results of the earliest report from our unit in 1972. RESULTS: In contemporary series, 421 patients underwent AAA repair; 38 (9%) were IAAA. In 58% patients, IAAA was an incidental finding, whereas 42% patients were symptomatic with abdominal or back pain. Of those, 32% were ruptured IAAA. Male-to-female ratio was 12:1. Thirty-day mortality was 13%; elective 11.5%; emergency 17%. Comparison with 1972 study showed no change in the incidence and gender predilection. Presentation as an incidental finding and rupture increased 4- and 2-folds, respectively. CONCLUSION: The incidence and gender predilection of IAAA have remained unchanged. The 4-fold increase in the presentation as an incidental finding reflects current trends in patient evaluation.

Inflammatory abdominal aortic aneurysms. A 20-year experience.

AIM: The aim of the study was to report a 20-year single Institution experience, with the early and late outcomes of surgical treatment of inflammatory abdominal aortic aneurysms. METHODS: In a 20-year period, 2 275 consecutive patients underwent elective surgical repair for non-rupture abdominal aortic aneurysm. Fifty-two patients (2.3%) were classified as inflammatory abdominal aortic aneurysms. Early and late outcomes were analyzed. RESULTS: One patient died in the perioperative period, giving a mortality rate of 1.92%. One patient died from a pseudoaneurysm rupture 7 months after operation. Three patients developed an aortic pseudoaneurysm in the follow-up period (mean 12.1 years, range 1-20 years) and underwent a redo operation. CONCLUSION: Overall surgical outcome of these patients, in terms of short-term and long-term is good. A high rate of pseudoaneurysm formation was observed.

Systemic inflammation and repair of abdominal aortic aneurysm.

BACKGROUND: Inflammation is integral to the pathogenesis of abdominal aortic aneurysm (AAA). This study examines preoperative biomarkers of systemic inflammation in patients undergoing open repair of intact and ruptured AAA. METHODS: One-hundred twelve patients were entered into a prospective observational study. Preoperative POSSUM physiology score, C-reactive protein (CRP), white blood count (WBC), platelet count, fibrinogen, and albumin were recorded and related to clinical variables using univariate analysis. RESULTS: Sixty-one patients with a ruptured AAA, 39 with an asymptomatic intact AAA, and 12 with an acutely symptomatic intact AAA underwent attempted repair. There were two inflammatory asymptomatic aneurysms and one inflammatory ruptured aneurysm. No patient had clinical evidence of coexistent inflammatory disease. Patients with a symptomatic intact AAA had a significantly greater level of CRP and fibrinogen, higher WBC, and lower serum albumin, than those with an asymptomatic intact AAA. Patients with a ruptured aneurysm had a significantly greater level of CRP, higher WBC, and lower serum albumin than those with an asymptomatic intact aneurysm. Patients with a symptomatic intact AAA had a significantly higher CRP level, but lower WBC, than those with a ruptured AAA. There was no difference in CRP level, WBC, or serum albumin between survivors and non-survivors of attempted repair of asymptomatic, symptomatic and ruptured AAA. CONCLUSIONS: Acutely symptomatic and ruptured AAAs are associated with an early elevation in systemic inflammatory biomarkers. This early activation of the inflammatory response might influence perioperative outcome.

Inflammatory abdominal aortic aneurysm: predictors of long-term outcome in a case-control study.

BACKGROUND: Inflammatory abdominal aortic aneurysms (AAAs) are relatively rare clinical entities. The aim of this study is to ascertain the risk factors in patients with inflammatory AAAs and clarify which feature plays a role in determining the long-term outcome in these patients. METHODS: Between 1990 and 1997, 238 patients underwent surgery for an AAA at our institution, 17 (7.1%) of whom had the diagnosis of inflammatory type AAA. This group was matched in a case-control fashion to a group of 35 patients with similar characteristics of age, gender, and preoperative risk factors who were operated on for a noninflammatory AAA. All available clinical, pathologic, and postoperative variables were retrospectively reviewed, and the 2 groups were compared. In the inflammatory group, risk factor analysis was performed for poor outcome. RESULTS: All operations were performed through a standard transperitoneal median laparotomy. The 2 groups did not differ significantly in terms of clinical characteristics and preoperative risk factors Patients with inflammatory AAAs were significantly more symptomatic (100% vs 31%, P = .03) and had larger aneurysm size on admission (8.2 +/- 1.2 cm vs 6.1 +/- 0.4 cm, P = .04). In inflammatory AAAs, preoperative erythrocyte sedimentation rate was found to be significantly elevated (mean, 48 +/- 14 mm/h vs 8 +/- 3 mm/h, P = .01). Surgical morbidity and mortality rates did not differ between 2 groups. The intensive care unit and hospital stay periods were similar in both groups (2.2 days vs 1.8 days, P = .25, and 9.2 days vs 8.1 days, P = .35). Eight-year survival rates of inflammatory and noninflammatory groups were 60% and 74%, respectively (P = .01). Results from Cox proportional hazards model analysis showed that a high sedimentation rate after surgical intervention (P = .02), cardiovascular disease (P = .01), postoperative persisting fibrosis with ureteral entrapment (P = .01), and postoperative chronic renal failure (P = .02) were independent risk factors for death. Other surgical variables did not prove to be risk factors for long-term mortality. CONCLUSIONS: Although the preoperative characteristics may differ in patients with inflammatory type AAAs, they can be treated today with low morbidity and mortality rates. However, inflammatory process may continue postoperatively because of unknown reasons, and the study documented that persisting, postoperative inflammatory process with or without retroperitoneal fibrosis may place a patient at high risk for poor outcome. This is important information for the long-term management of these patients, and we believe that their follow-up protocols should be more comprehensive to further improve their long-term survival rates.