J.M. Hendriks

Systematic review and meta-analysis of sex differences in outcome after intervention for abdominal aortic aneurysm

The aim of this study was to assess possible differences in mortality between men and women with an abdominal aortic aneurysm (AAA) treated either by elective repair or following aneurysm rupture.

Epidemiology, Aetiology, Risk of Rupture and Treatment of Abdominal Aortic Aneurysms: Does Sex Matter?

OBJECTIVES To unravel the extent to which gender plays a role in the epidemiology, aetiology, risk of rupture and treatment of abdominal aortic aneurysms (AAAs) and to give an overview of these factors. DESIGN, MATERIALS AND METHODS A literature review was performed in the Medline database and Cochrane Library for gender-specific articles on epidemiology, aetiology, risk of rupture and treatment of AAAs. RESULTS Our literature review suggests that the prevalence of AAA in women is underestimated. Regarding aetiology, an oestrogen-mediated reduction in macrophage MMP-9 production seems to be an important mechanism causing gender-related differences in AAA development. We found consensus in the literature that women run a greater risk of rupture compared to men under the current management rules for AAAs. Their treatment mortality also seems to be higher for both elective and ruptured repair. CONCLUSIONS Gender-specific guidelines should be put into place for the management of AAAs and awareness for this disease should be increased, both in women themselves and in their doctors.

Treatment of Post-implantation Aneurysm Growth by Laparoscopic Sac Fenestration: Long-term Results

OBJECTIVES Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. METHODS The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. RESULTS Follow-up had a median length of 6.6 (range 0.6-8.6) years. During this time, only three patients successfully achieved durable aneurysm shrinkage (n = 2) or stability (n = 1). The remaining patients suffered persistent (n = 2) or recurrent sac growth (n = 3), all regarded as failure of fenestration. A total of six additional interventions were performed, comprising open conversion (n = 2), relining (n = 1) and implantation of iliac extensions (n = 3). All additional interventions were successful at arresting further sac growth during the remainder of follow-up. CONCLUSIONS Despite being a less invasive alternative to conversion and open repair, the long-term outcome of sac fenestration is unpredictable and additional major procedures were often necessary to arrest sac growth.

The Impact of Gender on Prognosis After Non-cardiac Vascular Surgery

OBJECTIVES The objective was to evaluate the impact of gender on long-term survival of patients who underwent non-cardiac vascular surgery. DESIGN, MATERIAL AND METHODS Our prospectively collected data contained information on 560 patients undergoing carotid endarterectomy (CEA), 923 elective abdominal aortic aneurysm repairs (AAA) and 1046 lower limb reconstructions (LLR). Patient characteristics and long-term mortality of women were compared to that of men. Kaplan-Meier (KM) survival curves were constructed for men and women, on which we superimposed age- and sex-matched KM survival curves of the general population. Cox proportional hazards regression was used to identify risk factors for mortality. RESULTS Men in the CEA group had statistically significant higher all-cause mortality, hazard rate ratio (HRR) 1.41 (95% CI 1.01-1.98) No differences in mortality between the genders were observed in the AAA and LLR groups. Overall, men had more co-morbidities but received more disease-specific medication compared to women. Women retained their higher life expectancy after CEA but lost it in the AAA and LLR groups. CONCLUSION Women retain their higher life expectancy after CEA; however, after AAA repair and LLR, this advantage is lost. Both men and women received too little disease-specific medication, but women were worse off.

Quantity, particle size, and histologic composition of embolic debris collected in a distal protection filter after carotid angioplasty and stenting: Correlation with patient characteristics, timing of carotid artery stenting, and procedural details

Asymptomatic 5 (8.5) Symptomatic 54 (91.5) Amaurosis fugax 8 (14) Retinal infarction 1 (2) Transient ischemic attack 28 (48) Stroke 17 (29) Onset of symptoms before CAS 0-28 d 35 (59) >28 d 24 (41) Contralateral occlusion 10 (17) Percent stenosis The occurrence of distal embolization during carotid artery stenting (CAS) is a major complication. Determining the preoperative risk of embolization may lead to improved patient selection and outcome of CAS. This study examined the quantity, particle size, and histologic composition of embolic debris collected in a distal protection filter and its possible correlation with patient characteristics, timing of CAS, and procedural details.

Visceral aneurysms: Old paradigms, new insights?

True visceral artery aneurysms (VAAs) are a rare entity with an incidence of 0.01-2%. The risk of rupture varies amongst the different types of VAAs and is higher for pseudo aneurysms compared with true aneurysms. Size, growth, symptoms, underlying disease, pregnancy and liver transplantation have all been associated with increased risk of rupture. Mortality rates after rupture are around 25%. The splenic artery is most commonly affected and the etiology is predominantly atherosclerosis. Open repair can be done by simple ligation or reconstruction of the artery, while endovascular options include embolization or using a stent graft. Location, collateral circulation and medical condition of the patient should all be taken into account when an intervention is planned. We compared types of treatment and searched for risk factors for rupture but unfortunately, the level of evidence found in the literature is low. Therefore, deciding when and how to treat a patient with a VAA based on the current literature, remains challenging for clinicians.

Endovascular abdominal aortic aneurysm repair in women.

Abstract The objective of this review is to establish the role of endovascular aortic aneurysm repair (EVAR) in women. A step by step approach is taken looking at sex and gender differences in epidemiology, pathogenesis and natural history. We then proceed to discuss the results from the three randomized controlled trials comparing EVAR to open repair. Finally, sex-specific secondary prevention, risk factor management and medication, is discussed. Women seem to have higher mortality and more complications after EVAR. Risk factors such as diabetes and hypertension are associated with worse outcome in women compared to men. The role of EVAR in women is poorly investigated and its definite role remains to be determined. Aggressive treatment of risk factors and the optimisation of medication in women are indicated and deserve more attention in clinical practice and future research.

Cerebral Protection During Percutaneous Carotid Intervention: wich Device Should Be Used ?

Abstract Embolic complications remain the major and unpredictable clinical event during carotid angioplasty and stenting. Cerebral protection devices could play an important role in the prevention of such emboli. Protection devices such as occlusion balloons, filters and reversed flow devices are currently undergoing clinical evaluation and appear to be promising in reducing the incidence of embolic events. This article provides an overview of the three different types of embolic protection devices.Embolic complications remain the major and unpredictable clinical event during carotid angioplasty and stenting. Cerebral protection devices could play an important role in the prevention of such emboli. Protection devices such as occlusion balloons, filters and reversed flow devices are currently undergoing clinical evaluation and appear to be promising in reducing the incidence of embolic events. This article provides an overview of the three different types of embolic protection devices.