Publications by authors named "Hans-Henning Eckstein"

183 Publications

Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials.

Eur J Vasc Endovasc Surg 2021 Apr 5. Epub 2021 Apr 5.

Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK. Electronic address:

Objective: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed.

Methods: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation.

Results: A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019).

Conclusion: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.
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http://dx.doi.org/10.1016/j.ejvs.2021.02.024DOI Listing
April 2021

The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair.

Dtsch Arztebl Int 2020 Oct;117(48):820-827

Department for Vascular and Endovascular Surgery, University Hospital rechts der Isar, Technical University of Munich; Department of Statistics, Ludwig Maximilians University Munich.

Background: The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements.

Methods: The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility.

Results: The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects).

Conclusion: In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.
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http://dx.doi.org/10.3238/arztebl.2020.0820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005841PMC
October 2020

Multispectral optoacoustic tomography of peripheral arterial disease based on muscle hemoglobin gradients-a pilot clinical study.

Ann Transl Med 2021 Jan;9(1):36

Department for Clinical Radiology, University Hospital Münster, Münster, Germany.

Background: Current imaging assessment of peripheral artery disease (PAD) relies on anatomical cross-sectional visualizations of the affected arteries. Multispectral optoacoustic tomography (MSOT) is a novel molecular imaging technique that provides direct and label-free visualizations of soft tissue perfusion and oxygenation.

Methods: MSOT was prospectively assessed in a pilot trial in healthy volunteers (group n=4, mean age 31, 50% male and group n=4, mean age 37.3, 75% male) and patients with intermittent claudication (group n=4, mean age 72, 75% male, PAD stage IIb). We conducted cuff-induced ischemia (group n) and resting state measurements (groups n and n) over the calf region. Spatially resolved mapping of oxygenated (HbO), deoxygenated (Hb) and total (THb) hemoglobin, as well as oxygen saturation (SO), were measured via hand-held hybrid MSOT-Ultrasound based purely on hemoglobin contrast.

Results: Calf measurements in healthy volunteers revealed distinct dynamics for HbO, Hb, THb and SO under cuff-induced ischemia. HbO, THb and SO levels were significantly impaired in PAD patients compared to healthy volunteers (P<0.05 for all parameters). Revascularization led to significant improvements in HbO of the affected limb.

Conclusions: Clinical MSOT allows for non-invasive, label-free and real-time imaging of muscle oxygenation in health and disease with implications for diagnostics and therapy assessment in PAD.
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http://dx.doi.org/10.21037/atm-20-3321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859778PMC
January 2021

Multicompartmental non-invasive sensing of postprandial lipemia in humans with multispectral optoacoustic tomography.

Mol Metab 2021 Feb 5;47:101184. Epub 2021 Feb 5.

Technical University of Munich, School of Medicine, Chair of Biological Imaging, Germany; Helmholtz Zentrum München, Neuherberg, Institute of Biological and Medical Imaging, Germany. Electronic address:

Objective: Postprandial lipid profiling (PLP), a risk indicator of cardiometabolic disease, is based on frequent blood sampling over several hours after a meal, an approach that is invasive and inconvenient. Non-invasive PLP may offer an alternative for disseminated human monitoring. Herein, we investigate the use of clinical multispectral optoacoustic tomography (MSOT) for non-invasive, label-free PLP via direct lipid-sensing in human vasculature and soft tissues.

Methods: Four (n = 4) subjects (3 females and 1 male, age: 28 ± 7 years) were enrolled in the current pilot study. We longitudinally measured the lipid signals in arteries, veins, skeletal muscles, and adipose tissues of all participants at 30-min intervals for 6 h after the oral consumption of a high-fat meal.

Results: Optoacoustic lipid-signal analysis showed on average a 63.4% intra-arterial increase at ~ 4 h postprandially, an 83.9% intra-venous increase at ~ 3 h, a 120.8% intra-muscular increase at ~ 3 h, and a 32.8% subcutaneous fat increase at ~ 4 h.

Conclusion: MSOT provides the potential to study lipid metabolism that could lead to novel diagnostics and prevention strategies by label-free, non-invasive detection of tissue biomarkers implicated in cardiometabolic diseases.
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http://dx.doi.org/10.1016/j.molmet.2021.101184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7918675PMC
February 2021

Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis.

Dtsch Arztebl Int 2020 Nov;117(47):801-807

Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital "rechts der Isar", Technical University of Munich; Member of the Steering Group, Institute for Neuroradiology, University Hospital Frankfurt; Member of the Steering Group, Ettlingen; Member of the Steering Group, Department of Vascular and Thoracic Surgery, Karlsruhe Municipal Hospital Member of the Steering Group, Department of Neurology and Stroke Unit, Benedictus Hospital Tutzing; German Vascular Society (DGG); German Society of Neuroradiology (DGNR); German Society for Angiology/Vascular Medicine (DGA); German Society of Surgery (DGCH); German Society of Neurology (DGN).

Background: Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria.

Methods: A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations.

Results: The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses.

Conclusion: Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
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http://dx.doi.org/10.3238/arztebl.2020.0801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947643PMC
November 2020

Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials.

Stroke 2021 Jan 25;52(2):416-423. Epub 2021 Jan 25.

Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.).

Background And Purpose: CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) reported a higher periprocedural risk for any stroke, death, or myocardial infarction for women randomized to carotid artery stenting (CAS) compared with women randomized to carotid endarterectomy (CEA). No difference in risk by treatment was detected for women relative to men in the 4-year primary outcome. We aimed to conduct a pooled analysis among symptomatic patients in large randomized trials to provide more precise estimates of sex differences in the CAS-to-CEA risk for any stroke or death during the 120-day periprocedural period and ipsilateral stroke thereafter.

Methods: Data from the Carotid Stenosis Trialists' Collaboration included outcomes from symptomatic patients in EVA-3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty Versus Carotid Endarterectomy in Symptomatic Patients), ICSS (International Carotid Stenting Study), and CREST. The primary outcome was any stroke or death within 120 days after randomization and ipsilateral stroke thereafter. Event rates and relative risks were estimated using Poisson regression; effect modification by sex was assessed with a sex-by-treatment-by-trial interaction term, with significant interaction defined a priori as ≤0.10.

Results: Over a median 2.7 years of follow-up, 433 outcomes occurred in 3317 men and 1437 women. The CAS-to-CEA relative risk of the primary outcome was significantly lower for women compared with men in 1 trial, nominally lower in another, and nominally higher in the other two. The sex-by-treatment-by-trial interaction term was significant (=0.065), indicating heterogeneity among trials. Contributors to this heterogeneity are primarily differences in periprocedural period. When the trials are nevertheless pooled, there were no significant sex differences in risk in any follow-up period.

Conclusions: There were significant differences between trials in the magnitude of sex differences in treatment effect (CAS-to-CEA relative risk), indicating pooling data from these trials to estimate sex differences might not be valid. Whether sex is acting as an effect modifier of the CAS-to-CEA treatment effect in symptomatic patients remains uncertain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00190398 (EVA-3S) and NCT00004732 (CREST). URL: https://www.isrctn.com; Unique identifier: ISRCTN57874028 (SPACE) and ISRCTN25337470 (ICSS).
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http://dx.doi.org/10.1161/STROKEAHA.120.030184DOI Listing
January 2021

Chitinase 3 like 1 (CHI3L1) is a regulator of smooth muscle cell physiology and atherosclerotic lesion stability.

Cardiovasc Res 2021 Jan 20. Epub 2021 Jan 20.

Division of Vascular Surgery, Stanford University School of Medicine, Stanford, USA.

Aims: Atherosclerotic cerebrovascular disease underlies the majority of ischemic strokes and is a major cause of death and disability. While plaque burden is a predictor of adverse outcomes, plaque vulnerability is increasingly recognized as a driver of lesion rupture and risk for clinical events. Defining the molecular regulators of carotid instability could inform the development of new biomarkers and/or translational targets for at-risk individuals.

Methods And Results: Using two independent human endarterectomy biobanks, we found that the understudied glycoprotein, Chitinase 3 like 1 (CHI3L1), is upregulated in patients with carotid disease compared to healthy controls. Further, CHI3L1 levels were found to stratify individuals based on symptomatology and histopathological evidence of an unstable fibrous cap. Gain- and loss-of-function studies in cultured human carotid artery smooth muscle cells (SMCs) showed that CHI3L1 prevents a number of maladaptive changes in that cell type, including phenotype switching towards a synthetic and hyperproliferative state. Using two murine models of carotid remodelling and lesion vulnerability, we found that knockdown of Chil1 resulted in larger neointimal lesions comprised by de-differentiated SMCs that failed to invest within and stabilize the fibrous cap. Exploratory mechanistic studies identified alterations in potential downstream regulatory genes, including large tumor suppressor kinase 2 (LATS2), which mediates macrophage marker and inflammatory cytokine expression on SMCs, and may explain how CHI3L1 modulates cellular plasticity.

Conclusion: CHI3L1 is upregulated in humans with carotid artery disease and appears to be a strong mediator of plaque vulnerability. Mechanistic studies suggest this change may be a context-dependent adaptive response meant to maintain vascular SMCs in a differentiated state and to prevent rupture of the fibrous cap. Part of this effect may be mediated through downstream suppression of LATS2. Future studies should determine how these changes occur at the molecular level, and whether this gene can be targeted as a novel translational therapy for subjects at risk of stroke.

Translational Perspective: Taken together, CHI3L1 has the potential to become a new translational target for cardiovascular disease. With further studies to understand its full causal relationship to inflammatory pathways, it could have a role in the diagnosis and management of patients with cerebrovascular disease at risk for stroke.
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http://dx.doi.org/10.1093/cvr/cvab014DOI Listing
January 2021

Designed CXCR4 mimic acts as a soluble chemokine receptor that blocks atherogenic inflammation by agonist-specific targeting.

Nat Commun 2020 11 25;11(1):5981. Epub 2020 Nov 25.

Institute for Stroke and Dementia Research (ISD), Klinikum der Universität München, Ludwig-Maximilians-Universität (LMU) München, 81377, Munich, Germany.

Targeting a specific chemokine/receptor axis in atherosclerosis remains challenging. Soluble receptor-based strategies are not established for chemokine receptors due to their discontinuous architecture. Macrophage migration-inhibitory factor (MIF) is an atypical chemokine that promotes atherosclerosis through CXC-motif chemokine receptor-4 (CXCR4). However, CXCR4/CXCL12 interactions also mediate atheroprotection. Here, we show that constrained 31-residue-peptides ('msR4Ms') designed to mimic the CXCR4-binding site to MIF, selectively bind MIF with nanomolar affinity and block MIF/CXCR4 without affecting CXCL12/CXCR4. We identify msR4M-L1, which blocks MIF- but not CXCL12-elicited CXCR4 vascular cell activities. Its potency compares well with established MIF inhibitors, whereas msR4M-L1 does not interfere with cardioprotective MIF/CD74 signaling. In vivo-administered msR4M-L1 enriches in atherosclerotic plaques, blocks arterial leukocyte adhesion, and inhibits atherosclerosis and inflammation in hyperlipidemic Apoe mice in vivo. Finally, msR4M-L1 binds to MIF in plaques from human carotid-endarterectomy specimens. Together, we establish an engineered GPCR-ectodomain-based mimicry principle that differentiates between disease-exacerbating and -protective pathways and chemokine-selectively interferes with atherosclerosis.
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http://dx.doi.org/10.1038/s41467-020-19764-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689490PMC
November 2020

Biomechanical rupture risk assessment of abdominal aortic aneurysms using clinical data: A patient-specific, probabilistic framework and comparative case-control study.

PLoS One 2020 19;15(11):e0242097. Epub 2020 Nov 19.

Mechanics & High Performance Computing Group, Technical University of Munich, Garching, Germany.

We present a data-informed, highly personalized, probabilistic approach for the quantification of abdominal aortic aneurysm (AAA) rupture risk. Our novel framework builds upon a comprehensive database of tensile test results that were carried out on 305 AAA tissue samples from 139 patients, as well as corresponding non-invasively and clinically accessible patient-specific data. Based on this, a multivariate regression model is created to obtain a probabilistic description of personalized vessel wall properties associated with a prospective AAA patient. We formulate a probabilistic rupture risk index that consistently incorporates the available statistical information and generalizes existing approaches. For the efficient evaluation of this index, a flexible Kriging-based surrogate model with an active training process is proposed. In a case-control study, the methodology is applied on a total of 36 retrospective, diameter matched asymptomatic (group 1, n = 18) and known symptomatic/ruptured (group 2, n = 18) cohort of AAA patients. Finally, we show its efficacy to discriminate between the two groups and demonstrate competitive performance in comparison to existing deterministic and probabilistic biomechanical indices.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242097PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676745PMC
December 2020

A sparse deep learning approach for automatic segmentation of human vasculature in multispectral optoacoustic tomography.

Photoacoustics 2020 Dec 10;20:100203. Epub 2020 Sep 10.

Institute of Computational Biology, Helmholtz Center Munich, Neuherberg, Germany.

Multispectral Optoacoustic Tomography (MSOT) resolves oxy- (HbO) and deoxy-hemoglobin (Hb) to perform vascular imaging. MSOT suffers from gradual signal attenuation with depth due to light-tissue interactions: an effect that hinders the precise manual segmentation of vessels. Furthermore, vascular assessment requires functional tests, which last several minutes and result in recording thousands of images. Here, we introduce a deep learning approach with a sparse-UNET (S-UNET) for automatic vascular segmentation in MSOT images to avoid the rigorous and time-consuming manual segmentation. We evaluated the S-UNET on a test-set of 33 images, achieving a median DICE score of 0.88. Apart from high segmentation performance, our method based its decision on two wavelengths with physical meaning for the task-at-hand: 850 nm (peak absorption of oxy-hemoglobin) and 810 nm (isosbestic point of oxy-and deoxy-hemoglobin). Thus, our approach achieves precise data-driven vascular segmentation for automated vascular assessment and may boost MSOT further towards its clinical translation.
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http://dx.doi.org/10.1016/j.pacs.2020.100203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644749PMC
December 2020

Cholesterol, carotid artery disease and stroke: what the vascular specialist needs to know.

Ann Transl Med 2020 Oct;8(19):1265

Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK.

Hypercholesterolemia is a risk factor for carotid artery stenosis and stroke. Statins are the main drugs for the management of hypercholesterolemia and they are strongly recommended by international guidelines for the management of vascular patients. The present review will focus on the associations between cholesterol, carotid artery stenosis and stroke and will cover several topics, including the conservative and perioperative/periprocedural management of carotid patients, the effect of statins on contrast-induced nephropathy developing after endovascular carotid interventions, the role of statin loading prior to endovascular procedures, as well as the indirect beneficial effects of statin treatment on renal function. It will also discuss the topics of statin intolerance and alternative cholesterol-lowering options for statin-intolerant vascular patients. Cholesterol levels play a prognostic role in carotid patients with regards to both short- and long-term stroke and mortality rates. Physicians should keep in mind the pivotal role of cholesterol levels in determining cardiovascular outcomes and the pleiotropic beneficial effects associated with statin use and should not miss the opportunity for cardiovascular risk reduction with aggressive statin treatment.
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http://dx.doi.org/10.21037/atm.2020.02.176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607102PMC
October 2020

Lack of durability after transarterial ethylene-vinyl alcohol copolymer-embolization of type II endoleak following endovascular abdominal aortic aneurysm repair.

Vasa 2020 Oct;49(6):483-491

Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.

: Type II endoleak (T2EL) after endovascular aortic repair is associated with AAA sac enlargements in up to 25%, reduction of attachment zones and rarely with aortic rupture. Indications for therapy and efficacy of interventions of T2EL are not clearly established. Transarterial embolization with application of ethylene-vinyl alcohol copolymer has been described with varying outcomes. Aim of this study is to evaluate durability of Onyx embolization (OE) in T2EL in a consecutive series at a single tertiary vascular center. : Demographic data, technical success, pre- and postoperative aneurysm growth, morbidity, mortality and reintervention rates during hospital stay as well as in follow up were recorded in patients treated with OE for T2EL between 01/2015 and 12/2017. The primary endpoint was defined as persistence or reoccurrence of T2EL (durability of OE). : In total 15 patients (78 ± 6 years, 13 men) were treated with OE because of sac enlargement (average growth of 12 ± 8%, n = 12), persistent bleeding after AAA rupture (n = 2) or persistent T2EL with stable but large aneurysm diameter (n = 1). Mean length of stay was 8 ± 11 days. Technical success was 93.3% (n = 14). Inhospital-morbidity was 26.7%, in-hospital- and 1-year-mortality rate were 6.6% (n = 1) and 20.0% (n = 3). T2EL persisted in 20.0% (n = 3) despite of OE. Re-EL-II occurred after 40 (30-114) days in 33.3% (n = 5). Reintervention rate was 13.3% (n = 2, at day 48 and 319). Altogether clinical success with stable aneurysm diameter was achieved in 80.0% (n = 12), but durable elimination of EL was only achieved in 46.7% of patients (n = 7). : OE is technically possible in more than 90% of patients but might be associated with severe complications. Durability of this treatment is low, since T2EL persist or reoccur in more than 50% of all patients. OE of T2EL should be reserved for few selected cases.
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http://dx.doi.org/10.1024/0301-1526/a000905DOI Listing
October 2020

The TAXINOMISIS Project: A multidisciplinary approach for the development of a new risk stratification model for patients with asymptomatic carotid artery stenosis.

Eur J Clin Invest 2020 Dec 2;50(12):e13411. Epub 2020 Oct 2.

Department of Materials Science and Engineering, Unit of Medical Technology and Intelligent Information Systems, University of Ioannina, Ioannina, Greece.

Introduction: Asymptomatic carotid artery stenosis (ACAS) may cause future stroke and therefore patients with ACAS require best medical treatment. Patients at high risk for stroke may opt for additional revascularization (either surgery or stenting) but the future stroke risk should outweigh the risk for peri/post-operative stroke/death. Current risk stratification for patients with ACAS is largely based on outdated randomized-controlled trials that lack the integration of improved medical therapies and risk factor control. Furthermore, recent circulating and imaging biomarkers for stroke have never been included in a risk stratification model. The TAXINOMISIS Project aims to develop a new risk stratification model for cerebrovascular complications in patients with ACAS and this will be tested through a prospective observational multicentre clinical trial performed in six major European vascular surgery centres.

Methods And Analysis: The risk stratification model will compromise clinical, circulating, plaque and imaging biomarkers. The prospective multicentre observational study will include 300 patients with 50%-99% ACAS. The primary endpoint is the three-year incidence of cerebrovascular complications. Biomarkers will be retrieved from plasma samples, brain MRI, carotid MRA and duplex ultrasound. The TAXINOMISIS Project will serve as a platform for the development of new computer tools that assess plaque progression based on radiology images and a lab-on-chip with genetic variants that could predict medication response in individual patients.

Conclusion: Results from the TAXINOMISIS study could potentially improve future risk stratification in patients with ACAS to assist personalized evidence-based treatment decision-making.
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http://dx.doi.org/10.1111/eci.13411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757200PMC
December 2020

Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD.

J Card Surg 2020 Dec 16;35(12):3467-3473. Epub 2020 Sep 16.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Background: Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data.

Methods: Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am.

Results: Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference.

Conclusions: A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.
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http://dx.doi.org/10.1111/jocs.15017DOI Listing
December 2020

Early Outcomes in the ROADSTER 2 Study of Transcarotid Artery Revascularization in Patients With Significant Carotid Artery Disease.

Stroke 2020 09 19;51(9):2620-2629. Epub 2020 Aug 19.

St. Luke's University Hospital, Bethlehem, PA (T.O.).

Background And Purpose: Transcarotid artery revascularization (TCAR) is comprised of carotid artery stent placement with cerebral protection via proximal carotid artery clamping and reversal of cerebral arterial flow. The aim of the present study was to evaluate the safety and efficacy of TCAR performed by a broad group of physicians with variable TCAR experience.

Methods: The ROADSTER 2 study is a prospective, open label, single arm, multicenter, postapproval registry for patients undergoing TCAR. Patients considered at high risk for complications from carotid endarterectomy with symptomatic stenosis ≥50% or asymptomatic stenosis ≥80% were included. The primary end point was procedural success, which encompassed technical success plus the absence of stroke, myocardial infarction, or death within the 30-day postoperative period. Secondary end points included technical success and individual/composite rates of stroke, death, and myocardial infarction (MI). All patients underwent independent neurological assessments before the procedure, within 24 hours, and at 30 days after TCAR. An independent clinical events committee adjudicated all major adverse events.

Results: Between 2015 and 2019, 692 patients (Intent to Treat Population) were enrolled at 43 sites. Sixty cases had major protocol violations, leaving 632 patients adhering to the Food and Drug Administration-approved protocol (per-protocol population). The majority (81.2%) of operators were TCAR naïve before study initiation. Patients underwent TCAR for neurological symptoms in 26% of cases, and all patients had high-risk factors for carotid endarterectomy (anatomic-related 44%; physiological 32%; both 24%). Technical success occurred in 99.7% of all cases. The primary end point of procedural success rate in the Intent to Treat population was 96.5% (per-protocol 97.9%). The early postoperative outcomes in the Intent to Treat population included stroke in 13 patients (1.9%), death in 3 patients (0.4%), and MI in 6 patients (0.9%). The composite 30-day stroke/death rate was 2.3%, and stroke/death/MI rate was 3.2%. In the per-protocol population, there were strokes in 4 patients (0.6%), death in one patient (0.2%), and MI in 6 patients (0.9%) leading to a composite 30-day stroke/death rate of 0.8% and stroke/death/MI rate of 1.7%.

Conclusions: TCAR results in excellent early outcomes with high technical success combined with low rates of postprocedure stroke and death. These results were achieved by a majority of operators new to this technology at the start of the trial. Adherence to the study protocol and peri-procedural antiplatelet therapy optimizes outcomes. Longer-term follow-up data are needed to confirm these early outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02536378.
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http://dx.doi.org/10.1161/STROKEAHA.120.030550DOI Listing
September 2020

creening ardiovascular patients for aortic eurysms (SCAN) - high prevalence of abdominal aortic aneurysms in coronary heart disease patients requiring intervention.

Vasa 2020 Aug 7;49(5):375-381. Epub 2020 Jul 7.

Munich Aortic Center (MAC), Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany.

: Since the prevalence of abdominal aortic aneurysms (AAA) in Europe has declined to about 2.5%, general screening programs of elderly men are being called into question. On the other hand, other vascular diseases (e.g. coronary heart disease, CHD) are associated with a higher prevalence of AAA. This might have an impact on future targeted AAA screening programs. This study aimed to reevaluate the current prevalence of AAA in male patients with CHD, in order to assess whether CHD patients should be offered a targeted AAA ultrasound screening program. : The SCAN (Screening Cardiovascular Patients for Aortic Aneurysms) study prospectively evaluated the AAA prevalence in 1000 consecutive male CHD patients (70.1 ± 11.2 years) requiring any coronary intervention at an university hospital. All patients received transverse and longitudinal ultrasound scans of the abdominal aorta. Aortic diameter was assessed using the outer-to-outer measurement-technique. Primary endpoint was the prevalence of AAA. Secondary outcomes included stratification in 1-, 2-, or 3-vessel CHD. : AAA was detected in 85 patients (median diameter 38 mm, range 30-80 mm), corresponding to an overall prevalence of 8.5%. AAA prevalence was significantly associated with CHD severity: 5.6% in 1-vessel, 7.1% in 2-vessel, and 10.8% in 3-vessel CHD  = 0.037). The multivariable analysis showed, that age per 10 years increase (OR 1.5, 95% CI 1.2-1.9,  = 0.001) and hyperlipidemia (OR 2.2, 95% CI 1.3-3.8,  = 0.003) were significantly associated with an AAA. The likelihood to be diagnosed with an AAA was significantly lower in non-smokers (OR 0.24, 95% CI, P < 0.001). : This study confirms that CHD requiring any type of coronary intervention is strongly associated with AAA in male patients. AAA prevalence increases with CHD severity. Since the AAA prevalence is still significantly higher than in the general population, targeted ultrasound screening should be considered for all CHD patients.
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http://dx.doi.org/10.1024/0301-1526/a000881DOI Listing
August 2020

Prevention and Treatment of Ruptured Abdominal Aortic Aneurysms.

Angiology 2020 08 13;71(7):586-588. Epub 2020 May 13.

Divisions of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA.

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http://dx.doi.org/10.1177/0003319720923808DOI Listing
August 2020

Early and Midterm Outcomes of Open and Endovascular Revascularization of Chronic Mesenteric Ischemia.

World J Surg 2020 08;44(8):2804-2812

Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University of Munich, Munich, Germany.

Background: Revascularization strategies for chronic mesenteric ischemia (CMI) include open (OR) and endovascular (ER) modalities. The primary objective of this study was to analyze the safety and effectiveness of OR and ER and the impact of clinical and morphological variables on early and midterm outcomes in a consecutive series of CMI patients in a tertiary referral center.

Patients And Methods: From 2004 to 2017, all CMI patients treated with OR and ER were retrospectively identified. Patient records, preoperative imaging, as well as peri- and postoperative outcomes were analyzed. Univariable and multivariable analysis was performed to identify clinical or morphological variables affecting reintervention rates within 2 years.

Results: In total, 63 patients (33% male; mean age 71, range 60-76 years) were treated by ER (41 patients) or OR (22 patients) for CMI. Mean follow-up was 26 (10-71) months. 30-day mortality was 0.0% after ER and 4.5% after OR (p = 0.069); 30-day morbidity was 9.8% vs. 31.8%, respectively (p = 0.030). Length of stay was significantly longer after OR (14 vs. 4 days; p < 0.001). Freedom from reintervention rate after 2 years was 82% after OR and 73% after ER (p = 0.14). Overall survival did not differ after 2 years (OR 85% vs. ER 86%; p = 0.35). Multivariable analysis revealed that smoking was associated with higher risk of reintervention (hazard ratio, HR: 4.14; 95% confidence interval, CI 1.11-15.53; p = 0.03). Additionally, a nonsignificant trend of lower reintervention rates after OR was detected (HR 0.23 95% CI 0.05-1.08; p = 0.06).

Conclusion: Due to a lower invasiveness, despite the higher reintervention rate, an "endovascular first" strategy is justified and recommended.
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http://dx.doi.org/10.1007/s00268-020-05513-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326829PMC
August 2020

Distal Stent Graft-Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC.

Ann Thorac Surg 2020 11 10;110(5):1494-1500. Epub 2020 Apr 10.

Department of Cardiovascular Surgery, University Heart Centre Freiburg, Bad Krozingen, Germany.

Background: The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms.

Methods: In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison.

Results: The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE.

Conclusions: dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.079DOI Listing
November 2020

Prospective Comparison of Duplex Ultrasound and Angiography for Intra-operative Completion Studies after Carotid Endarterectomy.

Eur J Vasc Endovasc Surg 2020 Jun 17;59(6):881-889. Epub 2020 Mar 17.

Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. Electronic address:

Objective: The application of intra-operative completion studies may have contributed to the ongoing improvement of peri-operative outcomes in carotid surgery.

Methods: This prospective study aimed to compare angiography and duplex ultrasound (IDUS) as intra-operative completion studies after carotid endarterectomy (CEA) with respect to differences in the rating of vessel wall defects and interobserver reliability. Patients undergoing CEA for symptomatic or asymptomatic carotid stenosis were included. After CEA, angiography and IDUS were performed. Intra-operatively obtained video footage was evaluated at a later date by three independent and blinded raters with different levels of clinical experience. Rating was done according to a four step rating scale, with higher grades representing more severe defects. Standard statistical methods (Pearson's chi square test; permutation test; Wilcoxon signed rank test; Kendall's coefficient of concordance, Wt) were applied.

Results: In total, 150 patients (mean ± standard deviation age 72 ± 7 years, 68.7% male, 33.3% symptomatic) were enrolled between March 2016 and September 2017. Significantly more defects requiring intra-operative revision (grades 3 and 4 on rating scale) were detected by IDUS, which, in part, remained undetected by angiography: 22 (14.7%) vs. 10 (6.7%) (p = .040). Defects were also judged to be more severe with IDUS than with angiography: median rating grade 1: 74 (49.3%) vs. 102 (68.0%); grade 2: 54 (36.0%) vs. 38 (25.3%); grade 3: 21 (14.0%) vs. 9 (6.0%); grade 4: 1 (0.7%) vs.1 (0.7%) (p < .001). Furthermore, Wt was significantly higher for IDUS compared with angiography (0.70 vs. 0.57; p = .003).

Conclusion: IDUS revealed more defects after CEA than angiography. Despite both techniques only showing moderate interobserver reliability, IDUS is less dependent on the surgeon's subjectivity than angiography. Taking into account the absence of procedure associated risks (i.e., adverse effects of iodinated contrast media and Xray), IDUS could be considered as an alternative intra-operative morphological assessment tool in carotid surgery.
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http://dx.doi.org/10.1016/j.ejvs.2020.02.017DOI Listing
June 2020

Effect Modification of Sex and Age for the Hospital Volume-Outcome Relationship in Abdominal Aortic Aneurysm Treatment: Secondary Data Analysis of the Nationwide German Diagnosis Related Groups Statistics From 2005 to 2014.

J Am Heart Assoc 2020 03 14;9(6):e014534. Epub 2020 Mar 14.

Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany.

Background Trials and registries associated female sex and high age with unfavorable outcomes in abdominal aortic aneurysm treatment. Many studies showed an inverse correlation between annual hospital volume and in-hospital mortality. The volume-outcome relationship has not been investigated separately for women and men or across the age range. The aim was to analyze whether sex and age are effect modifiers or confounders of the volume-outcome association. Methods and Results In a nationwide setting, all in-hospital cases from 2005 to 2014 with a diagnosis of intact abdominal aortic aneurysm and procedure codes for endovascular or open aortic repair were included. Primary outcome was in-hospital mortality. Using a multilevel multivariable regression model, hospital volume was modeled as a continuous variable. Separate analyses were performed for women and men and for predefined age groups. A total of 94 966 cases were included (12% women; median age, 72 years). Mortality was 4.9% in women and 3.0% in men (3.2% overall). Mortality increased with age. Although there was no significant volume-outcome association in women (=0.57), there was in men (=0.02). The strongest volume-outcome association was found in younger men. The younger female subpopulation was found to show a trend for an inverse volume-outcome relationship, whereas an opposite association was found for the women aged >79 years. Conclusions Women have a higher mortality risk after elective abdominal aortic aneurysm treatment. Sex and age are modifiers of the volume-outcome relationship. Unlike in male patients, in women there is no consistent effect of hospital volume on outcome.
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http://dx.doi.org/10.1161/JAHA.119.014534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335519PMC
March 2020

Multispectral optoacoustic tomography of muscle perfusion and oxygenation under arterial and venous occlusion: A human pilot study.

J Biophotonics 2020 06 25;13(6):e201960169. Epub 2020 Mar 25.

Chair for Biological Imaging, Center for Translational Cancer Research (TranslaTUM), Technical University of Munich, Munich, Germany.

Perfusion and oxygenation are critical parameters of muscle metabolism in health and disease. They have been both the target of many studies, in particular using near-infrared spectroscopy (NIRS). However, difficulties with quantifying NIRS signals have limited a wide dissemination of the method to the clinics. Our aim was to investigate whether clinical multispectral optoacoustic tomography (MSOT) could enable the label-free imaging of muscle perfusion and oxygenation under clinically relevant challenges: the arterial and venous occlusion. We employed a hybrid clinical MSOT/ultrasound system equipped with a hand-held scanning probe to visualize hemodynamic and oxygenation changes in skeletal muscle under arterial and venous occlusions. Four (N = 4) healthy volunteers were scanned over the forearm for both 3-minute occlusion challenges. MSOT-recorded pathophysiologically expected results during tests of disturbed blood flow with high resolution and without the need for contrast agents. During arterial occlusion, MSOT-extracted Hb-values showed an increase, while HbO - and total blood volume (TBV)-values remained roughly steady, followed by a discrete increase during the hyperemic period after cuff deflation. During venous occlusion, results showed a clear increase in intramuscular HbO , Hb and TBV within the segmented muscle area. MSOT was found to be capable of label-free non-invasive imaging of muscle hemodynamics and oxygenation under arterial and venous occlusion. We introduce herein MSOT as a novel modality for the assessment of vascular disorders characterized by disturbed blood flow, such as acute limb ischemia and venous thrombosis.
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http://dx.doi.org/10.1002/jbio.201960169DOI Listing
June 2020

Management of Mycotic Aortic Aneurysms: Work in Progress.

Angiology 2020 09 13;71(8):765-766. Epub 2020 Feb 13.

Department for Vascular and Endovascular Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.

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http://dx.doi.org/10.1177/0003319720904508DOI Listing
September 2020

Response to "Re. Proposed NICE Abdominal Aortic Aneurysm Repair Guidelines: Swinging the Pendulum too Far?"

Eur J Vasc Endovasc Surg 2020 04 31;59(4):678. Epub 2020 Jan 31.

Athens Medical Centre, Vascular & Endovascular Surgery Clinic, 56, Kifissias Ave & Delfon Str., Athens, 15125, Greece.

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http://dx.doi.org/10.1016/j.ejvs.2020.01.004DOI Listing
April 2020

ZILVERPASS Study: ZILVER PTX Stent vs Bypass Surgery in Femoropopliteal Lesions.

J Endovasc Ther 2020 04 30;27(2):287-295. Epub 2020 Jan 30.

Flanders Medical Research Program, Dendermonde, Belgium.

To report the 12-month results of a multicenter, prospective, randomized controlled trial to determine if the ZILVER PTX paclitaxel-eluting stent was noninferior in terms of safety and efficacy compared with surgical bypass. This is a study in symptomatic TransAtlantic Inter-Society Consensus (TASC) C and D femoropopliteal lesions comparing endovascular ZILVER PTX stenting vs surgical bypass surgery using a prosthetic graft ( identifier NCT01952457). Between October 2013 and July 2017, 220 patients (mean age 68.6±10.5 years; 159 men) were enrolled and randomized to the ZILVER PTX treatment group (113, 51.4%) or the bypass treatment group (107, 48.6%). Most of the lesions were occlusions (208, 94.5%); the mean lesion length was 247.1±69.3 mm. The primary outcome measure was primary patency at 12 months, defined as no evidence of binary restenosis or occlusion within the target lesion or bypass graft based on a duplex-derived peak systolic velocity ratio <2.4 and no clinically-driven target lesion revascularization (TLR) in endovascular cases or reintervention to restore flow in the bypass. The estimated 12-month primary patency rate was 74.5% (95% CI 66.3% to 82.7%) for the ZILVER PTX group vs 72.5% (95% CI 63.7% to 81.3%) for the bypass arm (p=0.998). Freedom from TLR at 12 months was 80.9% (95% CI 73.3% to 88.5%) for the ZILVER PTX group vs 76.2% (95% CI 68.0% to 84.4%) for the bypass group (p=0.471). The 30-day complication rate was significantly lower in the ZILVER PTX group (4.4% vs 11.3%, p=0.004). Also, procedure time and hospital stay were significantly shorter in the ZILVER PTX group (p<0.001 for both). With noninferior patency results, a lower complication rate, and shorter procedures and hospital stays, paclitaxel-eluting stenting might become a recommended treatment for long TASC C and D femoropopliteal lesions.
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http://dx.doi.org/10.1177/1526602820902014DOI Listing
April 2020

Involvement of Myeloid Cells and Noncoding RNA in Abdominal Aortic Aneurysm Disease.

Antioxid Redox Signal 2020 09 16;33(9):602-620. Epub 2020 Apr 16.

Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.

Abdominal aortic aneurysm (AAA) is a potentially fatal condition, featuring the possibility of high-mortality rupture. To date, prophylactic surgery by means of open surgical repair or endovascular aortic repair at specific thresholds is considered standard therapy. Both surgical options hold different risk profiles of short- and long-term morbidity and mortality. Targeting early stages of AAA development to decelerate disease progression is desirable. Understanding the pathomechanisms that initiate formation, maintain growth, and promote rupture of AAA is crucial to developing new medical therapeutic options. Inflammatory cells, in particular macrophages, have been investigated for their contribution to AAA disease for decades, whereas evidence on lymphocytes, mast cells, and neutrophils is sparse. Recently, there has been increasing interest in noncoding RNAs (ncRNAs) and their involvement in disease development, including AAA. The current evidence on myeloid cells and ncRNAs in AAA largely originates from small animal models, making clinical extrapolation difficult. Although it is feasible to collect surgical human AAA samples, these tissues reflect end-stage disease, preventing examination of critical mechanisms behind early AAA formation. Gaining more insight into how myeloid cells and ncRNAs contribute to AAA disease, particularly in early stages, might suggest nonsurgical AAA treatment options. The utilization of large animal models might be helpful in this context to help bridge translational results to humans.
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http://dx.doi.org/10.1089/ars.2020.8035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7455479PMC
September 2020

Rationale for screening selected patients for asymptomatic carotid artery stenosis.

Curr Med Res Opin 2020 03 13;36(3):361-365. Epub 2020 Jan 13.

Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Canada.

Stroke is a leading cause of death and disability worldwide. Approximately 15% of all first-ever strokes occur due to atheroembolism from a previously undetected/untreated asymptomatic carotid stenosis (ACS). Despite that, international guidelines do not recommend screening for ACS. The rationale for not recommending screening include: (a) the harm associated with screening, (b) the questionable clinical benefit associated with surgery, (c) the lack of proven reduction in the risk of stroke, (d) the large number of false positive/false negative tests, and (e) the cost-effectiveness of such screening programs. A critical analysis of each of these arguments is presented. Patients with ACS have a very high risk of all-cause and cardiac mortality. Detection of ACS should not be viewed as an indication for surgery, but rather as an opportunity to implement best medical treatment (BMT) and lifestyle changes to prevent not only strokes, but also cardiac events. The implementation of screening programs for abdominal aortic aneurysms (AAAs) has led to a considerable reduction in the number of ruptured AAAs and AAA-related deaths. Similarly, screening high-risk individuals for ACS would enable timely identification of patients with ACS and implementation of BMT and lifestyle measures to prevent future strokes and cardiac events.
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http://dx.doi.org/10.1080/03007995.2020.1713075DOI Listing
March 2020

Linking obesity with abdominal aortic aneurysm development.

Eur Heart J 2020 07;41(26):2469-2471

Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University Munich, Germany.

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http://dx.doi.org/10.1093/eurheartj/ehz882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340355PMC
July 2020