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Rom J Morphol Embryol
Rom J Morphol Embryol
RJME
Romanian Journal of Morphology and Embryology
1220-0522
2066-8279
Academy of Medical Sciences, Romanian Academy Publishing House, Bucharest

39020539
650224251256
10.47162/RJME.65.2.11
Original Paper
Aortic aneurysms in patients with atherosclerotic coronary artery disease in the southwestern region of Romania – clinical and histopathological study
Brie Diduţa Alina 12
Jianu Adelina Maria 3
Popescu Roxana 12
Cerbulescu Teodor 12
Dema Sorin 4
Brie Daniel Miron 5
Borugă Veronica Mădălina 6
1 Department of Cell and Molecular Biology, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
2 ANAPATMOL Research Center, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
3 Department of Anatomy and Embryology, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
4 Department of Radiotherapy, Emergency City Hospital, Timişoara, Romania
5 Department of Interventional Cardiology, Institute of Cardiovascular Diseases Timişoara, Romania
6 Department of Toxicology and Drug Industry, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
Corresponding Author: Daniel Miron Brie, MD, PhD Department of Interventional Cardiology Cardiovascular Disease Institute Timişoara 13A Gheorghe Adam Street 300310 Timişoara Romania + 40747–392 680 brie_daniel@yahoo.com
Apr-Jun 2024
30 6 2024
65 2 251256
07 4 2024
14 7 2024
Copyright © 2024, Academy of Medical Sciences, Romanian Academy Publishing House, Bucharest
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open-access article distributed under the terms of a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Public License, which permits unrestricted use, adaptation, distribution and reproduction in any medium, non-commercially, provided the new creations are licensed under identical terms as the original work and the original work is properly cited.
An aneurysm is defined as a dilation of the arterial wall with a diameter exceeding 1.5 times the normal diameter of the vessel concerned. Aortic aneurysms (AAs) can develop at any level but are mostly found at the abdominal and infrarenal levels and extend to the iliac arteries. AAs are usually asymptomatic and are most often discovered incidentally during various imaging investigations for other conditions. Rupture of an AA is usually dramatic, being one of the causes of sudden cardiac death. Surgical treatment and, more recently, endovascular treatment are the only effective methods of AA repair. In this study, we screened for the diagnosis of AAs in patients with stable exertional angina who had indications for coronary angiography. The study was carried out in the period 2021–2023 in the Institute of Cardiovascular Diseases Timişoara, Romania. Of the 2458 patients with exertional angina who required coronary angiography, a number of 1844 (75%) patients had at least one stenotic atheromatous plaque, and of these 312 patients had AAs, of which 173 at the level of the abdominal aorta.

aortic aneurysms
dilatation
endovascular treatment
rupture of aortic aneurysm
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pmcIntroduction

An aneurysm is defined as the dilatation of the arterial wall with a diameter exceeding 1.5 times the standard diameter. Aortic aneurysms (AAs) can develop at any level but are mostly found at the abdominal and infrarenal levels and extend to the iliac arteries [1]. A diameter greater than 3 cm in the abdominal aorta is defined as an abdominal aortic aneurysm (AAA) [2]. A thoracic aortic aneurysm (TAA) is a dilatation of at least 50% of the expected size that includes all three layers of the wall structure [3]. AAs are usually asymptomatic and are discovered during various imaging investigations for other conditions [4, 5, 6]. Aneurysm rupture is usually dramatic, being one of the causes of sudden cardiac death [6, 7, 8]. Thus, screening for early detection before rupture or other complications is crucial [2, 9, 10]. Preventive treatment for aneurysms involves appropriate screening for diagnosis, follow-up imaging, and surgical repair or endovascular repair (ER) when indicated. Drug treatment of aneurysms is not effective in stopping their progression [11, 12]. Surgical treatment and, more recently, endovascular treatment are the only effective methods of aneurysm repair [12, 13].

Endovascular treatment is a modern, less invasive method for treating thoracic and abdominal aneurysms. The anatomy of the aneurysm plays a very important role in the success of ER procedures. Thus, an appropriate selection based on aneurysm anatomy is essential before surgery [14].

Aim

The aim of paper was the identification of favorable anatomy for ER of AAA and TAA in patients with AAA and/or TAA and coronary artery disease (CAD) [coronary atherosclerosis (ATS) >50% on at least one large epicardial artery] from the southwestern (SW) region of Romania.

Patients, Materials and Methods

In this study, we performed screening for the diagnosis of thoracic and/or abdominal aneurysms in patients with stable exertional angina pectoris (AP) and present cardiovascular risk (CVR) factors who had indications for coronary angiography. The study was carried out between the years 2021–2023 in the Institute of Cardiovascular Diseases Timişoara, Romania, with doctors from the Clinic of Cardiology and the Department of Interventional Cardiology.

In order to publish the results of the study, we obtained the Approval of the Ethics Committee from the Institute of Cardiovascular Diseases Timişoara.

All patients were asymptomatic in terms of AA, having exertional AP. Once coronary angiography was performed, patients who had coronary ATS >50% on at least one large epicardial coronary vessel, also did a peripheral aortography performed to diagnose AAs (thoracic, thoracoabdominal, or abdominal). Patients who had thoracic aortic dilatation (TAD) >4.5 cm or abdominal aortic dilatation >4 cm had a computed tomography angiography (CTA) of the thorax and/or abdomen performed for better assessment of the aneurysm. A diameter greater than 5 cm was evaluated for ER. The anatomy of aneurysms >5 cm was compared with the standard instructions for use (IFU) recommended for most endovascular prosthesis manufacturers and the extended IFU. The standard IFU was an aortic neck length ≥15 mm, suprarenal angulation ≤45°, infrarenal angulation ≤60°, and a neck diameter between 8 and 32 mm.

Extended IFU were aortic neck length ≥10 mm, suprarenal angulation ≤60°, infrarenal angulation ≤75°, and a neck diameter between 7–32 mm. The anatomy of the iliac arteries was also assessed regarding a concurrent aneurysm at this level, landing zones of at least 10 mm, and a minimum iliac artery diameter of at least 8 mm (extended IFU ≥7 mm).

Statistical analysis

Statistical analysis was performed using IBM Statistical Package for Social Sciences (SPSS) version 25.0 for Windows. For continuous variables, data are presented as mean ± standard deviation (SD). For those with normal distribution, t-test was used for continuous variables, and χ2 (chi-squared) or Fischer’s exact tests for categorical variables (if the sample was small). Statistical significance was reached at a value of p<0.05.

Histopathological assessment

Patients with atherosclerotic coronary disease and AA, who died or were repaired with classical surgery during the three years of the study, were carefully macroscopically examined. Tissue fragments were collected from the wall of the arterial aneurysm, which were fixed in a 10% neutral buffered formalin solution and included in histological paraffin, according to the histopathological (HP) tissue processing protocol. Using the rotary microtome, 4–5 μm thick sections were obtained, which were stained with Hematoxylin–Eosin (HE), Goldner–Szekely (GS) trichrome, and Orcein.

Results

After performing coronary angiography on 2458 patients with exertional AP addressed to Institute of Cardiovascular Diseases Timişoara, we found that 1844 (75%) patients had at least one >50% stenotic atheromatous plaque in the coronary arteries [n=686 (37%) with single-vessel CAD, n=623 (34%) with bivascular CAD, n=535 (29%) with triple-vessel CAD].

The prevalence of AA in patients with significant coronary ATS was 17.4% (n=312). Most of them were AAAs (n=173, 9.4%), followed by TADs (n=88, 4.8%), TAAs (n=38, 2.1%), and thoracoabdominal aneurysms (TAAAs, n=13, 0.7%). Out of the AAAs, 59 (34.1%) patients had a diameter between 3.0–3.9 cm, 60 (34.6%) patients had a diameter between 4.0–4.9 mm and 54 (31%) patients had a diameter >5.0 mm.

In our study, 2.4% of patients (n=1 with AAA, n=1 with TAA, n=2 with TAAA) refused CTA of the aorta. Thus, CTA was performed on 213 patients (164 with AAA, 37 with TAA, and 13 with TAAA).

In the anatomical analysis, which aimed to identify the favorable anatomy of aneurysms for ER, TAAAs were also excluded, and only AAAs and TAAs with diameter greater than 5 cm were considered for potential ER.

AAAs with diameters >5 cm were identified in 54 (2.92%) patients, and TAAs with diameters >5.5 cm in five (0.27%) patients.

Due to the small number of TAAs >5.5 cm in patients with CAD (n=5 in our study, but with an increased prevalence in the general population – 0.27 per 100 patients vs 5 per 100 000 patients), these were not included in the anatomical statistical analysis. The choice of treatment (surgical or endovascular) was determined on a case-by-case basis.

The mean age of patients with AAAs >5 cm was 67.3±6.2 years, and 80.7% (n=42) were males. At the initial evaluation, after using the standard criteria, only 19 (36.5%) patients had favorable anatomy for ER, increasing to 55.7% (n=29) after applying the extended criteria. In patients without favorable anatomy for ER, the majority had short aortic neck (60%), followed by a wide neck diameter (25%), a greater infrarenal angle (10%), and inadequate iliac artery diameter (5%). Aortic or iliac artery tortuosity assessed by the tortuosity index was not significant.

The anatomical characteristics of patients with AAAs >5 cm is described in Table 1.

Table 1 Anatomical characteristics in AAAs >5 cm

	Mean ± SD

	Male (mean ± SD)

	Female (mean ± SD)

	p -value

	
Diameter of AAA [mm]

	63.5±12.7

	65.7±14.2

	64.6±11.2

	NS

	
Neck diameter [mm]

	25.4±5.8

	26.7±6.2

	20.2±5.4

	NS

	
Neck length [mm]

	21.4±12.5

	22.5±13.9

	18.2.4±12.7

	<0.05

	
Suprarenal angulation [°]

	26.2±22.3

	25.3±21.7

	29.8±4.6

	NS

	
Infrarenal angulation [°]

	47.4±23.1

	42.5±24.5

	59.4±4.8

	<0.05

	
Small iliac diameter [mm]

	7.8±1.9

	8.3±1.8

	5.4±1.2

	<0.05

	
AAA: Abdominal aortic aneurysm; NS: Not significant; SD: Standard deviation

Females were older than males (74.6±11.2 vs 65.7±14.2 years, p<0.01), with a smaller neck length (18.2.4±12.7 vs 22.5±13.9 mm, p<0.05), larger infrarenal angle (59.4±4.8 vs 42.5±24.5°, p<0.05) and smaller iliac artery diameter (5.4±1.2 vs 8.3±1.8 mm, p<0.05). These anatomical differences might explain why women have a less favorable anatomy for the ER compared to men (for standard criteria IFU 21% vs 37%, p<0.001, and for extended criteria IFU 28% vs 55%, p<0.001).

The HP examination showed an uneven thickening of the arterial wall, by increasing the amount of collagen fibers, mainly at the level of the internal and middle tunics.

Thus, at the level of the internal tunic, especially in the subintimal area, thick collagen fibers were identified, organized in bundles, with an orderly arrangement, in the long axis of the aorta (Figure 1). The limit between the internal tunic and the middle tunic, respectively “the internal elastic limit” was invaded and disorganized by the increase in the amount of fibrillar collagen (Figure 2). This increase in the amount of collagen may be an adaptive process and was accompanied by an increase in the number of fibroblasts, the main cells that are responsible for the modification of the connective matrix. In the middle tunic, the elastic fibers were quantitatively reduced by increasing the amount of collagen, the elastic lamellae appeared thinned and sometimes disorganized (Figure 3).

Figure 1 Thick collagen fibers, organized into bundles. Goldner–Szekely (GS) trichrome staining, ×100.

Figure 2 Intense development of collagen fibers at the level of the inner and middle tunics, with the disorganization of the “internal elastic limit”. Orcein staining, ×200

Figure 3 Medium tunic with few elastic fibers, with thinned and disorganized elastic lamellae. Orcein staining, ×100

In the wall of some aneurysms, deposits of calcium salts have been identified in the form of punctate calcifications or extended calcifications in the form of plaques, often broken (Figures 4, 5).

Figure 4 Aneurysm area with “punctate calcifications”. Hematoxylin–Eosin (HE) staining, ×200

Figure 5 Extensive parietal calcification in the form of a broken calcareous plaque. HE staining, ×200

At the periphery of the tunica media and in the tunica externa in some aneurysms, microhemorrhage areas were identified (Figures 6, 7), excessive deposits of amorphous matrix (Figure 8) or inflammatory infiltrates formed mainly by lymphocytes (Figure 9).

Figure 6 Microhemorrhage in the middle tunic. GS trichrome staining, ×200

Figure 7 Diffuse and extensive hemorrhage in the tunica externa. GS trichrome staining, ×100

Figure 8 Aneurysm area with deposition of amorphous material, infiltrated with inflammatory cells. HE staining, ×100

Figure 9 Aneurysm wall infiltrated with inflammatory cells. HE staining, ×200

Discussions

Our study included patients with AP and CVR factors who were indicated coronary angiography. None of the patients included had previously experienced symptoms suggestive of AA. Patients with already known AA were excluded from this study. The prevalence of AA was 17.4%, and most of them were AAAs (n=173, 9.4%), TADs (n=88, 4.8%), TAAs (n=38, 2.1%), and TAAAs (n=13, 0.7%). Most AAAs had a diameter between 3–4.9 cm (n=119, 6.45%), and these patients were introduced into a surveillance program according to the American College of Cardiology (ACC) 2022 guidelines recommendations [15]. The same screening protocol was applied for TAAs and TAAAs with a diameter less than 5.5 cm. Upon initial inspection, the number of AAAs larger than 5 cm seems small, but the prevalence in our group (with high and very high CVR) was 2.81%, much higher than in the general population (0.6%) [16].

AAAs with a diameter >5 cm have an increased risk of rupture [17], which correlates with a higher mortality [18]. Thus, in selected cases, rupture prevention by aneurysm repair is mandatory (surgical or endovascular). In the short term, ER has certain advantages over surgery [19]: lower intra- and perioperative mortality [20, 21], a faster recovery time [22], and a lower risk of infection [23]). However, the use of this technique is dependent on a favorable anatomy to increase the procedural success rate [24].

In this study, we identified the anatomical characteristics of a selected population with high and very high CVR (CAD patients with >50% atherosclerotic lesions in at least one large epicardial coronary vessel). The number of studies assessing favorable AAA anatomy for ER based on the standard criteria is limited. To our knowledge, this current study would be the first to evaluate the anatomy of patients with CAD and AAA >5 cm. In this high CVR population, the favorable anatomy for ER initially had a low prevalence (37.5%) when standard IFU criteria were used. However, this improved to 56% when extended IFU criteria were used.

The results of our study were like those of a recent meta-analysis by Ulug et al. that reported a prevalence between 46–64% for men and between 25–47% for women [25]. The difference could be explained by the fact that this meta-analysis also included studies with AAAs >4 cm (we included AAAs >5 cm). At smaller AAAs sizes, the percentage of aneurysms suitable for ER using standard IFU criteria increases. Like our study, the primary anatomical obstacle, especially in women, was the length of the aneurysmal neck, followed in their case by the infrarenal angle, while in our study, the second cause was an increased aneurysmal neck width.

A study conducted in Korea considered only the aneurysmal neck anatomy as a criterion for ER. However, this criterion corresponded to only 32% of AAA patients suited for ER. The most encountered anatomical incompatibility in this study is the increased value of the infrarenal angle, while in our study a shorter aneurysmal neck [26]. In their study, women and those with ruptured aneurysms are most likely not to meet the standard IFU criteria for ER. We did not include patients with ruptured AAAs in our analysis.

Another study by Panthofer et al. reported an 85% eligibility rate (lower in women than men) for ER in patients with AAA (diameters ranging from 3.5–5 cm) that is maintained even two years after the diagnosis [27]. This again shows that smaller AAA sizes increase anatomic eligibility for ER. A possible explanation for the higher percentage of eligible patients (leaving aside the small size) would be the broad spectrum of endovascular prostheses included in the study. Some indicated in anatomies with short AAA necks, even less than 10 mm.

A study evaluating only two endovascular stent graft prostheses concluded that most patients with an AAAs >5 cm do not have a favorable anatomy for ER when using the standard IFU anatomical criteria. The main anatomical problem of incompatibility would be the AAA neck, especially its large diameter and short length. New generations of endovascular prostheses for AAA repair have tried to take these issues into account by improving anatomical compatibility.

The 2021 EXTREME study [28] included patients who would typically have been excluded using conventional anatomical selection criteria (90% had too short aneurysmal neck, and 10% had inadequate vascular access). The success rate of endovascular intervention was 98%, using a particular type of stent graft that provides a seal of the neck using a polymer [28]. Given that in our study, a short AAA neck was the leading cause of anatomical incompatibility, the use of this type of stent graft would increase the number of patients who would benefit from ER, improving anatomical eligibility.

Conversely, some studies have reported an increase in complications after ER when anatomical selection by standard IFU criteria is not followed [29, 30, 31].

Conclusions

In patients with atherosclerotic coronary disease from the SW region of Romania, the incidence of AAAs >5 cm is 2.8%, much higher than the general population. Of these, only 36.5% had favorable anatomy for ER when standard IFU criteria were used. This percentage increased to 55.7% when the extended IFU criteria were used. The main anatomical factors that do not favor endovascular intervention were a short aortic neck (60%), followed by a wide neck diameter (25%), a greater infrarenal angle (10%), and inadequate iliac artery diameter (5%).

Conflict of interests

The authors declare that they have no conflict of interests. All authors have read, reviewed, and agreed to the published version of the manuscript.

Availability of data and materials

All data and materials supporting the present study’s results are available on request from the corresponding author. The data are not publicly available to limit the amount of publicly available personal information, as classified by the European Union General Data Protection Regulation.

Ethics approval and consent to participate

The participant institutions granted the study ethical approval.

Patient consent for publication

Written informed consent was obtained from patients before enrollment.
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References

1 Clift PF Cervi E A review of thoracic aortic aneurysm disease Echo Res Pract 2019 7 1 R1 R10 32015897
2 Aggarwal S Qamar A Sharma V Sharma A Abdominal aortic aneurysm: a comprehensive review Exp Clin Cardiol 2011 16 1 11 15 21523201
3 Senser EM Misra S Henkin S Thoracic aortic aneurysm: a clinical review Cardiol Clin 2021 39 4 505 515 34686263
4 Tillman K Lee OD Whitty K Abdominal aortic aneurysm: an often asymptomatic and fatal men’s health issue Am J Mens Health 2013 7 2 163 168 23093077
5 Ahmed S Mitsky J Rawal U Sheth S Bronner J Asymptomatic abdominal aortic aneurysm: standardizing reporting recommendations at a large multistate radiology practice J Am Coll Radiol 2021 18 9 1317 1323 33984286
6 Barkhordarian M Tran HH Menon A Pulipaka SP Aguilar IK Fuertes A Dey S Chacko AA Sethi T Bangolo A Weissman S Innovation in pathogenesis and management of aortic aneurysm World J Exp Med 2024 14 2 91408 91408 38948412
7 Koba A Yamagishi K Sairenchi T Noda H Irie F Takizawa N Tomizawa T Iso H Ota H Risk factors for mortality from aortic aneurysm and dissection: results from a 26-year follow-up of a community-based population J Am Heart Assoc 2023 12 8 e027045 e027045 37042285
8 Guo MH Appoo JJ Saczkowski R Smith HN Ouzounian M Gregory AJ Herget EJ Boodhwani M Association of mortality and acute aortic events with ascending aortic aneurysm: a systematic review and meta-analysis JAMA Netw Open 2018 1 4 e181281 e181281 30646119
9 US Preventive Davidson KW Krist AH Barry MJ Cabana M Caughey AB Doubeni CA Epling JW Kubik M Landefeld CS Mangione CM Pbert L Silverstein M Simon MA Tseng CW Wong JB Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement JAMA 2019 322 22 2211 2218 31821437
10 Ying AJ Affan ET Abdominal aortic aneurysm screening: a systematic review and meta-analysis of efficacy and cost Ann Vasc Surg 2019 54 298 303 30081169
11 Pena RCF Hofmann Bowman Ahmad M Pham J Kline-Rogers E Case MJ Lee J Eagle K; An assessment of the current medical management of thoracic aortic disease: a patient-centered scoping literature review Semin Vasc Surg 2022 35 1 16 34 35501038
12 Golledge J Thanigaimani S Powell JT Tsao PS Pathogenesis and management of abdominal aortic aneurysm Eur Heart J 2023 44 29 2682 2697 37387260
13 Gao J Cao H Hu G Wu Y Xu Y Cui H Lu HS Zheng L The mechanism and therapy of aortic aneurysms Signal Transduct Target Ther 2023 8 1 55 55 36737432
14 Matsumoto T Anatomy and physiology for the abdominal aortic aneurysm repair Ann Vasc Dis 2019 12 3 329 333 31636742
15 Isselbacher EM Preventza O Hamilton Black Augoustides JG Beck AW Bolen MA Braverman AC Bray BE Brown-Zimmerman MM Chen EP Collins TJ DeAnda A Fanola CL Girardi LN Hicks CW Hui DS Schuyler Jones Kalahasti V Kim KM Milewicz DM Oderich GS Ogbechie L Promes SB Gyang Ross Schermerhorn ML Singleton Times Tseng EE Wang GJ Woo YJ; ACC/AHA Guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines Circulation 2022 146 24 e334 e482 36322642
16 Von Allmen Powell JT The management of ruptured abdominal aortic aneurysms: screening for abdominal aortic aneurysm and incidence of rupture J Cardiovasc Surg (Torino) 2012 53 1 69 76
17 Nevitt MP Ballard DJ Hallett JW Prognosis of abdominal aortic aneurysms. A population-based study N Engl J Med 1989 321 15 1009 1014 2674715
18 The UK Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms Lancet 1998 352 9141 1649 1655 9853436
19 Schermerhorn ML Buck DB O’Malley AJ Curran T McCallum JC Darling J Landon BE Long-term outcomes of abdominal aortic aneurysm in the Medicare population N Engl J Med 2015 373 4 328 338 26200979
20 United Kingdom Brown LC Powell JT Thompson SG Epstein D Sculpher MJ Endovascular versus open repair of abdominal aortic aneurysm N Engl J Med 2010 362 20 1863 1871 20382983
21 Greenhalgh RM Brown LC Kwong GPS Powell JT Thompson SG; Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial Lancet 2004 364 9437 843 848 15351191
22 Nedeau AE Pomposelli FB Hamdan AD Wyers MC Hsu R Sachs T Siracuse JJ Schermerhorn ML Endovascular vs open repair for ruptured abdominal aortic aneurysm J Vasc Surg 2012 56 1 15 20 22626871
23 Sicard GA Zwolak RM Sidawy AN White RA Siami FS; Endovascular abdominal aortic aneurysm repair: long-term outcome measures in patients at high-risk for open surgery J Vasc Surg 2006 44 2 229 236 16690242
24 Lederle FA Kyriakides TC Stroupe KT Freischlag JA Padberg FT Matsumura JS Huo Z Johnson GR; Open versus endovascular repair of abdominal aortic aneurysm N Engl J Med 2019 380 22 2126 2135 31141634
25 Ulug P Sweeting MJ von Allmen Thompson SG Powell JT; Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis Lancet 2017 389 10088 2482 2491 28455148
26 Hwang D Kim J Kim HK Huh S Suitability of the aortic neck anatomy for endovascular aneurysm repair in Korean patients with abdominal aortic aneurysm Vasc Specialist Int 2020 36 2 71 81 32611839
27 Panthofer AM Olson SL Rademacher BL Grudzinski JK Chaikof EL Matsumura JS; Anatomic eligibility for endovascular aneurysm repair preserved over 2 years of surveillance J Vasc Surg 2021 74 5 1527 1536 33957227
28 Sirignano P Mansour W Capoccia L Cuozzo S Camparini S de Donato Mangialardi N Ronchey S Talarico F Setacci C Speziale F; Endovascular aortic repair in patients with challenging anatomies: the EXTREME study EuroIntervention 2021 16 18 e1544 e1550 31793884
29 Matsumoto T Tanaka S Okadome J Kyuragi R Fukunaga R Kawakubo E Itoh H Okazaki J Shirabe K Fukuda A Maehara Y Midterm outcomes of endovascular repair for abdominal aortic aneurysms with the on-label use compared with the off-label use of an endoprosthesis Surg Today 2015 45 7 880 885 25030127
30 Schanzer A Greenberg RK Hevelone N Robinson WP Eslami MH Goldberg RJ Messina L Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair Circulation 2011 123 24 2848 2855 21478500
31 Aburahma AF Campbell JE Mousa AY Hass SM Stone PA Jain A Nanjundappa A Dean LS Keiffer T Habib J Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices J Vasc Surg 2011 54 1 13 21 21324631
