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Objectives: This study aimed to identify new predictors of sac behavior after endovascular aortic aneurysm repair (EVAR) and to investigate whether sac behavior is associated with long-term clinical outcomes., Methods: A total of 168 patients undergoing successful EVAR for abdominal aortic aneurysms with CTA follow-up of at least 1 year were included. Predictors of aneurysm sac behavior and its impact on long-term clinical outcomes were retrospectively analyzed., Results: According to sac behavior, eligible patients were stratified into the sac regression group (n = 79, 47.0%) and the sac non-regression group (n = 89, 53.0%). Patients in the regression group were younger (p = 0.036) and more likely to take sarpogrelate hydrochloride postoperatively (p = 0.011) than those in the non-regression group. The incidence of postimplantation syndrome (PIS) was significantly higher in the regression group (p = 0.005). On multivariate analysis, sac regression was more likely to occur in those with PIS (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.07-2.64; p = 0.023) and less likely to occur in those with transient type II endoleaks (HR, 0.43; 95% CI, 0.20-0.95; p = 0.037) and higher thrombus density within the sac on follow-up CTA (HR, 0.97; 95% CI, 0.95-0.99; p = 0.013). Non-regression of the sac was associated with significantly higher rates of re-intervention during the follow-up period (p = 0.001)., Conclusions: In addition to type II endoleaks, PIS and thrombus density are new predictors of aneurysm sac behavior, and sac regression is significantly associated with lower rates of re-intervention., Key Points: • After endovascular aortic aneurysm repair (EVAR), patients with sac regression were younger and more likely to take sarpogrelate hydrochloride postoperatively than those with sac non-regression. • The incidence of postimplantation syndrome (PIS) was significantly higher in patients with sac regression. • In our analysis, PIS and thrombus density within the sac were newly identified predictors of aneurysm sac behavior after EVAR.

This study is a prospective evaluation of the effectiveness of cardiac rehabilitation (CR) in terms of clinical outcomes for small abdominal aortic aneurysms (AAA) that were previously reported in a retrospective cohort study. We conducted a prospective non-randomized trial on patients with small AAA (N = 40; mean age 75.0 ± 6.6 years). Patients were enrolled into one of two groups, rehabilitation (CR) or non-rehabilitation (non-CR) group. Only CR group participated in a supervised-CR program including bicycle ergometer for 150 days. The AAA expansion rate and the risk of AAA repair were compared between two groups. We also researched the relationship between AAA expansion rate and body composition, blood IL-6 and TGFβ1 levels. The CR (N = 15) and non-CR groups (N = 25) were comparable in terms their baseline data. The CR group had a significantly smaller change in the maximal AAA size (- 1.3 ± 2.4 mm/years) compared to the non-CR group (2.0 ± 3.6 mm/years) (p < 0.01). The IL-6, and TGFβ1 levels were unrelated to the changes in AAA size. There was mild positive correlation between the change in systolic blood pressure from rest to exercise and the AAA expansion rate (p = 0.06). The risk of AAA repair after 12 months was lower in the CR group compared to the non-CR group (0% vs. 28%, respectively). CR in patients with small AAA significantly suppressed AAA expansion and resulted in a lowered risk of AAA repair.Clinical trial Trial name: The study of the profitability and protective effect of cardiac rehabilitation on abdominal aortic aneurysm. Number: UMIN000028237. UTL: https://upload.umin.ac.jp/cgi-open-bin/ctr&#95;e/ctr&#95;view.cgi?recptno=R0000323.

Purpose: To investigate the effects of exercise training on ventilatory efficiency and physiological responses to submaximal exercise in subjects with small abdominal aortic aneurysm (AAA)., Methods: Sixty-five male patients (72.3 ± 7.0 years) were randomized to exercise training (n = 33) or usual care group (n = 32). Exercise subjects participated in a training groups for 3 mo. Cardiopulmonary exercise testing was performed before and after the study period and peak (Equation is included in full-text article.)O2, the ventilatory threshold (VT), the oxygen uptake efficiency slope (OUES), and the (Equation is included in full-text article.)E2/(Equation is included in full-text article.)CO2 slope were identified. Baseline work rates at VT were matched to examine cardiopulmonary responses after training., Results: Significant interactions indicating improvements before and after training in the exercise group were noted for time (P < .01), (Equation is included in full-text article.)O2 (P < .01), and work rate (P < .01) at the VT. At peak effort, significant interactions were noted for time (P < .01) and work rate (P < .01), while borderline significance was noted for absolute (P = .07) and relative (P = .04) (Equation is included in full-text article.)O2. Significant interactions were observed for the OUES both when using all exercise data (P = .04) and when calculated up to the VT (P < .01). For the (Equation is included in full-text article.)E2/(Equation is included in full-text article.)CO2 slope, significance was noted only when calculated up to the VT (P = .04). After training, heart rate, (Equation is included in full-text article.)E, (Equation is included in full-text article.)O2 and respiratory exchange ratio were significantly attenuated for the same baseline work rate only in the exercise group (all P < .01)., Conclusions: Exercise training improves ventilatory efficiency in patients with small AAA. In addition, patients who exercised exhibited less demanding cardiorespiratory responses to submaximal effort.

Background: Virtually no reports on the effects of exercise in patients with a small abdominal aortic aneurysm (AAA) exist., Methods and Results: We conducted a retrospective cohort study on 1515 patients with a small AAA before surgery at 2 high-volume hospitals in Tokyo, Japan, from April 2004 to September 2015. A carefully modified cardiac rehabilitation program without excessive blood pressure elevation during exercise was prescribed to 50 patients with an AAA. Using propensity score matching, mortality and clinical outcomes, including AAA expansion rate, were compared between 2 groups: rehabilitation group and nonrehabilitation group. The background characteristics of the rehabilitation group (n=49) and the nonrehabilitation group (n=163) were almost identical. The risk for AAA repair was much lower in the rehabilitation group after matching (before matching: hazard ratio, 0.43; 95% confidence interval, 0.25-0.72; P =0.001; and after matching: hazard ratio, 0.19; 95% confidence interval, 0.07-0.50; P <0.001). AAA expansion rate was slower in the rehabilitation group (before matching: rehabilitation versus nonrehabilitation group, 2.3±3.7 versus 3.8±3.4 mm/y [ P =0.008]; after matching: rehabilitation versus nonrehabilitation group, 2.1±3.0 versus 4.5±4.0 mm/y [ P <0.001]). Elevation of blood pressure during exercise was positively correlated with AAA expansion rate after the rehabilitation program ( r =0.569, P <0.001)., Conclusions: Cardiac rehabilitation protects against the expansion of small AAAs and mitigates the risk associated with AAA repair, possibly because of the decreased elevation of blood pressure during exercise., Clinical Trial Registration: URL: upload.umin.ac.jp. Unique identifier: UMIN000028237., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Objective/background: The impact of post-operative complications in abdominal aortic aneurysm (AAA) surgery is substantial, and increases with age and concomitant co-morbidities. This systematic review focuses on the possible effects of pre-operative exercise therapy (PET) in patients with AAA on post-operative complications,aerobic capacity, physical fitness, and recovery., Methods: A systematic search on PET prior to AAA surgery was conducted. The methodological quality of the included studies was rated using the Physiotherapy Evidence Database scale. The agreement between the reviewers was assessed with Cohen's kappa., Results: Five studies were included, with a methodological quality ranging from moderate to good. Cohen's kappa was 0.79. Three studies focused on patients with an AAA (without indication for surgical repair) with physical fitness as the outcome measure. One study focused on PET in patients awaiting AAA surgery and one study focused on the effects of PET on post-operative complications, length of stay, and recovery., Conclusion: PET has beneficial effects on various physical fitness variables of patients with an AAA. Whether this leads to less complications or faster recovery remains unclear. In view of the large impact of post-operative complications, it is valuable to explore the possible benefits of a PET program in AAA surgery.

Abdominal aortic aneurysms (AAAs) are potentially fatal conditions that are characterized by decreased flexibility of the aortic wall due to proteolytic loss of the structural matrix. This leads to their gradual weakening and ultimate rupture. Drug-based inhibition of proteolytic enzymes may provide a nonsurgical treatment alternative for growing AAAs, although it might at best be sufficient to slow their growth. Regenerative repair of disrupted elastic matrix is required if regression of AAAs to a healthy state is to be achieved. Terminally differentiated adult and diseased vascular cells are poorly capable of affecting such regenerative repair. In this context, stem cells and their smooth muscle cell-like derivatives may represent alternate cell sources for regenerative AAA cell therapies. This article examines the pros and cons of using different autologous stem cell sources for AAA therapy, the requirements they must fulfill to provide therapeutic benefit, and the current progress toward characterizing the cells' ability to synthesize elastin, assemble elastic matrix structures, and influence the regenerative potential of diseased vascular cell types. The article also provides a detailed perspective on the limitations, uncertainties, and challenges that will need to be overcome or circumvented to translate current strategies for stem cell use into clinically viable AAA therapies. These therapies will provide a much needed nonsurgical treatment option for the rapidly growing, high-risk, and vulnerable elderly demographic.

Objective: To investigate the feasibility of endurance exercise training in patients with small abdominal aortic aneurysm (AAA), and to obtain preliminary data of its impact on important health outcomes., Design: Randomized controlled pilot study., Setting: University rehabilitation facility., Participants: Patients with small AAA (N=28; mean age ± SD, 72±7 y)., Intervention: Participants were randomized to a 12-week program of moderate-intensity endurance exercise or standard care control (encouragement to exercise only)., Main Outcome Measures: Safety was assessed in terms of the frequency of adverse events and changes in maximum AAA diameter. Outcomes were assessed at baseline and 12 weeks including cardiopulmonary fitness (ventilatory threshold), health-related quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey [version 2]), and markers of vascular risk (eg, blood pressure and high-sensitivity C-reactive protein)., Results: Of 545 patients contacted, 28 (5%) entered the trial. There were 3 (11%) dropouts. Adherence to the exercise program was 94%. There were no paradoxical increases in AAA size or adverse clinical events. Ventilatory threshold increased in the exercise group, but not the control group (adjusted mean difference, 2.5 mL·kg(-1)·min(-1); 95% confidence interval, 0.5-4.5; d=.82). Systolic blood pressure and high-sensitivity C-reactive protein decreased in the exercise group compared with the control group (d=.34 and d=.58, respectively). There were no substantial changes in anthropometric variables or quality of life., Conclusions: Despite a low recruitment rate, the findings suggest that moderate-intensity endurance exercise training is feasible in patients with small AAA, and can evoke improvements in important health outcomes., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery., Method: One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs., Results: The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n = 52) compared to the conventionally managed group (n = 75); with values of 59 ± 15 and 93 ± 25 h (p = 0.021), 9 ± 3 and 16 ± 5 days (p = 0.001), respectively. The medical costs for the ERAS group were 92 % of the costs of the conventionally managed group., Conclusion: Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.

Objective: No effective medical therapy exists for early abdominal aortic aneurysm (AAA) disease. Lower extremity exercise improves aortic hemodynamics and reduces inflammation, but the safety and efficacy of exercise training in AAA disease is unknown. As an interim analysis of our prospective, randomized, longitudinal trial of exercise for AAA suppression, we investigated whether subjects with early disease could safely achieve target metabolic and hemodynamic goals., Methods: One hundred eight participants were randomized to exercise training (EX) or usual care (UC). EX subjects participated in a combination of in-house and home exercise training, with efforts directed toward moderate daily exercise participation. Comparisons were made between EX and UC subjects who completed 1 year of follow-up (n = 26 and 31, respectively, mean age 72 ± 8 years). EX and UC groups were compared for safety, cardiopulmonary exercise test responses, weekly energy expenditure, and biometric indices., Results: No paradoxical increase in AAA growth rate or adverse clinical events occurred as a consequence of exercise training. EX participants expended an average of 2269 ± 1207 kcal/wk and increased exercise capacity (42% increase in treadmill time, 24% increase in estimated metabolic equivalents, P = .01 and .08 between groups, respectively). EX participants demonstrated a significant reduction in C-reactive protein and tended to reduce waist circumference and waist-to-hip ratio (P = .06 and .07, respectively)., Conclusions: Preliminary analyses suggest that exercise training is well tolerated and sustainable in small AAA subjects over 1 year. Despite age and comorbidities, exercising AAA subjects achieve meaningful exercise targets and significantly modify activity-dependent variables.

Abdominal aortic aneurysms (AAAs) affect 5-7% of older Americans. We hypothesize that exercise may slow AAA growth by decreasing inflammatory burden, peripheral resistance, and adverse hemodynamic conditions such as low, oscillatory shear stress. In this study, we use magnetic resonance imaging and computational fluid dynamics to describe hemodynamics in eight AAAs during rest and exercise using patient-specific geometric models, flow waveforms, and pressures as well as appropriately resolved finite-element meshes. We report mean wall shear stress (MWSS) and oscillatory shear index (OSI) at four aortic locations (supraceliac, infrarenal, mid-aneurysm, and suprabifurcation) and turbulent kinetic energy over the entire computational domain on meshes containing more than an order of magnitude more elements than previously reported results (mean: 9.0-million elements; SD: 2.3 M; range: 5.7-12.0 M). MWSS was lowest in the aneurysm during rest 2.5 dyn/cm(2) (SD: 2.1; range: 0.9-6.5), and MWSS increased and OSI decreased at all four locations during exercise. Mild turbulence existed at rest, while moderate aneurysmal turbulence was present during exercise. During both rest and exercise, aortic turbulence was virtually zero superior to the AAA for seven out of eight patients. We postulate that the increased MWSS, decreased OSI, and moderate turbulence present during exercise may attenuate AAA growth.

Background: Patients with abdominal aortic aneurysms (AAA) represent a high-risk surgical group. Despite medical optimization and radiological stenting interventions, mortality remains high and it is difficult to improve fitness. The aim of this pilot study was to evaluate the effect of a 6 week, supervised exercise programme (30 min continuous moderate intensity cycle ergometry, twice weekly) on anaerobic threshold (AT) in subjects with AAA., Methods: Thirty participants with an AAA under surveillance were randomized to either the supervised exercise intervention (n=20) or a usual care control group (n=10). AT was measured using cardiopulmonary exercise testing, at baseline (AT1), week 5 (AT2), and week 7 (AT3). The change in AT (AT3-AT1) between the groups was compared using a mixed model ancova, providing the mean effect together with the standard deviation (sd) for individual patient responses to the intervention. The minimum clinically important difference (MCID) was defined as an improvement in AT of 2 ml O(2) kg(-1) min(-1)., Results: Of the 30 participants recruited, 17 of 20 (exercise) and eight of 10 (control) completed the study. The AT in the intervention group increased by 10% (equivalent to 1.1 ml O(2) kg(-1) min(-1)) compared with the control (90% confidence interval 4-16%; P=0.007). The sd for the individual patient responses to the intervention was 8%. The estimated number needed to treat (NNT) for benefit was 5 patients., Conclusions: The small mean benefit was lower than the MCID. However, the marked variability in the individual patient responses revealed that a proportion of patients did benefit clinically, with an estimated NNT of 5.

Abdominal aortic aneurysm is a common and increasing health risk. Indication for therapy in men is an aneurysm over 55 mm and in women, over 50 mm in diameter. Novel endovascular treatment procedures are nowadays suitable for a large proportion of patients and will improve patient safety, shorten the duration of therapy and speed up rehabilitation. Therapeutically very challenging problems are aneurysms affecting the renal and visceral arteries, infections of aortic prostheses as well as aneurysmal ruptures during emergency services. Managing of these problems requires experience, whereby centralizing their treatment will improve treatment outcome.

Purpose: The author, a rehabilitation specialist of more than 30 years, presents her observations of the medical and rehabilitation services her husband received after a ruptured abdominal aortic aneurysm. Building on the person-centred approach, she identified several problems and describes theory-based strategies how she and her husband (patient) addressed these problems. In addition, she provides insight in the complex role she fulfilled as family caregiver: liaison, advocate and as personal health manager (taking care of her own health)., Method: A qualitative analysis and interpretation based on personal observations and discussions with medical and rehabilitation professionals., Results: The author argues that the culture of the institution (knowledge and compassion) and the role of the patient advocate have major implications on the outcome of a patient's functional gains. The International Classification of Functioning, Disability and Health can be a useful tool to enhance transparency within the patient-centred approach., Conclusion: Although this case study is described from the perspective of one case, the information shared in this paper may stimulate further discussion and research in the concept and implementation of person-centred rehabilitation.

The purpose was to assess health-related quality of life (HRQOL) in long-term survivors of thoracoabdominal aneurysm repair. Between 1983 and 2001, 43 patients underwent thoracoabdominal aneurysm repair. Long-term survivors (13) were investigated. Two were lost to follow-up. The mean follow-up period was 6.2 years. HRQOL was measured by Short Form (SF)-36, constructed of 36 items grouped into eight scales measuring physical functioning, role limitations caused by physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations caused by emotional problems, and mental health. Additional questions specific for vascular disease were ascribed. The patients' relatives received corresponding questions, responding on behalf of the patients. Patient data scores were compared with a selection of individuals from the general population. The patients' SF-36 scores were generally poorer than that of the healthy population in both physical and mental dimensions. Patients who had a complicated postoperative course generally scored lowest in physical dimensions. Comparing patients' scores with relatives scoring on behalf of the patients showed no statistical differences. According to disease-specific questions, impotence and pain were reported as major long-term postoperative problems. Patients with uncomplicated postoperative courses all reported improved health status (six) compared with the preoperative status, whereas five patients with complicated postoperative courses reported poorer health status. Nine of 11 patients experienced the same or improved HRQOL, and two patients reported reduced HRQOL after surgery. Ten of 11 patients evaluated the operation as successful. Although the sample size in this study is small, those who had postoperative complications or reported a decreased physical function in the years after surgery generally had low scores in almost all dimensions of the SF-36. When disease-specific questions were related to thoracoabdominal aneurysm surgery, most patients reported an acceptable HRQOL.

Aim: This paper reports on a study which aimed to evaluate the effects of structured written preoperative information on patients' postoperative psychological and physical wellbeing after surgery for abdominal aortic aneurysm (AAA)., Background: The possible benefits of current booklets written by professionals on postoperative psychological and physical wellbeing in patients with AAA are unknown. Previous studies have shown that preoperative information has a favourable effect on both mood state and physical mobilization., Method: Fifty-two patients admitted for elective repair of AAA were selected consecutively and randomized to receive only verbal (control group), or verbal and written information in booklet form (experimental group). The booklet contained procedural and sensory information about the disease and its treatment. Two questionnaires were used to establish whether the booklet had any effect on perceived health, psychological and physical wellbeing postoperatively., Results: The two groups were similar regarding their perceived health but differed significantly regarding psychological wellbeing pre- and postoperatively. Patients in the experimental group were significantly sadder both pre- and postoperatively compared with those in the control group. Both groups were similar in postoperative physical wellbeing., Conclusion: This group of patients often has asymptomatic disease, with a short interval between diagnosis and major surgery. When patients receive an information booklet during this period, this seems to cause more worries than anticipated. Hence, a more supportive educational programme might benefit this patient group, both pre- and postoperatively.

Although early discharge is common place, little is known about its impact after abdominal aortic aneurysm (AAA) surgery. We sought to prospectively describe patient outcomes and caregiving experience after early discharge following elective AAA repair using a standard or endovascular grafting system (EGS) procedure. Fifty-one patients (Standard, n=25; EGS, n=26) completed questionnaires on symptoms and health-related quality of life (HRQoL) while hospitalized and 1, 4, and 8 weeks after discharge. Data were also obtained from caregivers. HRQoL decreased at Week 1 in both groups but returned to near baseline by Week 8. Standard AAA patients experienced more symptoms and activity limitations, but these were concentrated in Week 1. Most caregivers were positive about caregiving and required no additional resources. Findings suggest that most patients who undergo early discharge following elective AAA surgery experience few problems. Those problems that occur concentrate in the week following discharge, suggesting the need for closer monitoring at this time., (Copyright 2002 Wiley Periodicals, Inc.)

Background: Quality of life issues following surgical procedures, especially those with high mortality, should be of prime importance. There have been few studies on the quality of life of patients following emergency abdominal aortic aneurysm repairs. The decision to continue to offer surgery to these patients, especially with present monetary constraints, should rely heavily on quality of life issues. Audits of major surgical procedures should be undertaken and quality of life included., Methods: All patients in the Hawkes Bay area who had undergone emergency abdominal aortic aneurysm repairs since 1981 were identified and their quality of life assessed by means of the short form-36 (SF-36) questionnaire., Results: One hundred and fifteen patients were identified as having had an abdominal aortic aneurysm repaired as an emergency. Sixty patients died peri-operatively and 19 subsequently. There were 28 patients available to complete the questionnaire, of whom 75% rated their global quality of life as good to excellent. Using the SF-36 questionnaire, there was no statistically significant difference between those patients who had undergone surgery (whether proven leak or not) and the age-matched healthy population., Conclusions: Quality of life remains good to excellent in the majority of patients following emergency abdominal aortic aneurysm repairs. This may help justify surgery being offered to patients with this condition. Quality of life should be considered as an important outcome rather than mortality only.