Objective: We aimed to predict patient-specific rupture risks and growth behaviors in abdominal aortic aneurysm (AAA) patients using biomechanical evaluation with finite element analysis to establish an additional AAA repair threshold besides diameter and sex. Methods: A total of 1219 patients treated between 2005 and 2024 (conservative and repaired AAAs) were screened for a pseudo-prospective single-center study. A total of 15 ruptured (rAAA) vs. 15 non-ruptured AAAs (control group) were matched for pre-rupture imaging (first rAAA) and the initial post-rupture imaging (second rAAA) with two images in the asymptomatic control group (first and second control). The matching criteria were as follows: aneurysm diameter, sex, and time period between imagings. The biomechanical properties were analyzed with the finite element method (A4clinicsRE, Vascops GmbH, Graz, Austria). Results: Both groups had the same median aortic diameter of 5.5 cm in the first imaging but had significantly different aneurysm progressions with 6.9 cm (5.5–9.4 cm) in the second rAAA vs. 6.0 cm (5.1–7.3 cm) in the second control group (p = 0.006). The first rAAA, compared to the first control, showed significantly a higher peak wall stress (PWS) (211.8 kPa vs. 180.5 kPa, p = 0.029) and luminal diameter (43.5 mm vs. 35.3 mm; p = 0.016). The second rAAA, compared to the matched second control, showed a significantly higher PWS (281.9 kPa vs. 187.4 kPa, p = 0.002), luminal diameter (58.3 mm vs. 39.7 mm; p = 0.007), PWRR (0.78 vs. 0.49, p = 0.014) and RRED (79.8 vs. 56.5, p = 0.014). The rAAA group showed over-proportional averages, over the observation time, and an increase in PWS (nearly 10× faster in rAAA) and luminal diameter (nearly 4× faster in rAAA) per month. Conclusions: The finite element analysis of biomechanical properties could be used for the early prediction of an increased rupture risk in AAA patients. This was confirmed by matched imaging analyses before and after AAA rupture. Further multicenter data are needed to support these findings.

Background: Thrombotic material in the non-aneurysmatic and non-atherosclerotic aorta is a rare entity without any recommended standard treatment so far. We present a successful treatment strategy for patients who do not fit into any of the common approaches. Case report: A free-floating thrombus in the descending aorta was found as source of embolism in an 82-year-old female patient with lower limb ischemia. After initial heparinization of the patient without relevant reduction of the thrombotic mass, the thrombus was removed using an interdisciplinary approach. Under echocardiographic guidance to locate the thrombus, the AngioVac device, usually licensed to remove floating thrombi from the venous system, was used off-label to remove the thrombus by a transfemoral approach. To avoid rebuilding of a new thrombus, the attachment point with an exulcerated plaque in the descending aorta was covered by a stent graft via the same femoral access. The patient did not experience any further embolic events, and the postoperative course was uncomplicated. Conclusion: Patients with uncommon aortic diseases, such as the reported free-floating thrombus, should be treated by an individualized, interdisciplinary approach. Besides the recommended treatment options, there are other uncommon approaches that might offer an alternative in complex cases. Clinical Impact: Evidence is rare for the treatment of a free-floating thrombus in the descending aorta and the treatment strategy remains discussed controversially. We present a rather uncommon approach of successful off-label treatment for patients who do not fit into any of the common approaches (operative, endovascular, or conservative treatment based on patient’s comorbidities). The AngioVac System has already been successfully used off-label in the arterial system but not in the above presented way of treating a free-floating thrombus in a patient with high embolization risk and treatment-limiting comorbidities.

Zusammenfassung: Einleitung: Um die Häufigkeit von COVID-19-assoziierten (Coronavirus SARS-CoV-2-19) vaskulären Komplikationen bei COVID-19-Infektion in österreichischen gefäßchirurgischen Zentren zu ermitteln, haben wir im Namen der Österreichischen Gesellschaft für Gefäßchirurgie (ÖGG) eine Umfrage durchgeführt. Methoden: 16 Zentren wurden im Oktober 2022 eingeladen, an einer Online-Umfrage (SurveyMonkey®, Momentive Europe UC, Dublin, Irland) teilzunehmen (Rücklaufquote 75 % n = 12). Es wurden in der fachspezifischen Literatur berichtete vaskuläre Komplikationen bei Patienten und Patientinnen bei manifester COVID-19-Infektion oder nach kürzlicher COVID-19-Impfung abgefragt. Ergebnisse: Zum Umfragezeitpunkt bestanden verpflichtende COVID-19-Testungen zum Zeitpunkt der Hospitalisierung (100 %) und häufige perioperative respiratorische Komplikationen und/oder Hyperkoagulabilität bei COVID-19-Patienten und Patientinnen. Vaskuläre Komplikationen im COVID-19-assoziierten Patientenkollektiv der Zentren waren akute Extremitätenischämien (92 %), Bypassverschlüsse (33 %), Viszeralarterienverschlüsse (58 %) sowie aortale- (33 %) und karotidale Thrombosen (17 %). Insgesamt 83 % der Zentren berichteten über verzögerte Wundbehandlungen als Folge der COVID-19-Maßnahmen mit resultierend vermehrt zu indizierenden Major- (67 %) und Minor-Amputationen (58 %) im Vergleich zu Vor-Covid-Zeit. Vaskuläre Komplikationen nach kürzlicher COVID-Impfung umfassten ausschließlich akute Extremitätenischämien (25 % der Zentren) und Bypassverschlüsse (17 %). Schlussfolgerungen Aufgrund häufiger postoperativer Komplikationen sollte lediglich bei dringlicher Indikation eine gefäßchirurgische OP/Intervention bei COVID-19-positiv getesteten Patienten und Patientinnen erfolgen. COVID-19-assoziierte arterielle Komplikationen sind je nach Lokalisation unterschiedlich häufig und komplex. Durch eine COVID-Impfung verursachte vaskuläre Komplikationen sind äußerst selten. Graphic