Results of surgical treatment and role of biomarkers in pathogenesis and risk prediction in patients with abdominal aortic aneurysm and peripheral artery disease

Abstract

Kõhuaordi aneurüsm (AAA) on aordi raske haigus, mille eluohtlik tüsistus – rebend – põhjustab suremust üle 80%. Seetõttu on haiguse õigeaegne diagnoosimine ja ravi väga olulised. Haiguse levimus ja esinemissagedus on langenud viimase 20 aastaga, tänapäeval on haiguse levimus 65-aastasel meestel vahemikus 1.3-3.3%. Alajäseme arterite haigus (PAD) on süsteemse ateroskleroosi ilming, mille levimus on ligikaudu 3% vanusegrupis 45-49 eluaastat ja tõustes umbes 18% vanusegrupis 60-90 eluaastat. Kogu maailmas on PAD haiged aladiagnoositud ja- ravitud ning nende südame ja veresoonkonna haigustest tingitud risk on väga kõrge. Käesolevas töös hindasime kirurgilise ja endovaskulaarse ravi tulemusi AAA ja PAD haigetel ning uurisime funktsionaalsete ja biokeemiliste markerite rolli haiguse patogeneesis ja riskis. Leidsime, et plaanilise aordikirurgia 30-, 90-päeva ja 5-aasta kogusuremuse määrad olid vastavalt 0.9%, 2.6% ja 32%. Rebenenud AAA haigetel olid 30-, 90-päeva ja 5-aasta kogusuremuse määrad vastavalt 22.9%, 33.3% ja 55.1%. Leidsime samuti, et 30-päeva suremus, tüsistused ja kordusinterventsioonid plaanilise endovaskulaarse ja avatud kirurgilise ravi korral olid võrdsed. Endovaskulaarne aordi stentproteseerimine oli ühtlasi 5-aasta suremuse sõltumatu riskifaktor. Neli aminohapet ja neli fosfatidüülkoliini olid AAA haigetel tervetega võrreldes statistiliselt oluliselt madalamas kontsentratsioonis. Samas ei esinenud ainsatki metaboliiti, mis oleks eristunud kiire ja aeglase kasvuga AAA haigetel, ega ka metaboliite, mille abil eristada kiire ja aeglase kasvuga AAA patsiente tervetest inimestest. PAD haigete postoperatiivne suremus rekonstruktiivsetel operatsioonidel alloveeniga infraingvinaalses segmendis oli 3.7%, transplantaadi kumulatiivne läbitavus oli 30. päeval, 3. ja 5. aastal vastavalt 82.9%, 38.7% ja 21.3%. Leidsime samuti, et PAD haigetel oli üldise ning südame ja veresoonkonna haiguste suremuse risk sõltumatult seotud langenud väikeste arterite elastsusega.

Abdominal aortic aneurysm (AAA) is a complex pathology with a high mortality rate (around 80%) due to its complication, AAA rupture, which is why timely treatment is crucial. AAA prevalence and incidence rates have decreased over the last 20 years, the current prevalence in 65-year-old men is between 1.3% and 3.3%. Peripheral artery disease (PAD) or lower extremity arterial disease is a manifestation of systemic atherosclerosis with a prevalence of 2.7-3% in population aged 45-49 years, increasing up to 18.2 % in persons aged 60-90 years. However, PAD patients remain underdiagnosed and -treated with regard to guideline-directed medical therapy. In the present thesis, patients with elective and emergency AAA and with symptomatic PAD were studied. We aimed to evaluate the results of surgical and endovascular therapy of patients with elective AAA (eAAA) and ruptured (rAAA) and symptomatic PAD; and to determine the role of functional and biochemical markers in pathogenesis and risk prediction in these patients. In patients with eAAA, 30-day, 90-day, and 5-year all-cause mortality rates were 0.9%, 2.6%, and 32%, respectively. In patients with rAAA, 30-day, 90-day, and 5-year all-cause mortality rates were 22.9%, 33.3%, and 55.1%, respectively. 30-day mortality, and complication and reintervention rates for endovascular aneurysm repair (EVAR) and open surgical repair in eAAA patients were similar. The EVAR procedure is an independent risk factor for 5-year mortality. The levels of only four amino acids and four phosphatidylcholines were found to be significantly lower after adjustment for confounders among the AAA patients compared with the controls. There were no differences in the metabolites distinguishing the AAA patients with slow or fast growth from the controls, or distinguishing the patients with slow growth from those with fast growth. The rate of operative mortality in PAD patients was 3.7%, the cumulative patency rate for all bypass operations was 82.9%, 38.7% and 21.3% at 30 days, 3 and 5 years, respectively. Small artery elasticity above the median was independently associated with decreased all-cause and cardiovascular disease mortality in PAD patients.