Introdução. A morbi-mortalidade durante e após anestesia para aneurismectomia de aorta abdominal é alta, pois esta doença acomete pacientes após a sétima década de vida e que possuem várias doenças concomitantes. Objetivos. Analisar e discutir as condutas anestésicas utilizadas nos períodos pré e intra-operatório no Serviço de Anestesiologia do HCFMRP-USP. Casuística e Método. Foram analisados os prontuários de 104 pacientes submetidos à aneurismectomia de aorta no tocante às condutas utilizadas pelos anestesiologistas para a condução destes casos. Resultados. Apenas um paciente possuía menos de 40 anos de idade, 76,80% estavam na sétima ou oitava década de vida e 88,46% eram do sexo masculino. A hipertensão arterial acometeu 70,19% dos pacientes e 26,92% possuíam coronariopatia. Pacientes com obesidade foram a minoria (26,92%). O ecocardiograma pré-operatório demonstrou que a grande maioria dos pacientes apresentava função ventricular normal. A cirurgia foi realizada em regime de urgência em 7,69% dos casos. A anestesia geral exclusiva foi realizada em 17 pacientes e associada com a peridural em 57 pacientes, com a raquianestesia em 11 e com a raqui-peri combinadas em 19. O tempo cirúrgico variou de 120 a 510 minutos enquanto que o tempo de clampeamento aórtico variou de 30 a 165 minutos. Houve um óbito no período intra-operatório e a causa foi choque hipovolêmico e 10 óbitos até o vigésimo dia pós-operatório. Sessenta e seis pacientes receberam concentrado de papa de hemácias durante o período intra-operatório, mas só em 43,27% desses casos a indicação esteve suportada por exame laboratorial. Oitenta pacientes foram extubados ainda na sala de cirurgia, enquanto que os demais (23) permaneceram intubados no período pós-operatório e 19 necessitaram de suporte ventilatório que teve tempo que variou de 3 a 96 horas com média de 42,31 horas. Apenas quatro pacientes fizeram pós-operatório imediato no Centro de Terapia Intensiva enquanto que os demais permaneceram na Sala de Recuperação Pós-Anestésica. Conclusão. Não existe um protocolo único para a realização de anestesia para aneurismectomia de aorta no HCFMRP-USP e a técnica anestésica utilizada não influenciou o morbi-mortalidade. / Introduction. The morbidity and mortality during and after anesthesia for aneurysmectomy of the abdominal aorta are high since this disease affects patients after the seventh decade of life who have several concomitant diseases. Objectives. To analyze and discuss the anesthetic conducts used during the preoperative and intra-operative periods at the Service of Anesthesiology of HCFMRP-USP. Cases and Method. The medical records of 104 patients submitted to aneurysmectomy of the aorta were analyzed regarding the conducts used by the anesthesiologists for the management of these cases. Results. Only one patient was less than 40 years old, 76.80% were in he seventh or eighth decade of life, and 88.46% were male. Arterial hypertension was present in 70.19% of the patients and 26.92% had coronary artery disease. Obese patients were a minority (26.92%). The preoperative echocardiogram demonstrated that most patients had normal ventricular function. Surgery was performed on an emergency basis in 7.69% of cases. Seventeen patients received exclusive general anesthesia, while general anesthesia was associated with peridural anesthesia in 57, with rachi-anesthesia in 11 and with combined rachi-peridural anesthesia in 19. Surgical time ranged from 120 to 510 minutes and time of aortic clamping ranged from 30 to 165 minutes. One death occurred intra-operatively due to hypovolemic shock and 10 patients died up to the 20th postoperative day. Sixty-six patients received a red blood cell concentrate intra-operatively, but this indication was supported by a laboratory exam in only 43.27% of these cases. Eighty patients were extubated while still in the operating room while the remaining 23 continued to be intubated during the postoperative period and 19 required ventilatory support lasting 3 to 96 hours (mean duration: 42.31 hours). Only four patients spent the immediate postoperative period in the Intensive Care Unit, while the remaining ones stayed in the Post-Anesthesia Recovery Room. Conclusion. There is no single protocol for the application of anesthesia for aneurysmectomy of the aorta at HCFMRP-USP and the anesthetic technique used did not influence morbidity-mortality.

Les anévrismes intracrâniens présentent des risques importants en raison de leur taux de rupture élevé et des conséquences qui peuvent être fatales comme lors d’hémorragies méningées. Afin d’effectuer une recherche hémodynamique sur l’anévrisme intracrânien in vitro, un fantôme est indispensable. Jusqu’à présent, des fantômes rigides ou simplifiés sont utilisés dans littérature, peu d’entre eux sont suffisamment fidèle à la réalité. Le travail de cette thèse se concentre sur la méthodologie de fabrication des fantômes patient-spécifiques d’anévrismes intracrâniens ainsi que leur mise en œuvre pour différentes utilisations. Ces fantômes possèdent la forme anatomique de l’artère du patient et une paroi élastique. Ils sont fabriqués en appliquant une technique originale de prototypage rapide. Les fantômes sont vérifiés selon plusieurs aspects. Pour effectuer des recherches hémodynamiques sur les fantômes, un banc d’essai compatible avec différentes modalités d’imagerie a été conçu. L’angiographie par résonance magnétique 2D par contraste de phase a été utilisée pour étudier l’hémodynamique des fantômes. Le comportement dynamique de paroi, les trajectoires 3D du flux et son champ de vélocité sont analysés. L’application potentielle dans domaine clinique du fantôme patient-spécifique a été aussi testée dans cette thèse, des simulations d’intervention sur des anévrismes intracrâniens ont été effectuées sur le banc d’essai et les fantômes, les résultats de différentes méthodes ont été analysés et comparés. / Intracranial aneurysms are a hazard to human health because of their high rupture rate and fatal subsequence, such as subarachnoid hemorrhage. In order to carry out a hemodynamic research in vitro on the intracranial aneurysm, a phantom is indispensable. Until now, rigid or simplified phantoms are mainly used in the literature, few among them possess sufficient properties compared with reality. The work of this thesis focuses on the methodology of manufacturing patient-specific phantoms of intracranial aneurysms as well as their implementation for different uses. The phantoms have an anatomical shape of patient’s artery and an elastic wall. They are manufactured by applying an original rapid prototyping technique. The phantoms are examined and verified in different ways. In order to perform a hemodynamic research of the phantoms, a testing platform compatible with different imaging modalities has been designed and established. 2D phase-contrast magnetic resonance angiography was applied in the hemodynamic study of the phantoms. The dynamic behavior of the artery wall, the 3D path-line of flow and the velocity field of flow were analyzed. The potential application in the clinical domain of the patient-specific phantoms was also tested in this thesis, simulations of intervention on intracranial aneurysms were carried out with the testing platform and the phantoms, the results of different treatment strategies were analyzed and compared.

L’Anévrisme de l’Aorte Abdominale (AAA) est une pathologie qui est définie par une dilatation localisée et permanente de l’artère et qui concerne plus de 8.8% des personnes âgées. Actuellement, lorsqu’un patient présente une dilatation de l’aorte impliquant l’éventualité d’une intervention chirurgicale en raison du risque de rupture, la décision thérapeutique est prise en fonction du rapport des diamètres de l’artère au niveau de l’anévrisme et à proximité de celui-ci. Pour déterminer ces diamètres, il est généralement procédé à un examen par imagerie médicale (Echographie, Tomographie, IRM,..). On constate cependant que le diagnostic ne peut pas se contenter d’une mesure dimensionnelle simple face aux risques induits: d’une part, passé une certaine excroissance, le risque de rupture peut atteindre 50% mais d’autre part plus de 5% des interventions chirurgicales provoquent le décès du patient. D’autres paramètres de mesure comme la compliance de l’artère, peuvent être à la base de la décision d’une intervention chirurgicale. La compliance correspond à une définition précise utilisée par les cardiologues : c’est une grandeur qui permet de caractériser l’aptitude à la déformation, décrivant la capacité de l'aorte à se distendre sous l'influence de la pression sanguine. De notre point de vue cette notion est insuffisante car, généralement, dans le cas d’un anévrisme, la rupture est très localisée du fait de la complexité de la forme de celui-ci. Il est donc nécessaire d’étendre sa définition à une grandeur localisée non pas au niveau d’une section mais à un endroit précis de la paroi. Les moyens de diagnostics seront d’autant plus fiables qu’ils pourront détecter la compliance localisée. De point de vue mécanique, la détermination de la compliance se transforme donc en la mesure de l'élasticité pariétale aortique localisée. L’élasticité n’est pas un paramètre mesurable directement. Donc, la problématique revient à la détermination de la déformation locale de la paroi aortique sous la sollicitation hémodynamique. La résolution de ce problème reste complexe. En effet, les sollicitations mécaniques dépendent de l’écoulement du sang, des organes environnants l’artère, des propriétés matérielles de l’artère et de la géométrie de l’anévrisme qui sont spécifiques à chaque patient. A l’heure actuelle, beaucoup de travaux numériques et expérimentaux sont effectués mais peu d’études ont permis de bien corréler les techniques d’imageries médicales pour l’aide au diagnostic. C’est dans ce contexte que se situent les travaux de ma thèse, réalisée en collaboration, à la fois avec le CHU de Dijon où ont été effectuées toutes les expérimentations à l’aide d’IRM, le laboratoire GMedTech, GMIT (Galway-Mayo Institute of Technology) en Irlande qui nous a fourni les répliques ainsi que leur savoir-faire dans le domaine cardio-vasculaire et le Laboratoire DRIVE situé à Nevers où ont été menées les mesures d’écoulement par PIV. Les travaux, menés sur des fantômes de diverses formes in vitro, ont pour finalité, d’une part, de construire une méthodologie métrologique pour aider les médecins à comprendre et à valider les mesures d’IRM à l’aide d’autres dispositifs de mesure, d’autre part, de permettre d’améliorer les méthodes de diagnostic des pathologies de type d’anévrisme de l’aorte abdominale. Le principe de ces travaux est donc de mettre en place une modélisation expérimentale in Vitro dans un cadre métrologique d’intercomparaison par divers moyens de mesure et de corréler leurs résultats au long d’un cycle reproduisant les conditions hémodynamiques de mesure, mais aussi de confronter ces résultats à de modélisations numériques. Pour prendre en compte le problème dans sa globalité, non seulement l’évolution de la déformation, représentant l’élasticité de l’aorte, a dû être étudiée mais aussi l’évolution du flux sollicitant la paroi (…). / The Abdominal Aorta Aneurysm (AAA) is a pathology that is defined by a localized and permanent dilation of the artery and which involves over 8.8% of the seniors. Currently, when a patient has a dilatation of the aorta leading to a surgery because of the rupture risk, the therapeutic decision is made depending on the diameter of the aneurysm. To determine this diameter, it is usually conducted an examination by medical imaging (ultrasound, CT, MRI...). However, it notes that the diagnosis can’t be satisfied with a single dimensional measurement face to induced risks: first of all, when the diameter exceed a certain growth, the risk of rupture can reach 50% but more than 5% of surgical procedures may cause the patient's death. Other metrics such as compliance of the artery can be used for the decision for surgery. Compliance corresponds to a precise definition by cardiologists: this is a quantity that characterizes the deformability, describing the ability of aorta to distend under the influence of blood pressure. From our point of view, this concept is insufficient because, generally, in the case of an aneurysm, rupture is highly localized because of the complexity of the shape. It is therefore necessary to extend its definition in a quantity not localized at a section or a specific location but to the whole wall. Diagnostics methods will be more reliable if they can determine localized compliance. From a mechanical standpoint, determining compliance is thus transformed into the measurement of localized parietal elasticity of aorta. The elasticity is not a directly measurable parameter. Therefore, the problem comes down to determining the local strain of the aortic wall in the hemodynamic condition. Solving this problem is complex. Indeed, the mechanical stresses are dependent on the flow of blood, the artery surrounding organs, the material properties of the artery and the geometry of the aneurysm which are specific to each patient. At present, many numerical and experimental works is done but few studies have well correlated medical imaging techniques for the diagnostic aid. It is in this context that are my thesis in collaboration both with the Dijon University Hospital where were performed all experiments using MRI and GMedTech laboratory GMIT (Galway- Mayo Institute of Technology) in Ireland who provided the replicas and their expertise in the cardiovascular area. This work, conducted on various form of phantoms in Vitro, are intended, first to build a metrological methodology to help doctors understand and validate MRI measurements using other devices measurement, on the other hand, to improve the methods of diagnosing the abdominal aortic aneurysm. The principle of this work is to develop experimental modeling in vitro in a metrology framework and correlate the results from different measurement techniques and numerical modeling throughout a cycle reproducing the hemodynamic conditions. To consider the problem as a whole, not only the evolution of deformation representing the elasticity of the aorta should be studied, but also the evolution of soliciting flow. Therefore, in this thesis, several devices such as stereovision, Particle image velocimetry (PIV), MRI kinetic sequence but also the flow 2D and 4D were employed. Various numerical models were established to not only correlate the results with those obtained experimentally, therefore, to improve the credibility of our study, but also to be part of the aid protocol to the diagnosis that we have proposed. In the end, all the results from different experimental and numerical models have led to propose a validated and feasible diagnosis protocol based on MRI sequences. The application of this protocol on a realistic AAA complex phantom showed its feasibility. We can therefore say that the feasibility of the proposed protocol is demonstrated and that based on MRI (…).

Les anévrysmes se développant au niveau des fistules artério-veineuses (FAV), représentent une complication rare mais potentiellement mortelle dont la physiopathologie reste inexplorée. Jusqu’à présent la pratique courante était de les remplacer par un segment prothétique. Nous avons proposé un nouveau traitement chirurgical consistant en une anévrysmorraphie veineuse renforcée extérieurement par une exoprothèse. Notre premier objectif a été de rapporter les résultats à un an de cette nouvelle technique. Dans un second temps nous avons perfusé ex vivo des veines saphènes humaines renforcées par la même exoprothèse dans des conditions hémodynamiques de shear stress (SS) artériel en faisant varier la pression. L’analyse morphologique a montré le développement d’une hyperplasie intimale dans la veine sans et avec exoprothèse à haute pression. L’analyse des gènes et des protéines impliqués dans le remodelage vasculaire n’a pas montré de différence entre la veine nue et la veine renforcée mais nous a permis de mieux caractériser le rôle du SS et de la pression dans le mécanisme de l’artérialisation veineuse. Notre troisième objectif a été de décrire le remodelage anévrysmal des FAV. A partir d’une tissuthèque constituée d’échantillons de veines prélevées chez les patients opérés, nous avons comparé la veine artérialisée anévrysmale à la veine non artérialisée non anévrysmale. Les métalloprotéinases et leurs inhibiteurs participent activement à ce remodelage. Les anévrysmes régulièrement ponctionnés ont un profil inflammatoire qui influence la nature de ce remodelage. / Aneurysm complicating arteriovenous fistula (AVF) is a rare but potentially life-threatening complication. To date, its pathobiology remains unexplored and prosthetic replacement constitutes the conventionnal treatment. We have proposed a new surgical technique consisting in a venous aneurysmorraphy reinforced by an exoprosthesis. Our first goal was to evaluate the one-year results in terms of patency and aneurysm recurrence. Secondly, we have studied the impact of the exoprosthesis on human saphenous veins perfused ex vivo and submitted to different flow conditions consisting in an arterial shear stress (SS) in association with a low or a high pressure setting. Morphological analysis revealed an intimal hyperplasia in veins with and without exoprosthesis under high pressure. Analysis of the proteins and genes involved in the vascular remodeling did not showed an exoprosthesis effect but allowed us to better decipher the selective role played by SS and pressure in the arterialization process. Thirdly, we have collected tissue samples from patients operated and compared aneurysmal arterialized veins to non-aneurysmal non-arterialized veins. Metalloproteinases and their inhibitors actively participate in the remodeling. In aneurysms frequently cannulated inflammation influence the remodeling process.

Objectives: Cardiovascular disease is the leading cause of mortality and morbidity in the developed world. Surgery can improve prognosis and relieve symptoms. Risk prediction models are increasingly being used to inform clinicians and patients about the risks of surgery, to facilitate clinical decision making and for the risk-adjustment of surgical outcome data. The importance of risk prediction models in cardiovascular surgery has been highlighted by the publication of cardiovascular surgery outcome data and the need for risk-adjustment. The overall objective of this thesis is to advance risk prediction modelling in cardiovascular surgery with a focus on the development of models for elective AAA repair and assessment of models for cardiac surgery. Methods: Three large clinical databases (two elective AAA repair and one cardiac surgery) were utilised. Each database was cleaned prior to analysis. Logistic regression was used to develop both regional and national risk prediction models for mortality following elective AAA repair. A regional model to identify the risk of developing renal failure following elective AAA repair was also developed. The performance of a widely used cardiac surgery risk prediction model (the logistic EuroSCORE) over time was evaluated using a national cardiac database. In addition an updated model version (EuroSCORE II) was validated and both models’ performance in emergency cardiac surgery was evaluated. Results: Regional risk models for mortality following elective AAA repair (VGNW model) and a model to predict post-operative renal failure were developed. Validation of the model for mortality using a national dataset demonstrated good performance compared to other available risk models. To improve generalisability a national model (the BAR score) with better discriminatory ability was developed. In a prospective validation of both models using regional data, the BAR score demonstrated excellent discrimination overall and good discrimination in procedural sub-groups. The EuroSCORE was found to have lost calibration over time due to a fall in observed mortality despite an increase in the predicted mortality of patients undergoing cardiac surgery. The EuroSCORE II demonstrated good performance for contemporary cardiac surgery. Both EuroSCORE models demonstrated inadequate performance for emergency cardiac surgery. Conclusions: Risk prediction models play an important role in cardiovascular surgery. Two accurate risk prediction models for mortality following elective AAA repair have been developed and can be used to risk-adjust surgical outcomes and facilitate clinical decision making. As surgical practice changes over time risk prediction models may lose accuracy which has implications for their application. Cardiac risk models may not be sufficiently accurate for high-risk patient groups such as those undergoing emergency surgery and specific emergency models may be required. Continuing research into new risk factors and model outcomes is needed and risk prediction models may play an increasing role in clinical decision making in the future.

L’épidémiologie des anévrismes de l’aorte est un problème de santé publique majeur dans les pays industrialisés. Cette pathologie peut engendrer la mort du patient en cas de rupture de l’anévrisme. Actuellement les critères d’intervention chirurgicale sont basés sur la morphologie de l’anévrisme et il existe des difficultés à évaluer correctement le risque de rupture pour chaque patient. L’objectif de cette thèse était de développer une méthode d’identification des propriétés mécaniques de la paroi artérielle de manière personnalisée permettant d’affiner les critères d’intervention chirurgicale. Des essais de gonflement utilisant des mesures de champs et le développement d’une méthodologie d’analyse ont permis de quantifier la distribution des contraintes des anévrismes de manière expérimentale et de mettre en évidence l’apparition des affaiblissements ponctuels dans la paroi afin de prédire la localisation de la rupture de l’anévrisme. Ensuite, une méthode d’identification de propriétés mécaniques a été mise en place pour mettre en évidence l’hétérogénéité du tissu artériel et pour localiser les endroits à l’origine de la rupture du tissu. L’identification des lois de comportement à partir de données expérimentales issues de patients permettra d’améliorer les modèles numériques artériels utilisées aujourd’hui. De plus, la méthodologie créée pour l’analyse de la rupture d’anévrismes pendant cette thèse ouvre la porte à une étape qui vise à développer la caractérisation mécanique in-vivo par l’utilisation de l’imagerie médicale. L’objectif final sera d’évaluer le risque de rupture de l’anévrisme de chaque patient de manière non-invasive. / Epidemiology of aortic aneurysms is a major public health issue that affects a significant proportion of the population in industrialized countries and can cause the death of the patient in case of rupture of the aneurysm.Currently the only criteria for surgery are based on the morphology of the aneurysm, and there are problems to accurately assess the risk of rupture for each patient.The aim of this thesis was to develop a method to identify the mechanical properties of the arterial wall in a personalized way to refine the criteria for surgery.Inflation tests, full-field measurements and a methodology developed were used in order to quantify experimentally the stress distribution of aneurysms. It was possible to highlight the appearance of localized weakening in the wall which will let us predict the location of the rupture on the aneurysm. Then a method was developed to identify the mechanical properties of the aortic tissue. It was possible to highlight the heterogeneity of arterial tissue and locate the places where the rupture of the tissue may occur.The identification of the aneurysm’s mechanical properties from experimental data will improved arterial numerical models used today. In addition, the methodology developed for the analysis of the rupture of aneurysms during this thesis opens the door to a step that aims to develop the in vivo mechanical characterization by the use of medical imaging. The ultimate goal will be to assess the risk of rupture of the aneurysm of each patient in a noninvasive manner.

The aim of this study is to create CFD tools and models capable of simulating pulsatile blood flow in abdominal aortic aneurysm (AAA) and stent graft. It helps to increase the current physiological understanding of rupture risk of AAA and stent graft fixation or migration. Firstly, in order to build a general solver for the AAA modeling with reasonable accuracy, a third/fourth order modified OCI scheme is originally developed for general numerical simulation. The modified OCI scheme has a wider cell Reynolds number limitation. This high order scheme performs well with general rectangular mesh for incompressible fluid. Second, a velocity based finite volume method is originally developed to calculate the stress field for solid in order to capture the transient changes of the blood vessel since the artery is a rubber like material. All one, two and three dimensional classical cases for solid are tested and good results are obtained. The velocity based finite volume method show good potential to calculate the stress field for solid and easy to blend with the finite volume fluid solver. It has been recognized that fluid structure interaction (FSI) is very crucial in biomechanics. In this regard, the velocity based finite volume method is then further developed for FSI application. A well known one dimensional piston problem is studied to understand the feasibility of the fluid structure coupling. The numerical prediction matches the analytical solution very well. The velocity based method introduces less numerical damping compared with a stagger method and a monolithic method. Finally, the work focuses on practical pulsatile boundary conditions, non-Newtonian blood viscous properties and bifurcating geometry, and provides an overview of the hemodynamic within the AAA model. A modified Womersley inlet and imbalance pressure outlet boundary conditions are originally used in this study. The Womersley inlet boundary represents better approximation for pulsatile flow compared with the parabolic inlet condition. Numerical results are presented providing comparison between different boundary conditions using different viscous models in both 2D and 3D aneurysms. Good agreement between the numerical predictions and the experimental data is achieved for 2D case. 3D stent models with different bifurcation angles are also tested. The Womersley inlet boundary condition improves the existing inlet conditions significantly and it can reduce the Aneurysm neck computation domain. The influence of the non-Newtonian model to the wall shear stress (WSS) and strain-rate is also studied. The non-Newtonian model tends to produce higher WSS at both proximal and distal end of the aneurysm as compared with the Newtonian model (both 2D and 3D cases). The computed strain-rate distribution at the centre of the aneurysm is different between these two models. The influence of imbalance outlet pressure at the iliac arteries to the blood flow is originally investigated. The imbalance outlet pressure boundary conditions affect the computed wall shear stress significantly near the bifurcation point. All the pulsatile Womersley inlet, non-Newtonian viscosity properties and the imbalance pressure outlet need to be considered in blood flow simulation of AAA.

Bakgrund: I Sverige avlider varje år cirka 600 män och 200 kvinnor till följd av ett brustet abdominalt aortaaneurysm. Mellan 1.5 och 4.0 procent av alla män över 65 år drabbas av ett abdominalt aortaaneurysm och sedan år 2015 erbjuds samtliga 65-åriga män screening för aortaaneurysm. De som diagnostiseras är således vanligen äldre personer, och i takt med stigande ålder ökar även risken att drabbas av andra sjukdomar. Patientgruppen kan därför vårdas på olika typer av vårdavdelningar, vilket gör att den grundutbildade sjuksköterskan kan möta dessa patienter på många olika vårdinstanser. För att kunna ge en god och personcentrerad vård krävs en förståelse för patienternas upplevelser relaterat till sitt aneurysm samt hur det påverkar det dagliga livet för patienterna.  Syfte: Litteraturöversiktens syfte var att beskriva vuxna patienters upplevelser relaterat till deras abdominala aortaaneurysm, både under konservativ behandling samt postoperativt och hur det påverkar det dagliga livet. Metod: Litteraturöversikten är baserad på tolv vetenskapliga artiklar med kvalitativ studiedesign. Artiklarna hämtades från tre olika databaser med medicin- och omvårdnadsfokus och analyserades därefter induktivt med en förenklad form av metasyntes. Resultat: Fem huvudkategorier och sju underkategorier av upplevelser hos patienter identifierades. Huvudkategorierna var: upplevelser kring behovet av information; upplevelser av att kunna lita på hälso- och sjukvården; oro, rädsla och ångest relaterat till AAA; AAAs påverkan på det dagliga livet; och möjlighet att vara delaktig i vårdprocessen. Konklusion: Litteraturöversikten visade att AAA upplevs med stor variation av patienter. Men framförallt upplever patienter en brist i information och kunskap om sitt AAA där ytterligare stöd, information och kunskap önskas av patienter.  Nyckelord: Abdominalt aortaaneurysm, Dagligt liv, Patienter, Personcentrerad vård, Upplevelser / Background: In Sweden, approximately 600 men and 200 women die each year as a result of a ruptured abdominal aortic aneurysm. Between 1.5 and 4.0 percent of all men over the age of 65 years suffer from an abdominal aortic aneurysm and since year 2015, all 65-years-old men have been offered a screening for aortic aneurysm. Those who are diagnosed are thus elderly and alongside an increasing age, the risk of being subject to other diseases also increases. The patient group can therefore be cared for in different types of care wards, which means that the undergraduate nurse can meet these patients in many different care institutions. In order to be able to provide good and person-centred care, an understanding of the patients' experiences of their aneurysm, and how it affects their daily lives, is required. Aim: The aim of this literature study was to describe adult patients' experiences related to abdominal aortic aneurysm, both during conservative treatment and postoperatively and how it affects daily life. Method: A literature study which is based on twelve scientific articles with qualitative study design. The articles were retrieved from three different databases with a focus on medicine and nursing and were thereafter analysed inductively with a simplified form of metasynthesis. Result: Five main categories and seven subcategories of patient experiences were identified. The main categories were: experiences around the need for information; experiences of being able to trust the health care; worry, fear and anxiety related to AAA; AAA's impact on daily life; and the possibility to be involved in the care process. Conclusion: The literature review shows that AAA is experienced with a large variety of patients. But above all, patients experience a lack of information and knowledge about their AAA where further support, information and knowledge is desired by patients.  Keywords: Abdominal aortic aneurysm, Daily life, Experiences, Patients, Person-centred care.

La physiopathologie de l’anévrysme de l’aorte abdominale (AAA) est multifactorielle. De la plaque athéro-thrombotique jusqu’à l’anévrisme menaçant, les phénomènes hémodynamiques, protéolytiques, oxydatifs et inflammatoires jouent un rôle aussi complexe qu’interdépendant. Aucun traitement pharmacologique n’a fait la preuve de son efficacité. Dans ce travail, nous étudions 2 voies pharmacologiques potentielles, et développons un modèle murin d’exclusion endovasculaire. La rapamycine est utilisée en oncologie. Ses propriétés anti-inflammatoires, antiprolifératives et anti-angiogéniques stabilisaient la progression anévrismale dans un modèle établi d’AAA. L’AZD9668 est un inhibiteur sélectif de l’élastase. Sécrétée par les neutrophiles, cette protéase joue un rôle clé dans la physiopathologie anévrismale. Les propriétés thérapeutiques ont été étudiées sur un modèle murin potentialisé par l’injection systémique de Porphyromonas Gingivalis, entretenant la réaction inflammatoire et protéolytique pariétale. Dans un second temps, nous avons développé un modèle murin d’exclusion endovasculaire. La spécificité de ce traitement a soulevé de nouvelles problématiques, soulignant le rôle crucial de l’activité biologique du thrombus. L’exclusion endovasculaire d’un AAA sur les modèles de grands animaux est complexe et coûteuse. Nous avons ainsi décrit la technique sur un modèle reconnu d’AAA chez le rat. Le traitement pharmacologique des AAAs a démontré son efficacité sur modèles murins, mais est difficilement transposable à l’homme en raison des effets secondaires. Un traitement endoluminal véhiculant un principe actif délivré in-situ permettrait de stabiliser durablement les AAA. / Abdominal aortic aneurysm (AAA) pathophysiology is multifactorial. From the athero-thrombotic plaque to a threatening aneurysm, hemodynamic, proteolysis, oxidation and inflammation play a complex but interdependent role. No pharmacological treatment has yet proved to be efficient. In this work, we study 2 potential pharmacological targets, and develop a murine model of endovascular abdominal aneurysm repair (EVAR). Rapamycine is used in oncology. Its anti-inflammatory, anti-proliferative and antiangiogenic properties stabilized aneurysm progression on an established AAA. AZD9668 is an elastase selective inhibitor. Secreted by neutrophils, this protease plays a key role in aneurysmal pathophysiology. Its therapeutic benefits have been study on a murine AAA model potentiated by Porphyromonas Gingivalis systemic injection, maintaining inflammatory reaction and wall proteolysis. Then, we developed a murine endovascular aneurysm exclusion model. EVAR raised new concern, underlining the crucial role of the thrombus biological activity. Endovascular AAA exclusion on big animals is complex and expensive. We hence described the technic on a rat AAA well known model. Pharmacological AAAs treatment has proved to be efficient on murine models, but is hard to transpose to humans because of systemic side effects. An endoluminal treatment carrying active drugs, and delivered in-situ, could durably stabilize AAAs.

Background: Impaired homocysteine metabolism is associated with a number of vasculopathies including extracranial aneurysms. We analyzed the possible association of nine genetic variants of homocysteine metabolism with the occurrence of intracranial aneurysms. Methods: Caucasian patients (n = 255) treated at two German hospitals for intracranial aneurysms and local controls (n = 348) were genotyped for the following polymorphisms: methionine synthase (MTR) c.2756A→G, methylenetetrahydrofolate reductase (MTHFR) c.677C→T, MTHFR c.1298A→C, cystathionine β-synthase (CBS) c.844_855ins68, CBS c.833T→C, dihydrofolate reductase (DHFR) c.594 + 59del19bp, glutathione S-transferase Ω-1 (GSTO1) c.428C→A, reduced folate carrier 1 (RFC1) c.80G→A and transcobalamin 2 (Tc2) c.776C→G. Results: The G-allele of the missense polymorphism Tc2 c.777C→G was found to be underrepresented in patients, suggesting that this variant may protect from the formation of cerebral aneurysms [odds ratio per two risk alleles (OR) 0.48; 95% confidence interval (CI) 0.30–0.77; p = 0.002]. We obtained borderline results for the G-allele of RFC1 c.80G→A (OR 1.64; 95% CI 1.01–2.65; p = 0.051) and the insertion allele of DHFR c.594 + 59del19bp (OR 1.61; 95% CI 1.00–2.60; p = 0.059), which were found to be overrepresented in patients. Conclusion: Polymorphisms of homocysteine metabolism are possible risk factors for the formation of intracranial aneurysms. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.