Search

Objective: In the majority of patients with chronic type B aortic dissection, there is persistent retrograde flow in the false lumen (FL) through distal re-entry tears. Among several endovascular techniques proposed for FL management, the "Candy Plug" (CP) technique has gained acceptance with good early results. The aim of this study is to report the types and outcomes of open and endovascular reinterventions and identify mechanisms of procedure failure as well as other causes for reinterventions., Methods: All patients with type B aortic dissection submitted to thoracic endovascular aneurysm repair and CP implantation for FL embolization from January 2016 to December 2022 at our institution were included in this study. The preoperative, intraoperative, and postoperative data of the primary intervention and secondary reinterventions, when performed, were prospectively collected and retrospectively analyzed. Preoperative and postoperative computed tomography angiography were also analyzed., Results: During the study period, 33 patients were submitted to thoracic endovascular aneurysm repair and CP implantation. Twenty-three patients (69.7%) showed thoracic FL complete thrombosis with aortic stability or positive remodeling at a mean follow-up of 45 ± 23.1 months. Ten patients (30.3%) underwent aortic reinterventions (male, n = 9; mean age, 60.5 ± 7.6 years). Of these 10 patients, in four patients, complete thrombosis of the FL was never achieved, leading to ongoing perfusion of the FL, defined as "primary failure." The other six patients underwent reinterventions for different causes: two patients, after initial sealing, showed a progressive enlargement of the abdominal FL leading to distal degeneration. One patient showed proximal degeneration, two patients showed a type II thoracoabdominal aortic aneurysm and CP implantation was used as a planned procedure to reduce the extent of the surgical procedure, and one patient had recurrent, intractable back pain despite complete thrombosis of the FL. Reinterventions were open in five cases and endovascular in five. One in-hospital death (postoperative day 27) after a type II thoracoabdominal aortic aneurysm open repair was recorded. In addition, two cases of delayed spinal cord ischemia after open reintervention were recorded: one resulting in permanent paraplegia and one transitory with complete recovery., Conclusions: The CP technique was safe and effective; however, a significant rate of aortic-related reintervention was observed. Several mechanisms led to reinterventions either in terms of "primary failure" of the CP or subsequent aneurysmal degeneration. Complex reinterventions were often necessary, with a high rate of major complications in case of open repair. Life-long and closer surveillance might be required in these patients., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: In the field of thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR), some preoperative characteristics are established risk factors for adverse outcomes, whereas others are supposed to be relevant, but their role still need to be defined; among them, the presence of "shaggy aorta" (SA), an extensive and irregular atheroma within the aorta. The aim of this study is to report the results of a single-center large cohort of patients treated with OSR for TAAA with SA, comparing the outcomes with patients affected by TAAA without SA, and analyzing the impact of the scores for SA on the outcomes., Methods: All consecutive patients receiving OSR for TAAA between 2012 and 2021 were retrospectively analyzed. Clinical data from patients with degenerative TAAA were included and analyzed for preoperative characteristics and postoperative outcomes; patients with ruptured TAAA, and patients with aortic dissection were excluded from the analysis. Patients with degenerative aortic aneurysm, thrombus measurement in non-aneurysmal aortic segments (≤40 mm), atheroma thickness ≥5 mm, and finger-like thrombus projection were included in the SA group, whereas the others were included in the non-shaggy aorta group (NSA group). The SA group and NSA group were compared using a propensity-matched comparison. Preoperative computed tomography scans of patients in the SA group were also stratified according to SA grading scores., Results: A total of 58 patients with SA were identified (male, n = 43 [74.1%], mean age 70.1 ± 7.8 years) among 497 patients with TAAA treated with open surgical repair. After propensity matching, there were 57 patients in the SA group and 57 in the NSA group with correction of all differences in baseline characteristics. Patients in the SA group presented significantly higher in-hospital mortality (SA group, 14.0% vs NSA group, 3.5%; P = .047), postoperative acute renal failure (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease [RIFLE], 3-5) (SA group, 21.1% vs NSA group, 5.3%; P = .013), and postoperative embolization (SA group, 28.1% vs NSA group, 8.8%; P = .008). Spinal cord ischemia and stroke rate were not significantly influenced by the presence of SA. In the SA group, 16 patients (27.6%) with end-organ embolization were compared with 42 patients (72.4%) without a documented embolization considering the grade of aortic "shagginess" and no significant difference was identified (P = .546)., Conclusions: Despite a better knowledge of the SA disease, new classifications, and intraoperative adjuncts, TAAA patients with SA treated with OSR have worse postoperative outcomes if compared with patients without SA. The presence of SA is a risk factor itself, whereas the grade of "shagginess" seems not to impact on postoperative outcomes., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aberrant subclavian artery (AScA) with or without associated Kommerell's diverticulum (KD) is the most frequently encountered anomaly of the aortic arch, it may be life threatening, especially when associated with aneurysmal degeneration. The best management is still debated and depends on many clinical and anatomical factors. A systematic review was conducted to assess the current evidence on the treatment options and their efficacy and safety for AscA and KD repairs., Methods: A literature search in PubMed and Cochrane Library was performed, and articles that were published from January 1947 to August 2021 reporting on AscA and KD management were identified. Multicenter studies, single-center series, and case series with three or more patients were considered eligible in the present review. A comparison of outcomes of patients who underwent open surgery (OS), a hybrid approach (HA), and total endovascular repair (ER) (ie, 30-day mortality and stroke were analyzed when available and compared among the three groups (P < .05; Benjamini and Hochberg-adjusted P < .05; Bonferroni-adjusted P < .05). Titles, abstracts, and full texts were evaluated by two authors independently. Primary outcomes included survival rate, perioperative stroke, arm ischemia, and spinal cord ischemia. Endoleak, in the case of HA and ER, and reintervention rates were considered outcomes., Results: Three hundred thirty-one articles were initially evaluated and 30 studies, totaling 426 patients treated for AScA with 324 KD, were included. Of the 426 patients, 241 were male (56.5%), and the mean patient age was 57.9 ± 12.0 years. The approach was OS in 228 patients, HA in 147 patients, and ER in 51. Dysphagia was the most common presentation in 133 cases. Aortic rupture was observed in 16 of the 426 patients (3.8%), including 14 AScA/KD (3.3%) aneurysm rupture. KD maximum diameter varied widely from 12.6 to 63.6 mm. The overall 30-day mortality was 20 (4.7%) (OS group 8/228 [3.5%]; HA group 10/147 [6.8%]; ER 2/51 [3.9%]; P = NS). The overall stroke rate was 4.9% (21/426) (OS group 10/228 [4.4%]; HA group 6/147 [4.1%]; ER group 5/51 [9.8%]; P = NS), including nine transient and nondisabling neurological deficits. Overall secondary procedures for complications were reported in 36 of the 426 cases (8.4%), mostly owing to endoleak. Follow-up varied from 13 to 74 months., Conclusions: This systematic review assessed the current outcomes of the three types of therapeutic management for AScA and KD and demonstrated that they are all relatively safe and effective, providing satisfactory early and midterm outcomes. Long-term outcomes are warranted, especially for total ERs since the long-term durability of stent grafts remains unknown., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The analysis of endovascular treatment of thoracic aortic diseases using new low-profile stent grafts in large series is crucial to understanding the durability of these devices. The present study reports the midterm outcomes of a single-center experience using the Zenith Alpha thoracic endovascular stent graft., Methods: The outcomes of 270 procedures performed on 262 patients (197 men; mean age, 70.5 ± 9.5 years) using the Zenith Alpha thoracic endovascular stent graft from November 2013 to December 2019 for different thoracic aortic diseases were analyzed. The primary endpoints were 30-day clinical success and midterm (5-year) clinical success. The secondary endpoints were the adverse event rate at 30 days and midterm and access- and device-related complications. The follow-up of surviving patients was performed using computed tomography angiography and office visits at 1, 6, and 12 months and annually thereafter. Kaplan-Meier analysis was performed for overall survival, and freedom from thoracic aortic endovascular repair-related mortality and related reinterventions., Results: The overall 30-day mortality was 5.2% (2.5% for elective and 30.8% for nonelective cases). Type I endoleaks were identified in six patients. The 30-day primary technical and clinical success rates were 97.8% and 92.6%, respectively. Femoral cutdown was used in 41.1% of cases and percutaneous access in 58.5%. The rate of femoral artery complications after the percutaneous approach was 5.1%, with the need for surgical conversion in 1.9%. The stroke rate was 4.1% (major stroke, 2.2%), and the spinal cord ischemia rate was 3.7% (permanent paraplegia, 0.7%). Of the 248 survivors, 239 complied with the follow-up protocol with adequate computed tomography angiograms available images. Overall follow-up survival was 94.0% at 1 year, 91.6% at 2 years, 88.9% at 3 years, and 88.5% at 5 years. The unplanned secondary endovascular procedure rate was 5.3%. No stent fractures or new-onset type I endoleaks due to stent graft migration were observed in the study cohort., Conclusions: The midterm outcomes of this new generation of low-profile devices were satisfactory. The reported low incidence of secondary procedures and the absence of migrations are promising for the long-term durability of these devices., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the perioperative and short-term results in a cohort of patients treated during the last year at our institution with the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique for acute complicated aortic dissection., Methods: Between June 2016 and June 2017, 10 patients (all male; mean age, 62.6 ± 7.4 years) received treatment for acute complicated aortic dissection with the STABILISE technique. After a standard provisional extension to induce complete attachment procedure using the commercially available endovascular dissection system (Cook Medical, Bloomington, Ind), the distal stent graft area and the bare stent area were ballooned to completely exclude the thoracic false lumen (FL) and to obtain a single-channeled abdominal aorta. Computed tomography was routinely performed within the first postoperative week before discharge and then at 3 months, at 6 months, and yearly thereafter. The technical and clinical success rates were analyzed., Results: The 30-day technical and clinical success rates were 100%, with complete thrombosis of the thoracic FL and no type I endoleak. Malperfusion was resolved in all cases. No aortic ruptures were recorded, and no open conversion was required. One case of delayed spinal cord ischemia fully resolved within the discharge period. Predischarge computed tomography showed complete thrombosis of the thoracic FL in all cases. In two cases, some degree of patency of the abdominal FL was observed. At short-term follow-up, the overall aortic diameters remained stable with no further dilation., Conclusions: The STABILISE technique was safe and feasible in this cohort of patients, with complete thrombosis of the thoracic FL and creation of a single-channeled aorta in most cases. Further studies are needed to ascertain the long-term behavior of the treated aorta., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR)., Methods: Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR., Results: A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months., Conclusions: Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Zenith Alpha thoracic endograft (William Cook Europe, ApS, Bjaeverskov, Denmark) is a new low-profile thoracic endograft that has recently become commercially available in Europe. The reduced profile offers potential benefits and extended applicability, especially in patients with small or diseased iliofemoral vessels. The aim of this study was to evaluate the safety and efficacy of thoracic endovascular aortic repair performed with the new Zenith Alpha thoracic endograft., Methods: From November 2013 to the present, Zenith Alpha thoracic stent grafts have been employed to treat 42 patients (31 men; median age, 71 years; range, 54-83 years) suffering from descending thoracic aortic disease: 34 degenerative aneurysms, 4 aortic ulcers, 2 false aneurysms following prior thoracic open repair, and 2 traumatic blunt injuries. The mean proximal neck length was 25 mm (range, 17-40 mm), with a mean access vessel diameter of 6.7 mm (range, 6-11 mm). In 11 cases, aortoiliac occlusive disease (TransAtlantic Inter-Society Consensus type B and C lesions) was present. The proximal landing was in zone 1 in 2 cases, in zone 2 in 25 cases, in zone 3 in 11 cases, and in zone 4 in 4 cases., Results: Fifty-one endografts (45 proximal components and 6 distal components) were deployed in 42 patients. The endografts were deployed safely and effectively from one surgical femoral access site in all cases. In patients with associated aortoiliac disease, no adjunctive procedures for device insertion, except for predilation with balloon angioplasty in two cases, were required. No major complications related to the devices were observed in any of the patients during the postoperative course, and there was no perioperative mortality, paraparesis, or paraplegia. At 30 days, morbid events included one case of major stroke, two cases of transient acute renal failure, and one case of postimplantation syndrome. No access-related complications were recorded. Computed tomography performed within 6 months was obtained in 39 patients and confirmed 100% clinical success without device-related complications. No type I endoleaks or bird's beak effects were documented., Conclusions: Our early experience shows that deployment of the new Zenith Alpha endograft from a surgical femoral access is safe and effective in treating thoracic aortic aneurysms, aortic ulcers, and traumatic blunt injuries, even in patients with small or diseased access vessels. Endograft conformance to the aorta and exclusion of the aneurysm were satisfactory. Long-term durability remains to be evaluated., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The PETTICOAT (Provisional ExTension to Induce COmplete ATtachment) technique may be employed during endovascular treatment of type B aortic dissection (TBD) using self-expandable bare stents distal to the covered stent graft placed over the proximal entry tear. The aim of this study is to evaluate the volume changes of the true (TL) and false lumen (FL) on computed tomography (CT) scans., Methods: Since 2005, 25 selected patients received endovascular treatment for complicated TBD with the PETTICOAT technique employing the Zenith Dissection Endovascular System (William Cook Europe, Bjaerverskov, Denmark). Indications to the use of the PETTICOAT technique were the evidence of clinical manifest dynamic malperfusion in five cases (20%) and/or radiologic evidence of TL collapse in 20 cases (80%). Five patients were treated within 2 weeks from onset, 13 patients between 2 weeks and 3 months, and seven patients over 3 months after the initial acute event. The volumetric analysis of the changes of TL and FL obtained from CT scan performed before endovascular treatment of TBD, postoperatively and yearly thereafter were analyzed using the OsiriX software v 3.9 (Pixmeo sarl, Bernex, Switzerland)., Results: Initial clinical (30 days) and midterm clinical success was observed in 21 cases (84%) and in 23 cases (92%), respectively. The volumes of the aortic TL and FL were evaluated at 30 days and midterm follow-up (mean, 38 ± 17 months). The following TL volumes were recorded: baseline 84 ± 29 cm(3), postoperative 167 ± 31 cm(3) (+98%), 1 year 193 ± 46 cm(3) (+131%), and 2 years 216 ± 54 cm(3) (+140%). The following FL volumes were recorded: baseline 332 ± 86 cm(3), postoperative 286 ± 85 cm(3) (-14%), 1 year 233 ± 81 cm(3) (-30%), and 2 years 248 ± 112 cm(3) (-32%). Progressive remodeling of the TL was recorded over time in both thoracic and abdominal segments with shrinkage of the FL mainly in the thoracic segment., Conclusions: These data provide insight into potential therapeutic benefit of the PETTICOAT technique. A significant immediate increase in TL could be achieved with resolution of all cases of dynamic malperfusion and TL collapse. A different behavior of volumes in the thoracic and abdominal segments was observed., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)