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Background: The most common complication after endovascular aortic aneurysm repair (EVAR) is continuous sac perfusion, known as endoleak. Evaluating markers released from the aneurysm wall into circulation has been suggested as a possible alternative for detecting endoleaks. The aim of this study was to examine whether circulating concentrations of different proinflammatory interleukins (IL-1β, IL-2, IL-6, IL-8), monocyte chemoattractant protein-1 (MCP-1), and tumor necrosis factor alpha (TNF-α) were elevated in patients with endoleak after EVAR., Methods: A prospective observational study with 100 patients undergoing elective EVAR was conducted. Blood samples were taken before surgery, at 7 days, 6 months, and 12 months after EVAR to quantify the mentioned cytokines using a Bio-Plex assay. Patients were followed up for 12 months to detect endoleak occurrence., Results: In patients with endoleak, mean concentrations of certain cytokines in plasma differed significantly from those without endoleak: preoperative IL-8 (9.83; P < 0.001), preoperative MCP-1 (75.94; P = 0.003), preoperative TNF-α (5.46; P = 0.05), among others. A binary logistic regression analysis revealed that preoperative IL-8 (P = 0.003), MCP-1 at 7 days postoperative (P = 0.002), and IL-1 at 12 months postoperative were significantly associated with endoleak, with IL-1 being the most influential biomarker (odds ratio = 2.2). A receiver operating characteristic curve showed an area under the curve of 0.7, with cutoff points of 33.4 for preoperative IL-8, 145 for MCP-1 at 7 days postoperative, and 2.3 for IL-1 at 12 months postoperative., Conclusions: This study suggests that inflammatory biomarkers such as IL-1, IL-8, MCP-1, and TNF-α have the potential to serve as important adjuncts to conventional imaging techniques in monitoring patients post-EVAR. These biomarkers may help identify individuals at higher risk of developing endoleaks, guiding more focused and timely imaging follow-up. However, their practical applicability requires further investigation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to explore the predictive value of endoleak in short-term follow-up after endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) via perioperative laboratory indicators., Methods: A retrospective study included 200 consecutive patients who received standard EVAR treatment for AAA and were followed-up for 1 year. Binary logistic regression analysis was used to evaluate the correlation of the level and changes of perioperative laboratory indicators with the endoleak events during the follow-up. The receiver operating characteristic (ROC) curve was used to assess the predictive value of laboratory indicators for endoleak., Results: A total of 45 cases of endoleak events occurred during follow-up. Binary logistic regression analysis showed that postoperative fibrinogen decrease, perioperative lymphocyte difference and lymphocyte monocyte ratio (LMR) difference were independent risk factors for short term endoleak. The area under the ROC curve (AUC) of postoperative fibrinogen was 0.596, the cut-off value was 284 mg/dl, and the corresponding specificity and sensitivity were 0.644 and 0.568. The AUC of the lymphocyte difference was 0.622, the cut-off value was -0.45 × 10 9 /L, and the corresponding specificity and sensitivity were 0.651 and 0.568. The AUC of the LMR difference was 0.597, the cut-off value was -1.719, and the corresponding specificity and sensitivity were 0.631 and 0.614., Conclusions: Decrease of postoperative fibrinogen, increase of lymphocyte difference and LMR difference were independent predictive factors for endoleak in short-term follow-up after EVAR for AAA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Endotension is one of the detrimental complications after endovascular aneurysm repair (EVAR) and surgical management has been considered as standard of care. However, there is a paucity of data regarding the findings, and outcomes of such surgical intervention. The aim of this study was to investigate intraoperative findings and outcomes of surgical treatment for endotension after EVAR., Methods: Between January 2005 and October 2018, of the 708 patients who underwent EVAR for aneurysm aortic aneurysm; 12 patients (mean age of 76.1; range 66-88) who underwent open repair for endotension were retrospectively analyzed. The anatomical characteristics of the aorta and surgical findings were reviewed. The rates of early and late procedural complications, and overall mortality were evaluated., Results: The median interval between the EVAR and surgical conversion was 45.9 months (range 17.1-46.9). Three of the twelve patients underwent emergency surgery due to aneurysm rupture. The median aneurysm sac size, the proximal neck diameter, and the proximal neck length before EVAR were 64 mm, 23.5 mm, and 30.5 mm, respectively, that changed before open repair to 93.5 mm (P = 0.02), 25 mm (P = 0.011), and 23 mm (P = 0.003), respectively. In four of the twelve patients, radiographically undetected endoleak was identified during surgery to be Type Ia, Ib, II, and III, respectively. The rates of early and late procedural complications, and overall mortality were 8.3%, 8.3% and 8.3%, respectively., Conclusions: Patients with endotension have a risk of delayed endoleak and aneurysm rupture; secondary intervention should be performed in such cases to prevent fatal complications. Surgical treatment appears to be a curative treatment for endotension with favorable outcomes. In addition, the possibility of an undetected endoleak should be considered as a potential cause of endotension., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described., Methods: We studied all elective EVAR from 2010 -2018 in a single institution. Late endoleaks were defined as those appearing after 1 year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival., Results: Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92-81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine 1-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P = 0.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P = 0.02), neck length <20mm (HR 3.0 [1.1-8.6], P = 0.04), and neck angle>60 degrees (HR 3.4 [1.5-7.9], P = 0.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. 2 patients had proximal degeneration and 5 experienced graft migration. There were 2 ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years)., Conclusion: Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Aneurysm sac regression after standard endovascular aortic repair is associated with improved outcomes, but similar data are limited after fenestrated endovascular aortic repair (FEVAR). We sought to evaluate sac regression after FEVAR, and identify any predictors of this favorable outcome., Methods: Patients undergoing elective FEVAR using the commercially available Zenith Fenestrated device (ZFEN; Cook Medical, Bloomington, IN) from 2012 to 2018 at a single institution were reviewed retrospectively. The maximal aortic diameter was compared between the preoperative scan and those obtained in follow-up. Patients with of 5 mm or more sac regression were included in the regression (REG) group, with all others in the nonregression (NONREG) group. Outcomes were compared between groups using univariate analysis, and logistic regression analysis was performed to identify any predictive factors for sac regression., Results: We included 132 patients undergoing FEVAR in the analysis. At a mean follow-up of 33.1 months, 65 patients (49.2%) had sac regression of 5 mm or more and comprised the REG group (n = 65 [49.2%]). The REG group had smaller diameter devices, and were less likely to have had concomitant chimney grafts placed (P < .05). The NONREG group had a higher incidence of type II endoleak (35.8% vs 12.3%; P = .002). Sac regression was associated with a significant mortality benefit on Kaplan-Meier analysis (log rank P = .02). Multivariate analysis identified adjunctive parallel grafting (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.03-0.36; P < .01), persistent type II endoleak (OR, 0.13; 95% CI, 0.02-0.74; P < .01), and a greater number of target vessels (OR, 0.25; 95% CI, 0.10-0.62; P = .002) as independent predictors of failure to regress., Conclusions: Sac regression after FEVAR occurred in nearly one-half of patients, but seems to be less common in patients with persistent type II endoleaks and those undergoing concomitant parallel grafting. Sac regression was associated with a significant survival advantage, and can be used as a clinical marker for success after FEVAR., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study evaluated the incidence and long-term outcomes of postoperative type 1a endoleak (PT1a) following endovascular aortic aneurysm repair (EVAR)., Methods: A retrospective review of consecutive aortoiliac EVARs performed at a single institution from June 2006 to June 2012 was conducted. Patients with PT1a were identified by postoperative imaging and compared with those who did not develop a PT1a. Late outcomes were also studied of a subset of patients with PT1a who had persistent intraoperative type 1a endoleak (iT1a) on completion angiogram during EVAR that had resolved on initial follow-up imaging., Results: Three hundred eighty-nine patients underwent EVAR with median follow-up of 87 months (interquartile range, 64-111 months). The incidence of PT1a was 8.2% (n = 32) with a median follow-up of 74 months (interquartile range, 52-138 months). Compared with the total cohort, those who developed PT1a were statistically more likely to be female (32% vs 17%; P = .03) and have a higher all-cause mortality (71% vs 40%; P < .01) and aneurysm-related mortality (15.6% vs 1.7%; P < .01). Median time to presentation was 52 months. Of the 32 patients with PT1a, five (15.6%) presented with aortic rupture, of which three underwent extension cuff placement, one had open graft explant, and one declined intervention. Six patients in total (18.7%) declined intervention; five of these died of nonaneurysmal causes and one remains alive. Of the 26 patients with PT1a who had intervention, 21 (80.7%) showed resolution of PT1a, and five (19.2%) had recurrence. For patients with recurrent PT1a, two had resulting aneurysm-related mortality, two endoleaks resolved after relining with an endograft, and one patient declined intervention but remains alive. Patients with PT1a who had intervention with resolution showed no significant difference in median survival estimates (140.0 months) compared with the remaining EVAR cohort (120.0 months; P = .80). Within the PT1a cohort, 6 (18.7%) had also experienced iT1a with a mean time to presentation of the late PT1a of 45 months. iT1a was associated with a significantly increased likelihood of developing a PT1a (P < .01) and decreased median survival (P < .01), but there was no known aneurysm-related mortality., Conclusions: Development of PT1a following elective EVAR is associated with increased all-cause and aneurysm-related mortality and presents an average of 52 months postoperatively. This underscores the importance of long-term surveillance. Patients with PT1a who had a successful intervention showed no significant difference in median survival. Those with iT1a had a higher risk for PT1a compared with the EVAR cohort overall and had decreased median survival, without increased aneurysm-related mortality., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Aortic neck dilatation (AND) occurs after endovascular aneurysm repair (EVAR) with self expanding stent grafts (SESs). Whether it continues, ultimately exceeding the endograft diameter leading to abdominal aortic aneurysm (AAA) rupture, remains uncertain. Dynamics, risk factors, and clinical relevance of AND were investigated after EVAR with standard SESs., Methods: All intact EVAR patients treated from 2000 to 2015 at a tertiary institution were included. Demographic, anatomical, and device related characteristics were investigated as risk factors for AND. Outer to outer diameters were measured at a single standardised aortic level on reconstructed computed tomography (CT) images., Results: A total of 460 patients were included (median follow up 5.2 years, interquartile range [IQR] 3.0, 7.7 years; CT imaging follow up 3.3 years, IQR 1.3, 5.4). Baseline neck diameter was 24 mm (IQR 22, 26) and increased 11.1% (IQR 1.5%, 21.9%) at last CT imaging. Endograft oversizing was 20.0% (IQR 13.6, 28.0). AND was greater during the first year (5.2% [IQR 0, 11.7]) decreasing subsequently (two to four years to 1.4%/year [IQR 0.0, 4.5%], p ≤ .001) and was associated with suprarenal fixation endografts (t value = 7.9, p < .001) and oversizing (t value = 4.4, p < .001). AND exceeding the endograft was 3.5% (95% CI 2.2% - 4.8%) and 14.4% (95% CI 11.0% - 17.8%) at five and eight years, respectively. Excessive AND was associated with baseline neck diameter (OR 1.2/mm, 95% CI 1.05 - 1.41) while the Excluder endograft had a protective effect (OR 0.15, 95% CI 0.04 - 0.58). Excessive AND was associated with type 1A endoleak (HR 3.3, 95% CI 1.1 - 9.7) and endograft migration > 5 mm (HR 3.1, 95% CI 1.4 - 6.9)., Conclusion: AND after EVAR with SES is associated with endograft oversizing and radial force but decelerates after the first post-operative year. Baseline aortic neck diameter and suprarenal stent bearing endografts were associated with an increased risk of AND beyond nominal stent graft diameter. However, it remains unclear whether patient selection, differences in endograft radial force or the suprarenal stent are accountable for this difference., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Thoracic aortic diseases, including disease of the descending thoracic aorta (DTA), are significant causes of death in the United States. Open repair of the DTA is a physiologically impactful operation with relatively high rates of mortality, paraplegia, and renal failure. Thoracic endovascular aortic repair (TEVAR) has revolutionized treatment of the DTA and has largely supplanted open repair because of lower morbidity and mortality. These Society for Vascular Surgery Practice Guidelines are applicable to the use of TEVAR for descending thoracic aortic aneurysm (TAA) as well as for other rarer pathologic processes of the DTA. Management of aortic dissections and traumatic injuries will be discussed in separate Society for Vascular Surgery documents. In general, there is a lack of high-quality evidence across all TAA diseases, highlighting the need for better comparative effectiveness research. Yet, large single-center experiences, administrative databases, and meta-analyses have consistently reported beneficial effects of TEVAR over open repair, especially in the setting of rupture. Many of the strongest recommendations from this guideline focus on imaging before, during, or after TEVAR and include the following: In patients considered at high risk for symptomatic TAA or acute aortic syndrome, we recommend urgent imaging, usually computed tomography angiography (CTA) because of its speed and ease of use for preoperative planning. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). If TEVAR is being considered, we recommend fine-cut (≤0.25 mm) CTA of the entire aorta as well as of the iliac and femoral arteries. CTA of the head and neck is also needed to determine the anatomy of the vertebral arteries. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). We recommend routine use of three-dimensional centerline reconstruction software for accurate case planning and execution in TEVAR. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). We recommend contrast-enhanced computed tomography scanning at 1 month and 12 months after TEVAR and then yearly for life, with consideration of more frequent imaging if an endoleak or other abnormality of concern is detected at 1 month. Level of recommendation: Grade 1 (Strong), Quality of Evidence: B (Moderate). Finally, based on our review, in patients who could undergo either technique (within the criteria of the device's instructions for use), we recommend TEVAR as the preferred approach to treat elective DTA aneurysms, given its reduced morbidity and length of stay as well as short-term mortality. Level of recommendation: Grade 1 (Strong), Quality of Evidence: A (High). Given the benefits of TEVAR, treatment using a minimally invasive approach is largely based on anatomic eligibility rather than on patient-specific factors, as is the case in open TAA repair. Thus, for isolated lesions of the DTA, TEVAR should be the primary method of repair in both the elective and emergent setting based on improved short-term and midterm mortality as well as decreased morbidity., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Type II endoleaks (T2ELs) are the most common type of endoleak after endovascular aneurysm repair (EVAR). The iliolumbar artery arising from the hypogastric artery is often a major source of T2ELs, and transarterial embolization of the iliolumbar artery through the hypogastric artery is sometimes performed to interrupt sac expansion during follow-up. Considering the equivocal results of an association between hypogastric embolization and T2ELs in previous studies, this topic has re-emerged after the advent of iliac branch devices. This study reviewed our series to clarify whether hypogastric embolization is associated with T2ELs at 12 months after EVAR., Methods: Patients who underwent elective EVAR between June 2007 and May 2017 at our institution were retrospectively reviewed. Patients with postoperative computed tomography angiography (CTA) at 12 months were included. Patients in whom CTA revealed type I or type III endoleaks during follow-up, who required reinterventions before 12 months, and who had solitary iliac aneurysms were excluded. The primary outcome was the incidence of T2ELs at 12 months after EVAR. The associations of patients' characteristics, anatomic factors, hypogastric embolization, and type of endograft with the primary outcome were analyzed., Results: In total, 375 patients were enrolled. During the median follow-up of 59.5 months (interquartile range, 19-126 months), 40 patients died, and 50 reinterventions were performed. In 108 patients (28.8%), either hypogastric artery was embolized to extend distal landings to the external iliac artery. Bilateral and unilateral embolization was performed in nine and 99 patients, respectively. In total, 153 patients (40.8%) had T2ELs found by CTA at 12 months. In the univariate analysis, the status of hypogastric artery occlusion or embolization was not significantly different between patients with and without T2ELs. However, there were not enough patients to detect a 10% difference in T2ELs with >80% statistical power. In the multivariate analysis, significant associations with T2EL were observed for female sex (P = .049), patent inferior mesenteric artery (P = .006), and presence of five or more patent lumbar arteries (P < .001) but not for hypogastric embolization. In addition, compared with the Zenith (Cook Medical, Bloomington, Ind) endograft, the Excluder (W. L. Gore & Associates, Flagstaff, Ariz) endograft was significantly related to T2EL (P = .001)., Conclusions: No significant association between hypogastric embolization and T2EL was demonstrated in this retrospective study, which lacked adequate statistical power., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Follow-up after endovascular aneurysm repair is necessary to detect potentially life-threatening complications such as endoleaks. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) is often used as standard of care for follow-up. Contrast-enhanced ultrasound (CEUS) has been shown to be a viable and fast real-time nonionizing imaging modality with equivalent diagnostic accuracy while also being superior to color Doppler ultrasound. The aim of this cost-utility analysis was to evaluate the cost-effectiveness of this imaging method in comparison to others for the evaluation of endoleaks requiring treatment., Methods: A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with CTA, MRA, CEUS, and color Doppler ultrasound. Model input parameters were obtained from recent literature. The applied sensitivity and specificity values amounted to 90.5% and 100.0% for CTA, 96.0% and 100.0% for MRA, 94.0% and 95.0% for CEUS, and 82.0% and 93.0% for color Doppler ultrasound. Probabilistic and deterministic sensitivity analysis was performed to estimate uncertainty of model results. To evaluate cost-effectiveness, incremental cost-effectiveness ratios were reported as a measure representing the economic value of a strategy compared with an alternative. The willingness to pay was set to $100,000/QALY., Results: In the base-case scenario for a willingness to pay of $100,000 per QALY, CEUS was the most cost-effective of the four diagnostic strategies with estimated costs of $17,383 and effectiveness of 9.770 QALYs. CTA was estimated to result in lifetime costs of $17,679 with an expected effectiveness of 9.768 QALYs, whereas color Doppler ultrasound showed expected costs of $17,287 with 9.763 QALYs. Expected costs and effectiveness of MRA amounted to $17,945 and 9.771 QALYs each. Base-case estimates of the incremental cost-effectiveness ratios for CEUS vs color Doppler ultrasound equaled $14,173.52/QALY., Conclusions: CEUS is a cost-effective imaging method for the evaluation of therapy-requiring endoleaks in endovascular aneurysm repair surveillance., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair., Methods: Patients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations., Results: Twenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10 -3  N ± 18.7 × 10 -3  N vs 12.31 × 10 -3  N ± 6.8 × 10 -3  N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively., Conclusions: Longer stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The most common endoleak after endovascular aneurysm repair is type II. Although type II endoleaks (TIIEL) are generally considered benign, there are reports that they can lead to aortic rupture. In this study, we reviewed the effect of TIIEL on sac size change to determine if sac expansion owing to a TIIEL could result in the development of a type IA endoleak (TIAEL)., Methods: After internal review board approval, all aortoiliac endovascular aneurysm repairs performed at a single institution between June 2006 and June 2012 were retrospectively reviewed. Patient demographics, comorbidities, aneurysm diameter, graft type, need for reintervention, and complications were collected. Patients with TIIEL diagnosed on follow-up imaging were categorized as those who underwent intervention for their TIIEL and those who did not. Outcomes were tabulated with attention to sac size change, development of TIAEL, rupture, and survival., Results: Six hundred twenty-seven patients underwent aortoiliac stent graft placement at our institution during this time period. Patients with an operative indication other than nonruptured infrarenal abdominal aortic aneurysm and those without preoperative computed tomography angiography or follow-up data available for review were excluded. The total number of patients included was 389 with an average follow-up of 58.8 months (range, 0-194 months). Follow-up imaging diagnosed 124 patients with TIIEL (32%). Patients with TIIEL were significantly older (P < .0001) and more likely to be hypertensive (P < .05) but less likely to be smokers (P = .01). They had a significantly larger sac size increase than patients without TIIEL (9.50 vs -0.78 mm; P < .0001). Those with TIIEL were significantly more likely to develop a TIAEL than patients who did not have TIIEL (14% vs 5%; P = .004), but the rate of rupture was not significantly different (4% vs 2%; P = .33). In those with a TIIEL, the average sac size increase at which TIAEL developed was 13 mm. Patients in the TIIEL group who underwent intervention for their TIIEL survived significantly longer than patients who did not undergo intervention (140 months vs 100 months; P = .004)., Conclusions: Our data suggest that there is an increased incidence of late TIAEL in patients with TIIEL compared with those without a TIIEL. Our study also demonstrates an increased overall survival in TIIEL patients who underwent intervention. Future studies are necessary to better define the association between TIIEL with enlarging sac and the development of TIAEL. However, it is reasonable to conclude that intervention for TIIEL should be undertaken at or before a cumulative sac size increase of 13 mm., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate early and late results of hybrid repair techniques for Kommerell's diverticulum (KD)., Methods: All patients who underwent hybrid repair (thoracic endovascular aortic repair + supra-aortic debranching) for KD between 2009 and 2018 were included in this retrospective multicenter study (three Italian centers). A proximal landing zone (PLZ) of at least 2 cm of healthy aorta was considered adequate for the deployment of a standard thoracic stent graft. The early end points were technical success, in-hospital mortality, and cerebrovascular events. Late outcomes included survival, reintervention, and patency of supra-aortic debranching. We used an embryogenetic anomaly based aortic arch classification for PLZ evaluation to identify the most appropriate hybrid adjunct., Results: Sixteen patients with KD were included. According to the aforementioned classification, stent graft deployment was required in six patients (37.5%) in PLZ 0, nine patients (56.3%) in PLZ 1, and one patient (6.3%) in PLZ 2. Technical success was achieved in all patients. One patient (6.3%) died in the hospital because of posterior cerebral hemorrhage after total debranching (PLZ 0). No further cerebrovascular events were observed. One patient (6.3%) had an asymptomatic left subclavian artery-right left subclavian artery bypass occlusion and required early reintervention. The 30-day secondary patency of supra-aortic debranching was 100%. Two type II endoleaks (12.5%) were detected at 1 month through computed tomography angiography. Further transient complications were found in three cases: hemidiaphragm paralysis in one patient and recurrent laryngeal nerve paralysis in two patients. At a mean follow-up of 48 months, four patients had died because of nonaortic reasons, and one RCCA-right subclavian artery bypass had lost its patency. None of the patients reported any growth of KD after hybrid repair. Ten patients (62.5%) showed aneurysmal sac shrinkage of at least 5 mm., Conclusions: Hybrid repair is confirmed to be a safe and effective approach for KD. Operative risk is associated primarily with the invasiveness of the hybrid adjunct., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Aortic geometry has been shown to influence the development of endograft malapposition (bird-beaking) in thoracic endovascular aortic repair (TEVAR), but the extent of this relationship lacks clarity. The aim of this study was to develop a reproducible method of measuring bird-beak severity and to investigate preoperative geometry associated with bird-beaking., Methods: The study retrospectively analyzed 20 patients with thoracic aortic aneurysms or type B dissections treated with TEVAR. Computed tomography scans were used to construct three-dimensional geometric models of the preoperative and postoperative aorta and endograft. Postoperative bird-beaking was quantified with length, height, and angle; categorized into a bird-beak group (BBG; n = 10) and no bird-beak group (NBBG; n = 10) using bird-beak height ≥5 mm as a threshold; and correlated to preoperative metrics including aortic cross-sectional area, inner curvature, diameter, and inner curvature × diameter as well as graft diameter and oversizing at the proximal landing zone., Results: Aortic area (1002 ± 118 mm 2 vs 834 ± 248 mm 2 ), inner curvature (0.040 ± 0.014 mm -1 vs 0.031 ± 0.012 mm -1 ), and diameter (35.7 ± 2.1 mm vs 32.2 ± 4.9 mm) were not significantly different between BBG and NBBG; however, inner curvature × diameter was significantly higher in BBG (1.4 ± 0.5 vs 1.0 ± 0.3; P = .030). Inner curvature and curvature × diameter were significantly correlated with bird-beak height (R = 0.462, P = .041; R = 0.592, P = .006) and bird-beak angle (R = 0.680, P < .001; R = 0.712, P < .001)., Conclusions: TEVAR bird-beak severity can be quantified and predicted with geometric modeling techniques, and the combination of high preoperative aortic inner curvature and diameter increases the risk for development of TEVAR bird-beaking., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The management of type II endoleak (T2E) remains controversial because of the heterogeneous outcome. For blood-based screening to detect malignant T2E, we focused on platelets after endovascular aneurysm repair (EVAR) and compared them with the prognosis of T2Es., Methods: From 2007 to 2015, there were 249 patients treated with EVAR for abdominal aortic aneurysm who were evaluated retrospectively. The mean follow-up period was 3.5 ± 0.2 years. T2Es that had aneurysm sac enlargement or converted to type I or type III endoleak were defined as malignant; the other T2Es were considered benign. Cases without any complications, including T2E, were defined as completed. We compared the platelet count on postoperative days (PODs) 1 to 7 with preoperative baseline values among the three groups. Sequentially, we calculated the cutoff of the platelet ratio on POD 7 to the baseline value in relation to malignant T2E using receiver operating characteristic analysis, and the cutoff ratio was 113% (sensitivity, 79%; specificity, 58%). We then reclassified T2E patients into T2E-high platelet (T2E-HP; ≥113%) or T2E-low platelet (T2E-LP; <113%) groups. The influence of platelets on T2E was evaluated with reintervention rate and cumulative aneurysm sac enlargement rate using the Kaplan-Meier method., Results: T2Es were found in 70 patients (28%), and 179 patients were assigned to the completed group. Malignant and benign T2Es were found in 33 and 37 patients, respectively. No difference was found in the preoperative baseline values. On POD 7, the platelet count in the malignant T2E group was significantly lower than that in the completed and benign T2E groups (168 × 10 3 /μL vs 207 × 10 3 /μL and 201 × 10 3 /μL; P = .0124). Then, 27 and 43 patients were assigned to the T2E-HP and T2E-LP groups, respectively. The reintervention-free survival rate in the T2E-LP group was lower than that in the completed group (at 3 years, 66.4% ± 8.0% vs 71.9% ± 4.0%; P = .0031). Among T2E patients, the cumulative aneurysm sac enlargement rates in the T2E-LP group were significantly higher than those in the T2E-HP group (at 3 years, 34.6% ± 8.2% vs 20.6% ± 8.2%; P = .0105). Univariate Cox proportional hazards analysis for the cumulative aneurysm sac enlargement rates among T2E patients showed that sex, dual antiplatelet therapy, and lower platelet ratio (<113%) were significant predictors; multivariate analysis showed that T2E-LP was the only significant predictor (hazard ratio, 2.60; P = .0355)., Conclusions: The platelet count of patients with malignant T2Es on POD 7 was definitively lower than that of patients with completed EVAR or with benign T2Es. The lower platelet count on POD 7 could be a risk factor for aneurysm sac enlargement among patients with T2Es., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Chimney endovascular aneurysm sealing (ch-EVAS) could potentially minimize gutter-associated endoleaks in patients with juxtarenal abdominal aortic aneurysms resulting from the use of the conformable endobags surrounding the chimney stent grafts (ch-SGs). The aim of the present study was to quantify the (non)apposition of the endobags in the proximal aortic neck, migration of the endograft stent frames, and changes in geometry of the ch-SGs during the follow-up period., Methods: The prospective data from 20 patients undergoing elective ch-EVAS were retrospectively reviewed. The aortic anatomy was analyzed on preoperative and postoperative computed tomography scans. The (non)apposition of the endobags in the aortic neck, Nellix (Endologix, Irvine, Calif) stent frame migration, and chimney graft geometry and migration were assessed., Results: The median preoperative infrarenal neck length was 4.0 mm (interquartile range [IQR], 0-6.0 mm). The median seal length in the juxtarenal aortic neck at the first follow-up was 23.0 mm (IQR 18.0-30.8 mm). Five type IA endoleaks were identified on postoperative imaging; one at 1 month and four newly diagnosed at 1 year. Of these five type IA endoleaks, two were type Is1 (not extending into the aneurysm sac) and did not need reintervention and other three were type Is2 (extending into the aneurysm sac). One of these patients died of malignancy before reintervention could be performed. Bilateral ch-SG occlusions in one patient were documented at the 1-month follow-up (patient needed hemodialysis) and two patients with a new single ch-SG occlusion were found at the 1-year follow-up. No reinterventions were performed for the ch-SG occlusions. An occluded Nellix stent frame in one patient was treated with femorofemoral crossover bypass. Kaplan-Meier estimate of reintervention-free survival was 85.0% after 1 year. Migration ≥5 mm of the proximal end of the Nellix stent frames was observed in 20.0% of the patients, but no reintervention was performed at the 1-year follow-up. Imaging showed 20.1% of the available sealing surface was not used, and the nonapposition surface increased to 30.6% of the preoperative aortic neck surface at 1 year. Median migration was 3.5 mm (IQR, 2.4-5.0 mm) and 3.1 mm (IQR, 2.0-4.8 mm) for the left and right proximal end of the Nellix stent frames, respectively, and was 3.0 mm (IQR, 2.2-4.8 mm) for the proximal end of the ch-SGs at 1 year of follow-up., Conclusions: Substantial distal migration of the Nellix endograft and positional changes of the ch-SGs in the juxtarenal aortic neck were observed at 1 year of follow-up, resulting in a 25.0% type IA endoleak rate, with three of these type IA endoleaks extending into the aneurysm sac. The reintervention-free survival rate was 85.0% at 1 year in this cohort of 20 patients. Careful follow-up after ch-EVAS is advised because changes are often subtle. The authors have stopped the ch-EVAS procedure so far. Long-term follow-up data on the stability of the Nellix endograft and the consequences of migration on ch-SGs is required before this technique should be used in clinical practice., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We report a case of late type IIIb endoleak with Willis covered stent (WCS) developed 14 months after endovascular paraclinoid aneurysm repair., Methods: A 52-year-old woman presented with episodic headache, caused by a giant paraclinoid aneurysm. She underwent a successful 3.5 x 16mm WCS positioning to treat the aneurysm. Fourteen months later, the patient was admitted with the same symptoms. Digital subtraction angiography examination showed recurrence of the aneurysm, which was similar to the preoperative one. DynaCT (Siemens, Erlangen, Germany) indicated the intact of the metal structure of the stent without migration. Type IIIb endoleak (defect in the graft fabric) was confirmed with a whole aneurysm neck located in the middle part of the stent. The type IIIb endoleak was treated with another WCS (4.0 x 16mm). The immediate digital subtraction angiography imaging indicated that the endoleak disappeared and the aneurysm was completely occluded. Re-examination done 1 year after the second treatment showed a complete exclusion of the aneurysm sac., Conclusions: Type IIIb endoleaks can be safely treated by the endovascular positioning of another WCS. Continuous surveillance after endovascular paraclinoid aneurysm repair for intracranial aneurysms is warranted to make ensure the safety of WCS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Late distal type I endoleak (ELIB) hampers the outcome of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA); however, only few dedicated experiences have been reported in the literature. The aim of the study was to evaluate the incidence, presentation and treatment of late ELIB and to identify possible anatomical and technical predictors., Methods: All patients undergoing elective EVAR between 2008 and 2013 were collected prospectively. Follow up was by post-operative computed tomography angiography (CTA) performed within 30 days and CTA and/or duplex ultrasound (DUS) at six or 12 months and yearly thereafter. Patients with late ELIB, defined as distal type I endoleak detected more than six months after the primary intervention without endoleak on the intra-operative completion angiogram and on the post-operative CTA, were retrospectively selected (G1) and compared with a control group with no ELIB (G2) homogeneous for clinical conditions, endograft implanted, and timing of follow up. The minimum follow up required for inclusion in the study was 24 months. Pre-operative morphological aorto-iliac features and EVAR implant details were evaluated, and measurements performed after centre lumen line reconstructions using dedicated software. The differences between G1 and G2 were analysed using the chi-square test, the Student t test, and logistic regression., Results: Six hundred and sixteen patients were submitted to EVAR. ELIB was detected in 14 cases (2.3%) (G1) at a median follow up of 32.8 (IQR 48) months. In three of the 14 cases ELIB was symptomatic (AAA rupture, 2; pain, 1); in the remaining 11 cases it was asymptomatic and found incidentally at routine follow up. Treatment was by open repair in one case and by endovascular iliac leg extension in 13 cases. Hypogastric exclusion was necessary in two of 14 cases. Thirty patients were included in G2, with a median follow up of 41.2 (25) months. Common iliac artery length <4 cm (OR 5.3, 95% CI 1.1-29.5, p = .05), diameter > 15 mm (OR 3.5, 95% CI 1.2-10.9, p = .03), and severe thrombotic apposition (>50% of circumference) (OR 5, 95% CI 1.2-19.2, p = .02), at the iliac sealing zone were significant predictors of ELIB, on univariable analysis; oversizing of the iliac leg diameter < 10% and distal sealing > 1 cm above the hypogastric origin were independently associated with ELIB (OR 5.4, 95% CI 1.3-21.5, p = .01 and OR 6.6, 95% CI 1.1-39.3, p = .03, respectively), on multivariable analysis., Conclusion: The present data underline that ELIB is a non-negligible occurrence during long term EVAR follow up and requires further interventions, most often by endovascular solutions. According to the ELIB risk factors identified in this study, an iliac leg diameter oversize >10% and extensive common iliac artery coverage (<1 cm above the hypogastric origin) would be suggested to prevent this complication., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: To evaluate the influence of baseline clinical and morphological parameters on the occurrence of a late stent graft related endoleak (srEL; types 1 and 3) after endovascular aneurysm repair (EVAR)., Methods: This is a retrospective case control study of patients who were routinely followed up after EVAR of abdominal aortic aneurysms. Pre-interventional, pre-discharge, and last available multislice computed tomography angiogram (MSCTA) of 279 patients were analysed. Stent graft related endoleaks detected by follow up MSCTA at least six months after EVAR were specified as late srEL. Baseline demographic characteristics and morphological variables were derived from the pre-interventional and pre-discharge MSCTA. Univariable and multivariable analysis with a Cox proportional hazards model were used to determine baseline factors associated with the occurrence of a late srEL., Results: Twenty-four (8.6%) of 279 patients suffered a late srEL, during a mean MSCTA follow up of 30.9 ± 25.8 (23.5, IQR 10.6-42.8) months. In the univariable analysis, age (hazard ratio [HR] 1.09; p = .001), female sex (HR 3.25; p = .014), right iliac sealing diameter (HR 10.04; p = .03), left iliac sealing diameter (HR 8.65; p = .001), infrarenal aortic neck angulation (HR 1.02; p = .011), and suprarenal fixation level (HR 3.47; p = .014) were significantly associated with an increased incidence of late srEL. Age (HR 1.08; p = .012), female sex (HR 2.72; p = .049), and left iliac sealing diameter (HR 4.48; p = .033) proved to be risk factors significantly associated with a higher incidence of late srEL in multivariable analysis., Conclusions: Older patients, those with female gender, and those with larger left iliac sealing diameters seem to experience higher rates of late srEL. Independent confirmation of these must be addressed in larger studies., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To describe and compare the clinical and anatomical characteristics and outcomes of patients with and without known cocaine use who underwent thoracic endovascular repair for type B aortic dissections., Methods: Between January 2012 and January 2017, 186 patients underwent thoracic endovascular repair for type B aortic dissection at our institution. Clinical data and anatomical characteristics were collected under an institutional review board-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with cocaine use (C+; n = 14) and those with no known cocaine use (C-; n = 172)., Results: Cocaine users were more likely to be young African American males who smoked. They tended to present with more extensive dissections as evidenced by larger false lumen diameters. They also had higher rates of endoleaks and more reinterventions., Conclusions: These results suggest that special care should be taken to provide close follow-up for these patients., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA) disease. However, the survival advantage is lost in the long term due the occurrence of endoleaks affecting the late rupture of aneurism sac. Few data are available on the role of blood pressure control in affecting the incidence of type 2 endoleaks in patients undergoing EVAR., Objective: Aim of this study was to evaluated whether systolic blood pressure (SBP) control to target 130 mmHg reached after preoperative cardiology consultant might decrease the incidence of type II endoleak(T2E), sac expansion and related aortic reintervention after elective endovascular aneurysm repair(EVAR)., Methods: We analyzed 386 patients undergoing EVAR between 2008 and 2016. The primary endpoints were T2E, sac expansion and related aortic re-intervention or sac shrinkage during a median follow-up of 24 months [12-48]. The secondary endpoint was every cause of vascular or cardiac morbidity and mortality., Results: The SBP value of 130 mmHg at the time of EVAR resulted, at ROC curve analysis, the most sensitive and specific for all the analyzed endpoints (T2E, n = 74; sac expansion n = 19; re-intervention, n = 10, sac shrinkage, n = 72). The combination antihypertensive therapy showed a significant inverse relationship with T2E occurrence. The incidence of primary endpoints was significantly higher (p < 0.001) in patients with SBP ≥ 130 mmHg. Cardiovascular death was significantly more prevalent (p < 0,001) in patients with SBP ≥130 mmHg. These findings were confirmed at the multivariable Cox regression analysis [primary endpoint HR = 0.09(0.06-0.15), p < 0.001; cardiovascular death HR = 0.33(0.12-0.85), p = 0.023]., Conclusions: Tight SBP control at the target of 130 mmHg at the time of elective EVAR significantly decreases TE2 occurrence, need of re-intervention and cardiovascular death in a prolonged follow-up of a large sample of patients., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: The objective of this study was to examine whether prophylactic use of EndoAnchors (Medtronic, Santa Rosa, Calif) contributes to improved outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms through 2 years., Methods: The Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) subjects who received prophylactic EndoAnchors during EVAR were considered for this analysis. Imaging data of retrospective subjects who underwent EVAR at ANCHOR enrolling institutions were obtained to create a control sample. Nineteen baseline anatomic measurements were used to perform propensity score matching, yielding 99 matched pairs. Follow-up imaging of the ANCHOR and control cohorts was then compared to examine outcomes through 2 years, using Kaplan-Meier survival analysis., Results: Freedom from type Ia endoleak was 97.0% ± 2.1% in the ANCHOR cohort and 94.1% ± 2.5% in the control cohort through 2 years (P = .34). The 2-year freedom from neck dilation in the ANCHOR and control cohorts was 90.4% ± 5.6% and 87.3% ± 4.3%, respectively (P = .46); 2-year freedom from sac enlargement was 97.0% ± 2.1% and 94.0% ± 3.0%, respectively (P = .67). No device migration was observed. Aneurysm sac regression was observed in 81.1% ± 9.5% of ANCHOR subjects through 2 years compared with 48.7% ± 5.9% of control subjects (P = .01). Cox regression analysis found an inverse correlation between number of hostile neck criteria met and later sac regression (P = .05). Preoperative neck thrombus circumference and infrarenal diameter were also variables associated with later sac regression, although not to a significant degree (P = .10 and P = .06, respectively). Control subjects with thrombus were significantly less likely to experience later sac regression than those without thrombus (6% and 43%, respectively; P = .001). In ANCHOR subjects, rate of regression was not significantly different in subjects with or without thrombus (33% and 36%, respectively; P = .82). Control subjects with wide aortic necks (>28 mm) were observed to experience sac regression at a lower rate than subjects with smaller diameter necks (10% and 44%, respectively; P = .004). Wide neck and normal neck subjects implanted with EndoAnchors experienced later sac regression at roughly equivalent rates (44% and 33%, respectively; P = .50)., Conclusions: In propensity-matched cohorts of subjects undergoing EVAR, the rate of sac regression in subjects treated with EndoAnchors was significantly higher. EndoAnchors may mitigate the adverse effect of wide infrarenal necks and neck thrombus on sac regression, although further studies are needed to evaluate the long-term effect of EndoAnchors., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective/background: The aim was to describe the re-interventions after endovascular and open repair of rupture, and investigate whether these were associated with aortic morphology., Methods: In total, 502 patients from the IMPROVE randomised trial (ISRCTN48334791) with repair of rupture were followed-up for re-interventions for at least 3 years. Pre-operative aortic morphology was assessed in a core laboratory. Re-interventions were described by time (0-90 days, 3 months-3 years) as arterial or laparotomy related, respectively, and ranked for severity by surgeons and patients separately. Rare re-interventions to 1 year, were summarised across three ruptured abdominal aortic aneurysm trials (IMPROVE, AJAX, and ECAR) and odds ratios (OR) describing differences were pooled via meta-analysis., Results: Re-interventions were most common in the first 90 days. Overall rates were 186 and 226 per 100 person years for the endovascular strategy and open repair groups, respectively (p = .20) but between 3 months and 3 years (mid-term) the rates had slowed to 9.5 and 6.0 re-interventions per 100 person years, respectively (p = .090) and about one third of these were for a life threatening condition. In this latter, mid-term period, 42 of 313 remaining patients (13%) required at least one re-intervention, most commonly for endoleak or other endograft complication after treatment by endovascular aneurysm repair (EVAR) (21 of 38 re-interventions), whereas distal aneurysms were the commonest reason (four of 23) for re-interventions after treatment by open repair. Arterial re-interventions within 3 years were associated with increasing common iliac artery diameter (OR 1.48, 95% confidence interval [CI] 0.13-0.93; p = .004). Amputation, rare but ranked as the worst re-intervention by patients, was less common in the first year after treatment with EVAR (OR 0.2, 95% CI 0.05-0.88) from meta-analysis of three trials., Conclusion: The rate of mid-term re-interventions after rupture is high, more than double that after elective EVAR and open repair, suggesting the need for bespoke surveillance protocols. Amputations are much less common in patients treated by EVAR than in those treated by open repair., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity., Methods: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations., Results: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion., Conclusions: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective/background: Proximal type I endoleaks are associated with abdominal aortic aneurysm (AAA) growth and rupture and necessitate repair. The Nellix™ EndoVascular Aneurysm Sealing (EVAS) system is a unique approach to AAA repair, where the appearance and treatment of endoleaks is also different. This study aimed to analyse and categorise proximal endoleaks in an EVAS treated cohort., Methods: All patients, treated from February 2013 to December 2015, in 15 experienced EVAS centres, presenting with proximal endoleak were included. Computed tomography scans were analysed by a core laboratory. A consensus meeting was organised to discuss and qualify each case for selection, technical aspects, and possible causes of the endoleak. Endoleaks were classified using a novel classification system for EVAS., Results: During the study period 1851 patients were treated using EVAS at 15 centres and followed for a median of 494 ± 283 days. Among these, 58 cases (3.1%) developed a proximal endoleak (1.5% early and 1.7% late); of these, 84% of 58 patients were treated outside the original and 96% outside the current, refined, instructions for use. Low stent positioning was the most likely cause in 44.6%, a hostile anatomy in 16.1%, and a combination of both in 33.9%. Treatment, by embolisation or proximal extension, was performed in 47% of cases, with a technical success of 97%., Conclusion: The overall incidence of proximal endoleak after EVAS is 3.1% after a mean follow-up period of 16 months, with 1.5% occurring within 30 days. Their occurrence is related to patient selection and stent positioning. Early detection and classification is crucial to avoid the potential of sac rupture., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak., Methods: MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR., Results: Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak., Conclusions: Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of our study is to verify the role of metalloproteinases in endovascular repair (EVAR) and OPEN surgery treatment for abdominal aortic aneurysm (AAA). Postoperatively, these enzymes could represent an important biomarker to adapt diagnostic tests and further investigations during follow-up., Material and Method: From 2004 to 2008, 55 patients were considered with AAA. Of these, 33 patients (mean age: 70.1 years), (mean AAA diameter: 5.4cm) were treated with OPEN surgery (group A) and 22 (mean age: 74.1 years) (mean AAA diameter: 5.1cm) were treated with EVAR. In 17 of them, there were no signs of endoleak (group B1), while in 5 patients, a presence of endoleak (group B2) was detected. Plasma samples were collected in order to determine MMP-9 activity. Enzyme immunoassay was performed preoperatively at 1, 3, 6 and 12 months. Patients treated conventionally were clinically examined after 1 and 12 months by ultrasound. Patients undergoing EVAR treatment were clinically examined by CT scan after 1, 3, 6 and 12 months. The analysis was done by assessing the interaction over time of the MMP-9 value in B1 and B2 groups., Results: The average values observed for MMP-9 were preoperatively and at 1, 3, 6 and 12 months, respectively: in group A 150.8ng/mL (SD=30.5), 252.5ng/mL (SD=25.2), 315.4ng/mL (SD=22.7), 295.3ng/mL (SD=26.8), 210.7ng/mL (SD=30.2); in group B1 105ng/mL (SD=10.8), 125.6ng/mL (SD=18), 85.8ng/mL (SD=19.9), 95ng/mL (SD=20.2), 80.4ng/mL (SD=15.6); in group B2 149ng/mL (29.2), 375.4ng/mL (SD=40.2), 215ng/mL (SD=35.9), 180ng/mL (SD=20.2), 175ng/mL (SD=33.4). The MMP-9 level was higher in group B2 compared to group B1 (P=0.01), suggesting a correlation with the presence of the endoleak., Conclusions: This preliminary study shows that MMP-9 may be a biomarker of the presence of endoleak. Other further investigations and larger series are needed to show that metalloproteases could play a role in the follow-up of EVAR treated patients., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: Persistent type II endoleaks (T2Ls) with sac enlargement after endovascular abdominal aortic aneurysm repair are still of concern in view of the potential for rupture. Current treatments (embolization and stent graft [SG] explantation) are associated with lack of efficacy or high perioperative morbidity and mortality. This study evaluated an alternative technique that combines sacotomy, ligation of patent back-bleeding vessels, and SG preservation for T2L or unspecified endoleak repair., Methods: This multicenter study in France included 28 patients (27 men; median age, 78 years). Twenty-one patients (75%) had a bifurcated SG (including 3 fenestrated SGs) and seven (25%) had an aortouni-iliac SG (2 for ruptured aneurysm). Unsuccessful embolization had been performed in 10 patients (36%). Four patients (14%) presented sac enlargement with no endoleak visible on computed tomography. The origin of the endoleak remained unspecified in three patients 3 (11%). The median diameter of the aneurysmal sac was 78 mm (vs 55 mm at the time of endovascular abdominal aortic aneurysm repair) after a median follow-up of 24 months., Results: A transperitoneal approach was used in 21 patients (75%) and a retroperitoneal approach was used in seven (25%). A guidewire was placed in the supraceliac aorta in 14 patients, and an occlusion balloon was temporarily inflated in six. Aortic cross-clamping was performed in five patients. T2Ls were identified in 26 patients, and associated with a distal type I endoleak in 1 patient, a type III endoleak in 3, and a type IV endoleak in 1. Two patients presented with endotension. All the endoleaks were treated successfully, with a mean operating time of 120 minutes and a mean blood loss of 450 mL. One SG was explanted 12 days after the procedure because of early infection. One patient died during SG explantation for an aortoduodenal fistula 26 months after the endoaneurysmorrhaphy. During a median follow-up of 24 months, the control computed tomography scan showed shrinkage of the aneurysmal sac with stable diameters in all patients. No missed T2Ls, no recurrence of T2L, and no SG migration or disjunction was observed., Conclusions: Obliterating endoaneurysmorrhaphy with SG preservation can be considered as an alternative to SG removal in cases of persistent T2L responsible for aneurysmal sac enlargement after embolization failure. By avoiding extensive dissection for surgical aortic cross-clamping, minimizing hemodynamic changes, and reducing blood loss and operating time, this procedure can be performed even in patients initially considered unfit for surgery., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Type II endoleaks are common after endovascular aneurysm repair (EVAR), but their clinical significance remains undefined and their management controversial. We determined risk factors for type II endoleaks and associations with adverse outcomes., Methods: We identified all EVAR patients in the Vascular Study Group of New England abdominal aortic aneurysm database. Patients were subdivided into two groups: (1) those with no endoleak or transient type II endoleak and (2) persistent type II endoleak or new type II endoleak (no endoleak at completion of case). Patients with other endoleak types and follow-up shorter than 6 months were excluded. Multivariable analysis was used to evaluate predictors of persistent or new type II endoleaks. Kaplan-Meier and Cox regression analysis were used to evaluate predictors of reintervention and survival., Results: Two thousand three hundred sixty-seven EVAR patients had information on endoleaks: 1977 (84%) were in group 1, of which 79% had no endoleaks at all, and 21% had transient endoleaks that resolved at follow-up. The other 390 (16%) were in group 2, of which 31% had a persistent leak, and 69% had a new leak at follow-up that was not seen at the time of surgery. Group 2 was older (mean age, 75 vs 73 years; P < .001) and less likely to have chronic obstructive pulmonary disease (COPD; 24% vs 34%; P < .001) or elevated creatinine levels (2.6% vs 5.3%; P = .027). Coil embolization of one or both hypogastric arteries was associated with a higher rate of persistent type II endoleaks (12 vs 8%; P = .024), as was distal graft extension (12% vs 8%; P = .008). In multivariable analysis, COPD (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.5-0.9; P = .017) was protective against persistent type II endoleak, while hypogastric artery coil embolization (OR, 1.5; 95% CI, 1.0-2.2; P = .044), distal graft extension (OR, 1.6; 95% CI, 1.1-2.3; P = .025), and age ≥ 80 (OR, 2.7; 95% CI, 1.4-5.3; P = .004) were predictive. Graft type was also associated with endoleak development. Persistent type II endoleaks were predictive of postdischarge reintervention (OR, 15.3; 95% CI, 9.7-24.3; P < .001); however, they were not predictive of long-term survival (OR, 1.1; 95% CI, 0.9-1.6; P = .477)., Conclusions: Persistent type II endoleak is associated with hypogastric artery coil embolization, distal graft extension, older age, the absence of COPD, and graft type, but not with aneurysm size. Persistent type II endoleaks are associated with an increased risk of reinterventions, but not rupture or survival. This reinforces the need for continued surveillance of patients with persistent type II endoleaks and the importance of follow-up to detect new type II endoleaks over time., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Hostile infrarenal neck characteristics are associated with complications such as type Ia endoleak after endovascular aneurysm repair. Aortic neck angulation has been identified as one such characteristic, but its association with complications has not been uniform between studies. Neck angulation assumes triangular oversimplification of the aortic trajectory, which may explain conflicting findings. By contrast, aortic curvature is a measurement that includes the bending rate and tortuosity and may provide better predictive value for neck complications., Methods: Data were retrieved from the Heli-FX (Aptus Endosystems, Inc, Sunnyvale, Calif) Aortic Securement System Global Registry (ANCHOR). One cohort included patients who presented with intraoperative endoleak type Ia at the completion angiogram as the indication for EndoAnchors (Aptus Endosystems), and a second cohort comprised those without intraoperative or late type Ia endoleak (controls). The aortic trajectory was divided into six segments with potentially different influence on the stent graft performance: suprarenal, juxtarenal, and infrarenal aortic neck (-30 to -10 mm, -10 to 10 mm, and 10-30 mm from the lowest renal artery, respectively), the entire aortic neck, aneurysm sac, and terminal aorta (20 mm above the bifurcation to the bifurcation). Maximum and average curvature were automatically calculated over the six segments by proprietary custom software. Aortic curvature was compared with other standard neck characteristics, including neck length, neck diameter, maximum aneurysm sac diameter, neck thrombus and calcium thickness and circumference, suprarenal angulation, infrarenal angulation, and the neck tortuosity index. Independent risk factors for intraoperative type Ia endoleak were identified using backwards stepwise logistic regression. For the variables in the final regression model, suitable cutoff values in relation to the prediction of acute type Ia endoleak were defined with the area under the receiver operating characteristic curve., Results: The analysis included 64 patients with intraoperative type Ia endoleak and 79 controls. Logistic regression identified only aortic neck calcification and aortic curvature, expressed over the juxtarenal aortic neck, the aneurysm sac, and the terminal aorta, as independent predictors of intraoperative type Ia endoleak., Conclusions: Together with aortic neck calcification, aortic curvature appears to be the best predictor of intraoperative type Ia endoleak, as expressed within the juxtarenal aortic neck, the aneurysm sac, and the terminal aorta. Aortic neck angulation was not a predictor for acute failure. Aortic curvature may provide a better anatomic characteristic to define patients at risk for early complications after endovascular aneurysm repair., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate the aneurysm-related complications and device issues in patients who underwent partial endograft explantation during late conversion of endovascular aneurysm repair (EVAR) to open repair., Methods: A retrospective analysis was performed on patients who had partially explanted endografts during late conversion between 1999 and 2012. Medical records were reviewed for patient demographics, subsequent operations, and aneurysm-related complications. Postoperative abdominal X-ray films and computed tomography scans were analyzed for endograft migration, component separation, device fracture, and arterial growth or aneurysm issues., Results: Between 1999 and 2012, 22 patients had late conversion after EVAR with portions of the device left in situ. Five of the partially removed devices were Zenith, 6 Talent, 5 Ancure, 3 AneuRx, 2 Excluder endografts, and 1 Cook Aorto uni-iliac (AUI) graft. There were 4 in hospital mortalities. There were no graft migrations, component separations, device fractures, new aneurysmal degeneration, or ruptures with a median follow-up of 26.5 months., Conclusions: Partial endograft removal during late conversion is not associated with complications from the remaining device pieces during follow-up. We recommend further study of this patient population., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The aim of this study is to give an overview of current knowledge regarding abdominal aortic aneurysm (AAA) growth after endovascular aortic aneurysm repair (EVAR) that could potentially lead to aortic rupture. A search on Pubmed was performed. A total of 705 articles were found after initial search, of which 49 were included in the final selection. Reports on the incidence of aneurysm enlargement after EVAR vary between 0.2% and 41%. Continuous growth could lead to rupture of the aneurysm sac. There are several supposed risk factors for growth after EVAR. Endoleaks remain a hot topic as these could lead to persistent pressurization of the aneurysm sac causing growth. Various types of endoleak exist, of which each kind requires an individual treatment approach, other risk factors for aneurysm growth include endotension and the use of EVAR outside instructions for use (IFU). Reinterventions after EVAR are common; however, it is unclear how frequently these are required because of aneurysm enlargement. Aneurysm enlargement after EVAR remains a subject of debate, as this could lead to aortic rupture. This emphasizes the need for life-long radiologic surveillance during follow-up. Aortic growth after EVAR is often a result of endoleak; however, in some cases, no endoleak is detectable. Endoleak in combination with aortic growth >5 mm generally requires reintervention. A cause of concern is the liberal use of endovascular devices outside the IFU that may result in increased risk of AAA growth after EVAR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Treatment of type IB endoleak after thoracic endovascular aortic repair (TEVAR) for post-dissection aortic aneurysm usually includes attempts of endovascular interventions using coils or plugs to occlude the false lumen or placement of a distal fenestrated endograft. Open conversion usually requires deep hypothermia and circulatory arrest with the associated increased mortality and complications. We present a case of a young patient with a 90 mm descending thoracic aneurysm caused by a chronic type B aortic dissection. A type II endoleak after TEVAR was successfully treated with left subclavian artery transposition. The patient had a rapidly increasing aortic aneurysm with a persistent type IB endoleak in spite of placement of an Amplatzer plug into the false lumen of the dissection. He developed progressive acute compression of the main stem bronchi by the aneurysm sac and his dyspnea worsened by an acute pulmonary embolism treated with anticoagulation. Adequate oxygenation could only be achieved with mechanical ventilation using a double-lumen endobronchial tube. A left thoracotomy was performed and the type IB endoleak was treated with bending of the distal aorta around the stent graft with a Dacron graft sleeve. Aortic clamping and circulatory support devices were avoided. The sac of the aneurysm was opened, a giant hematoma was evacuated, and aneurysmorrhaphy was performed to cover the stent graft. There was no residual endoleak and the bronchi were decompressed. The patient recovered after prolonged hospitalization and he was discharged home in good condition 24 days after admission. He returned to his normal activities and is asymptomatic 5 months later. Computed tomographic angiography showed decreased aneurysm sac, no evidence of endoleak, no residual pulmonary embolus, and no bronchial compression., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A delayed secondary open conversion (SOC) after endovascular aneurysm repair may be necessary due to a failing graft. Many surgical techniques can be performed, and one such approach is partial explantation of the graft with resuturing of a new graft to the retained components of the endograft. No guidelines exist with regards to the follow-up of retained endovascular components after a delayed SOC. The theoretical risk of endoleaks remains with retained components, and this case demonstrates the development of a type Ib endoleak after SOC leading to free flow of blood into a partially resected aneurysm sac and causing a symptomatic aneurysm rupture., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To report the causes of second rupture in patients treated with a stent graft for ruptured abdominal aortic aneurysm (rAAA)., Case Report: A 69-year-old man was admitted for abdominal pain and hypovolemic shock 22 months after endovascular exclusion of an rAAA with an aortomonoiliac stent graft and a crossover bypass despite normal duplex ultrasound and sac shrinkage at 1 year. During emergent laparotomy, a type IA endoleak was discovered and the aortomonoiliac stent graft was explanted. A Dacron bypass was interposed between the infrarenal aorta and the iliac extension stent graft., Conclusions: Considering the literature, this report has 3 implications for the endovascular treatment of rAAA. First, 30% oversizing is preferable to 15% when treating an rAAA assessed by computed tomography angiography (CTA) performed during permissive hypotension. Second, the surveillance program should rely on CTA and not on a duplex examination to detect any endoleaks or migration. Finally, partial stent graft explantation is a valid option for decreasing aortic clamping time., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate outcomes of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) in patients considered at risk for type II endoleak (EII), using a sac volume-dependent dose of fibrin glue and coils., Methods: Between January 2012 and December 2014, 126 patients underwent EVAR. Based on preoperative computed tomography evaluation of anatomic criteria, 107 patients (85%) were defined as at risk for EII and assigned to randomization for standard EVAR (group A; n = 55, 44%) or EVAR with intraoperative sac embolization (group B; n = 52, 42%); the remaining 19 patients (15%) were defined as at low risk for EII and excluded from the randomization (group C). Computed tomography scans were evaluated with OsiriX Pro 4.0 software to obtain aneurysm sac volume. Freedom from EII, freedom from EII-related reintervention, and aneurysm sac volume shrinkage at 6, 12, and 24 months were compared by Kaplan-Meier estimates. Patients in group C underwent the same follow-up protocol as groups A and B., Results: Patient characteristics, Society for Vascular Surgery comorbidity scores (0.99 ± 0.50 vs 0.95 ± 0.55; P = .70), and operative time (149 ± 50 minutes vs 157 ± 39 minutes; P = .63) were similar for groups A and B. Freedom from EII was significantly lower for group A compared with group B at 3 months (58% vs 80%; P = .002), 6 months (68% vs 85%; P = .04), and 12 months (70% vs 87%; P = .04) but not statistically significant at 24 months (85% vs 87%; P = .57). Freedom from EII-related reintervention at 24 months was significantly lower for group A compared with group B (82% vs 96%; P = .04). Patients in group B showed a significantly overall mean difference in aneurysm sac volume shrinkage compared with group A at 6 months (-11 ± 17 cm(3) vs -2 ± 14 cm(3); P < .01), 12 months (-18 ± 26 cm(3) vs -3 ± 32 cm(3); P = .02), and 24 months (-27 ± 25 cm(3) vs -5 ± 26 cm(3); P < .01). Patients in group C had the lowest EII rate compared with groups A and B (6 months, 5%; 12 months, 6%; 24 months, 0%) and no EII-related reintervention., Conclusions: This randomized study confirms that sac embolization during EVAR, using a sac volume-dependent dose of fibrin glue and coils, is a valid method to significantly reduce EII and its complications during early and midterm follow-up in patients considered at risk. Although further confirmatory studies are needed, the faster aneurysm sac volume shrinkage over time in patients who underwent embolization compared with standard EVAR may be a positive aspect influencing the lower EII rate also during long-term follow-up., (Copyright © 2016 Society for Vascular Surgery. All rights reserved.)

Objective/background: Persistent type II endoleak (EL II) with sac enlargement after endovascular repair of abdominal aortic aneurysm requires treatment to prevent rupture. Embolization is not always effective. Conversion to open repair with stent graft (SG) explantation is a high risk option. The aim of this study was to evaluate the feasibility and immediate results of an alternative technique combining obliterative endoaneurysmorrhaphy (OEA) with SG preservation., Methods: The open surgical technique combined sacotomy, ligation of all patent back-bleeding vessels and SG preservation. The aneurysmal shell was tightly closed over the SG to protect it from the intestines. An intra-aortic occlusion balloon was used when clamping was required., Results: Twelve patients were treated with the OEA technique at Amiens University Hospital. All 12 procedures were successful. Four patients had previously undergone unsuccessful transarterial or translumbar embolization. Aortic clamping was performed in four cases. No SG migration or graft dislocation was observed. Follow up computed tomography scan at a median of 12 months showed shrinkage of the aneurysm sac with stable diameters and no recurrence of EL II in all cases., Conclusion: The OEA technique is an alternative option for the treatment of progressive EL II, which can be particularly useful after failure of embolization., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The advent of branched and fenestrated aortic endografts has facilitated the treatment of increasingly complex aortic pathology. The management of complications and endoleaks involving the branches and fenestrations of these grafts represents an increasingly significant clinical and technical challenge., Methods: A 79-year-old woman developed a rare type IIIb endoleak from a tear in the graft fabric immediately posterior to the celiac axis branch 3 years after the placement of an off-the-shelf branched endograft for a type II thoracoabdominal aortic aneurysm. The patient presented urgently with abdominal pain and a maximal aneurysm diameter of 15.3 cm., Results: The operative plan was to create a chimney graft completely within the original branched endograft to cover the defect and maintain celiac branch flow. The celiac trunk was accessed from a left axillary approach and access for the main endograft body was achieved via the left femoral artery. Two balloon-expandable covered stents were deployed from the celiac branch extending into the main endograft as a chimney and molded to 2 aortic extension cuffs to cover the fabric defect. The resultant configuration was a modified-sandwich graft within the original stent graft and resulted in successful exclusion of the endoleak. Postoperative imaging at 1, 6, and 12 months has demonstrated continued patency of the celiac trunk, no further endoleak, and a 16-mm reduction in aneurysm size., Conclusions: The chimney technique was successfully applied as an endovascular option to salvage a multibranched endograft with a significant and anatomically unfavorable defect. Careful follow-up and additional clinical study are required to clarify the role of off-the-shelf solutions in complex endoleak management., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: A recent investigation has documented an increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR) of familial abdominal aortic aneurysms (fAAAs). We hypothesized that fAAA patients are not at increased risk for complications following open AAA repair or EVAR when compared with sporadic abdominal aortic aneurysm (spAAA) patients. To this end, we performed a single institution retrospective review., Methods: Epidemiologic data were collected through the electronic medical record. Family history data were obtained from a questionnaire administered at the initial vascular surgery consultation. Major adverse events were defined as myocardial infarction, respiratory failure, renal failure, bowel ischemia, limb ischemia, multisystem organ failure, intracranial hemorrhage, paraplegia, hemorrhage, or death. Endoleaks were classified in accordance with the standardized reporting practices of the Society for Vascular Surgery. AAA-related complications were defined as the need for a secondary intervention due to endoleak, limb ischemia, or postimplantation rupture., Results: A total of 392 patients with complete clinical data underwent elective AAA repair from 2004 to 2014. Of these 392 patients, 89 (23%) were classified as fAAA patients and 303 (77%) were classified as spAAA patients. With the exception of increased rates of chronic obstructive pulmonary disease (P = .0009) and pack-years smoked (P = .03) in spAAA patients, demographics did not differ. Sixty-two percent (n = 55) of fAAA patients and 68% (n = 205) of spAAA patients underwent EVAR (P = .30). fAAA patients did not incur any significant difference in major adverse events following open AAA repair (fAAA, 9% vs spAAA, 11%; P = .75). Additionally, fAAA patients did not incur any significant difference in major adverse events following EVAR (fAAA, 4% vs spAAA, 5%; P = .70). Patients with fAAA did have a significantly increased rate of endoleak (fAAA, 24% vs spAAA, 12%; P = .03) and secondary intervention following EVAR (fAAA, 21% vs spAAA, 12%; P = .04)., Conclusions: The current study shows that patients with fAAA do not have increased perioperative morbidity following open or endovascular AAA repair. However, patients with fAAA do have an increased risk of endoleak and secondary intervention following EVAR. These findings suggest that EVAR and open AAA repair are both safe and effective for fAAA patients. The increased rate of endoleak and secondary intervention in patients with fAAA suggests that this subpopulation may benefit from closer post-EVAR surveillance or open surgical repair in good risk patients., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify the predictive factors for the development of type II endoleaks (EL-II) after endovascular aneurysm repair (EVAR)., Methods: We assessed the preoperative and postoperative computed tomography data of 308 patients who underwent EVAR between 2000 and 2012 and in 84 of whom primary or secondary EL-II occurred. The data analyzed were: demographics, number and diameter of lumbar arteries (LAs), inferior mesenteric artery (IMA), median sacral artery (MSA), accessory renal arteries (ARas), maximum diameter of infrarenal abdominal aortic aneurysm, diameter and length of proximal aortic neck. Statistical analysis was performed using Stata software (version 12). Categorical parameters were compared between groups using chi-squared or Fisher's exact tests as appropriate. Continuous variables were analyzed using Student's t-test or Mann-Whitney test as appropriate (normality studied by the Shapiro-Wilk and homoscedasticity verified using the Fisher-Snedecor test)., Results: Of the 308 patients included (mean age, 73.8 ± 8.74 years), 284 (92%) were men, 61 (20%) were smokers, 113 (37%) had chronic obstructive pulmonary disease, 215 (70%) were taking antiplatelet. Respectively, 13, 51, 60, 103, 28, 40, 2, and 7 patients had 1, 2, 3, 4, 5, 6, 7, and 8 patent LAs. Before surgery, 221 IMAs and 136 MSA were patent. The sources of EL-II were: LA (n = 51), IMA (n = 22), MSA (n = 1), IMA and LA (n = 8), IMA and ARa (n = 1), and unknown (n = 1). Logistic regression models adjusting for clinically relevant covariables (age, American Society of Anesthesiologists, smoking status, dyslipidemia, and diuretics) were proposed to study morphologic EL-II predictive factors, first in the entire population, and then in the more specific population for whom IMA was patent. Risk factors of occurrence EL-II were: permeability of the IMA (70 patients [83%] vs. 155 [69%], P = 0.01), IMA diameter (3.49 mm vs. 2.71 mm, P < 0.001), number of LAs patent higher than or equal to 4 (P < 0.001), the mean LA diameter greater than 2.4 mm (P < 0.001), and MSA diameter (2.28 mm vs. 1.94 mm; P < 0.01)., Conclusions: Our results show the major role of the number and diameter of the patent aortic branches in the development of EL-II. As they can result in complications increasing the morbidity and mortality after EVAR, it is relevant to identify the risk factors of their occurrence., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Abdominal aneurysmal sac enlargement after endovascular aortic repair (EVAR) is a critical issue. However, the predictors have not yet been fully determined. Although unrecognized, intraluminal thrombus volume (ITV) is an important index. Therefore, we retrospectively evaluated the correlation among preoperative ITV, residual type II endoleak, and sac enlargement after EVAR, based on the long-term follow-up., Methods: Between 2006 and 2011, 151 consecutive patients underwent EVAR at a single cardiovascular institute. Emergency surgery was performed on 7 patients (4.7%). Of 148 patients excluding 3 patients with residual type I endoleak, sac enlargement (≥5 mm progression) after EVAR was observed in 24 patients (16.2%) and 8 patients required reintervention. The mean follow-up period was 2.4 ± 1.4 years. The outer volume and enhanced luminal volume were calculated from enhanced 1-mm slice computed tomography, and the difference was defined as ITV., Results: Age (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.04-1.20, P = 0.0007), outer volume (HR 1.04, 95% CI 1.01-1.07, P = 0.0118), percentage of ITV (HR 0.90, 95% CI 0.84-0.96, P = .0027), and type II endoleak (HR 10.15, 95% CI 3.55-31.10, P < 0.0001) were isolated as predictors of sac enlargement by multivariate analysis. Also, patent inferior mesenteric artery (odds ratio [OR] 4.45, 95% CI 1.38-20.07, P = 0.0105) and percentage of ITV < 30.1% (OR 3.52, 95% CI 1.32-10.30, P = 0.0112) were detected as independent risk factors for residual type II endoleaks. Additionally, in patients without endoleak, patient age (≥83 years) was an independent risk factor for sac enlargement after EVAR (P = 0.0056)., Conclusion: Age and ITV percentage had significantly great impact on sac enlargement and type II endoleak after EVAR., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: There is considerable controversy about the significance and appropriate treatment of type II endoleaks (T2Ls) after endovascular aneurysm repair (EVAR). We report our long-term experience with T2L management in a large multicenter registry., Methods: Between 2000 and 2010, 1736 patients underwent EVAR, and we recorded the incidence of T2L. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, major adverse events, and reintervention., Results: During the follow-up (median of 32.2 months; interquartile range, 14.2-52.8 months), T2L was identified in 474 patients (27.3%). There were no late abdominal aortic aneurysm ruptures attributable to a T2L. Overall mortality (P = .47) and ARM (P = .26) did not differ between patients with and without T2L. Sac growth (median, 5 mm; interquartile range, 2-10 mm) was seen in 213 (44.9%) of the patients with T2L. Of these patients with a T2L and sac growth, 36 (16.9%) had an additional type of endoleak. Of all patients with T2L, 111 (23.4%) received reinterventions, including 39 patients who underwent multiple procedures; 74% of the reinterventions were performed in patients with sac growth. Reinterventions included lumbar embolization in 66 patients (59.5%), placement of additional stents in 48 (43.2%), open surgical revision in 14 (12.6%), and direct sac injection in 22 (19.8%). The reintervention was successful in 35 patients (31.5%). After patients with other types of endoleak were excluded, no difference in overall all-cause mortality (P = .57) or ARM (P = .09) was observed between patients with T2L-associated sac growth who underwent reintervention and those in whom T2L was left untreated., Conclusions: In our multicenter EVAR registry, overall all-cause mortality and ARM were unaffected by the presence of a T2L. Moreover, patients who were simply observed for T2L-associated sac growth had aneurysm-related outcomes similar to those in patients who underwent reintervention. Our future work will investigate the most cost-effective ways to select patients for intervention besides sac growth alone., Competing Interests: Author conflict of interest: none., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives/background: To examine the additional diagnostic value of magnetic resonance imaging (MRI) after administration of a weak albumin binding contrast agent in post-endovascular aneurysm repair (EVAR) patients with aneurysm growth with no or uncertain endoleak after computed tomography angiography (CTA)., Methods: This was a prospective diagnostic cross sectional study carried out between April 2011 and August 2013. MRI was performed in all patients with aneurysm growth≥5 mm after EVAR implantation and no or uncertain endoleak on CTA, or the inability, on CTA, to identify the source of a visible endoleak. All MRI scans were performed on a 1.5 T clinical MRI scanner after administration of a weak albumin binding contrast agent. The presence of endoleaks was assessed by visually comparing pre- and post-contrast T1-weighted images with fat suppression. Post-contrast images were acquired 5 and 15 minutes after contrast administration., Results: Twenty-nine patients (26 men; 90%) with a median age of 74 years (interquartile range [IQR] 67-76) were included. The median interval between EVAR and MRI was 39 months (IQR 20-50). The median increase in maximum aneurysm diameter during total follow up after EVAR was 11 mm (IQR 6-17). At CTA, 16 patients (55%) had no detectable endoleak, five patients (17%) had suspected but uncertain endoleak, and eight patients had a definite endoleak (28%). On the post-contrast MRI images, endoleak was observed in 24 patients (83%). In all patients with uncertain endoleak on CTA, endoleak was detected with MRI. For type II endoleaks, feeding vessels were detected in 22/23 patients (96%) and these were all, except one, lumbar arteries., Conclusion: In patients with enlarging aneurysms of unknown origin after EVAR, MRI with a weak albumin binding contrast agent has additional value for both the detection and determination of the origin of the endoleak., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim of this study was the evaluation of the clinical and radiologic outcomes of parallel grafts in the treatment of patients with failed prior endovascular aneurysm repair and type Ia endoleak., Methods: Prospectively collected clinical and radiologic data of consecutive patients with prior endovascular aneurysm repair and evidence of type Ia endoleak were analyzed. All patients were treated between January 2009 and November 2014 by use of parallel grafts, ie, chimney/snorkel or periscope grafts and abdominal endovascular devices. Primary outcome of the study was the technical success. Secondary outcomes were patency of the chimney grafts and shrinkage of aneurysm morphology., Results: Technical success was 94.4% (17 of 18). One patient showed evidence of persistent type Ia endoleak after triple chimney graft placement and treated by Onyx embolization (Covidien, Plymouth, Minn) successfully. The mean preoperative and postoperative aneurysm diameters were 7.1 ± 1.7 and 7.0 ± 2 cm. Primary patency of the chimney grafts was 96.7% and assisted patency was 100% after successful retrograde recanalization of an acute occlusion of the superior mesenteric artery from the celiac trunk and the gastroduodenal artery. One patient who had undergone the sandwich technique with transfemoral placement of the flexible Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) due to impossible catheterization of the target vessel from the upper extremity presented with contained rupture caused by gutter-associated endoleak and underwent urgent embolization with Onyx successfully. No procedure-related death or open conversion was observed in the entire follow-up period., Conclusions: Use of parallel grafts showed midterm safety and feasibility with low incidence of persistent endoleaks requiring intervention or progression of aneurysm diameter. Reproducible results from other vascular centers will establish the chimney technique in the treatment of type I endoleaks as a viable endovascular modality., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) is widely adopted; however, the procedure may be jeopardized by type 2 endoleak (T2E). Most T2Es regress over time, but their evolution is unpredictable. There is some evidence about the pleiotropic statin effect on AAA and thrombus stabilization, but there are no data on the influence of statins on T2E. The study's aim is therefore to evaluate a possible effect of statins on T2E evolution., Methods: A retrospective analysis of patients discharged from 2008 to 2013 with T2E after EVAR was performed. Patients were followed up with duplex ultrasound and computed tomography angiography and divided on statin and no statin users. The primary end point was to evaluate the T2E persistence at 6 months and during follow-up. The secondary end points were to compare the shrinkage (median and rate), the sac increasing rate, and reintervention at 6 months and during follow-up., Results: In the period examined, 756 EVARs were performed and 85 (11%) had T2E at discharge. Thirty-two (37%) patients with T2E were on statins. The median follow-up was 19 (interquartile range [IQR] 7) months. Statin and no statin patients had similar clinical and anatomical characteristics, endoprosthesis type, and medical therapy. At 6 months, patients on statins had lower T2E persistence ([26] 81% vs. [49] 93%, P = 0.16), reaching the significance at 36 months (11 ± 9% vs. 64 ± 7%, P = 0.001). By Cox analysis, statins are independently associated with T2E regression (hazard ratio 0.40, 95% confidence interval 0.020-0.81, P = 0.01), other characteristics are: >2 lumbar arteries or inferior mesenteric artery patency or oral anticoagulant therapy did not reduce T2E. At 6 months, statin patients had higher shrinkage rate and diameter reduction compared with no statin patients (18% vs. 3%, P = 0.03 and 11 mm (IQR 4) vs. 6 mm (IQR 4), P = 0.05, respectively). Freedom from growth diameter and reintervention rate were not significantly different (85 ± 9% vs. 81 ± 14%, P = 0.10 and 75 ± 17% vs. 37 ± 16%, P = 0.13, respectively)., Conclusion: Statin therapy seems to influence T2E regression and aortic sac stabilization after EVAR in the early medium follow-up; however, prospective studies need to confirm the present results., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Endovascular aneurysm sealing (EVAS) has been proposed as a novel alternative to endovascular aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysms (AAA). The early clinical experience, technical refinements, and learning curve of EVAS in the treatment of AAA at a single institution are presented., Methods: One-hundred and five patients were treated with EVAS between March 2013 and November 2014. Prospective data were recorded on consecutive patients receiving EVAS. Data included demographics, preoperative aneurysm morphology, and 30-day outcomes, including rates of endoleak, limb occlusion, reintervention, and death. Postoperative imaging consisted of duplex ultrasound and computed tomographic angiography., Results: The mean age of the cohort was 76 ± 8 years and 12% were female. Adverse neck morphology was present in 72 (69%) patients, including aneurysm neck length <10 mm (20%), neck diameter >32 mm (18%), β-angulation >60° (21%), and conical aneurysm neck (51%). There was one death within 30 days. The incidence of Type 1 endoleak within 30 days was 4% (n = 4); all were treated successfully with transcatheter embolisation. All four proximal endoleaks were associated with technical issues that resulted in procedure refinement, and all were in patients with adverse proximal aortic necks. The persistent Type 1 endoleak rate at 30 days was 0% and there were no Type 2 or Type 3 endoleaks. Angioplasty and adjunctive stenting were performed for postoperative limb stenosis in three patients (3%)., Conclusions: EVAS appears to be associated with reasonable 30-day outcomes despite the necessity of procedural evolution in the early adoption of this technique. EVAS appears to be applicable to patients with challenging aortic morphology and endoleak rates should reduce with procedural experience. The utility of EVAS will be defined by the durability of the device in long-term follow-up, although the absence of Type 2 endoleaks is encouraging., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)