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Background: This study aimed to evaluate the suitability of a coronary-branched ascending aortic endograft, paired with aortic valve (AV) prosthesis (Endo-Bentall), for the endovascular repair of ascending aortic aneurysms., Methods: Preoperative ≤1 mm computed tomography angiographies of consecutive patients managed with Bentall procedure or ascending aortic replacement and AV reconstruction/replacement, in a single institution (from January 1, 2008, to December 31, 2023), were retrospectively analyzed. Dedicate software was used to assess (1) vascular access, (2) proximal landing zone, (3) coronary artery anatomy, and (4) distal landing. Eligibility criteria for Endo-Bentall were ≥8 mm iliac arteries, without severe calcification/tortuosity, proximal landing with an 18- to 29-mm aortic annulus diameter, ≥10 mm annulus-coronary ostium distance, no mechanical AV, absence of coronary grafts in the ascending aorta, no left ventricle thrombus, coronary arteries ≥3 mm wide and ≥10 mm long, with no anatomical abnormalities, ostial stent or stenosis, and ≥20 mm long and ≤38 mm wide distal landing zone within the ascending aorta or applicability of branched endovascular arch repair., Results: Twenty-nine patients (55.2% females) were included. All patients had adequate proximal landing zone in terms of annulus diameter (median, 25 mm; interquartile range [IQR], 5 mm). Two (6.8%) had inadequate iliac access (external iliac artery <8 mm). Two patients (6.8%) had a mechanical AV. Twenty-six patients (89.6%) had adequate landing zone for stenting of the left main coronary artery (median diameter, 5.2 mm; IQR, 1.8 mm) and 28 (96.6%) had adequate right coronary artery landing (median diameter, 4.1 mm; IQR, 1 mm). The left main coronary artery and right coronary artery were located at 5:00 minute and 10:50 minute clock positions, respectively. Three patients (20.7%) had an adequate distal landing zone within the ascending aorta. The remaining were suitable for extension with a branched arch device. According to the predefined criteria, 75.9% of patients were anatomically suitable for Endo-Bentall., Conclusions: Three out of four patients with ascending aortic aneurysms may be considered as anatomically eligible for endovascular treatment with an Endo-Bentall prosthesis., Competing Interests: Disclosures T.K. is a consultant and proctor for and has intellectual property with Cook Medical, receiving royalties, speaking fees, and research, travel, and educational grants., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection., Methods: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. End points included technical success, clinical success, early (30-day) computed tomography angiography findings, early (30-day) mortality, adverse events, and aortic remodeling in patients with available computed tomography angiography follow-up and reintervention., Results: A total of 155 patients received a custom-made CP, of whom 32 patients (44% male, mean age 61 ± 9 years) were treated urgently and 123 patients (63% male, mean age 62 ± 11 years) electively. The primary CP rate was higher in the urgent group (28/32, 88%, in the urgent group vs 96/123, 78%, in the elective group, P = .051). The mean contrast volume was higher in the urgent group (157 ± 56 mL in the urgent group vs 130 ± 71 mL in the elective group, P = .017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 of 32 (78%) patients in the urgent group vs 113 and 123 (92%) in the elective group (P = .159). The early mortality rate was 13% (4 of 32 patients) in the urgent group vs 1% (1 of 123 patients) in the elective group (P = .120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related reinterventions were required in 6 of 32 (19%) patients in the urgent group vs 6 of 123 (5%) in the elective group (P = .094). Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, 18%, in the urgent group vs 63/114, 55%, in the elective group, P = .001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, 79%, in the urgent group vs 47/114, 41%, in the elective group, P = .000). An increase in thoracic aortic aneurysm sac occurred in 1 of 28 (4%) patients in the urgent group vs 4 of 114 (4%) patients in the elective group (P = .096)., Conclusions: The urgent use of the CP technique for distal FL occlusion in aortic dissection was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved a high rate of aortic remodeling., Competing Interests: Disclosures T.K. has intellectual property with Cook Medical; and receives royalties, research, travel and educational grant, speaking fees from and is a consultant and proctor for Cook Medical. S.H. is a consultant for Cook Medical, GE Healthcare, and Bentley. L.B. is a proctor and consultant for Cook Medical. S.T. is a consultant and speaker for WL Gore and Medtronic. T.L. is a proctor and consultant for Cook Canada. T.J. has travel grants, consultation fees, and proctorship fees from Cook Medical and Hammered (Polish representative of Cook Medical). J.S. is a speaker, proctor, and consultant for Cook Medical. N.T. is a proctor for Cook Medical and receives institutional grant from Cook Medical. G.P. is a proctor for Cook Medical. The remaining authors report no conflicts., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the patency of bridging covered stents (BCS) bridged to inner branches in custom-made thoracoabdominal endografts., Methods: This was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f/b EVAR) in whom the reno-visceral target vessels (TVs) were bridged with a BCS to an inner branch of a custom-made (CMD) endograft. Technical success and perioperative complications were noted. Follow-up BCS patencies were evaluated, and in patients with follow-up, two groups based on BCS were created, a group with BCS occlusion and a group with BCS patent. Univariable and multivariable analyses were performed to analyze factors related to visceral and renal bridging stent occlusion., Results: From 2019 through 2022, 69 patients undergoing complex aortic repair had at least one TV bridged to an inner branch built into a CMD endograft. Eighty-six percent of the grafts had only inner branches, whereas 14% had a mix of fenestrations for the visceral TVs and inner branches for the renal arteries. Twenty-five percent of patients presented as urgent and received an endograft originally designed for another patient and available on our shelf at the time. A total of 245 TVs were connected to inner branches: celiac trunk (CT), 54; superior mesenteric artery (SMA), 59; and renal artery (RA), 132. Technical success was 99%. There was a 23% complication and 9% perioperative mortality rate. At follow-up, we identified 6% of visceral and 14% of renal BCS occlusions. The primary patency for RA BCS was 83% at 12 months and 58% at 24 months. For the CT-SMA BCS, Kaplan-Maier showed a patency of 99% and 96% at 12 and 24 months. In the univariate analysis, a misaligned TV ostium (P = .001), the postoperative BCS diameter on postoperative computed tomography angiography (P = .02), and the preoperative infrarenal aortic angle >60° (P = .007) were correlated with RA BCS occlusion. In the multivariate analysis, only the misaligned TV ostium (P = .002) and infrarenal angle >60° (P = .01) were significantly correlated., Conclusions: In our series of complex aortic repair, the incorporation of inner branches to bridge TVs is associated with a high renal BCS occlusion rate. Improper alignment of the branches with the TV ostium and acute aortic angles might play a significant role. Further research on this technology is needed., Competing Interests: Disclosures T.K. has intellectual property with Cook Medical., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Female sex is a risk factor for adverse events after endovascular aortic repair. Sex comparative early and midterm outcomes of fenestrated and branched endovascular aortic arch repair (F/B-Arch) are presented., Methods: A single centre retrospective sex comparative analysis of consecutive patients managed with F/B-Arch was conducted according to STROBE. Primary outcomes were sex comparative technical success, death, and cerebrovascular morbidity at 30 days. Kaplan-Meier estimates were used for follow up outcomes., Results: Among 209 patients, 38.3% were women. Coronary artery disease (p < .001) and previous myocardial infarction (p = .01) were more common in women. Non-native proximal aortic landing was higher in women (women: 51.3%; men: 31.8%, p = .005) and the aortic dissection rate was lower (28.8% vs. 48.1%, p = .005). Proximal landing to Ishimaru zones showed no difference (zone 0: p = .18; zone 1: p = .47; zone 2: p = .39). Graft configurations were equally distributed. In total, 416 supra-aortic trunks were bridged. The median number of revascularisations per patient was two (interquartile range 1, 3), with no difference between sexes (p = .54). Technical success (women: 97.5%; men: 96.9%, p = .80), 30 day mortality rate (women: 10%; men: 9.3%, p = .86), and cerebrovascular morbidity (women: 11.3%; men: 17.1%, p = .25) were similar. Women presented more access related complications (women: 32.5%; men: 16.3%, p = .006), without affecting access related re-interventions (p = .55). Survival (women: 81.1%, 95% confidence interval [CI] 76.3 - 85.9%; men: 79.8%, 95% CI 76.0 - 83.6%) and freedom from re-intervention (women: 56.6%, 95% CI 50.4 - 62.8%; men: 55.3%, 95% CI 50.1 - 60.5%) at 12 months were similar (log rank, p = .40 and p = .41, respectively)., Conclusion: Both sexes presented similar outcomes after F/B-Arch. Appropriate patient selection may decrease the effect of sex in F/B-Arch outcomes., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR., Methods: A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary., Results: A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively., Conclusions: Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up., Competing Interests: Disclosures T.K. is a consultant and proctor for and has intellectual property with Cook Medical, receiving royalties, speaking fees, and research, travel, and educational grants., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Fenestrated or branched endovascular aortic repair (F/B-EVAR) is a valuable treatment in patients with chronic post-dissection thoraco-abdominal aneurysm (PD-TAAA). This study aimed to analyse early and follow up outcomes of F/B-EVAR in these patients., Methods: Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with F/B-EVAR in a tertiary centre over eight years were analysed retrospectively. All patients presenting with PD-TAAA and managed with F/B-EVAR were eligible. A modified Crawford's classification system was used. Thirty day mortality and major adverse event (MAE) rates were analysed. Time to event data were estimated with Kaplan-Meier survival analysis., Results: Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with F-EVAR, nine (16%) with fenestrations and branches, and 31 (56%) with B-EVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. The thirty day mortality rate was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (standard error [SE] 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in F-EVAR at the 12 month follow up (p = .006) compared with B-EVAR., Conclusion: Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost a half of patients needed an unscheduled re-intervention within 24 months after F/B-EVAR., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: This study aimed to report the initial experience with a novel bidirectional double cuff inner branch design for incorporation of renal and mesenteric arteries in patients undergoing fenestrated and branched endovascular aortic repair (F/BEVAR)., Methods: A retrospective review was undertaken of the experience of F/BEVAR with grafts integrating at least one bidirectional double cuffed inner branch implanted at three tertiary aortic centres between March 2022 and June 2023. All consecutive patients were included. Baseline characteristics, operative data, and follow up data were collected. Results were presented as number or median (interquartile range) unless otherwise stated., Results: Thirteen patients (10 male; median age 72 [68, 77] years) had F/BEVAR using a total of 15 bidirectional double cuffed inner branches (30 cuffs). Indications for bidirectional doubled cuffed inner branches included cranial vessel orientation or double renal arteries in four patients each, common coeliomesenteric trunk in three patients, and early renal artery bifurcation, renal artery origin from a false lumen requiring a flexible route for catheterisation, and surplus configuration in one patient each. Twenty three of the 30 cuffs were used, whereas the remaining seven cuffs were intentionally occluded with vascular plugs. Target vessel incorporation was successful in all bidirectional branches. There was one technical failure related to unsuccessful catheterisation of a left renal artery targeted through a unidirectional caudal inner branch. During a median follow up of seven months there were no instances of target vessel instability or re-interventions and two patients died of causes unrelated to the bidirectional branches., Conclusion: The results of the use of bidirectional double cuff inner branches are promising, with high technical success and no short term branch related complications in this preliminary experience. This could potentially expand the applicability of branch endografting of complex endovascular aortic repairs, but long term results are still missing., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: Iliac branch devices (IBDs) have shown good results but there is little evidence for the risk of internal iliac artery (IIA) endoleak, so there are no clear recommendations on the maximum diameter it should be. Based on limited evidence, it was hypothesised that an IIA of ≥ 11 mm in diameter presents an increased risk of type Ic endoleak., Methods: This was a single centre, retrospective case control study. Patients undergoing an IBD with the main trunk of the IIA as the target vessel, between 2015 and 2021, were identified. Two groups were created: those with a main trunk diameter of < 11 mm; and those with a diameter of ≥ 11 mm. Technical success, freedom from type Ic endoleak, and re-intervention rates were compared. A receiver operating characteristic (ROC) curve was performed to show a cutoff IIA diameter value for risk of type Ic endoleak. Multivariate analysis was performed to assess the risk of type Ic endoleak and the presence of calcification, stenosis, and landing zone length in the IIA., Results: There were 182 IBDs identified. The dilated IIA group (54 IBDs) had significantly lower technical success (91% vs. 98.4%; p = .002), lower freedom from type Ic endoleak (77% vs. 97.1% at 24 months; p = .001), and lower freedom from re-interventions (70% vs. 92.4% at 24 months; p = .002). The ROC curve showed that 10.5 mm was the cutoff diameter for type Ic endoleak. Moderate or severe calcification as well as landing zone length < 5 mm also correlated with type Ic endoleak., Conclusion: IBDs have a statistically significantly higher rate of technical failure, lower freedom from type Ic endoleak, and lower freedom from re-intervention when the IIA is ≥ 11 mm in diameter., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Fenestrated and branched endovascular aortic repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs) has shown high technical success and low early mortality rates. Aneurysm extent has been reported as a factor affecting outcomes. This study aimed to assess the early and midterm follow-up outcomes of patients managed by F/BEVAR for types I through III TAAAs., Methods: A single-center retrospective analysis was conducted, including data from consecutive, elective and urgent (symptomatic and ruptured cases), patients treated for types I through III TAAAs, between October 1, 2011, and October 1, 2022, using F/BEVAR. Degenerative and postdissection TAAAs were included. Patients received prophylactic cerebrospinal fluid drainage (CSFD), except those under therapeutic anticoagulation, those who were hemodynamically unstable, or those with failed CSFD application. When an initial thoracic endovascular aortic repair was performed, as part of a staged procedure, no CSFD was used. Later stages and nonstaged procedures were performed under CSFD. Thirty-day mortality and major adverse events (MAEs) were analyzed. Kaplan-Meier estimates were used for follow-up outcomes., Results: F/BEVAR for types I through III TAAAs was performed in 209 patients (56.9% males; mean age, 69.6 ± 3.2 years; mean aneurysm diameter, 65.2 ± 6.2 mm); 29.2% type I, 57.9% type II, and 12.9% type III. Urgent repair was performed in 26.7% of patients (56 cases; 23 ruptured and 33 symptomatic cases) and 153 were treated electively. Thirty-two patients (15.3%) were classified as American Society of Anesthesiologists (ASA) class IV. CSFD was used in 91% and staged thoracic endovascular aortic repair was performed in 51.2% of patients. Technical success was 93.8% (96.7% in elective vs 94.6% in urgent cases; P = .92). Thirty-day mortality was 11.0% (4.6% in elective vs 28.5% in urgent cases; P < .001) and MAEs were recorded in 17.2% of cases (7.8% in elective vs 42.8% in urgent cases; P < .001). Spinal cord ischemia rate was 20.5% (17.6% in elective vs 28.7% in urgent cases; P = .08), whereas 2.9% of patients presented paraplegia (1.3% in elective and 7.1% in urgent cases; P = .03). The mean follow-up was 16 ± 5 months. Survival was 75.0% (standard error, 4.0%) and freedom from reintervention was 73.3% (standard error, 4.4%) at 36 months. ASA IV and urgent repair were detected as independent factors related to early mortality and MAE, whereas ruptured aneurysm status was related to spinal cord ischemia evolution., Conclusions: Endovascular repair for types I through III TAAAs provides encouraging early outcomes in terms of mortality, MAE, and paraplegia, especially in an elective setting. Setting of repair and baseline ASA score should be taken into consideration during decision-making., Competing Interests: Disclosures N.T. is a proctor for Cook Medical and has intellectual property with Cook Medical and Bentley receiving institutional fees. T.K. is a consultant and proctor for and has intellectual property with Cook Medical, receiving royalties, speaking fees, and research, travel, and educational grants. The remaining authors report no conflicts., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve replacement (TAVR) showed safety and efficacy in patients with severe aortic stenosis. Commissural alignment (CA) during TAVR has the potential to reduce the impact of the prostheses on accessibility of coronary arteries, as misalignment of the neocommissures could cause partial overlap with coronary ostia. Therefore, the aim of this study was to investigate the impact of CA on coronary overlap rates., Methods: We examined the techniques of CA and their impact on coronary access. Eligible studies were searched for on Pubmed, SCOPUS and DOAJ and selected using PRISMA guidelines. The primary endpoint was the incidence of a severe coronary overlap or failed coronary re-access. Results of the analysis are expressed as Risk Ratio (RR) with 95% CI., Results: Four studies were included in this analysis. In these, 681 patients underwent TAVR with CA and 210 underwent TAVR without CA. We examined Evolut valves and Acurate Neo valves. The primary endpoint occurred in 138 patients undergoing TAVR with CA and in 154 patients without CA (RR = 0.279; 95% CI 0.201-0.386; p < 0.001). Neither prosthesis-related, nor patient-related factors had a significant interaction with the measured effect., Conclusions: Commissural alignment was associated with significantly lower rates of commissure-to-coronary ostia overlap and failure of coronary access. Consequently, a modified insertion technique could reduce coronary overlap and coronary occlusion, particularly in supra-annular valves. Therefore, controlled orientation of prostheses by CA during TAVR could favour coronary access, especially in younger patients that could require coronary re-access after TAVR., Competing Interests: Declaration of Competing Interest the authors report no relationships that could be construed as a conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

Objective: Analyze the outcomes of endovascular complex abdominal and thoracoabdominal aortic aneurysm repair using the Cook fenestrated device with the modified preloaded delivery system (MPDS) with a biport handle and preloaded catheters., Methods: A multicenter retrospective single arm cohort study was performed, including all consecutive patients with complex abdominal aortic aneurysm repair and thoracoabdominal aortic aneurysms treated with the MPDS fenestrated device (Cook Medical). Patient clinical characteristics, anatomy, and indications for device use were collected. Outcomes, classified according to the Society for Vascular Surgery reporting standards, were collected at discharge, 30 days, 6 months, and annually thereafter., Results: Overall, 712 patients (median age, 73 years; interquartile range [IQR], 68-78 years; 83% male) from 16 centers in Europe and the United States treated electively were included: 35.4% (n = 252) presented with thoracoabdominal aortic aneurysms and 64.6% (n = 460) with complex abdominal aortic aneurysm repair. Overall, 2755 target vessels were included (mean ,3.9 per patient). Of these, 1628 were incorporated via ipsilateral preloads using the MPDS (1440 accessed from the biport handle and 188 from above). The mean size of the contralateral femoral sheath during target vessel catheterization was 15F ± 4, and in 41 patients (6.7%) the sheath size was ≤8F. Technical success was 96.1%. Median procedural time was 209 minutes (IQR, 161-270 minutes), contrast volume was 100 mL (IQR, 70-150mL), fluoroscopy time was 63.9 minutes (IQR, 49.7-80.4 minutes) and median cumulative air kerma radiation dose was 2630 mGy (IQR, 838-5251 mGy). Thirty-day mortality was 4.8% (n = 34). Access complications occurred in 6.8% (n = 48) and 30-day reintervention in 7% (n = 50; 18 branch related). Follow-up of >30 days was available for 628 patients (88%), with a median follow-up of 19 months (IQR, 8-39 months). Branch-related endoleaks (type Ic/IIIc) were observed in 15 patients (2.6%) and aneurysm growth of >5 mm was observed in 54 (9.5%). Freedom from reintervention at 12 and 24 months was 87.1% (standard error [SE],1.5%) and 79.2% (SE, 2.0%), respectively. Overall target vessel patency at 12 and 24 months was 98.6% (SE, 0.3%) and 96.8% (SE, 0.4%), respectively, and was 97.9% (SE, 0.4%) and 95.3% (SE, 0.8%) for arteries stented from below using the MPDS, respectively., Conclusions: The MPDS is safe and effective. Overall benefits include a decrease in contralateral sheath size in the treatment of complex anatomies with favorable results., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This multicenter international study aimed to describe outcomes of fenestrated-branched endovascular aortic repairs (FB-EVAR) in a cohort of patients treated for chronic post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs)., Methods: We reviewed the clinical data of all consecutive patients treated by FB-EVAR for repair of extent I to III PD-TAAAs in 16 centers from the United States and Europe (2008-2021). Data were extracted from institutional prospectively maintained databases and electronic patient records. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts. Endpoints were any cause mortality and major adverse events at 30 days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12 Fr sheath) and major (open or ≥12 Fr sheath) secondary interventions, patient survival, and freedom from aortic-related mortality (ARM)., Results: A total of 246 patients (76% male; median age, 67 years [interquartile range, 61-73 years]) were treated for extent I (7%), extent II (55%), and extent III (35%) PD-TAAAs by FB-EVAR. The median aneurysm diameter was 65 mm (interquartile range, 59-73 mm). Eighteen patients (7%) were octogenarians, 212 (86%) were American Society of Anesthesiologists class ≥3, and 21 (9%) presented with contained ruptured or symptomatic aneurysms. There were 917 renal-mesenteric vessels targeted by 581 fenestrations (63%) and 336 directional branches (37%), with a mean of 3.7 vessels per patient. Technical success was 96%. Mortality and rate of major adverse events at 30 days was 3% and 28%, including disabling complications such as new onset dialysis in 1%, major stroke in 1%, and permanent paraplegia in 2%. Mean follow-up was 24 months. Kaplan-Meier (KM) estimated patient survival at 3 and 5 years was 79% ± 6% and 65% ± 10%. KM estimated freedom from ARM was 95% ± 3% and 93% ± 5% at the same intervals. Unplanned secondary interventions were needed in 94 patients (38%), including minor procedures in 64 (25%) and major procedures in 30 (12%). There was one conversion to open surgical repair (<1%). KM estimated freedom from any secondary intervention was 44% ± 9% at 5 years. KM estimated primary and secondary TA patency were 93% ± 2% and 96% ± 1% at 5 years, respectively., Conclusions: FB-EVAR for chronic PD-TAAAs was associated with high technical success and a low rate of mortality (3%) and disabling complications at 30 days. Although the procedure is effective in the prevention of ARM, patient survival was low at 5 years (65%), likely due to the significant comorbidities in this cohort of patients. Freedom from secondary interventions at 5 years was 44%, although most procedures were minor. The significant rate of reinterventions highlights the need for continued patient surveillance., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Female sex has been characterized as a risk factor of increased mortality in patients managed for complex aortic aneurysm using endovascular means. This study aimed to present the perioperative and follow-up outcomes of females managed electively or urgently with the t-Branch device and investigate factors affecting the early outcomes., Methods: A 2-center retrospective observational study was conducted including elective and urgent female patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) for thoracoabdominal and pararenal aneurysms between January 1, 2018 and September 30, 2020. Primary early outcomes included technical success and 30-day mortality and morbidity [spinal cord ischemia (SCI) and acute kidney injury]. Follow-up survival and freedom from reintervention rates were assessed using Kaplan-Meier estimates., Results: In total, 153 females were included; 81 (52.9%) treated urgently. Urgent patients were older (73.2 ± 8.6 vs. 68.5 ± 6.8 years; P < 0.001) and presented higher previous coronary angioplasty/stenting (16.0% vs. 5.6%, P = 0.005) and lower double antiplatelet therapy (DAPT, 46.3% vs. 53.7%, P = 0.04) rates. Technical success was 97.4%. Early mortality was 16.3% (22% in urgent; 12% in elective; P = 0.2) and SCI and acute kidney injury were diagnosed in 13.7% (11% in urgent; 16% in elective; P = 0.2) and 18.3% (22.2% in urgent; 13.9% in elective; P = 0.18), respectively. Multivariate regression analyses showed that DAPT and b-blockers were related to lower 30-day mortality. DAPT was also preventive for SCI. Survival rates were 68.4% [standard error (SE) 0.07] at 12 months for the urgent and 75.6% (SE 0.09) at 24 months for the elective group (P = 0.14). Freedom from reintervention rates were 81.4% (SE 0.06) at 6 months and 64.7% (SE 0.09) at 18 months for the urgent and 81.7% (SE 0.06) at 6 months and 75.4% (SE 0.081) at 18 months for the elective group (P = 0.94)., Conclusions: Female patients managed with the t-Branch device for thoracoabdominal and pararenal aneurysms in elective and urgent setting presented similar 30-day mortality and SCI rates., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high-volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects, and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate early and midterm outcomes of the Candy Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection (AD) in a more real world cohort of patients from an international multicentre registry., Methods: A multicentre retrospective study was conducted of all consecutive patients from the contributing centres with subacute and chronic AD treated with the CP technique from October 2013 to April 2020 at 18 centres., Results: A custom made CP was used in 155 patients (92 males, mean age 62 ± 11 years). Fourteen (9%) presented with ruptured false lumen aneurysms. Technical success was achieved in all patients (100%). Clinical success was achieved in 138 patients (89%). The median hospital stay was 7 days (1 - 77). The 30 day mortality rate was 3% (n = 5). Stroke occurred in four patients (3%). Spinal cord ischaemia occurred in three patients (2%). The 30 day computed tomography angiogram (CTA) confirmed successful CP placement at the intended level in all patients. Early complete FL occlusion was achieved in 120 patients (77%). Early (30 day) CP related re-intervention was required in four patients (3%). The early (30 day) stent graft related re-intervention rate was 8% (n = 12). Follow up CTA was available in 142 patients (92%), with a median follow up of 23 months (6 - 87). Aneurysmal regression was achieved in 68 of 142 patients (47%); the aneurysm diameter remained stable in 69 of 142 patients (49%) and increased in five of 142 patients (4%). A higher rate of early FL occlusion was detected in the largest volume centre patients (50 [88%] vs. 70 [71%] from other centres; p = .019). No other differences in outcome were identified regarding volume of cases or learning curve., Conclusion: This international CP technique experience confirmed its feasibility and low mortality and morbidity rates. Aortic remodelling and false lumen thrombosis rates were high and support the concept of distal FL occlusion in AD using the CP technique., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to compare outcomes of single or multistage approach during fenestrated-branched endovascular aortic repair (FB-EVAR) of extensive thoracoabdominal aortic aneurysms (TAAAs)., Methods: We reviewed the clinical data of consecutive patients treated by FB-EVAR for extent I to III TAAAs in 24 centers (2006-2021). All patients received a single brand manufactured patient-specific or off-the-shelf fenestrated-branched stent grafts. Staging strategies included proximal thoracic aortic repair, minimally invasive segmental artery coil embolization, temporary aneurysm sac perfusion and combinations of these techniques. Endpoints were analyzed for elective repair in patients who had a single- or multistage approach before and after propensity score adjustment for baseline differences, including the composite 30-day/in-hospital mortality and/or permanent paraplegia, major adverse event, patient survival, and freedom from aortic-related mortality., Results: A total of 1947 patients (65% male; mean age, 71 ± 8 years) underwent FB-EVAR of 155 extent I (10%), 729 extent II (46%), and 713 extent III TAAAs (44%). A single-stage approach was used in 939 patients (48%) and a multistage approach in 1008 patients (52%). A multistage approach was more frequently used in patients undergoing elective compared with non-elective repair (55% vs 35%; P < .001). Staging strategies were proximal thoracic aortic repair in 743 patients (74%), temporary aneurysm sac perfusion in 128 (13%), minimally invasive segmental artery coil embolization in 10 (1%), and combinations in 127 (12%). Among patients undergoing elective repair (n = 1597), the composite endpoint of 30-day/in-hospital mortality and/or permanent paraplegia rate occurred in 14% of single-stage and 6% of multistage approach patients (P < .001). After adjustment with a propensity score, multistage approach was associated with lower rates of 30-day/in-hospital mortality and/or permanent paraplegia (odds ratio, 0.466; 95% confidence interval, 0.271-0.801; P = .006) and higher patient survival at 1 year (86.9±1.3% vs 79.6±1.7%) and 3 years (72.7±2.1% vs 64.2±2.3%; adjusted hazard ratio, 0.714; 95% confidence interval, 0.528-0.966; P = .029), compared with a single stage approach., Conclusions: Staging elective FB-EVAR of extent I to III TAAAs was associated with decreased risk of mortality and/or permanent paraplegia at 30 days or within hospital stay, and with higher patient survival at 1 and 3 years., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Fiber Optic RealShape (FORS) technology has recently been introduced as an adjunctive guidance technology that allows real-time three-dimensional visualization of dedicated endovascular devices while avoiding radiation exposure. It consists of equipment which sends pulses of light through hair-thin optical fibers that run within a dedicated hydrophilic wire and selective catheters. The purpose of the study was to report the observed benefits and limitations related to the first edition of FORS technology., Methods: Data were collected prospectively from the first 50 patients undergoing FORS-guided endovascular repair at a single center between February 2020 and February 2021 as part of the global multicenter FORS Learn registry. All consecutive, elective procedures with one or more navigation tasks attempted with FORS were included. Factors related to FORS navigation task success were assessed. The time required for the catheterization of each task as well as the amount of radiation exposure (fluoroscopy time, dose area product, and estimated skin dose) were collected. A per-task analysis was conducted. End points included the success rate in achieving a stable FORS-guided catheterization, catheterization time, and radiation dose during catheterization., Results: During the study period from February 2020 to February 2021, 50 patients were treated using FORS technology. Forty-five patients were treated for aortic aneurysm, 4 for iliac artery aneurysm, and 1 for splenic artery aneurysm. Overall, 201 navigation tasks were completed for these procedures and FORS was used in 186 tasks (92.5%). No FORS-related complication was recorded and a success rate of 60.2% (n = 116) was observed. Target vessel (TV) angle of 45° or greater, TV stenosis, and the renal arteries as navigation tasks (compared with celiac artery or superior mesenteric artery) were associated with a lower success rate. Catheterization of a TV through a branch more frequently required a standard catheter in combination with the FORS-enabled guidewire. Successful task catheterization using FORS guidance was associated with a shorter catheterization time 6 minutes (interquartile range, 3-11 minutes) versus 16 minutes (interquartile range, 10-24 minutes) (P < .001) and lower radiation exposure compared with unsuccessful catheterization (dose area product, 4.4 cGy/cm 2 vs 12.5 cGy/cm 2 ; P < .001)., Conclusions: FORS technology was implemented successfully as a new guidance technology in a complex endovascular aortic repair program and was associated with an encouraging success rate and a high potential for radiation reduction., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to evaluate renal function and renal parenchymal length changes secondary to the coverage or preservation of accessory renal arteries (ARAs) in complex aortic repair., Methods: This was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f-b EVAR) who presented with ARAs. Two groups were created, a preserved ARA group, with incorporation of the vessel as a dedicated fenestration or branch in the endograft plan, and a non-preserved ARA group, without incorporation of them. Early >30% decline of glomerular filtration rate (GFR), kidney infarcts, and endoleaks were evaluated. Mid-term results with freedom from kidney shrinkage (defined as length decrease >10%) at follow-up, freedom from GFR decrease >30%, or need for postoperative dialysis at follow-up were also analyzed. Primary assisted patency of incorporated ARAs was calculated., Results: From 2011 through 2020, 145 patients undergoing complex aortic repair presented with an ARA. After excluding ruptured aneurysms, 33 patients had the ARA preserved with their incorporation into the stent graft (preserved ARA group), and 99 did not have preservation of them (not-preserved ARA group). There were no statistical differences in demographics or type of aneurysm. Patients in the ARA-preserved group had more ARAs (median of two per patient vs one in the non-preserved ARA group; P = .01) and bigger ARAs (median 4 vs 3 mm in the non-preserved ARA group; P = .001). Early postoperative worsening >30% of GFR (23% vs 6%; P = .03) as well as postoperative renal infarction (57% vs 6%; P = .001) and ARA-related endoleaks (20% vs 0%; P = .01) were statistically higher for the not-preserved ARA group. Mid-term kidney length showed significant shrinkage in the not-preserved ARA group compared with the ARA preserved group (9.7% vs 0%; P = .001). Freedom from >30% GFR decline at 2 years was significantly higher for the preserved ARA group (83% vs 47%; P = .01).Two-year primary assisted patency of incorporated ARA was 94%., Conclusions: Complex aortic repair incorporation of ARA is feasible, with low complications and good primary assisted patency at 2 years. It leads to less postoperative early renal dysfunction as well as higher freedom for mid-term renal disfunction and kidney shrinkage., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A persistent endoleak type II (ET II) after endovascular repair for aortic aneurysms is not always a benign condition and has been associated to sac expansion, rupture, and reintervention. A variety of different endovascular approaches are available for ET II treatment. The aim of this systematic review was to assess the currently available literature on transcaval embolization for ET II treatment after standard or complex endovascular aortic aneurysm repair., Methods: This systematic review protocol was registered to the PROSPERO (CRD42021289686). The PRISMA guidelines and patient, intervention, comparison, outcome (P.I.C.O.) model was followed. A data search of the literature was conducted, using PubMed, EMBASE via Ovid, and CENTRAL databases, until September 30, 2021. Only studies reporting on ET II embolization using the transcaval approach after endovascular aneurysm repair were included. Studies reporting on different type of endoleak treatment or any other embolization approach were excluded. The quality of studies was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success and freedom from ET II persistence during follow-up; secondary outcomes were any postoperative complication associated with the transcaval embolization and need for reintervention., Results: The search yielded 2861 articles in total. Eight articles were included, reporting on 117 patients and 128 transcaval embolizations. The indication for treatment was ET II presence with sac expansion of more than 5 mm; in two studies, the presence of persistent endoleak has set the indication to intervene. The technical success was 91.4% (117/128); a variety of embolic materials were used, including coils, thrombin, and glue. Three cases of deep vein thrombosis were recorded and the remaining morbidity and mortality were null. Follow-up was ranging between 0 and 25 months. Out of 8 studies, persistent ET II rate was 12.8% and 18 reinterventions were performed (14.1%,), including 10 transcaval coil embolizations (56%). Sac expansion was reported in 11 cases, out of 3 studies (17%). Only one case of death, not associated with transcaval embolization, was recorded., Conclusions: Transcaval embolization for ET II treatment presents a high technical success and low mortality in the early and mid-term period. ET II persistence rate is low during the available 12-month follow-up., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To report early results of feasibility and patency of prophylactic hypogastric artery (HA) stenting during complex endovascular aortic repair., Methods: This is a single centre retrospective non comparative cohort study of all consecutive patients undergoing prophylactic HA stenting during fenestrated and/or branched EVAR (F/B EVAR) in order to prevent spinal cord ischemia (SCI). Endpoints included technical success and early outcomes in terms of morbidity, mortality and patency of the implanted stents., Results: Between May 2014 and June 2019 prophylactic HA stenting was performed in 36 consecutive patients with significant HA stenosis during F/B EVAR to prevent SCI. 69.4% of patients presented with asymptomatic, 25% with symptomatic and 5.6% with ruptured aortic aneurysms. 55.6% were treated for thoracoabdominal aortic aneurysms, 44.4% for pararenal abdominal aortic aneurysms. In 13.9% aortic coverage was limited to the abdominal aorta. In 86.1% the aortic coverage was in the thoracoabdominal aortic segment. Unilateral HA stenting was performed in 91.7%, whereas 8.3% underwent bilateral stenting. Technical success was 100%. The primary patency of the implanted stents after a median follow-up time of 9.5 months was 97.5%. One intraprocedural bleeding from an HA branch occurred and was successfully treated by coil embolization. No further procedure-related complications occurred. 11.1% of the patients developed SCI., Conclusions: HA stenting is feasible and safe with high rates of technical success and short-term patency., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We compared the outcomes between elective, urgent, and emergent treatment of thoracoabdominal aortic aneurysms (TAAAs) using the t-Branch off-the-shelf multibranched stent graft (Cook Medical, Bloomington, Ind)., Methods: All consecutive patients treated for TAAAs using the t-Branch between September 2012 and June 2019 were included in the present study. The patients were divided into three groups according to the urgency of repair: (1) elective, (2) urgent, and (3) emergent. The periprocedural details and 30-day outcomes were analyzed. Survival and reinterventions were analyzed using Kaplan-Meier curves and log-rank tests., Results: The t-Branch stent graft was used for 100 patients during the study period. Of the 100 patients, 30 (73% male; mean age, 65 ± 10 years) were treated electively, 49 (54% male; mean age, 72 ± 7 years) urgently, and 21 (81% male; mean age, 75 ± 9 years) emergently. Transfemoral access with a steerable sheath was used more frequently for target vessel catheterization in the elective group (57%) than in the urgent (8%) and emergent (5%) groups (P = .021). The total number of targeted vessels was 111 of 120 (93%) in the elective group vs 185 of 196 (94%) in the urgent group and 82 of 84 (98%) in the emergent group. The corresponding technical success rates were 97% (29 of 30), 98% (48 of 49), and 95% (20 of 21). The median intensive care unit stay was shorter in the elective group (3 days; range, 1-41 days) than in the urgent group (5 days; range, 1-41 days) and emergent group (11 days; range, 3-37 days; P = .004). The 30-day mortality rate was lower in the elective group (2 of 30; 7%) than in the urgent group (8 of 49; 16%) and emergent group (5 of 21; 24%; P = .049). The acute kidney injury rate was lower in the elective group (2 of 30; 7%) than in the urgent group (11 of 49; 22%) and emergent group (8 of 21; 38%; P = .002). The spinal cord ischemia rate was also lower in the elective group (5 of 30; 17%) than in the urgent group (5 of 49; 10%) and emergent group (8 of 21; 38%; P = .051). The median follow-up was 8 months (interquartile range, 3.2-18.5 months). The cumulative survival rate was 95%, 87%, and 87% at 6, 12, and 24 months, respectively. The cumulative freedom from reintervention during follow-up was 92%, 86%, and 77% at 6, 12, and 24 months, respectively., Conclusions: The technical success of TAAA repair using t-Branch stent graft was not affected by an urgent or emergent presentation. However, the occurrence of worse periprocedural morbidity and mortality was significantly associated with an urgent or emergent presentation., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The t-Branch, a standardized off-the-shelf multi-branched stent graft has been used for the treatment of elective and urgent cases in aortic disease. The aim of this study was to assess the early outcomes in terms of technical success, mortality, and morbidity in >500 patients being treated with the t-Branch device., Methods: A two-center retrospective observational study was undertaken including patients treated using the t-Branch (Cook Medical, Bloomington, IN) in elective or urgent settings for complex abdominal aortic aneurysm and thoraco-abdominal aortic aneurysm between 2014 and 2019 (early experience 2014-2016; late experience 2017-2019). Primary endpoints were technical success and early (30-day) mortality, and secondary endpoints were early morbidity, endoleak, and target vessel patency rates. Multivariable regression models were used to determine the independent association of risk factors with (1) mortality and (2) spinal cord ischemia., Results: A total of 542 patients (mean age, 70.5 ± 8.5 years; 388 men [72%]; mean aneurysm diameter, 7.5 ± 2.5 cm) were included (63% elective; 90% thoraco-abdominal aortic aneurysm). The technical success rate was 97% (526/542) (elective, 96.7% [328/339] vs urgent, 97.6% [208/213]). The total 30-day mortality rate was 12.3% (8.5% in elective, 15% in symptomatic, and 30% in contained rupture). After multivariate regression analysis, the mortality rate was associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.11; P < .001) and with lower baseline glomerular filtration rate (OR, 0.98; 95% CI, 0.98-0.99; P < .001). In elective cases, the mortality rate was associated with a history of coronary artery disease (OR, 0.26; 95% CI, 0.09-0.73; P < .011) and higher body mass index (OR, 0.87; 95% CI, 0.77-0.98; P < .027). In urgent cases, the mortality rate was associated with older age, (OR, 1.07; 95% CI, 1.02-1.13; P < .010) and lower baseline glomerular filtration rate (OR, 0.97; 95% CI, 0.95-0.99; P < .001). The spinal cord ischemia rate was 10.5% (6.5% temporary, 4% permanent) and was associated with the early study period (OR, 2.01; 95% CI, 1.03-3.89; P < .038). The renal impairment rate was 13%, the stroke rate was 2.5%, and the myocardial infarction rate was 1.8%, whereas the access complications rate was 7.7%. On early computed tomography angiography, the primary patency rate for the right renal artery was 99.6%, for the left renal artery was 100%, for the superior mesenteric artery was 99.4%, and for the coeliac trunk was 99.8%. The endoleak I and III rates were 2.7% (15/542) and 2.7% (15/542), respectively., Conclusions: Elective and urgent use of the t-Branch multi-branched off-the shelf stent graft showed high technical success and early target vessel patency rates. Early mortality and morbidity rates were acceptable., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort., Methods: This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes., Results: In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay., Conclusion: In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: This study aims to determine the outcomes of transcaval embolization (TCE) for type II endoleak after infrarenal endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/BEVAR)., Methods: A retrospective single-center cohort study of all consecutive TCE procedures between August 2015 and August 2019 was performed to investigate technical success, in-hospital morbidity, and 30-day mortality as well as clinical success during follow-up. The indication for TCE was an aneurysm sac growth of 5 mm or more owing to a type II endoleak after EVAR for infrarenal or F/BEVAR for juxtarenal and type IV thoracoabdominal aortic aneurysm., Results: A total 25 TCE procedures in 24 patients (95.8% male) were included. Technical success was 96.0% (24/25); selective and nonselective TCE were performed in 48% of patients. The in-hospital morbidity and 30-day mortality were 0%. The median follow-up was 23.1 months (interquartile range, 10.9-40.1 months). Freedom from type II endoleak-related reintervention was 84.6% at 12 months. Comparing clinical success after TCE, reintervention was necessary in 16.7% of patients after nonselective and 20% of patients after selective TCE. Regarding TCE after EVAR vs F/BEVAR, reintervention was performed in 12.5% of EVAR and 33.3% of F/BEVAR patients during follow-up., Conclusions: TCE is an acceptable treatment alternative for type II endoleak with aneurysm sac enlargement and can be used after EVAR for infrarenal abdominal aortic aneurysms and F/BEVAR for juxtarenal abdominal aortic aneurysms and type IV thoracoabdominal aortic aneurysms., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoracoabdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair., Methods: Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality., Results: We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and 8 with a tube graft. Of these, 2 patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, 3 of them with additional type Ia endoleak, 2 with stent-graft migration and 2 with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P = 0.746). Eighteen patients (86%) had branched stent grafting in the post-open versus 11 (52%) in the post-endo group (P < 0.01). In 2 patients in the post-open group, 3 renal arteries were not catheterized due to severe ostial stenosis, resulting in technical success of 91% in the post-open and 100% in the post-endo fbEVAR group. Four patients (19%) in the post-open fbEVAR group died in hospital, 2 due to cerebral hemorrhage and 2 due to pneumonia, and none in the post-endo fbEVAR group (P = 0.101). There were 5 nonstent-graft-related reinterventions, 2 (10%) in the post-open fbEVAR group and 3 (14%) in the post-endo fbEVAR group (P = 0.844). After 12 months there were 4 events in the post-endo fbEVAR group: one renal artery stent occluded, one renal artery stent required relining because of disconnection and 2 type II endoleaks were embolized with coils. There were no reinterventions in the post-open fbEVAR group during 12 months., Conclusions: Fenestrated and branched repair after previous open or endovascular abdominal aortic repair appears safe with high technical success rate. There is no difference in the technical success and in-hospital all-cause mortality rates between fbEVAR after previous open or endovascular abdominal aortic repair., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We studied the outcomes of transfemoral access (TFA) vs upper extremity access (UEA) for branched endovascular aortic repair (BEVAR)., Methods: From January 2016 to October 2019, 152 consecutive patients underwent BEVAR under general anesthesia at a single institution. In 2018, an alternative approach to the antegrade branches using TFA compared with conventional UEA was introduced. The cohort was divided into TFA and UEA groups according to the access approach. The end points were technical success, adverse events (including perioperative stroke/transient ischemic attack), access complications, operation time, and radiation exposure., Results: The TFA group included 60 patients (63% male; median age, 71 years; interquartile range [IQR], 65-76 years). The UEA group included 92 patients (67% male; median age, 73 years; IQR, 66-78 years). The number of target vessels (TVs) was similar in both groups (median, 4.0 TVs per procedure; range, 1-7 TVs for both). Technical success was greater in the TFA group (60 of 60 patients; 209 of 209 TVs) than in the UEA group (87 of 92 patients; 334 of 346 TVs; P < .01). The fluoroscopy time (median, 69 minutes; IQR, 48-87 minutes; vs 88 minutes; IQR, 65-104 minutes; P = .39) and contrast agent volume (median, 141 mL; IQR, 123-165 mL; vs median, 130 mL; IQR, 101-157 mL; P = .34) were similar in both groups. The radiation exposure (221 Gy × cm 2 ; IQR, 138-406 Gy × cm 2 ; vs median, 255 Gy × cm 2 ; IQR, 148-425 Gy × cm 2 ; P = .05) was lower and the operation time (median, 300 minutes; IQR, 240-356 minutes; vs median, 364 minutes; IQR, 290-475 minutes; P = .01) was shorter in the TFA group. Brachial access complications (0 of 60 vs 3 of 92 patients) and perioperative strokes/transient ischemic attacks (0 of 60 vs 8 of 92 patients) only occurred in the UEA group (P = .018)., Conclusions: The use of TFA to catheterize antegrade branches was associated with a lower rate of complications in the present study and has become our preferred approach for BEVAR., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate the outcome of t-Branch (Cook Medical, Bloomington, Ind) stent graft for the treatment of thoracoabdominal and pararenal aortic aneurysms in patients who had previous infrarenal aortic repair., Methods: A retrospective two-center study was undertaken. All consecutive patients who underwent endovascular repair using t-Branch stent graft after previous infrarenal aortic repair between January 2010 and August 2018 were included. Demographics, past medical history, cardiovascular risk factors, and intraoperative and perioperative details were recorded. Technical success and early (30-day) mortality, morbidity, target vessel patency, and presence of endoleak were analyzed. During the first year of follow-up, survival, freedom from reintervention, and patency rates were recorded., Results: There were 32 patients (mean age, 74 ± 7 years; 81% male) included in the study; 24 (75%) patients had prior open surgical repair, and 8 (25%) patients had undergone standard endovascular aneurysm repair. The index operation was performed 9 ± 5 years earlier, including 10 ± 5 years for open surgical repair and 8 ± 6 years for endovascular aortic repair. The indication was progression of the disease in 26 patients (81%) and type IA endoleak in 6 patients (19%). The total number of target vessels incorporated was 117 arteries (3.8 ± 0.6 target vessels per patient). Eleven patients had only three vessels incorporated; celiac trunk was occluded in three patients, and eight patients had one functioning kidney. Technical success rate was 97% (31/32). There was a single technical failure in one patient who had a type IA endoleak after endovascular repair with suprarenal fixation. The stenotic right renal artery was not catheterized at the initial procedure, and retrograde access was achieved through a right subcostal incision 3 days later with successful completion of the repair. Early mortality rate was 13%, and spinal cord ischemia rate was 22% (7/32); four patients had permanent and three had transient neurologic deficits. Early target vessel patency was 100%, and the rate of any endoleak was 9% (3/32); two patients had type II endoleaks and one patient had type III endoleak. The mean follow-up was 5.4 ± 5.9 months. The cumulative survival rate was 82% and 73% at 6 and 12 months, respectively. The freedom from aorta-related mortality was 92% at 6 and 12 months. The cumulative freedom from reintervention during follow-up was 90% at 6 and 12 months. The overall target vessel patency rate was 100% and 97.5% at 6 and 12 months, respectively., Conclusions: The use of t-Branch off-the-shelf stent graft for the treatment of aortic disease in patients who had previous infrarenal aortic repair appears to be feasible, with acceptable early outcomes in terms of morbidity and mortality., (Copyright © 2020 Society for Vascular Surgery. All rights reserved.)

Background: Presence of gas is a frequent finding on early postoperative computed tomography angiography (CTA) after endovascular aortic aneurysm repair (EVAR) with unclear clinical relevance. The aim of this study is to examine and compare the presence of gas within the aneurysm sac following EVAR on early postoperative CTA after the use of carbon dioxide (CO 2 ) flushing technique with saline flushing alone., Methods: A retrospective analysis of patients undergoing standard, fenestrated EVAR (fEVAR) or branched EVAR (bEVAR) with flushing of the delivery system with CO 2 between January 2016 and August 2018 was undertaken. Data of a previous report using standard saline flushing were included. Patients were classified into 2 main groups: group 1 with saline flushing and group 2 with CO 2 flushing and 3 subgroups according to the type of endograft. The presence, position, and volume of gas in the postoperative CTA (within 10 days) was examined and analyzed in terms of anatomical and procedural risk factors., Results: Group 1 included 210 patients (mean age 73 ± 8, 84% males), while group 2 included 300 patients (mean age 70 ± 11, 68% males). Presence of gas was more common in group 1 (83, 39% vs. 64, 21%, P = 0.000). Volume of gas was larger in group 1 [0.41 mL (0.01-2.7) vs. 0.2 mL (0.02-1), P = 0.001). In standard EVAR with saline flushing (subgroup 1a), 59 patients (45%) had presence of gas with CO 2 flushing (subgroup 2a); 35 patients (25%) had presence of gas (P = 0.005). The mean gas volume was larger in subgroup 1a compared to 2a (0.40 ± 0.47 vs. 0.15 ± 0.17 mL, P = 0.000). The location of the gas was more frequent in contact with the anterior wall of the aorta in both groups, standard EVAR subgroups and fEVAR subgroups. The presence of gas in group 2 was associated with larger preoperative size of the aortic diameter (P = 0.03) and larger perfused lumen diameter (P = 0.05). The type of the graft was not associated with the presence of gas in the aneurysm sac on postoperative CTA. However, the presence of gas was more frequent in standard EVAR than fEVAR and bEVAR. Endoleak type II was not associated with the presence of gas., Conclusions: CO 2 flushing of stent grafts during standard and complex EVAR prior to deployment reduces the frequency and volume of gas on postoperative CTA. This study indicates that the CO 2 flushing technique may effectively exchange trapped air for a less harmful gas in endografts., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Infection of the vascular graft represents one of the most threatening complications after aortic repair. It is rare and associated with high morbidity and mortality rates. The aim of this study was to present short-term outcomes after surgical treatment of infected aortic grafts after endovascular and open repair of abdominal aortic aneurysms (AAAs)., Methods: Data of all patients affected by aortic graft infection after aneurysm repair who underwent an explantation of a conventional or endovascular aortic graft between January 2008 and December 2016 were retrospectively reviewed. All patients underwent in situ reconstruction using a rifampicin soaked synthetic graft. The primary endpoint of this study was 30 day mortality; secondary endpoints were major post-operative complications., Results: Twenty-six patients were included in the cohort, 16 with an infected endograft (iEVAR) and 10 patients with an infected conventional graft (iOAR). Thirty-day mortality was 23.1% overall, 37.5% for iEVAR and 0% (p = .027) for iOAR. Post-operative major complications occurred in eight (50%) patients from the iEVAR group and in four (40%) patients from the iOAR group (p = .619). The supravisceral clamping rate was higher in patients with infected iEVAR (93.8 vs. 20%, p = .001), furthermore a greater incidence of post-operative acute kidney injury was observed (50 vs. 0%, p = .009)., Conclusions: Explantation of the graft and in situ reconstruction for aortic graft infection is accepted as the therapy of choice. However, re-operation for iEVAR is related to significantly higher mortality and morbidity rates. The need for suprarenal aortic clamping seems to be a possible explanation for worse outcomes in iEVAR., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The objective of this study was to analyze radiation risk to patients during endovascular aneurysm repair (EVAR) using mobile C-arm (MA) or fixed C-arm (FA) fluoroscopes and to describe the dose distribution during the different phases of the procedure., Methods: Patients treated with EVAR using a single stent graft system between November 2009 and June 2016 were included in this study. The patients were divided into one of two groups (MA or FA) according to the type of C-arm used in the procedure. Data regarding patients' demographics and the total amount of contrast agent (CA) used, dose-area product, and fluoroscopy time for the procedures were prospectively recorded. Based on the dose report from the FA system, five standard and two optional phases of the procedure were identified to determine the dose distribution., Results: Overall, 160 patients were included (mean age, 73.30 ± 8.97 years; 146 men); of these, 107 were treated with an MA system and 53 were treated with an FA system. The mean amounts of CA used were 108.55 ± 42.28 mL in the MA group and 85.37 ± 38.79 mL in the FA group (P = .0014). The mean total dose-area product values were 49.93 ± 38.06 Gy·cm 2 in the MA group and 168.34 ± 146.92 Gy·cm 2 in the FA group (P < .0001). There was no significant difference in fluoroscopy time between the groups. Per-phase analysis demonstrated that identification of the proximal landing zone and main body deployment required the most radiation, accounting for 24% of the total radiation dose. Overall, 47.6% of the exposure was due to digital subtraction angiography., Conclusions: Use of an FA system can significantly reduce the amount of CA needed but may also lead to higher radiation doses in EVAR procedures. Dose monitoring remains crucial for the safety of both patients and operators. A detailed analysis of dose distribution is possible with modern systems, which may improve the quality of monitoring in the future., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The introduction of lower profile endografts expanded the application of aortic endovascular repair. However, evidence about their durability is still scarce. The objective of this study was to assess longer term durability of the Zenith Alpha Thoracic Stent Graft (Cook Inc, Bloomington, Ind) after thoracic endovascular aortic repair., Methods: Prospectively collected data of all patients treated for thoracic aortic aneurysms or penetrating aortic ulcers and having computed tomography angiography-based follow-up of ≥12 months were retrospectively analyzed. The primary end point was ongoing clinical success. Among the secondary end points, stent graft migration and fracture were analyzed., Results: Between August 2010 and October 2015, 70 consecutive patients were treated in a single center with the Zenith Alpha stent graft. With computed tomography angiography-based follow-up of 22.3 ± 15.9 months, ongoing clinical success was 87.1%. There were three cases of type IA endoleak (4.3%), two cases of type IB endoleak (2.9%), and one case of aneurysm sac enlargement (1.4%). Five patients died postoperatively (7.1%). No type III or type IV endoleak was detected; there was one case of distal stent graft migration and no stent fracture. Reintervention was necessary in one case (1.4%) of a combined type IA and type II endoleak. There were no conversions to open repair and no ruptures or intraoperative deaths. All-cause mortality was 17.1% at 76 months., Conclusions: The Zenith Alpha Thoracic Stent Graft appears to maintain favorable results in a longer time frame with a low incidence of aneurysm sac growth and migration. Results from multicenter prospective trials are needed to validate these data., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the usability of a fully automated fusion imaging engine prototype, matching preinterventional computed tomography with intraoperative fluoroscopic angiography during endovascular aortic repair., Methods: From June 2014 to February 2015, all patients treated electively for abdominal and thoracoabdominal aneurysms were enrolled prospectively. Before each procedure, preoperative planning was performed with a fully automated fusion engine prototype based on computed tomography angiography, creating a mesh model of the aorta. In a second step, this three-dimensional dataset was registered with the two-dimensional intraoperative fluoroscopy. The main outcome measure was the applicability of the fully automated fusion engine. Secondary outcomes were freedom from failure of automatic segmentation or of the automatic registration as well as accuracy of the mesh model, measuring deviations from intraoperative angiography in millimeters, if applicable., Results: Twenty-five patients were enrolled in this study. The fusion imaging engine could be used in successfully 92% of the cases (n = 23). Freedom from failure of automatic segmentation was 44% (n = 11). The freedom from failure of the automatic registration was 76% (n = 19), the median error of the automatic registration process was 0 mm (interquartile range, 0-5 mm)., Conclusions: The fully automated fusion imaging engine was found to be applicable in most cases, albeit in several cases a fully automated data processing was not possible, requiring manual intervention. The accuracy of the automatic registration yielded excellent results and promises a useful and simple to use technology., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: After multi-branched endovascular aneurysm repair (mbEVAR), renal branch occlusion is the most frequent form of branch failure. Pre-operative renal angulation and post-operative morphology of the renal branch were quantified and their impact on occlusion was analyzed., Methods: Patients who underwent mbEVAR between January 2010 and December 2013 were reviewed retrospectively. Only renal branches constructed with caudally directed cuffs were included. Patients without post-operative computed (CT) angiography were excluded. The main outcome was the primary patency of the renal branches. The renal angulation and the morphology of renal branch (bridging length, renal coverage length, tortuosity index, and angulation of distal renal artery) were quantified using CT. The impacts of morphology, implanted stents, and patient characteristics were investigated by time to event analyses., Results: Ninety renal arteries in 49 patients were enrolled. Median follow up was 12 months (IQR 6-20 months). Balloon expandable stent grafts were used in 93% (84/90) of renal branches. Self expandable stent grafts were used in 12. Ninety-one percent (82/90) were lined with self expandable bare stents. Ten branches occluded after 8 months (median; IQR 1-14 months). Four of them underwent re-interventions, achieving secondary patency. The median renal angulation was -10° (IQR -40 to 0). The median bridging length was 42 mm (IQR 39-46 mm) and renal coverage 17 mm (IQR 12-22 mm). Median tortuosity index was 1.11 (IQR 1.04-1.19). The angulation of the distal renal artery was 140.7 ± 20.5°. In multivariate analysis, a tortuosity index > 1.11 was identified as the only significant predictor for occlusion (hazard ratio: 4.94; 95% CI: 1.01-24.30, p = .04)., Conclusions: High tortuosity was a significant predictor for the occlusion of renal branches, but renal angulation, bridging length, and the extent of renal coverage were not. By avoiding highly tortuous renal branch paths, good outcomes are expected even in upwardly directed renal arteries. Longer paths are acceptable., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective/background: Bridging stent grafts (BSGs) are used to connect the target vessel with the main body during fenestrated or branched aortic endografting (f/bEVAR). No dedicated devices are available for BSG. The aims of this study were to assess the performance of BSGs., Methods: Between January 2004 and May 2014 the data of patients treated with f/bEVAR were prospectively collected. Only patients treated after January 2010 were included. The main measurement outcome was any BSG related complications. A logistic regression analysis, including target vessel type, type of joint (fenestration or cuff), and type of BSG identified potential risk factors., Results: One hundred and fifty consecutive patients underwent f/bEVAR, and 523 target vessels were involved. These included 104 celiac, 140 superior mesenteric, 275 renal, and four other arteries. The technical success rate was 99% (520/523 target vessels). Balloon expandable BSGs were mainly used (n = 494; 95%), and in 336 (65%) relining stents were combined. The primary reasons for technical failure were the dislocation of the main body (n = 1) and unsuccessful cannulation (n = 2). One was revascularized by means of the periscope technique. Four target vessel injuries were recorded and four renal arteries occluded peri-operatively. After a median follow up of 14 months (interquartile range 5.5-23.0), 13 (2%) BSGs occluded and 19 (4%) required re-interventions. Two SMA occlusions occurred, leading to death in both patients. The patency and freedom from re-intervention rates at 3 years amounted to 85% and 91%, respectively. Use of a branched main body was the only independent risk factor for re-intervention and for the composite event (hazard ratio [HR] 3.5, 95% confidence interval [CI] 1.3-9.9 [p = .02]; and HR 2.8, 95% CI 1.2-7.0 [p < .01], respectively). Of note, the use of relining stents seemed not to prevent BSG related complications., Conclusion: The currently used BSGs had low occlusion and re-intervention rates. Modifications of the branched design or dedicated BSG devices may improve outcome, especially after bEVAR., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The introduction of fenestrated and multibranched endografting transformed the treatment paradigm of patients with thoracoabdominal aortic aneurysms (TAAAs). However, despite the minimally invasive character of the procedure, spinal cord ischemia (SCI) remains a devastating complication. The aim of this study was to address the SCI rates after endovascular TAAA repair and to analyze potential risk factors leading to this complication., Methods: A consecutive cohort of patients with nonruptured TAAAs treated by means of fenestrated and multibranched endografting between January 2010 and September 2014 was analyzed. Neurologic examination was routinely performed by an independent neurologist before operation and at discharge. The main outcome measure was the onset of SCI (paraplegia or paraparesis). Secondary outcomes were neurologic complications associated with cerebrospinal fluid drainage (CSFD) and 30-day mortality. Finally, a multivariate regression analysis identified risk factors for SCI., Results: A consecutive 142 patients with TAAAs (Crawford type II, n = 54 [38%]; type III, n = 76 [54%]; type IV, n = 12 [8%]) were included in this study. The majority of patients (n = 129 [91%]) were treated for an atherosclerotic aneurysm, whereas 13 patients (9%) were treated for a postdissection aneurysm. The mean maximal aortic diameter was 65 ± 13 mm. SCI developed in 23 patients (16%; paraplegia in 12 [8%] and paraparesis in 11 [8%]). Of these 23 patients, 10 patients (43%) showed the neurologic deficit directly after the procedure, 11 patients (48%) in the first 24 hours, and 2 patients (9%) after 24 hours. There was an improvement of the neurologic status in the majority of patients, with only three patients (2%) showing irreversible paraplegia at discharge. There was no difference in the 30-day mortality between patients with and without SCI (no SCI, n = 3 [3%] vs SCI, n = 1 [4%]; P = .511). Prophylactic use of CSFD before the procedure was performed in 64 patients (45%), and among them, 4 patients (6%) developed a CSFD-associated complication. No clinical benefit for patients receiving prophylactic placement of CSFD was found (P = .498). The multivariate analysis revealed the percentage of thoracic aortic coverage as the only significant risk factor for SCI (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P = .001)., Conclusions: The SCI rate after endovascular repair of TAAA was 16%, with 8% of those patients suffering from paraplegia. Prophylactic use of CSFD could not reduce the SCI rate and was associated with 6% adverse events. The percentage of thoracic aortic coverage was the most powerful determinant of SCI in these series., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Monitoring the expansion of abdominal aortic aneurysms (AAAs) is critical to avoid aneurysm rupture in surveillance programs, for instance. However, measuring the change of the maximum diameter over time can only provide limited information about AAA expansion. Specifically, regions of fast diameter growth may be missed, axial growth cannot be quantified, and shape changes of potential interest for decisions related to endovascular aneurysm repair cannot be captured., Methods: This study used multiple centerline-based diameter measurements between the renal arteries and the aortic bifurcation to quantify AAA growth in 51 patients from computed tomography angiography (CTA) data. Criteria for inclusion were at least 1 year of patient follow-up and the availability of at least two sufficiently high-resolution CTA scans that allowed an accurate three-dimensional reconstruction. Consequently, 124 CTA scans were systematically analyzed by using A4clinics diagnostic software (VASCOPS GmbH, Graz, Austria), and aneurysm growth was monitored at 100 cross-sections perpendicular to the centerline., Results: Monitoring diameter development over the entire aneurysm revealed the sites of the fastest diameter growth, quantified the axial growth, and showed the evolution of the neck morphology over time. Monitoring the development of an aneurysm's maximum diameter or its volume over time can assess the mean diameter growth (r = 0.69, r = 0.77) but not the maximum diameter growth (r = 0.43, r = 0.34). The diameter growth measured at the site of maximum expansion was ~16%/y, almost four times larger than the mean diameter expansion of 4.4%/y. The sites at which the maximum diameter growth was recorded did not coincide with the position of the maximum baseline diameter (ρ = 0 .12; P = .31). The overall aneurysm sac length increased from 84 to 89 mm during the follow-up (P < .001), which relates to the median longitudinal growth of 3.5%/y. The neck length shortened, on average, by 6.2% per year and was accompanied by a slight increase in neck angulation., Conclusions: Neither maximum diameter nor volume measurements over time are able to measure the fastest diameter growth of the aneurysm sac. Consequently, expansion-related wall weakening might be inappropriately reflected by this type of surveillance data. In contrast, localized spots of fast diameter growth can be detected through multiple centerline-based diameter measurements over the entire aneurysm sac. This information might further reinforce the quality of aneurysm surveillance programs., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To present endovascular techniques in the treatment of juxtarenal aortic aneurysms (JAAAs) in relation to surgical repair; this is the "gold standard.", Methods: Between January 2008 and December 2010, 90 consecutive patients were diagnosed with primary degenerative JAAAs (≥5.0 cm) and assigned prospectively to different operative strategies on the basis of morphologic and clinical characteristics. In particular, 59 patients were treated by endovascular means such as fenestrated endovascular abdominal aortic repair (f-EVAR, n = 29) or chimney endovascular abdominal aortic repair (ch-EVAR, n = 30) endografting, and 31 patients underwent open repair (OR, n = 31)., Results: Early procedure-related and all-cause (30-day) procedure-related mortality was 0% for the endovascular group and 6.4% (n = 2/31) for the OR group, due to systemic inflammatory response syndrome with consecutive multi-organ failure (P = .023). Persistent postoperative hemodialysis occurred only after OR (2/31; 6.4%). The overall estimated pre- and postoperative median estimated glomerular filtration rate and creatinine values were similar in the three subgroups. There was one left renal artery occlusion for each endovascular subgroup, which presented as flank pain and was treated by iliaco-renal bypass in both cases. Transfusion requirements and length of hospital stay were significantly less in the endovascular group (P = .014 and P = .004, respectively)., Conclusions: Endovascular treatment of JAAA is a safe alternative for the short-term management of JAAA., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: To present the clinical experience of consecutive series with use of balloon-expandable and self-expanding chimney endografts (balloon-expandable covered stent group [BECS] vs self-expanding covered stent group [SECS]) in the endovascular treatment of challenging aortic pathologies requiring renal and/or visceral revascularization., Methods: Between January 2009 and May 2011, data for 37 high-risk patients from one center and 35 patients from another institution, with pararenal aortic pathologies treated by the chimney endovascular technique, were prospectively collected. The chimney-graft technique is based on the deployment of a covered or bare-metal stent parallel to the aortic endograft, thereby creating a conduit that runs outside the aortic main endograft, and has been proposed to ensure secure proximal fixation extending the sealing zones., Results: Forty-six consecutive target vessels (43 renal arteries and 3 superior mesenteric arteries) were revascularized by the Advanta (Atrium, Hudson, NH) BECS (1.2 chimneys/patient); in contrast, 81 consecutive target vessels (64 renal arteries, 11 superior mesenteric arteries, and 6 celiac trunks) were revascularized by the Viabahn (Gore, Flagstaff, Ariz) SECS (2.3 chimneys/patient). The success rate for target vessel preservation was 97.8% for the BECS group and 100% for the SECS group in the entire follow up. There was one symptomatic left renal artery occlusion of the BECS group treated by open thrombectomy of the left renal artery and placement of 8-mm Dacron (BBraun, Aesculap AG, Tuttlingen, Germany) iliorenal bypass. Additionally, one patient underwent repeat balloon angioplasty with a 5-mm balloon due to high-grade in-stent stenosis of a 6 × 59 Advanta stent graft 12 months postoperatively. Overall, one perioperative (and not present in the computed tomography angiography at discharge) type Ia endoleak was detected in the BECS group. In contrast, five perioperative type Ia endoleaks were present in the SECS group; however, only one of them was persistent in the radiological imaging and was treated by proximal extension of a 5-mm cuff, 1 year postoperatively, due to continuous aneurismal sac increase. No patient of any subgroup developed postoperative persistent renal insufficiency with need of hemodialysis. Thirty-day and during the follow-up procedure-related mortality was 0% for both BECS and SECS groups., Conclusions: In summary, midterm results of use of covered chimney stents for pararenal aortic pathologies show safety and feasibility with excellent patency and low incidence of endoleaks., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Introduction: The purpose of this study was to report the early and late results of primary stenting for focal atherosclerotic lesions of the infrarenal aorta., Methods: A retrospective analysis of 52 consecutive patients treated for infrarenal occlusive aortic disease with primary stenting between January 2002 and November 2009 was performed. Original angiographic imaging, medical records, and noninvasive testing were reviewed. Primary stenting was the first line of treatment. Perioperative technical success and Kaplan-Meier estimates for patency and survival were calculated., Results: The majority of the patients (43) were treated for severe claudication (Rutherford III; 82.7%), 5 for ischemic rest pain (Rutherford IV; 9.6%), and 4 for minor tissue loss (Rutherford V; 7.7%). Aortic stenosis was found in 40 cases (76.9%) and occlusion in 12 (23%). Perioperative hemodynamic success was 100%. All patients had an improvement of ankle brachial index (ABI) >0.10. Clinical improvement was found in 96%. Early surgical revision was necessary for aortic rupture in 1 patient. One death occurred for pneumonia. The mean follow-up time was 39.4 ± 27.2 months. Ten reinterventions (19%) were needed for symptom recurrence. The estimated assisted primary patency at 9 years was 96% and the mean survival time was 86.6 months., Conclusion: Primary stenting offers safe and durable results and should be considered as the first line of treatment for focal aortic lesions., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: A great deal of attention has been directed at the necessity and potential for deleterious outcomes as a result of radiation exposure during diagnostic evaluations and interventional procedures. We embarked on this study in an attempt to accurately determine the amount of radiation exposure given to patients undergoing complex endovascular aortic repair. These measured doses were then correlated with radiation dose estimates provided by the imaging equipment manufacturers that are typically used for documentation and analysis of radiation-induced risk., Methods: Consecutive patients undergoing endovascular thoracoabdominal aneurysm (eTAAA) repair were prospectively studied with respect to radiation dose. Indirect parameters as cumulative air kerma (CAK), kerma area product (KAP), and fluoroscopy time (FT) were recorded concurrently with direct measurements of dose (peak skin dose [PSD]) and radiation exposure patterns using radiochromatic film placed in the back of the patient during the procedure. Simultaneously, operator exposure was determined using high-sensitivity electronic dosimeters. Correlation between the indirect and direct parameters was calculated. The observed radiation exposure pattern was reproduced in phantoms with over 200 dosimeters located in mock organs, and effective dose has been calculated in an in vitro study. Scatter plots were used to evaluate the relationship between continuous variables and Pearson coefficients., Results: eTAAA repair was performed in 54 patients over 5 months, of which 47 had the repair limited to the thoracoabdominal segment. Clinical follow-up was complete in 98% of the patients. No patients had evidence of radiation-induced skin injury. CAK exceeded 15 Gy in 3 patients (the Joint Commission on Accreditation of Healthcare Organizations [JCAHO] threshold for sentinel events); however, the direct measurements were well below 15 Gy in all patients. PSD was measured by quantifying the exposure of the radiochromatic film. PSD correlated weakly with FT but better with CAK and KAP (r = 0.55, 0.80, and 0.76, respectively). The following formula provides the best estimate of actual PSD = 0.677 + 0.257 CAK. The average effective dose was 119.68 mSv (for type II or III eTAAA) and 76.46 mSv (type IV eTAAA). The operator effective dose averaged 0.17 mSv/case and correlated best with the KAP (r = 0.82, P < .0001)., Conclusion: FT cannot be used to estimate PSD, and CAK and KAP represent poor surrogate markers for JCAHO-defined sentinel events. Even when directly measured PSDs were used, there was a poor correlation with clinical event (no skin injuries with an average PSD >2 Gy). The effective radiation dose of an eTAAA is equivalent to two preoperative computed tomography scans. The maximal operator exposure is 50 mSv/year, thus, a single operator could perform up to 294 eTAAA procedures annually before reaching the recommended maximum operator dose., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Endovascular repair of complex aortic aneurysms (CAAs) can be performed in high-risk individuals, yet is still associated with significant morbidity, including spinal cord ischemia, cardiac complications, and death. This analysis was undertaken to better define the cardiac risk for CAA., Methods: A prospective database of patients undergoing thoracoabdominal or juxtarenal aortic aneurysm repair with branched and fenestrated endografts was used to retrospectively determine the number of cardiac events, defined as myocardial infarction (MI), atrial fibrillation (AF), and ventricular arrhythmia (VA), that occurred ≤ 30 days of surgery. Postoperative serial troponin measurements were performed in 266 patients. Any additional available cardiac information, including preoperative echocardiography, physiologic stress tests, and history of cardiac disease, was obtained from medical records. The efficacy of preoperative stress testing and the association of various echo parameters were evaluated in the context of cardiac outcomes using univariable and multivariable logistic regression models., Results: Between August 2001 and December 2007, 395 patients underwent endovascular repair of a thoracoabdominal or juxtarenal aortic aneurysm. The incidence of AF, VA, and 30-day cardiac-related death was 9%, 3%, and 2%, respectively. Overall 30-day mortality was 6%. Univariable analysis showed the presence of mitral annulus calcification was associated with MI (odds ratio [OR], 3.5; 95% confidence interval [CI], 0.9-13.8; P = .07). Left atrium cavity area, ejection fraction, left ventricle mass, and left ventricular mass index were univariably associated with the presence of VA. Multivariable analysis showed only the left atrium cavity area was independently associated with VA (OR, 1.2; 95% CI, 1.0-1.5; P = .07). Stress test was done in 179 patients. Negative stress test results occurred in 152 (85%), of whom 9 (6%) sustained an MI during the 30-day perioperative course. MI occurred in 2 of the 27 patients (7%) who had a positive stress test result., Conclusions: Endovascular repair of CAA can be performed in high-risk individuals but is associated with significant cardiac risk. It remains difficult to risk stratify patients using preoperative stress testing. Echo evaluation may help to identify patients who may be more likely to develop ventricular arrhythmias in the postoperative period and thus warrant closer monitoring. Postoperative troponin monitoring of all patients undergoing repair of CAA is warranted given the overall risk of MI., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To analyze early and mid-term outcome of endovascular treatment in patients with iliac aneurysms, comparing the results of hypogastric revascularization by branch endografting with those of hypogastric occlusion., Methods: Consecutive patients with iliac aneurysms receiving side branch endograft (Group I) were compared with those receiving endograft with hypogastric exclusion (Group II) during the interval from January 2000 to May 2008. Procedural details and outcomes were prospectively collected and were analyzed at one year to avoid mismatch in follow-up length., Results: A total of 74 patients (mean age, 75.8 years, 95% males) were treated: 32 in Group I and 42 in Group II. No differences in baseline risk factors and aneurysm diameter (40.2 +/- 7.9 mm in Group I vs. 38.4 +/- 10.8 in Group II) were found. Concurrent treatment of aortic aneurysm was performed in 25/32 (78%) of Group I and 36/42 (86%) of Group II. Fluoro time was 48 minutes (interquartile range [IQR] 31-57) in Group I vs. 31 minutes (IQR 23-38) in Group II (P = .04). The amount of contrast was similar in both Groups: 184 ml (IQR 155-210) in Group I vs. 183 ml (IQR 155-200) in Group II. No intestinal ischemia or deaths occurred. There were no significant differences in failures of hypogastric side branch deployment (2/32) compared with hypogastric coiling (3/42). Limb occlusions all occurring in the external iliac artery side were 2/32 in Group I vs. 3/42 in Group II. Reintervention rates were similar (5/32 vs. 4/42) at one year. Shrinkage of 5 mm or more was detected in 7/23 (30%) of Group I and in 13/37 (34%) of Group II. Iliac endoleak was present in eight patients (19%) in Group II and in one patient in Group I (4%) (P = .1). Similarly, buttock claudication or impotence were more frequent after hypogastric exclusion, recorded in eight patients in Group II and in one patient in Group I (P = .1)., Conclusions: Endovascular treatment of iliac aneurysm with hypogastric revascularization through side branched endografts is feasible and safe in the mid-term. When compared with hypogastric embolization, this option leads to similar technical success and reintervention rates. Endoleak and buttock claudication occur frequently in patients with iliac aneurysm treated with hypogastric exclusion, while are uncommon in those with hypogastric revascularization. Side branch endografting for iliac aneurysm may be considered a primary choice in younger, active patients with suitable anatomy, but larger studies and longer postoperative observation periods are needed.

Objective: To evaluate frequency, causes and results of conversion to Open repair (OR) after endovascular repair (EVAR) in a single centre during an 8-year period., Design: Six hundred and forty-nine consecutive patients undergoing EVAR were followed up prospectively for endograft-related complications., Outcomes: Early conversion was any OR during or within 30 days from the primary EVAR. Late conversion was any OR with removal of the endograft after 30 days since a completed EVAR procedure., Results: Median patient follow-up was 38 months (1-93 months). Conversion to OR was performed in 38 patients; nine early and 29 late. Most (7/9) early conversions were due to extensive vessel calcification. Peri-operative mortality was 22% (2/9). Late conversions occurred at a median of 33 months after primary EVAR: 29 were elective and 4 urgent. During the same interval, 79 secondary endovascular interventions were performed, 7 of which failed. The risk of conversion to OR was 9% at 6 years. At multivariate logistic regression analysis, no single factor (short, large or angulated neck, suprarenal fixation, large pre-operative diameter, iliac aneurysms, ASA score risk) was associated with the risk of late failure requiring conversion to OR., Conclusion: The risk of death after early conversion should be recognized, to avoid forcing morphological indications for primary EVAR. Occurrence of late conversion after EVAR is not negligible, affecting almost 1 out of 10 patients after 6 years. In the presence of an expanding aneurysm after EVAR, especially after a failed secondary endovascular correction, an aggressive attitude in fit patients allows outcomes at similar to those of primary OR.