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Objective: Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA., Methods: A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30 days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis., Results: A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed., Conclusions: Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background/objective: Target vessels related complications are one of the most important 'Achille's heel' of complex thoracoabdominal endovascular procedures. The aim of this report is to describe a case of spontaneous bridging stent-graft (BSG) delayed expansion in a patient treated for type III mega-aortic syndrome, associated with aberrant right subclavian artery and independent origin of the two common carotid arteries., Methods: The patient underwent different surgical procedures (ascending aorta replacement with carotid arteries debranching, bilateral carotid-subclavian bypass with subclavian origins embolization and TEVAR in zone 0, associated with a multibranched thoracoabdominal endograft deployment). Visceral vessels stenting was performed using balloon-expandable BSGs for celiac trunk, superior mesenteric artery and right renal artery, while for the left renal artery a 6 × 60 mm self-expandable BSG was deployed.The first follow-up (FU) by computed tomography angiography (CTA) showed a severe compression of the left renal artery BSG. Considering the challenging access to the directional branches (SAT's debranching and a tightly curve of the steerable sheath inside the branched main body), a conservative treatment was considered, performing a control CTA after 6-months., Results: Six months later, the CTA demonstrated a spontaneous expansion of the BSG, with a two-fold increase in the minimum stent diameter, excluding the need for new reinterventions such as angioplasty or BSG relining., Conclusions: Directional branch compression is a frequent complication during BEVAR; however, in this case, it spontaneously resolved after 6 months, without the need for secondary adjunctive procedures. Further studies on predictor factors for BSG related adverse events and regarding spontaneous delayed BSGs' expansion mechanisms are needed., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.