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Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic aneurysms. However, thoracoabdominal aortic aneurysm patients have anatomic limitations to fenestrated stent-grafts given a large lumen, that is, the gap between the endograft and the inner aortic wall. This has led to the development of branched endovascular aneurysm repair as the ideal option for such patients. The Zenith t-Branch multibranched endograft (Cook Medical, Bloomington, IN), which has been commercially available in Europe to treat thoracoabdominal aortic aneurysm since June 2012, represents a feasible off-the-shelf alternative for treatment of such pathologies, especially in the urgent setting, for patients who cannot wait the time required for manufacturing and delivery of custom-made endografts. The device's anatomical suitability should be considered, especially for female patients with smaller iliofemoral vessels. Several tips may help deal with particularly complex scenarios (such as, for instance, in case of narrow inner aortic lumens or when treating patients with failure of prior endovascular aneurysm repair), and a broad array of techniques and devices must be available to ensure technical and clinical success. Despite promising early outcomes, concerns remain particularly regarding the risk for spinal cord ischemia and further assessment of long-term durability is needed, including the rate of target vessel instability and need for secondary interventions. As the published evidence mainly comes from retrospective registries, it is likely that reported outcomes may suffer from an intrinsic bias as most procedures reported to date have been carried out at high-volume aortic centers. Nonetheless, with the never-ceasing adoption of new and refined techniques, outcomes are expected to ameliorate., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5 cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach., Aim: To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management., Methods: A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair., Results: FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices., Conclusion: FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities., 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: Blunt thoracic aortic injury (BTAI) represents one of the most devastating scenarios of vascular trauma. Different management strategies are available with varying clinical outcomes. However, thoracic endovascular aortic repair (TEVAR) has become the first-line option for most BTAI patients, mainly owing to its minimally invasive nature, yielding improved immediate results. This meta-analysis aims to investigate mortality, long-term survival, and reintervention following TEVAR in BTAI., Material and Methods: A systematic review conducted a comprehensive literature search on multiple electronic databases using strict search terms. Twenty-seven studies met the set inclusion/exclusion criteria. A proportional meta-analysis of extracted data was conducted using the Comprehensive Meta-Analysis Software, v.4., Results: 1498 BTAI patients who underwent TEVAR were included. Using the SVS grading system, 2.6% of the population had Grade 1 injuries, 13.6% Grade 2, 62.2% Grade 3, 19.6% Grade 4, and 1.9% unspecific. All-cause mortality did not exceed 20% in all studies except one outlier with a 37% mortality rate. Using the random effects model, the pooled estimate of overall mortality was 12% (95% confidence interval [CI], 5.35-8.55%; I 2  = 70.6%). This was 91% (95% CI, 88.6-93.2; I 2  = 30.2%) at 6 months, 90.1% (95% CI, 86.7-92.3; I 2  = 53.6%) at 1 year, 89.2% (95% CI, 85.2-91.8; I2 = 62.3%) at 2 years, and 88.1% (95% CI, 83.3-90.9; I 2  = 69.6%) at 5 years. Moreover, the pooled estimate of reintervention was 6.4% (95% CI, 0.1-0.49%; I 2  = 81.7%)., Conclusions: Despite the high morbidity and mortality associated with BTAI, TEVAR has proven to be a safe and effective management strategy with favorable long-term survival and minimal need for reintervention. Nevertheless, diagnosis of BTAI requires a high index of suspicion with appropriate grading and prompt transfer to trauma centers with appropriate TEVAR facilities., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: With the incidence of thoracic aortic disease on the rise, total arch replacement (TAR) with frozen elephant trunk (FET) remains the gold-standard management strategy due to optimal results. Several FET devices exist commercially on the global market. However, the mainstay and most commonly used and reported device is the Thoraflex Hybrid Prosthesis (THP), with several recent reports suggesting its superiority., Areas Covered: This review aims to collate and summarize the evidence in the literature on the clinical outcomes of TAR with FET using THP, with a focus on mortality, neurological complications, endoleak, distal stent-induced new entry (dSINE), aortic remodeling, coagulopathy, and graft kinking. In addition, the design features of THP is discussed, and an overview of market competitors is also highlighted., Expert Opinion: THP consistently demonstrates its effectiveness in treating complex thoracic aortic pathology through favorable clinical outcomes, which can be attributed to its unique and innovative design. Rates of early mortality ranged 0.6-14.2%, neurological complications 0-25%, endoleak 0-8.4% and dSINE 0-14.5%, with minimal incidence of graft kinking and coagulopathy. Aortic remodeling is favorable and comparable to competitors. All this evidence solidifies THP as the leading FET device, particularly when combined with appropriate patient selection and surgical planning.

Background: Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD., Methods: A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant., Results: A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17)., Conclusions: Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: To analyze clinical outcomes and perform a macro-costing evaluation of endovascular aortic repair (EVAR) for aorto-iliac aneurysms., Methods: This is a retrospective, financially unsupported, physician-initiated observational cohort study. Patients with iliac artery involvement treated with EVAR between January 1st, 2014 and December 31st, 2021 were identified. Inclusion criteria were intact aneurysm, elective EVAR with at least 1 hypogastric artery (HA) treatment, use of bifurcated endograft (EG), and at least 6 months of follow-up. Primary outcomes of interest were overall survival, freedom from aneurysm-related mortality (ARM), freedom from EVAR-related reintervention, and overall EVAR(procedure)-related costs., Results: We studied 122 (9.1%) patients: 119 (97.5%) were male and 3 (2.5%) females. Median age of patients was 76 years (range, 68.75-81). Overall, 107 (87.7%) patients had both HAs preserved according to following strategy: 45 (36.9%) with flared limbs, 13 (10.6%) with bilateral branched device, and 49 (40.2%) with a combination of flared limb on 1 side and branched device on the contralateral side. Bilateral overstenting was performed in 15 (12.3%) patients. Estimated overall survival was not different between groups of EVAR (Log-rank, P = 0.561). There was only 1 (0.8%) ARM ascertained during the follow-up. Estimated freedom from EVAR-related reintervention was not different among groups (Log-rank, P = 0.464). During the follow-up, 9 (7.4%) patients developed buttock claudication (Society for Vascular Surgery (SVS) grade 1, n = 4, SVS grade 2, n = 5), more frequently in HA overstenting (hazard ratio (HR): 3.6; 95% confidence intervals (CIs): 0.96-13.5, P = 0.058). When all cots were included, branched EVAR still carried the highest burden (P = 0.001) in comparison with the mixed subgroup, the overstenting subgroup, and the flared limbs subgroup., Conclusions: Early mortality and pelvic ischemic syndromes rate were acceptably low in all techniques. Hypogastric artery preservation showed lower complication rate in comparison with HA overstenting which, however, appears to be safe an effective for option with similar overall costs for patients who are not candidates for HA preservation based on aortic anatomy., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: An abdominal aortic aneurysm (AAA) is a life-threatening abnormal dilation of the abdominal aorta that can be repaired either endovascularly or with open surgery. However, endovascular aortic repair (EVAR) has become the main treatment modality for AAA due to its more optimal results. EVAR devices can either be standard, fenestrated, or branched, with fenestrated EVAR (FEVAR) seemingly achieving superior prospects. Although EVAR is associated with excellent outcomes, it still carries a risk of certain complications requiring reintervention or 'rescue'. Several commercial EVAR devices are available on the global market, nevertheless, the Fenestrated Anaconda developed by Terumo Aortic can be considered the superior device due to the wide range of endovascular solutions that it offers along with its unique custom-made approach, excellent results and its highly promising potential to be used as a 'rescue' device for failed competitor endografts., Materials and Methods: The current study represents a 9-year cross-sectional international analysis of a custom-made Fenestrated Anaconda™ device. For the statistical analysis, SPSS 28 for Windows and R were utilised. Pearson Chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p < 0.05., Results: Out of 5058 EVARs performed using the Fenestrated Anaconda, 2987 (59%) were 'rescue' procedures for migrated Gore ( n  = 252) and Medtronic ( n  = 2735) devices. The Fenestrated Anaconda™ was indicated as the reintervention device either due to unsuitable/complex anatomy for the competitor ( n  = 2411) or based on surgeon preference ( n  = 576). Overall, the Fenestrated Anaconda was utilised to rescue 3466 (68.5%) failed previous EVARs using competitor devices. Yet, the primary endovascular solution offered by the Fenestrated Anaconda was FEVAR (91.3%), with 112 (2.2%) devices using custom-made iliac stents., Discussion: The use of the Fenestrated Anaconda endograft as a 'rescue' device to salvage failed competitor devices is well-established in the literature with excellent clinical outcomes achieved. The evidence in the literature also highlights the distinctive custom-made approach that the Fenestrated Anaconda offers which enables it to treat extremely complex aortic anatomy.

Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical emergency that requires urgent surgical intervention. The mainstay surgical approach to treating ATAAD with aortic arch involvement is total arch replacement (TAR). The frozen elephant trunk (FET) procedure involves TAR with hybrid endovascular stenting of the DTA in a single step using a hybrid prosthesis (HP). The prime example of a FET HP is Thoraflex Hybrid Prosthesis (THP). Another treatment option is the novel Ascyrus Medical Dissection Stent (AMDS) that is deployed as a non-covered stent along with the aortic arch as an adjunct to prior hemi-arch replacement., Aims: This comparative review highlights the clinical applications and outcomes of THP and AMDS in the treatment of ATAAD and discusses the main differences between both approaches., Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Google Scholar, Ovid, Scopus and Embase., Results: TAR with FET can be considered the superior approach to managing ATAAD with arch involvement relative to AMDS with hemi-arch replacement due to more optimal clinical outcomes. Upon comprehensively searching the literature, early mortality was substantially lower with FET ranging from 0-11% compared to 12.5-18.7% using AMDS, with more favourable long-term survival. The incidence of kidney injury and new stroke post-FET ranged from 3-20% and 5-16%, and 11-37.5% and 0-18.8% following AMDS implantation. However, evidence supporting the use of AMDS is extremely limited. Meanwhile, TAR with FET is a well-established and well-described procedure for ATAAD repair., Conclusion: Despite the novel nature of AMDS, its clinical safety and effectiveness are yet to be proven. In conclusion, THP remains the best evidenced-based approach to treat ATAAD in this era.

Introduction: Since the introduction of endovascular aortic repair (EVAR) it has become the mainstay treatment for abdominal aortic aneurysms. Several EVAR devices exist commercially, yet, the Terumo Aortic Fenestrated Anaconda™ endograft has demonstrated outstanding results. Evidence in the literature suggests that sac regression could be linked to patient survival and longevity. The main scope of this study is to evaluate sac regression and survival achieved using the Fenestrated Anaconda™ endograft and to discuss relevant literature., Materials and Methods: The current study represents a nine-year cross-sectional international analysis of custom-made Fenestrated Anaconda™ device. For the statistical analysis, SPSS 28 for Windows and R were utilised. Pearson chi-square analysis was used to assess differences in cumulative distribution frequencies between select variables. Statistical significance for all two-tailed tests was set at p  < 0.05., Results: A total of 5,058 patients received the Fenestrated Anaconda™ in this study, either due to unsuitable/complex anatomy for competitor devices ( n  = 3,891) or based on surgeon preference ( n  = 1,167). A sac regression of 0-30% was observed in 4,772 (94.3%) over the first four years post-EVAR. Here, 99.6% of patients receiving the Fenestrated Anaconda™ due to unsuitable/complex anatomy for competitor devices and 76.8% based on surgeon preference had 0-30% sac regression. During years 5-9 of follow-up, all patients had 20-45% sac regression. Patient survival during the first six years post-EVAR was 100% but dropped to 77.1% in years 7-9. Survival differed between categorical patient subsets based on the indication., Discussion: The Fenestrated Anaconda™ has been proven to be a highly effective EVAR endograft. Evidence in the literature clearly demonstrates that sac regression is an accurate prognostic factor for patient survival and longevity.

Objective: Application of thoracic endovascular aortic repair (TEVAR) to the aortic arch has been met with the development of purpose-made endoprostheses for on-label use in the aortic arch. An appraisal of the clinical efficacy of each major device is therefore useful towards informing clinical decision making for patients eligible for endovascular arch repair (EAR) rather than open surgical reconstruction., Methods: A literature review of publications outlining clinical experience with the RELAY™ Branched and Zenith™ devices was undertaken, and the results therefrom analysed to evaluate the clinical efficacies of each device., Results: Early- and long-term mortality rates associated with EAR appear favourable, especially compared against open surgical repair. EAR is also associated with good neurological outcomes and target vessel patency rates. However, EAR continues to be associated with substantial reintervention rates., Conclusions: At the present stage, EAR represents a promising alternative option to open surgical reconstruction in patients that meet its eligibility criteria. Though there remains a substantial learning curve associated with EAR, its favourable outcome profile is likely to increase its applicability in the future.

Background: Endovascular aortic repair (EVAR) has become the mainstay treatment for abdominal aortic aneurysms and is associated with excellent clinical outcomes. However, there remains a risk of complications requiring reintervention. Several EVAR devices exist commercially, yet, the Terumo Aortic Fenestrated Anaconda™ has demonstrated outstanding results. The main scope of this study is to evaluate survival/longevity, target vessel patency (TVP), endograft migration and reintervention following Fenestrated Anaconda™ implantation and discuss relevant literature., Methods: The current study represents a 9-year cross-sectional international analysis of custom-made Fenestrated Anaconda™ device. For the statistical analysis, SPSS 28 for Windows and R was utilised. Pearson Chi-Square analysis was used to assess differences in cumulative distribution frequencies between variables. Statistical significance for all two-tailed tests was set at p  < 0.05., Results: A total of 5058 patients received the Fenestrated Anaconda™ endograft. The Fenestrated Anaconda™ was indicated either due to complex anatomy for competitor devices ( n  = 3891, 76.9%) or based on surgeon preference ( n  = 1167, 23.1%). Both survival and TVP were 100% during the first 6 postoperative years but dropped to 77.1% and 81% thereafter. In the complex anatomy indication group, cumulative survival and TVP were both 100% until year 7 post-EVAR when they decreased to 82.8% and 75.7%. In the other indication group, survival and TVP were also 100% during the first 6 years but plateaued at 58.1% and 98.8% in years 7-9 of follow-up. No cases of endograft migration and reintervention were recorded., Conclusion: The Fenestrated Anaconda™ has been proven across the literature to be a highly effective EVAR endograft, as it has demonstrated excellent survival/longevity and TVP as well as minimal endograft migration and reintervention.

Background: Endovascular aortic repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA). Its main aim is to seal the perfusion of the aneurysmal sac and, thus, induce sac regression and subsequent aortic remodelling. Aneurysmal sac regression has been linked to the short- and long-term clinical outcomes post-EVAR. It has also been shown to be influenced by endograft device choice, with several of these available commercially. This review summarises and discusses current evidence on the influence of pre- and intraoperative factors on sac regression. Additionally, this review aims to highlight the device-specific variations in sac regression to provide an overall holistic approach to treating AAAs with EVAR., Methods: A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data., Results: Female sex, >70 mm original sac diameters, higher pre-procedural fibrinogen levels, smoking and low intra-aneurysmal pressure were found to positively impact sac regression. Whereas renal impairment, ischemic heart disease, high intra-aneurysmal pressure and aneurysm neck thrombus negatively influenced sac regression. Patent lumbar arteries, age, statins and hypercholesterolaemia displayed conflicting evidence regarding sac regression. Regarding the EVAR endografts compared, newer generation devices such as the Anaconda mainly showed the most optimal results., Conclusion: Sac regression following EVAR in AAA is an important prognostic factor for morbidity and mortality. Nevertheless, several pre- and intraoperative factors can have an influence on sac regression. Therefore, it is necessary to take them into account when assessing AAA patients for EVAR to optimise outcomes. The choice of EVAR stent-graft can also affect sac regression, with evidence suggesting that the Fenestrated Anaconda is associated with the most favourable results.

Background: The introduction of endovascular aortic repair has revolutionised the treatment of abdominal aortic aneurysms, replacing open surgical repair for the majority of elective cases due to its optimal morbidity and mortality. Several endovascular aortic repair stent grafts exist commercially, one of which is the Fenestrated Anaconda™ by Terumo Aortic which benefits from a very innovative design, unique custom-made approach and highly favourable results., Aims: The main scope of this narrative review is to provide a comprehensive overview of endovascular aortic repair clinical outcomes using the Fenestrated Anaconda™ stent-graft and comparing these with its market competitor, Zenith. This review will also examine the evidence in the literature on the Anaconda™'s custom-made approach., Methods: A comprehensive literature was conducted on several search engines including PubMed, Google Scholar, Ovid, Scopus and Embase to collate the evidence in the literature on clinical outcomes achieved with the Fenestrated Anaconda™ and Zenith including, but not limited to, survival, technical success, target vessel patency, endoleak, reintervention and aneurysm sac regression., Results: The Fenestrated Anaconda™ is associated with excellent results, including highly favourable survival, technical and clinical success and target vessel patency rates, very low need for reintervention or conversion, and minimal incidence of complications such as endoleak and endograft migration. The Fenestrated Anaconda™ also drives significant sac regression and aortic remodelling. In addition, its unique custom-made approach enables it to treat highly complex aortic anatomy as well as to 'rescue' failed competitor grafts., Conclusion: The Fenestrated Anaconda™ has proven that it is a very safe, highly applicable and extremely effective device used for complex aortic and/or iliac pathology based on its novel design and outstanding track record of clinical outcomes.

Background: Acute type B aortic dissection (TBAD) is relatively uncommon with an estimated incidence of up to 8 cases per 100,000 individuals annually. It can be classified based on presenting clinical and radiological features into complicated and uncomplicated. Following the initial tear, the direction and extent of the dissection flap is unpredictable, possibly propagating proximally or distally. One consequence of a dissection flap is the occurrence of organ malperfusion by occlusion of the origin of the branch vessel. The 2 types of malperfusion in TBAD are static and dynamic, with the latter being the more common mechanism. Thoracic endovascular aortic repair (TEVAR) has demonstrated its high safety and efficacy when used for TBAD and subsequent malperfusion., Aims: This original study specifically examines patients diagnosed with acute TBAD and treated with TEVAR at a single vascular unit, focusing on those presenting with organ malperfusion., Methods: Over 16 years, 28 TBAD patients were admitted to a single center and treated using TEVAR. After clinical examination, all patients underwent computed tomography of the thorax and abdomen/pelvis to confirm the diagnosis and classify the extent of the dissection proximally and distally. Once diagnosed, patients were transferred to the high dependency unit and started on blood pressure medication. Subsequent computed tomography scans were performed to classify patients, after which TEVAR was performed., Results: Twenty five patients underwent TEVAR for TBAD, of which 8 (32%) had symptoms of organ malperfusion. The majority of cases presented with hypertension (89%), describing a sudden onset of upper/midthoracic pain. The origin of the left subclavian artery was occluded in 14 (56%) patients with 9 (64%) needing an extra-anatomical bypass. There was only a single mortality due to a posterior circulation stroke 2 days after TEVAR. Median (range) length of coverage of thoracic aorta by the stent-graft was 33 (15-35) cm. The true lumen (TL) perfused the celiac artery in 6/8 malperfusion patients, superior mesenteric artery in 7/8, right renal artery in 6/8, and, conversely, left renal artery in only 2/8., Conclusions: Complicated TBADs behave in an unpredictable manner as it seems the propagating intimal flap invariably maintains vital organ perfusion via the TL. Maintenance of abdominal vessels perfusion from the TL following TEVAR is vital to ensuring optimal results., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Type B aortic dissection (TBAD) occurs due to an entry tear in the intimal layer of the aorta distal to the origin of the left subclavian artery where blood enters the newly formed false lumen (FL) and extends distally or proximally to form a dissection over an indeterminate length of the aorta which, over time, may eventually rupture. Thoracic endovascular aortic repair (TEVAR) aims to seal off the entry tear proximally with the stent-graft, occluding the origin of the dissection and excluding the FL. Nevertheless, in some cases, the perfusion to the FL is maintained, hindering the aortic remodelling process and increasing the risk of aneurysmal degeneration and rupture, particularly in the abdominal aorta where evidence suggest that remodelling is slower. This review examines the long-term effects of a patent or partially thrombosed FL on clinical outcomes following TEVAR in TBAD, also highlighting the pathological processes behind negative aortic remodelling. Another aim of this review is to provide an overview and appraisal of the currently available techniques for managing a patent or partially thrombosed FL to prevent long-term morbidity occurring., Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies., Results: Evidence in the literature show that a partially thrombosed FL is more dangerous than a patent FL due to the occlusion of the distal re-entry tears, impeding outflow and increasing mean arterial and diastolic pressures, whereas the latter is decompressed via distal re-entry sites. FL thrombosis and satisfactory remodelling is sometimes achieved in as few as 40% of patients after TEVAR due to the maintained perfusion of the FL either at the level of the thoracic or abdominal aorta. However, although the thoracic aorta is predominantly covered by the TEVAR stent-graft, poorer remodelling and more dilation is seen in the abdominal aorta. Several techniques are available to embolize the FL, including the Provisional Extension to Induce Complete Attachment, Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair, candy-plug, and Knickerbocker techniques., Conclusions: The management of TBAD is invariably TEVAR to seal off the proximal entry tear while extending the repair distally to completely exclude the FL. A risk of aortic wall dilatation distal to TEVAR stent-graft remains; hence, regular monitoring and accurate imaging are essential. At present, a patent FL can be treated using a range of different endovascular techniques., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There has been a revolution in the management of type B aortic dissection (TBAD) over the last 2 decades due to the increasing development of endovascular techniques, with the prime example being thoracic endovascular aortic repair (TEVAR). However, many controversies concerning the use of TEVAR in TBAD exist. For instance, there is little available evidence suggesting any differences in demographics, disease characteristics, intervention technicalities, and clinical outcomes between males and females as well as different ethnicities when undergoing TEVAR for TBAD, both in the short and long term. Also, there is no risk prediction model/tool available. The objective of this international study is to describe and delineate the disparities between male and female patients of different ethnicities in terms of demographics, disease and interventional characteristics, and clinical outcomes., Methods: Over 17 years a total of 58 TBAD patients were admitted to 2 tertiary vascular centres and treated using TEVAR. Mortality, postoperative complications and reintervention data were recorded for the first 30 days after the procedure as well as during follow-up. Follow-up for all patients lasted until the study endpoint or until a patient's death. Data were analysed retrospectively using IBM SPSS statistical package 26 for Windows., Results: The mean age was similar between the 2 groups, with the majority of patients in both being Caucasian. More than half of the males had complicated TBAD, while the majority of females were classed as having uncomplicated disease. The most commonly utilized proximal and distal landing zone for the TEVAR stent graft was zone 2 and zone 4, respectively. The mean proximal stent diameter was significantly larger in males compared to females (P = 0.004). The difference in mean distal diameter between the 2 groups was insignificant (P = 0.721). The mean total stent coverage of the thoracic aorta was 251.3 mm in male patients compared to 291.2 mm in females (P = 0.203). A total of 32 patients underwent adjunctive procedures. Seven (17%) of the males had one or more postoperative complications compared to 2 (12%) females. Nine (22%) males underwent a reintervention procedure post TEVAR compared to only 1 (6%) female (P = 0.136). Overall, males had a mortality rate of 24% (n = 10) compared to 41% of females (n = 7) (P = 0.201). Estimated survival of males and females post TEVAR was 80.4 ± 9.6 months and 69.7 ± 14.4 months (P = 0.428). For the total population, the number of stent grafts was inversely correlated with mortality., Conclusions: Despite the favourable clinical outcomes achieved by TEVAR in TBAD, there remains a grey area concerning its management. Thus, it is important to perform risk stratification of individual patients using their demographics and comorbidities, particularly scrutinizing patient sex and ethnic origin, when considering intervention for TBAD to achieve optimum results., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The introduction of endovascular aortic arch repair (EAR) represents a paradigm shift in the management of complex arch pathologies usually treated with open surgical repair (OSR). This shift in treatment of aortic arch disease has also been accompanied with a rise in commercial interest in EAR resulting in the development of several endografts. However, the RELAY™ Branched by Terumo Aortic can be considered the prime endograft choice. In this international original study, a retrospective comparative analysis of international prospective outcomes data on the single- and double-branch RELAY stent grafts is provided., Methods: International data on EAR procedures carried out from January 2019 to January 2022 using the single- and double-branch RELAY endograft configurations were collected prospectively. Follow-up data were collected at 30 days, 6 months, 12 months, and 24 months postoperatively. Retrospective descriptive analysis, logistic regression, and Kaplan-Meier analysis were performed., Results: A total of 125 patients were included, out of which 17 (13.6%) received the single-branch RELAY and 108 the double-branch device. In the single-branch group, no mortalities, strokes, or reinterventions were recoded over 24 months of follow-up. The rates of these outcomes were higher in the other group; however, the differences did not reach significance. Target vessel patency was maintained at 100% throughout the study period with the single-branched RELAY. Overall, our Kaplan-Meier analyses proved that both configurations of RELAY Branched yield excellent short- and mid-term survival and freedom from reintervention., Conclusions: Our series has clearly demonstrated that EAR using RELAY Branched is a highly efficacious strategy that yields very favorable results which can be considered superior to other EAR devices as well as OSR. Nevertheless, it seems that clinical outcomes with the single-branch RELAY are more optimal than with the double-branch device., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to evaluate the incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR)., Methods: This is a multicentre, retrospective, observational cohort study. We analysed data from patients treated with TEVAR between 22 June 2001 and 10 December 2022. Primary outcomes were postoperative overall organ ischaemic complications and early (≤30 days) survival. Secondary outcomes were long-term survival and freedom from aorta-related mortality., Results: A total of 255 patients were included in this study. We performed 233 (91.4%) isolated TEVARs, 14 (5.5%) fenestrated or branched TEVARs and 8 (3.1%) TEVARs in combination with normal infrarenal stent graft. Overall, 31 organ ischaemic complications were detected in 29 (11.4%) cases, out of which 8 (3.1%) complications were cerebrovascular, 8 (3.1%) spinal cord, 6 (2.3%) visceral, 4 (1.6%) renal, 2 (0.8%) peripheral and 3 (1.2%) myocardial. Binary logistic regression analysis identified grade III-IV aortic arch atheroma [odds ratio (OR): 6.6, P = 0.001; 95% confidence interval: 2.9-14.9] and shaggy aorta (OR: 12.1, P = 0.003; 95% confidence interval: 2.3-64.1) to be associated with the development of organ ischaemic complications. In patients with organ ischaemia, we observed higher early (≤30 days) mortality (20.7% vs 6.2%; OR: 3.6, P = 0.016), prolonged hospitalization (P = 0.001) and inferior estimated survival (log-rank, P = 0.001)., Conclusions: Aortic arch atherosclerotic overload as well as the presence of shaggy aorta are predictors of organ ischaemic complications following TEVAR. They are neither uncommon nor negligible and are associated with perioperative mortality, prolonged hospitalization and a negative impact on long-term survival., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Aortic dissection (AD) is a life-threatening medical emergency that affects an estimated 3-4 people per 100,000 annually, with 40% of cases classified as type B AD (TBAD). TBAD can be further classified as being complicated (co-TBAD) or uncomplicated (un-TBAD) based on the presence or absence of certain features such as malperfusion and rupture. TBAD can be managed conservatively with optimal medical therapy (OMT), or invasively with open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR), depending on several factors such as type of TBAD and its clinical acuity. The cost-effectiveness, or cost-benefit profile, of these strategies must be given equal consideration. However, TBAD studies featuring cost analyses are limited within the literature. This narrative review aims to address the gap in the literature on cost-effectiveness of TBAD treatments by providing an overview of cost analyses comparing OMT with TEVAR in un-TBAD and TEVAR with OSR in co-TBAD. Another aim is to provide a market analysis of the commercially available TEVAR devices., Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies., Results: Several TEVAR devices are available commercially on the global market costing $12,000-19,495. Nevertheless, the Terumo Aortic RELAY® stent graft seems to be the most cost-effective, yielding highly favourable clinical outcomes. Despite the higher initial cost of TEVAR, evidence in the literature strongly suggest that it is superior to OMT for un-TBAD on the long-term. In addition, TEVAR is well established in the literature as being gold-standard repair technique for co-TBAD, replacing OSR by offering a more optimal cost-benefit profile through lower costs and improved results., Conclusions: The introduction of TEVAR has revolutionized the field of aortovascular surgery by offering a highly efficacious and long-term cost-effective treatment for TBAD., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed., Methods: A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken., Results: Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis., Conclusion: An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Endovascular aneurysm repair (EVAR) has rapidly become the preferred management of abdominal aortic aneurysm (AAA). Sac regression status post-EVAR has been linked to clinical outcomes as well as the choice of EVAR device. The aim of this narrative review is to investigate the relationship between sac regression and clinical outcomes post-EVAR in AAA. Another aim is to compare sac regression achieved with the main EVAR devices., Areas Covered: We carried out a comprehensive literature search on multiple electronic databases. Sac regression was usually defined as a decrease in the sac diameter (>10 mm) over follow-up. This revealed that individuals who had sac regression post-EVAR had significantly lower mortality, and higher event-free survival rates. Further, lower rates of endoleak and reintervention were observed in patients with regressing aneurysm sacs. Sac regression patients also had significantly lower odds of rupture compared to counterparts with stable or expanded sacs. The choice of EVAR device was also shown to impact regression, with the Fenestrated Anaconda showing favorable results., Expert Opinion: Sac regression post-EVAR in AAA is an important prognostic factor as it translates to improved mortality and morbidity. Therefore, this relationship must be seriously taken into consideration during follow-up.

Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical condition requiring urgent surgical attention. It is estimated that 50% of ATAAD die within 24 h of onset, with the mortality rate is increasing by 1%-2% every additional hour without prompt intervention. A variety of ATAAD surgical repair techniques exist which has sparked controversy within the literature, with the main two strategies being proximal aortic replacement (PAR) and total arch replacement (TAR). Nevertheless, the question of which of these two strategies if the more optimal is still debatable., Aims: This commentary aims to discuss the recent study by Sa and colleagues which presents a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing aggressive (TAR) and conservative (PAR) approaches to manage ATAAD patients., Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Google Scholar, EMBASE, and Scopus to collate the relevant research evidence., Results: The more aggressive TAR approach for treating ATAAD seems to yield more favorable results including more optimal long-term survival as well as a lower need for reoperation. The frozen elephant trunk (FET) technique can be considered the mainstay TAR technique., Conclusion: It is valid to conclude that TAR with FET is the superior strategy for managing ATAAD patients., (© 2022 Wiley Periodicals LLC.)

Background: While open surgical repair continues to be the mainstay option for aortic arch reconstruction, the associated mortality, morbidity, and high turn-down rates have led to a need for the development of minimally invasive options for aortic arch repair. Though RELAY™ Branched (Terumo Aortic, Inchinnan, UK) represents a promising option for complex endovascular aortic arch repair, neurological complications remain a pertinent risk. Herein we seek to present multicenter data from Europe documenting the neurological outcomes associated with RELAY™ Branched., Methods: Prospective data collected between January 2019 and January 2022 associated with patients treated with RELAY™ single-, double-, and triple-branched endoprostheses from centers across Europe was retrospectively analyzed with descriptive and distributive analysis. Follow-up data from 30 days and 6, 12, and 24 months postoperatively were included. Patient follow-up was evaluated for the onset of disabling stroke (DS) and non-disabling stroke (NDS)., Results: Technical success was achieved in 147 (99.3%) cases. Over 24 months period, in total, six (4.1%) patients suffered DS, and eight (5.4%) patients suffered NDS after undergoing aortic arch repair with RELAY™. All patients that developed postoperative DS had been treated with the double-branched RELAY™ endoprosthesis., Discussion: The data presented herein demonstrates that RELAY™ Branched is associated with favorable neurological outcomes and excellent technical success rates. Key design features of the endoprosthesis and good perioperative management can contribute greatly to mitigating neurological complications following endovascular aortic arch repair., (© 2022 Wiley Periodicals LLC.)

Background: The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm., Materials and Methods: A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted., Results: A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% confidence interval [CI] 0.01-0.06, I 2  = 78%) and 3% (95% CI 0.01-0.11, I 2  = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I 2  = 89%) while the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I 2  = 92%). After subgroup analysis, heterogeneity for distal stent-graft induced new entry (dSINE) and endoleak resolved among European patients, where Thoraflex Hybrid (THP) and E-Vita stent-grafts were used (both I 2  = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I 2  = 15.1%) and Frozenix stent-grafts (I 2  = 1%)., Conclusion: Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, THP can be considered the primary FET device choice due to its superior results., (© 2022 Wiley Periodicals LLC.)

Background: Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD., Aims: The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD., Methods: A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD., Results: A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high-risk features. Two clinical features representative of "high risk" are refractory pain and persistent hypertension. First-line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the "high-risk" UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population., Conclusion: Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short- and long-term., (© 2022 Wiley Periodicals LLC.)

Background: There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remain debate on the optimal clinical, laboratory, morphological, and radiological parameters, which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR., Aim: This review summarizes evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients., Methods: A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients RESULTS: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter, and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in the future to optimize the development of balanced, risk-stratified treatment protocols., Conclusion: There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameters emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols., (© 2022 Wiley Periodicals LLC.)

Background: The frozen elephant trunk (FET) technique for total arch replacement (TAR) is widely used for repair of aortic arch dissections and aneurysms. Despite its widespread adoption, there are no international or regional guidelines for the sizing of FET prostheses in TAR. We seek to highlight the heterogeneity thereof and pave the way for evidence-based guidelines to advise FET prosthesis sizing in TAR., Methods: An online questionnaire was sent to 22 specialist aortic surgeons from 13 different countries across North America, Europe, Asia, and Australia, inquiring about each surgeon's approach to FET prosthesis sizing. The results were then pooled for frequency analysis., Results: All 22 surgeons responded to the questionnaire. Zone 2 is preferred implantation zone for AAD, CAD, and TAA (selected by 72.7%, 72.7%, and 68.2% respectively). The maximal diameter of the true lumen in the DTA is the most common index measurement for AAD and CAD (40.9% and 59.1%, respectively). Stent-graft diameters equal to the index measurement is the most common approach for AAD and CAD (77.3% and 45.5%, respectively) while 59.1% of surgeons oversize the index diameter by 10% for TAA; 100 mm is the preferred length for 50.0%, 27.3%, and 40.9% of surgeons in AAD, CAD, and TAA respectively., Conclusions: There is considerable heterogeneity in sizing practices for FET prostheses internationally, with variable evidence for its impact on clinical outcomes. This issue would be aided by the development of evidence-based guidelines to inform clinical decision making.

The introduction of the single-step hybrid frozen elephant trunk (FET) procedure expanded the surgeon's armamentarium in managing aortic dissection (AD). This is evident by the reduction in mortality and complication rates associated with conventional techniques used to repair ADs. Although FET still carries a risk of certain complications, it has been associated with excellent aortic remodeling following the procedure. The main scope of this review is to evaluate aortic remodeling in aortic dissection after FET as well as to highlight the challenges that may arise and ways to overcome them. A comprehensive literature search was conducted on multiple electronic databases including PubMed, Ovid, Scopus and Embase to highlight the evidence in the literature on aortic remodeling in aortic dissection after FET. The FET procedure promotes excellent long-term remodeling, this is seen in the substantial increase in the size of the true lumen along with the decrease in that of the false lumen (FL), in addition to significant FL thrombosis. However, this occurs to a lesser extent more distally at the level of the abdominal aorta. Negative remodeling may present a major challenge to the process of aortic remodeling, nevertheless, this can be overcome with endovascular reintervention which has demonstrated highly favorable results. Additionally, the choice of FET graft, in terms of type and length, seems to influence outcomes. Namely, the Thoraflex™ Hybrid graft can be considered the superior graft on the global market. On the other hand, there seems to be a debate in the literature on the optimal FET graft length. The FET procedure has revolutionized the field of aortovascular surgery and promotes excellent long-term aortic remodeling. Negative remodeling can occur but can also be favorably overcome with endovascular reintervention. Finally, the choice of FET graft may also influence results, thus, should be taken with great care.

The introduction of the single-step hybrid frozen elephant trunk (FET) procedure for total arch replacement has revolutionized the field of aortovascular surgery. FET has proven to achieve excellent results in the repair of complex thoracic aorta pathologies. However, there remains a risk of reintervention post-FET for a variety of causes. This secondary intervention can either be performed endovascular, with thoracic endovascular aortic repair (TEVAR), or via open surgery. Multiple FET hybrid prosthesis are commercially available, each requiring different rates of endovascular reintervention. The current review will focus on providing an overview of the reintervention rates for main causes in relation to the FET grafts on the market. In addition, strategies to prevent reintervention will be highlighted. A comprehensive literature search was conducted on multiple electronic databases including PubMed, Ovid, Scopus and Embase to highlight the evidence in the literature on endovascular reintervention after FET. The main causes for secondary intervention are distal stent graft-induced new entry (dSINE), endoleak and negative aortic remodeling, and to a much lesser extent, graft kinking and aorto-esophageal fistulae. In addition, it is clear that the Thoraflex Hybrid (Terumo Aortic, Inchinnan, UK) is the superior FET device, showing excellent reintervention rates for all the above causes. Interestingly, the choice of FET device as well as its size and length can help prevent the need for reintervention. The FET procedure is indeed associated with excellent clinical outcomes, however, the need for reintervention may still arise. Importantly, the Thoraflex Hybrid prosthesis has shown excellent results when it comes to endovascular reintervention. Finally, several strategies exist that can prevent reintervention.

Introduction: The treatment of complex aortic lesions involving the ascending, arch, and proximal descending aorta, remains challenging for surgeons despite the evolution of surgical techniques and aortic prostheses over decades. The frozen elephant trunk (FET) approach offers a one-stage repair of this entity of aortic pathologies. The main scope of this systematic review and meta-analysis is to evaluate the clinical outcomes and effectiveness of FET., Evidence Acquisition: In a systematic review, multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE were searched from inception to June 2021 to identify relevant studies reporting on outcomes of total arch replacement (TAR) with FET., Evidence Synthesis: Eighty-five studies met inclusion criteria, encompassing 10960 patients. Meta-analysis was conducted using the R-studio (RStudio, Boston, MA, USA) and STATA software (StataCorp LLC, College Station, TX, USA). The pooled in-hospital mortality rate was 7% (95% CI 0.05-0.09; I 2 =76%) and 12% for renal failure (95% CI 0.09-0.15; I 2 =88%), while the rates for paraplegia and cerebrovascular accidents were 3% (95% CI 0.02-0.04; I 2 =0%) and 6% (95% CI 0.05-0.08; I 2 =73%), respectively. Lower heterogeneity was attained after the stratification by the aortic pathologies, except for the renal failure. The distal anastomosis of the stent in zone 2 was significantly correlated with a lower renal failure development compared to zone 3 (odds ratio 0.52; 95% CI 0.33-0.82; P=0.069; I 2 =0%)., Conclusions: Our results indicate that the morbidities and mortality following TAR with FET were acceptable. We also associated the distal anastomosis in zone 2 with fewer renal failure development compared to that in zone 3.

Background: Uncomplicated type B aortic dissection (un-TBAD) has been managed conservatively with medical therapy to control the heart rate and blood pressure to limit disease progression, in addition to radiological follow-up. However, several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) in un-TBAD and suggested that TEVAR provides a survival benefit over medical therapy. Outcomes of TEVAR have also been linked with the timing of intervention., Aims: The scope of this review is to collate and summarize all the evidence in the literature on the mid- and long-term outcomes of TEVAR in un-TBAD, confirming its superiority. We also aimed to investigate the relationship between the timing of TEVAR intervention and results., Methods: We carried out a comprehensive literature search on multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on the mid- and long-term outcomes of TEVAR in un-TBAD, as well as its relationship with intervention timing., Results: TEVAR has proven to be a safe and effective tool in un-TBAD, offering superior mid- and long-term outcomes including all-cause and aorta-related mortality, aortic-specific adverse events, aortic remodeling, and need for reintervention. Additionally, performing TEVAR during the subacute phase of dissection seems to yield optimal results., Conclusion: The evidence demonstrating a survival advantage in favor TEVAR over medical therapy in un-TBAD means that with further research, particular trials and observational studies, TEVAR could become the gold-standard treatment option for un-TBAD patients., (© 2022 Wiley Periodicals LLC.)

Background: Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified., Aims: This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention., Methods: We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection., Results: TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention., Conclusions: Further research is required into both short- and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines., (© 2021 Wiley Periodicals LLC.)

Background: The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un-TBAD) remains controversial. There is a lack of consensus over whether pre-emptive TEVAR should be carried out in patients with un-TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un-TBAD may prove beneficial relative to pharmacotherapy alone., Methods and Materials: PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen (FL) expansion, and mortality. Papers were selected based on title and abstract., Results: Optimal medical therapy remains the mainstay treatment for patients with un-TBAD, however, patients with un-TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, FL thrombosis, and aortic branch involvement may potentiate progression from un-TBAD to complicated TBAD. Short- and long-term outcomes associated with TEVAR for TBAD remain promising., Conclusion: Pre-emptive TEVAR may be beneficial in patients with un-TBAD presenting with the above factors, however, further prospective research into the optimal timing for TEVAR in un-TBAD is required., (© 2022 Wiley Periodicals LLC.)

Background: The introduction of the single-step total arch replacement (TAR) with frozen elephant trunk (FET) has revolutionised the field of aortic surgery. TAR is indicated when the aortic arch is involved in aortic pathologies such as Type A aortic dissection and thoracic aortic aneurysms. Several FET devices are available commercially for global use, and example is the E-Vita Open NEO hybrid prosthesis (HP) developed by CryoLife-JOTEC. Unlike other FET devices available, this HP in particular features a design that puts it at a disadvantage as it does not incorporate gelatine or collagen in its structure, which makes it permeable to blood. Several studies have reported incidence of post-anastomotic blood oozing through the E-Vita Open NEO right after weaning from cardiopulmonary bypass., Aims: This commentary aims to discuss the recent study by Tan et al. which investigated E-Vita NEO device oozing as well as the implications of using BioGlue to overcome this serious complications., Methods: We carried out a literature search on multiple electronic databases including PUBMED and Scopus in order to collate research evidence on E-Vita NEO device oozing, BioGlue health risks, and other commercially available and globally used FET devices such as Thoraflex Hybrid., Results: It is proven fact that the E-Vita NEO excessively oozes blood, and while BioGlue is a safe and effective agent when used in small amounts, the amount needed to coat the E-Vita Open NEO and achieve haemostasis exceeds this by a wide margin which poses patients to great potential health risks. The Thoraflex Hybrid Prosthesis developed by Terumo Aortic is a commercially available and globally used FET device with long-standing favourable outcomes., Discussion: Tan et al. recently conducted an interesting study which proved that the E-Vita NEO HP does excessively ooze blood and tackled the issue of pre-emptive BioGlue use to tackle this complication as suggested by Ho et al. This leads on to the main question, is the use of BioGlue with E-Vita Open NEO to overcome oozing a long-term sustainable solution or is it merely a band aid?, Conclusion: In the face of fierce commercial competition, the choice of design and material of the E-Vita Open NEO HP would benefit from reconsideration., (© 2021 Wiley Periodicals LLC.)