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Objective : To provide an overview of the literature on the mid-term outcomes of chimney EVAR (ChEVAR) for the treatment of juxtarenal abdominal aortic aneurysms (JAAA). Methods : Different electronic databases were searched for published articles up to January 2020. The eligibility criteria were studies describing mid- or long-term outcomes of chimney EVAR (mean follow-up at least 1 year) for treatment of JAAA, including more than 10 cases, published in English, and with full text available. The outcomes measure were overall survival rate, target vessel patency, and freedom from reintervention at 3 years. Quality of the included studies was analysed using the MINORS criteria. Pooled effect estimates were analysed using random-effect models and heterogeneity was tested using I2 statistics. Results : Thirteen articles met the inclusion criteria. The included studies described 1,019 patients. According to the quality assessment, methodological quality was moderate to poor. The pooled overall survival, freedom from reintervention, and target vessel patency at 3 year was 81.4 % (95%CI 73.8 to 87.9), 85.7% (95%CI 75.6 to 93.5), and 95.1% (95%CI 89.3 to 98.7) respectively. Conclusion : The results of this review show good to acceptable short and mid-term survival and good mid-term durability, which supports that ChEVAR as a suitable alternative in high-risk JAAA. However, proper patient selection for ChEVAR seems essential to attain good mid-term outcomes, and further large prospective and good quality studies are required to demonstrate its long-term results and enable conclusions on specific determinants for outcome.

OBJECTIVES Malperfusion syndrome accompanying aortic dissection is an independent predictor of death with in-hospital mortality rates >60%. Asymmetrically decreased renal enhancement on computed tomography angiography is often considered evidence of renal malperfusion. We investigated the associations between renal enhancement, baseline laboratory values and the diagnosis of renal malperfusion, as defined by invasive manometry, among patients with aortic dissection. METHODS In this retrospective cohort study, we included all patients who were referred to our institution with acute dissection and suspected visceral malperfusion between 2010 and 2020. We determined asymmetric renal enhancement by visual assessment and quantitative density measurements of the renal cortex. We collected invasive renal artery pressures during invasive angiography at the aortic root and in the renal arteries. Logistic regression was performed to evaluate independent predictors of renal malperfusion. RESULTS Among the 161 patients analysed, the majority of patients were male (78%) and had type A dissection (52%). Invasive angiography confirmed suspected renal malperfusion in 83% of patients. Global asymmetric renal enhancement was seen in 42% of patients who did not have renal malperfusion during invasive angiography. Asymmetrically decreased renal enhancement was 65% sensitive and 58% specific for renal malperfusion. Both global [odds ratio (OR) 4.43; 1.20–16.41, P = 0.03] and focal (OR 11.23; 1.12–112.90, P = 0.04) enhancement defects were independent predictors for renal malperfusion. CONCLUSIONS In patients with aortic dissection, we found that differential enhancement of the kidney as seen on the computed tomography angiography is predictive, but not prescriptive for renal malperfusion. While detection of renal malperfusion is aided by computed tomography angiography, its diagnosis requires close monitoring and often invasive assessment.

OBJECTIVES Differential luminal enhancement [between true lumen (TL) and false lumen (FL)] results from differential flow patterns, most likely due to outflow restriction in the FL. We aimed to assess the impact of differential luminal enhancement at baseline computed tomography angiography on the risk of adverse events in patients with acute type B aortic dissection (TBAD). METHODS Baseline computed tomography angiographies of patients with acute TBAD between 2007 and 2016 (n = 48) were analysed using three-dimensional software at multiple sites along the descending thoraco-abdominal aorta. At each location, we measured contrast density in TL and FL [Houndsfield unit (HU)], maximal diameter (cm) and circumferential FL extent (°). Outcome data were collected via retrospective chart review. Multivariable logistic regression models were employed to determine the independent risk of TL–FL differential luminal enhancement on aneurysm formation (maximal diameter ≥55 mm) and medical treatment failure. RESULTS Patients were predominately male (75%) and 52.8±12.9 years at diagnosis. The mean follow-up was 5.9±2.6 years, and 42% (n = 20/48) patients were diagnosed with thoraco-abdominal aortic aneurysm. The baseline absolute difference between FL and TL contrast density measured at 2 cm distal to primary entry tear (TL–FLabs-Tear) was significantly higher among patients who developed aneurysm (26 HU, IQR: 15–53 vs 13 HU, IQR: 4–24, P = 0.001). Aneurysm development during follow-up was predicted by TL–FLabs-Tear (odds ratio 1.07, P = 0.012) and baseline maximal aortic diameter (odds ratio 1.90, P CONCLUSIONS Differential luminal enhancement may be a novel predictor of aneurysm formation among patients with acute TBAD.

Objective Endovascular procedures are conventionally conducted using two dimensional fluoroscopy. A new technology platform, Fiber Optic RealShape (FORS), has recently been introduced allowing real time, three dimensional visualisation of endovascular devices using fiberoptic technology. It functions as an add on to conventional fluoroscopy and may facilitate endovascular procedures. This first in human study assessed the feasibility of FORS in clinical practice. Methods A prospective cohort feasibility study was performed between July and December 2018. Patients undergoing (regular or complex) endovascular aortic repair (EVAR) or endovascular peripheral lesion repair (EVPLR) were recruited. FORS guidance was used exclusively during navigational tasks such as target vessel catheterisation or crossing of stenotic lesions. Three types of FORS enabled devices were available: a flexible guidewire, a Cobra-2 catheter, and a Berenstein catheter. Devices were chosen at the physician's discretion and could comprise any combination of FORS and non-FORS devices. The primary study endpoint was technical success of the navigational tasks using FORS enabled devices. Secondary study endpoints were user experience and fluoroscopy time. Results The study enrolled 22 patients: 14 EVAR and eight EVPLR patients. Owing to a technical issue during start up, the FORS system could not be used in one EVAR. The remaining 21 procedures proceeded without device or technology related complications and involved 66 navigational tasks. In 60 tasks (90.9%), technical success was achieved using at least one FORS enabled device. Users rated FORS based image guidance “better than standard guidance” in 16 of 21 and “equal to standard guidance” in five of 21 procedures. Fluoroscopy time ranged from 0.0 to 52.2 min. Several tasks were completed without or with only minimal X-ray use. Conclusion Real time navigation using FORS technology is safe and feasible in abdominal and peripheral endovascular procedures. FORS has the potential to improve intra-operative image guidance. Comparative studies are needed to assess these benefits and potential radiation reduction.

Aims Declining prevalence of abdominal aortic aneurysm (AAA) might force a more targeted screening approach (high-risk populations only) in order to maintain (cost-)effectiveness. We aimed to determine temporal changes in the prevalence of screening-detected AAA, to assess AAA-related surgery, and evaluate all-cause mortality in patients with manifest vascular disease. Methods and results We included patients with manifest vascular disease but without a history of AAA enrolled in the ongoing single-centre prospective UCC-SMART cohort study. Patients were screened at baseline for AAA by abdominal ultrasonography. We calculated sex- and age-specific prevalence of AAA, probability of survival in relation to the presence of AAA, and the proportion of patients undergoing AAA-related surgery. Prevalence of screening-detected AAA in 5440 screened men was 2.5% [95% confidence interval (CI) 2.1–2.9%] and in 1983 screened women 0.7% (95% CI 0.4–1.1%). Prevalence declined from 1997 until 2017 in men aged 70–79 years from 8.1% to 3.2% and in men aged 60–69 years from 5.7% to 1.0%. 36% of patients with screening-detected AAA received elective AAA-related surgery during follow-up (median time until surgery = 5.3 years, interquartile range 2.5–9.1). Patients with screening-detected AAA had a lower probability of survival (sex and age adjusted) compared to patients without screening-detected AAA (51%, 95% CI 41–64% vs. 69%, 95% CI 68–71%) after 15 years of follow-up. Conclusion The prevalence of screening-detected AAA has declined over the period 1997–2017 in men with vascular disease but exceeds prevalence in already established screening programs targeting 65-year-old men. Screening for AAA in patients with vascular disease may be cost-effective, but this remains to be determined.

Objective As elastin fibres in the aorta deteriorate with age, the descending thoracic aorta (DTA) becomes longer and more tortuous. In patients with DTA aneurysms, this increased tortuosity may result in a hostile haemodynamic environment for thoracic endovascular aortic repair (TEVAR). The objective of this study was to analyse how increased tortuosity affects haemodynamic displacement forces (DFs) in different segments of the DTA in patients with DTA aneurysms (DTAAs). Methods Thirty patients with DTAAs were selected to form three equal groups based on the maximum tortuosity of their DTA: low 60°. Computational fluid dynamics simulations were performed to calculate DFs in all patients. Image based segmentations were carried out to create patient specific models of the aortic geometry. When physiological simulation results were obtained, the haemodynamic DFs on the aortic wall were calculated in four segments of the DTA (zones 4A – D). To enable comparison of DFs in different segments, the DF was normalised by the aortic wall surface area, the equivalent surface traction (EST). Results The mean age was 73 years, with 67% male. In zone 4C, where most tortuosity occurs, the EST in patients with high tortuosity was more than three times higher, than those with low tortuosity (low, 743 N/m2; moderate, 956 N/m2; high, 2294 N/m2; p = .004). These differences could be attributed to the higher sideways components of the DF vectors, which were more than two times greater in patients with high tortuosity than in patients with low or moderate tortuosity (low, 5.01 N; moderate, 5.50 N; high, 13.21 N; p = .009). Conclusion High tortuosity results in increased displacement forces in the distal segments of the DTA. These forces should be taken into account when planning for TEVAR, as potentially they increase the risk of stent graft related complications, such as migration and endoleak.

Female sex is associated with worse outcomes after infrarenal abdominal aortic aneurysm (AAA) repair. However, the impact of female sex on complex AAA repair is poorly characterized. Therefore, we compared outcomes between female and male patients after open and endovascular treatment of complex AAA.We identified all patients who underwent complex aneurysm repair between 2011 and 2017 in the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Complex repairs were defined as those for juxtarenal, pararenal, or suprarenal aneurysms. We compared rates of perioperative adverse events between female and male patients stratified by open AAA repair and endovascular aneurysm repair (EVAR). We calculated propensity scores and used inverse probability-weighted logistic regression to identify independent associations between female sex and our outcomes.We identified 2270 complex aneurysm repairs, of which 1260 were EVARs (21.4% female) and 1010 were open repairs (30.7% female). After EVAR, female patients had higher rates of perioperative mortality (6.3% vs 2.4%; P = .001) and major complications (15.9% vs 7.6%; P .001) compared with male patients. In contrast, after open repair, perioperative mortality was not significantly different (7.4% vs 5.6%; P = .3), and the rate of major complications was similar (29.4% vs 27.4%; P = .53) between female and male patients. Furthermore, even though perioperative mortality was significantly lower after EVAR compared with open repair for male patients (2.4% vs 5.6%; P = .001), this difference was not significant for women (6.3% vs 7.4%; P = .60). On multivariable analysis, female sex remained independently associated with higher perioperative mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.9; P = .007) and major complications (OR, 2.0; 95% CI, 1.3-3.2; P = .002) in patients treated with EVAR but showed no significant association with mortality (OR, 0.9; 95% CI, 0.5-1.6; P = .69) or major complications (OR, 1.1; 95% CI, 0.8-1.5; P = .74) after open repair. However, the association of female sex with higher perioperative mortality in patients undergoing complex EVAR was attenuated when diameter was replaced with aortic size index in the multivariable analysis (OR, 1.9; 95% CI, 0.9-3.9; P = .091).Female sex is associated with higher perioperative mortality and more major complications than for male patients after complex EVAR but not after complex open repair. Continuous efforts are warranted to improve the sex discrepancies in patients undergoing endovascular repair of complex AAA.

Objective Complications after thoracic endovascular aortic repair (TEVAR) are common. Even after a successful TEVAR, a late endoleak (>30 days) can occur. The objective of this study is to summarize the current evidence and, if lacking, the need of evidence regarding the incidence and predictive factors for type 1b endoleak in patients with aortic aneurysm treated with TEVAR. Method A systematic review of the literature was performed on endoleak type 1b, in patients with aortic aneurysm, after TEVAR. The PubMed and EMBASE databases were systematically searched for articles regarding endoleak type 1b up to January 2019. The main subjects discussed are the incidence, risk factors, treatment and prognosis. Results Seven hundred and twenty-two articles were screened and sixteen articles were included in this review. The reported incidence of endoleak is between 1.0 – 15.0%, with a mean follow-up duration of at least 1 year. Type 1b endoleak is associated with an increased aortic tortuosity index (> 0.15 cm-1). No significant difference is found in relation to age and gender. Treatment is required in most cases (22/27) and is usually performed with distal extension of the stent graft (21/27). There is no data regarding stent graft oversizing, length of distal landing zone and differences between devices or the prognosis for patients with type 1b endoleak. Conclusion Limited literature is available on the occurrence of type 1b endoleak following TEVAR. A tortuous aorta can be associated as a predictive factor for the occurrence of type 1b endoleak. Data clearly delineating the anatomical variables predicting type 1b endoleak should be examined and listed. Likewise, the impact of more recent, conformable devices, to prevent complications like type 1b endoleaks from occurring, should be elucidated.

Accurate and contemporary prognostic risk prediction is essential to inform clinical decision-making surrounding abdominal aortic aneurysm (AAA) care. Therefore, we validated and compared three different in-hospital mortality risk scores in one administrative and two quality improvement registries.We included patients who had undergone elective AAA repair from 2012 to 2015 in the National Inpatient Sample (NIS), Vascular Quality Initiative (VQI; excluding the New England region), and the National Surgical Quality Improvement Program (NSQIP) datasets to validate three risk scores: Medicare, the Vascular Study Group of New England (VSGNE), and Glasgow Aneurysm Score (GAS). The receiver operating characteristic area under the curve (AUC) of all risk scores was calculated, and their discrimination was compared within a dataset using the Delong test and between datasets using a Z test. We constructed graphic calibration curves for the Medicare and VSGNE risk scores and compared the calibration using an integrated calibration index, which indicates the weighted average of the absolute difference between the calibration curve and the diagonal line of perfect calibration.We identified a total of 25,461 NIS, 18,588 VQI, and 8051 NSQIP patients who had undergone elective open or endovascular AAA repair. Overall, the Medicare risk score was more likely to overestimate mortality in the quality improvement registries and the VSGNE risk score underestimated mortality in all the databases. After endovascular AAA repair, the Medicare risk score had a higher AUC in the NIS than in the GAS (P .001) but not compared with the VSGNE risk score (P = .54). The VSGNE risk score was associated with a significantly higher receiver operating characteristic AUC compared with the Medicare (P .001) and GAS (P .001) risk scores in the VQI registry. Also, the VSGNE risk score showed improved calibration compared with the Medicare risk score across all three databases (P .001 for all). After open repair, the Medicare risk score showed improved calibration compared with the VSGNE risk score in the NIS (P .001). However, in the VQI registry, the VSGNE risk score compared with the Medicare risk score had significantly better discrimination (P = .008) and calibration (P .001).Overall, the VSGNE risk score performed best in the quality improvement registries but underestimated mortality. However, the Medicare risk score demonstrated better calibration in the administrative dataset after open repair. Although the VSGNE risk score appeared to perform better in the quality improvement registries, its overly optimistic mortality estimates and its reliance on detailed anatomic and clinical variables reduces its broader applicability to other databases.

Background. We report procedural and early results in the Netherlands of the Relay Branch device (Terumo Aortic, Sunrise, FL) for total endovascular repair of the aortic arch.Methods. Between 2014 and 2018, all consecutive patients who received the Aortic Relay double-branched stent graft in the Netherlands were included in a multicenter, retrospective registry.Results. The Relay Branch device was used in 11 patients to treat saccular (n = 4), fusiform (n = 5), or false aneurysms (n = 2) in the aortic arch. Patients were deemed unfit or extreme high-risk for open (redo) surgery. The brachiocephalic trunk and left common carotid artery were branched using a retrograde approach in all cases. Additional surgical left subclavian artery revascularization was performed in 8 patients. The main device and the branches were successfully introduced, positioned, and deployed with complete exclusion of the aortic pathology in all patients (100% technical success). There was no retrograde type A dissection or conversion to open surgery. Two procedure-related deaths occurred, both caused by perioperative or postoperative strokes. There were 2 minor strokes with full recovery. One patient recovered from transient paraplegia after spinal fluid drainage. No permanent paraplegia was observed. Follow-up imaging showed persistent adequate exclusion of aortic arch pathology. Mean follow-up was 17 months (range, 3-42 months).Conclusions. Total endovascular aortic arch repair using the Relay Branch device is technically feasible and effective in excluding aortic arch pathology. The observed stroke rate in the initial experience, however, was considerable. Although appealing, this new less-invasive technique should be carefully introduced and its progress thoroughly evaluated. (C) 2020 by The Society of Thoracic Surgeons

Objective: To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. Background: Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. Methods: All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of

Objective To describe the feasibility of a fresh frozen human cadaver model for research and training of endovascular image guided procedures in the aorta and lower extremity. Methods The cadaver model was constructed in fresh frozen human cadaver torsos and lower extremities. Endovascular access was acquired by inserting a sheath in the femoral artery. The arterial segment of the specimen was restricted by ligation of collateral arteries and, in the torsos, clamping of the contralateral femoral artery and balloon occlusion of the supratruncal aorta. Tap water was administered through the sheath to create sufficient intraluminal pressure to manipulate devices and acquire digital subtraction angiography (DSA). Endovascular cannulation tasks of the visceral arteries (torso) or the peripheral arteries (lower extremities) were performed to assess the vascular patency of the model. Feasibility of this model is based on our institute’s experiences throughout the use of six fresh frozen human cadaver torsos and 22 lower extremities. Results Endovascular simulation in the aortic and peripheral vasculature was achieved using this human cadaver model. Acquisition of DSA images was feasible in both the torsos and the lower extremities. Approximately 84 of the 90 target vessels (93.3%) were patent, the remaining six vessels showed signs of calcified steno-occlusive disease. Conclusions Fresh frozen human cadavers provide a feasible simulation model for aortic and peripheral endovascular interventions, and can potentially reduce the need for animal experimentation. This model is suitable for the evaluation of new endovascular devices and techniques or to master endovascular skills.

Purpose: Increased arterial tortuosity has been suggested as a predisposing factor for carotid artery dissection, which is an important risk factor for development of extracranial carotid artery aneurysms (ECAA). Prior to comparison with non-ECAA controls, the optimal measurement technique should be defined. This study describes the difference between software packages in terms of reproducibility and absolute outcome of arterial tortuosity measurements in ECAA patients. Methods: CT-angiography analysis was performed on 12 ECAA patients selected from our registry, using four software packages: 3mensio Vascular, TeraRecon, Vital Images, and Aycan OsiriX PRO. The tortuosity index (TI) was calculated from the skull base until the carotid bifurcation and aortic arch, and was defined as the centerline’s true length divided by the straight line distance. Intraclass correlation coefficients (ICC) with 95% confidence intervals were calculated to quantify inter- and intra-observer variability within one software package, and differences in measured TI between packages. Results: Inter-observer agreement was nearly perfect for 3mensio, excellent for Vital Images and OsiriX, and substantial for TeraRecon, with ICC 0.99 (0.96–1.0), 0.90 (0.69–0.97), 0.84 (0.53–0.95), and 0.72 (0.28–0.91), respectively. Intra-observer agreement ranged from ICC 1.0 for 3mensio to 0.91 for TeraRecon. Agreements in TI ranged from ICC 0.99 (0.98–1.0) for 3mensio vs. OsiriX, to 0.95 (0.82–0.98) for 3mensio vs. TeraRecon. Median time needed to complete one round of measurements was highest for OsiriX (p = 0.013). Conclusions: Carotid artery tortuosity measurements are reproducible and comparable between current commercially available software packages, with high intra-observer agreement. Although the reproducibility differed per software packages, all packages scored an acceptable inter-observer agreement.

PurposeAbdominal aortic aneurysms (AAA) have a multifactorial pathology with both genetic and environmental risk factors. Recent genome-wide association studies (GWAS) have discovered ten genetic risk loci for AAA. To what extent these genetic loci contribute to the aneurysm pathology is yet unknown. This study aims to investigate whether genetic risk variants are associated with three clinical features: diameter of aneurysm sac, type of artery and symptoms.MethodsWe used aneurysm tissue from 415 patients included within the Aneurysm-Express biobank. A best fit polygenic risk score (PRS) based on previous GWAS effect size estimates was modeled for each clinical parameter by comparing model predictions across different p-value thresholds. Next, the established 10 risk variants for AAA were tested individually for association with selected clinical phenotypes. Models were corrected for age, sex, ancestral background, smoking status and diameter of the aneurysm sac or artery type if applicable, and data was normalized.ResultsThe best fit PRS (including 272 SNPs with PT=0.01015) showed a significant correlation with diameter of the aneurysm sac (R2 = 0.019, p = 0.001). No association was found with clinical symptoms or type of artery. Individual variant analysis showed no clear associations with any of the clinical features.ConclusionsWithin the Aneurysm-Express Biobank Study, a weighted polygenic score of AAA susceptibility explained 1.9% of the phenotypic variation (p = 0.001) in aneurysm diameter. Individual risk variant analysis showed no clear associations. Given our limited sample size, future biobank collaborations need to confirm a potential causal role of individual SNPs on the pathology of aneurysms.

Tortuosity in the descending thoracic aorta (DTA) comes with aging and increases the risk of endoleaks after TEVAR. With this report, we would like to define and classify tortuosity in the DTA of patients with thoracic aortic disease.Retrospective case-control study of two hundred seven patients, comparing sixty-nine controls without aortic disease (CG), to sixty-nine patients with descending thoracic aortic aneurysm (AG) and sixty-nine patients with type B aortic dissection (DG). 3Mensio Vascular software was used to analyze CTA scans and collect the following measurements; tortuosity index, curvature ratio and the maximum tortuosity of the DTA. The DTA was divided into four equal zones. The maximum tortuosity was divided into three groups: low (30°), moderate (30°-60°) and high tortuosity (60°).Compared to the CG, tortuosity was more pronounced in the DG, and even more in the AG, evidenced by the tortuosity index (1.11 vs. 1.20 vs. 1.31; p 0.001), curvature ratio (1.00 vs. 1.01 vs. 1.03; p 0.001), maximum tortuosity in degrees (28.17 vs. 33.29 vs. 43.83; p 0.001) and group of tortuosity (p 0.001). The maximum tortuosity was further distal for the DG and AG, evidenced by the zone of maximum tortuosity (4A vs. 4B vs. 4B; p 0.001).This study shows that tortuosity in the DTA is more prominent in diseased aortas, especially in aneurysmal disease. This phenomenon needs to be taken into account during planning of TEVAR to prevent stent graft-related complications and to obtain positive long-term outcome.

Objectives Our goal was to assess the results after orthotopic branched endovascular aortic arch repair using a new double-branch endoprosthesis in patients with thoracic aortic disease affecting the aortic arch who cannot undergo classical surgery. Methods Within a 4-year period, 15 patients with thoracic aortic disease affecting the aortic arch were treated with the Bolton Relay plus double-branch endoprosthesis (Bolton Medical, Sunrise, FL, USA). We assessed clinical outcome, occurrence of endoleaks and the need for secondary interventions. The median logistic EuroSCORE I level was 13.6 (4.2; 22.8). Results The in-hospital mortality rate was 6.7%. A disabling stroke was observed in 1 (6.7%) patient, whereas non-disabling strokes occurred in 2 (13.3%) patients. Type I and III endoleaks occurred in 6.7%. The median follow-up period was 263 (1st quartile 84; 2nd quartile 564) days. Four patients died during the follow-up period. Aortic-related survival was 100%. Conclusions Orthotopic branched endovascular aortic arch repair using the Bolton Relay Plus double-branch endoprosthesis is a safe and feasible technique enriching the armamentarium to treat patients with thoracic aortic disease who cannot undergo classical surgery. Aortic-related survival is excellent, and the occurrence of disabling stroke and endoleaks warranting treatment is low. Further studies are needed to assess the long-term durability of this new method.

Item does not contain fulltext OBJECTIVE: Randomized trials have shown an initial survival benefit of endovascular over conventional open abdominal aortic aneurysm repair but no long-term difference up to 6 years after repair. Longer follow-up may be required to demonstrate the cumulative negative impact on survival of higher reintervention rates associated with endovascular repair. METHODS: We updated the results of the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, a multicenter, randomized controlled trial comparing open with endovascular aneurysm repair, up to 15 years of follow-up. Survival and reinterventions were analyzed on an intention-to-treat basis. Causes of death and secondary interventions were compared by use of an events per person-year analysis. RESULTS: There were 178 patients randomized to open and 173 to endovascular repair. Twelve years after randomization, the cumulative overall survival rates were 42.2% for open and 38.5% for endovascular repair, for a difference of 3.7 percentage points (95% confidence interval, -6.7 to 14.1; P = .48). The cumulative rates of freedom from reintervention were 78.9% for open repair and 62.2% for endovascular repair, for a difference of 16.7 percentage points (95% confidence interval, 5.8-27.6; P = .01). No differences were observed in causes of death. Cardiovascular and malignant disease account for the majority of deaths after prolonged follow-up. CONCLUSIONS: During 12 years of follow-up, there was no survival difference between patients who underwent open or endovascular abdominal aortic aneurysm repair, despite a continuously increasing number of reinterventions in the endovascular repair group. Endograft durability and the need for continued endograft surveillance remain key issues.

Purpose: To quantify both pulsatile longitudinal and circumferential aortic strains before and after thoracic endovascular aortic repair (TEVAR), potentially clarifying TEVAR-related complications. Methods: This retrospective study assessed the impact of TEVAR on pulsatile aortic strains through custom developed software and cardiac-gated computed tomography imaging of 8 thoracic aneurysm patients (mean age 71.0±8.2 years; 6 men) performed before TEVAR and during follow-up (median 0.1 months, interquartile range 0.1–5.8). Lengths of the ascending aorta, the aortic arch, and the descending aorta were measured. Diameters and areas were computed at the sinotubular junction, brachiocephalic trunk, left subclavian artery, and the celiac trunk. Pulsatile longitudinal and circumferential strains were quantified as systolic increments of length and circumference divided by the corresponding diastolic values. Results: Average pulsatile longitudinal strain ranged from 1.4% to 7.1%, was highest in the arch (p

Purpose: To evaluate the efficacy, feasibility, and long-term outcomes of the Zenith ZBIS iliac branch device (IBD) to preserve internal iliac artery (IIA) perfusion in a large Dutch multicenter cohort. Methods: Between September 2004 and August 2015, 140 patients (mean age 70.9 +/- 7.4 years; 130 men) with 162 IBD implantations were identified in 7 vascular centers. The indication for IBD implantation was an abdominal aortic aneurysm > 55 mm with a concomitant common iliac artery (CIA) aneurysm > 20 mm (n=40), a CIA aneurysm with a diameter > 30 mm (n=89), or revision of a type Ib endoleak after endovascular aneurysm repair (n=11). Results: Technical success (aneurysm exclusion, no type I or III endoleak, and a patent IIA) was obtained in 157 (96.9%) of 162 IBD implantations. Six (4.3%) patients developed major complications; 2 (1.4%) died. Mean follow-up was 26.6 +/- 24.1 months, during which 17 (12.1%) IBD-associated secondary interventions were performed. Including technical failures and intentional IIA embolizations, 15 (9.3%) IIA branch occlusions were identified; buttock claudication developed in 6 of these patients. The freedom from secondary intervention estimate was 75.9% (95% confidence interval 59.7 to 86.3) at 5 years. Conclusion: CIA aneurysms can be treated safely and effectively by IBDs with preservation of antegrade flow to the IIA. Secondary interventions are indicated in > 10% of patients during follow-up but can be performed endovascularly in most.

Background: Major surgery comes with a high risk for postoperative inflammatory complications. Preoperative risk scores predict mortality risk but fail to identify patients at risk for complications following cardiovascular surgery. We therefore assessed the value of preoperative red cell distribution width (RDW) as a predictor for pneumonia and sepsis after cardiovascular surgery and studied the relation of RDW with hematopoietic tissue activity. Methods: RDW is an easily accessible, yet seldomly used parameter from routine haematology measurements. RDW was extracted from the Utrecht Patient Orientated Database (UPOD) for preoperative measurements in patients undergoing open abdominal aortic anuerysm repair (AAA)(N = 136) or coronary artery bypass grafting (CABG)(N = 2193). The cohorts were stratified in tertiles to assess effects over the different groups. Generalized Linear Models were used to determine associations between RDW and postoperative inflammatory complications. Hematopoietic tissue activity was scored using fluor-18-(18F)-deoxyglucose positron emission tomography and associated with RDW using linear regression models. Results: In total, 43(31.6%) and 73 patients (3.3%) suffered from inflammatory complications after AAA-repair or CABG, respectively; the majority being pneumonia in both cohorts. Postoperative inflammatory outcome incidence increased from 19.6% in the lowest to 48.9% in the highest RDW tertile with a corresponding risk ratio (RR) of 2.35 ([95%CI:1.08-5.14] P = 0.032) in AAA patients. In the CABG cohort, the incidence of postoperative inflammatory outcomes increased from 1.8% to 5.3% with an adjusted RR of 1.95 ([95%CI:1.02-3.75] P = 0.044) for the highest RDW tertile compared with the lowest RDW tertile. FDG-PET scans showed associations of RDW with tissue activity in the spleen (B = 0.517 [P = 0.001]) and the lumbar bone marrow (B = 0.480 [P = 0.004]). Conclusion: Elevated RDW associates with increased risk for postoperative inflammatory complications and hematopoietic tissue activity. RDW likely reflects chronic low-grade inflammation and should be considered to identify patients at risk for postoperative inflammatory complications following cardiovascular surgery.

BackgroundAging changes the aorta in length, tortuosity and diameter. This is relevant in thoracic endovascular aortic repair (TEVAR) and in the long term follow up.Methods and resultsTwo groups of hundred patients < 65 years and hundred patients ≥ 65 years, with no vascular diseases were made. Thin cut CT scans were analyzed with 3Mensio Vascular software and the following measurements were collected; tortuosity index, curvature ratio, maximum tortuosity in degrees and the level of vertebrae of the maximum tortuosity. The descending thoracic aorta (DTA) was analyzed and was divided into four zones of equal length. Subjects were divided into three groups based on their maximum tortuosity value: low (< 30°), moderate (30° - 60°) and high (> 60°). A linear regression model was built to test the effect of age and gender on tortuosity. Tortuosity was more pronounced in the ≥ 65 compared to the < 65 group (tortuosity index: 1.05 vs. 1.14, respectively; p < 0.001), curvature ratio (1.00 vs. 1.01; p < 0.001), maximum tortuosity (22.24 vs. 27.26; p < 0.001), and group of angulation (low vs. low; p < 0.001). Additionally, the location of maximum tortuosity was further distal for the ≥ 65 group (level of vertebrae; 5.00 vs. 5.00; p < 0.001), and zone of maximum tortuosity (4A vs. 4A; p < 0.001). There was no significant difference between male and female subjects.ConclusionNormal DTA tortuosity increases with age. This is important to understand natural aging and for TEVAR planning and follow-up.

Purpose: To evaluate the effect of radiation dose reduction with the Allura ClarityIQ image processing technology for fixed C-arms in comparison with a mobile C-arm and an Allura fixed C-arm without ClarityIQ technology during endovascular aneurysm repair (EVAR) procedures. Methods: Radiation dose data from 85 patients (mean age 74.2±7.8 years; 68 men) undergoing EVAR with mobile and fixed C-arm fluoroscopy were retrospectively analyzed. The radiation dose parameters included the kerma area product (KAP), fluoroscopic time (FT), and number of digital subtraction angiography (DSA) frames (FrDSA). KAPtotal consisted of KAPfluoro (KAP for fluoroscopic imaging) and KAPDSA (KAP for DSA and single shots). Linear regression analysis was used to explore differences in the association of KAP with the FT, FrDSA, and body mass index (BMI) among the 3 C-arms. Results: The mean KAPtotal values for mobile, Allura C-arm, and AlluraClarity C-arm for noncomplex EVARs were 56±39, 245±142, and 157±120 Gy·cm2 (p2 (pfluoro tripled when the mobile C-arm was replaced by the fixed C-arm. There were no significant differences in the KAPfluoro adjusted for the FT between Allura and AlluraClarity (p=0.69). However, there was a major 61% reduction in KAPDSA from 1.36 Gy·cm2 per DSA frame for Allura to 0.54 Gy·cm2 per DSA frame with AlluraClarity (p=0.03). For the mobile C-arm, BMI was not associated with KAP (p=0.13). The associations of BMI with KAPfluoro and KAPDSA were significant for both fixed C-arms but were more robust for Allura compared to AlluraClarity (p=0.02 for KAPfluoro and pDSA). Conclusion: Changing a mobile C-arm for a fixed C-arm in a hybrid operating suite increased the average intraoperative dose during EVAR. Upgrading the Allura fixed C-arm with ClarityIQ technology resulted in a 61% reduction in the radiation per DSA frame.

OBJECTIVES Current endografts for thoracic endovascular aortic repair (TEVAR) are much stiffer than the aorta and have been shown to induce acute stiffening. In this study, we aimed to estimate the impact of TEVAR on left ventricular (LV) stroke work (SW) and mass using a non-invasive image-based workflow. METHODS The University of Michigan database was searched for patients treated with TEVAR for descending aortic pathologies (2013–2016). Patients with available pre-TEVAR and post-TEVAR computed tomography angiography and echocardiography data were selected. LV SW was estimated via patient-specific fluid–structure interaction analyses. LV remodelling was quantified through morphological measurements using echocardiography and electrocardiographic-gated computed tomography angiography data. RESULTS Eight subjects were included in this study, the mean age of the patients was 68 (73, 25) years, and 6 patients were women. All patients were prescribed antihypertensive drugs following TEVAR. The fluid–structure interaction simulations computed a 26% increase in LV SW post-TEVAR [0.94 (0.89, 0.34) J to 1.18 (1.11, 0.65) J, P = 0.012]. Morphological measurements revealed an increase in the LV mass index post-TEVAR of +26% in echocardiography [72 (73, 17) g/m2 to 91 (87, 26) g/m2, P = 0.017] and +15% in computed tomography angiography [52 (46, 29) g/m2 to 60 (57, 22) g/m2, P = 0.043]. The post- to pre-TEVAR LV mass index ratio was positively correlated with the post- to pre-TEVAR ratios of SW and the mean blood pressure (ρ = 0.690, P = 0.058 and ρ = 0.786, P = 0.021, respectively). CONCLUSIONS TEVAR was associated with increased LV SW and mass during follow-up. Medical device manufacturers should develop more compliant devices to reduce the stiffness mismatch with the aorta. Additionally, intensive antihypertensive management is needed to control blood pressure post-TEVAR.

Objective: Severe neck angulation is associated with complications after endovascular aneurysm repair (EVAR). Newer endografts may overcome this limitation, but the literature lacks long-term results. We studied the long-term outcomes of EVAR in patients with severe neck angulation. Methods: A retrospective case-control study of a prospective multicenter database was performed. All measurements were made with dedicated software with center lumen line reconstruction. A study group including patients with neck length >15 mm, infrarenal angle (β) >75 degrees or suprarenal angle (α) >60 degrees, and neck length 10 to 15 mm with β >60 degrees or α >45 degrees was compared with a control group matched for demographics and other morphologic neck features. The primary end point was type IA endoleak (EL1A). Secondary end points were freedom from neck-related secondary interventions, primary clinical success, and overall survival. Results: Forty-five patients were included in the angulated neck group and compared with 65 matched patients. Median follow-up was 7.4 years (interquartile range, 4.8-8.5 years). In the angulated neck group, mean α was 51.4 degrees (±21.1 degrees) and the mean β was 80.8 degrees (±15.6 degrees); in the nonangulated group, these were 17.9 degrees (±17.0 degrees) and 35.4 degrees (±20.0 degrees), respectively. At 7 years, five patients in the angulated neck group and two nonangulated patients developed EL1A, yielding a freedom from EL1A of 86.1% (n = 14; standard error [SE], 0.069) and 96.6% (n = 34; SE, 0.023), respectively (P = .056). After exclusion of a patient who developed an EL1A secondary to an endograft infection, this difference was significant: 86.1% (n = 14; SE, 0.069) in the angulated neck group and 98.2% (n = 34; SE, 0.018) in the nonangulated group (P = .016). At 7 years, freedom from neck-related secondary interventions was 91.7% (n = 14; SE, 0.059) and 91.6% (n = 29; SE, 0.029), respectively. The 7-year primary clinical success estimates were 41.2% (n = 11; SE, 0.085) and 56.6% (n = 20; SE, 0.072) for the angulated neck and nonangulated groups, respectively (P = .12). The 7-year survival rates were 44.3% (n = 18; SE, 0.076) vs 66.7% (n = 42; SE, 0.059) for the angulated neck and nonangulated groups, respectively (P = .25). Device integrity failure was not observed. Conclusions: Despite satisfactory results early and in the midterm, a higher rate of EL1A was identified among patients with severely angulated necks in the long term. However, mortality was not affected by this difference. These findings suggest that EVAR should be used judiciously in patients with extreme angulation of the proximal neck and highlight the need for close follow-up of EVAR, especially in the long term and in patients treated outside instructions for use. info:eu-repo/semantics/publishedVersion

Purpose: To analyze the movement of the aorta in the craniocaudal direction (through-plane movement) during the cardiac cycle at several levels to determine any potential impact on endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Methods: For this study, 30 patients (median age 73.0 years; 27 men) with an infrarenal AAA were randomly selected from a prospectively maintained EVAR database. All patients had undergone preoperative electrocardiogram-gated computed tomography angiography consisting of 8 phases. After semiautomatic segmentation, a 3-dimensional location probe was placed in the center of the aorta (center point) on the orthogonal slices at 12 different levels along the aorta and iliac arteries for all 8 phases. Movement of the center point during the cardiac cycle was analyzed for each level. Values are given as the median and interquartile range (IQR). Results: The median through-plane movement of all levels was 3.0 mm (IQR 2.8–3.2) and appeared to be lower in the region of the celiac and renal arteries: 2.6 mm (IQR 1.7–3.1) at 3 cm proximal to the most distal renal artery and 2.4 mm (IQR 1.9–2.9) at 1 cm distal to the most distal renal artery, respectively. The thoracic part of the aorta showed the largest through-plane motion: 4.1 mm (IQR 2.7–4.6). Conclusion: This study quantifies aortic through-plane motion in the craniocaudal direction. Since through-plane movement appears to be limited, findings of previous studies investigating pulsatile in-plane distension seem to be representative for aortic distension.

Objective: Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and postoperative benefits compared with femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR. Methods: We identified all patients undergoing either pEVAR (bilateral percutaneous access, whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms from January 2011 to December 2013 in the Targeted Vascular data set from the American College of Surgeons National Surgical Quality Improvement Program database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared by c2 test or t-test or the Mann-Whitney test where appropriate. Results: We identified 4112 patients undergoing elective EVAR, 3004 cEVAR patients (73%) and 1108 pEVAR patients (27%). Of all EVAR patients, 26% had bilateral percutaneous access; 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs); and the remainder had a planned cutdown, 63.9% bilateral and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter, or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs 2.4%; P [ .04) but more likely to undergo any concomitant procedure during surgery (32% vs 26%; P < .01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean, 135 vs 152 minutes; P < .01), shorter length of stay (median, 1 day vs 2 days; P < .01), and fewer wound complications (2.1% vs 1.0%; P [ .02). On multivariable analysis, the only predictor of percutaneous access failure was performance of any concomitant procedure (odds ratio, 2.0; 95% confidence interval, 1.0-4.0; P [ .04). Conclusions: Currently, one in four patients treated at Targeted Vascular National Surgical Quality Improvement Program centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared with cEVAR.

Purpose: To examine the long-term outcomes of bare metal stent placement for exclusion of extracranial internal carotid artery (ICA) aneurysms. Methods: From 2006 to 2011, 7 consecutive symptomatic patients (4 men; mean age 52 years) with surgically inaccessible extracranial ICA aneurysms were treated with a bare stent at a single center. Patients received clopidogrel for 3 months after the procedure and aspirin for life. Clinical follow-up with duplex ultrasound and/or computed tomographic angiography was performed at 3, 6, and 12 months and yearly thereafter. Results: All procedures were technically successful; no neurological complications occurred. After 6 months, there was complete thrombosis of the aneurysm in all except one case. In this asymptomatic patient, the residual active flow was successfully obliterated by additional coil embolization. Over a mean follow-up of 57±22 months, all patients were alive and free of local or central neurological symptoms. All stents were patent, and thrombosis of the aneurysms was complete. Conclusion: In this small series, treatment of extracranial ICA aneurysms with a bare stent seems technically feasible and safe. All treated extracranial ICA aneurysms were excluded by primary intervention or secondary coil embolization.

BACKGROUND Arterial pressure waveform analysis enables continuous, minimally invasive measurement of cardiac output. Haemodynamic instability compromises the reliability of the technique and a means of maintaining accurate measurement in this circumstance would be useful. OBJECTIVES To investigate the accuracy, precision and trending ability of arterial pressure waveform cardiac output obtained with FloTrac/Vigileo, versus pulmonary artery thermodilution in patients undergoing elective open abdominal aortic aneurysm repair. DESIGN A prospective observational study. SETTING Operating room in a university hospital. PATIENTS Twenty-two patients scheduled for elective, open abdominal aortic aneurysm repair. MAIN OUTCOME MEASURES Bias, limits of agreement and mean error as determined with Bland-Altman analysis between arterial waveform and thermodilution cardiac output assessment at four time points: after induction of anaesthesia (t1); after aortic cross-clamping (t2); after clamp release (t3); and after skin closure (t4). Trending ability from t1 to t2, t2 to t3 and t3 to t4, determined with four-quadrant and polar plot methodology. Clinically acceptable boundaries were defined in advance. RESULTS Bland-Altman analysis revealed a bias of 0.54 l min-1 (thermodilution minus arterial waveform cardiac output) for pooled data, and 0.51 (t1), -0.42 (t2), 0.98 (t3) and 0.98 (t4) l min-1 at the different time points. Limits of agreement (LOA) were [-3.0 to 4.0] (pooled), [-2.0 to 3.0] (t1), [-3.1 to 2.3] (t2), [-2.5 to 4.4] (t3) and [-1.7 to 3.7] (t4) l min-1, resulting in mean errors of 58% (pooled), 45% (t1), 53% (t2), 52% (t3) and 41% (t4). Four-quadrant concordance was 65%. Polar plot analysis resulted in an angular bias of -128, with radial LOA of -60° to 36°. CONCLUSION Bias between arterial waveform and thermodilution cardiac output was within a predefined acceptable range, but the mean error was above the accepted range of 30%. Trending ability was poor. Arterial waveform and thermodilution cardiac outputs are, therefore, not interchangeable in patients undergoing open abdominal aortic aneurysm repair.

To evaluate the applicability of an off-the-shelf scalloped stent-graft to preserve left subclavian artery (LSA) flow in thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection.The computed tomography angiograms (CTA) of 70 consecutive patients (median age 64 years; 44 men) with acute Stanford type B aortic dissection were retrospectively analyzed to identify patients in whom a short proximal landing zone (15 mm from the retrogradely dissected wall layers) would require LSA overstenting during TEVAR. A scalloped stent-graft was deemed possible in those patients with the intimal entry tear located at least 20 mm distant from the LSA ostium.The LSA needed to be covered in 56 (80%) patients. Of these, an off-the-shelf scalloped stent-graft would have been applicable in 23 (41%) patients. In the latter group, the median aortic diameter was 31 mm (range 26-37), the median length of the LSA ostium was 13 mm (range 10-20), and the median width of the LSA ostium was 15 mm (range 11-24). Three differently sized off-the-shelf stent-grafts with the largest scallop possible could have adequately treated 20 (36%) of the 56 patients in the acute phase.In this single-center imaging-based study, involvement of the LSA in the setting of acute type B aortic dissection was seen in 80% of patients treated with TEVAR. Three off-the-shelf stent-grafts would suffice to treat one-third of these acute type B aortic dissections and may offer a relatively simple solution to preserve LSA flow, thereby lowering the risk of malperfusion of the (posterior) cerebrum, spinal cord, and left arm in an urgent/emergent setting.

OBJECTIVE To assess whether the Modified Arch Landing Areas Nomenclature (MALAN), which merges Ishimaru's map with the Aortic Arch Classification, predicts the magnitude of displacement forces and their orientation in proximal landing zones for TEVAR. METHODS Computational fluid dynamic (CFD) modelling was employed to prove the hypothesis. Healthy aorta CT angiography scans were selected based on aortic arch geometry to reflect Types I to III arches equally (each n = 5). CFDs were used to compute pulsatile displacement forces along the Ishimaru's landing zones in each aorta including their three dimensional orientation along the upward component and sideways component. Values were normalised to the corresponding aortic wall area to calculate equivalent surface traction (EST). RESULTS In Types I and II arches, EST did not change across proximal landing zones (p = .297 and p = .054, respectively), whereas in Type III, EST increased towards more distal landing zones (p = .019). Comparison of EST between adjacent zones, however, showed that EST was greater in 3/II than in 2/II (p = .016), and in 3/III than in 2/III (p = .016). Notably, these differences were related to the upward component, that was four times greater in 3/II compared with 2/II (p

Purpose: To determine which patient and C-arm characteristics are the strongest predictors of intraoperative patient radiation dose rates (DRs) during endovascular aneurysm repair (EVAR) procedures and create a patient risk chart. Methods: A retrospective analysis was performed of 74 EVAR procedures, including 16,889 X-ray runs using fixed C-arm imaging equipment. Four multivariate log-linear mixed models (with patient as a random effect) were constructed. Mean air kerma DR (DRAK, mGy/s) and the mean dose area product DR (DRDAP, mGycm2/s) were the outcome variables utilized for fluoroscopy as differentiated from digital subtraction angiography (DSA). These models were used to predict the maximum radiation duration allowed before a 2-Gy skin threshold (for DRAK) or a 500-Gycm2 threshold (for DRDAP) was reached. Results: The strongest predictor of DRAK and DRDAP for fluoroscopy imaging was the radiation protocol, with an increase of 200% when changing from “low” to “medium” and 410% from “low” to “normal.” The strongest predictors of DRAK and DRDAP for DSA were C-arm angulation, with an increase of 47% per 30° of angulation, and body mass index (BMI), with an increase of 58% for every 5-point increase in BMI. Based on these models, a patient with a BMI of 30 kg/m2, combined with 45° of rotation and a field size of 800 cm2 in the medium fluoroscopy protocol has a predicted DRAK of 0.39 mGy/s (or 85.5 minutes until the 2-Gy skin threshold is reached). While using comparable settings but switching the acquisition to a DSA with a “2 frames per second” protocol, the predicted DRAK will be 6.6 mGy/s (or 5.0 minutes until the 2-Gy threshold is reached). Conclusion: X-ray radiation DRs are constantly fluctuating during and between patients based on BMI, the protocols, C-arm position, and the image acquisitions that are used. An instant patient risk chart visualizes these radiation dose fluctuations and provides an overview of the expected duration of X-ray radiation, which can be used to predict when follow-up dose thresholds are reached during abdominal endovascular procedures.

Purpose: To determine the midterm outcomes of internal iliac artery (IIA) coverage by a stent-graft in endovascular aortic aneurysm repair (EVAR) under specific anatomic and technical circumstances. Material and methods: From January 2003 until January 2014, 57 patients with aortoiliac aneurysms, including 20 with 24 IIA aneurysms (IIAAs), underwent EVAR with IIA coverage. IIAA diameter change or IIA thrombosis, buttock claudication, type II endoleak, and secondary interventions related to the IIA were studied. Results: Twenty-five of the 37 patients without IIAA were embolized prior to stent-graft placement, all unilateral, and in 12, the IAA orifice was only overstented. Buttock claudication occurred in only nine (20%) of the embolization patients (9/49 IIA’s) (p = .14), while one IIA-related type II endoleak, occurred in the nonembolization group (p = .16). In patients with IIAA(s), the aneurysm diameter decreased in 16 cases (67%). Buttock claudication occurred in 75% of bilateral, and in 14.6% of unilateral embolizations (p = .046). Conclusions: Carefully selected patients with aortoiliac aneurysm without IIAA may safely undergo hypogastric artery overstenting without preemptive embolization during EVAR. IIA embolization is associated with buttock claudication and should be avoided if possible. Otherwise, at least one IIA should be preserved.

Objective This study measured the cumulative occupational X-ray radiation dose received by support staff during endovascular aortic procedures and during additional intraoperative steps in the hybrid operating room. Methods Radiation dose measurements were performed during interventions on 65 patients receiving 90 stent grafts during endovascular aneurysm repair (EVAR), bifurcated EVAR, thoracic EVAR, iliac branched device deployment, aortouni-iliac stenting, and fenestrated/branched EVAR (F/BrEVAR). X-ray imaging was acquired using the Philips Allura FD20 Clarity System (Philips Medical Systems, Best, The Netherlands). The occupational radiation dose (also referred to as the estimated effective dose, E, measured in millisieverts) was measured with the DoseAware Xtend system (Philips Medical Systems) personal dosimeters. E was reported per staff member (E STAFF ), where "staff" was a generic term for each staff member included in the study: the first operator (FO), the second operator (ESO), a virtual maximum operator (MO), and all additional supporting staff, including the sterile nurse, nonsterile nurse, anaesthesiologist, and radiation technician. The primary outcome was the median cumulative E STAFF (or E FO , E MO , and so on), which was presented as the median cumulative dose per intervention and stratified for several within-interventional EVAR and F/BrEVAR steps or stents. The second outcome was the percentage of the absorbed E by a supporting staff member in relation to the E measured by the reference badge attached on the C-arm (E STAFF% or E FO% , E MO% , and so on). All outcomes are presented as median with interquartile range, unless stated differently. Results The occupational effective dose in millisieverts of the MO (E MO ) was 0.055 (0.029-0.082) for aortouni-iliac stenting (n = 6), 0.084 (0.054-0.141) during thoracic EVAR (n = 14), 0.036 (0.026-0.068) during bifurcated EVAR (n = 38), 0.054 (0.035-0.126) during iliac branched device deployment (n = 8), and 0.345 (0.235-0.757) during F/BrEVAR (n = 24). The median E MO in millisieverts was 0.025 (0.012-0.062) per renal target vessel (TV) and 0.146 (0.07-0.315) for a nonrenal visceral TV. During all noncomplex interventions, the E MO% was 4.4% (2.7%-7.3%), with the lowest median rate at 3.5% (2.5%-5%) for EVAR. The highest median rate E MO% was found for F/BrEVAR procedures: 8.2% (5.0%-14.4%). Conclusions With maximum operator shielding during femoral access, relative occupational radiation risk can be minimized. However, digital subtraction angiography image acquisition, recanalization of TVs, recanalization of superior mesenteric artery or celiac artery, and recanalization of branched TVs are predictors for increased occupational radiation dose risks caused by increased radiation doses to the patient and reduced options for shielding of the operator.

Objective The objective of this study was to describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for branch vessel preservation. Methods Patients treated with a chimney graft procedure between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair or for conventional, branched, or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cutdown access for the chimney grafts and bilateral femoral artery cutdown access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. In addition, evolution of gutter area over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24 months of follow-up were calculated. Results Thirty-three patients (mean age, 77.6 ± 6.8 years; 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7 ± 13.5 mm were included. A total of 54 of an intended 54 chimney grafts were deployed. Primary technical success and 30-day secondary clinical success rates were 87.9% and 84.8%, respectively. The early mortality rate was 6.1% (n = 2). The early type IA endoleak rate was 6.1% (n = 2), and the chimney graft occlusion rate was 6.1% (n = 2). Median follow-up duration was 26 months (interquartile range, 14.8-37.3 months). The estimated 2-year actuarial survival rate was 78.1% (standard error, ±7.4%). Late complications included type IA endoleak (n = 1), chimney graft occlusion (n = 2), type II endoleak with aneurysm growth (n = 4), and distal stent graft limb kinking and occlusion (n = 1). Late reinterventions included coil or glue embolization (n = 3), distal limb extension (n = 2), open endoleak ligation (n = 2), Palmaz stent placement (n = 1), repeated EVAR (n = 1), and femorofemoral bypass graft (n = 1). At 2 years, the estimated secondary clinical success and freedom from aneurysm growth rates were 80.5% (±7.2%) and 84.4% (±7.2%). Gutter size showed a small but significant decrease over time at the level of the proximal markers and at 10 mm distal from the markers. Conclusions Midterm results show that a standardized procedure for EVAR using chimney grafts for branch vessel preservation is an acceptable option for high-risk patients with large, complex aneurysms who are unfit for open repair and who have been excluded from fenestrated EVAR. Gutter size decreases over time, but the rate of branch vessel loss and reinterventions demonstrate that this approach should remain reserved for those who are at truly prohibitive risk for open or fenestrated stent graft repair.

Background: Conservative management of acute type B aortic dissection (ABAD) is often associated with aortic dilatation during follow-up increasing the risk of aortic rupture. The goal of this study was to investigate whether morphologic characteristics of the dissection can predict aortic growth. Methods: All conservatively managed ABAD patients from four referral centers were included (2000 to 2010). Aortic diameters were measured at five levels at baseline and at the last follow-up computed tomography angiography, and annual aortic growth rates were calculated for all segments. Linear regression was used to study the influence of aortic morphologic characteristics for aortic dilatation. Results: Included were 62 patients (41 men) with a mean age of 60.3 +/- 10.7 years. Among the 310 analyzed aortic segments, 248 (80.0%) were dissected, of which 211 (85.1%) showed aortic growth. Overall, the mean diameter increased from 36.1 +/- 9.4 to 40.2 +/- 11.1 mm (P < .01), which corresponds with a mean aortic growth rate of 3.1 +/- 6.3 mm/y. Multivariate linear regression analysis showed that male sex (95% confidence interval [CI], 0.60-4.04; P = .005) and a saccular false lumen (95% CI, 2.07-7.81: P = .001) were associated with a significantly increased aortic growth rate. Increasing age (95% CI, -0.23 to -0.04; P = .005), increased number of entry tears (95% CI, -2.40 to -0.43; P = .005), false lumen located on the aortic outer curvature (95% CI, -4.30 to -0.38; P = .019), and a circular configuration of the true lumen (95% CI, -5.35 to -0.32; P = .027) were associated with a decreased aortic growth rate. Conclusions: Multiple morphologic characteristics appear to predict aortic dilatation in ABAD patients treated medically. Early assessment of these morphologic signs may be useful in the selection of ABAD patients who might benefit from closer radiologic surveillance or prophylactic intervention.

Open repair of abdominal aortic aneurysm (AAA) generally involves postsurgery admission to the intensive care unit (ICU). Few studies have evaluated the impact of surgery for either ruptured or nonruptured AAA (with postoperative ICU treatment) on long-term survival and quality of life. The primary aim of this study was to quantify long-term survival and health-related quality of life (HrQpL) of a cohort of patients undergoing open AAA repair after hospital discharge. Consecutive patients undergoing open elective or acute AAA reconstruction with postoperative admission to the ICU and discharged alive from the hospital during 2009 were identified. Primary outcome measures were 1-year and long-term mortality. The secondary outcome was the HrQoL using the EuroQol-6D (EQ-6D) questionnaire at the end of the follow-up period. A total of 263 patients were treated and postoperatively discharged alive: 56 had a ruptured AAA (rAAA), 35 a symptomatic AAA, and 172 an asymptomatic AAA. The 1-year mortality after open AAA repair was 8 %. Overall, 39 % of patients died within 10 postoperative years (mean 6.0 ± 2.8 years). Long-term survival of patients with a ruptured or symptomatic aneurysm was similar to that of patients undergoing elective aneurysm repair. Long-term HrQoL of the total study population was worse than that of an age-matched general Dutch population on the EQ-us (range 0–1, difference 0.12). This decrease in HrQoL was mainly seen in mobility, self-care, usual activities, and cognition. Ten years after open AAA repair, the overall survival rate was 59 %. Long-term survival and HrQoL were similar for patients with a repaired ruptured or symptomatic aneurysm and those who underwent elective aneurysm repair. There were also no differences in patients with infrarenal versus juxtarenal/suprarenal aneurysms. Surviving patients had a lower HrQoL than the age-matched general Dutch population, especially regarding mobility, self-care, usual activities, and cognition.

Objective The Endurant endograft (Medtronic Inc, Minneapolis, Minn) is a new-generation device specifically developed to perform well in complex abdominal aortic aneurysm anatomy. Previous reports on the 1- and 2-year results of endovascular aneurysm repair (EVAR) with the Endurant endograft showed excellent outcome, including prevention of migration and type I endoleaks, but occurrence and outcome of post-EVAR occlusion have not been determined in a large multicenter patient cohort with midterm follow-up, which is the objective of this study. Methods Data of consecutive patients treated with the Endurant from December 2007 to April 2012 in three Dutch tertiary vascular referral hospitals were prospectively gathered and retrospectively analyzed. Follow-up consisted of regular office visits, computed tomography angiography at 1 and 12 months after EVAR, and subsequently, duplex ultrasound imaging or computed tomography angiography at regular intervals. Patients with ruptured aneurysms or with earlier abdominal aortic surgery were excluded. The incidence and clinical outcome of endograft occlusions were analyzed. An expert review board assessed all cases in the search for possible causes of occlusion. Results Included were 496 patients (87.7% male), who were a median age of 74 years (range, 68-78 years). Median follow-up was 1.7 years (range, 0-4.6 years). Twenty graft occlusions (4.0%) occurred during follow-up. Median time between primary EVAR and detection of the occlusion was 1 month, with 55% occurring ≤60 postoperative days and 90% ≤1 year. No association was found between occlusion and sex ( P = .28), age ( P = .96), or use of an aortouniiliac device ( P = .66). Technical error was the considered cause of the occlusion in 12 patients (60%). The estimated freedom from occlusion was 98.4% at 30 days, 95.7% at 1 year, and 95.3% at 3 years. Presenting symptoms of occlusion were acute limb ischemia in 50%. Treatment was surgical (75%) or percutaneous (25%). Successful revascularization was achieved in 17 of 20 patients, but reocclusions occurred in five, resulting in a transfemoral amputation in one patient. Occlusion-related mortality was 0.6% (3 of 496). Conclusions At a median follow-up of 1.7 years, Endurant endograft occlusion occurred in 4.0% of 496 patients. Most occlusions occurred ≤2 months after EVAR, and rarely after 1 year. A technical justification for occlusion could be found for 60% of patients. A more liberal intraoperative and early postoperative (re)intervention strategy may reduce the occlusion rates and improve outcome.

Background: Partial thrombosis of the false lumen has been reported as a significant predictor of mortality during follow-up in patients with acute type B aortic dissection. The purpose of this study was to investigate the correlation of false lumen thrombosis and aortic expansion during follow-up in patients with acute type B aortic dissection. Methods: All medically treated patients with acute type B aortic dissection observed in 4 cardiovascular referral centers between 1998 and 2011, with admission and follow-up computed tomography or magnetic resonance imaging scans, were included. Aortic diameters of the dissected aortas were measured at 4 levels on the baseline and follow-up scans, and annual growth rates were calculated. Univariate and multivariate regression analyses were used to investigate the effect of false lumen thrombosis on aortic growth rate. Results: A total of 84 patients were included, of whom 40 (47.6%) had a partially thrombosed false lumen, 7 (8.3%) had a completely thrombosed false lumen, and 37 (44.0%) had a patent false lumen. A total of 273 of the 336 (81.3%) evaluated aortic levels were dissected segments. Overall, the mean aortic diameter increased significantly at all evaluated levels (P

Introduction Thoracic aortic stent grafts are orders of magnitude stiffer than the native aorta. These devices have been associated with acute hypertension, elevated pulse pressure, cardiac remodelling and reduced coronary perfusion. However, a systematic assessment of such cardiovascular effects of thoracic endovascular aortic repair (TEVAR) is missing. The C ardi O vascular R emodelling following E ndovascular aortic repair (CORE) study aims to (1) quantify cardiovascular remodelling following TEVAR and compare echocardiography against MRI, the reference method; (2) validate computational modelling of cardiovascular haemodynamics following TEVAR using clinical measurements, and virtually assess the impact of more compliant stent grafts on cardiovascular haemodynamics; and (3) investigate diagnostic accuracy of ECG and serum biomarkers for cardiac remodelling compared to MRI. Methods and analysis This is a prospective, nonrandomised, observational cohort study. We will use MRI, CT, echocardiography, intraluminal pressures, ECG, computational modelling and serum biomarkers to assess cardiovascular remodelling in two groups of patients with degenerative thoracic aneurysms or penetrating aortic ulcers: (1) patients managed with TEVAR and (2) control patients managed with medical therapy alone. Power analysis revealed a minimum total sample size of 20 patients (α=0.05, power=0.97) to observe significant left ventricular mass increase following TEVAR after 1 year. Consequently, we will include 12 patients in both groups. Advanced MRI sequences will be used to assess myocardial and aortic strain and distensibility, myocardial perfusion and aortic flow. ECG, echocardiography and serum biomarkers will be collected and compared against the imaging data. Computational models will be constructed from each patient imaging data, analysed and validated. All measurements will be collected at baseline (prior to TEVAR) and 1-year follow-up. The expected study period is 3 years. Ethics and dissemination This study has been approved by the University of Michigan IRB. The results will be disseminated through scientific journals and conference presentations. Trial registration number NCT02735720.

Objective: We sought to compare current practices in patient selection and 30-day outcomes for transperitoneal and retroperitoneal abdominal aortic aneurysm (AAA) repairs. Methods: All patients undergoing elective transperitoneal or retroperitoneal surgical repair for AAA between January 2011 and December 2013 were identified in the Targeted Vascular National Surgical Quality Improvement Program database. Emergency cases were excluded. Baseline characteristics, anatomic details, and intraoperative and postoperative outcomes were evaluated among those with infrarenal or juxtarenal AAA only. Results: We identified 1135 patients: 788 transperitoneal (69%) and 347 retroperitoneal (31%). When only infrarenal and juxtarenal AAAs were evaluated, the retroperitoneal patients were less likely to have an infrarenal clamp location (43% vs 68%) and had more renal revascularizations (15% vs 6%; P

Objective: This study assessed whether the additional use of the aortic arch classification in type I, II, and III may complement Ishimaru's aortic arch map and provide valuable information on the geometry and suitability of proximal landing zones for thoracic endovascular aortic repair. Methods: Anonymized thoracic computed tomography scans of healthy aortas were reviewed and stratified according to the aortic arch classification, and 20 of each type of arch were selected. Further processing allowed calculation of angulation and tortuosity of each proximal landing zone. Data were described indicating both proximal landing zone and type of arch (eg, 0/I). Results: Angulation was severe (>60°) in 2/III and in 3/III. Comparisons among the types of arch showed an increase in proximal landing zones angulation (P

Objective The fenestrated Anaconda endograft (Vascutek, Renfrewshire, Scotland) was introduced in 2010 and showed promising short-term results with high technical success and low morbidity rates. The aim of this study was to present the midterm results, with a minimum of 12 months follow-up, for all patients treated with the fenestrated Anaconda endograft in The Netherlands. Methods Patients treated with the fenestrated Anaconda endograft between May 2011 and February 2015 were included. Follow-up consisted of computed tomography angiography at 1 month and 1 year, and duplex ultrasound yearly thereafter with additional computed tomography angiography if indicated using a standard protocol. Results A total of 60 patients were included; 48 patients (80.0%) were treated for juxtarenal aneurysms, and 12 (20.0%) were short-neck infrarenal aneurysms. Mean aneurysm size was 64 ± 9 mm. A total of 140 fenestrations were incorporated. Median follow-up was 16.4 months (interquartile range, 11.9-27.4). The 30-day mortality was 3.4% (n = 2). Kaplan-Meier estimates for 1-year, 2-year, and 3-year survival were 91.4%, 89.5%, and 86.3%, respectively, without aneurysm-related mortality during follow-up. Main body primary and secondary endograft patencies were 98.3% and 100%, respectively. Target vessel primary and secondary patencies were 95.0% and 98.6%, respectively. Early type IA endoleaks occurred in seven patients (11.7%) and spontaneously resolved in all patients. At 1-year follow-up 4 (6.7%) type II endoleaks persisted. One patient experienced aneurysm rupture because of a late type III endoleak attributable to a dislodged renal stent and subsequently underwent successful conversion to open surgery. Conclusions The fenestrated Anaconda is a viable treatment option for complex abdominal aortic aneurysms. Acceptable mortality and morbidity and low reintervention rates contribute to good midterm results. Occurrence of early type I endoleak was relatively common, but these resolved spontaneously in all patients.

ObjectiveThe main purpose of this study was to evaluate the influence of smoking on perioperative outcomes of endovascular aneurysm repair (EVAR), aneurysm sac behavior, abdominal aortic aneurysm (AAA) neck growth after EVAR, and its effect on stent graft migration during follow-up.MethodsBaseline characteristics and follow-up data were collected prospectively by patient record forms. Follow-up visits were scheduled at 1, 3, 6, 12, 18, and 24 months, and annually thereafter and included a clinical examination and imaging studies. Patients were stratified in three groups according to their smoking status as nonsmokers, former smokers, and smokers.ResultsThis study analyzed the data for 4176 nonsmokers, 2406 former smokers, and 2056 smokers who were enrolled prospectively in the European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) database. Compared with nonsmokers, smokers required more percutaneous transluminal angioplasty and stent placements during EVAR (P < .001), and stent graft migration occurred more often (hazard ratio, 1.45; 95% confidence interval, 1.03-2.05; P = .033). Nonsmokers had more late type II endoleaks than former smokers and smokers (58.5%, 55.9%, and 35.5%, respectively; P < .001). Smoking had no effect on aneurysm sac behavior or AAA neck growth after EVAR.ConclusionsSmokers need more percutaneous transluminal angioplasty procedures and stents during EVAR. They have fewer late type II endoleaks during follow-up; however, smokers should be closely monitored because they have an increased risk of stent graft migration.

ObjectivesWhether abdominal aortic aneurysm (AAA) enlargement after endovascular aneurysm repair (EVAR), without an identifiable endoleak, is a risk factor for AAA rupture remains controversial. To our knowledge, studies including large patient numbers investigating this topic have not been done. Therefore, a considerable number of conversions to open AAA repair have been performed in this patient group. This study evaluated AAA rupture risk in patients without detectable endoleaks but with AAA enlargement after EVAR treatment.MethodsBaseline characteristics and follow-up data were collected prospectively by case record forms. Follow-up visits were scheduled at 1, 3, 6, 12, 18, and 24 months, and annually thereafter. The follow-up assessment included clinical examination and imaging studies. Patients were divided into three groups according to the degree of shrinkage or enlargement of the aneurysm. Group A included patients with >8 mm aneurysm shrinkage, group B consisted of patients with ≤8 mm shrinkage to ≤8 mm enlargement, and group C patients had an aneurysm enlargement of >8 mm.ResultsThe basis for this analysis was 6337 patients who were enrolled prospectively in the European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) database between 1996 and 2006. Group A included 691 patients; group B, 5307 patients; and group C, 339 patients. Ruptures occurred in 3 patients in group A, in 14 patients in group B, and in 9 patients in group C. The annual rate of rupture in group C was

Introduction Anastomotic pseudoaneurysms and true para-anastomotic aneurysms after initial open abdominal aortic prosthetic reconstruction often need reintervention because they are at risk for rupture. However, open surgical reinterventions are technically challenging procedures with high mortality and morbidity rates. In the present multicenter study, we describe the long-term clinical course in an expanded number of patients who underwent endovascular repair of para-anastomotic aneurysms after previous open reconstruction. Methods The study included all patients who were treated with an endovascular stent graft between July 1999 and July 2009 for an aortoiliac anastomotic pseudoaneurysm or a true para-anastomotic aneurysm after previous aortic prosthetic reconstruction for aneurysmal or occlusive disease in one of the four participating centers. Main outcomes were long-term complications, reinterventions and conversion rate, mortality, and hospital length of stay. Results An endovascular stent graft was used to treat 58 patients (53 men; mean age, 71 ± 9 years), with 80 aortic or iliac pseudoaneurysms or true para-anastomotic aneurysm, or both. Bifurcated stent grafts were used in 32 patients, endovascular tube grafts in eight, aortouniiliac stent grafts in seven, and iliac extension grafts in 11. Stent graft deployment was successful in 55 patients, for a technical success rate of 95%. Median hospital admission was 3 days (range, 1-122 days). The 30-day and in-hospital mortality rates were 3.4% (n = 2) and 6.9% (n = 4), respectively. The 30-day clinical success rate was 91% (n = 53). Median follow-up was 41 months (range, 0-106 months). The cumulative and procedural-related mortality during follow-up was 19% (n = 11) and 10% (n = 6), respectively. Follow-up computed tomography angiography revealed nine endoleaks (three type I; six type II) in eight patients and endotension in two patients. The overall reintervention and conversion rate during follow-up was 26.9% (n = 15) and 6.9% (n = 4), respectively. Life-table analysis showed reduced freedom from reintervention for aortouniiliac and tube stent grafts. Type I endoleaks were observed in 25% of patients with endovascular aortic tube grafts for proximal anastomotic aneurysms. Conclusions The present study demonstrates that endovascular repair of para-anastomotic aortic and iliac aneurysms after initial prosthetic aortic surgery is safe and durable in patients with an appropriate anatomy. The long-term follow-up showed fewer complications occurred after procedures with bifurcated stent grafts compared with procedures with tube grafts, aortouniiliac, or iliac extension stent grafts.

Aneurysms of the proper hepatic artery comprise a rare but potentially dangerous entity for which treatment is performed both surgically and endovascularly. Covered stents are generally used for endovascular treatment of such aneurysms. When the aneurysm is contaminated due to an enteric fistula, however, use of a covered stent is considered inappropriate. This case report describes the endovascular repair of a proper hepatic artery aneurysm using overlapping bare metal stents after the patient was surgically treated for duodenal hemorrhage.

Objective: Electrocardiogram (ECG)-gated imaging offers insight into aortic shape changes throughout the cardiac cycle. Morphologic changes of the anchoring zones may influence stent graft fixation and scaling and may have serious implications for endograft design and durability. We used multiphase magnetic resonance imaging (MRI) scans to evaluate the asymmetric aspect of aortic shape changes in the aneurysm neck before and after endovascular aneurysm repair (EVAR). Methods: Eleven patients were scanned before and after EVAR using ECG-gated balanced gradient-echo MRI with 16 reconstructed phases. Transverse scan planes were planned perpendicular to the aorta in the coronal and sagittal planes. Three levels were studied: 3 cm above the lowest renal artery, between the renal arteries, and 1 cm below the lowest renal artery. After segmentation of the aortic area in the images, aortic radius changes during the cardiac cycle were determined over 360 axes and plotted. Radii were measured from the center of mass of the aortic lumen to the vessel wall. An ellipse was fitted over the plots allowing determination of radius changes over the major and minor axis, and the most prominent direction of distention. Results: The difference between radius change over the major and minor axis was significant preoperatively and postoperatively (P .05) between pre-EVAR and post-EVAR radius changes. Pre-EVAR, the ratio of the radius change over the major vs minor axis ranged from 1.10 to 1.82. The pre-EVAR and post-EVAR asymmetry ratios did not differ significantly (P > .1). Preoperatively, the suprarenal direction of distention showed a tendency to right-anterior; for infrarenal, the tendency was to left-anterior. Conclusions: We measured the asymmetric aspect of earlier reported pulsatile aortic shape changes. The rate of asymmetric distention varied by patient and level. Asymmetric aortic expansion may have consequences for endograft design because it probably affects endograft sealing, especially in patients with high radius changes and asymmetry ratios. Asymmetric expansion remained preserved after stent graft placement. The stent grafts with Z-stent rings used in the study participants seem to adapt to the aortic shape changes well. (J Vase Surg 2009;49:1395-402.)

Item does not contain fulltext The purpose of this study was to utilize dynamic computed tomographic angiography (CTA) on pre- and postoperative thoracic endovascular aneurysm repair (TEVAR) patients to characterize cardiac pulsatility-induced aortic motion on essential TEVAR proximal sealing zones and to study the influence of endograft placement. Six pre- and six postoperative dynamic CTA studies were obtained in six patients with thoracic aortic aneurysms (TAAs) undergoing TEVAR. Data were acquired using a retrospective electrocardiography-triggered dynamic CTA scan, with eight reconstructed phases over the cardiac cycle. Scans were acquired during a single breath hold. Multiplanar reconstructions were made perpendicular to the aorta at five surgically relevant anatomical thoracic landmarks: 1 cm proximal to the innominate trunk, 1 cm proximal and 1 cm distal to the left subclavian artery, and 1 cm proximal and 3 cm distal to the proximal end of the stent. After segmentation of the aortic lumen in the images, diameter change and area change over the cardiac cycle were measured. Diameter change was measured through the center of mass of the aortic lumen, and the average change over 180 axis is presented. We found significant distention of the thoracic aortic arch and descending thoracic aorta during the cardiac cycle before and after TEVAR. Distention ranged 3-12% in diameter and 2-20% in area. This distention was preserved after TEVAR. Patients with TAA experience aortic diameter and area changes during the cardiac cycle. The magnitude, and hence the clinical importance, of this aortic distention varies among patients. After stent-graft placement, aortic distention throughout the cardiac cycle is preserved. This may have major implications for correct sizing of the endograft as well as for stent-graft design and durability as the forces on the stents may be much larger after implantation than initially anticipated by stent manufacturers.

Purpose: To identify in-hospital and follow-up outcomes of thoracic endovascular aortic repair (TEVAR) for aortobronchial fistula (ABF) and aortoesophageal fistula (AEF). Methods: The authors reviewed all published cases of ABF and AEF undergoing TEVAR indexed in the MEDLINE, Cochrane Library CENTRAL, and EMBASE databases. After removal of duplicates, 850 articles were scrutinized for relevance and validity. Exclusion criteria included: (1) no clear description of the organs involved with the fistula, (2) no description of outcomes after TEVAR for ABF or AEF, or (3) no original data presented in the article. In this manner, 66 relevant articles were identified that included original data on 114 patients (76 men; mean age 63 +/- 1.5 years) with ABF (n=71) or AEF (n=43). Meta-analyses were performed to investigate outcomes of TEVAR for ABF and AEF. Results: Patients with AEF presented more frequently with hypovolemic shock (33% versus 13%, p=0.012) and systemic infection (36% versus 9%, p

This study evaluated the value of computed tomographic angiography (CTA) early after an endovascular aneurysm repair (EVAR) in relation to CTA 3 months after EVAR. We retrospectively reviewed all elective EVAR patients with available postprocedural and 3-month follow-up CTAs who were treated between 1996 and 2006. CTAs were analyzed for EVAR-related complications in terms of endoleaks, migration, and stent graft thrombosis. Secondary procedures and other complications within a 4-month time interval after EVAR were noted and analyzed for any association with the postprocedural CTA. During the study period, 291 patients (275 men), with a mean age of 71 years, underwent elective EVAR. All had postprocedural and 3-month follow-up CTAs, which detected 93 (32%) endoleaks (8 type I, 84 type II, 1 type III) and 1 stent graft thrombosis. These findings resulted in four secondary interventions (one interposition cuff, two extension cuffs, one conversion). All reinterventions were successfully done in an elective setting. During the first 3 postoperative months, five other reinterventions were required for acute ischemia in four patients (three Fogarty procedures, one femorofemoral crossover bypass) or groin infection in one patient. Eight patients died, but none of the deaths were related to abdominal aortic aneurysm or EVAR (four cardiac, two pulmonary, one gastric bleeding, one carcinoma). At 3 months, 43 endoleaks (3 type I, 40 type II), 3 stent graft thromboses, and 1 stent graft migration were seen. In two patients (0.7%), a new endoleak was diagnosed compared with the postprocedural CTAs. In 287 (99%) of 291 patients, the postprocedural CTA did not influence our treatment policy in the first 3 months after EVAR. More than half of the early endoleaks were self-limiting, and new endoleaks were seen in only two patients (< 1%) at the 3-month follow-up CTA. After an uneventful EVAR procedure, it is safe to leave out the early postprocedural CTA.