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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., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Screening for abdominal aortic aneurysm (AAA) during transthoracic echocardiography (TTE) may be an effective targeted screening strategy., Objective: The aim was to assess the feasibility of AAA screening during TTE and to estimate the prevalence of AAA in patients undergoing TTE., Methods: Electronic bibliographic sources were interrogated using a combination of free text and controlled vocabulary searches to identify studies reporting on AAA screening during TTE. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Fixed effect or random effects models were used to calculate pooled prevalence estimates., Results: Twenty observational cohort studies were identified reporting a total of 43,341 participants (23,291 men and 20,050 women). Hypertension was reported in 41% (95% CI 38-43), hypercholesterolemia in 31% (95% CI 29-32), diabetes mellitus in 20% (95% CI 19-22), and tobacco use in 37% (95% CI 35-38). The aorta was visualised in 86% (95% CI 84-88) of the screened population. The pooled prevalence of AAA in the entire screened population was 0.033 (95% CI 0.024-0.044). The pooled prevalence of AAA in men was 0.046 (95% CI 0.032-0.065) and in women it was 0.014 (95% CI 0.008-0.022). The mean age of participants in whom an AAA was detected ranged across the studies from 66 to 85 years. The mean diameter of the aneurysm identified ranged across the studies from 35 mm to 45 mm. Clinical outcomes in participants with a detected AAA were poorly reported., Conclusions: Screening for AAA during TTE may identify a population group with a high risk of AAA in whom targeted screening may be beneficial. Further research is required to investigate the cost-effectiveness and clinical benefits of AAA screening in this setting., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

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., (Copyright © 2017. Published by Elsevier Inc.)

Background: The benefit of catheter-directed thrombolysis for peripheral arterial occlusions is limited by hemorrhagic complications. Plasma fibrinogen level (PFL) has been suggested as a predictor of these hemorrhagic complications, but the accurateness of prediction is unknown. We summarized the available evidence on the predictive value of PFL for hemorrhagic complications after catheter-directed thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions., Methods: We systematically searched PubMed and Embase until January 2016 for peer-reviewed publications on adults undergoing thrombolysis for acute or subacute peripheral native artery or arterial bypass occlusions, assessing the predictive value of PFL for hemorrhagic complications. Two authors independently performed data extraction. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool., Results: In total, six studies (two randomized clinical trials and four cohort studies) reported on 613 patients undergoing 623 thrombolytic interventions for peripheral native artery or arterial bypass occlusions. No risk estimates for PFL and hemorrhagic complications were reported, two risk estimates were calculated, and nine associations between PFL and hemorrhagic complications were reported. For PFL <100 mg/dL compared with ≥100 mg/dL, the calculated relative risk was 0.33 (95% confidence interval, 0.05-2.25) for major bleeding and 1.39 (95% confidence interval, 1.06-1.81) for any bleeding. There were considerable differences in the time point of PFL measurement, the thrombolytic agents, the doses of the agents, and the definition of outcomes. PFL seems inaccurate in predicting hemorrhagic complications. Overall, the included studies were at high risk of bias., Conclusions: Based on the current literature, the predictive value of PFL for predicting hemorrhagic complications after catheter-directed thrombolysis for acute or subacute peripheral native artery and arterial bypass occlusions is unproven., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)