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Funding Information: On behalf of the Public and Community Oversight Group (PCOG) of the Health Protection Research Unit in Chemical and Radiation Threats and Hazards: Ian Wright; John Phipps; Colette Kelly; Robert Goundry; Eve Smyth; Andrew Wood; Paul Dale (also of the Scottish Environment Protection Agency). On behalf of the Society and College of Radiographers Patient Advisory Group: Lynda Johnson; Philip Plant; Michelle Carmichael – Specialist Senior Staff Nurse Guy's and St Thomas’ NHS Foundation trust.

BACKGROUND: The hybrid room (HR) is a complex, high-risk environment, requiring teams (surgeons, anesthesiologists, nurses, technolo-gists) to master various skills, including the 'As Low As Reasonably Achievable' principle of radiation safety. This prospective single center cohort reports the first use of the Operating Room Black Box (ORBB) in a HR. This medical data recording system captures procedural and audio-visual data to facilitate structured team performance analysis.METHODS: Patients planned for endovascular repair of an infrarenal abdominal aortic aneurysm (EVAR) or treatment of symptomatic iliac-femoral-popliteal atherosclerotic disease (Peripheral Vascular Interventions or PVI) were included. Validated measures and established assess-ment tools were used to assess (non-)technical skills, radiation safety performance and environmental distractions. RESULTS: Six EVAR and sixteen PVI procedures were captured. Technical performance for one EVAR was rated 19/35 on the procedure -specific scale, below the 'acceptable' score of 21. Technical skills were rated above acceptable in all PVI procedures. Shared decision making and leadership were rated highly in 12/22 cases, whereas surgical communication and nurses' task management were rated low in 14/22 cases. Team members rarely stepped back from the C-arm during digital subtraction angiography. Radiation safety behavior was scored below 'accept-able' in 14/22 cases. A median (interquartile range) number of 12 (6-23) auditory distractions was observed per procedure. CONCLUSIONS: The ORBB facilitates holistic workplace-based assessment of endovascular performance in a HR by combining objec-tive assessment parameters and rating scale-based evaluations. Strengths and weaknesses were identified in team members' (non-)technical and radiation safety practices. This technology has the potential to improve vascular surgical practice, though human input remains crucial. (NCT04854278)

Objective Myocardial injury after non-cardiac surgery (MINS) is an independent predictor of post-operative mortality in non-cardiac surgery patients and may increase health costs. Few data are available for MINS in vascular surgery patients, in general, and those undergoing fenestrated/branched endovascular aortic repairs (F/BEVAR), in particular. The incidence of MINS after F/BEVAR, the associated risk factors, and prognosis have not been determined. The aim of the present study was to help fill these knowledge gaps. Methods A single centre, retrospective study was carried out at a high volume F/BEVAR centre in a university hospital. Adult patients who underwent F/BEVAR between October 2010 and December 2018 were included. A high sensitivity troponin T (HsTnT) assay was performed daily in the first few post-operative days. MINS was defined as a HsTnT level ≥ 14 ng/L (MINS14) or ≥ 20 ng/L (MINS20). After assessment of the incidence of MINS, survival up to two years was estimated in a Kaplan–Meier analysis and the groups were compared according to MINS status. A secondary aim was to identify predictors of MINS. Results Of the 387 included patients, 240 (62.0%) had MINS14 and 166 (42.9%) had MINS20. In multivariable Cox models, both conditions were significantly associated with poor two year survival (MINS14: adjusted hazard ratio [aHR] 2.15, 95% confidence interval [CI] 1.10 – 4.19; MINS20: aHR 2.43, 95% CI 1.36 – 4.34). In a multivariable logistic regression, age, revised cardiac risk index, duration of surgery, pre-operative estimated glomerular filtration rate (eGFR), and haemoglobin level were independent predictors of MINS. Conclusion After F/BEVAR surgery, the incidence of MINS was particularly high, regardless of the definition considered (MINS14 or MINS20). MINS was significantly associated with poor two year survival. The modifiable predictors identified were duration of surgery, eGFR, and haemoglobin level.

Several international guidelines concerning lower extremity arterial disease (LEAD) have been published recently, in particular, by the American Heart Association the European Society of Cardiology/European Society for Vascular Surgery, the European Society for Vascular Medicine and the Society for Vascular Surgery. These guidelines differ in some respects and certain issues are not addressed. The objective of this consensus driven by the French Societies of vascular Medicine and surgery was to analyze the disparities between the different guidelines, as well as certain issues not covered, and develop proposals with regard to these points. The following fields of LEAD have been explored: 1) classifications, 2) clinical evaluation, 3) diagnostic criteria, 4) quantification of arterial stenosis using duplex ultrasound, 5) detection of asymptomatic multisite lesions, 6) screening for LEAD in the context of cardiac disease, 7) medical treatment, 8) supervised exercise therapy, 9) revascularization and revascularization of the internal artery stenosis, 10) management of chronic limb ischemia, 11) longitudinal follow-up, and 12) diet.

Purpose: To review a single-center experience with fenestrated and branched endovascular aneurysm repair (f/bEVAR) in patients with challenging iliac anatomies. Materials and Methods: A retrospective review of the department’s database identified 398 consecutive patients who underwent complex endovascular repair f/bEVAR between January 2010 and June 2018; of these, 67 had challenging accesses. The strategies implemented to overcome access issues were reviewed, using a dedicated scoring system to evaluate the access (integrating diameter, tortuosity, calcification, and previous open or endovascular repair). Results: In this subgroup of patients, the most common graft design was a 4-vessel fenestrated endograft (27, 40.3%). Hostile access was due to small diameter (Conclusion: Dedicated strategies can be implemented to overcome hostile iliac access in patients with complex aneurysms when f/bEVAR is required. Typically, these maneuvers are associated with favorable outcomes.

Objective Occupational exposure is a growing concern among the endovascular specialist community. Several types of imaging equipment are available, such as mobile C arms or hybrid rooms, and some have been shown to deliver higher levels of radiation. A literature review was conducted to identify studies reporting dose data during standard (EVAR) and complex abdominal aortic endovascular repair (fenestrated/branched EVAR [F/BEVAR]). Methods A search of the MEDLINE and the Cochrane databases was performed by two independent investigators using the medical subject heading terms “aortic aneurysms”, “radiation”, and “humans” over a search period of 10 years. Studies with full text available in English and reporting radiation data independently from the imaging equipment type were included. Experimental studies were excluded. Results The lowest dose–area product levels during EVAR and F/BEVAR were identified in hybrid rooms, while the highest were with fixed systems. When adherence to the as low as reasonably achievable principles was stipulated by the authors, dose reports tended to be among the lowest. Several studies, especially of F/BEVAR, report concerning levels of radiation for both patients and staff. Conclusion Modern imaging equipment type, team involvement with radiation management, and the support of recent imaging technologies such as fusion help to reduce the dose delivered during standard and complex EVAR. Investment in modern imaging technology should be considered in every centre providing endovascular management of aortic aneurysms.

International audience; ObjectiveWe evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft–related complications and, consequently, reintervention.MethodsAll consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft–related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft–related reinterventions. All-cause and aneurysm-related deaths were also recorded.ResultsOverall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft–related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft–related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft–related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47).ConclusionsTo the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft–related complications associated.

Drug-eluting stents have demonstrated efficiency in in-stent restenosis (ISR) but induced a risk of late acute thrombosis by delaying strut re-endothelialization. Polydopamine (PDA), a biocompatible polymer inspired from adhesive proteins of mussels, has been reported to promote endothelial cell (EC) proliferation while limiting SMC proliferation in vitro, thus suggesting the pro-healing potential. This study aimed at evaluating in vivo the impact of the pro-healing PDA-coated stent on ISR and on the quality of the strut re-endothelialization in a rat model. PDA-coated stents demonstrated a significant reduction in ISR in vivo compared to bare metal stents (ratio neointima/media = 0.48 (±0.26) versus 0.83 (±0.42), p < 0.001). Western blot analyses identified a trend towards an increased activation of p38 MAPK phosphorylation and its anti-proliferative effects on vascular SMC that could explain the results observed in morphological analyses. This bioinspired and biocompatible polydopamine layer could intrinsically limit ISR. In addition, according to its latent reactivity, PDA offers the possibility to immobilize some relevant drugs on the PDA-functionalized stent to provide potential synergistic effects.

Purpose To evaluate the impact of preemptive inferior mesenteric artery (IMA) embolization on outcomes of endovascular abdominal aortic aneurysm (AAA) repair (EVAR). Materials and Methods From January 2015 to July 2017, all patients undergoing elective EVAR or fenestrated EVAR (F-EVAR) for asymptomatic AAA in a single tertiary hospital were retrospectively included. Three groups of patients were defined: patients with a patent IMA who underwent embolization during EVAR/F-EVAR (group 1), those with a patent IMA who did not undergo embolization during EVAR/F-EVAR (group 2), and those with a chronically occluded IMA (group 3). Preoperative aortic morphology, demographics, and procedural details were recorded. Aneurysmal growth (≥5 mm), reintervention, and overall mortality rates were analyzed using multivariate proportional hazard multivariate modeling. Propensity scores were constructed, and inverse probability weighting was applied to a new set of multivariate analyses to perform a sensitivity analysis. Results A total of 266 patients (male, 95% [n = 249]) with a median age of 70 (65–77) years were included, with F-EVAR procedures comprising 87 (32.7%) of the interventions. There were 52, 142, and 72 patients in groups 1, 2, and 3, respectively. Changes in aneurysmal sac size did not differ between groups, nor did overall survival or reintervention rates at 24 months. IMA embolization was not identified as an independently protective factor for aneurysmal growth during follow-up (relative risk [RR] = 2.82/mm [0.96–8.28], P = .060), whereas accessory renal arteries (RR = 5.07/mm [1.72–14.96], P = .003) and a larger preoperative aneurysmal diameter (RR = 1.09/mm [1.03–1.15], P = .004) were independent risk factors for sac enlargement. Conclusions Preventive embolization of the IMA during EVAR or F-EVAR did not promote aneurysmal sac shrinking or decrease the reintervention rate at 2-year follow-up.

International audience; Current vascular drug-eluting stents based on immuno-proliferative drugs would reduce the rate of in-stent restenosis (ISR) but may be associated with a higher risk of acute stent thrombosis due to non-selective activity. In this paper, we aimed to develop a polydopamine (PDA) coated chromium‑cobalt (CoCr) stent functionalised with EP224283 (Endotis Pharma SA), which combines both a GPIIbIIIa antagonist (tirofiban moiety) and a factor Xa inhibitor (idraparinux moiety) to reduce acute stent thrombosis.PDA-coated chromium‑cobalt (CoCr) samples were first immersed in a polyethylenimine (PEI, pH 8.5) solution to increase amine function density (36.0 ± 0.1 nmol/cm2) on the CoCr surface. In a second step, avidin was grafted onto CoCr-PDA-PEI through the biotin linkage (strategy 1) or directly by coupling reactions (strategy 2). The HABA titration proved the fixation of biotin onto CoCr-PDA-PEI surface with a density of 0.74 nmol/cm2. The fixation of avidin was demonstrated by water contact angle (WCA) and surface plasmon resonance (SPR). SEM micrograph shows the flexibility of the thin layer coated onto the stent after balloon inflation. Independently of the strategy, a qualitative SEM analysis showed a reduction in platelet activation when the molecule EP224283 was immobilised on avidin. In parallel, the measurement of anticoagulant activity (anti-Xa) revealed a higher anti-factor Xa activity (2.24 IU/mL vs. 0.09 IU/mL in control) when EP224283 was immobilised on avidin. Interestingly, after seven days of degradation, the anticoagulant activity was persistent in both strategies and looked more important with the strategy 2 than in strategy 1.Throughout this work, we developed an innovative vascular stent through the immobilisation of EP224283 onto CoCr-PDA-PEI-(avidin) system, which provides a promising solution to reduce ISR and thrombosis after stent implantation.

Background Ultrasound ( US ) guidance provides the unique opportunity to control the puncture zone of the artery during transfemoral transcatheter aortic valve replacement and may decrease major vascular complications ( VC ) and life‐threatening or major bleeding complications. This study aimed to evaluate the clinical impact of US guidance using a propensity score–matched comparison. Methods and Results US guidance was implemented as the default approach for all transfemoral transcatheter aortic valve replacement cases in our institution in June 2013. We defined 3 groups of consecutive patients according to the method of puncture (fluoroscopic/ US guidance) and the use of a transcatheter heart valve. Patients in the US ‐guided second‐generation group (Sapien XT [Edwards Lifesciences, Irvine, CA], Corevalve [Medtronic, Dublin, Ireland]) were successfully 1:1 matched with patients in the fluoroscope‐guided second‐generation group (n=95) with propensity score matching. In a second analysis we described the consecutive patients of the US ‐guided third‐generation group (Evolut‐R [Medtronic], Sapien 3 [Edwards Lifesciences], n=308). All vascular and bleeding complications were reduced in the US ‐guided second‐generation group compared with the fluoroscope‐guided second‐generation group: VC (16.8% versus 6.3%; P =0.023); life‐threatening or major bleeding (22.1% versus 6%; P =0.004); and VC related to vascular access (12.6% versus 4.2%; P =0.052). In the US ‐guided third‐generation group the rates of major VC and life‐threatening or major bleeding were 3.2% (95% CI , 1.6% to 5.9%) and 3.6% (95% CI , 1.8% to 6.3%). In the overall population (n=546), life‐threatening or major bleeding was associated with a 1.7‐fold increased mortality risk ( P =0.02). Conclusions We demonstrated that US guidance effectively reduced VC and bleeding complications for transfemoral transcatheter aortic valve replacement and should be considered the standard puncture method. Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02628509.

Objectives To evaluate the outcomes of the second generation BeGraft balloon expandable covered stent Graft System (Bentley InnoMed, Hechingen, Germany) implanted as bridging stent grafts during fenestrated endovascular aortic repair (FEVAR) of complex aneurysms. Design This was a single centre prospective study including all consecutive patients treated by FEVAR performed with second generation BeGraft stent grafts as bridging stents. Methods Demographics of patients, diameter and length of the bridging stent grafts, technical success, re-interventions, occlusions, post-operative events, and imaging (Cone Beam CT and/or CT scan, and contrast enhanced ultrasound) were prospectively collected in an electronic database. Duplex ultrasound was performed before discharge and at 6 month follow-up. At 1 year, patients were evaluated clinically and by imaging (CT and ultrasound). Results Between November 2015 and September 2016, 39 consecutive patients (one woman) were treated with custom made fenestrated endografts (2–5 fenestrations) for complex aneurysms or type 1 endoleak after EVAR, using a variety of bridging stents including the BeGraft. All 101 BeGraft stent grafts were successfully delivered and deployed. There was no in hospital mortality. Early fenestration patency rate was 99% (96/97); the sole target vessel post-operative occlusion was secondary to a dissection of the renal artery distal to the stent. Complementary stenting was unsuccessful in recovering renal artery patency; bilateral renal stent occlusion was observed in the same patient on a CT scan performed 2 months after the procedure. He required post-operative dialysis. No additional renal impairment was observed. During follow-up (median 13 months [11–15]), all fenestrations stented with BeGraft stent grafts remained patent (95/97, 98%). One type 1b endoleak was detected and treated (2.6%). Conclusions BeGraft stent grafts used as bridging stents during FEVAR are associated with favourable outcomes at 1 year follow-up. Long-term follow-up is required to confirm these promising results.

Les endofuites de type 2 apres exclusion endovasculaire aortique peuvent s’associer a une progression de la taille du sac anevrismal. Cette situation, bien que peu frequente, peut presenter des difficultes diagnostiques en ce qui concerne la comprehension precise du mecanisme de la fuite, mais aussi concernant les modalites de prise en charge. L’interet de l’embolisation preventive de l’artere mesenterique inferieure presente des resultats discordants ; sans exposer le patient a une morbidite plus importante, le benefice ne serait pas evident en ce qui concerne le risque de croissance du sac. Il semblerait que des facteurs secondaires de l’anatomie, tels que la presence d’arteres renales accessoires ou d’arteres lombaires, puissent interferer dans les resultats de cette strategie. Nous presentons ici une revue de litterature sur le sujet, ainsi que notre attitude dans notre centre.

Purpose: To report emergent transcatheter aortic valve implantation (TAVI) to treat acute severe aortic regurgitation caused by valve cusp dysfunction following proximal migration of an endograft implanted in the ascending aorta during endovascular arch repair. Case Report: A 65-year-old man had been previously treated with thoracic and fenestrated endografts in a 2-stage procedure for a chronic type B dissection. At 2-year follow-up, aneurysmal evolution of the distal arch led to development of a proximal type Ia endoleak. The patient was deemed unfit for open repair because of severe nonrevascularizable coronary artery disease. A custom-made endograft was designed consisting of a double inner branch arch endograft with a proximal component to reline the ascending aorta to avoid iatrogenic type A dissection. The first component was successfully deployed. However, this device migrated toward the aortic valve when the delivery system of the branch device was advanced through the aortic valve. Aortography and transesophageal echography showed acute aortic regurgitation due to obstruction of the left coronary valve cusp. An emergency bailout TAVI procedure was performed to successfully treat the aortic regurgitation. Conclusion: TAVI can be used as a bailout procedure for acute aortic valve dysfunction during endovascular arch or ascending aorta repair.

To report early experience with a new endovascular graft developed for aortic arch aneurysm repair in patients unfit for open surgery.Three consecutive men (62, 74, and 69 years old) at high risk for open repair were treated for postdissection aortic arch aneurysms using a custom-made 3 inner branched endovascular graft. The 2 proximal branches are antegrade and perfuse the innominate artery and the left common carotid artery; the third branch is retrograde and perfuses the left subclavian artery. The latter is preloaded with a catheter and wire to aid cannulation. Technical success was achieved in each case. The mean procedure time, fluoroscopy duration, and contrast volume were 180 minutes, 35 minutes, and 145 mL, respectively. The perioperative period was uneventful. All branches were patent on 6-month computed tomography and duplex ultrasound imaging.This new patient-specific device allows total endovascular revascularization of the supra-aortic trunks during arch repair. These encouraging results support its more widespread use.

Background The aim of this study is to evaluate radiation exposure, endovascular theatre equipment, and practices in France during iliac angioplasty. Methods A prospective observational study was performed among vascular surgeons who attended a half day of radiation safety training in 2012 and 2015 and had to collect data on 3 patients undergoing iliac procedure. In 2012, 330 surgeons performed 899 procedures, compared with 114 surgeons and 338 procedures in 2015. Due to exclusions, 653 and 306 procedures were analyzed in 2012 and 2015, respectively. Endovascular environment, practices, anatomical characteristics, and radiation parameters were collected, analyzed, and compared generally and between the 2 groups. Results Endovascular theatre equipment significantly improved over the 3 years: mobile flat-panel detector (1.1% vs. 5.9%), hybrid rooms (1.5% vs. 14.7%), and dedicated radiology tables (37.2% vs. 51.2%). Lesion’s classification (Trans-Atlantic Society Consensus) was similar between groups but procedure complexity increased overtime: more than one stent implanted (32.3% vs. 41%, P

International audience; OBJECTIVE:To assess short- and long-term movement of renal arteries after fenestrated endovascular aortic repair (FEVAR).METHODS:Consecutive patients who underwent FEVAR at one institution with a custom-made device designed with fenestrations for the superior mesenteric (SMA) and renal arteries, a millimetric computed tomography angiography (CTA), and a minimum of 2 years' follow-up were included. Angulation between renal artery trunk and aorta, clock position of the origin of the renal arteries, distance between renal arteries and SMA, and target vessel occlusion were retrospectively collected and compared between the pre-operative, post-operative (12 months) CTA.RESULTS:From October 2004 to January 2014, 100 patients met the inclusion criteria and 86% of imaging was available for accurate analysis. Median follow-up was 27.3 months (22.7-50.1). There were no renal occlusions. A significant change was found in the value of renal trunk angulation of both renal arteries on post-operative compared with pre-operative CTA (17° difference upward [7.5-29], p < .001), but no significant change thereafter (p = .5). Regarding renal clock positions (7.5° of change equivalent to 15 min of renal ostial movement): significant anterior change was found between post-operative and pre-operative CTA (15 min [0-30], p = .03 on the left and 15 min [15-30], p < .001 on the right), without significant change thereafter (15 min [0-30], p = .18 on the left and 15 min [0-15] on the right, p = .28). No changes were noted on the distance between renal and SMA ostia (difference of 1.65 mm [1-2.5], p = .63).CONCLUSION:The renal arteries demonstrate tolerance to permanent changes in angulation after FEVAR of approximately 17° upward trunk movement and of 15-30 min ostial movement without adverse consequences on patency after a median of more than 2 years' follow-up. The distance between the target vessels remained stable over time. These results may suggest accommodation to sizing errors and thus a compliance with off the shelf devices in favourable anatomies.

Background The development of a postdissection aortic arch aneurysm after open ascending aortic replacement for type A dissection places the patient at increased risk for an open operation due to the need for redo sternotomy and total arch replacement. We conducted a computed tomography–based feasibility study to assess what proportion of these patients would be anatomically suitable for branched endograft repair of an arch aneurysm. We also aimed to identify ways to tailor the index operation to increase suitability for future endovascular repair. Methods Our study was conducted at the Aortic Centre, Lille University Hospital, Lille, France. Postoperative images were assessed for patients after open replacement of the ascending aorta for acute type A dissection in this center between 2009 and 2015 to determine suitability for use of an aortic arch inner-branched device. Results The assessment found 52 of 73 patients (71.2%) were anatomically suitable for treatment with the aortic arch inner-branched device. The only cause for absolute exclusion from suitability was the absence of a proximal landing zone in the ascending aorta. Reasons for this were the ascending aortic graft being too short (71.4%), the presence of a major kink in the graft (23.8%), and the graft diameter being too large (4.8%). Conclusions Approximately 70% of patients with arch aneurysm formation after open ascending aortic replacement for type A dissection are anatomically suitable for treatment with the aortic arch inner-branched device. In the future, surgeons will be able to fashion the prosthetic graft at the time of the index operation to ensure it fulfills criteria for an adequate proximal landing zone.

Background Major vascular (VAC) and life-threatening or major bleeding (LT/MB) complications still represent one of the most frequent adverse outcomes of percutaneous transfemoral TAVR (TF-TAVR) and are associated with an increased risk of mortality. Ultrasound guidance technique allows to puncture in the non-calcified central and horizontal segment of common femoral artery. However the clinical impact of ultrasound (US)-guidance has never been studied in TF-TAVR in comparison of standard fluoroscopic guidance and could explain the lack of adoption of US guidance. We sought first to evaluate in our study the impact of US-guidance on the vascular and bleeding complications. Methods US-guidance for vascular access was implemented as the default approach in our institution in June 2013 for all TF-TAVR and was applied by all operators after a short training course. Thus, we defined three period and groups of consecutive patients according to the method of percutaneous puncture (fluoroscopic or US-guidance) and the generation of THV (2nd or 3rd gen.). US-guided-2nd gen. group: TF-TAVR with 2nd generation THV and performed via US-guidance. This group refers to the period patients from June 2013 to November 2014 (n=119). Fluo-guided-2nd gen. group: The last TF-TAVR with 2nd gen. THV and performed via fluoroscopic guidance (n=119). US-guided-3rd gen. group: Patients implanted with 3rd gen. THV (SAPIEN 3, Evolut R) from November 2014 to December 2018 while US-guidance was systematic for all TF-TAVR (n=308). Patients performed with US-guidance were 1:1 successfully matched with 95 patients performed with fluoroscopic guidance (fluo-guided group) with propensity-score (10 variables). We separately analyzed the consecutive patients of the US-guided-3rd gen. group. Results After propensity-matching, resulting in similar baseline characteristics, all the vascular and bleeding complications were reduced in the US-guided-2nd gen. group compared to Fluo-guided-2nd gen. group with respectively: VAC (6.3% vs 16.8%; OR=0.31; 95% CI: 0.12–0.85; p=0.023); LT/MB (22.1% vs 6.3%; OR=0.24, CI: 0.09–0.63; p=0.004); and VAC related to vascular access (12.6 vs 4.2%; OR=0.31; CI: 0.10–1.01; p=0.052). We also observed a reduction of the mean fluoroscopic time (1753±620 min vs 1228±405 min; p In the US-guided-3rd gen. group (n=308), the US-guided puncture achieved a rate of VAC of 3.2% (CI: 1.6–5.9) and of LT/MB of 3.6% (CI: 1.8–6.3). In the overall population (n=546), we observed that LT/MB (p=0.02) was associated with a 1.7-fold increase of mortality risk. Conclusion The present study is the first and the largest to evaluate the impact of US-guidance in TF-TAVR. We demonstrated that US-guided cannulation is able to reduce the risk of vascular and bleeding complications. These data endorses US-guidance as the standard method of puncture for TAVR.

Connective tissue disease (CTD) represents a group of genetic conditions characterized by disruptive matrix remodeling. When this process involves aortic and vascular wall, patients with CTD have a high risk of developing arterial aneurysms, dissections and ruptures. Open surgical repair is still the gold standard therapy for patients with CTD with reasonable morbidity and mortality risk. The surgical treatment of CTD often requires multiple operations. In the endovascular era, fenestrated and branched stent grafts may play a role in reducing the complications of multiple open operations. Although the long-term results of endovascular treatment in the setting of CTD are unknown, it is generally accepted that endovascular treatment is restricted to selected patients with high surgical risk. In an emergency setting, endovascular intervention can serve as a lifesaving bridge to elective open aortic repair. Aortic centers performing a large volume of complex open and endovascular aortic repairs have started to combine these two techniques in a staged fashion. The goal is to reduce the morbidity and mortality associated with extensive aortic repairs in CTD patients. For this reason, recommend endovascular therapy when a "graft-to-graft" approach is possible. In this scenario, the surgeon who performs the open repair must take into consideration future interventions. Surgical repair in any aortic segment should allow creation of proximal and distal landing zones over 4 cm to secure the sealing of a future stent graft. Connective tissue disease should be treated with a multidisciplinary approach, in high volume centers. Endovascular treatment represents a potential option in patients at high risk for open repair. Staged hybrid procedures have emerged as a way to reduce spinal cord ischemia and avoid multiple open surgeries. The aim of this article is to discuss the management of aortic diseases in CTD, focusing on to the role of standard open surgery and emerging endovascular treatment, and to give an overview of the few series published regarding this topic with a small number of patients.

The objective of this study was to evaluate outcomes after fenestrated and branched endovascular aneurysm repair (F-BEVAR) performed in high-risk patients to treat pararenal (PR) aneurysms and thoracoabdominal aortic aneurysms (TAAAs) and to identify those patients likely to benefit from this treatment.A prospective single-center review of patients treated electively for PR aneurysm and TAAA using F-BEVAR between 2004 and 2016 was performed. Survival was estimated using the Kaplan-Meier method. Risk factors associated with 30-day morbidity and mortality during follow-up were determined using multivariate statistical techniques and a Cox regression model including all variables that were significant on univariate analysis (P .05).There were 468 patients (median age, 71.6 years) identified, with American Society of Anesthesiologists score ≥3 in 94.7%. There were 221 (47.2%) type I to type III TAAAs and 247 (52.8%) type IV and type V TAAAs and PR aneurysms, with a median diameter of 58 mm. Technical success for target vessel stenting was 99.1% (1493/1506). The 30-day mortality rate was 4.9% (23 patients). The spinal cord ischemia rate was 3.8% (18 patients). Twenty patients (4.3%) required postoperative dialysis and four patients (0.8%) long-term dialysis after discharge. Median follow-up was 29 months. Survival at 1 year, 3 years, and 5 years was 86.7% (95% confidence interval [CI], 83.1-89.6), 73.3% (95% CI, 68.3-77.6), and 59.6% (95% CI, 53.4-65.2), respectively. Freedom from any target vessel occlusion and freedom from secondary procedures were 96.2% (95% CI, 93.8-97.7) and 88.2% (95% CI, 84.8-90.9) at 1 year and 90.0% (95% CI, 84.5-91.9) and 70.2% (95% CI, 63.9-75.6) at 5 years, respectively. In multivariate analysis, early mortality was associated with procedure time (hazard ratio [HR], 1.007 per minute; 95% CI, 1.003-1.010; P .001), TAAA preoperative diameter (HR, 1.053 per millimeter; 95% CI, 1.020-1.087; P = .001), and chronic kidney disease (HR, 3.139; 95% CI, 1.369-7.196; P = .007). Mortality during the first 24 months of follow-up was associated with Crawford types I to III (HR, 1.526; 95% CI, 1.061-2.196; P = .023) compared with infradiaphragmatic repairs, chronic kidney disease (HR, 1.874; 95% CI, 1.294-2.712; P .001), and TAAA preoperative diameter (HR, 1.027 per millimeter; 95% CI, 1.010-1.044; P = .002). In addition to these risk factors, mortality after 24 months of follow-up was also associated with age at repair (HR, 1.055 per year; 95% CI, 1.021-1.090; P = .001).F-BEVAR performed in high-risk patients is associated with favorable outcomes. Judicious selection of patients should take into consideration the reported risk factors associated with early and late mortality.

Arterial revascularization techniques. Patients with critical limb ischemia are at risk of major amputation. The latest developments in endovascular technology and techniques provide a less invasive and valuable alternative to conventional open surgery. Major improvements in angioplasty balloons and stents have been achieved in recent years. New devices such as atherectomy catheters and dedicated guidewires have been developed and are available to treat chronic-total-occlusions (CTO) of the peripheral arteries. In parallel, new techniques have been developed to achieve more complex endovascular revascularisation; these include intraluminal recanalisation, and the SAFARI technique, which is the combination of antero and retrograde approaches to treat the femoral, popliteal and pedal arteries. Currently, only limited data are available to support these last advances in the literature. The continued uptake of these new techniques in the future will be associated with shorter hospital stay and faster recovery.Techniques de revascularisation des artériopathies. Dans le cadre de l’ischémie critique chronique, la menace pour le patient de perdre le membre hypoperfusé engage le chirurgien à proposer un geste de revascularisation rapide. Celui-ci peut être réalisé par chirurgie ouverte, ou par des techniques de revascularisation endovasculaires moins invasives. L’engouement récent pour les traitements endovasculaires en pathologie artérielle périphérique est contemporain du développement d’outils spécifiquement dédiés à ce type de procédures. Des améliorations sur les ballons et les stents ont été proposées ; de nouveaux dispositifs, comme les cathéters d’athérectomie ont été développés. Des améliorations sur les introducteurs, guides et cathéters ont été effectuées pour répondre à l’évolution des stratégies de revascularisation : des techniques comme SAFARI, avec ponction rétrograde des artères jambières pour le traitement de l’artère fémorale superficielle ou des artères jambières, sont désormais courantes. Il est néanmoins difficile d’évaluer les résultats de la modification de nos pratiques grâce à l’utilisation de ces nouvelles techniques. La grande hétérogénéité de patients traités et de morphologies des lésions artérielles rend complexe l’interprétation des résultats publiés.

L’aumento delle procedure endovascolari in chirurgia vascolare ha portato alla nascita di nuovi rischi per l’operatore e per il paziente, legati all’esposizione ai raggi X. I rischi sono di due tipi: stocastici, o aleatori e senza soglia, legati a un’alterazione genetica e che provocano un rischio a lungo termine di cancro e di malformazioni, e deterministici, o dose-dipendenti, che provocano soprattutto danni alla cute a breve o a medio termine. Ora e essenziale e obbligatorio avere una formazione in radioprotezione al fine di valutare il rapporto rischio-beneficio (giustificazione) dell’esposizione ai raggi X, per minimizzare il piu possibile le dosi somministrate (ottimizzazione) e per l’autovalutazione (confronto dei parametri di esposizione con le dosi riportate in letteratura). L’ottimizzazione della procedure comporta l’applicazione quotidiana dei principi as low as reasonably achievable (ALARA) o “piu bassa possibile” riguardo alla dose somministrata. Per questo e necessario eliminare tutte le immagini inutili quando le informazioni siano gia disponibili. La protezione dell’operatore e dell’equipe impone di lavorare il piu lontano possibile dalla fonte primaria e dalla radiazione diffusa dal paziente e l’uso di protezioni piombate (grembiuli piombati, scudi a soffitto e gonne da tavolo). La nuova apparecchiatura di imaging (sale fisse o ibride) consente l’uso di applicazioni avanzate di imaging non disponibili sugli amplificatori di brillanza mobili, ma, in cambio, puo esporre a dosi di radiazioni piu grandi. Il suo uso richiede imperativamente un ambiente ottimale in combinazione con un fisico medico, per lavorare non con una “bella immagine”, ma con l’esposizione piu bassa per il corretto svolgimento del procedimento.

Purpose: To describe a case of percutaneous retrograde left renal artery cannulation and restenting for severe distortion of a bridging stent diagnosed at the time of fenestrated endovascular aneurysm repair (FEVAR). Case Report: A 79-year-old man underwent 4-vessel FEVAR, during which completion angiography showed a good postoperative result, but cone beam computed tomography (CBCT) demonstrated severe distortion of the proximal part of the left renal stent. An antegrade or hybrid approach to recannulate the vessel was not possible due to the stent architecture and patient comorbidities. Contrast-enhanced CBCT was used to define the needle trajectory for a percutaneous translumbar approach. Fusion imaging software registered the planned needle track to the live fluoroscopy image. Respiratory motion compensation was used. Retrograde cannulation of the left renal artery was achieved; via a through-and-through wire with the left femoral artery, the left renal artery stent was relined using a covered stent. No deterioration of renal function was observed following the procedure. Contrast-enhanced duplex ultrasound demonstrated good flow in all target vessels without endoleak. Conclusion: Translumbar puncture and retrograde catheterization of a severely distorted left renal artery stent is possible during FEVAR using advanced imaging applications and can prevent target vessel loss.

Context Endovascular procedures, requiring X-ray guidance, are commonly performed in vascular surgery. X-ray exposure is associated with biological risks for both patients and physicians. Medical X-ray use must follow “as low as reasonably achievable” (ALARA) principles, which aim at using the lowest radiation exposure to achieve a procedure safely. This is underlined by European and international recommendations that also suggest that adequate theoretical and practical training is mandatory during the initial education of physicians. However, the content of this education and professional practices vary widely from one country to another. Objective This review aims to summarize the basic knowledge required for vascular surgeons on X-ray physics and image production. Methods A panel of endovascular therapists (vascular surgeons and radiologists) and physicists dedicated to X-rays was gathered. International recommendations were summarized. A literature review was performed via MEDLINE to identify studies reporting dosages of common endovascular procedures. Results The different mechanisms inducing biological risks, and the associated potential effects on health, are described. Details on dose metrics are provided and a common nomenclature to measure, estimate, and report dose is proposed in order to perform accurate comparisons between publications and practices. Key points of the European and international legislation regarding medical X-ray use are summarized, and radiation protection basics for patients and staff, are detailed. Finally, a literature review is proposed for physicians to evaluate their practice. Conclusions Today's trainees will be highly exposed to radiation throughout their practice. It is thus compulsory that they undergo dedicated radiation education during their initial training, and regular refresher sessions later. In daily practice, focus on dose reduction and monitoring of patient and staff exposure are mandatory.

Objectives This study evaluated a new strategy to assess technical success after standard and complex endovascular aortic repair (EVAR), combining completion contrast enhanced cone beam computed tomography (ceCBCT) and post-operative contrast enhanced ultrasound (CEUS). Methods Patients treated with bifurcated or fenestrated and branched endografts in the hybrid room during the study period were included. From December 2012 to July 2013, a completion angiogram (CA) was performed at the end of the procedure, and computed tomography angiography (CTA) before discharge (group 1). From October 2013 to April 2014, a completion ceCBCT was performed, followed by CEUS during the 30 day post-operative period (group 2). The rate of peri-operative events (type I or III endoleaks, kinks, occlusion of target vessels), need for additional procedures or early secondary procedures, total radiation exposure (mSv), and total volume of contrast medium injected were compared. Results Seventy-nine patients were included in group 1 and 54 in group 2. Peri-operative event rates were respectively 8.9% ( n = 7) and 33.3% ( n = 18) ( p = .001). Additional procedures were performed in seven patients (8.9%) in group 1 versus 17 (31.5%) in group 2 ( p = .001). Two early secondary procedures were performed in group 2 (3.7%), and three (3.8%) in group 1 ( p = .978). Median radiation exposure due to CBCT was 7 Gy cm 2 (5.25–8) (36%, 27%, and 9% of the total procedure exposure, respectively for bifurcated, fenestrated, and branched endografts). CEUS did not diagnose endoleaks or any adverse events not diagnosed by ceCBCT. Overall radiation and volume of contrast injected during the patient hospital stay in groups 1 and 2 were 34 (25.8–47.3) and 11 (5–20.5) mSv, and 184 (150–240) and 91 (70–132.8) mL respectively (reduction of 68% and 50%, p Conclusions Completion ceCBCT is achievable in routine practice to assess technical success after EVAR. Strategies to evaluate technical success combining ceCBCT and CEUS can reduce total in hospital radiation exposure and contrast medium volume injection.

We report two endovascular aneurysm repair procedures achieved under image fusion guidance accomplished with noncontrast injected preoperative computed tomography scans. Such use of this advanced imaging application reduces contrast media injection volume (respectively, 27 and 24 mL throughout the patients' hospital course). No changes in creatinine clearance occurred after the procedures. Contrast-enhanced ultrasound imaging confirmed technical success in both cases.

Introduction: The management and outcome of a patient with a type III thoracoabdominal aortic aneurysm (TAAA) are reported. Methods: The patient was scheduled for a two-stage endovascular repair strategy but experienced a contained TAAA rupture a week before the planned second stage fenestrated endovascular repair that had been postponed from 6 weeks to 5 months. Results: Fortunately, the fenestrated device had already been delivered to the hospital; the contained rupture was thus managed endovascularly in this high-risk patient. Conclusion: Staging extensive TAAA repairs to reduce the incidence of spinal cord ischemia is associated with a risk of interval aneurysm rupture. Keywords: Endovascular TAAA repair, Stage procedure, Paraplegia, Rupture

With the advent of endovascular techniques, rapid improvements have been made in intraoperative imaging. This review intends to summarize the latest imaging technologies available and the new leads currently investigated for the future.

The concept of hybrid room was defined as an optimized surgical theater, offering the best compromise between asepsis criteria from standard surgical rooms and high quality imaging equipment from fixed radiological suites. This review aimed at summarizing what vascular surgeons should expect from hybrid rooms in daily practice and in the near future.

To assess the displacement of the aorta and its visceral branch ostia after insertion of a rigid system including a stiff guidewire and endograft delivery system during endovascular aneurysm repair (EVAR).Between January and May 2013, 20 consecutive patients (19 men; mean age 67.2 years, range 61-83) undergoing EVAR (n=13) or fenestrated EVAR (FEVAR, n=7) were prospectively enrolled. Each patient underwent an intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) acquisition after the insertion of the endograft delivery system. Each ceCBCT was loaded on a workstation and manually registered with the preoperative computed tomographic angiogram (CTA) in a way that optimized superposition of the spine from both images. The locations of the superior mesenteric artery (SMA) and of both renal artery ostia were depicted in 3D multiplanar reconstructions by 3 independent operators on the CTA and on the ceCBCT. Motion of the aortic segment at the level of the visceral arteries was estimated by the barycenter of the origin of the SMA and both renal arteries.The ostium displacement between the CTA and ceCBCT images was 6.7 mm (range 2.2-13.5) for the SMA; 6.2 mm (2.5-13.5) and 6.4 mm (1.9-14.5) for the right and the left renal arteries, respectively; and 5.5 mm (2.3-11.4) for the aortic segment. The displacement was mostly posterosuperior and to the left (65%). The radiation dose and contrast volume required to perform the ceCBCT were 30% and 41%, respectively, of the amounts used in the EVAR procedures.This study demonstrates a significant displacement of the main aortic branches after rigid material insertion. Image fusion applications aimed at providing intraoperative guidance must allow an easy and rapid repositioning of the overlay during the procedure to match the deformation of the aortic anatomy during the procedure.

Background: The endovascular treatment of thoraco abdominal aortic aneurysms (TAAA) is a minimally invasive solution. However, patient selection remains a major problem. We have analysed our experience to identify the risk factors for post-operative morbidity and mortality and to construct a scoring system to identify those patients likely to benefit from this treatment.Methods : We have analysed a consecutive cohort of patients treated electively for TAAA using endovascular techniques between 2006 and October 2012. All data were collected prospectively. The risk factors associated with spinal cord ischemia (SCI), the need for post-operative dialysis and 30 day mortality were determined using multivariate statistical techniques and a logistic regression model including all variables that were significant on univariate analysis (p < 0.05). A predictive score was calculated using a Received Operating Characteristic (ROC) curve, defining best specificity and sensibility.Results : We analysed the data...

Background Prophylactic open surgery is the standard practice in patients with connective tissue and thoracoabdominal aortic aneurysm (TAAA) and aortic arch disease. Branched and fenestrated devices offer a less invasive alternative but there are concerns regarding the durability of the repair and the effect of the stent graft on the fragile aortic wall. The aim of this study is to evaluate mid-term outcomes of fenestrated and/or branched endografting in patients with connective tissue disease. Methods All patients with connective tissue disease who underwent TAAA or arch aneurysm repair using a fenestrated and/or branched endograft in a single, high-volume center between 2004 and 2015 were included. Ruptured aneurysms and acute aortic dissections were excluded from this study, but not chronic aortic dissections. Results In total, 427 (403 pararenal and TAAAs, and 24 arch aneurysms) endovascular interventions were performed during the study period. Of these, 17 patients (4%) (16 TAAAs, 1 arch) had connective tissue disease. All patients were classified as unfit for open repair. The mean age was 51 ± 8 years. Thirteen patients with TAAA were treated with a fenestrated, 1 with a branched, and 2 with a combined fenestrated/branch device. A double inner branch device was used to treat the arch aneurysm. The technical success rate was 100% with no incidence of early mortality, spinal cord ischemia, stroke, or further dissection. Postoperative deterioration in renal function was seen in 3 patients (18.8%) and no hemodialysis was required. The mean follow-up was 3.4 years (0.3–7.4). Aneurysm sac shrinkage was seen in 35% of patients (6/17) and the sac diameter remained stable in 65% of patients (11/17). No sac or sealing zone enlargement was observed in any of the patients and there were no conversions to open repair. Reintervention was required in 1 patient at 2 years for bilateral renal artery occlusion (successful fibrinolysis). One type II endoleak (lumbar) is under surveillance and 1 type III (left renal stent) sealed spontaneously. One patient died at 2 years after the procedure from nonaortic causes (endocarditis). Conclusions The favorable mid-term outcomes in this series that demonstrate fenestrated and/or branched endografting should be considered in patients with connective tissue and TAAA and aortic arch disease, which are considered unfit for open surgery. All patients require close lifetime surveillance at a center specializing in aortic surgery, with sufficient experience in both open and endovascular aortic surgery, so that if endovascular treatment failure occurs it can be recognized early and further treatment offered.

Introduction Major vascular (VAC) and life-threatening or major bleeding (LT/MB) complications represent the most frequent adverse outcomes of percutaneous transfemoral TAVR (TF-TAVR). Point-of-Care Ultrasound (POCUS) guidance allows the opportunity to obtain in real-time valuable anatomic informations to puncture in the ideal non-calcified central and horizontal segment of femoral artery. We sought to evaluate in our study the impact of implementation of POCUS-guidance on the vascular and bleeding complications. Method POCUS-guidance for vascular access was implemented as the default approach in our institution in 06/2013 for all TF-TAVR and was applied by all operators after a short training course. Thus, we defined three period and groups of consecutive patients according to the method of puncture (fluoroscopic or POCUS-guidance) and the generation of THV (2nd or 3rd gen.). TF-TAVR with POCUS-guidance and 2nd generation THV and from 06/2013 to 11/2014 (POCUS-guided-2nd gen. group; n = 119) were 1:1 successfully matched with 95 patients of the Fluo-guided-2nd gen. with propensity-score (10 variables) (The last TF-TAVR with guidance with 2nd gen. THV; n = 119). TF-TAVR implanted with 3rd gen. THV from 11/2014 to 12/2018 (POCUS-guided-3rd gen. group; n = 308) were analyzed separately. Results After propensity-matching, all the vascular and bleeding complications were reduced in the POCUS-guided-2nd gen. group compared to Fluo-guided-2nd gen. group with respectively: VAC (6,3% vs. 16,8%; OR = 0,31; 95% CI = 0,12–0,85; P = 0,023); LT/MB (22,1% vs. 6,3%; OR = 0.24, CI = 0.09-0.63; P = 0,004); and VAC related to vascular access (12,6 vs. 4,2%; OR = 0,31; CI = 0.10–1.01; P = 0,052). Conclusion This is the first and the largest study to demonstrate that POCUS-guided cannulation of the femoral artery is associated with a reduction of vascular and bleeding complication and support POCUS-guidance as the gold-standard for TF-TAVR.

Aim to evaluate the outcomes of EVAR performed with a new generation of bifurcated endografts and limbs. Methods prospectively collected data from fifty consecutive patients with abdominal aortic aneurysms (AAA) treated at our institution with a Low Profile Zenith ® bifurcated body/Zenith ® Spiral-Z legs combo were analysed. AngioCT scans and Ultrasound exams were performed prior to discharge. Ultrasound examination was repeated 6 months after the procedure to assess endograft patency and to depict endoleaks Results Median age was 70.6 years [50–88] and median ASA score was 3 [2–4]. Median aortic diameter was 56 mm [49–81]. Of the 100 external iliac access vessels, 14 had a diameter of 6 mm or lower. All endografts were successfully implanted. Post-operative Ultrasound examination and angioCT scan depicted both 1 type Ia, and 10 and 19 type 2 endoleaks respectively. An asymptomatic thrombosis of the left external iliac artery distal to the endograft limb was also depicted. 30-day mortality rate was 0%. Two patients died respectively three and four months after EVAR. Both deaths were not aneurysm related. All patients underwent an ultrasound exam 6–12 months after EVAR. All endografts main bodies and limbs were patent. Five endoleaks were depicted, all were type II endoleaks (the early type Ia endoleak had sealed spontaneously; it was confirmed by an angioCT scan). One patient presented a significant stenosis of the left iliac limb at the level of a narrow and calcified aortic bifurcation. It was successfully treated by bilateral iliac angioplasty and kissing balloon stenting. Conclusions EVAR performed with the Zenith LP main body in combination with Spiral-Z Iliac Legs is safe and effective. No limb occlusions were diagnosed at the 6 month follow up even in challenging iliac anatomies usually considered as contra indications for EVAR. Our first results are most satisfying and calling to be completed by a longer follow up.

Objectives: This study aims to assess patient outcomes and aortic remodelling following coverage of the proximal entry tear with an endograft in complicated acute type B aortic dissections (caTBADs). Material and methods: All patients with caTBAD treated with a thoracic endograft in three high-volume vascular centres were retrospectively studied. Inclusion criteria were branch-vessel malperfusion, impending or overt aortic rupture, maximal aortic diameter >= 40 mm and persistent pain or uncontrolled hypertension despite maximum pharmacological treatment. Postoperative aortic remodelling was evaluated using computed tomography angiography (CTA). on a three-dimensional (3D) imaging workstation. Results: A total of 52 patients (71% male, median age 65 years) were included in the study. Median inclusion criteria per patient were 2 (range 1-4). Branch-vessel malperfusion was diagnosed in 42% and impending aortic rupture in 33% of 52 patients. Median follow-up was 25 months (range 2-109 months). The 30-day mortality rate was 9.6% (5/52); patient survival according to the Kaplan-Meier method was 90.4% at 12 months and 87.6% at 24 months. Secondary interventions were performed in seven patients a median of 3 days after the initial procedure (range 2-865). Imaging follow-up at 12 months was performed in 36 patients (69%): 75% presented stable or shrinking (>5 mm) maximal aortic diameters and 86% had a completely thrombosed false lumen (vs. 5% before initial procedure) at thoracic level. Conclusion: Endograft treatment of complicated caTBAD is associated with favourable early outcomes and possibly promotes aortic remodelling in the majority of patients. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. (Less)

Conventional surgical repair of aortic arch aneurysms using cardiopulmonary bypass and hypothermic circulatory arrest remains the gold standard, however it is associated with a substantial mortality and morbidity rate, especially in the elderly. Hybrid techniques avoid aortic cross-clamping and circulatory arrest, but are of limited use and are only applicable to selected patients. The development of new devices to treat aortic arch aneurysms endovascularly has the potential to offer a treatment modality to patients unfit for an open repair. We present the challenges specific to endovascular arch repair based on our experience and the literature available from the first experience in 1999 to the third generation graft currently commonly used. Following an initial learning curve associated with the use of the third generation arch branch device, along with careful patient selection and operator experience, early results are promising. Technical success was achieved in all cases, there was no early mortality and strokes were noted in 11%. As with branched and fenestrated technology for thoracoabdominal aneurysm repair, the use of total endovascular repair for arch pathology will require an evolution in endovascular practice and device design. However, at present, the early use of the latest generation device offers a novel approach to patients who previously had no surgical options.