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This article presents the case of a 70-year-old obese patient with severe bilateral leg pain due to deep vein thrombosis. After unsuccessful venous recanalization, computed tomography angiography revealed an abdominal aortic aneurysm 15 cm in diameter with total compression of the inferior vena cava. For venous decompression as well as rupture prophylaxis, conventional open surgical repair was performed., (© 2022. The Author(s).)

Background: Recently used endografts for envascular aneurysm repair (EVAR) exclude the pathology by fixation at both the proximal and distal landing zone. Due to endoleaks and migration EVAR is associated with a relevant rate of secondary interventions. The Nellix® system (Endologix Inc., CA, USA) was developed to seal the complete aneurysm using a polymer filling, therefore stabilising endograft-position and reducing the rate of endoleaks and reinterventions. The present contribution introduces the method, describes the technique of implantation and presents the first clinical results. Material und Methods: The Nellix system consists of two balloon-expandable stent grafts made of a cobalt-chromium composition, surrounded with ePTFE and the so-called endobags. During the implantation each endobag is filled with a non-biodegradable polymer, sealing the aneurysm lumina including the proximal and distal landing zone. Hence, lumbar arteries will be sealed to reduce the probability of a type II endoleak., Results: Longterm durability as well as the structural integrity of the Nellix system has been proven over 4 years in sheep experiments. The technical success in a multicentre, prospective registry was 94% without the appearance of severe adverse events (migration, occlusion, secondary endoleak)., Conclusion: EVAS is a new and different concept of endovascular AAA repair. Recent clinical data of the Nellix system are promising showing a high technical success rate while the need for secondary intervention is low. Further studies in larger cohorts are needed., (Georg Thieme Verlag KG Stuttgart · New York.)

Endovascular repair has revolutionized the treatment of infrarenal aortic aneurysms. However, its application is still limited in patients with challenging access conditions such as small-caliber vessels, iliac tortuosity, excessive calcification or occlusive disease. The underlying manuscript addresses the crucial role of preoperative access vessel evaluation and summarizes recent developments in endograft manufacturing and surgical techniques allowing for coping with hostile access conditions. Furthermore, alternative access routes and complication management are discussed.

The spinal cord is particularly susceptible to ischaemic injury following repair of extensive descending thoracic and thoracoabdominal aortic aneurysms (TAAA). For the past decade, the Mount Sinai group in New York has intensively studied the anatomy of the extensive vascular network surrounding the spinal cord, as well as its dynamic morphology in response to decreased blood pressure and flow. Along with clinical data, experimental findings gave rise to the Collateral Network Concept, by which spinal cord injury in open TAAA repair can be significantly reduced. With the more recent widespread use of endovascular repair, strategies to prevent ischaemic spinal cord damage after extensive segmental artery sacrifice/occlusion are still evolving. The hypothesis that dividing extensive aneurysm repair into two steps may mitigate the impact of diminished blood flow to the collateral network has led to a recently conducted series of staged repair experiments. By exploiting the resources of the collateral network, spinal cord injury could be minimised in staged open, as well as in staged hybrid repair and seems equally adoptable for endovascular procedures. The contribution presented herein provides an overview of clinical and experimental studies on the staged approach. Furthermore, it briefly assesses the anatomic rationale for the collateral network concept., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Open repair of para-anastomotic aneurysms (pAAA) after conventional aortoiliac repair is associated with a high perioperative mortality and morbidity. Endovascular treatment options have evolved over the last decade. The aim of this article is to demonstrate and review these endovascular strategies., Material and Methods: Between 01/2009 and 06/2012, a total of 12 patients received endovascular treatment for proximal (n = 7) or distal (n = 5) pAAA (n = 2 contained rupture). A retrospective analysis of these patients was performed. Median age was 71.5 years (range 55-87 years). The median time interval between primary operation and endovascular repair of the pAAA was 15 years (range 1-31 years) and median follow-up was 1.3 years (range 0 days - 3 years). Endovascular exclusion of the pAAA was achieved by implantation of an aortouniiliac endograft (n = 6), chimney graft (n = 1), fenestrated endograft (n = 2) and iliac extension (n = 3)., Results: Technical success could be achieved in all patients and in-hospital mortality was 16.8  % (n = 2). No patient required a reintervention but during follow-up one additional patient died due to gastrointestinal bleeding. No primary or secondary type I/III endoleaks were observed., Conclusions: Despite a not negligible mortality rate endovascular treatment of para-anastomotic aneurysms and anastomotic pseudoaneurysms appears to be a safe alternative for conventional open repair.

Technical aspects are crucial for planning and performing successful endovascular repair of abdominal aortic aneurysms (AAA). Planning should be based on high-quality computed tomography angiography scans with a slice thickness of ≤ 1 mm. However, even without a workstation for image postprocessing, important angle estimations can be easily performed. Several devices are available today to treat abdominal aneurysms. In most elective cases all currently available 3rd generation devices perform comparably if minimal requirements are kept in mind. A safe and technically precise implantation requires cooperation with the involved anesthesiologist in order to manage anticoagulation, blood pressure regulation in general and in currently evolving regional anesthesia. Modern endograft implantation involves highly technical resources, for example guide wires or catheters. Beside patient selection, an optimal procedure planning, graft model choice and endovascular skills are mandatory aspects. In the near future, further improvements in device design and deployment mechanism will allow better device alignment, paving the way for an even broader application of endovascular aneurysm repair (EVAR).

In addition to classic aortic dissection and intramural hematoma, acute aortic syndrome also includes penetrating aortic ulcers (PAU). The recent advent of highly detailed axial imaging allows closer assessment of PAU and its pathophysiology. However, there is still ongoing discussion about the natural history of the disease, leading to challenging questions concerning the optimal treatment strategy, particularly in asymptomatic patients. In this review, current indications for treatment, with an emphasis on PAU repair in the endovascular era, are discussed.