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BACKGROUND: To report technical and clinical 30-day results following treatment with the Zenith Alpha™ abdominal stent graft from the ZEnith alPHa for aneurYsm Repair Registry (ZEPHYR).METHODS: Multicenter, nonrandomized, single arm, core laboratory-controlled, prospective registry collecting data on the Zenith Alpha Abdominal Endovascular Graft being used in subjects with abdominal aortic aneurysms (AAA) from sites in Germany, Belgium, and The Netherlands between December 2016 and December 2019. Inclusion criteria were non-ruptured AAAs with a maximum diameter ≥50 mm or enlargement >5 mm over 6 months with an AAA neck length ≥10 mm (site reported). Primary outcome measure was treatment success at 30 days. Treatment success was defined as a combined endpoint consisting of technical and clinical success. Technical success was defined as successful stent graft delivery and deployment as well as successful removal of the delivery system. Clinical success at 30 days was defined as freedom from type I and III endoleak, aneurysm rupture, conversion to open surgery and stent graft occlusion.RESULTS: Three hundred forty-seven subjects were included from 14 sites with a median age of 73.0 years (IQR 68.0-79.0). Thirty-four patients were female (9.8%). The median AAA diameter was 58.3 mm (IQR 55.0-63.5). The median proximal neck diameter was 23.6 mm (IQR 22.0-25.2) with a median proximal neck length of 24.4 mm (IQR 15.0-34.8) and a median infrarenal neck angulation of 24.5° (IQR 15.0-35.0). The right and left common iliac diameter were 16.1 mm (IQR 14.1-19.4) and 16.2 mm (IQR 14.1-19.1), respectively. The treatment success rate at 30 days was 94.8% (N = 329). Technical success was achieved in 333 patients (96.0%). The clinical success rate at 30 days was 98.8% (N = 343). Three patients had limb occlusions at 30 day follow up (0.9%). One patient had a type Ib endoleak (0.3%). Seventy percent of vascular access approaches were percutaneous. The reintervention rate was 1.7% (N = 6) within 30 days. Indications for reinterventions were a false aneurysm at puncture site (N = 1), limb complications (N = 2), stentgraft-associated renal artery occlusions (N = 2), and an external iliac artery thrombosis (N = 1).CONCLUSIONS: Endovascular aneurysm repair using the Zenith Alpha Abdominal Endovascular Graft is effective in the short term. Long term results will be reported in the future.

Objective To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR. Methods Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage. Results 18 male patients (76 years old; range 69 – 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 – 69 mm). Median interval between the procedures was 53 (29 – 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 – 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 – 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%. Conclusion F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.

Purpose: Fenestrated endovascular aneurysm repair (FEVAR) is a well-established endovascular treatment option for pararenal abdominal aortic aneurysms in which balloon-expandable covered stents (BECS) are used to bridge the fenestration to the target vessels. This study presents midterm clinical outcomes and patency rates of the Advanta V12 BECS used as a bridging stent. Methods: All patients treated with FEVAR with at least 1 Advanta V12 BECS were included from 2 large-volume vascular centers between January 2012 and December 2015. Primary endpoints were freedom from all-cause reintervention, and freedom from BECS-associated complications and reintervention. BECS-associated complications included significant stenosis, occlusion, type 3 endoleak, or stent fracture. Secondary endpoints included all-cause mortality in-hospital and during follow-up. Results: This retrospective study included 194 FEVAR patients with a mean age of 72.2±8.0 years. A total of 457 visceral arteries were stented with an Advanta V12 BECS. Median (interquartile range) follow-up time was 24.6 (1.6, 49.9) months. The FEVAR procedure was technically successful in 93% of the patients. Five patients (3%) died in-hospital. Patient survival was 77% (95% CI 69% to 84%) at 3 years. Freedom from all-cause reintervention was 70% (95% CI 61% to 78%) at 3 years, and 33% of all-cause reinterventions were BECS associated. Complications were seen in 24 of 457 Advanta V12 BECSs: type 3 endoleak in 8 BECSs, significant stenosis in 4 BECSs, occlusion in 6 BECSs, and stent fractures in 3 BECSs. A combination of complications occurred in 3 BECSs: type 3 endoleak and stenosis, stent fracture and stenosis, and stent fracture and occlusion. The freedom from BECS-associated complications for Advanta V12 BECSs was 98% (95% CI 96% to 99%) at 1 year and 92% (95% CI 88% to 95%) at 3 years. The freedom from BECS-associated reinterventions was 98% (95% CI 95% to 100%) at 1 year and 94% (95% CI 91% to 97%) at 3 years. Conclusion: The Advanta V12 BECS used as bridging stent in FEVAR showed low complication and reintervention rates at 3 years. A substantial number of FEVAR patients required a reintervention, but most were not BECS related.

Background Endovascular aortic aneurysm repair (EVAR) has become the treatment of choice for most patients with abdominal aortic aneurysm (AAA). Open aneurysm repair (OAR) is still being used in a number of patients for specific reasons. The aim of the present study was to investigate the reasons and perioperative outcomes of OAR in a high-volume endovascular center. Methods All patients who underwent OAR in a single center institution during the period April 2010 to July 2019 were retrospectively analyzed. Results During the study period, 222 patients underwent OAR. One hundred and forty-one (63.5%) patients underwent elective surgery, and eighty-one (36.5%) patients were treated acutely. The reasons for the decision to perform OAR instead of EVAR were as follows: anatomical in 89 (40.1%) cases, rupture in unstable patient in 57 (25.7%) cases, AAA with concomitant iliac arterial occlusive disease in 44 (19.8%) cases, previous EVAR with complications in 14 (6.3%) cases, large pararenal aneurysm considered risky to wait for a customized fenestrated stent graft in 7 (3.2%) cases, young patient age in 4 (1.8%) cases, the patient's preference in 3 (1.4%) cases, infected/mycotic AAA in 2 (0.9%) cases, and simultaneous OAR with colon cancer resection (n = 1, 0.5%) and renal transplantation (n = 1, n = 0.5). Thirty-day mortality in elective cases was 5% (7/141) and in acute cases 34.6% (28/81). Conclusions This study shows that OAR is still used for selected patients despite improvements in EVAR technology. The most common reason for OAR was an unsuitable anatomy for EVAR. Perioperative mortality of OAR both for acute and elective cases as observed in this study is in line with published outcomes of other centers.

Background Acute occlusion of renal bridging stent grafts after fenestrated/branched endovascular aortic repair (F/B-EVAR) is an acknowledged complication with high morbidity that often results in chronic dialysis dependence. The feasibility and effect of timely or late (≥6 hours of ischemia) renal artery revascularization has not been adequately reported. Methods We performed a retrospective, multicenter study across 11 tertiary institutions of all consecutive patients who had undergone revascularization of renal artery stent graft occlusions after complex EVAR. The end points were technical success, association between ischemia time and renal function salvage, interventional complications, mortality, and mid-term outcomes. Results From 2009 to 2019, 38 patients with 46 target vessels (TVs; eight bilateral occlusions) were treated for renal artery occlusions after complex EVAR (mean age, 63.5 ± 10 years; 63.2% male). Six patients had a solitary kidney (15.8%). Of the 38 patients, 16 (42.1%) had undergone FEVAR and 22 (57.9%) had undergone BEVAR. The technical success rate was 95.7% (44 of 46 TVs). The recanalization technique used was sole aspiration thrombectomy in 5.3%, aspiration thrombectomy and stent graft relining in 52.6%, and sole stent graft relining in 36.8%. The median renal ischemia time was 27.5 hours (range, 4-720 hours; interquartile range, 4-36 hours). Most patients (94.4%) had been treated after ≥6 hours of renal ischemia time, and 55.6% had been treated after 24 hours. In 14 patients (36.8%), renal function had improved after intervention (mean glomerular filtration rate improvement, 14.2 ± 9 mL/min/1.73 m2). However, 24 patients (63.2%) showed no improvement. Improvement of renal function did not correlate with the length of renal ischemia time. Of the 14 patients with bilateral renal artery occlusion or a solitary kidney, 9 experienced partial recovery of renal function and no longer required hemodialysis. In-hospital mortality was 2.6%. The cause of renal stent graft occlusion could not be identified in 50% of the TVs (23 of 46). However, in 19 (41.3%), significant stenosis or a kink of the renal stent graft was found. The median follow-up was 11 months (interquartile range, 0-28 months). The estimated 1-year patient survival and patency rate of the renal stent grafts was 97.4% and 83.8%, respectively. Conclusions Revascularization of occluded renal bridging stent grafts after F/B-EVAR is a safe and feasible technique and can lead to significant improvement of renal function, even after long ischemia times (>24 hours) of the renal parenchyma or bilateral occlusion, as long as residual perfusion of the renal parenchyma has been preserved. Also, the long-term patency rates justify aggressive management of renal artery occlusion after F/B-EVAR.

Purpose To investigate feasibility and outcomes of endovascular repair for acute thoracoabdominal aortic aneurysms (TAAA). Materials and Methods Data from a single center were retrospectively analyzed. Patients who underwent endovascular repair for acute TAAA between January 2010 and April 2020 were included. Perioperative and mid-term follow-up outcomes were analyzed. Survival, freedom from reintervention, and target vessel patency were calculated by Kaplan–Meier analysis. Results A total of 30 patients (18 men, 67.5 ± 6.9 years) underwent endovascular repair for acute symptomatic (n = 15) or contained ruptured (n = 15) TAAA. An off-the-shelf four-branched stent-graft (T-Branch) was used in 19 (63.3%) patients, a custom-made device (CMD) with expedite order in 5 (16.7%) patients, a CMD with short anticipated delivery time in 3 (10.0%) patients, and a CMD available in the hospital in 3 (10.0%) patients. Technical success was 90.0% (n = 27). Thirty-day mortality was 10% (n = 3). There was no complete persistent paraplegia, but one (3.3%) patient suffered permanent limb weakness. Estimated survival at 1 and 2 years was 86.3% ± 6.4%, and 82.3% ± 7.2%, respectively. Estimated freedom from reintervention at 1 and 2 years was 81.4% ± 7.6% and 73% ± 8.8%. Estimated target vessel patency at 1 and 2 years was 96.6% ± 2% and 92.6% ± 2.9%. Conclusion Endovascular treatment of acute TAAA in this selected group of patients was associated with low early mortality and excellent mid-term survival. The off-the-shelf stent-graft option (T-Branch) was used in the majority of patients. Endovascular repair should be considered the first option for suitable acute TAAA.

Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

OBJECTIVES: Operative caseload is thought to be associated with peri-operative mortality following intact aortic aneurysm repair. The aim was to study that association in the Australian setting, which has a unique healthcare provision system and geographical population distribution. METHODS: The Australasian Vascular Audit database was used to capture volume measurements for both individual surgeon and hospital and to separate it into quintiles (1, lowest, to 5, highest) for endovascular (EVAR), open surgical repair (OSR), and subgroups of repair types between 2010 and 2016. Multivariable logistic regression modelling was used to assess the impact of caseload volumes on in hospital mortality after adjustment for confounders. RESULTS: Volume counts were determined from 14,262 aneurysm repair procedures (4121 OSR, 10,106 EVAR). After exclusions, 2181 OSR (161 complex, 2020 standard) and 7547 EVAR (6198 standard, 1135 complex, 214 thoracic (TEVAR)) elective cases were available for volume analysis. Unadjusted mortality after EVAR was unaffected by either surgeon (Quintile 1, 1.0%; Quintile 5, 0.9%; p = .28) or hospital volume (Quintile 1, 0.8%; Quintile 5, 1.3%; p = .47). However, univariable analysis of the TEVAR subgroup revealed a significant correlation with hospital volume (Quintiles 1-2 vs. Quintiles 3-5; p = .02). Univariable analysis for OSR demonstrated a marginal, non-significant value for surgeon (Quintile 1, 4.0%; Quintile 5, 3.6%; p = .06), but not hospital volume (Quintile 1, 4.7%; Quintile 5, 4.0%; p = .67). After adjustment for confounders hospital volume remained a significant predictor of peri-operative TEVAR mortality (Quintile 1-2 vs. 3-5; OR 5.62, 95% CI 1.27-24.83; p = .02) and surgeon volume a predictor following standard OSR (Quintile 1-2 vs. Quintile 3-5; OR 2.15, 95% CI 1.21-3.83; p = .01). CONCLUSIONS: There is an inverse correlation between both surgeon volume of open aortic aneurysm repair, hospital volume of thoracic endovascular aneurysm repair and in hospital mortality. These findings suggest that in Australia TEVAR should be performed by high volume hospitals and OSR by high volume surgeons. ispartof: Eur J Vasc Endovasc Surg vol:57 issue:4 pages:510-519 ispartof: location:England status: published

Background This study analyses limb occlusion rates after endovascular aneurysm repair (EVAR) with a strategy including stent-graft limb selection and liberal primary stenting (relining) in anatomies at higher risk for occlusion with uncovered self-expandable or balloon-expandable stents. Methods All patients undergoing elective EVAR with a bifurcated stent-graft between January 2010-August 2018 were included. A protocol involving personalized stent-graft selection and liberal primary relining based on preoperative imaging was followed during the whole period. Primary endpoints were technical success and primary limb patency during follow-up. Secondary endpoints included mortality and limb reintervention rates. Risk factors associated to limb patency and reintervention rates were analyzed. Results Six hundred and fifteen patients (548 males; mean age 72.9 ± 9 years) were included. Overall technical success was 98.5% (606/615). One (0.16%) patient died during the first 30 days. Of the 1230 limbs, 96 (8%) were deemed at risk for occlusion in view of the anatomy, and primarily relined in 62 patients. Estimated primary limb patency at 6 months, 1 year and 3 years was 99.5 ± 0.2%, 99.2 ± 0.3% and 98.5 ± 0.5%, respectively. Freedom from limb-related reintervention at 6 months, 1 year and 3 years was 98.1 ± 0.4%, 97.4 ± 0.5% and 95.6 ± 0.7%, respectively. Only one (1%) of the 96 relined limbs occluded during follow-up. No differences were found in terms of patency or freedom from reintervention between limbs at risk that were primary stented and limbs without adjunctive stents. Gore Excluder stent-grafts presented better patency (Breslow P = 0.005) and lower reintervention rates (Breslow P = 0.001) than other devices during follow-up. Peripheral artery disease was also a risk factor for reintervention (Breslow P = 0.015). Conclusion Liberal use of primary limb relining in patients with iliac anatomy at higher risk for occlusion appears to be a safe and effective strategy to preserve limb patency after EVAR. Gore Excluder graft limbs present better patency and lower reintervention rates than other stent-graft types.

OBJECTIVES The aim of this study was to evaluate the effects of the coronavirus 2019 pandemic on elective and acute thoracic aortic surgery in the Netherlands. METHODS The Netherlands Heart Registration database was used to compare the volume of elective and acute surgery on the thoracic aorta in 2019 and 2020, starting from week 11 in both years. A sub-analysis was done to assess the impact of the pandemic on high-volume and low-volume aortic centres. RESULTS During the pandemic, the number of elective thoracic aortic operations declined by 18% [incidence rate ratio (IRR) 0.82 [0.73–0.91]; P < 0.01]. The decline in volume of elective surgery was significant in both high-volume (IRR 0.82 [0.71–0.94]; P < 0.01) and low-volume aortic centres (IRR 0.81 [0.68–0.98]; P = 0.03). The overall number of acute aortic operations during the pandemic remained similar to that in 2019 (505 vs 499; P = 0.85), but an increased share of these operations occurred at high-volume centres. The number of acute operations performed in high-volume centres increased by 20% (IRR 1.20 [1.01–1.42]; P = 0.04), while the number of acute operations performed in low-volume centres decreased by 17% (IRR 0.83 [0.69–1.00]; P = 0.04). CONCLUSIONS The coronavirus 2019 pandemic led to a significant decrease in elective thoracic aortic surgery but did not cause a change in the volume of acute thoracic aortic surgery in the Netherlands. Moreover, the pandemic led to a centralization of care for acute thoracic aortic surgery., The coronavirus disease 19 (COVID-19) pandemic has impacted the delivery of health care around the world.

The utilisation rate of endovascular aortic aneurysm repair has increased continuously over the past 2 decades. Endovascular aortic aneurysm repair is still performed frequently in patients with an unfavourable proximal seal zone, despite the associated late complications.We aimed to evaluate the mid-term durability of the GORE® EXCLUDER® AAA Endoprosthesis, featuring the C3 delivery system, in patients with a proximal neck anatomy outside the instructions for use (IFU).A retrospective sub-analysis of the Global Registry for Endovascular Aortic Treatment including patients treated for abdominal aortic aneurysms with the GORE EXCLUDER AAA Endoprosthesis (W.L. GoreAssociates, Inc, Flagstaff, Arizona) was performed. A "challenging neck" was defined as those treated outside the IFU with an aortic neck length15 mm and/or aortic neck angle60°. Cox proportional analyses were used to test for time-to-event differences between those treated within and outside the IFU while accounting for covariates, specifically proximal neck length and neck angle. The main outcomes assessed were 5-year all-cause mortality, 5-year endoleak development (type I or III), and 5-year device-related reinterventions.Of the 3,324 patients included in the analysis, 411 (12.4%) had a challenging neck and 2,913 (87.6%) did not. The patients in the challenging neck group were significantly older (74.9 years vs. 73.2 years, p≤0.0001) and had a significantly larger aortic aneurysm diameter at the time of the intervention than those treated within the IFU (61.2 mm vs. 56.4 mm, P0.0001), shorter proximal neck length (18 mm vs. 30 mm, P0.0001) and larger infrarenal neck angle (60.8° vs. 25.8°, P0.0001). In the multivariate analysis, brachial access site and challenging neck were not independent risk factors; increased age was associated with a shorter time to mortality (hazard ratio 1.051, 95% confidence interval 1.039-1.062, P0.0001), as was the use of tobacco (hazard ratio 1.329, 95% confidence interval 1.124-1.571, P= 0.0009). The 5-year all-cause mortality (36.2% vs. 27.5%, P= 0.002) and aorta-related mortality (3.8% vs. 1.1%, P= 0.002) were significantly higher in the challenging neck group. The risk of death within 5 years also increased significantly at 1.1% per millimetre increase in the abdominal aortic aneurysm diameter (P= 0.0005). Furthermore, the rates of type Ia endoleak development (7% vs. 1.2%, P0.001) and requirement for reintervention (13.3% vs. 9.7%, P0.001) were higher in those treated outside the IFU (challenging neck group).Treatment with the Excluder AAA Endograft outside the IFU was associated with higher 5-year mortality values, increased type Ia endoleak development rates, and a greater need for reintervention compared with treatment within the IFU. This reiterates that fenestrated and open treatments should be strongly considered in cases with aortic neck anatomies outside the IFU. Infrarenal endovascular intervention outside the IFU should only be used when there is no alternative, with meticulous procedural planning and intervention to promote satisfactory outcomes.

BACKGROUND Aneurysmal degeneration after acute dissection occurs in a significant proportion of patients. Fenestrated and branched stent-grafting (F/BEVAR) has been increasingly used to treat these post-dissection thoracoabdominal aortic aneurysms (PD-TAAA). The aim of this study was to report early and mid-term outcomes of F/BEVAR in PD-TAAA. METHODS Retrospective single center analysis of a prospectively maintained database including all patients undergoing F/BEVAR for PD-TAAA between October 2010-February 2020. RESULTS Fifty-five patients (45 males, mean age 66±10 years) were included. Technical success was achieved in all patients. Thirty-day mortality was two (3.6%) patients. Major perioperative complications were noted in nine (16.4%) patients including five (9.1%) with transient spinal cord ischemia (SCI) and one (1.8%) with permanent paraplegia. Mean follow-up was 24 months (1-76 months). Cumulative survival rates at 12, 24 and 36 months were 87±5.5%, 83.5±6.3% and 72.2±8.1%, respectively. Estimated freedom from reintervention at 12, 24 and 36 months was 82.2±6.7%, 60.1±9.2% and 55.9±9.5%, respectively. Main reasons for reintervention were endoleaks from target vessels and common iliac arteries. Estimated target vessel patency at 12, 24 and 36 months was 97.8±1.2%, 95.4±2.1%, and 94.1±2.4%, respectively. Mean aneurysm sac regression during follow-up was 7.9±7.1 mm, with complete false lumen thrombosis in 80% of patients. No ruptures occurred during follow-up. CONCLUSIONS F/BEVAR for PD-TAAA is associated with low perioperative mortality and morbidity in a large volume endovascular center. Mid-term results demonstrate a high rate of aneurysm sac regression. Extended sealing with longer bridging stents for target vessels is recommended.

OBJECTIVES: Patients surviving acute aortic dissection are at risk of developing a post-dissection thoraco-abdominal aortic aneurysm (PD-TAAA) during follow up, regardless of the type of treatment in the acute setting. Fenestrated and branched stent grafting (F/B-TEVAR) has been used with success to treat PD-TAAA, albeit reported only with short-term results. The aim of this study was to report mid-term results in a cohort of 71 patients. METHODS: This was a retrospective analysis of a prospectively maintained database including all patients with PD-TAAAs who underwent F/B-TEVAR within the period January 2010 - April 2017 at two vascular institutions experienced in endovascular techniques. RESULTS: A total of 71 consecutive patients (56 male, mean age 63.8 ± 10.6 years) were treated. Technical success was achieved in 68/71 (95.8%) patients. In hospital mortality was four (5.6%) patients. Peri-operative morbidity was 19.6%. Three (4.2%) patients developed severe spinal cord ischaemia, one of these patients 12 months post-operatively. Mean follow up was 25.3 months (1-77 months). Cumulative survival rates at 12, 24, and 36 months were 84.7 ± 4.5%, 80.7 ± 5.1%, and 70.0 ± 6.7%, respectively. Estimated freedom from re-intervention at 12, 24, and 36 months was 80.7 ± 5.3%, 63.0 ± 6.9%, and 52.6 ± 8.0%, respectively. The main reasons for re-intervention were endoleak from visceral/renal arteries and iliac endoleak requiring extension. Target vessel occlusion occurred in 8/261 (3.1%) vessels (renal artery n = 4; superior mesenteric artery n = 2; coeliac artery n = 2). Mean aneurysm sac regression during follow up was 9.2 ± 8.8 mm, with a false lumen thrombosis rate of 85.4% for patients with a follow up longer than 12 months. No ruptures occurred during follow up. CONCLUSION: F/B-TEVAR for post-dissection TAAA is feasible and associated with low peri-operative mortality and peri-operative morbidity. Mid-term results demonstrate a high rate of aneurysm sac regression. Rigorous follow up is required because of the significant re-intervention rate. Longer bridging covered stents for target vessels are advised. ispartof: Eur J Vasc Endovasc Surg vol:57 issue:1 pages:102-109 ispartof: location:England status: published

Die endovaskulare Behandlung von rupturierten Bauchaortenaneurysmen (rEVAR) hatte in Beobachtungsstudien groser Zentren mit entsprechender Erfahrung vielversprechende Uberlebensraten gezeigt, die denen der offenen Operation uberlegen waren. Die hierzu durchgefuhrten randomisiert-kontrollierten Studien zeigten vergleichbare Ergebnisse, die jedoch den breiteren Einsatz der rEVAR assoziiert nahelegen. Fur den Einsatz der rEVAR und fur die bestmogliche Versorgung von rupturierten Bauchaortenaneurysmen sowohl mit rEVAR, aber auch offener Operation ist ein standardisiertes Behandlungsprotokoll mit der entsprechenden Schulung aller beteiligter Berufsgruppen sowie eine adaquate raumliche, technische und materialtechnische Ausstattung im Gefaszentrum notwendig.

Im letzten Jahrzehnt hat sich die Technik der endovaskularen Aortenaneurysmareparation (EVAR) als Alternative zu der bisherigen offenen chirurgischen Therapie herauskristallisiert. Randomisierte Studien wie DREAM und EVAR1 konnten im Vergleich zur offenen chirurgischen Therapie deutliche Vorteile aufseiten der endovaskularen Methode aufzeigen (Greenhalgh et al. 2004; Prinssen et al. 2004). Auch wenn die mittelfristigen Ergebnisse der beiden Studien aufgrund einer erhohten Anzahl von Spatkomplikationen und dadurch notwendigen Reinterventionen zunachst eher enttauschend fur die endovaskulare Gruppe ausfielen, haben sich die endovaskulare Methode und die Prothesen dennoch kontinuierlich weiterentwickelt und zeigen einen klaren Trend zu einer deutlich verbesserten Haltbarkeit mit weniger Reinterventionsmasnahmen (Blankensteijn et al. 2005).

Objective Treatment of complex aortic pathologies with customised fenestrated/branched stent grafts (F/BEVAR) is associated with a longer waiting time to the procedure. This study aimed to investigate the prevalence of aneurysm rupture and mortality during the waiting time for a fenestrated/branched stent graft in a single centre. Methods All patients with a pararenal (PAA), thoraco-abdominal (TAAA), or aortic arch aneurysm planned to be treated with a customised F/BEVAR between January 2010 and December 2018 were included. Patients planned for F/BEVAR who in the end did not undergo the procedure were analysed. Results 906 patients were planned to undergo F/BEVAR during the study period. Of those, 862 (95.1%) underwent the procedure as planned (FEVAR for PAA; n = 494, F/BEVAR for TAAA; n = 348, F/BEVAR for arch aneurysm; n = 20). In 44 (4.9%) patients, the procedure was cancelled. Thirty-seven (4.1%) patients died before the procedure, four (0.4%) patients turned down the procedure, two (0.2%) were cancelled because of worsened general condition, and one (0.1%) ruptured but underwent emergency open repair in another institution. Causes of death during the waiting time were: aneurysm rupture, n = 15 (1.7%); cardiac, n = 7 (0.8%); stroke, n = 3 (0.3%); gastrointestinal, n = 3 (0.3%); death after complete arch debranching, n = 2 (0.2%); infection, n = 2 (0.2%); death after transcatheter aortic valve implantation, n = 1 (0.1%); death after urological surgery, n = 1 (0.1%); unknown, n = 3 (0.3%). Aneurysm diameter was larger in patients who died of aneurysm rupture compared with patients who died as a result of other causes (79.2 ± 13 mm vs. 66.7 ± 12 mm, respectively, p = .005). Conclusion Aneurysm rupture during the waiting time for F/BEVAR can occur but is rare. Patients with a larger aneurysm diameter may be at higher risk of rupture. Measures to reduce the risk of rupture during the waiting time might include the use of off the shelf devices for larger aneurysms, quicker measurement and graft plan order processes, and quicker graft construction and delivery.

Objective Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown. Methods The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR). Results Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13–3.21], Q2 vs. 5: 2.01[1.24–3.25], Q3 vs. 5: 1.41 [0.86–2.29], Q4 vs. 5: 1.92 [1.17–3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 – 3 vs. 4–5] (OR 1.63 [1.07–2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67). Conclusion There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.

Endovascular treatment of complex thoracoabdominal aneurysms with branched and fenestrated grafts (B/F-EVAR) has become the first option for patients with suitable anatomy and very high risk for open surgery, who would likely be refused for open repair. We present a case of a patient with a type III thoracoabdominal aneurysm submitted to endovascular repair with a custom-made endograft with branches to the celiac trunk and SMA, and a fenestration to the left renal artery. During the procedure there was the need to do a laparotomy to allow for retrograde catheterization of the SMA, with technical success. In this case, the retrograde access was of utmost importance for the completion of the procedure. Different techniques for target vessel catheterization, such as the one we describe, should be part of a vascular surgeon's resources in B/F-EVAR procedures.

Objective: The use of self-expanding stent grafts for treatment of popliteal artery aneurysms (PAA) is a matter of debate, although several studies have shown similar results compared with open surgery. In recent years, a new generation stent graft, with heparin-bonding technology, became available. The aim of this study is to present the results of endovascular PAA repair with heparin-bonded stent grafts.Methods: Data on all patients with PAA treated with a heparin-bonded polytetrafluoroethylene (ePTFE) stent graft between April 2009 and March 2014 were gathered in a database and retrospectively analyzed. Data were collected from four participating hospitals. Standard follow-up consisted of clinical assessment, and duplex ultrasound at 6 weeks, 6 months, 12 months, and annually thereafter. The primary endpoint of the study was primary patency. Secondary endpoints were primary-assisted and secondary patency and limb salvage rate.Results: A total of 72 PAA was treated in 70 patients. Mean age was 71.2 +/- 8.5 years and 93% were male (n = 65). The majority of PAA were asymptomatic (78%). Sixteen cases (22%) had a symptomatic PAA, of which seven (44%) presented with acute ischemia. Early postoperative complications occurred in two patients (3%). Median follow-up was 13 months (range 0-63 months). Primary patency rate at 1 year was 83% and after 3 years 69%; primary assisted patency rate was 87% at 1 year and 74% after 3 years. Secondary patency rate was 88% and 76% at 1 and 3 years, respectively. There were no amputations during follow-up.Conclusion: Endovascular treatment of PAA with heparin-bonded stent grafts is a safe treatment option with good early and mid-term patency rates comparable with open repair using the great saphenous vein. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objectives The outcomes of fenestrated endovascular aneurysm repair (FEVAR) as a first line strategy is reported. Methods All consecutive patients treated with FEVAR for short neck, juxtarenal, or suprarenal aortic aneurysms under the guidance of the senior author within the period January 2010 to December 2014 were included. Data were collected from a prospectively maintained database. Analyzed outcomes included technical success, defined by successful stent graft implantation with patent stented target vessels and no Type I/III endoleak, operative mortality and morbidity, target vessel patency, endoleak, re-intervention, and death. Survival, target vessel stent patency, and re-intervention during follow up were calculated by Kaplan–Meier analysis. Results A total of 281 patients (245 male, mean age 72.1 ± 7.7 years) were treated. The mean aneurysm diameter was 60.2 ± 9.3 mm and median proximal neck length 2 mm (range 0–10 mm). Technical success was 96.8% (272/281). Technical failure included one intra-operative death due to embolization and cardiac arrest, one open conversion due to iliac rupture, and seven target vessel complications. The thirty day mortality was 0.7% (2/281). Mean follow up was 21 ± 15.9 months. Estimated survival at 1 and 3 years was 94.7% ± 1.6% and 84.6% ± 3.0%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 96.1% ± 1.4%, and 90% ± 2.7%. Estimated target vessel stent patency at 1 and 3 years was 98.6% ± 0.5%, and 98.1% ± 0.6%, respectively. Mean aneurysm sac diameter decreased from 60.2 ± 9.3 mm pre-operatively to 53.2 ± 12.8 mm ( p Conclusions FEVAR as a first line strategy was associated with high technical success and a low operative mortality rate. Efficacy and durability in the mid-term appear very good, with significant regression of aneurysm sac diameter, high target vessel patency, and acceptable rate of re-intervention.

Purpose: To describe a novel endovascular bailout technique for successful completion of target vessel stenting during branched stent-graft repair of thoracoabdominal aortic aneurysms (TAAA) after ...

Background: Abdominal aortic aneurysms (AAAs) are more common in men. However, women have been shown to have more short- and long-term adverse outcomes after endovascular aneurysm repair. This disparity is thought to be multifactorial, including anatomical differences, hormonal differences, older age of presentation, and a greater degree of preoperative comorbidities. Methods: A retrospective analysis that included data for 3,758 patients from the Global Registry for Endovascular Aortic Treatment (GREAT) was conducted. Patients were recruited into GREAT between August 2010 and October 2016 and received the Gore Excluder stent graft for infrarenal AAAs repair. Cox multivariate regression analyses were performed to analyze any reintervention and device-related intervention rates. Results: Of the 3,758 patients, 3,220 were male (mean age 73 years) and 538 were female (mean age 75 years). Women had higher prevalence rates of chronic obstructive pulmonary disease (P < 0.0001) and renal insufficiency (P = 0.03), whereas men had higher rates of cardiovascular comorbidities. The AAAs in women were smaller in diameter with shorter and more angulated necks. Women did not experience a significantly higher rate of endoleaks but did exhibit higher reintervention rates, including reintervention for device-related issues. In terms of mortality, aorta-related mortality was most prevalent within the first 30 days after procedure in both sexes. Conclusions: Women were treated at an older age and had a more hostile aneurysmal anatomy. Although the mortality rates were lower in women, they had significantly higher rates of reintervention, and thus higher morbidity rates after endovascular aneurysm repair.

Objective The Global Registry for Endovascular Aortic Treatment (GREAT), a retrospective sponsored registry, was queried to determine the incidence and identify potential predictors of access related complications after TEVAR. Methods This is a multicentre, observational cohort study. For the current study, all patients were treated only with the Conformable GORE® TAG® Thoracic Endoprosthesis and GORE® TAG® Thoracic Endoprosthesis devices for any kind of thoracic aortic disease. All serious adverse events within 30 days of the procedure were documented by sites. The following were considered access related complications: surgical site infection, pseudoaneurysm, avulsion, dissection, arterial bleeding, access vessel thrombosis/occlusion, seroma, and lymphocoele. Results A total of 887 patients was analysed: most of the cases had an operative indication for TEVAR of degenerative atherosclerotic aneurysm (n = 414, 46.7%) and type B dissection (n = 270, 30.4% either complicated or uncomplicated). Two hundred and ninety-five patients (33.3%) were female. The overall access related complication rate was 2.8% (n = 25): 4.7% (n = 14) in women and 1.8% (n = 11) in men (p = .013). After adjustment for age, urgency, device diameter, introducer sheath (≥24Fr vs. ≤ 24Fr), access vessel diameters, and access method, female gender was significantly associated with the risk of access complications (OR 2.85; p = .038). Brachial artery for access was also found to be an independent predictor of access related complications (OR 8.32; p Conclusion This analysis suggests that women may have a higher access related complication rate after TEVAR, irrespective of the clinical setting, type of aortic disease, and device sizing.

ispartof: Eur J Vasc Endovasc Surg vol:57 issue:2 pages:303- ispartof: location:England status: published

Background This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center. Methods All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively. Results Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively. Conclusions Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.

ispartof: Eur J Vasc Endovasc Surg vol:57 issue:5 pages:615-616 ispartof: location:England status: published

Purpose To provide a systematic literature review on effectiveness of arteriovenous fistula (AVF) and Shunt (AVS) research animal models. Background Due to advancing human population age, there is increased incidence of patients suffering from vascular and renal diseases leading to dialysis access using AVF and/or AVS. During those interventions native venous or synthetic grafts are arterialized. Despite temporary good patency, complications are a consequence of neointimal hyperplasia (NIH) development that contributes to patients’ morbidity and mortality. Basic research attempts to elucidate the pathomechanisms, therefore the small and large animal models are becoming attractive. Methods Medline search (within 1966–2018) was performed on AVF/AVS animal models. Studies fulfilled following criteria: (1) reported complete material-methods-results section, (2) included statistically significant number of animals, (3) provided statistically significant results. 55 articles were identified encompassing six animal species used. Results Large animal models include creation of AVF and AVS in pig, sheep and dog. Porcine animal models use pelvic or femoral vessels, ovine use the common carotid artery (CCA) and jugular vein (JV). Canine animal models use the femoral vessels. Small animal models use rabbit (CCA/JV), rat (JV/CCA, abdominal aorta /Vena cava inferior and femoral artery/femoral vein) and mouse (aortocaval and supraortic AVF models). Conclusions Large animal models are best for haemodynamic shear stress studies and in vivo evaluation of new synthetic vascular grafts. Small animal models, especially the genetically manipulated ones, are ideal for analysis of molecular and cellular pathomechanisms. The selection of animal species to be used depends on the addressed research question.

Postdissection aortic aneurysms (PDAA) affect 20-40% of patients with aortic dissection. Open repair remains the first line therapy of PDAA, but is still associated with high mortality and morbidity rates. Endovascular repair is increasingly being used as a less invasive treatment option. Thoracic endovascular aneurysm repair (TEVAR) covering only the proximal entry tear has proven to be insufficient in most patients with chronic PDAA and has a limited role only for PDAA with distal sealing zone in the thoracic aorta. In PDAA extending to the thoracoabdominal aorta, a more complex repair is needed to achieve aneurysm exclusion. Fenestrated and branched stent-grafts have been used lately in some expert centres to treat PDAA of the thoracoabdominal aorta with good preliminary results despite the technical difficulties in these patients (narrow true lumen, stiff chronic dissection flap, target vessels that originate from the false lumen [FL]). A subset of patients with aneurysmal degeneration mainly in the descending thoracic aorta, can be treated with TEVAR landing proximal to the celiac artery along with adjuvant techniques such as coils, plugs, glue or "Candy-Plug" and "Knickerbocker" concepts to occlude the FL, preventing retrograde flow and reducing the pressure in the aneurysm. Other options that have been used in limited numbers of patients with PDAA include the PETTICOAT (provisional extension to induce complete attachment) and STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) techniques. This article aims to review the outcomes of different endovascular techniques and strategies available for the repair of PDAA.

ispartof: Eur J Vasc Endovasc Surg vol:56 issue:3 pages:318-319 ispartof: location:England status: published

To address target vessels in pararenal and thoracoabdominal aortic aneurysms with fenestrated and branched grafts, two solutions are available: fenestrations (holes in the graft) and directional side-branches. Fenestrations work well for target vessels that have a close to 90-degree take-off from the aorta, and when the main graft at the level of the target vessel is adjacent or close to the aortic wall. Directional side-branches work well when target vessels have a steeper take-off angle and when there is a larger gap to be bridged. A third option of "inner branches" has been evaluated by our group to address target vessels that are not very suitable for either a fenestration or a directional side-branch. Most pararenal aneurysms are treated with fenestrated grafts, whereas thoraco-abdominal aneurysms are treated mostly by grafts incorporating both fenestrations and branches. In Nuremberg, 347 patients were treated with fenestrated/branched grafts for thoraco-abdominal aneurysms. A stent-graft with fenestrations only was used in 108 (31.1%) patients, a stent-graft with branches only in 104 (30.0%) patients, and a stent-graft with a combination of fenestrations and branches in 135 (38.9%) patients. For the RAs (N.=625) fenestrations were used in 408 (65.3%) and branches in 217 (34.7%). For the SMA (N.=341) fenestrations were used in 169 (49.6%) and branches in 172 (50.4%). For the CA (N.=297), fenestrations were used in 84 (28.3%), and branches in 213 (71.7%). Target vessel patency at 3 years was 98.2±0.9% for vessels targeted with fenestrations and 92.2±1.9% for vessels targeted with branches (P=0.009).

The aim of this study was to report the incidence and associated risk factors of perioperative spinal cord ischemia (SCI) after endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent grafts.The study included consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004 to December 2014. Suprarenal abdominal aortic aneurysms treated with fenestrated and branched grafts, even if including all four visceral vessels, were excluded. Patients who died within 30 days after the procedure were excluded from the analysis for SCI. All data were collected prospectively.A total of 218 patients (167 men; mean age, 68.8 ± 7.5 years) were treated. Thirty-day mortality was 17 patients (7.8%). TAAA distribution among the 201 surviving patients was as follows: type I, n = 17 (8.5%); type II, n = 55 (27.4%); type III, n = 63 (31.3%); type IV, n = 54 (26.9%); and type V, n = 12 (5.9%). In the surviving patients, 21 (10.4%) developed perioperative SCI. At 30 days postoperatively, 13 (6.5%) of those patients had transient lower limb weakness, 5 patients (2.5%) had persistent lower limb weakness requiring assistance to stand or to walk, and 3 patients (1.5%) had persistent paraplegia. Five of the 21 patients awoke from anesthesia with a neurologic deficit. The remaining 16 patients had a later postoperative onset of SCI, with the majority of them (14 of 16) within 72 hours after the operation. Multivariate analysis using logistic regression identified operation time300 minutes (odds ratio [OR], 7.4; 95% confidence interval [CI], 2.6-21.1; P.001), peripheral arterial disease (OR, 6.6; 95% CI, 2-21.9; P = .002), and baseline renal insufficiency (glomerular filtration rate30 mL/min; OR, 4.1; 95% CI, 1.1-16.1; P = .04) as independent risk factors for SCI.In our experience, most SCI events after endovascular TAAA repair are transient, with persistent paraplegia being rare. Patients with prolonged procedure duration, peripheral arterial disease, and baseline renal insufficiency appear to be at higher risk for development of SCI after endovascular TAAA repair.

Fenestrated/branched thoracic endovascular aneurysm repair (F/Br-TEVAR) is a new minimal invasive treatment option for patients with post-dissection thoracoabdominal aortic aneurysms. This specific pathology is challenging to F/Br-TEVAR, especially when target vessels originate from the false lumen. Crossing from the true lumen into the false lumen to catheterize such target vessels may prove cumbersome in the usually thickened dissection flap. We describe a bailout technique when standard catheterization techniques fail, by using a transjugular intrahepatic portosystemic shunt (TIPS)-needle to perforate the dissection flap. The fenestration is subsequently dilated using balloon angioplasty to allow for insertion and deployment of the bridging stent graft. When other catheterization techniques fail in vessel originating from the false lumen, TIPS-needle perforation of the dissection flap is a useful bailout tool.

Complex iliac anatomy including extreme tortuosity constitutes a relative contraindication for endovascular abdominal aortic aneurysm repair with additional risk of limb-graft occlusion. The Gore Excluder limb-graft is a flexible stent-graft, which adapts easily to iliac tortuosity. Nevertheless, the presence of the stiff guide wire does not always allow for an ideal apposition of the stent graft to the angulated common iliac artery vessel wall. We describe herein a modified technique for Gore Excluder limb-graft deployment with partial removal of the stiff wire in cases with difficult tortuous or narrow iliac arteries during endovascular abdominal aortic aneurysm repair.

Objective/Background To develop a procedure specific global rating scale for assessment of operator competence in endovascular aortic repair (EVAR). Methods A Delphi approach was used to achieve expert consensus. A panel of 32 international experts (median 300 EVAR procedures, range 200–3000) from vascular surgery (n = 21) and radiology (n = 11) was established. The first Delphi round was based on a review of endovascular skills assessment papers, stent graft instructions for use, and structured interviews. It led to a primary pool of 83 items that were formulated as global rating scale items with tentative anchors. Iterative Delphi rounds were executed. The panellists rated the importance of each item on a 5 point Likert scale. Consensus was defined as 80% of the panel rating an item 4 or 5 in the primary round and 90% in subsequent rounds. Consensus on the final assessment tool was defined as Cronbach's alpha > .8 after a minimum of three rounds. Results Thirty-two of 35 invited experts participated. Three rounds of surveys were completed with a completion rate of 100% in the first two rounds and 91% in round three. The 83 primary assessment items were supplemented with five items suggested by the panel and reduced to seven pivotal assessment items that reached consensus, Cronbach's alpha = 0.82. The seven item rating scale covers key elements of competence in EVAR stent placement and deployment. Each item has well defined grades with explicit anchors at unacceptable, acceptable, and superior performance on a 5 point Likert scale. Conclusion The Delphi methodology allowed for international consensus on a new procedure specific global rating scale for assessment of competence in EVAR. The resulting scale, EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), represents key elements in the procedure. EVARATE constitutes an assessment tool for providing structured feedback to endovascular operators in training.

Objectives To present results from the first 100 patients treated with the new C3 Gore Excluder stent-graft in a single institution. Methods All patients treated with the C3 Excluder stent-graft between August 2010 and July 2013 in our institution were included. Patient demographics, treatment indication, need for intraoperative stent-graft repositioning, immediate technical success, survival, endoleak and migration rate, and need for reintervention during follow-up were analyzed. Results A total of 100 patients (86% male, mean age 71.1 ± 9.3 years) were enrolled. Elective abdominal aortic aneurysm (AAA) was the most common indication for treatment ( n = 90), followed by common iliac artery aneurysm ( n = 5), ruptured AAA ( n = 2), type Ia endoleak ( n = 1), and type IV endoleak ( n = 1) after prior EVAR, and penetrating aortic ulcer ( n = 1). Technical success was achieved in 98 patients. In two patients a small type I endoleak persisted at completion angiography, but had disappeared at the first control computed tomography angiogram. Stent-graft repositioning after initial deployment was required in 49 patients, almost equally distributed for level and contralateral gate reorientation. Exact positioning of the proximal trunk was achieved in 98 patients, with the remaining two cases within 5 mm of the intended location. Adverse events related to repositioning maneuvers were noticed in two cases. Mean follow-up duration was 12.2 ± 9.4 months (range 0–36 months). Eight patients died, none from aneurysm related causes. Cumulative patient survival was 96.2 ± 2.1% at 1 year, and 84 ± 6.1% at 2 years, respectively. No migration, or type I or III endoleak was detected during follow-up. Estimated freedom from reintervention was 96 ± 2.4% at 1 year, and 91 ± 5.2% at 2 years, respectively. Conclusions The new C3 Excluder stent-graft provides excellent short-term outcomes and offers important advantages in terms of stent-graft repositioning to achieve high proximal deployment accuracy. Longer follow-up is required to confirm improved long-term outcome compared with the previous generation Excluder stent-graft.

Visceral arteries in fenestrated and branched endovascular repair (F/BEVAR) have been addressed by fenestrations or directional side branches. Inner branches, as used in the arch branched device, could provide an extra option for visceral arteries "unsuitable" for fenestrations or directional side branches. Early experience with the use of inner branches for visceral arteries in F/BEVAR is described.All consecutive patients treated by F/BEVAR for complex abdominal aortic aneurysm (AAA) or thoraco-abdominal aneurysm (TAAA) using stent grafts with inner branches were included. Data were collected prospectively.Thirty-two patients (28 male, mean age 71.6 ± 8.3 years) were included. Seven (21.9%) patients had a complex AAA and 25 (78.1%) had a TAAA. A stent graft with inner branches only was used in four (12.5%) patients. The remaining 28 (87.5%) patients received a stent graft with fenestrations and inner branches. In total 52 vessels were targeted with inner branches. Technical success was achieved in all 32 (100%) patients. All 38 inner branch target vessels in grafts including fenestrations and inner branches were instantly catheterised (1 minute), whereas catheterisation of target vessels in "inner branch only" grafts proved more difficult (1 minute, n = 3; 1-3 min, n = 4; and3 min, n = 7). The 30 day operative mortality was 3.1% (1/32). Estimated survival at 1 year was 80.0% ± 8.3%. During follow-up, four renal inner branches occluded in three patients. The estimated inner branch target vessel stent patency at 1 year was 91.9 ± 4.5%. The estimated freedom from re-intervention at 1 year was 78.4% ± 8.9%.Early data suggest that visceral inner branches might represent a feasible third option to address selected target vessels in F/BEVAR. Stent grafts with inner branch(es) in combination with fenestrations seem to be a better configuration than stent grafts with inner branches alone. Durability of the inner branch design needs further investigation.