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ZusammenfassungDie komplexe endovaskuläre Therapie der Aorta mit fenestrierten und gebranchten Prothesen spielt eine wichtige Rolle in der heutigen Gefäßmedizin. Daraus resultieren innovative medizintechnische Lösungen, die für immer anspruchsvollere Aortenpathologien eingesetzt werden. Das Ziel dieser Arbeit war es, die zunehmende Bedeutung der „inner Branches“ in der komplexen Aortenchirurgie darzustellen. Die Vorteile und Grenzen dieser Technik sollten aufgezeigt und die aktuelle Datenlage zusammengefasst werden. Dazu wurden die „inner Branches“ (iBEVAR) den Standardverfahren (Fenestrationen [FEVAR], „outer Branches“ [BEVAR]) gegenübergestellt und ihre technischen Vor- und Nachteile erarbeitet. Kennzeichnend ist der weit verbreitete Einsatz der iBEVAR im Aortenbogen im Gegensatz zur thorakoabdominellen Aorta, was sich auch in der spärlichen Datenlage im thorakoabdominellen Abschnitt widerspiegelt. Die Letztere basiert auf kleineren retrospektiven Studien mit 1-jährigem Follow-up. Die seit 2 Jahren verfügbare thorakoabdominelle „off-the-shelf“-Prothese wird voraussichtlich zu einer weiteren Verbreitung der „inner Branches“ im thorakoabdominellen Abschnitt führen, wobei die von der Industrie geförderte Registerstudie wichtige Evidenz zur erörterten Technik bereitstellen könnte.

Purpose: The objective of this study was to compare the outcomes of patients treated with tube grafts and AFX stent-graft in the narrow infrarenal aortic anatomy. Materials and Methods: Patients with penetrating aortic ulcers (PAUs) or sacciform aneurysms of the infrarenal aorta and an aortic bifurcation diameter ≤20 mm who underwent endovascular aneurysm repair (EVAR) with bifurcated AFX or tube stent-grafts (TUBE) between 2012 and 2020 were included. Demographic data and the outcome of the AFX group were compared with the TUBE group. All morphological measurements in the preoperative and postoperative computed tomography scans were performed in the aortic centerline. Results: Fifty-one patients (female: 12/51; 29%; median age: 72 years [63, 77]) with a median follow-up of 10 (3, 39) months, were included, of whom 35/51 (69%) had PAUs and 11/51 were symptomatic (22%). The aortic bifurcation diameter was 17 mm (15, 18) with severe calcifications in 25/51 (49%). The distal aortic landing zone was longer in the TUBE group (9 mm vs 24 mm; pConclusion: AFX stent-graft showed a lower rate of type I endoleaks and reinterventions in sacciform infrarenal aortic pathologies during the early and midterm follow-up.

Objectives Age-related atherosclerosis has been shown to cause aortic stiffness and wall rigidification. This analysis aimed to correlate age and dissection extension length in a large contemporary multi-centre study. We hypothesize that younger patients suffer more extensive DeBakey Type I dissection due to aortic wall integrity, allowing unhindered extension within the layers. Methods The perioperative data of 3385 patients from the German Registry for Acute Aortic Dissection Type A (GERAADA) were retrospectively analyzed with regard to postoperative outcomes and dissection extension. Patients with DeBakey Type I aortic dissection (n = 2510) were retrospectively identified and divided into two age-groups for comparison: ≤ 69 years (n = 1741) and ≥ 70years (n = 769). Patients with DeBakey type II dissection or connective tissue disease were excluded from the analysis. Results In younger patients (≤ 69 years), aortic dissection involved the supraaortic vessels significantly more often (52.0% vs. 40.1%; p Conclusions Extensive DeBakey Type I aortic dissection is less frequent in older patients ≥70 years than in younger patients. In contrast, younger patients suffer more often from preoperative organ malperfusion and associated complications. Postoperative mortality remains high irrespective of age-groups.

OBJECTIVES The aim of this study was to assess the endograft position and aortic geometry changes after thoracic endovascular aortic repair (TEVAR) and frozen elephant trunk (FET) in distal stent-induced new entry (dSINE) patients. METHODS In this retrospective cohort study, the baseline demographic and the follow-up data were extracted from the hospital records, and computed tomography scans of dSINE patients after TEVAR or FET between 2011 and 2021 were analysed regarding endograft oversizing, length and migration, taper ratio, aortic diameter at the endograft end, aortic elongation (thoracic inner and outer curvature), wedge apposition angle and tortuosity angle in the distal landing zone. RESULTS dSINE was found in 22/213 (10%) of TEVAR and 10/31 (32%) of FET patients. The total follow-up time was 45 (27; 59) months. TEVAR was mainly performed with Relay NBS endograft (77%) and FET with Evita open prosthesis (80%). Paraplegia and stroke rates were 3%. dSINE occurred 17 (7; 35) months post-TEVAR and was instantly treated in 18 patients (56%) or followed up for 21 (11; 34) months (n = 14). Migration [+5 mm (1; 11; P CONCLUSIONS Aortic elongation may influence the endograft position and provoke TEVAR failure in the distal and proximal landing zones.

OBJECTIVES The aim of this study was to assess preoperative dissection flap motility and to evaluate its impact on the aortic remodelling and the development of distal stent-induced new entry after thoracic endovascular aneurysm repair (TEVAR)/frozen elephant trunk (FET). METHODS Patients with primary or residual type B dissections were included in a retrospective study with transoesophageal echocardiography analysis of the preoperative dissection flap motility assessed by the true lumen (TL) strain. Three-dimensional computing tomography centreline reconstructions before TEVAR/FET and during the follow-up were conducted to measure aortic remodelling: false lumen thrombosis, TL expansion and aortic diameters at 10 and 20 cm downstream the left subclavian artery, at the coeliac trunk and in the infrarenal aorta. All continuous variables are reported as median with first and third quartiles. RESULTS Fifty-six consecutive patients were treated with TEVAR (n = 45) or FET (n = 11) in the acute (n = 16), subacute (n = 16) and chronic (n = 24) dissection phase. At a median follow-up of 6 (3–12) months, they showed a favourable TL expansion in the descending aorta, significantly higher in the acute [+9 mm (5–12); P 22.5% (median)] was associated with a higher TL expansion rate in the thoracic aorta (P = 0.009) and a comparable distal stent-induced new entry incidence (overall: 16%) in comparison to the immobile flap (P = 0.89). CONCLUSIONS The intraoperative assessment and the inclusion of the dissection flap motility parameters in the decision-making during TEVAR/FET may refine the distal endograft sizing for an improved remodelling of the TL.

To evaluate the safety and efficacy of rotational thrombectomy (RT) in a large single-center real-world cohort for total vascular occlusions of the lower extremity. The clinical records and images of all patients between 2010 and 2020 treated via RT (Rotarex, BD) were assessed. Patient demographics, clinical data, procedural characteristics, and outcome parameters were documented. In total, 397 procedures in 293 patients were included (mean age 69.8 ± 12.0 years; 64.8 % male). Occlusions were acute (47.5 %), subacute and acute-on-chronic (22.2 %), and chronic (30.3 %). The target lesions were the iliac artery (7.1 %), iliac/femoropopliteal (5.0 %), femoropopliteal (59.4 %), femoropopliteal/below-the-knee (27.0 %), below-the-knee (1.5 %), and after bypass surgery (14.9 %). Lesion length was 20 cm in 61.5 % of cases. Clinically successful revascularization was achieved in 90.4 % of cases. Additional thrombolysis was necessary for 32.0 % of procedures. The arithmetic mean ankle-brachial index increased from 0.33 ± 0.29 to 0.81 ± 0.25 (p 0.0001). Bypass grafts were less likely to be fully treatable and required additional lysis (p 0.001). The overall primary patency (no clinically driven target lesion revascularization) was 93.2 %, 88.8 %, 79.1 %, and 72.4 % at 1, 3, 6, and 12 months, respectively. Adverse events occurred in 46.1 % of cases, of which peripheral embolization (22.4 %) was most frequent, requiring interventional treatment in 67.4 % of cases. RT was directly associated with 7.1 % (n = 28) of complications, which consisted of perforations 2.8 %, arteriovenous fistula 1.3 %, and dissections 2.0 %. Rotational thrombectomy is a safe and efficient method for the treatment of occlusions of the arterial circulation of the lower extremity with bypass occlusions having a higher propensity for residual thrombi requiring further lysis therapy. · Rotational thrombectomy was safe and efficacious for treating occlusions of the lower extremities.. · Rotational thrombectomy was associated with 7.1 % of complications.. · Distal embolization occurred in 22.4 % of cases with 67.4 % requiring interventional treatment.. · Primary patency was 93.2 %, 88.8 %, 79.1 %, 72.4 % after 1, 3, 6, and 12 months, respectively..· Artzner C, Martin I, Hefferman G et al. Safety and Efficacy of Rotational Thrombectomy for Treatment of Arterial Occlusions of the Lower Extremities: A Large Single-Center Retrospective Study. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1952-0092. Evaluierung der Sicherheit und Wirksamkeit der Rotationsthrombektomie (RT) in einer großen realen Kohorte eines einzelnen Zentrums bei totalen Gefäßverschlüssen der unteren Extremitäten. Die klinischen Aufzeichnungen und Bilder aller zwischen 2010 und 2020 mittels RT (Rotarex, BD) behandelten Patienten wurden ausgewertet. Es wurden demografische Daten der Patienten, klinische Daten, Verfahrensmerkmale und Ergebnisparameter dokumentiert. Insgesamt wurden 397 Eingriffe bei 293 Patienten eingeschlossen (Durchschnittsalter 69,8 ± 12,0 Jahre; 64,8 % Männer). Die Verschlüsse waren akut (47,5 %), subakut und akut-chronisch (22,2 %) und chronisch (30,3 %). Bei den Zielläsionen handelte es sich um die Arteria iliaca (7,1 %), die Arteria iliaca/femoropoplitea (5,0 %), die Arteria femoropoplitea (59,4 %), die Arteria femoroplitea/unter dem Knie (27,0 %), die Arteria femoroplitea unter dem Knie (1,5 %) und nach einer Bypassoperation (14,9 %). Die Läsionslänge betrug in 61,5 % der Fälle mehr als 20 cm. Eine klinisch erfolgreiche Revaskularisierung wurde in 90,4 % der Fälle erreicht. Eine zusätzliche Thrombolyse war in 32,0 % der Fälle erforderlich. Der arithmetische mittlere Knöchel-Arm-Index stieg von 0,33 ± 0,29 auf 0,81 ± 0,25 (p 0,0001). Bei Bypasstransplantaten war die Wahrscheinlichkeit geringer, dass sie vollständig behandelbar waren und eine zusätzliche Lyse erforderlich wurde (p 0,001). Die primäre Offenheit (keine klinisch bedingte Zielläsionsrevaskularisation) betrug 93,2 %, 88,8 %, 79,1 % und 72,4 % nach 1, 3, 6 bzw. 12 Monaten. Unerwünschte Ereignisse traten in 46,1 % der Fälle auf, wobei die periphere Embolie (22,4 %) am häufigsten war und in 67,4 % der Fälle eine interventionelle Behandlung erforderlich machte. Die RT stand in direktem Zusammenhang mit 7,1 % (n = 28) der Komplikationen, bei denen es sich um Perforationen (2,8 %), arteriovenöse Fisteln (1,3 %) und Dissektionen (2,0 %) handelte. Die Rotationsthrombektomie ist eine sichere und effiziente Methode zur Behandlung von Verschlüssen des arteriellen Kreislaufs der unteren Extremität, wobei Bypassverschlüsse eine höhere Neigung zu Restthromben aufweisen, die eine weitere Lysetherapie erfordern. · Rotationsthrombektomien waren sichere und wirksame Behandlungsmethoden von Verschlüssen der unteren Extremitäten.. · Rotationsthrombektomien waren mit 7,1 % der Komplikationen verbunden.. · 22,4 % der Fälle zeigten distale Embolien, hiervon erforderten 67,4 % eine interventionelle Therapie.. · Die primäre Offenheit betrug 93,2 %/88,8 %/79,1 %/72,4 % nach jeweils 1/3/6/12 Monaten..

Complex endovascular therapy of the aorta with fenestrated and branched endografts plays an essential role in modern vascular medicine. Innovative solutions for demanding aortic pathologies are therefore being constantly developed by the medical industry. The aim of this manuscript is to illustrate the growing importance of the inner branches in complex aortic repair and to show the advantages and limits of this technique with an overview of the current literature. The inner branches (iBEVAR) were therefore compared to the standard treatment options (fenestrations; [FEVAR], outer branches [BEVAR]) and the technical advantages of all platforms were evaluated. The widespread use of iBEVAR in the aortic arch stands in contrast to the thoracoabdominal aorta, which is mirrored by the scarce evidence for the thoracoabdominal inner branches. The published experience is based on smaller retrospective studies with a 1-year follow-up. The E-nside (Artivion, Hechingen, Germany) thoracoabdominal off-the-shelf inner-branch-based endograft was released 2 years ago. Its widespread deployment may increase the use of the inner branches in the thoracoabdominal aorta. Moreover, an ongoing industry-funded registry may provide new insights into the long-term durability of this innovative technique.Die komplexe endovaskuläre Therapie der Aorta mit fenestrierten und gebranchten Prothesen spielt eine wichtige Rolle in der heutigen Gefäßmedizin. Daraus resultieren innovative medizintechnische Lösungen, die für immer anspruchsvollere Aortenpathologien eingesetzt werden. Das Ziel dieser Arbeit war es, die zunehmende Bedeutung der „inner Branches“ in der komplexen Aortenchirurgie darzustellen. Die Vorteile und Grenzen dieser Technik sollten aufgezeigt und die aktuelle Datenlage zusammengefasst werden. Dazu wurden die „inner Branches“ (iBEVAR) den Standardverfahren (Fenestrationen [FEVAR], „outer Branches“ [BEVAR]) gegenübergestellt und ihre technischen Vor- und Nachteile erarbeitet. Kennzeichnend ist der weit verbreitete Einsatz der iBEVAR im Aortenbogen im Gegensatz zur thorakoabdominellen Aorta, was sich auch in der spärlichen Datenlage im thorakoabdominellen Abschnitt widerspiegelt. Die Letztere basiert auf kleineren retrospektiven Studien mit 1-jährigem Follow-up. Die seit 2 Jahren verfügbare thorakoabdominelle „off-the-shelf“-Prothese wird voraussichtlich zu einer weiteren Verbreitung der „inner Branches“ im thorakoabdominellen Abschnitt führen, wobei die von der Industrie geförderte Registerstudie wichtige Evidenz zur erörterten Technik bereitstellen könnte.

OBJECTIVES Our goal was to evaluate results of endovascular aortic arch repair using the Relay Branch system. METHODS Forty-three patients with thoracic aortic pathology involving the aortic arch have been treated with the Relay Branch system (Terumo Aortic, Sunrise, FL, USA) in 10 centres. We assessed in-hospital mortality, neurological injury, treatment success according to current reporting standards and the need for secondary interventions. In addition, outcome was analysed according to the underlying pathology: non-dissective disease versus residual aortic dissection (RAD) (defined as remaining dissection after previous type A repair, chronic type B aortic dissections). RESULTS In-hospital mortality was 9% (0% in patients with RAD). Disabling stroke occurred in 7% (0% in patients with RAD); non-disabling stroke occurred in 19% (7% in patients with RAD). Early type IA and B endoleak formation occurred in 4%. Median follow-up was 16 ± 18 months. During the follow-up period, 23% of the patients died. Aortic-related deaths were low (3% in patients with RAD). CONCLUSIONS The results of endovascular aortic arch repair using the Relay Branch system in a selected patient population with regard to technical success are good. In-hospital mortality is acceptable, the number of disabling strokes is low and technical success is high. Non-disabling stroke is a major concern, and every effort has to be taken to reduce this to a minimum. The best outcome is seen in patients with underlying RAD. Finally, more data are needed.

Prolonged ischemia of tissues inevitably leads to their necrosis. This is especially relevant in the case of transplantation or replantation. In such situations, reperfusion in a timely manner might not be possible due to transportation times or other unforeseen complications. Therefore, a readily available and simple method to oxygenate the tissue and thus widen the time frame to reperfusion seems desirable. Here, we present the case of extracorporal perfusion of a latissimus dorsi (LD) flap that was successfully transplanted after nearly 6 hr of ischemia. A 41-year-old patient suffered multiple injuries including complete severance of the popliteal artery requiring emergency bypass. After stabilization of the patient and subsequent debridement, a LD flap was performed for soft tissue coverage. However, there was an acute occlusion of the bypass during flap inset. To salvage the free flap, a one-way extracorporal perfusion of the flap with heparinized isotonic saline solution was performed for a total of 5 hr and 47 min. The flap survived with minimal tip necrosis. This case report describes the application of a simple extracorporal perfusion technique for salvage of a free flap over a prolonged ischemia time and discusses the relevant literature. Due to its ease and quickness of application as well as ubiquitous availability, it might serve as a valuable tool in cases of acute problems with the recipient vessels or other incidents where several hours of ischemia time are to be anticipated.

Objective To evaluate the safety and effectiveness of tibiopedal and distal femoral access for retrograde crossing of chronic total occlusion (CTO) in Rutherford stage III to VI peripheral arterial occlusive disease, and to determine factors that correlate with technical success. Material and methods One hundred seventy-one consecutive patients were included in this retrospective study. Rutherford stages were III, IV, and V/VI in 24%, 8%, and 67% of patients. Inclusion criteria were CTO at the superficial femoral (SFA), popliteal (PA), and/or below-the-knee (BTK) level, and a failed antegrade treatment followed by a distal retrograde approach. The numbers of occluded vascular levels (OVL), lesion length, degree of calcification, technical success rate, complications, and clinical outcome were noted. Results OVL were 1 in 72%, 2 in 20%, and 3 in 8% of patients. CTOs were longer than 20 cm in 45.6% of cases and showed severe calcifications in 50.3%. Target vessels for distal access were the distal SFA/PA in 17% and BTK in 83%. The overall technical success rate was 82%. Severe calcification decreased technical success (p = 0.01) despite lesion length and Rutherford stage. Clinical outcome improved in 123/152 patients with a significant increase of the median ABI (N = 158) from 0.53 (interquartile range 0.39 to 0.61) to 0.85 (0.59 to 1.03; p Conclusion The tibiopedal and distal femoral retrograde access presents a safe and effective treatment option of CTOs at the thigh and/or BTK after a failed antegrade attempt improving clinical outcome. Technical success decreased with lesion’s degree of calcification. Key Points • Safety and effectiveness of the tibiopedal and distal femoral access for retrograde crossing of chronic total occlusion. • Target lesion’s degree of calcification decreases technical success. • Complications related to the distal vascular access were rare.

Background Intracardial migration of a ventriculoperitoneal (VP) shunt (ICMVP) is a rare complication that has been described in only single case reports. Here we report the successful interdisciplinary management of an ICMVP and provide a review of the relevant literature. Case Description A 38-year-old-patient with shunt-dependent hydrocephalus caused due to a Blake's pouch cyst presented in our hydrocephalus outpatient clinic with thoracic pain and nocturnal cough at 7 months after VP shunt implantation (with initially a proper location on computed tomography scan of the head and X-ray of the abdomen). A new X-ray of the abdomen and the thorax revealed a dislocated shunt with migration of the distal catheter into the superior cava vein, right atrium, and right heart ventricle, with some loops in both pulmonary arteries. The catheter was successfully removed by an interdisciplinary team in general anesthesia under ultrasound, X-ray guidance, and cardiovascular parameter control by withdrawing the shunt into the superior cava vein and removing the remnant portion of the distal catheter (with a knot) by interventional snaring. Cardiac and vascular surgeons were on standby. Conclusions The management of an ICMVP is complex and carries a high risk for severe potential complications. Two different pathophysiological mechanisms have been discussed in the literature, including gradual erosion into an adjacent vein and transvenous catheter placement of the initial shunt secondary to subcostal placement of shunt tunneling instruments. The suction effect of the venous system results in gradual pulling of the catheter into the venous system.

Branched endovascular aneurysm repair (BEVAR) is increasingly being performed with the off-the-shelf devices. We evaluated the use of the wire-assisted sheath stabilization technique for the new inner branch-based (iBEVAR), off-the-shelf E-nside endograft in 2 patients. The cannulation of the 8 reno-visceral target vessels and the BSG implantation were successfully performed using the total transfemoral approach. Complications were not observed during the 3-month follow-up. The wire-assisted sheath stabilization technique was shown feasible in an off-the-shelf iBEVAR.

Purpose: The aim was to assess the mid-term aortic remodeling and bare-metal stent (BMS) integrity of the restricted bare stent (RBS) technique reconstruction in aortic dissections. Materials and Methods: This retrospective cohort study included prospectively collected patients treated with the modified RBS technique between 2017 and 2020. The preoperative, postoperative, and last follow-up computed tomographic (CT) scans were analyzed in the centerline at the mid-descending, celiac trunk (CeT), and the mid-abdominal levels for false lumen (FL) patency, aortic diameter, and true lumen (TL) diameter changes. Bare-metal stent integrity was assessed in the 3-dimensional multiplanar reformats. Results: The median follow-up of the cohort (n=17) was 26 (11, 45) months. The procedure was mainly performed with the Relay NBS endograft (15/17; 88%) + E-XL BMS (17/17; 100%). Postoperative mortality, paraplegia, stroke, renovisceral vessel loss, and type I and III endoleaks were not observed. BMS fractured in 6 patients (6/17; 36%), damaged the dissection flap in 4/17 (24%), and led to the reperfusion of the FL and re-interventions with TEVAR (4/17; 24%). Two patients without FL reperfusion showed stable CT follow-ups 13 and 17 months after the fracture diagnosis. The TL expansion was seen at all landmarks and peaked in the thoracic aorta (+10; 6, 15; pConclusion: The modified RBS technique could not stop aortic growth below the diaphragm and prevent new membrane rupture due to the fractures of the BMS and consecutive flap damage with the reperfusion of the FL. Clinical Impact The treatment of complicated type B aortic dissections with TEVAR has become a standard. Particularly, patients with true lumen collapse and malperfusion may benefit from a more aggressive treatment strategy including proximal TEVAR and distal bare-metal stent implantation to re-open the true lumen and to prevent distal stent-induced new entry. However, this study reports the challenges of this approach with a high rate of bare-metal stent fractures during the follow-up. The fractures that occurred at the site of vertical nitinol bridges led to the dissection membrane ruptures and the reperfusion of the false lumen with consecutive dilatation. A close follow-up is mandatory to detect this complication and to treat the patients with TEVAR extension.

The aim of this study was to evaluate morphologic changes in dissected aortas after thoracic endovascular aortic repair (TEVAR) with the use of the Relay Nonbare stent graft stent graft by focusing on the geometric stent graft's performance in remodeling aortas.We conducted a retrospective three-dimensional computed tomography analysis preoperatively, postoperatively, and 6 months after TEVAR in patients with residual dissection after type A and those with acute and chronic type B dissections at two German centers.Thirty-nine acute and 54 chronic aortic dissections were included. Median follow-up was 200 (interquartile range, 109-617) days. TEVAR induced aortic remodeling in both groups. Complete false lumen thrombosis along the stent graft (postoperative, 73%; follow-up, 84%; P .0001) led to a decrease in aortic diameter at the middle stent graft level (preoperative, 45.9 mm [38.6-56.6] vs follow-up, 43.6 [37.4-52.4] mm; P = .009). True lumen expansion was observed in both groups and peaked in acute dissections in the distal landing zone (acute, +9.3 mm vs chronic, +5.8 mm; P .0001). Migration was 2 (0-5) mm, and bird-beak and endoleak type IA rates were 20% and 4%, respectively. There was no retrograde type A dissection. Distal stent graft-induced new entry occurred in 15%; the major risk factor for incidence was the stent graft's wedge apposition angle (odds ratio, 1.365 [confidence interval, 1.115-1.671]; P = .003).TEVAR with the use of the Relay NBS promotes aortic remodeling in acute and chronic dissections, entailing a low risk of migration, type IA endoleaks, and retrograde type A dissections. Wedge apposition was the predominant risk factor for distal stent graft-induced new entry.

The aim was to evaluate the incidence of stroke in the setting of cardiac surgery with or without hemodynamically relevant asymptomatic carotid stenosis contralateral to the occlusion. We designed a historical cohorts study, focused on patients with unilateral totally occluded internal carotid arteries who were referred for any cardiac surgery at our center. Isolated unilateral occlusions were assigned to group 1 (n = 60), and those with a contralateral stenosis grade ≥ 60% were included in group 2 (n = 51). A total of 111 patients operated in our center from 1997 to 2016 were included. Patients in group 2 had an asymptomatic contralateral internal carotid artery stenosis with a mean stenosis grade of 71 ± 20%. Simultaneous carotid endarterectomy (CEA) was performed in 22 patients from group 2. The overall mortality was 8/111 (7.2%). Carotid-associated mortality was not observed, whereas an overall stroke incidence of 8/111 (7.2%) was detected. The group-related outcome showed comparable results for mortality (group 1: 4/60 (6.7%) vs. group 2: 4/51 (7.8%); p = 1.0). Regarding stroke incidence, group 2 had a higher incidence of overall strokes (2/60 (3.3%) vs. 6/51 (11.8%); p = 0.14) with more contralateral (0/60 (0%) vs. 2/51 (3.9%); p = 0.209) and ipsilateral strokes (2/60 (3.3%) vs. 4/51 (7.8%); p = 0.411). Stroke rate peaked in patients with simultaneous carotid and cardiac surgery (n = 22; 18.2%; p = 0.048). Performing simultaneous CEA during cardiac surgery in the presence of a contralateral occlusion may promote stroke. Asymptomatic contralateral carotid stenosis is a risk factor for stroke in patients with carotid occlusion prior to cardiac surgery.

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of-in analogy to the heart team-aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta-the aortic root, in particular in acute type A aortic dissection-which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.

Background The study sought to learn about incidence and reasons for distal stent graft–induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. Methods In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. Results The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. Conclusions dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.

Purpose To assess outcomes of a low-profile thoracic stent-graft in the treatment of thoracic aortic pathologies. Methods A retrospective analysis of all consecutive patients with aortic thoracic pathologies treated with the RelayPro device in two university hospitals between October 2018 and July 2019. Results 23 patients (65% men; mean age 63.4 ± 15 years) were treated. Pathologies included aortic dissections (n = 10), 5 residual type A (22%) and 5 type B (22%), 6 degenerative aortic aneurysms (26%), 4 penetrating aortic ulcers (17%), and aortic erosion, intramural hematoma and aortic rupture (n = 1 and 4% in each case). Two cases (9%) were emergent and two urgent. Proximal landing was achieved in zones 0 (4%), 1 (4%), 2 (43%), and 3 (26%). Five grafts were frozen elephant trunk extensions. Technical success was 100% with accurate device deployment in the intended landing zone of the aortic arch in all 23 patients and with no Ia/III endoleaks and three (13%) type II endoleaks. Apposition was adequate in 96%. Two patients had post-implantation syndromes (one fever, one leukocytosis). Mean follow-up was 11.6 ± 3.7 months (range, 2–16) with no other complications, secondary interventions or conversions to open surgery. There was no 30-day mortality and no aortic-related mortality; all-cause mortality was 4% during follow-up. Conclusion A 3–4 French reduced profile in the current generation of stent-grafts facilitates TEVAR particularly in patients with smaller vessels access. Early safety and effectiveness outcomes are favorable, even in endpoints such as deployment accuracy and apposition which may be surrogates for longer-term clinical success and durability.

Elastin is one of the most important and abundant extracellular matrix (ECM) proteins that provide elasticity and resilience to tissues and organs, including vascular walls, ligaments, skin, and lung. Besides hereditary diseases, such as Williams-Beuren syndrome (WBS), which results in reduced elastin synthesis, injuries, aging, or acquired diseases can lead to the degradation of existing elastin fibers. Thus, the de novo synthesis of elastin is required in several medical conditions to restore the elasticity of affected tissues. Here, we applied synthetic modified mRNA encoding tropoelastin (TE) for the de novo synthesis of elastin and determined the mRNA-mediated elastin synthesis in cells, as well as ex vivo in porcine skin. EA.hy926 cells, human fibroblasts, and mesenchymal stem cells (MSCs) isolated from a patient with WBS were transfected with 2.5 μg TE mRNA. After 24 hr, the production of elastin was analyzed by Fastin assay and dot blot analyses. Compared with untreated cells, significantly enhanced elastin amounts were detected in TE mRNA transfected cells. The delivered synthetic TE mRNA was even able to significantly increase the elastin production in elastin-deficient MSCs. In porcine skin, approximately 20% higher elastin amount was detected after the intradermal delivery of synthetic mRNA by microinjection. In this study, we demonstrated the successful applicability of synthetic TE encoding mRNA to produce elastin in elastin-deficient cells as well as in skin. Thus, this auspicious mRNA-based integration-free method has a huge potential in the field of regenerative medicine to induce de novo elastin synthesis, e.g., in skin, blood vessels, or alveoli.

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

To compare a low-dose, tin-filtered, nonenhanced, high-pitch Sn100 kVp CT protocol (Sn100) with a standard protocol (STP) for the detection of calcifications in the ascending aorta in patients scheduled for cardiac surgery. Institutional Review Board approval for this retrospective study was waived and the study was HIPAA-compliant. The study included 192 patients (128 men; age 68.8 ± 9.9 years), of whom 87 received the STP and 105 the Sn100 protocol. Size-specific dose estimates (SSDE) and radiation doses were obtained using dose monitoring software. Two blinded readers evaluated image quality on a scale from 1 (low) to 5 (high) and the extent of calcifications of the ascending aorta on a scale from 0 (none) to 10 (high), subdivided into 12 anatomic segments. The Sn100 protocol achieved a mean SSDE of only 0.5 ± 0.1 mGy and 0.20 ± 0.04 mSv compared with the mean SSDE of 5.4 ± 2.2 mGy achieved with the STP protocol (p < 0.0001). Calcification burden was associated with age (p < 0.0001), but was independent of protocol with mean calcification scores of 0.48 ± 1.23 (STP) and 0.55 ± 1.25 (Sn100, p = 0.18). Reader agreement was very good (STP κ = 0.87 ± 0.02, Sn100 κ = 0.88 ± 0.01). The STP protocol provided a higher subjective image quality than the Sn100 protocol: STP median 4, interquartile range 4–5, vs. SN100 3, 3–4; p < 0.0001) and a slightly better depiction of calcification (STP 5, 4–5, vs. Sn100 4, 4–5; p < 0.0001). The optimized Sn100 protocol achieved a mean SSDE of only 0.5 ± 0.1 mGy while the depiction of calcifications remained good, and there was no systematic difference in calcification burden between the two protocols. • Tin-filtered, low-dose CT can be used to assess aortic calcifications before cardiac surgery • An optimized Sn100 protocol achieved a mean SSDE of only 0.5 ± 0.1 mGy • The depiction of atherosclerosis of the thoracic aorta was similar with both protocols • The depiction of relevant thoracic pathologies before cardiac surgery was similar with both protocols

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.

Objective The objective of this study was to compare outcomes of patients with favorable neck angulation (FNA) and hostile neck angulation (HNA) treated with the Treovance stent graft (Terumo Aortic [formerly Bolton Medical], Sunrise, Fla). Methods Patients with abdominal aortic aneurysms suitable for endovascular repair with Treovance were included in the RATIONALE postmarket surveillance registry. A post hoc subgroup analysis compared patients with infrarenal neck angles Results After 1 year, 179 FNA (89.5%) and 21 HNA (10.5%) patients were analyzed. Both groups were similar in terms of sex (male, 92.7% FNA and 95.2% HNA) and age (73.0 years vs 72.6 years), but the HNA group had more Asian or other race representation (7.3% vs 19.0%) and more patients assigned to American Society of Anesthesiologists class 3 and class 4 (57.6% vs 66.7%). Mean suprarenal angles (standard deviation) were 13.1 (±13.5) degrees vs 29.0 (±16.4) degrees; mean infrarenal angles were 23.2 (±16.4) degrees vs 65.4 (±4.6) degrees, respectively. Aneurysm sac size maximum diameter was 58.1 (±9.8) mm vs 62.0 (±14.1) mm. There was a significant difference in unplanned adjunctive procedures (2.2% vs 19.0%; P = .01). Mean procedural duration was also significantly different for HNA patients, who underwent protracted operations (111.3 [±47.3] minutes vs 153.5 [±44.5] minutes; P Conclusions Patients with high neck angulation treated with Treovance underwent more complex procedures but showed equally good technical success and 1-year clinical success parameters.

Objective The aim was to evaluate the potential of near infrared spectrometry (NIRS) monitoring enhanced by autoregulation parameters to detect clamp ischaemia during awake carotid endarterectomy (CEA). Methods This was a prospective, hypothesis generating, single centre observational study. Fifty-nine consecutive patients with carotid artery stenosis, of whom 15 (25%) were symptomatic, were enrolled. The patients underwent awake CEA with NIRS monitoring. Regional oxygen saturation (rSO2), relative tissue haemoglobin concentration (rTHb), and mean arterial blood pressure were captured by ICM + software (University of Cambridge Enterprise, Cambridge, UK). The cerebral oxygenation index (COx) and haemoglobin volume index (HVx) were calculated continuously. Two groups were formed depending on neurological symptoms: a symptomatic group with shunt insertion (shunt) and an asymptomatic group (no shunt). Results Eight patients (14%) became symptomatic and needed intra-operative shunting. The decrease in ipsilateral rSO2 was higher in the shunt group (13.5% vs. 5.3%) and rTHB increased on the non-operated side (+0.05 ± 0.01; p = .016). In symptomatic patients no significant change in rTHB was found during clamping, whereas in asymptomatic patients there was a bilateral increase (ipsilateral: + 0.06 [p = .022]; contralateral: + 0.06 [p = .010]). In asymptomatic patients, ipsilateral COx decreased after clamping (−0.06 ± 0.02; p = .024), indicating functional autoregulation. In symptomatic patients, ipsilateral COx increased to 0.32 (+0.19 ± 0.05; p = .048), indicating loss of autoregulation. Accordingly, pooled ipsilateral and contralateral data showed increasing HVx and COx in symptomatic patients (HVx, p Conclusion In addition to a drop in rSO2, the loss of autoregulatory capacity may be useful in identifying clinically significant clamping ischaemia during CEA under general anaesthesia and may allow optimisation of blood pressure management during awake CEA.

Background We investigated the mid-term results of carotid-axillary bypass (CAB) in the setting of zone II thoracic endovascular aortic repair as an alternative method for the left subclavian artery (LSA) revascularization. Methods Our retrospective, single cohort study included all 69 patients from March 2015 to December 2018 with zone II thoracic endovascular aortic repair and CAB for the revascularization of the LSA. Demographics and clinical data were collected. We assessed several clinical outcomes: local complications (hematoma, injury of the brachial plexus, vagus and sympathetic chain nerve palsies, chyle leakage), subclavian steal, arm ischemia, paraplegia, mortality, and stroke. Follow-up computed tomography scans were analyzed for CAB and vertebral artery (VA) patency and the extent of thrombus formation in the LSA. Results The in-hospital mortality was 3% and the perioperative stroke rate was 4%. Permanent paraplegia occurred in 3%. Perioperative morbidity included irritation of the brachial plexus (1%), sympathetic chain nerve palsy (1%), and wound hematoma in 3% of the cases. Phrenic and vagus nerve lesions and chyle leakage were not observed. Bypass patency was 97% at mean follow-up of 333 ± 39 days. VA occlusion was found in 6% of all cases. Strokes did not occur during the follow-up. Morbidity at follow-up included arm claudication (3%) in two patients with bypass thrombosis. Subclavian steal was observed in 3%. The LSA ostium was ligated (44%), plugged (22%), or left open (35%) in patients without a type II endoleak. Subgroup analysis of LSA thrombosis to the level of the VA was more prevalent after surgical ligature (P = .02), but had no negative effects on CAB or VA patency or stroke. Conclusions CAB is a safe alternative to classic debranching procedures, with distinctive advantages regarding local complication rates described in the literature.

OBJECTIVES Our aim was to compare aortic remodelling in type B dissections after thoracic endovascular aortic repair (TEVAR) or conservative treatment. METHODS We conducted a retrospective analysis of computed tomography (CT) data sets at dissection onset and at the last follow-up in a group with conservative (group A) and TEVAR treatment (group B). An additional analysis of the preoperative CT images was performed in patients from group A, who were converted to TEVAR during follow-up. Diameters and lengths of all aortic segments were measured and growth rates were calculated. RESULTS We included 74 patients: 50 patients in group A (follow-up time: 1625 ± 209 days) and 24 patients in group B (follow-up time: 554 ± 129 days). The mean aortic diameter growth rate was significantly higher in group A than in group B in the mid-descending aorta (A: +7 mm/year; B: −4 mm/year; P = 0.003). Length growth difference was only present in the abdominal aortic segment and was more pronounced in group A (+2 vs ±0 mm/year; P = 0.009). The conversion rate from conservative treatment to TEVAR was 36% (n = 18). A false lumen diameter of >22 mm at baseline was associated with a higher rate of conversion (P = 0.036). After conversion, the mean growth rate in the proximal descending and mid-descending aorta decreased from preoperative +11 and +18 mm/year to postoperative −9 and −14 mm/year, respectively (P CONCLUSIONS In acute type B dissections, TEVAR stops aortic enlargement in the thoracic aorta, but promotes distal dilatation compared to the conservative treatment group. After conversion to TEVAR in conservatively pretreated chronic type B dissections, a more pronounced diameter decrease in the descending aorta was observed than in patients treated in the acute phase.

OBJECTIVES We measured aortic dimensions, particularly length parameters, using 3D imaging with the aim of refining the risk-morphology for Stanford type A aortic dissection (TAD). METHODS Computer tomography angiography studies were analysed using the curved multiplanar reformats. At defined landmarks, the diameters and lengths of aortic segments were recorded. Three groups were compared retrospectively: patients actually suffering from a TAD (TAD-group; n = 150), patients before suffering a TAD (preTAD-group n = 15) and a healthy control group ( n = 215). Receiver operating characteristic curves (ROCs) were analysed (control versus preTAD) to study the diagnostic value of the individual variables. RESULTS Median diameters of preTAD (43 mm) and TAD (50 mm) aortas were significantly ( P

Background Ascending aorta or hemi-arch repair are common in the acute phase of type A dissection. Postdissection aneurysms can develop with antegrade perfusion of the false lumen in the dissected aortic arch and require reoperation. Methods From 2012 to 2018, we reoperated nine patients with postdissection aneurysms using a hybrid technique without cardiopulmonary bypass. The patients had a EuroSCORE II of 13% and a logistic EuroSCORE I of 45% and were not candidates for frozen elephant trunk surgery. The median interval since the acute ascending repair was 184 (92; 528) days. All patients were treated by median resternotomy, ascending to carotid bypass on a partially clamped ascending graft, and transfemoral endovascular repair with a Relay NBS (nonbare stent) or conformable Gore C-TAG stent graft. Results Technical success was achieved in all cases. Mean follow-up was 405 (220; 672) days. There was no disabling stroke, endoleak, paraplegia, in-hospital, or late mortality. In all patients, the false lumen was completely thrombosed at the aortic arch level with a median aneurysm shrinkage of 13 mm in the distal arch. There was no bird beak or stent graft migration. Distal stent-induced new entry was observed in one case. Reinterventions were not necessary due to diameter stability. Conclusion Complete debranching with transfemoral thoracic endovascular aneurysm repair showed encouraging results in patients with relevant comorbidities. The used stent grafts performed well in the mid-term follow-up period with no endoleaks or migration.

Background Post-coarctation of the aorta (CoA) pseudoaneurysms is a complication of open repair. Thoracic endovascular repair (TEVAR) is feasible but complicated by proximity to the supra-aortic trunks and severe arch angulation. Methods We describe three cases of post-CoA pseudoaneurysms treated with custom-made Relay stent grafts (Vascutek, Scotland). Results Technical and clinical success was achieved in all three cases with no mortality, morbidity, endoleaks, or complications. In all three, pseudoaneurysm sac shrinkage was observed at the follow-ups; in one case, there was complete resolution. Conclusion Redo open surgery is challenging because of adhesions of the thoracic cavity and associated morbidity and mortality. TEVAR is less invasive and offers fewer complications. Custom-made modifications overcome difficult anatomies including short landing zones and diameter variability.

OBJECTIVES Thoracic endovascular aortic repair is the treatment of choice in complicated acute type B aortic dissection. How to infer predissection aortic diameter is not well understood. Our aim was to delineate changes in descending aortic geometry due to dissection. METHODS Five tertiary centres reviewed their acute aortic dissection type B databases containing 802 patients. All patients who had undergone computed tomography angiography less than 2 years before and immediately after aortic dissection onset were included. We compared the aortic geometry before and after the dissection onset. RESULTS Altogether 25 patients were included [median age 60 (first quartile 52, third quartile 72) years; 60% men]. In all except 1 patient, the maximum descending aortic diameter was less than 45 mm before aortic dissection onset. The largest increase in diameter induced by the dissection was observed in the proximal descending aorta 28.2 (25.1, 32.1) vs 34.6 (31.3, 39.1) mm (+6.4 mm; +23%; P < 0.001). The thoracic descending aortic length increased after the dissection onset [253.3 (229.3, 271.9) vs 261.3 (247.9, 285.4) mm; P = 0.003]. The predissection aortic diameter of the proximal thoracic descending aorta was 7.9 (5.2, 10.7) mm larger ( P < 0.001) than the post-dissection area-derived true-lumen diameter and 2.5 (1.3, 6.1) mm larger than the maximum true-lumen diameter ( P < 0.001). CONCLUSIONS Type B aortic dissection increases the diameter, length and volume of the descending thoracic aorta. The predissection aortic diameter most closely resembles the post-dissection maximum diameter of the true lumen.

Purpose: To evaluate the safety and performance of the Treovance stent-graft. Methods: The global, multicenter RATIONALE registry ( ClinicalTrials.gov; identifier NCT03449875) prospectively enrolled 202 patients (mean age 73.0±7.8 years; 187 men) with abdominal aortic aneurysms (AAA) suitable for endovascular aneurysm repair (EVAR) using the Treovance. The composite primary safety endpoint was site-reported all-cause mortality and major morbidity. The primary efficacy outcome was clinical success. Further outcomes evaluated included technical success; stent-graft migration, patency, and integrity; endoleak; and aneurysm size changes. Results: Technical success was 96% (194/202); 8 patients had unresolved type I endoleaks at the end of the procedure. There was no 30-day mortality and 1% major morbidity (1 myocardial infarction and 1 bowel ischemia). Clinical success at 1 year was confirmed in 194 (96%) patients; 6 of 8 patients had new/persistent endoleaks and 2 had aneurysm expansion without identified endoleak. A total of 8 (4%) reinterventions were required during the mean 13.7±3.1 months of follow-up (median 12.8). At 1 year, the Kaplan-Meier estimate for freedom from reintervention was 95.6% (95% CI 91.4% to 97.8%). Other estimates were 95.5% (95% CI 91.7% to 97.6%) for freedom from endoleak type I/III and 97.4% (95% CI 94.2% to 98.9%) for freedom from aneurysm expansion. Thirteen (6.4%) patients died; no death was aneurysm related. Conclusion: The RATIONALE registry showed favorable safety and clinical performance of the Treovance stent-graft for the treatment of infrarenal AAAs in a real-world setting.

OBJECTIVES To study the lengths and diameters of aortic segments in healthy and diseased aortas and to assess the role of aortic elongation in Type A aortic dissection (TAD) prediction. METHODS Ectasia and aneurysm were defined by ascending aorta diameters of 45-54 mm and ≥55 mm, respectively. Computed tomography angiography studies of 256 healthy, 102 ectasia, 38 aneurysm, 17 pre-TAD and 166 TAD aortas were analysed using curved multiplanar reformats. RESULTS The study groups were structurally equal. The diameter of the ascending aorta was 35 mm in the control group and was larger (P

Sowohl im thorakalen Abschnitt der Aorta als auch im Bereich der Aorta abdominalis werden zunehmend Endovaskularprothesen eingesetzt. So kann man uber einen minimalinvasiven Zugang – meist uber die A. femoraliscommunis – Aneurysmen ausschalten und damit eine spatere Ruptur verhindern. Auch Aneurysmarupturen und traumatische Aortenrupturen werden erfolgreich endovaskular behandelt. Bei Stanford-B-Aortendissektionen setzt man Endovaskularprothesen zum Verschluss des proximalen Intima-Einrisses („Entry“) ein und verhindert dadurch die Perfusion des „falschen Lumens“, das weitere Wachstum des Aneurysma und die Ruptur des falschen Lumens. Die Erfolge der endovaskularen Therapie haben zur Entwicklung moderner Stentprothesen mit Seitenarmen sowie von fenestrierten Prothesen mit Aussparungen fur abdominelle Gefasabgange gefuhrt, die eine Versorgung von komplexen thorakoabdominellenAortenpathologien moglich machen. Endovaskulare Eingriffe sind fur Patienten mit ausgepragter Komorbiditat deutlich schonender als die alternativen offenen chirurgischen Verfahren. Perioperative Morbiditat und Mortalitat sinken.