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Objective: The aim of this study is to evaluate the deformations of the femoropopliteal (FP) arterial segment due to knee flexion in patients suffering from popliteal aneurysm before and after endovascular treatment (ET)., Design and Methods: Nine patients were prospectively evaluated. Pre-operative and post-operative computed tomography angiography (CTA) scans were performed on the leg of each patient in both a flexed and extended knee position. The images were employed to reconstruct the FP segment through segmentation and the resulting models were subsequently used to calculate the average diameter, length, and tortuosity of both the superficial femoral artery (SFA) and popliteal artery (PA). Furthermore, the overall PA tortuosity was decomposed into 2 components, ie, antero-posterior and lateral direction., Results: Following knee flexion, both arterial segments experienced shortening in the pre-operative and post-operative phases. Specifically, the SFA was shortened by 3.5% in pre (p<0.001) and 1.21% in post-stenting (p<0.001), while the PA was shortened by 4.8% (p<0.001) and 5.63% (p<0.001), respectively. Tortuosity significantly increased in all considered segments; in particular, in SFA there was a pre-intervention increase of 85.2% (p=0.002) and an increase of 100% post-intervention (p=0.004), whereas in the PA, there was an increase of 128.9% (p<0.001) and 254.8% (p<0.001), respectively. The only diameter variation occurred in the SFA pre-operatively with an increase of 11.9% (p=0.007). Tortuosity decomposition revealed significant differences between the 2 planes during the pre-operative and post-operative phases in both extended and flexed configurations, confirming a change in artery position and geometry due to treatment., Conclusions: Knee flexion induces arterial shortening and increased tortuosity in both the pre- and post-operative configuration. Stent placement does not induce significant geometric differences between pre-treatment and post-treatment. These results seem to indicate that the geometry of the covered stent is not affected by the flexion of the knee joint. Despite this, a more detailed analysis of arterial tortuosity showed a change in artery deformation following treatment., Clinical Impact: This study aimed to evaluate femoropopliteal arterial deformations in nine patients with popliteal aneurysm before and after endovascular treatment (ET) during knee flexion, using a standardized protocol for CTA acquisition and analysis. The result can be useful in procedure planning and have shown that the Viabahn stent used can adapt to the morphological variations induced by limb flexion. Consequently, device failure does not be attributed to stent compression but rather to other factors, such as alterations in hemodynamic and biomechanical forces on the implant due to the significant changes in tortuosity observed, or biological causes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The aim of the study is to compare the short-term and medium-term outcomes in patients who underwent open repair (OR) or endovascular repair (ER) for peripheral arterial disease (PAD) also including stratifications based on severity and year of the first intervention., Methods: We conducted an observational retrospective single-center cohort study. We evaluated patients with PAD that primarily underwent ER, OR, minor, and major amputations in a single center from 2005 to 2020. The patients were then subdivided according to the type of intervention (OR versus ER), and stratified according to the International Classification of Diseases 9 code reported in the operating documents and to the year intervention. Mortality, minor, and major amputation rates occurring at 30 days, 2 years, and 5 years after the first intervention were evaluated as primary outcomes and compared between patient groups in both stratifications. Moreover, Kaplan-Maier curves were analyzed for these outcomes., Results: One thousand four hundred ninety two patients (67.0% males) with PAD were evaluated. Their clinical presentations were intermittent claudication in 51.4% of cases, rest pain in 16.8%, ulcers in 10.3%, and gangrene in 21.5%. Nine hundred ninety seven (66.8%) underwent OR and 495 (33.2%) ER as first intervention for PAD. No statistical differences were observed in terms of mortality in the 2 groups (OR versus ER, P = 1,000, P = 0.357, and P = 0.688 at 30 days, 2 years, and 5 years, respectively). The rate of minor amputations was significantly higher (P < 0.012, P < 0.002, and P < 0.007 at 30 days, 2 years, and 5 years, respectively) for ER group in any of the observed follow-up periods. Also, we have observed that OR and ER do not have any significant short-term and medium-term major amputation rate differences., Conclusions: In our experience, the impact of ER does not significantly change short-term and mid-term major outcomes in patients with PAD., (Copyright © 2024 Elsevier Inc. All rights reserved.)

A case of a new technique for branched endovascular aneurysm repair with a retrograde approach and ostial stenosis of the target vessel is reported. An angioplasty balloon was placed within the target vessel and used to give added stability to catheter advancement to place the stiff guidewire needed for placement of a bridging stent graft. In brief, a standard guidewire was first placed inside the target vessel through the retrograde approach. Next, the balloon was placed from outside the stent graft, again through a contralateral retrograde approach. Then, the angioplasty balloon was inflated, and a support catheter was advanced to the balloon and then slowly deflated to allow the catheter to advance. Finally, the stiff guidewire was placed. Subsequently, the bridging stent was placed and deployed. This technique is feasible and can be used in selected cases to use a retrograde approach when ostial stenosis of the target vessel is present., Competing Interests: None., (© 2023 The Author(s).)

Introduction: The development of intrastent thrombosis is one of the mechanisms related to medium- to long-term failure of endovascular treatment of popliteal artery aneurysm. The present study aims to investigate possible links between the development of endoluminal mural thrombotic apposition in the stented zone (EMTS) with both geometrical features of stent-graft(s) and time of follow-up., Methods: Patients with popliteal artery aneurysm who underwent endovascular treatment were recruited during the follow-up period. Segmentation of computed tomography angiography scan was performed to detect femoropopliteal artery lumen, leg bones, EMTS, and stent-graft(s). The following parameters were assessed: number, diameter, and length of stent-graft(s); and shape, volume, and length of thrombotic apposition within the stent(s). The spiral shape of the thrombotic apposition was evaluated as well., Results: Eighteen male patients were recruited in the study. EMTS was observed in 13 of them (72%) during the follow-up analysis. An average of 1.8 ± 0.79 stents-grafts were implanted per patient with a median diameter and length of 6.2 (1.9) mm and 125 (50) mm, respectively. The percentage of the stent length where EMTS was present was 42.1 on average (interquartile range: 42.4%) with a mean volume of 206.8 mm 3 . A positive correlation was found between the length and volume of EMTS (R-squared = 0.71, p  < 0.01). Moreover, EMTS had a helical shape in 8/13 patients, with 4/5 with counterclockwise rotation with stent-grafts in the left leg and 3/3 with clockwise direction treated in the right leg. A higher frequency of EMTS was observed in patients with longer follow-up and higher risk factors, as well., Conclusions: EMTS is observed in most of the patients under analysis, especially in those with medium- to long-term follow-up. The pattern of such EMTS follows a helical shape having a direction that depends on which leg, right or left, is treated. Our results suggest a close surveillance of popliteal aneurysm stenting by follow-up examinations to control the onset and progression of EMTS., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer FH declared a past co-authorship with the author MC to the handling editor., (© 2023 Spinella, Conti, Magliocco, Pisa, Finotello, Pulze, Pratesi, Cittadini, Salsano and Pane.)

Background: Spinal cord ischemia (SCI) is still a feared complication for patients suffering from thoracoabdominal aortic aneurysm (TAAA) who undergo endovascular treatment. The aims of this work are to review the available literature on different reperfusion methods of the aneurysm sac, and to analyze whether the different reperfusion methods, also in combination with other factors, are effective in reducing SCI risk and if the impact varies with the patient's age., Methods: PubMed/MEDLINE library was searched for studies published until November 2020 concerning TAAA, endovascular repair, and SCI preventive measures. Systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses criteria. Primary outcome consisted of correlation between endovascular repair techniques (type A: single step; type B: staged approach with reperfusion branches; type C: staged sequential approach with positioning of the thoracic component). A logistic-weighted regression for each event (SCI, transient, and permanent) was then performed with type of treatment, age, and interaction between them as input factors. Finally, another logistic-weighted regression was performed to analyze the other relevant factors for which observations are available together with the endovascular technique., Results: Data from 53 studies with a total of 3095 patients were analyzed. Type A, type B, and type C endovascular strategies were adopted in 75%, 13%, and 12% of studied patients, respectively. Data showed that both type B and type C treatments are associated with lower risk of SCI, with a higher reduction of type C with respect to type B, although this positive trend is limited for elder patients. Moreover, a greater aortic diameter, a reduced aneurysm extent, and the absence of cerebrospinal fluid drainage positioning contribute to lower the risk of SCI. Concerning permanent SCI, both type B and type C are effective in reducing percentages for all ages, with type C treatment more beneficial for younger patients and type B for elder ones., Conclusion: According to the anatomy and the endovascular repair feasibility criteria, staged endovascular treatment appears to offer relevant advantages over single-step treatment in reducing the risk of SCI, regardless of the reperfusion method adopted.

Background: The present study evaluates aneurysmal sac remodeling and the loss of the intercostal arteries after the first step of staged treatment of thoracoabdominal aortic aneurysms (TAAAs). The purpose of this approach is to keep the aneurysmal sac temporarily perfused to induce progressive thrombosis of the aneurysm while simultaneously allowing the spinal cord to establish adequate perfusion thereby promoting the development of collateral circulation., Methods: All patients with type II or type III TAAAs, having undergone 2-step endovascular treatment with at least a 2-branch endoprosthesis at our institution between April 2017 and May 2019, were retrospectively evaluated. Thirty-day mortality and spinal cord ischemia was assessed. The mean number of the intercostal and lumbar arteries, coverage length between the left subclavian artery and the stent graft proximal landing zone, total volume of the aneurysmal sac, lumen volume, and thrombosis volume were measured by preoperative and first-step postoperative computed tomography angiography. Patients were also grouped based on the chosen endoprosthesis (group A: double-branch aneurysmal sac reperfusion; group B: single-branch aneurysmal sac reperfusion)., Results: Eleven patients (mean age: 76.5 years; range: 61-86) were considered. No 30-day mortality was observed after the first-step procedure, and 1 patient died after second-step treatment. No permanent paraplegia was observed after either the first or second endovascular steps. The lumen volume significantly decreased (27%; P < 0.001) after first-step endovascular treatment although there was a significant increase in aneurysm thrombosis (34% to 54%). The mean number of the intercostal arteries decreased from 19.7 to 9.3 (P < 0.001) after first-step endovascular treatment. Volume variations and percentage of intercostal loss did not significantly differ between the 2 groups., Conclusions: Although aneurysm volume continued to increase after first-step treatment, two-step endovascular treatment is a feasible alternative to reduce the risk of severe ischemia in patients with extended TAAAs., (Copyright © 2020 Elsevier Inc. All rights reserved.)