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A multidisciplinary approach offering both open surgical repair (OSR) and complex endovascular aortic repair (cEVAR) is essential if patients with thoraco-abdominal aortic aneurysms (TAAAs) are to receive optimal care. This study reports early and midterm outcomes of elective and non-elective OSR and cEVAR for extent I – III TAAA in a UK aortic centre. Retrospective study of consecutive patients treated between January 2009 and December 2021. Primary endpoint was 30 day/in hospital mortality. Secondary endpoint was Kaplan–Meier estimates of midterm survival. Data are presented as median (interquartile range [IQR]). In total, 296 patients (176 men; median age 71 years [IQR 65, 76]; median aneurysm diameter 66 mm [IQR 61, 75]) underwent repair (222 elective, 74 non-elective). OSR patients (n = 66) were significantly younger with a higher incidence of heritable disease and chronic dissection, while cEVAR patients (n = 230) had a significantly higher prevalence of coronary, pulmonary, and renal disease. Overall, in hospital mortality after elective and non-elective repair was 3.2% (n = 7) and 23.0% (n = 17), respectively, with no significant difference between treatment modalities (elective OSR 6.5% vs. cEVAR 2.3%, p =.14; non-elective OSR 25.0% vs. cEVAR 20.3%, p =.80). Major non-fatal complications occurred in 15.3% (33/215) after elective repair (OSR 39.5%, 17/43, vs. cEVAR 9.3%, 16/172; p <.001) and 14% (8/57) after non-elective repair (OSR 26.7%, 4/15, vs. cEVAR 9.5%, 4/42; p =.19). Median follow up was 52 months (IQR 23, 78). Estimated survival ± standard error at 1, 3, and 5 years for the entire cohort was 89.6 ± 2.0%, 76.6 ± 2.9%, and 69.0% ± 3.2% after elective repair, and 67.6 ± 5.4%, 52.1 ± 6.0%, and 41.0 ± 6.2% after non-elective repair. There was no difference in 5 year survival comparing modalities after elective repair for patients younger than 70 years and those with post-dissection aneurysms. A multidisciplinary approach offering OSR and cEVAR can deliver comprehensive care for extent I – III TAAA with low early mortality and good midterm survival. Further studies are required to determine the optimal complementary roles of each treatment modality. [ABSTRACT FROM AUTHOR] more...

Reports of endovascular treatment of chronic post-dissection aneurysms are limited to high volumes centres, posing questions about generalisability. All endovascular repairs of intact pararenal and thoraco-abdominal aneurysms in the Vascular Quality Initiative from 2014 to 2021 were studied, and peri-operative and long term outcomes were compared between repairs of degenerative and post-dissection aneurysms. Peri-operative outcomes were compared using mixed effects logistic regression, and long term outcomes using Medicare linkage. There were 123 patients who completed treatment for post-dissection aneurysms and 3 635 for degenerative aneurysms, with 36% of post-dissection repairs and 6.7% of degenerative repairs performed in a staged fashion (p <.001). The majority (84%) of post-dissection aneurysms were extensive thoraco-abdominal aneurysms (TAAAs: Crawford Type 1, 2, 3, 5), compared with 22% of degenerative aneurysms (p <.001). Physician modified endografts were the primary repair type for post-dissection (73%), while commercially available fenestrated grafts were the dominant repair for degenerative (48%). The first stage of staged procedures was associated with a 2.8% peri-operative mortality rate, 5.1% spinal cord ischaemia, and 8.9% thoraco-abdominal life altering events (the composite of peri-operative death, stroke, permanent spinal cord ischaemia, and dialysis). Th final stage procedure and fluoroscopy times were similar, but technical success was lower in post-dissection repairs (75% vs. 83%, p =.018), both due to issues with the main endograft or bridging vessels (11% vs. 6.6%, p =.055), and types 1and 3 endoleak at completion (17% vs. 10%, p =.035). In addition, high volume surgeons had two fold higher odds of technical success than their low volume counterparts. Adjusted peri-operative outcomes were similar between pathology types, including when comparisons were restricted to extensive TAAAs. Crude and adjusted three year survival were similar, but three year re-interventions were significantly higher following post-dissection repairs (p <.001). Complex endovascular repair of chronic post-dissection aneurysms is feasible but is associated with high rates of re-interventions and non-trivial rates of lack of technical success. More data are needed to evaluate the long term durability of these procedures, and the utility of centralising these complex procedures. [ABSTRACT FROM AUTHOR] more...

A 67-year-old woman was referred to the cardiothoracic outpatient clinic with a long-standing asymptomatic type 2 thoracoabdominal aneurysm. Her CT aorta showed extensive disease in the distal arch with no safe landing zone for total endovascular aneurysm repair (TEVAR). An acute bend preceding the descending aorta also made using a conventional elephant trunk challenging. A multi-disciplinary team decision was made to perform an aortic arch replacement using a frozen elephant trunk at zone 0. Utilizing a zone 0 approach in an elective case can result in quicker organ perfusion and successful TEVAR if necessary. [ABSTRACT FROM AUTHOR] more...

Branched endovascular aneurysm repair (bEVAR) are routinely used in clinical practice in patients with complex aortic anatomy. However, they can lead to a number of complications, notable among which are the risk of stent-graft migration and rotation. We present the case of a patient treated for a thoracoabdominal aortic aneurysm in whom, as a result of stent-graft rotation, the dedicating branch of the left renal artery was located in the exit of the superior mesenteric artery. [ABSTRACT FROM AUTHOR] more...

Fenestrated and branched endografting (F/B-EVAR) has been proposed as an endovascular solution for chronic post-dissection thoraco-abdominal aneurysms (PD-TAAAs). The aim of this study was to analyse the experience of four high volume centres nationwide and the current available literature. Data on patients undergoing F/B-EVAR in four Italian academic centres between 2008 and 2019 were collected, and those from patients with PD-TAAAs were analysed retrospectively. Peri-operative morbidity and mortality were assessed as early outcomes. Survival, freedom from re-intervention (FFR), target visceral vessel (TVV) patency, and aortic remodelling were assessed as follow up outcomes. A MEDLINE search was performed for studies published from 2008 to 2020 reporting on F/B-EVAR in PD-TAAAs. Among 351 patients who underwent F/B-EVAR for TAAAs, 37 (11%) had PD-TAAAs (Crawford's extent I–III: 35% – 95%). Overall, 135 TVVs (from true lumen 120; false lumen seven; both true and false lumen eight) were accommodated by fenestrations (96% – 71%) and branches (39% – 29%). Technical success (TS) was achieved in 34 (92%) cases with three failures due to endoleaks (Ia: 1; Ic: 1; III: 1). There were no 30 day deaths. No cases of permanent spinal cord ischaemia (SCI) were recorded and six (16%) patients suffered from transient deficits. Renal function worsening (eGFR < 30% than baseline) and pulmonary complications were reported in two (5%) and four (11%) cases, respectively. From the Kaplan–Meier analysis, three year survival, FFR, and TVV patency were 81%, 66%, and 97%, respectively. Radiological imaging was available for 30 (81%) patients at 12 months with complete false lumen thrombosis in 26 (87%). Two hundred and fifty-six patients were reported in seven published papers with TS, 30 day mortality, and SCI ranging from 99% to 100%, 0 to 6%, and 0 to 16%, respectively. The mean follow up ranged from 12 to 26 months, with estimated two year survival between 81% and 90% and a re-intervention rate between 19% and 53%. F/B-EVAR is effective to treat PD-TAAAs. A high re-intervention rate is necessary to complete the aneurysm exclusion and promote aortic remodelling successfully. [ABSTRACT FROM AUTHOR] more...

Objective: The aim of the study was to report outcomes of a thoraco-abdominal, custom made, low profile (outer diameter 20 F) four branched endograft used as an off the shelf (OTS) solution for urgent juxta- and pararenal abdominal aortic aneurysms (JP-AAAs) and thoraco-abdominal aortic aneurysms (TAAAs) in the presence of hostile femoral or iliac access., Methods: Data for patients who underwent endovascular repair for urgent JP-AAAs and TAAAs with hostile femoral or iliac access by a low profile, four branched endograft in four European aortic centres between 2019 and 2023 were collected prospectively and analysed retrospectively. The investigated device was a custom made endograft with the configuration of a standard t-Branch, used as an OTS solution for urgent cases with hostile femoral or iliac access. Access related complications, spinal cord ischaemia (SCI), and 30 day death were assessed as primary outcomes. Survival, freedom from re-interventions (FFRs), and iliac limb occlusion (ILO) were evaluated as secondary outcomes., Results: Fifty five cases were enrolled: ruptures, n = 14 (25%); symptomatic, n = 12 (22%); and asymptomatic TAAAs with diameter ≥ 80 mm, n = 29 (53%). There were seven (13%) JP-AAAs and 48 (87%) TAAAs. The median right and left external iliac artery diameters were 6.7 (interquartile range [IQR] 5.5, 7.9) mm and 7.1 (IQR 6.5, 8.7) mm, respectively. Bilateral hostile femoral or iliac access was reported in 39 patients (71%). Access related complications occurred in five cases (9%). There were four cases (7%) of SCI with two permanent paraplegias. Four patients (7%) died within 30 days. The median follow up was 22 (IQR 11, 33) months. Overall, eight patients (15%) required re-interventions: four within 30 days and four during follow up. No ILO occurred. Estimated one year FFRs and survival were 91% and 87%, respectively., Conclusion: Low profile OTS thoraco-abdominal endografts seems safe and effective to manage urgent JP-AAAs and TAAAs in the presence of hostile femoral or iliac access. Further larger studies with long term follow up are needed to validate this preliminary experience., (Copyright © 2024. Published by Elsevier B.V.) more...

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Ischaemic spinal cord injury (SCI) is one of the most serious complications of aortic surgery. Ischaemic SCIs occur due to various aetiologies, and prediction of the risk is difficult. Magnetic resonance imaging (MRI) is useful to detect the details of spinal cord infarction. There are few studies about MRI for evaluating ischaemic SCI after cardiovascular surgery and aortic events. We report 9 cases of postoperative ischaemic SCI and analyse their MRI features. METHODS T2-weighted MRI scans of 9 patients who developed ischaemic SCI due to cardiovascular surgery and aortic events between 2012 and 2017 were evaluated. RESULTS In all patients, high-intensity areas were observed on T2-weighted magnetic resonance images. The site of infarction was the thoracic spinal cord level (9 cases) and additionally at the lumbar spinal cord level (5 cases). The area of infarction area was categorized based on the arterial territory: anterior spinal artery territory (3 cases), posterior spinal artery territory (2 cases), spinal sulcal artery territory (1 case) and artery of Adamkiewicz territory (3 cases). CONCLUSIONS MRI revealed the infarction sites in all cases and the differences in the infarction patterns in each case. MRI could thus be useful for investigating the aetiology of ischaemic SCI following aortic surgeries and events. [ABSTRACT FROM AUTHOR] more...

Abdominal aortic aneurysm prevalence is estimated between 4 and 8% in screening programs, predominantly in males. The risk of rupture is directly proportionate to the size of the aneurysm; thus, prophylactic repair is justifiable. The three chief randomized trials comparing Endovascular Aneurysm Repair (EVAR) with conventional repair of abdominal aortic aneurysm have all shown a benefit of EVAR with respect to 30-day operative mortality and these results have been reinforced by data from large registries. Therefore, endovascular repair is now a common treatment option that offers a less-invasive alternative to standard surgical repair with the likely reduced hospitalization, morbidity, and mortality. In this work, we report the short-term results of six cases treated by Thoracic Endovascular Aneurysm Repair (TEVAR)/EVAR at Alexandria Vascular Center. [ABSTRACT FROM AUTHOR] more...

A staged endovascular strategy was used to treat the aneurysmal evolution of the aortic island including intercostal arteries reimplanted in a loop-graft, following thoraco-abdominal aortic open repair in a young patient diagnosed with Marfan syndrome. First, selective coil embolization of patent intercostal arteries was performed in 2 separate sessions, to minimize the risk of spinal cord ischaemia. Then, the aneurysm was successfully excluded occluding the loop graft with 2 PTFE-membrane vascular plugs. [ABSTRACT FROM AUTHOR] more...

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. [ABSTRACT FROM AUTHOR] more...

Objective To evaluate the impact of renal artery (RA) anatomy on the renal outcome of fenestrated-branched endografts (FB-EVAR) for thoraco-abdominal aortic aneurysms (TAAA). Methods Between 2010 and 2016, all patients undergoing FB-EVAR for TAAA were prospectively collected. Anatomical, procedural, and post-operative data were retrospectively analysed. RA anatomy was assessed on volume rendering, multi planar and centre line reconstructions by dedicated software (3Mensio). RA diameter, length, ostial stenosis/calcification, orientation and aortic angles of the para-visceral aorta were evaluated. RA orientation was classified in four types: A (horizontal), B (upward), C (downward), D (downward + upward). RA revascularisation by fenestrations or branches was considered. Inability to cannulate and stent RA (RA loss), early RA occlusion (within three months), and composite RA events (one among RA loss, intra-operative RA lesion, RA related re-interventions, RA occlusion) were assessed. Results Seventy-three patients (male 77%; age 73 ± 6 years) with 39 (53%) type I, II, III and 34 (47%) type IV TAAA, underwent FB-EVAR, for a total of 128 RAs. The mean RA diameter and length were 6 ± 1 mm and 43 ± 12 mm, respectively. Type A, B, C, and D orientations were 51 (40%), 18 (14%), 48 (36%), and 11 (10%) RAs, respectively. Angulation of para-visceral aorta >45° was present in 14 cases (19%). Ostial stenosis and calcifications were detected in 20 (16%) and 16 (13%) RAs, respectively. Branches and fenestrations were used in 43 (34%) and 85 (66%) RAs, respectively. There were four (3%) intra-operative RA lesions (2 ruptures, 2 dissections). Ten (8%) RAs were lost intra-operatively because of the inability to cannulating and stenting. On univariable analysis, type B RA orientation ( p =.001; OR 13.2; 95% CI 3.2–53.6), para-visceral aortic angle > 45° ( p =.02; OR 4.9; 95% CI 1.3–18.5) and branches ( p =.003; OR 9.0; 95% CI 1.9–46.9) were risk factors for intra-operative RA loss; type C RA orientation was a protective factor ( p =.02; OR 0.1; 95% CI 0.01–0.9). On multivariable analysis, type B RA orientation ( p =.03; OR 5.9; 95% CI 1.1–31.1) and branches ( p =.03; OR 7.3; 95% CI 1.1–47.9) were independent risk factors for intra-operative RA loss. Fourteen patients suffered post-operative renal function worsening (> 30% of the baseline). The mean follow up was 19 ± 12 months. Four (3%) early RA occlusions occurred in three patients (2 single kidney patients required permanent haemodialysis). Type D RA orientation ( p =.00; RR 17.8; 8.6–37.0) and branches ( p =.004; RR 3.2; 2.4–4.1) were risk factors for early RA occlusion on univariable analysis. Five patients (7%) required early RA related re-interventions (recanalisation + relining 3; stent graft extension 1; parenchymal embolisation 1). No late RA occlusion or re-interventions were reported during follow up. Composite RA events occurred in 17 (13%) cases. Type B ( p =.05; OR 3.9; 95% CI 1.1–15.7) or D ( p =.006; OR 10.9; 95% CI 2.3–50.8) RA orientations and branches ( p =.006; OR 5.7; 95% CI 1.6–20.3) were independent predictors of composite RA events on multivariable analysis. Conclusion Renal artery orientation significantly affects the early RA outcome of FB-EVAR for TAAA. Intra-operative RA loss is predicted by type B RA orientation and branches, while early RA occlusion is predicted by type D orientation and branches. The present data suggest that in TAAA, fenestrations should be the first choice for renal revascularisation in type B and D RA orientations. [ABSTRACT FROM AUTHOR] more...

Aims: To report a series of patients treated with the Jotec custom-made endograft for thoraco-abdominal aneurysms and dissections and identify predictive factors for re-intervention.ld>Methods: We retrospectively analysed 49 patients unsuitable for surgery, treated between 2011 and 2017 (71.3 ± 9.5 years; 15 females). Indications included Crawford type 4 aneurysm in 25 patients, type 3 in 13, type 2 in 4, type 1 in 2 and chronic aneurysmal dilatation of the false lumen following dissection in 5 cases. Mean aneurysm diameter was 58.7 ± 8.4 mm. The study aims were to assess procedural success, complications rate, mortality and long-term follow-up. We also analysed factors that predicted the need for re-intervention.Results: The endograft was successfully deployed in all patients, catheterization of the fenestration and/or branches was achieved in 152/156 (97.4%) vessels. Early complications occurred in 10 patients (3 paraplegia, 3 haemorrhages, pancreatitis, aortic rupture, iliac artery rupture, 2 strokes). Thirty-day mortality was 10.2% and 180-day mortality 14.3%; two non procedure related deaths occurred. Mean follow-up was 23.6 ± 29.9 months [range 1-80]. No patients needed surgical explantation or developed significant renal impairment. Endoleak rate was 34.6% and re-intervention rate 9.7%. The aneurysm sac reduced or was stable in 36/49, and enlarged in 9/49 patients prompting re-intervention. Primary, primary-assisted and secondary patency of fenestrations/branches at 80 months was 90, 96 and 100%. Re-intervention was required more frequently in braches than in fenestrations, most commonly the external type branches.Conclusions: The results of the Jotec endograft are comparable to other devices, with acceptable complication and re-intervention rates. Fenestration and inner-branch should be preferred due to lower re-intervention rates. [ABSTRACT FROM AUTHOR] more...

Objective/Background Laser in situ fenestration (LISF) is emerging as an immediately available alternative in the endovascular treatment of complex aortic aneurysm. However, its biomechanical features remain poorly understood. The aim of this study was to experimentally evaluate textile damage secondary to LISF and to compare LISF with mechanical in situ fenestration (MISF). Methods An in vitro study evaluated the damage created by LISF on endograft fabrics versus MISF using a needle. Five different models of commercially available aortic endografts were used (32 samples of polyethylene terephthalate and expanded polytetrafluoroethylene fabrics). Tensile strength tests were performed on the fabrics before and after in situ fenestration, to determine the loss of mechanical strength. Integral water permeability tests at the stent–fenestration interface evaluated the watertightness of junctions. Stability of the connection was assessed with a fatigue bench test flexing the branch on the fenestration. In a second step, an in vivo study evaluating LISF in sheep was conducted. Results Resulting holes had circular and cauterised edges following LISF, whereas fabric filaments were pushed aside after MISF. Tensile tests demonstrated a 34% and a 27% mechanical resistance loss after LISF ( p = .004) and MISF ( p = .001) compared with non-fenestrated samples. A non-significant global decrease of 7% in mechanical resistance was found following LISF compared with MISF ( p = .520). Water permeability tests highlighted that leak rates were higher following LISF than with MISF with regard to multifilament specimens ( p < .05). Fatigue tests induced modification of the morphology of fenestrations. The surface area of the fenestration was increased for all samples after 170,000 cycles. Regarding the in vivo study, 14 LISF were performed in 12 sheep with a technical success rate of 88%. Conclusion This study demonstrates that both LISF and MISF create substantial damage to all available endograft fabrics. Until comparisons with reinforced fenestrations are performed, LISF and MISF should not be used outside investigational studies. [ABSTRACT FROM AUTHOR] more...

Objectives 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. Methods 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. Results 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; and >3 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%. Conclusions 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. [ABSTRACT FROM AUTHOR] more...

Objectives The outcome of endovascular repair (EVAR) for acute thoraco-abdominal aortic aneurysm (TAAA) is reported and the applicability of the t-Branch off the shelf (OTS) device is determined. Methods Interrogation of a prospectively maintained database identified all patients who underwent EVAR for acute TAAA between September 2012 (when the first non-elective t-Branch case was performed) and November 2015. Early and medium-term outcomes were analysed. Survival and re-intervention-free survival were calculated by Kaplan–Meier analysis. Results A total of 39 patients (27 men; mean ± SD age, 72 ± 8 years) were treated for acute symptomatic ( n = 29) or ruptured ( n = 10) TAAA (20 anatomical extent I–III, 19 extent IV). Fourteen patients had mycotic aneurysms. The mean aneurysm diameter was 80 ± 20 mm. The mean ± SD follow-up was 21.4 ± 15.4 months. Surgeon modified fenestrated EVAR was used in 24 patients, chimney/periscope EVAR in two, and t-Branch in 13 (33%) patients. Aortic coverage was greater than 40 mm above the coeliac axis in all patients. A total of 127 target vessels (TVs) were preserved (mean 3.3 per patient) and two occluded within 30 days. The 30 day mortality was 26%. Four (10%) patients developed spinal cord ischaemia (SCI): two with paraplegia died within 30 days, and two with paraparesis recovered completely with blood pressure manipulation and cerebrospinal fluid drainage. Estimated overall survival (±SD) at 12 and 24 months was 71.8 ± 7.2% and 63.2 ± 7.9%, respectively. Estimated freedom from re-intervention at 12 and 24 months was 93 ± 4.8% and 85.3 ± 6.8%, respectively. Conclusions EVAR for acute TAAA is associated with acceptable early and mid-term results in patients who have no other treatment options. Only one third of these patients were suitable for the t-Branch device, indicating that further advances in device design are required to treat the majority of acute TAAA patients with commercially available OTS technology. [ABSTRACT FROM AUTHOR] more...

Objectives Outcomes are reported in management of post-dissection aneurysms involving the aortic arch and/or thoraco-abdominal segment (TAAA) treated with fenestrated and branched (complex) endografts. Methods This report includes all patients with chronic post-dissection aneurysms >55 mm in diameter, deemed unfit for open surgery, treated using complex endografts between October 2011 and March 2015. When appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration or tear enlargement, and other endovascular procedures were performed at least 3 weeks prior to definitive complex endovascular repair. The following outcome data were collected prospectively at discharge, 12 months and annually thereafter: technical success, endoleaks, target vessel patency, false lumen patency, aneurysm diameter, major and minor complications, re-interventions, and mortality. Results The cohort comprised 23 patients with a median age of 65 years. Staged procedures were performed in 14 patients (61%). Seven patients with dissections involving the arch were treated with inner branched endografts, and 16 TAAA patients were treated with fenestrated or branched endografts. The technical success rate was 71% following arch repair and 100% following TAAA repair. During early follow up, one of the arch group patients died and one in the TAAA group suffered spinal cord ischemia. The median follow up was 12 months (range 3–48), during which time one patient died of causes unrelated to aneurysm or treatment. Two early re-interventions were performed in the arch group to correct access vessel complications and there were a further two late re-interventions in the TAAA group to treat endoleaks. All target vessels ( n = 72) remained patent. Conclusions This experience indicates that complex endovascular repair of post-dissection aneurysms is a viable alternative to open repair in patients deemed unfit for open surgery. There are insufficient data to allow comparison with the outcome of open surgery in anatomically similar, but fit, patients. [ABSTRACT FROM AUTHOR] more...

OBJECTIVES: Repair of extensive aortic disease carries a significant risk of death and morbidity, the most feared complication being spinal cord ischaemia. Objectives of this study are to characterize patients, describe repair methods and assess feasibility and safety of hybrid staged repair for treatment of extensive aortic disease. METHODS: From to 2001 to 2013, 22 patients underwent extensive aortic repair that included a thoracic endovascular aortic repair (TEVAR) first followed by an open completion repair extending through the visceral and infrarenal aorta for degenerative aneurysm and dissection. At the time of initial repair, all patients were deemed to be at a high risk for conventional open repair and had extensive disease. Indications for open completion included emergency failure of TEVAR (n = 3), early two-stage approach (n = 6) and delayed disease progression after TEVAR (n = 13). The median interval between stages was 6.5 months. The mean age was 56 ± 14 years, 5 patients had connective tissue disorder and the mean maximum aortic diameter was 58 ± 16 mm preoperatively. RESULTS: There was no death or major complication after initial TEVAR, but the operative mortality rate was 9% (n = 2) after the open procedure. One of these patients died from intraoperative myocardial infarction during emergency repair, and the other had disseminated intravascular coagulation during delayed repair for disease progression after TEVAR. Other complications included paralysis in 1 (4.5%), tracheostomy in 2 (9%) and dialysis in 1 (4.5%), and there was 1 reoperation for bleeding (4.5%). The median follow-up was 37 (range 3.3-93) months and there were no late deaths. There were four late reoperations for proximal disease progression leading to Type 1 endoleak (n = 2), Type A dissection (n = 1) and root aneurysm (n = 1). CONCLUSIONS: Use of a TEVAR-first approach in combination with a staged open repair is a safe and feasible treatment strategy for repair of extensive aortic disease. A staged hybrid approach to aortic repair in patients at high risk for total aortic replacement may limit morbidity. [ABSTRACT FROM AUTHOR] more...

OBJECTIVES: The repair of extensive thoraco-abdominal aortic aneurysms (TAAAs) is invasive and carries a high risk for spinal cord injury (SCI). The aim of this study was to assess the early results and collateral circulation to the spinal cord after hybrid repair for Crawford extent II aortic aneurysms. METHODS: Between 1997 and 2013, we performed 128 thoracic endovascular aortic repair (TEVAR) procedures for TAAAs. This study reviews 12 patients who underwent hybrid TEVAR for a Crawford extent II aortic aneurysm (mean age: 56 years, 6 men, chronic dissection: 10). Aortic arch repair was performed to create a proximal landing zone and visceral debranching bypass was performed to create a distal landing zone at separate stages prior to TEVAR. Subsequently, a stent graft was deployed to cover the residual downstream aorta. TEVAR was generally performed the day after the final debranching procedure. Cerebrospinal fluid drainage was performed, and the mean blood pressure was maintained at >90 mmHg in all cases. RESULTS: The median operation time for TEVAR was 94 min (range: 71–421 min) and the mean blood loss was 300 ml (range: 130–1350 ml). No SCI or in-hospital death was observed after TEVAR. Multidetector computed tomography identified three arteries (subclavian artery, external iliac artery and internal iliac artery) providing collateral circulation to spinal segmental arteries (SAs). In all cases, mid-thoracic SAs (Th5−8) and low lumbar SAs (L2−5) were fed by the subclavian artery and the internal iliac artery, respectively. Additionally, low thoracic to high lumbar SAs (Th9-L1) communicated with the subclavian artery via the lateral thoracic wall and/or the external iliac artery via the abdominal wall. CONCLUSIONS: We achieved satisfactory early and mid-term outcomes with hybrid repair for Crawford extent II TAAAs. Furthermore, collateral circulation to SAs was maintained during and after TEVAR regardless of the extent of the aortic repair. [ABSTRACT FROM AUTHOR] more...

Objective The purpose of this study was to analyze immediate and long-term renal outcomes (renal function and renal events) after fenestrated (FEVAR) and branched endovascular aortic aneurysm repair (BEVAR). Methods All FEVAR and BEVAR performed between October 2004 and October 2012 were included in this study. Post-operative acute renal failure (ARF) was defined according to the RIFLE criteria. Renal volume (calculated with a 3D workstation) and estimated glomerular filtration rate (GFR) (estimated with the Modification of Diet in Renal Disease [MDRD] formula) were evaluated before the procedure, before discharge, 12 months after, and yearly thereafter. Renal stent occlusion, dissection, fracture, stenosis, kink, renal stent related endoleak, and renal stent secondary intervention were all considered “renal composite events” and analyzed. A time to event analysis was performed for renal events and secondary renal interventions. Results 225 patients were treated with FEVAR and BEVAR. Renal target vessels ( n = 427) were perfused by fenestrations ( n = 374), or branches ( n = 53). Median follow up was 3.1 years (2.9–3.3 years). Technical success was achieved in 95.5% of patients. Post-operative ARF was seen in 64 patients (29%). Mean total renal volume and eGFR at 1 year, 2 year, and 3 year follow up were significantly lower when compared with pre-operative levels (after BEVAR and FEVAR); the decrease at 3 years was 14.8% (6.7%; 22.2%) ( p = .0006) for total renal volume and 14.3% (3.1%; 24.3%) ( p = .02) for eGFR. The 30 day and 5 year freedom from renal composite event was 98.6% (95.8–99.6%) and 84.5% (76.5–89.9%) after FEVAR and BEVAR (NS). The 30 day and 5 year freedom from renal occlusion was 99.5% (96.7–99.9%) and 94.4% (89.3–97.1%) after FEVAR and BEVAR (NS). Conclusion FEVAR and BEVAR are durable options for the treatment of complex aortic aneurysms and are associated with low renal morbidity, without differences between devices types. The clinical impact of decreasing renal volume over time in these patients is yet to be fully understood. [ABSTRACT FROM AUTHOR] more...

Purpose: To present a case series of patients with thoracoabdominal aortic aneurysm (TAAA) who were treated with the hybrid repair technique. Materials and Methods: From January 2009 to April 2013, TAAA patients who were treated with the hybrid repair technique were retrospectively reviewed. Results: There were three cases of hybrid repair performed during the study period. Aneurysm morphology included type IV TAAA in two patients and suprarenal in one patient. The average aneurysm diameter was 82.6 mm (range 73 to 91 mm). Technical success was obtained in all patients. Graft thrombosis occurred at a rate of 30% (3 in 10 visceral bypass grafts), which resulted in mesenteric ischemia and transient renal insufficiency. The average hospital length of stay was 53 days, with a median ICU stay of 11.3 days. Conclusion: Hybrid surgery could be considered a bridging measure between open and fenestrated/ branched endograft. The surgical technique will remain a robust and adaptable method of treating this complex and life-threatening disease in individuals with unfavorable anatomy. [ABSTRACT FROM AUTHOR] more...

Abstract: Objective: To determine the proportion of TAAAs which might be suitable for pure endovascular repair based on aneurysm morphology and to develop an MDCTA based scoring system to grade case complexity. Design: 70 consecutive MDCTA of patients with TAAAs were analysed in relation to specific morphological characteristics. Methods: The characteristics included potential stent landing zone lengths, arch angulation, thoraco-abdominal aorta angulation, branch vessel origin stenosis, access tortuosity/diameter and aortic dissection. Results: 60% of TAAAs would be suitable for branched/fenestrated stent grafting but 40% are unsuitable due to adverse anatomy. 27% had an aortic arch angulation of ≤110° and 24% had descending thoracic aorta angulation of ≤90°. Significant ostial stenosis was identified in 31% of celiac arteries, 7% superior mesenteric arteries, 24% left renal artery and 19% right renal arteries. 11% of left common iliac and 7% right common iliac arteries had angulation of ≤70°. There were 26 cases with aortic dissection and 54% of these had a true lumen of ≤26 mm. Conclusion: Successful fenestrated/branched stent graft repair of TAAAs requires adequate landing zones, cannulation of visceral arteries and suitable diameter access vessels. 60% of TAAAs studied were suitable for branched/fenestrated stent graft repair but 40% of TAAAs were unsuitable; aortic angulation, visceral vessel ostial stenosis and dissection true lumen diameter were the principle issues. Development in stent technology may address these anatomical challenges. [Copyright &y& Elsevier] more...

to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40–79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity. [ABSTRACT FROM AUTHOR] more...

Background. Surgical resection remains the only curative procedure for liver metastases but even in expert hands it has appreciable morbidity and mortality rates. The presence of a concomitant aortic aneurysm greatly increases these risks. Case outline. A 66-year-old woman who was known to have large aneurysms of the thoraco-abdominal aorta and middle cerebral artery presented with colorectal liver metastases. After detailed preoperative assessment, she underwent resection of segments V and VI of the liver. The surgical procedure was uneventful. She made a good initial recovery, but on day 7 she suddenly became hypotensive and died from a cardiorespiratory arrest. Post-mortem examination revealed a ruptured thoracic portion of the thoraco-abdominal aortic aneurysm. Conclusion. Despite careful control of perioperative blood pressure and the lack of abdominal complication, intrathoracic aneurysmal rupture on day 7 highlights the risk of major unrelated operations in patients with aneurysmal disease. [ABSTRACT FROM AUTHOR] more...

Physicians in charge of patients undergoing thoracic or thoraco-abdominal aneurysmectomy, frequently use lumbar spinal drainage of the cerebrospinal fluid (CSF) to prevent paraplegia. Whereas the profit of this technique is a much debated question, we report 2 case reports of delayed sub-dural hemorrhage, after lumbar spinal drainage of CSF. Cross clamping of the aorta decreases the spinal cord artery pressure, increases the cerebral pressure and by alterations of distribution of the venous return, is responsible for an increase of the CSF pressure. This increase of the CSF pressure decreases the spinal cord driving pressure. Lumbar spinal drainage of CSF aims to improve the spinal cord driving pressure close to the normal (where driving pressure = aortic pressure – CSF pressure). The two case reports have to be added to the liability of a method of prevention that, as attractive that it is, did not give the proof of its efficiency to decrease the frequency and/or the severity of paraplegia after thoracic or thoraco-abdominal aneurysmectomy. At this time, this technique should be reserved to the patients with documented risk, as it is possible using preoperative spinal cord arteriography. The insertion and the withdrawal of the catheter must be done in the usual conditions of medullar puncture with regard to anticoagulant and antiplatelet agents [Copyright &y& Elsevier] more...

Background: To assess the factors affecting visceral suitability of the use of the Zenith T-branch TM system in a group of patients with thoraco-adbominal aortic aneurysms (TAAAs)., Methods: Computer tomography angiography (CTA) of patients who presented a TAAA from 01/2015 to 12/2019 were retrospectively examined. Multi-Planar Reconstructions were performed on CTA images to assess the anatomic suitability of the Zenith T-branch in the visceral district. In particular, the branch deviation angle (BDA), and the branch-length were computed for each target vessel., Results: Fifty-four CTA were examined. In 33.3% of these patients the presence of either a common origin of the superior mesenteric artery and the celiac trunk, or the diameter of 1 or more visceral/renal artery limited the visceral suitability of the device. All patients except 1 (97.9%) fitted the BDA criterion when the graft was placed in a position in which the BDA for the SMA was 5 degrees to the left. The branch-length criteria was met in all patients, except for 1 (97.9%), when the graft was placed in the center of the aorta. The eccentrical placement of the endograft decreased the suitability to 93.7%., Conclusions: The Zenith T-branch system can be suitable in the visceral district for about 67% of patients. The target artery diameter was the most limiting criterion. The central location of the graft within the aortic lumen significantly affected the branch-length distance criteria., (Copyright © 2021. Published by Elsevier Inc.) more...

Abstract: Introduction: The association of aortic aneurysm with congenital pelvic kidney is an uncommon condition and has been described in association with abdominal aortic aneurysm (AAA) open repairs. Report: We present a case of a patient with a type IV thoraco-abdominal aortic aneurysm (TAAA) extending into the left common and internal iliac arteries associated with a congenital pelvic kidney who was treated with a customised endovascular prosthesis involving proximal fenestrations, bifurcation fenestration and a left internal deep iliac branch device. Discussion: Although branch technology continues to evolve, cases such as this are encouraging for future widespread use. This approach allowed us to offer TAAA repair without compromising renal function in a patient with multiple co-morbidities who probably would not have withstood conventional open treatment. [Copyright &y& Elsevier] more...

Introduction: The parallel grafting technique (PGT) is a valuable alternative to prefabricated branched or fenestrated endovascular aortic repair. An often overlooked advantage of PGT is its unique adaptability to different anatomical challenges that might appear intra-operatively., Report: A 72 year old male patient presented with a 60 mm thoracic aneurysm, 59 mm juxtarenal abdominal aortic aneurysm, and 32 mm common iliac aneurysm (CIAA). Thoracic endovascular aortic repair plus endovascular aortic repair with bilateral renal artery chimneys and CIAA exclusion applying the sandwich technique was proposed. Because of unfavourable angulation it was not possible to achieve selective left renal catheterisation via axillary access. Changing to a femoral approach allowed successful retrograde catheterisation. The procedure ended with a chimney for the right renal artery and a periscope for the left renal artery. The final angiogram showed no endoleaks and renal and hypogastric patency. The patient was discharged three days after the procedure and remains under ultrasound surveillance after 40 months because of a small type two endoleak., Conclusion: When using a prefabricated branched device, the possibility of selectively catheterising a visceral branch often has no straightforward solution. However, parallel grafting is an extremely flexible technique, which was of paramount importance for the surgical outcome of the present case. more...

Background: This study aims to investigate whether preconditioning with alpha-lipoic acid has any protective effect in neuronal damage in an experimental spinal cord ischemia-reperfusion injury model., Methods: Eighteen adult male New Zealand rabbits (2.4-3.5 kg) were equally divided into sham, control and treatment groups. The abdominal aorta was occluded for 30 min proximally 1 cm below the renal artery and distally 1 cm above the bifurcation using aneurysm clips in control and treatment groups. Treatment group received intraperitoneal 100 mg/kg lipoic acid 20 min before aortic cross-clamping. The animals were sacrificed 48 hours after the operation and spinal cord segments between L2 and L5 were removed for biochemical and histopathological analysis. Levels of glutathione, malondialdehyde, total nitrate/nitrite, advanced oxidation protein products, catalase, superoxide dismutase, and glutathione peroxidase were examined in spinal cord., Results: Preconditioning with alpha-lipoic acid demonstrated significantly favorable effects in all measured parameters of oxidative stress. Histopathological evaluation of the tissues also demonstrated significantly decreased neuronal degeneration, axonal damage, and microglial and astrocytic infiltration in the treatment group compared to the control group., Conclusion: The results of this study indicate that alpha-lipoic acid administration before aortic cross-clamping has significant neuroprotective effect on spinal cord injury in rabbits., Competing Interests: Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article., (Copyright © 2018, Turkish Society of Cardiovascular Surgery.) more...