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Degeneration of the thoracoabdominal aorta proximal to a prior fenestrated endovascular aortic repair represents a complex issue with limited options for repair. Previously, modified endografts or open conversion with endograft explant offered the only options for management. Here we describe use of the Gore Thoracoabdominal Multibranch Endoprosthesis for exclusion of an extent III thoracoabdominal aneurysm in the setting of degeneration proximal to a previously placed fenestrated device.

Loeys Dietz Syndrome (LDS) is an autosomal dominant connective tissue disorder resulting from a mutation in the transforming growth factor beta receptor (TGFBR) family of genes. It is commonly associated with the development of aortic aneurysms and dissections. We report the successful open surgical management of thoracoabdominal aneurysms in a father and daughter with Loeys-Dietz Syndrome after failed endovascular repair. The daughter required stent graft explantation, while the stent graft remained in the father. These cases highlight the importance of early genetic testing of both patients and first-degree family members in those with a strong history of aortic disease, even when there is a lack of typical connective tissue disorder associated physical exam findings and open surgical index operations. [ABSTRACT FROM AUTHOR]

The optimal bridging stent for fenestrations during complex endovascular aortic aneurysm repair (EVAR) has not been defined. At our institution, the Viabahn VBX is frequently used given its availability and mechanical and heparin-bonding characteristics. This study aimed to assess the performance of the Viabahn VBX vs the iCast balloon-expandable covered stents as bridging stents for fenestrations during complex EVAR. A retrospective study of consecutive patients undergoing complex EVAR between 2015 and 2021 was performed. Celiac arteries (CAs), superior mesenteric arteries (SMAs), left renal arteries, and right renal arteries stented with fenestrations were grouped according to the type of bridging stent, VBX vs iCast. Target vessels (TV) stented with a branch or scallop were excluded. The primary end points included primary patency and freedom from TV instability. A total of 292 patients undergoing complex EVAR were treated using VBX or iCast with a mean follow-up of 190 days (interquartile range, 36-384 days) for the VBX cohort and 804 days (interquartile range, 384-1507 days) for the iCast cohort. A total of 677 TVs were stented, including 134 CAs (20%), 175 SMAs (26%), 182 left RAs (27%), 186 right RAs (27%), and 12 additional vessels (2%). Proximal reinforcement was more frequent with VBX than with iCast stent (23% vs 2.4%; P <.0001). There was no difference in primary patency rates at 2 years between VBX and iCast stent for CA (100% vs 96.4%; P =.32), SMA (97.8% vs 100%; P =.14), and the RAs (96.7% vs 99.4%; P =.11). There was no difference between VBX and iCast in the cumulative incidence of type Ic and type IIIc endoleaks (3.2% vs 5.6%; P =.69) or freedom from TV instability at 2 years. Viabahn VBX stents are a safe and effective option as bridging stents in fenestrations during complex EVAR with comparable midterm outcomes to iCast stents. However, proximal stent reinforcement may be required with VBX stent to ensure adequate sealing at the fenestrations. Longer follow-ups and larger series are required to assess long-term outcomes and durability. [ABSTRACT FROM AUTHOR]

Open surgical repair of suprarenal abdominal aortic aneurysm (SRAAA) and type IV thoracoabdominal aortic aneurysm (TAAA) remains a surgical challenge because of the inducted intraoperative visceral and renal ischemia. We report a novel three-step technique named debranch, perfuse, reconstruct (DPR), using debranching and passive arterial shunt to decrease these ischemic complications. The main aim of this study was to evaluate the 30-day and 1-year mortality rates associated with these DPR technique. The secondary aim was to evaluate the impact on renal function and the primary patency of the repaired arteries. This retrospective study included all consecutive patients who underwent elective surgery for SRAAA or type IV TAAA using the DPR technique between January 2011 and June 2022. In debranching, using partial side clamping, a multibranch graft was implanted side-to-end into the descending thoracic aorta. The left renal artery was anastomosed end-to-end to the graft. As needed, the superior mesenteric artery (SMA), the celiac trunk, and the right renal artery could also be anastomosed to the graft. In the perfusion step, cannulas were connected to the last branch of the multibranch graft to perfuse other arteries during aortic cross-clamping. For repair, a tube or bifurcated graft was used for the aortic repair. The branch used as a passive temporary arterial shunt was ligated at the end of the intervention. Clinical, radiological, and biological preoperative and postoperative factors were reviewed using a standardized database. Procedural complications and reinterventions were analyzed, as well as artery patency. There were 40 patients who underwent DPR technique. The mean patient age was 67 ± 13 years and two were women. Twenty-three patients presented with a SRAAA and 17 with a type IV TAAA. The 30-day and 1-year mortality rates were 2.5% (one patient). Two respiratory complications (5%) and three mesenteric ischemic complications (7%) have been recorded. No patient developed signs of cardiac or spinal cord dysfunction. We did not observe a significant change in postoperative renal function. The celiac trunk, superior mesenteric artery, left renal artery, and right renal artery bypass patency rates at 1 year were 95%, 100%, 90%, and 100%, respectively. The SRAAA and type IV TAAA repair with DPR technique provides short visceral and renal ischemia times with a low mortality rate. This technique could be an option to consider for visceral and renal protection during open surgical repair. [ABSTRACT FROM AUTHOR]

Purpose: Chronic obstructive pulmonary disease (COPD) is common in patients with aortic aneurysms. Severe COPD is associated with an increased risk of aneurysm rupture and perioperative complications. This study assesses the outcomes of COPD and non-COPD patients after fenestrated-branched endovascular aortic aneurysm repair (FBEVAR). Materials and Methods: A single institution, retrospective study of FBEVAR patients between 2011 and 2020 compared outcomes between COPD and non-COPD patients. COPD patients were stratified by Global Initiative for Chronic Obstructive Lung Disease criteria and oxygen dependence. Outcome measures included 30-day mortality, pulmonary complications, major adverse events (MAE), and mid-term survival. Results: 387 patients (71% male, age 72 years, interquartile range [68–79]) underwent FBEVAR. 181 patients (47%) had COPD. Smoking history was more frequent in COPD patients (P =.022). Among COPD patients, 20.4% were oxygen-dependent. Technical success, defined as successful delivery of the main aortic endograft and all intended side branches, was 98.4%. 30-day mortality (P =.83) and MAE rates (P =.87) were similar between groups. While not statistically significant, COPD patients had more frequent pulmonary complications (6.1% vs. 2.4%, P =.13) and were more frequently discharged on oxygen (P =.002). There were no differences in intensive care unit or hospital length of stay between groups (P =.29; P =.85, respectively). 5-year survival was similar between groups (P =.10). Oxygen-dependent COPD and severe-very severe COPD were associated with decreased mid-term survival (Hazard Ratio 2.39, P =.048). Conclusions: FBEVAR is safe and effective for treating complex aortic pathology in COPD patients, including oxygen-dependent patients. Patients with more severe COPD were more frequently discharged on oxygen. Mid-term survival was slightly reduced in patients with oxygen-dependent and severe-very severe COPD. Level of Evidence: Level 3, non-randomized controlled cohort/follow-up study. [ABSTRACT FROM AUTHOR]

Resumen: El segmento toracoabdominal es actualmente tratable por técnicas endovasculares, permitiendo tratar pacientes con riesgo quirúrgico más elevado. Exponemos las ventajas de las distintas configuraciones con fenestraciones o ramas. Existen en el mercado prótesis prefabricadas adecuadas para la mayoría de los pacientes. El conocimiento de las peculiaridades anatómicas del paciente nos permitirá seleccionar a los pacientes con un resultado adecuado a medio y largo plazo, así como elegir la prótesis más adecuada.La aplicación de técnicas asociadas de protección medular y de nefroprotección completan el abordaje integral del paciente. Abstract: The thoracoabdominal segment is currently treatable by endovascular techniques, making it possible to treat patients with higher surgical risk. We expose the advantages of the different configurations with fenestrations or branches. There are prefabricated prostheses on the market suitable for most patients. Knowledge of the patient's anatomical peculiarities will allow us to select patients with an adequate result in the medium and long term, as well as choose the most appropriate prosthesis.The application of associated spinal cord protection and nephroprotection techniques complete the comprehensive approach to the patient.

Purpose: To report the initial outcomes of physician-modified inner branched endovascular repair (PMiBEVAR) for pararenal aneurysms (PRAs), thoracoabdominal aortic aneurysms (TAAAs), and aortic arch aneurysms in high-surgical-risk patients. Materials and Methods: A total of 10 patients (6 men; median age, 83.0 years) treated using PMiBEVAR were enrolled in this retrospective, single-center study. All patients were at high surgical risk because of severe comorbidities (American Society of Anesthesiologists physical status score≥3 or emergency repair). End points were defined as technical success per patient and per vessel (successful deployment), clinical success (no endoleaks postoperatively), in-hospital death, and major adverse events. Results: There were 3 PRAs, 4 TAAAs, and 3 aortic arch aneurysms with 12 renal-mesenteric arteries and 3 left subclavian arteries incorporated by inner branches. The technical success rate was 90.0% (9/10) per patient and 93.3% (14/15) per vessel. The clinical success rate was 90% (9/10). There were 2 in-hospital deaths, unrelated to aneurysms. Paraplegia and shower emboli occurred separately in 2 patients. Three patients experienced prolonged ventilation for 3 days after surgery. Aneurysm sac shrinkage occurred in 4 patients, and aneurysm size stabilized in 1 patient during follow-up, more than 6 months later. None of the patients required intervention. Conclusion: PMiBEVAR is a feasible approach for treating complex aneurysms in high-surgical-risk patients. This technology may complement the existing technology in terms of improved anatomical adaptability, no time delay and practicability in many countries. However, long-term durability remains undetermined. Further large-scale and long-term studies are needed. Clinical impact: This is the first clinical study to investigate outcomes of physician-modified inner branched endovascular repair (PMiBEVAR). PMiBEVAR for treating pararenal aneurysm, thoracoabdominal aortic aneurysm, or aortic arch aneurysm is a feasible procedure. This technology is likely to complement existing technology in terms of improved anatomical adaptability (compared to off-the-shelf devices), no time delay (compared to custom-made devices), and the potential to be performed in many countries. On the other hand, surgery time varied greatly depending on the case, suggesting a learning curve and the need for technological innovation to perform more consistent surgeries. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate the midterm outcomes of secondary extension of frozen elephant trunk (FET) by means of thoracic endovascular aortic repair (TEVAR). Methods: This single-center prospective study was conducted in a tertiary aortic center on consecutive patients having undergone TEVAR with an endograft covering most of the 10 cm FET module with 2 to 4 mm oversizing. All patients were monitored by computerized tomography angiography (CTA) at sixth month and yearly thereafter. Results: From January 2015 to July 2022, among 159 patients who received FET, 30 patients (18.8%) underwent a TEVAR procedure (13 for a thoracoabdominal aneurysm, 11 for a chronic aortic dissection and 6 for an emergency procedure). All connections were successfully achieved with 2 postoperative deaths (6.6%) and 1 paraplegia (3.3%). At a median follow-up of 21 months (interquartile range [IQR], 4.2–34.7), 5 patients (25%) required a fenestrated-branched endovascular aortic repair (F-BEVAR) extension followed by 4 patients with 5 reinterventions, 3 for a Type 3 endoleak due to disconnection between FET and TEVAR endograft, and 2 unrelated to the FET for a secondary Type 1C endoleak. All reinterventions were successful, without mortality or morbidity. Conclusions: In this series, FET connection with a TEVAR endograft was effective with low postoperative morbidity but with a risk of aortic reintervention related to disconnection between the FET and TEVAR endograft. These results suggest the need for annual CTA monitoring with no time limit in patients following connection of the FET with a TEVAR endograft. Clinical Impact: In this series of 30 patients, midterm outcomes of secondary extension of frozen elephant trunk (FET) by thoracic endovascular repair (TEVAR) showed 3 disconnections (10%) with a Type 3 endoleak between FET and TEVAR. These findings suggest the need for annual CTA monitoring with no time limit. But so far, only a few studies provide some information after one year while the risk of disconnection increases over time and becomes a concern after 3 years. This is the new message brought by our study. [ABSTRACT FROM AUTHOR]

Purpose: The Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) uses a bare-metal stent to scaffold the true lumen in patients with acute or subacute aortic dissections. While it is designed to facilitate remodeling, some patients with chronic post-dissection thoracoabdominal aortic aneurysms (TAAAs) require repair. This study describes the technical pitfalls of fenestrated-branched endovascular aortic repair (FB-EVAR) in patients who underwent prior PETTICOAT repair. Technique: We report 3 patients with extent II TAAAs who had prior bare-metal dissection stents treated by FB-EVAR. Two patients required maneuvers to reroute the aortic guidewire, which was initially placed in-between stent struts. This was recognized before the deployment of the fenestrated-branched device. A third patient had difficult advancement of the celiac bridging stent due to a conflict of the tip of the stent delivery system into one of the stent struts, requiring to redo catheterization and pre-stenting with a balloon-expandable stent. There were no mortalities and target-related events after a follow-up of 12 to 27 months. Conclusion: FB-EVAR following the PETTICOAT is infrequent, but technical difficulties should be recognized to prevent complications from the inadvertent deployment of the fenestrated-branched stent-graft component in-between stent struts. Clinical Impact: The present study highlights a few maneuvers to prevent or overcome possible complications during endovascular repair of chronic post-dissection thoracoabdominal aortic aneurysm following PETTICOAT. The main problem to be recognized is the placement of the aortic wire beyond one of the struts of the existing bare-metal stent. Moreover, encroachment of catheters or the bridging stent delivery system into the stent struts may potentially cause difficulties. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate the demographic and anatomic characteristics, as well as perioperative and follow-up results of fenestration and parallel techniques for the endovascular repair of complex aortic diseases. Materials and Methods: A retrospective study was conducted on 67 consecutive patients underwent endovascular treatment for complex aortic diseases including abdominal aortic aneurysm (AAA), thoracoabdominal aneurysm (TAAA), aortic dissection, or prior endovascular repair with either fenestrated and parallel endovascular aortic repair (f-EVAR or ch-EVAR) at a single institute from 2013 to 2021. Choices of intervention were made by the disease' emergency, patients' general condition, the anatomic characteristics, as well as following the recommendation from the devices' guidelines. Patients' clinical demographics, aortic disease characteristics, perioperative details, and disease courses were discussed. Short- and mid-term follow-up results were obtained and analyzed. Endpoints were aneurysm-related and unrelated mortality, branch instability, and renal function deterioration. Results: Totally, 34 and 27 patients received f-EVAR and ch-EVAR, while 6 patients received a combination of both. Fenestrated endovascular aortic repair was conducted mainly in AAA affecting visceral branches and TAAA, whereas ch-EVAR was normally utilized for infrarenal AAA. Regarding the average number of reconstructed arteries per patient, there was a significant difference among f-EVAR, ch-EVAR, and the combination group (mean = 2.3 ± 0.9, 1.4 ± 0.6, 3.5 ± 0.5, p<0.001). Primary technical success was achieved in 28 (82.4%), 22 (81.5%), and 3 (50.0%) patients for each group. Besides operational time (5.77 ± 2.58, 4.47 ± 1.44, p=0.033), no significant difference was observed for blood transfusion, intensive care unit (ICU) or hospital stay, blood creatinine level, 30-day complications, or follow-up complications between patients undergoing f-EVAR or ch-EVAR. Patients receiving combination of both techniques had a higher rate of blood transfusion (p=0.044), longer operational time (p=0.008) or hospital stay (p=0.017), as well as more stent occlusion (p=0.001), endoleak (p=0.004) at short-term and a higher rate of endoleak (p=0.023) at mid-term follow-up. Conclusion: In conclusion, this study demonstrated that f-EVAR and ch-EVAR techniques had acceptable perioperative and follow-up results and should be considered viable alternatives when encountering complex aortic diseases. Clinical impact: This study sought to investigate the baseline and pathological characteristics, as well as perioperative and follow-up results of f-EVAR and ch-EVAR at a single Chinese institution. F-EVAR (mostly physician-modified f-EVAR) was applied in patients with a wide range of etiologies and disease types, while ch-EVAR was preferred for AAA in older patients with an average higher ASA grade. Our experience suggested acceptable safety and efficacy both for techniques, and no significant difference was observed between the two groups regarding any short or mid-term adverse events. [ABSTRACT FROM AUTHOR]

The improved diagnosis of diseases of the thoraco-abdominal aorta combined with the advancement of technology and the development of the endoprosthetic technique through invasive implantation of stent-grafts in the affected areas led to an increased success rate of the procedures, reduced complications and mortality after treatment of this pathology. In the beginning, the methodology was developed and applied to high-risk patients with extensive comorbidity, but with the advancement of technology, endoprosthetics expands its indications and gradually replaces the conventional surgical treatment of the thoraco-abdominal aorta. A clinical case of a large aneurysmal expansion of the thoracic aorta, occupying almost the entire length of the latter in combination with a large intramural hematoma obturating the diameter of the thoracic aorta in certain sections up to 60% is presented. [ABSTRACT FROM AUTHOR]

Introduction: Women are generally underrepresented in trials focusing on aortic aneurysm. Nevertheless, sex-related differences have recently emerged from several studies and registries. The aim of this research was to assess whether sex-related anatomical disparities existed in fenestrated and branched aortic repair candidates and whether these discrepancies could influence endovascular repair outcomes. Methods: Data from all consecutive patients treated during the 2008–2019 period within the Italian Multicenter fenestrated or branched endovascular aortic repair (F/BEVAR) Registry were included in the present study. Propensity matching was performed using a logistic regression model adjusted for demographic data and comorbidities to obtain comparable male and female samples. The selection model led to a final study population of 176 patients (88 women and 88 men) among the total initial cohort of 596. Study endpoints were technical and clinical success, overall survival, aneurysm-related death, and reintervention rates evaluated at 30 days and during follow-up. Results: Twenty-eight patients (15.9%) received urgent/emergent repair. In most of the cases (71.6%), women received treatment for extensive thoracoabdominal pathology (Crawford type I, II, or III aneurysm rather than type IV or juxta-pararenal) versus 46.6% of men (p=0.001). Female patients presented with more challenging iliac accesses with at least one side considered hostile in 27.3% of the cases (vs 13.6% in male patients, p=0.039). Finally, women had significantly smaller visceral vessels. Women had significantly worse operative outcomes, with an 86.2% technical success rate versus 96.6% in the male population (p=0.016). No differences were recorded in terms of 30-day reinterventions between men and women. The 5-year estimate of freedom from late reintervention, according to Kaplan-Meier analysis, was 85.6% in men versus 81.6% in women (p=ns). No aneurysm-related death was recorded during follow-up (median observational time, 23 months [interquartile range, 7–45 months]). Conclusion: Women presented a significantly higher incidence of thoracoabdominal aneurysms, smaller visceral vessels, and more complex iliofemoral accesses, resulting in a significantly lower technical success after F/BEVAR. Further studies assessing sex-related differences are needed to properly determine the impact on outcomes and stratify procedural risks. Clinical Impact: Women are generally underrepresented in trials focusing on aortic aneurysms. Aiming to assess whether sex may affect outcomes after a complex endovascular aortic repair, a propensity score selection was applied to a total population of 596 patients receiving F/BEVAR aortic repair with the Cook platform, matching each treated female patient with a corresponding male patient. Women presented more frequently a thoracoabdominal aneurysm extent, smaller visceral vessels, and complex iliofemoral accesses, resulting in significantly worse operative outcomes, with an 86.2% technical success versus 96.6% (p=0.016). No differences were recorded in terms of short-term and mid-term reinterventions. According to these results, careful and critical assessment should be posed in case of female patients receiving complex aortic repair, especially regarding preoperative anatomical evaluation and clinical selection with appropriate surgical risk stratification. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this paper is to propose a sequential deployment technique for the E-nside off-the-shelf endograft that could potentially enhance target visceral vessel (TVV) cannulation and overstenting in narrow aortic anatomies. Methods: All data regarding patients consecutively treated in two aortic centers with the E-nside graft employing the partial deployment technique were included in the study cohort and analyzed. To execute the procedure with partial endograft deployment, the device should be prepared before insertion by advancing, under fluoroscopy, all four dedicated 400 cm long 0.018″ non-hydrophilic guidewires until their proximal ends reach the cranial graft's edge. Anticipating this guidewire placement prevents the inability to do so once the endograft is partially released, avoiding potentially increased friction inside the constricted pre-loaded microchannels. The endograft is then advanced and deployed in the standard fashion, stopping just after the inner branch outlets are fully expanded. Tip capture is released, and the proximal end of the device is opened. Visceral vessel bridging is completed from an upper access in the desired sequence, and the graft is fully released after revascularizing one or more arteries. Preventing the distal edge of the graft from fully expanding improves visceral vessel cannulation and bridging component advancement, especially when dealing with restricted lumina. Results: A total of 26 patients were treated during the period December 2019–March 2024 with the described approach. Procedure was performed in urgent settings in 14/26 cases. The available lumen was narrower than 24 mm at the origin of at least one target vessel in 11 out of 26 cases performed (42.3%). Technical success was obtained in 24 out of 26 cases (92.3%), with failures being due to TVVs loss. No intraoperative death or surgical conversion was recorded, and no early reintervention was needed in the perioperative period. Clinical success at 30 days was therefore 80.7%. Conclusions: The described technique could be considered effective in saving space outside of the graft, allowing for safe navigation and target vessel cannulation in narrow visceral aortas, similar to what has already been reported for outer-branched endografts. [ABSTRACT FROM AUTHOR]

Objectives: Target vessel endoleaks are one of the most common causes of revision procedures after a fenestrated or branched endovascular aneurysm repair. Usually, a redo stenting is an effective therapy, however, not always feasible. We present a case of a hybrid treatment for a type IIIb endoleak using the renal autotransplantation technique. Methods: A 60-year-old man with a thoracoabdominal aortic aneurysm has been treated with a custom-made branched endoprosthesis. Occlusion of the bridging stent to the right renal artery with total infarction of the right kidney was identified one week later and conservatively managed. After four years, a type IIIb endoleak was identified. Endovascular treatment was attempted unsuccessfully. So, the endoleak was corrected using a hybrid strategy with the kidney autotransplantation technique. Results: A left kidney autotransplantation followed by an aortic stent-graft relining with a tubular graft has been done uneventfully, in a phased manner. Postoperative computed tomography angiography confirmed the patency of vascular reconstructions with no endoleaks. No adverse events occurred during one year of follow-up. Conclusion: Our case highlights kidney autotransplantation as a viable solution for a hybrid treatment of target vessel endoleaks and shows that this technique can assist complex endovascular aortic reconstructions. [ABSTRACT FROM AUTHOR]

Introduction: The management of thoracoabdominal aortic aneurysms (TAAA) presents significant challenges for vascular and cardiothoracic surgeons due to the risk of ischemic complications. Various strategies have been implemented over time, including open repair with or without left heart bypass (LHB), endovascular, and hybrid approaches. Here, we explore the application of temporary extra-anatomic bypasses (TEAB) as a technique for complex open TAAA repair when the traditional standard of care is not feasible (i.e. Unavailability of LHB) or indicated (i.e. contraindication for systemic heparinization for LHB). Case reports: Case 1 is an undomiciled 59-year-old male with a chronic type B dissection (CTBD) and degenerative TAAA with failed attempt at endovascular repair at an outside institution. An open repair of the visceral segment was performed with TEAB due to risk of impending rupture, prior failed endovascular repair, and unavailability of cardiac surgery. Additionally, a staged TEVAR was planned for treatment of the thoracic portion of the CTBD in two weeks’ time. The patient experienced sudden chest pain 10 days following the TAAA repair, prompting urgent TEVAR. No complications were observed. Case 2 is a 65-year-old male with a type 2 TAAA who underwent an open repair with the use of TEAB. Technical success was achieved with no complications. Discussion: TAAA repair poses significant challenges regardless of the approach selected. However, the use of TEAB has shown promise in ensuring adequate perfusion of vital organs during complex repair when LHB is not an option. Preoperative planning is essential to minimize ischemic time and reduce complications. Studies have shown favorable outcomes with TEAB, however, evidence relies only on small series and case reports. Conclusion: The use of TEAB is a valuable technique for safeguarding organ perfusion during open repair of TAAA. While further research and experience are needed, TEAB offers a promising alternative for cases where traditional approaches are not available. Continued exploration and documentation of TEAB in current literature will contribute to optimizing TAAA management strategies.

Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome are genetic aortopathies that result from abnormal collagen matrix formation associated with vascular complications and early death. Identification of simultaneous COL3A1 and SMAD3 mutations as well as subsequent open and endovascular repair have not been reported. We present a case of a staged complete aortic replacement in a patient with a 7-cm aneurysm of his aortic arch and confirmed genetic mutations for Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome. This case highlights that, despite increased operative risk, successful staged repair of the entire aorta can be achieved in a patient with multiple severe genetic aortopathies.

Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access. [ABSTRACT FROM AUTHOR]

Background: Thoracoabdominal aneurysms and aortic dissections are a challenge for vascular surgeons. Open surgery, fenestrated or branched endograft, and the chimney technique are not possible in some patients, because of comorbidities or anatomical restrictions. However, the multilayer flow modulator (MFM) can be implanted in some of these patients. In this systematic review, we will describe the experience with the multilayer stent. To augment the limited number of studies available, we will include a cohort of patients from our hospital. Methods: We retrieved data on all consecutive patients treated using the MFM between May 2013 and August 2020. This included patients with type B dissections and thoracoabdominal or thoracic aneurysms who were unfit for open surgery. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all the studies that used the MFM in the aortic segment. Single-arm meta-analyses were performed using OpenMeta (Brown University, Providence, RI, USA). Results: A total of 37 patients were treated in our hospital during the study period. The technical success was 97.3% and the 30-day mortality was 5.4%. In 40.5% of the included patients, the instructions for use were not followed. Offlabel implantation was associated with a higher aneurysm-related mortality. A total of 12 studies were included in the meta-analysis and the technical success was 97.8%. In 68.5%, the aneurysm sack or false lumen remained perfused, 97% of all the covered side branches remained patent. After a follow-up period of 1 year, five patients in the meta-analysis presented with a ruptured aneurysm. Conclusions: The overall quality of evidence is poor because long-term results are lacking, patients are frequently lost during follow-up and all the studies were non-comparative. Our retrospective study suggests a relatively low incidence of perioperative complications, although there was a high incidence of persistent perfusion in the aneurysm sac (102 of 149 patients). The risk of rupture at the 1-year follow-up was 2.1%. [ABSTRACT FROM AUTHOR]

Explantation of traditional infrarenal aortic endografts has been previously described, and explanation of aortic endografts with standard suprarenal fixation at our center has been well defined. However, to the best of our knowledge, no cases have been reported on explantation of endografts with polymer rings present to facilitate the proximal seal. By obtaining full thoracoabdominal exposure with supraceliac clamping and opening the entire aorta along the graft, we were able to successfully explant the ALTO stent graft with polymer rings.

The use of intravascular ultrasound (IVUS) reduces contrast medium use and radiation exposure during conventional endovascular aneurysm repair (EVAR). The aim of this study was to evaluate the safety and efficacy of IVUS in detecting bridging stent graft (bSG) instability during fenestrated and branched EVAR (F/B-EVAR). This was a prospective observational multicentre study. The following outcomes were evaluated: (1) technical success of the IVUS in each bSG, (2) IVUS findings compared with intra-operative angiography, (3) incidence of post-operative computed tomography angiography (CTA) findings not detected with IVUS, and (4) absence of IVUS related adverse events. Target visceral vessel (TVV) instability was defined as any branch or fenestration issues requiring an additional manoeuvre or re-intervention. Any IVUS assessment that detected stenosis, kinking, or any geometric TVV issue was considered to be branch instability. All procedures were performed in ad hoc hybrid rooms. Eighty patients (69% males; median age 72 years; interquartile range 59, 77 years) from four aortic centres treated with F/B-EVAR between January 2019 and September 2021 were included: 70 BEVAR (21 off the shelf; 49 custom made), eight FEVAR (custom made), and two F/B-EVAR (custom made), for a total of 300 potential TVVs. Two TVVs (0.7%) were left unstented and excluded from the analysis. The TVVs could not be accessed with the IVUS catheter in seven cases (2.3%). Furthermore, 17 (5.7%) TVVs could not be examined due to a malfunction of the IVUS catheter. The technical success of the IVUS assessment was 91.9% (274/298), with no IVUS related adverse events. Seven TVVs (2.5%) showed signs of bSG instability by means of IVUS, leading to immediate revisions. The first post-operative CTA at least 30 days after the index procedure was available in 268 of the 274 TVVs originally assessed by IVUS. In seven of the 268 TVVs (2.6%) a re-intervention became necessary due to bSG instability. This study suggests that IVUS is a safe and potentially valuable adjunctive imaging technology for intra-operative detection of TVV instability. Further long term investigations on larger cohorts are required to validate these promising results and to compare IVUS with alternative technologies in terms of efficiency, radiation exposure, procedure time, and costs. [ABSTRACT FROM AUTHOR]

Background Aortic aneurysm as a presenting feature in Takayasu's arteritis is very rare. Here, we report three cases of extensive thoracoabdominal aortic aneurysm in Takayasu's arteritis as initial presentation. Case summary All three cases were males and presented with complaints of abdominal pain and refractory hypertension. The diagnosis was made from the finding of thickened and calcified aortic wall, stenosis of visceral arteries, and age < 40 years at diagnosis. Case 1 was a 34 years male with aortic aneurysm extending from left subclavian artery to infrarenal aorta. He underwent endovascular repair of aneurysm by sandwich chimney technique in view of impending aneurysm rupture. Case 2, a 37 years male had aortic aneurysm from descending thoracic aorta (D4 vertebral body) to infrarenal aorta (L4 level). While being evaluated for repair, he had sudden death probably due to ruptured aneurysm. Case three, a 40 years male had aortic aneurysm extending from left subclavian artery to aortic bifurcation and stenosis of visceral arteries. He did not consent for repair and died one year later due to chronic kidney disease and related complications. Discussion Thoracoabdominal aortic aneurysm is a very rare manifestation in Takayasu's arteritis; more common in males. Endovascular repair is challenging but feasible. Long-term monitoring and repeat intervention may be needed due to young age of patients and disease progression. [ABSTRACT FROM AUTHOR]

Failed fenestrated-branched endovascular aortic repair (F-BEVAR) requiring a redo F-BEVAR is a rare event. In this study, we report 2 cases of a failed F-BEVAR secondary to a type IIIb endoleak from tears on the fabric graft successfully treated with redo F-BEVAR. This is a technically challenging procedure that requires meticulous planning, advanced imaging technologies and experienced operators. Redo F-BEVAR appears to be a feasible and safe treatment option. However, larger series and long-term follow-up are needed to confirm effectiveness and durability. [ABSTRACT FROM AUTHOR]

The article discusses the challenges and insights related to managing large thoracoabdominal aneurysms using fenestrated and branched endografts (F/BEVAR) as an alternative to open repair. The study found that while aneurysm diameter did not significantly affect early technical success or mortality rates, larger aneurysms were associated with increased rates of reintervention and target visceral vessel instability during follow-up. The research emphasizes the importance of tailored strategies, volumetric assessment, and advanced imaging techniques to optimize outcomes for this complex patient group. The study underscores the need for collaborative, multicentre research to refine endovascular strategies and improve patient outcomes in the treatment of large-diameter thoracoabdominal aneurysms. [Extracted from the article]

Objective: To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoracoabdominal aneurysm repair (DTAAAR). Background: Compared with euglycemia, hyperglycemia, and ketosis make neurons respectively more vulnerable and more resilient to ischemia. Methods: During the study period (1997–2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary [operative mortality (OM), myocardial infarction, stroke, need for tracheostomy, de novo dialysis, and survival] endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching. Results: DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 nondiabetics. All preoperative variables had a standardized mean difference <0.1 between the matched groups. Patients with DM had higher SCI (6.5% vs. 1.6%, P 0.03) and OM (14.1% vs. 6.0%, P =0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (odds ratio: 5.05, 95% confidence interval: 1.17–21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) (P =0.03). The results are summarized in the graphical abstract. Conclusion: DM is associated to increased OM and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events. [ABSTRACT FROM AUTHOR]

Introduction: Lobar torsion is a rare, challenging diagnosis that requires a high index of suspicion and prompt investigation and management. Detection and urgent fixation or lung resection are critical to avoid catastrophic sequelae of lung necrosis, bronchopleural fistulae, and death. Report: A case of lobar torsion following open repair of a type B aortic dissection and thoraco-abdominal aortic aneurysm in a patient with Marfan syndrome is presented. After a non-specific constellation of symptoms, the diagnosis was confirmed with computed tomography and bronchoscopic findings and the patient underwent detorsion and plication of a torted, yet viable, left upper lobe on post-operative day 6. The patient is currently being followed with serial imaging to follow a necrotic consolidation of the left upper lobe. Discussion: This was a case of lobar torsion in a patient with Marfan syndrome and the degree of connective tissue disease may have predisposed the patient to this rare surgical complication. The case presents a challenging dilemma due to the risks associated with exposing a synthetic aortic graft to a potentially infected space if lobar resection or a pneumonectomy was performed.

Endoleaks are more common after fenestrated/branched endovascular aneurysm repair (F/B-EVAR) than infrarenal EVAR secondary to the length of aortic coverage and number of component junctions. Although reports have focused on type I and III endoleaks, less is known regarding type II endoleaks after F/B-EVAR. We hypothesized that type II endoleaks would be common and often complex (associated with additional endoleak types), given the potential for multiple inflow and outflow sources. We sought to describe the incidence and complexity of type II endoleaks after F/B-EVAR. F/B-EVAR data prospectively collected at a single institution in an investigational device exemption clinical trial (G130210) were retrospectively analyzed (2014-2021). Endoleaks were characterized by type, time to detection, and management. Primary endoleaks were defined as those present on completion imaging or at first postoperative imaging, and secondary were those on subsequent imaging. Recurrent endoleaks were those that developed after a successfully resolved endoleak. Reinterventions were considered for type I or III endoleaks or any endoleak associated with sac growth >5 mm. Technical success defined as the absence of flow in the aneurysm sac at procedure conclusion and methods of intervention were captured. Among 335 consecutive F/B-EVARs (mean ± standard deviation follow-up: 2.5 ± 1.5 years), 125 patients (37%) experienced 166 endoleaks (81 primary, 72 secondary, and 13 recurrent). Of these 125 patients, 50 (40% of patients) underwent 71 interventions for 60 endoleaks. Type II endoleaks were the most frequent (n = 100, 60%), with 20 identified during the index procedure, 12 (60%) of which resolved before 30-day follow-up. Of the 100 type II endoleaks, 20 (20%; 12 primary, 5 secondary, and 3 recurrent) were associated with sac growth; 15 (75%) of those with associated sac growth underwent intervention. At intervention, 6 (40%) were reclassified as complex, with a concomitant type I or type III endoleak. Initial technical success for endoleak treatment was 96% (68 of 71). There were 13 recurrences, all of which were associated with complex endoleaks. Nearly half of the patients who underwent F/B-EVAR experienced an endoleak. The majority were classified as type II, with nearly a fifth associated with sac expansion. Interventions for a type II endoleak frequently led to reclassification as complex, with a concomitant type I or III endoleak not appreciated on computed tomography angiography and/or duplex. Further study is needed to determine if the primary treatment goal for complex aneurysm repair is sac stability or sac regression, as this would inform both the importance of properly classifying endoleaks noninvasively and the intervention threshold for managing type II endoleaks. [ABSTRACT FROM AUTHOR]

Background: Thoracoabdominal aneurysms and aortic dissections are a challenge for vascular surgeons. Open surgery, fenestrated or branched endograft, and the chimney technique are not possible in some patients, because of comorbidities or anatomical restrictions. However, the multilayer flow modulator (MFM) can be implanted in some of these patients. In this systematic review, we will describe the experience with the multilayer stent. To augment the limited number of studies available, we will include a cohort of patients from our hospital. Methods: We retrieved data on all consecutive patients treated using the MFM between May 2013 and August 2020. This included patients with type B dissections and thoracoabdominal or thoracic aneurysms who were unfit for open surgery. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all the studies that used the MFM in the aortic segment. Single-arm meta-analyses were performed using OpenMeta (Brown University, Providence, RI, USA). Results: A total of 37 patients were treated in our hospital during the study period. The technical success was 97.3% and the 30-day mortality was 5.4%. In 40.5% of the included patients, the instructions for use were not followed. Off-label implantation was associated with a higher aneurysm-related mortality. A total of 12 studies were included in the meta-analysis and the technical success was 97.8%. In 68.5%, the aneurysm sack or false lumen remained perfused, 97% of all the covered side branches remained patent. After a follow-up period of 1 year, five patients in the meta-analysis presented with a ruptured aneurysm. Conclusions: The overall quality of evidence is poor because long-term results are lacking, patients are frequently lost during follow-up and all the studies were non-comparative. Our retrospective study suggests a relatively low incidence of perioperative complications, although there was a high incidence of persistent perfusion in the aneurysm sac (102 of 149 patients). The risk of rupture at the 1-year follow-up was 2.1%.

The use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access. Prospectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality. Among 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P <.001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P <.01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P =.036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P =.13) and TIAs (0.54% vs 0%; P =.10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P =.029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P =.72), perioperative mortality (2.9% vs 2.6%; P =.72), or local access-related complications (6.5% vs 5.5%; P =.43). In the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach. [Display omitted] [ABSTRACT FROM AUTHOR]

Complex aortic pathology still represents an open issue in contemporary endovascular management, with continuous technological advancement being introduced in practice over time aiming to improve outcomes. Thus far, the dualism between the fenestrated and branched configuration for visceral artery revascularization is yet unsolved, with each approach having its own pros and cons. The inner branched technology for endovascular aneurysm repair (iBEVAR) aims to take the best out of both strategies, offering wide applicability and stable bridging stent sealing. The objective of this study was to evaluate the early outcomes obtained with a single manufacturer custom-made inner-branched endograft in a multicenter Italian experience. All patients consecutively treated with E-xtra design devices in three Italian facilities were enrolled. Anatomic characteristics and perioperative data were analyzed. The main objective was to asses technical and clinical success after iBEVAR. Secondary end points were overall survival, aortic-related mortality, target visceral vessel (TVV) patency, and freedom from target vessel instability during follow-up. From 2016 to 2021, 45 patients were treated with an E-xtra design device revascularizing at least one visceral vessel through an inner branch. The mean age at the time of the procedure was 71.1 ± 9.3 years and 77.8% were males. The total number of target visceral arteries to be bridged with an inner branch was 159. The extent of aortic repair was thoracoabdominal in 91.1% of the cases. Technical success was achieved in 93.3% of the procedures (42/45) with all failures owing to a type I endoleak at final angiography. Each TVV was successfully connected to the graft's main body as planned without complications. Following their intervention, five patients developed spinal cord ischemia and in three of these cases symptoms persisted after discharge (6.7%). At 30 days clinical success was 93.3% (42/45). No death as well as no TVV thrombosis occurred within 30 days from the primary procedures. The mean follow-up was 22.8 ± 14.2 months. The Kaplan-Meier estimate of overall survival and TVV patency at 36 months were 83.9% and 95.9%, respectively. Inner branches seem to be a promising technology in the complex aortic repair landscape, with an applicability ranging from type II thoracoabdominal aneurysm to type I endoleak repair after infrarenal endografting. Whether iBEVAR could offer results comparable with those provided by fenestrated/branched endovascular aneurysm repair in terms of target vessel patency and stent stability is yet to be established and further studies are, therefore, needed. [ABSTRACT FROM AUTHOR]

Abstract Background Open surgery for thoracoabdominal aortic aneurysm is highly invasive. Staged repair for extensive TAAA is effective because it has low morbidity and mortality, and preserves spinal cord perfusion. An initial total arch replacement can create a proximal landing zone for thoracic endovascular aneurysm repair. Case presentation We performed a staged hybrid thoracoabdominal aortic aneurysm repair after total arch replacement, which consisted of a primary open repair procedure as Crawford Extent III and IV thoracoabdominal aortic aneurysms, and a secondary thoracic endovascular aneurysm repair for the residual lesions for four patients. No spinal cord injury was observed. In one patient, the residual descending aortic aneurysm ruptured six months after the primary open surgery. Conclusions Overall, staged hybrid repair is effective and shows low morbidity and mortality. Secondary thoracic endovascular aneurysm repair should be performed as soon as possible to reduce the risk of residual aneurysm rupture.

Minimizing ischemic injury during surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is vital for preventing complications such as paraplegia and acute renal failure. In this report, we describe a new technique for TAAA open repair that aims to minimize visceral organ ischemia times. Unlike typical Crawford extent II TAAA open repair, which begins with aortic clamping and proceeds from the proximal to the distal anastomoses, our method reverses the anastomosis order and minimizes aortic clamping. Between January 2016 and December 2020, we used this approach in 29 patients undergoing TAAA repair. We present one of these cases, a 29‐year‐old patient with progressive aneurysmal dilatation of a DeBakey type III chronic aortic dissection that extended beyond the aortic bifurcation. Our technique reduced aortic cross‐clamping, left heart bypass, and internal organ and spinal cord ischemia times and appears to be safe and effective. [ABSTRACT FROM AUTHOR]

Background: To compare perioperative and midterm outcomes in thoracic and thoraco‐abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia. Methods: From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis. Results: Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p < 0.0001) while the AC group had more TAAAs (80% vs. 30%, p < 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p < 0.0001) but shorter cross‐clamp time (39 vs. 120 min, p < 0.0001) and lower temperatures (18°C vs. 34°C, p < 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five‐year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36). Conclusions: Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair. [ABSTRACT FROM AUTHOR]

Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated. [ABSTRACT FROM AUTHOR]

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Open in new tab Download slide Open in new tab Download slide OBJECTIVES Our goal was to report outcomes of the endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) using the Cook Zenith t-Branch off-the-shelf multibranched endograft. METHODS Between 2010 and 2020, we collected patients with TAAAs who received an urgent endovascular repair using the Cook Zenith t-Branch (had a rupture, symptoms or diameter >80 mm). Thirty-day mortality, spinal cord ischaemia (SCI) and clinical success were assessed as early outcomes. Freedom from reintervention, target visceral vessel patency and survival were considered during follow-up. RESULTS Sixty-five cases were managed using the Cook Zenith t-Branch for 27 (42%) TAAA ruptures, 8 (12%) symptomatic TAAAs and 30 (46%) asymptomatic TAAAs with a diameter >80 mm. Crawford's extent I–II–III and IV were noted in 54 (83%) and 11 (17%), respectively. Eleven (17%) patients had SCI with 3 (5%) cases of permanent paraplegia. Postoperative dialysis (P  = 0.04) and ruptured TAAAs (P  = 0.05) were associated with SCI. Sixteen (25%) patients had reinterventions within the first 30 days postoperatively. The 30-day mortality was 14% (9). Ruptured TAAAs (P  = 0.05) and technical failures (P  = 0.01) were correlated with in-hospital mortality. Clinical success was 78% (51 patients). The mean follow-up was 18 ± 14 months. Survival at 24 months was 47% with no late TAAA-related deaths. Patients with ruptured TAAAs had lower survival than those who did not have ruptured TAAAs (52% vs 60% at 1 year; P  = 0.05). Target visceral vessel patency and freedom from reintervention at 24 months were 89% and 60%, respectively. CONCLUSIONS An off-the-shelf multibranched endograft is safe and effective for treating urgent TAAAs. Postoperative SCI and 30-day mortality are satisfactory for this challenging clinical scenario. The early reintervention rate is not negligible. Midterm survival is low, especially in patients with a ruptured TAAA; therefore, accurate patient selection is mandatory. [ABSTRACT FROM AUTHOR]

Spinal cord ischemia (SCI) is a devastating and unpredictable complication of thoracoabdominal aortic repair. Postischemic Toll-like receptor 3 (TLR3) activation through either direct agonists or shock wave therapy (SWT) has been previously shown to ameliorate damage in SCI models. Whether the same applies for pre- or postconditioning remains unclear. In a model of cultured SHSY-5Y cells, preconditioning with either poly(I:C), a TLR3 agonist, or SWT was performed before induction of hypoxia, whereas postconditioning treatment was performed after termination of hypoxia. We measured cytokine expression via RT-PCR and utilized Western blot analysis for the analysis of signaling and apoptosis. TLR3 activation via poly(I:C) significantly reduced apoptotic markers in both pre- and postconditioning, the former yielding more favorable results through an additional suppression of TLR4 and its downstream signaling. On the contrary, SWT showed slightly more favorable effects in the setting of postconditioning with significantly reduced markers of apoptosis. Pre- and post-ischemic direct TLR3 activation as well as post-ischemic SWT can decrease apoptosis and proinflammatory cytokine expression significantly in vitro and might therefore pose possible new treatment strategies for ischemic spinal cord injury. [ABSTRACT FROM AUTHOR]

Ischemic renal failure and visceral ischemia are two serious complications of the surgery for thoracoabdominal aortic aneurysm. The introduction of left atrial bypass, partial bypass, total circulatory arrest, and selective visceral perfusion has reduced the incidence of these complications over the past two decades. Yet these complications still persist, suggesting the sub-optimal nature of the available strategies. [ABSTRACT FROM AUTHOR]

Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access. During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. UE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P =.16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P =.99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P =.74). Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension. [ABSTRACT FROM AUTHOR]

Background: Open surgery for thoracoabdominal aortic aneurysm is highly invasive. Staged repair for extensive TAAA is effective because it has low morbidity and mortality, and preserves spinal cord perfusion. An initial total arch replacement can create a proximal landing zone for thoracic endovascular aneurysm repair.Case Presentation: We performed a staged hybrid thoracoabdominal aortic aneurysm repair after total arch replacement, which consisted of a primary open repair procedure as Crawford Extent III and IV thoracoabdominal aortic aneurysms, and a secondary thoracic endovascular aneurysm repair for the residual lesions for four patients. No spinal cord injury was observed. In one patient, the residual descending aortic aneurysm ruptured six months after the primary open surgery.Conclusions: Overall, staged hybrid repair is effective and shows low morbidity and mortality. Secondary thoracic endovascular aneurysm repair should be performed as soon as possible to reduce the risk of residual aneurysm rupture. [ABSTRACT FROM AUTHOR]

The development of aneurysms of thoracoabdominal aorta (TAAA) in a post-transplant patient is a rare clinical situation and requires special attention. Endovascular treatment is the most suitable option for these patients due to numerous comorbidities. Particular emphasis should be placed on the ejection fraction as one of the main criteria for qualifying for surgery. The treatment itself remains a major challenge relating to anatomical constrains; however, it is possible in select patients in experienced centers. [ABSTRACT FROM AUTHOR]

Purpose: To report a case of a symptomatic type IIIb endoleak treated by a transgraft embolization approach. Case description: A 66-year-old Caucasian male with a 5.7 cm type IV thoracoabdominal aneurysm (TAAA), which was previously urgently repaired with a four-vessel physician-modified endovascular graft (PMEG), presented with worsening of back pain. The patient has been deemed a prohibitive surgical risk for any open vascular procedure due to episodes of unstable angina and his poor candidacy for additional coronary revascularization despite multiple previous coronary stents. He was found to have a type IIIb endoleak, which was associated with the left renal fenestration on computed tomography (CT) angiogram. The patient was taken to the operating room and an initial attempt to improve the left renal artery stent apposition was unsuccessful after performing balloon angioplasty plus intravascular ultrasound interrogation. However, a tear underneath the fenestration ring was confirmed by placing a catheter underneath the fenestration ring. Thus, a decision was made to employ a transgraft approach to repair the endoleak and avoid transcaval or translumbar approach. A laser-assisted fenestration through the left iliac limb of the previous endograft was performed to access the aneurysm sac. Of note, there was no room to deploy an aortic cuff without converting the repair into a four-vessel chimney endovascular aortic repair (ChEVAR). A combination of microcoils and Gelfoam® thrombin particulates was carefully placed to the nidus of the leak from the inside of the stent-graft lumen forming a “sandwich” (thrombin behind coils) patch configuration. The patient was free of any symptoms or pertinent vascular findings at the one-year follow-up. A CTA showed a complete resolution of the previous endoleak and associated symptoms, and regression of the aneurysmal sac diameter. Conclusion: Transgraft embolization appears feasible in completely excluding a challenging type IIIb endoleak in patients not amenable to open repair. This method should be considered an alternative to relining the defect with the deployment of additional components (e.g., ChEVAR) or additional aortic stent-grafts, especially in inadequate luminal space and room between bridging stents.

Aneurysmal degeneration of the visceral artery patch (ADP) after open repair of thoracoabdominal aneurysms is a rare complication. We present the clinical case of a 77-year-old woman with a ruptured intercostal artery patch anuerysm three years after Crawford type II thoracoabdominal aneurysm repair surgery. Endovascular emergency treatment was performed with measures to protect against spinal cord ischemia, with technical success. There were no complications at 30 days.

Degeneration of the thoracoabdominal aorta proximal to a prior fenestrated endovascular aortic repair represents a complex issue with limited options for repair. Previously, modified endografts or open conversion with endograft explant offered the only options for management. Here we describe use of the Gore Thoracoabdominal Multibranch Endoprosthesis for exclusion of an extent III thoracoabdominal aneurysm in the setting of degeneration proximal to a previously placed fenestrated device., Competing Interests: None., (© 2024 The Author(s).)