Intravascular Lithotripsy and Aortic Bare-Metal Stenting: A Low-Profile Solution for the Treatment of Heavily Calcified Aorto-Iliac Disease.

PURPOSE: To present a novel technique for the treatment of heavily calcified aorto-iliac disease using intravascular lithotripsy (IVL) and self-expanding bare-metal stents (BMS). TECHNIQUE: We present our experience with 4 cases of calcified aorto-iliac disease that were treated with IVL as vessel preparation followed by BMS deployment. Intravascular lithotripsy was performed using a 7-mm or 8-mm Shockwave catheter from 1 access and a non-compliant balloon introduced from the second access in a "hugging-balloon" configuration. Afterward, a self-expandable BMS is deployed in the infrarenal aorta and additional bare-metal balloon-mounted stents are deployed in the iliac arteries as needed. This technique provides a low-profile solution with only 6- and 7-French introducers, preservation of the collateral circulation while also preserving the option for an up-and-over approach in the future. Technical success was achieved in all cases and no periprocedural complications were observed. CONCLUSION: Intravascular lithotripsy in combination with BMS for the infrarenal aorta and the aortic bifurcation seems to be a safe and effective low-profile treatment option for heavily calcified lesions. Large-scale studies with long-term follow-up are needed to validate our positive early results. CLINICAL IMPACT: Endovascular treatment of heavily calcified aortoiliac disease poses significant challenges, including the risk of rupture and dissection. The proposed technique uses intravascular lithotripsy and bare-metal stenting of the aortic bifurcation and represents a low-profile solution that preserves collaterals and potentially reduces the risk of dissection with IVL vessel preparation.

Outcome of the Be Graft Bridging Stent in Fenestrated Endovascular Aortic Repair in a High-Volume Single Center and an Overview of Current Evidence.

OBJECTIVE: Fenestrated endovascular aneurysm repair (FEVAR) has become one of the standard treatment options for complex abdominal aortic aneurysms (cAAAs) and thoraco-abdominal aortic aneurysms (TAAAs). Despite technological advances in the main endograft design, the lack of dedicated bridging stent-grafts (BSGs) is still the Achilles heel of the procedure. The aim of this study was to evaluate the mid-term outcomes of the BeGraft stent-graft as a dedicated bridging stent for FEVAR and to review the current evidence in literature. METHODS: Retrospective single center study, including all consecutive FEVARs performed between September 2018 and December 2022 for the treatment of cAAAs and TAAAs with implantation of at least one BeGraft peripheral as the main BSG in one of the target vessels (TVs). Primary endpoints were technical success and TV instability of TV bridged with a BeGraft stent, as well as 30-day mortality and re-intervention rates. Secondary endpoints were follow-up TV instability, re-interventions, and mortality. RESULTS: A total of 113 patients (93 male, mean age 71.1±9.7) and 440 TV (14 scallops and 426 fenestrations) were included. Of the 440 TV, 406 received primary stenting. Be Grafts were used in 88.9% of these (n=361; celiac trunk [CT]=67, superior mesenteric artery [SMA]=98, right renal artery [RRA]=97, and left renal artery [LRA]=99). The technical success rate was 99.4% (359/361). The 30-day TV instability rate was 0.27% (1/361) with one early renal artery occlusion. During a median follow-up of 20 months (6-32), TV instability rate was 0.8% (3/361). Freedom from TV instability was 99.3%, 98.8%, and 98.8% at 1, 2, and 3 years, respectively. CONCLUSION: Early-term and mid-term results regarding TV instability are satisfactory and support the use of BeGraft as BSG in FEVAR for cAAAs and TAAAs. CLINICAL IMPACT: The findings of the current study show that the use of the BeGraft stent graft as bridging stent in FEVAR is associated with a high technical success and low early and mid-term instability rate and support the standard use as a bridging stent in fenestrated aneurysm repair.

Outcomes after Endovascular Arch Repair in Patients with a Mechanical Aortic Valve: Results from a Multicentre Study.

OBJECTIVE: The aim of this study was to investigate outcomes after endovascular aortic arch repair in patients with a mechanical aortic valve where the valve needs to be crossed. METHODS: An international, multicentre, retrospective observational study was undertaken including all consecutive patients who underwent endovascular arch repair with mechanical aortic valve crossing. RESULTS: From March 2020 to August 2023, 12 patients were included in the study (median age 55 years, interquartile range 45, 67 years; 58% male). Five patients (42%) had a genetically confirmed connective tissue disorder (CTD) and three more had a high clinical suspicion of CTD. Most patients had a bileaflet valve (11/12; 92%) and one patient had a monoleaflet one. All patients had previously undergone surgical ascending aortic repair. Technical success was 100% with successful completion of the procedure with no valve damage. Two deaths (17%) were observed in the first 30 days post-operatively with no signs of valve malfunction: one patient died of major stroke due to excessive wire and sheath manipulation in the arch; and another due to cardiac arrest of unknown cause, with no valve damage being detected in the autopsy. No intra-operative technical difficulties regarding valve cannulation were observed. During a median follow up of eight months, one patient died fifteen months after the procedure owing to non-aortic related causes, and four endoleaks were present on the latest computed tomography angiography, none type I or III. CONCLUSION: Endovascular aortic arch repair in a selected group of patients with a mechanical aortic valve treated in experienced, high volume aortic centres seems technically feasible and reasonably safe. These preliminary results underline the complexity of the procedure and should be validated by larger cohort studies. With careful patient selection and adequate physician experience, the presence of a mechanical aortic valve could potentially no longer pose a major contraindication for endovascular arch repair in the future.

Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia.

PURPOSE: To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). METHODS: This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS: In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). CONCLUSION: Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. CLINICAL IMPACT: Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.

Systematic Review and Meta-Analysis of Outcomes After Operative Treatment of Aberrant Subclavian Artery Pathologies and Suggested Reporting Items.

OBJECTIVE: To synthesise and present all available evidence regarding the surgical treatment of patients with aberrant subclavian artery (aSA) pathologies during the last 30 years. The study also aimed to create a checklist of suggested reporting items to help increase reporting homogeneity. METHODS: A systematic search of medical databases was performed to identify all studies published between 1990 and 2020 reporting on the outcomes of patients undergoing surgery for an aSA pathology. Patients were divided into two groups; Group A included patients undergoing open or hybrid surgery through sternotomy/thoracotomy and Group B included patients undergoing endovascular or hybrid treatment without chest access. The % crude rates (CR) of all variables of interest were calculated. A proportion meta-analysis was performed reporting pooled rates with 95% confidence intervals (CIs). RESULTS: Three hundred and fourteen studies were identified reporting on the surgical outcomes of 732 patients (60.1% males; 440/732). The quality of evidence was generally low, with 286 studies including fewer than four patients and 28 studies with five or more cases. Aberrant right subclavian artery (aRSA) in a left sided aortic arch was present in 71.4% of the patients and a Kommerell's diverticulum was present in 50.1% of the cases. A total of 68% of the patients were symptomatic on presentation, with the majority complaining of dysphagia (49.6%). Group A included 453 and Group B 279 patients. Studies reporting on five or more patients were included in the main meta-analysis. The pooled early mortality rate was 1.62% (95% CI 0.05% - 4.53%) in Group A and 1.96% (95% CI 0 - 6.34%) in Group B. Pooled rates of symptom relief were 99.52% (95% CI 92.05% - 100.00%) in Group A and 95.79% (95% CI 83.96% - 100.00%) in Group B. CONCLUSION: The surgical techniques used to treat aSA and aortic pathologies involving an aSA had remarkably low mortality rates and high clinical success, regardless of the technique used.

Fenestrated versus debranching thoracic endovascular aortic repair for endovascular treatment of distal aortic arch and descending aortic lesions.

BACKGROUND: Cervical debranching, followed by thoracic endovascular aortic repair (TEVAR), is well-established for treating aortic arch lesions. However, total endovascular repair with fenestrated endografts has not been adequately studied. Thus, we performed a comparison of the two techniques. METHODS: The present study was a single-center, retrospective study comparing the treatment of thoracic aortic lesions with custom-made fenestrated stent-grafts (fenestrated TEVAR [fTEVAR]) with a single fenestration for the left subclavian artery (LSA), a scallop for the left carotid artery, and hybrid repair with a thoracic stent-graft and cervical debranching of the LSA. Emergency cases were excluded. RESULTS: From 2012 to 2018, 19 patients (58% male) underwent elective fTEVAR (group A) and 17 patients (82% male) underwent debranching TEVAR (dTEVAR; group B). The mean age ± standard deviation in group A was 65.8 ± 2 years and 68 ± 3 years in group B. Left carotid-subclavian bypass was performed in 15 of 17 patients (88%) and transposition of the LSA in 2 of 17 patients (12%) in group B. The two groups were comparable regarding comorbidities, except for peripheral arterial disease: 5 of 19 patients in group A (26%) and none in group B had had peripheral arterial disease (P = .049). Dissection or post-dissection aneurysm was the indication for treatment in 6 of 19 patients in the fTEVAR group (group A) and in 12 of 17 patients in the dTEVAR group (group B; 31.6% vs 70.6%; P = .04). The indication for the remaining patients was a degenerative aortic aneurysm. Technical success was achieved in all cases, except for one case of dTEVAR owing to a type Ia endoleak. The mean endovascular operative time was 191 ± 120 minutes for fTEVAR and 130 ± 75 minutes for dTEVAR (P = NS). The mean operative time for the debranching procedure was 181 ± 97 minutes. No deaths or major strokes had occurred in the early postoperative period (30 days). Of the 17 patients in group B, 5 (29.4%) had experienced a local complication related to the debranching procedure. The mean follow-up was 14.6 ± 2 months for group A and 17 ± 2 months for group B. Of the 19 patients in group A and 17 patients in group B, 2 (10.5%) and 6 (35.3%) had required an unplanned reintervention related to the thoracic stent-graft during the follow-up period, respectively (P = NS). The estimated freedom from unplanned reintervention at 12 months was 86% for group A and 81% for group B. Primary patency of the LSA stent-graft or the carotid-subclavian bypass/transposition was 100% in both groups. CONCLUSIONS: Both techniques showed excellent midterm patency rates for the target vessel and high technical success rate. The operation times were shorter for the fTEVAR group and complications related to the debranching procedure were avoided.

Revascularization of occluded renal artery stent grafts after complex endovascular aortic repair and its impact on renal function.

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

The Munich Valsalva Implantation Technique (MuVIT) for Cardiac Output Reduction During TEVAR: Vena Cava Occlusion With the Valsalva Maneuver.

PURPOSE: To demonstrate a physiologically induced alternative to the typical methods of reducing cardiac output during deployment of stent-grafts in the aortic arch and proximal aorta. TECHNIQUE: A modified Valsalva maneuver, the Munich Valsalva implantation technique (MuVIT), to raise the intrathoracic pressure, minimize backflow, and reduce the cardiac output is illustrated in a patient undergoing a triple-branch thoracic endovascular aortic repair (TEVAR). During manual mechanical ventilation, the adjustable pressure-limiting valve is carefully closed to 25 mm Hg, creating "manual bloating" of the lungs and sustained apnea. The increased intrathoracic pressure causes compression of the vena cava and pulmonary veins, reducing the venous backflow and gradually decreasing the arterial pressure. Once the desired pressure is obtained, the stent-graft is accurately deployed. The airway pressure is thereupon slowly reduced, and the patient is taken back to normal ventilation. The procedure is then finished following standard practice. CONCLUSION: The MuVIT is a simple, noninvasive technique for cardiac output reduction during aortic arch TEVAR, eliminating the need for other invasive techniques.

Emergent Triple-Branched TEVAR and Redistribution of the Branches to the Supra-Aortic Target Vessels for Treatment of a Contained Ruptured Descending Aortic Aneurysm Associated With a Chronic Type A Aortic Dissection.

PURPOSE: To demonstrate the feasibility of urgent endovascular treatment of a chronic type A dissection and contained rupture of the false lumen using a noncustomized triple-branched arch endograft, which necessitated reassignment of the branches to the supra-aortic vessels. CASE REPORT:: A 57-year-old patient with a contained rupture of the descending thoracic aorta, in the setting of a chronic type A dissection and a maximum aortic diameter of 85 mm, was converted to endovascular repair after failure of an open surgical approach. A custom-made triple-branched arch endograft designed for another patient was employed, with concomitant occlusion of the false lumen using a Candy Plug occluder. To adjust the graft's configuration to the patient's anatomy, the supra-aortic vessels were not assigned to the originally planned branches. The 12-month follow-up angiography demonstrated a satisfactory result. CONCLUSION: A noncustomized triple-branched arch endograft can be used in an emergency setting to treat chronic type A dissection, reassigning the branches to the supra-aortic vessels as needed.

Technical Aspects of Fenestrated Arch TEVAR With Preloaded Fenestration.

Fenestrated thoracic endovascular aortic repair (f-TEVAR) has expanded the possibilities of endovascular arch repair, allowing treatment of pathologies involving the aortic arch that require sealing in Ishimaru zones 1 and 2. The growing number of implantations has increased physician experience and helped identify critical procedural points, mainly wire entanglement and device malrotation. Herein we describe a step-by-step approach to a f-TEVAR procedure with the Zenith fenestrated preloaded thoracic endograft, identifying potential pitfalls and suggesting problem-solving solutions.

Passing a Mechanical Aortic Valve With a Short Tip Dilator to Facilitate Aortic Arch Endovascular Branched Repair.

PURPOSE: To present a novel technique to successfully cross a mechanical aortic valve prosthesis. TECHNIQUE: A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels. CONCLUSION: Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.

A Case Report: Is the Lack of Sufficient Radial Force Unfreezing the "Frozen Elephant Trunk"?

The "frozen elephant trunk" is a hybrid technique to treat aortic arch and proximal descending aortic pathologies in a single step. Despite its encouraging early and long-term results, some stent-graft-related adverse events have been reported. Here, we describe a possible treatment option to "re-freeze" the FET in case of loss of landing zone. We report a patient who developed significant kinking of the FET over the course of the first 2 postoperative years. The 1-year follow-up computed tomography angiography (CTA) showed significant kinking and proximal migration of the endograft portion of the FET, resulting in new thrombus formation. Due to kinking and thrombus progression in subsequent CTA follow-ups (2 years and 2½ years) with risk for peripheral embolization, a secondary endovascular repair was indicated. Transfemoral relining of the stent component with a thoracic aortic endovascular repair (Zenith®TX2®30142) stent-graft was performed. In the context of postoperative aneurysm sac shrinkage, the low radial force and lack of longitudinal stiffness of the hybrid graft may lead to proximal migration, thus secondary kinking, emphasizing the importance of an adequate degree of oversizing of the primary graft and an appropriate follow-up. Selection of a suitable graft for a particular pathology concerning the radial force and longitudinal stiffness is furthermore important.

Balloon-Assisted True Lumen Expansion and Fenestration of a Symptomatic, Triple-Barrel, Postdissection Thoracoabdominal Aneurysm with Collapsed True Lumen to Facilitate Endovascular Treatment with a t-Branch.

BACKGROUND: To present the challenging endovascular treatment of a symptomatic triple-barrel (3 lumens; 1 true and 2 false lumens) aortic dissection case. METHODS: A 43-year-old male was introduced with a symptomatic, 9 cm postchronic dissection thoracoabdominal aortic aneurysm with accompanying triple-barrel formation and true lumen collapse at the height of the distal thoracic aorta. The celiac axis and right renal artery were perfused from the true lumen, the left renal artery from the false lumen and the superior mesenteric artery from both lumens. Endovascular approach was decided due to the patient co-morbidities. Because of the collapsed true lumen, the aorta had to be preconditioned in order to facilitate the endovascular repair with a multibranched thoracoabdominal stent-graft. This was achieved through the dilation of the aortic true lumen with a 32 mm Coda balloon (COOK Medical, Bloomington, IN), then puncturing of the intimal flap in several places to create re-entries that were also dilated (first with a 12-mm noncompliant balloon and then with a compliant 32 mm Coda balloon), creating a single aortic lumen that could facilitate an endovascular repair with thoracic stent-grafts and an off-the-shelf multibranched endograft (t-Branch; COOK Medical). The patient was promptly discharged, and the 3-month follow-up CT-angiogram showed a satisfactory result with patent target vessels and only a small Type-IIb endoleak. CONCLUSIONS: Preconditioning of the aorta using this technique is a feasible and safe approach for the treatment of complex thoracoabdominal postdissection aortic aneurysms presenting with a true lumen collapse.

Systematic review and meta-analysis of published studies on endovascular repair of thoracoabdominal aortic aneurysms with the t-Branch off-the-shelf multibranched endograft.

BACKGROUND: Endovascular treatment of thoracoabdominal aortic aneurysms is becoming increasingly popular in clinical practice, mainly because of its reduced perioperative mortality and morbidity. However, the custom-made stent graft platform that companies offer requires detailed preoperative planning and production time that can take up to 12 weeks. This may delay surgery in elective patients and is not an option for urgent or emergent cases. To surpass this limitation, the t-Branch (Cook Medical, Bloomington, Ind) was launched in 2012 in Europe as the first off-the-shelf standardized multibranched endograft for the endovascular treatment of thoracoabdominal aneurysms. Our aim was to systematically evaluate all published experience with this commercially available off-the-shelf thoracoabdominal stent graft. METHODS: We performed a systematic inquiry of the medical databases to identify all published studies that reported on the outcomes of patients treated with the t-Branch stent graft and then conducted a qualitative synthesis and meta-analysis of the results. The main end points studied were technical success, mortality, major stroke, spinal cord ischemia, primary branch patency, and renal insufficiency during the first 30 days along with midterm mortality and reintervention rate. We estimated pooled proportions and 95% confidence intervals (CIs). RESULTS: We identified seven retrospective studies published between 2014 and 2018, with a total of 197 patients (mean age, 72.3 ± 7 years; 70% male). Among 165 patients, 45% were symptomatic and 19% were treated for a ruptured aortic aneurysm. In 197 patients, pooled technical success was 92.75% (95% CI, 83.9%-98.7%), and in 10% of the cases, an early endoleak was detected (95% CI, 0%-43.7%). Early mortality was 5.8% (95% CI, 2.5%-10%), and major stroke was observed in 4% of the patients (95% CI, 0.96%-8.40%). The rate of spinal cord ischemia was 12.2% (95% CI, 4.1%-23.2%), with the rate of permanent paraplegia at 1.3% (95% CI, 0%-8.7%). Acute renal failure was 18.7% (95% CI, 9.1%-30.4%), whereas primary branch patency was calculated at 98.2% (95% CI, 96.7%-99.2%). Mean follow-up was 15 ± 7 months. During this time, midterm mortality (after 30 days) was 6.9% (95% CI, 2.44%-12.8%) and pooled reintervention rate was 5.7% (95% CI, 1.70%-11.4%). CONCLUSIONS: This pooled analysis indicated good technical success rate after t-Branch endograft implantation, with acceptable mortality and neurologic complications despite a high rate of urgent procedures. Thoracoabdominal endovascular repair with the t-Branch endograft is a feasible and safe therapeutic option for elective and urgent patients.

[Aortic Aneurysm: Fenestrated/Branched Endovascular Aortic Repair (EVAR) and Fenestrated/Branched Thoracic Endovascular Aortic Repair (TEVAR). Is Total Endovascular Repair Already Here?] / Aortenaneurysma: fenestrierte/gebranchte abdominale EVAR (fbEVAR) und fenestrierte/gebranchte thorakale EVAR (fbTEVAR). Ist die komplette endovaskuläre Therapie schon da?

Five years after the first endovascular aortic repair (EVAR), Park et al. reported the first implantation of a fenestrated endoprosthesis. In the meantime, advanced generations of new fenestrated and branched endografts evolved. Endografts for complex pathologies are either so-called "off-the-shelf" grafts with predetermined length, width, diameter and clock position of the branches and fenestrations, predetermined by the manufacturer, "custom-made" grafts which need to be sized and planned individually for patients with specific thoracoabdominal anatomy. Open aortic repair in the treatment of thoracoabdominal aortic aneurysm (TAAA) still remains challenging and is associated with high morbidity and mortality, even in the elective setting. The ongoing development of endovascular treatment modalities, such as fenestrated and branched endovascular aneurysm repair (F-EVAR, B-EVAR), enables less invasive procedures for more challenging aortic pathologies. In recent years, extensive endovascular treatment of the aortic arch to the thoracoabdominal segment has become more and more important, but its outcomes have not been completely evaluated. The aim of this is article is to provide an overview of the currently available endovascular treatment options for complex aortic aneurysms requiring extensive coverage from the aortic arch to the infrarenal aorta.

Risk of spinal cord ischemia after fenestrated or branched endovascular repair of complex aortic aneurysms.

OBJECTIVE: The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. METHODS: A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. RESULTS: Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: odds ratio [OR], 2.43; 95% confidence interval [CI], 1.18-4.99; P = .016) and the number of vertebral segments covered (SCI with higher position of proximal stent in terms of vertebra: OR, 1.2; 95% CI, 1.1-1.3; P = .000). A similar outcome was derived when the height of the proximal end of the stent graft was replaced by the total length of aortic coverage (SCI with preoperative glomerular filtration rate <60 mL/min/1.73 m2: OR, 2.36 [95% CI, 1.11-5.00; P = .025]; SCI with longer length of aortic coverage: OR, 1.01 [95% CI, 1.003-1.009; P = .000]). CONCLUSIONS: The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF <60 mL/min/1.73 m2 and with longer aortic stent graft coverage are at higher risk of SCI.

Emergent Use of a Branched Arch Device to Treat an Ascending Aortic Rupture: A Branch-to-Branch Through-and-Through Wire Technique to Compensate for Rotation Error.

Purpose: To present a novel means of overcoming a rotation error when treating a ruptured ascending aorta with a branched arch endograft. Technique: The technique is demonstrated in an 83-year-old patient with cardiac and respiratory comorbidities and a contained rupture of the ascending aorta who was referred for endovascular therapy. Computed tomography angiography (CTA) showed progressive pseudoaneurysm and mediastinal hematoma, but the limited landing zone required the use of an inner branched arch endograft that was designed for another patient. The device became malrotated clockwise during deployment, so cannulation of the first inner branch was done using a branch-to-branch through-and-through wire from the second inner branch. The final angiogram showed a good result, with patency of the supra-aortic vessels and exclusion of the rupture. The patient was discharged 2 weeks later without complications. The 1-month CTA was free from endoleak. The patient returned to his normal activity 3 months later. Conclusion: The use of a branched arch stent-graft for emergent repair of a ruptured ascending aorta is feasible.

Cervical Debranching in the Endovascular Era: A Single Centre Experience.

OBJECTIVE/BACKGROUND: Debranching of the supra-aortic arteries is a common practice either as part of a hybrid treatment of aortic arch pathology or owing to arterial occlusive disease. Results of the debranching techniques have not been reported frequently. METHODS: This was a retrospective single centre study of all consecutive patients with cervical debranching procedures as part of hybrid aortic arch repair. RESULTS: Between 2010 and 2017, 201 patients underwent 211 cervical debranching procedures in a tertiary centre. Mean ± SD patient age was 67.7 ± 10.7 years (70.6% males; n = 142/201) and mean ± SD body mass index (BMI) was 26.3 ± 5. In 78.7% of the cases carotid-subclavian bypass was performed alone (n = 166/211) followed by transposition of the subclavian artery to the ipsilateral carotid (n = 17/211; 8.1%) and in 28 cases (13.3%) a combination of procedures was performed. Twenty-four cases (11.4%) were complicated with local bleeding and 21 cases required re-intervention (10.4%). Nineteen patients (9.5%) developed local peripheral neurological damage post-operatively. Eight patients (3.8%) developed a chylous fistula and five (2.4%) presented with a local wound infection. One patient (0.5%) developed a bypass graft infection. The thirty day mortality was 7.6% (n = 16/211): one death occurred after isolated debranching without thoracic endovascular aneurysm repair (TEVAR; 0.5%). Whether the hybrid procedures were undertaken in a single stage (simultaneous TEVAR and cervical debranching) or two stage fashion appeared to have a significant impact on 30 day mortality (single stage n = 9/60 [15%] vs. debranching alone or two stage hybrid procedures n = 7/144 [4.9%]; p = .018). The major stroke incidence was 4.3% (n = 9/211); no strokes occurred after isolated debranching. Stroke was correlated with longer operating times (odds ratio [OR] 1.006; 95% confidence interval [CI] 1.000-1.011; p = .045) and higher BMI (OR 1.195; 95% CI 1.009-1.415; p = .039). Mean ± SD follow up was 15 ± 17 months (range 0-89 months). Primary cumulative graft patency during follow up was 98.1% (n = 207/211) and secondary patency was 100%. CONCLUSION: The results of cervical debranching procedures showed not only excellent patency rates, but also a significant rate of local complications. Carotid-subclavian bypass appeared to be safer with significantly fewer post-operative complications. Staged hybrid procedures also seemed to be safer.

Endovascular Repair of a Large Ilioiliac Fistula Using a Reversed Iliac Limb Endograft.

Ilioiliac fistulae are a rare condition, for which diagnosis and treatment can be challenging. In this report, we describe the case of a 74-year-old patient with a high-flow fistula between the left common iliac artery and the ipsilateral common iliac vein presenting with heart failure. The fistula was probably iatrogenic, caused by prostatic surgery 1 year earlier. We describe imaging findings on computed tomography angiography and the treatment by 2 back-table reversed stent grafts. The satisfactory results demonstrated in our case and those in the literature suggest that an endovascular treatment for this rare condition should be considered as the first-line therapy.

Hybrid and open repair for patients with acute limb ischemia of the lower extremities.

BACKGROUND: Hybrid revascularization procedures for acute limb ischemia (ALI) are becoming increasingly common, bibliographic data on outcomes is however sparse. METHODS: Single-center, retrospective study of consecutive patients with ALI that underwent either surgical treatment (ST) or hybrid treatment (HT) between January 2015 and December 2021. The composite outcome of amputation-free survival (AFS) was the primary endpoint. Technical success, overall survival, amputation, and re-intervention rates were the secondary endpoints. RESULTS: During the study period 266 patients (mean age 70.2±14.5 years; 49.6% males) were treated for ALI, 67.3% undergoing ST and 32.7% HT. HT was more frequently used in patients with a previous vascular intervention in the index limb (38/87; 43.7% HT vs. 40/179; 22.3% ST, P=0.001), a stent- or stent graft-occlusion (16/87; 18.4% HT vs. 10/179; 5.6% ST, P=0.002) and/or a bypass occlusion (16/87; 18.4% HT vs. 16/179; 8.9% ST, P=0.043). Technical success was higher in the OR group (75/87; 86.2% HT vs. 173/179; 96.6% ST, P=0.003). Amputation-free survival rate during follow-up (43/87; 49.4% HT vs. 94/179; 52.5% ST, HR 0.76, 95% CI: 0.49 to 1.18, P=0.22) and overall survival (32/87; 36.8% HT vs. 84/179; 46.9% ST, HR 0.81, 95% CI: 0.49 to 1.34, P=0.41) were comparable between the two groups. No statistical differences were observed between the groups regarding major amputation (19/87; 21.8% HT vs. 15/179; 8.4% ST, HR 0.85, 95% CI: 0.33 to 2.23, P=0.74) or reintervention during follow-up (45/87; 51.7% HT vs. 65/179; 36.3% ST, HR 0.92, 95% CI: 0.56 to 1.51, P=0.73). CONCLUSIONS: Hybrid and open surgical treatments showed comparable results in our cohort, even though significantly more patients undergoing HT presented with stent and bypass occlusions rather than de-novo lesions.