Urgent endovascular repair of juxta/para-renal aneurysm by off-the-shelf multibranched endograft.

OBJECTIVE: To report outcomes of urgent juxta/para-renal aneurysms (J/P-AAAs) managed by off-the-shelf multibranched thoracoabdominal endografts (Cook, T-branch). METHODS: In this observational, multicenter, retrospective study, patients with J/P-AAAs treated by urgent endovascular repair by T-branch in 23 European aortic centers, from 2013 to 2023, were analyzed. Contained J/P-AAAs rupture, presence of related symptoms, and aneurysm diameter >70mm were considered as indication for urgent repair. Technical success (TS), spinal cord ischemia (SCI) and 30-day/hospital mortality were assessed as early outcomes. Survival, freedom from (FF) reinterventions and target arteries instability (TAI) were evaluated during follow-up. RESULTS: Overall, 197 patients [J-AAAs:64(33%), P-AAAs:95(48%), previous failed-EVAR 38(19%)] were analyzed. The mean age and aneurysm diameter was 75+8 years and 76+4 mm, respectively. The ASA score was 3 and 4 in 118(60%) and 79(40%) patients. Rupture, symptoms and diameter >70mm were present in 51(26%), 110(56%) and 53(27%) patients, respectively. An adjunctive proximal thoracic endograft was used in 28(14%) cases. The mean aortic coverage between the upper portion of the endograft and the lowest renal artery was 154+49mm. Single-stage repair and cerebral-spinal-fluid drainage were reported in 144(73%) and 53(27%) cases, respectively. TS was achieved in 182(92%) cases (rupture:84% vs no rupture:95%; P:.02). Failures consist of target artery loss (11-6%: renal artery - 9; celiac trunk - 2), type I-III endoleak (2-1%) and 24-h mortality (2-1%). Rupture was a risk-factor for technical failure (P:.02;OR:3.8;95%CI:1.1-12.1). Overall, 15(8%) patients had persistent SCI (rupture:14% vs no rupture:5%) with 11(6%) cases of paraplegia (rupture:10% vs no rupture:5%; P:.001). Rupture (P:.04;OR:3.1;95%CI:1.1-8.9) and adjunctive proximal thoracic endograft (P:.01;OR:4.1;95%CI:1.3-12.9) were risk-factors for SCI. Twenty-two (11%) patients died within 30-day or during a prolonged hospitalization. Previous failed-EVAR (P:.04;OR:3.6;95%CI:1.1-12.3), paraplegia (P:<.001;OR:9.9;95%CI:1.6-62.2), postoperative mesenteric complications (P:.03;OR:10.4;95%CI:1.2-93.3) as well as cardiac (P:.03;OR:8.2;95%CI:2.0-33.0) and respiratory (P:<.001;OR:10.1;95%CI:2.9-35.2) morbidities were associated with 30-day/hospital mortality. The mean follow-up was 19+5months. Estimated 3-year survival and FF-reinterventions was 58% and 77%, respectively. TAI occurred in 27(14%) patients (occlusion:15, endoleak:14) with an estimated 3-year FF-TAI of 72%. CONCLUSIONS: Urgent repair of J/P-AAAs by T-branchis feasible and effective with satisfactory TS and 30-day/hospital mortality in high-risk patients. However, extensive aortic coverage is necessary, leading to a not negligible SCI rate, especially in case of aortic rupture or when adjunctive thoracic endografts are necessary. Previous failed-EVAR, postoperative mesenteric complications as well as cardiac and respiratory morbidities were associated with 30-day/hospital mortality and they should be subjected to more research for the purpose of improving outcomes.

Cap Polyposis-A Rare Cause of Rectal Bleeding in a Young Woman.

Cap polyposis is a very rare clinical entity, with only few cases reported in the literature. It is a benign disease, characterized by inflammatory polyps of the gastrointestinal tract. A 35-year-old woman was referred to our Gastroenterology department due to rectal bleeding. Endoscopic examination revealed multiple polypoid lesions in the middle/lower rectum. Histology was compatible with cap polyposis. She underwent mucosectomy of the lesions, with clinical and endoscopic improvement. Clinical findings and therapeutic approach represent a challenge in this pathology.

Urgent Candy-Plug Technique for Distal False Lumen Occlusion in Chronic Aortic Dissection.

INTRODUCTION: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair (TEVAR) for aortic dissection (AD). METHODS: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. Endpoints included technical success, clinical success, early (30-day) computed tomography angiography (CTA) findings, early (30-day) mortality, adverse events, aortic remodeling in patients with available CTA follow-up and re-intervention. RESULTS: A total of 155 patients received a custom-made Candy-Plug with 32 patients (44% males, mean age 61±9 years) were treated urgently vs. 123 patients (63% males, mean age 62±11 years) electively. The primary CP rate was higher in the urgent group; (28/32, (88%) in the urgent group vs. 96/123 (78%) in the elective group, p=051). The mean contrast volume was higher in the urgent group; (157±56ml in the urgent group vs. 130±71ml in the elective group, p=.017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25/32 (78%) patients in the urgent group vs. 113/123 (92%) in the elective group, p=.159. The early mortality rate was 4/32, (13%) patients in the urgent group vs. 1/123 (1%) in the elective group, p=.120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related re-interventions were required in 6/32 (19%) patients in the urgent group vs. 6/123 (5%) in the elective group, p=.094. Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, (18%) in the urgent group vs. 63/114 (55%) in the elective group, p=001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, (79%) in the urgent group vs. 47/114 (41%) in the elective group, p=000). An increase in thoracic aortic aneurysm sac occurred in 1/28 (4%) patient in the urgent group vs. 4/114 (4%) patients in the elective group, p=.096. CONCLUSION: The urgent use of the CP technique for distal FL occlusion in AD was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved high rate of aortic remodeling.

Fenestrated Endovascular Repair Using Short Tipped Distal Components with No Cross Concept to Prevent Crushing of Target Vessel Bridging Stents.

OBJECTIVE: To compare and evaluate early and midterm outcomes of a novel no cross approach with short tip vs. standard tip introducer systems for all distal components to prevent target vessel bridging stent kink or collapse during fenestrated endovascular aortic repair (FEVAR). METHODS: A retrospective analysis was conducted on all patients who underwent FEVAR at a tertiary referral centre between October 2016 and July 2022. The inclusion criterion was the use of renal artery fenestrations. Patients who had chronic dissections were included. Endpoints were analysed in two groups comprising the no cross group and the standard group, with all cases being consecutive in their respective groups. Cone beam computed tomography was used intra-operatively in all cases, and post-operative computed tomography angiograms and re-interventions were reviewed. Primary endpoints included technical success, intra-operative adjunctive procedures, adverse events related to the fenestration, and re-interventions, while secondary endpoints were secondary interventions and overall mortality rate. RESULTS: Seventy patients (35 in each group) were enrolled in the study, with 64 (91%) having juxtarenal aneurysms. There were no differences in demographics, cardiovascular risk factors, or aneurysm characteristics between the two groups. The no cross group demonstrated a significantly higher technical success rate (100% in all cases) compared with the standard group (29 cases, 83%; p = .010). Additionally, there were statistically significantly fewer intra-operative adjunctive procedures required in the no cross group (1.5% of fenestrations) compared with the standard group (8.2% of fenestrations) (p = .013). The overall median follow up was 32 months (interquartile range 22, 62 months). CONCLUSION: Implementation of a novel no cross concept during FEVAR, using a short dilator introducer tip on the distal bifurcated component and iliac extensions, significantly reduced intra-operative fenestration related adverse events and enhanced technical success. Further studies with larger patient populations and longer follow up are needed to confirm these findings.

RIPPLE-VT study: Multicenter prospective evaluation of ventricular tachycardia substrate ablation by targeting scar channels to eliminate latest scar potentials without direct ablation.

BACKGROUND: Recurrent ventricular tachycardia (VT) can be treated by substrate modification of the myocardial scar by catheter ablation during sinus rhythm without VT induction. Better defining this arrhythmic substrate could help improve outcome and reduce ablation burden. OBJECTIVE: The study aimed to limit ablation within postinfarction scar to conduction channels within the scar to reduce VT recurrence. METHODS: Patients undergoing catheter ablation for recurrent implantable cardioverter-defibrillator therapy for postinfarction VT were recruited at 5 centers. Left ventricular maps were collected on CARTO using a Pentaray catheter. Ripple mapping was used to categorize infarct scar potentials (SPs) by timing. Earliest SPs were ablated sequentially until there was loss of the terminal SPs without their direct ablation. The primary outcome measure was sustained VT episodes as documented by device interrogations at 1 year, which was compared with VT episodes in the year before ablation. RESULTS: The study recruited 50 patients (mean left ventricular ejection fraction, 33% ± 9%), and 37 patients (74%) met the channel ablation end point with successful loss of latest SPs without direct ablation. There were 16 recurrences during 1-year follow-up. There was a 90% reduction in VT burden from 30.2 ± 53.9 to 3.1 ± 7.5 (P < .01) per patient, with a concomitant 88% reduction in appropriate shocks from 2.1 ± 2.7 to 0.2 ± 0.9 (P < .01). There were 8 deaths during follow-up. Those who met the channel ablation end point had no significant difference in mortality, recurrence, or VT burden but had a significantly lower ablation burden of 25.7 ± 4.2 minutes vs 39.9 ± 6.1 minutes (P = .001). CONCLUSION: Scar channel ablation is feasible by ripple mapping and can be an alternative to more extensive substrate modification techniques.

The role of CT-assessed sarcopenia and visceral adipose tissue in predicting long-term survival in patients undergoing elective endovascular infrarenal aortic repair.

OBJECTIVES: To evaluate if ileo-psoas muscle size and visceral adipose tissue (VAT) can predict long-term survival after endovascular aneurysm repair (EVAR). METHODS: Patients who underwent EVAR between 2004 and 2012 in a single centre were included. Total psoas muscle area (TPA), abdominal VAT area, subcutaneous adipose tissue (SAT), and total adipose tissue were measured on the preoperative CT. Primary endpoint was all-cause mortality. Values are presented as median and interquartile range or absolute number and percentage. Cox regression analyses were performed to assess the associations with mortality. RESULTS: Two hundred and eighty-four patients could be included in the study. During a median follow-up of 8 (4-11) years, 223 (79.9%) patients died. Age (P ≤ .001), cardiovascular (P = .041), cerebrovascular (P = .009), renal diseases (P = .002), and chronic obstructive pulmonary disease (P ≤ .001) were independently associated with mortality. TPA was associated with mortality in a univariate (P = .040), but not in a multivariate regression model (P = .764). No significant association was found between mortality and TPA index (P = .103) or any of the adiposity measurements with the exception of SAT (P = .040). However, SAT area loss in a multivariate analysis (P = .875). CONCLUSIONS: Assessment of core muscle size and VAT did not contribute to improving the prediction of long-term survival after EVAR. ADVANCES IN KNOWLEDGE: The finding of this study contradicts the previously claimed utility of core muscle size and VAT in predicting long-term survival after EVAR.

Multicentric Use of Commercially Available Infrarenal Endografts During Fenestrated Endovascular Aortic Repair: A Feasibility Study.

PURPOSE: This study aimed to assess the feasibility and short-term outcomes of different manufactured proximal and distal stent graft components during fenestrated endovascular aortic repair (FEVAR). MATERIALS AND METHODS: A multicenter retrospective review was conducted at 3 aortic centers, involving all consecutive patients who underwent FEVAR utilizing a customized Dacron-based tubular proximal and a distal bifurcated polytetrafluoreten (PTFE)-based commercially available stent grafts. Primary outcomes were 30 day mortality, major adverse events, and technical and clinical success. Secondary outcomes assessed stent graft migration, occurrence of types I/III endoleak, and reintervention. RESULTS: A total of 23 FEVAR cases across all centers were included in this study. Technical success was achieved in all cases, with a median procedure time of 183 (153-244) minutes. There were no major adverse events, except for 1 transient acute renal failure. The median follow-up period was 23 (17-28) months. All target vessels retained patent with the exception of 1 right renal fenestration that showed signs of kinking at the first follow-up, and despite secondary intervention with relining and distal extension, there was an occlusion afterward and 1 hepatic artery with a separate fenestration. This and 1 successful relining of a superior mesenteric artery kink were the only reinterventions in this cohort. One case of persistent type 1b endoleak was reported in a patient with chronic type B aortic dissection, which resolved with distal extension on the external iliac artery 5 months after the index procedure. No deaths occurred throughout the follow-up with, and there were no signs of stent graft migration or type 3 endoleak. CONCLUSION: The use of commercially available PTFE-based bifurcated stent grafts to extend distally the tubular graft appears to be a feasible approach during FEVAR, with promising short-term outcomes. Further studies are necessary to define the applicability of this solution and evaluate long-term outcomes. CLINICAL IMPACT: This multicentric study on fenestrated endovascular aortic repair (FEVAR) demonstrates the feasibility and good short-term outcomes of utilizing a PTFE-based commercially available stent graft to extend the proximal tubular custom-made fenestrated stent graft. The high technical success rate, absence of major adverse events, and low occurrence of complications such as stent graft migration and endoleaks highlight the potential clinical benefits of this approach with an off-the-shelf distal extension whose delivery system does not cross the fenestrations intraoperatively.

Multicentre Experience with Novel Bidirectional Double Cuffed Inner Branches for Complex Endovascular Aortic Repair.

OBJECTIVE: This study aimed to report the initial experience with a novel bidirectional double cuff inner branch design for incorporation of renal and mesenteric arteries in patients undergoing fenestrated and branched endovascular aortic repair (F/BEVAR). METHODS: A retrospective review was undertaken of the experience of F/BEVAR with grafts integrating at least one bidirectional double cuffed inner branch implanted at three tertiary aortic centres between March 2022 and June 2023. All consecutive patients were included. Baseline characteristics, operative data, and follow up data were collected. Results were presented as number or median (interquartile range) unless otherwise stated. RESULTS: Thirteen patients (10 male; median age 72 [68, 77] years) had F/BEVAR using a total of 15 bidirectional double cuffed inner branches (30 cuffs). Indications for bidirectional doubled cuffed inner branches included cranial vessel orientation or double renal arteries in four patients each, common coeliomesenteric trunk in three patients, and early renal artery bifurcation, renal artery origin from a false lumen requiring a flexible route for catheterisation, and surplus configuration in one patient each. Twenty three of the 30 cuffs were used, whereas the remaining seven cuffs were intentionally occluded with vascular plugs. Target vessel incorporation was successful in all bidirectional branches. There was one technical failure related to unsuccessful catheterisation of a left renal artery targeted through a unidirectional caudal inner branch. During a median follow up of seven months there were no instances of target vessel instability or re-interventions and two patients died of causes unrelated to the bidirectional branches. CONCLUSION: The results of the use of bidirectional double cuff inner branches are promising, with high technical success and no short term branch related complications in this preliminary experience. This could potentially expand the applicability of branch endografting of complex endovascular aortic repairs, but long term results are still missing.

Real-world assessment of multipolar and point-by-point mapping for premature ventricular contraction ablation.

AIMS: We aimed to assess the acute and midterm efficacy of premature ventricular contraction (PVC) ablation guided by multielectrode and point-by-point (PbP) mapping. METHODS AND RESULTS: This is a retrospective, international multicentre study of consecutive patients referred for PVC ablation in 10 hospital centres from January 2017 to December 2021. Based on the mapping approach, two cohorts were identified: the 'Multipolar group', where a dedicated high-density mapping catheter was employed, and the 'PbP group', where mapping was performed with the ablation catheter. Procedural endpoints, safety, and acute (procedural) and midterm efficacies were assessed. Of the 698 patients included in this study, 592 received activation mapping [46% males, median age of 55 (41-65) years]-248 patients in the Multipolar group and 344 patients in the PbP group. A higher number of activation points [432 (217-843) vs. 95 (42-185), P < 0.001], reduced mapping time (40 ± 38 vs. 61 ± 50 min, P < 0.001), and shorter procedure time (124 ± 60 vs. 143 ± 63 min, P < 0.001) were reported in the Multipolar group. Both groups had high acute success rates (84.7% with Multipolar mapping vs. 81.3% with PbP mapping, P = 0.63), as well as midterm efficacy (83.4% vs. 77.4%, P = 0.08), with no significant differences in the risk of adverse events (6.0% vs. 3.5%, P = 0.24). However, for left-sided PVC ablation specifically, there was a higher midterm efficacy in the Multipolar group (80.7% vs. 69.5%, P = 0.04), with multipolar mapping being an independent predictor of success [adjusted OR = 2.231 (95% CI, 1.476-5.108), P = 0.02]. CONCLUSION: The acute and midterm efficacies of PVC ablation are high with both multipolar and PbP mapping, although the former allows for quicker procedures and may potentially improve the outcomes of left-sided PVC ablation.

Prostatic Fossa Pseudoaneurysm After Robot-Assisted Radical Prostatectomy (RARP): A Case Report.

BACKGROUND RARP is an established procedure in treatment of localized prostate cancer. Hemorrhagic complications in the postoperative period are rare, but sometimes life-threatening. Adequate monitoring and prompt intervention in these unusual scenarios rely on clinical judgement and blood and imaging studies. Prostatic fossa pseudoaneurysm formation after RARP is very rare and its etiology is not well known; it may be related to small vessel trauma. It becomes apparent with the development of hematuria 1-6 weeks after surgery. CASE REPORT A 58-year-old man underwent RARP with extended lymph node dissection for intermediate-risk prostate cancer, with bilateral preservation of neurovascular bundles and puboprostatic ligaments. He was discharged on day 2 without complications. In the following 4 weeks he came to the Emergency Department 3 times with hematuria and acute urinary retention. Four weeks after surgery, a pelvic CT angiogram showed a 20-mm pseudoaneurysm in the prostatic fossa, which was embolized by percutaneous angiography, with resolution of symptoms. He was discharged soon thereafter. CONCLUSIONS This case study describes a patient with prostatic fossa pseudoaneurysm after RARP. It was diagnosed 1 month after surgery and effectively managed by percutaneous embolization. Despite being a very rare condition, it must be kept in mind, especially when postoperative hematuria develops 1-6 weeks after surgery. Use of a management algorithm including serial blood tests, CT angiogram, and percutaneous angiography can lead to early detection and avoid life-threatening hemorrhage and overall postoperative morbidity.

International Collaborative Study Comparing Outcomes of Fenestrated Endovascular Aortic Repair in OCtogenarian vs Non-Octogenarian Patients: The FEVOC study.

OBJECTIVE: With an increasing life expectancy, more octogenarian patients are referred with complex aortic aneurysms (cAAA). The aim of this study was to evaluate short and mid-term outcomes following fenestrated aortic repair (FEVAR) in octogenarians. SUMMARY BACKGROUND DATA: Few studies looking at octogenarian-specific outcomes with diverging results. METHODS: Retrospective, multicentre cohort study including consecutive patients undergoing elective FEVAR for cAAAs or type IV thoracoabdominal aortic aneurysms between 2007-2022 in eight high-volume centres. Octogenarians vs. non-octogenarians were compared. The primary outcome was 30-day mortality. Secondary outcomes included 1, 2 and 5-year survival and reintervention rates. RESULTS: A total of 729 patients (median age of 74.8 years [IQR 69.2 - 79.14]) were included, 169 (23%) of which were octogenarians, with 316 (43.3%) patients undergoing juxta/pararenal aneurysm repair. Although octogenarians presented less complex but larger (61 mm vs. 58 mm) aneurysms, the number of fenestrations was similar across groups. No differences in in-hospital mortality (4.1 vs. 3.0%), MAE (16.6% vs 12.2%) or reintervention rates (11.2 vs. 10%) were found. Multivariable logistic regression of in-hospital mortality identified BMI (OR 0.66, 95% CI 0.51-0.95, P=0.003), chronic heart failure (OR 7.70, 95% CI 1.36-36.15, P=0.003) and GFR<45 ml/min/1.73 m2 (OR 5.25, 95% CI 1.20-22.86, P=0.027) as independent predictors. Median follow-up was 41 months. The 1, 2 and 5-year survival rates were 91.3%, 81.8% and 49.5% in octogenarians vs 90.6%, 86.5% and 68.8% in non-octogenarian patients (Log-rank: =0.001). Freedom from aortic-related death and freedom from reintervention at five-years were similar across groups (log-rank=0.94 and .76, respectively). Age>80 was not an independent predictor of 30-day or long-term mortality on multivariable and Cox regression analysis. CONCLUSIONS: Elective FEVAR in octogenarians appears to be safe, with similar outcomes as in younger patients. Future studies looking at improved patient selection methods to ensure long-term survival benefits in both octogenarians and younger patients are warranted.

Endovascular Repair of One-hundred Urgent and Emergent free or Contained Thoraco-abdominal Aortic Aneurysms Ruptures. An International Multi-Center Trans-Atlantic experience.

OBJECTIVE: To analyze the outcomes of urgent/emergent endovascular aortic repair of patients with free/contained ruptured thoracoabdominal aortic aneurysms (rTAAA). BACKGROUND: Endovascular repair of rTAAA has been scarcely described in emergent setting. METHODS: An international multicenter retrospective observational study (ClinicalTrials.govID:NCT05956873) from January-2015 to January-2023 in 6 European and 1 United States Vascular Surgery Centers. Primary end-points were technical success, 30-day and/or in-hospital mortality and follow-up survival. RESULTS: A total of 100 rTAAA patients were included (75 male; mean age 73 y). All patients (86 contained and 14 free ruptures) were symptomatic and treated within 24-hours from diagnosis: multi-branched off-the-shelf devices (Zenith t-branch,Cook Medical Inc.Bjaeverskov,Denmark) in 88 patients, physician-modified endografts in 8, patient-specific device or parallel grafts in two patients each. Primary technical success was achieved in 89 patients and 30-day and/or in-hospital mortality was 24%. Major adverse events (MAEs) occurred in 34% of patients (permanent dialysis and paraplegia in 4 and 8 patients, respectively). No statistical differences were detected in mortality rates between free and contained ruptured patients (43%vs.21%; P =0.075). Multivariate analysis revealed contained rupture favoring technical success (Odd-Ratio10.1;95%Confidence-Interval:3.0-33.6; P =<0.001). MAEs (OR9.4;95%C-I:2.8-30.5; P =<0.001) and pulmonary complications (OR11.3;95%CI:3.0-41.5; P =<0.001) were independent risk factors for 30-day and/or in-hospital mortality. Median follow-up time was 13 months (interquartile range 5-24); 1-year survival rate was 65%. Aneurysm diameter>80 mm (Hazard-Ratio:2.0;95%CI:1.0-30.5; P =0.037), technical failure (HR:2.6;95%CI:1.1-6.5; P =0.045) and pulmonary complications (HR:3.0;95%CI:1.2-7.9; P =0.021) were independent risk factors for follow-up mortality. CONCLUSION: Endovascular repair of rTAAA shows high technical success; the presence of free rupture alone appear not to correlate with early mortality. Effective prevention/management of post-operative complications is crucial for survival.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms.

OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

3D Optical Coherence Tomography image processing in BISCAP: characterization of biofilm structure and properties.

MOTIVATION: BISCAP is a state-of-the-art tool for automatically characterizing biofilm images obtained from Optical Coherence Tomography. Limited availability of other software tools is reported in the field. BISCAP's first version processes 2D images only. Processing 3D images is a problem of greater scientific relevance since it deals with the entire structure of biofilms instead of their 2D slices. RESULTS: Building on the image-processing principles and algorithms proposed earlier for 2D images, these were adapted to the 3D case, and a more general implementation of BISCAP was developed. The primary goal concerns the extension of the initial methodology to incorporate the depth axis in 3D images; multiple improvements were also made to boost computational performance. The calculation of structural properties and visual outputs was extended to offer new insights into the 3D structure of biofilms. BISCAP was tested using 3D images of biofilms with different morphologies, consistently delivering accurate characterizations of 3D structures in a few minutes using standard laptop machines. Low user dependency is required for image analysis. AVAILABILITY AND IMPLEMENTATION: BISCAP is available from https://github.com/diogonarciso/BISCAP. All images used in the tutorials and the validation examples are available from https://web.fe.up.pt/∼fgm/biscap3d.

Clinical guidelines for posterior restorations based on Coverage, Adhesion, Resistance, Esthetics, and Subgingival management. The CARES concept: Part III ­ subgingival margins, "ferrule" design, and posts in severely compromised teeth

Despite the clear advances regarding the restoration of posterior teeth, especially with the minimally invasive approach, there are still several topics where the available scientific evidence does not provide clear answers in terms of clinical decisions. The indications, differences, and clinical protocols for partial adhesive restorations (onlays, overlays, and endocrowns) and resistance form restorations (full-contour resistive crowns) were presented in Parts I and II of the present article series based on Coverage of susceptible cusps, Adhesion advantages and limitations, Resistance forms to be implemented, Esthetic concerns, and Subgingival management - the CARES concept. Now, in Part III, the focus is on different approaches of managing subgingival areas, gaining "ferrule" design, and the role of posts on the restorability strategies of severely compromised teeth.

Diagnostic and prognostic contribution of DPD scintigraphy in transthyretin V30M cardiac amyloidosis.

BACKGROUND: Early diagnosis and prognostic stratification of cardiac transthyretin amyloidosis are crucial. Although 99mTc 3,3-diphosphono-1,2-propanedicarboxylic acid (DPD) scintigraphy is the preferred method for the non-invasive diagnosis, its accuracy appears to be limited in transthyretin amyloidosis protein (ATTR) V30M mutation. Furthermore, its prognostic value in this mutation is unknown. This study investigated the diagnostic value of DPD scintigraphy to detect ATTR cardiomyopathy in V30M mutation and explored its prognostic value regarding mortality. METHODS: A total of 288 ATTR V30M mutation carriers (median age: 46 years; 49% males) without myocardial thickening (defined as septal thickness ≥13mm) attributable to other causes and who underwent DPD scintigraphy were enrolled. ATTR cardiomyopathy was defined by septal thickness ≥13mm and at least one of the criteria: late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) uptake ratio <1.60; electrical heart disease or biopsy-documented amyloidosis. RESULTS: ATTR cardiomyopathy was identified in 41 (14.2%) patients and cardiac DPD uptake in 34 (11.8%). During a mean follow-up of 33.6 ± 1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with ATTR cardiomyopathy, 13 times higher in those with DPD uptake and 10 times higher in those with late H/M MIBG <1.60. The combined assessment of septal thickness and cardiac DPD uptake improved risk stratification: patients without septal thickening and without DPD retention had an excellent prognosis while those who presented either or both of them had a significantly worse prognosis, with 5-year mortality rates ranging from 39.9 to 53.3%. CONCLUSIONS: DPD scintigraphy is useful for prognostic stratification of ATTR V30M mutation carriers. Patients without septal thickening and no DPD uptake present the best prognosis compared to those with any signs of cardiac involvement.

Estimation of the Added Cancer Risk Derived From EVAR and CTA Follow-Up.

OBJECTIVE: The aim of this study was to assess the risk of radiation-induced cancer development in patients that have undergone an infrarenal EVAR, stratifying the relative contributions of the procedure and the preoperative and postoperative CTAs. METHODS AND MATERIALS: The organ-specific absorbed radiation doses from CTA and the EVAR procedure were estimated from the radiation exposures of 95 and 45 male patients, respectively. Lifetime attributable risk (LAR) cancer predictions were calculated for 14 different organs. Life expectancy was assumed from a previous cohort of patients undergoing infra-renal EVAR. RESULTS: The calculated total excess cancer risk was 0.0046, ie, 1 out of 220 patients will develop a neoplasm after being exposed to the ionizing radiation from the preoperative CTA, the EVAR and annual CTA examinations for 15 years. The procedure and the preoperative CTA contributed with 38% of the total excess risk, while the rest was derived from the follow-up. If the entire CTA based follow-up would have been eliminated, an excess risk of 0.0018 (1/560) would remain. CONCLUSIONS: 1 out of 219 patients who have undergone EVAR of an infra-renal AAA have a lifetime risk of developing cancer secondary to the radiation exposures related to the procedure and the CTAs used preoperatively and during follow-up. This risk derives mostly from the yearly postoperative CTAs, underlining the potential benefits of reducing or replacing their use. CLINICAL IMPACT: A simulation-based estimation reinforced the potential deleterious effects of the radiation exposure for patients undergoing Endovascular Aneurysm Repair (EVAR) of Abdominal Aortic Aneurysms (AAA) and subsequently followed by yearly Computer Tomography Angiographies (CTAs). The risk could be as high as 1 out 219 patients developing a neoplasm after 15 years. The largest exposure derives from the follow-up CTAs and efforts to minimize their use as well as the intraoperative radiation are greatly needed. The simulation-based estimations done in this study reinforce potential deleterious effects of the radiation exposure for patients undergoing EVAR of AAA. Efforts should be done to minimize the intraoperative radiation and the number of CTAs used during follow-up.

Association between the number of altered late potential criteria and increased arrhythmic risk in Brugada syndrome patients.

BACKGROUND: Brugada syndrome (BrS) is associated with abnormal electrophysiological properties at right ventricular epicardium, consisting of fragmented electrograms extending well beyond QRS termination. We aimed to evaluate the utility of signal-averaged electrocardiogram (SA-ECG) for the noninvasive assessment of late potentials (LP) and risk stratification of BrS patients. METHODS: A prospective, observational, single-center study of BrS patients is submitted to SA-ECG with the determination of the total filtered QRS duration (fQRS), root mean square voltage of the 40 ms terminal portion of the QRS (RMS40), and duration of the low-amplitude electric potential component of the terminal portion of the QRS (LAS40). LP were considered positive when above standard cut-offs: fQRS > 114 ms, RMS40 < 20 µV, and LAS40 > 38 ms. The rates of malignant arrhythmic events (MAEs), defined as sudden death or appropriate shocks, were compared in relation to clinical characteristics and SA-ECG findings. RESULTS: A total of 106 BrS patients (mean age, 48 ± 12 years, 67.9% male) were studied, 49% with type-1 spontaneous pattern and 81% asymptomatic. During a median follow up of 4.7 years, 10 patients (7.1%) suffered MAEs, including 4 sudden deaths. The presence of LP was significantly associated with the arrhythmic risk, which increased with the number of altered LP criteria. In comparison to the patients who had none or 1 altered LP criterium, MAE risk was 4.7 times higher in those with 2 altered criteria and 9.4 times higher in those with 3 altered LP criteria. CONCLUSIONS: SA-ECG may be a useful tool for risk stratification in BrS. The presence of 2 or 3 abnormal LP criteria could identify a subset of asymptomatic patients at high risk of arrhythmic events.