Editor's Choice - A Study of the Cost-effectiveness of Fenestrated/branched EVAR Compared with Open Surgery for Patients with Complex Aortic Aneurysms at 2 Years.

OBJECTIVES: The aim was to assess the cost-effectiveness of fenestrated and branched stent grafts (f/b EVAR) compared with open surgical repair (OSR) in thoraco-abdominal or complex abdominal aortic aneurysms (TAAA/AAA) at 2 years. METHODS: Two matched cohorts of patients with TAAA or complex AAA were compared after a follow-up of two years. Patients included in the WINDOW French multicentre prospective registry were treated by f/b EVAR, and OSR patients were extracted from the French national hospital discharge database. All cause mortality was assessed along with readmissions and hospital costs. The association between treatment and 2 year mortality was assessed by uni/multivariate Cox regression analyses using pre- and post-operative characteristics. Incremental cost-effectiveness ratios (ICER) were estimated for para/juxtarenal AAA, and infra- and supra-diaphragmatic TAAA. RESULTS: A total of 268 high risk patients were treated by f/b EVAR and 1678 average or low risk patients were treated with OSR during the same period. Mortality did not significantly differ between the groups (14.9% vs. 11.8%, p = .150) and multivariate Cox regressions did not find an association between 2 year mortality and treatment. Similar proportions of patients were readmitted at least once (69.7% with f/b EVAR vs. 64.2% with OSR, p = .096) but f/b EVAR patients had more readmissions on average (2.2 vs. 1.7, p = .001). Two year hospital costs were higher in the f/b EVAR group (€46,039 vs. €22,779, p < .001). At 2 years, f/b EVAR was dominated (more expensive and less effective), except in the supra-diaphragmatic TAAA subgroup with an ICER of €42,195,800 per death averted. CONCLUSIONS: f/b EVAR in high risk patients offers similar 2 year mortality to OSR performed in lower risk patients but at a higher cost. The cost is mainly driven by the cost of the stent graft, which is not compensated for by lower healthcare resource consumption. Further studies are necessary to evaluate the cost-effectiveness in low risk f/b EVAR patients who may experience fewer complications.

Feasibility of Three-Dimensional MR Angiography Image Fusion Guidance for Endovascular Abdominal Aortic Aneurysm Repair.

Magnetic resonance (MR) angiography image fusion (IF) with live fluoroscopy guidance was used while performing endovascular repair of abdominal aortic aneurysm (EVAR) in five patients with a history of chronic renal disease or severe contrast allergy. Intraprocedural technical success was 100%. Median procedure time was 120 minutes (range, 60-180 min), fluoroscopy time was 40 minutes (range, 17-65 min), dose-area product was 245,867 mGy × cm(2) (range, 68,435-690,053 mGy × cm(2)), and iodinated contrast volume injected was 15 mL (range, 0-40 mL). Technical success was achieved in four of five patients (80%); one case was complicated by a type 1 endoleak on follow-up MR angiography, which was successfully treated. EVAR with MR angiography IF guidance was technically feasible and safe in five patients and reduced or eliminated the use of iodinated contrast media.

Endovascular balloon occlusion is associated with reduced intraoperative mortality of unstable patients with ruptured abdominal aortic aneurysm but fails to improve other outcomes.

BACKGROUND: Proximal aortic control by endovascular balloon occlusion (EBO) is an alternative to conventional aortic cross-clamping (CAC) in hemodynamically unstable patients presenting with a ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to evaluate the potential clinical benefit of EBO over CAC. METHODS: Data from 72 patients with rAAA treated at our institution from 2001 to 2013 were retrospectively analyzed. All patients were hemodynamically unstable (mean arterial blood pressure at admission <65 mm Hg or associated unconsciousness, cardiac arrest, or emergency endotracheal intubation). Clinical end points of hemodynamic restoration, mortality rate, and major postoperative complications were assessed for CAC (group 1) and EBO (group 2). RESULTS: At admission, 72 patients were unstable. CAC was performed in 40 and EBO in 32. Intraoperative mortality was 43% in group 1 vs 19% in group 2 (P = .031). In group 1, the approach for CAC (thoracotomy [n = 23] vs laparotomy [n = 17]) did not influence intraoperative mortality (43% vs 41%). There was no significant difference in 30-day (75% vs 62%) and in-hospital (77% vs 69%) mortality rates between groups. After EBO, the treatment-open vs endovascular repair-did not influence the intraoperative mortality rate (31% vs 43%; P = .5). Eight surgical complications were secondary to CAC (1 vena cava injury, 3 left renal vein injuries, 1 left renal artery injury, 1 pancreaticoduodenal vein injury, and 2 splenectomies), but no EBO-related complication was noted (P = .04). Differences in colon ischemia (15% vs 28%) and renal failure (12% vs 9%) were not statistically significant. Abdominal compartment syndrome occurred in four patients in group 2 and in no patients in group 1. CONCLUSIONS: Compared with CAC, EBO is a feasible and valuable strategy and is associated with reduced intraoperative mortality of unstable rAAA patients, but not in-hospital mortality, in this retrospective study.

Feasibility and safety of renal and visceral target vessel cannulation using robotically steerable catheters during complex endovascular aortic procedures.

PURPOSE: To evaluate the safety and success of target vessel cannulation in the visceral aortic segment using the Magellan robotic catheter system (RCS) during complex endovascular aortic procedures. METHODS: Robotic navigation was attempted for access to 37 target vessels in 15 patients (14 men; mean age 75±10 years) during 16 fenestrated and/or branched stent-grafting procedures and 1 endovascular repair requiring the chimney technique. For each target vessel, robotic navigation was attempted for a maximum of 15 minutes; if cannulation was unsuccessful in that time, manual catheters were employed. Safety was evaluated by recording intraoperative adverse events, intraoperative complications related to robotic navigation, and postoperative complications. Technical success of robotic cannulation, wire cannulation times, and times for inserting the leader over the wire in the target vessels were recorded to assess RCS performance. RESULTS: Successful robotic cannulation was achieved for 30 (81%) of the 37 target vessels, with a median wire cannulation time of 263 seconds (range 40-780) and a median 15 seconds (range 5-450) for inserting the leader over the wire. No intraoperative complications related to robotic navigation were observed. Seven of 27 arteries accessed via 7 fenestrations could not be cannulated within 15 minutes; all were cannulated successfully using conventional catheters (mean cannulation time 31±7 minutes). All 10 target vessels accessed via branches and chimney stents were successfully cannulated with the RCS. CONCLUSION: Cannulation of target vessels with the RCS during complex endovascular aortic procedures is feasible and safe. The robotic system was particularly effective for branched and chimney stents.

Who should do endovascular repair of complex aortic aneurysms and how should they do them?

BACKGROUND: Cure of aneurysms which involve the aorta at the level of the visceral arteries and the thoracoabdominal segment remains a considerable surgical enterprise with a relatively high mortality and morbidity despite improvements of the surgical procedure and anesthetic technique. Fenestrated and branched endovascular stent grafts are currently available offering an attractive less invasive option especially for most frail patients. These grafts are relatively recent, technically more demanding to insert than the current stent graft for infrarenal aneurysm and besides, given the relative low frequency of the disease, they are much less used by practitioners. Thus, unconditional widespread of this sophisticated technique may not necessarily benefit patients. METHODS: We reviewed our experiences and articles regarding this concern, 1) who should perform this new technique and 2) in what kind of setting. CONCLUSION: Based on the combined complexities of 1) patients selection, 2) proper planning and manufacturing of the graft, 3) the need for outstanding imaging and operating facilities, 4) and the required endovascular skill of physicians involved in the procedure, we feel that only highly specialized centers should be allowed to perform this complex procedure.

Comparison of fenestrated endovascular aneurysm repair and chimney graft techniques for pararenal aortic aneurysm.

OBJECTIVE: This study compared early-term and midterm results of endovascular repair (EVAR) of juxtarenal or pararenal aortic aneurysms (PAAs) using fenestrated stent grafting (f-EVAR) and the chimney grafting (c-EVAR) technique. METHODS: Consecutive patients with PAAs who underwent f-EVAR using commercially available devices and c-EVAR in a tertiary vascular center from January 2006 to April 2013 were evaluated, including a retrospective scrutiny and update of a prospectively maintained database, calculation and comparison of perioperative mortality and morbidity, overall survival, reintervention-free rate, branch event-free rate, reconstructed vessel patency, and collection of data about intraoperative events, perioperative complications and reinterventions, and midterm sac behavior. RESULTS: During the study period, 80 patients (72 men) underwent f-EVAR and 38 (34 men) underwent c-EVAR. All f-EVAR patients were operated on electively, whereas six c-EVAR patients (15.8%; P = .002) were operated on in an emergent setting. The preoperative PAA diameter was significantly smaller in the f-EVAR group than in the c-EVAR group (58.6 ± 8.6 mm vs 65.9 ± 15.3 mm; P = .003). The mean number of reconstructed vessels per patient was 2.4 ± 0.7 (median, two) for the f-EVAR group and 1.6 ± 0.7 (median, one) for the c-EVAR group (P < .0001). The f-EVAR and c-EVAR groups did not differ in 30-day mortality (6.3% vs 7.9%; P = .71) or in moderate to severe complications (27.5% vs 39.5%; P = 1.0). Median follow-up duration was 14 months, (range, 0-88 months) in the f-EVAR group and 12 months (range, 0-48 months) in the c-EVAR group. After 2 years, estimated survival rates (77.3% vs 71.8%), reintervention-free rates (71.4% vs 72.0%), reconstructed vessel event-free rates (90.5% vs 84.1%), and primary patency of reconstructed vessel rates (97.1% vs 87.6%) were not statistically different. During follow-up, sac shrinkage (≥5 mm) was observed in 43.4% of f-EVAR patients and in 30.6% of c-EVAR patients (no statistical difference). CONCLUSIONS: In this limited retrospective series, short-term and midterm results of f-EVAR and c-EVAR were not statistically different. c-EVAR could be an attractive option for patients not suitable for f-EVAR.

Impact of intraoperative adverse events during branched and fenestrated aortic stent grafting on postoperative outcome.

OBJECTIVE: Fenestrated and branched endovascular devices are increasingly used for complex aortic diseases, and despite the challenging nature of these procedures, early experiences from pioneering centers have been encouraging. The objectives of this retrospective study were to report our experience of intraoperative adverse events (IOAEs) during fenestrated and branched stent grafting and to analyze the impact on clinical outcomes. METHODS: Consecutive patients treated with fenestrated and branched stent grafting in a tertiary vascular center between February 2006 and October 2013 were evaluated. A prospectively maintained computerized database was scrutinized and updated retrospectively. Intraoperative angiograms were reviewed to identify IOAEs, and adverse events were categorized into three types: target vessel cannulation, positioning of graft components, and intraoperative access. Clinical consequences of IOAEs were analyzed to ascertain whether they were responsible for death or moderate to severe postoperative complications. RESULTS: During the study period, 113 consecutive elective patients underwent fenestrated or branched stent grafting. Indications for treatment were asymptomatic complex abdominal aortic aneurysms (CAAAs, n = 89) and thoracoabdominal aortic aneurysms (TAAAs, n = 24). Stent grafts included fenestrated (n = 79) and branched (n = 17) Cook stent grafts (Cook Medical, Bloomington, Ind), Ventana (Endologix, Irvine, Calif) stent grafts (n = 9), and fenestrated Anaconda (Vascutek Terumo, Scotland, UK) stent grafts (n = 8). In-hospital mortality rates for the CAAA and TAAA groups were 6.7% (6 of 89) and 12.5% (3 of 24), respectively. Twenty-eight moderate to severe complications occurred in 21 patients (18.6%). Spinal cord ischemia was recorded in six patients, three of which resolved completely. A total of 37 IOAEs were recorded in 34 (30.1%) patients (22 CAAAs and 12 TAAAs). Of 37 IOAEs, 15 (40.5%) resulted in no clinical consequence in 15 patients; 17 (45.9%) were responsible for moderate to severe complications in 16 patients, and five (13.5%) led to death in four patients. The composite end point death/nonfatal moderate to severe complication occurred more frequently in patients with IOAEs compared with patients without IOAEs (20 of 34 vs 12 of 79; P < .0001). CONCLUSIONS: In this contemporary series, IOAEs were relatively frequent during branched or fenestrated stenting procedures and were often responsible for significant complications.

Two cases of misaligned deployment of Valiant Captivia thoracic stent graft.

Thoracic aortic stent grafts have been widely used. We report two cases of proximal misaligned deployment of the Valiant Captivia stent graft after hybrid treatment of thoracic aneurysms. This complication has, to our knowledge, never been previously reported in the literature with this stent graft. We discuss the various factors that may explain this complication. We also describe the bailout technique that was carried out.

Aneurysmal degeneration of the donor artery after vascular access.

OBJECTIVE: This retrospective study analyzed the characteristics, potential risks, and therapeutic options of true aneurysms of the donor artery in arteriovenous fistulas (AVFs) for dialysis access. METHODS: We retrospectively collected data of patients with aneurysmal degeneration (AD) after AVF creation from surgeons who were members of the French Society for Vascular Access, treated from January 2006 to May 2011. The study excluded patients with pseudoaneurysms. Patient demographics, type of access, aneurysm characteristics, symptoms, treatment, and follow-up were recorded. RESULTS: Seven men and three women (mean age, 38.1 ± 5.3 years) were identified with AD (mean diameter, 44.5; range, 24-80 mm) Mean duration of access was 83.6 ± 48.8 months. Diagnosis of AD was at 117.5 ± 53.8 months after access creation. The initial access was radiocephalic, six; ulnobasilic, one; brachiocephalic, two; and brachiobasilic, one. Three patients had two successive accesses: one brachioaxillary polytetrafluoroethylene (PTFE) graft and two proximalizations of a failed radiocephalic AVF. Symptoms were pain and swelling, four; pain related to total thrombosis without signs of ischemia, two; median nerve compression, two; pain related to contained rupture, one; and subacute ischemia due to embolic occlusion of both radial and interosseous arteries, one. AD location was brachial, seven; axillary, one; radial, one; and ulnar, one. Eight patients underwent surgical aneurysm excision associated with interposition bypass using great saphenous vein, two; basilic vein, one; PTFE, three; Dacron, one; and allograft, one. Two patients needed secondary PTFE bypass because of progression of AD to the inflow artery and dilatation of the venous bypass. With a mean follow-up of 20.3 ± 17 months, all bypasses but one remained patent. CONCLUSIONS: AD is a rare but significant complication of vascular access. Surgical correction should be discussed in most cases due to potential complications. After resection, the choice of reconstructive conduit is not straightforward.

Management of perioperative endoleaks during endovascular treatment of juxta-renal aneurysms.

BACKGROUND: Evolution of stentgraft and vascular imaging technologies allows endovascular treatment (ET) of juxta-renal aneurysms (JRA). However, endoleaks rates and implants stability are not well documented. The aim of this study was to report the incidence and the perioperative treatment of the endoleaks occurring during ET for JRA. MATERIAL AND METHODS: Between January 2000 and April 2010, a total of 957 treated aneurysms were prospectively collected in a database. ET cases for JRA were selected from this database. Pre- and postoperative imaging was retrospectively analyzed to determine the incidence, localization, and treatment of the endoleaks detected following this technique. RESULTS: The series included 50 patients (5%; age, 73 ± 12 years; 44 men). Mean diameter was 60 ± 12 mm. The ET included 38 fenestrated and/or branched endografts and 12 endografts implanted according to the chimney technique. One hundred and forty-three target vessels were perfused. Immediately after endograft deployment, angiography showed endoleaks in 15 patients (30%): 11 type Ia, 1 type II, and 3 type III endoleaks. These endoleaks were treated by aortic endograft modeling and/or stenting in 11 patients, and by placing an aortic extension in two patients. Despite modeling, two patients had a persistent type Ia endoleak and were respectively treated by placing a Palmaz stent and by performing proximal embolization. Despite these procedures, completion angiography showed five residual endoleaks (10%): two type Ia, two type II, and one type III. Immediate postoperative computed tomography (CT) angiography showed endoleaks in 13 patients (28%): six type I, six type II, and one mixed type II/III. Among these 13 patients, on the initial angiography, nine presented with an endoleak, three with a type II and one with a type Ib. Early mortality (<30 days) was 8% (four patients). With a mean follow-up of 12 months, (range, 1-42), six patients presented with a persisting endoleak (four type II, one type Ia, and one multiple type). Aneurysm growth (≥5 mm) was reported in two patients (4%), and nine secondary endovascular procedures were performed to treat these endoleaks. CONCLUSION: Endoleaks are frequent during ET of JRA. They are treated not only according to their type but also according to the implant characteristics (fenestrated or chimney). Although most endoleaks can be perioperatively treated with simple endovascular means, treatment of persisting type Ia endoleaks remains challenging.

A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients.

BACKGROUND: Several studies, including three randomized controlled trials (RCTs), have shown that endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) offered better early results than open surgical repair (OSR) but a similar medium-term to long-term mortality and a higher incidence of reinterventions. Thus, the role of EVAR, most notably in low-risk patients, remains debated. METHODS: The ACE (Anevrysme de l'aorte abdominale: Chirurgie versus Endoprothese) trial compared mortality and major adverse events after EVAR and OSR in patients with AAA anatomically suitable for EVAR and at low-risk or intermediate-risk for open surgery. A total of 316 patients with >5 cm aneurysms were randomized in institutions with proven expertise for both treatments: 299 patients were available for analysis, and 149 were assigned to OSR and 150 to EVAR. Patients were monitored for 5 years after treatment. Statistical analysis was by intention to treat. RESULTS: With a median follow-up of 3 years (range, 0-4.8 years), there was no difference in the cumulative survival free of death or major events rates between OSR and EVAR: 95.9% ± 1.6% vs 93.2% ± 2.1% at 1 year and 85.1% ± 4.5% vs 82.4% ± 3.7% at 3 years, respectively (P = .09). In-hospital mortality (0.6% vs 1.3%; P = 1.0), survival, and the percentage of minor complications were not statistically different. In the EVAR group, however, the crude percentage of reintervention was higher (2.4% vs 16%, P < .0001), with a trend toward a higher aneurysm-related mortality (0.7% vs 4%; P = .12). CONCLUSIONS: In patients with low to intermediate risk factors, open repair of AAA is as safe as EVAR and remains a more durable option.

Open vs endovascular repair of abdominal aortic aneurysm involving the iliac bifurcation.

INTRODUCTION: Aneurysmal involvement of the iliac bifurcation increases the level of difficulty during surgery for abdominal aortic aneurysm (AAA) repair, potentially increasing the risk of early postoperative complications. Three previous randomized trials comparing endovascular aneurysm repair (EVAR) and open repair (OR) for AAAs showed that EVAR is associated with a lower early mortality rate. However, whether these results are valid for AAA involving the iliac bifurcation (AAAIB) remains unclear. The aim of this study was to evaluate early and late results after OR and EVAR for patients with AAA involving the iliac bifurcation. METHODS: Of 1116 patients treated for elective AAA repair between January 1998 and January 2008, 131 presented with AAAIB as detected by computed tomography (CT) scan. Sixty-eight patients were treated by EVAR and 63 by OR. Clinical and anatomic data, operative intervention, and outcomes were collected prospectively and analyzed retrospectively. The median duration of follow-up was 38 months for both groups. RESULTS: Patients in the EVAR group (72 +/- 10 years) were older than those in the OR group (64 +/- 8 years; P < .0001), but there were no differences in cardiac, renal, or pulmonary comorbidities between the two groups. Inhospital mortality rates were 2.9% vs 6.3% for EVAR and OR groups, respectively (P = .43). Systemic postoperative complications occurred in 7.4% vs 9.5% (P = .76) and postoperative colonic ischemia in 0% vs 6.3% (P = .051) of patients with EVAR and OR, respectively. Survival rates by Kaplan-Meier analysis were 91 +/- 7% for patients with EVAR and 90 +/- 8% for patients with OR at 2 years, and 61% +/- 15 for EVAR and 79% +/- 13 for OR at 5 years. All-cause reoperation rates were 25% with EVAR and 22% with OR (P = .83). Patients with EVAR were more likely to develop buttock claudication (33.3% vs 3.6%; P < .0001), whereas patients with OR were more prone to develop abdominal wall complications (19.6% vs 0%; P < .001). CONCLUSION: In this series, the postoperative mortality and systemic complication rates after either EVAR or OR for AAAIB were not statistically different. In the OR group, there were more abdominal wall complications and a trend toward a higher rate of colonic ischemia. In the EVAR group, buttock claudication was more frequent.

Paraplegia as a symptom of failure after endovascular therapy of type B aortic dissection in Marfan syndrome.

This report describes successful treatment of an unusual case of concomitant paraplegia and type 1 endoleak during the early postoperative course of endovascular therapy of type B dissection in a patient with Marfan syndrome.

Tuberculous aneurysms of the abdominal aorta.

Mycotic aneurysm secondary to tuberculous infection of the aorta is a rare and life-threatening disease. We report a single-center experience of three patients treated with a combination of surgical aortic replacement and prolonged antituberculosis therapy. The first case is a 34-year-old woman with a suprarenal abdominal aortic aneurysm, the second case is a 77-year-old man with an infrarenal abdominal aortic aneurysm and a right psoas abscess, the third case is a 37-year-old woman with an infrarenal abdominal aortic aneurysm. All patients had a favorable outcome with a mean follow-up of 6.2 years (range, 6 months-10 years). Early diagnosis and a combination of surgical intervention (aortic reconstruction and extensive excision of the infected field) and prolonged antituberculous drug therapy provide long-term survival without evidence of recurrence after tuberculous aortic involvement.

[Acute aortic syndromes]. / Les syndromes aortiques aigus.

Acute aortic syndromes include aortic dissections, intramural hematomas, penetrating ulcers, ruptured or contained ruptured aortic aneurysms. In presence of acute thoracic or dorsal pain, elevated D-Dimers and if acute coronary artery syndrome has been ruled out, additional imaging should be performed to detect acute aortic pathologies. Acute type A dissections involve the ascending aorta. Emergent open repair is the preferred treatment. Acute type B dissections involve the thoracic descending aorta. Endovascular treatment using thoracic stent grafts is indicated in complicated cases (malperfusion, rupture, uncontrolled hypertension) or in cases where risk factors of aortic degeneration are identified. Regarding ruptured abdominal aortic aneurysms, optimization techniques recently led to a reduced postoperative mortality. They include adequate treatment of abdominal compartment syndrome, use of aortic stent grafts, endovascular balloon occlusion and permissive hypotension. Symptomatic complex aneurysms encompass renal and visceral arteries. Nowadays, they can be treated in an urgent setting using new endovascular techniques, such as "off-the shelf" branched stent grafts, parallel techniques, home made or in situ fenestrations of standard stent grafts.

[EVAR for aortic abdominal aneurysms: A 20-year's experience of 1900 patients]. / Endoprothèses aortiques pour anévrisme : 20 ans après, l'expérience de 1900 patients.

Abdominal aortic aneurysms (AAA), also called "silent killer" as they grow without symptoms until the final rupture, are the 3rd cause of cardiovascular deaths, after myocardial infarction and stroke. Surgery is the only efficient way of preventing aortic rupture. The initial technique, described by Charles Dubost in 1952 has evolved and results and provides fair long-term results: open repair (OR) is performed under general anesthesia, via a transperitoneal or a retroperitoneal approach. Laparoscopic repair aims to reduce the consequences of surgery, but its role is still debated due to limited experience and to variable results. Since initial reports by Volodos, and Parodi of endovascular aortic repair (EVAR) in 1993, there have been continuous technological improvements, initiated by Claude Mialhe's "modular" and "bifurcated" concepts. More recently, novel techniques and new devices have contributed to the widening of EVAR indications. In this article, we describe 20 years of our EVAR experience.

What can be done for cerebral embolic protection in TAVI? Analysis in the light of 10 years' experience with protected carotid artery stenting.

In the last 30 years, development of minimally invasive percutaneous procedures to treat cardiovascular defects has been thriving. Although these techniques present obvious advantages, like avoiding cardiopulmonary bypass, the passage of catheter systems and the deployment of devices in the blood circulation can cause particle embolization that may result in stroke. In carotid artery stenting, cerebral embolic protection devices (CEPD) such as filtering membranes have been available for already 10 years. In transcatheter aortic valve implantation (TAVI), the development of CEPD is starting and three membrane-based devices are in clinical trials. There are controversial discussions about the efficacy of CEPD in TAVI. The experience with CEPD in carotid artery stenting can help to understand some of the technical issues and shortcomings of current devices and thereby ultimately reduce cerebral complication risks during TAVI procedures.

Factors favoring stent-graft collapse after thoracic endovascular aortic repair.

OBJECTIVE: Our objective was to assess potential causative factors of stent-graft collapse after thoracic endovascular aortic repair. METHODS: We retrospectively reviewed clinical data and preoperative and postoperative computed tomographic scans of patients with thoracic stent-graft collapse in 2 French departments of vascular surgery. Aortic arch angulation, length of the lack of device wall apposition, proximal aortic diameter, and percentage of oversizing were assessed. RESULTS: We report 4 cases of stent-graft collapse among 285 patients treated by thoracic endovascular aortic repair. All 4 patients were treated with the TAG stent graft. Only one of the patients had a symptomatic collapse: he was treated by stent-graft explantation and open repair. Endovascular management was performed in 3 of the 4 patients. None of the patients died. Lack of device wall apposition and acute aortic arch angle (range 92 degrees-118 degrees ) were observed in all 4 patients. Oversizing over 20% was observed in 3 patients. CONCLUSION: This stent-graft-related complication seems related to poor apposition of the stent grafts in the highly angulated aortic arch. Excessive stent-graft oversizing could be an additional causative factor. Accurate assessment of aortic arch anatomic features, as well as the choice and sizing of the device, may prevent this complication.