Total Endovascular Repair of a Giant Iliac Vein Aneurysm: A Case Report and Review of Literature.

PURPOSE: The iliac veins are the least frequent location for venous aneurysms, with only a few cases described globally. The etiology and clinical presentation of this extremely rare entity is diverse and unclear and no treatment consensus has been reached yet. Our purpose is to present an interesting iliac vein aneurysm (IVA) case that we treated in our department, with a brief review of the literature. CASE REPORT: We report a case of a 74-year-old male patient with a giant, 55 mm in diameter, asymptomatic, right common IVA, with concurrent aplasia of the left common iliac vein and an extensive network of venous collaterals. The patient was treated, under general anesthesia, with total endovascular iliocaval reconstruction through implantation of a 32 × 100 mm thoracic aortic tubular Ankura stent graft. The computed tomography venography at first-month follow-up showed the complete exclusion of the IVA, without any endoleak and the patient remains up to date free of symptoms and thromboembolic events. CONCLUSION: Twelve cases of endovascular treatment of IVA have been reported so far, and our case is the first with implantation of a thoracic aortic stent graft. Our results suggest that this technique is safe, effective, and may be considered for appropriately selected patients. CLINICAL IMPACT: This is the first case with total endovascular repair of an iliac vein aneurysm with contralateral iliac vein aplasia through endovenous implantation of a thoracic aortic stent-graft. Our results suggest that this technique is safe and effective and thus, may be considered for appropriately selected cases.

Left ventricular end-diastolic pressure response to spinal anaesthesia in euvolaemic vascular surgery patients.

PURPOSE: Regional anaesthesia techniques provide highly effective alternative to general anaesthesia. Existing evidence on the effect of spinal anaesthesia (SA) on cardiac diastolic function is scarce. This study aimed to evaluate the effects of a single-injection, low-dose SA on left ventricular end-diastolic pressures (LVEDP) using echocardiography in euvolaemic patients undergoing elective vascular surgery. METHODS: This is a prospective study in adult patients undergoing elective vascular surgery with SA. Patients with contraindications for SA or significant valvular disease were excluded. During patients' evaluations fluid administration was targeted using arterial waveform monitoring. All patients underwent echocardiographic studies before and after SA for the assessment of indices reflective of diastolic function. LVEDP was evaluated using the E/e' ratio. Blood samples were drawn to measure troponin and brain natriuretic peptide (BNP) levels before and after SA. RESULTS: A total of 62 patients (88.7% males, 71.00 ± 9.42 years) were included in the analysis. In total population, end-diastolic volume (EDV, 147.51 ± 41.36 vs 141.72 ± 40.13 ml; p = 0.044), end-systolic volume (ESV, 69.50 [51.50] vs 65.00 [29.50] ml; p < 0.001) and E/e' ratio significantly decreased (10.80 [4.21] vs. 9.55 [3.91]; p = 0.019). In patients with elevated compared to those with normal LVEDP, an overall improvement in diastolic function was noted. The A increased (- 6.58 ± 11.12 vs. 6.46 ± 16.10; p < 0.001) and E/A decreased (0.02 ± 0.21 vs. - 0.36 ± 0.90; p = 0.004) only in the elevated LVEDP group. Patients with elevated LVEDP had a greater decrease in E/e' compared to those with normal LVEDP (- 0.03 ± 2.39 vs. - 2.27 ± 2.92; p = 0.002). CONCLUSION: This study in euvolaemic patients undergoing elective vascular surgery provides evidence that SA improved LVEDP.

A systematic review and meta-analysis of proximal aortic neck dilatation after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: To provide an updated systematic literature review summarizing current evidence on aortic neck dilatation (AND) after endovascular aortic aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysm. METHODS: An extensive electronic search in major electronic databases was conducted between January 2000 and December 2021. Eligible for inclusion were observational studies that followed up with patients (n ≥ 20) undergoing EVAR with self-expanding endografts, for 12 or more months, evaluated AND with computed tomography angiography and provided data on relevant outcomes. The primary end point was the incidence of AND after EVAR, and the secondary end points were the occurrence of type Ia endoleak, stent graft migration, secondary rupture, and reintervention. RESULTS: We included 34 studies with a total sample of 12,038 patients (10,413 men; median age, 71 years). AND was defined clearly in 18 studies, but significant differences in AND definition were evidenced. The pooled incidence of AND based on quantitative analysis of 16 studies with a total of 9201 patients (7961 men; median age, 72 years) was calculated at 22.9% (95% confidence interval [CI], 14.4-34.4) over a follow-up period ranging from 12 months to 14 years. The risk of a type Ia endoleak was significantly higher in AND patients compared with those without AND (odds ratio, 2.95; 95% CI, 1.10-7.93; P = .030). Similarly, endograft migration was more common in the AND group compared with the non-AND group (odds ratio, 5.95; 95% CI, 1.80-19.69; P = .004). The combined incidence of secondary rupture and reintervention did not differ significantly between the two groups, even though the combined effect was in favor of the non-AND group. CONCLUSIONS: Proximal AND after EVAR is common and occurs in a large proportion of patients with infrarenal abdominal aortic aneurysm. AND can influence the long-term durability of proximal endograft fixation and is significantly related to adverse outcomes, often leading to reinterventions.

Long-term Evaluation of Proximal Aortic Neck Dilatation After Endovascular Abdominal Aortic Aneurysm Repair With a Variety of Contemporary Endografts.

PURPOSE: To measure the long-term proximal aortic neck dilatation (AND) after elective endovascular aortic aneurysm repair (EVAR) with a variety of contemporary, third-generation, endograft devices. MATERIALS AND METHODS: This is a noninterventional prospective cohort study of 157 patients that underwent standard EVAR with self-expanding abdominal endografts. Patients' recruitment lasted from 2013 to 2017, and postoperative follow-up was up to 5 years. A computed tomography angiography (CTA) was performed at the first month and then at 1, 2, and 5 years. Proximal aortic neck's (PAN) basic morphological characteristics (diameter, length, angulation) were measured based on the analysis of CTA in a standardized fashion. Neck-related adverse events, such as migration, endoleak or rupture, and reinterventions were recorded. RESULTS: Significant straightening of the PAN was evident even in the first-month CTA with concurrent neck shortening that became significant at 5 years. Both the suprarenal aorta and the PAN significantly dilated overtime, with PAN dilating more progressively. Mean neck dilatation at the juxtarenal level was 0.8±0.4 mm at 1 year, 1.8±0.8 mm at 2 years, and 3.9±1.7 mm at 5 years, with a mean neck dilatation rate of 0.07 mm/month overall. The incidence of AND ≥2.5 mm was 37.2% at 2 years and 58.1% at 5 years after EVAR and was considered important (≥5 mm) in 11.5% of patients at 2 years and 30.6% of patients at 5 years. A multivariate analysis performed showed that the endograft oversizing, the preoperative neck diameter, and the preoperative abdominal aortic aneurysm sac diameter served as independent predictors of AND at 5 years. At the 5-year follow-up, 8 late type Ia endoleaks (6.5%) and 7 caudal migrations (5.6%) were identified, while no late ruptures were reported. In total, 11 late endovascular reinterventions (8.9%) were performed. Overall, proximal neck-related adverse outcomes (5/7 migrations and 5/8 endoleaks) and reinterventions (7/11) were significantly associated with the presence of important late AND. CONCLUSION: Proximal AND after EVAR is common. It can influence the long-term durability of proximal endograft fixation and is significantly associated with adverse outcomes, often leading to reinterventions. A systemic and extended surveillance protocol is needed for maintenance of good long-term results. CLINICAL IMPACT: This is a thorough and systematic analysis of the long-term geometric remodeling of the proximal aortic neck after EVAR, that highlights the importance of a strict, and extended surveillance protocol for maintenance of good long-term results of EVAR.

Early Results of Elective Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms With the MinosTM Stent-Graft System.

PURPOSE: A variety of last-generation endografts are currently available for standard endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs). The purpose of this study is to report the preliminary clinical outcomes of the Minos trimodular stent-graft system, which was recently introduced to the European market. MATERIALS AND METHODS: Between February 2020 and 2022, we treated 41 consecutive AAA patients (mean age 72.2±8.5, 37 males) with elective standard EVAR using the Minos. The mean maximum diameter of AAAs was 54.7±6.6 mm, the mean proximal neck's (PN) diameter was 24.8±2.7 mm, while the relevant length and angulation were 16.0 mm and 21.7°, respectively. Overall, 22 (53.6%) patients presented with shorter and angulated PN, according to the stent-graft's instructions of use, and in 6 (14.6%) patients the PN angulation >60° was combined with concomitant iliac angulation >60°. Eleven (26.8%) EVARs were performed with concomitant enormous iliac artery narrowing and tortuosity. Finally, in 19 (46.3%) AAAs, the distal iliac landing zone was aneurysmatic and they were treated with the bell-bottom technique in 17 patients and with limb extension to the external iliac artery in two cases. We evaluated technical and clinical success of the index procedures, which was based on the combination of five factors: freedom from EVAR-related mortality, from graft-related endoleak of any type, from migration at any part of graft as well the absence of notable increase AAA's sac maximum diameter and the patency of bifurcated stent-graft and of access vessels. RESULTS: Primary technical and clinical success of index procedures was 100%. During a median 12-month radiological follow-up the clinical success remained 100%. No type I or III endoleak, stent-graft migration, EVAR-related death, AAA rupture, or graft-related adverse events or reinterventions were documented. Four (9.8%) type II endoleaks were detected with stable AAA sac diameter. The overall incidence of sac regression was 34.1% (n=14). CONCLUSION: The preliminary results of our series showed that Minos provided excellent feasibility and safety features even through angulated and tortuous iliac vessels and in short and angulated PNs. The overall clinical success at 1 year suggests that performance of Minos follows very high standards. Further validation of these promising results with long-term data is acquired to complete the evaluation of this recently introduced stent-graft system. CLINICAL IMPACT: The current study explored the clinical performance of a new in market ultra-low profile bifurcated abdominal aortic stent-graft, the MINOS. The early and 12-month results of study suggest that implantation of this stent-graft in standard EVAR, even in hostile proximal aortic neck and iliac vessels conditions, follows very high clinical standards and encourage the further clinical use of MINOS.

In Vitro Radiological Evaluation of Different Types of Chimney Stents Using a Silicon Flow Model with Adjustable Physiological Simulating Conditions.

OBJECTIVE: To evaluate in vitro the performance of in vivo published covered or bare metal chimney stents (ChSs) in combination with the Endurant II abdominal endograft (Medtronic) as the only CE approved main graft (MG) in the treatment of juxtarenal abdominal aortic aneurysms with the chimney endovascular aneurysm repair (chEVAR) technique. METHODS: Bench top experimental study. A silicon flow model with adjustable physiological simulating conditions and patient based anatomy was used to test nine different MG-ChS combinations: Advanta V12 (Getinge); BeGraft+ (Bentley); VBX (Gore & Associates Inc.); LifeStream (Bard Medical); Dynamic (Biotronik); Absolute Pro (Abbott); double Absolute Pro; Viabahn (Gore) lined with Dynamic; and Viabahn lined with EverFlex (Medtronic). Angiotomography was performed after each implantation. DICOM data were analysed blindly twice per observer by three independent experienced observers. Each blinded evaluation was performed at one month intervals. The main analysed parameters were the area of gutters, MG and ChS maximum compression, and the presence of infolding. RESULTS: Bland-Altman analysis confirmed adequate results correlation (p < .05). Each employed ChS showed significantly different performance favouring the balloon expandable covered stent (BECS). The smallest gutter area was seen in the combination with Advanta V12 (0.26 cm2). MG infolding was observed in all tests. The lowest ChS compression was observed in the combination with BeGraft+ (compression 4.91%, D ratio 0.95). In our model, BECSs showed higher angulations than bare metal stents (BMSs) (p < .001). CONCLUSION: This in vitro study shows the variability of performance with each theoretically possible ChS and explains the divergent ChS outcomes in the published literature. BECS in combination with the Endurant abdominal device confirms their superiority vs. BMS. The presence of MG infolding in each test underlines the need for prolonged kissing ballooning. Angulation evaluation and comparison with other in vitro and in vivo publications demands the need for further investigation in transversely or upwardly oriented target vessels.

Multicenter Mid-Term Outcomes of the Chimney Technique in the Elective Treatment of Degenerative Pararenal Aortic Aneurysms.

PURPOSE: Chimney endovascular abdominal aortic aneurysm repair (CHEVAR) has predominantly been described as an alternative technique for the management of urgent presentations of degenerative pararenal aortic aneurysms (dPAAs). However, the role of CHEVAR in the treatment of asymptomatic patients remains unknown. The aim of current multinational study was to evaluate the outcomes of elective CHEVAR of dPAAs. MATERIAL AND METHODS: Retrospective analysis of 267 consecutive dPAA patients treated with elective CHEVAR at 13 European and US centers from 2008 to 2014. Primary endpoints were 30 days and out of hospital CHEVAR-related mortality. Secondary endpoints included persistent type Ia endoleak or endotension, angiographically confirmed occlusion and/or high-grade chimney graft (CG) or involved splanchnic vessel stenosis identified at index procedure and/or during follow-up, as well as CHEVAR-related re-intervention. RESULTS: Mean follow-up time was 25.5±13.3 months. The 442 visceral vessels were involved and mean number of CGs per patient was 1.63±0.7. 436 targeted vessels were successfully cannulated. The aortic graft intentionally covered 6 renal arteries and immediate technical success was 98.6%. The 30 days mortality was 1.9% (n=5), while the in-hospital complication rate was 10.1% (n=27) including 3 strokes, 1 permanent dialysis, and 1 intestinal ischemia. No 30 day type Ia endoleaks were detected and 3.2% of CGs (n=14, including the intentionally covered) had evidence of occlusion and/or stenosis. The overall CHEVAR-related mortality was 2.2% (n=6). Freedom from primary and secondary type Ia endoleak/endotension rates at 3 years was 93.0% and 98.0%, respectively. Primary and secondary CG patency was 87.0% and 89.0%. Primary and secondary endovascular freedom from any endpoint at 3 years was 81.0% and 94.0% respectively. CONCLUSION: Elective use of CHEVAR in the management of dPAAs seems to be durable. These results are comparable to published outcomes with other total endovascular strategies, which justifies an expanded role for CHEVAR in the treatment of asymptomatic patients presenting with dPAAs.

Outcomes of elective use of the chimney endovascular technique in pararenal aortic pathologic processes.

OBJECTIVE: In the treatment of pararenal abdominal aortic aneurysms and aortic pathologic processes, chimney endovascular aneurysm repair (CHEVAR) represents an alternative technique for urgent cases. The aim of the study was to evaluate the outcomes of CHEVAR in the elective setting. METHODS: We performed a retrospective analysis of prospectively collected records of 165 consecutive asymptomatic CHEVAR patients who were treated between March 2009 and January 2018 with the Endurant stent graft (Medtronic, Santa Rosa, Calif). A total of 244 chimney grafts (CGs) were implanted. The primary end point was clinical success, defined as freedom from procedure-related mortality, persistent type IA endoleak, occlusion or high-grade stenosis (>70%) of CGs, and any chimney technique-related secondary procedure for the entire follow-up period. Secondary clinical success included patients with successful treatment of a primary end point with a secondary endovascular procedure. RESULTS: All 244 targeted chimney vessels were successfully cannulated. Total perioperative morbidity was 7.8% (n = 13), including 3 (1.8%) cases of bowel ischemia, 1 (0.6%) patient with renal ischemia, and 1 patient (0.6%) with stroke. Median follow-up was 25.5 ± 2.2 months. Both 30-day and follow-up procedure-related mortality rates were 1.8% (n = 3). Primary and secondary freedom from persistent type IA endoleak rates were 96.4% (n = 159) and 99.4% (n = 164), respectively. Primary and secondary CG patency rates were 92.2% (n = 225) and 95.9% (n = 234), respectively. The rate of reinterventions related to the chimney technique was 10.9% (n = 18), and 83.3% of them were performed by endovascular means. The estimated cumulative primary patency and freedom from persistent type IA endoleak were 87.5% and 95.3%, respectively, and the primary and secondary clinical successes rates at midterm were 80.3% and 87.5%, respectively. CONCLUSIONS: The elective use of CHEVAR with the Endurant stent graft in our series showed favorable midterm clinical results, which are similar to the published results of other total endovascular modalities. A prospective randomized trial of elective treatment of pararenal abdominal aortic aneurysms and aortic pathologic processes with current endovascular options is needed to assess the value of CHEVAR in the elective setting.

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry.

OBJECTIVE: To evaluate early and follow-up outcomes following bilateral use of iliac branch devices (IBD) for aortoiliac endografting and assess the impact of center volume. We used data from the pELVIS international multicentric registry. METHODS: For the purpose of this study, only those patients receiving concomitant bilateral IBD implantation were analyzed. To assess the impact that procedural volume of bilateral IBD implantation could have on early and follow-up outcomes, participating institutions were classified as Site(s) A if they had performed >10 and/or >20% concomitant bilateral IBD procedure, otherwise they were classified as Site(s) B. Endpoints of the analysis included early (ie, 30-day) mortality and morbidity, as well as all-cause and aneurysm-related mortality during follow-up. Additional endpoints that were evaluated included IBD-related reinterventions, IBD occlusion or stenosis requiring reintervention (ie, loss of primary patency), and IBD-related type I endoleak. RESULTS: Overall, 96 patients received bilateral IBD implantation (out of 910 procedures collected in the whole pELVIS cohort), of whom 65 were treated at Site A (ie, Group A) and 31 were treated at Site(s) B (ie, Group B). In total, only 1 death occurred within 30 days from bilateral IBD implantation, and 9 patients experienced at least 1 major complication without any significant difference between subjects in Group A versus those in Group B (10.8% vs 6.5%, p=0.714). In the overall cohort, the 2-year freedom from IBD-related type I endoleaks and IBD primary patency were 96% and 92%, respectively; no significant differences were seen in those rates between Group A or Group B (95% vs 100%, p=0.335; 93% vs 88%, p=0.470). Freedom from any IBD-related reinterventions was 83% at 2 years, with similar rates between study groups (85% vs 83%, p=0.904). CONCLUSIONS: Within the pELVIS registry, concomitant bilateral IBD implantation is a safe and feasible technique for management of aortoiliac aneurysms in patients with suitable anatomy. Despite increased technical complexity, effectiveness of the repair is satisfactory with low rates of IBD-related adverse events at mid-term follow-up. Procedural volume does not seem to affect technical or clinical outcomes after bilateral use of IBD, which remains a favorable treatment option in selected patients.

Partial Renal Coverage after Endovascular Aortic Aneurysm Repair with Suprarenal Fixation Seems Not to be Associated with Early Renal Impairment.

BACKGROUND: Efforts to achieve optimal seal during endovascular aortic aneurysm repair (EVAR) may produce partial coverage of the lowest renal artery and in some cases even occlusion. This coverage might alter the renal ostial flow, which could finally affect renal function. We sought to evaluate the incidence of renal ostium coverage and its possible effects on renal function. METHODS: All patients undergoing elective EVAR with suprarenal fixation devices between January 2014, and December 2017, at our institution were identified. Patients with preoperative and postoperative computed tomography angiography (CTA), as well as the preoperative, postoperative, and one year postintervention creatinine levels and estimated glomerular filtration rate (eGFR) were included in the present study. Patients in hemodialysis, with a preoperative eGFR <30 mL/min, urgent EVAR, neck adjunctive procedures, excessive aortic thrombus, or procedure-related reintervention were excluded. RESULTS: A total of 127 patients received EVAR for aortoiliac aneurysmatic pathologies between January 2014, and December 2017. Forty-three of them met the inclusion criteria having a median follow-up of 18.8 months (range; 12.0-53.9). Twenty-six (60.5%) patients presented at least one criterion of hostile neck condition and 23 (53.5%) had a preoperative eGFR <60 mL/min. The average distance from the proximal endograft fabric to the lower renal artery was 1.5 mm (range, 0.0-6.0) while a total of 15 renal ostia (34.9%) suffered unintended partial coverage (range, 20 to 75% of the renal ostium) in the postoperative CTA. Nine of these patients (60%) had a hostile neck condition. Eight patients (18.6%) suffered significant deterioration (>20% of the eGFR), 27 patients (62.8%) maintained their renal function and 8 (18.6%) presented an improvement of the eGFR in the latest available blood sample. Renal function impairment showed no significant association with renal ostium coverage (P = 0.561), hostile neck condition (P = 0.973), or the diameter of the renal artery (P = 0.835). In the subgroup analysis, patients with the eGFR <60 mL/min did not show significantly greater renal function deterioration (P = 0.568). CONCLUSIONS: Partial renal coverage is not an uncommon phenomenon occurring in one-third of the treated patients. However, it was not associated with renal function impairment in the early term. Further studies with longer follow-up are needed to confirm our results in the long haul.

Coexisting hypogastric aneurysms worsen the outcomes of endovascular treatment by the iliac branch devices within the pELVIS Registry.

OBJECTIVE: Hypogastric aneurysms (HAs) frequently coexist with aortoiliac aneurysms (AIAs). However, the presence of an HA is a contraindication to endovascular aneurysm treatment by iliac branch devices (IBDs) because of the risk of distal sealing-related endoleaks. No robust evidence exists in the published literature, and therefore we sought to evaluate the performance of IBDs in the presence of HAs within a multicenter registry of nine vascular centers. METHODS: Clinical and radiographic information of 804 patients with AIAs treated by IBDs was retrospectively reviewed and analyzed using prearranged, defined, and documented protocols. The treatment period was between January 2005 and April 2017. RESULTS: HA was present in 315 (32.6%) of the overall 910 deployed IBDs. Mean radiologic follow-up was 32 months. The incidence of incomplete aneurysm exclusion and type I endoleak was 3% in the HA group vs 0.7% in the non-HA group (P = .019). The 5-year freedom from IBD-related type I endoleak was 93% vs 98% in the HA group vs the non-HA group, respectively (P = .006). Subgroup analysis of the HA group revealed that use of a single distal bridging stent graft vs multiple bridging devices led to higher rate of type I endoleak (9.6% vs 2.8%; P = .031), branch occlusions (8.3% vs 0.9%; P = .009), and buttock claudication (7.6% vs 1.9%; P = .038). CONCLUSIONS: This series of AIAs with HAs is the largest reported. It shows that HAs coexisting with AIAs, when treated with IBDs, have significantly worse outcomes. Lengthening the distal landing zone with more than one bridging stent graft into the distal healthy hypogastric artery or one of its main branches improves outcomes.

Conical neck is strongly associated with proximal failure in standard endovascular aneurysm repair.

OBJECTIVE: Hostile proximal aortic neck (HN) challenges the suitability for standard endovascular aneurysm repair (EVAR) of patients at high risk for "open" repair. However, there has been little if any focus placed on the individual role of the "nonlength" HN features in EVAR outcomes. The aim of this study was to evaluate their individual and potentially predictive role in outcomes of EVAR under HN conditions. METHODS: Data of 156 consecutive EVAR patients with short (<15 mm) HN, treated with the Endurant device (Medtronic Cardiovascular, Santa Rosa, Calif) at three European academic vascular centers between 2007 and 2015, were collected and retrospectively analyzed. All patients had at least one of the four well-known nonlength HN criteria (width >32 mm or bulge, angulation >60 degrees, reverse taper anatomy, and circumferential thrombus or calcification >50%) and underwent standard EVAR without additional techniques, such as use of chimney grafts or endoanchors. Primary end points were absence of type IA endoleak at 1 month and midterm follow-up and aneurysm sac stabilization or shrinkage. Secondary end points were 30-day mortality, overall survival, and secondary interventions related to EVAR. The study cohort was classified in two subgroups related to neck length (length <10 mm and length between 10 and 14 mm) as well as in two subgroups according to on-label or off-label stent graft use. RESULTS: Mean clinical and radiologic follow-up was 41.1 ± 24.7 and 31.7 ± 19.0 months, respectively. Overall EVAR-related mortality was 1.9% (n = 3). The total type IA endoleak rate was 5.8% (n = 9). In four patients, the type IA endoleak was detected intraoperatively and solved by endovascular means. A type IA endoleak was detected in three patients at 1 month and in two patients at 2-year follow-up. During follow-up, five patients showed an increase of aneurysm diameter due to type II endoleak and were treated by secondary endovascular reinterventions. The total number of all EVAR-related secondary procedures in the midterm was 12 (7.7%). Univariate analysis showed that the center of treatment and the clinical or anatomic features were not associated with adverse outcomes. Multiple regression and Cox regression analysis of HN features revealed that reverse taper anatomy (conical neck) was the single and significantly associated predictor of proximal EVAR failure (P < .012). Width >32 mm, angulation >60 degrees, and calcification or thrombus were not associated with adverse outcomes. Analysis between HN length cohorts and between on-label and off-label subgroups revealed no difference in outcomes. CONCLUSIONS: A conical neck in hostile anatomies represents the single strongest factor associated with proximal failure of standard EVAR. This finding should be considered and highlighted apart from the length of the infrarenal neck to prevent midterm failure of standard EVAR.

The role of Visfatin in atherosclerotic peripheral arterial obstructive disease.

Visfatin is an adipokine molecule acting as an essential coenzyme in multiple cellular redox reactions. The increased serum levels of Visfatin have been correlated with metabolic syndrome and endothelial homeostasis. In this study we investigate the possible relationship of Visfatin serum levels with the severity and location of atherosclerotic peripheral arterial occlusive disease (PAOD). Study protocol included 45 consecutive PAOD and 20 Control patients with age >55years old. Definition of PAOD was based in Rutherord's classification (RC). End-stage PAOD patients (RC-V & -VI) were excluded from study. Data were collected prospectively and included age, gender, atherosclerotic risk factors and the body mass index (BMI). In PAOD patients recorded the PAOD's clinical stage and the presence of carotid stenosis >50%. PAOD patients divided in two subgroups, those with mild (RC-I & -II) and moderate disease (RC-III & -IV). In all serum samples Visfatin was measured, blindly, twice by anosoenzymatic technique. Statistical analysis was performed by non-parametric Mann-Whitney U test, Pearson's chi-square, One Way Anova and Kruskall-Wallis tests, as appropriate. The mean Visfatin value in PAOD and Control groups were 38.5±16.0 and 13.9±3.8ng/ml respectively (p<0.0005). In-PAOD subgroup of patients the visfatin values were not affected by demographics, BMI and atherosclerotic risk factors (p>0.05). Univariate analysis showed that severity of PAOD (mild vs severe), presence of carotid stenosis >50% and multilevel disease significantly affected outcomes (p=0.018, p=0.010 and p=0.006 respectively). In multivariate regression analysis severity of PAOD was the solely factor with strong correlation with high visfatin values (p=0.001). High Visfatin levels seem to be strongly correlated with the presence and severity of PAOD. Further and in depth investigation is needed to define the possible role of Visfatin in atherosclerosis and it's value as a potential prognostic biomarker of PAOD.

Secondary Procedures Following Iliac Branch Device Treatment of Aneurysms Involving the Iliac Bifurcation: The pELVIS Registry.

PURPOSE: To evaluate the incidence and reasons for secondary procedures in patients treated with iliac branch devices (IBDs) for isolated iliac aneurysm or aortoiliac aneurysms involving the iliac bifurcation. METHODS: Between January 2005 and December 2015, 575 surgical-high-risk patients (mean age 72.0±8.4 years; 558 men) with isolated iliac aneurysms (n=79) or aortoiliac aneurysms involving the iliac bifurcation (n=496) were treated with placement of 650 ZBIS or Gore IBDs (75 bilateral) in 6 European centers. The primary outcome was procedure-related reinterventions for occlusion or high-grade (>70%) stenosis of the bridging device, occlusion of the ipsilateral common or external iliac artery (EIA), type I/III endoleak, rupture, or infection following IBD implantation. Clinical and radiological data were analyzed based on preset definitions of comorbidities, aneurysm morphology, intraoperative variables, and follow-up strategies. RESULTS: Nine (1.6%) reinterventions were performed within 30 days for occlusion or endoleak. Among 10 (1.5%) occluded EIAs ipsilateral to a deployed IBD, 6 underwent a reintervention with additional stent placement after thrombolysis (n=4) or a femorofemoral or iliofemoral crossover bypass (n=2). Three of 14 patients with early type I endoleak had a reintervention for an insufficient proximal sealing zone (stent-grafts in 2 common iliac arteries and 1 bifurcated endograft). Mean clinical and radiological follow-up were 32.6±9.9 and 29.8±21.1 months, respectively. Forty-two (7.3%) patients underwent reinterventions in the follow-up period. The overall postoperative reintervention rate was 8.9%. Both external and common iliac segments occluded in 30 (4.6%) IBDs; 2 patients had a crossover bypass and 14 were treated with endovascular techniques. In the other 14 patients, no specific treatment was performed. Seven (1.2%) patients with isolated EIA occlusion were treated during follow-up. Nineteen of the overall 28 patients with type I endoleak underwent endovascular repair. The other 9 were under radiological surveillance due to less significant (<5 mm) sac increase. No reintervention was performed to recanalize 11 (1.6%) occluded internal iliac arteries. CONCLUSION: Midterm experience with placement of IBDs is associated with a low incidence of secondary procedures due to type I endoleaks and occlusions. The main reasons for reinterventions seem to be short proximal sealing zone and poor conformability of the ZBIS device in elongated EIAs.

Endovascular treatment of occluded and stenotic visceral vessels in patients with chronic mesenteric ischemia.

Objective Current evidence in the literature about endovascular treatment (ET) of visceral vessels in patients with chronic mesenterial ischemia (CMI) based on morphological characteristics is limited. The aim of this study was the evaluation of ET in occluded and stenotic visceral vessels. Methods Patients undergoing ET for CMI between November 2000 and November 2012 were included in this retrospective study. Primary measure outcome was the symptom-free survival (SFS). Secondary outcomes were primary (PPR), secondary patency (SPR) rates and technical success rate (TSR). A Cox-regression analysis identified risk factors for the primary and secondary measure outcomes. Results Forty patients were included in the present study (men: 21, mean age: 68). The overall number of vessels with intention-to-treat was 62. Fifty-two visceral arteries (18 occlusions and 34 stenoses) were successfully treated by endovascular means. The overall TSR was 84%. Visceral vessel occlusions and atherosclerotic disease of the superior mesenteric artery (SMA) were identified as independent risk factors for poorer TSR ( p < 0.05). The 12-month SFS was 60%. The overall 12-month PPR and SPR were 71% and 94%, respectively. No significant differences were observed between occluded and stenotic vessels ( p > 0.05) concerning the PPR. On the other hand, the subgroup analysis revealed higher SPR among occluded visceral vessels ( p < 0.001) and coeliac axis lesions ( p < 0.001). Conclusions ET was associated with high incidence of symptoms recurrence despite the satisfying patency rates in both occluded and stenotic vessels. Additionally, visceral vessel occlusion and presence of atherosclerotic lesions in the SMA were associated with poorer TSR.

The PROTAGORAS study to evaluate the performance of the Endurant stent graft for patients with pararenal pathologic processes treated by the chimney/snorkel endovascular technique.

OBJECTIVE: The chimney/snorkel endovascular aortic repair (ch-EVAR) is gaining ever-greater acceptance in the treatment of pararenal pathologic processes. However, the published experience includes mainly short-term clinical results with combinations of several abdominal devices and types of chimney grafts. The aim of this study was the midterm evaluation of the Endurant stent graft (Medtronic, Santa Rosa, Calif) as a standard abdominal device for ch-EVAR. METHODS: Between January 2009 and January 2013, prospectively collected data of high-risk patients with pararenal pathologic processes who underwent ch-EVAR with placement of the Endurant abdominal device were analyzed. The chimney graft intended for use was a balloon-expandable covered stent. Main outcome measures were aneurysm sac regression and chimney graft patency. RESULTS: A total of 187 snorkel/chimney grafts were successfully placed in 128 patients (mean age, 76.6 years). The technical success was 100%. The mean preoperative proximal neck length and aneurysm size were 4.7 mm and 64.8 mm (range, 48-135 mm), respectively. The postoperative new neck length after use of chimney grafts was 18.7 ± 6.3 mm. The mean aneurysm sac decreased significantly (60.8 mm; 95% confidence interval, 2.036-7.084; P = .001) after a mean radiologic follow up of 24.6 ± 17.4 months. Thirty-day mortality and midterm mortality were 0.8% and 17.2%, respectively. Two patients (1.6%) with single chimneys presented with late new onset of type Ia endoleak and underwent additional tube and multiple chimney placement. Primary chimney graft patency was 95.7%. Freedom from chimney graft-related reinterventions was 93.1%. CONCLUSIONS: Standard use of the Endurant abdominal device for ch-EVAR in >120 patients is associated with high technical success, significant aneurysm sac regression, and low incidence of secondary procedures after 2-year radiologic follow-up. These results will give significant impetus to device selection, facilitating the standardization of technique.

Preservation of Clinically Relevant Accessory Renal Arteries in Infrarenal AAA Patients With Adequate Proximal Landing Zones Undergoing EVAR.

PURPOSE: To report techniques to preserve the flow to relevant accessory renal arteries (ARA) in patients undergoing infrarenal endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) with adequate landing zones. METHODS: ARAs that originate inferior to the lowest ipsilateral main renal artery, supply one-third of the renal parenchyma, and having a diameter >4 mm have significant clinical importance. Between May 2012 and January 2015, among 389 high-risk patients with infrarenal AAAs who underwent standard EVAR, 9 (2.3%) patients each presented with a coexistent clinically relevant ARA. Their perfusion was secured by placing covered stents in the target ARA, parallel and outside of the main abdominal, as chimney grafts. Evaluation of acute and chronic renal decline was based on the consensus definition of RIFLE criteria (risk, injury, failure, loss, and end-stage) and chronic kidney disease (CKD) staging system, respectively. RESULTS: The procedure was completed successfully in all cases. In the immediate postoperative period, no acute kidney injury was observed based on the RIFLE criteria. Eight of the 9 covered stents remained patent during a mean follow-up of 13.8 ± 6.2 months. A single covered stent occlusion was observed 30 days postoperatively with infarction of the caudal pole of the kidney. This patient developed renal function impairment based on the CKD staging system 12 months after the initial procedure. For the remaining 8 patients, improvement of one CKD stage (n=1) or no change (n=7) in the CKD stage was observed. CONCLUSION: In AAA patients unfit for surgical revascularization, EVAR is associated with a significant decline in renal function. For this reason, preservation of relevant coexistent ARAs using the chimney technique should be considered as an option.

Novel indication for chimney graft placement in the inferior mesenteric artery in AAA patients with coexistent bilateral internal iliac artery occlusion.

PURPOSE: To report a novel indication for the use of chimney grafts to preserve flow to the inferior mesenteric artery (IMA) in patients undergoing endovascular aneurysm repair (EVAR) for aortobi-iliac aneurysms with coexistent bilateral occlusion of the internal iliac arteries (IIA). TECHNIQUE: Via a cutdown over the left axillary artery, a 5-F vertebral catheter was delivered over a conventional 0.035-inch hydrophilic guidewire to selectively catheterize the IMA via a 7-F shuttle sheath, which was then advanced at least 2 cm into the target vessel. The first chimney graft was advanced into the sheath, and a standard EVAR procedure followed. The chimney graft was deployed at least 2 cm in the IMA; a second chimney graft was advanced and deployed with at least 2 cm overlapping with the first chimney stent parallel and outside of the main abdominal endograft and below the lowest renal artery. The chimney grafts were lined with additional bare nitinol stents. The technique is demonstrated in two male patients who suffered from symptomatic aortobi-iliac aneurysm with patent IMAs and bilateral IIA occlusion. The procedure was completed successfully in both cases without bowel ischemia. At 12 and 6 months, respectively, the chimney grafts remained patent without endoleak. The patients are asymptomatic. CONCLUSION: The IMA chimney endovascular technique can be considered in EVAR cases with coexistent bilateral IIA occlusion to minimize the risk for bowel ischemia.

Simultaneous transcervical angioplasty and stenting of innominate and right internal carotid arteries.

Severe stenosis of both the internal carotid and the innominate arteries is a rare condition. Hybrid procedures combining carotid endarterectomy and retrograde endovascular innominate angioplasty have been introduced to reduce the complications of open surgery. The recently reported good results of carotid angioplasty and stenting have encouraged us to perform simultaneous transcervical angioplasties and stenting of both arteries in a symptomatic 64-year-old woman. The procedure was successful and without complications and there have been no symptoms or restenosis in the 18-month follow-up period. Carrying out additional procedures of this will be necessary to reach wider conclusions.