Certification of Basic Skills in Endovascular Aortic Repair Through a Modular Simulation Course With Real Time Performance Assessment.

OBJECTIVE: Endovascular aortic repair (EVAR) is being used increasingly for the treatment of infrarenal abdominal aortic aneurysms. Improvement in educational strategies is required to teach future vascular surgeons EVAR skills, but a comprehensive, pre-defined e-learning and simulation curriculum remains to be developed and tested. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), an assessment tool for simulation based education (SBE) in EVAR, has previously been designed to assess EVAR skills, and a pass limit defining mastery level has been set. However, EVARATE was developed for anonymous video ratings in a research setting, and its feasibility for real time ratings in a standardised SBE programme in EVAR is unproven. This study aimed to test the effect of a newly developed simulation based modular course in EVAR. In addition, the applicability of EVARATE for real time performance assessments was investigated. METHODS: The European Society of Vascular Surgery (ESVS) and Copenhagen Certification Programme in EVAR (ENHANCE-EVAR) was tested in a prospective cohort study. ENHANCE-EVAR is a modular SBE programme in EVAR consisting of e-learning and hands-on SBE. Participants were rated with the EVARATE tool by experienced EVAR surgeons. RESULTS: Twenty-four physicians completed the study. The mean improvement in EVARATE score during the course was +11.8 (95% confidence interval 9.8 - 13.7) points (p < .001). Twenty-two participants (92%) passed with a mean number of 2.8 ± 0.7 test attempts to reach the pass limit. Cronbach's alpha coefficient was 0.91, corresponding to excellent reliability of the EVARATE scale. Differences between instructors' EVARATE ratings were insignificant (p = .16), with a maximum variation between instructors of ± 1.3 points. CONCLUSION: ENHANCE-EVAR, a comprehensive certifying EVAR course, was proven to be effective. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE) is a trustworthy tool for assessing performance within an authentic educational setting, enabling real time feedback.

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.

Danish Nationwide Study on Surgical Treatment of Infective Native Abdominal Aortic Aneurysms.

OBJECTIVE: This study aimed to describe surgical trends, survival, and infection related complications (IRC) in a Danish cohort of patients with infective native aortic aneurysms (INAAs). METHODS: A retrospective nationwide cohort study including all patients in Denmark who were surgically treated for abdominal INAA between 2000 and 2020 was conducted. Patients were identified through the Danish vascular registry, Karbase, which is a database registering all patients treated with vascular surgery in Denmark. Subsequent data on clinical presentation, treatment, all cause mortality, and complications were obtained from the electronic patient charts. RESULTS: Seventy-five patients were included in the study, of whom 60 (80%) were male, with a median age of 69 (IQR 64, 75) years. Open surgical repair (OSR) was performed in 54 (72%) patients and endovascular aortic repair (EVAR) in 21 (28%). Median follow up was 52 (IQR 32, 103) months. Open repair was consistently the most frequent treatment modality throughout the study period, but EVAR became more frequent over time. The 30 day survival of the total cohort was 97% (94 - 100%). Kaplan-Meier survival estimates for the cohort were 92% (95% CI 85 - 98%), 80% (95% CI 71 - 91%), 63% (95% CI 52 - 78%), and 48% (95% CI 35 - 66%) at one, three, five and 10 years, respectively. Patients treated by EVAR had comparable long term survival to patients treated by OSR, with a hazard ratio of 0.35 (95% CI 0.10 - 1.22), but was associated with better short term survival up to five years. The most common cause of death was sepsis. Five (9%) OSR patients had IRC compared with one (5%) EVAR patient. CONCLUSION: In this nationwide study of patients treated for abdominal INAA, an increasing number of patients were surgically treated during the study period. Patients treated by EVAR demonstrated long term survival comparable to OSR. The incidence of post-operative IRC was low. These results should be interpreted with caution and prospective registries are needed.

Endovascular aneurysm repair for symptomatic abdominal aortic aneurysms has comparable results to elective repair in the long term.

OBJECTIVE: Endovascular aneurysm repair (EVAR) has been extensively study regarding elective and ruptured abdominal aortic aneurysm (AAA) repair. However, much less is known about EVAR of symptomatic nonruptured AAA, especially concerning the long-term results. The aim of this study was to assess the outcomes of EVAR of symptomatic AAA compared with asymptomatic AAA at a tertiary center using a single graft. METHODS: All consecutive patients treated for symptomatic and asymptomatic AAAs from 1998 to 2012 at our institution, using the Cook Zenith stent graft (Cook Europe A/S, Bjaeverskov, Denmark), were included in the study. Ruptured AAAs were excluded. Patients' charts were reviewed to obtain preoperative, intraoperative, and postoperative data. All available imaging was reviewed. Life tables were constructed to assess for overall and late AAA-related survival, clinical success, and endoleak freedom. RESULTS: There were 680 patients included (137 symptomatic AAAs). No difference in technical success rate (96.1% for asymptomatic AAAs vs 94.9% for symptomatic AAAs) was present (P = .477). Thirty-day mortality was more common in symptomatic AAAs (6.6% vs 1.5% for asymptomatic AAAs; P = .002). Freedom from reinterventions was 72% ± 3% for asymptomatic AAAs vs 73% ± 5% for symptomatic AAAs (P = .785) at 10 years postoperatively. There was no difference in primary (P = .300) or secondary (P = .099) clinical success between groups, although there was higher assisted clinical success (P = .023) for asymptomatic AAAs compared with symptomatic AAAs. Persistent late clinical failure was similar in both groups (14.2% for asymptomatic AAAs vs 15.3% for symptomatic AAAs; P = .732). Freedom from late AAA-related death was higher (P = .016) for asymptomatic AAAs compared with symptomatic AAAs, but the differences disappeared when the first 30 days were disregarded. Overall survival (P = .687) was similar in both groups. An adequate aneurysm neck preoperatively conferred a better outcome in end points including overall survival. CONCLUSIONS: Symptomatic AAAs have an almost quadrupled 30-day mortality compared with asymptomatic AAAs, but the outcome differences fade in the long term. An adequate aneurysm neck was associated with better outcomes including overall survival independent of the initial presentation of the AAA. These results suggest the need of improving the identification of symptomatic patients requiring preoperative medical optimization. However, this is often limited by the acute need of the procedure, and more intensive postoperative monitoring may have greater potential. Independently, a strict anatomic selection for infrarenal EVAR is of paramount importance for the long-term outcome.

New Technique for Preconditioning of the Spinal Cord Before Endovascular Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms.

Purpose: To propose a new simplified technique to occlude multiple segmental arteries for staging and preconditioning of the spinal cord to decrease the potential for spinal cord ischemia after thoracic and thoracoabdominal aortic aneurysm repair. Technique: A thoracic stent-graft that flares out to a maximum of 51 mm is deployed in a standard fashion covering all segmental arteries where graft-wall apposition occurs in the first ~20 cm of the aneurysm. The segmental arteries are always closed at their ostia in contrast to selective coil embolization, where there is a risk of more peripheral closure. Follow-up imaging shows thrombus lining the stent-graft-covered portion of the aneurysm and secondary proximal segmental artery occlusion. Conclusion: A new and fast way of staging and preconditioning the spinal cord using a modified stent-graft prior to definitive repair might be an alternative to segmental artery embolization.

Aneurysm Shrinkage Is Compatible With Massive Endoleak in the Presence of an Aortocaval Fistula: Potential Therapeutic Implications for Endoleaks and Spinal Cord Ischemia.

PURPOSE: To present a patient with ruptured abdominal aortic aneurysm (AAA) and aortocaval fistula who was successfully treated with endovascular aneurysm repair in spite of developing a massive endoleak. CASE REPORT: A 70-year-old man with ruptured AAA and aortocaval fistula was treated with endovascular aneurysm repair (EVAR). During 8 years of follow-up, he had massive perfusion of the aneurysm sac by retrograde flow from the inferior mesenteric artery into the caval vein through the aortocaval fistula. The aneurysm diameter decreased continuously in spite of the type II endoleak. This observation illustrates the mechanisms of sac expansion and may have therapeutic implications for complicated type II endoleaks and prevention of spinal cord ischemia in thoracic stent-grafting. CONCLUSION: EVAR can be applied in this rare setting because the ensuing high-flow endoleak is associated with sac shrinkage owing to depressurization by the caval shunt.

Copenhagen Mesenteric stent study (COMESS)-a randomized trial of stent versus covered stent treatment for chronic mesenteric ischemia.

BACKGROUND: Current management of mesenteric ischemia is primarily endovascular stent treatment. Typical CMI symptoms are postprandial abdominal pain, food fear, weight loss, and diarrhea. Revascularization is often necessary, as mesenteric ischemia may progress to bowel necrosis and death if left untreated. This study aims to compare the outcome using bare metal stent (BMS) or covered stent (CS) in the endovascular treatment of chronic and acute on chronic mesenteric ischemia. METHODS: This is an investigator-driven, prospective, randomized, single-blinded, and single-center, national cohort study at the Copenhagen University Hospital, Denmark. A total of 98 patients with chronic mesenteric ischemia (CMI) and acute-on-chronic mesenteric ischemia (AoCMI) will be randomized to treatment with either BeSmooth BMS (Bentley Innomed GmbH) or BeGraft CS (Bentley Innomed GmbH). Randomization occurs intraoperatively after lesion crossing. DISCUSSION: There is currently no published data from prospective controlled trials regarding the preferred type of stent used for the treatment of chronic and acute-on-chronic mesenteric ischemia. This trial will evaluate the short- and long-term outcome of BMS versus CS when treating CMI and AoCMI, as well as the benefit of a more intense postoperative surveillance program. TRIAL REGISTRATION: ClinicalTrials.gov NCT05244629. Registered on February 8, 2022.

Single branch arch stent graft combined with laser fenestration in the treatment of a zone two penetrating thoracic aortic ulcer.

We present the case of a 75-year-old man with a symptomatic penetrating aortic ulcer located in zone 2 on the arch inner curve between the left subclavian artery and left carotid artery treated using a single branch thoracic endovascular aortic repair combined with in situ laser fenestration. The patient underwent a successful procedure with no neurologic impairment and was discharged on the second postoperative day. The postoperative follow-up showed a well-excluded penetrating aortic ulcer.

Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms.

PURPOSE: To evaluate the suitability of a standardized fenestrated endograft in patients with juxtarenal abdominal aortic aneurysms. METHODS: High resolution computed tomographic angiograms from 100 consecutive patients (96 men; mean age 72 years) with juxta- (n = 78) and pararenal (n = 22) aneurysms treated electively between 2005 and 2010 with custom-made fenestrated endografts were reviewed. A centerline of flow reconstruction was carried out in a 3D imaging workstation to precisely define the aortic morphology, including aortic diameters and distances between visceral and renal arteries. The applicability of 2 different "off-the-shelf" standardized fenestrated endografts designed by the manufacturer was evaluated in this cohort. Both designs included 2 fenestrations for the renal arteries, 1 for the superior mesenteric artery (SMA), and a scallop for the celiac trunk. The designs differed in the lengths of the SMA to renal fenestration and renal to renal fenestration. RESULTS: Endovascular treatment with one or both "off-the-shelf" endografts was deemed possible in 72 patients (56 with design 1, 52 with design 2, and 36 with both endografts). Of the 28 patients who were not candidates for a standardized fenestrated stent-graft of either design, the primary cause was a right renal artery that did not match the position of its corresponding fenestration. CONCLUSION: Standardized fenestrated designs suitable for endovascular treatment of >70% of patients with juxta- and pararenal aneurysms currently treated with custom-made fenestrated endografts will soon be available. This new generation of endografts will permit rapid treatment of a large majority of patients requiring fenestrated endograft repair.

Short- and midterm results of the fascia suture technique for closure of femoral artery access sites after endovascular aneurysm repair.

PURPOSE: To evaluate the midterm outcomes and potential risk factors associated with the fascia suture technique (FST) for closure of femoral artery access sites after percutaneous endovascular aneurysm repair (EVAR). METHODS: Between April 2007 and April 2008, 100 consecutive EVAR cases were evaluated retrospectively. A third of the procedures were emergent (16 ruptured aneurysms). Of the 187 femoral access sites, 160 (85.5%) were closed by the FST as a first choice. Pre- and postoperative chart and imaging data were collected from computerized medical records for analysis of demographics and the rate of complications (bleeding, infection, thrombosis, pseudoaneurysms, and stenosis). Preoperative risk factors for FST failure were analyzed with regard to obesity (based on the subcutaneous fat layer), plaque at the femoral access site, and stenosis based on the pre- and 1-year postoperative computed tomography scans. RESULTS: Of the 160 FST closures, 146 (91.3%) were technically successful. The 14 (8.8%) technical failures were converted to open cutdown intraoperatively because of bleeding (11, 6.8%), inadequate limb perfusion (2, 1.2%), and a broken guidewire (1, 0.6%). Two (1.2%) pseudoaneurysms required surgical repair after 2 weeks. Data from the 1-year follow-up showed no signs of increased stenosis, thrombosis, or formation of plaque. Nine small (<1 cm(3)) pseudoaneurysms were detected and managed conservatively. No preoperative risk factors were associated with FST failure. CONCLUSION: The fascia suture technique seems to be safe, effective, and simple to use for closing percutaneous access sites after EVAR. Complications are rare, and the outcome is not affected by obesity, femoral calcification, or femoral artery stenosis.

Impact of intrasac thrombus and a patent inferior mesenteric artery on EVAR outcome.

PURPOSE: To assess the significance of a patent inferior mesenteric artery (IMA) and presence of intrasac thrombus on the outcome of endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). METHODS: Between June 2004 and June 2007, 114 AAA patients (100 men; mean age 75 years, range 56-87) treated electively with a bifurcated stent-graft were assessed with computed tomography pre- and postoperatively. Incidences of type II endoleaks and reinterventions were compared with preoperative intrasac thrombus and IMA patency. RESULTS: Over a mean follow-up of 19 months (range 6-38), there was no aneurysm rupture. Eleven (11%) of 101 patients with and 7 (54%) of 13 patients without preoperative intrasac thrombus presented with a type II endoleak (p<0.01). The postoperative change in aneurysm diameter was 0 mm (-20 to 16) in 18 patients with type II endoleak and -9 mm (-30 to 18) in sealed aneurysms (p<0.001). Fourteen (78%) type II endoleaks originated from lumbar arteries and 4 (22%) from the IMA in spite of the fact that most patients (69%) had a patent IMA. There were 5 reinterventions for type II endoleak with expansion of the sac. The reinterventions did not seem related to intrasac thrombus or a patent IMA. Prophylactic embolization of the IMA was unsuccessful in 4 (33%) cases. CONCLUSION: In this series, type II endoleaks inhibited sac shrinkage and occurred more frequently in aneurysms without intrasac thrombus. Most type II endoleaks originated from lumbar arteries and not from the IMA. Prophylactic embolization of the IMA does not seem justified and is not always technically successful.