Case series of aortic arch disease treated with branched stent-grafts.

BACKGROUND: Surgical repair of aortic arch pathology is complex and associated with significant morbidity and mortality. Alternative approaches have been developed to reduce these risks, including the use of thoracic stent-grafts with fenestrations or in combination with bypass procedures to maintain supra-aortic trunk blood flow. Branched stent-grafts are a novel approach to treat aortic arch pathology. METHODS: Consecutive patients with aortic arch disease presenting to a single university hospital vascular centre were considered for branched stent-graft repair (October 2010 to January 2017). Patients were assessed in a multidisciplinary setting including a cardiologist, cardiac surgeon and vascular surgeon. All patients were considered prohibitively high risk for standard open surgical repair. The study used reporting standards for endovascular aortic repair and PROCESS (Preferred Reporting of Case Series in Surgery) guidelines. RESULTS: Some 30 patients (25 men) underwent attempted branch stent-graft repair. Mean age was 68 (range 37-84) years. Eighteen patients had chronic aortic dissection, 11 patients had an aneurysm and one had a penetrating ulcer. Fourteen patients had disease in aortic arch zone 0, six in zone 1 and ten in zone 2. Twenty-five patients had undergone previous aortic surgery and 24 required surgical revascularization of the left subclavian artery. Technical success was achieved in 27 of 30 patients. Four patients had an endoleak (type Ia, 1; type II, 3). The in-hospital mortality rate was three of 30. Mean length of follow-up was 12·0 (range 1·0-67·8) months, during which time 12 patients required an aortic-related reintervention. CONCLUSION: Repair of aortic arch pathology using branched stent-grafting appears feasible. Before widespread adoption of this technology, further studies are required to standardize the technique and identify which patients are most likely to benefit.

Changes in Renal Anatomy After Fenestrated Endovascular Aneurysm Repair.

OBJECTIVE: To assess short- and long-term movement of renal arteries after fenestrated endovascular aortic repair (FEVAR). METHODS: Consecutive patients who underwent FEVAR at one institution with a custom-made device designed with fenestrations for the superior mesenteric (SMA) and renal arteries, a millimetric computed tomography angiography (CTA), and a minimum of 2 years' follow-up were included. Angulation between renal artery trunk and aorta, clock position of the origin of the renal arteries, distance between renal arteries and SMA, and target vessel occlusion were retrospectively collected and compared between the pre-operative, post-operative (<6 months), and last (>12 months) CTA. RESULTS: From October 2004 to January 2014, 100 patients met the inclusion criteria and 86% of imaging was available for accurate analysis. Median follow-up was 27.3 months (22.7-50.1). There were no renal occlusions. A significant change was found in the value of renal trunk angulation of both renal arteries on post-operative compared with pre-operative CTA (17° difference upward [7.5-29], p < .001), but no significant change thereafter (p = .5). Regarding renal clock positions (7.5° of change equivalent to 15 min of renal ostial movement): significant anterior change was found between post-operative and pre-operative CTA (15 min [0-30], p = .03 on the left and 15 min [15-30], p < .001 on the right), without significant change thereafter (15 min [0-30], p = .18 on the left and 15 min [0-15] on the right, p = .28). No changes were noted on the distance between renal and SMA ostia (difference of 1.65 mm [1-2.5], p = .63). CONCLUSION: The renal arteries demonstrate tolerance to permanent changes in angulation after FEVAR of approximately 17° upward trunk movement and of 15-30 min ostial movement without adverse consequences on patency after a median of more than 2 years' follow-up. The distance between the target vessels remained stable over time. These results may suggest accommodation to sizing errors and thus a compliance with off the shelf devices in favourable anatomies.

Expansion rate of descending thoracic aortic aneurysms.

BACKGROUND: Surveillance is mandatory for all patients with a thoracic aortic aneurysm (TAA). The frequency of surveillance imaging, however, is not evidence-based, as few data exist regarding TAA growth rates. This study aimed to determine the rate of TAA expansion and to inform surveillance intervals based on TAA diameter. METHODS: Patients with a TAA for whom morphological data were available from serial CT scans were studied. Annualized growth rates based on diameter at presentation and time taken to reach a theoretical intervention threshold of 55 mm were calculated. The number of patients who would have achieved the threshold undetected was determined based on simulated imaging intervals of 6 months, 1, 2 and 3 years. RESULTS: A total of 2916 scans from 995 patients were analysed. The mean aortic expansion rate was 2·76 mm per year for all patients, with an exponential increase observed at sizes above 45 mm. Only 3·9 per cent of patients with a starting diameter of 30-39 mm and 5·3 per cent of those with a diameter of 40-44 mm achieved threshold size within 2 years. Conversely, the probability of expansion to more than 55 mm was 74·5 per cent in 2 years for patients with a starting diameter of 50-54 mm, rising to 85·7 per cent at 3 years. CONCLUSION: Based on a threshold of 55 mm for intervention, most patients with a maximum aortic diameter below 40 mm could safely undergo surveillance at 2-yearly intervals. Above 45 mm, annual surveillance is recommended. Patients with a diameter greater than 50 mm could be optimized for possible repair, if this is clinically appropriate.

Preoperative morphology influences thoracic aortic aneurysm sac expansion after endovascular repair.

BACKGROUND: The fate of the aneurysm sac after thoracic endovascular aortic repair (TEVAR) remains poorly defined. The aim of this study was to characterize the incidence of aneurysm sac expansion after TEVAR, and to determine the effect of aneurysm morphology on postoperative sac behaviour. METHODS: Preoperative and postoperative CT angiography (CTA) images were analysed from a proprietary database (M2S). TEVARs undertaken for thoracic aortic aneurysms from 2004 to 2013 were included. Preoperative aortic morphology was available for each patient. Post-TEVAR sac expansion was defined as an increase in aortic diameter of at least 5 mm. The influence of aortic morphological variables on sac expansion was assessed using Cox regression and Kaplan-Meier analysis. RESULTS: CTA images were available for 899 patients who underwent TEVAR. Median follow-up was 2·1 (i.q.r. 1·7-2·4) years. Some 46·0 per cent had a maximum aneurysm diameter of 55 mm or more at the time of repair. The 5-year rate of freedom from sac expansion of at least 5 mm was 60·9 per cent. The sac expansion rate after 3 years was higher when the proximal sealing zone was over 38 mm in diameter (freedom from expansion 51·2 per cent versus 76·6 per cent for diameter 38 mm or less; P < 0·001), or 20 mm or less in length (freedom from expansion 67·3 per cent versus 77·1 per cent for length exceeding 20 mm; P = 0·022). Findings for the distal sealing zone were similar. The risk of sac expansion increased according to the number of adverse morphological risk factors (freedom from expansion rate 79·1 per cent at 3 years in patients with 2 or fewer risk factors versus 45·7 per cent in those with more than 2; P < 0·001). CONCLUSION: Sac expansion was common in this cohort of patients undergoing TEVAR for thoracic aortic aneurysm. Aneurysm sac expansion was significantly influenced by adverse morphological features in the aortic stent-graft sealing zones.

Systematic Review of the Growth Rates and Influencing Factors in Thoracic Aortic Aneurysms.

OBJECTIVE/BACKGROUND: The growth rates of thoracic aortic aneurysms (TAAs) and factors influencing their expansion are poorly understood. This study aimed to review systematically published literature describing TAA expansion and examine factors that may be associated with this. METHODS: A comprehensive search of MEDLINE and Embase databases was performed until 30 April 2015. Studies describing rates of TAA growth were identified and systematically reviewed. Outcomes of interest were TAA growth rates and associated factors. Study quality was assessed using Scottish Intercollegiate Guidelines Network quality checklists for cohort studies. RESULTS: Eleven publications, involving 1383 patients, met the eligibility criteria and were included in the review. Included studies were generally low in quality. Aneurysm measurement and growth-rate estimation techniques were inconsistently reported. Mean growth rates for all TAAs ranged from 0.2 to 4.2 mm/year. Mean growth rates for ascending and aortic arch aneurysms ranged from 0.2 to 2.8 mm/year, while those for descending and thoracoabdominal aneurysms ranged from 1.9 to 3.4 mm/year in studies reporting according to anatomical location. Large aneurysm size, distal aneurysm locations, presence of Marfan's syndrome, and bicuspid aortic valve were consistently associated with accelerated TAA growth. Presence of chronic dissection and chronic obstructive pulmonary disorder were also implicated as risk factors for faster TAA growth. Associations between medical comorbidity and aneurysm expansion were conflicting. Previous aortic surgery and anticoagulants were reported to have a protective effect on aneurysm growth in two studies. CONCLUSION: There is a shortfall in the understanding of TAA expansion rates. Existing studies are heterogeneous in methodology and reported outcomes. Identified unifying themes suggest that TAAs grow at a slow rate with large presenting diameter, distal aneurysm, and history of bicuspid aortic valve or Marfan's syndrome serving as main risk factors for accelerated aneurysm growth. High-quality studies with a standardised approach to TAA growth assessment are required.

Early Experience of Endovascular Repair of Post-dissection Aneurysms Involving the Thoraco-abdominal Aorta and the Arch.

OBJECTIVES: Outcomes are reported in management of post-dissection aneurysms involving the aortic arch and/or thoraco-abdominal segment (TAAA) treated with fenestrated and branched (complex) endografts. METHODS: This report includes all patients with chronic post-dissection aneurysms >55 mm in diameter, deemed unfit for open surgery, treated using complex endografts between October 2011 and March 2015. When appropriate, staged management strategies including left subclavian artery revascularization, thoracic endografting, dissection flap fenestration or tear enlargement, and other endovascular procedures were performed at least 3 weeks prior to definitive complex endovascular repair. The following outcome data were collected prospectively at discharge, 12 months and annually thereafter: technical success, endoleaks, target vessel patency, false lumen patency, aneurysm diameter, major and minor complications, re-interventions, and mortality. RESULTS: The cohort comprised 23 patients with a median age of 65 years. Staged procedures were performed in 14 patients (61%). Seven patients with dissections involving the arch were treated with inner branched endografts, and 16 TAAA patients were treated with fenestrated or branched endografts. The technical success rate was 71% following arch repair and 100% following TAAA repair. During early follow up, one of the arch group patients died and one in the TAAA group suffered spinal cord ischemia. The median follow up was 12 months (range 3-48), during which time one patient died of causes unrelated to aneurysm or treatment. Two early re-interventions were performed in the arch group to correct access vessel complications and there were a further two late re-interventions in the TAAA group to treat endoleaks. All target vessels (n = 72) remained patent. CONCLUSIONS: This experience indicates that complex endovascular repair of post-dissection aneurysms is a viable alternative to open repair in patients deemed unfit for open surgery. There are insufficient data to allow comparison with the outcome of open surgery in anatomically similar, but fit, patients.

Editor's Choice - Minimizing Radiation Exposure During Endovascular Procedures: Basic Knowledge, Literature Review, and Reporting Standards.

CONTEXT: Endovascular procedures, requiring X-ray guidance, are commonly performed in vascular surgery. X-ray exposure is associated with biological risks for both patients and physicians. Medical X-ray use must follow "as low as reasonably achievable" (ALARA) principles, which aim at using the lowest radiation exposure to achieve a procedure safely. This is underlined by European and international recommendations that also suggest that adequate theoretical and practical training is mandatory during the initial education of physicians. However, the content of this education and professional practices vary widely from one country to another. OBJECTIVE: This review aims to summarize the basic knowledge required for vascular surgeons on X-ray physics and image production. METHODS: A panel of endovascular therapists (vascular surgeons and radiologists) and physicists dedicated to X-rays was gathered. International recommendations were summarized. A literature review was performed via MEDLINE to identify studies reporting dosages of common endovascular procedures. RESULTS: The different mechanisms inducing biological risks, and the associated potential effects on health, are described. Details on dose metrics are provided and a common nomenclature to measure, estimate, and report dose is proposed in order to perform accurate comparisons between publications and practices. Key points of the European and international legislation regarding medical X-ray use are summarized, and radiation protection basics for patients and staff, are detailed. Finally, a literature review is proposed for physicians to evaluate their practice. CONCLUSIONS: Today's trainees will be highly exposed to radiation throughout their practice. It is thus compulsory that they undergo dedicated radiation education during their initial training, and regular refresher sessions later. In daily practice, focus on dose reduction and monitoring of patient and staff exposure are mandatory.

Renal Outcomes Following Fenestrated and Branched Endografting.

OBJECTIVE: The purpose of this study was to analyze immediate and long-term renal outcomes (renal function and renal events) after fenestrated (FEVAR) and branched endovascular aortic aneurysm repair (BEVAR). METHODS: All FEVAR and BEVAR performed between October 2004 and October 2012 were included in this study. Post-operative acute renal failure (ARF) was defined according to the RIFLE criteria. Renal volume (calculated with a 3D workstation) and estimated glomerular filtration rate (GFR) (estimated with the Modification of Diet in Renal Disease [MDRD] formula) were evaluated before the procedure, before discharge, 12 months after, and yearly thereafter. Renal stent occlusion, dissection, fracture, stenosis, kink, renal stent related endoleak, and renal stent secondary intervention were all considered "renal composite events" and analyzed. A time to event analysis was performed for renal events and secondary renal interventions. RESULTS: 225 patients were treated with FEVAR and BEVAR. Renal target vessels (n = 427) were perfused by fenestrations (n = 374), or branches (n = 53). Median follow up was 3.1 years (2.9-3.3 years). Technical success was achieved in 95.5% of patients. Post-operative ARF was seen in 64 patients (29%). Mean total renal volume and eGFR at 1 year, 2 year, and 3 year follow up were significantly lower when compared with pre-operative levels (after BEVAR and FEVAR); the decrease at 3 years was 14.8% (6.7%; 22.2%) (p = .0006) for total renal volume and 14.3% (3.1%; 24.3%) (p = .02) for eGFR. The 30 day and 5 year freedom from renal composite event was 98.6% (95.8-99.6%) and 84.5% (76.5-89.9%) after FEVAR and BEVAR (NS). The 30 day and 5 year freedom from renal occlusion was 99.5% (96.7-99.9%) and 94.4% (89.3-97.1%) after FEVAR and BEVAR (NS). CONCLUSION: FEVAR and BEVAR are durable options for the treatment of complex aortic aneurysms and are associated with low renal morbidity, without differences between devices types. The clinical impact of decreasing renal volume over time in these patients is yet to be fully understood.

Benefits of Completion 3D Angiography Associated with Contrast Enhanced Ultrasound to Assess Technical Success after EVAR.

OBJECTIVES: This study evaluated a new strategy to assess technical success after standard and complex endovascular aortic repair (EVAR), combining completion contrast enhanced cone beam computed tomography (ceCBCT) and post-operative contrast enhanced ultrasound (CEUS). METHODS: Patients treated with bifurcated or fenestrated and branched endografts in the hybrid room during the study period were included. From December 2012 to July 2013, a completion angiogram (CA) was performed at the end of the procedure, and computed tomography angiography (CTA) before discharge (group 1). From October 2013 to April 2014, a completion ceCBCT was performed, followed by CEUS during the 30 day post-operative period (group 2). The rate of peri-operative events (type I or III endoleaks, kinks, occlusion of target vessels), need for additional procedures or early secondary procedures, total radiation exposure (mSv), and total volume of contrast medium injected were compared. RESULTS: Seventy-nine patients were included in group 1 and 54 in group 2. Peri-operative event rates were respectively 8.9% (n = 7) and 33.3% (n = 18) (p = .001). Additional procedures were performed in seven patients (8.9%) in group 1 versus 17 (31.5%) in group 2 (p = .001). Two early secondary procedures were performed in group 2 (3.7%), and three (3.8%) in group 1 (p = .978). Median radiation exposure due to CBCT was 7 Gy cm(2) (5.25-8) (36%, 27%, and 9% of the total procedure exposure, respectively for bifurcated, fenestrated, and branched endografts). CEUS did not diagnose endoleaks or any adverse events not diagnosed by ceCBCT. Overall radiation and volume of contrast injected during the patient hospital stay in groups 1 and 2 were 34 (25.8-47.3) and 11 (5-20.5) mSv, and 184 (150-240) and 91 (70-132.8) mL respectively (reduction of 68% and 50%, p < .001). CONCLUSIONS: Completion ceCBCT is achievable in routine practice to assess technical success after EVAR. Strategies to evaluate technical success combining ceCBCT and CEUS can reduce total in hospital radiation exposure and contrast medium volume injection.

The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair.

OBJECTIVE/BACKGROUND: Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage). METHODS: Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n = 43) and after (group 2, n = 161 patients) implementation of the modified implantation and peri-operative protocols were compared. RESULTS: Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2-77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53-65 mm]), and length of procedure (median 190 minutes [range 150-240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p = .09). The SCI rate was 14.0% versus 1.2% (p < .01). If type IV TAAAs were excluded from this analysis, the SCI rate was 25.0% (6/24 patients) in group 1 versus 2.1% (2/95 patients) in group 2 (p < .01). CONCLUSION: The early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri-operative management significantly reduces SCI following type I-III TAAA endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.

Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Controlled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac Aneurysms.

OBJECTIVES/BACKGROUND: ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus) is a prospective multicentre randomized controlled trial including consecutive patients with ruptured aorto-iliac aneurysms (rAIA) eligible for treatment by either endovascular (EVAR) or open surgical repair (OSR). Inclusion criteria were hemodynamic stability and computed tomography scan demonstrating aorto-iliac rupture. METHODS: Randomization was done by week, synchronously in all centers. The primary end point was 30 day mortality. Secondary end points were post-operative morbidity, length of stay in the intensive care unit (ICU), amount of blood transfused (units) and 6 month mortality. RESULTS: From January 2008 to January 2013, 107 patients (97 men, 10 women; median age 74.4 years) were enrolled in 14 centers: 56 (52.3%) in the EVAR group and 51 (47.7%) in the OSR group. The groups were similar in terms of age, sex, consciousness, systolic blood pressure, Hardman index, IGSII score, type of rupture, use of endoclamping balloon, and levels of troponin, creatinine, and hemoglobin. Delay to treatment was higher in the EVAR group (2.9 vs. 1.3 hours; p < .005). Mortality at 30 days and 1 year were not different between the groups (18% in the EVAR group vs. 24% in the OSR group at 30 days, and 30% vs. 35%, respectively, at 1 year). Total respiratory support time was lower in the EVAR group than in the OSR group (59.3 hours vs. 180.3 hours; p = .007), as were pulmonary complications (15.4% vs. 41.5%, respectively; p = .050), total blood transfusion (6.8 vs. 10.9, respectively; p = .020), and duration of ICU stay (7 days vs. 11.9 days, respectively; p = .010). CONCLUSION: In this study, EVAR was found to be equal to OSR in terms of 30 day and 1 year mortality. However, EVAR was associated with less severe complications and less consumption of hospital resources than OSR.

Total endovascular treatment of an aortic arch aneurysm in a patient with a mechanical aortic valve.

INTRODUCTION: Endovascular repair of aortic arch aneurysms using an inner-branched device is a new treatment option for patients unfit for open surgery. There are many anatomical restrictions, such as the presence of a mechanical aortic valve that can contraindicate this complete endovascular approach. REPORT: A new delivery system to overcome this issue has been developed. This new system was used to treat an aortic arch aneurysm 77 mm in diameter in a 37-year-old patient with Marfan's syndrome. The patient was considered to be at major risk for open surgery because of severe respiratory insufficiency following a second sternotomy. DISCUSSION: Total endovascular arch aneurysm repair is no longer contraindicated in patients with a mechanical aortic valve.

Impact of hybrid rooms with image fusion on radiation exposure during endovascular aortic repair.

OBJECTIVE: To evaluate exposure to radiation during endovascular aneurysm repair (EVAR) performed with intraoperative guidance by preoperative computed tomographic angiogram fusion. METHODS: All consecutive patients who underwent standard bifurcated (BIF) or thoracic (THO), and complex fenestrated (FEN) or branched (BR) EVAR were prospectively enrolled. Indirect dose-area product (DAP), fluoroscopy time (FT), and contrast medium volume were recorded. These data were compared with a previously published prospective EVAR cohort of 301 patients and to other literature. Direct DAP and peak skin dose were measured with radiochromic films. Results are expressed as median (interquartile range). RESULTS: From December 2012 to July 2013, 102 patients underwent standard (56.8%) or complex (43.2%) EVAR. The indirect DAP (Gy.cm(2)) was as follows: BIF 12.2 (8.7-19.9); THO 26.0 (11.9-34.9); FEN 43.7 (24.7-57.5); and BR 47.4 (37.2-108.2). The FT (min) was as follows: BIF 10.6 (9.1-14.7); THO 8.9 (6.0-10.5); FEN 30.7 (20.2-40.5); and BR 39.5 (34.8-51.6). The contrast medium volume (mL) was as follows: BIF 59.0 (50.0-75.0); THO 80.0 (50.0-100.0); FEN 105.0 (70.0-136.0); and BR 120.0 (100.0-170.0). When compared with a previous cohort, there was a significant reduction in DAP during BIF, FEN, and BR procedures, and a significant reduction of iodinated contrast volume during FEN and BR procedures. There was also a significant reduction in DAP during BIF procedures when compared with the literature (p < .01). DAP measurement on radiochromic films was strongly correlated with indirect DAP values (r(2) = .93). CONCLUSION: The exposure of patients and operators to radiation is significantly reduced by routine use of image fusion during standard and complex EVAR.

A new score to predict post operative complications after endovascular treatment of thoraco abdominal aortic aneurysms.

BACKGROUND: The endovascular treatment of thoraco abdominal aortic aneurysms (TAAA) is a minimally invasive solution. However, patient selection remains a major problem. We have analysed our experience to identify the risk factors for post-operative morbidity and mortality and to construct a scoring system to identify those patients likely to benefit from this treatment. METHODS: We have analysed a consecutive cohort of patients treated electively for TAAA using endovascular techniques between 2006 and October 2012. All data were collected prospectively. The risk factors associated with spinal cord ischemia (SCI), the need for post-operative dialysis and 30 day mortality were determined using multivariate statistical techniques and a logistic regression model including all variables that were significant on univariate analysis (p < 0.05). A predictive score was calculated using a Received Operating Characteristic (ROC) curve, defining best specificity and sensibility. RESULTS: We analysed the data from 123 patients (median age 70 years). The 30 day mortality rate was 8% (10 patients). The SCI rate was 6% (7 patients). One patient (1%) required long-term dialysis after the aortic procedure. The cumulative early mortality, SCI and permanent dialysis rate was 14% (17 patients). In multivariate analysis, adverse outcome was associated with advanced age (OR = 1.110 ; p = 0.022), and Crawford type I or II or III (OR = 9.292 ; p = 0.002) as compared with Crawford type IV. Pre-operative beta blocker (BB) treatment was a protective factor (OR = 0.099 ; p = 0.005). A predictive score was then constructed : Score = -10.060 + 0.104x(A) +2.229x(B) -2.315x(C) (A = patient age ; B = 1 if TAAA Crawford type 1, 2 or 3, 0 if TAAA type 4 ; C = 1 if on-going BB treatment (30 days pre-surgery minimum), 0 if none). Its sensitivity and specificity were 88% and 89% respectively. CONCLUSIONS: We propose a simple predictive scoring system. This tool is useful in predicting the most feared complications after endovascular TAAA repair and has potential use in the identification and counselling of vulnerable patients being considered for surgery. More data are needed to refine the prediction of individual operative risks.

Centerline is not as accurate as outer curvature length to estimate thoracic endograft length.

BACKGROUND: To assess the accuracy of the aortic outer curvature length for thoracic endograft planning. METHODS: Seventy-four patients (58 men, 66.4 ± 14 years) who underwent thoracic endovascular aortic repair between 2009 and 2011 treated with a Cook Medical endograft were enrolled in this retrospective study. Immediate postoperative CT scans were analysed using EndoSize software. Three vessel lengths were computed between two fixed landmarks placed at each end of the endograft: the straightline (axial) length, the centerline length and the outer curvature length. A tortuosity index was defined as the ratio of the centerline length/straightline length. A Student t test and a Pearson correlation coefficient were used to examine the results. RESULTS: We found a significant difference between the centerline length (135.4 ± 24 mm) and that of the endograft (160 ± 29 mm) (p < .0001). This difference correlates with the tortuosity index (r = .818, p < .0001), the endograft length (r = .587, p < .0001), and the diameter of the endograft (r = .53, p < .0001). However, the outer curvature length (161.3 ± 29 mm) and the endograft length (160 ± 29 mm) were similar (p = .792). CONCLUSION: The outer curvature length more accurately reflects that of the deployed endograft and may prove more accurate than centerlines in planning thoracic endografts.

An optimal combination for EVAR: low profile endograft body and continuous spiral stent limbs.

AIM: to evaluate the outcomes of EVAR performed with a new generation of bifurcated endografts and limbs. METHODS: prospectively collected data from fifty consecutive patients with abdominal aortic aneurysms (AAA) treated at our institution with a Low Profile Zenith(®) bifurcated body/Zenith(®) Spiral-Z legs combo were analysed. AngioCT scans and Ultrasound exams were performed prior to discharge. Ultrasound examination was repeated 6 months after the procedure to assess endograft patency and to depict endoleaks RESULTS: Median age was 70.6 years [50-88] and median ASA score was 3 [2-4]. Median aortic diameter was 56 mm [49-81]. Of the 100 external iliac access vessels, 14 had a diameter of 6 mm or lower. All endografts were successfully implanted. Post-operative Ultrasound examination and angioCT scan depicted both 1 type Ia, and 10 and 19 type 2 endoleaks respectively. An asymptomatic thrombosis of the left external iliac artery distal to the endograft limb was also depicted. 30-day mortality rate was 0%. Two patients died respectively three and four months after EVAR. Both deaths were not aneurysm related. All patients underwent an ultrasound exam 6-12 months after EVAR. All endografts main bodies and limbs were patent. Five endoleaks were depicted, all were type II endoleaks (the early type Ia endoleak had sealed spontaneously; it was confirmed by an angioCT scan). One patient presented a significant stenosis of the left iliac limb at the level of a narrow and calcified aortic bifurcation. It was successfully treated by bilateral iliac angioplasty and kissing balloon stenting. CONCLUSIONS: EVAR performed with the Zenith LP main body in combination with Spiral-Z Iliac Legs is safe and effective. No limb occlusions were diagnosed at the 6 month follow up even in challenging iliac anatomies usually considered as contra indications for EVAR. Our first results are most satisfying and calling to be completed by a longer follow up.

Endograft repair of complicated acute type B aortic dissections.

OBJECTIVES: This study aims to assess patient outcomes and aortic remodelling following coverage of the proximal entry tear with an endograft in complicated acute type B aortic dissections (caTBADs). MATERIAL AND METHODS: All patients with caTBAD treated with a thoracic endograft in three high-volume vascular centres were retrospectively studied. Inclusion criteria were branch-vessel malperfusion, impending or overt aortic rupture, maximal aortic diameter ≥ 40 mm and persistent pain or uncontrolled hypertension despite maximum pharmacological treatment. Postoperative aortic remodelling was evaluated using computed tomography angiography (CTA) on a three-dimensional (3D) imaging workstation. RESULTS: A total of 52 patients (71% male, median age 65 years) were included in the study. Median inclusion criteria per patient were 2 (range 1-4). Branch-vessel malperfusion was diagnosed in 42% and impending aortic rupture in 33% of 52 patients. Median follow-up was 25 months (range 2-109 months). The 30-day mortality rate was 9.6% (5/52); patient survival according to the Kaplan-Meier method was 90.4% at 12 months and 87.6% at 24 months. Secondary interventions were performed in seven patients a median of 3 days after the initial procedure (range 2-865). Imaging follow-up at 12 months was performed in 36 patients (69%): 75% presented stable or shrinking (> 5 mm) maximal aortic diameters and 86% had a completely thrombosed false lumen (vs. 5% before initial procedure) at thoracic level. CONCLUSION: Endograft treatment of complicated caTBAD is associated with favourable early outcomes and possibly promotes aortic remodelling in the majority of patients.

The benefits of EVAR planning using a 3D workstation.

OBJECTIVES: To evaluate the influence of planning endovascular aneurysm repair (EVAR) with a three-dimensional (3D) workstation on early and midterm outcomes. METHODS: All patients undergoing infrarenal EVAR performed between 2006 and 2009 at our institution were included in the current study. Prior to 2008 (group 1), endograft sizing was performed by interrogation of computed tomography angiography axial images. After 2008 (group 2), endograft sizing was routinely performed using a 3D workstation (Aquarius, Terarecon), allowing for multiplanar reconstruction and centerline analysis. Pre-, peri-, postoperative, and follow-up data were prospectively entered in an electronic database. All postoperative complications and subsequent secondary interventions depicted during the 2-year period following EVAR were compared. Secondary intervention and mortality rates were defined at 2 years and compared. Freedom from secondary intervention and overall survival rates were calculated using the Kaplan-Meier method during follow-up and compared by log-rank test. RESULTS: A total of 295 patients (149 patients in group 1 and 146 patients in group 2) were included. All patients had completed a minimum of 2 years of follow-up. During this 2-year period following EVAR, the type 1 endoleak rate was 8.7% in group 1 and 1.4% in group 2 (p = .004) respectively. Secondary intervention rates related to type 1 endoleak was 5.4% in group 1 and 0 in group 2 (p < .001). No difference was observed regarding all-cause mortality, aneurysm-related death, and freedom from secondary intervention rates during follow-up. CONCLUSION: The routine use of 3D workstations for EVAR planning significantly reduces the rate of type 1 endoleaks and, therefore, the rate of related secondary interventions.

Evaluation of radiation during EVAR performed on a mobile C-arm.

BACKGROUND: The aim of this study was to evaluate radiation exposure during aortic endovascular aneurysm repair (EVAR) on a mobile C-arm using a low dose and pulse mode. METHODS: We performed a retrospective analysis of a prospectively maintained database on patients undergoing EVAR. Indirect dose measurements of dose area product (DAP, mGy m²) calculated by the C-arm (OEC 9900MD), fluoroscopic time (FT), type of procedure, contrast media volume and body mass index were analysed. To confirm the correlation between direct and indirect DAP measurements, direct dose was measured with radiochromic films on a sample of 15 patients. Film grey level response was calibrated according to a reference dose measurement performed with a calibrated dosimeter. DAP and peak skin dose (PSD, Gy) were measured on each film. Correlation between DAP from direct and indirect measures, and between DAP and PSD, were analysed. RESULTS: From January 2009 to April 2011, 335 patients underwent EVAR. Complete data were available on 301 procedures including 188 bifurcated, 54 fenestrated, 28 thoracic, 20 branched and 11 aorto-uni-iliac endografts implantation. The respective median FT and DAP was 9.36 min (1.8-67) and 3 mGy m(2) (0.4-28); 27.2 min (2-69) and 7.3 mGy m(2) (1.2-29); 7.75 min (1.2-19.1) and 2 mGy m(2) (0.3-11); 42.98 min (2.4-95.4) and 15.95 mGy m(2) (2.98-77.7); 6.2 min (0.5-36.3) and 2 mGy m(2) (0.3-11). Direct DAP measurement on radiochromic films was strongly correlated with DAP values provided by the C-arm (r = 0.98). PSD correlated weakly with DAP. DAP was significantly increased (p < 0.001) in patients with a body mass index >30. Contrast media volume was significantly increased in the branched endograft group. CONCLUSION: Indirect DAP values measured by the C-arm are accurate to evaluate radiation exposure. Compared to the literature, our values for standard procedures are significantly decreased by the usage of low dose and pulse mode. DAP for fenestrated and branched procedures was comparable to published DAP values with standard procedures using a regular fluoroscopic mode.

Development of off-the-shelf stent grafts for juxtarenal abdominal aortic aneurysms.

INTRODUCTION: The use of EVAR for more complex aneurysm anatomy has become more widespread over the past decade. Fenestrated and branched stent grafts for the visceral and iliac segment show promising short- and midterm outcome and these procedures have become routine in many vascular centers. However, at present, such grafts are customized to the individual patient and planning and manufacturing leads to significant treatment delay subjecting the patients to the risk of rupture during the waiting period. The purpose of this report is to describe the first experience in treating juxta/suprarenal aneurysms using the first version of a new fenestrated stent graft MATERIAL AND METHODS: A fenestrated device was designed with two renal fenestrations, an SMA fenestration and a scallop for the coeliac artery. The renal arteries were designed with an inner 6 mm fenestration and an outer 15 mm diameter creating a dome to allow renal artery catheterization for a range of renal artery distribution. Seven patients with complex visceral artery anatomy were treated with customized stent grafts containing these pivot renal fenestrations. RESULTS: Technical success was uniform with 100% target vessel catheterization and 0% 30-day mortality. In one case, the graft was displaced slightly during delivery resulting in a renal artery stent occlusion at 2 months postoperatively. CONCLUSIONS: The development of a modified fenestrated device has shown this to be feasible and it has the potential to reduce the need for extensive preoperative graft customization and establishing a true off the shelf platform for juxta- and suprarenal AAA.