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

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

Image Guidance Techniques and Treatment Approach Optimization in the Management of Type-II Endoleak After Endovascular Aortic Aneurysm Repair.

BACKGROUND: Over the past 3 decades endovascular aortic aneurysm repair emerged as the primary approach for abdominal aortic aneurysm management, however the occurrence of endoleak following endograft implantation imposes a high toll on patients and hospitals alike. The early diagnosis and appropriate treatment of endoleaks is associated with better outcomes, which calls for more advanced imaging and a standardized approach for endoleak diagnosis and management following endovascular aortic aneurysm repair. Although conventional strategy with non-targeted deployment of coils and embolic material in the aneurysm sac is considered to be the standard approach in many hospitals, it may not prove to be a viable option, given that it affects any further follow-up imaging in the event of sub-optimal therapy and consequent recurrence. METHODS: Based on our tertiary aortic referral center experience we summarize and describe strategies for optimal selection of various treatment approaches for Type-II Endoleak management including endovascular, percutaneous and laparoscopic approaches with particular focus on intraoperative image guidance techniques. RESULTS: After failed conventional endovascular embolization attempt we recommend specific complex type II endoleak management approaches based on the location of the endoleak within the aneurysm sac along the x, y and z axis. A transabdominal or laparoscopic approach enable treatment in endoleaks located in the anterior portion of the sac. Endoleaks in the posterior portion of the sac could be treated using the transcaval or the translumbar approach, depending on whether the endoleak is situated on the left or the right side. Alternative strategies should be considered if patient anatomy does not allow for either transcaval or translumbar approach. The transgraft technique is reserved for endoleaks located in the cranial portion of the sac, while the perigraft approach could present a means of treatment for endoleaks situated in the caudal portion of the aneurysm sac. CONCLUSION: We encourage establishing a patient specific treatment plan in accordance with individual anatomy based on cross sectional imaging modality (time resolved dynamic imaging in selected cases) and intraoperative image guidance to provide a safe and accurate endoleak localization and embolization for patients undergoing type II endoleak treatment.

Integration of a Custom-Made Fenestration to Simplify Acute Reno-Visceral In Situ Aortic Repair.

PURPOSE: To illustrate the technique of antegrade in situ laser fenestration (ISLF) on a predesign custom-manufactured stent-graft with single reinforced fenestration for use in emergency endovascular repair of complex abdominal aortic aneurysms (AAAs). TECHNIQUE: A short custom-made device (CMD) fenestrated graft was predesigned with a single preloaded 8 mm strut-free fenestration at 12 o'clock position. A modified preloaded system was used to allow unilateral access from the distal port if necessary. After bilateral percutaneous femoral access, the graft was deployed under fusion guidance with the CMD fenestration matching the superior mesenteric artery (SMA) origin and immediately bridged as per standard technique. The aneurysm was then excluded with a bifurcated device. A large steerable sheath was used to allow for sequential antegrade laser in situ fenestration and stenting of the renal arteries. CONCLUSIONS: Single-vessel customized short fenestrated grafts for the SMA and antegrade in situ laser renal fenestrations are technically feasible for repair of acute complex AAAs even after previous infrarenal reconstruction. It could become an off-the-shelf solution to limit aortic coverage and reno-visceral ischemia, even in patients with a narrow aortic diameter at the renal level. CLINICAL IMPACT: Single-vessel precustomized short fenestrated grafts for the SMA combined with renal artery antegrade ISLF can be a feasible option for the acute repair of patients with complex aneurysms and a narrow aortic diameter at the reno-visceral segment. It may limit aortic coverage and reno-visceral ischemic time and also be applicable after previous infrarenal endovascular aneurysm repair (EVAR).

Dynamic, Time-Resolved CT Angiography After EVAR: A Quantitative Approach to Accurately Characterize Aortic Endoleak Type and Identify Inflow Vessels.

PURPOSE: Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis. METHODS: Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified. RESULTS: A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds. CONCLUSION: Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.

Sex-Specific Morphometric Analysis of Ascending Aorta and Aortic Arch for Planning Thoracic Endovascular Aortic Repair: A Retrospective Cohort Study.

OBJECTIVE: In many studies on aortic disease, women are underrepresented. The present study aims to assess sex-specific morphometric differences and gain more insight into endovascular treatment of the ascending aorta (AA) and arch. METHODS: Electrocardiogram-gated cardiac computed tomography scans of 116 consecutive patients who were evaluated for transcatheter aortic valve replacement were retrospectively reviewed. Measurements of the AA and aortic arch were made in multiplanar views, perpendicular to the semi-automatic centerline. Multiple linear regression analysis was performed to identify predictors affecting AA and aortic arch diameter in men and women. Propensity score matching was used to investigate whether sex influences aortic morphology. RESULTS: In both sexes, body surface area (BSA) was identified as a positive predictor and diabetes as a negative predictor for aortic diameters. In men, age was identified as a positive predictor and smoking as a negative predictor for aortic diameters. Propensity score matching identified 40 pairs. Systolic and diastolic mean diameters and AA length were significantly wider in men. On average, male aortas were 7.4% wider than female aortas, both in systole and diastole. CONCLUSIONS: The present analysis demonstrates that, in women, increased BSA is associated with increased aortic arch diameters, while diabetes is associated with decreased AA and arch diameters. In men, increased BSA and age are associated with increased AA and arch diameters, while smoking and diabetes are associated with decreased AA and arch diameters. Men were confirmed to have 7.4% greater AA and arch diameters than women. CLINICAL IMPACT: Men had 7.4% greater ascending aorta and arch diameters than women in a retrospective cohort, gated computed tomography-based study of 116 patients. Sex-specific differences in ascending aortic and arch size should be considered by aortic endovascular device manufacturers and physicians when developing ascending and arch endografts and planning aortic interventions.

Dynamic Computed Tomography Angiography is More Accurate in Diagnosing Endoleaks than Standard Triphasic Computed Tomography Angiography and Enables Targeted Embolization.

BACKGROUND: The primary objective was to compare the accuracy of dynamic computed tomography (CT) angiography (d-CTA) with standardized triphasic contrast enhanced CT angiography (t-CTA) in diagnosing endoleak type after endovascular aortic repair (EVAR) using digital subtraction angiography (DSA) as reference standard. The secondary objective was to study the impact of d-CTA on image fusion-guided endoleak embolization. METHODS: A retrospective review of patients who underwent d-CTA imaging after EVAR between March 2019 and July 2021 was performed. Deidentified images were independently reviewed by two-two blinded readers to document endoleak type and target vessels. An impact of d-CTA-guided embolization was evaluated by a number of planning angiograms, radiation exposure, and accuracy of target vessel overlay. RESULTS: During the study period, 52 patients underwent d-CTA and 19 had all 3 modalities available for analysis. DSA imaging confirmed 4 (21.0%) type-I, 14 (73.7%) type-II, and 1 (5.3%) type-III endoleak. Findings from d-CTA matched with DSA in 19/19 cases (100%), whereas t-CTA matched in 14/19 cases (73.7%). In type-II endoleaks, the number of target vessels identified by d-CTA, t-CTA, and DSA were 23, 17, and 16, respectively. Mean dose-length product from d-CTA and t-CTA was 1,445 ± 551 and 1,612 ± 530 mGy × cm (P = 0.26). Nine patients underwent d-CTA-guided type-II endoleak embolization, using a median of 1 (range: 1-4) planning angiogram before embolization using 21.6 (± 8.7)% of total procedural radiation dose. Target vessel overlay was accurate in 9/9 (100%) cases. CONCLUSIONS: Dynamic, time-resolved CTA is more accurate compared to standardized triphasic contrast enhanced CTA in diagnosing endoleak type after EVAR. In type-II endoleak, d-CTA better identified target vessels and enabled safe, targeted embolization.

Dynamic, Time-Resolved Computed Tomography Angiography Technique to Characterize Aortic Endoleak Type, Inflow and Provide Guidance for Targeted Treatment.

PURPOSE: To illustrate dynamic, time-resolved CTA (d-CTA) imaging technique in characterizing aortic endoleak type/inflow using quantitative parameters and its value in providing image guidance for targeted treatment approach. TECHNIQUE: Dedicated endoleak protocol involved acquiring multiple time-resolved contrast enhanced scans using third-generation CT scanner (Somatom Force®, Siemens Healthineers). Parameters such as scan field of view (FOV), kV, number/timing of scans were customized based on patient's body-mass-index, timing bolus, and prior imaging findings. D-CTA image datasets were evaluated qualitatively and quantitatively using time-attenuation curves (TAC) analysis after motion correction using a dedicated software (syngo.via®, Siemens). D-CTA findings from 4 illustrative cases demonstrating type I, type II (inferior mesenteric and lumbar artery inflow), and type III endoleak were illustrated. TAC analysis with time to peak parameter enabled better characterization of endoleak type and inflow. During endoleak intervention, target vessels from d-CTA images were electronically annotated and overlaid on fluoroscopy using 2D-3D image fusion to provide image guidance for targeted treatment. CONCLUSION: D-CTA imaging with TAC analysis characterizes aortic endoleak type and inflow, in addition to providing image guidance for targeted endoleak treatment. Such dynamic, time-resolved imaging techniques may provide further insights into understanding aortic endoleak that remains an Achilles heel for endovascular aortic aneurysm repair.

Added Value of Selective Intra-arterial Cone-Beam CT Angiography in the Management of Visceral Artery Aneurysms.

PURPOSE: The aim of this study is to evaluate the value of selective intra-arterial cone-beam computed tomography angiography (CBCTA) relative to conventional computed tomography angiography (CTA) in understanding visceral artery aneurysm (VAA) morphology, and its impact on treatment planning. MATERIALS AND METHODS: Between January 2017 and August 2021, all patients who had a diagnosis of VAA and underwent intraoperative CBCTA imaging were retrospectively reviewed. Impact on treatment decisions, optimal C-arm angulations derived from CBCTA, and additional radiation exposure were reported. Two blinded independent reviewers qualitatively reviewed CBCTA and conventional CTA images. A 5-point Likert scale (1=poor image quality, 5=excellent image quality) was used to assess the overall image quality of each modality. Number of vessels arising from the aneurysm sac was counted. RESULTS: A total of 16 patients had a diagnosis of VAA during the study period, of whom 10 patients had intraoperative CBCTA and conventional CTA available for review. Out of 10 patients, 7 underwent successful endovascular treatment, 2 were deemed not amenable for endovascular embolization based on intraoperative CBCTA findings, and 1 had resolved pseudoaneurysm. Total fluoroscopy time and radiation dose (dose area product [DAP] and skin dose) for all procedures were 27.7 ± 19.9 minutes, 28 362 (±18 651) µGy*m2, and 1879 (±1734) mGy, respectively. Radiation exposure from CBCTA (DAP and skin dose) was 5703 (±3967) µGy*m2 and 223.6 (±141.3) mGy, respectively. In patients who underwent endovascular treatment, the proportional DAP from CBCTA was 18.3% (±15.3%) of the total procedural radiation dose. Qualitative rating of overall image quality of CBCTA images was superior to CTA images (mean score: 4.55 vs 3, p<0.001). More branch vessels arising from the VAA were identified by all reviewers in CBCTA as compared with conventional CTA (median, min-max: 3, 0-4 vs 2,1-3 vessels). CONCLUSION: Intraoperative CBCTA after selective intra-arterial contrast injection, with better spatial resolution, provided better delineation of visceral aneurysm morphology as compared with conventional, intravenous CTA and enabled optimal treatment planning at a reasonable additional radiation exposure. CLINICAL IMPACT: Visceral artery aneurysms (VAA) are often diagnosed incidentally by conventional computed tomographic angiography (CTA). Endovascular treatment typically requires selective angiographies at multiple projections to better understand aneurysm morphology, location, and efferent branch vessels. Intra-arterial cone-beam CT angiography (CBCTA) for VAA has the advantage of selective contrast opacification, better spatial resolution, and three-dimensional/multi-planar visualization of aneurysm morphology. In addition, CBCTA enables identification of optimal C-arm working projection for subsequent endovascular treatment. The aim of this study is to evaluate the value of intraoperative CBCTA relative to conventional CTA in understanding visceral artery aneurysm morphology and its impact on treatment planning.

Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics.

PURPOSE: Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. MATERIALS AND METHODS: Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. RESULTS: Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. CONCLUSIONS: Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. CLINICAL IMPACT: Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.

Transcarotid access for remote robotic endovascular neurointerventions: a cadaveric proof-of-concept study.

OBJECTIVE: The purpose of this proof-of-concept study was to demonstrate the setup and feasibility of transcarotid access for remote robotic neurointerventions in a cadaveric model. METHODS: The interventional procedures were performed in a fresh-frozen cadaveric model using an endovascular robotic system and a robotic angiography imaging system. A prototype remote, robotic-drive system with an ethernet-based network connectivity and audio-video communication system was used to drive the robotic system remotely. After surgical exposure of the common carotid artery in a cadaveric model, an 8-Fr arterial was inserted and anchored. A telescopic guiding sheath and catheter/microcatheter combination was modified to account for the "workable" length with the CorPath GRX robotic system using transcarotid access. RESULTS: To simulate a carotid stenting procedure, a 0.014-inch wire was advanced robotically to the extracranial internal carotid artery. After confirming the wire position and anatomy by angiography, a self-expandable rapid exchange nitinol stent was loaded into the robotic cassette, advanced, and then deployed robotically across the carotid bifurcation. To simulate an endovascular stroke recanalization procedure, a 0.014-inch wire was advanced into the proximal middle cerebral artery with robotic assistance. A modified 2.95-Fr delivery microcatheter (Velocity, Penumbra Inc.) was loaded into the robotic cassette and positioned. After robotic retraction of the wire, it was switched manually to a mechanical thrombectomy device (Solitaire X, Medtronic). The stentriever was then advanced robotically into the end of the microcatheter. After robotic unfolding and short microcatheter retraction, the microcatheter was manually removed and the stent retriever was extracted using robotic assistance. During intravascular navigation, the device position was guided by 2D angiography and confirmed by 3D cone-beam CT angiography. CONCLUSIONS: In this proof-of-concept cadaver study, the authors demonstrated the setup and technical feasibility of transcarotid access for remote robot-assisted neurointerventions such as carotid artery stenting and mechanical thrombectomy. Using transcarotid access, catheter length modifications were necessary to achieve "working length" compatibility with the current-generation CorPath GRX robotic system. While further improvements in dedicated robotic solutions for neurointerventions and next-generation thrombectomy devices are necessary, the transcarotid approach provides a direct, relatively rapid access route to the brain for delivering remote stroke treatment.

Multistage Endovascular Management of an Aortic Aneurysm Rupture into the Retroaortic Left Renal Vein.

Aortic aneurysm rupture into the retroaortic left renal vein (RALRV) is an uncommon phenomenon. We herein present the case of a 66-year-old man with left flank pain, hematuria, fever, and symptoms of acute right-sided heart failure. Computed tomography angiography (CTA) demonstrated an 83-mm infrarenal aortic aneurysm with a fistula in between the aorta and the RALRV. The patient underwent an urgent endovascular aneurysm repair and a proximal cuff extension due to type Ia endoleak. In the early postoperative period, transcaval coil embolization was performed, 3 months later repeated CTA revealed recanalized fistula, after fluid embolization and vascular plug implantation control CTA showed no sign of endoleak. The patient recovered uneventfully, 1-year follow-up CTA demonstrated aneurysm shrinkage and no sign of endoleak.

Vascular e-Learning During the COVID-19 Pandemic: The EL-COVID Survey.

BACKGROUND: The corona virus disease (COVID-19) pandemic has radically changed the possibilities for vascular surgeons and trainees to exchange knowledge and experience. The aim of the present survey is to inventorize the e-learning needs of vascular surgeons and trainees as well as the strengths and weaknesses of vascular e-Learning. METHODS: An online survey consisting of 18 questions was created in English, with a separate bilingual English-Mandarin version. The survey was dispersed to vascular surgeons and trainees worldwide through social media and via direct messaging from June 15, 2020 to October 15, 2020. RESULTS: Eight hundred and fifty-six records from 84 different countries could be included. Most participants attended several online activities (>4: n = 461, 54%; 2-4: n = 300, 35%; 1: n = 95, 11%) and evaluated online activities as positive or very positive (84.7%). In deciding upon participation, the topic of the activity was most important (n = 440, 51.4%), followed by the reputation of the presenter or the panel (n = 178, 20.8%), but not necessarily receiving accreditation or certification (n = 52, 6.1%). The survey identified several shortcomings in vascular e-Learning during the pandemic: limited possibility to attend due to lack of time and increased workload (n = 432, 50.5%), no protected/allocated time (n = 488, 57%) and no accreditation or certification, while technical shortcomings were only a minor problem (n = 25, 2.9%). CONCLUSIONS: During the COVID-19 pandemic vascular e-Learning has been used frequently and was appreciated by vascular professionals from around the globe. The survey identified strengths and weaknesses in current e-Learning that can be used to further improve online learning in vascular surgery.

The effects of changing meteorological parameters on fatal aortic catastrophes.

BACKGROUND: Over the span of the last decade, medical research has been increasingly putting greater emphasis on the study of meteorological parameters due to their connection to cardiovascular diseases. The main goal of this study was to explore the relationship between fatal aortic catastrophes and changes in atmospheric pressure and temperature. METHODS: We used a Cox process model to quantify the effects of environmental factors on sudden deaths resulting from aortic catastrophes. We used transfer entropy to draw conclusion about the causal connection between mortality and meteorological parameters. Our main tool was a computer program which we developed earlier in order to evaluate the relationship between pulmonary embolism mortality and weather on data sets comprised of aortic aneurysm (AA) and acute aortic dissection (AAD) cases, where one of these two medical conditions had led to fatal rupture of the aorta. Our source for these cases were the autopsy databases of Semmelweis University, from the time period of 1994 to 2014. We have examined 160 aneurysm and 130 dissection cases in relation to changes in meteorological parameters. The algorythm implemented in our program is based on a non-parametric a Cox process model. It is capable of splitting slowly varying unknown global trends from fluctuations potentially caused by weather. Furthermore, it allows us to explore complex non-linear interactions between meteorological parameters and mortality. RESULTS: Model measures the relative growth of the expected number of events on the nth day caused by the deviation of environmental parameters from its mean value. The connection between ruptured aortic aneurysms (rAA) and changes in atmospheric pressure is more significant than their connection with mean daily temperatures. With an increase in atmospheric pressure, the rate of rAA mortality also increased. The effects of meteorological parameters were weaker for deaths resulting from acute aortic dissections (AAD), although low mean daily temperatures increased the intensity of occurrence for AAD-related deaths. CONCLUSION: The occurrence rate of fatal aortic catastrophes showed a slight dependence on the two examined parameters within our groups.

[The effect of alternating meteorological parameters on fatally ruptured aortic aneurysms (autopsy-based data)]. / Meteorológiai paraméterek változásának hatása a halálos kimenetelu aortaaneurysma-rupturákra.

INTRODUCTION: There are several statements about the connection between cardiovascular diseases and climate change. On behalf of our observation-based knowledge we hypothesized a relationship between the occurence of aortic aneurysm (AA) rupture and weather changes. AIM: The purpose of our study was to explore the relationship between fatal aortic catastrophe and changes in atmospheric pressure and temperature. By using a new method we could even measure the intensity of the connection. METHOD: We have developed a software earlier to examine the link between pulmonary embolism mortality and the weather on data sets comprised of aortic aneurysm cases, where the medical condition had led to the fatal rupture of the aorta. For the events mentioned earlier we used the autopsy database of Semmelweis University between January 1, 2005 and January 1, 2014. Altogether we examined 152 aneurysm-related aortic catastrophes. We reported the exact day of the incident and the weather conditions on that day and the day before. RESULTS AND CONCLUSION: We have defined that the occurrence rate of fatal aortic catastrophe showed a slight dependence on the two examined parameters within our groups. We have found the connection related to ruptured aortic aneurysm and changes in atmospheric pressure more significant than their connection with mean daily temperatures. With the increase in atmospheric pressure, the rate of AA mortality also increased. In the knowledge of our results we believe that the mathematical model we used can be an effective starting point for population-based and prospective studies. Orv Hetil. 2018; 159(37): 1501-1505.

[Role of the homograft bypass in extremity inferior's reconstructions]. / Homograftok szerepe az alsó végtagi érrekonstrukciókban.

INTRODUCTION: Vascular homografts are used for limb salvage in cases of graft infection after previous reconstructive vascular surgery or inadequate autologous veins. During multi-organ donation the thoracic aorta segment, aortic bifurcation, iliac arteries, femoral arteries, popliteal arteries, femoral veins and greater saphenous veins can be harvested. Our aim was to optimize the use of homografts by analyzing the results of previous procedures. METHODS: The patient information was processed retrospectively, using the clinical computer system. 162 procedures were performed on 144 patients between 2007 and 2014. The short- and long-term patency, hemorrhagic complication rate, amputation rate and mortality was examined in our study. The location, graft type and length of cryopreservation were taken into consideration. Aortoiliac and femoropopliteal reconstructions with arterial and venous homografts were examined. RESULTS: The mean age of the patients was 63.6 ± 10.7 years, the mean follow-up period was 36 ± 28 months. The primary patency rates at the postoperative 1, 3 and 6 months were 83.7%, 75.0% and 63.4%. In this study the arterial and deep venous homografts had better primary patency rates compared to the superficial venous homografts: at the postoperative 1, 3, 6 months the arterial homograft results were 85.6%, 78.6% and 74.3%, the greater saphenous vein homograft results were 81.4%, 70.4% and 47.7% in the same intervals. CONCLUSION: The reconstructive surgical procedures in septic area mean serious challenge for the vascular surgeons. The AB0 compatibility of the graft and the recipient did not result better long-term outcomes compared to the non-compatible grafts. According to our data the ideal choice of homogenous graft is an arterial homograft which was not cryopreserved longer than 6 months.

Dynamic Imaging of Aortic Pathologies: Review of Clinical Applications and Imaging Protocols.

The past decade has seen significant advances in dynamic imaging of the aorta. Today's vascular surgeons have the opportunity to choose from a wide array of imaging modalities to evaluate different aortic pathologies. While vascular ultrasound and aortography are considered to be the bread and butter imaging modalities, newer dynamic imaging techniques provide time-resolved information in various aortic pathologies. However, despite growing evidence of their advantages in the literature, they have not been routinely adopted. In order to understand the role of these emerging modalities, one must understand their principles, advantages, and limitations in the context of various clinical scenarios. In this review, we provide an overview of dynamic imaging techniques for aortic pathologies and describe various dynamic computed tomography and magnetic resonance imaging protocols, clinical applications, and potential future directions.

Radiation Exposure Reduction by Digital Variance Angiography in Lower Limb Angiography: A Randomized Controlled Trial.

BACKGROUND: digital variance angiography (DVA) provides higher image quality than digital subtraction angiography (DSA). This study investigates whether the quality reserve of DVA allows for radiation dose reduction during lower limb angiography (LLA), and compares the performance of two DVA algorithms. METHODS: this prospective block-randomized controlled study enrolled 114 peripheral arterial disease patients undergoing LLA into normal dose (ND, 1.2 µGy/frame, n = 57) or low-dose (LD, 0.36 µGy/frame, n = 57) groups. DSA images were generated in both groups, DVA1 and DVA2 images were generated in the LD group. Total and DSA-related radiation dose area product (DAP) were analyzed. Image quality was assessed on a 5-grade Likert scale by six readers. RESULTS: the total and DSA-related DAP were reduced by 38% and 61% in the LD group. The overall visual evaluation scores (median (IQR)) of LD-DSA (3.50 (1.17)) were significantly lower than the ND-DSA scores (3.83 (1.00), p < 0.001). There was no difference between ND-DSA and LD-DVA1 (3.83 (1.17)), but the LD-DVA2 scores were significantly higher (4.00 (0.83), p < 0.01). The difference between LD-DVA2 and LD-DVA1 was also significant (p < 0.001). CONCLUSIONS: DVA significantly reduced the total and DSA-related radiation dose in LLA, without affecting the image quality. LD-DVA2 images outperformed LD-DVA1, therefore DVA2 might be especially beneficial in lower limb interventions.

Initial experiences with percutaneous endovascular aortic reconstruction / Percutan endovascularis aortarekonstrukcióval szerzett kezdeti tapasztalataink

Introduction: Percutaneous aortic reconstruction is another milestone in aortic surgery. The evolution of vascular closure devices played a key role by enabling arterial closure after large -bore endovascular devices without the need of arterial cut -down.Objective: Our objective was to determine technical success of percutaneous endovascular aortic repair and to report our initial experience using this technique in a Hungarian cohort.Method: Between 15 October 2020 and 21 March 2021, patients who underwent endovascular aortic reconstruction were prospectively and consecutively collected. Patients who were deemed suitable for common femoral artery per cutaneous access were enrolled to the study. Technical success, access -site complications and risk factors were ana- lyzed.Results: A total of 43 patients underwent endovascular aortic reconstruction during the study period, of whom 38 were deemed feasible for percutaneous repair. Dominantly infrarenal aortic aneurysms were treated (n = 26, 68.4%). After ultrasound -guided access, suture -mediated devices were used 2 (1-4) per artery (median, min-max) for clo- sure. Technical success was reported in 37 out of 38 cases (97.4%). Access site complication was reported in 3 (7.9%) cases. The mean (+/- SD) in -hospital stay was 4.9 (+/- 1.7) days. Out of the 3 cases, 1 required intraoperative femoral cut-down. Sheath-size larger than 18 Fr (1.26, 0.09-17.75, 0.862) and body mass index (1.17, 0.923-1.5, 0.19) were positively associated with access site complication but no significant correlation was reported (OR, 95% CI, p- value). However, in patients with larger than 30 kg/m2 body mass index (n = 12), access-related complication was significantly higher than in smaller patients (p = 0.008).Conclusion: Percutaneous endovascular aortic repair is a promising and safe option that has a high technical success rate in patients deemed eligible for common femoral artery access.