Total aortic arch repair with double-fenestrated physician-modified endografts, at least 3-year follow-up.

OBJECTIVE: This study aims to report the efficacy and safety of double-fenestrated physician-modified endovascular grafts (PMEGs) for total aortic arch repair with at least 3 years of follow-up. METHODS: All consecutive patients with a pathological aortic arch who underwent aortic arch repair combined with a homemade double-fenestrated stent graft from 2017 to 2020 were reviewed. RESULTS: 74 patients were treated for pathological arch conditions with a double-fenestrated PMEG. Of these, 81% were male, the mean age was 69.9 years, and 59% were classified as American Society of Anesthesiology 3 or 4. Thirty-five percent were treated for a postdissection aneurysm, 36% for a degenerative aneurysm, and 14% for acute type B dissection. Fifteen percent had supra-aortic trunk dissection. Fenestration on the subclavian artery was performed in 96%; if not, a carotid-subclavian bypass was carried out. Technical success was 100%. The proximal landing zone is consistently in zone 0. Early outcomes revealed a 3% occurrence of type 1 endoleak, which was successfully treated by prompt reintervention. One retrograde dissection occurred, and one patient died from hemorrhage on an iliac conduit. A 5% stroke rate was reported. During long-term follow-up (mean time 40.7 months), one type 1 endoleak appeared and was successfully treated; no type 2 or type 3 endoleak requiring intervention occurred. No stent fractures or migrations were reported. Four percent of patients required reintervention, but no surgical conversion to open surgical repair was needed on the aortic arch. No patient died from a cause related to the main procedure. CONCLUSIONS: Total aortic arch repair with double-fenestrated PMEGs is associated with acceptable early and midterm major morbidity and mortality. It is suitable for the main aortic pathologies. Moreover, it is easily available for emergency situations.

Ex Vivo Comparison of the Elastic Properties of Vascular Substitutes Used for Pulmonary Artery Replacement.

INTRODUCTION: Study aims were to evaluate the elastic properties of vascular substitutes frequently used for pulmonary artery (PA) replacement, and then to compare their compliance and stiffness indexes to those of human PA. METHODS: A bench-test pulsatile flow experiment was developed to perfuse human cadaveric vascular substitutes (PA, thoracic aorta, human pericardial conduit), bovine pericardial conduit, and prosthetic vascular substitutes (polytetrafluorethylene and Dacron grafts) at a flow and low pulsed pressure mimicking pulmonary circulation. Intraluminal pressure was measured. An ultrasound system with an echo-tracking function was used to monitor vessel wall movements. The diameter, compliance, and stiffness index were calculated for each vascular substitute and compared to the human PA at mean pressures ranging from 10 to 50 mmHg. RESULTS: The compliance of the PA and the thoracic aorta were similar at mean physiological pressures of 10 mmHg and 20 mmHg. The PA was significantly less compliant than the aorta at mean pressures above 30 mmHg (P = 0.017). However, there was no difference in stiffness index between the two substitutes over the entire pressure range. Compared to the PA, human pericardial conduit was less compliant at 10 mmHg (P = 0.033) and stiffer at 10 mmHg (P = 0.00038) and 20 mmHg (P = 0.026). Bovine pericardial conduit and synthetic prostheses were significantly less compliant and stiffer than the PA for mean pressures of 10, 20, and 30 mmHg. There were no differences at 40 and 50 mmHg. CONCLUSIONS: Allogenic arterial grafts appear to be the most suitable vascular substitutes in terms of compliance and stiffness for PA replacement.

Acute Type B Aortic Dissection: Insights From a Single-Center Retrospective Experience Over 12 Years.

INTRODUCTION: The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group. MATERIALS AND METHODS: Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group. RESULTS: Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups. CONCLUSION: This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm. CLINICAL IMPACT: This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.

Ascending Aorta Anastomotic Aneurysm Exclusion with Double-Fenestrated PMEG after Open Repair.

BACKGROUND: The objective of this case series is to investigate the outcomes of double-fenestrated physician-modified endografts (PMEGs) in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement. METHODS: All consecutive patients with a distal anastomotic aneurysm after open ascending aorta surgery who underwent aortic arch repair with a homemade double-fenestrated stent-graft from 2017 to 2023 were reviewed. Study endpoints included technical success, 30-day, and long-term follow up analysis of mortality, morbidity, and reinterventions. RESULTS: 10 patients were treated with double-fenestrated PMEGs for anastomotic aneurysms after open surgery of the ascending aorta. Of these, 9 were male with a mean age of 58 years. Nine patients were initially treated for acute dissection, and 2 had mechanical aortic valves. The mean time between open surgery and the treatment of the pseudoaneurysm was 4.15 years. Technical success was 100%. The proximal landing zone was consistently in zone 0, and all endografts were deployed via femoral access. Early outcomes revealed one endoleak (type 1a), which was successfully treated by prompt reintervention. No deaths or strokes occurred during the early postoperative period. During long-term follow up (mean time 35 months), no endoleaks requiring intervention occurred, and there were no reports of stent fractures or migrations. No patient died from an aortic-related cause. CONCLUSIONS: Aortic arch repair with double-fenestrated PMEGs for distal anastomotic aneurysms after open surgery is feasible and represents a promising alternative in patients ineligible for redo surgery.

Zone 2 Aortic Arch Repair With Single-Fenestrated Physician-Modified Endografts, at Least 3 Years of Follow-up.

OBJECTIVE: The aim of this study is to report the efficiency and safety of single-fenestrated physician-modified endografts (PMEGs) in zone 2 aortic arch pathologies with at least 3 years of follow-up. METHODS: All consecutive patients with a pathological aortic arch who underwent aortic repair combined with homemade single-fenestrated stent-graft from 2015 to 2020 were reviewed. The patients with a target vessel different from the left subclavian artery (LSA) were excluded. RESULTS: A total of 63 patients were treated for a pathological arch in zone 2 with a single-fenestrated PMEG. 73% were male, and the mean age was 65 years old. 25% were treated for a degenerative aneurysm, 19% for a post dissection aneurysm and 24% for an acute type B dissection. 52% of the patients were treated as an emergency and half of those for an aortic rupture. The LSA fenestration was stented in 70%. During 30 days of follow-up, 2 strokes (3%) were reported, 6 patients (10%) died with 4 of those treated for aortic rupture and 1 had a retrograde aortic dissection. During at least 3 years of follow-up (median 49 months), no reintervention was needed for endoleaks, there was no stent fracture or stent migration. No patient died from an aortic cause. Subgroup analysis comparing the endovascular treatment for various aortic pathologies did not find significant differences in death rate or comorbidity including stroke. When comparing emergent and elective aortic repair, operating time was similar (64 vs 65 minutes), and the LSA fenestration was less frequently stented (52%) in the emergency group. There was no difference in stroke frequency. There was a higher rate of death in the emergency group at 30 days of follow-up, but no patient died from aortic cause in the long-term follow-up. CONCLUSIONS: Aortic arch repair with single-fenestrated PMEGs for zone 2 pathological arch disease is associated with acceptable early and midterm major morbidity and mortality. It is suitable for emergency situations. CLINICAL IMPACT: Single-fenestrated PMEG for the left subclavian artery is a safe and efficient option in the short and medium term for the treatment of the aortic arch in zone 2 with 98% technical success. It allows for aortic repair and subclavian artery revascularization in a single step for all patients. It is suitable for a range of main pathologies, including degenerative, dissection-related, isthmus rupture, and embolic pathologies. Additionally, it is always available and easily utilized in emergency cases.

Double Fenestrated Physician-Modified Stent Graft for Endovascular Treatment of Traumatic Aortic Isthmus Rupture With an Aberrant Right Subclavian Artery.

PURPOSE: The purpose of the study was to demonstrate the feasibility of urgent endovascular treatment of a traumatic aortic isthmus rupture in a patient with an aberrant right subclavian artery. CASE REPORT: A 23-year-old man was admitted to a regional trauma center after a motor vehicle collision and found to have cerebral trauma and a large pseudoaneurysm of the aortic arch. Trauma computed tomography (CT) identified a blunt traumatic thoracic aortic injury with an aortic false aneurysm in the context of an aberrant right subclavian artery. A hybrid repair was performed with bilateral subclavian carotid bypasses and a double fenestrated physician-modified stent graft. The patient had an uneventful postoperative course. Postoperative CT scan showed sealing of the aortic arch rupture and patency of all the supra-aortic trunks. CONCLUSION: Endovascular repair of blunt traumatic thoracic aortic injury is considered first-line therapy. Aortic arch anomalies add complexity to treatment. This report demonstrates that a hybrid strategy with bilateral carotid-axillary bypasses and homemade double fenestrated endograft of the aortic arch is a valuable approach for this challenging emergency in the context of an aberrant right subclavian artery.

Fenestrated Physician-Modified Endovascular Grafts for Aberrant Right Subclavian Artery and/or Kommerell's diverticulum.

OBJECTIVE: The aim of this case series is to report feasibility, efficiency, and safety of fenestrated physician-modified endografts (PMEGs) in aortic arch pathologies with aberrant right subclavian artery (ARSA) and/or Kommerell's diverticulum (KD). METHODS: All consecutive patients with ARSA and/or KD who underwent hybrid aortic arch repair combined with homemade fenestrated stent-graft from 2018 to 2022 were reviewed. RESULTS: Six patients with ARSA and/or KD underwent hybrid surgery for aortic repair, 4 of whom were men, with a mean age of 49 years. Furthermore, 2 of them were symptomatic with dysphagia, 1 was taken in emergency, 1 had a bovine arch and a KD, and 2 had right descending thoracic aortas. The mean operation time was 138 (111-216) minutes. In addition, 83% of the homemade grafts were double fenestrated. All the proximal landings were in zone 0; the mean proximal aortic diameter was 29 (23-34) mm. The range of diameters for the endografts were 24 to 38 mm. There was a 100% technical success, with 0% 30 days mortality, no stroke, and no endoleak. During the follow-up, no aortic-related death or secondary intervention was required and all supra-aortic vessels remain patent. CONCLUSION: Hybrid aortic arch repair, with fenestrated PMEGs for ARSA and/or KD, is associated with acceptable early and midterm major morbidity and mortality. CLINICAL IMPACT: This retrospective case series analyzed outcomes in 6 patients with an aberrant right subclavian artery and/or Kommerell's diverticulum treated with fenestrated PMEGs during an average 16 month follow-up. The case series suggests that the use of these fenestrated PMEGs for the management of patients with an aberrant right subclavian artery is a safe, effective and durable method in the medium-term.

Physician-Modified Stent Graft for Blunt Thoracic Aortic Injuries: Do the Benefits Worth the Trouble?

BACKGROUND: Obtaining a suitable proximal landing zone in blunt thoracic aortic injuries (BTAI) often necessitates coverage of the left subclavian artery (LSA). This study aimed to evaluate the outcomes of physician-modified endovascular grafts (PMEGs) in this indication. METHODS: We performed a retrospective analysis of a prospective registry including all patients who had undergone a thoracic endovascular aortic repair (TEVAR) for BTAI from October 2008 to October 2020. Starting in 2015, patients requiring coverage of the LSA were either treated using a physician-modified proximal scalloped or single-fenestrated stent graft. After an early postoperative computed tomography scan, follow-up was performed at 3 months, 6-months, and yearly. RESULTS: Among 58 patients treated with TEVAR for BTAI, 23 (39.6%) patients required a zone 2 landing zone of which 10 (17.2%) patients were treated with PMEGs. The median age was 48 [31-64.5] years, and 78.2% (n = 18) patients were male. The median Injury Severity Score was 38 [27-55.5]. Coverage of the LSA was performed in 25.8% (n = 15) of the total population in which 5 patients had an LSA transposition. The median modification time was 18 [14-27] minutes. Technical success of PMEGs was 90.0% overall and 100% for fenestrated stent grafts. No stroke, paraplegia, or retrograde dissection was observed. The primary patency of the LSA in the PMEGs group was 90 % at 1 year and 28.8 % in the LSA coverage group (P < 0.01). CONCLUSIONS: The use of PMEGs is feasible and effective in the management of BTAI with a short proximal landing zone. Further evaluation of long-term outcomes and durability are awaited.

Homemade fenestrated physician-modified stent grafts for arch aortic degenerative aneurysms.

OBJECTIVE: We evaluated the early- and medium-term outcomes of single- and double-fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular degenerative aortic arch aneurysm repair. METHODS: We performed a single-center, retrospective analysis of prospectively collected data from 52 patients from August 2013 through January 2021 who had undergone homemade fenestrated thoracic endovascular aortic repair for degenerative aortic aneurysms. In all cases, a distal smaller fenestration for the left subclavian artery (LSA) was fashioned and was the only one stented. For a double-fenestrated endograft, a proximal larger fenestration that incorporated both the brachiocephalic trunk and the left common carotid artery was added. RESULTS: A total of 52 patients with degenerative aortic arch aneurysms were treated. Of the 52 patients, 36 were men, the mean age was 75 ± 8 years, 31% had received a single LSA fenestration, and 69% had undergone double-fenestrated thoracic endovascular aortic repair. Of the 52 procedures, 5 (10%) were emergent procedures. The technical success was 100%. The median time required for stent graft modification was 22 ± 6 minutes. The 30-day mortality was 2% (n = 1). Five patients (10%) had experienced a cerebrovascular event, including two transient ischemic attacks, one minor stroke with full neurologic recovery, and two with sequelae. Two patients (4%) had experienced perioperative retrograde dissection during follow-up. No patient had developed a type I, II, or III endoleak from the LSA. No patient had required reintervention. All supra-aortic trunks were patent. During a mean follow-up of 18 ± 11 months, no patient had required conversion to open surgical repair, aortic rupture, or paraplegia. CONCLUSIONS: Single or double PMEG is a safe and suitable tool for the treatment of high morbidity pathology such as aortic arch degenerative aneurysm repair. In addition, this device can be used in patients requiring elective or emergency repair.

Surgical and endovascular treatment of late postcoarctation repair aortic aneurysms: Results from an international multicenter study.

OBJECTIVE: The formation of postaortic coarctation aneurysms (pCoAA) is well-described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair, depending on the clinical presentation, risk assessment, and anatomy. The aim of this study was to report the early and midterm results of open surgical and endovascular repair of pCoAA. METHODS: This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The preoperative, intraoperative, and postoperative data were recorded and analyzed. RESULTS: A total of 74 patients (46 male; median age, 44 years; interquartile range [IQR], 35-53 years) underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation at a median age of 11 years for the index procedure (IQR, 7-17 years). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. The median pCoAA diameter was 54 mm (IQR, 44-63 mm). The median time from the aortic coarctation repair to the pCoAA diagnosis was 33 years (IQR, 25-40 years). A total of 33 patients had symptoms at presentation, including thoracic or back pain in 8 patients. Open surgical repair was performed in 28 patients, including four frozen elephant trunk procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one frozen elephant trunk and one endovascular). After a median follow-up of 50 months (IQR, 14-127 months), there were a total of seven reinterventions. CONCLUSIONS: This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Because the median time between the coarctation repair and the aneurysm formation was more than 30 years, life-long surveillance of these patients is warranted.

Thoracoscopic Versus Open Lobectomy After Induction Therapy for Nonsmall Cell Lung Cancer: New Study Results and Meta-analysis.

INTRODUCTION: The use of video-assisted thoracoscopic surgery (VATS) lobectomy has become a mainstay of modern thoracic surgery practice and the technique of choice for resection of early-stage lung cancers. However, the benefits of VATS following induction therapy are yet to be clarified. This study aims to assess whether VATS lobectomy achieves similar perioperative and oncologic outcomes compared to thoracotomy for nonsmall cell lung cancer after induction therapy. METHODS: We retrospectively reviewed the outcomes of 72 patients who underwent lung lobectomy after induction therapy in our institution from January 2017 to January 2020. Subsequently, we carried out a comprehensive literature search and pooled our results with available data from previously published studies to perform a meta-analysis. RESULTS: VATS was associated with reduced intraoperative blood loss (P = 0.05) and less perioperative complications (P = 0.04) in our local institution. The meta-analysis comprised nine studies. A total of 943 patients underwent VATS and 2827 patients underwent open lobectomy. VATS was associated with significant shorter surgery duration (P < 0.0001), shorter chest-tube drainage duration (P < 0.0001), and shorter hospital stays (P < 0.0001). Furthermore, there was significantly less perioperative complications (P = 0.006) and less intraoperative blood loss (P = 0.036) in the VATS group. However, there were no significant differences in 3-y overall survival and 3-y disease-free survival rates. CONCLUSIONS: In some selected patients undergoing induction therapy, VATS lobectomy could achieve equivalent perioperative outcomes to thoracotomy but evidence is lacking on oncologic outcomes. Further trials with a focus on oncologic outcomes and longer follow-up are required.

Fate of the Dissected Thoraco-Abdominal Aorta Distal to TEVAR (Thoracic Endovascular Aortic Repair) for Complicated Acute and Subacute Type B Aortic Dissection.

PURPOSE: This study assessed morphological changes in the aortic true and false lumens during follow-up of patients undergoing TEVAR (Thoracic Endovascular Aortic Repair) for complicated acute and subacute type B dissection. The study analyzes the effectiveness of TEVAR in preventing distal aneurysmal progression. MATERIALS AND METHODS: All patients between 2009 and 2019 undergoing TEVAR for complicated acute and subacute type B dissection at the study institution were retrospectively reviewed. Maximal diameters were measured on the proximal descending aorta right below the left subclavian artery, thoraco-abdominal junction right above the celiac trunk, and infrarenal aortic right above the inferior mesenteric artery, pre-operatively and during follow-up, analyzing either expansion or shrinkage of true and false lumens at these 3 sites. RESULTS: Forty-one patients were included. Thirty-day incidence of death, stroke, paraplegia, and visceral ischemia was, respectively, 8% (n = 4), 6% (n = 3), 2% (n = 1), and 2% (n = 1). Three patients (6%) died from intervention-related cause. Mortality was 17% (n = 8) during a mean follow-up of 54 months. One patient had aneurysmal dilation of the descending aorta needing additional coverage and only 2 (4%) developed thoraco-abdominal aneurysms requiring re-intervention. In the remaining patients, both significant expansion of the true lumen and shrinkage of false lumen were observed at all 3 sites. CONCLUSION: Proximal coverage of the main entry tear appears to prevent aneurysmal progression in most patients (96%). With such promising results, TEVAR should be considered as a first-line treatment in acute and subacute type B dissection.

Total Arch Thoracic Endovascular Aortic Repair Using Double Fenestrated Physician-Modified Stent-Grafts: 100 Patients.

OBJECTIVE: The aim was to evaluate early and medium-term outcomes of double fenestrated physician-modified endovascular grafts for total endovascular aortic arch repair. METHODS: This single-center retrospective analysis of prospectively-collected data included 100 patients, from January 2017 to December 2021, undergoing thoracic endovascular aortic repair (TEVAR) for zone 0. The fenestrations were a proximal larger fenestration that incorporated the brach2iocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented. RESULTS: The median duration for stent-graft modification was 23±6 minutes. Of the 100 patients, 70 were men. The mean patient age was 70±10.5 years. Indications for treatment included degenerative aortic arch aneurysm (n=32), dissecting aortic arch aneurysm after type A dissections (n=23) and (n=19) after type B dissections, acute complicated type B dissection (n=16), and other pathologies (n=10). Technical success rate was 97%. The 30 day mortality was 2% (n=2). Four patients (4%) had minor stroke with full recovery. One patient (1%) had a type IA endoleak, 1 patient (1%) had a type IB endoleak, and 2 patients (2%) have a type II endoleak from the LSA. Eight patients (8%) required reintervention: 1 type IA endoleak, 1 type IB endoleak, 1 retrograde type A dissection, and 5 because of access-related complications. During a mean follow-up of 24±7.2 months, there were no aortic rupture, paraplegia, and all supra-aortic trunks were patent. CONCLUSIONS: Double homemade fenestrated TEVAR is both feasible and effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The long-term durability will need to be assessed in studies with long-term follow-up. CLINICAL IMPACT: Double homemade fenestrated TEVAR is effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The standout feature of this double fenestrated device is its simple handling during operation with the proximal fenestrations being directed to the orifices of the BT and LCCA automatically when the LSA fenestration is catheterized and secured by covered stent placement. The deployment algorithm actively steers the operator away from superfluous manipulations of the device within the arch and avoids guidewire manipulation in carotid arteries. The long-term durability will need to be assessed in studies with long-term follow-up.

Early outcomes of native and graft-related abdominal aortic infection managed with orthotopic xenopericardial grafts.

OBJECTIVE: Reconstruction of infected aortic cases has shifted from extra-anatomic to in situ. This study reports the surgical strategy and early outcomes of abdominal aortic reconstruction in both native and graft-related aortic infection with in situ xenopericardial grafts. METHODS: Included in the analysis are 21 consecutive patients (mean age, 69 years; 20 male) who underwent abdominal xenopericardial in situ reconstruction of native aortic infection (4) and endovascular (4) or open (13) graft aortic infection between July 2017 and September 2019. All repairs were performed on an urgent basis, but none were ruptured. All patients were followed up with clinical and biologic evaluation, ultrasound at 3 months, and computed tomography scan at 6 months and 1 year. RESULTS: Technical success was 100%; 8 patients were treated with xenopericardial tubes and 13 with bifurcated grafts. Thirty-day mortality was 4.7% (one death due to pneumonia with respiratory hypoxic failure in critical care.). Six patients (28%) developed acute kidney injury, four (19%) requiring temporary dialysis; five fully recovered and one died. Four patients (19%) required a return to the operating room. After a median follow-up of 14 months (range, 1-26 months), overall mortality was 19% (n = 4). Two patients presented with recurrent sepsis after reconstruction, leading to death due to multiorgan failure. Other patients (17/21) have discontinued antibiotics with no evidence of recurrence of infection clinically, radiologically, or on blood tests. Computed tomography scans at 1 year demonstrated no stenosis or graft dilation and one asymptomatic left graft branch thrombosis. Primary patency is 95%. CONCLUSIONS: In situ xenopericardial aortic reconstruction is a safe and effective management strategy for both native and graft-related abdominal aortic infection with good short-term results. The graft demonstrates appropriate resistance to infection such that reliable eradication of infection in this vascular bed is possible. Longer follow-up is required in future studies to determine the durability of the reconstruction and need for reinterventions.

Double fenestrated physician-modified stent-grafts for total aortic arch repair in 50 patients.

OBJECTIVE: Our aim was to evaluate the early- and medium-term outcomes of using double fenestrated physician-modified endovascular grafts (PMEGs) for total endovascular aortic arch repair. METHODS: The present single-center retrospective analysis of prospectively collected data included 50 patients from January 2017 through October 2019, who had undergone thoracic endovascular aortic repair (TEVAR). The fenestrations were a proximal larger fenestration that incorporated the brachiocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented. RESULTS: The median duration for stent graft modification was 26 ± 6 minutes. Of the 50 patients, 41 were men. The mean patient age was 68 ± 11.5 years. The indications for treatment included degenerative aortic arch aneurysm (n = 17), dissecting aortic arch aneurysm after type A dissection (n = 13), type B dissection (n = 13), aortic ulcer (n = 3), and other pathologies (n = 4). The technical success rate was 94% (47 of 50) overall, and 100% (28 of 28) after a technical modification incorporating a preloaded guide wire for the LSA fenestration (P < .05). The 30-day mortality was 2% (n = 1). Two patients (4%) had a minor stroke with full recovery. One patient (2%) had a type IB and two patients (4%) had a type II endoleak from the LSA. Four patients (8%) required reintervention: one because of a type IB endoleak and three because of access-related complications. All supra-aortic trunks were patent. During a mean follow-up of 16 ± 8.3 months, no conversions to open surgical repair were required and no aortic rupture, paraplegia, or retrograde dissection occurred. CONCLUSIONS: Using double fenestrated PMEGs for TEVAR is both feasible and effective for total endovascular aortic arch repair, avoiding the need for anatomic and extra-anatomic surgical revascularization. The absence of brachiocephalic trunk stenting was not associated with endoleaks or treatment failure and resulted in a lower stroke risk than alternative strategies. The midterm results suggest that stenting of the brachiocephalic trunk and right common carotid artery might not be necessary for a large proportion of patients undergoing total endovascular aortic arch repair. The persistence of the seal and ongoing durability require assessment in studies with long-term follow-up data available.

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms.

OBJECTIVE: Three of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. METHODS: This retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. RESULTS: Sixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. CONCLUSIONS: Technically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

Asymptomatic Internal Carotid Aneurysm: An Uncommon Disease of the Carotid Arteries.

Despite a low-incidence extracranial carotid artery aneurysm (ECAA) disease has important clinical repercussion that obliges understanding and knowledge of correct treatment. The 2 dominant etiologies are atherosclerotic degeneration and pseudoaneurysm. The natural history of ECAAs is understood. Neck pain, a pulsatile mass and central or peripheral neurological manifestations are the most common symptoms. Recommendations for diagnosis and treatment are not uniform and still under discussion, representing a challenge for clinicians. We discuss a case of 2.5 cm asymptomatic saccular atherosclerotic ECAA treated surgically in light of the most recent literature.

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR.

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

Aortic Arch Anatomy Pattern in Patients Treated Using Double Homemade Fenestrated Stent-Grafts for Total Endovascular Aortic Arch Repair.

Purpose: To analyze the structural variation of the aortic arch and the supra-aortic arteries and establish an average spatial configuration that would be a pattern for a "universal double fenestration" design for physician-modified endovascular grafts (PMEGs) used in total thoracic endovascular aortic repair (TEVAR). Materials and Methods: Aortic arch morphology was retrospectively analyzed by reviewing the preoperative thoracic computed tomography angiography scans in 33 consecutive patients (mean age 68 years; 27 men) treated between January 2017 and March 2019 using double-fenestrated PMEGs for zone 0 TEVAR. Image analysis was completed according to a standardized technique on a vascular workstation with center lumen line reconstruction for all measurements. Variations in branching pattern of the aortic arch were classified into 8 types. Results: The arch trunk configuration was type I in 26 patients (79%), type II in 5 (15%), type III in 1, and type IV in 1. Mean aortic diameters at the level of mid ascending aorta, innominate artery (IA), left common carotid artery (LCCA), and left subclavian artery (LSA) were 35.7±3.7, 34.2±4.5, 33.3±6.7, and 33.7±4.7 mm, respectively. Mean diameters of the trunk were 12.2±1.7, 7.5±1.4, and 8.0±0.8 mm, respectively. Mean longitudinal center to center lengths were 15.9±2.5 mm between the LSA and LCCA and 12.1±3.0 mm between the LCCA and IA. Mean clock positions using the LSA as reference were 12:50 for the IA and 12:05 for the LCCA. In 32 patients (97%) all the supra-aortic branch vessels fit perfectly inside two delimited areas defined by a proximal common square area of 30×30 mm for the IA and LCCA and a second distal 8-mm-diameter circle for the LSA. Conclusion: Variations of the aortic arch anatomy are numerous and common. A general morphological pattern is described that delimits the aortic area where these variations occur. This information can be utilized for the design of an off-the-shelf double-fenestrated stent-graft for zone 0 TEVAR.

Double homemade fenestrated stent graft for total endovascular aortic arch repair.

OBJECTIVE: The aim of this retrospective analysis was to evaluate the outcomes of physician-modified double fenestrated stent grafts for total endovascular aortic arch repair: one proximal large fenestration for the brachiocephalic trunk and the left common carotid artery and one distal fenestration for the left subclavian artery (LSA). METHODS: From January 2017 through February 2018, 17 patients (88.2% elective) underwent thoracic endovascular aortic repair (TEVAR) with double homemade fenestrated stent graft for total endovascular aortic arch repair to maintain supra-aortic trunk patency. Indications were degenerative aortic arch aneurysm (n = 7), dissecting aortic arch aneurysms subsequent to surgical treatment of acute type A dissections (n = 6), chronic complicated type B aortic dissection (n = 3), and acute complicated type B aortic dissection (n = 1). Routine postoperative follow-up imaging with computed tomography angiography was performed to assess TEVAR and supra-aortic trunks patency and endoleak. RESULTS: The median time for stent graft modification was 19 minutes (range, 16-20 minutes). Endovascular exclusion of the aortic arch was achieved in all the cases. One LSA catheterization failed and LSA revascularization was performed by carotid axillary bypass and coverage of the LSA fenestration by additional stent graft placement. Additional planned endovascular procedures were required in three patients: closure of supra-aortic trunks re-entry tears in two cases of dissecting aortic arch aneurysms and one transcatheter aortic valve replacement for severe native aortic valve regurgitation. One stroke, with no long-term deficit, was observed. No patients died. All left supra-aortic trunks are patent. No type I endoleak was observed. We only observed one patient with a type II endoleak. During a mean follow up of 7 ± 2 months, there were no conversions to open surgical repair, aortic rupture, paraplegia, or retrograde dissection. CONCLUSIONS: Double homemade fenestrated TEVAR is both feasible and effective for maintaining the patency of the supra-aortic trunks and allows total endovascular aortic arch repair. Durability concerns will need to be assessed in additional studies with long-term follow-up.