Sex disparities in popliteal artery aneurysms.

OBJECTIVE: Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. METHODS: POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. RESULTS: Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. CONCLUSIONS: Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Endosutured Aneurysm Repair of Abdominal Aortic Aneurysms with Short Necks Achieves Acceptable Midterm Outcomes-Results from the Peru Registry.

BACKGROUND: The study aims to describe midterm outcomes following treatment of infrarenal abdominal aortic aneurysms (AAAs) with short necks by endosutured aneurysm repair using the Heli-FX EndoAnchor system. METHODS: This is a retrospective study of prospectively collected data from 9 vascular surgery departments between June 2010 and December 2019, including treated AAAs with neck lengths ≤10 mm. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each center's practice. There were 2 Groups further assessed according to neck length, A (≥4 and <7 mm) and B (≥7 and ≤10 mm). The main outcomes analyzed were technical success, freedom from type Ia endoleaks (TIaELs), sac size increase, all-cause and aneurysm-related mortality. RESULTS: Seventy-six patients were included in the study, 17 fell into Group A and 59 into Group B. Median follow-up for the cohort was 40.5 (interquartile range 12-61) months. A median of 6 (interquartile range 3) EndoAnchors were deployed in each subject. Technical success was 86.8% for the total group, 82.4% and 88.1% (P = 0.534) for Groups A and B respectively. Six out of 10 (60%) of TIaELs at the completion angiographies showed spontaneous resolution. Cumulative freedom from TIaEL at 3 and 5 years for the total group was 89% and 84% respectively; this was 93% and 74% for Group A and 88% at both intervals in Group B (P = 0.545). In total, there were 7 (9.2%) patients presenting with TIaELs over the entire study period. Two (11.8%) in Group A and 5 (8.5%) in Group B (P = 0.679). There were more patients with sac regression in Group B (Group A = 6-35.3% vs. Group B = 34-57.6%, P = 0.230) with no statistical significance. All-cause mortality was 19 (25%) patients, with no difference (4-23.5% vs. 15-25.4%, P = 0.874) between groups; whereas aneurysm-related mortality occurred in 1 patient from Group A and 3 from Group B. CONCLUSIONS: This study demonstrates reasonable outcomes for patients with short-necked AAAs treated by endosutured aneurysm repair in terms of TIaELs up to 5-year follow-up. EndoAnchor use should be judiciously evaluated in short necks and may be a reasonable option when anatomical constraints are encountered, mainly for those with 7-10 mm neck lengths. Shorter neck length aspects, as indicated by the results from Group A, may be an alternative when no other options are available or feasible.

European Expert Opinion on Infrarenal Sealing Zone Definition and Management in Endovascular Aortic Repair Patients: A Delphi Consensus.

PURPOSE: The purpose of the study was to provide a consensus definition of the infrarenal sealing zone and develop an algorithm to determine when and if adjunctive procedure(s) or reintervention should be considered in managing patients undergoing endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). METHODS: A European Advisory Board (AB), made up of 11 vascular surgeons with expertise in EVAR for AAA, was assembled to share their opinion regarding the definition of preoperative and postoperative infrarenal sealing zone. Information on their current clinical practice and level of agreement on proposed reintervention paths was used to develop an algorithm. The process included 2 virtual meetings and 2 rounds of online surveys completed by the AB (Delphi method). Consensus was defined as reached when ≥ 8 of 11 (73%) respondents agreed or were neutral. RESULTS: The AB reached complete consensus on definitions and measurement of the pre-EVAR target anticipated sealing zone (TASZ) and the post-EVAR real achieved sealing zone (RASZ), namely, the shortest length between the proximal and distal reference points as defined by the AB, in case of patients with challenging anatomies. Also, agreement was achieved on a list of 4 anatomic parameters and 3 prosthesis-/procedure-related parameters, considered to have the most significant impact on preoperative and postoperative sealing zones. Furthermore, the agreement was reached that in the presence of visible neck-related complications, both adjunctive procedure(s) and reintervention should be contemplated (100% consensus). In addition, adjunctive procedure(s) or reintervention can be considered in the following cases (% consensus): insufficient sealing zone on completion imaging (91%) or on the first postoperative computed tomography (CT) scan (91%), suboptimal sealing zone on completion imaging (73%) or postoperative CT scan (82%), and negative evolution of the actual sealing zone over time (91%), even in the absence of visible complications. CONCLUSIONS: AB members agreed on definitions of the pre- and post-EVAR infrarenal sealing zone, as well as factors of influence. Furthermore, a clinical decision algorithm was proposed to determine the timing and necessity of adjunctive procedure(s) and reinterventions.

Changes in Aortic Diameter and Wall Strain in Progressing Abdominal Aortic Aneurysms.

OBJECTIVES: The analysis of wall strain opens new perspectives in the prediction of abdominal aortic aneurysm (AAA) rupture. This study investigates the capability of four-dimensional ultrasound (4D US) to detect and characterize changes in wall strain in the same patients during follow-up observations. METHODS: Eighteen patients were examined by 64 4D US scans during a median follow-up period of 24.5 months. After performing the 4D US and manual aneurysm segmentation, kinematic analysis was performed using a customized interface and evaluation of the mean and peak circumferential strain, as well as spatial heterogeneity. RESULTS: All aneurysms showed a continuous diameter growth with a mean rate of 4% per year (P < .001). The mean circumferential strain (MCS) tends to increase from a median 0.89% by 10.49% per year in follow-up independent of the aneurysm diameter (P = .063). The subgroup analysis reveals a cohort with increasing MCS and decreasing spatial heterogeneity, as well as a cohort with nonincreasing MCS and increasing spatial heterogeneity (P < .05). CONCLUSIONS: The 4D US is able to register the strain changes in AAA follow-up. The MCS tends to increase during the observation time in the entire cohort, but the changes were independent of the maximum aneurysm diameter. The kinematic parameters allow the entire AAA cohort to differentiate into two subgroups and provide additional information about the pathologic behavior of the aneurysm wall.

[Early Thoracic Endografting is Safe in Patients with Uncomplicated Type B Aortic Dissection]. / Die frühelektive endovaskuläre Versorgung der unkomplizierten Aortendissektion Typ B nach Stanford ist sicher.

There are many publications dealing with treatment options for uncomplicated type B aortic dissection (TBAD). Early TEVAR (Thoracic Endovascular Aortic Repair) may improve aortic-specific survival and delay disease progression in the long-term. Especially in patients with uncomplicated TBAD and additional high-risk features, preemptive TEVAR may improve late outcomes.We conducted a retrospective analysis of all patients treated for TBAD in our hospital between February 2017 and September 2021. Comorbidities, intraoperative data, 30-day mortality and postprocedural complications were analysed.During the above-mentioned period, 61 patients (38 males, median age 63 years) with TBAD were treated. Six patients received best medical treatment (BMT). 55 patients were treated by TEVAR and BMT. 11 patients (20%) had complicated TBAD, 12 patients (22%) had uncomplicated TBAD with high-risk features and 32 patients (58%) had uncomplicated TBAD. Technical success was 100%. No patient with uncomplicated TBAD died within the first 30 postoperative days. One patient with uncomplicated TBAD had a stroke after TEVAR. Two reinterventions were performed on day 7 and day 9 after TEVAR.Patients with uncomplicated TBAD could be treated by early TEVAR, with a low rate of perioperative complications. In patients with uncomplicated TEVAR and high-risk features, early TEVAR with BMT should be considered as the treatment of choice.

The Effect of EndoAnchors on Aneurysm Sac Regression for Patients Treated With Infrarenal Endovascular Repair With Hostile Neck Anatomies: A Propensity Scored Analysis.

PURPOSE: To analyze sac evolution patterns in matched patients with hostile neck anatomy (HNA) treated with standard endovascular aneurysm repair (sEVAR) and endosutured aneurysm repair (ESAR). METHODS: Observational retrospective study using prospectively collected data between June 2010 and December 2019. ESAR group data were extracted from the primary arm of the PERU registry with an assigned identifier (NCT04100499) at 8 centers and those from the sEVAR came from 4 centers. Suitability for inclusion required: no proximal endograft adjuncts (besides EndoAnchor use), ≤15 mm neck length and minimum of 12-months follow-up imaging. Bubble-shaped neck (noncylindrical short neck with discontinuous seal) aspect was analyzed. Both groups were analyzed using propensity score matching (PSM) for aortic neck length, width, angulation, and device fixation type. Main outcome assessed was sac evolution patterns (sac expansion and regression were defined as >5mm increase or decrease, of the maximum sac diameter respectively; all AAAs within this ±5 mm range in diameter change were considered stable) and secondary outcomes were type-Ia endoleaks; other endoleaks and mortality. A power analysis calculation >80% was confirmed for sac regression evaluation. RESULTS: After exclusions, PSM resulted in 96 ESAR and 96 sEVAR patients. Mean imaging follow-up (months) was 44.4±21.3 versus 43.0±19.6 (p=0.643), respectively. The overall number of patients achieving sac regression was higher in the ESAR group (n=57, 59.4% vs n=31, 32.3%; p<0.001) and the cumulative sac regression achieved at 5 years was 65% versus 38% (p=0.003) in favor of the ESAR group. There were no statistically significant differences in type-Ia endoleak and/or other endoleaks. Univariate analysis for sac regression patients in the sEVAR and ESAR group individually showed the bubble-shape neck as a predictor of sac regression failure. There were no statistical differences in overall and aneurysm-related mortality. CONCLUSION: Endosutured aneurysm repair provided improved rates of sac regression for patients with AAA and HNA when compared with sEVAR at midterm and up to 5 years, despite similar rates of type-Ia endoleaks, and the need to consider some important limitations. The presence of bubble-shaped neck was a predictor of sac regression failure for both groups equally. CLINICAL IMPACT: The use of EndoAnchors aids and improves EVAR treatment in hostile neck anatomies by an increased rate of sac regression when compared to EVAR treatment alone in up to 5 year analysis. Moreover, a trend to reduced number of type Ia endoleaks is also achieved, although not significant in the present study. This data, adds to current and growing evidence on the usefulness of EndoAnchors for AAA endovascular treatment.

Revascularization of occluded renal artery stent grafts after complex endovascular aortic repair and its impact on renal function.

BACKGROUND: Acute occlusion of renal bridging stent grafts after fenestrated/branched endovascular aortic repair (F/B-EVAR) is an acknowledged complication with high morbidity that often results in chronic dialysis dependence. The feasibility and effect of timely or late (≥6 hours of ischemia) renal artery revascularization has not been adequately reported. METHODS: We performed a retrospective, multicenter study across 11 tertiary institutions of all consecutive patients who had undergone revascularization of renal artery stent graft occlusions after complex EVAR. The end points were technical success, association between ischemia time and renal function salvage, interventional complications, mortality, and mid-term outcomes. RESULTS: From 2009 to 2019, 38 patients with 46 target vessels (TVs; eight bilateral occlusions) were treated for renal artery occlusions after complex EVAR (mean age, 63.5 ± 10 years; 63.2% male). Six patients had a solitary kidney (15.8%). Of the 38 patients, 16 (42.1%) had undergone FEVAR and 22 (57.9%) had undergone BEVAR. The technical success rate was 95.7% (44 of 46 TVs). The recanalization technique used was sole aspiration thrombectomy in 5.3%, aspiration thrombectomy and stent graft relining in 52.6%, and sole stent graft relining in 36.8%. The median renal ischemia time was 27.5 hours (range, 4-720 hours; interquartile range, 4-36 hours). Most patients (94.4%) had been treated after ≥6 hours of renal ischemia time, and 55.6% had been treated after 24 hours. In 14 patients (36.8%), renal function had improved after intervention (mean glomerular filtration rate improvement, 14.2 ± 9 mL/min/1.73 m2). However, 24 patients (63.2%) showed no improvement. Improvement of renal function did not correlate with the length of renal ischemia time. Of the 14 patients with bilateral renal artery occlusion or a solitary kidney, 9 experienced partial recovery of renal function and no longer required hemodialysis. In-hospital mortality was 2.6%. The cause of renal stent graft occlusion could not be identified in 50% of the TVs (23 of 46). However, in 19 (41.3%), significant stenosis or a kink of the renal stent graft was found. The median follow-up was 11 months (interquartile range, 0-28 months). The estimated 1-year patient survival and patency rate of the renal stent grafts was 97.4% and 83.8%, respectively. CONCLUSIONS: Revascularization of occluded renal bridging stent grafts after F/B-EVAR is a safe and feasible technique and can lead to significant improvement of renal function, even after long ischemia times (>24 hours) of the renal parenchyma or bilateral occlusion, as long as residual perfusion of the renal parenchyma has been preserved. Also, the long-term patency rates justify aggressive management of renal artery occlusion after F/B-EVAR.

Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. TECHNIQUE: The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. CONCLUSION: Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.

Multicenter Experience With Large Diameter Balloon-Expandable Stent-Grafts for the Treatment of Infrarenal Penetrating Aortic Ulcers.

PURPOSE: To describe the use of large-diameter balloon-expandable stent-grafts (BeGraft aortic stent-graft, Bentley InnoMed GmbH, Hechingen, Germany) in the treatment of infrarenal penetrating aortic ulcer (iPAU). MATERIALS AND METHODS: Retrospective analysis of patients undergoing endovascular treatment with the BeGraft aortic stent-graft in 8 European centers from January 2017 to October 2020. Demographics, perioperative data, and midterm outcomes were collected. Endpoints of the study were technical feasibility, early mortality, and morbidity. RESULTS: A total of 40 patients were included. The mean age was 73.9±7.05 years and 63.2% were male. Indications for treatment included size and morphology (65%), presence of symptoms (29.5%), and contained ruptures (5.5%). Urgent treatment was performed in 5% of cases. Technical success was 97.5%. Median operation time was 58 minutes (19-170 minutes), with 27.5% of patients having additional procedures during the main intervention (1 additional repair with a C-TAG (W.L. Gore & Associates, Inc, Flagstaff, AZ, USA) thoracic endoprosthesis, 5 covered endovascular reconstruction of aortic bifurcation procedures, 3 extensions with proximal cuffs, and 2 percutaneous angioplasties of the common iliac arteries). Percutaneous femoral access was used in 72.5%, while groin cut-down was performed in 27.5%. Repair was successful with only 1 stent in 45% of cases, while 37.5% required 2 stents and nearly 17.5% required 3/4 stent-grafts. The 30-day mortality was 0%, with a 2.5% reintervention rate (1 patient required evacuation of an intra-abdominal hematoma). Median follow-up was 13.9 months (2-39 months), during which no vascular-related reinterventions or deaths were reported. In 4 patients, a type II endoleak was observed. No cases of graft migration, thrombosis, or stent-fracture were observed. CONCLUSIONS: The treatment of iPAU with the BeGraft aortic stent-graft in a selective patient group is feasible with low rate of perioperative morbidity and mortality. Balloon-expandable stent-grafts offer the option to repair iPAUs with a shorter coverage of the aorta using low-profile sheath, that enables treatment in the presence of calcified access vessels and small diameter aortic bifurcations.

Midterm Results after Open Surgical and Endovascular Management of Arterioureteral Fistula.

BACKGROUND: Arterioureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery, and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential. METHODS: We performed a retrospective analysis of patients treated for arterioureteral fistula in a single-vascular institution from January 2013 to March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography, or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during midterm follow-up. RESULTS: Nine patients with ten arterioureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with 2 patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in 6 patients. In 4 cases, single stent-graft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, whereas in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stent-graft infection were observed during follow-up in three patients after endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery. DISCUSSION: Arterioureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of preexisting vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms.

OBJECTIVES: Patients surviving acute aortic dissection are at risk of developing a post-dissection thoraco-abdominal aortic aneurysm (PD-TAAA) during follow up, regardless of the type of treatment in the acute setting. Fenestrated and branched stent grafting (F/B-TEVAR) has been used with success to treat PD-TAAA, albeit reported only with short-term results. The aim of this study was to report mid-term results in a cohort of 71 patients. METHODS: This was a retrospective analysis of a prospectively maintained database including all patients with PD-TAAAs who underwent F/B-TEVAR within the period January 2010 - April 2017 at two vascular institutions experienced in endovascular techniques. RESULTS: A total of 71 consecutive patients (56 male, mean age 63.8 ± 10.6 years) were treated. Technical success was achieved in 68/71 (95.8%) patients. In hospital mortality was four (5.6%) patients. Peri-operative morbidity was 19.6%. Three (4.2%) patients developed severe spinal cord ischaemia, one of these patients 12 months post-operatively. Mean follow up was 25.3 months (1-77 months). Cumulative survival rates at 12, 24, and 36 months were 84.7 ± 4.5%, 80.7 ± 5.1%, and 70.0 ± 6.7%, respectively. Estimated freedom from re-intervention at 12, 24, and 36 months was 80.7 ± 5.3%, 63.0 ± 6.9%, and 52.6 ± 8.0%, respectively. The main reasons for re-intervention were endoleak from visceral/renal arteries and iliac endoleak requiring extension. Target vessel occlusion occurred in 8/261 (3.1%) vessels (renal artery n = 4; superior mesenteric artery n = 2; coeliac artery n = 2). Mean aneurysm sac regression during follow up was 9.2 ± 8.8 mm, with a false lumen thrombosis rate of 85.4% for patients with a follow up longer than 12 months. No ruptures occurred during follow up. CONCLUSION: F/B-TEVAR for post-dissection TAAA is feasible and associated with low peri-operative mortality and peri-operative morbidity. Mid-term results demonstrate a high rate of aneurysm sac regression. Rigorous follow up is required because of the significant re-intervention rate. Longer bridging covered stents for target vessels are advised.

[Indications for the Use of Endoanchors: State of the Art]. / Indikationen für den Einsatz von Endoanchors: State of the Art.

Complications during follow-up - including loss of seal and graft migration with endoleakage - are the Achilles heel of endovascular abdominal and thoracic aneurysm repair (EVAR and TEVAR, respectively). At the level of the proximal and distal landing zones, the characteristics of aortic anatomy include length and shape, thrombus, calcification, kinking and progressive dilatation, and these may impact the long-term durability of endovascular repair. Endoanchors have been shown to mimic the stability of a hand sewn aortic anastomosis. This report gives an overview of current literature on the use of endoanchors in EVAR and TEVAR. Indications for use include primary implantation to secure the proximal or distal landing zone, in case of unfavourable anatomy or intraoperative type I endoleak/suboptimal apposition to the aortic wall, as well as secondary use for the treatment of type I endoleaks and stent-graft migration often in conjunction with a proximal or distal extension of the stent-graft. To conclude the report, we analysed perioperative results of the first 100 patients treated with TEVAR/EVAR and endoanchors - primarily or secondarily - during re-interventions in our department. From March 2011 to November 2015, 100 patients (85 men, 15 women; mean age 70 ± 9.7 years) were treated. 82 applications were carried out in the abdominal and 18 in the thoracic aorta. The implantation was performed during the primary EVAR/TEVAR procedure in 80 cases (group A); 20 patients were treated secondarily (group B). Technical success was 100%. Clinical success was 98%. No endoanchors were lost. Perioperative mortality was 4% and morbidity 7%. During 30-day follow-up, endoleaks were found in 8/96 surviving patients. 7/8 patients had type II endoleaks, and one patient with secondary proximal extension of the thoracic stent-graft had a persistent type I endoleak.

[Management of Visceral Artery Aneurysms with Preservation of Organ Perfusion: More Than Twenty Years Experience]. / Management von Viszeralarterienaneurysmen unter besonderer Berücksichtigung der Organperfusion ­ Erfahrungen über mehr als 20 Jahre.

BACKGROUND: Visceral artery aneurysms (VAA) are rare and often incidental findings. Indications for treatment are symptomatic patients, pseudoaneurysms and a true aneurysm of diameter of ≥ 2.5 cm for mesenteric arteries and ≥ 3 cm for renal artery aneurysms. Pregnancy and liver transplantation play an important role in aneurysm rupture. Technical success after open or endovascular procedure and maintenance of organ perfusion are crucial. The aim of this review is to evaluate our data and experience of more than 20 years and to develop a strategy to deal with visceral artery aneurysm in elective and emergency cases. PATIENTS: Between 1995 and 2018, 179 patients (84 males, 95 females, median age 62 [18 - 87] years) were diagnosed with VAA at the Regensburg University Hospital. The site of aneurysm was the splenic artery in 113 (63%) patients (pts), hepatic and renal arteries in 22 and 21 pts (12% each), and gastropancreaticoduodenal artery in 14 (8%) and superior/inferior mesenteric artery in 9 (5%) cases. Surveillance without intervention occurred in 110 (62%) pts, and 34 (19%) pts underwent open and 35 (19%) endovascular repair. In all patients, preoperative imaging was performed, preferably by computed tomography angiography (CTA). RESULTS: A total of 69 patients underwent open or endovascular repair. 51 (74%) pts were treated electively, 18 (26%) pts presented urgently with acute bleeding. 16 emergency pts received endovascular treatment, and in 2 pts open surgery was performed. After emergency treatment, two pts exhibited segmental liver malperfusion without consequences. In one case, segmental bowel resection was necessary. 32/51 (63%) patients were treated electively by open surgery, 19/51 (37%) by endovascular procedures. There were no liver or bowel infarctions. Four splenectomies and one unilateral nephrectomy were necessary in patients with splenic or renal artery aneurysms. Moreover, three partial renal infarctions were noticed postoperatively (overall 8/21 [38%]). After endovascular repair of splenic or renal artery aneurysms, two cases of splenic and three cases of renal segmental infarction were observed. Splenectomy had to be performed twice (overall 7/14 [50%]). Organ perfusion was monitored by CTA, and preferentially by contrast enhanced ultrasound. CONCLUSION: The endovascular approach is the preferred option in an emergency to control bleeding in pseudoaneurysms. Patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully to achieve technical success with occlusion of the aneurysm and excellent organ perfusion. Imaging techniques such as ultrasound, especially CEUS, are strongly recommended in postoperative follow-up. Partial or complete splenic infarction leads to vaccination.

Comparison of outcomes for double fenestrated endovascular aneurysm repair versus triple or quadruple fenestrated endovascular aneurysm repair in the treatment of complex abdominal aortic aneurysms.

OBJECTIVE: This study compared outcomes of standard fenestrated endovascular aneurysm repair (St-FEVAR) with renal artery fenestrations only with more complex FEVAR (Co-FEVAR) with additional fenestrations for the superior mesenteric artery or the celiac trunk, or both. METHODS: All consecutive patients treated with FEVAR for short-necked, juxtarenal, or suprarenal aortic aneurysms between January 2010 and July 2016 were included. Patients with stent grafts with a combination of fenestrations and branches were excluded. Data were collected prospectively. All stent grafts used were customized based on the Zenith system (William A. Cook Australia, Ltd, Brisbane, Queensland, Australia). RESULTS: A total of 384 patients (345 men; mean age, 72.7 ± 7.8 years) were treated. St-FEVAR was used in 199 patients (51.8%) and Co-FEVAR in 185 (48.2%), including 30 patients with a quadruple FEVAR. Overall technical success was 373 of 384 (97.1%), and the difference between the St-FEVAR group (195 of 199 [98%]) and the Co-FEVAR group (178 of 185 [96.2%]) was not statistically significant (P = .37). Mean operative time was 135 ± 46 minutes for St-FEVAR and 176 ± 53 minutes for Co-FEVAR (P < .001). Mean fluoroscopy time was 45 ± 17 minutes for St-FEVAR and 57 ± 21 minutes for Co-FEVAR (P < .001). Overall 30-day mortality was two of 384 (0.5%), and the difference between the two groups was not statistically significant (St-FEVAR: 1 of 199 [0.5%] vs Co-FEVAR: 1 of 185 [0.5%]; P = 1.0). Major perioperative complications between St-FEVAR group (22 of 199 [11.1%]) and Co-FEVAR group (24 of 185 [13%]) were similar (P = .64). Mean follow-up was 20 ± 17.1 months. Estimated survival at 1 and 3 years was 95% ± 1.7% and 83.4% ± 3.6% for St-FEVAR vs 94% ± 2.4% and 89.4% ± 3.5%, respectively, for Co-FEVAR (P = .96). Estimated freedom from reintervention at 1 and 3 years was 97.9% ± 1.2% and 90.5% ± 3.1% for St-FEVAR vs 95.4% ± 2.0% and 89.1% ± 4.2%, respectively, for Co-FEVAR (P = .5). Estimated target vessel patency at 1 and 3 years was 99.2% ± 0.4% and 98.6.0% ± 0.6% for St-FEVAR vs 98.6% ± 0.6% and 97.9% ± 0.9%, respectively, for Co-FEVAR (P = .48). CONCLUSIONS: Co-FEVAR is not associated with an increase in perioperative mortality and morbidity compared with St-FEVAR. Co-FEVAR requires longer procedure and fluoroscopy duration, but technical success rates are as high as in St-FEVAR. A liberal use of Co-FEVAR is therefore justified whenever a longer and higher proximal sealing zone is needed.

Graft Complexity-Related Outcomes of Fenestrated Endografting for Abdominal Aortic Aneurysms.

PURPOSE: To report the outcomes of fenestrated endovascular aneurysm repair (FEVAR) and compare early and midterm results in relation to stent-graft complexity. METHODS: Between August 2006 and December 2014, 141 consecutive patients (mean age 72±7.6 years, range 50-89; 120 men) were treated electively with FEVAR for short-neck, juxtarenal, or suprarenal aortic aneurysms. Forty-five patients treated with stent-grafts featuring renal-only fenestrations were assigned to group A, while 96 patients receiving additional fenestrations for the superior mesenteric and/or celiac arteries were assigned to group B. Technical success, operative mortality and morbidity, target vessel patency, endoleak, reintervention, and survival were compared between the groups. Survival, target vessel stent patency, and reintervention during follow-up were estimated by Kaplan-Meier analysis; the estimates are presented with the 95% confidence interval (CI). RESULTS: Technical success was achieved in 135 (95.7%) patients. Overall 30-day operative mortality was 3.5% (5/141). Perioperative complications occurred in 16 (12.1%) patients. Mean follow-up was 33±23 months. Overall estimated survival was 85.1% (95% CI 79.1% to 91.1%) at 1 year and 75.8% (95% CI 68.2% to 83.5%) at 3 years. Freedom from reintervention was 90.6% (95% CI 85.6% to 95.6%) at 1 year and 79.2% (95% CI 71% to 87.5%) at 3 years. There was no statistically significant difference between the groups in terms of perioperative mortality or morbidity, endoleak, survival, target vessel patency, or reintervention. CONCLUSION: The use of FEVAR for juxta- and suprarenal aneurysms is associated with low 30-day mortality/morbidity and high midterm efficacy. So far, perioperative and midterm results are not affected by the use of more complex fenestrated designs.

A Systematic Review of Proximal Neck Dilatation After Endovascular Repair for Abdominal Aortic Aneurysm.

PURPOSE: To provide an updated systematic literature review and summarize current evidence on proximal aortic neck dilatation (AND) after endovascular aneurysm repair (EVAR). METHODS: A review of the English-language medical literature from 1991 to 2015 was conducted using MEDLINE and EMBASE to identify studies reporting AND after EVAR. Studies considered for inclusion and full-text review fulfilled the following criteria: (1) reported AND after EVAR, (2) included at least 5 patients, and (3) provided data on AND quantification. The search identified 26 articles published between 1998 and 2015 that encompassed 9721 patients (median age 71.8 years; 9439 men). RESULTS: AND occurred in 24.6% of patients (95% CI 18.6% to 31.8%) over a period ranging from 15 months to 9 years after EVAR. No significant dilatation of the suprarenal part of the aorta was reported by most studies. The incidence of combined clinical events (endoleak type I, migration, reintervention during follow-up) was higher in the AND group (26%) when compared with 2% in the group without AND (OR 28.7, 95% CI 5.43 to 151.67, p<0.001). CONCLUSION: AND affects a considerable proportion of EVAR patients and was related to worse clinical outcome, as indicated by increased rates of type I endoleak, migration, and reinterventions. Future studies should focus on a better understanding of the pathophysiology, predictors, and risk factors of AND, which could identify patients who may warrant a different EVAR strategy and/or a closer post-EVAR surveillance strategy.

Incomplete Expansion of Chimney Stent Graft during Chimney-Thoracic Endovascular Aneurysm Repair.

BACKGROUND: To report a technical complication during a chimney-thoracic endovascular aneurysm repair (Ch-TEVAR) procedure. METHODS: A 77-year-old female patient underwent Ch-TEVAR for a symptomatic thoracic aortic aneurysm with a short and angulated proximal neck. Deployment of the aortic stent graft over the left subclavian artery (LSA) was followed by placement of a balloon-expandable covered stent as a chimney for the LSA. RESULTS: Chimney deployment failed due to balloon perforation. Additional attempts with several balloons all failed, albeit gaining some additional expansion of the chimney stent graft. The technical complication was solved by deploying a self-expanding bare stent inside the chimney stent. This enabled additional ballooning and further expansion of the chimney stent graft leading to an acceptable end result. CONCLUSIONS: Ch-TEVAR with a balloon-expandable chimney stent graft can be complicated by incomplete chimney deployment due to balloon perforation. Relining of the chimney stent graft with a self-expanding stent improved the deployment with acceptable patency.

Hybrid Treatment of a Suprarenal Aortic Aneurysm with an Infrarenal Aortobifemoral Surgical Graft and a Fenestrated Stent Graft.

BACKGROUND: The aim of this study was to report a hybrid technique for the treatment of a suprarenal aortic aneurysm (SAA) in a patient with iliac occlusive disease. Initially, an infrarenal aortobifemoral surgical graft was implanted, followed by deployment of a fenestrated bifurcated stent graft at the suprarenal part of the aorta. METHODS: A 69-year-old man presented with a 51-mm saccular suprarenal aortic aneurysm and iliac occlusive disease with intermittent claudication. Both common iliac arteries had been previously treated with kissing stents. Both external iliac arteries were severely stenosed precluding a total endovascular approach. RESULTS: The patient was treated with an infrarenal aortobifemoral surgical graft, facilitating the implantation of a custom-made fenestrated stent graft with fenestrations for the renal arteries and the superior mesenteric artery and a scallop for the celiac artery. The procedure was uneventful. Postoperative computed tomography angiography confirmed complete exclusion of the aneurysm and patent target vessels. Postoperatively, the patient did not report claudication symptoms anymore. CONCLUSIONS: A hybrid approach is a viable alternative to treat patients with complex aortic aneurysms and simultaneous peripheral occlusive disease, otherwise excluded from fenestrated stent grafting due to unsuitable access vessels.

Radiation exposure to eye lens and operator hands during endovascular procedures in hybrid operating rooms.

OBJECTIVE: The purpose of this study was to evaluate the radiation exposure of vascular surgeons' eye lens and fingers during complex endovascular procedures in modern hybrid operating rooms. METHODS: Prospective, nonrandomized multicenter study design. One hundred seventy-one consecutive patients (138 male; median age, 72.5 years [interquartile range, 65-77 years]) underwent an endovascular procedure in a hybrid operating room between March 2012 and July 2013 in two vascular centers. The dose-area product (DAP), fluoroscopy time, operating time, and amount of contrast dye were registered prospectively. For radiation dose recordings, single-use dosimeters were attached at eye level and to the ring finger of the hand next to the radiation field of the operator for each endovascular procedure. Dose recordings were evaluated by an independent institution. Before the study, precursory investigations were obtained to simulate the radiation dose to eye lens and fingers with an Alderson phantome (RSD, Long Beach, Calif). RESULTS: Interventions were classified into six treatment categories: endovascular repair of infrarenal abdominal aneurysm (n = 65), thoracic endovascular aortic repair (n = 32), branched endovascular aortic repair for thoracoabdominal aneurysms (n = 17), fenestrated endovascular aortic repair for complex abdominal aortic aneurysm, (n = 25), iliac branched device (n = 8), and peripheral interventions (n = 24). There was a significant correlation in DAP between both lens (P < .01; r = 0.55) and finger (P < .01; r = 0.56) doses. The estimated fluoroscopy time to reach a radiation threshold of 20 mSv/y was 1404.10 minutes (90% confidence limit, 1160, 1650 minutes). According to correlation of the lens dose with the DAP an estimated cumulative DAP of 932,000 mGy/m(2) (90% confidence limit, 822,000, 1,039,000) would be critical for a threshold of 20 mSv/y for the eyes. CONCLUSIONS: Radiation protection is a serious issue for vascular surgeons because most complex endovascular procedures are delivering measurable radiation to the eyes. With the correlation of the DAP obtained in standard endovascular procedures a critical threshold of 20 mSv/y to the eyes can be predicted and thus an estimate of a potential harmful exposure to the eyes can be obtained.

Spinal cord ischemia after endovascular repair of thoracoabdominal aortic aneurysms with fenestrated and branched stent grafts.

OBJECTIVE: The aim of this study was to report the incidence and associated risk factors of perioperative spinal cord ischemia (SCI) after endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched stent grafts. METHODS: The study included consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004 to December 2014. Suprarenal abdominal aortic aneurysms treated with fenestrated and branched grafts, even if including all four visceral vessels, were excluded. Patients who died within 30 days after the procedure were excluded from the analysis for SCI. All data were collected prospectively. RESULTS: A total of 218 patients (167 men; mean age, 68.8 ± 7.5 years) were treated. Thirty-day mortality was 17 patients (7.8%). TAAA distribution among the 201 surviving patients was as follows: type I, n = 17 (8.5%); type II, n = 55 (27.4%); type III, n = 63 (31.3%); type IV, n = 54 (26.9%); and type V, n = 12 (5.9%). In the surviving patients, 21 (10.4%) developed perioperative SCI. At 30 days postoperatively, 13 (6.5%) of those patients had transient lower limb weakness, 5 patients (2.5%) had persistent lower limb weakness requiring assistance to stand or to walk, and 3 patients (1.5%) had persistent paraplegia. Five of the 21 patients awoke from anesthesia with a neurologic deficit. The remaining 16 patients had a later postoperative onset of SCI, with the majority of them (14 of 16) within 72 hours after the operation. Multivariate analysis using logistic regression identified operation time >300 minutes (odds ratio [OR], 7.4; 95% confidence interval [CI], 2.6-21.1; P < .001), peripheral arterial disease (OR, 6.6; 95% CI, 2-21.9; P = .002), and baseline renal insufficiency (glomerular filtration rate <30 mL/min; OR, 4.1; 95% CI, 1.1-16.1; P = .04) as independent risk factors for SCI. CONCLUSIONS: In our experience, most SCI events after endovascular TAAA repair are transient, with persistent paraplegia being rare. Patients with prolonged procedure duration, peripheral arterial disease, and baseline renal insufficiency appear to be at higher risk for development of SCI after endovascular TAAA repair.