Endovascular arch repair of anastomotic aneurysm and pseudoaneurysm in patients after open repair of the ascending aorta and aortic arch: a case series.

OBJECTIVES: The aim of the study was to investigate the outcomes of branched endovascular arch repair (b-TEVAR) with a custom-made double- or triple-branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement. METHODS: Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study end points were technical success, 30-day and follow-up mortality/morbidity and re-interventions. RESULTS: Between 2018 and 2022, 10 patients were treated with custom-made double- or triple-branched thoracic endovascular aortic repair due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and 2 a double arch-branched endograft. Eight cases were performed electively and 2 urgently for contained rupture. Technical success was achieved in 9 cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, 1 transient ischaemic attack occurred. No early endograft-related re-interventions were necessary. The median follow-up was 20 months. One patient died 2 months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed. CONCLUSIONS: Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.

Use of Secondary Iliac Branch Devices after Previous Endovascular Abdominal and Thoraco-Abdominal Aortic Aneurysm Repair.

OBJECTIVE: To assess the safety and effectiveness of iliac branch devices (IBDs), as secondary procedure, for the treatment of type Ib endoleak or evolution of iliac artery disease after prior endovascular aortic repair (EVAR) for thoraco-abdominal (TAAAs) or abdominal aortic aneurysms (AAAs). METHODS: A multicentre observational study of three European centres. The study included 75 patients (age 71 ± 9 years, 96% men) with previous EVAR (n = 64, 85%) or fenestrated or branched (FB) EVAR (n = 11, 15%). Overall, 88 IBDs were implanted to treat aneurysmal iliac artery evolution in 40 (53%) and type Ib endoleak in 35 (47%) cases, respectively. Thirteen (17%) patients received bilateral IBDs. Internal iliac artery (IIA) catheterisation was done through a transaxillary access (n = 82, 93%) or up and over (n = 6, 7%) technique. The primary endpoint was technical success. Secondary endpoints were 30 day major adverse event, early and long term freedom from re-intervention and target vessel instability. RESULTS: All procedures were technically successful (100%). During hospitalisation, there were four (5%) major adverse events and three (4%) early re-interventions, but no death, stroke, or damage to previous endografts. The median follow up was 47 (interquartile range 42) months, and the five year survival rate was 78 ± 6% with no aortic related death. Cox's regression analysis showed pre-operative renal function impairment (hazard ratio [HR] 3.4; 95% confidence interval [CI] 1.1 - 10.1; p = .033), and primary TAAA repair (HR 6.1; 95% CI 1.6-22.3; p = .006) as independent factors for long term mortality. Freedom from re-interventions was 85 ± 4% at five years with 11 (12%) cases (five endoleaks, four IBD thromboses, two stenoses). IIA instability was reported in three (3%) limbs and freedom from IIA instability was 95 ± 3% after 60 months. CONCLUSION: Secondary IBD after EVAR is a safe and effective procedure with high technical success and low complication rates. The technique of choice to revascularise the IIA seems not to affect early and follow up results. Long term durability of IBD repair is acceptable with low rates of IIA re-intervention.

A cross-sectional study on the anatomic feasibility of iliac side branch grafts in a real-world setting.

OBJECTIVE: The aim of this cross-sectional, single-center study was to analyze the feasibility of different commercially available iliac branch devices in Europe in a cohort of patients with aorto-iliac aneurysms. METHODS: All patients with aorto-iliac or iliac aneurysms that required iliac aneurysm repair, between 2017 and 2021, were included. Morphologic data was analyzed using computed tomography angiograms. The main outcome was the feasibility of each endoprosthesis (Cook ZBIS, Gore Iliac Branch Endoprosthesis [IBE], and JOTEC E-Iliac) according to the manufacturer's instructions for use. Secondary outcomes were feasibility in all three devices, in any device, and with adjunctive procedures (liberal criteria). Additionally, a comparative analysis of all three grafts was performed to analyze differences in feasibility. RESULTS: Overall, 119 iliac aneurysms in 101 patients were included. The mean age was 71 ± 11 years, and 91.6% were male. Feasibility was 52.9% for Cook ZBIS, 33.6% for Gore IBE, and 26.9% for the JOTEC E-Iliac device. A total of 65.5% of patients were feasible with at least one device, whereas only 10.1% complied with all three devices. The main reasons for lack of feasibility were a short common iliac artery length (Cook ZBIS), a narrow common iliac artery diameter (Gore IBE), and a >50° angulation between the external and internal iliac arteries (JOTEC E-Iliac). There was a significant difference between the feasibility of the three devices (P < .001). Cook ZBIS was the graft with the higher feasibility, with 3.3 and 4.4 higher odds when compared with Gore IBE and JOTEC E-Iliac devices, respectively. There was no significant difference between the Gore IBE and the JOTEC E-Iliac. By using liberal criteria, the overall feasibility increased to 95.8%. CONCLUSIONS: We found that only 65.5% of patients were feasible with one of the available devices according to the manufacturer's instructions for use. The Cook ZBIS was the device with the overall highest feasibility. Extending the use of these devices with adjunctive measures and a more liberal approach increased feasibility to 95.8%.