Safety, Effectiveness and Pitfalls of Carbon Dioxide Routine Use as a Contrast Agent for Endovascular Abdominal Aortic Repair.

BACKGROUND: Despite the evidence of good performance, carbon dioxide (CO2) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use. METHODS: We retrospectively collected data of every patient who underwent CO2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment. RESULTS: 49 patients underwent ICM guided EVAR and 52 patients underwent CO2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO2 patients. The radiation exposure was higher in the CO2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm2 - P < 0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups. CONCLUSIONS: EVAR can be safely performed under CO2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations.

Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair.

PURPOSE: Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers. MATERIALS AND METHODS: Consecutive patients undergoing hybrid (HG) or total endovascular (TEG) total aortic arch repair for aneurysms or dissections were included (2008-2022). Primary outcome measure was 30-day mortality. Secondary outcomes were major complications, technical success (defined as absence of surgical conversion/mortality, high-flow endoleaks or branch/limb occlusion), clinical success (defined as absence of disabling clinical sequelae), late and aortic-related mortality/reinterventions, freedom from endoleaks, aortic diameter growth > 5 mm, graft migration and supra-aortic trunks (SAT) patency. RESULTS: In total, 30 patients were included, 17 in HG and 13 in TEG. TEG presented shorter intervention time (240.5 vs 341 min, p = 0.01), median ICU stay (1 vs 4.5 days, p < 0.01) and median length of stay (8 vs 17.5 days, p < 0.01). No intraoperative deaths occurred. Technical success was 100%; clinical success was 70.6% in HG and 100% in TEG (p = 0.05). Thirty-day mortality was 13.3%, exclusively in HG (p = 0.11). Nine major complications occurred in 8 patients, 5 in HG and 3 in TEG (p = 0.99), among which five strokes, two in HG and three in TEG (p = 0.62). Late mortality was 38.5%, six patients in HG and four in TEG, p = 0.6. Two late aortic-related deaths occurred in HG (p = 0.9). Two aortic-related reinterventions, no graft migration or SAT occlusion was observed. CONCLUSIONS: Total endovascular repair seems to shorten operative times and provide higher clinical success compared with hybrid solutions, without significant 30-day mortality differences. The most common major complication is stroke.

Management of Nellix migration and type Ia endoleak from proximal endovascular aneurysm sealing relining to late open conversion.

BACKGROUND: Despite promising early results, midterm failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. METHODS: We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. RESULTS: We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques-2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non-aortic-related causes. CONCLUSIONS: The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.

Long-term failure after endovascular aneurysm sealing in a real-life, single-center experience with the Nellix endograft.

BACKGROUND: Endovascular aneurysm sealing (EVAS) is an innovative alternative to conventional endovascular aneurysm repair (EVAR). EVAS relies on sac anchoring without proximal fixation to achieve sealing and should have allowed for the treatment of a broader range of anatomic features compared with standard EVAR. Despite the encouraging early reports, the mid- and long-term follow-up data have shown increased rates of failure. To address the issue, the manufacturer introduced revised instructions for use (IFU) in 2016. The present study reports the outcomes of this system after a median follow-up of 45 months. METHODS: Data for all patients electively treated with EVAS at our institution were retrospectively collected. The patients were retrospectively reclassified according to the 2016 revised IFU of the device. All patients in the present series had undergone EVAS for the treatment of infrarenal abdominal aortic aneurysms (AAAs). The primary end point was therapeutic failure: graft migration >5 mm, sac expansion >5 mm, type IA endoleak (Is2 and Is3 using the Van den Ham classification), type Ib endoleak, and secondary rupture. The overall mortality, aortic-related mortality, and reintervention rates were also analyzed. RESULTS: A total of 101 patients had undergone elective treatment by EVAS from 2013 to 2018 for infrarenal AAAs. The median follow-up was 3.75 years. Therapeutic failure was observed in 31 of the 101 patients (30.7%), with no significant difference between the in-IFU and off-IFU 2016 subgroups. Failure occurred at a median interval of 34 months from the index procedure. Of the 101 patients, 6.9% had presented with secondary rupture. Freedom from aneurysm-related mortality was 96.9% at 1 and 2 years and 89.9% at 5 years. Freedom from reintervention decreased over time: 94.7% at 1 year, 77% at 4 years, and 52.1% at 6 years. Of the 101 patients, 14 (13.9%) had undergone emergent or elective graft explantation. CONCLUSIONS: EVAS performed worse than conventional endografts for several critical end points, regardless of any preoperative anatomic parameters. The incidence of therapeutic failures tended to increase over time, especially 4 years after the index procedure.

True Giant Ruptured Superficial Femoral Artery Aneurysm in Nonagenarian Female Patient: A Case Report and Review of the Literature.

Atherosclerotic superficial femoral artery (SFA) true aneurysm is rare and often associated with other aortic or peripheral aneurysms, usually discovered when it reaches a considerable diameter or becomes symptomatic. We present the case of a 92-year-old woman admitted in the emergency department with a huge ruptured SFA aneurysm. The patient underwent successful aneurysmectomy, followed by bypass grafting. Degenerative SFA aneurysms differ from other peripheral aneurysms, being usually larger and symptomatic at presentation, occurring in old people, and representing life-threatening situations. The commonest symptom is rupture.

Comparison of outcomes for short-neck and juxtarenal aortic aneurysms treated with the Nellix endograft versus conventional endovascular aneurysm sealing.

OBJECTIVE: The objective of this study was to evaluate the results of the off-label use of the Nellix endograft (Endologix, Irvine, Calif) for the treatment of short-neck aneurysms and juxtarenal aortic aneurysms (JAAs) compared with the outcomes of patients with infrarenal abdominal aortic aneurysms treated in accordance with the manufacturer's instructions for use. METHODS: Data available from patients treated with the Nellix endograft from September 2013 to January 2016 were reviewed to create a case-control analysis (1:2). Fourteen elective patients with a short-neck aneurysm or JAA (<10 mm) and mild aortic neck angulation (<35 degrees) were included. As a control group, 28 elective patients who had been treated in accordance with instructions for use were included. Patients were matched for age, sex, aortic diameter, and aortic neck angulation. The final cohort group included 42 patients: 14 in the JAA off-label group (5 with aortic neck length ≤4 mm and 9 with necks of 5 to 10 mm) and 28 in the control group. Technical and clinical success, freedom from any secondary intervention, any type of endoleak, and aneurysm-related death were evaluated. RESULTS: There were no significant differences between the two groups in terms of comorbidity, intraoperative time, radiation time, contrast agent volume, and perioperative mortality and morbidity. Two patients of the JAA group subsequently underwent open repair (14%), both with aortic neck length <4 mm (2/5; 40%), for type Ia endoleak. Two of the control group also subsequently underwent open repair (7%). At a mean follow-up of 22 ± 3.9 months, freedom from any reintervention was 85% for the JAA off-label group vs 92% for the control group (log-rank test, P = .33). CONCLUSIONS: The off-label use of the Nellix endograft for the treatment of JAA showed a higher rate of subsequent conversion to open repair for JAA patients (aortic neck length ≤4 mm), underlining the need for a proximal sealing zone. Longer term data are needed to verify the possible use of the Nellix endograft in selected short-neck aneurysms with aortic neck length >5 mm.

The Mid-Term Clinical Follow-Up Using Drug-Eluting Balloons on Tibial Artery "De Novo" Lesions in Patients With Critical Limb Ischemia: A Cohort Study.

RATIONALE: Restenosis due to intimal hyperplasia (IH) is a major clinical issue that affects the success of lower limb endovascular surgery. After 1 year, restenosis occurs in 40% to 60% of the treated vessels. The possibility to reduce IH using local antiproliferative drugs, such as taxols, has been the rationale for the clinical applications of drug-eluting stents and drug-eluting balloons (DEBs). The purpose of this study was to evaluate the clinical and instrumental efficacy of DEBs versus simple percutaneous transluminal angioplasty (PTA) in patients affected by chronic limb ischemia (CLI) with tibial artery "de novo" lesions. METHODS: A retrospective analysis was performed and included all consecutive patients who underwent endovascular treatment for CLI in our centers between January 2011 and March 2013. Inclusion criteria were (1) "de novo" tibial artery stenosis and (2) Rutherford class >4. Lesions were further divided by TransAtlantic Inter-Societal Consensus (TASC) classification into groups A, B, C, and D. RESULTS: Between January 2010 and March 2013, a total of 138 patients underwent simple PTA or DEB for CLI, and the groups were clinically and demographically homogenous. We decided to use DEBs in 70 cases. An improvement in the Rutherford Scale in cumulative and single TASC lesions classification was better in the DEB group (74% vs 51%; P = .024) at 24 months than in the PTA group. In the DEB group, the increase in ankle-brachial index was significantly higher than in the PTA group (P = .039). CONCLUSIONS: Our experience in addition to the existing literature supports the use of DEB in patients with CLI Rutherford class >3.

Increasing efficacy of endovascular recanalization with covered stent graft for TransAtlantic Inter-Society Consensus II D aortoiliac complex occlusion.

OBJECTIVE: We compared the outcomes and the durability of endovascular recanalization (EVR) with the Viabahn (W. L. Gore and Associates, Flagstaff, Ariz) covered stent graft vs traditional aortobifemoral or aortofemoral bypass grafting for complex aortoiliac occlusions. METHODS: Between 2008 and 2014, 11 unilateral iliac occlusions and 11 aortobiiliac occlusions were treated by EVR. Also collected were data from the last 21 consecutive patients treated in the same period by aortofemoral (n = 6) or aortobifemoral (n = 15) bypass grafting. In accordance with the TransAtlantic Inter-Society Consensus II (TASC II) document, only patients with type D lesions were considered. Kaplan-Meier estimates for patency were calculated, and Cox proportional hazard modeling was performed. RESULTS: The difference in risk factors between the groups was not significant. General anesthesia was required in 100% of the surgical group, and local or locoregional anesthesia was used for EVR. Suprarenal aortic cross-clamping was required in nine of the open surgical procedures (41%). A brachial percutaneous approach was performed in all patients undergoing EVR, and technical success was 100% in both groups. All of the attempts at EVR were successful. At the 2-year follow-up, primary patency did not differ significantly between the endovascular (91%) and surgical (95%) groups. This was seen in the univariate model (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.02-2.95; P = .28) and in the multivariate model (HR, 0.77; 95% CI, 0.06-10.07; P = .84) for group (HR, 0.58; 95% CI, 0.04-7.72; P = .68), age (HR, 0.89; 95% CI, 0.73-1.08; P = .24), symptoms (HR, 1.98; 95% CI, 0.42-9.46; P = .39), and occlusion (HR, 3.22; 95% CI, 0.51-20.35; P = .21). The average hospital length of stay was shorter for patients treated with ERV than for those treated with open surgery (3.9 ± 2.2 vs 5.8 ± 3.1 days, respectively; P = .03). The complication rate was 4% for EVR vs 18% in the surgical group (P = .32). CONCLUSIONS: At 2 years of follow-up, the results of endoluminal bypass grafting with the Viabahn stent to treat complex aortoiliac disease are promising. Longer-term results are needed to fully evaluate the potential benefits and longer-term patency.

U Stent-Graft Technique as a Treatment for Homolateral Metachronous Common Iliac and Internal Iliac Arteries Aneurysms after Open Surgery.

We report a case of a metachronous common iliac artery and the internal iliac artery (IIA) aneurysm developed 8 years after an aortobi-femoral bypass for treatment of abdominal aortic aneurysm associated at chronic occlusion of the right iliac axis. To exclude the metachronous aneurysm on the left iliac axis and to maintain the pelvic circulation, an external to IIA endografts were positioned ("U stent-graft technique"). At 6-month follow-up, the computed tomography scan showed patency of the endografts, of the bypass and of the IIA, without endoleak, or other adverse events.

The First Case of a Nellix Sac-Anchoring Endoprosthesis Removal for Aortoenteric Fistula.

The Nellix device (Endologix, Irvine, CA), has been designed with a brand new concept to seal the abdominal aortic aneurysms, minimizing endoleaks and reducing reinterventions. We present the first open conversion of a Nellix endograft due to aortoduodenal fistula of a 74-year-old male patient treated for an abdominal aortic aneurysms of 62-mm diameter.

Abdominal aortic endograft collapse due to false lumen radial force of an acute type B aortic dissection.

We report a case of abdominal endograft proximal collapse due to acute type B aortic dissection in a patient previously treated with endovascular repair (EVAR) for an infrarenal abdominal aortic aneurysm. Patient underwent axillobifemoral bypass grafting, in emergency. The postoperative computed tomography scan showed reexpansion of the occluded endograft. The patient died after 2 days with evidence of progression of the thrombosis of the false lumen and with involvement of renal, visceral, and medullar artery. EVAR collapse associated to acute type B aortic dissection is a challenging condition, which requires aggressive approach.

Fungal infection of aortic Endograft because of Aspergillus fumigatus.

A 59-year-old male, referred to our center with a ruptured aortic aneurysm, underwent urgent endovascular repair and femoro-femoral crossover bypass. An endograft infection because of Aspergillus fumigatus occurred about 20 days after surgery. We removed the endograft and femoral prosthesis and we then performed an aorto-bi-iliac bypass with autogenous reversed superficial femoral veins. Five days after surgery, the patient died. Microbiological examination and postmortem examination showed the presence of A. fumigatus in femoral prosthesis, aortic wall, and periaortic exudate.

Aortic arch rupture after multiple multilayer stent treatment of a thoracoabdominal aneurysm.

Despite the improvement in diagnostic and therapeutic strategies, the treatment of thoracoabdominal aneurysms is still burdened with a high incidence of peri/postoperative morbidity and mortality. The multilayer flow modulator is a new and promising technique for the treatment of such disease; however, some limits are still evident. We report the case of a 76-year-old woman affected by a symptomatic thoracoabdominal aneurysm treated with multiple Cardiatis multilayer flow modulators complicated by aortic arch rupture on the fifth postoperative day, with subsequent patient death.

Long-term follow-up of stentless prosthesis.

BACKGROUND: Stentless prostheses have an interesting hemodynamic performance when compared to stented prostheses and are recommended in cases of small aortic annulus. MATERIALS AND METHODS: From January 1996 to January 2004, 138 patients suffering from aortic disease, underwent aortic valve replacement. • Group A: 93 patients underwent stentless aortic valve implantation [stentless Biocor (Biocor Industria e Pesguisa Ltda, Belo Horizonte, Brazil) and stentless Sorin (Sorin Group, Saluggia, Italy)]. • Group B: 45 patients underwent stented aortic valve implantation (stented Biocor). Patients were assessed by clinical evaluation and echocardiography after a mean follow up of 124.5 ± 58.2 months. RESULTS: There was a significant difference in terms of time of extracorporeal circulation and aortic cross clamp. The actuarial survival at 4, 8, 12, and 15 years is 77%, 50%, 21%, and 18%, respectively. Freedom from reoperation at 4, 8, 12, and 14 years was 92%, 83%, 73%, and 63%, respectively. Freedom from all events, death, and reoperation at 4, 8, 12, and 14 years was 70%, 39%, 13%, and 8%, respectively. There is no statistical difference among the two groups in terms of actuarial survival, freedom from reoperation, and freedom from re-hospitalization for prosthesis-related causes. DISCUSSION: There was a significantly higher incidence of pacemaker implantation in Group A and the causes are not known. The rate of freedom from reoperation is high in both groups for the patients who remained alive. There was no statistical difference about prosthesis dysfunction between the two groups. The higher incidence of death in Group A cannot be explained by causes related to the prosthesis because there is no difference in terms of causes of death. Rates of reoperation did not differ between the two groups. CONCLUSIONS: The results obtained with stentless prostheses are encouraging even in long-term follow-up.

A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution.

BACKGROUND: Large randomized controlled trials have shown that carotid endarterectomy (CEA) is beneficial in the treatment of recent severe symptomatic carotid stenosis. Data are lacking concerning the risks of early CEA (<48 hours) for stroke in evolution (SIE) or crescendo transient ischemic attack (CTIA). The primary end point of this retrospective study was to evaluate the incidence of stroke, major adverse cardiac events (MACEs), and death within the first 30 days after early CEA performed within 48 hours in patients presenting with transient ischemic attack (TIA)/SIE. METHODS: Between 2001 and 2010, we treated 3,023 carotid artery stenoses, 29.5% (891/3,021) of which were in symptomatic patients. Early CEA within 48 hours after acute TIA/SIE was performed in 176 patients. Patients were divided into 3 groups for analysis of outcome after early CEA in symptomatic patients according to their initial neurologic deficit. Group 1 included 55 patients with TIA (single); group 2 included 55 patients with CTIA, and group 3 included 66 patients with SIE. Carotid artery stenosis was evaluated by duplex ultrasonography (DS). All patients were pre- and postoperatively visited by an experienced consultant neurologist who evaluated the neurologic status according to the modified Rankin Scale and the National Institutes of Health Stroke Scale (NIHSS). At admission, surgery was not performed on patients with disabling neurologic deficit (NIHSS score: >6) except for 4 selected cases (NIHSS score range: 8-14), patients with cerebral lesions >3 cm in diameter, patients with the presence or suspicion of parenchymal hemorrhage, patients with occlusion of the middle cerebral artery, and those who were deemed unfit for surgery. Clinical and DS follow-up examinations were performed after 6 and 12 months and annually thereafter. The mean duration of follow-up was 29.4 months (range: 0-120 months). RESULTS: The cumulative TIA/stroke/myocardial infarction/death rate at 30 days was 3.9% (7/176). TIA and stroke rates were 0% (0/176) and 3.4% (6/176), respectively. The stroke rate in groups 1, 2, and 3 was 1.8% (1/55), 0% (0/55), and 7.6% (5/66), respectively. No hemorrhagic strokes, TIAs, or MACEs were detected after surgery. Stroke risk was higher in group 3 than in groups 1 or 2, but the differences in the 3 groups were not statistically significant (group 1 vs. group 2: 1/55 vs. 0/55 events [P = 0.3151]); group 1 vs. group 3: 1/55 vs. 5/66 events [P = 0.3020]; and group 2 vs. group 3: 0/55 vs. 5/66 events [P = 0.1039]. Thirty-day follow-up was available for all patients, while long-term follow-up (mean: 32.7 ± 26.8 months) was available only for 158 patients (1 patient died and 17 were lost to follow-up). CONCLUSIONS: CEA can be performed with an acceptable risk in properly selected symptomatic patients within 48 hours after TIA or SIE. The benefits of early CEA in symptomatic patients include the prevention of recurrent stroke.

Open conversion after endovascular aortic aneurysm repair: a single-center experience.

BACKGROUND: The endovascular treatment of an abdominal aortic aneurysm (AAA) is a treatment with low risk and good reported results. This retrospective study analyzed experience with patients requiring surgical conversion after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: A total of 26 patients underwent open conversion (OC) after EVAR (18 endografts implanted at the authors' center and 8 in other centers). Patients were divided into 2 groups: early conversion if OC was performed within 30 days from the primary EVAR, and late conversion if OC was performed at least 30 days after EVAR. The authors analyzed all data on OC and the postoperative course. RESULTS: In this series, OC was performed for 22 endoleaks (13 type I, 5 type II, 2 type III, and 2 type V, which in 5 cases these were associated with AAA ruptures), 2 renal artery coverages, and 2 endograft infections. Six (23%) patients underwent early conversion with a mortality rate of 50%, and 20 (77%) had late conversion with a mortality rate of 20%. The overall mortality rate after OC, occurring before hospital discharge or within 30 days, was 26.9% (7 of 26). CONCLUSIONS: Endoleaks remain the weak point of endografts and can result in aneurysm rupture/death. Urgent OC and infections engender a high mortality. Elective OC can be performed with very low mortality and acceptable morbidity. Lifelong surveillance is necessary to detect and treat endoleaks.

Symptomatic aneurysm of a perforating peroneal artery after a blunt trauma.

A 48-year-old woman was referred to us for a pulsatile and painful mass on the right leg after a trauma occurred 2 months earlier. The duplex scan revealed the presence of an aneurysm of the perforating peroneal artery. The patient underwent an endovascular coil embolization of the aneurysm. The duplex-scan follow-up showed the patency of the peroneal vessel and the complete aneurysm thrombosis. The patient was discharged in good condition without pain. In literature, only four cases of aneurysm of perforating peroneal artery aneurysm, all with a clear traumatic etiology, are reported. In this case, the endovascular treatment was safe and effective.

Is total debranching a safe procedure for extensive aortic-arch disease? A single experience of 27 cases.

OBJECTIVE: Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections. METHOD: We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients. RESULTS: The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1-56), and the survival rate was 77.8%. The endoleaks' rate was 3.7% (1/27), due to a stent-graft migration. CONCLUSION: Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.

Acute management of aortoesophageal fistula and tracheoesophageal fistula treated by thoracic endovascular aortic repair and esophageal endoprosthesis: a case misdiagnosed as esophageal cancer.

Aortoesophageal fistula is rare but fatal if untreated. Open thoracic surgery is associated with high operative mortality and morbidity. We report a case of a 77-year-old man who, treated with thoracic endovascular aortic repair (TEVAR) for descending thoracic aneurysm in another center, after an acute episode of hematemesis and melena was referred to our center. The total body computed tomography scan showed the presence of reperfusion of the descending thoracic aneurysm sac (8.8 cm in diameter) in the proximal and distal TEVAR landing zone (endoleak type I) without clear signs of fistulous tract with the esophageal lumen. The patient underwent new TEVAR inside previous implantation with proximal landing very close to left subclavian artery and distal landing just above celiac trunk. For the presence of a tracheoesophageal fistula, an esophageal endoprosthesis was implanted few days later, and a jejunostomy was performed. At 30 days, patient was in good general condition, but he died at 3 months' follow-up. Aortoesophageal fistula is a rare and usually fatal condition; early recognition and TEVAR treatment prevent immediate exsanguination in patients, but after deployment of the endograft, most patients are at risk for infectious complications. Cessation of bleeding and restoration of circulation is of paramount urgency, but infectious diseases and esophageal repair remain open problems.