Endovascular Thrombectomy and Lysis for Acute Renal Vein Thrombosis: Indications, Technical Aspects, Outcome, and Disease Etiology.

PURPOSE: To report a rare case of acute renal vein thrombosis (RVT) that was treated with endovascular thrombectomy and lysis, and discuss potential etiology and indications for catheter-directed management. CASE REPORT: A 21-year-old female athlete presented with sudden pain in her left flank and vomiting. A 3-phase computed tomography (CT) angiogram identified total occlusion of the left renal vein with no excretion from the swollen tender left kidney. Catheter-directed thrombolysis and thrombectomy were initiated 24 hours after onset of symptoms. Complete resolution of the RVT with normalized renal function was achieved. Post-operative Doppler ultrasound scan confirmed normal renal resistance and flow in the renal vein. The patient was discharged on Apixaban and remains well at 6 months. Combined hormonal contraception via an intra-vaginal ring and raised Factor VIII activity were the only identified risk factors. CONCLUSION: Acute complete RVT with impaired kidney function is rare. Combined hormonal contraception and increased Factor VIII activity were potential risk factors. Endovascular thrombectomy and lysis restored renal perfusion and function, and can be used effectively in the management of fit patients with acutely compromised kidney function from total renal vein obstruction.

Giant Inferior Mesenteric Vein Aneurysm Secondary to Iatrogenic Inferior Mesenteric Arteriovenous Fistula.

PURPOSE: Visceral venous aneurysms are rare, especially in the inferior mesenteric vein (IMV). We report a giant IMV aneurysm secondary to an iatrogenic arteriovenous fistula (AVF). CASE REPORT: A woman presented with an incidental finding of a 7 cm large IMV aneurysm and an inferior mesenteric arteriovenous shunt. The patient underwent successful endovascular occlusion of the shunt to avoid aneurysm rupture and portal hypertension. CONCLUSION: Embolization is a possible treatment strategy for mesenteric venous aneurysms with an AVF. CLINICAL IMPACT: We describe an unusual mesenteric AV-shunt from a surgical crush injury that caused a giant venous mesenteric aneurysm and offer technical aspects on minimally invasive endovascular treatment.

A systematic review of the ipsilateral retrograde approach to the treatment of femoropopliteal arterial lesions.

OBJECTIVE: The endovascular treatment of femoropopliteal lesions is an integral part of managing peripheral arterial disease. The antegrade approach is the most widely used technique with good evidence for its safety and efficacy. However, crossing a lesion, particularly chronic total occlusions (CTO), can be technically challenging and so the retrograde approach is increasingly used to maximize the chances of procedural success. The objective of this systematic review was, therefore, to assess the safety and effectiveness of the ipsilateral retrograde approach to femoropopliteal lesions. METHODS: A systematic review conforming to the PRISMA standards was undertaken. MEDLINE, EMBASE, and The Cochrane Register were searched between January 1, 1988, and January 1, 2020. Full-text, English-language, peer-reviewed articles pertaining to peripheral arterial disease, endovascular intervention and access site were included. RESULTS: A total of 8599 articles were screened, of which 38, involving 1940 patients undergoing 2184 retrograde procedures, were included. The mean number of patients per study was 51.1, with three studies including fewer than 10 and four more than 100 patients. The reported follow-up ranged from 30 days to 3 years, and six articles did not report any long-term outcome data. A retrograde approach was used as the primary access route in 45.% of procedures (648/1438) with relevant data. Primary technical success was achieved in 88% (1920/2184; 64%-100%) with a reported complication rate of 11% (235/2117; 0%-27%). Overall, the quality of evidence was poor, with just seven articles deemed to be of high quality with a low risk of bias. A meta-analysis was not deemed appropriate owing to heterogeneity of data. CONCLUSIONS: An ipsilateral retrograde approach to femoropopliteal lesions has good primary technical success and a low rate of complications. It has a promising role as a bailout, or even a primary access technique, in complex lesions. Patient positioning, puncture site and technique, lesion anatomy, and the size of catheters and devices used are important considerations to achieve the best outcomes. There remains a paucity of robust evidence for its superiority over traditional antegrade approaches, and further work is required to identify the optimal technique and those patients who would benefit most from the approach.

Treatment of Aortoiliac Occlusive Disease With the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) Technique: Results of a UK Multicenter Study.

OBJECTIVE: This UK multicenter study aims to report early- and medium-term results following covered endovascular reconstruction of aortic bifurcation (CERAB) for the treatment of aortoiliac occlusive disease (AIOD) in patients with chronic limb threatening ischemia (CLTI) or intermittent claudication (IC). MATERIALS AND METHODS: Retrospective case analysis was performed of patients who underwent CERAB between November 1, 2012 and March 31, 2020 in 6 centers across the United Kingdom. Anatomical data, including degree of plaque calcification, were assessed using preoperative imaging. Outcome measures included mortality, perioperative complications, target lesion reintervention (TLR), and major limb amputation. Primary, assisted primary, and secondary patencies were calculated at set intervals. RESULTS: A total of 116 patients underwent CERAB over the study period for the following reasons [48% presenting with CLTI (Rutherford 4-6) and 52% with IC (Rutherford 1-3)]; 82% presented had Trans-Atlantic Inter-Society Consensus (TASC) D AIOD disease. Median age was 65 years (range 42-90 years); 76% of the cohort were male. Severely calcified aortic and iliac lesions were noted in 90% and 80% of patients, respectively. Over a median follow-up of 18 months (range 1-91 months), 2 (1.7%) patients were lost to follow up. In total 5, (4.3%) patients died and 2 (1.7%) had a major amputation. Endovascular TLR was required in 14 (12.1%) patients at last follow up. Surgical TLR was performed in 4 (3.4%) patients at last follow-up. Seven (6%) patients developed an aortic/iliac stent occlusion at last follow-up. The Kaplan-Meier (KM) freedom from TLR at 1 year was 94% and KM 1-year primary patency, assisted primary patency, and secondary patency were 88%, 94%, and 98% respectively. Subanalysis found the following features were associated with need for TLR; TASC D disease (OR = 2.45, 95% CI 1.44 to 3.71), severe aortic calcification (OR = 2.01, 95% CI 1.03 to 2.20), and presence of tissue loss at baseline (OR = 1.43, 95% CI 1.01 to 4.63). CONCLUSION: Perioperative (<30 days) and medium-term morbidity, mortality, and patency rates in this pragmatic cohort of patients with severe AIOD lesions show that CERAB is a valid revascularization option. A direct comparison with surgical treatments for AIOD in a randomized controlled trial is justified.

Pledget Reinforcement and Tractional Compression as Adjunctive Techniques for Suture-Mediated Closure (SMC) in Percutaneous Endovascular Aneurysm Repair (pEVAR): A Retrospective Observational Cohort Study.

BACKGROUND: Percutaneous endovascular aneurysm repair (pEVAR) is commonly utilized and requires the use of suture-mediated closure (SMC) devices to ensure adequate femoral artery hemostasis. Despite the use of such devices, puncture-related complications remain relatively common. We introduced two new adjuncts (pledget reinforcement and tractional compression) along with SMC to reduce such puncture-related complications. The aim of the study was to assess the efficacy and safety of the new adjunct techniques. METHODS: This retrospective observational cohort study examines the impact of two adjunctive techniques on puncture-related complications compared with the previous year data before this new introduction of adjunct techniques. RESULTS: Sixty-one percutaneous femoral punctures (in 31 patients) utilizing adjunct techniques for closure (the adjunct group) were retrospectively compared with 89 punctures (in 46 patients) closed with standard SMC technique (the standard group). The use of adjunctive techniques led to a significant reduction in overall puncture-related complications (3/61 (4.9%) vs. 20/89 (22.5%), P = 0.0106) and the need for emergent surgical repair after failed hemostasis (2/61 (3.3%) vs. 13/89 (14.6%), P = 0.037). CONCLUSIONS: These novel adjunctive techniques (pledget reinforcement and tractional compression) of SMC for pEVAR reduce puncture-related complications and increase the confidence to offer percutaneous techniques for more patients.

Subintimal Recanalization of an Occluded Common Iliac Stent: A Case Report.

The purpose of this report is to describe a minimally invasive alternative endovascular technique for the treatment of chronically occluded stents when it is not possible to cross them endoluminally. A 71-year-old patient with recurrent severe lower limb claudication due to occlusion of a stent placed in the common iliac artery 5 years earlier underwent subintimal recanalization of the stented segment and restenting after failed intraluminal approach. The postoperative computed tomography scan showed that the restented segment was patent with a flattening of the previous stent. Five years postoperatively the patient remains free from symptoms and the recanalized arteries are still patent at ultrasound.

Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions.

OBJECTIVE: Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions. METHODS: Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive. RESULTS: Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases. CONCLUSIONS: The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.

Postoperative CT Evaluation After EVAR: A Comparison of Image Assessment.

PURPOSE: To compare the postoperative computed tomography angiography (CTA) assessment made by vascular surgeons and interventional radiologists after endovascular aneurysm repair (EVAR) at a tertiary vascular clinic to an outside core review facility. METHODS: One hundred patients (mean age 78.7 years, range 88-55; 84 men) with consecutive, elective, routine CTA controls after EVAR were retrospectively studied. Consultant vascular surgeons or radiologists had evaluated all original scans and written the original report. All scans were then reevaluated by an independent core clinic. Findings were classified as vascular or extravascular and stratified as clinically significant or clinically nonsignificant by an independent external reviewer. RESULTS: The number of vascular findings detected by the vascular clinic was 72 vs 69 by the core clinic. The vascular clinic reported more clinically significant findings (primarily stent compression or kinks) as well as endoleaks and their origin. The core clinic reported more pseudoaneurysms (24 vs 12). None of the patients with puncture complications needed reintervention. Interrater analysis of all findings between the 2 clinics showed good agreement when comparing endoleaks overall (without subclassification) and moderate agreement when assessing aneurysm growth. The core clinic reported extravascular findings in 58 patients; 37 of these were classified as clinically significant. The vascular clinic reported extravascular findings in 23 patients; 7 of these were clinically significant. The core clinic also reported 2 cases of suspected malignancies, which had not been reported by the vascular clinic. CONCLUSION: During routine CTA follow-up after EVAR, a significant number of vascular and nonvascular findings are detected. Whereas a highly dedicated vascular clinic identifies most vascular findings regardless of the specialty of the reader, some extravascular findings are missed. However, the frequency of clinically significant findings or findings that might warrant reintervention was low in this study.

Aneurysm Shrinkage Is Compatible With Massive Endoleak in the Presence of an Aortocaval Fistula: Potential Therapeutic Implications for Endoleaks and Spinal Cord Ischemia.

PURPOSE: To present a patient with ruptured abdominal aortic aneurysm (AAA) and aortocaval fistula who was successfully treated with endovascular aneurysm repair in spite of developing a massive endoleak. CASE REPORT: A 70-year-old man with ruptured AAA and aortocaval fistula was treated with endovascular aneurysm repair (EVAR). During 8 years of follow-up, he had massive perfusion of the aneurysm sac by retrograde flow from the inferior mesenteric artery into the caval vein through the aortocaval fistula. The aneurysm diameter decreased continuously in spite of the type II endoleak. This observation illustrates the mechanisms of sac expansion and may have therapeutic implications for complicated type II endoleaks and prevention of spinal cord ischemia in thoracic stent-grafting. CONCLUSION: EVAR can be applied in this rare setting because the ensuing high-flow endoleak is associated with sac shrinkage owing to depressurization by the caval shunt.

Efficacy and durability of the chimney graft technique in urgent and complex thoracic endovascular aortic repair.

OBJECTIVE: This study reports the early and midterm to long-term experience of chimney grafts (CGs) in urgent endovascular repair of complex lesions in the thoracic aorta. METHODS: Twenty-nine high-risk patients (20 men) who were unfit for open repair were treated using CG technique for ruptured (n = 14) or symptomatic (n = 15) aortic lesions engaging the aortic arch itself (n = 9), the descending aorta (n = 10), or the thoracoabdominal aorta (n = 10). Twenty-two patients (76%) were treated urgently (≤24 hours) and seven were semiurgent (≤3 days). Of 41 chimneys used, 24 were placed in supra-aortic branches and 17 in visceral branches. Median follow-up (interquartile range) for the entire cohort was 2 years (0.6-3.8 years), 2.5 years (1-4 years) for 30-day survivors, and 3.5 years (1.9-6.4 years) for those who were still alive. RESULTS: Four patients (14%) died ≤30 days of cerebral infarction (n = 1), visceral ischemia secondary to the initial rupture (n = 1), multiple organ failure (n = 1), or heart failure (n = 1). There were 11 late deaths (38%); however, only two deaths were related to the CG technique. The primary and secondary technical success rates were 86% (25 of 29) and 97% (28 of 29), respectively. The secondary patency rate of CGs was 98%. Seventeen (68%) of the aortic lesions shrank significantly. Three patients (10%) had primary type I endoleak and another three (10%) had secondary type I endoleak. The endoleaks were managed with Onyx (ev3 Endovascular, Inc, Plymouth, Minn) or coil embolization (n = 2), restenting (n = 1), and conversion to open repair (n = 2). One secondary endoleak is still under observation after >20 months. All primary endoleaks and one secondary endoleak originated from CGs in the brachiocephalic trunk (4 of 6 [67%]). CONCLUSIONS: The midterm to long-term results of the CG technique for urgent and complex lesions of the thoracic aorta in high-risk patients are promising, with low early mortality and long durability of the CGs. More patients with longer follow-up are still needed.

Impact of renal chimney grafts on anatomical suitability for endovascular repair in ruptured abdominal aortic aneurysm.

PURPOSE: To evaluate the impact of renal chimney grafts on anatomical suitability for endovascular aneurysm repair (EVAR) in ruptured abdominal aortic aneurysm (rAAA). METHODS: Contrast-enhanced computed tomography images of 206 patients with rAAA [175 men (mean age 75 ± 7.8 years) and 31 women (mean age of 76 ± 7.5 years)] were evaluated in a dedicated 3-dimensional vascular workstation. Assessment of infrarenal EVAR suitability was based on predefined anatomical variables reflecting the Instructions for Use of commercially available stent-grafts. In patients where aneurysm neck length was the only limiting factor for suitability, reevaluation of the proximal sealing zone was done, accounting for chimney grafts in one or both renal arteries. RESULTS: Seventy (34%) rAAA patients were anatomically suitable for EVAR: 65 (37%) of 175 men and 5 (16%) of 31 women (p < 0.01). Eighty-nine (65%) of the 136 unsuitable patients had aneurysm necks < 15 mm long; short neck was the only exclusion criterion in 33 (24%) cases. In the 33 short-necked aneurysms without other limiting factors, a proximal sealing zone > 15 mm could potentially be achieved with one or two renal chimney grafts in 12 (36%) and 25 (76%) patients, respectively, increasing overall suitability to 40% and 46%. If access issues could also be solved and a similar strategy with chimneys for the renal arteries was applied, the EVAR suitability would increase further to 58%. CONCLUSION: Roughly one third of patients with rAAA are anatomically suitable for EVAR; short aneurysm neck is the most common exclusion criteria. In appropriate cases, chimney grafts in one or both renal arteries may increase overall suitability by 12%. Suitability increases to ~ 60% when iliac access issues are additionally overcome.

Outcomes of fenestrated endovascular repair of juxtarenal aortic aneurysm.

OBJECTIVE: To evaluate late outcomes after fenestrated endovascular aortic repair (f-EVAR) in a tertiary European referral center. METHODS: In 2009, we published short- and midterm results after f-EVAR in the first 54 patients treated with this technique at our center between September 2002 and June 2007. In this paper, we provide long-term follow-up of the same patient cohort with the main focus on target vessel (TV) patency, renal function, reinterventions, and survival. RESULTS: A total of 54 patients were included in this study. Median age was 72 years (interquartile range [IQR], 68-76 years) at primary operation, and 85% were men. Median preoperative aneurysm diameter was 60 mm (IQR, 53-66 mm). One hundred thirty-four vessels were targeted (mean, 2.5 per patient), and 96 TV stents were placed. The median clinical follow-up was 67 months (IQR, 37-90 months), and computed tomography follow-up was 60 months (IQR, 35-72 months). Aneurysm diameter decreased ≥ 5 mm in 39% ± 7% at 12 months, 64% ± 8% at 36 months, and 71% ± 8% at 60 months. Primary TV patency was 94% ± 2% at 12 months, 91% ± 3% at 36 months, and 90% ± 3% at 60 months. Glomerular filtration rate decreased by 17% at 59 months (IQR, 26-73 months) follow-up (60 [IQR, 46-79] vs 50 [IQR, 38-72] mL/min/1.73 m(2); P < .001), and one patient became dialysis-dependent secondary to a renal stent occlusion. Reintervention-free survival was 88% ± 5% at 12 months, 69% ± 7% at 36 months, and 56% ± 5% at 60 months. At least one reintervention was done in 37% of patients, of which 29% were endoleak-related, 26% TV-related, 13% graft-limb-related, and 32% due to other causes. The majority of reinterventions (68%) were based on complications detected on routine follow-up. Estimated overall survival was 93% ± 4% at 12 months, 76% ± 6% at 36 months, and 60% ± 7% at 60 months. In total, 54% of the patients died during the 10-year study period, where 9% died of aneurysm-related causes. CONCLUSIONS: Long-term mortality after f-EVAR is high, but most patients die from nonaneurysmal causes. Aneurysm-related mortality is associated with technical complications that can be reduced with increased experience. Reinterventions are common, and most complications are detected on routine follow-up.

The importance of socioeconomic factors for compliance and outcome at screening for abdominal aortic aneurysm in 65-year-old men.

OBJECTIVE: To evaluate compliance with screening and prevalence of abdominal aortic aneurysm (AAA) in relation to background data regarding area-based socioeconomic status. METHODS: Our department annually invites 4300 65-year-old men from the city of Malmö and 15 neighboring municipalities to ultrasound AAA screening. In a cross-sectional cohort study, compliance and AAA prevalence among 8269 men were related to background socioeconomic data such as mean income, proportion of immigrants, percentage of subjects on welfare, smoking habits, and unemployment rate in the different municipalities. The 10 different administrative areas in Malmö were evaluated separately. RESULTS: Compliance with screening in the entire area was 6630/8269 (80.2%) but varied between 64.4% and 89.3% in different municipalities (P < .001). In univariate analysis, compliance increased with increasing mean income (r = 0.873; P < .001) but decreased with increasing proportion of immigrants (r = -0.685; P =.005) and subjects on welfare (r = -0.698; P = .004). Compliance in 10 different administrative parts of Malmö (P = .002) also increased with increasing mean income (r = 0.948; P < .001), and decreased with increasing proportion of immigrants (r = -0.650; P = .042) and increasing unemployment rate (r = -0.796; P = .006). Altogether, 117 (1.8%) AAAs were found, the prevalence differing between both different municipalities (P =.003) and the 10 different administrative parts of Malmö (P =.02). The prevalence of AAA in the 10 administrative parts of Malmö increased with increasing percentage of smokers (r = 0.784; P = .007), percentage of immigrants (r = 0.644; P = .044), and unemployment rate (r = 0.783; P =.007) but decreased with increasing mean income (r = -0.754; P = .012). CONCLUSIONS: Compliance with ultrasound screening for AAA differed between different geographical areas. In areas with low socioeconomic status, compliance rates were lower, whereas AAA prevalence was higher. The identification of contextual factors associated with low compliance is important to be able to allow targeted actions to increase efficacy of ultrasound screening for AAA. Targeted actions to increase compliance in those areas are being scientifically investigated and implemented.

Chimney grafts preserve visceral flow and allow safe stenting of juxtarenal aortic occlusion.

OBJECTIVE: Chimney grafts have proven useful for urgent endovascular repair of juxtarenal aortic aneurysms. Stenting of juxtarenal aortic occlusive disease is not routinely advocated due to the risk of visceral artery obstruction. We report on the potential applicability of chimney grafts in 10 patients with juxtarenal aortic stenosis or occlusion. To our best knowledge, chimney grafts have not been applied previously in this challenging setting. METHODS: Ten high-risk female patients (mean age, 68 years) with severe stenosis or occlusion of the aorta at the level of the visceral arteries were offered stenting. "Chimney" stents or stent grafts (20-40 mm long) were implanted from a brachial approach into visceral arteries that needed to be covered by the aortic stent. The chimney stents were then temporarily obstructed by balloon catheters to prevent visceral embolization until the aortic stent or stent graft was deployed. RESULTS: All procedures were technically successful, and patency was obtained in all visceral arteries and the aorta without distal embolization. One patient died after 9 days of acute heart failure. The nine surviving patients presented no complications, and all stented vessels remained patent at up to 6 years. Another patient died after 5.5 years due to lung cancer. All three patients with renal impairment have improved renal function, and a reduction in antihypertensive medication has been possible. CONCLUSIONS: Chimney grafts may allow stenting of juxtarenal aortic occlusive disease by protecting the patency of visceral arteries. Further evaluation with more patients and longer follow-up is required.

Association between the SVS/AAVS anatomical severity grading score and operative outcomes in fenestrated endovascular repair of juxtarenal aortic aneurysm.

PURPOSE: To evaluate the association between the Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) anatomical severity grading (ASG) score and operative outcomes in fenestrated endovascular repair (f-EVAR) for juxtarenal aortic aneurysm. METHODS: A review was conducted of all patients treated at our clinic with commercially available, custom-made f-EVAR devices between June 2007 and December 2011. Preoperative computed tomography (CT) scans were analyzed in a dedicated vascular 3-dimensional workstation for calculation of the ASG score. Of the 100 patients treated with f-EVAR during the study period, 88 (69 men; mean age 70 years, range 50-82) had high quality CT scans available for generating semiautomatic centerline-of-flow reconstructions needed to calculate the ASG score. The mean score was used to divide the patients into high and low score groups for comparison of operative outcomes. RESULTS: A total ASG score ≥24 was associated with longer procedure time (357±121 vs. 298±131 minutes, p=0.03) and more frequent intraoperative adjunctive maneuvers (48% vs. 29% of patients, p=0.05). An ASG neck score ≥7 was associated with longer procedure time (365±126 vs. 288±119 minutes, p<0.01), more operative adverse events (31% vs. 14% of patients, p=0.05), higher radiation exposure (53828±37341 vs. 38788±25846 µGym(2), p=0.04), and more frequent postoperative complications (46% vs. 18% of patients, p<0.01). An ASG aneurysm score ≥5 was associated with operative adverse events (44% vs. 19% of patients, p=0.04). No relationship was found between the ASG score and blood loss, contrast volume, fluoroscopy time, or hospital stays. CONCLUSION: The ASG score is associated with operative adverse events, intraoperative adjunctive maneuvers, radiation exposure, and postoperative complications in patients treated with f-EVAR for juxtarenal aortic aneurysm.

Randomized clinical Trial Comparing drug Eluting Stent Zilver PTX® Versus Bare Metal Stent Zilver Flex® for Treatment of Lesions in Femoral and Popliteal Arteries in Chronic Limb Threatening Ischemia.

OBJECTIVE: Drug eluting stents (DES) might improve the results of stenting in the femoropopliteal (FP) segment, but randomized data between DES and BMS in the treatment of patients with chronic limb threatening ischemia (CLTI) is lacking. The aim of this study was to perform a randomized comparison, between DES and bare metal stent (BMS) implantation in a subgroup of CLTI patients with lesions in the superficial femoral artery (SFA) and the P1-P2 portion of the popliteal artery. METHODS: Patients presenting with CLTI scheduled for endovascular treatment of FP lesions were randomly assigned by blinded envelopes 1:1 in a single blinded, parallel group design to DES or BMS after lesion crossing. Primary endpoints were target lesion revascularization (TLR) at 12 and 24 months and primary patency at 12 and 24 months. Secondary endpoints were technical success (TS), clinical success, secondary patency at 12 and 24 months, limb salvage, serious adverse events (SAE) at 24 month and survival at five years. RESULTS: A total of 48 CLTI patients and 49 limbs, were enrolled, 22 in the BMS group and 27 in the DES group. Demographics, comorbidities, and Rutherford class were similar in both treatment arms. The overall rate of total occlusions was 96% and the corresponding overall median lesion length was 240 mm. No patients were lost to follow up. No significant differences were detected between groups regarding TLR and primary patency. The overall primary patency at 12 and 24 months was 42.9% and 36.7% respectively and the overall freedom from TLR was 67.3% and 61.2% respectively. The results in the two groups were also similar regarding secondary outcomes. CONCLUSIONS: This single centre, randomized study could not demonstrate superiority of DES compared to BMS when treating long FP lesions in patients with CLTI but was limited by insufficient patient inclusion.

New temporary internal introducer shunt for brain perfusion during total endovascular arch replacement with in situ fenestration technique.

Complete endovascular arch replacement by in situ fenestration technique requires maintenance of cerebral perfusion during the fenestration procedure by an extracorporeal femoral-carotid bypass. The bypass has the disadvantages of being invasive, requiring a pump, and shunting blood extracorporeally. This report describes bench testing and an in vivo experimental animal setup with an endovascular, temporary introducer shunt. This technique represents an adjunctive step toward a complete endovascular repair for the aortic arch.

Drug-eluting balloon (DEB) versus plain old balloon angioplasty (POBA) in the treatment of failing dialysis access: A prospective randomized trial.

OBJECTIVE: To compare the efficacy of angioplasty using drug-eluting balloons (DEB) compared with plain old balloon angioplasty (POBA) to reduce the rate of restenosis. METHODS: This prospective, single-centre, single-blinded, 1:1 randomized, clinical trial enrolled patients that had primary or restenotic lesions in native upper extremity arteriovenous (AV) fistulas or at the graft-venous anastomosis. Patients were randomized to angioplasty with a POBA or a DEB. The primary effectiveness endpoints were freedom from target lesion revascularization (TLR) and functional status of access circuit at 12 months. RESULTS: A total of 42 (28 male, 14 female; age range, 42-83 years) patients were enrolled. Patients were followed for 12 months. No significant differences were detected between the POBA and DEB groups regarding total number of TLR procedures (31 versus 36, respectively), freedom from TLR (3 versus 4, respectively) and functional status of the access circuit at 12 months (14 of 20 patients [70%] versus 17 of 22 patients [77%], respectively). CONCLUSION: This clinical trial did not demonstrate any significant differences between DEB angioplasty and standard balloon angioplasty when treating dysfunctional haemodialysis access.

Single superior mesenteric artery periscope grafts to facilitate urgent endovascular repair of acute thoracoabdominal aortic pathology.

PURPOSE: To assess the use of periscope grafts to the superior mesenteric artery (SMA) in extending the distal sealing zone of thoracic stent-grafts. CASE REPORTS: Three patients with ruptured Crawford type I thoracoabdominal aortic aneurysms (TAAA) and 1 patient with a symptomatic type B dissection underwent endovascular repair; the celiac trunk was intraoperatively occluded in all patients. The thoracic stent-graft was extended to immediately above the most cranial renal artery, and the SMA was simultaneously stented from a femoral approach (periscope graft). All 4 periscope grafts were successfully implanted. One patient with rTAAA and intraoperative hemodynamic instability died in the perioperative period with a patent SMA. The other 3 patients had patent SMA periscope grafts and were free from abdominal symptoms at 14, 12, and 7 months; follow-up CT scans showed excluded aneurysms in the 2 TAAAs. The patient with type B dissection became asymptomatic but had persistent retrograde perfusion and expansion of the false lumen. CONCLUSION: Periscope grafts are a viable option for urgent endovascular repair of acute Crawford type I TAAA. In type B dissections, however, they are at most a bridging solution until more definitive exclusion of the false lumen is achieved.

Examining the impact of psychological distress on short-term postoperative outcomes after elective endovascular aneurysm repair (EVAR).

PURPOSE: Preoperative psychological factors have an impact on postoperative outcomes and there is a paucity of research in vascular surgery. The objective of this study was to examine the impact of preoperative psychological factors on short-term postoperative outcomes in an infrarenal endovascular aneurysm repair (EVAR) cohort. METHODS: A prospective, multi-centre observational study was conducted across three vascular units in England. English-speaking participants who were older than 18 years, able to provide informed consent and awaiting an elective standard infrarenal EVAR were eligible for the study. A total of 46 patients undergoing elective infrarenal AAA repair were assessed preoperatively with the State Trait Anxiety Inventory (STAI), Beck's Depression Inventory (BDI-II) and Life Orientation Test-Revised (LOT-R). Data on five short-term postoperative outcomes was collected and analysed using Spearman's rank correlations. RESULTS: Higher preoperative anxiety levels (ρ = 0.38, p = 0.01), and depression scores (ρ = 0.36, p = 0.02) were moderately correlated with an increased length of postoperative critical care stay. Higher levels of preoperative depression were moderately correlated with greater postoperative opioid analgesia use (ρ = 0.34, p = 0.02). No correlation was witnessed between optimism scores and postoperative outcomes. No correlation was witnessed with respect to total length of stay, number of complications, or time to mobilisation. CONCLUSIONS: There is a potential link between preoperative psychological well-being and short-term postoperative outcomes in an EVAR cohort. Further work is necessary to validate this link and examine the role of preoperative interventions in optimising the psychological well-being of patients undergoing EVAR.