Evaluation of false lumen occluders implanted in the abdominal aorta false lumen.

OBJECTIVE: Management of postdissection thoracoabdominal aneurysms with a fenestrated and/or branched endograft (F/BEVAR) is associated with favorable outcomes. Treatment should include both true lumen endografting and false lumen occlusion (FLO). Favorable results have recently been reported for FLO in the false lumen of the thoracic aorta. The purpose of this study is to analyze the results of FLO of the abdominal aorta in patients treated for post dissection thoracoabdominal aneurysm. METHODS: A multicenter retrospective analysis of prospective data of consecutive patients managed for post dissection thoracoabdominal aortic aneurysm from April 2019 to December 2022 with F/BEVAR associated with FLO in the abdominal false lumen was conducted. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) was followed. Baseline demographics, operative details, and early outcomes (mortality, length of stay) were recorded. Primary endpoints were technical and clinical success. FLO technical success was defined as complete occlusion of false lumen backflow above the FLO on completion angiogram. RESULTS: During the 3-year study, 23 patients were treated for post dissection thoracoabdominal aneurysm with F/BEVAR and the use of abdominal FLO. Twenty-one patients (91.3%) had received prior endovascular treatment. The technical and clinical success was 95.7%. The abdominal FLO had a technical success rate of 78.3%. The median diameter of the FLO was 34 mm. No patient died during the perioperative period, and one patient had spinal cord ischemia (4.3%) with partial recovery. Six patients (26.1%) required early reintervention. The median duration of hospitalization in the intensive care unit and overall was 1 day (interquartile range, 0-3 days) and 7.5 days (interquartile range, 2-22 days), respectively. During the mean follow-up of 9.9 ± 9.0 months, no patient died. False lumen occlusion was complete or partial in nine (39.1%) and nine (39.1%) patients, respectively. No aortic rupture occurred during follow-up. Maximum aortic diameter decreased in 48% and remained stable in 39% of cases. CONCLUSIONS: Abdominal aorta FLO during endovascular treatment of post dissection thoracic abdominal aortic aneurysm is associated with favorable outcomes. It offers an additional staging therapeutic option before extensive aorto-bi-iliac coverage, associated with low spinal cord ischemia rates. FLO also provides high rates of false lumen occlusion and false lumen remodeling during follow-up. Longer follow-up and larger cohorts are required to confirm these very promising early findings.

Virtual Reality to Ease Endovascular Repair of Thoracoabdominal Aneurysms Under Local Anesthesia.

Purpose: Virtual reality (VR) has both a non-pharmacological analgesic and anxiolytic action that can be used as an alternative to general anesthesia for very high-risk patients. Case report: We present here the case of a patient treated for a complex endovascular thoracoabdominal aortic aneurysm exclusion using a 4-fenestrated aortic endograft using VR. The patient had no postoperative complications and was safely discharged from the hospital on postoperative day 6. Conclusion: This case demonstrates that the use of VR in addition to local anesthesia can be a safe alternative to general anesthesia.

Midterm Outcomes of BeGraft Stent Grafts Used as Bridging Stents in Fenestrated Endovascular Aortic Aneurysm Repair.

PURPOSE: Fenestrated endovascular aneurysm repair (fEVAR) is established for the treatment of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms (TAAAs). Bridging stents are used to connect the main body of the stent graft to the aortic branch vessels. Complications related to the bridging stents compromise the durability of the repair and require urgent re-intervention. Here we present the midterm results of the BeGraft stent graft system used for fEVAR. MATERIALS AND METHOD: All consecutive patients treated with fEVAR and the current BeGraft Peripheral Stent Graft between November 2015 and September 2016 were included. RESULTS: Thirty-nine consecutive patients (38 men) were enrolled and 101 BeGraft second-generation stent grafts were implanted. The median aneurysm diameter was 60 mm (54.5-67.0 mm). Aneurysms were juxtarenal and pararenal (19/39, 48.1%), type 4 TAAA (3/39, 7.7%), type 1, 2, and 3 TAAA (7/39, 17.8%), type 5 TAAA (4/39, 10.2%), and 15.4% (6/39) had a type I endoleak following a previous EVAR. Fifty-five BeGrafts were implanted in mesenteric arteries (22 in coeliac trunks, 31 in the superior mesenteric artery, and 2 in a hepatic or splenic artery) and 46 into renal arteries (24 right and 22 left). The renal artery diameters were 5, 6, 7, and 8 mm in 9, 7, 26, and 4 patients, respectively. Mesenteric arteries were exclusively stented with 9 and 10 mm diameter devices. The median follow-up was 33 months (IQ25 17-IQ75 36). During follow-up, 11 patients died (28%) from non-aneurysm-related causes. The overall patency rates for bridging stents were 98% and 97% at 1 and 2 years, respectively, with a freedom from secondary procedure rate on BeGraft stent grafts of 96% (97/101). All events occurred on stents implanted in renal arteries. CONCLUSION: Early favorable outcomes are confirmed during longer term follow-up. Vigilant surveillance is required.

Comparison of Short and Midterm Aortic Reinterventions in Acute Type A Aortic Dissection Treated by Frozen Elephant Trunk or Conventional Arch Repair.

BACKGROUND: Long-term outcomes after acute type A aortic dissection (ATAAD) are related to remodelling of the descending thoracic aorta and aortic reinterventions. We compared the impact of an extensive repair at the index procedure using the Frozen Elephant Trunk (FET) technique, versus a conventional arch repair, on long-term remodelling of the descending thoracic and reintervention related to the aorta. METHODS: Consecutive patients who underwent conventional arch repair (conventional group) or FET repair (FET group) for an ATAAD from September 2018 to November 2021 were included. Patients who died before discharge or were lost to follow-up prior to the first appointment were excluded from the analysis. Preoperative and postoperative computed tomography angiography was reconstructed and diameter of the true/false lumen of the remaining aorta was compared up to 1 year. Negative (increased total diameter ≥ 5 mm) aortic remodelling was collected for each computed tomography angiography, as well as aortic reinterventions. Comparison of demographic, anatomical, and perioperative complications data were performed using Wilcoxon test for continuous variables or Chi-square test for categorical covariates. The Kaplan-Meier method estimator was used to assess survival rates. The Log rank test was used to compare survival curves between the 2 groups. RESULTS: Thirty nine patients were included, 22 in the conventional group and 17 in the FET group (82% males, mean age 60 ± 12 years). In the FET group, distal anastomosis was performed in zone 0 or 1 for 82% of patients using the simplified delivery technique. Median maximum preoperative descending aortic diameter was larger in the FET group (33 mm [30; 37] vs. 30 mm [28; 32] [P = 0.0172]). At 30 days, the rate of negative remodelling on the descending thoracic aorta was significantly higher in the conventional group (50%) than in the FET group (8%, P = 0.02). At 1 year, Kaplan-Meier analysis shown a freedom from descending aortic negative remodeling of 35.1% (95% confidence interval (CI) 18.7-66.1%) in conventional group and 44.9% (CI 95% 26.1-77.2%) in FET group with no significant difference. However, early negative remodelling was observed for the conventional group. Within a year, freedom from reintervention was observed for 74.4% (95% CI 57.1-97%) of patients in the conventional group and 75.5 (95% CI 57.1-99.7%) of patients in the FET group with no significant difference. CONCLUSIONS: Negative evolution of descending aorta remains a challenge after ATAAD. An extensive repair using the FET technique during the index procedure seems to be associated with satisfying short-term remodelling of descending aorta.

Obesity is Not Associated with Adverse Perioperative or Poorer Clinical Outcomes following Thoracic and Fenestrated-Branched Endovascular Aortic Repair.

BACKGROUND: Obesity is a risk factor for higher morbidity and mortality following open aortic repair but currently there is limited literature on its impact on clinical and procedural outcomes following thoracic endovascular aortic repair (TEVAR) and branched-fenestrated endovascular aortic repair (B-FEVAR). METHODS: We conducted a retrospective case-control analysis of a prospectively collected nonrandomized database to evaluate the effects of obesity on procedural and clinical outcomes after B-FEVAR/TEVAR in treatment of pararenal/thoracoabdominal aortic aneurysm and dissection at the University hospital of Nantes (France) between January 2016 and December 2021. Patients were divided in 2 groups according to their body mass index (BMI) and the rate of technical success, complications (renal, pulmonary, cardiac, and neurological events), 30-day and long-term survival, freedom from target vessel instability and reintervention were compared. RESULTS: 195 patients were included (mean age 69.6 DS±11.2; n = 135, 69.2% men; mean BMI: 26.6 kg/m2 range 19-41) totalling n = 72 (36.8%) TEVAR, n = 107 (55.4%) FEVAR and n = 14 (7.3%) BEVAR. Patients were divided in 2 groups [obese: BMI≥30 kg/m2n = 52 (26.7%); and nonobese, BMI<30 kg/m2, n = 143 (73.3%) that statistically differed only in terms of coronary artery disease (obese 42.3% vs. 26.6% nonobese, P = 0.035) and diabetes (obese 25% vs. 12.6% nonobese, P = 0.03). No statistical differences were noted in primary technical (94.2% vs. 94.4%, P = 1.00) and clinical (92.3% vs. 95.1%, P = 0.49) success. Overall morbidity (30.8% vs. 21.1%, P = 0.16), visceral vessels instability (1.9% vs. 1.4% P = 1.00), reintervention rate within 30 days (9.6% vs. 5.6% P = 0.33), 90 days (7.7% vs. 9.8%, P = 0.78) and during follow-up (9.8% vs. 20%, P = 0.14) were comparable. No statistical difference were noted in 30-day mortality (3.8% vs. 4.9%, P = 1.00) and the 2-year follow-up survival (86.8% vs. 78.4%, P = 0.180) between the 2 groups. CONCLUSIONS: In this series, obesity was not associated to worst clinical outcomes or higher mortality rate following TEVAR/B-FEVAR. However, considering our small patient sample, a conclusive analysis on obesity as risk factors for adverse events after endovascular treatment is not possible. A larger sample from the collaboration of multiple centers will be required to obtain definitive conclusions.

Fusion imaging guidance for endovascular recanalization of peripheral occlusive disease.

OBJECTIVE: Endovascular procedures are now the first line option for treatment of lower extremity arterial disease. Fusion imaging guidance has been reported to reduce radiation exposure and reintervention rates during fenestrated and branched endovascular repairs, but limited literature exists on its benefits during lower extremity arterial disease endovascular procedures, and more specifically peripheral occlusive disease (POD). This study aims to evaluate the radiation exposure and technical success benefits of fusion imaging guidance in a large cohort of patients treated endovascularly for complex POD. METHODS: From January 2017 to September 2019, in a single center, all consecutive patients presenting symptomatic occlusions (Rutherford Baker categories 3 to 6) in the setting of POD and treated endovascularly were retrospectively assessed for inclusion. All procedures were performed under augmented fluoroscopy guidance (Vessel ASSIST, GE Healthcare), overlaying on live imaging the 3D path for transluminal recanalization based on the preoperative computed tomography angiography. Technical success, dose area product (DAP), total cumulated air kerma (CAK), and fluoroscopy time were collected. DAP results were compared with the literature. RESULTS: During the study period, 179 patients were treated for iliac (n = 56) or femoropopliteal (n = 123) symptomatic arterial occlusions. Technical success was reported in 171 of 179 procedures (95.5%). The use of a re-entry catheter was required to achieve technical success in 11 patients (6.1%). Mean DAP and CAK were 12.70 Gy·cm2 and 135 mGy, respectively, with a mean fluoroscopy time of 15.26 minutes. DAP and CAK were significantly higher in the iliac group when compared with the femoropopliteal group, although fluoroscopy time was not significantly different. DAP was lower than levels reported in the literature. CONCLUSIONS: Routine use of fusion imaging guidance during POD endovascular treatment is associated with low radiation exposure, high technical success, and reduced need for re-entry systems.

"First in Man" Total Percutaneous Aortic Arch Repair With 3-Inner-branch Endografts: A Report of Two Cases.

SUMMARY BACKGROUND DATA: Aneurysms of the arch are a complex clinical problem and a technical challenge. Currently, over 40% of patients are considered unfit for conventional open surgery, requiring a cardiopulmonary bypass and hypothermic circulatory arrest. In experienced hands and appropriate anatomic conditions, arch-branched graft technology has shown to be a safe and effective alternative to open conventional surgery to patients that historically have had no surgical options. OBJECTIVES: This report summarizes the first in man implant of a three-vessel arch branch stent graft using a total percutaneous approach without the need for exposure of the cervical arteries-a surgical step with inherent problems and risks. METHODS: This approach was performed in two consecutive patients, a 66-year-old woman with a chronic post type A dissection 60 mm diameter aneurysm of the aortic arch, and a 72-year-old man with a 70 mm saccular degenerative atheromatous aortic arch aneurysm. RESULTS: Technical success was obtained in both cases. The patients were extubated in the operating theatre. Neither suffered any pre- or postoperative neurological deficits. Both were discharged home after remarkably uneventful hospital stays. There were no access complications. Postoperative computerized tomography scans and ultra-sound confirmed patent supra-aortic branches and completely excluded aneurysms. CONCLUSIONS: Our new truly minimally invasive approach demonstrates that it is possible to manage one of the most challenging treatments of aortic pathologies without any surgical incision. Further, evaluation and experience are required to confirm these promising results.

Respiratory-induced changes in renovisceral branch vessel morphology after fenestrated thoracoabdominal aneurysm repair with the BeGraft balloon-expandable covered stent.

OBJECTIVE: We evaluated the respiratory-induced changes in branch vessel geometry after thoracoabdominal fenestrated endovascular aneurysm repair (fEVAR) with the Bentley BeGraft graft (Innomed GmbH, Hechingen, Germany) as the covered bridging stent. METHODS: Patients treated with fEVAR for thoracoabdominal aortic aneurysms with a custom-made Zenith fenestrated endograft (Cook Medical Europe Ltd, Limerick, Ireland) and Bentley BeGraft peripheral stents were prospectively recruited. Using SimVascular software (Open-Source Medical Software Corp, San Diego, CA), the pre- and postoperative aortic and branch contours were segmented from computed tomography angiograms performed during inspiratory and expiratory breath-holds. The centerlines were extracted from the lumen contours, from which the branch take-off angles, distal stent angles, and peak branch curvature changes were computed. Paired, two-tailed t tests were performed to compare the pre- and postoperative deformations. RESULTS: Renovisceral vessel geometry was evaluated in 12 patients undergoing fEVAR with a total of 46 target vessels (10 celiac arteries, 12 superior mesenteric arteries [SMAs], 24 renal arteries). Implantation of BeGraft bridging stents was associated with a significant reduction in respiration-induced changes in vessel branch angulation (Δ5.3° ± 3.9° vs Δ12.0° ± 8.3° [postoperative vs preoperative]; P = .001) and mean curvature (0.72 ± 0.22 cm-1 vs 0.53 ± 0.18 cm-1) in the renal arteries, without significant changes in the celiac arteries or SMAs. No significant difference was found in end-stent angle motion in the renal arteries (P = .77), celiac arteries (P = .34), or SMAs (P = .55). The maximum local vessel curvature change decreased after fEVAR in the SMAs (Δ0.28 cm-1 vs Δ0.47 cm-1; P = .04) but was unchanged in the celiac (P = .61) and renal (P = .51) arteries. CONCLUSIONS: Implantation of the BeGraft as a bridging stent in fEVAR was associated with decreased respiratory-induced deformation in the renal branch take-off angulation and mean renal artery curvature, with reduced maximum curvature bending in the SMA compared with the preoperative anatomy. However, the BeGraft allowed for celiac and renal artery bending similar to that in the native preoperative state. These findings suggest that the use of BeGraft peripheral stents with fEVAR will closely mimic the native arterial branch geometry and vessel conformability caused by relatively aggressive respiratory motion.

Carotid webs management in symptomatic patients.

BACKGROUND: Atypical fibromuscular dysplasia (AFMD), also known as carotid web, is a rare underdiagnosed shelf-like fibrous tissue arising from the posterior carotid artery bulb that is a cause of cryptogenic stroke of the anterior cerebral vascularization. Despite the recurrence and severity of strokes caused by embolization associated with AFMD, there are no recommendations on the best strategy to manage single and bilateral lesions, which have unsatisfactory outcomes when treated with medical treatment exclusively. METHODS: From January 2016 to April 2019, 365 patients were operated on for a carotid stenosis in our institution. This cohort included 11 patients (3%), with a median age of 41 years (range, 39-51 years), referred by a stroke unit, treated for a symptomatic (10 strokes and 1 recurrent transient ischemic attack) AFMD lesion. Preoperative workup revealed a contralateral similar lesion in 45% of patients (5/11), which all also underwent surgery during a subsequent hospitalization. The diagnosis was confirmed by histologic examination when open surgery was performed. The 30-day and 1-year outcomes were retrospectively reviewed. RESULTS: Of the 16 AFMD lesions operated, 13 were treated by open surgery (2 by classic endarterectomy and 11 by internal carotid resection-anastomosis) and 3 by carotid artery stenting, respectively, with a mean delay of 85.5 days and 20.5 days after the latest stroke. There was one complication after stenting (external iliac rupture) that was treated by a covered stent, and no perioperative complications after open surgery. The follow-ups at 30 days and 1 year were uneventful for all patients, without any deaths or stroke recurrences. CONCLUSIONS: Symptomatic AFMD is a rare cause of cryptogenic stroke. Bilateral lesions are frequent. Early intervention is associated with favorable perioperative and 1-year outcomes. Open surgery is the first-line therapeutic option in this young patient population.

Multicenter global early feasibility study to evaluate total endovascular arch repair using three-vessel inner branch stent-grafts for aneurysms and dissections.

OBJECTIVE: We evaluated the outcomes of total endovascular aortic arch repair using three-vessel inner branch stent-grafts for aneurysms and chronic dissections. METHODS: We reviewed the clinical data and outcomes of consecutive patients treated by total endovascular aortic arch repair at eight academic centers using three-vessel inner branch stent-grafts (William Cook Europe, Bjaeverskov, Denmark) from 2016 to 2019. All patients received three-vessel designs with two antegrade and one retrograde inner branch, which was used to incorporate the innominate, left common carotid, and left subclavian arteries. The antegrade inner branches were accessed via a carotid or an upper extremity approach. A preloaded catheter was used for access to the retrograde left subclavian artery branch via a transfemoral approach. The endpoints were technical success, mortality, major adverse events, any stroke (minor or major) or transient ischemia attack, secondary interventions, target vessel patency, target vessel instability, aneurysm-related mortality, and patient survival. RESULTS: A total of 39 patients (31 men [79%]; mean age, 70 ± 7 years) had undergone treatment of 14 degenerative (36%) and 25 chronic (64%) postdissection arch aneurysms. The clinical characteristics included American Society of Anesthesiologists class ≥III in 28 patients (95%) and previous median sternotomy for ascending aortic repair in 28 patients (72%). The technical success rate was 100%. Two patients had died in-hospital or within 30 days (5%), and two patients had experienced a stroke (one minor). The combined mortality and any stroke rate was 8% (n = 3). Major adverse events occurred in 10 patients (26%), including respiratory failure in 4 (10%) and estimated blood loss >1 L, myocardial infarction, and acute kidney injury in 2 patients each (5%). The median follow-up was 3.2 months (interquartile range, 1-14 months). Of the 39 patients, 12 (31%) required secondary interventions to treat vascular access complications in 5, endoleak in 6 (three type II, one type Ic, one type Ia/Ib, one type IIIa), and target vessel stenosis in 1 patient. At 1 year, the primary and secondary patency rates and freedom from target vessel instability were 95% ± 5%, 100%, and 91% ± 5%, respectively. Freedom from aortic-related mortality and patient survival was 94% ± 4% and 90% ± 6%, respectively. CONCLUSIONS: The findings from the present multicenter global experience have demonstrated the technical feasibility and safety of total endovascular aortic arch repair for aneurysms and chronic dissections using three-vessel inner branch stent-grafts. The mortality and stroke rates compare favorably with those after open surgical repair in a higher risk group of patients. However, the rate of secondary interventions was high (31%), emphasizing need for greater experience and longer follow-up.

Pre-surgical and Post-surgical Aortic Aneurysm Maximum Diameter Measurement: Full Automation by Artificial Intelligence.

OBJECTIVE: The aim of this study was to evaluate an automatic, deep learning based method (Augmented Radiology for Vascular Aneurysm [ARVA]), to detect and assess maximum aortic diameter, providing cross sectional outer to outer aortic wall measurements. METHODS: Accurate external aortic wall diameter measurement is performed along the entire aorta, from the ascending aorta to the iliac bifurcations, on both pre- and post-operative contrast enhanced computed tomography angiography (CTA) scans. A training database of 489 CTAs was used to train a pipeline of neural networks for automatic external aortic wall measurements. Another database of 62 CTAs, including controls, aneurysmal aortas, and aortic dissections scanned before and/or after endovascular or open repair, was used for validation. The measurements of maximum external aortic wall diameter made by ARVA were compared with those of seven clinicians on this validation dataset. RESULTS: The median absolute difference with respect to expert's measurements ranged from 1 mm to 2 mm among all annotators, while ARVA reported a median absolute difference of 1.2 mm. CONCLUSION: The performance of the automatic maximum aortic diameter method falls within the interannotator variability, making it a potentially reliable solution for assisting clinical practice.

Prospective, Randomised Two Centre Trial of Endovascular Repair of Abdominal Aortic Aneurysm With or Without Sac Embolisation.

OBJECTIVE: The benefit of aneurysm sac coil embolisation (ASCE) during endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) remains unclear. This prospective randomised two centre study (SCOPE 1: Sac COil embolisation for Prevention of Endoleak) compared the outcomes of standard EVAR in patients with AAA at high risk of type II endoleak (EL with EVAR with ASCE during the period 2014-2019. METHODS: Patients at high risk of type II EL were randomised to standard EVAR (group A) or EVAR with coil ASCE (group B). The primary endpoint was the rate of all types of EL during follow up. Secondary endpoints included freedom from type II EL related re-interventions, and aneurysm sac diameter and volume variation at two year follow up. Adverse events included type II EL and re-interventions. CTA and Duplex ultrasound scans were scheduled at 30 days, six months, one year, and two years after surgery. RESULTS: Ninety-four patients were enrolled, 47 in each group. There were no intra-operative complications. At M1, 16/47 early type II EL occurred (34%) in group A vs. 2/47 (4.3%) in group B (p < .001). At M6, 15/36 type II EL (41.7%) occurred in group A vs. 2/39 (4.26%) in group B (p < .001). At M12, 15/37 type II El (40.5%) occurred in group A vs. 5/35 (14.3%) in group B (p = .018). At 24 months, 8/32 type 2 El (25%) occurred in group A vs. 3/29 (6.5%) in group B (p = .19). Kaplan-Meier curves of survival free from EL and re-interventions were significantly in favour of group B (p < .001). Aneurysm sac volume decreased significantly in group B compared with group A at M6 (p = .081), at M12 (p = .004), and M24 (p = .001). CONCLUSION: For selected patients at risk of EL, ASCE seems effective in preventing EL at one, six, and at 12 months. However, the difference was not statistically significant at 24 months. ASCE decreases the re-intervention rate two years after EVAR. A significantly faster aneurysm volume shrinkage was observed at one and two years following surgery. (SCOPE 1 trial: NCT01878240).

Applicability of a standardized thoracic endograft with a single branch for the left subclavian artery to treat aortic disease involving the distal arch.

OBJECTIVE: Coverage of the left subclavian artery (LSA) origin during thoracic endovascular aortic repair (TEVAR) is associated with increased neurologic complications. Our group is involved in the development of an off-the-shelf (OTS) thoracic endograft incorporating a left common carotid artery (LCCA) scallop and a retrograde inner branch for LSA perfusion. This study aimed to evaluate the arch morphology of patients treated by TEVAR and requiring LSA coverage to determine the applicability of this OTS device. METHODS: The preoperative anatomy of consecutive patients from three separate cohorts treated with TEVAR with LSA coverage was studied. High-quality preoperative computed tomography angiography images were analyzed on an imaging workstation. Location of the origin of the supra-aortic trunks and their anatomic relationship were depicted in all patients; the LCCA origin was set as reference point. We determined the proportion of arch morphology in our cohort of patients eligible for this OTS device configuration. RESULTS: There were 196 patients included in this study, 132 in the dissection cohort and 64 in the aneurysm cohort. The median length from the lower margin of the LCCA to the proximal aspect of the pathologic process was 25.0 mm (18.2-35.2 mm), with 68.4% (n = 134) of our cohort presenting with a proximal sealing zone length >20 mm. The median LCCA-LSA distance was 20.8 mm (16.6-25.4 mm). The median clock position of the LSA from the LCCA was -10 minutes (-30 to 0 minutes). In total, 127 patients (64.8%) could have been treated with the current OTS branched TEVAR configuration; 59 were excluded for proximal neck length distal to the LCCA <20 mm and 10 because of the clock position of the LCCA, and 9 first required a vertebral artery transposition. CONCLUSIONS: The low variability of LSA and LCCA locations in patients with distal aortic arch disease offers wide applicability of a new standardized thoracic branched endograft.

Off-the-shelf multibranched endograft for total endovascular repair of the aortic arch.

OBJECTIVE: The goal of this study was to select branched endograft designs that could fit most aortic arch anatomies. Such off-the-shelf endografts, once available, would be an endovascular therapeutic option to consider in the acute setting and would shorten the design and manufacturing process. METHODS: We retrospectively analyzed the endograft plans of all custom-made aortic arch branched endografts implanted between 2013 and early 2018 provided by the Cook Planning Center (EMEA Planning Services; Cook Medical, London, United Kingdom). Available data points of the endograft plans include proximal, intermediate, and distal endograft diameters; number of sealing stents; total length of the endograft; and number of branches. RESULTS: There were 286 two-branch endografts analyzed. We divided the endografts in three groups according to their proximal diameters: 34 mm, 36 mm, and 38 mm (group 1); 40 mm and 42 mm (group 2); and 44 mm and 46 mm (group 3). In group 1, 63% of the endografts had one proximal sealing stent, whereas in group 3, 63% had two proximal sealing stents. The distal diameters of the endografts ranged from 26 mm to 46 mm. The mean length was 236 mm (186-256 mm). A shorter standardized length of 211 mm was selected to anticipate distal extensions. According to our analysis, most group 1 patients could have been treated with a 38-mm proximal diameter and 30-mm distal diameter endograft with one sealing stent; most group 2 patients, with a 42-mm proximal diameter and 32-mm distal diameter endograft with both one and two proximal sealing stents; and most group 3 patients, with a 46-mm proximal diameter and 36-mm distal diameter endograft, also with both one and two proximal sealing stents. CONCLUSIONS: Five standardized off-the-shelf endografts can cover a majority of aortic arch anatomies and offer an option for acute endovascular treatment of aortic arch disease.

Endovascular management of chronic post-dissection aneurysms of the aortic arch.

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

Stent coating by electrospinning with chitosan/poly-cyclodextrin based nanofibers loaded with simvastatin for restenosis prevention.

The main cause of failure of angioplasty stenting is restenosis due to neointimal hyperplasia, a too high proliferation of smooth muscle cells (SMC). The local and sustained delivery of selective pleiotropic drugs to limit SMC proliferation seems to be the hopeful solution to minimize this post surgery complication. The aim of this study is to develop a stent covered by nanofibers (NFs) produced by electrospinning, loaded with simvastatin (SV), a drug commonly used for restenosis prevention. NFs were prepared from the electrospinning of a solution containing SV and a mixture of chitosan (cationic) and ß-cyclodextrin (CD) polymer (anionic) which form together a polyelectrolyte complex that makes up the NFs matrix. First, the SV/CD interactions were studied by phase solubility diagram, DRX and DSC. The electrospinning process was then optimized to cover a self-expandable NiTiNOL stent and the mechanical resistance of the NFs sheath upon its introduction inside the delivery catheter was considered, using a crimper apparatus. The morphology, coating thicknesses and diameters of nanofibers were studied by scanning electron microscopy. The SV loading rates on the stents were controlled by the electrospinning time, and the presence of SV in the NFs was confirmed by FTIR. NFs stability in PBS pH 7.4 buffer could be improved after thermal post-treatment of NFs and in vitro release of SV in dynamic conditions demonstrated that the release profiles were influenced by the presence of CD polymer in NFs and by the thickness of the NFs sheath. Finally, a covered stent delivering 3 µg/mm2 of SV within 6 h was obtained, whose efficiency will be investigated in a further in vivo study.