Perspective or Spectacle? Teaching thoracic aortic anatomy in a mixed reality assisted educational approach- a two-armed randomized pilot study.

PURPOSE: Anatomical understanding is an important basis for medical teaching, especially in a surgical context. The interpretation of complex vascular structures via two-dimensional visualization can yet be difficult, particularly for students. The objective of this study was to investigate the feasibility of an MxR-assisted educational approach in vascular surgery undergraduate education, comparing an MxR-based teaching-intervention with CT-based material for learning and understanding the vascular morphology of the thoracic aorta. METHODS: In a prospective randomized controlled trial learning success and diagnostic skills following an MxR- vs. a CT-based intervention was investigated in 120 thoracic aortic visualizations. Secondary outcomes were motivation, system-usability as well as workload/satisfaction. Motivational factors and training-experience were also assessed. Twelve students (7 females; mean age: 23 years) were randomized into two groups undergoing educational intervention with MxR or CT. RESULTS: Evaluation of learning success showed a mean improvement of 1.17 points (max.score: 10; 95%CI: 0.36-1.97). The MxR-group has improved by a mean of 1.33 [95% CI: 0.16-2.51], against 1.0 points [95% CI: -0.71- 2.71] in the CT-group. Regarding diagnostic skills, both groups performed equally (CT-group: 58.25 ± 7.86 vs. MxR-group:58.5 ± 6.60; max. score 92.0). 11/12 participants were convinced that MxR facilitated learning of vascular morphologies. The usability of the MxR-system was rated positively, and the perceived workload was low. CONCLUSION: MxR-systems can be a valuable addition to vascular surgery education. Further evaluation of the technology in larger teaching situations are required. Especially regarding the acquisition of practical skills, the use of MxR-systems offers interesting application possibilities in surgical education.

Role of Antiplatelet Therapy in Patients Managed for Complex Aortic Aneurysms using Fenestrated or Branched Endovascular Repair.

OBJECTIVE: Despite the increasing number of fenestrated/branched endovascular aortic repair (f/bEVAR) procedures, evidence on post-operative antiplatelet therapy is lacking. This study aimed to investigate the role of single antiplatelet therapy (SAPT) vs. double antiplatelet therapy (DAPT) after f/bEVAR on 30 day and follow up outcomes. METHODS: A multicentre retrospective analysis was conducted, including f/bEVAR patients managed from 1 January 2018 to 31 December 2022. Comparative outcomes were assessed according to post-operative antiplatelet therapy. The cohort was divided into the SAPT group (acetylsalicylic acid [ASA] or clopidogrel) and DAPT group (ASA and clopidogrel). The duration of SAPT or DAPT was one to six months. Primary outcomes were 30 day death, and cardiovascular ischaemic and major haemorrhagic events. Secondary outcomes were survival and target vessel (TV) patency during follow up. RESULTS: A total of 1 430 patients were included: 955 under SAPT and 475 under DAPT. The 30 day mortality was similar (SAPT 2.1% vs. DAPT 1.5%; p = .42). Cardiovascular ischaemic events were lower in the DAPT group (SAPT 11.9% vs. DAPT 8.2%; p = .040), with DAPT being an independent protector for acute mesenteric (p = .009) and lower limb ischaemia (p = .020). No difference was found in 30 day major haemorrhagic events (SAPT 7.5% vs. DAPT 6.3%; p = .40). The mean follow up was 21.8 ± 2.9 months. Cox regression showed no cofounders on survival, with similar rates between groups (log rank p = .71). DAPT patients presented higher TV patency (SAPT 93.4%, standard error [SE] 0.7% vs. DAPT 96.6%, SE 0.7%; log rank p = .007) at thirty six months. Cox regression revealed bEVAR as a predictor of worse TV patency (hazard ratio 2.03, 95% confidence interval 1.36 - 3.03; p < .001). DAPT was related to higher patency within bEVAR patients (SAPT 87.2%, SE 2.1% vs. DAPT 94.9%, SE 1.9%; p < .001). CONCLUSIONS: DAPT after f/bEVAR was associated with lower risk of cardiovascular ischaemic events and higher TV patency, especially in bEVAR cases. No difference in major haemorrhagic events was observed at 30 days.

Gender-Specific Long-Term Results After Elective Open Abdominal Aortic Aneurysm Repair Depending on the Site of Distal Anastomosis.

OBJECTIVE: Analysis of gender-specific differences in short- and long-term outcome after elective open abdominal aortic aneurysm repair (OAR) regarding the distal anastomosis. METHODS: In this retrospective cohort study, data from 4853 patients of a German health insurance company undergoing OAR for infrarenal abdominal aortic aneurysms (AAAs) between 2010 and 2016 were analysed. The patients were followed through 2018. RESULTS: A total of 4050 (83.5%) men and 803 (16.6%) women underwent OAR. Women were older than men (72.9 ± 8.7 vs 69.8 ± 8.5 years; P < .001). A tube graft was used in 2644 (54.5%) patients, an aorto-biiliac bifurcated graft in 1657 (34.1%) and an aorto-bifemoral bifurcated graft in 552 (11.4%). Perioperative mortality was not significantly different between men (5.7%) and women (6.5%) in the total patient population (P = .411). This was true for aorto-aortic tube grafting (P = .361), aorto-biiliac reconstructions (P = 1.000) and aorto-bifemoral reconstructions (P = .345). Kaplan-Meier estimated long-term survival of men after 9 years was better than that of women (55.0% vs 43.8%; P = .006). However, separated by the site of the distal anastomosis, this was only true for aorto-aortic reconstructions (survival men vs women 56.0% vs 42.1%; P = .005), not for aorto-biiliac and aorto-bifemoral reconstructions. In the multivariate Cox regression analysis, age over 80 years, heart failure, aorto-bifemoral reconstruction, chronic kidney disease stage 3-5, chronic obstructive pulmonary disease, peripheral artery disease, arterial hypertension, but not gender (P = .531), had a negative impact on long-term survival. CONCLUSION: If possible, an aorto-aortic tube graft should be preferred to aorto-biiliac and aorto-bifemoral reconstructions in OAR. Patients selected for aorto-bifemoral artery reconstruction exhibit higher perioperative morbidity and mortality as well as worse long-term survival compared to patients selected for an intra-abdominal reconstruction. In the multivariate regression analysis, gender was not an independent risk factor for either short- or long-term outcomes.

Biomarker-guided detection of acute kidney injury in abdominal aortic surgery: the new and the old.

Introduction: Acute kidney injury (AKI) is a common complication in patients undergoing major vascular surgery. Despite significant research efforts in this area, the incidence of AKI remains high, posing a significant challenge to healthcare systems, especially in situations where resources are limited. Early prediction of AKI severity and individualized postoperative care is therefore essential. Methods: The primary objective of this exploratory study was to assess the diagnostic value of urine cell-cycle arrest biomarkers [(TIMP-2) × (IGFBP7)] and soluble urokinase plasminogen activator receptor (suPAR) for predicting moderate or severe AKI within 24 h after open aortic surgery, and compared to routine kidney biomarkers. Seventy-five patients undergoing elective aortic surgery were included. Clinical parameters, urine and blood samples were collected preoperatively, immediately postoperatively, and 24 h later. AKI was defined using KDIGO criteria. Individual and combined diagnostic performance of biomarkers were evaluated. Results: Of the 75 patients, 61% developed AKI, of which 28% developed moderate or severe AKI within 24 h of surgery. Baseline demographics, comorbidities and kidney parameters did not differ between patients with moderate or severe AKI (AKI II/III) and none or mild AKI (AKI 0/I), except for higher preoperative suPAR levels in later AKI II/III patients. Urine osmolality, Cystatin C and serum creatinine had the highest predictive power for AKI II/III with AUCs of 0.75-0.72. (TIMP-2) × (IGFBP7), and neither (TIMP-2) × (IGFBP7) nor suPAR individually showed superior diagnostic value. Combining CysC or SCr with urine osmolality and 6 h urine output gave the best performance with AUCs of 0.86 (95% CI, 0.74-0.96) and 0.85 (95% CI, 0.75-0.95) respectively. Conclusion: Our study suggests that routine parameters like urine osmolality, CysC, SCr and 6 h urine output perform best in predicting postoperative AKI after aortic surgery compared to the new biomarkers (TIMP-2) × (IGFBP7) and suPAR. Combining biomarkers, particularly CysC or SCr with urine output, urine osmolality, may enhance diagnostic accuracy. Further validation in larger cohorts and clinical settings is warranted to establish their clinical utility.

Long-Term Outcome of Lower Extremity Bypass Surgery in Patients with Chronic Kidney Disease and Critical Limb Ischemia in Germany.

BACKGROUND: The aim of this study is to present short- and long-term outcomes after lower extremity bypass (LEB) surgery in patients with chronic limb-threatening ischemia and chronic kidney disease (CKD), differentiated by peripheral artery disease (PAD) Fontaine stage III and IV. METHODS: Retrospective analysis of anonymized data from a nationwide German health insurance company (AOK). Data from 22,633 patients (14,523 men) who underwent LEB from 2010 to 2015 were analyzed, presenting 18,271 with CKD stage 1/2, 2,483 patients with CKD stage 3, and 1,879 with CKD stage 4/5. RESULTS: Perioperative mortality (60-day mortality) was 7.2% for CKD stage 1/2, 12.4% for CKD stage 3, and 19.8% for CKD stage 4/5. Patients with PAD stage IV had significantly higher perioperative mortality (10.3%) than patients with PAD stage III (4.5%). The perioperative major amputation rate depended significantly on PAD stage IV (odds ratio [OR]: 2.57 confidence interval [CI]: 2.16-3.05, P < 0.001), the LEB level below the knee and crural/pedal (OR: 2.49 CI: 2.14-2.90, P < 0.001), CKD stage 4/5 (OR: 1.28, CI: 1.06-1.54, P = 0.009), and the presence of diabetes mellitus type 2 (OR: 1.19, CI: 1.05-1.36, P = 0.007). Kaplan-Meier estimated long-term survival of up to 9 years after surgery was 31.7% for patients with CKD stage 1 and 2, 14.3% for CKD stage 3, and only 10.1% for CKD stage 4 and 5 (P < 0.001). PAD Fontaine stage IV versus III (hazard ratio: 1.64, CI: 1.56-1.71, P < 0.001), but not bypass level, had an independent adverse influence on long-term survival. CONCLUSION: CKD and PAD stage were equally significant independent predictors of patient survival and major adverse cardiovascular events with higher PAD and CKD stages associated with less favorable long-term outcomes.

Multicenter CT Image-Based Anatomic Assessment of Patients with Aortoiliac Aneurysm Undergoing Endovascular Repair with Iliac Branch Devices.

BACKGROUND: The Global Iliac Branch Study (NCT05607277) is an international, multicenter, retrospective cohort study of anatomic predictors of adverse iliac events (AIEs) in aortoiliac aneurysms treated with iliac branch devices (IBDs). METHODS: Patients with pre-IBD and post-IBD computed tomography imaging were included. We measured arterial diameters, stenosis, calcification, bifurcation angles, and tortuosity indices using a standardized, validated protocol. A composite of ipsilateral AIE was defined, a priori, as occlusion, type I or III endoleak, device constriction, or clinical event requiring reintervention. Paired t-test compared tortuosity indices and splay angles pretreatment and post-treatment for all IBDs and by device material (stainless steel and nitinol). Two-sample t-test compared anatomical changes from pretreatment to post-treatment by device material. Logistic regression assessed associations between AIE and anatomic measurements. Analysis was performed by IBD. RESULTS: We analyzed 297 patients (286 males, 11 females) with 331 IBDs (227 stainless steel, 104 nitinol). Median clinical follow-up was 3.8 years. Iliac anatomy was significantly straightened with all IBD treatment, though stainless steel IBDs had a greater reduction in total iliac artery tortuosity index and aortic splay angle compared to nitinol IBDs (absolute reduction -0.20 [-0.22 to -0.18] vs. -0.09 [-0.12 to -0.06], P < 0.0001 and -19.6° [-22.4° to -16.9°] vs. -11.2° [-15.3° to -7.0°], P = 0.001, respectively). There were 54 AIEs in 44 IBDs in 42 patients (AIE in 13.3% of IBD systems), requiring 35 reinterventions (median time to event 41 days; median time to reintervention 153 days). There were 18 endoleaks, 29 occlusions, and 5 device constrictions. There were no strong associations between anatomic measurements and AIE overall, though internal iliac diameter was inversely associated with AIE in nitinol devices (nAIE, nitinol = 8). CONCLUSIONS: Purpose-built IBDs effectively treat aortoiliac disease, including that with tortuous anatomy, with a high patency rate (91.5%) and low reintervention rate (9.1%) at 4 years. Anatomic predictors of AIE are limited.

Simulation of thoracic endovascular aortic repair in a perfused patient-specific model of type B aortic dissection.

PURPOSE: Complicated type B Aortic dissection is a severe aortic pathology that requires treatment through thoracic endovascular aortic repair (TEVAR). During TEVAR a stentgraft is deployed in the aortic lumen in order to restore blood flow. Due to the complicated pathology including an entry, a resulting dissection wall with potentially several re-entries, replicating this structure artificially has proven to be challenging thus far. METHODS: We developed a 3d printed, patient-specific and perfused aortic dissection phantom with a flexible dissection flap and all major branching vessels. The model was segmented from CTA images and fabricated out of a flexible material to mimic aortic wall tissue. It was placed in a pulsatile hemodynamic flow loop. Hemodynamics were investigated through pressure and flow measurements and doppler ultrasound imaging. Surgeons performed a TEVAR intervention including stentgraft deployment under fluoroscopic guidance. RESULTS: The flexible aortic dissection phantom was successfully incorporated in the hemodynamic flow loop, a systolic pressure of 112 mmHg and physiological flow of 4.05 L per minute was reached. Flow velocities were higher in true lumen with a up to 35.7 cm/s compared to the false lumen with a maximum of 13.3 cm/s, chaotic flow patterns were observed on main entry and reentry sights. A TEVAR procedure was successfully performed under fluoroscopy. The position of the stentgraft was confirmed using CTA imaging. CONCLUSIONS: This perfused in-vitro phantom allows for detailed investigation of the complex inner hemodynamics of aortic dissections on a patient-specific level and enables the simulation of TEVAR procedures in a real endovascular operating environment. Therefore, it could provide a dynamic platform for future surgical training and research.

Deciphering Popliteal Artery Aneurysm Patient Diversity: Insights From a Cluster Analysis of the POPART Registry.

BACKGROUND: Popliteal artery aneurysms (PAAs) are the most common peripheral aneurysm. However, due to its rarity, the cumulative body of evidence regarding patient patterns, treatment strategies, and perioperative outcomes is limited. This analysis aims to investigate distinct phenotypical patient profiles and associated treatment and outcomes in patients with a PAA by performing an unsupervised clustering analysis of the POPART (Practice of Popliteal Artery Aneurysm Repair and Therapy) registry. METHODS AND RESULTS: A cluster analysis (using k-means clustering) was performed on data obtained from the multicenter POPART registry (42 centers from Germany and Luxembourg). Sensitivity analyses were conducted to explore validity and stability. Using 2 clusters, patients were primarily separated by the absence or presence of clinical symptoms. Within the cluster of symptomatic patients, the main difference between patients with acute limb ischemia presentation and nonemergency symptomatic patients was PAA diameter. When using 6 clusters, patients were primarily grouped by comorbidities, with patients with acute limb ischemia forming a separate cluster. Despite markedly different risk profiles, perioperative complication rates appeared to be positively associated with the proportion of emergency patients. However, clusters with a higher proportion of patients having any symptoms before treatment experienced a lower rate of perioperative complications. CONCLUSIONS: The conducted analyses revealed both an insight to the public health reality of PAA care as well as patients with PAA at elevated risk for adverse outcomes. This analysis suggests that the preoperative clinic is a far more crucial adjunct to the patient's preoperative risk assessment than the patient's epidemiological profile by itself.

The Effect of One Year Aneurysm Sac Dynamics on Five Year Mortality and Continued Aneurysm Sac Evolution.

OBJECTIVE: One year aneurysm sac dynamics after endovascular abdominal aortic aneurysm repair (EVAR) were independently associated with a greater all cause mortality risk in prior registry studies but were limited in completeness and granularity. This retrospective analysis aimed to study the impact of sac dynamics on survival within the Endurant Stent Graft Global Registry (ENGAGE) with five year follow up. METHODS: A total of 1 263 subjects were enrolled in the ENGAGE Registry between March 2009 and April 2011. One year aneurysm sac changes were calculated between the one month post-operative imaging scans and the scan closest to the time of one year follow up. Sac regression was defined as a sac decrease of ≥ 5 mm and sac expansion as aneurysm sac growth ≥ 5 mm. The primary outcome was the five year all cause mortality rate. Kaplan-Meier estimates for freedom from all cause death were calculated. Multivariable Cox regression was used to determine the association between sac dynamics and all cause death. RESULTS: At one year, 441 of the 949 study participants with appropriate imaging (46%) had abdominal aortic aneurysm sac regression, 462 (49%) remained stable, and 46 (4.8%) had sac expansion. For patients with sac regression, the five year all cause mortality rate was 20%, compared with 28% for stable sac (p = .007) and 37% for the sac expansion (p = .010) cohorts. After adjustment, the sac expansion and stable sac cohorts were associated with a greater all cause mortality rate (expansion: hazard ratio [HR] 1.8; 95% CI 1.1 - 3.2; p = .032; stable: HR 1.4; 95% CI 1.1 - 1.9; p = .019). CONCLUSION: In the ENGAGE Global Registry, the one year rate of sac regression was 46%, and one year sac regression was observed to be associated with greater five year survival, corroborating prior findings using data from vascular registries. Sac regression could become the new standard for success after EVAR.

Five-year outcomes of endovascular treatment for aortic dissection from the Global Registry for Endovascular Aortic Treatment.

OBJECTIVE: The Global Registry for Endovascular Aortic Treatment (GREAT) is an International prospective multicenter registry collecting real-world data on performance of Gore aortic endografts. The purpose was to analyze the long-term outcomes and patient survival rates, as well as device performance in patients undergoing thoracic endovascular aortic repair for acute and chronic and complicated or uncomplicated type B aortic dissection (TBAD). METHODS: From August 2010 to October 2016, 5014 patients were enrolled in the GREAT registry. The study population were patients treated with thoracic endovascular aortic repair for TBAD through 5-year follow-up (days 0-2006). The primary outcomes for this analysis were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, and any reintervention through 5 years. RESULTS: We identified 265 patients. The mean age was 60.9 ± 11.9 years (range, 19-84 years; 211 males [79.6%]). Devices used were the Gore TAG and Conformable Gore TAG Thoracic Endoprosthesis. There were 228 patients (86.0%) who underwent primary endovascular treatment (144 off-label [54.3%]); 22 (8.3%) underwent reintervention after prior endovascular procedure and 15 (5.7%) underwent reintervention after prior open procedure. Kaplan-Meier estimated freedom from all-cause mortality at 5 years was 71.1%. Freedom from aortic-related mortality through 5 years was 95.8%. There was no significant difference in freedom from all-cause mortality during the follow-up period in complicated or uncomplicated disease. At 30 days and through 5 years, respectively, for all the following outcomes, the aortic rupture rate was 1.1% (n = 3) and 1.9% (n = 5). The stroke rate was 1.1% (n = 3) and 4.2% (n = 11). The spinal cord ischemic event rate was 1.5% (n = 4) and 2.6% (n = 7). Reinterventions were required in 6.4% (n = 17) and 21.1% (n = 56) of patients. The need for conversion to open repair was 0.4% (n = 1) and 2.6% (n = 7). Additional graft placement was required in 3 patients (1.1%) and 16 patients (6.0%). The endoleak rate at 30 days was 3.4% (n = 9); type IA (n = 1 [0.4%]), type IB (n = 4 [1.5%]), type II (n = 1 [0.4%]), type III (n = 1 [0.4%]), and unspecified (n = 4 [1.6%]). Through 5 years, the endoleak rate was 12.1% (n = 32); type IA (n = 7 [2.6%]), type IB (n = 10 [3.8%]), type II (n = 9 [3.4%]), type III (n = 2 [0.8%]), and unspecified (n = 12 [4.5%]). There were no cases of stent migration, compression or fracture through 5 years. CONCLUSIONS: Results at the 5-year follow-up demonstrate that the use of the Gore TAG and Conformable Gore TAG Thoracic Endoprosthesis can be supported in treatment of TBAD (acute, chronic, complicated, and uncomplicated). These data demonstrate strong device durability, beneficial patient outcomes, and support for the treatment of thoracic aortic dissection with an endovascular approach. Complete 10-year follow-up in GREAT as planned will be advantageous.

Correlation of four-dimensional ultrasound strain analysis with computed tomography angiography wall stress simulations in abdominal aortic aneurysms.

Objective: Biomechanical modeling of infrarenal aortic aneurysms seeks to predict ruptures in advance, thereby reducing aneurysm-related deaths. As individual methods focusing on strain and stress analysis lack adequate discretization power, this study aims to explore multifactorial characterization for progressive aneurysmal degeneration. The study's objective is to compare stress- and strain-related parameters in infrarenal aortic aneurysms. Methods: Twenty-two patients with abdominal aortic aneurysms (AAAs) (mean maximum diameter, 53.2 ± 7.2 mm) were included in the exploratory study, examined by computed tomography angiography (CTA) and three-dimensional real-time speckle tracking ultrasound (4D-US). The conformity of aneurysm anatomy in 4D-US and CTA was determined with the mean point-to-point distance (MPPD). CTA was employed for each AAA to characterize stress-related indices using the semi-automated A4-clinics RE software. Five segmentations from one 4D-US examination were fused into one averaged model for strain analysis using MATLAB and the Abaqus solver. Results: The mean MPPD between the adjacent points of the 4D-US and CTA-derived geometry was 1.8 ± 0.4 mm. The interclass correlation coefficients for all raters and all measurements for the maximum AAA diameter in 2D, 4D ultrasound, and CTA indicate moderate to good reliability (interclass correlation coefficient1 0.69 with 95% confidence interval [CI], 0.49-0.84; P < .001). The peak wall stress (PWS) correlates fairly with the maximum AAA diameter in 2D-US (r = 0.54; P < .01) and 4D-US (r = 0.53; P < .05) and moderately strongly with the maximum exterior AAA diameter (r = 0.63; P < .01). The peak wall rupture risk index shows a strong correlation with the PWS (ρ > 0.9; P < .001) and is influenced by anatomical parameters with equal strength. Isolated observation of the intraluminal thrombus does not provide significant information in the determination of PWS. The maximum AAA diameter in 2D-US shows a fair negative correlation with the mean circumferential, longitudinal and in-plane shear strain (ρ = -0.46; r = -0.45; ρ = -0.47; P < .05 for all). The circumferential strain ratio as an indicator of wall motion heterogeneity increases with the aneurysm diameter (r = 0.47; P < .05). The direct comparison of wall strain and wall stress indices shows no quantitative correlation. Conclusions: The strain and stress analyses provide independent biomechanical information of AAAs. At the current stage of development, the two methods are considered complementary and may optimize a more patient-specific rupture risk prediction in the future.

Comparing Different Registration and Visualization Methods for Navigated Common Femoral Arterial Access-A Phantom Model Study Using Mixed Reality.

Mixed reality (MxR) enables the projection of virtual three-dimensional objects into the user's field of view via a head-mounted display (HMD). This phantom model study investigated three different workflows for navigated common femoral arterial (CFA) access and compared it to a conventional sonography-guided technique as a control. A total of 160 punctures were performed by 10 operators (5 experts and 5 non-experts). A successful CFA puncture was defined as puncture at the mid-level of the femoral head with the needle tip at the central lumen line in a 0° coronary insertion angle and a 45° sagittal insertion angle. Positional errors were quantified using cone-beam computed tomography following each attempt. Mixed effect modeling revealed that the distance from the needle entry site to the mid-level of the femoral head is significantly shorter for navigated techniques than for the control group. This highlights that three-dimensional visualization could increase the safety of CFA access. However, the navigated workflows are infrastructurally complex with limited usability and are associated with relevant cost. While navigated techniques appear as a potentially beneficial adjunct for safe CFA access, future developments should aim to reduce workflow complexity, avoid optical tracking systems, and offer more pragmatic methods of registration and instrument tracking.

Image-based assessment of aortoiliac aneurysm anatomical characteristics in patients from the global iliac branch study.

OBJECTIVE: Endovascular repair is the preferred treatment for aortoiliac aneurysm, with preservation of at least one internal iliac artery recommended. This study aimed to assess pre-endovascular repair anatomical characteristics of aortoiliac aneurysm in patients from the Global Iliac Branch Study (GIBS, NCT05607277) to enhance selection criteria for iliac branch devices (IBD) and improve long-term outcomes. METHODS: Pre-treatment CT scans of 297 GIBS patients undergoing endovascular aneurysm repair were analyzed. Measurements included total iliac artery length, common iliac artery length, tortuosity index, common iliac artery splay angle, internal iliac artery stenosis, calcification score, and diameters in the device's landing zone. Statistical tests assessed differences in anatomical measurements and IBD-mediated internal iliac artery preservation. RESULTS: Left total iliac artery length was shorter than right (6.7 mm, P = .0019); right common iliac artery less tortuous (P = .0145). Males exhibited greater tortuosity in the left total iliac artery (P = .0475) and larger diameter in left internal iliac artery's landing zone (P = .0453). Preservation was more common on right (158 unilateral, 34 bilateral) than left (105 unilateral, 34 bilateral). There were 192 right-sided and 139 left-sided IBDs, with 318 IBDs in males and 13 in females. CONCLUSION: This study provides comprehensive pre-treatment iliac anatomy analysis in patients undergoing endovascular repair with IBDs, highlighting differences between sides and sexes. These findings could refine patient selection for IBD placement, potentially enhancing outcomes in aortoiliac aneurysm treatment. However, the limited number of females in the study underscores the need for further research to generalize findings across genders.

Co-prevalence of arterial aneurysm location - a correlation analysis based on a retrospective cross-sectional observational study.

Background: The aim of this retrospective single-centre cross-sectional observational study was to investigate co-prevalence of arterial aneurysm location systematically. Patients and methods: Patients with the diagnosis of any arterial aneurysm from January 2006 to January 2016 were investigated in a single centre. Patients with hereditary disorders of connective tissue, systemic inflammatory disease, or arterial pathologies other than true aneurysms were excluded. Aneurysm locations were assessed for every patient included. For patients with at least two co-existing aneurysms, co-prevalence of aneurysm location was investigated by calculating correlation coefficients and applying Fisher's exact test. This study report is prepared according to the STROBE statement. Results: Of 3107 identified patients with arterial aneurysms, 918 were excluded. Of the remaining 2189 patients, 951 patients with at least two aneurysms were included in the study. Bilateral aneurysm combinations of paired iliac, femoral and popliteal arteries showed the highest correlation (ϕ=0.35 to 0.67), followed by bilateral combinations of subclavian (ϕ=0.36) and internal carotid (ϕ=0.38) arteries. Abdominal aortic aneurysms in combination with visceral artery aneurysms (ϕ=-0.24 to -0.12), popliteal arteries (ϕ=-0.22) and the ascending aorta (ϕ=-0.19) showed the lowest correlation, followed by the descending aorta in combination with the common iliac arteries (ϕ=-0.12 to -0.13). Conclusions: In our study sample, aneurysm co-prevalence was highly non-random. This should be considered in the context of aneurysm screening programs.

Clinical Performance of the Low Profile Zenith Alpha Abdominal Endovascular Graft: 2 Year Results from the ZEPHYR Registry.

OBJECTIVE: The midterm outcomes of the low profile Zenith Alpha Abdominal Endovascular Graft from the ZEnith alPHa for aneurYsm Repair (ZEPHYR) registry are reported. METHODS: The ZEPHYR registry is a physician initiated, multicentre, non-randomised, core laboratory controlled, prospective registry. Inclusion criteria were patients with a non-ruptured abdominal aortic aneurysm with a maximum diameter ≥ 50 mm or enlargement > 5 mm within 6 months, with a site reported infrarenal neck length of ≥ 10 mm and with the intention to electively implant the Zenith Alpha abdominal endograft. Patients from 14 sites across Germany, Belgium, and the Netherlands were included. The primary endpoint was treatment success, defined as technical success and clinical success. Technical success was defined as successful delivery and deployment of the endograft in the planned position without unintentional coverage of internal iliac or renal arteries, with successful removal of the delivery system. Clinical success was defined as freedom from aneurysm sac expansion > 5 mm, type I or type III endoleaks, aneurysm rupture, stent graft migration > 10 mm, open conversion, and stent graft occlusion. RESULTS: Three hundred and forty-seven patients were included in the ZEPHYR registry. The median clinical follow up was 743 days (interquartile range [IQR] 657, 806) with a median imaging follow up of 725 days (IQR 408, 788). Treatment success at 6 months, 1, and 2 years was 92.5%, 90.4%, and 85.3%, respectively. Freedom from secondary intervention was 94.3%, 93.4%, and 86.9%, respectively. The predominant reason for secondary intervention was limb complications. Freedom from limb occlusion (per patient) at 6 months, 1, and 2 years was 97.2%, 95.8%, and 92.5%, respectively. Univariable and multivariable Cox regression analyses could not identify any independent predictor for limb complications. CONCLUSION: While treatment success is comparable with other commercially available grafts, the rate of limb complications at 2 years is of concern. The manufacturer's instructions for use should be followed closely. Further studies are necessary to investigate the root cause of the increased rate of limb complications with the Zenith Alpha Abdominal Endovascular Graft.

[Cost-revenue aspects of endovascular treatment of distal aortic arch pathologies with respect to the introduction of a new thoracic side-branch prosthesis]. / Kosten-Erlös-Aspekte der endovaskulären Versorgung distaler Aortenbogenpathologien im Hinblick auf die Einführung einer neuen thorakalen Seitenarmprothese.

BACKGROUND: The standard vascular surgical procedure (SV) for the treatment of distal aortic arch pathologies involves a hybrid approach using a left carotid-subclavian bypass and thoracic endovascular aortic repair. Considering the introduction of a thoracic side branch prosthesis (TBE), the aim of this study was to analyze the cost-revenue aspects of both procedures. MATERIAL AND METHODS: A retrospective analysis was conducted on cases treated by SV from 2017 to 2022. To draw conclusions regarding the use of TBE, the main diagnoses and procedures of SV were recoded based on current classifications (ICD/OPS 2023) for revenue calculations and regrouped according to aG-DRG 2023. An OPS modification and regrouping were performed for modeling TBE revenues. RESULTS: A total of 13 cases were identified (mean age 62.5 ± 13.8 years; 10 males). After regrouping, the following DRGs were obtained: F42Z in N = 5, F51A in N = 4, F08B in N = 2, and F07A and F36B each in N = 1. The total revenue after regrouping was €â€¯666,514.13, including an additional payment (ZE) of €â€¯132,729.14. With the modeled application of TBE, a total revenue of €â€¯659,212.19 was achieved. Compared to SV, this represents a revenue decrease of €â€¯16,886.71 (changed DRG), but with an increase in ZE revenue by €â€¯65,559.78 (different ZE). The use of TBE resulted in a saving of 74 occupancy days, including 13.5 days in intensive care. CONCLUSION: A cost coverage seems probable with a change in the procedure, despite the yet to be determined pricing of TBE. This is highly dependent on the coding quality and the future development of ZE, given the annually changing DRG relative weights. Precise and transparent performance and cost documentation are essential for determining the pricing.

[Recommendations for the specialist further training of nursing personnel on intensive care units in the treatment of abdominal aortic aneurysms: results of a modified Delphi procedure with experts]. / Empfehlungen zur Fachweiterbildung von Pflegefachpersonen der Intensivstation bei der Behandlung des Bauchaortenaneurysmas: Ergebnisse eines modifizierten Delphi-Verfahrens mit Expert:innen.

INTRODUCTION: The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist. METHODS: Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4­point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit. RESULTS: Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota. CONCLUSION: In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.

Standing the test of time: total aortic remodeling 13 years after TEVAR for acute type B aortic dissection.

Long-term outcome after thoracic endovascular aortic repair (TEVAR) of acute type B aortic dissection (aTBAD) is still underreported in current literature. This case report shows persistence of aortic remodeling without secondary complication or need of reintervention 13 years after TEVAR. A 45-year-old woman was referred to the emergency room with aTBAD. Due to early diameter progression in combination with therapy-refractory pain and uncontrolled hypertension, TEVAR was performed. Hereafter, the patient showed complete remodeling of the descending thoracic aorta without persistent false lumen perfusion in this segment and with stable true and false lumen diameter in the untreated abdominal segment for a 13-year period. No aortic-related reintervention was needed. With contemporary devices and adapted therapy, TEVAR seems able to treat complex thoracic disease. Long-term follow-up (FU) is mandatory to monitor the efficacy and durability of endovascular treatment in aortic disease.

[Inpatient rehabilitation for patients 65 years and older with abdominal aortic aneurysm repair: Indications and long-term outcome]. / Stationäre Frührehabilitation nach endovaskulärer und offener Versorgung eines Bauchaortenaneurysmas bei über 65-Jährigen: Indikation und langfristiges Outcome.

BACKGROUND: In Germany, there is no data available on the frequency of inpatient rehabilitation (IR) after elective endovascular (EVAR) and open (OAR) abdominal aortic aneurysm (AAA) repair. OBJECTIVE: To report for the first time on the outcome of patients 65 years and older and thus of retirement age with and without IR after AAA repair in a retrospective analysis of routine data from all eleven regional companies of the AOK health insurance fund (AOK-Gesundheit). METHODS: Anonymized data of 16,358 patients 65 years and older with intact abdominal aortic aneurysm treated with EVAR (n = 12,960) or OAR (n = 3,398) between 01/01/2010 and 12/31/2016 were analyzed. Patients with postoperative IR (n = 1,531) were compared to those without postoperative IR (n = 14,827) with respect to general patient characteristics, comorbidities, perioperative and postoperative outcomes, and survival. The average follow-up of patients with postoperative and without postoperative IR was 49.9 months and 51.8 months, respectively. RESULTS: 5.4% of EVAR patients, but 24.6% of OAR patients were referred to IR (p < 0.001). Patients with IR were sicker than those without IR. Parameters significantly influencing the use of IR included OAR vs EVAR (Odds Ratio [OR] 6.03), condition after cerebral infarction (OR 1.53), and women vs men (OR 1.49). Perioperative influencing parameters were cerebral infarction (OR 2.40), blood transfusions (OR 2.21) and complex critical care (OR 2.15). After nine years, the Kaplan-Meier estimated survival was 41.9% for patients with vs 43.4% for those without IR in the EVAR group (p = 0.178). For OAR, it was 50.2% for patients with IR vs 49.8% for patients without IR (p = 0.006). In multivariate regression analysis, postoperative IR had a significant effect on long-term survival in OAR but not in EVAR patients. CONCLUSION: There are no generally binding guidelines for the indication of IR after AAA repair. It should therefore be a requirement for the future that the fitness of each patient with elective AAA repair be determined with a score before and after the procedure in order to make indications for AHB more comparable. The score should be documented in the hospital discharge letter.