Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms.

OBJECTIVE: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS: The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS: A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION: The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Outcome of different endovascular modalities to treat common iliac artery aneurysms, single center study.

INTRODUCTION: Iliac aneurysms occur in 10% of patients with abdominal aortic aneurysms (AAA). There are three different endovascular approaches to their treatment in the context of infrarenal Endovascular Aortic Aneurysm Repair (EVAR): occlusion by coiling the internal iliac, incorporation using an iliac branch device, and delaying repair using a bell bottom limb. We sought to determine outcomes associated with these three strategies in our practice. METHODOLOGY: The study was a combined prospective cohort study with a retrospective arm: prospective patient recruitment was done for 1 year from September 2019 and ended by September 2020, and retrospective data was collected from 2017 to 2019. Demographic, procedural, and imaging data was collected. SPSS was used to analyze data as patients were classified by limbs in four groups: iliac branched, bell bottom, coil and cover technique, and standard treated limbs. RESULTS: There were 65 male and 4 female patients included in this study incorporating 137 limbs with a mean age of 78 years (SD ± 8 years). Two patients died after discharge (at 3 and 21 months postoperatively, without hospital admission) and five patients were lost to long-term follow-up. Three patients had operations that deviated from the plan: one was an IBD converted to bell bottom, one was an IBD that was converted to coil and cover, and one was a bell bottom that did not seal. Follow-up revealed late type IB endoleak in three bell bottom limbs and one limb treated with coil and cover. Common iliac occlusion occurred in one IBD, three bell bottom limbs, and two limbs treated with coil/cover technique. There were four additional ischemic events (buttock claudication in three and intestinal ischemia in one): all ischemic events occurred in the coil and cover group (p = .001). CONCLUSIONS: Given the small population size examined in this study, there is no statistical difference between treatment groups; however, there was a trend toward bell bottom technique being associated with higher incidence of type IB endoleak. Coil and cover technique was associated with decreased IB endoleak; however, Buttock claudication and intestinal ischemia occurred more significantly in this group. Using IBD may be the best strategy to improve short- and long-term outcomes in patients with iliac aneurysms.

An observational assessment of aortic deformation during infrarenal and complex endovascular aortic aneurysm repair.

OBJECTIVE: Real-time aortic deformation during endovascular aortic aneurysm repair (EVAR) has not been reported. Successful EVAR relies on predicting intraoperative aortic-endograft deformation from preoperative imaging. Correct prediction is essential, because malalignment of endografts decreases patient survival. We describe intraoperative aortic deformation during infrarenal EVAR and complex fenestrated/branched EVAR (F/BEVAR), relating deformation to preoperative anatomy and follow-up outcomes. METHODS: A multicenter, retrospective cohort of aortic aneurysm patients undergoing operation between January 2019 and February 2021, substratified by repair, infrarenal EVAR (n = 50), F/BEVAR (n = 80), and iliac branch graft with F/B/EVAR (IBG + F/B/EVAR; n = 27), were compared using software-based nonrigid two- and three-dimensional aortic deformational intraoperative assessment (CYDAR). Preoperative computed tomography reconstructions of aortic and iliac tortuosities were assessed against intraoperative deformation, the primary outcome, and related to perioperative and follow-up adverse outcomes. RESULTS: All treatment groups had low preoperative visceral aortic tortuosity; the EVAR group had higher iliac tortuosity (1.43 ± 0.05; P = .018). Intraoperative aortic visceral deformation was consistently cranial and anterior; IBG + F/B/EVAR patients had the largest magnitude deformation (superior mesenteric artery, EVAR 5.1 ± 0.9 mm; F/BEVAR 4.4 ± 0.4 mm; IBG 8.3 ± 1.2 mm; P = .004). Celiac artery, superior mesenteric artery, and bilateral renal artery deformations were correlated (R = 0.923-0.983). Iliac deformation was variable in magnitude and direction. Preoperative tortuosity was not correlated with the magnitude of intraoperative deformation nor was deformation magnitude related to endograft instability during follow-up, including endoleak development, reinterventions, or visceral vessel complications. CONCLUSIONS: The aorta deforms consistently during EVAR at the visceral aortic segment but unpredictably at the iliac bifurcation. Aortoiliac deformation is unrelated to adverse perioperative outcomes, branch instability, or reinterventions during short-term follow-up.

Survival and durability after endovascular aneurysm repair reflect era-related surgical judgement.

OBJECTIVE: Abdominal aortic aneurysm management guidelines from the National Institute for Clinical Excellence in 2020, based heavily on randomized controlled trials in an early era of infrarenal endovascular aneurysm repair (EVAR), suggested that the long-term outcomes after EVAR jeopardize its use in elective abdominal aortic aneurysm repair. We hypothesized that, in a rapidly evolving surgical field, the era of aneurysm repair may have a significant influence on long-term patient outcomes. METHODS: Using a single-center retrospective cohort design, we identified two EVAR cohorts, the early cohort (n = 166) who underwent EVAR from 2008 to 2010, and a contemporary late cohort (n = 129) from 2015 to 2017. We assessed patient preoperative demographics and era of repair against the primary outcomes of reinterventions, reintervention-free survival, and mortality, addressing their relationships to anatomic selection criteria, graft durability, endoleak, and aneurysm diameter to 5 years after the procedure. RESULTS: Early cohort patients had decreased reintervention-free survival (early 80.1% vs late 93.3%) and decreased overall survival (early 71.3% vs late 81%) at 3 years and throughout follow-up. The preoperative anatomy judged suitable for EVAR in early cohort patients was more variable than for late cohort patients, including 104% larger proximal and 106% larger distal landing zone diameters, with a mean 11.6-mm shorter length infrarenal aortic and 13.3-mm shorter length iliac sealing zones in the early group. Early cohort patients had more complications during follow-up, including graft kinking and endoleaks, and 24.4% of early vs 8.5% of late patients underwent one or more reinterventions. CONCLUSIONS: Although technical skill in EVAR implantation may not evolve significantly after a threshold of cases, surgical judgement, relating to anatomic selection and device sizing, requires feedback from long-term sequalae and significantly impacted EVAR outcomes by era. EVAR patients from an early repair era had significantly worse outcomes, with more complications, reinterventions, and a decrease in survival.

Era of endovascular aortic aneurysm repair is linked to preoperative anatomic severity and perioperative patient outcomes.

OBJECTIVE: Varying opinions on optimal elective and emergent surgical management of infrarenal abdominal aortic aneurysms are expressed by the most recent Society for Vascular Surgery (SVS), European Society for Vascular Surgery, vs UK National Institutes for Health and Care Excellence guidelines. The UK National Institutes for Health and Care Excellence guidelines propose that open surgical repair serve as the default treatment for infrarenal abdominal aortic aneurysm. The rationale for this approach relied on data from the early era of endovascular aneurysm repair (EVAR) and are in contrast to the more balanced approaches of the SVS and European Society for Vascular Surgery. We hypothesize that significant differences in patient selection, management, and postoperative outcome are related to the era in which treatment was undertaken, contextualizing the outcomes reported in early-era EVAR randomized controlled trials. METHODS: Retrospectively, two cohorts representing all EVAR patients from "early" (n = 167; 2008-2010) and "late" (n = 129; 2015-2017) periods at a single treating institution were assembled. Primary outcomes of era-related changes in preoperative demographics, anatomy, and intraoperative events were assessed; anatomy was compared using the SVS anatomic severity grading system. These era-related differences were then placed in the context of early perioperative outcomes and at follow-up to 1 year. RESULTS: Choice of surgical strategy differed by era, despite the same patient preoperative comorbidities between EVAR groups. Preoperative anatomic severity was significantly worse in the early cohort (P < .001), with adverse proximal and distal seal zone features (P < .001). Technical success was 16.2% higher in the late cohort, with significantly fewer type 1A/B endoleaks perioperatively (P < .001). In-hospital complications, driven by higher acute kidney injury and surgical site complications in the early cohort, resulted in a 16.5% difference between cohorts (P < .05). At 1 year of follow-up, outcome differences persisted; late-era patients had fewer 1A endoleaks, fewer graft complications, and better reintervention-free survival. CONCLUSIONS: From a granular dataset of EVAR patients, we found an impact of EVAR repair era on early clinical outcomes; late cohort infrarenal EVAR patients had less severe preoperative anatomy and improved perioperative and follow-up outcomes to 1 year, suggesting that the results of early EVAR randomized controlled trials may no longer be generalizable to modern practice.

Coeliac Incorporation Strategy Impacts Visceral Branch Vessel Stability in Fenestrated Endovascular Aneurysm Repair.

OBJECTIVE: During fenestrated endovascular repair (FEVAR), mesenteric vessels may be incorporated with a scallop or fenestration. The benefits/harms of techniques to incorporate the coeliac axis (CA) have not been assessed for their impact on procedural complexity vs. peri-operative and longer term outcomes; this assessment may instruct a balanced operative strategy for the CA and complex FEVAR, minimising adverse intra- or peri-operative events, and maximising durability. METHODS: This was a retrospective cohort study. Patients undergoing fenestrated or scalloped CA incorporation during FEVAR for a juxtarenal/pararenal/suprarenal aortic aneurysm (January 2015 - December 2019) were reviewed (n = 159) for demographics, intra-procedural/peri-operative outcomes, and re-interventions to five years. Mean follow up for all groups was 3.28 years. The primary outcome of CA instability (occlusion/stenosis/endoleak/re-intervention) was assessed. CA specific re-intervention, re-intervention free survival, and all cause mortality were assessed against incorporation strategy. Secondarily, the harm of CA stenting, comprising intra-operative harms and peri-operative adverse outcomes was interrogated. RESULTS: The CA was incorporated with a stented fenestration (n = 74), an unstented fenestration (n = 59), and a minority with scallop (n = 26). There were no between group differences in operative indication, or anatomical aneurysm/CA features. Fenestrated stented and unstented patients had longer aortic coverage but the same primary technical success. At follow up, three CA endoleaks occurred in stented fenestrated patients, although scallop patients more often had type 3 endoleaks at the SMA and renal fenestrations (23%). Elevated CA instability in fenestrated unstented patients was driven by CA occlusion (16.9%), but not associated with CA re-intervention, worse re-intervention free survival, or all cause mortality. Regression analysis for visceral branch instability revealed predictors of CA non-stenting and diminished aortic coverage. CONCLUSION: In the present authors' experience, the practice of not stenting a CA fenestration does not pose peri-operative or long term clinical harm. At follow up, not stenting the CA is associated with CA instability; however, both fenestration groups are preferable to a shorter (scalloped) endograft as increasing aortic coverage reduces non-CA branch vessel instability.

Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively.

OBJECTIVE: A rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy. METHODS: We used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival. RESULTS: Assessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men. CONCLUSIONS: Women and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.

A prospective observational trial of fusion imaging in infrarenal aneurysms.

OBJECTIVE: Use of three-dimensional fusion has been shown to significantly reduce radiation exposure and contrast material use in complex (fenestrated and branched) endovascular aneurysm repair (EVAR). Cydar software (CYDAR Medical, Cambridge, United Kingdom) is a cloud-based technology that can provide imaging guidance by overlaying preoperative three-dimensional vessel anatomy from computed tomography scans onto live fluoroscopy images both in hybrid operating rooms and on mobile C-arms. The aim of this study was to determine whether radiation dose reduction would occur with the addition of fusion imaging to infrarenal repair in all imaging environments. METHODS: All patients who consented to involvement in the trial and who were treated with EVAR in our center from March 2016 until April 2017 were included. A teaching session about radiation protection and Cydar fusion software use was provided to all operators before the start of the fusion group enrollment. This group was compared with a retrospective cohort of patients treated in the same center from March 2015 to March 2016, after a dedicated program of radiation awareness and reduction was introduced. Ruptured aneurysms and complex EVAR were excluded. Preoperative and perioperative characteristics were recorded, including parameters of radiation dose, such as air kerma and dose-area product. Results were expressed in median and interquartile range. RESULTS: Forty-four patients were prospectively enrolled and compared with 21 retrospective control patients. No significant differences were found in comparing sex, body mass index, and age at repair. The median operation time (wire to wire) and fluoroscopy time were 90 (75-105) minutes and 30 (22-34) minutes, respectively, without significant differences between groups (P = .56 and P = .36). Dose-area product was nonsignificantly higher in the control group, 21.7 (8.9-85.9) Gy cm2, compared with the fusion group, 12.4 (7.5-23.4) Gy cm2 (P = .10). Air kerma product was significantly higher in the control group, 142 (61-541) mGy, compared with 82 (51-115) mGy in the fusion group (P = .03). The number of digital subtraction angiography runs was significantly lower in the fusion group (8 [6-11]) compared with the control group (10 [9-14]); (P = .03). There were no significant differences in the frequency of adverse events, endoleaks, or additional procedures required. CONCLUSIONS: When it is used in simple procedures such as infrarenal aneurysm repair, image-based fusion technology is feasible both in hybrid operating rooms and on mobile systems and leads to an overall 50% reduction in radiation dose. Fusion technology should become standard of care for centers attempting to maximize radiation dose reduction, even if capital investment of a hybrid operating room is not feasible.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.

BACKGROUND: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity. METHODS: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations. RESULTS: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion. CONCLUSIONS: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.

Accuracy of implementing principles of fusion imaging in the follow up and surveillance of complex aneurysm repair.

Fusion imaging is standard for the endovascular treatment of complex aortic aneurysms, but its role in follow up has not been explored. A critical issue is renal function deterioration over time. Renal volume has been used as a marker of renal impairment; however, it is not reproducible and remains a complex and resource-intensive procedure. The aim of this study is to determine the accuracy of a fusion-based software to automatically calculate the renal volume changes during follow up. In this study, computerized tomography (CT) scans of 16 patients who underwent complex aortic endovascular repair were analysed. Preoperative, 1-month and 1-year follow-up CT scans have been analysed using a conventional approach of semi-automatic segmentation, and a second approach with automatic segmentation. For each kidney and at each time point the percentage of change in renal volume was calculated using both techniques. After review, volume assessment was feasible for all CT scans. For the left kidney, the intraclass correlation coefficient (ICC) was 0.794 and 0.877 at 1 month and 1 year, respectively. For the right side, the ICC was 0.817 at 1 month and 0.966 at 1 year. The automated technique reliably detected a decrease in renal volume for the eight patients with occluded renal arteries during follow up. This is the first report of a fusion-based algorithm to detect changes in renal volume during postoperative surveillance using an automated process. Using this technique, the standardized assessment of renal volume could be implemented with greater ease and reproducibility and serve as a warning of potential renal impairment.

Early experience with a modified preloaded system for fenestrated endovascular aortic repair.

OBJECTIVE: Preloaded endovascular delivery systems expand the anatomic eligibility for complex aortic repair by requiring only one iliac access vessel and providing a stable platform for guiding sheaths into challenging target vessels. This article reports the lessons learned and early clinical outcomes using a modified preloaded delivery system for fenestrated endovascular aneurysm repair (FEVAR) in three aortic centers in Europe. METHODS: From October 2015 to March 2016, consecutive patients presenting with extensive aortic aneurysm treated with a modified preloaded FEVAR were prospectively enrolled from three high volume European aortic centers. The new design is a modification of previous designs of preloaded fenestrated stent grafts and of the p-branch device platform. The technical details of implantation are described and perioperative outcomes, including the learning curve, are collected and reported. RESULTS: All patients (30 patients; 80% men; 70.2 years old) presented for nonurgent repair of either a type Ia endoleak (3/30; 10%), a type I-II-III thoracoabdominal (8/30; 27%), or a type IV thoracoabdominal or pararenal (19/30; 63.%) aneurysm repair of a mean size of 64 ± 13 mm using a custom made device. Primary technical success was achieved in 28 of 30 patients (93%) and assisted primary technical success in 29 of 30 patients (97%). The two technical failures included open conversion to repair a ruptured iliac artery and restenting of a dissected superior mesenteric artery which was recognized hours after the index procedure had finished. The mean procedure time was 277 ± 153 minutes, fluoroscopy time 79 ± 36 minutes, dose area product 112 ± 90 Gy cm2, and contrast volume 87 ± 46 mL. All renal fenestrations were successfully stented without type III endoleak on completion angiogram; the preloaded guiding sheaths were used for 53 of 58 renal arteries (91%). Challenges related to learning to the use of the modified preloaded system were experienced early and had no clinical consequences. Major complications occurred in seven cases (23%), including two perioperative deaths because of stroke and sepsis following primary conversion attributable to iliac rupture. There were no target vessel occlusions or type I/III endoleaks found on postoperative imaging. CONCLUSIONS: Based on early experience, the modified preloaded system can be safely and effectively used during FEVAR, with good technical result and a short period of learning. This device expands treatment to patients with compromised iliac access, thus, additional patients and more follow-up will be required to determine unique risks of operating in this patient population.

Results from multiple prospective single-center clinical trials of the off-the-shelf p-Branch fenestrated stent graft.

OBJECTIVE: The purpose of this study was to report prospective data of an off-the-shelf fenestrated endograft (Zenith p-Branch; Cook Medical, Bloomington, Ind) from four centers for the treatment of patients with pararenal abdominal aortic aneurysms. METHODS: Data were combined from four single-center investigational studies conducted in the United States and Europe. The p-Branch endograft consists of a proximal off-the-shelf component incorporating a scallop for the celiac artery, a superior mesenteric artery fenestration, and two conical pivot fenestrations to preserve flow to the renal vessels. The device is available in two configurations, a left renal fenestration at the same (configuration A) or lower (configuration B) longitudinal position than the right to accommodate varied anatomy of the patients. RESULTS: Between August 2011 and September 2015, 76 patients (82% male; mean age, 72 years; 65 elective and 11 emergent) were enrolled, with 55% implanted with option A and 45% with B. The device was deployed successfully in all patients, and stents were placed in all target vessels except in three cases (one elective, two emergent): a left kidney was sacrificed in one patient, and a right renal artery was left unstented in two patients during the index procedure. There was no 30-day mortality. During follow-up (mean, 25 ± 13 months), 10 late deaths occurred (6 elective, 4 emergent; none related to device or procedure), and there were no ruptures or conversions to open repair. Two patients experienced bowel ischemia; one case resolved with nonoperative treatment and one required superior mesenteric artery and celiac artery angioplasty and stent placement. Renal artery occlusion occurred in eight patients (11%) and was deemed procedure related in 63% (5/8) of these patients. Four of these were successfully intervened on with preservation of renal function. The overall renal insufficiency incidence was 7% (5/76). One patient developed renal failure requiring dialysis. CONCLUSIONS: Early results incorporating learning curves for physicians with a new device and delivery system indicate that the use of the Zenith p-Branch device is feasible and safe. Long-term follow-up is needed to assess the effectiveness and durability of this treatment strategy and to refine the indications for use.

Ten-year single-centre experience with type II endoleaks: Intervention versus observation.

Our objective was to determine the relative merits of intervention or observation of type II endoleaks (T2Ls). A retrospective analysis was performed on 386 infra-renal endovascular aneurysm repair (IR-EVAR) patients from 2006 to 2015. Annual surveillance imaging of patients undergoing EVAR at our centre were analysed, and all endoleaks were subjected to a multidisciplinary team meeting for consideration and treatment. In the 10-year time frame, 386 patients (79.5±8.7 years) underwent an IR-EVAR. Eighty-one patients (21.0%) developed a T2L and intervention was undertaken in 28 (34.6%): 17 (60.7%) were treated via a transarterial approach (TA) and 11 (39.3%) using the translumbar approach (TL). Fifty-three patients (65.4%) with T2Ls were managed conservatively. Patients who received T2L treatment had a greater proportion of recurrent T2Ls than patients who were conservatively managed ( p=0.032). T2Ls associated with aneurysmal growth were more resistant to treatment than those where there was no change or a decrease in aneurysm size during follow-up (0.033). There was no significant difference in the TA and TL approach with respect to endoleak repair success ( p=0.525). Treatment of a T2L did not confer a survival advantage compared to conservative management ( p=0.449) nor did the choice of either the TA or TL approach ( p=0.148). Our study suggests the development of a T2L associated with aneurysm growth may represent an aggressive phenotype that is resistant to treatment. However, this did not lead to an increased risk of mortality over follow-up. Neither a transarterial nor a translumbar approach to treating a T2L conferred superiority.

Open surgery for chronic dissection.

Chronic aortic dissection is one of the most challenging pathologies faced by aortic surgeons. The variety of presentations and the multiple comorbidities of the patients make treatment and follow-up a subject of much debate. Historical data is difficult to interpret because of the heterogeneity of the included populations, and the common tendency of authors to pool outcomes of thoracoabdominal aortic aneurysm repair secondary to degenerative pathology or connective tissue disorder with those who have an underlying dissection. As the endovascular treatment of chronic aortic dissection becomes more commonplace with the increasing use of branched and fenestrated technology, it will be important to have an historical "gold standard" to use as a comparator. This narrative review of the literature describes the challenges to interpretation of data and the available information published about chronic aortic dissection.