Dynamic, Time-Resolved CT Angiography After EVAR: A Quantitative Approach to Accurately Characterize Aortic Endoleak Type and Identify Inflow Vessels.

PURPOSE: Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis. METHODS: Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified. RESULTS: A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds. CONCLUSION: Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.

Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics.

PURPOSE: Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. MATERIALS AND METHODS: Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. RESULTS: Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. CONCLUSIONS: Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. CLINICAL IMPACT: Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.

Transcarotid access for remote robotic endovascular neurointerventions: a cadaveric proof-of-concept study.

OBJECTIVE: The purpose of this proof-of-concept study was to demonstrate the setup and feasibility of transcarotid access for remote robotic neurointerventions in a cadaveric model. METHODS: The interventional procedures were performed in a fresh-frozen cadaveric model using an endovascular robotic system and a robotic angiography imaging system. A prototype remote, robotic-drive system with an ethernet-based network connectivity and audio-video communication system was used to drive the robotic system remotely. After surgical exposure of the common carotid artery in a cadaveric model, an 8-Fr arterial was inserted and anchored. A telescopic guiding sheath and catheter/microcatheter combination was modified to account for the "workable" length with the CorPath GRX robotic system using transcarotid access. RESULTS: To simulate a carotid stenting procedure, a 0.014-inch wire was advanced robotically to the extracranial internal carotid artery. After confirming the wire position and anatomy by angiography, a self-expandable rapid exchange nitinol stent was loaded into the robotic cassette, advanced, and then deployed robotically across the carotid bifurcation. To simulate an endovascular stroke recanalization procedure, a 0.014-inch wire was advanced into the proximal middle cerebral artery with robotic assistance. A modified 2.95-Fr delivery microcatheter (Velocity, Penumbra Inc.) was loaded into the robotic cassette and positioned. After robotic retraction of the wire, it was switched manually to a mechanical thrombectomy device (Solitaire X, Medtronic). The stentriever was then advanced robotically into the end of the microcatheter. After robotic unfolding and short microcatheter retraction, the microcatheter was manually removed and the stent retriever was extracted using robotic assistance. During intravascular navigation, the device position was guided by 2D angiography and confirmed by 3D cone-beam CT angiography. CONCLUSIONS: In this proof-of-concept cadaver study, the authors demonstrated the setup and technical feasibility of transcarotid access for remote robot-assisted neurointerventions such as carotid artery stenting and mechanical thrombectomy. Using transcarotid access, catheter length modifications were necessary to achieve "working length" compatibility with the current-generation CorPath GRX robotic system. While further improvements in dedicated robotic solutions for neurointerventions and next-generation thrombectomy devices are necessary, the transcarotid approach provides a direct, relatively rapid access route to the brain for delivering remote stroke treatment.

[Open and endovascular repair of iliac artery aneurysms]. / Arteria iliaca aneurysma nyitott és endovascularis kezelése.

INTRODUCTION AND AIM: Iliac artery aneurysms make up 2% of all aneurysms. There are only a few data available on the results of surgical treatment, therefore the optimal treatment is unclear. Our objective was the retrospective analysis of the perioperative morbidity and mortality of patients who underwent iliac artery surgery as well as the comparison of elective open surgery and endovascular iliac aneurysm repair (EVIAR). METHOD: Retrospective analysis of patients who underwent surgery for iliac artery aneurysm between 1 January 2005 and 31 December 2014. RESULTS: During the 10-year period, 62 patients with a mean age of 68.9 years underwent elective surgery for iliac artery aneurysm (54 males, 87.1%). In 10 cases acute surgery was performed due to aneurysm ruptures (13.9%), 3 patients died within the perioperative period (30%). Regarding anatomical localisation, aneurysm developed mostly on the common iliac artery (80.6%). As an elective surgery, 35 patients (56.5%) underwent open surgery, 25 (40.3%) underwent EVIAR and other endovascular interventions were performed in 2 cases (3.2%). Postoperative complications (1 patient [4.0%] vs. 17 patients [48.5%]; p<0.001) and intensive care treatment (29 patients [82.8%] vs. 2 patients [8.0%]; p<0.001) were significantly rarer after EVIAR than after open surgery. Furthermore, EVIAR resulted in considerably shorter postoperative hospital stays (4.7 ± 2.3 days vs. 11.8 ± 12.2 days; p = 0.006) and significantly less blood transfusion demand (1 patient [4.0%] vs. 26 patients [74.2%]; p<0.001). There were no significant differences regarding long-term survival rates between EVIAR and open surgery (81.4% vs. 71.4%; p = 0.95). CONCLUSION: In case of the surgical treatment of iliac artery aneurysms, owing to the lower complication rates and shorter postoperative length of stay, EVIAR is primarily recommended. Orv Hetil. 2018; 159(13): 520-525.

[Endovascular treatment of acute iliofemoral deep venous thrombosis - our results with catheter-directed thrombolysis and AngioJet]. / Az akut proximális mélyvénás thrombosis endovascularis kezelése ­ a lokális katéteres lysissel és az AngioJet-tel szerzett tapasztalataink.

INTRODUCTION: Most of the patients with iliofemoral thrombosis treated with anticoagulants only are affected with postthrombotic syndrome (PTS) that worsens the patients' quality of life. In the acute phase of proximal deep venous thrombosis (DVT) catheter-directed (CDT) and pharmacomechanical thrombolysis may be a reasonable alternative therapeutic method. Our aim was to summarize our results using these methods. METHODS: Since 2009 twenty-four patients with iliofemoral DVT were treated with these endovascular procedures and with stenting at our Institution. RESULTS: The median age of the patients was 35.83 ± 15.9 years, the female: male ratio was approximately 2:1. The mean time between the onset of the symptoms and the procedures was eleven days. CDT alone was performed in 8 patients, thrombus aspiration in addition to CDT using AngioJet device in 16 patients; in 19 cases the procedure was completed with venous stenting. During the follow-up we performed US examinations and estimated the severity of PTS by Villalta-scale. The total recanalization-rate was more than 50%, which even improved during the follow-up. The total lysis time and the amount of used recombinant tissue plasminogen activator decreased significantly by applying the AngioJet. We did not find any severe PTS among our patients during the follow-up visits. CONCLUSION: Our data suggests that these methods can be used efficiently and safely in the treatment of acute iliofemoral DVT.

The intracranial effects of flow reversal during transcarotid artery revascularization.

Background: This study aimed to assess intraoperative cerebral hemodynamic responses and embolic events during transcarotid artery revascularization via transcranial Doppler, near-infrared spectroscopy, and bispectral index monitoring. Methods: Twelve patients (7 males, 5 females; mean age: 72.8±9.0 years; range, 63 to 91 years) undergoing transcarotid artery revascularization with simultaneous transcranial Doppler, near-infrared spectroscopy, and bispectral index monitoring were analyzed in this retrospective study between September 2017 and December 2019. The mean flow velocity and pulsatility index of the middle cerebral artery, alongside near-infrared spectroscopy and bispectral index values, before flow reversal, during flow reversal, and after flow reversal phases were investigated. The presence and frequency of high-intensity transient signals were recorded to evaluate embolic incidents. Results: Significant reductions in middle cerebral artery mean flow velocity were noted during flow reversal (40.58±10.57 cm/sec to 20.58±14.34 cm/sec, p=0.0004), which subsequently returned to and exceeded baseline values after flow reversal cessation (53.33±17.69 cm/sec, p=0.0005). Near-infrared spectroscopy (71±4.4% to 66±6.2%) and bispectral index (45.71±8.5 to 40.14±8.1) values mirrored these hemodynamic changes, with notable decreases during flow reversal, and recoveries after flow reversal. The highest concentration of high-intensity transient signals was observed during stent deployment, signifying a critical embolic phase. No perioperative neurological complications or other significant adverse events were documented. Conclusion: Transcranial Doppler, near-infrared spectroscopy, and bispectral index effectively monitor cerebral hemodynamics and embolic potential during transcarotid artery revascularization, providing real-time data crucial for optimizing perioperative management. These findings underscore the clinical value of multimodal monitoring in improving patient outcomes in transcarotid artery revascularization procedures.

Radiation Exposure Reduction by Digital Variance Angiography in Lower Limb Angiography: A Randomized Controlled Trial.

BACKGROUND: digital variance angiography (DVA) provides higher image quality than digital subtraction angiography (DSA). This study investigates whether the quality reserve of DVA allows for radiation dose reduction during lower limb angiography (LLA), and compares the performance of two DVA algorithms. METHODS: this prospective block-randomized controlled study enrolled 114 peripheral arterial disease patients undergoing LLA into normal dose (ND, 1.2 µGy/frame, n = 57) or low-dose (LD, 0.36 µGy/frame, n = 57) groups. DSA images were generated in both groups, DVA1 and DVA2 images were generated in the LD group. Total and DSA-related radiation dose area product (DAP) were analyzed. Image quality was assessed on a 5-grade Likert scale by six readers. RESULTS: the total and DSA-related DAP were reduced by 38% and 61% in the LD group. The overall visual evaluation scores (median (IQR)) of LD-DSA (3.50 (1.17)) were significantly lower than the ND-DSA scores (3.83 (1.00), p < 0.001). There was no difference between ND-DSA and LD-DVA1 (3.83 (1.17)), but the LD-DVA2 scores were significantly higher (4.00 (0.83), p < 0.01). The difference between LD-DVA2 and LD-DVA1 was also significant (p < 0.001). CONCLUSIONS: DVA significantly reduced the total and DSA-related radiation dose in LLA, without affecting the image quality. LD-DVA2 images outperformed LD-DVA1, therefore DVA2 might be especially beneficial in lower limb interventions.

Initial experiences with the use of covered stents in endovascular treatment of aortoiliac stenoocclusive diseases / Aortoiliacalis stenoocclusiv betegség fedett sztentekkel végzett endovascularis ellátásával szerzett kezdeti tapasztalataink

Introduction: Treatment for complex aortoiliac stenoocclusive disease traditionally is open surgical repair. Endovascular approach is associated with less perioperative stress for the patient, and is a reasonable solution. Covered stent implantation is an alternative treatment option in this patient population even in the case of aortobiiliac or aortobifemoral bypasses. Objective: Assessing outcomes of aortoiliac covered stent implantation at our vascular center. Method: We retrospectively analysed the data of 36 prospectively registered, consecutive patients who underwent aortoiliac covered stent implantations at our department between the 1th November 2019 and 30th September 2021. Medical records, perioperative complications, preoperative and postoperative Rutherford stages and ankle-brachial index were recorded. One-year survival and primary patency as primary endpoints were presented on Kaplan-Meier curve. Our secondary endpoints were change of the ankle-brachial index and Rutherford stage, and the incidence of the major amputation. Results: 36 patients were included in the study. Mean follow-up time was 12 +/- 6.9 months. TASC C-D aortoiliac lesions were the indication of the procedures in 72.2% (n = 26). Patients had critical limb ischaemia in 44% (n = 16). In 64% (n = 23), interventions were performed via percutaneous puncture. In-hospital stay was 5 +/- 7 days. Perioperative bleeding and reoperation occured in 4 (11.1%) and 6 (16.6%) cases, respectively. Perioperative mortality was zero. The one-year survival and primary patency were 94.3% and 91.4%, respectively. The postoperative Rutherford stage (3 [2] vs. 1 [1]; p < 0.001) and ankle-brachial index (0.4 [0.55] vs. 1 [0.4]; p < 0.001) improved significantly compared to the preoperative ones. Unplanned major amputation was not performed. Conclusion: Significant clinical improvement with low perioperative mortality, acceptable morbidity and high one-year primary patency and survival can be obtained by the use of covered stents in the treatment of aortoiliac stenoocclusive disease. This procedure can be an alternative to open surgical repair.

Long-term results of open surgical repair of non-infrarenal abdominal aortic aneurysms / Nem infrarenalis lokalizációjú hasi aortaaneurysmák miatt végzett nyitott mutétek hosszú távú adatainak elemzése

Introduction: Solid evidence is not available on the ideal technique of surgical repair (open or endovascular) of noninfrarenal abdominal aortic aneurysms. Objective: Our aim was to analyze the postoperative effect of mortality and the level of proximal cross-clamping of the patients who underwent open surgical aortic repair of non-infrarenal abdominal aortic aneurysms with intact wall. Method: This is a retrospective, single-centre study, which reviews the results of open surgical repair, performed for intact non-infrarenal abdominal aorta aneurysms between 2005 and 2017. Aneurysms were analyzed in two groups, based on the level of aortic cross-damping: juxta-pararenal aortic aneurysm group with inter- or suprarenal aortic cross-clamping and suprarenal aortic aneurysm group with supraceliac aortic cross-clamping. Primary endpoints were 30-day, 1-, 2- and 5-year mortality. Secondary endpoints were postoperative acute kidney injury, including hemodialysis, and major postoperative complications. Results: In our clinic, 94 patients underwent open surgical aortic repair with cross-clamping above at least one renal artery. The median follow-up was 3.14 (1.55-5.00) years. The overall 30-day, 1-, 2- and 5-year mortality were 9%, 20%, 27% and 48%, respectively. The mortality was significantly lower in the juxta/pararenal abdominal aortic aneurism group at 30 day and 1 year. The overall perioperative incidence of acute kidney injury was 54% and 30% at discharge. Significantly more in-hospital acute renal dysfunction was noticed in the patients with suprarenal aortic aneurysm than with juxta/pararenal aneurysm, however, the difference was not significant at discharge. Major postoperative complications were more frequent in the suprarenal aneurysm group. Conclusion: Open surgical repair of abdominal aortic aneurysms with supraceliac aortic cross-clamping is associated with significantly higher morbidity, early and mid-term mortality than the repair of juxta/pararenal aneurysms. Chronic kidney disease and major postoperative complications are independent factors of mid- and long-term mortality.

Long-term results of the treatment of Stanford type B aortic dissection with medical and invasive therapy in Hungary / Akut Stanford B típusú aortadissectio konzervatív és invazív terápiájának hosszú távú eredményei Magyarországon

Introduction and objective: Acute Stanford type B aortic dissection (ATBAD) is a potentially life-threatening condi-tion, which may require immediate intervention. This study aims to compare the short-and long-term results of medical, open surgical and endovascular management of ATBAD. Method: This is a retrospective, multi-centre cohort study, where patients admitted with acute and subacute TBAD between Jan. 2011 and Dec. 2020 were included. Results were compared between patients treated with medical, open surgical and thoracic endovascular aortic repair (TEVAR). 30-day mortality and major complications were registered. Survival and freedom from reintervention were noted. Results: A total number of 188 patients were included (69.7% man, mean age: 57 +/- 12.2 years). Hypertension was present in 88.8% of the patients. The 30-day mortality was more higher among patients who underwent open sur-gery, than among patients after TEVAR (26% and 16.7%, p = 0.12). Postoperative lung complication (22.6% and 19.4%) and vascular complication (25.9% and 16.7%) were common in both open and TEVAR groups. In the con-servatively treated group, three patients required intervention in the first 30 days (renal stent implantation: n = 2, TEVAR: n = 1). Median follow-up was 41 (IQR, 73.5) months. There was no significant difference in reoperations during follow-up between the three groups (p = 0.428). 6-year survival was significantly lower among patients with open surgery compared to the other two patient populations (54.8% vs. 79.3% and 75%, p = 0.017). Conclusion: In the invasive treatment of ATBAD, TEVAR is associated with superior short-and long-term compli-cation rate, and survival. There is no significant difference between the long-term results of medical therapy and TEVAR.

Impact of network performance on remote robotic-assisted endovascular interventions in porcine model.

Remote robotic-assisted endovascular interventions require real-time control of the robotic system to conduct precise device navigation. The delay (latency) between the input command and the catheter response can be affected by factors such as network speed and distance. This study evaluated the effect of network latency on robotic-assisted endovascular navigation in three vascular beds using in-vivo experimental model. Three operators performed femoral, carotid, and coronary endovascular robotic navigation blinded from the hybrid room with the prototype remote-enabled CorPath GRX system in a porcine model. Navigation was performed to different targets with randomly assigned network latencies from 0 to 1000 ms. Outcome measurements included navigation success, navigation time, perceived lag (1 = imperceptible, 5 = too long), and procedural impact scored by the operators (1 = no impact, 5 = unacceptable). Robotic-assisted remote endovascular navigation was successful in all 65 cases (9 femoral, 38 external carotid, 18 coronary). Guidewire times were not significantly different across the simulated network latency times. Compared to 0 ms added latency, both the procedural impact and perceived lag scores were significantly higher when the added latency was 400 ms or greater (< 0.01). Remote endovascular intervention was feasible in all studied anatomic regions. Network latency of 400 ms or above is perceptible, although acceptable to operators, which suggests that remote robotic-assisted femoral, carotid or coronary arterial interventions should be performed with network latency below 400 ms to provide seamless remote device control.

Preclinical study testing feasibility and technical requirements for successful telerobotic long distance peripheral vascular intervention.

BACKGROUND: Robotic-assisted endovascular surgery enables us to perform interventions from long distances. This study evaluates the workflow and telecommunication requirements of telerobotic peripheral vascular interventions. METHODS: Ten superficial femoral artery cases were performed by the operator being 44 miles away from the interventional suite, with an endovascular robotic system, on a high-fidelity endovascular simulator. Procedural success, technical success, fluoroscopy time, residual stenosis, contrast dose and network delay were registered. Communication success was assessed after each procedure on a scale from 1 (unacceptable) to 5 (ideal). RESULTS: Procedural success and technical success were 100% and 80%, respectively. The mean residual stenosis, fluoroscopy time and contrast dose were 1.7 ± 5.25%, 6.5 ± 1.8 min and 58.8 ± 14.8 ml. The mean network latency was 38.9 ± 3.5 ms. Median communication success scores were 4.5 (min: 4, max: 5) reported by both the operator and the bedside technician on a scale of 1 (unacceptable) to 5 (ideal). CONCLUSION: With a stable network connection and good communication protocol, a high success rate was achieved for remote robotic-assisted peripheral vascular intervention in an ex vivo model.

Comparing Manual and Robotic-Assisted Carotid Artery Stenting Using Motion-Based Performance Metrics.

Carotid artery stenting (CAS) is a minimally invasive endovascular procedure used to treat carotid artery disease and is an alternative treatment option for carotid artery stenosis. Robotic assistance is becoming increasingly widespread in these procedures and can provide potential benefits over manual intervention, including decreasing peri- and post-operative risks associated with CAS. However, the benefits of robotic assistance in CAS procedures have not been quantitatively verified at the level of surgical tool motions. In this work, we compare manual and robot-assisted navigation in CAS procedures using performance metrics that reliably indicate surgical navigation proficiency. After extracting guidewire tip motion profiles from recorded procedure videos, we computed spectral arc length (SPARC), a frequency-domain metric of movement smoothness, average guidewire velocity, and amount of idle tool motion (idle time) for a set of CAS procedures performed on a commercial endovascular surgical simulator. We analyzed the metrics for two procedural steps that influence post-operative outcomes. Our results indicate that during advancement of the sheath to the distal common carotid artery, there are significant differences in SPARC (F(1, 22.3) = 6.12, p = .021) and idle time (F(1, 22.6) = 6.26, p = .02) between manual and robot-assisted navigation, as well as a general trend of lower SPARC, lower average velocity, and higher idle time values associated with robot-assisted navigation for both procedural steps. Our findings indicate that significant differences exist between manual and robot-assisted CAS procedures. These are quantitatively detectable at the granular-level of physical tool motion, improving the ability to evaluate robotic assistance as it grows in clinical use.

Current utilization and future directions of robotic-assisted endovascular surgery.

INTRODUCTION: Endovascular surgery has become the standard of care to treat most vascular diseases using a minimally invasive approach. The CorPath system further enhances the potential and enables surgeons to perform robotic-assisted endovascular procedures in interventional cardiology, peripheral vascular surgery, and neurovascular surgery. With the introduction of this technique, the operator can perform multiple steps of endovascular interventions outside of the radiation field with high precision movements even from long-geographical distances. AREAS COVERED: The first and second-generation CorPath systems are currently the only commercially available robotic devices for endovascular surgery. This review article discusses the clinical experiences and outcomes with the robot, the advanced navigational features, and the results with recent hardware and software modifications, which enables the use of the system for neurovascular interventions, and long-distance interventional procedures. EXPERT OPINION: A high procedural success was achieved with the CorPath robotic systems in coronary and peripheral interventions, and the device seems promising in neurovascular procedures. More experience is needed with robotic neurovascular interventions and with complex peripheral arterial cases. In the future, long-distance endovascular surgery can potentially transform the management and treatment of acute myocardial infarction and stroke, with making endovascular care more accessible for patients in remote areas.

In situ reconstruction of an MRSA-infected paravisceral aortic pseudoaneurysm with cryopreserved aortic allograft.

OBJECTIVES: Treatment of paravisceral aortic infections poses several challenges because standard therapy with excision of all infected tissues and extraanatomic reconstruction is frequently not possible without jeopardizing visceral perfusion. In situ reconstruction with rifampin-soaked prosthetic graft or endovascular repair with stent grafts runs the risk of reinfection. We present a case of a paravisceral aortic infection, where cryopreserved allograft was used for the reconstruction of the aorta. METHODS: Medical documentation and CT angiography studies were retrospectively reviewed for a patient in a tertiary care center. RESULTS: A 62-year-old male patient presented with an infected pseudoaneurysm of the paravisceral aorta at the level of the celiac artery. He had previously undergone multiple orthopedic surgical interventions and developed methicillin-resistant Staphylococcus aureus infections. We successfully repaired the paravisceral pseudoaneurysm with excision of all infected tissues and in situ aortic replacement with a cryopreserved allograft. CONCLUSION: In case of infected aortic pseudoaneurysm, the use of cryopreserved aortic allograft is a reliable choice for reconstruction of the aorta.

[The use of HeRO (Hemodialysis Reliable Outflow) graft in hemodialysis]. / HeRO (Hemodialysis Reliable Outflow) graft alkalmazása tartós hemodialíziskezelés során.

Creating durable vascular access has become more complicated with the improvement of the management and with the increasing survival of patients with end-stage renal disease. HeRO (Hemodialysis Reliable Outflow) graft allows to maintain vascular access on the upper limb in patients with the presence of bilateral central venous occlusion. Our institute was the first in Hungary to perform a HeRO graft implantation in a patient receiving regular hemodialysis. Our objective was to present our findings with this recent innovation. Case report, medical documentation and imaging studies were reviewed. The patient (73-year-old, female) has been receiving hemodialysis since 12 years with the history of several arteriovenous fistula (AVF) creations, thrombectomies, use of central venous catheter in both sides. Following the occlusion of a left cubital arterio-venous fistula, none of the conventional vascular access types could have been performed due to bilateral subclavian vein occlusion. Successful HeRO graft implantation was performed. The patient underwent graft thrombectomy and endovascular intervention 7 and 12 months after the original procedure. After both reoperations, the graft functioned well for hemodialysis. HeRO graft can be a good alternative to central venous catheters and lower limb arterio-venous grafts in cases of bilateral central venous occlusion. Orv Hetil. 2019; 160(31): 1231-1234.