Multicentric experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases.

OBJECTIVES: Aim of this multicentre retrospective cohort study is to evaluate technical success, early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside-down through antegrade access, to treat thoracic aortic diseases. METHODS: Antegrade TEVAR performed between January 2010 and December 2021 have been collected and analyzed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed into previous or concomitant surgical or endovascular repairs. RESULTS: Fourteen patients were enrolled; 13 males (94%) with mean age of 71 years (IQR 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indication to treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (IQR 1; 44). Late death occurred in 2 (20%) patients, both operated in elective setting. The first died at 19 months due to aortic-related reintervention, the second died at 34 months for a not aortic-related cause. Two patients (14%) underwent aortic-related reintervention for late type I endoleak. Survival rate in elective procedures was 100%, 84% and 67% at 12, 24 and 36 months respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months respectively. CONCLUSIONS: Antegrade TEVAR can seldomly be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and low access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.

Standardized approach for four-fenestrated physician-modified endograft to treat complex abdominal aortic aneurysms using Valiant Captivia.

We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.

Outcomes of Off the Shelf Outer Branched Versus Inner Branched Endografts in the Treatment of Thoraco-abdominal Aortic Aneurysm in the B.R.I.O. (BRanched Inner - Outer) Study Group.

OBJECTIVE: This study aimed to compare two commercially available off the shelf branched endografts for thoraco-abdominal aortic aneurysm (TAAA) repair, namely the E-nside (Artivion) and Zenith t-Branch (Cook Medical) devices. METHODS: This multicentre retrospective study (2020 - 2023) included patients treated by branched endovascular aortic repair (BEVAR) for TAAA using the inner branched E-nside or the outer branched t-Branch. Endpoints were 30 day technical success and major adverse events (MAEs) as well as 1 year freedom from target vessel instability and main endograft instability. RESULTS: The study included 163 patients: 79 (307 target vessels) treated with E-nside and 84 (325 target vessels) with t-branch. Aneurysm extent was I - III in 91 patients (55.8%; 47% of E-nside and 66% of t-Branch) and IV in 72 patients (44.2%; 53% of E-nside and 34% of t-Branch) (p = .011). An adjunctive proximal thoracic endograft was used in 43% of E-nside vs. 69% of t-Branch (p < .001), with less frequent thoracic endografting (14% vs. 76%; p < .001) and shorter length of coverage (p = .024) in extent IV TAAA treated by E-nside. E-nside cases had shorter bridging length of renal arteries (66 ± 17 mm vs. 76 ± 20 mm; p < .010) and less frequent use of a distal bifurcated endograft (53% vs. 80%; p < .001). Comparing 30 day results, mortality was 1% vs. 2% (p = .62), any MAE occurred in 18% vs. 21% (p = .55), the stroke rate was 3% vs. 0% (p = .23), and the elective spinal cord ischaemia rate was 5% vs. 8% (p = .40) for E-nside and t-Branch, respectively. At 1 year, freedom from target vessel instability was 96 ± 3% for E-nside and 95 ± 3% for t-Branch (p = .58), and freedom from endograft instability was 98 ± 2% vs. 97 ± 3% (p = .46) respectively. CONCLUSION: Both off the shelf devices provided excellent early and 1 year results. The E-nside may require shorter thoracic aorta coverage and bridging length for the renal arteries, and less frequent implantation of concomitant proximal thoracic or distal abdominal bifurcated endograft. However, these aspects did not determine significant differences in clinical outcomes.

Erasing narrow paravisceral true lumen with endoseptostomy to favor adequate expansion of branched endograft during postdissection thoracoabdomimal aortic aneurysm endovascular repair.

Narrow paravisceral aortic true lumen in postdissection thoracoabdominal aneurysm, represents a challenging situation when branched endovascular aneurysm repair is required; it may be responsible for intraprocedural technical difficulties, such as inadequate main endograft deployment, difficult vessels catheterization, or long-term branch instability related to compression. We describe the case of a 56-year-old man with post-type B thoracoabdominal aortic aneurysm and a severely narrow true lumen (10 mm) at the paravisceral segment. Endovascular aortic septostomy was performed first, to erase the narrow paravisceral aortic true lumen, and subsequently allow branched endograft adequate expansion and regular vessels catheterization.

Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation.

OBJECTIVE: The aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D). METHODS: All consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients' baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. RESULTS: Overall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups. CONCLUSIONS: Surgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.

Six-year clinical and computed tomography angiography follow-up after Nexus implantation.

Endovascular aortic arch repair (Ar-TEVAR) with single-branch, off-the-shelf Nexus aortic arch system has shown promising early and 3-year outcomes. There is lack of data regarding long-term results of this specific device, particularly regarding patency of supra-aortic bypasses and stability of the connection between the 2 modules. This case report describes 6-year clinical and imaging follow-up of a 74-year-old patient who underwent Ar-TEVAR with Nexus. Over 6 years, the patient experienced minor complications unrelated to the device. The patency of supra-aortic bypasses and integrity of the device's connection were confirmed. Computed tomography angiography constantly showed exclusion of the aneurysm and reduction of the aneurysmal sac. In conclusion, although extended research and broader data are needed, this case provides encouraging evidence of long-term results of Ar-TEVAR with Nexus.

Role of intravascular ultrasound for the technical assessment of endovascular reconstruction of the aortic bifurcation.

OBJECTIVE: The aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. METHODS: We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. RESULTS: IVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. CONCLUSIONS: IVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.

Endovascular aortic arch repair under monitored anaesthesia care: maximizing microinvasiveness.

Patients with aortic arch pathologies after surgery for type-A acute aortic dissection represent a challenging population since open surgery is associated with a non-negligible rate of mortality and complications. Microinvasive endovascular aortic arch repair Arch-Thoracic EndoVascular Aortic Repair (Ar-TEVAR) has shown promising results in high-risk patients. Ar-TEVAR is usually performed under general anaesthesia. We report the case of an 83-year-old man with a history of ascending aorta replacement for type-A acute aortic dissection who was referred for an anastomotic pseudoaneurysm. Ar-TEVAR using an off-the-shelf single-branch aortic arch stent graft was chosen. In order to further minimize procedural invasiveness, monitored anaesthesia care (local anaesthesia with sedation and analgesia) was performed since it provides less stress on the cardiovascular and respiratory systems and overall leads to a faster recovery especially in elderly patients.

Mid-Term Results of an Italian Multicentric Experience with the RoadsaverTM Dual-Layer Carotid Stent System.

BACKGROUND: Carotid artery stenting (CAS) using first-generation single-layer stents is widely accepted as a good alternative to standard carotid endarterectomy (CEA) but it is associated with worse outcomes in terms of both plaque prolapse and cerebral embolization. AIM: To evaluate the perioperative and midterm outcomes of CAS using the new-generation RoadsaverTM dual-layer micromesh-covered carotid stent. METHODS: Herein, we present the results of an observational, retrospective, multicentric study on non-consecutive patients who underwent the CAS procedure between January 2017 and December 2022 at three Italian, high-volume vascular surgery centers. The inclusion criteria were the patients' eligibility for the CAS procedure in accordance with the current Italian guidelines, and the implantation of a Roadsaver stent. Both symptomatic and asymptomatic patients were included in the study. The patients requiring reintervention for carotid restenosis following CEA were also included. Perioperative data regarding procedural success was defined as the successful implantation of the device in the desired position, less than 30% residual stenosis, and the absence of intraoperative neurological complications. The primary outcome was any adverse cerebrovascular event such as stroke or transient ischemic attack (TIA) during the procedure and/or after discharge. The secondary outcomes were the need for further intervention, and all-cause death following procedure. RESULTS: Three-hundred-fifty-three (353) patients were included in our study; the mean age was 74.3 years. A total of 5.9% of the patients were symptomatic on their operated side, while 7.3% had contralateral carotid occlusion. A cerebral embolic protection device (CPD) was employed in all patients. A total of 13.3% of the patients were operated on for restenosis after CEA Technical success was achieved in 96.9% of the cases with an intraoperative report of six TIAs (1.7%) and six ipsilateral strokes (1.7%). The mean hospital stay was 1.8 days. The thirty-day follow up showed one TIA and one more stroke. At the mean 35-month follow-up time, the primary outcome was present in six patients (1.7%), where four TIAs (1.1%) and two strokes (0.5%) were reported. Restenosis occurred in five patients (1.4%). Death for any cause was reported in 11 patients (3.1%). CONCLUSIONS: As most recent, high-quality studies show, the CAS procedure with second-generation devices such as the Roadsaver stent is safe and effective in preventing carotid-related cerebrovascular events in both symptomatic and asymptomatic patients. The intraoperative and postoperative cerebrovascular complication rate in high volume centers is very low, ensuring confidence in its employment for the CAS procedure along with a CPD as a valid alternative to CEA.

Fate of primary determinate and indeterminate target vessel endoleaks after fenestrated-branched endovascular aortic repair.

OBJECTIVE: The aim of this study was to investigate the outcomes of primary determinate and indeterminate target vessel endoleaks (TVELs) after fenestrated-branched endovascular aortic repair (F-BEVAR). METHODS: We conducted a single-center retrospective study (2014-2023) on F-BEVAR for thoracoabdominal (TAAAs) or pararenal aortic aneurysms (PRAAs). TVELs were classified as "primary" if present at the first postoperative computed tomography angiogram. Endoleaks were defined "determinate" (dELs) if the cause (type Ic or IIIc) and implicated target vessel were identifiable and "indeterminate" (iELs) if contrast enhancement was detectable at the level of fenestrations/branches without any evident source. Endoleaks involving multiple inflows (type II and target vessels) were defined as "complex" (cELs). Endpoints were endoleak spontaneous resolution, 1-year aneurysm sac failure to regress (>5 mm diameter decrease), and 4-year endoleak-related secondary interventions. Kaplan-Meier estimates and Cox regression were used for the analysis. RESULTS: There were 142 patients with JRAAs/PRAAs (n = 85; 60%) or TAAAs (n = 57; 40%), with 513 target arteries incorporated through a fenestration (n = 294; 57%) or directional branch (n = 219; 43%). Fifty-nine primary TVELs (12%) were identified in 35 patients (25%), a dEL in 20 patients (14%) and iEL in 15 (11%); 22 (15%) had a determinate or indeterminate cEL. Overall spontaneous resolution rate was 75% (95% confidence interval [CI], 51%-87%) at 4 years. cELs (odds ratio [OR], 5.00; 95% CI, 1.10-49.4; P < .001) and iELs after BEVAR (OR, 9.43; 95% CI, 3.41-56.4; P = .002) were more likely to persist >6 months, and persistent forms were associated with sac failure to regress at 1 year (OR, 1.72; 95% CI, 1.03-12.59; P = .040). Overall freedom from endoleak-related reinterventions was 85% (95% CI, 79%-92%) at 4 years, 92% (95% CI, 87%-97%) for those without primary TVELs and 62% (95% CI, 46%-84%) for those with any primary TVEL (P < .001). In particular, cELs (hazard ratio, 1.94; 95% CI, 1.4-18.81; P = .020) were associated with an increased need for reintervention. In case a secondary intervention was needed, iEL or cEL had an increased risk for multiple secondary procedures (hazard ratio, 2.67; 95% CI, 1.22-10.34; P = .034). CONCLUSIONS: Primary TVELs are frequent after F-BEVAR, and a clear characterization of the endoleak source by computed tomography angiogram is not possible in 40% of patients. Most primary TVELs spontaneously resolve, but during follow-up, patients with any primary TVEL experience a worsened freedom from endoleak-related reinterventions that is mostly driven by persistence of cELs and post-BEVAR iELs. Multiple secondary procedures may be required in case of iELs or cELs.

Rotational Mechanical Thrombectomy to Treat Iliac Limb Occlusion after Endovascular Aortic Aneurysm Repair: The Rotational Mechanical Thrombectomy Italian Study.

PURPOSE: To assess the safety and effectiveness of a rotational mechanical atherothrombectomy device in patients with symptomatic iliac limb occlusion after abdominal endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: A retrospective analysis was conducted on patients who underwent rotational mechanical thrombectomy using the Rotarex S device for symptomatic acute, subacute, or chronic graft limb thrombosis at 5 vascular centers between 2017 and 2021. This study comprised 23 male patients with a mean age of 74.5 years (SD ± 7.2) at the time of the procedure. The clinical presentation of the patients varied, with 1 patient experiencing acute limb ischemia and 11 patients (47.8%) experiencing disabling intermittent claudication. The remaining patients developed chronic limb-threatening ischemia after iliac limb occlusion. Early outcomes included technical success, postprocedural complications, and periprocedural mortality. Follow-up evaluations encompassed primary patency, patient survival, freedom from reintervention, and the need for surgical conversion. RESULTS: Technical success was achieved in all cases, with no occurrences of distal embolization during or after the procedure, and no periprocedural deaths were reported. Endograft relining was performed in 82.6% of patients to establish a new, nonthrombogenic surface within the graft. Over a median follow-up period of 8 months (interquartile range, 3-16 months), 2 patients experienced iliac limb reocclusion. No deaths or other reinterventions occurred during the observational follow-up period. CONCLUSIONS: Rotational mechanical thrombectomy for iliac limb occlusion after EVAR appears to be both safe and effective. This technique may uncover intraluminal defects contributing to graft occlusion and enable their resolution within the same procedure.

Intravascular Ultrasound in the Detection of Bridging Stent Graft Instability During Fenestrated and Branched Endovascular Aneurysm Repair Procedures: A Multicentre Study on 274 Target Vessels.

OBJECTIVE: The use of intravascular ultrasound (IVUS) reduces contrast medium use and radiation exposure during conventional endovascular aneurysm repair (EVAR). The aim of this study was to evaluate the safety and efficacy of IVUS in detecting bridging stent graft (bSG) instability during fenestrated and branched EVAR (F/B-EVAR). METHODS: This was a prospective observational multicentre study. The following outcomes were evaluated: (1) technical success of the IVUS in each bSG, (2) IVUS findings compared with intra-operative angiography, (3) incidence of post-operative computed tomography angiography (CTA) findings not detected with IVUS, and (4) absence of IVUS related adverse events. Target visceral vessel (TVV) instability was defined as any branch or fenestration issues requiring an additional manoeuvre or re-intervention. Any IVUS assessment that detected stenosis, kinking, or any geometric TVV issue was considered to be branch instability. All procedures were performed in ad hoc hybrid rooms. RESULTS: Eighty patients (69% males; median age 72 years; interquartile range 59, 77 years) from four aortic centres treated with F/B-EVAR between January 2019 and September 2021 were included: 70 BEVAR (21 off the shelf; 49 custom made), eight FEVAR (custom made), and two F/B-EVAR (custom made), for a total of 300 potential TVVs. Two TVVs (0.7%) were left unstented and excluded from the analysis. The TVVs could not be accessed with the IVUS catheter in seven cases (2.3%). Furthermore, 17 (5.7%) TVVs could not be examined due to a malfunction of the IVUS catheter. The technical success of the IVUS assessment was 91.9% (274/298), with no IVUS related adverse events. Seven TVVs (2.5%) showed signs of bSG instability by means of IVUS, leading to immediate revisions. The first post-operative CTA at least 30 days after the index procedure was available in 268 of the 274 TVVs originally assessed by IVUS. In seven of the 268 TVVs (2.6%) a re-intervention became necessary due to bSG instability. CONCLUSION: This study suggests that IVUS is a safe and potentially valuable adjunctive imaging technology for intra-operative detection of TVV instability. Further long term investigations on larger cohorts are required to validate these promising results and to compare IVUS with alternative technologies in terms of efficiency, radiation exposure, procedure time, and costs.

Effect of narrow paravisceral aorta on target vessel instability after fenestrated and branched endovascular aortic repair.

OBJECTIVE: To investigate the effect of narrow paravisceral aorta (NPA) on target vessel instability (TVI) after fenestrated-branched endovascular aortic repair. METHODS: We conducted a single-center retrospective study (2014-2023) of patients treated by fenestrated-branched endovascular aortic repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms. The paravisceral aorta was defined as the aortic segment limited by the diaphragmatic hiatus proximally and the emergence of lower renal artery distally, and was considered "narrow" in case of a minimum inner diameter of <25 mm. The minimum aortic diameter, location, longitudinal extension, angulation, calcification, and thrombus thickness of NPA were evaluated at the preoperative computed tomography angiogram. End points were 30-day technical success and freedom from TVI. RESULTS: There were 142 patients with JRAA/pararenal aortic aneurysm (n = 85 [59%]) and extent IV (n = 24 [17%]) or extent I-III (n = 33 [23%]) TAAA, with 513 target arteries successfully incorporated through a fenestration (n = 294 [57%]) or directional branch (n = 219 [43%]). A NPA was present in 95 patients (70%), 73 (86%) treated by fenestrated endovascular aortic repair (FEVAR) and 22 (39%) by branched endovascular aortic repair (BEVAR). The overall 30-day mortality was 2% and technical success was 99%, without differences between NPA and non-NPA (P = .99). Kaplan-Meier estimated freedom from TVI at 4 years was 82%, 81% (95% CI, 75-95) in patients with a NPA and 80% (95% CI, 68-94) and in those without NPA (P = .220). The result was maintained for both FEVAR (NPA: 81% [95% CI, 62-88]; non-NPA: 76% [95% CI, 60-99]; P = .870) and BEVAR (NPA: 77% [95% CI, 69-99]; non-NPA: 80% [95% confidence interval (CI) 66-99]; P = .100). After multivariate analysis, the concomitant presence of a NPA <20 mm and angulation of >30° was significantly associated with TVI in FEVAR (HR, 3.21; 95% CI, 1.03-48.70; P = .036), being the result mostly driven by target vessel occlusion. In BEVAR, a NPA diameter of <25 mm was not associated with TVI (HR, 2.02; 95% CI, 0.59-5.23; P = .948); after multivariate analysis, the use of outer branches in case of a NPA longitudinal extension of >25 mm (hazard ratio [HR], 3.02; 95% CI, 1.01-36.33; P = .040) and NPA severe calcification (HR, 1.70; 95% CI, 1.00-22.42; P = .048) were associated with a higher chance for TVI. CONCLUSIONS: FEVAR and BEVAR are both feasible in cases of NPA and provide satisfactory target vessels durability. The use of outer branches should be avoided in cases with an inner aortic diameter of <25 mm with a longitudinal extension of >25 mm or moderate to severe NPA calcifications. In FEVAR, bridging stent patency may be negatively influenced by NPA of <20 mm in association with aortic angulation of >30°.

Effect of plaque morphological characteristics on the outcomes of carotid artery stenting.

Carotid artery stenting (CAS) represents today an accepted option for the treatment of severe carotid artery stenosis. The evolution of materials, techniques, perioperative medical management and patients' selection, has allowed to progressively reduce CAS complications. However, the main drawback of CAS is still represented by the risk of cerebral embolization, that may occur during several steps of the procedure and also in the early postoperative period. Preoperative carotid plaque morphological characteristics may have a great role in determining the risk of embolization during CAS. This review summarizes the current knowledge on carotid plaque characteristics that may influence the risk of complication during CAS. This information may be important for the optimization of CAS patients' selection and adaptation of the materials and techniques.

Physician-Modified Single-Fenestrated EndoSuture Aneurysm Repair (FESAR) for Urgent Juxtarenal AAA Repair.

PURPOSE: To describe the endovascular treatment of a symptomatic juxtarenal abdominal aortic aneurysm (JAAA) using a combination of endoanchors (Heli-FX EndoAnchor, Medtronic, Minneapolis, Minnesota) and a physician-modified single-fenestrated endograft. TECHNIQUE: An 85 year-old patient unfit for open aortic repair presented for a symptomatic JAAA, characterized by an infrarenal neck with 0.6 cm in length and 23 mm in diameter. A 28 mm-diameter Endurant aortic cuff (Medtronic, Minneapolis, Minnesota) was modified with a single fenestration for the left renal artery (LRA) and diameter-reducing tie, then re-sheathed and deployed. The LRA was cannulated with a 7F sheath and the constraining wire was withdrawn. Being the shortest neck length on the right side of the cuff, the endograft was anchored to the aortic wall on this side with 2 endoanchors. The LRA was stented and flared, then a distal physician-modified (without free-flow) bifurcated Endurant graft (Medtronic, Minneapolis, Minnesota) was overlapped with the proximal cuff and stabilized with 6 endoanchors. Correct positioning with complete aneurysm exclusion was confirmed with a 30 day and 9 month computed tomography angiograms. CONCLUSIONS: In extremely selected cases, association of endoanchors and single-fenestrated physician-modified graft may be useful to treat complex urgent aortic aneurysm using readily available devices. CLINICAL IMPACT: This technical note demonstrates the feasibility of a single-fenestrated physician-modified Endurant endograft deployed in combination with endosuture fixation (FESAR), to urgently treat a juxtarenal aortic aneurysm unfit for open repair and not suitable for standard endovascular repair nor off-the-shelf endografts.

Clinical Impact and Determinants of Fenestration to Target Vessel Misalignment in Fenestrated Endovascular Aortic Repair.

OBJECTIVE: This single centre, retrospective study (2014 - 2022) on juxta-, pararenal, or thoraco-abdominal aortic aneurysms treated by fenestrated endovascular aortic repair (FEVAR) was conducted to investigate the clinical impact and determinants of fenestration to target vessel misalignment in FEVAR. METHODS: Pre-operative supracoeliac, pararenal, and infrarenal aortic angles were measured on three dimensional computed tomography angiography (CTA) reconstructions. Two components of misalignment were measured on the first post-operative CTA: horizontal misalignment (angle between the fenestration and the target vessel ostium on perpendicular CTA cuts) and vertical misalignment (vertical distance between the fenestration and the target vessel at its origin). Endpoints were freedom from target vessel instability (TVI) and alignment change over time. RESULTS: Of 65 patients treated by FEVAR, 60 (202 target arteries) with juxta-, pararenal (80%), or thoraco-abdominal aortic aneurysm (20%) were included. Mean horizontal misalignment was 9 ± 12° (median 5°; IQR 0 - 16) and mean vertical misalignment was 0.7 ± 1 mm (median 0 mm, IQR 0 - 1). Freedom from TVI was 92% (95% CI 88 - 98) at 36 months. Horizontal misalignment > 15° was significantly associated with TVI (HR 5.19; 95% CI 1.54 - 17.48; p = .008); vertical misalignment did not significantly impact TVI (HR 0.99; 95% CI 0.56 - 1.73; p = .97). By multivariable analysis, pararenal aortic angle (OR 1.01 per increased degree of angulation; 95% CI 1.00 - 1.02; p = .044), bridging distance > 5 mm (OR 1.07; 95% CI 1.02 - 1.11; p = .003), and use of higher profile endografts in tortuous iliac access (OR 7.55; 95% CI 4.55 - 1.11; p = .003) were associated with clinically significant misalignment. Bridging distance > 5 mm (OR 2.00; 95% CI 1.02 - 11.29; p = .044), degree of baseline misalignment (OR 1.04; 95% CI 1.01 - 1.08; p = .036), and persistence of any primary endoleak for > 6 months (OR 5.85; 95% CI 1.23 - 29.1; p = .023) were associated with misalignment increase during follow up. CONCLUSION: Horizontal misalignment > 15° is associated with worsened target vessel outcomes. This may occur as a result of excessive iliac access tortuosity, high pararenal aortic angulation, and bridging distance > 5 mm.

Impact of Carotid Stent Design on Embolic Filter Debris Load During Carotid Artery Stenting.

BACKGROUND: The carotid stent design may influence the risk of embolization during carotid artery stenting. The aim of the study was to assess this risk by comparing the quantity of embolized material captured by filters during carotid artery stenting, using different stent designs. METHODS: We conducted a single-center retrospective study of patients undergoing carotid artery stenting for asymptomatic carotid stenosis >70% (2010-2022) in a tertiary academic hospital (Padua University Hospital, Italy). Carotid stents were classified according to their design as open-cell (OCS), closed-cell (CCS), or micromesh stents (MMS). A distal filter protection was used in all patients, and the amount of captured embolized particles was semiautomatically analyzed using a dedicated software (Image-Pro Plus, Media Cybernetics). Primary end point was embolic filter debris (EFD) load, defined as the ratio of the filter area covered by particulate material to the total filter area. Secondary end points were 30 days major stroke and death. RESULTS: Four-hundred-eighty-one carotid artery stentings were included; 171 (35%) using an OCS, 68 (14%) a CCS, and 242 (50%) a MMS. Thirty-days mortality was 0.2% (n=1) and major stroke rate was 0.2% (P=0.987). Filters of patients receiving MMS were more likely to be free from embolized material (OCS, 30%; CCS, 13%; MMS, 41%; P<0.001) and had a lower EFD load (OCS, 9.1±14.5%; CCS, 7.9±14.0%; MMS, 5.0±9.1%; P<0.001) compared with other stent designs. After stratification by plaque characteristics, MMS had a lower EFD load in cases of hypoechogenic plaque (OCS, 13.4±9.9%; CCS, 10.9±8.7%; MMS, 6.5±13.1%; P<0.001), plaque length>15 mm (OC, 10.2±15.3; CC, 8.6±12.4; MM, 8.2±13.6; P<0.001), and preoperative ipsilateral asymptomatic ischemic cerebral lesion (OCS, 12.9±16.8%; CCS, 8.7±19.5%; MMS, 5.4±9.7%; P<0.001). After multivariate linear regression, use of MMS was associated with lower EFD load (P=0.038). CONCLUSIONS: The use of MMS seems to be associated with a lower embolization rate and EFD load, especially in hypoechogenic and long plaques and in patients with a preoperative evidence of asymptomatic ischemic cerebral lesion.

Bypass vs endovascular treatment for occluded femoro-popliteal stents in patients with critical limb-threatening ischemia.

OBJECTIVE: The aim of the study was to compare the early and medium-term outcomes of bypass vs endovascular treatment of occluded femoro-popliteal stents in patients with chronic limb-threatening ischemia (the OUT-STEPP multicentric registry). METHODS: Between January 2016 and December 2021, 317 patients in 14 centers underwent treatment for a symptomatic occlusion of femoro-popliteal stent/stents. One hundred sixty-one patients were included into the present study: 46 (28.6%) underwent open bypass surgery (Group OPEN), and 115 (71.4%) underwent endovascular revascularization (Group ENDO). Early (30 days) results were assessed and compared between the two groups. Estimated 5-year outcomes were evaluated and compared with the log rank test. RESULTS: At 30 days, no differences were found in terms of major adverse cardiovascular events, acute kidney injury, reinterventions, major amputation, and all-cause mortality between the two groups. The need for blood transfusions was higher for patients in Group OPEN (17; 36.9% vs 13; 11.3%; P < .001). The mean length of intensive care unit stay and the mean hospital stay were higher for patients in Group OPEN ([0.3 ± 0.9 vs 0 days; P < .001] and [9.7 ± 5.8 vs 3.3 ± 1.4 days; P < .001], respectively). The overall median duration of follow-up was 33.1 months (interquartile range, 14-49.5 months). At 5 years, there were no differences between the two groups in terms of survival (68.7% Group OPEN vs 68.8% Group ENDO; P = .27; log-rank, 1.21), primary patency (56.3% Group OPEN vs 67.8% Group ENDO; P = .39; log-rank, 0.75), secondary patency (59.1% Group OPEN vs 77.8% Group ENDO; P = .24; log-rank, 1.40), absence of target lesion restenosis (56.8% Group OPEN vs 62.7% Group ENDO; P = .42; log-rank, 0.65), and limb salvage (77.2% Group OPEN vs 90.4% Group ENDO; P = .17; log-rank, 1.87). CONCLUSIONS: Both bypass and endovascular treatment provided safe and effective restoration of patency for femoro-popliteal in-stent occlusion in patients with chronic limb-threatening ischemia. Open surgery was associated with longer stay in hospital and increased use of blood transfusions. At 5 years, no significant differences were found in the rates of overall patency or limb salvage between bypass and endovascular treatment.

The "safe-line" technique as theoretical additional attempt to mitigate spinal cord ischemia after urgent complete endovascular exclusion of a thoracoabdominal aortic aneurysm.

We describe the feasibility of a technique for temporary aneurysm sac reperfusion after endovascular single-stage thoracoabdominal aortic aneurysm exclusion, to be used in the case of postoperative spinal cord ischemia. Two cases were treated for impending rupture of a thoracoabdominal aortic aneurysm. Before completion of sac exclusion, a supplementary buddy wire (V-18 control guidewire; Boston Scientific) was advanced in parallel fashion from the left percutaneous femoral access into the aneurysmal sac on the posterior aspect of the endograft. Distal aneurysm exclusion was completed using the main superstiff guidewire, and the femoral access was closed with a percutaneous closure device (ProGlide; Abbott) in standard fashion, leaving in place the sole V-18 guidewire, draped in sterile fashion. In the case of spinal cord ischemia, the "safe-line" can be rapidly used for spinal reperfusion after trans-sealing exchange with a 6F, 65-cm-long Destination sheath (Terumo) connected to a 6F introducer on the contralateral femoral artery.

Open Versus Endovascular Repair With Covered Stents for Complex Aortoiliac Occlusive Disease: Cost Analysis Results.

BACKGROUND: The aim of this work is to value cost-effectiveness of complex aortoiliac occlusive disease (AIOD) revascularization, by comparing in-hospital clinical outcomes and detailed costs of hospitalization of open and endovascular techniques. METHODS: This observational single-center retrospective cohort study included all patients who underwent AIOD revascularization from May 2008 to February 2018 and met inclusion and exclusion criteria. Patients were divided into 2 groups: open surgical repair and endovascular repair. Inclusion criteria were type C and D AIOD, and type of intervention: aorto-bifemoral bypass and covered kissing stenting. Costs were directly compared between the 2 groups, and subsequently a multivariate logistic regression model was performed to define which group most influenced major in-hospital costs. Cox proportional hazard models were used to identify predictors of long-term mortality and primary patency (PP). RESULTS: The 2 groups included 50 patients each, and all patients had a bilateral iliac axis revascularization. Mean age was 67 ± 9 years and 71% of patients were males. The open surgical repair group had a significantly longer length of hospitalization (P < 0.001) and in-hospital medical complications rate (22%, P = 0.003). No differences were found in the total cumulative cost of hospitalization, including ward, intensive care unit, and operating room. In a multivariate logistic model, higher total hospitalization costs were not significantly associated with either one or the other type of treatment. We did not find any statistically significant differences in overall medium-term survival (P = 0.298) and PP (P = 0.188), which were not influenced by the type of revascularization on Cox proportional hazard models (overall survival: hazard ratio 2.09 confidence interval 95% [0.90-4.84] P = 0.082; PP: hazard ratio 1.82 confidence interval 95% [0.56-6.16] P = 0.302). CONCLUSIONS: Total in-hospital stay cost analysis did not reveal significant differences between aorto-bifemoral bypasses and covered kissing stentings for AIOD revascularization.