Perceptions, awareness, and implementation surrounding the assessment of frailty amongst vascular surgeons in Italy: Results from a nationwide cross-sectional survey.

OBJECTIVES: We conducted this survey to gain insight into the real-life application and perceptions regarding the importance of peri-operative frailty assessment amongst vascular surgeons in Italy. METHODS: Italian vascular surgeons were invited to participate in the survey using the list provided by the Italian Society for Vascular and Endovascular Surgery (1050 invited participants). A dedicated link to the survey was emailed through Google Forms, and reminders were automatically sent on a bi-weekly basis for a total of 8 weeks before stopping data collection. RESULTS: The survey was completed by 225 respondents, thereby yielding an overall 21.5% response rate. While the vast majority of respondents stated they were aware of the meaning of frailty (93%) and agreed that its assessment was clinically relevant for patients undergoing vascular surgery (99%), only 44% of surveyed surgeons reported that they used a specific tool for peri-operative frailty assessment. However, most respondents indicated that routine evaluation of frailty was not performed at their institution (87%). The main limitations were identified as being the lack of confidence in choosing the best tool, followed by lack of awareness, lack of skilled operators, and lack of time. CONCLUSIONS: Our study showed that whilst most vascular surgeons in Italy are aware of the importance of frailty in affecting surgical outcomes across various interventions in the elective and non-elective settings, there is poor implementation of formal frailty assessment.

Intraoperative Predictors and Proposal for a Novel Prognostic Risk Score for In-Hospital Mortality after Open Repair of Ruptured Abdominal Aortic Aneurysms (SPARTAN Score).

(1) Background: Several mortality risk scores have been developed to predict mortality in ruptured abdominal aortic aneurysms (rAAAs), but none focused on intraoperative factors. The aim of this study is to identify intraoperative variables affecting in-hospital mortality after open repair and develop a novel prognostic risk score. (2) Methods: The analysis of a retrospectively maintained dataset identified patients who underwent open repair for rAAA from January 2007 to October 2023 in three Italian tertiary referral centers. Multinomial logistic regression was used to calculate the association between intraoperative variables and perioperative mortality. Independent intraoperative factors were used to create a prognostic score. (3) Results: In total, 316 patients with a mean age of 77.3 (SD ± 8.5) were included. In-hospital mortality rate was 30.7%. Hemoperitoneum (p < 0.001), suprarenal clamping (p = 0.001), and operation times of >240 min (p = 0.008) were negative predictors of perioperative mortality, while the patency of at least one hypogastric artery had a protective role (p = 0.008). Numerical values were assigned to each variable based on the respective odds ratio to create a risk stratification for in-hospital mortality. (4) Conclusions: rAAA represents a major cause of mortality. Intraoperative variables are essential to estimate patients' risk in surgically treated patients. A prognostic risk score based on these factors alone may be useful to predict in-hospital mortality after open repair.

Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair.

OBJECTIVE: Post implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. METHODS: Systematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. RESULTS: After screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. CONCLUSIONS: This systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.

Robustness of Longitudinal Safety and Efficacy After Paclitaxel-Based Endovascular Therapy for Treatment of Femoro-Popliteal Artery Occlusive Disease: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: The aims of this study were: i) to assess fragility indices (FIs) of individual randomized controlled trials (RCTs) that compared paclitaxel-based drug-coated balloons (DCBs) or drug-eluting stents (DESs) versus standard endovascular devices, and ii) to meta-analyze mid-term and long-term safety and efficacy outcomes from available RCT data while also estimating the FI of pooled results. METHODS: This systematic review has been registered in the PROSPERO public database (CRD42022304326 http://www.crd.york.ac.uk/PROSPERO). A query of PubMed (Medline), EMBASE (Excerpta Medical Database), Scopus, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was performed to identify eligible RCTs. Rates of primary patency (PP) and target lesion revascularization (TLR) were assessed as efficacy outcomes, while lower limb amputation (LLA) consisting of major amputation that is. below or above the knee and all-cause mortality were estimated as safety outcomes. All outcomes were pooled with a random effects model to account for any clinical and study design heterogeneity. The analyses were performed by dividing the RCTs according to their maximal follow-up length (mid-term was defined as results up to 2-3 years, while long-term was defined as results up to 4-5 years). For each individual outcome, the FI and reverse fragility index (RFI) were calculated according to whether the outcome results were statistically significant or not, respectively. The fragility quotient (FQ) and reverse fragility quotient (RFQ), which are the FI or RFI divided by the sample size, were also calculated. RESULTS: A total of 2,337 patients were included in the systematic review and meta-analysis. There were 2 RCTs examining DES devices and 14 RCTs evaluating different DCBs. For efficacy outcomes, there was evidence that paclitaxel-based endovascular therapy increased the PP rate and reduced the TLR rate at mid-term, with a calculated pooled risk ratio (RR) of 1.66 for patency (95% CI, 1.55-1.86; P < 0.001), with a corresponding number needed-to-treat (NNT) of 3 patients (95% CI, 2.9-3.8) and RR of 0.44 for TLR (95% CI, 0.35-0.54; P = 0.027), respectively. Similarly, there was evidence that paclitaxel-based endovascular therapy both increased PP and decreased TLR rates at long-term, with calculated pooled RR values of 1.73 (95% CI, 1.12-2.61; P = 0.004) and 0.53 (95% CI, 0.45-0.62; P = 0.82), respectively. For safety outcomes, there was evidence that paclitaxel-based endovascular therapy increased all-cause mortality at mid-term, with a calculated pooled RR of 2.05 (95% CI, 1.21-3.24). However, there was no difference between treatment arms in LLA at mid-term (95% CI, 0.1-2.7; P = 0.68). Similarly, neither all-cause mortality nor LLA at long-term differed between treatment arms, with a calculated pooled RR of 0.66, 1.02 (95% CI, 0.31-3.42) and 1.02 (95% CI, 0.30-5.21; P = 0.22), respectively. The pooled estimates of PP at mid-term were robust (FI = 28 and FQ = 1.9%) as were pooled rates of TLR (FI = 18 and FQ = 0.9%). However, when safety outcomes were analyzed, the robustness of the meta-analysis decreased significantly. In fact, the relationship between the use of paclitaxel-coated devices and all-cause mortality at mid-term showed very low robustness (FI = 4 and FQ = 0.2%). At 5 years, only the benefit of paclitaxel-based devices to reduce TLR remained robust, with an FI of 32 and an FQ of 3.1%. CONCLUSIONS: The data supporting clinical efficacy endpoints of RCTs that examined paclitaxel-based devices in the treatment of femoral-popliteal arterial occlusive disease were robust; however, the pooled safety endpoints were highly fragile and prone to bias due to loss of patient follow-up in the original studies. These findings should be considered in the ongoing debate concerning the safety of paclitaxel-based devices.

Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review.

PURPOSE: The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). MATERIALS AND METHODS: A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? RESULTS: The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. CONCLUSIONS: The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.

Major vascular traumas to the neck, upper limbs, and chest: Clinical presentation, diagnostic approach, and management strategies.

Major vascular traumas to the neck, upper limbs, and chest may arise from penetrating and/or blunt mechanisms, resulting in a range of clinical scenarios. Lesions to the carotid arteries may also lead to neurologic complications, such as stroke. The increasing use of invasive arterial access for diagnostic and/or interventional purposes has increased the rate of iatrogenic injuries, which usually occur in older and hospitalized patients. Bleeding control and restoration of perfusion represent the two main goals of treatment for vascular traumatic lesions. Open surgery still represents the gold standard for most lesions, although endovascular approaches have increasingly emerged as feasible and effective options, particularly for management of subclavian and aortic injuries. In addition to advanced imaging (including ultrasound, contrast-enhanced cross-sectional imaging, and arteriography) and life support measures, multidisciplinary care is required, particularly in the setting of concomitant injuries to the bones, soft tissues, or other vital organs. Modern vascular surgeons should be familiar with the whole armamentarium of open and endovascular techniques needed to manage major vascular traumas safely and promptly.

A Scoping Review on the Incidence, Risk Factors, and Outcomes of Proximal Neck Dilatation after Standard and Complex Endovascular Repair for Abdominal Aortic Aneurysms.

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.

Association Between the Lockdown for SARS-CoV-2 (COVID-19) and Reduced Surgical Site Infections after Vascular Exposure in the Groin at Two Italian Academic Hospitals.

BACKGROUND: The aim of this study was to evaluate whether the scrupulous hygiene rules and the restriction of contacts during the lockdown owing to the COVID-19 pandemic affected the rate and severity of surgical site infections (SSI) after vascular exposure in the groin at two Italian University Hospitals. METHODS: Starting from March 2020, strict hygiene measures for protection of health care workers (HCW) and patients from COVID-19 infection were implemented, and partly lifted in July 2020. The main exposure for analysis purposes was the period in which patients were operated. Accordingly, study subjects were divided into two groups for subsequent comparisons (preCOVID-19 era: March-June 2018-2019 versus COVID-19 era: March-June 2020). The primary endpoint was the occurrence of superficial and/or deep SSI within 30 days after surgery. The Centers for Disease Control and Prevention definitions were used to classify superficial and deep SSI. RESULTS: A total of 194 consecutive patients who underwent vascular exposure in the groin were retrospectively analyzed. Of those, 60 underwent surgery from April 1, 2018 to June 30 of the same year; 83 from April 1, 2019 to June 30 of the same year; and 51 from April 1, 2020 to June 30 of the same year. The mean age of the study cohort was 75 years and 140 (72%) were males. Patients who were operated in the COVID-19 era were less likely to develop SSI (10% vs. 28%; P = 0.008), including both deep SSI (4% vs. 13%; P = 0.04) and superficial SSI (6% vs. 15%; P = 0.05). After multivariate adjustments, being operated in the COVID-19 era was found to be a negative predictor for development of an SSI (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.09-0.76; P < 0.001) or deep SSI (OR = 0.21; 95% CI = 0.03-0.98; P < 0.001). Operative time was also found as independent predictor for the development of deep SSI (OR = 1.21; 95%CI = 1.21-1.52; P = 0.02). Using binary logistic regression, there were no independent predictors of superficial SSI that could be identified. CONCLUSIONS: Vascular exposure in the groin carries a non-negligible risk of SSI. In this study, we provided important insights that are simple and easily viable precautions (such as the universal use of surgical masks both for patients and health care professionals during wound care, the widespread diffusion of hand sanitizers, and the reduction of the number of visitors in the surgical wards) could be promising and safe tools for SSI risk reduction.

Prediction of long-term mortality for patients with severe asymptomatic de novo carotid stenosis undergoing carotid endarterectomy (PREMY2SE-CEA): Derivation and validation of a novel risk score.

OBJECTIVE: The aim of the present study was to develop and validate a risk prediction model for the prediction of long-term mortality for patients with severe asymptomatic de novo carotid stenosis undergoing carotid endarterectomy (PREMY2SE-CEA). METHODS: Data were collected retrospectively from a dedicated database of consecutive patients who had undergone elective CEA for severe (>70% using the NASCET [North American Symptomatic Carotid Endarterectomy Trial] criteria) asymptomatic carotid stenosis at two Italian University Hospitals from 2008 through 2016. Internal validation of the score was performed after random sampling in a 3:1 fashion. The primary end point of the PREMY2SE-CEA risk score was the 5-year mortality. RESULTS: Of the 1214 patients, 901 were included in the derivation cohort and 313 in the validation cohort. Using multivariable logistic regression with backward elimination, a parsimonious model was derived. A risk score incorporating eight risk factors was generated and found to be highly predictive of long-term mortality in the derivation (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.28-1.41; P < .001) and validation (OR, 1.29; 95% CI, 1.21-1.37; P <.001) cohorts. The discrimination power in the receiver operating characteristic curve analysis was C = 0.775 (95% CI, 0.74-.80), and the optimism-corrected area under the curve in the bootstrapped samples was 0.761 (P < .001). A strong correlation was found between the predicted and actual mortality rates in the validation cohort (r = 0.71; P < .001). CONCLUSIONS: In the present study, we have described the development, evaluation, and validation of a risk prediction model (PREMY2SE-CEA) for long-term mortality after CEA in asymptomatic patients. Physicians could use the PREMY2SE-CEA risk scoring tool to complement their estimates of life expectancy and prompt selective consideration of prophylactic CEA to improve the long-term benefits of interventions.

A scoping review on the approaches for cannulation of reno-visceral target vessels during complex endovascular aortic repair.

OBJECTIVES: The aim of this study was to assess the approaches to reno-visceral target vessels (TVs) cannulation during branched-fenestrated endovascular aortic repair, determine the evidence base that links these approaches to clinical outcomes and identify literature gaps. METHODS: A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English (PubMed, Cochrane and EMBASE databases; last queried, 31 June 2022) were systematically reviewed and analysed. Data were reported as descriptive narrative or tables, without any statistical analysis nor quality assessment. RESULTS: Fourteen retrospective articles were included. Seven articles studied the use of upper extremity access (UEA) during branched-fenestrated endovascular aortic repair, 3 studied the use of steerable sheaths and 4 included both approaches. A left UEA was used in 757 patients (technical success: 99%, stroke rate: 1-3%) and a right UEA in 215 patients (technical success: 92-98%, stroke rate: 0-13%). Seven studies (1066 patients) described a surgical access only (technical success: 80-99%, stroke rate: 0-13%), while 3 studies (146 patients) described a percutaneous access only (technical success: 83-90%, stroke rate: 3%) and lastly 4 studies compared UEA versus use of steerable sheaths from the transfemoral approach (TFA) (UEA: 563 patients, technical success: 95-98%, stroke rate: 1-8%; TFA: 209 patients, technical success: 98-100%, stroke rate: 0-1%). CONCLUSIONS: Both UEA and TFA as cannulation approaches were associated with high technical success and low perioperative complications. Currently, there is a paucity of high-quality data to provide definitive indication. Optimal UEA in terms of side (left versus right) and approach (surgical versus percutaneous) needs further study.

Association Between Psoas Muscle Sarcopenia and Long-Term Survival Following Elective Endovascular Aortic Repair.

INTRODUCTION: The aims of this study were as follows: i) to identify the prevalence of sarcopenia in patients undergoing elective endovascular aortic repair (EVAR) for intact abdominal aortic aneurysm; ii) to assess its association with perioperative morbidity and long-term survival; and iii) to estimate its diagnostic accuracy for prediction of 5-year mortality following the intervention. METHODS: We performed a retrospective review of all patients who underwent elective EVAR from January 1, 2010 through December 31, 2019. The lean psoas muscle area (LPMA; cm2 × HU) was calculated on computed tomography angiography by multiplying psoas muscle area and psoas muscle density. The main exposure variable for this study was the presence of preoperative sarcopenia (LPMA value < 350), and the study cohort was divided in two groups for all subsequent analyses. The primary endpoint was all-cause mortality. RESULTS: The study cohort eventually comprised 338 patients who underwent elective EVAR for intact abdominal aortic aneurysm. In the overall population, 154 patients (45.5%) were classified as sarcopenic. At baseline, patients with sarcopenia were older (mean age: 78 ± 5 versus 75 ± 7 y, P < 0.001) and had lower proportion of males (73.5% versus 93.5%, P < 0.001). At 5 y, the estimated survival rates were 52% versus 74% in sarcopenic and nonsarcopenic patients, respectively (P < 0.001). Using multivariate Cox proportional hazard regression, an independent association was identified between sarcopenia and all-cause mortality in the whole cohort (hazard ratio: 2.63, 95% confidence interval: 1.43-3.36, P = 0.009). CONCLUSIONS: Sarcopenia, defined as LPMA <350 as measured on preoperative computed tomography angiography, can be highly prevalent in patients undergoing elective EVAR. Although the intervention remains safe in the short term, presence of sarcopenia was significantly associated to lower long-term survival irrespective of patients' age or gender.

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes.

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

Scoping review of radiologic assessment and prognostic impact of skeletal muscle sarcopenia in patients undergoing endovascular repair for aortic disease.

OBJECTIVE: The primary objectives of our scoping review were to evaluate the methods used by research groups to assess the incidence of sarcopenia in patients with aortic disease and the extent of the evidence base that links sarcopenia to the survival of patients undergoing elective endovascular aortic repair and to identify the recurring themes or gaps in the literature to guide future research. METHODS: A scoping review in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) protocols extension for scoping reviews was performed. The available studies included those fully reported in English (last query, April 30, 2022). The following PICO question was used to build the search equation: "in patients with aortic disease [population] undergoing endovascular repair [intervention], what was the prevalence and prognosis of radiologically defined sarcopenia [comparison] on the short- and long-term outcomes?" RESULTS: A total of 31 studies were considered relevant, and 18 were included in the present scoping review. In brief, 12 studies had focused on standard endovascular aneurysm repair (EVAR), 2 on thoracic EVAR, and 4 on complex EVAR. All but two studies were retrospective in design, and only one study had included patients from a multicenter database. Sarcopenia had generally been defined using the computed tomography angiography (CTA) findings of the cross-sectional area of the psoas muscle at L3 or L4, sometimes with normalization against the height. Overall, despite the heterogeneity in the methods used for its definition, sarcopenia was highly prevalent (range, 12.5%-67.6%). The patients with sarcopenia had had higher rates of mortality (ratio ranged from 2.28 [95% confidence interval, 1.35-3.84] to 6.34 [95% confidence interval, 3.37-10.0]) and adverse events (41% vs 16%; P = .020). CONCLUSIONS: Sarcopenia, as identified using computed tomography angiography-based measurements of the skeletal muscle mass, was prevalent among patients undergoing elective EVAR, thoracic EVAR, or complex EVAR. The presence of sarcopenia has been shown to have a negative prognostic impact, increasing the operative risk and has been linked to poorer long-term survival.

Remodeling of abdominal aortic aneurysm sac following endovascular aortic repair: association with clinical, surgical, and genetic factors.

After successful endovascular aortic repair (EVAR), abdominal aortic aneurysms (AAA) sac will undergo negative remodeling (i.e., shrinkage) as a measure of successful exclusion. Determinants of shrinkage after EVAR are not fully known. In 84 post-EVAR patients, time course of AAA diameter after repair and occurrence of endoleaks (ELs) have been correlated with clinical history, medications, anthropometric data, vascular anatomy, and matrix metalloprotease (MMP) genetic variants (namely MMP-1 rs1799750, MMP-3 rs35068180, MMP-9 rs2234681, rs917576, rs917577, MMP-12 rs652438, and TIMP1 rs4898). During follow-up, 41 ELs were detected in 37 patients (44%, 10.4 events/100 pt./y), accounting for AAA dilation or reduced shrinkage (P < .001). High-flow ELs (type 1 and/or 3) occurrence was associated with warfarin use, MMP9 rs17577 polymorphism, and unfavorable anatomy, while low-flow type 2 ELs occurred more often in TIMP1 rs4898 non-T carriers. In EL-free patients, AAA diameter decreased for the first three years, (-4, -3 and - 2 mm/year respectively) and remained stable thereafter. Shrinkage between two measurements (n = 120) was associated with smaller AAA diameter at the baseline, peripheral arterial disease (PAD), patients' older age at intervention, and G-/G- genotype in MMP1 rs1799750 (binary logistic regression, P = .0001). Aneurysmal sac shrinking occurs for few years after EVAR, only in patients without EL, and is related to older age, PAD, smaller aneurysm size and putative lower MMP1 expression while EL occurrence prevents such a remodeling and is mainly related to local-acting factors like unfavorable anatomy, anticoagulation, and MMP9 and TIMP1 genetic polymorphisms.

Secondary Relining With Focal Flaring of Novel-Generation Balloon-Expandable Covered Stents for Endovascular Treatment of Significant Diameter Mismatch in the Aorto-Iliac Territory.

OBJECTIVES: The aim of this study was to report on the safety and feasibility of secondary relining with focal flaring of novel-generation balloon-expandable covered stents for endovascular treatment of significant diameter mismatch in the aorto-iliac territory. Significant diameter mismatch was defined as >20% difference in the nominal diameter between the intended proximal and distal landing zones. METHODS: Patient A was an 84-year-old man with prior abdominal aortic aneurysm open repair with a straight 20 mm Dacron tube. He presented with a right common iliac artery aneurysm (Ø88 mm) with contained rupture. The Gore Viabahn endoprosthesis (9 mm × 5 cm) was inserted proximally about 15 mm above the occluded ostium of the internal iliac artery. Subsequently, the BeGraft Aortic® (16 mm × 48 mm) was inserted proximally up to the common iliac artery origin; its proximal portion was flared to 22 mm. Patient B was a 77-year-old man with prior endovascular abdominal aortic aneurysm repair with a Medtronic Endurant stent-graft. He presented with occlusion of the right limb of the aortic endoprosthesis and thrombosis that extended down to the level of the superficial femoral artery. After mechanical thrombectomy, two Gore Viabahn endoprosthesis (first one, 8 mm × 10 cm; second one, 10 mm × 15 cm) were inserted into the right iliac limb. Subsequently, the BeGraft Aortic® (12mm × 39mm) was inserted proximally up to the gate of the aortic stent-graft; its proximal portion was flared to 16 mm. RESULTS: Technical success and clinical success were achieved in both patients. Imaging follow-up (6 months for Patient A, 12 months for Patient B) showed correct placement of all stent-grafts without any graft-related adverse event. The patients remained free from new reinterventions or recurrent symptoms. Patient A died 8 months after the index procedure from acute respiratory failure after community acquired pneumonia. CONCLUSION: Secondary relining with focal flaring of novel-generation balloon-expandable covered stents for endovascular treatment of significant diameter mismatch in the aorto-iliac territory is safe and feasible. Although mid-term results seem to be effective, longer follow-up is warranted to establish durability of the technique.

Novel Application of Custom-Made Stent Grafts with Inner Branches for Secondary Treatment After Stent Graft Migration of Previous Infrarenal Endovascular Aortic Repair.

PURPOSE: We present a novel application of custom-made stent grafts (CMSGs) with inner branches to incorporate target vessels (TVs) as an alternative to fenestrations or directional branches for secondary treatment after stent graft migration of previous infrarenal endovascular aortic repair (EVAR). CASE REPORT: Two consecutive patients with stent graft migration of previous EVAR were electively treated at our institution from January 1, 2018 through December 31, 2018. Stent graft migration was defined as radiologic evidence of stent graft displacement >10 mm. In both cases, a proximal type I endoleak was noted, and the residual infrarenal aorta above the previous endograft was unsuitable as the proximal landing zone for a nonfenestrated cuff. Repair was planned by means of a CMSG with 4 inner branches. The procedures were conducted in two-stage fashion to minimize the risk of spinal cord ischemia. The procedures were technically successful with a total of 8 TVs stented. Both patients did not suffer from any early (i.e., up to 30 days) major adverse events, and no access-site complications were noted. At one-year follow-up, computed tomography angiography showed regular placement of the CMSGs, widely patent TVs, absence of any type I or III endoleak, and stable sac size. No late reinterventions were recorded. CONCLUSIONS: Secondary treatment of stent graft migration after previous EVAR is safe and feasible using CSMGs with 4 inner branches. This technique is effective as showed by stable sac size and 100% freedom from TVI at mid-term imaging follow-up. Larger cohorts and longer follow-up are needed to confirm the preliminary results.

Secondary Endovascular Repair of Recurring Lesions and Perioperative Complications after Open Aortic Repair: The Complementary Role of Different Technical Solutions.

BACKGROUND: The aim of our article was to describe the complementary role of different technical solutions for secondary endovascular repair of recurring lesions and perioperative complications after open aortic repair (OAR). METHODS: We describe our clinical experience of secondary endovascular repair after OAR. We included in the analysis all consecutive patients who presented recurring lesions and perioperative complications after OAR and underwent secondary endovascular repair between January 1, 2015 and June 31, 2018. Both elective and nonelective cases were captured. Early end points were technical success, 30-day mortality, 30-day major adverse events, and 30-day vascular access complications. Late end points were survival and freedom from secondary interventions. RESULTS: Three different techniques were used in 6 patients: 2 cases of fenestrated-branched endovascular aortic repair (F-BEVAR), 2 cases of parallel-graft EVAR (pg-EVAR), and 2 cases of off-label use of standard devices. Technical success was 100%. One patient died within 30 days from acute pulmonary embolism. One patient developed acute kidney injury not requiring renal replacement therapy, whereas the remaining 4 patients were free from 30-day major adverse events. The cumulative rate of 30-day vascular access complications was 0%. All the 5 patients who survived the index hospitalization had ≥12 months of clinical and imaging follow-up. At the longest individual follow-up, they all were alive and free from secondary interventions. Computed tomography angiography showed in all cases sustained clinical success. CONCLUSIONS: Secondary endovascular repair of recurring lesions and perioperative complications after OAR is safe and feasible and offers a minimally invasive effective treatment option when a redo surgical operation would be associated with a considerable risk to the patient. Different solutions are available (including F-BEVAR, pg-EVAR, and off-label use of standard devices) and are complementary rather than competitive. Careful preoperative assessment and familiarity with advanced techniques are essential to achieve satisfactory outcomes.

Hypogastric Artery Occlusion with Evoked Potentials Monitoring as Bailout Technique to Assess the Risk of Postoperative Spinal Cord Ischemia.

A 65-year-old man, with previous open surgical repair of an infrarenal abdominal aortic, presented with acute complicated (paraplegia) Type B aortic dissection. He successfully underwent endovascular repair of the descending thoracic and abdominal aorta. Following the procedure, the neurological manifestations resolved. As he had a concomitant aneurysm of the right hypogastric artery (HGA), we executed a 10-minute balloon occlusion of this artery with evoked potential measurements to assess the risk of spinal cord ischemia after exclusion of the right HGA. The examination was interpreted as negative, and we proceeded with coil embolization of the right HGA and subsequent placement of an endograft landing distally within the external iliac artery. The postoperative course was totally uneventful, and the patient was discharged home 4 days after the operation. Computed tomography angiography follow-up at 1, 6, 12 and 24 months showed patency of all endografts without any signs of endoleak and effective remodeling of the descending thoracic aorta with volume reduction of the false lumen.

Custom-Made Unibody Conical Endografts for Elective Endovascular Repair of Saccular Infrarenal Abdominal Aortic Aneurysms with Narrow Aortic Bifurcations-Novel Implementation of the Aortoaortic Concept.

The aortoaortic concept for endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) is nearly forgotten but may constitute a valuable option for focal pathologies. Herein, we describe our experience using custom-made (CM) unibody conical endografts for saccular AAAs with narrow (≤20 mm wide) aortic bifurcation (AB) in three patients. Given the narrow AB, the option for a bifurcated stent graft was reputed not optimal. Therefore, we decided to further suggest the construction of a CM unibody conical stent graft with respect to unique anatomical characteristics of the patients. Technical success rate was 100%, and computed tomography angiography at first-month follow-up showed complete sealing proximally and distally with excellent conformability of the endografts in all the cases. All the patients were free from any-type endoleak (EL) and had no evidence of any endograft-related complication (i.e., fracture, thrombosis, or migration) or required any reintervention at their longest follow-up. We conclude that in the proper anatomic setting, the use of CM unibody conical endografts for elective EVAR of saccular AAAs with narrow AB is technically feasible with excellent short-term safety regarding ELs or migration.

Successful Off-Label Use of an Iliac Branch Device to Rescue an Occluded Aortofemoral Bypass Graft.

PURPOSE: To report an alternative approach for rescue of an occluded aortofemoral bypass using the Gore Excluder Iliac Branch Endoprosthesis (IBE). CASE REPORT: A 52-year-old man presented with acute right limb ischemia because of displaced and occluded iliac stents and was treated with aortofemoral bypass. On the third postoperative day, there was early bypass failure due to distal embolization from aortic thrombus. After fluoroscopy-guided balloon thrombectomy of the bypass, an endovascular bailout strategy was used. The Gore Excluder IBE was deployed below the renal arteries (with the external iliac limb opening in the surgical prosthesis and the gate opening within the aortic lumen). After antegrade catheterization of the gate, a Gore Viabahn endoprosthesis was inserted as the bridging endograft and deployed so that it landed just above the preimplanted aortoiliac kissing stents without overlapping them. Completion angiography showed technical success without complications; results were sustained at 1-year follow-up. CONCLUSION: The Gore Excluder IBE may represent a versatile solution for the rescue of complex cases when open surgery would be associated with a considerable risk. This off-label application of a well-recognized endovascular device is safe and feasible and may prove useful as a valuable alternative in properly selected patients.