Editor's Choice - Long Term Outcomes of the Advanta V12 Covered Bridging Stent for Fenestrated and Branched Endovascular Aneurysm Repair in 1 675 Target Vessels.

OBJECTIVE: To report outcomes of the Advanta V12 as a covered bridging stent in fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS: Patients treated with F/BEVAR and followed in a single centre receiving the Advanta V12 as a covered bridging stent between January 2010 and May 2020 were included. RESULTS: A total of 636 patients (543 men) were analysed. A total of 1 675 target vessels (TVs) were bridged with the Advanta V12. Estimated TV patency at one, five, and eight years was 99.1% ± 0.2%, 96.9% ± 0.5% and 96.2% ± 0.7%, respectively. Estimated patency at eight years was 98.1% ± 0.5% for fenestrations and 87.3% ± 2.9% for branches (p < .001). Estimated patency of renal arteries was statistically significantly lower for those targeted with branches compared with fenestrations (p = .001). Multivariable analysis showed that targeting a TV with a branch compared with a fenestration was the only independent risk factor for occlusion during follow up (hazard ratio 6.41, 95% CI 3.4 - 11.9; p < .001). Estimated freedom from endoleak at one, five, and eight years was 99.4% ± 0.2%, 96.4% ± 0.6%, and 95.4% ± 0.8%, respectively. Estimated freedom from target vessel instability (TVI) at one, five, and eight years was 98.5% ± 0.3%, 93.0% ± 0.8%, and 91.3% ± 1%, respectively. Estimated freedom from TVI at eight years was 93.2% ± 0.9% for fenestrations and 82.7% ± 3.5% for branches (p < .001). Estimated freedom from TVI was statistically significantly lower for renal arteries targeted with branches compared with those targeted with fenestrations (p < .001) CONCLUSION: The Advanta V12 shows excellent technical success rates as a covered bridging stent in F/ΒEVAR. Late outcomes remain good with low rates of TV occlusion, endoleak, and re-intervention. Renal arteries targeted with branches demonstrated a higher risk of occlusion and instability compared with those targeted with fenestrations.

Editor's Choice - Single Centre Midterm Experience with Primary Fenestrated Endovascular Aortic Aneurysm Repair for Short Neck, Juxtarenal, and Suprarenal Aneurysms.

OBJECTIVE: The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre. METHODS: Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed. RESULTS: A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088). CONCLUSION: Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival.

Mid-Term Results of Fenestrated Endovascular Repair after Prior Open Aortic Reconstruction.

This study aims to assess the mid-term results of fenestrated endovascular aneurysm repair (FEVAR) for the treatment of proximal aortic pathology after previous open surgical repair (OSR). All patients with a previous history of OSR of an abdominal aortic aneurysm undergoing a FEVAR procedure between October 2010 and November 2021 were included. The endpoints of the study were technical success, mortality, target vessel patency and reinterventions during follow-up. Thirty-five patients (34 male, mean age 72.9 ± 7 years) were included. The median interval from the primary surgery to the FEVAR procedure was 136 months (range 47-261). The indication for treatment was a para-anastomotic aneurysm in 18 (51%) patients and a true aneurysm due to progression of disease in 17 (49%) patients. Technical success was achieved in 33 (94%) patients. There was one (3%) early death due to postoperative bleeding from a renal artery. Estimated survival at 12, 24 and 36 months was 89.1% ± 6%, 84.4% ± 7.3% and 84.4% ± 7.3%, respectively. There was no aneurysm-related mortality. One (3%) target vessel occluded during follow-up and three (9%) patients underwent late reinterventions. In conclusion, FEVAR is a safe and effective alternative for the endovascular treatment of para-anastomotic aneurysms/pseudoaneurysms after OSR showing high technical success, low mortality and morbidity, and good mid-term outcomes.

Fenestrated and branched stent grafts for the treatment of post-dissection thoracoabdominal aortic aneurysms.

The present study aims to analyze fenestrated/branched endovascular aneurysm repair (F/BEVAR) in the treatment of post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs). Focus is given on indication, anatomic suitability, device planning, and clinical outcomes. PD-TAAAs present with additional challenges in F/BEVAR. These include true lumen compression and visceral arteries originating from the false lumen. These technical challenges limited the use of F/BEVAR in PD-TAAAs to a few institutions in the beginning, but the good results reported with this approach have led to an increase in its use in a growing number of centers. Our current single-center experience includes 75 patients treated with F/BEVAR for a PD-TAAA between October 2010 and October 2021. Technical success was achieved in 74 cases (98.7%). Two patients (2.6%) died in the first 30 postoperative days. Ten patients (13.3%) had postoperative symptoms of spinal cord ischemia: 9 (12%) with transient limb weakness and 1 (1.3%) with permanent paraplegia. There was only 1 death (1.3%) related to the aneurysm during follow-up. Mean ± SD estimated primary patency rates of the target vessels at 12, 24, and 36 months were 97.9% ± 1%, 96.1% ± 1.6%, and 95.2% ± 1.9%, respectively. The estimated freedom from re-intervention rates at these time points were 81.4% ± 5.3%, 56.9% ± 7.3%, and 53.9% ± 7.5%, respectively. In conclusion, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results with regard to mortality and morbidity. The additional technical challenges posed by PD-TAAAs need to be considered to prevent complications and decrease the high rate of re-interventions.

Outcomes of Upper Extremity Access with Surgical Exposure of the Axillary Artery in Fenestrated and Branched Endovascular Aneurysm Repair.

OBJECTIVE: This study aims to assess the safety of upper extremity access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurological and local complications as well as re-interventions associated with the technique. METHODS: All patients undergoing an F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single centre study. Endpoints were neurological and access related complications and re-interventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury, and arterial complications. RESULTS: 264 patients (192 male, mean age 70 ± 7 years) were included. Upper extremity access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2.2%) patients had early complications related to the arterial access: four with post-operative bleeding and two with acute arm ischaemia. Two patients with post-operative bleeding and both patients with ischaemic complications required re-intervention. One of these patients with arm ischaemia died five weeks after the re-intervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented with transient arm paraesthesia or sensory neurological deficit post-operatively. The symptoms completely recovered in all cases with no residual deficits. Peri-operative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion. CONCLUSION: Upper extremity access with surgical exposure of the axillary artery is a safe method for antegrade catheterisation of fenestrations and branches in complex endovascular aneurysm repair.

Limb Occlusion Rate after EVAR With Individualized Graft Limb Selection and a Liberal Protocol of Primary Relining.

BACKGROUND: This study analyses limb occlusion rates after endovascular aneurysm repair (EVAR) with a strategy including stent-graft limb selection and liberal primary stenting (relining) in anatomies at higher risk for occlusion with uncovered self-expandable or balloon-expandable stents. METHODS: All patients undergoing elective EVAR with a bifurcated stent-graft between January 2010-August 2018 were included. A protocol involving personalized stent-graft selection and liberal primary relining based on preoperative imaging was followed during the whole period. Primary endpoints were technical success and primary limb patency during follow-up. Secondary endpoints included mortality and limb reintervention rates. Risk factors associated to limb patency and reintervention rates were analyzed. RESULTS: Six hundred and fifteen patients (548 males; mean age 72.9 ± 9 years) were included. Overall technical success was 98.5% (606/615). One (0.16%) patient died during the first 30 days. Of the 1230 limbs, 96 (8%) were deemed at risk for occlusion in view of the anatomy, and primarily relined in 62 patients. Estimated primary limb patency at 6 months, 1 year and 3 years was 99.5 ± 0.2%, 99.2 ± 0.3% and 98.5 ± 0.5%, respectively. Freedom from limb-related reintervention at 6 months, 1 year and 3 years was 98.1 ± 0.4%, 97.4 ± 0.5% and 95.6 ± 0.7%, respectively. Only one (1%) of the 96 relined limbs occluded during follow-up. No differences were found in terms of patency or freedom from reintervention between limbs at risk that were primary stented and limbs without adjunctive stents. Gore Excluder stent-grafts presented better patency (Breslow P = 0.005) and lower reintervention rates (Breslow P = 0.001) than other devices during follow-up. Peripheral artery disease was also a risk factor for reintervention (Breslow P = 0.015). CONCLUSION: Liberal use of primary limb relining in patients with iliac anatomy at higher risk for occlusion appears to be a safe and effective strategy to preserve limb patency after EVAR. Gore Excluder graft limbs present better patency and lower reintervention rates than other stent-graft types.

Reasons for and Outcomes of Open Abdominal Aortic Repair in the Endovascular Era.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has become the treatment of choice for most patients with abdominal aortic aneurysm (AAA). Open aneurysm repair (OAR) is still being used in a number of patients for specific reasons. The aim of the present study was to investigate the reasons and perioperative outcomes of OAR in a high-volume endovascular center. METHODS: All patients who underwent OAR in a single center institution during the period April 2010 to July 2019 were retrospectively analyzed. RESULTS: During the study period, 222 patients underwent OAR. One hundred and forty-one (63.5%) patients underwent elective surgery, and eighty-one (36.5%) patients were treated acutely. The reasons for the decision to perform OAR instead of EVAR were as follows: anatomical in 89 (40.1%) cases, rupture in unstable patient in 57 (25.7%) cases, AAA with concomitant iliac arterial occlusive disease in 44 (19.8%) cases, previous EVAR with complications in 14 (6.3%) cases, large pararenal aneurysm considered risky to wait for a customized fenestrated stent graft in 7 (3.2%) cases, young patient age in 4 (1.8%) cases, the patient's preference in 3 (1.4%) cases, infected/mycotic AAA in 2 (0.9%) cases, and simultaneous OAR with colon cancer resection (n = 1, 0.5%) and renal transplantation (n = 1, n = 0.5). Thirty-day mortality in elective cases was 5% (7/141) and in acute cases 34.6% (28/81). CONCLUSIONS: This study shows that OAR is still used for selected patients despite improvements in EVAR technology. The most common reason for OAR was an unsuitable anatomy for EVAR. Perioperative mortality of OAR both for acute and elective cases as observed in this study is in line with published outcomes of other centers.

Increasing Role of Fenestrated and Branched Endoluminal Techniques in the Thoracoabdominal Segment Including Supra- and Pararenal AAA.

Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.

Outcomes of fenestrated and branched endovascular aortic repair for chronic post-dissection thoracoabdominal aortic aneurysms.

BACKGROUND: Aneurysmal degeneration after acute dissection occurs in a significant proportion of patients. Fenestrated and branched stent-grafting (F/BEVAR) has been increasingly used to treat these post-dissection thoracoabdominal aortic aneurysms (PD-TAAA). The aim of this study was to report early and mid-term outcomes of F/BEVAR in PD-TAAA. METHODS: Retrospective single center analysis of a prospectively maintained database including all patients undergoing F/BEVAR for PD-TAAA between October 2010-February 2020. RESULTS: Fifty-five patients (45 males, mean age 66±10 years) were included. Technical success was achieved in all patients. Thirty-day mortality was two (3.6%) patients. Major perioperative complications were noted in nine (16.4%) patients including five (9.1%) with transient spinal cord ischemia (SCI) and one (1.8%) with permanent paraplegia. Mean follow-up was 24 months (1-76 months). Cumulative survival rates at 12, 24 and 36 months were 87±5.5%, 83.5±6.3% and 72.2±8.1%, respectively. Estimated freedom from reintervention at 12, 24 and 36 months was 82.2±6.7%, 60.1±9.2% and 55.9±9.5%, respectively. Main reasons for reintervention were endoleaks from target vessels and common iliac arteries. Estimated target vessel patency at 12, 24 and 36 months was 97.8±1.2%, 95.4±2.1%, and 94.1±2.4%, respectively. Mean aneurysm sac regression during follow-up was 7.9±7.1 mm, with complete false lumen thrombosis in 80% of patients. No ruptures occurred during follow-up. CONCLUSIONS: F/BEVAR for PD-TAAA is associated with low perioperative mortality and morbidity in a large volume endovascular center. Mid-term results demonstrate a high rate of aneurysm sac regression. Extended sealing with longer bridging stents for target vessels is recommended.

Aneurysm Rupture and Mortality During the Waiting Time for a Customised Fenestrated/Branched Stent Graft in Complex Endovascular Aortic Repair.

OBJECTIVE: Treatment of complex aortic pathologies with customised fenestrated/branched stent grafts (F/BEVAR) is associated with a longer waiting time to the procedure. This study aimed to investigate the prevalence of aneurysm rupture and mortality during the waiting time for a fenestrated/branched stent graft in a single centre. METHODS: All patients with a pararenal (PAA), thoraco-abdominal (TAAA), or aortic arch aneurysm planned to be treated with a customised F/BEVAR between January 2010 and December 2018 were included. Patients planned for F/BEVAR who in the end did not undergo the procedure were analysed. RESULTS: 906 patients were planned to undergo F/BEVAR during the study period. Of those, 862 (95.1%) underwent the procedure as planned (FEVAR for PAA; n = 494, F/BEVAR for TAAA; n = 348, F/BEVAR for arch aneurysm; n = 20). In 44 (4.9%) patients, the procedure was cancelled. Thirty-seven (4.1%) patients died before the procedure, four (0.4%) patients turned down the procedure, two (0.2%) were cancelled because of worsened general condition, and one (0.1%) ruptured but underwent emergency open repair in another institution. Causes of death during the waiting time were: aneurysm rupture, n = 15 (1.7%); cardiac, n = 7 (0.8%); stroke, n = 3 (0.3%); gastrointestinal, n = 3 (0.3%); death after complete arch debranching, n = 2 (0.2%); infection, n = 2 (0.2%); death after transcatheter aortic valve implantation, n = 1 (0.1%); death after urological surgery, n = 1 (0.1%); unknown, n = 3 (0.3%). Aneurysm diameter was larger in patients who died of aneurysm rupture compared with patients who died as a result of other causes (79.2 ± 13 mm vs. 66.7 ± 12 mm, respectively, p = .005). CONCLUSION: Aneurysm rupture during the waiting time for F/BEVAR can occur but is rare. Patients with a larger aneurysm diameter may be at higher risk of rupture. Measures to reduce the risk of rupture during the waiting time might include the use of off the shelf devices for larger aneurysms, quicker measurement and graft plan order processes, and quicker graft construction and delivery.

Prognostic Value of Initial Aneurysmal Sac Regression after EVAR.

BACKGROUND: The objective of the study was to evaluate the impact of initial aneurysmal sac reduction after endovascular aneurysm repair on the evolution of aneurysmal sac over follow-up. METHODS: A retrospective cohort study was made of patients subjected to elective treatment between January 2005 and December 2014, with a minimum follow-up of 18 months. An analysis was made of the evolution of the aneurysmal sac according to its condition one year after surgery, defining of two groups: A (sac reduction) and B (stable sac). Follow-up by computed tomography (CT) angiography was made after one month and then every 6 months or annually, depending on the presence of endoleak. RESULTS: A total of 128 patients were included. Fifty-one patients (39.8%) showed a significant decrease in diameter during the first year (group A), whereas 77 patients (60.2%) showed no initial decrease (group B). Preoperative CT angiography showed the patients in group A to have larger aneurysms (63.5 mm vs. 59.25; P = 0.048), a greater presence of posterior thrombus (68.6% vs. 30.7%; P < 0.001), and fewer patent lumbar vessels (56.9% vs. 83.1%; P = 0.001). The prevalence of endoleak at some point during follow-up was lower in group A (31.4% vs. 74% in group B; P < 0.001), and 100% of all aneurysmal growths were associated to the presence of endoleak. After 5 years, significant differences were observed in the growth-free rate (96.9% in group A vs. 85.2% in group B; hazard ratio [HR] 4.8 [1.1-21.4; P = 0.036]) and in the reintervention-free rate (95,7% vs. 84.6%; HR 6.6 [0.8-52.4; P = 0.07]). No reoperation in group A was due to type II endoleak. CONCLUSIONS: The aneurysmal sac can be expected to take a favorable course in those cases characterized by initial aneurysmal sac reduction. These findings may imply a change in the follow-up protocol, even in cases with type II endoleak.

A systematic review of outcomes of upper extremity access for fenestrated and branched endovascular aortic repair.

OBJECTIVE: Upper extremity access (UEA) is an important component of complex fenestrated and branched endovascular aneurysm repair (F/BEVAR). Open and percutaneous UEA approaches have been reported during these procedures. The aim of this review was to assess the outcomes of UEA done to facilitate F/BEVAR. METHODS: A systematic review of studies focusing on upper extremity arterial access during F/BEVAR was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Three databases including PubMed MEDLINE, Embase, and Cochrane Library were queried. Outcomes of interest included UEA-related and other unrelated early and late morbidity and mortality, such as arterial occlusion, neurologic deficit, bleeding complications, and stroke, in patients undergoing UEA during F/BEVAR. RESULTS: Five full-text manuscripts and one abstract met criteria to be included, accounting for a total of 495 patients. The median age of patients who underwent UEA during F/BEVAR was 73.4 years. Predominantly male patients (371 [74.9%]) were treated. Indications for F/BEVAR were thoracoabdominal aortic aneurysms in 325 (65.6%), pararenal aneurysms in 96 (19.4%), juxtarenal aneurysms in 44 (8.9%), and suprarenal aortic aneurysms in 30 (6.1%). Axillary conduits were created in 29 (5.8%) patients. A total of 41 (8.2%) UEA-related complications were reported. Of those 41 complications, 17 (41.5%) were access bleeding, 10 (24.4%) were ischemic strokes, 7 (17.1%) were arterial occlusions, 4 (9.7%) were upper extremity neurologic deficits, 2 (4.9%) were arterial stenoses, and 1 (2.4%) was pseudoaneurysm. UEA-related complications were reported in 15 of 56 (26.8%) patients undergoing percutaneous UEA and 26 of 439 (5.9%) undergoing open UEA (P < .001). CONCLUSIONS: The overall complication rate associated with UEA during F/BEVAR is low, with 2% stroke rate reported. The percutaneous approach showed a higher UEA-related complication rate compared with open UEA. More studies on percutaneous UEA and randomized studies comparing open vs percutaneous UEA during F/BEVAR are warranted to determine the safest and most efficient UEA approach strategy during complex aortic procedures.

Rescue of proximal failure of endovascular abdominal aortic aneurysm repair with standard and fenestrated grafts.

BACKGROUND: This study aimed to assess the outcomes of standard and fenestrated grafts to treat proximal failure of previous endovascular aneurysm repair (EVAR) in a tertiary referral center. METHODS: All patients undergoing elective implantation of a standard or fenestrated graft after proximal failure of a previous EVAR between April 2010-November 2018 were included. Data were collected prospectively. RESULTS: Fifty procedures were performed in 49 patients (45 male; mean age 74.6±7 years). A fenestrated proximal cuff was used in 24 (48%) cases, a composite bifurcated configuration in 21 (42%) cases, and EVAR in 5 (10%) cases. Technical success was achieved in all 5 EVAR cases and 41 of 45 FEVAR cases (91.1%). Iliac artery access problems due to the presence of the previous graft were encountered in eight (16%) procedures and renal artery catheterization difficulties in grafts with suprarenal fixation in seven (15.6%) procedures. There was one (2%) early death due to retroperitoneal bleeding. Early major complications occurred in three (6%) patients. Median follow-up was 26 months (range 1-77). Late occlusion occurred in two (1.3%) of the 151 targeted vessels. One patient needed permanent dialysis. Nine patients died during follow-up, one (2%) of them aneurysm-related. Ten (20.4%) patients presented with major complications during follow-up of which nine (18.4%) needed reintervention. Estimated freedom from reintervention at 1 and 3 years was 89.3±5.1% and 78.8±7.3%, respectively. CONCLUSIONS: Repair with fenestrated grafts represents a safe and effective treatment option. Increased technical challenges are to be expected due to the previous graft.

Graft design and selection of fenestrations vs. branches for renal and mesenteric incorporation in endovascular treatment of pararenal and thoracoabdominal aortic aneurysms.

To address target vessels in pararenal and thoracoabdominal aortic aneurysms with fenestrated and branched grafts, two solutions are available: fenestrations (holes in the graft) and directional side-branches. Fenestrations work well for target vessels that have a close to 90-degree take-off from the aorta, and when the main graft at the level of the target vessel is adjacent or close to the aortic wall. Directional side-branches work well when target vessels have a steeper take-off angle and when there is a larger gap to be bridged. A third option of "inner branches" has been evaluated by our group to address target vessels that are not very suitable for either a fenestration or a directional side-branch. Most pararenal aneurysms are treated with fenestrated grafts, whereas thoraco-abdominal aneurysms are treated mostly by grafts incorporating both fenestrations and branches. In Nuremberg, 347 patients were treated with fenestrated/branched grafts for thoraco-abdominal aneurysms. A stent-graft with fenestrations only was used in 108 (31.1%) patients, a stent-graft with branches only in 104 (30.0%) patients, and a stent-graft with a combination of fenestrations and branches in 135 (38.9%) patients. For the RAs (N.=625) fenestrations were used in 408 (65.3%) and branches in 217 (34.7%). For the SMA (N.=341) fenestrations were used in 169 (49.6%) and branches in 172 (50.4%). For the CA (N.=297), fenestrations were used in 84 (28.3%), and branches in 213 (71.7%). Target vessel patency at 3 years was 98.2±0.9% for vessels targeted with fenestrations and 92.2±1.9% for vessels targeted with branches (P=0.009).

Use of Bilateral Cook Zenith Iliac Branch Devices to Preserve Internal Iliac Artery Flow During Endovascular Aneurysm Repair.

OBJECTIVES: Iliac branch devices (IBD) have become a widespread option to preserve antegrade internal iliac artery (IIA) flow during endovascular aneurysm repair (EVAR). Reported experience with bilateral implantation of IBDs is limited. This study aimed to describe the indications, technical options, and outcomes with the use of bilateral IBDs. METHODS: All patients undergoing elective implantation of bilateral Cook Zenith IBD between January 2010 and September 2017 in a single centre were included. Bilateral IBD was indicated in physically active, anatomically suitable patients and those with previous or concomitant surgery for a thoraco-abdominal aortic aneurysm or impaired collateral circulation to the IIA. Data were collected prospectively. RESULTS: Twenty-nine patients (29 male, mean age 64.1 ± 10 years) were included. Of the 58 IBDs, 48 (83%) were implanted in one procedure and 10 (17%) in two procedures (mean time between procedures 30.4 ± 9 months). Nineteen patients (65%) had a previous or simultaneous EVAR and the remaining 10 (35%) a previous or simultaneous complex aortic repair. Mean CIA diameter was 35.2 ± 8 mm. Technical success was achieved in 55 of the 58 IBDs (95%) with no mortality. Axillary artery access was used in 13 (38%) procedures. During follow up, four (7%) IIA branches occluded (1 bilateral occlusion and 2 unilateral). Estimated IIA branch patency at one and three years was 97.8% ± 2% and 88.5% ± 7%, respectively. All patients with late IIA occlusion remained asymptomatic. Re-intervention was needed in four patients (14%): two bridging stent graft extensions for type Ib endoleak, one relining of the external iliac artery because of mural in-stent thrombus and one femoro-femoral crossover bypass to treat an external iliac limb occlusion. CONCLUSIONS: Bilateral implantation of IBDs is a safe and effective technique to preserve IIA flow in selected patients with suitable anatomy, showing similar technical success and mid-term outcomes to the unilateral use of the device.

Mid-Term Results of Fenestrated/Branched Stent Grafting to Treat Post-dissection Thoraco-abdominal Aneurysms.

OBJECTIVES: Patients surviving acute aortic dissection are at risk of developing a post-dissection thoraco-abdominal aortic aneurysm (PD-TAAA) during follow up, regardless of the type of treatment in the acute setting. Fenestrated and branched stent grafting (F/B-TEVAR) has been used with success to treat PD-TAAA, albeit reported only with short-term results. The aim of this study was to report mid-term results in a cohort of 71 patients. METHODS: This was a retrospective analysis of a prospectively maintained database including all patients with PD-TAAAs who underwent F/B-TEVAR within the period January 2010 - April 2017 at two vascular institutions experienced in endovascular techniques. RESULTS: A total of 71 consecutive patients (56 male, mean age 63.8 ± 10.6 years) were treated. Technical success was achieved in 68/71 (95.8%) patients. In hospital mortality was four (5.6%) patients. Peri-operative morbidity was 19.6%. Three (4.2%) patients developed severe spinal cord ischaemia, one of these patients 12 months post-operatively. Mean follow up was 25.3 months (1-77 months). Cumulative survival rates at 12, 24, and 36 months were 84.7 ± 4.5%, 80.7 ± 5.1%, and 70.0 ± 6.7%, respectively. Estimated freedom from re-intervention at 12, 24, and 36 months was 80.7 ± 5.3%, 63.0 ± 6.9%, and 52.6 ± 8.0%, respectively. The main reasons for re-intervention were endoleak from visceral/renal arteries and iliac endoleak requiring extension. Target vessel occlusion occurred in 8/261 (3.1%) vessels (renal artery n = 4; superior mesenteric artery n = 2; coeliac artery n = 2). Mean aneurysm sac regression during follow up was 9.2 ± 8.8 mm, with a false lumen thrombosis rate of 85.4% for patients with a follow up longer than 12 months. No ruptures occurred during follow up. CONCLUSION: F/B-TEVAR for post-dissection TAAA is feasible and associated with low peri-operative mortality and peri-operative morbidity. Mid-term results demonstrate a high rate of aneurysm sac regression. Rigorous follow up is required because of the significant re-intervention rate. Longer bridging covered stents for target vessels are advised.

Renal function after abdominal aortic aneurysm repair in patients with baseline chronic renal insufficiency: open vs. endovascular repair.

BACKGROUND: The aim of this study is to analyze renal function impairment (RFI) after abdominal aortic aneurysm (AAA) repair in patients with preoperative chronic kidney disease (CKD). METHODS: Retrospective cohort study of patients with CKD undergoing elective AAA repair between 2008-2015, dividing the sample into two groups: open repair (OR) and endovascular repair (EVAR). The primary outcome was RFI defined by the RIFLE scale, studying Risk (1.5-fold increase in Cr or GFR decline >25% compared to baseline) and kidney injury (doubling of Cr or GFR decline >50%). RESULTS: Seventy-five patients (OR=29, EVAR=46). Baseline characteristics for OR and EVAR were similar except for age (70.4 vs. 77.2 years; P<0.001), coronary artery disease (31% vs. 56.5%; P=0.04), neck length (12.3 vs. 22.7 mm; P=0.001) and baseline GFR (40.6 vs. 36.9 mL/min; P=0.03). There were no inter-group differences in postoperative RFI: Risk of RFI 13.8% OR vs. 13% EVAR and kidney Injury 6.9% vs. 0% (P=0.19). There were also no differences in RFI at one year. Comparing GFR and Cr after surgery and at 12 months to baseline values, the OR group presented a significant postoperative decline in GFR compared to EVAR group (-3.8% vs. 11.1%; P=0.03), which had recovered at one-year follow-up (16.6% vs. 9.5%; P=0.43), while EVAR group presented with a tendency toward increased Cr during follow-up (-9.2% vs. 2.2%; P=0.08). Multivariate analysis did not identify independent RFI prognostic factors. CONCLUSIONS: Both techniques can be used safely in patients with CKD and baseline CKD is not a limiting factor for either technique. RFI is rare and transient in both groups.

Thromboprophylaxis in gynecologic cancer surgery: Is extended prophylaxis with low molecular weight heparin justified?

OBJECTIVE: Evidence on the optimal duration of thromboprophylaxis with low molecular weight heparin after gynecologic cancer surgery is scarce and the benefits of extended prophylaxis have not been validated specifically in these patients. The aim of this study is to assess the efficacy and safety of postoperative venous thromboembolism (VTE) prophylaxis with enoxaparin 40 mg for 28 days, as recommended by international guidelines, compared to 7 days in patients undergoing surgery for gynecologic cancer. STUDY DESIGN: Prospective cohort study compared to a historic cohort of women who underwent surgery for gynecologic cancer in our center between 2004 and 2014. Pre- and postoperative screening with a routine duplex scan was done in the prospective cohort. Comparative analysis of comorbidity, surgical technique and incidence of VTE, as well as prognostic factors of events and mortality. RESULTS: N:571 patients (28 days: 207, 7 days: 364). No significant differences were identified between groups in regard to the factors related to VTE in our series. There were no differences in VTE incidence between groups after one month (1.9% vs 1.4%; p = 0.729), 90 days (2.4% vs 2.5%; p > 0.99) or during follow-up (Breslow p = 0.156). No deaths due to VTE at 90 days were recorded. Only one case of asymptomatic DVT was identified in the screening with duplex. The incidence of postoperative bleeding was similar in both groups (0.5% vs 2.2%; p = 0.166). The presence of a history of VTE was the only independent risk factor for VTE after one month (OR 14.31 CI 95% 2.67-76.87; p = 0.002) and 90 days (OR 8.27 CI 95% 1.65-41.45; p = 0.010). No differences were identified regarding age, other comorbidities, type of tumor, stage, surgical approach, reintervention or adjuvant therapy in the multivariate analysis. CONCLUSION: Extended prophylaxis for 28 days with enoxaparin did not improve the rates of VTE following gynecologic oncological surgery in our series compared to the 7-day therapy, although neither was this extended duration associated with adverse events or mortality.

Techniques and outcomes of secondary endovascular repair for postdissection TAA/TAAA.

Postdissection aortic aneurysms (PDAA) affect 20-40% of patients with aortic dissection. Open repair remains the first line therapy of PDAA, but is still associated with high mortality and morbidity rates. Endovascular repair is increasingly being used as a less invasive treatment option. Thoracic endovascular aneurysm repair (TEVAR) covering only the proximal entry tear has proven to be insufficient in most patients with chronic PDAA and has a limited role only for PDAA with distal sealing zone in the thoracic aorta. In PDAA extending to the thoracoabdominal aorta, a more complex repair is needed to achieve aneurysm exclusion. Fenestrated and branched stent-grafts have been used lately in some expert centres to treat PDAA of the thoracoabdominal aorta with good preliminary results despite the technical difficulties in these patients (narrow true lumen, stiff chronic dissection flap, target vessels that originate from the false lumen [FL]). A subset of patients with aneurysmal degeneration mainly in the descending thoracic aorta, can be treated with TEVAR landing proximal to the celiac artery along with adjuvant techniques such as coils, plugs, glue or "Candy-Plug" and "Knickerbocker" concepts to occlude the FL, preventing retrograde flow and reducing the pressure in the aneurysm. Other options that have been used in limited numbers of patients with PDAA include the PETTICOAT (provisional extension to induce complete attachment) and STABILISE (Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair) techniques. This article aims to review the outcomes of different endovascular techniques and strategies available for the repair of PDAA.