Comparison of the Snare Loop Technique and the Hungaroring Reinforcement for Physician-Modified Endograft Fenestrations-An In Vitro Study.

BACKGROUND: We conducted an in vitro comparison of the snare loop reinforcement against a closed-loop reinforcement (Hungaroring) for physician-modified endograft (PMEG) fenestrations regarding preparation time and stability during flaring balloon dilatation. MATERIALS AND METHODS: The time to complete a PMEG fenestration with reinforcement was measured and compared between the Hungaroring and snare loop groups. The number of stitches was counted. Each fenestration was dilated using a 10 mm high-pressure, non-compliant balloon up to 21 atm in pressure, and fluoroscopic images were taken. The presence of indentation on the oversized balloon at the level of the reinforcement was evaluated at each fenestration. RESULTS: Five fenestrations were created in each group (n = 5) for a total of ten pieces. The completion time in the snare loop group was 1070 s (IQR:1010-1090) compared to 760 s (IQR:685-784) in the Hungaroring group (p = 0.008). Faster completion time was achieved by faster stitching (23.2 s/stitch (IQR 22.8-27.3) for the snare loop group and 17.3 s/stitch (IQR 17.3-20.1) for the Hungaroring group (p = 0.016). None of the fluoroscopic images of the snare loop reinforcement showed an indentation on the balloon during the overexpansion; on the contrary, the Hungaroring showed indentation in every case, even at 21 atm. CONCLUSION: Fenestrations reinforced with Hungaroring can be completed significantly faster. Furthermore, the Hungaroring resists over-dilation even at high pressures, while snare loop reinforcements dilate at nominal pressure.

The impact of increasing saline flush volume to reduce the amount of residual air in the delivery system of aortic prostheses-a randomized controlled trial.

Background: Air embolism is a known risk during thoracic endovascular aortic repair (TEVAR) and is associated with an incomplete deairing of the delivery system despite the saline lavage recommended by the instructions for use (IFU). As the delivery systems are identical and residual air remains frequently in the abdominal aortic aneurysm sac, endovascular aortic repair (EVAR) can be used to examine the effectiveness of deairing maneuvers. We aimed to evaluate whether increasing the flush volume can result in a more complete deairing. Methods: Patients undergoing EVAR were randomly assigned according to flushing volume (Group A, 1× IFU; Group B, 4× IFU). The Terumo Aortic Anaconda and Treo and Cook Zenith Alpha Abdominal stent grafts were randomly implanted in equal distribution (10-10-10). The quantity of air trapped in the aneurysm sac was measured using a pre-discharge computed tomography angiography (CTA). Thirty patients were enrolled and equally distributed between the two groups, with no differences observed in any demographic or anatomical factors. Results: The presence of air was less frequent in Group A compared to that in Group B [7 (47%) vs. 13 (87%), p = .02], and the air volume was less in Group A compared to that in Group B (103.5 ± 210.4 vs. 175.5 ± 175.0 mm3, p = .04). Additionally, the volume of trapped air was higher with the Anaconda graft type (p = .025). Discussion: These findings suggest that increased flushing volume is associated with a higher amount of trapped air; thus, following the IFU might be associated with a reduced risk of air embolization. Furthermore, significant differences were identified between devices in terms of the amount of trapped air. Clinical trial registration: [NCT04909190], [ClinicalTrials.gov].

Endosutured aneurysm repair (ESAR) of abdominal aortic aneurysms with short necks achieves acceptable mid-term outcomes - results from the PERU registry.

INTRODUCTION: The study aims to describe midterm outcomes following treatment of infrarenal abdominal aortic aneurysms (AAAs) with short necks by endosutured aneurysm repair (ESAR) using the Heli-FX EndoAnchor system. METHODS: This is a retrospective study of prospectively collected data from nine vascular surgery departments between June 2010 - December 2019, including treated AAAs with neck lengths ≤ 10mm. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each centre's practice. There were two subgroups further assessed according to neck length, A (≥4 and < 7mm) and B (≥7 and ≤10mm). The main outcomes analysed were technical success, freedom from type Ia endoleaks (TIaEL), sac size increase, all-cause (ACM) and aneurysm related mortality (ARM). RESULTS: 76 patients were included in the study, 17 fell into Subgroup A and 59 into subgroup B. Median follow-up for the cohort was 40.5 (IQR 12-61) months. A median of 6 (IQR 3) EndoAnchors were deployed in each subject. Technical success was 86.8% for the total group, 82.4% and 88.1% (p=0.534) for subgroups A and B respectively. Six out of ten (60%) of TIaELs at the completion angiographies showed spontaneous resolution. Cumulative freedom from TIaEL at 3 and 5 years for the total group was 89% and 84% respectively; this was 93% and 74% for subgroup A and 88% at both intervals in subgroup B (p=0.545). In total, there were 7 (9.2%) patients presenting with type Ia endoleaks over the entire study period. Two (11.8%) in subgroup A and 5 (8.5%) in subgroup B (p=0.679). There were more patients with sac regression in subgroup B (subgroup A=6 - 35.3% versus subgroup B=34 - 57.6%, p=0.230) with no statistical significance. ACM was 19 (25%) patients, with no difference (4 - 23.5% versus 15 - 25.4%, p=0.874) between subgroups; whereas ARM occurred in one patient from subgroup A and 3 from subgroup B. CONCLUSIONS: This study demonstrates reasonable outcomes for patients with short-necked AAAs treated by ESAR in terms of type Ia endoleaks up to 5 year follow up. EndoAnchor use should be judiciously evaluated in short necks and may be a reasonable option when anatomical constraints are encountered, mainly for those with 7-10mm neck lengths. Shorter neck length aspects, as indicated by the results from Group A, may be an alternative when no other options are available or feasible.

One-Day Interruption of NOAC Is Associated with Low Risk of Periprocedural Adverse Events during Pulmonary Vein Isolation If Combined with Left Atrial Thrombus Exclusion with Computed Tomography.

BACKGROUND: Safety, efficacy, and patient comfort are the expectations during pulmonary vein isolation (PVI). We aimed to validate the combined advantages of pre- and periprocedural anticoagulation with non-vitamin K anticoagulants (NOACs) and rigorous left atrial appendage thrombus (LAAT) exclusion with computed tomography (CT). METHODS: This study included a population of consecutive patients, between March 2018 and June 2020, who underwent cardiac CT within 24 h before PVI to guide the ablation and rule out LAAT. NOAC was omitted 24 h before the ablation. RESULTS: A total of 187 patients (63% male) underwent CT before PVI. None of the patients experienced stroke during or after the procedure. The complication rate was low, with no thromboembolic events and 2.1% of patients experiencing a major bleeding event. CONCLUSIONS: Omitting NOAC 24 h before the ablation might be safe if combined with left atrial thrombus exclusion with computed tomography.

Association of growth and differentiation factor-15 with coronary artery calcium score and ankle-brachial index in a middle-aged and elderly Caucasian population sample free of manifest cardiovascular disease.

Growth and differentiation factor-15 (GDF-15) is a stress-associated cytokine of the transforming growth factor-ß superfamily. The inflammatory and angiogenic effects of GDF-15 in atherosclerosis are controversial, and its correlation with the long asymptomatic phase of the disease is not well understood. Coronary artery calcium score (CACS) and ankle-brachial index (ABI) are sensitive markers of subclinical atherosclerosis. To date, only a few studies have examined the impact of GDF-15 on coronary artery calcification, and the association between GDF-15 and ABI has not been evaluated. Therefore, we aimed to investigate the possible relationship between serum GDF-15 concentrations and CACS and ABI in a Caucasian population sample of middle-aged (35-65 years) and elderly (> 65 years) people. In addition to recording demographic and anthropometric characteristics, atherosclerotic risk factors, and laboratory tests including serum HDL-cholesterol, LDL-cholesterol, hemoglobin A1c (HbA1c), high-sensitivity C-reactive protein, and N-terminal pro-B-type natriuretic peptide (NT-proBNP); GDF-15 level, cardiac computed tomography, and ABI measurements were also performed. A total of 269 asymptomatic individuals (men, n = 125; median age, 61.5 [IQR, 12.7] years) formed the basis of this study. Participants were divided into two groups according to their age (middle-aged, n = 175 and elderly, n = 94). Hypertension and diabetes mellitus were significantly more prevalent and CACS values and HbA1c, NT-proBNP, and GDF-15 levels were significantly higher (all p < 0.001) in the elderly group compared to the middle-aged group. Multivariate ridge regression analysis revealed a significant positive association between GDF-15 and CACS (middle-aged group: ß = 0.072, p = 0.333; elderly group: ß = 0.148, p = 0.003), and between GDF-15 and ABI (middle-aged group: ß = 0.062, p = 0.393; elderly group: ß = 0.088, p = 0.041) only in the elderly group. Our results show that GDF-15 is not only a useful biomarker of inflammation but can also predict early signs of asymptomatic atherosclerosis, especially in elderly people with chronic systemic inflammation associated with aging (inflammaging).

[Secondary ruptures of an abdominal aortic aneurysm treated with a physician-modified fenestrated endograft, endoanchors and finally with open repair]. / Hasi aorta aneurysma másodlagos rupturáinak kezelése orvos által módosított fenesztrált grafttal, endocsavarozással, majd nyitott mutéttel.

Secondary rupture is a late complication of endovascular aneurysm repair (EVAR). Open surgery is a technically feasible treatment option in most cases, however, late conversion carries a significant risk of morbidity and mortality, as it usually requires at least partial explantation of the in situ device, which is of major concern especially if suprarenal fixation is present. Endovascular treatment of these cases is usually challenging, especially since the custom-made devices that are often needed are not readily available but having a production time of several weeks. To overcome this limitation, physician-modified stent grafts are getting accepted to treat such urgent cases. We present the case of a patient receiving EVAR who later experienced two ruptures, treated first with a physician-modified endograft and adjunctive endoanchoring, later with open ligation of the lumbar arteries. Orv Hetil. 2023; 164(36): 1426-1431.

Pulsatile Changes of the Aortic Diameter May Be Irrelevant Regarding Endograft Sizing in Patients With Aortic Disease.

PURPOSE: Endovascular aortic repair has become the preferred elective treatment of infrarenal aortic aneurysms. Aortic pulsatility may pose problems regarding endograft sizing. The aims of this study are to determine the aortic pulsatility in patients with aortic disease and to evaluate the effect of pulsatility on the growth of aneurysms. MATERIALS AND METHODS: In this retrospective study, analyses of computed tomography angiography (CTA) images of 31 patients under conservative treatment for small abdominal aortic aneurysms were performed. Reconstructions of the raw electrocardiography (ECG) gated dataset at 30% and 90% of the R-R cycle were used. After lumen segmentation, total aortic cross-sectional area was measured in diastole and systole in the following zones: Z0, Z3, Z5, Z6, Z8, and Z9. Effective diameters (EDs) were calculated from the systolic (EDsys) and diastolic (EDdia) cross-sectional areas to determine absolute (EDsys - EDdia, mm) and relative pulsatility [(EDsys - EDdia) / EDdia, %]. Diameter of the aneurysms was measured on baseline images and the last preoperative follow-up study of each patient. RESULTS: A total of 806 measurements were completed, 24 pulsatility and 2 growth measurements per patient. The mean pulsatility values at each point were as follows: Z0: 0.7±0.8 mm, Z3: 1.0±0.6 mm, Z5: 1.0±0.6 mm, Z6: 0.8±0.7 mm, Z8: 0.7±1.0 mm, Z9: 0.9±0.9 mm. Follow-up time was 5.5±2.2 years during which a growth of 13.42±9.09 mm (2.54±1.55 mm yearly) was observed. No correlation was found between pulsatility values and growth rate of the aneurysms. CONCLUSION: The pulsatility of the aorta is in a submillimetric range for the vast majority of patients with aortic disease, thus probably not relevant regarding endograft sizing. Pulsatility of the ascending aorta is smaller than that of the descending segment, making an additional oversize of a Z0 implantation questionable. CLINICAL IMPACT: Endovascular aortic repair reqiures precise preoperative planning. Pulsatile changes of the aortic diameter may pose issues regarding endograft sizing. In our retrospective single-centre study, aortic pulsatility of patients with AAA was measured on ECG gated CTA images. Pulsatility values reached a maximum at the descending aorta, however absolute pulsatility values did not exceed 1 mm at any point along the aorta. Therefore, significance of aortic pulsatility regarding the sizing of EVAR prostheses is questionable. Correlation between pulsatility and AAA growth was not found.

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

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

Neutrophil-to-Lymphocyte Ratio Is an Independent Risk Factor for Coronary Artery Disease in Central Obesity.

Several inflammatory biomarkers were found to be associated with an increased risk of cardiovascular disease. Neutrophil-to-lymphocyte ratio (NLR) is a marker of subclinical inflammation that increases with the stress response. Visceral adiposity index (VAI) calculated as a combination of anthropometric and metabolic parameters reflects both the extent and function of visceral adipose tissue. Given the association of subclinical inflammation with both obesity and cardiovascular diseases, it is plausible that the inflammation-CVD association is modulated by the amount and function of adipose tissue. Thus, our aim was to examine the association between NLR and coronary artery calcium score (CACS), an intermediate marker of coronary artery disease in asymptomatic patients across VAI tertiles. Methods: Data from 280 asymptomatic participants of a cardiovascular screening program were analysed. In addition to the collection of lifestyle and medical history, a non-contrast cardiac CT scan and laboratory tests were performed on all participants. Multivariate logistic regression was conducted with CACS > 100 as the outcome and with conventional cardiovascular risk factors and NLR, VAI, and NLR by VAI tertile as predictors. Results: We found an interaction between VAI tertiles and NLR; NLR values were similar in the lower VAI tertiles, while they were higher in the CACS > 100 in the 3rd VAI tertile (CACS ≤ 100: 1.94 ± 0.58 vs. CACS > 100: 2.48 ± 1.1, p = 0.008). According to multivariable logistic regression, the interaction between NLR and VAI tertiles remained: NLR was associated with CACS > 100 in the 3rd VAI tertile (OR = 1.67, 95% CI 1.06-2.62, p = 0.03) but not in the lower tertiles even after adjustment for age, sex, smoking, history of hypertension, hyperlipidaemia, and diabetes mellitus, as well as high-sensitivity C-reactive protein. Our findings draw attention to the independent association between subclinical, chronic, systemic inflammation and subclinical coronary disease in obesity.

[Complex endovascular repairs of the aortic arch.] / Komplex endovascularis rekonstrukciók az aortaíven.

Thoracic endovascular aneurysm repair (TEVAR) of the aortic arch has started to spread in recent years. We present our initial experience with TEVAR involving supra-aortic branches using parallel and branched grafts. Parallel grafts are typically used in emergency cases. In the case of Z0 proximal fixation, we can perform a combined hybrid surgery with Z1 debranching and securing of the innominate artery with chimney graft, which can also be used instead of Z0 debranching when the patient is unfit for sternotomy. In the case of TEVAR with planned Z2 position with inadvertent covering of the left common carotid artery, we can perform chimney conversion to rapidly recover the circulation of the left common carotid artery (LCCA). Instead of prior revascularization of the left subclavian artery, chimney graft can be used to recover the lumen, in the case of left upper limb ischemia after Z2 TEVAR. Exclusion of penetrating aortic ulcers located in the lesser curvature can be facilitated by use of a custom-made graft, where a scallop is placed around the origin of the supra-aortic vessel, thus increasing the length of the proximal neck. For elective interventions, custom-made branching grafts can be allowed to save all three branches with Z0 fixation. Technical success was obtained in all cases. Orv Hetil. 2023; 164(11): 426-431.

Coronary CTA Amidst the COVID-19 Pandemic: A Quicker Examination Protocol with Preserved Image Quality Using a Dedicated Cardiac Scanner.

There has been an ongoing debate on the means to minimize the time patients spend at health care providers during the COVID-19 pandemic. We propose a strategy relying solely on intravenous (i.v.) beta-blocker administration for heart-rate (HR) control prior to coronary CT angiography (CCTA). We aimed to assess a potential difference in CCTA image quality (IQ) after implementation of a modified strategy compared to our standard protocol of oral premedication during the first wave of COVID-19. We analyzed CCTA examinations conducted one year before (n = 1511) and after (n = 1064) implementation of this new regime. Examinations were performed both on our 256-slice multidetector CT (MDCT) and dedicated cardiac CT (DCCT) scanners. We used a four-point Likert scale (excellent/good/moderate/non-diagnostic) for IQ assessment of the coronaries. We detected a significant increase in mean HR during examinations on both CT scanners (MDCT: 62.4 ± 10.0 vs. 65.3 ± 9.7, p < 0.001; DCCT: 61.7 ± 15.2 vs. 65.0 ± 10.7, p < 0.001). The rate of moderate/non-diagnostic IQ significantly increased on the MDCT (192/1005, 19.1% vs. 144/466, 30.9%, p < 0.001), while this ratio did not change significantly on the DCCT (62/506, 12.3% vs. 84/598, 14.0%, p = 0.38). The improved temporal resolution of DCCT allows the stand-alone use of i.v. premedication with preserved IQ; hence, the duration of visits can be shortened.

The Impact of Novel Reconstruction Algorithms on Calcium Scoring: Results on a Dedicated Cardiac CT Scanner.

Contemporary reconstruction algorithms yield the potential of reducing radiation exposure by denoising coronary computed tomography angiography (CCTA) datasets. We aimed to assess the reliability of coronary artery calcium score (CACS) measurements with an advanced adaptive statistical iterative reconstruction (ASIR-CV) and model-based adaptive filter (MBAF2) designed for a dedicated cardiac CT scanner by comparing them to the gold-standard filtered back projection (FBP) calculations. We analyzed non-contrast coronary CT images of 404 consecutive patients undergoing clinically indicated CCTA. CACS and total calcium volume were quantified and compared on three reconstructions (FBP, ASIR-CV, and MBAF2+ASIR-CV). Patients were classified into risk categories based on CACS and the rate of reclassification was assessed. Patients were categorized into the following groups based on FBP reconstructions: 172 zero CACS, 38 minimal (1-10), 87 mild (11-100), 57 moderate (101-400), and 50 severe (400<). Overall, 19/404 (4.7%) patients were reclassified into a lower-risk group with MBAF2+ASIR-CV, while 8 additional patients (27/404, 6.7%) shifted downward when applying stand-alone ASIR-CV. The total calcium volume with FBP was 7.0 (0.0-133.25) mm3, 4.0 (0.0-103.5) mm3 using ASIR-CV, and 5.0 (0.0-118.5) mm3 with MBAF2+ASIR-CV (all comparisons p < 0.001). The concomitant use of ASIR-CV and MBAF2 may allow the reduction of noise levels while maintaining similar CACS values as FBP measurements.

Long-term prognostic value of left atrial longitudinal strain in an elderly community-based cohort.

Despite the well-known importance of left atrial (LA) mechanics in diastolic function, data are scarce regarding the prognostic power of LA longitudinal strain and its potential added value in the risk stratification of an elderly population. Accordingly, our aim was to determine the long-term prognostic importance of 2D speckle-tracking echocardiography-derived peak atrial longitudinal strain (PALS) in a community-based screening sample. Three hundred and fourteen volunteers were retrospectively identified from a population-based screening program (mean age 62 ± 11 years; 58% female) with a median follow-up of 9.5 years. All subjects who participated in the screening program underwent 2D echocardiography to measure left ventricular (LV) ejection fraction (EF), global longitudinal strain (GLS), and PALS, as well as low-dose cardiac CT to determine the Agatston score. The primary endpoint was all-cause mortality. Thirty-nine subjects (12.4%) met the primary endpoint. Subjects with adverse outcomes had significantly lower LV GLS (dead vs. alive; - 19.2 ± 4.3 vs. - 20.6 ± 3.5%, p < 0.05) and PALS (32.3 ± 12.0 vs. 41.8 ± 14.2%, p < 0.001), whereas LV EF did not show a difference between the two groups (51.1 ± 7.0 vs. 52.1 ± 6.2, %, p = NS). By multivariable Cox regression analysis, PALS was found to be a significant predictor of adverse outcomes independent of LV GLS, and Agatston and Framingham scores. In subjects with PALS values below the standard cut-off of 39%, the risk of all-cause mortality was almost 2.5 times higher (hazard ratio: 2.499 [95% confidence interval: 1.334-4.682], p < 0.05). Beyond the assessment of LV EF and LV GLS, PALS offers incremental value in cardiovascular risk stratification in a community-based elderly cohort. PALS was found to be a significant and independent predictor of long-term mortality among other classical cardiovascular risk estimators.

Diagnostic performance of non-contrast magnetic resonance angiography in patients with lower extremity arterial disease / A kontrasztanyag nélküli mágnesesrezonancia-angiográfia diagnosztikus teljesítménye alsó végtagi veroérbetegekben

Hungary. Knowing the consequences of burnout syndrome, it is important to prevent and recognize symptoms as early as possible.

Percutaneous transaxillary endovascular repair of a degenerated aortic homograft / Degenerált aortahomograft percutan transaxillaris rekonstrukciója

Late degeneration is a feared complication of homograft aortic repair. As homograft use is usually associated with graft infection, a second open repair of a complication may be associated to significant mortality. We describe the endovascular exclusion of a degenerated homograft with a contained rupture in a hostile abdomen via a transaxillary approach. The medical history of a 69-year-old male includes prosthetic aorto-biiliac bypass implantation in 2010 due to Leriche syndrome. In 2018, an aorto-duodenal fistula led to a redo bypass surgery using homografts, followed by right femoral amputation. In 2021, the patient was admitted with sudden abdominal pain due to a contained rupture of the homograft. The occluded right allograft limb and the calcified left common femoral artery was not suitable for access. Percutaneous left axillary puncture was performed under general anesthesia. Lesions were crossed and three 8 × 57 mm covered stents were positioned distally, finishing with a 12 × 57 mm graft. For safety reasons, left radial access was performed before closure. After deployment of closure devices, angiography showed near-occlusion of the axillary artery. Patency was restored with a 9 × 37 mm covered stent via the radial access. The patient was discharged on the following day. Follow-up imaging at 30 days showed complete exclusion of the aneurysm sac.