Aortic arch endovascular branch and fenestrated repair: Initial Canadian experience with novel technology.

Objective: The objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies. Methods: We performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes. Results: Eleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation. Conclusions: To the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.

AI-powered assessment of biomarkers for growth prediction of abdominal aortic aneurysms.

Objective: The purpose of this study was to employ biomechanics-based biomarkers to locally characterize abdominal aortic aneurysm (AAA) tissue and investigate their relation to local aortic growth by means of an artificial intelligence model. Methods: The study focused on a population of 36 patients with AAAs undergoing serial monitoring with electrocardiogram-gated multiphase computed tomography angiography acquisitions. The geometries of the aortic lumen and wall were reconstructed from the baseline scans and used for the baseline assessment of regional aortic weakness with three functional biomarkers, time-averaged wall-shear stress, in vivo principal strain, and intra-luminal thrombus thickness. The biomarkers were encoded as regional averages on axial and circumferential sections perpendicularly to the aortic centerline. Local diametric growth was obtained as difference in diameter between baseline and follow-up at the level of each axial section. An artificial intelligence model was developed to predict accelerated aneurysmal growth with the Extra Trees algorithm used as a binary classifier where the positive class represented regions that grew more than 2.5 mm/year. Additional clinical biomarkers, such as maximum aortic diameter at baseline, were also investigated as predictors of growth. Results: The area under the curve for the constructed receiver operating characteristic curve for the Extra Trees classifier showed a very good performance in predicting relevant aortic growth (area under the curve = 0.92), with the three biomechanics-based functional biomarkers being objectively selected as the main predictors of growth. Conclusions: The use of features based on the functional and local characterization of the aortic tissue resulted in a superior performance in terms of growth prediction when compared with models based on geometrical assessments. With rapid growth linked to increasing risk for patients with AAAs, the ability to access functional information related to tissue weakening and disease progression at baseline has the potential to support early clinical decisions and improve disease management.

A Systematic Review of Total Endovascular Aortic Arch Repair: A Promising Technology.

BACKGROUND: Total endovascular aortic arch repair (TEAAR) represents an emerging alternative for the treatment of aortic arch disease in patients at prohibitive risk for open surgery. A systematic review of TEAAR was performed to delineate early outcomes with this new technology. METHODS: All studies (excluding single-patient case reports) of CE-certified "custom made" or "off-the-shelf" zone 0 stent graft deployments were included. The primary search of Medline, Embase, CINAHL, and the Cochrane CENTRAL registry was supplemented with searches of Web of Science, ClinicalTrials.gov, and conference abstracts (within last 3 years), and a hand search of citations within relevant articles. Articles underwent 2-stage screening by 2 independent reviewers before inclusion. RESULTS: Fifteen relevant investigations were identified. Indications for TEAAR were chronic arch dissection with degenerative aneurysmal disease (54%, 148/273), pure arch aneurysm (41%, 112/273), penetrating atherosclerotic ulcer (2%, 5/273), and type IA endoleak from a zone 2 thoracic endograft (1%, 3/273). Double-branch (70%, 192/273), triple-branch (19%, 53/273), and single-branch (into innominate artery; 10%, 28/273) devices were used. Adjunct left carotid-subclavian bypass occurred in 90% of double- and single-branch procedures. Procedural success with TEAAR was 93% (95% CI 85.8%-96.3%). The proportion of all-cause mortality was 16% (95% CI 8%-26%), stroke 14% (8%-24%), peripheral vascular events 7% (1%-33%), and myocardial infarction 4% (2%-7%). Endoleaks were identified in 13% (7%-25%) of the study population. CONCLUSIONS: TEAAR represents an emerging option for the management of aortic arch disease wth high procedural success rates and acceptable early outcomes in a high-risk patient population.

The Aortic Team Model for the Management of the Distal Arch, Descending Thoracic and Thoracoabdominal Aorta: Appraisal at 3 Years.

BACKGROUND: This study aimed to assess feasibility, logistical challenges, and clinical outcomes associated with the implementation of an Aortic Team model for the management of distal arch, descending thoracic and thoracoabdominal aortic disease. METHODS: An Aortic Team care pathway was implemented in November 2019. Working as a unit, two cardiac surgeons, two vascular surgeons, an interventional radiologist, a cardiologist, and an anesthesiologist collectively determined care decisions via multispecialty presence at an Aortic Clinic. Cardiac and vascular surgeons operated in tandem for open procedures. Interventional radiology participated alongside cardiac and vascular for endovascular procedures. Cardiology aided in medical therapies for heritable and degenerative disease, and had a lead role for genetics and high-risk pregnancy referrals. The model spanned three hospitals. Clinical outcomes at 3 years were assessed. RESULTS: There were 35 descending thoracic and thoracoabdominal surgeries and 77 thoracic endovascular aortic repairs. Endoarch devices were used in 7 cases (Gore Thoracic Branch Endoprosthesis, 4, Terumo RelayBranch, 3) and an endothoracoabdominal device in 4 cases (Cook Zenith t-branch). The Aortic Clinic acquired 456 patients, with yearly increases (54 patients [year 1], 181 patients [year 2], 221 patients [year 3]). For surgery, mortality was 8.6% (3/35), permanent paralysis 5.7% (2/35), stroke 8.6% (3/35), permanent dialysis 0%, and reinterventions 8.6% (3/35). For endovascular cases, mortality was 3.9% (3/77), permanent paralysis 3.9% (3/77), stroke 5.2% (4/77), permanent dialysis 1.3% (1/77), and reinterventions 16.9% (13/77). CONCLUSION: An Aortic Team model is feasible and ensures all treatment options are considered. Conventional open thoracoabdominal procedures showed acceptable outcomes. Endoarch technology shows early promise.

Deep-learning method for fully automatic segmentation of the abdominal aortic aneurysm from computed tomography imaging.

Abdominal aortic aneurysm (AAA) is one of the leading causes of death worldwide. AAAs often remain asymptomatic until they are either close to rupturing or they cause pressure to the spine and/or other organs. Fast progression has been linked to future clinical outcomes. Therefore, a reliable and efficient system to quantify geometric properties and growth will enable better clinical prognoses for aneurysms. Different imaging systems can be used to locate and characterize an aneurysm; computed tomography (CT) is the modality of choice in many clinical centers to monitor later stages of the disease and plan surgical treatment. The lack of accurate and automated techniques to segment the outer wall and lumen of the aneurysm results in either simplified measurements that focus on few salient features or time-consuming segmentation affected by high inter- and intra-operator variability. To overcome these limitations, we propose a model for segmenting AAA tissues automatically by using a trained deep learning-based approach. The model is composed of three different steps starting with the extraction of the aorta and iliac arteries followed by the detection of the lumen and other AAA tissues. The results of the automated segmentation demonstrate very good agreement when compared to manual segmentation performed by an expert.

Zone 0 Aortic Arch Reconstruction Using the RelayBranch Thoracic Stent Graft.

Endovascular therapies have had a considerable impact on contemporary management of thoracic aortic disease. Still, with the anatomic challenges of the aortic arch, endovascular experience with devices that traverse the arch and deploy in the Zone 0 position remains limited. We report the first Canadian experience with the RelayBranch Thoracic Stent Graft (Terumo Aortic, Sunrise, FL) with Zone 0 deployment for total endovascular aortic arch repair in a patient at very high risk for redo open surgery. We demonstrate safe deployment of the device and successful treatment of a type 1A endoleak. Features of the RelayBranch design that mitigate challenges of arch deployment are also discussed.

Les traitements endovasculaires ont eu un impact considérable sur la gestion contemporaine des pathologies de l'aorte thoracique. Pourtant, en raison des contraintes anatomiques de la crosse aortique, l'expérience endovasculaire avec des dispositifs qui traversent la crosse et se déploient dans la zone 0 reste limitée. Nous rapportons la première expérience canadienne de l'endoprothèse thoracique RelayBranch avec déploiement (Terumo Aortic, Sunrise, FL) en zone 0 pour une réparation endovasculaire totale de la crosse aortique chez un patient présentant un risque très élevé de reprise de chirurgie ouverte. Nous décrivons le déploiement en toute sécurité du dispositif et le traitement réussi d'une endofuite de type 1A. Enfin, nous examinons les caractéristiques du système RelayBranch qui limitent les difficultés liées au déploiement du dispositif dans la crosse aortique.

Rapid endovascular bailout revascularization of the renal arteries with a steerable guiding sheath after endovascular abdominal aortic aneurysm repair.

Advancements in endovascular therapy have made it increasingly available for patients with complex cases but not without complications. Unintentional coverage of the renal arteries is a rare occurrence during endovascular aortic aneurysm repair. Given the potentially devastating repercussions, it is important that surgeons understand the suitability and the risks and benefits of the available revascularization options. We have described two cases of unintentional renal coverage, with subsequent successful bailout via direct manipulation of the stent-graft with a steerable sheath. We also conducted a review of the reported data, discussed the breadth of management options and their technical aspects, and provided several distinct solutions.

The Many Care Models to Treat Thoracic Aortic Disease in Canada: A Nationwide Survey of Cardiac Surgeons, Cardiologists, Interventional Radiologists, and Vascular Surgeons.

BACKGROUND: Several specialties treat thoracic aortic disease, resulting in multiple patient care pathways. This study aimed to characterize these varied care models to guide health policy. METHODS: A 57-question e-survey was sent to staff cardiac surgeons, cardiologists, interventional radiologists, and vascular surgeons at 7 Canadian medical societies. RESULTS: For 914 physicians, the response rate was 76% (86 of 113) for cardiac surgeons, 40% (58 of 146) for vascular surgeons, 24% (34 of 140) for radiologists, and 14% (70 of 515) for cardiologists. Several services admitted type B dissections (vascular 37%, cardiology 31%, cardiac 18%, other 7%), and care was heterogeneous. Ownership of disease management was overestimated relative to the perspective of the other specialties. Type A dissection admissions and treatment were more uniform, but emergent call coverage varied. A 24/7 aortic specialist on-call schedule was present only 4% of the time. "Aortic" case rounds promoted attendance by a broader aortic specialty contingency relative to rounds that were specialty specific. Although 89% of respondents felt an aortic team was best for patient care, only 54% worked at an institution with an aortic team present, and only 28% utilized an aortic clinic. Questions designed to define an aortic team derived 63 different combinations. CONCLUSIONS: Thoracic aortic disease follows a network of undefined and variable care pathways, despite its high-risk population in need of complex treatment considerations. Multidisciplinary aortic teams and clinics exist in low volume, and the "aortic team" remains an obscure construct. A multispecialty initiative to define the aortic team and outline standardized navigation pathways within the health systems hospitals is advocated.

CONTEXTE: La prise en charge de la maladie de l'aorte thoracique peut faire appel à plusieurs spécialités, ce qui a pour effet de multiplier les trajectoires de soins des patients. Cette étude visait à caractériser ces différents modèles de soins afin d'éclairer l'élaboration des politiques de santé. MÉTHODOLOGIE: Un sondage électronique de 57 questions a été envoyé aux chirurgiens cardiaques, aux cardiologues, aux radiologistes interventionnels et aux chirurgiens vasculaires membres de 7 associations médicales canadiennes. RÉSULTATS: Sur un total de 914 médecins, le taux de réponse a été de 76 % (86 sur 113) chez les chirurgiens cardiaques, de 40 % (58 sur 146) chez les chirurgiens vasculaires, de 24 % (34 sur 140) chez les radiologistes et de 14 % (70 sur 515) chez les cardiologues. Plusieurs services avaient admis des cas de dissection aortique de type B (chirurgie vasculaire 37 %, cardiologie 31 %, chirurgie cardiaque 18 %, autre 7 %) et les soins étaient hétérogènes. Les spécialistes surestimaient leur responsabilité de la prise en charge des cas par rapport à celle des autres spécialistes. Les admissions de cas de dissection de type A et leur traitement étaient plus uniformes, mais la présence de spécialistes de garde pouvant traiter les cas urgents était variable. La présence continue d'un spécialiste de l'aorte de garde n'était observée que pendant 4 % du temps. Les séances de discussion de cas « aortiques ¼ favorisaient la participation par une gamme plus large de spécialistes de l'aorte que les discussions axées sur une spécialité donnée. Si 89 % des répondants estimaient qu'une équipe « aortique ¼ était la meilleure option pour les soins aux patients, ils n'étaient que 54 % à travailler dans un établissement disposant d'une telle équipe et 28 % à utiliser les services d'une clinique de l'aorte. En réponse aux questions portant sur les éléments constitutifs d'une équipe aortique, 63 combinaisons différentes de spécialités ont été proposées. CONCLUSIONS: La prise en charge de la maladie de l'aorte thoracique emprunte un dédale de trajectoires de soins non définies et variables, alors que sa population à haut risque a besoin de traitements complexes. Les équipes multidisciplinaires et les cliniques spécialisées dans le traitement de l'aorte sont rares, et la notion d' « équipe aortique ¼ demeure un concept obscur. Nous préconisons une initiative réunissant des spécialistes de différents domaines pour définir les éléments constitutifs d'une équipe aortique et établir des trajectoires de navigation normalisées au sein des hôpitaux du système de santé.

Linking Aortic Mechanical Properties, Gene Expression and Microstructure: A New Perspective on Regional Weakening in Abdominal Aortic Aneurysms.

Background: Current clinical practice for the assessment of abdominal aortic aneurysms (AAA) is based on vessel diameter and does not account for the multifactorial, heterogeneous remodeling that results in the regional weakening of the aortic wall leading to aortic growth and rupture. The present study was conducted to determine correlations between a novel non-invasive surrogate measure of regional aortic weakening and the results from invasive analyses performed on corresponding ex vivo aortic samples. Tissue samples were evaluated to classify local wall weakening and the likelihood of further degeneration based on non-invasive indices. Methods: A combined, image-based fluid dynamic and in-vivo strain analysis approach was used to estimate the Regional Aortic Weakness (RAW) index and assess individual aortas of AAA patients prior to elective surgery. Nine patients were treated with complete aortic resection allowing the systematic collection of tissue samples that were used to determine regional aortic mechanics, microstructure and gene expression by means of mechanical testing, microscopy and transcriptomic analyses. Results: The RAW index was significantly higher for samples exhibiting lower mechanical strength (p = 0.035) and samples classified as low elastin content (p = 0.020). Samples with higher RAW index had the greatest number of genes differentially expressed compared to any constitutive metric. High RAW samples showed a decrease in gene expression for elastin and a down-regulation of pathways responsible for cell movement, reorganization of cytoskeleton, and angiogenesis. Conclusions: This work describes the first AAA index free of assumptions for material properties and accounting for patient-specific mechanical behavior in relation to aneurysm strength. Use of the RAW index captured biomechanical changes linked to the weakening of the aorta and revealed changes in microstructure and gene expression. This approach has the potential to provide an improved tool to aid clinical decision-making in the management of aortic pathology.

A novel combined fluid dynamic and strain analysis approach identified abdominal aortic aneurysm rupture.

Clinical decision-making for surgical repair of abdominal aortic aneurysms based on maximum aortic diameter presents limitations as rupture can occur below threshold for some aneurysms, whereas others are stable at large sizes. The proposed approach combines hemodynamics and geometric indices with in vivo deformation analysis to assess local weakening of the aortic wall for a case of impending rupture that was confirmed during open surgical repair. A new combined index, the Regional Rupture Potential, is introduced to help the assessment of individual aneurysms and their rupture risk, providing a rationale for clinical decisions.

Cardiac rehabilitation in people with peripheral arterial disease: A higher risk population that benefits from completion.

BACKGROUND: Peripheral arterial disease (PAD) is common in people referred for cardiac rehabilitation (CR). However, the associations between PAD diagnosis and CR attendance and mortality remain to be defined. METHODS: All patients referred to a 12-week exercise-based CR program were included. Associations between PAD diagnosis and starting CR as well as between PAD diagnosis and completing CR were measured using multivariable logistic regression. Associations between CR completion and mortality were measured using adjusted Cox proportional hazards models, and a propensity-based matching sensitivity analysis was performed. RESULTS: 23,215 patients (mean age 61.3 years; 21.6% female) were referred to CR; 1366 (5.9%) had PAD. Those with PAD were less likely to start CR (57.0% vs 68.2%, adjusted OR 0.81, 95%CI 0.72, 0.91) and complete CR if they started (70.6% vs 76.7%, adjusted OR 0.80, 95%CI 0.68, 0.94). Patients with PAD completing CR had lower exercise capacity at baseline (6.6 vs. 7.6 METs, p < 0.0001) and completion (7.5 vs 8.6 METs, p < 0.0001). There were 3510 deaths over follow-up; 10-year survival was lower in those with PAD (66.9 vs 84.5%; p < 0.0001). CR completion was associated with lower mortality for all (adjusted HR 0.62 (95%CI 0.57, 0.67)), and the magnitude of the association was independent of PAD status. CONCLUSIONS: Patients with PAD referred to CR had a higher mortality than those without, and were less likely to start and complete CR. Completion of CR was associated with improved fitness and survival for PAD patients. These data support broader use of CR by those with PAD.

Correction to: Mycotic aortic aneurysms post-Intravesical BCG treatment for early-stage bladder carcinoma.

In the published article [1] the statement under the subheading 'Consent for publication' is incorrect.

Case Study: Intra-Patient Heterogeneity of Aneurysmal Tissue Properties.

Introduction: Current recommendations for surgical treatment of abdominal aortic aneurysms (AAAs) rely on the assessment of aortic diameter as a marker for risk of rupture. The use of aortic size alone may overlook the role that vessel heterogeneity plays in aneurysmal progression and rupture risk. The aim of the current study was to investigate intra-patient heterogeneity of mechanical and fluid mechanical stresses on the aortic wall and wall tissue histopathology from tissue collected at the time of surgical repair. Methods: Finite element analysis (FEA) and computational fluid dynamics (CFD) simulations were used to predict the mechanical wall stress and the wall shear stress fields for a non-ruptured aneurysm 2 weeks prior to scheduled surgery. During open repair surgery one specimen partitioned into different regions was collected from the patient's diseased aorta according to a pre-operative map. Histological analysis and mechanical testing were performed on the aortic samples and the results were compared with the predicted stresses. Results: The preoperative simulations highlighted the presence of altered local hemodynamics particularly at the proximal segment of the left anterior area of the aneurysm. Results from the post-operative assessment on the surgical samples revealed a considerable heterogeneity throughout the aortic wall. There was a positive correlation between elastin fragmentation and collagen content in the media. The tensile tests demonstrated a good prediction of the locally varying constitutive model properties predicted using geometrical variables, i.e., wall thickness and thrombus thickness. Conclusions: The observed large regional differences highlight the local response of the tissue to both mechanical and biological factors. Aortic size alone appears to be insufficient to characterize the large degree of heterogeneity in the aneurysmal wall. Local assessment of wall vulnerability may provide better risk of rupture predictions.

Mycotic aortic aneurysms post-Intravesical BCG treatment for early-stage bladder carcinoma.

BACKGROUND: Intravesicular Bacillus Calmette-Guérin (BCG) is an effective adjunctive therapy for superficial bladder cancer that has been shown to delay recurrence and progression of disease. Serious side effects are relatively rare but are difficult to diagnose and are often overlooked. Vascular complications are particularly rare. CASE PRESENTATION: We report two cases of mycotic aortic aneurysms secondary to BCG treatment, one managed with endovascular stent-graft placement and the other with open surgical repair. The present understanding of disseminated BCGosis, including a literature review, will be discussed. CONCLUSION: The incidence of mycotic aneurysms from BCG treatment is rare and very few cases have been reported in the literature. These cases further expand the current knowledge on vascular complications related to BCG treatment. In the absence of formal guidelines, we recommend a multidisciplinary approach involving vascular surgery, diagnostic and interventional radiology, and infectious disease to manage these patients.

Rehabilitation Therapy in Peripheral Arterial Disease.

Peripheral arterial disease (PAD) is the result of atherosclerosis in the lower limb arteries, which can give rise to intermittent claudication (IC), limb ulceration, infections, and, in some circumstances, amputation. As a result of PAD, patients are frequently limited in both walking duration and speed. These ambulatory deficits impact both functional capacity and quality of life. The prevalence of PAD is increasing, and patients with this diagnosis have high cardiovascular morbidity and mortality. A comprehensive approach is required to improve outcomes in patients with PAD and include tobacco cessation, pharmacologic management of metabolic fitness, risk-factor modification, and exercise training. Supervised exercise programs significantly improve functional capacity and quality of life in addition to reducing IC. These programs reduce morbidity and mortality and are cost-effective; yet they are uncommonly prescribed. Supervised exercise training is an accepted intervention in the PAD population and has been included in both Canadian and American guidelines for PAD management. This review describes (1) key background information related to PAD, (2) the initial approach to PAD diagnosis, (3) pharmacologic management options, (4) risk-factor modification, and (5) the currently accepted approach to exercise training. Key recommendations for enhancing PAD care in a Canadian context are also discussed.

Local Quantification of Wall Thickness and Intraluminal Thrombus Offer Insight into the Mechanical Properties of the Aneurysmal Aorta.

Wall stress is a powerful tool to assist clinical decisions in rupture risk assessment of abdominal aortic aneurysms. Key modeling assumptions that influence wall stress magnitude and distribution are the inclusion or exclusion of the intraluminal thrombus in the model and the assumption of a uniform wall thickness. We employed a combined numerical-experimental approach to test the hypothesis that abdominal aortic aneurysm (AAA) wall tissues with different thickness as well as wall tissues covered by different thrombus thickness, exhibit differences in the mechanical behavior. Ultimate tissue strength was measured from in vitro tensile testing of AAA specimens and material properties of the wall were estimated by fitting the results of the tensile tests to a histo-mechanical constitutive model. Results showed a decrease in tissue strength and collagen stiffness with increasing wall thickness, supporting the hypothesis of wall thickening being mediated by accumulation of non load-bearing components. Additionally, an increase in thrombus deposition resulted in a reduction of elastin content, collagen stiffness and tissue strength. Local wall thickness and thrombus coverage may be used as surrogate measures of local mechanical properties of the tissue, and therefore, are possible candidates to improve the specificity of AAA wall stress and rupture risk evaluations.

Five-year results of thoracic endovascular aortic repair with the Zenith TX2.

BACKGROUND: This trial evaluated thoracic endovascular aortic repair (TEVAR) compared with open surgical repair of descending thoracic aortic aneurysms and large ulcers at 42 international sites. Whereas several studies demonstrate early safety and utility advantages with TEVAR, longer follow-up is important because of concerns about durability of TEVAR. METHODS: This prospective, nonrandomized study enrolled 160 TEVAR patients treated with the Cook Zenith TX2 and 70 open surgical repair patients. RESULTS: Although follow-up was limited, 5-year mortality rate was similar at 37% for both groups. Aneurysm-related mortality rate was 5.9% with TEVAR compared with 12% with open surgical repair (P = .11). There were no ruptures of the treated aneurysms in either group or open conversions in the TEVAR group. Predefined severe morbidity occurred at a significantly lower rate in TEVAR (21%) compared with open surgical repair (39%; P < .001). Aneurysm growth was seen by core laboratory in 5.9% of patients and endoleak in 5.7% of patients. Secondary intervention rates were similar between TEVAR (8%) and open surgical repair (12%; P = .49) patients. CONCLUSIONS: Five-year results indicate similar all-cause mortality and aneurysm-related mortality with TEVAR compared with open repair. There was a persistent reduction of severe complications with TEVAR. Reinterventions occurred with similar frequency. TEVAR with the TX2 is a safe and effective alternative to open surgical repair for the treatment of anatomically suitable descending thoracic aortic aneurysms and ulcers.

Neoadjuvant radiotherapy and reconstruction using autologous vein graft for the treatment of inferior vena cava leiomyosarcoma.

BACKGROUND AND OBJECTIVES: Inferior vena cava (IVC) leiomyosarcomas are rare and are a relatively small subset of retroperitoneal sarcomas. The current approach is resection and ligation or reconstruction of the IVC. This study was undertaken to analyze the outcomes associated with the use of neoadjuvant radiotherapy and IVC reconstruction in the treatment of IVC leiomyosarcoma. METHODS: A retrospective clinicopathological review of patients treated during a 10-year period. RESULTS: Four patients were treated with neoadjuvant radiotherapy, median 47.5 Gy, all underwent margin negative resection with 75% of the tumors being high grade and all patients requiring resection of adjacent organs. Reconstruction of the IVC was performed with an autologous superficial femoral vein graft. There were no mortalities and the morbidity rate was 50%. At a median follow up of 37 months; two patients had a patent IVC, no patients had a local recurrence, and one patient developed a distant metastases treated successfully with metastectomy. CONCLUSIONS: Neoadjuvant radiotherapy and resection of the IVC leiomyosarcoma resulted in 100% local control, and all patients are alive at median follow up of 37 months. IVC reconstruction with the superficial femoral vein is safe and associated with acceptable short and long term morbidity.

Open versus endovascular repair of popliteal artery aneurysms.

A 72-year-old male presents with a large asymptomatic aneurysm of his left popliteal artery. He has a history of noninsulin dependent diabetes, hypertension, and a prior history of a percutaneous intervention for a coronary artery stenosis. He is anatomically and physiologically a candidate for surgical or endovascular repair of his aneurysm. The following debate attempts to resolve whether open repair remains the gold standard for the treatment of popliteal artery aneurysms.