Acute kidney injury in patients undergoing endovascular or open repair of juxtarenal or pararenal aortic aneurysms.

BACKGROUND: The aim of this cohort study was to report the proportion of patients who develop periprocedural acute kidney injury (AKI) after endovascular repair (ER) and open surgery (OS) in patients with juxta/pararenal abdominal aortic aneurysm and to assess potential risk factors for AKI. The study also aimed to report the short- and long-term outcomes of patients with and without AKI. METHODS: This was a multicenter cohort study of five European academic high-volume centers (>50 OS or 50 ER infrarenal AAA repairs, plus >15 complex AAA repairs per year). All consecutively treated patients were extracted from a prospective vascular surgical registry and the data were scrutinized retrospectively. The primary end point for this study was the development of AKI. AKI was diagnosed when there is a two-fold increase of serum creatinine or decrease of glomerular filtration rate of >50% within 1 week of AAA repair. Secondary end points included long-term mortality and end-stage renal disease (ESRD). RESULTS: AKI occurred in 16.6% of patients in the ER group vs 30.3% in the OS group (P < .001). The 30-day mortality rate was higher among patients with AKI in both ER (15.4% vs 3.1%; P = .006) and OS (13.2% vs 5.3%; P = .001) groups. Age, chronic kidney disease, presence of significant thrombus burden in the pararenal region, >1000 mL blood loss in ER group were associated with development of AKI. Age, diabetes mellitus, chronic kidney disease, presence of significant thrombus burden in the pararenal region, and a proximal clamping time of >30 minutes in the OS group were associated with the development of AKI, whereas renal perfusion during clamping was the protective factor against AKI development. After a median follow-up of 91 months, AKI was associated with higher mortality rates in both the ER group (58.9% vs 29.7%; P < .001) and the OS group (61.5% vs 27.3%; P < .001). After the same follow-up period, AKI was associated with a higher incidence of ESRD in both the ER group (12.8% vs 3.6%; P = .009) and the OS group (9.9% vs 2.9%; P < .001). CONCLUSIONS: The current study identified important pre and postoperative factors associated with AKI after juxta/pararenal abdominal aortic aneurysm repair. Patients with postoperative AKI had significantly higher short- and long term mortality and higher incidence of ESRD than patients without AKI.

Short Term and Long Term Clinical Outcomes of Endovascular versus Open Repair for Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using Propensity Score Matching: Results from Juxta- and pararenal aortic Aneurysm Multicentre European Study (JAMES).

OBJECTIVE: The aim of this study was to compare the short and long term clinical outcomes of endovascular (EVAR) vs. open surgical repair (OSR) of juxtarenal (JAAAs) and pararenal abdominal aortic aneurysms (PAAAs) in five high volume European academic centres. METHODS: This was a retrospective multicentre cohort study of five high volume European academic centres (> 50 open or 50 endovascular abdominal aortic aneurysm repairs annually) including 834 consecutive patients who were operated on and prospectively followed. Using propensity score matching (PSM) each patient who underwent OSR was matched with one patient who underwent EVAR in a 1:1 ratio (145 patients per group). The primary endpoint was long term all cause mortality, while the secondary endpoint was freedom from aortic related re-intervention. RESULTS: After a follow up of 87 months, no difference in overall survival between the two groups was observed (38.6% for EVAR vs. 42.1% for OSR; p = .88). Patients undergoing EVAR underwent aortic related re-interventions more frequently (24.1% vs. 6.9%; p < .001). Acute kidney injury (AKI) occurred more frequently in patients in the OSR group (40.7% vs. 24.8%; p = .006). However, most patients who suffered from AKI recovered without further progression to renal failure. In hospital (3.4% for EVAR vs. 4.1% for OSR; p = 1.0) and 30 day (4.1% for EVAR vs. 5.5% for OSR; p = .80) mortality rates did not differ between groups. CONCLUSION: Both open and endovascular treatment can be performed in high volume aortic centres with low short term mortality and morbidity rates, and good long term outcomes. These data provide useful information to help patients choose between the two procedures when both are feasible.

A Planned Multidisciplinary Surgical Approach to Treat Primary Pelvic Malignancies.

The pelvic anatomy poses great challenges to orthopedic surgeons. Sarcomas are often large in size and typically enclosed in the narrow confines of the pelvis with the close proximity of vital structures. The aim of this study is to report a systematic planned multidisciplinary surgical approach to treat pelvic sarcomas. Seventeen patients affected by bone and soft tissue sarcomas of the pelvis, treated using a planned multidisciplinary surgical approach, combining the expertise of orthopedic oncology and other surgeons (colleagues from urology, vascular surgery, abdominal surgery, gynecology and plastic surgery), were included. Seven patients were treated with hindquarter amputation; 10 patients underwent excision of the tumor. Reconstruction of bone defects was conducted in six patients with a custom-made 3D-printed pelvic prosthesis. Thirteen patients experienced at least one complication. Well-organized multidisciplinary collaborations between each subspecialty are the cornerstone for the management of patients affected by pelvic sarcomas, which should be conducted in specialized centers. A multidisciplinary surgical approach is of paramount importance in order to obtain the best successful surgical results and adequate margins for achieving acceptable outcomes.

Infrarenal EVAR for Penetrating Aortic Ulcer: A Comparative Study with Abdominal Aortic Aneurysm.

BACKGROUND: Endovascular aortic repair (EVAR), currently the preferred treatment for abdominal aortic aneurysm (AAA), has been described also for penetrating aortic ulcers (PAU) of the infrarenal aorta. However, data on its performance in this particular setting are still sparse in the literature. Aim of this study is to compare patient clinical characteristics, aorto-iliac features, and post-operative outcomes between infrarenal PAU and AAA treated by standard EVAR. METHODS: In this retrospective observational case-control multicenter study, the patients treated for infrarenal PAU (G1) with EVAR in 2 high-volume European centers from January 2014 to December 2019 were prospectively entered into a dedicated database and retrospectively analyzed. A 4-fold control group (G2) of infrarenal AAA patients, homogeneous for age and gender, was also considered. Preoperative clinical characteristics, aorto-iliac features (rupture, aortic maximum diameter, proximal neck diameter and length, aortic bifurcation diameter, distance between the lowest renal artery and the aortic bifurcation [RA-AoBi], severe aortic calcification), technical success, 30-day (morbidity, reintervention, complications, mortality) and follow-up outcomes (freedom from reintervention [FFR] and survival) were compared in the 2 groups (chi square/Fisher exact test, t-student test, Mann-Whitney test, logistic regression and Kaplan-Meier analysis). RESULTS: Seventy-three patients (age 78 ± 7 years; male 84.9%) were included in G1 and 299 (age 78.4 ± 6.6 years; male 89.3%) in G2. At the time of diagnosis, G1 patients were more often symptomatic compared with G2 (odds ratio OR 10.21, 95% confidence interval CI 4.17-24.99, P < 0.001). At preoperative computed tomography angiography, G1 patients had more ruptures (OR 8.11, 95% CI 3.50-18.78, P < 0.001), smaller maximum diameter (OR 1.05, 95% CI 1.03-1.08, P < 0.001), longer and narrower proximal neck (OR 0.97, 95% CI 0.95-0.99, P = 0.020 and OR 1.47, 95% CI 1.32-1.64, P < 0.001, respectively) narrower aortic bifurcation (OR 1.34, 95% CI 1.24-1.45, P < 0.001), lower RA-AoBi (OR 1.09, 95% CI 1.07-1.12, P < 0.001), and more severe aortic calcification (OR 57, 95% CI 16-198, P = 0.001). Technical success (G1 98.6% vs G2 95.7% P = 0.320), 30-day morbidity (G1 2.7% vs G2 8.7% P = 0.133), reintervention (G1 2.7% vs G2 2.3% P = 0.691), complications (G1 6.8% vs G2 8% P = 0.737) and mortality (G1 1.4% vs 2% P = 0.720) were comparable in the 2 groups. The mean follow-up was 17.7 ± 16.4 months in G1 and 18.8 ± 15.1 in G2 (P = 0.576). Late FFR and survival were comparable in the 2 groups (1-year FFR: G1 94.8% vs G2 97.5%, P = 0.995; 1-year survival: G1 91.7% vs G2 92.3%, P = 0.960). CONCLUSIONS: Infrarenal PAU are more often symptomatic with a higher rupture rate compared to infrarenal AAA. Despite some negative anatomical characteristics (narrower aortic bifurcation, lower RA-AoBi, extensive calcification), the results of EVAR are extremely satisfactory in this setting, suggesting that endovascular exclusion could be considered a valid treatment for infrarenal PAU.

Midterm results of complicated penetrating abdominal aortic ulcer treated by aortobi-iliac endograft and embolization.

BACKGROUND: Penetrating aortic ulcer (PAU) is determined by atherosclerotic degeneration of the tunica media with disruption of the intima. Usually it is detected in the thoracic aorta, with few series describing an abdominal location. The aim of the study was to report early and late outcomes of the endovascular repair of complicated infrarenal abdominal PAU (a-PAU) by aortobi-iliac endograft and embolization. METHODS: Data from all complicated a-PAU submitted to endovascular repair by aortobi-iliac endograft (Cook-Zenith Alpha) between 2016 and 2021 (February) were analyzed. The a-PAU coil embolization was performed to decrease the risk of persistent type II endoleak whenever possible. Complicated a-PAU were defined according with the presence of symptoms, aortic rupture, or saccular or pseudo-aneurysm. Technical success, 30-day morbidity and mortality, and reinterventions were assessed as early outcomes. Survival, endoleaks, and freedom from reinterventions were evaluated during follow-up. RESULTS: Of 1153 endovascular aortic procedures, 45 cases (4%) of complicated a-PAU were identified. Fourteen cases (31%) were managed in urgent setting (symptoms, n = 10 [22%]; shock, n = 4 [9%]). The median diameter of a-PAU was 49 mm (interquartile range, 14 mm). Thirteen patients (29%) had severe femoral or iliac access (angle >90°, circumferential calcification [>50%], hemodynamic iliac stenosis or obstruction, an external iliac artery diameter of less than 7 mm, or a previous femoral surgical graft). The a-PAU embolization was performed in 30 cases (67%). Technical success was achieved in all patients. Postoperative cardiac, pulmonary and renal morbidity occurred in one (2%), two (4%), and eight (18%) patients, respectively. Two patients (4%) required reintervention within 30 days for access related complications. The 30-day mortality was 2%. At a median follow-up of 24 months (interquartile range, 18 months), no type I or III endoleaks, iliac leg occlusion, or graft infection occurred and no patient required late reinterventions; the 36-month survival rate was 72%. No a-PAU enlarged or ruptured during follow-up. CONCLUSIONS: Endovascular repair of complicated a-PAU by a low-profile aortobi-iliac endograft and embolization is safe and effective. Excellent technical results are reported even in challenging anatomic features. Midterm clinical results are satisfactory in terms of aortic-related complications or mortality, freedom from reintervention, and survival.

The Impact of the First COVID-19 Wave on European Vascular Education.

INTRODUCTION: Public health was severely affected by the first wave of the COVID-19 pandemic, imposing major daily life changes across the world, including health services that had to restructure significantly. REPORT: Considering the potential side effects on the quality of vascular training, a digital survey (Survey Monkey®) was developed and submitted to vascular trainees from 7 July to 20 September 2020 through European mailing lists and social media platforms. The aim was to evaluate the standpoint of vascular education across Europe during the first wave of the COVID-19 pandemic and to identify possible measures to mitigate the negative effects on vascular trainees. A total of 104 answers across 27 European countries were received. The mean age of the responders was 31.2 ± 3.58 years, of whom 60.6% were male. Forty-four (42.3%) of the vascular trainees actively participated on the COVID-19 front line; 76.9% of them reported a decrease in surgical procedures performed and/or assisted, with 60% reporting a reduction >50%. Emergency procedures were the only surgical activities for 7.5% of the trainees. Annual or final examinations were re-scheduled or cancelled for 16.3% and 10.6% of the participants, respectively. According to the survey, 73.5% of the responders claimed that the first wave of the COVID-19 pandemic had a negative impact on vascular education and 73.4% agreed the need for "compensation measures" to be taken. DISCUSSION: The first wave of the COVID-19 pandemic brought a significant negative impact on vascular education. Considering an extended pandemic situation, it is believed that compensatory measures should be addressed to maintain the high standards of vascular education and develop new educational tools for future trainees.

Parallel Graft to Preserve a Reimplanted Inferior Mesenteric Artery During Thoracoabdominal Multibranched Endografting.

INTRODUCTION: Preserving pelvic circulation is crucial to minimize the risk of spinal cord and colonic ischemia, especially during the endovascular treatment of extended thoraco-abdominal aneurysm (TAAA) after previous open repair (OR). CASE REPORT: A 78-years-old patient, previously treated for AAA with OR and reimplantation of inferior mesenteric artery (IMA), has presented with 9 cm type-III TAAA and underwent to a multi-stage endovascular procedure. Two thoracic endografts, t-Branch and a straight endograft by Cook Zenith platform were deployed. Renal and superior mesenteric arteries were cannulated and revascularized. Through the left axillary access, a 5F-vertebral catheter was delivered over a 0.035 inch guidewire to selectively catheterize IMA. A post-anastomotic stenosis was stented to advance the sheath and the parallel-graft (Viabahn 7 × 150 mm, Gore) into the artery. Thus, a bifurcated endograft was deployed inside the previous OR. According to the Sandwich-Technique, the stentgraft was deployed parallel and outside the bifurcated device, inside the straight one and 2 cm into the IMA and then reinforced by a bare-metal-stent (Protégé EverFlex™ 7 × 120 mm, Medtronic). Finally, a kissing ballooning of iliac endografts and parallel-graft was performed. The procedure was completed five days later, by stenting the celiac trunk. Post-operative course was uneventful. The 36-months CTA showed the patency of the IMA with no complications. CONCLUSION: The combination of t-Branch and Sandwich-Technique for IMA could be employed to treat extended TAAA with previous OR and reimplanted IMA thus minimizing the risk of colonic and spinal cord ischemia.

Platelet Depletion after Thoraco-Abdominal Aortic Aneurysm Endovascular Repair is Associated with Clinically Relevant Hemorrhagic Complications.

BACKGROUND: Thoraco-abdominal endovascular aortic repair (TA-EVAR) can be associated with platelet depletion (PD); the present study aims to evaluate PD incidence after TA-EVAR and to investigate its possible predictors and its influence on hemorrhagic complications and mortality. METHODS: A retrospective analysis of all TA-EVAR from 2010 to 2021 was performed to identify patients with PD, (reduction > 60%). Spontaneous hemorrhages considered were: intracranial or any hemorrhages requiring surgery. Risk factors for PD, correlation with hemorrhagic complications and 30-day mortality were investigated by uni/multivariate analysis. RESULTS: A total of 158 TA-EVAR were considered, 35(22%) female, 86(54%) extended thoraco-abdominal aortic aneurysm (TAAA) (Crawford type I, II, III), 79(50%) staged procedure, 31(20%) urgent treatment (symptomatic/ruptured). PD was identified in 42 (27%) patients and correlated to female sex, thrombus-free aortic lumen > 50mm, urgent treatment, extensive TAAA, blood transfusion >3 units and staged procedure at the univariate analysis. The multivariate analysis confirmed a significant correlation between PD and thrombus-free aortic lumen > 50mm, urgent treatment, blood transfusion > 3 units and staged procedure (odds ratio [OR]: 2.5 (95% confidence interval [CI] 1.03-7.0), P = 0.04, OR 3.2 (95% CI 1.01-8.6), P= 0.03, OR 3.16 (95% CI 1.23-7.7), P = 0.03 and OR 2.71 (95% CI 1.2-6.2), P= 0.04, respectively). Overall, 13 hemorrhagic complications occurred (8 intracranial and 5 peripheral); PD was associated with higher risk of hemorrhagic complications (9/42 - 21% vs. 4/116 - 3%, OR: 7.6 [95% CI: 2.2-26.3], P= 0.001) and a higher risk of 30-day mortality in elective cases 4/25 - 16% vs. 3/101 - 3%, OR: 6.2 (95% CI: 1.3-29.8), P= 0.03. CONCLUSIONS: PD is a relatively common event after TA-EVAR and is associated with thrombus-free aortic lumen > 50mm, urgent treatment, blood transfusion > 3 units and staged procedure. Hemorrhagic complications and mortality are increased under these circumstances.

Dataset of the vascular e-Learning during the COVID-19 pandemic (EL-COVID) survey.

This dataset supports the findings of the vascular e-Learning during the COVID-19 pandemic survey (the EL-COVID survey). The General Data Protection Regulation (GDPR) of the European Union was taken into consideration in all steps of data handling. The survey was approved by the institutional ethics committee of the Primary Investigator and an online English survey consisting of 18 questions was developed ad-hoc. A bilingual English-Mandarin version of the questionnaire was developed according to the instructions of the Chinese Medical Association in order to be used in mainland People's Republic of China. Differences between the two questionnaires were minor and did affect the process of data collection. Both questionnaires were hosted online. The EL-COVID survey was advertised through major social media. All national and regional contributors contacted their respective colleagues through direct messaging on social media or by email. Eight national societies or groups supported the dissemination of the EL-COVID survey. The data provided demographics information of the EL-COVID participants and an insight on the level of difficulty in accessing or citing previously attended online activities and whether participants were keen on citing these activities in their Curricula Vitae. A categorization of additional comments made by the participants are also based on the data. The survey responses were filtered, anonymized and submitted to descriptive analysis of percentage.

Editor's Choice - Effect of Carotid Interventions on Cognitive Function in Patients With Asymptomatic Carotid Stenosis: A Systematic Review.

OBJECTIVE: To determine the effect of carotid endarterectomy (CEA) and carotid artery stenting (CAS) on early (baseline vs. maximum three months) and late (baseline vs. at least five months) cognitive function in patients with exclusively asymptomatic carotid stenoses (ACS). METHOD: Searches were conducted in PubMed/Medline, Embase, Scopus, and the Cochrane library. This systematic review includes 31 non-randomised studies. RESULTS: Early post-operative period: In 24 CEA/CAS/CEA+CAS cohorts (n = 2 059), two cohorts (representing 91/2 059, 4.4% of the overall study population) reported significant improvement in cognitive function, while one (28/2 059, 1%) reported significant decline. Three cohorts (250/2 059, 12.5% reported "mixed findings" where some cognitive scores significantly improved, and a similar proportion declined. The majority (nine cohorts; 1 086/2 059, 53%) reported no change. Seven cohorts (250/2 059, 12.1%) were mostly unchanged but one to two individual test scores improved, while two cohorts (347/2 059, 16.8%) were mostly unchanged with one to two individual test scores worse. Late post-operative period: In 21 cohorts (n = 1 554), one (28/1 554, 1.8%) reported significantly worse cognitive function, one reported significant improvement (24/1 554, 1.5%), while a third (19/1 554, 1.2%) reported "mixed findings". The majority were unchanged (six cohorts; 1 073/1 554, 69%) or mostly unchanged, but with one to two cognitive tests showing significant improvement (11 cohorts; 386/1 554, 24.8%). Overall, there was a similar distribution of findings in small, medium, and large studies, in studies with controls vs. no controls, in studies comparing CEA vs. CAS, and in studies with shorter/longer late follow up. CONCLUSION: Notwithstanding accepted limitations regarding heterogeneity within non-randomised studies, CEA/CAS rarely improved overall late cognitive function in ACS patients (< 2%) and the risk of significant cognitive decline was equally low (< 2%). In the long term, the majority were either unchanged (69%) or mostly unchanged with one to two test scores improved (24.8%). Until new research identifies vulnerable ACS subgroups (e.g., impaired cerebral vascular reserve) or provides evidence that silent embolisation from ACS causes cognitive impairment, evidence supporting intervention in ACS patients to prevent/reverse cognitive decline is lacking.

Vascular e-Learning During the COVID-19 Pandemic: The EL-COVID Survey.

BACKGROUND: The corona virus disease (COVID-19) pandemic has radically changed the possibilities for vascular surgeons and trainees to exchange knowledge and experience. The aim of the present survey is to inventorize the e-learning needs of vascular surgeons and trainees as well as the strengths and weaknesses of vascular e-Learning. METHODS: An online survey consisting of 18 questions was created in English, with a separate bilingual English-Mandarin version. The survey was dispersed to vascular surgeons and trainees worldwide through social media and via direct messaging from June 15, 2020 to October 15, 2020. RESULTS: Eight hundred and fifty-six records from 84 different countries could be included. Most participants attended several online activities (>4: n = 461, 54%; 2-4: n = 300, 35%; 1: n = 95, 11%) and evaluated online activities as positive or very positive (84.7%). In deciding upon participation, the topic of the activity was most important (n = 440, 51.4%), followed by the reputation of the presenter or the panel (n = 178, 20.8%), but not necessarily receiving accreditation or certification (n = 52, 6.1%). The survey identified several shortcomings in vascular e-Learning during the pandemic: limited possibility to attend due to lack of time and increased workload (n = 432, 50.5%), no protected/allocated time (n = 488, 57%) and no accreditation or certification, while technical shortcomings were only a minor problem (n = 25, 2.9%). CONCLUSIONS: During the COVID-19 pandemic vascular e-Learning has been used frequently and was appreciated by vascular professionals from around the globe. The survey identified strengths and weaknesses in current e-Learning that can be used to further improve online learning in vascular surgery.

Editor's Choice - Asymptomatic Carotid Stenosis and Cognitive Impairment: A Systematic Review.

OBJECTIVE: The aim was to evaluate the relationship between asymptomatic carotid stenosis (ACS) of any severity and cognitive impairment and to determine whether there is evidence supporting an aetiological role for ACS in the pathophysiology of cognitive impairment. DATA SOURCES: PubMed/Medline, Embase, Scopus, and the Cochrane library. REVIEW METHODS: This was a systematic review (35 cross sectional or longitudinal studies) RESULTS: Study heterogeneity confounded data interpretation, largely because of no standardisation regarding cognitive testing. In the 30 cross sectional and six longitudinal studies (one included both), 33/35 (94%) reported an association between any degree of ACS and one or more tests of impaired cognitive function (20 reported one to three tests with poorer cognition; 11 reported four to six tests with poorer cognition, while three studies reported seven or more tests with poorer cognition). There was no evidence that ACS caused cognitive impairment via silent cortical infarction, or via involvement in the pathophysiology of lacunar infarction or white matter hyperintensities. However, nine of 10 studies evaluating cerebral vascular reserve (CVR) reported that ACS patients with impaired CVR were significantly more likely to have cognitive impairment and that impaired CVR was associated with worsening cognition over time. Patients with severe ACS but normal CVR had cognitive scores similar to controls. CONCLUSION: Notwithstanding significant heterogeneity within the constituent studies, which compromised overall interpretation, 94% of studies reported an association between ACS and one or more tests of cognitive impairment. However, "significant association" does not automatically imply an aetiological relationship. At present, there is no clear evidence that ACS causes cognitive impairment via silent cortical infarction (but very few studies have addressed this question) and no evidence of ACS involvement in the pathophysiology of white matter hyperintensities or lacunar infarction. There is, however, better evidence that patients with severe ACS and impaired CVR are more likely to have cognitive impairment and to suffer further cognitive decline with time.

Current status on aortic endografts.

Endovascular treatment has become widespread to treat aneurysmal disease, especially located in the aorta. The modern era of abdominal aortic aneurysm repair started between 1986 and 1991, and in the last 30 years, Endovascular Treatment for abdominal aortic aneurysms evolved both due to the development of new materials and devices and the increasing appeal and effectiveness of the endovascular therapy itself. Vascular surgeons are using nowadays different solutions of Endovascular Treatment to treat all the expressions of aortic pathology (aneurysms, dissections and trauma) both in the acute and elective setting. Despite its use in every location of the aorta (the ascending aorta, the aortic arch, the thoracic aorta, thoraco-abdominal aorta, pararenal, iuxtarenal and infrarenal aortic aneurysms and iliac aneurysms), its safety and efficiency, endovascular treatment for aortic aneurysms presents some drawbacks: despite a lower short-term morbi-mortality, reinterventions and long-term patency are higher compared to open repair. In this review, we detail the most used types of endografts according to location, their performances and durability for each device. We conclude by discussing options to overcome ET limitations. Therefore, an obvious question arises: what we need in the future? What can the technological progress gives to physicians to further improve this new way of treating aorta?

Endovascular Repair of a Common Carotid Artery Perforation during Pacemaker Insertion.

BACKGROUND: We report the percutaneous endovascular management of an iatrogenic perforation of the left common carotid artery (LCCA) during an attempted trans-subclavian pacemaker (PM) placement. METHODS: An 87-year-old woman was urgently transferred after an attempted left subclavian vein PM implantation. Computed tomography angiography scan showed the accidental cannulation of LCCA in its most proximal segment. Owing to the significant surgical risks, the mortality rate, and the distal position of the vessel from the skin, we opted for an endovascular strategy with a balloon-expandable stent graft. The Advanta 8 × 38 mm V12 was inserted via a 7 French Flexor Introducer sheath through the right common femoral artery. RESULTS: The patient was discharged on postoperative day 2 without complications. A 6-month follow-up computed tomography angiography demonstrated stent graft and LCCA patency and the patient was in a good stable condition. CONCLUSIONS: This case highlights the effectiveness of a minimal invasive endovascular approach to treat this uncommon but potentially lethal injury.

The Combined Use of a Distal Self-Expandable and Proximal Balloon-Expandable Stent Graft in Bridging Hostile Renal Arteries in Thoracoabdominal Branched Endografting.

BACKGROUND: To evaluate early/midterm outcomes of a specific configuration of a bridging stent graft-that is a distal self-expandable (SE) stent graft combined with proximal balloon-expandable (BE) one-in hostile renal artery (RA) anatomy in branched thoracoabdominal aneurysm (TAAA) repair. METHODS: Between 2010 and 2019, all TAAAs undergoing fenestrated and branched endografting (FB-EVAR) were prospectively collected. Preoperative, procedural, and postoperative data of RAs accommodated by branch design and patent at the completion angiography were retrospectively analyzed. Hostile RA anatomy included upward (type B) and downward + upward (type D) orientations. Type B and D RAs treated by the combination of an SE + BE stent graft as a bridging stent (BE + SE group) were compared with RAs treated by a BE stent graft only (BE group). RA occlusion, reinterventions, and branch instability were assessed. RESULTS: Over a total of 112 TAAAs undergoing FB-EVAR, 189 RAs were treated by fenestrations (113-60%) and branches (76-40%). Among the 66 (86%) RAs accommodated by branch and patent at completion angiography, 55 had a type B/D orientation. BE stent grafts were used in 15/55 (27%) RAs and SE + BE in 40/55 (73%). At a median follow-up of 12 (8) months, 5/55 (9%) RAs occluded: 4/15 (27%) in the BE group and 1/40(2.5%) in the SE + BE group (P: 0.017). RA patency was 83 ± 5% at 24 months. The SE + BE group had higher patency than the BE group (90 ± 5% vs. 68 ± 5% at 12 months; P: 0.039). Overall freedom from RA-related reinterventions was 87 ± 5% at 24 months. Six (9%) RAs required reinterventions: 4/15 (27%) in the BE group and 2/40 (5%) in the BE + SE group (P: 0.041). RAs managed by an SE + BE stent graft had lower reinterventions than RAs treated by a BE stent graft only (93 ± 5% vs. 76 ± 5% at 12 months; P: 0.01). Freedom from branch instability was 78 ± 5% at 24 months, with 8 overall cases (12%) occurring-5/15 (33.3%) in the BE group versus 3/40 (7.5%) in the SE + BE group (P: 0.02). RAs managed by an SE + BE stent graft had lower branch instability than RAs treated only by a BE stent graft (BE: 68 ± 5% vs. SE + BE: 80 ± 5% at 12 months; P: 0.02). CONCLUSIONS: In hostile renal anatomy, the combination of a distal SE and proximal BE stent graft as a bridging stent in branched endografting is safe and effective with lower rates of occlusion, reinterventions, and branch instability at midterm follow-up compared with a BE stent graft alone.

The risk of aneurysm rupture and target visceral vessel occlusion during the lead period of custom-made fenestrated/branched endograft.

OBJECTIVE: The objective of this study was to evaluate adverse events occurring during the lead period of custom-made fenestrated/branched endograft for juxtarenal/pararenal abdominal aortic aneurysm (j/p-AAA) and thoracoabdominal aortic aneurysm (TAAA). METHODS: Between 2008 and 2017, patients enrolled for custom-made fenestrated/branched endograft repair were prospectively collected. Anatomic, procedural, and postoperative data were retrospectively analyzed. Lead period was defined as the time between the endograft order to the manufacturer and implantation. Aneurysm diameter, target visceral vessel (TVV) severe stenosis (>75% of ostial lumen), and number of planned TVVs were evaluated at preoperative computed tomography angiography. Patency of TVVs was evaluated intraoperatively. Aneurysm rupture and TVV occlusion during the lead period were assessed. RESULTS: There were 141 custom-made fenestrated/branched endograft repairs planned. Of these, 133 patients (male, 87%; age, 73 ± 6 years) with complete available data were considered for the study. There were 75 (56%) j/p-AAAs and 58 (44%) TAAAs. The mean aneurysm diameter was 58 ± 6 mm (j/p-AAA, 56 ± 6 mm; TAAA, 67 ± 8 mm); 15 cases (11%) had >70-mm diameter. Planned TVVs were 431 (mean, 3 ± 1 TVVs/patient). The mean lead period was 89 ± 25 days, with five (3.8%) aneurysm ruptures (j/p-AAA, one; TAAA, four) occurring, two (1.5%) during manufacture and three (2.3%) with endograft available in the hospital (all three procedures were postponed because of cardiac or pulmonary comorbidities). In one TAAA rupture, the endograft was successfully implanted and the patient survived. Four of five ruptures had >70-mm diameter. On univariate analysis, chronic obstructive pulmonary disease (P = .01; odds ratio [OR], 2.6; 95% confidence interval [CI], 2.1-3.2) and aneurysm diameter >70 mm (P = .001; OR, 42; 95% CI, 4-411) were risk factors for aneurysm rupture during the lead period, with aneurysm diameter >70 mm being confirmed as an independent risk factor on multivariate analysis (P = .005; OR, 29.3; 95% CI, 2.8-308). Overall, eight endografts (6%) were not implanted (refusal, two; aneurysm rupture, four; death not related to aneurysm, two). In the remaining 125 patients (94%), 405 TVVs were planned. Of them, 46 (11%) had severe stenosis at preoperative computed tomography angiography. Twelve (3%) TVVs occluded in the lead period (renal arteries, five; celiac trunks, seven); six were recanalized and six were abandoned. Severe preoperative stenosis was a risk factor for TVV occlusion during the lead period (P = .000; OR, 1.3; 95% CI, 1.1-1.6). CONCLUSIONS: In our series, custom-made design required a mean lead period of 89 days, which was determined by both manufacturing time and clinical reasons. During this delay, there is a high risk of both rupture in aneurysms >70 mm and TVV occlusion in severely stenosed vessels. These factors should be considered in the indication for custom-made fenestrated/branched endograft repair.

Early and Mid-term Efficacy of Fenestrated Endograft in the Treatment of Juxta-Renal Aortic Aneurysms.

BACKGROUND: The aim of this study was to report early and mid-term outcomes of fenestrated endografting (FEVAR) for juxtarenal aneurysm (J-AAAs). METHODS: Between 2008 and 2017, all consecutive J-AAAs treated by FEVAR were prospectively collected. Early endpoints were technical success, renal function worsening, and 30-day mortality. Follow-up endpoints were survival, freedom from reinterventions (FFRs), target visceral vessels (TVVs) patency, J-AAAs shrinkage, and renal function worsening. RESULTS: Among 181 cases who underwent FB-EVAR, 66 (36%) were J-AAAs. Endograft with 1, 2, 3, and 4 fenestrations were planned in 2 (3%), 22 (33%), 27 (41%) and 15 (23%) cases, respectively. Overall, 236 TVVs were treated by fenestrations and scallops. Technical success was achieved in 65 (99%) cases. The only failure occurred for a type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening occurred in 7 (10%) cases: 4 returned to baseline within 30-day, 1 required hemodialysis and died within 30 days (1.5%). This was the only case of 30-day mortality. The mean follow-up was 46 ± 32 months. Aneurysm sac shrinkage or stability was observed in 42 (64%) and 22 (33%) cases, respectively. Two patients (3%) with persistent type II endoleak had sac enlargement and required reinterventions. Freedom from reinterventions at 5 years was 88%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24 months in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. Overall, renal function worsening was reported in 5 (8%) patients during follow-up. Survival at 5 years was 67%, with no j-AAA-related mortality. COPD was the only independent predictor for mortality at the multivariate analysis (P: 0.021; OR: 5.3; 95% CI, 1.3-21.9). CONCLUSIONS: FEVAR for J-AAAs is safe and effective at early and mid-term follow-up. According to these results, it could be proposed as the first-line treatment in high-risk patients if anatomically fit. Long-term survival is reduced in the presence of preoperative COPD.

The different effect of branches and fenestrations on early and long-term visceral vessel patency in complex aortic endovascular repair.

BACKGROUND: Aortic endovascular treatment with fenestrated or branched devices (f/bEVAR) requires a connection between the aortic graft and the visceral vessel (VV). However, data on the perioperative and long-term fate of the VVs remain scarce. The aim of our study was to evaluate the VV loss (VVL) according to the type of revascularization performed (fenestrations vs branched) and the necessity for adjunctive visceral procedures (AVPs). METHODS: From 2012 to 2017, all f/bEVAR procedures for juxtarenal abdominal aortic aneurysms (JAAAs), pararenal abdominal aortic aneurysms (PAAAs), and thoracoabdominal aortic aneurysms (TAAAs) were considered. The perioperative VVL, AVPs, and graft configuration were considered and evaluated during the follow-up period. RESULTS: In 158 patients, 523 VVs were considered, 140 (26%) in JAAAs, 165 (32%) in PAAAs, and 218 (42%) in TAAAs. Branches were used for 114 vessels (52%) in TAAAs, 8 (5%) in PAAAs, and 0 (0%) in JAAAs. The overall perioperative VVL was 20 (3.8%) and was significantly greater in TAAAs than in PAAAs or JAAAs (6.4% vs 2.4% vs 1.4%; P = .03). The branches resulted in greater perioperative VVL compared with fenestration (9% [11 of 122] vs 2% [9 of 401]; P = .0001). A significant VVL difference between the branches and fenestrations was identified selectively only for the renal arteries: 11 of 52 (21%) vs 6 of 224 (2.5%; P = .001). The results of the multivariate analysis confirmed the independent greater risk of VVL for branches and renal arteries (odds ratio, 4.7; 95% confidence interval, 12.5-1.7; P = .04; odds ratio, 7.1; 95% confidence interval, 52.6-1.05; P = .05, respectively). AVPs were performed in 43 VVs (8.2%) because of dissection (n = 2; 0.4%), stenosis (m = 3; 0.6%), bleeding (n = 3; 0.6%), or kinking between the bridging stent graft and the VV (n = 35; 7%). A significant difference between the branches and fenestrations was seen only for kinking between the bridging stent graft and VV (12% [15 of 112] vs 5% [20 of 401]; P = .005). At 5 years, the incidence of VVL was 2% ± 1%. The fenestrations had significantly greater freedom from VVL compared with the branches (100% vs 87% ± 6%; P = .04), which was confirmed selectively for TAAAs (100% vs 87% ± 6%; P = .04). The use of AVPs did not affect long-term visceral patency. CONCLUSIONS: Early and late VVL was infrequent in complex aortic procedures but seemed to occur more frequently in branches than in fenestration, especially for renal arteries. AVPs were often required to correct artery kinking but this did not affect the long-term patency.