Single-session catheter-directed lysis using adjunctive clot fragmentation with power pulse spray only is a fast, safe and effective option for acute pulmonary embolism.

OBJECTIVE: A single session catheter-directed thrombolysis (CDT) with adjunctive power pulse spray (PPS) only without thrombectomy was evaluated for its safety and effectiveness. DESIGN: Single-centre retrospective analysis of prospectively collected data. METHODS: Patients with high-risk or intermediate-risk pulmonary embolism (PE) who met the inclusion criteria and underwent a single session of CDT-PPS technique. The primary outcomes assessed were technical and clinical success and major adverse events. Secondary outcomes included effectiveness based on pre- and post-intervention clinical examination, radiographic findings, and reversal of right ventricular (RV) dysfunction at 48 hours and 4 weeks after discharge on echocardiography (ECHO) and computed tomography pulmonary angiography (CTPA). The length of stay (LOS) in the intensive care unit (ICU) and overall admission were also analysed. Return to pre-morbid exercise tolerance was evaluated at 12 months post procedure. RESULTS: Between May 2016 and January 2023, 104 patients at the Wollongong Hospital were diagnosed with high or intermediate-risk PE and underwent CDT-PPS technique. 49 (47%) were classified as high-risk PE and 55 (53%) intermediate-risk PE. Eleven patients (11%) had absolute contraindications and 49 patients (47%) had relative contraindications to systemic thrombolysis. Technical success was achieved in 102 patients (98%). Survival was 99% at 48 hours, 96% at 4 weeks and 91% at 12 months. At 4 weeks, ECHO showed 98% of patients had no evidence of right heart dysfunction and CTPA showed complete resolution of PE in 72%. There were no major adverse events at 48 hours. The median ICU LOS was 1 day and the overall LOS was 6 days. At 12 months, 96% had returned to their premorbid status. CONCLUSION: The CDT-PPS technique is fast, safe and effective in the treatment of high and intermediate-risk PE even in patients with high bleeding risk and should be considered first line management when skills and resources are available. Further multi-centre prospective studies are needed to corroborate these results.

Review of the literature supporting international clinical practice guidelines on iliac venous stenting and their applicability to Australia and New Zealand practice.

BACKGROUND: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO). METHODS: A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts. RESULTS: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib). CONCLUSIONS: Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments.

Pharmacomechanical thrombectomy of iliofemoral deep vein thrombosis is associated with a low incidence of post-thrombotic syndrome and perioperative complications.

BACKGROUND: Iliofemoral deep venous thrombosis (IFDVT) is associated with an incidence of post-thrombotic syndrome (PTS) of up to 50%. PTS is associated with high morbidity, impaired quality of life and a significant economic burden. The aim of the current study was to assess the impact of a single session pharmacomechanical thrombectomy (PMT), dedicated venous stents and a risk mitigation protocol on the rate of PTS. METHODS: Between 2015 and 2022, patients presenting with acute or subacute IFDVT treated with the same protocol of single session PMT, dedicated venous stents, and risk-mitigation measures were included. Procedural success rate, complications, stent patency and incidence of PTS were determined. RESULTS: Of 60 patients (58 ± 19 years; 65% male), the procedural success rate was 93%, with 7% of patients experiencing complications but no long-term sequelae or mortality. Most (n = 52; 87%) patients were stented, including 46% across the inguinal ligament. At 3 months post-procedure, primary, assisted primary and secondary stent patency rates were 89%, 93% and 98%, respectively, with no loss of patency or re-interventions after that. At latest follow-up of a median 48 months (n = 32), stent patency rate was 97%, with only three patients (9%) experiencing symptoms of PTS. CONCLUSION: Single session PMT, dedicated venous stents and a risk-mitigation protocol results in high success rate, excellent long-term stent patency and low incidence of PTS without compromising safety. These results support early intervention for iliofemoral DVT.

Iliac vein stenting and pregnancy.

Venous stenting is the mainstay treatment of symptomatic iliofemoral venous outflow obstruction. However, because pregnancy and the postpartum period are hypercoagulable, concerns exist regarding stent placement in women of childbearing age. We performed a systematic review up to April 2023 of studies reporting on the performance of venous stents in women who subsequently became pregnant. The data collected included demographics, indication for stenting, stent characteristics, stent-related complications, incidence of venous thromboembolism, medical management during pregnancy, and follow-up. The indications for stenting included acute iliofemoral deep vein thrombosis in 39 patients (51%), nonthrombotic iliac vein lesions in 35 (46%), and post-thrombotic lesions in 2 patients. A total of 76 women with 87 subsequent pregnancies after stenting were included. Of the 76 women, 1 (1.14%) experienced stent occlusion, 2 (2.29%) developed asymptomatic nonocclusive in-stent thrombus, and 2 (2.29%) experienced permanent stent compression. The only patency loss occurred because of inadequate anticoagulation therapy in a patient with antiphospholipid antibodies. The two cases of permanent compression occurred in an arterial stent and a balloon-fenestrated Vici stent (Boston Scientific). Venous stents performed well through pregnancy and can be safely used in women of childbearing age. Given the increased risk of venous thromboembolism and the low bleeding risk, it is prudent to recommend anticoagulation therapy for all stented patients until more data are available.

Outcomes of dedicated iliac venous stents during pregnancy and postpartum.

OBJECTIVE: The aim of this study was to assess the performance of dedicated iliac venous stents during subsequent pregnancy and postpartum, including stent patency and stent integrity, as well as incidence of venous thromboembolism and bleeding complications. METHODS: This study included retrospective analysis of prospectively collected data of patients attending a private vascular practice. Women of child-bearing age who had received dedicated iliac venous stents were included in a surveillance program and then, for any subsequent pregnancies, followed the same pregnancy care protocol. This included an antithrombotic regime of 100 mg aspirin daily until gestation week 36, and subcutaneous enoxaparin at a dose dependent on risk of thrombosis: low-risk patients, those stented for non-thrombotic iliac vein lesion, received a prophylactic dose of 40 mg/day from the third trimester; high-risk patients, those stented for thrombotic indication, received a therapeutic dose of 1.5 mg/kg/day from the first trimester. All women underwent follow-up with duplex ultrasound assessment of stent patency during pregnancy and at 6 weeks postpartum. RESULTS: Data was analyzed for a total of 10 women and 13 post-stent pregnancies. Stents were placed for non-thrombotic iliac vein lesions in seven patients, and for post-thrombotic stenoses in three patients. All stents were dedicated venous stents, and four crossed the inguinal ligament. All stents remained patent during pregnancy, at 6 weeks postpartum, and latest follow-up (median time post-stent, 60 months). There were no cases of deep vein thrombosis or pulmonary embolism, and no bleeding complications. There was only one reintervention case due to in-stent thrombus, and one case of asymptomatic stent compression. CONCLUSIONS: Dedicated venous stents performed well through pregnancy and post-partum. A protocol including the use of low dose antiplatelets in combination with anticoagulation at either a prophylactic or therapeutic dose depending on the patient's risk profile appears safe and effective.

RETRACTED: Australian and New Zealand Society for Vascular Surgery clinical practice guidelines on venous outflow Obstruction of the femoral-iliocaval veins.

BACKGROUND: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO) in Australia and New Zealand. METHODS: A group of vascular surgeons from the Australian and New Zealand Society for Vascular Surgery with specific interest, training, and experience in the management of VOO were surveyed to assess current local practice. The results were analyzed and areas of disagreement identified. Following this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. Finally, a selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. RESULTS: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with a CEAP (Clinical-Etiologic-Anatomic-Physiologic) score of ≥3 or a venous clinical severity score for pain of ≥2, or both, and evidence of >50% stenosis on venography, computed tomography venography, magnetic resonance venography, and/or intravascular ultrasound should be considered for venous stenting (level of recommendation Ib) Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion has been uncovered, should be considered for venous stenting (level of recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should be considered for venous stenting (level of recommendation Ic). Asymptomatic patients should not be offered venous stenting (level of recommendation IIIc). CONCLUSIONS: Patients with deep VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. The advent of simpler and safer treatment options has revolutionized its management, but, unfortunately, formal training for venous disease has not grown at the same rate. Simplifying the technology and training required can result in inconsistent outcomes. These guidelines are aimed at developing standards of care and will serve as an educational platform for future developments.

An estimate of the economic burden of venous leg ulcers associated with deep venous disease.

INTRODUCTION: Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of chronic venous disease. Approximately 40% of patients with VLU present with the underlying deep venous disease (DVD). Although the data are scarce, these deep venous disease-related VLU (DRV) are thought to have higher recurrence rates and a substantial economic burden. The objective of this study was to assess the economic burden of DRV across Australia, France, Germany, Italy, Spain, the UK, and the USA. METHODS: A comprehensive literature review was undertaken to identify publications documenting the incidence and prevalence of VLU and DRV, medical resource utilization, and associated costs of DRV. Findings from this literature review were used to estimate the economic burden of illness, including direct medical costs over a 12-month interval following initial presentation of a newly formed DRV. RESULTS: Total annual incidence of new or recurrent DRV in Australia, France, Germany, Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000, 253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019. Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated annual direct medical costs for patients managed conservatively in these geographies total ~ $10.73 billion (USD) or $5527 per person per year. CONCLUSION: The availability of published data on the costs of VLU care varies widely across countries considered in this analysis. Although country-specific VLU practice patterns vary, there is a uniform pattern of high-cost care.

Transabdominal duplex ultrasound and intravascular ultrasound planimetry measures of common iliac vein stenosis are significantly correlated in a symptomatic population.

OBJECTIVE: The objectives of the present study were to determine the validity of transabdominal duplex ultrasound (TAUS) against the reference standard of intravascular ultrasound (IVUS) examinations for the detection of iliac vein obstruction (IVO). METHODS: We analyzed the data from patients at a private vascular laboratory who had undergone IVUS investigation with an intention to treat because of symptoms of chronic venous insufficiency and a high suspicion of IVO. These patients had also previously undergone a TAUS examination at the same location. The TAUS and IVUS planimetry measures of the left common iliac vein (CIV) were correlated. These included the TAUS-measured minimum and maximum diameter and the percentage of stenosis with the IVUS-measured minimum and maximum diameter and area and the percentage of stenosis. RESULTS: The TAUS and IVUS data from 47 patients (83% female; age, 49.3 ± 17.3 years; 64% obese) were included in the analyses. We found 89% agreement between the TAUS and IVUS findings regarding the identification of left CIV stenosis of ≥50%. The TAUS data had a positive predictive value of 95.5%. The TAUS measures of the minimum diameter and percentage of stenosis correlated significantly with the IVUS measures of the minimum diameter, minimum area, and cross-sectional area of the percentage of stenosis. The strongest correlations were between the TAUS-measured minimum diameter and IVUS-measured minimum area and percentage of the area of stenosis according to the literature-derived value. The TAUS-measured vein diameter of 8 mm equated to an IVUS cross-sectional area of 94.2 mm2 (53% stenosis), and an IVUS cross-sectional area of 50% of stenosis equated to a TAUS diameter of 8.56 mm. CONCLUSIONS: The findings from the present study support the validity of TAUS evaluation as a workup diagnostic tool for the detection of IVO. Our findings also support the use of TAUS planimetry-in particular, the CIV diameter of ≤8 mm as a threshold value-to indicate clinically relevant stenosis and trigger an IVUS investigation with an intention to treat, because this correlated with a cross-sectional area stenosis of ≥50%, as determined by IVUS examination.

Common iliac vein obstruction in a symptomatic population is associated with previous deep venous thrombosis, and with chronic pelvic pain in females.

OBJECTIVE: The objectives of this study were to determine the incidence of common iliac vein obstruction, gonadal vein incompetence, and renal vein compression/stenosis and to ascertain which referral reasons were associated with common iliac vein obstruction and gonadal vein incompetence in a population symptomatic for chronic venous insufficiency. METHODS: Data were obtained from patients, at least 18 years old, who were referred to a private vascular laboratory for venous duplex ultrasound examination between 2016 and 2017. Transabdominal ultrasound was used to assess the iliac, gonadal, and renal veins in a dedicated protocol. Demographic data, referral reasons (varicose veins, lower limb pain, lower limb edema, lower limb ulcers, chronic pelvic pain [CPP]) and history of previous deep venous thrombosis (DVT) were recorded. RESULTS: Among 421 patients (78.6% female; 57.7 ± 16.7 years), 46.7% had iliac vein obstruction, 40.1% had gonadal vein incompetence, and 29.9% had renal vein compression/stenosis. Venous disorders were significantly more prevalent among female patients and on the left side. The most common referral reasons were varicose veins for both sexes, followed by lower limb pain for females and lower limb edema for males, none of which were associated with any venous obstruction or incompetence. Previous DVT was significantly associated with common iliac vein obstruction for all patients (ß = .189; P = .001), despite its being a previous known diagnosis for only 11.4% of patients. Among females, CPP was also significantly associated with common iliac vein obstruction and gonadal vein incompetence (ß = .246 [P < .001] and ß = .201 [P = .012], respectively). Among those with CPP in this study, common iliac vein obstruction, with and without gonadal vein incompetence (33% and 35%, respectively), was more prevalent than gonadal vein incompetence alone (14%). CONCLUSIONS: History of DVT, as well as CPP among females warrants investigations of common iliac vein obstruction. Common iliac vein obstruction is likely to be a more significant contributor to CPP than gonadal vein incompetence.

High Output Chylous Fistula Post First Rib Resection.

We present a patient who developed high output chyle leak post left first-rib resection for neurogenic thoracic outlet syndrome. The persistent high output chylorrhea was refractory to 3 surgical reexplorations attempting to ligate leaking branches, bed rest, nonfat diet, parenteral nutrition, octreotide administration, and vacuum-assisted closure (VAC) therapy. In addition, she developed hypovolemia, hyponatremia, and hypoalbuminemia. Control of the chylous fistula was achieved by reattaching the sternocleidomastoid muscle laterally to protect the phrenic nerve and brachial plexus in order to redirect chyle to the medial portion of the neck incision site. This was supported by the application of fibrin sealants in combination with VAC therapy. The patient was discharged after a 27-day hospital stay with complete resolution of her chylous fistula prior to discharge.

Single-session catheter-directed lysis using adjunctive power-pulse spray with AngioJet for the treatment of acute massive and submassive pulmonary embolism.

OBJECTIVE: An alternative single-session catheter-directed thrombolysis (CDT) method using adjunctive power-pulse spray (PPS) technique (with the AngioJet system; Boston Scientific, Fremont, Calif) was investigated to evaluate its safety and effectiveness in the treatment of acute massive and submassive high-risk pulmonary embolism (PE). METHODS: Between May 2016 and July 2018, patients diagnosed with extensive massive or submassive PE who triggered intensive care unit involvement and were considered for escalation of treatment were offered CDT with adjunctive PPS technique, provided they met the clinical inclusion criteria. Clinical success was defined as stabilization of hemodynamic parameters, resolution of hypoxia, and survival to discharge. In addition, reversal of right ventricular (RV) failure and pulmonary artery hypertension was evaluated after 24 to 48 hours using echocardiography. After 4 weeks, echocardiography was repeated to check for reversal of RV failure and pulmonary artery hypertension. In addition, computed tomography pulmonary angiography was performed to check for residual thrombus. Functional capacity was also re-evaluated at the follow-up consultation. RESULTS: During the study period, 575 inpatients were diagnosed with PE at The Wollongong Hospital. Of these patients, 32 (5.6%) were referred for escalation of treatment, met the inclusion criteria, and received treatment with the CDT and PPS technique. These patients were classified as having massive (23 [71.9%]) or submassive (9 [28.1%]) PE. Technical success was achieved in all 32 patients, and 31 patients survived to discharge (96.9%). There were no major or minor adverse events and no procedure-related complications. Improvement of RV strain and pulmonary hypertension was achieved in all survivors within 48 hours of the intervention. Furthermore, all echocardiograms completed at 4 weeks after discharge were reported normal. Results from computed tomography pulmonary angiography 4 weeks after discharge demonstrated complete resolution of thrombus in 79.3% of patients, and the remaining 20.7% had only minor residual thrombus reported. In addition, 82.8% of patients reported a return to premorbid exercise tolerance by the time of postoperative consultation with the treating physician (mean follow-up, 6.7 weeks). CONCLUSIONS: This initial series indicates that single-session CDT with adjunctive PPS technique using the AngioJet system is safe and effective in treating massive and submassive acute PE. It appears to offer several potential advantages compared with current options, allowing safer and faster thrombus resolution. Multicenter prospective trials are required to validate these findings.

Multicentre, randomised, blinded, control trial of drug-eluting balloon vs Sham in recurrent native dialysis fistula stenoses.

BACKGROUND: Endovascular treatment of autogenous arteriovenous haemodialysis fistula stenosis has high reintervention rates. We investigate the effect of drug-eluting balloons in the treatment of recurrent haemodialysis fistula stenosis. METHODS: This is a randomised, controlled, investigator-initiated and run, prospective, blinded, multicentre trial. Patients with recurrent autogenous arteriovenous haemodialysis fistula stenosis received standard endovascular treatment plus drug-eluting balloon or standard endovascular treatment plus uncoated balloon (Sham). Primary endpoint was late lumen loss in trial area on ultrasound at 6 weeks, 3, 6 and 12 months. Secondary endpoints were freedom from reintervention to the Index Trial Area and decline in fistula flow (Qa). Interim analysis was performed at 6 months (unblinded due to timeliness). RESULTS: Patients with 132 recurrent stenoses (48% in bare Nitinol stents) were randomised with 70 receiving drug-eluting balloon and 62 Sham. At 6 months, decline in late lumen loss was 0.23 ± 0.03 mm/month for Sham and 0.045 ± 0.03 mm/month for drug-eluting balloon arm, a significant difference (0.18 mm, p = 0.0002). At 12 months, this difference persisted at 0.12 mm (p = 0.0003). At 6 months, significant difference in late lumen loss for instent restenoses (p = 0.0004) was observed, with non-significant difference for unstented restenoses (p = 0.065). Mean time for freedom from reintervention was 10.14 months for Sham versus 42.39 months for drug-eluting balloon (p = 0.001). The same was shown for instent (p = 0.014) and unstented (p = 0.029) restenoses. Qa decline rate at 6 months was 36.89 mL/min/month (Sham) and 0.41 mL/min (drug-eluting balloon). The difference was significant (36.48 mL/min; p = 0.02) and persisted to 12 months (p = 0.44). CONCLUSION: Paclitaxel drug-eluting balloon significantly delays restenosis after angioplasty for recurrent autogenous arteriovenous haemodialysis fistula stenosis, persisting to 12 months. Drug-eluting balloon significantly increases freedom from reintervention at 12 months with these effects true in stented and unstented fistulas.

Using bilateral iliac branch devices for endovascular iliac aneurysm repair.

INTRODUCTION: The endovascular repair of bilateral iliac aneurysms using bilateral Iliac Branch Devices (IBDs) has been infrequently performed and reported.We aim to describe this technique and report on the results of our case series. METHODS: Three different device designs are available. The procedural options include a totally transfemoral approach, or a combined transfemoral and brachial approach. Clinical records for patients who have had this procedure were reviewed. RESULTS: The indications for the technique include bilateral common iliac artery aneurysm repair, with or without concomitant abdominal aortic aneurysm repair. Considerations include the timing of main body endovascular aortic aneurysm repair (EVAR) device introduction, the use of a proximal access site and the type of IIA stent-graft that is used. Between 2007 and 2010, six patients had bilateral IBD implantation. All patients required an EVAR main body device in addition to bilateral IBDs. Eighty-three per cent were males, mean age was 73 years. Mean follow up was 15 months. Technical success was obtained in 100% of cases. There was one branch occlusion (8.3%). There were no type I endoleaks. One patient had a type II endoleak. CONCLUSIONS: Bilateral IBDs can be used safely and with excellent rates of technical success and branch patency in appropriately selected patients.

Endovascular treatment for aortic disease: is a surgical environment necessary?

OBJECTIVE: Interventional radiologists, cardiologists, and vascular surgeons are capable of performing endovascular procedures successfully in their respective environments. Suboptimal anatomy or intraoperative technical problems can be encountered, and endovascular management alone is not always suitable. The objectives of this study were to define the incidence of adjunctive surgical techniques, to discuss the rationale for endovascular reconstruction in a well-developed surgical environment, and to assess the effect of experience on the incidence of adjunctive repair. METHODS: All primary aortic and aortoiliac elective, urgent, and emergent endovascular procedures performed at the Peter Lougheed Center and entered into a prospective database from May 25, 1999 to June 01, 2005, were reviewed. All adjunctive surgical techniques to enable stent deployment, enhance attachment site, or solve intraoperative difficulties were captured. The study period was divided into two time periods based on learning curve data to assess the effect of experience on the rate of adjunctive repairs. RESULTS: Four hundred thirty-eight patients underwent elective (80%), urgent (15%), or emergent (5%) endovascular procedures during the study period. These consisted of 101 thoracic and 337 abdominal operations, including the use of 13 fenestrated stents. One hundred thirty-nine patients (31.7%) required 180 open surgical procedures. Complete data were available for the entire patient cohort. The mean follow-up was 793.2 days (SD, 519.1 days). Procedures were necessary for vascular access, arterial dissection/rupture, limb ischemia, and enhancement/elongation of the stent attachment site. The persistent endoleak rate was 5.3%, the late rupture rate was 0.7%, the conversion rate was 1.6%, the 30-day surgical mortality rate was 3.2%, all-cause mortality to date is 7.3%, and the reintervention rate was 4.6%. There was no statistically significant effect of the learning curve on the incidence of surgical adjunctive procedures in either the thoracic group (11/26 [42.3%] for phase 1 vs 17/75 [22.6%] for phase 2) or the abdominal group (14/50 [28.0%] for phase 1 vs 97/287 [33.8%] for phase 2). Overall, 31.5% of patients required adjunctive surgical repair. CONCLUSIONS: Successful endografting requires endovascular expertise in addition to a well-developed surgical environment to increase applicability and decrease patient risk. Despite advances in endovascular technology, hybrid techniques will continue to be required to achieve good overall success rates.