Indication and Outcome of Late Open Conversion after Abdominal Endovascular Aortic Repair.

BACKGROUND: Endovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last 2 decades. Endograft technology and treatment of complications like endoleaks, graft migration, or graft occlusion developed over time. However, sometimes open surgical conversion maybe required. Our aim was to analyze the indications, the technical aspects and outcomes in patients who underwent open conversion after EVAR with different types and generations of endografts. METHODS: This retrospective single-center study reviewed all patients who underwent EVAR from 2004 to 2020. Open surgical conversions >1 month post EVAR were identified. Conversions for graft infection were excluded. Indications for conversion and operative technique were analyzed. Primary endpoint of the study was 30-day mortality. Secondary endpoints were re-interventions and follow-up mortality. RESULTS: During 2004 and 2020, 443 consecutive EVARs were performed, and 28 patients required open surgical conversion, with an additional 3 referred from other hospitals (N = 31). The median age was 75 (range 58-93); 94% were male. Conversion was performed after a median time of 55 months (range 16-209). Twenty patients underwent elective and 11 emergency conversion. Indications for open conversion were graft migration, respectively, disease progression with endoleak type Ia and/or Ib in 52% (16/31) and sac expansion due to endoleak type II in 26% (8/31). Of the 31 patients, 17 (55%) had at least one previous endovascular re-intervention. All patients met the device-specific instructions for use for each implanted endograft. In-hospital intervention rate was 16% (5/31). Thirty-day mortality rate was 3% (1/31) with one patient died due to multiorgan failure after rupture with complete endograft replacement. Five patients (16%) died during follow-up. Mid-term follow-up was 47.5 months (range 24-203) with estimated cumulative survival rates of 97%, 89%, and 84%, at 1, 3, and 5 years, respectively. CONCLUSIONS: Late open conversion remains a valuable treatment option and can be performed safely in elective and emergency setting with a low early mortality. Lifelong surveillance and prompt intervention when necessary are essential in ensuring optimal outcomes after EVAR and preventing the need for emergent conversions.

Novel Surgeon-Modified Fenestrated Iliac Stent Graft.

PURPOSE: We describe the feasibility and early results of a novel endovascular approach with a surgeon-modified fenestrated iliac stent graft to preserve pelvic perfusion in patients with iliac aneurysms not suitable for iliac branch devices (IBDs). TECHNIQUE: Seven high-risk patients, median age 76 years (range 63-83), with a complex aortoiliac anatomy with contraindications for commercially available IBDs were treated with a novel surgeon-modified fenestrated iliac stent graft between August 2020 and November 2021. The modified device was built using an iliac limb stent graft (Endurant II Stent Graft; Medtronic), which was partially deployed, surgically fenestrated with a scalpel, reinforced, re-sheathed, and inserted via femoral access. The internal iliac artery was cannulated and bridged with a covered stent. Technical success rate was 100%. After a median follow-up period of 10 months, there was 1 type II endoleak and no migrations, stent fractures, or loss of device integrity. One iliac limb occlusion occurred after 7 months, which needed a secondary endovascular intervention, restoring patency. CONCLUSION: Surgeon-modified fenestrated iliac stent graft is feasible and might be used as an alternative in patients with a complex iliac anatomy not suitable to commercially available IBDs. Long-term follow-up is needed to evaluate stent graft patency and potential complications. CLINICAL IMPACT: Surgeon modified fenetrated iliac stent grafts might be a promising alternative to iliac branch devices, extending endovascular solutions to a broader patient population with complex aorto-iliac anatomies preserving antegrade internal iliac artery perfusion. It is possible to treat small iliac bifurcations and large angulations of the iliac bifurcation safely and there is no need for a contralateral or upper-extremity access.

Protected and Unprotected Radiation Exposure to the Eye Lens During Endovascular Procedures in Hybrid Operating Rooms.

OBJECTIVE: Radiation cataract has been observed at lower doses than previously thought, therefore the annual limit for equivalent dose to the eye lens has been reduced from 150 to 20 mSv. This study evaluated radiation exposure to the eye lens of operators working in a hybrid operating room before and after implementation of a dose reduction program. METHODS: From April to October 2019, radiation exposure to the first operator was measured during all consecutive endovascular procedures performed in the hybrid operating room using BeOSL Hp(3) eye lens dosimeters placed both outside and behind the lead glasses (0.75 mm lead equivalent). Measured values were compared with data from a historic control group from the same hospital before implementation of the dose reduction program. RESULTS: A total of 181 consecutive patients underwent an endovascular procedure in the hybrid operating room. The median unprotected eye lens dose (outside lead glasses) of the main operator was 0.049 mSv for endovascular aortic repair (EVAR) (n = 30), 0.042 mSv for thoracic endovascular aortic repair (TEVAR) (n = 23), 0.175 mSv for complex aortic fenestrated or branched endovascular procedures (F/BEVAR; n = 15), and 0.042 mSv for peripheral interventions (n = 80). Compared with the control period, EVAR had 75% lower, TEVAR 79% lower, and F/BEVAR 55% lower radiation exposure to the unprotected eye lens of the first operator. The lead glasses led to a median reduction in the exposure to the eye lens by a factor of 3.4. CONCLUSION: The implementation of a dose reduction program led to a relevant reduction in radiation exposure to the head and eye lens of the first operator in endovascular procedures. With optimum radiation protection measures, including a ceiling mounted shield and lead glasses, more than 440 EVARs, 280 TEVARs, or 128 FEVARs could be performed per year before the dose limit for the eye lens of 20 mSv was reached.

Limb Salvage by Open Surgical Revascularisation in Acute Ischaemia due to Thrombosed Popliteal Artery Aneurysm.

OBJECTIVE: Acute ischaemia due to thrombosed popliteal artery aneurysm (PAA) is associated with a high risk of limb loss. The aim of this study was to analyse the outcome, in particular the limb salvage rate in patients undergoing urgent open surgery for acute ischaemia due to thrombosed PAA. METHODS: This was a retrospective analysis of consecutive patients undergoing urgent open surgery for acute limb ischaemia (Rutherford category ≥ II) due to thrombosed popliteal artery aneurysm between January 2007 and December 2016 at a tertiary referral centre. RESULTS: Fifty-one patients (92% male), median age 75 years (range 46-97 years), were identified. Twenty patients (39%) presented with category IIa acute limb ischaemia, 20 (39%) with category IIb, and 11 (22%) with category III. Four patients (8%) underwent primary major amputation. Forty-seven (92%) underwent bypass surgery, 43/47 (91%) using great saphenous vein. One vessel runoff was present in 27/47 patients (57%). Thirty day mortality was 4% (n = 2). Four patients needed major amputation within 30 days, resulting in an overall 30 day major amputation rate of 16% (8/51, 95% confidence interval 7.0-28.6). No further major amputations were necessary during a median follow up of 41 months (range 4-114 months) resulting in an estimated 4 year limb salvage of 84%. The one year primary assisted and secondary bypass patency rates were 90% and 95%, respectively. The estimated four year primary assisted and secondary patency rates were 82% and 87%, respectively. CONCLUSION: Rapid open surgical revascularisation in patients with acute limb ischaemia due to a thrombosed popliteal artery aneurysm results in good long-term limb salvage rates, especially Rutherford category IIa and IIb acute ischaemia. Revascularisation may be attempted in clinically severe cases not fulfilling all criteria to be classified as category III. Such patients may, in fact, be borderline between IIb and III. Despite poor runoff, good bypass patency rates and low rates of claudication can be achieved.

Acute aortic dissection determines the fate of initially untreated aortic segments in Marfan syndrome.

BACKGROUND: The aim of the current study was to investigate incidence and causes of surgical interventions in primarily nontreated aortic segments after previous aortic repair in patients with Marfan syndrome. METHODS AND RESULTS: Retrospective analysis of 86 consecutive Marfan syndrome patients fulfilling Ghent criteria that underwent 136 aortic surgeries and were followed at this institution in the past 15 years. Mean follow-up was 8.8±6.8 y. Thirty-day, 6-month, 1-year, and overall mortality was 3.5%, 5.8%, 7.0%, and 12.8%, respectively. Ninety-two percent of patients initially presented with aortic root, ascending aortic or arch lesions, whereas 8% presented with descending aortic or thoraco-abdominal lesions. Primary presentation was acute aortic dissection (AAD) in 36% (77% type A, 23% type B) and aneurismal disease in 64%. Secondary complete arch replacement had to be performed in only 6% of patients without AAD, but in 36% with AAD (P=0.0005). In patients without AAD, 11% required surgery on primarily nontreated aortic segments (5 of 6 patients experienced type B dissection during follow-up), whereas in patients after AAD, 48% underwent surgery of initially nontreated aortic segments (42% of patients with type A and 86% of those with type B dissection; P=0.0002). CONCLUSIONS: The need for surgery in primarily nontreated aortic segments is precipitated by an initial presentation with AAD. Early elective surgery is associated with low mortality and reintervention rates. Type B dissection in patients with Marfan syndrome is associated with a high need for extensive aortic repair, even if the dissection is being considered uncomplicated by conventional criteria.

Intravascular lithotripsy: a powerful tool to treat peripheral artery calcifications.

Calcification represent one the most important predictors of treatment failure of endovascular therapy for peripheral arterial disease, since it restricts wall expansion and acts as a barrier for drug uptake. It also increases complications after PTA like dissection, perforation, and embolization with poor outcomes. Intravascular lithotripsy (IVL) is a novel approach for the treatment of vascular calcifications with the goal to optimize outcome in patients with PAD and heavy calcifications. This review gives an overview of the currently published articles regarding the use of IVL within the vascular field. In conclusion, IVL is a safe and effective approach in the treatment of highly calcified arteries with excellent results and low rates of related complications, such as embolization, dissection, and perforation. However, it seems to require adjunctive therapies to enhance long-term patency as well as an adequate sizing (1.1:1 ratio). Its use to facilitate access of large-bore devices seems to be valuable by changing vessel compliance and achieving luminal gain. Further studies are nonetheless mandatory.

Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms.

BACKGROUND: There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required. METHODS: Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency. RESULTS: Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality. CONCLUSION: Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation.

Outcome of Stanford type B dissection in patients with Marfan syndrome.

OBJECTIVES: The aim of this study was to determine the outcome of Stanford type B aortic dissection in patients with Marfan syndrome (MFS) and to evaluate aortic diameters at time of dissection as well as the impact of previous aortic root replacement. METHODS: Analysis of all patients with MFS fulfilling Ghent criteria seen at this institution since 1995 until 2022. RESULTS: Thirty-six (19%) out of 188 patients with MFS suffered from Stanford type B aortic dissection during the study period. The Mean aortic diameter at the time of dissection was 39.0 mm [95% confidence interval (CI): 35.6-42.3]. The mean pre-dissection diameter (available in 25% of patients) was 32.1 mm (95% CI: 28.0-36.3) and the mean expansion was 19% (95% CI: 11.9-26.2). There was no correlation between age and diameter at the time of dissection (<20, 21-30, 31-40, 41-50, 51-60, <61 years; P = 0.78). Freedom from intervention after dissection was 53%, 44% and 33% at 1, 5 and 10 years. Aortic growth rate in those patients that had to undergo intervention within the 1st year after dissection was 10.2 mm/year (95% CI: 4.4-15.9) compared to 5.8 mm/year (95% CI: 3.3-8.3, P = 0.109) in those thereafter. The mean time between dissection and intervention was 1.8 years (95% CI: 0.6-3.0). While type B dissection seems more frequent after previous elective aortic repair (58% vs 42%), there was no difference between valve-sparing root replacement (VSRR) compared to Bentall procedures [Hazard ratio (HR) for VSRR 0.78, 95% CI: 0.31-2.0, P-value = 0.61]. The mean age of the entire population at the end of follow-up was 42 years (95% CI: 39.2-44.7). The mean follow-up time was 9 years (95% CI: 7.8-10.4). CONCLUSIONS: Stanford type B dissection in patients with MFS occurs far below accepted thresholds for intervention. Risk for type B dissection is present throughout lifetime and two-thirds of patients need an intervention after dissection. There is no difference in freedom from type B dissection between a Bentall procedure and a VSRR.

The impact of sex and gender on aortic events in patients with Marfan syndrome.

OBJECTIVES: The aim of this study was to explore sex and gender differences regarding aortic events in Marfan patients. METHODS: We analysed all data from our connective tissue disorder database. Only patients with Marfan syndrome were included. For analysis, patients were divided by sex. Female patients were further divided into 2 subgroups: with versus without children. Aortic events were defined as Stanford type A aortic dissection (TAAD) or type B aortic dissection (TBAD) or any aortic intervention. RESULTS: A population of 183 Marfan patients was analysed for the purpose of this study. One hundred four (57%) were male and 79 (43%) were female patients. Thirty-seven (47%) of the 79 female patients had at least 1 child. Male patients had a significantly higher probability of experiencing an aortic event (P = 0.015) compared to female patients. However, there was no increased probability for recurrent events in male patients compared to female patients (P = 0.063). Follow-up revealed no sex and gender differences in the occurrence of Stanford TAAD or TBAD between male and female patients (P = 0.324/P = 0.534). While 11% of women with children suffered from peripartum aortic events, 24% experienced Stanford TAAD unrelated to pregnancy. CONCLUSIONS: Male patients have a higher risk of aortic events than female patients. The majority of women were not aware of their Marfan syndrome diagnosis before conceiving. One out of 10 women suffered from peripartum Stanford TAAD or TBAD. Twice as many female patients with children suffered from aortic dissection unrelated to childbirth. There were no sex and gender differences affecting mortality in Marfan patients.

Surgeon-modified fenestrated endovascular aortic repair for ruptured anastomotic aneurysm after open thoracoabdominal repair.

We report the case of a 60-year-old female patient with a contained rupture of a proximal anastomotic pseudoaneurysm after previous open repair of a type IV thoracoabdominal aneurysm. A repeat open repair was considered to be too risky. We performed an urgent endovascular repair with a thoracic stent-graft and a surgeon-modified fenestrated aortic cuff with two fenestrations. The final angiogram and postoperative imaging studies showed complete aneurysm exclusion without any endoleak. Surgeon-modified fenestrated endovascular aortic repair is a feasible treatment option for emergency cases for which repeat open repair or custom-made complex endovascular repair is not an option.

Long-term outcome of patients with Marfan syndrome with previous aortic surgery but native aortic roots.

OBJECTIVES: The goal of this study was to report the long-term outcomes of patients with Marfan syndrome who had aortic surgery on any aortic segment except for the replacement of the aortic root itself. METHODS: An observational retrospective single-centre study was conducted with 115 Marfan syndrome patients who underwent 189 major aortic interventions from 1995 until 2018. Patients without aortic root replacement were identified and aortic root growth was analysed over time. RESULTS: Eleven of 115 patients (9.5%) did not have aortic root replacement during a follow-up of 10.5 [standard deviation (SD) 5.7] years and a mean age at last follow-up of 53.9 (SD 13.4) years. Patients without root replacement did not suffer less frequently from any type of acute aortic dissection (type A 27% vs 25%, P = 0.999; type B 36% vs 25%, P = 0.474). Patients with native aortic roots did not undergo fewer aortic interventions than those with aortic root replacement [12/11, mean 1.09 (SD 0.54) operations/patient vs 177/104, mean 1.7 (SD 1.3); P = 0.128]. Progression of the aortic root dimension was 0.5 (SD 0.3) mm/year in the group of patients with native aortic roots. CONCLUSIONS: Current data suggest that 10% of patients with Marfan syndrome with previous aortic surgery will be free from aortic root replacement until the sixth decade of life.

Symptomatic or aneurysmal aberrant subclavian arteries: results of surgical and hybrid repair.

OBJECTIVES: Indications and techniques of repair for symptomatic or aneurysmal aberrant subclavian arteries (ASA) are controversial. This study analyses presentation, treatment and outcome of patients with symptomatic and/or aneurysmal ASA. METHODS: Retrospective analysis of consecutive adult patients undergoing symptomatic and/or aneurysmal ASA repair between January 2000 and June 2016. RESULTS: Of 12 patients (4 females) with a median age of 66 years (range 24-75), 10 had right ASA and 2 had left ASA originating from a right aortic arch. Six patients (50%) had Kommerell's diverticulum and 6 patients had aneurysmal dilatation of the ASA itself. Six patients presented with symptoms (dysphagia n = 4, chest pain n = 1, recurrent aspiration n = 1). Nine patients (75%) were treated by open ASA resection/ligation with or without aortic repair. Three patients (25%) underwent hybrid repair using thoracic endovascular aortic repair to exclude the aberrant artery. ASA revascularization was achieved by subclavian-carotid transposition (n = 7), carotid-subclavian bypass (n = 1), aorto-subclavian bypass (n = 3) or reimplantation after aortic graft replacement (n = 1). Thirty-day mortality was 8% (n = 1). The median follow-up duration was 44 months (range 24-151). Symptoms were relieved in 4 and persisted partially in 1, while symptom relief remained unknown in 1 patient who died during follow-up. Imaging after a median of 34 months (range 2-134) after the operation showed patent ASA revascularization in all patients and no endoleaks in the hybrid group. CONCLUSIONS: Surgical and hybrid repair allows satisfying results in patients with symptomatic and/or aneurysmal ASA. The optimal procedure has to be defined on an individual patient basis. Further studies, preferably with a multicentre approach, are required to answer more specific questions on the management of these patients and especially to assess long-term results following hybrid repair.

The fate of nonaortic arterial segments in Marfan patients.

OBJECTIVES: The aim of this study was to investigate the fate of nonaortic arterial segments in patients with Marfan syndrome (MFS). METHODS: This was a retrospective analysis of 100 consecutive patients with MFS fulfilling Ghent criteria who underwent 192 interventions on any segment of the arterial tree and were followed over the past 20 years. A review of the available imaging regarding 9 defined regions of interest of the carotid, innominate, subclavian, iliac, and femoral arteries was performed. RESULTS: Mean follow-up interval was 11.6 ± 7.7 years. Of 600 measurements that were performed, 414 (69%) arterial segments showed dilatation above the upper range of normal. There were no significant sex differences. In 100 patients, 66 dissections in nonaortic arterial segments in 33 patients were identified. Nineteen patients with or without previous dissection underwent 34 interventions. Most interventions were performed on the iliac arteries (56%), followed by the subclavian arteries (21%), the intercostal arteries (9%), the carotid arteries (6%), the visceral arteries (6%), and the innominate artery (3%). Most iliac artery interventions (88%) were caused by dilatations due to previous dissections, whereas this was only the case in 17% of interventions on the subclavian arteries. CONCLUSIONS: Most patients with MFS presented with at least 2 dilated nonaortic arterial segments. The current data suggest that 20% of MFS patients will need some form of intervention on nonaortic arterial segments 5 to 6 years after their first aortic intervention, referring to the first aortic dissection of the patient if the patient had a history of dissection. Routine long-term follow-up imaging should include the iliac arteries as well as the supra-aortic branches.

Should aortic arch replacement be performed during initial surgery for aortic root aneurysm in patients with Marfan syndrome?

OBJECTIVES: The aim of this study was to investigate whether total arch replacement (TAR) during initial surgery for root aneurysm should be routinely performed in patients with Marfan syndrome (MFS). METHODS: Retrospective analysis of 94 consecutive MFS patients fulfilling Ghent criteria who underwent 148 aortic surgeries and were followed at this institution during the past 16 years. RESULTS: The mean follow-up interval was 8.8 ± 7 years. Initial presentation was acute aortic dissection (AAD) in 35% of patients (76% Type A and 24% Type B) and aneurysmal disease in 65%. TAR was performed in 8% of patients during initial surgery for AAD (otherwise a hemi-arch replacement was performed) and 1.6% in elective root repair. Secondary TAR had to be performed in only 3% of patients without, but in 33% following AAD (33% Type A and 33% Type B; P = 0.0001). Thirty-day, 6-month, 1-year and overall mortalities were 3.2, 5.3, 6.4 and 11.7%, respectively. Operative and 30-day mortalities in secondary aortic arch replacement were zero. Secondary TAR after AAD did not increase the need for the replacement of the entire thoracoabdominal aorta during follow-up compared with patients without secondary TAR (37 vs 40%, P = 1.0). CONCLUSIONS: MFS patients undergoing elective root repair have small risk of reinterventions on the aortic arch, and primary prophylactic replacement does not seem to be justified. In patients with AAD, the need for reinterventions is precipitated by the dissection itself and not by limiting the procedure to the hemi-arch replacement in the emergency setting. Limiting surgery to the aortic root, ascending aorta and proximal aortic arch is associated with low mortality in MFS patients presenting with AAD.