Early outcomes of the Conformable endograft in severe neck angulation from the Triveneto Conformable Registry.

OBJECTIVE: The study reports retrospective evaluation of early outcomes from a multicentric experience with the Excluder conformable endograft with active control system (CEXC Device) in the treatment of abdominal aortic aneurysms. Its design allows more flexibility, given by proximal unconnected stent rows and a bending wire within the delivery catheter enables control of proximal angulation. This study specifically focuses on the severe neck angulation (SNA) subgroup (≥60°). METHODS: All patients treated with CEXC Device in nine vascular surgery centers of Triveneto area (Northeast Italy) between January 2019 and July 2022 were enrolled prospectively and analyzed retrospectively. Demographic and aortic anatomical characteristics were evaluated. Endovascular aneurysm repair in SNA were selected for analysis. Major investigated outcomes were technical success, endoleaks, morbidity, mortality, and reinterventions at 30 days and during follow-up. Endograft migration and postoperative aortic neck angulation changes were also analyzed. RESULTS: A total of 129 patients were enrolled. An infrarenal angle of ≥60° was observed in 56 patients (43%) (SNA group) and their data analyzed. The mean patient age was 78.9 ± 5.9 years and median abdominal aortic aneurysm diameter 59 mm (range, 45-94 mm). Median aortic infrarenal neck length, angulation and diameter were 22 mm (range, 13-58 mm), 77° (range, 60°-150°), and 22.0 ± 3.5 mm respectively. Analysis revealed a technical success rate of 100% and perioperative major complication rate of 1.7%. Intraoperative and perioperative morbidity and mortality rates were 3.5% (one buttock claudication and one inguinal surgical cutdown) and 0%, respectively. No perioperative type I endoleaks were observed. The median follow-up was 13 months (range, 1-40 months). Five patients died during follow-up from aneurysm-unrelated causes. Two reinterventions occurred (3.5%): one conversion for a type IA endoleak and one sac embolization for a type II endoleak. Aneurysm sac shrinkage was observed in 15 patients (26%) and aneurysm stability in 35 patients (62%), respectively. Estimated freedom from reinterventions at 24 months was 92%. Aortic neck median postoperative angulation was 75° (range, 45°-139°). CONCLUSIONS: The Triveneto Conformable Registry shows good early results of the CEXC device in severely angulated aortic infrarenal necks. These data need confirmation on longer follow-up and a wider cohort of patients to further increase endovascular aneurysm repair eligibility in SNA.

Endovascular repair of an intrathoracic subclavian artery aneurysm with a single-branched thoracic endograft in a hostile anatomy.

OBJECTIVE: Subclavian artery aneurysms (SAA) are rare and usually involve the proximal segment of the artery. In this setting traditional surgical treatment or hybrid procedures are associated with significative morbidity rate so that new endovascular solutions are preferred. METHODS: Authors report a case of a patient with an intrathoracic left SAA involving the aortic arch's outer curve. Patient's comorbidities contraindicated open surgical treatment while anatomical issues were not favourable to hybrid or standard endovascular solutions. Thus a single-branched custom-made thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) was implanted. RESULTS: Technical success was achieved with no intra-operative complications and technical steps of the procedure are accurately described.A pre-discharge CT scan showed the correct position of the endograft, complete aneurysm exclusion and branch patency. CONCLUSION: Single-branched thoracic stentgrafts could be a good option in unfavourable anatomies with supra-aortic vessels disease involving the aortic arch, with good results in terms of morbidity and early outcomes.

Unsuspected Limitations of 3D Printed Model in Planning of Complex Aortic Aneurysm Endovascular Treatment.

OBJECTIVE: Static 3-dimensional (3D) printing became attractive for operative planning in cases that involve difficult anatomy. An interactive (low cost, fast) 3D print allowing deliberate surgical practice can be used to improve interventional simulation and planning. BACKGROUND: Endovascular treatment of complex aortic aneurysms is technically challenging, especially in case of narrow aortic lumen or significant aortic angulation (hostile anatomy). The risk of complications such as graft kinking and target vessel occlusion is difficult to assess based solely on traditional software measuring methods and remain highly dependent on surgeon skills and expertise. METHODS: A patient with juxtarenal AAA with hostile anatomy had a 3-dimensional printed model constructed preoperatively according to computed tomography images. Endovascular graft implantation in the 3D printed aorta with a standard T-Branch Cook (Cook® Medical, Bloomington, IN, USA) was performed preoperatively in the simulation laboratory enabling optimized feasibility, surgical planning and intraoperative decision making. RESULTS: The 3D printed aortic model proved to be radio-opaque and allowed simulation of branched endovascular aortic repair (BREVAR). The assessment of intervention feasibility, as well as optimal branch position and orientation was found to be useful for surgeon confidence and the actual intervention in the patient. There was a remarkable agreement between the 3D printed model and both CT and X-ray angiographic images. Although the technical success was achieved as planned, a previously deployed renal stent caused unexpected difficulty in advancing the renal stent, which was not observed in the 3D model simulation. CONCLUSION: The 3D printed aortic models can be useful for determining feasibility, optimizing planning and intraoperative decision making in hostile anatomy improving the outcome. Despite already offering satisfying accuracy at present, further advancements could enhance the 3D model capability to replicate minor anatomical deformities and variations in tissue density.