Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair.

PURPOSE: The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS: A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS: Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION: The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT: This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.

Fractured Sealing Rings in a Fenestrated Anaconda Stent-Graft.

An 81 year-old man presented with an asymptomatic juxtrarenal abdominal aortic aneurysm and was subsequently treated with a fenestrated endovascular Anaconda stent-graft. Surveillance imaging within the first postoperative year demonstrated a lower proximal sealing ring fracture. In the second postoperative surveillance year, the upper proximal sealing ring was also fractured with extension of the wire into the right paravertebral space. Despite these sealing ring fractures, there were no endoleak nor visceral stent complications and the patient continued on standard surveillance protocols. There are an increasing number of reports of fractured proximal sealing rings with the fenestrated Anaconda platform. Those analysing the surveillance scans of patients treated with this device should stay vigilant for the development of this complication.

New Preloaded System for Renal and Visceral Arteries in Fenestrated Endografting.

AIM/BACKGROUND: The New Preloaded System (NPS) for renal/visceral arteries (TVVs) is an emerging technology in fenestrated endografting (FEVAR) that allows TVVs cannulation and stenting through the same access of the endograft main body. However, only few preliminary experiences are currently available in the literature. The aim of this study is to report the outcomes of NPS-FEVAR in juxta/para-renal (J/P-AAAs) and thoracoabdominal (TAAAs) aneurysms repair. METHODS: This is a prospective (NCT05224219), single-center/observational study of patients submitted to NPS-FEVAR for J/PAAAs and TAAAs between 2019 and 2022 (July). Definitions and outcomes were evaluated according to the current SVS-reporting standard. Technical success (TS) and TS preloaded related, spinal cord ischemia (SCI), and 30-day mortality were assessed as early endpoints. Survival, freedom from reinterventions (FFRs), and freedom from TTVs-instability (FFTVVs-instability) were analyzed during follow-up. RESULTS: Among 157 F/B-EVAR cases, 74 (47%) NPS-FEVAR were planned and enrolled in the study [48 (65%) J/P-AAAs; 26 (35%) TAAAs]. The main indication for NPS-FEVAR was the presence of a hostile iliac axis (54%-73%) or the necessity of expeditious pelvic/lower-limb reperfusion for SCI prevention in TAAAs (20%-27%). Overall, 292 TVVs were accommodated by 289 fenestrations and 3 branches; 188 of 289 (65%) fenestrations were preloaded. NPS-FEVAR configuration was from "below" and "from below to above" in 28 (38%) and 46 (62%) cases, respectively. TS and TS preloaded system-related was 96% (71/74) and 99% (73/74), respectively. Target visceral vessels patency at the completion angiography was 99% (290/292). Failures were 2 renal arteries loss and 1 massive bleeding from a percutaneous closure system breakage. The latter patient developed postoperative multiorgans failure and died on the fifth postoperative day, causing only 30-day/in-hospital mortality (1.3%). One (1.3%) patient with a JAAA and preoperative bilateral occlusion of the hypogastric arteries suffered SCI. The median follow-up was 14 (IQR: 8) months. The estimated 3-year survival was 91% with no aneurysm-related mortality during follow-up. The estimated 3-year FFR and FFTVVs-instability were 85 and 92%, respectively. CONCLUSION: New preloaded system FEVAR is a safe and effective option in the treatment of J/PAAAs and TAAAs in the presence of hostile iliac access or to guarantee an expeditious pelvic/lower limb reperfusion, leading to satisfactory results in terms of TS, early and mid-term clinical outcomes. CLINICAL IMPACT: New preloaded system for fenestrated and branched endografting allows to increase the feasibility of the advanced endovascular aortic repair in challenging iliac access, thoracoabdominal aneurysm repair and reduce difficulties in target visceral vessels cannulation.

Off-the-Shelf Single-Fenestrated Endograft for Emergent Juxtarenal and Pararenal Abdominal Aortic Aneurysm.

INTRODUCTION: Endovascular solutions to emergent juxtarenal and pararenal abdominal aortic aneurysms (AAAs) are complicated. Endovascular aortic repair (EVAR) with in situ laser fenestration (ISLF) is promising but requires a period of visceral ischemia. With an off-the-shelf, single superior mesenteric artery (SMA)-fenestrated device mesenteric ischemia is avoided and renal ischemia decreased. The aim was to develop an optimized design of such an endograft suitable for >90% of juxtarenal and pararenal AAAs. METHODS: Single-center analysis on 44 consecutive preoperative CTs for previously elective fenestrated EVARs for juxtarenal and pararenal aneurysms. Anatomical characteristics were analyzed to define: (1) shortest aortic coverage above SMA fenestration to achieve ≥4 cm seal; (2) feasibility of a scallop for the celiac artery; (3) shortest distance between the SMA and lowest renal, to facilitate renal ISLF in a straight endograft; (4) distance from the lowest renal to the aortic bifurcation, to allow an overlapping zone >40 mm with a bifurcated stent graft; (5) aortic diameter in the sealing zone, for optimal proximal stent graft diameter with 10% to 30% oversizing; (6) the final design was then tested on individual level. RESULTS: (1) The stent graft needs to start 40 mm above the SMA fenestration to achieve a 4 cm sealing zone in >90% of cases. (2) A proximal sealing zone of 40 mm without a scallop covers 77% of celiac arteries. With an addition of a 20 mm deep, 20 mm wide scallop at 12:30, the stent graft still covers 27% of celiacs. This suggests that a scallop would not be practically feasible. (3) In >90% of cases, the lowest renal was <31 mm from the SMA, suggesting that the tapering should start 30 mm below the SMA. (4) The distance from the lowest renal to the aortic bifurcation ranged from 82 to 166 mm. This allows for a 20 mm tapering and 50 mm straight part in all cases. (5) The 5th and 95th percentile of the aortic diameter in the sealing zone was 22 and 31 mm, respectively. Thus, 2 different stent graft diameters (28 and 34 mm) would fit >90% of cases. (6) The final design was suitable in 91% cases. CONCLUSIONS: Two sizes of a single-fenestrated aortic stent graft without scallop cover >90% of juxtarenal and pararenal anatomies. CLINICAL IMPACT: Emergent juxta- and pararenal aortic aneurysms is a difficult clinical scenario that continuously challenges physicians. An endovascular option is in situ laser fenestrated endografts. One risk with these is the complete visceral ischemia occurring before the fenestrations are completed. An off-the-shelf single-fenestrated stent graft facilitates the treatment by removing the ischemia time for the SMA and reducing the ischemia time for the celiac and renal arteries thus decreasing the risk of visceral ischemia complications.

Additional Aortic Coverage With an Off The Shelf, Multibranched Endograft Compared With Custom Made Devices For Endovascular Repair of Pararenal Abdominal Aortic Aneurysms.

OBJECTIVE: Pararenal abdominal aortic aneurysms (p-AAA) require complex endovascular aortic repair or open surgical repair with suprarenal clamping. Custom made devices (CMD), including fenestrated and branched endovascular aortic repair (F/B-EVAR) or off the shelf (OTS) multibranched devices, are available treatment options. The aim of this study was to determine the additional healthy aortic coverage using an OTS multibranched endograft vs. a CMD for the treatment of p-AAAs. METHODS: This was a retrospective single centre analysis of prospectively collected data. Consecutive patients with p-AAAs requiring a proximal landing zone above the coeliac artery (CA), planned and treated with CMDs (Zenith Fenestrated) between January 2017 and December 2021 were included in this study. Treatment with supracoeliac coverage using available OTS multibranched devices was simulated using available pre-operative images: T-Branch; E-nside; and TAMBE. Study endpoints included the need for additional proximal aortic coverage, and the number of the segmental arteries additionally covered proximally from the CA for OTS devices compared with CMDs. RESULTS: Eighty three patients with p-AAAs were treated with CMDs (all FEVAR), including juxtarenal AAAs (n = 46; 56%), suprarenal AAAs (n = 20; 24%), and short neck AAAs (n = 17; 20%). In this study, treatment with 249 (3 × 83) OTS endografts was simulated. When compared with CMDs, OTS devices required a mean of 74 ± 19 mm of additional proximal healthy aortic coverage from the CA (CMD: 33 ± 19 mm vs. OTS: 108 ± 6 mm; p ≤ .001), as well as an average sacrifice of 2.5 additional segmental arteries (CMD: 1.3 ± 0.8 vs. OTS: 3.8 ± 0.9; p ≤ .001). In 94% of patients, at least one of the available multibranched endografts could have been implanted in accordance with instructions for use. CONCLUSION: Despite not requiring customisation time, OTS endografts for the treatment of p-AAA lead to more extensive healthy aortic coverage, as well as an average sacrifice of 2.5 additional segmental arteries, compared with CMDs. When compared with OTS devices, CMDs appear to limit the extent of unnecessary aortic coverage and the theoretical subsequent risk of spinal cord ischaemia.

Palliative Repair of a Mycotic Aortic Arch Pseudoaneurysm With a Physician-Modified Endograft and In-Situ Laser Fenestration.

PURPOSE: Open aortic arch repair is the gold standard in the treatment of diseases involving the ascending aorta and aortic arch. However, due to the invasive nature of open repair, high-risk patients with multiple comorbidities are often not suitable candidates for open surgical repair. While endovascular aortic repair is far less invasive, endovascular arch repair remains a difficult challenge due to the aortic arch diameter and angulation, origin of the supra-aortic arteries, and the lack of commercially available thoracic branched devices in the United States. CASE REPORT: Here we describe palliation of a mycotic aortic arch pseudoaneurysm with a physician-modified endograft and in situ laser fenestration. Our technique allowed for rapid repair of the pseudoaneurysm with minimal physiologic disturbances and no perioperative complications in a high-risk surgical patient. CONCLUSION: Physician-modified endografts are feasible and may be an effective treatment option for palliation of acute aortic arch lesions in high-risk surgical patients.

Endovascular Management of Unused Fenestrations or Branches in Fenestrated/Branched Aortic Endograft.

Fenestrated and branched aortic endograft (F/B EVAR) has become a widely accepted technique in the management of aneurysmal aortic pathology. However, intra-procedurally in some situations, there are F/B that remain unused because of target vessel occlusion or failure to cannulate the target artery. Leaving the F/B open will result in an ongoing endoleak, unless treated at the time. Herein we described the necessary considerations and several endovascular techniques to occlude these fenestrations and branches in this situation.

Sex Influence on Fenestrated and Branched Endovascular Aortic Aneurysm Repair: Outcomes From a National Multicenter Registry.

INTRODUCTION: Women are generally underrepresented in trials focusing on aortic aneurysm. Nevertheless, sex-related differences have recently emerged from several studies and registries. The aim of this research was to assess whether sex-related anatomical disparities existed in fenestrated and branched aortic repair candidates and whether these discrepancies could influence endovascular repair outcomes. METHODS: Data from all consecutive patients treated during the 2008-2019 period within the Italian Multicenter fenestrated or branched endovascular aortic repair (F/BEVAR) Registry were included in the present study. Propensity matching was performed using a logistic regression model adjusted for demographic data and comorbidities to obtain comparable male and female samples. The selection model led to a final study population of 176 patients (88 women and 88 men) among the total initial cohort of 596. Study endpoints were technical and clinical success, overall survival, aneurysm-related death, and reintervention rates evaluated at 30 days and during follow-up. RESULTS: Twenty-eight patients (15.9%) received urgent/emergent repair. In most of the cases (71.6%), women received treatment for extensive thoracoabdominal pathology (Crawford type I, II, or III aneurysm rather than type IV or juxta-pararenal) versus 46.6% of men (p=0.001). Female patients presented with more challenging iliac accesses with at least one side considered hostile in 27.3% of the cases (vs 13.6% in male patients, p=0.039). Finally, women had significantly smaller visceral vessels. Women had significantly worse operative outcomes, with an 86.2% technical success rate versus 96.6% in the male population (p=0.016). No differences were recorded in terms of 30-day reinterventions between men and women. The 5-year estimate of freedom from late reintervention, according to Kaplan-Meier analysis, was 85.6% in men versus 81.6% in women (p=ns). No aneurysm-related death was recorded during follow-up (median observational time, 23 months [interquartile range, 7-45 months]). CONCLUSION: Women presented a significantly higher incidence of thoracoabdominal aneurysms, smaller visceral vessels, and more complex iliofemoral accesses, resulting in a significantly lower technical success after F/BEVAR. Further studies assessing sex-related differences are needed to properly determine the impact on outcomes and stratify procedural risks. CLINICAL IMPACT: Women are generally underrepresented in trials focusing on aortic aneurysms. Aiming to assess whether sex may affect outcomes after a complex endovascular aortic repair, a propensity score selection was applied to a total population of 596 patients receiving F/BEVAR aortic repair with the Cook platform, matching each treated female patient with a corresponding male patient. Women presented more frequently a thoracoabdominal aneurysm extent, smaller visceral vessels, and complex iliofemoral accesses, resulting in significantly worse operative outcomes, with an 86.2% technical success versus 96.6% (p=0.016). No differences were recorded in terms of short-term and mid-term reinterventions. According to these results, careful and critical assessment should be posed in case of female patients receiving complex aortic repair, especially regarding preoperative anatomical evaluation and clinical selection with appropriate surgical risk stratification.

Emergent In Situ Fenestration in the Ascending Aorta for the Endovascular Repair of a Large Pseudoaneurysm: A Technical Note.

PURPOSE: The purpose of this article is to describe an emergent in situ fenestration (ISF) technique in the ascending aorta for the endovascular repair of a large pseudoaneurysm using a trans-septal needle device through direct right common carotid artery access, in a patient with left ventricular assist device (LVAD). TECHNIQUE: We performed, in a multidisciplinary team-work approach, an emergent ISF to correct the displacement of a physician-modified thoracic endograft released in the ascending aorta to correct a large anastomotic pseudoaneurysm in a patient who underwent ascending aorta replacement and subsequent LVAD implantation. We used a trans-septal needle device inserted through a direct access to the right carotid artery and performed an ISF to restore the patency of the outflow ostium of the LVAD. Window was then completed and stabilized with a nitinol balloon expandable covered stent graft obtaining an effective exclusion of the anastomotic aortic aneurism and the regular patency of the LVAD outflow graft with no signs of leaks. CONCLUSIONS: Multidisciplinary teamwork approach can be crucial in challenging procedures where an alternative approach may lead to problem solving. The ISF technique may be a valid option to adopt in emergency cases in which no other technical solutions are suitable. CLINICAL IMPACT: The endovascular approach has become more and more frequent for the treatment of vascular pathologies, getting increasingly refined and complex. Thereby the chance of incurring intraprocedural troubles has grown and bailout strategies should always be present. In situ fenestration is a technique to be aware of and that could help you recover from difficult situations. We report a possible rescue maneuver that can be applied also in arduous anatomies such as the ascending aorta. Moreover, we would like to highlight the importance of a multidisciplinary working environment that can enrich our everyday practice accomplishing effective and unexpected solutions.

Novel Technique for the Treatment of Type Ia Endoleak After Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. TECHNIQUE: The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. CONCLUSION: Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.

A Modified Proximal Stent-Graft for Spinal Cord Preconditioning During Staged Endovascular Repair of Thoracoabdominal Aortic Aneurysms.

Purpose: To describe a new custom-made thoracic device able to seal against the aortic wall and occlude intercostal arteries for spinal cord preconditioning during the first thoracic stage of a thoracoabdominal endovascular repair. Technique: The custom-made device, based on the Zenith Alpha stent-graft, combines different features from 2 previously described devices: the outer part is designed with a bell-bottom configuration similar to the "Embo" stent-graft, while the inner part mimics the "2 in 1" design. The outer stent-graft is designed to span the entire length of the thoracic aorta and cover as many intercostal arteries as possible during the first stage to effectively precondition the spinal cord. The sutured inner component is customizable in diameter and 20 to 40 mm shorter than the outer stent-graft. The technique has been used in 5 patients. Conclusion: The use of this new custom-made thoracic stent-graft might represent an additional tool for effectively preconditioning the spinal cord during fenestrated and branched staged procedures whenever a proximal thoracic proximal component is needed.

[Review of patient-specific instrumentation for total knee prosthesis]. / Revue des guides personnalisés à usage unique dans les prothèses totales de genou.

OBJECTIVES: Single use patient-specific instruments (PSI) for total knee prosthesis are introduced as a new alternative to conventional ancillaries and computer assisted surgery by improving implants positioning. An exhaustive review was carried out to identify their specific characteristics, with their advantages and disadvantages. METHODS: Medical devices suppliers were consulted in 2015 for reviewing their PSI. Their technical, clinical and economic data were compared. The results had been submitted to an orthopaedics expert commission of our university hospital for clinical and financial opinion. RESULTS: Ten companies have provided the documentation for the analysis. PSI are manufactured by suppliers using a three dimensional printing method based on CT scans or MRI images. PSI are produced according to the surgeon's preferences after a preliminary data check, which can be performed by the suppliers' engineers, the surgeon and automatic calculation. Five suppliers can produce sterile PSI with optional delivery of 3D bone models. According to the experts, the studies failed to demonstrate the superiority of a PSI or hospital economic gain. The prices listed remain high and operating room time is not always significantly reduced. CONCLUSIONS: With the development of personalized medicine, the role of PSI grows in importance. They facilitate the surgeon's work by fully respecting the anatomy. These systems offer an interesting perspective in their technical and pedagogical aspects. But it seems premature to take them into routine use given the low number of high-level studies that were currently done.

Single Centre Results of Total Endovascular Repair of Complex Aortic Aneurysms with Custom Made Anaconda Fenestrated Stent Grafts.

OBJECTIVE: Fenestrated endovascular aneurysm repair (F-EVAR) has increased the number of patients with aneurysmal disease and a short or no existing neck being eligible for endovascular treatment. The aim of the study is to report experience using the Anaconda fenestrated device with special emphasis on target vessel patency and pitfalls with the device. METHODS: Between 2011 and 2016, 48 F-EVAR procedures were performed in 37 males and 11 females under general anaesthesia using the Anaconda custom made device (CMD). Cerebrospinal fluid drainage was performed in selected cases only. Primary endpoints were 30 day mortality and any stent graft related complications. RESULTS: The median aneurysm diameter was 56 mm. Most of the patients had a juxtarenal aneurysm and six had an aorto-iliac aneurysm. The primary technical success was 94% with three unsuccessful cannulations of reno-visceral arteries, two of which were successfully performed later. In the third patient an open repair was necessary because of occlusion of the main graft. The 30 day mortality was 4% because of colonic ischemia with two thrombotic occlusions of the superior mesenteric artery. Thirty day morbidity included four cases (8%) of acute limb ischemia: one with a complete limb occlusion caused by a torsion of the main body; two cases (4%) of assumed temporary spinal cord ischemia; six cases (12%) of acute renal failure; and 16 endoleaks (33%) (15 type II, 1 type III). During the median 24 months (range 0-53) follow up, three patients died (6%). One had migration of the stent graft, leading to open repair and post-operative multi-organ failure. The second had graft limb occlusion and died because of multi-organ failure caused by post-operative thrombosis of the reno-visceral stents. The third patient died of an unrelated cause. Two occlusions of the right renal stent/artery were detected. Moreover, there were three cases (6%) of late partial and seven cases (15%) of total graft limb thrombosis, with one being bilateral. CONCLUSIONS: "Real world" feasibility of the fenestrated Anaconda stent graft is demonstrated with 4% peri-operative mortality. Target vessel patency is in line with other series; however, limb thrombosis during follow up is of concern.

Comparison of Macintosh Laryngoscope, King Vision®, VividTrac®, AirAngel Blade®, and a Custom-Made 3D-Printed Video Laryngoscope for Difficult and Normal Airways in Mannequins by Novices-A Non-Inferiority Trial.

Background: Endotracheal intubation (ETI) is a cornerstone of airway management. The gold standard device for ETI is still the direct laryngoscope (DL). However, video laryngoscopes (VLs) are now also widely available and have several proven advantages. The VL technique has been included in the major airway management guidelines. During the COVID-19 pandemic, supply chain disruption has raised demand for 3D-printed medical equipment, including 3D-printed VLs. However, studies on performance are only sparsely available; thus, we aimed to compare 3D-printed VLs to the DL and other VLs made with conventional manufacturing technology. Methods: Forty-eight medical students were recruited to serve as novice users. Following brief, standardized training, students executed ETI with the DL, the King Vision® (KV), the VividTrac® (VT), the AirAngel Blade® (AAB), and a custom-made 3D-printed VL (3DVL) on the Laerdal® airway management trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma, and user satisfaction. Results: The KV and VT are proved to be superior (p < 0.05) to the DL in both scenarios. The 3DVL's performance was similar (p > 0.05) or significantly better than that of the DL and mainly non-inferior (p > 0.05) compared to the KV and VT in both scenarios. Regardless of the scenario, the AAB proved to be inferior (p < 0.05) even to the DL in the majority of the variables. The differences between the devices were more pronounced in the difficult airway scenario. The user satisfaction scores were in concordance with the aforementioned performance of the scopes. Conclusions: Based upon our results, we cannot recommend the AAB over the DL, KV, or VT. However, as the 3DVL showed, 3D printing indeed can provide useful or even superior VLs, but prior to clinical use, meticulous evaluation might be recommended.

A giant left atrial appendage: a case report on the feasibility of closure with a custom-made device.

Background: Transcatheter left atrial appendage occlusion (LAAO) is a valuable therapeutic option for stroke prevention in patients with atrial fibrillation (AF) at high bleeding risk. However, complex LAA anatomies sometimes preclude the adoption of commercially available LAAO devices. The design of a custom-made LAAO device is a promising strategy in these cases. However, few examples of custom-made devices in case of giant LAAs have been reported. Case summary: An 85-year-old man with permanent AF with CHA2DS2-VASc 4 and recurrent active gastrointestinal major bleedings was referred for transcatheter LAAO at Parma University Hospital after multidisciplinary team evaluation. Pre-procedural coronary computed tomography angiography revealed a giant windsock LAA, with a maximum ostium diameter of 44 mm, a landing zone diameter of 34 mm, and maximal length of 49 mm. Patient's management was particularly challenging given that available LAAO devices were too small to completely exclude the LAA. In accordance with the manufacturer, a custom-made LAmbre™ Closure System (Lifetech Scientific, Shenzhen, China), which specifically fitted with patient's LAA anatomy, was designed and successfully deployed under transoesophageal echocardiography (TEE) and fluoroscopic guidance. Periprocedural TEE confirmed the appropriate position of the device and the absence of peri-device leaks. No adverse ischaemic and haemorrhagic events were reported at 3-months follow-up. Discussion: We present a case of a successful transcatheter LAAO procedure by deploying a custom-made LAmbre device 38/46 mm to mechanically exclude a giant windsock LAA. This case illustrates the effectiveness of a custom-made device strategy, which potentially enables the closure of all complex LAA anatomies.

Case report: Thoracic endovascular aortic repair using a non-touch exclusion technique with a custom-made device for the treatment of a large patent ductus arteriosus.

Patent ductus arteriosus (PDA) is a common congenital heart disease affecting roughly one in every 2,000 term births. Although most of the patients are diagnosed and treated during childhood, few cases may persist into adulthood. We presented a 27-year-old male patient with a 20.2 mm diameter PDA who was referred to our hospital with progressive fatigue and exertional dyspnea. Given the potential complications, usual techniques such as coil occlusion and duct occluders were deemed inappropriate for this patient. Thoracic endovascular aortic repair (TEVAR) using a non-touch exclusion technique was successfully performed for this patient. The patient was discharged with no major post-surgical complications. TEVAR could be a new, safe, and effective alternative treatment to other transcatheter procedures for complicated PDAs in some patients.

Does endovascular duration impact clinical outcomes in aortic arch repair? The RELAY™ branched international stance.

Background: The high mortality and morbidity rates in surgical aortic arch repair are a barrier to therapy for a considerable proportion of patients with aortic arch aneurysm or dissection. There is hence a demand for the development and adoption of a minimally invasive alternative to aortic arch repair, such as thoracic endovascular aortic repair (TEVAR). Procedural duration is a key factor in the pathogenesis of complications in surgical aortic arch repair. Herein, we evaluate whether endovascular duration impacts neurological outcomes, target vessel patency, and reintervention rates in aortic arch TEVAR with RELAY™ Branched (Terumo Aortic, Inchinnan, UK), which is specifically developed for on-label use within the aortic arch. Methods: Prospective data was collected between January 2019 and January 2022 on the clinical outcomes of TEVAR for aortic arch dissection and aneurysm with RELAY™ single-, double-, and triple branched endoprostheses from centers across Europe. They were then retrospectively analyzed with descriptive and distributive analysis. Follow-up data on the incidence of disabling stroke (DS), target vessel patency, and reintervention from 30 days and 6-, 12-, and 24 months postoperative was included in the analysis. Results: 147 (99.3%) of all 148 cases were successful. Over the 24 month follow-up period, in total 6 (4.1%) patients suffered DS, 24 (16.3%) required reintervention, and target vessel patency was exhibited in 118 (80.2%) patients. The modal endovascular duration was 100-150 min (in 64.6%, n = 95 cases). Analysis revealed that endovascular duration was associated with a lower likelihood of reintervention at 30 days, 6-, and 12 months (P = 0.011, P = 0.019, P = 0.037), a greater likelihood of target vessel patency at 6- and 24 months (P = 0.032, P = 0.035). No relationship between endovascular duration and DS was revealed. Discussion: The data demonstrates that RELAY™ Branched is associated with promising clinical outcomes for on-label aortic arch TEVAR. The underlying mechanism linking endovascular duration and reintervention rates, or target vessel patency is likely multifactorial and complex. Given that TEVAR is carried out under general anesthetic only, it is unlikely that prolonged procedural duration has any major effect over neurological outcomes for arch TEVAR.

Total Percutaneous Access for Deployment of a Custom Made Fenestrated Stent Graft in a 90 Year Old with a Large Symptomatic Thoracic Aortic Aneurysm.

INTRODUCTION: Open surgical cut down has been the standard for gaining carotid access in most thoracic endovascular repairs of aortic aneurysm (TEVAR) cases; however, when suitable, total percutaneous repair can be beneficial. REPORT: A relatively fit 90 year old man with few medical comorbidities presented with six months of worsening upper back pain and an Ishimaru zone 2 fusiform thoracic aortic aneurysm of 7.2 cm diagnosed on CT aortography. A total percutaneously inserted custom made device (CMD) with innominate artery (IA) scallop, left common carotid artery (LCCA) fenestration combined with left subclavian artery (LSA) occlusion provided an effective repair. Haemostasis was obtained with Abbott Perclose ProGlide suture-mediated devices. The patient was discharged on post-operative day two. Follow up CT at one month was unremarkable without any endoleak, and an improvement in symptoms. DISCUSSION: There are risks of cerebral ischaemia and other complications with open carotid cut down, hence it is worth considering avoiding if possible, especially for select patients. Retrograde carotid access and subsequent closure device deployment is not new, but in conjunction with CMD, TEVAR allowing for carotid stenting is feasible and less often described in the literature.

Long-Term Outcomes of Thoracic Endovascular Repair for Aortic Arch Dissection Using Customized Single-Branched Fenestrated Stent-Graft.

OBJECTIVES: To report outcomes of thoracic endovascular repair using customized single-branched fenestrated stent-grafts in treatment of aortic arch dissections. MATERIALS AND METHODS: Between November 2009 and November 2011, 16 patients with aortic arch dissections underwent thoracic endovascular aortic repair utilizing customized unibody single-branched fenestrated stent-graft (UBFSG) in our institution. RESULTS: All 16 patients were male with mean age of 54.50 ± 11.33. The technical success rate was 100%. 30-day mortality rate was 6.25% (n = 1). The median follow-up period was 98 months (range, 0-119). During follow-up, 4 nonaorta-related deaths were recorded. Two (2) cases of left subclavian artery occlusion were observed 12 and 14 months after the operation. Two (2) patients had another successful endovascular repair in time, including one case of type Ib endoleak occurred 100 months after the operation and one case of stent-graft induced new entry tear 38 months after the operation. No stroke and migration of stent-grafts were observed. CONCLUSIONS: The branched fenestrated stent-graft may be an effective alternative treatment for aortic arch dissections unfit for open surgery.