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Objective: The aim of this study was to report outcomes of the BeGraft and BeGraft Plus as bridging covered stents in fenestrated and branched endovascular aneurysm repair (F/BEVAR)., Methods: Patients treated and followed in two institutions receiving at least one BeGraft or BeGraft Plus as bridging covered stent between January 2018 and July 2023 were included., Results: A total of 765 target vessels (TVs) in 281 patients were aimed to be bridged with the BeGraft or BeGraft Plus. TV technical success was 99.5% (761/765). Estimated TV patency at one and two years was 98.5 ± 0.5% and 96.7 ± 0.9%, respectively, with no difference between fenestrations and branches. Estimated freedom from TV related endoleak at one and two years was 98.5 ± 0.5% and 97.9 ± 0.6%, respectively. Estimated freedom from endoleak at two years was lower for TVs targeted with branches compared with TVs targeted with fenestrations (94.2 ± 1.9% vs. 99.7 ± 0.3%, respectively; p < .001). Estimated freedom from TV related re-intervention at one and two years was 97.7 ± 0.6% and 97.1 ± 0.7%, respectively. Estimated freedom from TV related re-intervention at two years was lower for TVs targeted with branches compared with TVs targeted with fenestrations (93.1 ± 2.0% vs. 99.0 ± 0.5%, respectively; p < .001). Estimated freedom from TV instability at one and two years was 96.8 ± 0.7% and 94.5 ± 1.1%, respectively. Estimated freedom from TV instability at two years was 96.0 ± 1.3% for fenestrations and 91.2 ± 2.2% for branches (p = .003)., Conclusion: The BeGraft and BeGraft Plus covered stents showed good midterm outcomes as bridging covered stents in F/ΒEVAR. Branches showed higher instability rates compared with fenestrations. Branches showed similar patency rates to fenestrations., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: As a result of conflicting, inadequate or controversial data in the literature, several issues concerning the management of patients with abdominal aortic aneurysms (AAAs) remain unanswered. The aim of this international, expert-based Delphi consensus document was to provide some guidance for clinicians on these controversial topics., Methods: A three-round Delphi consensus document was produced with 44 experts on 6 prespecified topics regarding the management of AAAs. All answers were provided anonymously. The response rate for each round was 100%., Results: Most participants (42 of 44 [95.4%]) agreed that a minimum case volume per year is essential (or probably essential) for a center to offer open or endovascular AAA repair (EVAR). Furthermore, 33 of 44 (75.0%) believed that AAA screening programs are (probably) still clinically effective and cost effective. Additionally, most panelists (36 of 44 [81.9%]) voted that surveillance after EVAR should be (or should probably be) lifelong. Finally, 35 of 44 participants (79.7%) thought that women smokers should (or should probably/possibly) be considered for screening at 65 years of age, similar to men. No consensus was achieved regarding lowering the threshold for AAA repair and the need for deep venous thrombosis prophylaxis in patients undergoing EVAR., Conclusions: This expert-based Delphi consensus document provides guidance for clinicians regarding specific unresolved issues. Consensus could not be achieved on some topics, highlighting the need for further research in those areas., Competing Interests: Disclosures A.K. has received speaker fees from Cook Inc., & W.L. Gore & Associates, and is a consultant for Bentley Innomed. M.A.F. has received clinical trial support and is a Consultant for Cook, W. L. Gore & Associates, Getinge, and ViTAA. He has received research support from Cook and has stock options in Centerline Biomedical. M.E. is a paid consultant for W. L. Gore & Associates and Silk Road Medical. M.G. is a consultant for Cook Medical, W. L. Gore & Associates and Medtronic and a proctor for Cook Medical., (Copyright © 2024 Society for Vascular Surgery. All rights reserved.)

Objective: To report outcomes of the Advanta V12 as a covered bridging stent in fenestrated and branched endovascular aneurysm repair (F/BEVAR)., Methods: Patients treated with F/BEVAR and followed in a single centre receiving the Advanta V12 as a covered bridging stent between January 2010 and May 2020 were included., Results: A total of 636 patients (543 men) were analysed. A total of 1 675 target vessels (TVs) were bridged with the Advanta V12. Estimated TV patency at one, five, and eight years was 99.1% ± 0.2%, 96.9% ± 0.5% and 96.2% ± 0.7%, respectively. Estimated patency at eight years was 98.1% ± 0.5% for fenestrations and 87.3% ± 2.9% for branches (p < .001). Estimated patency of renal arteries was statistically significantly lower for those targeted with branches compared with fenestrations (p = .001). Multivariable analysis showed that targeting a TV with a branch compared with a fenestration was the only independent risk factor for occlusion during follow up (hazard ratio 6.41, 95% CI 3.4 - 11.9; p < .001). Estimated freedom from endoleak at one, five, and eight years was 99.4% ± 0.2%, 96.4% ± 0.6%, and 95.4% ± 0.8%, respectively. Estimated freedom from target vessel instability (TVI) at one, five, and eight years was 98.5% ± 0.3%, 93.0% ± 0.8%, and 91.3% ± 1%, respectively. Estimated freedom from TVI at eight years was 93.2% ± 0.9% for fenestrations and 82.7% ± 3.5% for branches (p < .001). Estimated freedom from TVI was statistically significantly lower for renal arteries targeted with branches compared with those targeted with fenestrations (p < .001) CONCLUSION: The Advanta V12 shows excellent technical success rates as a covered bridging stent in F/ΒEVAR. Late outcomes remain good with low rates of TV occlusion, endoleak, and re-intervention. Renal arteries targeted with branches demonstrated a higher risk of occlusion and instability compared with those targeted with fenestrations., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The use of fenestrated stent grafts to treat short neck, juxta- and suprarenal aortic aneurysms is increasing worldwide, but midterm outcome reports are scarce. This study aimed to report peri-operative results and midterm outcomes after five years from a single centre., Methods: Patients treated with primary fenestrated endovascular aortic aneurysm repair (FEVAR) for short neck, juxta- or suprarenal aortic aneurysms within the period January 2010 to May 2020 with follow up in the centre were included. Early (technical success, operative mortality, spinal cord ischaemia) and five year outcomes (cumulative survival, freedom from aortic related death, target vessel patency, target vessel instability [TVI], re-interventions) were analysed., Results: A total of 349 patients (313 male, mean age 72.3 ± 7.7 years) were included in the study. Technical success was 98% (342/349). The thirty day mortality rate was 0.9% (3/349). Estimated survival at five years was 69.3 ± 3.1%. Freedom from aneurysm related death at five years was 98.8% ± 0.7%. Estimated target vessel patency at five years was 98.7 ± 0.4%. Estimated freedom from TVI at five years was 97.2 ± 0.6%. Estimated freedom from re-intervention at five years was 86.5 ± 2.3%. Survival did not differ significantly between patients with and without re-interventions (p = .088)., Conclusion: Midterm results of FEVAR remain good as indicated by sustained target vessel patency and low aortic related mortality rates. An important proportion of patients require re-interventions, which do not have a negative impact on midterm survival., (Copyright © 2023. Published by Elsevier B.V.)

In balloon-expandable covered stent (BECS) associated complications after fenestrated endovascular aneurysm repair (FEVAR), geometric analysis may determine the cause of failure and influence reintervention strategies. This study retrospectively classifies BECS-associated complications based on computed tomographic angiography (CTA) applied geometric analysis. BECS-associated complications of FEVAR-patients treated in two large vascular centers between 2012 and 2021 were included. The post-FEVAR CTA scans of complicated Advanta V12 BECSs were analyzed geometrically and complications were classified according to its location in the BECS. BECS fractures were classified according to an existing classification system. In 279 FEVAR-patients, 34 out of the 683 included Advanta V12 BECS (5%) presented with a complication. Two Advanta V12 complications occurred during the FEVAR procedure and 32 occurred during follow-up of which five post-FEVAR CTA scans were missing or not suitable for analysis. In the remaining 27 BECSs complications were classified as (endoleaks (n = 8), stenoses (n = 4), occlusions (n = 6), fractures (n = 3), and a combination of complications (n = 6)). All BECSs associated complications after FEVAR with available follow up CTA scans could be classified. Geometric analysis of BECS failure post-FEVAR can help to plan the reintervention strategy.

Purpose: Fenestrated endovascular aneurysm repair (FEVAR) is a well-established endovascular treatment option for pararenal abdominal aortic aneurysms in which balloon-expandable covered stents (BECS) are used to bridge the fenestration to the target vessels. This study presents midterm clinical outcomes and patency rates of the Advanta V12 BECS used as a bridging stent., Methods: All patients treated with FEVAR with at least 1 Advanta V12 BECS were included from 2 large-volume vascular centers between January 2012 and December 2015. Primary endpoints were freedom from all-cause reintervention, and freedom from BECS-associated complications and reintervention. BECS-associated complications included significant stenosis, occlusion, type 3 endoleak, or stent fracture. Secondary endpoints included all-cause mortality in-hospital and during follow-up., Results: This retrospective study included 194 FEVAR patients with a mean age of 72.2±8.0 years. A total of 457 visceral arteries were stented with an Advanta V12 BECS. Median (interquartile range) follow-up time was 24.6 (1.6, 49.9) months. The FEVAR procedure was technically successful in 93% of the patients. Five patients (3%) died in-hospital. Patient survival was 77% (95% CI 69% to 84%) at 3 years. Freedom from all-cause reintervention was 70% (95% CI 61% to 78%) at 3 years, and 33% of all-cause reinterventions were BECS associated. Complications were seen in 24 of 457 Advanta V12 BECSs: type 3 endoleak in 8 BECSs, significant stenosis in 4 BECSs, occlusion in 6 BECSs, and stent fractures in 3 BECSs. A combination of complications occurred in 3 BECSs: type 3 endoleak and stenosis, stent fracture and stenosis, and stent fracture and occlusion. The freedom from BECS-associated complications for Advanta V12 BECSs was 98% (95% CI 96% to 99%) at 1 year and 92% (95% CI 88% to 95%) at 3 years. The freedom from BECS-associated reinterventions was 98% (95% CI 95% to 100%) at 1 year and 94% (95% CI 91% to 97%) at 3 years., Conclusion: The Advanta V12 BECS used as bridging stent in FEVAR showed low complication and reintervention rates at 3 years. A substantial number of FEVAR patients required a reintervention, but most were not BECS related.

Purpose: To investigate feasibility and outcomes of endovascular repair for acute thoracoabdominal aortic aneurysms (TAAA)., Materials and Methods: Data from a single center were retrospectively analyzed. Patients who underwent endovascular repair for acute TAAA between January 2010 and April 2020 were included. Perioperative and mid-term follow-up outcomes were analyzed. Survival, freedom from reintervention, and target vessel patency were calculated by Kaplan-Meier analysis., Results: A total of 30 patients (18 men, 67.5 ± 6.9 years) underwent endovascular repair for acute symptomatic (n = 15) or contained ruptured (n = 15) TAAA. An off-the-shelf four-branched stent-graft (T-Branch) was used in 19 (63.3%) patients, a custom-made device (CMD) with expedite order in 5 (16.7%) patients, a CMD with short anticipated delivery time in 3 (10.0%) patients, and a CMD available in the hospital in 3 (10.0%) patients. Technical success was 90.0% (n = 27). Thirty-day mortality was 10% (n = 3). There was no complete persistent paraplegia, but one (3.3%) patient suffered permanent limb weakness. Estimated survival at 1 and 2 years was 86.3% ± 6.4%, and 82.3% ± 7.2%, respectively. Estimated freedom from reintervention at 1 and 2 years was 81.4% ± 7.6% and 73% ± 8.8%. Estimated target vessel patency at 1 and 2 years was 96.6% ± 2% and 92.6% ± 2.9%., Conclusion: Endovascular treatment of acute TAAA in this selected group of patients was associated with low early mortality and excellent mid-term survival. The off-the-shelf stent-graft option (T-Branch) was used in the majority of patients. Endovascular repair should be considered the first option for suitable acute TAAA.

Objectives: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures., Methods: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared., Results: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02)., Conclusions: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Fenestrated and branched stent-grafts are being increasingly used to address complex pararenal and thoracoabdominal aortic aneurysms by endovascular means. The present paper describes the current indications, anatomical suitability and techniques of fenestrated and branched stent-grafts in the treatment for pararenal and thoracoabdominal aortic pathologies. Published outcomes with regard to perioperative mortality and morbidity, survival, reinterventions and target vessel patency during follow-up are also presented. Finally, advantages and disadvantages of endovascular repair as compared to open repair are discussed.

Objective: Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown., Methods: The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR)., Results: Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67)., Conclusion: There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Purpose: To provide a systematic literature review on effectiveness of arteriovenous fistula (AVF) and Shunt (AVS) research animal models., Background: Due to advancing human population age, there is increased incidence of patients suffering from vascular and renal diseases leading to dialysis access using AVF and/or AVS. During those interventions native venous or synthetic grafts are arterialized. Despite temporary good patency, complications are a consequence of neointimal hyperplasia (NIH) development that contributes to patients' morbidity and mortality. Basic research attempts to elucidate the pathomechanisms, therefore the small and large animal models are becoming attractive., Methods: Medline search (within 1966-2018) was performed on AVF/AVS animal models. Studies fulfilled following criteria: (1) reported complete material-methods-results section, (2) included statistically significant number of animals, (3) provided statistically significant results. 55 articles were identified encompassing six animal species used., Results: Large animal models include creation of AVF and AVS in pig, sheep and dog. Porcine animal models use pelvic or femoral vessels, ovine use the common carotid artery (CCA) and jugular vein (JV). Canine animal models use the femoral vessels. Small animal models use rabbit (CCA/JV), rat (JV/CCA, abdominal aorta /Vena cava inferior and femoral artery/femoral vein) and mouse (aortocaval and supraortic AVF models)., Conclusions: Large animal models are best for haemodynamic shear stress studies and in vivo evaluation of new synthetic vascular grafts. Small animal models, especially the genetically manipulated ones, are ideal for analysis of molecular and cellular pathomechanisms. The selection of animal species to be used depends on the addressed research question., (Copyright © 2019 Elsevier GmbH. All rights reserved.)

Objectives: Operative caseload is thought to be associated with peri-operative mortality following intact aortic aneurysm repair. The aim was to study that association in the Australian setting, which has a unique healthcare provision system and geographical population distribution., Methods: The Australasian Vascular Audit database was used to capture volume measurements for both individual surgeon and hospital and to separate it into quintiles (1, lowest, to 5, highest) for endovascular (EVAR), open surgical repair (OSR), and subgroups of repair types between 2010 and 2016. Multivariable logistic regression modelling was used to assess the impact of caseload volumes on in hospital mortality after adjustment for confounders., Results: Volume counts were determined from 14,262 aneurysm repair procedures (4121 OSR, 10,106 EVAR). After exclusions, 2181 OSR (161 complex, 2020 standard) and 7547 EVAR (6198 standard, 1135 complex, 214 thoracic (TEVAR)) elective cases were available for volume analysis. Unadjusted mortality after EVAR was unaffected by either surgeon (Quintile 1, 1.0%; Quintile 5, 0.9%; p = .28) or hospital volume (Quintile 1, 0.8%; Quintile 5, 1.3%; p = .47). However, univariable analysis of the TEVAR subgroup revealed a significant correlation with hospital volume (Quintiles 1-2 vs. Quintiles 3-5; p = .02). Univariable analysis for OSR demonstrated a marginal, non-significant value for surgeon (Quintile 1, 4.0%; Quintile 5, 3.6%; p = .06), but not hospital volume (Quintile 1, 4.7%; Quintile 5, 4.0%; p = .67). After adjustment for confounders hospital volume remained a significant predictor of peri-operative TEVAR mortality (Quintile 1-2 vs. 3-5; OR 5.62, 95% CI 1.27-24.83; p = .02) and surgeon volume a predictor following standard OSR (Quintile 1-2 vs. Quintile 3-5; OR 2.15, 95% CI 1.21-3.83; p = .01)., Conclusions: There is an inverse correlation between both surgeon volume of open aortic aneurysm repair, hospital volume of thoracic endovascular aneurysm repair and in hospital mortality. These findings suggest that in Australia TEVAR should be performed by high volume hospitals and OSR by high volume surgeons., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Iliac branch devices (IBD) have become a widespread option to preserve antegrade internal iliac artery (IIA) flow during endovascular aneurysm repair (EVAR). Reported experience with bilateral implantation of IBDs is limited. This study aimed to describe the indications, technical options, and outcomes with the use of bilateral IBDs., Methods: All patients undergoing elective implantation of bilateral Cook Zenith IBD between January 2010 and September 2017 in a single centre were included. Bilateral IBD was indicated in physically active, anatomically suitable patients and those with previous or concomitant surgery for a thoraco-abdominal aortic aneurysm or impaired collateral circulation to the IIA. Data were collected prospectively., Results: Twenty-nine patients (29 male, mean age 64.1 ± 10 years) were included. Of the 58 IBDs, 48 (83%) were implanted in one procedure and 10 (17%) in two procedures (mean time between procedures 30.4 ± 9 months). Nineteen patients (65%) had a previous or simultaneous EVAR and the remaining 10 (35%) a previous or simultaneous complex aortic repair. Mean CIA diameter was 35.2 ± 8 mm. Technical success was achieved in 55 of the 58 IBDs (95%) with no mortality. Axillary artery access was used in 13 (38%) procedures. During follow up, four (7%) IIA branches occluded (1 bilateral occlusion and 2 unilateral). Estimated IIA branch patency at one and three years was 97.8% ± 2% and 88.5% ± 7%, respectively. All patients with late IIA occlusion remained asymptomatic. Re-intervention was needed in four patients (14%): two bridging stent graft extensions for type Ib endoleak, one relining of the external iliac artery because of mural in-stent thrombus and one femoro-femoral crossover bypass to treat an external iliac limb occlusion., Conclusions: Bilateral implantation of IBDs is a safe and effective technique to preserve IIA flow in selected patients with suitable anatomy, showing similar technical success and mid-term outcomes to the unilateral use of the device., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Patients surviving acute aortic dissection are at risk of developing a post-dissection thoraco-abdominal aortic aneurysm (PD-TAAA) during follow up, regardless of the type of treatment in the acute setting. Fenestrated and branched stent grafting (F/B-TEVAR) has been used with success to treat PD-TAAA, albeit reported only with short-term results. The aim of this study was to report mid-term results in a cohort of 71 patients., Methods: This was a retrospective analysis of a prospectively maintained database including all patients with PD-TAAAs who underwent F/B-TEVAR within the period January 2010 - April 2017 at two vascular institutions experienced in endovascular techniques., Results: A total of 71 consecutive patients (56 male, mean age 63.8 ± 10.6 years) were treated. Technical success was achieved in 68/71 (95.8%) patients. In hospital mortality was four (5.6%) patients. Peri-operative morbidity was 19.6%. Three (4.2%) patients developed severe spinal cord ischaemia, one of these patients 12 months post-operatively. Mean follow up was 25.3 months (1-77 months). Cumulative survival rates at 12, 24, and 36 months were 84.7 ± 4.5%, 80.7 ± 5.1%, and 70.0 ± 6.7%, respectively. Estimated freedom from re-intervention at 12, 24, and 36 months was 80.7 ± 5.3%, 63.0 ± 6.9%, and 52.6 ± 8.0%, respectively. The main reasons for re-intervention were endoleak from visceral/renal arteries and iliac endoleak requiring extension. Target vessel occlusion occurred in 8/261 (3.1%) vessels (renal artery n = 4; superior mesenteric artery n = 2; coeliac artery n = 2). Mean aneurysm sac regression during follow up was 9.2 ± 8.8 mm, with a false lumen thrombosis rate of 85.4% for patients with a follow up longer than 12 months. No ruptures occurred during follow up., Conclusion: F/B-TEVAR for post-dissection TAAA is feasible and associated with low peri-operative mortality and peri-operative morbidity. Mid-term results demonstrate a high rate of aneurysm sac regression. Rigorous follow up is required because of the significant re-intervention rate. Longer bridging covered stents for target vessels are advised., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Aortic neck diameter is an independent anatomical feature that is poorly understood, yet potentially linked to proximal seal failure and adverse outcome following standard EVAR. The aim of this study was to assess whether large proximal aortic neck (LAN) diameter is associated with adverse outcome using prospectively collected individual patient data from The Global Registry for Endovascular Aortic Treatment (GREAT)., Methods: A total of 3166 consecutive patients, from 78 global centres, receiving Gore Excluder stent grafts for infrarenal abdominal aortic aneurysm repair between 2011 and 2017 were included. Patient demographics, biometrics, operative details, and clinical outcome were analysed. Patients were divided into two groups: normal baseline proximal aortic neck (NAN) diameter (<25 mm on computed tomography aortography), and LAN (≥25 mm). Clinical follow up (including imaging) was available for 76.5% of patients 5 years post-intervention. Primary endpoints analysed were Type IA endoleak and any aortic re-intervention up to 5 years post-procedure. A composite endpoint of Type IA endoleak, re-intervention, aortic rupture, or aortic related mortality was also assessed., Results: A total of 1977 (62.4%) patients were classified NAN and 1189 (37.6%) were LAN. Immediate technical success was achieved in 3164 out of 3166 (>99.9%) of cases. Freedom from Type IA endoleak was achieved in 99.3% at 1 year and 97.3% at 5 years (lower in LAN vs. NAN: 96.8% [CI 93.7-98.4] vs. 98.6% [CI 94.5-99.6], p = .007). Freedom from aortic re-intervention was 93.7% at 1 year and 83.2% at 5 years (78.6% [CI 66.0-87.0] LAN vs. 86.0% [CI 81.8-89.3] NAN, p = .11). Freedom from primary composite endpoint was 95.9% at 1 year and 84.9% at 5 years (81.3% [CI 69.2-89.0] LAN vs. 87.0% [CI 81.6-91.0] NAN, p = .066). Five year survival was lower in the LAN group; 64.6% (CI 50.1-75.7) vs. 76.5% (CI 70.7-81.3), p = .03)., Conclusion: LAN is associated with delayed Type IA endoleak occurrence and lower overall survival., (Crown Copyright © 2018. Published by Elsevier B.V. All rights reserved.)

Objectives: Visceral arteries in fenestrated and branched endovascular repair (F/BEVAR) have been addressed by fenestrations or directional side branches. Inner branches, as used in the arch branched device, could provide an extra option for visceral arteries "unsuitable" for fenestrations or directional side branches. Early experience with the use of inner branches for visceral arteries in F/BEVAR is described., Methods: All consecutive patients treated by F/BEVAR for complex abdominal aortic aneurysm (AAA) or thoraco-abdominal aneurysm (TAAA) using stent grafts with inner branches were included. Data were collected prospectively., Results: Thirty-two patients (28 male, mean age 71.6 ± 8.3 years) were included. Seven (21.9%) patients had a complex AAA and 25 (78.1%) had a TAAA. A stent graft with inner branches only was used in four (12.5%) patients. The remaining 28 (87.5%) patients received a stent graft with fenestrations and inner branches. In total 52 vessels were targeted with inner branches. Technical success was achieved in all 32 (100%) patients. All 38 inner branch target vessels in grafts including fenestrations and inner branches were instantly catheterised (<1 minute), whereas catheterisation of target vessels in "inner branch only" grafts proved more difficult (<1 minute, n = 3; 1-3 min, n = 4; and >3 min, n = 7). The 30 day operative mortality was 3.1% (1/32). Estimated survival at 1 year was 80.0% ± 8.3%. During follow-up, four renal inner branches occluded in three patients. The estimated inner branch target vessel stent patency at 1 year was 91.9 ± 4.5%. The estimated freedom from re-intervention at 1 year was 78.4% ± 8.9%., Conclusions: Early data suggest that visceral inner branches might represent a feasible third option to address selected target vessels in F/BEVAR. Stent grafts with inner branch(es) in combination with fenestrations seem to be a better configuration than stent grafts with inner branches alone. Durability of the inner branch design needs further investigation., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Purpose: To describe a novel endovascular bailout technique for successful completion of target vessel stenting during branched stent-graft repair of thoracoabdominal aortic aneurysms (TAAA) after encountering difficulties with standard catheterization techniques., Technique: Technical difficulties when using fenestrated and branched grafts should be expected, especially in difficult anatomy or when an off-the-shelf device (eg, standard 4-branch device) is used that does not perfectly "match" the anatomy. The "snare-ride technique" facilitates antegrade transaxillary side branch catheterization and stent placement during TAAA branched grafting using a snare via a transfemoral approach. The branch of the graft is catheterized from an axillary access. The respective target vessel is then catheterized via a femoral access. An Indy snare is advanced over the transfemoral wire and positioned near the entrance of the target vessel. The transaxillary wire inside the branch of the graft is then advanced, snared, and pushed inside the target vessel with the snare. The procedure is thereafter continued with antegrade bridging of the target vessel in routine fashion., Conclusion: The snare-ride technique can be a useful maneuver to catheterize target vessels with difficult anatomy in TAAA branched stent-graft repair. Early experience shows safety and feasibility.

Objective: This study compared outcomes of standard fenestrated endovascular aneurysm repair (St-FEVAR) with renal artery fenestrations only with more complex FEVAR (Co-FEVAR) with additional fenestrations for the superior mesenteric artery or the celiac trunk, or both., Methods: All consecutive patients treated with FEVAR for short-necked, juxtarenal, or suprarenal aortic aneurysms between January 2010 and July 2016 were included. Patients with stent grafts with a combination of fenestrations and branches were excluded. Data were collected prospectively. All stent grafts used were customized based on the Zenith system (William A. Cook Australia, Ltd, Brisbane, Queensland, Australia)., Results: A total of 384 patients (345 men; mean age, 72.7 ± 7.8 years) were treated. St-FEVAR was used in 199 patients (51.8%) and Co-FEVAR in 185 (48.2%), including 30 patients with a quadruple FEVAR. Overall technical success was 373 of 384 (97.1%), and the difference between the St-FEVAR group (195 of 199 [98%]) and the Co-FEVAR group (178 of 185 [96.2%]) was not statistically significant (P = .37). Mean operative time was 135 ± 46 minutes for St-FEVAR and 176 ± 53 minutes for Co-FEVAR (P < .001). Mean fluoroscopy time was 45 ± 17 minutes for St-FEVAR and 57 ± 21 minutes for Co-FEVAR (P < .001). Overall 30-day mortality was two of 384 (0.5%), and the difference between the two groups was not statistically significant (St-FEVAR: 1 of 199 [0.5%] vs Co-FEVAR: 1 of 185 [0.5%]; P = 1.0). Major perioperative complications between St-FEVAR group (22 of 199 [11.1%]) and Co-FEVAR group (24 of 185 [13%]) were similar (P = .64). Mean follow-up was 20 ± 17.1 months. Estimated survival at 1 and 3 years was 95% ± 1.7% and 83.4% ± 3.6% for St-FEVAR vs 94% ± 2.4% and 89.4% ± 3.5%, respectively, for Co-FEVAR (P = .96). Estimated freedom from reintervention at 1 and 3 years was 97.9% ± 1.2% and 90.5% ± 3.1% for St-FEVAR vs 95.4% ± 2.0% and 89.1% ± 4.2%, respectively, for Co-FEVAR (P = .5). Estimated target vessel patency at 1 and 3 years was 99.2% ± 0.4% and 98.6.0% ± 0.6% for St-FEVAR vs 98.6% ± 0.6% and 97.9% ± 0.9%, respectively, for Co-FEVAR (P = .48)., Conclusions: Co-FEVAR is not associated with an increase in perioperative mortality and morbidity compared with St-FEVAR. Co-FEVAR requires longer procedure and fluoroscopy duration, but technical success rates are as high as in St-FEVAR. A liberal use of Co-FEVAR is therefore justified whenever a longer and higher proximal sealing zone is needed., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The chimney technique in endovascular aortic aneurysm repair (Ch-EVAR) involves placement of a stent or stent-graft parallel to the main aortic stent-graft to extend the proximal or distal sealing zone while maintaining side branch patency. Ch-EVAR can facilitate endovascular repair of juxtarenal and aortic arch pathology using available standard aortic stent-grafts, therefore, eliminating the manufacturing delays required for customised fenestrated and branched stent-grafts. Several case series have demonstrated the feasibility of Ch-EVAR both in acute and elective cases with good early results. This review discusses indications, technique, and the current available clinical data on Ch-EVAR.