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Introduction: There is an increasing number of elderly in society and some of them may have an abdominal aortic aneurysm (AAA). The prevalence of AAA in octo- and nonagenarians indicates that this number could be substantial. The question is: is there an age limit for repair? This complex question incorporates ethical, political, economic and medical aspects. To answer part of this question a review of the outcome of elective and emergent AAA repair in those over 80 was done., Evidence Acquisition: A literature research was done in the PubMed and Embase databases between 2007 and 2017 for either emergent and/or elective repair of AAA in individuals older than 80 years of age., Evidence Synthesis: Ten of 663 studies were found eligible for the review. Elective AAA repair in individuals more than 80 years shows a very varying outcome with 30-day mortality between 0% and 20.1% and 1-year mortality between 7% and 26%. Length of procedure, hospital stay, and number of major adverse events are also more in those over 80 years of age. In ruptured AAA 30-day mortality is between 29 and 59 % and 1 one year between 45% and 63%., Conclusions: No definitive answer whether to perform a repair of AAA in the elderly can be given. The decision has to be individualized and will also vary depending on ethical, political, economic factors and type of healthcare system the individual lives in.

Endovascular redo aortic operations are a challenging undertaking. Techniques for treatment date almost as far back as the original open repair itself. Risk factors for failure following aortic repair include larger abdominal aortic aneurysm necks, severe neck angulation, as well as clinical variables such as age, family history, obesity and chronic obstructive pulmonary disease. The armamentarium of endovascular treatments is vast and increasing. Aside from provisional embolization of endoleaks or deferment to open repair conversion, attention should be directed toward obtaining adequate proximal and distal sealing. This can be achieved with Palmaz stents, endoanchors, and extension with fenestrated or branched endovascular repair. Thoracic aortic coverage may be required, and revascularization of the left subclavian artery should be considered. Technical issues such as these, as well as target vessel cannulation and accommodation of the new graft within the previous implanted graft, require experience and careful planning. Distal extension can likewise resolve a failing repair, and this may require the use of internal iliac artery embolization or iliac-branch devices. Redo aortic operations are technically demanding and are carried out with increased risks. Improving technology, such as fusion imaging, should mitigate some of this risk and are recommended.

Endovascular repair has an established role in aortic treatment and has with evolving technologies expanded its applicability to the whole aorta. Whereas open repair is still the standard treatment for aortic arch and ascending aortic pathology, in high-risk patients, endovascular treatment has gained an increasing role. Endovascular options range from hybrid procedures to total endovascular repair using chimney grafts, branched and fenestrated stent grafts. Thoracic endovascular repair (TEVAR) for descending aortic pathologies including aneurysms, traumatic aortic transection, and complicated type B aortic dissection (TBAD) have also been firmly established and in many cases shown superior to open alternatives. For uncomplicated type B aortic dissection, TEVAR is controversial weighing the benefits of the long-term outcomes with increased short-term morbidity and mortality. Endovascular thoracoabdominal aortic aneurysm repair with fenestrated and branched stent grafts have also established its role with excellent short-term results and promising long-term durability. Staging of extensive repairs is widely adopted to prevent spinal cord ischemia. Off-the-shelf (OTS) devices have a complimentary role in emergency situations where custom-made device (CMD) are not available. Chimney and parallel graft techniques also still have a place in emergency situations. Fenestrated stent graft is a solid treatment for pararenal aneurysms with the trend toward more complex repair that aims for durability without compromising the operative outcomes. OTS fenestrated repair for juxtarenal aneurysms have shown its feasibility in the short-term but long-term results are yet to be published. Techniques for infrarenal aneurysm repair have reached a plateau. New devices have been developed to overcome the anatomical limitations of current stent grafts, especially for unfavorable neck anatomy. New polymer-based endovascular sealing (EVAS) technique has shown its feasibility and promising early outcomes, however long-term evidence is needed to define its role in the treatment armamentarium. Lastly, hypogastric artery preservation is now more feasible when iliac-branched devices have shown a good long-term patency and some new devices are available in clinical trial. This article gives an overview of available options and the results of endovascular solutions for the entire aorta from the ascending aorta to the iliac artery.

This article reviews endovascular strategies for aortic arch repair. Open repair remains the gold standard particularly for good risk patients. Endovascular treatment potentially offers a less invasive repair. Principles, technical considerations, devices and outcomes of each technique are discussed and summarized. Hybrid repair combines less invasive revascularization options, instead of arch replacement while extending stent-graft into the arch. Outcomes vary with regard to extent of repair and aortic arch pathologies treated. Results of arch chimney and other parallel graft techniques perhaps make it a less preferable choice for elective cases. However, they are very appealing options for urgent or bailout situations. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration techniques emerge to avoid these problems, but durability of stent-grafts after fenestration and ischemic consequences of temporary carotid arteries coverage raises some concern total arch repair using this technique. Arch branched graft is a new technology. Early outcomes did not meet the expectation; however the results have been improving after its learning curve period. Refining stent-graft technologies and implantation techniques positively impact outcomes of endovascular approaches.

Endovascular aortic repair of aortic pathologies has become widely spread among vascular surgeons. Much focus has been directed at perfecting and developing endovascular procedures to treat evermore complex issues. Much less focus has been directed at the radiation hazards to patients as well as operators and staff when such procedures are performed. Radiation exposure must be used according to the ALARA (As Low As Reasonably Achievable) principle to avoid short- and long-term negative side effects. Modern imaging technology offers many technological developments to reduce radiation such as low-dose programs, pulsed imaging, flat-panel technology and advanced intraoperative imaging techniques. But beside this, simple measures, based on the understanding of radiation exposure, can easily be implemented in everyday standard practice. Appropriate shielding of patients and staff, using adjuncts to be able to keep a safe distance to the radiation source and avoiding working with inappropriate C-arm angulations should be used routinely. Continued education of vascular surgeons is imperative to implement changes in practice to reduce radiation exposure.

Aortic arch repair, is a surgical challenge irrespective of which technique is applied. While open surgical repair is a major trauma and a technically difficult procedure that many elderly patients tolerate poorly, the branched and fenestrated stent-grafts remain complex to implant safely. Hybrid procedures combine some of the advantages of both open and endovascular techniques but also many disadvantages. The possibility of total arch replacement with a standard off-the-shelf thoracic stent-graft and preservation of precerebral vessels by in situ fenestration has recently been reported. Some technical issues remain but recent technical adjuncts seem to facilitate temporary cerebral shunting during implantation as well as piercing of the stent-graft fabric. The positioning of fenestrations is inherently accurate by this technique which may be associated with less material fatigue and improve durability. Preliminarily, this technology holds the promise of simpler implantation, less risk for stroke and improved durability of the devices.

This article reviews the solutions for the revascularization of the left subclavian artery during thoracic endovascular aortic repair (TEVAR). Open surgical revascularization has been the predominant technique used but recent developments may lead to an increasing role of the endovascular revascularization. The different open and endovascular technical options are discussed and the results summarized.

The aim of this article was to present juxtavisceral aortic occlusive disease with particular reference to a novel therapeutic approach, namely protected stenting by means of so called chimney grafts. The juxta renal aortic occlusion is the last aortoiliac occlusive lesion not to be stented routinely because of the risk for trash and/or need for overstenting of vital aortic side branches. The risk for trash also exists in open repair which makes it particularly challenging in this setting. The patients have advanced atherosclerosis and are poor risks for major surgery. A safe endovascular approach is therefore desirable. These lesions are either predominantly thrombotic or heavily calcified plaques. The thrombotic lesions can be stented under protection of the visceral branches by temporary occlusion balloons. The calcified lesions, on the other hand, require overstenting of the visceral vessels that then need to be preserved by chimney grafts. These endovascular procedures are complex and time consuming but they are associated with less surgical trauma and hence improved morbidity, mortality and recovery. The median term results of chimney grafts are encouraging, although more patients and longer follow-up are still needed.

Endovascular treatment of complex aortic aneurysms with fenestrated and branched stentgrafts is in rapid development. Early and midterm results from centers of excellence are very promising but the technique is still in its infancy. With the introduction of EVAR for complex aneurysms a new set of failure modes have also been introduced. These relate both to the specific deployment techniques of the devices and to their intrinsic design characteristics. Procedural planning is of utmost importance for success. Failure to accomplish this may result in disastrous and uncorrectable perioperative failure. The endograft must be correctly tailored to the patient with regards to branch and fenestration positioning and design. Migration of stent-graft components, target vessel occlusions due to branch compression or dislocation and fenestration malpositioning must be recognized during follow up and treated accordingly. The clinical consequences of complex aneurysm repair include spinal cord ischemia and peripheral embolisation and strategies to handle this must be present.

Aim: Proximal fixation is often limiting for thoracic endovascular aortic repair (TEVAR) and the stent graft may need to cover the origin of the arch branch vessels. Chimney grafts have been proposed to preserve flow into over stented branches during urgent TEVAR. The aim of this report is to share our initial experience of this technique., Method: Eleven patients underwent urgent TEVAR combined with a chimney graft between January 2004 and April 2009. The indications included acute complicated type B dissection (N. = 2), ruptured aneurysms of the aortic arch (1) and descending aorta (2), traumatic aortic transaction (1), aortoesophageal fistula (1) and accidental over stenting of the left carotid artery during TEVAR (4). Chimney grafts were implanted into the innominate (N. = 3), left carotid (7) and left subclavian (1) arteries. Mean length of follow up was 20 months., Results: All chimney grafts were successfully implanted. Two patients developed a primary proximal type I endoleak: one leak was successfully coil embolized, the other awaits treatment. One paraplegia was reversed by spinal drainage but two months later, this patient presented with a contained rupture and underwent successful conversion to open repair. No other postoperative aneurysm expansion has occurred and the chimney grafts remain patent. The only aneurysm related death occurred in a patient with an unrecognized chronic occlusion of his right carotid artery who received a left carotid chimney graft and suffered from a lethal stroke., Conclusion: Chimney grafts in the supra-aortic branches seem feasible and may facilitate urgent TEVAR in patients with an inadequate proximal neck.

Aim: Endovascular repair of complicated type B dissections has evolved as a promising alternative to open repair. Previous studies have indicated that continued false lumen flow is a predictor of continued aortic dilatation and risk of rupture during follow-up. This multicenter study was conducted to analyze the postoperative changes of the false lumen after endografting of complicated type B dissections., Methods: All patients treated with endovascular stent grafts for thoracic type B dissections at 5 major Vascular Centers in Sweden were identified through local databases. Review of charts and all available pre- and postoperative CT scans were performed to identify demographics, indications for repair as well as postoperative changes of the aorta and false lumen., Results: A total of 129 patients treated for type B dissections between 1994 and December 2005 were identified. Median radiological follow-up was 14 months. Fourteen patients died perioperatively leaving 115 patients available for analysis. Seventy-four of these had CT imaging of sufficient quality for morphological analysis. The vast majority of acute patients were treated for rupture or end-organ ischemia whereas most chronic patients were treated for asymptomatic aneurysms. In 80% of patients, the false lumen thrombosed along the stent graft but it remained perfused distal to the stent graft fixation in 50% of patients. Only 5% of patients presented with aortic enlargement of the stent grafted area when adequate proximal sealing was achieved. The distal, uncovered aorta displayed expansion in 16% of patients., Conclusions: The stent grafted thoracic aorta after type B dissection appears to be stabilized by covering the primary entry site with a stent graft in the majority of both acute and chronic dissections. The uncovered portion of the aorta distal to the stent graft, however, remains at risk of continuous dilatation. Stent grafting for complicated type B thoracic dissections seems to be a treatment option with reasonable morbidity and mortality even though the incidence of severe complications is still significant.

3D imaging and endovascular repair have greatly increased the number of interventions in the thoracic aorta. Excellent early results of endovascular repair compensate unproven long term durability. Challenging anatomy is associated with increased risk for late failure of the stent graft (SG) but the option of open repair usually remains and complications from open surgery are also more frequent in these cases. The indications for endovascular repair of the descending aorta include aneurysms larger than 5-6 cm in diameter, pseudoaneurysms and type B dissection complicated by rupture, aortic dilation or distal hypoperfusion. Traumatic transections and certain types of coarctation are also treated endovascularly. Aortic rupture is associated with a high mortality and treatment is attempted liberally. Logistics remain a limitting factor for urgent stent grafting in many centers. Adequate pre and intraoperative imaging is mandatory for correct SG implantation. The mechanical forces of aortic blood flow jeopardize durable fixation of the device. Extended fixation zones of at least 5 cm, generous overlap between SG components and SG positioning along the outer curvature of the sac improve durability. Primary complications include stroke and paraplegia in about 5% of the cases. Late complications are mainly associated with SG dislodgement and inadequate seal. Surveillance is required. Future development focuses on treatment of leasions in the aortic arch. Debranching of the arch and branched SGs are currently being investigated.