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Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms., Competing Interests: C.H.T. is a consultant for Cook Medical Inc, W.L. Gore & Associates, and Philips Medical Systems Netherland BV. G.S.O. and the University of Texas Health Science Center at Houston have received consulting fees and/or grants from 10.13039/100010479Cook Medical, W.L. Gore & Associates, Centerline Biomedical, and GE Healthcare. A.B.-O., S.S., T.M., T.S., A.K.M., and S.B. have no conflicts of interest.

Endoleaks remain one of the most common indications for reintervention after endovascular aortic repair. Occasionally, aneurysm sac expansion will occur in the absence of a visible endoleak or due to endotension. We describe a case of continued sac expansion without an identifiable endoleak after endovascular aortic repair. Technical challenges during the case included a short distance from the renal arteries to the flow divider and a significant metal artifact. These challenges were addressed by shortening the gate of a Gore Excluder (W.L. Gore & Associates, Flagstaff, Ariz) to the desired length. The contralateral gate was preloaded to allow for use of the snare-ride technique for gate cannulation and overcome the metal artifact that was hindering visualization., (© 2021 Published by Elsevier Inc. on behalf of Society for Vascular Surgery.)

Aortic pseudoaneurysms are rare entities caused by infection, trauma, atherosclerotic plaque rupture, or aortic instrumentation. Their natural course remains unknown; however, repair is invariably recommended. We present a case of a 71-year-old man with a history of recurrent deep venous thrombosis and pulmonary embolisms who underwent an inferior vena cava filter placement 8 years prior and was found to have a 3.6-cm contained ruptured infrarenal aortic pseudoaneurysm on imaging performed for abdominal pain. His pseudoaneurysm was excluded using a Gore Excluder Endoprosthesis. We further reviewed literature on the subject to highlight the various surgical approaches to this lethal condition., (© 2021 The Author(s).)

We present two preloaded techniques to facilitate gate cannulation during endovascular aortic repair. In the first case, we relined the aorta using a Gore iliac branch endoprosthesis (WL Gore and Associates, Flagstaff, Ariz) for acute occlusion. This allowed for preloading the contralateral gate, which was compressed when deployed, and subsequently dilated open over the preloaded wire to allow for cannulation. The second patient had had an infrarenal aneurysm. A Gore Excluder was partially deployed extracorporeally to preload the gate from the ipsilateral side. The "snare ride" technique was used to rapidly cannulate the gate. Preloaded wire techniques during endovascular aortic repair can facilitate rapid gate cannulation, especially in patients with challenging anatomy., (© 2020 The Authors.)

A 54-year-old woman presented with an enlarging, pulsatile left neck mass and a history of Takayasu arteritis. She had seven prior cervical vascular reconstructions, including a prosthetic right-to-left carotid crossover, and left vertebral and subclavian bypasses done with saphenous vein. The skin of her neck was scarred and thin. The anastomotic pseudoaneurysms were resected, the left carotid bifurcation was reconstructed with the cryopreserved femoral artery because of the concern about wound healing, and the subclavian and vertebral vein grafts were reimplanted. Intraoperative management, clamp sites and sequence, manner of shunting, choice of conduit, and wound healing were important considerations., (© 2020 The Authors.)

Fenestrated-branched endovascular repair of thoracoabdominal aneurysms carries a risk of spinal cord ischemia owing to extensive coverage of intercostal arteries, but other consequences of decreased flow to the paraspinal muscles have not been delineated. We describe a 54-year-old woman treated by multibranched thoracoabdominal aneurysm repair who developed severe disabling exertional thoracic and lumbar back pain after the operation. Despite physical therapy, the patient remains with disabling symptoms at 2 years of follow-up. Transcutaneous oxygen pressures confirmed exercise-induced decrease in oxygen pressure, consistent with decreased muscle perfusion. We propose the term paraspinal muscle claudication to describe these symptoms., (© 2020 The Author(s).)

Median arcuate ligament syndrome is the result of celiac axis compression by the diaphragmatic crura. Although the celiac artery is the most common vessel to have compression, the renal arteries may also rarely be compressed by the crural fibers of the diaphragm, which may cause secondary hypertension. We present two cases of renovascular hypertension secondary to renal artery compression by the diaphragmatic crura. The first patient was treated with open decompression and wide resection of the crural fibers, and the second patient was decompressed laparoscopically. Neither case required renal artery reconstruction. Antihypertensives were discontinued in both patients postoperatively., (© 2020 The Authors.)

Occult endoleaks can pose a diagnostic and treatment challenge. These endoleaks are not effectively identified by multiphase computed tomography angiography, magnetic resonance angiography, or contrast-enhanced ultrasound. Possible causes are small fabric tears and slow-flow, dynamic, or positional endoleaks. We describe a patient with rapid aneurysm sac expansion and disseminated intravascular coagulopathy 46 months after four-vessel branched physician-modified endograft repair of a ruptured extent III thoracoabdominal aneurysm. Imaging failed to demonstrate an endoleak but identified fresh blood products within the sac. The patient underwent total realignment using branch-in-branch repair with a physician-modified endograft. Repeated imaging 25 days postoperatively revealed decrease in aneurysm diameter by 10 mm., (© 2020 The Authors.)

Infolding of a fenestrated-branched stent graft is an infrequent complication due to excessive oversizing. We report the case of an 89-year-old man who underwent a four-vessel fenestrated-branched endovascular aortic repair for a pararenal aortic aneurysm. Computed tomography angiography revealed severe infolding across the mesenteric-renal vessels. The patient was treated by angioplasty and placement of Palmaz stent. Cone-beam computed tomography confirmed patent visceral vessels with resolution of the infolding. This case illustrates an uncommon complication that can be prevented by modifications in the stent design and by immediate assessment using intraoperative cone-beam computed tomography.