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Successful thoracic endovascular aortic repair (TEVAR) for type B aortic dissections (TBAD) relies on securing the stentgraft's distal landing zone to prevent retrograde flow and false lumen pressurization. We describe a 60-year-old male with a TBAD undergoing TEVAR with electrocautery-wire fenestration of the dissection septum, providing a controlled method to enhance the distal landing zone for graft placement. Postoperatively, the patient experienced spinal cord ischemia, resolving with the placement of a lumbar drain and increasing mean arterial pressures. Follow-up imaging demonstrated a well-sealed repair without endoleaks. This case highlights the importance of surgical technique selection and postoperative monitoring for complications.

Penetrating traumatic aortic injury (PTAI) is increasing in prevalence given the rise in firearm violence in the United States and is associated with significant morbidity and mortality. These injuries often result in hemorrhagic shock, with patients presenting in extremis or pulseless, traditionally requiring open approaches for repair. A rare but potentially devastating complication of firearm-related PTAI is bullet embolization. This case report describes the successful resuscitation and endovascular treatment of a patient with a firearm-induced PTAI complicated by acute limb ischemia secondary to bullet arterial embolization to the common femoral artery requiring arteriotomy for bullet removal.

Addressing proximal complications that arise after endovascular aortic repair for type B aortic dissection, such as type Ia endoleaks, “bird-beaking” of the thoracic endovascular aortic repair (TEVAR) stent, retrograde type A dissection, and postdissection aneurysms, bears considerable complexities. We present a novel and safe method for open arch repair that can ensure a secure and efficient approach for TEVAR complications. The key element of the operative technique is approximating the grafted stent portion to the aortic wall and the arch prosthesis. The technique has successfully been implemented in 11 patients, who received secondary open arch repair from 2019 to 2022 after TEVAR for type B dissection. Our objective is not only to introduce this reliable concept but also to provide a comprehensive demonstration of its advantages and disadvantages compared with currently used open treatment methods and discuss patient outcomes after secondary open arch repair.

Type B aortic dissections can carry significant morbidity and mortality when not promptly treated. Although anti-impulse control remains the mainstay treatment of type B aortic dissection, they may often require repair when the dissection becomes complicated or develops high risk features. Thoracic endovascular aortic repair (TEVAR) has been successful for those who require repair but still carry associated procedural risks. Inadvertent coverage of a branch vessel is a rare but serious complication. We describe a case report of a patient with accidental proximal TEVAR deployment resulting in left common carotid artery partial coverage and malperfusion necessitating prompt carotid revascularization with stent placement adjacent to TEVAR.

Objective: The relationship among increased aortic arch angulation, aortic flow dynamics, and vessel wall stiffness remains unclear. This experimental ex vivo study investigated how increased aortic arch angulation affects aortic stiffness and stent-graft induced aortic stiffening, assessed by pulse wave velocity (PWV). Methods: Porcine thoracic aortas were connected to a circulatory mock loop in a Type I and Type III aortic arch configuration. Baseline characteristics and blood pressures were measured. Proximal and distal flow curves were acquired to calculate PWV in both arch configurations. After that, a thoracic stent-graft (VAMF2626C100TU) was deployed in aortas with adequate proximal landing zone diameters to reach 10% t0 20% oversizing. Acquisitions were repeated for both arch configurations after stent-graft deployment. Results: Twenty-four aortas were harvested, surgically prepared, and mounted. Cardiac output was kept constant for both arch configurations (Type I: 4.74 ± 0.40 and Type III: 4.72 ± 0.38 L/minute; P = .703). Compared with a Type I arch, aortic PWV increased significantly in the Type III arch (3.53 ± 0.40 vs 3.83 ± 0.40 m/second; P

A male patient, 70 years of age, was evaluated for an infected thoracic endovascular aneurysm repair (TEVAR). After presenting with persistent fever, a positron emission tomography scan found an infected aortic stent graft. The patient underwent open repair with explantation of the infected TEVAR, extensive periaortic debridement, graft replacement with a Dacron graft, and complete coverage with a latissimus dorsi muscle flap. Tissue culture revealed Clostridium spp. He was discharged home with long-term ampicillin and sulbactam. A postoperative computed tomography scan showed no recurrence of infection. Open surgery with latissimus muscle flap coverage is an achievable option for infected TEVAR.

We present a case of a 62-year-old male patient with chronic distal aortic arch aneurysm causing recurrent nerve palsy and prolonged total occlusion of the left main pulmonary artery (PA). During diagnostic work up, the aneurysm ruptured requiring cardio-pulmonary resuscitation (CPR) and emergency retrograde stenting. After circulatory stabilization the patient was treated with controlled hypothermia for 24 h, and successive extubation without neurological deficit.Postinterventional imaging revealed a reversed perfusion of the aneurysmal sac through the PA, prompting open surgical treatment. Surgery consisted of reconstruction of the left PA by pulmonary endarterectomy (PEA), xenopericardial patchplasty of the left PA and frozen elephant trunk (FET) repair after removal of the bare springs of the previously inserted Gore Tag stent graft. Pre-discharge computed tomography angiography (CTA) demonstrated a fully recanalized left PA system and a completely excluded aneurysm. At ten-year follow-up the patient presented physically unimpaired (NYHA I). CTA confirmed a fully intact thoracic aorta and improved pulmonary function despite persisting left recurrent nerve palsy.

ABSTRACT: Background: Aortic diameter growth in type B aortic dissection (TBAD) is associated with progressive aortic dilation, resulting in increased mortality in patients with both de novo TBAD (dnTBAD) and residual dissection after type A dissection repair (rTAAD). Preemptive thoracic endovascular aortic repair may improve mortality in patients with TBAD, although it is unclear which patients may benefit most from early intervention. In vivo hemodynamic assessment using four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) has been used to characterize TBAD patients with growing aortas. In this longitudinal study, we investigated whether changes over time in 4D flow-derived true and false lumen (TL and FL) hemodynamic parameters correlate with aortic growth rate, which is a marker of increased risk. Methods: We retrospectively identified TBAD patients with baseline and follow-up 4D flow CMR at least 120 days apart. Patients with TBAD intervention before baseline or between scans were excluded. 4D flow CMR data analysis included segmentation of the TL and FL, followed by voxel-wise calculation of TL and FL total kinetic energy (KE), maximum velocity (MV), mean forward flow (FF), and mean reverse flow (RF). Changes over time (Δ) were calculated for all hemodynamic parameters. Maximal diameter in the descending aorta was measured from magnetic resonance angiogram images acquired at the time of 4D flow. Aortic growth rate was defined as the change in diameter divided by baseline diameter and standardized to scan interval. Results: Thirty-two patients met inclusion criteria (age: 56.9 ± 14.1 years, female: 13, n = 19 rTAAD, n = 13 dnTBAD). Mean follow-up time was 538 days (range: 135–1689). Baseline aortic diameter did not correlate with growth rate. In the entire cohort, Δ FL MV (Spearman’s rho [rho] = 0.37, p = 0.04) and Δ FL RF (rho = 0.45, p = 0.01) correlated with growth rate. In rTAAD only, Δ FL MV (rho = 0.48, p = 0.04) and Δ FL RF (rho = 0.51, p = 0.03) correlated with growth rate, while in dnTBAD only, Δ TL KE (rho = 0.63, p = 0.02) and Δ TL MV (rho = 0.69, p = 0.01) correlated with growth rate. Conclusion: 4D flow-derived longitudinal hemodynamic changes correlate with aortic growth rate in TBAD and may provide additional prognostic value for risk stratification. 4D flow MRI could be integrated into existing imaging protocols to allow for the identification of TBAD patients who would benefit from preemptive surgical or endovascular intervention.

A type A aortic dissection is a challenging condition for both cardiothoracic and vascular surgeons. Although open surgery remains the gold standard, there is considerable interest in the use of endovascular techniques for patients who present with malperfusion. We present the case of an unstable 55-year-old man with visceral malperfusion from a type A dissection who was stabilized using an endovascular technique as a bridge to open surgery. A bare metal thoracic endograft was used in the ascending aorta to rapidly restore perfusion. This hybrid approach to the problem of malperfusion in type A dissection could be useful for these patients with complicated cases.

We present a rare manifestation of a common pathology: left sided sensorineural hearing loss secondary to subclavian steal syndrome after thoracic endovascular aortic repair for complicated acute aortic dissection. We describe the vascular physiology that can result in unilateral hearing loss and provide a brief review of subclavian steal syndrome. This case report highlights the importance of avid clinical recognition of an atypical presentation of a common vascular disease.

Objective: The objective is to describe the initial Canadian experience using novel aortic arch branched endograft technologies. Methods: We performed a retrospective consecutive case series of all patients undergoing aortic arch branched repair with newly available endograft technology since 2020 at our site. We describe the patient characteristics, treatment characteristics, and postoperative outcomes. Results: Eleven patients received arch branched endografts, indicated for penetrating aortic ulcer in seven patients (64%), arch degeneration after prior aortic dissection repair in three (27%), and acute aortobronchial fistula in one patient (9%). Their average age was 72 ± 7 years. Complete arch repair from zone 0 to 4 was performed in six cases (55%); the remaining repairs landed proximally in zones 1 or 2. Seven repairs used a single retrograde facing inner branch (thoracic branch endoprosthesis; W.L. Gore & Associates), three used double antegrade inner branch (Bolton Relay; Terumo Interventional Systems), and one emergent case used double in situ fenestrations. Seven repairs (64%) used an adjunctive extra-anatomic bypass to complete great vessel perfusion, two of which were created during a prior aortic repair. Inferior vena cava balloon inflow occlusion during deployment was used in all cases. No mortalities, transient or permanent spinal cord paralysis, myocardial infarction, dialysis dependence, venous thromboembolism, or bleeding requiring reintervention occurred. No patient undergoing elective arch branch repair experienced a stroke. The one patient undergoing emergent repair did suffer a stroke. The median length of stay was 5 days (interquartile range, 2-8 days). Two endoleaks developed: a type Ia endoleak successfully treated with a Palmaz stent (Cordis) during the index admission, and a type II endoleak with ongoing sac regression on postoperative follow-up. Postoperatively, one patient suffered a suspected aortic graft infection that was treated with lifelong antibiotics. During a mean radiographic follow-up of 7.2 months, no cases of branch vessel instability (ie, no migration, reintervention, arterial rupture, intraluminal thrombus, occlusion, stenosis, or kinking of the branch grafts) developed. Three patients experienced sac regression of >5 mm, and no patient experienced continued postoperative dilation. Conclusions: To the best of our knowledge, this is the largest reported Canadian volume of aortic arch repair using novel branched or fenestrated technology. The series demonstrates that a multidisciplinary program and properly selected patients can yield excellent results using endovascular repair for complex aortic arch pathology.

We present the case of a 75-year-old man with a symptomatic penetrating aortic ulcer located in zone 2 on the arch inner curve between the left subclavian artery and left carotid artery treated using a single branch thoracic endovascular aortic repair combined with in situ laser fenestration. The patient underwent a successful procedure with no neurologic impairment and was discharged on the second postoperative day. The postoperative follow-up showed a well-excluded penetrating aortic ulcer.

Numerical simulations of thoracic endovascular aortic repair (TEVAR) may be implemented in the preoperative workflow if credible and reliable. We present the application of a TEVAR simulation methodology to an 82-year-old woman with a penetrating atherosclerotic ulcer in the left hemiarch, that underwent a left common carotid artery to left subclavian artery bypass and consequent TEVAR in zone 2. During the intervention, kinking of the distal thoracic stent graft occurred and the simulation was able to reproduce this event. This report highlights the potential and reliability of TEVAR simulations to predict perioperative adverse events and short-term postoperative technical results.

A 76-year-old man was diagnosed with a Stanford type B aortic dissection that resulted in an occluded abdominal AFX2 endograft (Endologix Inc., Irvine, CA, USA), which had been placed four months prior, and bilateral limb ischemia. Malperfusion was successfully treated using thoracic endovascular aortic repair and bilateral thrombectomy. Here, we describe the collapse of an AFX2 endograft owing to acute aortic dissection, highlighting that endovascular treatment should be initially considered in such cases.

A 30-year-old woman presented following a motor vehicle collision with a grade III blunt thoracic aortic injury and an aberrant right subclavian artery. Using intraoperative ultrasound and diagnostic subtraction angiography, we deployed an aortic endograft (cTAG; W.L. Gore & Associates), excluding the injury and aberrant right subclavian artery. The patient immediately lost arterial waveforms in her left arm, confirming incidental coverage of the left subclavian artery, likely due to the polytetrafluoroethylene sheath of the endograft. Her pulses returned after placement of a left subclavian chimney via retrograde brachial artery access.

Introduction: Calcification of a vascular endograft and adjacent tissues (adventitia, media, and neointima) can result in graft failure. This report shows a rare case of intraluminal calcifications in the distal end of a thoracic endovascular aortic repair (TEVAR) endograft implanted 11 years previously for grade IV blunt traumatic aortic injury (BTAI) in a young patient. Report: A 24 year old man required TEVAR for a BTAI caused by a motorcycle accident. The procedure consisted of TEVAR and an emergency left carotid subclavian venous bypass. Eleven years after the procedure, he had severe hypertension. Intra-TEVAR calcifications appeared, gradually increasing on computed tomography angiography (CTA). Calcifications in the distal luminal end of the TEVAR were responsible for a 60% stenosis on CTA. An open approach was indicated after multidisciplinary discussion, based on the gradient value. The patient underwent explantation, with total replacement of the aortic arch and descending thoracic aorta with re-implantation of the supra-aortic vessels, under extracorporeal circulation. Macroscopic analysis showed no device degeneration but revealed a solid mass at the distal end of the TEVAR. Both microcomputed tomography and histopathology confirmed the calcific nature of the lesions. Conclusion: This case highlights a rare long term graft failure due to calcified neo-atherosclerosis in a TEVAR.

Background: Thoracic endovascular aortic repair (TEVAR) in children and adolescents after blunt traumatic aortic injury (BTAI) is being performed increasingly despite no endovascular graft being approved for TEVAR in this population. The smaller diameter of the aorta and access vessels and steeper angle of the aortic arch pose specific challenges for TEVAR in this population. Moreover, data are lacking regarding medium to long term complications. This case presents an adolescent patient who underwent TEVAR for BTAI and suffered a focal aortic dissection several months later. Report: The patient initially presented after a motor vehicle accident and underwent an uncomplicated TEVAR procedure with a 28 mm diameter stent graft (the smallest device available at the time) for Grade III traumatic aortic dissection; the native aortic diameter was 15 mm. The diameter mismatch was accepted due to the lifesaving nature of the procedure. More than 7 months later the patient presented to the emergency department after not being able to urinate for several days and experiencing pain, tingling, and weakness in both legs. Blood samples showed a severe acute kidney injury and computed tomography angiography showed significant aortic stenosis in the distal part of the stent graft, probably caused by a focal dissection. The stenosis and dissection were successfully treated using a Palmaz stent, after which his renal function and extremity complaints recovered. Conclusion: The focal dissection was probably caused by stress on the aortic wall due to the aorta–stent graft diameter mismatch. This case demonstrates that complications after TEVAR in adolescents can arise months after the initial procedure and underscores the need for continued vigilance, especially in cases with an aorta–stent graft mismatch. The threshold for additional imaging and consultation by a vascular surgeon should be low.

Thoracic endovascular aortic repair will typically require adequate caliber iliofemoral arteries for device deployment. We describe the case of a patient with extensive iliofemoral disease, which necessitated transcaval delivery of an aortic graft to repair a distal aortic arch aneurysm. Our case report highlights the novel use of intravascular ultrasound to localize an optimal site for creation of an aortocaval connection and the subsequent use of a ventricular septal defect occluder to close the connection after successful stent deployment.

We have presented a case of a ruptured descending aortic aneurysm that was accompanied by extreme tortuosity and a pseudocoarctation at the level of the ligamentum arteriosum. We performed successful endovascular repair, covering the left subclavian artery, using a transapical-to-femoral artery (through-and-through) guidewire technique to overcome the tortuosity, with the option to perform balloon angioplasty in the case of an increased gradient over the coarctation. In the present case report, we have underlined the role of close collaborations with aortic expertise centers.

We describe a 78-year-old woman with a large ascending aortic pseudoaneurysm who underwent thoracic endovascular aortic repair under intraoperative image fusion guidance and real-time transcranial Doppler (TCD) monitoring. TCD monitoring revealed a total of 419 microembolic signals throughout the procedure, with the majority occurring as the first stent graft crossed the ascending aorta. Two days later, she underwent endovascular repair of a graft type IA endoleak. We highlight the role of image fusion guidance and TCD monitoring in enabling successful thoracic endovascular aortic repair in an elderly woman and in identifying procedural areas of improvement to minimize stroke risk.

Thoracic endovascular aortic repair (TEVAR) has become the most common strategy for management of traumatic aortic injury. Surgical planning and execution may involve several imaging modalities, including CT, fluoroscopy, and intravascular ultrasound (IVUS). This article describes the technique and successful intraoperative application of transesophageal echocardiogram (TEE) in TEVAR as an adjunct imaging modality to guide stent placement and deployment and evaluate pre- and post-TEVAR flow within an aortic pseudoaneurysm. When coupled with conventional techniques, including IVUS and fluoroscopy, this tool can be an important tool in the vascular surgeon's armamentarium for evaluating intraoperative anatomic questions related to TEVAR with little additional risk, cost, or increased operating time.

Background: Although commonly used for the treatment of descending aortic dissection, endovascular repair is challenging for ascending aortic pseudoaneurysms. Rapid ventricular pacing (RVP), a method that temporarily impedes cardiac output by stopping ventricular activity, heralds potential benefits for thoracic endovascular aortic repair (TEVAR) during precision landing. Recently, we successfully treated an anastomosis pseudoaneurysm after the Bentall procedure using TEVAR assisted by RVP. Case report: A 69-year-old male was admitted to our hospital with a ascending aortic anastomosis pseudoaneurysm. He had undergone a Bentall procedure and a coronary artery bypass grafting nine years prior. After extensive consultation, the decision was made to perform TEVAR with the assistance of RVP. After a covered stent graft was delivered to the precise location of the ascending aorta, RVP was performed at a frequency of 180 beats/min with a pacemaker. When a flattened arterial blood wave of

Background: Persistent distal false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) can lead to aneurysmal degeneration and an increased risk of rupture. We have presented our initial experience using a modified “candy-plug” (CP) technique for FL embolization. Methods: From February 2021 to July 2022, we treated six patients using the modified CP technique. All the patients had undergone prior or simultaneous TEVAR for chronic TBAD with persistent FL perfusion and aneurysm expansion. Bilateral common femoral artery access was obtained, and intravascular ultrasound was used to confirm wire access in the true lumen (TL) and FL. A conformable TAG device (W.L. Gore & Associates, Flagstaff, AZ) was used in four cases and an Excluder aortic cuff (W.L. Gore & Associates) in two cases. The device was modified by placing a constraining “napkin-ring” suture through the middle segment of the device. Femoral sheaths were placed in the TL and FL. A standard TL TEVAR extension was performed at the level of the celiac artery (zone 5). Next, the CP device was advanced and deployed in the FL, distally aligning it with the TL device. An appropriately sized Amplatzer II plug (Abbot Vascular, Santa Clara, CA) was then deployed in the constrained segment of the modified stent graft. Completion angiography was performed to confirm successful FL embolization. Results: Technical success was defined as successful deployment of the CP device in the FL. The technical success rate was 100% (six of six patients). Clinical success was defined as the cessation of aneurysm growth on follow-up computed tomography angiography. No 30-day mortality, myocardial infarction, stroke, spinal cord ischemia, access site complications, or aortic-related reinterventions occurred. Surveillance imaging at a mean follow-up of 10 months confirmed clinical success (stable aneurysm size or shrinkage) for all five patients with follow-up data available. Conclusions: The modified CP embolization technique is a promising solution for persistent distal FL perfusion after TEVAR for TBAD. Further investigation is required to determine the long-term durability of this technique as an adjunct to TEVAR to promote aortic remodeling.

Chronic distal thoracic dissections treated with thoracic endovascular repair are prone to type Ib false lumen perfusion. When the supraceliac aorta is of normal caliber, fenestration of the dissection flap proximal to the visceral vessels creates a seal zone for the thoracic stent graft and eliminates the type Ib false lumen perfusion. We describe a novel way of crossing the septum using electrocautery delivered through a wire tip then fenestrating the septum using electrocautery delivered over a 1-mm area of uninsulated wire to cut the septum. We believe the use of electrocautery creates a controlled and deliberate aortic fenestration during endovascular repair of a distal thoracic dissections.

To the best of our knowledge, the present report is the first on the safety and efficacy of complete endovascular aortic reconstruction from zone 0 to 10 using a standardized approach and parallel stent graft configurations in high-risk patients considered unfit for surgery. During a 7-year period, five patients with complex thoracoabdominal aortic aneurysms and dissections involving zone 0-10 presented with rupture (n = 1; 20%), were symptomatic (n = 2; 40%), or had an aortic pseudoaneurysm (n = 2; 40%) and underwent complete endovascular zone 0-10 reconstruction using off-the-shelf stent grafts in parallel configurations that included chimneys, periscopes, and endovascular docking stations. The zone 0-5 complete arch chimney thoracic endovascular repair included chimneys that extended from the ascending thoracic aorta to the innominate, left common carotid, and left subclavian arteries and a thoracic stent graft extending from zone 0 to 5. The zone 5-10 aortic reconstructions were staged. Stage 1 included either thoracic stent graft and antegrade four visceral chimney placement or abdominal aortic stent graft and retrograde four visceral chimney placement. Stage II included completion of the remainder of the aortic reconstruction with cerebrospinal fluid drainage. A total of 15 aortic procedures included 34 chimneys (14 aortic arch and 20 visceral). Two patients (40%) underwent zone 0-5 aortic reconstruction first, and three patients (60%) underwent zone 5-10 aortic reconstruction first. The incidence of 30-day mortality, spinal cord ischemia, myocardial infarction, stroke, and visceral ischemia was 0%. At a mean follow-up of 4.5 ± 3.1 years, the aortic reconstruction-related mortality was 0%. All-cause mortality was 20%; one patient had died of pneumonia at 3 years postoperatively. Two endoleaks each occurred in zone 0-5 and zone 5-10 (40% for both groups). All endoleaks were treated with coil embolization. Complete endovascular zone 0-10 aortic reconstruction using parallel stent grafts with a docking station is a feasible and relatively safe technique that offers the ability to customize off-the-shelf devices for the treatment of high-risk patients with limited morbidity and mortality.

Patients presenting with a Stanford type A acute aortic dissection require immediate surgical treatment; however, up to 30% of patients are deemed inoperable. Here we describe a case of a patient with a complicated type A acute aortic dissection presenting with a severe impact of brain malperfusion. In contrast with open surgery, an emergent thoracic endovascular aortic repair was performed with a Gore cTAG 45 × 150 mm graft and an additional chimney graft Advanta V12 7 × 59 mm graft for the brachiocephalic trunk. After early extubation, unexpected complete neurological recovery was observed. A follow-up computed tomography scan demonstrated complete remodeling of the ascending aorta. This report underlines the potential of thoracic endovascular aortic repair as an alternative for immediate open surgical repair in case of high-risk or inoperable patients.

A 70-year-old woman with a bioprosthetic aortic valve replacement for aortic valve endocarditis complicated by recurrent endocarditis and requiring homograft aortic root replacement 10 years earlier had presented at 1 month after her admission for pseudomonal bacteremia with right-sided chest pain. An aortic pseudoaneurysm, identified on computed tomography, was treated with an ascending aorta thoracic endovascular aortic repair using two overlapping abdominal aortic stent grafts in the ascending aorta. Postoperative and follow-up imaging demonstrated exclusion of the pseudoaneurysm with stable positioning of the stent grafts. Ascending aorta thoracic endovascular aortic repair can be performed safely with good short-term results in patients presenting with infected pseudoaneurysms of the ascending aorta.

Understanding and recognizing anatomic anomalies of the aortic arch is important when planning extra-anatomic debranching before thoracic endovascular aortic repair. A rare anomaly is the left vertebral artery aberrantly arising from the aortic arch; found in ∼5% of adults. When present, the artery courses through the carotid sheath at a variable length before entering the third or fourth cervical transverse foramen. In the present report, we have described the case of a 49-year-old man with a symptomatic, enlarging type B aortic dissection with an aberrant left vertebral artery and the novel methods used to surgically correct his pathology.

Aorto-cutaneous fistulas are an unusual and life-threatening complication after aortic surgery. We present the case of an endovascular intervention for an aorto-cutaneous fistula of the ascending aorta that was intended to be a bridge to definitive surgical treatment and report a literature review. A 56-year-old woman had a previous Bentall’s procedure and mitral valve annuloplasty in 2016. Four years later she re-presented with an infective pseudoaneurysm of the distal anastomosis of the ascending aortic graft, with aorto-cutaneous fistulation. She was at high risk for a revision operation and required optimization before a major open surgery. A thoracic endovascular aortic repair stent graft (Valiant Navion; Medtronic Inc) was implanted to exclude the distal anastomotic pseudoaneurysm. Two months later she re-presented with a new infected pseudoaneurysm at the proximal end of the previously implanted stent graft, and a further thoracic endovascular aortic repair was undertaken.

Resumen: El manejo de la enfermedad aórtica que involucra el arco sigue siendo un gran desafío. El acercamiento a la patología del arco aórtico es complejo debido a la presencia de los vasos supra-aórticos. La patología clásica incluye disección, aneurismas, hematoma intramural y la úlcera penetrante. La indicación convencional de la cirugía sigue estando relacionada con el tamaño aórtico, la velocidad de crecimiento y los síntomas. Hay dos líneas de tratamiento bien definidas. La primera es la cirugía clásica abierta y uso de injertos de Dacron, con circulación extracorpórea (CE), pinzamiento aórtico y paro circulatorio en hipotermia profunda (PCHP). Este procedimiento sigue siendo considerado el tratamiento estándar, particularmente en pacientes jóvenes de bajo riesgo y aquellos con trastorno del tejido conectivo. Es evidente, particularmente cuando se trata de una disección aórtica, que una resección y reparación más extensas podrían ofrecer un mejor resultado a largo plazo con menor necesidad de otros procedimientos en el futuro. La combinación de técnicas quirúrgicas clásicas con tecnología endovascular ha ganado un rol fundamental y ha cambiado el paradigma del tratamiento quirúrgico aislado clásico y lo ha movido hacia un procedimiento combinado con el uso de un stent cubierto autoexpandible para prevenir el colapso del lumen verdadero y favorecer la trombosis y oclusión del lumen falso. Este procedimiento se conoce como “trompa de elefante congelada”. Esta segunda línea de tratamiento es esencialmente crítica para aquellos pacientes con más comorbilidades y mayor riesgo quirúrgico. Los procedimientos híbridos con una combinación de des-ramificado quirúrgico y TEVAR percutáneo, evitando la CE, el pinzamiento aórtico y el PCHP, tienen resultados similares a los de la cirugía estándar. Actualmente existen muchas experiencias con el tratamiento endovascular total con combinación de diferentes técnicas y dispositivos percutáneos. Claramente, este sigue siendo un proceso en curso que debe demostrar resultados comparables a corto, mediano y largo plazo. Abstract: The management of aortic disease involving the arch remains a formidable effort. The approach to aortic arch pathology is very challenging due to the presence of supra-aortic vessels. Classic pathology includes dissection, aneurisms, intramural hematoma, and penetrating ulcers. Conventional indication of surgery remains related to aortic size, growth rate and symptoms. There are two-well defined lines of treatment. The first one still remains the gold standard, particularly in young low risk patients and those with connective tissue disorder and involves open surgery grafts with extracorporeal circulation (EC), aortic cross clamp, and deep hypothermic circulatory arrest (DHCA). It is evident however, particularly when treating aortic dissection, that a more extensive resection and repair could offer better long-term results with less need of follow-up procedures. Combination of classic surgical techniques with endovascular technology have taken a role and led to a paradigm shift from classical isolated surgical treatment to a combination with self-expanding covered stent graft to prevent true lumen collapse and favor false lumen thrombosis and occlusion. This procedure is known as a frozen elephant trunk. This second line of treatment is essentially critical to those patients with more comorbidities and higher surgical risk. Hybrid procedures with a combination of surgical debranching and percutaneous thoracic endovascular aortic repair (TEVAR), avoiding EC, aortic cross-clamp and DHCA, have similar results when compared to standard surgery. Currently there are many experiences with total endovascular treatment combined with different percutaneous techniques and devices. Clearly this is still an ongoing process with emerging data that will need to be compared with open surgical outcomes in the short, medium, and long term.

Endovascular treatment of the chronically dissected aorta can be especially challenging due to unending variations in post-dissection configurations. Traditionally, basic principles of thoracic endovascular aortic repair rely on bilateral femoral access and deployment of a stent-graft within the true lumen. In the present report, we describe a case of trans-septal thoracic endovascular aortic repair in a patient with complex chronic residual type B aortic dissection (1,10) with dilation up to 10 cm in the context of a chronically occluded right external iliac artery, and a left iliofemoral system supplied by the false lumen.

Subclavian artery aneurysms are rare peripheral artery aneurysms, and open surgical repair is the reference standard treatment. We have reported the case a patient with a right subclavian artery aneurysm who was not indicated for open surgical repair because of comorbidities. Thus, endovascular treatment using the Gore Excluder Iliac Branch Endoprosthesis (WL Gore and Associates, Flagstaff, Ariz) was performed, leading to complete aneurysmal exclusion without perioperative complications. Although anatomic limitations exist, this technique could be alternative treatment option for right subclavian artery aneurysms.

Objective: Formation of a bird-beak configuration in thoracic endovascular aortic repair (TEVAR) has been shown to be influenced by various factors. However, the main cause of bird-beak formation remains poorly understood. The hypothesis has been that the geometric and mechanical properties of both the aorta and the stent graft contribute to the formation and extent of a bird-beak configuration. The goal of the present study was to use parameter-based computational simulations of TEVAR to predict for bird-beak formation and identify its most significant contributing factors. Methods: In the present study, we considered five parameters for the computational simulations of TEVAR, including aortic curvature, aortic arch angle, age as a surrogate for thoracic aortic tissue properties, TEVAR landing zone, and stent graft oversizing. Using an experimental design approach, computational models for 160 TEVAR scenarios were developed by varying the values of the simulation parameters within clinically relevant ranges. The bird-beak length and angle were used as metrics to evaluate the simulation results. Statistical analysis of the simulation data using a random forest model was conducted to identify significant parameters and interactions. Results: The mean ± standard deviation of the bird-beak length and angle across 160 simulations were 4.32 ± 4.87 mm and 9.16° ± 12.21°, respectively. The largest mean bird-beak length and angle were found in the most distal location in zone 0 (10.04 mm) and zone 2 (21.48°), respectively. An inverse correlation was found between the aortic arch angle and the bird-beak length and angle. In ∼75% of the scenarios, increased stent graft oversizing either fully resolved the presence of the bird-beak configuration or had reduced its size. In the remaining 25%, oversizing minimally changed the bird-beak length and enlarged the bird-beak angle, which mainly occurred in cases with a smaller aortic arch angle and landing zones near the arch apex. This was justified by the mechanism of stent graft bending in the arch angulation. The aortic curvature and tissue properties were shown to be statistically insignificant in relation to bird-beak formation. Conclusions: Significant parameters predictive of a bird-beak configuration in TEVAR were identified, and the trends in which each parameter influenced the bird-beak size were determined. The findings from the present study can inform the surgical planning and device selection process with the goal of minimizing bird-beak formation. : Clinical Relevance: The presence of a bird-beak configuration after thoracic endovascular aortic repair (TEVAR) has been correlated with the risk of type Ia endoleaks. The underlying cause of bird-beak formation remains poorly understood. In the present study, parameter-based computational models of TEVAR were used to identify the most significant mechanical and geometric factors contributing to bird-beak formation. Our findings have suggested that the aortic arch angle, landing zone, and stent graft oversizing are statistically significant in relation to the formation and extent of bird-beak configurations. With proper validation, these findings could be useful in the identification of patients with a greater risk of bird-beak formation preoperatively, optimal stent graft selection, and procedure modifications to minimize bird-beak formation.

Objective: The treatment of complex aortic disease has been described with various retrograde visceral bypass techniques. An original technique with a single stem retrograde visceral graft (SSRVG) is presented. Methods: This was a single centre retrospective study including 16 patients between 2015 and 2019. Patients were treated for aortic dissection (AD; type A and acute or chronic type B), thoraco-abdominal aortic aneurysms (TAAAs), and visceral occlusive disease. Surgery consisted of visceral vessel debranching from the native infrarenal aorta or from an aortic graft. In the case of AD, surgical fenestration was performed. Additional thoracic endovascular aneurysm repair (TEVAR) completed the treatment when indicated, during the same procedure or later. Patient outcomes and reconstruction patency were studied. Results: The mean patient age was 64 years (median 68 ± 12.6). Ten (62%) patients were treated for AD, three (19%) for TAAA, and three (19%) for occlusive disease. Sixty-nine target vessels were debranched with this SSRVG technique. Aortic surgical fenestration was performed in eight cases and TEVAR in four. During their hospital stay, three (19%) TAAA patients died, seven cases of renal insufficiency (44%), four cases of pneumonia (25%), and three colonic ischaemia cases (19%) were noted. After a mean follow up of 21 months, no other deaths occurred. All vessels (except two inferior mesenteric arteries) were patent and no endoleak was noted. Conclusion: The SSRVG technique can be offered in various complex aortic diseases. The use of a single graft is feasible and reduces the volume of multiple branch assembly in the retroperitoneal space. The observed patency rate is high.

Objectives: Formation of bird-beak configuration in thoracic endovascular aortic repair (TEVAR) has been shown to be correlated with the risk of complications such as type Ia endoleaks, stent graft migration, and collapse. The aim of this study was to use patient-specific computational simulations of TEVAR to predict the formation of bird-beak configuration preoperatively. Methods: Patient-specific TEVAR computational simulations are developed using a retrospective cohort of patients treated for thoracic aortic aneurysm. The preoperative computed tomography images were segmented to develop three-dimensional geometry of the thoracic aorta. These geometries were used in finite element simulations of stent graft deployment during TEVAR. Simulated results were compared against the postoperative computed tomography images to assess the accuracy of simulations in predicting the proximal position of a deployed stent graft and presence of bird-beak. In cases with a bird-beak configuration, the length and angle of the bird-beak were measured and compared between the simulated and postoperative results. Results: Twelve TEVAR patient cases were simulated. Computational simulations were able to accurately predict whether the proximal stent graft was fully apposed, proximal bare stents were protruded, or bird-beak configuration was present. In three cases with bird-beak configuration, simulations predicted the length and angle of the bird-beak with less than 10% and 24% error, respectively. Other factors such as a small aortic arch angle, small oversizing value, and landing zones close to the arch apex may have played a role in formation of bird-beak in these patients. Conclusions: Computational simulations of TEVAR accurately predicted the proximal position of a deployed stent graft and the presence of bird-beak preoperatively. The computational models were able to predict the length and angle of bird-beak configurations with good accuracy. These simulations can provide insight into the surgical planning process with the goal of minimizing bird-beak occurrence. : Clinical Relevance: Finite element analysis is a noninvasive method for simulation and prediction of thoracic endovascular aortic repair (TEVAR) outcomes. In this study, a computational approach for patient-specific simulations of TEVAR was implemented to accurately predict bird-beak configuration preoperatively. In addition, the length and angle of bird-beak configurations, which have been shown in previous studies to be correlated with bird-beak adverse events, were predicted with good accuracy. This computational approach is clinically significant as it has the potential to enhance TEVAR surgical planning capabilities with the goal of minimizing bird-beak occurrence. For patients with risk of bird-beaking, additional emphasis can be placed on optimal stent graft oversizing and device selection.

A 69-year-old female patient presented with a 5.8 cm thoracoabdominal aortic aneurysm Crawford type II after partial arch replacement. She was treated by a branched thoracic endovascular aortic repair procedure using a branched arch endograft with one retrograde branch to the left subclavian artery. After deployment of a Viabahn as a bridging covered stent to the left subclavian artery, the deployment line did not detach and the delivery catheter could not be removed. With the use of a physician-modified sidehole catheter and balloon fixation, the pulling line could be released without displacement of the Viabahn endoprosthesis.

Objective: Cardiovascular complications remain one of the major all-cause mortalities among patients who receive either thoracic endovascular aortic repair (TEVAR) or open surgical repair (OSR). Increased aortic stiffness after endograft deployment has been shown to induce left ventricular hypertrophy, diastolic dysfunction, and reduced coronary flow reserve. However, there is limited data on the hemodynamic effects after OR. The purpose of this study is to compare the cardiovascular and hemodynamic changes after TEVAR and OR., Methods: A retrospective analysis of 100 patients with thoracic aortic aneurysm or dissection who underwent open (n=50) or endovascular repair (n=50) was conducted. Information on demographics, medical and surgical history, and clinical outcomes were retrieved. Transthoracic echocardiographic (TTE) imaging results were collected to assess cardiac function. Changes to antihypertensive medication dosage and number were used as surrogate markers for hemodynamic changes and aortic stiffness., Results: No statistically significant differences were observed in antihypertensive medication number or dosage between the TEVAR and OSR group at 12 months, 24 months, and 36 months post-surgery. When adjusting for patient demographic factors of age, sex, and BSA in a multivariable generalized estimating equation model, patients who underwent TEVAR had a higher likelihood of receiving more antihypertensive medications (IRR = 1.131; P = .044). Patient characteristics such as BSA (IRR = 1.266; P = .001), HTN (IRR = 2.070; P ≤ .001), DM (IRR = 1.474; P ≤ .001), ESRD (IRR = 1.304; P = .011) were also associated with a higher number of antihypertensive medications. A significant increase in beta-blockers (P ≤ .001) and diuretics (P = .046) intake was observed post-TEVAR and post-OR. No significant differences in left ventricular ejection fraction and left ventricular hypertrophy were observed between the two groups., Conclusions: We observed a greater likelihood of antihypertensive medications escalation following TEVAR, suggesting an increase in aortic stiffness post-operatively. No significant differences in cardiac remodeling were observed between the two groups. Our findings emphasize the need for an improved post-operative cardiac surveillance program in patients undergoing both TEVAR and OSR. Furthermore, additional innovation is needed to create aortic grafts that are more compatible with the native aorta in order to reduce long-term cardiovascular complications., (Copyright © 2024. Published by Elsevier Inc.)

Objective: This retrospective, multicentre, observational study analysed patients who underwent endovascular repair for blunt traumatic aortic injury at four tertiary trauma referral centres over twenty years. It aimed to determine early and long term survival, analyse aortic and device related complications, and assess the re-intervention rate after endovascular repair for blunt traumatic aortic injury., Methods: All patients treated from 1 January 2001 to 31 October 2021 were identified using local hospital registries and two national registries: the Swedish vascular registry (Swedvasc) and Swedish trauma registry (SweTrau). Patient, treatment, and follow up data were extracted from medical records and radiology data by review of congregated imaging. The report was structured according to the STROBE checklist., Results: Ninety five patients were included: 80 were male (84%), median age was 42 years (IQR 27, 64), and median follow up time was 6.1 years (IQR 0.7, 12.4). Thirty day mortality was 16% (15 of 93), 40% of these were caused by traumatic brain injury and 33% of aortic related causes. Estimated overall survival was 57% (SE 6.6) at fifteen years after index treatment. Aortic re-intervention procedures (re-stenting, coiling, or explantation) were performed in 14 of 86 (16%) patients, six of whom underwent stent graft explantation. Seven of the 14 patients (50%) who underwent aortic re-intervention presented with symptoms and six of 14 had a device related complication. All complications that required aortic re-intervention were diagnosed within 18 months after the index procedure. There was no association between injury grade and aortic re-intervention., Conclusion: Thoracic endovascular aortic repair is an effective treatment for patients with blunt traumatic aortic injury needing intervention. It carries low rates of device related complications and mortality, and the long term outcomes are acceptable. As all aortic complications requiring re-intervention were identified during the first two years after index treatment, with half of the patients reporting symptoms, future follow up protocols should be adjusted accordingly., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objective: High risk, inoperable patients with ascending aortic disease are increasingly managed with thoracic endovascular aortic repair (TEVAR). The aim of this study was to assess the available literature on TEVAR confined to the ascending aorta (aTEVAR), describing study and patient characteristics, procedural and stent graft details, and outcomes., Data Sources: This was a systematic review and meta-analysis. MEDLINE, Web of Science, and Scopus were systematically searched for eligible studies reporting on outcomes after aTEVAR (PROSPERO ID: CRD42023440826). Eligible studies reported outcomes after aTEVAR without adjunctive supra-aortic vessel treatment., Review Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The ROBINS-I and Joanna Briggs Institute Critical Appraisal Checklist were used as quality assessment tools. A Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence certainty analysis was performed for the main outcomes. The main outcome was death. A proportional meta-analysis was performed with a mean and 95% confidence interval (CI) for the main outcomes. All articles were included up until 1 January 2024., Results: Ninety four studies were included (19 cohort studies, 75 case reports or series), reporting on 259 patients (57.8% male). Mean age was 69.1 (95% CI 65.0 - 73.1) years and mean follow up was 19.6 (95% CI 14.5 - 24.6) months. The most common comorbidity was prior cardiac/thoracic surgery (n = 191). The most frequent indications for aTEVAR (52.1% urgent aTEVAR) were type A aortic dissection (43.8%) and pseudoaneurysm (38.8%). The most commonly deployed stent grafts were Gore (44.5%), Cook (23.5%), and Medtronic (17.0%). In hospital mortality rate was 7.3% (95% CI 4.7 - 11.2%), 30 day mortality rate was 7.7% (95% CI 5.1 - 11.6%), and overall mortality rate was 17.0% (95% CI 12.9 - 22.0%) during follow up. GRADE showed very low evidence certainty for all outcomes. Eighty eight complications were reported and there was a re-operation rate of 13.1% (95% CI 9.5 - 17.8%). In hospital mortality and 30 day mortality rates for type A dissection were 12.4% (95% CI 7.5 - 19.7%) (n = 14) and 13.3% (95% CI 8.2 - 20.8%) (n = 15), respectively, and for pseudoaneurysm were 4.0% (95% CI 1.6 - 9.8%) (n = 4), and 4.0% (95% CI 1.6 - 9.8) (n = 4), respectively., Conclusion: Despite heterogeneous literature and very low GRADE evidence certainty, aTEVAR seems technically feasible in high risk patients. In addition, there is need for a consensus on when and how to use aTEVAR and a need for a specific endograft for use in the ascending aorta., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection., Methods: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. End points included technical success, clinical success, early (30-day) computed tomography angiography findings, early (30-day) mortality, adverse events, and aortic remodeling in patients with available computed tomography angiography follow-up and reintervention., Results: A total of 155 patients received a custom-made CP, of whom 32 patients (44% male, mean age 61 ± 9 years) were treated urgently and 123 patients (63% male, mean age 62 ± 11 years) electively. The primary CP rate was higher in the urgent group (28/32, 88%, in the urgent group vs 96/123, 78%, in the elective group, P = .051). The mean contrast volume was higher in the urgent group (157 ± 56 mL in the urgent group vs 130 ± 71 mL in the elective group, P = .017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 of 32 (78%) patients in the urgent group vs 113 and 123 (92%) in the elective group (P = .159). The early mortality rate was 13% (4 of 32 patients) in the urgent group vs 1% (1 of 123 patients) in the elective group (P = .120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related reinterventions were required in 6 of 32 (19%) patients in the urgent group vs 6 of 123 (5%) in the elective group (P = .094). Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, 18%, in the urgent group vs 63/114, 55%, in the elective group, P = .001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, 79%, in the urgent group vs 47/114, 41%, in the elective group, P = .000). An increase in thoracic aortic aneurysm sac occurred in 1 of 28 (4%) patients in the urgent group vs 4 of 114 (4%) patients in the elective group (P = .096)., Conclusions: The urgent use of the CP technique for distal FL occlusion in aortic dissection was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved a high rate of aortic remodeling., Competing Interests: Disclosures T.K. has intellectual property with Cook Medical; and receives royalties, research, travel and educational grant, speaking fees from and is a consultant and proctor for Cook Medical. S.H. is a consultant for Cook Medical, GE Healthcare, and Bentley. L.B. is a proctor and consultant for Cook Medical. S.T. is a consultant and speaker for WL Gore and Medtronic. T.L. is a proctor and consultant for Cook Canada. T.J. has travel grants, consultation fees, and proctorship fees from Cook Medical and Hammered (Polish representative of Cook Medical). J.S. is a speaker, proctor, and consultant for Cook Medical. N.T. is a proctor for Cook Medical and receives institutional grant from Cook Medical. G.P. is a proctor for Cook Medical. The remaining authors report no conflicts., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: In patients undergoing elective thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) coverage, routine preoperative LSA revascularization is recommended. However, in the current endovascular era, the optimal surgical approach is debated. We compared baseline characteristics, procedural details, and perioperative outcomes of patients undergoing open or endovascular LSA revascularization in the setting of TEVAR., Methods: Adult patients undergoing TEVAR with zone 2 proximal landing and LSA revascularization between 2013 and 2023 were identified in the Vascular Quality Initiative. We excluded patients with traumatic aortic injury, aortic thrombus, or ruptured presentations, and stratified based on revascularization type (open vs any endovascular). Open LSA revascularization included surgical bypass or transposition. Endovascular LSA revascularization included single-branch, fenestration, or parallel stent grafting. Primary outcomes were stroke, spinal cord ischemia (SCI), and perioperative mortality (Pearson's χ 2 test). Multivariable logistic regression was used to evaluate associations between revascularization type and primary outcomes. Secondarily, we studied other in-hospital complications and 5-year mortality (Kaplan-Meier, multivariable Cox regression). Sensitivity analyses were performed in patients undergoing concomitant LSA revascularization to TEVAR., Results: Of 2489 patients, 1842 (74%) underwent open and 647 (26%) endovascular LSA revascularization. Demographics and comorbidities were similar between open and endovascular cohorts. Compared with open, endovascular revascularization had shorter procedure times (median, 135 minutes vs 174 minutes; P < .001), longer fluoroscopy times (median, 23 minutes vs 16 minutes; P < .001), lower estimated blood loss (median, 100 mL vs 123 mL; P < .001), and less preoperative spinal drain use (40% vs 49%; P < .001). Patients undergoing endovascular revascularization were more likely to present urgently (24% vs 19%) or emergently (7.4% vs 3.4%) (P < .001). Compared with open, endovascular patients experienced lower stroke rates (2.6% vs 4.8%; P = .026; adjusted odds ratio [aOR], 0.50 [95% confidence interval (CI), 0.25-0.90]), but had comparable SCI (2.9% vs 3.5%; P = .60; aOR, 0.64 [95% CI, 0.31-1.22]) and perioperative mortality (3.1% vs 3.3%; P = .94; aOR, 0.71 [95% CI, 0.34-1.37]). Compared with open, endovascular LSA revascularization had lower rates of overall composite in-hospital complications (20% vs 27%; P < .001; aOR, 0.64 [95% CI, 0.49-0.83]) and shorter overall hospital stay (7 vs 8 days; P < .001). After adjustment, 5-year mortality was similar among groups (adjusted hazard ratio, 0.85; 95% CI, 0.64-1.13). Sensitivity analyses supported the primary analysis with similar outcomes., Conclusions: In patients undergoing TEVAR starting in zone 2, endovascular LSA revascularization had lower rates of postoperative stroke and overall composite in-hospital complications, but similar SCI, perioperative mortality, and 5-year mortality rates compared with open LSA revascularization. Future comparative studies are needed to evaluate the mid- to long-term safety of endovascular LSA revascularization and assess differences between specific endovascular techniques., Competing Interests: Disclosures J.H. is or has been proctor or consultant for W. L. Gore & Associates, Terumo Aortic, and Cook Medical. S.T. is consultant and speaker for Medtronic, W. L. Gore & Associates, and Terumo Aortic., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to analyze early and midterm results of custom-made proximal scallop and fenestrated stent grafts for thoracic endovascular aortic repair (TEVAR) with a proximal landing zone (PLZ) in the aortic arch., Methods: All consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc.) in 10 Italian centers between January 2014 and December 2022 were included. The primary end points were technical success, incidence of intraoperative major adverse events, deployment accuracy, and rate of early neurological complications, endoleaks (ELs) and retrograde aortic dissection., Results: During the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The proximal landing zone was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) owing to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III EL were detected. There were no cases of in-hospital mortality, major adverse events, or retrograde dissection. Three minor strokes (6.1%) (National Institutes of Health Stroke Scale score of ≤4) were observed. At a mean follow-up time of 36.3 ± 21.3 months the rate of types I to III ELs and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) from nonaortic causes., Conclusions: Our early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique., Competing Interests: Disclosures None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Proximal ExTension to Induce COmplete ATtachment (PETTICOAT), which uses downstream bare metal stents for structural support, demonstrates potential, yet its adoption is limited by variable outcomes. This study elucidates the potential of PETTICOAT in aortic dissection, emphasizing the determinants that guide patient selection., Methods: A retrospective analysis of 60 patients who underwent full PETTICOAT for aortic dissections was conducted. A multivariate logistic regression model identified predictors of favorable aortic remodeling. Patients underwent standardized follow-up with computed tomography scans to assess size, volumetric changes, and anatomical conditions. Selection criteria included full PETTICOAT application and a minimum of 3 months of follow-up. Demographics, preoperative conditions, and procedural details were collected and analyzed., Results: The analysis identified predictors of favorable aortic remodeling, including age >60 years, a larger downstream aorta stent graft, a smaller abdominal aorta (<450 mm 2 ), and oral angiotensin II receptor blocker administration. Over a median 47.5 months of follow-up, survival rates in the favorable remodeling (97.3%) and unfavorable groups (100%) were similar. Downstream aortic event-free survival rates did not differ significantly (89.2% vs 73.9%), although the unfavorable group had a relatively higher incidence of distal stent-induced new entries (26.1% vs 8.1%)., Conclusions: The PETTICOAT concept effectively enhances aortic remodeling in complex aortic dissections. Predictors for favorable remodeling, including age, stent graft sizing, aortic diameter, and angiotensin II receptor blocker therapy, offer insights for optimizing patient selection. This approach improves survival outcomes, mitigates risks associated with untreated aortic segments, and provides a minimally invasive solution for aortic dissections. Despite some outcome variations, the technique holds promise for addressing the challenges of aortic dissections, with the potential for further refinement in patient selection and technique application., Competing Interests: Disclosures None., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: This study aims to investigate results and outcomes of distal endovascular extensions after FET procedure., Methods: Between September 2018 and December 2022, all consecutive patients who underwent thoracic endovascular aortic repair (TEVAR) or complex thoraco-abdominal repair (TAA-EVAR) after FET were included in the study. Patients were assigned to "Aneurysm" group or to "Dissection" group according to underlying patology before FET repair. The primary endpoints were overall technical success and early re-intervention rate. Secondary endpoints included 30-day and mid-term overall survival., Results: A total of 29 patients were included in the study and divided as follows, n=12 in the aneurysm group and n=17 in the dissection group. The mean age of the population was 64.6±10.2 years, 69% were male. All patients received TEVAR as primary extension while 9 of them underwent further extension to a subsequent TAA-EVAR in a second stage. Among the dissection group, 7 patients experienced a distal stent-graft induced new entries (dSINE) caused by the stent-graft portion of the FET. Technical success of the first stage (TEVAR) was fully achieved as well as for the second stage (TAA-EVAR). Within the first 30 days, no patient expired or required early reinterventions. Freedom-from-reintervention at 36 months was 72% and 64% in the aneurysm and dissection group, respectively. Overall, 1 major adverse event (MAE) (3,4%) and 3 access-related complication (10.3%) occurred among the entire cohort. The Kaplan-Meier survival estimation showed a non-significant log-rank value (p=.248) with a survival rate of 91.7% and 100% at 12, 24 and 36 months each for aneurysm and dissection group, respectively., Conclusion: Distal endovascular extensions after FET repair is feasible with low perioperative morbidity and mortality regardless of the underlying pathology. Technical success rate of endovascular extension is high but aortic-related re-intervention rate remains quite consistent over time. Thus, a close surveillance is advocated for such patients., (Copyright © 2024. Published by Elsevier Inc.)

Objective: We present a review of our hybrid management (endovascular + open surgery) of large thoracic aortic aneurysms (>80 mm). The strategy comprises a primary endovascular repair using thoracic endovascular aortic repair (TEVAR), and/or fenestrated and branched endografts (FBEVAR), followed by open thoracotomy and aneurysmorraphy, specifically without the need for aortic cross-clamping., Methods: We performed a retrospective review of all patients who had undergone aneurysmorraphy via thoracotomy following TEVAR and FBEVAR in two high-volume aortic centers between December 2017 and March 2024. We performed aneurysmorraphy in two clinical situations: (1) in the setting of a planned staged treatment, shortly after TEVAR or FBEVAR in young patients with aneurysm diameter >100 mm; and (2) as a secondary intervention during follow-up for patients with persistent sac enlargement and aneurysm diameters >80 mm. The primary end points were 30-day survival and aneurysm-related mortality during follow-up. Secondary endpoints were sac size evolution, perioperative and postoperative complications, freedom from further reintervention, and late aortic complications., Results: Twelve patients underwent aneurysmorraphy following TEVAR and/or FBEVAR during the study period. Mean patient age was 60 ± 12 years, and the mean sac diameter before thoracotomy was 101 ± 25 mm. Endovascular embolization of intercostal arteries prior to aneurysmorraphy was performed in four patients. The 30-day survival rate was 100%. During the mean follow up period of 21 months, two patients died-one of COVID and another of intra-cerebral hemorrhage. No aneurysm-related mortality occurred, and sac regression was achieved in all patients except one experiencing aortic growth below the aneurysmorraphy., Conclusions: This study demonstrates that thoracic aneurysmorraphy performed after TEVAR and FBEVAR for complex thoracic aneurysms is a safe and effective technique. This procedure allows the eradication of endoleaks and an immediate sac volume reduction, which prevents aorta-bronchial or esophageal fistulation and secures the endovascular repair; the reduction of the aneurysm mass effect restores normal lung parenchyma expansion. This hybrid management strategy drastically reduces the morbidity associated with standard open surgery performed for thoracic endograft explantation., Competing Interests: Disclosures S.H. is a consultant and has intellectual property with Cook Medical, GE Healthcare, and Bentley., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Prevention of late type Ia endoleaks is the main concern in thoracic endovascular aortic aneurysm repair (TEVAR) for thoracic aortic aneurysm. Since 2017, we have performed zone 0 TEVAR with proximal fixation augmentation using a Najuta thoracic fenestrated stent graft in addition to zone 2 TEVAR for distal arch aneurysms. We report the early and midterm outcomes of TEVAR performed using this strategy., Methods: This single-center retrospective study enrolled 386 cases of TEVAR for thoracic aortic disease between January 2013 and December 2020. Patients with thoracic aortic aneurysm treated by TEVAR landing at zone 2 was referred to as the standard group, whereas those treated by TEVAR landing at zone 0 using a Najuta fenestrated stent graft in addition to zone 2 TEVAR was referred to as the augmentation group. We retrospectively compared the clinical outcomes between the two groups. The primary end point was secondary intervention for postoperative type Ia endoleaks. Secondary end points were technical success, aneurysm-related death, and major adverse events (MAEs), including stroke, paraplegia, endoleaks, and secondary interventions., Results: We performed TEVAR in 41 and 30 cases in the standard and augmentation groups, respectively. The mean aneurysm sizes in the standard and augmentation groups were 54.5 and 57.3 mm (P = .23), and the proximal neck lengths were 16.8 and 17.4 mm (P = .65), respectively. The anatomical characteristics seemed to be similar in both groups. The technical success rate in both groups was 100%. Three cases in the standard group had MAEs, including two stroke and one brachial artery pseudoaneurysm; whereas two cases had MAEs in the augmentation group, including one stroke and one paraplegia. There was no 30-day mortality or retrograde type A dissection in both groups. The mean observation periods in the standard and augmentation groups were 46 months (range, 1-123 months) and 35 months (range, 1-73 months), respectively. At 36 and 60 months after the procedure, the freedom from aneurysm-related death was 97.6% and 97.6% in the standard group, 100.0% and 100.0% in the augmentation group (P = .39); and the freedom from reintervention for type Ia endoleaks was 79.2% and 65.2% in the standard group, 100.0% and 100.0% in the augmentation group (P = .0087). A statistically significant decrease in reinterventions for type Ia endoleaks was observed in the augmentation group., Conclusions: Proximal fixation augmentation using the Najuta fenestrated stent graft during TEVAR for distal arch aneurysm is effective in preventing the postoperative late type Ia endoleaks., Competing Interests: Disclosures T.O. is a paid consultant for W. L. Gore & Associates., (Copyright © 2024. Published by Elsevier Inc.)

Objective: The Global Registry for Endovascular Aortic Treatment (GREAT) is an International prospective multicenter registry collecting real-world data on performance of Gore aortic endografts. The purpose was to analyze the long-term outcomes and patient survival rates, as well as device performance in patients undergoing thoracic endovascular aortic repair for acute and chronic and complicated or uncomplicated type B aortic dissection (TBAD)., Methods: From August 2010 to October 2016, 5014 patients were enrolled in the GREAT registry. The study population were patients treated with thoracic endovascular aortic repair for TBAD through 5-year follow-up (days 0-2006). The primary outcomes for this analysis were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, and any reintervention through 5 years., Results: We identified 265 patients. The mean age was 60.9 ± 11.9 years (range, 19-84 years; 211 males [79.6%]). Devices used were the Gore TAG and Conformable Gore TAG Thoracic Endoprosthesis. There were 228 patients (86.0%) who underwent primary endovascular treatment (144 off-label [54.3%]); 22 (8.3%) underwent reintervention after prior endovascular procedure and 15 (5.7%) underwent reintervention after prior open procedure. Kaplan-Meier estimated freedom from all-cause mortality at 5 years was 71.1%. Freedom from aortic-related mortality through 5 years was 95.8%. There was no significant difference in freedom from all-cause mortality during the follow-up period in complicated or uncomplicated disease. At 30 days and through 5 years, respectively, for all the following outcomes, the aortic rupture rate was 1.1% (n = 3) and 1.9% (n = 5). The stroke rate was 1.1% (n = 3) and 4.2% (n = 11). The spinal cord ischemic event rate was 1.5% (n = 4) and 2.6% (n = 7). Reinterventions were required in 6.4% (n = 17) and 21.1% (n = 56) of patients. The need for conversion to open repair was 0.4% (n = 1) and 2.6% (n = 7). Additional graft placement was required in 3 patients (1.1%) and 16 patients (6.0%). The endoleak rate at 30 days was 3.4% (n = 9); type IA (n = 1 [0.4%]), type IB (n = 4 [1.5%]), type II (n = 1 [0.4%]), type III (n = 1 [0.4%]), and unspecified (n = 4 [1.6%]). Through 5 years, the endoleak rate was 12.1% (n = 32); type IA (n = 7 [2.6%]), type IB (n = 10 [3.8%]), type II (n = 9 [3.4%]), type III (n = 2 [0.8%]), and unspecified (n = 12 [4.5%]). There were no cases of stent migration, compression or fracture through 5 years., Conclusions: Results at the 5-year follow-up demonstrate that the use of the Gore TAG and Conformable Gore TAG Thoracic Endoprosthesis can be supported in treatment of TBAD (acute, chronic, complicated, and uncomplicated). These data demonstrate strong device durability, beneficial patient outcomes, and support for the treatment of thoracic aortic dissection with an endovascular approach. Complete 10-year follow-up in GREAT as planned will be advantageous., Competing Interests: Disclosures D.B. is a consultant and speaker for W. L. Gore & Associates. R.M. is a consultant and speaker Cydar, Endospan, Medtronic, Silk Road Medical, and W. L. Gore & Associates. A.A. is a consultant and speaker for W. L. Gore & Associates. S.T. is a consultant and speaker for and received research support from W. L. Gore & Associates, Medtronic, and Terumo Aortic. D.G. is a consultant and speaker for Medtronic, Silk Road Medical, Teleflex, Terumo Aortic, and W. L. Gore & Associates., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Respiratory adverse events (RAEs) after thoracic endovascular aortic repair (TEVAR) remain poorly characterized owing to the lack of comprehensive studies that identify individuals prone to these complications. This study aims to determine the incidence, factors associated with, and outcomes of RAEs after TEVAR., Methods: We identified patients in the Vascular Quality Initiative undergoing TEVAR isolated to zones 0 to 5 from 2010 to 2023 for nontraumatic pathologies. After determining the incidence of postoperative RAEs, we assessed baseline characteristics, pathology, procedural details, and postoperative complications stratified by respiratory complication status: none, pneumonia only, reintubation only, or both. We then examined preoperative and intraoperative variables independently associated with the development of postoperative RAEs using multivariable modified Poisson regression. Kaplan-Meier analysis and Cox proportional hazards regression models were used to determine associations between postoperative RAEs and 5-year survival adjusting for preoperative variables and other nonrespiratory postoperative complications in a separate model., Results: Of 10,708 patients, 8.3% had any RAE (pneumonia only, 2.1%; reintubation only, 4.8%; both, 1.4%). Patients with any RAE were more likely to present with aortic dissection (any respiratory complication, 46% vs no respiratory complication, 35%; P < .001), and be symptomatic (58% vs 48%; P < .001). Developing RAEs after TEVAR was associated with male sex (adjusted relative risk [aRR], 1.19; 95% confidence interval [CI], 1.01-1.41; P = .037), obesity (aRR, 1.31; 95% CI, 1.07-1.61; P = .009), morbid obesity (aRR, 1.68; 95% CI, 1.20-2.32; P = .002), renal dysfunction (aRR, estimated glomerular filtration rate 30-45, 1.45; 95% CI, 1.15-1.82; P = .002; estimated glomerular filtration rate <30/hemodialysis, 1.7; 95% CI, 1.37-2.11; P < .001), anemia (aRR, 1.31; 95% CI, 1.09-1.58; P = .003), aortic diameter >65 mm (aRR, 1.54; 95% CI, 1.25-1.89; P < .001), proximal disease in the aortic arch (aRR, 1.23; 95% CI, 1.03-1.48; P = .025) or ascending aorta (aRR, 1.61; 95% CI, 1.19-2.14; P = .002), acute aortic dissection (aRR, 2.13; 95% CI, 1.72-2.63; P < .001), ruptured presentation (aRR, 3.07; 95% CI, 2.43-3.87; P < .001), same-day surgical thoracic branch treatment (aRR, 1.51; 95% CI, 1.25-1.82; P < .001), chronic obstructive pulmonary disease on home oxygen (aRR, 1.58; 95% CI, 1.08-2.25; P = .014), limited self-care or bed-bound status (aRR, 2.12; 95% CI, 1.45-3.03; P < .001), and intraoperative transfusion (aRR, 1.88; 95% CI, 1.47-2.40; P < .001). Patients who developed postoperative RAEs had higher 30-day mortality (27% vs 4%; P < .001) and 5-year mortality than patients without respiratory complications (46% vs 20%; P < .001). After adjusting for preoperative and postoperative variables, the 5-year mortality was higher in patients who developed any postoperative RAE (adjusted hazard ratio [aHR], 1.8; 95% CI, 1.6, 2.1; P < .001), postoperative pneumonia only (aHR, 1.4; 95% CI, 1.0, 1.8; P = .046), reintubation only (aHR, 2.2; 95% CI, 1.8, 2.6; P < .001) or both (aHR, 1.5; 95% CI, 1.1, 2.0; P = .008)., Conclusions: RAEs after TEVAR are common, more likely to occur in male patients with obesity, renal dysfunction, anemia, chronic obstructive pulmonary disease on home oxygen, acute aortic dissection, ruptured presentation, same-day surgical thoracic branch treatment, who received intraoperative transfusion, and are associated with a two-fold increase in 5-year mortality regardless of the development of other postoperative complications. Considering these factors in assessing the risks and benefits of TEVAR procedures, along with implementing customized postoperative care, can potentially improve clinical outcomes., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear., Methods: The Vascular Quality Initiative was queried for TEVARs performed for acute TBAD with zone 3 entry tear, zone 3 proximal zone of disease, treated with TEVAR extending between zone 2 and zone 5. The primary outcomes were SCI and related reintervention. Secondary outcomes were stroke, arm ischemia, and retrograde type A dissection (RTAD). The exposure variables were PSZ 2 vs 3, DSZ 4 vs 5, prophylactic lumbar drain, and LSA revascularization. Univariate analyses were conducted with χ 2 analysis, and multivariable logistic regression was used to evaluate association with outcomes., Results: Of 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain, and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs 39 [9.2%]; P = .01) and multivariable (odds ratio, 7.384; 95% confidence interval, 2.193-24.867; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (odds ratio, 2.966; 95% confidence interval, 1.016-8.656; P = .05)., Conclusions: This study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible., Competing Interests: Disclosures G.A.M. is a consultant for W.L. Gore and Cook. S.M.H. is a consultant for WL Gore, Cook, and Terumo. L.D. is supported by grants UL1TR001855 and UL1TR000130 from the National Center for Advancing Translational Science (NCATS) of the United States National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)