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Introduction Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement.Methods and analysis We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors.Ethics and dissemination No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online.PROSPERO registration number CRD42022347881.

We describe the feasibility of covered endovascular reconstruction of the aortic bifurcation (CERAB) through a single femoral access and a steerable sheath. We present the technique, which we used for a patient with severe aortoiliac calcification and bilateral involvement of the common femoral artery. The patient underwent endarterectomy of the left common femoral artery plus CERAB with an aortic stent graft and bilateral covered stents for the common iliac artery with kissing dilatation with a steerable sheath using only left femoral access. CERAB can be performed using unilateral access with the aid of a steerable sheath, reducing the potential for access site complications.

IntroductionEndovascular repair using off-the-shelf endografts is a viable solution in patients with ruptured or symptomatic complex aortic aneurysms. This analysis aimed to present the peri-operative and follow-up outcomes in urgent and emergent cases managed with the t-Branch multibranched thoracoabdominal endograft.MethodsProspectively collected data from all consecutive urgent and emergent cases managed in two aortic centers between January 1st, 2014, to November 30th, 2022, using the t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) were analyzed. Patients presenting with ruptured aortic complex aneurysms were characterized as emergent and patients with aneurysms >90 mm of diameter, or symptomatic aneurysms were characterized as urgent. Technical success, 30-day mortality, major adverse events (MAE) and spinal cord ischemia (SCI) rates were assessed.Results225 patients (36.5% females, 72.5 ± 2.8 years) were included; 73.0% were urgent. The mean aneurysm diameter was 109 ± 3.9 mm and 44.4% were type I–III TAAAs. Females (p = .03), para-renal aneurysms (p = .02) and ASA score IV (p

Introduction: Despite a high rate of success when performed in specialised centres, current techniques for thoraco-abdominal aortic repair are associated with serious complications. The problem of spinal cord ischaemia remains unsolved. Surgical technique: The new hybrid graft for thoraco-abdominal aortic repair was developed based on the frozen elephant trunk principle. The device consists of a proximal stent graft for transabdominal retrograde delivery to the descending thoracic aorta, combined with a distal six branched abdominal device for open aortic repair. An additional seventh branch is provided for possible lumbar artery re-implantation. Because the stent graft is implanted via a transabdominal approach, it avoids the need for thoracotomy and extracorporeal circulation. A 56 year old patient with Loeys–Dietz syndrome was placed in a supine position. The aorto-iliac axis was exposed via a midline transperitoneal approach. Following an end to side anastomosis of the iliac branch to the left common iliac artery, the stent graft portion was inserted into the thoracic aorta via the coeliac trunk ostium. After stent implantation and graft de-airing by needle puncture, retrograde blood flow to the abdominal aortic segment, and the lumbar and visceral arteries was established via the end to side iliac anastomosis creating an extra-anatomic bypass. Subsequently, the visceral and renal arteries were anastomosed to the branches. Finally, the aorta was opened and surgical graft attached via the collar. The reconstruction ended with end to end anastomoses of both common iliac arteries to the graft branches. Discussion: The first and successful implantation of the new Thoracoflo hybrid device via a novel surgical technique is reported, eliminating the need for thoracotomy and extracorporeal circulation for thoraco-abdominal aortic repair.

Objective: To report methodology and first-year results of a new educational project called Televascular Games,” which took place during coronavirus disease 2019 pandemic. Methods: Complex aneurysmal aortic disease was discussed during a 2-hour competition webinar, according to three modalities. (1) Planning case competition (PCC): Two to four preoperative computed tomography angiography (CTA) scans of an already performed selected case were submitted for the competition. CTA scans were uploaded anonymously, without any reference to the center or the surgeon who performed the case. The competitor had to prepare a presentation of how he or she would have diagnosed, sized, planned, treated, and followed up the case, of the medical therapy and of the bail-out maneuvers. (2) Challenging case competition (CCC): The competitor elaborates a presentation of an already treated case concerning an aortic topic and discusses sizing, planning, treatment, possible bail-out maneuvers and obtained results. For the CCC and PCC, the competitors with the best score were preselected to present and discuss their plan during the webinars. (3) Quiz competition: Two to six CTA scans of already performed selected aortic cases were submitted for the competition. A quiz with multiple choice questions was answered by the competitors. The top four competitors were selected for the webinars and then they discussed the cases during the webinar. Finally, at the end of the case discussion, the effective case resolution and follow-up were shown. A final winner was voted via televoting, based on six preestablished criteria. The project was endorsed by different national and international societies. Results: Between October 2020 and December 2021, there were 12 Italian and 1 international webinars with 1695 participants overall (mean, 130; range, 86-177). Competitors were 54 years of age (mean, 27 years; range, 22-38 years). Two editions were CCCs, two quiz competitions, and nine PCCs. The reliability of the interobserver sizing of competitors was κ = 0.43 and κ = 0.62 for the proximal and distal sealing measurements respectively and very good (κ = 0.88-0.95) in the evaluation of orientation of the vessels, presence of angulations, calcifications, and thrombus. The sizing discrepancy resulted in a significant variability of the planning (κ = 0.45). The project ranked 9.6 on a 10-point rating scale by all the participants and competitors. Conclusions: The formula of gaming and collegial discussion of aortic cases herein reported has proved valid and attractive during coronavirus disease 2019 pandemic period. The variability of the results on sizing and planning suggested to confer with a second opinion, especially for less experienced surgeons.

Abstract Transthoracic echocardiography (TTE) and cine cardiac magnetic resonance imaging (CMR) are established imaging methods of the aortic root. We aimed to evaluate the comparability of measurements in TTE and standard cine CMR sequences of the aortic root. Our study included 741 subjects (mean age 63.5 ± 8 years, 43.7% female) from the Hamburg City Health Study (HCHS). Subjects underwent CMR and TTE. Aortic root measurements were performed at the level of the aortic annulus (AoAn), sinus of Valsalva (SoV), and sinotubular junction (STJ) by standard cine CMR in left ventricular long axis and left ventricular outflow tract view. Measurements were performed applying the leading-edge to leading-edge (LL) convention and inner-edge to inner-edge (II) convention in TTE and the II convention in CMR. Inter correlation coefficients (ICCs) demonstrated high inter- and intraobserver reproducibility for CMR and TTE measurements of SoV and STJ (ICCs 0.9–0.98) and moderate reproducibility for AoAn (ICCs 0.68–0.91). CMR measurements of SoV and STJ showed strong agreement with TTE: while correlations were comparable (r = 0.75–0.85) bias was lower with TTE II (bias − 0.1 to − 0.74) versus TTE LL measurements (mean bias − 1.49 to − 2.58 mm). The agreement for AoAn was fair (r = 0.51–0.57) with variable bias (mean bias 0.39–3.9). Standard cine CMR and TTE derived aortic root measurements are reproducible and comparable with higher agreement for TTE II instead of LL measurements. These results support an interchangeable application of TTE and standard CMR for screening of aortic root diseases thereby possibly reducing redundant multimodality imaging.

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.

We have described a technique to treat iatrogenic coarctation caused by a branched thoracic endovascular aortic repair (TEVAR) procedure with a Palmaz XL stent (Palmaz Genesis; Cordis Corp, a Cardinal Health Company, Milpitas, Calif) and triple kissing balloons. A 42-year-old woman with Marfan syndrome had presented with aneurysmatic dilatation of the aortic arch 10 years after open aortic arch repair. After successful branched TEVAR, a significant coarctation just short of the left common carotid artery was noted with significant pressure gradient between the ascending and descending aorta. Branched TEVAR in previous open aortic arch replacement can result in iatrogenic coarctation that can be successfully treated using a Palmaz XL stent and triple kissing balloons.

Objective: This in vitro study investigates the antimicrobial efficacy of impregnation of commercially available aortic endografts (EG) with rifampicin (RIF) and nanocolloidal silver. Methods: Endografts were flushed with 50 mL of RIF 600 mg, 70 mL of a silver-based aqueous solution (AG), or 50 mL of phosphate-buffered saline (PBS) over 15 minutes. Endografts were then retrieved from the sheath and cut in 1 × 1 cm sized graft units (n = 80 of each impregnation), which were then incubated for 1 hour separately with inoculates containing 106 or 103 bacteria per milliliter (bact/mL) of each of the following bacteria: Staphylococcus epidermidis, Escherichia coli, multisensitive Staphylococcus aureus, and Pseudomonas aeruginosa. After sonication of the graft units, bacterial counts were measured by plating out twice the sonication solution on Mueller-Hinton plates. Results: RIF showed a statistically significant decrease of colony forming units per milliliter for all four bacterial strains in both concentrations compared with PBS and AG, except for 103 bact/mL of E coli. AG showed a significant decrease of colony forming units per milliliter compared with PBS only for 106 bact/mL of E coli and was statistically significantly inferior to RIF for all four bacterial strains in both concentrations with the exception of E coli at a concentration of 103 bact/mL. Conclusions: This in vitro study demonstrated infectivity resistance of aortic EG after flushing with RIF. Moreover, the feasibility of flushing aortic EG with a new silver-based agent could be demonstrated, but without statistically significant antimicrobial efficacy compared with native EG. : Clinical Relevance: Because the number of elective and emergency endovascular procedures on the thoracic and abdominal aorta is continuously increasing, endograft infections in both locations are also more frequently observed. The necessity and use of antimicrobial-impregnated EG in the prophylaxis or treatment of endograft infections has so far neither been discussed in the literature nor addressed in existing guidelines. This is the first study investigating the influence of antiseptic impregnations of commercially available aortic EG on in vitro contamination with bacteria commonly causing vascular graft infections. Owing to proven infectivity resistance, flushing EG with RIF could, despite known limitations, lead to a modification of established therapeutic principles in patients at high risk for aortic graft infections.

Background: Extended downstream endovascular management has been applied in acute complicated type B aortic dissection (acTBAD), distally to standard thoracic endovascular aortic repair (TEVAR), using bare metal stents, with or without lamina disruption, using balloon inflation. The aim of this systematic review was to assess technical success, 30-day mortality, and mortality during follow-up in patients with acTBAD managed with the Provisional Extension To Induce Complete Attachment (PETTICOAT) or stent-assisted balloon-induced intimal disruption and relamination (STABILISE) technique. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement was followed. A search of the English literature, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until 30th August 2022, was executed. Randomized controlled trials and observational studies (published between 2000–2022), with ≥5 patients, reporting on technical success, 30-day mortality and mortality during the available follow-up among patients that underwent PETTICOAT or STABILISE technique for acTBAD were eligible. The Newcastle-Ottawa Scale was applied to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, and secondary outcome was mortality during the available follow-up. Results: Thirteen studies were considered eligible, twelve in the quantitative analysis. In total, 418 patients with acTBAD managed with the PETTICOAT (83%) or STABILISE (17%) technique were included. Technical success ranged between 97–100%, 99% for the PETTICOAT and 100% for the STABILISE sub-cohort. Thirty-day mortality was estimated at 3.7% (12/321), 1.4% for the STABILISE and 4.4% for the PETTICOAT technique. All studies reported the mean available follow-up which was estimated at 20 months (range 3–168 months), 22 months (mean value) for the PETTICOAT and 17 months (mean value) for the STABILISE technique. Twenty-three patients died during follow-up, with an estimated mortality rate at 5.7% for the total cohort. The mortality during follow-up was 0% for the STABILISE and 7.0% for the PETTICOAT approach. Conclusions: Both, the PETTICOAT and STABILISE techniques presented less than 4% perioperative mortality in patients with acTBAD with high technical success rate. The mid-term mortality rate was at 6%. However, the heterogeneity in the available studies’ highlights the need for further prospective studies, including larger volume and longer follow-up.