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Connective tissue disease (CTD) syndromes involve the ascending, aortic arch, and thoracoabdominal aorta and are associated with higher risk of aortic aneurysm or dissection. Currently, vascular societies generally recommend open repair as the first option for aortic disease in patients with CTD. However, the implementation of endovascular techniques for patients with CTD with aortic pathologies seems to have increased in recent years, mainly in patients of high surgical risk or in urgent situations. Endovascular treatment of aortic arch pathologies in patients with CTD have been feasible in experienced centers; however, the evidence is scarce. Thoracic endovascular aneurysm repair in patients with CTD is more evident; in 15 studies, 304 patients with CTD were treated with thoracic endovascular aneurysm repair with high technical success rates (88% to 100%) and a low early mortality rate (1.6%). During the median follow-up, 33 patients died and 64 patients underwent a re-intervention. In 6 studies, 26 patients with CTD were treated with fenestrated/branched endovascular aneurysm repair for thoracoabdominal aortic aneurysm, with a technical success rate of 100%, without early mortality and morbidity. The endovascular approach to thoracoabdominal aortic aneurysm, especially in post-dissection patients, mandates adjunctive techniques to achieve false lumen thrombosis with various approaches; in our experience, the Candy-Plug technique has been proven to be technically feasible with good outcomes. Endovascular treatment of aortic pathologies in patients with CTD seems to be feasible and safe in high-risk and urgent patients. Re-intervention remains an issue. The constant development of endovascular techniques and devices may provide improved mortality and morbidity outcomes.

Sarcopenia is the loss of muscle mass and strength. It manifests as decreased core muscle area in axial abdominal computed tomography scans. The predictive value of sarcopenia in outcome research has been widely discussed. A systematic review was conducted to assess sarcopenia as a biomarker in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and its association with long-term survival.A systematic search of the English medical literature, published from 1991 to 2021, was conducted, using PubMed, EMBASE, and CENTRAL, as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA, 2020) guidelines. The study protocol was registered to the International Prospective Register of Systematic Reviews (CRD 42021260192). Observational studies reporting on sarcopenic and nonsarcopenic patients undergoing EVAR were included. The Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) risk of bias evaluation tool was used for the quality assessment. The outcomes were summarized as odds ratio (OR) along with their 95% confidence intervals (CI), through a paired meta-analysis. The primary outcome was 5-year survival following EVAR.Eleven observational studies, including 2,385 patients (89.6% males) treated with EVAR, between 1999 and 2018, were included in the qualitative synthesis. The mean age was 72.9 years (range 70-76.4 years). Nine of the studies reported on a negative prognostic value of sarcopenia on survival during a long-term follow-up. Six studies stratified their cohorts in sarcopenic versus nonsarcopenic patients (40.3% sarcopenic). The cutoff values (mmThe available data derived from observational studies suggest an association between sarcopenia and worse long-term survival in patients treated with EVAR. There is a lack of a universally accepted definition for sarcopenia and future reporting standards should address this issue. Prospective studies are necessary to establish this negative prognostic value of sarcopenia on long-term survival.

Fenestrated endovascular aneurysm repair (F-EVAR) has allowed successful treatment of patients with complex aortic aneurysms. Custom-made devices (CMDs) are manufactured by companies and tailored to the patient's anatomy to incorporate target vessels, while there is also the "off label" alternative with the devices modified by a surgeon in the operating room: surgeon-modified FEVAR (sm-FEVAR). This study aims to present and compare technical durability of CMDs- and sm-FEVAR for complex abdominal and thoracoabdominal aortic pathologies.A retrospective cohort study was undertaken including all consecutive patients treated with sm- or CMD-FEVAR during a 3-year period in a single center. Only cases with at least 3 reno-visceral target vessels were included. Primary outcomes were technical success, and freedom from endoleak (EL) (Ia or III; all branch related) and re-intervention during follow-up period. Mortality and morbidity were also recorded.Thirty-two sm-FEVAR patients (81,3% male) and 79 CMD-FEVAR patients (77,2% male) were included. Indication for sm-FEVAR was exclusively urgent, while all CMD- FEVAR were elective. Technical success was similar in sm-FEVAR (100%) and CMD-FEVAR (98,7%) (P = 0.523). Mean follow-up was 16.3 ± 13 and 20 ± 17.3 months for sm-FEVAR and CMD- FEVAR, respectively (P = 0.28). The freedom from EL Ia rate was 91.7% [standard error (SE) 5.7%] at 12 months in sm-FEVAR, while it was 97.7% (SE 2.2%) and 92.3% (SE 4.3%) at 12 and 24 months, respectively in CMD-FEVAR (P = 0.69). The freedom from EL III rate was 95.5% (SE 4.4%) and 88% (SE 8.2%) at 12 and 24 months, respectively in sm-FEVAR, while it was 92.1% (SE 3.8%) and 89.2% (SE 4.7%) at 12 and 24 months, respectively in CMD-FEVAR (P = 0.68). The freedom from re-intervention rate was 91.6% (SE 5.7%) and 84.6% (SE 8.6%) at 12 and 24 months, respectively in sm-FEVAR, while it was 91.7% (SE 4%) and 83.4% (SE 5.9%) at 12 and 24 months, respectively in CMD-FEVAR (P = 0.90). The survival rate was 87.5% (5.8%) and 76.3% (7.9%) at 1 and 12 months, respectively in sm-FEVAR, while it was 93.7% (2.7%) at 1 month in CMD-FEVAR without any other death during FU period. No bridging stent occlusions were noted during follow-up period in any patient.Sm-FEVAR offers good technical success and mid-term clinical outcomes in urgent cases of complex aortic pathologies. Its durability is acceptable and comparable to CMD-FEVAR with a relatively low re-intervention rate.

BACKGROUND: To report technical and clinical 30-day results following treatment with the Zenith Alpha™ abdominal stent graft from the ZEnith alPHa for aneurYsm Repair Registry (ZEPHYR).METHODS: Multicenter, nonrandomized, single arm, core laboratory-controlled, prospective registry collecting data on the Zenith Alpha Abdominal Endovascular Graft being used in subjects with abdominal aortic aneurysms (AAA) from sites in Germany, Belgium, and The Netherlands between December 2016 and December 2019. Inclusion criteria were non-ruptured AAAs with a maximum diameter ≥50 mm or enlargement >5 mm over 6 months with an AAA neck length ≥10 mm (site reported). Primary outcome measure was treatment success at 30 days. Treatment success was defined as a combined endpoint consisting of technical and clinical success. Technical success was defined as successful stent graft delivery and deployment as well as successful removal of the delivery system. Clinical success at 30 days was defined as freedom from type I and III endoleak, aneurysm rupture, conversion to open surgery and stent graft occlusion.RESULTS: Three hundred forty-seven subjects were included from 14 sites with a median age of 73.0 years (IQR 68.0-79.0). Thirty-four patients were female (9.8%). The median AAA diameter was 58.3 mm (IQR 55.0-63.5). The median proximal neck diameter was 23.6 mm (IQR 22.0-25.2) with a median proximal neck length of 24.4 mm (IQR 15.0-34.8) and a median infrarenal neck angulation of 24.5° (IQR 15.0-35.0). The right and left common iliac diameter were 16.1 mm (IQR 14.1-19.4) and 16.2 mm (IQR 14.1-19.1), respectively. The treatment success rate at 30 days was 94.8% (N = 329). Technical success was achieved in 333 patients (96.0%). The clinical success rate at 30 days was 98.8% (N = 343). Three patients had limb occlusions at 30 day follow up (0.9%). One patient had a type Ib endoleak (0.3%). Seventy percent of vascular access approaches were percutaneous. The reintervention rate was 1.7% (N = 6) within 30 days. Indications for reinterventions were a false aneurysm at puncture site (N = 1), limb complications (N = 2), stentgraft-associated renal artery occlusions (N = 2), and an external iliac artery thrombosis (N = 1).CONCLUSIONS: Endovascular aneurysm repair using the Zenith Alpha Abdominal Endovascular Graft is effective in the short term. Long term results will be reported in the future.

Objectives: To study the outcome of endovascular treatment of aortic pathologies in patients with Marfan syndrome (MFS) at a single institution. Methods: Consecutive MFS patients who underwent endovascular repair or hybrid procedures for aortic pathologies from January 2010 to May 2020 were identified. Several endovascular and hybrid strategies have been used. Technical success, short- and mid-term survival, complications, and re-interventions were retrospectively analyzed. Results: During the study period, 24 patients with MFS (median age, 48 [13–78] years; 58% males) were treated. Indications for intervention were chronic aortic dissection with aneurysm degeneration in 16 patients (67%), acute type B aortic dissection in 4 patients (17%), aortic aneurysm without any dissection in 3 patients (13%), and aortic intramural hematoma in 1 patient (4%). Most patients were asymptomatic (83%), three (13%) were symptomatic and one (4%) had a contained rupture. The median aneurysm diameter was 56 (35–86) mm. Hybrid procedures were performed in 7 (29%) patients. Thoracic endovascular repair was performed in 12 (50%) patients, a fenestrated or branched endovascular aortic repair in 4 (17%) patients, and placement of an iliac artery stent-graft in 1 (4%) patient. Procedures were staged in 12 (50%) patients. Technical success was achieved in all patients. The median intensive care unit stay was 6 (range, 1–30) days, and the median hospital stay was 23 (range, 3–112) days. Early mortality was reported in 1 (4%) patient. Wound infection was seen in 7 (29%) patients and gastrointestinal complications in 3 (13%) patients. The median follow-up was 42 (range, 1–127) months. The cumulative survival rate was 87% at 24 months. The cumulative freedom from re-intervention was 77% at 12 months. Conclusions: Endovascular treatment of aortic pathologies in patients with MFS appears feasible with acceptable early and mid-term outcomes in terms of mortality and re-intervention rates. Endovascular therapy plays an increasing role in MFS patients with aortic pathology.

Purpose: The concept of a single endovascular valve-carrying conduit device was designated endo-Bentall, but published experience is limited to a single case. This technical note describes an alternative modular endo-Bentall technique and a novel access technique to implant it. Technique: A 82-year-old woman with chest pain referred for a 10 cm symptomatic aneurysm of the distal arch and descending aorta. An ascending aortic aneurysm of 5.5 cm prevented endovascular aortic arch repair due to lack of a proximal landing zone. The technique is a modular approach combining a physician-modified endograft (PMEG) with 3 large fenestrations for coronary artery perfusion and a transcatheter aortic valve implantation (TAVI). A “rendez-vous access” with a transapical and transfemoral through-and-through wire offered rapid sequential deployment in a modular fashion of both components. The PMEG was deployed first, landing 5 mm deep in the left ventricular outflow tract (LVOT) and the transcatheter aortic valve was implanted few millimeters below. The endo-Bentall procedure was combined with endovascular aortic arch repair. Conclusion: A modular endo-Bentall procedure combining a PMEG and TAVI is feasible and adaptable to emergent setting using the “rendez-vous access.”

Background: Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence. Methods: The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases. Results: The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited. Conclusion: In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.

The t-Branch, a standardized off-the-shelf multi-branched stent graft has been used for the treatment of elective and urgent cases in aortic disease. The aim of this study was to assess the early outcomes in terms of technical success, mortality, and morbidity in500 patients being treated with the t-Branch device.A two-center retrospective observational study was undertaken including patients treated using the t-Branch (Cook Medical, Bloomington, IN) in elective or urgent settings for complex abdominal aortic aneurysm and thoraco-abdominal aortic aneurysm between 2014 and 2019 (early experience 2014-2016; late experience 2017-2019). Primary endpoints were technical success and early (30-day) mortality, and secondary endpoints were early morbidity, endoleak, and target vessel patency rates. Multivariable regression models were used to determine the independent association of risk factors with (1) mortality and (2) spinal cord ischemia.A total of 542 patients (mean age, 70.5 ± 8.5 years; 388 men [72%]; mean aneurysm diameter, 7.5 ± 2.5 cm) were included (63% elective; 90% thoraco-abdominal aortic aneurysm). The technical success rate was 97% (526/542) (elective, 96.7% [328/339] vs urgent, 97.6% [208/213]). The total 30-day mortality rate was 12.3% (8.5% in elective, 15% in symptomatic, and 30% in contained rupture). After multivariate regression analysis, the mortality rate was associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.11; P .001) and with lower baseline glomerular filtration rate (OR, 0.98; 95% CI, 0.98-0.99; P .001). In elective cases, the mortality rate was associated with a history of coronary artery disease (OR, 0.26; 95% CI, 0.09-0.73; P .011) and higher body mass index (OR, 0.87; 95% CI, 0.77-0.98; P .027). In urgent cases, the mortality rate was associated with older age, (OR, 1.07; 95% CI, 1.02-1.13; P .010) and lower baseline glomerular filtration rate (OR, 0.97; 95% CI, 0.95-0.99; P .001). The spinal cord ischemia rate was 10.5% (6.5% temporary, 4% permanent) and was associated with the early study period (OR, 2.01; 95% CI, 1.03-3.89; P .038). The renal impairment rate was 13%, the stroke rate was 2.5%, and the myocardial infarction rate was 1.8%, whereas the access complications rate was 7.7%. On early computed tomography angiography, the primary patency rate for the right renal artery was 99.6%, for the left renal artery was 100%, for the superior mesenteric artery was 99.4%, and for the coeliac trunk was 99.8%. The endoleak I and III rates were 2.7% (15/542) and 2.7% (15/542), respectively.Elective and urgent use of the t-Branch multi-branched off-the shelf stent graft showed high technical success and early target vessel patency rates. Early mortality and morbidity rates were acceptable.

Objective To determine short and midterm outcomes of a pre-loaded fenestrated thoracic endograft (f-TEVAR) for exclusion of distal aortic arch pathologies. Methods This was a multicentre, retrospective study including consecutive patients from six experienced European vascular centres undergoing f-TEVAR for distal arch pathologies. Primary endpoints included peri-operative mortality and peri-operative stroke and/or spinal cord ischaemia rates. Secondary outcomes were technical success and mid to late events, including death and re-interventions. Statistical analysis was performed with SPSS 26. Mid to late term events were calculated using Kaplan–Meier survival analysis. Results One hundred and eight patients were included (mean age 68 ± 11 years, 70% men). A total of 38% (n = 42) had a prior history of aortic dissection, and 24% (n = 26) prior aortic surgery. The mean aneurysm diameter was 59 ± 12 mm and the most frequent indication for treatment was post-dissection aneurysms (n = 42, 39%). Technical success was 99% (n = 107) despite intra-operative wire entanglement occurring in 29% (n = 31). The 30 day mortality rate was 3.7% (n = 4), with a 5.6% major stroke incidence (n = 6) and 3.7% (n = 4) spinal cord ischaemia rate. Three cases of retrograde dissection occurred (two of which were fatal), all in post-type B dissecting aneurysm patients without prior aortic surgery (three of 19, 15.8%). Median follow up was 12 months (range, 1 – 26). Endoleaks were documented during follow up, with 3.5% type Ia (4/104) and 2.9% type Ib (3/104) as a result of persistent false lumen perfusion. The one, two, and three year survivals and freedom from re-intervention rates were 93.2% and 92.1%, 89.1% and 86.3%, and 84.4% and 73%, respectively. Conclusion This multicentre study shows that treatment of the distal aortic arch by f-TEVAR is feasible, with promising 30 day mortality, stroke, and spinal cord ischaemia rates.

Objective To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR. Methods Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage. Results 18 male patients (76 years old; range 69 – 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 – 69 mm). Median interval between the procedures was 53 (29 – 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 – 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 – 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%. Conclusion F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.

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.

Journal of endovascular therapy 28(6), 914-926 (2021). doi:10.1177/15266028211030536, Published by Sage, Thousand Oaks, Calif.

Objective This study aims to determine the outcomes of transcaval embolization (TCE) for type II endoleak after infrarenal endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/BEVAR). Methods A retrospective single-center cohort study of all consecutive TCE procedures between August 2015 and August 2019 was performed to investigate technical success, in-hospital morbidity, and 30-day mortality as well as clinical success during follow-up. The indication for TCE was an aneurysm sac growth of 5 mm or more owing to a type II endoleak after EVAR for infrarenal or F/BEVAR for juxtarenal and type IV thoracoabdominal aortic aneurysm. Results A total 25 TCE procedures in 24 patients (95.8% male) were included. Technical success was 96.0% (24/25); selective and nonselective TCE were performed in 48% of patients. The in-hospital morbidity and 30-day mortality were 0%. The median follow-up was 23.1 months (interquartile range, 10.9-40.1 months). Freedom from type II endoleak-related reintervention was 84.6% at 12 months. Comparing clinical success after TCE, reintervention was necessary in 16.7% of patients after nonselective and 20% of patients after selective TCE. Regarding TCE after EVAR vs F/BEVAR, reintervention was performed in 12.5% of EVAR and 33.3% of F/BEVAR patients during follow-up. Conclusions TCE is an acceptable treatment alternative for type II endoleak with aneurysm sac enlargement and can be used after EVAR for infrarenal abdominal aortic aneurysms and F/BEVAR for juxtarenal abdominal aortic aneurysms and type IV thoracoabdominal aortic aneurysms.

Background Cervical debranching, followed by thoracic endovascular aortic repair (TEVAR), is well-established for treating aortic arch lesions. However, total endovascular repair with fenestrated endografts has not been adequately studied. Thus, we performed a comparison of the two techniques. Methods The present study was a single-center, retrospective study comparing the treatment of thoracic aortic lesions with custom-made fenestrated stent-grafts (fenestrated TEVAR [fTEVAR]) with a single fenestration for the left subclavian artery (LSA), a scallop for the left carotid artery, and hybrid repair with a thoracic stent-graft and cervical debranching of the LSA. Emergency cases were excluded. Results From 2012 to 2018, 19 patients (58% male) underwent elective fTEVAR (group A) and 17 patients (82% male) underwent debranching TEVAR (dTEVAR; group B). The mean age ± standard deviation in group A was 65.8 ± 2 years and 68 ± 3 years in group B. Left carotid–subclavian bypass was performed in 15 of 17 patients (88%) and transposition of the LSA in 2 of 17 patients (12%) in group B. The two groups were comparable regarding comorbidities, except for peripheral arterial disease: 5 of 19 patients in group A (26%) and none in group B had had peripheral arterial disease (P = .049). Dissection or post-dissection aneurysm was the indication for treatment in 6 of 19 patients in the fTEVAR group (group A) and in 12 of 17 patients in the dTEVAR group (group B; 31.6% vs 70.6%; P = .04). The indication for the remaining patients was a degenerative aortic aneurysm. Technical success was achieved in all cases, except for one case of dTEVAR owing to a type Ia endoleak. The mean endovascular operative time was 191 ± 120 minutes for fTEVAR and 130 ± 75 minutes for dTEVAR (P = NS). The mean operative time for the debranching procedure was 181 ± 97 minutes. No deaths or major strokes had occurred in the early postoperative period (30 days). Of the 17 patients in group B, 5 (29.4%) had experienced a local complication related to the debranching procedure. The mean follow-up was 14.6 ± 2 months for group A and 17 ± 2 months for group B. Of the 19 patients in group A and 17 patients in group B, 2 (10.5%) and 6 (35.3%) had required an unplanned reintervention related to the thoracic stent-graft during the follow-up period, respectively (P = NS). The estimated freedom from unplanned reintervention at 12 months was 86% for group A and 81% for group B. Primary patency of the LSA stent-graft or the carotid–subclavian bypass/transposition was 100% in both groups. Conclusions Both techniques showed excellent midterm patency rates for the target vessel and high technical success rate. The operation times were shorter for the fTEVAR group and complications related to the debranching procedure were avoided.

Purpose: This study describes technical success, feasibility, and early results of fenestrated and branched endovascular aortic repair (F/B-EVAR) for treatment of thoracoabdominal aortic aneurysms (TAAAs) or pararenal aneurysms with more than 4 target visceral vessels (TVs) due to renovisceral arterial anatomical variations. Materials and Methods: Patients with TAAAs or pararenal aortic aneurysms who had more than 4 TVs due to renovisceral arterial anatomical variations of renal, celiac, and/or superior mesenteric arteries and received F/B-EVAR between January 2017 and September 2019 at a single aortic center were included in this study. We analyzed technical success, feasibility, and early outcomes. Results: Twelve patients (mean age 70±10 years, 9 males) were included. The anatomical variations included 6 right accessory renal arteries, 8 left accessory renal arteries, and 1 celiac artery variant. Stent-grafts were fenestrated, branched or combined in 6, 5, or 1 patients, respectively. The mean operating time was 346±120 minutes, the mean fluoroscopy time was 80±29 minutes, and the mean radiation dose area product was 430±219 Gy·cm2. The mean contrast volume was 129±45 mL. The total number of TVs was 64; 5 TVs in 9 patients, 6 in 2 patients, and 7 in 1 patient. Technical success was achieved in all cases. The mean intensive care unit stay was 6±5 days, and the mean total hospital stay was 14±10 days. One patient died early (30-day). Early morbidities included respiratory complication in 1 patient, renal insufficiency in 1 patient, and wound infection in 2 patients. No spinal cord ischemia, stroke, or bowel ischemia occurred. Early computed tomography angiography showed 100% patency of the bridging covered stents and TVs. The mean follow-up was 13±4.3 months. No mortality or adverse major event occurred during the follow-up. Two patients with developed type Ic endoleak related to 1 right renal artery and 1 celiac artery covered stent. Patency of the TVs during follow-up was 100%. Conclusion: The use of F/B-EVAR for the treatment of TAAA with more than 4 TVs due to renovisceral arterial anatomical variations in our own experience is feasible and not related to increased morbidity and mortality.

Purpose Endovascular repair of chronic thoracoabdominal aortic dissection with aneurysmal degeneration presents a therapeutic challenge when one or more visceral branches arise from the false lumen without an adjacent reentry. The chronic dissection flap can be thick and resistant to flap fenestration with standard techniques. Technique The powered cheese wire technique facilitates cutting of a dissection flap using electrical current on a noninsulated through-and-through wire segment. The mid-shaft of the guidewire is denuded and kinked to form the “flying V” configuration. This solution is based on the BASILICA procedure, which uses electrosurgery to split aortic valve tissue lengthwise prior to transcatheter aortic valve replacement to prevent coronary artery obstruction. We demonstrate the technique in a case of branched endovascular aortic repair of a complex thoracoabdominal dissecting aneurysm in which a renal artery from the false lumen was catheterized by creating a powered cheese wire fenestration. Conclusion The powered cheese wire technique is an effective approach to access false lumen originating branches during endovascular aortic repair of chronic aortic dissections.

Background Acute occlusion of renal bridging stent grafts after fenestrated/branched endovascular aortic repair (F/B-EVAR) is an acknowledged complication with high morbidity that often results in chronic dialysis dependence. The feasibility and effect of timely or late (≥6 hours of ischemia) renal artery revascularization has not been adequately reported. Methods We performed a retrospective, multicenter study across 11 tertiary institutions of all consecutive patients who had undergone revascularization of renal artery stent graft occlusions after complex EVAR. The end points were technical success, association between ischemia time and renal function salvage, interventional complications, mortality, and mid-term outcomes. Results From 2009 to 2019, 38 patients with 46 target vessels (TVs; eight bilateral occlusions) were treated for renal artery occlusions after complex EVAR (mean age, 63.5 ± 10 years; 63.2% male). Six patients had a solitary kidney (15.8%). Of the 38 patients, 16 (42.1%) had undergone FEVAR and 22 (57.9%) had undergone BEVAR. The technical success rate was 95.7% (44 of 46 TVs). The recanalization technique used was sole aspiration thrombectomy in 5.3%, aspiration thrombectomy and stent graft relining in 52.6%, and sole stent graft relining in 36.8%. The median renal ischemia time was 27.5 hours (range, 4-720 hours; interquartile range, 4-36 hours). Most patients (94.4%) had been treated after ≥6 hours of renal ischemia time, and 55.6% had been treated after 24 hours. In 14 patients (36.8%), renal function had improved after intervention (mean glomerular filtration rate improvement, 14.2 ± 9 mL/min/1.73 m2). However, 24 patients (63.2%) showed no improvement. Improvement of renal function did not correlate with the length of renal ischemia time. Of the 14 patients with bilateral renal artery occlusion or a solitary kidney, 9 experienced partial recovery of renal function and no longer required hemodialysis. In-hospital mortality was 2.6%. The cause of renal stent graft occlusion could not be identified in 50% of the TVs (23 of 46). However, in 19 (41.3%), significant stenosis or a kink of the renal stent graft was found. The median follow-up was 11 months (interquartile range, 0-28 months). The estimated 1-year patient survival and patency rate of the renal stent grafts was 97.4% and 83.8%, respectively. Conclusions Revascularization of occluded renal bridging stent grafts after F/B-EVAR is a safe and feasible technique and can lead to significant improvement of renal function, even after long ischemia times (>24 hours) of the renal parenchyma or bilateral occlusion, as long as residual perfusion of the renal parenchyma has been preserved. Also, the long-term patency rates justify aggressive management of renal artery occlusion after F/B-EVAR.

Endovascular repair of the ascending aorta and aortic arch has evolved at an astonishing pace in the past several decades. Results of endovascular arch repair in experienced centers have been improving and the technology evolving, and it has begun to challenge the current gold standard status of open surgery in some groups of patients. Hybrid strategies with adjunctive cervical debranching for distal arch lesions are being replaced by fenestrated arch repairs. Total endovascular repair for proximal aortic arch pathologies with the use of inner branches has achieved the best results; however, the main current limitations of endovascular arch repair are diameter-, length-, and angulation-related issues with the ascending aorta (proximal landing zone). Ascending aorta endovascular repair has allowed extending treatment further proximally in patients with post-surgical pseudoaneurysms of the ascending aorta or post-type A chronic aortic dissections. However, sufficient proximal landing zone is still needed in the proximal aorta for these repairs; in a significant number of patients, this is not feasible with simple proximal tubular grafts. Therefore, new technologies and techniques are being developed to deal with this limitation, including the endovascular Bentall concept, with incorporation of the aortic valve and coronary ostia. In this review, the current state and future directions of endovascular ascending and arch repairs and the motion towards an endovascular Bentall procedure are discussed.

OBJECTIVES The goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery. METHODS One hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis. RESULTS A total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19–35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23–3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091]. CONCLUSIONS Elective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.

Cardiovascular societies have developed recommendations regarding the management of thoracic aortic diseases. While improvements in treatment have been observed during the past decade in regard to patient selection, thoracic endovascular aortic repair (TEVAR) and associated techniques, and high-volume centralization, the broad expansion of TEVAR has raised considerations about its indications, appropriateness, limitations, and application. The aim of this systematic review was to assess the similarities and differences among current cardiovascular societies’ guidelines for the management of thoracic aortic diseases. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from January 2009 to May 2020. The initial search identified 990 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from cardiovascular societies published between 2010 and 2020. Selected controversial topics were analyzed, including diagnosis, imaging, spinal cord ischemia prevention, and management of the most important thoracic aortic pathologies. The analysis included data concerning the therapeutic approach in acute and chronic type B aortic dissection, penetrating aortic ulcer, intramural hematoma, thoracic aortic aneurysm, and traumatic aortic injury, as well a discussion of inflammatory aneurysms, aortitis, and genetic syndromes. The review presents consistent and controversial recommendations, as well as “gray zone” issues that need further investigation. There was significant overlap and agreement among the 5 societies regarding the management of thoracic aortic diseases. Especially in dissection and aneurysm management, TEVAR has established its role as the treatment of choice. However, robust evidence is still needed in many aspects of the management of thoracic aortic pathologies.

The aim of this study was to analyse the influence of true, false, and combined lumen perfusion of renal arteries on mid- and long-term kidney volume in patients with type B aortic dissection (TBAD).Retrospective analysis of patients diagnosed with a TBAD between 2008 and 2015 in a single high-volume European center. The origin of the renal arteries was evaluated on a dedicated 3D workstation (TeraRecon Inc., San Mateo, CA, USA) and coded as either arising from the true lumen (TL), false lumen (FL) or from a combination of both (CL). Additional evaluated anatomical parameters were renal volume, length, width, and depth of the kidneys. Measurements were recorded at the time of diagnosis (T0) and at 1-month (T1), 6-months (T2), 18-months (T3) and 36-month of follow-up time (T4).A total of 131 renal arteries and kidneys were evaluated in 69 patients. Mean age was 64±13 years and 77% were male. The absolute number and percentage of assessed renal arteries/kidneys was 131 (100%) at T0, 89 (68%) at T1, 73 (56%) at T2, 57 (44%) at T3 and 43 (44%) at T4. At the time of diagnosis, 71.6% renal arteries originated from the TL, 19.1% from the FL and 9.2% from a CL. TEVAR was performed in 92.7% patients and nine patients had additional renal artery stenting. At T0 the mean renal volume was 212.1±70.9cmThere is a significant mid-term renal-volume reduction in patients with TBAD, independent of the origin of the renal arteries. Albeit not statistically significant, combined renal artery perfusion may lead to a greater volume reduction, potentially secondary to a relevant dynamic compression by the dissection membrane. Further multicentre studies are warranted to determine the effect on long-term renal function and on possible preventive strategies.

OBJECTIVE: Fiber Optic RealShape (FORS) technology has recently been introduced as an adjunctive guidance technology that allows real-time three-dimensional visualization of dedicated endovascular devices while avoiding radiation exposure. It consists of equipment which sends pulses of light through hair-thin optical fibers that run within a dedicated hydrophilic wire and selective catheters. The purpose of the study is to report the observed benefits and limitations related to the first edition of FORS technology.METHODS: Data was prospectively collected from the first 50 patients undergoing FORS-guided endovascular repair at a single center between February 2020 and February 2021 as part of the global multi-center FORS Learn registry. All consecutive, elective procedures, with one or more navigation tasks attempted with FORS were included. Factors related to FORS navigation task success were assessed. Time required for the catheterization of each task as well as the amount of radiation exposure (fluoroscopy time, dose area product and estimated skin dose) were collected. A per-task analysis was conducted. Endpoints included success rate in achieving a stable FORS guided catheterization, catheterization time, and radiation dose during catheterization.RESULTS: During the study period from February 2020 to February 2021, 50 patients were treated using FORS technology. Forty-five patients were treated for aortic aneurysm, 4 for iliac artery aneurysm, and 1 for splenic artery aneurysm. Overall, 201 navigation tasks were completed for these procedures and FORS was used in 186 tasks (92.5%). No FORS-related complication was recorded and a success rate of 60.2% (n=116) was observed. Target vessel (TV) angle of ≥45°, TV stenosis, and the renal arteries as navigation tasks (compared to celiac artery or superior mesenteric artery) were associated with a lower success rate. Catheterization of a TV through a branch more frequently required a standard catheter in combination with the FORS enabled guidewire. Successful task catheterization using FORS guidance was associated with a shorter catheterization time 6 min (IQR 3-11) vs. 16 min (10-24); pCONCLUSION: FORS technology was successfully implemented as a new guidance technology in a complex endovascular aortic repair program and was associated with an encouraging success rate and a high potential for radiation reduction.

This study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection.Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches.A total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P .05), longer postoperative hospital stay (22 vs 9 days; P .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P .003).Female AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR.

Objective The goal of this study was to select branched endograft designs that could fit most aortic arch anatomies. Such off-the-shelf endografts, once available, would be an endovascular therapeutic option to consider in the acute setting and would shorten the design and manufacturing process. Methods We retrospectively analyzed the endograft plans of all custom-made aortic arch branched endografts implanted between 2013 and early 2018 provided by the Cook Planning Center (EMEA Planning Services; Cook Medical, London, United Kingdom). Available data points of the endograft plans include proximal, intermediate, and distal endograft diameters; number of sealing stents; total length of the endograft; and number of branches. Results There were 286 two-branch endografts analyzed. We divided the endografts in three groups according to their proximal diameters: 34 mm, 36 mm, and 38 mm (group 1); 40 mm and 42 mm (group 2); and 44 mm and 46 mm (group 3). In group 1, 63% of the endografts had one proximal sealing stent, whereas in group 3, 63% had two proximal sealing stents. The distal diameters of the endografts ranged from 26 mm to 46 mm. The mean length was 236 mm (186-256 mm). A shorter standardized length of 211 mm was selected to anticipate distal extensions. According to our analysis, most group 1 patients could have been treated with a 38-mm proximal diameter and 30-mm distal diameter endograft with one sealing stent; most group 2 patients, with a 42-mm proximal diameter and 32-mm distal diameter endograft with both one and two proximal sealing stents; and most group 3 patients, with a 46-mm proximal diameter and 36-mm distal diameter endograft, also with both one and two proximal sealing stents. Conclusions Five standardized off-the-shelf endografts can cover a majority of aortic arch anatomies and offer an option for acute endovascular treatment of aortic arch disease.

Purpose: To evaluate if the elderly could benefit from the implantation of iliac branch devices (IBDs) to preserve the patency of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation. Materials and Methods: From January 2005 to April 2017, 804 patients enrolled in the pELVIS registry underwent endovascular aneurysm repair with 910 IBDs due to aneurysmal involvement of the iliac bifurcation. Among the 804 patients, 157 (19.5%) were octogenarians (mean age 82.9±2.5 years; 157 men) with 171 target IIAs for preservation. Outcomes at 30 days included technical success, death, conversion to open surgery, and major complications. Outcomes evaluated in follow-up were patency of the IBD and target vessels, type I and type III endoleaks, aneurysm-related reinterventions, aneurysm-related death, and overall patient survival. Kaplan-Meier analyses were employed to evaluate the late outcome measures; the estimates are presented with the 95% confidence interval (CI). Results: Technical success was 99.4% with no intraoperative conversions or deaths (1 bridging stent could not be implanted, and the IIA was sacrificed). Perioperative mortality was 1.9%. The overall perioperative aneurysm-related complication rate was 8.9% (14/157), with an early reintervention rate of 5.1% (8/157). Median postoperative radiological and clinical follow-up were 21.8 months (range 1–127) and 29.3 months (range 1–127), respectively. Estimated rates of freedom from occlusion of the IBD, the IIA, and the external iliac artery at 60 months were 97.7% (95% CI 96.1% to 99.3%), 97.3% (95% CI 95.7% to 98.9%), and 98.6% (95% CI 97% to 99.9%), respectively. Estimated rates of freedom from type I and type III endoleaks and device migration at 60 months were 90.9% (95% CI 87% to 94.3%), 98.7% (95% CI 97.5% to 99.8%), and 98% (95% CI 96.4% to 99.6%), respectively. Freedom from all cause reintervention at 60 months was 87.4% (95% CI 82.6% to 92.2%). The estimated overall survival rate at 60 months was 59% (95% CI 52.4% to 65.6%). Conclusion: IBD implantation in octogenarians provided acceptable perioperative mortality and morbidity rates, with satisfying long-term freedom from IBD-related complications and should be considered a feasible repair option for selected elderly patients affected by aneurysms involving the iliac bifurcation.

Purpose: To describe the implantation steps and tips and tricks for the Inner Branch Arch Endograft designed to treat aortic arch aneurysm and chronic type A aortic dissection. Technique: Anatomical suitability criteria should be met in order to use this device. The proximal segment of the graft lands in the ascending aorta distally to the sinotubular junction and the distal segment lands in the descending aorta. The device includes 2 inner branches; the proximal branch is used for a connection to the innominate artery (positioned slightly posterior at 12:30 o’clock), while the second branch is positioned slightly anterior at 11:30 o’clock and is used as a connection to the left common carotid artery. Access, implantation technique, deployment of the device, and catheterization of the branches are described thoroughly. Conclusion: This Inner Branch Arch Endograft is an appealing alternative to treat aortic arch pathology, especially in patients unsuitable for open repair. Nevertheless, complex aortic arch repair is associated with a learning curve. Meticulous preoperative planning and a high level of concentration intraoperatively are mandatory.

The urgent treatment of ruptured abdominal aortic aneurysms (rAAA) remains a challenging condition with devastating morbidity and mortality. Available studies are often limited due to a significant selection bias. This study aims to illuminate real-world evidence using comprehensive data from electronic health records, registries, postmortem findings, and administrative data on all consecutively treated patients presenting with rAAA at a tertiary care center.This is a retrospective cross-sectional cohort study covering consecutively treated patients with rAAA between 2009 and 2018. All noninvasive treatments, fatalities, and invasive repairs were included. Information on patient's characteristics, prehospital, and inpatient care was gathered. Short-term outcomes and long-term survival were analyzed for relevant subgroups.In total, 139 patients with rAAA (median age 75 years and 20.9% females, 79.9% infrarenal) were treated increasingly frequent by endovascular aortic repair (EVAR) when compared to open-surgical aortic repair (OSR) during the study period (16.7% in 2009 to 33.3% in 2018, P 0.05). The rate of patients who had been turned down for rAAA repair was 10.8%, and the overall in-hospital mortality was 43.2%. Perioperative morbidity and mortality were similar for EVAR and OSR, although patients treated by OSR presented with a lower mean Glasgow Coma Scale during the prehospital (12.7 vs. 14.3) and inpatient care (12.7 vs. 14.4) (both P 0.001), higher rates of intubation (12.8% vs. 10.9%, P 0.001), lower systolic blood pressure (115 mm Hg vs. 127 mm Hg, P = 0.042), and more often had a cardiac arrest before the operation (14.1% vs. 2.3%, P 0.001). Higher patient's age (Odds Ratio, OR 1.09; Hazard Ratio, HR 1.06), history of stroke or transient ischemic attack (OR 5.30; HR 2.64), higher serum creatinine (OR 1.81; HR 1.31), and occurrence of colonic ischemia (OR 11.31; HR 2.82) were significantly associated with higher odds of dying in hospital and in the longer term, respectively.We observed comparable outcomes following OSR and EVAR, although hemodynamically unstable patients were more likely to be treated by OSR. This study also confirmed the impact of colonic ischemia as a devastating complication following rAAA repair emphasizing the need for further reflection by the vascular community.

Purpose: The aim was to report short and mid-term outcomes of a novel, investigational, dissection-specific stent-graft (DSSG), specifically designed to address the features of chronic type B aortic dissection (CTBAD) and reduce the risk of distal stent-graft-induced new entry tears (dSINE). Materials and Methods: A retrospective single center cohort study of all patients undergoing TEVAR with the DSSG for CTBAD from January 1, 2017 to January 31, 2020. The DSSG, which is a modified stent-graft based on the Cook Zenith Alpha Thoracic platform, has no proximal barbs and a customized longer body length with substantial taper. The second and third distal Z-stents are sited internally to avoid any contact of the metal skeleton with the dissection membrane and have reduced radial force, while the most distal stent was removed creating a distal 30 mm unsupported Dacron graft. Results: Sixteen patients (13 males, 3 females) with a median age of 66 years (range 31-79 years) underwent elective TEVAR of CTBAD using the DSSG. Six patients (38%) had an underlying connective tissue disorder. The median tapering was 10mm (range 4mm-21mm) and median length 270mm (range 210-380 mm). Technical success was achieved in all but one case (96%). One patient died within 30 days, due to retrograde type A dissection with cardiac tamponade. The 30-day rate of stroke, spinal cord ischemia and re-interventions was 0%. After median imaging follow-up time of 17 months (range 1 – 31 months), one patient developed a dSINE four months after the index procedure. After median survival follow-up of 23 months (range 2 – 35 months), one late death occurred due to traumatic brain injury, while no aortic-related death occurred during follow-up. Complete false lumen (FL) thrombosis was achieved in nine patients while the remaining six showed partial FL thrombosis. No instances of diameter increase at the level of treated aortic segment were noted with serial measurements showing either stable (n=7) or decreased (n=8) maximal transverse diameter. Conclusions: Use of a novel DSSG with low radial force for TEVAR in the setting of CTBAD is safe and feasible. This early real-world experience shows promising mid-term effectiveness with low rates of dSINE or unplanned re-interventions and satisfactory aortic remodelling during follow-up. Longer follow-up is needed, however, before any firm conclusions can be drawn.

Purpose To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms. Technique We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography. Conclusion Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.

A persistent endoleak type II (ET II) after endovascular repair for aortic aneurysms is not always a benign condition and has been associated to sac expansion, rupture, and reintervention. A variety of different endovascular approaches are available for ET II treatment. The aim of this systematic review was to assess the currently available literature on transcaval embolization for ET II treatment after standard or complex endovascular aortic aneurysm repair.This systematic review protocol was registered to the PROSPERO (CRD42021289686). The PRISMA guidelines and patient, intervention, comparison, outcome (P.I.C.O.) model was followed. A data search of the literature was conducted, using PubMed, EMBASE via Ovid, and CENTRAL databases, until September 30, 2021. Only studies reporting on ET II embolization using the transcaval approach after endovascular aneurysm repair were included. Studies reporting on different type of endoleak treatment or any other embolization approach were excluded. The quality of studies was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success and freedom from ET II persistence during follow-up; secondary outcomes were any postoperative complication associated with the transcaval embolization and need for reintervention.The search yielded 2861 articles in total. Eight articles were included, reporting on 117 patients and 128 transcaval embolizations. The indication for treatment was ET II presence with sac expansion of more than 5 mm; in two studies, the presence of persistent endoleak has set the indication to intervene. The technical success was 91.4% (117/128); a variety of embolic materials were used, including coils, thrombin, and glue. Three cases of deep vein thrombosis were recorded and the remaining morbidity and mortality were null. Follow-up was ranging between 0 and 25 months. Out of 8 studies, persistent ET II rate was 12.8% and 18 reinterventions were performed (14.1%,), including 10 transcaval coil embolizations (56%). Sac expansion was reported in 11 cases, out of 3 studies (17%). Only one case of death, not associated with transcaval embolization, was recorded.Transcaval embolization for ET II treatment presents a high technical success and low mortality in the early and mid-term period. ET II persistence rate is low during the available 12-month follow-up.

Purpose: The purpose of this study was to evaluate early and mid-term results of non-standard management of the supraaortic target vessels with the use of the inner branch arch endograft in a single high-volume center. Material and methods: A single-center retrospective study including all patients undergoing implantation of an inner branch arch endograft from December 2012 to March 2021, who presented a non-standard management of the supraaortic target vessels (any bypass other than a left carotid-subclavian or landing in a dissected target vessel). Technical success, mortality, reinterventions, endoleak (EL), and aortic remodeling at follow-up were analyzed. Results: Twenty-four patients were included. In 17 (71%) cases, the non-standard management was related to innominate artery (IA) compromise (12 with IA dissection, 2 with short IA, 2 with short proximal aortic landing zone that required occlusion of IA, 1 with occluded IA after open arch repair). Two (8%) cases were related to an aberrant right subclavian artery (RSA), 1 patient (4%) due to the concomitant presence of a left vertebral artery (LVA) arising from the arch and an occluded left subclavian artery (LSA), and another patient presented with an occluded LSA distal to a dominant vertebral artery. Three (13%) cases were exclusively related to management in patients with genetic aortic syndromes. Twenty (83%) patients had a previous type A aortic dissection. Ten (42%) patients presented a thoracic or thoracoabdominal aortic aneurysm and 8 (33%) patients an arch aneurysm, 6 of them associated to false lumen (FL) perfusion. There were 2 (8%) perioperative minor strokes, and 1 patient with perioperative mortality. Seven patients presented an early type I endoleak, all resolved at follow-up. Seven patients required reinterventions during follow-up (7 reinterventions related to continuous false lumen perfusion, 3 related to Type Ia endoleak, 2 related to surgical bypass). All patients who presented with FL perfusion had complete FL thrombosis at follow-up. No patient presented aneurysm growth at follow-up. Conclusions: The use of the inner branch arch endograft with a non-standard management of the supraaortic target vessels is a possible option. Despite a high reintervention rate, regression or stability of the aneurysmal diameter was achieved in all the patients with follow-up.

Purpose: The purpose of this article is to study 1-year results of Zenith branch iliac endovascular graft (ZBIS) with the off-label use of a 13 mm spiral Z limb to connect to the aortic main body. Materials and Methods: A retrospective review from 2015 to 2019 of all iliac branch devices (IBDs) was performed at 1 institution that were connected to an aortic main body with a 13 mm spiral Z limb and had at least 1-year follow-up with computed tomography (CT). Primary endpoints are freedom from ZBIS separation from the connection limb, endoleak (EL), or reintervention at 1 year. Secondary endpoints are primary and secondary ZBIS patency, presence of any EL, and aortic reinterventions. Results: Of 149 IBDs implanted in this period, 45 ZBIS in 35 patients were connected with a 13 mm limb and had a 1-year CT; 97% of patients had common iliac artery (CIA) aneurysms, 7% of patients had hypogastric artery (HA) aneurysms, and 30% of patients had bilateral ZBIS implantation. Technical success was 98%. In 84% of cases, the Advanta V12 was used as the HA mating stent; 56% of patients had an EL, mostly type II, which resolved spontaneously in 70% at 1 year, and 9% of ZBIS required reinterventions at 1 year (2 for thrombosis, 2 for type Ic EL from HA mating stent). One-year ZBIS primary patency and secondary patency were 96% and 100%, respectively. No EL was noted to be related to the 13 mm connection limb. No migration or separation of the devices occurred. Conclusions: The use of 13 mm spiral Z limb to connect a ZBIS with the main body in our series yields a high technical success rate and good 12-month outcomes without device separation or migration.

Treatment of complex abdominal and thoracoabdominal aortic aneurysms is challenging. Open surgical repair is a high-risk operation, especially in emergency cases. Endovascular aneurysm repair with a patient-specific custom-made stent graft in patients with symptomatic or ruptured complex aortic aneurysms is not possible, due to the manufacturing time required. In such cases, alternative endovascular techniques can be used.The "off-the-shelf" and "surgeon-modified" stent grafts are valid options for the endovascular treatment of complex aneurysms in urgent and emergent patients. The former are standardised commercially manufactured fenestrated or branched stent grafts, which are available off-the-shelf with an anatomical feasibility in 50 - 80% of the patients. The "surgeon-modified" stent grafts refer to a technique, in which a commercially available stent graft is modified by the surgeon under sterile conditions directly before the implantation, in order to add the required fenestrations, scallops and/or branches. The modification takes approximately 60 - 120 min and haemodynamic stability of the patient is mandatory. Because of the off-label use of the commercial stent graft, detailed patient consent about the modification complications and risks should be performed whenever possible. A comparison of results on mortality and morbidity between "off-the-shelf" and "surgeon-modified" stent grafts has been published, although a direct comparison would be unfair for several reasons (different design, lack of extensive outcomes reports, long learning curve and different modification techniques).The "surgeon-modified" and "off-the-shelf" fenestrated/branched stent grafts are used in the treatment of high-risk patients with symptomatic or contained ruptured complex aneurysms. The outcomes of the two techniques are good, although the long-term durability of the former should be further investigated.Die Behandlung komplexer abdomineller und thorakoabdomineller Aortenaneurysmen stellt für alle Beteiligten eine Herausforderung dar. Die offene chirurgische Versorgung ist ein Hochrisikoeingriff und ist besonders im Notfall mit erhöhter Morbidität und Mortalität assoziiert. Die endovaskuläre Ausschaltung mithilfe eines patientenspezifischen maßgefertigten Stentgrafts steht aufgrund der erforderlichen Herstellungszeit bei Patienten mit symptomatischen oder rupturierten komplexen Aneurysmen nicht zur Verfügung. In diesen Fällen müssen alternative endovaskuläre Techniken angewendet werden.Zu den endovaskulären Therapieoptionen komplexer Aneurysmen in dringenden Fällen und Notfällen zählen die „off-the-shelf“ und die „surgeon-modified“ Stentgrafts. Die ersten sind standardisiert hergestellte fenestrierte oder gebranchte Endoprothesen, die aufgrund der anatomischen Gegebenheiten bei etwa 50 – 80% der Patienten eingesetzt werden können. Die „surgeon-modified“ oder „vom Chirurgen modifizierten“ Stentgrafts beschreiben eine Technik, bei der eine kommerzielle Stentprothese unter sterilen Bedingungen und direkt vor der Implantation durch den Operateur bearbeitet wird, damit die benötigten Fenestrierungen, Scallops und Branches geschaffen werden. Die Modifikationsdauer beträgt 60 – 120 min angepasst an die Anatomie des Patienten. Es handelt sich um einen „off-label“-Gebrauch eines kommerziellen Stentgrafts außerhalb der Anweisungen des Herstellers und wenn möglich, sollte eine entsprechende ausführliche Patientenaufklärung als Behandlungsversuch stattfinden. In der Literatur sind ähnliche Ergebnisse bez. Morbidität und Mortalität zwischen „off-the-shelf“ und „surgeon-modified“ Prothesen publiziert. Ein direkter Vergleich dieser Verfahren scheint aus mehreren Gründen (unterschiedliches Prothesendesign, Selektionsbias, unterschiedliche Techniken in der Prothesenmodifikation) jedoch schwierig und anhand der Literatur allein nicht eindeutig durchführbar.Die „surgeon-modified“ sowie die „off-the-shelf“ fenestrierten/gebranchten Stentprothesen werden in der Versorgung von Hochrisikopatienten mit symptomatischen oder gedeckt rupturierten komplexen Aortenaneurysmen angewendet. Die Ergebnisse beider Techniken sind vergleichbar gut, obwohl die langfristige Funktionsdauer der modifizierten Stentprothesen weiter getestet werden sollte.

The objective of this study was to evaluate renal function and renal parenchymal length changes secondary to the coverage or preservation of accessory renal arteries (ARAs) in complex aortic repair.This was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f-b EVAR) who presented with ARAs. Two groups were created, a preserved ARA group, with incorporation of the vessel as a dedicated fenestration or branch in the endograft plan, and a non-preserved ARA group, without incorporation of them. Early30% decline of glomerular filtration rate (GFR), kidney infarcts, and endoleaks were evaluated. Mid-term results with freedom from kidney shrinkage (defined as length decrease10%) at follow-up, freedom from GFR decrease30%, or need for postoperative dialysis at follow-up were also analyzed. Primary assisted patency of incorporated ARAs was calculated.From 2011 through 2020, 145 patients undergoing complex aortic repair presented with an ARA. After excluding ruptured aneurysms, 33 patients had the ARA preserved with their incorporation into the stent graft (preserved ARA group), and 99 did not have preservation of them (not-preserved ARA group). There were no statistical differences in demographics or type of aneurysm. Patients in the ARA-preserved group had more ARAs (median of two per patient vs one in the non-preserved ARA group; P = .01) and bigger ARAs (median 4 vs 3 mm in the non-preserved ARA group; P = .001). Early postoperative worsening30% of GFR (23% vs 6%; P = .03) as well as postoperative renal infarction (57% vs 6%; P = .001) and ARA-related endoleaks (20% vs 0%; P = .01) were statistically higher for the not-preserved ARA group. Mid-term kidney length showed significant shrinkage in the not-preserved ARA group compared with the ARA preserved group (9.7% vs 0%; P = .001). Freedom from30% GFR decline at 2 years was significantly higher for the preserved ARA group (83% vs 47%; P = .01).Two-year primary assisted patency of incorporated ARA was 94%.Complex aortic repair incorporation of ARA is feasible, with low complications and good primary assisted patency at 2 years. It leads to less postoperative early renal dysfunction as well as higher freedom for mid-term renal disfunction and kidney shrinkage.

Right aortic arch aneurysm originating from a Kommerell’s diverticulum associated with an aberrant left subclavian artery is a rare congenital entity. We report a case of an asymptomatic 60-year-old female with right aortic arch aneurysm with an aberrant left subclavian artery, treated with a modified frozen elephant trunk technique using a 4-branched prosthesis, with the perfusion branch as an extra-anatomical bypass to the aberrant left subclavian artery. This case demonstrates short-term safety and efficacy of this technique.

Fiber Optic RealShape technology is a new endovascular guidance system that aims to sim-plify endovascular procedures by improving wire, catheter, and device visualization, while reducing reliance on ionizing radiation. Developed by Philips, the system uses light re-fracted through optical fibers to generate real-time renderings of wires and catheters in three-dimensional space. Currently, devices with embedded Fiber Optic RealShape technol-ogy are being studied in human patients undergoing endovascular procedures. Early find-ings demonstrate the technology to be safe and effective in offsetting procedural complex-ity. Research and development to improve rendering accuracy and expand the selection of available Fiber Optic RealShape-enabled endovascular devices continues. (c) 2021 Elsevier Inc. All rights reserved.

Summary Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding UK Medical Research Council and Health Technology Assessment Programme.

Purpose To report endovascular repair of postdissection thoracoabdominal aortic aneurysm (TAAA) in 2 patients with vascular Ehlers-Danlos syndrome (vEDS). Case Reports Case 1. A 56-year-old vEDS male patient with a 50-mm type III TAAA [history of aortic root repair, hemiarch replacement, and thoracic endovascular aortic repair (TEVAR) for acute type A aortic dissection (TAAD) 7 years ago] was treated by a 2-stage procedure; first, cervical debranching of the left subclavian artery and second TEVAR and t-branch. The postoperative course was uneventful. Follow-up computed tomography angiography (CTA) 3.5 years postoperatively demonstrated aortic remodeling with patency of targeted visceral vessels and no endoleak. Case 2. A 47-year-old vEDS male patient presented with a TAAA (diameter of 67 mm). The patient had a history of aortic valve and arch replacement with elephant trunk for acute TAAD, and consequently a TEVAR and candy-plug procedure after a ruptured false lumen (FL) aneurysm of the descending thoracic aorta. He also had a surgical repair by an aorto-bi-iliac graft. Two years later, CTA demonstrated aneurysmal FL dilatation distally to the candy-plug and he was treated with fenestrated EVAR (F-EVAR). Conclusion Endovascular repair of postdissection TAAA was feasible and safe with good short-term outcome in 2 patients with vEDS.

Background To report early results of feasibility and patency of prophylactic hypogastric artery (HA) stenting during complex endovascular aortic repair. Methods This is a single centre retrospective non comparative cohort study of all consecutive patients undergoing prophylactic HA stenting during fenestrated and/or branched EVAR (F/B EVAR) in order to prevent spinal cord ischemia (SCI). Endpoints included technical success and early outcomes in terms of morbidity, mortality and patency of the implanted stents. Results Between May 2014 and June 2019 prophylactic HA stenting was performed in 36 consecutive patients with significant HA stenosis during F/B EVAR to prevent SCI. 69.4% of patients presented with asymptomatic, 25% with symptomatic and 5.6% with ruptured aortic aneurysms. 55.6% were treated for thoracoabdominal aortic aneurysms, 44.4% for pararenal abdominal aortic aneurysms. In 13.9% aortic coverage was limited to the abdominal aorta. In 86.1% the aortic coverage was in the thoracoabdominal aortic segment. Unilateral HA stenting was performed in 91.7%, whereas 8.3% underwent bilateral stenting. Technical success was 100%. The primary patency of the implanted stents after a median follow-up time of 9.5 months was 97.5%. One intraprocedural bleeding from an HA branch occurred and was successfully treated by coil embolization. No further procedure-related complications occurred. 11.1% of the patients developed SCI. Conclusions HA stenting is feasible and safe with high rates of technical success and short-term patency.

Treatment reality of abdominal aortic aneurysm (AAA) is changing. Up to date, approximately 65% of intact AAA and 30% of ruptured AAA are treated endovascularly. As most comparative studies focus upon mortality and few major complications, some outcomes as lower extremity ischemia (LEI) after invasive AAA repair are often underreported. However, there is evidence for a worse outcome of patients suffering from this kind of complication.Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) vascular surgery targeted module from 2011 to 2014, we identified all patients undergoing endovascular aortic repair (EVAR) and open aortic repair (OAR) for AAA to illuminate the incidence and outcome of LEI after AAA repair.In total, 185 patients (1.9%) developed LEI after AAA repair. 1.6% of all patients showed LEI after treatment of asymptomatic or symptomatic intact AAA, compared with 4.8% of ruptured AAA repair (P 0.001). Operation time, male gender, current smoking, and increased creatinine levels (1.5 mg/dL) were associated with an increased likelihood of exhibiting LEI. No statistically significant differences between EVAR versus OAR were noted in the multivariate model. If LEI occurred, length of hospital stay (6 vs. 2 days, P 0.001) and mortality (20.5 vs. 4.6%, P 0.001) was significantly higher as compared with the patients without LEI. Furthermore, 30-day mortality and most major complications were more common if LEI occurred.In this specialized analysis regarding LEI after AAA repair up to 2% develop this severe ischemic complication. Since the occurrence of LEI is associated with significantly worse outcome, future research and strategies to avoid this complication is needed.

Purpose: To present the early results of false lumen (FL) occlusion in chronic aortic dissection using the Candy-Plug generation II (CP II), which has a self-closing fabric channel that obviates the need for separate occlusion of its center. Materials and Methods: Fourteen consecutive patients (mean age 60±11 years; 10 men) with persistent FL backflow and aneurysm formation at the thoracic segment in chronic aortic dissection underwent thoracic endovascular aortic repair (TEVAR) with FL occlusion using the refined CP II. Primary endpoints were technical success (successful deployment) and clinical success (no FL backflow at the CP II level). Secondary endpoints included 30-day mortality and morbidity and aortic remodeling during follow-up. Results: Technical success was 100%. One patient required additional intraprocedural FL embolization at the CP II level due to persistent FL backflow on final angiography (clinical success 93%), though there was no flow through the CP II center. There were no intraprocedural complications. Immediate complete FL occlusion was achieved in 12 patients; the other 2 required reintervention. One had contrast enhancement in the distal FL proximal to the CP II and was treated with coil embolization. The other patient had persistent type I endoleak at the level of the left subclavian artery (LSA) and underwent left carotid–LSA bypass and proximal stent-graft extension. One patient died due to retrograde type A aortic dissection that was not related to CP II placement. Over a mean 8-month follow-up (range 3–12), 9 patients had computed tomography angiography; 8 patients had evidence of aortic remodeling, while 1 aneurysm sac was stable. Conclusion: The CP II reduces the number of procedural steps and offers good seal, with minimal morbidity and mortality and a high rate of aortic remodeling.

Objective Fenestrated or branched endovascular aortic repair (FB-EVAR) usually represents the last stage in endovascular treatment of postdissection aneurysm after thoracic endograft coverage of entry tear and false lumen embolization. Methods The study was a retrospective analysis of all patients with postdissection thoracoabdominal aneurysm treated with FB-EVAR in a single center. Short-term outcomes included technical success, operative mortality, and morbidities. Midterm outcomes included secondary intervention, false lumen thrombosis rate, aneurysm size regression, and subsequent survival. Results Twenty patients (95% male with a mean age of 64 ± 9 years) were treated between January 2014 and December 2017. The technical success was 100%. There was one death (5%) within 30 days. Postoperative complications included two patients with spinal cord ischemia (10%; one partial and one full). The median follow-up period was 12 months (range, 0-31 months). A secondary intervention was required in six patients, including thoracic stent graft relining for type III endoleak (n = 2), covered stent relining for junctional leak between main body and renal stent (n = 2), and iliac false lumen embolization (n = 2). Twelve patients completed the 1-year follow-up computed tomography angiogram, and their mean aneurysm diameters were 71 ± 18, 66 ± 19, and 62 ± 19 mm preoperatively, immediate postoperatively, and at 1 year, respectively; the corresponding false lumen thrombosis rates were 0% (0/20), 58% (7/12), and 92% (11/12), respectively. One more patient died during follow-up from a non-aneurysm-related cause. The estimated overall survival rates were 95 ± 5%, 88 ± 8%, and 88 ± 8% at 6, 12, and 18 months, respectively. Conclusions FB-EVAR was feasible for postdissection thoracoabdominal aneurysm. Despite the associated perioperative risk and high probability of planned or unplanned reintervention, the procedure led to favorable aortic remodeling with false lumen thrombosis and aneurysm regression.

Introduction: Thoracic endovascular aortic repair has been increasingly used to treat type B aortic dissection (TBAD) when it is indicated, offering better outcome in terms of mortality and morbidi...

Background To introduce the new generation Candy-Plug II with a self-closing channel construction inside the plug. Methods The technique of the Candy-Plug II was demonstrated in a 50-year-old patient with residual chronic aortic dissection and thoracic false lumen aneurysm with false lumen backflow after open surgical repair of the ascending aorta for acute type A aortic dissection. The Candy-Plug Technique was applied in addition to a branched arch procedure using a new generation Candy-Plug II for false lumen occlusion. The Candy-Plug II is a short tubular stent graft with a small open channel inside the graft to accommodate the central cannula and allow retrieval of the dilator tip, which closes itself as soon as the dilator tip is removed. The channel inside the graft is unsupported and will collapse and thereby close. This new design obviates additional placement of a plug to occlude the midsection of the first-generation Candy-Plug. After deployment of the Candy-Plug, distal false lumen occlusion was confirmed on final angiogram and postoperative computed tomography scans without any leakage through the Candy-Plug. Conclusions The new generation Candy-Plug II is a useful refinement of the previously available model. It reduces the procedural steps and provides a longer sealing segment.

Abstract. Background: Worldwide prevalence of peripheral artery disease (PAD) is increasing and peripheral vascular intervention (PVI) has become the primary invasive treatment. There is evidence that multidisciplinary team decision-making (MTD) has an impact on in-hospital outcomes. This study aims to depict practice patterns and time changes regarding MTD of different medical specialties. Methods: This is a retrospective cross-sectional study design. 20,748 invasive, percutaneous PVI of PAD conducted in the metropolitan area of Hamburg (Germany) were consecutively collected between January 2004 and December 2014. Results: MTD prior to PVI was associated with lower odds of early unsuccessful termination of the procedures (Odds Ratio 0.662, p < 0.001). The proportion of MTD decreased over the study period (30.9 % until 2009 vs. 16.6 % from 2010, p < 0.001) while rates of critical limb-threatening ischemia (34.5 % vs. 42.1 %), patients´ age (70 vs. 72 years), PVI below-the-knee (BTK) (13.2 % vs. 22.4 %), and rates of severe TASC C/D lesions BTK (43.2 % vs. 54.2 %) increased (all p < 0.001). Utilization of MTD was different between medical specialties with lowest frequency in procedures performed by internists when compared to other medical specialties (7.1 % vs. 25.7 %, p < 0.001). Conclusions: MTD prior to PVI is associated with technical success of the procedure. Nonetheless, rates of MTD prior to PVI are decreasing during the study period. Future studies should address the impact of multidisciplinary vascular teams on long-term outcomes.

MINI: The objective of this study was to evaluate the outcome of endovascular repair of chronic aortic arch dissecting aneurysms with a custom-made branched endograft during follow-up after acute type A aortic dissection open repair. Unmatched outcomes are reported in a population at high risk for a redo sternotomy. OBJECTIVE The objective of this study was to evaluate the outcome of endovascular aortic arch repair for chronic dissection with a custom-made branched endograft. BACKGROUND Acute type A aortic dissections are often treated with prosthetic replacement of the ascending aorta. During follow-up, repair of an aneurysmal evolution of the false lumen distal to the ascending prosthesis can be a challenge both for the surgeon and the patient. METHODS We conducted a multicenter, retrospective study of consecutive patients from 14 vascular units treated with a custom-made, inner-branched device (Cook Medical, Bloomington, IN) for chronic aortic arch dissection. Rates of in-hospital mortality and stroke, technical success, early and late complications, reinterventions, and mortality during follow-up were evaluated. RESULTS Seventy consecutive patients were treated between 2011 and 2018. All patients were considered unfit for conventional surgery. In-hospital combined mortality and stroke rate was 4% (n = 3), including 1 minor stroke, 1 major stroke causing death, and 1 death following multiorgan failure. Technical success rate was 94.3%. Twelve (17.1%) patients required early reinterventions: 8 for vascular access complication, 2 for endoleak correction, and 2 for pericardial effusion drainage. Median follow-up was 301 (138-642) days. During follow-up, 20 (29%) patients underwent secondary interventions: 9 endoleak corrections, 1 open repair for prosthetic kink, and 10 distal extensions of the graft to the thoracic or thoracoabdominal aorta. Eight patients (11%) died during follow-up because of nonaortic-related cause in 7 cases. CONCLUSIONS Endovascular treatment of aortic arch chronic dissections with a branched endograft is associated with low mortality and stroke rates but has a high reintervention rate. Further follow-up is required to confirm the benefits of this novel approach.

Background Residual patent false lumen (FL) after chronic type B aortic dissection (cTBAD) or type A aortic dissection (TAAD) treatment is independently associated with poor long-term outcomes. The aim of our study was to present endovascular techniques and the existing experience with targeted FL thrombosis after cTBAD or TAAD treatment. Material and Methods A systematic review was performed (Preferred Reporting Items for Systematic reviews and Meta-Analyses) searching in MEDLINE, CENTRAL, and Cochrane databases for studies reporting on targeted FL occlusion after cTBAD or TAAD treatment. Results One hundred one patients either after open repair of a TAAD (n = 40; 3 case reports and 3 retrospective studies) or after cTBAD (n = 61; 13 case reports and 6 retrospective studies) underwent an endovascular procedure for intentional FL occlusion (2 studies reported on both procedures). Among TAAD patients, 27 of 40 (68%) had previous open repair, whereas 48 of 61 (79%) with cTBAD had a previous endovascular repair. Thirty-one (78%) patients with TAAD and fifty-one (83%) with cTBAD were treated electively. Four main techniques were used: (1) the candy-plug (19/101), (2) the knickerbocker (3/91), (3) the “cork in the bottle neck” technique (2/101), and (4) FL embolization with combined use of coils, onyx, plugs, and glue (77/101). The technical success rate was 100%, with a 30-day mortality rate of 2.5% (1/40) in TAAD and 0% in cTBAD patients. During follow-up (ranging: 2 to 63 months), the mortality rate was 0% (0/31) and 7.1% (4/61) in TAAD and cTBAD patients, respectively. The FL remained completely thrombosed in 78% (31/40) of TAAD and 62% (38/61) of cTBAD patients, whereas it was partially thrombosed in 3 and 2 patients, respectively (no report for 22 patients). Conclusions Intentional FL occlusion seems to be a feasible less invasive approach after cTBAD or TAAD treatment, which is not broadly used. Future larger studies with longer follow-up duration may demonstrate the apparent benefit in terms of aortic remodeling or stabilization of the disease progression.