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Objective: The treatment for arch aneurysms by endovascular repair is often difficult. This study evaluated the long-term outcomes of thoracic endovascular aortic repair for aortic arch aneurysms treated with the Najuta stent-graft system. Materials and Methods: From January 2009 to December 2019, 37 patients underwent treatment for aortic aneurysms with the Najuta stent graft system at two institutes, including our hospital. We retrospectively analyzed the short- and long-term clinical outcomes. Results: Of all 37 cases, the technical success rate was 97.3% (36 of 37). The mean proximal neck length was 20.1±5.3 mm. The postoperative results revealed 10 patients with type Ia endoleaks (27.8%), 6 with stroke (16.7%), and one with paraplegia (2.8%). In the chronic phase, the overall survival rates and the rates of freedom from aorta-related events at 7 years were 71.3% and 50.7%, respectively. Between two groups divided based on the proximal neck diameter of 20 mm, the

Objective: The interactions between aortic morphology and hemodynamics play a key role in determining type B aortic dissection (TBAD) progression and remodeling. The study aimed to provide qualitative and quantitative hemodynamic assessment in four different TBAD morphologies based on 4D flow MRI analysis.Materials and Methods: Four patients with different TBAD morphologies underwent CT and 4D flow MRI scans. Qualitative blood flow evaluation was performed by visualizing velocity streamlines and flow directionality near the tears. Quantitative analysis included flow rate, velocity and reverse flow index (RFI) measurements. Statistical analysis was performed to evaluate hemodynamic differences between the true lumen (TL) and false lumen (FL) of patients.Results: Qualitative analysis revealed blood flow splitting near the primary entry tears (PETs), often causing the formation of vortices in the FL. All patients exhibited clear hemodynamic differences between TL and FL, with the TL generally showing higher velocities and flow rates, and lower RFIs. Average velocity magnitude measurements were significantly different for Patient 1 (t = 5.61, p = 0.001), Patient 2 (t = 3.09, p = 0.02) and Patient 4 (t = 2.81, p = 0.03). At follow-up, Patient three suffered from left renal ischemia because of FL collapse. This patient presented a complex morphology with two FLs and marked flow differences between TL and FLs. In Patient 4, left renal artery malperfusion was observed at the 32-months follow-up, due to FL thrombosis growing after PET repair.Conclusion: The study demonstrates the clinical feasibility of using 4D flow MRI in the context of TBAD. Detailed patient-specific hemodynamics assessment before treatment may provide useful insights to better understand this pathology in the future.

Objective: Aortic diseases remain an acute and debatable problem. Among all the aortic pathologies, the most dangerous are dynamic aneurysmal expansion, traumatic dissections and / or aneurysms, pure aortic intima dissections. Contemporary and less invasive treatment method is the stent graft implantation into aorta. This report describes the first experience of thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) in the Kyrgyz Republic in consecutive patients with life-threatening aortic conditions. Methods: Nine patients, who underwent TEVAR and EVAR, were presented after all clinical examinations, echocardiography and computed tomography angiography with various life-threatening aortic diseases. Among the pathologies there were 2 (22.2%) dissections only, traumatic aneurysm 1 (11.1%), aneurysm without dissection 1 (11.1%), aneurysm with intimal dissection 5 (55.6%). Seven patients with dissection had type B (The Stanford classification). Results: TEVAR was performed in eight cases EVAR just in one. All patients reached the 6-month endpoint. None of the following, such as aneurysm expansion, aneurysm thrombosis or a functioning of false lumen at the sites of the stent graft implantation have been recorded. In addition, no further progression of the false lumen below the implantation zones was visualized. Mean diameter of stent grafts was 31.4 ± 4.8 mm and 188.9 ± 34.6 mm in length. Conclusion: This modest observation showed the effectiveness of stent grafts implantation procedures in various aortic life-threatening conditions, such as aneurysm and / or aortic intima dissection.

Aberrant origin of the left vertebral artery (LVA) can pose a challenge during thoracic endovascular aortic repair. We encountered such a patient who was involved in a motor vehicle accident in whom computed tomography angiography revealed a grade IIIB blunt aortic injury with an anomalous origin of the LVA distal to the origin of the left subclavian artery. On-table aortography confirmed dominance of the LVA. Hence, an open left carotid-vertebral and then left carotid-subclavian artery bypass was performed, followed by thoracic endovascular aortic repair. The patient recovered well and was discharged home 3 days later. Keywords: Thoracic endovascular aortic repair (TEVAR), Vertebral artery revascularization, Carotid-subclavian bypass, Carotid-vertebral bypass, Aberrant origin of left vertebral artery

Background: Aortic intramural hematoma constitutes one of the three classifications of acute aortic syndrome (AAS). Type B intramural hematoma (IMH-B) is localized to the descending thoracic aorta and can be managed through medical, endovascular or surgical means. Data comparing contemporary management with thoracic endovascular aortic repair (TEVAR) versus traditional medical management (MM) is sparse and only moderate strength recommendations for TEVAR are provided in guidelines. This meta-analysis aimed to pool available data from comparative studies between TEVAR and MM and examine differences in outcomes. Methods: Literature search of electronic medical databases was conducted to identify studies comparing TEVAR and MM for management of IMH-B. Data extraction from studies fulfilling the inclusion criteria was performed by two authors and meta-analysis using a random-effects model applied to pool baseline data and examine risk ratios (RR) for management outcomes. Results: Of the initial 2,349 studies, nine studies were identified for analysis. There were 161 TEVAR patients and 166 who were medically managed. The mean age of the cohort was 62.2 years [95% confidence interval (CI): 55.8–68.7 years]. Patients with complicating features of IMH-B at presentation were more likely to appear in the TEVAR group, with more penetrating atheromatous ulcer (PAU) [risk difference (RD), 0.565, 95% CI: 0.240–0.889, P=0.001], ulcer-like projection (ULP) (RD 0.240, 95% CI: 0.965–0.384, P=0.001), and greater IMH size (mean difference, MD 5.47 mm, 95% CI: 0.320–10.6, P=0.037). There was no statistical difference between TEVAR and MM for the primary endpoints of aortic-related death (RR 0.535, 95% CI: 0.191–1.5, P=0.234) or IMH-B regression (RR 1.25, 95% CI: 0.859–1.81, P=0.246). Of the secondary endpoints, TEVAR had both significantly less dissection during follow-up (RR 0.295, 95% CI: 0.0881–0.989, P=0.048) and less rupture during follow-up (RR 0.206, 95% CI: 0.0462–0.921, P=0.039). Conclusions: A small number of series comparing TEVAR and MM for management of IMH-B are available and random-effects meta-analysis did not reveal any statistically significant difference between treatments for aortic related death or IMH-B regression at a mean follow-up of 37 months. TEVAR was found to be associated with lower risk of dissection and lower risk of rupture during follow-up. Baseline data meta-analysis showed patients with complicating features of PAU, ULP, and larger IMH size were more likely to be managed with TEVAR.

Postoperative ischemic complications, especially cerebral infarction due to atheroembolization following thoracic endovascular aortic repair, can be catastrophic. Herein, we present a maneuver of prevention of cerebral infarction using temporary cerebral arterial perfusion from the femoral artery, with the extracorporeal circuit including roller pump and filter in case of severe atherosclerotic change in thoracic aorta.

‐Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67‐year‐old man with symptomatic severe aortic stenosis after TAVR. ‐Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication., ‐Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67‐year‐old man with symptomatic severe aortic stenosis after TAVR.‐Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

Spinal cord infarction is reported to account for less than 1% of all strokes and is a relatively rare disease. In recent years, thoracic endovascular aortic repair (TEVAR) has become a common treatment for aortic aneurysms, and spinal cord ischemia is one of its complications. Most cases occur in the perioperative period; however, a few cases have been reported in the chronic stage. Here, we report a case of spinal cord infarction, 6 months after TEVAR. A 77-year-old man experienced sudden onset paraparesis following dumbbell exercises and defecation. He had a history of an infectious thoracoabdominal aortic aneurysm treated by TEVAR 6 months prior. Paralysis and disturbance of the thermal pain and tactile sensations of the lower limbs were observed, but proprioception and deep sensation were preserved. Computed tomography (CT) showed no evidence of intraspinal hemorrhage, new aortic dissection, or endoleak around the aortic stent placed from Th11 to L3. Magnetic resonance imaging (MRI) showed intramedullary hyperintensity from Th11 to the conus 2 days after onset. Anticoagulant therapy and rehabilitation were performed, and the lower-limb muscle strength gradually improved. After aortic stenting, particularly including the level of the Adamkiewicz artery, the risk of spinal cord ischemia must be monitored, because spinal circulation depends on collateral circulation., Spinal cord infarction, Thoracic endovascular aortic repair (TEVAR), Adamkiewicz artery, Neuroscience, Nervous system, Systems neuroscience, Neuroanatomy.

Thoracic endovascular aortic repair (TEVAR) is used to treat retrograde type A acute aortic dissection (RTAAD). In case 1, a 52-year-old man, who was conservatively managed, reported worsening back pain. Emergency TEVAR was performed 7 days after onset. After deploying two GORE Conformable TAG (CTAG) in the descending aorta, his symptoms disappeared. In case 2, a 52-year-old man with progressive worsening resistant hypertension, renal dysfunction, and respiratory failure despite maximal medical therapy underwent TEVAR 8 days after onset. A CTAG was deployed from the left subclavian artery under rapid pacing, and two Zenith Dissection stents were placed, which resolved complications. In both cases, after 6 months, computed tomography (CT) scan showed complete resorption of the false lumen in the ascending aorta. TEVAR for RTAAD with complete thrombosis of false lumen in the ascending aorta can be an alternative to surgery when the primary tear is located in descending aorta.

Aortoesophageal fistula after thoracic endovascular aortic repair is a rare but fatal complication, and no clear guidelines exist in the literature for optimal management. Herein, we report a complex case of a patient with an infected thoracic endograft that led to an aortoesophageal fistula. The treatment comprised a two-stage open surgical approach—an extra-anatomic aortic bypass in the first stage, followed by explantation of the infected endograft with ligation of the descending thoracic aorta in the second. This approach controls the focus of infection while allowing flow to the aorta distal to the infected endograft, minimizing visceral ischemia time. Keywords: Thoracic endovascular aortic repair (TEVAR), Aorta, Complication, Aortoesophageal fistula, Operative technique

We report a rare case of delayed paraplegia triggered by gastrointestinal (GI) bleeding 8 months after thoracic endovascular aortic repair (TEVAR). A 78-year-old male underwent TEVAR of a descending thoracic aortic aneurysm without a postoperative neurological deficit and was discharged. Magnetic resonance image showed spinal cord infarction from Th8 to L1, and enhanced computed tomography showed a patent Adamkiewicz artery. The ostium of the intercostal artery connected with the Adamkiewicz artery was occluded. Patients with a history of TEVAR might be more vulnerable to spinal cord ischemia around the Adamkiewicz artery, which can be triggered by common hemorrhagic diseases, such as GI bleeding, even remote from the procedure.

Branched endografts have been developed to treat complex pathology in the aortic arch and ascending aorta. This study aims to evaluate the haemodynamic performance of a double-branched thoracic endograft by detailed comparison of flow patterns and wall shear stress in the aorta and supra-aortic branches before and after stent-graft implantation. Pre- and post-intervention CT images were acquired from two patients who underwent thoracic endovascular aortic repair (TEVAR) with a double-branched endograft for thoracic aortic aneurysms. These images were used to reconstruct patient-specific models, which were analysed using computational fluid dynamics employing physiologically realistic boundary conditions. Our results showed that there was sufficient blood perfusion through the arch branches. The presence of inner tunnels caused flow derangement and asymmetric wall shear stress in the ascending aorta, where shear range index was up to 6 times higher than in the pre-intervention model. Wall shear stress in the aortic arch increased considerably after intervention as a result of accelerated flow. The maximum flow-induced displacement forces on the branched endografts were around 22 ​N for both patients, which was below the threshold for device migration. Results from this pilot study demonstrated that aortic flow patterns were significantly altered by the branched endograft which caused increased spatial variation of wall shear stress in the ascending aorta and the arch. Although no obvious adverse hemodynamic features were found immediately after intervention for the cases we analysed, follow-up studies will be needed to assess durability of the device.

Penetrating aortic ulcer (PAU) of the arch has a focal extent which often represents an adequate anatomic target for thoracic endovascular aortic repair (TEVAR). However, the anatomic constraints represented by the supra-aortic vessels pose either clinical or technical challenges that increase when the PAU develops proximally in the arch. Currently, different types of endografts are commercially available and have been used to treat aortic arch lesions. These include branched/fenestrated endografts for a total endovascular approach, and standard devices that can be used in combination with open/hybrid surgical operations, with the aim to exploit the minimally invasive nature of TEVAR by extending the proximal landing zone when necessary. We describe several current techniques adopted in such settings.

Objective This study aimed to evaluate the safety and feasibility of total endovascular repair of the aortic arch using a novel designed stent-graft system (Yanger stent-graft system; Lifetech Scientific, Shenzhen, China) in vitro and in a canine model. Methods The Yanger stent-graft system is composed of a main stent-graft, branched stent-graft, and a delivery system. In an in vitro aortic arch simulation test bench, the system was tested, and the success rate of stent-graft releasing, anchoring, and positioning was recorded and analyzed. Meanwhile, in vivo implantation of the Yanger stent-graft system was carried out in 16 healthy adult crossbreed dogs. The feasibility of using these stent-grafts was evaluated with aortography, multislice computed tomography, and autopsy 6 months after the procedure. Results All stent-graft releasing and positioning were successful for in vitro test. In the canine model, the Yanger stent-graft system was placed successfully in the aortic arch in all 14 dogs with the exception of 2 mortalities. All dogs survived for at least 3 months with normal physiologic signs. Aortography, multislice computed tomography, and animal necropsy revealed good fixation in all cases. The ascending aorta, descending aorta, brachiocephalic trunk, and left subclavian artery were all covered without endoleak. There was no significant obstruction or stenosis in brachiocephalic branches at the 6-month follow-up. Conclusions Total endovascular repair of aortic arch with the novel designed Yanger stent-graft system is safe and feasible in preclinical studies. With a better understanding of preclinical knowledge, patient selection criteria and first-in-human studies will be addressed.

Background Traumatic aortic arch rupture with pseudoaneurysm is a rare high fatal injury. Thoracic endovascular aortic repair(TEVAR) is widely used in the treatment of aortic diseases. However a unified traumatic aortic injury risk stratification tool still lacks. The patients’ disease assessment and operation method still rely on the doctors’ subjective anticipation of disease and surgical results. Case presentation A 31-year-old male presented with chest pain and hoarseness of recent onset. Imageological examination showed aortic rupture with mediastinal pseudoaneurysm in Zone 1. Debranching + TEVAR hybrid operation was considered: Using artificial blood vessels rebuild the arch branches, the covered stent was placed in aortic arch for endovascular repair via femoral artery. The follow-up was good in postoperative 7d, 1 year and > 2 years. Conclusion The traumatic aortic arch rupture with pseudoaneurysm treated by Debranching+TEVAR hybrid operation is feasible. The short-term and medium-term follow-up results are satisfactory. For traumatic aortic arch injury, hybrid operation is recommended to reduce the risk of cardiopulmonary bypass and deep hypothermia circulatory arrest under no open operation conditions or emergency situation.

Introduction One of the most severe complications after TEVAR is ischemic stroke and spinal cord ischemia (SCI) resulting in severe disability. These complications can be fatal up to 30% of cases, so it is very important to define risk factors associated with the occurrence of such events. The aim of this study was to define the causes and risk factors associated with the occurrence of neurological complications in patients after TEVAR. Materials and methods We performed a retrospective analysis of 51 patients undergoing TEVAR in the Department of Vascular Surgery of Military Teaching Hospital in Wroclaw between 2014 and 2017. In 18 patients LSA coverage was managed without revascularization (35.29%), and in 33 patients LSA remained uncovered (64.71%). Results We did not find any statistically significant difference in the incidence of stroke and spinal cord ischemia in patients with covered and uncovered LSA (stroke p = 0.37, SCI p = 0.58). In the group of patients with covered and uncovered LSA, we did not find any significant differences in the incidence of additional comorbidities such as obesity, ischemic heart disease, hypertension or previous stroke. Conclusions There is no difference in stroke and SCI occurrence between patients with covered and uncovered LSA. Although there are many studies analysing the risk of such complications, there is no specific consensus regarding the treatment of LSA coverage. Randomised clinical trials on a large group of patients are still needed.

Introduction. Hybrid procedures represent staged or simultaneous endovascular and open surgical techniques in the treatment of complex pathologies of the thoracic and abdominal aorta. We are presenting a patient with previous abdominal aortic surgery in whom hybrid vascular procedure for descending aorta and left subclavian artery aneurysm was performed. Case Outline. A 63-year-old female patient was admitted for computed tomography angiography. Descending aorta aneurysm (7.6 cm) as well as aneurysm of the left subclavian artery (LSA) was noted. Eight years ago she underwent abdominal aortic aneurysm resection and aortoiliac bypass. Standard TEVAR (thoracic endovascular aortic repair) procedure couldn’t be done due to small dimensions of previous “Y” graft (12.6 mm), so first we did LSA transposition and after three days hybrid procedure. After “Y” graft exposure, anastomosis between the corps of “Y” graft and tubular graft 10 mm was created and through this conduit thoracic stent-graft was placed followed by complete “Y” graft replacement. After 6 months angiography showed regular postoperative findings. Conclusion. Combined surgical and endovascular procedures in thoracic aorta pathology treatment could be useful solutions with favorable outcome. [Projekat Ministarstva nauke Republike Srbije, br. 41002]

An aortoesophageal fistula (AEF) is an extremely rare, potentially fatal condition, and aortic surgery is usually performed together with extracorporeal circulation. However, this surgical method has a high rate of surgical complications and mortality. This report describes an AEF caused by tuberculous esophagitis that was treated successfully using a two-stage operation. A 52-yr-old man was admitted to the hospital with severe hematemesis and syncope. Based on the computed tomography and diagnostic endoscopic findings, he was diagnosed with an AEF and initially underwent thoracic endovascular aortic repair. Esophageal reconstruction was performed after controlling the mediastinal inflammation. The patient suffered postoperative anastomotic leakage, which was treated by an endoscopic procedure, and the patient was discharged without any further problems. The patient received 9 months of anti-tuberculosis treatment after he was diagnosed with histologically confirmed tuberculous esophagitis; subsequently, he was followed as an outpatient and has had no recurrence of the tuberculosis or any further issues., Graphical Abstract