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Ilioiliac fistulae are a rare condition, for which diagnosis and treatment can be challenging. In this report, we describe the case of a 74-year-old patient with a high-flow fistula between the left common iliac artery and the ipsilateral common iliac vein presenting with heart failure. The fistula was probably iatrogenic, caused by prostatic surgery 1 year earlier. We describe imaging findings on computed tomography angiography and the treatment by 2 back-table reversed stent grafts. The satisfactory results demonstrated in our case and those in the literature suggest that an endovascular treatment for this rare condition should be considered as the first-line therapy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to assess the early and midterm outcomes of endovascular repair of complex aortic aneurysm cases using the Multilayer Flow Modulator (MFM; Cardiatis, Isnes, Belgium) endograft in Germany., Methods: A retrospective study including patients presenting with abdominal aortic aneurysm (AAA), thoracic aortic aneurysm, or thoracoabdominal aortic aneurysm treated with the MFM was conducted in Germany. Mortality and morbidity (in terms of spinal cord ischemia, visceral ischemia, and stroke) at 30 days postoperatively were evaluated. In addition, during follow-up, freedom from reintervention, rupture, and failure mode were also assessed., Results: Between 2009 and 2014, a total of 61 patients with AAA, thoracoabdominal aortic aneurysm, or thoracic aortic aneurysm were treated with the MFM endograft in 29 hospitals around Germany. However, data of 40 patients with a mean age of 73.4 ± 11.2 years (72.5% male; 29/40) and mean aortic aneurysm diameter of 60.3 ± 16.6 mm from 14 hospitals were available for this retrospective study. Thirty-seven (93%) patients were treated urgently. In 12 cases (12/40 [30%]), patients were treated outside instructions for use because of aortic aneurysm diameter >65 mm. A total of 69 MFM stents were used (1.7/patient). The technical success rate was 95% (38/40). Postoperatively, no patient presented with spinal cord ischemia, renal function deterioration, stroke, or intestinal ischemia, except for one patient who developed multiorgan failure because of early stent migration. The intraoperative and 30-day mortality rate was 0% and 2.5%, respectively. The mean follow-up was 12.9 months (±14.9 months), with a survival rate at 1 month, 6 months, and 12 months of 97%, 78%, and 70%, respectively. Freedom from failure mode (type I or II) at 1 month, 6 months, and 12 months was 97.5%, 88%, and 86%, respectively, and visceral vessel patency was 99.3% (155/156 available). During follow-up, 4 patients (4/39 [10%]) had an aneurysm sac rupture and 10 (10/39 [25%]) underwent a reintervention. Freedom from rupture and freedom from reintervention at 1 month, 6 months, and 12 months were 97.5% and 100%, 96% and 84%, and 86% and 75%, respectively., Conclusions: The use of the MFM for endovascular treatment of complex aortic aneurysm in urgent cases appears to be technically feasible in terms of mortality and morbidity, with moderate 30-day and acceptable midterm outcomes. Reinterventions may be needed to expand the utility of outcomes., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: This study evaluates the current experience on endovascular repair of the aortic arch pathologies, the feasibility and safety of the procedure., Evidence Acquisition: A systematic review was performed. MEDLINE, CENTRAL, and Cochrane databases were searched with PRISMA methodology for published studies reporting on endovascular repair of aortic arch pathologies from 2000 to 2018., Evidence Synthesis: Thirteen non-randomized retrospective studies (either single or multicenter), two multicenter Registries and one multicenter non-randomized interventional study were included in the systematic review. The total number of patients who underwent total endovascular repair of the aortic arch pathology with either fenestrated, branched, or a combination of those devices or chimney technique was 952 patients (73%; 634/872 males, mean age ranging from 51 to 78 years). The technical success rate was 96.7% (921/952), while the 30-day mortality rate was 3.3% (32/952). The most common adverse events were endoleak type I (13.5%; 35/259), stroke (5.1%; 49/952), spinal cord ischemia (1.4%; 14/952) and retrograde dissection (1%; 8/952). During the follow-up period (mean ranging: 16.9 to 41.4 months; median ranging: 9 to 44.8 months) the total number of deaths was 31 (4.4%; 31/693). The total loss of supra-aortic vessel patency rate was 1.7% (14/803) and a re-intervention was needed in 50 patients (9%; 50/559; 11 open conversion)., Conclusions: Endovascular repair of aortic arch pathologies is a feasible treatment option with good early and reasonable mid-term outcomes. This treatment modality approaches a level of maturity and may be considered as a solid alternative method of treatment.

Background: The aim of the present study was to examine the frequency of gas within the aneurysm sac following endovascular aneurysm repair (EVAR) on early postoperative computed tomography (CT) scans, to measure its volume, record the location, and analyze anatomical and procedural risk factors of its presence., Methods: A retrospective analysis of prospectively collected data of patients undergoing standard, fenestrated, or branched EVAR between January 2013 and December 2015 was undertaken. The presence, position, and size of gas in the postoperative computed tomography angiography (CTA) (within 10 days) was examined, classified as (1) gas near aortic wall; (2) between aortic wall and endograft; and (3) near endograft and further analyzed in terms of anatomical and procedural risk factors associated with its presence., Results: From a total of 241 (85% males, 204/241 and 15% females, 37/241) patients who were treated with EVAR, CTA within 10 days was available in 211 patients with mean age of 73 ± 8.3 years. Gas was present on postoperative CT scan in 83 of 211 (39%) patients; 59/83 (71%) standard, 19/83 (23%) fenestrated, and 5/83 (6%) branched EVAR. The location of the gas was more frequently near the aortic wall (a) (46/83; 55.4%), with the mean gas volume to be 0.41 mL (range 0.01-2.74). Endoleak type II was diagnosed in 31.2% (66/211) of the cases and was not associated with the presence of gas (20/83; presence vs. 46/128; absence of gas; P = 0.069). The presence of gas was associated with larger preoperative diameter of the aortic perfused lumen (P = 0.013). The type of graft was correlated to the presence of gas on postoperative CTA (more frequent in standard EVAR [odds ratio 8; 95% confidence interval {CI} 2.01-31.25] and fenestrated [odds ratio 5.81; 95% CI 1.41-23.81]). In standard EVAR patients, the presence of gas was more frequently identified in early CTA (<5 days) than in later one (6-10 days) (P = 0.000). During the first month follow-up, no patient demonstrated any signs of infection in clinical and radiological assessment., Conclusions: The presence of gas in the aneurysm sac after EVAR is a frequent finding on postoperative CTA and not related to infection or endoleak. Type of stent graft and size of the perfused lumen is associated with the presence of gas., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to assess the immediate postoperative and midterm outcome of complex aortic aneurysm treatment necessitating four-vessel revascularization with either a total endovascular approach (fenestrated-branched stent graft [FBSG]) or a hybrid technique of visceral debranching plus stenting., Methods: The clinical data of consecutively treated patients presenting with a complex aortic aneurysm that necessitated four-vessel revascularization between 2010 and 2015 were retrospectively analyzed., Results: There were 98 patients (65 men [68%]) with a mean age of 70.65 ± 4 years who presented with aortic aneurysm (Crawford type I, 12; type II, 18; type III, 12; type IV, 24; type V, 6; and juxtarenal and suprarenal, 26) and were treated with either FBSG (76/98 [77.5%]) or hybrid repair (22/98 [22.4%]). Twenty-six patients were symptomatic (16, pain; 10, contained rupture). The mean maximum aneurysm diameter was 65 ± 15 mm, and 53% of the patients had a prior aortic intervention. In FBSG-treated patients, 15 off-the-shelf multibranched stent grafts, 3 surgeon-modified fenestrated stent grafts, and 58 custom-made devices tailored to the patient's anatomy were used. Four fenestrations, four branches, and their combination were used in 38 cases, 30 cases, and 8 cases, respectively. A total of 304 target vessels were addressed, with technical success rate of 96% (292/304). In most hybrid cases (18/22 [82%]), a two-stage procedure was undertaken. All target vessels were successfully revascularized with 88 bypasses. The 30-day mortality was 15.3% (15/98), and the early target vessel occlusion was 9.1% (2 in FBSG, 7 in hybrid). After multivariate analysis, type of procedure (hybrid) was independently associated with higher early mortality (odds ratio, 6.3; P = .01). The morbidity was mainly attributed to pulmonary complications (16.3%), lower extremity weakness (16.3%), mesenteric ischemia (6.1%), dialysis on discharge (6.1%), and complete paraplegia (4.3%). Acute renal failure (2.6% vs 18%; P = .03) and mesenteric ischemia (3% vs 23%; P = .001) presented more commonly in the hybrid group. The mean follow-up was 16.4 ± 5 months, and the mortality rate was 19.4% (12% in the FBSG group vs 45% in the hybrid group; P = .05). The graft and stent graft patency rate was 87.8% (three branches and nine bypasses were occluded)., Conclusions: FBSG and hybrid technique seem to be feasible treatment options for complex aortic aneurysms that necessitate four-vessel revascularization. FBSG may be associated with lower mortality and morbidity rates in comparison to the hybrid procedure. FBSG should be the treatment of choice for complex aneurysms in patients with comorbidities, whereas hybrid repair should be considered for acute cases unsuitable for endovascular repair., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgeon modification of commercially available aortic stent grafts represents a salvage option to treat complex aortic pathologies in high-risk patients., Technique: A 68-year-old male was referred to our hospital with a contained rupture of the visceral aorta. The patient was previously treated with an infrarenal tube graft 16 years earlier as well as with a Crawford procedure with island patch of the celiac trunk (TC) and the superior mesenteric artery (SMA) and bypasses to both renal arteries 6 years before admission. The computed tomography demonstrated a "blowout aneurysm" of the TC and SMA patch. The bypass to the left renal artery originated from the level of the TC. We therefore modified a commercially available t-branch (Cook ® Medical, Bloomington, IN) with surgeon-made fenestrations for both renal arteries. The procedure was successful, and the patient could be discharged to home on the seventh postoperative day., Conclusions: The use of surgeon-modified "off-the-shelf" t-branches broadens the possibilities of treating even anatomically very challenging aortic pathologies otherwise not suitable for the t-branch., (Copyright © 2017 Elsevier Inc. All rights reserved.)