Search

The epicardial adipose tissue volume (EATV) is associated with cardiovascular diseases such as coronary artery disease. However, no information is available regarding the relationship between the EATV and abdominal aortic aneurysm (AAA) expansion. In the present study, we evaluated the association between the EATV and AAA growth and sought to identify the predictors of AAA expansion.Between June 2009 and December 2019, 906 patients had undergone endovascular or open repair of AAAs at our institution. Patients with previous cardiac surgery, previous ascending thoracic aortic surgery, a ruptured AAA, an infected AAA, an inflammatory AAA, a saccular aneurysm, a solitary iliac aneurysm, or reintervention after treatment of the AAA were excluded. A total of 237 patients with at least two preoperative computed tomography (CT) scans performed180 days apart were included in the present study. The EATV within the pericardium was retrospectively quantified from the preoperative non-contrast-enhanced CT images using a three-dimensional workstation. The EATV index was defined as the EATV divided by the body surface area. The AAA expansion rate was defined as an increase in the AAA diameter annually, and the patients were divided into the slow-expansion group (expansion rate, 5 mm/y) and the fast-expansion group (expansion rate, ≥5 mm/y). The correlation between the expansion rate and the EATV index was analyzed, and the cutoff value for the EATV index was determined using a receiver operating characteristics curve. Multivariate analysis was used to assess the predictors of the AAA expansion rate.The expansion rate of AAA correlated positively with the EATV index (R = 0.237; P .001). The initial aneurysm diameter (P .001) and EATV index (P = .009) differed significantly between the two groups. The cutoff for the EATV index was 60.3 cmThe results of the present study have demonstrated that the EATV index is associated with AAA expansion.

Background Not every elderly person is frail, and whether it would be beneficial to perform endovascular aneurysm repair (EVAR) solely because a patient is older is unclear. This study aimed to compare the results of EVAR and open surgical repair (OSR) in elderly individuals.Methods and Results:From May 1998 to March 2021, 828 EVAR patients and 886 OSR patients with abdominal aortic aneurysm (AAA) were reviewed. Patients aged ≥80 years were included among them. After propensity score matching by age, sex, and American Society of Anesthesiologists (ASA) classification, the outcomes were compared between patients who underwent EVAR and OSR. The study cohort was composed of 351 EVAR patients and 90 OSR patients. The groups had similar comorbidities, except that EVAR patients were significantly older and had higher ASA classifications. After propensity score matching, 79 pairs of patients were selected. The 30-day mortality (0 vs. 1.2%) and aneurysm-related death (ARD) rates during follow up (2.3% vs. 2.3%, respectively) were similar between the groups. Kaplan-Meier curves revealed that estimated overall survival and freedom from ARD were also similar. Conclusions This study suggests that EVAR cannot improve survival outcomes compared with OSR if applied solely because a patient is aged ≥80 years. Not only age but also other risk factors and quality of life after surgery need to be further studied.

Purpose: An accurate distal deployment is essential for successful thoracic endovascular aortic repair (TEVAR) of a paradiaphragmatic aortic aneurysm. This study aimed to investigate the anatomical and intraoperative factors that affect the accuracy of distal deployment during TEVAR. Methods: We conducted a retrospective review of preoperative and postoperative computed tomography scans of 426 patients undergoing TEVAR at our institution between October 2008 and May 2021, of which the stent-graft was attempted to be deployed just above the celiac axis or the superior mesenteric artery in 56 patients. Based on the anatomical factors related to the malposition (deployed >10 mm away from the target vessel) and the greater curve to the straight-line ratio (G/S ratio), the patients were categorized as severe tortuosity (n=21) and mild tortuosity (n=35) groups to compare the operative and clinical outcomes. Result: Stent-graft malpositioning occurred in 21 cases. Among all anatomical variables, only the G/S ratio was significantly larger in the malpositioned cases (p=0.049). A cutoff G/S ratio value of 1.15 was determined using the receiver operating curve analysis. In the severe tortuosity group, the distal end of the stent-graft was significantly farther (median: 10.0 [interquartile range (IQR): 2.5–19.5] mm vs 3.0 [0–8.0] mm; p=0.015) from the target vessel, and the tilt angle of the stent-graft’s distal edge was larger (median: 21.4 [IQR: 15.8–24.5] vs 9.5 [5.5–12.5] degree; pConclusion: Severe tortuosity in the distal descending thoracic aorta is associated with a malpositioned and tilted distal end of the stent-graft. Clinical Impact Thoracic endovascular aortic repair (TEVAR) for paradiaphragmatic thoracic aortic aneurysms requires accurate distal landing. In this paper, a retrospective CT analysis revealed that the greater curve to the straight-line ratio (G/S ratio) was associated to affects the malposition of the stent graft, defined as being deployed more than 10 mm away from the target vessel. Further, a comparative analysis based on the G/S ratio demonstrated that severe aortic tortuosity was associated with a more distal and tilted deployment of the stent graft.

Sarcopenia and malnutrition are often used as surrogates for frailty, which is predictive of poor prognosis after surgery. We investigated the effects of sarcopenia and malnutrition on mortality after endovascular aneurysm repair (EVAR). The subjects of this study were patients who underwent EVAR at our hospital between June 2007 and December 2013, excluding those who underwent reintervention. The psoas muscle area at the L4 level was used as an indicator of sarcopenia. The Geriatric Nutritional Risk Index was used as an indicator of malnutrition. There were 324 patients included in the study, with a mean age of 78.1 years and a median follow-up period of 56.7 months. Multivariate analysis revealed that sarcopenia (HR, 1.79; p = .042) and malnutrition (HR, 1.78; p = .043) were independent prognostic factors. Patients with both factors were classified as the high-risk group and others were classified as the low-risk group. The survival rate was significantly lower in the high-risk group than in the low-risk groups (p

Although randomized studies have revealed the long-term outcomes of the endovascular repair (ER) of abdominal aortic aneurysm (AAA) compared to open repair (OR), there is controversy surrounding chronic renal decline (CRD) after ER. This study reviewed our propensity-matched cohorts of ER and OR to compare CRD rates using a time-to-event analysis. The ER groups undergoing suprarenal (SR) or infrarenal (IR) proximal fixation were also compared with the OR group.This retrospective review of infrarenal AAA repair was conducted from June 2007-December 2017. Patients with ≥1 year of follow-up were included. Cases of supra/pararenal AAAs, infectious AAAs, rupture, or severe chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR)15 mL/min/1.73 mIn total, 1087 patients underwent elective AAA repair. Among them, 944 (512 ER and 432 OR) were enrolled. The ER group was older than the OR group (median age 79 vs 71; P0.001). The ER group had significantly lower baseline eGFR and more comorbidities than the OR group. Among 187 propensity-score matched pairs (187 mER and 187 mOS patients), background characteristics, including age and baseline eGFR, were comparable, but median renal function follow-up was significantly longer in the mER group than in the mOR group (48 vs 26 months; P0.001). CRD was observed in 57 patients in the mER group and 30 patients in the mOR group. Kaplan-Meier analysis of the freedom from CRD showed no significant difference between the matched groups (P=0.268); however, in the later follow-up of4 years, CRD was more common in the mER group. The matched analyses between the OR group and specific fixation groups, comprising 102 OR-SR and 73 OR-IR pairs, demonstrated no significant differences in CRD.Compared to OR, there was no significant impact of ER on CRD at up to 4 years, supporting the safety of ER in terms of the mid-term renal outcome of our present clinical practice.

Purpose: Recent studies suggested that continuous clotting renewal in thrombi plays a central role in sac enlargement after endovascular aneurysm repair (EVAR). We reviewed patients with persistent type 2 endoleak (T2EL) to estimate the impact of D-dimer level on sac enlargement. Methods: A retrospective review of elective EVAR for infrarenal abdominal aortic aneurysm performed between June 2007 and February 2020. Persistent T2EL was defined as T2EL confirmed at both the 6 and 12 month contrast-enhanced computed tomography (CECT) follow-ups. “Isolated” T2EL was defined as T2EL without other types of endoleak within 12 months. Patients with >2 year follow-up, persistent isolated T2ELs, and D-dimer level data at 1 year (DD1Y) were included. Patients with any reintervention within 12 months were excluded. The association between DD1Y and aneurysm enlargement (AnE), defined as a ≥5 mm diameter increase, within 5 years was analyzed. Among 761 conventional EVAR, 515 patients had >2 years of follow-up. Thirty-three patients with any reintervention within 12 months and 127 patients without CECT at either 6 or 12 months were excluded. Among 131 patients with persistent isolated T2ELs, 74 patients with DD1Y data were enrolled. During a 37 month median follow-up [25–60, IQR], 24 AnEs were observed. In the AnE patients, the median DD1Y was significantly higher than that in the other patients (12.30 [6.88–21.90] vs 7.62 [4.41–13.00], P=0.024). ROC curve analysis indicated that the optimal cutoff point of DD1Y for AnE was 5.5 µg/mL (AUC=0.681). In univariate analysis, angulated neck, occlusion of the inferior mesenteric artery, and DD1Y≥5.5 µg/mL were significantly associated with AnE (P= 0.037, 0.038, and 0.010). Cox regression analysis revealed that DD1Y≥5.5 µg/mL was correlated with AnE (P=0.042, HR [95% CI] 4.520 [1.056–19.349]). Conclusion: A 1 year higher D-dimer level can potentially predict AnE within 5 years in persistent T2EL patients. AnE was considered improbable when the D-dimer level was low enough. Clinical Impact The present study suggests that a 1-year higher D-dimer level could potentially predict aneurysm expansion within 5 years in patients with persistent type 2 endoleak (T2EL). On the other hand, aneurysm expansion was considered unlikely if the D-dimer level was low enough. As there are many patients with T2EL who require regular follow-up, any predictor of future aneurysm expansion could be of great help in conserving medical resources. In patients with a low likelihood of future expansion, we might consider delaying follow-up, similar to patients with sac shrinkage.

Background: Several reports have indicated that suprarenal (SR) fixation may impair renal function after endovascular abdominal aortic aneurysm repair (EVAR). However, most were short-term or at most, 1-year observational studies; therefore, the midterm effects on renal function remain unclear. This study aimed to identify predictors of midterm renal dysfunction after EVAR and compare renal outcomes in patients after EVAR with SR and infrarenal (IR) fixation. Methods: A total of 467 patients who underwent EVAR of nonruptured IR abdominal aortic aneurysm between 2007 and 2014 were reviewed in a prospectively collected database. Patients on hemodialysis at baseline were excluded. Among the remaining patients, those with 3-year laboratory testing were included in this study. Patients who developed acute kidney injury were excluded from the late renal function estimation. Predictors of 3-year renal function decline were estimated using logistic regression analysis. In addition, patients undergoing EVAR with IR (IR group) and SR fixation devices (SR group) were propensity matched by age, sex, baseline renal function, baseline aneurysm diameter, comorbidities, smoking habits, and regular use of medicines that may act on kidney function. Changes in renal function after surgery were compared between the IR group and the SR group. Results: During the study period, 237 patients (102 IRs and 135 SRs) were followed up with laboratory testing 3 years after surgery. Logistic regression analysis revealed that the use of a SR fixation device was independently predictive of a more than 20% decrease in the estimated glomerular filtration rate at 3 years after EVAR (odds ratio, 2.06; 95% confidence interval, 1.18-3.58; P = .011). Eleven patients who developed acute kidney injury (1 IR and 10 SRs) were excluded from the subsequent analysis. After propensity score matching, 87 pairs were selected (mean age, 77.2 ± 6.3 years; 151 males [86.8%]). The mean follow-up duration was 5.5 ± 1.8 years. In the SR group, estimated glomerular filtration rate at 3 years after surgery decreased significantly more than that in the IR group (mean of 17.8% vs 11.6%, respectively; P = .034). Conclusions: This study suggests that, compared with EVAR with IR endograft fixation, EVAR with SR endograft fixation is associated with worse outcomes for midterm renal function., ファイル公開：2021-02-01

Purpose: Despite controversy surrounding the management of type 2 endoleaks (T2ELs) after endovascular aortic aneurysm repair (EVAR), the current European guidelines recommend reintervention for T2ELs when the aneurysm expands by ≥10 mm. Meanwhile, sac shrinkage ≥10 mm can be considered low risk for failure even with T2ELs, and the guidelines suggest less frequent follow-up delayed until 5 years after EVAR. This study reviewed patients with persistent T2ELs to identify predictors of spontaneous sac shrinkage (SpS) within 5 years. Methods: A retrospective review of elective EVAR for infrarenal aortic aneurysms between June 2007 and December 2017. Patients with >1 year follow-up and persistent T2ELs, defined as T2ELs confirmed at both the 6 and 12 month follow-up with contrast-enhanced computed tomography (CT), were included. Any reintervention or type 1 or 3 endoleaks within 12 months were excluded. SpS was defined as a ≥10 mm reduction in diameter without any reintervention. Aneurysm enlargement (AnE) was defined as a ≥5 mm increase in diameter. Factors associated with SpS within 5 years were analyzed. The clinical outcomes were reviewed. Results: Among 726 patients, 162 patients had persistent isolated T2ELs. After excluding 21 patients, 141 patients were enrolled. During a median follow-up of 43 months (interquartile range [IQR], 26–60), 28 SpS and 39 AnE were observed, and 31 reinterventions were performed. The cumulative rates of SpS were 14.2%±2.9% and 25.6%±5.1% at 1 and 5 years. Cox regression analysis revealed that the presence of ≥6 patent lumbar arteries had a significant negative correlation with SpS (p=0.036). During further follow-up after SpS, 2 reinterventions for type 1a and 3b endoleaks were required at 49 and 45 months. Conclusions: Patients with fewer patent lumbar arteries were likely to experience SpS within 5 years, even in the presence of persistent T2ELs. Follow-up imaging studies were advisable earlier than 5 years, even after SpS.

Although the predictors of long-term prognosis after endovascular aneurysm repair (EVAR) have been investigated, several reports have suggested that early sac shrinkage (ESS) is associated with superior long-term prognosis. However, it was not clear whether ESS was associated with aneurysm-related mortality. The aim of this study was to define fatal adverse events and to examine their association with ESS.All consecutive patients who underwent EVAR for an abdominal aortic aneurysm at Nagoya University Hospital between June 2007 and August 2018 were identified. We defined ESS as an aneurysm diameter decrease of 10 mm or more at 1 year after EVAR, and we defined fatal adverse events as aneurysm-related death, aneurysm sac rupture, open conversion, secondary type Ia endoleak, or secondary type IIIa/b endoleak. Then, we evaluated the association between ESS and fatal adverse events and identified predictors of ESS.During the study period, 553 patients were identified and included. Fatal adverse events occurred in 42 patients (7.6%), and the details of the fatal adverse events were as follows: 13 aneurysm-related deaths, 17 aneurysm sac ruptures, 14 open conversions, 13 type Ia endoleaks, and 6 type III endoleaks. ESS occurred in 146 patients (26.4%). Kaplan-Meier curves showed that the ESS group had a significantly lower incidence of fatal adverse events (P .001). Multivariate analysis showed that there were significant differences in terms of 5 or more preoperatively patent lumbar arteries (odds ratio [OR], 0.67; P = .049; 95% confidence interval [CI], 0.45-1.00), chronic kidney disease (OR, 0.49; P .01; 95% CI, 0.29-0.84), and Zenith endograft use (OR, 1.76; P .01; 95% CI, 1.16-2.67). Furthermore, the percentage of cases that achieved an aneurysm diameter of less than 40 mm was significantly higher in the ESS group (76.0% vs 15.5%; P .01). The use of Zenith endografts showed a significantly higher rate of aneurysm disappearance than the use of Endurant endografts (P .01) and Excluder endografts (P .01). In addition, it was found that ESS was more likely to occur with the use of Zenith endografts, even when propensity score matching was performed for the neck morphology.ESS was associated with a lower rate of life-threatening adverse events after EVAR. The use of Zenith endografts was a predictor of ESS and was associated with increased rates of long-term sac shrinkage and aneurysm disappearance compared with the Endurant and Excluder endografts. Using the predictors of ESS identified in this study, we may be able to expand the indications for EVAR to patients with a longer life expectancy.

Background : Although we have witnessed several cases of late proximal type I endoleak (T1AEL) after endovascular aneurysm repair (EVAR), most patients did not have “hostile neck” preoperatively. We hypothesized that the distance between the lowest renal artery and the neck angulation point and neck length are the two most important factors for maintaining long-term proximal sealing. This study evaluated “neck hostility”, which is the product of the distance to the angulation point and the neck length, as a preoperative morphological risk factor for the development of late T1AEL after EVAR. Methods : A retrospective review of a prospectively assembled database was performed for all patients who had undergone EVAR at a single institution from June 2007 to May 2017. Patient demographics and preoperative imaging data were collected, and Cox regression analysis was performed to identify the risk factors for late T1AEL. Results : Of the 655 patients who underwent EVAR during the study period, 115 were excluded due to complex EVAR (n=14), primary indications for iliac aneurysms (n=86), primary T1AEL (n = 3), or other reasons (n=15). Of the remaining 537 patients, twelve patients (2.2%) developed late T1AEL a median of 3.2 (interquartile range [IQR]; 3.0, 5.4) years after EVAR. Receiver operating characteristic (ROC) curve analysis revealed a neck hostility cutoff value of 8. Cox regression analysis revealed that a neck hostility value ≤8 and conical neck anatomy were risk factors for the development of late T1AEL after EVAR. Well-known hostile neck factors such as short neck, severe angulated neck, and severe calcification/thrombus in the proximal neck were not significantly different. Conclusions : The present study demonstrated a correlation between late T1AEL and the product of the angulation distance and the neck length. This factor may be useful for predicting poor late proximal outcomes after EVAR.

PurposeSurgical revascularization is the standard treatment for chronic limb-threatening ischemia (CLTI). However, some patients may require reintervention. The Global Anatomic Staging System (GLASS), which evaluates the complexity of infrainguinal lesions, was proposed. This study aimed to identify predictors for graft revision and evaluate whether GLASS impacts vein graft revision.MethodsBetween 2011 and 2018, CLTI patients who underwent de novo infrapopliteal bypass using autogenous veins were retrospectively analyzed. To assess anatomic complexity with GLASS, femoropopliteal, infrapopliteal, and inframalleolar/pedal (IM) disease grades were determined. The outcomes of patients with or without graft revision were compared. Cox regression analysis was performed.ResultsThirty-six of the 80 patients underwent reintervention for graft revision. Compared to the non–graft revision group, the graft revision group exhibited significantly higher rates of GLASS stage III (66% vs 81%, p = 0.046) and grade P2 IM disease (25% vs 58%, p = 0.009). Multivariate analysis revealed that IM grade P2 (hazard ratio [HR], 3.35; 95% confidence interval [CI], 1.66–6.75; p = 0.001) and spliced vein grafts (HR, 3.18; 95% CI, 1.43–7.06; p = 0.005) were significantly associated with graft revision.ConclusionsThis study demonstrated that IM grade P2 and spliced vein grafts were predictors of graft revision. The GLASS stratification of IM disease grade may be useful in optimizing treatment for CLTI.

Background Early spontaneous shrinkage (ESS) of abdominal aortic aneurysm (AAA) within 1 year after endovascular aortic aneurysm repair (EVAR) could be a predictor of durable success. However, late spontaneous shrinkage (LSS) during longer follow-up has not been well addressed. We compared late complications of ESS and LSS. Methods Our series of elective EVAR for infrarenal AAA from June 2007 to December 2017 was reviewed. Patients with ≥1 year of follow-up with computed tomography (CT) studies were included. Patients with any reintervention within 1 year were excluded. Spontaneous shrinkage (SpS) was defined as a diameter reduction ≥10 mm without any reintervention. ESS was defined as SpS within 1 year, and LSS was defined as SpS occurring after 1 year of follow-up. Aneurysms that became larger than the original size after SpS were defined as re-expansion. Late complications (re-expansion, reintervention, and aneurysm-related death) and related factors were compared between ESS and LSS. Results A total of 495 patients were enrolled. Median follow-up was 43 months [24–67, interquartile range (IQR)]. Among patients, 126 ESS and 55 LSS occurred. The cumulative rates of SpS were 25.7±2.0%, 37.4±2.4%, and 47.3±3.7% at 1, 3, and 7 years, respectively. There was 1 re-expansion and 6 reinterventions during further follow-up after SpS. The rates of freedom from late complications at 5 years were not significantly different between ESS (89.2±4.0%) and LSS (95.8±4.1%) (P = 0.465). Regression analysis revealed that the Zenith device was significantly related to ESS compared to the Excluder (P = 0.006) and Endurant (P = 0.040) . More than 6 preoperative patent lumbar arteries negatively correlated with ESS (P = 0.023). However, these factors had no significant impact on LSS. Conclusions The rates of late complications after SpS were comparable between ESS and LSS. Patients with delayed sac shrinkage with a reduction in diameter ≥10 mm should expect the same durable success as patients with quick shrinkage.

A popliteal artery aneurysm is one of the most common peripheral arterial aneurysms. These aneurysms can cause distal embolization and thrombosis, leading to limb loss. However, their rupture is unusual. Here we report a case in which a popliteal aneurysm with chronic occlusion at its outflow artery developed a nonfatal, painful rupture. We performed only coil embolization of the proximal artery, and the aneurysm was successfully excluded. After the procedure, collateral circulation was maintained. No ischemic symptoms such as intermittent claudication or pain at rest were observed. This approach may be useful in treating similar cases.

Endovenous laser ablation (EVLA) with concomitant phlebectomy is commonly performed in many institutions. However, phlebectomy is associated with cosmetic complications such as surgical scarring, hemorrhage, and hematoma. This study aims to compare the need for additional sclerotherapy during follow-up after EVLA with and without concomitant phlebectomy.Between November 2013 and December 2018, we performed EVLA on 1,363 limbs in 1,009 patients with symptomatic primary varicose veins, of which 954 limbs in 771 patients with great saphenous vein (GSV) or small saphenous vein (SSV) insufficiency were included in this study. Data were collected prospectively and supplemented with retrospective medical record review. Demographic and clinical characteristic profiles were collected. The outcomes of EVLA with or without concomitant phlebectomy were compared. Logistic regression was used to assess predictors for additional sclerotherapy after EVLA.CEAP classification (P 0.001), operative time (P 0.001), laser device type (P 0.001), length of the treated vein (P 0.001), linear endovenous energy density (P 0.001), and tumescent local anesthesia volume (P 0.001) differed significantly. Pain after EVLA was significantly more frequent in the nonphlebectomy group than in the phlebectomy group (P = 0.005). During follow-up, 34 of 954 limbs (3.6%) underwent additional sclerotherapy for residual visible varicose veins after EVLA. No statistical difference was found in the rate of additional sclerotherapy between the groups (P = 0.849). Logistic regression showed that female sex (odds ratio [OR], 6.18; 95% confidence interval [CI], 1.86-20.6; P = 0.003) is significantly associated with additional sclerotherapy, and concomitant phlebectomy is not a significant predictor of additional sclerotherapy (OR, 0.844; 95% CI, 0.375-1.90; P = 0.682).Patient preference for additional sclerotherapy was comparable between those who underwent EVLA with and without concomitant phlebectomy. This result supports our present strategy of avoiding simultaneous phlebectomy at the time of primary EVLA.

Background In thoracic endovascular aortic repair (TEVAR), covering the celiac artery (CA) is sometimes necessary to secure the distal seal. We report the outcomes of planned CA coverage in our experience with TEVAR. Methods Cases requiring CA coverage during TEVAR from October 2008 to September 2018 were retrospectively reviewed. Patient demographics, indications for CA coverage, communication between the CA and the superior mesenteric artery (SMA), concomitant CA embolization, and perioperative and late results were collected in a prospective database and analyzed. Results During the study decade, 357 patients underwent TEVAR at our institution. Of these patients, 15 (4.2%) required CA coverage. All 15 patients were male, and the mean age was 72.8 years (range, 44-80 years). The mean aneurysm size was 67.5 mm (range, 50-82 mm). The etiologies included 10 degenerative aneurysms (66.7%; 2 ruptures [13.3%], 4 dissecting aneurysms [26.7%], and 1 case of type IB endoleak [6.7%]) after TEVAR. Communicating collaterals between the CA and the SMA were confirmed by preoperative computed tomography angiography in eight patients (53.3%) and by intraoperative angiography in four patients (26.7%). Seven patients (46.7%) underwent concomitant embolization of the CA. CA coverage offered a mean extension of 20.3 mm (range, 12-22 mm) in the length of the distal seal. Postoperative computed tomography angiography revealed a type IB endoleak that resolved spontaneously in one patient (6.7%). Postoperative complications included splenic infarction/pancreatitis in one patient (6.7%) and spinal cord ischemia in two patients (13.3%). There were no cases of postoperative in-hospital mortality. During the follow-up period (mean, 3.6 years; range, 0.9-8.0 years), two patients developed a new type IB endoleak. One patient underwent distal extension of the stent graft with ilio-SMA bypass, and one patient was observed conservatively in accordance with the patient's decision. There were no cases of type II endoleak via the CA. Most aneurysms (86.7%) were stable or reduced in size at the most recent follow-up. There were no cases of targeted aneurysm-related death during the follow-up period. Conclusions Our study demonstrates the safety and efficacy of CA coverage in facilitating adequate distal sealing in selected patients undergoing TEVAR. Because the distal sealing length is not completely sufficient in most cases requiring CA coverage, the long-term efficacy of CA coverage during TEVAR should be determined in a large prospective study.

Similar to open surgical repair, thoracic endovascular aortic repair (TEVAR) carries a risk of spinal cord ischemia (SCI). However, the generally lower incidence of SCI after TEVAR compared with that after open surgical repair, despite the inability to preserve the intercostal arteries, indicates different pathophysiologic mechanisms with the two procedures. We hypothesized that a microembolism from an aortic mural thrombus is the main cause of SCI. Thus, we evaluated the association between the density of a mural thrombus in the descending thoracic aorta and the development of SCI.A retrospective review of a prospectively assembled database was performed for all patients who had undergone surgery at a single institution from October 2008 to December 2018. Patient demographics and procedure-related variables were collected. The volume and Hounsfield unit (HU) value of mural thrombi in the whole descending thoracic aorta were estimated on preoperative computed tomography using a three-dimensional workstation. Logistic regression analysis was performed to identify the risk factors for SCI development.Of the 367 patients who had undergone TEVAR during the study period, 155 were excluded because of previous arch surgery (n = 59), previous descending thoracic aortic surgery (n = 6), previous TEVAR (n = 6), unavailability of optimal preoperative computed tomography data (n = 17), double-barreled dissection (n = 40), and other reasons. The mean ± standard deviation age of the remaining 212 patients was 75.8 ± 6.4 years, and 42 (19.8%) were women. Of the 212 patients, 14 (6.6%) developed SCI after TEVAR. The low mean density of the mural thrombus, total thrombus volume, low-density (≥-100 HU but 30 HU) thrombus volume, intermediate-density (≥30 HU but 150 HU) thrombus volume, treatment length, urgent surgery, and baseline dialysis differed significantly between patients with and without SCI. Although subsequent multivariate analysis could not be performed owing to the small number of SCI events, vulnerable low-density thrombus/plaque was a stronger predictor among the aneurysm-related factors of SCI after TEVAR on univariate analysis. Well-known risk factors, such as distal coverage between T8 and L1, left subclavian artery coverage, previous abdominal aortic surgery, and prophylactic spinal drainage, did not show significant differences.The results from the present study have demonstrated that among aneurysm-related factors, a lower density mural thrombus/plaque in the descending thoracic aorta is a predictor of SCI development after TEVAR. These results suggest that microembolism is one of the important mechanisms of SCI after TEVAR, which might change the prophylactic strategy.