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Purpose: To describe planning and a technique for fenestrated endovascular repair of a large Crawford type IV thoracoabdominal aortic aneurysm after previous 2-fenestration endovascular aneurysm repair (FEVAR). Technique: The first FEVAR procedure performed at another center implanted a standard Zenith device with 2 fenestrations and 1 scallop for a juxtarenal abdominal aortic aneurysm. The diameter of the Crawford type IV thoracoabdominal aortic aneurysm had progressed from 68 to 75 mm within a year after the FEVAR. Since the celiac trunk was already occluded, a 3-fenestration 22-×172-mm stent-graft was chosen to extend the existing stent-graft further proximally. A tapered 38/22-×179-mm Zenith custom-made device was designed for the thoracic component. The technique addresses several issues that arise during a FEVAR-in-FEVAR case, such as the orientation of the new stent-graft and its fenestrations, the absence of space between the 2 devices for maneuvers, and the difficulty in catheterizing target vessels with existing bridging stents, for which a bailout “snare-ride” maneuver is described. Conclusion: FEVAR after previous FEVAR is a feasible and efficient treatment option. The modified “snare-ride” technique can be used to catheterize target vessels in the absence of an Indy snare.

Objective The aim of our study was to analyze the incidence of spinal cord ischemia (SCI) in patients presenting with complex aortic aneurysms treated with endovascular aneurysm repair (EVAR) and to identify risk factors associated with this complication. Methods A retrospective study was undertaken of prospectively collected data including patients presenting with complex aortic aneurysm (pararenal abdominal aortic aneurysm and thoracoabdominal aortic aneurysm) treated with fenestrated EVAR (F-EVAR) or branched EVAR (B-EVAR). The primary end point was the incidence of SCI and the assessment of any associated factors. Results Between January 2011 and August 2017, a total of 243 patients (mean aneurysm diameter, 65.2 ± 15.3 mm; mean age, 72.4 ± 7.5 years; 73% male) were treated with F-EVAR or B-EVAR. Asymptomatic patients were treated in 73% of the cases (177/243, in contrast to 27% urgent), and 52% (126/243) were treated for thoracoabdominal aortic aneurysm (in contrast to 48% for pararenal abdominal aortic aneurysm). F-EVAR (mean number of fenestrations, 3.3/case) and B-EVAR (mean number of branches, 3.7/case) were undertaken in 67% (164/243) and 33% (79/243), respectively. The total incidence of SCI was 17.7% [43/243; paraplegia in 4% (10/243) and paraparesis in 13.7% (33/243)]. Most of the patients with SCI presented with immediate postoperative symptoms (72% [31/43]). A spinal drain was preoperatively placed in 53% (130/243) and was associated with the prevention of SCI (SCI with spinal drainage, 12% [16/130]; SCI without spinal drainage, 24% [27/113]; P = .018). The 30-day mortality rate was 9% (21/243). After multiple logistic regression analysis, SCI was associated with preoperative renal function (SCI with preoperative glomerular filtration rate Conclusions The majority of SCI incidence after F-EVAR or B-EVAR of complex aortic aneurysms is manifested immediately postoperatively. The use of preoperative spinal drainage may prevent SCI. Patients with GRF

Die chronische Typ-B-Aortendissektion ist eine komplexe Erkrankung, die individuelle therapeutische Strategien benotigt und bei der andere Therapieansatze als bei der Behandlung von akuten oder subakuten Typ-B-Dissektionen erforderlich sind. Therapieindikationen ergeben sich vor allem aus einer persistierenden Falschlumenperfusion mit Aneurysmabildung. Eine weitere Herausforderung bei der Therapie chronischer Typ-B-Aortendissektionen ist die zunehmende Rigiditat und Verhartung der Dissektionslamelle, die ein Remodeling der Aorta erschwert. Dieser Artikel gibt eine Ubersicht uber die chronische Typ-B-Aortendissektion und die aktuellen konservativen, offen-chirurgischen und insbesondere endovaskularen Therapiemoglichkeiten dieser Erkrankung. Einbeziehung der aktuellen Literatur zur Therapie der chronischen Typ-B-Aortendissektion sowie Beschreibung neuer endovaskularer Techniken. Neben offen-chirurgischen Therapieoptionen, gewinnen endovaskulare Techniken bei der Behandlung der chronischen Typ-B-Aortendissektion zunehmend an Bedeutung, insbesondere bei multimorbiden Patienten. Die Falschlumenokklusion spielt eine wichtige Rolle fur den Therapieerfolg. Die chronische Typ-B-Aortendissektion ist eine komplexe Erkrankung mit vielen Aspekten, bei der die alleinige Behandlung mittels thorakalem Stentgraft oft nicht ausreicht. Die schnelle Entwicklung neuer endovaskularer Techniken bahnt neue Optionen zur Therapie dieser Krankheit.

We report a case of a large three-level spinal osteosarcoma infiltrating the adjacent aorta. This is the first case in which a combined modified three-level en bloc corpectomy with resection and replacement of the adjacent aorta was successful as a part of interdisciplinary curative treatment.Case report.The surgical procedure was performed as a two-step treatment. A heart lung machine (HLM) was not used, in order to avoid cerebral and spinal ischemia and to decrease the risk of hematogenous tumor metastases. Instead, a bypass from the left subclavian artery the distal descending aorta was used. We modified the en bloc corpectomy procedure, leaving a dorsal segment of the vertebral bodies to enable rapid surgery. The procedure was successful and the en bloc resection of the vertebral body with aortal resection could be achieved. Except for pallhypesthesia in the left dermatomes Th7-Th10, the patient does not have any postoperative neurologic deficits.Combined corpectomy with aortic replacement should be considered as a reasonable option in the curative treatment of osteosarcoma with consideration of the immense surgical risks. The use of an HLM is not necessary, especially considering the inherent risk of hematogenous tumor metastases. Modified corpectomy leaving a dorsal vertebral body segment was considered a reasonable variation since tumor-free margins could still be expected.

Purpose: To compare the technical feasibility and hemodynamic alterations during antegrade transcardiac access routes vs conventional transfemoral access (TFA) for endovascular treatment of the ascending aorta in a porcine model. Methods: Antegrade transseptal access (TSA), transapical access (TAA), and TFA were used for implantation of custom-made endografts into the ascending aorta under fluoroscopy (6 pigs each). Hemodynamic parameters, myocardial and cerebral blood flow, and carotid artery blood flow were evaluated during baseline (T1), sheath advancement (T2), after sheath retraction (T3), and after endograft deployment (T4). Results: Endograft deployment was feasible in all animals; all coronary arteries remained patent. Hemodynamic parameters were comparable in all 3 study groups during all measurements. During T2, transient hemodynamic alteration occurred in all groups, with transient severe valve insufficiency in TSA and TAA reflected by the higher pulmonary to mean arterial pressure ratio (pConclusions: TSA, TFA, and TAA to the ascending aorta are feasible for endograft delivery to the ascending aorta in a porcine model. Transient hemodynamic instability in TSA and TAA recovered to near preoperative values. TAA appeared technically easier.

ObjectiveThe objective of this study was to evaluate the remodeling of abdominal aortic aneurysms after endovascular aortic aneurysm repair (EVAR) with the Zenith (Cook Medical, Bloomington, Ind) device.MethodsThis was a retrospective study of anatomic data related to characteristics of the aortic neck diameter, iliac artery diameter, and aneurysm sac diameter collected during a clinical study of the Zenith device.ResultsIn this study, 739 patients were observed for 2 years and 158 of them were observed for 5 years. The monthly rate of change for the neck diameter was more rapid in the early postoperative period (postoperative–30 days), with an expansion of 0.7 ± 0.09 mm/month, and during the third year of follow-up (24-36 months), with a monthly expansion rate of 0.10 ± 0.24 mm. The iliac arteries were also more prone to expansion during the first postoperative month (right iliac, 0.95 ± 0.08 mm/month; left iliac, 0.91 ± 0.08 mm/month) and in the next 6 months with a monthly expansion rate of 0.18 ± 0.02 mm and 0.21 ± 0.02 mm for the right and left iliac arteries, respectively. Remodeling of the aneurysm sac occurred mainly in the first postoperative year with a regression rate of 0.89 ± 0.05 mm/month between 1 and 6 months and 0.44 ± 0.04 mm/month for the second half of the year. The aneurysm sac regression rate dropped to 0.2 mm/month in the second postoperative year. Changes in the aortic neck diameter were statistically significant (P < .001) only at the 24- to 36-month postoperative interval. Changes in the aortic sac diameter were statistically significant (P < .001) at the 30-day to 6-month, 6- to 12-month, and 12- to 24-month intervals. Among patients who underwent reintervention, aortic sac expansion occurred primarily in the 24- to 36-month interval.ConclusionsExpansion of the aortic neck after EVAR for the Zenith endograft occurs mainly between 24 and 36 months; aortic aneurysm sac regression occurs more obviously at 1 to 12 months. Iliac arteries at the landing zone expand more rapidly in the first postoperative year. Late surveillance of EVAR patients is essential to avoid late complications after aortic remodeling.

Purpose: To describe the technique of carbon dioxide (CO2) flushing of thoracic stent-grafts to reduce the risk of cerebral air embolism. Technique: To remove room air, thoracic stent-grafts were preoperatively flushed 2 minutes with carbon dioxide from a cylinder connected to the flushing chamber of the captor valves of Zenith custom-made endografts; this was followed by the standard saline flush. Thirty-six patients undergoing thoracic endovascular aortic repairs (TEVAR) involving the ascending aorta and the aortic arch received CO2-flushed Zenith endografts. One patient with a highly calcified arch experienced a minor stroke. Conclusion: Arterial air embolism is a potentially underappreciated problem of aortic endografting, especially in the proximal segments of the aorta. CO2 flushing may have the potential to reduce air embolization during TEVAR.

Objective Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak. Methods MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR. Results Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak. Conclusions Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes.

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.

Acute aortic thrombosis (AAT) is a rare life threatening event that leads to a sudden occlusion of the aorta. The mortality and morbidity of AAT is still high despite modern surgical techniques. Usually it is the result of a large saddle embolus to the aortic bifurcation, in situ thrombosis of an atherosclerotic aorta or acute occlusion of an abdominal aortic aneurysm. Clinical symptoms depend on the level of the aortic occlusion and can be mistaken for a stroke or similar neurological disease. The combination of age and advanced cardiac disease seems to be significant risks factors for AAT. In patients who have no cardiac or vascular disease this catastrophic event is very rare and is mostly due to hypercoagulable disorders. Revascularization of the ischemic organ/limb as soon as possible is the major aim in the therapy of AAT to avoid further ischemic damage. Surgical reperfusion is the first line approach. If the accepting clinic has no facilities for an immediate surgical intervention it is of primary importance that these patients should be referred to an appropriate center for further management. Paradox seems the fact that most of the patients die as a consequence of reperfusion injury/postperfusion syndrome that occurs after revascularization of acute ischemic limbs.

Endovascular repair has become the treatment of choice for thoracic and abdominal aortic pathologies in the last decades, and is associated with excellent results in terms of perioperative, mid- and long-term morbidity and mortality. Access vessels play a central role in these procedures since access-related issues can increase the rates of technical failures and determine clinical complications for the patient. Therefore, accurate preoperative clinical evaluation and review of the preoperative images are mandatory. In this review, we report on the access-related issues that can be encountered during EVAR and TEVAR, and present solutions and strategies to minimize access-related adverse outcomes.

Purpose: To describe a hybrid technique of reversed frozen elephant trunk to treat thoracoabdominal aortic aneurysms (TAAA) through an abdominal only approach. Technique: The technique is demonstrated in a 29-year-old Marfan patient with a chronic type B aortic dissection previously treated with a thoracic stent-graft who presented with a thoracoabdominal false lumen aneurysm. Through an open distal retroperitoneal approach to the abdominal aorta, a frozen elephant trunk graft was implanted over a super-stiff wire upside down with the stent-graft component in the thoracic aorta. Following deployment of the stent-graft proximally and preservation of renovisceral perfusion in a retrograde manner, the renovisceral vessels were sequentially anastomosed to the elephant trunk graft branches, thus reducing the ischemia time of the end organs. The aortic sac was then opened, and the distal part of the hybrid graft was anastomosed with a further bifurcated graft to the iliac vessels. Conclusion: The reversed frozen elephant trunk technique is feasible for hybrid treatment of TAAAs via an abdominal approach only. This has the benefit of substantially reducing the trauma of thoracic exposure, thus preserving major benefits of open thoracoabdominal surgery, such as the presence of short bypasses to the renovisceral vessels and reimplantation of lumbar arteries to reduce spinal cord ischemia.

IMPORTANCE Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions. OBJECTIVE To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015. DESIGN A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis. MAIN OUTCOMES AND MEASURES Mean SBP level, cause-specific deaths, and health burden related to SBP (>110-115mmHg and also >= 140 mm Hg) by age, sex, country, and year. RESULTS Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73 119 (95% uncertainty interval [UI], 67 949-78 241) to 81 373 (95% UI, 76 814-85 770) per 100000, and SBP of 140 mm Hg or higher increased from 17 307 (95% UI, 17 117-17 492) to 20526 (95% UI, 20283-20746) per 100000. The estimated annual death rate per 100000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). Loss of disability-adjusted life-years (DALYs) associated with SBP of at least 110 to 115 mm Hg increased from 148 million (95% UI, 134-162 million) to 211 million (95% UI, 193-231 million), and for SBP of 140 mm Hg or higher, the loss increased from 5.2 million (95% UI, 4.6-5.7 million) to 7.8 million (95% UI, 7.0-8.7 million). The largest numbers of SBP-related deathswere caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg. CONCLUSIONS AND RELEVANCE In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (>= 110-115 and >= 140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher. Copyright 2016 American Medical Association. All rights reserved.

Die offene Operation stellt aktuell den „Goldstandard“ fur die Versorgung der Aorta ascendens und des Aortenbogens dar. Die konventionellen Operationstechniken erfordern allerdings einen hypothermen Kreislaufstillstand, der mit relevanten Komplikationen assoziiert ist. Die minimalinvasive Therapie von pathologischen Veranderungen des Aortenbogens bedeutet aufgrund der komplexen Probleme dieser vaskularen Region eine technische Herausforderung. Die aus dem Aortenbogen abgehenden Abzweigungen versorgen u. a. das Gehirn, das eine minimale Ischamietoleranz hat. Weiterhin ist der Aortenbogen weit, gebogen, starker pulsatil und weiter von den Femoralarterien entfernt. Die endovaskularen Therapieoptionen zur Behandlung von pathologischen Veranderungen der Aorta ascendens und des Aortenbogens sind Hybridtechniken im Aortenbogen, Chimney-Prozeduren fur die supraaortalen Aste, In-situ-Fenestration von thorakalen Stent-Prothesen sowie individuell angefertigte fenestrierte und gebranchte Stent-Prothesen. Individuell angefertigte fenestrierte und gebranchte Stent-Prothesen sind eine sehr gute Option fur Patienten, die fur offene Operation nicht geeignet sind, und konnten in der Zukunft die endovaskuare Therapie der Wahl werden. Eine gute praoperative Planung, die exakte Kenntnis der individuellen anatomischen Verhaltnisse sowie das Verstandnis der Besonderheiten der Aorta ascendens und des Aortenbogens sind fur die erfolgreiche endovaskulare Versorgung entscheidend.

Die zunehmende Okonomisierung des Gesundheitswesens, anstehende gesetzliche Novellierungen und ein inhomogenes Patientenkollektiv verlangen nach leistungsfahigen Methoden der Qualitatssicherung und Versorgungsforschung in der Gefasmedizin. Mehr als 12 etablierte internationale Registerprojekte zeigen bereits seit Jahren, wie wichtig klinische Register als komplementare Methode zu den randomisierten kontrollierten Studien („randomized controlled trial“, RCT) sind. In Nordamerika beispielsweise konnte durch Ableitung von Behandlungsparametern die Rezidivstenoserate bei der Versorgung der extrakraniellen Karotisstenose signifikant gesenkt werden. In England fuhrte die registerbasierte Qualitatssteigerung bei der elektiven Versorgung des Bauchaortenaneurysmas (BAA) zu einer Senkung der Mortalitatsrate von 7,5 auf etwa 2,4 % innerhalb von 4 Jahren. Im Gegensatz zu vielen Landern im europaischen und ausereuropaischen Ausland verfugt Deutschland derzeit noch uber kein gemeinsames populationsbezogenes Register fur alle vaskularen Behandlungen. Mit dem prospektiven BAA-Register wird derzeit nur ein kleiner Teil des vaskularen Versorgungsspektrums erfasst. Die verpflichtende sektorenubergreifende Qualitatssicherung zur Karotisrevaskularisation bietet mit jahrlich etwa 33.000 Datensatzen zwar ein annahernd vollstandiges Bild der deutschen Karotisversorgung, in die Auswertung gehen allerdings nur Sekundardaten mit eingeschrankter Validitat ein. Mit dem gemeinsamen Gefasregister fur Deutschland GermanVasc konnen die Versorgungsrealitat des einwohnerreichsten europaischen Landes erfasst und bisher unbeantwortete Fragestellungen besser beantwortet werden.

To describe an innovative technique to occlude distal backflow into a false lumen aneurysm by controlled rupture of the dissection membrane after stent-graft implantation.The "Knickerbocker technique" involves relining the true lumen in the descending aorta with an oversized thoracic tubular endograft, followed by controlled rupture of the dissection membrane using a large compliant balloon within the graft's midsection. This maneuver, which allows expansion of the stent-graft's midsection into the false lumen, was developed in order to occlude the large false lumen distally and thus prevent continued false lumen perfusion through distal abdominal entry tears. The technique has been successfully used in 3 patients with ruptured or symptomatic chronic false lumen aneurysm in type B aortic dissection. There was no short-term mortality associated with the procedure. After a mean follow-up of 8 months, the false lumen aneurysm remained thrombosed, with no mortality after a mean clinical follow-up of 22 months.The Knickerbocker technique appears to be feasible and effective in inducing false lumen thrombosis in selected patients who undergo stent-grafting for chronic type B aortic dissection.

Purpose: To investigate the amount of gas released from Zenith thoracic stent-grafts using standard saline flushing vs the carbon dioxide flushing technique. Methods: In an experimental bench setting, 20 thoracic stent-grafts were separated into 2 groups of 10 endografts. One group of grafts was flushed with 60 mL saline and the other group was flushed with carbon dioxide for 5 minutes followed by 60 mL saline. All grafts were deployed into a water-filled container with a curved plastic pipe; the deployment was recorded and released gas was measured using a calibrated setup. Results: Gas was released from all grafts in both study groups during endograft deployment. The average amount of released gas per graft was significantly lower in the study group with carbon dioxide flushing (0.79 vs 0.51 mL, p=0.005). Conclusion: Thoracic endografts release significant amounts of air during deployment if flushed according to the instructions for use. Application of carbon dioxide for the flushing of thoracic stent-grafts prior to standard saline flush significantly reduces the amount of gas released during deployment. The additional use of carbon dioxide should be considered as a standard flush technique for aortic stent-grafts, especially in those implanted in proximal aortic segments, to reduce the risk of air embolism and stroke.

Objective Whereas open repair is the "gold standard" for most aortic arch diseases, a subgroup of patients might benefit from an endovascular approach. The introduction of branched stent grafts with dedicated design to address the challenges of the ascending aorta and the aortic arch has opened an entirely new area of treatment for these patients. We investigated the early outcomes of branched thoracic endovascular aortic repair (b-TEVAR) in various types of disease of the aortic arch. Methods A retrospective analysis was conducted of prospectively collected data from a single center of all consecutive patients treated with b-TEVAR. The indication for elective endovascular repair was consented in an interdisciplinary case conference. All patients were treated with a custom-made inner branched arch endograft with two internal branches (Cook Medical, Bloomington, Ind) and left-sided carotid-subclavian bypass. Study end points were technical success, 30-day mortality, and complications as well as late complications and reinterventions. Results Between 2012 and 2017, there were 54 patients (38 male; median age, 71 years) treated with diseases of the aortic arch. Indications for therapy involved degenerative aortic arch or proximal descending aortic aneurysms requiring arch repair (n = 24), dissection with or without false lumen aneurysms (n = 26), and penetrating aortic ulcers (n = 4). Forty-three cases (80%) were performed electively and 11 urgently for contained ruptures (n = 3) or symptomatic aneurysms (n = 8) with endografts already available for the patient or with grafts of other patients with similar anatomy. Technical success was achieved in 53 cases (98%). The 30-day mortality and major stroke incidence were 5.5% (3/54) and 5.5% (3/54), respectively; in-hospital mortality was 7.4% (n = 4), and minor strokes (including asymptomatic new cerebral lesions) occurred in 5.5% (n = 3). There were two cases of transient spinal cord ischemia with complete recovery and one of paraplegia. No retrograde type A dissections or cardiac injuries were observed. Three early stent graft-related reinterventions were necessary to correct proximal endograft kinking with type IA endoleak in one patient, a bridging stent graft stenosis in another patient, and false lumen persistent perfusion from dissected supra-aortic vessels in the last patient. Mean in-hospital stay was 14 ± 8 days. During a mean follow-up of 12 ± 9 months, three nonaorta-related deaths and one aorta-related death distal to the arch repair were observed. Conclusions Treatment of aortic arch diseases with b-TEVAR is feasible and safe with acceptable mortality and stroke rates.

Background Thoracic endovascular aortic repair (TEVAR) with self-expanding endograft is increasingly used as a viable treatment option for adult aortic coarctation (AC). Methods We hereby reported a 55-year-old gentleman with late presentation of AC, treated by a novel strategy with thoracic endograft and in situ laser fenestration for left subclavian artery (LSA) revascularization. Results AC was incidentally discovered during coronary angiogram as an investigation for his angina pectoris. TEVAR with self-expanding endograft was chosen because preoperative computer tomography scan showed ectatic thoracic aorta and stenosis just distal to the LSA. The patient was planned for a timely second-stage aortic valve replacement and coronary artery bypass grafting using left internal mammary artery shortly after TEVAR, which required a patent LSA. The procedure was arranged semiurgently. A 34-mm thoracic tube endograft was placed across the coarctation with proximal landing distal to the left common carotid artery. In situ fenestration was created by laser catheter through retrograde left brachial access. The fenestration was then enlarged by balloon dilatation and bridged to the left subclavian origin with a 16-mm balloon-expandable covered stent. Conclusions TEVAR with in situ fenestration for LSA is a reliable choice for adult AC. The technique added to the armamentarium of treatment options.

Background Chronic limb-threatening ischemia (CLTI), defined as ischemic rest pain or tissue loss secondary to arterial insufficiency, is caused by multilevel arterial disease with frequent, severe infrageniculate disease. The rise in CLTI is in part the result of increasing worldwide prevalence of diabetes, renal insufficiency, and advanced aging of the population. The aim of this study was to compare a bypass-first with an endovascular-first revascularization strategy in patients with CLTI due to infrageniculate arterial disease. Methods We reviewed the American College of Surgeons National Surgical Quality Improvement Program targeted lower extremity revascularization database from 2012 to 2015 to identify patients with CLTI and isolated infrageniculate arterial disease who underwent primary infrageniculate bypass or endovascular intervention. We excluded patients with a history of ipsilateral revascularization and proximal interventions. The end points were major adverse limb event (MALE), major adverse cardiovascular event (MACE), amputation at 30 days, reintervention, patency, and mortality. Multivariable logistic regression was used to determine the association of a bypass-first or an endovascular-first intervention with outcomes. Results There were 1355 CLTI patients undergoing first-time revascularization to the infrageniculate arteries (821 endovascular-first revascularizations and 534 bypass-first revascularizations) identified. There was no significant difference in adjusted rate of 30-day MALE in the bypass-first vs endovascular-first revascularization cohort (9% vs 11.2%; odds ratio [OR], 0.73; 95% confidence interval [CI], 0.50-1.08). However, the incidence of transtibial or proximal amputation was lower in the bypass-first cohort (4.3% vs 7.4%; OR, 0.60; CI, 0.36-0.98). Patients with bypass-first revascularization had higher wound complication rates (9.7% vs 3.7%; OR, 2.75; CI, 1.71-4.42) compared with patients in the endovascular-first cohort. Compared with the endovascular-first cohort, the incidence of 30-day MACE was significantly higher in bypass-first patients (6.9% vs 2.6%; adjusted OR, 3.88; CI, 2.18-6.88), and 30-day mortality rates were 3.23% vs 1.8% (adjusted OR, 2.77; CI, 1.26-6.11). There was no difference in 30-day untreated loss of patency, reintervention of treated arterial segment, readmissions, and reoperations between the two cohorts. In subgroup analysis after exclusion of dialysis patients, there was also no significant difference in MALE or amputation between the bypass-first and endovascular-first cohorts. Conclusions CLTI patients with isolated infrageniculate arterial disease treated by a bypass-first approach have a significantly lower 30-day amputation. However, this benefit was not observed when dialysis patients were excluded. The bypass-first cohort had a higher incidence of MACE compared with an endovascular-first strategy. These results reaffirm the need for randomized controlled trials, such as the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL-2) trial and Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI), to provide level 1 evidence for the role of endovascular-first vs bypass-first revascularization strategies in the treatment of this population of challenging patients.

Endovascular treatment (ER) of renal artery aneurysms (RAA) has been widely used recently due to its assumed lower morbidity and mortality compared with open surgery (OS). The purpose of this study was to investigate the outcomes of OS and ER, and compare long-term renal function.Data from 2000 to 2012 were retrospectively collected to identify patients who were treated for RAA in a single institution. Morbidity, mortality, freedom from reinterventions, and renal function were compared between OS and ER for RAA.Forty-four RAA repairs were identified in 40 patients (28 women, mean age ± SD 54 ± 13 years). Twenty RAA were repaired with OS (45%) and 24 RAA (55%) with ER. Mean aneurysm sizes were 2.5 ± 1.5 cm (OS) and 2.2 ± 2.2 cm (ER; p = 0.66). Endovascular repair included coil embolization with or without stent placement in 19 patients (79%) and stent grafts in 4 (17%). Open surgery included excision or aneurysmorrhaphy of the aneurysm in 11 kidneys (55%), graft interposition or bypass in 4 (20%), and 4 nephrectomies (20%). There was 1 technical failure in each group. Comorbidities were similar between the 2 groups (American Society of Anesthesiologists III-IV: OS, 40%; ER, 58%; p = 0.44). Endovascular repair and OR had equivalent perioperative morbidity (any complication OS, 15%, ER, 17%, p = 1.0) and no mortality (OS, 0%, ER, 0%). Endovascular repair was associated with shorter hospitalization (OS, 6.3 ± 2.5; ER, 2 ± 3.4 days, p0.001). Mean follow-ups were 21 ± 32 months (OS) and 27 ± 36 months (ER). A 30% reduction in glomerular filtration rate occurred in 12.5% of OS patients and 9.1% of ER patients (p = 1.00). Freedom from reintervention at 12 and 24 months were OS, 82%/82% and ER, 82%/74%, respectively (log-rank-test = 0.23).Endovascular repair of RAA is as safe and effective as open repair in selected patients with appropriate anatomy. There was no difference in decline in renal function between OS and ER.

The aim of the study was to investigate the effect of recent chemotherapy (Chx) on outcome of aorto-iliac aneurysm (AAA) repair. The 2005–2010 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify vascular patients undergoing AAA repair within 30 days after Chx. Seventy-one patients underwent AAA repair within 30 days of receiving Chx, group A (71 ± 8.4 years, 77.5% males) and 20,024 patients underwent AAA repair without prior Chx, group B (73 ± 9 years, 79.2% males). The two groups did not significantly differ with respect to open or endovascular repair (open repair A: 32%, B: 35%, P = 0.66). However, patients in group A presented more often as emergent cases (A: 27%, B: 12%, P = 0.001). Multivariable regression analysis for emergent cases after adjustment for relevant confounders also demonstrated that patients with recent Chx present more often as emergency ( P = 0.001, odds ratio [OR]: 2.4). Thirty-day non-surgical complications were more common in group A (A: 25%, B: 16.5%, P = 0.046) while surgical complications were equivalent (A: 15.5%, B: 12.3%, P = 0.414). Risk of death was significantly higher in group A in univariate analysis (A: 13%, B: 5%, P = 0.005, OR: 2.6). Patients who receive Chx within 30 days prior to AAA repair present more frequently as emergencies leading to higher mortality. The reason for this cannot be sufficiently explained by the current database but patient selection for elective repair or the effect of Chx on the natural course of AAA may play a role.

ObjectivesChallenging iliac access during thoracic endovascular aortic repair (TEVAR) is associated with a higher risk of access site complications such as injury or rupture of the iliac vessels. As a result, the use of iliac conduits is frequently used to facilitate access during TEVAR. This report evaluates the effect of iliac conduits on TEVAR outcomes.MethodsThe 2005–2010 American College of Surgeons Surgical Quality Improvement Program database was queried to identify vascular patients undergoing elective TEVAR. Patients without conduit (Group A) were compared to patients who underwent TEVAR with conduit (Group B).ResultsWe identified 1037 patients (90%) in Group A (69 ± 12.7 years, 42% female) and 117 patients (10%) in Group B (70 ± 12.6 years, 68% female). Women received conduits more often than men (Male:5.8%, Female:15.7%, p

Die Therapie des abdominalen Aortenaneurysmas (AAA) hat sich durch die Einfuhrung der endovaskularen Stentgraftbehandlung [“endovascular aortic repair“ (EVAR)] entscheidend verandert. In randomisierten Multicenterstudien konnte schlussig nachgewiesen werden, dass die periprozedurale Komplikations- und Mortalitatsrate nach EVAR im Vergleich zur offenen Behandlung niedriger ist. Allerdings ist nach EVAR mit Folgeproblemen durch Endoleckagen, Migration, Knickbildungen oder Uberstentung von Seitenasten bei ungunstiger Morphologie zu rechnen, die eine lebenslange Nachsorge erforderlich machen. Da der groste Teil der therapiebedurftigen Patienten jedoch ein hoheres Alter und eine entsprechende Komorbiditat aufweist, hat sich bei gunstiger Morphologie die endovaskulare Behandlung durchgesetzt. Eine medikamentose und konservative Therapie kann bei Patienten mit kleinen bis mittleren Aneurysmen von Bedeutung sein. Rauchen zahlt zu den wichtigsten Risikofaktoren fur die Entstehung eines AAA. Daher sollten alle Patienten angewiesen werden, das Rauchen zu unterlassen. Die Langzeitbehandlung mit Statinen fuhrte in Studien bei Patienten nach operativem AAA-Ersatz zu einem Ruckgang der Gesamt- sowie der kardiovaskularen Mortalitat. Entsprechend sollten Patienten mit AAA zur Sekundarpravention Statine erhalten.

Background Endovascular repair is associated with better 30-day outcomes than open surgical repair for patients with infrarenal aortic aneurysms. In patients with complex aortic aneurysms (CAAs) requiring suprarenal or supravisceral aortic cross-clamping during open repair, few data exist directly comparing the real-world outcomes of open repair versus endovascular repair with fenestrated-branched stent grafts (FEVAR). Methods Outcomes for patients who underwent elective CAA repair using open repair and FEVAR between 2005 and 2010 were analyzed using the American College of Surgeons National Surgical Quality Improvement Program database. CAA was defined as aneurysm of the aorta involving the visceral and/or renal arteries. Results This study compared 1091 patients who underwent open repair (group A: male, 71.5%; age, 71 ± 9 years) with 264 patients treated with FEVAR (group B: male, 82.2%; age, 74 ± 9 years). The 2 groups did not significantly differ with respect to American Society of Anesthesiologists (ASA) classification (ASA III/IV: A, 93%; B, 95%, P = 0.6), severe chronic obstructive pulmonary disease (A: 21%; B: 22%; P = 0.7), prior cardiac surgery (A: 24%; B: 20%; P = 0.19), or preoperative renal function (glomerular filtration rate: A: 69 ± 2; B: 70 ± 27; P = 0.535). Group A had significantly higher risk of any complication (A: 42%; B: 19%; P < 0.001), nonsurgical complications (A: 30%; B: 8%; P < 0.001), pulmonary complications (A: 21%; B: 2%; P < 0.001), renal complications (A: 10%; B: 1.5%; P = 0.001), and any cardiovascular complication (A: 8%; B: 2%; P < 0.001). The composite end point of surgical site infections/graft failure/bleeding transfusions were also higher in group A (A: 22%; B: 15%; P = 0.014). Thirty-day mortality was significantly lower for FEVAR (A: 5.4%; B: 0.8%; P = 0.001), as was total length of hospital stay (A: 11 ± 10 days; B: 4 ± 5 days; P < 0.001). Conclusions This nationwide real-world database suggests that in similar patient populations, repair of CAAs with FEVAR is associated with reduced 30-day morbidity and mortality compared with open repair. Although long-term comparative studies are needed, FEVAR may represent a preferred treatment alternative to open repair for patients with CAAs.

Until fairly recently, experience with advanced endovascular technologies, including fenestrated endovascular repair (FEVAR), has been limited to a relatively small number of practitioners worldwide. Excellent outcomes have been achieved by these accomplished surgeons who, at least initially, have primarily used custom-made devices constructed by a single endograft manufacturer. Access to this technology has been limited by the skills necessary for such procedures and by the customization process with industry partners. However, several issues are changing rapidly with FEVAR. Increasing numbers of surgeons now have the necessary endovascular skills, and off-the-shelf endografts from several manufacturers have become, or are becoming, available. Also, the regulatory landscape is changing with device approval in the United States. Surgeons and patients alike are anticipating the widespread adoption of this advanced technology that will surely benefit increasing numbers of patients. Or will it? Will widespread adoption in a larger number of smaller-volume hospitals, by less experienced surgeons, result in poor patient outcomes, or will excellent results continue with more patients benefitting from these technologic advances? These are important questions to ask before such adoption and are the subject of this debate.

The value of fenestrated-branched stent-grafts (FBSG) in the management of complex aortic aneurysms has been clearly demonstrated from data derived from several centers of excellence. Reducedmorbidity andmortality aswell as shorter length of hospital stay has been demonstrated to be associated with FBSG compared to traditional open surgery for patients with complex aortic aneurysms. FBGS have an even greater benefit in patients considered to be at high-risk for open repair. Fenestrated-branched technology was first introduced in 1996 with larger series reported in 2001. Recent reports have proven FBSG to be safe, effective, and durable with excellent long-term results. Reinterventions that were performed were mostly for stenoses of branch stents and type 1 and 3 endoleaks. Cook Medical Inc (Bloomington, IN) has been a leading manufacturer in this area for several years with the company reportingmore than 4000 implantations of FBSG worldwide and recently acquiring FDA approval for its pararenal device in the United States and CE approval for its thoracoabdominal device (T-fenestrated) in Europe. Recently, however, fenestrated-branched technology has rapidly evolved and become more widespread with 2 more FBSG devices under investigation or marketed outside of the U.S. and FBSG for thoracoabdominal and aortic arch aneurysms being approved as investigational devices. Despite these recent advancements, this technology which was introduced more than 15 years ago and which has been used to treat more than 4000 patients worldwide, not counting the countless patients treated with surgeonmodified FBSG or FBSG from other companies, continues to be restricted to only a few centers of excellence. The intent of this paper is to argue in favor of a wider distribution of FBSG to vascular centers and to demonstrate how any effort to restrict this kind of technology would only compromise patient care.

Persistent sciatic artery (PSA) is an anatomical variation which is rare and most frequently diagnosed secondary to its clinical complications. The sciatic artery walls have a tendency to aneurysmal degeneration and may evolve to thrombosis or thromboembolism. This article reports the case of a 13-year-old male patient with left superficial femoral artery pseudoaneurysm after gunshot wound and complete PSA with in-line flow to the popliteal artery as incidental finding. The patient underwent coil embolization of the pseudoaneurysm with the sciatic artery left intact. The technical aspects are discussed and the literature on diagnosis and therapeutic approach of this anatomical variation is reviewed.

Introduction Fenestrated-branched stent grafts have been developed as a minimally invasive, endovascular alternative for the treatment of complex aortic aneurysms in high-risk patients. However, the manufacture of these devices can take as long as 6 to 12 weeks, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified, fenestrated-branched stent grafts (sm-FBSGs) in high-risk patients who presented as emergencies with ruptured or symptomatic complex aortic aneurysms. Methods All patients treated with sm-FBSGs at our institution were retrospectively reviewed. Patients presenting with acute symptoms or an emergency indication for repair were analyzed. Results Twelve high-risk patients (nine men), of which seven were at American Society of Anesthesiologists class 4 and five were at class 3, presented with seven symptomatic and five ruptured aortic aneurysms. Mean age was 71 years (range, 52-86 years), and mean maximal aneurysm size was 8.1 cm (range, 5-12 cm). Six patients (50%) had prior aortic surgery or a hostile abdomen. Relevant comorbidities included coronary disease in all 12 patients, and seven (58%) had an ejection fraction ≤35%. Nine patients (75%) had severe pulmonary dysfunction. Four aneurysms were pararenal, and eight were thoracoabdominal (two type II, three type III, and three type IV). An average of three visceral vessels (range, 2-4) were treated per patient, with 35 branches targeted. Endografts were successfully implanted in all patients. There was no paraplegia or intraoperative death. One patient (8.3%) died of subarachnoid hemorrhage ≤30 days. Reintervention was necessary in two patients, for a type 3 endoleak and for evacuation of a retroperitoneal hematoma. Morbidity included one myocardial infarction, and two patients each with transient respiratory failure and transient renal insufficiency not requiring dialysis. Mean postoperative length of stay was 4 days in the intensive care unit and 8 days in the hospital. At a mean follow-up of 9 months (range, 3-18 months), two patients died of non–aneurysm-related causes. Branch vessel patency was 100%. No late reinterventions were necessary. No type I or III endoleaks occurred. One type II endoleak is under observation. Conclusions Sm-FBSG may play an important role in the treatment of select patients with symptomatic or ruptured complex aortic aneurysms who are at prohibitive risk for open surgery and in whom endovascular repair cannot be delayed to allow implantation of a custom-made commercial device. Until an off-the-shelf fenestrated-branched device is created that does not require a prolonged waiting period, this may be the best option to treat patients with symptomatic or ruptured complex aneurysms that are at excessively high surgical risk.

Einleitung: Ein Aneurysma verum der A. profunda femoris (AAPF) ist sehr selten. In den meisten Fallen sind nur Kasuistiken beschrieben. Empfehlungen zur Diagnostik und Therapie des AAPF basieren ausschlieslich auf Daten eines niedrigen Evidenzniveaus. Das Ziel dieser Arbeit war eine Zusammenfassung der bisher vorliegenden Erfahrung zum AAPF. Material/Methoden: Aus Anlass eines eigenen Falles wurde eine systematische Literaturanalyse zur Diagnostik und Therapie des echten AAPF vorgenommen. Die Literaturrecherche erfolgte in PubMed, EMBASE und in der Cochrane-Datenbank sowie durch eine Handsuche nach Auswertung der Literaturverzeichnisse der einzelnen Publikationen. Ergebnisse: Es wurden 25 Publikationen uber echte AAPF nach 2002 veroffentlicht. Neben 2 retrospektiven Studien uber einen langeren Zeitraum handelte es sich ausschlieslich um Kasuistiken. In diesen Arbeiten wurde uber insgesamt 55 AAPF verum berichtet bei 47 Patienten mit einem mittleren Alter von 63 Jahren. Die Therapie erfolgte aufgrund einer Ruptur in 10 Fallen (18 %). Der Maximaldurchmesser des AAPF bei klinischer Vorstellung der Patienten betrug im Durchschnitt 5,4 cm (2–18 cm). Bei nicht rupturiertem AAPF bestand eine Symptomatik in den meisten Fallen in Form einer schmerzhaften pulsierenden Schwellung in der Leistenregion und am Oberschenkel. Die Ausschaltung des AAPF erfolgte konventionell uber einen offenen Zugang oder endovaskular, mit oder ohne Revaskularisation der A. profunda femoris. Diskussion: Bei der klinischen Symptomatik einer Schwellung und Schmerzen infrainguinal am proximalen Oberschenkel sollte ein AAPF in die Differenzialdiagnose einbezogen werden. Die gefaschirurgische Therapie zur Aneurysmaausschaltung ist elektiv bei einem Maximaldurchmesser von mehr als 2 cm oder Grosenprogredienz und in jedem Fall bei Symptomatik oder Ruptur indiziert. Die Moglichkeiten einer endovaskularen Therapie sollten in jedem Fall in Betracht gezogen werden.

In the endovascular era, elderly patients are offered repair of their aortoiliac aneurysms (AAA) more frequently than in the past. Our objective is to compare age groups and draw inferences for AAA repair outcomes.We identified 20,095 patients who underwent AAA repair between 2005 and 2010 using the American College of Surgeons NSQIP national database. Preoperative characteristics and outcomes were compared among age groups (group A: 0 to 64 years; B: 65 to 79 years; C: 80 to 89 years; and D: 90 years and older).The age distribution of the cohort was A: 17.1%, B: 57.2%, C: 24%, and D: 1.7%. Nonagenarians presented significantly more often as emergencies in comparison with groups A to C (A: 13.8%, B: 10.8%, C: 12.9%, D: 22.1%; p0.001). Endovascular aneurysm repair was performed more frequently in older patients (A: 55.2%, B: 63.7%, C: 74.6%, D: 77.9%; p0.001). Risk of any complication was significantly different among groups, becoming more prevalent with advanced age (A: 22.8%, B: 23.4%, C: 24.7%, D: 27.8%; p = 0.041). Nonsurgical complications (A: 14.7%, B: 16.4%, C: 18%, D: 19.8%; p0.001) and cardiovascular complications (A: 3.9%, B: 4.5%, C: 5.5%, D: 5.2%; p = 0.003) were also higher with advanced age. Overall mortality was 3.1%, 4.9%,7.2%, and 13.2% for groups A to D, respectively (p0.001). Mortality after elective AAA repair was significantly higher for open surgery compared with endovascular aneurysm repair in all age groups (open surgery vs endovascular aneurysm repair, A:1.9% vs 0.5%; p = 0.001; B: 3.9% vs 1.2%; p0.001; C: 7.4% vs 2%; p0.001; D: 18.8% vs 3.8%; p = 0.004). After adjusting for confounders in the entire cohort, advanced age persisted as an independent factor for postoperative mortality with a higher risk of death of 1.8 (95% CI, 1.3-2.5), 2.7 (95% CI, 1.9-3.8), and 3.3 (95% CI, 1.8-6.1) times for groups B, C, and D, respectively (group A reference).Advanced age is independently associated with higher risk of death after AAA repair and indication for surgery should be adjusted for different age groups accordingly. Endovascular aneurysm repair should be preferred for octogenarians and nonagenarians with indication to undergo repair of their AAA.

Background Spontaneous dissection of iliac arteries, without involvement of the aorta, is rare. Only few cases of endovascular treatment of this condition are reported in the current literature. Methods We report false lumen embolization strategy as an adjunct to stent grafting of the true lumen. Results A 68-year-old male patient was admitted to our institution with the incidental finding of an isolated iliac dissection with a false lumen aneurysm. He was electively treated with successful segmental iliac stent grafting to cover the primary entry tear in the common iliac artery. Coil embolization of the false lumen was chosen to provide distal seal of the false lumen aneurysm. Conclusions As in the treatment of aortic dissections, also in the iliac arteries, false lumen thrombosis should be targeted. To our knowledge, this is the first case of false lumen embolization of an isolated iliac dissection reported in literature. The technique we report was effective and could be easily reproduced.

Purpose: To report implantation of an iliac branch device (IBD) for preserving antegrade blood flow to a sole internal iliac artery (IIA) via an ipsilateral approach during endovascular repair to reline an aortobi-iliac allograft. Technique: The technique is described in a 55-year-old man with an enteric fistula involving an aortobi-iliac Y-prosthesis. After complete excision, the prosthesis was replaced by an allograft. Due to rebleeding and resuturing of the graft, total stent-graft relining of the allograft was planned with preservation of the sole left IIA using an iliac side branch (ZBIS). During introduction of a 12-F sheath over the allograft’s neobifurcation to establish a femorofemoral through-and-through approach, the allograft ruptured. A compliant balloon was inflated to control the hemorrhage. The IBD was first fully deployed, followed by stent-graft relining. Consequently, stent-graft implantation in the left IIA using a crossover maneuver was no longer feasible, so a 0.035-inch super stiff wire was introduced through the IBD’s 20-F sheath. A 12-mm semi-compliant balloon was inflated in the common iliac artery above the iliac branch to act as an abutment for a 7-F sheath to run over the stiff wire into the IIA for delivery/deployment of a stent-graft. Conclusion: It is feasible to use a complete ipsilateral femoral approach for IBD implantation after aortic stent-graft placement.

OBJECTIVE: The objective of this study was to evaluate the safety and feasibility of a novel stent graft specifically designed for treatment of the ascending aorta.METHODS: This was a multicenter, retrospective analysis of all consecutive patients treated with the dedicated Zenith Ascend TAA Endovascular Graft (William Cook Europe, Bjaeverskov, Denmark) for pathologic processes requiring stent grafting of the ascending aorta. The graft is short (6.5 cm), with a delivery system designed for transfemoral placement in the ascending aorta.RESULTS: In 10 patients (five men; age, 67 years; range, 26-90 years), the Zenith Ascend graft was implanted for the following indications: dissection (n = 5) and aneurysm (n = 4) of the ascending aorta and fixation of an intraprocedural dislocated aortic valve (n = 1). All patients were judged to be at high risk for open surgery (nine patients were classified as American Society of Anesthesiologists class 3 or class 4). A transfemoral approach was selected in eight cases and a transapical approach in two. All endografts were successfully deployed without intraoperative adverse events at the targeted landing zone. Clinical success in coverage of the lesions was achieved in all cases with the exception of an attempted treatment of an intraprocedural aortic valve implantation dissection that resulted in early mortality. The 30-day survival was 90%. Early neurologic events included one patient with stroke and paraplegia and one patient with a transient ischemic attack. One patient underwent early evacuation of a hemopericardium. There were two late reinterventions for persisting endoleaks. At a mean follow-up of 10 months (range, 1-36 months), three late deaths occurred, with one treatment related, as a result of graft infection.CONCLUSIONS: Despite the fact that in this first published series the graft was frequently used as a "rescue tool" outside its intended indication, treatment with the Zenith Ascend graft in this early experience appears to be safe and feasible for repair of ascending aorta pathologic processes in high-risk patients unsuitable for open repair.

Ruptured Abdominal Aortic Aneurysms (rAAA) represent the most common abdominal aortic emergency with an incidence of 6.3 per 100,000 inhabitants whereas the incidence of rAAA in the population over 65 years was 35.5/100.000 inhabitants. Early suspicion and diagnosis of rAAA is essential for good outcomes and over the past decades a great variety of perioperative management concepts, techniques and materials have been implemented to further improve the outcomes of this acute and life-threatening disease. Corner-stones for the improvement of outcomes include the introduction of management protocols for rAAA, the principle of hypotensive hemostasis and the introduction of endovascular techniques as well as the improved anesthesia and postoperative intensive care therapy with early identification and management of devastating complications such as the abdominal compartment syndrome. While the role of endovascular aortic repair in rAAA is not yet answered, it appears to be very promising especially in the presence of new techniques that could resolve a number of the problems restricting success of EVAR in rAAAs.

Objective Endovascular repair of the aortic arch represents a formidable challenge because of aortic diameter, angulation, elasticity, and greater distance to the femoral access vessels. Whereas both fenestrated and branched endografts have been customized to accommodate complex pathologic processes of the arch, no data comparing the techniques are available. The aim of this study was to compare the outcomes of custom-made fenestrated vs branched thoracic endovascular aortic repair (fTEVAR vs bTEVAR). Methods This was a single-center, retrospective comparative study of all consecutive patients treated with fTEVAR and bTEVAR for aortic arch diseases. All patients were considered unsuitable for open surgical therapy and treated with customized stent grafts (Cook Medical, Bloomington, Ind). Results Within 42 months, 29 patients underwent fTEVAR and bTEVAR (66 ± 9 years; nine female patients). The fTEVAR patients (n = 15) had no differences in comorbidities compared with the bTEVAR patients (n = 14). Dissection or postdissection aneurysm was the indication in 6 of 15 fTEVARs and 5 of 14 bTEVARs (40% vs 36%; P = NS); the remaining procedures were performed for aneurysms. Six (40%) fTEVAR patients underwent previous cervical debranching compared with all bTEVAR patients. In all patients with bTEVAR, two arch vessels were targeted (innominate, 13; left carotid artery, 14; left subclavian artery, 1), whereas fTEVAR targeted 1.6 ± 0.5 arch vessels (bovine trunk, 4; innominate artery, 1; left carotid artery, 10; left subclavian artery, 9). Technical success was achieved in all but one case of a fenestrated endograft that was displaced, resulting in major stroke and death of the patient. Strokes occurred in two fTEVAR patients and one bTEVAR patient ( P = NS). The 30-day mortality was 20% in the fTEVAR patients (n = 3) vs 0% in the bTEVAR patients ( P = NS). The causes of early mortality were major stroke (n = 1), access complication (n = 1), and myocardial infarction (n = 1). Mean follow-up was 8 (1-35) and 10 (2-22) months for fTEVAR and bTEVAR, respectively. No branch occlusions occurred, and two patients underwent coil embolization for endoleaks ( P = NS). One patient was readmitted with infected branched endograft 4 months after intervention and has so far been successfully treated with aneurysm sac drainage and antibiotics. There was one late nonaneurysm-related death in each group. Conclusions Both fTEVAR and bTEVAR are feasible for the treatment of aortic arch diseases in high-risk patients. Results are promising, although fTEVAR was associated with higher mortality in this early experience. bTEVAR was more commonly used in Ishimaru zone 0.

To investigate the course of health-related quality of life (HQL) over time in patients with peritoneal carcinomatosis (PC) after complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Prospective, single-center, nonrandomized cohort study using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. Ninety patients who underwent CRS and HIPEC for PC in our institution were enrolled in the study. Mean age was 56 years (range 27–77 years) (61 % female). Primary tumor was colorectal in 21 %, ovarian in 19 %, pseudomyxoma peritonei in 16 %, an appendix tumor in 16 %, gastric cancer in 10 %, and peritoneal mesothelioma in 13 % of cases. Mean peritoneal carcinomatosis index was 22 (range 2–39). Mean global health status score was 69 ± 25 preoperatively and 55 ± 20, 66 ± 22, 66 ± 23, 71 ± 23, and 78 ± 21 at months 1, 6, 12, 24, and 36, respectively. Physical and role function recovered significantly at 6 months and were close to baseline at the 24-month measurement. Emotional function starting from a low baseline recovered to baseline by month 12. Cognitive and social function had slow recovery on follow-up. Fatigue, diarrhea, dyspnea, and sleep disturbance were symptoms persistent at 6-month follow-up, improving later on in survivors. Survivors after CRS and HIPEC have postoperative quality of life similar to preoperatively, with most of the reduced elements recovering after 6–12 months. We conclude that reduced quality of life of patients after CRS and HIPEC should not be used as an argument to deny surgical therapy to these patients.