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Complex aortic aneurysms such as paravisceral aneurysm represent a challenging condition especially in the case of rupture. The presence of an aortoenteric fistula in this setting is associated with a very high mortality and morbidity. We report the case of a 72-year-old patient with contained ruptured paravisceral aortic aneurysm who underwent surgeon-modified fenestrated endovascular aneurysm repair (sm-fEVAR) with fenestrations for multiple renal arteries and the superior mesenteric artery. The patient successfully recovered from the repair but developed an aortogastric fistula on the basis of a preexisting gastric ulceration so that second-stage atypical gastrectomy was conducted. The further postoperative course was complicated by severe pancreatitis and sepsis resulting in multiorgan failure and in-hospital death 1.5 months later. We were able to demonstrate the technical feasibility of an sm-fEVAR for a contained ruptured paravisceral aneurysm. Coverage of the celiac artery is required in some complex cases but may lead to severe ischemic complication despite from angiographic sufficient collateralization.

Purpose: To describe the deployment into the ascending aorta of a fenestrated stent-graft with a scallop for the innominate artery. Technique: A 72-year-old multimorbid patient presented with a chronic DeBakey type II aortic dissection of the ventral ascending aorta with close proximity (16 mm) to the innominate artery. A 1-piece, 46-mm-diameter Zenith Ascend Thoracic Endovascular Graft with circumferential diameter-reducing sutures (ProForm) was custom made with a 15×30-mm scallop for the innominate artery. The stent-graft was loaded on a Z-Trak Plus Introducer System with a 20-F hydrophilic-coated sheath and successfully implanted under inflow occlusion in a procedure that lasted 35 minutes. Conclusion: The use of fenestrated stent-grafts in the ascending aorta is feasible, and a scallop in the distal stent-graft can extend coverage of the ascending aorta in pathologies close to the innominate artery. This technique broadens the range of endovascular options for patients not suitable for open surgery.

Erratum to: Gefasschirurgie (2018) https://doi.org/10.1007/s00772-018-0387-7 The article was wrongly published under the article type “Review”. Please note that the article is an “Original Paper”. The publisher apologizes to the authors and …

Hintergrund Die zytoreduktive Chirurgie mit hyperthermer intraperitonealer Chemotherapie (HIPEC) bietet fur Patienten mit einer Peritonealkarzinose verschiedenen Ursprungs die Chance auf eine relevante Lebensverlangerung. Diese Falle sind aus medizinischer Sicht komplex und aus okonomischer Sicht teuer. Durch Analyse der Fallkostenkalkulationen sollte herausgefunden werden, ob ein universitarer Maximalversorger dieses Verfahren im Mittel kostendeckend durchfuhren kann.

Background Mediastinal ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism, traditionally treated by open surgery. Thoracoscopic access is associated with reduced morbidity in mediastinal surgery. The aim of this study was to evaluate the feasibility and effectiveness of robot-assisted dissection for mediastinal ectopic parathyroid glands. Methods Two patients with recurrent secondary hyperparathyroidism and three with complicated primary hyperparathyroidism were operated on between July 2004 and August 2008 for ectopic mediastinal parathyroid glands. Fusion of single-photon emission computed tomography and computed tomography led to an exact identification of the culprit glands. Surgery was performed thoracoscopically with the da Vinci® robotic system using a three-trocar approach. Results All procedures were completed successfully with the robotic system. No perioperative morbidity or mortality was noted. Median operating time was 58 (range 42–125) min. Intraoperative parathyroid hormone reduction indicated complete resection. Median hospital stay was 3 (range 2–4) days. Conclusion Robot-assisted dissection is a promising approach for resection of ectopic parathyroid glands in remote narrow anatomical locations such as the mediastinum.

Introduction Redo surgery or reintervention following conventional or endovascular aortoiliac reconstruction often requires exclusion of new aneurysms. In the present study the potentials of endovascular management of such lesions are investigated. Methods All patients with endovascular reoperation for of newly developed aortoiliac aneurysms were identified from a prospectively run data-base. The indications and results of endovascular therapy were analysed retrospectively. In detail, data were analysed for the type of original operation, interval until and kind of reoperation, and results concerning survival, technical success and complications. Results From 12 / 2003 through 3 / 2007 195 patients with aortoiliac aneurysms were operated. Endovascular repair was performed in 15 cases of previously excluded aneurysms. Mean age of these 15 patients (12 men) was 73 (64-85) years. Ten patients had a primary conventional (group A) and 5 patients had a primary endovascular (group B) aneurysm repair. The mean time interval between the first and second operation was 8.9 (1-26) years. The secondary endovascular therapy in group A was successful in all cases. In group B endoleaks type I a (n = 1), I a / b (n = 1), II (n = 2) and III (n = 1) were treated. One type II endoleak could only be treated successfully by conversion to open repair, the other one was successfully treated by reintervention. All but one patient are alive and -remained free of pathological findings during a median follow-up of 13 (2-39) months. Discussion Because of the clearly elevated operation risk of redo surgery after conventional or endovascular aneurysm repair, endovascular aneurysm exclusion represents the method of first choice. The reasonable selection and combination of procedures allows for an optimal adaptation of therapy to the individual case.

INTRODUCTION: The indications for endovascular aortic aneurysm repair (EVAR) are mainly established in hostile abdomen, in patients with significant comorbidities which affect the general operability of the patient and, given the necessary infrastructure, also in ruptured aneurysm. Along to those, we present another possible indication in the presence of a kidney allograft in patients with aortic aneurysm. METHODS: Based on a case report of aorto-biiliac stent-graft repair of an infrarenal aortic aneurysm in a patient with renal allograft, a systematic review of the literature was performed of all similar cases concerning surgical therapy in this constellation. RESULTS: EVAR was performed using an aorto-biiliac system (Zenith) Trifab, COOK) in a 61-year-old male patient 11 years after heterotopic renal allotransplantation in the right iliac fossa. Preoperative renal function was normal. Because the donor renal artery was anastomosed to the recipient's external iliac artery the stent-graft was implanted from the left common femoral artery to minimize temporary allograft ischemia. The intra- and postoperative course was uneventful with a follow-up of presently 12 months. A primary type-II endoleak (retroleak from a lumbar artery) is being treated conservatively so far with embolization being a future option. At present there are 15 cases of EVAR in renal allograft patients that have been reported, all of them being successful. DISCUSSION: All data existing in the literature reported to date as well as our own experience justify the first choice of EVAR in morphologically suitable cases. One major advantage of EVAR in this constellation is the avoidance of aortic cross clamping which poses the graft at risk of ischemia. Long-term results will be most important for definite assessment of EVAR. However, contrast media application during the operation and for CT surveillance should be considered as a major disadvantage.

Cystic adventitial disease is a rare non-atheromatous cause of popliteal artery disease. We report a case of a 54-year-old patient with claudication of the right calf caused by cystic adventitial disease. Intra-operatively, a communication between the adventitia and the knee joint was identified. Connections between the adventitial cyst and the nearby joint have been reported in the literature that support the developmental theory. This theory suggests that cystic adventitial disease is a developmental manifestation of mucin-secreting cells derived from the mesenchyme of the adjacent joint. This case is the first, to our knowledge, in which a communication between joint and adventitia has been clearly documented by operative findings.

Open surgical repair of thoracoabdominal aortic aneurysms remains associated with significant morbidity and mortality. We sought to analyse multicentre national data on early outcomes of open surgical thoracoabdominal aortic aneurysm repair. Patients who underwent open repair of thoracoabdominal aortic aneurysm from 2005 to 2010 were identified from the National Surgical Quality Improvement Program database. The primary endpoint was mortality at 30 days. Patient demographics, clinical variables, and intraoperative parameters were analysed by univariate and multivariate logistic regression methods to identify risk factors for mortality. Of the 682 elective repairs, 30-day outcomes of elective repairs were: 10.0% mortality, 21.6% surgical complications, 42.2% pulmonary complications, 17.2% renal complications, 12.9% cardiovascular complications, 19.2% septic complications, and 6.6% wound complications. Multivariate logistic regression analysis showed that age, ASA-class IV, dependent functional status prior to surgery, and operation time are independent risk factors for mortality. Our study found a higher rate of mortality nationwide, as compared to several previous single center studies.

PURPOSE To describe a simple and quick technique for converting a Zenith bifurcated stent-graft to an aortouni-iliac device for emergency treatment of hemorrhage when a suitable marketed stent-graft is not readily available. TECHNIQUE The technique is described in an emergent case involving a 72-year-old man presenting with an aortoduodenal fistula and acute gastrointestinal bleeding. The Zenith device was prepared and flushed in the typical fashion. An extra stiff Lunderquist wire was advanced through the graft for better stability during the modification. The peel-away sheath was advanced beyond the hemostatic valve to allow partial release of the graft from the back then the grey positioner was retracted while the sheath was held firmly on the table, partially deploying the iliac limbs from the back side of the sheath. An occluding non-absorbable braided suture was placed at the short limb of the bifurcated graft close to the middle of the contralateral limb stent, through the webbing connecting both limbs below the flow divider of the bifurcated Zenith device. The graft was then resheathed using manual pinching of the graft or compression with umbilical tape. In the illustrated case, the stent-graft was intentionally deployed with the uncovered stents below the renal arteries to facilitate easier explantation later on. CONCLUSION Back-table modification of stent-grafts is feasible in emergencies for operators familiar with all technical aspects and potential risks of the modifications.

Malignant melanoma is a disease with an increasing rate of incidence, currently at 10 cases per 100,000. In most cases, malignant melanoma metastasizes over the lymph vessels to parenchymal organs. Symptomatic metastases are found in the gastrointestinal tract in only about 2% of the patients.A 43-year-old patient with a known metastasized malignant melanoma (brain, liver, bones) was admitted to the department of dermatology due to fatigue, headache and unspecified abdominal symptoms. Because of persistent abdominal symptoms, a computed tomography (CT) scan of the abdomen was performed, showing a perforation of the ileum with an abscess on the basis of multiple small-bowel metastases. A segmental small-bowel resection with primary anastomosis was performed. The postoperative course of the patient was complicated by a subcutaneous wound infection and a prolonged period of convalescence (due to multiple brain metastases).Novel therapy concepts and medication in the treatment of patients with malignant melanoma have improved life expectancy. These patients are therefore expected to suffer more frequently from complications of the primary disease. Interdisciplinary management and cooperation is required to adequately diagnose and handle such cases.

Mycobacterium avium complex (MAC) infection occurs in up to 50% of advanced-stage human immunodeficiency 1 (HIV-1) infections when the CD4 counts is50/mm³. We report the case of a 52-year-old HIV-positive patient who presented with a symptomatic, rapidly growing suprarenal abdominal aortic aneurysm. He had been diagnosed and treated for disseminated MAC infection 3 years earlier. He was treated with antiretroviral medications and had a CD4 count250 cells/mm³ and an undetectable viral load. Open repair was performed using cryopreserved homograft. Microbiologic cultures from the specimen revealed infection with mycobacterium avium. This is the first case to report a mycotic suprarenal aortic aneurysm caused by an active conversion of a latent MAC infection.

© 2016 Elsevier Ltd GBD 2015 HIV Collaborators. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015. Lancet HIV 2016; 3: e361–87—In this Article, Kerrie E Doyle and David M Pereira have been added to the list of collaborators and Claudia C Pereira has been removed. These corrections have been made as of Aug 22, 2016.

Objective: To investigate the effect of aneurysm size on long-term survival after endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). Methods: Retrospective study of all consecutive patients treated with EVAR for AAA at a single institution. Results: One hundred and nineteen patients (mean age 71, range 45-91) underwent EVAR during a 4-year period. The mean maximal aneurysm diameter was 58 mm (range 34-93 mm). Mean follow-up was 34 months (range 1-80). Cox regression analysis after controlling for age, renal function, coronary disease, and smoking showed a 4.9-fold higher risk of death for patients with preoperative aneurysm size ≥60 mm as compared to patients with aneurysm size

Endovascular repair of aneurysms involving the visceral and thoracoabdominal aorta and iliac arteries has become a reality with over 1,000 cases performed worldwide. Sm-FBSG for pararenal, thoracoabdominal, and aortoiliac aneurysms have emerged as a viable endovascular alternative for patients unfit for open repair in circumstances not allowing the use of customized stent grafts or suitable off-the-shelf devices. The major limitation for widespread of this technique is the fact that a time window of 1–2 h is needed to construct the graft and the fact that it is rather complex to complete when not performed routinely.

Popliteal artery aneurysms (PAAs) have been referred to as "the silent killer" because of the devastating thromboembolic events they can cause without warning symptoms. Open surgical repair of PAA remains the gold standard, although the endovascular approach has being increasingly reported during the past years. Open repair can be performed over the medial or posterior approach, depending on the extent of the aneurysm and surgeon's preference. The goal of the present article is to summarize the clinical results of open and endovascular repair of PAA and to serve as a practical and prompt literature search tool for all surgeons and endovascular specialists who encounter this disease process in their practices.

Peritoneal carcinomatosis represents a clinical condition with a limited perspective concerning long term survival. The combination of surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) represents a complex multimodal therapeutic management concept with promising results for prolongation of survival. For the identification of pitfalls during implementation of the HIPEC procedure into clinical practice an observational study was conducted.Between 2005 and 2009 data from all patients treated with cytoreductive surgery and HIPEC for peritoneal carcinomatosis was prospectively collected and analysed.During the observational interval a total of 42 patients underwent surgical treatment for peritoneal carcinomatosis. In 34 patients the complete procedure with surgical cytoreduction and HIPEC was performed. Perioperative mortality (6%) and morbidity (35%) was similar to other reported series. Twenty-five patients (76%) survived the 18 months follow-up period after complete procedure.The multimodal therapeutic treatment concept of surgical cytoreduction and following HIPEC leads to promising results for patients suffering from peritoneal carcinomatosis. However this treatment concept is afflicted with a relevant risk of postoperative complications.

Background We sought to present endovascular management options of persistent or recurrent aneurysm sac flow (“endoleak”) after operative retroperitoneal exclusion of infrarenal abdominal aortic aneurysm (AAA). Methods Recurrent or persistent aneurysm perfusion was diagnosed in three patients primarily treated with aneurysm exclusion and bypass. The medical history, course of disease, and surgical management of these patients were reviewed. Results Three patients primarily treated for infrarenal AAA by division of the aorta with suture closure of the proximal aneurysm end, ligation of the outflow vessels, and bypass of the excluded aortoiliac segment presented with persistent or recurrent AAA sac perfusion and growth. The feeding vessels were the iliac arteries in all cases. Endovascular repair using coil embolization and/or deployment of an occluder or stent-graft was successful in all patients with a follow-up of 42, 36, and 30, months respectively. Conclusion Open AAA repair using the exclusion and bypass technique is associated with the risk of persistent perfusion or reperfusion of the aneurysm sac, which is similar to an endoleak after endovascular aortic aneurysm exclusion. Endovascular therapy should be considered as first-choice treatment when feasible.

Background: The aim of the present study was to analyse the short-term results of treatment of internal iliac artery aneurysms (IIAA). Methods: In a prospective single-centre cohort study all patients with IIAA (symptomatic or maximal diameter ≥30 mm) were evaluated for endovascular repair, which included coil embolization of the run-off vessels and coverage of the orifice of the IIAA with a stent graft. Open repair was performed with aneurysm excision or aneurysmorrhaphy. Outcome criteria were technical and clinical success and complications of treatment. Results: In a period of 40 months 11 patients underwent operation for 12 IIAA. Nine aneurysms were repaired endovascularly and three with open repair. Coil embolization was routinely performed in all cases. At a median follow up of 18 months, technical and clinical success was 100%. Major complications included two early limb thromboses, a contrast-agent-induced nephropathy, and an intraoperative ureteric injury. Conclusion: Despite the limited number of patients, the present series, with good short-term results, further supports the trend towards endovascular repair of suitable IIAA.

Background: Surgical cytoreduction and simultaneous hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis is afflicted with a high incidence of postoperative complications. The knowledge of intraoperative volume therapy during surgery and chemotherapy is limited. On the other hand, the choice of a ‘liberal’ or ‘restrictive’ regimen of fluid administration has a deep impact on the postoperative morbidity. The aim of this observational trial was to report detailed data on volume replacement and cardiocircular function during the HIPEC procedure. Methods: Eighteen consecutive patients undergoing cytoreductive surgery and HIPEC for peritoneal carcinomatosis were enrolled. The intraoperative volume administration was observed as well as the postoperative morbidity and mortality. Cardiofunctional data were assessed by the invasive transthoracic thermodilution technique. Results: The study showed that large amounts of volume (1,240 ml h–1; range: 810–1,570 ml h–1) are given during the HIPEC procedure to replace fluid loss and maintain a stable circulatory function. Signs of a hyperdynamic status during intraoperative intraperitoneal chemotherapy were not found. Conclusions: During surgical cytoreduction and simultaneous HIPEC, large amounts of volume were administered. HIPEC in itself did not lead to an increased fluid requirement. Further prospective studies with larger populations are needed to investigate whether goal-oriented therapies and a restricted volume regimen can contribute to decrease the postoperative morbidity.

Introduction Above knee (AK) femoropopliteal bypass remains a sufficient and durable therapy for long occlusions of the superficial femoral artery in the era of endovascular repair. A novel, precuffed expanded polytetrafluoroethylene (ePTFE) graft that was designed for AK femoropopliteal bypass (Dynaflo, Bard Peripheral Vascular Inc, Tempe, Ariz) has been available for clinical use since March 2005, promising better patency rates by optimizing the hemodynamic patterns within the distal anastomosis. Methods A prospective, multicenter, nonrandomized study was performed to investigate the clinical results of the Dynaflo graft. Primary end points were patency rates, limb salvage, and complications. Results Between March 2005 and August 2007, the Dynaflo graft was used in 135 AK bypasses in 134 patients (110 men) with a mean age of 66 years. Indication for revascularization was claudication in 99 (73%) and critical ischemia in 36 (27%). With a mean follow-up of 18 months the 6-, 12- and 24-month primary patency rates were 90%, 83% and 72.5% and the secondary patency rates were 93%, 88.6% and 82.2%, respectively. The cumulative limb salvage rate at 24 months was 95%. Complications were observed in 39 patients (29%), with bypass failure (29 cases) and significant thrombus accumulation at the distal anastomosis (4 cases) being the most severe. Conclusion This study presents the first clinical results of a novel ePTFE graft for supragenicular revascularization. The implantation of the Dynaflo graft seems to be safe and feasible for AK bypass, achieving acceptable medium-term patency rates. Nevertheless, long-term results have to be awaited, and prospective comparative studies are warranted.

Introduction: Due to anastomotic engineering, the Dynaflo™ prosthetic graft, like the Distaflo®prosthesis, offers a precuffed distal anastomotic site similar to the Miller cuff aiming at optimized hemodynamics within the distal termino-lateral anastomosis particularly for femoropopliteal supragenual bypasses. Graft thrombosis and subendothelial myointimal hyperplasia may thus be reduced. The aim of the present study is to obtain the first clinical results with this new prosthetic graft.

Objective: Secondary aortoenteric fistula (SAF) is a rare but fatal complication of reconstructive aortoiliac surgery. The purpose of this study was to identify variables associated with poor outcome, after reviewing the clinical presentation, surgical management, and late events.

Compression of adjacent anatomic structures by an abdominal aortic aneurysm (AAA) can result in a variety of symptoms. We describe the case of an 88-year-old Caucasian woman with jaundice, elevated laboratory parameters for extrahepatic and intrahepatic cholestasis, and concomitant juxtarenal AAA compressing the liver hilum. Following exclusion of other common causes for cholestasis, the patient was considered to have a symptomatic AAA. Open abdominal aortic surgery revealed a contained rupture and was repaired. Obstructive jaundice secondary to a compromising AAA is a rare condition and to the best of our knowledge has not been reported to date.

ObjectiveData on the influence of contralateral carotid occlusion (CCO) on carotid endarterectomy (CEA) are conflicting and are absent for carotid artery stenting (CAS). This study evaluated the influence of CCO on CEA and CAS.MethodsWe evaluated patients with and without CCO in the Society for Vascular Surgery Vascular Registry. Primary outcome was a composite of periprocedural death, stroke, or myocardial infarction (MI) (major adverse cardiovascular events [MACE]) and its individual components. Further analysis was done to identify the influence, if any, of symptom status on outcomes.ResultsThere were 1128 CAS and 666 CEA patients with CCO. CAS patients were more often symptomatic with a greater incidence of coronary artery disease, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and New York Heart Association class >III. Absolute risk of periprocedural MACE (2.7% for CAS vs 4.2% for CEA), death (1.1% for CAS vs 0.7% for CEA), stroke (2.1% for CAS vs 3.1% for CEA), and MI (0.3% for CAS vs 0.6% for CEA) was statistically equivalent for both. This equivalence was maintained when patients with CCO were segregated according to symptom status and after adjusting for periprocedural risk. There were 16,646 patients without contralateral occlusion (5698 CAS; 10,948 CEA). Patients without contralateral occlusion with CEA have better outcomes in periprocedural MACE (1.8% for patients without contralateral occlusion vs 4.2% for patients with CCO), and stroke (1.1% for patients without contralateral occlusion vs 3.1% for patients with CCO) (P < .0001 for both). In CAS patients, CCO did not significantly affect periprocedural MACE (3.2% for patients without contralateral occlusion vs 2.7% for patients with CCO), death (0.8% for patients without contralateral occlusion vs 1.0% for patients with CCO), stroke (2.3% for patients without contralateral occlusion vs 2.1% for patients with CCO), or MI (0.6% for patients without contralateral occlusion vs 0.3% for patients with CCO). In CEA patients, CCO increased MACE, primarily by increasing stroke rates in asymptomatic (0.7% vs 2.0%; P = .0095) and symptomatic (1.7% vs 4.9%; P = .0012) patients.ConclusionsAlthough CEA is preferred in patients without contralateral occlusion, regardless of symptom status, based on lower rates of periprocedural MACE, death, and stroke, the benefit of CEA is lost in patients with CCO because of increased stroke rates in CCO patients after CEA but not after CAS regardless of symptom status. The results of CAS and CEA in patients with CCO are equivalent and within acceptable American Heart Association guidelines.

Background To describe successful endovascular rescue of a prior fenestrated endograft repair of a thoracoabdominal aneurysm that presented with combined type I and type III endoleaks due to aortic stent migration and subsequent visceral stent dislodgement. Method A 67 year old male with significant cardiac dysfunction and chronic renal insufficiency underwent fenestrated endograft repair of a 7 cm type IV thoracoabdominal aneurysm with 4 fenestrations in 2008. He presented with acute onset abdominal pain. CT scan revealed type I and III endoleaks with aneurysm enlargement to 10 cm. Angiography revealed the superior mesenteric and renal artery stents within their target vessels, but separation from their respective fenestrations in the aortic graft with significant gaps (>15 mm) and resultant type 3 endoleaks. The celiac artery stent was fractured; part of it remained within the celiac artery and part within the celiac fenestration and a 30 mm craniocaudal gap between the two pieces. All 4 visceral stents were patent with intact distal flow. A large proximal type 1 endoleak was also seen. All fenestrations were successfully catheterized via percutaneous approach and gaps were successfully bridged with covered stents eliminating the type III endoleaks. A thoracic endograft was placed proximally to repair the type I endoleak. Results Completion angiography demonstrated successful resolution of the type I and type III endoleaks with flow through all 4 branches and tertiary vessels. Conclusion Endovascular rescue of prior branched endografts is a feasible solution in patients at prohibitive risk for open surgery.

Objectifs Nous avons cherche a presenter des options endovasculaire de traitement d’un flux persistant ou recurrent dans le sac anevrismal (« endofuite ») apres exclusion retroperitoneale chirurgicale d’un anevrisme de l’aorte abdominale sous-renale (AAA). Methodes La perfusion recurrente ou persistante d’un anevrisme a ete diagnostiquee chez trois patients initialement traites par exclusion et pontage d’un anevrisme. Les antecedents medicaux, l’evolution de la maladie, et la gestion chirurgicale de ces patients ont ete passes en revue. Resultats Trois patients initialement traites pour AAA sous-renal par section de l’aorte avec fermeture du moignon proximal de l’anevrisme, ligature des arteres d’aval, et pontage du segment aorto-iliaque exclu avait la perfusion persistante ou recurrente et la croissance du sac de l’AAA. Les arteres d’alimentation etaient les arteres iliaques dans tous les cas. Une reparation endovasculaire utilisant l’embolisation par spires et/ou le deploiement d’un occluder ou d’un stentgraft etait reussie chez tous les patients avec un suivi de 42, de 36, et de 30, mois respectivement. Conclusion La reparation ouverte des AAA par exclusion et pontage est associee au risque de perfusion ou de reperfusion persistante du sac anevrismal, qui est semblable a une endofuite apres exclusion endovasculaire d’un anevrisme de l’aorte. Le traitement endovasculaire devrait etre considere celui de premier choix s’il est faisable.

Introduction Mural thrombus of the thoracic aorta is a rare clinical finding in the absence of aneurysm or atherosclerosis. Methods The medical records of all patients diagnosed with a thrombus of a non-aneurysmatic and non-atherosclerotic descending thoracic aorta (NAADTA) and treated by the senior author between 04/1997 and 04/2010 were reviewed. Results Eight patients with mural thrombus of the NAADTA were identified. Arterial embolism was the main clinical finding in all cases and involved the lower extremities ( n = 6), mesenteric ( n = 3) or renal arteries ( n = 2). Hypercoagulable disorders were present in 3 cases and a concurrent malignancy in another 3. Two patients underwent open surgery while 4 patients were treated conservatively with anticoagulation. Of the remaining 2 patients, one was treated with a thoracic stent-graft and aorto-biiliac bypass and the other one with transfemoral thrombectomy. Technical success was achieved in all surgical cases and thrombus resolution or stable disease in the conservative management group. No thrombus recurrence was observed during a mean follow-up of 49 months. Conclusion The management of mural thrombus in NAADTA represents a challenge, especially in case of malignant disease or hypercoagulable disorder as a potential underlying pathology and should be individualized. Although no consensus exists in the literature, therapeutic anticoagulation is proposed as first-line therapy. The indication for surgical intervention results from contraindication to anticoagulation, mobile thrombus or recurrent embolism. Whenever possible, endovascular therapy should be preferred.

Chronic type B aortic dissection is a distinctive condition that needs individual treatment strategies and different considerations than in therapy of acute or subacute type B aortic dissection. The most common indication for treatment of this complex disease is aneurysmal dilatation of the dissected aortic segment. While open repair of the enlarged dissected aorta remains the best option for good-risk patients and patients with connective tissue disorders in high-volume centers with respective expertise, endovascular management of chronic type B aortic dissection with postdissection aneurysms has significantly gained ground in the past years. But the concept of TEVAR with implantation of a tubular stent-graft into the thoracic aorta to seal the proximal entry tear and reroute the blood flow into the true lumen alone, is not associated with satisfactory results. This is mainly due to the sparse remodeling capacity of the aortic tissue compared to earlier stages of the disease as the aortic wall and the dissection membrane are thickened and more rigid. On the other hand, it is restricted by the most limiting factor for endovascular success in chronic type B aortic dissection: persistent false lumen perfusion. This problem also affects patients with residual dissection after surgical repair of a DeBakey type I aortic dissection or dissection after ascending aortic repair for other pathologies. Hence, it is evident that strategies to achieve endovascular false lumen occlusion are of increasing importance and novel techniques have been introduced to solve the problem of persisting false lumen flow. Thus, the evolution of a large variety of techniques to address the false lumen perfusion issue indicates that complicated chronic type B dissection involves a high diversity in clinical presentation and morphology. A large armamentarium of catheter skills as well as critical individualized treatment strategies are required to address the heterogenous morphological disease pattern for each individual patient. The rapid development in endovascular techniques gives new directions for treatment indications and strategies in chronic aortic dissection and enables new insights into this old disease.