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Purpose: To highlight the importance of 3-dimensional (3D) arterial printing in a case of type II endoleak (EL) embolization. Case Report: An 81-year-old patient, previously treated with endovascular aortic repair (EVAR), developed a type II EL requiring treatment. The EL’s main origin was the median sacral artery (MSA). Initial attempts in embolization via a transsealing and transarterial approach were unsuccessful owing to extremely tortuous arterial communications between the left hypogastric artery and the MSA. The construction of a clear resin 3D model of the aorta and iliolumbar arteries improved anatomy understanding and moreover allowed a preoperative simulation. The subsequent transarterial attempt in embolization was resolutive, significantly reducing total procedural time and radiation dose. Conclusion: Printing of clear resin 3D arterial models facilitates type II EL transarterial embolization, improving anatomy understanding and allowing simple fluoroscopy-free simulations. Clinical Impact The aim of our work is to highlight the additional value of three-dimensional (3D) printing during preoperative planning of challenging endovascular cases. To our best knowledge, this is the first report about 3D printing use in a case of type II endoleak (EL). We believe that realizing life-size aortic models in selected cases where a complex type II EL embolization procedure is indicated, could lead to a better understanding of arterial anatomy, thus allowing to increase procedural success and reduce operative and most importantly fluoroscopy time.

We report a case of Kommerell's diverticulum (KD) treated with a total endovascular approach, maintaining supra-aortic trunk (SAT) patency. A 75 year-old female with aneurysmal KD was deemed unsuitable for open surgery. Landing zone 2 was unfeasible; therefore, we planned an endovascular approach with landing in zone 1, chimney to left subclavian artery and periscope to right subclavian artery. Postoperatively she was free from complications, with complete exclusion of KD and SAT patency at 3-year follow-up.

Purpose To evaluate the Covera Plus (Bard, Tempe, Arizona) covered stent as a bridging stent in branched thoraco-abdominal endovascular aneurysm repair (BEVAR). Materials and Methods Retrospective analysis of 112 self-expandable stents was performed at 2 university centers between August 2017 and March 2019. Thirty-one consecutive BEVAR procedures were studied (21 males; mean age, 75 years; 29 American Society of Anesthesiologists grade III/IV) with 119 patent target vessels (7 did not receive the studied device). Primary endpoints were technical success, branch instability, and primary/secondary clinical success. Secondary endpoints included primary/secondary patency and any adverse events. Results Technical success was 100%. Median follow-up was 12 months (interquartile range, 6–14 months). Branch instability was registered twice (2/112), due to immediate renal occlusion and type Ic endoleak; no additional events occurred during the follow-up. Primary clinical success was 84%. There were 2 immediate deaths, 1 upper limb ischemia, 1 hemorrhage from splenic artery, and 1 type Ic endoleak; these last 3 events were successfully treated, with a secondary clinical success of 100% that was maintained during the follow-up. One late death occurred. Primary patency was 99% (111/112) and 100% (105/105) within 30 days and at the end of the study period,respectively. Adverse events included 4 acute kidney injuries and 2 spinal cord ischemia. No type I/III endoleaks, occlusion, fracture, or dislodging were diagnosed after 30 days. Conclusions The stent graft seems safe and effective for bridging in BEVAR with low branch instability and high patency rate. Longer follow-up is required to confirm these promising results.

Background The aim was to describe a single-center experience with the Conformable GORE TAG Thoracic Endoprosthesis (C-TAG) with active control system, specifically designed to evaluate the accuracy of proximal and distal deployment and its capability to adapt to the aortic wall. Methods This is a single-center prospective study including all patients treated with the C-TAG with active control system for thoracic aorta pathologies from September 2017 to May 2018. Proximal and distal accuracy of deployment was measured as the distance between “intended” and “actual landing” zone measured on the digital subtraction angiography images. Mean lack of wall apposition was measured at postoperative computed tomography (CT) angiogram images as the distance between the proximal or distal graft radiopaque ring marker and the point of graft aortic complete apposition, using parasagittal multiplanar reconstructions. Results Eleven cases were treated: 6 atherosclerotic aneurysms (5 descending and 1 arch), 1 dissecting aneurysm, 2 type B acute dissections, 1 thoracic pseudoaneurysm, and 1 Kommerell diverticulum. The proximal deployment was in landing zone 3 in 6 cases (54%), 2 in 2 cases (18%), 1 in 1 case (9%), and 0 in 2 (18%). The distal landing was in zone 4 in 1 case (9%), zone 5 in 9 cases (81%), and in 1 case (9%), it was in zone 6 with intentional coverage of the celiac trunk. Rapid pacing was used only in 2 cases. Mean accuracy of deployment was 1.8 ± 1.3 mm for the proximal and 0.7 ± 1 mm for the distal landing zones. Mean lack of wall apposition was 1.1 ± 1.9 mm at the proximal landing zone and 0.6 ± 1.8 mm at the distal landing zone. Conclusions The C-TAG with active control system offers accurate deployment both at the proximal and at the distal levels. The conformability, staged deployment, and angulation control allow good adaptation to aortic arch and precise deployment.

Background The treatment of residual pathology of the aortic arch after surgical repair for type A acute dissection (AAD) represents a therapeutic challenge. Recently, new branched endovascular devices have expanded the possibility of aortic arch stent-grafting (ASG) with proximal landing in zone 0. The aim of this retrospective, single-center study was to evaluate outcomes of patients with a history of surgical repair for AAD undergoing ASG with branched devices. Methods We analyzed patients undergoing ASG after treatment for type AAD with 2 different branched devices: Nexus (dual-module, single branch, off-the-shelf) and RelayBranch (single-module, dual branch, custom-made). Before ASG, surgical bypass of supra-aortic vessels was performed according to patient's anatomy and to the selected device. All patients underwent clinical and computed tomography scan evaluation before hospital discharge, at 6 months, and on a yearly basis thereafter. Results From March 2017 to April 2019, 4 consecutive patients underwent ASG after surgery for AAD at our institution. Mean time from surgery for AAD to ASG was 20 months. Mean age at the time of ASG was 72 years. Nexus and Relay were implanted in 2 patients each. All patients survived and were successfully discharged. Mean intensive care unit stay and hospital stay were 3 and 19 days, respectively. We did not observe any major adverse events. At a mean follow-up of 28 months, all patients are alive and computed tomography scans showed good anatomic results with no endoleaks. Conclusions This preliminary experience shows that ASG after surgery for AAD is feasible and provides encouraging clinical and anatomic early results., Graphical abstract Results of aortic arch stent grafting after surgery for type A acute aortic dissection with 2 different branched devices: the custom-made, double branch RelayBranch and the single-branch, bi-modular, off-the-shelf Nexus. Each device was implanted in 2 patients. We observed 100% technical success, no major complications, and all patients were alive and in good clinical conditions after a mean follow-up of 28 months.

Objective The objective of this study was to assess early and midterm results after endovascular aortic arch repair using a double inner branch stent graft (DIBSG) in patients with aortic arch aneurysm or dissection unfit for open surgery. Methods Between 2012 and 2018, there were 24 patients with aortic arch disease who were treated with a single model of a DIBSG (Terumo Aortic, Glasgow, United Kingdom) in nine Italian cardiovascular centers. We investigated technical success, mortality, occurrence of major complications, and need for reintervention in a multicenter, nonrandomized, retrospective fashion. Results The in-hospital mortality rate was 16.7%. Cerebrovascular events occurred in 25% of patients and major strokes in 12.5%. Two patients experienced a retrograde dissection (8.3%), whereas none reported any type I or type III endoleak. During a mean follow-up of 18 months (range, 1-60 months), one patient died of a nonaortic cause and one reported a nonarch-related major stroke. No late secondary intervention was needed during the follow-up. Excluding from the analysis the first six patients treated until 2014 as part of the learning curve, in-hospital mortality, major stroke, and retrograde dissection rates were 11.1%, 11.1%, and 5.6%, respectively. Conclusions Endovascular aortic arch repair using this model of DIBSG is feasible, and results are acceptable for a new technique in a high-risk subset of patients. Operative mortality suffers the effect of a learning curve, whereas midterm aorta-related survival is promising. Endovascular repair of aortic arch disease with a DIBSG should always be considered to give high-risk patients a chance of repair. Large-scale studies are needed to assess the long-term durability of this technique.

Objective: The objective of this study was to assess immediate and midterm outcomes for urgent/emergent and elective patients with thoracoabdominal aortic aneurysms (TAAAs) treated with the first commercially available “off-the-shelf“ multibranched endograft for endovascular aneurysm repair, with a single-step or a staged surgical approach. Methods: A multicenter, nonrandomized, retrospective study was conducted of TAAA patients grouped by urgent/emergent and elective treatment with multibranched endograft for endovascular aneurysm repair at 13 Italian centers from November 2012 to August 2016. Urgent/emergent repair was classified as rupture in 16%, impending rupture in 9%, pain in 53%, or a maximum TAAA diameter ≥80 mm in 22%. Study end points were technical success, mortality, spinal cord ischemia, target visceral vessel (TVV) patency, and procedure-related reinterventions at 30 days and at follow-up. Results: Seventy-three patients (274 TVVs) were enrolled. Treatment was performed in elective (n = 41 [56%]) or urgent/emergent (n = 32 [44%]) settings, according to a single-step (n = 30 [41%]) or staged (n = 43 [59%]) approach. Technical success was 92%. Mortality within 30 days was 4% (n = 3 urgent/emergent patients) due to myocardial infarction. Spinal cord ischemia was recorded in two patients (3%; elective group). The primary patency of TVVs was 99% (three renal branch occlusions). Procedure-related reinterventions were required in five cases (7%). At least one adverse event from any cause ≤30 days was registered in 42% (n = 31). At a median follow-up of 18 months (range, 1-43 months), eight (11%) deaths (elective vs urgent/emergent, 2% vs 22%; P = .018), three (1%) cases of branch occlusion or stenosis, and five (7%) reinterventions were recorded. A survival of 88% (standard error [SE], 4%), 86% (SE, 4%), and 82% (SE, 5%) was evidenced at 12, 24, and 36 months, respectively. Urgent/emergent repair and female gender were identified as independent risk factors for all-cause mortality (P < .001 and P = .015, respectively), and the staged approach was identified as protective (P = .026). Freedom from reintervention was 86% (SE, 4%) and 83% (SE, 5%) at 12 and 24 months. Conclusions: The first off-the-shelf multibranched endograft seems safe in both urgent/emergent and elective settings. The staged surgical approach appears to positively influence overall survival. This unique device and its operators will usher in a new treatment paradigm for TAAA repair.

Objectives The aim was to compare outcomes of self expanding PTFE covered stents (CSs) with bare metal stents (BMSs) in the treatment of iliac artery occlusions (IAOs). Methods Between January 2009 and December 2015, 128 iliac arteries were stented for IAO. A CS was implanted in 78 iliac arteries (61%) and a BMS in 50 (49%). After propensity score matching, 94 limbs were selected and underwent stenting (47 for each group). Thirty day outcomes and midterm patency were compared; follow-up results were analysed with Kaplan–Meier curves. Results Overall, iliac lesions were classified by limb as TASC B (19%), C (21%), and D (60%). Technical success was 98%. Comparing CS versus BMS, the early cumulative surgical complication rate (12% vs. 12%, p = 1.0) and 30 day mortality rate (2% vs. 2%, p = 1.0) were equivalent. At 36 months (average 23 ± 17), overall primary patency was similar between CS and BMS (87% vs. 66%, p = .06), and this finding was maintained after stratification by TASC B ( p = .29) and C ( p = .27), but for TASC D, CSs demonstrated a higher patency rate (CS, 88% vs. BMS, 54%; p = .03). In particular, patency was in favour of CSs for IAOs > 3.5 cm in length ( p = .04), total lesion length > 6 cm ( p = .04), and IAO with calcification > 75% of the arterial wall circumference ( p = .01). Conclusions Overall, the use of self expanding CS for IAOs has similar early and midterm outcomes compared with BMS. Even if further confirmatory studies are needed, CSs seem to have higher midterm patency rates than BMSs for TASC D lesions, IAOs with a total lesion length > 6 cm, occlusion length > 3.5 cm, and calcification involving > 75% of the arterial wall circumference. These specific anatomical parameters may be useful to the operator when deciding between CS and BMS during endovascular planning.

Objective The purpose of the study was to evaluate the results of reoperative surgery and carotid artery stenting (CAS) in cases of recurrent carotid artery stenosis (RCS) and to compare the results of all RCS (reoperative surgery + CAS) with primary carotid endarterectomy (CEA) performed during the study period. Summary Background Data Consensus has not yet been established on the best treatment for RCS. Recently CAS has emerged as a potential alternative to carotid endarterectomy. Methods A 6-year (Jan 2000-Dec 2005) prospective study was performed. Eligible patients were those with symptomatic or asymptomatic RCS ≥80% at a preoperative angiography or angio-computed tomography. The carotid plaques were classified at a preoperative ultrasonographic scan, according to the five type classification proposed by Geroulakos (Br J Surg 1993;80:1274-7). Patients with type 1 and 2 carotid plaque were not considered for CAS. Results 56 patients were enrolled. Fifteen patients with a type 1-2 plaque underwent reoperative surgery, 41 with type 3-4 plaque underwent CAS. In 90.6% of primary closure a type 3-4 carotid plaque was found; a type 1-2 was observed in 84.5% of the polytetrafluoroethylene patch closure group. No statistical difference for the 30-day and the 6 year stroke-free rate was observed; similarly no differences emerged between all RCS (reoperative surgery + CAS) performed and primary CEA. Conclusions CAS is an acceptable alternative to surgery in the management of RCS. An accurate patient selection is required. Restenosis after CEA and direct closure is mostly associated with fibrous material. In these cases CAS might be the best choice.

PurposeThe aim of this prospective randomized study was to evaluate the relative risks and advantages of using the Hemobahn graft for popliteal artery aneurysm (PAA) treatment compared with open repair (OR). The primary end point was patency rate; secondary end points were hospital stay and length of surgical procedure.MethodsThe study was a prospective, randomized clinical trial carried out at a single center from January 1999 to December 2003. Inclusion criteria were an aneurysmal lesion in the popliteal artery with a diameter ≥2 cm at the angio-computed tomography (CT) scan, and proximal and distal neck of the aneurysm with a length of >1 cm to offer a secure site of fixation of the stent graft. Exclusion criteria were age 120°) at 6 and 12 months, and then yearly.ResultsBetween January 1999 and December 2003, 30 PAAs were performed: 15 OR (group A) and 15 ET (group B). Bypass and exclusion of the PAA was the preferred method of OR; no perioperative graft failure was observed. Twenty stent grafts were placed in 15 PAAs. Endograft thrombosis occurred in one patient (6.7%) in the postoperative period. The mean follow-up period was 46.1 months (range, 12 to 72 months) for group A and 45.9 months (range, 12 to 65 months) for group B. Kaplan-Meier analysis showed a primary patency rate of 100% at 12 months for OR and 86.7% at 12 months with a secondary patency rate of 100% at 12 and 36 months for ET. No statistical differences were observed at the log-rank test. The mean operation time (OR, 155.3 minutes; ET, 75.4 minutes) and hospital stay (OR, 7.7 days; ET, 4.3 days) were statistically longer for OR compared with ET (P < .01).ConclusionWe can conclude, with the power limitation of the study, that PAA treatment can be safely performed by using either OR or ET. ET has several advantages, such as quicker recovery and shorter hospital stay.

ObjectiveThis single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center.MethodsFrom January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was 60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up.ResultsThirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter