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The use of chimney technique in endovascular repair of abdominal aortic aneurysms (ChEVAR) has had a secondary role. Although it was first developed in an emergent/urgent setting, the publication of various important studies has helped overcome scepticism towards this technique in elective procedures. This paper reviews current evidence about ChEVAR, focusing on clinical results, technical notes and comparisons with other techniques. The new ChEVAR findings show favourable mid- and long-term clinical outcomes, even in elective patients. These results, comparable to those related to fenestrated endografts, have been achieved through standardisation in planning and materials. An adequate endograft oversizing associated to the right aortic neck length is fundamental to avoid ChEVAR-related complications, such as type 1a endoleaks. These data indicate that ChEVAR, compared to other complex endovascular treatments, has comparable outcomes along with features that could make it an essential option in every clinical setting.

Objective: Management of antithrombotic therapy in patients undergoing elective fenestrated branched endovascular aortic repair (F-BEVAR) is not standardised, nor are there any recommendations from current guidelines. By designing an international expert based Delphi consensus, the study aimed to create recommendations on the pre-, intra-, and post-operative management of antithrombotic therapy in patients scheduled for elective F-BEVAR in high volume centres.Methods: Eight facilitators created appropriate statements regarding the study topic that were voted on, using a four point Likert scale, by a selected panel of international experts using a three round modified Delphi consensus process. Based on the experts’ responses, only those statements reaching Grade A (full agreement ≥ 75%) or B (overall agreement ≥ 80% and full disagreement < 5%) were included in the final document. The round answers’ consistency was graded using Cohen's k, the intraclass correlation coefficient, and, in case of double re-submission, the Fleiss k.Results: Sixty-seven experts were included in the final analysis and voted the initial 43 statements related to pre- (n = 15), intra- (n = 10), and post-operative (n = 18) management of antithrombotic drugs. At the end of the process, six statements (13%) were rejected, 20 statements (44%) received a Grade B consensus, and 18 statements (40%) reached a Grade A consensus. Most statements (27; 71%) exhibited very high or high consistency grades, and 11 (29%) a fair or poor grading. The intra-operative statements mostly concentrated on threshold for and monitoring of proper heparinisation. The pre- and post-operative statements mainly focused on indications for dual antiplatelet therapy and its management, considering the possible need for cerebrospinal fluid drainage.Conclusion: Based on the elevated strength and high consistency of this international expert based Delphi consensus, most of the statements might guide current clinical management of antithrombotic therapy for elective F-BEVAR. Future studies are needed to clarify the debated issues.

In this clinical vignette, we present the case of an 83-year-old female patient with acute limb ischemia, resulting from a large (1.8 × 2.8 cm) mobile thrombus in the descending aorta. The peripheral obstruction was treated with mechanical thrombectomy, whereas the intra-aortic thrombus was treated conservatively with clopidogrel and fondaparinux. (Level of Difficulty: Beginner.).

Summary: Background: Ruptured juxtarenal aortic aneurysms (RJAAA) represent a special challenge in clinical practice, but the evidence to guide therapeutic decision-making is scarce. The aim of this study was to present two different approaches, open surgical (OAR) and chimney endovascular repair (CHEVAR), for treating patients with RJAAA. Patients and methods: This retrospective two-center study included all patients per center undergoing OAR or CHEVAR for RJAAA between February 2008 and January 2020. Juxtarenal aortic aneurysms were defined as having an infrarenal neck of 2–5 mm, measured after three-dimensional reconstruction of the computed tomography angiography scan. Results: 12 OAR patients (10 male, median age 73 years [58–90 years]) and 6 CHEVAR patients (all male, median age 74 years [59–83 years]) were included. In the OAR group, the proximal aortic clamping was suprarenal in 7 and interrenal in 5 patients. Cold renal perfusion was used in 4 patients, in 2 with suprarenal aortic clamping and in 2 with interrenal aortic clamping. 3 CHEVAR patients received a single renal chimney, the other 3 received double renal chimneys. Technical success was 12/12 in the OAR group 5/6 in the CHEVAR group. In-hospital mortality and 30-day mortality were 3/12 after OAR and 0/6 after CHEVAR. 2 OAR patients required transient dialysis. Median in-hospital stay was 14 (10–63) and 8 (6–21) days and median follow-up (FU) was 20 (3–37) and 30 (7–101) months, respectively. No further deaths occurred during FU. One OAR patient and 4 CHEVAR patients required aortic reinterventions. Conclusions: RJAAAs are rare. Both OAR and CHEVAR can represent adequate treatments for RJAAAs. OAR is the traditional approach, but CHEVAR has - in a high-volume center - promising early results with nonetheless a need for continuous FU to prevent reinterventions. Defining the studied aortic pathology precisely is essential for future research in order to draw valid conclusions.

Background: Treatment of calcified popliteal artery lesions represents an ongoing challenge for vascular specialists. Biomechanical forces of external compression, torsion and elongation that occur with locomotion in the popliteal segment can lead to stent fractures and occlusions. The aim of our study was to assess the procedural success rate of atherectomy in combination with balloon angioplasty for isolated calcified popliteal artery lesions. Methods: Between January 2020 and December 2022, 62 patients with isolated atherosclerotic lesions of the popliteal artery underwent endovascular treatment by use of rotational atherectomy (Phoenix, Philips USA, (subgroup A) or Jetstream, Boston USA, (subgroup B), atherectomy systems) and additional balloon angioplasty in two vascular centers. The primary outcome measures were: 1. periprocedural clinical and technical success (

Background/Objective To evaluate the safety and utility of a new in Europe intravascular ultrasound (IVUS) catheter in a case of peripheral arterial disease caused by in-stent restenosis of the superficial femoral artery. Method Pre-therapeutic computed tomographic angiography identified severe stent restenosis related to device underexpansion, which was caused by an underlying eccentric severely calcified stenosis leading to suboptimal device deployment. The OptiCross 18 (30 MHz Peripheral Imaging Catheter, Boston Scientific, USA) is a short rail imaging catheter. It consists of two main assemblies: The imaging core is composed of a hi-torque, flexible, rotating drive cable with a radial looking 30 MHz ultrasonic transducer at the distal tip. An electro-mechanical connector interface at the proximal end of the catheter makes the connection to the Motordrive Unit (MDU5 PLUSTM) Instrument. The MDU5 PLUS-catheter interface consists of an integrated mechanical drive socket and electrical connection. Results The use of the IVUS-guided imaging revealed in-stent restenosis, fracture, and protrusion of the calcified plaque in the stent and confirmed the preoperative computed tomography angiography which showed stent compression. Use of intravascular litotripsy catheter (intravascular lithotripsy Shockwave Medical, Santa Clara, California) and drug coated balloon led to improvement in stent expansion, having minimal patent diameter of 5.77 mm. The patient’s subsequent clinical course was uneventful, and clinically had palpable pulses in the foot and ankle-brachial index of 1. Conclusions Whether acoustic pulse application might affect device structure in the long term remains to be determined, use of the novel IVUS system demonstrated excellent visibility of the etiology of the in-stent restenosis improving the perioperative diagnostic modalities of suboptimal endovascular outcome.

Objectives Endovascular therapy using balloon expandable stents has become the treatment standard for most iliac atherosclerotic lesions. We aimed to assess the safety and performance of the Dynamic stainless-steel balloon-expanding stent system in this location. Methods BIODYNAMIC is a retrospective single center study including consecutive patients with iliac lesions treated with the Dynamic stent system. Not included were implantations inside an endograft. The primary endpoint was freedom from major adverse limb events (MALE) at 12 months, defined as index limb amputation or target lesion revascularization (TLR). Secondary endpoints were procedure success, ankle brachial index (ABI) and Rutherford class change, mortality and freedom from TLR after 12 months. Results Within two years, 182 patients with 234 lesions in the common iliac artery were enrolled. Rutherford class 5 and 6 were present in 11.5% of patients, average stent diameter was 8.0 ± 0.5 mm and stented length 40.0 ± 15.3 mm. The primary endpoint was reached in 96.2% (225/234) of the cases, with six TLR (2.6%) and three target limb amputations (1.3%). Procedure success was obtained in all but three patients (98.4%). In paired analysis, ABI improved by 0.25 ± 0.21 from baseline to 0.90 ± 0.16 post-procedure and Rutherford class improved by −1.75 ± 1.53. There were four non-device–related deaths (2.2%). Freedom from TLR was 97%, 95.3%, 94% and 92.7% at 24, 36, 48 and 60 months, respectively. Conclusion The Dynamic balloon-expandable stent system proved to be safe and effective in a population with common iliac artery lesions.

Purpose: To evaluate if the elderly could benefit from the implantation of iliac branch devices (IBDs) to preserve the patency of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation. Materials and Methods: From January 2005 to April 2017, 804 patients enrolled in the pELVIS registry underwent endovascular aneurysm repair with 910 IBDs due to aneurysmal involvement of the iliac bifurcation. Among the 804 patients, 157 (19.5%) were octogenarians (mean age 82.9±2.5 years; 157 men) with 171 target IIAs for preservation. Outcomes at 30 days included technical success, death, conversion to open surgery, and major complications. Outcomes evaluated in follow-up were patency of the IBD and target vessels, type I and type III endoleaks, aneurysm-related reinterventions, aneurysm-related death, and overall patient survival. Kaplan-Meier analyses were employed to evaluate the late outcome measures; the estimates are presented with the 95% confidence interval (CI). Results: Technical success was 99.4% with no intraoperative conversions or deaths (1 bridging stent could not be implanted, and the IIA was sacrificed). Perioperative mortality was 1.9%. The overall perioperative aneurysm-related complication rate was 8.9% (14/157), with an early reintervention rate of 5.1% (8/157). Median postoperative radiological and clinical follow-up were 21.8 months (range 1–127) and 29.3 months (range 1–127), respectively. Estimated rates of freedom from occlusion of the IBD, the IIA, and the external iliac artery at 60 months were 97.7% (95% CI 96.1% to 99.3%), 97.3% (95% CI 95.7% to 98.9%), and 98.6% (95% CI 97% to 99.9%), respectively. Estimated rates of freedom from type I and type III endoleaks and device migration at 60 months were 90.9% (95% CI 87% to 94.3%), 98.7% (95% CI 97.5% to 99.8%), and 98% (95% CI 96.4% to 99.6%), respectively. Freedom from all cause reintervention at 60 months was 87.4% (95% CI 82.6% to 92.2%). The estimated overall survival rate at 60 months was 59% (95% CI 52.4% to 65.6%). Conclusion: IBD implantation in octogenarians provided acceptable perioperative mortality and morbidity rates, with satisfying long-term freedom from IBD-related complications and should be considered a feasible repair option for selected elderly patients affected by aneurysms involving the iliac bifurcation.

Objective Endovascular aneurysm repair has gained field over open surgery for the treatment of abdominal aortic aneurysm. However, type Ia endoleak represents a common complication especially in hostile neck anatomy that is recently faced using endoanchors. We conducted a systematic review and meta-analysis to collect and analyse all the available comparative evidence on the outcomes of the endosuture aneurysm repair in patients with or without hostile neck in standard endovascular aneurysm repair. Methods The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the prospective and retrospective studies reporting primary use of the Heli-FX EndoAnchor implants were considered eligible for inclusion in this study. The main study outcomes (technical success of endoanchor implantation, incidence of type Ia endoleak, aortic stent graft migration and the percentage of patients who presented regression or expansion of aneurysm sac throughout the follow-up) were subsequently expressed as proportions and 95% confidence intervals. Results Eight studies with a total of 968 patients were included in a pooled analysis. The technical success of the primary endoanchor fixation was 97.12% (95%CI: 92.98–99.67). During a mean six months follow-up period, a pooled rate of 6.23% (95%CI: 0.83–15.25) of the patients developed a persistent type Ia endoleak despite the primary implantation. Migration of the main graft was reported in five studies, in which a 0.26% (95%CI = 0.00–1.54) of the patients required an additional proximal aortic cuff. Regression of the aneurysm sac was observed at 68.82% (95%CI: 51.02–84.21). An expansion of the aneurysm sac was found in 1.93% (95%CI: 0.91–3.24) of the participants. The overall survival rate was 93.43% (95%CI: 89.97–96.29) at a mean six months follow-up period. Conclusions Endosuture aneurysm repair with the Heli-FX EndoAnchor implants seems to be technically feasible and safe either for prevention or for repair of intraoperative type Ia endoleak. Despite the primary implants of endoanchors, few cases of persistent type Ia endoleak and migration are still conspicuous. Long-term follow up is needed to determinate the role of this therapeutic option in the treatment of aortic aneurysms.

Extrakranielle Aneurysmen der A. carotis sind sehr selten. Aufgrund des thrombembolischen Risikos sowie der Rupturgefahr besteht haufig die Indikation zur operativen Versorgung. Ziel dieser Arbeit ist es, eine Ubersicht uber die verschiedenen Ursachen und den damit verbunden Therapieoptionen des Karotisaneurysmas unter Berucksichtigung des aktuellen Wissensstands zu geben. Literaturrecherche in Medline (PubMed) mit den Schlusselwortern „extracranial carotid artery aneurysm“, „pseudoaneurysm of carotid artery“ fur Publikationen der letzten 25 Jahre. Die Atiologie des Karotisaneurysmas ist ein wichtiger Faktor fur die spatere Lokalisation und dessen Ausdehnung sowie fur die nachfolgende operative Therapie. Arteriosklerotische Wandveranderungen werden als hauptursachlich fur Aneurysmen der proximalen A. carotis interna gewertet, gefolgt von Postdissektionsaneurysmen und Pseudoaneurysmen nach Thrombendarteriektomie und Patchplastik der A. carotis. Symptomatische Aneurysmen stellen eine dringende Operationsindikation dar, wahrend symptomfreie Aneurysmen mit begleitender oraler Antikoagulation oder dualer Thrombozytenaggregation des Patienten zunachst duplexsonographisch kontrolliert werden konnen. Eine erganzende Bildgebung mittels CT- oder MR-Angiographie hilft bei der Eingriffsplanung. „Golden standard“ ist die offene chirurgische Resektion bei geringem intraoperativen Schlaganfallrisiko (0–2 %) und akzeptablem intraoperativen Nervenverletzungsrisiko (1–7 %) mit anschliesender Rekonstruktion mittels Venen- oder Kunststoffinterponat. Vor allem fur weit kranial gelegene Aneurysmen der A. carotis interna, multimorbide Patienten oder bei narbig verandertem Operationsgebiet ist die endovaskulare Therapie mittels Stenting oder Coil-Embolisation eine Alternative. Postoperativ empfiehlt sich eine lebenslange Thrombozytenaggregationshemmung und bei Stenting die duale Plattchenhemmung analog zur CAS. Das gewahlte Therapiekonzept des extrakraniellen Karotisaneurysmas bleibt eine Einzelfallentscheidung. Bevorzugt wird das Aneurysma reseziert und durch autologes Venenmaterial oder ein Kunststoffinterponat ersetzt. Bei schwierigen anatomischen Verhaltnissen, wie z. B. schadelbasisnahen Aneurysmen, kann eine endovaskulare Intervention, z. B. die Stentgraft-Versorgung oder die Coil-Embolisation als Alternative erwogen werden.

Objective Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR. Methods Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery. Results Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18 months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5 mm; p = 0.059), iliac diameter (7.3 vs 7.1 mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0 mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37 mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67 mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7 mm3; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71). Conclusion Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.

There appears to be an association between paclitaxel-coated devices and increased 5-year all-cause mortality.We are conducting a prospective, randomized, controlled, single-center, noninferiority study. All consecutive patients with femoropopliteal arterial disease who fulfilled the inclusion/exclusion criteria are sequentially and consecutively assigned to either paclitaxel (Ranger, Boston Scientific) or sirolimus (MagicTouch, Concept Medical) coated balloon angioplasty treatment. The primary outcome are procedural success and primary vessel patency at index procedure. The secondary outcomes are 30-day and 12-month freedom from MAEs (amputation, death, TLR/TVR, MI, distal embolization that requires a separate intervention or hospitalization), procedural success (≤30% residual diameter stenosis or occlusion after the procedure), Rutherford category improvement (reduction ≤1 category) and ABI improvement (increase ≥0.10 from baseline).A total of six patients have been enrolled in the present study up to now. The mean age was 72.6 years old and five were male. All patients had angiographic evidence of isolated occlusion in the transition segment of the distal femoral superficial artery in the popliteal artery. The mean length was 109 mm. Three patients were treated by sirolimus-coated (group A) and three by paclitaxel coated balloon angioplasty (group B). The primary patency and procedural success was in two of three and three of three patients, for group A and B, respectively.Preliminary results show safety and feasibility of the Sirolimus-coated balloon angioplasty. Further investigation and increase of sample size will allow for more sustained conclusions regarding patency and procedural success of this type of balloons for the endovascular treatment of peripheral arterial disease.

The purpose of this study was to define patient and anatomical factors associated with technical results specific to rotational atherectomy. Controversy exists surrounding appropriate utilization of atherectomy to treat femoral-popliteal atherosclerosis. Importantly, the existence of different atherectomy devices and lack of technical reports highlighting variables that impact outcomes obscures the ability to assess perioperative performance.The nonindustry sponsored, Multicentric National Registry on the use of rotational atherectomy in femoral-popliteal occlusive atherosclerotic disease (MORPHEAS) database was queried. The MORPHEAS investigators included experienced providers at four centers who previously had not utilized rotational atherectomy. The primary endpoint was flow-limiting dissection and/or50% recoil resulting in stent-placement while a secondary endpoint included peripheral thromboembolism incidence.One hundred thirteen patients were enrolled. Only femoropopliteal occlusions were included in the analysis and anatomic distribution and calcification severity were depicted separately. The most common adjunctive therapy was drug-coated balloon angioplasty (84%; N.=96). Flow-limiting dissection was identified in 16% (N.=18) and thromboembolism occurred in 4% (N.=4). Diabetes increased risk of thromboembolism (P=0.03) while lesion length ≥8.0 cm (P=0.07) and SFA-popliteal adductor canal location (P=0.01) were associated with flow-limiting dissection. In multivariable analysis, SFA-popliteal adductor canal occlusion had a 4.7-fold risk of perioperative complications (OR=4.7, 95%CI: 1.1-21.0; P=0.04).Rotational atherectomy was characterized by reproducible performance among four centers; however, diabetic patients, as well as those with long-segment, heavily calcified SFA-popliteal adductor canal occlusion present greatest risk of complications.

Objective: To identify and analyze the published in vitro benchtop experiments for the assessment of endovascular techniques used for the treatment of juxtarenal abdominal aortic aneurysms (jAAAs). Data sources: Scopus, PubMed, and Web of Science. Review methods: A systematic literature search was carried out throughout March 2021 following PRISMA guidelines. Two investigators independently performed title and abstract screening to reveal all benchtop testing evaluating the endovascular treatment of jAAA. Results: A total of 19 studies were included, 8 evaluating fenestrated (FEVAR) and 11 parallel grafts (PGs). FEVAR studies used different custom testing apparatus (n=7) or 3D-printed models (n=1) to analyze dislodgement and migration resistance, misalignment consequences and causation, and bridging stents’ radial force, flareability, fatigue, and fracture resistance. All PG studies used silicone-based models to analyze optimal oversizing, sealing length, gutter behavior, and possible reduction. Test evaluation in FEVAR in vitro testing was based on pullout force analysis (N=5), photo evaluation (n=1), fluoroscopy (n=1), X-rays (n=4), CT analysis (n=3), macro- and microscopic evaluation (n=4), water permeability (n=1), and fatigue simulator testing (n=1), while it was based on CT analysis in all PG studies adding ECG-gate in one study. The most frequently tested devices were Zenit (Cook) (n=7), Endurant (Medtronic) (n=5), and Excluder (Gore) (n=5) as main grafts, and Advanta V12 (n=14) as the bridging device. Conclusions: This systematic review presents a broad analysis of the current in vitro methods evaluating the endovascular treatment of jAAA. Fundamental issues have been benchtop tested in both FEVAR and PGs. The analysis of the included studies allowed to recommend an optimal testing design. In vitro testing is a potential tool to further elucidate points of attention hard to investigate in vivo to finally enhance the endovascular treatment outcomes. Future in vitro studies are needed to evaluate the in vitro performance of all indistinctively used devices in the clinical practice.

Purpose Chimney endovascular abdominal aortic aneurysm repair (CHEVAR) has predominantly been described as an alternative technique for the management of urgent presentations of degenerative pararenal aortic aneurysms (dPAAs). However, the role of CHEVAR in the treatment of asymptomatic patients remains unknown. The aim of current multinational study was to evaluate the outcomes of elective CHEVAR of dPAAs. Material and Methods Retrospective analysis of 267 consecutive dPAA patients treated with elective CHEVAR at 13 European and US centers from 2008 to 2014. Primary endpoints were 30 days and out of hospital CHEVAR-related mortality. Secondary endpoints included persistent type Ia endoleak or endotension, angiographically confirmed occlusion and/or high-grade chimney graft (CG) or involved splanchnic vessel stenosis identified at index procedure and/or during follow-up, as well as CHEVAR-related re-intervention. Results Mean follow-up time was 25.5±13.3 months. The 442 visceral vessels were involved and mean number of CGs per patient was 1.63±0.7. 436 targeted vessels were successfully cannulated. The aortic graft intentionally covered 6 renal arteries and immediate technical success was 98.6%. The 30 days mortality was 1.9% (n=5), while the in-hospital complication rate was 10.1% (n=27) including 3 strokes, 1 permanent dialysis, and 1 intestinal ischemia. No 30 day type Ia endoleaks were detected and 3.2% of CGs (n=14, including the intentionally covered) had evidence of occlusion and/or stenosis. The overall CHEVAR-related mortality was 2.2% (n=6). Freedom from primary and secondary type Ia endoleak/endotension rates at 3 years was 93.0% and 98.0%, respectively. Primary and secondary CG patency was 87.0% and 89.0%. Primary and secondary endovascular freedom from any endpoint at 3 years was 81.0% and 94.0% respectively. Conclusion Elective use of CHEVAR in the management of dPAAs seems to be durable. These results are comparable to published outcomes with other total endovascular strategies, which justifies an expanded role for CHEVAR in the treatment of asymptomatic patients presenting with dPAAs.

Many patients with peripheral arterial disease (PAD) exhibit undiagnosed obstructive coronary artery disease. We aim to identify the patients with lifestyle limiting claudication due to PAD and without cardiac symptoms, requiring coronary revascularization based on high-sensitive troponin T (hsTnT) values. We assessed hsTnT in consecutive patients referred for elective endovascular treatment due to claudication [Rutherford categories (RC) 2 & 3] between January 2018 and December 2021. Diagnostic work-up by non-invasive imaging and, if required, cardiac catheterization was performed according to clinical data, ECG findings and baseline hsTnT. The occurrence of cardiac death, myocardial infarction or urgent revascularization during follow-up was the primary endpoint. Of 346 patients, 14 (4.0%) exhibited elevated hsTnT ≥ 14 ng/L, including 7 (2.0%) with acute myocardial injury by serial hsTnT sampling. Coronary revascularization by percutaneous coronary intervention was necessary in 6 of 332 (1.5%) patients with normal versus nine of 14 (64.3%) patients with elevated hsTnT (p < 0.001). During 2.4 ± 1.4 years of follow-up, 20 of 286 (7.0%) patients with normal versus four of 13 (30.8%) with elevated hsTnT at baseline reached the composite primary endpoint (p = 0.03 by log-rank test). In conclusion, elevated troponins in cardiac asymptomatic patients with claudication modify subsequent cardiac management and may increase the need for closer surveillance and more aggressive conservative management in polyvascular disease.

Purpose: To compare balloon-expandable covered stents (BECS) available for use as renal chimney grafts to the Advanta V12 approved for use with the Endurant endograft. Materials and Methods: A silicone model was manufactured based on preoperative computed tomography angiography (CTA) scans of a patient with a 7-cm juxtarenal aneurysm treated with an Endurant bifurcated endograft and an Advanta V12 covered stent for the 6-mm-diameter right renal artery. The model was placed in a flow box filled with a 37°C blood-mimicking solution equipped with a pulsatile pumping system (140/60 mm Hg). The tested BECS were the Advanta V12, the VBX, and the BeGraft+. A 36-mm-diameter Endurant II endograft with a 16-mm-diameter contralateral limb and a 6×59-mm BECS chimney graft were used in 9 consecutive tests (3 for each combination). After each implantation, the model was placed in the CT scanner, and 2 radiologists blinded to the test device independently measured the gutter areas and the patent chimney graft lumen at the level of the Endurant’s suprarenal stent, at the level of the chimney’s maximum curvature, and 10 mm inside the renal artery. The intraclass correlation coefficients (ICC) were calculated to assess interreader reliability. Results: The mean gutter areas were 19.3±7, 20.2±8, and 22.3±8 mm2 for the Advanta, VBX, and BeGraft+, respectively (all p>0.05). At the level of the aortic endograft’s suprarenal stent struts, the mean diameter of the Advanta V12, VBX, and BeGraft+ were 4.46±0.3, 4.12±0.4, and 4.12±0.3 mm, respectively (all p>0.05). At the level of the maximum chimney graft angulation, the mean diameters were 3.77±0.3, 4.16±0.1, and 3.74±0.3 mm, respectively (all p>0.05). In the right renal artery, the mean diameters were 3.91±0.2, 4.05±0.9, and 4.3±0.4 mm, respectively (all p>0.05). The ICCs varied between 0.7 and 0.9, indicating good agreement between readers. Conclusion: These in vitro findings showed comparable results between the Advanta V12 and the available BECS used in conjunction with the Endurant endograft according to the instructions for use. Further clinical evaluation is needed to confirm these results.

Objectives Leriche syndrome, defined as a chronic obliteration of a segment of the infrarenal aorta and the iliac arteries, represents a challenging pathology. Surgical reconstruction represents the standard treatment option. However, the endovascular therapy is gaining ever greater applicability in several vascular territories comparable with the open repair results. The aim of the present study was to evaluate the role of endovascular repair in patients with chronic Leriche syndrome. Methods Between January 2008 and September 2016, 82 patients with Leriche syndrome underwent surgical and endovascular repair at two European vascular centers. After risk stratification, 40 patients were matched based on chronic TASC D obstructive arterial disease with involvement of the aortic bifurcation and bilateral iliac arteries, the age, and the cardiovascular risk factors identifying finally 20 patients who underwent surgical repair (open group) and 20 patients who were treated by deployment of stents/stent-grafts in the aortic and iliac segment (endo group). Kaplan–Meier estimation for patency and freedom from reintervention were calculated and univariate analyses were performed. Results Estimated primary patency rate was 100% vs. 84% at one year for the open group vs. endovascular group, respectively ( p = .05). Freedom from reintervention was 100% vs. 89% at one year for the open group vs. endo group ( p = .09). During the entire follow-up of 34.9 ± 23.1 months, five reinterventions were performed for the endo group vs. two for the open group ( p = .212). Additionally, the major adverse cardiac and cerebrovascular events were 5/20 vs. 2/20 for the endovascular vs. open group, respectively ( p = .212). The postoperative ankle–brachial index improved in 0.66 in the endo group vs. 0.71 in the open group ( p = .624). Conclusions Endovascular techniques for the treatment of complex chronic Leriche lesions seem not to be associated with better early or mid-term outcomes compared to surgical repair.

Objective Data in literature suggest iliac artery dilatation and endograft retraction as complications after endovascular aneurysm repair. However, mainly older generation endografts were included. Therefore, we sought to evaluate the distal sealing zone chronological changes after endovascular aneurysm repair with newer generation stent-grafts. Methods Clinical and radiological data of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair between January 2010 and December 2013 were reviewed. Measurements were made using volumetric reconstructions in the first and last available computed tomography angiography. Endpoints of the study were the presence of iliac dilatation and retraction of the endograft. Association with distal oversizing and sealing length was analyzed. Results Consecutive patients with a total of 52 common iliac arteries were included in the study (mean age 74.9 ± 6.8 years, four women (7.7%)). The mean follow-up was 3.1 years. The mean iliac diameter increased from 15.5 to 17.1 mm ( p Conclusion Iliac dilatation and endograft limb retraction are common findings after endovascular aneurysm repair despite the use of new generation endografts. Optimizing the iliac sealing length and meticulous computed tomography angiography surveillance are recommended especially in case of use ≥24 mm iliac stent-grafts to prevent possible complications.

Introduction The aim was to describe possible management of a persistent gutter related type Ia endoleak after treatment of a symptomatic pararenal aortic aneurysm with the chimney endovascular technique. Report A 77 year old man with a symptomatic 6 cm pararenal aortic aneurysm was referred. Computed tomography angiography (CTA) showed a pararenal aortic aneurysm with involvement of both renal arteries and extension up to the superior mesenteric artery. The patient underwent treatment by placement of triple chimney grafts and an abdominal stent graft. Completion angiography showed a gutter related type Ia endoleak. As the type Ia endoleak persisted at the three month CTA follow up and according to the PERICLES registry classification of endoleaks, a type B causative mechanism was detected. Embolization of the gutters was performed with coils and onyx, leading to complete resolution of the gutters on completion angiography. The 10 month post-operative magnetic resonance angiogram showed no further evidence of any endoleak and complete exclusion of the aneurysm. Conclusion Treatment of persistent type B gutter related endoleaks after triple chimney endovascular aneurysm repair can be performed with the placement of coils and adjunctive use of fluid agents., Highlights • A 15 mm sealing zone and 30% oversizing are crucial in chimney EVAR (Ch-EVAR) to avoid endoleaks. • Most gutter related endoleaks after Ch-EVAR will resolve spontaneously. • When an endoleak appears, conservative management is reasonable. • Gutter embolization is recommended if a type Ia endoleak persists after three months.

Objectives To collect and analyse the available evidence in the outcomes of patients treated with fenestrated endovascular aortic repair (f-EVAR) technique focusing specifically on visceral vessel outcomes. Methods The current meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All the studies reporting the f-EVAR technique for the management of degenerative pararenal and/or type IV thoracoabdominal aortic aneurysms (TAAA) were considered eligible for inclusion in the study. The main study outcomes (technical success, type I endoleaks, fracture or occlusion of the bridging stents, overall aneurysm-related mortality, and the reintervention rate) were subsequently expressed as proportions and 95% confidence intervals. Results Fourteen studies with a total of 1804 patients were included in a pooled analysis. The technical success of the procedure was 95.97% (95%CI = 92.35–98.60). Intraoperatively, the pooled proportion of reported type I endoleak was 7.6% (95%CI = 2.52–14.60) while during a median follow-up of 41 months (range 11–96) follow-up period the pooled rate of fracture and occlusion of the bridging stents was 2.79% (95%CI = 0.00–8.52) and 4.46% (95%CI = 1.93–7.77), respectively. The overall aneurysm-related mortality was detected to be 0.63% (95%CI = 0.04–1.63), and the pooled estimate for re-intervention rate was 15.69%. Conclusions Fenestrated endovascular repair for p-AAA is an effective and safe treatment. Target vessel complications and endoleaks remain the two most important concerns for fenestrated endovascular procedures, contributing to most of the secondary interventions. The lack of computed tomography angiography follow-up evaluation does not allow us to draw robust conclusions about the complication rates for the superior mesenteric artery during f-EVAR. Due to the potential implications of SMA complications on aneurysm-related mortality, standardized reporting of short- and long-term target visceral vessel outcomes is required.

OBJECTIVES The aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures. METHODS Non-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010–1 August 2020. RESULTS Current general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR. CONCLUSIONS The overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.

Objective In the treatment of pararenal abdominal aortic aneurysms and aortic pathologic processes, chimney endovascular aneurysm repair (CHEVAR) represents an alternative technique for urgent cases. The aim of the study was to evaluate the outcomes of CHEVAR in the elective setting. Methods We performed a retrospective analysis of prospectively collected records of 165 consecutive asymptomatic CHEVAR patients who were treated between March 2009 and January 2018 with the Endurant stent graft (Medtronic, Santa Rosa, Calif). A total of 244 chimney grafts (CGs) were implanted. The primary end point was clinical success, defined as freedom from procedure-related mortality, persistent type IA endoleak, occlusion or high-grade stenosis (>70%) of CGs, and any chimney technique-related secondary procedure for the entire follow-up period. Secondary clinical success included patients with successful treatment of a primary end point with a secondary endovascular procedure. Results All 244 targeted chimney vessels were successfully cannulated. Total perioperative morbidity was 7.8% (n = 13), including 3 (1.8%) cases of bowel ischemia, 1 (0.6%) patient with renal ischemia, and 1 patient (0.6%) with stroke. Median follow-up was 25.5 ± 2.2 months. Both 30-day and follow-up procedure-related mortality rates were 1.8% (n = 3). Primary and secondary freedom from persistent type IA endoleak rates were 96.4% (n = 159) and 99.4% (n = 164), respectively. Primary and secondary CG patency rates were 92.2% (n = 225) and 95.9% (n = 234), respectively. The rate of reinterventions related to the chimney technique was 10.9% (n = 18), and 83.3% of them were performed by endovascular means. The estimated cumulative primary patency and freedom from persistent type IA endoleak were 87.5% and 95.3%, respectively, and the primary and secondary clinical successes rates at midterm were 80.3% and 87.5%, respectively. Conclusions The elective use of CHEVAR with the Endurant stent graft in our series showed favorable midterm clinical results, which are similar to the published results of other total endovascular modalities. A prospective randomized trial of elective treatment of pararenal abdominal aortic aneurysms and aortic pathologic processes with current endovascular options is needed to assess the value of CHEVAR in the elective setting.

Background A considerable number of patients with abdominal aortic aneurysms (AAA) is not eligible for standard endovascular repair. These complex cases require alternative surgical approaches including the readily available chimney graft endovascular aneurysm repair (Ch-EVAR) or sealing (Ch-EVAS). The optimal configuration for Ch-EVAR or Ch-EVAS is important for success but not yet known. Objective The aim of the present study was to analyze current data of the outcomes of in-vitro chimney graft treatment in complex AAA. Methods A systematic review following PRISMA guidelines was conducted including studies reporting on gutter size, main graft compression, and chimney graft compression in in-vitro configurations. Results The search resulted in 285 articles. 11 studies considering 219 individual tests could be included. Gutter size was comparable between Ch-EVAR and Ch-EVAS configurations. In Ch-EVAR set-ups, the deployed BECG were Advanta V12, VIABAHN®, and BeGraft. One type of SECG was used: VIABAHN®. The four types of main grafts (MG) deployed were: Endurant™ I/II; EXCLUDER Conformable AAA Endoprosthesis and AAA Endoprosthesis, and AFX™ Endovascular AAA Delivery System. In the EVAS-configurations, the Nellix® EVAS system was deployed. In general, SECG presented smaller gutters with higher chimney graft compression. 30% main grafts oversizing seems to give the smallest gutters without high risk of infolding of MG. Oversizing, EndoAnchors, and secondary endobag filling (in Ch-EVAS) reduced gutter sizes. CG ballooning during the entire polymer injection in Ch-EVAS prevented CG compression. Conclusion In-vitro investigations provide insight in optimal Ch-EVAR and Ch-EVAS configurations for simulated complex AAA repair. The findings above might aid physicians in their planning to potential CG set-ups and can be used in future research to refine the most optimal configuration for chimney graft technique in complex AAA.

The treatment of isolated calcified lesions involving the popliteal artery are demanding and they often require stent placement to achieve acceptable luminal gain. This study evaluates the safety and performance of the orbital atherectomy system (Cardiovascular Systems Inc.) and percutaneous transluminal angioplasty with a drug-coated balloon (PTA-DCB) for the treatment of chronic atherosclerotic lesions within the popliteal artery segment. From November 2018 to November 2019, a series of six patients with Rutherford classification stage III peripheral arterial disease with isolated, focal, calcified occlusions of the popliteal artery were treated with orbital atherectomy followed by PTA-DCB. No embolic protection devices were used. The technical success rate was 100%, the primary patency rate was 100% at 7.0 (±4.2) months of follow-up. The Rutherford classification improved in all patients from stage III to stage II and the mean ankle brachial pressure index after the procedure was 0.97 (±0.08), with a preoperative mean ankle brachial pressure index of 0.69 (±0.21). In one instance, spasm was noted in a distal arterial bed and it was successfully treated with local nitroglycerine. No distal embolisation, perforation or aneurysmal degeneration was observed. During follow-up there were no deaths, major amputations or revascularisation of target lesions. The use of orbital atherectomy system in combination with PTA-DCB was found to be safe and effective in modifying focal, chronic, calcified plaques in the popliteal artery segment in these six cases.

Currently, patients with complex abdominal clinical entities such as juxtarenal aortic aneurysms (JAAAs) and signigficant comorbidities deemed unfit for open surgical repair and beingoffered advances endovascular techniques.

Purpose: To compare the outcomes of iliac branch devices (IBD) used in combination with standard endovascular aneurysm repair (EVAR) vs with fenestrated/branched EVAR (f/bEVAR) to treat complex aortoiliac aneurysms. Materials and Methods: The pELVIS Registry database containing the outcomes of IBD use at 8 European centers was interrogated to identify all IBD procedures that were combined with either standard EVAR or f/bEVAR. Among 669 patients extracted from the database, 629 (mean age 72.1±8.8 years; 597 men) had received an IBD combined with standard EVAR vs 40 (mean age 71.1±8.0 years; 40 men) who underwent f/bEVAR with an IBD. The mean aortic aneurysm diameters were 46.4±13.3 mm in the f/bEVAR patients vs 45.0±15.5 mm in the standard EVAR cases. The groups were similar in terms of baseline clinical characteristics and aneurysm morphology. The Kaplan-Meier method was used to compare patient survival, IBD occlusion, type III endoleak, and aneurysm-related reinterventions in follow-up. The estimates are presented with the 95% confidence interval (CI). Results: Technical success was 100% in the f/bEVAR+IBD group and 99% in the EVAR+IBD group (p=0.85). The 30-day mortality was 0% vs 0.5%, respectively (p=0.66), while the 30-day reintervention rates were 7.5% vs 4.1% (p=0.31). The mean follow-up was 32.1±21.3 months for f/bEVAR+IBD patients (n=30) and 35.5±26.8 months for EVAR+IBD patients (n=571; p=0.41). The 12-month survival estimates were 93.4% (95% CI 93.2% to 93.6%) in the EVAR+IBD group vs 93.6% (95% CI 93.3% to 93.9%) for the f/bEVAR+IBD group (p=0.93). There were no occlusions or type III endoleaks in the f/bEVAR+IBD group at 12 months, while the estimates for freedom from occlusion and from type III endoleak in the EVAR+IBD group were 97% (95% CI 96.8% to 97.2%) and 98.5% (95% CI 98.4% to 98.6%), respectively. The 12-month estimates for freedom for aneurysm-related reintervention were 93% (95% CI 92.7% to 93.3%) in the EVAR+IBD group vs 86.4% (95% CI 85.9% to 86.9%) in the f/bEVAR+IBD patients (p=0.046). Conclusion: Treatment of complex aortoiliac disease with f/bEVAR+IBD can achieve equally good early and 1-year outcomes compared to treatment with IBDs and standard bifurcated stent-grafts, except for a somewhat higher reintervention rate in f/bEVAR patients.

The early and short-term efficacy of the snorkel/chimney technique for endovascular aortic aneurysm repair (ch-EVAR) have been previously reported. However, long-term ch-EVAR performance, vessel patency, and patient survival remain unknown. Our study evaluated the late outcomes to identify possible predictors of failure within the PERICLES (performance of the chimney technique for the treatment of complex aortic pathologies) registry.Clinical and radiographic data from patients who had undergone ch-EVAR from 2008 to 2014 in the PERICLES registry were updated with an extension of the follow-up. Regression models were used to evaluate the relevant anatomic and operative characteristics as factors influencing the late results. We focused on patients with ≥30 months of follow-up (mean, 46.6 months; range, 30-120 months).A total of 517 patients from the initial PERICLES registry were included in the present analysis, from which the mean follow-up was updated from 17.1 months to 28.2 months (range, 1-120 months). All-cause mortality at the latest follow-up was 25.5% (n = 132), with an estimated patient survival of 87.6%, 74.4%, and 66.1% at 1, 3, and 5 years, respectively. A subgroup of 244 patients with 387 chimney grafts placed (335 renal arteries, 42 superior mesenteric arteries, 10 celiac arteries) and follow-up for ≥30 months was used to analyze specific anatomic and device predictors of adverse events. In the subgroup, the technical success was 88.9%, and the primary patency was 94%, 92.8%, 92%, and 90.5% at 2.5, 3, 4, and 5 years, respectively. The mean aneurysm sac regression was 7.8 ± 11.4 mm (P .0001). Chimney graft occlusion had occurred in 24 target vessels (6.2%). Late open conversion was required in 5 patients for endograft infection in 2, persistent type Ia endoleak in 2, and endotension in 1 patient. The absence of an infrarenal neck (odds ratio, 2.86; 95% confidence interval, 1.32-6.19; P = .007) was significantly associated with long-term device-related complications. A sealing zone diameter30 mm was significantly associated with persistent or late type Ia endoleak (odds ratio, 4.86; 95% confidence interval, 1.42-16.59; P = .012).The present analysis of the PERICLES registry has provided the missing long-term experience for the ch-EVAR technique, showing favorable results with more than one half of the patients surviving for5 years and a chimney graft branch vessel patency of 92%. The absence of an infrarenal neck and treatment with a sealing zone diameter30 mm were the main anatomic long-term limits of the technique, requiring adequate preoperative planning and determination of the appropriate indication.

Background: The prevailing evidence calls for using chimney/snorkel endovascular repair (ch-EVAR) with one or two chimney grafts. No studies up to now focus on its applicability and results for the treatment of suprarenal aortic pathologies (SRAP). Hence, we evaluated the clinical and radiologic results of ch-EVAR treatment for SRAP placing three or more chimney grafts within the PERICLES Registry. Methods: Data from 517 patients suffering complex aortic pathologies treated by ch-EVAR between 2008 and 2014 at 13 European and U.S. centers were retrospectively reviewed and analyzed. Results: Sixty-seven ch-EVAR-treated patients (12.9% of the entire PERICLES cohort) presented SRAP (83.5% elective, 16.5% urgent). The majority of patients (95.5%) received three chimney grafts; four patients received four chimney grafts. The Endurant device was the most commonly used (35.8%) followed by the Zenith abdominal endograft (19.4%). Overall, 204 chimney grafts were placed (56.7% covered self-expandable, 40.3% covered balloon-expandable stents, and 10.4% bare metal balloon-expandable stents). At a median follow-up of 24 months (range, 0.1-67.0 days), 30-day mortality was 6.1% (4 patients), and the overall mortality was 16.4% (11 patients). Overall survival was 87.4% (range, 79.5%-96.0%) at 1 year, 81.8% (range, 72.2%-92.2%) at 2 years and thereafter. Type IA endoleak was noted in nine patients (13.4%) intraoperatively and successfully treated in seven cases (97.1% technical success). Aneurysm sac diameter significantly decreased from 70.5 ± 19.3 mm to 66.9 ± 20.6 mm (P

Juxtarenale Aortenaneurysmen stellen eine besondere Herausforderung fur den behandelnden Gefaschirurgen dar. Grund ist die operative Rekonstruktion unter Mitbeteiligung der Nierenarterien. Neben der langjahrigen als Goldstandard etablierten offenen Therapie stellen neuere endovaskulare Techniken, wie die Chimney-Technik („chimney technique with endovascular aneurysm repair“, Ch-EVAR), eine attraktive Alternative dar, die besonders fur Hochrisikopatienten geeignet sind. Die Chimney-Technik ist insbesondere dann vorteilhaft, wenn anatomische oder klinische Gegebenheiten eine Behandlung mithilfe der fenestrierten Technik nicht zulassen. Die zunehmende Erfahrung bestatigt ihre komplementare Rolle von „bailout“ als eine valide Therapieoption von juxtarenalen Aneurysmen.

Objective Gender-related differences in outcomes in complex endovascular aortic repair have not been profoundly investigated. Use of low profile abdominal devices as in chimney endovascular repair may be beneficial for female patients with pararenal pathologies. With the chimney technique, there is no need for large introduction sheaths. This could be an advantage in case of smaller in diameter iliac access especially in combination with stenosis or elongation. Aim of the present study was to compare the perioperative and mid-term outcomes between males and females patients treated with the chimney/snorkel technique for pararenal aortic pathologies. Methods The PERICLES registry collected the world wide experience with the chimney technique. According to the gender, patients were classified in two cohorts. Primary endpoints were freedom from occlusion of the chimney grafts and reintervention. Secondary endpoints included access site complications and need for surgical or interventional revision, Endoleak Type I rate, 30-day overall complications and mortality. Univariate comparison P-values were generated using either the likelihood ratio χ2 test, the Fisher exact test, the Wilcoxon rank sum test, or the log rank test. Kaplan–Meier curves estimated the outcomes in the long run. Results A total of 412 patients underwent Ch-EVAR, 71 (17%) females and 341 (83%) males with a mean age for both groups being 74 years were included in the present study. After 36 months of mean follow-up, no statistically significant difference was observed between the two cohorts regarding re-interventions ( P= .44). Freedom from occlusion rates at 36 months did not differed between the two groups (females 84% vs. 80% for males ( P= .033). For patients receiving more than one chimney stent, the odds of having a complication did not differ between males and females (M:F OR = 2.0, 95% CI: 0.6–6.4, P = 0.228); 30-day mortality was 0% in the female group, instead five male patients died within one month. ( P = 0.59). The incidence of acute renal failure was low in both groups without statistical difference: 2 (3.1%) vs. 13 (4.6%) 58 ( P = 1.00). Neither patient received an endoconduit to insert the abdominal device. Conclusions No statistically significant difference regarding the freedom from reintervention and chimney graft patency was observed between the two genders. The results highlight the beneficial use of the chimney technique in female patients who can have potentially higher risk of access complications.

Purpose: The aim of this retrospective analysis was to evaluate the performance of the chimney (ch) technique in the treatment of type Ia endoleaks after standard endovascular aneurysm repair (EVAR). Methods: Between January 2008 and December 2014, 517 chEVAR procedures were performed in 13 US and European vascular centers (PERICLES registry). Thirty-nine patients (mean age 76.9±7.1 years; 33 men) were treated for persistent type Ia endoleak and had computed tomography angiography or magnetic resonance angiography follow-up at >1 month. Endurant abdominal stent-grafts were used in the 20 cases. Single chimney graft placement was performed in 18 (46%) patients and multiple in 21 (54%). Overall, 70 visceral vessels were targeted for revascularization. Results: Technical success was achieved in 35 (89.7%) cases; 3 persistent type Ia endoleaks and 1 chimney graft occlusion were detected within the first 30 days. Thirty-day mortality was 2.6%. Two other deaths (not aneurysm related) occurred during a mean follow-up of 21.9 months (0.23–71.3). Primary patency of the chimney grafts was 94.3% at 36 months. In a subgroup analysis comparing Endurant to other stent-grafts, no significant differences were observed regarding persistent endoleak [1/20 (5%) vs 2/19 (11%), p=0.6] or reintervention [1/20 (5%) vs 0/19 (0%)]. Conclusion: The present series demonstrates that chEVAR in the treatment of post-EVAR type Ia endoleaks has satisfactory results independent of the abdominal and chimney graft combinations. Midterm results show that chEVAR is an effective method for treating type Ia endoleaks.

The pErformance of iLiac branch deVIces for aneurysmS (pELVIS) Registry is the largest retrospective analysis of prospectively collected data on the use of iliac branch devices (IBD) for the treatment of iliac and aortoiliac aneurysms. It shows the feasibility of the technique with good short- and mid-term results. The most common anatomical challenge for IBD use is the presence of aneurysmal deterioration of the internal iliac arteries (IIA). Experience acquired in the registry treating concomitant aneurysmal lesions of the IIA provides significant information on the performance of IBDs for this specific clinical presentation. Treatment of isolated aneurysms in the common iliac artery without extension to the infrarenal aorta showed favourable results with lower costs, and lower use of irradiation and contrast media. Overall, the relatively low procedure-related complications and repeat interventions show broad applicability of the technique. Further analysis is required to evaluate the longstanding performance of IBD.

Vascular Ehlers-Danlos syndrome is associated with life-threatening events. The management of the disease is challenging because of the emergency presentation of symptoms and the tissue friability of the aorta. We describe the successful treatment of a late type I endoleak after previous EVAR. Keywords: Ehlers-Danlos syndrome, Endovascular repair, Open repair, Endoleak, Connective tissue disorders

Type 2 endoleaks usually constitute a benign and self-limited phenomenon, which rarely leads to aneurysmal sac expansion. However, in a small subset of patients, a persistent type 2 endoleak might pressurise the aneurysmal sac causing expansion. The authors present two cases with delayed new-onset type 2 endoleak. One occurred after standard endovascular aortic repair and the other after chimney endovascular aortic repair, causing expansion of the aneurysmal sac after a period of complete aneurysmal sac shrinkage. Accordingly, there is a risk of sac re-expansion due to delayed onset endoleaks, independent of the technique, justifying the need for a continuous follow-up despite long-term aneurysmal sac shrinkage.

This article demonstrates a less-invasive combined surgical and endovascular alternative approach in a case in which an excessive thrombotic formation in the infrarenal aorta caused occlusion of the iliac artery and the ipsilateral crural arteries. A 51-year-old man was admitted to the authors’ hospital with symptomatology of acute lower limb ischaemia. He had undergone endovascular treatment with placement of kissing stents in the common iliac arteries 2 years previously. A CT angiography scan revealed an extensive thrombus formation in the entire infrarenal aorta occluding the distal infrarenal aorta, the iliac artery and the crural arteries. He underwent a hybrid approach, with exposure of only the right common femoral artery and over-the-wire embolectomy of the infrarenal aorta and the iliac artery, and after the restoration of the inflow, an embolectomy of the peripheral vessels was carried out. To cover the residual aortic thrombus and to restore the severe in-stent restenosis of the previously deployed bare stents, three covered balloon-expandable stents were deployed in kissing technique. The patient was discharged on the fourth postoperative day with palpable peripheral pulses. Combined surgical and endovascular techniques minimise the operative trauma and length of hospital stay for the patient, successfully restoring the perfusion in a physiological manner.