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Background Pre-operative myocardial fibrosis and remodeling impact on outcomes after aortic valve replacement (AVR). We aimed at investigating the prognostic impact of preoperative electrocardiographic (ECG) markers of left ventricular (LV) myocardial damage, i.e. bundle branch block (BBB) and ECG strain pattern after (surgical or transcatheter) AVR for severe aortic stenosis (AS). Methods Between April 2008 and October 2017, we explored consecutive patients referred to our Heart Valve Clinic for first AVR for severe AS. Detailed pre-operative phenotyping and ECG analysis were performed. Patients were followed-up after AVR for major cardiac events (ME), i.e. cardiovascular death, cardiac hospitalization for acute heart failure and stroke. Results BBB and ECG strain were respectively observed in 13.5 and 21% of the 1122 patients included. These ECG markers identified a subgroup of older patients, with higher NYHA class and more advanced myocardial disease as detected by echocardiography, i.e. higher LV mass and lower LV ejection fraction, global longitudinal strain and integrated backscatter, than patients without ECG strain or BBB. ME occurred in 212 (18.6%) patients during a mean follow-up of 4.4 ± 1.5 years with higher incidence in case of ECG strain or BBB (HR 1.56, 95%CI 1.13–2.14, p = 0.006; HR 1.47, 95%CI 1.02–2.13, p = 0.04 respectively). The prognostic value of ECG strain remained significant after adjustment for age, diabetes and pre-operative LVEF. Conclusions Pre-operative ECG markers of myocardial damage identify a subgroup of AS patients at high risk of post-AVR cardiovascular complications irrespective of other prognostic factors and should help the multiparametric staging of cardiac damage to guide AVR.

We sought to determine outcomes of aortic valve replacement (AVR) versus root replacement after transcatheter AVR (TAVR) explantation because they remain unknown.From November 2009 to September 2020, data from the EXPLANT-TAVR International Registry of patients who underwent TAVR explant were retrospectively reviewed, divided by AVR versus root replacement. After excluding explants performed during the same admission as the initial TAVR and concomitant procedures involving the other valves, 168 AVR cases were compared with 28 root replacements, and outcomes were reported at 30 days and 1 year.Among 196 patients (mean age, 73.5 ± 9.9 years) who had primary aortic valve intervention at TAVR explant, the median time from TAVR to surgical explant was 11.2 months (interquartile range, 4.4-32.9 months). Indications for explant were similar between the 2 groups. Compared with AVR, patients requiring root replacement had fewer comorbidities but more unfavorable anatomy for redo TAVR (52.6% vs 26.4%; P = .032), fewer urgent/emergency cases (32.1% vs 58.3%; P = .013), longer median interval from index TAVR to TAVR explant (17.6 vs 9.9 months; P = .047), and more concomitant ascending aortic replacement (58.8% vs 14.0%; P .001). Median follow-up was 6.9 months (interquartile range, 1.4-21.6 months) after TAVR explant and 97.4% complete. Overall survival at follow-up was 81.2% with no differences between groups (log rank P = .54). In-hospital, 30-day, and 1-year mortality rates and stroke rates were not different between the 2 groups.In the EXPLANT-TAVR Registry, AVR and root replacement groups had different clinical characteristics, but no differences in short-term mortality and morbidities. Further investigations are necessary to identify patients at risk of root replacement in TAVR explant.

Summary Background Transfemoral percutaneous transcatheter aortic valve implantation (TF-TAVI) is a safe, reproducible and established procedure, mainly performed under local anaesthesia, which is mostly administered and monitored by a dedicated anaesthesia team (regular approach). Our centre has developed a standardized pathway of care, and eligible patients are selected for a minimalist TF-TAVI, entirely managed by operators without the presence of the anaesthesia team in the operating room, like most interventional coronary procedures (“percutaneous coronary intervention-like” approach [PCI approach]). Aim To compare the safety and efficacy of TF-TAVI performed with the PCI approach versus the regular approach. Methods The analysis population comprised all patients who underwent TF-TAVI with the PCI or regular approach in our institution from November 2016 to July 2019. The two co-primary endpoints were early safety composite and early efficacy composite at 30 days as defined by the Valve Academic Research Consortium-2. The PCI (n = 137) and Regular (n = 221) approaches were compared using the propensity score based method of inverse probability of treatment weighting. Results No differences were observed after comparison of TAVI performed with the PCI or regular approach regarding the composite safety endpoint (7.3% vs. 11.3%; odds ratio 0.63, 95% confidence interval 0.37 to 1.07; P = 0.086) or the composite efficacy endpoint (4.4% vs. 6.3%; odds ratio 0.78, 95% confidence interval 0.41 to 1.49; P = 0.45). Conclusions This study suggests that the efficacy and safety of TF-TAVI entirely managed by a PCI approach for selected patients are not different to those when TF-TAVI is performed with the attendance of a full anaesthesia care team. The PCI approach appears to be a safe and efficient clinical pathway, providing an appropriate and rational utilization of anaesthesiology resources, and could be used for the majority of TF-TAVI procedures.

Purpose: To report emergent transcatheter aortic valve implantation (TAVI) to treat acute severe aortic regurgitation caused by valve cusp dysfunction following proximal migration of an endograft implanted in the ascending aorta during endovascular arch repair. Case Report: A 65-year-old man had been previously treated with thoracic and fenestrated endografts in a 2-stage procedure for a chronic type B dissection. At 2-year follow-up, aneurysmal evolution of the distal arch led to development of a proximal type Ia endoleak. The patient was deemed unfit for open repair because of severe nonrevascularizable coronary artery disease. A custom-made endograft was designed consisting of a double inner branch arch endograft with a proximal component to reline the ascending aorta to avoid iatrogenic type A dissection. The first component was successfully deployed. However, this device migrated toward the aortic valve when the delivery system of the branch device was advanced through the aortic valve. Aortography and transesophageal echography showed acute aortic regurgitation due to obstruction of the left coronary valve cusp. An emergency bailout TAVI procedure was performed to successfully treat the aortic regurgitation. Conclusion: TAVI can be used as a bailout procedure for acute aortic valve dysfunction during endovascular arch or ascending aorta repair.

Objectifs L’objectif de cette video est de decrire les differentes etapes chirurgicales d’une nephrectomie droite avec thrombectomie cave (niveau 2) par voie coelio-robotisee. Methodes Expliquer les differentes etapes chirurgicales en robotique et en particulier le controle vasculaire de la veine cave (en toute securite). Resultats La duree d’intervention est de 90 min avec 14 min de clampage cave. Les pertes sanguines sont de 300 ml. Suites simples et sortie a J4. Conclusion La nephrectomie droite avec thrombectomie cave de niveau 2 est realisable par voie coelio-robotisee en toute securite dans un centre expert de chirurgie renale. Le benefice de la voie coelio -robotisee sont les pertes sanguines faibles, sortie precoce et recuperation amelioree.

Background and Purpose Acute stroke in the setting of acute type A aortic dissection is not rare and may contraindicate immediate surgery. Evaluating irreversible brain damage is critical in this setting and magnetic resonance imaging is a key determinant in the decision of selecting surgical over medical treatment for these patients. Summary of Cases We report herein 2 cases assessed at a tertiary care center for acute stroke. The initial diagnosis workup revealed cerebral hemispheric severe hypoperfusion without any brain infarction. The absence of ischemic lesions prompted surgical repair, despite the severity of clinical symptoms. Both patients demonstrated complete neurological recovery and neuroimaging showed no persistent sequel. Conclusion Acute type A aortic dissection is an important differential diagnosis in the causative workup for stroke. Brain hypoperfusion alone should not be a contraindication for urgent surgical treatment, regardless of initial clinical neurological severity.

Objectives The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR). Background Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients. Methods The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria. Results Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 ± 9.2 years and 7.1 ± 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium–defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%. Conclusions Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes.

Objectives We compared the outcomes of transcatheter aortic valve implantation (TAVI) in three different aortic stenosis syndromes: paradoxical low-flow low-gradient aortic stenosis (PLFLG), high-gradient aortic stenosis (HGAS), and low ejection fraction low-gradient severe aortic stenosis (LEF-LG). Background Outcomes for PLFLG patients after TAVI procedure are not well known. Methods Between 2010 and 2013, patients with severe (indexed aortic valve area iAVA≤0.6 cm2/m2) symptomatic aortic stenosis were consecutively referred to our institution for TAVI because of multiple comorbidities and excessive surgical risk. About 262 patients were split into three groups as following, PLFLG: mean gradient MG≤40 mm Hg, stroke volume index SVI≤35 mL/m2, ejection fraction EF≥55%, valvuloarterial impedance Zva>4.5 mm Hg/mL/m2, maximal aortic jet velocity MaxV 4 m/s, MG>40 mm Hg, EF>55%. The primary endpoint of our study was to evaluate mid-term global and cardiovascular mortalities; secondary endpoints included recommended VARC-2 variables. Results PLFLG (n = 31) mid-term survival was similar to HGAS (n = 172) (mean follow-up = 13.2 months [4.6–26]). Conversely LEF-LG patients (n = 59) displayed significant higher rates of all-cause (P = 0.01) and cardiovascular mortalities (P = 0.05). Postprocedural outcomes (VARC-2 criteria) were similar in the PLFLG and HGAS groups except regarding major bleeding (P = 0.02), while the LEF-LG group had more congestive heart failure and a higher BNP before discharge (both P

The definition of prosthesis–patient mismatch (PPM) remains to be refined to enhance its prognosis insight after surgical aortic valve replacement (SAVR) for severe aortic stenosis, especially in obese patients [(1)][1]. We aimed at investigating the respective prevalence and prognostic value of

OBJECTIVES Radiation exposure is a concern for both patients and operators during transcatheter aortic valve implantation (TAVI). Efforts to reduce radiation dose are warranted. We aimed at investigating if per-operative advanced image processing can reduce patient and operator irradiation use during TAVI. METHODS We performed a prospective single-centre observational study comparing patient and operator radiation exposure using standard fluoroscopy (control group) or a novel technology of live advanced fluoroscopic image processing (test group) among consecutive patients undergoing TAVI between August 2015 and April 2016. Patient irradiation (dose-area product, effective dose and air kerma), contrast media volume and clinical outcomes were assessed. RESULTS Among 152 elderly [median age (interquartile range): 83 (78-87)] patients (n = 76 per group) undergoing TAVI, baseline clinical characteristics were similar between the control and test groups, except for a higher median EuroSCORE II (2.8% vs 2.3%, P = 0.02) and higher rate of TAVI for failing surgical bioprosthesis (11.8% vs 2.6%, P = 0.03) in the control group. The dose-area product was reduced in the test group: mean reduction of -27.5 Gy × cm2 [95% confidence intervals (CIs): 15.9-39.1, P

Objective To assess the outcomes of inferior vena cava replacement with polytetrafluoroethylene expanded prosthesis in patients with renal cell carcinoma and caval thrombosis. Methods All patients who underwent radical nephrectomy with inferior vena cava replacement by polytetrafluoroethylene expanded prosthesis for renal cancer associated with inferior vena cava thrombosis and a suspicion of inferior vena cava wall invasion from January 2000 to June 2011 were considered for this study. Demographic data, postoperative course, graft patency and survival data were evaluated. Results A total of 26 patients (median age 59.5 years, range 19.9–85.6 years) were included in the analysis. The median tumor diameter was 10 cm (range 5–14 cm). Histological invasion of the wall of the inferior vena cava was found in 16 (61.5%) cases. The median follow up was 28 months (range 1–136). A graft thrombosis occurred in five (19.2%) patients within the first year. Four of these patients died before the end of the second year. Patency of the inferior vena cava graft at 6 and 12 months was 88% and 79%, respectively. Overall survival probability at 3 years was 64%. Conclusion Prosthetic replacement of the inferior vena cava can be carried out when invasion of the wall of the inferior vena cava is suspected. The postoperative complication rate in this subset of high-risk patients undergoing radical nephrectomy seems acceptable, and the patency of the prostheses is good in most of the cases.

Changes in parameters of longitudinal systolic function after cardiac surgery (i.e., tricuspid annular plane systolic excursion [TAPSE] and peak systolic velocity [PSV] of tricuspid annulus obtained by M-mode or Doppler tissue imaging) have been described for many years, with almost no data on their

Acute valve-sparing procedures are effective in the treatment of aortic root dilation when there is no valve pathology. In this review, we discuss the role of aortic valve-sparing procedures in the presence of connective tissue disorders such as scleroderma. doi: 10.1111/jocs.12239 (J Card Surg 2014;29:55-58)

Background In some patients, transfemoral, transaxillary, or transapical aortic valve implantation is not possible. Thus, carotid artery access may represent a safe alternative to those accesses, and even offers certain advantages. In this article, we describe aortic valve implantation using the left carotid arterial approach and report our initial experience. Methods Using a self-expandable nitinol based device (CoreValve ReValving system, Medtronic Ltd, Luxembourg), we exposed the left carotid artery through a small incision. Arterial puncture and initial 6F sheath introduction were achieved through a contraincision. The same implantation technique as for transaxillary implantation was used. Progressive artery dilatation was achieved using sheaths of increasing diameter. Rapid ventricular pacing was used to reduce cardiac output while performing a routine aortic balloon valvuloplasty. Only then, an 18F sheath was inserted into the carotid artery and pushed down into the ascending aorta. The patients were monitored using cerebral oxymetry to assess cerebral perfusion. Results Twelve consecutive patients, at high surgical risk, were implanted and studied prospectively. Transfemoral and subclavian catheterization were considered unfeasible or at risk of severe complications. Carotid arterial injury did not occur in any patient. A transient ischemic attack occurred in 1 patient, contralateral to the carotid access. There were no deaths in either intraprocedural or during the 30-day follow-up period. Conclusions This initial experience suggests that left carotid transarterial aortic valve implantation, in selected high-risk patients, is feasible and safe with satisfactory short-term outcomes.

Summary Aim To assess the feasibility and safety of a hybrid myocardial revascularization strategy combining “exclusive arterial” conventional coronary artery bypass grafting (CABG) followed by early drug-eluting stent (DES) implantation in multivessel coronary artery disease (CAD). Methods Eighteen consecutive patients with multivessel CAD were enrolled prospectively. Within 48 hours of CABG using left internal mammary artery (IMA) to left anterior descending (LAD) coronary artery with or without right IMA to non-LAD vessel in an open chest approach, DESs were implanted systematically in an additional vessel after a clopidogrel 300-mg preloading dose. This group was compared with 18 matched patients who underwent standard CABG alone using left IMA to LAD and at least one additional graft. Results Baseline clinical characteristics were similar in both groups. There were 46 grafts in the CABG group and 28 in the hybrid group. In the hybrid group, 27.8% of patients were treated off-pump versus none in the CABG group; a median of 2 (interquartile range: 1–2) stents was implanted per patient. The hybrid procedure was associated with shorter durations of cardiopulmonary bypass (77 [67–100] min versus 97 [90–105] min, P = 0.049). Major bleeding rates were higher in the CABG group, but the difference was not statistically significant (44.4% versus 11.1%, P = 0.06). Re-intervention for bleeding was not needed in either group. One (5.6%) myocardial infarction occurred in hospital in each group following CABG. At 1 year, the cumulative rates of major adverse cardiac events (death, myocardial infarction, target vessel revascularization) were similar (11.2% in hybrid group versus 5.6% in CABG group, P = 0.99). One death occurred in the CABG group and one target vessel revascularization in the hybrid group. Conclusion A hybrid revascularization strategy, combining conventional CABG with exclusive arterial conduits followed by early DES implantation, is feasible. One-year event rates compare favourably to those with traditional CABG alone.

Acute kidney injury (AKI) is a major postoperative complication following cardiac surgery. Diabetes mellitus is a major cause of nephropathy and end-stage renal failure. We aimed to evaluate the occurrence of adverse renal outcomes, in diabetic patients, between on-pump (CPB) and off-pump (OPCAB) coronary artery bypass graft (CABG). Seventy-one diabetic patients (36 and 35 patients in the CPB and OPCAB groups, respectively) were enrolled in a prospective randomized study. Renal tubular and glomerular functions, were monitored preoperatively and over five consecutive days. There was no significant difference between the groups in terms of age, gender, New York Heart Association class, Canadian Cardiovascular Society functional classification of angina grade and number of CABG. Intensive care unit stay, duration of intubation, hospital stay and bleeding were significantly higher in the CPB group. No significant differences in plasmatic creatinine, urinary creatinine, creatinine clearance, proteinuria or osmolality were detected. A significant rise in urinary albumine excretion occurred in both groups peaking on the operative day; for the on-pump CABG group (10±5 vs. 48±57; P=0.015) and for the OPCAB group (11±6 vs. 37±59; P=0.04). Values were less important in the OPCAB group and return to the baseline was faster than in the CPB group. OPCAB attenuates sub-clinical AKI, in diabetic patients.

PURPOSE To report the feasibility and midterm results of aortic bifurcation reconstruction in patients with small abdominal aortas using commercially available stents applied in a modified T-stenting technique adapted from coronary angioplasty. METHODS Twenty-three patients (16 men; mean age 52.4 years) with lower limb ischemia (Fontaine stage IIb or III) and distal abdominal aortas

Objectives To evaluate the early outcomes following thoracoabdominal aortic aneurysm (TAAA) repair utilising fenestrated and branched endografts. Design and materials and methods A prospective analysis of all patients undergoing endovascular repair of TAAA in a single academic centre. All patients were deemed unfit for open surgical repair. Customised endografts were designed using CT data reconstructed on 3D workstations. Post-operatively all patients were evaluated radiologically at hospital discharge, at 6, 12, 18 and 24 months, and annually thereafter. Results Thirty-three consecutive patients (30 males) were treated over 33 months (August 2006 to April 2009). Median age and aneurysm size were 70 years (range 50–83 years) and 64 mm (range 55–100 mm) respectively. 114/116 (98%) of the targeted visceral vessels were successfully catheterised and perfused. The in-hospital mortality rate was 9% (3/33). Transient spinal cord ischaemia was diagnosed in 4/33 (12%) patients, and permanent paraplegia in one (3%). The median follow-up period was 11 months (range 1–33 months). Endoleaks were identified in 5/33 (15%) patients: type II in four patients and a type III endoleak in one patient which required the only secondary intervention. During follow-up, two patients died: one from stroke and the other from myocardial infarction 9 and 29 months respectively after the procedure. Conclusion This preliminary study, which includes our learning curve, confirms the feasibility and safety of the endovascular repair of TAAA in high-risk patients. Meticulous follow-up to assess sac behaviour and visceral perfusion is critical in order to ensure optimal results of these complex endovascular repairs requiring numerous mating components.

Purpose: To evaluate the medium-term outcomes following aortic aneurysm repair utilizing fenestrated endografts performed in 13 French academic centers. Materials and Methods: A retrospective analysis of prospectively collected data. All patients had asymptomatic aneurysms involving or close to the visceral-bearing abdominal aorta and were judged to be at high-risk for open surgical repair. Fenestrated endografts were designed using computed tomography reconstructions performed on three-dimensional workstations. The procedures were conducted under fluoroscopic control by experienced endovascular teams. All patients were evaluated with computed tomography, duplex ultrasound, and plain film radiograph at discharge, 6, 12, 18, and 24 months, and annually thereafter. Results: Eighty patients (78 males) were treated over 44 months (May 2004–January 2008). Median age and aneurysm size were 78 years (range: 48–90 years) and 59 mm (range: 47–82 mm), respectively. A total of 237 visceral vessels were perfused through a fabric fenestration (median of 3 per patient). One early conversion to open surgery was required. Completion angiography showed that 234 of 237 (99%) target vessels were patent. Two patients (2.5%) died within 30 days of device implantation. Predischarge imaging identified 9 (11%) endoleaks: 3 type I, 5 type II, and 1 type III. The median duration of follow-up was 10 months (range: 1–38 months). No aneurysms ruptured or required open conversion during the follow-up period. Four of 78 (5%) died during follow-up (actuarial survival at 24 months 92%), none of these deaths were aneurysm related. Aneurysm sac size decreased by more than 5 mm in 33%, 53%, and 58% at 6, 12, and 18 months, respectively. One patient had sac enlargement within the first year, associated with a persistent type II endoleak. In-stent stenoses or occlusion affected 4 renal arteries. Secondary procedures were performed in 8 patients (10%) during follow-up, 5 to correct endoleaks and 3 to correct threatened visceral vessels. Conclusions: The use of endovascular prostheses with graft material incorporating the visceral arteries is safe in high risk patients with high risk aneurysms. In the medium-term it is effective in preventing rupture. However, meticulous follow-up to assess sac behavior and visceral ostia is critical to ensure optimal results.

Resume Le traitement endovasculaire des anevrismes thoracoabdominaux (ATA) est une nouvelle option therapeutique chez les patients a haut risque chirurgical selon les criteres de l’AFSSAPS. Quelques equipes ont evalue les resultats initiaux de ces reparations endovasculaires complexes effectuees avec des endoprotheses fenetrees et/ou multibranches. Le taux de succes technique varie de 88 a 100 %. Les complications peri operatoires, notamment les taux de mortalite et d’ischemie medullaire, sont comparables a ceux de la chirurgie ouverte. L’evaluation a moyen et long terme de cette nouvelle generation d’endoprotheses est indispensable avant d’elargir les indications du traitement endovasculaire des ATA a tous les patients.

Il trattamento endovascolare degli aneurismi dell’aorta toracoaddominale e un’alternativa terapeutica al trattamento chirurgico convenzionale nei pazienti ad «alto rischio chirurgico». La selezione dei pazienti per una chirurgia convenzionale si effettua sulla base di criteri fisiologici, mentre vi sono criteri anatomici che stabiliscono quali pazienti possono essere sottoposti a un trattamento endovascolare. Le endoprotesi sono fenestrate e/o multibranche per perfondere le arterie viscerali che originano dalla sacca aneurismatica. Vengono confezionate su misura a partire dall’angio-TC preoperatorio. Per limitare i rischi del trattamento (paraplegia, insufficienza renale) e indispensabile una rianimazione aggressiva durante il periodo perioperatorio. E necessario un controllo mediante angio-TC ed ecodoppler.

Purpose To review the use of thoracic endovascular aortic repair (TEVAR) for late pseudoaneurysm formation after surgical repair of aortic coarctation. Methods From May 2001 to May 2005, 8 patients (5 men; mean age 47.6 years, range 18-73) with a history of aortic coarctation repairs 17 to 40 years prior were referred to our institution for an anastomotic thoracic pseudoaneurysm. TEVAR was performed successfully in 7 patients; 1 died of suspected aneurysm rupture before the scheduled procedure. A carotid-subclavian bypass was performed in 3 patients. Results All the procedures were immediately successful. No type I endoleaks were seen on the final control angiogram, but 2 of the patients with carotid-subclavian bypasses required additional left subclavian artery embolization due to type II endoleak. One of these patients died before embolotherapy on the 5th postoperative day from presumed aneurysm rupture (14% 30-day mortality rate). Over a follow-up period ranging from 15 to 72 months (mean 37), all the false aneurysms have remained thrombosed and the mean diameter has decreased from 44 to 23 mm. No endograft-related complications have occurred, and no further interventions have so far been necessary. Conclusion TEVAR is a feasible alternative treatment for patients who have already undergone surgical repair of aortic coarctation. Technical issues regarding the endovascular strategy should be discussed with a multidisciplinary team to define the correct interventional plan.

Purpose. To evaluate a novel approach to preserve pelvic perfusion during endovascular AAA repair in patients with common iliac aneurysms extending to the iliac bifurcation. Materials and methods. A multicenter prospective analysis of patients undergoing implantation of a branched endograft designed to perfuse the internal iliac artery was conducted. All patients enrolled were considered high risk for open surgical repair and presented with common iliac artery aneurysms greater than 20 mm and anatomy amenable to implant the branched device. Preoperative high resolution spiral CT, and follow-up CT studies in addition to abdominal radiographs were obtained at discharge, 1, 6, 12, and 24 months. Results. Between 2003 and 2006, 52 patients (53 internal iliacs) were implanted with an investigational device. Mean common iliac aneurysm maximal diameter was 38 mm. The branch graft was combined with a proximal standard bifurcated component (61%), a fenestrated or a visceral branch component (33%), an aortouni-iliac component (2%), and alone in 2 patients (4%, following prior aortobi-iliac repair). Technical success was achieved in 94% of patients. Within the first month, 6 (11%) internal iliac branches occluded. No occlusions were noted after 1 month. The mean follow-up was 14.2 months. Common iliac aneurysm shrinkage was noted in 42% and 81% of patients at 6 and 12 months. There were no rupture, aneurysm related deaths or conversions, but there were 7 deaths during follow-up. Conclusions. The placement of endovascular prostheses that maintain antegrade perfusion of one or both internal iliac arteries is feasible, and early results provide evidence for optimism with regard to safety and efficacy.

The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR).Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients.The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria.Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 ± 9.2 years and 7.1 ± 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium-defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%.Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes.

We compared the outcomes of transcatheter aortic valve implantation (TAVI) in three different aortic stenosis syndromes: paradoxical low-flow low-gradient aortic stenosis (PLFLG), high-gradient aortic stenosis (HGAS), and low ejection fraction low-gradient severe aortic stenosis (LEF-LG).Outcomes for PLFLG patients after TAVI procedure are not well known.Between 2010 and 2013, patients with severe (indexed aortic valve area iAVA≤0.6 cm(2)/m(2)) symptomatic aortic stenosis were consecutively referred to our institution for TAVI because of multiple comorbidities and excessive surgical risk. About 262 patients were split into three groups as following, PLFLG: mean gradient MG≤40 mm Hg, stroke volume index SVI≤35 mL/m(2), ejection fraction EF≥55%, valvuloarterial impedance Zva4.5 mm Hg/mL/m(2), maximal aortic jet velocity MaxV4 m/s;MG≤40 mm Hg, MaxV4 m/s, EF≤50%, SVI≤35 mL/m(2); and HGAS: MaxV4 m/s, MG40 mm Hg, EF55%. The primary endpoint of our study was to evaluate mid-term global and cardiovascular mortalities; secondary endpoints included recommended VARC-2 variables.PLFLG (n = 31) mid-term survival was similar to HGAS (n = 172) (mean follow-up = 13.2 months [4.6-26]). Conversely LEF-LG patients (n = 59) displayed significant higher rates of all-cause (P = 0.01) and cardiovascular mortalities (P = 0.05). Postprocedural outcomes (VARC-2 criteria) were similar in the PLFLG and HGAS groups except regarding major bleeding (P = 0.02), while the LEF-LG group had more congestive heart failure and a higher BNP before discharge (both P 0.001) than the other groups. 30-days deaths were significantly more frequent in LEF-LG and PLFLG in comparison to HGAS (P = 0.03).As opposed to LEF-LG patients, mid-term prognosis after TAVI procedure in PLFLG patients is similar to HGAS patients despite higher perioperative mortality.

Purpose: To propose a classification system based on the position and extension of the intimal flap to assist in the endovascular repair of aortic dissection complicated by a malperfusion syndrome. Methods: Forty-one patients (34 men; mean age 58 years, range 22–78) with 19 type A and 22 type B dissections complicated by a malperfusion syndrome were treated with stenting, fenestration, or both for the peripheral ischemia. A retrospective review of the preprocedural imaging studies (computed tomographic angiography and arteriography) was performed to determine and categorize the position of the aortic intimal flap. In type 1, the flap was either parallel to or perpendicular to the origin of the malperfused collateral artery; type 2 referred to extension of the dissection into the collateral vessel, while type 3 represented the presence or absence of an avulsed branch ostium. Results: Patients treated with stenting (n = 19) alone had type 2 or type 3 arterial dissections, whereas the 12 patients who were treated with fenestration alone had type 1 lesions. Ten patients treated with stenting and fenestration had arterial lesions in which a type 1 dissection was associated with types 2 or 3. Conclusions: This appearance-based imaging approach combined with the symptoms of malperfusion syndromes during aortic dissection can help guide the endovascular treatment strategy.

Transcatheter aortic valve implantation (TAVI) is still under active investigation. When the femoral route is impossible for anatomic reasons, the transapical, transaxillary and direct aortic approaches have demonstrated their effectiveness. We report the successful implantation of a Sapien XT bioprosthesis with the NovaFlex catheter through a left carotid approach.

Acute valve-sparing procedures are effective in the treatment of aortic root dilation when there is no valve pathology. In this review, we discuss the role of aortic valve-sparing procedures in the presence of connective tissue disorders such as scleroderma.

To assess the outcomes of inferior vena cava replacement with polytetrafluoroethylene expanded prosthesis in patients with renal cell carcinoma and caval thrombosis.All patients who underwent radical nephrectomy with inferior vena cava replacement by polytetrafluoroethylene expanded prosthesis for renal cancer associated with inferior vena cava thrombosis and a suspicion of inferior vena cava wall invasion from January 2000 to June 2011 were considered for this study. Demographic data, postoperative course, graft patency and survival data were evaluated.A total of 26 patients (median age 59.5 years, range 19.9-85.6 years) were included in the analysis. The median tumor diameter was 10 cm (range 5-14 cm). Histological invasion of the wall of the inferior vena cava was found in 16 (61.5%) cases. The median follow up was 28 months (range 1-136). A graft thrombosis occurred in five (19.2%) patients within the first year. Four of these patients died before the end of the second year. Patency of the inferior vena cava graft at 6 and 12 months was 88% and 79%, respectively. Overall survival probability at 3 years was 64%.Prosthetic replacement of the inferior vena cava can be carried out when invasion of the wall of the inferior vena cava is suspected. The postoperative complication rate in this subset of high-risk patients undergoing radical nephrectomy seems acceptable, and the patency of the prostheses is good in most of the cases.

Aims High rates of permanent pacemaker (PPM) implantation are reported after transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve® system. The Accutrak™ catheter is designed to allow a more predictable landing zone. Little is known about the real clinical impact of this catheter. The aims of this paper were to describe the potential impact of the Accutrak™ catheter on the accuracy of positioning a 26 or 29 mm CoreValve® across the aortic annulus and its impact on the need for a pacemaker. Methods and results A total of 134 patients were treated with the CoreValve® Accutrak™ system at two French centres (Lille and Toulouse). Mean age was 82.4 ± 4.7 years; logistic EuroSCORE was 24.3 ± 9.5%. Procedural success rate was 99.2%; mean depth of implantation was 4.9 mm. A final position between 0 and 6 mm was achieved in 85.8% of the patients. All-cause mortality at 30 days was 6%. The PPM implantation rate was 10.6%. Due to a limited number of events, we could not identify any predictor of need for a PPM: pre-existing right bundle branch block (RBBB) (OR 2.72 [0.63-11.87], p=ns), use of a 29 mm prosthesis (OR 2.73 [0.33-22.90], p=ns) and left ventricular septal hypertrophy (OR 2.63 [0.08-83.32], p=ns). Conclusions In this cohort of patients treated with the CoreValve® Accutrak™ system, the incidence of permanent pacemaker implantation was low, which may be a consequence of an average small implantation depth. The Accutrak™ catheter seems to be helpful in achieving higher and more predictable implants. Operators could standardise their technique to place the CoreValve® prostheses less than 6 mm below the aortic annulus.

In this section, we will present four examples of aortic arch aneurysm. In the first section, we performed a hybrid approach. Subsequent sections present three instances of total endovascular aneurysm repair using a fenestrated endograft, a multibranched endograft, or the so-called chimney-graft technique.

Surgical management of extensive thoracoabdominal aortic aneurysms is associated with high rates of mortality and morbidity, including spinal cord ischemia. We report a successful three-stage repair combining open and endovascular surgery in a patient presenting with an ascending, arch, and thoracoabdominal aneurysm. Spinal cord protective measures included a staged approach, preserved antegrade flow to the left subclavian and hypogastric arteries, absence of aortic cross-clamping, and aggressive perioperative hemodynamic monitoring.

Corevalve dislocation has been reported to significantly increase the perioperative risk for severe complications and poor outcomes. We describe the case of an 87-year-old man who was referred to our center for transcatheter aortic valve implantation and who experienced an original complication after Corevalve dislocation by subclavian approach. Indeed, during the attempt to retrieve the partially expanded and dislocated valve through the subclavian introducer sheath, we experienced a dislodgment of the valve from the housing sheath that led to a delivery catheter cone separation and systemic embolization.

The study aim was to describe the characteristics and operative mortality of patients requiring valve surgery during active infective endocarditis (IE).This retrospective analysis involved 141 surgically treated patients with active IE. All cardiac operations were performed by the same surgical team between January 1998 and July 2009. All patients had definite (n = 128) or possible (n = 13) endocarditis according to modified Duke criteria. The IE was considered active if surgery was required before completion of a standard course of antimicrobial therapy. Operative mortality included any death occurring within the same hospital admission as surgery.Among the patients (108 males, 33 females; mean age 56.3 +/- 14.9 years), native valve endocarditis was present in 122 cases (87%). Multiple valve involvement was observed in 27 patients. The infected valves were the aortic (n = 81), mitral (n = 70), tricuspid (n = 15), or pulmonary (n = 2). The most common pathogens were staphylococci (n = 49), streptococci (n = 46) and enterococci (n = 27). The operative mortality was 16%. In univariate analysis, factors linked to operative mortality were age, prosthetic valve endocarditis (PVE) and inadequate antimicrobial therapy. In multivariate analysis, only PVE was an independent adverse predictor (adjusted Odds Ratio = 4.16; 95% confidence intervals 1.14-12.2; p = 0.01).Surgery for active IE is associated with a high mortality rate. The prognosis is impaired in patients with PVE, but might be improved by adequate antimicrobial therapy.

The aim of the study was to assess the prognosis of three different aortic stenosis populations operated by TAVI: Severe aortic stenosis (SAS), lowflow low-gradient aortic stenosis (LFLG) and paradoxical low-flow low-gradient aortic stenosis (PLFLG).Between January 2010 and August 2013, patients with severe symptomatic aortic stenosis were consecutively referred to our institution, for TAVI because of multiple comorbidities and excessive surgical risk. We defined and split patients into 3 populations as followed: PLFLG (iAVA≤0.6cm2, MG≤40mmHg, SVI≤35mL/m2, LVEF≥50%, Zva>4.5mmHg/mL/m2, MaxV4m/s, MG>40mmHg, LVEF>50%). The primary endpoint of our study was to evaluate global and cardiovascular mortalities; secondary endpoints included VARC 2 variables. A significant decrease in survival rate regarding the all-cause mortality (p=0.02) and cardiovascular mortality (p=0.05) was observed in the LFLG group (n=59) in comparison to the PLFLG (n=31) and SAS (n=172) groups, which had similar survival rates. Regarding the immediate post-procedural outcomes, the LFLG group had more CHF (p

La societe europeenne de cardiologie a publie en 2001 une nouvelle classification en cinq classes pour des lesions acquises aigues de l’aorte (tableau I). Open image in new window Tableau I -Classification des lesiions aigues de l’aorte selon le type d’atteinte parietale. Dans ce chapitre, seule la dissection aortique de classe 1 sera discutee. Cette dissection aortique est caracterisee par un clivage longitudinal plus ou moins etendu de la media de l’aorte. Le plan de clivage est habituellement situe entre les deux tiers internes et le tiers externe de la media et aboutit a la creation de deux chenaux, le vrai (VC) et le faux (FC) separes par le voile (flap) intimal. L’extension du clivage est en general anterograde mais peut etre retrograde. Le faux chenal a un trajet helicoidal. Il est habituellement de siege anterieur et droit au niveau de l’aorte ascendante, superieur et legerement posterieur au niveau de la crosse, posterieur et gauche au niveau de l’aorte descendante. Le passage du sang de la lumiere arterielle vers la concavite se fait par un ou plusieurs orifices d’entree et se propage le long de l’aorte a hauteur de l’isthme ou dans la region immediatement sous-isthmique.

We determined whether renal vein ostium wall invasion could be predicted by renal vein and inferior vena cava diameter on imaging. We also determined whether it is a prognostic factor for recurrence and survival after radical nephrectomy and thrombus ablation for renal cell carcinoma with an inferior vena cava tumor thrombus.From January 2000 to January 2006 nephrectomy for renal cell carcinoma was performed in 446 patients, of whom 32 (7.2%) underwent inferior vena cava thrombus extraction with complete resection of the renal vein ostium. When necessary, inferior vena cava partial and circumferential ablation was done in 5 and 8 patients, respectively, as well as replacement for thrombus adhesions. The largest coronal or axial diameter of the renal vein ostium and inferior vena cava anteroposterior diameter were measured on preoperative magnetic resonance imaging. Renal vein ostium wall invasion was assessed in all patients and determined microscopically by tumor cell infiltration into the intima. ROC curves were used to assess the value of these measurements for diagnosing patients with renal vein ostium invasion with 90% sensitivity. The risk of recurrence and survival was analyzed.Renal vein ostium wall invasion was present in 13 of 32 patients (40.6%). It significantly correlated with mean +/- SD inferior vena cava anteroposterior diameter (27.8 +/- 10.2 vs 17.3 +/- 6.8 mm, p = 0.01) and with the largest mean renal vein ostium diameter (22.3 +/- 7.9 vs 12.6 +/- 6.9 mm, p = 0.01). The upper level of the inferior vena cava thrombus correlated with renal vein ostium invasion (p = 0.002). The inferior vena cava anteroposterior diameter or renal vein ostium diameter cutoff value to predict wall invasion with 90% sensitivity was 18 and 14 mm, respectively. The AUC was 0.78 for inferior vena cava diameter and 0.86 for renal vein ostium diameter. No inferior vena cava recurrence was observed. Renal vein ostium wall invasion was associated with a higher risk of recurrence and decreased specific survival (p = 0.01 and 0.03, respectively). The association of ostium renal vein wall invasion with death from renal cell carcinoma was seen on multivariate analysis after adjusting for tumor size, TNM stage and thrombus level (RR 5.9, 95% CI 1.45-30.8, p = 0.01).Preoperative imaging measurements of renal vein and inferior vena cava diameter can accurately predict renal vein ostium wall invasion. Renal vein ostium wall invasion is an independent prognostic marker that is associated with a higher risk of recurrence and decreased specific survival.

PURPOSE To report percutaneous closure of aortocaval fistulas with the Amplatzer Duct Occluder. CASE REPORTS An aortocaval fistula was diagnosed after surgical repair of an abdominal aortic aneurysm in a 73-year-old man. A 3-year-old girl was treated for a congenital aortocaval fistula in another case. An 8 x 6-mm Amplatzer Duct Occluder was introduced via a 6-F introducer in each case, successfully occluding the fistulous track. Both patients are well and without any echocardiographic evidence of a shunt at 6 months. CONCLUSIONS In selected patients, transcatheter closure of aortocaval fistula with the Amplatzer Duct Occluder could be an alternative to open surgery. Further evaluation is necessary.

The purpose of this study was to evaluate the overall outcome of repair of thoracic aortic lesions with endoluminal grafts. Patients were studied prospectively following the implantation of a thoracic endovascular device. Preoperative imaging was performed by helical computed tomography (CT), angiography, transesophageal ultrasonography, or magnetic resonance imaging. Procedures were performed in an endovascular surgical suite under general anesthesia. All patients were evaluated with CT and chest radiography at discharge and at 1, 6, and 12 months. From December 1999 to November 2001, thirty-two patients were enrolled in the study (mean age 62 years; 20 male and 12 female patients). Seventeen patients had dissections, five patients had ruptured aortic ulcer, five patients had traumatic ruptures, three patients had atherosclerotic aneurysms, and two patients had pseudoaneurysms. An American Society of Anesthesiology score of III or IV was evaluated in 22 (69%) patients. The procedure was performed under emergency conditions in 11 cases. All prostheses were implanted successfully. There were no conversions. Three patients (9%) presented with a neurologic event following the implantation procedure, which was lethal in one case (hemorrhagic stroke). Two other patients died during early follow-up of myocardial infarction and multiorgan failure. The early death rate was 9%. The mean follow-up was 13.5 months. During follow-up, the maximal diameter of the aorta shrunk (≥ 5 mm) in 9 (28%) patients, remained stable in 17 (53%) patients, and increased (≥ 5 mm) in 6 (19%) patients. All patients presenting with an increased diameter were initially treated for dissections. A type 1 endoleak was diagnosed on the discharge CT scan in one patient. It sealed spontaneously thereafter. A type 3 endoleak was diagnosed 3 months after the procedure in one patient. A complementary stent graft was implanted in two patients presenting with a dissection with persistent patent false lumen and aortic enlargement. Three patients died during follow-up (two aneurysm-related and one aneurysm-unrelated death). The morbidity and mortality rates reported in our series related to the preoperative morbid conditions of the patients treated. Thoracic aorta endografting is an alternative to open surgery in this subset of patients.

Purpose: To evaluate the long-term results using the kissing stents technique for treatment of occlusive disease involving the aortoiliac bifurcation. Methods: One hundred six patients (97 men; mean age 52.5 ± 10.2 years, range 33–78) were treated with the kissing stents technique for bilateral aortoiliac stenosis (55, 51.9%), unilateral occlusion of the common iliac artery (CIA) with contralateral stenosis (47, 44.3%), and bilateral CIA occlusion (4, 3.8%). Clinical examination and duplex scans were performed prior to discharge and at 1, 6, and 12 months, followed by yearly examinations thereafter. Results: Bilateral stent implantation was successful in all patients. No major procedure-related complications were observed. Self-expanding stents were deployed in 62 (58.5%) patients and balloon-expandable devices in 44 (41.5%). Fifteen (7.1%) hematomas were observed at the 212 access sites. Mean follow-up was 30.1 ± 11.1 months (range 12–137). Duplex imaging diagnosed significant (>50%) restenosis in 15 (14.8%) of 101 patients and reocclusion in 4 (4%); 17 (89.5%) of these patients had recurrent symptoms and all were retreated (endovascular procedure in 18 and an aortobifemoral bypass in 1). Primary and secondary cumulative patency rates at 36 months were 79.4% and 97.7%, respectively. Balloon-expandable stents had a nonsignificantly higher patency rate compared to self-expanding stents. Conclusions: Based on our experience, aortoiliac endovascular reconstruction with the kissing stents technique is a safe and effective procedure, representing an alternative to conventional surgery in selected patients.

Introduction echography revealed a retroperitoneal effusion. A CT scan diagnosed a pseudoaneurysm of the infrarenal Mycotic aortic aneurysms due to Salmonella are asabdominal aorta (Fig. 2), without associated spondylodiskitis or vertebral osteomyelitis. Angiography sociated with high morbidity and mortality, due to rapid expand and rupture. Cases previously reported confirmed the pseudoaneurysm, and revealed a posterior rupture of the aortic wall, in front of the knitted involved patients over age 50, with pre-existing atherosclerotic disease, and frequent diabetes mellitus. L2 vertebra. We report a pseudoaneurysm in a young patient, without any atherosclerotic disease, with a documented history of lumbar vertebral fracture, followed by recurrent episodes of gastro-enteritis.

Culture of a mitral valve prosthesis excised for streptococcal endocarditis yielded Aspergillus fumigatus. The patient had undergone valve replacement 20 years earlier for A fumigatus endocarditis. Data suggest that quiescent A fumigatus may have survived in a biofilm on the surface of the prosthesis. An antifungal therapy was initiated for 6 months.

Oversizing strategies to avoid post-procedural aortic leak following TAVI are developing. The purpose of the study was to investigate if the oversizing strategy compared with normal sizing was deleterious on the immediate and late post-procedural outcomes. From January 2010 to August 2013, consecutive severe symptomatic aortic stenosis patients were referred for TAVI. They all underwent preoperative MultiSlice- angio CT scan (MSCT) and the procedures were achieved using Edwards Sapien® or Corevalve devices®. Early and late follow-up were completed. Retrospectively, according to pre-procedural MSCT and the valve size, patients were classified into three continuous groups: normal sizing, moderate and severe oversizing; depending on the ratio between the prosthesis area and the annulus area indexed and calculated on MSCT. Main endpoint was the all-cause and cardiovascular mortality and secondary endpoints corresponded to the VARC2 endpoints. 268 patients had a MSCT and underwent TAVI procedure, with mainly Corevalve ®. While all-cause and cardiovascular mortality rates were similar in all groups, post-procedural new pace-maker implantation rate was significantly higher in the severe oversizing group (p=0.03), while we observed more in-hospital congestive heart-failure (p=0.02) and tamponade (p=0.02) in the normal sizing group. There was also a trend toward more moderate to severe AR in the normal sizing group (p=0.12). At 1 month there was significantly more MACCE in the normal sizing group (p=0.03). Oversizing based on this ratio is a safe and feasible strategy to reduce aortic leak with lower rates of immediate post-procedural complications and a similar long-term survival. Download : Download full-size image Abstract 0050 – Figure: All-cause mortality Survival curve

Purpose: We report the procedural details and immediate results of treatment of type II endoleaks after aortic stent-graft implantation. Methods: In a consecutive series of patients who had either Vangard (n = 53) or Talent (n = 7) aortic stent-grafts implanted, type II endoleaks were confirmed by means of angiography in 18 patients, with a mean (± SD) age of 69 ± 11 years; 16 patients had Vangard stent-grafts, and two patients had Talent stent-grafts. After superselective catheterization of the feeding vessel, with 3F microcatheters, and liberal injections of vasodilators, embolization was performed with either a mixture of biologic glue and Lipiodol (n = 16) or Microcoils (n = 2). Results: The procedure was performed through the femoral artery in 16 patients and through the brachial artery in the remaining two patients. Overall, superselective catheterization and embolization were successfully undertaken in 17 (94.4%) of 18 patients. In the remaining patient, superselective catheterization proved impossible. This patient was treated with an injection of microparticles completed by means of embolization of biologic glue more proximally in an iliolumbar branch. During follow-up (mean, 13.3 months) after embolization, the aneurysm sac shrank in 13 (72.2%) of 18 patients. A new type II endoleak was diagnosed on helical computed tomography or magnetic resonance imaging in two (11.1%) of 18 patients. Conclusion: Percutaneous embolization is a safe and effective technique for treatment of type II endoleaks. However, despite these initially promising results, large long-term follow-up studies will be required to confirm its efficiency. (J Vasc Surg 2001;34:600-5.)