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Konstantinos G Moulakakis,1,* Christos F Pitros,1,* Ioannis T Theodosopoulos,2 Spyridon N Mylonas,3 John D Kakisis,2 Christos Manopoulos,4 Nikolaos PE Kadoglou5 1Department of Vascular Surgery, Patras University Hospital, University of Patras, Patras, Greece; 2Department of Vascular Surgery, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; 3Department of Vascular and Endovascular Surgery, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, 50937, Germany; 4Biofluid Mechanics and Biomedical Engineering Laboratory, Fluids Section, School of Mechanical Engineering, National Technical University of Athens, Athens, Greece; 5Medical School, University of Cyprus, Nicosia, Cyprus*These authors contributed equally to this workCorrespondence: Konstantinos G Moulakakis, Associate Professor of Vascular Surgery, Vascular Surgery Department, Patras University Hospital, Patras, Greece, Tel +0030 6937357508, Email konmoulakakis@yahoo.grAbstract: It has been documented that large-artery stiffness is independently associated with increased cardiovascular risk and may potentially lead to heart and kidney failure and cerebrovascular disease. A systematic review of studies investigating changes in arterial stiffness in patients undergoing endovascular repair of aortic disease was conducted. In addition, a review of the available literature was performed, analyzing findings from studies using the cardio-ankle vascular index (CAVI) as a marker of arterial stiffness. Overall, 26 studies were included in the present analysis. Our research revealed a high heterogeneity of included studies regarding the techniques used to assess the aortic stiffness. Aortic stiffness was assessed by pulse wave velocity (PWV), elastic modulus (Ep), and augmentation index (AI). Currently a few studies exist investigating the role of CAVI in patients having an aortic aneurysm or undergoing endovascular aortic repair. The majority of studies showed that the treatment of an abdominal aortic aneurysm (AAA) either with open repair (OR) or endovascular aortic repair (EVAR) reduces aortic compliance significantly. Whether EVAR reconstruction might contribute a higher effect on arterial stiffness compared to OR needs further focused research. An increase of arterial stiffness was uniformly observed in studies investigating patients following thoracic endovascular aortic repair (TEVAR), and the effect was more pronounced in young patients. The effects of increased arterial stiffness after EVAR and TEVAR on the heart and the central hemodynamic, and an eventual effect on cardiac systolic function, need to be further investigated and evaluated in large studies and special groups of patients.Keywords: arterial stiffness, pulse wave velocity, PWV, cardio-ankle vascular index, CAVI, augmentation index, AI, aortic aneurysm, endovascular aortic aneurysm repair, EVAR, thoracic endovascular aortic aneurysm repair, TEVAR

BACKGROUND: Many authors using a hybrid debranching strategy for the treatment of thoracoabdominal pathologies have reported disappointing results and the initial enthusiasm for the technique has given way to criticism and ambiguity. The aim of the present meta-analysis study was to assess the safety and efficacy of the technique in patients with thoracoabdominal aortic aneurysms or other aortic pathologies. METHODS AND RESULTS: A multiple electronic search was performed on all articles describing hybrid open endovascular repair. Separate meta-analyses were conducted for technical success, visceral graft patency, spinal cord ischemia symptoms, renal insufficiency, and other complications as well as 30-day/in-hospital mortality. Nineteen publications with a total of 507 patients were analyzed. The pooled estimates for primary technical success and visceral graft patency were 96.2% (95% CI, 93.5%-98.2%) and 96.5% (95% CI, 95.2%-97.8%) respectively. A pooled rate of 7.5% (95% CI, 5.0%-11.0%) for overall spinal cord ischemia symptoms was observed; whereas for irreversible paraplegia the pooled rate was 4.5% (95% CI, 2.5%-7.0%). The pooled estimate for renal failure was 8.8% (95% CI, 3.9%-15.5%). The pooled 30-day/in-hospital mortality rate was 12.8% (95% CI, 8.6%-17.0%). During the mean follow-up period of 34.5 (95% CI, 31.5-37.5) months, a total of 119 endoleaks were identified in 111 patients (22.7%). CONCLUSIONS: The repair of thoracoabdominal pathologies by means of hybrid procedures in patients who are poor surgical candidates is still associated with significant morbidity and mortality rates. Future studies may substantiate whether the technique is amenable to amelioration and improvement. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this retrospective study was to evaluate the results of complementary TEVAR following the frozen elephant trunk (FET) procedure for patients with residual type A aortic dissection (rTAAD) in terms of technical feasibility, safety and mid-term outcomes. Methods: This was a retrospective single-centre analysis of patients who received TEVAR after FET for rTAAD from January 2012 up to December 2021. The primary endpoint was technical success. Safety parameters included 30-day/in-hospital morbidity and mortality. Furthermore, mid-term clinical and morphological outcomes were evaluated. Results: Among 587 TEVAR procedures, 60 patients (11 with connective tissue disorders) who received TEVAR after FET for rTAAD were identified. The median interval between FET and TEVAR was 28.5 months. Indications for TEVAR after FET were true lumen collapse distal to FET prosthesis (n = 7), dSINE (n = 2), planned completion (n = 13) and aortic diameter progression (n = 38). In forty-seven patients, TEVAR was performed in an elective setting; eight and six patients were operated on in an urgent or emergency setting, respectively. All TEVAR procedures were successfully completed. The 30-day mortality and spinal cord ischemia rates were 1.7%. During a median follow-up of 37 months, two further patients died. Nine patients had to undergo a further aortic intervention: fenestrated stent-graft (n = 3) or open repair of the infrarenal abdominal aorta (n = 6). Conclusions: Complementary TEVAR following FET for rTAAD showed excellent technical success and low perioperative risk, supporting the feasibility and safety of this strategy. Despite the favourable mid-term survival, certain patients might require a further aortic procedure.

Introduction: We undertook a systematic review of the currently published literature on TEVAR for DTAAs and we combined the eligible studies into a meta-analysis with the intention of evaluating the efficacy and the long-term durability of this treatment option., Evidence Acquisition: A systematic search of the literature from January 2015 up to December 2022 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. For events during follow-up we calculated the incidence rates (IRs) with 95% confidence intervals (95% CIs) per 100 patient-years (p-ys) as the number of patients with outcome events occurring during the specific time period divided by the total number of p-ys., Evidence Synthesis: A total of 4127 study titles were identified by the initial search strategy, of which 12 were considered eligible for inclusion in the meta-analysis. A Total of 1976 patients (62% male) were identified among the eligible studies. One-year survival was 90.1% (95% CI 86.3% to 93.0%), 3-year survival was estimated at 80.5% (95% CI 69.2% to 88.4%) and the 5-year survival was estimated at 73.2% (95%CI 64.3% to 80.5%) with significant heterogeneity among studies regarding these outcomes. Regarding freedom from reintervention analysis for 1 year and 5 years was 96.5% (95% CI 94.5% to 97.8%) and 85.4% (95% CI 56.7% to 96.3%) respectively. The pooled late complications IR per 100 p-ys was 55.0 (95% CI 39.1 to 70.9), whereas the pooled IR for late reinterventions per 100 p-ys was 21.2 (95% CI 26.0 to 87.5). Late type I endoleak was reported with a pooled IR of 26.7 per 100 p-ys (95% CI 19.8 to 33.6) and late type III endoleak with a pooled IR of 7.6 per 100 p-ys (95% CI 5.5 to 9.7)., Conclusions: TEVAR presents a safe and feasible solution for the treatment of DTAA with sustained long-term effectivity. Current evidence supports a satisfactory 5-year survival with low rates of reinterventions.

The objective of this study is to present the current outcomes of fenestrated/branched endovascular repair (F/BEVAR) for post-dissection thoracoabdominal aortic aneurysms (PDTAAAs). A systematic review of the literature according to PRISMA guidelines up to October 2023 was conducted (protocol CRD42023473403). Studies were included if ≥10 patients were reported and at least one of the major outcomes was stated. A total of 10 studies with 585 patients overall were included. The pooled estimate for technical success was 94.3% (95% CI 91.4% to 96.2%). Permanent paraplegia developed with a pooled rate of 2.5% (95% CI 1.5% to 4.3%), whereas a cerebrovascular event developed with a pooled rate of 1.6% (95% CI 0.8% to 3.0%). An acute renal function impairment requiring new-onset dialysis occurred with a pooled rate of 2.0% (95% CI 1.0% to 3.8%). Postoperative respiratory failure was observed with a pooled estimate of 5.5% (95% CI 3.8% to 8.1%). The pooled estimate for 12-month overall survival was 90% (95% CI 85% to 93.5%), and the pooled estimates for 24-month and 36-month survival were 87.8% (95% CI 80.9% to 92.5%) and 85.5% (95% CI 76.5% to 91.5%), respectively. Freedom from reintervention was estimated at 83.9% (95% CI 75.9% to 89.6%) for 12 months, 82.8% (95% CI 68.7% to 91.4%) for 24 months and 76.1% (95% CI 60.6% to 86.8%) for 36 months. According to the present findings, F/BEVAR can be performed in PD-TAAAs with high rates of technical success and good mid-term results.

Background: We investigated the relationship of matrix metalloproteinases (MMPs), cardio-ankle vascular index (CAVI), and Gray-Scale Median (GSM) score with the severity and vulnerability of carotid atherosclerosis and major adverse cardiovascular events (MACE) during follow-up of carotid artery revascularization., Methods: We enrolled 262 patients undergoing carotid revascularization therapy (GRT), 109 asymptomatic patients with low-grade carotid stenosis (40-70%) receiving conservative treatment (GCT), and 92 age- and sex-matched control subjects without carotid atherosclerosis (GCO). All participants underwent carotid ultrasound and we assessed at baseline clinical parameters, metabolic profile, CAVI, GSM, and circulating levels of hsCRP, MMP-3,-7,-9, and TIMP-1., Results: Both GRT and GCT presented with elevated CAVI, MMPs, and TIMP-1 levels compared to GCO ( p < 0.001). The escalation highly correlated to the presence of symptoms or paralleled the degree of carotid stenosis ( p < 0.001). During follow-up (mean duration: 55 months), 51 GRT patients experienced MACE unrelated to the revascularization procedure. Within GRT, diabetes (HR: 2.07; CI: 1.55-2.78, p < 0.001), smoking (HR: 1.67; CI: 1.35-1.95, p < 0.001), high CAVI (HR: 1.22; CI: 1.09-1.43, p = 0.023) and MMP-9 (HR: 1.44; CI: 1.29-2.15, p = 0.005), and low GSM (HR: 1.40; CI: 1.16-2.12, p = 0.002) independently predicted MACE occurrences, despite the optimum medical therapy., Conclusions: Novel imaging and biochemical biomarkers were positively associated with atherosclerosis severity, while CAVI, MMP-9, and low GSM showed a positive, independent relationship with MACE after carotid revascularization, describing "vulnerable patients".

Arterial stiffness and its valid index, the cardio-ankle vascular index (CAVI), have emerged as predictors of adverse cardiovascular outcomes. We investigated the relationship of the CAVI with significant carotid stenosis (> 50%) and the related cerebrovascular symptoms or carotid plaque echogenicity, assessed by ultrasound gray-scale median (GSM) score, at baseline and after carotid artery stenting (CAS). We prospectively enrolled 113 patients with carotid stenosis (70-99% for asymptomatic and > 50% for symptomatic participants) eligible for CAS. Age- and sex-matched individuals (n = 38) served as controls (CON). Clinical data, CAVI, and biochemical profile were obtained at baseline. Clinical assessment and CAVI measurement were performed 6 months after CAS. Compared with the CON group, the CAS group had a higher incidence of co-morbidities (diabetes, hypertension, and hyperlipidemia), higher CAVI values (9.94 ± 2.14 vs 7.85 ± .97 m/sec, P < .001), but a better lipid profile due to increased prescription of statins. The symptomatic CAS subgroup showed higher CAVI ( P < .001), high-sensitivity C-reactive protein ( P = .048), and osteoprotegerin ( P = .002) levels than the asymptomatic one. In multivariate analysis, CAVI at baseline was independently associated with the presence of significant carotid atherosclerosis (β = .695, P < .001), cerebrovascular events (β = .474, P < .001), and GSM score (β = -.275, P = .042). Raised CAVI values were independently associated with significant carotid stenosis and plaque vulnerability.

Purpose: The aim of the present study was to investigate a potential difference on the arterial stiffness among aneurysm patients and non-aneurysm controls, as well as to explore potential changes between patients treated either with endovascular or open repair., Materials and Methods: A 110 patients with an infrarenal AAA were prospectively enrolled in this study. Fifty-six patients received an EVAR, whereas 54 patients received an open surgical repair. Moreover, 103 gender and age-matched subjects without AAA served as controls. The cardio-ankle vascular index (CAVI) was applied for measurement of the arterial stiffness., Results: CAVI values were statistically higher in the AAA patients when compared with control subjects. Although at 48 hours postoperatively the CAVI values were increased in both groups when compared to baseline values, the difference in CAVI had a tendency to be higher in the open group compared to the endovascular group. At 6 months of follow up the CAVI values returned to the baseline for the patients of the open repair group. However, in the endovascular group CAVI values remained higher when compared with the baseline values., Conclusion: Patients with AAAs demonstrated a higher value of CAVI compared to healthy controls. A significant increase of arterial stiffness in both groups during the immediate postoperative period was documented. The increase in arterial stiffness remained significant at 6 months in EVAR patients. Further studies are needed to elucidate the impact of a decreased aortic compliance after stentgraft implantation on the cardiac function of patients with AAA.

Purpose: To compare and contrast the midterm outcomes of the E-liac and Zenith (ZBIS) iliac branch devices (IBDs) for the preservation of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation. Materials and Methods: Between January 2014 and December 2018, 84 consecutive patients (median age 74 years; 76 men) were electively treated with the E-liac (n=44) or ZBIS (n=40) IBDs and were retrospectively analyzed to evaluate the technical success, patency, need for reintervention, and mortality associated with these devices. Results: Technical success was achieved in 95 of 99 implantations (95.9%) without any statistically significant difference between the groups (93.7% vs 98.0%, p=0.114). During the first 30 days, 3 occlusions in the ZBIS group and 1 in the E-liac group were identified. There was 1 perioperative death in the ZBIS group. The median follow-up was 37 months for the ZBIS group and 28 months for the E-liac group (p=0.657). Six patients from the ZBIS group and 7 from the E-liac group were lost to follow-up. Among the remaining, there were 2 further deaths recorded, 1 in each group. Four further reinterventions in the E-liac group and 2 in the ZBIS group were performed during follow-up. The Kaplan-Meier estimates of freedom from reintervention were 87.2% (95% CI 82.6% to 90.2%) for the ZBIS group and at 86.0% (95% CI 83.7% to 89.1%) for the E-liac group (p=0.563); the freedom from occlusion estimates were 89.7% (95% CI 85.8% to 94.5%) and 95.3% (95% CI 92% to 98.7%; p=0.317), respectively. Conclusion: The E-liac and the ZBIS IBDs showed equally high technical success, midterm patency, and low reintervention rates.

Near occlusion of internal carotid artery (ICA) is a rare and easily misdiagnosed condition and the decision for revascularisation still remains controversial. We conducted an updated meta-analysis in order to investigate outcomes after carotid endarterectomy (CEA), carotid artery stenting (CAS) or best medical treatment (BMT) in patients with near-occlusion of the ICA. We also aimed to investigate the role of time as a potential moderator of the near-ICA occlusion-stroke rate association. A multiple electronic health database search on articles published up to November 2019 was performed. The pooled stroke rate after CEA, CAS and BMT were calculated. We also investigated transient ischemic attack (TIA), stroke-related death, myocardial infarction (MI), any cause of death and ICA restenosis crude rates (%). A total of 33 articles were finally deemed eligible. The pooled stroke rate was 1.52% [95% confidence interval (CI): 0.09-4.02%] after CEA, 1.80% (95% CI: 0.61-3.40%) after CAS and 8.39% (95% CI: 3.39-14.80%) after BMT. Out of 896 CEA patients, we recorded 22 TIAs (2.5%), 33 all-cause deaths (3.7%), 5 stroke-related deaths (0.6%) and 6 MIs (0.7%). Concerning outcomes after 603 CAS patients, we recorded 7 TIAs (1.2%), 56 all-cause deaths (9.3%), 4 stroke-related deaths (0.7%) and 22 MIs (3.6%). Among 263 patients who were treated with BMT, we found 16 TIAs (6.1%), 10 all-cause deaths (3.8%), no stroke-related death, and no MI. Crude restenosis rate during follow-up was 9.0% (54/601) for CEA and 4.1% (24/592) for CAS patients. No significant effect of publication year upon stroke rate after CEA was recorded. However, there was a significant reversed association between pooled stroke rate after CAS and publication year (P=0.05). A statistically significant reversed association between pooled stroke rate after BMT and publication year was also recorded (P<0.01). The results of this updated meta-analysis revealed high stroke rate for patients with near-occlusion of ICA who treated only with BMT, while intervention seemed to be safe and effective. A downward trend in the stroke rates over time after CAS and BMT was also discovered. These highlight that patients with near-occlusion of ICA should be included and investigated in future studies., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm.2020.03.148). The series “Carotid Artery Stenosis and Stroke: Prevention and Treatment Part I” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare., (2020 Annals of Translational Medicine. All rights reserved.)

Objective/background: To investigate the prevalence of bovine arch (BA) among patients with type A and B aortic dissection, and to provide insight into the implication of this variation on the outcome of patients with acute or subacute type B aortic dissection (a/sTBAD)., Methods: This retrospective cohort analysis includes patients with a/sTBAD admitted between January 2006 and December 2016. Computed tomographic angiograms (CTAs) of patients referred because of type A aortic dissection were also re-evaluated with regard to the presence of BA. As a control group, 110 oncological patients who had undergone a chest CTA for disease staging during the study period were enrolled. A total of 154 patients with a/sTBAD and 168 with type A aortic dissection were identified during the study period., Results: An overall prevalence of 17.6% for BA variants was revealed. The comparison between patients with aortic dissection and the control group showed no statistically significant difference in BA prevalence (17.7% vs. 17.3%; p = 1.0). No statistically significant difference in BA prevalence was observed when comparing patients with type A aortic dissection with those with type B aortic dissection (16.6% vs. 18.8%; p = .66). During a median follow-up period of 27.8 months, 30 patients died. The mortality rate among patients presenting a BA variant was 34.5%, whereas among patients without, it was 16.0% (p = .04). Multivariate analysis revealed the presence of a BA as an independent predictor of mortality (adjusted odds ratio 3.4, 95% confidence interval 1.2-9.8)., Conclusion: The BA should be considered as a predictor of the outcome for patients with type B aortic dissection., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Bilateral limb occlusion after endovascular aortic repair (EVAR) is relatively uncommon. The aim of this study was to investigate the incidence of bilateral endograft limb occlusion after EVAR and identify potential anatomical predictive factors of occurrence., Methods: A total of 579 patients underwent elective EVAR for abdominal aortic aneurysm between January 2010 and December 2015. All patients presenting with unilateral and bilateral occlusions were prospectively analyzed. A group of patients who underwent EVAR but did not present with endograft limb occlusion were matched for sex, age, and commercial type of endograft and were used as controls., Results: Overall, 21 (3.6%) patients were complicated with unilateral endograft limb occlusion, whereas 8 (1.4%) of them presented with sequential (in different time) bilateral limb occlusion. We found that iliac artery angulation ≥60°, iliac perimeter calcification ≥50%, and endograft oversizing in the common iliac artery of more than 15% had the same impact and could equally result in limb occlusion. We coded the variables angle, calcification, and endograft limb oversizing of the common iliac artery with a score from 0 to 2 as follows: (1) 0: angle <60° in both limbs, 1: angle ≥60° in one limb, 2: angle ≥60° in both limbs; (2) 0: calcification <50%: in both limbs, 1: calcification ≥ 50%: in one limb, 2: calcification ≥ 50%: in both limbs; and (3) 0: endograft limb oversizing <15%, 1: endograft limb oversizing ≥15% in one limb, 2: endograft limb oversizing ≥15% in both limbs. A composite variable, consisting of the sum of scoring in variables was analyzed, with a score from 0 to 6. Our study showed that it was the most probable to be in the control group when score in the composite variable was 0-3, it was the most probable to have unilateral limb occlusion when score was 4-5, and finally, it was the most probable to have bilateral limb occlusion when score in the composite variable was equal to 6., Conclusions: Our study evidenced that the highest probability for bilateral limb occlusion occurred when implantation of a more than 15% oversized endograft in iliac arteries with iliac artery angulation ≥60° and iliac perimeter calcification ≥50% was present in both iliac arteries. It is therefore clear that limb occlusion requires the synergistic effect and interaction of bilateral multiple thrombogenic components in the iliac artery before it is manifested., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Acute early carotid stent thrombosis (AcuteCST) is a rare complication after carotid artery stenting (CAS). The purpose of this retrospective study was to investigate the incidence, causes, and optimal management of AcuteCST., Methods: Medical records of all patients undergoing CAS between 2008 and 2016 were retrospectively reviewed. The time of thrombosis, grade of stenosis, lesion side, preprocedural and postprocedural anticoagulants, causes, symptoms, treatment, recanalization, and outcome were reviewed., Results: Overall, 674 patients were treated with CAS. Four cases of AcuteCST were identified (0.59%). In the first patient, the stent thrombosis was attributed to dissection caused by filter deployment within a distal internal carotid artery with 360° coiling. Notably, in 3 of the 4 cases of thrombosis a second overlapping stent had been deployed. In total, 41 patients of the cohort under investigation underwent overlapping stent deployment. The use of a second overlapping stent as a bail-out procedure due to dissection or malposition or due to long lesions was correlated with increased rate of thrombosis (3/41 [7.3%] vs. 1/633 [0.002%]). In 2 patients, carotid stents were thrombosed within 2 hr of the procedure. Endovascular thrombus aspiration and subsequent eversion carotid endarterectomy with stent explantation in the first patient and intrathrombus urokinase administration with thromboaspiration and additional stent placement in the second patient were followed. In the other 2 patients having their carotid stents thrombosed 3 and 4 days after the procedure, treatment with low weight molecular heparin and antiplatelet regimens was followed., Conclusions: The use of overlapping stents in the carotid artery is a predisposing factor for AcuteCST. Prognostic factors of this potentially devastating complication are the initial clinical presentation expressing the grade of ischemic brain damage, the accurate and timely recognition of the thrombosis, and the prompt restoration of oxygenated blood flow into the viable tissue at risk of infarction., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Treatment of superficial femoral artery (SFA) lesions remains challenging. We conducted a network meta-analysis of randomized controlled trials aiming to explore the efficacy of treatment modalities for SFA "de novo" lesions., Methods: Eleven treatments for SFA occlusive disease were recognized. We used primary patency and binary restenosis at 12-month follow-up as proxies of efficacy for the treatment of SFA lesions., Results: A total of 33 studies (66 study arms; 4659 patients) were deemed eligible. In terms of primary patency, odds ratios (ORs) with 95% confidence intervals (CIs) were statistically significantly higher in drug-eluting stent (DES; OR, 10.05; 95% CI, 3.22-31.39), femoropopliteal bypass surgery (BPS; OR, 7.15; 95% CI, 2.27-22.51), covered stent (CS; OR, 3.56; 95% CI, 1.33-9.53), and nitinol stent (NS; OR, 2.83; 95% CI, 1.42-5.51) compared with balloon angioplasty (BA). The rank order from higher to lower primary patency in the multidimensional scaling was DES, BPS, NS, CS, drug-coated balloon, percutaneous transluminal angioplasty with brachytherapy, stainless steel stent, cryoplasty (CR), and BA. Combination therapy of NS with CR and drug-coated balloon were the two most effective treatments, followed by NS, CS, percutaneous transluminal angioplasty with brachytherapy, cutting balloon, stainless steel stent, BA, and CR in terms of multidimensional scaling values for binary restenosis., Conclusions: DES has shown encouraging results in terms of primary patency for SFA lesions, whereas BPS still maintains its role as a principal intervention. On the contrary, BA and CR appear to be less effective treatment options., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Limited data exist concerning the biomechanical and central hemodynamic changes induced by endograft implantation in the descending thoracic aorta. The aim of this prospective ongoing study was to evaluate changes in arterial stiffness, assessed by pulse wave velocity (PWV; m/sec), and N-terminal pro-brain natriuretic peptide (NT-proBNP; pg/mL) levels in patients undergoing endovascular repair of descending thoracic aorta (thoracic endovascular aortic repair [TEVAR])., Methods: Twenty-seven patients with thoracic aorta pathology who underwent elective TEVAR were included in the study. Blood samples were obtained preoperatively, 24 hr, 48 hr, and 6 months postoperatively, and serum levels of NT-proBNP were measured. PWV was determined before and 6 months after TEVAR. One-way analysis of variance by ranks was used to test the alterations in PWV (from baseline to 6 months) and NT-proBNP (along the 4 phases of evaluation). Post hoc analyses were appropriately performed., Results: We recorded an increase in values of NT-proBNP from baseline (median = 96.1, interquartile range [IQR] = 82.7-117.9) to 24 hr postoperative (median = 201.6, IQR = 82.8-425.9), 48 hr postoperative (median = 317.0, IQR = 102.5-1,479.5), and 6 months postoperative (median = 144, IQR = 82.8-276.4). The Kruskal-Wallis H test showed a statistically significant increase (x 2 (3) = 11.17, P = 0.01) in NT-proBNP from baseline (rank mean = 22.19) toward the postoperative time points of evaluation (24 hr postoperative: 35.17 [change: +12.9, P = 0.02]; 48 hr postoperative: 42.64 [change: +20.5, P < 0.001]; 6 month postoperative: 34.91 [change: +12.7, P = 0.03]). An increase in PWV values was recorded from baseline (median = 11.9, IQR = 10.0-13.5) to 6 months postoperatively (median = 13.9, IQR = 11.9-16.4). That change achieved statistically significant level [x 2 (1) = 4.86, P = 0.03], with an increase in mean rank PWV (+7.5)., Conclusions: Implementation of thoracic stent grafts may be associated with considerable increase of both arterial stiffness and NT-proBNP serum levels along time. Those results may indicate an adverse cardiac impact of TEVAR. However, the early and long-term effects of TEVAR on cardiovascular outcomes require further investigation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to investigate the 1-year safety and efficacy of a new iliac side-branched device (IBD) for revascularization of the hypogastric arteries., Methods: Patients receiving the E-liac (Jotec GmbH, Hechingen, Germany) side-branched device at six German vascular centers either as a stand-alone procedure or in combination with abdominal aortic aneurysm exclusion were included in a prospectively created data bank. Collected data were analyzed for baseline characteristics, procedural events, and clinical follow-up; variables included endoleaks, reinterventions, and internal iliac artery (IIA) patency., Results: Between January 2012 and January 2015, a total of 70 patients (69 men [98.6%]) with a median age of 74 years (range, 51-87 years) were consecutively treated; 66 patients had aneurysmatic disease of the iliac arteries, 2 patients had a para-anastomotic aneurysm after aortobi-iliac reconstruction, and another 2 patients had a type Ib endoleak after endovascular aneurysm repair. A total of 82 IIAs were revascularized, 12 bilaterally. Technical success was achieved in 100% (82/82) of the revascularized IIAs. All IBDs were patent at the end of the procedure. No instances of myocardial infarction, stroke, conversion to open repair, mesenteric or spinal cord infarction, or buttock necrosis were observed. There was one perioperative death (1.4%) in a 70-year-old patient with intraoperative gastrointestinal bleeding leading to multiple organ failure, which resulted in the patient's death on the fifth postoperative day. Within 30 days, one symptomatic occlusion of a treated common iliac artery (CIA) was observed. In two other patients, an asymptomatic kinking of the CIA segment of the IBD was revealed in the predischarge follow-up duplex ultrasound examination and corrected with relining. Median follow-up was 12 months (range, 6-16 months). One patient was lost during the follow-up period. Survival at 1 year was 98.5% with all IIAs remaining patent, whereas two CIA and two external iliac artery limb occlusions occurred. According to life-table analysis, the freedom from occlusion in a patient was 92% at 1 year, and freedom from type I endoleak was 87% at 1 year., Conclusions: This first ever 1-year study reports the results with the new E-liac device and shows that it can be safely applied for the treatment of aortoiliac aneurysmatic disease with low reintervention rates and high patency rates. Long-term data are needed to confirm the durability of the device., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role., (© The Author(s) 2016.)

Purpose The purpose of the study was to investigate the patency rate of the brachial vein transposition-arteriovenous fistula [BVT-AVF] and to review the available literature regarding the comparison of the one-stage with the two-stage procedure. Methods A multiple electronic health database search was performed, aiming to identify studies on brachial vein superficialization. Case reports and series with five or less patients were excluded from the study. End points of the study were the patency rates at 12, 24, and 36 months of follow-up. The patency of the one- or two-stage BVT-AVF procedure was investigated. Results Overall, 380 BVT-AVFs were analyzed. The primary patency rate at 12 months ranged between 24 and 77%. Rate of early fistula malfunction or failure of maturation of the fistula resulting in loss of functionality ranged from 0 to 53%. Forearm edema, hematomas, wound infection, and early thrombosis were among the most common complications. Limited data were available for the comparison of patency rates between the one- and the two-stage procedure because of the absence of sufficient comparative studies. However, series with one-stage procedure presented a lower patency rate at 12 months compared to series with two stages. Conclusion Patency rates after BVT-AVF, although not excellent, has encouraging results taking into account that patients undergoing these procedures do not have an accessible superficial vein network; failure of maturation and the increased rate of early postoperative complications remain a concern. The BVT-AVF is a valuable option for creating an autologous vascular access in patients lacking adequate superficial veins.

Background: The decision for revascularization in patients with near-total internal carotid artery (ICA) occlusion still remains controversial. We undertook an extensive review of the literature and conducted a meta-analysis aiming to investigate the appropriate therapeutic approach for patients with near-total ICA occlusion., Methods: A multiple electronic health database search was performed on all articles published up to December 2014. All available data were analyzed giving emphasis on the applied therapeutic approach (best medical therapy [BMT], carotid endarterectomy [CEA], and carotid artery stenting [CAS]), whereas the main endpoints of the meta-analysis were transient ischemic attack (TIA), stroke, stroke-related death, myocardial infarction (MI), major adverse event (MAE), overall mortality, and restenosis., Results: Five articles on BMT and CEA, 8 articles on CEA, and 11 articles on CAS were deemed eligible. A statistically significant difference was recorded in pooled stroke incidence rates (IRs) per 100 patient-years (p-ys) of BMT (IR = 6.19) compared with CEA (IR = 2.24, P = 0.002) and CAS (IR = 1.64, P < 0.001) studies. No statistically significant differences were recorded in pooled IRs per 100 p-ys between CEA and CAS, concerning TIA (P = 0.96), stroke (P = 0.44), stroke-related death (P = 0.30), and MAE (P = 0.99), whereas a borderline significance was recorded concerning overall mortality (P = 0.08) and restenosis (P = 0.08). No nominally significant effects were demonstrated with respect to almost all the studied potential modifiers in meta-regression analysis among the eligible studies., Conclusions: An intervention is probably indicated for patients with near-total ICA occlusion. The results of our study underline the need for including patients with near-total ICA occlusion in future randomized controlled trials. Meanwhile, the treatment of these patients should be individualized., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To evaluate inflammatory response and renal function after thoracic endovascular aortic repair (TEVAR) of lesions in the descending thoracic aorta., Methods: Thirty-two consecutive patients treated with TEVAR from January 2010 to August 2013 were enrolled in this prospective study. Two were excluded owing to dissecting thoracic aortic aneurysm (TAA) extending into the renal arteries with renal failure in one and a saccular TAA in which a multilayer flow-modulating stent was implanted in the other. This left 30 patients (28 men; mean age 68.8±5.9 years) with 28 TAAs, an aortic dissection, and an aortic ulcer for the analysis. Temperature and serum levels of white blood cells (WBCs), C-reactive protein (CRP), interleukin-10 (IL-10), IL-6, IL-8, tumor necrosis factor-alpha (TNF-α), creatinine, urea, and cystatin C were measured preoperatively and at 24 and 48 hours postoperatively., Results: Statistically significant increases in temperature and serum levels of WBCs, CRP, IL-10, and IL-6 were observed 24 and 48 hours postoperatively compared to baseline (all p<0.05). The number of endografts and the coverage of the celiac or subclavian artery did not affect the magnitude of the inflammatory response. No significant differences were observed concerning serum levels of IL-8, TNF-α, creatinine, or cystatin C from baseline to 24 or 48 hours postoperatively., Conclusion: Endograft implantation in the thoracic aorta may propagate an inflammatory response during the early postoperative period. No clinical adverse events related to the increased inflammatory response were observed. Renal function does not seem to be deteriorated after TEVAR in the descending thoracic aorta., (© The Author(s) 2015.)

Endovascular abdominal aortic aneurysm repair (EVAR) and thoracic aortic aneurysm repair (TEVAR) have been widely incorporated into clinical practice. However, changes in arterial stiffness and post-implantation syndrome after aortic endografting remain important issues under investigation. The aneurysm sac wall motion after successful EVAR and TEVAR reflects complex interactions between all the components of the excluded aneurysm, including true compliance of the aneurysm wall itself, intra-aneurysm sac pressure, remodeling of the thrombus, and mechanical characteristics of the endograft. Experimental and clinical studies have shown that aortic endografting results in increased arterial stiffness in animal models. It can be assumed that the alterations of aortic mechanical properties can have a direct impact on heart output. The long-term impact of these mechanical changes on cardiovascular outcomes and the potential effects of different endografts on hemodynamics are important issues under investigation. Post-implantation syndrome (PIS) is a systemic inflammatory response frequently observed after endovascular treatment of aortic pathologies. The main features of PIS include fever, leukocytosis, elevated C-reactive protein levels, and coagulation disturbances. Endograft design appears to influence this inflammatory response following aortic endografting; woven polyester endografts have been shown to be associated with greater inflammatory response compared to PTFE stent grafts. The purpose of this paper is to review the literature to elucidate arterial stiffness alterations and inflammatory response after EVAR and TEVAR and the impact of endograft design on aortic stiffness and the post-inflammatory response., Competing Interests: The authors have no conflict of interest relevant to this publication.

Objectives: The aim of this study was to investigate risk factors for endograft limb occlusion after endovascular abdominal aneurysm repair (EVAR), using a case control design., Methods: All patients presenting with endograft limb occlusion after elective EVAR between January 2010 and June 2013, along with age, sex, and type of endograft matched controls were included in the study. The impact of atherosclerotic risk factors, anatomic characteristics of the aneurysm, procedural details, and antiplatelet therapy was investigated. Multivariate logistic regression analysis and conditional logistic regression analysis for 1:3 matched pairs deriving adjusted odds ratios (ORs) with 95% confidence intervals (CIs) in order to detect significant risk factors for endograft limb occlusion among cases and controls were modeled., Results: Of the 439 patients treated by EVAR, 18 patients (4.1%) presented with endograft limb occlusion. These patients were compared to 54 matched controls. Limb occlusion was associated with iliac artery angulation ≥ 60° (OR = 5.76, 95% CI =1.24-26.74; p = .03) or perimeter calcification ≥ 50% (OR =5.87, 95% CI = 1.10-31.32; p = .04). Limb occlusion was also associated with ≥ 15% endograft oversizing in the common iliac artery (OR = 5.54, 95% CI = 1.11-27.60; p = .04). No other risk factors for limb occlusion were recognized., Conclusions: The presence of significant angulation and calcification of the iliac arteries as well as excessive limb oversizing appear to be independent predictors of endograft limb occlusion after EVAR.

Objective: The objective of this study was to evaluate the impact of contrast medium volume, inferior mesenteric artery (IMA) patency, and pre-existing as well as new-onset thrombus on the inflammatory response after elective endovascular aneurysm repair (EVAR)., Methods: The study included 87 patients undergoing elective endovascular repair of asymptomatic infrarenal aneurysms between January 2011 and November 2011. The patency of the IMA was determined by preoperative computed tomography angiography; the volume of the contrast medium used during the procedure was measured, and the volumes of chronic mural as well as new-onset thrombus were calculated from the preoperative and postoperative computed tomography angiograms with dedicated imaging software. The results were correlated to the occurrence of postimplantation syndrome (PIS) as well as to the main clinical and laboratory components of PIS: fever; increased white blood cell (WBC) count and C-reactive protein (CRP) level; decreased platelet count; and increased interleukin (IL)-6, IL-8, and IL-10 levels., Results: Postoperatively, a statistically significant increase was recorded in the mean values of body temperature, WBCs, CRP, IL-6, IL-8, and IL-10, and a statistically significant decrease was recorded in the number of platelets. After adjustment for endograft type, the volume of new-onset thrombus was found to be significantly correlated with the peak postoperative temperature (β = .307; P < .05) and the increase in WBC count (β = .271; P < .05), CRP level (β = .484; P < .001), and IL-6 level (β = .288; P < .05). On the contrary, the volume of chronic mural thrombus, the patency of the IMA, and the volume of contrast medium were not found to significantly affect any parameter of the PIS. PIS occurred in 34 patients (39%). Multiple logistic regression analysis showed that both the volume of new-onset thrombus and the type of endograft were independently associated with the development of PIS., Conclusions: The volume of new-onset thrombus is associated with the development of PIS after EVAR, whereas chronic mural thrombus appears to be an inert material. IMA patency and contrast medium volume are irrelevant to the inflammatory response after EVAR., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Endograft infection after thoracic endovascular aortic repair (TEVAR) is associated with a substantial mortality rate that exceeds 70% in the largest published series. The aim of this study was to review all published reports on infection after TEVAR treated with either preservation of the endograft or surgical excision of the stent graft with the intention of providing a comparison of the safety, efficacy, and durability of the two different treatment strategies., Methods: An extensive electronic health database search was undertaken to identify all articles that were published up to December 2013 reporting on endograft infection after TEVAR. Overall, 55 patients treated with endograft preservation (group A) and 41 patients treated with endograft explantation (group B) were included in this review., Results: The most frequently isolated microorganisms were Streptococcus species (29.4%) and Staphylococcus species (29.4%). The mortality for both groups was 66.6%. The in-hospital mortality rate in group A was 42% and reached 81.8% in a mean follow-up period of 8.6 months. The in-hospital mortality rate in group B was 36.6%. Four (9.7%) further deaths due to reinfection or fistula recurrence were recorded in a mean follow-up period of 15.3 months, leading to an overall mortality of 46.3%. The meta-analysis showed a trend of better outcome with endograft explantation compared with endograft preservation (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.18-1.48). In group A, a trend of better outcome was revealed when drainage and repair of the fistula were applied (OR, 2.22; 95% CI, 0.55-8.90). A trend of worse outcomes was detected in fistula patients compared with nonfistula patients (OR, 1.26; 95% CI, 0.43-3.74)., Conclusions: Endograft preservation seems not a durable option. It can be offered to patients who refuse surgery or as a palliative option or bridging procedure for severely ill patients. Compared with antibiotic therapy alone, antibiotic therapy followed by drainage and repair of the fistula may control the sepsis, providing, however, mainly a temporary benefit. The presence of fistula is a predictor of dismal outcome. Endograft explantation remains the "gold standard" of treatment. The mortality rate of surgical conversion is much higher in the presence of fistula., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To review the published outcomes of aortic endograft infection treated with preservation of the stent-graft., Methods: An extensive electronic health database search was undertaken to identify all articles published up to May 2013 that reported endograft infection after endovascular aneurysm repair (EVAR) in which treatment included preservation of the stent-graft. The search found 17 articles with 29 patients (27 men; mean age 73.1±7.6 years) fulfilling the inclusion criteria., Results: In 2 (7%) cases, the endograft infection was diagnosed within 30 days of the initial procedure; 4 (14%) were identified within 3 months and the remaining 23 (79%) within 12 months. Staphylococcus species, Streptococcus species, and Escherichia coli were the most common isolated microorganisms. Seven (24%) had a secondary aortoenteric fistula after EVAR. Twelve (41%) patients received only antibiotic therapy, while the remaining had an additional procedure (drainage, surgical debridement, sac irrigation, and/or omentoplasty). The in-hospital mortality was 21% (n=6). During a mean follow-up of 11.4±3.1 months, 7 more patients died (overall mortality 45%). None of the 7 patients with fistula survived. Half (50%) of the 12 patients who received only antibiotic therapy died, while 7 (41%) of the 17 patients who underwent an additional procedure died during follow-up., Conclusion: Among patients treated for endograft infection without explantation, those with aortoenteric fistula had the worst outcome. There is evidence for lower mortality in patients who underwent an additional procedure, such as drainage, surgical debridement, and sac irrigation. Larger studies are needed to examine the efficacy of this approach compared to surgical conversion with endograft excision and in situ reconstruction or extra-anatomical bypass.

Background: The management of acute type B dissection represents a clinical challenge. We undertook a systematic review of the available literature regarding medical, surgical and endovascular treatments of acute type B aortic dissection and combined the eligible studies into a meta-analysis., Methods: An extensive electronic health database search was performed on all articles published from January 2006 up to November 2013 describing the management of acute type B aortic dissection. Studies including less than 15 patients were excluded., Results: ACUTE COMPLICATED TYPE B DISSECTION: overall, 2,531 patients were treated with endovascular repair (TEVAR) and the pooled rate for 30-day/in-hospital mortality was 7.3%. The pooled estimates for cerebrovascular events, spinal cord ischemia (SCI) and total neurologic events were 3.9%, 3.1% and 7.3%, respectively. A total of 1,276 patients underwent open surgical repair and the pooled rate for 30-day/in-hospital mortality was 19.0%. The pooled rate for cerebrovascular events was 6.8%, for SCI 3.3% and for total neurologic complications 9.8%. Acute uncomplicated type B dissection: outcome of 2,347 patients who underwent conservative medical management were analyzed. The pooled 30-day/in-hospital mortality rate was 2.4%. The pooled rate for cerebrovascular events was 1%, for SCI 0.8% and for overall neurologic complications 2%., Conclusions: Endovascular repair provides a superior 30-day/in-hospital survival for acute complicated type B aortic dissection compared to surgical aortic reconstruction. However, open repair still has a significant role as endovascular repair is not applicable in all patients and there remains concerns regarding the durability of this technique. TEVAR seems to have a more favorable outcome regarding aortic remodeling and the aortic-specific survival rate when compared with medical therapy alone. Randomized controlled trials focusing on the prognostic factors of early and late complications in uncomplicated type B dissections are needed.

Evolution in the endovascular era has influenced the management of aortic arch pathologies. "Chimney" or "snorkel" graft technique has been used as an alternative in high risk patients unfit for open repair. We reviewed the published literature on the chimney graft technique for preservation of the supra-aortic branches in order to provide an extensive insight of its feasibility and efficacy and investigate its outcomes. 18 reports were identified, with a total of 124 patients and 136 chimney. Primary technical success was achieved in 123/124 patients (99.2%). The perioperative mortality rate was 4.8% and the stroke rate was 4%, while events of spinal cord ischemia were rare. The overall endoleak rate was 18.5%; 13 patients (10.5%) developed a type I endoleak and 10 (8%) patients a type II endoleak. During a median follow-up period of 11.4 months (range, 0.87-20.1 months) all implanted chimney grafts remained patent. From this, we conclude that endovascular aortic arch repair with chimney grafts is associated with a lower mortality rate compared to totally open or hybrid reconstruction. However, the stroke rate remains noteworthy, and requires longterm data to elucidate.

Background: Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies., Methods: Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality., Results: Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort., Conclusions: Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.

Purpose: To present a systematic review and meta-analysis investigating the incidence of carotid artery stenting (CAS)-induced hemodynamic instability (HI) and to explore differences in periprocedural risk among patients with and without CAS-associated HI., Methods: Multiple electronic health databases were searched for all articles published between January 2000 and December 2011 describing CAS-associated hemodynamic instability. Twenty-seven studies with a total of 4204 patients were analyzed, placing emphasis on the HI incidence and its correlation with postprocedure morbidity and mortality. A meta-regression analysis was conducted to investigate the role of potential meaningful modifiers upon HI., Results: The meta-analysis for overall HI rate showed a pooled proportion of 39.4%. The pooled estimate for hypotension was 12.1%, 12.2% for bradycardia, and 12.5% for both hypotension and bradycardia. Persistent HI was found to occur in a pooled rate of 19.2%. No statistically significant differences were found between patients with and without HI after CAS with respect to death, stroke, transient ischemic attack (TIA), or major adverse events. The meta-regression analysis revealed statistically significant associations of mean age with HI, of ≤10-mm distance between the carotid bifurcation and the site of minimum lumen diameter with bradycardia, and of prior ipsilateral CEA with persistent HI., Conclusion: CAS-induced HI occurs in a considerable percentage of patients without increasing the perioperative risk. However, applying the appropriate prophylactic measures and strictly monitoring blood pressure and heart rate during the procedure and immediately after should be encouraged for early recognition and correction of these hemodynamic disturbances.

Background: A combined open-endovascular technique has emerged as an alternative treatment option for thoracoabdominal pathologies. However, reported experiences from various medical centers have been contradictory and heterogeneous. The aim of this study is to assess the mortality rate and various complication rates associated with this approach., Methods: An electronic health database search was performed on all articles published up to March of 2012 describing combined open-endovascular repair of thoracoabdominal pathologies. Studies were included in the meta-analysis if they had ≥10 patients and reported the basic outcome criteria. End points of the meta-analysis were defined as primary technical success, endoprosthesis related complications, 30-day/in-hospital mortality, symptoms of spinal cord ischemia (SCI) and irreversible paraplegia, permanent renal function impairment, and other major complications., Results: Fourteen studies were deemed eligible for this meta-analysis with a total of 528 patients (68.0% male, mean age 70.5 years). The mean follow-up period was 34.2 months. The pooled estimate for primary technical success and visceral graft patency was 95.4% and 96.5% respectively. An endoleak developed in 106 (21.1%) patients in whom both stages had been completed. The pooled rate for symptomatic SCI was 7.0% and for irreversible paraplegia 4.4%. The pooled proportion for permanent renal failure was 7.0% and for mesenteric ischemia 4.5%. Prolonged respiratory support and cardiac complications were observed in a pooled rate of 7.8% and 4.6% respectively. The meta-analysis for 30-day/in-hospital mortality revealed a pooled rate of 14.3%., Conclusions: Although the hybrid technique for thoracoabdominal aortic pathology provides a less invasive approach, the technique is still associated with a considerable morbidity and mortality rates. High risk patients unfit to withstand open repair, are equally likely to suffer significant complications with the hybrid procedure. The choice of the optimal treatment strategy for thoracoabdominal pathologies should be carefully made on a patient to patient basis, assessing the clinical fitness and the anatomical suitability of each patient. The hybrid approach should be reserved for high volume centers with accumulated experience and high standards of perioperative management.

Objective: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The "chimney graft" or "snorkel" technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique., Methods: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011., Results: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%., Conclusions: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

This experimental study investigates the effects of hypothyroidism on the descending thoracic aorta. Hypothyroidism was induced in 20 male Wistar rats by administering 0.05% of 6-n propyl 2-thiouracil (PTU) in their drinking water for 8 weeks. Euthyroid rats were used as controls. Animals were sacrificed and longitudinal strips of the descending aorta were subjected to various preselected levels of stress in a uniaxial tensile-testing device. Analysis of stress-strain, elastic modulus-strain curves disclosed significant differences between groups, indicative of stiffer aortas in hypothyroid animals at the upper physiologic and higher levels of pressure. Remodeling of the aortic wall of hypothyroid animals revealed significant histological changes. The thoracic aorta of hypothyroid rats compared with that of euthyroid ones became stiffer at high strains, including the upper physiologic range, loosing part of its distensibility. Hypothyroidism was also associated with diameter enlargement and substantial lengthening of the aorta.

Cerebral hyperperfusion syndrome is a rare, serious complication of carotid revascularization either after carotid endarterectomy or carotid stent placement. Impaired cerebral autoregulation and post-revascularization changes in cerebral hemodynamics are the main mechanisms involved in the development of the syndrome. Hyperperfusion syndrome may be fatal once an intracranial hemorrhage occurs. This article reviews the literature, intending to make a synthesis of all new data concerning the clinical manifestations of hyperperfusion syndrome, the pathophysiologic pathways involved in its development, the prediction, and the appropriate management. Also, a review of the most recent series of hyperperfusion syndrome following carotid revascularization, both with classic open endarterectomy and carotid artery stenting has been performed.