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Introduction: Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor. Methods: A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest. Results: During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest. Discussion: In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare the short and long term clinical outcomes of endovascular (EVAR) vs. open surgical repair (OSR) of juxtarenal (JAAAs) and pararenal abdominal aortic aneurysms (PAAAs) in five high volume European academic centres. This was a retrospective multicentre cohort study of five high volume European academic centres (> 50 open or 50 endovascular abdominal aortic aneurysm repairs annually) including 834 consecutive patients who were operated on and prospectively followed. Using propensity score matching (PSM) each patient who underwent OSR was matched with one patient who underwent EVAR in a 1:1 ratio (145 patients per group). The primary endpoint was long term all cause mortality, while the secondary endpoint was freedom from aortic related re-intervention. After a follow up of 87 months, no difference in overall survival between the two groups was observed (38.6% for EVAR vs. 42.1% for OSR; p =.88). Patients undergoing EVAR underwent aortic related re-interventions more frequently (24.1% vs. 6.9%; p <.001). Acute kidney injury (AKI) occurred more frequently in patients in the OSR group (40.7% vs. 24.8%; p =.006). However, most patients who suffered from AKI recovered without further progression to renal failure. In hospital (3.4% for EVAR vs. 4.1% for OSR; p = 1.0) and 30 day (4.1% for EVAR vs. 5.5% for OSR; p =.80) mortality rates did not differ between groups. Both open and endovascular treatment can be performed in high volume aortic centres with low short term mortality and morbidity rates, and good long term outcomes. These data provide useful information to help patients choose between the two procedures when both are feasible. [ABSTRACT FROM AUTHOR]

During the last years a great progress has been noted in device technology and operator experience in treating complex aortic aneurysms. Fenestrated and branched custom-made devices require detailed preoperative planning and production time that can take ≤12 weeks. During this awaiting period, aortic-related mortality is increased. To overcome this limitation, off-the-shelf standardized multibranched devices were launched in the market for the treatment of pararenal and thoracoabdominal aortic aneurysms (TAAAs). Our aim was to evaluate systematically all the published studies of off-the-shelf endografts for the treatment of pararenal and TAAAs. We performed a systematic review to identify all the eligible studies that reported outcomes to the off-the-shelf with inner or outer multibranched devices and then conducted a qualitative synthesis and meta-analysis of the results. The main outcomes were technical success, mortality, target visceral vessel instability, major adverse events, and reintervention rates. We estimated pooled proportions and 95% confidence intervals (CIs). A total of 1605 study titles were identified by the initial search strategy, of which 13 (8 t-Branch, 3 E-nside, 1 We-Flow, and 1 TAMBE) were considered eligible for inclusion in the meta-analysis. A total of 595 patients (70% male) were identified among the eligible studies. In terms of procedures, 64.4% were elective, 19.2% (13.4% outer multibranched group [OMG]; 6.1% inner multibranched group [IMG]) were emergent, and 16.4% (15.6% OMG; 0.8% IMG) were urgent. The pooled technical success was 92.1% (95% CI, 83.8%-96.4%) and 96.9% (95% CI, 92.5%-98.8%) for the outer and inner multibranched endografts, respectively. The pooled 30-day mortality was 10.4 % (95% CI, 6.6%-16.1%,) and 4.2% (95% CI, 2.0%-8.6%) for the OMG and IMG, respectively. The pooled 30-day and late target visceral vessel instability for the OMG was 3.5% (95% CI, 2.0%-6.1%) and 6.2% (95% CI, 4.7%-8.0%) and for the IMG 10.4% (95% CI, 4.5%-22.5%) and 1.6% (95% CI, 0.7%-3.3%) respectively. This pooled analysis indicated good technical success and mortality rates for both devices despite the high rate of urgent procedures. Pararenal and TAAAs can be treated safely using the included devices. However, further studies are required to draw additional conclusions for the IMG owing to the small sample size. [ABSTRACT FROM AUTHOR]

Introduction: This systematic review with network meta-analysis aimed at comparing the medium-term results of open surgery (OS), fenestrated endovascular repair (FEVAR), and chimney endovascular repair (ChEVAR) in patients with juxta/pararenal abdominal aortic aneurysms (JAAAs/PAAAs). Materials and methods: MEDLINE, SCOPUS, and Web of Science were searched from inception date to 1st July 2022. Any studies comparing the results of two or three treatment strategies (ChEVAR, FEVAR, or OS) on medium-term outcomes in patients with JAAAs/PAAAs were included. Primary outcomes were all-cause mortality, aortic-related reintervention, and aortic-related mortality, while secondary outcomes were visceral stent/bypass occlusion/occlusion, major adverse cardiovascular events (MACEs), new onset renal replacement therapy (RRT), total endoleaks, and type I/III endoleak. Results: FEVAR (OR = 1.53, 95%CrI 1.03–2.11) was associated with higher medium-term all-cause mortality than OS. Sensitivity analysis including only studies that analysed JAAA showed that FEVAR (OR = 1.65, 95%CrI 1.08–2.33) persisted to be associated with higher medium-term mortality than OS. Both FEVAR (OR = 8.32, 95%CrI 3.80–27.16) and ChEVAR (OR = 5.95, 95%CrI 2.23–20.18) were associated with a higher aortic-related reintervention rate than OS. No difference between different treatment options was found in terms of aortic-related mortality. FEVAR (OR = 13.13, 95%CrI 2.70–105.2) and ChEVAR (OR = 16.82, 95%CrI 2.79–176.7) were associated with a higher rate of medium-term visceral branch occlusion/stenosis compared to OS; however, there was no difference found between FEVAR and ChEVAR. Conclusions: An advantage of OS compared to FEVAR and ChEVAR after mid-term follow-up aortic-related intervention and vessel branch/bypass stenosis/occlusion was found. This suggests that younger, low-surgical-risk patients might benefit from open surgery of JAAA/PAAA as a first approach. [ABSTRACT FROM AUTHOR]

This study investigated the long-term outcomes of patients treated with open surgical repair for complex abdominal aortic aneurysms (c-AAAs). A total of 119 patients with c-AAAs undergoing repair between January 2010 and June 2016 in a high-volume aortic center were included. The long-term imaging follow-up consisted of yearly abdominal ultrasound examinations and 5-year computed tomography angiography. At a median follow-up of 76 months (IQR 38 months), forty-three deaths (37%) and three (2.5%) aortic-related deaths were observed. Long-term chronic renal decline was observed in fifty (43.8%) patients, significantly correlated with post-operative acute kidney injury. During the follow-up, five reinterventions (4.3%) were performed. The present study suggests that open c-AAA repair can be performed with acceptable operative risk with durable results. To achieve the best possible long-term outcome, the open surgery repair of complex AAA should be performed in high-volume aortic centers and tailored to the patient. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair. Methods: Data from consecutive F-BEVAR (2010–2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency. Results: A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002). Conclusions: F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term. [ABSTRACT FROM AUTHOR]

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

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

The aim of this cohort study was to report the proportion of patients who develop periprocedural acute kidney injury (AKI) after endovascular repair (ER) and open surgery (OS) in patients with juxta/pararenal abdominal aortic aneurysm and to assess potential risk factors for AKI. The study also aimed to report the short- and long-term outcomes of patients with and without AKI. This was a multicenter cohort study of five European academic high-volume centers (>50 OS or 50 ER infrarenal AAA repairs, plus >15 complex AAA repairs per year). All consecutively treated patients were extracted from a prospective vascular surgical registry and the data were scrutinized retrospectively. The primary end point for this study was the development of AKI. AKI was diagnosed when there is a two-fold increase of serum creatinine or decrease of glomerular filtration rate of >50% within 1 week of AAA repair. Secondary end points included long-term mortality and end-stage renal disease (ESRD). AKI occurred in 16.6% of patients in the ER group vs 30.3% in the OS group (P <.001). The 30-day mortality rate was higher among patients with AKI in both ER (15.4% vs 3.1%; P =.006) and OS (13.2% vs 5.3%; P =.001) groups. Age, chronic kidney disease, presence of significant thrombus burden in the pararenal region, >1000 mL blood loss in ER group were associated with development of AKI. Age, diabetes mellitus, chronic kidney disease, presence of significant thrombus burden in the pararenal region, and a proximal clamping time of >30 minutes in the OS group were associated with the development of AKI, whereas renal perfusion during clamping was the protective factor against AKI development. After a median follow-up of 91 months, AKI was associated with higher mortality rates in both the ER group (58.9% vs 29.7%; P <.001) and the OS group (61.5% vs 27.3%; P <.001). After the same follow-up period, AKI was associated with a higher incidence of ESRD in both the ER group (12.8% vs 3.6%; P =.009) and the OS group (9.9% vs 2.9%; P <.001). The current study identified important pre and postoperative factors associated with AKI after juxta/pararenal abdominal aortic aneurysm repair. Patients with postoperative AKI had significantly higher short- and long term mortality and higher incidence of ESRD than patients without AKI. [ABSTRACT FROM AUTHOR]

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

Castleman disease represents a rare lymphoproliferative disorder of unknown etiology. It is usually located in the mediastinum and in very few cases in the retroperitoneal space. We present the case of a 43-year-old male patient with a retroperitoneal tumor that was incidentally diagnosed during an abdominal computed tomography scan. The patient underwent surgery by open approach, and the tumor, which was adherent to the superior pole of the left kidney, was entirely removed. The histology examination revealed a vascular-hyaline-type Castleman disease. The postoperative evolution was uneventful, with no signs of tumor recurrence at the 4-month check-up. The surgeon should be aware of the possible retroperitoneal location of Castleman disease, even if it is a rare occurrence, and a complete removal of the tumor is followed by a favorable long-term prognosis.

The objective of this study was to evaluate the proportion of pararenal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs) that could theoretically be treated with the investigational GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE; W. L. Gore & Associates, Flagstaff, Ariz) off-the-shelf multibranched endograft. The preoperative computed tomography scans of patients with pararenal aortic aneurysms and TAAAs treated at a single institution between 2007 and 2017 were reviewed. This cohort included both open and endovascular repairs performed in either elective or urgent/emergent settings. These studies were included in a retrospective feasibility study to verify anatomic feasibility of the TAMBE graft (with four antegrade portals) employed within the manufacturer's investigational instructions for use during the U.S. pivotal trial. The patient cohort was divided into two groups: extended thoracoabdominal aneurysm (E-TAA)—extent I, II, and III TAAA; and limited pararenal and thoracoabdominal aneurysm (L-TAA)—pararenal aortic aneurysm and extent IV TAAA. The anatomic factors determining the overall theoretical feasibility were further divided into three groups: vascular access feasibility, aortic feasibility, and visceral vessel feasibility. Computed tomography scans of 227 patients with degenerative aneurysms were analyzed, 166 with E-TAA and 61 with L-TAA. In the L-TAA group, 49% of the cases could have been treated with the TAMBE endograft alone; access feasibility was 85%, aortic feasibility 74%, and visceral vessel feasibility 72%. In the E-TAA group, only 23% of the cases could have been treated with a TAMBE combined with a GORE CTAG proximal thoracic stent graft; access feasibility was 79%, aortic feasibility 48%, and visceral vessel feasibility 63%. The different feasibility rate was related to a difference in aortic feasibility between L-TAA and E-TAA (74% vs 48%; P =.0008) because of the lack of a dedicated tapered thoracic component. The TAMBE multibranched endograft can theoretically be employed in half of an all-comers cohort of patients with degenerative L-TAA. Development of a dedicated tapered thoracic component is warranted to increase the feasibility for E-TAA, and comparative studies are required to investigate differences with other available off-the-shelf stent grafts. [ABSTRACT FROM AUTHOR]

Background-Aim: Limited data exist concerning the fluid dynamic changes induced by endovascular aortic repair with fenestrated and chimney graft modalities in pararenal aneurysms. We aimed to investigate and compare the wall shear stress (WSS) and flow dynamics for the branch vessels before and after endovascular aortic repair with fenestrated and chimney techniques. Methods: Modeling was done for patient specific pararenal aortic aneurysms employing fenestrated and chimney grafts (Materialise Mimics 10.0) before and after the endovascular procedure, using computed tomography scans of patients. Surface and spatial grids were created using the ANSYS CFD meshing software 2019 R2. Assessment of blood flow, streamlines, and WSS before and after aneurysm repair was performed. Results: The endovascular repair with chimney grafts leaded to a 43% to 53% reduction in perfusion in renal arteries. In fenestrated reconstruction, we observed a 15% reduced perfusion in both renal arteries. In both cases, we observed a decrease in the recirculation phenomena of the aorta after endovascular repair. Concerning the grafts of the renal arteries, we observed in both the transverse and longitudinal axes low WSS regions with simultaneous recirculation of the flow 1 cm distal to the ostium sites in both aortic graft models. High WSS regions appeared in the sites of ostium. Conclusions: We observed reduced renal perfusion in chimney grafts compared to fenestrated grafts, probably caused by the long and kinked characteristics of these devices. [ABSTRACT FROM AUTHOR]

Endovascular repair of complex abdominal aortic aneurysms has become increasingly common, but reports have mostly been limited to single centers and single devices. We studied all endovascular repairs of complex abdominal aortic aneurysms (zone 6 or caudal) from 2014 to 2018 in the Vascular Quality Initiative. This included all commercially available fenestrated endovascular aneurysm repair (FEVAR), chimney/snorkel repairs, and physician-modified endografts (PMEGs), exclusive of investigational device exemptions and clinical trial devices. We used inverse probability-weighted multilevel logistic regression to compare rates of perioperative outcomes including death, acute kidney injury (AKI), and major adverse cardiac events (MACEs; the composite of death/stroke/myocardial infarction) and Cox regression for long-term mortality. During the study period, surgeons performed 1396 complex endovascular repairs: 1308 (94%) elective, 63 (4.5%) for symptomatic aneurysms, and 25 (1.8%) for rupture. The number of centers performing complex endovascular repairs expanded steadily from 39 in 2014 to 81 in 2017. There were 880 FEVAR (63%), 256 PMEG (18%), and 260 chimney/snorkel repairs (19%). In elective cases, 3214 visceral vessels were incorporated and revascularized; 120 repairs (9%) involved one vessel, 481 (38%) repairs involved two vessels, 560 (44%) involved three vessels, and 113 (9%) involved four vessels. The mean number of arteries incorporated was 2.5 ± 0.8, with PMEGs involving the most arteries (3.3 ± 0.8 for PMEG vs 2.5 ± 0.6 for FEVAR and 1.9 ± 0.9 for chimney/snorkel; P <.001). PMEGs were used to treat more extensive aneurysms, and more incorporated the celiac and superior mesenteric arteries. There was no change in aneurysm extent, but the length of proximal seal extended over time. Chimney/snorkel cases employed more arm or neck access, had longer procedure times, and used more contrast material. Rates of perioperative death (3.4% for FEVAR vs 2.7% for PMEG vs 6.1% for chimney/snorkel; P =.13) and AKI (17% vs 18% vs 19%; P =.42) were similar, but chimney/snorkel was associated with higher rates of stroke (0.8% vs 0.9% vs 3.3%; P =.03) and MACEs (6.1% vs 5.4% vs 11.7%; P =.02). After adjustment, rates of perioperative death, AKI, and overall complications remained similar, but chimney/snorkel was associated with significantly higher odds of stroke (odds ratio [OR], 7.3 [1.5-36.4]; P =.015), myocardial infarction (OR, 18.7 [2.6-136.8]; P =.004), and MACEs (OR, 11.1 [2.1-58.9]; P =.005). Overall survival after elective repair was 91% at 1 year and 88% at 3 years, with no difference between repair types in crude or adjusted analysis. The Vascular Quality Initiative provides a unique opportunity to study the real-world application and outcomes of complex endovascular aneurysm repair. Perioperative morbidity appears to be higher after chimney/snorkel repair, but further study is needed to confirm these findings and to establish the durability of these novel technologies. [ABSTRACT FROM AUTHOR]

Objective: Custom-made fenestrated aortic endografts allow exclusion of pararenal aortic aneurysms while maintaining blood flow to aortic branches. Meticulous device planning and precise deployment of the main body are essential to allow successful cannulation of the fenestrations. This study investigates whether a learning curve can be observed with more reliable cannulation and connection of fenestrations over time at a single department of vascular and endovascular surgery with multiple surgeons trained to use the device.Methods: A retrospective analysis of data from all patients undergoing primary fenestrated endovascular aneurysm repair during the study period was performed. Outcome measures included case volume and average number of fenestrations over time, average fluoroscopy dose area product per calendar year and primary unconnected fenestration and 30-day mortality rates.Results: Between 1 January 2013 and 31 December 2016, 89 patients with no history of endovascular aneurysm repair underwent fenestrated endovascular aneurysm repair at our institution. The number of fenestrations per case increased over time, averaging 2.6 in 2013 and 3.3 in 2016. Primary unconnected fenestration and 30-day mortality rates were 5.6%. Primary-assisted technical success was 93.3%, secondary-assisted technical success was 94.4%. Fluoroscopy dose area product declined over the study period. Thirty-day mortality and primary unconnected fenestration rates did not significantly change over the study period.Conclusion: Albeit the reduction in lethal complications and primary technical success rates were not statistically significant, a lower percentage of unconnected fenestrations and 30-day mortality per calendar year were observed over time. At the same time, an increasing complexity of performed cases, as reflected by an increasing number of fenestrations per case, was observed. Complications associated with this complex endovascular procedure are potentially lethal and remain an unfortunate reality and may not be entirely dependent on overcoming a learning curve. A higher volume of cases performed over the study period and a reduction in fluoroscopy use can be considered a representation of the institutional development and learning curve for the Anaconda fenestrated endograft at a department with prior complex endovascular aortic repair experience, but due to limitations of the current retrospective observation, deserve further consideration in future trials, ideally designed in a prospective fashion. [ABSTRACT FROM AUTHOR]

Purpose: To report a single-center result of patients with pararenal aneurysms treated with inner-branched endograft., Materials and Methods: This retrospective study analyzed prospectively collected data of patients treated with elective inner-branched endovascular aneurysm repair (iBEVAR) using an Artivion ® E-xtra custom-made endograft. Primary endpoints were clinical and technical success after iBEVAR. Secondary endpoints were overall survival, target vessel patency during follow-up, aneurysm-related mortality, and freedom from reintervention., Results: Over a 56-month period, a total of 23 patients (19 men; 72.3±7.2 years) were treated with iBEVAR with a mean follow-up of 15 months. Technical success was achieved in 96% of procedures, incorporating 87 inner branches. Two (8.3%) intraoperative complications (target vessel dissection) were reported, without additional reinterventions needed. Two (8.3%) patients died within 30 days after initial procedure. One due to respiratory failure and the other from an ischemic stroke. During follow-up, 3 patients (13%) required reintervention, either to repair a type I or type III endoleak (n=2) or to place an iliac-branched device, that did not succeed during the initial iBEVAR procedure (n=1). Primary target vessel patency and freedom from reintervention during follow-up was, respectively, 98.9% and 87%. We revealed no aneurysm-related mortality. Overall survival was 78.3%., Conclusion: The present study confirms previous findings that iBEVAR on the Artivion ® E-xtra design platform is an effective and safe procedure achieving high technical success rate in the treatment of pararenal abdominal aortic aneurysms., Clinical Impact: Inner branched stent-graft configuration combines the benefits of FEVAR and outer-branched stent-graft technology. Implementation of inner branches in stent-grafts is gradually becoming more widespread for the treatment of aneurysms. This report supports the safe and high technical success rate of inner branched stent-grafts in treatment of pararenal abdominal aortic aneurysms., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: OY is consultant of Artivion. LB is consultant of Artivion. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Synopsis of presentation at APVIC VII, June 2015. [ABSTRACT FROM AUTHOR]

Endovascular abdominal aortic repair can involve the incorporation of renal arteries. Revascularization after intentional or unintentional renal artery (RA) coverage is not always technically successful, and the loss of a single RA may result in the need for postoperative dialysis. Thus, we compared the outcomes after endovascular aneurysm repair (EVAR) stratified by RA involvement (RAI). Patient data from the Vascular Quality Initiative from 2009 to 2018 registry were analyzed. The exclusion criteria were preoperative dialysis, missing RAI data, and repair above the superior mesenteric artery. The repair type cohorts were defined as (1) no RAI (NRAI), (2) RAI with revascularization (RAI-R), and (3) RAI with no revascularization (RAI-NR). A sensitivity analysis was performed by excluding ruptured presentations. The primary outcome was the need for postoperative dialysis. The secondary outcomes were 30-day mortality, dialysis at follow-up, postoperative renal function, and 2-year survival. Multivariate analysis was used to determine the independent predictors for postoperative dialysis. The 2-year survival analysis was performed using Kaplan-Meier log-rank test. Of 54,020 patients in the EVAR and TEVAR (thoracic EVAR)/complex EVAR modules in the Vascular Quality Initiative, 25,724 met the criteria for inclusion (NRAI, n = 24,879; RAI-R, n = 733; RAI-NR, n = 112). The demographics and comorbidities were similar among the three groups. The RAI-NR group had more frequently had ruptured or symptomatic aneurysms. The postoperative dialysis requirement was higher in the RAI-NR group (NRAI, 0.7%; RAI-R, 2.2%; RAI-NR, 17%; P <.0001), as were the 30-day mortality and dialysis requirement at follow-up. On multivariate analysis, RAI-R (odds ratio [OR], 2.2; P =.03) and RAI-NR (OR, 5.9; P <.0001) were independent predictors of postoperative dialysis and remained so after excluding ruptured presentations (RAI-R: OR, 3; P =.003; RAI-NR: OR, 22.3; P <.0001). Other independent predictors of the need for postoperative dialysis were worse preoperative renal function, a symptomatic presentation, any preoperative or intraoperative blood transfusion, and larger blood loss (≥200 mL). Excluding those with rupture, the overall survival at 2 years on Kaplan-Meier analysis was lower for the RAI-NR group (NRAI, 92%; RAI-R, 89%; RAI-NR, 80%; P =.004). RAI is highly predictive of the need for postoperative and permanent dialysis after EVAR. RAI-NR was associated with lower overall survival. These risks should be considered when planning and performing EVAR and should be weighed against the risks of open repair when considering the treatment options. [ABSTRACT FROM AUTHOR]

Background: Complex endovascular repair of abdominal aortic aneurysm carries higher perioperative morbidity than standard infrarenal endovascular repair., Objective: This study reviews the incidence and associated factors of acute kidney injury in complex aortic endovascular repair of juxtarenal, pararenal, and thoracoabdominal aortic aneurysms., Methods: A literature review was performed for all studies on the endovascular repair of juxtarenal, pararenal, and thoracoabdominal aneurysms that evaluated rates of acute kidney injury as an outcome. Outcomes were further analyzed by the level of anatomic complexity and method of repair., Results: 52 studies met inclusion criteria, with a total of 5454 individuals undergoing repair from 2004 to 2017. The overall rate of acute kidney injury ranged widely from 0 to 41%, with a rate of hemodialysis from 0 to 19% (temporary) and 0 to 14% (permanent). Increasing anatomic complexity was associated with higher rates of acute kidney injury. Mode of endovascular repair, learning curve effect, and preoperative chronic renal insufficiency did not demonstrate any associations with the outcome., Conclusion: Published rates of acute kidney injury in complex aortic aneurysm repair vary widely with few definitively associated factors other than increasing anatomic complexity and operative time. Further study is needed for the identification of predictors related to postoperative acute kidney injury., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

We successfully treated small saccular abdominal aortic aneurysms involving the renal artery origin with direct sagittal suture closure under supra-celiac or supra-superior mesenteric artery cross clamping after renal artery reconstruction in two cases. This technique might be a useful option for localized saccular aortic aneurysms in selected cases.