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Published interim results of the extended provisional extension to induce complete attachment (e-PETTICOAT) technique suggested favorable remodeling in chronic type B Aortic Dissection (cTBAD). This report presents long-term results of the e-PETTICOAT technique for the management of cTBAD (without aneurysmal dilatation).Patients with cTBAD below the 55 mm aortic size were eligible for the management using the e-PETTICOAT technique. Follow-up was conducted at 1, 2 and 5 years based on the computed tomography angiogram. All the presurgery risk factors (entry1 cm, inner curve entry, fusiform index0.65, false lumen 22 mm, aortic size40 mm, recurrent pain or hypertension, and Stanford Dissection Risk Calculation) and postsurgery complications were examined in the study.A total of 20 patients underwent the e-PETTICOAT surgery. The survival rate at 1, 2, and 5 years was 75%, 70%, and 64%, respectively, and the percentage of patients without any reinterventions was 100%, 93%, and 18%. Aortic degeneration was recognized in 30%, 55%, and 85% of the patients. Only 3 of the 20 patients were alive and without any reintervention after 5 years. The receiver operating curve analysis does not indicate any factor that would predict the remodeling result in the long-term follow-up.The use of e-PETTICOAT technique in cTBAD might not have a beneficial influence on the long-term results.

BACKGROUND: Advances in 3D printing technology allow us to continually find new medical applications. One of them is 3D printing of aortic templates to guide vascular surgeons or interventional radiologists to create fenestrations in the stent-graft surface for the implantation procedure called fenestrated endovascular aortic aneurysm repair. It is believed that the use of 3D printing significantly improves the quality of modified fenestrated stent-grafts. However, the accuracy and reliability of personalized 3D printed models of aortic templates are not well established. METHODS: Thirteen 3D printed templates of the visceral aorta and sixteen of the aortic arch and their corresponding computer tomography of angiography images were included in this accuracy study. The 3D models were scanned in the same conditions on computed tomography (CT) and evaluated by three physicians experienced in vascular CT assessment. Model and patient CT measurements were performed at key landmarks to maintain quality for stent-graft modification, including side branches and aortic diameters. CT-scanned aortic templates were segmented, aligned with sourced patient data, and evaluated for the Hausdorff matrix. Next, Bland-Altman plots determined the degree of agreement. RESULTS: The Intraclass Correlation Coefficients values were more than 0.9 for all measurements of aortic diameters and aortic branches diameter in all landmark locations. Therefore, the reliability of the aortic templates was considered excellent. The Bland-Altman plots analysis indicated measurement biases of 0.05 to 0.47 for aortic arch templates and 0.06 to 0.38 for reno-visceral aortic templates. The arithmetic mean of Hausdorff’s mean distances of the aortic arch templates was 0.47 mm (SD =0.06) and ranged from 0.34 to 0.58. The mean metrics for abdominal models was 0.24 mm (SD =0.03) and ranged from 0.21 to 0.31. CONCLUSIONS: The printed models of 3D aortic templates are accurate and reliable, thus can be widely used in endovascular surgery and interventional radiology departments as aortic templates to guide the physician-modified fenestrated stent-graft fabrication.

Introduction: An ectopic renal artery originating from the aortic bifurcation can strongly interfere with surgical or endovascular intervention in the infrarenal aorta. Case: We present an infrarenal symptomatic aneurysm with a right ectopic/pelvic kidney associated with 1 renal artery originating from the aortic bifurcation. Result: During an endovascular aortic repair (EVAR) procedure, the dominant ectopic right kidney was perfused by an iliac branch device (IBD) used as an iliac extension. However, out of instructions for use (IFU), this is an “off-the-shelf” resolution for this type of rare case. Conclusion: The use of an “off-the-shelf” IBD to perform an EVAR with an ectopic renal artery, in patients unfit for open surgery, is a potentially valuable option.

Objective This study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections. Methods Twenty patients with chronic type B aortic dissection with aneurysmal degeneration qualified for an expanded Petticoat strategy (stent graft in the thoracic, plus additional distal bare stent into the abdominal and infrarenal aorta, followed by parallel stent grafts into common iliac arteries). Computed tomography was performed preoperatively and at 1, 6, and 12 months after surgery. Results The primary technical success was 100%. The 30-day mortality rate was 0%. At 12 months, favorable aortic remodeling and complete false lumen (FL) thrombosis were noted as 100% in the thoracic and infrarenal aorta. The volume of contrast-enhanced FL decreased from 186 ± 75.4 mL all along the dissection preoperatively (range, 70-360 mL), to 6.32 ± 5.4 mL postoperatively (range, 0.0-19.6 mL) and was only observed in the visceral aorta (P = .000089). Despite persistent flow in a small area of the FL, the maximal aortic size was stable in follow-up. Neither paraplegia nor visceral branch occlusion were noted in the follow-up. Conclusions The treatment of aortic dissections with an expanded Petticoat strategy seems to be safe and offers good early results. It significantly reduced the volume of contrast enhanced FL. Further investigation of any subsequent results will be necessary.

An aortic arch stent graft is usually contraindicated with a mechanical aortic valve. However, a modified stent graft plus the use of an externalized transapical guidewire technique allowed a safe implantation close to a mechanical aortic valve.

Introduction: Critical limb ischemia (CLI) is a condition resulting from chronic impaired limb perfusion by arterial blood, which is always accompanied by rest pain. The key objectives of treatment are to prevent high-level amputations and to manage pain. Currently there are no strong recommendations regarding pharmacotherapy for pain in patients with CLI. The aim of the study was to evaluate analgesics currently used in patients with CLI on an outpatient basis and to assess their effectiveness in pain treatment. Materials and methods: The study included 88 patients diagnosed with CLI, who declared taking a painkiller in the past 12 h. Patients were asked for the name of the drug. The truth of the declaration was verified by the presence of the drug in the serum of 45 randomly selected patients. All patients rated pain intensity on a numerical scale (NRS) before and after treatment. Their mental state was evaluated by Mini-Mental State Examination (MMSE) test. Results: The most commonly used analgesics were ketoprofen, ibuprofen and acetaminophen. Pain management was successful in 11.4% of patients. Average pain intensity before taking the drug was 8.34 points (SD 1.27) and 5.85 (SD 1.57) after. In only 11 patients the presence of the declared drug was confirmed in serum. In 22 patients other drugs were found. For patients who reported that analgesic medication was ineffective, MMSE value averaged 22.1 (SD 4.95) and 25.1 (SD 4.25) for the group reporting effective treatment, p = 0.07. Patients reporting ineffectiveness of medications had suffered for an average duration of 8.2 weeks (SD 1.39), while the effective group average 5.2 weeks (SD 5.13), p = 0.06. Conclusions: Treatment of pain in patients with CLI in an out-patient setting is ineffective because it is based on medications used in the treatment of nociceptive pain and not neuropathic pain. There is an urgent need to improve the treatment of pain in patients with CLI by educating family doctors.

Purpose: To demonstrate the feasibility of augmented reality visualization in planning and navigating endovascular aortic repair. Technique: A 77-year-old patient with abdominal aortic aneurysm was treated with endovascular repair. An augmented reality head-mounted display was used during the procedure. The aneurysm and bones were projected as 3-dimensional holograms. The operator controlled the device with gestures and voice commands (movement, rotation, cutting through, and zooming). Moreover, the hologram was placed in front of the angiography monitor and manually registered with fluoroscopy. Conclusion: Augmented reality with holographic rendering is feasible and helpful during endovascular aortic repair. Its routine use could possibly lead to shorter operating time, reduced contrast volume, and lower radiation dose; however, larger studies are required to obtain statistically significant results on the outcomes.

Purpose. Carotid endarterectomy (CEA) is considered an effective therapeutic method for improving ocular circulation. The choroid is a predominantly vascular tissue; thus, systemic and local vascular alterations may influence its morphology and function. The aim of the current study was to analyse changes in choroidal thickness and volume in patients with significant internal carotid artery stenosis (ICAS) before and after unilateral CEA. Methods. The 42 eyes of the 21 asymptomatic patients included in the study were divided into two groups: those ipsilateral (EIE) and those contralateral (ECE) to CEA. All participants underwent a complete ophthalmologic examination, including enhanced depth imaging-optical coherence tomography (EDI-OCT). A comparative analysis of subfoveal thickness (CT) and choroidal volume (CV) measured in nine Early Treatment of Diabetic Retinopathy Study (ETDRS) subfields at baseline, on the 2nd day after CEA, and in the 3rd month after CEA was performed. Results. In the EIE and ECE groups, no significant differences in either CT or CV values before and on the 2nd day after the CEA were observed. In the EIE group, a significant increase in CT and CV in the 3rd month after CEA compared to baseline was noted in the specific ETDRS region. Changes in CT and CV after surgery were positively correlated with the participants’ physical activity status and diastolic blood pressure and negatively correlated with the participants’ age and smoking status. Additionally, the analysis of changes in CV after CEA showed a positive correlation between the EIE and ECE groups. Conclusions. CT and CV fluctuations in the central and perifoveal areas visualized with EDI-OCT enabled the observation of the processes of tissue adaptation to variable blood flow conditions.

Purpose: To demonstrate the utility of a 3-dimensional (3D) printed template of the aortic arch in the construction of a fenestrated and scalloped physician-modified stent-graft (PMSG). Case Report: A 73-year-old woman with descending thoracic aneurysm was scheduled for thoracic endovascular aortic repair after being disqualified for open surgery. Computed tomography angiography (CTA) revealed no proximal landing zone as the aneurysm began from the level of the left subclavian artery, so a fenestrated/scalloped PMSG was planned. To facilitate accurate placement of the openings in the graft, a 3D printed aortic arch template was prepared from the CTA data and gas sterilized. In the operating room, a Valiant stent-graft was inserted into the 3D printed template and deployed. Using ophthalmic cautery, a fenestration and a scallop were created; radiopaque markers were added. The PMSG was successfully deployed with no discrepancy between the openings and the target vessels. Conclusion: A 3D printed aortic arch template facilitates handmade fenestrations and scallops in PMSGs and may improve accuracy and quality.

Introduction Despite the increasing use of carotid angioplasty and stenting (CAS), carotid endarterectomy (CEA) nonetheless remains a more medically beneficial method of treatment for carotid artery stenosis. Therefore, one possibility for progress within this procedure may be to use minimally invasive carotid surgery, especially when the scar is in plain sight: the use of the natural wrinkles (skin crease) as a camouflage of the skin incision provides significant cosmetic improvements. Aim To compare the cosmetic effects of classic and trans-wrinkle CEA. To assess the distance between the carotid artery bifurcation (CAB) and the skin-crease incision whilst attempting CEA. Material and methods It was a randomized prospective study with two groups: patients undergoing classic surgery (control group; n = 100) and skin-crease trans-wrinkle camouflaged CEA (study group; n = 100). Follow-up was at 2 months and 1 year. Results The medical results of the treatment were similar in both groups. The cumulative count of strokes and myocardial infarctions was 0.5% within 30 days, and after one year 3.5% (and 5.5% including cases of death). The superiority of the transverse crease being hidden compared to the conventional longitudinal technique was proven in the Patient and Observer Scar Assessment Scale (POSAS) score, respectively 11.4 ±1.0 vs. 14.1 ±3.4 (p = 0.0001) after 2 months and 13.5 ±2.8 vs. 14.1 ±3.4 (p = 0.039) after a year. Conclusions Trans-wrinkle incision gives better cosmetic results, can be safely performed in most cases, and offers a comfortable approach during CEA.

Giant-cell arteritis is associated with a higher risk of aortic aneurysm and aortic dissection formation. We present a women with aortic dissection type B treated with a stent graft and bare-metal stent implantation. After the stent deployment we noticed aortic rupture, which was successfully treated with implantation of an additional stent graft. This report highlights the difficulty of endovascular therapy in patients with giant-cell arteritis. We have to bear in mind that chronic inflammation of the aorta leads to a more fragile aortic wall than normal. We recommend the use of a stent graft over a bare-metal stent and gentle use of a balloon catheter.

Background The aim of this paper was to evaluate a new technique called an “extended” provisional extension to induce complete attachment (e-PETTICOAT) technique. Methods In this prospective single-center clinical study, the primary safety end mid-term remodeling is evaluated for the new endovascular technique. It was based on a standard Petticoat and limited Stabilize technique, extended by the placement of 2 covered stents within the abdominal bare metal stent as parallel iliac stent grafts down to the iliac bifurcations. Computed tomographic angiography was performed postoperatively to assess aortic remodeling after 12 and 24 months. Changes in aortic size and volumes of the false and true lumen were assessed. Results Between January 2014 and December 2015, 17 patients were treated due to acute, complicated aortic dissection type III B, according to the DaBekey classification. All patients presented with branch vessel obstruction/compromise, including six cases with aortic impending rupture. A 100% technical success rate was recorded regarding the resolution of complications. Favorable remodeling was achieved in 100% of the cases. Complete false lumen thrombosis in the thoracic, infra-renal aorta and the iliac artery was noted. A small volume (9.51 ± 6.9 mL) contrast-enhanced false lumen in the abdominal aorta was observed in 76% of cases with stable aortic size after 1 and 2 years. No visceral branch occlusion, type I endo-leak, renal insufficiency or paraplegia was recorded in follow-up. Conclusions The expanded PETTICOAT technique was feasible in achieving favorable remodeling in acute extensive aortic dissection. Extended followup is needed to ascertain long-term results. This article presents a series of 17 cases of a new endovascular method called E-PETTICOAT (EJVES 2018 https://doi.org/10.1016/j.ejvs.2018.07.038 ) used in complicated acute and extensive type IIIB dissections. Favorable remodeling was achieved in 100% cases with stable aorta diameter after 1 and 2 years. It was shown that the extended PETTICOAT technique gives good remodeling in acute and extensive aortic dissection. This method can potentially provide a one-step solution and an easier alternative to FEVAR/BEVAR procedures. In order to ensure favorable results, further research is needed on a wider scale with long-term followup.

BACKGROUND The goal of this study was to assess the retinal microvascular function in asymptomatic patients with hemodynamically significant internal carotid artery stenosis (ICAS) and to assess the potential efficacy of carotid endarterectomy (CEA) for the improvement of vessel functionality. METHODS Retinal vessel caliber and reactions to flicker stimulation were assessed in both eyes of 65 asymptomatic patients with unilateral hemodynamically significant ICAS and 34 healthy subjects. Subsequently, the recruited ICAS patients were referred for standard unilateral CEA procedure. The full ophthalmologic examination of both eyes and vessel analysis were performed 1 day before and 3 months after CEA. RESULTS The venous responses to flicker stimulation were significantly lower in the EIS (eyes ipsilateral to stenosis) and ECS (eyes contralateral to stenosis) compared with those in the controls (P

INTRODUCTION The corrective effect of carotid endarterectomy (CEA) on impaired ophthalmic artery flow in patients with significant internal carotid artery (ICA) stenosis presenting with ocular ischemic syndrome (ie, symptomatic patients) is well established. However, there is no clear evidence regarding the efficacy of CEA for improvement of neuroretinal function in patients without symptoms of ocular ischemic syndrome. OBJECTIVES We aimed to determine the effects of CEA on retinal function in asymptomatic patients with hemodynamically significant ICA stenosis. PATIENTS AND METHODS We enrolled 46 patients with ICA stenosis referred for CEA. Full-field electroretinogram (ERG), pattern ERG, and pattern visual evoked potentials, as well as optical coherence tomography and ophthalmologic examination of both eyes were performed 1 day before and 3 months after CEA. We analyzed eyes ipsilateral (EIE) and contralateral (ECE) to CEA. RESULTS We observed an increase in several ERG wave parameters in both eye groups, compared with baseline values: rod b-wave amplitudes (P

Thoracic endovascular aortic repair (TEVAR) is an established treatment option, although some anatomical challenges require a through-and-through wire technique, and subsequently transapical access via minithoracotomy can be required. It is clear that an objective tool to facilitate decision-making is needed. A 3D print of a severely angulated aortic arch was used as a template to advance a stent graft, and this was achieved after pulling the top of the wire. This simulation assisted in decision-making relating to transapical access with a wire externalization. A 3D aortic print could be used in advance to simulate the TEVAR procedure and facilitate any other decisions regarding additional transapical access.

Rationale: Type A aortic dissection (TAAD) usually requires emergency open repair of the ascending aorta. In cases of diffuse dissection that spreads along the descending and abdominal aorta (type I, DeBakey classification), the risk of aneurysmal degeneration varies between 30% and 50% during 5 years and increases even higher during a longer follow-up. Those patients might require complex intervention to prevent aortic rupture. A combination of hybrid arch debranching and the extended provisional extension to induce complete attachment (e-PETTICOAT) technique might be an available alternative in such cases. This is the first report of the successful use of the e-PETTICOAT technique for treating degenerative, diffuse TAAD. Patient concerns: Acute chest pain and syncope were the initial symptoms of diffuse TAAD in our 66-year-old female patient. Open replacement of the ascending aorta followed by surgical arch debranching was performed as a staged procedure. Unfortunately, progressive aneurysmal degeneration was revealed 6 months later in the thoracic, abdominal, and infrarenal aorta with the recurrence of chest and lumbar pain. Diagnoses: Computed angiotomography revealed severe aneurysmal degeneration of aortic dissection in the thoracic and abdominal aorta. Intervention: The e-PETTICOAT enabled good remodeling and stopped degeneration. Outcome: At the 2-year follow-up, good remodeling with complete false lumen thrombosis and a stable aortic size were confirmed. Lesson: Lifelong follow-up in extensive TAAD should be considered. The e-PETTICOAT technique is an available alternative to fenestrated endovascular aortic repair for degenerative TAAD, as it promotes favorable remodeling after successful surgery of the ascending aorta.

Rationale Endovascular aortic repair in children in the case of aortic dissection (AD) is currently unavailable. This is the first report of aortic dissection type B in an 11-years old child treated in endovascular way. Patient concerns Complicated AD. Since bowel malperfusion and aortic rupture the surgery was necessary in emergency. Diagnoses Computed angio tomography. Intervention The modified PETTICOAT technique (Provisional Extension To Induce Complete Attachment) was used. Outcome Full recovery. Lessons For the first-time telescope modification were used, to allow aorta to grow with a child. Such a strategy seems to be possible with long overlap and lack of oversizing between implants.