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Background : Endotension is one of the detrimental complications after endovascular aneurysm repair (EVAR) and surgical management has been considered as standard of care. However, there is a paucity of data regarding the findings and outcomes of such surgical intervention. The aim of this study was to investigate intraoperative findings and outcomes of surgical treatment for endotension after EVAR. Methods : Between January 2005 and October 2018, of the 708 patients who underwent EVAR for aneurysm aortic aneurysm; 12 patients (mean age of 76.1; range 66–88) who underwent open repair for endotension were retrospectively analyzed. The anatomical characteristics of the aorta and surgical findings were reviewed. The rates of early and late procedural complications, and overall mortality were evaluated. Results : The median interval between the EVAR and surgical conversion was 45.9 months (range 17.1–46.9). Three of the twelve patients underwent emergency surgery due to aneurysm rupture. The median aneurysm sac size, the proximal neck diameter, and the proximal neck length before EVAR were 64 mm, 23.5 mm, and 30.5 mm, respectively, that changed before open repair to 93.5 mm (p = .02), 25 mm (p = .011), and 23 mm (p = .003), respectively. In four of the twelve patients, radiographically undetected endoleak was identified during surgery to be Type Ia, Ib, II, and III, respectively. The rates of early and late procedural complications, and overall mortality were 8.3%, 8.3% and 8.3%, respectively. Conclusions : Patients with endotension have a risk of delayed endoleak and aneurysm rupture; secondary intervention should be performed in such cases to prevent fatal complications. Surgical treatment appears to be a curative treatment for endotension with favorable outcomes. In addition, the possibility of an undetected endoleak should be considered as a potential cause of endotension.

Background Surgical treatment of ophthalmic segment aneurysms (OSAs) remain challenging because of complex anatomy surrounding the aneurysm and entails extensive drilling of anterior clinoid process to define proximal neck of the aneurysm and carotid exposure in the neck for proximal control. Materials and Methods Authors present a retrospective analysis of 36 aneurysms in 35 patients with OSAs operated surgically by first author. Surgical clipping was done for the aneurysms as primary modality of treatment along with wrapping and trapping as required. Results Commonest age group was 40 to 60 years with female preponderance of 3:1. Maximum (23) patients presented with subarachnoid hemorrhage (WFNS Gr 1), followed by asymptomatic patients (six). There were 18 small, 14 large, and four giant aneurysms, 15 dorsal wall, 17 ventral wall, three proximal posterior wall, and one blister aneurysm. Good outcome, as measured by Glasgow Outcome Score (GOS) was achieved in 29 patients. Conclusion OSAs are technically demanding aneurysms, but with due diligence to surgical principles, good outcomes may be obtained.

Objective: The treatment for arch aneurysms by endovascular repair is often difficult. This study evaluated the long-term outcomes of thoracic endovascular aortic repair for aortic arch aneurysms treated with the Najuta stent-graft system. Materials and Methods: From January 2009 to December 2019, 37 patients underwent treatment for aortic aneurysms with the Najuta stent graft system at two institutes, including our hospital. We retrospectively analyzed the short- and long-term clinical outcomes. Results: Of all 37 cases, the technical success rate was 97.3% (36 of 37). The mean proximal neck length was 20.1±5.3 mm. The postoperative results revealed 10 patients with type Ia endoleaks (27.8%), 6 with stroke (16.7%), and one with paraplegia (2.8%). In the chronic phase, the overall survival rates and the rates of freedom from aorta-related events at 7 years were 71.3% and 50.7%, respectively. Between two groups divided based on the proximal neck diameter of 20 mm, the

Objectives Endovascular procedures are now the standard of care for endovascular aortic aneurysm repair but treatment of hostile proximal neck anatomy is still challenging. New endografts were brought to the market specifically designed to accommodate severe neck angulation. Authors describe a preliminary experience and early results using the Gore Excluder Conformable endograft (W. L. Gore & Associates, Flagstaff, Ariz) and its active control system in severe neck angulation with a standardized technical approach to achieve precise deployment in this hostile anatomy. Methods From June 2019 to May 2020, five patients with abdominal aortic aneurysm and severe neck angulation (≥70°) were treated with the Gore Excluder Conformable endograft at two different centers. Deployment of this endograft in this kind of anatomy should be aggressive starting over the level of renal arteries due to risk of distal migration downward on the external curvature and difficulty in upward repositioning. Authors suggested a standard technique with a routine through-and-through axillary–femoral approach, using a floppy guidewire together with preventive cannulation of the lower renal artery if a short neck (Results Endovascular aortic procedures were successfully completed in all patients. Final deployment of the stent graft using our standardized technical approach was extremely precise in all cases even if redeployment of the graft was necessary in all cases. No other secondary procedures were needed. At 30 days, no type IA endoleak was recorded and no aneurysm-related secondary procedures were performed. Median follow-up for this group of patients was 5.2 months (range 1–11). Early results revealed no type IA endoleak and no migration at Ct angiogram. No aneurysm-related secondary procedures were required. Conclusion Routine use of through-and-through axillary–femoral guidewire associated with selective pre-cannulation of the lower renal artery allows a precise deployment of the Gore Excluder Conformable endograft in difficult anatomies possibly affecting early outcomes.

This case report describes a patient with a distal aortic arch and left subclavian artery aneurysm who was considered unsuitable for open surgical repair because of comorbidities and previous bypass surgery. Inadequate peripheral access precluded standard transfemoral thoracic endovascular aortic repair. Nonetheless, successful endovascular repair was possible via transapical access using the new Gore cTAG deployment mechanism, which allowed precise antegrade stent graft deployment in a short proximal neck. Keywords: TEVAR, Aortic aneurysm, Transapical access, Subclavian aneurysm, Stent graft

This study analysed the progression of proximal aortic neck diameter in patients with asymptomatic abdominal aortic aneurysms, treated by endovascular aortic repair using four different, contemporary types of endograft. This is a retrospective study of four cohorts of 30 patients presenting with asymptomatic abdominal aortic aneurysms and treated with endovascular aortic repair using four different types of contemporary endografts, namely Endurant® (Medtronic), Excluder® (W.L. Gore), Zenith® (Cook Medical) and Ovation® (Endologix) endografts. Patients’ demographics and aortic aneurysm measurements, including suprarenal aortic, proximal infrarenal neck and maximum aortic aneurysmal diameter, were gathered from the patients’ electronic medical records, pre- and post-interventional computed tomography studies, respectively. Diameter measurements were modelled as a function of endograft type; an interaction test was used to test whether the evolutions over time were different between the four types of endograft. Suprarenal aortic diameter increased over time (P = 0.0235) and maximum aortic aneurysm diameter decreased over time (P = 0.0008) in the four types of endograft. The progressive increase in proximal neck diameter from preoperative baseline up to five years of follow-up was 1.20 mm for Endurant (P = 0.0054), 1.72 mm for Ovation (P = 0.0006), 1.14 mm for Excluder (P = 0.0102) and 2.83 mm for Zenith (P

Purpose: This study investigated the effect of different EndoAnchor configurations on aortic endograft displacement resistance in an in vitro model. Materials and Methods: An in vitro model was developed and validated to perform displacement force measurements on different EndoAnchor configurations within an endograft and silicone tube. Five EndoAnchor configurations were created: (1) 6 circumferentially deployed EndoAnchors, (2) 5 EndoAnchors within 120° of the circumference and 1 additional, contralateral EndoAnchor, (3) 4 circumferentially deployed EndoAnchors, (4) 2 rows of 4 circumferentially deployed EndoAnchors, and (5) a configuration of 2 columns of 3 EndoAnchors. An experienced vascular surgeon deployed EndoAnchors under C-arm guidance at the proximal sealing zone of the endograft. A constant force with increments of 1 newton (N) was applied to the distal end of the endograft. The force necessary to displace a part of the endograft by 3 mm was defined as the endograft displacement force (EDF). Two video cameras recorded the measurements. Videos were examined to determine the exact moment 3-mm migration had occurred at part of the endograft. Five measurements were performed after each deployed EndoAnchor for each configuration. Measurements are given as the median and interquartile range (IQR) Q1, Q3. Results: Baseline displacement force measurement of the endograft without EndoAnchors resulted in a median EDF of 5.1 N (IQR 4.8, 5.2). The circumferential distribution of 6 EndoAnchors resulted in a median EDF of 53.7 N (IQR 49.0, 59.0), whereas configurations 2 through 5 demonstrated substantially lower EDFs of 29.0 N (IQR 28.5, 30.1), 24.6 N (IQR 21.9, 27.2), 36.7 N, and 9.6 N (IQR 9.4, 10.0), respectively. Decreasing the distance between the EndoAnchors over the circumference of the endograft increased the displacement resistance. Conclusion: This in vitro study demonstrates the influence EndoAnchor configurations have on the displacement resistance of an aortic endograft. Parts of the endograft where no EndoAnchor has been deployed remain sensitive to migration. In the current model, the only configuration that rivaled a hand-sewn anastomosis was the one with 6 EndoAnchors. A circumferential distribution of EndoAnchors with small distances between EndoAnchors should be pursued, if possible. This study provides a quantification of different EndoAnchor configurations that clinicians may have to adopt in clinical practice, which can help them make a measured decision on where to deploy EndoAnchors to ensure good endograft fixation.

Objectives A hostile proximal neck anatomy is the most common cause of abdominal aorta endovascular aneurysm repair failure leading to a higher risk of device migration, proximal type I endoleak, and subsequent open surgical repair. Endostapling is a technique to attain better fixation of the endograft to the aortic wall, and the only available device in the USA is Aptus Heli-FX EndoAnchor system (Medtronic Vascular, Santa Rosa, CA, USA). Preliminary data have shown efficacy and safety of its use, and the aim of this study is to assess device-related adverse events in real-world clinical use. Methods We quarried data from the publicly available Manufacturer and User Facility Device Experience database to identify Aptus Heli-FX EndoAnchor system-related adverse reports in endovascular aneurysm repair since FDA approval till August 31, 2017. An estimate of total devices implanted in the United States was quoted around 7,000 (Medtronic marketing internal data). Results Our query identified 229 separate reports, of which there were 85 adverse events (1.2% of the estimated EndoAnchor systems used). The most common adverse events were device dislodgement/fracture (65) and applicator malfunction (20). Conclusion In early post-FDA approval use in a real-world setting, the EndoAnchor system is associated with a low rate of adverse events. Device dislodgement and embolization remain the most common adverse events. With increasing use of these devices in more difficult anatomy, careful patient selection and careful attention to technique may help to reduce these events even further.

Background Endovascular aortic sealing (EVAS) using the Nellix system was a new approach to reduce the frequency of type II endoleaks after endovascular aortic repair. We analyzed the mid-term results, specifically looking at device migration, endoleaks and subsequent necessary secondary interventions. Results Ten patients underwent elective EVAS treatment during our study period. 7 patients were within the IFU while 3 patients had a proximal neck shorter than 10 mm. Technical success rate was 100% and there were no short-term vascular complications. One patient died from urosepsis 14 days after the procedure and was excluded from further analysis. A total of 6 out of 9 patients (67%) experienced device complications such as proximal graft kinking, limb separation or caudal migration. 5 also showed type Ia endoleak. Discussion While no complication occurred short-term (up to 12 months), the Nellix system showed a high percentage of limb separation, caudal graft migration, and type Ia endoleak on mid-term follow-up, likely due to insufficient proximal anchoring of the device. Possible salvage treatments are discussed.

Aneurysms are considered as a critical cardiovascular disease worldwide when they rupture. The clinical understanding of geometrical impact on the flow behaviour and biomechanics of abdominal aortic aneurysm (AAA) is progressively developing. Proximal neck angulations of AAAs are believed to influence the hemodynamic changes and wall shear stress (WSS) within AAAs. Our aim was to perform pulsatile simulations using computational fluid dynamics (CFD) for patient-specific geometry to investigate the influence of severe angular (≥ 60°) neck on AAA's hemodynamic and wall shear stress. The patient's geometrical characteristics were obtained from a computed tomography images database of AAA patients. The AAA geometry was reconstructed using Mimics software. In computational method, blood was assumed Newtonian fluid and an inlet varying velocity waveform in a cardiac cycle was assigned. The CFD study was performed with ANSYS software. The results of flow behaviours indicated that the blood flow through severe bending of angular neck leads to high turbulence and asymmetry of flows within the aneurysm sac resulting in blood recirculation. The high wall shear stress (WSS) occurred near the AAA neck and on surface of aneurysm sac. This study explained and showed flow behaviours and WSS progression within high angular neck AAA and risk prediction of abdominal aorta rupture. We expect that the visualization of blood flow and hemodynamic changes resulted from CFD simulation could be as an extra tool to assist clinicians during a decision making when estimation the risks of interventional procedures.

The utilisation rate of endovascular aortic aneurysm repair has increased continuously over the past 2 decades. Endovascular aortic aneurysm repair is still performed frequently in patients with an unfavourable proximal seal zone, despite the associated late complications.We aimed to evaluate the mid-term durability of the GORE® EXCLUDER® AAA Endoprosthesis, featuring the C3 delivery system, in patients with a proximal neck anatomy outside the instructions for use (IFU).A retrospective sub-analysis of the Global Registry for Endovascular Aortic Treatment including patients treated for abdominal aortic aneurysms with the GORE EXCLUDER AAA Endoprosthesis (W.L. GoreAssociates, Inc, Flagstaff, Arizona) was performed. A "challenging neck" was defined as those treated outside the IFU with an aortic neck length15 mm and/or aortic neck angle60°. Cox proportional analyses were used to test for time-to-event differences between those treated within and outside the IFU while accounting for covariates, specifically proximal neck length and neck angle. The main outcomes assessed were 5-year all-cause mortality, 5-year endoleak development (type I or III), and 5-year device-related reinterventions.Of the 3,324 patients included in the analysis, 411 (12.4%) had a challenging neck and 2,913 (87.6%) did not. The patients in the challenging neck group were significantly older (74.9 years vs. 73.2 years, p≤0.0001) and had a significantly larger aortic aneurysm diameter at the time of the intervention than those treated within the IFU (61.2 mm vs. 56.4 mm, P0.0001), shorter proximal neck length (18 mm vs. 30 mm, P0.0001) and larger infrarenal neck angle (60.8° vs. 25.8°, P0.0001). In the multivariate analysis, brachial access site and challenging neck were not independent risk factors; increased age was associated with a shorter time to mortality (hazard ratio 1.051, 95% confidence interval 1.039-1.062, P0.0001), as was the use of tobacco (hazard ratio 1.329, 95% confidence interval 1.124-1.571, P= 0.0009). The 5-year all-cause mortality (36.2% vs. 27.5%, P= 0.002) and aorta-related mortality (3.8% vs. 1.1%, P= 0.002) were significantly higher in the challenging neck group. The risk of death within 5 years also increased significantly at 1.1% per millimetre increase in the abdominal aortic aneurysm diameter (P= 0.0005). Furthermore, the rates of type Ia endoleak development (7% vs. 1.2%, P0.001) and requirement for reintervention (13.3% vs. 9.7%, P0.001) were higher in those treated outside the IFU (challenging neck group).Treatment with the Excluder AAA Endograft outside the IFU was associated with higher 5-year mortality values, increased type Ia endoleak development rates, and a greater need for reintervention compared with treatment within the IFU. This reiterates that fenestrated and open treatments should be strongly considered in cases with aortic neck anatomies outside the IFU. Infrarenal endovascular intervention outside the IFU should only be used when there is no alternative, with meticulous procedural planning and intervention to promote satisfactory outcomes.

Objectives Abdominal aortic aneurysms with a wide proximal neck (>32 mm) are a contraindication for the use of conventional abdominal endovascular stent grafts because of their limited maximum proximal diameter (36 mm). In these cases, it is customary to resort to sophisticated techniques such as parallel or fenestrated grafts. In very selected cases, such as symptomatic wide neck aneurysm or patient with limited life expectancy, Funnel Technique may find an indication. Methods It consists in placing a bifurcated endograft in the abdominal aorta embricated with a thoracic endograft as a proximal cuff in an infrarenal position. Results In the literature review, we found 32 cases of this technique, whose characteristics are collected in a table. Conclusion The Funnel Technique, taking advantage of the larger diameters of the thoracic prostheses, may easily treat abdominal aortic aneurysm cases with a wide neck.

Female patients undergoing endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysms present with more challenging anatomy and historically have worse outcomes compared with men. The Ovation Abdominal Stent Graft platform (Endologix, Irving, Calif) contains a polymer-filled proximal sealing ring and has a low-profile delivery system, potentially beneficial in female patients. We therefore investigated differences in long-term outcomes between men and women treated with this device.We used data collected prospectively in the Effectiveness of Custom Seal with Ovation: Review of the Evidence (ENCORE) database, comprising five trials and the European Post-Market Registry. Anatomic characteristics of the proximal aneurysm neck and iliac arteries were compared between male and female patients. Outcomes were 5-year freedom from type IA and type I/III endoleaks, abdominal aortic aneurysm-related reinterventions, and overall survival. We used Kaplan-Meier analysis to estimate survival proportions and tested univariate differences in survival using log-rank tests. Cox proportional hazards modeling was used to adjust for baseline differences.We identified 1045 (81%) male and 251 (19%) female patients undergoing EVAR. Female patients were older (mean age, 75 ± 8.4 years vs 73 ± 8.1 years; P .006). Aneurysm diameter (52 ± 7.5 mm vs 55 ± 9.2 mm; P .001) and proximal neck diameter (21 ± 3.3 mm vs 23 ± 2.9 mm; P .001) were smaller in female patients, but adjusted for body surface area, female patients had relatively larger aneurysms and aneurysm necks. Furthermore, female patients presented with shorter proximal necks, smaller iliac artery diameters, more angulated necks, and higher rates of reverse-tapered necks. Five-year freedom from type IA endoleak was similar between men and women (97% vs 96%; P = .38), as was freedom from type I/III endoleaks (91% vs 94%; P = .37) and reinterventions (91% vs 93%; P = .67). Five-year survival was 81% for female patients, similar to the 79% in male patients (P = .55), with one aneurysm-related death in female patients (0.4%) and five in male patients (0.8%; P = .76). Risk-adjusted analyses showed no association between sex and type IA endoleak (hazard ratio [HR], 1.4; 95% confidence interval [CI], 0.6-3.1; P = .41), type I/III endoleak (HR, 1.4; 95% CI, 0.7-2.8; P = .33), reintervention (HR, 1.0; 95% CI, 0.6-2.0; P = .77), and overall mortality (HR, 0.7; 95% CI, 0.4-1.1; P = .14).Female patients undergoing EVAR with the Ovation platform presented with substantially more adverse proximal neck characteristics. Despite these differences, 5-year freedom from endoleaks and overall survival did not differ between sexes.

Background Device selection for endovascular treatment of abdominal aortic aneurysms (AAAs) with necks >60° is challenging. We sought to identify whether such anatomy necessitated graft oversizing during (endovascular aneurysm repair [EVAR]), and whether this increased the risk of type 1A endoleaks. Methods Prospective analysis of patients undergoing implantation of a C3 Gore Excluder, with aortic anatomy defined as outside Instructions for Use (IFU) due to proximal neck angulation >60° was performed. Results Of the 1,394 patients enrolled, 127 patients (9.2%) were included, with median follow-up of 236 days. Mean neck angle was 78.0 ± 13.2%, neck length 2.88 ± 1.31, and mean graft oversize 23.5 ± 9.6%. There were 7 type 1A endoleaks (5.5% males, 5.6% females). Neither neck length, angle, nor degree of oversizing were predictors of type IA endoleak. Conclusions In conclusion, when selecting endografts for patients with proximal neck angulation over 60°, endovascular interventionalists are not adhering to IFU. However, this was not associated with increased risk of type 1A endoleaks.

The anatomy of aortic aneurysms from the proximal neck to the access vessels may create technical challenges for endovascular repair. Upwards of 30% of patients with abdominal aortic aneurysms (AAA) have unsuitable proximal neck morphology for endovascular repair. Anatomies considered unsuitable for conventional infrarenal stent grafting include short or absent necks, angulated necks, conical necks, or large necks exceeding size availability for current stent grafts. A number of advanced endovascular techniques and devices have been developed to circumvent these challenges, each with unique advantages and disadvantages. These include snorkeling procedures such as chimneys, periscopes, and sandwich techniques; "homemade" or "back-table" fenestrated endografts as well as manufactured, customized fenestrated endografts; and more recently, physician modified branched devices. Furthermore, new devices in the pipeline under investigation, such as "off-the-shelf" fenestrated stent grafts, branched stent grafts, lower profile devices, and novel sealing designs, have the potential of solving many of the aforementioned problems. The treatment of aortic aneurysms continues to evolve, further expanding the population of patients that can be treated with an endovascular approach. As the technology grows so do the number of challenging aortic anatomies that endovascular specialists take on, further pushing the envelope in the arena of aortic repair.

Background Large gutters after chimney procedures are one of the main causes of type I endoleak (EL-I). This study aims to evaluate a new tailored planning named “Over-SIRIX,” based on Osirix Imaging Software, to choose the correct main graft oversizing in order to minimize EL-I incidence. Methods From 2008 to 2015, 34 patients were treated with parallel grafts for aortic arch diseases at our institution. The study included 22 patients with single stent and antegrade flow configuration; they were divided into 2 groups (PRE- and POST-“Over-SIRIX”). “Over-SIRIX” was carried out in the retrospective group (PRE-“Over-SIRIX”), and it was used to plan the endovascular procedure in the prospective group (POST-“Over-SIRIX”). Through the multiplanar reconstruction (MPR) of the preoperative computed tomography angiography (CTA), the proximal neck of the chimney grafts was studied. Stent and endograft configurations were drawn in order to minimize the “gutters.” To obtain the ideal main graft sizing (I-Size), a formula was used by adding the custom sizing (C-Size) to the disease oversizing (D-Over). The same MPR imaging was evaluated on postoperative CTA to study gutters area and presence of EL-I. Results The mean I-Size was 41.67 mm that was equivalent to an ideal oversizing of 19.3% (range 10–28%). The gutters area decreased from 7.3 to 1.7 mm 2 (PRE/POST) and EL-I rate from 28.5% to 0% (PRE/POST). Gutters area bigger than 7.5 mm 2 and planning made without “Over-SIRIX” were significantly associated ( P Conclusions “Over-SIRIX” appears to be a feasible method to customize planning during chimney technique, reducing the risk of EL-I which is significantly related to the presence and size of the gutters.

Endovascular repair is often difficult in the case of a huge abdominal aortic aneurysm for anatomic reasons. Here, we describe open repair of a huge infrarenal abdominal aortic aneurysm. Open repair was performed through laparotomy with the Cattell-Braasch maneuver, a technique for right-sided medial visceral rotation. Laparotomy with the Cattell-Braasch maneuver is simple and effective in open repair of a huge abdominal aortic aneurysm extending into the right common iliac artery, for which proximal clamping is difficult because of a tortuous proximal neck just below the hepatic region. Keywords: Laparotomy, Cattell-Braasch maneuver, Abdominal aortic aneurysm

Nowadays, endovascular aneurysm repair (EVAR) is the first line approach in abdominal aortic aneurysm (AAA) repair. A sufficient infrarenal aortic neck is one of the key points for successful outcome after EVAR. Proximal neck characteristics remain a challenge in endovascular treatments. In these case report, we present you a 75-year-old, male patient with a large neck AAA. He was unsuitable to standard EVAR therapy and open surgery because of his comorbidities. Funnel technique in which a thoracic stent-graft is placed through the main body of a bifurcated or uni-iliac endograft could be a feasible and succesfull treatment in such cases.

Endograft sizing for endovascular abdominal aortic aneurysm repair (EVAR) is not consistent despite published instructions for use (IFU). We sought to identify factors associated with over/undersizing, determine sex influence on sizing, and examine sizing effects on endoleak, reintervention, and mortality by analyzing data obtained from the W.L. GoreAssociates Global Registry for Endovascular Aortic Treatment (GREAT).All patients enrolled in GREAT undergoing EVAR were included for analysis. Proximal/distal aortic landing zones were compared with device implanted to assess sizing as related to IFU. χThere were 3607 EVAR subjects enrolled in GREAT as of March 2020. Of them, 1896 (53%) were within IFU for sizing, 791 (22%) were oversized, 540 (15%) were undersized, and 380 (10%) had both over- and undersized components. Factors predictive of use outside of IFU included female sex (P = .001), non-white race (P = .0003), decreased proximal neck length (P .061), or larger iliac diameters (P .0001). Women were more likely than men to have proximal neck undersizing and iliac limb oversizing, and men were more likely to have iliac limb undersizing. On multivariate analysis, undersizing of the proximal graft was associated with endoleak (hazard ratio [HR], 1.8) and aortic (HR, 60.5) and all-cause (HR, 18.0) mortality. Undersizing of iliac limbs was associated with endoleak (HR, 1.5) and device-related reintervention (HR, 1.4). Iliac limb outside IFU sizing was associated with aortic (HR, 2.6) and all-cause (HR, 1.3) mortality. Proximal and distal oversizing was not associated with adverse outcomes. Female sex was associated with mortality on univariate but not multivariate analysis.Women undergoing EVAR with GORE EXCLUDER abdominal aortic aneurysm Endoprosthesis (W.L. Gore Associates Inc, Flagstaff, Ariz) are more likely to have proximal stent-graft undersizing and iliac limb oversizing, whereas men are more likely to have undersized iliac limbs. Proximal aortic graft undersizing is associated with endoleak and all-cause/aortic mortality, whereas undersizing of iliac limbs is associated with endoleak and device-related reintervention. Oversizing was not associated with adverse outcomes.

Background In recent years, endovascular abdominal aortic aneurysm repair (EVAR) for treating abdominal aortic aneurysms (AAA) has become quite prevalent in Japan. Though little information is available about temporal changes in proximal neck angulation due to the difficulties encountered in measuring the angle. Therefore, we examined temporal changes in proximal neck angulation and its relationship to stent-graft migration after EVAR. Methods Between June 2007 and March 2010, 159 patients underwent EVAR for treatment of fusiform AAAs at our hospital. This study focuses on the 80 patients among this group whose treatment sites and subsequent stent grafts were examined by contrast computed tomographic angiography before surgery, directly after surgery (within 4 days), as well as 1 year and 2 years thereafter. We created curved planar reconstruction (CPR) images and measured the length of migration and neck angle using our method. Results At 2 years after EVAR, the average length of proximal landing zone was 21.4 ± 9.2 mm. The average length of stent migration after 2 years was 1.41 ± 2.68 mm. The average neck angle was 33.9° preoperatively and 29.9° directly after surgery yielding a significant difference. However, 1 and 2 years after surgery the average neck angle was 28.2° and 28.4°, respectively. The number of patients experiencing a change >6° in the angle of the proximal neck between the preoperative condition and that directly after surgery was 16 (34.8%) with the use of Zenith stent grafts ( n = 46) and 14 (41.2%) with the use of Excluder stent grafts ( n = 34). There was no correlation between the proximal neck angle and migration of the proximal stent graft. In addition, there was no correlation between the changes in proximal neck angle and the secondary intervention rate and the occurrence of endoleak. Conclusions There was a significant change in the neck angle between the preoperative condition and the immediate postoperative condition. However, there was no clear relationship found between the angle of the neck and the proximal stent-graft migration. Postoperative changes in the proximal neck angle just after EVAR and subsequent temporal changes during a 2-year follow-up period do not appear to predict stent-graft migration, secondary intervention rates, or the occurrence of endoleak.

Abdominal aortic aneurysm is a common vascular disease requiring surgical treatment. Currently, endovascular aortic repair is a good alternative to open surgery. However, high incidence of unfavorable anatomical variants of the proximal landing zone limit the use of endovascular aortic repair in these patients. Additional techniques can increase applicability of endovascular procedure with optimal results. Two patients with unfavorable proximal neck anatomy undergoing endovascular aortic repair with anchor type of proximal fixation devices are reported in the article.Аневризма брюшного отдела аорты - распространенное сосудистое заболевание, которое требует хирургического лечения. В настоящее время эндоваскулярное протезирование является полноценной альтернативой открытому вмешательству. Однако высокая частота встречаемости вариантов неблагоприятной анатомии проксимальной зоны фиксации ограничивает применение эндоваскулярного лечения аневризм брюшного отдела аорты у таких пациентов. Использование дополнительных техник может увеличить применимость эндоваскулярной методики с сохранением оптимальных результатов. Приводим 2 клинических случая эндоваскулярного лечения аневризм брюшного отдела аорты у пациентов с неблагоприятной анатомией проксимальной шейки и использованием устройств проксимальной фиксации якорного типа.

The overall goal of the study was to develop new recommendations for tie-rail placement combining both vertical and horizontal positions to improve dairy cow welfare. Four treatments were tested: 2 new tie-rail positions that followed the natural neckline of cows when feeding and rising [neckline 1 (NL1), neckline 2 (NL2)], current recommendation (CR), and the average tie-rail position currently found on Quebec farms (current average on farm; CF). All other stall dimensions followed CR based on average cow size. Forty-eight cows blocked by parity and stage of lactation were randomly allocated to a treatment for 10 wk. Live scoring was performed weekly to evaluate injury, cow and stall cleanliness, and bedding quantity. Daily lying time, lying bout frequency, and lying bout duration were continuously recorded using leg-mounted accelerometers. Cows were recorded 1 d/wk by overhead cameras to evaluate lying down and rising events. Tie-rail placement did not affect cow and stall cleanliness, bedding quantity, and lying time. All tie-rail placements tested resulted in neck injuries with the position of neck injuries shifting based on the change in tie-rail placement: CR increased in proximal neck injuries (mean ± standard deviation, difference in injury score from baseline: +0.89 ± 0.153) compared with NL2 (+0.06 ± 0.153), but decreased in medial neck injuries (−0.11 ± 0.166) compared with NL2 (+0.78 ± 0.166) and NL1 (+0.53 ± 0.166). All treatments showed a decrease over time in average lying intention time (mean, difference between overall short- and long-term: −5.8 s/event), lying-down time (−1.1 s/event), contact with stall during lying (−32.5%), slipping during lying (−9.1%), backward movement on knees during rising (−10.9%), contact with tie-rail during rising (−14.3%), and overall abnormal rising (−15.6%) over time. Although lying and rising ability improved over time, abnormal lying and rising behaviors were still highly prevalent in the long term. Overall, our results show that dairy cows are limited in their ability to move within their environment without coming in contact with the stall confines (tie-rail and divider bars), warranting further research to determine alternatives to metal tie-rail bars, such as a flexible bar or chain, or provide fewer obstacles through the elimination of some stall hardware.

Purpose: To evaluate the advantages of chimney endovascular aneurysm repair (chEVAR) using an Endurant stent-graft with uncovered balloon-expandable stents (BES) for patients with juxtarenal aortic aneurysms. Materials and Methods: Twenty-two patients (mean age 78.5±9.0 years; 13 men) who underwent chEVAR using Endurant and uncovered BES between January 2014 and December 2017 were analyzed retrospectively. The maximum aneurysm diameter was 59.1±11.9 mm, and the proximal neck length was 5.2±2.9 mm. Of the 22 cases, 9 (40%) involved proximal neck angulation and 9 (40%) had a conical neck. Single and double chimneys were performed using BES in 19 and 3 cases, respectively. In 2 cases, an additional self-expanding covered stent was used inside the uncovered BES. Results: The technical success was 91% (20/22) as 2 (9%) cases showed minor type Ia endoleak. No postoperative systemic complications or acute renal dysfunction (Acute Kidney Injury Network classification stage 2 or higher) were observed. The mean radiologic observation period was 16.1±9.6 months, and no aneurysm expansion (>5 mm) was observed during this time. The mean maximum aneurysm diameter decreased to 52.9±10.2 mm (p