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Introduction: Worldwide, there is an increase in scrutiny after surgical treatment of a vast array of pathologies. Doing so, a large body of evidence clearly supports centralisation, such as teaching hospitals, where a larger caseload enables optimal outcomes. These institutions have a strong presence of surgical residents seeking training in both technical and non-technical skills. Inevitably, as part of training, they will be involved in the surgical treatment of those patients, even as the primary operator. We sought to investigate the impact of trainee performed procedures in outcomes of common vascular procedures of different technical complexity., Methods: A non-systematic MEDLINE and Scopus databases review on the outcomes of resident performed common vascular procedures was performed., Results: Specific evidence in many procedures (venous disease, aortic aneurysms, peripheral artery disease) is lacking. After carotid endarterectomy (CEA), resident performed procedures seem to have similar cranial nerve palsy and stroke when compared to expert surgeons. Generally, resident-performed primary radiocephalic and elbow arteriovenous fistula (AVF) presents similar primary and secondary patency. As with CEA, AVF procedures performed by residents took longer. On aortic aneurysms, although no specific comparison has been performed, resident involvement (irrespective of surgeon or assistant) in these procedures does not seem associated with increased adverse events., Conclusion: In most vascular surgery procedures, little is known about resident performance and their impact on outcomes. Notwithstanding, resident-performed CEA and primary AVF seem free of major compromise to patients. Further research is warranted to clarify this topic.

Objective: Post-implantation syndrome (PIS), characterised by malaise, fever, and increased inflammatory markers, is a common occurrence after endovascular aneurysm repair (EVAR), causing prolonged hospitalisation and increased cost. This study aimed to determine the incidence and short-term outcomes of PIS after fenestrated or branched procedures in aorto-iliac aneurysms compared with standard EVAR., Methods: A retrospective, comparative study from a tertiary academic institution was undertaken. All patients who underwent elective EVAR with polyester stent grafts from January 2015 to June 2021 were considered. Two groups were defined: standard EVAR (sEVAR) and complex EVAR (cEVAR). The latter included visceral fenestrated and branched or iliac branch and chimney stent grafts. The primary outcome was the incidence of PIS within three days of the index procedure. Secondary outcomes were short-term complications and risk factors for PIS. A multivariable model was constructed to correct for confounders., Results: Overall, 253 patients were included: 165 (65.2%) sEVAR and 88 (34.8%) cEVAR. Complex EVAR patients were younger, with larger aneurysms, had longer procedures, and were more likely to have intra-operative complications. The PIS incidence was 23.7% (n = 60), significantly higher in cEVAR (34.1% vs. 18.2%; p = .005) and increased with the complexity of the procedure (EVAR: 18.2% vs. EVAR + iliac branch device: 25.0% vs. fenestrated and branched EVAR: 36.2%; p = .030). On multivariable analysis, cEVAR (OR 2.833, 95% CI 1.295 - 6.198; p = .009) was associated with a significantly increased risk of PIS. No differences in short term outcomes according to PIS status were noted. Group sub-analysis for cEVAR patients did not reveal any statistically significantly different outcomes according to PIS occurrence., Conclusion: In this cohort, cEVAR procedures were associated with a significantly increased risk of developing PIS compared with standard infrarenal repair. Post-implantation syndrome also appears to have a benign course with no major impact on peri-operative outcomes after cEVAR. Further research to confirm these findings is required., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Portuguese nationwide estimates indicate that 20% of abdominal aortic aneurysms (AAAs) are treated when ruptured. In these cases, intra-operative unfractionated heparin (UFH) usage rates vary widely. Evidence on this topic is scarce and focused on patients treated by open repair (OSR). The aim was to determine the influence of UFH on peri-operative thromboembolic events (TEs) and death in a cohort of ruptured AAA (rAAA)., Methods: Retrospective, single-centre, comparative study. From 2011 to April 2023, all consecutive rAAAs (endovascular repair [EVAR] and OSR) were considered. Primary outcomes were 30-day TE free survival and TE rates. The secondary outcome was 30-day death. Safety endpoints were procedural blood loss, blood product requirements, and secondary interventions due to haemorrhage. Using propensity score matching (PSM) each UFH patient was matched with one no UFH patient in a 1:1 ratio., Results: The study included 250 patients. After PSM, 190 patients were analysed (EVAR: 60.0% no-UFH vs. 64.4% UFH). TE free survival estimates favoured the UFH group (67.3% vs. 47.2%, p = .009; UFH adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 1.04-4.17). TEs were more frequent in the no UFH group (20.0% vs. 44.2% patients, p < .001; UFH aOR 0.31, 95% CI 0.15-0.65 for any TE), driven by an increase in bowel ischaemia (17.9% no UFH vs. 3.2% UFH, p = .001). Most events occurred in the first 72 hours. EVAR was associated with reduced TE and improved TE free survival (aOR 0.20, 95% CI 0.09-0.45 and aOR 5.54, 95% CI 2.34-13.08, respectively). No significant differences in 30-day survival were noted (75% no-UFH vs. 83% UFH, p = .26; aOR 1.08, 95% CI 0.48-2.43) nor in blood loss, peri-operative red blood cell and fresh frozen plasma requirements, or secondary interventions due to haemorrhage ( p = .10; p = .11; p = .13 and p = .18 respectively)., Conclusion: In this cohort, intra-operative UFH was safe and associated with improved TE free survival, driven by a reduction in bowel ischaemia. Conversely, mortality remained unaffected. Randomised controlled trials are required to confirm these findings., Competing Interests: Frederico Bastos Gonçalves has received speaker and proctoring fees from W.L. Gore, Medtronic, and Cook Medical., (© 2023 The Author(s).)

A 42-year-old previously healthy male presented with 5 days of spontaneous mid-epigastric intense abdominal pain and mild epigastric tenderness on palpation. CT angiography revealed a Sakamoto type 2 isolated superior mesenteric artery dissection (SMA) with a "cul-de-sac" shaped false lumen (B- C: large arrow), side branch perfusion from both lumens, and compression of the true (A-D: small arrow) by the false lumen (A-D: large arrow). Dissection flap presented just distal to an aberrant right hepatic artery arising from the SMA (B.D: star). CT, clinical and analytic findings did not suggest visceral compromise and was successfully treated with bowel rest and anticoagulation. He is now on close clinical and imaging follow-up.

Objective: The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis., Methods: One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for confounders., Results: The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 - 8.3), similar in both groups (p = .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p = .63). However, Kaplan-Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p = .005). Sac dynamics were similar in both groups., Conclusion: The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Purpose: To compare changes in abdominal aortic aneurysm (AAA) sac volume between endovascular aneurysm repairs (EVAR) performed for ruptured (rEVAR) vs intact (iEVAR) AAAs and to determine the impact of early volume shrinkage on future complications., Materials and Methods: A retrospective analysis was performed of all patients undergoing standard infrarenal EVAR from 2002 to 2016 at a tertiary referral institution. Only patients with degenerative AAAs and with 30-day and 1-year computed tomography angiography (CTA) imaging were included. Early sac shrinkage was defined as a volume sac reduction >10% between the first (<30-day) and the 1-year CTA. The primary endpoint was to compare AAA sac volume changes between patients undergoing rEVAR (n=51; mean age 71.0±8.5 years; 46 men) vs iEVAR (n=393; mean age 72.3±7.5 years; 350 men). Results are reported as the mean difference with the interquartile range (IQR Q1, Q3). The secondary endpoint was freedom from aneurysm-related complications after 1 year as determined by regression analysis; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI)., Results: At baseline, the rEVAR group had larger aneurysms (p<0.001) and shorter (p<0.001) and more angulated (p=0.028) necks. Aneurysm sac volume decreased more in the rEVAR group during the first year [-26.3% (IQR -38.8%, -12.5%)] vs the iEVAR group [-11.9% (IQR -27.5%, 0); p<0.001]. However, after the first year, the change in sac volume was similar between the groups [-3.8% (IQR -32.9%, 31.9%) for rEVAR and -1.5% (IQR -20.9%, 13.6%) for iEVAR, p=0.74]. Endoleak occurrence during follow-up was similar between the groups. In the overall population, patients with early sac shrinkage had a lower incidence of complications after the 1-year examination (adjusted HR 0.59, 95% CI 0.39 to 0.89, p=0.01)., Conclusion: EVAR patients treated for rupture have more pronounced aneurysm sac shrinkage compared with iEVAR patients during the first year after EVAR. Patients presenting with early shrinkage are less likely to encounter late complications. These parameters may be considered when tailoring surveillance protocols.

Objective: Endovascular aneurysm repair (EVAR) became an increasingly preferred modality for abdominal aortic aneurysm (AAA) repair both in elective AAA repair (el-EVAR) and EVAR of a ruptured AAA (r-EVAR) setting. Ruptured AAAs usually have more hostile anatomies and less time for planning. Consequently, more complications may arise after r-EVAR. The purpose of this study was to compare mi-term outcomes between r-EVAR and el-EVAR., Methods: A retrospective cohort analysis of patients undergoing EVAR from 2000 to 2015 at a tertiary institution was performed. Patients with previous aortic surgery, nonatherosclerotic AAA and isolated iliac aneurysms were excluded. In-hospital casualties or patients who were intraoperatively converted to open repair were also excluded. For the midterm outcome analysis, only patients with at least two postoperative examinations (a 30-day computed tomography scan and a second postoperative examination performed 6 months or later) were considered. The primary end point was freedom from aneurysm-related complications (a composite of type I or III endoleak, aneurysm sac growth, migration of more than 5 mm, device integrity failure, AAA-related death, late postimplant rupture, or AAA-related secondary intervention). Freedom from secondary interventions, neck-related events (defined as a composite of type IA endoleak, migration of more than 5 mm, or preemptive neck-related secondary intervention) and late survival were secondary end points. The impact of device instructions for use (IFU) compliance on neck events was also assessed., Results: The study included 565 patients (65 r-EVAR and 500 el-EVAR). Eighty-two patients were treated outside proximal neck IFU, 13 in the r-EVAR group (21.3%) and 69 (14.5%) in the el-EVAR (P = .16). During the index hospitalization, there were more complications (12.3% vs 3.2%; P = .001) and reinterventions (12.3% vs 2.8%; P < .001) in the r-EVAR group. After discharge, median clinical follow-up time was 4.3 years (interquartile range, 2.1-7.0 years) without differences between both groups. Five-year freedom from AAA-related complications was 53.9% in the r-EVAR group and 65.4% in the el-EVAR (P = .21). In multivariable analysis the r-EVAR group was not at increased risk for late complications (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.54-1.61; P = .81). Five-year freedom from neck-related events was 74% in r-EVAR and 82% in the el-EVAR group (P = .345). Patients treated outside neck IFU were at greater risk for neck-related events both in r-EVAR (HR, 6.5; 95% CI, 1.8-22.9; P = .004) and el-EVAR group (HR, 2.6; 95% CI, 1.5-4.5; P < .001). Freedom from secondary interventions at 5 years was 63.0% for r-EVAR and 76.9% for el-EVAR (P = .16). Survival at 5 years was 68.8% in the r-EVAR group and 73.3% in the el-EVAR group (P = .30)., Conclusions: Durable and sustainable midterm outcomes were found for both r-EVAR and el-EVAR patients who survived the postoperative period. Patients treated outside the IFU are at greater risk for late complications. Surveillance protocols may be tailored according to individual anatomy and IFU compliance rather than timing of repair., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Vascular procedures in general, and specifically abdominal aortic aneurysm (AAA) repair, are associated with worse outcomes in female patients. However, how female gender influences outcomes in the setting of aneurysm-rupture remains unclear and may be even more pronounced when compared to elective operations. In this report, the authors aim to review the literature regarding ruptured AAA repair in women. Using the traditional threshold for AAA of 30 mm of maximum diameter, the prevalence in women is lesser than in men. However, the true prevalence may be underestimated due to gender discrepancies in normal aortic diameter. For females, aneurysmal disease seems to manifest later, have more associated comorbidities, and rupture occurs at smaller aortic diameters. This has obvious implications for management. There is still no consensus over the optimal treatment for ruptured AAA in women. They are less frequently treated by endovascular aneurysm repair, possibly due to anatomical restrains. When feasible, endovascular repair shows better outcomes, at least in the short-term, and there is new evidence suggesting a lasting benefit as well. For open repair the results are consensually worse when compared to male counterparts. Finally, despite benefitting of apparently similar healthcare, women have a lower relative survival after rAAA repair when compared to men. Further investigation to determine the reasons of these discrepancies is warranted.

Durability of endovascular aneurysm repair is critical, since a significant proportion of patients suffer from procedure-related complications and secondary interventions after repair of abdominal aortic aneurysms. Therefore, regular follow up including imaging is recommended. The rationale behind current surveillance programs is to allow early detection and elective treatment of complications. However, current recommendations are laborious and resource consuming, may be deleterious to many patients and are largely inefficient. Furthermore, they do not account for novel imaging modalities or for the use of new endovascular devices. The authors review the current recommendations from international societies, and of the evidence for new imaging modalities that could be as alternatives, namely contrast enhanced ultrasound, three-dimensional contrast-enhanced ultrasound and digital tomosynthesis. The evidence on surveillance after repair with new devices, specifically with sealing technology, and its imaging specificities is also discussed. Lastly, the authors review the evidence for risk stratification of surveillance. Stratified follow up regimes may be based on preoperative anatomical characteristics or on postoperative imaging results, at different time points. Effective sealing, absence of endoleaks and sac dynamics are the most commonly used factors for stratification. In conclusion, there is still no consensus on surveillance after endovascular aneurysm repair, with regard to both modality and timing. Novel devices, and especially those using sealing technology, require more intensive surveillance as the expected results at mid- and long-term remain undetermined. Risk stratification of follow-up seems possible but still requires prospective validation before generalization.

Introduction: Subclavian artery pseudoaneurysms are rare and occur mostly as a consequence of an inadvertent arterial puncture during central venous catheterization, endovascular therapeutic procedures or after penetrating or blunt trauma. They usually have a late clinical presentation, with pain, swelling or other compressive symptoms. The optimal treatment in this situation is still a matter of debate. The authors describe a case of late presentation of subclavian artery pseudoaneurysm after transjugular hepatic biopsy and discuss the several options for treatment., Methods: A 41-year-old woman was admitted in our hospital due to symptomatic subclavian artery pseudoaneurysm. She underwent a biopsy 20 years earlier for an undetermined febrile syndrome. The pseudoaneurysm was diagnosed during investigation of a right non-pulsatile cervical mass that was associated to cervical edema and Horner's syndrome. CTA revealed a pseudoaneurysm of right subclavian artery with 35 mm of diameter and an arteriovenous fistula to jugular vein which presented with significant enlargement. Additionally, the vertebral venous plexus was also ingurgitated. The pseudoaneurysm caused a left shift of the thyroid, common carotid artery and trachea. The vertebral artery arised 4 mm distal to pseudoaneurysm., Results: After a multidisciplinary evaluation including vascular surgery, neuroradiology and cardiac surgery, she underwent surgical exclusion of false aneurysm and arteriovenous fistula via partial upper sternotomy with cervicotomy. Care was taken to preserve the vertebral artery. There was a complete resolution of compressive symptoms and there were no complications during the first year of follow up., Conclusion: Subclavian artery pseudoaneurysms impose a major surgical challenge, especially when originating from the proximal third. Large pseudoaneurysms may rupture or produce signs and symptoms of compression. If intervention is considered necessary, several options are available: open surgical resection and vascular reconstruction, endovascular exclusion, stentgraft implantation or ultrasound-guided thrombin injection have all been described. The choice of procedure should be tailored to the patient, based on comorbidities, clinical presentation and anatomic characteristics. When compressive symptoms exist, an open approach is advised. However, because of their location, surgical exposure of the pseudoaneurysm may be technically difficult, requiring a sternotomy or a clavicular resection for adequate exposure. An endovascular approach demands an adequate landing zone and absence of severe tortuosity. When arteriovenous fistulae and enlargement of vertebral veins are verified, with subsequent increase in venous pressure, there is a risk of cervical radiculopathy (2-4%). This case report describes an uncommon presentation of subclavian pseudoaneurysm and exemplifies the complexity of their treatment.