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Objective: The EXPAND registry is a post-market, multicenter registry that aims at evaluating the safety and performance of the GORE® VIABAHN® VBX Balloon Expandable Endoprosthesis (VBX stent) implanted in peripheral vessels. This subgroup analysis assesses the three-year outcomes of the VBX stent as a bridging stent-graft (BSG) for visceral vessels during branched endovascular aortic repair (BEVAR)., Methods: This prospective, multicenter, observational registry includes 16 European sites. Patients were enrolled from November 2018 to March 2022. Endpoints included three-year primary patency (PP), secondary patency (SP), and stent graft-related death and serious adverse events (SAE)., Results: Seventy-three patients of whom 57 (78.1%) were male with a mean age of 73 years (± 8.1) were included. At three years, 42 (57.5%) patients returned for follow-up. Overall, 223 target vessels (TV) were treated. The estimated freedom from loss of TV primary patency was 93.6%. Per target vessel primary patency rates were 97.0% for the celiac trunk, 93.9% for the superior mesenteric artery (SMA), 91.2% for the left renal artery, and 92.5% for the right renal artery. The overall estimated freedom from loss of secondary patency was 96.8%, and freedom from target vessel instability was 94.5%., Conclusions: The VBX stent demonstrated excellent sustained results at three years with almost 94% primary patency, 97% secondary patency, and 94.5% freedom from target vessel instability. Patency in the renal arteries was lower than in the celiac trunk and SMA. The VBX stent appears to be a reliable bridging stent for target vessels in BEVAR., (Copyright © 2024. Published by Elsevier Inc.)

Objective: We present the case of a 58-year-old male patient referred to our department from a smaller facility for further evaluation and treatment strategy regarding the choice between open or endovascular surgery. The patient was diagnosed with a 6 cm asymptomatic juxtarenal aortic aneurysm and a 5 mm diameter accessory renal artery (ARA) supplying the lower half of left kidney. Further diagnostic assessments indicated that the left ARA was perfusing over 40% of the left kidney., Methods: Given the patient's significant pre-existing medical conditions and elevated perioperative risk, the decision was made to proceed with minimally invasive endovascular surgery using a custom-made 5-branches stent graft (BEVAR)., Results: In the early postoperative period, the patient reported left flank pain. A subsequent CT scan identified a partial infarction in the left kidney due to the occlusion of an early small branch from the upper left renal artery. However, laboratory results showed no significant change in renal function compared to preoperative values. The patient was discharged 6 days post-surgery, with no additional complications observed during the early postoperative period., Conclusion: This case report demonstrates that BEVAR is acceptable technique with satisfactory early postoperative outcomes for treating juxtarenal aortic aneurysms with an accessory renal artery in patients who are high-risk candidates for open repair and anatomically unsuitable for FEVAR or Ch-EVAR procedures., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This technical note presents a case of a patient with a failed Nellix device (Endologix, Irvine, Calif) who was not deemed fit for open conversion. Our planned approach for repair involved an endovascular procedure utilizing a custom-made branched device., Technique: An endovascular repair was performed via a custom-made four outer branched device in conjunction with a custom-made bifurcated graft featuring inverted limbs (Cook Inc., Bloomington, Ind). All branches were connected to the target vessel with Gore Viabahn VBX balloon-expandable covered stents (Gore & Associates Inc.)., Conclusion: Endovascular conversion with branched endovascular repair in a patient not deemed fit for open surgery was successfully performed, thereby reducing the risk of a high morbid and mortal procedure., Clinical Impact: Novel useful treatment solution of failed EVAR with Nellix device., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: While the link between carotid plaque composition and cerebrovascular vascular (CVE) events is recognized, the role of calcium configuration remains unclear. This study aimed to develop and validate a CT angiography (CTA)-based machine learning (ML) model that uses carotid plaques 6-type calcium grading, and clinical parameters to identify CVE patients with bilateral plaques., Material and Methods: We conducted a multicenter, retrospective diagnostic study (March 2013-May 2020) approved by the institutional review board. We included adults (18 +) with bilateral carotid artery plaques, symptomatic patients having recently experienced a carotid territory ischemic event, and asymptomatic patients either after 3 months from symptom onset or with no such event. Four ML models (clinical factors, calcium configurations, and both with and without plaque grading [ML-All-G and ML-All-NG]) and logistic regression on all variables identified symptomatic patients. Internal validation assessed discrimination and calibration. External validation was also performed, and identified important variables and causes of misclassifications., Results: We included 790 patients (median age 72, IQR [61-80], 42% male, 64% symptomatic) for training and internal validation, and 159 patients (age 68 [63-76], 36% male, 39% symptomatic) for external testing. The ML-All-G model achieved an area-under-ROC curve of 0.71 (95% CI 0.58-0.78; p < .001) and sensitivity 80% (79-81). Performance was comparable on external testing. Calcified plaque, especially the positive rim sign on the right artery in older and hyperlipidemic patients, had a major impact on identifying symptomatic patients., Conclusion: The developed model can identify symptomatic patients using plaques calcium configuration data and clinical information with reasonable diagnostic accuracy., Clinical Relevance: The analysis of the type of calcium configuration in carotid plaques into 6 classes, combined with clinical variables, allows for an effective identification of symptomatic patients., Key Points: • While the association between carotid plaques composition and cerebrovascular events is recognized, the role of calcium configuration remains unclear. • Machine learning of 6-type plaque grading can identify symptomatic patients. Calcified plaques on the right artery, advanced age, and hyperlipidemia were the most important predictors. • Fast acquisition of CTA enables rapid grading of plaques upon the patient's arrival at the hospital, which streamlines the diagnosis of symptoms using ML., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Background: The aim of this study was to evaluate the early results of the CE-marked standardized device combination consisting of Endurant and the Radiant chimney graft (En-ChEVAR) for the treatment of juxtarenal aortic aneurysms., Methods: We analyzed multicentric non-industry sponsored case series evaluating the EnChEVAR technique for patients treated between December 2022 and February 2024. Clinical, perioperative procedure-related and radiological data were collected. The primary outcome measure was the freedom of a type Ia gutter-related endoleak at postoperative computed tomography angiography (CTA). Secondary outcome measures included early type Ia endoleak-related reinterventions, target vessel complications including dissection or loss of target vessel, major adverse events, and mortality. Continuous variables were presented as median (interquartile range [IQR]) and categorical variables as count and percentage., Results: Ten patients were included in the present study. Eight (80%) were males, in nine cases a single chimney was implanted, and the other one was a double chimney graft placement. The treated aneurysms had an infrarenal neck length of 3.4 (1.2) mm. The rate of main body oversizing was 30%. The new neck length after chimney graft placement was 18 (3) mm. The median procedural time was 130 (17) mm, contrast medium use was 109 (26) mL, radiation time was 45 (12) min. The technical success was 100%. No type Ia endoleak was detected at the postoperative CTA. There were no target vessel issues. No major adverse events or death were observed., Conclusions: First reported cohort of patients treated with EnChEVAR demonstrated reproducible clinical and procedural outcomes within the 3 vascular centers with total exclusion of the aneurysms, patent renal arteries, and no evidence of gutter-related type IA endoleak. Further evidence with larger sample size of treated patients and longer follow-up are needed.

Objective: This post-market multicenter registry aimed to evaluate the safety and performance of the GORE VIABAHN VBX balloon expandable endoprosthesis (VBX stent) implanted in peripheral vessels. In this subgroup analysis, we assessed the outcomes of the VBX stent as a bridging stent graft for visceral vessels during branched endovascular aortic repair at 1 year., Methods: A single cohort from a prospective, multicenter, observational, 16-site European registry. Patients were enrolled from November 2018 to March 2022. Endpoints included 1-year primary patency (PP), primary assisted patency (PAP), and secondary patency (SP), stent graft-related death and serious adverse events through 30 days., Results: Seventy-three patients were enrolled in this registry sub-cohort, 57 (78.1%) were male, and the mean age was 73 ± 8.1 years. Thoracoabdominal aneurysms predominated the cohort with 68 patients (93.2%), followed by five patients (6.8%) with pararenal and infrarenal aneurysms. Overall, 233 target vessels were treated with the index bridging graft. The overall per stent graft analysis demonstrated a PP of 95.8% at 1 year; PAP was 95.8%, and SP reached 97.9%. The per-target vessel analysis demonstrated a PP, PAP, and SP in the celiac trunk of 100%, 100%, and 100%; in the superior mesenteric artery of 96.0%, 96.0%, and 100%, and in the renal arteries of 94.2%, 94.2%, and 95.1%, respectively. Four patients (5%) died at 1 year; none of the deaths were device-related. The composite endpoint of target vessel technical success and freedom from VBX stent-related serious adverse events through 30 days was achieved in 98.6% of patients., Conclusions: In this prospective post-market multicenter registry, the VBX stent demonstrated excellent results at 1 year, with almost 96% primary patency and 98% secondary patency. Patency in the renal arteries seems to be lower. Nevertheless, the VBX stent appears to be a reliable bridging stent for branched endovascular aortic repair., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Axillary artery aneurysms in children are rare and multifactorial. The presenting clinical picture can range from an incidental discovery to threatening symptoms, including loss of extremity function. With the present study we aim to give a comprehensive review of the existing literature focusing on the etiology and management of this rare but threatening pathology., Method: A comprehensive review was made in a multi-staged manner. All identified studies have been categorized based on the type of lesions (true or false aneurysm) and their etiologies., Results: The treatments differ from the extension of the lesions and from the etiology., Conclusions: Open surgery repair with great saphenous vein is still the best long-term approach, but even endovascular, embolization, or conservative management can be considered., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Thoracic endovascular aortic repair (TEVAR) is a widespread minimally invasive procedure prevalently used to treat thoracic aortic pathologies. However, when the left subclavian artery (LSA) is involved in the pathology, a more complex surgical approach is required to guarantee the perfusion of the vertebral and brachial arteries. In fact, coverage of the LSA has been proven to be associated with a higher risk of stroke, spinal cord ischemia, and arm ischemia.Historically, carotid-subclavian bypass or subclavian transposition has been the only treatment options to restore the perfusion of the LSA. For the past 10 years, different endovascular techniques have been implemented in the endovascular armamentarium to reduce the risk of complications related to surgical treatment such as infection, bleeding, and chylothorax.Currently, physician-modified grafts, in situ fenestration, chimneys, and branched or fenestrated devices are available. The aim of this overview is to describe the technique with the Ankura thoracic stent graft and in situ fenestration with the Futhrough needle and thus to shed light on the different approaches by comparing their pros and cons., Competing Interests: Marco Virgilio Usai is consultant for Lifetech Company., (Thieme. All rights reserved.)

Objective: To evaluate in vitro the performance of in vivo published covered or bare metal chimney stents (ChSs) in combination with the Endurant II abdominal endograft (Medtronic) as the only CE approved main graft (MG) in the treatment of juxtarenal abdominal aortic aneurysms with the chimney endovascular aneurysm repair (chEVAR) technique., Methods: Bench top experimental study. A silicon flow model with adjustable physiological simulating conditions and patient based anatomy was used to test nine different MG-ChS combinations: Advanta V12 (Getinge); BeGraft + (Bentley); VBX (Gore & Associates Inc.); LifeStream (Bard Medical); Dynamic (Biotronik); Absolute Pro (Abbott); double Absolute Pro; Viabahn (Gore) lined with Dynamic; and Viabahn lined with EverFlex (Medtronic). Angiotomography was performed after each implantation. DICOM data were analysed blindly twice per observer by three independent experienced observers. Each blinded evaluation was performed at one month intervals. The main analysed parameters were the area of gutters, MG and ChS maximum compression, and the presence of infolding., Results: Bland-Altman analysis confirmed adequate results correlation (p < .05). Each employed ChS showed significantly different performance favouring the balloon expandable covered stent (BECS). The smallest gutter area was seen in the combination with Advanta V12 (0.26 cm 2 ). MG infolding was observed in all tests. The lowest ChS compression was observed in the combination with BeGraft + (compression 4.91%, D ratio 0.95). In our model, BECSs showed higher angulations than bare metal stents (BMSs) (p < .001)., Conclusion: This in vitro study shows the variability of performance with each theoretically possible ChS and explains the divergent ChS outcomes in the published literature. BECS in combination with the Endurant abdominal device confirms their superiority vs. BMS. The presence of MG infolding in each test underlines the need for prolonged kissing ballooning. Angulation evaluation and comparison with other in vitro and in vivo publications demands the need for further investigation in transversely or upwardly oriented target vessels., (Copyright © 2023 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objectives: Carbon dioxide (CO 2 ) angiography for endovascular aortic repair (CO 2 -EVAR) is used to treat abdominal aortic aneurysms (AAAs), especially in patients with chronic kidney disease or allergy to iodinated contrast medium (ICM). However, some technical issues regarding the visualization of the lowest renal artery (LoRA) and the best quality image through angiographies performed from pigtail or introducer sheath are still unsolved. The aim of this study was to analyze different steps of CO 2 -EVAR to create an operative standardized protocol., Methods: Patients undergoing CO 2 -EVAR were prospectively enrolled in five European centers from 2019 to 2021. CO 2 -EVAR was performed using an automated injector (pressure, 600 mmHg; volume, 100 cc); a small amount of ICM was injected in case of difficulty in LoRA visualization. LoRA visualization and image quality (1 = low, 2 = sufficient, 3 = good, 4 = excellent) were analyzed at different procedure steps: preoperative CO 2 angiography from pigtail and femoral introducer sheath (first step), angiographies from pigtail at 0%, 50%, and 100% of proximal main body deployment (second step), contralateral hypogastric artery (CHA) visualization with CO 2 injection from femoral introducer sheath (third step), and completion angiogram from pigtail and femoral introducer sheath (fourth step). Intraoperative and postoperative CO 2 -related adverse events were also evaluated. χ 2 and Wilcoxon tests were used for statistical analysis., Results: In the considered period, 65 patients undergoing CO 2 -EVAR were enrolled (55/65 [84.5%] male; median age, 75 years [interquartile range (IQR), 11.5 years]). The median ICM injected was 17 cc (IQR, 51 cc); 19 (29.2%) of 65 procedures were performed with 0 cc ICM. Fifty-five (84.2%) of 65 patients underwent general anesthesia. In the first step, median image quality was significantly higher with CO 2 injected from femoral introducer (pigtail, 2 [IQR, 3] vs introducer, 3 [IQR, 3]; P = .008). In the second step, LoRA was more frequently detected at 50% (93% vs 73.2%; P = .002) and 100% (94.1% vs 78.4%; P = .01) of proximal main body deployment compared with first angiography from pigtail; similarly, image quality was significantly higher at 50% (3 [IQR, 3] vs 2 [IQR, 3]; P ≤ .001) and 100% (4 [IQR, 3] vs 2 [IQR, 3]; P = .001) of proximal main body deployment. CHA was detected in 93% cases (third step). The mean image quality was significantly higher when final angiogram (fourth step) was performed from introducer (pigtail, 2.6 ± 1.1 vs introducer, 3.1 ± 0.9; P ≤ .001). The intraoperative (7.7%) and postoperative (12.5%) adverse events (pain, vomiting, diarrhea) were all transient and clinically mild., Conclusions: Preimplant CO 2 angiography should be performed from femoral introducer sheath. Gas flow impediment created by proximal main body deployment can improve image quality and LoRA visualization with CO 2 . CHA can be satisfactorily visualized with CO 2 alone. Completion CO 2 angiogram should be performed from femoral introducer sheath. This operative protocol allows performance of CO 2 -EVAR with 0 cc or minimal ICM, with a low rate of mild temporary complications., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic endovascular aortic repair (TEVAR) can be challenging in cases involving the aortic arch and the visceral segment. We report our initial experience with fenestrated TEVAR (f-TEVAR) for thoracic aortic disease involving aortic branches using physician-modified stent grafts (PMSGs)., Methods: Between February 2019 and November 2020 nine patients were treated with a PMSG. Indication to treatment were a symptomatic acute type B aortic dissection (TBAD) in three cases, a penetrating aortic ulcer in three cases (two in zone 3 and one in zone 6), one case of an endoleak type IA after TEVAR, a chronic TBAD after TEVAR in one case and one case of a contained rupture of a thoracoabdominal aneurysm in zone 3. Pre-, intra- and postoperative clinical data were recorded., Results: The median patient age was 65 (IQR 60.5-71) years, and eight (89%) patients were men. Nine stent grafts (six Bolton Relay Plus and three Bolton Relay Pro, Terumo Aortic, Vascutek Ltd., Inchinnan, UK) were deployed. Small fenestrations (8 mm) were created on table, median duration for on table stent graft modifications was 20 minutes (range 13-22). The technical success rate was 100%. Median operative time was 188 (range 116-252) minutes. No major adverse events of any sort occurred during the first 30-day postoperatively. There were no type I or type III endoleaks at the end of the procedure, and no cases of spinal cord ischemia. Two access related complications occurred (22%). After a median of 12 (range 5-12) months all patients survived and all target vessels remained patent with one case of fenestration-related type I endoleak, which required open conversion., Conclusions: The results of our initial experience with f-TEVAR using PMSGs with the Bolton Relay stentgraft for the treatment of aortic diseases are acceptable. These results should be confirmed on larger patient cohorts.

Introduction: Surgical endarterectomy represents the gold standard for the treatment of atherosclerotic lesions of the groin vessels. Endovascular treatment such as atherectomy with or without drug coated angioplasty (DCA) of the so called no stenting zones, i.e. inguinal and popliteal vessels, is gaining growing acceptance as alternative option to open surgery. This systematic review aims to scrutiny the current clinical evidence regarding atherectomy and DCA for the common artery (CFA)., Evidence Acquisition: We conducted an exhaustive research in multiple platforms (Medline, PubMed, Cochrane, Google Scholar, Embase) on studies over atherectomy and angioplasty for inguinal atherosclerotic lesions published between 2000 and 2021. As search strategy we used a wide list of MeSH items, words, synonyms. Bibliographies of review articles were checked for further relating studies regarding atherectomy of CFA. A qualitative and quantitative data analysis was carried out., Evidence Synthesis: Fifteen studies were included in the qualitative review. Not all studies were focused only on atherectomy of inguinal vessels, despite including such treatment. Hence, data regarding this treatment were not exhaustive. A fairly homogeneous data analysis was possible in 7 of 15 studies. The remaining 8 studies were qualitatively analyzed but not included in the statistical analysis. In all 7 included studies directional atherectomy and DCA under filter protection were carried out. In this subgroup, overall, 497 patients were treated with atherectomy. Sixty-eight percent of the patients were males. Rutherford class from 1-3 dominated against 4-6 (63% vs. 37%). Mean technical success rate was 96%, with a primary and secondary patency rate of 92% and 98% respectively at one year. Procedure related vascular complications ranged from 1% to 6%., Conclusions: Current literature about atherectomy for inguinal arteries is scant, data are inhomogeneous and so are treatment modalities. Nevertheless, the results of this systematic review suggest that this endovascular strategy is feasible with good short and midterm results. Prospective trials with larger patient cohorts are necessary to confirm these preliminary results.

Background: Aim of this study was to compare the modifications of systemic blood pressure in patients with subacute type b aortic dissection (TBAD) and refractory (rHTN) and non-refractory arterial hypertension (N-rHTN) treated by thoracic endovascular aortic repair (TEVAR)., Methods: Patients were divided into two groups, rHTN defined as blood pressure >140/90 mmHg with ≥5 antihypertensive drugs and patients with N-rHTN. Primary endpoint was the variation of mean systolic, diastolic and overall pressure (MSP, MDP and MAP) before and after antihypertensive treatment or TEVAR. Secondary endpoints were the 30-days mortality. Fifty-seven patients were included in this study., Results: Of the 44 Patients of the TEVAR group 21 were included in the N-rHTN group. The MSP before and after surgery for the N-rHTN group was 130 (±10 SD) and 111 (±22 SD) mmHg, P=0.01. In the rHTN group 164 (±17 SD) and 118 (±17 SD) mmHg (P=0.01). The reduction of MSP was greater in the rHTN group (P=0.01). The MAP before and after the TEVAR for the N-rHTN group was 90 (±10 SD) and 74 (±12 SD) mmHg (P=0.01), in the rHTN group 111 (±14 SD) and 70 (±9 SD) mmHg (P=0.01). The overall mortality rate group was 2.2% (1/44)., Conclusions: TEVAR for TBAD appears to positively affect blood pressure in patients with rHTN and N-rHTN.

Background: Frozen elephant trunk (FET) is an established approach to reduce late complications of type A aortic dissection (AADA) by diminishing false lumen perfusion. Currently, surface size of aortic lumina are evaluated using Computed tomography (CT). However, this 2D method is prone to error as it evaluates dissection progression slice by slice. Volume measurement on the other hand can overcome this limitation and deliver better insights in aortic remodeling. Therefore, the aim was to quantify volume changes of the descending and abdominal aorta at short- and mid-term follow-up after FET., Methods: Between April 2015 and March 2018, 20 patients who underwent surgical repair of AADA using the Thoraflex™ Hybrid Plexus (Vascutek, Terumo Aortic, Scotland) were included in this study. We measured volumetric change before surgical treatment, at discharge, at 12 and at 24 months based on CTAs (Computed tomography angiography). Surfaces and volumes have been analyzed using Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA)., Results: One hundred fifty-eight volumetric measures were obtained. The findings show a significant increase of volume of the true lumen (TL) while surface measurement of the TL did not show any significant change at other levels besides level C (diaphragm, P=0.00193). Variance analysis showed significant increase of volume, whereas no significant change was seen in false lumen. Post-hoc analysis revealed a significance at 24 months (P=0.047)., Conclusions: Although previous studies outline the clinical benefit of Thoraflex hybrid prosthesis on short-term follow up, this study provides a more precise understanding of aortic remodeling based on volumetric measurement. Thus, quantification of volume changes should be included for the assessment of optimal follow-up timing and consecutive procedure planning., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-2356). The authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Cardiovascular disease remains the most frequent cause of death worldwide. Atherosclerosis, an underlying cause of cardiovascular disease, is an inflammatory disorder associated with endothelial dysfunction. The endothelin system plays a crucial role in the pathogenesis of endothelial dysfunction and is involved in the development of atherosclerosis. We aimed to reveal the expression levels of the endothelin-A receptor (ET A R) in the course of atherogenesis to reveal possible time frames for targeted imaging and interventions. We used the ApoE -/- mice model and human specimens and evaluated ET A R expression by quantitative rtPCR (qPCR), histology and fluorescence molecular imaging. We found a significant upregulation of ET A R after 22 weeks of high-fat diet in the aortae of ApoE -/- mice. With regard to translation to human disease, we applied the fluorescent probe to fresh explants of human carotid and femoral artery specimens. The findings were correlated with qPCR and histology. While ET A R is upregulated during the progression of early atherosclerosis in the ApoE -/- mouse model, we found that ET A R expression is substantially reduced in advanced human atherosclerotic plaques. Moreover, those expression changes were clearly depicted by fluorescence imaging using our in-house designed ET A R-Cy 5.5 probe confirming its specificity and potential use in future studies.

Background: Endovascular treatment offers an alternative, less invasive approach to open repair for subclavian artery atherosclerotic disease (SAAD). However, only few studies compared the outcomes of both strategies in the long run. This study reports on the performance of endovascular and surgical revascularization for SAAD., Methods: A retrospective review was conducted on patients treated for SAAD at two institutions between January 1998 and December 2015. Primary outcome of this study was the composite endpoint of reintervention-free survival (RFS) defined as time to reintervention and/or death from any cause. Secondary endpoints included primary patency (PPR) and secondary patency (SPR) rates as well as overall survival and time to reintervention., Results: Surgical treatment was the preferred treatment option in 27 (25%) patients, while 83 (75%) patients underwent primary stent therapy. The median follow-up was 87 months (interquartile range [IQR]: 38 to 151) in the surgical group and 27 (IQR: 12 to 59) in the endovascular (P=0.0001). Severe arterial wall calcification was more commonly observed in the surgical arm (P<0.0001), while mild and moderate calcification in the endovascular (P=0.0004 and P=0.014). Vessel occlusion was more frequent among patients treated surgically (100% vs. 34%, P<0.0001). At 98 months RFS was significantly higher after surgical treatment (95% vs. 54%, HR: 8.4, 95% CI: 3.9 to 18.1, P=0.0002). Although overall survival did not differ significantly between the two groups (HR: 4.28, 95% CI: 0.86 to 21.22, P=0.093), open repair was associated with reduced reintervention rate (HR: 12.04, 95% CI: 4.98 to 29.12, P=0.001). The PPR at 98 months following surgical and endovascular therapy amounted to 96% and 65% (HR: 12.87, 95% CI: 5.44 to 30.44, P=0.0008) respectively. No significant difference was observed regarding the SPR between the two groups (100% vs. 95%, P=0.090)., Conclusions: Surgical treatment was associated in this cohort with increased patency and a significant reduction of reinterventions compared to the endovascular approach.

A surgical intervention for type A acute aortic dissection is the only effective method of treatment making it possible to prevent the development of life-threatening complications and to attain clinical recovery of the patient. Supracoronary replacement of the ascending aorta and the proximal portion of the aortic arch is considered to be the classical and most commonly used method of an open operative intervention. On the one hand, it is technically the simplest and shortest operation, and on the other, this surgical technique is often accompanied by long-term proximal and distal complications, and first of all those caused by a persistent false lumen. The accumulated surgical experience and contemporary operative techniques, as well as advances of intensive therapy in treatment of type A acute aortic dissection make it possible to currently perform more extensive primary resections in order to improve the remote results. Total aortic arch replacement, including the use of the 'frozen elephant trunk' technique leads to fast thrombosis of the false lumen, preventing progression of the disease of the thoracic aorta and promoting its positive remodelling. The article describes the perioperative therapeutic policy accepted and pursued in our medical facility, also presenting the authors' opinion on the role and place of the 'frozen elephant trunk' technique in rendering medical care for patients with type A acute aortic dissection.

Objective: To compare the efficacy and safety as well as associated image quality of catheter-directed CT angiography (CCTA) with a low dose of iodine contrast agent compared to intravenous CTA in patients undergoing endovascular aortic aneurysm repair (EVAR)., Methods: Retrospective data analysis of 92 patients undergoing EVAR between January 2009 and December 2017 was performed. Patients were divided in two groups; those receiving CTA (n = 59) after intravenous contrast agent application and those receiving CCTA (n = 33) via an intraarterial catheter placed in the descending aorta. Demographic and cardiovascular risk factors as well as renal function parameters before, immediately after and 6-60 months after EVAR were evaluated. As primary endpoint, changes in serum creatinine levels in the two groups were evaluated. Secondary endpoints encompassed complications associated with intraarterial catheter placement. Objective (signal-to-noise ratios) and subjective image quality (5-point Likert scale) were compared., Results: Amount of contrast medium was significantly lower in CCTA compared to i.v. CTA (23 ± 7 ml vs. 119 ± 15 ml, p<0.0001). Patients undergoing catheter-directed CTA had higher baseline creatinine values compared to the group with intravenous iodine application (1.9 ± 0.6 mg/dl vs. 1.3 ± 0.5 mg/dl; p<0.0001). Follow-up serum creatinine levels however did not show significant alterations between the two groups (1.9 ± 0.4 mg/dl vs. 1.3 ± 0.5 mg/dl). No major complications were detected in the CCTA group. Signal-to-noise ratio (SNR) was comparable between i.v. CTA and CCTA (8.5 ± 4.6 vs. 7.7 ± 4.0; p = 0.37) and subjective image similarly revealed no differences with a good interobserver agreement (ICC = 0.647)., Conclusions: Catheter-directed CTA is safe and provides comparable image quality with a substantial retrenchment of the needed amount of iodine-based contrast medium. However, no benefit of the reduced contrast medium protocol with respect to renal function was observed., Competing Interests: The authors have declared that no competing interests exist.

Objective: Chimney endovascular aortic aneurysm repair is gaining ever greater acceptance. However, persistent gutters leading to type IA endoleaks represent an unsolved issue. The aim of the current study was to analyze the impact of abdominal endograft oversizing to the occurrence of this phenomenon., Methods: The PERformance of the snorkel/chImney endovascular teChnique in the treatment of compLex aortic PathologiesES registry includes the largest experience with chimney endovascular aortic aneurysm repair from 13 vascular centers in Europe and the U.S. Prospectively collected data from centers with standard use of the Endurant stent-graft and balloon-expandable covered stents as chimney grafts only were included in the present analysis. The parameter which varied was the degree of oversizing of the aortic stent-graft classifying the cohort in two groups, group A (20% and less oversizing) and group B (>20% of oversizing). The primary endpoint was the incidence of persistent type IA endoleak needed reintervention. Secondary endpoints were all-cause mortality and freedom from reintervention., Results: Group A included 21 patients while group B 144. The mean preoperative pathology's neck length and diameter was 5.8 mm (±4.4) versus 4.9 mm (±3.8) and 27.6 mm (±4.7) versus 24.9 mm (±3.7) for group A and group B, respectively. The mean length of the new sealing zone after chimney graft placement was similar for both groups (group A versus group B; 17.9 mm versus 18.3 mm, respectively, P = .21). The percentage of oversizing of the aortic stent-graft ranged between 13.8 and 20% versus 22.2 and 30%, for group A and group B, respectively. Patients of group A had more type 1A endoleaks, (14.3%) versus patients of group B (2.1%) based on the first follow-up imaging, P = .02. The incidence of persistent type IA endoleaks needing a reintervention was 14.3 and 1.4% for the group A and group B, respectively, P = .01. The mean volume of contrast medium used was greater in group A versus group B with 239 ml versus150 ml, P = .05. Additionally, 14.3% of patients of group A experienced acute renal failure compared to those in group B which was 1.0%, P = .01., Conclusions: Oversizing of ideally 30% of the Endurant stent-graft is associated with significant lower incidence of type IA endoleaks requiring reintervention for patients treated by chimney endovascular aortic aneurysm repair.

Objectives: Infection of the vascular graft represents one of the most threatening complications after aortic repair. It is rare and associated with high morbidity and mortality rates. The aim of this study was to present short-term outcomes after surgical treatment of infected aortic grafts after endovascular and open repair of abdominal aortic aneurysms (AAAs)., Methods: Data of all patients affected by aortic graft infection after aneurysm repair who underwent an explantation of a conventional or endovascular aortic graft between January 2008 and December 2016 were retrospectively reviewed. All patients underwent in situ reconstruction using a rifampicin soaked synthetic graft. The primary endpoint of this study was 30 day mortality; secondary endpoints were major post-operative complications., Results: Twenty-six patients were included in the cohort, 16 with an infected endograft (iEVAR) and 10 patients with an infected conventional graft (iOAR). Thirty-day mortality was 23.1% overall, 37.5% for iEVAR and 0% (p = .027) for iOAR. Post-operative major complications occurred in eight (50%) patients from the iEVAR group and in four (40%) patients from the iOAR group (p = .619). The supravisceral clamping rate was higher in patients with infected iEVAR (93.8 vs. 20%, p = .001), furthermore a greater incidence of post-operative acute kidney injury was observed (50 vs. 0%, p = .009)., Conclusions: Explantation of the graft and in situ reconstruction for aortic graft infection is accepted as the therapy of choice. However, re-operation for iEVAR is related to significantly higher mortality and morbidity rates. The need for suprarenal aortic clamping seems to be a possible explanation for worse outcomes in iEVAR., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The objective of this study was to analyze radiation risk to patients during endovascular aneurysm repair (EVAR) using mobile C-arm (MA) or fixed C-arm (FA) fluoroscopes and to describe the dose distribution during the different phases of the procedure., Methods: Patients treated with EVAR using a single stent graft system between November 2009 and June 2016 were included in this study. The patients were divided into one of two groups (MA or FA) according to the type of C-arm used in the procedure. Data regarding patients' demographics and the total amount of contrast agent (CA) used, dose-area product, and fluoroscopy time for the procedures were prospectively recorded. Based on the dose report from the FA system, five standard and two optional phases of the procedure were identified to determine the dose distribution., Results: Overall, 160 patients were included (mean age, 73.30 ± 8.97 years; 146 men); of these, 107 were treated with an MA system and 53 were treated with an FA system. The mean amounts of CA used were 108.55 ± 42.28 mL in the MA group and 85.37 ± 38.79 mL in the FA group (P = .0014). The mean total dose-area product values were 49.93 ± 38.06 Gy·cm 2 in the MA group and 168.34 ± 146.92 Gy·cm 2 in the FA group (P < .0001). There was no significant difference in fluoroscopy time between the groups. Per-phase analysis demonstrated that identification of the proximal landing zone and main body deployment required the most radiation, accounting for 24% of the total radiation dose. Overall, 47.6% of the exposure was due to digital subtraction angiography., Conclusions: Use of an FA system can significantly reduce the amount of CA needed but may also lead to higher radiation doses in EVAR procedures. Dose monitoring remains crucial for the safety of both patients and operators. A detailed analysis of dose distribution is possible with modern systems, which may improve the quality of monitoring in the future., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the use of a brachial artery access for endovascular treatment of iliac artery disease., Methods: A retrospective review was conducted of 201 patients (mean age 73 years; 147 men) treated via a brachial artery access for iliac artery stenosis. The majority (n=141, 70%) presented with lifestyle-limiting claudication (Rutherford category 3), whereas the incidence of critical limb ischemia (Rutherford categories 4-6) was 30% (n=70). Diagnostic angiography revealed a TransAtlantic Inter-Society Consensus II (TASC) C/D lesion in 114 (57%) patients. The primary outcome was technical success achieved exclusively with a brachial artery access. Secondary outcomes were secondary technical success (adjunctive transfemoral access), access site complications, and stroke/transient ischemic attack (TIA)., Results: In 17 (8%) patients, lesion crossing was unsuccessful, while an adjunctive transfemoral approach was necessary to restore iliac vessel patency in 23 (11%) cases. Thus, the primary and secondary technical success rates were 81% and 92%, respectively. Local hematomas (9, 4%) dominated the access site complications, followed by pseudoaneurysms (8, 4%), late brachial artery bleeding (4, 2%), brachial artery occlusion (2, 1%), and puncture site infection (2, 1%). No transient or permanent median nerve dysfunction was observed. The stroke/TIA rate was 2% (n=4). A single patient died due to acute coronary syndrome (0.5% mortality). TASC II class (p=0.58), sex (p=0.66), and target vessel (p>0.3 for all locations) had no effect on technical success. Female gender unfavorably influenced the incidence of access site complications (hazard ratio 6.7, 95% confidence interval 2.7 to 15, p<0.001), but sheath size did not (p=0.22)., Conclusion: Brachial artery access enables endovascular treatment of iliac artery disease in the majority of patients, although an adjunctive transfemoral access may be required. However, the high incidences of access site complications and cerebral events remain a significant limitation of the transbrachial approach., (© The Author(s) 2016.)

Purpose: To review the literature on pararenal endovascular aneurysm repair (EVAR) to determine the frequency and clinical relevance of chimney graft occlusions., Methods: A comprehensive search of the English-language literature abstracted in the Medline and the Cochrane Library databases was performed to identify case series involving pararenal aortic pathologies (degenerative aneurysms, penetrating atherosclerotic ulcers, type Ia endoleaks, and para-anastomotic aneurysms) treated with EVAR and chimney grafts; thoracoabdominal, iliac, or aortic arch chimney graft placements were excluded, as were case reports in which the total number of chimney grafts implanted at the reporting center could not be determined. The literature search identified 83 studies regarding chimneys/snorkels for pararenal pathologies published between January 2007 and March 2014. Of these, 7 studies met the inclusion criteria and were included in the analysis., Results: There were 15 (4.5%) occlusions in the overall 334 renovisceral vessels in which chimney grafts were deployed. The mean time to chimney graft occlusion was 3.5 months (range 1-270 days) over a mean follow-up of 1.4 months (range 9-24). The target arteries were the renal artery (n=12) and the superior mesenteric artery (SMA; n=3). Seven patients were asymptomatic, and no description was given in 5 cases. In the other 3 patients, the symptoms were acute renal failure, intestinal ischemia, and malignant hypertension. The treatment strategy included open conversion and iliorenal bypass (n=1), exploratory laparotomy to revascularize the SMA (n=1), hemodialysis (n=1), placement of bare metal stents (n=4), conservative treatment (n=2), and unknown (n=6). One (6.7%) patient died (an occluded SMA). Two patients with renal chimney occlusion suffered from temporary renal function deterioration., Conclusion: The present analysis identified a low rate of chimney graft occlusions, which appear to occur generally a few months after placement. Involvement of the renal artery had no severe clinical consequences, while occlusion of the SMA can be associated with life-threatening complications. More detailed information regarding occluded chimney grafts will be needed in future publications to help identify the causes., (© The Author(s) 2015.)