New ischemic cerebral lesions in post-procedural MRI in Carotid Artery Stenting versus Carotid Endarterectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: Recent randomized controlled trials have demonstrated similar outcomes in terms of ischemic stroke incidence after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in asymptomatic carotid disease, while CEA seems to be the first option for symptomatic carotid disease. The aim of this meta-analysis is to assess incidence of silent cerebral microembolization detected by Magnetic Resonance Imaging (MRI) following these procedures. METHODS: A systematic search was conducted using PubMed, Scopus and Cochrane databases including comparative studies involving symptomatic or asymptomatic patients undergoing either CEA or CAS, and reporting on new cerebral ischemic lesions in post-operative MRI. The primary outcome was the newly detected cerebral ischemic lesions. Pooled effect estimates for all outcomes were calculated using the random-effects model. Pre-specified random effects meta-regression and subgroup analysis were conducted to examine the impact of moderator variables on the presence of new cerebral ischemic lesions. RESULTS: 25 studies reporting on total 1827 CEA and 1500 CAS interventions fulfilled the eligibility criteria. The incidence of new cerebral ischemic lesions was significantly lower after CEA comparing to CAS, regardless of the time of MRI assessment (first 24 hours; OR: 0.33, 95% CI: 0.17-0.64, p<0.001), (the first 72 hours, OR: 0.25, 95% CI 0.18-0.36, p<0.001), (generally within a week after the operation; OR: 0.24, 95% CI: 0.17-0.34, p<0.001). Also, the rate of stroke (OR: 0.38, 95% CI: 0.23-0.63, p<0.001) and the presence of contralateral new cerebral ischemic lesions (OR: 0.16, 95% CI 0.08-0.32, p<0.001) were less frequent after CEA. Subgroup analysis based on the study design and the use of embolic protection device during CAS showed consistently lower rates of new lesions after CEA. CONCLUSIONS: CEA demonstrates significant lower rates of new silent cerebral microembolization, as detected by MRI in postoperative period, compared to CAS.

Initial Experience of the Covered Endovascular Reconstruction of Iliac Bifurcation Technique.

INTRODUCTION: The distal landing zone in iliac arteries represents an important issue during endovascular repair of abdominal aortic aneurysms (EVAR). The aim of this study is to present a case series for landing in the external iliac artery (EIA) during EVAR while preserving blood flow in the internal iliac artery (IIA) with the covered endovascular reconstruction of the iliac bifurcation (CERIB) technique. METHODS: This is a single-center, retrospective analysis of prospectively collected data of patients that underwent EVAR either for intact abdominal aortic aneurysm (AAA) or previous failed EVAR from December 2022 up to September 2023. Indications for treatment were presence of common iliac artery aneurysm (CIAA), short CIA, or endoleak type Ib (ETIb). For the distal sealing zone, we used balloon-expandable covered stent (BXCS). Primary outcomes were technical success and first-month patency rate. Secondary outcomes were endoleak and re-intervention rate. RESULTS: Sixteen patients being treated with 20 CERIBs were included in the study. Four patients had a previous failed EVAR, while 3 patients were treated urgently for a symptomatic para-renal aneurysm. The indications for treatment were EIb (n=2), short CIA (n=4), CIAA with narrow lumen (n=3), and CIA aneurysm (n=11). Platforms that were used were the Cook Zenith Alpha (n=5), Gore C3 (n=2 and 3 limbs), Endurant IIs (n=2, and 3 limbs), and a t-branch device (n=3). Technical success rate was 100% with no adjunctive procedure. No death or re-intervention was recorded for all patients at postoperative 30-day period and at 6 months for 2 patients. At first-month CTA, patency rate was 100% (20/20), while in 2 patients that had 6-month CTA, the patency was also 100% (2/2). No kinking or stenosis was also noted. Two patients had ETIII after branched EVAR (BEVAR), 2 patients had ETII, and 1 patient had gutter ET in the area of the CERIB. CONCLUSION: The CERIB technique seems to be effective and safe in the early period. It is suitable with a variety of commercial endograft platforms. It may be a valuable alternative to iliac branch devices when there are anatomical considerations. Longer follow-up is needed to conclude for long-term patency and durability. CLINICAL IMPACT: The distal landing zone in iliac arteries represents an important issue during EVAR while it is important to preserve blood flow in the internal iliac artery. The covered endovascular reconstruction of the iliac bifurcation (CERIB) technique is a technique for the preservation of internal iliac arteries during EVAR, while it is suitable with a variety of commercial endograft platforms. The CERIB technique seems to be effective and safe in the early period. It may be valuable alternative to iliac branch devices when there are anatomical considerations.

Branched and fenestrated endovascular aortic arch repair in patients with native proximal aortic landing zone.

OBJECTIVE: Fenestrated and branched thoracic endovascular repair (f/bTEVAR) have been successfully applied in patients with diverse aortic arch pathologies. The aim of this study is to present the early and mid-term outcomes of patients with native proximal aortic landing (NPAL) managed with f/bTEVAR. METHODS: A single-center retrospective analysis of patients with NPAL, managed with f/bTEVAR, between September 1, 2011, and June 30, 2022, was conducted. All patients were treated with custom-made devices (Cook Medical) with landing within Ishimaru zones 0 to 2. Primary outcomes were technical success, mortality, stroke, and retrograde type A dissection at 30 days. Follow-up outcomes were considered secondary. RESULTS: A total of 126 patients were included (69.8% males; mean age, 70.8 ± 4.2 years; 18.3% urgent). The main indications (60.4%) for repair were aortic arch (29.4%) and thoracoabdominal aortic aneurysms (31.0%). Seventy-two patients (57.1%) were managed with fTEVAR. Proximal landing in zone 0 and 1 was chosen in 97.6%. Technical success was 94.4%, and 30-day mortality was 11.9%. Strokes were diagnosed in 13.5% of patients and major strokes were identified in 7.9% cases. Retrograde type A dissection rate was 3.9%. The multivariate analysis confirmed landing in Ishimaru zone 0 as an independently related factor for stroke (P = .005), whereas stroke (P < .001), pericardial effusion (P < .001), and acute kidney injury (P < .001) were independently related to 30-day mortality. Mean follow-up was 17.5 ± 9.3 months. The estimated survival rate and the freedom from reintervention rate were 72.6% (standard error, 4.4%) and 46.4% (standard error, 6.0%) at 24-month follow-up, respectively. CONCLUSIONS: Stroke rate after endovascular arch repair was alarming among patients with NPAL. Proximal landing to zone 0 was related to higher risk of stroke. Reinterventions were common within the 24-month follow-up.

Sex Comparative Analysis on Branched and Fenestrated Endovascular Aortic Arch Repair Outcomes.

OBJECTIVE: Female sex is a risk factor for adverse events after endovascular aortic repair. Sex comparative early and mid term outcomes of fenestrated and branched endovascular aortic arch repair (f/b-Arch) are presented. METHODS: Single centre retrospective sex comparative analysis of consecutive patients managed with f/b-Arch according to STROBE. Primary outcomes were sex comparative technical success, mortality, and cerebrovascular morbidity at 30 days. Kaplan-Meier estimates were used for follow up outcomes. RESULTS: Among 209 patients, 38.3% were women. Coronary artery disease (p < .001) and previous myocardial infarction (p = .001) were more common in women. Non- native proximal aortic landing was higher in women (women: 51.3%; men: 31.8%, p = .005) and aortic dissection rate was lower (28.8% vs. 48.1%, p = .005). Proximal landing to Ishimaru zones showed no difference (zone 0: p = .18; zone 1: p = .47; zone 2: p = .39). Graft configurations were equally distributed. In total, 416 supra-aortic trunks were bridged. Median number of revascularisations per patient was 2 (interquartile range 1, 3), with no difference between sexes (p = .54). Technical success (women: 97.5%; men: 96.7%, p = .80), 30 day mortality (women: 10%; men: 9.3%, p = .86), and cerebrovascular morbidity (women: 11.3%; men: 17.1%, p = .25) were similar. Women presented more access related complications (women: 32.5%; men: 16.3%, p = .006), without affecting access related re-interventions (p = .55). Survival (women: 81.1%, 95% confidence interval [CI] 76.3 - 85.9%; men: 79.8%, 95% CI 76.0 - 83.6%) and freedom from re-intervention (women: 56.6%, 95% CI 50.4 - 62.8%); men: 55.3%, 95% CI 50.1 - 60.5%) at 12 months were similar (log rank, p = .40 and p = .41, respectively). CONCLUSION: Both sexes presented similar outcomes after f/b-Arch. Appropriate patient selection may decrease the effect of sex in f/b-Arch outcomes.

Trans-Carotid Artery Revascularization Versus Carotid Endarterectomy in Patients With Carotid Artery Disease: Systematic Review and Meta-analysis of 30-day Outcomes.

This systematic review and meta-analysis compared trans-carotid artery revascularization (TCAR) as an alternative approach to carotid endarterectomy (CEA) in patients with carotid artery disease. An electronic search was conducted using PubMed, Scopus, and Cochrane databases including comparative studies with patients who underwent either TCAR or CEA. This meta-analysis is according to the recommendations of the PRISMA statement. Eight studies met our eligibility criteria, incorporating 7,606 and 7,048 patients in the TCAR and CEA groups, respectively. Thirty-day mortality (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.56-1.56, P = .81) and stroke (OR: 0.92, 95%CI 0.70-1.22, P = .57) were similar between the two groups, with low heterogeneity. The odds of myocardial infarction (OR: 1.79, 95% CI: 1.18-2.71, P = .01) and cranial nerve injury were significantly higher in patients undergoing CEA compared with TCAR (OR: 4.11, 95% CI: 2.59-6.51, P < .001). The subgroup analysis according to symptomatic pre-intervention status revealed no statistically significant difference regarding 30-day mortality (symptomatic OR: 0.91, 95% CI: 0.40-2.07, P = .82, asymptomatic OR: 0.93, 95% CI: 0.46-1.86, P = .83) and stroke (symptomatic OR: 0.88, 95% CI:0.47-1.64, P = .68, asymptomatic OR: 0.93, 95% CI: 0.64-1.35, P = .70). TCAR offers an alternative treatment for patients with carotid artery stenosis with comparable to CEA mortality and stroke rates during a 30-day post-operative period.

A Systematic Review on Thoracic Endovascular Repair Outcomes in Blunt Thoracic Aortic Injuries.

PURPOSE: Blunt thoracic aortic injury (BTAI) represents a potentially life-threatening condition and thoracic endovascular aortic repair (TEVAR) is recommended as the first-line treatment (Class I level of evidence C) by the current guidelines. The aim of this systematic review was to determine the perioperative and mid-term follow-up outcomes of patients with BTAI treated with TEVAR. MATERIALS AND METHODS: We reviewed the English literature published between 2000 and 2022, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until July 30, 2022. Observational studies and case series, with ≥5 patients, reporting on the perioperative and follow-up outcomes of patients who underwent TEVAR for BTAI were included. The Newcastle-Ottawa Scale was used to assess the risk of bias. Primary outcomes were technical success and 30-day mortality, cerebrovascular morbidity. Secondary outcomes were mortality and re-interventions during the mid-term follow-up. RESULTS: From 5201 articles identified by the literature search, 35 eligible studies were included in this review. All studies had a retrospective study design. In total, 991 patients were included. The mean age was 34.5±16.5 years (range=16-89 years). Technical success was 98.0% (odds ratio [OR], 95% confidence interval [CI]=0.98, 0.99, p<0.001, I2=0%). Mortality at 30 days was 5.0% (OR, 95% CI=0.03, 0.06, p<0.001, I2=5.56%). Spinal cord ischemia occurred in 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and stroke rate was 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%). The available follow-up was estimated at 29 months (range=3-119 months) with mortality rate at 2.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=0%) and re-intervention rate at 1.0% (OR, 95% CI=0.01, 0.02, p<0.001, I2=10.5%). CONCLUSION: Thoracic endovascular aortic repair showed high technical success and low early cerebrovascular morbidity and mortality rates. In the mid-term follow-up, the estimated mortality and re-intervention rates were also low. Furthermore, higher quality prospective studies are needed. CLINICAL IMPACT: Thoracic endovascular aortic repair (TEVAR) is recommended as the first line treatement in patients with blunt thoracic aortic injuries (BTAI). This systematic review of 35 retrospective studies and 991 patients showed high technical success (98.0%) with an associated 30-day mortality at 5.0% and low spinal cord ischemia (1%) and stroke rates (2.0%). Mid-term mortality and re-intervention rates reassure the effectiveness of TEVAR in BTAI cases.

Target Vessel-Related Outcomes in Patients Managed With Branch Thoracic Aortic Endovascular Repair.

INTRODUCTION: Data on target vessel (TV)-related outcomes in patients managed with branched thoracic endovascular aortic repair (BTEVAR) are limited. This study aimed to present the TV-related outcomes of BTEVAR in patients managed for aortic arch pathologies at 30 days and during follow-up. METHODS: A retrospective analysis of consecutive patients, managed between September 1, 2011, and June 30, 2022, with custom-made aortic arch endografts (Cook Medical, Bloomington, IN, USA), presenting at least one branch configuration, were eligible. Primary outcomes were technical success, TV-related patency, and reinterventions at 30 days. RESULTS: In total, 255 TVs were revascularized using branches: 107 innominate arteries (IAs), 108 left common carotid arteries (LCCAs), and 40 left subclavian arteries (LSAs). Covered stents were used as bridging stents of which 10.2% were balloon expandable. Relining, using bare-metal stents (BMS), was performed in 14.0% of IAs, 35.2% of LCCAs, and 22.5% of LSAs. Technical success on case basis was 99.2%; no failure was related to unsuccessful TV bridging. At 30 day follow-up, no TV occlusion was detected. In 5.6% of cases, a type Ic or III endoleak, attributed to TVs, was recorded. Two patients needed early branch-related reintervention. The mean follow-up was 18.3±9.2 months. Freedom from TV instability was 94.6% (standard error [SE] 2.5%] at 12 months. No TV stenosis or occlusion was detected up to 48 months of follow-up. Freedom from TV-related reinterventions was 95.4% [SE 2.4%] at 12 months. CONCLUSION: TV stenosis or occlusion in BTEVAR cases is rare and TV-related reinterventions and instability events are mainly attributed to type Ic and III endoleak formation. CLINICAL IMPACT: Previous studies focusing on target vessel (TV) outcomes after endovascular aortic arch repair are limited. In this study, including 255 TVs revascularized using branched arch devices, bridging was performed with covered stents, of which 90% were self-expanding. Relining was at the discretion of the operator and was 14% for the innominate, 35.2% for the left common carotid and 22.5% for the left subclavian artery branches. No 30-day occlusion was detected. The freedom from TV instability was almost 95% at 12 months. TV instability and reintervention were mainly attributed to endoleaks type Ic and IIIc.

Systematic review and meta-analysis of fenestrated or branched devices after previous open surgical aortic aneurysm repair.

OBJECTIVE: Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require further repair, and fenestrated and branched endovascular aneurysm repair (F/BEVAR) may be applied to address these pathologies. The aim of this systematic review was to assess technical success, mortality, and morbidity (acute kidney injury, spinal cord ischemia) at 30 days, and mortality and reintervention rates during the available follow-up, in patients managed with F/BEVAR after previous OSR. METHODS: The PRISMA statement was followed, and the study was pre-registered to the PROSPERO (CRD42022363214). The English literature was searched, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, through November 30, 2022. Observational studies and case series with ≥5 patients (2000-2022), reporting on F/BEVAR outcomes after OSR, were considered eligible. The Newcastle-Ottawa Scale and GRADE were used to assess the risk of bias and quality of evidence. The primary outcome was technical success, mortality, and morbidity at 30 days. Data on the outcomes of interest were synthesized using proportional meta-analysis. RESULTS: The initial search yielded 1694 articles. Eight retrospective studies (476 patients) were considered eligible. In 78.3% of cases, disease progression set the indication for reintervention. Technical success was estimated at 96% (95% confidence interval [CI], 89%-98%; I2 = 0%; 95% prediction interval [PI], 79%-99%). Thirty-day mortality was 2% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-28%). The estimated spinal cord ischemia and acute kidney injury rates were 3% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-30%) and 6% (95% CI, 2%-15%; I2 = 0%; 95% PI, 1%-40%), respectively. During follow-up, overall mortality was 5% (95% CI, 2%-12%; I2 = 34%; 95% PI, 0%-45%) and aorta-related mortality was 1% (95% CI, 0%-2%; I2 = 0%; 95% PI, 0%-3%). The rate of reinterventions was 16% (95% CI, 9%-26%; I2 = 22%; 95% PI, 3%-50%). CONCLUSIONS: According to the available literature, F/BEVAR after OSR may be performed with high technical success and low mortality and morbidity during the perioperative period. Follow-up aortic-related mortality was 1%, whereas the reintervention rates were within the standard range following F/BEVAR.

Transition from Open Repair to Endovascular Aneurysm Repair for Rupture Aortic Aneurysms throughout a 16-Year Period of Time in a Single Tertiary Center.

BACKGROUND: Endovascular aneurysm repair (EVAR) is recommended as the first option for both elective and ruptured abdominal aortic aneurysms (rAAAs) with suitable anatomy. The aim of this study was to evaluate the outcomes of the gradual adoption of ruptured EVAR (rEVAR) as first option in the management of rAAAs in a reference tertiary center over a 16 year-period. METHODS: A retrospective analysis of prospectively collected clinical data was undertaken, including all patients that were treated for rAAA infrarenal or juxtarenal either with open surgical repair (OSR) or EVAR from 2006-2023. Three periods were identified and analyzed: Initial (2006-2011); intermediate (2012-2017); and current (2018-2023). The primary outcomes were the 30-day mortality rate in relation to the changing pattern of treatment. Secondary outcomes were re-intervention and mortality during the follow up period. RESULTS: Two hundred patients were treated for rAAA; 52% by endovascular means [EVAR (94), Ch-EVAR (9), and branched endovascular aneurysm repair (1)] and 48% by OSR (96). In the initial period, 61 patients were treated for rAAA (21% EVAR vs. 79% OSR), 68 in intermediate patients (47% EVAR vs. 53% OSR), and 71 in current period (83% EVAR vs. 17% OSR). Only in the current period juxta -renal rAAAs were treated by endovascular means (14%). The 30-day mortality rate was 46% in initial period (31% for EVAR vs. 50% for OSR), 64% in second period (46% in EVAR vs. 80% for OSR), and 35% in third period (25% for EVAR vs. 83% for OSR). The mean follow up did not differ between the groups, (EVAR 28.3 ± 2 months, vs. OSR 33.1 ± 3 months, P = 0.56). The survival rate did not differ between the groups; in rEVAR was 82% (SE 5%), 74% (SE 6%), 68% (SE 6.5%), and 63% (SE 7.7%) at 12, 24, 36, and 48 months, respectively, and in OSR was 76% (SE 7%), 66% (SE 8%), and 56% (SE 9.5%) at 6, 24, and 48 months, respectively (P = 0.544). CONCLUSIONS: Through a 16-year period, the implementation of EVAR as treatment of choice for rAAAs over OSR resulted in a noticeable reduction in the 30-day mortality. rEVAR was feasible in over 80% of rAAA patients.

Endovascular Recanalization of Aortic Isthmus Atresia with an "Electrified Wire Technique".

PURPOSE: For aortic coarctation in adults endovascular repair is the treatment of choice with an acceptable safety profile. Aortic isthmus atresia is a related condition with a complete occlusion of the aorta not allowing catheterization across the isthmus. This technical note describes a recanalization of an aortic isthmus atresia using radiofrequency with an "electrified wire technique." TECHNIQUE: A guidewire was selectively denuded of PTFE (polytetrafluoroethylene) at the distal end and was placed through a catheter distal to the aortic isthmus atresia. The denuded end of the wire was clamped to an electrosurgery pencil. By pushing the wire toward a tulip-snare, which was placed as a target proximal of the occlusion via left trans-brachial access, and shortly activating of the electrosurgery pencil the electrified wire recanalized the occlusion and was snared and used to guide implantation of a balloon-expandable covered stent. CONCLUSION: The electrified wire puncture technique can be used to recanalize adult aortic isthmus atresia after failed conventional attempts. CLINICAL IMPACT: The electrified wire technique offers an off-the shelf option to modify standard guidewires for the use with radiofrequency to cross a complete aortic isthmus occlusion after failed conventional attempts. This new technique may be applied also in other situations like dissection flap fenestration, transcaval access and similar.

Urgent and emergent repair of complex aortic aneurysms using an off-the-shelf branched device.

Introduction: Endovascular repair using off-the-shelf endografts is a viable solution in patients with ruptured or symptomatic complex aortic aneurysms. This analysis aimed to present the peri-operative and follow-up outcomes in urgent and emergent cases managed with the t-Branch multibranched thoracoabdominal endograft. Methods: Prospectively collected data from all consecutive urgent and emergent cases managed in two aortic centers between January 1st, 2014, to November 30th, 2022, using the t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) were analyzed. Patients presenting with ruptured aortic complex aneurysms were characterized as emergent and patients with aneurysms >90 mm of diameter, or symptomatic aneurysms were characterized as urgent. Technical success, 30-day mortality, major adverse events (MAE) and spinal cord ischemia (SCI) rates were assessed. Results: 225 patients (36.5% females, 72.5 ± 2.8 years) were included; 73.0% were urgent. The mean aneurysm diameter was 109 ± 3.9 mm and 44.4% were type I-III TAAAs. Females (p = .03), para-renal aneurysms (p = .02) and ASA score IV (p < .001) were more common in emergent cases. Technical success was 97.8%. Thirty-day mortality and MAE rates were 17.8% and 30.6%, respectively. SCI rate was 14.7%, (4.8% paraplegia rate) with 22.2% of patients receiving prophylactic cerebrospinal drainage. Thirty-day mortality (13.3% vs. 26.7%, p = .04) and MAE (26.0% vs. 43.0%, p = .02) were more common among emergent cases while technical success (97.6% vs. 98.3%, p = .9), and SCI (13.3% vs. 18.3%, p = .4) were similar. Survival at 12-months was 83.5% (SE 5.9%) for the urgent and 77.1% (SE 8.2%) for the emergent group (log rank, p = 0.96). Conclusion: T-Branch represents an effective and safe solution for the management of urgent and emergent cases with complex aortic aneurysms, with high technical success, promising early mortality and SCI rates.

Artificial intelligence in vascular surgical decision making.

Despite advances in prevention, detection, and treatment, cardiovascular disease is a leading cause of mortality and represents a major health problem worldwide. Artificial intelligence and machine learning have brought new insights to the management of vascular diseases by allowing analysis of huge and complex datasets and by offering new techniques to develop advanced imaging analysis. Artificial intelligence-based applications have the potential to improve prognostic evaluation and evidence-based decision making and contribute to vascular therapeutic decision making. In this scoping review, we provide an overview on how artificial intelligence could help in vascular surgical clinical decision making, highlighting potential benefits, current limitations, and future challenges.

Sex-Comparative Outcomes of the T-Branch Device for the Treatment of Complex Aortic Aneurysms.

INTRODUCTION: Females are at increased risk of mortality compared to males after complex endovascular aortic repair. This study aims to examine sex-related peri-operative and follow-up outcomes in patients managed with the t-Branch device. METHODS: A two-center retrospective analysis of patients managed with the off-the-shelf t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) between 1 January 2014 and 30 September 2020 was performed. Primary outcomes were sex-comparative 30-day mortality, major adverse events (MAEs) and spinal cord ischemia (SCI). RESULTS: A total of 542 patients were included; 28.0% were females. Urgent repair and type I-III thoracoabdominal aneurysms were more common among females (52.6% vs. 34%, p = 0.01, and 57.1% vs. 35.8%, p = 0.004). Technical success was similar (97.4% vs. 96.9%, p = 0.755), as well as early mortality (16.2% in females vs. 10.8% in males; p = 0.084). SCI rates were similar between groups (13.6% vs. 9.2% p = 0.183). MAEs were more common in females; 33.7% vs. 21.4% (p = 0.022). Multivariate analysis did not identify sex as an independent predictor of adverse events. The 12-month survival rate was 75.7% (SE 0.045) for females and 84.1% (SE 0.026) for males (log rank, p = 0.10). CONCLUSIONS: Sex was not detected as an independent factor of mortality, MAEs and SCI within patients managed with the t-Branch device. Feasibility was high in both groups. No significant difference was shown in survival during the 12-month follow-up.

A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia.

OBJECTIVE: Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. DATA SOURCES: Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. REVIEW METHODS: The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. RESULTS: Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. CONCLUSION: Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.

A Systematic Review and Meta-analysis on Stenting for Aortic Coarctation Management in Adults.

PURPOSE: Endovascular treatment of aortic coarctation (CoA) constitutes a valuable alternative with low morbidity and mortality. The aim of this systematic review and meta-analysis was to assess the technical success, re-intervention, and mortality after stenting for CoA in adults. MATERIALS AND METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analysis statement and PICO (patient, intervention, comparison, outcome) model were followed. An English literature data search was conducted, using PubMed, EMBASE, and CENTRAL, until December 30, 2021. Only studies reporting on stenting, for native or recurrent CoA, in adults were included. The risk of bias was assessed using the Newcastle-Ottawa Scale. A proportional meta-analysis was performed to assess the outcomes. Primary outcomes were technical success, intra-operative pressure gradient and complications, and 30-day mortality. RESULTS: Twenty-seven articles (705 patients) were included (64.0% males, 34.0±13.6 years). Native CoA was present in 65.7%. Technical success was 97% (95% confidence interval [CI], 0.96%-0.99%; p<0.001, I2=9.49%). Six (odds ratio [OR]: 1%; 95% CI, 0.00%-0.02%; p=0.002, I2=0%) ruptures and 10 dissections (OR: 2%; 95% CI, 0.001%-0.02%; p<0.001, I2=0%) were reported. The intra-operative and 30-day mortality were 1% (95% CI, 0.00%-0.02%; p=0.003, I2=0%) and 1% (95% CI, 0.00%-0.02%; p=0.004, I2=0%), respectively. The median follow-up was 29 months. Sixty-eight re-interventions (OR: 8%; 95% CI, 0.05%-0.10%; p<0.001, I2=35.99%) were performed; 95.5% were endovascular. Seven deaths were reported (OR: 2%; 95% CI, 0.00%-0.03%; p=0.008, I2=0%). CONCLUSION: Stenting for CoA in adults presents high technical success and the intra-operative and 30-day mortality rates were acceptable. During the midterm follow-up, the re-intervention rate was acceptable, and mortality was low. CLINICAL IMPACT: Aortic coarctation is a quite common heart defect that may be diagnosed in adult patients, as a first diagnosis in native cases or as a recurrent after previous repair. Endovascular management using plain angioplasty has been associated to a high intra-operative complication and re-intervention rate. Stenting in this analysis seems to be safe and effective as is related a high technical success rate, exceeding 95%, with a low intra-operative complication and death rate. During the mid-term follow-up, the re-interventions rate is estimated at less than 10% while most cases are managed using endovascular means. Further analyses are needed on the impact of stent type on endovascular repair outcomes.

The Association of Sarcopenia and ASA Score to Spinal Cord Ischemia in Patients Treated With the t-Branch Device.

PURPOSE: Sarcopenia has been identified as an independent predictor of mortality in patients with infrarenal abdominal aortic aneurysm and may also affect outcomes in patients with complex aortic pathologies. The aim of this study was to assess sarcopenia, combined with the American Society of Anesthesiologists (ASA) score, as predictors for spinal cord ischemia (SCI) in patients treated with the t-Branch off-the-shelf device. MATERIALS AND METHODS: A single-center retrospective observational study was conducted including elective and urgent patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) between January 1, 2018, and September 30, 2020. Data were collected according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement. The psoas muscle area (cm2) and attenuation (Hounsfield units, HU) were measured in the arterial phase of the pre-operative computed tomography angiography for each patient. The lean psoas muscle area (LPMA) was used to stratify patients into 3 groups, and further stratification was performed with a combination of the ASA score and LPMA. RESULTS: Eighty patients were included (mean age at 71±9 years; 62.5% males). Thoracoabdominal aneurysms were managed in 72.5% of cases (42.5% for type I-III). Thirty-seven (46%) were treated urgently. Eleven patients died within 30 days (14%). Twelve patients (15%) presented SCI of any severity. Among the LPMA groups, the only statistically significant difference was recorded in age; group 3 was older compared with groups 1 and 2 (67.1 years vs 72.1 years vs 73.5 years, p=0.004). After ASA combined LPMA categorization, 28 patients were considered as low risk, 16 as moderate risk, and 36 as high risk. A statistically significant difference was recorded in terms of SCI (3.5% [1/28] in low risk vs 12.5% [2/16] in moderate risk vs 25% [9/36] in high risk, p=0.049). Multivariate analysis showed that moderate-risk patients were at risk to evolve to SCI (p=0.04). CONCLUSIONS: Low-risk patients, with ASA score I-II or LPMA>350cm2HU, are at lower risk for developing SCI after BEVAR using the t-Branch device. Patients' stratification according to the combination of ASA score and psoas muscle area and attenuation may identify a group at higher risk of SCI after branched endovascular aneurysm repair. CLINICAL IMPACT: Sarcopenia has been identified as a factor of increased mortality in patients managed for aortic aneurysm repair. However, significant heterogeneity has been recorded in the tools assessing its presence. In this analysis, an already used method, combining the ASA score and psoas muscle area and attenuation, has been used to assess the impact of sarcopenia in patients managed with the t-branch device. This analysis showed that patients at low risk, with an ASA score I-II or LPMA>350cm2HU were at lower risk to evolve spinal cord ischemia. Along this line, sarcopenia may be a valuable marker for the prediction of perioperative adverse events , other than mortality, in patients managed using complex endovascular repair.