Clinical characteristics and early surgical outcomes of aortoesophageal fistula.

BACKGROUND: The incidence and prognosis of aortoesophageal fistula (AEF) has not been clarified. The clinical characteristics and surgical outcomes of AEF were investigated. METHODS: The clinical data of patients who underwent surgical treatment for AEF from January 2020 to December 2021 that were registered in the Japan Cardiovascular Surgery Database (JCVSD) were analyzed. RESULTS: During the period, 123 patients (71.0 [IQR: 61.0-78.0] years old; 76.4% men) underwent surgical treatment for AEF. The prevalence of secondary AEF was 61%. Secondary AEF after aortic grafting was the most frequent (n = 40; 32.5%), followed by AEF after thoracic endovascular aortic repair (TEVAR) (n = 30; 24.4%). Operative mortality was observed in 23 patients (18.7%). TEVAR for AEF (p = 0.019), postoperative bleeding (p = 0.047), stroke (p = 0.004), renal failure (p < 0.001), newly required hemodialysis (p = 0.023), pneumonia (p = 0.003), multisystem failure (p < 0.001), and dyslipidemia (p = 0.02) were associated with risk factors of operative mortality after surgical treatment of AEF on univariable logistic regression analyses. CONCLUSIONS: This first nationwide study on the surgical treatment for AEF demonstrated a higher incidence of secondary AEF than primary AEF. Both open surgical repair and TEVAR for AEF were associated with high operative mortality. TEVAR and dyslipidemia were risk factors for operative mortality. Precautions and further improved treatment strategies for AEF are still required.

Infected Abdominal Aortic Aneurysm Successfully Treated With Endovascular Aortic Repair and Antibiotics: A Case Report.

Surgical treatment of infected aneurysms is problematic due to their high complication and mortality rates. Infected aortic aneurysms are at high risk of rupture and should be operated on as soon as possible after diagnosis. A 72-year-old female patient with a medical history of diabetes mellitus, hyperlipidemia, and hypertension presented with a fever of 38°C and back pain, without any apparent cause, in 2021. Her C-reactive protein (CRP) level increased to 20 mg/dL. Further evaluation with contrast-enhanced computed tomography (CT) revealed a low-density area with air pockets surrounding the abdominal aorta. The patient was diagnosed with native abdominal aortic infection and transferred to our hospital for treatment. The next day, endovascular aortic repair (EVAR) was performed using an Endurant stent graft (161682). Postoperatively, the patient was treated with antibiotics, and subsequently, blood infection was alleviated. Moreover, the CRP levels normalized. Follow-up contrast-enhanced CT showed resolution of the air pockets surrounding the abdominal aorta. The patient was discharged home on postoperative day 33. During her three-year follow-up as an outpatient, no recurrence of the infection was detected. While open surgical repair with prosthetic graft replacement is often the preferred treatment for infected abdominal aortic aneurysms, in select cases, as demonstrated by our patient, EVAR can be employed to prevent rupture, followed by antibiotic therapy to achieve infection control.

A case of minimum invasive debranch thoracic endovascular aortic repair for isolated left vertebral artery: complete revascularization without artificial vessels via a single small incision.

Isolated left vertebral artery (ILVA) is one of the most frequent vertebral abnormalities. When performing thoracic endovascular aortic repair (TEVAR), the ILVA may have to be closed depending on the position of the stent graft; in these cases, the decision to reconstruct the ILVA depends on the state of cerebral blood flow. Here, we report a case of a 68-year-old male, in whom the Willis arterial circle was incomplete; we therefore performed a reconstructive method during zone 2-landing TEVAR that ensured ILVA and left subclavian artery blood flow without the use of artificial vessels. Only one supraclavicular incision was required for reconstruction. This method has some procedural difficulties; however, it does not use artificial blood vessels and can be performed with a single incision.

Endovascular Aortic Repair in Traumatic Descending Thoracic Aortic Transection: A Case Report.

Aortic transection, a near-complete tear through the layers of the aorta, is a critical condition often resulting from trauma such as motor vehicle collisions. The urgency of managing aortic transection underscores the critical need for effective interventions. We report the case of a male in his early 50s with no significant medical history who presented to the emergency department following a motor vehicle collision, sustaining multiple injuries including a descending thoracic aortic transection. Rapid diagnostic assessment confirmed the severity of the injury, necessitating immediate intervention. Endovascular aortic repair was successfully employed, highlighting its efficacy in managing acute aortic injuries. The patient responded well to treatment, underscoring the importance of timely intervention in improving patient outcomes. This case emphasizes the critical role of rapid diagnostic assessment and endovascular intervention in managing life-threatening thoracic aortic injuries, particularly in the acute setting.

Complete Recovery After Thoracic Endovascular Aortic Repair for Type a Aortic Dissection With Cerebral Malperfusion: A Case Report.

A 52-year-old woman presented with chest pain, shortness of breath and loss of sensation in her left limbs. Computed tomography angiography revealed an type A aortic dissection involving the brachiocephalic trunk and right common carotid artery. Endovascular therapy successfully managed the condition by reconstructing the artery and occluding the false lumen.

Effectiveness of the 5As Model-Based Transitional Care Program among Chinese Patients with Type B Aortic Dissection Post-TEVAR: A Randomized Controlled Trial.

Background: Thoracic aortic endovascular repair (TEVAR) is the primary treatment for Stanford type B aortic dissection (type B AD). However, patients often encounter significant difficulties post-TEVAR that endanger their safety when transitioning from hospital- to home-based care. Moreover, information on the ideal transitional care for patients with type B AD post-TEVAR is scarce in China. This single-masked randomized clinical trial aimed to assess the effectiveness of the Assess, Advise, Agree, Assist, and Arrange (5As) model-based transitional care in improving discharge preparation level and transitional care quality post-TEVAR among patients with type B AD in China. Methods: This study was conducted at a hospital in China between January 2021 and October 2021. Patients with type B AD were randomly divided into intervention and control groups. Participants in the intervention group received the 5As model-based transitional nursing care. The 5As model is an evidence-based intervention strategy comprising: (1) Assess: assessing the preoperative cardiovascular risk behavior of patients with AD. (2) Advise: making suggestions according to the risk behaviors of the patients. (3) Agree: reaching a consensus on goals and action plans by making decisions with the patients and their families. (4) Assist: assisting patients in solving obstacles to implementing health plans. (5) Arrange: arranging follow-up visits according to the actual situation of the patients and guiding them in adhering to a schedule. The control group received the usual nursing care for the same duration and number of follow-up visits. A trained research nurse collected all the baseline data of the patients on admission, assessed discharge readiness level (using the Readiness for Hospital Discharge Scale) on the day of discharge, and collected transitional quality of care (by the Care Transition Measure-15) data on day 30 after discharge. Results: Overall, 72 patients with type B AD were recruited. Discharge readiness level and transitional care quality in the intervention group were significantly superior to those in the control group. Conclusions: This study showed that the 5As model-based transitional care program can effectively promote discharge readiness and transitional care quality of patients with type B AD post-TEVAR. Clinical Trial Registration: The Chinese Clinical Trial Registry Center: ChiCTR2200060797 (https://www.chictr.org.cn/showproj.html?proj=167403).

A Case of Transapical Thoracic Endovascular Repair for Thoracic Aortic Aneurysm with a Complicated Access Route.

Thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAAs) is an alternative treatment option for high-risk patients. While conventionally performed via a transfemoral approach, it is sometimes difficult due to poor access routes. We report the case of a 90-year-old man who was incidentally diagnosed with a descending TAA while undergoing computed tomography for esophageal cancer. The patient had undergone Y-graft replacement twice. His Y-graft leg was highly angulated; therefore, a transfemoral approach was considered difficult. Consequently, transapical TEVAR was performed. The postoperative course was uneventful. Transapical TEVAR can be a useful treatment option for TAAs with poor access routes in super-old patients.

Spinal Cord Infarction after Endovascular Aortic Repair for Infrarenal Abdominal Aortic Aneurysm.

Spinal cord infarction (SCI) is a rare but serious complication of endovascular aortic repair (EVAR) for abdominal aortic aneurysms (AAA). It is difficult to predict, prevent, and treat and can cause significant impairment. We describe the case of a patient who experienced paraplegia and thermal pain dysfunction of the lower extremities shortly after EVAR for an infrarenal AAA. Immediately after confirming SCI, we initiated cerebrospinal fluid drainage, administered steroids, naloxone, and free radical scavengers, and maintained high blood pressure. However, the patient's symptoms did not improve sufficiently. Since the possibility of a SCI exists, prompt treatment should be initiated.

Use of Branched EVAR in Treatment of Juxtarenal Aortic Aneurysm and Essential Accessory Renal Artery: Another Tool on the Shelf? A Case Report.

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.

Hybrid approach to achieve secure distal seal zones during endovascular aortic repair in a patient with Marfan syndrome.

This report details a hybrid approach for treatment of abdominal aortic aneurysm in a patient with Marfan syndrome (MFS). A 34-year-old patient with MFS and prior open thoracoabdominal aortic aneurysm repair underwent bilateral common iliac artery interposition graft repair and endovascular aortic repair. The bifurcated stent graft was implanted into the previous thoracoabdominal graft proximally and iliac interposition grafts distally. Postoperatively, the patient recovered uneventfully with sac regression to 4.5 cm through 2-year follow-up, without seal zone degeneration. This hybrid approach aimed to eliminate landing zone degeneration in patients with MFS undergoing endovascular repair.

A prevention protocol reduces spinal cord ischemia in patients undergoing branched/fenestrated endovascular aortic repair.

OBJECTIVE: Spinal cord ischemia (SCI) is a devastating complication that is associated with thoracoabdominal aortic repair, with higher risk associated with increased aortic coverage length, making patients undergoing branched/fenestrated endovascular repair (B/FEVAR) particularly vulnerable. A bundled SCI prevention protocol was previously reported to reduce SCI rates when compared to a historic cohort in a single-center study. Therefore, this analysis aims to further validate and update outcomes associated with the protocol given the routine implementation of this strategy at two institutions (University of Florida and the University of Alabama at Birmingham) since inception. METHODS: Components of the SCI prevention protocol include selective cerebrospinal fluid drainage, specified blood pressure parameters, transfusion goals, and selective pharmacologic adjuncts (naloxone, steroids). This protocol was routinely implemented in May 2015. Patients undergoing B/FEVAR from May 2015 to December 2022 constituted the post-protocol cohort (n = 402) and were compared with the pre-protocol cohort (n = 160; January 2010-April 2015). The primary outcome was SCI incidence, and subgroup analysis was conducted among patients deemed to be high-risk (Crawford extent I-III thoracoabdominal aneurysm dissection-related disease, prior aortic repair, coverage proximal to zone 5). Survival analysis was performed using Kaplan-Meier methodology. RESULTS: The pre- and post-protocol cohorts were demographically similar, although more post-protocol patients were American Society of Anesthesiology class IV (86.1% vs 55.0%; P < .001). Thoracoabdominal aneurysm was the most common indication in both groups. Cerebrospinal fluid drain placement was more common in the post-protocol group, particularly among high-risk patients. SCI occurred in 15.9% of pre-protocol patients vs 3.0% of post-protocol patients (P < .001). In high-risk patients, the pre- and post-protocol cohort SCI incidence was 23.2% vs 5.0%, respectively (P < .001). Thirty-day mortality was decreased in the post-protocol cohort (6.3% vs 2.2%; P = .02). Although the post-protocol group had a trend toward improved 1-year survival, this was not statistically significant (84.4% vs 88.3%; log-rank P = .35). Among patients with SCI, 1-year mortality was 28% and 33.3% in the pre- and post-protocol groups, respectively (P = .46). CONCLUSIONS: Implementation of a bundled SCI prevention protocol significantly reduces SCI rates in patients undergoing B/FEVAR, which has now been validated at two institutions, with the most significant reductions occurring among high-risk patients. Although the overall 1-year mortality difference was not significantly different between the cohorts, the high mortality rates among patients with SCI highlights the importance of preventative measures.

Early three-dimensional growth in uncomplicated type B aortic dissection is associated with long-term outcomes.

OBJECTIVE: Late adverse events (LAEs) are common among initially uncomplicated type B aortic dissection (uTBAD); however, identifying those patients at highest risk of LAEs remains a significant challenge. Early false lumen (FL) growth has been suggested to increase risk, but confident determination of growth is often hampered by error in two-dimensional clinical measurements. Semi-automated three-dimensional (3D) mapping of aortic growth, such as by vascular deformation mapping (VDM), can potentially overcome this limitation using computed tomography angiograms (CTA). We hypothesized that FL growth in the early pre-dissection phase by VDM can accurately predict LAEs. METHODS: We performed a two-center retrospective study of patients with uTBAD, with paired CTAs in the acute (1-14 days) and subacute/early chronic (1-6 months) periods. VDM analysis was used to map 3D growth. Standard clinical CT measures (ie, aortic diameters, tear characteristics) were also collected. Multivariate analysis was conducted using a decision tree and Cox proportional hazards model. LAEs were defined as aneurysmal FL (>55 mm); rapid growth (>5 mm within 6 months); aorta-specific mortality, rupture, or re-dissection. RESULTS: A total of 107 (69% male) patients with uTBAD initially met inclusion criteria with a median follow-up of 7.3 years (interquartile range [IQR], 4.7-9.9 years). LAEs occurred in 72 patients (67%) at 2.5 years (IQR, 0.7-4.8 years) after the initial event. A multivariate decision tree model identified VDM growth (>2.1 mm) and baseline diameter (>42.7 mm) as optimal predictors of LAEs (area under the receiver operating characteristic curve = 0.94), achieving an 87% accuracy (sensitivity of 93%, specificity of 76%) after leave-one-out validation. Guideline reported high-risk features were not significantly different between groups. CONCLUSIONS: Early growth of the FL in uTBAD was the best tested indicator for LAEs and improves upon the current gold-standard of baseline diameter in selecting patients for early prophylactic thoracic endovascular aortic repair.

Volume Measurements for Surveillance after Endovascular Aneurysm Repair using Artificial Intelligence.

OBJECTIVE: Surveillance after endovascular aneurysm repair (EVAR) is suboptimal due to limited compliance and relatively large variability in measurement methods of abdominal aortic aneurysm (AAA) sac size after treatment. Measuring volume offers a more sensitive early indicator of aneurysm sac growth or regression and stability, but is more time consuming and thus less practical than measuring maximum diameter. This study evaluated the accuracy and consistency of the artificial intelligence (AI) driven software PRAEVAorta 2 and compared it with an established semi-automated segmentation method. METHODS: Post-EVAR aneurysm sac volumes measured by AI were compared with a semi-automated segmentation method (3mensio software) in patients with an infrarenal AAA, focusing on absolute aneurysm volume and volume evolution over time. The clinical impact of both methods was evaluated by categorising patients as showing either AAA sac regression, stabilisation, or growth comparing the 30 day and one year post-EVAR computed tomography angiography (CTA) images. Inter- and intra-method agreement were assessed using Bland-Altman analysis, the intraclass correlation coefficient (ICC), and Cohen's κ statistic. RESULTS: Forty nine patients (98 CTA images) were analysed, after excluding 15 patients due to segmentation errors by AI owing to low quality CT scans. Aneurysm sac volume measurements showed excellent correlation (ICC = 0.94, 95% confidence interval [CI] 0.88 - 0.99) with good to excellent correlation for volume evolution over time (ICC = 0.85, 95% CI 0.75 - 0.91). Categorisation of AAA sac evolution showed fair correlation (Cohen's κ = 0.33), with 12 discrepancies (24%) between methods. The intra-method agreement for the AI software demonstrated perfect consistency (bias = -0.01 cc), indicating that it is more reliable compared with the semi-automated method. CONCLUSION: Despite some differences in AAA sac volume measurements, the highly consistent AI driven software accurately measured AAA sac volume evolution. AAA sac evolution classification appears to be more reliable than existing methods and may therefore improve risk stratification post-EVAR, and could facilitate AI driven personalised surveillance programmes. While high quality CTA images are crucial, considering radiation exposure is important, validating the software with non-contrast CT scans might reduce the radiation burden.

Early Experience With Fenestration Modification of Castor Branched Stent-Graft for Aortic Arch Diseases.

PURPOSE: This study aimed to assess the safety and viability of combining branched stent graft with fenestrated thoracic endovascular aortic repair (TEVAR) in treating aortic arch lesions. MATERIALS AND METHODS: The cohort included patients presenting with aortic arch lesions who underwent treatment with a combination of branched stent graft and fenestrated TEVAR between July 2020 and November 2022. Technical success was defined as the precise deployment of the stent graft, maintenance of branch vessel patency, and the absence of type I endoleak. The secondary outcomes examined were complications and all-cause mortality. RESULTS: The study cohort comprised 21 patients (average age: 61.0±14.8 years) with aortic arch lesions from 3 tertiary care hospitals. The aortic arch lesions encompassed aortic dissection (N=8), aortic aneurysm (N=8), pseudoaneurysm (N=1), intramural hematoma (N=1), and penetrating aortic ulcer (N=3). The technical success rate achieved was 95.2% (20/21). Failure in one case was due to an intraoperative type I endoleak, which was rectified with an additional stent graft placement. The 30-day mortality rate was 4.8% (1/21). One patient suffered a stroke but responded well to medical intervention. The median hospital stay was 10.9±5.4 days. During the follow-up period, one death (4.8%) was associated with aortic complications. A type II endoleak was observed and managed with close monitoring. Two patients underwent re-interventions for retrograde type A dissection and stent migration, respectively. No occlusions were observed in the target branch arteries. CONCLUSIONS: The combination of branched stent graft with fenestrated TEVAR emerges as a viable strategy for addressing specific lesions in the aortic arch. CLINICAL IMPACT: This study demonstrates the feasibility of using branched stent grafts with fenestrated TEVAR for treating aortic arch lesions, achieving a technical success rate of 95.2%. Compared to traditional open surgery, this innovative, minimally invasive approach reduces perioperative mortality and complications, such as stroke and spinal cord ischemia. For clinicians, it offers a viable alternative for patients unfit for open repair, particularly in complex aortic arch cases. While the initial outcomes are promising, further research is needed to assess long-term durability and risks, including stent graft migration and late endoleak, ensuring the technique's safety and efficacy over time.

Physician-Modified and In Situ Fenestrated Stent Grafts in Zone 0 for Aortic Arch Pathology After Ascending Aortic Replacement.

BACKGROUND: We sought to describe our experience and outcomes of a zone 0 landing physician-modified aortic stent for the treatment of aortic arch pathologies late after open ascending aortic replacement. METHODS: This study included consecutive patients with aortic arch diseases treated with total endovascular repair using different techniques. The indication for endovascular repair was agreed on in a multidisciplinary discussion. Study end points were technical success, early and late outcomes. RESULTS: From November 2018 to May 2022, 16 consecutive patients underwent total endovascular repair of aortic arch pathologies. Median time for surgery was 4.8 hours (range, 2.6-6.6 hours). All the new-onset aortic arch pathologies were successfully treated. The 30-day mortality rate was 0%. Two patients had endoleak. The median length of postoperative stay was 4 days (range, 3-6 days). During follow-up, 1 patient underwent reintervention for type II endoleak. There were no conversions to retrograde dissection, aortic rupture and stroke. CONCLUSIONS: Our experience of using different total endovascular techniques for selective patients with arch pathologies who may be unfit or too risky for reopen surgery revealed favorable initial results. In addition, these techniques are promising options for urgent arch pathologies without availability of custom-manufactured devices. Durability concerns will need to be assessed in additional studies with long-term follow-up. CLINICAL IMPACT: The use of physician-modified and in situ fenestrated stent grafts in zone 0 landing for aortic arch pathologies in patients with prior open ascending aortic replacement is effective in endovascular therapy. This innovation enables clinicians to offer an alternative option to high-risk patients, potentially reducing morbidity and mortality. It underscores the feasibility of tailored endovascular therapy in complex aortic diseases, where customized devices may not be available.

Comparison of the novel Ankura Plus stent and Castor stent for the treatment of Stanford type B aortic dissection with an insufficient proximal anchoring area.

OBJECTIVE: To compare the efficacy and safety of the Ankura Plus and Castor stents in Stanford type B aortic dissection (TBAD) with an insufficient proximal anchoring area. METHODS: Between January 2020 and October 2022, 54 patients with TBAD were enrolled, including 16 patients with Ankura Plus stents and 38 patients with Castor stents. Data from the two stents were retrospectively analyzed. RESULTS: The surgical success rate for both stents was 100%, and no endoleaks or deaths occurred during hospitalization. The Ankura Plus stent group had a longer surgery time than the Castor stent group (122.6±5.1 vs. 103.7±10.0, P ＜0.001). After an average follow-up of 12 months, the patency rates of the main and branch stents were 100% in both groups. The diameter of the true lumen (TL) was significantly increased, the diameter of the false lumen (FL) was reduced, and there was no statistically significant difference in the probability of complete thrombosis of the FL (68.8% vs. 67.6%, P=0.993). There were no significant differences in the incidences of renal failure (6.3% vs. 8.1%, P = 0.814), stroke (6.3% vs. 2.7%, P = 0.520), or endoleaks (6.3% vs. 10.5%, P = 0.621) between the Ankura Plus and Castor stent groups. One patient in the Castor stent group underwent reintervention because of a type I endoleak three months after surgery. One patient in the Ankura Plus stent group had an additional covered stent placed after one month due to distal TL stenosis of the main stent. One patient in the Castor stent group died of renal failure four months after surgery. CONCLUSION: Both the Ankura Plus and Castor stents are feasible, safe, and effective in the treatment of TBAD with an insufficient proximal anchoring area. Additional long-term studies are required to evaluate the robustness and applicability of Ankura Plus stents.

Stent Graft-Induced High Wall Stress Promoted Aortic Wall Failure and Aortic Wall Injurious Complications After TEVAR: A Study of Numerical Simulation and Bioinformatics Analysis Based on Pig Models.

OBJECTIVES: Stent graft-related aortic injury is a major complication after thoracic endovascular aortic repair (TEVAR) and seriously affects patient prognosis. However, the distribution characteristics of aortic wall stress under the action of stent grafts and the mechanism of abnormal wall stress leading to aortic wall injury and adverse remodeling were unclear. The aim of this study was to explore the potential mechanisms of high wall stress on the structural and functional alterations of the aortic wall by combining animal experiments, numerical simulations, and bioinformatics. METHODS: We observed stent graft-induced aortic injury by performing fenestrated TEVAR in 6 pigs, and quantitatively analyzed and visualized the stress distribution of the aortic wall under the stent graft through numerical simulation. Hematoxylin and eosin (HE) staining, Masson's trichrome staining, Verhoeff's Van Gieson (EVG) staining, and immunostaining were used to evaluate pathological changes in the aorta. Based on the numerical simulation results, the corresponding high-stress and low-stress regions of the aortic wall were subjected to bulk-RNA sequencing, and hub genes were identified by bioinformatics analysis. RESULTS: Stent grafts were successfully implanted in 5 pigs. In all computational models, we found that obvious deformation and characteristic maximum stress concentration occurred on the side of the greater curve of the aortic arch in contact with the stent graft tip, and the high wall stress concentration areas were highly consistent with the obvious pathological injury area. Subsequent pathological analysis revealed that high wall stress-induced confusion and fragmentation of elastic fibers, collagen deposition, loss and phenotypic switching of vascular smooth muscle cells, and increased inflammatory responses. Gene expression profiles of the aortic wall under different wall stress conditions were described for the first time, and the hub genes (TGFB1, CDH5, DCN, ITGA5, ITGB3, and WT1) that may be involved in regulating the aortic injury and remodeling process in response to high wall stress stimulation were identified. CONCLUSIONS: This study revealed a panoramic view of stent graft-associated high wall stress-induced aortic wall injury through technical approaches of multiple dimensions. Understanding these biomechanical features and hub genes is pivotal for advancing our comprehension of the complications associated with aortic injury after TEVAR and facilitating the development of future therapeutic interventions. CLINICAL IMPACT: This study revealed a panoramic view of stent graft-associated high wall stress-induced aortic wall injury through technical approaches of multiple dimensions. The biomechanical distribution characteristics of the aortic wall, the secondary pathological injury and the alteration of gene expression profile under the action of stent graft were comprehensively revealed by animal experiments for the first time. This will advance clinicians' comprehension of complications associated with aortic injury after TEVAR, provide a new biomechanical perspective for the rational preoperative planning of TEVAR and the management of postoperative complications, and facilitate the development of future therapeutic interventions and stent graft device designs.

The Role of Downsizing of Large-Bore Percutaneous Femoral Access for Pelvic and Lower Limb Perfusion in Transfemoral Branched Endovascular Aortic Repair.

Background: Transfemoral access (TFA) is a valuable alternative to upper extremity access (UEA) for branched endovascular aortic repair (bEVAR). However, TFA requires large introducer sheaths, which can reduce blood flow to lower limbs and the pelvis. This study aimed to evaluate the efficacy of sheath downsizing to maintain lower limb perfusion during TFA-bEVAR. Methods: A single-center retrospective review was conducted including patients managed with TFA-performed bEVAR between December 2020 and May 2021. Intra-operative lower limb perfusion was assessed using non-invasive ankle blood pressure measurements and great toe pulse oximetry, with measurements being taken prior to puncture (baseline), one minute after 10F-sheath insertion, three minutes after the main body delivery system insertion, and three minutes after downsizing to a 14F sheath. Outcomes included the incidence of limb perfusion reduction (LPR), defined as a drop in the ankle-brachial index (ABI) < 0.5 or peripheral oxygen saturation (SpO2) < 90%. Results: Out of 47 patients, 24 met the inclusion criteria. LPR occurred in 4.2% of cases after 10F-sheath placement, and 87.5% after main body delivery system placement, and decreased to 12.6% after downsizing to a 14F sheath. No periprocedural major bleeding occurred. Two patients required revision for inadequate hemostasis post-operatively. SCI occurred in 16% of patients, all recovered by discharge. Pre-operative hypogastric artery occlusion was related to persistent LPR after downsizing (100% vs. 16%, p = 0.009). Conclusions: Downsizing the introducer sheath during bEVAR is feasible and safe to restore lower limb and pelvic perfusion. Further research is needed to clarify the access downsizing value during bEVAR.