Factors Affecting Compression of the Left Subclavian Artery Bridging Stent In Zone 2 Fenestrated Endovascular Arch Repair.

INTRODUCTION: Left subclavian artery (LSA) preservation during thoracic endovascular aortic repair (TEVAR) has been related to low morbidity. This study investigated the incidence of LSA stent compression in patients managed with fenestrated endovascular arch repair (f-Arch) and evaluated the impact of anatomic and technical factors on LSA stent outcomes. METHODS: A single-center retrospective analysis of patients managed with single-fenestration devices (Cook Medical, Bloomington, IN, USA) for LSA preservation, between January 1, 2012 and November 30, 2023, was conducted. Anatomic (arch type, bovine arch, distance between the LSA and most proximal bone structure, left common carotid artery and aortic lesion, take-off angle, diameter, thrombus, calcification, dissection, tortuosity) and technical parameters (stent type, diameter, length, relining, post-dilation) were evaluated. Stent compression was any ≥50% stenosis (using center luminal line) of the stent compared with its initial diameter. Clinical outcomes included stroke and upper limb ischemia at 30 days and follow-up. Technical outcomes included stent compression and need for reintervention. RESULTS: Fifty-four cases were included. Only balloon-expandable covered stents were used, and relining during the index procedure was performed in 18%. No stroke or arm ischemia was recorded. One stent compression was detected at 30 days. During follow-up, no stroke or arm ischemia was diagnosed. Nine cases (18%) presented stent compression, with a mean time of stent-compression diagnosis at 18 months (interquartile range [IQR]=37, range=1-58 months) after the index procedure. Five (56%) underwent secondary relining. Follow-up after reintervention was uneventful. Lower distance to the nearest bone structure (compression group [CG]: 11.7±8.9 mm vs non-compression group [NCG]: 23.0±7.8 mm, p=0.003) and higher tortuosity index (CG: 1.3±0.4 vs NCG: 1.2±0.1, p=0.03) were associated with LSA stent compression. CONCLUSION: LSA stent compression in patients managed with f-Arch affected 1 in 5 cases, without clinical consequences. Distance to the nearest bone structure and higher tortuosity were associated with LSA stent compression. CLINICAL IMPACT: Fenestrated endovascular arch repair for the preservation of the left subclavian artery (LSA) in patients needing landing within the aortic arch has been performed with encouraging outcomes. This analysis showed that LSA stent compression is met in 18% of patients, without though any clinical consequence. Pre-operative anatomic parameters, as lower distance to the nearest bone structure and higher tortuosity index affect negatively LSA stent performance while stent parameters seem to have no impact.

Physician-Modified Reversed Iliac Branch Device to Prevent Spinal Cord Ischemia in an Urgent Branched Endovascular Aortic Repair.

PURPOSE: Repair of pararenal aneurysms poses a challenge, especially in an urgent setting. Despite the minimally invasive nature of the fenestrated/branched endovascular aortic repair, the technique may require extensive coverage of the aorta, increasing the risk of spinal cord ischemia. TECHNIQUE: A 68-year-old man was admitted with a rapid enlargement of an asymptomatic juxtarenal aortic aneurysm. A minimally invasive treatment with an off-the-shelf branched endovascular graft was planned. Before completing the aneurysm exclusion, an angiography highlighted a large lumbar artery, potentially significant for the perfusion of the spinal cord collateral network. Owing to this finding and an unsuccessful placement of the cerebrospinal fluid drainage, the procedure was staged and completed 5 days later using a physician-modified iliac branch device (IBD) for the segmental artery. The device was shortened and reversely loaded to obtain a cranially-oriented branch. A balloon-expandable covered stent was used to connect the retrograde branch (8 mm) to the lumbar artery (4 mm). Pre-discharge computed tomography (CT)-angiography confirmed the vessel patency. No neurological symptoms occurred. CONCLUSION: The use of a reversely-loaded IBD for segmental artery preservation appears feasible and safe. CLINICAL IMPACT: Intraoperative modification of an iliac branch device during an urgent branched endovascular aortic repair enabled preservation of a potentially critical segmental artery, thus reducing the risk of spinal cord ischemia. This adaptive interventional technique may also offer a strategy for preserving other anatomically significant vessels, such as accessory renal arteries, during complex aortic reconstructions in urgent settings.

Single Access and X-Over Reversed Iliac Extension Technique in a PAD Patient Needing Complex Endovascular Aortic Aneurysm Repair.

PURPOSE: To describe the X-over reversed iliac extension technique in a patient with severe peripheral arterial disease (PAD) scheduled for inner branched endovascular aortic repair (iBEVAR). TECHNIQUE: A multimorbid 62-year-old male patient was planned for iBEVAR due to a 58 mm suprarenal aortic aneurysm. The patient had a previous right femoropopliteal bypass and stenting of the left iliac axis. At admission, he presented with recent onset severe left limb claudication, which was attributed to left iliac stent occlusion. To avoid the postoperative compression of the right common femoral artery (CFA) and preserve the patency of the bypass, a single left CFA access, followed by left iliac artery recanalization, was decided. The right iliac axis was catheterized with a Lunderquist wire using X-over access from the left CFA. An iliac extension (ZISL, 24-59, Cook Medical, Bloomington, USA) was reversed and resheathed on back-table and implanted in the right common iliac artery using the X-over technique. The left CFA access was used to complete the remaining steps of the procedure. The predischarge computed tomography angiography confirmed bilateral iliac artery and femoropopliteal bypass patency. CONCLUSION: The X-over reversed iliac extension technique may be applied in selected PAD patients, when undergoing complex endovascular aortic repair. CLINICAL IMPACT: As the number of patients with peripheral arterial disease (PAD) is expected to increase the upcoming decades, out of the box solutions may be needed to assist complex endovascular aortic management. The X over technique, which consist of the contralateral advancement of an on-table reversed iliac limb, was successfully applied in a patient with severe PAD and numerous previous peripheral interventions, who was managed with branched endovascular aortic repair . The X Over technique may provide an additional alternative in well-selected patients with demanding vascular access undergoing complex endovascular aortic procedures.

Urgent Candy-Plug technique for distal false lumen occlusion in chronic aortic dissection.

OBJECTIVE: This study aimed to assess the impact of urgency on early and midterm outcomes of the Candy-Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection. METHODS: The CP registry was reviewed, and patients were categorized into elective and urgent/emergent groups for analysis. End points included technical success, clinical success, early (30-day) computed tomography angiography findings, early (30-day) mortality, adverse events, and aortic remodeling in patients with available computed tomography angiography follow-up and reintervention. RESULTS: A total of 155 patients received a custom-made CP, of whom 32 patients (44% male, mean age 61 ± 9 years) were treated urgently and 123 patients (63% male, mean age 62 ± 11 years) electively. The primary CP rate was higher in the urgent group (28/32, 88%, in the urgent group vs 96/123, 78%, in the elective group, P = .051). The mean contrast volume was higher in the urgent group (157 ± 56 mL in the urgent group vs 130 ± 71 mL in the elective group, P = .017). Technical success was achieved in all patients in both groups. Clinical success was achieved in 25 of 32 (78%) patients in the urgent group vs 113 and 123 (92%) in the elective group (P = .159). The early mortality rate was 13% (4 of 32 patients) in the urgent group vs 1% (1 of 123 patients) in the elective group (P = .120). There was no statistically significant difference regarding the early adverse events between the urgent and elective CP groups. Early aortic-related reinterventions were required in 6 of 32 (19%) patients in the urgent group vs 6 of 123 (5%) in the elective group (P = .094). Thoracic aortic aneurysm sac regression was lower in the urgent group (5/28, 18%, in the urgent group vs 63/114, 55%, in the elective group, P = .001). Stable thoracic aortic aneurysm sac was higher in the urgent group (22/28, 79%, in the urgent group vs 47/114, 41%, in the elective group, P = .000). An increase in thoracic aortic aneurysm sac occurred in 1 of 28 (4%) patients in the urgent group vs 4 of 114 (4%) patients in the elective group (P = .096). CONCLUSIONS: The urgent use of the CP technique for distal FL occlusion in aortic dissection was feasible and effective. The decrease in aortic FL sac diameter may be affected by the urgent use of CP due to limited sizing availability. However, it achieved a high rate of aortic remodeling.

Early and Mid-Term Outcomes of Transcaval Embolization for Type 2 Endoleak after Endovascular Aortic Repair.

Background: Among the endovascular approaches for the management of endoleak type 2 (EL 2), transcaval embolization (TCE) has shown encouraging outcomes. However, the literature is still limited. This study aimed to present the early and mid-term outcomes of TCE for EL 2 after endovascular aortic repair. Methods: A retrospective, single-center analysis of consecutive patients managed with TCE for EL 2 after standard or complex endovascular aortic repair, from August 2015 to March 2024, was conducted. The indication for TCE was the presence of an EL 2 related to ≥5 mm sac increase, compared to the first imaging after aneurysm exclusion or the smallest diameter during follow-up. Patients managed with TCE for other types of endoleaks were excluded. The primary outcomes were technical and clinical successes during follow-up. Results: Forty-three patients were included (mean age: 75.1 ± 6.0 years, 90.7% males). Technical success was 97.7%. Selective embolization was performed in 48.8% and non-selective in 51.2%. No death was recorded at 30 days. The estimated clinical success was 90.0% (standard error; SE: 6.7%) and the freedom from EL 2 was 89.0% (SE 6.4%) at 36 months. Cox regression analysis showed that the type of embolization (selective vs. non-selective), type of previous repair (f/bEVAR vs. EVAR), and use of anticoagulants did not affect follow-up outcomes. Reinterventions related to EL 2 were performed in 12.5%; three underwent an open conversion. Conclusions: TCE was related to high technical success and limited peri-operative morbidity, regardless of the type of initial endovascular aortic repair. Clinical success was encouraging with reinterventions for EL 2 affecting 12.5% of patients.

Multicentre Experience with Novel Bidirectional Double Cuffed Inner Branches for Complex Endovascular Aortic Repair.

OBJECTIVE: This study aimed to report the initial experience with a novel bidirectional double cuff inner branch design for incorporation of renal and mesenteric arteries in patients undergoing fenestrated and branched endovascular aortic repair (F/BEVAR). METHODS: A retrospective review was undertaken of the experience of F/BEVAR with grafts integrating at least one bidirectional double cuffed inner branch implanted at three tertiary aortic centres between March 2022 and June 2023. All consecutive patients were included. Baseline characteristics, operative data, and follow up data were collected. Results were presented as number or median (interquartile range) unless otherwise stated. RESULTS: Thirteen patients (10 male; median age 72 [68, 77] years) had F/BEVAR using a total of 15 bidirectional double cuffed inner branches (30 cuffs). Indications for bidirectional doubled cuffed inner branches included cranial vessel orientation or double renal arteries in four patients each, common coeliomesenteric trunk in three patients, and early renal artery bifurcation, renal artery origin from a false lumen requiring a flexible route for catheterisation, and surplus configuration in one patient each. Twenty three of the 30 cuffs were used, whereas the remaining seven cuffs were intentionally occluded with vascular plugs. Target vessel incorporation was successful in all bidirectional branches. There was one technical failure related to unsuccessful catheterisation of a left renal artery targeted through a unidirectional caudal inner branch. During a median follow up of seven months there were no instances of target vessel instability or re-interventions and two patients died of causes unrelated to the bidirectional branches. CONCLUSION: The results of the use of bidirectional double cuff inner branches are promising, with high technical success and no short term branch related complications in this preliminary experience. This could potentially expand the applicability of branch endografting of complex endovascular aortic repairs, but long term results are still missing.

Midterm outcomes of "wide neck" abdominal aortic aneurysm after open or endovascular repair in two European centers: a propensity score matching analysis.

BACKGROUND: The aim of this study was to compare mid-term clinical and morphological outcomes in patients undergoing open (OR) and endovascular aortic repair (EVAR) with a proximal wide neck abdominal aortic aneurysm (WN-AAA). METHODS: Between 2009 and 2014 data of all patients undergoing OR at IRCCS San Raffaele Hospital and EVAR at German Aortic Center Hamburg were retrospectively analyzed. Primary endpoints were aneurysm-related mortality at 5 years, reintervention, and overall mortality. Secondary endpoint was proximal neck enlargement. A 1:1 propensity score matching (PSM) was performed. Survival and freedom from AAA-related reintervention were investigated in matched OR and EVAR group by Kaplan-Meier analysis. RESULTS: Of all OR performed at IRCCS San Raffaele Hospital 70 were found to have a proximal neck >28 mm (mean age: 69.8±7.2 years, 67 [95.71%] male); of all consecutive EVAR performed at German Aortic Center Hamburg, 52 required an endograft size of at least 32 mm (mean age of 73.1±8.7 years, 49 [94.2%] male). After PSM, the study cohort consisted of 30 OR and EVAR. One early mortality was registered in both groups (P=NS). Mid-term freedom from reintervention compared in OR and EVAR, with no statistically significant differences (P=0.979). Eight (15.4%) patients treated with EVAR developed a significant proximal diameter enlargement (≥3 mm) while only 1 (1.4%) patient in the OR group had the same evolution (P<0.01). CONCLUSIONS: In WN-AAA neck enlargement is observed more frequently in patients undergoing EVAR, but reintervention rate was similar in the 2 groups, demonstrating that both options were safe and effective.

Post-dissection Thoraco-abdominal Aortic Aneurysm Managed by Fenestrated or Branched Endovascular Aortic Repair.

OBJECTIVE: Fenestrated or branched endovascular aortic repair (F/B-EVAR) is a valuable treatment in patients with chronic post-dissection thoraco-abdominal aneurysm (PD-TAAA). This study aimed to analyse early and follow up outcomes of F/B-EVAR in these patients. METHODS: Thirty day and follow up outcomes of consecutive patients with PD-TAAA treated with F/B-EVAR in a tertiary centre over eight years were analysed retrospectively. All patients presenting with PD-TAAA and managed with F/B-EVAR were eligible. A modified Crawford's classification system was used. Thirty day mortality and major adverse event (MAE) rates were analysed. Time to event data were estimated with Kaplan-Meier survival analysis. RESULTS: Fifty five patients (80% men, mean age 63.7 ± 7.7 years) were included: 12 (22%) were managed urgently; 25 (46%) for chronic type B aortic dissection; and the remainder for residual type A aortic dissection. Of these patients, 88% had undergone previous thoracic endovascular aortic repair. Prophylactic cerebrospinal fluid drainage (CSFD) was used in 91%. Fifteen (27%) patients were treated with F-EVAR, nine (16%) with fenestrations and branches, and 31 (56%) with B-EVAR. False lumen adjunctive procedures were used in 56%. Technical success was achieved in 96% of patients. The thirty day mortality rate was 7% and MAE rate was 20%. Spinal cord injury (SCI) grades 1 - 3 and grade 3 rates were 13% and 2%, respectively. Mean follow up was 33.0 ± 18.4 months. Survival and freedom from unscheduled re-intervention were 86% (standard error [SE] 5%) and 55% (SE 8%) at 24 months, respectively. Freedom from target vessel stenosis and occlusion was higher in F-EVAR at the 12 month follow up (p = .006) compared with B-EVAR. CONCLUSION: Fenestrated or branched endovascular repairs in patients with PD-TAAA showed high technical success, with acceptable early mortality and MAE rates. The SCI rate was > 10%, despite CSFD use and staged procedures. Almost a half of patients needed an unscheduled re-intervention within 24 months after F/B-EVAR.

Design, evolution, and experience with the candy plug device for endovascular false lumen occlusion of chronic aortic dissections.

INTRODUCTION: The management of the false lumen (FL) when dealing with aortic dissection is a crucial aspect since inducing its thrombosis is necessary in order to achieve aortic remodeling. One of the pitfalls of endovascular treatment of aortic dissection (AD) is retrograde distal FL perfusion and pressurization, which prevents FL thrombosis and thus aortic remodeling, while being associated with aneurysmal degeneration of the FL and poor long-term outcomes. AREAS COVERED: Currently, there is no CE/FDA approved device for FL closure, however different techniques and devices have been proposed to overcome this challenge, the most known of which is the Candy Plug (CP). This review aims to describe the CP device, its implantation technique, and the available data in the literature (PubMed, Cochrane, and EMBASE databases; last queried, December 31, 2023). EXPERT OPINIONS: While the treatment of AD remains technically challenging, the use of the CP technique to close any distal FL reperfusion proved to be feasible and safe with excellent rates of both technical and clinical success. Furthermore, recent studies have shown a quick learning curve with this technique.

Unintended Exchange of Target Vessels for Celiac Trunk and Superior Mesenteric Artery Branches in Complex Endovascular Aortic Repair.

PURPOSE: The treatment of thoracoabdominal aortic aneurysms (TAAAs) using branched endovascular aortic repair (BEVAR) is safe and effective. During deployment, the superior mesenteric artery (SMA) branch can unintentionally open into the celiac trunk (CT) ostium and switched catheterization of the SMA from the CT branch and the CT from the SMA branch can be used as an alternative technique in these cases. This study aimed to investigate the outcome of exchanging the intended target vessels (TVs) for the CT and SMA branches during BEVAR. MATERIALS AND METHODS: A single-center retrospective analysis of patients with TAAAs who underwent BEVAR, using off-the-shelf or custom-made devices (CMDs), with an unintended exchange of TVs for the CT and SMA branches was performed. RESULTS: Between 2014 and 2023, 397 patients were treated with BEVAR for TAAA. Eighteen (4.5%) of those patients were treated with an exchange of TVs for the CT and SMA branches. T-branch was used in 9 cases (50%) and the remaining patients were treated with CMDs. Twelve patients were treated electively, 3 were symptomatic and 3 presented with rupture. Of 36 mesenteric TVs in those 18 patients, 34 (94%) were catheterized successfully, including all 18 SMAs and 16 of the 18 CTs. No branch stenosis or occlusion of the switched mesenteric TVs was detected during follow-up. During 30-day follow-up, 3 patients died and during a median follow-up of 3 (interquartile range [IQR]: 1-15) months 3 more patients died. None of the deaths or the 2 unintended reinterventions was induced by the mesenteric TV exchange. The median hospital stay was 14 (IQR: 9-22) days with a median of 4 (IQR: 2-11) days at the intensive care unit. CONCLUSION: The exchange of the mesenteric TVs for the CT and SMA branches during BEVAR with off-the-shelf and CMD endografts is feasible with good TV patency and freedom from TV-related reinterventions. This alternative technique should be considered in selected cases when direct catheterization via the intended branch is deemed more time-consuming or not feasible. CLINICAL IMPACT: This is the first description of using an exchange of target vessels for the celiac trunk and the superior mesenteric artery branches in patients with thoracoabdominal aortic aneurysms undergoing BEVAR, using off-the-shelf or custom-made devices. The high success rate as well as the good clinical results without any branch stenosis or occlusion during follow-up highlight the feasibility of this alternative technique. It could help in challenging cases when catheterization of the intended target vessels is not possible or too time consuming, resulting in higher success rates of BEVAR and better clinical results.

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 of 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 midterm outcomes of fenestrated and branched endovascular aortic arch repair (F/B-Arch) are presented. METHODS: A single centre retrospective sex comparative analysis of consecutive patients managed with F/B-Arch was conducted according to STROBE. Primary outcomes were sex comparative technical success, death, 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 the 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. The median number of revascularisations per patient was two (interquartile range 1, 3), with no difference between sexes (p = .54). Technical success (women: 97.5%; men: 96.9%, p = .80), 30 day mortality rate (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.

The Electrified Wire Technique in Complex Aortic Interventions: A Case Series.

OBJECTIVES: Electrosurgery has been long used in endovascular procedures, with only case reports in the aortic field. Our aim is to present a case series with the use of an electrified wire to perform catheter-based electrosurgery by applying external current through an electrocautery pen. METHODS: Single-center retrospective case series of all patients undergoing complex aortic surgery from October 2020 to August 2023, in whom the electrified wire technique was used: (1) Perforation of a dissection flap or left subclavian artery (LSA) in situ endograft fenestration-a 0.014" polytetrafluoroethylene (PTFE) insulated guidewire is detached from the insulation with a scalpel at the end and a cautery pen is here attached with a clamp. A curved tip catheter or sheath is positioned against the aortic flap or the endograft (through a left brachial access in this case) and the wire pushed, crossing the flap by activating the electrocautery pen and (2) slicing a dissection flap ("powered cheese-wire technique")-after same preparation as above, the middle section of the 0.014 guidewire is removed from the PTFE and bent into a V-shape. Once in the aorta, the guidewire crosses from the true lumen (TL) to the false lumen (FL) and a through-and-through access is obtained. Sheaths are positioned against the flap from both sides and moved up or down while the electricity is activated, slicing the flap and communicating both lumens. Technical success and technical-related complications were evaluated. RESULTS: Eleven cases concerning aortic dissections and 1 case of aortic atresia were treated. Four patients presented urgently, whereas the rest were planned procedures. Seven cases underwent perforation of a dissection flap, 2 cases underwent the powered cheese-wire technique, in 2 cases for an LSA in situ fenestration, and in 1 case to cross an aortic atresia at the aortic isthmus. The technique was in all cases successfully applied. No complications related to the technique occurred. CONCLUSIONS: The "electrified wire" technique is a feasible and ready-available tool that can be safely used in complex aortic interventions, especially to perforate aortic tissue like dissection flaps or to perform in situ fenestrated repairs by perforation of the endograft fabric. CLINICAL IMPACT: The electrified wire technique described herein is a straightforward technique that uses readily available tools to perform electrosurgery. We present its use in complex aortic procedures. However, it could be envisioned for any vascular procedure that requires crossing of the vessel or even prosthetic material. As we have described in this series, when used along with an adequate properative planning, it can be a safe tool of great utility, as has already been demonstarted in the field of the interventional cardiology.

Early and midterm outcomes of fenestrated and branched endovascular aortic repair in thoracoabdominal aneurysms types I through III.

BACKGROUND: Fenestrated and branched endovascular aortic repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs) has shown high technical success and low early mortality rates. Aneurysm extent has been reported as a factor affecting outcomes. This study aimed to assess the early and midterm follow-up outcomes of patients managed by F/BEVAR for types I through III TAAAs. METHODS: A single-center retrospective analysis was conducted, including data from consecutive, elective and urgent (symptomatic and ruptured cases), patients treated for types I through III TAAAs, between October 1, 2011, and October 1, 2022, using F/BEVAR. Degenerative and postdissection TAAAs were included. Patients received prophylactic cerebrospinal fluid drainage (CSFD), except those under therapeutic anticoagulation, those who were hemodynamically unstable, or those with failed CSFD application. When an initial thoracic endovascular aortic repair was performed, as part of a staged procedure, no CSFD was used. Later stages and nonstaged procedures were performed under CSFD. Thirty-day mortality and major adverse events (MAEs) were analyzed. Kaplan-Meier estimates were used for follow-up outcomes. RESULTS: F/BEVAR for types I through III TAAAs was performed in 209 patients (56.9% males; mean age, 69.6 ± 3.2 years; mean aneurysm diameter, 65.2 ± 6.2 mm); 29.2% type I, 57.9% type II, and 12.9% type III. Urgent repair was performed in 26.7% of patients (56 cases; 23 ruptured and 33 symptomatic cases) and 153 were treated electively. Thirty-two patients (15.3%) were classified as American Society of Anesthesiologists (ASA) class IV. CSFD was used in 91% and staged thoracic endovascular aortic repair was performed in 51.2% of patients. Technical success was 93.8% (96.7% in elective vs 94.6% in urgent cases; P = .92). Thirty-day mortality was 11.0% (4.6% in elective vs 28.5% in urgent cases; P < .001) and MAEs were recorded in 17.2% of cases (7.8% in elective vs 42.8% in urgent cases; P < .001). Spinal cord ischemia rate was 20.5% (17.6% in elective vs 28.7% in urgent cases; P = .08), whereas 2.9% of patients presented paraplegia (1.3% in elective and 7.1% in urgent cases; P = .03). The mean follow-up was 16 ± 5 months. Survival was 75.0% (standard error, 4.0%) and freedom from reintervention was 73.3% (standard error, 4.4%) at 36 months. ASA IV and urgent repair were detected as independent factors related to early mortality and MAE, whereas ruptured aneurysm status was related to spinal cord ischemia evolution. CONCLUSIONS: Endovascular repair for types I through III TAAAs provides encouraging early outcomes in terms of mortality, MAE, and paraplegia, especially in an elective setting. Setting of repair and baseline ASA score should be taken into consideration during decision-making.

A Retrospective Analysis of 10-year Experience on Branched and Fenestrated Endovascular Aortic Arch Repair.

OBJECTIVE: This study aimed to present the early and mid-term outcomes of fenestrated/branched thoracic endovascular aortic repair (f/bTEVAR) for aortic arch pathologies. BACKGROUND: f/bTEVAR represents a less invasive treatment option for aortic arch diseases. Previous published series showed decreased early mortality and morbidity compared to open repair. METHODS: A single-center retrospective analysis of consecutive patients, managed with f/bTEVAR (Cook Medical, Bloomington, IN, USA) between 01.09.11and 30.06.22 was conducted. Primary outcomes were technical success, 30-day mortality and stroke. Data during follow-up and factors affecting early mortality and stroke were analyzed. RESULTS: 209 patients were included (38.3% females; mean age 69.8±3.4years; mean aortic diameter 61±4.7 mm); 14.4% were managed urgently. Fenestrations/scallop configuration was used in 39.7%, branched devices in 55.5% and branch/scallop combination in 4.8%. Landing to zone 0 was performed in 65.5% and in zone 1 in 32.1%. Non-native aortas were used for landing in 39.2%. Technical success was 97.1% and 30-day mortality 9.5%. Strokes were identified in 10%; 5.7% major. Non-native proximal aortic landing zone was an independent protective factor for stroke (P=0.002). Post-operative stroke (P<0.001) and pericardial effusion (P<0.001) were independently related to 30-day mortality. The mean follow-up was 21±8 months. The estimated survival and freedom from reintervention rates were 79.5% (standard error; SE3.1%) and 47.1% (SE 4.3%) at 24months, respectively. CONCLUSIONS: f/bTEVAR presented high technical success and acceptable 30-day mortality. Non-native proximal landing zone was related to lower stroke rate. Half of patients needed a reintervention within the 24-month follow-up.

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.

Dilated Internal Iliac Artery Confers a Higher Risk of Endoleak in Iliac Branch Devices in a Single Centre Retrospective Experience.

OBJECTIVE: Iliac branch devices (IBDs) have shown good results but there is little evidence for the risk of internal iliac artery (IIA) endoleak, so there are no clear recommendations on the maximum diameter it should be. Based on limited evidence, it was hypothesised that an IIA of ≥ 11 mm in diameter presents an increased risk of type Ic endoleak. METHODS: This was a single centre, retrospective case control study. Patients undergoing an IBD with the main trunk of the IIA as the target vessel, between 2015 and 2021, were identified. Two groups were created: those with a main trunk diameter of < 11 mm; and those with a diameter of ≥ 11 mm. Technical success, freedom from type Ic endoleak, and re-intervention rates were compared. A receiver operating characteristic (ROC) curve was performed to show a cutoff IIA diameter value for risk of type Ic endoleak. Multivariate analysis was performed to assess the risk of type Ic endoleak and the presence of calcification, stenosis, and landing zone length in the IIA. RESULTS: There were 182 IBDs identified. The dilated IIA group (54 IBDs) had significantly lower technical success (91% vs. 98.4%; p = .002), lower freedom from type Ic endoleak (77% vs. 97.1% at 24 months; p = .001), and lower freedom from re-interventions (70% vs. 92.4% at 24 months; p = .002). The ROC curve showed that 10.5 mm was the cutoff diameter for type Ic endoleak. Moderate or severe calcification as well as landing zone length < 5 mm also correlated with type Ic endoleak. CONCLUSION: IBDs have a statistically significantly higher rate of technical failure, lower freedom from type Ic endoleak, and lower freedom from re-intervention when the IIA is ≥ 11 mm in diameter.

Single access covered endovascular reconstruction of the aortic bifurcation.

We describe the feasibility of covered endovascular reconstruction of the aortic bifurcation (CERAB) through a single femoral access and a steerable sheath. We present the technique, which we used for a patient with severe aortoiliac calcification and bilateral involvement of the common femoral artery. The patient underwent endarterectomy of the left common femoral artery plus CERAB with an aortic stent graft and bilateral covered stents for the common iliac artery with kissing dilatation with a steerable sheath using only left femoral access. CERAB can be performed using unilateral access with the aid of a steerable sheath, reducing the potential for access site complications.

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.

Ascending Aorta Nose-Cone Loop Technique as Bail Out for Precise Branched Endovascular Aortic Arch Endograft Delivery Without Valve Re-Crossing.

PURPOSE: To describe a right carotid-femoral through-and-through (T&T) guidewire technique during branched thoracic endovascular aortic arch repair (B-TEVAR) to facilitate endograft delivery in a very tortuous aortic anatomy for a type Ia endoleak (EL) of a previous aortic endograft implantation. TECHNIQUE: AT&T guidewire was established between the right common carotid artery and the right common femoral artery to facilitate a difficult endograft delivery. Once in the aortic arch, a loop in the ascending aorta was formed to allow the endograft to reach the desired position without losing tension on the guidewire. This maneuver allowed the T&T guidewire to be kept in place until the desired position was reached. The nose-tip of the endograft was curved over the looped guidewire pointing toward the innominate artery without crossing the valve. After endograft deployment, the T&T guidewire was released, and the branches were bridged in a standard fashion. Completion angiography documented correct deployment of the endograft and no sign of type I/III EL. The 1-month computed tomography angiography confirmed the correct deployment. CONCLUSION: Carotid-femoral T&T guidewire to facilitate endograft delivery in difficult anatomies can be feasible even in B-TEVAR. Possible bailout maneuvers are available if the aortic valve needs to be crossed after endograft delivery. CLINICAL IMPACT: Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. A through-and-through (T&T) guidewire for endovascular arch repair with a landing zone in zone 0 according to Ishimaru is usually performed through the externalization of the femoral guidewire through a transapical access, but this may not always be feasible in frail patients. A right carotid-femoral though-and-through guidewire with a loop formation in the ascending aorta is proposed to achieve the support of a T&T wire to pass tortuous aortoiliac anatomies and access the ascending aorta without the need for aortic valve crossing.