A Case Report of Aortic Intramural Hematoma: From Diagnosis to Endovascular Treatment Guided by Transesophageal Echocardiography.

Aortic intramural hematoma (IMH) accounts for approximately 10%-25% of acute aortic syndromes (AAS), and multi-slice computed tomography and magnetic resonance imaging are the leading techniques for diagnosis and classification. In this context, endovascular strategies provide a valid alternative to traditional open surgery and transesophageal echocardiography (TEE) could play a role in therapeutic decision-making and in endovascular repair procedure guidance. A 57-year-old female patient with IMH extending from the left subclavian artery to the upper tract of the abdominal aorta, underwent endovascular aortic repair using an unibody single-branched stent grafting in the aortic arch and descending aorta with a side branch inserted in the left common carotid artery. To restore proper flow in the left axillary artery, a carotid-subclavian bypass graft was performed. The procedure was guided by angiography and TEE. Intraoperative TEE revealed aortic IMH with a significant fluid component in the middle tunic of the aorta with a wall thickness of over 13 mm. TEE was useful in monitoring of all steps of the procedure, showing the presence of the guidewires into the true lumen, the advancement of the prosthesis, and the phases of release and anchoring. This case highlights the importance of using multimodality imaging techniques to evaluate AAS and demonstrates the growing potential of TEE in guiding endovascular repairs.

Endovascular Aortic Repair of an Infective Native Aortic Aneurysm.

An infective native aortic aneurysm (INAA) is a rare, life-threatening, and complex disease. Therefore, the diagnosis and treatment of INAA remain uncertain. We describe the case of a 64-year-old man who had abdominal pain and a fever for more than one week. We diagnosed him with INAA on the basis of the clinical presentation, laboratory findings, and computed tomography (CT) images. After administering preoperative antibiotic therapy for four weeks, we performed endovascular aortic repair (EVAR). He then received antibiotic treatment for 12 months postoperatively. After successful treatment of an INAA with endovascular aortic repair, the patient had no recurrence for more than six years after the end of antibiotic therapy.

Clinical efficacy of TEVAR utilizing fenestrated stent-grafts for zone 0 in an elderly frail patient with giant aortic arch aneurysm.

Introduction and importance: Elderly and frail patients with thoracic aortic aneurysms (TAAs) near to origins of cervical arteries present facing challenges with aortic arch replacement with cardiopulmonary bypass, and traditional tube-type stent-grafts are also inadequate for transcatheter endovascular aortic repair (TEVAR). Thus, necessitating precise treatment with fenestrated stent-grafts from zone 0. This approach is crucial for achieving favorable postoperative outcomes without compromising activities of daily living (ADL). Case presentations: An 85-year-old-man admitted to the hospital for treatment of a large TAA. While arch replacement is a definitive procedure, it is highly invasive, and the postoperative ADL are expected to be significantly lower than preoperative levels. Therefore, we performed a debranching TEVAR from Zone 0 with fenestrated stent-graft. The patient was discharged from the hospital on the 11th postoperative day. Clinical discussion: In frail and elderly patients for whom conventional surgery may not be viable, TEVAR emerges as a preferred alternative. However, TEVAR of TAA proximal to the aortic arch continues to pose challenges, necessitating meticulous attention to the cervical branches in the intervention strategy. While surgical intervention in these patients necessitates careful consideration of its suitability, including the potential for postoperative enhancement in ADL, the use of fenestrated stent-grafts from Zone 0 emerges as one of the treatment modalities. Conclusion: The authors present a very elderly case in which fenestrated stent-grafts were used to avoid aortic arch replacement for a large aortic arch aneurysm, resulting in a good postoperative course with no decline in ADL.

Scoring System to Predict Mid-term Adverse Events after Elective Thoracic Endovascular Aortic Repair.

OBJECTIVE: To develop and validate a scoring system to predict mid-term adverse events after elective thoracic endovascular aortic repair (TEVAR). METHODS: A multi-center, retrospective, and observational cohort study. A total of 350 patients who underwent elective TEVAR for thoracic aortic disease between January 2008 and December 2021 were analyzed. The primary outcome was the first adverse event occurring within 5 years of the initial TEVAR, which included death during the initial hospitalization, perioperative neurological complication, stent graft-induced new entry, dissection, rupture, graft infection, and reintervention related to the initial TEVAR. The scoring system was developed using the regression coefficients of the Fine-Gray subdistribution hazard model. Its performance was evaluated using the area under the receiver operating characteristic curve (AUC) for competing risk analysis and internally validated by cross-validation. RESULTS: Eighty-two patients had at least one adverse event within 5 years of the initial TEVAR. The 5-year cumulative incidence of adverse events was 26% (95% confidence interval, 21-31). Female gender, comorbidity score, use of anticoagulants, preoperative aortic diameter at the diaphragm level, proximal oversizing ratio, aortic coverage length, and hybrid procedure were included in the scoring system. The AUC of the scoring system in the internal validation was 0.748 (standard error, 0.009). When the scoring system was validated in patients with intact thoracic aortic aneurysm only, the AUC was 0.780 (standard error, 0.012). CONCLUSIONS: Although external validation is mandatory, our scoring system may be useful for decision making, especially in patients with intact thoracic aortic aneurysm.

Thoracic Endovascular Aortic Repair for an Aortoesophageal Fistula Caused by Esophageal Cancer: A Case Report and Literature Review.

Aortoesophageal fistula (AEF) is an uncommon complication of esophageal cancer and can be extremely fatal if left untreated. Compared to open repair, thoracic endovascular aortic repair (TEVAR), a less invasive technique, is the initial recommended treatment in cases of hemorrhagic shock secondary to AEF, as this procedure showed a favorable outcome in controlling the overt bleeding. Here, we present a case of a patient with a history of stage IV esophageal cancer being treated with chemotherapy and an esophageal stent due to a previous tracheoesophageal fistula who presented to the emergency room due to severe gastroesophageal bleeding and hemorrhagic shock. A CT angiography of the chest revealed an AEF. The patient was subsequently resuscitated and treated with TEVAR. After the procedure, the hemorrhage was managed, and the patient was discharged with palliative radiation therapy. However, after one month, the patient had a major gastrointestinal hemorrhage, which caused her death. This example indicates the necessity of early detection and surgical intervention in AEF patients with unstable hemodynamics who have underlying unresectable esophageal cancer and chemotherapy. TEVAR should be conducted as soon as possible before the open surgery to achieve the best outcome for patients.

3 Year Outcomes of Off-the-shelf Gore Thoracoabdominal Multibranch Endoprosthesis and Physician-Modified Endografts for Complex Abdominal and Thoracoabdominal Aortic Aneurysms.

OBJECTIVE: Fenestrated-branched endovascular aortic repair (FB-EVAR) has shown favorable outcomes for repair of complex aneurysms and thoracoabdominal aortic aneurysms (TAAA). Physician-modified endografting (PMEG) and the Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) provide custom and off-the-shelf devices for FB-EVAR, respectively. This study compares the outcomes of TAMBE and PMEG at a single institution. METHODS: A retrospective review of patients who underwent TAMBE as part of the multicenter pivotal trial or PMEG as part of a prospective physician sponsored investigational device exemption at a single institution between 2020-2022 were completed. Patient demographics, characteristics, perioperative and midterm outcomes were compared. RESULTS: A total of 68 patients were included, with 12 in the TAMBE group and 56 in the PMEG group. Baseline characteristics were comparable between groups. Aneurysm type was most often TAAA in both groups (58% TAMBE and 52% PMEG). TAMBE had a higher rate of upper extremity access (100% vs 63%, P=.013) and longer mean procedure time (247 ± 36 vs 189 ± 49 minutes, P<.001). Other intraoperative metrics were similar between groups. Technical success was 100% in TAMBE and 95% in PMEG (P=0.412). There was no 30-day mortality in either group. No major adverse events occurred with TAMBE, while in PMEG cases, 2% had respiratory failure, 2% required dialysis, and 4% experienced spinal cord ischemia. While overall endoleak rates were similar (50% of TAMBE vs 41% of PMEG, P=0.57), type II accounted for all of the endoleaks in the TAMBE group, while type I or III endoleaks were seen in 11% of PMEG patients. At the median follow-up of 26.7 months for the TAMBE group and 21.2 months for the PMEG group, target vessel instability was seen in 10.4% of TAMBE, and 6.9% of PMEG targeted branches (P=0.401). Reintervention was required in 33% of TAMBE patients and 27% of PMEG patients (P=.646). Estimated freedom from reintervention at 3 years were similar (56% TAMBE vs. 62% PMEG, log-rank P=0.910). Freedom from visceral renal target vessel instability at 3 years was 89% for both groups (log-rank P=0.459). Kaplan Meier 3-year estimated survival was 100% for patients in the TAMBE group and 77% for patients in the PMEG group (log-rank P=.157). CONCLUSIONS: At experienced centers, FB-EVAR can be completed with PMEG or TAMBE with comparable, excellent perioperative and midterm outcomes. Reinterventions are frequently needed for both TAMBE and PMEG.

Risk Factors for Adverse In-Hospital Outcomes in Patients With Traumatic Blunt Thoracic Aortic Injuries Undergoing Thoracic Endovascular Aortic Repair (TEVAR): An Analysis of the US Nationwide Inpatient Sample.

PURPOSE: Thoracic endovascular aortic repair (TEVAR) is a treatment for traumatic blunt thoracic aortic injury (BTAI) with good survival rates and safety. However, there is limited study on the risk factors for in-hospital mortality and complications. This study aimed to identify risk factors associated with poor in-hospital outcomes after TEVAR. MATERIALS AND METHODS: This is a population-based, retrospective observational study. Data of adults ≥20 years admitted for BTAI who received TEVAR were extracted from the Nationwide Inpatient Sample (NIS) database 2005 to 2018. The primary outcome was in-hospital mortality, and the secondary outcomes were length of stay (LOS) and unfavorable discharge (ie, non-routine discharge, including nursing homes or long-term care facilities). Associations between study variables and in-hospital outcomes were determined using univariate and multivariable logistic and linear regression analyses. RESULTS: Data of 1095 participants (representing 5360 hospitalized patients in the United States) were analyzed. Multivariable analysis revealed that older age (adjusted odds ratio [aOR]=1.02) and having at least 1 perioperative complication (aOR=4.01) were significantly associated with increased risk for in-hospital mortality. Patients with at least 1 perioperative complication (aOR=11.19) had significantly increased odds for prolonged LOS. Risk for unfavorable discharge was significantly increased by older age (aOR=1.02), household income at quartile 2 (aOR=1.58), Charlson Comorbidity Index (CCI) 2 to 3 (aOR=1.66), and having at least 1 complication (aOR=3.94). Complications including perioperative cerebrovascular accident (CVA) (aOR=2.75), venous thromboembolism (VTE) (aOR=2.87), pneumonia (aOR=3.93), sepsis (aOR=4.69), infection (aOR=4.49), respiratory failure (aOR=4.55), mechanical ventilation (aOR=3.27), and acute kidney injury (AKI) (aOR=3.09) significantly predicted prolonged LOS. CONCLUSIONS: In adults with traumatic BTAI undergoing TEVAR, advanced age and perioperative complications are risk factors for poor in-hospital outcomes. Acute kidney injury, CVA, respiratory failure, and sepsis are strong predictors of prolonged LOS, unfavorable discharge, and in-hospital mortality. CLINICAL IMPACT: The study identifies advanced age and perioperative complications as key risk factors for poor in-hospital outcomes in patients undergoing TEVAR for BTAI. Clinicians should be vigilant in managing these patients, particularly those with comorbidities, to mitigate risks. The findings suggest a need for tailored perioperative care strategies to improve survival rates and reduce complications. This research highlights the critical importance of early identification and intervention in high-risk patients, offering an innovative approach to refining TEVAR protocols and enhancing patient outcomes in trauma care.

Evaluating the effectiveness of immediate vs. elective thoracic endovascular aortic repair for blunt thoracic aortic injury.

PURPOSE: To evaluate the relationship between the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) and prognosis. METHODS: This is a single-center retrospective cohort study. Patients who received TEVAR for BTAI at our institution from October 2016 to September 2023 were divided into 2 categories depending on the injury severity score (ISS) (≤ 25 vs. > 25) and when the TEVAR was performed for BTAI (within 24 h vs. after 24 h), respectively. The analysis included all patients who received TEVAR treatment after being diagnosed with BTAI through whole-body CT angiography. Patients treated with open repair and non-operative management were excluded. After propensity-score matching for various factors, outcomes during hospitalization and follow-up were compared. These factors included demographics, comorbidities, concomitant injuries, cause and location of aortic injury, Glasgow coma scale score, society for vascular surgery grading, hemoglobin concentration, creatinine concentration, shock, systolic blood pressure, and heart rate at admission. The comparison was conducted using SPSS 26 software. Continuous variables were presented as either the mean ± standard deviation or median (Q1, Q3), and were compared using either the t-test or the Mann-Whitney U test. Categorical variables were expressed as n (%), and comparisons were made between the 2 groups using the χ2 test or Fisher's exact test. Statistical significance was defined as a 2-sided p < 0.05. RESULTS: In total, 110 patients were involved in the study, with 65 (59.1%) patients having ISS scores > 25 and 32 (29.1%) receiving immediate TEVAR. The perioperative overall mortality rate in the group with ISS > 25 was significantly higher than that in the group with ISS ≤ 25 (11 (16.9%) vs. 2 (4.4%), p < 0.001). Upon admission, the elective group exhibited a notably higher Glasgow coma scale score (median (Q1, Q3)) compared to the immediate group (15 (12, 15) vs. 13.5 (9, 15), p = 0.039), while the creatinine concentration (median (Q1, Q3)) at admission was significantly higher in the immediate group (90.5 (63.8, 144.0) vs. 71.5 (58.3, 80.8), p = 0.012). The final sample included 52 matched patients. Complications occurred significantly less frequently in the elective group compared to the immediate group (16 (50.0%) vs. 3 (10.0%), p < 0.001). Single-factor analysis of variance showed that complications in hospitalized patients were significantly associated with immediate TEVAR as the sole independent risk factor (odds ratio: 9.000, 95% confidence interval: 2.266 - 35.752, p = 0.002). CONCLUSION: In this propensity-score matched analysis of patients undergoing TEVAR for BTAI, elective TEVAR was significantly associated with a lower risk of complication rates. In this study using propensity-score matching, patients who underwent elective TEVAR for BTAI had lower complication rates than immediate TEVAR.

In Situ Needle Fenestration during Thoracic Endovascular Aneurysm Repair: Successful Fenestration of Two Overlapping Thoracic Stent Grafts.

Endovascular stent grafting is becoming more common in treating complex thoracic aortic aneurysms and dissections. When it becomes necessary to cover the supra-aortic vessels, maintaining blood supply through the supra-aortic branches can be achieved by performing in situ needle fenestration. We present a case of a 65-year-old man with a type B aortic dissection that extended from the origin of the left subclavian artery. A stent graft was inserted into the thoracic aorta distally of the origin of the left common carotid artery. Due to the stent graft moving distally and not adequately sealing the subclavian artery, a second stent graft was placed more proximally. Both stent grafts were successfully in situ fenestrated using a needle, and a stent graft was inserted into the subclavian artery. In conclusion, during thoracic endovascular aortic repair, in situ needle fenestration can be successfully carried out on two overlapping thoracic stent grafts.

Predictors for thoracic aortic growth in patients with type B aortic dissection after thoracic endovascular aortic repair.

OBJECTIVE: To identify independent predictors of thoracic aortic growth in patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR). METHODS: A retrospective analysis of the patients undergoing TEVAR for TBAD or intramural hematoma (IMH) from April 2014 to April 2023 was performed. The baseline morphological data of TBAD was established through computed tomography angiography (CTA) before discharge. Patients were divided into two groups based on aortic growth: growth and no growth. Aortic growth defined as an increase ≥5 mm in thoracic maximal aortic diameter during any serial follow-up CTA measurement. Logistic regression following propensity score matching (PSM) was used to identify independent predictors for aortic growth. Receiver operating characteristic curve and cutoff value of independent predictors were calculated. Linear regression was used to establish a correlation between anatomical variables and follow-up aortic diameter. RESULTS: A total of 145 patients with TBAD (n = 122) or IMH (n = 23) undergoing TEVAR were included, with a male of 83.4% and a mean age of 56 ± 14.1 years. Patients in growth group and no growth group was 26 (17.9%) and 119 (80.1%), respectively. After using PSM method, matched regression analysis showed residual maximal tear diameter (OR = 0.889, 95% CI 0.830-0.952, p = 0.001) and follow-up aortic diameter (OR = 0.977, 95% CI 0.965-0.989, p < 0.001) were independent predictors for aortic growth. The cutoff value was 8.55 mm for residual tear diameter and 40.65 mm for follow-up maximal aortic diameter. The residual maximal tear diameter showed a linear correlation with follow-up aortic diameter (DW = 1.74, R2 = 6.2%, p = 0.033). CONCLUSIONS: This study suggested that residual maximal tear diameter >8.55 mm and follow-up aortic diameter >40.65 mm could predict aortic growth in patients with TBAD undergoing TEVAR.

Physician Modified Endograft for Ruptured Dissecting Aortic Arch Aneurysm.

BACKGROUND: Endovascular repair of thoracic aortic aneurysms (TAA) in elective settings has demonstrated successful clinical outcomes. However, life-threatening conditions such as rupture are more often managed with open surgical repair due to the high complexity of arch endovascular repair, lack of available off-the-shelf devices, and limited long-term data. CASE SUMMARY: A 49-year-old female with a recent history of prior ascending aortic repair for Type A10 aortic dissection presented with chest pain and dyspnea. Chest computed tomography angiogram (CTA) revealed acute bilateral pulmonary emboli and a 6.2 cm post dissection aneurysm of the posterior aortic arch with the dissection extending to the right iliac artery. She was treated with thrombolysis and subsequently became hemodynamically unstable. Repeat CTA revealed a massive left hemithorax with concern for aortic arch rupture. Given significant cardiorespiratory compromise and recent open repair, she was considered unfit for redo open repair. Thoracic endovascular aortic repair (TEVAR) with a physician-modified endograft (PMEG) was planned. An Alpha Zenith endograft was modified adding an internal branch for the innominate artery and a fenestration for the left common carotid artery. The left subclavian artery was occluded with a microvascular plug and coil embolization up to the level of the vertebral artery. TEVAR PMEG extension to the celiac artery was performed followed by deployment of a Zenith dissection stent to the aortic bifurcation. Completion angiogram demonstrated successful aneurysm exclusion and patency of target vessels. CONCLUSION: Endovascular treatment of ruptured TAA with PMEGs is feasible. This approach may be an alternative for unfit patients for open repair in emergent settings.

Prevalence and Prognostic Significance of Malnutrition in Patients with Type B Aortic Dissection Undergoing Endovascular Repair.

Background: Malnutrition is a poor prognostic factor in a wide range of diseases. Nevertheless, there is a lack of data investigating the association between malnutrition and outcomes of patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR). Therefore, the aim of the present study was to report the prevalence and clinical impact of malnutrition assessed by the controlling nutritional status (CONUT) score in TBAD patients undergoing TEVAR. Methods: The retrospective study indicated that a total of 881 patients diagnosed with TBAD and treated with TEVAR from January 2010 to December 2017 were categorized into subgroups based on their CONUT score (low ≤ 5 vs. high > 5). To assess the correlation between malnutrition and early and follow-up outcomes of TBAD patients, logistic and Cox regression analysis were utilized, incorporating inverse probability weighting. Results: Malnutrition was present in 20.3% of patients according to the CONUT score. Multivariate logistic regression analysis revealed that pre-operative CONUT score modeled as a continuous variable was an independent risk factor for prolonged intensive care unit stay (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.02-1.17; p = 0.015), 30-day death (OR, 1.43; 95% CI, 1.19-1.72; p < 0.001), delirium (OR, 1.11; 95% CI, 1.01-1.23; p = 0.035) and acute kidney injury (OR, 1.09; 95% CI, 1.01-1.16; p = 0.027). During a median follow-up of 70.8 (46.1-90.8) months, 102 (11.8%) patients died (high CONUT group: 21.8% vs. low CONUT group: 9.0%; p < 0.001). Multivariable Cox proportional-hazards models showed that malnutrition was an independent predictor for follow-up mortality (hazard ratio, 1.68; 95% CI, 1.11-2.53; p = 0.014). Results remained consistent across various sensitivity analyses. Conclusions: Malnutrition assessed by the CONUT score could profoundly affect the early and follow-up prognosis in patients undergoing TEVAR. Routine pre-intervention nutritional evaluation might provide valuable prognostic information.

A dedicated preventive protocol sustainably avoids spinal cord ischemia after endovascular aortic repair.

Objective: To analyze the incidence of spinal cord ischemia (SCI) after complex endovascular aortic repair (EVAR) after the introduction of a dedicated SCI preventive protocol. Methods: Retrospective review of all consecutive patients undergoing complex EVAR with branched (BEVAR) and/or fenestrated grafts (FEVAR) during a 6-year period starting January 1st, 2015. The preventive protocol consisted of staging extensive aortic repairs, maintaining a mean arterial pressure (MAP) >80 mm Hg, Hb level >110 g/L, early lower limb reperfusion and neurological control per hour during the post-operative stay in the intensive care unit (36-72 h). Prophylactic cerebrospinal fluid drainage (CSFD) was used selectively. Pre- intra-, and 30-day postoperative clinical data and imaging were collected. Primary end point was the development of perioperative SCI. Secondary outcome included technical and clinical success. Results: Complex EVAR was performed in 205 patients (167 males, 72 (67-75) years, 182 (88.8%) elective) with juxtarenal aneurysms (JRA, 155 patients) or thoracoabdominal aortic aneurysms (TAAA). SCI occurred after JRA repair in two patients (1.3%, both ruptures) and after TAAA repair in three (6.0%, one rupture) (p = 0.06), all within 9 h postoperatively. There was symptom regression in three cases (one partial, two complete), resulting in a persistent SCI level of 0.6% and 4.0% for JRA and TAAA, respectively. Only one patient with persistent SCI could be discharged from the hospital alive. Patients developing SCI were more commonly female (n = 3, p = .016), presented with rupture (n = 3, p < .001), had preoperative renal insufficiency (n = 5, p < .001) and had lower minimal MAP (p = .015). No regression analysis was done due to the limited number of SCI events in relation to the study population size. Primary technical success was achieved in 162 patients (83.5%) and clinical success in 153 patients (75.4%), without any differences between the groups. Conclusions: The incidence of persistent SCI after complex EVAR is low with the use of a dedicated SCI preventive protocol allowing the early diagnosis. Females, patients with ruptured aneurysms and preoperative renal insufficiency are at higher risk. Further studies are needed to customize the protocols particularly in those high-risk patients.

Hemodynamic changes for half cover left subclavian artery ostium during thoracic endovascular aortic repair.

Purpose: Some clinicians use endografts to cover half the left subclavian artery (LSA) ostium to cure some cases with insufficient proximal landing zone (PLZ) in thoracic endovascular aortic repair (TEVAR) treatment. We used computational fluid dynamics (CFD) to study the hemodynamic changes in the LSA because they may cause acute thrombosis or arteriosclerosis. Methods: The digital model of the aortic arch was established and named model A, which only included the supraarch branch of the LSA. By directly covering half of the LSA ostium, which was named as model B. All established models were imported into the Gambit grid division software for grid division and were subsequently imported into the Fluent software for hemodynamic numerical simulation and calculation to analyze the related changes in LSA hemodynamic parameters after stent implantation. Results: Under the same aortic inlet flow, in model B, the local blood flow velocity of the LSA ostium increased and the whole blood flow velocity at the distal end decreased. The average wall shear stress (WSS) of the LSA was significantly decreased. Meanwhile there was an obvious turbulent flow in the LSA lumen, and the related blood flow state was disordered. Conclusion: CFD research confirmed that the implantation of an endograft covering half the LSA ostium can cause obvious hemodynamic changes, which is likely to cause a long-term arteriosclerosis or acute thrombosis of the LSA, finally increasing the risk of stroke. Once this operation is performed in some specific clinical cases for simplicity and economy, it seems that we should actively antiplatelet and follow up regularly.

Comparative Evaluation of the Short-Term Outcome of Different Endovascular Aortic Arch Procedures.

Objectives: There are several endovascular treatment options to treat aortic arch and thoracic aortic pathologies with custom-made or surgeon-modified aortic stent grafts. This study seeks to assess endovascular treatment methods for aortic arch and thoracic aortic pathologies with no acceptable proximal landing zone for standard thoracic endovascular aortic repair (TEVAR), comparing different treatment methods and evaluating technical success, intraoperative parameters and short-term outcomes. Methods: All patients undergoing elective or emergency endovascular treatment of aortic arch and thoracic aortic pathologies, with no acceptable landing zone for standard TEVAR, between 1 January 2010 and 31 March 2024, at the University Hospital Düsseldorf, Germany were included. An acceptable landing zone was defined as a minimum of 2 cm for sufficient sealing. All patients were not suitable for open surgery. Patients were categorized by an endovascular treatment method for a comprehensive comparison of pre-, intra- and postoperative variables. IBM SPSS29 was used for data analysis. Results: The patient cohort comprised 21 patients, predominantly males (81%), with an average age of 70.9 ± 9 years with no acceptable proximal landing zone for standard TEVAR procedure. The most treated aortic pathologies were penetrating aortic ulcers and chronic post-dissection aneurysms. Patients were sub-grouped according to the applied procedure as follows: five patients with chimney thoracic endovascular aortic repair (chTEVAR), seven patients with in situ fenestrated thoracic endovascular aortic repair (isfTEVAR), six patients with custom-made fenestrated thoracic endovascular aortic repair (cmfTEVAR) and three patients with custom-made branched thoracic endovascular aortic repair (cmbTEVAR). Emergency procedures involved two patients. There were significant differences in the total procedure and fluoroscopy time, as well as in contrast agent usage among the treatment groups. cmfTEVAR had the shortest total procedure time, while chTEVAR exhibited the highest contrast agent usage. The overall mortality rate among all procedures was 9.5% (two patients) and 4.7% for elective procedures, respectively. Deaths were associated with either retrograde type A dissection or stent graft infection. Both patients were treated with chTEVAR. There was one minor and one major stroke; these patients were treated with isfTEVAR. No endoleak occurred during any procedure. The reintervention rate for chTEVAR was 20% and 0% for all other procedures during the in-hospital stay. The patients who were treated with cmfTEVAR had no complications, the shortest operating and fluoroscopy time, and less contrast agent was needed in comparison with other treatment methods. Conclusions: Complex endovascular procedures of the aortic arch with custom-made or surgeon-modified aortic stent grafts offer a safe solution, with acceptable complication rates for patients who are not suitable for open aortic arch repair. In terms of procedure-related parameters and complication rates, a custom-made fenestrated TEVAR is potentially advantageous compared to the other endovascular techniques.

Clinical cases referring to the 2023 EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ.

Clinical cases referring to the EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ aim to assist physicians in selecting the best management strategies for individual patients with a given condition. These expert opinions consider the impact on patient outcomes as well as the risk-benefit ratio of different diagnostic or therapeutic methods. These cases serve as a vital tool to aid physicians in making decisions in their daily practice. However, in essence, although these recommendations serve as a valuable resource to guide clinical practice, their application should be tailored to the needs of the individual patient. Each patient's case is unique, presenting its own set of variables and circumstances. This editorial is a tool designed to support, but not supersede, the decision-making process of physicians, based on their knowledge, expertise and understanding of their patients' individual situations. Furthermore, these clinical cases are based on the EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ but should not be interpreted as legally binding documents. The legal responsibilities of healthcare professionals remain firmly grounded in applicable laws and regulations, and the guidelines and the clinical cases presented in this document do not alter these obligations.

Mid-term Outcomes of Thoracic Endovascular Aortic Repair (TEVAR) in Acute Complicated Type B Aortic Dissection: A Comprehensive Analysis of Aortic Remodeling Patterns.

Purpose: This study provides a comprehensive analysis of the clinical outcomes associated with endovascular treatment for acute complicated type B aortic dissection, with a focus on the complex process of aortic remodeling. Materials and Methods: We conducted a retrospective investigation using data extracted from the Songklanagarind Hospital database between January 2010 and January 2022. Electronic medical records of patients who underwent thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissections were reviewed. The analysis focused on in-hospital outcomes, overall survival, aorta-related survival, reintervention-free survival, and changes in aortic lumen diameter to assess aortic remodeling. Results: Over the study period, 32 patients with acute complicated type B aortic dissections underwent TEVAR. The in-hospital mortality rate was 9.4%, with complications occurring in 21.9% of patients. Temporary acute kidney injury was observed in 9.4% of the cases, wound bleeding in 6.3%, pneumonia in 6.3%, and permanent spinal cord ischemia in 3.1%. Re-intervention was necessary in 6.3% of cases. The overall survival rates at 6 months, 1 year, 3 years, and 6 years were 78%, 75%, 65%, and 44%, respectively. Aorta-related survival rates were 87%, 87%, 83%, and 75% at the corresponding time intervals. The reintervention-free survival rates were 96%, 96%, 71%, and 71%, respectively. Survival analysis revealed that patients with ideal aortic remodeling experienced the most favorable outcomes, whereas those with undesirable aortic remodeling exhibited the least favorable survival. Notably, undesirable pattern of aortic remodeling emerged as a singular factor with a statistically significant influence on predicting survival (hazard ratio 4.37, P-value=0.021). Conclusion: TEVAR resulted in favorable aorta-related survival outcomes. Notably, the identification of changes in aortic lumen diameter alongside false lumen thrombosis, encapsulated within the framework of aortic remodeling patterns, has emerged as a robust predictor of post-TEVAR survival outcomes.

Complicated type B aortic dissection in a pregnant woman with Marfan syndrome.

Marfan syndrome is a rare inherited connective tissue disorder that can result in significant morbidity and mortality. We report a case of a 29-year-old pregnant woman presenting with an acute type B aortic dissection. Owing to cardiopulmonary decompensation and intestinal malperfusion, she underwent an emergency cesarean section followed by left subclavian to carotid transposition and thoracic endovascular aortic repair that was complicated by a retrograde type A aortic dissection and was managed surgically. Molecular testing confirmed the diagnosis of Marfan syndrome. This case highlights that multidisciplinary and hybrid management of challenging cases of acute aortic syndromes can result in a favorable outcome.

Modified Ex Vivo Renal Reconstruction to Facilitate Fenestrated-Branched Endovascular Repair of a Thoracoabdominal Aortic Aneurysm.

PURPOSE: To report the use of modified ex vivo renal artery (RA) reconstruction in a patient with 2 small right RAs (RRAs) in anticipation of planned fenestrated-branched endovascular aortic repair (FB-EVAR) of thoracoabdominal aortic aneurysm (TAAA). CASE REPORT: A staged hybrid repair was utilized in a patient with Extent II TAAA involving celiac axis (CA), superior mesenteric artery (SMA), single left RA (LRA), and 2 small (<3 mm) RRAs. The first-stage operation consisted of hepato-renal bypass using modified ex vivo renal reconstruction with single end-to-end anastomosis to both RAs using a saphenous vein graft. A second stage FB-EVAR was performed using patient-specific manufactured stent-graft with 3 fenestrations for the CA, SMA, and LRA 6 weeks later. The patient recovered with no complications. At 4 years, the patient had widely patent hepato-renal bypass and target vessels with normal renal function. CONCLUSION: The use of adjunctive hybrid procedures may optimize or facilitate FB-EVAR. In this patient, salvage of 2 small RAs was not ideally suited for branch stenting but was possible using modified ex vivo RA reconstruction with preservation of kidney parenchyma and function. CLINICAL IMPACT: This case report illustrates a hybrid approach to overcome one of the most frequent limitations to total endovascular incorporation of renal arteries, eg small diameter, early bifurcation and multiple vessels. The modified ex vivo technique allows meticulous renal artery reconstruction without the deleterious effect of warm ischemia and without the cumbersome reconstruction of ureter and vein that is needed with traditional on table ex vivo auto transplantation. The technique is used in a minority of cases and adds the morbidity of open approach. Case selection is of paramount importance.