Residual Popliteal Aneurysm Perfusion Leading to Embolic Complications: A Case Report.

Introduction: Surgical management of popliteal artery aneurysms has been described for half a century. Long term development of the excluded aneurysm sac in the popliteal segment however remains widely unknown, with only a few small series describing outcomes. Residual aneurysm perfusion has the potential to lead to serious complications. Report: A 63 year old man presents with skin and soft tissue necrosis of the right calf two years after proximal and distal aneurysm ligation and great saphenous vein bypass for a popliteal artery aneurysm. Computed tomography and magnetic resonance angiography show perfusion of the excluded aneurysm as well as extensive necrosis of the gastrocnemius muscle. Direct angiography of the aneurysm demonstrated retrograde aneurysm perfusion due to insufficient distal ligation with recurrent micro-embolisation to the calf via geniculate arteries. Coiling of the geniculate arteries was performed, plugging the connection to the tibiofibular trunk and embolisation of the aneurysm sac. After the intervention, no flow was seen in the aneurysm sac and the patient made full recovery. Discussion: Residual aneurysm sac perfusion can lead to complications long after successful aneurysm exclusion. Follow-up after surgery of popliteal aneurysms should include observation of the excluded aneurysm sac with control of residual blood flow. For persistent sac perfusion, aneurysm enlargement or symptoms, further treatment should be considered. Surgical aspects such as complete transection of the artery after aneurysm ligation or end to end anastomosis of the bypass may be considered, to prevent such complications.

Peri-operative Mortality and Morbidity of Complex Abdominal Aortic Aneurysms Repair in Switzerland: A Swissvasc Report.

OBJECTIVE: Complex abdominal aortic aneurysms (cAAA) pose a clinical challenge. The aim of this study was to assess the 30 day mortality and morbidity for open aneurysm repair (OAR) and fenestrated/branched endovascular aortic repair (F/BEVAR), and the effect of hospital volume in patients with asymptomatic cAAA in Switzerland. METHODS: Retrospective, cohort study using data from Switzerland's national registry for vascular surgery, Swissvasc, including patients treated from 1 January 2019 to 31 December 2022. All patients with asymptomatic, true, non-infected cAAA were identified. Primary outcome was 30 day mortality and morbidity reported using the Clavien-Dindo classification. Outcomes were compared between OAR and F/BEVAR after propensity score weighting. RESULTS: Of the 461 patients identified, 333 underwent OAR and 128 underwent F/BEVAR for cAAA. At 30 days, overall mortality rate was 3.3% after OAR and 3.1% after F/BEVAR (p = .76). Propensity scores weighted analysis indicated similar morbidity rates for both approaches: F/BEVAR (OR 0.69, 95% CI 0.45 - 1.05, p = .055); intestinal ischaemia (1.8% after OAR, 3.1% after F/BEVAR, p = .47) and renal failure requiring dialysis (1.5% after OAR, 5.5% after F/BEVAR, p = .024) were associated with highest morbidity and mortality. Treatment specific complications with high morbidity were abdominal compartment syndrome and lower limb compartment syndrome following F/BEVAR. Overall treatment volume was low for most of the hospitals treating cAAA in Switzerland; outliers with increased mortality were identified among low volume hospitals. CONCLUSION: Comparable 30 day mortality and morbidity rates were found between OAR and F/BEVAR for cAAA in Switzerland; lack of centralisation was also highlighted. Organ specific complications driving mortality were renal failure, intestinal ischaemia, and limb ischaemia, specifically after F/BEVAR. Treatment in specialised high volume centres, alongside efforts to reduce peri procedural kidney injury and mesenteric ischaemia, offers potential to lower morbidity and mortality in elective cAAA treatment.

Physician Made Bovine Pericardial Tube Grafts in Aortic Infection: A European Multicentre Study.

OBJECTIVE: This study examines outcome and durability of physician made bovine pericardial tube grafts in aortic infections in all anatomical locations. METHODS: This was a retrospective and prospective international multicentre study. Peri-operative and long term outcomes of patients undergoing in situ aortic reconstruction for native or graft infections with physician made bovine pericardial tube grafts between January 2008 and December 2020 in four European tertiary referral centres were analysed. The primary endpoint was recurrent aortic infection. Secondary endpoints were persistent infection, aortic re-operation for infection, graft related complications, and death. RESULTS: One hundred and sixty eight patients (77% male, mean age 67 ± 11 years) were identified: 38 (23%) with native and 130 (77%) with aortic graft infection. The thirty day mortality rate was 15% (n = 26) overall, 11% (n = 4), and 17% (n = 22) for native and aortic graft infections, respectively (p = .45). Median follow up was 26 months (interquartile range [IQR] 10, 51). Estimated survival at one, two, three, and five years was 64%, 60%, 57%, and 50%, and significantly better for native (81%, 77%, 77%, and 69%) than for graft infections (58%, 55%, 51%, and 44%; p = .011). Nine patients (5.3%) had persistent infection and 10 patients (6%) had aortic re-infection after a median of 10 months (IQR 5, 22), resulting in an estimated freedom from re-infection at one, two, three, and five years of 94%, 92%, 90%, and 86%. Estimated freedom from graft complications at one, two, three, and five years was 91%, 89%, 87%, and 87%. CONCLUSION: This multicentre study demonstrates low re-infection rates when using physician made bovine pericardial tube grafts, comparable to those of other biological grafts. The rate of graft complications, mainly anastomotic aneurysms and stenoses, was low, while graft degeneration was absent. Physician made bovine pericardial tube grafts are an excellent tool for in situ reconstruction in the setting of native aortic infection or aortic graft infection.

Infective Native Aortic Aneurysm: a Delphi Consensus Document on Treatment, Follow Up, and Definition of Cure.

OBJECTIVE: Evidence is lacking to guide the management of infective native aortic aneurysm (INAA). The aim of this study was to establish expert consensus on surgical and antimicrobial treatment and follow up, and to define when an INAA is considered cured. METHODS: Delphi methodology was used. The principal investigators invited 47 international experts (specialists in infectious diseases, radiology, nuclear medicine, and vascular and cardiothoracic surgery) via email. Four Delphi rounds were performed, three weeks each, using an online questionnaire with initially 28 statements. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements were revised and added or deleted, and the results were presented in the iterative rounds. Consensus was defined as ≥ 75% of the panel rating a statement as strongly agree or agree on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha > 0.80. RESULTS: All 49 panellists completed all four rounds, resulting in 100% participation. One statement was added based on the results and comments of the panel, resulting in 29 final statements: three on need for consensus, 20 on treatment, five on follow up, and one on definition of cure. All 29 statements reached agreement of ≥ 86%. Cronbach's alpha increased for each consecutive round; round 1, 0.85; round 2, 0.90; round 3, 0.91; and round 4, 0.94. Thus, consensus was reached for all statements. CONCLUSION: INAAs are rare, and high level evidence to guide optimal management is lacking. This consensus document was established with the aim of helping clinicians manage these challenging patients, as a supplement to current guidelines. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Practice of neuromonitoring in open and endovascular thoracoabdominal aortic repair-an international expert-based modified Delphi consensus study.

OBJECTIVES: Spinal cord injury is detrimental for patients undergoing open or endovascular thoracoabdominal aortic aneurysm (TAAA) repair. The aim of this survey and of the modified Delphi consensus was to gather information on current practices and standards in neuroprotection in patients undergoing open and endovascular TAAA. METHODS: The Aortic Association conducted an international online survey on neuromonitoring in open and endovascular TAAA repair. In a first round an expert panel put together a survey on different aspects of neuromonitoring. Based on the answers from the first round of the survey, 18 Delphi consensus questions were formulated. RESULTS: A total of 56 physicians completed the survey. Of these, 45 perform open and endovascular TAAA repair, 3 do open TAAA repair and 8 do endovascular TAAA repair. At least 1 neuromonitoring or protection modality is utilized during open TAAA surgery. Cerebrospinal fluid (CSF) drainage was used in 97.9%, near infrared spectroscopy in 70.8% and motor evoked potentials or somatosensory evoked potentials in 60.4%. Three of 53 centres do not utilize any form of neuromonitoring or protection during endovascular TAAA repair: 92.5% use CSF drainage; 35.8%, cerebral or paravertebral near infrared spectroscopy; and 24.5% motor evoked potentials or somatosensory evoked potentials. The utilization of CSF drainage and neuromonitoring varies depending on the extent of the TAAA repair. CONCLUSIONS: The results of this survey and of the Delphi consensus show that there is broad consensus on the importance of protecting the spinal cord to avoid spinal cord injury in patients undergoing open TAAA repair. Those measures are less frequently utilized in patients undergoing endovascular TAAA repair but should be considered, especially in patients who require extensive coverage of the thoracoabdominal aorta.

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

OBJECTIVE: There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. METHODS: The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80. RESULTS: All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. CONCLUSION: This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Peripheral Artery Disease Leading to Major Amputation: Trends in Revascularization and Mortality Over 18 Years.

BACKGROUND: Patients with peripheral artery disease (PAD) are at risk for amputation. The aim of this study was to assess the type of revascularization prior to and the 30-day mortality rate after major amputation due to PAD. METHODS: Retrospective analysis of consecutive patients undergoing major amputation for PAD between 01/2000 and 12/2017 at a tertiary referral center. The number and target level of ipsilateral revascularizations prior to amputation were analyzed per patient and over the years. There were 3 types of revascularization (open, endovascular and combined treatment) at 3 levels: aortoiliac, femoropopliteal and infrapopliteal. Univariate and multivariate logistic regression models were used to assess the association of level of amputation and patient characteristics with 30-day mortality. RESULTS: A total of 312 patients (65.7% male) with a mean age of 73.3 ± 11 years underwent 338 major amputations: 70 (21%) above/through knee and 268 (79%) below knee. A median of 2 (interquartile range, IQR 1-4) revascularizations were performed prior to amputation, with a slight decrease of 1.4% per year from 2000-2017 (incidence rate ratio of 0.986 0.974-0.998; Poisson regression analysis, P = 0.021). 16% (53/338) of patients underwent primary amputation without revascularization; this number remained relatively stable throughout the study period. The proportion of exclusively open treatment before amputation decreased substantially from 35% in 2006 to none in 2016, while exclusively endovascular revascularizations were performed increasingly from 17% in 2002 to 64% in 2016. Amputation occurred after a median of 9.5 months (IQR 0.9-67.6 months) if the first revascularization was aortoiliac or femoropopliteal and after 2.1 months (IQR 0.5-13.8 months) if the first intervention was infrapopliteal (P < 0.001) with no significant change over the years (normal linear regression, P= 0.887). Thirty-day mortality was 8.9% (22/247) after below knee and 27.7% (18/65) after above/through knee amputation (adjusted OR 3.84, 95% CI 1.74-8.54, P= 0.001) with a slight increase of mortality over the study period (adjusted OR 1.09, 95% CI 1.018-1.159, Poisson regression analysis, P= 0.021). The uni- and multivariate analysis of patient characteristics did not show an association with mortality, except higher ASA classification (adjusted OR 2.65, 95% CI 1.23-5.72, P= 0.012). CONCLUSIONS: Mortality, especially after above/through knee amputation, remains high over the past 2 decades. There is a clear shift towards endovascular treatment of patients with PAD prior to major amputation. In patients needing infrapopliteal revascularizations, amputation was performed much sooner than in those with aortoiliac or femoropopliteal interventions, with no improvement over the years. Strategies to extend limb salvage in these patients should be the focus of further research.

Current trends in reduction or elimination of the aortic impulse during stent-graft deployment and balloon moulding during thoracic endovascular aortic repair.

OBJECTIVES: A survey was performed to evaluate the methods used for reduction or elimination of the aortic impulse (REAI) to facilitate precise stent graft placement and balloon moulding during thoracic endovascular aortic repair (TEVAR). METHODS: A total of 127 physicians (1 per hospital) were contacted and asked to fill out a short, comprehensive questionnaire on an internet-based platform. RESULTS: Fifty physicians (39.4%) responded and completed the survey. Routine use of REAI for stent graft deployment is most frequently used in the ascending aorta and less frequently in the aortic arch and the descending aorta (86.4% vs 69.4% vs 56%). Some physicians based the decision of whether to use REAI on the type of stent graft in the respective location (13.6% vs 24.5% vs 24.0%). Stent-graft deployment without REAI, irrespective of the type of stent graft used, was never done in the ascending aorta (0.0%), in 3 centres in the aortic arch (6.1%) and in 10 centres in the descending aorta (20%). The REAI method most frequently used was dependent on the aortic segment (ascending aorta vs aortic arch vs descending aorta) rapid right ventricular pacing (90.9% vs 59.2% vs 28.0%), followed by pharmacological blood pressure reduction (13.6% vs 53.1% vs 64.0%) and venous inflow occlusion (13.6% vs 14.3% vs 4.0%), respectively. Tip capture and non-occlusive deployment systems were frequently quoted as reasons for not using REAI. CONCLUSIONS: REAI is the fundament for TEVAR in all thoracic aortic segments, with a decline in usage from proximal (ascending) to distal (descending). Rapid right ventricular pacing is the preferred REAI method used in TEVAR. Most procedures are performed with the patient under general anaesthesia. The types of stent grafts and moulding balloons used have an impact on the use or non-use of REAI.

Emergent open conversion for stent-graft deployment failure in a ruptured thoracic aneurysm.

Thoracic endovascular aortic repair (TEVAR) is the standard of care for ruptured thoracic aortic aneurysms. A 92-year-old man had presented in stable condition but with acute severe back pain. Computed tomography revealed a ruptured thoracic aortic aneurysm. TEVAR (Valiant; Medtronic Vascular, Santa Rosa, Calif) into zone 2 with intentional coverage of the left subclavian artery was planned. After release of the stent-graft body, proximal release of the bare springs was impossible. Troubleshooting techniques were applied; but tip capture could not be released. Emergent conversion to open repair was performed. Intraoperative device deployment failure in TEVAR is rare. The findings from the present report have demonstrated the advantages of having in-house cardiac surgery backup available.

Efficacy and Safety of Heparinization before Deployment of Endograft for Blunt Traumatic Aortic Injury in Severely Injured Patients.

BACKGROUND: The administration of unfractionated heparin (UFH) during endovascular repair of blunt traumatic aortic injury (BTAI) is controversial. The aim of the study is to report the early outcomes of patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI, and to assess the individualized intraoperative use and dose of UFH. METHODS: This is a retrospective analysis including consecutive patients treated with TEVAR for BTAI of the descending aorta between January 1st, 2005 and December 31st, 2018. Intraoperative use and doses of UFH were analyzed. Primary outcome included a reintervention because of new onset bleeding and/or thromboembolic complication and 30-day mortality. Technical success, injury severity score (ISS), timing of treatment, and neurologic deterioration were secondary outcome. RESULTS: Thirty-six patients with a mean age of 47 ± 18 years, 30 males (83%), were included. Intraoperative administration of UFH was recorded in 30/36 patients (83%) with a mean dose of 4750 ± 2180 IU. Two patients had no UFH because of extensive intracranial hemorrhage or suspected relevant liver laceration, respectively; 1 died in theatre, 1 was already anticoagulated having a mechanical aortic valve, and in 2 no information about heparin use was found. During 30 days of follow-up, 3 patients died (8%; 3/36): 1 patient with completely transected aorta died on-table and 2 on the fifth postoperative day, 1 from trauma-associated brain injury and 1 with multi organ failure. No bleeding or thromboembolic complication requiring reintervention occurred in any patient during 30 days follow-up. In 3 patients partial unintentional coverage of the left common carotid artery occurred, resulting in technical success of 89% (32/36). Mean ISS was 43 ± 15. Thirty-five patients (97%) were severely injured having an ISS ≥ 25. Twenty-nine patients (81%) were treated within 24 hr and 6 patients (17%) within 1 week. No stroke or spinal cord ischemia was observed. CONCLUSIONS: Systemic heparinization in different doses during TEVAR for BTAI can be safe with no intraoperative bleeding or thromboembolic complications in early postoperative period.

Long-term results of cryopreserved allografts in aortoiliac graft infections.

OBJECTIVE: Different graft materials have been proposed for in situ reconstruction in the setting of vascular graft infection (VGI). We analyzed the long-term outcomes after in situ aortoiliac reconstruction with cryopreserved allografts. METHODS: We performed a retrospective analysis of patients who had undergone in situ aortoiliac reconstruction with cryopreserved arterial allografts for VGI from 2000 to 2015. The end points were the perioperative and long-term mortality and graft-related complications, including stenosis, occlusion, pseudoaneurysm, and reinfection. RESULTS: A total of 33 patients (91% male) with a median age of 67 years (range, 53-83 years) had undergone in situ aortoiliac reconstruction with cryopreserved allografts. The 30-day mortality was 6% (n = 2); both deaths were related to the allograft (one early allograft-enteric fistula and one graft rupture). Another two patients had experienced early (≤30 days) graft-related events (one allograft-enteric fistula and one graft limb occlusion), for an early graft-related complication rate of 12% (n = 4). Of the 31 discharged patients, 13 (42%) had died after a median of 47 months (range, 2-97 months). The median follow-up for the 18 remaining patients was 96 months (range, 10-146 months). The estimated survival at 1, 3, and 5 years was 88%, 81%, and 66%, respectively. Nine patients (29%) had experienced at least one of the following graft-related events during follow-up, including graft stenosis requiring intervention in five (16%), graft occlusion in four (13%), pseudoaneurysm in three (10%), and reinfection in two patients (6%). The estimated freedom from any first graft-related event at 1, 3, and 5 years was 78%, 71%, and 62%, respectively. The estimated primary patency and primary assisted patency at 1 and 3 years was 87% and 79%, and 90% and 83%, respectively. CONCLUSIONS: In situ aortoiliac reconstruction with cryopreserved allografts to treat VGI was associated with relevant perioperative graft-related complications. Although the reinfection rate was acceptable, other graft-related complications were frequent in the long term, in particular, graft occlusion and stenosis.

Development and internal validation of a prognostic model for mortality of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair.

Background: Morbidity and mortality associated with elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) must be balanced against the impending risk of aneurysm rupture and the estimated remaining lifetime. The aim of this study is to develop and validate a prognostic model for mortality of patients with AAA treated with EVAR. Methods: This retrospective observational study included 251 consecutive patients treated with EVAR for asymptomatic AAA between January 2001 and December 2012 at the University Hospital in Bern, Switzerland. Pre-selection of variables was based on a literature review; least absolute shrinkage and selection operator technique was used for the final variable selection. A Firth's bias reduced Cox proportional hazard model was developed and validated using 10,000 bootstrap samples to predict survival after EVAR. Results: The median follow-up time was 5.3 years (range 0.1 to 15.9). At the study closing date 95% of follow-up information was available. The mortality rates were 31.9% at 5 years and 50.5% at the study closing date, respectively. Identified predictors for overall mortality after EVAR were age, hazard ratio (HR) = 2.24 per 10-year increase (95% CI 1.64 to 3.09), the presence of chronic obstructive pulmonary disease (COPD), HR = 2.22 (95% CI 1.48 to 3.31), and lower estimated glomerular filtration rate, HR = 1.24 per 10 ml/min/1.73 m2 decrease (95% CI 1.12 to 1.39). The model showed good discrimination ability, Harrell's C = 0.722 (95% CI 0.667 to 0.778) and was very robust in the bootstrap in-sample validation Harrell's C = 0.726 (95% CI 0.662 to 0.788). Conclusion: Higher age, the presence of COPD and impaired kidney function are independent predictors for impaired survival after EVAR. The expected remaining lifetime should be considered in patients with AAA. This prognostic model can help improving patient care; however, external validation is needed prior to clinical implementation.

The Impact of EndoAnchor Penetration on Endograft Structure: First Report of Explant Analysis.

OBJECTIVE: The adjunctive use of Heli-FX EndoAnchors (EAs) in endovascular aneurysm repair has been proposed for the treatment or prevention of type Ia endoleaks. The aim of this study was to evaluate the impact of the penetration of EAs on endograft textile structure from two aortic endografts that had been explanted for persistent type Ia endoleak despite the implantation of EAs. METHODS: An Aorfix aortic endograft was implanted in an 85 year old man. Six months later, six EAs were implanted for Ia endoleak. The endograft was explanted as an emergency seven months later for aneurysm rupture. An Endurant II aortic endograft was implanted in an 80 year old man. Seven EAs were implanted 24 months later for type Ia endoleak. A proximal cuff extension with bilateral renal and superior mesenteric artery chimneys was performed 18 months later to treat a persistent type Ia endoleak. Endograft explantation was performed six months later owing to persistent type Ia endoleak and aneurysm sac enlargement. Explant analysis in both cases was performed at GEPROVAS. RESULTS: Systematic analysis of both explants, including the 13 EAs, revealed the following lesions: (1) alteration of textile structure directly linked to several penetrations of the fabric with the same EA and tears of the textile fibres in two cases; (2) tears of the binding threads as the EA had passed through them in five cases; and (3) interactions between EA and endograft stents in four cases. CONCLUSION: The site of EA penetration into the endograft might contribute to endograft fabric damage and to a loss of stability of the endograft at the level of the aortic neck.

In situ Reconstruction of Infected Groin Pseudoaneurysms in Drug Abusers With Biological Grafts.

OBJECTIVES: The aim of this study was to evaluate outcomes after in situ reconstruction using biological grafts in infected groin pseudoaneurysms in drug abusers. METHODS: This was a single centre retrospective analysis of all patients undergoing in situ reconstruction with biological vascular grafts for infected groin pseudoaneurysms in drug abusers from 2000 to 2017. Outcome measures included wound healing problems, re-infection, graft patency, lower limb amputation, and mortality. RESULTS: Twenty-two patients (14 male) with a median age of 39 years (range 27-49) were identified. Fifteen patients (68%) underwent urgent in situ reconstruction with a xenograft, five patients (23%) with a homograft, and two patients (9%) with an autologous vein. There were no in hospital deaths, in hospital re-infections, or early major limb amputations. Four (18%) patients developed wound healing complications requiring re-operation. During a median follow up of 56 months (range 13-180 months), six patients (27%) developed re-infection requiring complete graft replacement with a new biological graft. Thereafter, three (14%) had re-re-infection. Seven patients (32%) had graft occlusions: two were treated endovascularly, two underwent re-operation, and three were treated conservatively. Two patients (9%) had patent grafts but significant stenosis: one had successful angioplasty and another one was left untreated. One patient required above knee amputation, resulting in an overall major amputation rate of 4%. Estimated primary patency was 87% after one year and 40% after five years. Six patients (27%) died during follow up from non-vascular causes. CONCLUSIONS: In situ reconstruction using biological grafts of infected groin pseudoaneurysms in drug abusers can be achieved with no peri-operative graft related complications, although rates of wound complications may be high. In the longer term, a significant number of patients develop re-infection, graft occlusion, or stenosis, although the amputation rate remains low. The management of this demanding group of patients remains a major challenge.

Symptomatic or aneurysmal aberrant subclavian arteries: results of surgical and hybrid repair.

OBJECTIVES: Indications and techniques of repair for symptomatic or aneurysmal aberrant subclavian arteries (ASA) are controversial. This study analyses presentation, treatment and outcome of patients with symptomatic and/or aneurysmal ASA. METHODS: Retrospective analysis of consecutive adult patients undergoing symptomatic and/or aneurysmal ASA repair between January 2000 and June 2016. RESULTS: Of 12 patients (4 females) with a median age of 66 years (range 24-75), 10 had right ASA and 2 had left ASA originating from a right aortic arch. Six patients (50%) had Kommerell's diverticulum and 6 patients had aneurysmal dilatation of the ASA itself. Six patients presented with symptoms (dysphagia n = 4, chest pain n = 1, recurrent aspiration n = 1). Nine patients (75%) were treated by open ASA resection/ligation with or without aortic repair. Three patients (25%) underwent hybrid repair using thoracic endovascular aortic repair to exclude the aberrant artery. ASA revascularization was achieved by subclavian-carotid transposition (n = 7), carotid-subclavian bypass (n = 1), aorto-subclavian bypass (n = 3) or reimplantation after aortic graft replacement (n = 1). Thirty-day mortality was 8% (n = 1). The median follow-up duration was 44 months (range 24-151). Symptoms were relieved in 4 and persisted partially in 1, while symptom relief remained unknown in 1 patient who died during follow-up. Imaging after a median of 34 months (range 2-134) after the operation showed patent ASA revascularization in all patients and no endoleaks in the hybrid group. CONCLUSIONS: Surgical and hybrid repair allows satisfying results in patients with symptomatic and/or aneurysmal ASA. The optimal procedure has to be defined on an individual patient basis. Further studies, preferably with a multicentre approach, are required to answer more specific questions on the management of these patients and especially to assess long-term results following hybrid repair.