Introduction: While the benefits of carotid surgery for symptomatic carotid artery disease are well-established, the management of asymptomatic carotid lesions remains controversial, with wide variation in clinical practice. Recent studies suggest that plaque characteristics, such as thrombus versus calcium content, may predict cerebral events more accurately than the degree of stenosis alone. This study investigates the feasibility of segmenting carotid lesions on computed-tomography (CT) angiography using artificial intelligence (AI), and evaluates differences in plaque composition between symptomatic and asymptomatic patients. Methods: Carotid plaques were analyzed using 2 segmentation approaches: physician-controlled manual segmentation and fully automated segmentation with the AI-based software PRAEVAorta2 (Nurea). Thrombus content, calcium burden, and residual lumen were analyzed and compared between the 2 techniques. The AI-based software was pre-trained on 19 CT angiograms. Sensitivity, specificity, Dice similarity coefficient (DSC), and volumetric similarity were calculated to evaluate the performance of both methods. A total of 156 patients who underwent carotid artery surgery between February 2019 and February 2022 were included in the analysis, comprising 81 symptomatic and 75 asymptomatic lesions. Results: The DSC between fully automatic segmentation and physician-controlled manual segmentation was strong for lumen (0.83), calcification (0.68) and plaque (0.60) assessments but weaker for thrombus (0.33). Volume similarity, intra- and inter-observer reliability were high, with correlation coefficients of 0.98 for intra-observer, 1.00 for inter-observer analyses and 0.86 for fully automatic vs physician-controlled manual segmentation. Symptomatic carotid lesions exhibited significantly larger thrombus-to-total volume ratios (p<0.0001), higher raw thrombus volumes (p<0.0001), and greater total lesion volumes (p=0.003) than asymptomatic lesions. Conversely, asymptomatic lesions demonstrated higher calcification-to-total volume ratios (p=0.002). Conclusion: This study demonstrates the potential of PRAEVAorta2 to automate carotid lesion analysis, offering promise for identifying high-risk asymptomatic plaques and therefore aid surgical decision-making. Symptomatic carotid lesions displayed higher thrombus volume, lower calcium content, and larger plaque volumes than asymptomatic lesions. Clinical Impact This study introduces an AI-based tool, PRAEVAorta2, capable of automatically segmenting and quantifying carotid plaque components on CT angiography. By distinguishing between thrombus and calcification, the tool provides a more nuanced assessment of plaque vulnerability beyond stenosis grading. Clinically, this innovation could enhance risk stratification in asymptomatic carotid stenosis, supporting more individualized decisions for surgery. The demonstrated correlation between thrombus burden and symptoms highlights the potential to identify high-risk plaques before neurological events occur. This advancement may bridge the gap between imaging and clinical decision-making, promoting proactive and targeted management of carotid artery disease.

Purpose: The complexity of fenestrated and branched endovascular aneurysm repair (F/BEVAR) has been linked to substantially longer procedural duration compared with standard endovascular aneurysm repair (EVAR). These complex procedures rely heavily on fluoroscopic guidance, leading to prolonged radiation exposure for both patients and operators. Given the potential risks associated with high radiation doses, this meta-analysis aimed to assess and compare patient radiation exposure between EVAR and F/BEVAR and evaluate time trends. Methods: Mendeley reference manager was used by 2 independent reviewers to evaluate articles identified in the MEDLINE, Cochrane Library, and Scopus databases over a 7-year period. A meta-analysis was conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria using the medical subject headings (MeSH) terms “AAA,” “aortic aneurysm,” and “radiation” to search and index journal articles systematically. Only full-text, English-language publications reporting radiation data on humans treated with standard EVAR or F/BEVAR were included. The SPSS statistical package was employed to generate fluoroscopy time (FT), kerma-area product (KAP), and cumulative air kerma (CAK) regression lines. The STATA statistical software was used to perform the meta-analysis and present the forest plots. Results: Seventy-two articles, encompassing 92 EVAR and F/BEVAR studies, were eligible for inclusion in this meta-analysis. The pooled mean values were lower in standard EVAR compared with the more complex F/BEVAR cases for FT (26.05 vs 77.51 minutes; p<0.001), KAP (131.34 vs 209.50 Gycm 2 ; p=0.010), and CAK (806.76 vs 2798.61 mGy; p<0.001). This translates to a 197.5% increase in FT, a 59.5% increase in KAP, and a 246.9% increase in CAK for F/BEVAR compared with EVAR. Except for the increase in KAP during F/BEVAR procedures (r=0.531, p=0.028), all investigated parameters showed a decreasing trend over time for both EVAR (FT: r=–0.037, p=0.810; KAP: r=–0.098, p=0.540; CAK: r=–0.115, p=0.740) and F/BEVAR (FT: r=–0.387, p=0.034; CAK: r=–0.377, p=0.037). Conclusion: This meta-analysis highlights the substantial increase in radiation exposure associated with F/BEVAR compared with standard EVAR. Even though there is a clear paucity of rigorous, high-quality studies, the considerable radiation burden associated with F/BEVAR underscores the need for optimization efforts that minimize patient exposure without compromising procedural success. Clinical Impact This article provides information for better understanding of how patient intraoperative radiation exposure varies between the standard and the more complex endovascular aneurysm repair procedures using fenestrated and branched devices. This meta-analysis identified trends and heterogeneities in the fluoroscopy time, kerma-area product, and cumulative air kerma values among the studies. The regression lines deliver a clearer picture of the radiation exposure trends over the last years, offering insights into improving surgical techniques and patient safety by providing guidance on how to balance between the technical demands of complex devices and technology of the C-arm systems with the need to minimize patients’ radiation doses.

Background: The Auryon laser atherectomy system has been shown to have high procedural success in the prospective, multicenter Auryon BTK study. We present the 12-month outcomes of the Auryon BTK in treating infrapopliteal arterial disease in patients with chronic limb-threatening ischemia (CLTI). Methods: Patients at 4 US centers with CLTI were prospectively enrolled in the Auryon BTK study after obtaining informed consent. The study was approved by a central ethics committee. The 30-day primary safety and procedural success were recently published. Secondary endpoints included target lesion revascularization (TLR), clinical patency (defined as peak systolic velocity ratio ≤2.4 and no TLR), major adverse limb events (amputation, target vessel revascularization, and/or all-cause mortality), Walking Impairment Questionnaire (WIQ), Rutherford Becker (RB) category, and EQ-5D quality of life questionnaire. Proportional and Kaplan–Meier (K-M) survival analysis were performed. Results: A total of 60 patients (61 lesions) were enrolled. At 12-month, 42 patients were still in the study (7 lost-to-follow-up, 5 withdrawals, 7 deceased). The mean age was 74.6 ± 10.3 years with 58.3% diabetics, 43.3% RB IV, and 56.7% RB V. Of the 61 lesions, 59% had severe calcification, 31.1% were chronic total occlusions, and 90.2% were de novo disease. Bailout stenting occurred in 1/61 lesions (1.6%). Proportional analysis for freedom from TLR at 1-year was 94.2%, and TVR was 89.4%. K-M analysis for freedom from TLR was 94.0% at 12-month. There was a significant difference in median WIQ score from to baseline to 3-month (p = 0.0020) and baseline to 6-month (p = 0.0290) but not from baseline to 12-month (Δ−0.073, p = 0.678). Wounds healed in 33.3% (n = 4/12) of patients at 12-month. There was also a significant difference in median EQ-5D total score from baseline to 30-day (p = 0.0030), 3-month (p = 0.0060), 6-month (p = 0.0500), and 12-month (p = 0.00005). In addition, there was a significant median difference between 30-day ankle-brachial index (ABI) and baseline ABI (p < 0.0005) and the 12-month ABI and baseline ABI (p = 0.2100). Rutherford–Becker category improved by ≥1 category among 67.6% (n = 23/34) patients, stayed the same in 29.4% (n = 10/34) patients and worsened in 2.9% (n = 1/34) patients at 1-year. Conclusion: The 355-mm laser has a high rate of freedom from TLR at 12-month with a significant improvement in RB categories, WIQ and quality of life (EQ-5D). Clinical Impact The Auryon BTK demonstrates the safety and effectiveness of the 355-nm Auryon laser system in treating infrapopliteal arterial disease in patients with critical limb ischemia yielding high freedom from TLR and improvement in quality of life despite complex disease. The Auryon laser can treat all lesion morphologies below the knee including severe calcium and needs to be considered by operators for vessel prepping prior to adjunctive balloon angioplasty.

Objective: Our primary endpoint was to determine the prevalence of superior mesenteric artery aneurysms (SMAAs) in infectious endocarditis (IE) patients. Methods: Retrospective study of 474 IE-patients (2005–2020) with abdominal computed tomography-angiography (CTA): the data of 10 SMAA-IE-patients (2.1%) are analyzed. Results: The median age of the 10 patients was 50.4 years (6 men). Microorganisms were Streptococcus spp. (n=6), Gemella spp. (n=2), Staphylococcus aureus (n=1), Enterococcus faecalis (n=1). Aneurysms were saccular (n=9), fusiform (n=1). Five SMAAs were partially thrombosed. Three patients presented acute abdominal pain, associated with partial thrombosis. Three became symptomatic: SMAA growth (n=2) and delayed aneurysm, enlargement, rupture, and bowel ischemia (n=1). Four were small (<25 mm), 6 were large (25–70 mm), mostly distally located (6/10). Five (3 small, 2 large) regressed under antibiotic therapy alone, 2 (25 and 40 mm) underwent coil embolization. Three underwent surgery (30, 50, and 60 mm), because of large aneurysm at SMA origin, rapid enlargement and rupture, and bowel ischemia. The outcome was favorable (mean follow-up: 43.5 months; range: 9–72). Conclusion: Abdominal pain, vomiting, diarrhea, occurring in a patient with a current or recent history of IE should be carefully evaluated by CTA. Symptomatic, growing aneurysms and fusiform aneurysms mainly underwent an operative repair. Five silent aneurysms (<20 mm, n=2; >20 mm, n=3) were safely monitored under antibiotic therapy, enhancing the need to further have cross-sectional imaging of the visceral circulation in all cases of left-sided IE to detect asymptomatic aneurysms. SMAAs can regress, thus conservative management of small asymptomatic ones is possible. Clinical Impact In our series of superior mesenteric artery infectious aneurysms (SMAA) in infective endocarditis (IE) patients (incidence: 2.1%), symptomatic, growing aneurysms and fusiform aneurysms mainly underwent an operative repair. Five silent aneurysms (<20mm, n=2; >20mm, n=3) were safely monitored under antibiotic therapy. Our study showed first, the need to have cross-sectional imaging of the visceral circulation in all cases of left sided infective endocarditis. Obviously, abdominal CT-angiography monitoring is also a cornerstone of the efficacy of the antibiotic regimen. Second, SMAAs in IE patients can regress: thus conservative management of small asymptomatic ones is possible.

Objectives: Contrast-induced nephropathy is still a big issue related to using iodine contrast medium in patients with renal impairment undergoing complex endovascular aneurysm repair such as fenestrated or branched endovascular aneurysm repair (F/BEVAR). Although the use of carbon dioxide being well investigated in literature for standard EVAR, there are a few evidence about its use in F/BEVAR. The potential damage to kidneys is not only related to the procedure alone but also to the need to perform computed tomography angiography in the preoperative and postoperative period. With the aim to reduce the damage to renal function in patients with preexisting renal impairment, we report our experience of a total iodine contrast-free protocol in 6 patients with chronic kidney disease (stages from 3 to 5) who require a complex endovascular aneurysm repair due to an aneurysmatic disease of the thoracoabdominal aorta. Materials and Methods: Six consecutive patients with chronic kidney disease underwent F/BEVAR at our institution following a total iodine contrast-free protocol, from perioperative period to follow-up. These patients were preoperatively evaluated with duplex ultrasounds and plain-computed tomography scan to perform proper reconstruction with dedicated 3D software. All the procedures were carried on with CO 2 as contrast medium. During follow-up, every patient underwent plain-computed tomography scan at 1 month and then duplex ultrasound evaluations. Results: Technical success was achieved in all cases. There were no aneurysm or procedure-related complications related to the use of CO 2 in the perioperative period. At 6 months, in each case, the sac was stable and no endoleak were found. Serum creatinine and estimated glomerular filtration rate values were similar to preoperative ones both in the perioperative period and during follow-up. Conclusions: The total iodine contrast-free protocol showed its feasibility and safety to carry on complex endovascular procedures in patients affected by chronic kidney disease from stages 3 to 5 and concomitant aneurysmatic disease of the thoracoabdominal aorta. This protocol could also avoid further deteriorations of renal function that could lead those patients to hemodialysis. A large cohort of patient and an extended follow-up are required in the future to achieve more accurate data. Clinical Impact This study aims to evaluate an iodine-contrast-free protocol for patients with chronic kidney disease undergoing complex endovascular aortic repair, such as FEVAR or BEVAR. The use of this protocol may help preserve renal function and prevent further deterioration in patients at high risk for acute kidney injury or hemodialysis. Although the literature describes the role of CO 2 as a non-nephrotoxic contrast agent, there are no reported experiences involving both preoperative and postoperative evaluation without the use of iodine-based contrast media.

Background: Hereditary aortopathies traditionally require open repair when significant pathologies arise. Open provides the most durable outcome for nominally a younger patient population that can tolerate larger procedures well. In certain situations, literature has described proceeding with endovascular repair in patients with known hereditary aortopathies. Case Report: This case report describes the treatment of a 29-year-old female with a history of type A dissection previously treated with a valve sparing aortic root repair and a type B dissection with a thoracic endovascular aortic repair (TEVAR) 2 years prior. Genetic testing then confirmed Marfan’s syndrome, and she was followed by vascular medicine specialists and optimized medically. Several other family members also tested positive and imaging revealed aortic abnormalities. She arrived at our institution endorsing severe nausea, vomiting, back, flank, and abdominal pain. She was found on imaging to have a rapidly degenerating type II thoracoabdominal aortic aneurysm (TAAA) with dissection. A multidisciplinary team evaluated the patient and working with cardiothoracic (CT) surgery, our initial plan was an open repair. Following admission to the ICU, her symptoms improved with tight blood pressure control; however, she rapidly clinically decompensated with worsening pain and hypotension the day prior to her planned open repair. A massive transfusion protocol was initiated and CT scan revealed more than a 1 cm growth and evolution of her dissection. At the time, the CT surgery group were in cases and could not free an attending, and therefore recommended that we temporize the situation with balloon control and a fenestrated repair. We emergently proceeded to the operating room and obtained balloon control prior to induction of anesthesia while the 4-vessel fenestrated/branched endograft (F/BEVAR) was constructed. Repair was carried out with a bifurcated graft into the bilateral iliac arteries. However, following the endovascular repair, the patient did not want to proceed with a large open surgery and was managed definitively with endovascular means and ultimately required reintervention for a type 3 endoleak (EL) (bridging TEVAR) and type 1B EL requiring hypogastric preservation to minimize spinal cord ischemia. CT scan prior to discharge revealed only a type 2 EL, and she was discharged home with full motor and sensory function. Approximately 1 year later, a CT scan revealed regression of the aneurysm near her visceral segment, but growth near the aortic bifurcation and a type 2 EL. This was treated with a trans-caval approach and embolization of several segmental branches and the aneurysm sac with thrombin and gelfoam. Subsequent CT scans over the next 2 years have shown continued sac regression. Conclusion: This case serves as an example that an endovascular repair may play a role in the emergent treatment of complex anatomies in patients with Marfan syndrome especially when refusing open surgery. This repair has to date shown mid-term success with near-complete aneurysm sac regression and no endoleak, but to achieve this the patient has required strict surveillance and 2 reinterventions in the first year following the index case. Ultimately, this represents one of the first ruptured TAAA in a Marfan patient treated with a F/BEVAR. Clinical Impact Patients with genetic aortopathies are at risk for aneurysmal degeneration and disease progression. It is important to manage patients with genetic aortopathies expeditiously and in emergency settings a total endovascular approach can be used. Each case requires a multidisciplinary approach and thoughtful planning.

Introduction: The profunda femoral artery (PFA) puncture is generally fraught with risk of bleeding and iatrogenic damage, leading to possible impaired flow in such a valuable artery. However, the PFA represents a potential retrograde path to the common femoral artery (CFA) due to its usual good size and convenient location. Since endovascular treatment of the CFA and its bifurcation is gaining popularity, this study intends to report the use of PFA access in complex revascularizations. Materials and Methods: This is a retrospective multicenter registry on PFA retrograde approaches, including 15 cases in which this access was used during challenging recanalizations of iliac and femoral chronic total occlusions (CTO). This access was performed as a bailout in 11 cases (73.3%). The puncture’s technical success and the diseased segments’ recanalization were achieved in all cases. Hemostasis was done by intraluminal balloon inflation (9/15, 60%), external manual compression (4/15, 26.7%), or closure device deployment (2/15, 13.3%). No complications related to the access were noted. Conclusion: This series represents the largest cohort of patients who underwent retrograde PFA puncture for iliac and femoral CTO crossing. It shows how different clinical and anatomical settings may suit this endovascular approach, making it a safe alternative that vascular specialists should be aware of. Clinical Impact Retrograde puncture of the profunda femoral artery (PFA) could represent a strategic approach during complex iliac and femoral endovascular revascularizations and total endovascular femoral reconstruction. This article presents 15 cases of PFA retrograde puncture and conveys technical tips for performing this maneuver correctly and avoiding potential risks at the level of this vessel. Surgeons and interventionalists should be aware of this possibility, especially with the increasing number of total endovascular treatments of the femoral bifurcation.

Endovascular stenting has emerged as the gold standard for treating various occlusive vascular disorders. However, it has its own challenges. Reperfusion injury, a paradoxical tissue damage that occurs after the restoration of blood flow, is one such challenge seen with endovascular interventions. This case series presents three instances of reperfusion injury involving the carotid, superior mesenteric, and renal arteries following stenting procedures. Timely management with targeted interventions, including coil embolization and hemodynamic stabilization, was crucial in mitigating adverse outcomes. By examining these cases, this series highlights the importance of increased awareness, early recognition, and targeted interventions in order to optimize patient outcomes. Clinical Impact Reperfusion injury after endovascular stenting is a serious but often overlooked complication that can lead to life-threatening consequences. This case series highlights the need for early recognition, careful blood pressure control, and prompt intervention to prevent complications. By examining cases involving the carotid, renal, and superior mesenteric arteries, we emphasize the importance of close post-procedure monitoring and tailored treatment strategies. Raising awareness about this issue and developing better management guidelines can improve patient outcomes and make vascular interventions safer. Our findings reinforce the need for vigilance and proactive care in endovascular treatments.

Purpose: To investigate the stroke risk factors following thoracic endovascular aortic repair (TEVAR) with a single-branch stent graft. Materials and Methods: We retrospectively analyzed 128 patients of acute aortic syndromes with inadequate proximal landing zones (PLZ) who underwent TEVAR from September 2019 to December 2023. Patient survival was evaluated using the Kaplan–Meier method, and the relationship between subclavian artery patency and stroke incidence was determined through Cox regression analysis. Results: Technical success rates for aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) were 98.3%, 100%, and 100%, respectively. There were no significant differences in surgery duration, hospital stay, stent length, and oversize across the groups. Over an 18-month follow-up, there were no significant differences in mortality, stroke incidence, or re-intervention rates among the groups. The rates of stroke post-treatment were 4.9% for AD, 11.8% for IMH, and 12.0% for PAU. Notably, subclavian artery stenosis increased the stroke risk by 37.94 times (hazard ratio, 37.94; 95% CI: 4.76–302.35; p < 0.001). Female patients had a 16.57-fold increased risk of stroke (hazard ratio: 16.57; 95% CI: 1.00–272.88; p = 0.049). In addition, each standard deviation increase in operation time raised the stroke rate by 1.03 times (hazard ratio: 1.03; 95% CI: 1.001–1.05; p = 0.003). Subclavian artery stenosis also significantly increased the risk of re-intervention by 44.14 times (hazard ratio: 44.14; 95% CI: 7.50–259.73; p < 0.001), with significant differences in re-intervention rates among the 3 groups, notably improved in the PAU group compared to the AD group (hazard ratio: 3.60; 95% CI: 1.01–12.82; p = 0.042). Conclusion: This study underscores the critical importance of maintaining subclavian artery branch patency post-TEVAR to mitigate stroke and re-intervention risks. Clinical Impact This study comprehensively investigates the risk of stroke following the reconstruction of subclavian artery branches during thoracic endovascular aortic repair (TEVAR). While previous literature has extensively documented stroke rates associated with the coverage of subclavian artery branches post-TEVAR, reports on stroke following single-branch stent placement are relatively scarce. By analyzing data from patients with inadequate proximal landing zones who received a single-branch stent, this study identifies potential risk factors for stroke and provides a new perspective on postoperative complications specifically related to subclavian artery reconstruction. Our findings significantly contribute to the literature by offering a novel approach to understanding complications after TEVAR, enhancing the precision of risk analysis for postoperative complications.

Background: This meta-analysis aimed to compare postoperative outcomes between endovascular and surgical revascularization of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR). Methods: We performed a comprehensive search of the MEDLINE and EMBASE databases through February 2024. Pooled results were calculated, and subgroup analyses focused on the chimney technique for LSA revascularization. Kaplan–Meier curves for mid-term all-cause mortality were reconstructed by extracting time-to-event data from the included studies. Results: Twelve nonrandomized studies, including a total of 4158 patients, were analyzed. Procedural duration was significantly longer in the surgical revascularization cohort (p < 0.01). No statistically significant differences were found in other short-term outcomes between the 2 groups. However, subgroup analysis of studies focusing on the chimney technique showed that surgical revascularization was associated with a significantly lower rate of postoperative endoleak [odds ratio; OR (95% confidence interval; CI) = 0.17 (0.06–0.49), p < 0.01]. For mid-term outcomes, there were no significant differences in mortality [hazards ratio; HR (95% CI) = 1.25 (0.71–2.22), p = 0.44], aortic re-intervention rate [HR (95% CI) = 1.10 (0.49–2.47), p = 0.81], or LSA patency rate [HR (95% CI) = 1.24 (0.40–3.89), p = 0.71] between the 2 strategies. The follow-up endoleak rate tended to be lower in the surgical revascularization group [HR (95% CI) = 0.50 (0.24–1.03), p = 0.06], with a more pronounced trend in the subgroup analysis of studies exclusively employing the chimney technique [HR (95% CI) = 0.33 (0.10–1.02), p = 0.05], though the differences were not statistically significant. Reconstructed Kaplan–Meier curves for all-cause mortality indicated no significant difference in mid-term survival between the groups [HR (95% CI) = 0.94 (0.74–1.19), p = 0.60]. Conclusions: This meta-analysis reveals comparable postoperative outcomes between surgical and endovascular LSA revascularization in patients undergoing TEVAR. However, the chimney technique was associated with a higher rate of postoperative endoleak. Clinical Impact This meta-analysis provides insights into the comparative effectiveness of surgical versus endovascular left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR). While both techniques demonstrated comparable short- and mid-term outcomes, the chimney stent-graft technique showed a higher incidence of postoperative endoleak, suggesting a need for careful patient selection and follow-up. These findings will guide clinicians in optimizing LSA revascularization strategies and balancing procedural risks with postoperative outcomes in patients requiring LSA coverage during TEVAR.