Emergency Endovascular Repair Research Articles

Urgent or Emergent Endovascular Aortic Repair of Infective Aortitis.

Background: Aortitis is a rare inflammation of the aorta. It can be classified as infective, non-infective, or idiopathic. Infective aortitis can debut as an acute aortic syndrome that needs urgent or emergent treatment. Historically, these kinds of patients have been preferably treated by open surgery, with subsequent lack of information about the endovascular repair. The aim of the present study is to report the results of our experience with the urgent or emergent endovascular repair of infective aortitis with acute presentation. Methods: All consecutive urgent or emergent endovascular repairs, performed between January 2019 and January 2024 for the treatment of infective aortitis, were included. The inclusion criteria were clinical, laboratory, and radiological findings recognized as aortitis risk factors. Patients with graft or endograft infection, aortic fistulae, and mycotic aneurysm were excluded. Primary endpoints were technical success and 30-day and follow-up survival. Early and late major adverse events, any changes in lesion morphology over time, and need for re-intervention were also assessed. Results: A total of 15 patients (14 males and 1 female) with a mean age of 74.2 ± 8.3 were included. All the subjects were treated by endovascular means in an urgent or emergent setting because of a rapidly growing aneurysm, symptomatic lesion, or contained or free aortic rupture. The diagnosis of infective aortitis was confirmed postoperatively by positive blood cultures in all the patients. A rapidly growing or symptomatic lesion was noted in all 15 subjects. Among these there were six (40%) contained and two (13%) free aneurysm ruptures. The endovascular techniques performed were as follows: four thoracic-EVAR (TEVAR), three off-the-shelf branched-EVAR (BEVAR), one Chimney-EVAR (Ch-EVAR), six EVAR with bifurcated graft, and one EVAR with straight tube graft. Technical success was achieved in 100% of the patients. Two patients (13%) died within 30 days after the index procedure. No case of early aortic-related mortality was registered. During a mean follow-up of 31.6 ± 23.1 months (range 1-71), no further death or major adverse event was registered among the remaining 13 alive patients. Re-interventions were performed in three cases (20%). Aneurysm's shrinkage > 5 mm or stability was noted in 10 of the 13 patients who survived the early period after repair. Conclusions: Despite the relative reluctance to use an endograft in an infected area, in our experience the endovascular approach resulted to be feasible, safe, and effective in the treatment of infective aortitis with acute presentation, with acceptable peri-operative and mid-term follow-up outcomes. Further studies are needed to confirm our results.

Impact of Neck Morphology on Outcomes of Emergent Endovascular Abdominal Aortic Aneurysm Repair

Impact of Neck Morphology on Outcomes of Emergent Endovascular Abdominal Aortic Aneurysm Repair

Emergency Endovascular Repair of a Right Axillary Artery Injury with Viabahn Stent Grafting after Proximal Humeral Fracture

Emergency Endovascular Repair of a Right Axillary Artery Injury with Viabahn Stent Grafting after Proximal Humeral Fracture

Oversizing Consideration of Proximal Stent Graft in Hemodynamically Stable and Unstable Patients Undergoing Emergent Endovascular Aortic Repair

Consideration for oversizing the proximal stent graft is suggested in endovascular aortic repair. However, a special recommendation for the proximal oversizing ratio (OSR) in patients with ruptured abdominal aortic aneurysm (rAAA) is ambiguous. This study aims to evaluate the effect of different degrees of the proximal oversizing ratio (OSR) on risk of type IA endoleak (TIAEL) in hemodynamically stable and unstable patients with rAAA undergoing emergency endovascular aortic repair (EVAR). Our study included 134 rAAA patients undergoing emergent EVAR, and we did not observe a significant association between hemodynamic instability and risk of T1AEL (HR 3.89, 95%CI 0.40–37.75, p = 0.24). All three T1AELs in the hemodynamically unstable subgroup were observed in patients with OSR ≤ 30%, but no significant difference was found regarding T1AEL between patients with OSR > 30% and OSR ≤ 30% (0.00% vs. 11.11%, p = 0.19). As for hemodynamically stable patients, OSR > 20% was associated with a significantly decreased risk of T1AEL (HR 0.03, 95%CI 0.01–0.53, p = 0.016). In conclusion, a proximal OSR > 20% is associated with a decreased risk of T1AEL in hemodynamically stable patients, while an OSR > 30% did not add an additional advantage of lowering the risk of T1AEL in hemodynamically unstable patients.

Emergency endovascular repair for endoleak with rupture after frozen elephant trunk for type A aortic dissection

Emergency endovascular repair for endoleak with rupture after frozen elephant trunk for type A aortic dissection

Integration of a Custom-Made Fenestration to Simplify Acute Reno-Visceral In Situ Aortic Repair.

To illustrate the technique of antegrade in situ laser fenestration (ISLF) on a predesign custom-manufactured stent-graft with single reinforced fenestration for use in emergency endovascular repair of complex abdominal aortic aneurysms (AAAs). A short custom-made device (CMD) fenestrated graft was predesigned with a single preloaded 8 mm strut-free fenestration at 12 o'clock position. A modified preloaded system was used to allow unilateral access from the distal port if necessary. After bilateral percutaneous femoral access, the graft was deployed under fusion guidance with the CMD fenestration matching the superior mesenteric artery (SMA) origin and immediately bridged as per standard technique. The aneurysm was then excluded with a bifurcated device. A large steerable sheath was used to allow for sequential antegrade laser in situ fenestration and stenting of the renal arteries. Single-vessel customized short fenestrated grafts for the SMA and antegrade in situ laser renal fenestrations are technically feasible for repair of acute complex AAAs even after previous infrarenal reconstruction. It could become an off-the-shelf solution to limit aortic coverage and reno-visceral ischemia, even in patients with a narrow aortic diameter at the renal level. Single-vessel precustomized short fenestrated grafts for the SMA combined with renal artery antegrade ISLF can be a feasible option for the acute repair of patients with complex aneurysms and a narrow aortic diameter at the reno-visceral segment. It may limit aortic coverage and reno-visceral ischemic time and also be applicable after previous infrarenal endovascular aneurysm repair (EVAR).

Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access.

To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases. Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle. Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases. A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge.

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment. we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies. the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention. RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

Postoperative Complications in Emergent vs Non-emergent Thoracic Endovascular Aortic Repair in Blunt Thoracic Aortic Injuries From the Aortic Trauma Foundation Global Registry

Postoperative Complications in Emergent vs Non-emergent Thoracic Endovascular Aortic Repair in Blunt Thoracic Aortic Injuries From the Aortic Trauma Foundation Global Registry

Endovascular Repair of Traumatic Infrarenal Aortic Injury in an 8-Year-Old.

The patient is an 8 year-old male presenting to outside facility following high-speed motor vehicle collision in which he was a restrained passenger. CT imaging at that time demonstrated a traumatic infrarenal aortic pseudoaneurysm, extensive pneumoperitoneum and free fluid, and an unstable L2 vertebral body fracture. He underwent exploratory laparotomy with small bowel resection prior to transfer. The patient was left in discontinuity and temporary closed. Vascular surgery was consulted upon arrival to tertiary care children's hospital. The decision was made to proceed with emergent endovascular repair. An aortogram confirmed the location of the aortic disruption well below the renal arteries, superior to the bifurcation. An 11 mm × 5 cm Viabahn covered stent was placed across the injury with adequate proximal and distal seal. This is a case of seatbelt-related pediatric infrarenal aortic injury in the setting of polytrauma. Endovascular repair was pursued in this damage-control setting.

Lengthwise regional mechanics of the human aneurysmal ascending thoracic aorta.

The prognosis of patients undergoing emergency endovascular repair of ascending thoracic aortic aneurysm (ATAA) depends on defect location, with root disease bearing worse outcomes than proximal or distal aortopathy. We speculate that a spatial gradient in aneurysmal tissue mechanics through the length of the ascending thoracic aorta may fuel noted survival discrepancies. To this end, we performed planar biaxial testing on 153 root, proximal, and distal segments of ATAA samples collected from 80 patients receiving elective open surgical repair. Following data averaging via surface fitting-based interpolation of strain-controlled protocols, we combined in-vitro and in-vivo measurements of loads and geometry to resolve inflation-extension kinematics and evaluate mechanical metrics of stress, stiffness, and energy at consistent deformation levels. Representative (averaged) experimental data and simulated in-vivo conditions revealed significantly larger biaxial stiffness at the root compared to either proximal or distal tissues, which persisted as the entire aorta stiffened during aging. Advancing age further reduced biaxial stretch and energy storage, a measure of aortic function, across all ATAA segments. Importantly, age emerged as a stronger predictor of tissue mechanics in ATAA disease than either bicuspid aortic valve or connective tissue disorders. Besides strengthening the general understanding of aneurysmal disease, our findings provide specifications to customize the design of stent-grafts for the treatment of ATAA disease. Optimization of deployment and interaction of novel endovascular devices with the local native environment is expected to carry significant potential for improving clinical outcomes. STATEMENT OF SIGNIFICANCE: Elucidating the lengthwise regional mechanics of ascending thoracic aortic aneurysms (ATAAs) is critical for the design of endovascular devices tailored to the ascending aorta. Stent-grafts provide a less invasive alternative to support the long-term survival of ATAA patients ineligible for open surgical repair. In this study, we developed a numerical framework that combines semi-inverse constitutive and forward modeling with in-vitro and in-vivo data to extract mechanical descriptors of ATAA tissue behavior at physiologically meaningful deformation. Moving distally from the aortic root to the first ascending aortic branch, we observed a progressive decline in biaxial stiffness. Furthermore, we showed that aging leads to reduced aortic function and is a stronger predictor of mechanics than either valve morphology or underlying syndromic disorder.

Re-hybrid thoracic stent graft implantation with total aortic arch debranching in urgent procedure: case report

INTRODUCTION: Implementation of emergency endovascular aortic repair provides an opportunity to treat complicated acute aortic syndromes involving descending aorta. CASE REPORT: A 40-year-old man with a history of aortic coarctation surgical repair as a child and an anastomosis aneurysm repair with a double endovascular stent graft implantation with hemi-arch transposition was urgently admitted with intensifying shortness of breath and hoarseness. A computed tomography study confirmed a blood leak into an aneurysm sac in proximal landing zones of implanted stent grafts (Type I endoleak). Therefore, he qualified for hybrid surgery. First, the ascending aorta brachiocephalic trunk was anastomosed with a 12 mm vascular prosthesis from an upper mini-sternotomy. In the next step, normothermic extracorporeal circulation was necessary to prevent cerebral circulation. Finally, a GORE stent graft (Gore Medical, Flagstaff, AZ, USA) was implanted with a proximal landing zone directly behind the anastomosis site of the vascular prosthesis and ascending aorta. The hospital course was uncomplicated, and the patient was discharged home 5 days after the procedure. CONCLUSIONS: Complicated aortic pathologies requiring emergent interventions can be treated by a hybrid approach utilizing multistep surgical and endovascular techniques achieving optimal results.

The management of patients with popliteal artery aneurysms presenting with acute limb ischemia

ObjectiveEndovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI. MethodsThe Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year. ResultsUrgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality. ConclusionsEndovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.

Emergent Total Endovascular Arch Repair for Contained Aortic Arch Rupture: Another Tool in the Box.

To date, emergent total endovascular aortic arch repair has not been described in the literature. We present a 67-year-old female with a poorly differentiated posterior mediastinal sarcoma. Imaging obtained was concerning for intravascular extension of the tumor into the thoracic aorta. While awaiting radiation therapy, the patient complained of worsening chest and arm pain, vital signs demonstrating tachypnea and hypoxia. Subsequent imaging revealed an increase in vascular erosion, concerning for a contained rupture, with complete obliteration of the left mainstem bronchus. The patient was emergently taken for percutaneous endovascular repair of her aortic arch. A three-vessel physician modified fenestrated graft was created and deployed with concurrent stenting of the innominate, left carotid, and left subclavian arteries. Interval computed tomography angiography revealed patency in all stented vessels, with no endoleak and no evidence of pseudoaneurysm. The patient was able to undergo chemotherapy with favorable decrease in tumor burden. Total endovascular aortic arch repair, when planned carefully, is an attractive option in high-risk patients who are otherwise not ideally suited for open total arch replacement.

A standard experiment with emergency endovascular interventions on the descending thoracic aorta

Background: Using emergency endovascular aortic repair to treat severe acute aortic disorders affecting the descending aorta is an appealing prospect. Aim: This study's objective was to evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in the management of acute surgical emergencies involving the descending thoracic aorta. Methods: The medical records of every patient who underwent TEVAR in a single centre since 2007 were retrospectively evaluated. Emergency criteria for inclusion were used to treat patients with aortic disease who had complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other symptoms calling for urgent treatment. The Society for Vascular Surgery reporting guidelines for thoracic endovascular aortic repair were used to evaluate the technical and clinical success with regard to patient mortality, survival, and re-operation rate (TEVAR). Results: In 74 cases (51.0%), emergency procedures were required, including those involving patients with traumatic aortic acute injuries (TAIs) (31.1%) and complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48). Aortic iatrogenic dissection (AID) in one case and two other fistulas following the prior stent graft were also identified as implantation's. While 2 hybrid operations required extra approaches, all procedures were performed through surgically exposed femoral arteries. The main technical success rate was 95.9%; endoleak was recorded in 3 instances. In 94.5% of cases, the main clinical success was achieved. All of the patients made it through the endovascular procedures, however one of them passed away in the hospital as a result of multi-organ failure (early mortality: 1.3%). 11 patients passed away throughout the follow-up period, which lasted 6 to 164 months (median 67). The probability of survival over one year, five years, and 10 years was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, following TAI (95.2%) compared to scAAS (63.4%), the rate of 5-year survival was significantly greater (p=0.008). One person experienced temporary para-paresis right after the operation (1.3%). Throughout the post-discharge follow-up period, no more severe stent-graft-related adverse events were reported. Conclusion: The probability of survival over one year, five years, and 10 years was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, following TAI (95.2%) compared to scAAS (63.4%), the rate of 5-year survival was significantly greater (p=0.008). One person experienced temporary para-paresis right after the operation (1.3%). Throughout the post-discharge follow-up period, no more severe stent-graft-related adverse events were reported.

Emergency Endovascular Interventions on Descending Thoracic Aorta: A Single-Center Experience.

Implementation of emergency endovascular aortic repair provides an attractive opportunity in the treatment of complicated acute aortic syndromes involving descending aorta. The aim of this study was to analyze the effectiveness of thoracic endovascular aortic repair (TEVAR) for the treatment of acute surgical emergencies involving the descending thoracic aorta. A retrospective review of the medical records of all patients undergoing TEVAR in a single center since 2007 was undertaken. Patients with the aortic disease treated on emergency inclusion criteria were complicated spontaneous acute aortic syndrome (csAAS), traumatic aortic acute injuries (TAIs), and other indications requiring emergent intervention. Technical and clinical success with patient mortality, survival, and reoperation rate was evaluated according to Society for Vascular Surgery reporting standards for thoracic endovascular aortic repair (TEVAR). The emergency interventions were necessary in 74 cases (51.0%), including patients with the complicated spontaneous acute aortic syndrome (csAAS) (64.8%; n = 48) and traumatic aortic acute injuries (TAIs) (31.1%). In addition, in one case aortic iatrogenic dissection (AID) and in 2 other fistulas after the previous stent graft, implantations were diagnosed. All procedures were done through surgically exposed femoral arteries while 2 hybrid procedures required additional approaches. The primary technical success rate was 95.9%, in 3 cases endoleak was reported. The primary clinical success occurred in 94.5%. All patients survived the endovascular interventions, whereas during in-hospital stay one of them died due to multiorgan failure (early mortality 1.3%). During the follow-up period, lasting 6 through 164 months (median 67), 11 patients died. Annual, five- and ten-year probability of survival was 86.4 ± 0.04%, 80.0 ± 0.05%, and 76.6 ± 0.06%, respectively. However, the rate of 5-year survivors was significantly higher after TAI (95.2%) than scAAS (63.4%) (p=0.008). Early after the procedure, one individual developed transient paraparesis (1.3%). No other serious stent-graft-related adverse events were noted within the postdischarge follow-up period. Descending aortic pathologies requiring emergent interventions can be treated by endovascular techniques with optimal results and low morbidity and mortality in an experienced and dedicated team.

Association Between Blood Flow Pattern and Rupture Risk of Abdominal Aortic Aneurysm Based on Computational Fluid Dynamics

This study aimed to derive a novel classification of blood flow pattern in abdominal aortic aneurysms (AAA) based on computational fluid dynamics (CFDs), and to determine the predictive value of flow patterns in AAA rupture. This was an age and sex matched case control study. Cases were identified as patients who underwent emergency endovascular or open repair due to ruptured or AAA at risk of impending rupture. Controls were age and sex matched with patients with an AAA who were asymptomatic and had a confirmed unruptured AAA from computed tomography angiography images from the same period. Classification of blood flow pattern (type I: non-helical main flow channel with multiple vortices; type II: non-helical main flow channel with single vortices; and type III, helical main flow channel with helical vortices) and haemodynamic parameters (areas of low wall shear stress [AlowWSS], aneurysm pressure drop [Δ pressure], etc) were derived from CFD analyses. Multivariable regression was used to determine independent AAA rupture risk factors. The incremental discriminant and reclassification abilities for AAA rupture were compared among different models. Fifty-three ruptured and 53 intact AAA patients were included. Ruptured AAA showed a higher prevalence of type III flow pattern than intact AAA (60.4% vs. 15.1%; p < .001). Type III flow pattern was associated with a significantly increased risk of aneurysm rupture (odds ratio 10.22, 95% confidence interval 3.43 – 30.49). Among all predicting models, the combination of AAA diameter, haemodynamic parameters (AlowWSS or Δ pressure), and flow pattern showed highest discriminant abilities in both the overall population (c-index = 0.862) and subgroup patients with AAAs < 55 mm (c-index = 0.972). Compared with AAA diameter, adding the flow pattern could significantly improve the reclassification abilities in both the overall population (net reclassification index [NRI] = 0.321; p < .001) and the subgroup of AAAs < 55 mm (NRI = 0.732; p < .001). Type III flow pattern was associated with a significantly increased risk of AAA rupture. The integration of blood flow pattern may improve the identification of high risk aneurysms in both overall population and in those with AAAs < 55 mm.

Abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysm: A case report and literature review

Background: Abdominal compartment syndrome (ACS) arises in approximately 7% after ruptured abdominal aortic aneurysm (RAAA) treatment. Decompressive laparotomy is a satisfactory way to treat ACS. The problem is deciding when to complete abdominal closure with appropriate alternative treatments.[1]&#x0D; Methods: This is a case report of successful ACS treatment following RAAA intervention at Ho Chi Minh University Hospital of Medicine and Pharmacy with a literature review.&#x0D; Clinical case: A 61-year-old male patient was hospitalized for abdominal pain. Computed tomography angiography demonstrated RAAA. He underwent the emergency endovascular repair of ruptured aneurysms (rEVAR). At 30 minutes post-intervention, the patient's abdomen was distended following intraabdominal hypertension measured via bladder catheter. Within ACS diagnosing, emergency decompressive laparoscopy was performed. The abdominal wall was left open and covered with a sterile nylon cover. The fascial closure was performed on the sixth postoperative day with the support of vacuum-assisted wound closure (VAC) and mesh-mediated fascial traction. On the 27th postoperative day, the wound could close completely, and the patient could be discharged successfully.&#x0D; Conclusion: A bladder pressure is required to monitor intraabdominal pressure postoperatively after decompressive laparotomy. Delayed fascial closure is appropriate with supporting VAC until total abdominal closure.

Totally percutaneous endovascular repair for ruptured abdominal aortic aneurysms.

The PEVAR Trial demonstrated that compared to open femoral exposure, elective percutaneous endovascular AAA repair (ePEVAR) is associated with decreased perioperative morbidity and access site complications. We hypothesized that PEVAR for ruptured AAA (rPEVAR) may also improve perioperative morbidity compared to open femoral exposure (rEVAR). There are currently no reports that evaluate the utility and outcomes of rPEVAR. From 2015 to 2021, all patients who underwent an endovascular repair of a ruptured AAA at a single institution were included in the study and grouped into rPEVAR and rEVAR. Demographics, procedural details (successful preclose technique, conversion to femoral cutdown), postoperative variables (blood transfusion, ICU and hospital length of stay) and short-term outcomes (30-day major adverse events (30-day MAE) and 30-day femoral access-site complications (30-day FAAC)) were collected and compared with 50 historical ePEVAR patients from the PEVAR Trial. Statistical significance was determined using χ 2 or Fisher's exact test for categorical variables, and Mann-Whitney U-test for continuous variables. 35 patients were identified (21 rPEVAR; 14 rEVAR), 86% were male with a mean age of 72 ± 9 years. All patients underwent emergent endovascular aortic repair with 100% technical success. Seventeen patients (49%) presented with evidence of hemorrhagic shock and 22 patients (63%) had blood transfusion. 30-day MAE occurred in 12 patients (34%) (7 rPEVAR; 5 rEVAR). There was no difference in demographic, perioperative outcomes and 30-day MAE rate between rPEVAR and rEVAR patients. Compared to ePEVAR patient (from PEVAR trial), rPEVAR patients had higher rate of 30-day MAE (34% vs. 6%; p < 0.006) but no difference in 30-day FAAC (19% vs. 12%; p = 0.54). The success rate of the preclose technique was higher in ePEVAR compared to rPEVAR (96% vs. 76%; p = 0.02), but the rate of conversion to femoral cutdown was similar between the two groups (10% vs. 4%; p = 0.57). Emergent rPEVAR appears to have similar outcomes when compared to rEVAR. Although patients undergoing rPEVAR have higher 30-day major adverse events rate compared to ePEVAR, the method of percutaneous femoral cannulation does not appear to increase the overall procedural or 30-day femoral artery access-site complications.

Successful Management of Abdominal Aortocutaneous Fistula Following Emergency Endovascular Aneurysm Repair for Aortoenteric Fistula in a Patient with Takayasu Arteritis

Aortocutaneous fistula is an extremely rare complication after aortic endograft infection. We report on the management of a patient who presented with aortocutaneous fistula following emergency endovascular aneurysm repair (EVAR) of an aortoenteric fistula (AEF). A 50-year-old female with Takayasu arteritis who had undergone thoracic endovascular aortic repair (TEVAR) for a thoracic aortic aneurysm, 23 years ago presented with a spontaneous abdominal AEF and another contained ruptured descending thoracic aortic aneurysm distal to the previous endograft. She underwent emergency bridge EVAR and redo-TEVAR. Thirteen months following EVAR, she presented with endograft infection and a spontaneous aortocutaneous fistula. She was successfully managed with an axillo-unifemoral bypass followed by EVAR endograft explantation. She was discharged on long-term antibiotics and has been symptom free for 12 months.