Endovascular Treatment Of Aortic Aneurysms Research Articles

Tactics for Treating Thoracic Aortic Aneurysms using Hybrid and Endovascular Techniques in Patients with Concomitant Coronary Heart Disease

The presence of ischemic heart disease (IHD) in patients with aortic dissection increases the risk of intraoperative and postoperative complications during aortic repair. Researches on the effect of IHD on the treatment outcomes of patients with type B aortic dissection have not been carried out often. Only single publications based on relatively small statistical material are devoted to this problem in the literature. The cohort of patients with aortic dissection and IHD is extremely complex, and surgical correction of this comorbid condition is still a controversial topic. The aim. To analyze the impact of IHD with prior correction of coronary artery lesions on the results of hybrid and endovascular treatment of patients with thoracic aortic aneurysms. Materials and methods. From 2017 to 2023, on the basis of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine, 245 patients with thoracic aortic aneurysm were treated using hybrid and endovascular techniques. Of these, 14 (5.7%) patients with coronary malperfusion underwent previous cor-rection of IHD either alone or in combination with prosthetics of the aortic valve, ascending aorta and arch of the aorta, initial section of the descending aorta (elephant trunk) with a good outcome. The comparison group included 30 (12.2%) patients who underwent endovascular or hybrid correction of the descending thoracic aorta without coronary pathology. Results. In the experimental group, 5 complications (42.9%) were detected (3 in the intraoperative period and 2 in the postoperative period). The frequency of complications of a similar nature in patients without concomitant IHD (com-parison group) was 13.3%. Endoleak type 1 was also dominant in this group. In most cases, it was eliminated by balloon dilatation of the stent graft. Only in 1 case, Endoleak type 1b was the reason for re-intervention with placement of an additional stent after 6 months. Conclusions. Studies show that the presence of even corrected IHD complicates the course of endovascular and hy-brid surgical treatment of thoracic aortic aneurysms, as evidenced by significantly higher rates of postoperative compli-cations, longer length of stay in the intensive care unit, as well as time on mechanical ventilation. Preliminary myocardial revascularization in patients with IHD should be one of the main conditions for the endovas-cular treatment of aortic aneurysms, taking into account the specifics of performing such operations and the possibility of fatal complications with hemodynamically significant narrowing of the coronary arteries.

Unsuspected Limitations of 3D Printed Model in Planning of Complex Aortic Aneurysm Endovascular Treatment.

Static 3-dimensional (3D) printing became attractive for operative planning in cases that involve difficult anatomy. An interactive (low cost, fast) 3D print allowing deliberate surgical practice can be used to improve interventional simulation and planning. Endovascular treatment of complex aortic aneurysms is technically challenging, especially in case of narrow aortic lumen or significant aortic angulation (hostile anatomy). The risk of complications such as graft kinking and target vessel occlusion is difficult to assess based solely on traditional software measuring methods and remain highly dependent on surgeon skills and expertise. A patient with juxtarenal AAA with hostile anatomy had a 3-dimensional printed model constructed preoperatively according to computed tomography images. Endovascular graft implantation in the 3D printed aorta with a standard T-Branch Cook (Cook® Medical, Bloomington, IN, USA) was performed preoperatively in the simulation laboratory enabling optimized feasibility, surgical planning and intraoperative decision making. The 3D printed aortic model proved to be radio-opaque and allowed simulation of branched endovascular aortic repair (BREVAR). The assessment of intervention feasibility, as well as optimal branch position and orientation was found to be useful for surgeon confidence and the actual intervention in the patient. There was a remarkable agreement between the 3D printed model and both CT and X-ray angiographic images. Although the technical success was achieved as planned, a previously deployed renal stent caused unexpected difficulty in advancing the renal stent, which was not observed in the 3D model simulation. The 3D printed aortic models can be useful for determining feasibility, optimizing planning and intraoperative decision making in hostile anatomy improving the outcome. Despite already offering satisfying accuracy at present, further advancements could enhance the 3D model capability to replicate minor anatomical deformities and variations in tissue density.

Numerical investigation of pulsed flow in aortic aneurism with and without stent by lattice Boltzmann method

Endovascular treatment of aortic aneurysms with an endoprosthesis is proposed for the prevention of the aneurysms' rupture risk and clogging of blood vessels. This paper aims to study the impact of stents with different porosities, placed in fusiform aortic aneurysms, on the hemodynamic parameters: velocity and shear rate of the flow inside the aneurysms, using pulsed boundary conditions derived from real measurements. The numerical investigations are performed with the Lattice Boltzmann method. The blood is treated as a Newtonian fluid and then as a non- Newtonian fluid with the Carreau-Yasuda and Cross models. The reduction obtained by a single stent is modest and unfavorable to thrombotic occlusion. Overlapping of several stents is proposed to promote occlusion. The results found show good agreement with medical theory.

Comparison of two percutaneous arterial closure systems used for EVAR

With the development of percutaneous endovascular surgery for the treatment of aortic aneurysms, several percutaneous systems of closure became available. The aim of this study was to compare the effectiveness and the safety of two of these systems, Manta® (Teleflex) and Proglide® (Abbott) during the endovascular treatment of aortic aneurysms.

Thoracic endovascular aortic repair: Current evidence and challenges.

In 1987 Nikolay Volodos performed the world's first endovascular treatment of aortic aneurysms. Endovascular technology has progressed significantly since then. There are now many thoracic endovascular aortic repair (TEVAR) systems commercially available. By applying them, we can treat many pathologies: aneurysms, dissections, aortic ruptures, and penetrating aortic ulcers. However, TEVAR technology still has its limitations, namely the risk of a retrograde type A dissection, the issue of precise landing in the distal landing zone, and the risk of air embolism and paraplegia. Furthermore, there are no appropriate stent grafts widely available to treat acute dissections. Those currently used are designed for aneurysms, not for dissections. As a result, there are several challenges facing the future TEVAR surgical community, such as the need to develop new and more precise systems with retrograde deployment for the distal landing zone, as well as to introduce flexible stent grafts to treat dissections. The endo-Bentall is being developed as an alternative treatment method for acute type-A aortic dissection.

High Risk of Early and Late Cardiovascular Events After Endovascular Aortic Aneurysm Repair

The objective of this population-based study was to analyze short- and long-term major adverse cardiovascular events (MACE) after endovascular repair of ruptured or nonruptured thoracic (TAA) and abdominal aortic aneurysms (AAA). Nationwide retrospective registry study including all patients who underwent endovascular repair (thoracic endovascular aortic repair, TEVAR; abdominal endovascular aneurysm repair, EVAR) for nonruptured/intact (iAAA/iTAA) or ruptured (rAAA/rTAA) abdominal or thoracic aneurysms between 2000 and 2018. The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction (MACE). There were 8,641 patients with TAA and AAA; 634 TEVAR procedures [iTAA 488; rTAA 146], and 8007 EVAR procedures [iAAA 7071; rAAA 936] were performed. MACE incidence at 90-day after TEVAR for iTAA was 10.2% and for rTAA 26.7% [HR 3.02, 95% CI 1.99-4.6]; MACE at 90-day after EVAR for iAAA was 3.7% and for rAAA 26.9% [HR 8.5, 95% CI: 7.16-10.11]. There was a higher cumulative incidence of MACE at 90-day after TEVAR for iTAA compared to EVAR for iAAA [HR 2.82, 95% CI 2.09-3.82] but no difference between the procedures after ruptured aneurysm repair. The median follow-up time was 3.28years [IQR 1.31-5.94]. There was no long-term difference in MACE between EVAR and TEVAR after ruptured [90days-5years: HR 1.14, 95% CI 0.76-1.71; 5-10years: HR 0.78, 95% CI 0.31-1.96] or intact [90days-5years: HR 1.19, 95% CI 0.97-1.46; 5-10years: HR 0.82, 95% CI 0.56-1.21] aneurysm repair. Female gender had higher long-term incidence of MACE after intact [HR 1.14, 95% CI 1.03-1.27] and ruptured [HR 1.36, 95% CI 1.12-1.65] endovascular aortic aneurysm treatment. After intact aneurysms repair; age [HR 1.05, 95% CI 1.04-1.05], history of angina pectoris [HR 1.19, 95% CI 1.08-1.32], heart failure [HR 1.90, 95% CI 1.69-2.13], and stroke [HR 1.33, 95% CI 1.15-1.53] were associated with MACE. This nationwide cohort study still demonstrated a high risk of early and late cardiovascular events after endovascular aortic repair. Comprehensive strategies for postoperative cardiovascular disease prevention may be needed here.

Treatment Site Does Not Affect Changes in Pulse Wave Velocity but Treatment Length and Device Selection Are Associated With Increased Pulse Wave Velocity After Thoracic Endovascular Aortic Repair.

Background: Endovascular treatment of aortic aneurysm is associated with an increase in pulse wave velocity (PWV) after surgery. However, the effect of different types of endovascular devices on PWV at different sites of the thoracic aorta remains unclear.Objectives: The purposes of this study were (1) to investigate the changes in PWV after endovascular treatment of thoracic aortic aneurysm; (2) to evaluate whether there is a difference in the changes in PWV at different treatment sites; and (3) to evaluate the effect of treatment length on changes in PWV.Methods: From July 2008 to July 2021, 276 patients underwent endovascular treatment of the true thoracic aortic aneurysm. Of these patients, 183 patients who underwent preoperative and postoperative PWV measurement within 1 year of surgery were included in the study. The treatment length index was calculated by treatment length divided by the height of the patients.Results: Five different types of endovascular devices were used (Najuta, Kawasumi Laboratories, Inc., Tokyo, Japan; TAG, W.L. Gore & Associates, Inc., AZ, USA; Relay, Bolton Medical, Inc., FL, USA; Talent/Valiant, Medtronic, MN, USA; and Zenith, Cook Medical, IN, USA). There was no significant change in PWV in patients receiving Najuta (Before: 2,040 ± 346.8 cm/s vs. After: 2,084 ± 390.5 cm/s, p = 0.14). However, a significant increase was observed in other devices: TAG (Before: 2,090 ± 485.9 cm/s vs. After: 2,300 ± 512.1 cm/s, p = 0.025), Relay (Before: 2,102 ± 465.3 cm/s vs. After: 2,206 ± 444.4 cm/s, p = 0.004), Valiant (Before: 1,696 ± 330.2 cm/s vs. After: 2,186 ± 378.7 cm/s, p < 0.001), and Zenith (Before: 2,084 ± 431.7 cm/s vs. After: 2,321 ± 500.6 cm/s, p < 0.001). There was a significant increase in PWV in patients treated from aortic arch (Before: 2,006 ± 333.7 cm/s vs. After: 2,132 ± 423.7 cm/s, p < 0.001) and patients treated from descending thoracic aorta (Before: 2,116 ± 460.9 cm/s vs. After: 2,292 ± 460.9 cm/s, p < 0.001). Multivariate analysis showed that treatment site was not an independent factor associated with changes in PWV. However, Najuta (Coef −219.43, 95% CI −322.684 to −116.176, p < 0.001) and treatment index (Coef 147.57, 95% CI 24.826 to 270.312, p = 0.019) were independent factors associated with changes in PWV.Conclusion: Najuta did not show a significant increase in PWV, while other commercially available devices showed a significant increase. The treatment site did not have a different effect on PWV. However, the treatment length was an independent factor associated with an increase in PWV.

Ascending Aorta and Aortic Arch - Endovascular Therapy Today and in the Future

Pathologies in the region of the aortic arch may occur in isolation, but adjacent segments of the thoracic aorta - the ascending or descending aorta - are much more commonly affected. The first surgical procedures to treat the aortic arch were performed nearly six decades ago. Despite numerous improvements and innovations in the 20th and early 21st centuries, these procedures are still associated with relevant operative mortality and neurological complication rates. Endovascular techniques and modern hybrid procedures are increasingly expanding the therapeutic spectrum in the aortic arch, although the open surgical approach is currently still the gold standard. Endovascular treatment of aortic aneurysm was first performed in the early 1990s in the infrarenal abdominal aorta. It was not long before the first attempts at endovascular therapy were made for the treatment of the aortic arch. In 1996, Inoue et al. reported the use of the first commonly used endoprosthesis to treat aneurysms in the aortic arch. Continuous improvements and refinements in implantation techniques and also implanted material have resulted in endovascular therapy now being an increasingly important option compared to open surgical procedures in the descending thoracic and abdominal aorta and has partially replaced them as the gold standard. This review article aims to provide an overview of the prerequisites, results, but also limitations of endovascular surgery of the aortic arch.

Late surgical conversion of failed Multilayer Flow Modulator stenting in thoraco-abdominal aneurysms.

The aim of this study was to report the outcomes of open or hybrid repair of failed thoraco-abdominal aortic aneurysm endovascular treatment with Multilayer Flow Modulator (MFM) stents. All patients who underwent open or hybrid repair of a failed MFM aortic treatment were retrospectively analysed. Perioperative and postoperative data, as well as midterm survival, were assessed. Between 2013 and 2020, 39 patients received an open or hybrid conversion after endovascular treatment. Five of them [13%; 4 males; median age 68 years (interquartile range 66-76)] were previously treated with aortic MFM stents (Cardiatis, Isnes, Belgium). Among these, the median interval between index repair and conversion was 84 months (interquartile range 75-84). The median aneurysm diameter was 9.6 cm (interquartile range 8-10). Renovisceral vessels steno-occlusion was highly prevalent: 2 renal arteries were occluded; 3 coeliac trunks, 2 renal arteries and 1 superior mesenteric artery had a >70% ostial stenosis. Open standard thoraco-abdominal aneurysm conversion was performed in 3 fit patients, while a hybrid approach with visceral debranching and tube endografting was performed in 2 high-risk patients. Two patients (2 open repairs) died intraoperatively, and 1 (hybrid repair) postoperatively. The 2 successfully treated patients are alive at 4- and 34-month follow-up, respectively, with patent visceral branches. Open or hybrid thoraco-abdominal aortic aneurysm treatment after failed endovascular aortic repair with MFM stents might be the only surgical option to address sac enlargements and ruptures or branch-related failures. However, both procedures had a poor prognosis due to both the impaired preoperative patient's status and the surgical complexity in the presented series.

Hybrid Operating Room System for the Treatment of Thoracic and Abdominal Aortic Aneurysms: Evaluation of the Radiation Dose Received by Patients.

In recent years, endovascular treatment of aortic aneurysms has attracted considerable attention as a promising alternative to traditional surgery. Hybrid operating room systems (HORSs) are increasingly being used to perform endovascular procedures. The clinical benefits of endovascular treatments using HORSs are very clear, and these procedures are increasing in number. In procedures such as thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR), wires and catheters are used to deliver and deploy the stent graft in the thoracic/abdominal aorta under fluoroscopic control, including DSA. Thus, the radiation dose to the patient is an important issue. We determined radiation dose indicators (the dose–area product (DAP) and air karma (AK) parameters) associated with endovascular treatments (EVAR and TEVAR) using a HORS. As a result, the mean ± standard deviation (SD) DAPs of TEVAR and EVAR were 323.7 ± 161.0 and 371.3 ± 186.0 Gy × cm2, respectively. The mean ± SD AKs of TEVAR and EVAR were 0.92 ± 0.44 and 1.11 ± 0.54 Gy, respectively. The mean ± SD fluoroscopy times of TEVAR and EVAR were 13.4 ± 7.1 and 23.2 ± 11.7 min, respectively. Patient radiation dose results in this study of endovascular treatments using HORSs showed no deterministic radiation effects, such as skin injuries. However, radiation exposure during TEVAR and EVAR cannot be ignored. The radiation dose should be evaluated in HORSs during endovascular treatments. Reducing/optimizing the radiation dose to the patient in HORSs is important.

Endovascular Treatment of High Output Heart Failure from Aortocaval Fistulas

Aortocaval fistulas are a rare cause of high output heart failure. The infrequency with which it is encountered makes these fistulas a formidable diagnostic and treatment challenge. In the absence of infection, traditional repair with open surgical approach has required in-situ graft replacement of the affected portion of the aorta with concomitant repair of the cava defect. Mortality associated with open repair is reported to be as high as 66%. Technical advances in endovascular treatment of aortic aneurysms over the past two decades are increasingly used in other large vessel pathologies. This mini-review summarizes current evidence for employing endovascular techniques for aortocaval fistulas.

Endovascular Treatment of Aortic Aneurysms with Minimalistic Approach

Introduccion: Los aneurismas de aorta siguen siendo una patologia frecuente, en especial aquellos localizados en la aortaabdominal. Desde 1990, gracias al avance en los dispositivos y las tecnicas endovasculares, la cirugia convencional ha dejadode ser la unica opcion de tratamiento. Presentamos nuestros resultados en el manejo del aneurisma de aorta con tecnicaendovascular minimamente invasiva.Objetivos: Analizar los resultados a 30 dias del implante de endoprotesis en la aorta toracica y abdominal con una estrategiaminimamente invasiva.Material y metodos: Entre marzo de 2012 y abril de 2019 se realizaron 395 implantes consecutivos de endoprotesis de aorta;en 264 (67%) de los cuales se utilizo una tecnica minimamente invasiva (MIN-A). De este grupo 240 procedimientos (90,9%)fueron llevados a cabo para reparar la aorta abdominal (EVAR) y 24 (9,1%) la aorta toracica (TEVAR).Resultados: De 264 pacientes se logro exito tecnico (ET) del implante en el 99,6% y exito clinico (EC) en el 97,7%. La mortalidada 30 dias fue del 1,1% dado por neumonia, insuficiencia cardiaca y EPOC. Ningun paciente presento IAM, ACV o necesito deconversion a reparacion quirurgica de urgencia. El tiempo promedio del procedimiento fue de 62 minutos (SD ± 17). Algunospacientes requirieron conversion a cierre quirurgico del acceso [20 (7%) durante los primeros 100 casos, y 7 (3%) en los ultimos164 pacientes p = 0,05)]. El sangrado mayor que requirio transfusion fue del 1,1%. El tiempo promedio para la deambulacionfue de 18 horas (SD ± 10), que luego de los primeros 100 pacientes disminuyo en forma significativa a 13 horas (SD ± 2,9 p =0,05). La estadia hospitalaria en promedio fue de 1,4 dias (SD ± 1,14) con 5 casos externados el mismo dia del procedimiento.Conclusiones: Los procedimientos de reparacion endovascular de aneurismas de la aorta con una estrategia miniinvasivafueron factibles y seguros, ya que permitieron convertir estos procedimientos en abordajes percutaneos, con bajas tasas decomplicaciones asociadas al acceso, menor tiempo quirurgico, rapida deambulacion y menor estadia hospitalaria, sin modificarla seguridad global del procedimiento. La curva de aprendizaje permitio bajar la tasa de conversiones a cirugia, asi como lostiempos de deambulacion.

Technical Success of Percutaneous Closure Devices in Endovascular Treatment of Aortic Aneurysms and Aortic Aneurysm Ruptures: A Systematic Review and Meta-Analysis

Endovascular aneurysm repair has become the mainstay of repair for both abdominal and thoracic aortic aneurysms across the globe, with possibility of both cutdown and total percutaneous procedures available. Percutaneous approaches along with percutaneous closure (Perclose; Abbott Vascular, Santa Clara, Calif) devices have been shown to improve patient outcomes in regard to pain, duration of hospitalization, and risk of complications. It is therefore of interest to understand the ease of use and success rate of these closure devices after abdominal and thoracic aortic aneurysmal repair.

Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair

ObjectiveThe objective of this study was to evaluate the performance of percutaneous femoral access with large-bore sheaths (>21F outer diameter) mainly employed for thoracic and thoracoabdominal aortic endovascular treatment and to stratify the outcomes on the basis of the introducer size. MethodsBetween December 2015 and December 2018, all consecutive patients who received endovascular repair through a percutaneous approach with a suture-mediated vascular closure device (VCD) and the preclose technique were included in a retrospective single-center study called Totally Percutaneous Approach to Endovascular Treatment of Aortic Aneurysms (PEVAR-PRO). The morphologic characteristics of the access vessels and patients' demographics were recorded, and 30-day closure success was defined as the primary end point. Analysis of the closure success comparing large-bore sheaths vs small-bore sheaths (≤21F outer diameter) was performed after 1:1 propensity score matching of preoperative confounding variables. ResultsThe closure success rate of the entire study cohort was 94% (622 femoral accesses in 360 patients; median age, 74 years; 84% male). Univariate analysis identified eight different factors associated with failure, but only two remained significant on multivariate analysis: diabetes (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .011) and common femoral artery stenosis >50% (OR, 4.5; 95% CI, 1.3-13.7; P = .019). After propensity score matching (1:1, 172 femoral accesses per group), closure success rate was not significantly different between large-bore and small-bore sheaths (90.7% vs 93.0%; P = .43). Multivariate analysis of the large-sheath group identified two factors associated with failure: small (<9 mm) femoral arteries (OR, 6.9; 95% CI, 1.5-31.6; P = .13) and access vessel calcifications involving more than one-third of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P = .002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay. ConclusionsOff-label use of VCDs and the preclose technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.

Infrarenal Abdominal Aortic Aneurysm Endovascular Treatment: Long-term Results From a Single-Center Experience in an Unselected Patient Population

The aim of the present study was to evaluate early-, mid-, and long-term outcomes in an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) with different commercially available off-the-shelf devices. A retrospective study was conducted on a prospectively compiled computerized database on patients presenting an infrarenal AAA treated between January 2008 and December 2015 in a high-volume Italian tertiary referral Center. Demographic, clinical, and specific morphological features were considered as potentially influencing the outcomes and the type of the implanted device. Outcome measures were procedure-related reintervention, AAA-related, and all-cause mortality rates at 30-day, 12-month, and long-term follow-up. Reinterventions considered for the analysis were AAA rupture, graft infection, type I or III endoleaks, type II endoleaks with sac enlargement > 5mm, graft stenosis or occlusions, procedures related to renal or visceral ischemia, and reintervention for access vessel injury. Of 498 EVAR procedures performed for elective infrarenal AAA treatment during the entire study period, 479 patients were enrolled, the mean age was 73.5±7.34years (range 51-91), and 416 (86.84%) were men. The mean maximum AAA diameter was 52.02±8.04mm (range 39-90.2), a maximum AAA diameter ≥59mm was recorded in 107 patients (22.33%), and an aortic neck length was <10mm in 137 (28.60%). Technical success was achieved in all patients. At a mean follow-up of 52.97±26.16months (range 1-120), overall reintervention and death rates were 8.14% and 20.04%, respectively, without AAA-related deaths. At univariate analysis, hypertension was the only demographical variable found to be associated with higher risk of reintervention, P=0.04 (OR: 2.34; CI 95%: 1.00-5.42). Furthermore, male sex (P=0.02; OR: 2.62; CI 95%: 1.09-6.27) and chronic renal insufficiency (P=0.003; OR: 2.08; CI 95%: 1.27-3.42) were associated with higher mortality rates. AAA diameter ≥59mm was statistically associated with a higher rate of both reintervention and mortality: P<0.001 (OR: 9.05; CI 95%: 4.52-18.11) and <0.001 (4.00; 2.46-6.49), respectively. Our experience seems to suggest that EVAR could be safely and effectively performed in an unselected patients' population, with encouraging results up to a ten-year follow-up.

Cerebrovascular Complications After Upper Extremity Access for Complex Aortic Interventions: A Systematic Review and Meta-analysis

The purpose of this study was to review the risk of developing cerebrovascular complications from upper extremity access during endovascular treatment of complex aortic aneurysms. A systematic review and meta-analysis were conducted according to the PRISMA guideline. An electronic search of the public domains Medline (PubMed), Embase (Ovid), Web of Science and Cochrane Library was performed to identify studies related to the treatment of aortic aneurysms involving upper extremity access. Meta-analysis was used to compare the rate of cerebrovascular event after left, right and bilateral upper extremity access. Results are presented as relative risk (RR) and 95% confidence intervals (CIs). Thirteen studies including 1276 patients with complex endovascular treatment of aortic aneurysms using upper extremity access were included in the systematic review. Left upper extremity access (UEA) was used in 1028 procedures, right access in 148 and bilateral access in 100 procedures. The rate of cerebrovascular complications for patients treated through left UEA was 1.7%, through right UEA 4% and through bilateral UEA 5%. In the meta-analysis, we included seven studies involving 645 patients treated with a left upper extremity access, 87 patients through a right and 100 patients through a bilateral upper extremity access. Patients, who underwent right-sided (RR 5.01, 95% CI 1.51–16.58, P = 0.008) or bilateral UEA (RR 4.57, 95% CI 1.23–17.04, P = 0.02), had a significantly increased risk of cerebrovascular events compared to those who had a left-sided approach. Left upper extremity access is associated with a significantly lower rate of cerebrovascular complications as compared to right or bilateral upper extremity access.

A New technical solution in custom-made aortic stent graft for complex aortic aneurysms

Background: The endovascular treatment of aortic aneurysm with complex anatomy, requires adjunctive procedures for anchoring, sealing and visceral arteries perfusion, with increase of morbidity and mortality. A new custom-made Aortic Stent Graft (ASG) platform, the Dominus (Braile Biomedica®, Sao Jose do Rio Preto, Brasil) modified on the design of Endovsmarts.r.l.™ (Bergamo, Italy), based on the principle of the radial force modulation, is available in the market, simplifying the procedure. The study focuses on device design, technical features and results. Methods: We treated 4 patients: 2 with abdominal aortic aneurysm and 2 with thoraco-abdominal aortic aneurysm, previously rejected by the others manufacturers, due to at least one of the following anatomical complexities: 78° aortic arch angle, 30° descending thoracic aorta angle, 40 mm aortic diameter at the level of renal arteries, 90° alfa angle, 60° abdominal aortic angle, and 6 mm iliac access diameter. The primary endpoints were 30-day clinical and technical success. The follow-up was made by physical examination and computed tomography angiography at 1,3,6 months and then yearly. Results: The thirty-day clinical and technical success was 100%. There was not any neurologic event. The mean fluoroscopy time, contrast medium volume and, time of procedure, were respectively 17.2 min, 300 ml, and 228 min. In 1 case occurred the postoperative laceration of the external iliac artery, treated by a covered stent. Themean time of hospitalization was4.4 days. During the 16 months median follow-up the patients were well and the computed tomography angiography confirmed the exclusion of the aneurysms and supraortic and abdominal visceral arteries patency. Conclusions: In this preliminary experience, the new Dominus ASG platform allowed the effective endovascular exclusionof complex aortic aneurysms, otherwise un-treatable with the current available devices. More cases and longer follow-up are required for validating these encouraging outcomes.

Endovascular Treatment of Aortic Aneurysms with Complex Proximal Anatomy

Endovascular Treatment of Aortic Aneurysms with Complex Proximal Anatomy

Three-dimensional Ultrasound Volume Measurements in an Aortic Aneurysm Model

Measuring the aneurysm sac’s size is vital in postoperative surveillance following endovascular treatment of aortic aneurysms. A three-dimensional ultrasound technique may enable accurate volume measurements. However, there is no validation of any commercially available electro-mechanical 3D ultrasound equipment or of the software used when measuring the volume of the aortic aneurysm sac. This investigation used a phantom model to study a three-dimensional ultrasound technique on aortic aneurysm sac volume measurements. High volume measurement accuracy indicates that this method may be useful for postoperative surveillance following endovascular aortic aneurysm operations. These results must be confirmed in clinical studies.

Aortic aneurysm endovascular treatment with the parallel graft technique from the aortic arch to the iliac axis.

The chimney technique has been developed for the treatment of complex aortic aneurysms. We analyzed the midterm to long-term outcomes of this approach from a single-center experience. From October 2008 to July 2016, 58 patients underwent endovascular aortic aneurysm repair using the chimney technique. Indications for treatment were thoracic aortic aneurysm (TAA) (N.=11), thoracoabdominal aortic aneurysm (TAAA) (N.=2), pararenal aortic aneurysm (PAAA) (N.=15), aortoiliac/isolated hypogastric artery aneurysm (N.=25), type I endoleak after previous TEVAR/EVAR (N.=4), proximal pseudoaneurysm after AAA open repair (N.=1). Elective (82.8%) and emergent (17.2%) procedures were included. The immediate technical success was 100%. Single, double and triple chimneys were performed in 46, 10, and two patients, respectively. Overall, 61 target vessels (three left common carotid arteries, eight left subclavian arteries, three celiac trunks, three superior mesenteric arteries, 19 renal arteries and 25 hypogastric arteries) were involved. Postoperative mortality was 0. No neurologic complications were registered. Primary patency rate of the chimney stent/stent graft was 98.3%. Low-flow type I endoleak was observed in four patients (6.9%). Postoperative chimney graft re-intervention rate was 1.7%. The median follow-up was 32±20 months (range 3-96 months). Overall estimated survival at 12, 50, and 80 months was 100%, 89% and 44%, respectively. Estimated freedom from endoleak at 1, 12, 24, and 36 months was 96.5%, 95%, 95%, and 93%, respectively. One hypogastric artery stent-graft occluded at the 3rd month of follow-up. No reintervention was performed. Our experience with the chimney technique for aortic aneurysms from the aortic arch to the iliac axis shows promising and durable mid- and long-term results. Endograft oversizing, associated with the chimney graft diameter and length choice remain fundamental to reduce the risk of the most frequent procedure complications: type I endoleak and CG occlusion. The wider use of this technique should be justified in patients considered at high risk for open repair and/or not suitable for the custom-made branched/fenestrated endografts.