Endovascular Abdominal Aortic Repair Research Articles

Endovascular aortic repair in patients with Marfan and Loeys-Dietz syndrome is safe and durable when employed by a multi-disciplinary aortic team.

The aim of this study was to report on mid-term outcomes after endovascular aortic repair (EVAR) in patients with Marfan (MFS) or Loeys-Dietz (LDS) syndrome. We analysed data from 2 European centres of patients with MFS and LDS undergoing EVAR. Patients were analysed based on (i) timing of the procedure (planned versus emergency procedure) and (ii) the nature of the landing zone (safe versus non-safe). The primary end-point was freedom from reintervention. Secondary end-points were freedom from stroke, bleeding and death. A population of 419 patients with MFS (n = 352) or LDS (n = 67) was analysed for the purpose of this study. Thirty-nine patients (9%) underwent EVAR. Indications for thoracic endovascular aortic repair or EVAR were aortic dissection in 13 (33%) patients, aortic aneurysm in 22 (57%) patients and others (intercostal patch aneurysm, penetrating atherosclerotic ulcer, pseudoaneurysm, kinking of frozen elephant trunk (FET)) in 4 (10%) patients. Thoracic endovascular repair was performed in 34 patients, and abdominal endovascular aortic repair was performed in 5 patients. Mean age at 1st thoracic endovascular aortic repair/EVAR was 48.5 ± 15.4 years. Mean follow-up after 1st thoracic endovascular aortic repair/EVAR was 5.9 ± 4.4 years. There was no statistically significant difference in the rate of reinterventions between patients with non-safe landing zone and the patients with safe proximal landing zone (P = 0.609). Furthermore, there was no increased probability for reintervention after planned endovascular intervention compared to emergency procedures (P = 0.916). Mean time to reintervention, either open surgical or endovascular, after planned endovascular intervention was in median 3.9 years (95% confidence interval 2.0-5.9 years) and 2.0 years (95% confidence interval -1.1 to 5.1 years) (P = 0.23) after emergency procedures. EVAR in patients with MFS and LDS and a safe landing zone is feasible and safe. Endovascular treatment is a viable option when employed by a multi-disciplinary aortic team even if the landing zone is in native tissue.

Outcomes of fenestrated endovascular abdominal aortic repair in distal entry tears of chronic debakey IIIb aortic dissection.

Currently, there have been very few reports within the literature which specifically address using fenestrated and branched stent grafts to completely isolate and repair distal entry tears of chronic DeBakey IIIb aortic dissection. This study aimed to evaluate the clinical outcomes of a 3-dimensional (3D) printed aortic model-guided fenestrated stent in the treatment of distal tears of chronic DeBakey IIIb aortic dissection after thoracic endovascular aortic repair (TEVAR). The study was a one-center retrospective study comprising 36 patients who underwent TEVAR and fenestrated endovascular abdominal aortic repair (F-EVAR) between April 2014 and December 2022. Patient data was compiled and analysed for preoperative, intraoperative, and perioperative characteristics. In total, 36 patients (12 females and 24 males) were incorporated into this study. All of the patients included in this study had hypertension, and among them, the leading cause for undergoing II-stage F-EVAR was the progression of a false lumen, accounting for 24 cases (66.7% of the total). The technical success rate was 97.2% and there were no cases of 30-day mortality, myocardial infarction, permanent paraparesis, or organ failure. One year post-F-EVAR treatment, surviving patients showed significant false and true lumen remodelling with 100% complete false-lumen thrombosis. A total of five patients died during the follow-up, two patients died related to aorta complications and three patients died of heart failure, multiple organ failure, or septic shock. II-stage F-EVAR was safe and feasible operation to repair all distal tears of chronic DeBakey IIIb aortic dissection.

Effects of abdominal aortic aneurysm on long-term survival in lung cancer patients

The major causes of death in patients with abdominal aortic aneurysm (AAA) are cardiovascular disease and cancer. The purpose of this study was to evaluate the effect of AAA on long-term survival in lung cancer patients. All patient data with degenerative type AAA and lung cancer over 50 years of age during the period 2009 to 2018 was collected retrospectively from a National Health Insurance Service (NHIS) administrative database and matched to lung cancer patients without AAA by age, sex, metastasis, and other comorbidities. Mortality rate was compared between the groups. A total of 956 AAA patients who could be matched with patients without AAA were included, and 3824 patients in the matched group were used for comparison. Patients with AAA showed higher risk of death compared with the matched cohort (adjusted hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.06–1.23, p < 0.001). When compared to a matched group of untreated AAA patients, patients with of history of AAA exhibited a significantly increased risk of overall mortality [HR (95%CI) 1.219 (1.113–1.335), p < .001, adjusted HR (95% CI) 1.177 (1.073–1.291), p = .001]. By contrast, mortality risk of AAA patients treated either by endovascular abdominal aortic repair or open surgical repair was not significantly different from that of the matched group (p = 0.079 and p = 0.625, respectively). The mortality risk was significantly higher when AAA was present in lung cancer patients, especially in patients with unrepaired AAA, suggesting the need for continuous cardiovascular risk management.

Endovascular abdominal aortic repair in a patient with common iliac artery occlusion

Endovascular abdominal aortic repair in a patient with common iliac artery occlusion

Endograft position and endoleak detection after endovascular abdominal aortic repair with low-field tiltable MRI: a feasibility study

BackgroundAbdominal aortic endoleaks after endovascular aneurysm repair might be position-dependent, therefore undetectable using supine imaging. We aimed to determine the feasibility and benefit of using a low-field tiltable magnetic resonance imaging (MRI) scanner allowing to study patients who can be imaged in both supine and upright positions of endoleaks.MethodsTen EVAR patients suspected of endoleak based on ultrasound examination were prospectively included. MRI in upright and supine positions was compared with routine supine computed tomography angiography (CTA). Analysis was performed through (1) subjective image quality assessment by three observers, (2) landmark registration between MRI and CTA scans, (3) Euclidean distances between renal and endograft landmarks, and (4) evaluation of endoleak detection on MRI by a consensus panel. Statistical analysis was performed by one-way repeated measures analysis of variance.ResultsThe image quality of upright/supine MRI was inferior compared to CTA. Median differences in both renal and endograft landmarks were approximately 6–7 mm between upright and supine MRI and 5–6 mm between supine MRI and CTA. In the proximal sealing zone of the endograft, no differences were found among all three scan types (p = 0.264). Endoleak detection showed agreement between MRI and CTA in 50% of the cases, with potential added value in only one patient.ConclusionsThe benefit of low-field upright MRI for endoleak detection was limited. While MRI assessment was non-inferior to standard CTA in detecting endoleaks in selected cases, improved hardware and sequences are needed to explore the potential of upright MRI in patients with endoleaks.Relevance statementUpright low-field MRI has limited clinical value in detecting position-dependent endoleaks; improvements are required to fulfil its potential as a complementary modality in this clinical setting.Key points• Upright MRI shows potential for imaging endoleaks in aortic aneurysm patients in different positions.• The image quality of upright MRI is inferior to current techniques.• Upright MRI complements CTA, but lacks accurate deformation measurements for clinical use.• Advancements in hardware and imaging sequences are needed to fully utilise upright MRI capabilities.Graphical

Safety, Effectiveness and Pitfalls of Carbon Dioxide Routine Use as a Contrast Agent for Endovascular Abdominal Aortic Repair

Despite the evidence of good performance, carbon dioxide (CO2) routine employment as a contrast agent for endovascular procedures is far from being adopted with its use currently limited to patients with renal impairment and known allergy to iodinated contrast medium (ICM). The purpose of our study is to evaluate the safety and effectiveness of CO2 guided endovascular abdominal aortic aneurysm repair (EVAR) in a standard population and to assess the rationale for a future widespread use. We retrospectively collected data of every patient who underwent CO2 guided standard EVAR from September 2020 to May 2021 and compared them with the data of every patient who underwent EVAR using ICM from December 2019 to August 2020 in our unit. The selection of the contrast medium was not based on any preoperative factor as the contrast medium was routinely used in every patient in both periods. The primary end point of the study was the technical success rate. Secondary end points were the early and late complication rates, radiation exposure and renal function impairment. 49 patients underwent ICM guided EVAR and 52 patients underwent CO2 guided EVAR in our unit in the time frames specified above. The technical success rate was 100% in both groups with no accidental coverage of any target vessel. Intraoperative endoleaks were observed in 14% of ICM patients and 25% of CO2 patients. The radiation exposure was higher in the CO2 group if compared to the ICM group (311.48 vs. 159.86 median mGy/cm2 - P<0.001). The incidence of postoperative acute kidney injury was low and similar in the 2 groups. No significant worsening over time of the renal function has been reported in both groups. EVAR can be safely performed under CO2 guidance without the integration of any quantity of ICM but with an increase in radiation exposure. The nephroprotective role of CO2 guided EVAR in a standard population is unclear and the same role in renal impaired patients should be validated with further studies on selected populations.

National UK Survey of Radiation Doses During Endovascular Aortic Interventions

PurposeEndovascular aortic repair (EAR) interventions, endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR), are associated with significant radiation exposures. We aimed to investigate the radiation doses from real-world practice and propose diagnostic reference level (DRL) for the UK.Materials and MethodsRadiation data and essential demographics were retrospectively collected from 24 vascular and interventional radiology centres in the UK for all patients undergoing EAR—standard EVAR or complex, branched/fenestrated (BEVAR/FEVAR), and TEVAR—between 2018 and 2021. The data set was further categorised according to X-ray unit type, either fixed or mobile. The proposed national DRL is the 75th percentile of the collective medians for procedure KAP (kerma area product), cumulative air kerma (CAK), fluoroscopy KAP and CAK.ResultsData from 3712 endovascular aortic procedures were collected, including 2062 cases were standard EVAR, 906 cases of BEVAR/FEVAR and 509 cases of TEVAR. The majority of endovascular procedures (3477/3712) were performed on fixed X-ray units. The proposed DRL for KAP was 162 Gy cm2, 175 Gy cm2 and 266 Gy cm2 for standard EVAR, TEVAR and BEVAR/FEVAR, respectively.ConclusionThe development of DRLs is pertinent to EAR procedures as the first step to optimise the radiation risks to patients and staff while maintaining the highest patient care and paving the way for steps to reduce radiation exposures.

Surgical Treatment for Branched Endograft Thrombosis of the Abdominal Aorta

Introduction. Endovascular intervention was firstly introduced for repairing aortic aneurysms in the early 1990s. The greatest advantage of endovascular aneurysm repair (EVAR) is its minimally-invasive character, thus implying shorter post-operative period. The operative mortality rate comprises 3.3 % (95 % CI 2.9–3.6); however, according to recent studies, the rate has declined to 1.4 % due to a rapid improvement in outcomes. According to the DREAM-trial, the incidence of a branched endograft thrombosis accounts for 6.4% within the first 30 days. The EVAR trial reports an incidence of 2.6% after the first year of follow-up. Stent bending and small distal aortic diameters (less than 20 mm) are believed to be the most common causes of endograft thrombosis.Aim. To identify the causes of complications following the abdominal aortic stent-graft repair and to determine the optimal treatment strategy.Materials and methods. The paper presents a case of 71-year-old patient with late complication after endovascular abdominal aortic repair of an infrarenal aortic aneurysm. The patient was admitted to the hospital on January 05, 2020 as an emergency due to the pain in the left lower limb. On December 03, 2019 the patient underwent endovascular abdominal aortic repair. Angiography of January 06, 2020 revealed thrombosis of the left branch of the stent graft. Thrombectomy of the brunched left stent graft, left iliac artery and balloon dilatation of the brunched left stent-graft were performed.Results and discussion. Endovascular abdominal aortic repair stands as the first choice for patients with appropriate aortic anatomy and those with significant comorbidity. Despite the significant progress in endovascular abdominal aortic repairing, the EVAR procedure is followed by a nearly fivefold increase in the 30-day reintervention rate as compared to open surgery which comprises 9.8 % according to the EVAR-I, and 18 %, according to the EVAR-II trials.Conclusion. Our multidisciplinary team consisted of vascular and endovascular surgeons managed to perform hybrid surgery, thus eliminating the EVAR-associated complication together with its cause.

Midterm Outcomes of Primary and Secondary Use of an Endoanchor System for Thoracic and Abdominal Aortic Endovascular Aortic Repair

PurposeTo assess the safety, technical success, and midterm outcomes of endoanchor (Heli-FX, Medtronic, Santa Rosa, California) deployment in thoracic endovascular aortic repair (TEVAR) or abdominal endovascular aortic repair (EVAR). Materials and MethodsThis single-institution, retrospective study of all endoanchor procedures was performed from February 1, 2017 to March 30, 2021. All procedures were performed percutaneously by interventional radiologists. Clinical information and outcome data were retrieved from electronic medical records. Fifty patients (14% females, n = 7; 86% males, n = 43; median age, 79 years [range, 56–93 years]) underwent Endoanchor procedures, with 349 Endoanchors implanted; 33 procedures were primary deployments (at initial stent deployment) and 17 were secondary deployments (previous stent deployment). For the primary group (4 TEVARs and 29 EVARs), indications were prophylactic (n = 30), hostile neck (n = 28), hostile distal landing zone (n = 2), and intraprocedural type 1a endoleaks (n = 3). For the secondary group (4 TEVARs and 13 EVARs), indications were graft migration (n = 8), seal zone expansion without proven endoleak (n = 7) (proximal [n = 4] or distal seal [n = 3]), and proven type 1a endoleak (n = 2). ResultsMedian number of endoanchors deployed per procedure was 7 (range, 3–10). Median time to deploy endoanchors was 22 minutes (range, 8–46 minutes). The technical success rate of Endoanchor was 99.7% (348/349). The 30-day mortality rate was 0%. The overall adverse event rate was 6% (n = 3). Reinterventions were performed in 12% of patients (n = 6). Median follow-up was 38 months (range, 2–71 months). Overall survival at 1 and 3 years was 95% and 85%, respectively. Overall freedom from type 1a endoleak at 1 and 3 years was 96% and 93%, respectively. ConclusionsEndoanchor procedures are safe with excellent technical success rate and good midterm clinical outcomes.

Combined Endovascular Treatment of Complex Aortic Pathologies.

Multisegmented aortic pathologies present challenging issues independent of the treatment chosen. Whether open or endovascular, staged, or simultaneous, every treatment modality has its own pros and cons. We revealed our patients retrospectively with early and midterm results who had simultaneous endovascular thoracic and abdominal aortic repair for thoracic aortic pathologies and infrarenal abdominal aortic aneurysm (iAAA) as a single-center experience. Between January 2016 and January 2021, 16 patients were diagnosed with thoracic aortic pathology and iAAA was simultaneously repaired in an endovascular manner. All patients were operated on with the same cardiovascular surgeon team. The average age of the patients were 76.9 ± 6.2 (64-86) years. There was no early mortality. The technical success was 100%. In total, 18 thoracic endografts were deployed in 16 patients for thoracic aortic pathologies. Follow-up period was 21.85 ± 8.96 months, and in the follow-up period, two patients had a secondary intervention. One cardiac and one coronavirus disease 2019 mortality was detected in the follow-up period. There was no aneurysm-related mortality. The postoperative first-year survival was 84.6 ± 10.0. Simultaneous endovascular solution for complex multisegmented aortic pathologies provides a rapid, less-invasive approach with successful early and midterm morbidity, mortality with short intensive care unit period, and length of hospital stay. A combination of endovascular aortic aneurysm repair and thoracic endovascular aortic repair where anatomic suitability exists is a strong alternative over staged and hybrid therapies. Contrast-induced nephropathy, postimplantation syndrome, and spinal cord ischemia should be carefully monitored with this strategy.

Intimal tear closure by false lumen stent graft placement for postdissection thoracoabdominal aortic aneurysm

We report a false lumen (FL) stent graft technique to close the intimal tears at the visceral segment for a postdissection thoracoabdominal aneurysm after initial thoracic endovascular aortic repair. Following endovascular abdominal aortic repair, a stent graft was deployed in the FL, overlapping the main bodies from both previous repairs just after a bare metal stent was implanted in the FL proximal to the target lesion to prevent overdilation. A reentry tear at the iliac level was intentionally preserved to protect spinal cord perfusion and develop a collateral network and will be closed in the future staged procedure.

Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study

Endovascular abdominal aortic repair (EVAR) is the main therapeutic option for repairing abdominal aortic aneurysms (AAA). We aimed to determine the long-term outcomes of patients who underwent EVAR at our center. In this retrospective cohort study, patients who underwent EVAR for intact isolated AAA at Tehran Heart Center between 2007 and 2017 were included. Clinical outcomes and frequency of mortality were analyzed for follow-up periods. We calculated the five-year survival rate and its predictors for our patients using Kaplan-Meier estimation. We included the data of all patients (154 patients, mean age = 70.7 [±8.0] years, 96.1% men) who successfully underwent EVAR at our center. The most common risk factors were coronary artery disease (70.1%), hypertension (68.2%), smoking (64.9%), and dyslipidemia (39.6%). There was no mortality during the procedure. The median follow-up was 65.5 months. An average decrease of 9.07 mm (95% CI: 6.9-11.2) occurred in the size of the AAA. During follow-up, 12 patients developed some complications, 49 died, and seven did not complete the follow-up. The 5-year survival was 75% (3.9%). The independent predictors for five-year survival were age (HR=1.06, P=0.002) and anemia (HR=1.91, P=0.029). Despite not being statically significant, dyslipidemia (HR=0.573, P=0.078) and long ICU/CCU stay (HR=1.08, P=0.070) were borderline mortality predictors. This study depicted an acceptable survival rate for patients who underwent EVAR at our center. age and anemia, two modifiable predictors of five-year survival, can probably prolong the survival rate of patients, which requires evaluation later.

Improved Detection of Endoleaks in Virtual Monoenergetic Images in Dual-Energy CT Angiography Following EVAR

The objective of this prospective study was to evaluate the virtual monoenergetic images (VMI) and virtual noncontrast (VNC) phase in the detection of endoleaks after endovascular abdominal aortic repair (EVAR). The potential dose reduction of abbreviated examination protocols was calculated. Ninety-seven patients after the EVAR procedure were enrolled in this study. An initial single-source noncontrast acquisition was followed by two dual-energy acquisitions (arterial and 60 s delayed). Fast-kVp switching scanner was used. VNC images were reconstructed from the delayed phase. First examination session (reference) included a full triphasic study protocol consisting of true noncontrast (TNC) images and two postcontrast phases, the latter ones presented as classical polyenergetic reconstructions. Reading sessions II and III were performed by two independent and blinded readers evaluating VMIs in abbreviated protocols-biphasic (VNC+arterial, delayed phase), monophasic (VNC+delayed phase). The diagnostic accuracy of sessions II and III was calculated. The calculated sensitivity of the biphasic protocol with the use of VMIs in endoleak detection was 100%, with a statistically significant increase in the number of endoleaks detected in comparison with the reference study. The monophasic protocol showed 83.33% sensitivity. The use of abbreviated examination protocols led to a decrease in the mean effective dose (ED) of 23.28% (biphasic protocol) and 61.37% (monophasic protocol). The use of VMIs increases the number of endoleaks diagnosed with a possible radiation reduction by up to ¼ (biphasic protocol). Further reduction to a monophasic protocol leads to over 60% dose reduction but with a decrease in diagnostic accuracy.

Randomised controlled trial to evaluate the effect of contrast material dilution on renal function in patients after endovascular aortic repair: rationale and design for the CULTURE trial

IntroductionPostoperative renal function decline is a major concern for thoracic endovascular aortic repair (TEVAR) and endovascular abdominal aortic repair (EVAR). Diluting contrast medium in the power injector may be helpful...

Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair.

The objective of this study was to investigate the mid-term outcomes of embolization procedures for type II endoleak after endovascular abdominal aortic repair, and clarify the risk factors for aneurysm enlargement after embolization procedures. This was a retrospective multicenter registry study enrolling patients who underwent embolization procedures for type II endoleaks after EVAR from January 2012 to December 2018 at 19 Japanese centers. The primary end point was the rate of freedom from aneurysm enlargement, more than 5mm in the aortic maximum diameter, after an embolization procedure. Demographic, procedural, follow-up, and laboratory data were collected. Continuous variables were summarized descriptively, and Kaplan-Meier analyses and a Cox regression model were used for statistical analyses. A total of 315 patients (248 men and 67 women) were enrolled. The average duration from the initial embolization procedure to the last follow-up was 31.6± 24.6months. The rates of freedom from aneurysm enlargement at 3 and 5years were 55.4± 3.8% and 37.0± 5.2%, respectively. A multivariate analysis revealed that a larger aortic diameter at the initial embolization procedure and the presence of a Moyamoya endoleak, defined as heterogeneous contrast opacity with an indistinct faint border, were associated with aneurysm enlargement after embolization management. The embolization procedures were generally ineffective in preventing further expansion of abdominal aortic aneurysms in patients with type II endoleaks after EVAR, especially in patients with a large abdominal aortic aneurysm and/or a presence of a Moyamoya endoleak.

Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair

Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair

Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials

Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States. We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups. The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P< .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P= .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P= .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P= .75). Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.

Abdominal aortic endograft infection. A decade of experience and literature review

IntroductionAortic endograft infection is an infrequent but life-threatening complication after endovascular abdominal aortic repair (EVAR). There is no consensus on management of endograft infection and little evidence has been published in our country. Endograft explantation is considered the “gold standar” treatment whereas percutaneous or surgical perigraft and sac drainage associated to antibiotics should be considered and alternative therapy. MethodsWe carried out a retrospective and descriptive review of abdominal aortic endograft infections at our tertiary center (Hospital Universitario Cruces) during last ten years (2010–2019). ResultsWe describe the clinical and microbiological characteristics of 10 EVAR infections, their management and outcomes. The incidence of graft infection after EVAR was 3%. The mean time to the clinical presentation of infection was 16.9 months (median 4.5 months). The microbiological diagnosis was reached in 100% of cases (predominance of gram-positive species). The overall mortality rate was 50% (although the survival rate was 100% after surgical drainage of the sac). ConclusionPerigraft or aneurysm sac aspiration culture show their diagnostic utility as microbiological diagnosis was reached in all cases despite of blood cultures being only positive in 50% of the samples. Surgical drainage and endograft preservation combined with antibiotherapy show remarkable results. The high heterogeneity in our case series makes difficult to offer general recommendations, thus far, a tailored approach to treatment is suggested.

Reversed and Antegrade Iliac Side Branch Stentgraft as an Alternative or Rescue Maneuver in Complex (Thoraco)Abdominal Endovascular Aortic Repair to Preserve Renal Perfusion

Purpose To describe a technique that can preserve renal perfusion in failed bridging stent implantation of renal arteries or as intentional procedure in emergency cases, when the (thoraco)abdominal aneurysm anatomy does not meet the criteria for instructions for use of an “off-the-shelf” graft. The technique is based on reversed or antegrade integration of a standard iliac side branch graft into the aortic stentgraft system, which allows cannulation of (accessory) renal vessels. Technique A standard iliac side branch prosthesis is deployed and re-sheathed in reversed direction on the back table. The endograft is then implanted in the unibody in analogy to an iliac limb. The iliac side branch is cannulated followed by target vessel cannulation and covered bridging stents are deployed for completion. Furthermore, an iliac side branch prothesis can also be used to preserve relevant accessory renal arteries, when implanted in delivered antegrade loading position. Conclusion The use of a reversed and antegrade iliac side branch technique to revascularize renal vessels is feasible and safe in selected patients. This technique may also allow to extend the range of an “offthe- shelf” (multibranch) stentgraft, when immediate treatment is required.

Long-Term Outcomes of Open and Endovascular Abdominal Aortic Repair in Younger Patients

Aim of this study is to evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open aortic repair (OAR) or endovascular aortic repair (EVAR) in patients under 70years of age. A retrospective analysis of a prospectively collected database of patients with age under 70years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into 2 groups: OAR and EVAR. Primary end points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications. One hundred ninety-one patients younger than 70years old treated with elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65±4years) and 34 EVAR (94% males, mean age 66±4years). Hospital stay, 30-day mortality, and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs. 2.9%; P = 0.01) while minor complications were 32% in the OAR versus 21% in the EVAR group (P = 0.08). Median follow-up was 69months for OAR (interquartile range [IQR] 53months) vs. 79months (IQR 51months) for EVAR (P = 0.9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; P = 0.01) while AAA-related long-term mortality was similar in both subgroups (1.3% OAR and 3% EVAR; P = 0.8). At univariate analysis higher risk of reintervention was reported for conical necks in the EVAR group (P = 0.03) and for the concomitant presence of iliac aneurysms in both groups (P = 0.01). According to our data, EVAR in young patients is presenting an excessive rate of reintervention compared to OAR. The presence of conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in the OAR group. Open surgery should be considered the first option in younger patients with a long-life expectancy.