From Equipoise to Evidence: Pre-Trial Setup of the European Uncomplicated Type B Aortic Repair Clinical Trial.

Midterm Outcomes of Preemptive Side Branch Embolization Aimed for Total Branch Embolization During Endovascular Aneurysm Repair.

Case series report on long-term result of endovascular approach to thrombosed limb or limb graft occlusion of aortoiliac endoprosthetic stent graft using the first-order percutaneous mechanical arterial advanced thrombectomy technology protocol.

Abdominal aortic aneurysm (AAA) is less common in women than in men; however, when present, women appear to follow a more aggressive disease course, rupturing at smaller diameters and experiencing worse operative outcomes. The United Kingdom provides a unique environment in which to evaluate sex-specific outcomes, as national screening invitations are extended to men only and National Institute for Health and Care Excellence guidance applies a uniform 5.5 cm threshold for elective repair irrespective of sex. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. MEDLINE, EMBASE, and the Cochrane Library were searched to September 2025. Eligible studies reported sex-stratified outcomes for AAA in the United Kingdom. Gray literature was included through review of the National Vascular Registry, National Health Service AAA Screening Program reports, and National Institute for Health and Care Excellence guidance. Where sex-stratified numerators and denominators were available, crude odds ratios (ORs) were calculated and pooled using Der Simonian-Laird random-effects models. A separate adjusted-effects meta-analysis was performed using the generic inverse-variance method for studies reporting multivariable-adjusted ORs (adjORs). Five peer-reviewed studies met inclusion, supported by national reports. Women had significantly higher perioperative mortality after elective endovascular repair (pooled OR 1.61, 95% confidence interval [CI] 1.31-1.97) and elective open repair (pooled OR 1.37, 95% CI 1.16-1.63). After ruptured repair, mortality was similar between sexes following endovascular aneurysm repair (EVAR) (pooled OR 1.11, 95% CI 0.89-1.39), but higher in women after open surgery (pooled OR 1.53, 95% CI 1.24-1.89), although with substantial heterogeneity. Adjusted-effects synthesis confirmed higher mortality for women after elective EVAR (summary adjOR ≈1.55, 95% CI 1.25-1.80) and open repair (adjOR 1.39, 95% CI 1.25-1.56). Women were less likely to undergo surgery following rupture, more likely to be readmitted after elective EVAR, had longer hospital stays, and higher long-term aortic-related mortality. Women with AAA in the United Kingdom remain disadvantaged at every stage of care: they are less likely to be screened, rupture at smaller diameters, less often selected for repair, and when treated, face higher perioperative and long-term mortality. These disparities reflect a combination of anatomical and biomechanical differences, together with systemic factors. Current UK policy, based on male-only screening and a sex-neutral 5.5 cm threshold, does not reflect this reality. Sex-specific thresholds for repair, targeted female screening, and the development of devices optimized for female anatomy are needed to address inequity.

Complex aortic reconstruction using double-barrel frozen elephant trunks.

The endovascular treatment of pathologies of the aortic arch has become established in recent years, not only as a complementary treatment option but also as an alternative to open surgery for selected patients. The prevalence of thoracic aortic aneurysms is approximately 0.16%. In this narrative review, we present the endovascular treatment options for aortic arch disorders. The endovascular treatment of aortic arch pathologies has been evaluated to date mainly in uncontrolled, retrospective studies. A prerequisite for endovascular treatment of the aorta is the availability of an adequate landing zone in which the stent graft can be anchored both proximally and distally. Stable, asymptomatic aneurysms can be treated conservatively with frequent follow-up. Endovascular aortic arch procedures have high technical success rates (branched thoracic endovascular aortic repair: 96.3%, fenestrated thoracic endovascular aortic repair: 95.7%), a 30-day mortality of 6.3%, and a 30-day stroke rate of 9.4% (weighted average values). The endoleak rates range from 2.6% to 37.6% (weighted average, 19.6%). Especially for patients with a high surgical risk, this minimally invasive method can be used as an alternative to open surgery in specialized centers. Indications must be determined on a case-by-case basis. The published studies vary widely in case numbers and patient collectives; randomized controlled trials are lacking, as is a direct comparison with open aortic arch replacement surgery. Improvements in aortic arch prostheses enable improved, more individualized treatment; the risk profile of each patient must be considered by the interdisciplinary aorta team along with the advantages and disadvantages of the various available types of prosthesis.

Aim: Thoracic endovascular aortic repair (TEVAR) is currently the preferred treatment for different pathologies of the thoracic aorta because of its technical advantages over open surgery. This single-center study analyzes early outcomes of TEVAR with a special focus on spinal cord ischemia (SCI) and reintervention rates and their relationship to patient and procedural variables. Material and Methods: Data were retrospectively collected from patients who underwent TEVAR between February 2012 and August 2023. Patients were classified by pathology type: thoracic aortic aneurysms (n=97, 66.4%), type B aortic dissections (n=28,19.2%), traumatic aortic injuries (n=12, 8.2%), and other pathologies (n=9, 6.2%). Primary outcomes included SCI and reintervention rates at one year post-procedure; secondary outcomes included stroke, upper extremity ischemia, and 30-day mortality. The statistical analysis used univariate and multivariate logistic regression models as well as Kaplan-Meier survival analyses with subgroup comparisons between elective and urgent cases. Results: A total of 146 patients were analyzed; 79.45% were male with an average age of 63.23±12.50 years. Of this population, 121 patients (82.9%) had elective procedures and 25 patients (17.2%) had urgent/emergent procedures; postoperative spinal cord ischemia developed in 11 patients (7.5%). The stroke rate was 13.7% (n=20).The 30-day mortality rate was significantly higher in patients undergoing urgent TEVAR compared to those undergoing elective procedures (32.0% vs. 13.2%, p=0.02). TEVAR-related reintervention was required within a year for 38 patients (26%).There are no independent predictors for spinal cord ischemia; however, the multivariate analysis shows that early reintervention has a strong association with diabetes mellitus (OR 3.2, 95% CI 1.3–7.8, p=0.01), history of smoking (OR 2.1, 95% CI 1.0–4.4, p=0.05), and lesions in distal zones (OR 2.4, 95% CI 1.1–5.2, p=0.03). Urgent cases showed a trend toward higher reintervention rates compared to elective procedures (40.0% vs. 23.1%, p=0.08). Conclusion: This study demonstrates that the risk of reintervention is increased in cases with a history of diabetes mellitus, smoking, and aortic pathologies located in the distal thoracic zone. Urgent procedures carry higher morbidity and mortality risks but should be confirmed by larger randomized multicenter studies.

Aortic graft infection (AGI) is a devastating complication with high mortality and morbidity. Reported incidence is 0.5–5% after open aortic surgery and 0.5–1% after endovascular aneurysm repair (EVAR). Open surgery with aggressive debridement and, in selected cases, extra-anatomic bypass may be required. We report a woman who developed AGI nine months after aortobifemoral bypass and who was successfully treated with bilateral obturator bypass, achieving limb revascularization and infection control.

Effect of the Alto Endovascular Aneurysm Repair Device on Postoperative Large Artery Stiffness.

Type II endoleak (T2EL), the most common complication after endovascular aortic aneurysm repair (EVAR), remains a leading cause of reintervention due to persistent retrograde flow from patent inferior mesenteric artery (IMA) and lumbar arteries (LAs). The influence of specific anatomical features of these vessels on the hemodynamic environment remains poorly understood. This study evaluated two key anatomical characteristics: branch vessel count and luminal diameter. Eight post-EVAR models were constructed. Computational fluid dynamics (CFD) simulations were performed to quantify key hemodynamic parameters, including flow velocity, pressure, wall shear stress (WSS), oscillatory shear index (OSI), and relative residence time (RRT). IMA patency and an increased LA number synergistically primarily altered flow field patterns and shear stress distribution, while larger vessel diameters significantly affected flow rate, WSS directionality, and RRT. Enlarged IMA diameter combined with multiple patent LAs expanded retrograde flow regions and created high-shear-stress environments that inhibited thrombus formation, which may promote T2EL persistence and sac expansion. A risk-stratified embolization strategy was proposed: high-risk patients (IMA ≥ 2.5 mm with ≥ 2 patent LAs) should undergo embolization of IMA and LAs ≥ 2 mm; intermediate-risk (IMA 2.0-2.5 mm or ≤ 1 LA) receive IMA embolization; low-risk patients (IMA < 2.0 mm with ≤ 1 LA) require standard clinical follow-up. This study confirms that an increased number of LAs primarily alters flow field patterns and shear stress distribution within the aneurysm sac, while enlargement of branch vessel diameters elevates perfusion flow rate and pressure. These findings provide a hemodynamic basis for assessing T2EL risk.

Osteoporosis has been suggested to be associated with abdominal aortic aneurysms, yet its impact on endovascular aneurysm repair (EVAR) outcomes remains unclear. This study evaluated the impact of osteoporosis on long-term outcomes and aneurysm sac remodeling in patients undergoing EVAR. This single-center retrospective study included 119 patients who underwent EVAR between 2014 and 2018. Osteoporosis was defined as morphological vertebral compression fractures or an L1 vertebral trabecular attenuation (⩽ 110 Hounsfield units [HU]) on preoperative computed tomography. Patients were stratified into osteoporosis (O; n = 74) and nonosteoporosis (NO; n = 45) groups to compare clinical outcomes and aneurysm sac behavior. Multivariable analyses were performed to identify predictors of mortality and sac changes. The O group had a significantly higher all-cause mortality (39.2% vs 18.1%, p = 0.012) and lower 10-year survival (40.8% vs 79.5%, p < 0.05). Sac shrinkage was more frequent in the NO group (1.6 ± 8.6 vs -7.6 ± 10.3 mm, p < 0.001). Lower L1 HU was significantly associated with sac expansion. Pharmacologic treatment yielded greater sac reduction than nontreatment (-4.3 ± 2.6 vs 2.6 ± 1.0 mm, p = 0.015). Multivariable analysis identified osteoporosis, older age, and type II endoleaks as independent predictors of sac enlargement, whereas osteoporosis treatment was independently associated with sac shrinkage. Osteoporosis is associated with reduced survival and impaired aneurysm sac remodeling following EVAR. Pharmacological treatment may promote sac remodeling and improve clinical outcomes. Routine evaluation and management of osteoporosis may be important post-EVAR care strategies.

Background/Objectives: This study compared the hemodynamic performance of fenestrated (FEVAR), branched (BEVAR), and chimney endovascular aortic aneurysm repair (chEVAR) in patients with complex aortic aneurysms. Methods: The pre- (native) and post-endovascular repair (endograft-defined) blood lumen was reconstructed from computed tomography angiographies of nine (9) elective patients treated with FEVAR (n = 3), BEVAR (n = 3), and chEVAR (n = 3). Computational fluid dynamics (CFD) simulations obtained blood flow properties. Velocity magnitude, wall shear stress (WSS), time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and local normalized helicity (LNH) were computed at peak systole and mid-diastole. The hemodynamic data were statistically analyzed to evaluate correlations between FEVAR, BEVAR, and chEVAR, focusing on targeted visceral arteries. Results: Only slight differences were observed regarding RRT, OSI, and TAWSS between FEVAR and BEVAR, whereas the chEVAR group demonstrated a marked deviation from both. In FEVAR, the postoperative helical flow structures appeared more compact, while in BEVAR they were more developed and exhibited a more rotational configuration. The LNH of the visceral vessel patterns exhibited similar qualitative features across groups. Regarding TAWSS, higher values were found in BEVAR, whereas chEVAR showed the lowest. Conclusions: FEVAR, BEVAR, and chEVAR improved postoperative blood flow characteristics toward near-physiological conditions, reducing undesired flow patterns and recirculation zones. FEVAR showed more stable visceral flow, and BEVAR demonstrated higher flow rates and fewer recirculation zones, while chEVAR exhibited more streamlined visceral artery flow with reduced regurgitation at bridging stent entries. Despite variations, all approaches effectively preserved visceral artery perfusion.

Nationwide outcomes of early thoracic endovascular aortic repair for type B aortic dissection.

Background: Open thoracoabdominal aortic aneurysm (TAAA) repair for Crawford extent II aneurysms carries substantial risks. This study compares outcomes of open TAAA repair following prior thoracic endovascular aortic repair (TEVAR) with conventional open extent II repair. Patients and methods: A retrospective analysis of 91 patients (2006-2024) divided into prior TEVAR (n=29) and conventional repair Crawford extent II repair without previous TEVAR (n=62). Primary endpoints included mortality and complications; secondary endpoints assessed survival and reinterventions. This study was designed according to STROBE criteria. Results: The prior TEVAR group (n=29) had a mean age of 61.5±10.7 years and 72.4% were male, while the conventional extent II repair group (n=62) had a mean age of 63.2±9.8 years and 69.4% were male. Prior TEVAR patients underwent open repair for extent II (13.8%), III (58.6%), or IV (27.6%) aneurysms. In-hospital mortality was lower in the prior TEVAR group (6.9% vs. 25.8%, p =.07), as were rates of spinal cord ischemia (3.4% vs. 8.1%, p =.55), acute kidney injury (24.1% vs. 35.5%, p =.28), and massive transfusion (24.1% vs. 30.6%, p =.54). Pulmonary complications occurred less frequently after TEVAR (69.0% vs. 82.3%, p =.25). Kaplan-Meier analysis revealed no significant survival difference (log-rankp=.05), with 5-year survival rates of 94% (prior TEVAR) and 61% (conventional). Aortic reintervention rates were also similar (10.5% vs. 18.8%, p=.69). Conclusions: Open TAAA repair following prior TEVAR may offer clinically meaningful advantages over conventional open type II repair with acceptable survival rates; however, these findings should be interpreted cautiously given the study's retrospective design and small sample size.Staged hybrid approach could be a viable strategy for managing complex aortic pathologies.

Risk-Stratified Timing of Thoracic Endovascular Aortic Repair for Complicated Type B Aortic Dissection with Acute Limb Ischemia.

Background: Type II endoleaks (T2EL) remain the most common complication after endovascular aneurysm repair (EVAR). Aneurysm sac regression is a predictor for better treatment outcomes compared to sac stability and growth. T2EL are associated with aneurysm sac regression and prophylactic embolization of the sac or side branches may result in lower T2EL incidence. This review aims to assess the current evidence on whether prophylactic treatment strategies provide improved clinical outcomes after EVAR. Materials and methods: A systematic search was performed of the Scopus, PubMed and Web of Science databases. Original studies reporting prophylactic embolization to prevent endoleaks were included and a meta-analysis was performed on important clinical outcome parameters; T2EL incidence, sac remodelling and T2EL related reinterventions. Results: A total of 1,870 publications were identified. After screening and quality assessment by two reviewers, data were extracted from 29 studies and analysed. T2EL incidence was significantly lower in the embolization group; odds ratio 0.29 [0.19-0.45, 95% confidence interval] at 6 months, 0.20 [0.13-0.31] at 12 months and 0.28 [0.14-0.55] at 24 months. Sac growth was significantly lower in the embolization group with odds ratios of 0.08 [0.01-0.59], 0.16 [0.05-0.53] and 0.24 [0.11-0.52] at 6, 12 and 24 months, respectively. Sac shrinkage was significantly higher in the embolization group with odds ratios of 0.42 [0.28-0.63], 0.49 [0.32-0.77] and 0.28 [0.16-0.50] at 6, 12 and 24 months, respectively. Reintervention rates were lower in the embolization group, although not statistically significant. Conclusions: The results from this review and meta-analysis show that prophylactic embolization, either through non-selective sac filling or selective side branch embolization, result in better clinical outcomes at 6, 12 and 24 months. Prophylactic embolization seems promising in increasing sac regression rates and reducing T2EL incidence, but more data about other clinical outcome parameters is required.

Hypertension is a key risk factor for type II endoleaks after endovascular aneurysm repair (EVAR), but the biomechanical mechanisms linking blood pressure to outcomes are unclear. This study aimed to elucidate these mechanisms by examining how elevated branching vessel pressure affects sac hemodynamics and wall mechanics. This study constructed a type II endoleak model with a patent inferior mesenteric artery (IMA) and two lumbar arteries (LAs). The non-Newtonian fluid model and a two-way fluid-structure interaction (FSI) method were utilized to simulate the blood flow and vessel wall mechanics for type II endoleak. By setting different inlet pressures for the branching vessels, this study investigated the impact of blood pressure on the biomechanical environment following EVAR. An increase in IMA and LA inlet pressures led to a reversal of blood flow at the branch vessels and resulted in an unstable flow field within the aneurysm sac. This was accompanied by elevated wall shear stress (WSS), energy loss (EL), sac wall displacement, and Von Mises stress. The pressure within the aneurysm sac also rose correspondingly. Elevated inlet pressures in the IMA and LA lead to increased and prolonged retrograde flow into the aneurysm sac, elevate sac pressure, raise WSS and EL, and amplify wall displacement and mechanical stress-collectively intensifying hemodynamic disturbance and structural loading on the aneurysm wall.

Lower Household Income Is Associated With Higher Cardiac and Vascular Mortality After Endovascular Abdominal Aortic Aneurysm Repair.

Vascular surgery residents and fellows graduate at higher levels of proficiency in endovascular as compared to open aortic operations.

Background: Thoracic endovascular aortic repair (TEVAR) involving the left subclavian artery (Ishimaru zone 2) presents technical challenges. This multicentre study evaluates the Ankura thoracic stent graft with in-situ fenestration using a dedicated needle system (Lifetech, Shenzhen, China) for various thoracic aortic pathologies. Patients and methods: Between January 2020 and December 2025, 59 patients from three tertiary centres underwent in-situ fenestration TEVAR (if-TEVAR) for thoracoabdominal aortic pathologies. Clinical and imaging data were analysed, focusing on technical success, complications, and mid-term outcomes. Results: Demographics and comorbidities were comparable across pathologies. The SVS/AAVS age score was higher in TAAA and PAU patients (p=.005). Dissection cases required more grafts (p=.027), larger proximal diameters (p=.022), and showed less distal oversizing in TAAA (p=.031). Differences were noted in fenestration time (p=.049), stent type (p=.032), and adjunctive procedures (p<.001). Technical success was 93.2% (55/59), with no significant variation among groups. One patient died within 30 days (2% mortality). ICU/hospital stays and complications were similar. Conclusions: if-TEVAR with the Ankura graft in zone 2 is feasible with acceptable outcomes. Larger studies with extended follow-up are needed to confirm durability.