Endovascular Aortic Repair Research Articles

Open Conversion After Branched Endovascular Aortic Repair With a Novel Hybrid Graft.

This technical note introduces the first open surgical conversion after a failed branched endovascular repair of a thoracoabdominal aortic aneurysm, using the new hybrid Thoracoflo device. This innovative technique reduces reno-visceral ischemia time and can be performed through a xipho-pubic laparotomy without the need for extracorporeal circulation. It offers a safe and effective solution for complex thoracoabdominal aortic diseases, and can also serve as a bailout option following endovascular failure.

Radiation Exposure from Preemptive Coil Embolization vs. Secondary Interventions for Endoleak-Induced Aneurysm Sac Growth following Endovascular Abdominal Aortic Aneurysm Repair.

Preemptive embolization of the inferior mesenteric artery (IMA) and lumbar arteries (LA) has been shown to reduce aneurysm sac growth and secondary interventions following endovascular aneurysm repair (EVAR). It is unclear if this strategy will increase radiation exposure compared to secondary interventions performed for endoleak-induced sac growth. We examined the cumulative procedural radiation exposure associated with preemptive embolization of aneurysm sac branches and compared it to that of secondary interventions. A retrospective analysis was performed on patients who underwent EVAR for non-ruptured, infrarenal abdominal aortic aneurysms (AAA) from January 2012 to December 2022, followed-up until February 2024. Procedural radiation data was collected using fluoroscopy time (mins), dose area product (DAP, μGym2), and radiation dose (mGy). Cumulative radiation exposure included preemptive embolization, EVAR, and any endovascular secondary interventions for sac growth. There were 112 patients (90 male, mean age 72.4±8.3 yrs., mean AAA diameter 58.4±12.3 mm) with available radiation data. Preemptive embolization was associated with significantly fewer secondary interventions (8/55 [14.5%] preemptive embolization only vs. 20/57 [35%] no preemptive embolization, needed secondary intervention, p=0.012). Patients were grouped as follows: Group 0 (G0) no preemptive embolization or secondary intervention (n=37), Group 1 (G1) preemptive embolization only (n=47), Group 2 (G2) secondary intervention only (n=20), Group 3 (G3) both preemptive embolization and secondary intervention (n=8). Fluoroscopy time, total DAP, and radiation dose from EVAR did not differ significantly among the four groups. Radiation exposure was significantly higher in those with secondary intervention only (G2: DAP 110,567 μGym2 ±132,296) compared to those who were preemptively embolized and still needed a secondary intervention (G3: DAP 71,566 μGym2 ±49,592, p=0.0016). This is because patients with secondary interventions only required more sessions of endovascular procedures compared to those who received preemptive embolization and still required secondary interventions (G2: 2.2 vs G3: 1.23 sessions, p<0.001). Total radiation exposure was significantly different across groups, with the highest in patients who received secondary interventions only (Group 2). Preemptive embolization of aneurysm sac branches was associated with less secondary interventions for sac growth post-EVAR. Cumulative radiation exposure in patients who received preemptive embolization was significantly less compared to that in patients who underwent secondary interventions for endoleak-induced sac growth. Preemptive embolization may mitigate secondary interventions and reduce overall radiation exposure in patients with AAA being treated with EVAR.

Endovascular Aortic Aneurysm Repair for Abdominal Aortic Aneurysm With Type V Horseshoe Kidney.

Abdominal aortic aneurysm (AAA) with concomitant Horseshoe kidney (HSK) is rare. When open surgery is not feasible, preserving the renal isthmus artery (RIA) during endovascular treatment presents a challenge. A 70-year-old male presented with a 57.8 mm × 54.3 mm AAA and type V HSK perfused by a 4.4 mm RIA from the inferior mesenteric artery and a 4.6 mm RIA from the aortic bifurcation. This case report describes an endovascular aortic aneurysm repair (EVAR) performed on an AAA coexisting with a type V HSK. One-year follow-up: the AAA had regressed, and the HSK remained perfused without any endoleak or increase in serum creatinine levels. The utilization of EVAR offers a feasible option for AAA combined with type V HSK, particularly in cases of high surgical risk. In Abdominal aortic aneurysm (AAA) with type V horseshoe kidney (HSK), preserving renal isthmus arteries (RIAs) is critical when they provide a substantial portion of the HSK blood supply.When open surgery is not feasible, preserving the RIA during endovascular treatment presents a challenge.The use of EVAR, incorporating a periscope stent and embolization, provides a viable treatment option for patients with AAA and type V HSK, especially in high surgical risk cases.

Comparison of percutaneous versus cutdown access in patients after endovascular abdominal aortic repair: a randomized controlled trial (SWEET-EVAR trial).

The optimal choice of either percutaneous or cutdown access for endovascular abdominal aortic repair (EVAR) remains uncertain due to insufficient evidence, particularly regarding patient-centered outcomes (PCOs). This study aimed at comparing both clinician-reported outcomes (ClinROs) and PCOs of percutaneous versus cutdown access in patients after EVAR. The study was a single-blind, single-center, non-inferiority, randomized controlled trial. After eligibility screening, patients diagnosed with abdominal aortic diseases were randomly assigned to either the intervention group receiving percutaneous EVAR or the control group receiving cutdown EVAR. Primary ClinRO was access-related complications, and primary PCO was time return to normal life/work. Overall, 120 patients (containing 240 accesses) were allocated to either intervention group (n =62) or control group (n =58). Percutaneous EVAR (10/124, 8.1%) was non-inferior and not superior to cutdown EVAR (17/116, 14.7%) regarding access-related complications (P =0.110; OR: 0.521, 95% CI: 0.225-1.157). As for PCOs, the recovery time back to normal life or work was superior in percutaneous EVAR compared to cutdown EVAR (16 vs. 28days, P =0.025; median difference: 7days, 95% CI: 0-13days). Moreover, percutaneous access did better in other PCOs, including a reduction in the duration of access-related pain (4 vs. 8days, P =0.001), decreased use of analgesics for access-related pain (0/61, 0% vs. 6/55, 10.9%; P =0.026), and improved quality of life scores at 2 weeks following EVAR (0.876 vs. 0.782; P =0.022). Prespecified subgroup analyses demonstrated percutaneous access significantly reduced the incidence of access-related complications compared to cutdown access in patients with thick subcutaneous tissue (1/42, 2.4% vs. 7/32, 21.9%; P =0.026). In patients without massive common femoral artery calcification, percutaneous access may accelerate postoperative recovery and enhance patient experience and quality of life following EVAR, but did not provide obvious advantages regarding access-related complications.

Thoracic Endovascular Aortic Repair for Aortic Arch Penetrating Atherosclerotic Ulcer Using Castor Single-Branched Stent-Graft With Zone 2 Landing.

This study evaluated the feasibility and safety of thoracic endovascular aortic repair (TEVAR) for aortic arch penetrating atherosclerotic ulcer (PAU) using Castor single-branched stent-graft with zone 2 landing. Between May 2020 and April 2022, a total of 25 aortic arch PAU patients were treated by TEVAR with Castor single-branched stent-graft. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and patency of left subclavian artery (LSA). All patients had aortic arch PAU with intramural hematoma (IMH). The proximal landing zone for all patients was in zone 2, which was between the distal edge of the left common carotid artery and proximal edge of LSA, in all cases. Technical success was achieved in all cases. During hospitalization after the operation, 1 patient died of gastrointestinal bleeding, and 2 patients (8.0%) had ischemic stroke. At a median follow-up of 29 months (interquartile range [IQR], 24-30 months), 2 (8.0%) patients died, including 1 ischemic stroke and 1 hemorrhagic stroke. One patient (4.0%) had reintervention owing to retrograde type A aortic dissection (RTAD) 2 months after the operation, and was successfully treated with aortic root remodeling, ascending aorta and total aortic arch replacement and frozen elephant trunk procedure. No endoleak or LSA occlusion occurred. The maximal diameter of aorta at proximal (30.2±2.4 mm vs 31.2±3.0 mm; p>0.05) and distal (25.7±2.8 mm vs 24.5±2.3 mm; p>0.05) landing zone showed no significant difference before and after the operation. The TEVAR for aortic arch PAU using Castor single-branched stent-graft is a safe and efficient option with zone 2 landing. For patients with diagnosis of PAU with IMH, TEVAR with Castor single-branched stent-graft presents low mid-term mortality and morbidity rate, which should be considered as an optimal option when proximal landing zone is insufficient and revascularization of left subclavian artery (LSA) is needed. With Castor single-branched stent-graft, LSA could be revascularized easily and accurately.

Endovascular repair of an aortic aneurysm incorporating eight branches

AbstractThoracoabdominal aneurysms with extent I and II usually represent a challenge for endovascular aortic repair, given the absent proximal landing zone for a standard thoracic endovascular aortic repair. We report a successful endovascular treatment of such an aneurysm with a staged complex repair incorporating a total of eight branches, without the need of a surgical bypass.

Roy K. Greenberg and His Work on Endovascular Aortic Aneurysm Repair.

Roy K. Greenberg and His Work on Endovascular Aortic Aneurysm Repair.

Factors Associated with Increased Fluoroscopy Time During Elective Endovascular Abdominal Aortic Aneurysm Repair and its Utilization as an Indicator of Intraoperative and Postoperative Outcomes

ObjectivesThis study explores the impact of prolonged fluoroscopy time (FT) on outcomes in endovascular aortic repair (EVAR) for abdominal aortic aneurysms (AAA). While total operative time includes multiple variables, FT precisely captures the technical precision of the EVAR procedure. By examining the factors that extend FT, we aim to establish FT as a critical quality metric for evaluating surgical performance and predicting postoperative outcomes. MethodsA retrospective review of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) was conducted (2003-2021). The FT was studied based on a median dichotomy of ≤18 mins (Group I) and >18 mins (Group II). Primary outcomes of in-hospital mortality and discharge status were studied, along with numerous secondary outcomes pertaining to systemic complications. Factors associated with more extended FT were also measured. All the variables examined in multivariate analyses were estimated in odds ratios, and a p-value of <0.05 was deemed significant for all the analyses performed. Results41,841 patients were studied, of which 20,339 were categorized in Group I and 21,502 in Group II. The average fluoroscopy time in the selected patients was reported to be 23.2 minutes. Patients in Group II generally had overall poorer health status with multiple comorbidities and on various medications. Aortic aneurysm parameters can influence the FT, including the greater aorta-neck angle, neck angle, neck diameter, and neck length. Patients treated by high-volume surgeons were observed to have less likelihood of prolonged FT. On trends analysis, it was observed that the FT has been consistent over the study period. ConclusionVarious factors can influence the FT in patients undergoing EVAR, including the patient characteristics and the complexity of the aneurysm. Identifying the risk factors associated with prolonged FT can help prepare the surgeons and devise ways to ensure a high quality of care, better risk stratification, and enhanced safety, especially for more prolonged exposure to radiation and contrast volumes.

Evaluating the Proposal of the European Society for Vascular Surgery Abdominal Aortic Aneurysm Guidelines to Stratify Surveillance after Endovascular Aortic Aneurysm Repair in a Single Centre.

The aim of this study was to evaluate and compare methods that identify patients at low risk of developing complications after endovascular aortic aneurysm repair (EVAR) and thus would not require surveillance in the first post-operative years. This was a retrospective, single centre, cohort study including all patients after elective infrarenal EVAR with both immediate post-operative and one year computed tomography angiography (CTA) imaging. Patients were categorised by adherence to instructions for use (IFU), adequate seal, and absence of endoleak (method A1), and without high risk features (method A2) on the first post-operative CTA. Additionally, these patients were dichotomised based on aneurysm sac shrinkage at one year (> 5 mm maximal diameter reduction, method B). Outcomes were graft related adverse events and all cause death. Negative predictive value (NPV) was utilised to compare risk classifications. Of 422 eligible patients, 297 underwent the required imaging for classification: 140 (47.1%) and 109 (36.7%) patients were classified as low risk based on methods A1 and A2, respectively, while 147 (49.5%) were assumed low risk based on method B. The five year cumulative incidence of adverse events in low risk patients according to method A1 was 14.6% (95% confidence interval [CI] 8.5 - 20.9%), similar to method A2 (16.1%, 95% CI 8.8 - 23.4%) and method B (15.4%, 95% CI 9.3 - 21.5%). The five year median NPV for adverse events of method A1 was 85.2% (95% CI 79.7 - 90.8%), comparable with method A2 (83.8%, 95% CI 76.9 - 90.3%; p = .37) and method B (84.7%, 95% CI 79.4 - 89.5%; p = .87). Significantly higher NPVs were found by combining method A1 or A2 with method B, with median values ≥ 95% up to four years after EVAR. The five year NPV for death did not differ between methods (five year NPVmethod A1, 81.7%, 95% CI 76.6 - 86.5%). Refraining from imaging in the first five years after EVAR in patients treated within IFU and with a favourable post-operative CTA would have failed to detect important complications at an early stage. It is proposed to combine the post-operative CTA and sac shrinkage at one year in order to stratify post-EVAR surveillance. No benefit was found in considering the high risk features suggested in the European Society for Vascular Surgery (ESVS) guidelines.

Open thoracic aortic aneurysm sac exploration following thoracic endovascular aortic repair and fenestrated branched endovascular aortic repair: New hybrid approach to fixing the Achilles heel of endovascular repair, while raising new questions.

Open thoracic aortic aneurysm sac exploration following thoracic endovascular aortic repair and fenestrated branched endovascular aortic repair: New hybrid approach to fixing the Achilles heel of endovascular repair, while raising new questions.

Evolving Practices of Spinal Drain Use for Branch/Fenestrated Endovascular Aortic Repair Patients in the United States Aortic Research Consortium.

The utilization of cerebrospinal fluid drains (CSFD) for the prevention or mitigation of spinal cord ischemia (SCI) is a subject of debate for patients undergoing branch/fenestrated endovascular aortic repair (B/FEVAR). We sought to evaluate the practices surrounding CSFD use concurrently with rates of SCI occurrence, recovery, and CSFD complications in the United States Aortic Research Consortium (US-ARC). We conducted a retrospective analysis of the US-ARC registry consisting of patients undergoing B/FEVAR under individual physician-sponsored investigational device exemptions from January 2011 to April 2024. A composite variable consisting of SCI, major CSFD complication, or intracerebral hemorrhage was designated as the primary outcome. Patterns of CSFD use, rates of SCI and recovery, and CSFD complications were analyzed by year. Subanalyses were stratified by Crawford extent (CE) classification based on the length of aortic coverage, with high-risk patients defined as CE I-III. To further characterize the relationship between SCI and CSFD use, patient cohorts were compared by prophylactic CSFD (pCSFD) (n=949), therapeutic CSFD (tCSFD) (n=27), and no CSFD(n=1609). Multivariable logistic regression was performed to determine variables associated with the composite outcome. Survival analysis was conducted using the Kaplan-Meier method. Among 2,585 patients, 196(7.6%) experienced the composite outcome, gradually declining from a maximum of 25.0%(5 patients) in 2011 to 2.9%(11 patients) in 2023. Concurrently, the use of pCSFDs declined from a maximum of 100% in 2011 to 11.0% in 2023 without any substantial increase in tCSFDs. In high-risk patients (n=1026), 132(12.9%) experienced the primary composite outcome, declining from a maximum of 38.5% (5 patients) in 2013 to 3.1%(4 patients) in 2023. PCSFDs in high-risk patients, while nearly universal(92.9-100%) until 2016, have also been on a continuous decline, reaching a minimum of 23.1% in 2024, without increase in tCSFD use(0-5.9%). The degree of SCI resolution was not significantly different in the pCSFD(94 patients, 45.7% complete resolution), tCSFD(23 patients, 43.5% complete resolution) or no CSFD(21 patients, 42.9% complete resolution) cohorts(p=0.11). Major CSFD complications did not differ between the pCSFD and tCSFD cohorts(13.4% vs 12.0%, p=0.85). Multivariable logistic regression revealed CE II(OR 2.35 (1.48-3.75), p<0.001) and III(OR 2.11(1.31-3.40), p=0.002), staging(OR 1.66(1.17-2.35), p=0.004), and estimated blood loss>350cc(OR 1.52(1.11-2.09), p=0.009) to be significantly associated with the composite outcome. Composite outcome rates have continued to improve despite declining pCSFD use. SCI recovery was not favorably impacted regardless of pCSFD, tCSFD, or no CSFD use. In the setting of comprehensive SCI prevention protocols, pCSFD use may not be warranted, even in most high-risk patients.

Endovascular Treatment of Abdominal Aortic Aneurysm with Hostile Artery Access: A Multi-Center Retrospective Study

PurposeThe objective of this study is to document our experience using low-profile endografts for the endovascular repair of abdominal aortic aneurysms (AAAs) in cases where access arteries are challenging, commonly referred to as hostile access arteries. MethodsData regarding patients with narrow or tortuous access arteries who underwent endovascular aortic repair (EVAR) using low-profile endografts at three tertiary medical centers between January 2020 and December 2022 were retrospectively collected and analyzed. A total of 76 patients were enrolled in the study. The primary endpoints included technical success, occurrence of endoleaks, endograft occlusion, and any device- or procedure-related major adverse events. Secondary endpoints were assessed for endograft migration, endograft fracture, access site complications, and aneurismal sac shrinkage. ResultsThe mean follow-up duration was 28.1±9.0 months (range, 14.0-54.0). Among the patients, 32 (42.1%) had narrow artery access (diameter ≤ 6.0 mm), 29 (38.2%) had access arteries characterized by tortuosity, and 15 (19.7%) patients presented with both narrow and tortuous access arteries. Technical success was achieved in 73 (96.1%) cases. A total of four (5.2%) patients received reintervention due to endograft occlusion. During follow-up, a total of eight (10.5%) type II endoleaks were observed during follow-up without intervention, and the endoleak disappeared in the follow-up period. Abdominal aortic aneurysm-sac shrinkage and stability were observed in 25 (32.9%) and 51 (67.1%) cases, respectively. The overall survival rate was 98.7%. The perioperative and follow-up outcomes for the groups categorized by ‘Narrow arteries’, ‘Tortuous arteries’, and ‘Narrow and Tortuous arteries’ did not show statistically significant differences when compared to each other. ConclusionThis preliminary investigation indicates that the use of low-profile endografts is associated with safety and effectiveness within the observed period.

How should failed infrarenal endovascular aortic repair with a short renal artery to bifurcation distance be managed?

How should failed infrarenal endovascular aortic repair with a short renal artery to bifurcation distance be managed?

Clinical outcomes and quality of life measures among 5-year survivors of fenestrated-branched endovascular aortic repair.

To report clinical outcomes and quality-of-life (QOL) changes among 5-year survivors of fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal (CAAA) and thoracoabdominal aortic aneurysms (TAAA). There is limited long-term data on FB-EVAR. All consecutive patients enrolled in a prospective, non-randomized study of FB-EVAR for CAAAs and TAAAs between 2013-2019 was analyzed (ClinicalTrials.gov NCT01937949 and NCT02089607). Patients who completed 5-year clinical and imaging follow-up were classified as 5-year survivors. Primary endpoint was the cumulative incidence of aortic repair failure (ARF), defined as a composite of aortic-related mortality (ARM), aortic rupture (ARR), conversion to open repair, and type I or III endoleak. Secondary endpoints included physical (PCS) and mental component (MCS) QOL scores. Among 342 patients, 159 (70% male; median age 74-years (IQR 69-79-years) 5-year survivors were analyzed. Median follow-up was 63-months (IQR 59-82). Cumulative incidence of ARF at 5 years was 5.0% (95% CI 2.4-9.2). Cumulative incidences of ARR was 1.3% (95% CI 0.0-3.1) and type IIIB endoleaks was 2.4% (95% CI 0.0-5.2) at 5-years. There were no conversions to open repair or type IA endoleaks. PCS decline post-procedure improved but remained below baseline at 5-years. There was no change in MCS. The 8-year survival rate among patients who survived the first 5-years was 58.9% (95% CI 47.4-73.3%). The 5-year risk of FB-EVAR failure is 5% among survivors, with a low risk of aortic rupture or device integrity issues. Early decline in physical QOL scores improves but does not return to baseline values.

Trends and Outcomes Over Time with Fenestrated and Branched Endovascular Aortic Repair in the United States Aortic Research Consortium.

To characterize trends and outcomes with fenestrated and branched endovascular aortic repair (F/B-EVAR) performed at centers participating in the United States Aortic Research Consortium. F/B-EVARs performed in 10 prospective, non-randomized, physician-sponsored investigative device exemption studies from 2015-2023 were retrospectively studied. Outcomes included 30-day major adverse event (MAE) and 1-year secondary reintervention. Outcome determinants were modeled with mixed-effects multivariable regression. Adjusted observed-minus-expected cumulative sum analysis was used to evaluate outcomes achieved over time. In the study period, 2,377 patients underwent F/B-EVAR. Median[IQR] follow-up was 2.3 years [0.7-3.5]. The proportion of thoracoabdominal aneurysms (p = 0.01) and aortic dissections (p = 0.001) increased over the study period while technical failure rates (p = 0.6) and length of hospital stay (p = 0.1) remained stable. Fusion imaging (p = 0.0005), low-profile devices (p < 0.0001), and completely transfemoral repair (p = 0.0005) were increasingly adopted over time. There were decreases in fluoroscopy time, procedure time, radiation dosage, and blood loss throughout the study (all p < 0.0001). Adjusted 30-day survival was 99.6% [99.3-99.8] and MAE occurred in 240 (10%). MAE determinants included age (OR[95%CI]: 1.3 per 10-years [1.1-1.6]; p = 0.005), eGFR (0.9 per 10-mL/min/1.73m2 [0.82-0.95]; p = 0.001), thoracoabdominal aneurysm (1.8 [1.3-2.6]; p = 0.002), operative time (1.04 per 10-minutes [1.03-1.06]; p < 0.0001), and technical failure (3.0 [1.7-5.1]; p = 0.0001). The cumulative rate of 30-day MAE remained stable, reflecting expected outcomes rates. The 1-year reintervention rate was 18% (n=435). Secondary intervention determinates included patient-specific device usage (0.4 [0.28-0.65]; p = 0.045) technical failure (3.1 [1.9-5.3]; p < 0.0001), total target vessels (1.3 per vessel [1.05-1.6]; p = 0.002), and prior aortic dissection (1.9 [1.3-2.6]; p = 0.0005). The cumulative rate of 1-year reintervention remained stable during the study period. Data from multiple U.S. centers demonstrate that F/B-EVAR can be performed safely and with acceptable outcomes. Despite increasing repair extent and complexity, the rates of technical failure, adverse events, and reintervention remained stable, likely driven, in part, by evolutions in minimally-invasive technique.

Outcomes of thoracic endovascular aortic repair for complicated type B acute aortic dissection from a multicenter Japanese post-market surveillance study.

A primary goal of thoracic endovascular aortic repair (TEVAR) for type B acute aortic dissection (BAAD) is exclusion of the primary entry tear with a suitable stent graft (SG) to reestablish true lumen flow and promote aortic remodeling. This study aimed to determine the safety and efficacy of a conformable thoracic SG in a Japanese population with complicated BAAD. Between 2016 and 2017, 43 patients with complicated BAAD were enrolled in this prospective, nonrandomized, multicenter post-market surveillance study at 27 sites in Japan. All patients underwent TEVAR using the Gore TAG Conformable Thoracic Endoprosthesis (CTAG) (W.L. Gore and Associates, Flagstaff, AZ). The most common TEVAR indication for complicated BAAD was malperfusion (41.9%; 24 out of 43) and aortic rupture was observed in 32.5% of patients (14 out of 43). All SG implants were successfully completed and there was no patient with surgical conversion. Thirty-day mortality was 7.0% (3 out of 43) and one patient (2.3%) experienced spinal cord ischemia during hospitalization. Entry tear exclusion was achieved in 91.3% of patients at 1month, and 95.7% at 24months. Through 24months after TEVAR, no retrograde type A aortic dissection was observed and distal stent graft induced new entry was observed in two patients (4.7%). TEVAR utilizing the CTAG device for complicated BAAD in Japan demonstrated a low incidence of perioperative mortality and complications. Complications directly attributed to the SG including RTAD and dSINE were uncommon and the midterm outcomes were deemed satisfactory.

Time is aorta in uncomplicated type B aortic dissection.

While cardiovascular control optimization through best medical therapy (BMT) remains the gold standard of treatment for uncomplicated type B aortic dissection (uTBAD) according to international guidelines, thoracic endovascular aortic repair (TEVAR) has increasingly emerged as a viable and appealing treatment option due to its potential to induce favourable aortic remodelling and improve long-term outcomes. However, the optimal timing of TEVAR in uTBAD remains debatable. This narrative review aims to evaluate the safety, efficacy, and outcomes of TEVAR at different time points in the disease history. We conducted a comprehensive literature review across multiple electronic databases, including PUBMED and Scopus, to synthesize research evidence on the timing of TEVAR in uncomplicated type B aortic dissection. Hyperacute-phase TEVAR (<24 hours) is associated with prohibitive periprocedural risks and is thus discouraged. Acute-phase TEVAR (1-14 days) may provide benefits in aortic remodelling, but it is burdened by relatively elevated rates of early complications and reinterventions. The subacute phase (14-90 days) is consistently identified as the optimal therapeutic window, balancing procedural safety and efficacy, with studies reporting superior mortality, complications, and aortic remodelling outcomes. Chronic-phase TEVAR (>90 days), although sometimes necessary in cases of disease progression, is associated with poorer outcomes, including higher rates of reintervention, complications, and limited aortic remodelling for the subacute phase. The consistent findings across the studies indicate that the subacute phase offers the best combination of reduced procedural risks and favourable long-term outcomes. However, ,more substantial evidence is needed to refine timing strategies.

Safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery: a prospective, single-center, randomized controlled study

BackgroundThoracic aortic pathologies involving the aortic arch are a great challenge for vascular surgeons. Maintaining the patency of supra-aortic branches while excluding the aortic lesion remains difficult. Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations provides a feasible and effective approach for this type of disease. The main purpose of this trial is to assess the safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery.MethodsThis is a prospective, single-center, randomized controlled study. A total of 170 eligible patients will be recruited from The Fourth Affiliated Hospital, Zhejiang University School of Medicine in China and randomized on a 1:1 basis either to the group A (extracorporeal fenestration) or the group B (in situ fenestration). The primary outcome will be the all-cause mortality (30 days). The secondary outcomes will include incidence of secondary intervention (30 days, 6 months, 1 year), incidence of endoleak (30 days, 6 months, 1 year), incidence of major adverse events (MAE) (i.e., immediate procedural success and complications) (30 days, 6 months, 1 year), immediate technical success rate, and all-cause mortality (6 months, 1 year).DiscussionSuppose extracorporeal fenestration non-inferior to in situ fenestration in patients with aortic disease involving the left subclavian artery. This trial aims to demonstrate the safety and validity of extracorporeal fenestration and in situ fenestration in patients with aortic disease involving the left subclavian artery, which is expected to provide a reference for Thoracic EndoVascular Aortic Repair (TEVAR) with fenestrations.Trial registrationClinicalTrials.gov NCT06256757. Registered on February 5, 2024. https://clinicaltrials.gov/study/NCT06256757.

Sex Differences in Textbook Outcomes among Adults Undergoing Elective Abdominal Aortic Aneurysm Repair

Background: Female patients with abdominal aortic aneurysms (AAA) undergoing repair have worse outcomes than males. Textbook outcomes (TO) have been described as a metric to direct quality improvement efforts and assess institutional performance. We investigated sex differences among patients achieving a TO after open (OAR) and endovascular aortic aneurysm repair (EVAR). Study design: Vascular Quality Initiative registry data from 80,948 patients undergoing elective AAA repair was reviewed. TO was defined as absence of major medical/surgical complication, prolonged postoperative length of stay (based on 75th percentile of the cohort), reintervention, or mortality and non-home discharge. EVAR and OAR cohorts were analyzed separately, stratified by TO and sex, and compared based on patient demographics, outcomes, and one-year survival. Results: More males had a TO compared to females (EVAR: 80% vs 67%; OAR: 54% vs 47%, p&lt;0.001, respectively). Obstacles for achieving TO for females were prolonged POLOS, surgical complications, and non-home discharge. TO was associated with improved one-year survival in EVAR and OAR. High volume center status (based on case volume quartiles) was not associated with TO for EVAR but was associated with TO for males undergoing OAR. Conclusions: Females are less likely to achieve a TO regardless of surgical approach and have a lower one-year survival than males when they do not. Importantly, when females do achieve a TO, there are no sex differences in one-year survival. TO is as a patient- centered quality standard and provides objective support for patient-provider decision- making and expectations and may serve as a quality metric that should be implemented to mitigate sex disparities. Further investigation utilizing multi-level modeling to examine patient, provider, and facility variables that impact TO is warranted.

Physiology of bridging stent grafts after fenestrated/branched endovascular aortic repair: Where translational science meets the clinical profile.

Fenestrated/branched endovascular aortic repair emerges as the primary therapeutic modality for intricate aortic pathologies encompassing the paravisceral and thoracoabdominal segments, where bridging stent grafts (BSGs) play a vital role in linking the primary aortic endograft with target vessels. Bridging stent grafts can be categorized mainly into self-expanding stent grafts (SESGs) and balloon-expandable stent grafts (BESGs). Physiological factors significantly influence post-complex endovascular aortic repair BSG behaviour, impacting clinical outcomes of SESGs and BESGs in different but overlapping ways. Crucial prerequisites for BSGs encompass not only flexibility but also resilience against mechanical stress and compliance mismatch, especially when bridging the rigid aortic main body with dynamic target vessels. The significance of considering these physiological factors in clinical decision-making is underscored by recognizing the interplay between SESG and BESG characteristics, vessel physiology and patient haemorheology. Such factors include the anatomy and tortuosity of the vessel, diameter of the vessel and BSG, deployment and durability, extrinsic stenosis and respiratory motion. Haemorheological factors, such as anti-thrombotic therapy and hydration status, need to be considered. This narrative review examines both in vitro and in vivo evidence regarding the impact of physiological factors on the behaviour of BSGs and assesses the consequences for clinical outcomes following complex endovascular aortic repair.