Hostile Necks Research Articles

Gallbladder Necrosis Following Fenestrated Endovascular Aneurysm Repair

: Fenestrated endovascular aortic repair of aneurysms with challenging necks has advanced significantly over the last three decades. In cases with extremely hostile proximal necks, such as the one described here (a common trunk between the superior mesenteric artery and the celiac artery), it may be necessary to cover the celiac trunk to ensure better graft attachment and avoid endoleaks. However, unexpected events can still occur, even with collateral circulation present. To our knowledge, this is the second reported case of gallbladder necrosis following fenestrated endovascular aortic repair.

Endovascular Aortic Repair With the E-Tegra Device: Preliminary Outcomes From a Multicenter National Registry.

Endovascular aortic repair (EVAR) is currently expanding its feasibility thanks to design innovations, but hostile proximal necks and narrow iliac arteries are still a constraint, as expressed by the Instructions for Use (IFU) of most devices. Our aim is to report the preliminary results of the E-Tegra endograft in infrarenal abdominal aortic aneurysms (AAAs) performed in 15 high-volume centers. The e-Tegra Italian endoGraft REgistry (TIGRE) is a prospectively maintained database of consecutive EVAR with the E-Tegra stent-graft across 15 participating centers between March 2021 and March 2023. The registry records baseline clinical data, anatomic measurements of the abdominal aorta, perioperative and postoperative outcomes, with a scheduled follow-up period of 3 years for all patients. This is a preliminary analysis of the first results updated to January 2024. The primary endpoints are technical and clinical success, perioperative mortality, freedom from endograft rupture, and aortic-related mortality. The secondary endpoints are freedom from reintervention, and any type of endoleak (EL). The results were analyzed in relation with the anatomic characteristics of the AAAs, namely, iliac axes tortuosity and proximal neck hostility. The registry included 147 consecutive EVAR (138 elective and 9 in emergent setting), 7 of which were associated with an iliac branch implantation. Ninety patients had at least 1 criterion of anatomical hostility, and 25 were treated outside the device IFU. Primary technical success was achieved in 146 cases (99.3%) and assisted success in 147 (100%), with no perioperative mortality. After a median follow-up period of 20 months, no aneurysm-related mortality occurred. Reinterventions were 5: 2 for type IB EL and 3 for type II ELs with aneurysm sac increase. Five more type II ELs with aneurysm sac stability are under observation. No differences in terms of reinterventions were noted between aneurysms with standard and hostile anatomy. The E-Tegra endograft is safe and effective in treating AAAs with standard and hostile anatomy, with a low rate of complications and reinterventions, although longer-term outcomes and larger numbers are needed to compare its performances related to specific anatomic criteria. This multi-center nationwide Registry reports a real-world experience of EVAR performed with the E-Tegra abdominal endograft across 15 high-volume Centers, providing early- and mid-term device-specific results, which will help vascular surgeons in endograft selection. In particular, this study focuses on clinical results obtained in treating aneurysms with hostile anatomy, analyzing the performances of the E-Tegra endograft in cases of hostile proximal necks and narrow or tortuous iliac axes.

Outcomes of endovascular intervention for infrarenal abdominal aortic aneurysm with hostile necks

Overview: Currently, endovascular intervention of the abdominal aortic aneurysm is considered the standard treatment method. Aneurysm neck’s morphology can affect 60% of the success or failure of endovascular intervention. Many advanced techniques to treat hostile necks have gradually become popular. However, endovascular intervention of the abdominal aortic aneurysms with hostile aneurysm necks are still considered a challenge. Objectives: Describe the characteristics of patients with infrarenal abdominal aortic aneurysms with hostile necks. Evaluate the perioperative and mid-term outcomes of endovascular intervention to treat infrarenal abdominal aortic aneurysms with hostile necks. Methods: The patients were diagnosed with infrarenal abdominal aortic aneurysms at the Vascular Surgery Department of Cho Ray Hospital, and were treated by endovascular intervention, from January 2020 to August 2023, and met the including criteria. Results: The technical success rate was 95.12%. The early death rate was 2.44%. There were no aneurysm-related deaths. Early endoleak rate was low at 4.88%. Late type I endoleak was 7.5%. The mid-term mortality rate was 9.76%. The mid-term mortality rate recorded in the aneurysm necks length ≤ 15mm group was significantly higher than the other group. Late type I endoleak had no significant difference, when comparing the short neck groups and the angulated neck groups. Conclusion: Endovascular intervention to treat infrarenal abdominal aortic aneurysms with hostile necks is a safe and effective method.

Incidence of endoleak type IA in patients undergoing chimney endovascular aortic repair (ChEVAR) vs. standard endovascular repair.

Almost half of endovascular aortic aneurysm repair (EVAR) procedures are performed in hostile anatomy, increasing the risk of procedure related complications such as type IA endoleaks, which may be prevented with the chimney technique in EVAR (ChEVAR). Our aim is to describe the differential characteristics between EVAR in favorable anatomy and ChEVAR in hostile necks. A cohort of patients with infrarenal abdominal aortic aneurysms (AAA) that were treated with EVAR or ChEVAR were included. The primary outcome was the incidence of type IA endoleak. Secondary outcomes were the rate of chimney occlusion, reintervention, migration, rupture, acute limb ischemia, sac growth, and aneurysm-related mortality during the follow-up period. . With a median follow-up of 11.5 months, 79 patients were treated with EVAR and 21 with ChEVAR. The overall age was 76.49 ± 7.32 years old, and 82% were male. The ChEVAR cohort had a higher prevalence of tobacco use than the EVAR cohort (38.1% vs. 17.7%, p = 0.041), and a shorter neck (7.88 mm ± 5.73 vs 36.28 mm ± 13.73, p<0.001). There were no differences in type IA endoleak incidence between the groups (a single endoleak type IA in the EVAR group, p = 0.309). One patient experienced an asymptomatic chimney occlusion in the ChEVAR group, and another patient required a reintervention due to chimney occlusion. Sac regression and reinterventions were not different between groups. There were no migration, rupture, acute limb ischemia, or aneurysm-related mortality events. . In patients with abdominal aortic aneurysms, ChEVAR in hostile necks had similar event rates to EVAR in favorable necks.

Carotid Endarterectomy in a Hostile Neck: To Do or Not to Do

Abstract Carotid endarterectomy (CEA) is the procedure of choice in patients with symptomatic carotid stenosis. However, in patients with hostile necks due to previous surgery or radiotherapy, there is a fear of higher complication rate, blood loss, and poor wound healing. We report two patients with hostile necks in whom we performed standard CEA with no cranial nerve injuries, no stroke, no blood transfusion, and normal wound healing and briefly review the literature.

Endovaskuläre Versorgung: der komplizierte Aneurysmahals

DefinitionA hostile neck is defined by various anatomical conditions that describe a morphology of the proximal aneurysmal neck of infrarenal aortic aneurysms that is unfavorable for endovascular treatment (endovascular aortic repair, EVAR): proximal landing zone length ≤ 15 mm, angulation of the aortic neck > 60°, conical aortic neck, diameter of the aortic neck > 32 mm, and circumferential calcification/thrombus.Effects on outcomeThese morphological parameters are not only associated with a higher perioperative technical failure rate (primary type 1 endoleak) but also with poorer long-term results (secondary type 1 endoleak) and thus a higher reintervention rate in standard EVAR, so that standard EVAR should be reserved for a few exceptions in these cases.Treatment optionsDue to the rapid development of endovascular techniques in the last decade, we now have a variety of endovascular options for aneurysms with hostile necks, for both elective treatment and emergency care, in addition to conventional open surgery, which is still the standard method in many cases and is currently undergoing a renaissance: fenestrated endovascular aortic repair (FEVAR) as the method of first choice in the elective setting, EVAR with chimneys (ChEVAR), endosuture aneurysm repair (ESAR). An important option is the conservative approach, which can be a reasonable choice if the patient’s preference is taken into account and a careful risk–benefit assessment is performed.

Update on the TREO endograft device: overview of its safety and efficacy

ABSTRACT Introduction The TREO abdominal aortic stent graft system (Terumo Aortic, Sunrise, Fla) is a low-profile, trimodular endovascular endoprosthesis for the endovascular repair of abdominal aortic aneurysm (AAA). The objective of the present study was to collect and discuss all the available modern data of this device highlighting especially its mid-and long-term clinical results. Areas covered This updated review article presents the most current results from great-scale clinical studies and the RATIONALE registry involving also angulated neck anatomies and challenging AAA geometries, reflecting the real-world experience. Expert opinion The global, multicenter RATIONALE registry prospectively enrolled 202 patients (mean age 73.0 ± 7.8 years) who underwent EVAR. Technical success, primary clinical success and assisted primary patency rate was 96%, 92.2% and 97%, respectively. The clinical success at 1 year was 96%. Another multicenter, non-randomized, clinical trial confirmed also high technical and clinical success. Additionally, a comparative study comparing favorable and hostile necks in AAA, demonstrated a comparable technical success (95.2%), achieving proper sealing and technical success in the hostile neck group. TREO endograft seems to be safe and effective for EVAR, especially in hostile neck anatomies. Long-term outcomes from ongoing registries are awaited to complete these results.

Open repair versus EVAR with parallel grafts in patients with juxtarenal abdominal aortic aneurysm excluded from fenestrated endografting

We compared the outcomes of open surgical repair (OSR) versus endovascular aortic repair (EVAR) with parallel graft technique (PG) in patients with juxtarenal abdominal aortic aneurysm (JAAA) excluded from fenestrated endovascular aortic repair (FEVAR) due to clinical, anatomical, technical or manufacturing time reasons. A single-center analysis of consecutive patients who underwent elective and urgent (within 24-48 hours) repair of JAAA from January 2010 to January 2019 was performed. Two groups were compared: patients excluded from FEVAR and respectively treated by OSR or by PG for JAAA. Perioperative clinical, anatomic and operative data were collected in a dedicated database. The endpoints were primary technical success, changes in renal function, early and long-term mortality, freedom from aortic related reinterventions (ARRs) and aortic related mortality (ARM). Overall, 118 consecutive patients were treated for JAAA, 32 of whom (27.1%) with FEVAR. Eighty-six patients were enrolled in the study (OSR group, N.=61; PG group, N.=25). The mean age was 77.4±6.5 years for PG group and 71.1±6.7 years for OSR group (P=0.0001); the average comorbidity score of the Society for Vascular Surgery was higher for patients treated by PG (10.2±4.8 vs. 5.5±0.4, P=0.0001), with no differences for hypertension and renal score. After propensity score matching, 42 patients (27 OSR, 15 PG) without differences in the preoperative risk factors were selected. Conical shape and neck mural thrombus were respectively more represented in the OSR group (95.1% vs. 56.0%; 63.9% vs. 36.0%). Aortic clamp site was supraceliac for 12 patients (19.7%), suprarenal for 21 (34.4%) and trans-renal for 28 patients (45.9%). In the PG group, 16 patients (64%) were treated with a single renal chimney. Primary technical success was similar in the two groups (100.0% vs. 92.0%, P=0.08), with a higher rate of procedure achieved by assisted technical success for the PG group after propensity score matching analysis (20.0% vs. 0%, P=0.04). Deterioration of renal function occurred for both groups of patients, with a significant creatinine increasing 12 months after surgery in the PG group compared with OSR group (1.72±0.66 vs. 1.18±0.40, P=0.006). Multiple logistic regression shows no independent predictor of peri-operative medical complication among demographics and pre-operative relevant clinical factors between the two cohorts. No difference in terms of early mortality was observed between the groups (1.6% vs. 0%, P=1.00). At 5 years, overall survival was lower for patients treated by PG (53.5% vs. 70.2%, P=0.007), such as freedom from ARRs (64.6 vs. 90.5%, P=0.03). Freedom from ARM at 5 years did not show significant differences among the two groups (100% vs. 98.4%, P=1.00). PG represents a feasible procedure for patients excluded from FEVAR due to clinical, anatomical, technical or device manufacturing time reasons, ensuring low rates of ARM. However, ARRs during the follow-up remain the Achilles heel of this technique. OSR is still the most durable procedure in the endovascular era, allowing the treatment of proximal "hostile necks" with low rates of reoperation and a similar impact on the renal function compared to PG.

Real-World Utilization and Outcomes of EndoAnchors for Endovascular Aneurysm Repair

In patients with hostile aortic necks, endovascular aneurysm repair (EVAR) remains a significant challenge. EndoAnchors have been used as an adjunct to limit the risk of type IA endoleaks and stent migration. We aimed to assess the utilization and outcomes of patients undergoing EVAR with EndoAnchors in a real-world setting.

Endovascular aortic repair with EndoAnchors demonstrate good mid-term outcomes in physician-initiated multicenter analysis-The PERU registry.

We aim to describe real-world outcomes from multicenter data about the efficacy of adjunct Heli-FX EndoAnchor usage in preventing or repairing failures during infrarenal endovascular aneurysm repair (EVAR), so-called EndoSutured-aneurysm-repair (ESAR). The current study has been assigned an identifier (NCT04100499) at the US National Library of Medicine (https://ClinicalTrials.gov). It is an observational retrospective study of prospectively collected data from seven vascular surgery departments between June 2010 and December 2019. Patients included in the ANCHOR registry were excluded from this analysis. The decision for the use of EndoAnchors was made by the treating surgeon or multidisciplinary aortic committee according to each center's practice. Follow-up imaging was scheduled according to each center's protocol, which necessarily included either abdominal ultrasound or radiography or computed tomographic scan imaging. The main outcomes analyzed were technical success, freedom from type Ia endoleaks (IaEL), all-cause and aneurysm-related mortality, and sac variation and trends evaluated for those with at least six months imaging follow-up. Two hundred and seventy-five patients underwent ESAR in participating centers during the study period. After exclusions, 221 patients (184 males, 37 females, mean age 75 ± 8.3 years) were finally included for analysis. Median follow-up for the cohort was 27 (interquartile range 12-48) months. A median 6 (interquartile range 3) EndoAnchors were deployed at ESAR, 175 (79%) procedures were primary and 46 (21%) revision cases, 40 associated with type IaEL. Technical success at operation (initial), 30-day, and overall success were 89, 95.5, and 96.8%, respectively; the 30-day success was higher due to those with subsequent spontaneous proximal endoleak seal. At two years, freedom from type IaEL was 94% for the whole series; 96% and 86% for the primary and revision groups, respectively; whereas freedom from all-cause mortality, aneurysm-related mortality, and reintervention was 89%, 98%, and 87%, respectively. Sac evolution pre-ESAR was 66 ± 15.1 vs. post ESAR 61 ± 17.5 (p < 0.001) and for 180 patients with at least six-month follow-up, 92.2% of them being in a stable (51%) or regression (41%) situation. This real-world registry demonstrates that adjunct EndoAnchor usage at EVAR achieves high rates of freedom from type IaEL at mid-term including in a high number of patients with hostile neck anatomy, with positive trends in sac-size evolution. Further data with longer follow-up may help to establish EndoAnchor usage as a routine adjunct to EVAR, especially in hostile necks.

Preoperative Planning for EndoAnchor Use During Thoracic Endovascular Aortic Repair in the Distal Aortic Arch

Purpose: To describe steps related to intraoperative C-arm orientations that can be taken during preoperative planning of thoracic stent-graft repair to facilitate the deployment of EndoAnchors in the distal aortic arch. Technique: Previous experience from transcatheter aortic valve implantation (TAVI) may be helpful in addressing issues with C-arm orientation. In TAVI, preoperative computed tomography (CT) images are routinely obtained to generate a patient-specific curve that represents a virtually complete rotation of the C-arm perpendicular to the annulus. The curve clearly demonstrates that each adjustment in cranial or caudal view needs parallax correction in the left or right anterior oblique direction to remain perpendicular, and vice versa. This experience can be translated to the preoperative planning of EndoAnchor use in the aortic arch. By placing markers along the circumference of the proximal landing zone of the preoperative CT scan, the required C-arm orientations can be determined for each marker. Conclusion: Determining the optimal C-arm orientation during preoperative planning will facilitate successful EndoAnchor deployment and may contribute to improved durability of endovascular repair in hostile necks in the aortic arch.

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping.

Juxtarenal abdominal aortic aneurysm (AAA) comprises 15-20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs. Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included. All patients had fusiform-type AAAs and were divided into infrarenal (N=98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4months (95% CI: 48.6-54.2). Mean survival time was 51.4months (95% CI: 48.6-54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P>.999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P>.999). Old age (HR: 1.084; 95% CI: 1.025-1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225-4.553; P=.010) were substantially associated with in-hospital complications. Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

Preliminary Results of the Evar 30-D SACVA Registry. The First and Largest Multicentric Registry in Southern Spain of Evar for Abdominal Aortic Aneurysms

Introduction: EVAR has been adopted worldwide as a standard approach for AAA in high risk patients unfit for open repair (OR), but also offered to no high-risk patients with no friendly anatomy for EVAR, based in the lower short-term morbidity of the endovascular approach. But published data are still controversial about the benefits of this approach in patients fit for surgery or with hostile aortic anatomies. Methods: Consecutive cases included from January 2016 to December 2017 in a collaboration between 10 Vascular Surgery departments and the Sociedad Andaluza de Angiología y C Vascular(SACVA). Retrospective multicentre data collected through specific designed formularies analyzed by the statistical department FIBAO(CHU Jaen). Initial descriptive analysis are presented in this paper. Results: 372 cases were collected from 10 centers, range cases/center (74-3). Elective EVAR 306(82%) and emergent EVAR 66 cases(18%). Epidemiological data: 357(96%) males and 15(4%) females, mean age of 73,69y.o. for no emergent EVAR VS 75y.o. for emergent EVAR. Tobacco use(89%) followed by arterial hypertension(80%) are the most prevalent cardiovascular risk factors. Based on AAA anatomy 76% were aortic aneurysms, 21% aorto-iliac and just 3% isolated iliac aneurysms. Mean of the AAA max diameter was 60.44mm for elective VS 75.54mm for emergent/ruptured cases. Mean neck diameter at renal arteries level was 24,3mm for elective VS 24.9mm for emergencies, and 2cm lower to renal was 26.57mm for elective vs 27.99mm for emergent. Anaesthetic risk 57.4% of the patients were ASA III and 25.7% ASA IV. Percutaneous access in 41.8% of the elective and 27.3% of the emergent cases. 29.7% of the cases where considered hostile neck anatomies, with 18.8% treated out of the instructions of use(IFU's) of the stentgraft. Stentgraft devices: 45.9 % with infrarenal fixation versus 54.1% suprarenal fixation. Technical success for EVAR achieved in 97.8%, with a conversion to OpenRepair rate inferior to 1.3%. 30-D endoleaks in 17.5% of the cases, from those 6% classed as type I. Hospital stay for elective EVAR was 4.85 days VS 8.44 for emergencies. Post-Implant syndrome in 17.4% patients. 30-D mortality for the 62 emergent cases was 22.2% VS 0.7% for the 312 elective. No major 30-D complications reported after EVAR in 85% of the elective cases versus 57.1% of the emergencies. Conclusion: The results of this multicentric registry, the largest with these characteristics performed in Spain shows similar 30-D results compared with other international registries and trials published in the literature, with a global decrease in 30-D mortality, lower than 1.5% for elective AAA repair and close to 20% for ruptured AAA, and reported technical success of superior to 98%. But the elevate number of cases included in this registry performed in hostile necks and out of the stentgrafts IFU's should be clearly remarked. Although it seems not to be relevant at the initial presented 30-D data after EVAR there is a need of close follow-up of these patients and it is mandatory to report the mid and long-term results of these patients over the next years. Disclosure: Nothing to disclose

Procedural Complexity of TransCarotid Artery Revascularization Is Not Increased in Irradiated and Reoperative Necks

TransCarotid Revascularization (TCAR) with dynamic flow reversal using the ENROUTE Neuroprotection System (ENPS) is a Food and Drug Administration-approved alternative carotid revascularization modality. The purpose of this investigation was to determine whether TCAR in a hostile (fibrotic) surgical field increases procedural complexity and postoperative complications. Perioperative variables for all institutional TCARs performed between December 2015 and April 2019 were prospectively captured. Procedures performed as part of the ongoing ROADSTER-2 registry were excluded. Univariate analysis, consisting of Student's T and Fisher's exact testing, comparing virgin and hostile neck TCAR, was performed at an alpha of 0.05. During the study period, 149 total procedures (n=30, hostile ipsilateral necks) qualified for inclusion. Both hostile and virgin neck groups were comparable with respect to preoperative comorbidities and medication profiles. The ipsilateral hostile neck cohort consisted of ten patients who underwent previous ipsilateral neck radiation and 23 who were status after neck dissection (3 had both). Intraoperatively, there were no differences with respect to estimated blood loss (47.2 vs. 44.8mL, P=0.81), operative time (69.5 vs. 74.5min, P=0.38), reverse flow time (12.4 vs. 10.4min, P=0.34), radiation exposure (217.7 vs. 226.2mGy, P=0.88), fluoroscopy time (5.4 vs. 5.0min, P=0.65), contrast usage (23.5 vs. 25.0mL, P=0.55), and ability to achieve technical success (96.7% vs. 100%, P=0.58) between virgin and hostile necks, respectively. Perioperative (30-day) ipsilateral stroke and death rate was 2.5% vs. 0% (P=1.0) and 2.5% vs. 0% (P=1.0), respectively, between virgin and hostile necks. We observed one postoperative cranial nerve injury in any of our TCAR patients (hostile neck, P=0.20). Finally, a total of 3 hematomas (requiring washout) occurred in our (2 in virgin necks and one in a hostile neck) surgical cohort (P=0.49). Based on this limited, small series, TCAR in hostile surgical fields is not associated with an increase in case complexity and maintains a similar perioperative risk to virgin field procedures.

IP095. Severe Tandem Carotid Lesions in an Irradiated Field with Tracheostomy and Contralateral Carotid Occlusion and Contraindication to Carotid Artery Stenting

This is a case report and literature review of a patient with severe tandem carotid lesions in an irradiated field after radical neck dissection with tracheostomy, contralateral carotid occlusion, and contraindication to carotid artery stenting. We conducted a systematic review of the English language literature with information on severe tandem carotid lesions in a hostile field (previous surgical intervention, irradiation) and contralateral carotid occlusion. We present the case of a 71-year-old woman with asymptomatic, severe carotid artery stenosis and a past medical history significant for laryngeal cancer status post laryngectomy with stoma, radical neck dissection, and neck irradiation. Aortic arch and carotid angiography demonstrated a left internal carotid artery (ICA) occlusion, right common carotid artery (CCA) stenosis of 80%, right ICA stenosis of 50% to 60% with severe tortuosity, and occluded right external carotid artery. Given the severe ICA tortuosity with tandem lesions, carotid artery stenting was not feasible, and we proceeded with carotid endarterectomy, ICA resection, and primary anastomosis. Intraoperatively, the ICA was mobilized and the proximal ICA was resected, thus addressing the tortuosity and the distal tandem lesion. For the proximal tandem lesion located in the CCA, we performed a standard endarterectomy of the proximal portion of the CCA lesion and an eversion endarterectomy of the distal transected CCA. Next, we performed an end-to-end anastomosis of the ICA to the CCA. This was completed with a Sundt shunt in place, given the contralateral ICA occlusion. Postoperatively, the patient has done well and continues to be free of any complication, with duplex ultrasound demonstrating patency. After a thorough literature review, it is clear that this in an unusual case with a novel solution. The patient’s prior radical neck dissection with tracheostomy and irradiation would generally have made her an ideal candidate for carotid artery stenting. However, the patient was at high risk for carotid artery stenting, given the tortuosity and tandem lesions. The literature provides ample data on the benefits of carotid artery stenting for carotid stenosis in hostile necks. However, there is very little information clarifying how to approach lesions in a hostile neck when they are not amenable to stenting. Our case represents a novel open carotid endarterectomy approach to tandem lesions with associated tortuosity in a hostile operative field.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abdominal aorta aneurysm with hostile neck: Early outcomes in outside instruction for use in patients using the treovance® stent graft.

Purpose:The efficacy and safety of endovascular aneurysm repair (EVAR), in patients outside instruction for use (IFU), is very challenging and widely debated. The aim of this study was to evaluate the placement of the Treovance® abdominal aorta stent-graft in patients with hostile proximal necks considered outside IFU.Materials and Methods:Between May 2013 and August 2014, 5 patients with outside IFU underwent EVAR with the Treovance® stent-graft. Technical and clinical successes were evaluated. All 5 patients underwent clinical and imaging follow-up.Results:Technical and clinical successes were achieved in all 5 patients without adjunctive endovascular procedures or surgical conversion. During the mean follow-up of 21 months, no type I/III endoleaks, stent-graft migration nor kinking/occlusion were observed. In all 5 patients, a reduction of the proximal neck angle was observed.Conclusion:In our small series of selected outside IFU patients, EVAR with the Treovance® stent-graft was technically feasible and safe, with satisfactory short-term follow-up results, when performed by experienced operators. Long-term follow-up will be necessary to confirm the durability of our preliminary promising results.

Could Preoperative Neck Anatomy Influence Follow-up of EVAR?

The aim of the study was to assess the clinical utility of strict CT scan surveillance after endovascular abdominal aneurysm repair (EVAR) and evaluate whether the anatomy of abdominal aortic aneurysm (AAA) neck (favorable/hostile) influences regular imaging control. A retrospective study of AAA patients who underwent EVAR with aortobi-iliac endoprostheses during 2006-2013 was conducted. Exclusion criteria included other types of devices. Variables analyzed were technical and clinical success, morbimortality, complications (such as endoleaks, sac enlargement), reinterventions, reintervention-free survival, and survival rate. Preoperative CT scans were performed and repeated at 1, 6 (in selective cases), 12, and 24months postoperatively. Patients were divided into two groups according to preoperative anatomic characteristics: group I (favorable neck) and group II (hostile neck: angle > 60°, length < 15mm, diameter > 28mm, and calcification or circumference thrombus ≥50%). A total of 127 patients with AAA (96.8% male) were included in the study. The mean age of the patients was 75.9years (range: 51-90 years). The mean AAA diameter was 62.1mm. Hostile neck was found in 52 patients (40.9%). The technical and clinical success rate was 100% and 30-day mortality was 0.8%. The reintervention-free survival rate was 97.6%, 96.1%, and 93.7% and the survival rate was 97.6%, 96.9%, and 91.3%, during follow-up at 6, 12, and 24months, respectively. Accumulated complications in proximal sealing occurred in 0%, 0%, and 1.6% in group I and 1.9%, 6.1%, and 7.7% in group II at 1, 12, and 24months, respectively. Type II endoleaks occurred in 24.3%, 14.3%, and 11.4% in group I and 9.8%, 6.3%, and 6.8% in group II at 1, 12, and 24months, respectively. No increased diameter was detected at 6 and 12months. No differences were observed in reinterventions and mortality rate depending on anatomy. CT scans performed at 6 and 12months postoperatively did not detect complications or need for reintervention in patients with favorable necks, even in the presence of endoleaks type II, and could therefore be omitted. Hostile necks may compromise proximal sealing and require regular imaging follow-ups.

Novel endovascular procedures and new developments in aortic surgery

Endovascular repair has evolved to become a viable mainstream treatment for aortic pathology in both acute and elective settings. As technology advanced, traditional anatomical barriers were progressively tackled using new devices and novel procedures, and there are now multiple options available to the vascular surgeon. In the abdominal aorta, advances in endovascular aneurysm repair have been in the treatment of hostile aortic necks using new sealing concepts and ancillary procedures, and in branch preservation using fenestrations and snorkels. Access challenges have been met with a percutaneous approach and low-profile devices, and standard protocols have improved mortality for ruptured aneurysms. In the thoracic aorta, more invasive hybrid procedures have given way gradually to branched endografts. Particular challenges to the anaesthetist include blood pressure control and the prevention of stroke and paraplegia. Current focus in the thoracic aorta is in treating aortic arch pathology and in optimal management of acute and chronic dissections. This review describes the latest trends in the endovascular treatment of aortic diseases and examines the current evidence for different modalities of management.

Preliminary results of adjunctive use of endoanchors in the treatment of short neck and pararenal abdominal aortic aneurysms.

To present our initial experience with the use of EndoAnchors for endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with little to no infrarenal landing zone. EndoAnchors have been reported to assist in the prevention and treatment of type 1a endoleaks in patients with hostile aortic necks who undergo EVAR. Between July 2013 and July 2014, nine patients with AAAs and short proximal aortic necks (i.e., 0-10 mm in length) underwent EVAR. In five patients, utilization of the chimney graft technique was necessary. A mean of 2.5 (range 1-4) visceral vessels underwent chimney graft. The prophylactic use of EndoAnchors was utilized in all 9 patients. The decision to use the EndoAnchors was made in the preoperative planning phase. Technical success was achieved in 100% of cases. In two cases, type 1a endoleaks were noted before the deployment of any EndoAnchors. In both cases, a final angiogram depicted resolution of the type 1a endoleak after insertion of the EndoAnchors. Mean follow-up time was 8 months. At 30 days, 3 months, and 6 months, 100% of the endografts remained patent and free from type 1a endoleaks. No adverse renal complications or mortality was reported. EndoAnchors are an applicable adjunct to EVAR as treatment for short infrarenal neck and pararenal AAAs. Further investigations are needed to determine the durability of this novel application.

Fatores de risco para crescimento do saco aneurismático pós‐endovascular aneurysm repair: revisão de literatura

About 75% of the Abdominal Aortic Aneurysms (AAA) are currently repaired by endovacular means (EVAR). Aneurysm sac shrinkage post‐EVAR represents the principal marker of absence of rupture or mortality aneurysm related. However, in about 40% of cases aneurysm sac does not shrink or even enlarges.Several pre‐operative risk factors may predict aneurysm sac enlargement post‐EVAR. The aim of this review is to summarize all risk factors that may condition an aneurysm sac enlargement so that one could adapt the best follow‐up method to each patient according to the risk score.Most of those risk factors are described in this review: advanced age, hostile necks, endoleak occurrence or even systemic inflammation. These constitute important determinants that predict a worst prognosis pre‐operatively.The early identification of these risk factors have remarkable implications in the follow up strategy. Patients with none or only one risk factor may be suitable for a US‐Dupplex follow‐up, while those patients with several pre‐operative risk factors could be good candidates for Angio‐Computed Tomography surveillance, which presents more sensivity in the detection of complications, despite its greater iatrogeny.