Thoracoabdominal Aneurysm Repair Research Articles

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs, but not Juxtarenal Repairs, are Associated with Outcomes following Endovascular Repair of Thoracoabdominal Aneurysms.

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair remains one of the more technically challenging aspect of vascular surgery, with significant risk of mortality, spinal cord ischemia (SCI), and end organ damage. Although fenestrated devices are available for juxtarenal aneurysms, there are no commercially available eTAAA devices on the US market currently. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms. We studied all eTAAA repairs (Crawford type 1-3) in the Vascular Quality Initiative from 2014-2021 and categorized surgeons into quartiles based on their average annual eTAAA volume and endovascular juxtarenal volume. Our primary outcome was thoracoabdominal life altering events (TALE-composite of perioperative death, stroke, permanent SCI and dialysis). We employed mixed effects logistic regression clustering by center and surgeon. We identified 5335 repairs from 607 surgeons, with annual average eTAAA volumes of 2,629 from 400 surgeons. Quartile 1 involved <2 repairs and quartile 4 involved >12 repairs per year. Repairs at higher quartiles were for larger aneurysms, more commonly employed staged repairs, utilized spinal drains, and more frequently utilized physician modified endografts, whereas low volume surgeons most commonly employed parallel grafting. Higher volume surgeons had overall shorter procedural times, fluoroscopy time, and less total contrast. Technical success similarly increased as procedure volume increased. In adjusted analyses, rates of perioperative death, TALE, stroke, acute kidney injury and major adverse cardiac events were all lower in the highest volume quartile compared to the lowest. However, after accounting for eTAAA volume, surgeon volume of endovascular juxtarenal repairs was not associated with any postoperative outcome, and there was no significant interaction between juxtarenal and eTAAA volume. Medium term mortality was lowest in patients treated in the top two quartiles of volume (HR 0.77 [0.61-0.97], P = .024. Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate post operative period and in permanent patient-centered outcomes. However, experience in less extensive aneurysms did not directly translate to thoracoabdominal aneurysms. Further study is needed to evaluate the role that commercial graft availability and repair type contributes to these findings.

Application of three-dimensional printing in the planning and execution of aortic aneurysm repair

IntroductionThe accuracy of fenestrations in stent grafts for complex aortic aneurysms and dissections can be significantly improved using three-dimensional (3D)-printed phantoms. Standardization is enhanced by using artificial intelligence (AI) for image pre-processing before 3D printing. These methods address fallacies in centerline image analysis and manual image pre-processing. This review examines the application of 3D printing and AI in complex aortic aneurysm repair, highlighting current clinical trends.MethodsAn exhaustive literature review was performed using keywords such as “3D printing,” “Artificial intelligence,” “Thoracoabdominal aneurysm,” “Abdominal aortic aneurysm,” “Aortic arch aneurysm,” “Endovascular repair,” and “Open repair” in PubMed and Google Scholar indexes up to June 2022.ResultsThis analysis included seven studies: four focused on 3D-printed phantoms for endovascular repair of various aortic pathologies (aortic arch, thoracoabdominal aorta, juxtarenal and pararenal aorta), one on open thoracoabdominal aneurysm repair using 3D-printed models for graft construction, and two on the use of convolutional neural networks, an AI-based technology, for the pre-processing of aortic computed tomography angiography images.ConclusionThe application of 3D printing and AI-based image pre-processing in the planning of complex aortic aneurysms offers several benefits, including enhanced patient and trainee education, more accurate fenestration placement, reduced surgical time and complications, and decreased surgeon stress.

T-branch by partial deployment technique in the endovascular repair of complex aortic and thoracoabdominal aneurysms with narrow or severe angulated para-visceral aorta.

The partial deployment technique (PDT) is an unconventional option of T-branch deployment to allow target arteries (TAs) cannulation/stenting from the upper arm access, in case of narrow (NPA<25mm) or severely angulated (APA >60°) aorta. Aim of this study was to report outcomes of the endovascular repair of complex aortic (c-AAAs) and thoracoabdominal (TAAAs) aneurysms by T-branch and PDT. All consecutive patients underwent urgent endovascular repair of c-AAAs and TAAAs by T-branch (Cook Medical) and PDT from 2021 to 2023 were analyzed. Technical success (TS), 30-day mortality, and TA instability within 30 days and 1 year, as well as reinterventions, were assessed as primary endpoints. Time of intraoperative pelvic/lower limb ischemia, spinal cord ischemia (SCI), and perioperative stroke were assessed as secondary endpoints. Thirty-three cases were analyzed. There were six type I endoleaks (18%) in failed endovascular aortic repair, nine juxta/para-renal aneurysms (28%), six post-dissection TAAAs (18%), and 12 degenerative TAAAs (36%), respectively. The median para-visceral aortic lumen diameter was 23 mm (interquartile range [IQR], 19-27 mm), and 10 cases (30%) had APA. Of 128TAs, 111 (87%) were cannulated/stented with distally captured aortic graft. The median time of pelvic/lower limb ischemia was 120 minutes (IQR, 90-150 minutes). TS was achieved in all patients. One patient (3%) suffered SCI, and there were no cases of stroke. An asymptomatic renal artery occlusion was detected at postoperative imaging, which was recanalized by thrombus-aspiration/relining. This was the only case of TA instability (1/128; 0.8%) and reintervention (1/33; 3%) within 30 days. Two patients (6%) died within 30 days. Median follow-up was 14 months (IQR, 6-22 months). One case (3%) of bilateral renal artery occlusion occurred at 6 months. No superior mesenteric artery or celiac trunk events occurred, with an overall TA instability rate of 2% (3/128). Eighteen patients (55%) completed the radiologic follow-up at 1 year with no new cases of TA instability. Freedom from TA instability was 91% at 1 year. T-branch by PDT seems to be safe and effective in the management of c-AAAs/TAAAs with NPA or APA. Results were satisfactory in terms of TS and mid-term TA instability, suggesting a possible enlargement of the anatomical feasibility criteria for outer branches in urgent cases.

Impact of aetiology on short- and long-term outcomes in open descending and thoracoabdominal aneurysm repair.

We analysed the impact of chronic type B aortic dissection (cTBAD) and degenerative aneurysm (DA) on the short- and long-term outcomes of patients undergoing open descending thoracic aortic aneurysm and thoracoabdominal aortic aneurysm repair. We performed a retrospective analysis of a prospectively maintained aortic database. From 1999 to 2023, 245 patients underwent open descending thoracic aortic aneurysm or thoracoabdominal aortic aneurysm repair. We compared preoperative comorbidities, postoperative complications and operative and long-term mortality for patients with cTBAD (120 patients, 49%) and DA (125 patients, 51%). Patients with cTBAD were significantly younger, more likely to be male and less likely to have comorbidities including diabetes, chronic obstructive pulmonary disease and coronary artery disease. There were no statistically significant differences in the incidence of operative mortality between cTBAD (7.5%) and DA patients (11.2%) (P = 0.44). Survival at 1, 5, 10 and 15 years for cTBAD versus DA patients was 90% versus 76%, 79% versus 59%, 59% versus 42% and 50% versus 29%, respectively (P < 0.01); however, this lost statistical significance in the Cox regression (P = 0.86). Following multivariable analysis, older age, female gender, coronary artery disease, urgent or emergent procedure and descending thoracic aortic aneurysm were independent predictors of long-term outcomes. There were no statistically significant differences in the incidence of postoperative complications, operative deaths and long-term survival between cTBAD and DA patients. (#20D.802), Obtained: 1/31/23.

The Role of Fluoroscopic Guidance in Spinal Drain Placement for Thoracoabdominal Aneurysm Repair Patients: A Retrospective Study.

To evaluate outcomes after implementation of a preoperative protocol requiring fluoroscopic guidance in patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair identified as being at risk for spinal drain placement complications. This retrospective analysis included patients who underwent spinal drain placement for TAAA repair between November 2013 and November 2018. Patient outcomes were assessed before (control) and after (study) protocol implementation. Single tertiary care hospital. A total of 58 patient records were analyzed. The protocol was implemented in November 2015 to identify at-risk patients for difficult spinal drain placement undergoing TAAA repair who would benefit from placement under fluoroscopic guidance. The mean operating room arrival time to drain placement was lower in the study group than in the control group (44.9 ± 12.7 minutes v 80.5 ± 55.8 minutes; p = 0.03). The mean time to incision was lower in the study group than in the control group (114.9 ± 38.1 minutes v 172.4 ± 32.0 minutes; p < 0.001), and fewer drain placement attempts were done in the study group than in the control group (mean, 1.3 ± 0.7 attempts v 2.7 ± 2.5 attempts; p = 0.006). The mean length of stay was lower in the study group (9.5 ± 6.7 days v 18.7 ± 22.7 days; p = 0.04). Preoperative identification of at-risk patients before TAAA repair may reduce operating room arrival to the incision time, operating room to spinal drain placement time, number of spinal drain placement attempts, length of hospital stay, and complications associated with spinal drain placement.

Anesthetic Considerations for Repair of Thoracoabdominal Aortic Aneurysms.

Anesthetic management of open thoracoabdominal aneurysm (TAAA) repair poses a number of challenges for even the most experienced of cardiovascular anesthesiologists. This procedure encompasses a large number of unique anesthetic techniques, including one-lung ventilation, invasive hemodynamic monitoring, left-heart bypass, massive transfusion, selective renal and visceral perfusion, and central nervous system monitoring with CSF drainage. In this article, we aim to describe the anesthetic management for thoracoabdominal aortic aneurysm repair, including preoperative workup, intraoperative management, as well as postoperative concerns in the intensive care unit.

Low Profile Off the Shelf Multibranched Endografts for Urgent Endovascular Repair of Complex Aortic and Thoraco-abdominal Aneurysms in Patients with Hostile Iliac Access: European Multicentre Observational Study

The aim of the study was to report outcomes of a thoraco-abdominal, custom made, low profile (outer diameter 20 F) four branched endograft used as an off the shelf (OTS) solution for urgent juxta- and pararenal abdominal aortic aneurysms (JP-AAAs) and thoraco-abdominal aortic aneurysms (TAAAs) in the presence of hostile femoral or iliac access. Data for patients who underwent endovascular repair for urgent JP-AAAs and TAAAs with hostile femoral or iliac access by a low profile, four branched endograft in four European aortic centres between 2019 and 2023 were collected prospectively and analysed retrospectively. The investigated device was a custom made endograft with the configuration of a standard t-Branch, used as an OTS solution for urgent cases with hostile femoral or iliac access. Access related complications, spinal cord ischaemia (SCI), and 30 day death were assessed as primary outcomes. Survival, freedom from re-interventions (FFRs), and iliac limb occlusion (ILO) were evaluated as secondary outcomes. Fifty five cases were enrolled: ruptures, n= 14 (25%); symptomatic, n= 12 (22%); and asymptomatic TAAAs with diameter ≥ 80 mm, n= 29 (53%). There were seven (13%) JP-AAAs and 48 (87%) TAAAs. The median right and left external iliac artery diameters were 6.7 (interquartile range [IQR] 5.5, 7.9) mm and 7.1 (IQR 6.5, 8.7) mm, respectively. Bilateral hostile femoral or iliac access was reported in 39 patients (71%). Access related complications occurred in five cases (9%). There were four cases (7%) of SCI with two permanent paraplegias. Four patients (7%) died within 30 days. The median follow up was 22 (IQR 11, 33) months. Overall, eight patients (15%) required re-interventions: four within 30 days and four during follow up. No ILO occurred. Estimated one year FFRs and survival were 91% and 87%, respectively. Low profile OTS thoraco-abdominal endografts seems safe and effective to manage urgent JP-AAAs and TAAAs in the presence of hostile femoral or iliac access. Further larger studies with long term follow up are needed to validate this preliminary experience.

The impact of large aneurysm diameter on the outcomes of thoracoabdominal aneurysm repair by fenestrated and branched endografts.

Aim of the study was to analyse the impact of preoperative thoracoabdominal aneurysm diameter on the outcomes of fenestrated/branched endografting. Patients who underwent endovascular thoracoabdominal repair at 2 European centres (2011-2021) were analysed. Median diameter was calculated; the third quartile was considered a cut-off. Outcomes were compared in 2 groups based on the diameter value. Primary endpoints were technical success, spinal cord ischaemia and 30-day/in-hospital mortality. Survival, freedom from reintervention and target visceral vessels instability were follow-up outcomes. Out of 247 thoracoabdominal aortic aneurysms, the median diameter was 65 mm, first quartile was 57 mm; third quartile was 80 mm, set as cut-off value. Fifty-nine (24%) patients had diameter ≥80 mm. Custom-made and off-the-shelf branched endograft were used in 160 (65%) and 87 (35%), respectively. Technical success was 93% (<80 mm: 91% vs ≥80 mm: 94%; P = 0.47). Twenty-three (9%) patients had spinal injury (<80 mm: 7% vs ≥80mm: 17%; P = 0.03). Twenty-two (9%) patients died within 30-day/in-hospital (<80 mm: 7% vs ≥80 mm: 15%; P = 0.06). Multivariate analysis did not report preoperative diameter ≥80 mm as significant risk factor for primary endpoints. The median follow-up was 13 (interquartile range: 2-37) months and at 3-year survival and freedom from reintervention rates were 65% and 62%, respectively. After univariate and multivariate analyses, preoperative diameter ≥80 mm was considered an independent risk factor for reinterventions [hazard ratio (HR): 1.9; 95% confidence interval (CI) 1.1-3.6; P = 0.04], and for target visceral vessels instability (HR: 3.1; 95% CI: 1.3-5.1; P = 0.04), occurred in 45 (18%) cases. However, after competing risk methods, preoperative diameter did not show significance for follow-up results. A preoperative thoracoabdominal aortic aneurysm diameter >80 mm has not had a direct impact on early technical and clinical outcomes. A diameter≥80 mm is considered risk factor for reinterventions and target vessels instability is considered separately during follow-up.

Custom-Made Device (CMD) for the Repair of Thoraco-Abdominal Aneurysm (TAA): Mid-Long Term Outcomes from a Single Southeast Asian Centre Experience in Singapore.

Introduction: Given the high risk of peri-operative morbidity and mortality associated with open repair, endovascular repair for thoraco-abdominal aneurysms is increasingly performed. This study aims to describe mid to long-term results for patients who were treated with COOK Custom-Made Endograft Device at a single Southeast Asian tertiary centre. Methods: Mid to long-term results of patients treated from 2012 to 2022 were retrospectively reviewed. Indications for treatment were aortic diameter > 5.5 cm, enlargement > 5 mm in 6 months or high-risk morphology. Clinical, operative, early to late complications and reintervention details were captured. The endpoints were technical success, primary patency and primary assisted patency. Results: Electronic medical records of 29 consecutive patients (64.4 ± 1.6 years old; 26/29 males 89.6%) were reviewed. 24/29 (83%) were hypertensive, and 20/29 (69%) were smokers. The mean diameter was 5.5 cm, and the majority were treated for Crawford type IV (19/29, 65.5%). Endograft deployment was 100%. Catheterisation of fenestration was successful in 109/116 (94%). 30-day mortality and morbidity were observed in 12/29 (41%), for which access site complications were most common. No significant haemorrhage or graft explant was recorded. The mean follow-up period was 32.4 months (range 1-108 months). Primary patency was 92.9% (95% CI: 83.8-100.0) at 6 months and decreased to 77.7% (95% CI: 63.4-95.2) at 24 months. Sac shrinkage or stability was noted in 17/29 (58.6%). Re-intervention was performed in 9/29 (31%) for limb occlusion (2/9, 22.2%), renal artery stent occlusion (1/9, 11.1%) and endoleaks (6/9, 66.6%). Assisted patency was maintained at 100% for 12 months before decreasing to 66.7% (95% CI: 37.9-100.0) at 24 months. Conclusions: The study reports the first mid-long-term result in this region, though limited by the sample size. Re-intervention at 30% suggests that disease and procedures remain challenging, emphasising the need to assimilate lessons and experience at high-volume centres.

Women Experience Higher Rates of Mortality Following Thoracic Endovascular Aneurysm Repair

Thoracic endovascular aortic repair (TEVAR) and complex endovascular thoraco-abdominal aneurysm repair have been increasingly adopted in the treatment of thoracic and thoracoabdominal aorta aneurysms, offering a less invasive approach for patients with appropriate anatomy. Women usually present with smaller aortic diameter. However, they usually have greater aneurysm growth rates. How sex can affect postoperative and short-term outcomes after TEVAR is not well reported. The aim of this study was to assess outcomes in female versus male patients undergoing TEVAR for treatment of thoracic and thoracoabdominal aneurysms in a Medicare-linked database. We retrospectively reviewed patients undergoing TEVAR for thoracic and thoracoabdominal aneurysm repair in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018. Patients were divided into males and females. Patients presented with ruptured aneurysm were excluded from the analysis. Postoperative outcomes included in-hospital stroke, myocardial infarction, spinal cord ischemia, and 30-day mortality. One-year outcomes included mortality, aneurysmal rupture, and reintervention. Postoperative outcomes were assessed using multivariable logistic regression analysis and 1-year outcomes were evaluated using Kaplan-Meier Survival and Cox regression analyses. A total of 3,058 males and 1,843 females were available for the analysis. Female patients had smaller median aortic diameter, were more likely to be Black, with chronic obstructive pulmonary disease, and chronic kidney disease, and to be symptomatic on presentation. Male patients were more likely to be on preoperative medications such as aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, P2Y12 antagonists, and anticoagulants. After adjusting for potential confounders, female gender was associated with double the risk of in-hospital stroke (odds ratio: 2.3, 95% confidence interval [CI] [1.5-3.7], P<0.001) and 80% increase in 30-day mortality (odds ratio: 1.8, 95% CI [1.3-2.6], P=0.001). At 1year, female gender was associated with a higher risk of mortality (hazard ratio: 1.2, 95% CI [1.05-1.4], P=0.011). There was a trend toward higher risk of reintervention (hazard ratio: 1.2, 95% CI [0.97-1.6], P=0.079). Mortality after TEVAR seems to be higher in female patients at 30days and up to 1year of follow-up. Female patients also face a 2 times higher risk of in-hospital stroke. Future studies with a larger female population should aim to identify and potentially ameliorate the factors associated with these unfavorable outcomes in females.

Outcomes of Deep Hypothermic Circulatory Arrest for Descending and Thoracoabdominal Aneurysm Repair

Deep hypothermic circulatory arrest (DHCA) in patients undergoing descending thoracic (DTAA) or thoracoabdominal aortic aneurysm (TAAA) repair is associated with increased morbidity and mortality. We present our outcomes after open DTAA and TAAA repair with and without DHCA. From 1999 to 2022, 81 (38.8%) patients undergoing DTAA or TAAA repair required DHCA because proximal cross-clamping was not feasible or aneurysmal pathology extended into the arch and 128 (61.2%) patients required only distal bypass. Because of intrinsic pathological differences in patients requiring DHCA, confidence intervals (CIs) were used to compare groups in lieu of formal hypothesis tests. DHCA patients had more chronic dissections (64.2% vs. 43.8%, 95% CI for difference: 6-35%) and higher body mass indices (29.5±6.8 vs. 27.2±6.6, CI: 26-421%). More non-DHCA patients had medial degeneration (9.9% vs. 31.3%, CI: -33 to -7%). There were 10 (12.4%) in-hospital deaths for the DHCA and 10 (7.8%) for the non-DHCA group (CI: -5 to 14%). Survival at 10years was 52.6% (CI: 42.1-65.7%) for the non-DHCA group and 48.3% (CI: 40.3-57.9%) for the DHCA group. The only meaningful differences in postoperative outcomes were intensive care unit (5.5days vs. 6days, CI: 12-410%) and hospital stay (19days vs. 12days, CI: 74-470%), which were longer in the DHCA group. Despite longer intensive care unit and hospital length of stays, selective use of DHCA is safe and effective with comparable morbidity and mortality to non-DHCA in open DTAA and TAAA repair.

Commentary on cerebrospinal fluid drain pilot study in high-risk fenestrated/branched endovascular aneurysm repair of thoracoabdominal aneurysm repair

Commentary on cerebrospinal fluid drain pilot study in high-risk fenestrated/branched endovascular aneurysm repair of thoracoabdominal aneurysm repair

Intestinal Fatty Acid–Binding Protein as a Potential Biomarker for Gastrointestinal Complications after Complex Endovascular Aortic Surgery

This study aimed to investigate the association between intestinal fatty acid-binding protein (I-FABP), acute gastrointestinal injury (AGI) grade, and gastrointestinal (GI) complications after fenestrated or branched endovascular aortic aneurysm repair. A total of 17 patients undergoing endovascular aortic repair for thoracoabdominal, juxtarenal, suprarenal, or pararenal aneurysm between May 2017 and September 2018 were enrolled. Blood samples were collected preoperatively and during postoperative intensive care. The blood samples were analyzed for I-FABP with enzyme-linked immunosorbent assay. Gastrointestinal function was assessed according to the AGI grade every day during postoperative intensive care. Higher concentrations of I-FABP at 24hr and 48 hr correlated to higher AGI grade on postoperative days 1, 2, and 3 (P=0.032 and P=0.048, P=0.040 and P=0.018, and P=0.012 and P=0.016, respectively). Patients who developed a GI complication within 90days postoperatively had a higher overall AGI grade than those who did not develop a GI complication (P<0.001), as well as higher concentrations of I-FABP at 48 hrs (P=0.019). Patients developing GI dysfunction (AGI grade ≥2) had a higher frequency of complications (P=0.009) and longer length of stay in the intensive care unit (P=0.008). In patients undergoing endovascular aortic repair for complex aneurysm increased postoperative plasma I-FABP concentrations and postoperative GI dysfunction, evaluated using the AGI grade, were associated with GI complications, indicating that these measures may be useful in the postoperative management of these patients.

Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database

Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. A total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortalitydid not differ by hospital volume (quartile [Q]1= 35/1059 [3.3%]; Q2= 30/1063 [2.8%]; Q3= 33/1120 [2.9%]; and Q4= 44/1060 [4.2%]; P= .308). The high volume group had a higher rate of major complication (Q1= 14.9%; Q2=12.8%; Q3= 13.3%; and Q4= 20.1%; adjusted P< .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1= 4.5%; Q2= 18.7%; Q3= 11.3%; and Q4= 19.2%; P< .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1= 34.9%; Q2= 32.8%; Q3= 30.0%; and Q4= 29.0%; P= .003). In themultivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1= 1.1 [0.6-1.9], Q2= 0.6 [0.4-1.1], and Q3= 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.

Intravascular Iliac Artery Lithotripsy to Facilitate Aortic Endograft Delivery: Midterm Results of a Dual-Center Experience.

To assess the feasibility and safety of intravascular lithotripsy (IVL) for enabling transfemoral abdominal (EVAR), thoracic (TEVAR), and thoracoabdominal (BEVAR) endovascular aneurysm repair in patients with narrow and calcified iliac arteries. Consecutive patients treated with IVL for severe calcified and narrowed iliac access before EVAR, TEVAR, or BEVAR between November 2020 and June 2022 were retrospectively evaluated. All anatomical iliac characteristics were acquired by multi-planar reconstruction of preoperative computed tomography angiography (CTA). The hostility of the vascular accesses was classified based on Peripheral Arterial Calcium Scoring System (PACSS) and calcified access severity score (CASS), a new score considering both anatomical (calcium grade and length, minimum lumen diameter [MLD], and tortuosity index) and aortic stent-graft (SG/MLD index) parameters. Primary endpoint was technical success defined as successful aortic endograft delivery and deployment without iliac rupture. Freedom from complications and primary patency were additionally analyzed. Twenty-eight iliac axes were treated with IVL (8 bilateral) in 20 patients (mean age 74.5±6.7 years) with a mean follow-up of 26.5±6.2 (range 17-36) months. Ten patients underwent EVAR: 3 TEVAR, and 7 BEVAR procedures. In 14 patients (70%), aneurysm disease was associated with symptomatic aorto-iliac occlusive disease (AIOD), with Rutherford class III to IV. The PACSS was grade IV in 89% of the cases and the CASS (mean 14±2) was grade III to IV in all cases. The stent-graft (SG) outer diameter (5.60±1.65 mm) was significantly larger by 50% than MLD (3.96±1.20 mm), with an SG/MLD index of 1.50±0.51 (p<0.001). Technical success was 100%. No dissection, rupture, or distal embolization occurred. One (3.4%) bail-out stenting was necessary as endoconduit after IVL treatment. One month CTA showed that postoperative luminal gain increased by 93% (p<0.001). An improvement of 2 Rutherford classes occurred in all AIOD patients with a primary patency of 100% at last follow-up. This study shows the safety and feasibility of IVL as a valuable option to treat narrow and calcified iliac arteries to facilitate endograft delivery. Further studies will be useful to confirm these results. In this article, the use of intravascular iliac artery lithotripsy to facilitate aortic endograft delivery is explored. The presence of iliac severe calcifications still represents a contraindication for aortic endovascular repair. Intravascular lithotripsy increases the feasibility and safety of endovascular aortic procedures, facilitating endograft delivery and reducing the risk of iliac rupture and/or dissections by improving vessel compliance and luminal gain. This novel vessel preparation could be an alternative to "paving and cracking" and/or iliac conduits. This study describes a new score to classify the severity of iliac calcifications, considering anatomical parameters and the profile of aortic endografts delivery system.

Thoracoabdominal aneurysm repair using the Unitary Manifold Device

To present a single-center prospective study of 126 consecutively treated patients who underwent endovascular repair of a thoracoabdominal aortic aneurysm with the physician-modified, nonanatomic-based Unitary Manifold (UM) device. Data were collected from 126 consecutive all-comer patients treated with the physician-modified, nonanatomic-based UM from 2015 to 2023. Treatment was performed at a single center by a single physician under a Physician Sponsored Investigation Exemption G140207. The UM was indicated for repair of all Crawford extents including juxtarenal, pararenal, and short-neck infrarenal aneurysms (<10mm) in 126 consecutive patients. Patients were not excluded from the study based on presentation, extent of aneurysm or dissection, or history of a spinal cord event. Patients with a thoracoabdominal aortic aneurysm were categorized by Crawford classification: types I and V (3.3%, n= 4), type II (3.3%, n= 4), type III (1%, n= 1), and type IV (93.3%, n= 117). The type IV classification patients were further categorized with 33 (28.2%) true type IV, 68 (58.1%) pararenal or infrarenal, and 16 (13.7%) with dissection. Technical success was 99.2% (n= 125). The most common major adverse event within both 30days and 365days of all patients was respiratory failure (11.9%, n= 15, and 13.5%, n= 17, respectively). One patient (0.8%) experienced persistent paraplegia at 365days. Reintervention for patients at 365days was 5.6% (n= 7). Of the 444 branches stented, the primary patency rate was remarkably high as only three patients (2.4%) required reintervention due to loss of limb patency within 365days. Aneurysm enlargement (≥5mm) occurred in 1.6% (n= 2) patients, and no patients experienced aneurysm rupture. No patients underwent conversion to open repair. The aneurysm-related mortality at 365days for all patients was 4.0% (n= 5), whereas all-cause mortality was 16.7% (n= 21). Physician-modified endograft device integrity failure was not observed in any patient. The UM device demonstrated remarkable technical surgical success, treatment success, and device patency rates with very reasonable major adverse events and reintervention rates. This study is the most representative example of the general population in comparison with other studies of off-the-shelf devices, with 126 consecutive all-comer patients with diverse pathologies.

Parallel intercostal artery stenting and exclusion of symptomatic bucket-handle intercostal patch aneurysm

Intercostal patch aneurysms after open thoracoabdominal aneurysm repair represent a challenging pathology, with highly variable patient anatomy and spinal cord ischemia risk. We present a case of a 51-year-old man with a large symptomatic "bucket-handle" loop graft intercostal patch aneurysm, which was treated with endovascular exclusion with concurrent parallel intercostal stent grafting. This case highlights specialized endovascular techniques to treat intercostal patch aneurysms and the necessity of meticulous operative case planning in both open and endovascular thoracoabdominal aneurysm repair.

Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score.

Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs are Associated With Outcomes

Surgeon Volumes of Endovascular Thoracoabdominal Aneurysm Repairs are Associated With Outcomes

Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access.

To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases. Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle. Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases. A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.