Treatment Of Complex Aortic Aneurysms Research Articles

5-year Outcomes of Fenestrated and Branched Endovascular Repair of Complex Aortic Aneurysms Based on Aneurysm Extent

To evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent. Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms-TAAA), group 2 (type IV TAAA), and group 3 (juxtarenal, pararenal, or paravisceral aortic aneurysms - JRAA, PRAA, PVAA). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions. Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I-III TAAA, 69 with type IV TAAA, and 236 with JRAA, PRAA, or PVAA. All cases were treated under a physician-sponsored IDE protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3, P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%, P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%, P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm, P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%, P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared to group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared to group 3 (5.3 vs 4.3% vs .4%, P = .004). The 5-year survival was significantly higher in group 3 when compared to group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared to group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined. Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups make meticulous follow-up paramount in complex aortic aneurysm patients treated with F/BEVAR.

EXTENT study: Medium-term outcomes of EXTra-design engineering inner-branch ENdografts for the treatment of complex aortic aneurysms from a multicenter collaboration

ObjectiveThis study aims to present the medium-term outcomes of Extra-Design engineering endografts with inner branches (EDE-iBEVARs, Artivion) in endovascular aortic repairs of complex aneurysms building upon promising early results. MethodsA retrospective, international, multi-center study was conducted including consecutive patients who underwent complex endovascular aortic repairs using EDE-iBEVARs between 2018 and 2022. Patient demographics, aneurysm anatomical features, procedural details, reinterventions, complications, and endograft failures during follow-up were assessed. The primary outcome was aneurysm-related mortality. Secondary outcome measures included the freedom from all-cause mortality and reintervention, technical and clinical success, and late related complications including branch instability, endoleaks, and serious adverse events. ResultsOur study encompassed a total of 260 patients across 13 European centers. The cohort included patients with thoracoabdominal aortic aneurysms (n = 116), suprarenal or juxta-renal aneurysms (n = 95), and those who had previous open repair or previous endovascular aortic repair with type 1A endoleak (n = 49). Of 982 possible inner branches (937 antegrade and 45 retrograde), 962 (98%) were successfully cannulated and bridged with covered stents during the index procedure. Overall, the endograft was successfully deployed in 98% of patients, and 93% were discharged from hospital following surgery. At 3 years, freedom from aneurysm-related mortality was 97%, whereas the freedom of all-cause mortality was 89%. Freedom from reinterventions was 91% and 76% at 1 and 3 years, respectively. The rate of late complications such as endoleaks or branch instability events was 12% (n = 30). The late branch occlusion rate during follow-up was 1.5% (n = 15), of which 12 were renal branches. ConclusionsEDE-iBEVARs demonstrate satisfactory medium-term outcomes with reintervention rates comparable to other endografts. Encouragingly, rates of branch patency were high, and major adverse events were low. This technology could expand the treatment options for patients with challenging complex aortic conditions.

Unsuspected Limitations of 3D Printed Model in Planning of Complex Aortic Aneurysm Endovascular Treatment

Objective Static 3-dimensional (3D) printing became attractive for operative planning in cases that involve difficult anatomy. An interactive (low cost, fast) 3D print allowing deliberate surgical practice can be used to improve interventional simulation and planning. Background Endovascular treatment of complex aortic aneurysms is technically challenging, especially in case of narrow aortic lumen or significant aortic angulation (hostile anatomy). The risk of complications such as graft kinking and target vessel occlusion is difficult to assess based solely on traditional software measuring methods and remain highly dependent on surgeon skills and expertise. Methods A patient with juxtarenal AAA with hostile anatomy had a 3-dimensional printed model constructed preoperatively according to computed tomography images. Endovascular graft implantation in the 3D printed aorta with a standard T-Branch Cook (Cook® Medical, Bloomington, IN, USA) was performed preoperatively in the simulation laboratory enabling optimized feasibility, surgical planning and intraoperative decision making. Results The 3D printed aortic model proved to be radio-opaque and allowed simulation of branched endovascular aortic repair (BREVAR). The assessment of intervention feasibility, as well as optimal branch position and orientation was found to be useful for surgeon confidence and the actual intervention in the patient. There was a remarkable agreement between the 3D printed model and both CT and X-ray angiographic images. Although the technical success was achieved as planned, a previously deployed renal stent caused unexpected difficulty in advancing the renal stent, which was not observed in the 3D model simulation. Conclusion The 3D printed aortic models can be useful for determining feasibility, optimizing planning and intraoperative decision making in hostile anatomy improving the outcome. Despite already offering satisfying accuracy at present, further advancements could enhance the 3D model capability to replicate minor anatomical deformities and variations in tissue density.

Sex-Comparative Outcomes of the T-Branch Device for the Treatment of Complex Aortic Aneurysms.

Females are at increased risk of mortality compared to males after complex endovascular aortic repair. This study aims to examine sex-related peri-operative and follow-up outcomes in patients managed with the t-Branch device. A two-center retrospective analysis of patients managed with the off-the-shelf t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) between 1 January 2014 and 30 September 2020 was performed. Primary outcomes were sex-comparative 30-day mortality, major adverse events (MAEs) and spinal cord ischemia (SCI). A total of 542 patients were included; 28.0% were females. Urgent repair and type I-III thoracoabdominal aneurysms were more common among females (52.6% vs. 34%, p = 0.01, and 57.1% vs. 35.8%, p = 0.004). Technical success was similar (97.4% vs. 96.9%, p = 0.755), as well as early mortality (16.2% in females vs. 10.8% in males; p = 0.084). SCI rates were similar between groups (13.6% vs. 9.2% p = 0.183). MAEs were more common in females; 33.7% vs. 21.4% (p = 0.022). Multivariate analysis did not identify sex as an independent predictor of adverse events. The 12-month survival rate was 75.7% (SE 0.045) for females and 84.1% (SE 0.026) for males (log rank, p = 0.10). Sex was not detected as an independent factor of mortality, MAEs and SCI within patients managed with the t-Branch device. Feasibility was high in both groups. No significant difference was shown in survival during the 12-month follow-up.

Increased Aortic Exclusion in Endovascular Treatment of Complex Aortic Aneurysms.

Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair. This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test. A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I-IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05). There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison.

The Use of the Off-the-Shelf Inner Branch E-nside Endograft for the Treatment of Elective and Emergent Complex Aortic Aneurysms—A Single-Center Experience

The aim of this single-center study was to evaluate the early results of the off-the-shelf inner branch E-nside endograft in the treatment of complex aortic aneurysms and thoracoabdominal aortic aneurysms. We performed a retrospective analysis of a prospectively maintained database of all patients treated with the E-nside endograft at our institution during the years 2021-2023. Parameters evaluated were technical success, early major adverse events, target vessel patency, and the presence of endoleaks. In total 16 patients underwent treatment with the E-nside endograft. Six additional patients were evaluated for the device but were excluded due to anatomical considerations. Mean age was 71 (range 59-84) and 14 (88%) were males. Mean aneurysm diameter was 66mm(range 54-85). Aneurysms treated included thoracoabdominal in 9 (56%), juxtarenal aneurysms in 5 (31%), postdissection aneurysm in 1 (6%) and a type 1A endoleak after a failed endovascular aneurysm repair in 1 (6%). Five of the treated aneurysms were symptomatic. A total of 58 side branches were placed into target visceral arteries. Mean operative time was 190min (range 150-360). Technical success was achieved in 15/16 of the patients (94%). At 30days, 1 perioperative mortality and 3 major adverse events occurred, 2 of them branch related. The E-nside endograft is a feasible option for the treatment of a broad spectrumof aortic pathologies. As it is an off-the-shelf device, it can be used selectively inelective and emergent settings with acceptable30-day mortality and morbidity. Further follow-up is required to determine the durability of this treatment option and patency of side branches.

Endovascular Solutions for Abdominal Aortic Aneurysms: Fenestrated, Branched and Custom-Made Devices.

Abdominal aortic aneurysm (AAA) has a prevalence of 4.8%. AAA rupture is associated with significant mortality, thus surgical intervention is generally required once the aneurysm diameter exceeds 5.5cm. Endovascular aneurysm repair (EVAR) is the predominant repair modality for AAA. However, in patients with complex aortic anatomy, fenestrated or branched EVAR is a superior repair option vs standard EVAR. Fenestrated and branched endoprostheses can be off-the-shelf or custom-made, which offers a more individualised approach. To summarise and evaluate the clinical outcomes achieved by fenestrated EVAR (FEVAR) and branched EVAR (BEVAR), and to explore the role of custom-made endoprostheses in contemporary AAA management. A literature search using Ovid Medline and Google Scholar was conducted to identify literature pertaining to the use and outcomes of fenestrated, branched, fenestrated-branched and custom-made endoprostheses for AAA repair. FEVAR is an effective repair modality for patients with AAA that offers similar early survival, improved early morbidity but higher rates of reintervention in comparison to open surgical repair (OSR). Compared with standard EVAR, FEVAR is associated with similar in-hospital mortality yet higher rates of morbidity, especially regarding renal outcomes. BEVAR outcomes are rarely reported exclusively in the context of AAA repair. When reported, BEVAR is an acceptable alternative to EVAR in the treatment of complex aortic aneurysms and has similar reported complication issues to FEVAR. Custom-made grafts are a good alternative treatment option for complex aneurysms where hostile aneurysm anatomy precludes the use of conventional EVAR and sufficient time is available for the manufacturing of such devices. FEVAR offers a very effective treatment for patients with complex aortic anatomy and has been well-characterised over the past decade. RCTs and longer-term studies are desirable for unbiased comparison of non-standard EVAR modalities.

Experience with inner branch off the shelf device for thoracoabdominal aneurysms.

Endovascular treatment of complex aortic aneurysms (cAAA) including thoracoabdominal aortic aneurysms is becoming more common. Most patients require custom made devices and until recently the off the shelf (OTS) options were limited. The aim of this manuscript was to describe a new inner branch OTS device and its clinical applications. A review of the current literature on the ENSIDE device from Artivion was performed and the authors' experience presented. The short outcomes of this particular OTS device are acceptable and the anatomical suitability on par with other similar devices. The preloaded configuration of the device can offer benefits in complex anatomy. New OTS devices for cAAA can provide treatment in emergent or urgent situations in many patients. Long term follow-up is needed and caution must be made against excessive use in less extensive aneurysms due to the risk of spinal cord ischemia.

Use of surgical augmented intelligence maps can reduce radiation and improve safety in the endovascular treatment of complex aortic aneurysms

ObjectiveThe introduction of endovascular procedures has revolutionized the management of complex aortic aneurysms. Although repair has traditionally required longer operative times and increased radiation exposure compared with simple endovascular aneurysm repair, the recent introduction of three-dimensional technology has become an invaluable operative adjunct. Surgical augmented intelligence (AI) is a rapidly evolving tool initiated at our institution in June 2019. In our study, we sought to determine whether this technology improved patient and operator safety. MethodsA retrospective review of patients who had undergone endovascular repair of complex aortic aneurysms (pararenal, juxtarenal, or thoracoabdominal), type B dissection, or infrarenal (endoleak, coil placement, or renal angiography with or without intervention) at a tertiary care center from August 2015 to November 2021 was performed. Patients were stratified according to the findings from intelligent maps, which are patient-specific AI tools used in the operating room in conjunction with real-time fluoroscopic images. The primary outcomes included operative time, radiation exposure, fluoroscopy time, and contrast use. The secondary outcomes included 30-day postoperative complications and long-term follow-up. Linear regression models were used to evaluate the association between AI use and the main outcomes. ResultsDuring the 6-year period, 116 patients were included in the present study, with no significant differences in the baseline characteristics. Of the 116 patients, 76 (65.5%) had undergone procedures using AI and 40 (34.5%) had undergone procedures without AI software. The intraoperative outcomes revealed a significant decrease in radiation exposure (AI group, 1955 mGy; vs non-AI group, 3755 mGy; P = .004), a significant decrease in the fluoroscopy time (AI group, 55.6 minutes; vs non-AI group, 86.9 minutes; P = .007), a decrease in the operative time (AI group, 255 minutes; vs non-AI group, 284 minutes; P = .294), and a significant decrease in contrast use (AI group, 123 mL; vs non-AI group, 199 mL; P < .0001). No differences were found in the 30-day and long-term outcomes. ConclusionsThe results from the present study have demonstrated that the use of AI technology combined with intraoperative imaging can significantly facilitate complex endovascular aneurysm repair by decreasing the operative time, radiation exposure, fluoroscopy time, and contrast use. Overall, evolving technology such as AI has improved radiation safety for both the patient and the entire operating room team.

Augmented Intelligence Maps Can Improve Intraoperative Outcomes

Endovascular treatment of complex aortic aneurysms has traditionally required increased operative time, radiation exposure, fluoroscopy time, and contrast compared with treatment of simple aortic aneurysms. However, previous literature has shown that this minimally invasive approach improves patient morbidity and mortality compared with open repair. Surgical overlay software using augmented intelligence (AI) is a fast-developing area that was initiated at our institution in June 2019. In the present study, we have sought to show that the use of this software can aff5ct patient safety.

The Impact of the Proctor Assistance for a Safe Learning Curve in the Development of a Complex Aortic Endovascular Program

Introduction: Initiating an endovascular aortic program for treatment of complex aortic aneurysms with fenestrated and branched grafts (FB-EVAR) is challenging. Using a Proctor is one option for training and development of the team. However, this approach has not been formally analyzed. The aim of this study was to analyze the learning curve and the effect of the Proctor regarding safety and effectiveness in FB-EVAR. Methods: A single-center retrospective cohort study was performed, including all consecutive elective patients submitted to FB-EVAR (including both thoraco-abdominal-TAAA and complex abdominal aortic aneurysms-C-AAA) from 2013 to 2021. Patients were divided into 2 groups, the first operated with the Proctor present and the second without. Primary outcomes were 30-day mortality (safety) and technical and procedure success (efficacy). Secondary outcomes included treatment performance (procedure time, blood loss, contrast, and radiation use), re-interventions, aneurysm shrinking, target vessel patency, 30-day mortality, aneurysm-related mortality, and overall mortality. Results: Overall, 105 patients were included in the study, 35 operated with Proctor and 70 operated without. The first 20 patients were operated always with the Proctor, and the remaining were operated with the Proctor selectively. Mean age was 71.8 (±7.3) years and 95 patients were male (90.5%). Overall, 62 (65%) patients had C-AAA or extent IV TAAAs and 43 (35%) had extensive TAAAs. There were no significant differences regarding 30-day mortality (Log Rank=0.99), technical success (p=0.4), or procedure success (p=0.8). Mean surgical time was longer in the non-Proctor group (p=0.005), as well as significant intra-operative blood loss (p=0.042). Contrast use (p=0.5) and radiation (p=0.53) were non-significantly different between groups. There were no significant differences regarding length of stay (p=0.4), major adverse events (p=0.6), target vessel patency (Log Rank=0.97), early (p=0.7) and late endoleaks (0.7), aneurysm shrinking (p=0.6), re-interventions (p=0.2), and overall mortality (Log Rank=0.87). Conclusion: In our experience, the use of a Proctor to start and accompany our complex endovascular aortic program for FB-EVAR was both safe and effective and may serve as a template by other countries and centers that aim to developing their programs.

The Use of Surgical Augmented Intelligence in the Treatment of Complex Aortic Aneurysms

The introduction of endovascular procedures has revolutionized the management of complex aortic aneurysms. Although these repairs traditionally require longer operative times and increased radiation exposure compared with simple endovascular aneurysm repairs, the recent introduction of three-dimensional technology has become an invaluable operative adjunct. Surgical augmented intelligence (AI) is a rapidly evolving tool initiated at our institution in June 2019. Our study aims to show this technology improves patient and operator safety.

Outcomes of multibranched off-the-shelf stent graft in elective and urgent/emergent repair of complex aortic aneurysms with narrow internal aortic lumen

ObjectivesTo assess the outcomes of Cook t-Branch off-the-shelf multibranched stent graft in the treatment of complex aortic aneurysms with narrow internal aortic lumen. MethodsBetween 2016 and 2020, 48 patients (mean age, 73 years) underwent elective or urgent or emergent Cook t-Branch implantation for thoracoabdominal or para/juxtarenal aortic aneurysms in two Italian vascular centers. Among these, 20 patients presented a paravisceral or pararenal luminal diameter of less than 25 mm. Major clinical and radiologic outcomes of patients with narrow aortic lumen were compared with patients with a larger lumen in a multicenter, nonrandomized, retrospective fashion. ResultsThe in-hospital mortality was 10% (5% in the elective setting). Spinal cord ischemia occurred in 6% of the cases. During a mean follow-up of 18 months (range, 1-63 months), late t-Branch procedure-related mortality and the need for reintervention was 0% and 12%, respectively. Comparing the outcomes of patients with large internal aortic lumen (group 1) with patients with small lumen (group 2), no significant difference was found regarding fluoroscopy time (P = .3); technical success (P = 1); early (P = .4) and late (P = 1) mortality; spinal cord ischemia (P = .2); bowel ischemia (P = .5); renal (P = .7), cardiac (P = 1), and respiratory complications (P = 1); reintervention rate (P = 1); and primary patency rate of stented target vessels (P = 1). ConclusionsThe use of the Cook t-Branch in our experience was safe and effective in the treatment of complex aortic aneurysms regardless the caliber of the aortic lumen. With all the limitations of a small sample size, this approach has demonstrated to be feasible when maneuverability is decreased, with low mortality and morbidity, and acceptable reintervention rates. Perioperative mortality remains closely related to clinical presentation. Large-scale studies are needed to confirm these results.

Cannulation of Visceral Vessels Using a Steerable Sheath in Fenestrated and Branched Aortic Endografts

A critical step in the endovascular treatment of complex aortic aneurysms is the cannulation and stenting of renovisceral vessels, especially in cases with a complex anatomy or atherosclerotic lesions. This study aimed to demonstrate the results of renovisceral vessel cannulation using a steerable sheath in fenestrated or branched endovascular aortic procedures (FB-EVAR). Patients undergoing elective FB-EVAR for asymptomatic thoracoabdominal or juxtarenal aneurysm at a single tertiary referral center from 2016 to 2019 were included in this study. Underlying pathologies, renovisceral target vessels (TV), technical success (TS), freedom from reintervention (FFR), and TV patency were assessed. Target vessels were categorized as challenging or nonchallenging TV. Fifty-three patients (median age 73 (Q1, Q3 (68-80)); 43 male (81%)) who underwent elective FB-EVAR were included. Indications comprised thoracoabdominal aneurysms (Crawford I-IV) (n=26; 49%), juxtarenal aneurysms (n=23; 43.5%) and penetrating aortic ulcers (PAU) (n=4; 7.5%). Two patients (4%) had prior open aortic surgery, and three patients (6%) had undergone a failed standard EVAR before. Of the 196 treated TV, 131 (67%) were categorized as challenging. Cannulation was successful in 194 of 196 vessels (99%). A total of 3TV (1.5%) showed periprocedural complications. No significant difference was found in the rate of intraoperative complications between challenging versus nonchallenging TV (P=0.457). One patient died within 30days of the procedure (1.9%). No stroke or intestinal ischemia occurred. After 12, 24, and 36months, the survival rate was 87%, 87%, and 81%, respectively. Primary patency after 12months was 98.6%, and 97.9% of vessels remained FFR during follow-up. Transfemoral, retrograde cannulation of renovisceral vessels using a steerable sheath is feasible and safe and provides good mid-term results, especially in cases with challenging renovisceral vessels. The potential complications of antegrade vascular access can be avoided.

Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies

Purpose To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms. Technique We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography. Conclusion Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.

Collective Consciousness on Complex Aortic Repair: Time to Focus on Data Capture

In this issue of EJVES, Antoniou et al. synthesise the current literature comparing open treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms (TAAs) with endovascular treatment using branched and fenestrated techniques.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Their meta-analysis of >7 000 patients should be commended, particularly given the fact that they only include comparative studies that utilise propensity or regression analyses, thereby limiting bias. They also capture follow up data. The take home messages are clear. Firstly, their analysis does not show a statistically significant difference in early or late survival between patients treated with either technique. Secondly, re-intervention is twice as likely in patients who have had endovascular vs. open repair, but there is a lack of granular data relating to the impact of these re-interventions, including any adverse effect on survival or quality of life. The third, and perhaps most important, message is that the quality of evidence found to inform both of the aforementioned conclusions is poor. The work by Antoniou et al. is a stark reminder of the need to improve the evidence base that guides treatment of complex aortic aneurysms. However, it is important that we do not obsess with the prospective randomised trial as the only acceptable standard of evidence and recognise the value of other study designs. The European Society for Vascular Surgery guidelines recommended fenestrated endografting as the preferred treatment for juxtarenal aneurysms (Class IIa, Level C), despite the lack of randomised trial data.2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (757) Google Scholar Antoniou et al. consider a prospective trial randomising open and endovascular juxtarenal aneurysm repair as feasible but, rightly, suggest that TAA are a different proposition without equipoise for randomisation.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Branched/fenestrated techniques allow treatment of significant numbers of patients with TAAs who would otherwise be turned down for open repair. However, detractors point to a risk of overenthusiasm for endovascular techniques and undue influence by manufacturers driving the operators' decisions to offer repair. To address this there is a need to instigate large scale, structured, prospective data collation from centres performing both endovascular and open repair to the same standard and to analyse these using the latest data science tools.3Dey D. Slomka P.J. Leeson P. Comaniciu D. Shrestha S. Sengupta P.P. et al.Artificial intelligence in cardiovascular imaging.J Am Coll Cardiol. 2019; 73: 1317-1335Crossref PubMed Scopus (151) Google Scholar In addition to post-operative survival and durability of repair, data on this scale may inform (1) objective assessment of anatomical characteristics that affect choice of repair modality; (2) the projected life expectancy of the patient, identifying those best served by conservative management; and (3) the relative effect on quality of life and likelihood of functional decline with each type of repair. For now, we must recognise that our life changing treatment decisions are best made in multidisciplinary teams consisting of a critical mass of experts. At a minimum, these teams should offer equal expertise in both open and endovascular repair so as not to limit the choice offered to the patient. They should also include medical colleagues able to give an objective opinion on the patient's physiology to aid decision making. The recent furore over the drafting of the National Institute for Health and Care Excellence aneurysm guidelines should be a wakeup call.4National Institute for Health and Care Excellence. Abdominal Aortic Aneurysm: Diagnosis and Management. NICE guideline NG156. Available at: https://www.nice.org.uk/guidance/ng156 [Accessed 25 November 2020].Google Scholar The time to gather better evidence that informs treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms is now. Editor's Choice – Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched DataEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 2PreviewThe aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. Full-Text PDF

Contribution of hybrid rooms on the results of fenestrated and branched stentgrafts

No literature data demonstrate the contribution of hybrid rooms equipped with tools like image fusion or CBCT (Cone Beam Computed Tomography) to the late results of the treatment of complex aortic aneurysms with fenestrated and/or branched stentgrafts (SG) (F/BEVAR). Our study aimed to evaluate this contribution after F/BEVAR.

Comparative study of the early results of laser fenestrated stentgrafts and manufactured fenestrated stentgrafts for the treatment of complex aortic aneurysms

The objective of this study was to compare the 6-month results of laser fenestrated stentgrafts (LFS) and manufactured fenestrated stentgrafts (MFS) for the treatment of complex aneurysms of the abdominal aorta (CAA), of thoracoabdominal aneurysms (TAA) and type I endoleaks in high surgical-risk patients.

Physician-Modified Endovascular Gore Excluder Graft (Handmade Modified) for Complex Abdominal Aortic Aneurysm: A Step-by-Step Approach.

Endovascular repair has become the gold standard for the treatment of infrarenal abdominal aortic aneurysmal disease. Branched and fenestrated commercially custom-made devices have been developed as a treatment option for short necks or juxtarenal aneurysms. However, the lack of availability in some countries and centers, manufacturing time (6-8 weeks requirements), urgent setting in ruptured abdominal aortic aneurysms, and elevated costs make them not a widespread option. Hereby, we expose our step-by-step technique of physician modified Gore Excluder to treat complex aneurysms.Physician-modified endovascular graft (PMEG) has emerged as an alternative to open repair for the treatment of complex aortic aneurysms. The ultimate goal of fenestrations is to increase the proximal sealing zone length. The Gore C3 delivery system allows repositioning of the graft by constraining the proximal part after a back-table physician modification; the PMEG technique with the Gore Excluder C3 delivery system can be used for complex aortic aneurysms repair as an alternative treatment option.

Cerebrovascular Complications After Upper Extremity Access for Complex Aortic Interventions: A Systematic Review and Meta-analysis

The purpose of this study was to review the risk of developing cerebrovascular complications from upper extremity access during endovascular treatment of complex aortic aneurysms. A systematic review and meta-analysis were conducted according to the PRISMA guideline. An electronic search of the public domains Medline (PubMed), Embase (Ovid), Web of Science and Cochrane Library was performed to identify studies related to the treatment of aortic aneurysms involving upper extremity access. Meta-analysis was used to compare the rate of cerebrovascular event after left, right and bilateral upper extremity access. Results are presented as relative risk (RR) and 95% confidence intervals (CIs). Thirteen studies including 1276 patients with complex endovascular treatment of aortic aneurysms using upper extremity access were included in the systematic review. Left upper extremity access (UEA) was used in 1028 procedures, right access in 148 and bilateral access in 100 procedures. The rate of cerebrovascular complications for patients treated through left UEA was 1.7%, through right UEA 4% and through bilateral UEA 5%. In the meta-analysis, we included seven studies involving 645 patients treated with a left upper extremity access, 87 patients through a right and 100 patients through a bilateral upper extremity access. Patients, who underwent right-sided (RR 5.01, 95% CI 1.51–16.58, P = 0.008) or bilateral UEA (RR 4.57, 95% CI 1.23–17.04, P = 0.02), had a significantly increased risk of cerebrovascular events compared to those who had a left-sided approach. Left upper extremity access is associated with a significantly lower rate of cerebrovascular complications as compared to right or bilateral upper extremity access.