Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

Outcome Following Open Repair of Hereditary and Non-Hereditary Thoracoabdominal Aortic Aneurysm in Patients Under 60 Years Old-A Multicenter Study

Objective: This multicenter study compares outcomes of open thoracoabdominal aortic aneurysm (TAAA) repair in patients < 60 years with (n = 106), versus without (n = 167), hereditary aortopathy. Methods: We conducted a retrospective analysis of 273 consecutive open TAAA repairs (2000-2024) at two European centers. The primary endpoint was early outcome. We used a Kaplan-Meier curve to assess survival, and logistic regression to identify predictors. Results: Operative death rates were similar (hereditary: 13/106 [12.3%] vs. non-hereditary: 22/167 [13.2%], p = 0.83). Hereditary aortopathy patients were younger (median 42 vs. 54 years, p < 0.001) with lower BMI (24.1 vs. 28.4 kg/m2, p < 0.001). Non-genetic patients had higher rates of chronic kidney insufficiency (58/167 (34.7%) vs. 14/106 (13.2%), p < 0.001), coronary artery disease (43/167 (25.7%) vs. 9/106 (8.5%), p < 0.001), and prior myocardial infarction (31/167 (18.6%) vs. 4/106 (3.8%), p < 0.001). Hereditary aortopathy patients suffered more often from post-dissection TAAA (68/106 [64.2%] vs. 44/167 [26.3%], p < 0.001) and prior aortic surgery (81/106 (76.4%) vs. 79/167 (47.3%), p < 0.001). Pulmonary complications (67.0% vs. 61.1%, p = 0.32), acute kidney injury (25.5% vs. 22.8%, p = 0.61), and spinal cord ischemia (6.6% vs. 10.2%, p = 0.31) were comparable between groups. Overall 5-year survival was 65.7%; the rate of any reintervention during follow up was 21.2%. Logistic regression identified no predictors for perioperative mortality. Conclusions: Open TAAA repair in patients < 60 years carries relevant perioperative mortality, which is comparable between hereditary and non-hereditary groups; non-hereditary patients had impaired preoperative cardiopulmonary status.

A Systematic Review and Meta-Analysis of Local-Regional versus General Anesthesia for Elective Endovascular Abdominal Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment for abdominal aortic aneurysms. The choice between general anesthesia (GA) and local-regional anesthesia (LRA) may impact outcomes, but evidence remains inconsistent. This systematic review and meta-analysis aimed to compare GA and LRA in elective EVAR, focusing on mortality, major adverse cardiovascular events (MACE), endoleaks, intensive care unit admissions, and hospital stay (HS). A comprehensive search of PubMed, Embase, Cochrane Central, and ClinicalTrials.gov included studies from inception to December 2024. Observational studies meeting predefined criteria were analyzed using a fixed-effects model in R, and evidence certainty was assessed using the GRADE framework. This work was registered on PROSPERO (CRD42024547446). Seventeen studies with 91,560 patients were included. LRA was associated with reduced mortality (OR 0.75; 95% CI 0.59-0.97), lower MACE (OR 0.74; 95% CI 0.61-0.90), fewer intensive care unit admissions (OR 0.77; 95% CI 0.73-0.81), fewer type 1 endoleaks (OR 0.84; 95% CI 0.72-0.97), fewer type 2 endoleaks (OR 0.63; 95% CI 0.57-0.70), and shorter HS (-0.38 days; 95% CI -0.46 to -0.30). Sensitivity analyses confirmed most results, but mortality lost significance in some cases. The certainty of evidence ranged from low to very low due to some inconsistencies in studies. LRA may offer better outcomes than GA in elective EVAR, including lower mortality, MACE, and shorter HS. However, further randomized trials are needed to confirm these findings and guide clinical practice.

Endoanchors for the distal fixation of iliac limb in endovascular aneurysm repair

This report details the case of an 84-year-old male with an infrarenal abdominal aortic aneurysm and a dilated right common iliac artery eligible for endovascular treatment. A bifurcated stent graft (Medtronic Endurant IIs) was used to treat the aneurysm. To address the concerns of instability of the right iliac limb, four endoanchors (Heli-FX EndoAnchor, Medtronic) were placed at the distal landing zone to provide additional fixation. This case shows good result in the improvement of stability of the iliac limb with potentially enhanced durability.

Imaging Surveillance Adherence After Endovascular Abdominal Aortic Aneurysm Repair at VA Hospitals

Importance

Guidelines recommend annual imaging surveillance after endovascular abdominal aortic aneurysm repair (EVAR). How these guidelines translate into practice among veterans remains poorly described.

Objective

To characterize post-EVAR surveillance among veterans.

Design, Setting, and Participants

This retrospective cohort study evaluated veterans who underwent EVAR between January 1, 2000, and December 31, 2023, at US Department of Veterans Affairs (VA) hospitals and received follow-up care at VA and non-VA hospitals and imaging centers with payment via Medicare or the VA. Veterans treated with EVAR in VA hospitals during the study period were included.

Exposure

Years after EVAR.

Main Outcomes and Measures

The primary outcome was annual surveillance adherence, measured as 1 or more imaging studies in the abdomen or pelvis each year after EVAR. Stepwise logistic regression modeling was used to determine factors associated with poor adherence. Secondary outcomes were imaging type (cross-sectional, ultrasonography, or ultrasonography followed by cross-sectional imaging) and factors associated with lower adherence.

Results

The cohort included 27 792 veterans (27 624 male [99.4%]; 22 521 aged ≥65 years [81.0%]). Mean (SD) follow-up was 6.0 (4.0) years. The mean (SD) proportion of time that veterans were surveillance adherent was 71.1% (28.5%). Surveillance was initially high, with 25 026 of 27 792 veterans (90.0%) undergoing surveillance imaging in year 1 after EVAR. However, this proportion decreased further out from EVAR, with 12 401 of 21 384 veterans (58.0%) undergoing surveillance imaging by year 4 after EVAR. Veterans were most likely to undergo imaging with computed tomography scans (21 911 veterans [78.8%]). However, the proportion with surveillance via ultrasonography alone increased from 823 of 25 026 veterans (3.3%) in year 1 after EVAR to 2567 of 12 401 veterans (20.7%) in year 4 after EVAR. White race (odds ratio [OR] vs all other racial groups, 0.84; 95% CI, 0.72-0.98), married status (OR vs all other social status categories, 0.80; 95% CI, 0.71-0.89), having a service-connected disability (OR, 0.69; 95% CI, 0.62-0.77), and a higher Charlson Comorbidity Index score (OR per 1-unit increase, 0.93; 95% CI, 0.91-0.95) were associated with lower odds of poor surveillance adherence.

Conclusions and Relevance

In this study, post-EVAR imaging surveillance was high, although surveillance lapses were more likely further out from EVAR and for patients with certain characteristics. This information may inform future patient-centered efforts to improve post-EVAR imaging adherence.

Infective native aortic and iliac artery aneurysms: Clinical profiles and short-term outcomes from a single-center cohort

INTRODUCTION

Infective native aortic and iliac artery aneurysms, although rare, have high mortality rates of 21%-44 %. Diagnosis is often delayed owing to nonspecific symptoms. Treatment includes surgical intervention and antimicrobial therapy. This study aimed to describe the clinical characteristics and short-term outcomes of 32 patients with infective aneurysms at a single center.

METHODS

This retrospective study, conducted at the Saitama International Medical Center from January 2011 to December 2020, included patients diagnosed with infective native aortic and iliac artery aneurysms. The patients' clinical data, microbiological and radiological findings, treatment methods, and outcomes were collected and analyzed.

RESULTS

Of the 32 patients, 56.3 % presented with fever (≥37.5 °C) and 87.5 % exhibited nonspecific symptoms, such as pain and loss of appetite. Blood cultures were positive in 18 patients (58.1 %), with Staphylococcus aureus being the predominant pathogen, isolated in 11 patients. Pathogens in 5 of the 11 cases (45 %) were resistant to methicillin. Surgery was performed in 75 % of patients, with 20 undergoing open surgical repair (OSR) and 4 undergoing endovascular treatment (EVT). The 1-year mortality rates of the patients who underwent OSR and EVT were 23.5 % (4/17) and 0 % (0/4), respectively. Postoperative infection-related complications occurred in 25 % of patients who underwent OSR. For nonsurgical patients, the 30-day and 1-year mortality rates were 25 % (2/8) and 85.7 % (6/7), respectively.

CONCLUSION

The findings of this study highlight the high mortality rates associated with infective aneurysms. S. aureus was the predominant pathogen, differing from trends observed in other Asian regions.

Long-term outcomes of abdominal aortic aneurysm screening in patients undergoing transthoracic echocardiography

PURPOSE

Reports on the usefulness of abdominal aortic aneurysm (AAA) screening during transthoracic echocardiography (TTE) in Japan are limited. This study aimed to describe the prevalence of AAA among patients who underwent routine screening during TTE, as well as the long-term clinical outcomes of patients in whom AAA was detected.

METHODS

We screened 46,353 consecutive patients who underwent TTE for suspected cardiac disease at our institution. Among these, a total of 1133 patients were identified as having AAA, defined as an abdominal aorta diameter of 30 mm or greater. After excluding patients with prior aortic surgery, including endovascular repair (n = 104), those with known AAA (n = 569), and those with known aortic dissection (n = 25), the study population consisted of 435 patients, all diagnosed with AAA for the first time.

RESULTS

The overall prevalence of AAA among patients undergoing TTE was 0.94%. The mean age was 76.8 years, and the study population was predominantly males (81.6%). The prevalence of AAA in patients under 60 years of age was low: 0.24% for men and 0.076% for women. The left atrial volume index was 43.8 ± 23.1 ml/m2, the left ventricular mass was 164.9 ± 52.0 g, and the diameter of the sinus of Valsalva was 32.6 ± 4.4 mm, all of which were numerically higher than the normal values observed in a healthy Japanese population. During the median follow-up period of 2.0 years, 43 surgical or endovascular repairs of AAA, six aorta-related deaths, and 90 all-cause deaths occurred. The cumulative incidence of surgical or endovascular repair of AAA was 5.3% at 1 year, 11.5% at 3 years, and 18.1% at 5 years. The cumulative incidence of aorta-related death was modest: 0.3% at 1 year, 0.8% at 3 years, and 1.6% at 5 years.

CONCLUSION

The prevalence of newly diagnosed AAA among patients who underwent routine screening during TTE for suspected cardiac disease was 0.94% in the Japanese population, with the majority being 60 years or older. Approximately 10% of patients diagnosed with AAA underwent surgical or endovascular repair during follow-up, suggesting that this approach may be effective in preventing deaths caused by AAA.

Iliac branch endoprosthesis for endovascular treatment of complex aorto-iliac aneurysms - from device design to practical experience: how to translate physiology considerations into clinical applications

This article provides a narrative review of the current literature and our expert opinion concerning the iliac branch endoprosthesis (IBE) and its use in the treatment of complex abdominal aortic aneurysm (AAA) cases with concomitant aneurysmal involvement of the common iliac artery (CIA) and/or the internal iliac artery (IIA). Up to 25% of those with an AAA may present with extension of the aneurysmal disease into the iliac vessels. This anatomy may complicate the standard endovascular aortic repair (EVAR) procedure, as the available length of distal landing zones is altered. The optimum treatment requires both the adequate sealing of the distal landing zone as well as the preservation of the pelvic circulation through the IIA. Extensive preoperative assessment of the anatomy, as well as an accurate deployment following all procedural steps, enables endovascular treatment of complex aorto-iliac aneurysms safe with excellent midterm clinical outcomes. The current literature shows that the utilization of the IBE offers a durable treatment of these complicated cases with results equal to those of the open repair, without the associated morbidity. Preservation of the pelvic circulation is recommended to prevent pelvic ischaemic symptoms and can also be carried out on both sides provided certain anatomical requirements are met.

Abdominal Compartment Syndrome After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Single-Center Experience of Total Endovascular Care for Ruptured Abdominal Aneurysms

OBJECTIVE

Open repair of ruptured abdominal aortic aneurysms (rAAA) has been increasingly replaced by endovascular aortic repair (EVAR) in many centers. Despite being a minimally invasive procedure, EVAR is associated with a risk of abdominal compartment syndrome (ACS), which can lead to significant morbidity and mortality. This study examines the incidence and clinical manifestation of ACS in a consecutive cohort of rAAA patients treated exclusively with EVAR at Örebro University Hospital over a 12-year period.

METHODS

This is a retrospective analysis of prospectively collected data. We identified 139 patients who had presented to Örebro University Hospital with rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic and thoracoabdominal aortic ruptures, previous aortic interventions (open or endovascular), and patients receiving palliative treatment were excluded. Patients developing ACS after rAAA were compared with those who did not develop ACS.

RESULTS

A total of 100 patients treated using EVAR were included in this study. ACS was identified in 17 patients, and these were compared with 83 patients who did not develop ACS. Mortality at 30 days was 53% in the ACS group (9/17) and 22% in the No-ACS group (18/83, p = 0.015). Regression analysis showed that advanced age and ACS were independent risk factors for death, with ACS increasing the hazard 4-fold (HR 4.26, CI 1.99-9.10, p < 0.001) and age increasing the hazard by 6% for every year (HR 1.06, CI 1.06-1.1, p = 0.004). The use of aortic balloon occlusion was not independently associated with the development of ACS.

CONCLUSIONS

ACS is a life-threatening complication of rAAA treated using EVAR and a significant number of patients developed ACS with high mortality and complication rates. All rAAA patients treated using EVAR should be monitored closely for ACS and treatment with decompressive laparotomy should be initiated without delay.Clinical ImpactOpen repair of ruptured abdominal aortic aneurysms (rAAA) has been increasingly replaced by endovascular aortic repair (EVAR). Despite being a minimally invasive procedure, EVAR is associated with a risk of abdominal compartment syndrome (ACS), which can lead to significant morbidity and mortality This article investigates abdominal compartment syndrome (ACS) in a cohort of total endovascular treated rAAA in a single centre and the treatment as well as the results, and gives insight on ACS in this patient group and might contribute to better understanding how to treat them and avoid this life-threatening complication.

The Impact of Neutrophil-to-Lymphocyte Ratio on Short- and Long-Term Prognosis Following Elective Infrarenal EVAR

BACKGROUND

Neutrophil-to-lymphocyte ratio (NLR) is a readily available parameter, associated with long-term outcomes in cardiovascular conditions. This study aims to analyze the predictors of NLR and its impact on prognosis and disease-specific outcomes following endovascular aneurysm repair (EVAR).

METHODS

Single-center retrospective cohort study. Consecutive patients who underwent elective EVAR (2011-2023) were considered. Primary outcome is short-term major adverse events (MAE) and long-term mortality. Secondary outcomes were freedom-from EVAR failure, aortic reintervention, and NLR predictors. Multivariable logistic regression analyses were performed for binary outcomes. Survival outcomes were analyzed through Kaplan-Meier and Cox regression analyses.

RESULTS

Overall, 434 patients were included. A 2.4 NLR cutoff was a fair discriminator for long-term-mortality (area under the curve, 0.62), and groups were dichotomized according to this premise. Increasing age (adjusted odds ratio [aOR]: 1.06; 1.03-1.09, per 1-year increase) and a pulmonary comorbidity (aOR: 1.91; 1.24-2.96) associated to NLR ≥ 2.4. No significant association between comorbidity burden and NLR was observed. MAE occurred more often if NLR ≥ 2.4 (6.2 vs. 11.6% high-NLR, P = 0.049; NLR ≥ 2.4 aOR: 2.10; 1.01-4.36). At 8-years follow-up, survival estimates favored NLR < 2.4 (55.7% vs. 33.7% high-NLR, P < 0.001, NLR ≥ 2.4 adjusted hazard ratio [aHR]: 1.07; 1.05-1.98), without differences in freedom-from EVAR failure (70.6 vs. 68.2% high-NLR, P = 0.27, NLR ≥ 2.4 aHR: 1.26; 0.82-1.94). Conversely, NLR ≥ 2.4 associated with lower freedom from aortic reinterventions (80.0% vs. 70.2% high-NLR, P = 0.01, NLR ≥ 2.4 aHR: 1.80; 1.08-3.01).

CONCLUSION

NLR appears as a prognostic marker with reduced impact of comorbidity burden. Following EVAR, it independently predicts MAE and mortality. Over time, elevated NLR appears associated with increased aortic reinterventions, although rates and mode of failure seem similar across groups.

Lipidomic insights on abdominal aortic aneurysm and peripheral arterial disease

Abdominal aortic aneurysm (AAA) and peripheral arterial disease (PAD) are two cardiovascular diseases associated with considerable morbidity, mortality and quality of life impairment. As they are multifactorial diseases, several factors contribute to their pathogenesis, including oxidative stress and lipid peroxidation, and these may have key roles in the development of these pathologies. Alterations of the lipid metabolism and lipid profile have been reported in cardiovascular diseases but to a lesser extent in AAA and PAD. Modifications in the profile of some molecular lipid species, in particular, native phospholipid and triglyceride species were mainly reported for AAA, while alterations in the fatty acid profile were noticed in the case of PAD. Oxidized phospholipids were also reported for AAA. Although AAA and PAD have a common atherosclerotic root, lipidomics demonstrates the existence of distinct lipid. Lipidomic research regarding AAA and PAD is still scarce and should be set in motion to increase the knowledge on the lipid changes that occur in these diseases, contributing not only to the discovery of new biomarkers for diagnosis and prognosis assessment but also to tailor precision medicine in the clinical field.

Standards for Abdominal Aortic Aneurysm Repair Quality Improvement Registries: A Delphi Consensus Report From VASCUNET and the International Consortium of Vascular Registries

OBJECTIVE

Outcome registries in vascular surgery are used increasingly to drive quality improvement by vascular societies. The VASCUNET collaboration, within the European Society for Vascular Surgery (ESVS), and the International Consortium of Vascular Registries (ICVR) developed a set of variables for quality improvement registries on abdominal aortic aneurysm (AAA) repair as a registry standard.

METHODS

Representatives from international vascular registries within VASCUNET, ICVR, and other nations with established registries were invited to provide the variables. The final variables were developed through a two stage modified Delphi process. Variables from the established registries with at least 60% consensus among all the registries were included for round 1. A five point Likert scale (strongly disagree to fully agree) was used. If the limit of consensual agreement was not reached in round 1, the variable was discussed again in round 2. For round 2, an array question method (yes, no to unsure) was used. Agreement of at least 70% resulted in the variable being included in the final dataset.

RESULTS

A total of 88 of 371 variables extracted from all AAA registries were circulated in the modified Delphi process as they reached the 60% consensus threshold. The questionnaire was circulated to 55 participants (round 1: 49; 89%; round 2: 43; 78%). After two rounds, 70 variables were recommended on consensual agreement. These variables comprised demographics (n = 4), pre-operative information (n = 28), intra-operative variables (n = 18), post-operative variables (n = 5), and follow up (n = 13).

CONCLUSION

Based on this modified Delphi process, an international panel of vascular surgeons representing quality improvement registries recommended 70 core variables as standard in AAA repair registries. The inclusion of a core set of variables in AAA vascular registries may help to further harmonise observational research and quality of AAA repair among global healthcare systems.

Effect of Aortic Thrombus on Outcomes Following Repair of Juxtarenal Aneurysms Using Physician Modified Endografts

OBJECTIVE

Studies have suggested that aortic thrombus may be associated with adverse outcomes following endovascular repair of aortic aneurysms, while other reports have suggested higher rates of sac regression and a reduced risk of endoleak. However, the effect of thrombus burden on outcomes following physician modified endografts (PMEGs) remains unknown. This study aimed to assess the volume and morphology of thrombus burden and the effect on outcomes following PMEG for juxtarenal abdominal aortic aneurysm.

METHODS

This was a retrospective cohort study of patients who underwent PMEG from 2009 to 2021 in a single centre, investigational device exemption trial. Thrombus burden was measured as a percentage of luminal volume using pre-operative computed tomography scans from the lowest renal artery to the level of the aortic bifurcation using centreline reconstruction software. Morphology was documented by the presence of finger like projections. Univariable and multivariable analyses evaluated the impact on peri-operative and long term outcomes.

RESULTS

Volumetric and morphological measures of thrombus burden were assessed in 142 patients; 40.1% of the cohort were classified as having a high thrombus burden (≥ 50% luminal volume) on volumetric assessment and 22.5% had finger like projections on morphological assessment. Type II endoleak was more frequently observed in those with low thrombus burden (60.0% vs. 33.3%; p = .008) and persisted after multivariable analysis (odds ratio 2.5, 95% confidence interval 1.1 - 5.8), but there were no other statistically significant differences in peri-operative adverse events or late outcomes, including sac behaviour, freedom from re-intervention, and overall survival when stratifying thrombus burden by quantitative or qualitative measures. There were no observed differences in operative or anatomical characteristics, including landing zone characteristics and rates of inferior mesenteric artery patency.

CONCLUSION

While thrombus burden and morphology were not associated with adverse peri-operative events or survival, low thrombus burden was associated with an increase in type II endoleak. These findings suggest that thrombus burden should not deter treatment for patients requiring PMEG.

Risk Stratification and Treatment Selection in Patients With Asymptomatic Abdominal Aortic Aneurysms

Importance

Open surgical repair (OSR) should be prioritized for patients with asymptomatic abdominal aortic aneurysm (AAA) and long life expectancy, whereas endovascular repair (EVAR) is preferred for patients with suitable anatomy and life expectancy less than 2 to 3 years. However, life expectancy estimation and risk stratification are not well established.

Objective

To evaluate risk-stratified survival differences between OSR and EVAR following elective AAA treatment.

Design, Setting, and Participants

This cohort study used data from Danish national health registries. Patients older than 60 years undergoing elective AAA repair between 2004 and 2023 were categorized into 4 risk groups according to age, estimated glomerular filtration rate, and chronic obstructive pulmonary disease. Follow-up was until March 31, 2024.

Exposure

OSR or EVAR for AAA.

Main Outcomes and Measures

The primary outcome was overall survival. Secondary outcomes were incidence of AAA rupture and new cancer diagnosis. Comorbidities were balanced using inverse probability weighting. Kaplan-Meier estimators were generated for both treatments and the 4 risk score groups.

Results

Of 6891 identified patients, 5757 (83.4%) were men. Women were older (median [IQR] age, 75.4 [70.9-79.3] vs 74.5 [70.5-78.5] years), more often had chronic obstructive pulmonary disease (156 women [13.6%] vs 512 men [8.9%]), and had lower estimated glomerular filtration rate (median [IQR], 68.4 [54.2-80.4] vs 70.4 [56.5-82.4] mL/min/1.73 m2) compared with men. The median follow-up was 8.28 years (95% CI, 8.10-8.50 years). OSR was associated with higher perioperative mortality in all risk groups. In low-risk patients, OSR was associated with a 10-month (95% CI, 2.2-18.3 months; P = .02) longer mean survival time restricted at 15 years compared with EVAR. In moderate-to-high-risk patients, OSR was associated with a 9-month (95% CI, 1.9-16.9 months; P = .008) shorter mean survival time restricted after 12.5 years compared with EVAR. No difference in mean survival time was seen in low-to-moderate-risk and high-risk patients at the study end. No differences in 10-year incidence of secondary AAA ruptures (OSR, 2.6% [95% CI, 1.9%-3.4%] vs EVAR, 2.2% [95% CI, 1.7%-2.7%]; P = .34) or solid malignant tumor (OSR, 18.6% [95% CI, 16.7%-20.5%] vs EVAR, 20.5% [95% CI, 18.9%-22.1%]; P = .35) were detected.

Conclusions and Relevance

In this cohort study of 6891 patients with AAA, OSR was associated with higher perioperative mortality in all risk groups, but with longer mean survival only in low-risk patients. Conversely, EVAR was associated with longer mean survival in moderate-to-high-risk patients. These findings highlight the potential benefits of risk stratification when planning AAA treatment.

Systematic Review and Meta-analysis of Outcomes of the Advanta V12 or iCAST Bridging Stent Graft Used for Fenestrated and Branched Endovascular Aortic Repair

OBJECTIVE

Half of re-interventions after fenestrated and branched endovascular aortic repair (FB-EVAR) are target vessel related. Regarding bridging stent choice, existing data are controversial. This meta-analysis aimed to evaluate the performance of Advanta V12/iCAST as the bridging stent in FB-EVAR.

DATA SOURCES

The English medical literature was searched through MEDLINE, Embase (via Ovid), and Cochrane databases (end date 15 April 2024).

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and PICO (Patient, Intervention, Comparison, Outcome) model were followed. A predefined protocol was registered to PROSPERO (CRD42024556603). Randomised controlled trials and observational studies (2010 - 2024) reporting on Advanta V12/iCAST related target vessel outcomes were eligible. Risk of bias was assessed using ROBINS-I, and evidence quality was assessed via Grading of Recommendations Assessment, Development and Evaluations (GRADE). Primary outcomes were freedom from instability, stenosis and or occlusion, types Ic and IIIc endoleak, and re-intervention of target vessels bridged with the Advanta V12/iCAST. Prevalence and regression meta-analysis were performed.

RESULTS

From 1 439 articles, ten retrospective studies (7 525 target vessels; 3 890 target vessels bridged with Advanta V12/iCAST) were included. According to ROBINS-I, no study was of high quality. Mean follow up was 24.3 (95% confidence interval [CI] 23.9 - 24.7) months. Freedom from instability, stenosis and or occlusion, and types Ic and IIIc endoleak were 94% (95% CI 91 - 96%; p < .010; I2 = 91%; GRADE certainty, very low), 97% (95% CI 96 - 98%; p =  .070, I2 = 44%; GRADE certainty, low), and 97% (95% CI 94 - 98%; p < .010; I2 = 81%; GRADE certainty, very low), respectively. Freedom from target vessel re-intervention was 95% (95% CI 92 - 97%; p < .010; I2 = 85%; GRADE certainty, very low). Four studies provided extractable data on Advanta V12/iCAST in fenestrations and four in branches. No difference was detected in freedom from instability (p = .47), stenosis and or occlusion (p = .36), and types Ic and IIIc endoleak (p = .90). Freedom from re-intervention was 93% (95% CI 87 - 96%; p < .010; I2 = 90%) in fenestrations and 95% (95% CI 91 - 97%; p = .060, I2 = 64%) in branches.

CONCLUSION

The Advanta V12/iCAST bridging stent showed high freedom from target vessel instability, stenosis and or occlusion, and endoleak. Freedom from re-intervention was 95%, being similarly high in fenestrations and branches.

Perioperative Advances in Repair of Abdominal Aortic Aneurysm: A Narrative Review of Strategies to Enhance Outcomes and Reduce Complications

Despite ongoing advancements in abdominal aortic aneurysm (AAA) repair, perioperative complications remain a major concern. This narrative review offers a novel analysis of emerging perioperative strategies, uniquely integrating recent guideline updates with evolving innovations such as AI-driven risk models, frailty and sarcopenia assessment, and personalized hemodynamic management. Unlike previous reviews, this article bridges evidence-based practices with real-world implementation challenges, highlighting barriers to guideline adherence, especially in low-resource settings. The review evaluates the latest developments in anesthetic approaches, fluid and transfusion protocols, Enhanced Recovery After Surgery (ERAS) programs, and infection control measures, with a strong emphasis on tailored pathways for both open surgical repair (OPS) and endovascular aneurysm repair (EVAR). Long-term surveillance protocols and antimicrobial graft technologies are explored as key future directions. By connecting recent literature with practical, patient-centered applications, this work provides a forward-looking roadmap for optimizing AAA care across diverse clinical environments. Its novelty lies in presenting a comprehensive, multidisciplinary framework that incorporates precision medicine and implementation science to advance perioperative vascular surgery outcomes.

Rupture of Abdominal Aortic Aneurysm due to Listeria Monocytogenes infection

Infective native aortic aneurysms (INAA) caused by Listeria monocytogenes are rare, with most cases involving Streptococcus sp. We report a case of a woman in her mid-60s who presented with a contained rupture of an infrarenal abdominal aortic aneurysm (AAA) due to Listeria The woman presented with intermittent abdominal and lower back pain, malaise, nausea, elevated inflammatory markers and ketoacidosis. CT angiography revealed a 40 mm AAA with inflammation and rupture. Intravenous ampicillin and gentamicin were initiated, and emergency open aortic repair was performed. Cultures confirmed Listeria infection. Postoperative neurological symptoms resolved, and the patient improved with continued antibiotics. One month postoperatively, she was asymptomatic with normalised inflammatory markers. This case underscores the rarity of Listeria-induced aneurysms and highlights the need for international registries to guide the management of INAA and further research on optimal surgical management.

Endotension following endovascular aortic repair: systematic review and meta-analysis on occurrence rate, treatment approaches and outcomes

INTRODUCTION

Endotension is still a poorly understood phenomenon in terms of occurrence rate, treatment indications and outcomes. The aim of this study was to report incidence, different treatment approaches and outcomes of patients affected by endotension after EVAR.

EVIDENCE AQUISITION

A systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library) was undertaken until June 2024. Articles reporting data about occurrence rate, strategy of treatment and outcomes of patients affected by endotension, including at least five cases of endotension were included. Meta-analyses of proportions were performed using a random-effects model.

EVIDENCE SYNTHESIS

Thirteen non-randomized studies published between 2005 and 2024 were examined, with a total of 22,118 patients undergoing EVAR due to abdominal aortic aneurysm. Among them, 209 patients developed endotension during follow-up, resulting in an estimated occurrence rate of 1.6% (95% CI 0.9-2.3). Four approaches to treat endotension were reported in literature. Estimated rates were: open surgical conversion (OSC) in 37.3% (95% CI 10.5-64.0), conservative approach in 25.9% (95% CI -4.4-56.2), endovascular relining in 23.3% (95% CI 11.4-35.2) and semi-conversions in 19.5% (95% CI 4.9-34.2). The technical success (TS) in OSC, relining and semi-conversion subgroups were respectively: 93.4% (95% CI 85.7-101), 80.7% (95% CI 60.5-101) and 94.5% (95% CI 85.2-103.8).

CONCLUSIONS

OSC is the most used method, achieving high TS rate. OSC and semi-conversion presented a high CS during follow-up, while relining had lower "durability" compared to surgical treatments. Data about conservative treatment are scarce but in can be considered for selected cases.

Hybrid repair of aortic aneurysm in a patient with a congenital pelvic kidney

We describe a patient with an asymptomatic infrarenal abdominal aortic aneurysm. Treatment decisions were complicated by the presence of a left congenital pelvic kidney supplied by two renal arteries originating from the proximal common iliac arteries bilaterally and respiratory status that was prohibitive to open repair. A hybrid surgical repair was performed with a bifurcated aortic endograft and parallel grafting to revascularize the pelvic renal arteries. This procedure was combined with a right common iliac endovascular occlusion and femoral-femoral bypass. This case adds to the limited reports of endovascular management of patients with concomitant aneurysmal disease and ectopic kidneys.

Functional anti-inflammatory mesoporous silica nanoplatform for Synergistic and Targeted abdominal aortic aneurysm treatment

Abdominal aortic aneurysm (AAA) is a chronic inflammation-driven disease characterized by aortic wall destruction and expansion, leading to high morbidity and mortality. However, previous drug treatments for its common risk factors have not achieved favorable results, and the early prevention and treatment is still the main clinical dilemma. Anti-inflammation therapy is a promising therapeutical method targeting its pathogenesis mechanism, but it has not been explored in depth. Herein, interleukin-1 receptor antagonist-loaded manganese-doped mesoporous silica nanoparticles (IL-1Ra@MMSN) were designed and synthesized to target macrophage-mediated chronic aortic inflammation for AAA treatment. IL-1Ra@MMSN showed high IL-1Ra-loading efficiency, great stability and pH-responsive drug-releasing property. IL-1Ra@MMSN specially phagocytosed by macrophages can protect against oxidative stress injury and promoted the M2 polarization via transforming growth factor-β (TGF-β) signaling in vitro. Furthermore, IL-1Ra@MMSN exhibited good lesion targeting ability, hemocompatibility and biocompatibility in angiotensin II-induced murine AAA model. In vivo experiments also confirmed the excellent treatment efficacy in reducing AAA formation and progression via protecting aortic wall integrity and promoting anti-inflammatory microenvironment. Taken together, the current study demonstrated that IL-1Ra@MMSN is a promising nanoplatform for early intervention of AAA, which provides a novel treatment strategy based on anti-inflammatory immune regulation.

Perioperative Antithrombotic Strategies in Vascular Surgery: A Survey in Germany

Background and Aims

The variety of modern antithrombotic medications complicates the choice of individual perioperative therapy in vascular surgery, especially when more than one antithrombotic option is possible. The aim of this study was to determine the perioperative and periinterventional setting concerning antithrombotics in vascular surgery in Germany.

Methods

This article is based on a survey from year 2018 of heads of German vascular surgical departments or units regarding their experience with different anticoagulants. The survey asked for the frequency and time of preoperative pausing of the antithrombotics before various vascular operations or interventions.

Results

The evaluable response rate was 52% (169/324). Acetylsalicylic acid was discontinued before open aortic surgery in 9% (15/169) of respondents. Clopidogrel was paused in 65% (107/169) before open aortic surgery, in 25% (41/169) before vascular surgery (like carotid endarterectomy, endovascular aortic repair, or operations on peripheral arteries), and in 11% (18/169) before peripheral percutaneous interventions. Discontinuation of vitamin K antagonists or direct oral anticoagulants (took place before conventional operations in 99.4%; oral anticoagulation was continued for peripheral percutaneous interventions in only 6% (8/169). Management was heterogeneous with regard to the timing of the perioperative medication pause. Clopidogrel was not discontinued according to time specifications in 8%; ticagrelor in 75%; rivaroxaban in 23%; and dabigatran in 29%, compared to the recommendations of the industrial information sheets.

Conclusion

The perioperative antithrombotic therapy in German vascular surgery clinics is not uniform and does not correspond to the current specialist recommendations in a notable proportion of clinics.

Kidney Function, Kidney Function Decline, and the Risk of Abdominal Aortic Aneurysm: The Stockholm CREAtinine Measurements (SCREAM) Project

OBJECTIVE

Low estimated glomerular filtration rate (eGFR) increases the risk of arterial diseases, possibly including abdominal aortic aneurysm (AAA). This study explored the relationship between eGFR (2008 CKD-EPI equation), annual eGFR decline, and subsequent risk of developing AAA in a large, community based sample.

METHODS

This was an observational study using complete healthcare records of Stockholm residents free from AAA who underwent routine creatinine testing during 2011 - 2021. Cox regression, adjusted for age, sex, comorbidities, and ongoing medications, was used to analyse the association between a single point eGFR or the change in eGFR within a year and the rate of both a de novo AAA diagnosis (both intact and ruptured) and fatal AAA (i.e., AAA followed by death within 30 days).

RESULTS

The study included 1 586 410 participants (mean age 48 years; 53% female; median eGFR 96 mL/min/1.73 m2). During a median follow up of 7.6 years, 5 313 participants (0.34%) experienced AAA, of which 321 (0.02%) were fatal. In multivariable analyses, compared with eGFR 90 mL/min/1.73 m2, the rates of AAA events were higher across lower eGFRs: for eGFR 30 mL/min/1.73 m2, the hazard ratio (HR) of AAA was 1.24 (95% confidence interval [CI] 1.09 - 1.40) and of fatal AAA was 2.51 (95% CI 1.67 - 3.75); for eGFR 15 mL/min/1.73 m2, the HR of AAA was 1.49 (95% CI 1.19 - 1.86) and of fatal AAA was 3.73 (95% CI 2.04 - 6.81). When analysed separately, the results were similar for intact and ruptured AAA risk. Among the 638 959 participants who had repeated eGFR tests, 3 447 (0.54%) experienced AAA events, of which 217 (0.04%) were fatal. Compared with stable eGFR (change -1 to 1 mL/min/year), the rate of AAA events was 15% higher (HR 1.15, 95% CI 1.05 - 1.26) in participants with an eGFR decline of 1 to 3 mL/min/year and 46% higher (HR 1.46, 95% CI 1.16 - 1.84) in those with an eGFR decline of > 3 mL/min/year.

CONCLUSION

In this observational study, both a single point eGFR and a faster eGFR decline were associated with the risk of experiencing AAA. The incidence of AAA, and particularly fatal AAA, was higher in individuals with greater severity of chronic kidney disease or faster eGFR decline.

Inflammatory Aneurysm of the Common Iliac Artery With Elevated Serum Levels of Immunoglobulin G4 Manifesting After Endovascular Aneurysm Repair: A Case Report

Inflammatory aneurysms (IAs) are characterized by the thickening of the arterial wall and fibrosis of periarterial tissues. Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is related to IAs, and about half of IA cases are considered IgG4-related. Although some cases of inflammation after endovascular aneurysm repair (EVAR) have been reported, its relationship with the serum levels of IgG4 has rarely been discussed. Here, we report on a patient diagnosed with and treated for an IA with elevated serum levels of IgG4 following EVAR. An 83-year-old man presented with a bilateral common iliac artery aneurysm. We observed no inflammatory features in his vital signs, laboratory test results, or computed tomography (CT) images. The patient was diagnosed with a non-inflammatory bilateral common iliac artery aneurysm. EVAR was performed using an infrarenal bifurcated stent graft (diameter, 31 mm; length, 15 cm; GORE EXCLUDER AAA Endoprosthesis (WL Gore & Associates, Inc., Flagstaff, AZ, USA)), with an ipsilateral limb stent graft (diameter, 12 mm; length, 7 cm; GORE EXCLUDER) deployed in the left external iliac artery and a contralateral limb stent graft (diameter, 12 mm; length, 14 cm; GORE EXCLUDER) deployed in the right external iliac artery. The patient was discharged in good condition. However, signs of inflammation were observed approximately one month after EVAR. CT images demonstrated the periarterial thickening of the common iliac arteries, and 18F-fluorodeoxyglucose positron emission tomography-CT revealed increased metabolic activity overlying the thickened periarterial tissue. The serum levels of IgG4 and soluble interleukin-2 receptor (sIL-2R) were elevated. The patient underwent steroid therapy based on the suspicion of IgG4-related IA of the common iliac arteries, resulting in reductions of inflammatory signs and periarterial thickening. However, when steroids were reduced, hydronephrosis, periarterial thickening, and increased serum IgG4 and sIL-2R levels were observed. The patient was diagnosed with a relapsed IA and treated with an increased steroid dosage. IAs may occur following EVAR. Steroid therapy may be an effective treatment for post-EVAR IAs, similar to common IAs. Long-term follow-up is desirable to monitor patients for the recurrence of inflammation during the treatment of post-EVAR IAs.

Outcome Analysis of Pre-Emptive Embolization of the Collateral Branches of the Abdominal Aorta During Standard Infrarenal Endovascular Aortic Repair

Objectives: To report the results of pre-emptive embolization of collateral branches of the abdominal aorta in patients undergoing standard bifurcated EVAR versus those undergoing standard EVAR without embolization. Methods: This study is a single-center, retrospective, observational cohort analysis of consecutive patients who underwent elective standard endovascular aneurysm repair (EVAR) between 1 October 2013, and 31 December 2022, with a minimum follow-up period of 2 years. The patients were divided into two groups: group A, which did not receive embolization, and group B, which underwent pre-emptive embolization of aortic collateral branches. The primary outcomes for this study include overall survival, freedom from aorta-related mortality (ARM), and freedom from reinterventions related to type 2 endoleak (T2E). In cases of multiple reinterventions, only the first one was considered for this analysis. The secondary outcome focused on assessing freedom from aneurysm sac enlargement. Results: We analyzed a total of 265 endovascular aneurysm repairs (EVARs): 183 (69.1%) were classified into group A, and 82 (30.9%) into group B. The median follow-up duration was 48 months [interquartile range (IQR), 28-65.5], which was not significantly different between the two groups [45 months (26-63) in group A vs. 52.5 months (29.5-72.5) in group B, p = 0.098]. The estimated cumulative survival rates were 87% (0.2) at 2 years (95% confidence interval [CI]: 82.6-92.9) and 67% (0.3) at 5 years (95% CI: 60.3-73.1), with no significant difference between the groups (p = 0.263). The aorta-related mortality rate was 1.1% (n = 3); all instances occurred following open conversion due to graft infection (n = 2) and in one case of secondary aortic rupture (n = 1). In total, 34 cases (12.8%) indicated a secondary intervention related to type 2 endoleak (T2E). The freedom from T2E-related reintervention rate was 99% (0.01) at 2 years (95% CI: 99.4-99.8) and 88% (0.3) at 5 years (95% CI: 81.4-92.5), with no differences between the groups (p = 0.282). Cox regression analysis revealed that age over 80 years is an independent negative predictor of survival, with a hazard ratio (HR) of 3.5 (95% confidence interval [CI]: 2.27-5.50; p < 0.001). Additionally, T2E-related reintervention was identified as a negative predictor, with an HR of 2.4 (95% CI: 1.05-5.54; p = 0.037). In this study, conversion to open repair was necessary for 14 patients (5.3%), with three conversions occurring due to rupture; however, T2E was not a determining factor in any of these conversions. At the last available follow-up computed tomography angiography (CT-A), the median aneurysm diameter was significantly lower in group B, measuring 44 mm (range 37.7-50), compared to group A, measuring 48 mm (range 39-57.5) (p < 0.001). Both groups showed a significant change from baseline measurements (p = 0.001). Conclusions: Pre-emptive embolization of the aortic collateral branches does not lead to improved aorta-related outcomes after EVAR.

Preoperative and postoperative imaging as a surgical strategy and feedback on abdominal aortic aneurysm with horseshoe kidney: Case report

A 77-year-old man was diagnosed with an infrarenal abdominal aortic aneurysm coexisting with a horseshoe kidney detected on a computed tomography (CT) scan. Since the presence of three accessory renal arteries was confirmed, reconstruction for renal protection was done by performing transperitoneal laparotomy instead of endovascular treatment. After performing anastomosis of a Y-shaped artificial graft, the major accessory renal artery was reconstructed under intraoperative renal perfusion. We report a successful surgical repair without renal isthmus division, where only autologous blood transfusion was performed. Although a postoperative CT scan showed partial renal infarction, creatinine levels, indicative of renal function, were comparable to preoperative levels. Horseshoe kidney is the most common fusion defect of the kidneys with aberrant accessory renal arteries. Thus, clearly constructed images are key to establish an effective operative strategy. Furthermore, comparing preoperative and postoperative CT images could also provide important feedback on the accuracy of treatment strategy.

Midterm Outcomes of the Fenestrated Anaconda Stent Graft for Complex Aortic Aneurysm Repair: A Large, Single Centre, Retrospective Study

OBJECTIVE

The aim of this study was to evaluate the short and midterm outcomes of the Anaconda fenestrated stent graft for the treatment of complex abdominal and thoraco-abdominal aneurysms.

METHODS

This was a retrospective study in a single academic centre. All patients treated consecutively with a fenestrated Anaconda device between January 2019 and May 2024 were included. Outcomes analysed included technical success (TS), procedure related death, occurrence of major adverse events (MAEs) and target vessel instability (TVI), type Ia endoleak (T1aEL), abdominal aortic aneurysm (AAA) related re-interventions, sac changes, and death.

RESULTS

Two hundred and ten patients were treated with the Anaconda stent graft. The mean AAA diameter was 60.4 ± 9.4 mm, with a mean of 3.9 ± 0.6 fenestrations per patient for a total of 816 target vessels (TVs). TS was 96.2% (202/210), MAEs occurred in 6.2% of patients (13/210), and procedure related death was 2.9% (6/210). The mean follow up was 24.0 ± 18.3 months. AAA related re-intervention was necessary in 18.6% of patients. Primary and secondary TV patency at follow up were 97.1% (8792/816) and 98.0% (800/816), respectively Freedom from TVI at one, three, and five years was 95.5% (95% confidence interval [CI] 93.9 - 97.1%), 92.5% (95% CI 90.2 - 94.8%), and 91.7% (95% CI 89.0 - 94.4%), respectively. No T1aELs were observed during follow up. Estimated freedom from sac enlargement at one, three, and four years was 96.9% (95% CI 94.3 - 99.6%), 88.4% (95% CI 82.6 - 94.3%), and 82.8% (95% CI 74.1 - 91.6%), respectively. Estimated overall survival at one, three, and five years was 92.2% (95% CI 88.6 - 95.9%), 80.0% (95% CI 73.3 - 86.8%), and 71.6% (95% CI 62.1 - 81.0%), respectively, with one case (0.5%) of late aortic related death.

CONCLUSION

Endovascular repair of complex abdominal or thoraco-abdominal aneurysms using the fenestrated Anaconda stent graft is safe and effective with a high TS and low procedure related mortality rate. The midterm results appear satisfactory in terms of sac evolution, with a low TVI rate. The need for re-intervention is acceptable and justifies the need for meticulous imaging follow up.

Type II Endoleak after Endovascular Aneurysm Repair Using the EXCLUDER Stent Graft System in Patients with Abdominal Aortic Aneurysm

Purpose: This study aimed to evaluate type II endoleak incidence and its outcome in patients who underwent endovascular aneurysm repair using the EXCLUDER device for abdominal aortic aneurysm. Material and Methods: One hundred sixty-seven patients who underwent endovascular aneurysm repair for abdominal aortic aneurysm (96 with patent and 71 with occluded inferior mesenteric artery) between 2008 and 2017 were retrospectively evaluated. Type II endoleak incidence and aneurysm enlargement of >5 mm after endovascular aneurysm repair were evaluated. The predictive factors for late type II endoleak identified >6 months after endovascular aneurysm repair and aneurysm enlargement were assessed based on the preoperative patient and anatomical characteristics. Results: Late type II endoleak incidence was higher in the patent inferior mesenteric artery at 42.7% (41/96; 95% confidence interval, 33.3-52.7), compared with 22.5% (16/71; 95% confidence interval, 13.5-34.0) in the occluded inferior mesenteric artery group (p = 0.01). Freedom from aneurysm sac enlargement at 1, 3, and 5 years was 100%, 85.0%, and 68.1% in the patent inferior mesenteric artery and 98.9%, 86.7%, and 73.9% in the occluded inferior mesenteric artery group, respectively (p = 0.22). Freedom from aneurysm sac enlargement at 1, 3, 5 years was 100%, 76.9%, 43.5%, and 99.1%, 90.6% and 87.8% in the patients with and without late type II endoleak (p < 0.01). Patent inferior mesenteric artery (odds ratio, 3.43; 95% confidence interval, 1.43-8.21) and an increasing number of patent lumbar arteries (odds ratio, 2.14; 95% confidence interval, 1.48-3.08) were risk factors for late type II endoleak. Conclusions: Patent inferior mesenteric artery was a risk for late type II endoleak without contributing to aneurysm enlargement after endovascular aneurysm repair using the EXCLUDER. Late type II endoleak was associated with aneurysm enlargement. Patent inferior mesenteric artery and an increasing number of patent lumbar arteries were risk factors for late type II endoleak.

Current Status of Diagnostic Process in Asymptomatic Abdominal Aortic Aneurysm in Japan

Objectives: This study aimed to investigate the actual detection process and diagnostic methods for asymptomatic abdominal aortic aneurysm (AAA) in a multicenter setting, and to plan an effective screening strategy for asymptomatic AAA. Methods: The subjects of this multicenter study were collected in a retrospective manner at 7 facilities. A total of 1894 patients with AAA, including iliac artery aneurysms, who were considered asymptomatic with a confirmed initial diagnosis from January 2018 to December 2022, were collected and reviewed. Results: A total of 1666 patients who were diagnosed with asymptomatic AAA were included [83.9% males, median age of 75 (69-81) years]. Asymptomatic AAAs were frequently diagnosed during examinations for other diseases in 1339 patients (80.4%), whereas health screenings accounted for only 313 (18.8%). Computed tomography (CT) was the most commonly used diagnostic method (n = 1352, 81.2%) compared to abdominal ultrasonography (n = 252, 15.2%). Conclusions: Asymptomatic AAAs are detected incidentally during examinations for other diseases, and there is an urgent need to promote health screening. Most AAAs are diagnosed by CT; nevertheless, we consider that abdominal ultrasonography would be the most appropriate modality for AAA screening because of its reasonable accuracy, noninvasiveness, and low cost.

Longitudinal study on 3D ultrasound-based rupture risk assessment of abdominal aortic aneurysms

AIMS

Image-based, patient-specific rupture risk analysis of abdominal aortic aneurysms (AAAs) is promising but it is limited by invasive and costly imaging modalities. Ultrasound (US) offers a safe, more affordable alternative, allowing multiple assessments during follow-up and enabling longitudinal studies on AAA rupture risk.

METHODS AND RESULTS

This study used time-resolved 3D US to assess AAA rupture risk parameters over time, based on vessel and intraluminal thrombus (ILT) geometry. The locations and magnitude of peak wall rupture index (PWRI), peak wall stress (PWS), and maximum ILT thickness for varying AAA growth rates, and the correlation between PWRI, PWS, and geometric parameters were investigated. This study demonstrated that US-based biomechanical analysis is suitable for assessing rupture potential, providing insights into the evolution through various phases in AAA development. For the fast-growing AAAs, the location of PWRI moved closer to the locations of maximum ILT thickness, whereas the location of PWS moved further away. The newly introduced parameter, i.e. percentage of ILT expected for an aneurysm with a healthy lumen, showed a stronger correlation with PWS and PWRI and was less dependent on AAA size, indicating the potential for further research on ILT's impact on AAA rupture risk.

CONCLUSION

This study represents a step towards clinical introduction of US-based AAA rupture risk analysis. Further research and randomized trials are required to directly correlate PWRI with rupture risk. Further improvement of ILT visibility and personalization of the US-based models will be required to achieve clinical acceptance of model-based rupture risk predictions.

Efficacy and Safety of Tranexamic Acid in Noncardiac Arterial Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Noncardiac arterial procedures (NCAPs) are associated with a high risk of bleeding. Tranexamic acid (TXA) is used among surgical disciplines to reduce blood loss; however, its effectiveness and safety in NCAP remain unclear. This review evaluates the efficacy and safety of TXA during NCAP.

METHODS

Systematic review and meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Literature searches in PubMed, Embase, and Cochrane databases (October 2023 and October 2024) identified studies investigating TXA in open and endovascular NCAP. Meta-analyses were conducted using Cochrane's Review Manager.

RESULTS

Five studies (n = 4304) were identified. One randomized controlled trial of TXA in noncardiac surgery (n = 9535), including a vascular cohort (14.8%; n = 699 TXA, n = 700 placebo), showed lower composite bleeding outcomes in the overall cohort receiving TXA (9.5% vs 11.7%; P < 0.001), but not in the vascular cohort (hazard ratio 0.85; 95% confidence interval [CI] 0.64-1.13). Another trial found no difference in blood loss or transfusion rates in 100 patients undergoing open abdominal aortic aneurysm surgery. Both trials reported no increased cardiovascular or thromboembolic complications (TECs) or 30-day mortality. A prospective study showed similar thrombosis-related technical failure rates in traumatic vascular injury patients (TXA 6.3% vs 3.8%, P = 0.14) and no significant differences in bleeding or hematoma (TXA 11.4% vs 4.3%, P = 0.13). In 297 carotid endarterectomy (CEA) patients, TXA significantly reduced postoperative hematoma (7.9% vs 1.3%; P = 0.01) without increasing TEC or stroke. TXA during an intraoperative hemostasis protocol during CEA (TXA n = 8) reported similar results. Meta-analysis showed no significant differences in TEC (risk ratio [RR] 1.10; 95% CI 0.71-1.70) or reoperation rates (RR 0.55; 95% CI 0.19-1.63).

CONCLUSION

TXA does not increase the risk of TEC in NCAP. However, there is currently insufficient evidence that TXA reduces bleeding complications.

Local Versus General Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm: A Systematic Review and Meta-analysis

BACKGROUND

Endovascular aneurysm repair (EVAR) has become increasingly popular compared with open repair due to its minimally invasive approach for treating abdominal aortic aneurysms (AAAs). However, the ideal anesthetic choice for patients undergoing EVAR remains debated. While some advocate for local anesthesia (LA), others believe that general anesthesia (GA) offers certain advantages.

OBJECTIVE

To compare LA with GA in patients undergoing EVAR.

METHODS

A search was conducted in the PubMed, Scopus, Embase, and Cochrane databases, focusing on studies that compared postoperative outcomes. Data were pooled using fixed- or random-effects models, and results are given in mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was calculated using the I2 statistic. All statistical analyses were performed using R software.

RESULTS

A total of 16 studies were included, comprising 45,566 patients. LA was associated with a decline in total hospital stay (MD: -1.00 day, 95% CI: -1.38 to -0.63, p < 0.01), myocardial infarction (OR: 0.52, 95% CI: 0.29 to 0.93, p = 0.02), and pneumonia (OR: 0.25, 95% CI: 0.11 to 0.55, p < 0.01). The LA group had an insignificant association with lower incidence of mortality (OR: 0.85, 95% CI: 0.64 to 1.13, p = 0.26) and in intensive care unit length of stay (MD: -0.20 day, 95% CI: -0.47 to 0.07, p = 0.14).

CONCLUSION

These results indicate that patients treated with LA are likely to be discharged more quickly and experience fewer adverse events.

Unstented large fenestration for close target vessel ostia: Long-term follow-up

PurposeTo report the 10-year follow-up of a patient managed with a custom-made fenestrated endograft, including a large fenestration for the preservation of a celiac trunk (CT) anatomic variation.Case reportIn 2014, a 75-year-old female was treated endovascularly for descending thoracic and visceral aortic pseudoaneurysms (PA). Due to a celiac trunk (CT) anatomic variation, consisting of separate origins of the hepatic and splenic artery, a custom-made four-fenestrated endograft was planned, including a large fenestration (18 × 10 mm) for CT preservation. Balloon-expandable covered stents bridged all target vessels (TVs), except the large fenestration, which was left unstented. Imaging at 10 years showed patency of TVs, no signs of instability or device migration and complete PA exclusion.ConclusionUsing a patient-specific device for complex endovascular aortic repair provided favorable extended follow-up outcomes. An unstented large fenestration remained patent during 10 years of follow-up. This case highlights the importance of individualized approach in complex aortic pathologies.

Utilizing CO2 Cone Beam Computed Tomography for Post-Procedure Completion Control Following Fenestrated Endovascular Repair of Complex Aortic Aneurysm With a Standardized CO2 Protocol

PURPOSE

To assess the feasibility and efficacy of a standardized CO2 protocol and CO2 cone beam computed tomography (CBCT) for procedural completion in fenestrated endovascular aneurysm repair (FEVAR) of complex aortic aneurysms in patients with chronic kidney disease (CKD).

MATERIALS AND METHODS

Ten patients with complex aortic aneurysms and CKD (estimated glomerular filtration rate <90 ml/min) underwent FEVAR with custom-made fenestrated devices, using CO2 as the primary contrast agent. Procedures were conducted in a hybrid operating room following a standardized CO2 protocol with optimized injection parameters and visualization techniques to maximize CO2 imaging efficacy. CO2 CBCT was performed intraoperatively to verify stent graft deployment, bridging stent positioning, target vessel patency, and the presence of potential endoleaks.

RESULTS

All 10 procedures were completed successfully without intraoperative complications or CO2-related adverse effects. Completion CO2 CBCT provided clear visualization of visceral and renal vessels, and no significant endoleaks were detected. One procedure was entirely iodine contrast-free, while minimal iodine contrast was used in others to address diagnostic uncertainties. Postoperative renal function remained stable across all patients.

CONCLUSION

CO2 CBCT is a feasible and effective alternative for completion imaging in complex FEVAR procedures for patients with CKD, potentially reducing the need for iodine contrast and the associated risk of nephropathy. A standardized CO2 protocol can enhance procedural safety. Further research with larger cohorts is needed to confirm these findings.Clinical ImpactCO2 serves as the preferred contrast medium for the endovascular treatment of patients with iodine contrast allergies or those afflicted with chronic kidney disease (CKD) to preserve further renal deterioration. Ensuring protection from potentially harmful substances is paramount during endovascular repair in such patients. Equally crucial is performing the procedure safely through a standardized protocol and confirming its accuracy upon completion. Nevertheless, the possibility of employing CO2 for cone beam computed tomography provides invaluable insights into procedural efficacy, thereby enhancing outcomes for CKD patients undergoing complex endovascular repair.

Technical Approach to Rescuing a Previous Physician-Modified Endovascular Graft with a New Physician-Modified Endovascular Graft

PURPOSE

To demonstrate the feasibility of the physician-modified endovascular graft (PMEG) technique in acute aorta disease, even in cases with a previous PMEG requiring a new repair.

TECHNIQUE

A 77-year-old man presented with an infectious native aortic aneurysm (INAA), which was treated with a PMEG containing fenestrations for the renal arteries and superior mesenteric artery (SMA). After 4 months, a new infectious aneurysm developed at the right renal hilum, which was treated by occluding the right renal artery with a vascular plug. At the 1-year follow-up, computerized tomography angiography (CTA) demonstrated a new suspected INAA at the level of the celiac trunk, just proximal to the previous PMEG. A new PMEG with fenestrations for the left renal artery and SMA was deployed within the previous PMEG, followed by a proximal extension of the PMEG with a thoracic stent graft. Completion angiography and CTA follow-up at 1 month showed successful exclusion of the aneurysm.

CONCLUSION

Treatment with a PMEG may provide an endovascular solution for patients requiring urgent aneurysm repair even after a previous PMEG. This case also highlights the importance of anticipating a future proximal extension when planning a PMEGClinical ImpactThis article demonstrates the use of a physician-modified endovascular graft (PMEG) to reline and proximally extend a previously implanted PMEG requiring urgent repair. Although technically challenging, this approach provides a safe and effective endovascular solution for patients with a previous fenestrated endograft requiring urgent repair, thereby avoiding the need for open surgery. This case underscores the benefit of PMEGs to the vascular surgeon's armamentarium and emphasizes the importance of anticipating future reinterventions during primary procedures.

Use of Fenestrated/Branched Devices for Rescue of Proximal Endograft Failure After Endovascular Aneurysm Repair: A Systematic Review of the Literature and an Updated Meta-Analysis

OBJECTIVE

To present the current outcomes of fenestrated and branched endovascular aneurysm repair (F/BEVAR) for rescue of proximal endograft failure after endovascular aneurysm repair (EVAR). A systematic review of the currently published literature on F/BEVAR for failed EVAR is undertaken, and the eligible studies are combined into a meta-analysis with the intention of evaluating the safety, efficacy, and the durability of this treatment option.

MATERIALS AND METHODS

A systematic review of the literature up to September 2024 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (CRD42024590847). Studies were included in the meta-analysis if they reported ≥10 patients and at least one of the major outcomes was stated. Primary endpoint was technical success (efficacy). Secondary endpoints included 30-day/in-hospital mortality and morbidity (safety) and survival and reinterventions rate (durability). Methodological quality and robustness of the results of the eligible articles were assessed according to Joanna Briggs Institute (JBI's) critical appraisal tool.

RESULTS

A total of 16 studies with overall 1079 patients were included. The pooled estimate for technical success was 94.4% (95% CI 92.5-95.8), whereas for the 30-day/in-hospital mortality 3.9% (95% CI 2.9-5.4). Permanent paraplegia was developed in a pooled rate of 1.6% (95% CI 0.8-3.0), whereas a cerebrovascular event in a pooled rate of 1.5% (95% CI 0.9-2.8). An acute renal function impairment requiring new onset dialysis occurred with a pooled rate of 4.4% (95% CI 3.2-6.1). Postoperative respiratory failure was observed with a pooled estimate of 7.2% (95% CI 5.5-9.4). The pooled estimate for 12-month overall survival was 88% (95% CI 83.4-91.4), and the pooled estimate for 24- and 36-month survival were 79.8% (95% CI 75.6-83.4) and 72.2% (95% CI 66.7-77.2), respectively. Freedom from reintervention was estimated at 83.7% (95% CI 79.9-86.9) for 12 months, 75.8% (95% CI 61.0-86.2) for 24 months and 59.3% (95% CI 36.5-78.7) for 36 months.

CONCLUSION

This study showed that F/BEVAR is a feasible, safe, and reliable strategy for achieving proper proximal endograft sealing when previous EVAR has failed. The midterm survival of these patients is acceptable, whereas reinterventions are not negligible.Clinical ImpactThis work summarizes the current experience with fenestrated and branched endovascular aneurysm repair for the rescue of failed endovascular aneurysm repair in the most contemporary meta-analysis including 16 studies with a total of 1079 analyzed patients. Feasibility of the method is proven with a technical success of 94.4%, whereas a 30-day/in-hospital mortality of 3.9% was recorded. The compromised survival and freedom from reinterventions rates (72.2% and 59.3% for 36 months, respectively) pose, however, concerns regarding durability of the method.

Feasibility of tomographic freehand three-dimensional ultrasound for surveillance of abdominal aortic aneurysms after endovascular repair

ObjectivesThis study aimed to investigate the feasibility of a commercially available tomographic freehand three-dimensional ultrasound (3D-US) system for surveillance of abdominal aortic aneurysms (AAAs) after endovascular repair (EVAR).MethodsIn 10 patients who underwent EVAR, a 3D-US scan was obtained post-operatively in addition to regular computed tomography angiography (CTA). Five independent observers evaluated 12 EVAR surveillance parameters for the 10 scans, resulting in a total of 600 individual observations.ResultsThe diameters of the neck, sac and iliac arteries were evaluable in most of the observations (neck: 80%, AAA sac: 98%, right CIA: 90%, left CIA: 68%). The diameter measurements of the 3D-US strongly correlated with the diameters measured on CTA (ρ = 0.90, p < .001). The general offset of 3D-US compared to CTA was -4.4 mm and the proportional bias was 3%. For all observers, the diameter measurements were significantly strongly correlated (O1:ρ = 0.85, O2:ρ = 0.88, O3:ρ = 0.93, O4:ρ = 0.96, O5:ρ = 0.86, p < .001 for all). The inter-observer reliability was excellent with an overall concordance correlation coefficient of 0.98. The start of the endograft, the lowest renal artery, the distance between these landmarks, and the proximal and distal sealing zones were evaluable in fewer than half of the observations (42%, 12%, 10%, 32%, 32%, 26%).Conclusion3D-US after EVAR is feasible. Diameters measured in 3D-US correlate strongly with CTA-based diameters and have a good interrater variability. However, the sealing zones are difficult to assess on 3D-US. This technique could be a useful addition to duplex ultrasound to facilitate offline 3D analysis, increase measurement reproducibility, enable volume measurements, and minimise the use of harmful CTA for surveillance after EVAR.

Atherosclerotic Abdominal Aortic Aneurysms on Computed Tomography Angiography: A Narrative Review on Spectrum of Findings, Structured Reporting, Treatment, Secondary Complications and Differential Diagnosis

Atherosclerotic abdominal aortic aneurysms (AAAs) are a common vascular pathology with significant morbidity and mortality risks. Timely diagnosis, accurate characterization, and standardized reporting are critical for effective management and monitoring of atherosclerotic AAAs. Imaging modalities, particularly computed tomography angiography (CTA), play a pivotal role in the detection, treatment planning, and identification of both primary and secondary complications, as well as distinguishing AAAs from other etiologies. This narrative review provides a comprehensive exploration of the spectrum of imaging findings in atherosclerotic AAAs on CTA, underscoring the importance of structured reporting. Additionally, it examines therapeutic approaches and complications, and it differentiates AAAs from inflammatory, mycotic, and traumatic variants, serving as a primer for radiologists in AAA evaluation.

Clinical frailty predicts long-term survival and return to functional status following fenestrated and branched aortic repair for thoracoabdominal aortic aneurysm

OBJECTIVE

Prior studies have demonstrated that frailty, characterized by a patient's burden of chronic medical comorbidities, is predictive of adverse outcomes across surgical specialties. This study uses the clinical frailty score (CFS) to assess the impact of phenotypic frailty on long-term mortality and return to preoperative functional status (RFS) following fenestrated and branched endovascular repair (F/BEVAR) for thoracoabdominal aortic aneurysm (TAAA).

METHODS

All patients enrolled in a prospective, physician-sponsored investigational device exemption clinical trial from 2012 to 2023 following F/BEVAR for TAAA were included. Patients were assigned to a standard or high-risk category, if they had one or more of the following criteria: CFS ≥4, metabolic equivalent of ≤2, prior spinal cord injury or stroke, CHF, chronic obstructive pulmonary disease (COPD) with oxygen requirement, chronic kidney disease (CKD) stage IV or V, peripheral artery disease, active cancer with life expectancy of more than 1 year, heavy aortic atheroma burden, history of cirrhosis, and/or substance use disorder. Long-term survival and RFS were assessed using Kaplan-Meier analysis and Cox regression analysis based on high-risk status. A secondary survival analysis based on CFS (CFS ≥4 and <4) was performed with adjustment for age, sex, congestive heart failure, COPD with oxygen requirement, CKD stage IV/V.

RESULTS

213 patients underwent F/BEVAR, including 96 standard-risk (45%) and 117 high-risk patients (55%). Other than high-risk classifiers, there were no differences in comorbidities, operative presentation, or maximum aneurysm diameter. Within the high-risk study cohort, a total of 57 patients had a CFS of ≥4 (48.7%), 49 patients had CKD stage IV/V (41.9%), and 33 patients had a metabolic equivalent of <2 (28.2%). Higher CFS (hazard ratio [HR], 1.37; 95% CI, 1.07-1.74), lower body mass index (HR, 0.87; 95% CI, 0.82-0.99), larger aneurysm size (HR, 1.03; 95% CI, 1.01-1.05), COPD with oxygen requirement (HR, 2.64; 95% CI, 1.62-4.30), and CKD stage IV or V (HR, 2.85; 95% CI, 1.29-6.28) were associated with reduced long-term survival in multivariable analysis. Standard-risk patients were more likely to RFS (92.7% vs 68.4%; P < .01), whereas a higher CFS (odds ratio [OR], 0.49; 95% CI, 0.34-0.72) and COPD with oxygen requirement (OR, 0.42; 95% CI, 0.20-0.88) were associated with a lower likelihood of RFS. High-risk patients had lower survival at 1 year (76% vs 95%) and 5 years (39% vs 58%; P < .01). When stratified by CFS, differences in survival persisted. Patients with CFS of ≥4 also had reduced survival at 1 year (70% vs 90%) and 5 years (33% vs 53%; P = .01), respectively.

CONCLUSIONS

Patients with a higher CFS have worse long-term survival and are less likely to RFS, even after adjustment for medical comorbidities. Given these findings, the identification of high-risk patients, including direct measurement of phenotypic frailty using the clinical frailty scale is an important tool for preoperative risk stratification and patient selection for F/BEVAR.