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

From Planning to Practice: Impact of Achieved Proximal Sealing Zone in Endovascular Aneurysm Repair (EVAR)

Background: Endovascular aneurysm repair (EVAR) is the preferred treatment for abdominal aortic aneurysms (AAAs). This study evaluated the differences between the anticipated and actual achieved proximal sealing zones for standard EVAR endografts and their potential implications in a real-world AAA population. Methods: Data from 275 consecutive EVAR patients treated with the Endurant endograft (Medtronic, Minneapolis, MN, USA) between 2009 and 2022 were retrospectively analyzed. The proximal sealing zone was calculated preoperatively (target anticipated sealing zone, TASZ) and postoperatively (real achieved sealing zone, RASZ) from computed tomography angiography (CTA) images. These metrics were evaluated by assuming that they had a truncated cone shape, calculating the cone's lateral surface by measuring the proximal and distal centerline areas and the distance between the planes. The primary outcome was the occurrence of type 1A endoleak at the longest available follow-up. Results: RASZ was significantly smaller and shorter than TASZ (p = 0.001), with an average area reduction of 24.5 mm2 and a median length reduction of 3 mm. Area and cranial length loss were present even when correcting for graft positioning imperfections. In the Cox proportional hazard regression model, TASZ and RASZ lengths were both independently associated with a lower risk of type 1A endoleak (HR: 0.88, 95% CI 0.80-0.96 and HR: 0.92, 95% CI 0.86-0.99, respectively). A Kaplan-Meier analysis confirmed that patients with RASZ > 5.5 mm had a survival free from endoleak higher than patients with RASZ ≤ 5.5 mm. Conclusions: In this real-world AAA population, the achieved proximal sealing zone was significantly shorter and smaller than planned, regardless of optimal endograft placement. The early calculation of RASZ, i.e., the PSZ achieved via CTA, is critical for risk stratification and follow-up.

Practices of low value or unnecessary practices in vascular prevention

BACKGROUND

Low-value practices are avoidable interventions that provide no health benefits. The objective of this study was to conduct a narrative review of the recommendations for practices of low value-care in vascular prevention.

METHODS

A narrative review of all low value-care recommendations for vascular prevention published in the main European and North American scientific societies for clinical practice guidelines between 2014 and 2024 was carried out.

RESULTS

A total of 38 clinical practice guidelines and consensus documents from international organizations in the United States, Canada, the United Kingdom, and Europe were reviewed, 28 of which included between 1 and 20 recommendations on practices of low value-care in vascular prevention. The total number of recommendations was 141. The American Heart Association is the society that offers the largest number of recommendations of low value-care, with 39 recommendations (27.7%) in 5 clinical practice guidelines (13.2% of the total guidelines with recommendations). The guideline for the management of arterial hypertension of the European Society of Hypertension is the guideline that concentrates the largest number of recommendations of low value-care in a single guideline, with 20 recommendations (14.2% of the total guidelines with recommendations).

CONCLUSIONS

There are more and more guidelines that explicitly describe diagnostic or pharmacological activities of low value-care or Do Not Do Class III or recommendation D. Some guidelines agree, but others show clear discrepancies, which can illustrate the uncertainty of the scientific evidence and the differences in its interpretation.

Global Epidemiology of Early-Onset Aortic Aneurysm: Temporal Trends, Risk Factors, and Future Burden Projections

BACKGROUND

Aortic aneurysm has a subtle onset, high rupture mortality, rapid progression in younger individuals, and increasing annual mortality rates. Our study aimed to estimate the global burden and trends of early-onset aortic aneurysm from 1990 to 2021.

METHODS

Participants aged 15-39 years from 204 countries and regions (Global Burdern of Disease, GBD) from 1990 to 2021.The primary assessment indicators include age-standardized death rates (ASDR), age-standardized disability-adjusted life years rates (ASDALYR), annual average percent change (AAPC), attributable risk factor proportions, slope index, concentration index, and predictive model for early-onset aortic aneurysm.

RESULTS

From 1990 to 2021, the ASDR for aortic aneurysm in adolescents and young adults increased from 0.12 (95% confidence interval [CI] 0.11, 0.14) to 0.13 (0.11, 0.14) per 100,000 population, with an AAPC of 0.08% (-0.08%, 0.25%). The ASDALYR rose from 7.25 (6.52, 8.30) to 7.35 (6.51, 8.37), with an AAPC of 0.07% (-0.09%, 0.23%). Both ASDR and ASDALYR are higher in males than females, with a declining trend in females. Higher Socio-Demographic Index (SDI) countries exhibit higher ASDR and ASDALYR compared to lower SDI countries, with a continuous decline observed in high SDI nations. Smoking remains the top risk factor, with population growth being the primary driver. Models predict a global increase in aortic aneurysm deaths, predominantly among males.

CONCLUSION

The overall burden of early-onset aortic aneurysms has exhibited an increasing trend over the last three decades, especially in lower SDI countries. There is an urgent need to develop targeted prevention and control strategies across different regions and countries worldwide.

The Role of Dynamic Computed Tomography Angiography in Endoleak Detection and Classification After Endovascular Aneurysm Repair: A Comprehensive Review

Backgroud: The use of dynamic computed tomography angiography (dCTA) for the detection of endoleaks in patients who underwent endovascular repair of abdominal aortic aneurysms is gaining interest. This study aims to provide an overview of the current applications of dCTA technologies in vascular surgery. Methods: We performed a comprehensive review by searching in the PubMed database and Cochrane Library (last search: 1 November 2024). We included studies considering endoleak investigation after endovascular aneurysm repair (EVAR). We included papers that reported the outcome of applications of dCTA, excluding case reports or very limited case series (≤4). Finally, 14 studies regarding 377 computed tomography angiographies (CTA) were included and evaluated. Results: Persistent perfusion of the aneurysm sac is the most common complication after EVAR. Imaging-based surveillance post-EVAR is essential with the aim of early detection, characterization, and localization of endoleaks to guide therapeutic intervention or follow-up. dCTA detected 36 type I endoleaks versus 16 identified with standard CTA and 138 versus 95 type II endoleaks. Conclusions: The emergence of dCTA offers a promising solution through enhanced temporal resolution, allowing the visualization of real-time flow dynamics within the aneurysmal sac essential to establishing endoleak treatment or post-EVAR follow-up.

Spontaneous Inferior Mesenteric Artery Occlusion after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm and its Impact on Clinical Outcomes

OBJECTIVE

The incidence and related factors of spontaneous occlusion of a patent inferior mesenteric artery (IMA) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) without pre-emptive embolisation remain unclear. This study aimed to elucidate the incidence, clinical implications, and predictors of spontaneous IMA occlusion after EVAR.

METHODS

This was a single centre, retrospective cohort study. Patients who underwent elective EVAR between 2007 and 2022 were categorised into three groups (group 1, spontaneous IMA occlusion; group 2, patent IMA with no type II endoleak [T2EL] from IMA; group 3, T2EL from IMA). Endpoints were the incidence of spontaneous IMA occlusion, sac enlargement, freedom from re-intervention, and overall survival after EVAR.

RESULTS

Of 372 cases of elective EVAR for AAA, 230 who had patent IMA pre-operatively were analysed, after excluding 127 with pre-occluded IMA and 15 who underwent pre-emptive IMA embolisation. Spontaneous IMA occlusion occurred in 101 patients (43.9%). The sac enlargement rate was lower in group 1 than in groups 2 and 3. The freedom from re-intervention rate was higher in group 1 than in group 3 but did not differ between groups 1 and 2. Multivariable analysis revealed the absence of antiplatelet therapy, pre-operative higher haematocrit, absence of concomitant iliac artery aneurysm, posterior thrombus in the sac, and use of Endurant as predictors associated with spontaneous IMA occlusion. Spontaneous IMA occlusion was observed in 7.1% and 77.5% of patients with zero and four or five predictors, respectively.

CONCLUSION

Spontaneous IMA occlusion occurred in nearly half of cases and was associated with positive clinical outcomes. In patients with a high prediction of spontaneous IMA occlusion, pre-emptive IMA embolisation may be omitted.

Intraoperative rescue of a dislodged renal stent during fenestrated endovascular aortic repair for treatment of type 1A endoleak

In the past 15 years, fenestrated-branched endovascular aortic repair (F-BEVAR) has progressively become the first-line option for management of most complex abdominal aortic aneurysms (AAAs); with increasing experience, as well as persistent technological refinements, F-BEVAR indications have been expanded to include rescue of failures after prior EVAR. Despite the feasibility and effectiveness, F-BEVAR procedures in the presence of prior infrarenal endografts may come with higher technical complexity that should be properly anticipated, and several anatomical challenges can be expected. Among these, presence of suprarenal bare stents from prior EVAR device are certainly a frequent scenario and may sometimes make target vessel cannulation more difficult because of encroachment on the target vessel origins. In this manuscript, we report a case intraoperative rescue of a dislodged renal stent during FEVAR for treatment of type 1 endoleak with the aim of showing the culprit of the complication, how to recognize it, and the off-label solution that was devised to solve it.

Effectiveness of single-energy metal artifact reduction algorithm in CT: application to contrast-enhanced CT with EVAR and coil embolization

This study aimed to evaluate the efficacy of the single-energy metal artifact reduction (SEMAR) algorithm in reducing metal artifacts and enhancing image quality in contrast-enhanced computed tomography (CT) for patients undergoing endovascular aneurysm repair (EVAR) with coil embolization. Thirty-eight patients (mean age 81.0 ± 6 years; 31 men, 7 women) who underwent contrast-enhanced CT following EVAR and internal iliac artery coil embolization between September 2022 and May 2023 were retrospectively analyzed. The Artifact Index (AI) quantified metallic artifacts from internal iliac artery aneurysm coils in CT images, calculated from the standard deviation of the artifact-containing region relative to a reference region. CT values of the external iliac artery at the same slice were also evaluated and compared. Two radiologists independently performed qualitative assessments of SEMAR and non-SEMAR images. SEMAR significantly reduced metal artifacts, decreasing the AI from 171.9 ± 74.5 HU to 35.8 ± 16.9 HU (p < 0.001). The mean CT values of the external iliac artery were similar for SEMAR (259.4 ± 63.7 HU) and non-SEMAR (257.1 ± 63.6 HU, indicating no significant difference. Qualitative assessment scores improved significantly with SEMAR (from 1.0 ± 0.0 to 2.5 ± 0.5; p < 0.001), enhancing visualization of internal iliac artery aneurysms. Interobserver agreement was high (κ = 0.83). The SEMAR algorithm effectively reduces metal artifacts in contrast-enhanced CT, significantly enhancing image quality without altering adjacent artery CT values. These improvements enhance the image quality of post-operative assessments in patients undergoing EVAR with coil embolization.

Editor's Choice - Role of Antiplatelet Therapy in Patients Managed for Complex Aortic Aneurysms using Fenestrated or Branched Endovascular Repair

OBJECTIVE

Despite the increasing number of fenestrated and branched endovascular aortic repair (F/B-EVAR) procedures, evidence on post-operative antiplatelet therapy is very limited. This study aimed to investigate the role of single antiplatelet therapy (SAPT) vs. double antiplatelet therapy (DAPT) after F/B-EVAR in 30 day and follow up outcomes.

METHODS

A multicentre retrospective analysis was conducted, including F/B-EVAR patients managed from 1 January 2018 to 31 December 2022. Comparative outcomes were assessed according to post-operative antiplatelet therapy. The cohort was divided into the SAPT group (acetylsalicylic acid [ASA] or clopidogrel) and DAPT group (ASA and clopidogrel). The duration of SAPT or DAPT was one to six months. Primary outcomes were 30 day death, and cardiovascular ischaemic and major haemorrhagic events. Secondary outcomes were survival and target vessel (TV) patency during follow up.

RESULTS

A total of 1 430 patients were included: 955 under SAPT and 475 under DAPT. The 30 day mortality rate was similar (SAPT 2.1% vs. DAPT 1.5%; p = .42). Cardiovascular ischaemic events were lower in the DAPT group (SAPT 11.9% vs. DAPT 8.2%; p = .040), with DAPT being an independent protector for acute mesenteric (p = .009) and lower limb ischaemia (p = .020). No difference was found in 30 day major haemorrhagic events (SAPT 7.5% vs. DAPT 6.3%; p = .40). The mean follow up was 21.8 ± 2.9 months. Cox regression showed no survival confounders, with similar rates between groups (log rank p = .71). DAPT patients enjoyed higher TV patency (SAPT 93.4%, standard error [SE] 0.7% vs. DAPT 97.0%, SE 0.6%; log rank p = .007) at thirty six months. Cox regression revealed B-EVAR as a predictor of worse TV patency (hazard ratio 2.03, 95% confidence interval 1.36 - 3.03; p < .001). DAPT was related to higher patency within B-EVAR patients (SAPT 87.2%, SE 2.1% vs. DAPT 94.9%, SE 1.9%; p < .001).

CONCLUSION

DAPT after F/B-EVAR was associated with lower risk of cardiovascular ischaemic events and higher TV patency, especially in B-EVAR cases. No difference in major haemorrhagic events was observed at 30 days.

Fenestrated and Branched Endovascular Aortic Repair and Mortality at Hospitals Without Investigational Device Trials

Importance

Fenestrated and branched endovascular aortic repairs (F/BEVAR) have been adopted by many centers. However, national trends of F/BEVAR use remain unclear, particularly at sites who perform them without an US Food and Drug Adminstration (FDA)-approved investigational device exemption (IDE).

Objective

To quantify the use of F/BEVAR in the US and to determine if mortality was different at IDE vs non-IDE sites.

Design, Setting, and Participants

This retrospective cohort study examined 100% fee-for-service Medicare claims data from 2016 to 2023. Participants were patients who underwent endovascular treatment of the visceral aorta incorporating 2 or more visceral artery endoprostheses. Hospitals with vs without an IDE were identified using hospitals' Employer Identification Number as a time varying exposure.

Exposure

F/BEVAR.

Main Outcomes and Measures

Trends in the center-level F/BEVAR case volume stratified by IDE status were assessed using cumulative incidence curves. Mortality outcomes at 30 days and 3 years were compared using Kaplan-Meier methods and Cox proportional hazards models with adjustment for baseline patient characteristics.

Results

From 2016 to 2023, 8017 patients were treated with F/BEVAR at 549 hospitals. The median (IQR) age was 75.8 (71.3-80.8) years; 5795 patients (72.3%) were male and 2222 (27.7%) female. A total of 2226 F/BEVAR (27.8%) were performed at 22 hospitals with an IDE. The number of patients treated with F/BEVAR increased from 771 in 2016 to 1251 in 2023. The median (IQR) annual case volume per hospital was significantly higher at IDE sites (22.3 [11.0-30.4] vs 1.2 [1.0-2.0] cases/y; P < .001); 18 IDE sites (90.0%) and 20 non-IDE sites (3.7%) completed 9 or more cases per year. The 30-day mortality (3.0% vs 4.9%) but not 3-year mortality (26.0% vs 27.1%) was lower for patients treated at hospitals with vs without an IDE. After risk adjustment, both 30-day (odds ratio, 0.47; 95% CI, 0.32-0.69) and midterm mortality (hazard ratio, 0.81; 95% CI, 0.69-0.95) were lower for patients treated at IDE sites.

Conclusions and Relevance

The use of F/BEVAR is increasing across the United States, with the majority of cases being performed outside of IDE studies and at low-volume centers. F/BEVAR performed at non-IDE centers are associated with higher adjusted 30-day and midterm mortality. Transparent outcome reporting and identification of process measures from IDE sites may help achieve more equity in patient outcomes.

Long-Term Outcomes of Fenestrated Aortic Endovascular Repair in Patients Bearing JuxtaRenal Aneurysms

BACKGROUND

Fenestrated endografts have been a safe and effective solution in our institution for patients with juxtarenal abdominal aortic aneurysms (AAAs) that were not candidates for conventional repair and had suitable anatomy. The objective of our study was to evaluate the long-term outcomes of these interventions.

METHODS

Between September 2005 and December 2021, this study included all the patients bearing juxtarenal aneurysm electively treated with a fenestrated endograft. We conducted a retrospective analysis of prospectively collected monocentric data. Preoperative, perioperative, and postoperative data were processed. Postoperative follow-up included at least a systematic computed tomography scan at 6, 12, 18, and 24 months then every year. Secondary procedure was defined as any additional procedure performed to treat aneurysm or endograft-related complications after index procedure. Demographic and perioperative data were analyzed descriptively. Overall survival and freedom from secondary procedures were determined using the Kaplan-Meier estimate.

RESULTS

A total of 169 patients (92% male) were treated by fenestrated endograft with a mean 55 ± 37 months follow-up. The median aneurysm diameter was 59 mm. In 39 patients (23.1%), we performed a secondary procedure, by endovascular means in 57% of cases, mostly after the first year of follow-up (53.8%). The most frequent cause for secondary procedure was type 1b endoleak due to the evolution of aneurysmal disease of the iliac arteries (25.6%), followed by endograft limb thrombosis (20.5%), local complications related to index procedure (17.9%) and procedures performed to insure target vessel patency over time (18%). On the last CT scan of the follow-up, patients without secondary procedure were significantly more likely to present a shrinkage of the aneurysmal sac (P = 0.001), defined as a modification of the maximum diameter > 5 mm. Overall survival was not significantly different between patients that had secondary procedures compared to those that had not (80 months vs. 62 months, P = 0.3). Freedom from secondary procedures was 87% at 24 months and 63% at 60 months. Excluding secondary procedures within 30 days, freedom from secondary procedures was 76% at 50 months.

CONCLUSIONS

Fenestrated endografts constitute a sustainable therapeutic solution in the treatment of juxtarenal AAAs. The occurrence of late complications justifies a rigorous follow-up of treated patients.

Numerical Simulation of Intravascular Ultrasound Images Based on Patient-Specific Computed Tomography

Intravascular ultrasound (IVUS) provides detailed imaging of the artery circumference. Over the past years, the interest in artificial intelligence (AI) for interpretation and automatic analysis of IVUS images has grown. Development of such algorithms typically requires considerable amounts of annotated data. However, manual annotation of IVUS data is time-consuming and expensive. An alternative solution would be the simulation of IVUS data, which yields images with all necessary ground-truth data available. Therefore, in this study, we present an IVUS simulator to simulate realistic IVUS data based on computed tomography (CT) images. The IVUS transducer is modeled accurately, which is reflected in the in vitro and in silico measurements of the point-spread function (PSF) and speckle size. The capability of simulating realistic IVUS images is showcased on an in vivo co-registered CT-IVUS dataset of two patients with an abdominal aortic aneurysm (AAA). Quantitative results, expressed in terms of the Jensen-Shannon divergence (JSD), speckle signal-to-noise ratio (sSNR), and contrast-to-noise ratio (CNR), reveal the high similarity between the in vivo and in silico IVUS images. The proposed simulator is promising for ultrasound data generation, enabling the generation of IVUS images with the desired ground truth.

An international, expert-based, Delphi consensus document on controversial issues in the management of abdominal aortic aneurysms

OBJECTIVE

As a result of conflicting, inadequate or controversial data in the literature, several issues concerning the management of patients with abdominal aortic aneurysms (AAAs) remain unanswered. The aim of this international, expert-based Delphi consensus document was to provide some guidance for clinicians on these controversial topics.

METHODS

A three-round Delphi consensus document was produced with 44 experts on 6 prespecified topics regarding the management of AAAs. All answers were provided anonymously. The response rate for each round was 100%.

RESULTS

Most participants (42 of 44 [95.4%]) agreed that a minimum case volume per year is essential (or probably essential) for a center to offer open or endovascular AAA repair (EVAR). Furthermore, 33 of 44 (75.0%) believed that AAA screening programs are (probably) still clinically effective and cost effective. Additionally, most panelists (36 of 44 [81.9%]) voted that surveillance after EVAR should be (or should probably be) lifelong. Finally, 35 of 44 participants (79.7%) thought that women smokers should (or should probably/possibly) be considered for screening at 65 years of age, similar to men. No consensus was achieved regarding lowering the threshold for AAA repair and the need for deep venous thrombosis prophylaxis in patients undergoing EVAR.

CONCLUSIONS

This expert-based Delphi consensus document provides guidance for clinicians regarding specific unresolved issues. Consensus could not be achieved on some topics, highlighting the need for further research in those areas.

Perioperative and mid-term results of trans-graft embolization of the hypogastric artery for treatment of type II endoleaks after endovascular aortic repair with off-label use of re-entry catheters

Type II endoleaks after endovascular aortic repair are a common scenario that, although infrequently, may sometimes require secondary interventions when leading to significant enlargement of the aneurysm sac. Herein, we present the perioperative and mid-term results of one of our endovascular aortic repair cases with type II endoleak from the hypogastric artery, whose ostium was covered by the prior stent graft limbs and that were successfully treated with a novel technique employing re-entry catheters in an off-label fashion. This technique may represent a valid alternative solution when conventional access between artery and prosthesis is laborious or impossible to achieve.

Geometry and local wall thickness of abdominal aortic aneurysms using intravascular ultrasound

Currently, abdominal aortic aneurysms (AAAs) are treated based on the diameter of the aorta, however, a more robust patient-specific marker is needed. The mean thickness of the wall is a potential indicator for AAA rupture risk, which varies significantly within and between patients. So far, regional thickness has not been used in previous rupture risk analysis studies, since it is challenging to measure in CT, MRI, and non-invasive ultrasound (US). This study shows how to map locally varying wall thickness of AAAs using intravascular ultrasound (IVUS). Since no ground truth of AAA wall thickness can be obtained in vivo, a novel ex vivo dataset was created of porcine, phantom and simulated aortas, of which ground truth data are available. A U-net model was trained on the ex vivo data and results show that the predicted wall segmentation is in good agreement with the ground truth (DSC = 0.86, HD = 0.97 mm). Wall thickness and geometry plots show that the variation in wall thickness can be recognized. The in vivo demonstration in patients shows that the diseased wall can be segmented, a regionally varying wall thickness can be measured, and detailed maps of AAA geometries can be created. The measured local wall thickness could be used for better general understanding of AAA wall properties resulting in more advanced rupture risk assessment of AAAs.

Sealing Zone Failure Decreases the Long Term Durability of Endovascular Aneurysm Repair

OBJECTIVE

Endovascular aneurysm repair (EVAR) has a higher long term aneurysm related mortality rate compared with open surgery, mainly due to aneurysm rupture. Loss of stent graft to vessel apposition at the EVAR sealing zones is a potential cause of post-EVAR rupture. This study aimed to investigate sealing zone failure and its relationship with post-EVAR rupture.

METHODS

This was a retrospective structured review of pre- and post-operative computed tomography (CT) scans of 399 consecutive patients treated with standard bifurcated EVAR. The primary outcome was total loss of seal at last post-operative CT. Secondary outcomes were partial loss of seal, standard follow up detection, post-EVAR rupture, aneurysm sac development, and endoleaks.

RESULTS

During a median follow up of 5.3 years, total and partial loss of seal occurred in 85 (21.3%) and 78 (19.5%) patients, respectively. Initial mean sealing zone lengths were within current recommendations but decreased over time, mainly due to vessel dilatation. Mean proximal sealing length at the one month CT was 15.5 ± 10.5 mm (95% confidence interval [CI] 12.6 - 18.5 mm) in the group with total loss of seal, 14.3 ± 6.9 mm (95% CI 12.2 - 16.4 mm) with partial loss of seal, and 23.2 ± 7.4 mm (95% CI 22.3 - 24.0 mm) with preserved seal through follow up (p < .001). Mean iliac sealing lengths were 22.4 ± 12.1 mm (95% CI 18.9 - 25.8 mm) if total loss and 21.8 ± 10.0 mm (95% CI 19.6 - 24.0 mm) if partial loss of seal vs. 34.7 ± 12.4 mm (95% CI 33.8 - 35.7 mm) if preserved seal. Larger vessel diameters were associated with loss of seal in both the proximal and distal sealing zones. During the study period, 13 post-EVAR ruptures occurred, all preceded by CT findings of total (n = 7) or partial (n = 6) loss of seal. Aneurysm sac expansion was seen in 40% of patients with total loss of seal, 18% with partial loss of seal, and 6.6% with preserved seal.

CONCLUSION

Loss of seal after EVAR is frequent and associated with post-EVAR rupture. Increased recommended sealing zones lengths and focus on sealing zones in surveillance may reduce post-EVAR ruptures and aneurysm related death.

Laparoscopic resection of an isolated iliac artery aneurysm with synthetic graft implantation

The current treatment options for isolated iliac artery aneurysm (IIAA) are mainly endovascular treatment (ET) and open surgery. ET carries risks such as endoleaks and stent displacement, while open elective surgical repair of IIAAs carries significant risk of mortality. Therefore, this report presents a case of laparoscopic surgery for IIAA, providing a new approach for treating IIAA. Under laparoscopic guidance, the IIAA was resected, and an artificial graft was implanted to complete the surgery. At 6 months follow-up, the patient remained well, and the artificial graft was patent.

An Updated Review on Arterial Stiffness Measurement Techniques and Arterial Stiffness Alterations After Aortic Aneurysm Repair

BACKGROUND

Studies over the last years have revealed the possible impact of endovascular repair of abdominal or thoracic aortic aneurysms on the arterial stiffness and secondary on the cardiac function and the central hemodynamics.

METHODS

A literature search was conducted to collect data on current methods of arterial stiffness assessment and the induced changes in arterial stiffness after endovascular or open surgical repair of abdominal or thoracic aortic aneurysms.

RESULTS

Seventeen studies were analyzed. In most of these studies, arterial stiffness, either assessed by pulse wave velocity or augmentation index, was found to be increased after aortic aneurysm repair. Factors that increase arterial stiffness seem to be endovascular repair of the aneurysm and the proximity of the stent graft to the heart. The clinical implications of increased arterial stiffness are left ventricular hypertrophy, coronary arteries malperfusion and potential end-organ damage.

CONCLUSIONS

Both endovascular and open aortic aneurysm repair can alter arterial stiffness, with endovascular repair having a greater effect. Future research is essential, particularly in exploring the impact of aortic aneurysm repair methods on vital organs and cardiac function. Extended follow-up studies are proposed to gain a better understanding of the long-term cardiovascular consequences of both endovascular and open surgical repair outcomes.

Open aneurysmorraphy following branched and fenestrated endovascular repair of complex thoracic aneurysms

OBJECTIVE

We present a review of our hybrid management (endovascular + open surgery) of large thoracic aortic aneurysms (>80 mm). The strategy comprises a primary endovascular repair using thoracic endovascular aortic repair (TEVAR), and/or fenestrated and branched endografts (FBEVAR), followed by open thoracotomy and aneurysmorraphy, specifically without the need for aortic cross-clamping.

METHODS

We performed a retrospective review of all patients who had undergone aneurysmorraphy via thoracotomy following TEVAR and FBEVAR in two high-volume aortic centers between December 2017 and March 2024. We performed aneurysmorraphy in two clinical situations: (1) in the setting of a planned staged treatment, shortly after TEVAR or FBEVAR in young patients with aneurysm diameter >100 mm; and (2) as a secondary intervention during follow-up for patients with persistent sac enlargement and aneurysm diameters >80 mm. The primary end points were 30-day survival and aneurysm-related mortality during follow-up. Secondary endpoints were sac size evolution, perioperative and postoperative complications, freedom from further reintervention, and late aortic complications.

RESULTS

Twelve patients underwent aneurysmorraphy following TEVAR and/or FBEVAR during the study period. Mean patient age was 60 ± 12 years, and the mean sac diameter before thoracotomy was 101 ± 25 mm. Endovascular embolization of intercostal arteries prior to aneurysmorraphy was performed in four patients. The 30-day survival rate was 100%. During the mean follow up period of 21 months, two patients died-one of COVID and another of intra-cerebral hemorrhage. No aneurysm-related mortality occurred, and sac regression was achieved in all patients except one experiencing aortic growth below the aneurysmorraphy.

CONCLUSIONS

This study demonstrates that thoracic aneurysmorraphy performed after TEVAR and FBEVAR for complex thoracic aneurysms is a safe and effective technique. This procedure allows the eradication of endoleaks and an immediate sac volume reduction, which prevents aorta-bronchial or esophageal fistulation and secures the endovascular repair; the reduction of the aneurysm mass effect restores normal lung parenchyma expansion. This hybrid management strategy drastically reduces the morbidity associated with standard open surgery performed for thoracic endograft explantation.

From Emergency Room to Operating Room: Multidisciplinary Simulation Training in Emergency Laparotomy for Ruptured Abdominal Aortic Aneurysm - Learning Outcomes and Costs

BACKGROUND

Opportunities to practice emergency laparotomy (EL) and open surgical repair (OSR) for a ruptured abdominal aortic aneurysm (rAAA) are limited. While simulation-based training (SBT) is effective in educating healthcare professionals in medical emergencies, SBT specifically in EL and OSR for rAAA is scarce. It takes a team to diagnose a patient with massive abdominal bleeding, such as in rAAA, to organize primary care, and to provide definite treatment without unnecessary delays. This study investigated the effects of multidisciplinary EL simulation training in OSR for rAAA, from the emergency room (ER) to the operating room (OR), on trainees' learning outcomes and the costs of the training.

METHODS

A total of 162 healthcare professionals in 21 simulated emergency laparotomy teams participated in a structured 2-hour course consisting of an introductory lecture and a simulation scenario followed by debriefing. Data were collected using a pre-post self-assessment questionnaire and the T-NOTECHS scale. Implementation costs and the cost of education were calculated.

RESULTS

Simulation training improved knowledge, skills, and attitudes of both physicians and nurses. Most of the non-technical skills studied were significantly enhanced in both professional groups. The total cost of the simulation training was €29 415, cost per team €1,400 and cost per participant €182.

CONCLUSIONS

Multidisciplinary EL simulation training in OSR for rAAA from the ER to the OR is effective in improving knowledge, skills, and attitudes, as well as non-technical skills among both physicians and nurses. The overall costs of training seem reasonable given the significant learning outcomes.

The Impact of Surgeon Experience-Consultant Versus Supervised Trainees After Elective Infrarenal EVAR: Short-term to Mid-term Outcomes

INTRODUCTION

Vascular trainees are required to have a comprehensive training program, encompassing the completion of clinical, surgical, and research tasks. To fulfill their surgical abilities and performance, sufficient supervised operating time is mandatory. After open vascular procedures, it has been observed that trainee involvement does not lead to detrimental outcomes. On the contrary, its impact during endovascular procedures, which require distinct technical skills, is scarcely reported. The authors aim to analyze the impact of primary operator experience on the outcomes of elective infrarenal endovascular aneurysm repair (EVAR) performed within a teaching institution over a 14-year period.

METHODS

This is a single-center, retrospective, comparative study. All consecutive patients submitted to elective EVAR (2011-2023) were considered. Two groups were defined: supervised trainee (ST) and consultant (C), according to the experience of the primary operator. The primary outcome was the incidence of 30-day major adverse events (MAEs). The secondary outcomes were contrast usage, operative time, bleeding, length of stay (LOS), return to operating room (OR), and freedom from aortic-related interventions up to 2 years.

RESULTS

Overall, 507 patients were included (62.1% ST vs 32.5% C). Seventy-two MAEs occurred in 8.1%, with no differences across groups (7.0% ST vs 9.9% C, p=0.31, adjusted odds ratio [aOR]=0.94, 95% confidence interval [CI]=0.46-1.91 for ST-performed procedures), even when MAE components were depicted individually. After adjustment for confounders, no significant differences were found in contrast usage ≥120 mL (aOR=0.89, 95% CI=0.50-1.56), operative time ≥160 minutes (aOR=0.73, 95% CI=0.45-0.18), bleeding (aOR=1.13, 95% CI=0.60-2.12), intensive care unit admission (aOR=0.68, 95% CI=0.40-1.17), prolonged LOS (aOR=0.93, 95% CI=0.60-1.43), return to OR (aOR=0.91, 95% CI=0.37-2.20), and mid-term freedom from aortic-related interventions (adjusted hazard ratio [aHR]=1.39, 95% CI=0.69-2.79).

CONCLUSION

In carefully selected cases, elective EVAR performed by supervised trainees seems as safe and effective at mid-term as operations performed by consultants. These findings may have important implications for training programs. Further studies to confirm and clarify our findings are required.

CLINICAL IMPACT

In carefully selected cases, elective EVAR performed by supervised trainees seems safe, when compared to operations performed by consultants. Short-term major adverse events, contrast usage, operative time, bleeding, secondary interventions and length of stay appear similar. Mid-term freedom-from aortic interventions is comparable. These findings may have important implications for vascular training programs.

Pre-clinical Evaluation of a New Generation Bridging Stent for Fenestrated Endovascular Aneurysm Repair Using Realistic 3D Printed Aneurysm Models

OBJECTIVE

The aim of this study was to perform a comparative pre-clinical evaluation of a new fenestrated endovascular aneurysm repair dedicated stent using perfused 3D printed patient anatomies.

METHODS

The test setup included a pulsatile pump set to reproduce human haemodynamics, four 3D printed pararenal aneurysms connected to a bench test, and four corresponding fenestrated grafts (Zenith Fenestrated; Cook, Bloomington, IN, USA). Bridging stents were sized based on analysis of patients computed tomography scans and included either four standard covered stents (BeGraft [BG]; Bentley, Hechingen, Germany) or four similar covered stent grafts mounted on a modified balloon to allow stent implantation and flaring in one step (BeFlared [BF]; Bentley). Each anatomy and corresponding endograft was used for four sets of four bridging stent implantations. Selective angiography following each stent implantation was used to assess efficacy (patency and absence of type Ic or IIIc endoleak), procedure time was recorded, and cone beam computed tomography at the end of each set of four stent implantations enabled comparison of geometric layout between stents. Physician assessment evaluated technical performance and failure modes.

RESULTS

Sixty four stents were successfully implanted. Selective angiograms depicted three type IIIc (two in BG, one in BF) and seven type Ic (four in BG, three in BF) endoleaks, which were all corrected intra-operatively. Compared with BG, the BF had a larger mean proximal diameter inside the endograft (10.5 mm vs. 9.2 mm; p < .001) and greater opening flaring angle (46.1° vs. 33.4°; p < .001). The eight procedures performed with the BF were quicker than BG (17.0 ± 4 minutes vs. 23.9 ± 4.7 minutes; p = .004). Physician assessment did not reveal any failure mode and concluded an excellent technical performance of both devices.

CONCLUSION

The BF demonstrated similar efficacy and performance compared with the BG for bridging target vessels in an innovative test setup using 3D printed patient anatomies.

A European Delphi Consensus on the Management of Abdominal Aortic Aneurysms in Patients with Heritable Aortic Diseases

OBJECTIVE

Abdominal aortic aneurysm (AAA) in a patient with an underlying heritable aortic disease (HAD) is rare, and evidence based recommendations for its management are lacking. This study aimed to generate a consensus from multidisciplinary specialists on the diagnosis, treatment, and surveillance of AAA associated with HAD and to define topics of interest for future research.

METHODS

A Delphi consensus was designed involving European multidisciplinary specialists and reported using the ACcurate COnsensus Reporting Document (ACCORD) reporting guideline. Four rounds were carried out by email: the first two rounds to agree on the content of the questionnaire and the final two rounds to reach an agreement. Questions focused on the composition of the team, imaging, clinical suspicion, genetic testing, medical management, indications for surgical repair, surgical technique, surveillance, exercise, and quality of life. The level of agreement for each question was graded using a Likert type scale and classified into four categories: A (very strong), B (strong), C (fair), and D (no agreement).

RESULTS

A total of 35 experts from 18 different hospitals and 10 different countries participated in the study: 19 vascular surgeons, 11 cardiologists, four geneticists, and one cardiac surgeon. Of the 97 statements of the final questionnaire, 16 were graded A (16%), 23 B (24%), five C (5%), 44 D (45%) and nine (9%) were invalid. The experts highlighted the need to develop personalised therapies for each pathology, as well as international multicentre databases to collect data on the natural course of AAA patients with HAD.

CONCLUSION

This Delphi process led to consensus on several aspects of care for patients with AAA and underlying HAD, providing guidance to manage them in a more standardised fashion. The agreements reached focus on multidisciplinary aortic teams, imaging and genetic diagnosis, treatment, and follow up. Furthermore, several topics for future research were identified.

Semi-Branched Endovascular Aortic Repair: A New Feature in the Treatment of Complex Aortic Aneurysms

PURPOSE

To report a case series on using a novel semi-branch feature in custom-made stent-grafts in the endovascular treatment of complex aortic aneurysms and summarize the contemporary usage of this technology.

CASE SERIES

Four patients underwent endovascular aortic aneurysm repair (EVAR) with a custom-made semi-branch stent-graft (Semi-Branch Endovascular Aortic Aneurysm Repair [SBEVAR]). Two male patients, 75- and 76-year-old, were treated due to failed EVAR with late-type Ia endoleak, and the other two, 80- and 55-year-old male patients, due to a juxta-renal aortic abdominal aneurysm (JRAAA). In 3 cases, the celiac trunk (CT) vessel was targeted through an inner semi-branch; in the other case, all target vessels were bridged through inner semi-branches. Intra-operative technical success was accomplished in all 4 patients. Post-operative recovery was uneventful in all cases. The 30-day computed tomography angiography (CTA) follow-up for each patient showed patent target vessels, excellent apposition of the bridging stent to the semi-branch, and complete exclusion of the aneurysm.

CONCLUSION

The present report and the literature review demonstrate that introducing this novel semi-branch technology for the endovascular treatment of complex aortic aneurysms is feasible and holds great potential. The encouraging outcomes in cases of JRAAA and failed EVAR with late-type Ia endoleak inspire further studies to explore additional uses of this new tool in treating aortic pathologies.

CLINICAL IMPACT

The inner semi-branch is a novel technology for the incorporation of the renal and mesenteric vessels during complex endovascular aortic aneurysm repair. This new feature allows the use of a branched stent graft with a shorter length of the proximal sealing zone, reducing, consequently, the aortic coverage. It efficiently treats pathologies in which fenestrations could be inappropriate because precise stent graft placement might be difficult and in which tiny diameters leave inadequate room for typical inner branches. Although encouraging findings have been reported, long-term outcomes in target vessel stability have yet to be described.

Early and Mid-Term Outcomes of Isolated Type 2 Endoleak Refractory to an Embolization Procedure

Introduction: A type 2 endoleak (EL2) remains the most prevalent complication of endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA). Methods: We conducted a retrospective, single-center analysis, including patients who underwent embolization for an isolated EL2 after EVAR. The study population was stratified into two groups: Group A, consisting of patients whose EL2 resolved after the first embolization procedure, and Group B, consisting of those with refractory EL2 (rEL2). The indication for EL2 treatment was aneurysmal sac growth amounting to >10 mm from the index EVAR. The indications for endograft explantation were the absence of high comorbidities and persisting aneurysmal sac expansion. Those with high comorbidities were subjected to another endovascular procedure or a conservative approach, the latter being preferred. The primary endpoint was EL2 resolution. The secondary endpoints were mid-term outcomes in terms of aneurysmal sac shrinkage, stability and expansion rates, and aneurysm-related complications. Results: Among 57 patients, 19 patients (33.3%) showed signs of EL2 after the first embolization, whereas 38 (66.6%) presented rEL2. Of these, 14 (36.8%) presented significant aneurysmal sac expansion: 8 patients underwent a secondary embolization, while an open conversion was performed in the remaining 6 patients (42.8%), 4 of whom, in an elective setting, showed a complete resolution of EL2, while 2 patients treated in an urgent setting died from a ruptured aneurysm. Among the patients treated with a secondary embolization, only 2 patients presented EL2 resolution, while the other 6 patients (75%) showed rEL2. Out of the 38 patients with rEL2, 24 patients did not undergo further interventions; of these, 11 (45.8%) presented sac expansion, and 16% developed type IA EL. Conclusions: A strict follow-up and possibly a more aggressive treatment should be considered in an elective setting for patients with rEL2.

Impact of Sex-Related Differences in Infrarenal Aortic Neck Morphology on Outcomes of Endovascular Aneurysm Repair for Similar-Sized Aortic Aneurysm

Objectives: This study aimed to evaluate whether gender-related anatomical differences in proximal aortic neck morphology affect the feasibility and outcomes of endovascular aortic aneurysm repair (EVAR) in women with abdominal aortic aneurysms (AAA). Methods: This study performed a retrospective analysis of patients electively treated by EVAR for infrarenal AAA between January 2019 and December 2023. Demographics, anatomical characteristics, and stent graft details were analyzed. The primary endpoint was technical success. Secondary endpoints included freedom from aortic and neck-related reinterventions, endoleak rate, and freedom from aneurysm-related mortality during follow-up. Technical aspects, including adherence to the instructions for use (IFUs), were retrospectively analyzed. Results: One-hundred-seventeen patients (fifty-six females; mean age 76.2 ± 5.3 years) underwent elective EVAR for AAA. Demographics and comorbidities were homogeneous across genders. Female patients (Group A) demonstrated a higher prevalence of hostile proximal aortic neck features, including neck length < 10 mm and angulation > 60° (p = 0.009, p = 0.029, respectively) and a higher frequency of off-label EVAR procedures (28.6% vs. 11.5%; p = 0.034). The overall technical success rate was 98.3%, with no significant differences between genders in terms of stent graft selection, use of suprarenal fixation, or incidence of type 1-3 endoleaks. The median follow-up period was 35.2 ± 12.7 months, showing comparable rates of neck-related reinterventions, open conversions, and aneurysm-related mortality between genders. Notably, off-label EVAR was identified as an independent risk factor for type 1A endoleaks, reinterventions, and aneurysm-related mortality (p < 0.00001, p < 0.0001, and p = 0.001, respectively). Conclusions: Female patients undergoing EVAR often present with hostile proximal aortic neck features and are treated at an older age than males. Despite these differences, technical success rates and mid- to long-term outcomes were comparable between genders, with no variation in stent graft selection or suprarenal fixation use. Effective procedural planning, device selection, and surgical expertise appear to mitigate historical gender-related anatomical challenges. Further large-scale studies are needed to confirm whether anatomical factors alone drive outcomes, irrespective of gender.

The Impact of Diabetes Mellitus and Metformin Use on Outcomes After Endovascular Aneurysm Repair

Objective: To study the influence of diabetes mellitus (DM) and metformin treatment on aneurysm sac remodeling after endovascular aneurysm repair (EVAR). Methods: A retrospective single-center cohort analysis was conducted on consecutive patients who underwent elective EVAR for an infrarenal abdominal aortic aneurysm (AAA) between January 2011 and December 2021. Differences between study groups were analyzed and Kaplan-Meier analysis were employed to describe overall and reintervention-free survival. Cox regression analysis was performed to identify predictors of sac shrinkage. Results: A total of 529 patients were included: 74 (14.0%) had DM and metformin treatment, 26 (4.9%) had DM without metformin treatment, and 429 (81.1%) did not have DM. At one-year follow-up, diabetic patients showed significantly less sac shrinkage compared to non-diabetic patients (40.0% vs. 52.0%; p = 0.038), with a trend toward more stable sac behavior in diabetic patients (52% vs. 42%; p = 0.055). At last follow-up, sac shrinkage was significantly less in diabetic patients on metformin treatment compared to non-diabetics (48.6% vs. 59.9%; p = 0.047). No differences in sac shrinkage were observed between diabetics with and without metformin treatment. The presence of endoleak was significantly higher in groups showing stable sac behavior and growth. Through nine-year follow-up, overall survival was significantly less in diabetic patients compared to non-diabetic ones (23.5% vs. 37.5%; p < 0.001). Conclusions: This study showed a negative impact of diabetes mellitus and metformin treatment on sac shrinkage following EVAR. The presence of any type of endoleak was associated with reduced sac shrinkage at both time points. Overall survival was significantly lower in diabetic patients compared to non-diabetic patients.

Single-Stage Microsurgical Clipping of Multiple Intracranial Aneurysms in a Patient with Cerebral Atherosclerosis: A Case Report and Review of Surgical Management

The management of multiple intracranial aneurysms presents significant clinical challenges, particularly when complicated by underlying conditions such as cerebral atherosclerosis. This case report highlights the successful treatment of a 66-year-old female diagnosed with three intracranial aneurysms located in the right middle cerebral artery (MCA), pericallosal artery, and M2 segment. The patient also had a history of systemic atherosclerosis and right-sided breast cancer, factors that increased the complexity of surgical intervention. The aim of this report is to demonstrate the efficacy of single-stage microsurgical clipping in managing multiple aneurysms with favorable outcomes in a complex patient profile. Methods: The patient underwent right-sided pterional craniotomy for microsurgical clipping of all three aneurysms during a single-stage procedure. Two aneurysms in the MCA were clipped using Yasargil clips, and a third aneurysm located at the bifurcation of the pericallosal artery was also secured with a clip. The procedure was performed under microscopic visualization, with meticulous dissection of the atherosclerotic vessels and careful intraoperative hemostasis. Postoperative care involved proactive perioperative management, including blood pressure control and vigilant neurological monitoring. Results: Postoperative imaging at three months confirmed proper clip placement with no evidence of residual aneurysm filling or ischemic complications. The patient exhibited a full neurological recovery, with no deficits or further complications, highlighting the effectiveness of the surgical approach in managing multiple aneurysms concurrently. Conclusions: This case supports the use of single-stage microsurgical clipping as an effective treatment for patients with multiple intracranial aneurysms, even in the presence of complicating factors such as atherosclerosis. A meticulous surgical technique and perioperative management are critical to achieving favorable outcomes and reducing the risk of delayed ischemia or other postoperative complications.

Unveiling the uncommon: hypoplasia of external iliac artery-a case report and literature review

The absence or dysplasia of the iliac artery(IA) is an exceedingly rare condition, with limited cases documented in the literature. In this report, we present a case of hypoplasia of the right external iliac artery (EIA) in a 69-year-old male patient. The patient presented with right lower abdominal pain attributed to an aneurysm of the right internal iliac artery (IIA), yet notably, there was no evidence of lower limb ischemia at the time of consultation. Computed tomography angiography (CTA) of the aorta revealed a slender and occluded right EIA. Additionally, aneurysms were identified in the abdominal aorta (AA), the common iliac artery (CIA), and the right IIA, with collateral circulation involving the deep femoral artery and internal pathways. We performed aortoiliac aneurysm repair with a bifurcated synthetic graft on the patient's AA and iliac artery (IA), successfully excising the abdominal aorta aneurysms (AAA) and the CIA aneurysm. Postoperatively, thrombosis of the internal iliac aneurysm was observed, and the patient experienced a resolution of pain symptoms in the right lower abdomen. This paper delineates the vascular variations and treatment strategies employed and provides a review of the existing literature on IA malformations.

Long-Term Outcomes of Endovascular Aortic Repair with Parallel Chimney or Periscope Stent Grafts for Ruptured Complex Abdominal Aortic Aneurysms

Background: The parallel stent graft endovascular aortic repair (PGEVAR) technique is an off-the-shelf option used for elective complex abdominal aortic aneurysm repair with acceptable outcome results, as reported so far. The PGEVAR technique, using chimney or periscope parallel grafts, can also be used for patients with ruptured complex abdominal aortic aneurysms. However, only few data about the mid- to long-term outcomes are available. Methods: Data from patients treated between August 2009 and July 2023 with the PGEVAR technique for ruptured complex abdominal aortic aneurysms were analyzed. The endpoints of this study were primary and secondary technical success, perioperative mortality, rate of proximal type 1a (gutter) endoleaks (T1aEL), and overall and aneurysm-related survival. Secondary endpoints were major adverse events, durability of parallel grafts, and factors associated with overall survival. Results: Twenty patients (mean age: 77 ± 9 y; 18 male) with ruptured complex abdominal aortic aneurysm were treated, receiving PGEVAR for ruptured juxtarenal (n = 11), suprarenal (n = 7), or distal thoracoabdominal Crawford IV aortic aneurysms (n = 2) with a mean diameter of 82 ± 18 mm (range 59-120). The patients had PGEVAR with implantation of 39 parallel grafts (1.95 PGs per patient; 23 chimney and 16 periscope) for revascularization of the celiac artery (n = 3), superior mesenteric artery (n = 9), and renal arteries (n = 27). Three patients had delayed PG implantation within 10 days. Primary technical success was 15/20 (75%) with five patients having an early proximal T1aEL, three of them having successful reintervention (secondary success rate: 18/20; 90%), with no persistent bleeding. Two patients had late T1aELs. The presence of an early T1aEL was related to the number of PGs (≥2) implanted (p = 0.038) or insufficient aortic SG oversizing (p = 0.038). In-hospital mortality was 1/20 (5%). Perioperative mortality up to 32 days was 3/20 (15%), with two further late aneurysm-related deaths and eight late aneurysm-unrelated deaths (overall mortality 13/20; 65%) during follow-up (median 34 months; range 1-115). Major adverse events were observed in 11 (55%) patients. Secondary parallel stent graft patency at 1 and 3 years was 97.4 and 94.1%. During follow-up, aneurysm sac behavior was determined in 19 patients, which showed diameter progression (n = 3), stable aneurysm disease (n = 3), and aneurysm diameter regression in 13 (68.4%) patients. Overall survival was 75% after 1 year, and 53% and 22% after 3 and 5 years. Factors associated with overall long-term survival were age < 80 years (p = 0.037), juxtarenal aneurysms (p = 0.023), the absence of major adverse events (p = 0.025), and aneurysm sac regression (p = 0.003). Conclusions: Treatment of ruptured complex abdominal aortic aneurysm with the PGEVAR technique is associated with acceptable perioperative and long-term outcomes with high PG patency rates. Early proximal T1aELs are observed with a relevant frequency, requiring early reintervention with successful sealing of most relevant endoleaks. To note, limitation of the number of parallel stent grafts implanted at the proximal aortic sealing sites, sufficient PG sealing length, and adequate main aortic SG oversizing are most relevant to avoid T1a (gutter) ELs. The selection of juxtarenal aortic aneurysms and evidence for aneurysm sac diameter regression after PGEVAR had a prognostic impact.

External Validation of Traditional and Modified Harborview Risk Scores for Ruptured Abdominal Aortic Aneurysm 30-day Mortality Prediction

BACKGROUND

A critical issue in the preoperative assessment of a patient with a ruptured abdominal aortic aneurysm (rAAA) is death risk prediction. The traditional and modified Harborview Risk Score (tHRS and mHRS) consider readily available variables to estimate 30-day mortality. The aim of the study was to validate tHRS and mHRS in a rAAA external population.

METHODS

Consecutive patients undergoing rAAA repair from January 2012 to January 2024 at a tertiary Vascular Surgery Center were retrospectively reviewed. The scores were calculated for each patient; receiver operating characteristic curves (ROC), area under the curve (AUC) with 95% confidence intervals (CIs) and calibration plots were built to evaluate discrimination and calibration. Furthermore, the relationship of mortality with score variables was updated running a multivariate logistic model, and then applied to one thousand bootstrap samples.

RESULTS

One hundred and five patients treated for rAAA (97 males, 92.4%) were included in the study (77 ± 8.5 years). An endovascular repair (rEVAR) was performed in 35 patients (3 women, 80 ± 9.0 years) while an open repair (rOAR) in 70 patients (5 women, 75 ± 8.0 years). The 30-day mortality rate was 31.4%, (33/105), 25.7% (9/35), and 34.3% (24/70) for rEVAR and rOAR, respectively (p 0.5). Eight patients (7.6%) were on therapy with warfarin at the time of admission. AUC for tHRS was 0.56 while AUC for mHRS was 0.68 (DeLong test = 0.29). The tHRS' calibration showed underestimation for patients with predicted mortality <25% and overestimation for the remaining; for mHRS, the predictions were well calibrated for patients with estimated mortality <40% with overprediction afterward. The model update demonstrated that the wider effects are due to the interaction between the HRS factors.

CONCLUSIONS

tHRS and mHRS showed limited prediction capability with 30-day mortality overestimation in an external validation, raising many concerns about their extended and systematic application. Interaction between factors should be taken into account to enhance the score's performance, especially in high risk patients.

Volume Measurements for Surveillance after Endovascular Aneurysm Repair using Artificial Intelligence

OBJECTIVE

Surveillance after endovascular aneurysm repair (EVAR) is suboptimal due to limited compliance and relatively large variability in measurement methods of abdominal aortic aneurysm (AAA) sac size after treatment. Measuring volume offers a more sensitive early indicator of aneurysm sac growth or regression and stability, but is more time consuming and thus less practical than measuring maximum diameter. This study evaluated the accuracy and consistency of the artificial intelligence (AI) driven software PRAEVAorta 2 and compared it with an established semi-automated segmentation method.

METHODS

Post-EVAR aneurysm sac volumes measured by AI were compared with a semi-automated segmentation method (3mensio software) in patients with an infrarenal AAA, focusing on absolute aneurysm volume and volume evolution over time. The clinical impact of both methods was evaluated by categorising patients as showing either AAA sac regression, stabilisation, or growth comparing the 30 day and one year post-EVAR computed tomography angiography (CTA) images. Inter- and intra-method agreement were assessed using Bland-Altman analysis, the intraclass correlation coefficient (ICC), and Cohen's κ statistic.

RESULTS

Forty nine patients (98 CTA images) were analysed, after excluding 15 patients due to segmentation errors by AI owing to low quality CT scans. Aneurysm sac volume measurements showed excellent correlation (ICC = 0.94, 95% confidence interval [CI] 0.88 - 0.99) with good to excellent correlation for volume evolution over time (ICC = 0.85, 95% CI 0.75 - 0.91). Categorisation of AAA sac evolution showed fair correlation (Cohen's κ = 0.33), with 12 discrepancies (24%) between methods. The intra-method agreement for the AI software demonstrated perfect consistency (bias = -0.01 cc), indicating that it is more reliable compared with the semi-automated method.

CONCLUSION

Despite some differences in AAA sac volume measurements, the highly consistent AI driven software accurately measured AAA sac volume evolution. AAA sac evolution classification appears to be more reliable than existing methods and may therefore improve risk stratification post-EVAR, and could facilitate AI driven personalised surveillance programmes. While high quality CTA images are crucial, considering radiation exposure is important, validating the software with non-contrast CT scans might reduce the radiation burden.

Outcomes of fenestrated and branched endovascular aneurysm repair with an inverted contralateral limb

OBJECTIVE

To report technical success and evaluate clinical outcomes of fenestrated and branched endovascular aortic repair (F/B-EVAR) incorporating a contralateral inverted limb.

METHODS

Patients who underwent F/B-EVAR with a custom-made bifurcated device containing an inverted limb between January 2010 and September 2023 were retrospectively analyzed. Time-to-event data were analyzed using the Kaplan-Meier method.

RESULTS

A total of 32 patients (26 men; mean age 77±6.2 years) were included in the analysis. Technical success was achieved in 28 patients (87.5%). Two technical failures resulted from misplaced contralateral limbs in patients with previous endovascular aortic repair (EVAR), necessitating one open conversion due to a type 3b endoleak, and one femoro-femoral crossover bypass after occlusion of a misplaced contralateral limb. Additionally, two technical failures were attributed to a type 3c endoleak and a type 1c endoleak, originating from a fenestrated device at the level of the left and right renal artery, respectively. One patient (3.1%) died <30 days post-operatively due to a subdural hemorrhage. Estimated patient survival after 1 and 2 years was 92.7%±5.1%, and 74.3%±10.1%, respectively. No aneurysm-related deaths were observed. During the median follow-up of 13 months, one (3.1%) inverted limb occluded, in addition to the occlusion resulting from a misplaced contralateral limb, and was treated with a femoro-femoral crossover bypass. One target vessel (right renal artery) occluded (0.9%), resulting in a permanent, significantly reduced renal function. Freedom from overall reintervention after 1 and 2 years was 73.5%±8.0% and 68.3%±9.0%, respectively. An additional four patients (12.5%) presented with a type 3c endoleak during follow-up scans, three of which originated from fenestrations at the level of the renal stents. There were no junctional problems between the inverted limb device and the main endograft, and no significant correlation was found between the one-sealing-stent inverted limb device design and the onset of type 3 endoleak (log-rank P=.064).

CONCLUSIONS

F/B-EVAR incorporating an inverted limb can be a viable endovascular option to manage complex aneurysms with a short renal artery to bifurcation distance. However, using the inverted limb presents a notable technical challenge and could be associated with a higher need for reintervention. Carefully confirming correct cannulation of the inverted limb is warranted.

Staged Therapy of Polyaneurysmal Disease Including the World's First BeFlared Use in Anaconda FEVAR

Background

Abdominal aortic aneurysms frequently coincide with popliteal artery aneurysms. The association with multiple peripheral aneurysms, sometimes called polyaneurysmal disease, is less frequent.

Case Description

An 82-year-old male was diagnosed with polyaneurysmal disease. He was treated by femoral, popliteal, and profundal interposition grafts as well as fenestrated endovascular repair (FEVAR) using an Anaconda (Terumo Aortic, Inchinnan, Scotland) endoprosthesis combined with BeGraft peripheral and BeFlared (BF) bridging stent grafts (Bentley InnoMed, Hechingen, Germany).

Conclusion

Polyaneurysmal disease in an aged patient can be treated successfully by thorough case planning, staging of procedures, and combining different vascular surgical techniques. It demonstrates the smooth implantation of the BeFlared in an Anaconda FEVAR.

Clinical Application of n-Butyl-2- Cyanoacrylate (NBCA) in the Transarterial Embolization for Type I/II Endoleak During and After EVAR Surgery

BACKGROUND

Exploring the effectiveness and safety of n-butyl-2-cyanoacrylate (NBCA) in the transarterial embolization for common endoleak during and after endovascular repair of aortic aneurysm (EVAR).

METHODS

A total of 226 patients with abdominal aortic aneurysm (AAA) were treated with EVAR in 4 years from August 2019 to February 2023, including 46 patients with ruptured aneurysms (rAAA). 37 cases, 28 nonruptured AAA patients and 9 rAAA patients, developed endoleak during EVAR surgery and follow-up period and were then treated with NBCA for transarterial embolization. A follow-up was done for at least 6 months to observe its clinical efficacy and adverse reactions.

RESULTS

Among 37 cases of endoleak, there were 8 cases of primary type Ia endoleak and one case of primary right type Ib endoleak in the rAAA group, one case of primary type Ib endoleak, 2 cases of secondary type Ia endoleak, and 25 cases of postoperative type II endoleak in the nonruptured AAA group. Three patients with primary type Ia endoleak were treated with coil-assisted NBCA in the rAAA group, while the remaining 34 patients with type I and type II endoleaks were treated with NBCA alone. All transarterial embolization achieved technical success, and the endoleak disappeared. Postoperative hospitalization observation showed that 3 cases of patients in the rAAA group who experienced primary type Ia endoleak during emergency EVAR surgery died within 4 days after surgery due to hemorrhagic shock and multiple organ failure. Two patients experienced non-AAA-related deaths during the follow-up period.

CONCLUSIONS

Transarterial embolization with NBCA for the treatment of primary and secondary endoleak is a safe and effective method. It can achieve more dense embolization of the aneurysm sac and more complex endoleaks embolization. And, it showed a low recurrence rate of endoleak and the incidence of perioperative complications after surgery, which is worthy of clinical promotion and application. Even in emergency EVAR combined with primary type I endoleak treatment in rAAA patients, patients can still benefit.

Editor's Choice - Peri-operative Mortality and Morbidity of Complex Abdominal Aortic Aneurysm Repair in Switzerland: A Swissvasc Report

OBJECTIVE

Complex abdominal aortic aneurysms (cAAA) pose a clinical challenge. The aim of this study was to assess the 30 day mortality and morbidity rates for open aneurysm repair (OAR) and fenestrated or branched endovascular aortic repair (F/B-EVAR), and the effect of hospital volume in patients with asymptomatic cAAA in Switzerland.

METHODS

Retrospective, cohort study using data from Switzerland's national registry for vascular surgery, Swissvasc, including patients treated from 1 January 2019 to 31 December 2022. All patients with asymptomatic, true, non-infected cAAA were identified. The primary outcome was 30 day mortality and morbidity rates reported using the Clavien-Dindo classification. Outcomes were compared between OAR and F/B-EVAR after propensity score weighting.

RESULTS

Of the 461 patients identified, 333 underwent OAR and 128 underwent F/B-EVAR for cAAA. At 30 days, the overall mortality rate was 3.3% after OAR and 3.1% after F/B-EVAR (p = .76). Propensity score weighted analysis indicated similar morbidity rates for both approaches: F/B-EVAR (OR 0.69, 95% CI 0.45 - 1.05, p = .055); intestinal ischaemia (1.8% after OAR, 3.1% after F/B-EVAR, p = .47) and renal failure requiring dialysis (1.5% after OAR, 5.5% after F/B-EVAR, p = .024) were associated with highest morbidity and mortality rates. Treatment specific complications with high morbidity were abdominal compartment syndrome and lower limb compartment syndrome following F/B-EVAR. Overall treatment volume was low for most of the hospitals treating cAAA in Switzerland; outliers with increased mortality rates were identified among low volume hospitals.

CONCLUSION

Comparable 30 day mortality and morbidity rates were found between OAR and F/B-EVAR for cAAA in Switzerland; lack of centralisation was also highlighted. Organ specific complications driving death were renal failure, intestinal ischaemia, and limb ischaemia, specifically after F/B-EVAR. Treatment in specialised high volume centres, alongside efforts to reduce peri-procedural kidney injury and mesenteric ischaemia, offers potential to lower morbidity and mortality rates in elective cAAA treatment.

Low-Profile Minos TM Stent Graft System for Endovascular Abdominal Aorta Aneurysm Repair-Early and Late Outcomes in Elective and Emergent Situations

BACKGROUND

The aim of the study was to present the results of a novel abdominal stent graft for patients with abdominal aortic aneurysm (AAA), through 2-year follow-up.

METHODS

A single-center retrospective review with prospectively collected data was performed to assess the safety and effectiveness of the Minos Abdominal stent device for treating AAAs. We estimated technical success rate, in-hospital and 30-day mortality, and mortality at the end of follow-up as well as complication and reintervention rate in our study cohort. Follow-up imaging assessments consisted of computed tomography angiography at 1 and 6 months and yearly thereafter.

RESULTS

A total of 52 patients (92% males; mean age, 74 ± 6 years) were enrolled with Minos Abdominal stent device from July 2020 until September 2023. Thirty one (60%) patients were asymptomatic while 21 (40%) were symptomatic. The technical success of the endovascular aortic repair was 95% (49 of 52 patients). In 5% (3 of 52) of the cases, cannulation of the contralateral limb was unsuccessful and was converted to aorto-uni-iliac graft. Two (4%) aortic related death were recorded during the 30-day period. The major adverse event rate was 3.8%. The overall mean follow-up was 30 ± 6 months; no aorta-related deaths or graft related complications were observed. Sac shrinkage (>5 mm) has been observed in 70% of patients.

CONCLUSIONS

Minos endoprosthesis seems to be safe, effective, and durable for treating AAA either in elective or emergent situations.

Presence of Atherosclerosis in Multiple Arterial Beds is Associated with Increased Mortality in Patients Undergoing Endovascular Aortic Aneurysm Repair

OBJECTIVE

Patients with polyvascular disease are considered high risk for major adverse cardiac events (MACE). This retrospective study used the Vascular Quality Initiative (VQI) database to quantify the effect of polyvascular disease on outcomes after endovascular aneurysm repair (EVAR).

METHODS

The VQI database was queried from 2012 - 2022 for elective EVAR. Patients were identified as having peripheral arterial disease, coronary artery disease, or cerebrovascular disease, and then stratified based on the number of arterial beds involved (one to three). Primary outcomes were peri-operative death and MACE. Multivariable analysis was performed to find associations between comorbidities and primary outcomes.

RESULTS

Of the 21 160 patients with arterial disease included in the study, 83.7% were male and the mean age was 73.73 ± 8.57 years. After stratification, 16 892 patients had atherosclerosis in one arterial bed, 3 869 in two arterial beds, and 399 in three arterial beds. Pre-operatively, patients with atherosclerosis in three arterial beds were more likely to have hypertension, diabetes, and renal failure (all p < .001). Post-operatively, patients with disease in three arterial beds were more likely to experience a post-operative complication (11.5% vs. 8.3% vs. 5.4%; p < .001), including MACE (4.3% vs. 2.5% vs. 1.3%; p < .001) and death (2.8% vs. 1.1% vs. 0.5%; p < .001). On multivariable analysis, polyvascular disease was associated with MACE (odds ratio 1.54, 95% confidence interval 1.29 - 1.84; p < .001). Kaplan-Meier analysis estimates showed statistically significant differences in survival at approximately the three year follow up (p < .001).

CONCLUSION

In this review of patients undergoing elective EVAR, patients with polyvascular disease experienced worse peri-operative outcomes, including death and MACE, the latter of which was confirmed on multivariable analysis. These patients should be considered high risk and managed accordingly.