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

Outcome of a dedicated complex aortic surgery fellowship program

Introduction

Advancements in endovascular therapy, especially in complex aortic procedures, underscore the need for additional post-certification training. Dedicated post-residency vascular fellowship programs offer exposure to diverse cases, research opportunities, and professional networking. The study aims to describe and present outcomes from the complex aortic fellowship program at the Vascular Surgery Department of the Uppsala University Hospital.

Methods

Nine former fellows who completed the aortic fellowship program at the Uppsala University Hospital from 2018 to 2023 were invited to take part in an anonymous 29-question survey through email. Demographic data, information about the existence of local aortic programs as well as on the types of aortic procedures performed were gained. The overall experience and impact of the fellowship were assessed using multiple interval scale questions, with a rating scale (1 excellent to 5 very poor). Finally, we provided the option to the participants to share additional feedback.

Results

Median age of participants was 34 years (IQR, 30.5-36), with 44.4% being women (4/9). There was a significant variation in the number of publications produced during the fellowship, with an overall mean of 4 papers (IQR, 2-10). Regarding the long-term impact of the fellowship, 5/9 (55.6%) of the fellows have contributed to the implementation of a complex aortic program after finishing the fellowship, providing a broad range of complex aortic procedures. All fellows (9/9, 100%) stated that the quality of the fellowship was excellent. The clinical experience 7/9 (77.8%), the academic environment 7/9 (77.8%) and the research opportunities 7/9 (77.8%) together with the mentorship 9/9 (100%) and the work environment 8/9 (88.9%), were considered of most value among the fellows. In general, the survey participants agreed that the fellowship atmosphere was suitable for learning, 9/9 (100%), and that it had a positive impact on their current practice, 7/9 (77.8%). Currently, 5/9 (55.5%) of the fellows hold a position including academic involvement.

Conclusions

There is a universal need for additional post-certification training. The current study showed that a balanced clinical and scientific exposure to complex aortic diseases is broadly welcomed among young vascular surgeons. The extension of the fellowship to cover other disciplines dealing with complex aortic procedures can be of value.

Systematic Review on the Use of 3D-Printed Models for Planning, Training and Simulation in Vascular Surgery

The use of 3D-printed models in simulation-based training and planning for vascular surgery is gaining interest. This study aims to provide an overview of the current applications of 3D-printing technologies in vascular surgery. We performed a systematic review by searching four databases: PubMed, Web of Science, Scopus, and Cochrane Library (last search: 1 March 2024). We included studies considering the treatment of vascular stenotic/occlusive or aneurysmal diseases. We included papers that reported the outcome of applications of 3D-printed models, excluding case reports or very limited case series (≤5 printed models or tests/simulations). Finally, 22 studies were included and analyzed. Computed tomography angiography (CTA) was the primary diagnostic method used to obtain the images serving as the basis for generating the 3D-printed models. Processing the CTA data involved the use of medical imaging software; 3DSlicer (Brigham and Women's Hospital, Harvard University, Boston, MA), ITK-Snap, and Mimics (Materialise NV, Leuven, Belgium) were the most frequently used. Autodesk Meshmixer (San Francisco, CA, USA) and 3-matic (Materialise NV, Leuven, Belgium) were the most frequently employed mesh-editing software during the post-processing phase. PolyJet™, fused deposition modeling (FDM), and stereolithography (SLA) were the most frequently employed 3D-printing technologies. Planning and training with 3D-printed models seem to enhance physicians' confidence and performance levels by up to 40% and lead to a reduction in the procedure time and contrast volume usage to varying extents.

Circulating monocyte populations as biomarker for abdominal aortic aneurysms: a single-center retrospective cohort study

Background

Abdominal aortic aneurysm (AAA) development is driven by inflammation, in particular myeloid cells, which represent attractive biomarker candidates. Yet to date, the maximum aortic diameter is the only clinically applied predictor of AAA progression and indicator for surgical repair. We postulated that aortic inflammation is reflected in a systemic change of monocyte populations, which we investigated regarding marker potential in AAA diagnosis and prognosis.

Methods

We conducted a single-center retrospective cohort study in a diagnostic setting, measuring monocyte subsets by flow cytometry in peripheral blood samples of 47 AAA patients under surveillance, matched with 25 healthy controls and 25 patients with peripheral artery disease (PAD). In a prognostic setting, we acquired longitudinal data of 60 AAA patients including aneurysm growth assessment by computed tomography at 6-month intervals.

Results

Blood levels of total monocytes, CD16+ monocytes and particularly intermediate monocytes were significantly increased in AAA patients versus healthy individuals and were also elevated compared to PAD patients. The combination of intermediate monocyte and D-dimer blood levels outperformed the individual diagnostic marker values. Additionally, the elevated concentrations of total monocytes, intermediate monocytes, and monocyte-platelet aggregates (MPA) were suited to predict rapid AAA progression over short-term periods of six months. Of note, MPA were identified as independent predictor of AAA disease progression in multivariable analysis.

Conclusion

Circulating monocyte subsets are elevated in AAA patients and support diagnosis and prediction of aneurysm progression. Monocyte subsets and D-dimer reflect different hallmarks (inflammation and hemostasis) of AAA pathology and when combined, may serve as improved biomarker.

The Outcome after Endovascular and Open Repair of Abdominal Aortic Aneurysms-A Binational Study Conducted between 1998 and 2017

Objective: We aimed to analyse patient outcomes following open (OAR) or endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) in Finland and Sweden from 1998 to 2017. Both intact and ruptured AAAs (rAAAs) were included in the analysis. Methods: Patient-level data from national registries in Finland and Sweden were analysed, pairing operations for intact and ruptured AAA repair with mortality data (date of death). All-cause mortality was the primary endpoint. Anonymized patient data from both countries were pooled, comprising a total of 32,324 operations. Ruptured and intact AAAs were considered separately. In total, EVAR was performed on 9619 intact AAAs and 1470 rAAAs, while OAR was performed on 13,241 intact AAAs and 7994 rAAAs. The patient's age, sex and the date of operation were obtained as demographic information. Cox regression and Kaplan-Meier analyses were used to evaluate long-term (10-year) survival after the treatment of AAA or rAAA with either modality. Kaplan-Meier analysis was performed in three different age groups (<65 years, 65-79 years and ≥80 years). Results: Considering all age groups together, the 1-, 3- and 10-year Kaplan-Meier survival rates after EVAR were 93.4%, 80.5% and 35.3%, respectively, for intact AAA repair and 67.2%, 55.9% and 22.2%, respectively, for rAAA repair. For OAR of intact AAAs, the 1-, 3- and 10-year Kaplan-Meier survival rates were 92.1%, 84.8% and 48.7%, respectively. The respective rates for OAR of rAAAs were 55.4%, 49.3% and 24.6%. In a Cox regression analysis, a more recent year of operation was associated with improved survival, and older age affected survival negatively for both intact and ruptured AAA repair. If patients survived the first 90 days after the operation, the survival after intact AAA repair was 13.5 years for those <65 years (general population: 18.0 years), and 7.3 years for those ≥80 years (general population: 7.9 years). After rAAA repair, the mean survival was 13.1 years for patients <65 years and 5.5 years for patients ≥80 years, respectively. Conclusions: The long-term survival of patients undergoing intact AAA treatment at the age of 80 or older is close to that of the general population, provided they survive the operation. Conversely, for patients younger than 65, the long-term survival is markedly worse. The long-term survival of AAA patients has improved over time. Open surgery is still a safe and effective option for young patients undergoing intact AAA repair. Our results support the ESVS guidelines recommendation of EVAR being the first-line treatment for patients with rAAA.

Single Access and X-Over Reversed Iliac Extension Technique in a PAD Patient Needing Complex Endovascular Aortic Aneurysm Repair

PURPOSE

To describe the X-over reversed iliac extension technique in a patient with severe peripheral arterial disease (PAD) scheduled for inner branched endovascular aortic repair (iBEVAR).

TECHNIQUE

A multimorbid 62-year-old male patient was planned for iBEVAR due to a 58 mm suprarenal aortic aneurysm. The patient had a previous right femoropopliteal bypass and stenting of the left iliac axis. At admission, he presented with recent onset severe left limb claudication, which was attributed to left iliac stent occlusion. To avoid the postoperative compression of the right common femoral artery (CFA) and preserve the patency of the bypass, a single left CFA access, followed by left iliac artery recanalization, was decided. The right iliac axis was catheterized with a Lunderquist wire using X-over access from the left CFA. An iliac extension (ZISL, 24-59, Cook Medical, Bloomington, USA) was reversed and resheathed on back-table and implanted in the right common iliac artery using the X-over technique. The left CFA access was used to complete the remaining steps of the procedure. The predischarge computed tomography angiography confirmed bilateral iliac artery and femoropopliteal bypass patency.

CONCLUSION

The X-over reversed iliac extension technique may be applied in selected PAD patients, when undergoing complex endovascular aortic repair.

CLINICAL IMPACT

As the number of patients with peripheral arterial disease (PAD) is expected to increase the upcoming decades, out of the box solutions may be needed to assist complex endovascular aortic management. The X over technique, which consist of the contralateral advancement of an on-table reversed iliac limb, was successfully applied in a patient with severe PAD and numerous previous peripheral interventions, who was managed with branched endovascular aortic repair . The X Over technique may provide an additional alternative in well-selected patients with demanding vascular access undergoing complex endovascular aortic procedures.

Nationwide analysis of EVAR explantation outcomes in Korea: A comprehensive dataset study

OBJECTIVE

Endovascular aortic aneurysm repair (EVAR) is the primary treatment for abdominal aortic aneurysms, constituting 70%-80% of interventions. Despite initial benefits, long-term studies show increased mortality. Using nationwide data, this study assesses outcomes of EVAR, open aortic repair (OAR), and EVAR explantation (EE) in Korea, while exploring characteristics of late open conversion, including the rising EE incidence.

METHODS

Employing the National Health Insurance Service database, covering health-related data for nearly 50 million Koreans, the study spanned from 2002 to 2020. Patients with AAA diagnoses (I71.3 or I71.4) were categorized into OAR, EVAR, and EE groups based on procedural codes. Statistical analyses, including t-tests, Fisher's exact tests, Cox proportional hazard models, and multivariate Cox regression, assessed baseline characteristics, mortality risks, and factors within the EE group.

RESULTS

The analysis encompassed 26,195 patients, with 66.19% in the EVAR group, 31.87% in the OAR group, and 1.94% in the EE group. EVAR cases steadily increased from 2002 to 2018. Survival rates favored EVAR, followed by OAR and EE. 30-day survival was lower in EE than EVAR. Multivariate analysis for EE revealed no risk factors for 30-days survival but identified age, chronic kidney disease, high Charlson Comorbidity Index scores, and less than 6 months since EVAR as risk factors for overall mortality.

CONCLUSION

Rising EE trends with increased EVAR adoption, particularly evident in the Korean dataset, underscore inferior outcomes. This highlights the critical need for strategic initial treatment decisions and timely interventions to enhance overall results and mitigate the unfavorable EE incidence.

Understanding Type II Endoleak: A Harmless Imaging Finding or a Silent Threat?

Type II endoleak (T2EL) represents a challenging clinical entity following endovascular abdominal aortic aneurysm repair (EVAR). Although several studies have suggested that T2ELs are related to an increased risk of aneurysm sac growth and subsequent rupture, the exact role that T2ELs play in long-term outcomes remains debatable. Understanding the pathophysiology, diagnostic modalities, and management options of T2ELs is important for patients' safety and proper resource utilization. While conservative management may be suitable for asymptomatic patients with a stable aneurysm size, interventional approaches, including transarterial embolization, direct sac puncture embolization and open conversion have been described for patients with persistent T2EL associated with sac expansion. However, more research is needed to better determine the clinical benefit of such interventions. A thorough evaluation of all endoleak types before T2EL treatment would be reasonable for patients with T2ELs associated with sac expansion. Further studies are needed to refine treatment strategies aimed at minimizing T2EL-related complications. Collaborative efforts among vascular specialists, radiologists, and researchers are of paramount importance to address this ongoing clinical challenge.

Physician-Modified Endografts for Repair of Complex Abdominal Aortic Aneurysms: Clinical Perspectives and Medico-Legal Profiles

Standard endovascular aortic repair (EVAR) has become the standard of care for treating infrarenal abdominal aortic aneurysms (AAAs) in patients with favorable anatomies, while patients with challenging AAA anatomies, and those with suprarenal or thoraco-abdominal aneurysms, still need alternative, more complex, solutions, including custom-made branched or fenestrated grafts, which are constrained by production delay and costs. To address urgent needs and complex cases, physicians have proposed modifying standard endografts by manually creating graft fenestrations. This allows for effective aneurysm exclusion and satisfactory patency of visceral vessels. Although physician-modified grafts (PMEGs) have demonstrated high technical success, standardized creation processes and long-term safety data are still lacking, necessitating further study to validate their clinical and legal standing. The aim of this article is to illustrate the state of the art with regard to this surgical technique, summarizing its origin, evolution, and the main clinical evidence supporting its effectiveness. The paper also aims to discuss the main medico-legal issues related to the use of PMEGs, with particular reference to the issue of safety related to the standardization of the surgical technique, medical liability profiles, and informed consent.

Intra- and Early Post-Operative Factors Affecting Spinal Cord Ischemia in Patients Undergoing Fenestrated and Branched Endovascular Aortic Repair

Background: Spinal cord ischemia (SCI) is a severe complication after fenestrated/branched endovascular repair (f/bEVAR). The underlying causes of SCI are still under investigation. This study aimed to evaluate intra- and early post-operative parameters that may affect SCI evolution. Methods: A single-center retrospective analysis was conducted including SCI patients with complete anesthesiologic records (1 January 2011 to 31 December 2023). Values of intra-operative glucose, hemoglobin, lactate, activated clotting time (ACT), and the need for transfusion were collected. The cohort was compared to a matched cohort of non-SCI patients. Results: Fifty-one patients with SCI and complete anesthesiologic records were included (mean age: 69.8 ± 6.2 years; 39.2% male). Intra-operative glucose value < 110 mg/dL (AUC: 0.73; sensitivity 91%, specificity of 83%) and hemoglobin value > 8.5 mg/dL (AUC: 0.61; sensitivity 83%, specificity 78%) were protective for Grade 3 SCI. Twenty-three patients with SCI were matched to 23 patients without SCI. SCI patients presented significantly higher glucose levels intra-operatively (glucose mean value: SCI 150 ± 46 mg/dL vs. non-SCI: 122 ± 30 mg/dL, p = 0.005). ACT (SCI 259 ± 31 svs. non-SCI 288 ± 28 s, p = 0.001), volume input (SCI 4030 ± 1430 mL vs. non-SCI 3020 ± 113 mL, p = 0.009), and need for transfusion (SCI: 52.5% vs. 4.3%, p < 0.001) were related to SCI. Higher glucose levels were detected among patients with SCI, at 24 (SCI: 142 ± 30 mg/dL vs. non-SCI: 118 ± 26 mg/dL, p=0.004) and 48 h (SCI: 140 ± 29 mg/dL vs. non-SCI: 112 ± 20 mg/dL, p < 0.001) post-operatively. Conclusions: SCI is a multifactorial complication after f/bEVAR. Intra-operative and early post-operative glucose levels may be related to SCI evolution. Targeted glucose < 110 mg/dL may be protective for Grade 3 SCI.

Screening Men and Women above the Age of 50 Years for Abdominal Aortic Aneurysm: A Pilot Study in an Upper Middle Income Country

OBJECTIVE

Screening for abdominal aortic aneurysm (AAA) is recommended in high risk populations based on local conditions. Differences in lifestyle and risk factors between countries with different income status make risk stratification based on geographic location necessary. The majority of epidemiological studies on AAA have reported data from high income countries. The aim of this study was to explore the prevalence and risk factors for AAA in an upper middle income country in Eastern Europe.

METHODS

A pilot screening project for AAA, supported by a mass media campaign, was conducted in 2023 in seven cities in Serbia. Ultrasound evaluation of the abdominal aorta was performed by a registered vascular surgeon on individuals who agreed to participate. Participants who attended screening completed a questionnaire on demographic and clinical information. To assess risk factors for AAA, univariable logistic regression analysis was performed to compute the odds ratio (OR) with 95% confidence interval (CI). Multivariable logistic regression was subsequently performed with adjustments for sex, age, family history of AAA, and other relevant factors.

RESULTS

A total of 4 046 participants (51.2% male and 48.8% female; mean age 68.8 ± 7.6 years) responded to the campaign. An aneurysm was found in 195 (4.8%) screened individuals (8.2% of men and 1.3% of women). In males aged 50 - 64 years, the prevalence of AAA was 5.4%. Male sex, older age, family history of AAA, being a smoker or ex-smoker, being overweight, and alcohol consumption were predictors of AAA in the univariable analysis. After adjustments in the multivariable analysis, male sex (OR 8.04, 95% CI 4.87 - 13.28), older age (OR 1.04, 95% CI 1.02 - 1.07), positive family history (OR 2.47, 95% CI 1.61 - 3.78), smoker status (OR 3.10, 95% CI 2.10 - 4.59), ex-smoker status (OR 2.13, 95% CI 1.39 - 3.27), and being overweight (OR 1.85, 95% CI 1.25 - 2.74) were independent risk factors for AAA.

CONCLUSION

The prevalence of AAA has not been reduced in all countries, and screening strategies might be changed based on local epidemiological data. The results of this pilot study underline the importance of exploring the prevalence of AAA in populations with a high prevalence of smoking.

Clinical Performance of the Low Profile Zenith Alpha Abdominal Endovascular Graft: 2 Year Results from the ZEPHYR Registry

OBJECTIVE

The midterm outcomes of the low profile Zenith Alpha Abdominal Endovascular Graft from the ZEnith alPHa for aneurYsm Repair (ZEPHYR) registry are reported.

METHODS

The ZEPHYR registry is a physician initiated, multicentre, non-randomised, core laboratory controlled, prospective registry. Inclusion criteria were patients with a non-ruptured abdominal aortic aneurysm with a maximum diameter ≥ 50 mm or enlargement > 5 mm within 6 months, with a site reported infrarenal neck length of ≥ 10 mm and with the intention to electively implant the Zenith Alpha abdominal endograft. Patients from 14 sites across Germany, Belgium, and the Netherlands were included. The primary endpoint was treatment success, defined as technical success and clinical success. Technical success was defined as successful delivery and deployment of the endograft in the planned position without unintentional coverage of internal iliac or renal arteries, with successful removal of the delivery system. Clinical success was defined as freedom from aneurysm sac expansion > 5 mm, type I or type III endoleaks, aneurysm rupture, stent graft migration > 10 mm, open conversion, and stent graft occlusion.

RESULTS

Three hundred and forty-seven patients were included in the ZEPHYR registry. The median clinical follow up was 743 days (interquartile range [IQR] 657, 806) with a median imaging follow up of 725 days (IQR 408, 788). Treatment success at 6 months, 1, and 2 years was 92.5%, 90.4%, and 85.3%, respectively. Freedom from secondary intervention was 94.3%, 93.4%, and 86.9%, respectively. The predominant reason for secondary intervention was limb complications. Freedom from limb occlusion (per patient) at 6 months, 1, and 2 years was 97.2%, 95.8%, and 92.5%, respectively. Univariable and multivariable Cox regression analyses could not identify any independent predictor for limb complications.

CONCLUSION

While treatment success is comparable with other commercially available grafts, the rate of limb complications at 2 years is of concern. The manufacturer's instructions for use should be followed closely. Further studies are necessary to investigate the root cause of the increased rate of limb complications with the Zenith Alpha Abdominal Endovascular Graft.

Long Term Outcomes of the Gore Excluder Low Permeability Endoprosthesis for the Treatment of Infrarenal Aortic Aneurysms

OBJECTIVE

This study evaluated the long term outcomes of endovascular aneurysm repair using the Gore Excluder Low Permeability (LP) endoprosthesis across high volume Dutch hospitals.

METHODS

A retrospective analysis was conducted of patients treated with the Excluder LP for infrarenal abdominal aortic aneurysm (AAA) in four hospitals between 2004 and 2017. Primary outcomes were overall survival, freedom from re-interventions (overall, inside and outside instructions for use, IFU), and AAA sac dynamics: growth (> 5 mm), stabilisation, and regression (< 5 mm). Secondary outcomes were technical success (device deployment), procedural parameters, and re-interventions. Follow up visits were extracted from patient files, with imaging assessed for complications and AAA diameter.

RESULTS

Five hundred and fourteen patients were enrolled, with a median (IQR) follow up of 5.0 (2.9, 6.9) years. Survival rates were 94.0% at one year, 73.0% at five years, and 37.0% at 10 years, with freedom from re-interventions of 89.0%, 79.0%, and 71.0%, respectively. 37.9% were treated outside IFU, leading to significantly more re-interventions over 10 years compared with those treated inside IFU (36.0% vs. 25.0%, respectively; p = .044). The aneurysm sac regressed by 53.5% at one year, 65.8% at five years, and 77.8% at 10 years, and grew by 9.8%, 14.3%, and 22.2%, respectively. Patients with one year sac growth had significantly worse survival (p = .047). Seven patients (1.4%) had a ruptured aneurysm during follow up. Over 15 years, type 1a endoleak occurred in 5.3%, type 1b in 3.1%, type 3 in 1.9%, type 4 in 0.2%, and type 2 in 35.6% of patients.

CONCLUSION

This multicentre study of real world endovascular aneurysm repair data using the Gore Excluder LP endoprosthesis demonstrated robust long term survival and re-intervention rates, despite 37.9% of patients being treated outside IFU, with type 4 endoleak being rare. Treatment outside IFU significantly increased re-intervention rates and one year sac growth was associated with statistically significantly worse survival.

Small AAAs: Recommendations for Rodent Model Research for the Identification of Novel Therapeutics

CLINICAL PROBLEM

Most abdominal aortic aneurysms (AAAs) are small with low rupture risk (<1%/y) when diagnosed but slowly expand to ≥55 mm and undergo surgical repair. Patients and clinicians require medications to limit AAA growth and rupture, but drugs effective in animal models have not translated to patients.

RECOMMENDATIONS FOR INCREASING TRANSLATION FROM MOUSE MODELS

Use models that simulate human AAA tissue pathology, growth patterns, and rupture; focus on the clinically relevant outcomes of growth and rupture; design studies with the rigor required of human clinical trials; monitor AAA growth using reproducible ultrasound; and perform studies in both males and females.

SUMMARY OF STRENGTHS AND WEAKNESSES OF MOUSE MODELS

The aortic adventitial elastase oral β-aminopropionitrile model has many strengths including simulating human AAA pathology and modeling prolonged aneurysm growth. The Ang II (angiotensin II) model performed less well as it better simulates acute aortic syndrome than AAA. The elastase plus TGFβ (transforming growth factor-β) blocking antibody model displays a high rupture rate, making prolonged monitoring of AAA growth not feasible. The elastase perfusion and calcium chloride models both display limited AAA growth.

An Asymptomatic Sigmoid Colonic Fistula Arising from a Large Aneurysm of the Internal Iliac Artery Was Discovered during a Medical Examination

The rupture of an internal iliac artery aneurysm in the colon is a rare but potentially fatal complication. We report a rectal fistula of an asymptomatic internal iliac artery aneurysm that was discovered incidentally during a medical examination. A 77-year-old man presented at a local hospital for a general medical examination. Although the blood reports revealed severe anemia, the patient did not complain of any associated symptoms including dizziness and hematochezia. Moreover, there was no palpable mass in the patient's abdomen, and there was no evidence of hematochezia, as the patient had been using a bidet. Interestingly, computed tomography (CT) revealed a large right internal iliac artery aneurysm. There was a suspicious finding of a fistula within the colon in the CT, but it was undetected in the preoperative sigmoidoscopy. Furthermore, operative findings showed a protruding retroperitoneal mass adhering to the mesentery of the sigmoid colon. During aneurysm resection, the presence of a fistula was unclear. However, a fistula tract, devoid of any infectious bacteria such as tuberculosis, was found in the specimen after colon resection. After a recovery period of approximately one week, the patient was discharged from the hospital without any unusual findings on the post-operative CT. Sigmoid colonic fistulas arising from iliac artery aneurysms are rare. Also, diagnosis may be delayed in special circumstances wherein a patient routinely uses a bidet.

Midterm Outcomes With the Nellix Endograft Alone or With Chimneys

Introduction

Endovascular aneurysm sealing (EVAS) appeared to be an innovative alternative to conventional endovascular abdominal aortic aneurysm repair. However, high rates of midterm failure of EVAS led to withdrawal of the device from the market. The study aim was to report midterm outcomes of patients treated with EVAS alone or associated with chimneys (Ch-EVAS) and the management of their complications.

Methods

In this single centre study, all consecutive Nellix implants between 2013 and 2016 were included. The primary endpoint was device failure: (1) a triad of caudal migration of the Nellix stents >5 mm, separation of the endobags (>5 mm), and sac enlargement (>5 mm), with or without visible endoleak, (2) secondary aneurysm rupture, (3) surgical explant of the graft, or (4) any intervention for a type I endoleak. Overall mortality, aneurysm related mortality, and re-intervention rates were analysed.

Results

Fifty patients (male n = 43, female n = 7) were included. Median follow-up was 3.05 years (interquartile range [IQR] 0.52, 4.63) and follow up index was 0.51 (IQR 0.10, 0.88). Device failures occurred in 17 patients (34%). Overall and aneurysm related mortality rates during the follow up period were 30% and 13%. Fourteen (28%) patients required re-interventions. Five EVAS patients (17%) presented with complications. Type Ia endoleaks were managed by device explantation for three patients, and endovascular aneurysm repair in Nellix for two patients. Type Ib endoleaks were managed with an iliac branched device and limb extension. Nine Ch-EVAS patients (42.9%) presented with complications. Type Ia endoleaks were was managed by Nellix stent prolongation and renal extension, two multibranched thoraco-abdominal devices, and two device explantations. Type Ib endoleaks were managed by limb extension and stent complications by stent angioplasty and iliorenal bypass.

Conclusion

The midterm outcome of EVAS is poor. All patients who underwent EVAS implantation must be informed and should undergo frequent surveillance. Open repair and device explantation should be considered as the primary treatment.

Early and Mid-Term Outcomes of Transcaval Embolization for Type 2 Endoleak after Endovascular Aortic Repair

Background: Among the endovascular approaches for the management of endoleak type 2 (EL 2), transcaval embolization (TCE) has shown encouraging outcomes. However, the literature is still limited. This study aimed to present the early and mid-term outcomes of TCE for EL 2 after endovascular aortic repair. Methods: A retrospective, single-center analysis of consecutive patients managed with TCE for EL 2 after standard or complex endovascular aortic repair, from August 2015 to March 2024, was conducted. The indication for TCE was the presence of an EL 2 related to ≥5 mm sac increase, compared to the first imaging after aneurysm exclusion or the smallest diameter during follow-up. Patients managed with TCE for other types of endoleaks were excluded. The primary outcomes were technical and clinical successes during follow-up. Results: Forty-three patients were included (mean age: 75.1 ± 6.0 years, 90.7% males). Technical success was 97.7%. Selective embolization was performed in 48.8% and non-selective in 51.2%. No death was recorded at 30 days. The estimated clinical success was 90.0% (standard error; SE: 6.7%) and the freedom from EL 2 was 89.0% (SE 6.4%) at 36 months. Cox regression analysis showed that the type of embolization (selective vs. non-selective), type of previous repair (f/bEVAR vs. EVAR), and use of anticoagulants did not affect follow-up outcomes. Reinterventions related to EL 2 were performed in 12.5%; three underwent an open conversion. Conclusions: TCE was related to high technical success and limited peri-operative morbidity, regardless of the type of initial endovascular aortic repair. Clinical success was encouraging with reinterventions for EL 2 affecting 12.5% of patients.

Appropriateness of care in complex fenestrated-branched aortic endografting

Fenestrated and branched endovascular repair of complex abdominal and thoracoabdominal aortic aneurysms is increasingly replacing open repair as the primary modality of treatment. Mid- and long-term results are encouraging and support its use in the correct settings. Nevertheless, appropriateness of indication for treatment, patient selection, and surgeon and hospital performance has not been clearly evaluated and reviewed. The objective of this review article was to identify areas in which appropriateness of care is relevant and can be optimized when considering treatment of patients with fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms.

Editor's Choice - An Endovascular Approach to Abdominal Aortic Aneurysm Rupture is Associated With Improved Outcomes for Patients With Prior Aortic Repair

OBJECTIVE

To assess whether outcomes of rupture repair differ by aortic repair history and determine the ideal approach for rupture repair in patients with previous aortic repair.

METHODS

This retrospective review included all patients who underwent repair of a ruptured infrarenal abdominal aortic aneurysm from 2003 - 2021 recorded in the Vascular Quality Initiative (VQI) registry. Pre-operative characteristics and post-operative outcomes and long term survival were compared between patients with and without prior aortic repair. To assess the impact of open and endovascular approaches to rupture, a subgroup analysis was then performed among patients who ruptured after a prior infrarenal aortic repair. Univariable and adjusted analyses were performed to account for differences in patient characteristics and operative details.

RESULTS

A total of 6 197 patients underwent rupture repair during the study period, including 337 (5.4%) with prior aortic repairs. Univariable analysis demonstrated an increased 30 day mortality rate in patients with prior repairs vs. without (42 vs. 36%; p = .034), and prior repair was associated with increased post-operative renal failure (35 vs. 21%; p < .001), respiratory complications (32 vs. 24%; p < .001), and wound complications (9 vs. 4%; p < .001). Following adjustment, all outcomes were similar with the exception of bowel ischaemia, which was decreased among patients with prior repair (OR 0.7, 95% CI 0.6 - 0.9). Subgroup analysis demonstrated that patients with a prior aortic repair history who underwent open rupture repair had increased odds for 30 day death (OR 1.3, 95% CI 1.2 - 1.7) and adverse secondary outcomes compared with those managed endovascularly.

CONCLUSION

Prior infrarenal aortic repair was not independently associated with increased morbidity or mortality following rupture repair. Patients with a prior aortic repair history demonstrated statistically significantly higher mortality and morbidity when treated with an open repair compared with an endovascular approach. An endovascular first approach to rupture should be strongly encouraged whenever feasible in patients with prior aortic repair.

Appropriate management of the small abdominal aortic aneurysm

There is variation in the management of small aneurysms in the United States today, with some surgeons moving forward with elective repair and others practice ongoing surveillance. Literature exists to suggest that small aneurysms are repaired at a higher rate than should be considered acceptable, and this represents a deviation from current standards of care. To best understand the optimal care of this patient population, this article aims to evaluate the current management of small aneurysms, review contemporary guidelines and the literature behind them, and assess the appropriateness of surgical management of small aneurysms.

Dynamic Radial MR Imaging for Endoleak Surveillance after Endovascular Repair of Abdominal Aortic Aneurysms with Inconclusive CT Angiography: A Prospective Study

Background/Objectives: To assess free-breathing, dynamic radial magnetic resonance angiography (MRA) for detecting endoleaks post-endovascular aortic repair (EVAR) in cases with inconclusive computed tomography angiography (CTA). Methods: This prospective single-center study included 17 participants (mean age, 70 ± 9 years; 13 males) who underwent dynamic radial MRI (Golden-angle RAdial Sparse Parallel-Volumetric Interpolated BrEath-hold, GRASP-VIBE) after inconclusive multiphasic CT for the presence of endoleaks during the follow-up of EVAR-treated abdominal aortic aneurysms. CT and MRI datasets were independently assessed by two radiologists for image quality, diagnostic confidence, and the presence/type of endoleak. Statistical analyses included interrater and intermethod agreement, and diagnostic performance (sensitivity, specificity, area under the curve (AUC)). Results: Subjective image analysis demonstrated good image quality and interrater agreement (k ≥ 0.6) for both modalities, while diagnostic confidence was significantly higher in MRA (p = 0.03). There was significantly improved accuracy for detecting type II endoleaks on MRA (AUC 0.97 [95% CI: 0.87, 1.0]) compared to CTA (AUC 0.66 [95% CI: 0.41, 0.91]; p = 0.03). Although MRA demonstrated higher values for sensitivity, specificity, AUC, and interrater agreement, none of the other types nor the overall detection rate for endoleaks showed differences in the diagnostic performance over CT (p ≥ 0.12). CTA and MRA revealed slight to moderate intermethod concordance in endoleak detection (k = 0.3-0.64). Conclusions: The GRASP-VIBE MRA characterized by high spatial and temporal resolution demonstrates clinical feasibility with good image quality and superior diagnostic confidence. It notably enhances diagnostic performance in detecting and classifying endoleaks, particularly type II, compared to traditional multiphase CTA with inconclusive findings.

Individualizing Surveillance after Endovascular Aortic Repair Using a Modular Imaging Algorithm

OBJECTIVES

Surveillance after endovascular aortic repair (EVAR) and fenestrated EVAR (FEVAR) is mainly directed by one-size-fits-all approaches instead of personalized decision making, even though treatment strategies and often endografts themselves are tailor-made to adjust for individual patients. We propose a modular imaging algorithm that escalates surveillance imaging based on invasiveness and need.

MATERIALS AND METHODS

In this retrospective observational study of single-center data, results of a modular imaging algorithm were analyzed. The algorithm is characterized by initiating the examination with standard B-mode then transitioning to Duplex ultrasound, B-Flow, and CEUS. Additional CT(A) studies are conducted where required. The study population included both patients receiving EVAR or FEVAR. A comparative analysis was conducted regarding endoleak detection.

RESULTS

The study population included 28 patients receiving EVAR and 40 patients receiving FEVAR. They accounted for 101 follow-up visits, which led to 431 distinct imaging studies. CEUS has the highest endoleak detection rate, followed by CTA and B-Flow. Duplex ultrasound and B-Flow resulted in 0 and 1 false positive cases, respectively, considering CEUS the reference standard. In a select group of six patients, CEUS was omitted after endoleaks were displayed by Duplex ultrasound or B-Flow, leading to a successful type II coiling and no aneurysm-related adverse events.

CONCLUSIONS

The proposed modular algorithm showed great potential to incorporate principles of personalized medicine in surveillance after endovascular aortic treatment. Since Duplex ultrasound and B-Flow rarely cause false positive endoleaks, more resource-intensive and invasive imaging studies such as CEUS and CTA can be omitted after positive identification.

Laparoscopic Ligation of the Inferior Mesenteric Artery: A Systematic Review of an Emerging Trend for Addressing Type II Endoleak Following Endovascular Aortic Aneurysm Repair

Background/Objectives: this systematic review aims to explore the efficacy and safety of the laparoscopic ligation of the inferior mesenteric artery (IMA) as an emerging trend for addressing a type II endoleak following endovascular aortic aneurysm repair (EVAR). Methods: A comprehensive literature search was conducted across several databases including Medline, Scopus, and the Cochrane Central Register of Controlled Trials, adhering to the PRISMA guidelines. The search focused on articles reporting on the laparoscopic ligation of the IMA for the treatment of a type II endoleak post-EVAR. Data were extracted regarding study characteristics, patient demographics, technical success rates, postoperative outcomes, and follow-up results. Results: Our analysis included ten case studies and two retrospective cohort studies, comprising a total of 26 patients who underwent a laparoscopic ligation of the IMA between 2000 and 2023. The mean age of the cohort was 72.3 years, with a male predominance (92.3%). The mean AAA diameter at the time of intervention was 69.7 mm. The technique demonstrated a high technical success rate of 92.3%, with a mean procedure time of 118.4 min and minimal blood loss. The average follow-up duration was 19.9 months, with 73% of patients experiencing regression of the aneurysmal sac, and no reports of an IMA-related type II endoleak during the follow-up period. Conclusions: The laparoscopic ligation of the IMA for a type II endoleak following EVAR presents a promising, minimally invasive alternative with high technical success rates and favorable postoperative outcomes. Despite its potential advantages, including reduced contrast agent use and radiation exposure, its application remains limited to specialized centers. The findings suggest the need for further research in larger prospective studies to validate the effectiveness of this procedure and potentially broaden its clinical adoption.

Can Biomarkers and PET Imaging Predict Abdominal Aortic Aneurysm Growth Rate?

Background: Abdominal aortic aneurysm (AAA) is a life-threatening condition due to the risk of aneurysm growth and rupture. Biomarkers linked to AAA pathogenesis are attractive candidates for AAA diagnosis and prognosis. The aim of this study was to assess circulating biomarkers levels relationship with PET imaging positivity and their predictive value in AAA growth rate. Methods: A total of 164 patients with AAA had whole body [18F]FDG PET/CT examination and blood drawn for biomarkers analysis at inclusion. Of these, 121 patients had at least one follow-up imaging assessment for AAA progression. Median (quartiles) imaging follow-up period was 32.8 months (15.2-69.6 months). Results: At baseline, PET was visually positive in 28 (17%) patients. Among PET+ patients, female proportion was higher compared to PET-patients (respectively, n = 6, 21.4% vs. n = 11, 8.1%, p = 0.046). Biomarkers of inflammation (CRP, CCL18), of proteolytic activity (MMP9), of extracellular matrix, and calcification regulation (OPN, OPG) were all significantly increased in PET+ patients (p < 0.05). During follow-up, rapid AAA growth (increase in size ≥ 1 cm per year) was observed in 36 (29.8%) patients and several biomarkers (CRP, MMP9, OPN, and OPG) were increased in those patients compared to patients without rapid growth (p < 0.05). Conclusions: Although PET positivity at baseline was not associated with rapid growth, CRP levels showed a significant association.

Hospital Incidence and Treatment Outcomes of Patients with Aneurysms and Dissections of the Iliac Artery in Switzerland-A Secondary Analysis of Swiss DRG Statistics Data

Background/Objectives: Aneurysms and dissections of the iliac artery (ADIAs) are significant vascular conditions often associated with aortic pathologies. Despite their importance, reports on isolated iliac artery pathologies are rare. This study aimed to investigate the epidemiology of ADIA in Switzerland including treatment incidence and hospital outcomes. Methods: A retrospective analysis of diagnosis-related group (DRG) statistics from 2011 to 2018 in Switzerland was conducted, identifying all cases of ADIA while excluding those with concomitant treatment of aortic pathologies. Age-standardized incidence rates and treatment outcomes were assessed, with multivariable logistic regression performed to identify factors associated with hospital mortality. Results: From 2011 to 2018, 1037 ADIA cases were hospitalized in Switzerland. Incidence rates for elective treatment were significantly higher in men than women, increasing in men from 1.5 to 2.4 cases per 100,000 men (p = 0.007), while remaining stable in women at around 0.2 cases per 100,000 women. Acute treatment incidence rates were lower but still higher in men, at 0.9 cases per 100,000 men and 0.2 cases per 100,000 women. Crude hospital mortality rates were lower for endovascular repair than open surgical repair in both elective (0.8% vs. 3.1%, p = 0.023) and emergency treatment (6.7% vs. 18.4%, p = 0.045). Multivariable analysis showed that endovascular repair was associated with significantly reduced hospital mortality compared to open repair (OR 0.27, 95%-CI: 0.10 to 0.66, p = 0.006). Conclusions: This nationwide study of iliac artery pathologies shows that the treatment incidence was about 10 times higher in men than in women for elective procedures, but only about five times higher for emergency treatment. Endovascular procedures were associated with significantly lower hospital mortality than open procedures, while hospital mortality rates were comparable for men and women.

Plug-Based Embolization Techniques of Aortic Side Branches during Standard and Complex Endovascular Aortic Repair

Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.

Neutrophil Extracellular Traps in Cardiovascular and Aortic Disease: A Narrative Review on Molecular Mechanisms and Therapeutic Targeting

Neutrophil extracellular traps (NETs), composed of DNA, histones, and antimicrobial proteins, are released by neutrophils in response to pathogens but are also recognized for their involvement in a range of pathological processes, including autoimmune diseases, cancer, and cardiovascular diseases. This review explores the intricate roles of NETs in different cardiovascular conditions such as thrombosis, atherosclerosis, myocardial infarction, COVID-19, and particularly in the pathogenesis of abdominal aortic aneurysms. We elucidate the mechanisms underlying NET formation and function, provide a foundational understanding of their biological significance, and highlight the contribution of NETs to inflammation, thrombosis, and tissue remodeling in vascular disease. Therapeutic strategies for preventing NET release are compared with approaches targeting components of formed NETs in cardiovascular disease. Current limitations and potential avenues for clinical translation of anti-NET treatments are discussed.

Infective Native Aortic Aneurysm: a Delphi Consensus Document on Treatment, Follow Up, and Definition of Cure

OBJECTIVE

Evidence is lacking to guide the management of infective native aortic aneurysm (INAA). The aim of this study was to establish expert consensus on surgical and antimicrobial treatment and follow up, and to define when an INAA is considered cured.

METHODS

Delphi methodology was used. The principal investigators invited 47 international experts (specialists in infectious diseases, radiology, nuclear medicine, and vascular and cardiothoracic surgery) via email. Four Delphi rounds were performed, three weeks each, using an online questionnaire with initially 28 statements. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements were revised and added or deleted, and the results were presented in the iterative rounds. Consensus was defined as ≥ 75% of the panel rating a statement as strongly agree or agree on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha > 0.80.

RESULTS

All 49 panellists completed all four rounds, resulting in 100% participation. One statement was added based on the results and comments of the panel, resulting in 29 final statements: three on need for consensus, 20 on treatment, five on follow up, and one on definition of cure. All 29 statements reached agreement of ≥ 86%. Cronbach's alpha increased for each consecutive round; round 1, 0.85; round 2, 0.90; round 3, 0.91; and round 4, 0.94. Thus, consensus was reached for all statements.

CONCLUSION

INAAs are rare, and high level evidence to guide optimal management is lacking. This consensus document was established with the aim of helping clinicians manage these challenging patients, as a supplement to current guidelines. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Editor's Choice - Comparison of Open Surgery and Endovascular Techniques for Juxtarenal and Complex Neck Aortic Aneurysms: The UK COMPlex AneurySm Study (UK-COMPASS) - Peri-operative and Midterm Outcomes

OBJECTIVE

Treatment of juxtarenal and complex neck abdominal aortic aneurysms (AAAs) is now commonly by endovascular rather than open surgical repair (OSR). Published comparisons show poor validity and scientific precision. UK-COMPASS is a comparative cohort study of endovascular treatments vs. OSR for patients with an AAA unsuitable for standard on label endovascular aneurysm repair (EVAR).

METHODS

All procedures for AAA in England (November 2017 to October 2019) were identified, AAA anatomy assessed in a Corelab, peri-operative risk scores determined, and propensity scoring used to identify patients suitable for either endovascular treatment or OSR. Patients were stratified by aneurysm neck length (0 - 4 mm, 5 - 9 mm, or ≥ 10 mm) and operative risk; the highest quartile was considered high risk and the remainder standard risk. Death was the primary outcome measure. Endovascular treatments included fenestrated EVAR (FEVAR) and off label standard EVAR (± adjuncts).

RESULTS

Among 8 994 patients, 2 757 had AAAs that were juxtarenal, short neck, or complex neck in morphology. Propensity score stratification and adjustment method comparisons included 1 916 patients. Widespread off label use of standard EVAR devices was noted (35.6% of patients). The adjusted peri-operative mortality rate was 2.9%, lower for EVAR (1.2%; p = .001) and FEVAR (2.2%; p = .001) than OSR (4.5%). In standard risk patients with a 0 - 4 mm neck, the mortality rate was 7.4% following OSR and 2.3% following FEVAR. Differences were smaller for patients with a neck length ≥ 5 mm: 2.1% OSR vs. 1.0% FEVAR. At 3.5 years of follow up, the overall mortality rate was 20.7% in the whole study population, higher following FEVAR (27.6%) and EVAR (25.2%) than after OSR (14.2%). However, in the 0 - 4 mm neck subgroup, overall survival remained equivalent. The aneurysm related mortality rate was equivalent between treatments, but re-intervention was more common after EVAR and FEVAR than OSR.

CONCLUSION

FEVAR proves notably safer than OSR in the peri-operative period for juxtarenal aneurysms (0 - 4 mm neck length), with comparable midterm survival. For patients with short neck (5 - 9 mm) and complex neck (≥ 10 mm) AAAs, overall survival was worse in endovascularly treated patients compared with OSR despite relative peri-operative safety. This warrants further research and a re-appraisal of the current clinical application of endovascular strategies, particularly in patients with poor general survival outlook owing to comorbidity and age.

Protagoras 3.0: feasibility of current fenestrated endografts and chimney technique for complex abdominal aortic aneurysms

BACKGROUND

The aim of this study was to evaluate the anatomical feasibility of current available fenestrated endografts (FEVAR) and on-label chimney technique (EnChEVAR) in patients with complex abdominal aortic aneurysms (C-AAA).

METHODS

Feasibility of EnChEVAR (Endurant II/IIS CE-marked [Medtronic]) and 4 types of FEVAR (Zenith Fenestrated CE-marked, Zenith Fenestrated Low-Profile [LP] custom-made device [CMD] [Cook Medical], Fenestrated Anaconda LoPro90 CMD, Fenestrated Treo CMD [Terumo Aortic]) was assessed according to the manufacturer's instructions for use. Computed tomography angiograms of patients with C-AAA previously included in the Protagoras 2.0 study were retrospectively reviewed. The aortic coverage was ideally planned to involve a maximum of two chimney grafts or fenestrations.

RESULTS

Iliac access and aortic neck of 73 C-AAAs were analyzed. The overall feasibility was significantly different between EnChEVAR (33%) and FEVAR (Zenith Fenestrated 15%, Zenith Fenestrated LP 15%, Fenestrated Anaconda LoPro90 45%, Fenestrated Treo 48%). The iliac access feasibility was significantly lower for Zenith Fenestrated with standard profile compared to all other grafts. The aortic neck feasibility was significantly higher for EnChEVAR and both Terumo Aortic fenestrated stent grafts, compared to both Cook Medical grafts. The treatment using any of the three current available fenestrated grafts with lower profile (Zenith Fenestrated LP, Fenestrated Anaconda LoPro90, Fenestrated Treo) would have been feasible in 71% of the cases.

CONCLUSIONS

Most of the patients treated by ChEVAR would have not been treated by first generation fenestrated stent graft. The current available fenestrated endografts, with lower profile and suitable also for angulated necks, increase the anatomical feasibility.

Impact of Frailty and Sarcopenia on Thirty-Day and Long-Term Mortality in Patients Undergoing Elective Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis

Background: The aim of this study was to assess the prognostic role of frailty and sarcopenia on the survival of patients with AAA undergoing elective endovascular repair (EVAR). Methods: A systematic review of the literature was conducted in accordance with Meta-analysis of Observational Studies in Epidemiology (MOOSE). The association of frailty or sarcopenia with 30-day mortality and late survival was expressed as odds ratios (ORs) or hazard ratios (HRs) with a 95% confidence interval (CI). Meta-analysis random effects models were applied. The five-factor modified frailty index (mFI-5) was used as a frailty metric and sarcopenia was determined using computed tomography angiography (CTA) with measurements of the total psoas muscle area. Frailty was defined as patients with mFI-5 ≥ 0.6 and sarcopenia was defined as the total psoas muscle area (TPA) within the lowest tertile. Results: Thirteen observational cohorts reporting a total of 56,756 patient records were eligible for analysis. Patients with frailty (mFI-5 ≥ 0.6) had significantly increased 30-day mortality than those without frailty (random effects method: OR, 4.84, 95% CI 3.34-7.00, p < 0.001). Patients with sarcopenia (lowest TPA tertile) had significantly increased 30-day mortality according to the fixed effects method (OR, 3.30, 95% CI 2.17-5.02, p < 0.001), but not the random effects method (OR, 2.64, 95% CI 0.83-8.39, p = 0.098). Patients with sarcopenia or frailty had a significantly increased hazard ratio (HR) for late mortality than those without frailty or sarcopenia according to the random effects method (HR, 2.39, 95% CI 1.66-3.43, p < 0.001). The heterogeneity of the studies was low (I2: 0.00%, p = 0.86). The relation of frailty to age extracted from four studies demonstrates that the risk of frailty increases with age according to the random effects method (standard mean differences, SMD, 0.52, 95% CI 0.44-0.61, p < 0.001). The heterogeneity of the studies was low (I2: 0.00%, p = 0.64). Conclusions: Patients with sarcopenia or frailty have a significantly increased risk of mortality following elective EVAR. Prospective studies validating the use of frailty and sarcopenia for risk prediction after EVAR are needed before these tools can be used to support decision making.

Intraoperative Predictors and Proposal for a Novel Prognostic Risk Score for In-Hospital Mortality after Open Repair of Ruptured Abdominal Aortic Aneurysms (SPARTAN Score)

(1) Background: Several mortality risk scores have been developed to predict mortality in ruptured abdominal aortic aneurysms (rAAAs), but none focused on intraoperative factors. The aim of this study is to identify intraoperative variables affecting in-hospital mortality after open repair and develop a novel prognostic risk score. (2) Methods: The analysis of a retrospectively maintained dataset identified patients who underwent open repair for rAAA from January 2007 to October 2023 in three Italian tertiary referral centers. Multinomial logistic regression was used to calculate the association between intraoperative variables and perioperative mortality. Independent intraoperative factors were used to create a prognostic score. (3) Results: In total, 316 patients with a mean age of 77.3 (SD ± 8.5) were included. In-hospital mortality rate was 30.7%. Hemoperitoneum (p < 0.001), suprarenal clamping (p = 0.001), and operation times of >240 min (p = 0.008) were negative predictors of perioperative mortality, while the patency of at least one hypogastric artery had a protective role (p = 0.008). Numerical values were assigned to each variable based on the respective odds ratio to create a risk stratification for in-hospital mortality. (4) Conclusions: rAAA represents a major cause of mortality. Intraoperative variables are essential to estimate patients' risk in surgically treated patients. A prognostic risk score based on these factors alone may be useful to predict in-hospital mortality after open repair.

Complex abdominal aortic aneurysms: a review of radiological and clinical assessment, endovascular interventions, and current evidence of management outcomes

Endovascular aortic aneurysm repair (EVAR) is an established approach to treating abdominal aortic aneurysms, however, challenges arise when the aneurysm involves visceral branches with insufficient normal segment of the aorta to provide aneurysm seal without excluding those vessels. To overcome this, a range of technological developments and solutions have been proposed including fenestrated, branched, physician-modified stents, and chimney techniques. Understanding the currently available evidence for each option is essential to select the most suitable procedure for each patient. Overall, the evidence for fenestrated endovascular repair is the most comprehensive of these techniques and shows an early post-operative advantage over open surgical repair (OSR) but with a catch-up mortality in the mid-term period. In this review, we will describe these endovascular options, pre- and post-procedure radiological assessment and current evidence of outcomes.