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

Slow growth rate in a rare isolated external iliac aneurysm

A 91-year-old man was referred for an asymptomatic saccular left external iliac aneurysm. Comorbidities included hypertension, hyperlipidemia, peripheral arterial disease, prior radical prostatectomy with bilateral pelvic lymphadenectomy for prostate cancer, left partial nephrectomy for small renal cell carcinoma, and fundoplication for Barrett's esophagus. Review of prior computed tomography scan of the abdomen revealed that the aneurysm had been present for the last 24 years (measuring 1.6 cm in 1999) with slow growth until 2023 (measuring 2 cm). On surveillance imaging the next year, the maximum diameter had increased to 2.8 cm. He was treated successfully with an endograft limb. Isolated external iliac artery aneurysms are extremely rare, and this single case report supports that these have a very slow growth rate.

Anxiety and disease awareness in individuals with heredity for abdominal aortic aneurysm

ObjectiveThe psychological consequences of being aware of an increased risk of developing abdominal aortic aneurysm as a first-degree relative of a person with abdominal aortic aneurysm are hitherto unexplored. This study investigates the awareness of heritability and anxiety in male and female adult offspring of abdominal aortic aneurysm patients compared to controls. Health-related quality of life among participants with aortic pathology was compared to participants with normal aortic diameters.MethodsThis was a cross-sectional point prevalence study based on the participants examined in the Detecting Abdominal Aortic Aneurysm in First Degree Relatives Trial (DAAAD; 752 adult offspring, 756 matched controls), 2020-2022. Questionnaires about health-related quality of life and study-specific questions regarding awareness of heritability were collected prior to the aortic ultrasound.ResultsAttendance rate was higher among individuals with heredity compared to controls (67% vs. 52%, p < 0.001). Of 1508 adult offspring examined, 65% reported having a close relative with abdominal aortic aneurysm (6% in controls). Female adult offspring reported higher awareness of heritability than controls (38% vs. 12%, p < 0.001), as did males (32% vs. 8%, p < 0.001). A slight majority of participants with awareness reported anxiety (54% of female offspring; 51% of male). There were no measured differences in health-related quality of life between the groups when standard health-related quality of life instruments were used.ConclusionThe higher-than-expected proportion of adult offspring with awareness of heritability and anxiety about such risk indicates that we fail to communicate risk to this group appropriately via the current channels of information within the healthcare system. This calls for the development of dedicated strategies for improved communication of abdominal aortic aneurysm risk to patients and their next of kin.

Giant para-anastomotic aneurysms following open abdominal aortic surgery: Open surgery or endovascular management? Report of two cases and literature review

INTRODUCTION AND IMPORTANCE

Para-anastomotic aneurysms (PAAs) represent a late complication of open surgical repair for occlusive or aneurysmal disease of the abdominal aorta. Due to limited literature and management challenges, we present two cases of PAAs and review existing evidence.

CASE PRESENTATION

CLINICAL DISCUSSION: The FEVAR approach avoids redo laparotomy, reducing risks of blood loss, and splanchnic injury. However, prior open repair requires careful endograft design, considering the graft's configuration, reduced compliance, and altered visceral anatomy. For distal anastomotic aneurysms, open repair was chosen due to fewer challenges from adjacent structures.

CONCLUSION

Based on our experience, FEVAR is effective for juxta-renal PAAs near the proximal anastomosis, while open repair is preferred for PAAs at the distal anastomosis. Further large-scale, long-term studies comparing these treatments are warranted.

Surgeon volumes of endovascular thoracoabdominal aneurysm repairs, but not juxtarenal repairs, are associated with outcomes following endovascular repair of thoracoabdominal aneurysms

OBJECTIVE

Endovascular thoracoabdominal aortic aneurysm (eTAAA) repair remains one of the more technically challenging aspect of vascular surgery, with significant risk of mortality, spinal cord ischemia, and end organ damage. Although fenestrated devices are available for juxtarenal aneurysms, there are no commercially available eTAAA devices on the United States market currently. We therefore studied how the volume of juxtarenal repairs would translate to outcomes of these more complicated aneurysms.

METHODS

We studied all eTAAA repairs (Crawford type 1-3) in the Vascular Quality Initiative from 2014 to 2021 and categorized surgeons into quartiles based on their average annual eTAAA volume and endovascular juxtarenal volume. Our primary outcome was thoracoabdominal life altering events (composite of perioperative death, stroke, permanent spinal cord ischemia, and dialysis). We employed mixed effects logistic regression clustering by center and surgeon.

RESULTS

We identified 5335 repairs from 607 surgeons, with annual average eTAAA volumes of 2629 from 400 surgeons. Quartile 1 involved less than two repairs and quartile 4 involved >12 repairs per year. Repairs at higher quartiles were for larger aneurysms, more commonly employed staged repairs, utilized spinal drains, and more frequently utilized physician-modified endografts, whereas low-volume surgeons most commonly employed parallel grafting. Higher volume surgeons had overall shorter procedural times, fluoroscopy time, and less total contrast. Technical success similarly increased as procedure volume increased. In adjusted analyses, rates of perioperative death, thoracoabdominal life altering events, stroke, acute kidney injury, and major adverse cardiac events were all lower in the highest volume quartile compared with the lowest. However, after accounting for eTAAA volume, surgeon volume of endovascular juxtarenal repairs was not associated with any postoperative outcome, and there was no significant interaction between juxtarenal and eTAAA volume. Medium-term mortality was lowest in patients treated in the top two quartiles of volume (hazard ratio, 0.77; 95% confidence interval, 0.61-0.97; P = .024).

CONCLUSIONS

Surgeon eTAAA experience shows a strong volume-outcome effect on outcomes in the immediate post operative period and in permanent patient-centered outcomes. However, experience in less extensive aneurysms did not directly translate to thoracoabdominal aneurysms. Further study is needed to evaluate the role that commercial graft availability and repair type contributes to these findings.

The Implications of Oxygen-Dependent Chronic Obstructive Pulmonary Disease on Sac Growth and Mortality Following Endovascular Aneurysm Repair

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a known risk factor for abdominal aortic aneurysm (AAA) growth and rupture. The impact of COPD on AAA sac behavior following endovascular aneurysm repair (EVAR) is poorly understood. This study aimed to determine the association between COPD and sac remodeling after EVAR.

METHODS

We identified all EVAR patients (2010-2021) in the Society for Vascular Surgery-Vascular Quality Initiative database. COPD severity (none, medication-treated, oxygen (O2)-dependent) was the primary exposure variable. The primary end point was 1-year sac growth post-EVAR. Mixed effects linear and logistic regression were used to assess the effects of COPD severity on sac remodeling, controlling for covariates. Cox proportional hazards regression and competing risks regression identified predictors of mortality and reintervention.

RESULTS

30,686 patients met inclusion criteria. COPD was present in 24% of patients (no COPD, 75.8% [n = 23,260], medication-treated COPD, 19.7% [n = 6,057], O2-dependent COPD, 4.5% [n = 1,369]). O2-dependent COPD was associated with persistent sac growth (mean difference: +0.55 mm, 95% confidence interval [CI] [0.05-1.05], P = 0.03) following EVAR implantation; however, medication-treated COPD was not (mean difference: -0.06 mm, 95% CI [-0.32 to 0.19]; P = 0.64). O2-dependent COPD patients did not experience increased reintervention rates (hazard ratio [HR] 0.82, 95% CI [0.65-1.02], P = 0.07) but were identified to have significantly increased mortality (HR 1.8, 95% CI [1.52-2.22], P < 0.0001).

CONCLUSION

O2-dependent COPD was significantly associated with increased sac growth after EVAR. O2-dependent COPD did not correlate with increased reintervention, likely due to the disproportionately elevated mortality rates in this group. These findings highlight that patients with O2-dependent COPD have limited life expectancy and potentially less favorable sac remodeling, and elective EVAR should thus be reserved for only those at greatest risk for AAA-related mortality.

Mid-term follow-up of renal artery reimplant in open surgical repair for abdominal aortic aneurysm with a crossed-fused renal ectopia

Crossed-fused renal ectopia is an uncommon congenital condition, and its association with abdominal aortic aneurysm can present a complex surgical scenario. We present a case of a 71-year-old male with abdominal aortic aneurysm and crossed-fused renal ectopia who underwent open surgical repair with renal artery reimplantation, using mannitol infusion and cold crystalloid perfusion for renal protection. Postoperatively, after transient creatinine rise, renal function normalized without dialysis. At 24 months follow-up, the reimplanted renal artery remains patent with normal renal function. This case illustrates open surgical repair's effectiveness in addressing complex vascular anatomy, ensuring durable outcomes, and preserving vessel patency and renal function.

Predictors of abdominal aortic aneurysm progression in men with small infrarenal aortic diameters at screening

OBJECTIVE

Screening for abdominal aortic aneurysm (AAA) defined as an infrarenal aortic diameter (IAD) of ≥30 mm reduces mortality, but managing patients with diameters of 25 to 29 mm is debated. Incorporating body surface area into the diagnostic criteria may improve the identification of those at risk of developing treatment-requiring aneurysms in this group. In a previous study, we defined a relative AAA as an IAD ≥150% larger than expected, with the normal diameter calculated using body surface area as a scaling factor. This study aimed to determine if this criterion could identify those at risk of aneurysmal development among patients with aortic diameter of 25 to 29 mm at screening.

METHODS

A cohort study was conducted on men with abdominal aortic diameters of 25 to 29 mm at AAA screening in Malmö, Sweden, with a median follow-up of 9.9 years. Growth rates were compared between the relative aneurysm group and the nonrelative aneurysm group using a linear mixed-effects model to account for both fixed and random effects. Time and hazard ratio to reach 40 mm, a marker of significant aneurysmal progression, were assessed using a log-rank test and a Cox proportional hazards model, both adjusted for smoking status and diabetes.

RESULTS

In a cohort of 270 men, three developed AAAs ≥55 mm. The baseline growth rate was 0.1 mm/year (95% confidence interval [CI], 0.0-0.3). Growth rates were increased by 0.4 mm/year (95% CI, 0.0-0.7) in the relative aneurysm group, and by 0.4 mm/year (95% CI, 0.2-0.7) in smokers. The median time to reach an IAD of ≥40 mm was 11.5 years for relative aneurysms and was not reached for those without, with a significant difference shown by a log-rank test stratified for smoking (P = .009). Hazards ratio to reach an IAD of ≥40 mm for relative aneurysms was 2.77 (95% CI, 1.34-5.74; P = .006) compared with those without.

CONCLUSIONS

In men with diameters of 25 to 29 mm at screening for AAAs, the use of an individualized diagnostic criterion, based on height and weight, could identify those with increased aneurysm growth and a significantly shorter time to reach 40 mm compared with baseline. The relative aortic diameter, beyond the absolute diameter, seemed to be important for aneurysmal development. However, the differences were likely too small to warrant changes in clinical practice, highlighting the need for further research to establish clinical relevance.

Factors influencing stent graft occlusion in endovascular repair of internal iliac artery aneurysms

OBJECTIVE

This study aimed to evaluate technical factors influencing stent graft occlusion following endovascular repair of internal iliac artery aneurysms (IIAAs), with a specific focus on the longitudinal length of unsupported stent graft segments and connecting stent grafts.

METHODS

A retrospective single-center analysis was performed on 61 IIAAs treated with endovascular techniques between 2010 and 2022. Anatomical and technical factors, including the unsupported stent graft length within the aneurysm sac (Distance A) and the length of the distal sealing zone (Distance B), were assessed. Statistical analyses were conducted to identify factors associated with stent graft occlusion, type Ib endoleaks, and clinical outcomes.

RESULTS

The primary technical success rate was 90.2%, with a stent graft occlusion rate of 23% documented over a mean follow-up period of 25.7 months. A longer unsupported stent graft length (Distance A) was significantly associated with increased risk of occlusion (53.7 vs 37.0 mm in nonoccluded cases; P = .017). Occlusion rates were also higher in cases with a greater number of connecting stent grafts used to extend the iliac branched device to healthy vessel segments (P = .015). Type Ib endoleaks occurred in 6.6% of cases and were significantly associated with shorter distal sealing zones (≤15 mm; odds ratio, 18.0). Despite these technical challenges, clinical success was achieved in 83.3% over the follow-up period, with low rates of ischemic complications. Buttock claudication occurred in 12.9% of cases, and erectile dysfunction was reported in one patient.

CONCLUSIONS

Endovascular repair of IIAAs is effective and provides a viable option for patients unfit for open surgery. However, it carries risks of stent graft occlusion and endoleaks, particularly when the unsupported stent graft length is extended or when multiple connecting stents are used. Optimizing graft configurations and minimizing unsupported segments may reduce occlusion risks. Furthermore, ensuring an adequate distal sealing zone length is critical to minimizing the occurrence of type Ib endoleaks. These findings highlight the importance of careful procedural planning and technical considerations to improve long-term outcomes and enhance durability in endovascular management of IIAAs.

Beyond Endovascular Solutions: Open Sac Revision with Graft Preservation for Persistent Aortic Sac Expansion Post-EVAR

BACKGROUND

Aortic sac expansion after endovascular aortic aneurysm repair (EVAR) is associated with higher reintervention rates, late rupture, and long-term all-cause mortality. Endovascular options have limitations, and guidelines recommend open sac revision (OSR) if these fail. This study reviews the technique, indications, and outcomes for OSR following EVAR at Auckland City Hospital.

METHODS

We identified all OSR cases with stent-graft preservation for aortic sac expansion post-EVAR at Auckland City Hospital from January 2010 to October 2023. Techniques included sac closure, plication, or omental wrapping. Cases involving infected grafts were excluded.

RESULTS

Seventeen patients (median age: 82 years, predominantly male) underwent OSR, with a median follow-up of 3 years. The primary indication was sac expansion with type 2 endoleak in 88.24% of patients, while 2 cases were type V endoleaks. Intraoperatively, endoleaks were found in 94.12% of patients, with 88.24% having type 2 endoleak and 17.65% having type 3 endoleaks. Omentoplasty was performed in 58.82% of cases. Although not statistically significant, there was a trend toward lower endoleak recurrence with omentoplasty than sac closure. Reintervention for progressive sac expansion was required in 17.65% of patients (3/17), with 2 additional patients (11.76%) monitored for recurrent endoleak without further intervention. All patients were discharged, with 82.35% going home without needing rehabilitation. The median hospital stay was 7 days, and the 30-day mortality rate was 0%.

CONCLUSION

OSR with graft preservation is effective for sac expansion post-EVAR, facilitating endoleak identification and repair while avoiding aortic clamping. Ongoing surveillance is necessary.

International Cross-Sectional Survey on Management of Type II Endoleak and the Role of Preemptive Embolization

BACKGROUND

Type II endoleaks (TIIELs) commonly occur following endovascular aneurysm repair (EVAR). There is a lack of unified consensus regarding the management of TIIEL. Preemptive embolization is a potential method to reduce the risk for TIIEL, but its role is debated. We performed a survey among aortic experts internationally to assess perspectives on TIIEL management and the role of preemptive embolization.

METHODS

A questionnaire was prepared covering aspects on effect of TIIEL on EVAR outcome, strategies to manage TIIEL, and attitudes toward preemptive embolization techniques. The questionnaire was distributed using an online platform among vascular specialists across 80 specialized aortic centers worldwide.

RESULTS

Of 80 survey recipients, 56 (70%) responded. Only 12% of participants did not believe TIIEL to affect the durability of EVAR. Nearly 82.2% of respondents believed TIIEL increases the likelihood of reintervention. One-quarter agreed that TIIEL increases aortic-related mortality post-EVAR. For established TIIEL, 12% find "any sac expansion" to be an indication for intervention, while 41% would intervene at >5 mm sac expansion, and 52% at >10 mm sac expansion. Majority (63%) perform selective embolization in this setting. Only 3.6% of participants reported routinely conducting preemptive embolization in over 30% of their EVAR cases, while 42.9% never performed this procedure, and 53.6% performed preemptive embolization in <30% of cases. A substantial 76.8% believed that existing literature lacked sufficient evidence to support the integration of preemptive embolization into their clinical practice. Additionally, almost 90% expressed interest in participating in a multicenter randomized controlled trial evaluating the safety and efficacy of preemptive embolization.

CONCLUSION

Management of TIIEL is highly diverse among aortic experts. There is a need for further evidence on when and how to best treat TIIEL, as well as robust studies with long-term data to assess the potential role of preemptive embolization in increasing the durability of EVAR.

Endovascular inferior mesenteric artery revascularisation for chronic mesenteric ischaemia in selected clinical scenarios

Background: Experience on endovascular inferior mesenteric artery (IMA) revascularisation for atherosclerotic chronic mesenteric ischaemia (CMI) is limited and its clinical benefit remains uncertain. Patients and methods: This retrospective single-centre study included 12 patients with CMI who underwent endovascular IMA revascularisation between January 2014 and January 2024. Indications were: (1) IMA stenosis with endoscopically confirmed colonic ischaemia, (2) IMA stenosis with retrograde filling of a proximally occluded superior mesenteric artery ineligible for revascularisation, and (3) overall improvement of collateralisation in critical CMI due to multi-vessel disease. Technical success, clinical success and primary clinical patency were assessed. Procedure-related adverse events, symptom recurrence, mortality and survival rates were also analysed. Results: Seven isolated IMA interventions and five IMA revascularisations as part of a multi-vessel approach were performed. Balloon-expandable stents were used in 11 cases; one patient underwent balloon angioplasty with intravascular lithotripsy. Technical success was 83% (10/12); two cases had >50% residual stenosis due to annular aortic calcification impeding stent expansion. Median final residual stenosis was 27% (IQR 23.5). Four minor procedure-related adverse events occurred. Clinical success was 92% (11/12). Median follow-up was 17 months (IQR 20.7). The all-cause mortality rate was 25% (3/12). The mesenteric ischaemia-related mortality rate was 8% (1/12). The symptom recurrence rate was 33% (4/12). At 6 and 12 months, primary clinical patency rates were 71% and 54%, and survival rates were 83% and 72%. Conclusions: Endovascular IMA revascularisation is a viable treatment for CMI in selected scenarios where other options are inappropriate. Despite the specific calcification pattern at the IMA origin predisposing to residual stenosis, most patients had symptom resolution and acceptable clinical patency with low recurrence and mortality rates. However, 33% of patients had early symptom recurrence requiring treatment. It remains difficult to assess whether IMA revascularisation is curative or a bridge to open revascularisation.

Effects of Pre-emptive Aortic Side Branch Embolization on Early-Stage Type II Endoleaks and Sac Changes After Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm

Purpose

This study evaluated the effect of pre-emptive embolization of the aortic side branches on the short-term incidence of type II endoleaks (T2ELs) and aneurysm sac changes following endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs).

Materials and Methods

Data of 157 patients with degenerative large AAAs (≥50 mm for males and ≥45 mm for females) treated between January 2019 and October 2024 were retrospectively analyzed. The patients were categorized into the pre-emptive embolization (n=30, 19.1%) and non-embolization (n=127) groups. Embolization was considered for patients with high-risk factors for T2EL, specifically an inferior mesenteric artery (IMA) diameter ≥3 mm and a large lumbar artery diameter. Outcomes were assessed 1 month and 1 year postoperatively. The primary outcome was T2EL incidence, and the secondary outcomes were changes in aneurysm size and reintervention rates.

Results

At 1 month postoperatively, T2EL incidence was significantly lower in the embolization group (3.3%, 1/30) than in the non-embolization group (22.8%, 29/127) (P=0.015). At 1 year postoperatively, the T2EL incidence was 8.0% (2/25) in the embolization group and 23.0% (23/100) in the non-embolization group, although the difference was not statistically significant (P=0.094). Sac expansion was absent in the embolization group, whereas 4.0% of patients in the non-embolization group experienced expansion (P=0.583). Subgroup analysis for 37 patients with patent IMA ≥3 mm showed a significantly lower T2EL incidence at 1 month (5.6% vs. 52.6%, P=0.002) and 1 year (12.5% vs. 52.9%, P=0.014) postoperatively in the embolization group. Additionally, sac shrinkage was higher in the embolization group than in the non-embolization group (56.2% vs. 23.5%, P=0.055). Multivariable analysis confirmed pre-emptive embolization as an independent protective factor for T2EL at 1 year postoperatively (odds ratio 0.071, 95% confidence interval, 0.008-0.663; P=0.020).

Conclusion

Pre-emptive embolization reduced the incidence of early T2EL after EVAR and showed stable outcomes at the 1-year follow-up, particularly in patients with large patent IMA diameters.

Improved Endovascular Aortic Repair Durability in Patients Achieving Increased Shortest Apposition Length: A Multi-Centre Analysis

OBJECTIVE

Endovascular aortic repair (EVAR) for an aneurysm of the abdominal aorta (AAA) is associated with long-term complications, such as endoleaks, resulting in a significant re-intervention rate. This study investigates the prognostic value of (change of) proximal seal length on post-EVAR computed tomography angiography (CTA) for predicting type 1a endoleak. It further proposes a risk-stratified imaging follow-up algorithm.

DESIGN

Multicentre, retrospective, observational study of consecutive patients who underwent elective EVAR for infrarenal AAA between 2015 and 2018 at 3 high-volume hospitals in the Netherlands.

MATERIALS AND METHODS

Aorta morphology and endograft position analysis was performed. Shortest apposition length (SAL) was measured on the first post-EVAR CTA and, if available, on the last CTA. Change of SAL through time was categorized as increasing, stable, or decreasing and correlated with type 1a endoleak and secondary interventions for endoleak. Kaplan-Meier analysis was used to calculate type 1a endoleak free and re-intervention-free survival.

RESULTS

Three hundred ten AAA patients with a median follow-up of 51 (Q1, 17; Q3, 71) months were included. A median SAL of 22.8 mm (Q1, 15.9; Q1, 30.4) was measured on the first post-EVAR CTA. In 168 of 310 patients (54%), a second post-EVAR CTA was available, in which 71 (42%) showed increasing SAL over time. No type 1a endoleak developed in the increasing SAL group, whereas 1 of 43 (2%) in the stable group and 10 of 54 (19%) in the decreasing group developed type 1a endoleak. Five years post-EVAR, type 1a endoleak-free survival was 100% in the increasing SAL group versus 97.1% in the stable SAL group (p=0.195), and 81.6% in the decreasing SAL group (p<0.001). The re-intervention for all types of endoleak-free survival was 100% in the increasing SAL group versus 84.6% in the stable SAL group (p<0.001), and 60.7% (p<0.001) in the decreasing SAL group.

CONCLUSION

Increasing SAL after EVAR for infrarenal degenerative AAA is an indicator of durable success without type 1a endoleak and endoleak-associated secondary intervention within 5 years. Decreasing SAL is associated with development of type 1a endoleak after EVAR. Evaluation of (change of) the proximal seal could be a valuable part of follow-up after EVAR.Clinical ImpactEvaluation of proximal seal length after endovascular aortic repair offers valuable prognostic information regarding the risk of type 1a endoleak. Implementation could refine current follow-up algorithms to better stratify patients who have a substantial risk of type Ia endoleak from patients who may benefit from limited image surveillance.

Automatic CTA analysis for blood vessels and aneurysm features extraction in EVAR planning

Endovascular Aneurysm Repair (EVAR) is a minimally invasive procedure crucial for treating abdominal aortic aneurysms (AAA), where precise pre-operative planning is essential. Current clinical methods rely on manual measurements, which are time-consuming and prone to errors. Although AI solutions are increasingly being developed to automate aspects of these processes, most existing approaches primarily focus on computing volumes and diameters, falling short of delivering a fully automated pre-operative analysis. This work presents BRAVE (Blood Vessels Recognition and Aneurysms Visualization Enhancement), the first comprehensive AI-driven solution for vascular segmentation and AAA analysis using pre-operative CTA scans. BRAVE offers exhaustive segmentation, identifying both the primary abdominal aorta and secondary vessels, often overlooked by existing methods, providing a complete view of the vascular structure. The pipeline performs advanced volumetric analysis of the aneurysm sac, quantifying thrombotic tissue and calcifications, and automatically identifies the proximal and distal sealing zones, critical for successful EVAR procedures. BRAVE enables fully automated processing, reducing manual intervention and improving clinical workflow efficiency. Trained on a multi-center open-access dataset, it demonstrates generalizability across different CTA protocols and patient populations, ensuring robustness in diverse clinical settings. This solution saves time, ensures precision, and standardizes the process, enhancing vascular surgeons' decision-making.

Transcarotid Artery Approach for Endovascular Aortic Repair in Treating Complex Descending Thoracic Aortic Pseudoaneurysm With Aortoiliac Occlusion: A Case Report

BackgroundEndovascular aortic repair has emerged as the preferred treatment modality over open surgery for aortic diseases, primarily because of its association with lower perioperative morbidity and mortality rates. Current diagnostic and treatment guidelines generally advocate for endovascular aortic repair in most cases, with the femoral artery serving as the conventional access route. However, this approach may not be feasible for all patients, particularly those with aortoiliac artery occlusion, necessitating alternative access strategies.Case SummaryThis paper presents a complex case study of a patient with aortoiliac artery occlusion who underwent endovascular aortic repair via the left carotid artery approach for a pseudoaneurysm at the anastomotic site of a descending aortic prosthetic graft. This case underscores the potential value of utilizing the carotid artery as an alternative access route in anatomically challenging situations.ConclusionResearch on transcarotid artery approach endovascular aortic repair is limited and predominantly consists of case reports, with a notable absence of randomized controlled trials. This case report suggests that endovascular aortic repair via the carotid artery approach may be a viable alternative for selecting patient groups when the conventional femoral artery approach is not feasible. While our single case demonstrated successful management with minimal complications, larger studies are needed to fully establish the safety profile and determine if perioperative complications and mortality rates are indeed manageable across diverse patient populations.Clinical ImpactThis study provides valuable insights into the feasibility of the carotid artery as an alternative access route for endovascular aortic repair in patients with aortoiliac artery occlusion. It offers clinicians a potential strategy for cases where the conventional femoral artery route is not feasible. The findings presented herein aim to demonstrate the practicality and relative safety of utilizing the carotid artery for endovascular procedures in anatomically challenging scenarios, contributing to the broader understanding of access alternatives in aortic repair interventions.

The essential difference in measuring health status and quality of life in patients with an abdominal aortic aneurysm

OBJECTIVE

Quality of life (QoL) and health status (HS) are important patient reported outcomes following abdominal aortic aneurysm (AAA) repair. In current literature, HS questionnaire outcomes are often reported as health-related QoL, although they primarily measure functional outcomes. The literature on actual QoL in AAA patients is limited. This study evaluated QoL and HS in AAA patients after aneurysm repair, including both open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This prospective observational cohort study included AAA patients from a prehabilitation program between 2018 and 2022. QoL was assessed using the WHOQOL-BREF and HS using the SF-12 questionnaire, at baseline (before surgery), six months, and 12 months postoperatively. Changes in QoL and HS over time were evaluated using linear mixed models that adjusted for sex and type of surgery.

RESULTS

Of the 91 included patients, 38 underwent OSR and 53 EVAR, with a mean age of 76.7 years. Compared to baseline, overall QoL was significantly lower at 12 months follow-up (mean difference -0.24, p=0.023). Group-analysis revealed a significant decline in overall QoL in EVAR patients only. No significant change in QoL following OSR was observed. No significant change in HS was observed in either group.

CONCLUSIONS

The findings suggest that the WHOQOL-BREF questionnaire is more appropriate for evaluating QoL in AAA patients. Overall QoL, rather than HS, significantly declined between baseline and postoperative follow-up in older prehabilitated AAA patients, especially after EVAR. Understanding the impact of surgical interventions beyond traditional health status measures is crucial for shared decision-making and value-based healthcare.

Acute kidney injury and aorta-related mortality during open surgery of the abdominal aorta with suprarenal clamping using different renal protection strategies

OBJECTIVES

The aim was to evaluate the incidence of acute kidney injury in patients treated with open surgical repair and suprarenal cross-clamp comparing no-perfusion strategy versus the renal perfusion with the histidine-tryptophan-ketoglutarate solution.

METHODS

It is a physician-initiated, multicentre, retrospective observational study including patients treated with open surgical repair for abdominal aortic aneurysm between 1 January 2015 and 31 December 2021. Patients already on dialysis were excluded from the final analysis. A coarsened exact match identified 2 cohorts: no-perfusion strategy versus renal perfusion with the histidine-tryptophan-ketoglutarate solution. Primary outcomes were acute kidney injury incidence and survival at 30 day. Secondary outcomes were freedom from haemodialysis and survival at 1 year.

RESULTS

We analysed 125 (28.7%) patients: 63 (14.5%) who did not receive renal perfusion and 62 (14.2%) who received the histidine-tryptophan-ketoglutarate perfusion. At 30 day, acute kidney injury rate (37.6%) was not different between the 2 groups [n = 24 (38.7%) vs 23 (36.5%); OR: 1.1, P = 0.855]. At 30 day, acute kidney injury development was associated with aneurysm extent (pararenal, OR: 2.28, 95% CI: 1.031-5.031, P = 0.042) and total time of intervention (threshold: 365 min, OR: 1.008, 95% CI: 1.003-1.012, P = 0.001). At 1 year, postoperative acute kidney injury did not impact mortality (OR: 3.4, P = 0.556), and freedom from haemodialysis was 100%.

CONCLUSIONS

Postoperative acute kidney injury remains high at nearly 38%, but it did not impact on freedom from haemodialysis at 1 year as well as on overall survival.

Has the Centralization of Vascular Services changed the 30-day mortality in Elective Abdominal Aortic Aneurysm (AAA) repairs in North Wales?

THE BACKGROUND

North Wales Vascular Services were centralized to Glan Clwyd hospital in 2019 with the establishment of a new hybrid vascular theatre. Several studies have demonstrated the efficacy of centralization of such services in the country. However, there were no previous studies done with regard to the status of North Wales. This study aimed to assess any significant difference in 30-day/ in-hospital mortality and the immediate cause of death following elective AAA repairs done before and after centralization of services in April 2019.

METHODOLOGY

All the elective AAA surgeries (open and endovascular) were included from April 2014 to April 2024 while excluding the emergency surgeries done for ruptured AAA. The retrospective data were extracted from Betsi Cadwaladr University Health Board (BCUHB) digital operative records, Welsh Clinical Portal (WCP), case notes, death certificates, and Coroner reports. The Chi-square test for independence was used to assess any significance of mortality rates with centralization status. A detailed analysis of multivariable correlation analysis of centralization status was done with mortality rate, age and sex.

RESULTS

A total of 437 elective AAA records were scrutinized during the study period. Overall, 30-day mortality for elective AAA repairs done before and after centralization was 4% (N=252) and 3% (N=185) respectively with p value of 0.69. OSR mortality slightly increased due to the relatively small numbers, far-reaching conclusions cannot be drawn. There were no EVAR deaths after centralization. The main immediate causes of death were myocardial infarction, multi-organ failure (MOF) and pulmonary embolism.

CONCLUSION

There is no statistical significance deference in overall death rates despite of centralization status. However, the EVAR has zero 30-day mortality after centralization which means an immediately apparent clinical difference in the EVAR group.

Self-reported outcomes following lower extremity, carotid and aortic artery disease: protocol for the Danish Vascular (DanVasc) survey

INTRODUCTION

Among lower extremity artery disease (LEAD), symptomatic carotid stenosis (SCS) and abdominal aortic aneurysm (AAA), the disease burden is insufficiently illuminated from a patient and societal perspective. Such knowledge is central to identifying patients at risk of poorer outcomes. Therefore, the Danish Vascular (DanVasc) survey aims to describe self-reported health status, health literacy, medication adherence and loneliness, including changes over time, and investigate characteristics associated with worse self-reported health at baseline and their associations with poorer outcomes within 1 year (healthcare utilisation and mortality) in patients with LEAD, SCS and AAA.

METHODS AND ANALYSIS

The DanVasc survey, a national prospective cohort study combining survey data measured at several time points with register-based data, includes validated patient-reported outcome measures (PROMs) and ancillary questions developed with patient representatives. Our baseline survey (T0) follows the index contact in vascular outpatient clinics with follow-up surveys determined by the patient's trajectory: (1) newly referred patients in conservative treatment trajectories; the date for the outpatient visit activates 1-month (T1), 3-month (T2) and 12-month (T3) follow-ups. (2) Patients referred for vascular surgery; the surgery date activates 1-month (T1), 3-month (T2) and 12-month (T3) follow-ups. The included PROMs assess health-related quality of life (HRQoL), anxiety and depression, sleep, frailty status, health literacy, medication adherence and loneliness. For LEAD, a disease-specific PROM evaluates HRQoL. For AAA, disease-specific ancillary questions are added. Additionally, the DanVasc survey includes questions on health behaviour, preventive measures and sexual life. The DanVasc survey will be linked to national registries to obtain socio-demographic information and data on redeemed prescriptions, clinical information, healthcare utilisation, comorbidities and mortality. From December 2023 to December 2024, we aim to recruit approximately 5500 patients from all seven DanVasc surgery departments. Patient characteristics will be reported using descriptive statistics. Changes over time and factors associated with poorer health outcomes will be analysed using linear, logistic and Cox proportional hazard models, presented as univariate and multivariate regressions.

ETHICS AND DISSEMINATION

Approval for the collection of medical record data was granted by the Central Denmark Region, acting on behalf of all Danish regions (record 1-45-70-94-22). Consent to participate is obtained prior to answering the survey. Results will be disseminated through peer-reviewed scientific publications and conference presentations, and findings will be shared with patients and relevant stakeholders via public and social media.

Technical and Clinical Outcomes of 13 years of Endovascular Repair of Infrarenal, Atherosclerotic, Penetrating Aortic Ulcers

BACKGROUND

To report the technical and clinical outcomes of endovascular repair of all infrarenal, penetrating aortic ulcers (PAUs) that were treated at a single institution over a 13-year period.

METHODS

This is a single-center, retrospective observational study. All patients consecutively treated for atherosclerotic, infrarenal PAU were included between 2010 and 2023. Outcomes were technical success, overall survival, PAU-related death, freedom from secondary rupture, freedom from secondary interventions, freedom from aortic expansion >5 mm, freedom from type 1 and type 3 endoleak (EL), and freedom from stent graft migration, each at 30 days, 1 year, 2 years, and 5 years of follow-up. The study was registered at the German Clinical Trials Register (DRKS00028794).

RESULTS

Forty-seven patients were included (8 female patients, 17.0%) with a median age of 75.7 years (interquartile range (IQR): 70.2-81.0). The median maximum aortic diameter was 39.7 mm (IQR: 33.6-45.2). Overall, primary and secondary technical success was achieved in 42 of 47 (89.4%) and 46 of 47 patients (97.9%). Standard aortobiiliac endovascular aneurysm repair (EVAR) was the most frequent procedure in 25 patients (53.2%). An aortomonoiliac stent graft system was used in 5 patients (10.6%). The remaining 17 patients (36.2%) were treated using an aorto-aortic tube stent graft configuration. The median clinical follow-up was 5.1 years (IQR: 1.9-8.1) with a median imaging follow-up of 1.5 years (IQR: 0.4-5.0). Overall survival at 30 days, 1, 2, and 5 years of follow up was estimated at 100% (confidence interval (CI), 100%-100%), 95.4% (CI, 89.4%-100%), 87.9% (CI, 78.4%-98.4%), and 82.0% (70.7%-95.2%), respectively. There was 1 PAU-related death (2.1%). Freedom from secondary intervention at 30 days, 1, 2, and 5 years of follow-up was 93.6% (CI, 86.9-100%), 89.2% (CI, 80.6-98.6%), 81.5% (CI, 70.7-94.0%), and 75.2% (CI, 62.8-90.2%), respectively. No patient who underwent either preoperative (n = 1) or intraoperative embolization (N = 7) of lumbar arteries (LAs) and/or the inferior mesenteric artery (IMA) demonstrated type 2 EL during follow-up.

CONCLUSION

A variety of alternatives to standard aortobiiliac EVAR are required for endovascular PAU repair. To identify the optimal management strategy in these cases further studies are needed. Type 2 EL in abdominal PAU disease appears to be preventable by LA and/or IMA embolization.

The effect of aneurysm diameter on perioperative outcomes following complex endovascular repair

OBJECTIVES

Endovascular aneurysm repair (EVAR) for large infrarenal abdominal aortic aneurysms (AAAs) has been associated with worse outcomes compared with EVAR for smaller AAAs. Whether these findings apply to complex AAAs (cAAA) remains uncertain.

METHODS

We identified all intact complex EVAR (cEVAR) from 2012 to 2024 in the Vascular Quality Initiative. cEVAR was defined as having a proximal extent between zones 6 and 9 and at least one side branch/fenestration/chimney/parallel grafting. Aneurysm size was defined as follows: large: >65 mm (males), >60 mm (females); medium: 55 to 65 mm (males), 50 to 60 mm (females); and small: <55 mm (males), <50 mm (females). We assessed perioperative death, any complication, and in-hospital reintervention using logistic regression and midterm mortality using adjusted Kaplan-Meier methods and Cox regression analyses. Medium-sized aneurysms were compared with large and small aneurysms.

RESULTS

Of the 3426 patients, 22.6% had large, 60.4% medium, and 17.0% had small aneurysms. As compared with medium and small aneurysms, large aneurysms demonstrated higher rates of perioperative death (4.8% vs 2.6% vs 0.5%), any complication (33.3% vs 23.6% vs 19.4%), and in-hospital reintervention (6.2% vs 4.0% vs 2.6%) (all P < .05). The median follow-up was 445 days. One-year mortality rates were higher in large aneurysms (12.3% vs 7.8% vs 3.8%; P < .001). After adjustment, when compared with medium-sized aneurysms, large aneurysms were associated with a significantly higher risk of perioperative death (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.09-2.72), any complication (aOR, 1.44; 95% CI, 1.18-1.76), and midterm mortality (adjusted hazard ratio, 1.50; 95% CI, 1.19-1.88), but not in-hospital reintervention (aOR, 1.46; 95% CI, 0.99-2.13). Although small aneurysms, as compared with medium-sized aneurysms, did not demonstrate a difference in any complication (aOR, 0.87; 95% CI, 0.68-1.10), in-hospital reintervention (aOR, 0.77; 95% CI, 0.42-1.33), and midterm mortality (adjusted hazard ratio, 0.78; 95% CI, 0.57-1.08], they did demonstrate a lower risk of perioperative death (aOR, 0.26; 95% CI, 0.06-0.71).

CONCLUSIONS

In cEVAR for cAAA, large aneurysms, compared with medium-sized aneurysms, were associated with higher rates of perioperative death, any complication, and midterm mortality, with in-hospital reinterventions trending toward a statistically significant higher risk. Although these results align with expectations, they emphasize the importance of effectively managing patients with large cAAAs and highlight the need for future research to determine whether patients might benefit more from medical therapy or open repair.

Single Centre Evaluation of the Proposal of the European Society for Vascular Surgery Abdominal Aortic Aneurysm Guidelines to Stratify Surveillance after Endovascular Aortic Aneurysm Repair

OBJECTIVE

The aim of this study was to evaluate and compare methods that identify patients at low risk of developing complications after endovascular aortic aneurysm repair (EVAR) and who would thus not require surveillance in the first post-operative years.

METHODS

This was a retrospective, single centre, cohort study including all patients after elective infrarenal EVAR with both immediate post-operative and one year computed tomography angiography (CTA) imaging. Patients were categorised by adherence to instructions for use (IFU), adequate seal, and absence of endoleak (method A1), and without high risk features (method A2) on the first post-operative CTA. Additionally, these patients were dichotomised based on aneurysm sac shrinkage at one year (> 5 mm maximum diameter reduction, method B). Outcomes were graft related adverse events and all cause death. Negative predictive value (NPV) was used to compare risk classifications.

RESULTS

Of 422 eligible patients, 297 underwent the required imaging for classification: 140 (47.1%) and 109 (36.7%) patients were classified as low risk based on methods A1 and A2, respectively, while 147 (49.5%) were assumed low risk based on method B. The five year cumulative incidence of adverse events in low risk patients according to method A1 was 14.7% (95% confidence interval [CI] 8.5 - 20.9%), similar to method A2 (16.1%, 95% CI 8.8 - 23.4%) and method B (15.4%, 95% CI 9.3 - 21.5%). The five year median NPV for adverse events for method A1 was 85.2% (95% CI 79.7 - 90.8%), comparable with method A2 (83.8%, 95% CI 76.9 - 90.3%; p = .37) and method B (84.7%, 95% CI 79.4 - 89.5%; p = .87). Significantly higher NPVs were found by combining method A1 or A2 with method B, with median values ≥ 95% up to four years after EVAR. The five year NPV for death did not differ between methods (five year NPVmethod A1, 81.7%, 95% CI 76.6 - 86.5%).

CONCLUSION

Refraining from imaging in the first five years after EVAR in patients treated within IFU and with a favourable post-operative CTA would have failed to detect important complications at an early stage. It is proposed to combine the post-operative CTA with sac shrinkage at one year in order to stratify post-EVAR surveillance. No benefit was found in considering the high risk features suggested in the European Society for Vascular Surgery (ESVS) guidelines.

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

OBJECTIVE

The partial deployment technique (PDT) is an unconventional option of T-branch deployment to allow target arteries (TAs) cannulation/stenting from the upper arm access, in case of narrow (NPA <25 mm) or severely angulated (APA >60°) aorta. Aim of this study was to report outcomes of the endovascular repair of complex aortic (c-AAAs) and thoracoabdominal (TAAAs) aneurysms by T-branch and PDT.

METHODS

All consecutive patients underwent urgent endovascular repair of c-AAAs and TAAAs by T-branch (Cook Medical) and PDT from 2021 to 2023 were analyzed. Technical success (TS), 30-day mortality, and TA instability within 30 days and 1 year, as well as reinterventions, were assessed as primary endpoints. Time of intraoperative pelvic/lower limb ischemia, spinal cord ischemia (SCI), and perioperative stroke were assessed as secondary endpoints.

RESULTS

Thirty-three cases were analyzed. There were six type I endoleaks (18%) in failed endovascular aortic repair, nine juxta/para-renal aneurysms (28%), six post-dissection TAAAs (18%), and 12 degenerative TAAAs (36%), respectively. The median para-visceral aortic lumen diameter was 23 mm (interquartile range [IQR], 19-27 mm), and 10 cases (30%) had APA. Of 128 TAs, 111 (87%) were cannulated/stented with distally captured aortic graft. The median time of pelvic/lower limb ischemia was 120 minutes (IQR, 90-150 minutes). TS was achieved in all patients. One patient (3%) suffered SCI, and there were no cases of stroke. An asymptomatic renal artery occlusion was detected at postoperative imaging, which was recanalized by thrombus-aspiration/relining. This was the only case of TA instability (1/128; 0.8%) and reintervention (1/33; 3%) within 30 days. Two patients (6%) died within 30 days. Median follow-up was 14 months (IQR, 6-22 months). One case (3%) of bilateral renal artery occlusion occurred at 6 months. No superior mesenteric artery or celiac trunk events occurred, with an overall TA instability rate of 2% (3/128). Eighteen patients (55%) completed the radiologic follow-up at 1 year with no new cases of TA instability. Freedom from TA instability was 91% at 1 year.

CONCLUSIONS

T-branch by PDT seems to be safe and effective in the management of c-AAAs/TAAAs with NPA or APA. Results were satisfactory in terms of TS and mid-term TA instability, suggesting a possible enlargement of the anatomical feasibility criteria for outer branches in urgent cases.

Current Trends and Evidence on Post-Thoracic Endovascular Aortic Repair Aorto-Pulmonary and -Bronchial Fistula: A Narrative Review

BACKGROUND

Aorto-bronchial or aorto-pulmonary fistulas (ABPF) are a rare but life-threatening complication following thoracic endovascular aortic repair (TEVAR). This narrative review aims to provide an overview of the current trends and available evidence on ABPF following TEVAR, evaluating risk factors, diagnostic approaches, and possible preventive and therapeutic strategies.

METHODS

Relevant publications on post-TEVAR ABPF were selected through a literature search on PubMed. Studies providing data on post-TEVAR ABPF concerning pathogenesis, clinical presentation, diagnostic tools, surgical approaches, and outcomes were included.

RESULTS

The literature search obtained 169 articles. After selection, 37 studies, published between 2000 and 2024, remained for analysis. The primary symptom of ABPF is typically hemoptysis, which may be recurrent or persistent. The diagnostic pathway for ABPF encompasses medical history, clinical evaluation, blood tests, sputum and blood cultures. Computed tomography angiography is the first-line imaging modality in suspected ABPF, while bronchoscopy is reserved for hemodynamically stable patients. Moreover, 18-fluoro-deoxyglucose positron emission tomography can aid in the diagnosis of graft infection. Post-TEVAR ABPF are associated with multiple risk factors, mainly patient-specific clinical conditions (i.e. chronic inflammatory conditions, underlying mediastinal oncologic pathologies, and infectious diseases) and anatomical characteristics, mainly large aortic aneurysms, severe aortic tortuosity, and an extensive periaortic hematoma. Strategies to minimize the risk of ABPF formation include appropriate device oversizing, long sealing zones, limited extent of aortic coverage, selective hematoma evacuation, and strict adherence to sterility and antibiotic prophylaxis. Radical surgical interventions have shown superior outcomes compared to endovascular approaches, which may be adopted as initial step to stabilize the patient in a staged treatment.

CONCLUSION

Post-TEVAR ABPF is a rare and life-threatening condition. Literature is scarce and a deeper understanding of risk factors, diagnostic pathways, and therapeutic strategies is essential for the prevention and management of ABPF secondary to TEVAR.

Elevated High Sensitivity C Reactive Protein and Risk of Abdominal Aortic Aneurysm: A Prospective Population Based Study in The Norwegian HUNT Study

OBJECTIVE

Inflammation seems to be crucial in the pathogenesis of abdominal aortic aneurysm (AAA). Previous research links inflammatory biomarkers, such as high sensitivity C reactive protein (hs-CRP), to AAA. Few studies, however, have used a prospective design. The aim of this study was to examine whether individuals with elevated hs-CRP have increased risk of AAA, using a prospective and population based design.

METHODS

This prospective, population based, cohort study included 46 322 participants in the Trøndelag Health Study (HUNT) in Norway (53.7% female). During a median follow up of 12.6 years (range 0 - 26 years), 407 individuals were diagnosed with AAA (22.4% female). Cox proportional hazards regression was applied to examine associations between hs-CRP and risk of AAA. hs-CRP was treated either as a continuous or a categorical variable (dichotomised at 2 mg/L, 1 mg/L, or median [1.2 mg/L], or as quartiles).

RESULTS

The hazard ratio (HR) of developing AAA per 1 mg/L increase in hs-CRP (continuous hs-CRP) was 1.02 (95% confidence interval [CI] 1.01 - 1.03) in the analysis adjusted for smoking, coronary heart disease, hypertension, diabetes, body mass index, and total cholesterol. Individuals with hs-CRP ≥ 2 mg/L had almost twice the risk of AAA compared with individuals with hs-CRP < 2 mg/L (adjusted HR 1.84, 95% CI 1.51 - 2.25). Dichotomising hs-CRP at a clinical cutoff point of 1 mg/L (adjusted HR 2.13, 95% CI 1.64 -2.76) or at the median of 1.2 mg/L (adjusted HR 2.12, 95% CI 1.62 - 2.76) slightly strengthened the HR. The adjusted HR gradually increased through the ordered hs-CRP quartiles, and was almost four times higher (HR 3.87, 95% CI 2.54 - 5.92) in the highest hs-CRP quartile (hs-CRP > 2.7 mg/L) compared with the lowest quartile (hs-CRP ≤ 0.6 mg/L).

CONCLUSION

Individuals with elevated hs-CRP had significantly increased risk of developing AAA.

Volumetric Abdominal Aortic Aneurysm Analysis in Post EVAR Surveillance Settings

BACKGROUND

Early detection of abdominal aortic aneurysms (AAA) is a mainstay of diagnosis, with endovascular aneurysm repair (EVAR) emerging as the primary mode of repair. Maximum diameter measurement remains central to risk assessment; however, recent studies suggest AAA volumetric analysis may be more sensitive to true size changes. We compare the utility of volume and diameter in AAA size assessment and further investigate related clinical factors.

METHODS

We retrospectively reviewed all patients who underwent EVAR at our institution between August 2017 and March 2023 with available pre and postoperative computed tomography (CT) angiograms. AAA total aneurysm and lumen volume were measured using semiautomatic segmentations. The maximum diameter and clinical variables were extracted from the medical record. The direct comparison of volume to diameter was completed using percent change from baseline. A subgroup of patients with long-term follow-up (LTFU) data (>231 days between scans) were used for additional analyses.

RESULTS

Of 116 patients, 69 (59.5%) were included in the long-term patient cohort. Postintervention, percent change volume and percent change diameter had a moderate positive correlation (rs = 0.6662), and average AAA percent change did not differ between volume and diameter (1.5% vs. -1.8%, respectively; P = 0.1654). Volumetric analysis was more likely to detect aneurysm sac enlargement (P = 0.0315). On univariable analysis, increase in volume and diameter was associated with older age and endoleak. A diameter decrease was associated with metformin therapy.

CONCLUSION

Aneurysm volume is more likely to detect AAA enlargement than diameter. The benefit of early detection of high-risk aneurysms may translate to changes in surveillance and ultimately decrease aneurysm-related mortality.

Proximity and prior medical engagement influence follow-up after ruptured abdominal aortic aneurysm

OBJECTIVE

Post-repair surveillance of ruptured abdominal aortic aneurysm (rAAA) is critical for detecting potential complications. Substantial loss to follow-up has been reported in populations undergoing elective endovascular aortic repair (EVAR); however, there is limited data on follow-up rate among patients presenting with rupture. Thus, we investigated follow-up trends and factors influencing retention at a major academic referral center with a wide service area.

METHODS

We included patients with rAAAs from 2002 through 2023 in this retrospective study. Loss to follow-up was defined as absence of vascular surgeon evaluation for 2 years (EVAR) or 5 years (open repair) prior to death or present day. Multivariate regression and survival models assessed the influence of potential factors on follow-up and survival outcomes.

RESULTS

Of 455 patients who presented with rAAAs, 60% who underwent EVAR and 39% who underwent open repair were lost to follow-up. Twenty percent of patients who underwent EVAR were lost after initial admission, and 40% of patients were lost after the 1-month postoperative follow-up visit. There were no significant differences in baseline demographics. Patients lost to follow-up less commonly had stage 4 chronic kidney disease (7.2% vs 24.3%; P = .02) and prior EVAR (10.0% vs 29.2%; P = .01) at time of rupture. Secondary interventions were less common in patients lost to follow-up (14.5% vs 39.0%; P = .01). In multivariate analysis of patients who underwent an EVAR, residing more than 10 miles from hospital was associated with loss to follow-up (odds ratio [OR], 4.93; 95% confidence interval [CI], 1.14-21.29). Prior endograft at time of rupture (OR, 0.24; 95% CI, 0.06-0.89), and estimated glomular filtration rate <30 mL/min/1.73m2 (OR, 0.23; 95% CI, 0.06-0.93) were associated with complete follow-up in patients who underwent EVAR. Patients who were lost to follow-up trended towards worse survival (hazard ratio, 2.04; 95% CI, 0.67-6.26), whereas prior endograft was associated with significantly worse survival after EVAR (hazard ratio, 3.11; 95% CI, 1.20-8.04).

CONCLUSIONS

Although most patients with rAAAs attend their 1-month postoperative visit, the majority are subsequently lost to follow-up. Geographic proximity to the hospital and higher baseline medical engagement, as indicated by prior endograft and chronic kidney disease, appeared to be protective against such loss. Targeted counseling and engagement at the 1-month postoperative visit, particularly in patients with less comorbid conditions, may enhance retention to long-term follow-up.

In situ Laser Fenestration of Visceral Endografts (InLoVE): Midterm Outcomes from a Multicentre Study

OBJECTIVE

Emergency complex abdominal aortic diseases are challenging to treat. During in situ laser fenestration (ISLF), aortic branches are covered and flow is restored by in situ fenestration of the stent graft, with promising midterm results. This study aimed to expand on the limited body of knowledge of midterm outcomes of ISLF in renovisceral aortic pathology in a multicentre setting.

METHODS

Retrospective pooled data on consecutive ISLF cases of visceral aortic stent grafts undertaken between 2018 - 2023 in three aortic centres were analysed. Technical success was defined as successful vascularisation with a bridging stent graft and acceptable final angiographic images without signs of endoleak related to the bridging stent graft. Target vessel instability was defined as an endoleak related to the bridging stent graft, disconnection, kink, stenosis, occlusion of bridging stent, re-intervention to the bridging stent graft, or rupture or death related to the bridging stent graft.

RESULTS

Sixtyfive ISLFs were performed in 34 patients, with a mean age 74 years. The procedure was acute in 79%, and 35% were ruptures. Pre-stenting was performed on 56 target vessels (86%). Four patients (12%) died within 30 days; all presented with a rupture. Technical success was achieved in 61 of 65 (94%) ISLFs. All failed cannulations were in the renal arteries: three due to difficult angulations and one dissected during cannulation. Median follow up was 16 (interquartile range 5, 22) months. Cumulative survival at six months, one, and two years was 88%, 81%, and 72%, respectively. Six (10%) target vessel instabilities were detected: two (3%) type III endoleaks and four (7%) stent stenosis; all of which required re-lining. Freedom from target vessel instability at six months until the end of follow up was 89%. On the latest follow up scan, all successfully deployed ISLF bridging stents were patent (primary assisted patency 100%; 61 of 61) without signs of type III endoleak.

CONCLUSION

ISLF is a promising tool for emergency endovascular procedures in complex anatomies.

Anatomical Suitability of Iliac Branch Devices for East Asian Patients with Abdominal Aortic Aneurysm

OBJECTIVE

This study aimed to identify the iliac artery characteristics of East Asian patients with abdominal aortic aneurysms (AAAs) and to evaluate anatomical suitability rates with current iliac branch devices (IBDs).

METHODS

This was a single centre, retrospective, cross sectional study. Patients diagnosed with AAA between 2008 and 2023 were enrolled. The morphological parameters of the iliac arteries were measured, and their eligibility for four IBDs (Cook ZBIS, Gore IBE, E-Liac IBD, and G-Iliac IBD) was evaluated according to the manufacturer's latest instructions for use (IFU).

RESULTS

Among 1 144 AAAs observed in the study, 45.5% (n = 521) presented with concurrent common iliac artery aneurysm (CIAA). In total, 304 patients (26.6%) and 371 iliac arteries necessitated internal iliac artery (IIA) reconstruction. The anatomical suitability rates for the Cook ZBIS, Gore IBE, E-Liac IBD, and G-Iliac IBD were 18.9%, 21.8%, 11.9%, and 22.6%, respectively. The E-Liac IBD exhibited a significantly lower anatomical suitability rate compared with the other three devices (p < .001). The primary IBD exclusion criteria were: a common iliac artery (CIA) length of < 50 mm for Cook ZBIS (n = 211, 56.9%); an IIA diameter of < 6.5 mm or > 13.5 mm for Gore IBE (n = 177, 47.7%); and a CIA bifurcation diameter of < 18 mm both for E-Liac IBD and G-Iliac IBD (n = 244, 65.8%). A total of 198 patients (53.4%) failed to meet the anatomical criteria for any device, while 112 (30.2%) qualified for just one device, 26 (7.0%) for two devices, 25 (6.7%) for three devices, and 10 (2.7%) for all four devices.

CONCLUSION

A significant proportion of East Asian patients with AAA present with concurrent CIAA, necessitating substantial IIA reconstruction. IBD techniques show low anatomical suitability rates among the East Asian population, with 53.4% of patients failing to meet anatomical criteria for any IBD based on the manufacturer's IFU.

International multicenter experience on early and late outcomes after endovascular repair of ruptured abdominal aortic aneurysms in patients with vs without type II endoleaks

BACKGROUND

Ruptured abdominal aortic aneurysms (rAAAs) remain as a great clinical challenge for vascular surgeons and endovascular aortic repair (EVAR), which is currently regarded as the first-line treatment for rAAA in patients with appropriate anatomy. While recommendations for management of type II endoleaks (T2ELs) are well-established in the elective setting, data after rAAAs are limited.

METHODS

Between January 2018 and December 2022, all patients who were treated with EVAR for rAAA in three tertiary referral centers from different countries (Germany, Italy, and Switzerland) were screened for inclusion in the study. The patients were divided into two groups based on the presence or absence of early T2EL (at completion angiography or at first postoperative computed tomography angiography). The primary end points for this study were 30-day mortality and long-term survival.

RESULTS

Overall, 123 patients were included in the final analysis. Of these, 73 were categorized as not having an early T2EL (group A) and 50 presented an early T2EL (group B). Except for a significantly lower proportion of males in group A as compared with group B (79.5% vs 92%; P = .05), no significant baseline differences were found. At 30 days, the overall mortality rate was not significantly different between study groups (22% vs 16%; P = .16). Using binary regression, the presence of a T2EL was not associated independently with 30-day mortality (odds ratio, 1.712; 95% confidence interval, 0.591-3.964; P = .54). Five-year survival estimates in the whole study cohort did not show any significant difference in patients without a T2EL as compared to those with a T2EL (53% vs 59%; log-rank P = .31). Using Cox proportional hazard regression, the presence of T2ELs was not independently associated with increased risk for long-term mortality (hazard ratio. 1.068; 95% confidence interval, 0.437-2.611; P = .079).

CONCLUSIONS

Although the occurrence of a T2EL seems to be a relatively common scenario after EVAR for rAAA, their presence does not seem to be associated with worse outcomes in the immediate perioperative period or to decrease long-term survival. Therefore, careful observation may be warranted in the early phase, with selective treatment only in cases of ongoing hemodynamic decompensation. In the long run, it seems prudent to assume that the same indication for treatment as for standard EVAR could be recommended in the presence of T2EL.

Sex-Specific Characteristics of Perivascular Fat in Aortic Aneurysms

Aortic aneurysms (AAs), the dilation or widening of the aorta, lead to dissection or rupture with high morbidity and mortality if untreated. AA displays gender disparities in its prevalence, progression and outcomes, with women having worse outcomes and faster aneurysm growth. However, current guidelines do not address gender dimorphism, emphasizing the urgent need for personalized treatment strategies and further research. Perivascular adipose tissue (PVAT), a unique type of fat surrounding blood vessels, plays a critical role in maintaining vasomotor tone and vascular homeostasis, with dysfunction associated with chronic inflammation and vessel-wall remodeling. Indeed, PVAT dysfunction promotes the development of aortic aneurysms, with hormonal and biomechanical factors exacerbating the pathological vascular microenvironment. The sexually dimorphic characteristics of PVAT include morphological, immunological, and hormonally mediated differences. Thus, targeting PVAT-mediated mechanisms may be a promising option for the (gender-specific) therapeutic management of cardiovascular pathologies. This review examines the emerging importance of PVAT in vascular health, its potential therapeutic implications for AA, and identifies gaps in the current state of research.

Prolene encircling reducing ties combined with through-and-through wire: An additional technique for physician-modified EndoGraft in challenging anatomy

PurposeTo describe the endovascular treatment of symptomatic pararenal abdominal aortic aneurysm (PAAA) with severe infrarenal angulation using a combination of Prolene Encircling Reducing Ties (PERT), through-and-through wire, and a physician-modified 4-fenestrated endograft (PMEG).TechniqueA 73-year-old male presented with symptomatic PAAA with a 105-degree infrarenal angulation. A right common femoral artery (CFA) to right axillary artery through-and-through wire (0.035 soft hydrophilic wire) was placed, and a modified Valiant Captivia stent graft was advanced through the right CFA. The modified stent graft was deployed until the superior mesenteric artery (SMA) fenestration was opened. The SMA fenestration was then adjusted to the correct position, then the free-flow bare stent was opened. Sequential deployment of the modified stent graft was performed. After successful cannulation of three visceral arteries (SMA and renal arteries) from axillary approach, a 7 Fr sheath was advanced into the SMA, and the modified stent graft was fully deployed. Following removal of the delivery system, the stent graft was fully opened by compliance balloon inflation, which ruptured the 6-0 Prolene ties. The SMA and both renal arteries were then stented and flared. A modified bifurcated Endurant stent graft (without free-flow bare stent) was deployed approximately 1 cm below the lowest renal fenestration, and the iliac limbs were deployed to complete the procedure. 6-month follow-up computed tomography angiography (CTA) demonstrated complete exclusion of the aneurysm without endoleak.ConclusionA combination of PERT, through-and-through wire, and PMEG for the treatment of symptomatic PAAA with severe infrarenal angulation demonstrated acceptable early results.

Experience with a Large-Bore Vascular Closure Device in Patients Undergoing a Percutaneous Endovascular Aneurysm Repair (EVAR): A Multicentre Study

PURPOSE

Endovascular aneurysm repair (EVAR) is the preferred treatment for infrarenal aortic aneurysms, offering lower perioperative morbidity and mortality compared to open surgery. Common femoral artery (CFA) access can be achieved percutaneously or through surgical cutdown, with a percutaneous approach gaining more and more popularity. The MANTA vascular closure device (VCD), a collagen plug-based device, has shown promising results in transcatheter aortic valve replacement, but data on its use in percutaneous EVAR (pEVAR), particularly in obese patients, remain limited.

MATERIAL AND METHODS

This retrospective study included all patients who underwent pEVAR from October 2018 to December 2022 across three Dutch hospitals and in whom the MANTA VCD has been applied. Patient demographics, perioperative characteristics, and clinical outcomes were recorded. Subgroup analysis was performed based on body mass index (BMI), comparing outcomes in obese (BMI ≥ 30) and non-obese (BMI < 30) patients. Technical success and access site complications were primary and secondary outcomes, respectively.

RESULTS

A total of 549 patients (mean age 75.16 ± 7.09 years, 88.9% male) were included, with 140 classified as obese. The MANTA VCD was used in 1024 CFAs. Overall technical success, defined as vascular closure with patent CFA, without requiring immediate surgery, was 98%, with a 3.1% complication rate, primarily due to closure failure. In obese patients, technical success was 98.9%, with a 1.5% complication rate, showing comparable outcomes to non-obese patients.

CONCLUSION

The MANTA VCD is effective and safe for CFA closure in pEVAR, including in obese patients. Given rising obesity rates, the favorable outcomes in this population are encouraging and suggesting a broader applicability in large-bore percutaneous procedures.

Venous stents for post-EVAR graft limb kinking: two case reports

ObjectivesTo assess dedicated venous stents' feasibility and early outcomes as a post-EVAR graft limb kinking treatment.MethodsWe report two clinical cases of severe graft limb kinking detected 1 year after EVAR.ResultsBoth patients were successfully treated with dedicated venous stents and experienced no further aortic-related events during follow-up. Graft limb kinking is a common EVAR complication, particularly in anatomically complex cases involving iliac tortuosity. Current literature emphasises the evaluation of graft-related complications but lacks recommendations for preemptive stenting or standardised management.ConclusionsOur findings highlight the potential of venous stents' adaptability to challenging anatomy vessels. Venous stents' flexibility and high radial force may reduce early occlusion rates. Further research is needed to compare the outcomes of dedicated venous stents with bare-metal stents and to optimise prevention and treatment strategies for post-EVAR graft limb kinking.

A Systematic Review of Transcarotid Approach for Endovascular Aortic Repair in Treating Aortic Disease

PurposeThe purpose of this study is to evaluate the feasibility, efficacy, and safety of transcarotid approach endovascular aortic repair (EVAR) in patients where conventional femoral access is not possible.Materials and MethodsA systematic review of all articles discussing transcarotid approach EVAR published in the PubMed, Embase, Ovid, Web of Science, and Cochrane Library databases were conducted. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsIn accordance with the inclusion criteria, 17 articles discussing transcarotid approach EVAR were retrieved, encompassing 18 patients. Among these patients, 6 patients were related to ascending aortic disease, including 4 cases of pseudoaneurysms, 1 case of penetrating ulcer, and 1 case of dissection. 9 patients had descending aortic disease, comprising 6 aneurysms, 2 penetrating ulcers, and 1 pseudoaneurysm. There were 3 cases of abdominal aortic disease, including 2 aneurysms and 1 endoleak. Among these patients, 10 cases had access through the left common carotid artery, and 8 cases had access through the right common carotid artery. One patient experienced spinal cord ischemia and subsequently died of multi-organ failure caused by acute pancreatitis. Additionally, there was one case of minor embolization in the nonsurgical carotid supply area. No cerebral infarctions were observed in the vascular territory of the ipsilateral carotid artery at the surgical approach site.ConclusionsResearch on transcarotid approach EVAR is limited and predominantly consists of case reports, with a notable absence of randomized controlled trials. This systematic review suggests that transcarotid approach EVAR may be a viable alternative for selecting patient groups when the conventional femoral artery approach is not feasible. These findings indicate that this method is associated with a relatively manageable perioperative complications and mortality rates.

Height Index and Diameter as Predictors of Outcomes in Males With Abdominal Aortic Aneurysms

INTRODUCTION

Abdominal aortic aneurysms (AAAs) affect over 1 million adults in the United States, with current guidelines recommending elective repair for males at diameters greater than 5.5 cm. While aneurysm diameter (AD) remains the primary predictor of rupture in men, indexed measurements such as the aortic size index (ASI) and aortic height index (AHI) may improve risk stratification. This study aims to evaluate the association between AD, ASI, and AHI with aortic-related complications in male patients following elective AAA repair.

METHODS

We conducted a single-center retrospective cohort study between 2014 and 2024 in male patients who underwent open or endovascular (endovascular aneurysm repair or fenestrated-endovascular aneurysm repair) AAA repair. Ruptured and saccular aneurysms were excluded. The primary outcome was 30-d and mid-term follow-up aortic-related complications and reintervention. Bivariate analysis was performed between the outcomes and stratified ASI (>2, >2.5, >3, and >3.5), AHI (>2.5, >3, >3.5, and >4), and AD in cm (>5, >5.5, >6, and >6.5 cm). Cox regression analysis was performed between each index as a continuous variable and each outcome. Area under the receiver operating characteristic curve analysis was conducted, and cumulative proportions were calculated.

RESULTS

Two hundred male patients were included with a mean age of 74.3 ± 8.5 y. Bivariate analysis demonstrated no significant association between ASI, AHI, or AD categories and 30-d aortic-related complications. During follow-up (mean: 2.6 ± 2.8 y), larger AD at the time of repair was significantly associated with an increased rate of aortic-related complications (AD > 5.5 cm: P = 0.01; >6 cm: P = 0.02; >6.5 cm: P = 0.02) and reinterventions at mid-term (AD > 5.5 cm: P = 0.02; >6 cm: P = 0.02; >6.5 cm: P = 0.01). In Cox regression analysis, AD (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.41-3.2) and AHI (HR: 3.26, 95% CI: 1.47-7.22) were independently associated with mid-term aortic-related complications. Similarly, AD (HR: 1.72, 95% CI: 1.20-2.47) and AHI (HR: 2.21 95% CI: 1.13-4.32) were independently related to reinterventions at mid-term. Cumulative proportions for 30-d complications were 66.7%, 38.5% for mid-term complications, and 39.1% for reinterventions at a 5.5 cm AD, which was equivalent to ASI of 3.2 cm/m2 and AHI of 2.9 cm/m for 30-d complications and ASI of 2.35 cm/m2 and AHI of 2.9 cm/m for both mid-term complications and reinterventions.

CONCLUSIONS

Larger AD at the time of repair was associated with increased rates of mid-term aortic-related complications and reinterventions for diameters exceeding 5.5 cm. Cox regression analysis identified AD and AHI as independent predictors of mid-term complications and reinterventions. Indexed metrics for risk stratification promote personalized management approaches for AAA repair.

Prevention and Management of Spinal Cord Ischemia After Aortic Surgery: An Umbrella Review

Background/Objectives: Spinal cord injury is a devastating complication of aortic surgery, with significant morbidity and mortality. This review aimed to summarize the current literature on preventing and managing spinal cord ischemia after open and endovascular aortic repair. Methods: We conducted a comprehensive review of PubMed, Scopus, and the Web of Science, focusing on systematic reviews and meta-analyses of the pathophysiology, risk factors, and strategies for mitigating the risk of spinal cord injury after aortic repair. We assessed the quality of the reporting for the eligible studies using the AMSTAR-2 tool and evaluated the strength of the evidence using the GRADE approach. Due to the absence of homogeneous clinical data, the evidence was synthesized in a narrative form. Results: Spinal cord ischemia can occur after both open and endovascular aortic repair, with a higher incidence reported in more extensive thoraco-abdominal aortic aneurysm repairs. The underlying pathogenesis is largely understudied. Several preventive strategies have been partially investigated, including cerebrospinal fluid drainage, hypothermia, and distal aortic perfusion. While the employment of neuromonitoring has been established in spine surgery, its efficacy in aortic repair remains uncertain due to confounding factors like hypothermia, anesthesia medications, and cardiopulmonary bypass. The prompt management of spinal cord complications is crucial to optimizing outcomes. No clear treatment algorithm has been universally adopted. Conclusions: Spinal cord ischemia remains a major challenge in aortic surgery, with a significant impact on patient outcomes. Further research is needed to elucidate the relevant pathophysiology and develop more effective intraoperative monitoring and management strategies.

Effect of Bicuspid Versus Tricuspid Aortic Valve Morphology on the Fate of the Ascending Aorta

BACKGROUND

Bicuspid aortic valves are associated with ascending aortic pathology, but their impact on long-term outcomes, including aortic growth and adverse events, remains unclear.

METHODS AND RESULTS

This prospective cohort-study included adult patients undergoing aortic valve surgery or ascending aortic surgery at a single center (2007-2013). The primary outcome was aortic diameter growth; secondary outcomes included all-cause mortality and adverse aortic events. Inverse probability of treatment weighting was used to adjust for baseline differences. Among 570 patients, 204 underwent echocardiographic follow-up, and 566 were followed for adverse aortic events. At 10-year follow-up, ascending aortic diameter increased significantly (mean 4 mm, P<0.001), with no difference between patients with BAV and TAV (P=0.68). After multivariable adjustment, there was no difference in all-cause mortality (HR, 0.87 [95% CI, 0.65-1.18]), but BAV was associated with a decreased risk of adverse aortic events (HR, 0.39 [95% CI, 0.19-0.82]). Concomitant ascending aortic surgery was associated with an increased risk of adverse aortic events in patients with TAV (HR, 8.89 [95% CI, 3.36-23.6]) but was associated with a decreased risk in patients with BAV (HR, 0.06 [95% CI, 0.01-0.29]).

CONCLUSION

Ten years after surgery, ascending aortic growth occurred regardless of valve morphology. Adverse aortic events were more common in patients with TAV, whereas patients with BAV benefited from concomitant ascending aortic surgery. These findings suggest a more liberal approach to ascending aortic surgery in patients with BAV undergoing valve replacement, but improved risk stratification is needed.