Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era

Total arch replacement using frozen elephant trunk and repair of bilateral subclavian artery aneurysms in a patient with type 2 Loeys-Dietz syndrome

Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. Vessel tortuosity and aneurysms throughout the vasculature are unique to LDS. Aortic root enlargement is ubiquitous, with most patients undergoing root replacement at some point in their lifetime. Multiple vascular procedures are required to prolong life expectancy. We describe a staged hybrid approach to a 17-year-old patient with LDS presenting with ascending aorta, arch, and bilateral subclavian artery aneurysms and prominent tortuosity. Transposition of the left vertebral and subclavian arteries onto the common carotid artery was performed. Total aortic arch replacement with frozen elephant trunk extension into the descending thoracic aorta was performed as a second stage. Bilateral subclavian artery aneurysms were excluded with the use of a four-branched graft.

A meta-analysis on the effect of proximal landing zone location on stroke and mortality in thoracic endovascular aortic repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR.

METHODS

MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I2 of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant.

RESULTS

Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I2 = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I2 = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I2 = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I2 = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87).

CONCLUSIONS

The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.

Hybrid staged approach to subclavian artery aneurysm repair with aberrant dominant left vertebral artery

Intrathoracic subclavian aneurysms are a rare entity, accounting for only a small percentage of all repaired aneurysms. These are repaired to alleviate symptoms and prevent complications of rupture, thrombosis and distal embolization. Most of these are amenable to thoracic endovascular aneurysm repair (TEVAR), which has resulted in an associated reduction in operative mortality. When there is a proximal involvement of the artery, revascularization is recommended prior to TEVAR. Herein, we present the case of a proximal subclavian aneurysm with an aberrant left vertebral artery that originated off the aortic arch. This was repaired using a two staged approach; carotid-subclavian bypass with vertebral artery-transposition followed by TEVAR.

Coil embolization with open frozen hybrid graft for complex left subclavian artery/proximal descending aortic aneurysm in a young patient

An LSCA aneurysm is a rare disease. When and how to operate are debated. While open surgery was initially considered the sole option, emerging endovascular techniques have been described. The present report describes a novel hybrid technique to treat an LSCA aneurysm combined to a proximal descending aneurysm in a young 25-year-old patient.

Endovascular Repair of an Intrathoracic Subclavian Artery Aneurysm in a Patient With Dextrocardia

This manuscript describes an endovascular repair of a symptomatic, large proximal left subclavian artery aneurysm in a patient with dextrocardia and right-sided aortic arch and absent bilateral internal carotid arteries. The patient had surgical reconstruction as an infant for congenital heart disease with Ventricular Septal Defect, bifid sternum . Given her previous surgical history, we declined an open operation and performed an endovascular repair with stent grafts to successfully repair the subclavian artery aneurysm. The patient had an uneventful postoperative course and follow-up ultrasonography demonstrated successful repair with preservation of flow through the left subclavian and vertebral arteries with resolution of her symptoms.

Revascularization of Left Subclavian to Common Carotid Artery Prepares for Covered Stent Implantation in Patients With Complex Aortic Coarctation

Seven adult patients underwent a two-stage treatment of complex coarctation (CoA), including surgical revascularization of the left subclavian artery (LSA) to left common carotid artery (LCCA), followed by transcatheter covered stent implantation. The majority of patients (5 of 7, 71%) received 1 covered stent (covered Cheatham Platinum stent: 8 zig/45 mm [n = 2], 10 zig/60 mm [n = 1], 10 zig/65 mm [n = 1]; BeGraft: 24/48 mm [n = 2]). In 1 patient (14%), the implantation of 2 covered stents (BeGraft 20/48 mm) was necessary. During a median follow-up of 2.4 years (interquartile range, 0.1 to 4.9 years), complications occurred in 3 of 7 patients (43%), including an asymptomatic but severe stenosis of the LSA bypass (n = 1), a recoarctation with a mild endoleak (n = 1), and a severe endoleak (n = 1). Surgical revascularization of the LSA to the LCCA can successfully prepare for covered stent implantation in complex CoA in adult patients. This two-stage approach was feasible and safe with complications occurring in 3 of 7 patients (43%). All complications were managed by catheter reintervention only.

Endovascular Stent Graft Repair for True and Post-Traumatic False Aneurysms of the Subclavian Artery

OBJECTIVE

Subclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs.

METHODS

The clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed.

RESULTS

Eighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak.

CONCLUSIONS

Endovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.

A Systematic Review of Total Thoracic Endovascular Aortic Repair in Treatment of Kommerell Diverticulum Combined with Right-Sided Aortic Arch

Kommerell diverticulum (KD) combined with right-sided aortic arch (RAA) and aberrant left subclavian artery (ALSA) are rare and limited to a few case reports and small series. Thoracic endovascular aortic repair (TEVAR), which is mini-invasive, is widely utilized in complicated aortic disease. We performed a systematic review of the literature to identify all patients who underwent endovascular repair for KD in terms of technical feasibility and procedural outcomes. Published and accepted studies only in English as well as article reference lists were searched and extracted to assess case series reporting solely TEVAR in KD patients. There were 28 patients with KD/RAA identified from 19 studies. All of them underwent endovascular technique for KD exclusion and the median age was 69 years (range 39-83 years). Hypertension (n=17) was the most common comorbidity in this cohort, followed by diabetes mellitus (n=3), hyperlipidemia (n=3), and smoking (n=3). The presenting symptoms were dysphagia (n=8, 29%), intermittent back pain (n=4, 14%), and acute aortic dissection (n=6, 21%), while asymptomatic was found in 9 patients (n=9, 32%). A technical success rate of 100% was reported associated with various managements of ALSA, proximal embolization (n=19, 68%), in-situ revascularization (n=3, 11%), and left carotid-subclavian bypass (n=3, 11%). All patients survived without severe complications and were discharged home within less than 14 days. The mean follow-up time was 9.3 months, patency was found in all patients, thrombosis and distinct shrinkage of KD aneurysm as indicated by CT-scans were noted (n=20, 71%), and type II endoleak was found in only 4 patients (n=4, 14%). TEVAR appears to be safe and offers favorable results, but it still needs substantial evidence to support routine use in KD. TEVAR is an alternative to open repair in selected cases, but it needs further investigation in a large cohort.

Aneurysmal Aberrant Right Subclavian Artery in an Active Duty U.S. Military Male (Case Report)

We present a rare case of four-vessel aortic arch with an aneurysmal aberrant right retro-esophageal subclavian artery (ARSA) in a healthy, asymptomatic active duty U.S. military male. ARSA has a prevalence of 0.6%-1.4%, of which ∼80%-84% are retro-esophageal ARSAs. Intrathoracic subclavian artery aneurysms are rare and often occur in association with congenital aortic arch anomalies and/or concomitant thoracic aortic pathology. This case adds to three previously documented cases of thoracic aortic disease (TAD) in the U.S. military and is the second documented case of ARSA in the U.S. military. This case highlights successful TAD identification in a service member before clinical decompensation.

[Subclavian artery aneurysms: pathogenesis, diagnosis, and therapeutic decision-making]

The article deals with the relevant literature data concerning diagnosis and treatment of subclavian artery aneurysms. This nosological entity is relatively uncommon, however its importance for modern medicine should not be underestimated. Despite a low incidence of the pathology, it should be understood that the disease's course for the patient is associated with the development of severe complications which may lead to disability or even death. The development of complications is extremely difficult to predict and stratification of risks for such patients is too complicated. It is also known that the diagnosis of a subclavian artery aneurysm is frequently an accidental finding, since the pathology may for a long time proceed symptom-free. At the same time, the subclavian artery occupies the first place by the frequency of localization of upper-limb aneurysms, thus making this problem currently important. Besides, separate attention should be paid to modern methods of correction of this disease, since implementation of high-tech interventions into vascular surgery have significantly expanded the arsenal of the operating surgeon.

Open Surgical Approach for Type II Endoleak in Subclavian Artery Pseudoaneurysm Presented With Neurological Symptoms After Endovascular Repair

We present a rare case of a 10-cm right subclavian artery pseudoaneurysm, with slow growth over 4 years after a traumatic fracture of the right clavicle. The patient had multiple prior endovascular attempts of embolization and stenting at other hospitals; despite this the pseudoaneurysm continued to grow and caused mass effect and neurologic symptoms. We present our open approach for the repair and a review of literature.

Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.

Single center experience in the management of a case series of subclavian artery aneurysms

OBJECTIVE

Subclavian artery aneurysms (SAAs) are rare, but they may cause life- and limb-threatening complications.

METHODS

Retrospective review was performed of all SAA patients that underwent treatment at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade between January 1st 2006 and January 1st 2018. The paper includes analysis of etiology and therapeutic options based on the experience from our institution.

RESULTS

Twenty (80%) of SAAs involved extrathoracic (ET), while five (20%) intrathoracic (IT) segment. Out of total five IT SAAs, two were asymptomatic (40%), one had dyspnea (20%), while two (40%) had hematothorax due to rupture. Seven (35%) patients with ET SAA had shoulder pain and pulsatile mass, five (25%) acute, seven (35%) had chronic limb ischemia, while one was asymptomatic (5%). Two IT SAAs were treated with open surgery (OS). Other three cases underwent hybrid procedure. One case with ET SAA was treated endovascularly due to hostile anatomy, while in all other 19 cases of ET SAAs open repair was performed, which included: graft interposition in 10 (52.63%), end-to-end anastomosis in 7 (36.84%) cases, while bypass procedure in 2 (10.52%) patients. One of our patients (4%) died during the first 30 postoperative days.

CONCLUSIONS

SAAs are rare, however because of their natural history they have huge clinical significance. OS is the method of choice in cases of ET SAAs caused by TOS. Endovascular and hybrid treatment decrease significantly perioperative morbidity and mortality rates in cases of intrathoracic SAAs and thus should be the first option.

A case report of a ruptured subclavian artery aneurysm presenting to the emergency department

Subclavian artery aneurysms are uncommon and present a diagnostic dilemma. Our patient attended with life-threatening rupture, requiring prompt management. However, lack of on-site facilities and specialist input posed a logistical challenge. The patient was stable enough to allow an urgent transfer to a specialist unit for successful endovascular repair.

Outcomes of carotid-subclavian bypass performed in the setting of thoracic endovascular aortic repair

BACKGROUND

Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR). However, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass in this clinical setting. As such, this study sought to define the early and late outcomes associated with this procedure.

METHODS

Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including cervical plexus nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications.

RESULTS

Of 579 consecutive patients undergoing TEVAR during this time interval, 112 patients (19%) underwent concomitant carotid-subclavian bypass. The cohort was 38% female (n = 43), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [95.5%]), with a minority being reversed saphenous vein (n = 4 [3.6%]) or Dacron (n = 1 [0.9%]) grafts. The bypass procedure was done concurrently at the time of TEVAR in 91% (n = 102) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 29% (n = 33). These complications included phrenic nerve palsy in 25% (n = 27), recurrent laryngeal nerve palsy in 5% (n = 6), axillary nerve palsy in 2% (n = 2), and neck hematoma requiring re-exploration in 1% (n = 1) of patients. The 30-day in-hospital all-cause mortality rate was 5% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 106), follow-up imaging of the bypass graft was available in 87% (n = 92) of patients. Actuarial primary graft patency was 97% at 5 years. There were three patients (3%) with bypass graft occlusions, two of which were clinically silent and detected on follow-up imaging. The third was detected because of symptoms of subclavian steal and required repeated revascularization. Two patients (2%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention.

CONCLUSIONS

Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely higher than is generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as "gold standard" comparison data for emerging branch graft devices.

Endovascular Repair of Incidentally Found Subclavian Artery Aneurysm: A Case Report From an Urban Level 1 Trauma Center

Subclavian artery aneurysms (SAAs) are historically rare peripheral aneurysm. However, it can be associated with serious life-threatening complications including rupture, thrombosis, and embolism. The majority of such aneurysms are found incidentally. Historically, SAA have been repaired via an open approach. Increasing case reports demonstrate successful management of SAAs with endovascular repair. The present report describes a case of incidentally discovered large proximal saccular subclavian aneurysm with suspected remote traumatic etiology with a successful endovascular repair.

Endovascular Repair of Descending Thoracic Aorta in Loeys-Dietz II Syndrome

Loeys-Dietz syndrome (LDS) is an autosomal dominant disorder that is predominantly characterized by involvement of the aorta, manifesting as aneurysmal dilatation or aortic dissection. Patients with LDS manifest with spontaneous aneurysms and dissections of central and peripheral arterial beds. We present 2 cases of young male patients with Loeys-Dietz II aortopathy, who manifested with spontaneous intimal tear of descending thoracic aorta and contained aortic rupture. Both patients were managed by endovascular repair, with collaborative efforts of teams comprising interventional cardiologists and radiologists, and a vascular surgeon.

Hybrid Repair of Proximal Subclavian Artery Aneurysm

OBJECTIVE

Conventional open repair for proximal subclavian artery aneurysms (SCAAs) requires cardiopulmonary bypass. However, patients with proximal SCAA can be treated with hybrid repair.

METHODS

Between 2007 and 2012, we performed hybrid repair to treat six consecutive patients with proximal SCAA (three left SCAAs, one right aberrant SCAA, two right SCAAs). Their median age was 73.5 [70-87] years, and the size of their aneurysm was 33.5 [30-45] mm. Thoracic endovascular aneurysm repair (TEVAR) only was used for one patient with left SCAA, TEVAR and supra-aortic bypass for two with left SCAA and one with right aberrant SCAA, and endovascular repair with reconstruction of the vertebral artery using the saphenous vein graft (SVG) for two with right SCAA.

RESULTS

The follow-up duration was 3.7 [0.2-6.8] years. There was no 30-day mortality and only one early complication consisting of a minor stroke after TEVAR for shaggy aorta. Two late deaths occurred, one caused by cerebral infarction due to occlusion of SVG to the dominant vertebral artery 2 months after the operation and the other by aortic dissection 5 years postoperatively.

CONCLUSIONS

Hybrid repair can be a less-invasive alternative for proximal SCAA. Revascularization of neck vessels and TEVAR should be performed very carefully to prevent neurologic complications.

Percutanous closure of left ventricular aneurysms in a patient with Loeys-Dietz syndrome

We report a case of percutaneous closure of multiple left ventricular aneurysms in a patient with inherited aortic-aneurysm syndrome-the Loeys-Dietz syndrome. One aneurysm was a true aneurysm in the subaortic region and the second one was a pseudoaneurysm at the left ventricular apex. The patient was a high-risk candidate for repeated operations. Both aneurysms were closed successfully percutaneously in staged procedures. There were no complications. The patient remained clinically well with stable echocardiographic results upon reassessment. This case illustrated that catheter-based closure of left ventricular aneurysms is a feasible approach in the context of connective tissue abnormalities related to the Loeys-Dietz syndrome.

Kommerell's diverticulum in the current era: a comprehensive review

Kommerell's diverticulum is a developmental error with a remnant of fourth dorsal aortic arch, named after Dr. Kommerell, a radiologist, who made the first diagnosis in a living individual. The diverticulum can occur in both the left and right aortic arch, from which an aberrant subclavian artery rises to the contralateral side. Pediatric patients often present with airway symptoms whereas dysphagia and chest discomfort are more common in the adult patients. Computed tomography or magnetic resonance imaging can provide details of the diverticulum, associated arch anomalies, and its relationship with surrounding organs. Recent histological studies indicated the presence of cystic medial necrosis in the diverticulum wall, which would explain the reported high rates of aortic dissection and rupture associated with the diverticulum. Accumulated knowledge on this entity and the recent advancement of imaging techniques, surgical/endovascular strategies, and perioperative management, have led to more aggressive intervention to the diverticulum in the early phase. While still under debate it is generally accepted to consider surgical intervention when the diameter of the diverticulum orifice exceeds over 30 mm, and/or the diameter of the descending aorta adjacent to the diverticulum exceeds over 50 mm. Treatment options include open surgical repair, hybrid endovascular repair, and total endovascular repair. The selection of treatment strategy for Kommerell's diverticulum should be based on the anatomy, comorbidities of the patient, and surgical expertise available. The summaries of open and endovascular repairs of over 210 cases from literature search from 2004 to 2014 are also provided in this review.

Successful treatment of a ruptured subclavian artery aneurysm presenting as hemoptysis with a covered stent

An aneurysm of the subclavian artery is rare. Recently, we experienced a case of a ruptured subclavian artery aneurysm presenting as hemoptysis. The patient had experienced atypical chest discomfort, and computed tomography (CT) revealed a small aneurysm of the left subclavian artery (SCA). Hemoptysis occurred 2 weeks later. Follow-up CT showed a ruptured aneurysm at the proximal left SCA. Endovascular treatment with a graft stent was performed by bilateral arterial access with a 12-Fr introducer sheath placed via cutdown of the left axillary artery and an 8-Fr sheath in the right femoral artery. A self-expandable Viabahn covered stent measuring 13×5 mm was introduced retrogradely via the left axillary sheath and was positioned under contrast guidance with an 8-Fr JR4 guide through the femoral sheath. After the procedure, hemoptysis was not found, and the 3-month follow-up CT showed luminal patency of the left proximal SCA and considerable reduction of the hematoma.

[Rare aortic diseases: infections, tumors, congenital anomalies]

Congenital malformations, tumors and aortic infections are rare and mostly asymptomatic. Unspecific clinical symptoms may cause delayed verification of the underlying disease. Contrast enhanced computer tomography- and magnetic resonance angiography are important sectional imaging methods for diagnostic completion. Consistent guidelines concerning diagnosis and therapy of rare aortic diseases are non-existent. Aortic tumors must be resected by open surgery, aortic infections in general require medical treatment and anomalies, if indicated, are treated more and more by endovascular or hybrid procedures. Therefore, it is recommended to treat these entities in an interdisciplinary approach in specialized aortic centers.

Pathology-specific secondary aortic interventions after thoracic endovascular aortic repair

OBJECTIVE

Despite improved short-term outcomes, concerns remain regarding durability of thoracic endovascular aortic repair (TEVAR). The purpose of this analysis was to evaluate the pathology-specific incidence of secondary aortic interventions (SAI) after TEVAR and their impact on survival.

METHODS

Retrospective review was performed of all TEVAR procedures and SAI at one institution from 2004-2011. Kaplan-Meier analysis was used to estimate survival.

RESULTS

Of 585 patients, 72 (12%) required SAI at a median of 5.6 months (interquartile range, 1.4-14.2) with 22 (3.7%) requiring multiple SAI. SAI incidence differed significantly by pathology (P = .002) [acute dissection (21.3%), postsurgical (20.0%), chronic dissection (16.7%), degenerative aneurysm (10.8%), traumatic transection (8.1%), penetrating ulcer (1.5%), and other etiologies (14.8%)]. Most common indications after dissection were persistent false lumen flow and proximal/distal extension of disease. For degenerative aneurysms, SAI was performed primarily to treat type I/III endoleaks. SAI patients had a greater mean number of comorbidities (P < .0005), stents placed (P = .0002), and postoperative complications after the index TEVAR (P < .0005) compared with those without SAI. Freedom from SAI at 1 and 5 years (95% confidence interval) was estimated to be 86% (82%-90%) and 68% (57%-76%), respectively. There were no differences in survival (95% confidence interval) between patients requiring SAI and those who did not [SAI 1-year, 88% (77%-93%); 5-year, 51% (37%-63%); and no SAI 1-year, 82% (79%-85%); 5-year, 67% (62%-71%) (log-rank, P = .2)].

CONCLUSIONS

SAI after TEVAR is not uncommon, particularly in patients with dissection, but does not affect long-term survival. Aortic pathology is the most important variable impacting survival and dictated need, timing, and mode of SAI. The varying incidence of SAI by indication underscores the need for diligent surveillance protocols that should be pathology-specific.

Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger?

Peripheral artery aneurysms are rarer than abdominal aortic aneurysms (AAA), although the true prevalence is not well known. They often coexist with aortic and other peripheral artery aneurysms. In contrast to AAA, where the principal risk is that of rupture, thromboembolism is more common, contributing a bigger risk in the more common lesions. Although rupture does occur, with incidence related to anatomical site, aneurysm diameter cannot be used to guide management with the same confidence as in AAA. In addition, the rarity of these lesions results in a paucity of evidence with which to guide intervention. Consequently they are difficult lesions to manage, and numerous aneurysm and patient factors must be considered to provide treatment individualised for each case. We discuss popliteal, femoral, carotid, subclavian, upper limb, visceral and false aneurysms, focussing on the risk of rupture and thromboembolism, and current thresholds for intervention, based on the available published literature.