Search Results (26)

Background/Objectives: Not all patients with acute aortic dissection undergo endovascular repair at initial presentation, and surgical or endovascular interventions are often required for late aneurysmal degeneration. This study aims to report the mid-term outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) of post-dissection thoracoabdominal aortic aneurysms (PDTAAAs) and to compare them with the outcomes of patients treated for degenerative thoracoabdominal aortic aneurysms (DTAAAs). Methods: A single-center retrospective analysis was performed, including all consecutive patients who underwent F/BEVAR for TAAAs between 2020 and 2025. A total of 95 patients were identified (18 PDTAAAs and 77 DTAAAs). All patients underwent elective repair; ruptured TAAAs were excluded. A comparative analysis was performed between the PDTAAA and DTAAA groups. Results: During the study period, a total of 95 patients who underwent F/BEVAR for TAAAs (mean age 66 ± 10 years, males n = 68, 72%) were identified. Eighteen patients (males n = 14, 78%) underwent F/BEVAR for PDTAAAs, and 77 (males n = 54, 78%) for DTAAAs. The patients in the post-dissection group were younger (62 ± 14 years vs. 70 ± 8 years; p < 0.01). Aneurysms in the PDTAAA group more commonly involved the proximal descending aorta (Crawford type 1 and 2 TAAA: n = 12/18, 67% vs. n = 14/77, 18%; p < 0.01). Aortic arch debranching procedures were performed at a higher rate in the PDTAAA group (8/18, 44% vs. 8/77, 10%; p < 0.01). No mortality within 30 days occurred in the post-dissection group but it did occur in 2/77 (3%) patients in the degenerative group (p = 0.68). Mean follow-up was 31 months (range: 3–121 months). Freedom from reintervention was similar between the two groups (55% vs. 60%, non-significant). Overall survival was significantly higher in the PDTAAA group (90% vs. 60%; p = 0.021). Conclusions: F/BEVAR is technically feasible for PDTAAAs. Technical success and reintervention rates do not differ between post-dissection and degenerative TAAAs; however, overall survival is higher in patients with post-dissection aneurysms. Full article

Background: Complex EVAR is a well-established option for treating complex aortic pathologies. However, depending on the type of it, long-term effectiveness is often compromised. For example, chimney EVAR is related to type IA endoleaks related to the gutter and proximal neck degeneration, late failures after fenestrated or branched EVAR are rare. Although redo-endovascular procedures are recommended for failed repairs, the use of branched endoprostheses (BEVAR) to address failed Complex EVAR (C-EVAR) cases is rarely documented. This study aims to evaluate the technical feasibility and 30-day outcomes of using BEVAR as a definitive rescue strategy for these patients. Methods: A retrospective single-center analysis was conducted on a series of twelve patients who had previously undergone failed C-EVAR. Clinical and procedure-related variables were collected. Statistical analysis was performed using Stata v18.0 software. Results: The reasons for reintervention were type Ia endoleak (ten patients), type Ib (one patient), and type III + Ia (one patient). Branched devices were used: eleven patients received the Zenith t-Branch (Cook Medical, Bloomington, IN, USA), and one received the G-Branch device (Lifetech Scientific, Shenzhen, China). Technical and clinical success was achieved in 11 out of 12 patients (91.7%). One perioperative death (due to haemothorax and sepsis) and three major complications were recorded in the first 30 days following repair. No patient of this cohort was deemed fit enough for open conversion. Imaging follow-up at 30 days revealed two type I leaks and seven type II leaks, with no type III leaks recorded. Patency was maintained in all treated visceral vessels (the celiac trunk, the superior mesenteric artery, and the renal arteries) in survivors. Conclusions: Repairing failed C-EVAR using branched endovascular aneurysm repair is a feasible and effective technique. This approach can resolve complex issues such as proximal sealing and component integrity failures, successfully excluding the aneurysmal sac while avoiding the morbidity and mortality associated with open surgery in high-risk patients. Full article

Objectives: The study objectives are to evaluate the impact of the operator’s learning curve on the outcomes of off-the-shelf branched endovascular aortic repair (OTS-BEVAR) in complex and thoracoabdominal (C/TAAAs) aneurysms. Methods: Patients who underwent OTS-BEVAR (T-Branch, Cook-Medical) between 2013 and 2023 were considered. The first and last 25 cases with at least 1 year of follow-up were clustered in two groups (early experience: E.Exp.; late experience: L.Exp.) and compared. Technical success (TS), intraoperative target visceral vessel (TVV) loss, spinal cord ischemia (SCI), 30-day mortality, and TVV instability at 1 year were assessed as primary outcomes. Procedure/fluoroscopy time, iodinated contrast media (ICM) amount and length of hospitalization were assessed as secondary outcomes. A p value < 0.05 was considered statistically significant. Results: Overall, 106 cases were analyzed. Technical success was higher in L.Exp. than E.Exp. (L.Exp.: 25/25 vs. E.Exp.: 17/25; p: 0.004). Moreover, intraoperative TVVs loss was higher in E.Exp. than L.Exp. (E.Exp.: 12/25 vs. L.Exp.: 0/25; p: 0.0001). There were no differences in terms of 30-day/in-hospital mortality (E.Exp.:4/25 vs. L.Exp.:4/25; p: 1), SCI (E.Exp.:2/25 vs. L.Exp.:1/25; p: 1), and paraplegia (E.Exp.: 2/25 vs. L.Exp.: 0/25; p: 0.48) between E.Exp. and L.Exp. Cases of L.Exp. had lower fluoroscopy [E.Exp.: 160(21) vs. L.Exp.:72(18) min; p: 0.003] and overall procedure time [E.Exp.: 518(156) vs. L.Exp.:400(130) min; p: 0.04], ICM [EE: 220(45) vs. L.Exp.: 138(61) mL; p: 0.005] and hospitalization [E.Exp.: 17(9) vs. L.Exp.: 12(4) days; p: 0.03] than cases of E.Exp. Finally, patients managed in L.Exp. had lower TVVs instability at 12 months than patients managed in the E.Exp. (E.Exp.: 8/25 vs. L.Exp.: 1/25; p: 0.04). Conclusions: Cases managed in L.Exp. have higher TS, lower intraoperative TVVs loss and instability at 1-year than cases of E.Exp. Moreover, procedural/fluoroscopy time, ICM, radiation exposure and hospitalization are lower in L.Exp. than E.Exp. Full article

Background/Objectives: Fenestrated and branched endovascular aortic repair (F/BEVAR) is increasingly used for the treatment of complex aortic aneurysms, and is traditionally performed under general anesthesia (GA). Data on the use of local anesthesia (LA) for F/BEVAR remain limited. This study aimed to report early outcomes of F/BEVAR performed under LA versus GA, with a focus on feasibility and perioperative complications in a high-risk patient population. Methods: This single-center retrospective analysis included patients undergoing F/BEVAR under LA or GA. Primary outcomes were in-hospital mortality and in-hospital complications. Secondary outcomes included early reintervention, intensive care unit and hospital length of stay, blood transfusion requirements, and technical success. Results: A total of 359 patients were included, of whom 25 (7.0%) were treated under LA and 334 (93.0%) under GA. Conversion from LA to GA occurred in 6 patients (24%). Patients in the LA group represented a higher-risk cohort, with advanced age, higher ASA class, larger aneurysm diameters, and a greater proportion of emergency and ruptured repairs. Technical success was high, and procedural metrics were within expected ranges. In-hospital mortality was numerically higher in the LA group (12.0% vs. 2.9%, p = 0.05). Overall, in-hospital complications were more frequent in the LA group (68.0% vs. 41.3%, p = 0.009), including a higher rate of spinal cord ischemia (24.0% vs. 8.5%, p = 0.02). Blood transfusion requirements were also greater in patients treated under LA (p = 0.004), while blood loss, ICU stay, and hospital length of stay were comparable. Early reintervention occurred more frequently in the LA group (31.8% vs. 10.4%, p = 0.009). Conclusions: LA appears feasible in selected high-risk patients undergoing complex F/BEVAR. However, given substantial baseline differences between groups, no conclusions can be drawn regarding comparative safety or efficacy relative to GA. These findings should be considered preliminary. Full article

Background/Objectives: To describe our experience of using an alternative technique for retrograde branch graft cannulation during Branched EndoVascular Aortic Repair (B-EVAR) of complex abdominal and thoraco-abdominal aortic aneurysm (TAAA) with branched endografts. Methods: Data from patients who underwent B-EVAR for TAAA/complex abdominal aneurysms and in whom the cannulation of a branch was performed through a retrograde approach with our technique were retrospectively collected and analyzed. The technique consists of the placement of two 4F Ber catheters in both femoral arteries, which are advanced in parallel with the main graft before its deployment and left in the aneurysmal sac. These catheters are then used as a bailout for the retrograde cannulation of one or more branches of the endograft. Results: The technique was employed in 4 patients (1 female, 1 urgent) treated from 2018 onward, allowing the successful catheterization of 4 challenging branches that could not be catheterized using other approaches. The patients’ mean age was 80.7 + 2.2 years. No intraoperative nor postoperative complications linked to the technique occurred. Conclusions: The placement of two catheters from both femoral arteries inside the aneurysmal sac before graft deployment can be safe and useful for bailout retrograde cannulation of any branch of the endograft, when other techniques fail. Full article

Neutrophils and their extracellular traps (NETs) are pivotal elements of the immune response. This study investigates the dynamics of neutrophil-related markers during the perioperative period of branched endovascular aortic repair (BEVAR) in patients with thoracoabdominal aortic aneurysms (TAAAs) and evaluates their association with one-year clinical outcomes. A prospective, single-center study was conducted on 20 TAAA patients treated with T-branch devices. The analysis focused on surrogate markers associated with NETosis, including double-stranded DNA (dsDNA), single-stranded DNA (ssDNA), and citrullinated histone H3 (citH3). Peripheral venous blood was collected 24 h before BEVAR, and on the third and fifth postoperative days. Patients were monitored for one year to evaluate mortality and hospitalization risks, with predictors identified using Cox regression analysis. Increased postoperative levels of inflammatory markers were significantly associated with higher risks of mortality and hospital readmission. On the third postoperative day, key parameters emerged as predictors of adverse outcomes: dsDNA (HR = 1.000; 95% CI 1.000–1.000; p = 0.027), ssDNA (HR = 1.000; 95% CI 1.000–1.000; p = 0.022), and NLR (HR = 1.226; 95% CI 1.043–1.440; p = 0.013). Markers assessed in the early postoperative period (the third postopearive day) demonstrated superior predictive utility compared to those measured on the fifth postoperative day. CitH3 levels did not show statistical significance as a prognostic factor. Early postoperative evaluation of NET-associated markers, particularly dsDNA and ssDNA, offers prognostic value for predicting mortality and hospitalization risks in TAAA patients undergoing BEVAR. These markers may provide superior predictive accuracy compared to conventional post-implantation syndrome criteria. Enhanced postoperative monitoring of these markers could help identify high-risk patients who may benefit from intensified follow-up. Full article

Background/Objectives: This study compared the hemodynamic performance of fenestrated (FEVAR), branched (BEVAR), and chimney endovascular aortic aneurysm repair (chEVAR) in patients with complex aortic aneurysms. Methods: The pre- (native) and post-endovascular repair (endograft-defined) blood lumen was reconstructed from computed tomography angiographies of nine (9) elective patients treated with FEVAR (n = 3), BEVAR (n = 3), and chEVAR (n = 3). Computational fluid dynamics (CFD) simulations obtained blood flow properties. Velocity magnitude, wall shear stress (WSS), time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and local normalized helicity (LNH) were computed at peak systole and mid-diastole. The hemodynamic data were statistically analyzed to evaluate correlations between FEVAR, BEVAR, and chEVAR, focusing on targeted visceral arteries. Results: Only slight differences were observed regarding RRT, OSI, and TAWSS between FEVAR and BEVAR, whereas the chEVAR group demonstrated a marked deviation from both. In FEVAR, the postoperative helical flow structures appeared more compact, while in BEVAR they were more developed and exhibited a more rotational configuration. The LNH of the visceral vessel patterns exhibited similar qualitative features across groups. Regarding TAWSS, higher values were found in BEVAR, whereas chEVAR showed the lowest. Conclusions: FEVAR, BEVAR, and chEVAR improved postoperative blood flow characteristics toward near-physiological conditions, reducing undesired flow patterns and recirculation zones. FEVAR showed more stable visceral flow, and BEVAR demonstrated higher flow rates and fewer recirculation zones, while chEVAR exhibited more streamlined visceral artery flow with reduced regurgitation at bridging stent entries. Despite variations, all approaches effectively preserved visceral artery perfusion. Full article

Background and Objectives: Hostile iliofemoral anatomy (HIA) challenges large-bore access in thoracic, branched, or fenestrated endovascular aortic repair (t/b/fEVAR). Retroperitoneal open iliac conduit (ROIC) enables safe delivery, but data in complex t/b/fEVAR are scarce. Materials and Methods: This retrospective single-center cohort study (2017–2025) of 80 t/b/fEVAR patients followed STROBE guidelines. Eight (10%) required elective ROIC for HIA (small iliac diameter < 7 mm or occlusive disease). Outcomes were compared to 23 no-conduit complex endovascular aortic repair cases. Results: ROIC patients [50% female, 87.5% smokers] had higher PAD [62.5% vs. 17.4%, p-value = 0.015]. All ROICs were elective [vs. 69.5% no-conduit, p-value = 0.076]; indications: Type V TAAA [50%], synchronous aneurysms (25%), Type II TAAA [12.5%] and arch aneurysm [12.5%]. Median operative time [365 vs. 200 min, p-value = 0.002], blood loss [1190 vs. 600 cc, p-value < 0.001], and contrast [420 vs. 300 cc, p-value = 0.004] were higher. Technical success was 100% [8/8] vs. 86.9% [20/23] (p-value = 0.28), and clinical success was 87.5% vs. 78.2% (p-value = 0.569). Median ICU stay [3 d vs. 2 d, p-value = 0.817] and hospital stay [12 d vs. 9 d, p-value = 0.404] were prolonged, albeit without statistically significant differences. In-hospital mortality was similar (12.5% vs. 17.4%, p-value = 0.746) between groups. One ROIC patient had intraoperative cardiac arrest [sheath dislodgement]; another required a covered stent for anastomotic rupture. At 12-month follow-up, one Type III endoleak required relining. Conclusions: Planned retroperitoneal open iliac conduits achieved 100% technical success in patients with hostile iliofemoral anatomy, without ischemic complications, despite longer operative times and higher blood loss. ROIC remains a safe and indispensable technique that extends complex endovascular aortic repair to otherwise ineligible patients. Full article

This is a single-center study about upward facing in branched endovascular aortic repair. Background: The evolution of branched endovascular aortic repair (BEVAR) has introduced upward-facing branches as a novel approach to facilitate exclusive transfemoral access in complex aortic aneurysm repair. This study evaluates the feasibility, safety, and early outcomes of custom-made BEVAR devices incorporating upward-facing branches in patients with cranially oriented renal arteries. The investigation further aims to analyze the technical success and mid-term outcomes related to these novel devices, as well as to identify any challenges or complications specific to the use of upward-facing branches in clinical practice. Methods: We retrospectively analyzed 17 patients treated at a single center between January 2020 and December 2024 using custom-made Cook Medical branched stent grafts with at least one upward-facing branch. Demographics, comorbidities, target vessel details, bridging stent graft (BSG) configurations, and procedure-related complications were collected. The primary endpoints were technical success and branch patency. Secondary endpoints included short- and mid-term branch-related complications. Results: The cohort had a mean age of 70 years, with hypertension (88%) and coronary artery disease (47%) being common comorbidities. Technical success was achieved in 100% of cases. The left renal artery was the most frequently targeted vessel (63.2%). Most upward-facing branches were bridged using a combination of balloon-expandable and self-expandable stents. One patient (5.9%) experienced a renal bleeding complication requiring embolization. There were no cases of primary stent occlusion or dislocation. At a mean follow-up of 14 months, one asymptomatic occlusion of an upward-facing branch was detected in computed tomography angiography. No further upward-facing branch-related complications occurred, and 1-year follow-up was available in 41.2% of patients. Conclusions: In our single-center study including 17 patients, upward-facing branches in BEVAR demonstrate high technical success and a low complication rate, offering a promising alternative to traditional access strategies. These findings support broader adoption in select anatomical scenarios, pending larger comparative studies and longer-term data collection. Full article

Late ruptures of abdominal aortic aneurysms post-endovascular aneurysm repair present a significant risk, occurring in about 0.9% of cases. The typical timeframe leading to rupture is roughly 37 months, with the primary factors often linked to endoleaks, especially types I and III, which sustain pressure within the aneurysm sac. The approaches to managing late ruptures consist of endovascular approaches, open surgical interventions, and conservative care, each customised to the patient’s specific characteristics. When feasible endovascular repair is favoured, additional stent grafts are deployed to seal endoleaks and offer lower perioperative mortality rates compared to those for open surgery. Open repair is considered when endovascular solutions fail or are not feasible. Conservative management with active monitoring and supportive treatment can be considered for haemodynamically stable non-surgical patients. Endovascular repair methods like fenestrated/branched EVAR (F/BEVAR) and parallel grafting (PGEVAR) are effective for complicated anatomies and show high technical success with reduced morbidity compared to that with open repairs. Chimney techniques and physician-modified endografts may help regain and broaden the sealing zone. Limb extensions with or without embolisation, interposition endografting, and whole-body relining are helpful options for type IB and type 3–5 endoleaks. Open surgical repair carries a higher perioperative mortality but may be essential in preventing death due to rupture following failed EVAR. The choice depends on the patient’s clinical stability and fitness for surgery in the absence of a viable endovascular alternative. This article discusses the available options for treating late rupture after EVAR, emphasising the importance of individualised treatment plans and the need for rigorous postoperative surveillance to prevent such complications. Full article

Pathophysiological conditions in arteries, such as stenosis or aneurysms, have a great impact on blood flow dynamics enforcing the numerical study of such pathologies. Computational fluid dynamics (CFD) could provide the means for the calculation and interpretation of pressure and velocity fields, wall stresses, and important biomedical factors in such pathologies. Additionally, most of these pathological conditions are connected with geometric vessel changes. In this study, the numerical solution of the 2D flow in a branching artery and a multiscale model of 3D flow are presented utilizing CFD. In the 3D case, a multiscale approach (3D and 0D–1D) is pursued, in which a dynamically altered velocity parabolic profile is applied at the inlet of the geometry. The obtained waveforms are derived from a 0D–1D mathematical model of the entire arterial tree. The geometries of interest are patient-specific 3D reconstructed abdominal aortic aneurysms after fenestrated (FEVAR) and branched endovascular aneurysm repair (BEVAR). Critical hemodynamic parameters such as velocity, wall shear stress, time averaged wall shear stress, and local normalized helicity are presented, evaluated, and compared. Full article

Background: The aim of this case series is to describe technical considerations and preliminary outcomes of preventive aneurysm sac embolization during fenestrated or branched EVAR (embo F/BEVAR technique). Methods: Five male patients suffering from juxtarenal or pararenal abdominal aortic aneurysms, preoperatively identified as being at “high risk” of type 2 endoleak (EL2) development, were treated with embo F/BEVAR. The patients presented at least two of these risk factors: patent inferior mesenteric artery (IMA) > 3 mm; more than three pairs of patent lumbar arteries (LAAs); more than two pairs of LAAs, associated with an accessory efferent artery or at least a pair of intercostal arteries; aneurysm thrombus volume < 40%; aneurysm sac diameter > 65 mm. Embo F/BEVAR was performed with 15 × 20 mm MReye Inconel coils (Cook Medical, Limerick, Ireland), using different aortic endografts. Results: Technical success was 100%, with no complications related to perioperative or postoperative coils implantation. An average number of 11 ± 4.4 coils/patient was deployed. No reinterventions were observed during the follow-up (12.4 ± 3.6 months). One case of EL2 (20%) was detected during the follow-up, without aneurysm sac enlargement. Conclusions: According to this preliminary experience, embo F/BEVAR technique with Inconel coils seems a feasible adjunctive procedure to manage the risk of EL2 after FEVAR or BEVAR, allowing a simple follow-up with low levels of scatter artifacts, and ensuring limited additional procedural costs. Moreover, embo F/BEVAR can be used with different endografts, requiring minimal increases in operating times. Further studies with larger cohorts of patients and longer follow-up periods are mandatory to better define the potential of this technique and its limitations. Full article

Background/Objectives: Few clinical studies have reported on physician-modified inner-branched endovascular repair (PMiBEVAR) for aortic arch aneurysm. Herein, we evaluate the outcomes of proximal landing zone 2 PMiBEVAR. Methods: This retrospective study analyzed data from six patients who underwent zone 2 PMiBEVAR for aortic arch aneurysms at a single center between October 2021 and June 2024. The outcomes were in-hospital mortality and postoperative complications. Results: The median follow-up period was 12.5 (7.3–25) months. Males constituted four out of six cases and females constituted two out of six cases. The patients had a median age of 78.5 (76.5–79.0) years, and the aneurysm diameter was 56 (50–61) mm. Technical success was achieved in 5/6 (83.3%) cases. The median modification and operative times were 56 (45–60) min and 92 (79–308), respectively. Postoperatively, delayed type Ia endoleak and vascular access-site pseudoaneurysm occurred in one patient each. However, no patients experienced other complications. The median hospital stay was 10 (7–41) days, and no deaths or reinterventions occurred after 30 days. During the post-discharge follow-up, the aneurysm diameter remained “unchanged” in four patients, including the one with delayed type Ia endoleak, while two patients experienced “shrinkage”. Conclusions: PMiBEVAR for distal aortic arch aneurysm might be effective in improving postoperative outcomes. Full article

Objectives: This study aims to evaluate the technical and clinical outcomes of the E-nside stent graft for thoraco-abdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PAAA) endovascular treatment at our University Hospital Center. Methods: We conducted a retrospective analysis of patients electively treated by inner branched EVAR (iBEVAR) between 05/2021 and 03/2023. Demographic, procedural, and clinical data were analyzed. The technical success and clinical outcomes, such as access-site-related complications were reported. The perioperative and early mortality rate, freedom from aortic reintervention, target vessels’ (TVs) patency, and the endoleak rate were evaluated during the follow-up. The technical aspects (external iliac artery diameter, iliac tortuosity, extent of aortic coverage) were retrospectively analyzed. Results: Twenty-two patients were included (age 75.9 ± 5.5; 72.7% male). The aneurism extent was Crawford I = 4 (18.2%), III = 8 (36.4%), IV = 5 (22.7%), V = 1 (4.5%), and PAAA = 4 (18.2%). The mean aortic diameter was 63.5 ± 9.9 mm. The technical success was 95.5% (assisted primary success 100%). The clinical success was 86.4%. The perioperative and early freedom from all-cause mortality rates were 90.9% and 90%, respectively. No case of inter-stage aortic-related mortality was reported, and there was no permanent/temporary spinal cord ischemia (SCI). Seventy-eight out of 81 patent TVs were incorporated through a bridging stent (96.3%). The TV success was 95.1%. The mean external iliac artery (EIA) diameter was 7.5 ± 1.1 mm. Twelve patients (54.5%, including all female patients) were considered outside the instructions for use (IFU) due to narrow iliac arteries. One access-site-related complication was reported. Conclusions: Our experience confirms that E-nside has promising technical and clinical success rates, as well as a low reintervention rate, but it requires a significant compromise of the healthy aortic tissue and adequate iliac arteries that still represents a limitation, especially among women. Mid- to long-term studies and prospective registries are mandatory to evaluate the long-term efficacy and safety, as a comparison between E-nside and other alternative off-the-shelf solutions. Full article

Purpose: This paper aims to describe a straightforward, efficient, and reliable technique to simplify cannulation maneuvers during aortic branched endograft repair. Technique: The suggested approach utilizes the Penumbra Neuron Select catheter, which combines diagnostic, sizing, and support capabilities in one. This has the potential to reduce procedural time and minimize the need for serial catheter and guidewire exchanges. Conclusions: The proposed technique offers a simple yet effective tool to mitigate the risk of vessel loss and injury, and to streamline complex aortic repair procedures. Full article