Search Results (40)

Background: Fenestrated stentgrafting has become a first-line treatment for juxtarenal aneurysms, and the incorporation of all renovisceral vessels with fenestrations has become common to increase the proximal sealing zone. This increases the complexity of the repair compared to using fewer fenestrations, and stenting of the celiac artery (CA), in particular, can be technically challenging. Objective: This study evaluates the mid-term outcomes of leaving the celiac artery unstented during quadruple fenestrated stentgrafting for complex aortic aneurysms. Additionally, it explores the clinical and anatomical factors that influence the decision to not stent the celiac artery. Methods: A retrospective review was conducted of patients with complex aortic aneurysms who underwent elective fenestrated endovascular aneurysm repair (FEVAR) between 2018 and 2023. Custom Cook Zenith grafts were used, and all patients underwent preoperative computed tomography angiography (CTA) as well as follow-up CTA to assess the celiac artery. This study evaluated celiac artery anatomic factors, such as proximal and distal diameter; presence of stenosis (<50% or >50%) and patency; length of any CA stenosis; CA takeoff angulation, CA tortuosity, early CA division; calcification; and presence of CA aneurysm or ectasia anatomical abnormalities. Recorded outcomes of CA instability included any stent stenosis, target vessel occlusion, reintervention, or endoleak (types 1C and 3). Results: A total of 101 patients underwent FEVAR, with 72 receiving a stent in the celiac artery and 29 not receiving it. Rates of technical success (96.5% vs. 100%), intervention times (256 min vs. 237 min), and lengths of hospital stay (5.1 vs. 4.7 days) were similar between unstented vs. stented groups. At one year, no significant difference in celiac artery instability was noted (17.2 vs. 5.5%; p = 0.06). Risk factors for CA occlusion on univariate analysis included a steep takeoff angle (≥140°), length of stenosis >6.5 mm, proximal diameter ≤6.5 mm, preoperative stenosis ≥50%, and celiac artery tortuosity. Conclusions: Anatomical features of the CA impact the ability to achieve routine CA stenting during FEVAR. Selectively not stenting the celiac artery during FEVAR might simplify the procedure without compromising patient safety and mid-term outcomes. Full article

Background/Objectives: Physician-modified endografts (PMEGs) have emerged as a treatment option for complex aortic pathologies. Uncertainty remains regarding the modification techniques and the most suitable materials for customization of fenestrated endografts. The aim of this study was to evaluate CE-marked endovascular aortic repair (EVAR) devices and suitable materials for device modification in PMEGs for juxtarenal and pararenal aortic pathologies. Methods: This single-center observational study included patients treated with the physician-modified TREO (Terumo Aortic, Inchinnan, UK) device between April and December 2024. All patients had aortic ruptures or symptomatic aneurysms and unfavorable anatomy or severe comorbidities, making standard EVAR and open repair unsuitable. Procedural data were recorded and analyzed, including in-hospital outcomes. The “wire visibility” and “sheath–wire contrast” of endografts were assessed under fluoroscopy, and different resheathing techniques were compared. Results: Technical success was achieved in all five patients. The number of fenestrations per patient was 2.6 (range: 1–4). In one patient (1/5), type Ib and type IIIc endoleaks were observed postoperatively, requiring reintervention. No in-hospital mortality occurred. The ICU and hospital stay were 24 h (range: 18–40 h) and 8 days (range: 6–20 days), respectively. Moreover, the One SNARE wire was identified as the wire with the highest “wire visibility”, and Endurant II showed the best “sheath–wire contrast”. Resheathing with the dedicated crimping device was superior to the tape-assisted method. Conclusions: The TREO platform, in synergy with suitable additional materials, offers a viable solution for urgent aortic pathologies requiring PMEGs. Continued refinement of materials and procedural standardization could enhance the long-term outcome. Full article

The natural history of focal non-infected lesions of the abdominal aorta (fl-AA) remains unclear and largely depends on their aetiology. These lesions often involve a focal “tear” or partial disruption of the arterial wall. Penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs) are examples of focal tears in the aortic wall that can either progress to dilatation (saccular aneurysm) or fail to fully propagate through the medial layers, potentially leading to aortic dissection. These conditions typically exhibit a morphology consistent with eccentric saccular aneurysms. The management of focal non-infected pathologies of the abdominal aorta remains a subject of debate. Unlike fusiform abdominal aortic aneurysms, the inconsistent definitions and limited information regarding the natural history of saccular aneurysms (sa-AAAs) have prevented the establishment of universally accepted practice guidelines for their management. As emphasized in the latest 2024 ESVS guidelines, the focal nature of these diseases makes them ideal candidates for endovascular repair (class of evidence IIa—level C). Moreover, the Society for Vascular Surgery just referred to aneurysm diameter as an indication for treatment suggesting using a smaller diameter compared to fusiform aneurysms. Consequently, the management of saccular aneurysms is likely heterogeneous amongst different centres and different operators. Endovascular repair using tube stent grafts offers benefits like reduced recovery times but carries risks of migration and endoleak due to graft rigidity. These complications can influence long-term success. In this context, the use of endovascular bifurcated grafts may provide a more effective solution for treating these focal aortic pathologies. It is essential to achieve optimal sealing regions through anatomical studies of aortic morphology. Additionally, understanding the anatomical characteristics of focal lesions in challenging necks or para-visceral locations is indeed crucial in device choice. Off-the-shelf devices are favoured for their time and cost efficiency, but new endovascular technologies like fenestrated endovascular aneurysm repair (FEVAR) and custom-made devices enhance treatment success and patient safety. These innovations provide stent grafts in various lengths and diameters, accommodating different aortic anatomies and reducing the risk of type III endoleaks. Although complicated PAUs and focal saccular aneurysms rarely arise in the para-visceral aorta, the consequences of rupture in this segment might be extremely severe. Experience borrowed from complex abdominal and thoracoabdominal aneurysm repair demonstrates that fenestrated and branched devices can be deployed safely when anatomical criteria are respected. Elective patients derive the greatest benefit from a fenestrated graft, while urgent cases can be treated confidently with off-the-shelf multibranch systems, reserving other types of repairs for emergent or bail-out cases. While early outcomes of these interventions are promising, it is crucial to acknowledge that limited aortic coverage can still impede effective symptom relief and lead to complications such as aneurysm expansion or rupture. Therefore, further long-term studies are essential to consolidate the technical results and evaluate the durability of various graft options. Full article

Background/Objectives: We sought to demonstrate the versatility and economy of physician-modified endograft (PMEG) fenestrated endovascular aortic repair (FEVAR) based on the Treo (Terumo Aortic) platform for patients referred for custom-made device (CMD) FEVAR due to a complex abdominal aortic aneurysm (CAAA). Endovascular planning was performed utilizing a standardized design incorporating all visceral arteries with a low supra-celiac landing zone. The pure cost of the aortic components was compared between the PMEG and CMD designs. Methods: A total of 39 consecutive patients treated with CMD FEVAR due to a CAAA between September 2018 and December 2023 were recruited at a tertiary vascular center for a retrospective evaluation. Endovascular planning was performed on readily available computed tomography angiography (CTA) datasets using 3Mensio Vascular (Pie Medical Imaging) software. The actual cost of the major components was compared between the implanted CMD platform produced by Cook and the planned Treo-based PMEG repair. Results: A total of 155 fenestrations were planned on 3 triple-, 34 quadruple-, and two quintuple-fenestrated devices. The 90 mm distance between the proximal edge and the flow divider of the 120 mm long main body of the Treo graft allowed for the placement of all necessary fenestrations of the target arteries without the need to reduce the 3 cm supra-celiac landing zone while also preserving a safety distance of >1 cm to the flow divider. The costs of the components were EUR 33896 for CMD and EUR 8878 for a PMEG. Conclusions: This retrospective study suggests that a quadruple-fenestrated PMEG based on the Treo bifurcation is a highly versatile alternative with a significant price advantage over custom-made devices for the treatment of complex abdominal aortic aneurysms. Full article

Background/Objective: To report mid-term to long-term outcome data for endovascular aortic repair using the Ovation stent graft system (Endologix, Santa Rosa, CA) for the correction of abdominal aortic aneurysms (AAAs) in a single center. Methods: All patients treated with the Ovation stent graft between December 2011 and February 2018 were included. Patient demographics, anatomical and operative details, as well as follow- up data including complications, the need for further interventions, and mortality were recorded prospectively in an electronic dataset and analyzed. Results: A total of 99 patients (86.10% males; mean age 73.6 ± 7.26 years) were treated with the Ovation stent graft. The mean maximal aortic diameter was 53.7 ± 8.8 mm mm. The main indications for Ovation use were small iliac accesses and thrombus/calcification at the proximal neck level. The technical success rate was 93.06%. No perioperative reintervention or limb occlusion was reported. Two graft-related perioperative adverse events were recorded. At a mean follow up of 82.70 ± 40 months, cumulative late survival was 97.90%, 92.60%, 81.00%, 73.40%, 48.70%, and 45.10%, respectively, at 12, 24, 48, 60, 108, and 120 months. No AAA-related death was recorded. Actuarial freedom from reintervention rate was 97.90%, 95.70%, 92.10%, and 80.10%, respectively, at 12, 24, 60, 108, and 120 months; estimated freedom from conversion was 98.90%, 97.70%, and 95.20% at 24, 60, 108, and 120 months. Conclusions: The Ovation stent graft demonstrated durable AAA exclusion even in complex anatomies evidenced by successful aneurysm exclusion and mid- to long-term freedom from aneurysm-related mortality. However, in this series, the not insignificant graft-related adverse event rate suggested the need for structural improvements, which were implemented in the next-generation devices. Full article

Background/Objectives: Endovascular aneurysm repair (EVAR) of the aorta may trigger an inflammatory response that affects coagulation. In the EVAR of para-renal and thoraco-abdominal aortic aneurysms, the implants are more complex and the duration of surgery is longer. However, the exact pathophysiological mechanisms of coagulation activation are not yet well understood. The primary aim of this study is to investigate the effects of complex EVAR of para-renal and thoraco-abdominal aortic aneurysms on the coagulation status of patients. Methods: This prospective observational study (STROBE), approved and registered by the Ethics Committee of the University Hospital of Larissa (UHL) (NCT06432387), will enroll consecutive patients undergoing elective EVAR of para-renal and thoraco-abdominal aortic aneurysms. Exclusion criteria: Refusal to participate, previous surgery within 3 months, American Society of Anesthesiologists physical status (ASA PS) > 3, known history of thrombophilia or functional platelet dysfunction. Perioperative laboratory tests will be performed according to institutional guidelines. These include a complete blood count, conventional coagulation tests, and kidney and liver function tests. In addition, the following parameters will be determined: von Willebrand factor, factors VIII and XI, D-dimers, fibrinogen, Adamts-13, anti-Xa, platelet activation (multiplate), and high-sensitivity troponin. Blood samples will be taken pre-operatively before induction of anesthesia (01), on postoperative day 1 (02), and on postoperative day 3–4 (03). During hospitalization, myocardial injury after non-cardiac surgery (MINS), major adverse cardiovascular events after non-cardiac surgery (MACE), acute kidney injury (AKI), post-implantation syndrome (PIS), and death from any cause will be recorded. In addition, our patients will be reviewed at 30 days, 3, 6, and 12 months for MACE, implant failure, or death from any cause. All enrolled patients will be treated by the same medical team at UHL according to the indications. According to our power analysis, for a cohort of patients with three consecutive measurements, 58 patients should be included in the study. To compensate for possible dropouts, the sample size was increased to 65 patients. Conclusions: The results of the present study could help physicians to better understand the effects of complex EVAR of para-renal and thoraco-abdominal aortic aneurysms on blood coagulation and platelet activation. Full article

Background: Endovascular aortic aneurysm repair (EVAR) is a commonly used treatment for abdominal aortic aneurysms (AAAs), but anatomical complexities limit its application in certain cases. Objective: This study evaluates the mid-term outcomes, referring to a follow-up period with a mean of 29.9 ± 24.1 months (approximately 1–5 years), of a novel double-barrel technique that employs overlapping tubular stent grafts to address these challenges. Methods: A retrospective analysis was conducted on seven patients treated with this technique from May 2014 to February 2023. Patients had narrow and short proximal necks, inadequate landing zones, or required re-do procedures. Results: The double-barrel technique achieved technical success in 85.7% of cases with zero mortality. Patients had an average hospital stay of 11.9 ± 10.0 days and attended follow-up for a mean of 29.9 ± 24.1 months. Minimal complications and no significant adverse events were reported. Conclusions: These findings suggest that the double-barrel technique is a cost-effective and viable alternative for anatomically complex cases where standard EVAR is unsuitable. While promising mid-term outcomes were observed, further studies with larger cohorts are necessary to confirm its long-term effectiveness and broader applicability. Full article

Background: Mycotic aneurysms of the subclavian artery are infrequent and pose significant diagnostic challenges, particularly in the context of recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The concomitant presence of upper extremity deep vein thrombosis (UEDVT) further complicates the management of bleeding risk and the necessity for anticoagulation therapy. Methods: This report discusses a 75-year-old male patient with a medical history of lung and skin cancer undergoing immunotherapy who presented with a swollen and painful right arm. Ultrasound examination identified deep vein thrombosis in the right axillary and basilic veins, and blood cultures confirmed MRSA infection. Subsequent imaging revealed bilateral subclavian artery aneurysms with contained ruptures involving previously placed stent grafts. Emergent endovascular interventions were performed to prevent catastrophic hemorrhage. Results: Despite the initial interventions, concerns regarding infected stent grafts persisted due to ongoing MRSA bacteremia and the presence of an endoleak. The complexity of balancing anticoagulation for DVT with the risk of aneurysm rupture necessitated the patient’s transfer to a tertiary care center for potential open surgical debridement. Conclusions: This case underscores the diagnostic and therapeutic challenges associated with the simultaneous occurrence of vascular infection, thrombosis, and aneurysmal pathology. Although emergency endovascular repair provided temporary hemostatic control, definitive management may require graft removal if stent infection is confirmed. Optimal care in such complex clinical scenarios demands a multidisciplinary approach and may necessitate advanced surgical interventions. Full article

Background/Objectives: The frozen elephant trunk (FET) technique was introduced as a possible single-stage procedure for treating aortic arch pathologies. However, up to a third of patients are reported to need subsequent completion (extension). This retrospective analysis aimed to evaluate the impact of early (within 30 days; EC group) versus late (>30 days; LC group) endovascular completion with thoracic endovascular aortic repair (TEVAR) in patients treated with FET. Methods: A single-center, retrospective analysis of all consecutive patients for the period between June 2017 and December 2023 who underwent FET and received endovascular extension was conducted. Indications for endovascular extension were aneurysms of the descending aorta, aneurysmal progress, endoleak, malperfusion, distal stent-induced new entry (dSINE), and aortic rupture. Results: A total of 37 of 232 FET patients received endovascular extension (15.9%). Average age at the time of TEVAR was 63.3 ± 10.3 years. There was an increase in the maximum total aortic diameter post-FET from 40.8 ± 9 mm to 45.1 ± 14 mm prior to TEVAR. Only 14 patients (37.8%) had the desired complete occlusion of the false lumen or aneurysm prior to extension; 23 (62.2%) still had relevant perfusion of the false lumen or aneurysm. The EC and LC groups were defined by time between FET and TEVAR: a mean of 4.8 ± 5.2 days in the EC group and 18.4 ± 18 months in the LC group. The EC group had markedly more complex procedures, reflected in intensive care (10.7 ± 6.9 vs. 0.1 ± 0.3 days, p < 0.001) and hospitalization (22.4 ± 14.0 vs. 8.1 ± 5.6 days, p = 0.003) durations. There was one early death due to multiorgan failure in the EC group and there were none in the LC group. There were no major cardiac events in either group. In the EC group, seven patients (50%) suffered from postoperative respiratory failure and four (28.6%) developed acute kidney failure requiring dialysis. Only one patient in the LC group (4.3%) experienced complications. During follow-up, another three patients (21.4%) of the EC group died, but none of the LC group did. Post-extension aortic remodeling was similar in both groups, with complete occlusion achieved in 27 cases (72%) during early follow-up and increased to 90.6% after a mean of 22.0 ± 23.4 months. Conclusions: Following aortic arch repair using FET, there is still a need for second-stage repair in 16% of patients. Endovascular completion post-FET is safe and feasible with a technical success rate of 100%, but early completion is associated with greater morbidity and mortality. TEVAR extension surgery may be better delayed, if possible, until after recovery from the hybrid arch repair. Full article

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

Background: Stent-graft implantation is a widely recognized method for endovascular treatment of aortic aneurysms. In cases where the aneurysm involves the thoracic and abdominal aorta, repair including fenestrated and branched stent grafts provides a viable alternative. This approach, initially reserved for patients unsuitable for open surgery, has become preferred for anatomically appropriate thoracoabdominal aortic aneurysms. The Zenith t-Branch system has been extensively studied, demonstrating high technical success rates and acceptable mortality and morbidity. However, complications such as endoleaks, kinking, and stent-graft branch rupture remain significant challenges. Methods: We present the case of an 82-year-old male with a thoracoabdominal aortic aneurysm treated with endovascular aneurysm repair using the Zenith t-Branch. Four years post-implantation, he developed a spontaneous rupture of the stent-graft branch, leading to dangerous leakage and aneurysm sac enlargement. An urgent surgical intervention was performed, implanting additional Be-Graft into the damaged branch, restoring stent-graft continuity and revascularizing the superior mesenteric artery. Results: The procedure was completed successfully. We conducted a review of the latest literature on endovascular treatment of thoracoabdominal aortic aneurysms with particular emphasis on the possibility of repairing postoperative complications, especially endoleaks. Conclusions: While modern technologies have significantly improved outcomes, serious complications persist. Studies emphasize the importance of regular imaging follow-up for early complication detection and management. Continuous advancements in stent-graft technology aim to reduce complications further and improve outcomes. This case underscores the necessity of experienced operators in managing complex and rare complications and highlights the promising future of endovascular techniques in treating thoracoabdominal aortic aneurysms. Full article

Background: This study addresses the need for enhanced patient education in the context of abdominal aortic aneurysm (AAA) and its treatment through endovascular aneurysm repair (EVAR). Effective patient education is essential for improving comprehension and engagement, particularly for those facing complex medical conditions. Methods: A total of 55 patients scheduled for EVAR participated in the study. Patient-specific three-dimensional (3D)-printed models of the participants’ aneurysms were created using computed tomography angiogram (CTA) scans. The educational intervention included a structured session utilizing these 3D models, with assessments conducted before and after the session, including the Mini-Mental State Examination (MMSE). Statistical analyses evaluated the knowledge gain and its correlation with cognitive function. Results: The results showed a significant increase in knowledge scores post-education (p < 0.001), with a mean knowledge gain of 2.36 points. Patients rated the effectiveness of the 3D models highly on a Likert scale, with a mean score of 4.64 for improving their understanding of the medical condition and procedural aspects. A weak correlation was observed between MMSE scores and knowledge test results. Conclusions: This study demonstrates the potential of patient-specific 3D models to enhance patient education in the context of EVAR, improving patients’ understanding of their medical condition and the procedure and thereby facilitating more informed decision-making. Full article

Background: Performing percutaneous coronary intervention (PCI) and endovascular aneurysm repair (EVAR) at the same time represents a groundbreaking development in the multidisciplinary treatment of cardiovascular disease. This combined PCI–EVAR approach bridges a critical gap by offering treatment for patients who have both coronary artery disease and aortic aneurysms. This innovative strategy exemplifies the evolving landscape of cardiovascular care, providing a new solution for complex clinical situations that previously required separate procedures. Methods: Six patients with critical coronary artery lesions and asymptomatic infrarenal aortic aneurysms (AAAs) ≥ 6 cm diameter, as well as one patient with critical coronary artery lesions and endoleak type 1A with aneurysms ≥ 6 cm, underwent simultaneous coronary artery revascularization through percutaneous intervention (PCI) and endovascular aneurysm repair (EVAR). The occurrence of any intraoperative or postoperative complication was considered to be the primary endpoint of the study, including the abortion or failure of either PCI or EVAR, bleeding requiring a conversion to open surgical procedures, the failure of local anesthesia, postoperative myocardial or lower limb ischemia, and a postoperative serum creatinine level of >125 mmol/L or of >180 mmol/L in patients affected by chronic renal failure. The overall length of the procedure, X-ray exposure, the quantity of iodine contrast medium administered, and the length of recovery were considered to be secondary endpoints. Results: Postoperative complications included two episodes of acute renal failure in the two patients already affected by chronic renal failure, which were easily resolved with adequate daily hydration and the elimination of nephrotoxic drugs. In no cases did cardiac ischemia or lower limb ischemia occur. The average procedure duration was 198 min (range: 180–240 min), the average fluoroscopy duration was 41.7 min (range: 35–50 min), the average amount of iodinated contrast medium was 34.8 mL (range: 30–40 mL), and the mean length of hospitalization was 2.7 days (range: 2–5 days). Conclusions: In selected patients, this surgical approach has demonstrated safety, reduced hospitalization times, minimized risks associated with complications from the untreated condition if procedures were performed at different times, and facilitated the effective management of intraoperative complications due to the presence of a multidisciplinary team. However, the limited number of patients necessitates further research. Full article

Comparative sonographic examination of the renal resistance index (RRI) can provide evidence of renal artery stenosis. The extent to which the RRI is changed after stent graft implantation is not known. The aim of this study was to investigate the influence of stent graft implantation into non-diseased renal arteries during endovascular treatment of pararenal aortic aneurysms on the RRI. Sonographic examinations of the kidneys were conducted using a GE ultrasound system. The evaluation was performed according to the European Society for Vascular Surgery (ESVS) 2D standard criteria. RRI values were determined in consecutive patients on the day before and after stent graft implantation and compared for each kidney. A total of 32 consecutive patients (73.9 ± 8.2 years, 5 females, 27 males) were treated with a fenestrated or branched aortic stent graft including bridging stent graft implantations into both renal arteries and received pre- and postinterventional examinations. Sonomorphologically, the examined kidneys were inconspicuous. The arborisation of the renal perfusion was preserved pre- and post-implantation. The RRI did not differ (0.66 ± 0.06 versus 0.67 ± 0.07; p = ns). Successful stent graft implantation into non-stenosed renal arteries did not lead to a relevant change in RRI. Therefore, the RRI is a suitable tool for assessing renal perfusion after fenestrated or branched endovascular aortic therapy. Full article

Objectives: There are several endovascular treatment options to treat aortic arch and thoracic aortic pathologies with custom-made or surgeon-modified aortic stent grafts. This study seeks to assess endovascular treatment methods for aortic arch and thoracic aortic pathologies with no acceptable proximal landing zone for standard thoracic endovascular aortic repair (TEVAR), comparing different treatment methods and evaluating technical success, intraoperative parameters and short-term outcomes. Methods: All patients undergoing elective or emergency endovascular treatment of aortic arch and thoracic aortic pathologies, with no acceptable landing zone for standard TEVAR, between 1 January 2010 and 31 March 2024, at the University Hospital Düsseldorf, Germany were included. An acceptable landing zone was defined as a minimum of 2 cm for sufficient sealing. All patients were not suitable for open surgery. Patients were categorized by an endovascular treatment method for a comprehensive comparison of pre-, intra- and postoperative variables. IBM SPSS29 was used for data analysis. Results: The patient cohort comprised 21 patients, predominantly males (81%), with an average age of 70.9 ± 9 years with no acceptable proximal landing zone for standard TEVAR procedure. The most treated aortic pathologies were penetrating aortic ulcers and chronic post-dissection aneurysms. Patients were sub-grouped according to the applied procedure as follows: five patients with chimney thoracic endovascular aortic repair (chTEVAR), seven patients with in situ fenestrated thoracic endovascular aortic repair (isfTEVAR), six patients with custom-made fenestrated thoracic endovascular aortic repair (cmfTEVAR) and three patients with custom-made branched thoracic endovascular aortic repair (cmbTEVAR). Emergency procedures involved two patients. There were significant differences in the total procedure and fluoroscopy time, as well as in contrast agent usage among the treatment groups. cmfTEVAR had the shortest total procedure time, while chTEVAR exhibited the highest contrast agent usage. The overall mortality rate among all procedures was 9.5% (two patients) and 4.7% for elective procedures, respectively. Deaths were associated with either retrograde type A dissection or stent graft infection. Both patients were treated with chTEVAR. There was one minor and one major stroke; these patients were treated with isfTEVAR. No endoleak occurred during any procedure. The reintervention rate for chTEVAR was 20% and 0% for all other procedures during the in-hospital stay. The patients who were treated with cmfTEVAR had no complications, the shortest operating and fluoroscopy time, and less contrast agent was needed in comparison with other treatment methods. Conclusions: Complex endovascular procedures of the aortic arch with custom-made or surgeon-modified aortic stent grafts offer a safe solution, with acceptable complication rates for patients who are not suitable for open aortic arch repair. In terms of procedure-related parameters and complication rates, a custom-made fenestrated TEVAR is potentially advantageous compared to the other endovascular techniques. Full article