Search Results (236)

Colonic ischemia (CI) is a serious and potentially fatal complication after major abdominal vascular surgery. This literature review explores the pathogenesis, risk factors, diagnostic methods, and preventive strategies associated with CI, emphasizing the differences between emergency and elective treatments. Early diagnosis through clinical signs and instrumental diagnostics, such as sigmoidoscopy and computed tomography, is crucial. Preventive measures, including preoperative evaluation and perioperative management, are emphasized to reduce the incidence of CI. The results of different studies suggest that endovascular aneurysm repair (EVAR), both emergency and elective, has lower risks of ischemic complications than open surgical repair (OSR), as well as better survival for patients. Further research and standardized clinical guidelines are needed to improve patient outcomes and minimize CI severity. Full article

Background/Objective: Sarcopenia is a predictor of poor surgical outcomes in older adults. The Psoas Muscle Index (PMI), calculated from routine preoperative CT scans, has been proposed as an imaging-based marker of physiological reserve, but its diagnostic utility in vascular surgery remains unclear. We aimed to assess the predictive value of PMI for early complications following elective abdominal aortic aneurysm (AAA) repair in two European centers. Methods: We retrospectively analyzed 245 patients who underwent open or endovascular AAA repair between 2018 and 2022 in Poland and The Netherlands. PMI was measured at the level of third lumbar vertebrae (L3) level, normalized to height, and stratified into center-specific tertiles. Early complications were compared across tertiles, procedures, and centers. Multivariate logistic regression was used to adjust for age, comorbidities, and procedure type. Results: Low PMI was significantly associated with early complications in EVAR patients at the Polish center (p = 0.004). No associations were found in open repair or at the Dutch center. Mean PMI values did not differ significantly between centers. Conclusions: PMI may serve as a context-dependent imaging biomarker for early risk stratification following AAA repair, particularly in endovascular cases. Its predictive value is influenced by institutional and procedural factors, highlighting the need for prospective validation and standardization before clinical adoption. Full article

Background/Objectives: There are no reports about the nationwide trends in abdominal aortic aneurysm (AAA) repair and mortality rates. This study aims to evaluate the trend in AAA treatment and related mortality, including ruptured AAAs (rAAAs) and intact AAAs (iAAAs) over the last 13 years. Methods: This serial, cross-sectional study investigated the time trends in patients who were treated for an AAA and underwent an aneurysm repair between 2010 and 2022. Data from the Health Insurance Review and Assessment Service (HIRA) and Statistics Korea were used. A linear-by-linear association and Poisson regression analysis were performed to determine the changes in the treatment of AAAs and related mortality. Results: The number of patients with an rAAA increased from 462 in 2010 to 770 in 2022 (relative risk, RR 1.57; p < 0.0001). The number of patients with an iAAA increased from 3685 to 12,399 in the same period (RR 3.16; p < 0.0001). Endovascular aneurysm repair (EVAR) has been more commonly performed since 2011. During the study period, EVAR increased from 406 to 1161 (RR 2.68; p < 0.0001). Although the annual mortality rates after iAAA treatment decreased from 1.4% to 0.7% (mean mortality rate, 1.1%), the mortality rates after rAAA treatment were similar, ranging from 34.6% to 34.2%, during the study period (mean mortality rate, 35.2%). Conclusions: During the last 13 years, the annual number of patients with rAAAs and iAAAs has increased. Since 2011, EVAR has been more commonly performed. The annual iAAA-related mortality rate decreased along with the increasing trend in EVAR. However, the annual rAAA-related mortality rate did not change. Full article

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

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

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: Wide and conical-shaped infrarenal necks are risk factors for neck-related complications after Endovascular Aorta Aneurysm Repair (EVAR). The aim of this study is to investigate the performance of the Endurant endoprosthesis in wide/conical-shaped aortic neck anatomies compared to its performance in a normal infrarenal neck (reference group). Methods: A single-center, retrospective observational cohort study was performed, including consecutive subjects with an infrarenal abdominal aortic aneurysm, treated electively with an Endurant endoprosthesis. The primary endpoint was the freedom from aneurysm-related reinterventions through 1 year. Secondary endpoints included proximal fixation failure, type IA endoleak, stent migration, aneurysm sac remodeling, aneurysm-related mortality, freedom from reinterventions throughout available follow-up, and rupture. Results: A total of 268 patients were included, with a mean age of 73.3 years, and 85.1% were male. Freedom from aneurysm-related reinterventions was significantly lower in the wide-neck group (60.0%) compared to the reference group (81.1%; p = 0.018) but not for the conical-neck group (70.3%; p = 0.286). Median time to first reintervention was 1.7 (IQR 0.8; 4.4 years) in the reference group, 2.9 years (IQR 0.3; 5.0 years) in the wide-neck group (p = 0.547) and 3.8 years (IQR 0.4; 6.5) in the conical-neck group (p = 0.123). The proximal fixation failure rate was 7.4% in the wide-neck group compared to 3.3% in the reference group (p = 0.155) and 1.7% in the conical-neck group (p = 0.525). The type IA endoleak rate was 4.9% in the wide-neck group versus 3.3% in the reference group (p = 0.250). Conclusions: In the group with wide necks, reintervention-free survival was lower compared to the reference group, which seems to be driven by proximal fixation failure. Full article

Objective: Endovascular repair of visceral artery aneurysms (VAAs) and visceral artery pseudoaneurysms (VAPAs) using covered stent grafts is a novel technique that preserves efferent vessel patency and prevents end-organ ischemia; however, long-term results are lacking in the literature. This study aims to evaluate ultra-long-term outcomes (>5 years) using CT angiography (CTA) and technical aspects of covered stents in treating VAAs and VAPAs. Methods: A single-center retrospective study was conducted on patients with VAAs and VAPAs treated with stent grafts between 2004 and 2023. The study included an ultra-long-term follow-up using CTA. Stent graft patency, aneurysm characteristics, technical success, 30-day and long-term follow-up clinical success, and mortality were assessed. Results: Among 23 patients presenting with VAAs and VAPAs treated exclusively with covered stents implantation, 7 (mean age: 68 years, SD 14), including 5 with VAAs and 2 with VAPAs, met the inclusion criteria for the study. Six of the seven patients underwent elective procedures with no significant periprocedural complications. Both technical and 30-day clinical success rates were 100%. The mean follow-up period was 10 years (125 months SD 53). At the 5-year follow-up, 71% of stent grafts remained patent. No patient experienced aneurysm sac revascularization or rupture. Stent obstruction did not affect survival. Conclusions: This study demonstrates that endovascular covered stenting is a durable and effective treatment for VAAs and VAPAs, even in the ultra-long term, with a patency rate of 71% at a mean CTA follow-up of 125 months, the longest reported to date and no cases of sac revascularization. Stent thrombosis was significantly associated with VAPAs. Full article

Background/Objectives: Aortic stiffness is a strong independent factor in cardiovascular outcomes. The method of choice for evaluating aortic stiffness is the measurement of aortic pulse wave velocity (PWV). Endovascular aortic repair (EVAR) increases aortic rigidity and thus aortic stiffness. The aim of this study is to investigate the correlation between endograft length and post-operative increases in PWV in patients with abdominal aortic aneurysms (AAAs) subjected to EVAR. Methods: A prospective observational study enrolling 107 patients from February to December 2025 was conducted. Patient demographics and comorbidities were recorded. The length of the endografts was calculated by studying computed tomography angiograms (CTAs) and digital subtraction angiographies (DSAs) of the patients. PWV was measured pre-operatively and post-operatively during the first 24 h after EVAR, and the difference in PWV (dPWV) was calculated. Results: The mean age of the patients was 72 ± 7.5 years, and 93.5% of them were males. The mean transverse AAA diameter was 5.7 ± 1.1 mm, and the mean endograft length was 169.7 ± 26.9 mm. An extension to the external iliac artery was deployed in 10 patients (9.3%). A strong positive correlation was observed between dPWV and endograft length, indicating that each additional 1 mm in graft length corresponded to a 0.541% increase in dPWV. Patients with an extension to external iliac arteries exhibited a significantly higher mean dPWV (9.95 ± 2.08% vs. 27.12% ± 12.15%, t = −4.463, p = 0.002). No statistically significant differences in dPWV between the different endograft types were found (p = 0.74). Conclusions: Endograft length is strongly related to PWV elevation during the immediate post-operative time after EVAR, especially when the endograft is extended to the external iliac arteries. Full article

Background/Objectives: Our aim was to assess the feasibility of hyperspectral imaging (HSI) to detect changes in tissue oxygenation (StO₂) of the back, as non-invasive spinal cord collateral network (CN) monitoring during staged endovascular repair (ER) of thoracoabdominal aortic aneurysm (TAAA). Methods: Between September 2019 and June 2021, 20 patients were treated for TAAA and underwent HSI. They were randomized 1:1 to minimally invasive staged segmental artery coil embolization (MIS2ACE) (n = 10) and staged stentgraft implantation (n = 10) as priming methods. HSI of paravertebral regions was taken during each procedure and up to 10 days after. The primary endpoint was the identification of StO₂ changes after ER of TAAA. Results: TAAA Crawford Type II (n = 17) and Type III (n = 3) were treated. After stentgrafting, StO₂ increased immediately (p < 0.001), followed by a decrease after 5 days (p < 0.001) and 10 days (p = 0.028). StO₂ was significantly higher in the thoracic compared to the lumbar region. There was no significant difference between MIS2ACE and the first stentgrafting for StO₂ (p = 0.491). Following MIS2ACE, definitive ER caused a significant decrease in StO₂ after 5 days (p = 0.021), which recovered to baseline after 10 days (p = 0.130). After stentgraft priming, definitive ER caused a significant decrease in StO₂ after 24 h (p = 0.008), which did not return to baseline after 5 (p < 0.001) and 10 days (p = 0.019). Conclusions: HSI detected significant changes in StO₂ in the thoracic and lumbar paravertebral regions during ER of TAAA. These preliminary data suggest the efficacy of MIS2ACE in priming the CN before ER of TAAA. Full article

(1) Background: Renal artery occlusion after F/B EVAR for abdominal aortic aneurysm is a serious complication that may require re-intervention, and understanding the hemodynamic mechanisms by which it occurs is essential to optimize the surgical procedure. (2) Methods: We used computational fluid dynamics (CFD) to analyze the impact of various parameters on blood flow. Theoretical vascular models were constructed based on the common dimensions and angles of aortic stents and branch arteries in clinical practice. Actual case models were constructed from CT image data of six patients treated with F/B-EVAR. Data were collected for analysis after simulation and calculation by FLUENT software. (3) Results: Theoretical model simulations showed that a larger tilt angle of the branch stent, smaller branch entry depth, and larger branch stent diameter were beneficial for blood flow. In the case models, a significant difference in the tilt angle of the renal artery stents was observed between the high- and low-flow groups, while the differences in entry depth and branch stent diameter were not significant. Occluded renal arteries had lower WSS values than patent ones. (4) Conclusions: This study offers valuable guidance for optimizing stent placement in F/B EVAR to mitigate renal artery occlusion risk. 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