Search Results (197)

Introduction: Acute type A aortic dissection (ATAAD) is a rare but potentially catastrophic complication following transcatheter aortic valve implantation (TAVI). Most reported cases occur during or shortly after the procedure and are attributed to procedural aortic injury. Very late presentations occurring years after successful TAVI are exceptionally uncommon, and evidence regarding their optimal management remains limited. Case Presentation: An 86-year-old man presented with acute chest pain four years after transfemoral implantation of a self-expanding Evolut R 29-mm transcatheter heart valve. Transthoracic echocardiography revealed pericardial effusion with signs of impending cardiac tamponade. Computed tomography angiography confirmed Stanford type A acute aortic dissection involving the ascending aorta. Emergency surgical repair was performed through replacement of the ascending aorta and hemiarch using a vascular graft. The previously implanted transcatheter valve was preserved because it remained structurally intact and functionally normal. The postoperative course was uneventful, and the patient was discharged on postoperative day 9 with preserved prosthetic valve function (mean gradient 11 mmHg, peak velocity of 2.1 m/s, EOA 1.8 cm², EF 50%, TAPSE 18 mm and no evidence of paravalvular or intraprosthetic regurgitation). Discussion: To better contextualize this rare presentation, a focused review of the literature on delayed and late ATAAD after TAVI was performed. Only a limited number of cases were identified, highlighting the exceptional rarity of this complication. Reported management strategies included conservative treatment, endovascular interventions, and open surgical repair, with considerable heterogeneity in outcomes. Compared with previously published reports, the present case is notable for the exceptionally long interval between TAVI and dissection onset and for the successful valve-preserving surgical repair. These findings suggest that emergency surgery with preservation of a functioning transcatheter valve may be a feasible option in carefully selected patients. Conclusions: Very late ATAAD after TAVI is an exceptionally rare but life-threatening condition. This case demonstrates that valve-preserving surgical repair can be successfully performed even in selected octogenarian patients. As the population of long-term TAVI survivors continues to expand, awareness of late aortic complications, prompt diagnosis, and referral to specialized aortic centers remain essential for achieving favorable outcomes. Full article

Endovascular aortic aneurysm repair (EVAR) has become the first-line treatment for abdominal aortic aneurysms (AAA); however, its long-term durability is affected by Type II endoleak. This narrative review describes the evolution of sac filling techniques and concepts developed to address this complication. In selected cases of diagnosed Type II endoleaks, early therapeutic sac filling, while clinically indicated, is frequently constrained by difficult access, variable success rates, and recurrence. Consequently, prophylactic sac filling during primary EVAR has been adopted as an alternative approach, with reported high technical success and reduced endoleak incidence. The subsequent Nellix Endovascular Aneurysm Sealing (EVAS) system, although early results showed technical feasibility, was associated with graft migration, endobag separation, and reintervention at long-term follow-up, leading to its withdrawal from the market. Currently, devices based on shape memory polymer (SMP) provide early observations of decreased endoleaks and sac regression. This review outlines the transition from reactive management to preventive strategies, and, more recently, to patient-specific, material-based approaches, while showcasing emerging strategies that may influence long-term EVAR outcomes. However, these novel approaches remain under investigation, and larger controlled studies with extended follow-up are required to establish their clinical utility. Full article

Background: The right renal vein is about half the length of the right renal artery and is shortened further by endovascular stapling at laparoscopic donor nephrectomy. Right-sided living-donor grafts carry roughly twice the adjusted risk of delayed graft function and of early graft loss, a penalty absent from deceased donation, where the inferior vena cava accompanies the graft. The deficit is one of venous length, not of the organ; extension is the remedy, and no guideline specifies how the conduit should be obtained. Methods and cases: Three consecutive recipients of right living-donor kidneys had the renal vein extended with a deceased-donor iliac vein. Conduits were recovered at multiorgan retrieval from ABO-identical or ABO-compatible donors, immersed in University of Wisconsin solution at 4 °C, and used within seven days; elective right donor nephrectomy was booked to follow a suitable retrieval within that window. Extension was an end-to-end back-table anastomosis with continuous 5-0 or 6-0 polypropylene, converting a short-vein implantation into a routine end-to-side anastomosis to the external iliac vein. All three grafts functioned immediately, without venous thrombosis, technical graft loss, or delayed graft function; the last serum creatinine was 0.91, 1.22, and 1.42 mg/dL. Conclusions. A calibre- and ABO-matched deceased-donor iliac vein, held in University of Wisconsin solution at 4 °C and used within seven days, makes venous extension a scheduled step of an elective right living-donor operation and requires no cryopreservation infrastructure. Where a donor’s safety mandates right nephrectomy, a short right renal vein need not preclude donation. Three cases establish feasibility; the low thrombotic risk of venous extension rests on published series rather than on this report. Full article

Objective: The aim of this study was to evaluate the efficacy and safety of endovascular and hybrid treatment approaches in patients with aortic arch aneurysms. Materials and Methods. This retrospective study included 68 male and female patients with a confirmed diagnosis of either an aortic arch aneurysm or a descending thoracic aortic aneurysm with a short proximal landing zone (<1.5 cm) who underwent either hybrid or endovascular treatment at the Department of Vascular Surgery between January 2017 and December 2024. Study outcomes included a composite measure of technical success, a composite measure of in-hospital clinical success, and a composite measure of long-term treatment outcomes, including stroke, myocardial infarction, and aortic-related mortality. Results. All 68 patients were divided into two groups: Group I comprised patients who underwent endovascular treatment, whereas Group II included patients who underwent hybrid surgical treatment. The groups were comparable with regard to demographic and anatomical characteristics, clinical presentation, and comorbidities. The composite technical success rate (defined as successful target stent-graft deployment without conversion to open surgery and absence of type I or type III endoleaks) was comparable between the groups at the intraoperative stage (p = 1.000). The composite measure of in-hospital clinical success was achieved in 33 patients (94%) in Group I and 22 patients (67%) in Group II and was significantly higher in the endovascular group (adjusted p = 0.005). This difference was primarily attributable to a higher incidence of complications in the hybrid treatment group, including stroke (9%) and peripheral nerve injury (9%), associated with the open surgical component of the procedure. The mean follow-up duration was shorter in Group I (19.3 ± 10.4 months) than in Group II (63.9 ± 29.5 months), reflecting the fact that most patients in Group I underwent treatment during the later years of the study period. Although a difference in the composite long-term outcome measure was observed before adjustment (p = 0.031), this finding did not remain statistically significant after correction for multiple testing (adjusted p = 1.000). Conclusions. In this preliminary single-centre study, endovascular and hybrid approaches showed comparable technical efficacy in the early postoperative period. However, hybrid surgical treatment was associated with a less favourable safety profile during the early postoperative period, as reflected by the significantly lower in-hospital composite clinical success rate and longer hospital stay than in the endovascular group. These findings remained robust after correction for multiple testing. Long-term results should be interpreted with caution and require confirmation in larger prospective studies with longer and balanced follow-up periods. Full article

Physician-modified endografts (PMEGs) represent an important treatment option for urgent and semi-urgent complex abdominal aortic aneurysms (cAAAs). The Zenith Alpha Thoracic Endovascular Graft (Cook Medical, Bloomington, IN, USA) is a common choice for PMEGs due to its low strut interference, albeit at the cost of requiring removal of the proximal fixation barbs for resheathing—a process that remains technically challenging. The current article details a step-by-step approach on how to modify an Alpha thoracic endograft without requiring removal of the proximal barbs. The Zenith Alpha Thoracic Endovascular Graft is fully unsheathed on a sterile back-table and completely detached from the delivery system by removing the blue rotational handle. The grey positioner is removed from the introducer sheath. Next, a 0.018-inch guidewire is introduced distally through the inner positioner and retrieved via the exposed grey handle to function as a trigger wire. Following the creation and reinforcement of the fenestrations, circular diameter-reducing ties are constructed and secured using an insertion tool. The endograft is placed back on the delivery system and the guidewire is passed through the endograft fabric at the distal end and through the insertion tool, which is then removed. At the proximal end, the trigger wire is again passed through the endograft fabric, and both the proximal bare alignment stent and the distal end of the endograft are secured to the delivery system using 2-0 Prolene sutures (Ethicon Inc., Somerville, NJ, USA). The endograft is subsequently resheathed through the distal end of the introducer sheath using a tourniquet-assisted resheathing technique and a cut-off tip from an introducer sheath to guide the endograft’s passage through the valve. Using the current standardized modification protocol, a PMEG can be constructed using the Zenith Alpha Thoracic Endovascular Graft while preserving the active fixation barbs for the treatment of cAAAs. Full article

Background/Objectives: Blunt thoracic aortic injury (BTAI) is a rare, highly lethal trauma typically occurring at the aortic isthmus. Advanced BTAI is primarily treated with thoracic endovascular aortic repair (TEVAR). Because emergent surgical debranching is rarely feasible, management depends heavily on patient anatomy, especially regarding the left subclavian artery (LSA). Patient-specific computational fluid dynamics (CFD) models offer critical insights into periprocedural planning and outcome prediction. Methods: This study investigates hemodynamic changes in a patient-specific BTAI case following intentional LSA coverage by a stent graft. Three-dimensional patient-specific models were coupled with RCR-Windkessel boundary conditions for both pre- and post-procedural imaging data to simulate blood flow in each scenario. Results: Post-intervention, flow distribution improved significantly; relative perfusion to the brachiocephalic trunk and left common carotid artery increased by 3.51% and 4.02%, respectively, alongside an elevated overall pressure throughout the entire computational domain. However, regions with high oscillatory, low magnitude shear (HOLMES), specifically wall areas with values < 0.3 Pa, expanded post-stenting. This warrants careful monitoring during follow-ups, given the associated risk of thrombus formation. Furthermore, time-averaged swirling strength (TASS) variation along the aorta decreased (standard deviation dropped from 1.8610 to 1.3835), indicating stabilized flow within the stented region, while normalized swirling strength increased distally. Conclusions: This study establishes an effective, non-invasive framework for assessing pre- and post-TEVAR hemodynamics. It demonstrates that LSA coverage induces uniformly elevated pressure and alters wall shear stress and helicity indices, highlighting the need for future research into pharmacological management to optimize long-term outcomes. Full article

Popliteal artery aneurysms (PAA) lose their pulsatility once thrombosed and may therefore be mistaken for a Baker cyst or a soft-tissue tumor. A 58-year-old male presented with a 6-month history of progressive right popliteal swelling and pain, accompanied by right foot paresthesia and diminished distal pulses for two months. The presence of accompanying neurovascular deficits shifted the diagnostic consideration from a benign soft-tissue lesion to a vascular disorder. In this patient, non-contrast imaging protocol integrating grayscale ultrasound, power Doppler, and magnetic resonance imaging (MRI) successfully identified a chronically thrombosed popliteal artery aneurysm, supporting a vascular rather than neoplastic etiology. While ultrasound cannot replace contrast-enhanced MRI for definitive tissue characterization, its real-time capability established a vascular etiology and guided subsequent diagnostic digital subtraction angiography with urgent endovascular stent-graft reconstruction. Furthermore, serial ultrasonographic surveillance at three and 18 months confirmed long-term stent-graft patency and favorable aneurysmal sac remodeling. Neurovascular deficits accompanying a popliteal mass should redirect the workup toward vascular imaging. This case underscores a critical diagnostic pitfall, demonstrating that a stepwise strategy combining real-time ultrasound and non-contrast MRI ensures rapid definitive management for complex popliteal masses while preserving the unique role of sonography in non-invasive follow-up. Full article

Introduction: Major retroperitoneal arterial bleeding may remain clinically difficult to recognize when vital signs are initially stable. Case presentation: We report the case of a 67-year-old man who developed progressive abdominal and right groin pain radiating to the ipsilateral flank, accompanied by two episodes of vomiting and an early hemoglobin (Hb) and hematocrit decline on the first postoperative day after right-sided direct anterior total hip arthroplasty (THA). Despite the absence of hemodynamic instability, computed tomography angiography (CTA) demonstrated active contrast extravasation from the right external iliac artery (EIA) with a large retroperitoneal hematoma. CTA localized the bleeding source and enabled immediate endovascular treatment planning. Subsequent angiography confirmed active extravasation from the right EIA, and a covered stent–graft was deployed through ultrasound-guided superficial femoral artery access, achieving complete exclusion of the bleeding source with preserved arterial patency. The subsequent Hb nadir and transfusion were interpreted as reflecting preceding retroperitoneal blood loss rather than persistent bleeding, because follow-up CTA showed a stable hematoma without active extravasation. The patient was discharged in stable condition, and 1-month duplex ultrasound and following 3-month CTA confirmed stent–graft patency. Discussion: This case highlights the diagnostic mismatch that may occur between substantial retroperitoneal blood loss and initially reassuring hemodynamic findings. When progressive abdominal or groin symptoms are accompanied by a serial, otherwise unexplained Hb decline, CTA may be more informative than DUS for suspected deep pelvic bleeding because it can identify active extravasation, define hematoma extent, assess alternative abdominopelvic causes, and support treatment planning. In anatomically suitable lesions, covered stent–graft repair can rapidly control hemorrhage while preserving EIA patency. Conclusions: Stable vital signs do not exclude major retroperitoneal arterial bleeding after direct anterior THA. Progressive abdominal or groin pain with early postoperative Hb decline should raise suspicion for occult vascular injury, for which CTA can provide rapid diagnosis and guide immediate endovascular management. Full article

Background: Arteriovenous fistula is an abnormal connection between an artery and a vein. Post-traumatic fistulas are uncommon and usually occur after penetrating injuries, including gunshot wounds. Cervical arteriovenous fistulas are particularly rare and may coexist with a pseudoaneurysm, creating diagnostic and therapeutic challenges because of the proximity of major vascular, neurological, and aerodigestive structures. In hemodynamically stable patients, the limited external appearance of the wound may underestimate the extent of internal vascular injury; therefore, imaging is central to diagnosis and treatment planning. Case Presentation: We report the case of a 49-year-old man who presented to the emergency department with a gunshot wound to the left side of the neck. Computed tomography angiography (CTA) demonstrated a vascular injury adjacent to the left common carotid artery (LCCA), and further evaluation revealed an arteriovenous fistula (AVF) between the LCCA and the left internal jugular vein (LIJV), coexisting with a pseudoaneurysm of the LCCA. Doppler ultrasonography (DUS) identified an arterial wall defect and extrinsic compression of the LCCA by the hematoma. Selective digital subtraction angiography (DSA) confirmed an AVF between the LCCA and the LIJV, coexisting with an LCCA pseudoaneurysm. A covered stent-graft was implanted and completion angiography confirmed exclusion of both lesions with preserved patency of the LCCA. Discussion: This case demonstrates the complementary value of CTA, DUS and DSA in penetrating neck trauma. CTA provided rapid cross-sectional assessment of the injury trajectory and associated lesions, DUS added information on the arterial wall and local hemodynamic consequences, and DSA confirmed arteriovenous shunting while enabling immediate endovascular treatment. Conclusions: In hemodynamically stable patients with penetrating neck trauma, CTA should be considered when the wound trajectory approaches major vessels, even in the absence of active external bleeding. DUS and DSA may provide complementary information for lesion characterization and procedural planning. Covered stent-graft implantation may be a feasible reconstructive option in carefully selected patients. Full article

A 64-year-old woman presented with recurrent abdominal pain and rapid weight loss of 10 kg. Five years prior, an abdominal endovascular aneurysm repair (EVAR) was performed, followed by an open repair with proximal graft interposition due to an endoleak type IA two years ago. Laboratory tests revealed only moderately elevated infection markers (CrP 66 mg/L, WBC 14 GPt/L). ¹⁸F-FDG PET/CT showed a hypermetabolic peri-aortic mass initially suspected to be inflammatory. However, the patient did not exhibit signs of fever. Because of the equivocal constellation, a fine-needle biopsy was conducted, revealing malignant cells. The patient underwent complete tumor resection including aortic replacement. Histopathology confirmed the diagnosis of an angiosarcoma. The treatment was then supplemented with chemotherapy using doxorubicin and ifosfamide. Full article

Background and Objectives: The Ankura stent graft was introduced in Europe in 2015 for the endovascular repair of infrarenal abdominal aortic aneurysms (AAAs). Evidence regarding its long-term efficacy remains limited. This study presents eight years of clinical experience with the Ankura endograft for endovascular aneurysm repair (EVAR) at a tertiary university vascular center. Materials and Methods: This single-center retrospective study included patients who underwent elective EVAR with the Ankura endograft between January 2015 and January 2023. All patients were anatomically suitable according to the instructions for use (IFU). Computed tomography angiography was performed at 1 and 12 months and annually thereafter during follow-up; the surveillance protocol was subsequently modified to use duplex ultrasound. Primary outcomes were categorized as early (technical success, clinical success, and 30-day mortality and morbidity) or late (aneurysm-related and non-aneurysm-related mortality). Results: A total of 220 patients were included (211 men [95.9%]); the mean age was 71.41 years (range, 49–87 years); and the mean aneurysm diameter was 59.15 mm (range, 32–109 mm). Primary and secondary technical success rates were 97.3% and 100%, respectively, and the clinical success rate was 96.8%. Thirty-day morbidity and mortality rates were 6.3% and 0%, respectively. No perioperative conversions occurred. The mean follow-up duration was 51.76 months (range, 1–131 months). Freedom from reintervention at 24, 36, 48, and 72 months was 98.2%, 97.7%, 97.2%, and 95.9%, respectively. Iliac limb patency was 99.5%. Aneurysm-related and non-aneurysm-related mortality during follow-up were 2.2% and 20.45%, respectively. Conclusions: In this study, the Ankura AAA stent graft demonstrated durable efficacy, with a high iliac limb patency rate, a low reintervention rate, and low aneurysm-related mortality during follow-up. Its long-term efficacy and safety should be evaluated in larger studies. Full article

This case demonstrates the efficacy and feasibility of visceral–renal debranching with endovascular repair for the treatment of a distal stent graft-induced new entry (dSINE) that occurred 47 months after a frozen elephant trunk procedure in a patient with chronic aortic dissection type B. There were no perioperative complications. Postoperative computed tomography scans confirmed sealing dSINE and the patency of visceral and renal arteries. Full article

Background: Endovascular repair with covered stent is an established minimally invasive treatment for popliteal artery lesions, particularly in elderly or high-risk patients. Infectious complications are exceptionally rare but may result in arterial destruction, limb loss, and death. Salmonella species demonstrate a well-recognized affinity for diseased arterial walls and prosthetic vascular material. Case Presentation: An 82-year-old man with stage G4 chronic kidney disease and previous nephrectomy for renal cell carcinoma, complicated by Salmonella Enteritidis septic shock 20 years earlier, presented with acute left lower limb ischemia caused by a post-traumatic popliteal artery pseudoaneurysm. Urgent endovascular repair was performed using a 6 × 100 mm covered stent (Viabahn) with adjunctive angioplasty of the anterior tibial artery. Two weeks later, he was readmitted with fever, severe popliteal pain, local erythema, and elevated inflammatory markers. Imaging demonstrated early stent occlusion with a large peri-graft abscess and contained arterial rupture. Emergency open conversion included radical debridement, complete graft explantation, and popliteal-to-posterior tibial bypass using an autologous great saphenous vein. Cultures grew Salmonella Enteritidis. Retrospective history revealed a previously undocumented episode of Salmonella Enteritidis bacteremia approximately 20 years earlier. At 2-year follow-up, the patient remained free of recurrent infection with a patent vein graft and preserved ambulatory function. Conclusions: Early Salmonella Enteritidis infection of a popliteal covered stent is an exceptionally rare but life-threatening complication. This case suggests that remote Salmonella bacteremia may represent a potential, hypothesis-generating risk factor for prosthetic graft infection. Prompt graft explantation followed by radical debridement and autologous venous reconstruction remain essential for durable limb salvage. Full article

Post-dissection thoracoabdominal aortic aneurysm (PD-TAAA) is a late sequela of chronic aortic dissection. Complex endovascular aneurysm repair (EVAR), including fenestrated and branched techniques (F/B-EVAR), enables aneurysm exclusion while preserving visceral perfusion; however, bridging stents are not specifically designed for PD-TAAA and are frequently used off-label. Evidence on bridging stent performance is largely derived from degenerative aneurysm cohorts, and PD-TAAA-specific data remain limited. This study evaluated outcomes of the VBX Stent Graft when used as a bridging stent during F/B-EVAR for PD-TAAA. This retrospective analysis included patients with PD-TAAA from the EMBRACE registry (ClinicalTrials.gov: NCT05143138), a multicenter, single-arm registry with retrospective and prospective components, with all outcomes core-laboratory-adjudicated. Procedural, early (thirty-day), and midterm outcomes at one and three years were assessed. The primary endpoints were all-cause mortality and freedom from target vessel instability, defined as loss of durable target vessel reconstruction. Twenty-one patients (mean age 61.5 years; range, 28–77 years) underwent F/B-EVAR with at least one VBX Stent Graft. In total, 82 visceral arteries were treated, of which 51 were bridged with a VBX Stent Graft. Technical success was 100%. Two serious adverse events occurred perioperatively, one requiring reintervention, with no thirty-day mortality or major adverse events. Freedom from all-cause mortality was 95.2% at one year and 90.5% at three years, with two deaths during follow-up. Freedom from target vessel instability at the patient level was 85.7% at both one and three years (95% CI, 62.0–95.2%). VBX Stent Grafts used as bridging stents during F/B-EVAR for PD-TAAA demonstrated high technical success, low early morbidity and mortality, and acceptable mid-term survival and target vessel stability, supporting their use in this challenging anatomical setting within the limitations of a small PD-TAAA cohort. Full article

Background: Thoracic endovascular aortic repair (TEVAR) is an established minimally invasive approach for selected aortic arch pathologies; however, it is associated with risks including stroke and spinal cord ischemia. Revascularization techniques, such as in situ fenestration (ISF), play a critical role in preserving supra-aortic branch perfusion and reducing neurological complications. Methods: This prospective, single-center observational cohort study enrolled 74 consecutive patients undergoing TEVAR with ISF between October 2017 and September 2023. Data collected included demographics, lesion morphology, procedural details, and clinical outcomes. The primary endpoint was procedural technical success; secondary endpoints included 30-day complications, reintervention rate, and all-cause mortality. Results: Technical success was achieved in 100% of cases (74/74; 95% CI: 95.2–100.0%), defined as successful fenestration creation, patent bridging stent graft without kinking or embolization, absence of Type I or III endoleak on completion angiography, and restored antegrade branch flow. Physician-modified fenestration was combined with ISF-thoracic endovascular aortic repair (TEVAR) in 28.4% (21/74) of cases. At 30-day follow-up, 30-day clinical success (freedom from mortality, reintervention, and procedure-related complications) was achieved in 87.8% (65/74) of patients. No mortality was recorded at 30 days. Treatment-related complications included subclavian branch thrombosis (n = 1, 1.4%), transient ischemic attack (n = 1, 1.4%), and endoleaks (n = 7, 9.5%; including Type Ia, Type II, and Type III), with reintervention required in 6 patients (8.1%) during the follow-up period. Beyond 30 days, three late deaths were documented: one aorta-related death (aneurysm rupture at 9 months), one neurological death (ischemic stroke at 13 months), and one cardiovascular death (myocardial infarction at 60 days post-procedure), yielding a late all-cause mortality rate of 4.1% (3/74). Conclusions: ISF-TEVAR demonstrated a high procedural technical success rate and a low 30-day complication and mortality profile in this single-center prospective series of selected patients treated at an experienced center. These early and mid-term results are encouraging; however, given the single-center, non-comparative design and limited standardized follow-up, broader conclusions regarding durability and comparative effectiveness remain premature. Larger multicenter prospective studies with standardized long-term imaging follow-up are warranted. Full article