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This report provides an (retrospective) assessment of mid term outcomes in an institutional cohort. (1/2020- 6/2024) of 77supra aortic debranching procedures
The total endovascular approaches to the aortic arch are now technicaly available.
long term outcomes, and durability for both groups of (open & total endovascular repaire) are still unansweard questions.
regard to feasibility, stroke rates is the hybrid management of complex diseases of the aortic arch and descending thoracic aorta still the first choice.

Supra aortic Debranching Procedures in 77 Patients According to the Landing Zone:
Zone 1 (n=23) RCCA-LCCA-LSA bypass
Zone 2 (n= 54)
LCCA-LSA bypass/(transposition n=2)
57% cases as a single procedure
43% staged procedures
27% patients had a spinal drain
13% emergency setting
Revisions n=3 (Left Carotid-subclavian Bypass)

Primary technical success was achieved in 76 (98%) cases.
In 2 zone 2 case, a type Ia endoleaks seen and successfully managed with a proximal cuff extension
No conversion to open surgical arch repair was required in any of the cases performed.
Three (3.8%) patients died in hospital (1 of 67 elective and 2 of 10 emergency cases), one staged patient died following an uncomplicated debranching procedure (RCCA-LCCA-LSA bypass) as a result of MI 10 days postoperatively.
2 (2.6%) patients had a TIA following their procedure, one elective and one of the emergency patients.

Hybrid repair of the aortic arch is a feasible technique even for challenging aortic pathologies, with acceptable success rates and 30-day mortality.
There is a low rate of reintervention when hybrid techniques are used to create an adequate proximal landing zone, and extra anatomic bypass grafts have a good long term patency rate.
The results may suggest that procedures should be extend proximally into zone 1 if there are doubt about the suitability of a landing in zone 2/3
The perioperative rates of Stroke/TIA (2.6%) are comparable to those previously reported and probabely superior to open, and total endovascular procedures.
Chimney grafts implantations are associated with a significant type Ia endoleak rate of 15% to 20%, „via falsa?!“
The total endovascular approach to the arch has been described as a feasible alternative.
Excellent alternatives for LSA
In zones 0&1 the music is more dramatic
It is safe to considre the excellent hybrid procedures

Physician-modified endografts (PMEGs) are increasingly used to treat complex abdominal aortic aneurysms (cAAA) and aortic dissections, especially when custom-made grafts are unfeasible. Despite their growing use, PMEGs lack standardization and are influenced by practitioner experience and institutional resources.

A global cross-sectional survey was conducted using the EDDDIE platform, with 31 questions across six sections covering practitioner demographics, indications, device selection, planning, technical preparation, and free-text comments. Invitations were sent to 4,286 vascular specialists, supplemented by targeted outreach through professional platforms and social media. Participants were not anonymous to enhance accountability for their responses. Responses were analysed using descriptive statistics and subgroup analyses to identify variations in practice patterns based on procedural expertise and geographic location.

Results: Of the 1,542 respondents who accessed the survey, 227 from 30 countries completed it. Among participants, 40% reported limited PMEG experience, while 25% had performed over 30 procedures. PMEGs were most commonly selected for symptomatic cAAAs, ruptured juxtarenal AAAs, and perforating aortic ulcers. Confidence in addressing challenging anatomies, such as small target vessel diameters or severe stenosis, was significantly higher among practitioners with greater experience. Thoracic grafts were the most frequently used devices (52%), followed by bifurcated abdominal endografts (30%). Approximately 67% of respondents did not use 3D-printed templates, though 22% employed them routinely, often with in-house printing capabilities. Planning preferences for minimal proximal sealing zones varied widely, with 33% opting for at least 20 mm. Amognst technical modifications, preloading vessel fenestrations and using reducing ties showed significant variability based on practitioner experience.

This study underscores the variability in PMEG practices and the need for standardization to enhance accessibility and patient safety. Findings provide a foundation for further efforts to develop practice recommendations based on the areas of uncertainty.

To evaluate the clinical application and outcomes of a physician-modified endograft (PMEG) based on a fenestrated custom-made device (CMD) from COOK Medical with one reinforced fenestration and prefabricated diameter-reducing ties for the treatment of complex abdominal aortic aneurysms.

All patients treated with PMEGs with a CMD with a single fenestration were included in the study. The single prefabricated fenestration was located 57 mm from the proximal edge. Two proximal diameters (34 mm and 36 mm) tapered to 22 mm distally, with tapering beginning 67 mm from the top and extending 40 mm were used. All grafts had a fixed length of 160 mm.

Ten patients (74 years IQR 5,25year; 8 male (80%)) were included. Indications included degenerative abdominal aortic aneurysms (n=6 (60%)), penetrating aortic ulcers (n=2 (20%)), and mycotic aneurysms (n=2 (20%). Three (30%) presented with contained rupture, six (60%) were symptomatic without rupture, and one (10%) was asymptomatic. Median diameter of the aneurysm was 53mm (IQR 29mm)
Physician modification involved creation of three additional fenestrations in nine cases and four in one case, all reinforced with Goose Snare wire and secured with sutures. Target vessels were successfully incorporated in all patients. The median operating time was 208.5 min (IQR: 104 min), while the median modification time was 71.5 min (IQR 40.5 min)
Postoperative CT revealed one type III endoleak, one type Ib, and two type II endoleak. In-hospital mortality was 20%, both in patients with ruptured mycotic aneurysms. One patient underwent reintervention for the type III endoleak with a Palmaz stent. Eight are under follow-up with patency of all target vessels and have returned to baseline functional status.

Use of a simplified PMEG with one prefabricated fenestration and diameter-reducing ties is feasible and offers favorable early outcomes with technical advantages in modification and deployment.

In the past decades, endovascular treatment of abdominal aortic- and iliac artery aneurysms using dedicated branched and fenestrated endografts has greatly expanded. However, the use of these devices in complex arterial morphologies cannot always be offered to patients unfit or unsuitable for open surgical repair. In the literature, ISF is described as a treatment alternative for this challenging patient cohort. However, there is only limited data concerning the acute and mid-term results of this endovascular procedure.

In situ fenestrations for treatment of complex aorto-iliac and isolated iliac artery aneurysms was performed in patients unsuitable neither for open repair nor for a conventional endovascular approach. Duplex ultrasound, and CT scans were used for the evaluation of branch patency and for endoleak detection at 3 to 6 months, and 1- and 2 years post procedure.

Fourteen consecutive patients with at least one in situ fenestration during endovascular repair of an infrarenal aortic aneurysm (N=11) or isolated iliac artery aneurysm (N=3) were included in this registry. Fifteen in situ fenestrations were performed to preserve antegrade blood flow into the hypogastric (N=12), renal (N=2), and accessory renal arteries (N=1), respectively. The 1- and 2-year examinations showed patent branches in all patients. One type III and 1 type Ia endoleak of a hypogastric artery were successfully treated by an endovascular procedure at 1-and 2 years, respectively.

This study indicates that in situ fenestration during endovascular repair of infrarenal aortic- and iliac artery aneurysms is feasible, and reveals promising mid-term patency, and a low rate of branch-related endoleaks. However, despite these promising results, in situ fenestration is likely to be used only as a rescue procedure in the treatment of aorto-iliac aneurysms.

To evaluate the effects of median arcuate ligament (MAL) compression on celiac artery (CA) outcomes after fenestrated/branched endovascular aortic repair (f/b-EVAR) for pararenal (PRAA) and thoracoabdominal aortic aneurysms (TAAA).

We conducted a retrospective cohort study of 107 patients who underwent f/b-EVAR with CA incorporation between January 2021 and December 2023. Inclusion criteria were PRAA or TAAA requiring CA incorporation. Exclusion criteria included chronic CA occlusion, scallop-based repair, or unstented CA reconstruction. Patients were categorized into MAL-positive (MAL+) and MAL-negative (MAL−) groups based on preoperative computed tomography angiography (CTA), with MAL severity (A–C) determined by degree of stenosis and CA deflection distance. Primary outcomes included procedural characteristics, device use, CA patency, and vessel instability.

Devices used included physician-modified endografts (16.5%, N=18), commercially available T-branch devices (24.8%, N=27), and custom-made devices (58.7%, N=64). Of the cohort, 37 patients had asymptomatic CA compression (MAL+) and 70 were MAL−. MAL+ patients had significantly steeper CA exit angles (39.7° vs. 50.5°, p=0.01) and a higher incidence of ≥70% CA origin stenosis (29.7% vs. 11.3%, p=0.02). However, no significant differences were found with regard to operative time (260±88 vs. 244±65 minutes, p=0.29), estimated blood loss, CA instability (10.5% vs. 5.8%, p=0.37) or reintervention rate (5.3% vs. 5.8%, p=0.91). Subgroup analyzes according to MAL grade and bridging stent type showed no significant differences in results (p=0,536).

Despite the anatomic complexity associated with MAL compression, CA patency and mid-term outcomes after f/b-EVAR were not affected. These results emphasize the importance of thorough preoperative planning, appropriate device selection, and precise technical execution. Our results refute previous concerns regarding MAL-related risks in aortic repair and highlight the need for prospective studies to validate long-term durability and optimize interventional strategies

Our aim was to investigate clinical and radiographic differences between male and female patients presenting with acute type B aortic dissections.

Between 04/2009 and 06/2021, 196 patients (127 male, 69 female) with acute type B aortic dissection were treated at a single aortic center. High-resolution CT scans were analyzed using multi-planar reconstruction software. Patient characteristics and radiographic findings were compared by sex. Multivariable regression assessed aortic interventions and mortality.

Age did not differ significantly between sexes (p = 0.3). However, females had a higher incidence of heritable thoracic aortic disease (16% vs. 5.5%; p = 0.016) and acute aortic rupture (22% vs. 6.8%; p = 0.003). False lumen patency in the descending thoracic (p = 0.066) and abdominal aorta (p = 0.081), as well as true and false lumen perfusion of abdominal branch vessels, were comparable between groups.

Male patients had significantly larger absolute aortic lengths and diameters, reflecting their greater height and weight (p < 0.001), but relative true lumen diameter did not differ between sexes. Treatment rates were similar (p = 0.9), with early intervention (<30 days) in 49%, including frozen elephant trunk (7.7%), open descending aortic replacement (0.5%), and TEVAR (41%).

In competing risk regression, sex was not a predictor of aortic intervention (p = 0.9). Significant predictors included heritable thoracic aortic disease (p < 0.001), the number of communications (p = 0.005), and absolute aortic diameter (p <0.001). However, in our multivariable regression analysis, sex was identified as a predictor of all-cause mortality (p = 0.02). While there was no statistically significant difference in 30-day mortality (p = 0.5), 1-year mortality was higher in women (12% vs. 3.9%; p = 0.067) and over a 5-year follow-up period, women exhibited significantly worse survival (Figure 1, p = 0.016).

Dissection details, treatment and cardiovascular risk profile did not differ significantly between male and female patients. Nevertheless, female patients exhibited significantly worse survival over a 5-year follow-up period, despite comparable 30-day mortality, intervention rates, and types of interventions. These findings suggest that women may require more frequent follow-up and could have a greater need for earlier re-interventions to improve survival outcomes.

Treatment of juxta - and pararenal abdominal aortic aneurysms (J/PAAA) presents significant challenges due to the complex anatomy of the aneurysm neck. While fenestrated endovascular aortic repair (FEVAR) has emerged as an alternative to open surgical repair (OSR), limited mid- and long-term data comparing both modalities exists. This study aims to compare outcomes between FEVAR and OSR for management of J/PAAA in a large cohort from 10 centers in 5 countries.

Multicenter, retrospective cohort study including patients undergoing elective repair of J/PAAA between January 2017 and December 2022. Data including demographic and aneurysm characteristics, treatment details, and outcomes, including major adverse events, TIA/Stroke, myocardial infarction, renal failure, ischemic colitis, spinal cord ischemia, death, re-intervention) were collected. Primary endpoints were mid-term mortality and reintervention rates, while secondary endpoints included 30-day mortality and reintervention rates. Statistical analysis was performed using SPSS version 26.0. Survival analysis was performed with Kaplan-Meier curves and Cox regression.

A total of 714 patients were included, of which 399 (55.9%) underwent FEVAR and 315 (44.1%) OSR. The mean follow-up in the FEVAR group was 28.0 ± 21.2 months and 23.7 ± 20.8 months in the OSR group (p = .009). Thirty-day mortality was low in both groups (1.5% for FEVAR vs. 1.0% for OSR; p = 0.738), and there were no differences in short-term reinterventions (9.0% FEVAR vs. 6.3% OSR, p=0.209). However, reintervention-free survival at 1, 3- and 5- years was significantly lower for patients undergoing FEVAR in comparison to OSR (89.4%, 81.7% and 74.0% after FEVAR vs 98.4%, 97.7% and 96.4% after OSR; log-rank p < .001). Long-term mortality was also higher after FEVAR (13.5% vs. 6.3%, p = 0.002), with survival rates at 1, 3 and 5 years of 94.7%, 86.3% and 72.2% after FEVAR vs. 95.7%, 90.5% and 87.0% after OSR (Log-rank, p = .039).

FEVAR and OSR are both associated with good perioperative outcomes in the treatment of elective J/PAAA. However, FEVAR is associated with a higher incidence of long-term reinterventions and overall mortality, which could be due to a more elderly and comorbid patient cohort. Further studies are needed to refine patient selection and optimize long-term outcomes for complex aneurysm repairs.

Objective: To examine trends in treatment methods and perioperative outcomes for intact and ruptured complex abdominal aortic aneurysms (cAAA) across six countries over a five-year period.
Design: Multinational, registry-based, observational study within the VASCUNET framework, utilizing data from six vascular registries.

This study used aggregated data from vascular registries in Australia, Denmark, Finland, New Zealand, Sweden, and Switzerland. Patients treated with open repair (OR) and fenestrated (or branched) endovascular aortic repair (F/BEVAR) for intact and ruptured cAAA between 2018-2022 were included. The primary outcome was perioperative mortality (30-day or in-hospital). Weighted perioperative mortality rates with 95% confidence intervals (95%-CI) were calculated and variations in treatment practices and outcomes were assessed.

3246 patients treated for intact cAAA and 526 patients treated for ruptured cAAA were included. An overall increase in the use of F/BEVAR for intact cAAA was observed, rising from 50% in 2018 to 54% in 2022, with Denmark showing the largest growth, from 33% to 71%. The highest F/BEVAR rate was seen in Australia at 68%, the lowest in Switzerland at 25%. In contrast, OR was the predominant treatment for ruptured cAAA, accounting for 94% of all procedures without a clear trend.
The overall perioperative mortality for intact cAAA decreased from 5.2% (95%-CI: 3.3-7.0%) in 2018 to 2.1% (1.0-3.2%) in 2022, p=.042. No time trend was observed in the perioperative mortality for ruptured cAAA, with an overall mortality rate of 34.8%. Complication rates, including myocardial infarction, acute kidney failure, and respiratory failure were more frequent in OR patients.

While the use of F/BEVAR for elective cAAA repair has increased and mortality rates have declined, the treatment of ruptured cAAA continues to rely predominantly on OR, with high perioperative mortality rates. These findings highlight the need for ongoing advancements in endovascular technologies for emergent cAAA repairs.