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Percutaneous transfemoral thoracic endovascular aortic repair (pTEVAR) is becoming more attracting as a minimally invasive procedure. Numerous vascular closure devices have been introduced to achieve hemostasis in these procedures. This study evaluates the biomechanical vascular closure device (BVCD) in pTEVAR.

A retrospective analysis was conducted of all consecutive patients who underwent pTEVAR with BCVD between January 2021 and June 2024.

51 patients (64.7% men, mean age 67.5 years). The mean BMI was 27.3. Comorbidities included COPD (13.7%), Cardiac disease (35%), and peripheral artery disease (11.8%). Prior aortic and iliac interventions were detected in 49% and 3.9% of cases, respectively.
Indications for pTEVAR included: Type B aortic dissection (35.3%), type A aortic dissection (33.3%), penetrating aortic ulcer (17.6%), aortic aneurysm (9.8%) and intramural hematoma (4%). Contained aortic rupture was detected in one patient (2%). 39.2% of cases were elective, 17.6% were emergency, and 43.1% urgent.
The mean diameter of the common femoral artery (CFA) was 8 mm. Furthermore, 33.3% of patients exhibited a calcified CFA. The mean delivery system profile of the TEVAR prosthesis was 22. A Low-profile TEVAR was implanted in 84.3 % of cases, with more than one Prosthesis used in 22.6% of cases.
The technical success rate was 96.1%. The mean operative time was 133 minutes and the mean hospital stay was 9 days.
Early postoperative vascular complications occurred in 6% of cases, including a CFA Pseudoaneurysm in two patients and a major hemorrhage in one patient, all of which required surgical revision. During follow-up, one patient (2%) developed a CFA pseudoaneurysm 4 months postoperatively, necessitating a subsequent revision and arterial reconstruction.

The biomechanical vascular closure technique seems to be safe and effective to close the large-bore arteriotomies in pTEVAR, even in cases involving the implantation of multiple TEVAR prostheses. Despite a low incidence of early complications (4%), a midterm vascular complication rate (2%) highlights the need for continued surveillance and routine follow-up to monitor vascular integrity.

To facilitate the preservation of iliac vascular territory in a selected group of patients, requiring upper extremity access following previous EVAR, an adopted approach, the novelty of which implied internal iliac artery (IIA) catheterization using contralateral transfemoral access without through-and-through wire access and sheath support has been adopted. This study aimed to compare the outcome of non-sheath technique (NSG) to a history control group.

A retrospective analysis of 51 consecutive patients treated for aortoiliac or isolated IIA aneurysm with IBD from January 2020 to July 2023 was undertaken. Study population was divided into two groups – sheath (SG) and non-sheath (NSG) group. Primary endpoints were radiation exposure, dose of contrast agent (CA), operation time and incidence of intraoperative target vessel (TV) complications. Type IB/C and IIIA/C endoleak, presence of incomplete/complete thrombotic occlusion of TV, and re-intervention rates at 3 follow-up phases were defined as secondary endpoints.

39 patients (48 IBDs) in SG and 12 patients (15 IBDs) in NSG were identified. History of previous EVAR was more prevalent in NSG, P = .001. Operation time (median, 204 vs. 262 minutes), dose-area product (median, 301 vs. 361 Gy x cm2), CA applied (median, 148 vs. 190 mL) were non-significantly lower in NSG vs. SG. TV complications were observed in SG only (7.7% of cases). At early follow-up 2 vs. none patients in SG and NSG, respectively, required re-intervention. At short- and intermediate follow-up 2 secondary re-interventions were performed in NSG only. IC endoleak was observed only in 3 cases of SG. Type IIIA/C endoleaks was more abundant at an early follow-up in SG vs. NSG (5 vs. 2 cases, respectively). Incomplete/complete thrombotic occlusion of IIA branch was more frequently observed in SG vs. NSG at 3 follow-up phases (4 vs. 1 case, 5 vs. 1 case, respectively).

In patients with previous history of EVAR with bifurcation grafts, necessitating brachial access for IIA repair with IBD, non-sheath technique presents a viable and safe treatment option.

During proximal TEVAR procedures, preservation of the left subclavian artery (LSA) is recommended if possible, otherwise stroke risk. Surgical debranching is standard of care to allow coverage of the LSA. Recently, endovascular options to preserve the LSA have emerged. The GORE® TAG® Thoracic Branch Endoprosthesis (TBE) is newly available in Switzerland.

A 59-year-old patient was admitted with a complicated acute non-A-non-B aortic dissection with severe malperfusion of the left kidney. Anatomical criteria were within the instructions for use for the GORE® TAG® TBE. A 400 cm through-and-through wire was established from the left cubital artery to the left femoral artery. Introduction of the TBE on the stiff main wire as well as the through-and-through wire for the branch portal was uneventful.

Without active control mechanism, bird beaking at the inner curvature of the arch was observed after deployment of the graft. This was likely aggravated by a somewhat proximal positioning of the graft right at the ostium of the left common carotid artery, which also resulted in a slightly proximal positioning of the branch portal. Despite this, introduction and deployment of the LSA branch was uneventful and the final result was acceptable. The TBE was extended with a tapered TX2 graft from Cook Medical. Perfusion of the left kidney was fully restored and extension with a dissection stent was not necessary. There were no complications. His left radial pulse was strongly palpable and his creatinine levels decreased from 217 μmol preoperatively to 137 μmol postoperatively.

The GORE® TAG® TBE is a newly available, off-the-shelf solution for fully endovascular LSA preservation during TEVAR. It is based on the established GORE® TAG® platform and was easy to use. Care must be taken during deployment to reduce bird beaking and to ensure correct positioning of the branch portal.

This study investigates whether bare-metal stent (BMS) relining of the iliac limbs and neo-aortic bifurcation can reduce the incidence of limb occlusion and in-graft thrombosis following standard EVAR.

We conducted a retrospective analysis of patients treated for infrarenal AAAs with low-profile Cook Medical endografts between 2017 and 2023. All procedures used the ZIMB main body within the device’s Instructions for Use, with distal extensions via either ZISL or ZSLE iliac limbs. Patients receiving ZSLE limbs underwent additional BMS relining using Omnilink, Dynetic or Express-LD stents, while no adjunctive procedure was performed in ZISL cases. Only patients with a minimum follow-up of 12 months were included. The primary endpoint was the occurrence of limb occlusion or in-graft thrombosis (partial or complete) at 12 months.

Of 144 patients treated during the study period, 97 were excluded due to rupture, loss to follow-up, or adjunctive therapies. A total of 83 iliac limbs were analyzed (58 ZISL, 25 ZSLE with BMS relining). Baseline characteristics, including age, sex, cardiovascular risk factors, ASA classification, aortic diameter (ZISL: 54±11 mm, ZSLE: 53±8 mm), and proximal landing zone diameter (ZISL: 23±2 mm, ZSLE: 22±2 mm, p=.840), were comparable. The ZSLE group had a longer proximal neck length (ZISL: 25±7 mm vs. ZSLE: 33±10 mm, p=.013). Iliac diameters for the distal landing zone were comparable in both groups (ZISL: 16.9±6.8 mm vs. ZSLE: 15.3±4.0 mm, p=.311). Mean follow-up was longer in the ZISL group (41±14 vs. 16±3.5 months, p<.0001). Limb occlusion occurred in 7 cases (8.2% overall): 7 in the ZISL group (12.1%) and none in the ZSLE group (0%, p=0.069). In-graft thrombosis occurred in 12 cases (14.1%): 10 in the ZISL group (17.2%) and 2 in the ZSLE group (8.0%, p=0.272).

Bare-metal stent relining of the iliac limbs and neo-aortic bifurcation in standard EVAR using low-profile devices appears to be a safe and technically simple adjunct that may reduce the risk of limb occlusion and in-graft thrombosis. Although statistical significance was not reached, early outcomes are promising. Longer-term follow-up and larger studies are warranted to confirm durability and clinical benefit.

Abdominal aortic aneurysms (AAA) are defined as diameter >30mm, corresponding to two standard deviations above the mean in men. This definition, used in screening, diagnosis, surveillance and management in guidelines does not take gender into account. Guidelines compensate for this somewhat by considering treatment from >50mm in women vs >55mm in men. Nevertheless, meta-analysis shows that women have a 4-fold greater risk of rupture at all AAA sizes, and consistently fare worse after open or endovascular AAA repair. An alternative to AD is the Aortic Size Index (ASI), obtained by dividing the AD by the Body Surface Area, thus correcting for generally smaller body sizes of women. This scoping review aims to compare the use of ASI and AD in men and women with AAA.

The Cochrane, Medline, and Web of Science Core Collection databases were searched in May 2024 for studies reporting on ASI, which included sex disaggregated data, in patients with AAA. A scoping review was performed according to the PRISMA guidelines.

11 studies with 150,028 data entries (19.8% women) were included. There was considerable heterogeneity in reported outcomes. Compared to AD using ASI corrects some of the differences in incidence and rupture rates between sexes. One study reported that AD>30mm found 5.7% AAA in men vs 2.4% in women, while ASI>1. 5cm/m^2 found a much closer prevalence of 5.7% in men and 4.5% in women. Another study calculated that for 12% of repairs to be ruptured ASI would be ≥ 2.7cm/m^2, which corresponded to a 55mm AD in men and 49mm AD in women.

Women are consistently treated for AAA at lower ADs but higher ASIs than men, which could partially explain some of the sex-disparities found in surgical outcomes. ASI suggests that not only treatment, but also AAA diagnosis, is being performed at a later disease stage in women. The authors suggest three possible interpretations of the data. The first is a systematic use of ASI s for both men and women (1.5mm/m^2 for diagnosis, 2.75mm/m^2 for consideration to treat). This comes with a series of impracticalities and may not benefit men. The second is to consider a strategic use of ASI in women at the moment of first diagnosis and at the moment of elective intervention. Thirdly ASI data could be used to help reconsider current unstratified diameter thresholds for AAA diagnosis and repair in men and women.

An aorto-esophageal fistula (AOF) is a life-threatening complication caused by a pathological connection between the thoracic aorta and the esophagus. In this study:
The incidence, classification and management strategies are reviewed and the results of a series of AOFs are presented.

Since 2014, five cases of AOF post- Thoracic Endovascular Aortic Repair (TEVAR) were diagnosed. The initial indications in two patients (50%) was penetrating aortic ulcer (PAU), while the remaining two (50%) had thoracoabdominal aneurysms. Surgical operations included extra-anatomic ascending-to-descending aortic bypass with a Dacron graft in one patient and in situ reconstruction with a home-made pericardial tube, subtotal esophagostomy, and gastrostomy in another. One patient declined the operation and prefer conservative management with endoscopic vacuum therapy, fibrin glue application, and antibiotics. In the context of multimorbid diseases, the other 2 patients were treated with antibiotics in a palliative approach.

The one-year mortality rate was 80%. The longest survival was observed in the patient who underwent conservative endoscopic closure with fibrin glue, who survived for 31 months.

AOF vigilance incidence is critical because of the increasing use of TEVAR. Accurate diagnosis relies on clinical, laboratory tests and imaging findings. The stability of the organ wall determines the complication risk, which also influences the best treatment for each patient. A new AOF classification system, proposed in this study, will allow for better diagnosis and clearer assessment of treatment options.

The implantation of left atrial appendage (LAA) occluder devices has emerged as a therapeutic alternative for treatment of patients with nonvalvular atrial fibrillation (NVAF) and ineligibility for anticoagulation. Percutaneous implantation of LAA occluder devices can be associated with various complications. We aim to present a patient with dislocation and migration of a LAA occluder device from the LAA to the descending aorta leading to a complete occlusion of the infrarenal aorta. For this, a novel endovascular approach for retrieving a LAA occluder device from the infrarenal aorta was developed.

A 83-year-old patient who was diagnosed with NVAF underwent a percutaneous LAA occluder implantation. During the post-interventional phase, a progressive hypotension ensued due to a hemodynamically significant pericardial tamponade with pericardial effusion which was promptly punctured. A clip was surgically placed to enclose the LAA. During this procedure an occluder dislocation and migration to the abdominal aorta occurred. A small-caliber introducer sheath was inserted in the right groin. After placement of a stiff wire and advancement of a Reliant® balloon above the dislocated LAA occluder device, the balloon was inflated and the device was trapped between the sheath and the balloon. The trapped device was then carefully mobilized and withdrawn into the sheath. Follow-up angiography revealed no bleeding and all visceral branches showed free perfusion.

A successful endovascular retrieval of the LAA occluder was achieved using the Sandwich-Bail-Out-Technique.

In this technical guide we present a novel approach for endovascular retrieval of a migrated LAA occluder device from the descending aorta.

Primary aortic mural thrombi (PAMT) are a rare source of arterial embolization. In most cases, distal arterial embolism is the first clinical manifestation. This case report discusses two cases of young, otherwise healthy women with PAMT-related acute arterial occlusions. This report aims to highlight the clinical presentation, surgical management and outcomes of acute arterial occlusion resulting from PAMT in young female patients.

Case 1 involved a 38-year-old woman with a 3-day history of progressive left leg pain. Imaging revealed multiple bilateral embolic arterial occlusions of varying ages and a floating thrombus of the infrarenal aorta. Case 2 concerned a 44-year-old female with sudden pain, pallor, and paresthesia of the right leg. Imaging confirmed thromboembolic occlusion of the tibiofibular trunk as well as chronic occlusion of all lower right leg arteries and a floating mural thrombus of the proximal right common iliac artery. Both underwent open embolectomy and thrombectomy.

In case 1, complications included macroperfusion decompensation and compartment syndrome, requiring venous bypass and fasciotomy. Following bypass revision, adequate perfusion was achieved. Case 2 experienced sufficient perfusion restoration after embolectomy without further interventions. Both patients showed favorable outcomes upon discharge and at follow-up after 6 weeks and 6 months.

While aortic mural thrombi are typically associated with atherosclerosis, aneurysms, or hypercoagulable states, they can also occur in the non-diseased aorta. While conservative management is feasible, surgical thromboendarterectomy especially in the event of acute embolization in young, otherwise healthy patients, is an appropriate therapeutic option. The cases demonstrated the importance of considering PAMT as an embolic source and showed favorable outcomes after surgical therapy in both multiple bilateral and localized occlusions.

Acute mesenteric ischemia is a life-threatening condition with a high mortality rate of up to 50%. The most common cause is an embolus from the left heart (up to 90%) followed by thrombotic occlusion, non-occlusive mesenteric ischemia and mesenteric venous thrombosis. Occlusion due to spontaneous isolated dissection of the superior mesenteric artery (SMA) is rare with an incidence of 0.06%.

We report on a 69-year-old female patient who was admitted to our emergency department complaining about aggravated inappetence and abdominal pain with watery diarrhea since two days. CT scan showed an extended thrombus in the SMA, without evidence of intestinal ischemia or free air intra-abdominally. The patient underwent emergency exploratory laparotomy, where the extended thrombus in the SMA was confirmed. Therefore, an endarterectomy and patch plasty of the SMA was performed. Planned second look laparotomy was uneventful and the patient was discharged to rehabilitation.

Meanwhile, cardiologic and rheumatologic examinations revealed no source of embolism or evidence of vasculitis as cause of mesenteric ischemia. However, histopathological findings of the thrombus and the arterial wall revealed a dissection of the SMA explaining subacute mesenteric ischemia.

Isolated spontaneous dissection of the SMA is a rare cause of subacute mesenteric ischemia with only few cases reported. Although, in this patient’s medical history, there was no source of embolism or known advanced arteriosclerosis of the visceral vessels, spontaneous isolated dissection of the SMA should still be considered, if the clinical findings are appropriate.

Aortic arch pathologies are relatively rare and technically challenging to treat. Traditional open repair carries significant risks due to the procedure's complexity and the aortic arch's critical anatomy. Furthermore, not all patients are suitable candidates for open aortic arch repair. Endovascular repair systems have been developed to address these challenges, including the Lombard Hector® Multi-Branch Stent-Graft System. Since endovascular arch repair systems are relatively new, clinical experience and available data remain limited. This case series aims to evaluate the technical feasibility and preliminary outcome of the Hector® endoprosthesis for endovascular repair of aortic arch pathologies.

Two patients with aortic arch pathologies were treated with endovascular implantation of the Hector® endoprosthesis. The first patient, an 83-year-old female, presented with a pseudoaneurysm at the distal anastomosis following supracoronary ascending aortic repair. The second patient had a penetrating aortic ulcer in Ishimaru zone 3. Both were deemed unsuitable for open aortic arch repair, leading to the decision for endovascular treatment.
The main body of the aortic arch device, including the branch for the brachiocephalic trunk, was deployed using a pull-through wire between the right brachial artery and the right common femoral artery. The endoprosthesis for the left common carotid artery was implanted using different approaches: in the first patient, it was placed retrogradely via direct access to the left common carotid artery, whereas in the second patient, it was implanted antegradely via the right subclavian artery.

Postoperatively, both patients had regular postoperative courses without neurological complications. The postoperative CT scan confirmed patency of the branch vessels, with no evidence of endoleaks.

The endovascular implantation of the Hector® endoprosthesis represents a significant advancement in treating aortic arch pathologies, expanding the feasibility of minimally invasive interventions. Further studies with larger patient cohorts and long-term follow-up are necessary to confirm these findings and define the role of this technique in routine clinical practice.