Endoleak

Objective: This study was conducted to provide insight into the safety, applicability, and outcomes of thoracic endovascular aortic repair (TEVAR) with the chimney graft technique. Methods: Original data regarding the chimney technique in TEVAR in the emergent and elective setting were collected from MEDLINE, Embase, and Scopus databases. All variables were systematically extracted and included in a database. Patient and procedural characteristics, details, and outcomes were analyzed. Results: In total, 94 patients with 101 chimney-stented aortic arch branches were analyzed, consisting of the brachiocephalic artery in 20, the left common carotid artery in 48, and the left subclavian artery in 33. Balloon-expandable stents were used in 36% and self-expandable stents in 64% for the aortic side branch. The interventions were elective in 72% and emergent in 28%. Technical success was achieved in 98% in elective and emergent settings combined. Endoleaks were described in 18%; with type Ia being most frequently reported in 6.4% overall and in 6.5% in the elective setting. Stroke was reported in 5.3% of the patients, of which 40% were fatal. The overall perioperative mortality was 3.2%. Median follow-up time was 11 months, and chimney stents remained patent in all patients. Conclusions: TEVAR with the chimney technique is a viable treatment option and may expand treatment strategies for patients with challenging thoracic aortic pathology and anatomy in the emergent and elective setting. Patency of the thoracic chimney stents appears to be good during short-term follow-up. Other complications, such as endoleak and stroke, deserve attention by future research to further improve treatment strategies and the prognosis of these patients. (J Vasc Surg

Open surgical repair is considered the traditional treatment for patients with thoracic aortic aneurysms (TAA). In view of the persistent perioperative mobidity and mortality, endovascular stent-graft placement as a minimally invasive and potentially safer treatment for aneurysm of the descending aorta was introduced in 1992. Since then, progress has been made and several institutions have substantiated the safety and effectiveness of stent grafts in the repair of descending TAAs or type-B aortic dissections. Currently, both custom-designed, home-made, and commercially available stent grafts are used. Prior to placement of the endoprosthesis, three major prerequisites must be considered: the localization and mor-phology of the aneurysm; the distal vascular access of sufficient size; and a limited tortuosity of the abdominal and thoracic aorta. Although short-term results are encouraging, severe complications, including paraplegia, cerebral strokes, and aortic rupture, have been encountered. The long-term durability of currently available stent-graft systems is nonexistent and material fatigue are of major concern to both surgeons and radiologists. Nevertheless, endovascular stent-graft placement could become the procedure of choice in a substantial number of patients with descending TAA.

urpose: To scrutinize registry data on thoracoabdominal repairs performed using the Multilayer Flow Modulator (MFM) outside the indications for use (IFU) and analyze the adverse outcomes. Methods: Of 380 patients from Europe registered in the MFM Global Registry after treatment for thoracoabdominal aortic aneurysm (TAAA) or dissection, 38 (10%) patients (30 men; median age 71 years, range 30-91) treated on a compassionate basis outside the IFU were analyzed. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation .6 cm. There were 6 mycotic and 4 saccular aneurysms in addition to 15 primary TAAAs. The mean aneurysm diameter was 7.1 cm. Ten patients presented with rupture, and 23 patients had previous open or thoracic endovascular aortic repair (TEVAR). Results: Although no death, paraplegia, stroke, or renovisceral compromise was documented during the initial hospital stay, technical success was zero. There were 31 (81.6%) cases in which there was failure to land the device in normal aorta. Other violations of the IFU included 12 with inadequate stent overlap and 11 cases involving a small MFM being deployed inside a larger one. Five of the 9 cases in which an undersized device was used resulted in a type I endoleak (failure mode I). During a mean follow-up of 10.066.9 months, all-cause mortality was 89.5% (34/38), of which 27 (71.1%) were aneurysm-related deaths. Overall survival, freedom from aneurysm-related death, and rupture-free survival estimates were 17.5%, 25.0%, 31.5%, respectively, at 18 months. There were 8 visceral branch complications; in all, 14 secondary endovascular interventions were required in 11 patients for endoleak (failure modes I and II) or stent foreshortening. No false lumen was completely thrombosed in the dissecting aneurysms. All aneurysms showed a mean sac growth rate of 0.1260.16 cm/month. Factors having a significance influence on risk of aneurysm-related death included maximum aneurysm diameter (p¼0.025, HR 1.37, 95% CI 1.04 to1.82), previous TEVAR (p¼0.03, HR 2.44, 95% CI 1.10 to 2.08), and inadequate overlap between MFM devices (p,0.002, HR 4.02, 95% CI 1.70 to 9.49). Conclusion: There are clinical scenarios in which the MFM does not perform well. The MFM is not a solution for patients living on borrowed time and should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. Its use must adhere to the IFU, and robust clinical data are required before constructing a randomized controlled trial.

Purpose : To report the use of a endograft to manage a type IB endoleak in a patient with a juxtarenal aortic aneurysm previously treated with a multylayer stent Case report : Under compassionate use a 68 years old patient with a juxtarenal aortic aneurysm and multiple comorbidities was treated with a multilayer flow modulating stent. Twelve months later a new CT scan identified a type Ib endoleak with an increase of the aortic aneurysm size due to extension of the aneurysmal disease to the aortic carrefour . A new endovascular procedure was then performed , deploying an aorto bisiliac endoprosthesis . After 18 months serial echocolor duplex and CT scans have shown normal visceral arteries patency, no signs of endoleak and sac shrinkage of 5 mm Conclusion: In this case, MARS failed to treat the AAA and required a reoperation with conventional covered stentgraft for distal sealing, which may be considered a feasible solution to manage potential endoleaks

Endovascular aneurysm repair (EVAR) will fail over time in a percentage of patients. Mechanical failure of the device, progression of aortic disease, or interface complications between the device and the native vasculature may contribute. Our aim was to evaluate the role of fenestrated and branched endografts as treatment options for failed devices. Between January 2001 and June 2013, 970 patients were enrolled into a physician-sponsored investigational device exemption (PSIDE) study and treated with a fenestrated/branched endograft. All patients treated for nonurgent proximal neck failure of an infrarenal endoprosthesis previously implanted during EVAR comprised the study group. Patients treated for a primary aneurysm within the PSIDE were evaluated as a comparison group to identify preoperative risk factors for failure. A retrospective review was undertaken to determine the details of the initial EVAR, whereas the prospective PSIDE database was used to assess outcomes of secondary...

To describe early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair. (25 months), 14 patients (13 men, one woman) with a mean age of 70.1 years (range, 59.3-80.0 y) were treated with IBGs. Indications were abdominal aneurysm with common iliac artery (CIA) involvement (n ϭ 11), juxtarenal aortic aneurysm with CIA involvement (n ϭ 1), and bilateral CIA and internal iliac artery (IIA) aneurysms (n ϭ 1). Postoperative endoleaks and patency rate were determined with computed tomography within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 18.7 months (range, 6 -35 mo).

E ndovascular aneurysm repair (EVAR) is universally accepted as an alternative to open surgery for the treatment of infrarenal abdominal aortic aneurysms because of its association with lower perioperative mortality and morbidity (1). The main drawback of EVAR is the relatively high rate of re-interventions (approximately 20%) required during the follow-up (1); endoleaks are usually the culprit responsible for these re-interventions. Type II endoleaks are most common, with a frequency varying from 10% to 25%, in EVAR procedures (2). They are caused by retrograde perfusion of the aneurysm sac from collateral aortic branches.

urpose: To report the bench-top evaluation and initial clinical use of an instrument for onsite fenestration of aortic stent-grafts. Methods: A stainless steel thermal cautery instrument was designed to create circular stentgraft fenestrations from 3 to 10 mm in diameter. Three operators independently benchtested the instrument on thoracic stent-graft samples to evaluate size, shape, location, and quality of fenestrations created. For clinical use, on-site fenestration was performed 2 days before the endovascular procedure in a sterile room without access to supplemental oxygen. A fenestrator 1 or 2 mm smaller in diameter than the target vessel was used; the edges of the fenestrations were strengthened using flexible radiopaque nitinol wire. The aortic stent-graft was then re-sheathed and sterilized for added safety. Eighteen patients (17 men; mean age 51 years, range 18-80) with a variety of thoracic and juxtarenal pathologies were treated using Zenith TX2, Valiant Captivia, Zenith AAA, and Endurant stent-grafts modified in this manner. Results: After successful bench testing, the instrument was used to create 34 fenestrations in aortic stent-grafts deployed in the 18 patients. Size and location of fenestrations obtained were as desired. Subsequent catheterization of the fenestration/target vessel and covered stent deployment were successfully achieved in 31 (91%) fenestrations; 2 fenestrations had type III endoleaks and 1 fenestration was unused. There was no perioperative mortality, stroke, embolization, vessel dissection, renal failure, or graft infection. Follow-up to 1 year in the majority of patients has revealed no new fenestration-related problems. Conclusion: This simple-to-use instrument makes on-site creation of aortic stent-graft fenestrations easy, accurate, and precise. The instrument is inexpensive, robust, and easily sterilized.

Objectives: Hybrid aortic arch repair procedure was introduced to reduce invasiveness in high-risk patients with aortic arch pathology. The good results are expanding its application, but endoleak, particularly type I, remains its Achilles' heel. Design: We describe our experience with hybrid treatment of aortic arch diseases focussing on techniques and results to avoid type I endoleak. Materials and Methods: A total of 15 high-risk patients with zone 0e2 aortic arch pathology underwent supra-aortic debranching on ascending aorta and proximal aortic arch reinforcement with a Dacron prosthesis. Metachronously, the procedure was completed with endovascular stent grafting (ESG). Results: Median age was 70 years with a mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12.7 AE 6.8. One patient died between aortic debranching and ESG. Mean time between surgical debranching and ESG was 32 AE 27.7 days. No major neurological events occurred. Mean length of the landing zone for ESG was 3.8 AE 0.8 cm. Computed tomography (CT) angiography scan performed soon after operation, and at 3, 6, and 12 months did not show any type I endoleak.

Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.

Aortic endovascular exclusion technique called ‘chimney’ consists of placing stents through abdominal aortic visceral branches and a prosthesis that excludes the thoraco-abdominal aneurysm. Stents and an aortic endoprosthesis are placed in the renal arteries.  is method is primarily used when open surgery is too risky.  e mechanism that provides aneurysm sac increase without the visible presence of endoleaks has not been fully elucidated.  e expansion of the aneurysm sac, due to endotension, is di cult to diagnose, even with the use of advanced imaging tests. Its diagnosis is made by exclusion. We present a case of a late complication in a high-risk patient after a ‘chimney’ endovascular procedure. Following the surgery, the patient presented a ruptured aneurysm sac without a visible endoleak. A second intervention was not feasible due to the high risk of occluding all of the branches, and complicated by previous ‘chimney’. Endotension is a possible cause of aneurysm rupture and death.

Background: This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). Methods: Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ؎ 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. Results: DPSI using thrombin (n ‫؍‬ 16), coils (n ‫؍‬ 7), gelfoam (n ‫؍‬ 6), or glue (n ‫؍‬ 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P ‫؍‬ .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P ‫؍‬ .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P ‫؍‬ .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. Conclusions: This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail.

Endovascular repair is a standard of treatment for patients with abdominal aortic aneurysm who are unfit for open surgery. Type 1A endoleak (T1A-E) is defined as persistent blood flow outside the lumen of the endograft due to a failure of the graft to seal the proximal landing zone adequately. Accordingly, T1A-E treatment is mandatory, and endovascular options, when possible, consist of standard adjuncts as cuffs and stents or sometimes mere ballooning. Alternatively, different embolization techniques have been described in little or case series. We describe a successful management of large T1A-E with solely coil embolization of the isolated leakage area.

Objective. To evaluate frequency, causes and results of conversion to Open repair (OR) after endovascular repair (EVAR) in a single centre during an 8-year period. Design. Six hundred and forty-nine consecutive patients undergoing EVAR were followed up prospectively for endograftrelated complications. Outcomes. Early conversion was any OR during or within 30 days from the primary EVAR. Late conversion was any OR with removal of the endograft after 30 days since a completed EVAR procedure. Results. Median patient follow-up was 38 months (1-93 months). Conversion to OR was performed in 38 patients; nine early and 29 late. Most (7/9) early conversions were due to extensive vessel calcification. Peri-operative mortality was 22% (2/9). Late conversions occurred at a median of 33 months after primary EVAR: 29 were elective and 4 urgent. During the same interval, 79 secondary endovascular interventions were performed, 7 of which failed. The risk of conversion to OR was 9% at 6 years. At multivariate logistic regression analysis, no single factor (short, large or angulated neck, suprarenal fixation, large pre-operative diameter, iliac aneurysms, ASA score risk) was associated with the risk of late failure requiring conversion to OR. Conclusion. The risk of death after early conversion should be recognized, to avoid forcing morphological indications for primary EVAR. Occurrence of late conversion after EVAR is not negligible, affecting almost 1 out of 10 patients after 6 years. In the presence of an expanding aneurysm after EVAR, especially after a failed secondary endovascular correction, an aggressive attitude in fit patients allows outcomes at similar to those of primary OR.

The last few years have seen an increase in popularity of endovascular aneurysm repair because of the improvements made to the endografts design as well as experience gained by physicians, but the long-term results of this procedure are still uncertain. The majority of late complications after an endograft can be treated with an endovascular approach but, in some cases, it may need conversion to open surgery. In this paper, we discuss the case of a male patient who presented with an aorto-duodenal fistula on an endograft requiring explant. After two operations and 20 days in hospital, the patient was discharged and after 1 year he is doing well. In medical literature, there are very few reported cases of aortoenteric fistula complicating endovascular prosthesis, the diagnosis is quite difficult, surgical treatment is fairly complex consisting in endograft removal and we refer to our experience on this difficult and life-threatening operation.

Background: This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). Methods: Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ؎ 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. Results: DPSI using thrombin (n ‫؍‬ 16), coils (n ‫؍‬ 7), gelfoam (n ‫؍‬ 6), or glue (n ‫؍‬ 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P ‫؍‬ .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P ‫؍‬ .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P ‫؍‬ .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. Conclusions: This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail. ( J Vasc Surg 2012;56:965-72.)

Background: Lifelong surveillance is standard after endovascular repair of abdominal aortic aneurysm (EVAR), but remains costly, heterogeneous and poorly calibrated. This study aimed to develop and validate a scoring system for aortic complications after EVAR, informing rationalized surveillance.

Background: Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue. Methods: Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, c 2 tests, and Fisher's exact testing were used for group comparisons.

Objective: Endovascular aneurysm repair (EVAR) decreases 30-day mortality for patients with ruptured abdominal aortic aneurysms (r-AAAs) compared with open surgical repair (OSR). However, which patients benefit or whether there is any long-term survival advantage is uncertain. Methods: From 2002 to 2011, 283 patients with r-AAA underwent EVAR (n [ 120 [42.4%]) or OSR (n [ 163 [57.6%]) at Albany Medical Center. All data were collected prospectively. Patients were analyzed on an intention-to-treat basis, and outcomes were evaluated by a logistic regression multivariable model. Kaplan-Meier analysis was used to compare long-term survival. Results: The EVAR patients had a significantly lower 30-day mortality than did the OSR patients (29/120 [24.2%] vs 72/163 [44.2%]; P < .005) and better cumulative 5-year survival (37% vs 26%; P < .005). Men benefited more from EVAR (mortality: 20.9% for EVAR vs 44.3% for OSR; P < .001) than did women (mortality: 32.4% vs 43.9%; P [ .39). Age $80 years was a significant predictor of death for EVAR (odds ratio [OR], 1.07; P [ .003) but not for OSR (OR, 1.04; P [ .056). Preexisting hypertension was a significant predictor of survival for both EVAR (OR, 0.17; P < .001) and OSR (OR, 0.48; P [ .021). Almost one fourth of EVAR patients (21/91 [23.1%]) required secondary interventions. Survival advantage was maintained for EVAR patients to 5 years.

Background: Few studies have specifically correlated the amount of thrombus in the aneurysm sac and the presence of type II endoleaks (TIIE). This study examined the correlation of preoperative thrombus load and location to the incidence of TIIE and late sac regression. Methods: Prospectively collected data from 266 endovascular aneurysm repair (EVAR) patients were analyzed. Maximum thrombus thickness (MTT) and percentage of the circumference of the aortic wall lined by thrombus (thrombus-lined aneurysm circumference [TLAC]) were determined from preoperative computed tomography angiography (CTA) images at four levels:

Methods: Prospectively collected data from 258 EVAR patients using modular devices were analyzed. Patients were classified as having favorable neck anatomy (FNA) or hostile neck anatomy (HNA). HNA was defined as any or all of length of <10 mm, angle of >60°, diameter of >28 mm, >50% circumferential thrombus, >50% calcified neck, and reverse taper. Univariate, multivariate, and Kaplan-Meier analyses were used to compare early and late clinical outcomes. Results: FNA was present in 37% and HNA was present in 63%. Clinical and demographic characteristics were comparable. Technical success was 99%. Mean follow-up was 22 months (range, 1-78 months). Perioperative complication rates were 3% for FNA vs 16% for HNA (P ‫؍‬ .0027). Perioperative deaths were 0% for FNA and 3% for HNA (P ‫؍‬ .2997). Proximal type I early endoleaks (intraoperative) occurred in 9% of FNA vs 22% for HNA (P ‫؍‬ .0202). Intraoperative proximal aortic cuffs were used to seal endoleaks in 9% of FNA vs 22% of HNA (P ‫؍‬ .0093). At late follow-up, abdominal aortic aneurysm expansion was noted in 6% of FNA vs 7% of HNA (P ‫؍‬ .8509). Rates of freedom from late type I endoleaks at 1, 2, 3, and 4 years were 97%, 97%, 97%, and 90% for FNA vs 89%, 89%, 89%, and 89% for HNA (P ‫؍‬ .1224); rates for late interventions were 95%, 90%, 90%, and 90% for FNA vs 95%, 93%, 91%, and 85% for HNA (P ‫؍‬ .6902). Graft patency at 1, 2, and 3 years was 99%, 99%, and 99% for FNA vs 97%, 92%, and 90% for HNA (P ‫؍‬ .0925). The survival rates were 93%, 84%, 76%, and 76% for FNA vs 88%, 82%, 74%, and 66% for HNA (P ‫؍‬ .2631). Reverse taper was a significant predictor for early type I endoleak (odds ratio [OR], 5.25, P < .0001), reverse taper (OR, 5.95; P < .0001) and neck length (OR, 4.15; P ‫؍‬ .0146) were for aortic cuff use; circumferential thrombus (OR, 2.44; P ‫؍‬ .0448), and neck angle (OR, 3.38; P ‫؍‬ .009) were for perioperative complications. Conclusions: Patients with HNA can be treated with EVAR, but with higher rates of early (intraoperative) type I endoleak and intervention. The midterm outcomes are similar to FNA. ( J Vasc Surg 2011;54:13-21.)

We present the case of a patient with a persisting type II endoleak after endovascular repair of an iliac aneurysm with an iliaco-caval fistula. We describe the pathophysiological mechanism behind this phenomenon and discuss why conservative treatment is unlikely to seal this type of endoleak. A more aggressive treatment strategy is therefore advocated.

The purpose of this study was to examine the fate of aneurysmal iliac arteries managed during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Methods: We analyzed data from the Cook Zenith trial. Follow-up was at 1 month, 6 months, 12 months, and then annually for 5 years. Patients were evaluated according to the largest iliac artery diameter: group A (>20 mm) and group B (<20 mm). These groups were further subdivided based on iliac artery growth >5 mm during follow-up. The Fisher exact test and 2 test were used. Results: Of 736 patients treated, 671 had a follow-up examination (group A ‫؍‬ 274). In group A, 220 (80%) were treated with flared limbs in the common iliac artery. Group A did not demonstrate increased iliac growth as compared to group B. Furthermore, both groups had a similar percentage of patients that experienced iliac artery expansion of 32.1% and 31.5%, respectively. Extension to the external iliac artery did not affect growth (P ‫؍‬ .4). No difference was noted in the need for secondary interventions between groups. However, group A patients that did not experience growth were more likely to develop a distal type I endoleak than group B patients who did not develop growth (P ‫؍‬ .03). There was no difference in serious adverse events (SAEs) between groups (P ‫؍‬ .51). However, patients that developed iliac artery growth in either group were less likely to have an SAE compared to patients who did not experience growth (P ‫؍‬ .035). There was no difference in the mean percent oversizing of the iliac limbs between groups A and B. However, the mean percent oversizing in groups A and B that had iliac artery growth was significantly higher than in those that demonstrated no growth (P < .01).

Emergency aortic arch surgery still remains a challenge, especially in elderly patients. We report a case about the open surgical management by graft-to-endograft anastomosis of a complicated aortic arch aneurysm because of a type I endoleak after thoracic endovascular aortic repair of a chronic type B aortic dissection.

Abdominal aortic aneurysm (AAA) is a condition where the weakening of the aortic wall leads to its widening and the generation of a thrombus. To prevent a possible rupture of the aortic wall, AAA can be treated non-invasively by means of the endovascular aneurysm repair technique (EVAR), consisting of placing a stent-graft inside the aorta by a cateter to exclude the aneurysm sac from the blood circulation. A major complication is the presence of liquid blood turbulences, called endoleaks, in the thrombus formed in the space between the aortic wall and the stent-graft. In this paper we propose an automatic method for the detection of type II endoleaks in computer tomography angiography (CTA) images. The lumen and thrombus in the aneurysm area are first segmented using a radial model approach. Then, these regions are split into Thrombus Connected Components (TCCs) using a watershed-based segmentation and geometric and image content-based characteristics are obtained for each TCC. Finally, TCCs are classified into endoleaks and non-endoleaks using a multilayer Perceptron (MLP) trained on manual labeled sample TCCs provided by experts.

Objectives: Hybrid aortic arch repair procedure was introduced to reduce invasiveness in high-risk patients with aortic arch pathology. The good results are expanding its application, but endoleak, particularly type I, remains its Achilles' heel. Design: We describe our experience with hybrid treatment of aortic arch diseases focussing on techniques and results to avoid type I endoleak. Materials and Methods: A total of 15 high-risk patients with zone 0e2 aortic arch pathology underwent supra-aortic debranching on ascending aorta and proximal aortic arch reinforcement with a Dacron prosthesis. Metachronously, the procedure was completed with endovascular stent grafting (ESG). Results: Median age was 70 years with a mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12.7 AE 6.8. One patient died between aortic debranching and ESG. Mean time between surgical debranching and ESG was 32 AE 27.7 days. No major neurological events occurred. Mean length of the landing zone for ESG was 3.8 AE 0.8 cm. Computed tomography (CT) angiography scan performed soon after operation, and at 3, 6, and 12 months did not show any type I endoleak.

Paravalvular leak after prosthetic mitral valve surgery may lead to symptomatic mitral regurgitation and hemolytic anemia requiring reoperation. Percutaneous closure of paravalvular leaks is a relatively recent technique still considered a challenging procedure burdened by possible complications, to be offered only to poor redo surgical candidate patients. Multimodality imaging is advocated to plan and guide the procedure, to minimize the risk of complications. We report on a case of dehisced prosthetic mitral valve in which transthoracic real time three-dimensional echocardiography was used to locate the dehiscence area and characterize mitral paraprosthesis leak, whereas intracardiac echocardiography was used to guide and monitor the percutaneous closure procedure. (Echocardiography 2011;28:E168-E171)

Purpose: Thoracic endovascular aortic repair is increasingly becoming the standard treatment of many thoracic aortic pathologies. New reliable and accurate stent grafts are emerging to widen the endovascular treatment options. We report the results of RELAY (Bolton Medical, Barcelona, Spain) in the large RELAY Endovascular Registry for Thoracic Disease (RESTORE) European registry. Methods: RESTORE is a multicenter, prospective European registry involving 22 centers in seven European countries. The RELAY device is composed of a stent graft (self-expanding nitinol stents and a polyester vascular graft) and a delivery device specifically designed for the thoracic aorta. Included were acute and elective patients presenting with a variety of pathologies (aneurysms, dissections, ulcerations, intramural hematomas, pseudoaneurysms) and lesions in different aortic and anatomic locations (ascending, arch, descending and thoracoabdominal). Results: The registry enrolled 304 patients from April 2005 to January 2009. All-cause mortality at 30 days was 7.2%. Freedom from all cause mortality and freedom from device-and procedure-related mortality at 2 years were 78.5% and 95.9%, respectively. An average of 1.26 graft components were used per patient, with a technical success of 97.7% irrespective of the etiology. Early endoleak rate was 4.6%. Perioperatively, stroke and paraplegia were registered in 1.6% and 2.0%, respectively. Conclusions: The results of RESTORE support the safety of thoracic endovascular aortic repair with the RELAY stent graft, even in acute and complicated situations. The device was highly efficient in angulated aortic anatomies, with acceptable mortality and a low rate of neurologic complications.

Objective: The objective of this study was to describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for branch vessel preservation. Methods: Patients treated with a chimney graft procedure between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair or for conventional, branched, or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cutdown access for the chimney grafts and bilateral femoral artery cutdown access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. In addition, evolution of gutter area over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24 months of follow-up were calculated. Results: Thirty-three patients (mean age, 77.6 6 6.8 years; 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7 6 13.5 mm were included. A total of 54 of an intended 54 chimney grafts were deployed. Primary technical success and 30-day secondary clinical success rates were 87.9% and 84.8%, respectively. The early mortality rate was 6.1% (n ¼ 2). The early type IA endoleak rate was 6.1% (n ¼ 2), and the chimney graft occlusion rate was 6.1% (n ¼ 2). Median follow-up duration was 26 months (interquartile range, 14.8-37.3 months). The estimated 2-year actuarial survival rate was 78.1% (standard error, 67.4%). Late complications included type IA endoleak (n ¼ 1), chimney graft occlusion (n ¼ 2), type II endoleak with aneurysm growth (n ¼ 4), and distal stent graft limb kinking and occlusion (n ¼ 1). Late reinterventions included coil or glue embolization (n ¼ 3), distal limb extension (n ¼ 2), open endoleak ligation (n ¼ 2), Palmaz stent placement (n ¼ 1), repeated EVAR (n ¼ 1), and femorofemoral bypass graft (n ¼ 1). At 2 years, the estimated secondary clinical success and freedom from aneurysm growth rates were 80.5% (67.2%) and 84.4% (67.2%). Gutter size showed a small but significant decrease over time at the level of the proximal markers and at 10 mm distal from the markers. Conclusions: Midterm results show that a standardized procedure for EVAR using chimney grafts for branch vessel preservation is an acceptable option for high-risk patients with large, complex aneurysms who are unfit for open repair and who have been excluded from fenestrated EVAR. Gutter size decreases over time, but the rate of branch vessel loss and reinterventions demonstrate that this approach should remain reserved for those who are at truly prohibitive risk for open or fenestrated stent graft repair.