Fate of target visceral vessels in fenestrated and branched complex endovascular aortic repair

Objective: To assess branch vessel outcomes after endovascular repair of complex aortic aneurysms analyzing possible factors influencing early and long-term results.Methods: The Italian Multicentre Fenestrated and Branched registry enrolled 596 consecutive patients treated with fenestrated and branched endografts for complex aortic disease from January 2008 to December 2019 by four Italian academic centers. The primary end points of the study were technical success (defined as target visceral vessel [TVV] patency and absence of bridging device-related endoleak at final intraoperative control), and freedom from TVV instability (defined as the combined results of type IC/IIIC endoleaks and patency loss) during follow-up. Secondary end points were overall survival and TVV-related reinterventions.Results: We excluded 591 patients (3 patients with a surgical debranching and 2 patients who died before completion from the study cohort) were treated for a total of 1991 visceral vessels targeted by either a directional branch or a fenestration. The overall technical success rate was 98.4%. Failure was related to the use of an off-the-shelf (OTS) device (custom-made device vs OTS, HR, 0.220; P = .007) and a preoperative TVV stenosis of >50% (HR, 12.460; P < .001). The mean follow-up time was 25.1 months (interquartile range, 3-39 months). The overall estimated survival rates were 87%, 77.4%, and 67.8% at 1, 3, and 5 years, respectively (standard error [SE], 0.015, 0.022, and 0.032). During follow-up, TVV branch instability was observed in 91 vessels (5%): 48 type IC/IIIC endoleaks (2.6%) and 43 stenoses-thromboses (2.4%). The extent of aneurysm disease (thoracoabdominal aortic aneurysm [TAAA] types I-III vs TAAA type IV/juxtarenal aortic aneurysm/pararenal aortic aneurysm) was the only independent predictor for developing a TVV-related type IC/IIIC endoleak (HR, 3.899; 95% confidence interval [CI]:, 1.924-7.900; P < .001). Risk of patency loss was independently associated with branch configuration (HR, 8.883; P < .001; 95% CI, 3.750-21.043) and renal arteries (HR, 2.848; P = .030; 95% CI, 1.108-7.319). Estimated rates at 1, 3, and 5 years of freedom from TVV instability and freedom from TVV-related reinter-vention were 96.6%, 93.8%, and 90% (SE, 0.005, 0.007, and 0.014) and 97.4%, 95.0%, and 91.6% (SE, 0.004, 0.007, and 0.013), respectively.Conclusions: Intraoperative failure to bridge a TVV was associated with a preoperative TVV stenosis of >50% and the use of OTS devices. Midterm outcomes were satisfying, with an estimated 5-year freedom from TVV instability and reintervention of 90.0% and 91.6%, respectively. During follow-up, the larger extent of aneurysm disease was associated with an increased risk of TVV-related endoleaks, whereas a branch configuration and renal arteries were more prone to patency loss

Aortic type B dissection with acute expansion of iliac artery aneurysm in previous endovascular repair with iliac branched graft

We report the case of a patient previously treated with an iliac branch endograft for isolated iliac artery aneurysm who developed, more than 2 years later, a type B aortic dissection resulting in the acute expansion of the previously excluded iliac aneurysm. Successful endovascular salvage is described

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics

Alternative hybrid reconstruction for bilateral common and internal iliac artery aneurysms associated with external iliac artery occlusion

Purpose: To describe an alternative reconstruction for bilateral common (CIA) and internal (IIA) iliac artery aneurysms associated with external iliac artery (EIA) occlusion in a patient unfit for open surgery. Case Report: A high-risk 81-year-old man presented with contained rupture of a left CIA aneurysm in the presence of bilateral CIA and IIA aneurysms associated with complete occlusion of the left EIA and normal patency of both common femoral arteries. In an emergent procedure, the left EIA was recanalized subintimally, and the right IIA was embolized with a 14-mm Amplatzer Plug. The main body of a standard Excluder endograft was deployed just distal to the origin of the left renal artery, and the ipsilateral leg was extended into the proximal right EIA. On the contralateral side, a short 10-mm-diameter limb was inserted through a 12-F sheath and deployed in the CIA, proximal to the iliac bifurcation. Via a percutaneous left brachial artery access, 3 covered stents (9359 mm, 10359 mm, 10359 mm) were deployed from the distal IIA to the endograft contralateral limb. A right-to-left femorofemoral crossover bypass graft concluded the operation. The patient was discharged on the 5th postoperative day without complications; follow-up imaging at 6 months showed patency of the stent-graft and crossover bypass, with complete exclusion of the aneurysms and no evidence of endoleak. Conclusion: This case demonstrates an effective solution for complex aortoiliac lesions using commercially available devices, underlining how an accurate knowledge of alternative endovascular techniques and materials is crucial in the management of complex cases