Journal of Endovascular Therapy

This study aimed to assess the midterm outcomes of a novel embedded modular single-branched stent-graft (EMSBSG) designed to preserve the left subclavian artery (LSA) of type B aortic dissection (TBAD).

From December 2020 to November 2021, a total of 120 patients with TBAD treated with an EMSBSG were enrolled in a multicenter prospective clinical trial at 18 Chinese tertiary hospitals. Follow-up computed tomography angiography scanning was conducted at 1, 6, and 12 months postprocedure.

The technical success rate was 99.17% (n = 119/120), with only 1 technical failure attributed to aortic intimo-intimal intussusception. The 30-day mortality rate was 0.83% (n = 1). Thirty-day major complications included 2 cases (1.67%) of retrograde type A aortic dissection (RTAD), 3 cases (2.50%) of stroke, and 6 cases (5.22%) of Type Ia endoleaks. The median follow-up time was 12.84 (range, 11–16) months. The 1-year mortality rate was 4.17% (n = 5/120), and the follow-up patency rate of the branch section was 99.09% (n = 109/110). The overall 12-month reintervention rate was 4.17% (n = 5), including 3 RTAD cases, 2 Type I endoleaks, and 1 stent-induced new entry.

For patients with TBAD involving the LSA, the midterm outcomes are encouraging for EMSBSG as a relatively safe, effective, and noncustomized endovascular option. However, long-term outcomes warrant attention and further investigation.

The midterm outcomes indicate that EMSBSG offers a safe, and effective endovascular option for preserving the LSA in patients with TBAD. The EMSBSG achieves LSA preservation through a non-customized endovascular solution, making it particularly suitable for emergency procedures. The core innovation of EMSBSG lies in its flexible, modular Embedded design, which adapts to the anatomical characteristics of TBAD in patients.

To perform a systematic review and meta-analysis of the outcomes of Anaconda fenestrated endograft for the treatment of complex abdominal aortic aneurysms (cAAA).

A systematic search of all the literature reported until May 2024 was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The pooled 30-day mortality rate, technical success rate, reintervention rate as well as bridging stent occlusion rate, and corresponding 95% confidence intervals (CIs) were estimated using fixed or random effect methods.

A total of 526 study titles were identified by the initial search strategy, of which 6 were considered eligible for inclusion in the meta-analysis. A total of 782 patients (89% male) were identified among the eligible studies. The pooled 30-day mortality rate was 4.8% (95% CI, 3.5%–6.5%) while the reintervention rate was 7.9% (95% CI, 4.3%–14.1%) and 10.2% (95% CI, 5.8%–17.4%) in the early and late period, respectively. The pooled bridging stents occlusion was 2.7% (95% CI, 1.5%–4.9%) during 30 days and 3.5% (95% CI, 1.6%–7.6%) during follow-up. Overall technical success was 86.1% (95% CI, 62.9%–95.8%).

The use of the Anaconda fenestrated endograft in treatment of complex aortic aneurysms involving the abdominal visceral vessels has low early and late mortality. Low rate of bridging stent occlusion occurs early postoperatively and during follow-up, mostly involving the renal arteries. Reinterventions during follow-up are mostly induced by limb occlusion. Lower early technical success rate is explained by the presence of a type Ia endoleak on final angiography, which however resolves spontaneously early postoperatively.

The present systematic review and meta-analysis of observational studies provide evidence-based data regarding the safety and efficacy of the fenestrated Anaconda device for the primary treatment of cAAA in the perioperative period and at long-term follow-up. Six studies with an overall 782 patients were included. The technical success in patients with cAAA treated with Anaconda fenestrated endograft was 86% while the reintervention rate was 7.9% and 10.2 during the perioperative and long-term follow up period. The pooled 30-day occlusion rate for the bridging stents was 2.7% while the late pooled occlusion rate for the bridging stents among the studies was 3.5%. The use of the Anaconda fenestrated endograft in treatment of complex aortic aneurysms involving the abdominal visceral vessels seems feasible with promising outcomes. The lower early technical success is obscured by the presence of type Ia endoleak which, resolves spontaneously early postoperatively.

Limus-based balloons, stents, and scaffolds are alternatives to paclitaxel-coated devices in peripheral endovascular treatment. This study aims to review contemporary evidence on the efficacy and safety of limus-coated devices in the treatment of lower extremity peripheral arterial disease (PAD).

A systematic literature review was performed using PubMed, Web of Sciences, OvidSP, and EMBASE, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Efficacy endpoints were primary patency (PP), freedom from clinically driven target lesion revascularization (CD-TLR) and Rutherford-Becker improvement; safety endpoints included target limb amputation and all-cause mortality.

From a primary search of 453 articles between 27th June 2002 to 15th September 2024, 30 publications, among which were 27 prospective trials, 10 multicenter studies and 11 double-arm studies, with 2325 patients were analyzed. The numbers for above-the-knee (ATK) limus-balloons, stents, scaffolds and below-the-knee (BTK) limus-balloons, stents, scaffolds were 76, 333, 35, 55, 1445, 381 respectively. With a mean 12-month follow-up, PP for ATK lesions was 86.50% for sirolimus-coated balloons (SCB), 86.80% for sirolimus-eluting stents (SES), 72.60% for everolimus-eluting stents (EES), 86.20% for everolimus bioresorbable vascular scaffold (EBVS); whereas PP for BTK lesions was 72.60%, 73.20%, 71.60 and 83.80% respectively. Absence of CD TLR for ATK lesions was 96.50%, 95.50%, 87.60%, 89.20% respectively; meanwhile 84.90%, 75.80%, 87.70%, 94.30% for BTK lesions respectively. Rutherford-Becker improvement with 86.70%, 84.50%, 79.80 and 90.80% were seen in ATK lesions respectively, similarly, 76.50%, 81.90%, 79.50%, 92.30% respectively were observed in BTK lesions. Efficacy and clinical outcomes of SES, EES and EBVS in BTK lesions were significantly superior, where vascular complications had no proven significant difference regardless of lesion locations nor device types.

Limus-coated/eluting balloons, stents, and scaffolds are safe adjuncts and potentially superior alternative in endovascular treatment for lower extremity PAD, especially well proven in BTK lesions. However, more statistically significant evidence is recommended to validate the long-term efficacy on ATK lesions and overall use of non-SES devices regardless of locations.

Limus (siro-, zotaro-, evero-, bio-, amphi-, tacrolimus) have potent antiproliferative effects in atherosclerosis. This systematic review analyzes evidence for the efficacy and safety of limus devices (balloons, stents, and scaffolds) in the treatment of femoropopliteal and below-the-knee PAD. There were 5 single-arm studies with 309 patients on femoropopliteal disease, and 11 studies with 679 patients on below-the knee (BTK) diseases. The overall primary patency rate, significant freedom from target lesion revascularization and improvement in Rutherford-Becker classification were high. Certain limus devices have shown to be superior to non-limus devices. Limus scaffolds are new developments with promising short-term results.

Over the years, paclitaxel-coated balloons (PCBs) have been considered a standard treatment for femoropopliteal (FP) lesions due to their higher efficacy compared to noncoated balloon angioplasty. However, some studies have raised concerns about a potential link between PCBs and increased long-term mortality. Although relatively new, sirolimus is studied as an alternative that could be safer and more efficacious.

This study aims to analyze the efficacy and safety of novel sirolimus-coated balloons (SCBs) for the treatment of femoropopliteal lesions.

A literature search was conducted across PubMed, Scopus, Cochrane, Science Direct, and Google Scholar databases. Five single-arm trials met the predefined eligibility criteria for inclusion and were assessed using the ROBINS-I tool. Data extraction was followed by single-arm meta-analysis in RStudio with meta package software.

Overall, a total of 5 single-arm trials were included. During 6-month follow-ups, SCBs have proven to have a high primary patency rate (pooled: 92%) and high freedom to target lesion revascularization (TLR) rates (pooled: 96%) with no heterogeneity (I² = 0%). In terms of safety, the pooled incidence of clinically driven—target vessel revascularization (CD-TVR) is 1%, while pooled clinically driven—target lesion revascularization (CD-TLR) rate is 2%, pooled amputation rate is 3%, and pooled incidence of mortality was 1%. During 12-month follow-ups, SCBs have high primary patency rate (pooled: 87%), high freedom to TLR rates (pooled: 96%), low amputation rate (pooled: 3%), and pooled incidence of mortality was 4%.

Novel SCB is efficacious and safe in treating femoropopliteal lesions and thus could be a prompt alternative in treating FP lesions, although further studies are still needed. Hopefully, this method could be a treatment option for FP disease in symptomatic patients.

Sirolimus-coated balloons (SCBs) offer a promising alternative to paclitaxel-coated balloons (PCBs) for femoropopliteal lesions, demonstrating high efficacy with superior primary patency and low target lesion revascularization rates. The findings suggest SCBs may mitigate safety concerns associated with PCBs, potentially reducing long-term mortality risks. For clinicians, this innovation provides a safer, effective endovascular option, enhancing patient outcomes while maintaining procedural simplicity. With further validation, SCBs could redefine the standard of care for peripheral artery disease, ensuring optimal long-term vascular health with minimal complications.

Malposition of central venous catheter is a notable technical complication and often need retrieval to avoid further complications. We present a retrospective assessment of case series and literature review of the safety and efficacy of open and endovascular procedures performed to retrieve malpositioned central venous catheters in the subclavian artery.

PubMed/Medline, Ovid and Embase.

A retrospective analysis was conducted of the clinical data of seven patients referred to our hospital between 2014 and 2023, in whom malpositioned central venous catheters were incidentally inserted within the subclavian artery and were retrieved. A systematic literature review was undertaken according to PRISMA guidelines to evaluate the efficacy and safety of the reported ways of management. Two investigators independently performed case series and case reports screening in the literature to reveal and evaluate the efficacy of open and endovascular treatment of malpositioned central venous catheterization.

Technical success in safe removal of the misplaced catheter was achieved in all cases. Out of the seven patients, 6 patients (85.7%) were treated endovascularly (four of them (66.6%) treated by ANGIO-SEAL^® closure device (Terumo) and two of them (33.3%) were treated with adjunct VIABAHN^® covered stent (GORE^®), while only one patient was managed by open surgery. All the patients went through uneventful recovery, with mean hospital stay of 3.67 days for the endovascular-treated patients, while the open surgery-treated patient stayed for 12 days. Literature review identified 21 cases of malpositioned central venous catheter, 13 cases were managed by ANGIO-SEAL^® closure device (Terumo), three cases were managed by StarClose SE™ (Abbott), two cases were managed by EXOSEAL™ (Cordis), two cases were managed by VIABAHN^® ENDOPROTHESIS (GORE^®), and one case was treated by open surgical repair. Twenty cases showed no postoperative complications, and only one case showed postoperative pseudoaneurysm which was treated by ultrasound-guided compression.

Closure devices, with ANGIO-SEAL (Terumo) being the commonest method, can be safely and effectively utilized for endovascular closure of the subclavian artery following removal of malpositioned central venous catheters. The endovascular options are also accompanied by short hospital stay and lower morbidities. Open surgery should be reserved for patients in whom endovascular options fail.

This patient case series and the literature review provided a safe and efficient intervention for treatment of malpositioned central venous catheters in arterial access using Angioseal closure devices, Despite using it out of its IFUs, but it proved to be a proper solution for such complication apart from the known open surgical intervention which accompanied by long hospital stay and morbidity.

To systematically review the literature on the effectiveness, safety, and long-term outcomes of genicular artery embolization (GAE) for knee joint osteoarthritis (OA) associated pain.

After registering the protocol with the PROSPERO database, a search was conducted from inception until July 31, 2023, in MEDLINE, Cochrane Central Register of Controlled Trials, and ScienceDirect databases to gather studies evaluating GAE’s safety and efficacy in knee OA. A total of 4979 studies were identified and evaluated against the inclusion criteria. Data on study characteristics, success parameters, and adverse events were collected and synthesized.

Twenty-three studies, primarily single-center prospective studies with a total of 657 patients, were included. Most studies reported a 100% technical success rates, except one study reporting a rate of 84.2%. Clinical success rates, defined variably across studies, ranged from 30% to 100%, depending on the study’s follow-up period and outcome measures. The most frequent adverse events included skin discoloration without an ulcer (15.6%, n = 98) and transient post-procedural knee pain (10.2%, n = 64). Most studies were rated as fair in terms of quality, but the lack of robust randomized controlled trials highlighted the need for further comparative studies to standardize outcome reporting.

GAE appears to be a promising option for knee OA pain, particularly for patients unresponsive to conservative treatments or ineligible for surgery. High-quality studies are needed to confirm long-term effectiveness and standardize outcome measures.

This study highlights the safety and efficacy of genicular artery embolization as a minimally invasive treatment for knee osteoarthritis, particularly in patients who are unresponsive to conservative treatments or unsuitable for surgery. By targeting neovascularization and reducing inflammation, genicular artery embolization provides pain relief and functional improvement. Clinicians can consider genicular artery embolization as an alternative to surgery for mild-to-moderate OA, offering a lower adverse event rate and faster recovery.

To identify, synthesize, and critically appraise the published studies reporting outcomes of atherectomy and/or intravascular lithotripsy (IVL) for symptomatic common femoral artery (CFA) atherosclerosis and therefore provide support in clinical decision-making.

Systematic review with meta-analysis.

This review was registered in PROSPERO and followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A search was performed on MEDLINE and Embase. Inclusion criteria were prospective or retrospective comparative or non-comparative studies and research letters, published between Jan 01, 2000 and Dec 01, 2023, written in English or French, that reported on adults with symptomatic atherosclerotic stenosis or occlusion, localized within the CFA, treated with atherectomy and/or IVL. Study and lesion characteristics, clinical and technical outcomes were extracted independently by 2 reviewers, and data were pooled for 5 selected outcomes. Risk of bias was assessed with Mixed Methods Appraisal Tool (MMAT).

Sixteen studies (13 on atherectomy, 960 limbs; 3 on IVL, 66 limbs) were included. Both atherectomy and IVL had good outcomes in terms of technical success (96% vs 97%), proportion of bailout stenting (6% vs 8%), freedom from target lesion revascularization (TLR; 90% vs 91%), and limb salvage (97% vs 95%). IVL tended to have more perioperative complications than atherectomy (16% vs 10%). Five studies on atherectomy and 2 studies on IVL met all 7 MMAT criteria, 4 studies on atherectomy met 6 criteria, while 4 studies on atherectomy and 1 study on IVL met 4 or 5 criteria.

Atherectomy and IVL can have equally good short- to mid-term outcomes for the treatment of symptomatic CFA atherosclerosis in terms of technical success, as well as freedom from TLR and limb salvage. Although these findings suggest that the choice between atherectomy and IVL for CFA atherosclerosis can be at the discretion of the clinician, further studies with longer follow-up are needed to formulate clinical recommendations.

This systematic review with meta-analysis can help clinicians to make evidence-based choices between endovascular treatments for common femoral artery (CFA) atherosclerosis. It shows that atherectomy and intravascular lithotripsy (IVL) have equally good short- to mid-term outcomes in treating CFA atherosclerosis, both in terms of technical success, as well as limb salvage and freedom from target lesion revascularization. These findings suggest that the choice between atherectomy and IVL for CFA atherosclerosis can be at the discretion of the clinician, however, further studies with longer follow-up are needed to formulate clinical recommendations.

Aim of this review is to compare pooled data on early and late outcomes between endovascular and open treatment for chronic mesenteric ischemia (CMI).

The present systematic review and meta-analysis was conducted under the PRISMA guidelines. The following databases were utilized: Pubmed, Embase, Scopus, and Cochrane Library. All eligible studies published online up to April 2024 were investigated. Eligible studies should compare early and/or late outcomes between endovascular repair (ER) and open surgery (OS) for CMI. Early outcomes included 30-day mortality, myocardial infarction (MI), pulmonary, gastrointestinal, and renal complications. Late outcomes included all-cause survival, symptom recurrence, and re-intervention.

In total, 15 studies (published from 1995 to 2024) were evaluated (12,326 patients under ER versus 6008 patients under OS). Regarding 30-day outcomes, ER was associated with a lower 30-day mortality risk (pooled OR = 0.58; 95% CI [0.347-0.975]; p = 0.039), a lower 30-day MI risk (pooled OR = 0.59; 95% CI [0.351-0.989]; p=0.045), a lower pulmonary complications risk (pooled OR = 0.18; 95% CI [0.075-0.426]; p=0.0001), and a lower 30-day renal complications risk (pooled OR = 0.28; 95% CI [0.146–0.553]; p=.00002). Regarding late outcomes, ER was associated with a lower overall 5-year survival (pooled OR = 0.414; 95% CI [0.291-0.591]; p < 0.0001). ER was also associated with a higher 3-year symptom recurrence risk (pooled OR = 3.77; 95% CI [2.314–6.142]; p < 0.0001) and a higher 5-year re-intervention risk (pooled OR = 2.40; 95% CI [1.538–3.739]; p=0.0001).

ER is associated with superior early outcomes and worse late outcomes compared to OS among patients treated for CMI.

This is the most updated meta-analysis comparing pooled data between percutaneous endovascular repair (ER) and open surgery (OS) for patients with chronic mesenteric ischemia. This review verifies the advantage of endovascular treatment regarding early outcomes. However, this benefit is lost in the long-term as far as mortality and re-interventions are concerned. These findings seem to further support the current endovascular-first approach. One should take into consideration that ER is probably selected for patients of worse clinical status. OS may be more suitable for fitter patients who are not candidates for ER.

For the treatment of infrapopliteal artery disease (IPAD), endovascular intervention is a main choice, including atherectomy (ATH) and balloon angioplasty. However, the comparative efficacy between both approaches was heterogeneous in prior studies. Lesion length is a critical factor in IPAD anatomy classification. There is no meta-analysis to study the influence of lesion length on the effects of atherectomy for IPAD treatment. This meta-analysis aimed to determine the efficacy of angioplasty with ATH in different ranges of lesion length compared to angioplasty without ATH.

Studies comparing ATH and angioplasty without ATH, which published up to April 2024 were retrieved from Pubmed, Embase, and Web of Science. Endpoints included limb prognosis and vessel complications. Referring to Trans-Atlantic Inter-Society Consensus, 10 cm lesion length was defined as a cutoff value for subgroup analysis. Pooled data were calculated using the Revman 5.4 and Stata 15, presented as odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was calculated using I² value. Methodological quality was assessed by Cochrane tool and Newcastle-Ottawa Scale. The robustness of findings would be evaluated by sensitivity analysis. Egger’s test was performed to detect publication bias.

Eleven studies (8412 patients) were included in this meta-analysis. Significant higher technical success was detected in ATH group (OR=1.99, 95% CI 1.44–2.76, I²=0%). In a subgroup of mean lesion length <10cm, ATH was associated with lower incidence of dissection (OR=0.19, 95% CI 0.05–0.67, I²=15%, p=0.01) and bailout stenting (OR=0.18, 95% CI 0.05–0.71, I²=16%, p=0.01). No significant differences were found between ATH and no ATH cohorts in primary patency (OR=1.65, 95% CI 0.85–3.19), all-cause death (OR=0.75, 95% CI 0.5–1.13), limb salvage (OR=1.03, 95% CI 0.75–1.41), target-lesion revascularization (OR=0.77, 95% CI 0.47–1.27), and embolization (OR=1.19, 95% CI 0.5–2.83).

For IPAD, lesion length is a notable factor affecting the efficacy of ATH. In comparisons with angioplasty without ATH, the use of ATH is contributable in achieving higher technical success. The superiority of ATH may appear in reducing dissection and bailout stenting in treating IPAD with length <10cm. Nevertheless, regardless of lesion length, there seems that ATH cannot effectively improve limb salvage compared to angioplasty alone.

Prior results of several meta-analyses comparing angioplasty with atherectomy to angioplasty alone were inconsistent in prognosis of infrapopliteal artery disease (IPAD), due to high heterogeneity. Considering the lesion length plays a critical role in IPAD anatomy classification, we performed an updated meta-analysis and subgroup analysis based on average lesion length to furtherly evaluate the efficacy of angioplasty following atherectomy. Our study revealed atherectomy showed advantages in obtaining technical success for IPAD ≥ 10cm and reducing the risks of bailout stenting and dissection for IPAD < 10cm. Atherectomy may prevent target-vessel complications rather than improving late patency and limb salvage effectively.

To evaluate the clinical outcomes after endovascular treatment of native femoropopliteal lesions with a drug-coated balloon (DCB) and drug-eluting stent (DES) as a primary option in patients with symptomatic peripheral artery disease.

A comprehensive literature search was performed through PubMed and Embase databases. Studies written in the English language and reporting a direct comparison of the outcomes between primary angioplasty with DCB and primary stenting with DES were included. The endpoints were considered the primary patency (PP), clinical-driven target lesion revascularization (cdTLR), major adverse limb events (free-MALE), and freedom from all-cause mortality.

Eleven studies were considered eligible for the metanalysis (3 randomized clinical trials and 8 cohort studies). Overall, 3231 femoropopliteal lesions in 3137 patients were included, with DCB and DES performed in 1951 and 1280 lesions, respectively. No differences were found in demographics, clinical limb presentation, lesions length [173.9±80.2 mm DES vs 195.1±103.3 mm DCB; odds ratio (OR) −2.44; 95% confidence interval (CI) −11.26 to 6.38; p=0.59] and total occlusions (OR 1.41; 95% CI 0.87–2.27; p=0.16). In the DCB group, there was a significant rate of adjunctive procedures such as atherectomy and bailout stenting OR 0.13 (95% CI 0.09–0.18; p<0.001). No differences among PP, cdTLR, free-MALE and freedom from all-cause mortality at 1 year for DCB and DES: OR 1.11 (95% CI 0.74–1.66, p=0.61); OR 1.01 (95% CI 0.72–1.41, p=0.97); OR 1.08 (95% CI 0.69–1.69, p=0.74) and OR 1.85 (95% CI 0.82–4.17, p=0.14) respectively. No differences were found at 2 years: OR 0.89 (95% CI 0.64–1.23, p=0.47); OR 0.79 (95% CI 0.49–1.27, p=0.32); OR 0.74 (95% CI 0.49–1.10, p=0.14); OR 1.21 (95% CI 0.75–1.96, p=0.44) respectively.

Both approaches proved to be effective and safe for treating complex femoropopliteal lesions, with comparable clinical outcomes between the 2 groups. In the DCB arm, adjunctive procedures such as atherectomy and bailout stenting were required to optimize the results.

The introduction of drug-coated technologies, such as drug-coated balloons (DCBs) and drug-eluting stents (DESs), has significantly improved clinical outcomes for native femoropopliteal lesions. However, despite ongoing advancements in drug-coated device technology, the optimal treatment approach remains unclear due to limited comparative data in the literature. This meta-analysis aims to bridge this gap by reviewing current evidence, highlighting the latest developments, and providing valuable insights that may aid clinical decision-making in the management of native femoropopliteal lesions.

To report a case series on using a novel semi-branch feature in custom-made stent-grafts in the endovascular treatment of complex aortic aneurysms and summarize the contemporary usage of this technology.

Four patients underwent endovascular aortic aneurysm repair (EVAR) with a custom-made semi-branch stent-graft (Semi-Branch Endovascular Aortic Aneurysm Repair [SBEVAR]). Two male patients, 75- and 76-year-old, were treated due to failed EVAR with late-type Ia endoleak, and the other two, 80- and 55-year-old male patients, due to a juxta-renal aortic abdominal aneurysm (JRAAA). In 3 cases, the celiac trunk (CT) vessel was targeted through an inner semi-branch; in the other case, all target vessels were bridged through inner semi-branches. Intra-operative technical success was accomplished in all 4 patients. Post-operative recovery was uneventful in all cases. The 30-day computed tomography angiography (CTA) follow-up for each patient showed patent target vessels, excellent apposition of the bridging stent to the semi-branch, and complete exclusion of the aneurysm.

The present report and the literature review demonstrate that introducing this novel semi-branch technology for the endovascular treatment of complex aortic aneurysms is feasible and holds great potential. The encouraging outcomes in cases of JRAAA and failed EVAR with late-type Ia endoleak inspire further studies to explore additional uses of this new tool in treating aortic pathologies.

The inner semi-branch is a novel technology for the incorporation of the renal and mesenteric vessels during complex endovascular aortic aneurysm repair. This new feature allows the use of a branched stent graft with a shorter length of the proximal sealing zone, reducing, consequently, the aortic coverage. It efficiently treats pathologies in which fenestrations could be inappropriate because precise stent graft placement might be difficult and in which tiny diameters leave inadequate room for typical inner branches. Although encouraging findings have been reported, long-term outcomes in target vessel stability have yet to be described.

This technical note introduces the first open surgical conversion after a failed branched endovascular repair of a thoracoabdominal aortic aneurysm, using the new hybrid Thoracoflo device. This innovative technique reduces reno-visceral ischemia time and can be performed through a xipho-pubic laparotomy without the need for extracorporeal circulation. It offers a safe and effective solution for complex thoracoabdominal aortic diseases, and can also serve as a bailout option following endovascular failure.

The purpose of this study is to describe a new bailout maneuver for use during fenestrated thoracic endovascular aneurysm repair (fTEVAR) in the event of wire wrap or wire entanglement with the proximal graft fabric.

A 68-year-old-man with hypertension and chronic atrial fibrillation underwent elective thoracic endovascular aneurysm repair (TEVAR) with a left subclavian fenestration to treat a residual arch and thoracic aortic aneurysm after previous type A dissection repair. The procedure was challenging due to malrotation of the main body graft, as well as wire entanglement of the precannulated through-and-through wire on the leading edge of the main body fabric. A novel bailout maneuver is described. Through-and-through access was maintained, and a long 8F sheath was delivered through the fenestration from femoral access, and an 8.5F steerable sheath was delivered through upper extremity access. This allowed coaxial snaring of a new through-and-through wire via the gutter between the stent-graft and native aorta in the seal zone, which both reoriented the fenestration, and permitted placement of a bridging stent to the left subclavian artery.

The retrograde-access gutter snare (RAGS) technique described above provides a streamlined approach to achieve technical success in challenging fenestrated thoracic endovascular aneurysm repair (fTEVAR) cases.

This technical note describes the retrograde-access gutter snare (RAGS) technique that can provide a successful bailout maneuver for fenestrated TEVAR (fTEVAR) devices. The RAGS technique offers an approach to be used with precannulated custom-made or physician-modified fTEVAR devices in which wire wrap or wire entanglement precludes access through the fenestration after deployment of the main body device. Instead of traditional attempts at de novo cannulation of the fenestration from upper extremity or femoral access, the maneuver offers an approach to maintaining through-and-through access to facilitate snaring a new wire proximal to the leading edge of the main body fabric, which can then be used to deliver a covered stent into the fenestration from either the upper extremity or femoral access. This technique offers an added benefit of potentially realigning malrotated fenestrations via tensioning of the new through-and-through wire.

Endovascular interventions have become the primary choice for treating complex aortic pathologies, particularly with the use of fenestrated and branched endografts. However, limitations, such as manufacturing time have restricted their applicability in urgent situations. This has led to explore alternative off-the-shelf solutions, including in situ fenestration. Within this technical note, we describe technical aspects of in situ fenestration using electrosurgical guidewire, in both antegrade and retrograde approaches, explaining advantages and limitation compared with other in situ fenestration techniques.

The technique involves standard main body endograft deployment followed by targeted in situ fenestration using an electrified guidewire. Two illustrative cases are presented to demonstrate the technical aspects and clinical outcomes of this procedure.

Electrosurgical in situ fenestration emerges as an effective technique for urgent treatment of complex aortic diseases. Further research is warranted to validate its safety and durability in larger patient cohorts.

Electrosurgical in situ fenestration allows to expand the feasibility of complex endovascular repairs in emegency settings. Electrosurgical in situ fenestration combines the benefits of thermal methods, offering broad availability and lower costs. Compared to other in situ fenestration techniques, the proposed technology allows for the creation of extremely small fenestrations with minimal and precise tissue disruption.

To present the use of the electrified wire technique as bailout for target vessel (TV) branch preservation after unintended coverage by a bridging stent during branched endovascular repair (bEVAR).

A 73-year-old male, previously treated with thoracic endovascular aortic repair and Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) for type B aortic dissection, presented with a 68 mm type V thoracoabdominal aortic aneurysm. The patient presented an anatomic variation with a common trunk for the superior mesenteric artery (SMA) and celiac artery (CA). After a previously failed open surgical attempt, a triple-branch custom-made device (2 renal branches and 1 for the SMA/CA trunk) was chosen. Endograft deployment and TV catheterization were uneventful, until an unintended coverage of the CA occurred, due to bridging stent unmount. Using the electrified wire technique, an in situ fenestration was created into the CA/SMA trunk covered bridging stent to preserve CA patency. A bare metal stent was used for CA revascularization. Renal arteries were catheterized and bridged as planned. The 6-month computed tomography angiography confirmed TV patency.

The electrified wire technique may be used as bailout for in situ fenestration creation in unintended coverage of early TV side-branches.

Anatomic variations may increase the technical complexity of branched endovascular aortic repair while technical pitfalls related to target vessel preservation may demand the application of bailout techniques. In this case, the electrified wire technique was used to create an in situ fenestration within the bridging stent of a celiac artery (CA) and superior mesenteric artery common trunk (anatomic variation), after bridging stent unmount during advancement and CA unintended coverage.

The profunda femoral artery (PFA) puncture is generally fraught with risk of bleeding and iatrogenic damage, leading to possible impaired flow in such a valuable artery. However, the PFA represents a potential retrograde path to the common femoral artery (CFA) due to its usual good size and convenient location. Since endovascular treatment of the CFA and its bifurcation is gaining popularity, this study intends to report the use of PFA access in complex revascularizations.

This is a retrospective multicenter registry on PFA retrograde approaches, including 15 cases in which this access was used during challenging recanalizations of iliac and femoral chronic total occlusions (CTO). This access was performed as a bailout in 11 cases (73.3%). The puncture’s technical success and the diseased segments’ recanalization were achieved in all cases. Hemostasis was done by intraluminal balloon inflation (9/15, 60%), external manual compression (4/15, 26.7%), or closure device deployment (2/15, 13.3%). No complications related to the access were noted.

This series represents the largest cohort of patients who underwent retrograde PFA puncture for iliac and femoral CTO crossing. It shows how different clinical and anatomical settings may suit this endovascular approach, making it a safe alternative that vascular specialists should be aware of.

Retrograde puncture of the profunda femoral artery (PFA) could represent a strategic approach during complex iliac and femoral endovascular revascularizations and total endovascular femoral reconstruction. This article presents 15 cases of PFA retrograde puncture and conveys technical tips for performing this maneuver correctly and avoiding potential risks at the level of this vessel. Surgeons and interventionalists should be aware of this possibility, especially with the increasing number of total endovascular treatments of the femoral bifurcation.

To describe a novel endovascular technique to treat ilio-femoral reflux in post-thrombotic syndrome (PTS). It consists of regulated exclusion of a femoral vein (FV) segment with indication based on Doppler ultrasound (DUS) scan and ascending and descending venogram.

Through lower limb venous DUS, we identify a post-thrombotic refluxing FV, characterized by a duplicated FV and/or ascending collateral veins draining into a common trunk with a re-entry point into the refluxing FV itself. The above findings indicate a second-level venogram. If the descending phase confirms the FV reflux pattern, we perform an ascending venogram to confidently locate where the draining blood is shunted into the FV. We proceed with the scleroembolization of the segment below the shunt. The postoperative venogram documents the treated segment occlusion and the elimination of the reflux. We described 4 cases: 3 successful reflux eliminations and 1 case where we decided not to treat. Mean follow-up lasts 6.5 months with DUS showing the abolition of the reflux; the overall Villalta score, performed at the baseline and last follow-up visit, resulted statistically significant (p = 0.0087).

Performing an endovascular regulated exclusion of FV refluxing segment opens a great scenario for PTS treatment; multicenter randomized trials are warranted.

Recanalized post-thrombotic syndrome, with reflux involving the ilio-popliteal segments, affects the patient’s life without any clear surgical indication. The proposed protocol and technique are based on performing a descending and ascending venogram to identify the point of femoral vein duplication. The regulated exclusion of the refluxing FV segment, below the duplication, by means of scleroembolization, allowed to permanent abolish the reflux. This novel technique is minimally invasive and presents great potential for treating a significant proportion of patients currently managed exclusively with conservative approaches.

To describe and share our experience of the “Lasso-Technique,” employing a Snare® catheter combined with a small-sized 7F steerable sheath to facilitate transfemoral access to antegrade aortic branches during branched endovascular aortic repair.

Cannulation of antegrade branches of a thoracoabdominal aortic stent graft via transfemoral access is technically challenging, even with a steerable sheath. For example, introducing a bridging stent may deflect the sheath cranially and prohibit successful implantation. To avoid alternative brachial access and associated complications, we employed and presented herein the “Lasso-Technique.”

The tip of the 7F steerable sheath is caught using the Snare® catheter (introduced via a contralateral femoral access with a minimum sheath size of 4F), which is then locked by a mosquito clamp. While introducing the bridging stent into the target branch, the assistant stabilizes the sheath by slightly pulling the Snare-catheter.

The presented approach is an easily accomplished maneuver enabling transfemoral implantation of bridging stents in thoracoabdominal aortic stent grafts. Compared to similar techniques, it requires sheaths with smaller diameters (7F and 4F vs 12F) yet bilateral femoral artery puncture. It allows for hooking the sheath in the target branch, offering increased stability while being safer compared to upper extremity access approaches.

The “Lasso-Technique” is a practical and reproducible method for accessing branches during branched endovascular aortic repair (b-EVAR) procedures. The technique eliminates the need for brachial access, potentially reducing radiation exposure and complications associated with upper-extremity access. It utilizes readily available tools and small-caliber sheaths, making it easy for most vascular centers to adopt without requiring additional resources. Its straightforward design may help streamline workflows while enhancing patient safety.

Emergent repair of paravisceral aortic aneurysms (pAAs) with in situ laser fenestration (ISLF) technique is associated with renovisceral ischemia. We describe two strategies of temporary gutter endoleak creation to ensure renovisceral perfusion during ISLF.

Two patients (79- and 83-year-old) presented with symptomatic pAA. A Cook Zenith Alpha endograft (Cook Medical LLC, Bloomington, IN, USA) was used in both cases. All visceral vessels were prestented to serve as guide markers. Prior to the deployment of the endograft, a Cook Flexor 8F-sheath (Cook Medical LLC, Bloomington, IN, USA) was placed in the superior mesenteric artery (SMA) (patient #1), and a 5 mm × 200 mm angioplasty Armada balloon (Abbott, Green Oaks, Illinois, USA) was placed between the endograft and the aortic wall (patient #2). Angiograms after visceral coverage confirmed perfusion of the renovisceral arteries through the intentional gutter endoleaks. Thereafter, ISLF and bridging stenting for SMA and the renal arteries were performed before the removal of the sheath or balloon to stop the gutter endoleak. Both patients did not experience any kind of perioperative complications.

The above-described techniques for gutter endoleak creation during emergent pAA repair with ISLF can potentially reduce reno visceral ischemia and increase the ISLF technique’s safety.

The ISLF technique for pAA repair typically requires coverage of the visceral arteries with unpredictable ischemia time until laser fenestrations are established. The gutter endoleak technique reduces the renovisceral ischemia and potentially increases the safety of the ISLF repair.

To experimentally investigate the behavior of a clinically used microcatheter during transarterial radioembolization (TARE) microsphere injection in a successively bifurcating in vitro model.

A symmetrical phantom was developed which bifurcated 3 times into 8 outlets. A blood-mimicking fluid was pumped through the phantom using a physiological representative waveform. Holmium-165 microspheres were injected in a pulsed manner at 3 different locations using a standard microcatheter and a rigid counterpart with same dimensions as a control. Motion of the catheter was studied with a top- and side-view camera on the phantom. Microspheres were collected at each outlet and their distribution over the 8 outlets was analyzed.

Due to the pulsatile flow in the phantom, strengthened by the pulsatile microsphere injection, the clinical catheter showed maximum displacements of 0.87 mm within a vessel with a diameter of 3.6 mm. This motion resulted in a different microsphere distribution for the clinical catheter compared with the rigid counterpart (75.9% vs 49.4% of the microspheres went to outlet 1–4, respectively).

In this in vitro model, the motion of the clinical catheter affected distribution of microspheres. Since the pulsatile administration of microspheres resulted in increased motion of the clinical catheter, standardizing microsphere administration could be beneficial to reduce interprocedural differences in TARE.

Our study demonstrated that microsphere distribution during transarterial radioembolization (TARE) is affected by catheter motion. Furthermore, increased catheter motion was observed as a result of the injection profile. Predictive tools such as the contrast CBCT and scout dose use different injection profiles compared to therapeutic TARE injections, potentially altering catheter tip behaviour and microsphere distribution, which could compromise their predictive values. Additionally, current TARE microsphere injection guidelines provide limited details, which may lead to variability across institutes and interventional radiologists. Standardizing injection techniques could reduce catheter motion variability and may facilitate more consistent and predictable microsphere distribution patterns.

The optimal design concept and the safety of drug-coated balloons (DCBs) have not been completely determined yet. Also, the optimal approach for DCB-based revascularization of peripheral artery diseases still remains undefined. This study was designed to explore the in vivo pharmacokinetic and histopathological effects of DCBs using Ranger and 4 Chinese DCBs after implantation and administration in New Zealand rabbits.

Fifty New Zealand rabbits were divided into 5 groups with 10 rabbits in each group according to the DCB used: Ranger (Boston Scientific), Orchid (Acotec), Reewarm (Endovastec), Ultrafree (Zylox), and Yaohang (Polyrey). After being guided to the lower segment of the abdominal aorta, the DCB was inflated for 3 minutes. Plasma, inflated infrarenal aorta, vastus lateralis muscle, anterior tibial muscle, and right toes were harvested for histological and paclitaxel concentration analyses 4 hours or 28 days after the angioplasty.

At 4 hours after aortic angioplasty, the overall paclitaxel concentrations in aortic wall were not statistically different (p = 0.050), but the paclitaxel concentrations in vastus lateralis muscle (p = 0.002), anterior tibial muscle (p = 0.006) and toe (p < 0.001) were not totally same according to the results of Kruskal-Wallis test. In toe, concentrations of paclitaxel were significantly lower for the Ranger (120.8 ng/g) DCB than for the Orchid (1880 ng/g; p = 0.008), Reewarm (347 ng/g; p = 0.016), and Ultrafree (261 ng/g; p = 0.016) DCBs. Concentrations of paclitaxel in the toe were not statistically different between Ranger and Yaohang DCBs (p = 0.421). Neointimal area (p < 0.001), neointimal thickness (p < 0.001), and percentage of luminal stenosis (p < 0.001) were less for Ranger DCB than for other DCBs 28 days after aortic angioplasty. The differences in paclitaxel concentrations in tissues 28 days after aortic angioplasty were not statistically significant.

Different design concepts will make a difference in the in vivo pharmacokinetic and histopathological effects of DCBs. The Ranger DCB can achieve similar drug delivery efficiency as other higher-dose DCBs and fewer neointimal hyperplasia. Although clinical implications remain to be further investigated, the present results may provide implications for the design and use of DCBs.

The current preclinical study suggested that different design concepts would make a difference in the pharmacokinetic and histopathological effects of drug-coated balloons (DCBs). Though Ranger DCB had the lowest paclitaxel loading in this study, it still achieved similar drug delivery efficiency with other higher-dose DCBs. Also, neointimal hyperplasia was less for the Ranger DCB than for the other DCBs 28 days after aortic angioplasty. Although clinical implications remain to be further investigated, the present results may provide implications for the design and use of DCBs.

Management of patients with large aortic arch aneurysms who are considered high risk for frozen elephant trunk technique have been challenging, especially when they have a dilated ascending aorta (AA) that precludes total endovascular branched repair (arch BEVAR). A viable option in our armamentarium is wrapping of the AA (AW), and zone 0 Ishimaru TEVAR.

Retrospective analysis of our aortic database from 2013 to 2024 to select high-risk patients with aortic arch aneurysm that had an AW and TEVAR. We performed CTA analysis before and after wrapping and TEVAR, and last available CTA. The primary end points were 30-day mortality and stroke.

A total of 12 patients had AA wrap and TEVAR, with supra-aortic vessels (SAVs) debranching (open or endovascular). In 9 patients, the indication for treatment was a large arch atherosclerotic aneurysm, and in 3 patients a dissecting arch aneurysm depicted during follow-up of AW initially performed for acute type A dissection (51.5 months on average between the wrap and the TEVAR). Average age was 72.9 years. Ascending aorta wrap and TEVAR were performed concomitantly in 3/12 patients, including 2 patients with rupture. It was staged in the other 9 patients. The average diameter of the AA pre-wrap was 47.7 (41.3-57), and post-wrap 35.6 (31.9-43) mm. The wrap provided an average seal length of 68.5 (38.4-97.4) mm. A total of 34 SAV were successfully debranched. No type 1 or 3 endoleaks were depicted on completion angiogram. Within the first 30 days, no strokes were diagnosed, and 1 patient with Horton disease died of cardiac arrest on postoperative day 7. Three patients required early reinterventions, including redosternotomy in 2 patients. Mean follow-up (FU) was 28 months (1-75). During FU, 1 patient developed a left vertebral artery steal phenomenon requiring a carotid subclavian bypass, and another patient died of an unknown cause.

Ascending aorta wrap technique with debranching of the SAVs and zone 0 TEVAR might be a good option in patients at high risk for open replacement of the AA and with unfavorable proximal seal zone for a total endovascular repair.

In the current study, we describe the treatment of aortic arch aneurysms in patients considered at high risk for open replacement of the aortic arch and also not candidate for complete endovascular arch repair (arch BEVAR). Ascending aorta wrap with surgical or endovascular debranching of SAVs and zone 0 TEVAR was performed in 12 patients with favorable outcomes. It should thus be considered a treatment option in this subset of fragile patients with unfavorable proximal seal zone for total endovascular repair. This technique does not require cardiopulmonary bypass (CPB) support, neither aortic cross-clamping

There are little available data about the impact of geriatric nutritional risk index (GNRI) on clinical outcomes following endovascular therapy (EVT) in chronic limb-threatening ischemia (CLTI) regarding the severities of renal dysfunction (RD).

The aim of this study is to evaluate the impact of GNRI on clinical outcomes following EVT in CLTI regarding the severities of RD.

We enrolled 705 consecutive CLTI cases treated with EVT between January 2010 and December 2019 at our hospital. The GNRI on admission was calculated as follows: [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight)]. Study population were divided into 2 groups based on the median GNRI: low group (GNRI < 92) and high group (GNRI ≥ 92). Next, study population was divided to 3 groups according to estimate glomerular filtration rate (eGFR), which was defined as early RD group (60 ≤ eGFR), advanced RD group (15 ≤ eGFR < 60), and end-stage renal dysfunction (ESRD) group (eGFR < 15). The primary endpoint was 2-year amputation-free survival (AFS).

The median follow-up duration was 25.2 months. Amputation-free survival was significantly lower in the low GNRI group regardless of any severities of RD (59.1% vs 90.2%, Log Rank P<0.001 in early RD group, 59.6% vs 80.8%, Log Rank P=0.011 in advanced RD group, 32.8% vs 61.1%, Log Rank P<0.001 in ESRD group).

The decrease of GNRI could predict clinical outcomes in CLTI following EVT regardless of any severities of RD based on eGFR.

The decrease of geriatric nutritional risk index was associated with worse outcomes in chronic limb-threatening ischemia following endovascular therapy regardless of any severities of renal dysfunction. Because both renal dysfunction and chronic limb-threatening ischemia could potentially have any inflammation, the geriatric nutritional risk index, which can reflect both nutrition-related risks and inflammation severity, can be a plausible marker in predicting adverse events after endovascular therapy in chronic limb-threatening ischemia patients with renal dysfunction.

Abdominal aortic aneurysms (AAA) are major causes of morbidity and mortality in the elderly population. Endovascular aneurysm repair (EVAR) is associated with lower complications rates than conventional treatment; however, rigorous follow-up with contrast imaging is required to confirm aneurysmal sac exclusion. The main objective of this study was to quantify and evaluate miRNA expression response to EVAR based on serum dosages at the 6-month follow-up.

47 patients with indication for EVAR were recruited and 10 patients without comorbidities. miRNA-181b and miRNA-21 were selected for this study and their serum dosages were measured at two time points: preoperatively and after 6 months of follow-up, and only once in the control group. Demographic profiles, clinical follow-ups, and imaging examinations with angiotomography performed preoperatively and after 6 months were collected.

Overexpression of miRNA-181b and miRNA-21 was observed in the whole blood of patients with AAA. EVAR of patients with AAA resulted in decreased expression of the studied miRNAs, indicating that exclusion of the aneurysmal sac alters the expression of these markers. In addition, the expressions of miRNAs did not correlate with endoleaks or the diameter of the aneurysm or with the different types of devices used for the EVAR.

The overexpression of miRNA-181b, miRNA-21 with its reduction after EVAR, may suggest the use of these molecules as potential biomarkers in the follow-up of these patients. However, miRNAs were not able to identify possible endoleaks or discriminate them into subtypes.

The clinical application of the use of biomarkers in other areas such as oncology is already well established. In endovascular surgery it is still incipient although with great potential in daily practice, in order to anticipate or schedule possible interventions in patients with endoleak. In addition, understand the mechanisms of action of miRNAs in Atherosclerotic diseases and aortic syndromes could provide a better understanding of the pathophysiology as well as pharmacological development for AAA prevention as well as remodeling of the aneurysm sac after EVAR.

This updated UK multicenter study aims to report long-term results following use of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD) in patients with chronic limb-threatening ischemia (CLTI) or intermittent claudication (IC).

A retrospective analysis was conducted including 85 patients who underwent CERAB between November 1, 2012, and March 31, 2020, till March 2024. Anatomical data were assessed using pre-operative imaging. Outcome measures included freedom from target lesion reintervention (fTLR), freedom from major limb amputation (fMLA), and overall survival.

The median age was 65 years, with 62.4% males. Over a median follow-up of 58.2 months (IQR 55.7–67.1 months), 2 patients were lost to follow-up. There were 16 deaths (18.8%) and 2 major amputations (2.4%) in the entire study period. Target lesion reintervention was required in 14 patients (16.5%) at the last follow-up. The Kaplan-Meier fTLR at 1, 3, and 5 years was 89.2%, 83.0%, and 83.0%, respectively. fMLA at 1, 3, and 5 years was 98% at all intervals, and survival rates at 1, 3, and 5 years were 94.1%, 89.4%, and 80.1%, respectively. Subintimal iliac access was associated with worse fTLR (HR 4.33 (95% CI 1.30–14.37, p=0.017)), which remained significant when adjusted to patient and anatomical characteristics (HR 5.88 (95% CI 1.02–33.95, p=0.047)). There was no significant association between fTLR and the need for common femoral endarterectomy (HR 3.57 (95% CI 0.42–30.5, p=0.244)] or external iliac artery stenting (HR 0.47 (95% CI 0.07–3.05, p=0.427)) during the index procedure.

The long-term outcomes of CERAB for treating AIOD demonstrate its viability as a durable revascularization option, with acceptable morbidity, mortality, and patency rates. Factors reflecting more complex lesions are associated with poorer outcomes. Findings support the need for randomized controlled trials on CERAB and a focus on the pre- and intra-operative decision-making based on the complexity of TASC C and D lesions.

The findings of this study reinforce the long-term durability of the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique for treating aortoiliac occlusive disease (AIOD), demonstrating favourable reintervention and limb salvage rates. These results support CERAB as a viable alternative to open surgery, particularly in patients with complex anatomies or significant comorbidities. This data enables clinicians to make more informed decisions regarding patient selection and procedural strategies, such as minimising the use of subintimal iliac access to improve long-term outcomes. The study underscores the need for further randomised trials to establish CERAB’s role in evidence-based clinical guidelines for AIOD management.

Vascular trainees are required to have a comprehensive training program, encompassing the completion of clinical, surgical, and research tasks. To fulfill their surgical abilities and performance, sufficient supervised operating time is mandatory. After open vascular procedures, it has been observed that trainee involvement does not lead to detrimental outcomes. On the contrary, its impact during endovascular procedures, which require distinct technical skills, is scarcely reported. The authors aim to analyze the impact of primary operator experience on the outcomes of elective infrarenal endovascular aneurysm repair (EVAR) performed within a teaching institution over a 14-year period.

This is a single-center, retrospective, comparative study. All consecutive patients submitted to elective EVAR (2011-2023) were considered. Two groups were defined: supervised trainee (ST) and consultant (C), according to the experience of the primary operator. The primary outcome was the incidence of 30-day major adverse events (MAEs). The secondary outcomes were contrast usage, operative time, bleeding, length of stay (LOS), return to operating room (OR), and freedom from aortic-related interventions up to 2 years.

Overall, 507 patients were included (62.1% ST vs 32.5% C). Seventy-two MAEs occurred in 8.1%, with no differences across groups (7.0% ST vs 9.9% C, p=0.31, adjusted odds ratio [aOR]=0.94, 95% confidence interval [CI]=0.46-1.91 for ST-performed procedures), even when MAE components were depicted individually. After adjustment for confounders, no significant differences were found in contrast usage ≥120 mL (aOR=0.89, 95% CI=0.50-1.56), operative time ≥160 minutes (aOR=0.73, 95% CI=0.45-0.18), bleeding (aOR=1.13, 95% CI=0.60-2.12), intensive care unit admission (aOR=0.68, 95% CI=0.40-1.17), prolonged LOS (aOR=0.93, 95% CI=0.60-1.43), return to OR (aOR=0.91, 95% CI=0.37-2.20), and mid-term freedom from aortic-related interventions (adjusted hazard ratio [aHR]=1.39, 95% CI=0.69-2.79).

In carefully selected cases, elective EVAR performed by supervised trainees seems as safe and effective at mid-term as operations performed by consultants. These findings may have important implications for training programs. Further studies to confirm and clarify our findings are required.

In carefully selected cases, elective EVAR performed by supervised trainees seems safe, when compared to operations performed by consultants. Short-term major adverse events, contrast usage, operative time, bleeding, secondary interventions and length of stay appear similar. Mid-term freedom-from aortic interventions is comparable. These findings may have important implications for vascular training programs.

Geriatric nutritional related index (GNRI) is a simple and well-established screening method of nutritional status. We aimed to develop and validate a scoring system including GNRI to predict long-term outcomes in patients with chronic limb-threatening ischemia (CLTI) undergoing endovascular treatment (EVT).

Patients undergoing EVT for symptomatic LEAD from August 2015 to August 2016 were enrolled into the I-PAD NAGANO registry, a prospective, multicenter, observational registry. We identified predictors of amputation-free survival (AFS) at 5 years using Cox proportional hazards regression and developed a risk scoring system. The predictive performance of the risk score was assessed.

A total of 126 patients with CLTI were analyzed. Cox multivariate analysis revealed GNRI score <92 points, ≥72 years of age, hemodialysis, heart failure, and anemia to be significant predictors. We developed a 5-item risk score (I-PAD CLTI score) assigning points to each factor based on the magnitude of association with AFS at 5 years. The I-PAD CLTI score showed a c-index of 0.80 for 5-year AFS. Patients with high score (≥7 points, n=50) had an increased risk of AFS at 5 years compared with those with low score (<7 points, n=68) (26.5% vs 72.1%, p<0.001).

A simple 5-item risk score including nutritional status showed reasonable discriminative and prognostic ability for long-term AFS among patients with CLTI.

The I-PAD CLTI score, a simple five-item risk score including nutritional status determined by geriatric nutritional related index, showed reasonable discriminative and prognostic ability for long-term amputation free survival among patients with chronic limb-threatening ischemia. This risk score may be useful for clinicians to accurately predict patient’s prognosis and thus identify high-risk patients who may derive the greater clinical benefit from more intensive risk modification. Further research is required to test the clinical utility of risk-score-based treatment approach to improve the prognosis of patients with chronic limb-threatening ischemia.

This study evaluated the feasibility and safety of thoracic endovascular aortic repair (TEVAR) for aortic arch penetrating atherosclerotic ulcer (PAU) using Castor single-branched stent-graft with zone 2 landing.

Between May 2020 and April 2022, a total of 25 aortic arch PAU patients were treated by TEVAR with Castor single-branched stent-graft. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and patency of left subclavian artery (LSA).

All patients had aortic arch PAU with intramural hematoma (IMH). The proximal landing zone for all patients was in zone 2, which was between the distal edge of the left common carotid artery and proximal edge of LSA, in all cases. Technical success was achieved in all cases. During hospitalization after the operation, 1 patient died of gastrointestinal bleeding, and 2 patients (8.0%) had ischemic stroke. At a median follow-up of 29 months (interquartile range [IQR], 24-30 months), 2 (8.0%) patients died, including 1 ischemic stroke and 1 hemorrhagic stroke. One patient (4.0%) had reintervention owing to retrograde type A aortic dissection (RTAD) 2 months after the operation, and was successfully treated with aortic root remodeling, ascending aorta and total aortic arch replacement and frozen elephant trunk procedure. No endoleak or LSA occlusion occurred. The maximal diameter of aorta at proximal (30.2±2.4 mm vs 31.2±3.0 mm; p>0.05) and distal (25.7±2.8 mm vs 24.5±2.3 mm; p>0.05) landing zone showed no significant difference before and after the operation.

The TEVAR for aortic arch PAU using Castor single-branched stent-graft is a safe and efficient option with zone 2 landing.

For patients with diagnosis of PAU with IMH, TEVAR with Castor single-branched stent-graft presents low mid-term mortality and morbidity rate, which should be considered as an optimal option when proximal landing zone is insufficient and revascularization of left subclavian artery (LSA) is needed. With Castor single-branched stent-graft, LSA could be revascularized easily and accurately.

The present paper highlighted a significant feasibility rate for the Gore Thoracic Branch Endoprothesis among patients previously treated with TEVAR and proximal landing in zone. The limited number of stent-graft configurations that could have been implanted in a considerable portion of our cohort could help clinicians to develop a proper endovascular inventory related to this device, paving the way for its wide application.

The Nexus stent graft offers a minimally-invasive option for treating aortic arch aneurysms (AArA). Despite strict instructions for use (IFU), it is sometimes applied in complex anatomies for patients who are surgically inoperable or unsuitable for other devices. This study evaluates outcomes in patients treated outside the IFU, providing real-world insights.

We analyzed patients treated with the Nexus endograft outside its IFU between January 2022 and August 2024. The primary endpoint was the occurrence of major adverse cardiovascular and cerebral events (MACCE) such as death, stroke, or myocardial infarction. Secondary endpoints included the reasons for outside-IFU implantation, technical success, any aortic-related adverse events and postoperative endoleaks.

Thirteen patients underwent endovascular treatment for AArA outside IFU. Five (38.5%) had a post-type A dissection, 5 had de novo AArA (38.5%), and 3 (23%) lacked a landing zone in zones 1 to 3 of the aortic arch for thoracoabdominal aortic repair. Seven patients (54%) received the Nexus One device, while 6 (46%) received the Nexus Duo endograft. No perioperative MACCE occurred. Mean follow-up was 17 ± 12 months, with a 79% survival rate at 1 year. Primary reasons for outside IFU use included an inner ascending length <30 mm and a descending aortic diameter >40 mm in 46% of patients accordingly. Technical success was achieved in all cases. A type Ic endoleak (7%) due to aneurysmatic degeneration of the brachiocephalic artery was identified at 2 years. No further aortic-related adverse events were reported.

The Nexus endograft demonstrated a favorable safety profile and promising clinical outcomes at 1 year, even in patients treated outside IFU criteria, with high technical success and no evidence of stroke. Reassessment of certain IFU criteria could enhance the device’s applicability.

Our findings highlight the potential for expanding the clinical use of the Nexus stent-graft beyond its current IFU, offering a safe and effective alternative for complex aortic arch anatomies. With high technical success and no perioperative cerebrovascular events, these results suggest that carefully selected patients who are otherwise ineligible for surgery may still benefit from endovascular repair. This study provides real-world evidence supporting the reconsideration of IFU criteria, potentially broadening treatment options. The innovation lies in demonstrating that even outside IFU conditions, the Nexus endograft maintains a strong safety profile, paving the way for more inclusive patient selection.

Our study demonstrated the clinical impact in real-world practice of using In-situ fenestration TEVAR with the innovative dedicated perforation-needle technique, which is characterized by an immediate availability as off-the-shelf device, compatibility with the various pathologies and anatomies, as well as minimal invasiveness in comparison to the debranching bypass-procedure for the preservation of the supra-aortic vessels during the endovascular repair of aortic arch pathologies. According to center experience, this approach can applied in elective cases, however, due to its practicability, it can be especially valuable in emergencies, when the other methods are considered as an unfavorable.

To assess the incidence, outcomes, and predictors of type III endoleaks (TIIIELs) in patients treated with different generations of Endologix unibody devices for abdominal aortic aneurysm (AAA).

Patients treated with unibody endografts between 1999 and 2020 in a single unit were prospectively enrolled, retrospectively analyzed, and stratified according to device generation. The primary outcome was the incidence of TIIIEL in patients treated with unibody devices. Secondary outcomes included: (1) TIIIEL incidence among the different device generations; (2) comparison of type IIIa (TIIIaELs) and type IIIb endoleaks (TIIIbELs) incidence, treatment, and complications; (3) risk factor analysis for TIIIEL; (4) overall survival and survival free from TIIIEL.

A total of 872 patients who underwent endovascular aortic repair (EVAR) were analyzed. The cumulative incidence of TIIIEL was 4.8% (42/872). The incidence among different generations was 2.4% (10/414), 21.7% (15/69), and 4.6% (16/341), and 2.1% (1/48) for Powerlink, AFXs, AFXd, and AFX2. Freedom from TIIIEL by device generation was significantly lower in the AFXs group (p<0.001). Type III endoleaks was higher in urgent EVAR (p=0.011), large AAA (p<0.001), angulated and calcified necks (p=0.002), and when more than one modular component or non-proprietary extension was used (p<0.001). AFXs was found as independent risk factor for TIIIEL (hazard ratio [HR]=3.1, p=0.003), while the use of a single component decreased the risk (HR=0.3, p=0.005). Finally, every 10-mm increase in AAA diameter resulted in a 2-fold increase in TIIIEL risk (HR=2.0, p<0.001).

The first generation of AFX endograft was associated with an increase in TIIIEL risk by 3.1 times, claiming a strict and careful follow-up in patients implanted with this device.

The old-generation of unibody endograft AFXs was associated with an increase in TIIIEL risk by 3.1 times. Angulated and calcified neck, large aneurysms and the use of nonproprietary graft extension were found as independent risk factors for TIIIEL. Patients implanted with these devices and with these anatomical features should be intensively monitored during follow-up.

To classify the radiographic characterization of the inferior vena cava (IVC) diameter, as well as to quantitatively describe the dimensional alternations in response to variations in filter placement, using cross-sectional computer tomographic venography (CTV) imaging.

A single-center retrospective study was conducted on eligible patients who underwent CTV of IVC both before and after the placement of spindle-shaped filters, from September 2018 to June 2023. Baseline data, IVC diameter and orientation pre- and post-filter placement, IVC enlargement rate, and related complications were analyzed.

A total of 70 eligible patients were included, 52 (74.3%) with type 1 IVC, 11 (15.7%) with type 2, 4 (5.7%) with type 3, 3 (4.3%) with type 4, and none with type 5. An accompanying morphological alteration turned IVC into a quasi-round shape with Lin CCC of 0.870, and orientation was significantly altered after filter placement. In patients with type 1, 3, and 4 IVCs, the mean diameter of the IVC increased almost 1.5-fold in the minor axis (95% confidence intervals [CIs]=−7.77 to −5.83, p<0.001), while only a slight expansion of the major axis to its initial size (p>0.05). Greater IVC enlargement rate was seen in the diameter of the minor axis than in the major axis (95% CI=40.31 to 65.12, p<0.001). Notably, regional clots around the filter were found in 22 (31.4%) patients. Among them, 14 (20.0%) were located on the anterior or posterior walls of caval minor axis, 5 (7.1%) in the lateral walls, and 3 (4.3%) in the central part of the IVC filter. Patients exhibited a higher incidence of clots on anterior and posterior walls compared to lateral wall (20.0% vs 7.1%, p=0.014).

The morphology of IVC shifted toward an approximated as circles after filter placement, with greater diameter changes seen in the minor axis compared to the major axis, where filter-related thrombosis most occurs.

The findings of this study offer insights into the biomechanical interaction between the inferior vena cava (IVC) and spindle-shaped filters, highlighting the anisotropic dimensional changes triggered by filter placement. The pronounced expansion along the minor axis, where filter-related thrombosis was more frequently observed, underscores a previously underrecognized risk factor for post-implantation complications. These results indicate that perioperative optimization of IVC dimensions and vigilant post-placement monitoring are crucial for improving patient outcomes.

This study observed the anatomical relation between the popliteal vein and surrounding structures via computed tomography venography (CTV) to determine the optimal position for popliteal vein puncture in the supine position. We then conducted a small follow-up clinical trial to confirm our findings.

The data on CTV of the lower extremities were collected from 112 patients. The anatomical type, diameter, and confluent location of the popliteal vein were observed to determine the location and angle of the appropriate approach for anterior popliteal vein puncture. The successful rate and complications of the anterior puncture of the popliteal vein were analyzed in 52 patients.

In the popliteal vein autopsy, most are the 2 branching veins converged into the popliteal vein. The medial channel was generally large. The popliteal vein was located on the medial side of the artery at the tuberosity tibia level and gradually turned to the back and lateral side during an upward course. When the lateral edge of the tibia overlapped the medial edge of the vein, the coverage area between the popliteal vein and the artery was 37.2%, which was relatively small. The coverage area is suitable for anterior approach puncture. The success rate of this method was 100%. No complications were reported after follow-up for 12 months.

The projected angle was left or right anterior oblique, and the lateral edge of the tibia overlapped the medial edge of the popliteal vein. The puncture angle should be as medial as possible.

In this study, the anatomical type, diameter and intersection position of popliteal vein through popliteal fossa were observed to determine the appropriate approach position and angle of popliteal vein puncture in supine position to provide experience for the future treatment of deep venous thrombosis.Based on this theory, a small follow-up clinical trial was conducted to confirm the safety of this method.

The aim of this study was to review the results of fenestrated stent-graft (Fenestrated Endovascular Aortic Repair [FEVAR]) implantation to treat patients with type IA endoleaks after prior infrarenal endovascular aortic repair (EVAR).

A retrospective single-center analysis of prospectively collected data was conducted, including consecutive patients who underwent FEVAR to correct a type IA endoleak between November 2009 and April 2021. All devices were manufactured by Cook Medical (INC, Bloomington, Indiana). Demographic details, anatomical features, fenestrated stent-graft configuration, technical success, and major adverse events (MAEs) were recorded according to current SVS standards. The primary endpoint was freedom-from-significant aneurysm sac expansion (≥5 mm) and survival according to the Kaplan-Meier analysis. Secondary endpoints included 30-day outcomes, freedom-from-all-cause mortality, and aortic-related secondary interventions. Multivariate Cox regression was performed to identify factors associated with the study endpoints.

Overall, 47 patients (89% male, median age 80) were included. Median time from initial EVAR was 60 months [41-72]. Median pre-FEVAR maximal aneurysm diameter was 68mm [62-79]. Median fluoroscopy time and dose area product were, respectively, 49 min [36-63] and 66 Gy.cm² [38-101]. Technical success rate was 96% with no 30-day deaths reported. Two (4.3%) renal MAE occurred. Median follow-up was 22 months [12-36]. Two-year freedom-from-aneurysm sac expansion and aortic-related secondary intervention were 80% [66-96] and 69% [55-87], respectively. From the multivariate analysis, the configuration of the fenestrated device was not predictive of aneurysm sac expansion, whereas only the preoperative aneurysm maximal diameter was an independent predictor (hazard ratio [HR] [per 1 mm increment]=1.05 [1.01-1.10]; p=0.016) and was associated with a higher risk of aortic-related secondary intervention (HR [per 1 mm increment]=1.07 [1.02-1.12]; p=0.006). Other predictors of aortic-related secondary intervention were pre-existing type IB or III endoleak (HR=7.89 [1.39-44.8]; p=0.020) and aortic degeneration above the primary EVAR (HR=16.6 [1.88-147], p=0.011).

Late type IA endoleak after EVAR can be treated safely with a fenestrated stent-graft; preoperative maximum aneurysm diameter is associated with an increased risk of later aneurysm sac growth. Close follow-up is mandatory in this subgroup of patients given the high reintervention rate.

Type IA endoleak following endovascular aneurysm repair (EVAR) can be treated using a fenestrated stent-graft (FEVAR). Treatment options include the addition of a fenestrated cuff alone or complete relining of the previous graft with either a 3-component device or a unibody bifurcated FEVAR. Regardless of the device configuration the treatment appears to be safe but remains associated with high rates of reintervention and aneurysm growth. Although no significant differences have been observed in long-term outcomes, a complete relining with a bifurcated FEVAR may be preferred as a first-line approach, as it offers the advantage of addressing occult associated Type III endoleaks and reducing the risk of component disconnection.

The occurrence of type II endoleak (T2EL) presents a significant challenge in standard endovascular aneurysm repair (EVAR), with ongoing debate in the literature regarding its optimal management. Although spontaneous resolution has been observed in many cases, intervention is often required to prevent progressive sac enlargement and rupture. Various approaches have been described, including translumbar, transarterial, and transcaval embolization, as well as direct sac puncture. The aim of this study is to evaluate the role of videolaparoscopic-guided saccography and direct sac embolization (ViSE) in patients with sac enlargement following EVAR.

A prospectively maintained registry of patients undergoing standard EVAR between 2016 and 2022 at our institution was retrospectively reviewed. Exclusion criteria included concomitant computed tomography (CT)-diagnosed type I endoleak or type III endoleak (T1EL or T3EL), less than 6 months of follow-up, or no available imaging study for review. A nidus posterior to the main body of endograft and a hostile abdomen (severe obesity body mass index [BMI] >35 kg/m², previous open surgery, or history of peritonitis) were considered contraindications to ViSE.

A total of 259 standard EVAR procedures were performed during the study period, with 63 patients (24.3%) identified as having T2EL, 26 underwent endovascular treatment for significant sac growth during follow-up; 14 of these patients received ViSE (5.4%) and were included in the study. The median procedure time and median fluoroscopic time were 140 (interquartile range [IQR]=105–150) and 40.5 (IQR=31–45) minutes, respectively. Technical success was achieved in 12 of 14 patients (87%). In 7 patients (50%), the inferior mesenteric artery (IMA) was ligated. An occult T1EL or T3EL endoleak was revealed in 5 patients (35%), requiring an immediate or staged adjunct procedure. After a median follow-up of 32.4 months (IQR=25.3–51.7), 2 patients presented sac growth and required surgical conversion. None of the patients died due to aortic-related causes.

Videolaparoscopic-guided saccography and direct sac embolization may be considered a valid alternative in patients with T2EL and sac growth. In our early experience, it has proven to be safe and effective in treating the nidus and IMA, and identifying hidden T1EL or T3EL.

Videolaparoscopic-guided saccography and direct sac embolization (ViSE) represent a valuable option for managing type II endoleak (T2EL) with sac enlargement after EVAR. This approach allows precise treatment of the nidus and the inferior mesenteric artery while also identifying undetected type I and III endoleaks that may require further intervention. By integrating ViSE into clinical practice, physicians can improve diagnostic accuracy and expand treatment strategies for complex endoleak cases. The technique enhances endovascular options, potentially reducing the need for open conversion and improving long-term outcomes in patients with persistent sac growth.

The INCRAFT™ Stent Graft System is a trimodular, bifurcated, ultra-low-profile endovascular device designed for endovascular aneurysm repair in patients with abdominal aortic aneurysm (AAA).

The study population comprised a prospective multi-center cohort (n = 85) and a single-center retrospective cohort (n = 61) of Korean AAA patients treated with INCRAFT. Postprocedural follow-up involved computed tomography (CT) imaging at 1 and 12 months post-procedure to monitor aneurysm dimensions and detect any endoleak.

The mean age of participants was 72.0 ± 7.1 years, with the majority being male (91.8%). The average maximal aortic sac diameter was 54.7 ± 8.6 mm. Technical success was achieved in 82.9%, primarily due to the relatively high incidence of type I endoleak (17.1%) observed on immediate angiographical assessment. The rate of 30-day major vascular complication was 0.7%. For the hemostasis of bilateral femoral access arteries, 57.5% required only 2 ProGlides. At the 30-day follow-up CT, the prevalence of endoleaks was 30.4% including type I (1.4%), type II (26.1%), and undermined type (2.8%). At the 12-month follow-up, the major adverse event rate was 6.2% attributed to noncardiovascular mortality. Aneurysm-related events included 3 cases (2.1%) of re-interventions due to graft occlusion (n = 2) and type II endoleak with sac expansion (n = 1). Aneurysm shrinkage and enlargement occurred in 37.8% and 3.4% of patients, respectively. At the 12-month follow-up, type II endoleak was the most frequent type, with a prevalence of 22.7%. Type I endoleak and undetermined type were found in 0.8% and 17.8% of cases, respectively, with no instances of type III endoleak.

INCRAFT demonstrated favorable early and 12-month clinical efficacy and safety profiles for treating Korean patients with AAA.

K-INCRAFT; www.clinicaltrials.gov Identifier: NCT03952780

Endovascular aneurysmal repair (EVAR) is effective treatment option for unruptured abdominal aortic aneurysm (AAA) in patients with high perioperative risk and suitable anatomy. The INCRAFT stent graft system is an ultra-low-profile endovascular graft designed for EVAR, and its efficacy and safety have been demonstrated in multi-center European and U.S. trials. Our study found that the INCRAFT stent graft system has favorable early and 12-month clinical efficacy and safety profiles in treating AAAs within Korean population, with a 30-day major vascular complications rate of 0.7% and no cases of aneurysmal-related mortality or rupture.

While general anesthesia (GA) has been the common choice of anesthesia for patients undergoing endovascular aneurysm repair (EVAR), local anesthesia (LA) has been proposed as an effective alternative for eligible patients. However, the choice of anesthesia in emergency EVAR situations remains less explored. Therefore, this study aimed to perform a retrospective analysis to compare the 30-day outcomes of patients who underwent emergency infrarenal EVAR receiving either LA or GA.

Patients who underwent emergency infrarenal EVAR were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted database from 2012 to 2022. Exclusion criteria included age less than 18 years, acute intraoperative conversion to open surgery, and intraoperative anesthesia conversion. The 1:1 propensity-score matching and multivariable logistic regression were separately used to balance preoperative factors between patients who received LA and GA. Thirty-day postoperative outcomes were examined.

There were 258 (14.58%) and 1512 (85.42%) patients who underwent emergency EVAR under LA and GA, respectively. After multivariable analysis, patients who were under LA had lower mortality (11.24% vs 13.96%, aOR=0.61, 95% confidence interval [CI]=0.395-0.944, p=0.03), pulmonary complications (10.85% vs 17.59%, aOR=0.495, 95% CI=0.322-0.76, p<0.01), renal complications (5.04% vs 7.47%, aOR=0.545, 95% CI=0.303-0.983, p=0.04), wound complications (0.39% vs 3.64%, aOR=0.089, 95% CI=0.012-0.649, p=0.02), and 30-day readmission (6.59% vs 11.24%, aOR=0.564, 95% CI=0.334-0.953, p=0.03). Moreover, patients under LA had shorter operative time (p<0.01) and shorter length of stay (p=0.02).

The LA is associated with better 30-day outcomes in emergency infrarenal EVAR. Therefore, in emergency EVAR, it may be advisable to consider LA over GA for eligible patients. Prospective studies in the future can be warranted to further support this anesthesia practice.

The choice of anesthesia in emergency endovascular aneurysm repair (EVAR) remains unexplored. This study performed a retrospective analysis to compare the 30-day outcomes of patients who underwent emergency infrarenal EVAR receiving local anesthesia (LA) or general anesthesia (GA). After propensity-score matching/multivariable analysis to balance preoperative differences, patients under LA were found to have lower 30-day mortality, pulmonary, renal, and wound complications, 30-day readmission, shorter operative time, and shorter hospital stay. In emergency EVAR, it may be advisable to consider LA over GA for eligible patients. Prospective studies in the future can be warranted to further support this anesthesia practice.

Peripheral artery disease (PAD) and chronic obstructive pulmonary disease (COPD) are both systemic inflammatory diseases that may share similar pathophysiological pathways. Given their potential overlap, the impact of COPD on perioperative outcomes following infrainguinal endovascular revascularization warrants further examination. Therefore, this study aimed to analyze the 30-day postoperative outcomes for COPD patients after infrainguinal endovascular revascularization.

Chronic obstructive pulmonary disease and non-COPD patients who underwent infrainguinal endovascular revascularization were identified in the ACS-NSQIP database from 2012 to 2022. Exclusion criteria included aged less than 18 years and emergency cases. A 1:1 propensity-score matching was used to match demographics, baseline characteristics, symptomatology, and anesthesia. Thirty-day postoperative outcomes were compared.

Of 24 223 patients who underwent infrainguinal endovascular revascularization, 2472 (10.21%) had COPD. All COPD patients were 1:1 propensity-score-matched to the non-COPD patients. Chronic obstructive pulmonary disease patients had higher risks of mortality (3.24% vs 2.18%, p=0.03), major adverse cardiovascular events (MACE) (3.48% vs 2.47%, p=0.04), pulmonary complications (3.24% vs 2.02%, p=0.01), and 30-day readmission (15.41% vs 13.23%, p=0.03). All other 30-day outcomes were comparable between the groups.

Chronic obstructive pulmonary disease independently increases the risk of 30-day mortality and cardiopulmonary complications after infrainguinal endovascular revascularization. Identification and optimization of COPD patients before considering invasive treatment can be important for preventing complications. Patients may undergo mini-spirometry to screen for COPD. If identified, COPD patients may begin intensive inhalation therapy and medical treatment prior to the surgery.

Both PAD and COPD are systemic inflammatory diseases that may share similar pathophysiological pathways. This study analyzed the 30-day postoperative outcomes for COPD patients after infrainguinal endovascular revascularization. It was found that COPD independently increases the risk of mortality, cardiopulmonary complications, and 30-day readmissions. Identification and optimization of COPD patients before considering invasive treatment can be important for preventing complications in infrainguinal endovascular revascularization. Patients may undergo mini-spirometry to screen for COPD. If identified, COPD patients may begin intensive inhalation therapy and medical treatment prior to the surgery.

The link between bovine aortic arch (BAA) and stroke after thoracic endovascular aortic repair (TEVAR) was investigated.

The multicenter retrospective study included consecutive Stanford type B aortic dissection patients undergoing TEVAR from January 2019 to December 2023. A multivariable logistic regression was utilized to assess the correlation between BAA and early stroke, while a multivariable Cox regression was employed to evaluate the association between BAA and overall stroke. Kaplan-Meier curves were used to compare the freedom from overall stroke rates.

In total, 138 (14.3%) had a BAA and 825 (85.7%) had a standard aortic arch (SAA). Patients with a BAA showed a greater early stroke incidence (11 [8.0%] vs 25 [3.0%]; p=0.005). An independent association was found between BAA and early stroke (odds ratio, 2.009 [95% confidence interval (CI), 1.491-2.684]; p=0.012). During follow-up, a greater incidence of overall stroke was seen in patients with a BAA (15 [10.9%] vs 42 [5.1%]) (hazard ratio, 2.310 [95% CI, 1.889-2.950]; p=0.006). Moreover, the freedom from the overall stroke rate was notably lower in the BAA group (80.42% vs 88.74%) (log-rank p=0.0068). Furthermore, patients with type A BAA showed significantly lower freedom from overall stroke rates (79.48%) relative to those with type B BAA (82.09%) (log-rank p=0.0431), and the freedom from overall stroke rate for patients with BAA ≥60 years was markedly lower (63.35%) than that in those <60 years (93.51%) (log-rank p=0.004).

BAA was correlated with an increased risk of early and overall stroke following TEVAR, particularly among older and type A BAA patients.

Individualized stroke prevention protocols and efficient neuroprotective measures should be developed for patients with BAA and adequate anticoagulation should be ensured to reduce the risk of embolism during TEVAR. This population should also ensure proper needle alignment. For instance, minimize the contact between the guide wire and the aortic arch wall. Temporal-occlusion of the carotid dynamic pulse during stent release might prevent solid fragments from entering into the craniocerebral artery. Additionally, thorough CO₂ or saline flushing technique can be utilized for all the stentgrafts. Furthermore, distal cerebral embolic protection devices should be conducted in patients with a BAA during TEVAR

The introduction of off-the-shelf (OTS) multibranch stent-grafts represented an advancement in the endovascular treatment of thoraco-abdominal aortic aneurysms (TAAAs), particularly in urgent settings. In certain cases (e.g, target vessel [TV] occlusion), unused directional branches (DBs) require proper occlusion with a vascular plug to prevent type III endoleaks. However, no standardized technique for DB closure has been established. We aim to evaluate the safety, feasibility, time-effectiveness and cost-effectiveness of using single-disk vascular plug (Amplatzer Vascular Plug [AVP]) for DB closure during urgent branched endovascular aneurysm repair (B-EVAR).

Retrospective analysis of 16 patients (16/101, 15.8%) undergoing urgent B-EVAR with OTS devices requiring intentional occlusion of at least 1 DB using vascular plug due to unavailable TVs or anatomical constraints. Amplatzer Vascular Plugs were deployed in 2 different techniques: with or without DB elongation with balloon-expandable stent-grafts. Technical success, clinical outcomes, side branches plugging time, and plug-constrained length after its deployment were assessed.

Balloon-expandable stent-graft plus AVP were used to occlude 7 unused DBs (36.8%), whereas AVP without elongation was used in 8 (42.1%), with a median oversizing rate of 58.7%. The technical success rate was 100%, with no instances of plug migration or endoleak during a median follow-up of 20.9±14.4 months. Perioperative mortality rate was 25%, exclusively in patients with ruptured aneurysms. Clinical success was maintained in all patients, with no late reinterventions or DBs recanalization. Side-branch plugging time was significantly shorter when performed without elongation (3.9±0.6 vs. 6.4±1.3 minutes; p=.0003). Despite greater oversizing, even without elongation, the mean plug-constrained length (15.1±4.5 mm) did not exceed the shortest DB, effectively reducing the risk of complications associated with increased plug-constrained length while ensuring proper and secure deployment.

Single-disk vascular plugs without DB elongation provide a safe, feasible, time-effective and cost-effective solution for DB closure during B-EVAR, with favorable outcomes and reduced procedural complexity, even in urgent setting. Multicenter studies are needed to validate these findings and establish standardized DB management techniques for challenging anatomical and urgent cases.

Our study demonstrated the feasibility, safety, and time- and cost-effectiveness of single-disc vascular plug (AVP) embolization for directional branches during urgent or emergent branched endovascular aortic aneurysm repair using off-the-shelf devices, even without elongation using balloon-expandable stent-grafts. This technique simplifies the procedure, reducing complexity and potential complications. It is particularly advantageous in urgent scenarios, where minimizing procedural time is critical to improve patient outcomes and survival. Moreover, it offers significant benefits in resource-limited settings by ensuring efficient use of healthcare resources. Overall, this approach represents a practical, effective solution that can enhance procedural efficiency and broaden clinical applicability.

This meta-analysis aimed to compare postoperative outcomes between endovascular and surgical revascularization of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR).

We performed a comprehensive search of the MEDLINE and EMBASE databases through February 2024. Pooled results were calculated, and subgroup analyses focused on the chimney technique for LSA revascularization. Kaplan–Meier curves for mid-term all-cause mortality were reconstructed by extracting time-to-event data from the included studies.

Twelve nonrandomized studies, including a total of 4158 patients, were analyzed. Procedural duration was significantly longer in the surgical revascularization cohort (p < 0.01). No statistically significant differences were found in other short-term outcomes between the 2 groups. However, subgroup analysis of studies focusing on the chimney technique showed that surgical revascularization was associated with a significantly lower rate of postoperative endoleak [odds ratio; OR (95% confidence interval; CI) = 0.17 (0.06–0.49), p < 0.01]. For mid-term outcomes, there were no significant differences in mortality [hazards ratio; HR (95% CI) = 1.25 (0.71–2.22), p = 0.44], aortic re-intervention rate [HR (95% CI) = 1.10 (0.49–2.47), p = 0.81], or LSA patency rate [HR (95% CI) = 1.24 (0.40–3.89), p = 0.71] between the 2 strategies. The follow-up endoleak rate tended to be lower in the surgical revascularization group [HR (95% CI) = 0.50 (0.24–1.03), p = 0.06], with a more pronounced trend in the subgroup analysis of studies exclusively employing the chimney technique [HR (95% CI) = 0.33 (0.10–1.02), p = 0.05], though the differences were not statistically significant. Reconstructed Kaplan–Meier curves for all-cause mortality indicated no significant difference in mid-term survival between the groups [HR (95% CI) = 0.94 (0.74–1.19), p = 0.60].

This meta-analysis reveals comparable postoperative outcomes between surgical and endovascular LSA revascularization in patients undergoing TEVAR. However, the chimney technique was associated with a higher rate of postoperative endoleak.

This meta-analysis provides insights into the comparative effectiveness of surgical versus endovascular left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR). While both techniques demonstrated comparable short- and mid-term outcomes, the chimney stent-graft technique showed a higher incidence of postoperative endoleak, suggesting a need for careful patient selection and follow-up. These findings will guide clinicians in optimizing LSA revascularization strategies and balancing procedural risks with postoperative outcomes in patients requiring LSA coverage during TEVAR.

Fenestrated endovascular aortic arch repair (fTEVAR) has been successfully used for the exclusion of aortic lesions extending to distal arch. This study aimed to present the outcomes of fTEVAR for the preservation of the left common carotid artery (LCCA) or left subclavian artery (LSA) in lesions extending to Ishimaru zone 2 and 3.

A single-center retrospective analysis of patients managed with fTEVAR for the preservation of the LCCA or LSA, between September 1st, 2011 and December 31st, 2023, was conducted, following the STROBE guidelines. Only preloaded fenestrated custom-made devices (Cook Medical, Bloomington, IN, USA) were used. Primary outcomes were technical success, mortality, and stroke at 30 days. Survival and freedom from secondary intervention were assessed using Kaplan–Meier estimates.

Seventy-five patients were included [72 years (IQR 13), range 48–86; 66.7% males]; 54 scheduled for LSA and 21 for LCCA preservation. Seven (9.3%) were treated urgently. Twenty-one (28.0%) presented with aortic dissection; 19 type B. Ishimaru zone 2 disease extension was recorded in 44 (58.7%) and zone 3 in 32 (42.7%). Debranching was performed in 22 patients: 81.8% LCCA-LSA bypass. Technical success was 93.3% with proximal landing to zone 0 in 18.7% cases, zone 1 in 70.7%, and zone 2 in 10.6%. Six (8.0%) deaths were recorded at 30-days and 4 (5.3%) strokes; 2 (2.7%) major. All strokes were diagnosed in patients with LCCA preservation. The multivariate analysis showed LCCA bridging (OR 0.2, 95% CI 0.08–0.3, p < 0.001) as independently related to stroke. The median follow-up was 12 months. The survival and freedom from secondary intervention were 85.2% [standard error (SE) 4.7%] and 75.0% (SE 6.5%) at 12 months, respectively.

Patients treated by fTEVAR for diseases extending to zones 2 and 3 presented encouraging early outcomes. LCCA bridging seems to be independently related to higher stroke rate. Preservation of the LSA seems safe, without neurological consequences.

Fenestrated endovascular arch repair has been applied with acceptable mortality in distal aortic arch lesions. However, the published experience is limited. This retrospective study of 75 patients with disease extend to zones 2 and 3 showed encouraging early outcomes with 93.3% technical success, 8.0% mortality, and 5.3% strokes. The inclusion of the left common carotid artery to the repair was related to higher stroke rate, while the preservation of the left subclavian seems to have no neurological consequences.

The surgical intervention for Stanford type B aortic dissection (TBAD) has been revolutionized by thoracic endovascular aortic repair (TEVAR). While diabetes mellitus (DM) is associated with increased risks of short-term mortality and infectious complications after major surgeries, previous studies present conflicting findings regarding the outcomes of TEVAR in DM patients. This study aimed to assess the 30-day postoperative outcomes for DM patients who have undergone TEVAR for TBAD using a dataset from a multi-institutional national registry.

Patients who underwent TEVAR for TBAD were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2022. A 1:4 propensity-score matching was used to balance demographics and preoperative characteristics between patients with and without DM. Thirty-day postoperative outcomes were compared.

There were 160 (8.89%) DM and 1640 (91.11%) non-DM patients who underwent TEVAR for TBAD. After propensity-score matching, all DM patients were matched to 594 non-DM patients. DM patients had a higher rate of mortality that was trending toward significance (10.19% vs 5.89%, p = 0.07). All 30-day complications were comparable between DM and non-DM patients.

TEVAR can generally be safe for DM patients in terms of short-term outcomes, but the potential for higher perioperative mortality rates in these patients may warrant careful consideration. Further large-scale studies may be necessary to fully understand the impact of DM on both short-term and long-term outcomes following TEVAR for TBAD.

This study assessed the 30-day postoperative outcomes for diabetes mellitus (DM) patients who have undergone thoracic endovascular aortic repair (TEVAR) for Stanford type B aortic dissection (TBAD) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. After propensity-score matching, DM patients had a higher rate of mortality that was trending toward significance but all 30-day complications were comparable between DM and non-DM patients. Therefore, TEVAR can generally be safe for DM patients in terms of short-term outcomes, but the potential for higher perioperative mortality rates in these patients may warrant careful consideration. Further large-scale studies may be necessary to fully understand the impact of DM on both short-term and long-term outcomes following TEVAR for TBAD.

Open repair of ruptured abdominal aortic aneurysms (rAAA) has been increasingly replaced by endovascular aortic repair (EVAR) in many centers. Despite being a minimally invasive procedure, EVAR is associated with a risk of abdominal compartment syndrome (ACS), which can lead to significant morbidity and mortality. This study examines the incidence and clinical manifestation of ACS in a consecutive cohort of rAAA patients treated exclusively with EVAR at Örebro University Hospital over a 12-year period.

This is a retrospective analysis of prospectively collected data. We identified 139 patients who had presented to Örebro University Hospital with rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic and thoracoabdominal aortic ruptures, previous aortic interventions (open or endovascular), and patients receiving palliative treatment were excluded. Patients developing ACS after rAAA were compared with those who did not develop ACS.

A total of 100 patients treated using EVAR were included in this study. ACS was identified in 17 patients, and these were compared with 83 patients who did not develop ACS. Mortality at 30 days was 53% in the ACS group (9/17) and 22% in the No-ACS group (18/83, p = 0.015). Regression analysis showed that advanced age and ACS were independent risk factors for death, with ACS increasing the hazard 4-fold (HR 4.26, CI 1.99–9.10, p < 0.001) and age increasing the hazard by 6% for every year (HR 1.06, CI 1.06–1.1, p = 0.004). The use of aortic balloon occlusion was not independently associated with the development of ACS.

ACS is a life-threatening complication of rAAA treated using EVAR and a significant number of patients developed ACS with high mortality and complication rates. All rAAA patients treated using EVAR should be monitored closely for ACS and treatment with decompressive laparotomy should be initiated without delay.

Open repair of ruptured abdominal aortic aneurysms (rAAA) has been increasingly replaced by endovascular aortic repair (EVAR). Despite being a minimally invasive procedure, EVAR is associated with a risk of abdominal compartment syndrome (ACS), which can lead to significant morbidity and mortality This article investigates abdominal compartment syndrome (ACS) in a cohort of total endovascular treated rAAA in a single centre and the treatment as well as the results, and gives insight on ACS in this patient group and might contribute to better understanding how to treat them and avoid this life-threatening complication.

To investigate the stroke risk factors following thoracic endovascular aortic repair (TEVAR) with a single-branch stent graft.

We retrospectively analyzed 128 patients of acute aortic syndromes with inadequate proximal landing zones (PLZ) who underwent TEVAR from September 2019 to December 2023. Patient survival was evaluated using the Kaplan–Meier method, and the relationship between subclavian artery patency and stroke incidence was determined through Cox regression analysis.

Technical success rates for aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) were 98.3%, 100%, and 100%, respectively. There were no significant differences in surgery duration, hospital stay, stent length, and oversize across the groups. Over an 18-month follow-up, there were no significant differences in mortality, stroke incidence, or re-intervention rates among the groups. The rates of stroke post-treatment were 4.9% for AD, 11.8% for IMH, and 12.0% for PAU. Notably, subclavian artery stenosis increased the stroke risk by 37.94 times (hazard ratio, 37.94; 95% CI: 4.76–302.35; p < 0.001). Female patients had a 16.57-fold increased risk of stroke (hazard ratio: 16.57; 95% CI: 1.00–272.88; p = 0.049). In addition, each standard deviation increase in operation time raised the stroke rate by 1.03 times (hazard ratio: 1.03; 95% CI: 1.001–1.05; p = 0.003). Subclavian artery stenosis also significantly increased the risk of re-intervention by 44.14 times (hazard ratio: 44.14; 95% CI: 7.50–259.73; p < 0.001), with significant differences in re-intervention rates among the 3 groups, notably improved in the PAU group compared to the AD group (hazard ratio: 3.60; 95% CI: 1.01–12.82; p = 0.042).

This study underscores the critical importance of maintaining subclavian artery branch patency post-TEVAR to mitigate stroke and re-intervention risks.

This study comprehensively investigates the risk of stroke following the reconstruction of subclavian artery branches during thoracic endovascular aortic repair (TEVAR). While previous literature has extensively documented stroke rates associated with the coverage of subclavian artery branches post-TEVAR, reports on stroke following single-branch stent placement are relatively scarce. By analyzing data from patients with inadequate proximal landing zones who received a single-branch stent, this study identifies potential risk factors for stroke and provides a new perspective on postoperative complications specifically related to subclavian artery reconstruction. Our findings significantly contribute to the literature by offering a novel approach to understanding complications after TEVAR, enhancing the precision of risk analysis for postoperative complications.

To identify the most valuable predictor associated with overall survival (OS) and amputation-free survival (AFS) and to develop and validate OS and AFS prediction models for patients with peripheral arterial disease (PAD) who underwent endovascular therapy (EVT).

This study included patient with PAD who EVT between January 2018 to June 2023 across 3 hospitals in southwest China. Outcomes were OS and AFS at 1, 2, and 3 years.

A total of 2792 consecutive patients with PAD who underwent EVT were included, with an average follow-up period was 14.0 ± 8.7 months. During the follow-up period, 412 (14.8%) patients died, and 737 (26.4%) patients experienced either amputation or death. The OS rates in 1-, 2-, and 3-years were 89.3%, 81.2%, and 74.2% in the whole cohort, respectively. In terms of AFS, the rates at 1-, 2-, and 3-years were 81.7%, 68.3%, and 54.1%, respectively. Predictors in the OS prediction model included age, diabetes mellitus (DM), body mass index (BMI) classification, dialysis-dependent renal failure (DRF), Rutherford classification, antiplatelet therapy, and cilostazol therapy (p < 0.05). Predictors in the AFS prediction model included DM, chronic obstructive pulmonary disease, DRF Rutherford classification, antiplatelet therapy, and cilostazol therapy (p < 0.05). The area under the curve and calibration curves for training, internal, and external validation of both OS and AFS prediction models indicated good performance.

This study demonstrates that both OS and AFS prediction models exhibit good discriminative ability to predict survival rate and AFS rate in patients with PAD. PAD patients with DM, DRF, Rutherford classification R5 and R6, absence of antiplatelet, and cilostazol therapy were associated with significantly lower OS and AFS rates. Controlling these risk predictors may be guide patient care in clinical settings.

In this multicenter longitudinal study, 2792 patients were included in the overall survival (OS) and amputation-free survival (AFS) prediction models development and validation. Patients with modifiable risk factors could potentially benefit from strategies aimed at preventing disease process (Rutherford classification), controlling comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, and dialysis-dependent renal failure), and enhancing adherence to medical therapy (antiplatelet and cilostazol therapy). Our models have ability to predict survival and AFS rates at multiple time points, thereby facilitating early identification of high-risk patients and enabling timely interventions to optimize patient outcomes.

To compare the sensitivity of measuring iliac vein stenosis using two-dimensional digital subtraction angiography (2D-DSA) and three-dimensional digital subtraction angiography (3D-DSA), with multidetector computed tomography venography (MDCTV) as the reference standard.

Between January 2020 and January 2023, a total of 103 patients suffered from chronic venous insufficiency symptoms categorized as CEAP Level 3 or above were included from three centers. These patients were admitted to our hospital after abdominal vascular ultrasound and MDCTV positivity. During hospitalization, all patients underwent both 2D-DSA and 3D-DSA procedures simultaneously. Ensure double-blind and rigorous evaluation process when evaluating images. All patients were categorized into two groups based on the degree of CTV stenosis: Group A (50%–70%) and Group B (>70%). Considering the morphology of iliac vein compression, all patients were categorized into three groups: central, lateral, and partial obstruction. Subsequently, the effectiveness analysis was performed for each diagnostic method based on the aforementioned classification.

With MDCTV as the reference standard, in Group A, the sensitivity of 2D-DSA and 3D-DSA is 78.69% and 90.48%, respectively. In Group B, the sensitivity of 2D-DSA and 3D-DSA is 93.44% and 97.62%, respectively. In Group A, the accuracy of 3D-DSA is significantly higher than that of 2D-DSA (p = 0.019). However, there is no statistically significant difference in Group B (p = 0.360). The accuracy rates for central, lateral, and partial obstruction using 2D-DSA are, respectively, 77.55%, 69.70%, and 95.24%. The accuracy rates for central, lateral, and partial obstruction using 3D-DSA are, respectively, 93.88%, 93.94%, and 100%. In central group, the accuracy of 3D-DSA is significantly higher than that of 2D-DSA (p = 0.021). In lateral group, no significant difference was observed between the accuracy obtained by both methods (p = 0.011). Similarly, no significant difference was found in partial obstruction group (p = 1.000). During the angiography procedure using 3D-DSA, a significant reduction was observed in both contrast agent quantity and exposure time (p < 0.05) without any apparent effects on renal function.

Regardless of the degree or type of iliac vein stenosis, 3D-DSA exhibits superior sensitivity compared to 2D-DSA for the diagnosis and evaluation of stenosis. Particularly in instances of noncentral stenosis, 3D-DSA outperforms 2D-DSA.

This will provide new insights for the clinical diagnosis and treatment of iliac vein compression syndrome (IVCS), significantly enhancing the diagnostic accuracy of IVCS. For clinicians, three-dimensional digital subtraction angiography (3D-DSA)offers a more comprehensive and detailed assessment in clinical practice, leading to more precise diagnosis and treatment of the disease. The efficacy of two-dimensional digital subtraction angiography (2D-DSA) in treating IVCS is significantly compromised without the guidance from computed tomography venography (CTV). We consider that 3D-DSA can replace CTV in both diagnosis and treatment, providing a new diagnostic and therapeutic strategy.

The performance of self-expanding stent graft (Gore^® Viabahn^®) in femoropopliteal interventions has been proven through trials with long lesions. However, there are limited data on the incorporation of additional edge-protection to reduce focal edge stenosis. The aim of this study was to assess the clinical safety and efficiency of Viabahn^® stent graft incorporating additional edge-protection in the treatment of long femoropopliteal lesions [TransAtlantic Inter-Society Consensus (TASC) C/D] in patients with symptomatic peripheral arterial disease.

This is 2 centers, retrospective, observational, single-arm study. Patients with symptomatic (Rutherford category 2–6) de novo and restenosis TASC C/D lesions of the femoropopliteal segment were treated with Viabahn^® stent graft. Additional edge-protection bare metal stent (BMS), drug-coated balloon (DCB), or drug-eluting stent (DES) were allowed at the proximal and distal edges of the Viabahn^® stent graft. The primary endpoint was the primary patency.

Between October 2019 and October 2022, 188 symptomatic patients with 198 limbs were treated (TASC D=68, 34%). The mean lesion length was 256±118 mm, and 88% were total occlusion. Additional BMS, DCB, or DES were used at Viabahn^® edges in 24%, 16%, and 13% of cases, respectively. The mean follow-up was 12 months. The primary patency rate at 12 months was 70.8%. A significantly lower rate of primary patency was reported in the Viabahn^® + BMS group (54.3%) compared to Viabahn^® group (76.5%), Viabahn^® + DCB group (81.4%), and Viabahn^® + DES group (72.5%; p=0.01). The primary sustained clinical improvement rate was 85%. The Rutherford category assessment was significantly improved at last follow-up compared to baseline (p<0.0001). There were 2 cases of acute ischemia.

The use of Viabahn^® stent graft in long lesions (TASC C/D) with drug-coated devices as additional edge-protection seems to improve the results in the treatment of long and complex femoropopliteal lesions. These results reinforce the need for randomized clinical trials to assess the value of self-expanding stent graft for long femoropopliteal lesions.

This study evaluates the clinical impact of the performance of a self-expanding stent graft (Gore® Viabahn®) in femoropopliteal lesions and demonstrates its safety and efficacy in the treatment of long and complex lesions. The results indicate that the combination of the Viabahn® with paclitaxel-eluting devices on its proximal and distal edges increases clinical improvement and decreases the incidence of restenosis. Overall, this study highlights the benefit of active therapy in the Viabahn® edges and supports its increased use in clinical practice to optimise long-term outcomes in long and complex femoropopliteal lesions.

To assess the feasibility and efficacy of a standardized CO₂ protocol and CO₂ cone beam computed tomography (CBCT) for procedural completion in fenestrated endovascular aneurysm repair (FEVAR) of complex aortic aneurysms in patients with chronic kidney disease (CKD).

Ten patients with complex aortic aneurysms and CKD (estimated glomerular filtration rate <90 ml/min) underwent FEVAR with custom-made fenestrated devices, using CO₂ as the primary contrast agent. Procedures were conducted in a hybrid operating room following a standardized CO₂ protocol with optimized injection parameters and visualization techniques to maximize CO₂ imaging efficacy. CO₂ CBCT was performed intraoperatively to verify stent graft deployment, bridging stent positioning, target vessel patency, and the presence of potential endoleaks.

All 10 procedures were completed successfully without intraoperative complications or CO₂-related adverse effects. Completion CO₂ CBCT provided clear visualization of visceral and renal vessels, and no significant endoleaks were detected. One procedure was entirely iodine contrast-free, while minimal iodine contrast was used in others to address diagnostic uncertainties. Postoperative renal function remained stable across all patients.

CO₂ CBCT is a feasible and effective alternative for completion imaging in complex FEVAR procedures for patients with CKD, potentially reducing the need for iodine contrast and the associated risk of nephropathy. A standardized CO₂ protocol can enhance procedural safety. Further research with larger cohorts is needed to confirm these findings.

CO₂ serves as the preferred contrast medium for the endovascular treatment of patients with iodine contrast allergies or those afflicted with chronic kidney disease (CKD) to preserve further renal deterioration. Ensuring protection from potentially harmful substances is paramount during endovascular repair in such patients. Equally crucial is performing the procedure safely through a standardized protocol and confirming its accuracy upon completion. Nevertheless, the possibility of employing CO₂ for cone beam computed tomography provides invaluable insights into procedural efficacy, thereby enhancing outcomes for CKD patients undergoing complex endovascular repair.

Thoracic Endovascular Aortic Repair (TEVAR) is the preferred treatment for thoracic aneurysms for eligible patients. Chronic obstructive pulmonary disease (COPD) is a common comorbidity that shares common inflammatory pathways with atherosclerosis, the major cause of thoracic aneurysms. However, surgical outcomes of TEVAR among patients with COPD have not been thoroughly investigated. This study aimed to assess the 30-day postoperative outcomes for COPD patients who have undergone TEVAR for non-ruptured thoracic aortic aneurysms, using data from a multi-institutional national registry.

Patients who underwent TEVAR for non-ruptured thoracic aneurysms were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2022. A 1:1 propensity-score matching was used to match demographics, preoperative characteristics, and anesthesia between COPD and non-COPD patients. Thirty-day mortality and other postoperative outcomes were compared.

There were 525 (20.2%) COPD and 2,071 (79.8%) non-COPD patients who underwent TEVAR for the non-ruptured thoracic aneurysm. COPD was significantly more prevalent among patients with thoracic aneurysms compared to its incidence in the general population, and COPD patients also exhibited a higher burden of comorbidities. After 1:1 propensity-score matching, COPD and non-COPD patients had comparable 30-day mortality (5.7% vs 4.8%, p = 0.58). All other 30-day outcomes were comparable in COPD patients.

While COPD might be linked to the development of thoracic aneurysms through potentially shared pathophysiological pathways, COPD does not appear to be related to major adverse 30-day outcomes in TEVAR. Future studies should aim to explore the long-term outcomes in COPD patients undergoing TEVAR.

COPD was significantly more prevalent among patients with thoracic aneurysms compared to the general population, and COPD patients also exhibited a higher burden of comorbidities. However, after propensity-score matching, COPD patients demonstrated comparable risks across all 30-day outcomes. Therefore, while COPD might be linked to the development of thoracic aneurysms through potentially shared pathophysiological pathways, COPD does not appear to be related to major adverse 30-day outcomes in TEVAR.

This study investigated the effectiveness and safety of sac prefilling (SP) with fibrin glue and/or a coil to prevent type II endoleaks (T2ELs) after endovascular aneurysm repair. The main outcome measure was prevalence of incidence of T2ELs.

First, this is a retrospective observational study on patients treated in our institution. Patients who underwent endovascular aneurysm repair between January 2017 and July 2022 were included and divided into the endovascular aneurysm repair and endovascular aneurysm repair with SP groups. Additionally, all patients were divided into high-risk (HR) and low-risk (LR) groups based on their risk for T2ELs. The prevalence of incidence of T2ELs at 1 year postoperatively was the main effectiveness index, and the colorectal ischemia complication rate was the main safety index.

A total of 431 patients were included in this clinical study. The endovascular aneurysm repair group and SP group comprised 383 patients and 48 patients, respectively. No statistically significant differences between these groups were observed. The HR group included 282 patients; 246 of these patients were in the HR endovascular aneurysm repair group, and 36 were in the HR SP group. The prevalence of incidence of T2ELs in the endovascular aneurysm repair group was higher than that of the SP group at 6 and 12 months postoperatively (15.4% vs 2.8% and 13.2% vs 0%); statistically significant differences between these groups were observed (p = 0.039 and p = 0.032). The postoperative follow-up period was 60 months. A Kaplan–Meier curve analysis indicated that the cumulative T2EL incidence rate of the endovascular aneurysm repair group was significantly higher than that of the SP group (p = 0.011). The LR group included a total of 149 patients; 137 of these patients were in the endovascular aneurysm repair group, and 12 were in the SP group. No statistically significant differences between these groups were observed.

For patients with an abdominal aortic aneurysm who are at HR for T2ELs, SP could effectively, and safely prevent postoperative T2ELs.

This study points out that in patients with AAA, the sac prefilling technique is more suitable for patients with high-risk factors, so the operator should evaluate the patient’s anatomical condition more thoroughly before EVAR.

To evaluate and compare the efficacy and safety of drug-coated balloon angioplasty (DEB) versus rotational atherectomy combined with DEB (RA + DEB) in patients with in-stent restenosis (ISR) in the femoropopliteal territory.

Retrospective multicenter observational study based on data from a prospective registry of patients with femoropopliteal stents treated between January 2017 and March 2022.

One hundred and six patients were included (53 in each group) with 3 years median follow-up. At 2 years, freedom from clinically driven target lesion revascularization (CD-TLR) was 87.1 ± 3.9% in the RA + DEB group compared to 75.5 ± 8.7% in the DEB group. At 5 years, the CD-TLR rates were 64.0 ± 9.4% in RA + DEB and 30.5 ± 10.6% in DEB (P = .036). Additionally, 5-year thrombosis-free survival was significantly higher in RA + DEB (74.6 ± 7.6%) compared to DEB (37.2 ± 10.5%, P = .026). There were no statistically significant differences in MALE between the treatment groups. In multivariable analysis, RA + DEB reduced TLR risk and improved assisted primary patency, while Tosaka 3 and lesion length predicted worse outcomes.

RA combined with DEB offers advantages over DEB alone in femoropopliteal ISR, reducing reinterventions, enhancing assisted primary patency, and lowering thrombosis rates without increasing MALE.

This study addresses the current lack of long-term evidence on the treatment of femoropopliteal in-stent restenosis (ISR) using drug-coated balloons (DEB) alone versus DEB combined with rotational atherectomy (RA). Clinically, RA+DEB significantly reduces reinterventions and thrombosis, and improves assisted primary patency without increasing complications. For clinicians, this supports a more effective and durable option for complex ISR, particularly in occlusive or long lesions. The innovation lies in demonstrating the added value of vessel preparation with RA, offering a lesion-specific strategy in the absence of clear guideline recommendations.

Our primary endpoint was to determine the prevalence of superior mesenteric artery aneurysms (SMAAs) in infectious endocarditis (IE) patients.

Retrospective study of 474 IE-patients (2005–2020) with abdominal computed tomography-angiography (CTA): the data of 10 SMAA-IE-patients (2.1%) are analyzed.

The median age of the 10 patients was 50.4 years (6 men). Microorganisms were Streptococcus spp. (n=6), Gemella spp. (n=2), Staphylococcus aureus (n=1), Enterococcus faecalis (n=1). Aneurysms were saccular (n=9), fusiform (n=1). Five SMAAs were partially thrombosed. Three patients presented acute abdominal pain, associated with partial thrombosis. Three became symptomatic: SMAA growth (n=2) and delayed aneurysm, enlargement, rupture, and bowel ischemia (n=1). Four were small (<25 mm), 6 were large (25–70 mm), mostly distally located (6/10). Five (3 small, 2 large) regressed under antibiotic therapy alone, 2 (25 and 40 mm) underwent coil embolization. Three underwent surgery (30, 50, and 60 mm), because of large aneurysm at SMA origin, rapid enlargement and rupture, and bowel ischemia. The outcome was favorable (mean follow-up: 43.5 months; range: 9–72).

Abdominal pain, vomiting, diarrhea, occurring in a patient with a current or recent history of IE should be carefully evaluated by CTA. Symptomatic, growing aneurysms and fusiform aneurysms mainly underwent an operative repair. Five silent aneurysms (<20 mm, n=2; >20 mm, n=3) were safely monitored under antibiotic therapy, enhancing the need to further have cross-sectional imaging of the visceral circulation in all cases of left-sided IE to detect asymptomatic aneurysms. SMAAs can regress, thus conservative management of small asymptomatic ones is possible.

In our series of superior mesenteric artery infectious aneurysms (SMAA) in infective endocarditis (IE) patients (incidence: 2.1%), symptomatic, growing aneurysms and fusiform aneurysms mainly underwent an operative repair. Five silent aneurysms (<20mm, n=2; >20mm, n=3) were safely monitored under antibiotic therapy. Our study showed first, the need to have cross-sectional imaging of the visceral circulation in all cases of left sided infective endocarditis. Obviously, abdominal CT-angiography monitoring is also a cornerstone of the efficacy of the antibiotic regimen. Second, SMAAs in IE patients can regress: thus conservative management of small asymptomatic ones is possible.

Coral reef aorta (CRA) is a rare condition described as severe hard-rock calcifications in the aortic lumen. It may present as renal hypertension, lower limb claudication, or even visceral ischemia in some cases. Management is usually by open surgical repair, by aortic endarterectomy, or surgical bypass. Recently, severe arterial calcifications have been treated with intravascular lithotripsy (IVL) with promising results. We aim to present our experience in using IVL in the treatment of CRA.

This is a retrospective case series of a cohort of patients treated for visceral aorta CRA with IVL. Patients’ demographics, symptomatology, perioperative data, and follow-up are described.

Four patients (1 man, 3 women) with a mean age of 71 years were treated by IVL for CRA between January 2023 and June 2024. All patients (n=4, 100%) presented with severe lower limb claudication (Rutherford grade III). Upon investigations, CRA was diagnosed by CT angiogram, with no associated significant iliac or infra-inguinal lesions. Involvement of the renal and mesenteric arteries was inconstant and always asymptomatic. Patients were deemed high risk for open aortic repair and thus underwent IVL. Aortic angioplasty was performed in a kissing position (normal angioplasty balloon + IVL balloon). None of the patients required aortic stenting or mesenteric and renal stenting post-IVL. Preoperative aortography showed an absence of complications in the digestive and renal arteries, and no aortic rupture. Mean operative time was 90.2 minutes with a scopy time of 19.7 minutes. Mean hospital stay was 2.5 days. After a mean of 11 months of follow-up, patients presented with significant clinical improvement, granting reduction to Rutherford grade II.

This series describes the technical feasibility and perioperative safety in treating visceral aorta CRA by IVL. It could be used as an alternative treatment for coral reefs in a highly selected cohort of patients. Larger studies are needed, however, to demonstrate efficacy in the long term and for well-selecting candidates for IVL for CRA.

Taking advantages of innovations in vascular surgery, we describe the use of Intravascular lithotrispsy (IVL) in treating heavily calcified aortic lesions in the visceral aorta. The use of IVL in the aorta is still Off-Label, however, from this case series, the use of intravascular lithotripsy seems safe and feasible, and could be used as an alternative treatment for coral reef in highly selected patients.

Acute limb ischemia (ALI) is a serious condition leading to amputation and mortality.

This prospective randomized study included 50 patients with thrombotic ALI treated at 2 hospitals between September 1, 2021, and August 31, 2023. Patients were randomly assigned using a double-blind method into Group A (n = 25), treated with percutaneous mechanical thrombectomy (PMT), and Group B (n = 25), receiving catheter-directed thrombolysis (CDT).

The mean age was 67.16 ± 9.56 years in Group A and 56.88 ± 11.38 years in Group B (P = .001), though gender distribution was comparable. Diabetes mellitus (DM) was the most prevalent risk factor (88% in Group A, 72% in Group B), followed by hypertension (68%) in Group A and smoking (56%) in Group B, with no significant differences between groups. Superficial femoral artery and popliteal artery occlusions were the most common findings (68% and 56% in Group A, 72% and 68% in Group B). Retrograde contralateral femoral access was used in 60% of Group A and 56% of Group B. The technical success rate showed a tendency to be higher but did not reach statistical significance in Group A (96%) than in Group B (80%). Perioperative complications occurred in 8% of patients in both groups, with Group A experiencing 1 vessel perforation and 1 distal embolization, while Group B had 1 intracranial hemorrhage and 1 pseudoaneurysm. The 30-day mortality rate was 0% in Group A and 8% in Group B (not statistically significant). Primary patency rates at 1 month were 84.0% in Group A and 81% in Group B, decreasing to 62.5% and 55.6% at 1 year, respectively. Group A had 1 below-knee amputation and no above-knee amputations, whereas Group B had 2 below-knee and 3 above-knee amputations.

PMT appeared to have a tendency toward higher technical success and lower amputation rates, with a safety profile similar to CDT, though these differences were not statistically significant. Its single-session approach and potential for reduced bleeding risk might offer some advantages, while CDT generally requires prolonged infusion.

This randomized study suggests that percutaneous mechanical thrombectomy (PMT) using the Rotarex®️ device may offer advantages over catheter-directed thrombolysis (CDT) in selected patients with acute thrombotic lower limb ischemia without motor deficit. PMT achieved rapid revascularization in a single session with a tendency toward higher technical success and fewer amputations, while maintaining a safety profile comparable to CDT. By potentially reducing treatment time, bleeding risk, and the need for intensive monitoring, PMT could represent a valuable addition to current endovascular practice. Larger multicenter studies with longer follow-up are warranted to confirm these findings and guide future clinical adoption.

Endovascular revascularization of below-the-knee lesions is a crucial treatment for patients with chronic limb-threatening ischemia (CLTI). However, the optimal approach to revascularizing infrapopliteal arteries remains uncertain. This study aims to compare the safety and efficacy outcomes of various endovascular treatment modalities for infrapopliteal artery disease and provide an evidence-based update through a network meta-analysis.

We performed a systematic literature search in MEDLINE, EMBASE, and the Cochrane Database for randomized controlled trials published between January 01, 2005, and January 12, 2025. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was prospectively registered in PROSPERO database (CRD42022323480). The primary safety outcome was major adverse events defined as a composite of all-cause death, major amputation, and any re-intervention of the target limb at 30 days. The primary efficacy outcomes included freedom from composite of major amputation, target lesion occlusion, and clinically driven target lesion revascularization (CD-TLR) and primary patency defined as freedom from binary restenosis and CD-TLR at 6 months. The network meta-analysis was conducted in the frequentist framework using random effects model and conventional percutaneous transluminal angioplasty (PTA) as the reference intervention. Treatment effects were reported as odds ratio (OR) with 95% confidence interval (CI) compared with conventional PTA and interventions were ranked using P-scores.

Twenty-three studies including 3091 patients treated with PTA, paclitaxel drug-coated balloons (DCB), drug-eluting stents (DES), bare metal stents (BMS), bioresorbable vascular scaffold (BVS), and atherectomy were included. There were no significant differences in the primary safety outcome between different treatment modalities. At 6 months, DCB, atherectomy with DCB, and DES produced the largest benefit for primary efficacy outcomes. DCB (OR, 3.68; 95% CI, 1.37–9.92) had a higher freedom from the primary composite, and atherectomy with DCB (OR, 7.65; 95% CI, 1.03–56.98) and DES (OR, 5.48; 95% CI, 1.54–19.49) had higher primary patency compared with PTA. At 12 months, the benefit of atherectomy with DCB was sustained for primary patency, and BVS was ranked first for freedom from the primary composite. There was no benefit of BMS compared with PTA at any timepoint.

This network meta-analysis evaluating 7 endovascular treatment modalities provides evidence of improved efficacy outcomes with DCB, atherectomy with DCB, DES, and BVS compared with PTA for treating infrapopliteal lesions in patients with CLTI.

Local antiproliferative drug delivery, whether by balloon-expandable sirolimus/everolimus DES or paclitaxel DCB or everolimus BVS, is necessary to improve patency and efficacy outcomes for the treatment of infrapopliteal artery disease. Furthermore, combining atherectomy with drug delivery shows promising potential. Emerging endovascular targeted drug delivery therapies with limus-based DCB or scaffolds promise to provide greater drug transfer efficiency and a more effective therapeutic alternative that overcomes the limitations of metallic stents in one of the most challenging vascular beds.

Branched endograft exclusion of chronic type A dissections resulting from a TEVAR complication is a minimally-invasive approach to consider in very fragile patients to mitigate the potential risks associated with conventional open surgical repair.

Through these clinical cases, we present a new protocol of action, updated with the latest evidence on percutaneous pulmonary thrombectomy using dedicated catheters, for high-risk PE in pregnant women or during the early postpartum period.

Although arteriovenous malformations (AVMs) are typically benign lesions, massive ones can lead to severe complications, including heart failure. Notably, there is no standardized treatment for AVMs. Moreover, management of AVMs can be challenging when these lesions involve vital organ systems, such as the head and neck. In this report, we describe embolization of a massive cervical AVM in a pediatric patient with heart failure.

A 10-year-old boy presented with severe heart failure secondary to a massive AVM in the neck (right side). Despite 3 unsuccessful arterial embolization procedures, venous embolization of the dominant outflow vein using a coil and n-butyl-2-cyanoacrylate, lipiodol, and ethanol proved effective, and symptoms, cerebral natriuretic peptide level (568-29 pg/mL), and echocardiography were significantly improved. Although residual AVM persisted in the right upper extremity for 6 months after surgery, his cardiac function remained preserved, and his activities of daily living have improved.

Venous embolization is a valuable treatment modality for type II AVMs with a dominant outflow vein. However, considering the patient burden associated with large AVMs, multiple therapeutic interventions at appropriate intervals and long-term follow-up are important.

We present a pediatric patient with a type II massive arteriovenous malformation (AVM) in the neck and severe heart failure. Despite undergoing 3 arterial embolization procedures, his condition remained unchanged. However, venous embolization of the dominant outflow vein resulted in a significant improvement in symptoms. This case emphasizes the importance of considering multiple and appropriately timed therapeutic interventions, particularly for massive AVMs, to optimize patient outcomes while minimizing treatment burden.