A Systematic Review and Meta-analysis on Stenting for Aortic Coarctation Management in Adults

PURPOSE

Endovascular treatment of aortic coarctation (CoA) constitutes a valuable alternative with low morbidity and mortality. The aim of this systematic review and meta-analysis was to assess the technical success, re-intervention, and mortality after stenting for CoA in adults.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis statement and PICO (patient, intervention, comparison, outcome) model were followed. An English literature data search was conducted, using PubMed, EMBASE, and CENTRAL, until December 30, 2021. Only studies reporting on stenting, for native or recurrent CoA, in adults were included. The risk of bias was assessed using the Newcastle-Ottawa Scale. A proportional meta-analysis was performed to assess the outcomes. Primary outcomes were technical success, intra-operative pressure gradient and complications, and 30-day mortality.

RESULTS

Twenty-seven articles (705 patients) were included (64.0% males, 34.0±13.6 years). Native CoA was present in 65.7%. Technical success was 97% (95% confidence interval [CI], 0.96%-0.99%; p<0.001, I²=9.49%). Six (odds ratio [OR]: 1%; 95% CI, 0.00%-0.02%; p=0.002, I²=0%) ruptures and 10 dissections (OR: 2%; 95% CI, 0.001%-0.02%; p<0.001, I²=0%) were reported. The intra-operative and 30-day mortality were 1% (95% CI, 0.00%-0.02%; p=0.003, I²=0%) and 1% (95% CI, 0.00%-0.02%; p=0.004, I²=0%), respectively. The median follow-up was 29 months. Sixty-eight re-interventions (OR: 8%; 95% CI, 0.05%-0.10%; p<0.001, I²=35.99%) were performed; 95.5% were endovascular. Seven deaths were reported (OR: 2%; 95% CI, 0.00%-0.03%; p=0.008, I²=0%).

CONCLUSION

Stenting for CoA in adults presents high technical success and the intra-operative and 30-day mortality rates were acceptable. During the midterm follow-up, the re-intervention rate was acceptable, and mortality was low.

CLINICAL IMPACT

Aortic coarctation is a quite common heart defect that may be diagnosed in adult patients, as a first diagnosis in native cases or as a recurrent after previous repair. Endovascular management using plain angioplasty has been associated to a high intra-operative complication and re-intervention rate. Stenting in this analysis seems to be safe and effective as is related a high technical success rate, exceeding 95%, with a low intra-operative complication and death rate. During the mid-term follow-up, the re-interventions rate is estimated at less than 10% while most cases are managed using endovascular means. Further analyses are needed on the impact of stent type on endovascular repair outcomes.

The Association of Sarcopenia and ASA Score to Spinal Cord Ischemia in Patients Treated With the t-Branch Device

PURPOSE

Sarcopenia has been identified as an independent predictor of mortality in patients with infrarenal abdominal aortic aneurysm and may also affect outcomes in patients with complex aortic pathologies. The aim of this study was to assess sarcopenia, combined with the American Society of Anesthesiologists (ASA) score, as predictors for spinal cord ischemia (SCI) in patients treated with the t-Branch off-the-shelf device.

MATERIALS AND METHODS

A single-center retrospective observational study was conducted including elective and urgent patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) between January 1, 2018, and September 30, 2020. Data were collected according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement. The psoas muscle area (cm²) and attenuation (Hounsfield units, HU) were measured in the arterial phase of the pre-operative computed tomography angiography for each patient. The lean psoas muscle area (LPMA) was used to stratify patients into 3 groups, and further stratification was performed with a combination of the ASA score and LPMA.

RESULTS

Eighty patients were included (mean age at 71±9 years; 62.5% males). Thoracoabdominal aneurysms were managed in 72.5% of cases (42.5% for type I-III). Thirty-seven (46%) were treated urgently. Eleven patients died within 30 days (14%). Twelve patients (15%) presented SCI of any severity. Among the LPMA groups, the only statistically significant difference was recorded in age; group 3 was older compared with groups 1 and 2 (67.1 years vs 72.1 years vs 73.5 years, p=0.004). After ASA combined LPMA categorization, 28 patients were considered as low risk, 16 as moderate risk, and 36 as high risk. A statistically significant difference was recorded in terms of SCI (3.5% [1/28] in low risk vs 12.5% [2/16] in moderate risk vs 25% [9/36] in high risk, p=0.049). Multivariate analysis showed that moderate-risk patients were at risk to evolve to SCI (p=0.04).

CONCLUSIONS

Low-risk patients, with ASA score I-II or LPMA>350cm²HU, are at lower risk for developing SCI after BEVAR using the t-Branch device. Patients' stratification according to the combination of ASA score and psoas muscle area and attenuation may identify a group at higher risk of SCI after branched endovascular aneurysm repair.

CLINICAL IMPACT

Sarcopenia has been identified as a factor of increased mortality in patients managed for aortic aneurysm repair. However, significant heterogeneity has been recorded in the tools assessing its presence. In this analysis, an already used method, combining the ASA score and psoas muscle area and attenuation, has been used to assess the impact of sarcopenia in patients managed with the t-branch device. This analysis showed that patients at low risk, with an ASA score I-II or LPMA>350cm2HU were at lower risk to evolve spinal cord ischemia. Along this line, sarcopenia may be a valuable marker for the prediction of perioperative adverse events , other than mortality, in patients managed using complex endovascular repair.

Systematic review of reintervention with fenestrated or branched devices after failed previous endovascular aortic aneurysm repair

BACKGROUND

A proximal seal extension, after previously failed standard endovascular abdominal aortic aneurysm repair (EVAR), has been described using various endovascular techniques. The aim of the present systematic review was to assess the technical success, 30-day mortality, and mortality and reintervention rates during the available follow-up for patients managed with endovascular methods after failed endovascular repair.

METHODS

The present systematic review followed the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement and was preregistered at PROSPERO (no. CRD42022350436). A search of the English literature, via Ovid, using the MEDLINE, EMBASE, and CENTRAL databases, until June 15, 2022, was performed. Observational studies (2000-2022) and case series with at least five patients who had undergone fenestrated/branched EVAR (F/BEVAR) after failed EVAR were considered eligible. Technical success and mortality at 30 days and the mortality and reintervention rates during available follow-up had to have been reported. The Newcastle-Ottawa scale was used to assess the risk of bias. The primary outcome was technical success and mortality at 30 days.

RESULTS

The initial search yielded 2558 reports. Ten studies were considered eligible, two of which were prospective. A total of 423 patients had undergone F/BEVAR after failed EVAR. The indication for reintervention was the presence of a type Ia endoleak in 44.9%. Technical success was reported in seven studies, and 319 of 336 interventions were considered successful (94.9%), according to each study's criteria. Of the 423 patients, 10 had died within 30 days (2.4%). Seven patients had presented with spinal cord ischemia (2.4%). Twenty-three acute kidney injury events were reported (6.8%). The mean follow-up was 18 months (range, 1-77 months). During follow-up, 47 deaths were reported (14.8%). Finally, 50 reinterventions of 303 procedures (16.5%) had been performed.

CONCLUSIONS

According to the available literature, F/BEVAR after failed EVAR can be performed with high technical success and low mortality during the perioperative period. The midterm mortality and reintervention rates were acceptable. However, further data are needed to provide firm conclusions regarding the safety and durability of F/BEVAR after failed EVAR.

Effect of Sarcopenia on Mortality and Spinal Cord Ischaemia After Complex Aortic Aneurysm Repair: Systematic Review and Meta-Analysis

OBJECTIVE

Sarcopenia has been related to higher mortality rates after abdominal aortic aneurysm repair. This analysis aimed to assess sarcopenia related mortality and spinal cord ischaemia (SCI) at 30 days, and mortality during the available follow up, in patients with complex aortic aneurysms, managed with open or endovascular interventions.

DATA SOURCES

A search of the English literature, via Ovid, using Medline, EMBASE, and CENTRAL up to 15 June 2022 was done.

REVIEW METHODS

This meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and preregistered in PROSPERO (CRD42022338079). Observational studies (2000 - 2022), with five or more patients, reporting on sarcopenia related mortality and SCI at 30 days, and midterm mortality after thoraco-abdominal aneurysm repair (open or endovascular), were eligible. The ROBINS-I tool (Risk Of Bias In Non-Randomised Studies of Interventions) was used for risk of bias, and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) for the assessment of evidence quality. The primary outcome was 30 day and midterm mortality, and the secondary outcome was SCI at 30 days, in sarcopenic and non-sarcopenic patients. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Four retrospective studies (1 092 patients; 40.0% sarcopenic) were included. Thirty day mortality was similar, with low certainty between groups (6% [95% CI 1 - 11] in sarcopenic vs. 5% [95% CI 1 - 9] non-sarcopenic patients [OR 0.30, 95% CI -0.21 - 0.81; p = .94, Ι2 = 0%). The estimated midterm mortality was statistically significantly higher (very low certainty) in sarcopenic patients (25% [95% CI 0.19 - 0.31] vs. 13% [95% CI -0.03 - 0.29] in non-sarcopenic patients (1.11 OR 0.95, 95% CI -0.21 - 2.44; p < .001, Ι2 = 88.32%). SCI was significantly higher (very low certainty) in sarcopenic patients (19%, 95% CI 4 - 34) vs. 7% (95% CI 5 - 20) in non-sarcopenic patients (OR 1.80, 95% CI -0.17 - 3.78; Ι2 = 82.4%), despite an equal distribution of aneurysm type between the groups.

CONCLUSION

Early mortality does not appear to be affected by sarcopenia in patients treated for thoraco-abdominal aneurysms. However, sarcopenia may be associated with higher peri-operative SCI and midterm mortality rates.

Treatment of Aortocaval Fistula Secondary to Abdominal Aortic Aneurysm: A Systematic Review

BACKGROUND

Aortocaval fistula (ACF) secondary to an abdominal aortic aneurysm is a rare complication, inadvertently caused by a rupture into the inferior vena cava. Different treatment modalities have been applied toward the repair of such lesions, including open surgical and endovascular repair. The aim of this study was to report on ACF treatment and to analyze its early and mid-term outcomes.

METHODS

A systematic search of the English medical literature published between 2000 and 2022 was undertaken, using PubMed, SCOPUS, and CENTRAL databases as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis 2020 guidelines. A study protocol was registered in PROSPERO (CRD42022329058). Studies reporting on primary ACF outcomes following open surgical or endovascular repair were included. The ROBINS-I tool was applied for risk of bias assessment. Outcomes included technical success, 30-day and mid-term survival, endoleak following endovascular repair, and reintervention rates.

RESULTS

In total, 110 case studies, incorporating 196 patients (mean age; 66.2 years, males 96%) were included. Open surgical repair was applied in 78% (153/196). From the available data, technical success rate for each modality was 99% (152/153) and 100% (43/43), respectively. Open and endovascular repair demonstrated 87.5% (126/144) and 97.6% (42/43) 30-day survival, respectively, while mid-term survival was 86% (74/86) and 95.2% (20/21), respectively (medial follow-up: 14 months [1-54 months]). Endoleaks were reported in 19 endovascular cases (39.5%). Type II endoleak was the most frequent with a rate at 32.5% (14/43). Reintervention rates were 2.5% (4/151) and 35.7% (15/42) for open and endovascular repair, respectively.

CONCLUSIONS

Only few case studies were published on the treatment of this rare condition, while almost all invasive procedures were performed in males. Management of ACF repair with both open and endovascular approach was associated with excellent technical success rate and acceptable early and mid-term survival outcomes. Reintervention remained an issue for patients who were managed endovascularly.

Conical Aortic Neck as a Predictor of Outcome after Endovascular Aneurysm Exclusion: Midterm Results

BACKGROUND

Conical neck may affect endovascular aneurysm repair (EVAR) outcomes. The aim of this study was to present EVAR neck adverse events [endoleak type Ia (ET Ia) and graft migration], in patients with conical neck morphology compared to patients with non-conical necks. An additional analysis of the factors that may affect neck adverse events in patients with conical necks, during the first postoperative year, was executed.

METHODS

A retrospective analysis of prospective data was conducted, including patients that underwent elective EVAR, between 2017 and 2019. All patients completed the clinical and imaging follow-up of the initial 12 months. Regarding imaging, all cases underwent computed tomography angiography (CTA), preoperatively, at the 1st and 12th month of follow-up. Preoperative and postoperative aneurysm anatomic characteristics (supra-renal and infra-renal aortic diameters, aneurysm diameter, neck angle, thrombus, and calcification) were recorded. Proximal neck was defined as the infrarenal aortic segment, with a diameter less than 30 mm. Conical neck was any neck with a diameter increase ≥2 mm per cm of length (from outer-to-outer aortic wall). The proximal 15 mm of the neck length were considered the zone of endograft sealing. Migration was any ≥10 mm caudal movement of the endograft, relative to its position detected at the CTA of the first month. Neck adverse events were defined as the composite event of ET Ia and migration.

RESULTS

The cohort included 150 patients; 66 (44%) presented conical neck morphology. No significant difference was detected regarding the preoperative anatomic characteristics between the conical and non-conical groups. Only distal (15 mm) neck diameter was wider in the conical group (P < 0.001). Supra-renal active fixation was used in 63.3% of the total cohort; 59.5% in patients with non-conical necks and 68.2% in patients with conical morphology (P = 0.275). Graft oversizing was 18.2% and 18.7% in the non-conical and conical group, respectively (P = 0.248). Oversizing >20% was equal between groups [37.8% vs. 33.3%% (P = 0.608) while oversizing ≥30% was more common among patients with conical necks (3.5% vs. 10.6%, P < 0.001, 3.2 odds ratio, 95% confidence interval: 0.79, 12.91). Regarding ET Ia and migration, no difference was recorded between the groups. In a subanalysis among patients with conical necks, a lower graft migration rate was detected among patients with higher oversizing rate (P = 0.037).

CONCLUSIONS

EVAR may offer similarly good midterm outcomes in patients with conical and non-conical neck anatomy. An oversizing to the higher suggested rate may be preventive of graft migration during the first postoperative year in necks with conical morphology. Aggressive oversizing (>20%) do not offer any benefit regarding the prevention of adverse events among patients with conical necks.

Outcomes of a pilot abdominal aortic aneurysm screening program in a population of Central Greece

BACKGROUND

Abdominal aortic aneurysm (AAA) screening has contributed in the decrease of aneurysm related and all-cause mortality. The objective of our study is to present our experience from the only existing pilot AAA screening program in Greece.

METHODS

Men from both urban and rural areas in Central Greece, aged >60 years old without a previously known diagnosis of AAA were invited through the public primary health care units to participate to a screening program. Demographics, comorbidities, family history and anthropometric data were recorded. Aortic diameter values of >30 mm and common iliac artery (CIA) diameter values of >18 mm, were defined as aneurysmatic by ultrasound.

RESULTS

The screening program included 1256 individuals (1256/1814; response rate 69%). The incidence of AAA and CIA aneurysm was 2% (25/1256) and 2.3% (29/1256), respectively. Increased age (P<0.042), tobacco use (P<0.006) and its duration (P<0.008) were related to higher incidence of AAA, while diabetes mellitus to lower one (P<0.048). Multivariate analysis showed that AAA was associated to longer duration of smoking (1.05, CI: 0.02-6.6; P=0.01). Statin and antiplatelet therapy were administrated in 40% (10/25) and 44% (11/25), respectively of individuals with AAA. An additional analysis was provided between subjects with AD of 25-30 mm and AD <25 mm. In multivariate analysis, no factor was associated to AD of 25-30 mm.

CONCLUSIONS

The incidence of AAA and CIA aneurysm in Central Greece is 2% and 2.3%, respectively. Smoking duration was the strongest associated factor with AAA incidence. This provides to healthcare policy makers a strong valid point for the prevention strategies.

Midterm Outcomes of Endoleak Type 2 Embolization after Endovascular Aortic Aneurysm Repair Using a Neurointerventional Approach

BACKGROUND

Type 2 endoleaks (T2ELs) have been considered a benign condition and intervention is recommended when they are associated to sac expansion. The aim of this study was to report on T2EL embolization midterm outcomes, using neurointerventional material.

METHODS

A single-center retrospective analysis of consecutive patients treated with transarterial embolization, using neurointerventional material, for T2EL after standard endovascular aortic aneurysm repair (EVAR) between January 01, 2017 and July 30, 2022, was undertaken. Primary outcome was technical success and secondary outcome was T2EL recurrence during follow-up.

RESULTS

Twenty six patients [92.3% males, mean age 73.9 ± 7.7 years] were included. The median time between EVAR and T2EL diagnosis was 12 months (range: 1-84 months). In 38.5% of patients, T2EL was detected at first month after EVAR. The time to embolization was 18 months (range: 1-96 months). In 42.3% of cases, a patent inferior mesenteric artery was suspected to relate to T2EL formation while in 42.3% of cases, a lumbar artery. Twelve procedures (38.4%) were performed using coils and Onyx and 13 (50%), using only Onyx. Technical success was 84.6%. The mean follow-up was 24 months (range: 1-60 months), including 20 patients. In 30% of cases, an T2EL recurrence was detected. Three patients (11.5%) underwent secondary embolization.

CONCLUSIONS

Transarterial embolization for T2EL, using neurointerventional material, provided acceptable technical success and T2EL recurrence rates at 2 years of follow-up. Longer follow-up data would further estimate the durability of the technique.

Groin surgical site infection incidence in vascular surgery with intradermal suture versus metallic stapling skin closure: A study protocol for a pragmatic open-label parallel-group randomized clinical trial (VASC-INF trial)

BACKGROUND

Surgical site infection is 1 of the most frightening complications in vascular surgery due to its high morbimortality. The use of intradermal sutures for skin closure might be associated with a reduction in infections incidence. However, the data available in the literature is scarce and primarily built on low-evidence studies. To our knowledge, no multicenter clinical trial has been published to assess if the intradermal suture is associated with a lower surgical site infection incidence than metallic staples in patients who will undergo revascularization surgery requiring a femoral approach.

METHODS

VASC-INF is a pragmatic, multicenter, multistate (Spain, Italy, and Greece), randomized, open-label, clinical trial assessing the surgical site infection incidence in patients undergoing revascularization surgery requiring a femoral approach. Patients will be randomized on a 1:1 ratio to intradermal suture closure (experimental group) or to metallic staples closure (control group).The primary outcome is the number (percentage) of patients with surgical site infection (superficial and/or deep) associated with a femoral approach up to 28 (±2) days after surgery. Among the secondary outcomes are the number (percentage) of patients with other surgical wound complications; the number (percentage) of patients with surgical site infections who develop sepsis; type of antibiotic therapy used; type of microorganisms' species isolated and to describe the surgical site infection risk factors.

DISCUSSION

Intradermal suture closure may be beneficial in patients undergoing revascularization surgery requiring a femoral approach. Our working hypothesis is that intradermal suture closure reduces the incidence of surgical site infection respect to metallic staples closure.

Risk factors and adverse events related to supra- and infra-renal aortic dilation at twelve months after endovascular abdominal aortic aneurysm repair

BACKGROUND

Aortic remodeling and its effect on adverse events after endovascular abdominal aneurysm repair (EVAR) remain under investigation. This study aimed to assess aortic diameter alterations after EVAR, related risk factors and consequences to proximal sealing at 12 months.

METHODS

A single-center retrospective analysis of consecutive EVAR patients was undertaken. All patients underwent computed tomography angiography, preoperatively, at 1^st and 12^th month. The infrarenal diameter was measured just below the inferior renal artery, at 7 mm and 15 mm while the suprarenal, just above the superior renal artery (SRA), superior mesenteric artery (SMA) and just below the celiac trunk. Neck-related adverse events included migration and endoleak Ia.

RESULTS

A hundred fifty patients were included. At 1^st month, no significant diameter alteration was recorded at any level. At 12^th month, all infra-renal diameters increased (P<0.001) and diameters at SRA and SMA also augmented (P=0.024 and P=0.007, respectively). Neck diameter >29 mm, supra-renal fixation and oversizing >20% were associated to dilation at 12^th month. Neck adverse events were related to diameter alterations below the inferior renal artery (P=0.017), SRA (P=0.007) and SMA (P=0.05).

CONCLUSIONS

During the 12-month follow-up, aortic dilation may be detected from the supra-renal aorta to the total neck length. Neck dilation may be attributed to large neck diameter, supra-renal fixation, and aggressive oversizing. Neck-related adverse events are more common in patients with aortic dilation at 12 months.

Systematic Review on Customized and Non-customized Device Techniques for the Endovascular Repair of the Aortic Arch

PURPOSE

Open repair remains the standard of care for aortic arch pathologies. However, endovascular management became an attractive alternative for high-risk patients. This study aimed to assess the outcomes of the available endovascular techniques for aortic arch pathology management.

MATERIALS AND METHODS

A search of the English literature (2000-2022) using PubMed, EMBASE, via Ovid, and CENTRAL databases (February 1, 2022) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies reporting on patients with aortic arch pathologies managed with custom-made devices ([CMDs] fenestrated or branched thoracic endovascular aortic repair [F/BTEVAR]) and non-CMDs (parallel graft or surgeon-modified FTEVAR) were eligible. Studies reporting on hybrid or open repair were excluded. Studies' quality was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success, 30 day mortality, and cerebrovascular events (CVEs). Secondary outcomes were re-intervention and mortality during follow-up.

RESULTS

Thirty studies (2135 patients) were included. Treatment indications were mainly dissections (652 cases [48.0%, 652/1358]; 90 type A, 506 type B; 364 acute, 163 chronic) and aneurysms (46.9%, 582/1239). Five studies (211 patients) reported on FTEVAR and 10 (388 patients) on BTEVAR. For FTEVAR, technical success rate was 98.3%. Thirty-day mortality was 3.8% and CVE rate was 12.3%. Ten deaths (9.7%) and 19 re-interventions (9%) were recorded during follow-up (24 months). Regarding BTEVAR, technical success rate was 98.7%, and 30 day mortality and CVE rates were 5.4% and 11.0%, respectively. During follow-up (27 months), 64 deaths (18.7%) and 33 re-interventions (9.6%) were recorded. Parallel graft technique was reported in 11 studies (901 patients). Technical success rate was 76.4%. Thirty-day mortality was 3.9% and 32 (4.3%) CVEs were recorded. Thirty-five deaths (4.4%) and 43 re-interventions (5.5%) were reported during follow-up (27 months). Surgeon-modified FTEVAR was described in 5 studies (635 patients). Technical success rate was 91.6%. At 30 days, 15 deaths (2.3%) and 22 CVEs (3.5%) were recorded. During follow-up (19 months), 26 deaths (4.2%) and 21 re-interventions (3.6%) were detected.

CONCLUSIONS

Endovascular arch repair presented a variable technical success; >95% for F/BTEVAR; ≤90% for non-CMDs. Acceptable 30 day mortality rates were reported. Cerebrovascular event rates ranged up to 10%. These findings, adjacent to the estimated midterm mortality and re-interventions, set the need for further improvement.

CLINICAL IMPACT

Endovascular arch repair gains popularity as a valuable alternative, especially in patients considered unfit for open repair. According the available literature, any endovascular technique, including custom-made or off-the-shelf solutions, may be applied successfully, with acceptable early mortality. However, the perio-operative cerebrovascular event rate is still an issue, indicating the need for further advancements.

Branched Endovascular Aortic Repair After a Migrated EVAR Bypassing a Severely Kinked Previous Endograft

PURPOSE

To describe a novel technique to repair a juxtarenal abdominal aortic aneurysm (JAAA) after failed endovascular aortic repair (EVAR) with severely kinked anatomy.

TECHNIQUE

We present a patient who underwent an EVAR with a Medtronic Talent device 15 years ago and a proximal cuff extension 3 years earlier for an abdominal aortic aneurysm. Computed tomography (CT) done for a known gastritis showed a 12 cm JAAA, with a migrated endograft and a type Ia endoleak (EL). Endovascular repair was performed, accessing and navigating the aneurysmal sac outside the previous graft. The type I EL was reached and the suprarenal aorta catheterized. A 4-vessel inner-branched EVAR device was deployed in the distal thoracic aorta and their target vessels bridged through femoral access. A distal bifurcated component was deployed and both iliac limbs were extended to the native distal iliac arteries. Completion angiogram as well as early and 12-month CT showed a fully patent straight course branched EVAR with no ELs.

CONCLUSION

Complex aortic reinterventions in the presence of previous EVAR can be performed by choosing a straighter course along and parallel to the previous endograft. Several technical aspects must be considered to successfully perform this type of reinterventions.

CLINICAL IMPACT

We present a technique of a complex endovascular aortic repair in a failed EVAR with kinked anatomy, navigating through the thrombosed aneurysmal sac, outside the previously placed endograft and thus obtaining a straighter path for a new branched endograft. The novelty lies in a different approach to repair a failed EVAR with a branched graft through an uncommon access on the side of the previous endograft, avoiding repeated displacement or occlusion of the new endograft. We exemplify the feasibility of such a complex procedure and highlight important steps to perform it, whether in the abdominal or even thoracic Aorta.

Outcomes of Directional Branches of the T-Branch Off-the-Shelf Multi-Branched Stent-Graft

Background: A controversy on bridging covered stent (BCS) choice, between self-expanding (SECS) and balloon-expandable (BECS) stents, still exists in branched endovascular repair. This study aimed to determine the primary target vessel (TV) patency in patients treated with the t-Branch device and identify factors impairing the outcomes. Methods: A retrospective study was undertaken, including patients treated with the t-Branch (Cook Medical, Bloomington, IN, USA) between 2014 and 2019 (early 2014–2016; late 2017–2019). The endpoint was the primary patency (CT: celiac trunk, SMA, superior mesenteric artery, RRA: right renal artery, LRA: left renal artery) during the follow-up. Any branch instability event was assessed. The factors affecting the patency were determined using multivariable regression models and Kaplan–Meier analyses. Results: In total, 2018 TVs were analyzed; 1542 SECSs and 476 BECSs. The CT patency was 99.8% (SE 0.2%) at the 1st month, with no other event. The SMA patency was 97.8% (SE 1) at the 12th month. The RRA patency was 96.7% (SE 2) at the 24th month. The LRA patency was 99% (SE 0.4) at the 6th month. Relining was the only factor independently associated with the SMA patency (OR 8.27; 95% CI 1.4–4.9; p = 0.02). The freedom from instability was 62% (SE 4.3%) and 45% (SE 5.4%) at the 24th month and 36th month. No significant difference was identified between the BECSs and SECSs in the early or late experience. Conclusion: BCS for the t-Branch branches performed with a good primary patency during the short-term follow-up. The type of BCS did not influence the patency. Relining might be protective for SMA patency.

Editor's Choice - Sex Specific Outcomes After Complex Fenestrated and Branched Endovascular Aortic Repair: A Systematic Review and Meta-analysis

OBJECTIVE

As females are at higher mortality risk after endovascular aortic repair, this study aimed to compare the 30-day and 12-month mortality, morbidity, and re-intervention rates between the sexes, treated with fenestrated or branched endovascular aortic repair (F/BEVAR).

DATA SOURCES

A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL, up to 30 July 2021, was performed.

REVIEW METHODS

This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, and its protocol was registered in PROSPERO (CRD42021273418). Observational studies (2010-21), with ≥ 20 patients, reporting on sex specific outcomes (mortality, acute kidney injury [AKI], spinal cord ischaemia [SCI], and re-intervention, after F/BEVAR), were considered eligible. Risk of bias in the studies was assessed using ROBINS-I, and evidence quality was assessed using GRADE. The primary outcome was the sex specific 30-day mortality rate, AKI, SCI, and re-intervention rates; secondary outcomes were survival and freedom from re-intervention at 12 months after F/BEVAR. The outcomes were summarised as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Four retrospective and one prospective study (2 421 patients; 26% females) were included. The 30-day mortality rate was 12% in females vs. 3% in males (OR 2.65, 95% CI 1.79 - 3.92; Ι² = 0%). The 30-day AKI, SCI, and re-intervention rates were similar (OR 1.45, 95% CI 1.03 - 2.03; Ι² = 0%; OR 1.86, 95% CI 1.27 - 2.74; Ι² = 38%; and OR 1.06, 95% CI 0.66 - 1.77; Ι² = 0%, respectively). The 12-month survival rate was lower in females (OR 0.95, 95% CI 0.91 - 0.99; Ι² = 38%). When excluding 30-day deaths, there was no difference in 12-month survival between sexes (OR 0.99, 95% CI 0.95 - 1.02; Ι² = 32%). The 12-month freedom from re-intervention was similar between sexes (OR 0.87, 95% CI 0.75 - 1.01; Ι² = 0%).

CONCLUSION

Female patients treated by F/BEVAR may present worse outcomes in terms of 30-day and 12-month survival. The high peri-operative mortality rate remains an issue. When excluding 30-day deaths, the 12-month survival rate was similar between the sexes. Early morbidity and re-intervention rates were comparable.

Impact of true or false lumen renal perfusion after type B aortic dissection on renal volume

BACKGROUND

The aim of this study was to analyse the influence of true, false, and combined lumen perfusion of renal arteries on mid- and long-term kidney volume in patients with type B aortic dissection (TBAD).

METHODS

Retrospective analysis of patients diagnosed with a TBAD between 2008 and 2015 in a single high-volume European center. The origin of the renal arteries was evaluated on a dedicated 3D workstation (TeraRecon Inc., San Mateo, CA, USA) and coded as either arising from the true lumen (TL), false lumen (FL) or from a combination of both (CL). Additional evaluated anatomical parameters were renal volume, length, width, and depth of the kidneys. Measurements were recorded at the time of diagnosis (T0) and at 1-month (T1), 6-months (T2), 18-months (T3) and 36-month of follow-up time (T4).

RESULTS

A total of 131 renal arteries and kidneys were evaluated in 69 patients. Mean age was 64±13 years and 77% were male. The absolute number and percentage of assessed renal arteries/kidneys was 131 (100%) at T0, 89 (68%) at T1, 73 (56%) at T2, 57 (44%) at T3 and 43 (44%) at T4. At the time of diagnosis, 71.6% renal arteries originated from the TL, 19.1% from the FL and 9.2% from a CL. TEVAR was performed in 92.7% patients and nine patients had additional renal artery stenting. At T0 the mean renal volume was 212.1±70.9cm³, 178±61.2 in women versus 222.2±70.6 in men (P=0.002). Forty-three percent of the patients had a renal volume reduction ≥15% from T0 to their last available CTA. Mixed model analysis showed a significant overall renal volume reduction of 13.7cm³ from T0 to T4 (P<0.05). No significant differences in renal-volume reduction were observed depending on origin of the renal artery, though an estimated reduction of renal volume from T0 to T4 of 40.8 cm³ was seen when the kidneys were perfused by a CL, while TL perfusion only caused a reduction of 15.6 cm³ and no relevant volume change over time was observed when the renal artery originated from FL. Alongside a renal volume reduction, mixed model analysis also showed a significant serum-creatinine increase, from 0.8618mg/at T0 to 1.38±0.56 mg/dL at T4 (P<0.001), as well as a significant glomerular filtration rate reduction over time, from > 60mL/min at T0 to 49±13 mL/min at T4 (P<0.001). A negative correlation was observed between creatinine values and renal volume change, while a positive correlation was observed between GFR and renal volume change (P<0.001).

CONCLUSIONS

There is a significant mid-term renal-volume reduction in patients with TBAD, independent of the origin of the renal arteries. Albeit not statistically significant, combined renal artery perfusion may lead to a greater volume reduction, potentially secondary to a relevant dynamic compression by the dissection membrane. Further multicentre studies are warranted to determine the effect on long-term renal function and on possible preventive strategies.

Meta-analysis of Comparative Studies Between Self- and Balloon-Expandable Bridging Stent Grafts in Branched Endovascular Aneurysm Repair

PURPOSE

Currently there is no robust evidence which type of bridging stent graft provides better outcomes after branched endovascular aortic repair (BEVAR). Self-expanding (SESG) and balloon-expandable (BESG) stent grafts are both commonly used to connect branches to their respective target vessels (TV). The aim of the current review was to evaluate the impact of the type of bridging stent grafts on TV outcomes during the mid-term follow-up after BEVAR.

MATERIALS AND METHODS

The study protocol was registered to the PROSPERO (CRD42021274766). A search of the English literature was conducted, using PubMed and EMBASE databases via Ovid and Cochrane database via CENTRAL, from inception to June 30, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Only comparative studies on BEVAR reporting TV outcomes related to BESG vs SESG were considered eligible. Individual studies were assessed for risk of bias using the Newcastle Ottawa Scale. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcomes were primary patency, freedom from endoleak, TV instability, and re-intervention between BESG and SESG, used as bridging stents in branches. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis.

RESULTS

Five out of 609 articles published from 2016 to 2020 were included in the analysis. In total, 1406 TV were revascularized, 547 (38.9 %) with BESGs and 859 with SESGs. The overall pooled primary patency (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.29-1.09; p=.256, I²=4.24%) and freedom from branch-related endoleak (OR, 0.65; 95% CI, 0.17-1.48; p<.122, I²=0.18%) did not differ between the stent types during the available follow-up (17 months, range = 12-35 months). In 4 studies (619 TV), SESG required fewer secondary interventions (OR, 1.04; 95% CI, 0.23-1.83; p=.009, I²=0%) and TV instability rate was lower (OR, 0.99; 95% CI, 0.33-1.65; p=.003, I²=0%) compared with BESG during the available follow-up.

CONCLUSION

BESG and SESG seem to perform similarly in terms of primary patency and branch-related endoleak during the mid-term follow-up. Current data from retrospective studies suggest that overall TV instability and re-intervention rates are favorable for SESG as bridging stent grafts in BEVAR.