Polidocanol-foam treatment of varicose veins: Quality-of-life impact compared to conventional surgery

BACKGROUND AND OBJECTIVE

Lower limb varicose veins are a prevalent disease associated with several available treatment options, including conventional surgery and polidocanol foam sclerotherapy. However, few studies have analyzed therapeutic modality outcomes based on Patient-Reported Outcome Measures (PROMs). This large sample-size study was designed to evaluate the outcomes of polidocanol foam sclerotherapy compared to conventional surgery based on an analysis of PROMs.

METHODS

This was a prospective, observational, and qualitative study of 205 patients who underwent varicose vein treatment with either polidocanol foam sclerotherapy (57 patients, 90 legs) or conventional surgery (148 patients, 236 legs). Patients were preoperatively assessed and re-evaluated 30 days after the procedure using the Venous Disease Severity Score (VCSS) and specific venous disease quality-of-life questionnaires (VEINES-QoL/Sym).

RESULTS

Both treatments significantly improved VCSS and VEINES results 30 days after the procedure (p < 0.05). However, surgery promoted greater improvements in VCSS (on average 4.02-points improvement, p < 0.001), VEINES-QoL (average 8-points improvement, p < 0.001), and VEINES-Sym (average 11.66 points improvement, p < 0.001) than did sclerotherapy. Postoperative pain and aesthetic concerns about the legs were the domains of the questionnaires in which the results varied the most between the treatment modalities, with worse results for sclerotherapy.

CONCLUSION

Both polidocanol foam sclerotherapy and conventional surgery positively impact patients' quality of life after 30 days, but the improvement is more significant for patients who undergo conventional surgery.

Shared decision-making and specific informed consent in patients with aortic aneurysms

OBJECTIVE

To analyze the refusal rate of elective aortic aneurysm surgery in asymptomatic patients after the presentation of a detailed informed consent form followed by a meeting where patient and their families can analyze each item.

METHODS

We conducted a retrospective analysis of 49 patients who had aneurysms and were offered surgical treatment between June 2017 and February 2019. The patients were divided into two groups: the Rejected Surgery Group, which was composed of patients who refused the proposed surgical treatment, and the Accepted Surgery Group, comprising patients who accepted the proposed surgeries and subsequently underwent them.

RESULTS

Of the 49 patients, 13 (26.5%) refused surgery after reading the informed consent and attending the comprehensive meeting. We observed that patients who refused surgery had statistically smaller aneurysms than those who accepted surgery (9% versus 26%). These smaller aneurysms were above the indication size, according to the literature.

CONCLUSION

One-quarter of patients who were indicated for elective surgical repair of aortic aneurysms rejected surgery after shared decision-making, which involved presenting patients with an informed consent form followed by a clarification meeting for them and their families to analyze each item. The only factor that significantly influenced a rejection of the procedure was the size of the aneurysm; patients who rejected surgery had smaller aneurysms than those who accepted surgery. Up to 26% of patients with aortic aneurysms refused surgical repair. The proposed technique, whether open or endovascular, did not influence patients' decisions. Patients with smaller aneurysms were more likely to refuse aortic aneurysm treatment.

Conventional Varicose Vein Surgery: Comparison between Single versus Staged Surgery Using Patient Reported Outcomes

BACKGROUND

In the Brazilian public health system, conventional surgery is the standard procedure for treatment of varicose veins (VV). We aimed to compare clinical and quality of life (QoL) results of patients subjected to bilateral treatment of VV by a single-procedure or staged-procedure approach.

METHODS

A total of 111 patients undergoing bilateral treatment for VV were treated either by a single-surgery or 2 staged procedures (minimal: 30-day interval) depending on institutional protocol. Patients were evaluated with respect to clinical symptoms and quality of life markers before and after treatment, by use of the VEINES-Sym/QoL and EQ5D-5L scores, and these results were then compared between groups.

RESULTS

QoL scores improved in general after treatment. VV specific symptoms and QoL aspects improved equally between the Staged-procedure and Single-surgery groups (VEINES-Sym mean variation 29.7 ± 2.1 vs. 29.9 ± 2.7, respectively; P = 0.340 and VEINES-QoL mean variation 5.5 ± 3.4 vs. 4.5 ± 4.3, respectively; P = 0.369). General QoL, however, showed more improvement in the Staged-procedure than the Single-surgery group (EQD5-5L mean increase 0.1678 ± 0.1555 and 0.0785 ± 0.1384, respectively; P = 0.007). When propensity matched, patient subgroups maintained this same differences in QoL results.

CONCLUSIONS

Our findings suggest that the both the Staged- and Single-surgery approach for VV surgical treatment incur similar improvement in disease-specific QoL, and that the Staged-approach may impose less of a burden in the patients' recovery.

Retrospective Observational Single-Center Study of Complications of Arterial Indwelling Catheters for Invasive Blood Pressure in Intensive Care Unit Patients

This study aimed to analyze the incidence of complications resulting from the use of an indwelling arterial catheter (IAC). We compared the characteristics of the patients with an IAC who developed complications with those who did not present any complications. The study included 1,869 patients with an IAC hospitalized in intensive care units (ICUs) between 2017 and 2018. Most patients were male (58.7%), in the seventh decade of life, and had systemic arterial hypertension. The most common site of IAC implantation was the radial artery. Fifty-four (2.88%) cases of complications related to an IAC were identified including bleeding, hematomas, and thrombosis. Female patients had a higher risk of complications (P = .030). Comorbidities such as arrhythmias (P < .001) and peripheral arterial disease (P = .041) also increased that risk. The use of vasoactive drugs (P = .001), hemodialysis (P = .001), and orotracheal intubation (OTI) (P = .001) was significantly associated with the occurrence of complications as well as length of stay in ICUs (P < .001) and IAC duration (P = .001). IACs are safe devices commonly used in ICUs, with an incidence of complications of 2.88%.

Intraoperative evaluation of tunneled dialysis catheter mobility and function with arm movement

OBJECTIVE

The main objectives of the present study were to analyze the right internal jugular vein tunneled dialysis catheter (TDC) tip displacements, functional changes, pathway deformities, and angulations associated with different arm positions.

METHODS

We prospectively studied 21 patients who had undergone TDC implantation for hemodialysis via the right internal jugular vein at a single center from February to September 2020. After implantation, a baseline resting fluoroscopy image was taken, and three movement-mimicking images of the ipsilateral arm were obtained for comparison, with the arm in maximum abduction, maximum flexion, and maximum adduction. Device function was analyzed for each movement-mimicking position and correlated with catheter tip displacement, catheter deformity, and catheter pathway angulation.

RESULTS

TDC pathway deformity occurred in 16 patients (69.5%). Deformities were more frequent in the movement-mimicking positions than in to the control resting baseline images (P = .004). The different arm positions did not lead to significant tip displacement (either horizontal or vertical; P > .05), nor did they result in significant pathway angulation between the subcutaneous and intravenous regions (P = .114). However, in the maximum abduction position, a positive relationship was present between the catheter pathway angle and impairment of catheter function (P = .028).

CONCLUSIONS

Catheter deformity was more frequent and more severe with maximum adduction and flexion of the arm. Although no significant changes were observed in the tip of the catheter with the movements, a positive relationship was found between the catheter pathway angle and impairment of catheter function with the arm in the maximum abduction position.

Anxiety and depression scores in patients subjected to aortic and iliac aneurysm repair procedures

OBJECTIVE

This study examines the changes in anxiety and depression scores of 84 patients subjected to aortic or iliac aneurysm correction with no previous psychiatric history.

METHODS

Patients were referred to the evaluation using the Beck Anxiety and Depression Inventories no more than 3 days before surgery (i.e., preoperative [Pre-Op]), 30 days after revascularization (i.e., Early postoperative [PO]), and at least 6 months after revascularization (i.e., Late PO).

RESULTS

Mean anxiety scores declined from baseline at both the Early (mean difference: 2.75, p<0.001) and Late PO (mean difference: 2.74, p=0.001). The depression levels showed no significant variation in either evaluation (Early PO; mean difference: -0.84, p>0.05, Late PO: 0.87, p=0.05). A more severe degree of anxiety at baseline was related to better anxiety results both in the Early PO (p=0.041) and Late PO (p=0.008). An endovascular technique was related to the improvement in depression symptoms in the Early PO (p=0.01) but the worsening of the symptoms in the Late PO (p=0.033).

CONCLUSIONS

Patients subjected to aortoiliac aneurysm corrections have a higher incidence of anxiety and depressive symptoms. Anxiety symptoms, but not the depressive ones, improved considerably following the successful treatment. The formal psychiatric evaluation may be beneficial for patients with less improvement in the symptom.

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis?

The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES

This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients.

METHODS

This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping.

RESULTS

From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter.

CONCLUSIONS

The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Use of carbon dioxide for therapeutic decision-making in endoleaks: a case report

Endovascular aneurysm repair is currently the most frequently treatment modality for infrarenal aortic aneurysms. Endoleaks are the most common cause of reintervention after endovascular aneurysm repair. It is often unclear which type of endoleak is the correct diagnose, making the treatment decision difficult. We report the case of a 72-year-old man with an endoleak two years after endovascular aneurysm repair. Images suggested a type III endoleak, but this was not confirmed by contrast aortography. We proceeded with the investigation using aortography with carbon dioxide and observed a type IA endoleak. This was successfully treated by implantation of a proximal cuff. A review of the literature shows that the role of carbon dioxide in endoleak management is still unclear. We present a case in which carbon dioxide was essential to both diagnosis and therapeutic decision-making in a type IA endoleak.

Evaluation of the Activity of Heparin Injected into the Fully Implantable Catheter for Chemotherapy (Portocath) between Two Moments of Use

BACKGROUND

The aim of this study is to analyze whether heparin, used as a lock in fully implantable catheter for chemotherapy (portocath), maintains its activity even if it remains in the catheter for a long period of time.

METHODS

According to the institutional protocol, all catheters routinely use the lock solution with 3 mL of heparinized solution after chemotherapy and the time interval between each change as lock in the catheters studied ranged from 7 to 30 days. A total of 25 blood samples from 22 patients with 6 types of neoplasia on chemotherapy or not were collected according to routine, and the 10 mL of liquid contained in the first aspirated reservoir/catheter (corresponding to the lock of the last section), were sent for laboratory analysis for prospectively studied with the following tests: anti-Xa, partially activated thromboplastin time (APTT), thrombin time (TT), reptilase, and thromboelastogram.

RESULTS

Heparin activity was found in 96% of the anti-Xa and APTT tests. In relation to TT, 92% presented activity. The reptilase test was performed on 24 samples with significant time reduction in all of them. In the INTEM stage, the thromboelastometry test showed activity in 92% of samples and in the HEPTEM phase there was reduction in time in all samples. In all samples, the heparin activity was found to be independent of the time of use.

CONCLUSIONS

We can conclude that lock of heparinized solution used in our service in fully implantable central venous catheters for chemotherapy was maintained with active heparin even after a long period of time (up to 30 days), demonstrating that the half-life of the substance within the catheter is greater than its plasma half-life.

Combination of topical agents and oxybutynin as a therapeutic modality for patients with both osmidrosis and hyperhidrosis

INTRODUCTION

The association of osmidrosis and hyperhidrosis often causes emotional and social problems that may impair the patients' quality of life. The purpose of our study was to analyze the therapeutic results of oxybutynin and topical agents in 89 patients with both osmidrosis and hyperhidrosis.

METHOD

We conducted an observational study at two specialized centers of hyperhidrosis between April 2007 and August 2013. Eighty-nine (89) patients with both osmidrosis and hyperhidrosis were treated with oxybutynin and topical agents. Patients were evaluated before treatment and at 3 and 6 weeks after treatment started, by using the Quality of Life Questionnaire and the Sweating Evolution Scale.

RESULTS

Before treatment, 98% of the patients presented with poor or very poor quality of life. After six weeks of treatment, 70% stated their quality of life as being slightly better or much better (p<0.001) and nearly 70% of the patients experienced a moderate or great improvement in sweating and malodor. Improvement in osmidrosis was significantly greater when the axillary region was the first most disturbing site of hyperhidrosis.

CONCLUSION

There was a significant improvement in quality of life and a reduction in sweating and malodor after six weeks of treatment with topical agents and oxybutynin in patients with both hyperhidrosis and osmidrosis. Therefore, clinical treatment should be considered before invasive techniques.

Endovascular revascularization of TASC C and D femoropopliteal occlusive disease using carbon dioxide as contrast

Objective

To analyze the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO₂ as primary contrast in patients with no formal contraindication to iodine, aiming to decrease allergic reactions and potential nephrotoxicity in high-risk patients.

Methods

We describe the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO₂ as primary contrast in patients with high risk for open revascularization and no formal contraindication to iodine. We analyzed feasibility of the procedures, complications, quality of the angiographic images, clinical and surgical outcomes, and costs of C and D lesions treated using CO₂ as contrast medium.

Results

The use of CO₂ in C and D lesions needed iodine complementation in most of the cases (nine cases) but decreased the potential nephrotoxicity of iodine contrast medium by the reduction of its volume in this group of high-risk patients. The extension of the arterial lesions was the factor that most contributed to the need for iodine supplementation due to the difficulty to visualize the refill after a long arterial occlusion.

Conclusion

The use of CO₂ as contrast in patients with C and D lesions with no restriction for iodine contrast medium was an alternative that did not dismiss the need of iodine supplementation in most of the cases, but could decrease the potential nephrotoxicity of iodine constrast medium.

Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know

OBJECTIVES:

This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control.

METHOD:

This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911.

RESULTS:

Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery.

CONCLUSIONS:

If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.

Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair

BACKGROUND

Iodine contrast medium (ICM) is considered to be gold standard in endovascular procedures, but its nephrotoxicity and hypersensitivity limit the widespread use. Carbon dioxide (CO₂) is considered as an alternative for endovascular procedures in patients with contraindication to ICM. However, no studies have compared the outcomes of endovascular aneurysm repair (EVAR) performed with ICM or CO₂ among patients with no contraindication to ICM.

METHODS

From May 2012 to April 2014, 36 patients with abdominal aortic aneurysms underwent EVAR in a prospective, randomized, and controlled study. Patients were randomized into 2 groups, CO₂ or ICM group.

RESULTS

We were able to perform the proposed procedures in all patients in this study. There were no conversions to open surgery and no CO₂-related complications. Endovascular material costs, duration of surgery, and time of fluoroscopy were similar between groups, and the cost of the contrast media was smaller in the CO₂ group than in the ICM group. Among CO₂ group procedures, 62.5% of the patients needed ICM complementary use.

CONCLUSIONS

The use of CO₂ as a contrast medium for EVAR is an alternative in patients with no restriction for ICM, with similar outcomes when compared to ICM, regarding duration of surgery, duration of fluoroscopy, and endovascular material costs. Using CO₂, there were no changes in creatinine clearance and no risk of hypersensitivity reactions; moreover, there was a reduction in contrast-related costs for EVAR procedures. However, in our study, additional use of ICM to visualize the internal iliac artery was needed in most procedures.

Carbon dioxide contrast medium for endovascular treatment of ilio-femoral occlusive disease

OBJECTIVES

Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine.

MATERIALS AND METHODS

From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty.We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group.

RESULTS

No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers.

CONCLUSIONS

The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.

Carbon dioxide as a substitute for iodine contrast in arteriography during embolectomy

Acute limb ischemia can be potentially harmful to the limb and life threatening. Renal failure is a possible outcome associated with release of products of ischemic limb reperfusion. Some authors reported the benefit of performing angiography after embolectomy, even though iodine contrast is also nephrotoxic. We report a case of embolectomy on a patient with renal insufficiency in whom carbon dioxide was used as a substitute for iodine contrast.

Abstract 709: Aging Determines Different Osteochondrogenic Protein Expression Profile Associated With Increased Calcification and Elastocalcinosis in Diabetic Patients Submitted to Amputation

Peripheral artery disease (PAD) frequently occurs in diabetes mellitus (DM) and associates with limb ischemia and amputation. Vascular calcification, which is very prevalent both in DM and in the elderly, contributes to PAD pathophysiology and further increases amputation risk. Our objectives were to quantify vascular calcification, elastic and collagen fiber content, besides osteochondrogenic protein expression in arteries from 2 diabetic patients at the extremes of age. Femoral and dorsalis pedis artery from a 92-year-old male (O) and a 40-year-old male (Y), both with DM, were harvested at the time of amputation caused by limb ischemia. Other cardiovascular risk factors were similar among patients. Specimens were fixed in buffered formaldehyde, processed and stained for hematoxylin-eosin, Verhoeff-van-Gieson and Masson’s trichrome. Immunohistochemical analysis was performed to assess osteogenic protein expression such as RUNX2, alkaline phosphatase (ALP) and Osterix (OSX), which are upregulated during vascular smooth muscle cell reprogramming to an osteogenic phenotype, responsible for hydroxyapatite deposition. Arteries from 92-year-old patient showed markedly architectural changes of the vascular wall in comparison with the younger patient sample, such as decreased collagen (O=0.8±0.2% versus Y=33.5±5.2% area/field, p<.05) and elastic fibers (O=1.6±0.4% vs. Y=7.8±1.5% area/field, p<.05) content. Coincidently, we demonstrated increased vascular calcification (O=209.7±27.5mm 2 /field vs. Y=30.6±6.3 mm 2 /field). Osteochondrogenic protein expression also showed opposing results: OSX stained around large calcification nuclei, mostly in the older, but not in the younger patient samples. Furthermore, RUNX2 and ALP expression, which determines early osteoblastic cell differentiation, occurred around small calcium deposits, mainly in the 40-year-old patient. We demonstrated that age and time-length exposure to diabetes are predictive of collagen and elastic fibers content associated with increased calcification area. Moreover, osteochondrogenic protein expression profile favors RUNX2 and ALP in the younger vs OSX in the older patient respectively, implying different stages of the disease.

Public private partnership in vascular surgery

Objective

To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. Methods: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide).

Results

A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide – was effective and cheaper.

Conclusion

The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge.

Combined use of GORE TAG® and Gore Exculder® endografts for treatment of abdominal aortic aneurysm with severe angulation

The advances in endovascular surgery for treatment of aortic aneurysms have allowed a greater number of patients, who were previously considered unsuitable for the approach, to benefit from this therapeutic modality. Despite the current availability of highly comfortable endografts, cases with unfavorable anatomy remain a challenge for surgeons. We report a case with difficult anatomy that was successfully managed using an unconventional endovascular technique.