Fenestrated Physician-Modified Endografts for Preservation of Main and Accessory Renal Arteries in Juxtarenal Aortic Aneurysms.

BACKGROUND There is a paucity of reporting outcomes of complex aortic aneurysm treatment such as juxtarenal abdominal aortic aneurysms, where additional techniques to preserve renal artery perfusion are required. METHODS Retrospective analysis of consecutive patients who underwent emergent and elective aortic repair with fenestrated PMEGs between March 2019 and January 2023. Endpoints were technical success, reinterventions, secondary reinterventions and target vessel patency. RESULTS Forty-seven target vessels in 37 patients (23 male, median age 75 years) were targeted, of which 44 were renal arteries (RAs) with a mean diameter of 5.4 ± 1.0 mm. Thirteen were accessory RAs and six had a diameter ≤ 4 mm. Technical success rate was 87% overall; 97% for main and 62% for accessory RAs respectively. Target vessel patency and freedom from secondary reintervention was 100% and 97% at 30 days and 96% and 91% at one year, respectively. There was no 30-day mortality. CONCLUSION Fenestrated physician-modified endografts are safe and effective for the treatment of patients with juxtarenal abdominal aortic aneurysms when incorporating main renal arteries. Limited technical success may be expected when targeting accessory renal arteries, especially when small in diameter. Long-term follow-up is needed to confirm durability of PMEGs for renal artery preservation

The sac evolution imaging follow-up after endovascular aortic repair: An international expert opinion-based Delphi consensus study

Objective: Management of follow-up protocols after endovascular aortic repair (EVAR) varies significantly between centers and is not standardized according to sac regression. By designing an international expert-based Delphi consensus, the study aimed to create recommendations on follow-up after EVAR according to sac evolution. Methods: Eight facilitators created appropriate statements regarding the study topic that were voted, using a 4-point Likert scale, by a selected panel of international experts using a three-round modified Delphi consensus process. Based on the experts’ responses, only those statements reaching a grade A (full agreement $75$80% and full disagreement <5%) were included in the final document. Results: One-hundred and seventy-four participants were included in the final analysis, and each voted the initial 29 statements related to the definition of sac regression (Q1-Q9), EVAR follow-up (Q10-Q14), and the assessment and role of sac regression during follow-up (Q15-Q29). At the end of the process, 2 statements (6.9%) were rejected, 9 statements (31%) received a grade B consensus strength, and 18 (62.1%) reached a grade A consensus strength. Of 27 final statements, 15 (55.6%) were classified as grade I, whereas 12 (44.4%) were classified as grade II. Experts agreed that sac regression should be considered an important indicator of EVAR success and always be assessed during follow-up after EVAR. Conclusions: Based on the elevated strength and high consistency of this international expert-based Delphi consensus, most of the statements might guide the current clinical management of follow-up after EVAR according to the sac regression. Future studies are needed to clarify debated issues. (J Vasc Surg 2024;80:937-45.

Great saphenous vein versus expanded polytetrafluoroethylene graft in patients undergoing elective treatment of popliteal artery aneurysm with posterior approach

Background: Aim of this study is to compare 30-day and 5-year outcomes of great saphenous vein (GSV) vs. expanded polytetrafluoroethylene (ePTFE) graft in patients undergoing elective treatment of popliteal artery aneurysm (PAA) using a posterior approach. Methods: Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs who underwent open repair with posterior approach or endovascular repair in 40 centers was investigated. Out of of 971 cases, 525 patients were included in the present analysis. These were further divided into: posterior approach with GSV graft (252, GSV Group), and posterior approach with ePTFE graft (273, ePTFE Group). Thirty-day outcomes were assessed and compared. During follow-up, survival, primary patency, secondary patency, freedom from reintervention(s), and amputation-free survival were compared between the two groups using log-rank tests. Uni- and multivariate Cox regression analyses were performed in ePTFE Group to find predictive factors of poor outcomes. Results: Two groups were homogeneous in terms of preoperative risk factors and morphological data. Median follow-up duration was similar [24 months (IQR 10 - 36) GSV Group vs. 21 months (IQR 7-47) ePTFE Group; p = .123]. At 5 years, there were no differences between the two groups in terms of survival (84.7% GSV Group vs. 86.1% ePTFE Group; p = .097, log-rank = 2.756), secondary patency (94.9% GSV Group vs. 89.4% ePTFE Group; p = .068, log-rank = 3.336), and amputation-free survival (99.1% GSV Group vs. 99.6% ePTFE Group; p = .567, log-rank = .328). Five-year primary patency (89.5% GSV Group vs. 76.2% ePTFE Group; p = .007, log-rank = 7.239), and freedom from reintervention(s) (92.8% GSV Group vs. 80.6% ePTFE Group; p = .011, log-rank = 6.449) were significantly higher in GSV Group. Using multivariate analysis in ePTFE Group, factors compromising primary patency were patients on dialysis (p = .054, OR = 3.641), and patients that were not on any preoperative antiplatelet therapy or anticoagulation (p = .019, OR = 5.532), whilst none of the perioperative factors affected freedom from reintervention(s). Conclusion: GSV as graft guaranteed better primary patency with less reinterventions rates at mid-term follow-up after treatment of PAAs via a posterior approach. Patients on dialysis and who were not on any preoperative antiplatelet therapy or anticoagulation had lower patency rates

Thorakoabdominelles Aortenaneurysma

Thoracoabdominal aortic aneurysms (TAAA) are rare events with an incidence of 5.9 cases per 100,000 persons per year. In Germany approximately 940 TAAA procedures are performed annually. The cause of TAAA is mostly degenerative but they can also occur on the basis of an aortic dissection or connective tissue disease (e. g. Marfan’s syndrome). Patients often have severe comorbidities and suffer from hypertension, coronary heart disease or chronic obstructive pulmonary disease, mostly as a result of smoking. Operative treatment is indicated when the maximum aortic diameter has reached 6 cm (> 5 cm in patients with connective tissue disease) or the aortic diameter rapidly increases (> 5 mm/year). Treatment options are open surgical aortic repair with extracorporeal circulation, endovascular repair with branched/fenestrated endografts and parallel grafts (chimneys) or a combination of open and endovascular procedures (hybrid procedures). Mortality rates after both open and endovascular procedures are approximately 8 % depending on the extent of the repair. Furthermore, there are relevant risks of complications, such as paraplegia (up to 20 %) and the necessity for dialysis. In recent years several approaches to minimize these risks have been proposed. Besides cardiopulmonary risk evaluation, clinical assessment of patients by the physician with respect to the patient-specific anatomy influences the allocation of patients to one treatment option or another. Surgery of TAAA should ideally be performed in high-volume centers in order to achieve better results