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Objective: Abdominal aortic aneurysm (AAA) in a patient with an underlying heritable aortic disease (HAD) is rare, and evidence based recommendations for its management are lacking. This study aimed to generate a consensus from multidisciplinary specialists on the diagnosis, treatment, and surveillance of AAA associated with HAD and to define topics of interest for future research.

Methods: A Delphi consensus was designed involving European multidisciplinary specialists and reported using the ACcurate COnsensus Reporting Document (ACCORD) reporting guideline. Four rounds were carried out by email: the first two rounds to agree on the content of the questionnaire and the final two rounds to reach an agreement. Questions focused on the composition of the team, imaging, clinical suspicion, genetic testing, medical management, indications for surgical repair, surgical technique, surveillance, exercise, and quality of life. The level of agreement for each question was graded using a Likert type scale and classified into four categories: A (very strong), B (strong), C (fair), and D (no agreement).

Results: A total of 35 experts from 18 different hospitals and 10 different countries participated in the study: 19 vascular surgeons, 11 cardiologists, four geneticists, and one cardiac surgeon. Of the 97 statements of the final questionnaire, 16 were graded A (16%), 23 B (24%), five C (5%), 44 D (45%) and nine (9%) were invalid. The experts highlighted the need to develop personalised therapies for each pathology, as well as international multicentre databases to collect data on the natural course of AAA patients with HAD.

Conclusion: This Delphi process led to consensus on several aspects of care for patients with AAA and underlying HAD, providing guidance to manage them in a more standardised fashion. The agreements reached focus on multidisciplinary aortic teams, imaging and genetic diagnosis, treatment, and follow up. Furthermore, several topics for future research were identified.

OBJECTIVE: The aim of this study was to describe the occurrence of branch thrombosis following endovascular treatment of aortic arch pathology using an arch branched device (ABD) and to determine whether this is influenced by clinical and geometric parameters.

METHODS: In this retrospective observational study of patients treated with an ABD in three centres, the primary endpoint was thrombus formation within a branch during follow up. Secondary endpoints were technical success, serious adverse events (SAEs), early and late death, stroke, and re-interventions. Geometric measurements (tortuosity index and curvature) were determined on pre- and post-operative computed tomography angiograms.

RESULTS: Thirty nine patients were treated and 68 antegrade branches were analysed (innominate artery, n = 27; common carotid artery [CCA], n = 40; left subclavian artery [LSA], n = 1). Thrombus was identified within seven branches (10%) on surveillance imaging (innominate artery, n = 6; CCA, n = 1; LSA, n = 0; p = .021) and was associated with a wider distal bridging stent diameter (median 14.0 mm [13.3, 15.3] vs. 8.7 mm [IQR 5.9]; p = .026), a higher degree of reversed tapering (4.3 mm [3.8, 5.2] vs. 1.2 mm [0.3, 3.1]; p = .023), use of polyethylene terephthalate (Dacron) covered (vs. expanded polytetrafluoroethylene) bridging stents (23% vs. 2%; p = .011), and higher body mass index (BMI) (32.1 kg/m² [28.7, 36.2] vs. 25.7 kg/m² [23.8, 29.2]; p = .029), but not with pre-operative or post-operative tortuosity index or curvature or alterations. Regarding secondary outcomes, the technical success rate was 97%, SAEs occurred in 15 patients (38%), early and late death rates were 8% and 23%, respectively, and early and late stroke rates were 5% and 23%, respectively.

CONCLUSION: The risk of developing branch thrombosis after endovascular intervention with an ABD is considerable, especially of innominate artery branches, characterised by Dacron covered large diameter bridging stents, and in patients with a high BMI. Large prospective studies are required to analyse factors associated with branch thrombosis.

Objectives: To analyze device designs, similarities and overlaps of custom-made fenestrated arch endografts intended for mid/distal arch thoracic endovascular aortic repair. Materials and

Methods: A multicenter cross-sectional study analyzing custom-made anonymized graft plans was performed. Graft plans were included from a cohort of mid/distal aortic arch repairs using custom-made fenestrated aortic endografts treated at 8 centers. Grafts targeting >2 arteries were excluded. No patient/clinical data were analyzed. A descriptive analysis was performed followed by an analysis of overlap of the designs to reach a common design in which the greatest number of grafts would overlap.

Results: One hundred thirty-one graft plans were included. All grafts were custom-made grafts from the COOK Medical Fenestrated arch platform. Ninety-four (71.8%) had a scallop-and-single-fenestration design, 33 (25.2%) had a single fenestration and 4 (4.3%) a single scallop. For analysis purposes, these latter 4 grafts were excluded. Two main graft plans (Plans 1 and 2) were proposed after analysis with similar configuration (1 scallop with 30 mm width, 20 mm height, 12:00 position; 1 preloaded fenestration with 8 mm diameter, 26 mm from the top of the graft and 12:00 position; tapered, with a 193 mm length and 32 mm distal diameter) but with 2 different proximal diameters of 38 mm (Plan 1) and 44 mm (Plan 2), reaching an overall feasibility of 85.8% (n=109), being 47.2% (n=60) and 38.6% (n=49) for each design, respectively.

Conclusion: The degree of overlap between the studied fenestrated and/or scalloped thoracic endovascular aneurysm repair (TEVAR) graft designs was high. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility. Clinical Impact In a multicenter study analyzing 127 fenestrated aortic arch endograft plans from 9 aortic centers, we found that the degree of overlap between the studied fenestrated and/or scalloped arch graft designs was high and that 2 proposed graft designs would be theoretically applicable in 85.8% of cases. Future studies analyzing these designs in a real-world cohort of patients are needed to further address off-the-shelf feasibility.

BACKGROUND: Previous studies suggest partly different risk factor profiles of thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA), but prospective data are scarce.

AIM/OBJECTIVES: The purpose of this prospective population-based case-control study was to investigate differences in risk factor profile between TAA and AAA.

METHODS: Participants in two prospective population-based studies, the Västerbotten Intervention Project (VIP) and the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, between 1986 and 2010 underwent cardiovascular risk assessments, including blood samples, oral glucose tolerance test, blood pressure readings and a self-reported health questionnaire. All individuals who were later diagnosed with TAA or AAA were identified. Age, sex, and time-matched controls were selected from the same cohorts, aiming at four controls / case. Adjusted odds ratios for potential risk factors for later diagnosis of TAA and AAA respectively, were estimated by multivariate conditional logistic regression analyses.

RESULTS: From total 96,196 individuals with prospectively collected data in the VIP/MONICA cohort, a total of 236 individuals with AAA (181 men and 55 women) and 935 matched controls, and 168 individuals with TAA (115 men and 53 women) and 662 controls were included. The average age at baseline examination was 57.0 ± 5.7 years for AAA cases and controls, and 52.1 ± 8.8 years for TAA cases and controls. Mean time between baseline examination and diagnosis of AAA/TAA was 12.1 and 11.7 years respectively. There was a clear difference in risk factor profile between AAA and TAA. Smoking, hypertension and coronary artery disease were significantly associated with later diagnosis of AAA with highest adjusted odds ratio for a history of smoking (OR 10.3, 95% CI 6.3-16.8). For TAA, hypertension was the only positive risk factor (OR 1.7, CI 1.1-2.7), while smoking was not associated. Diabetes was not associated with either AAA or TAA, neither was self-reported physical activity.

CONCLUSIONS: In this prospective population-based case-control study risk factor profile differed between AAA and TAA. This suggests a partially different etiology for TAA and AAA.

Objective: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

Methods: The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from Ito III, and the letters A to C mark the level of evidence.

Results: A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

Conclusion: The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma. Article history: Received 22 November 2024, Accepted 9 December 2024, Available online 13 January 2025 (c) 2024 The Authors.

Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY-NC- ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Objective

High risk, inoperable patients with ascending aortic disease are increasingly managed with thoracic endovascular aortic repair (TEVAR). The aim of this study was to assess the available literature on TEVAR confined to the ascending aorta (a-TEVAR), describing study and patient characteristics, procedural and stent graft details, and outcomes.

Data sources

This was a systematic review and meta-analysis. MEDLINE, Web of Science, and Scopus were systematically searched for eligible studies reporting on outcomes after a-TEVAR (PROSPERO ID: CRD42023440826). Eligible studies reported outcomes after a-TEVAR without adjunctive supra-aortic vessel treatment.

Review Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The ROBINS-I and Joanna Briggs Institute Critical Appraisal Checklist were used as quality assessment tools. A Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence certainty analysis was performed for the main outcomes. The main outcome was death. A proportional meta-analysis was performed with a mean and 95% confidence interval (CI) for the main outcomes. All articles were included up to 1 January 2024.

Results

Ninety four studies were included (19 cohort studies, 75 case reports or series), reporting on 259 patients (57.8% male). The mean age was 69.1 (95% CI 65.0 – 73.1) years and mean follow up 19.6 (95% CI 14.5 – 24.6) months. The most common comorbidity was prior cardiac or thoracic surgery (n = 191). The most frequent indications for a-TEVAR (52.1% urgent a-TEVAR) were type A aortic dissection (43.6%) and pseudoaneurysm (38.6%). The most commonly deployed stent grafts were Gore (44.5%), Cook (23.5%), and Medtronic (17.0%). The in hospital mortality rate was 7.3% (95% CI 4.7 – 11.2%), 30 day mortality rate 7.7% (95% CI 5.1 – 11.6%), and overall mortality rate 17.0% (95% CI 12.9 – 22.0%) during follow up. GRADE showed very low evidence certainty for all outcomes. Eighty eight complications were reported and there was a re-operation rate of 13.1% (95% CI 9.5 – 17.8%). In hospital and 30 day mortality rates for type A dissection were 12.4% (95% CI 7.5 – 19.7%) (n = 14) and 13.3% (95% CI 8.2 – 20.8%) (n = 15), respectively, and for pseudoaneurysm 4.0% (95% CI 1.6 – 9.8%) (n = 4) and 4.0% (95% CI 1.6 – 9.8) (n = 4), respectively.

Conclusion

Despite heterogeneous literature and very low GRADE evidence certainty, a-TEVAR seems technically feasible in high risk patients. In addition, there is need for a consensus on when and how to use a-TEVAR and a need for a specific endograft for use in the ascending aorta.

Objective: Complex endovascular aortic repair (EVAR) involves tertiary surgical care, with short in-hospital recovery. This study aimed to explore patients’ and healthcare professionals’ experiences of what can improve patient recovery after complex EVAR.Methods: Three qualitative data collection stages building on each other were analysed with thematic analysis. Stages 1 and 2 separately explored patients’ and healthcare professionals’ experiences of what works well and what can be improved with current care. In stage 3, participants reviewed the relevance and feasibility of intervention suggestions.Results: Three matching themes were identified in stages 1 and 2: Adequate information; Patient involvement; Continuity and follow-up. In stage 3: Individual care plan, Team meetings, and Contact nurse were all found relevant, while only Information routines was found both relevant and feasible.Conclusion: What patients and healthcare professionals experienced could improve patients recovery after complex EVAR seem universal for complex surgical patients, and relevant interventions were identified. However, the feasibility of person-centred interventions seem affected by various contextual factors, like current routines and availability of staff.Practice implications: Interventions that facilitate communication, both involving and supporting the patient, should be tested to strengthen patients’ ability to self-care, and ensure access to care and support when needed.

Objective

Emergent complex abdominal aortic diseases are challenging to treat. During In-situ laser fenestration (ISLF), aortic branches are covered and flow restored with in-situ fenestration of the stentgraft with promising mid-term results(1). The aim of this study was to expand on the limited body of knowledge of mid-term outcomes of ISLF in renovisceral aortic pathology in a multicenter setting. 

Methods

Retrospective pooled data on consecutive ISLF cases of visceral aortic stent-grafts 2018-2023 in three aortic centers. Technical success was defined as a successful vascularization with bridging stentgraft and acceptable final angiographic series without sign of endoleak related to the bridging stentgraft. Target vessel instability was defined as an endoleak related to the bridging stentgraft, disconnection, kink, stenosis, occlusion of bridging stent, reintervention on bridging stentgraft or rupture or death related to bridging stentgraft.(2)

Results

A total of 65 ISLFs were performed in 34 patients, mean age 74 years. The procedure was acute in 79%, and 35% were ruptures. Pre-stenting was performed on 56 target vessels (86%). Four patients (12%) died within 30 days, all presented with a rupture. Technical success was achieved in 61/65 ISLF (94%). All failed cannulations were in renals, three due to difficult angulations and one dissected during cannulation. Median follow up was 16 [5;22] months. Cumulative survival at six months, one year and two years was 88%, 80% and 72%. There were in total six (10%) target vessel instability detected: Two (3%) type III endoleaks, and four (7%) stent stenosis, all requiring relining. Freedom from target vessel instability at six months till end of follow up was 89%.

On latest follow-up scan, all successfully deployed ISLF bridging stents were patent (primary assisted patency 100%, 61/61) without signs of endoleak type 3.

Conclusion

ISLF is a promising tool for emergent endovascular procedures in complex anatomies.