OBJECTIVE: The Centers for Medicare and Medicaid Services (CMS) now approve reimbursement for Transfemoral Carotid Artery Stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid Artery Revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR versus TFCAS across all aortic arch types and degrees of arch atherosclerosis.
METHODS: All patients undergoing Carotid Artery Stenting (CAS) between September 2016 and October 2023 were identified in the VQI database. Patients were stratified into four groups: Group-A (Mild Atherosclerosis and Type I/II Arch), Group-B (Mild Atherosclerosis and Type III Arch), Group-C (Moderate/Severe Atherosclerosis and Type I/II Arch), Group-D (Moderate/Severe Atherosclerosis and Type III Arch). The primary outcome was in-hospital composite stroke or death. ANOVA and χ2tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan Meier survival estimates, Log Rank test, and multivariable Cox regression models analyzed hazard ratios for one-year mortality.
RESULTS: A total of 20,114 patients were included [Group-A:12,980 (64.53%); Group-B: 1,175 (5.84%); Group-C: 5,124 (25.47%); Group-D: 835 (4.15%)]. TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94% 69.22%; p<0.001). Compared to patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group-C and Group-D were more likely to be female, hypertensive, smokers, and have CKD. Patients with Type-III arch in Group-B and Group-D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than half the risk of stroke/death and one-year mortality compared to TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (group A) (OR=0.43,95%CI:0.31-0.61, p<0.001; HR=0.42,95%CI:0.32-0.57, p<0.001). Group-B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared to TFCAS (OR=0.30,95%CI:0.12-0.75, p=0.01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR=0.66,95%CI:0.44-0.97, p=0.037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group-D) (OR=0.91,95%CI:0.39-2.16, p=0.834).
CONCLUSIONS: TCAR is safer than TFCAS in patients with simple and advanced arch anatomy. This could be related to the efficiency of flow reversal vs distal embolic protection. Current CMS decision will likely increase stroke and death outcomes of carotid stenting nationally if multidisciplinary approach and appropriate patient selection are not implemented.

OBJECTIVE: To describe the circumflex left aortic arch as a new form of canine congenital vascular ring anomaly leading to esophageal constriction.
METHODS: 3 large-breed dogs of variable age: a 9-month-old entire male German Shepherd Dog-Rottweiler cross, a 17-week-old entire male German Shepherd Dog, and a 9-year-old neutered female Labrador Retriever, seen between April 2022 and May 2023.
METHODS: Dogs presented for chronic postprandial regurgitation and poor growth. One dog presented for a hard mass on the caudal mandibular region.
RESULTS: Computed tomography revealed a normal leftward-oriented cranial half and an abnormal caudal half of the aortic arch crossing toward the right dorsal hemithorax leading to esophageal constriction in all dogs. In addition, 1 dog presented with a right patent ductus arteriosus and 1 with an aberrant right subclavian artery.
CONCLUSIONS: Circumflex left aortic arch is a newly discovered rare type of congenital vascular ring anomaly in dogs, which presents a similar anatomical derangement to the human form. Clinical signs include postprandial regurgitation and poor growth. Circumflex left aortic arch vascular anomaly cannot be surgically corrected via the left thoracotomy that is commonly used for the more common vascular ring anomalies in dogs. Computed tomography is a useful diagnostic modality for the diagnosis of this condition, detection of concomitant congenital vascular malformations, evaluation of associated pathologies, and surgical planning.

OBJECTIVE: This study aims to analyze early and midterm results of custom-made proximal scallop and fenestrated stent-grafts for thoracic endovascular aortic repair (TEVAR) with proximal landing zone (PLZ) in the aortic arch.
METHODS: All consecutive patients treated with the custom made proximal scalloped and fenestrated Relay stent grafts (Terumo Aortic Bolton Medical Inc., Sunrise, USA) in ten Italian centers between January 2014 and December 2022 were included. The primary endpoints were technical success, incidence of intraoperative major adverse events (MAEs), deployment accuracy, and rate of early neurological complications, endoleaks (Els) and retrograde aortic dissection.
RESULTS: During the study period, 49 patients received TEVAR with Relay custom-made endograft in Italy were enrolled. The median patient age was 70.1 years (interquartile range, 23-86 years) and 65.3% were male. The indication for treatment was atherosclerotic aneurysms in 59.2% of cases and penetrating aortic ulcer in 22.4%. The endograft configuration was proximal fenestration in 55.1% and scallop in 44.9%. The PLZ was zone 0 in 25 cases (51%), zone 1 in 14 cases (28.6%), and zone 2 in 10 cases (20.4%). The supra-aortic debranching procedures were 38 (77.5%). Technical success was 97.9% (48/49) due to one case (2.0%) of inaccurate deployment. Intraoperatively, one (2.0%) type Ia and one (2.0%) type III Els were detected. There were no cases of in-hospital mortality, MAEs and retrograde dissection. Three (6.1%) minor strokes (National Institutes of Health Stroke Scale score≤4) were observed. At a mean follow-up time of 36.3 + 21.3 months the rate of type I-III Els and reintervention was 4.1%, respectively. Four patients (8.2%) died during the follow-up period, one (2.1%) from abdominal aortic rupture and three (6.1%) for non-aortic causes.
CONCLUSIONS: Our early and midterm outcomes suggest that scalloped and fenestrated TEVAR may provide an acceptable alternative treatment option for aortic arch pathologies. Large-scale studies are needed to assess the long-term durability of this technique.

UNASSIGNED: Atherosclerotic cardiovascular disease is associated with a high mortality rate due to vascular calcification. The role of fetuin-A in aortic arch calcification (AAC) is less well understood.
UNASSIGNED: An analysis of secondary biomarkers was performed on 800 individuals from the biobank using the community database. AAC was defined by radiologists based on imaging. Multiple variables logical analysis was used for risk analysis.
UNASSIGNED: A total of 736 individual samples were collected based on age and gender. The average age is 65 ± 10 years, and half the population comprises men. In spite of similar body weight, renal function, and hepatic function, the AAC group had higher blood pressure and fetuin-A levels independently: systolic blood pressure (SBP) index ≥130 mmHg [adjusted odds ratio (aOR) 1.85, 95% confidence interval (CI) 1.34-2.57, p = 0.002] and fetuin-A (aOR 0.62, 95% CI 0.50-0.76, p < 0.001). Moreover, it is evident that AAC can be predicted more accurately when combined with SBP ≥130 mmHg and a low fetuin-A level (<358 μg/ml: aOR 5.39, 95% CI 3.21-9.08) compared with the reference.
UNASSIGNED: Low fetuin-A levels are significantly correlated with AAC while there is an increased association between vascular calcification and coexisting hypertension.

OBJECTIVE: The quick establishment of adequate vascular access is essential for the technical success of mechanical thrombectomy (MT). Focusing on shifts in aortic arch geometry and aging-related changes, we propose an imaging parameter for predicting access difficulty using chest CT.
METHODS: Patients with acute anterior circulation large-vessel occlusion who underwent MT from April 2020 to September 2021 were included in this retrospective multicenter observational study. The distance from the sternum to the ascending aorta (S-AAD) was defined as the surrogate marker of access difficulty. Access was defined as difficult when the time from femoral sheath placement to guiding catheter induction (guiding time: GT) ≥ 30 minutes, and the patients were dichotomized into groups with short GT (sGT: GT < 30 min) and long GT (lGT: GT ≥ 30 min).
RESULTS: One hundred fifteen patients were included. There were 12 patients (10.4 %) in lGT group. The median (IQR) S-AAD was 11.9 mm (6.3, 18.3 mm) in sGT group and 6.6 mm (4.0, 10.3 mm) in lGT group, and a significant difference in S-AAD was observed (P = 0.026). In multivariate analyses, dyslipidemia and S-AAD < 5 mm were significantly associated with difficult access (OR, 5.938 [95 % CI, 1.468, 24.022], P = 0.012 for dyslipidemia; OR, 5.147 [95 % CI, 1.267, 20.917], P = 0.022 for S-AAD < 5 mm).
CONCLUSIONS: S-AAD is a simple and reliable imaging parameter to predict access difficulty. This parameter may be helpful in selecting the appropriate devices and access routes in preinterventional practice.

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BACKGROUND: Vascular Rings (VRs) are congenital malformations of the aortic arch that can compress the trachea and esophagus producing symptoms. Approximately, 5%-10% of patients experience persistent symptoms postrepair and 9% require reintervention. There are various approaches to repair-simple ligation and division of the ring or more complex procedures. Our objective was to describe outcomes for VR repair using a \"simple\" surgical approach.
METHODS: We identified patients who underwent VR repair from 2012 to 2022 at our institution. Clinical and surgical data, demographics, intraoperative, and postoperative outcomes were extracted from their electronic medical records. Outcomes were analyzed and regression analysis was used to identify risk factors for residual symptoms after repair.
RESULTS: Ninety three patients with VR repair were included. Prevalence of symptoms were reduced following surgery (80% preoperative versus 13% postoperative, P 0.03). Tracheomalacia also decreased from 16% to 7% postrepair. No deaths were reported in our cohort and 2% of our patients required reintervention. Multivariable regression analysis showed that preoperative tracheomalacia was associated with having persistent symptoms after VR repair (odds ratio 6.2, 95% CI 1.02-37.6).
CONCLUSIONS: Our institutional experience using a simple surgical approach showed a significant decrease in symptoms, a very low reintervention rate and no mortality. Preoperative tracheomalacia can be a risk factor for persistent symptoms postrepair. We believe a simple surgical approach for children with complete VR repair can be effective in relieving symptoms.

A 74-year-old male entered the hospital with a medical history of an aortic arch and a descending thoracic aneurysm. To prevent arm ischaemia after the frozen elephant trunk procedure, a left subclavian artery to left common carotid artery anastomosis was performed. The postoperative period was complicated by sepsissternal infection and mediastinitis. We decided to perform a combined total aortic root and aortic arch replacement with 3 cryopreserved homografts. In addition, the \"reverse arch technique\" was applied to adapt the distal anastomosis. The operation is associated with a high risk of mortality in the postoperative period.

OBJECTIVE: To report experience with a Relay® stent-graft custom-made platform in treating different aortic arch pathology in 2 high-volume aortic centres.
METHODS: A retrospective analysis of all patients treated between July 2016 and July 2023 with custom-made Relay® stent-graft (custom-made device). Underlying aortic arch pathology was an aneurysm, penetrating aortic ulcer, and dissection. Three custom-made device designs were used: proximal scallop, fenestrations, and inner branches. The endpoints were technical success, perioperative stroke, death, and reintervention rate.
RESULTS: Thirty-five patients (89% males) with a mean age of 70 ± 11 years were treated.Indication for treatment was penetrating aortic ulcer in 14 patients (40%), aneurysm in 11 patients (31%) and aortic dissection in 10 patients (29%). The technical success rate was 100%. Twenty-eight patients (80%) had proximal sealing in zone 0, and 7 (20%) had proximal sealing in zone 1. Nine patients (25.6%) had proximal scallops, 9 (25.6%) had 1 big fenestration and 17 (48.8%) had a branched device; 1 with single branch, 15 with double branches and 1 with triple branches. Thirty patients (86%) had previous or simultaneous left subclavian artery revascularization. No patient died during 30 days. Two patients (5.7%) had stroke postoperatively; both recovered without disabling deficits. The mean follow-up was 35 ± 26 months. Six patients (17.1%) died during follow-up. One patient required reinforcement of the bridging stent in the left common carotid artery and one additional vascular plugging of the left subclavian artery. Three patients received distal extension.
CONCLUSIONS: The Relay® stent-graft custom-made platform showed a good performance in our study with a high technical success rate, low perioperative stroke and mortality, and low reintervention rates during the follow-up.