OBJECTIVE: This study assesses the efficacy and safety of self-expandable (SE) versus balloon-expandable (BE) stent grafts for managing visceral artery aneurysms (VAAs), focusing on procedural success and complication rates.
METHODS: We conducted a retrospective analysis of VAA patients treated at our institution from April 2006 to September 2021. The study reviewed patient demographics, aneurysm characteristics, treatment details, and outcomes, including endoleaks.
RESULTS: Among the 23 patients analyzed, splenic artery aneurysms represented 44% of cases. Fifteen patients were treated with balloon-expandable stent grafts (BE SGs), and eight patients were treated with self-expandable stent grafts (SE SGs). For saccular aneurysms, the average neck size was 10.10 ± 8.70 mm in the BE group versus 18.50 ± 3.40 mm in the SE group (p = 0.23), with an average sac size of 20.10 ± 18.9 mm in the BE group versus 15.60 ± 12.7 mm in the SE group (p = 0.16). The average sac-to-neck ratio was 1.69 ± 2.23 in the BE group versus 1.38 ± 0.33 in the SE group (p = 0.63). The BE group exhibited a significantly higher endoleak rate (60%) compared to the SE group (12.5%; p = 0.03).
CONCLUSIONS: While further investigation is needed to fully assess the outcomes of stent graft treatment for VAAs, initial data show a significantly higher endoleak rate with BE SGs compared to SE SGs. The SE SGs may offer better outcomes due to their superior ability to conform to tortuous and mobile visceral arteries.

OBJECTIVE: To assess viability and safety of preemptive treatment of type II endoleak for abdominal aortic aneurysm (AAA) repairs.
METHODS: A 69-year-old man with renal fusion (horseshoe kidney) was referred for treatment of a 5.5 cm AAA. His anatomy was suitable for endovascular repair. The risk for type II endoleak was increased because of multiple infrarenal arterial orifices originating within the aneurysm sac. These included an accessory renal artery that supplied the renal isthmus, a patent inferior mesenteric artery, and a pair of large lumbar arteries originating from a single orifice (8 mm) at L3 spinal level. The lumbar orifice was selectively cannulated and occluded with thrombogenic coils 1 week prior to his endovascular aneurysm repair.
RESULTS: Aneurysm repair was uneventful with no signs of early or delayed endoleak and long-term follow-up of 5 years.
CONCLUSIONS: Preemptive coil embolization of perianeurysmal arteries may be considered as a safe and effective strategy for management of potential type II endoleak.

BACKGROUND: Metallic and hyperdense artifacts and T1-shortening substances in the abdominal aortic aneurysm (AAA) sac generated by embolic materials and lipiodol pose challenges in the identification of endoleaks on follow-up computed tomography (CT) or magnetic resonance imaging (MRI).
OBJECTIVE: To evaluate the usefulness of contrast-enhanced subtraction MRI (CES-MRI) for detecting endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) with intraoperative AAA sac embolization compared with CE-CT, this study was conducted.
METHODS: In this study, 28 consecutive patients who underwent EVAR with prophylactic AAA sac embolization were included. All patients underwent CES-MRI and CE-CT to detect endoleaks. The definitive diagnosis of endoleaks was a consensus reading of CE-CT and CES-MRI by two certified radiologists, in addition to angiography or reproducible radiological findings in the observational examination. Analysis was performed to evaluate which examination was better for detecting endoleaks.
RESULTS: The sensitivity, specificity, and area under the curve of CE-CT and CES-MRI according to observer 1 were 50%, 100%, and 0.813 (95% confidence interval [CI] = 0.625-1.00) and 100%, 95%, and 0.997 (95% CI = 0.984-1.00), respectively, and those according to observer 2 were 50%, 100%, and 0.750 (95% CI = 0.514-0.986) and 100%, 95%, and 0.969 (95% CI = 0.903-1.00), respectively. Intolerable artifacts were significantly observed on CE-CT. The severity of the artifacts did not depend on the stent graft on CT and MRI.
CONCLUSIONS: Although no significant difference was observed, CES-MRI tended to have better accuracy for endoleak detection in EVAR with intraoperative AAA sac embolization than CE-CT.

BACKGROUND: Our aim was to analyse abdominal aneurysm sac thrombus density and volume on computed tomography (CT) after endovascular aneurysm repair (EVAR).
METHODS: Patients who underwent EVAR between January 2005 and December 2010 and had at least four follow-up CT exams available over the first five years of follow-up were included in this retrospective single-centre study. Thrombus density and aneurysm sac volume were calculated on unenhanced CT scans. Linear mixed models were used for data analysis.
RESULTS: Out of 82 patients, 44 (54%) had an endoleak on post-EVAR contrast-enhanced CT. Thrombus density significantly increased over time in both the endoleak and non-endoleak groups, with a slope of 0.159 UH/month (95% confidence interval [CI] 0.115-0.202), p < 0.0001) and 0.052 UH/month (95% CI 0.002-0.102, p = 0.041). In patients without endoleak, a significant decrease in aneurysm sac volume was identified over time (slope -0.891 cc/month, 95% CI -1.200 to -0.581); p < 0.001) compared to patients with endoleak (slope 0.284 cc/month, 95% CI -0.031 to 0.523, p = 0.082). The association between thrombus density and aneurysm sac volume was positive in the endoleak group (slope 1.543 UH/cc, 95% CI 0.948-2.138, p < 0.001) and negative in the non-endoleak group (slope -1.450 UH/cc, 95% CI -2.326 to -0.574, p = 0.001).
CONCLUSIONS: We observed a progressive increase in thrombus density of the aneurysm sac after EVAR in patients with and without endoleak, more pronounced in patients with endoleak. The association between aneurysm volume and thrombus density was positive in patients with and negative in those without endoleak.
CONCLUSIONS: A progressive increase in thrombus density and volume of abdominal aortic aneurysm sac on unenhanced CT might suggest underlying endoleak lately after EVAR.
CONCLUSIONS: Thrombus density of the aneurysm sac after EVAR increased over time. Progressive increase in thrombus density was significantly associated to the underlying endoleak. The association between aneurysm volume and thrombus density was positive in patients with and negative in those without endoleak.

There have been significant technologic advances in endovascular aortic therapies since the introduction of conventional infrarenal endovascular aortic aneurysm repair (EVAR). These advances have sought to address the weaknesses of conventional EVAR- particularly the difficult or \"hostile\" infrarenal aortic aneurysm neck. We review anatomical features that create a hostile neck and the most recent advancements to overcome these limitations. EndoAnchors replicate open suture fixation to seal endograft to aortic tissue and have been shown to be useful as a prophylactic measure in short, angulated necks as well as therapeutic for type Ia endoleaks. Fenestrated EVAR (FEVAR) devices such as the Z-fen (Cook Medical, Bloomington, IN, USA) raises the seal zone to the suprarenal segment while maintaining renal perfusion. Finally, multibranch aortic grafts such as the Thoracoabdominal Branch Endoprosthesis (Tambe; W. L. Gore & Associates, Flagstaff, AZ, USA) raise the seal zone above the visceral segment and can be used off the shelf with promising results.

BACKGROUND: Several studies have reported short- and intermediate-term outcomes after TEVAR for descending thoracic aortic aneurysm (DTAA), however, reports on long-term (10 years) outcomes are sparse. Therefore, the aim of this study was to analyze predictors impacting long-term outcome following thoracic endovascular aortic repair (TEVAR) for DTAA.
METHODS: Databases from four academic institutions were reviewed and consecutive cases of TEVAR for DTAA between 1999 and 2021 were included in this retrospective multicenter study (Case series). Ethical approval from Institutional review board was obtained and patient demographics, treatment data as well as follow-up information were retrieved and analyzed.
RESULTS: 305 patients (mean age 72±10 years) treated with TEVAR for degenerative DTAA with mean aortic diameter of 64mm were identified. Altogether 445 endografts were implanted via femoral access (93%) with a technical success of 94%. Operative mortality, stroke rate and rate of spinal cord ischemia were 6% (5% for intact, 12% for ruptured DTAA), 4% and 3%, respectively. Kaplan-Meier estimates for overall survival rates were 76%, 59% and 34% at 1, 5 and 10 years and freedom from reintervention rates were 84%, 73% and 58% at 1, 5 and 10 years, respectively. In multivariate analysis, ASA grade 3-5 and non-elective case were identified as predictors for death, wheres as fusiform DTAA, proximal landing zone 2 and hypertension but not device generation were predictive for reintervention.
CONCLUSIONS: This is to date the largest study reporting long-term (10 years) outcome on TEVAR for DTAA. We found acceptable rates for long-term survival and freedom-from reintervention that were independent of endovascular device generation.

OBJECTIVE: To quantify dynamic gutter phenomena and endograft deformations during double chimney thoracic endovascular aortic repair (ch-TEVAR) in a physiological model of the thoracic aorta subjected to pulsatile haemodynamic conditions.
METHODS: Two in vitro procedures revascularizing the brachiocephalic trunk and left common carotid artery were performed representing both balloon-expandable (BE, Ankura-BeGraft) and self-expandable (SE, Ankura-Viabahn) double ch-TEVAR configurations. Retrospectively gated computed tomography (CT) was used to evaluate endograft behaviour. Device interactions were characterised according to gutter volume, gutter surface deviation, and endograft deformation (D-ratio) at end-diastolic and peak-systolic aortic pressure.
RESULTS: Use of BE chimney grafts resulted in three times total gutter volume compared to SE chimney grafts. Gutter volumes were observed to vary dynamically between the end-diastolic and peak-systolic phases of the cardiac cycle, with the most substantial change associated with the BE configuration. Chimney graft deformations were dependent on device type, with SE devices exhibiting up to twice the deformation as BE devices. When adjacent, SE chimney grafts were observed to support each other, and thus tended towards a more consistently circular shape.
CONCLUSIONS: Gutter and chimney graft behaviour were dependent on device type, and exhibited both spatial and temporal variability. This study emphasises notable differences between BE and SE double ch-TEVAR configurations which should be considered when evaluating risk of endoleak. The findings reported here also support the use of gated CT to better identify device-related complications with ch-TEVAR, and can be used in the design of next generation devices.

BACKGROUND: Type II endoleaks (T2ELs) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) can lead to aneurysm growth, compromising the stent graft seal and risking rupture. Preventing these endoleaks during EVAR involves filling the AAA sac around the stent graft to exclude the aneurysm and block any arteries causing the endoleak. This study investigates the feasibility and safety of using AneuFix, a biocompatible injectable polymer developed by TripleMed (Geleen, the Netherlands), for aneurysmal sac filling during EVAR in high-risk T2EL patients.
METHODS: A feasibility, single-arm, single-centre clinical trial will initially include five patients with infrarenal AAA, eligible for EVAR, and at high risk for T2EL based on the number of patent lumbar arteries and the cross-sectional area of the aortic lumen at the level of the inferior mesenteric artery. Postevaluation by the Data Safety and Monitoring Board, the study cohort will extend to 25 patients. During EVAR and after stent graft deployment, the aneurysm sac is filled with AneuFix polymer using a filling sheath positioned parallel to the contralateral limb with the tip inside the aneurysm sac. Primary outcome is technical success (successful AAA sac filling). The secondary outcomes include clinical success at 6 and 12 months (occurrence of T2ELs and AAA growth assessed with CT angiography), intraoperative and perioperative complications, all endoleaks, adverse events, re-interventions, aneurysm rupture and patient survival.
BACKGROUND: This trial was approved by the Dutch Authorities (Central Committee on Research Involving Human Subjects, IGJ), Amsterdam University Medical Centre Ethical Commission, and adheres to the Declaration of Helsinki and European Medical Device Regulation. Results will be shared at (inter)national conferences and in peer-reviewed journals.
BACKGROUND: NCT04307992.

OBJECTIVE: To develop and validate a deep learning model for detecting post-endovascular aortic repair (EVAR) endoleak from non-contrast CT.
METHODS: This retrospective study involved 245 patients who underwent EVAR between September 2016 and December 2022. All patients underwent both non-enhanced and enhanced follow-up CT. The presence of endoleak was evaluated based on computed tomography angiography (CTA) and radiology reports. First, the aneurysm sac was segmented, and radiomic features were extracted on non-contrast CT. Statistical analysis was conducted to investigate differences in shape and density characteristics between aneurysm sacs with and without endoleak. Subsequently, a deep learning model was trained to generate predicted segmentation of the endoleak. A binary decision was made based on whether the model produced a segmentation to detect the presence of endoleak. The absence of a predicted segmentation indicated no endoleak, while the presence of a predicted segmentation indicated endoleak. Finally, the performance of the model was evaluated by comparing the predicted segmentation with the reference segmentation obtained from CTA. Model performance was assessed using metrics such as dice similarity coefficient, sensitivity, specificity, and the area under the curve (AUC).
RESULTS: This study finally included 85 patients with endoleak and 82 patients without endoleak. Compared to patients without endoleak, patients with endoleak had higher CT values and greater dispersion. The AUC in validation group was 0.951, dice similarity coefficient was 0.814, sensitivity was 0.877, and specificity was 0.884.
CONCLUSIONS: This deep learning model based on non-contrast CT can detect endoleak after EVAR with high sensitivity.

BACKGROUND: The occurrence of type II endoleaks after endovascular repair of aortic aneurysm has gradually gained increasing attention. We present a case of a patient with an expanding aneurysm after thoracic endovascular aortic repair (TEVAR) for a type II endoleak, in which successful direct ligations of the intercostal artery were performed using a sac incision without cardiopulmonary bypass (CPB) or graft replacement.
METHODS: A 62-year-old male patient, previously treated with TEVAR for a descending thoracic aortic aneurysm, presented with ongoing chest discomfort. Based on the diagnosis of a growing aneurysm and type II endoleak, the patient was prepared for CPB and aortic cross-clamping, as a precautions against the possibility of a type I endoleak. A longitudinal opening of the thoracic aortic aneurysm sac was performed following left thoracotomy. Visual confirmation identified the T5 level intercostal artery as the source of the endoleak, and after confirming the absence of a type I endoleak, multiple ligations were applied to the intercostal artery. Follow-up computed tomography confirmed the absence of endoleaks or sac growth.
CONCLUSIONS: In a case involving TEVAR for a thoracic aortic aneurysm, open suture ligations were used to treat type II endoleaks without having to resort to CPB, resulting in successful outcomes.