OBJECTIVE: To evaluate the mid-term outcomes of different treatment strategies for the internal iliac artery (IIA) during EVAR.
METHODS: This was a retrospective study. All patients undergoing EVAR, who required treatment of at least one side of IIA from January 2013 to July 2022 in a single center, were included. According to the different treatment strategies for IIA, the patients were divided into UP (unilateral preservation), BP (bilateral preservation) and BE (bilateral embolization) groups. The primary outcomes included buttock claudication, bowel ischemia and iliac-related reintervention. Then patients who underwent IIA reconstruction were divided into IPG (iliac parallel stent graft) and IBG (iliac branch stent graft) groups according to the reconstruction technique. The primary outcomes included endoleak, iliac branch occlusion and iliac-related reintervention.
RESULTS: A total of 237 patients were included, including 167 in the UP group, 9 in the BP group and 61 in the BE group. The mean follow-up time was 39.0 ± 27.7, 50.0 ± 22.1 and 25.8 ± 18.9 months in UP, BP and BE groups, respectively. Thirty cases (12.7%) of buttock claudication occurred, and it was significantly higher in the BE group than the UP group (26.2% vs. 7.8%, p < 0.001). There were no significant differences in the other follow-up outcomes among three groups. The K-M analysis indicated that the patients in the BE group had a lower survival rate than those in the other two groups (p = 0.024). 24 patients underwent IIA reconstruction, including 8 in the IPG group and 16 in the IBG group. The endoleak in the IBG group was significantly lower than that in the IPG group (0% vs. 25.0%, p = 0.041). The iliac-related reintervention, iliac occlusion and mortality were similar between the two groups.
CONCLUSIONS: Overall it is beneficial for patients to preserve at least one side of IIA during EVAR as much as possible. Compared with IPG, IBG might be more applicable for IIA reconstruction.

Complex endovascular aortic repair (EVAR) requires the use of multiple small sheath cannulation inside a large sheath. Because the large sheath is not designed for multiple small sheath cannulation, large amounts of blood loss can be encountered in complex EVARs. Cell Saver can be used effectively in complex EVARs using a modified draping technique, allowing for increased cell salvage and autogenous transfusions as needed.

OBJECTIVE: This study aims to identify preoperative factors associated with non-home discharge (NHD) after endovascular aneurysm repair (EVAR). NHD has implications for patient care, readmission, and long-term mortality; nevertheless, existing literature lacks information regarding factors associated with NHD for patients undergoing EVAR. In contrast, our study assesses preoperative factors associated with NHD for this population by utilizing national data from the Vascular Quality Initiative (VQI).
METHODS: We identified adult patients who underwent elective EVAR in the VQI (2003-2022) and excluded those who were not living at home preoperatively. Multivariable logistic regression was used to identify preoperative factors associated with NHD. Kaplan-Meier methods and Cox-regression analyses were used to assess the impact of NHD on 5-year survival as a secondary outcome.
RESULTS: 61,792 patients were included, of which 3,155 (5.1%) had NHD. NHD patients were more likely to be older (79 [73-18] years vs. 73[67-79] years), female (33.7% vs. 18.2%; P<.001), non-white (16.0% vs. 11.7%; P<.001) and have more comorbidities. NHD patients had higher rates of postoperative complications (acute kidney injury: 11.9% vs. 2.0%; P<.001, myocardial infarction: 3.8% vs. 0.5%; P<.001, and in-hospital reintervention: 4.7% vs. 0.5%; P=.033). Multivariable analysis revealed many preoperative characteristics were associated with higher odds of NHD: most notably, age (per additional decade: OR=2.15, 95% CI:2.03-2.28; P<.001), female sex (OR=1.79, 95% CI:1.63-1.95; P<.001) and aneurysm diameter >65mm (OR=2.18, 95% CI:1.98-2.39; P<.001), along with potentially modifiable factors including: anemia, COPD, CHF, weight, and diabetes. In contrast, aspirin, statin, and ACE-inhibitor/ARB usage were associated with lower odds of NHD. NHD was associated with higher hazards of 5-year mortality, even after adjusting for confounders (40% vs. 14%, aHR=2.13, 95% CI:1.86-2.44; P<.001).
CONCLUSIONS: Several factors were associated with higher odds of NHD following elective EVAR, including non-modifiable factors such as female sex and larger aortic diameter, and potentially modifiable factors such as anemia, COPD, CHF, BMI, and diabetes. Special attention should be given to populations with non-modifiable factors, and efforts at optimizing medical conditions with higher NHD likelihood seems appropriate to improve patient outcomes and quality of life after EVAR.

Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.

The frozen elephant trunk (FET) technique can be applied to extensive aortic pathology, including lesions in the aortic arch and proximal descending thoracic aorta. FET is useful for tear-oriented surgery in dissections, managing malperfusion syndrome, and promoting positive aortic remodeling. Despite these benefits, complications such as distal stent-induced new entry and spinal cord ischemia can pose serious problems with the FET technique. To prevent these complications, careful sizing and planning of the FET are crucial. Additionally, since the FET technique involves total arch replacement, meticulous surgical skills are essential, particularly for young surgeons. In this article, we propose several techniques to simplify surgical procedures, which may lead to better outcomes for patients with extensive aortic pathology. In the era of precision medicine, the next-generation FET device could facilitate the treatment of complex aortic diseases through a patient-tailored approach.

OBJECTIVE: Japan has adopted its own reimbursement system, which differs from other countries in terms of its diagnostic procedure combination (DPC) methods. However, there are few reports on the cost analysis of open repair and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms in Japan. We aimed to evaluate the long-term outcomes and cost-effectiveness of these two procedures.
METHODS: This study included patients who underwent open repair (n = 224) and EVAR (n = 87) between January 2012 and December 2022. After propensity score matching, we compared the two groups.
RESULTS: The drug and blood products, procedures, and DPC costs were significantly higher in the open repair group (p < 0.001) than in the EVAR group. The surgical equipment and total costs were significantly higher in the EVAR group than in the open repair group (p < 0.001). There was no significant difference in the 5-year survival rate (88.5% in the open repair group vs. 72.0% in the EVAR group; p = 0.33) and freedom from re-intervention rate at 5 years (93.1% in the open repair group vs. 89.9% in the EVAR group; p = 0.15) between the two groups.
CONCLUSIONS: Open repair is more cost-effective than EVAR. The cost-effectiveness of EVAR may therefore depend on the cost of the endograft.

OBJECTIVE: To evaluate the impact of osteoporosis on overall survival following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs).
METHODS: This was a retrospective, single-center cohort study on 172 patients who had undergone primary EVAR for AAA between 2016 and 2018. Bone mineral density (BMD) was assessed by measuring the Hounsfield units (HUs) of the 11th thoracic vertebra on preoperative computed tomography; a BMD value of <110 HU was considered osteoporosis. All patients were divided into those with osteoporosis and those without osteoporosis, and long-term outcomes were compared. In addition, hazard ratios of each variable for all-cause mortality were evaluated using univariate and multivariate analysis.
RESULTS: All 172 patients were divided into two groups: 72 patients (41.9%) with osteoporosis and 100 patients (58.1%) without osteoporosis. The mean age was higher and mean BMD was lower in osteoporosis patients than non-osteoporosis patients (mean ± standard deviation [SD], 79.2 ± 7.2 vs. 75.0 ± 8.7 years, respectively; P < 0.05; 78.1 ± 26.7 vs. 155.1 ± 36.3 HU, respectively; P < 0.05). During the median follow-up period of 68 months, overall survival was significantly lower in osteoporosis patients than non-osteoporosis patients (osteoporosis: 63.9% and 36.7% at 5 years and 7 years; non-osteoporosis: 83.8% and 74.6% at 5 years and 7 years, respectively; log-rank P < 0.05); freedom from aneurysm-related mortality did not differ significantly between groups (osteoporosis: 94.3% and 89.0% at 5 years and 7 years; non-osteoporosis: 100.0% and 96.7% at 5 years and 7 years, respectively; log-rank P = 0.078). In a multivariate analysis for overall survival following EVAR, coexistence of osteoporosis was found to be an independent risk factor for all-cause mortality (hazard ratio, 1.76, 95% confidence interval, 1.01-3.06; P < 0.05), as well as variables including age, statin use, sarcopenia, and aneurysm diameter.
CONCLUSIONS: Patients with osteoporosis showed a higher all-cause mortality following EVAR than patients without osteoporosis. We believe that comorbidity of osteoporosis may be useful in estimating the life expectancy of patients with AAA.

Background: Aortitis is a rare inflammation of the aorta. It can be classified as infective, non-infective, or idiopathic. Infective aortitis can debut as an acute aortic syndrome that needs urgent or emergent treatment. Historically, these kinds of patients have been preferably treated by open surgery, with subsequent lack of information about the endovascular repair. The aim of the present study is to report the results of our experience with the urgent or emergent endovascular repair of infective aortitis with acute presentation. Methods: All consecutive urgent or emergent endovascular repairs, performed between January 2019 and January 2024 for the treatment of infective aortitis, were included. The inclusion criteria were clinical, laboratory, and radiological findings recognized as aortitis risk factors. Patients with graft or endograft infection, aortic fistulae, and mycotic aneurysm were excluded. Primary endpoints were technical success and 30-day and follow-up survival. Early and late major adverse events, any changes in lesion morphology over time, and need for re-intervention were also assessed. Results: A total of 15 patients (14 males and 1 female) with a mean age of 74.2 ± 8.3 were included. All the subjects were treated by endovascular means in an urgent or emergent setting because of a rapidly growing aneurysm, symptomatic lesion, or contained or free aortic rupture. The diagnosis of infective aortitis was confirmed postoperatively by positive blood cultures in all the patients. A rapidly growing or symptomatic lesion was noted in all 15 subjects. Among these there were six (40%) contained and two (13%) free aneurysm ruptures. The endovascular techniques performed were as follows: four thoracic-EVAR (TEVAR), three off-the-shelf branched-EVAR (BEVAR), one Chimney-EVAR (Ch-EVAR), six EVAR with bifurcated graft, and one EVAR with straight tube graft. Technical success was achieved in 100% of the patients. Two patients (13%) died within 30 days after the index procedure. No case of early aortic-related mortality was registered. During a mean follow-up of 31.6 ± 23.1 months (range 1-71), no further death or major adverse event was registered among the remaining 13 alive patients. Re-interventions were performed in three cases (20%). Aneurysm\'s shrinkage > 5 mm or stability was noted in 10 of the 13 patients who survived the early period after repair. Conclusions: Despite the relative reluctance to use an endograft in an infected area, in our experience the endovascular approach resulted to be feasible, safe, and effective in the treatment of infective aortitis with acute presentation, with acceptable peri-operative and mid-term follow-up outcomes. Further studies are needed to confirm our results.

Background/Objectives: Carbon dioxide digital-subtraction angiography (CO2-DSA) is an increasingly adopted technique in endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/B-EVAR); it is used to reduce the amount of iodinate contrast medium (ICM) and prevent postoperative renal function worsening (PO-RFW). Our aim is to report results from the literature on EVAR and F/B-EVAR procedures using CO2-DSA, together with wider applications in aortic endovascular treatment. Methods: We performed a literature review by searching electronic databases for published data on CO2-DSA during EVAR and F/B-EVAR procedures. The endpoints were postoperative renal function worsening (PO-RFW) and efficacy of intraoperative arterial visualization. Further, applications of CO2 for thoracic endovascular aortic repair (TEVAR) were described. Results: Seventeen studies reporting results on CO2-DSA in EVAR (644 patients) were retrieved. Overall, 372 (58%) procedures were performed with CO2 alone, and 272 (42%) were performed with CO2+ICM. Eight studies analyzed the effect of CO2-DSA angiography on PO-RFW; four studies showed a significantly lower rate of PO-RFW compared to ICM. Five studies (153 patients) analyzed intraoperative arterial visualization with CO2-DSA; renal and hypogastric arteries were effectively visualized in 69% and 99% of cases, respectively. The use of CO2-DSA in F/B-EVAR has not been widely investigated. The largest series reported that PO-RFW was lower in the CO2 vs. ICM group. Conclusions: Carbon dioxide is widely applied in modern aortic endovascular treatment. CO2-DSA for EVAR and F/B-EVAR is an efficient technique for reducing PO-RFW while allowing acceptable arterial intraoperative visualization.

BACKGROUND: This study was conducted to evaluate the differences between pre- and postoperative access conditions in percutaneous endovascular aortic repair (PEVAR).
METHODS: Between December 2021 and October 2023, PEVAR was performed on 61 patients using the Perclose ProStyle (Abbott Vascular). Enhanced computed tomography and ankle-brachial index tests were performed preoperatively and postoperatively. The inner diameter and area of the iliofemoral artery were automatically measured, and the pre- and postoperative values were compared (114 legs). The same analysis was performed on 12 legs with previous groin operations; open surgical EVAR was performed in 9 legs, an endarterectomy of the femoral artery in 1, and a femoropopliteal bypass in the other leg.
RESULTS: All patients were discharged without surgical site infections, lymphatic fistulas, or retroperitoneal haematomas. There were no significant differences between the pre-and postoperative inner diameter and inner area of the external iliac artery and common femoral artery. There were no significant differences between the preoperative and postoperative ankle-brachial index tests. In 12 legs with a previous groin operation, the postoperative ankle-brachial index tests and inner diameter and area of the external iliac artery and common femoral artery were statistically equal to the preoperative values.
CONCLUSIONS: This study can support the safety of percutaneous endovascular aortic repair, even in patients with redo groin operations.