Search Results (58)

Aim: Hostile aortic neck anatomy—characterized by short neck length, severe angulation, conical shape, and mural thrombus or calcifications—represents a major limitation to the durability and applicability of standard endovascular aneurysm repair (EVAR). In response to these challenges, newer endografts with improved conformability have been developed. This study aimed to evaluate the mid-term outcomes of EVAR using the GORE EXCLUDER Conformable AAA Endoprosthesis (CEXC) (W.L. Gore & Associates Inc., Flagstaff, AZ, USA) in patients with hostile neck anatomy, with specific attention to type III endoleak occurrence, aortic sac remodeling, and maintenance of distal sealing. Methods: A retrospective observational analysis was conducted on 50 consecutive patients treated with the CEXC endograft between October 2019 and September 2023. Patients included had either elective or urgent indications for EVAR and were evaluated preoperatively using CT angiography. Hostile neck criteria were defined according to the 2019 Delphi Consensus. Procedural variables, imaging follow-up, and clinical outcomes were collected. The primary endpoints were technical and clinical success, while secondary outcomes included endoleak rates, aneurysm sac evolution, and reintervention-free survival. Results: Technical success was achieved in 100% of cases, with a clinical success rate of 98%. No type Ia, Ib, or III endoleaks were observed at a median follow-up of 23 months. Sac shrinkage (>5 mm reduction) occurred in 70% of patients, and distal sealing was preserved in 100% of cases. One perioperative death occurred in an emergency setting, and no late reinterventions or aneurysm-related mortalities were reported. The use of intravascular ultrasound (IVUS) and floppy guidewires contributed to precise deployment and sealing in angulated anatomies. Conclusions: The CEXC endograft proved to be a safe and effective option for EVAR in patients with hostile aortic anatomy, ensuring durable proximal and distal sealing, promoting favorable sac remodeling, and preventing type III endoleaks. These findings support the use of CEXC in anatomically complex settings, as long as procedures are meticulously planned and guided by appropriate intraoperative imaging and deployment techniques. Full article

Background: Long-term follow-up after endovascular aortic repair (TEVAR) is crucial to detect adverse aortic remodeling, even with modern stent grafts offering enhanced flexibility and durability. Conventional imaging, based on diameter measurements, may fail to identify complications such as endograft migration. Methods: We conducted a longitudinal 3D geometric analysis of thoracic aortic and stent-graft evolution over 10 years in a patient treated for descending thoracic aortic aneurysm (DTAA) by endovascular treatment. A three-dimensional morphological analysis (length, tortuosity, angulation, and diameter) was carried out using advanced imaging software (EndoSize, MATLAB) to track aortic geometry and stent-graft behavior over time. A focused review of the literature on stent-graft migration, its risk factors, complications, and surveillance strategies was also performed. Results: This case illustrates how progressive geometric remodeling—including aortic elongation and increased tortuosity—can lead to delayed stent-graft migration and late type III endoleaks, with an elevated risk of rupture. The 3D analysis revealed early morphological changes that were undetectable using standard diameter-based follow-up. These observations are consistent with published data showing higher migration rates over time, particularly in tortuous anatomies. The literature review further emphasizes the clinical relevance of geometric surveillance, given the high rates of reintervention, morbidity, and mortality associated with stent-graft migration. Conclusions: This study underlines the importance of personalized and geometry-based surveillance after TEVAR. Advanced morphological assessment tools provide valuable insights for the early detection of complications and tailored patient management. Their integration into routine follow-up could help optimize long-term outcomes and prevent life-threatening events such as rupture. Full article

Background: This study investigated whether branched thoracic endovascular aortic repair (bTEVAR), a treatment for distal aortic arch diseases, could serve as an alternative to open aortic surgery (OAS). Methods: This single-center, retrospective, observational cohort study comprised 80 patients (bTEVAR, n = 28; TAR, n = 52) treated from October 2012 to June 2018. The median age and median follow-up periods were 73 years (interquartile range [IQR], 66–79 years) and 6.0 years (IQR, 2.8–9.7 years). Results: The patients in the bTEVAR group were older than those in the OAS group (p < 0.001), and the EuroSCORE2 was significantly higher in the bTEVAR group (6.6%) than in the OAS group (2.4%; p < 0.001). There were no 30-day or in-hospital mortalities in either group. Stroke was observed in four (5.0%) patients, all of whom were in the bTEVAR group (p = 0.013). However, no other significant differences were observed between the two groups in other early aortic events. Kaplan–Meier curves regarding the survival, aorta-related death, and aortic events showed no significant differences between the two groups. Conclusions: Although bTEVAR involves an older patient population and a higher surgical risk, the early and mid-term outcomes were comparable to those of OAS, except for cerebral infarction. However, because cerebral infarction significantly reduces a patient’s quality of life, for bTEVAR to become more widespread, it is necessary to reduce the incidence of cerebral infarction. Full article

Background/Objectives: The aim of our study was to document and analyze the long-term geometric alterations that occur in the infrarenal aorta and iliac arteries over time after a successful elective standard endovascular abdominal aneurysm repair (EVAR) as well as to investigate the potential relationship of aortoiliac remodeling with the long-term complications of EVAR. Methods: The prospectively collected clinical and computed tomography angiography (CTA) data from 168 patients treated with elective standard EVAR between 2013 and 2018 were retrospectively analyzed. Follow-up assessments were performed at 1, 24, and 60 months postoperatively. Primary anatomical variables included 11 measurements: total right and left aortoiliac lengths, infrarenal aortic length, right and left aortoiliac angles on the frontal CTA plane, right and left intra-iliac angles, inter-iliac angle, infrarenal aortic body angle on the sagittal CTA plane, and right and left aortoiliac angles on the sagittal CTA plane. Secondary variables were the mean percentage changes in anatomical measurements between the follow-up time intervals. The primary clinical endpoint was the occurrence of any complication related (ARC) to the index EVAR or reinterventions. Secondary endpoints included any graft migration (AM) observed in proximal aortic or distal iliac sealing zones, and failure of aneurysm sac regression (FSR) or an increase in sac diameter by >5 mm. Six different bifurcated endografts were used. For subgroup analysis, the primary differentiating feature among grafts was the presence or absence of suprarenal fixation with hooks. Results: Median follow-up was 77 months, with an interquartile range (IQR) of 24.0 months. Observed EVAR-related mortality was 2.4%. Twenty-seven (16.1%) ARC events occurred, and migration was detected in 21 (12.5%) patients, combined with endoleak in 20 of them. The incidence of FSR was 43.5%, and approximately a third of ARCs and AMs occurred after the 60th month of follow-up. Across all measured lengths and the inter-iliac angle on the frontal CTA plane, a significant increase was observed, while all other angles demonstrated a significant decrease over time. The pattern of aortoiliac remodeling followed a linear progression for the first 24 months, transitioning to either a quadratic or cubic trend by the 60-month mark. Linear regression analysis revealed that an excessive increase in length variables was significantly associated with lower AAA sac regression rates. Furthermore, multivariate analysis identified that suprarenal fixation with hooks was the only factor associated with a reduced likelihood of AMs and a five-fold decrease in FSRs. Conclusions: Despite a fully successful EVAR, significant aortoiliac geometrical remodeling is evident over time. Extensive remodeling of aortoiliac lengths appears to be associated with lower rates of AAA sac regression. Suprarenal proximal aortic fixation with hooks may serve as a protective mechanism, reducing the likelihood of long-term complications. Life-long follow-up remains an essential measure for early detection of long-term EVAR failures. Full article

Background/Objectives: Physician-modified endografts (PMEGs) have emerged as a treatment option for complex aortic pathologies. Uncertainty remains regarding the modification techniques and the most suitable materials for customization of fenestrated endografts. The aim of this study was to evaluate CE-marked endovascular aortic repair (EVAR) devices and suitable materials for device modification in PMEGs for juxtarenal and pararenal aortic pathologies. Methods: This single-center observational study included patients treated with the physician-modified TREO (Terumo Aortic, Inchinnan, UK) device between April and December 2024. All patients had aortic ruptures or symptomatic aneurysms and unfavorable anatomy or severe comorbidities, making standard EVAR and open repair unsuitable. Procedural data were recorded and analyzed, including in-hospital outcomes. The “wire visibility” and “sheath–wire contrast” of endografts were assessed under fluoroscopy, and different resheathing techniques were compared. Results: Technical success was achieved in all five patients. The number of fenestrations per patient was 2.6 (range: 1–4). In one patient (1/5), type Ib and type IIIc endoleaks were observed postoperatively, requiring reintervention. No in-hospital mortality occurred. The ICU and hospital stay were 24 h (range: 18–40 h) and 8 days (range: 6–20 days), respectively. Moreover, the One SNARE wire was identified as the wire with the highest “wire visibility”, and Endurant II showed the best “sheath–wire contrast”. Resheathing with the dedicated crimping device was superior to the tape-assisted method. Conclusions: The TREO platform, in synergy with suitable additional materials, offers a viable solution for urgent aortic pathologies requiring PMEGs. Continued refinement of materials and procedural standardization could enhance the long-term outcome. Full article

Late ruptures of abdominal aortic aneurysms post-endovascular aneurysm repair present a significant risk, occurring in about 0.9% of cases. The typical timeframe leading to rupture is roughly 37 months, with the primary factors often linked to endoleaks, especially types I and III, which sustain pressure within the aneurysm sac. The approaches to managing late ruptures consist of endovascular approaches, open surgical interventions, and conservative care, each customised to the patient’s specific characteristics. When feasible endovascular repair is favoured, additional stent grafts are deployed to seal endoleaks and offer lower perioperative mortality rates compared to those for open surgery. Open repair is considered when endovascular solutions fail or are not feasible. Conservative management with active monitoring and supportive treatment can be considered for haemodynamically stable non-surgical patients. Endovascular repair methods like fenestrated/branched EVAR (F/BEVAR) and parallel grafting (PGEVAR) are effective for complicated anatomies and show high technical success with reduced morbidity compared to that with open repairs. Chimney techniques and physician-modified endografts may help regain and broaden the sealing zone. Limb extensions with or without embolisation, interposition endografting, and whole-body relining are helpful options for type IB and type 3–5 endoleaks. Open surgical repair carries a higher perioperative mortality but may be essential in preventing death due to rupture following failed EVAR. The choice depends on the patient’s clinical stability and fitness for surgery in the absence of a viable endovascular alternative. This article discusses the available options for treating late rupture after EVAR, emphasising the importance of individualised treatment plans and the need for rigorous postoperative surveillance to prevent such complications. Full article

Background/Objectives: We sought to demonstrate the versatility and economy of physician-modified endograft (PMEG) fenestrated endovascular aortic repair (FEVAR) based on the Treo (Terumo Aortic) platform for patients referred for custom-made device (CMD) FEVAR due to a complex abdominal aortic aneurysm (CAAA). Endovascular planning was performed utilizing a standardized design incorporating all visceral arteries with a low supra-celiac landing zone. The pure cost of the aortic components was compared between the PMEG and CMD designs. Methods: A total of 39 consecutive patients treated with CMD FEVAR due to a CAAA between September 2018 and December 2023 were recruited at a tertiary vascular center for a retrospective evaluation. Endovascular planning was performed on readily available computed tomography angiography (CTA) datasets using 3Mensio Vascular (Pie Medical Imaging) software. The actual cost of the major components was compared between the implanted CMD platform produced by Cook and the planned Treo-based PMEG repair. Results: A total of 155 fenestrations were planned on 3 triple-, 34 quadruple-, and two quintuple-fenestrated devices. The 90 mm distance between the proximal edge and the flow divider of the 120 mm long main body of the Treo graft allowed for the placement of all necessary fenestrations of the target arteries without the need to reduce the 3 cm supra-celiac landing zone while also preserving a safety distance of >1 cm to the flow divider. The costs of the components were EUR 33896 for CMD and EUR 8878 for a PMEG. Conclusions: This retrospective study suggests that a quadruple-fenestrated PMEG based on the Treo bifurcation is a highly versatile alternative with a significant price advantage over custom-made devices for the treatment of complex abdominal aortic aneurysms. Full article

Background/Objective: To report mid-term to long-term outcome data for endovascular aortic repair using the Ovation stent graft system (Endologix, Santa Rosa, CA) for the correction of abdominal aortic aneurysms (AAAs) in a single center. Methods: All patients treated with the Ovation stent graft between December 2011 and February 2018 were included. Patient demographics, anatomical and operative details, as well as follow- up data including complications, the need for further interventions, and mortality were recorded prospectively in an electronic dataset and analyzed. Results: A total of 99 patients (86.10% males; mean age 73.6 ± 7.26 years) were treated with the Ovation stent graft. The mean maximal aortic diameter was 53.7 ± 8.8 mm mm. The main indications for Ovation use were small iliac accesses and thrombus/calcification at the proximal neck level. The technical success rate was 93.06%. No perioperative reintervention or limb occlusion was reported. Two graft-related perioperative adverse events were recorded. At a mean follow up of 82.70 ± 40 months, cumulative late survival was 97.90%, 92.60%, 81.00%, 73.40%, 48.70%, and 45.10%, respectively, at 12, 24, 48, 60, 108, and 120 months. No AAA-related death was recorded. Actuarial freedom from reintervention rate was 97.90%, 95.70%, 92.10%, and 80.10%, respectively, at 12, 24, 60, 108, and 120 months; estimated freedom from conversion was 98.90%, 97.70%, and 95.20% at 24, 60, 108, and 120 months. Conclusions: The Ovation stent graft demonstrated durable AAA exclusion even in complex anatomies evidenced by successful aneurysm exclusion and mid- to long-term freedom from aneurysm-related mortality. However, in this series, the not insignificant graft-related adverse event rate suggested the need for structural improvements, which were implemented in the next-generation devices. Full article

Background/Objectives: Aortic stiffness is a strong independent factor in cardiovascular outcomes. The method of choice for evaluating aortic stiffness is the measurement of aortic pulse wave velocity (PWV). Endovascular aortic repair (EVAR) increases aortic rigidity and thus aortic stiffness. The aim of this study is to investigate the correlation between endograft length and post-operative increases in PWV in patients with abdominal aortic aneurysms (AAAs) subjected to EVAR. Methods: A prospective observational study enrolling 107 patients from February to December 2025 was conducted. Patient demographics and comorbidities were recorded. The length of the endografts was calculated by studying computed tomography angiograms (CTAs) and digital subtraction angiographies (DSAs) of the patients. PWV was measured pre-operatively and post-operatively during the first 24 h after EVAR, and the difference in PWV (dPWV) was calculated. Results: The mean age of the patients was 72 ± 7.5 years, and 93.5% of them were males. The mean transverse AAA diameter was 5.7 ± 1.1 mm, and the mean endograft length was 169.7 ± 26.9 mm. An extension to the external iliac artery was deployed in 10 patients (9.3%). A strong positive correlation was observed between dPWV and endograft length, indicating that each additional 1 mm in graft length corresponded to a 0.541% increase in dPWV. Patients with an extension to external iliac arteries exhibited a significantly higher mean dPWV (9.95 ± 2.08% vs. 27.12% ± 12.15%, t = −4.463, p = 0.002). No statistically significant differences in dPWV between the different endograft types were found (p = 0.74). Conclusions: Endograft length is strongly related to PWV elevation during the immediate post-operative time after EVAR, especially when the endograft is extended to the external iliac arteries. Full article

Background: The aim of this case series is to describe technical considerations and preliminary outcomes of preventive aneurysm sac embolization during fenestrated or branched EVAR (embo F/BEVAR technique). Methods: Five male patients suffering from juxtarenal or pararenal abdominal aortic aneurysms, preoperatively identified as being at “high risk” of type 2 endoleak (EL2) development, were treated with embo F/BEVAR. The patients presented at least two of these risk factors: patent inferior mesenteric artery (IMA) > 3 mm; more than three pairs of patent lumbar arteries (LAAs); more than two pairs of LAAs, associated with an accessory efferent artery or at least a pair of intercostal arteries; aneurysm thrombus volume < 40%; aneurysm sac diameter > 65 mm. Embo F/BEVAR was performed with 15 × 20 mm MReye Inconel coils (Cook Medical, Limerick, Ireland), using different aortic endografts. Results: Technical success was 100%, with no complications related to perioperative or postoperative coils implantation. An average number of 11 ± 4.4 coils/patient was deployed. No reinterventions were observed during the follow-up (12.4 ± 3.6 months). One case of EL2 (20%) was detected during the follow-up, without aneurysm sac enlargement. Conclusions: According to this preliminary experience, embo F/BEVAR technique with Inconel coils seems a feasible adjunctive procedure to manage the risk of EL2 after FEVAR or BEVAR, allowing a simple follow-up with low levels of scatter artifacts, and ensuring limited additional procedural costs. Moreover, embo F/BEVAR can be used with different endografts, requiring minimal increases in operating times. Further studies with larger cohorts of patients and longer follow-up periods are mandatory to better define the potential of this technique and its limitations. Full article

Objective: To evaluate the impact of a prosthetic and native aorta proximal landing zone (PLZ) for hybrid thoracic aorta repair with a stent graft deployed in the Zone 0 ascending aorta. Methods: Retrospective analysis of 100 patients who underwent Zone 0 hybrid thoracic aorta repair between 2005 and 2022, at a single institution. Fifty-eight (58%) had a Dacron PLZ (ascending aorta replacement with debranching), and forty-two (42%) had a native ascending aorta PLZ (off-pump aortic arch debranching). All the surviving patients had at least one radiological follow-up. Results: Patients with a native aorta PLZ were older (p = 0.01) and had higher rates of pulmonary disease (p = 0.01) and chronic kidney disease (p = 0.01) and a higher Logistic EUROscore (p = 0.02). In-hospital mortality was similar between the two groups (2.3% vs. 1.7%; p = 0.68). Retrograde aortic dissection was observed in four (9.2%) of the native PLZ group. The mean follow-up was 37 ± 22 months in the Dacron PLZ group and 42 ± 20 months in the native PLZ group (p = 0.05). At 1,3, and 5 years, freedom from Type Ia endoleak was significantly higher in patients with a Dacron PLZ: 100% vs. 96 ± 0.3%, 100% vs. 85 ± 1%, and 100% vs. 66 ± 1.3% (p = 0.03). Despite this, the 1-, 3-, and 5-year survival was similar between groups: 100% vs. 96 ± 0.4%, 90 ± 1% vs. 89 ± 0.6%, and 66 ± 1% vs. 64 ± 2%. (p = 0.96). Conclusions: Endograft deployment in a prosthetic ascending aorta is a safe and durable option for aortic repair. A Dacron PLZ is associated with a lower rate of Type Ia endoleak and can prevent retrograde aortic dissection when compared with native aorta. Full article

Background: Endovascular aneurysm repair (EVAR) is the preferred treatment for abdominal aortic aneurysms (AAAs). This study evaluated the differences between the anticipated and actual achieved proximal sealing zones for standard EVAR endografts and their potential implications in a real-world AAA population. Methods: Data from 275 consecutive EVAR patients treated with the Endurant endograft (Medtronic, Minneapolis, MN, USA) between 2009 and 2022 were retrospectively analyzed. The proximal sealing zone was calculated preoperatively (target anticipated sealing zone, TASZ) and postoperatively (real achieved sealing zone, RASZ) from computed tomography angiography (CTA) images. These metrics were evaluated by assuming that they had a truncated cone shape, calculating the cone’s lateral surface by measuring the proximal and distal centerline areas and the distance between the planes. The primary outcome was the occurrence of type 1A endoleak at the longest available follow-up. Results: RASZ was significantly smaller and shorter than TASZ (p = 0.001), with an average area reduction of 24.5 mm² and a median length reduction of 3 mm. Area and cranial length loss were present even when correcting for graft positioning imperfections. In the Cox proportional hazard regression model, TASZ and RASZ lengths were both independently associated with a lower risk of type 1A endoleak (HR: 0.88, 95% CI 0.80–0.96 and HR: 0.92, 95% CI 0.86–0.99, respectively). A Kaplan–Meier analysis confirmed that patients with RASZ > 5.5 mm had a survival free from endoleak higher than patients with RASZ ≤ 5.5 mm. Conclusions: In this real-world AAA population, the achieved proximal sealing zone was significantly shorter and smaller than planned, regardless of optimal endograft placement. The early calculation of RASZ, i.e., the PSZ achieved via CTA, is critical for risk stratification and follow-up. Full article

Background: Penetrating aortic ulcer (PAU) is an acute aortic syndrome characterized by a high rupture risk. There are several PAU-treatment procedures indicated for the management of this pathology associated with different effects on vessel morphology and hemodynamics. A deep evaluation of the different types of treatment may be helpful in decision making. Computational Fluid Dynamics (CFD) is a powerful tool for detailed inspection of cardiovascular diseases. The aim of this work was to implement a comparative analysis based on CFD evaluation of the effects of two type of PAU treatments. Methods: Thoracic endovascular aortic repair (TEVAR) with a left subclavian artery (LSA) branched aortic endograft (SBSG) and a hybrid approach including TEVAR and carotid-LSA bypass were considered. Aortic anatomical models were created from computed tomography (CT) images acquired before and after PAU treatment with SBSG for three patients. Starting from these models, a new aortic geometry corresponding to the outcome of the hybrid strategy was generated. Morphological analysis and CFD simulations were carried out for all aortic models to evaluate LSA outflow for the same predefined boundary conditions. Results: Reductions in LSA diameter were found between aortic models before and after the SBSG (18.2%, 20.8%, and 12.4% for CASE 1, CASE 2, and CASE 3, respectively). The flow rate at LSA changed between pre-configuration and aortic configuration after the PAU treatments: an averaged decrement of 1.08% and 7.5% was found for SBSG and the hybrid approach, respectively. The larger increase in pressure drop between the aortic arch and the LSA extremity was shown in the hybrid approach for all cases. Conclusions: CFD simulations suggest that SBSG preserves LSA perfusion more than a hybrid strategy and has less impact on thoracic aorta hemodynamics. Full article

Background/Objectives: We aim to quantify the effect of sex upon the presentation of acute lower limb ischemia (ALI) and the outcomes after surgical thromboembolectomy with a Fogarty catheter. Methods: This was a monocentric retrospective observational study of ALI treated by a Fogarty catheter. Demographics, comorbidities, and clinical characteristics were analyzed. The logistic regressions were used to estimate mortality and secondary outcomes. Results: Over 8 years, 193 patients (79 males and 114 females) underwent Fogarty catheter thromboembolectomy to treat acute lower limb ischemia. Females were older (74.5 for females vs. 82.5 for males) and more affected by congestive heart failure (27% vs. 8%; p = 0.001) and atrial fibrillation (68% vs. 37%; p = <0.001) than the male counterparts. Regarding etiology (p < 0.001), a cardiac embolism (males: 35%; females: 67%) and aortic thrombosis (males: 1%; females: 8%) were more associated with the female gender in the development of acute lower limb ischemia, while vascular bypass/endograft failure (males: 20%; females: 7%) and iatrogenic complications (males: 13%; females: 1%) were more associated with the male gender. After 30 days from surgery, 19% of men and 32% of women had died. Males had higher rates of loss of vascular patency (males: 25%; females: 9%; p = 0.002) and vascular reintervention (males: 20%; females: 8%; p = 0.012). After 90 days from surgery, 23% of men and 41% of women had died. If women had higher mortality (males: 23%; females: 41%; p = 0.008), men had higher rates of loss of vascular patency (males: 27%; females: 12%; p = 0.011) and vascular reintervention (males: 23%; females: 9%; p = 0.007). Conclusions: Older females with atrial fibrillation and/or chronic heart failure are at high risk for ALI. Regarding the thromboembolectomy with a Fogarty catheter, male sex appears to be a risk factor (OR: 2.2, CI: 1.08–4.56) for loss of primary patency, major amputation, and new vascular surgery. A further prospective analysis is warranted to understand the impact of sex in the presentation of acute lower limb ischemia (ALI) and the outcome after surgical thromboembolectomy. Full article

Introduction: A type 2 endoleak (EL2) remains the most prevalent complication of endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA). Methods: We conducted a retrospective, single-center analysis, including patients who underwent embolization for an isolated EL2 after EVAR. The study population was stratified into two groups: Group A, consisting of patients whose EL2 resolved after the first embolization procedure, and Group B, consisting of those with refractory EL2 (rEL2). The indication for EL2 treatment was aneurysmal sac growth amounting to >10 mm from the index EVAR. The indications for endograft explantation were the absence of high comorbidities and persisting aneurysmal sac expansion. Those with high comorbidities were subjected to another endovascular procedure or a conservative approach, the latter being preferred. The primary endpoint was EL2 resolution. The secondary endpoints were mid-term outcomes in terms of aneurysmal sac shrinkage, stability and expansion rates, and aneurysm-related complications. Results: Among 57 patients, 19 patients (33.3%) showed signs of EL2 after the first embolization, whereas 38 (66.6%) presented rEL2. Of these, 14 (36.8%) presented significant aneurysmal sac expansion: 8 patients underwent a secondary embolization, while an open conversion was performed in the remaining 6 patients (42.8%), 4 of whom, in an elective setting, showed a complete resolution of EL2, while 2 patients treated in an urgent setting died from a ruptured aneurysm. Among the patients treated with a secondary embolization, only 2 patients presented EL2 resolution, while the other 6 patients (75%) showed rEL2. Out of the 38 patients with rEL2, 24 patients did not undergo further interventions; of these, 11 (45.8%) presented sac expansion, and 16% developed type IA EL. Conclusions: A strict follow-up and possibly a more aggressive treatment should be considered in an elective setting for patients with rEL2. Full article