Search Results (97)

Pararenal abdominal aortic aneurysm/pseudoaneurysms (PAAA/PAAP) are rare, high-risk complex aortic lesions involving the renal arteries. Management includes open surgical repair (OSR), endovascular aortic repair (EVAR), or hybrid repair, each with specific advantages and limitations. A review of the literature was performed to assess treatment strategies and outcomes for PAAA and PAAP. A PubMed search using relevant MeSH terms identified 184 articles published in the last five years. After applying inclusion and exclusion criteria, 34 studies comprising 6460 patients with complex AAA/AAP were included for analysis. Treatment strategies were predominantly endovascular (79.4%), followed by open (5.8%) and hybrid approaches (2.9%) (11.7% have used EVAR or OSR in the same study). To emphasize difficulties in the management of this pathology, a case report of a large PAAP involving both renal arteries and occluded celiac trunk with retrograde flow from patent superior mesenteric artery (SMA) is presented. Given the complex anatomy and high surgical risk, hybrid treatment was chosen consisting of bilateral ilio-renal Dacron bypasses followed by ChEVAR (chimney stenting of the SMA), with favorable postoperative recovery. The management of PAAP requires an individualized, anatomy- and risk-adapted approach. Open surgical repair remains preferable for younger, low-risk patients for superior long-term durability, whereas endovascular repair offers lower perioperative morbidity in high-risk cohorts. Optimal outcomes are dependent on high-volume centers with multidisciplinary expertise. Full article

Background and Clinical Significance: Concomitant severe aortic stenosis (AS) and abdominal aortic aneurysm (AAA) in elderly patients presents a significant therapeutic challenge. While transcatheter aortic valve replacement (TAVR) and endovascular aneurysm repair (EVAR) have become established minimally invasive treatments for high-risk patients, simultaneous management of both conditions remains rare. Case Presentation: We report the first documented case in Serbia of a simultaneous TAVR and EVAR in a 75-year-old male with severe symptomatic AS and AAA. The patient had a history of hypertension, diabetes mellitus, atrial fibrillation, prior radiofrequency pulmonary vein ablation, and pacemaker implantation. Echocardiography demonstrated severe AS with a transvalvular gradient of 116/61 mmHg, an aortic valve area of 0.6 cm², and a left ventricular ejection fraction of 30–35%. Coronary angiography revealed 50–60% stenosis of the right coronary artery. Following evaluation by a multidisciplinary Heart and Vascular Team, a combined procedure was performed under general anesthesia via bilateral femoral access. TAVR with a Medtronic Evolut R valve was successfully deployed, followed by EVAR with satisfactory stent graft positioning and angiographic results. The patient’s postoperative course was uneventful, and he was discharged on the ninth day. At six-month follow-up, echocardiography showed optimal valve function, and CT identified a type II endoleak, which was managed conservatively. Conclusions: This case demonstrates the feasibility and safety of simultaneous TAVR and EVAR in a high-risk elderly patient, emphasizing the importance of careful preoperative planning and a coordinated multidisciplinary approach. Further studies are warranted to establish standardized guidelines for the management of patients with coexisting severe AS and AAA. Full article

An abdominal aortic aneurysm (AAA) poses a significant risk of arterial wall rupture, which critically endangers the patient’s life. To address this condition, an endovascular aneurysm repair (EVAR) is required, involving the insertion and expansion of a stent-graft within the aorta, to support and isolate the weakened vessel wall. In this context, this article aims to approach the problem from a mechanical perspective and to simulate the expansion and deployment procedure realistically, utilizing the Finite Element Analysis (FEA). The process initiates with the computation evaluation of the aortic structure in order to identify critical regions of stress and strain in an aneurysmatic aortic region. Then, a customized 3D-designed stent graft model was developed for the aorta and positioned properly. Applying all the necessary boundary conditions, a complex nonlinear FEA was conducted until the stent-graft expanded radially, reaching a final diameter 25% larger than the aorta’s vessel wall while withstanding mean stress and strain values close to 400 MPa and 1.5%, respectively. Finally, the mechanical behavior of the stent-graft and its interaction with the internal aortic wall, during the expansion process, was evaluated, and the extracted results were analyzed. Full article

Objectives: This study investigated the impact of aortoiliac geometry on thrombotic complication following aortic endovascular aneurysm repair (EVAR). Methods: Data from 54 patients who received abdominal EVAR between January 2015 and December 2023, in which 18 developed unilateral iliac limb in-stent thrombus, were retrospectively reviewed. Clinical data, including cardiovascular risk factors, laboratory findings, and geometrical factors, including iliac diameter, sectional area, limb angles, and tortuosity, were collected. Aortoiliac geometry analyses were performed on the 3D model reconstructed from abdominal aortic computed tomography angiography (CTA) using semi-automated software (MIMICS version 25.0). Results: Compared to non-thrombotic limbs, thrombotic iliac limbs showed larger maximum diameters (17.48 ± 0.95 mm vs. 14.14 ± 0.62 mm, p = 0.006), lower graft limb angles (117.52° ± 5.61° vs. 148.54° ± 4.31°, p < 0.001), lower aortoiliac angles (123.48° ± 4.66° vs. 141.96° ± 4.76°, p = 0.009), and higher iliac tortuosities (0.2 ± 0.03 vs. 0.12 ± 0.02, p = 0.02). Paired comparisons between normal and diseased limbs in 18 patients with thrombotic events also showed statistical differences in terms of iliac limb maximum diameter, graft limb angle, aortoiliac angle, and iliac tortuosity. Conclusions: Thrombosis formation following EVAR in iliac limbs was associated with limb diameter, graft limb angle, aortoiliac angle, and tortuosity. Full article

Objectives: To analyze the effect of abdominal aortic aneurysm (AAA) diameter on late complication occurrence and survival in patients following endovascular aneurysm repair (EVAR). Methods: The study was a retrospective cohort analysis with a prospective follow-up of 176 patients diagnosed with unruptured AAA who underwent EVAR from 2016 to 2024. Preoperative computed tomography (CT) images were used to measure maximal aneurysm diameter. Prospective follow-up data were collected post-EVAR at 1 month, 6 months, and annually through clinical evaluations and imaging studies. The mean follow-up duration was 26 months. For statistical purposes, the group was divided into tertiles based on aneurysm size. This study was intentionally focused on aneurysm size as an isolated imaging parameter, and did not incorporate other known predictors of complications, such as neck morphology or device-related variables. As such, key limitations include the single-center design, relatively small sample size, and lack of data on anatomical features beyond maximum diameter. Results: Kaplan–Meier survival analysis demonstrated that patients in the highest tertile of aneurysm size experienced significantly higher rates of long-term adverse outcomes compared to those in the lower two tertiles, both in terms of late complications (log-rank p = 0.049) and all-cause mortality at 36 months (p = 0.022). In multivariate logistic regression, the occurrence of late complications was independently associated with symptomatic presentation (p = 0.003, OR = 3.616, 95% CI: 1.533–8.529) and acute admission (p = 0.033, OR = 0.345, 95% CI: 0.130–0.916). The largest aneurysms were significantly associated with late endoleak (p = 0.041, OR = 5.365, 95% CI: 1.071–26.871). Conclusions: This study demonstrates that AAA size is an independent predictor of both late complications and long-term survival following EVAR. Patients with larger aneurysm diameters experienced significantly higher rates of late complications and reduced overall survival. 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/Objective: Sarcopenia is a predictor of poor surgical outcomes in older adults. The Psoas Muscle Index (PMI), calculated from routine preoperative CT scans, has been proposed as an imaging-based marker of physiological reserve, but its diagnostic utility in vascular surgery remains unclear. We aimed to assess the predictive value of PMI for early complications following elective abdominal aortic aneurysm (AAA) repair in two European centers. Methods: We retrospectively analyzed 245 patients who underwent open or endovascular AAA repair between 2018 and 2022 in Poland and The Netherlands. PMI was measured at the level of third lumbar vertebrae (L3) level, normalized to height, and stratified into center-specific tertiles. Early complications were compared across tertiles, procedures, and centers. Multivariate logistic regression was used to adjust for age, comorbidities, and procedure type. Results: Low PMI was significantly associated with early complications in EVAR patients at the Polish center (p = 0.004). No associations were found in open repair or at the Dutch center. Mean PMI values did not differ significantly between centers. Conclusions: PMI may serve as a context-dependent imaging biomarker for early risk stratification following AAA repair, particularly in endovascular cases. Its predictive value is influenced by institutional and procedural factors, highlighting the need for prospective validation and standardization before clinical adoption. Full article

Background/Objectives: There are no reports about the nationwide trends in abdominal aortic aneurysm (AAA) repair and mortality rates. This study aims to evaluate the trend in AAA treatment and related mortality, including ruptured AAAs (rAAAs) and intact AAAs (iAAAs) over the last 13 years. Methods: This serial, cross-sectional study investigated the time trends in patients who were treated for an AAA and underwent an aneurysm repair between 2010 and 2022. Data from the Health Insurance Review and Assessment Service (HIRA) and Statistics Korea were used. A linear-by-linear association and Poisson regression analysis were performed to determine the changes in the treatment of AAAs and related mortality. Results: The number of patients with an rAAA increased from 462 in 2010 to 770 in 2022 (relative risk, RR 1.57; p < 0.0001). The number of patients with an iAAA increased from 3685 to 12,399 in the same period (RR 3.16; p < 0.0001). Endovascular aneurysm repair (EVAR) has been more commonly performed since 2011. During the study period, EVAR increased from 406 to 1161 (RR 2.68; p < 0.0001). Although the annual mortality rates after iAAA treatment decreased from 1.4% to 0.7% (mean mortality rate, 1.1%), the mortality rates after rAAA treatment were similar, ranging from 34.6% to 34.2%, during the study period (mean mortality rate, 35.2%). Conclusions: During the last 13 years, the annual number of patients with rAAAs and iAAAs has increased. Since 2011, EVAR has been more commonly performed. The annual iAAA-related mortality rate decreased along with the increasing trend in EVAR. However, the annual rAAA-related mortality rate did not change. 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: Wide and conical-shaped infrarenal necks are risk factors for neck-related complications after Endovascular Aorta Aneurysm Repair (EVAR). The aim of this study is to investigate the performance of the Endurant endoprosthesis in wide/conical-shaped aortic neck anatomies compared to its performance in a normal infrarenal neck (reference group). Methods: A single-center, retrospective observational cohort study was performed, including consecutive subjects with an infrarenal abdominal aortic aneurysm, treated electively with an Endurant endoprosthesis. The primary endpoint was the freedom from aneurysm-related reinterventions through 1 year. Secondary endpoints included proximal fixation failure, type IA endoleak, stent migration, aneurysm sac remodeling, aneurysm-related mortality, freedom from reinterventions throughout available follow-up, and rupture. Results: A total of 268 patients were included, with a mean age of 73.3 years, and 85.1% were male. Freedom from aneurysm-related reinterventions was significantly lower in the wide-neck group (60.0%) compared to the reference group (81.1%; p = 0.018) but not for the conical-neck group (70.3%; p = 0.286). Median time to first reintervention was 1.7 (IQR 0.8; 4.4 years) in the reference group, 2.9 years (IQR 0.3; 5.0 years) in the wide-neck group (p = 0.547) and 3.8 years (IQR 0.4; 6.5) in the conical-neck group (p = 0.123). The proximal fixation failure rate was 7.4% in the wide-neck group compared to 3.3% in the reference group (p = 0.155) and 1.7% in the conical-neck group (p = 0.525). The type IA endoleak rate was 4.9% in the wide-neck group versus 3.3% in the reference group (p = 0.250). Conclusions: In the group with wide necks, reintervention-free survival was lower compared to the reference group, which seems to be driven by proximal fixation failure. 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/Objectives: Endovascular aneurysm repair (EVAR) of the aorta may trigger an inflammatory response that affects coagulation. In the EVAR of para-renal and thoraco-abdominal aortic aneurysms, the implants are more complex and the duration of surgery is longer. However, the exact pathophysiological mechanisms of coagulation activation are not yet well understood. The primary aim of this study is to investigate the effects of complex EVAR of para-renal and thoraco-abdominal aortic aneurysms on the coagulation status of patients. Methods: This prospective observational study (STROBE), approved and registered by the Ethics Committee of the University Hospital of Larissa (UHL) (NCT06432387), will enroll consecutive patients undergoing elective EVAR of para-renal and thoraco-abdominal aortic aneurysms. Exclusion criteria: Refusal to participate, previous surgery within 3 months, American Society of Anesthesiologists physical status (ASA PS) > 3, known history of thrombophilia or functional platelet dysfunction. Perioperative laboratory tests will be performed according to institutional guidelines. These include a complete blood count, conventional coagulation tests, and kidney and liver function tests. In addition, the following parameters will be determined: von Willebrand factor, factors VIII and XI, D-dimers, fibrinogen, Adamts-13, anti-Xa, platelet activation (multiplate), and high-sensitivity troponin. Blood samples will be taken pre-operatively before induction of anesthesia (01), on postoperative day 1 (02), and on postoperative day 3–4 (03). During hospitalization, myocardial injury after non-cardiac surgery (MINS), major adverse cardiovascular events after non-cardiac surgery (MACE), acute kidney injury (AKI), post-implantation syndrome (PIS), and death from any cause will be recorded. In addition, our patients will be reviewed at 30 days, 3, 6, and 12 months for MACE, implant failure, or death from any cause. All enrolled patients will be treated by the same medical team at UHL according to the indications. According to our power analysis, for a cohort of patients with three consecutive measurements, 58 patients should be included in the study. To compensate for possible dropouts, the sample size was increased to 65 patients. Conclusions: The results of the present study could help physicians to better understand the effects of complex EVAR of para-renal and thoraco-abdominal aortic aneurysms on blood coagulation and platelet activation. Full article

Objectives: To report the results of pre-emptive embolization of collateral branches of the abdominal aorta in patients undergoing standard bifurcated EVAR versus those undergoing standard EVAR without embolization. Methods: This study is a single-center, retrospective, observational cohort analysis of consecutive patients who underwent elective standard endovascular aneurysm repair (EVAR) between 1 October 2013, and 31 December 2022, with a minimum follow-up period of 2 years. The patients were divided into two groups: group A, which did not receive embolization, and group B, which underwent pre-emptive embolization of aortic collateral branches. The primary outcomes for this study include overall survival, freedom from aorta-related mortality (ARM), and freedom from reinterventions related to type 2 endoleak (T2E). In cases of multiple reinterventions, only the first one was considered for this analysis. The secondary outcome focused on assessing freedom from aneurysm sac enlargement. Results: We analyzed a total of 265 endovascular aneurysm repairs (EVARs): 183 (69.1%) were classified into group A, and 82 (30.9%) into group B. The median follow-up duration was 48 months [interquartile range (IQR), 28–65.5], which was not significantly different between the two groups [45 months (26–63) in group A vs. 52.5 months (29.5–72.5) in group B, p = 0.098]. The estimated cumulative survival rates were 87% (0.2) at 2 years (95% confidence interval [CI]: 82.6–92.9) and 67% (0.3) at 5 years (95% CI: 60.3–73.1), with no significant difference between the groups (p = 0.263). The aorta-related mortality rate was 1.1% (n = 3); all instances occurred following open conversion due to graft infection (n = 2) and in one case of secondary aortic rupture (n = 1). In total, 34 cases (12.8%) indicated a secondary intervention related to type 2 endoleak (T2E). The freedom from T2E-related reintervention rate was 99% (0.01) at 2 years (95% CI: 99.4–99.8) and 88% (0.3) at 5 years (95% CI: 81.4–92.5), with no differences between the groups (p = 0.282). Cox regression analysis revealed that age over 80 years is an independent negative predictor of survival, with a hazard ratio (HR) of 3.5 (95% confidence interval [CI]: 2.27–5.50; p < 0.001). Additionally, T2E-related reintervention was identified as a negative predictor, with an HR of 2.4 (95% CI: 1.05–5.54; p = 0.037). In this study, conversion to open repair was necessary for 14 patients (5.3%), with three conversions occurring due to rupture; however, T2E was not a determining factor in any of these conversions. At the last available follow-up computed tomography angiography (CT-A), the median aneurysm diameter was significantly lower in group B, measuring 44 mm (range 37.7–50), compared to group A, measuring 48 mm (range 39–57.5) (p < 0.001). Both groups showed a significant change from baseline measurements (p = 0.001). Conclusions: Pre-emptive embolization of the aortic collateral branches does not lead to improved aorta-related outcomes after EVAR. Full article

Background: Endovascular aortic aneurysm repair (EVAR) is a commonly used treatment for abdominal aortic aneurysms (AAAs), but anatomical complexities limit its application in certain cases. Objective: This study evaluates the mid-term outcomes, referring to a follow-up period with a mean of 29.9 ± 24.1 months (approximately 1–5 years), of a novel double-barrel technique that employs overlapping tubular stent grafts to address these challenges. Methods: A retrospective analysis was conducted on seven patients treated with this technique from May 2014 to February 2023. Patients had narrow and short proximal necks, inadequate landing zones, or required re-do procedures. Results: The double-barrel technique achieved technical success in 85.7% of cases with zero mortality. Patients had an average hospital stay of 11.9 ± 10.0 days and attended follow-up for a mean of 29.9 ± 24.1 months. Minimal complications and no significant adverse events were reported. Conclusions: These findings suggest that the double-barrel technique is a cost-effective and viable alternative for anatomically complex cases where standard EVAR is unsuitable. While promising mid-term outcomes were observed, further studies with larger cohorts are necessary to confirm its long-term effectiveness and broader applicability. Full article