Publications by authors named "Bernardo C Mendes"

72 Publications

Impending Arteriovenous Fistula Bleeding With Skin Ulceration.

Mayo Clin Proc 2022 08;97(8):1577-1580

Division of Vascular and Endovascular Surgery, Mayo Clinic Rochester, MN USA.

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http://dx.doi.org/10.1016/j.mayocp.2022.05.032DOI Listing
August 2022

Multicenter Study to Evaluate Endovascular Repair of Extent I-III Thoracoabdominal Aneurysms Without Prophylactic Cerebrospinal Fluid Drainage.

Ann Surg 2022 Aug 4. Epub 2022 Aug 4.

Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston.

Objective: To assess outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of Extent I-III thoracoabdominal aortic aneurysms (TAAAs) without prophylactic cerebrospinal fluid drainage (CSFD).

Background: Prophylactic CSFD has been routinely used during endovascular TAAA repair, but concerns about major drain-related complications gave led to revising this paradigm.

Methods: We reviewed a multicenter cohort of 541 patients treated for Extent I-III TAAAs by FB-EVAR without prophylactic CSFD. Spinal cord injury (SCI) was graded as ambulatory (paraparesis) or non-ambulatory (paraplegia). Endpoints were any SCI, permanent paraplegia, response to rescue treatment, major drain-related complications, mortality, and patient survival.

Results: There were 22 Extent I, 240 Extent II and 279 Extent III TAAAs. Thirty-day mortality was 3%. SCI occurred in 45 patients (8%), paraparesis occurring in 23 (4%) and paraplegia in 22 patients (4%). SCI was more common in patients with Extent I-II compared to Extent III TAAAs (12% vs. 5%, P=0.01). Rescue treatment included permissive hypertension in all patients, with CSFD in 22 (4%). Symptom improvement was noted in 73%. Twelve patients (2%) had permanent paraplegia. Two patients (0.4%) had major drain-related complications. Independent predictors for SCI by multivariate logistic regression were sustained peri-operative hypotension (OR 4.4, 95% CI 1.7-11.1), patent collateral network (OR 0.3, 95% CI 0.1-0.6), and total length of aortic coverage (OR 1.05, CI 95% 1.01-1.10). Patient survival at 3-years was 72±3%.

Conclusion: FB-EVAR of Extent I-III TAAAs without CSFD has low mortality and low rates of permanent paraplegia (2%). SCI occurred in 8% of patients, and rescue treatment improved symptoms in 73% of them.
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http://dx.doi.org/10.1097/SLA.0000000000005653DOI Listing
August 2022

Outcomes of Low and Standard-Profile Fenestrated and Branched Stent-Grafts for Treatment of Complex Abdominal and Thoracoabdominal Aortic Aneurysms.

J Vasc Surg 2022 Jul 7. Epub 2022 Jul 7.

Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX. Electronic address:

Objectives: To compare outcomes of fenestrated-branched endovascular repair (FB-EVAR) using low-profile (LP) and standard-profile (SP) stent-grafts for treatment of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs).

Methods: We reviewed the clinical data of 466 consecutive patients (70% male; mean 74±8 years-old) enrolled in a prospective nonrandomized study to investigate FB-EVAR for treatment of CAAAs and TAAAs (2013-2021). Endpoints were compared in patients treated with LP (18-20F) and SP (20-22F) devices, including procedural metrics, access-related complications, major adverse events (MAE), patient survival, freedom from secondary intervention, thromboembolic events, stent-graft integrity issues, aneurysm sac enlargement, and rate of sac shrinkage.

Results: There were 138 CAAAs, 141 Extent IV and 187 Extent I-III TAAAs treated by FB-EVAR, with mean of 3.9±0.5 vessels/patient. LP devices were used in 239 patients (51%) and SP devices in 227 patients (49%). LP devices were used more frequently for chronic dissections (12%vs7%; P=.041), with preloaded systems (77%vs65%; P=.005) and bilateral percutaneous femoral access (83%vs74%; P=.020), and less frequently with upper extremity access (67%vs88%; P<.001) and with iliac conduits (2%vs6%; P=.020). Patients treated by LP devices had similar technical success (96%vs97%; P=.527), but lower total operating time (225±81 vs 243±78 min; P =.018), radiation exposure (median 0.93 and [interquartile range 0.94] vs 1.01 [0.91] Gy; P <.001) and use of contrast (135 [68] vs 144 [80] ml; P=.008). There was no difference in rates of iliofemoral access complications for patients with LP and SP devices (1.3%vs3.5%, P=.107). At 30-days, mortality and MAEs occurred in five (1%) and 89 patients (19%), with no differences between groups. Mean follow-up was 28 months (95% Confidence Interval 25-30 months). At 4-years, patients treated by LP devices had similar freedom from all-cause mortality (69%±6% vs 68%±4%; P=.199), freedom from aortic-related mortality (97%±1% vs 98%±1%; P=.488), freedom from any secondary intervention (65%±6% vs 70%±4%; P=.433), thromboembolic events (98±1% vs 99±1%; P=.364) and aneurysm sac enlargement (93%±3% vs 91±3%; P=.293), but lower freedom from any integrity-related issues (92±5% vs 100%; P<.001). Cumulative risk of sac shrinkage was higher in patients treated with LP devices with an adjusted Hazards Ratio of 2.040 (95%CI 1.516-2.744; P<.001).

Conclusions: FB-EVAR was performed with low rates of mortality and MAEs irrespective of device profile, but procedures performed with LP devices required lower need for iliac conduits and presented better procedural metrics. LP devices resulted in higher rates of sac shrinkage, however results on stent-graft integrity deserve future investigation.
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http://dx.doi.org/10.1016/j.jvs.2022.05.028DOI Listing
July 2022

Characterization of Secondary Interventions After Fenestrated-branched Endovascular Repair of Complex Aortic Aneurysms and Its Effect on Quality of Life and Patient Survival.

Ann Surg 2022 Jul 8. Epub 2022 Jul 8.

Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.

Objective: To assess the impact of secondary intervention (SI) on health-related quality of life (HR-QOL) after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms.

Background: The effect of SI after FB-EVAR on physical and mental HR-QOL has not been described.

Methods: A cohort of 430 consecutive patients enrolled in a prospective, nonrandomized study to evaluate FB-EVAR (2013-2020) was assessed with 1325 short-form 36 HR-QOL questionnaires preoperatively and during follow-up visits. SIs were classified as major or minor procedures. Endpoints included patient survival, freedom from aortic-related mortality (ARM), freedom from SIs, and changes in HR-QOL physical component score (PCS) and mental component score.

Results: There were 302 male with mean age 74±8 years treated by FB-EVAR for 133 complex abdominal aortic aneurysms and 297 thoracoabdominal aortic aneurysms. After a mean follow up of 26±20 months, 97 patients (23%) required 137 SIs. At 5 years, freedom from any SI was 64%±4%, including freedom from minor SIs of 77%±4% and major SIs of 87%±3%. There was no difference in patient survival and freedom from ARM at same interval. On adjusted analysis, minor SIs correlated with improved survival. SIs had a negative correlation with PCS (r=-0.8). There were no significant changes in mental component score with SIs. Predictors for SIs were fluoroscopy time, graft design, and aneurysm sac change.

Conclusion: SIs were needed in nearly 1 out of 4 patients treated by FB-EVAR with no effect on patient survival or ARM. SI resulted in decline in PCS.
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http://dx.doi.org/10.1097/SLA.0000000000005454DOI Listing
July 2022

Patency rates of hepatic arterial resection and revascularization in locally advanced pancreatic cancer.

HPB (Oxford) 2022 Jun 16. Epub 2022 Jun 16.

Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA. Electronic address:

Background: Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization.

Methods: We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed.

Results: HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p = 0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158.

Conclusion: CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.
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http://dx.doi.org/10.1016/j.hpb.2022.06.005DOI Listing
June 2022

Effect of patient frailty status on outcomes of fenestrated-branched endovascular aortic repair for complex abdominal and thoracoabdominal aortic aneurysms.

J Vasc Surg 2022 Jun 11. Epub 2022 Jun 11.

Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston, TX. Electronic address:

Objective: In the present study, we assessed the effects of patient frailty status on the early outcomes and late survival after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal and thoracoabdominal aortic aneurysms.

Methods: We retrospectively reviewed the clinical data and outcomes of consecutive patients who had undergone elective FB-EVAR from 2007 to 2019 in a single institution. A previously validated 11-item modified frailty index (mFI-11) was derived from the comorbidity and preoperative functional status data. An mFI-11 <0.3 was defined as low risk, 0.3 to 0.5 as medium risk, and >0.5 as high risk. The studied outcomes were 90-day mortality, major adverse events (MAE), and long-term survival. Multivariate analyses were performed to identify the independent predictors of these outcomes.

Results: A total of 592 patients (155 women, mean age, 75 ± 8 years) had undergone FB-EVAR. Using the mFI-11, 310 patients (52%) were included in the low-risk, 199 (34%) in the medium-risk, and 83 (14%) in the high-risk group. The 90-day mortality was significantly higher in the high-risk group than in the medium- and low-risk groups (13%, 4%, and 3%, respectively; P < .01). The corresponding MAE rates were 27%, 18%, and 19% (P = .23). As a subgroup, 44 patients in the high-risk group had had chronic kidney disease (CKD). The 90-day mortality for these patients was as high as 23%, and 32% had experienced MAE. On multivariable analysis, the independent risk factors for 90-day mortality were CKD, respiratory disease, and a high mFI-11. The independent risk factors for MAE were female sex, CKD, larger aneurysm diameter, and the high-risk subgroup with CKD. The independent risk factors for long-term mortality were age, a low body mass index, CKD, larger aneurysm diameter, extent I-III thoracoabdominal aortic aneurysm, respiratory disease, congestive heart failure, a history of cerebrovascular problems, and higher mFI-11. The estimated survival at 1 year was 91% ± 2% in the low-risk, 88% ± 2% in the medium-risk, and 78% ± 5% in the high-risk group (P < .001). The corresponding 5-year survival estimates were 60% ± 4%, 52% ± 5%, and 32% ± 6%. The mean follow-up time was 2.9 ± 2.3 years. The patients treated during the first quartile of the study period were significantly more frail than were those in the later quartiles. Also, the outcomes of FB-EVAR had improved over time.

Conclusions: Greater frailty was significantly associated with early mortality. Together with CKD, frailty was also associated with MAE and lower patient survival after FB-EVAR. The mFI-11 represents the accumulation of comorbidities and can be used to assist in better patient selection for FB-EVAR.
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http://dx.doi.org/10.1016/j.jvs.2022.05.008DOI Listing
June 2022

Outcomes of Unilateral Versus Bilateral Use of the Iliac Branch Endoprosthesis for Elective Endovascular Treatment of Aorto-iliac Aneurysms.

Cardiovasc Intervent Radiol 2022 Jul 2;45(7):939-949. Epub 2022 Jun 2.

Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.

Purpose: The aim of the study was to evaluate outcomes after bilateral implantation of the Gore Excluder Iliac Branch Endoprosthesis (IBE) versus those achieved after unilateral implantation.

Methods: All consecutive patients electively treated in a single center for aorto-iliac aneurysm using the IBE device between January 1, 2014, and December 31, 2018, were reviewed. Early outcome measures were technical success, 30 days or in-hospital mortality, and major adverse events (MAE). Late outcome measures were survival, internal iliac artery (IIA) patency, and freedom from IIA branch instability.

Results: A total of 74 patients (97% males, mean age 74 ± 7 years) were included. Thirteen patients (17%) received bilateral IBE implantation for a total of 85 vessels evaluated. The technical success rate was 97% and was not significantly different between the two groups (p = .32). Two patients died within 30 days, both in the unilateral group (p = 1). No significant differences were seen in the rates of 30 days MAE (p = .10). At one year, the overall survival rate was 95 ± 2% vs 90 ± 3% in the unilateral and bilateral group, respectively (Log-rank = .05). There were no differences in 1-year primary and secondary patency rates between groups (Log-rank = .75 and Log-rank = .34, respectively). Freedom from IIA branch instability at one year was also not significantly different (unilateral: 94 ± 3% vs. bilateral: 82 ± 9%, Log-rank = .22)..

Conclusions: Bilateral IBE use for elective endovascular treatment of aorto-iliac aneurysms appears safe and feasible and may achieve satisfactory short-term and mid-term outcomes. Bilateral IBE use should be employed judiciously in the context of a comprehensive risk/benefit evaluation.
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http://dx.doi.org/10.1007/s00270-022-03166-3DOI Listing
July 2022

Outcomes Following Urgent Fenestrated-Branched Endovascular Repair for Pararenal and Thoracoabdominal Aortic Aneurysms.

Ann Vasc Surg 2022 May 17. Epub 2022 May 17.

Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN. Electronic address:

Background: To evaluate outcomes following urgent or emergent fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAA) in patients who are considered high-risk for open repair.

Methods: A retrospective, single institution evaluation of outcomes following F-BEVAR of symptomatic, rapidly enlarging, or ruptured PRA or TAAA treated with physician modified endograft (PMEG) and company manufactured devices (CMD). Outcomes were technical success, 30-day morbidity and mortality, and 1 year aortic related outcomes.

Results: Thirty-two patients (23 male, mean age, 74 ± 9 years) underwent F-BEVAR using PMEG or CMD over a 12-year period. Fourteen patients underwent emergent repair for contained rupture and 18 patients underwent urgent repair for symptomatic, mycotic, or rapidly growing aneurysms. Aneurysm classification was PRA in 10 patients and TAAA in 22 (9 extent IV and 13 extent I-III). Twenty-three patients (72%) were repaired with PMEG and 8 patients (26%) with CMD. Technical success was 97% with a total of 98 renal-mesenteric arteries incorporated using 67 fenestrations (68%), 29 directional branches (29%), and 2 double-wide scallops (2%). A 30-day mortality was 6%, with 1 patient expiring from unclear causes after hospital discharge and the other from mesenteric ischemia. Mortality and major adverse events MAEs otherwise occurred in 16 patients (50%), including minor stroke in 3 patients, transient paraparesis and heart failure in 1 patient each, and early return to the operating room in 6 patients. Mean follow-up was 24 ± 22 months. At 1-year, overall survival, freedom from aortic-related mortality and freedom from secondary intervention were 70% ± 8%, 94% ± 3 and 83% ± 7, respectively.

Conclusions: Urgent F-BEVAR of selected patients with PRA and TAAA is a feasible and potentially safe treatment in patients with suitable anatomy, with low rates of early mortality and spinal cord complications. Long-term follow-up is needed to assess the durability of repair and device-related complications.
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http://dx.doi.org/10.1016/j.avsg.2022.05.003DOI Listing
May 2022

Safety of Percutaneous Femoral Access for Endovascular Aortic Aneurysm Repair Through Previously Surgically Exposed or Repaired Femoral Arteries.

J Endovasc Ther 2022 May 6:15266028221092980. Epub 2022 May 6.

Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Objective: Percutaneous femoral artery access is being increasingly used in endovascular aortic repair (EVAR). The technique can be challenging in patients with previously surgically exposed or repaired femoral arteries because of excessive scar tissue. However, a successful percutaneous approach may cause less morbidity than a "re-do" open femoral approach. The aim of this study was to assess the impact of prior open surgical femoral exposure on technical success and clinical outcomes of percutaneous approach.

Methods: This study retrospectively reviewed the clinical data of patients who underwent percutaneous EVAR between 2010 and 2020 at 2 major aortic centers. Patients were divided into 2 groups (with or without prior open surgical femoral access) for analysis of clinical outcomes. Only punctures with sheaths ≥12Fr were included for analysis. The access and (pre)closure techniques were similar in both institutions. Primary end points were intraoperative technical success, access-related revision, and access complications. A multivariate analysis was performed to identify determinants of conversion to open approach and femoral access complications in intact and re-do groins.

Results: A total of 632 patients underwent percutaneous (complex) EVAR: 98 had prior open surgical femoral access and 534 patients underwent de novo femoral percutaneous access. A total of 1099 femoral artery punctures were performed: 149 in re-do and 950 in intact groins. The extent of endovascular repair included 159 infrarenal, 82 thoracic, 368 fenestrated/branched, and 23 iliac branch devices. No significant differences were seen in technical success (re-do 93.3% vs intact 95.3%, p=0.311), access-related surgical revision (0.7% vs 0.6%, p=0.950), and access complications (2.7% vs 4.0%, p=0.443). For the whole group, significant predictors for access complications in multivariate analyses were main access site (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.07%-5.35%; p=0.033) and increase of the procedure time per hour (OR 1.65; 95% CI 1.34%-2.04%; p<0.001), while increase in sheath-vessel ratio had a protective effect (OR 0.33; 95% CI 0.127%-0.85%; p=0.021). Surgical conversion was predicted by main access site (OR 2.32; 95% CI 1.28%-4.19%; p=0.007) and calcification of 50% to 75% of the circumference of the access vessel (OR 3.29; 95% CI 1.38%-7.86%; p=0.005).

Conclusion: Within our population prior open surgical femoral artery exposure or repair had no negative impact on the technical success and clinical outcomes of percutaneous (complex) endovascular aortic aneurysm repair.
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http://dx.doi.org/10.1177/15266028221092980DOI Listing
May 2022

Effective treatment of type IIb endoleak via targeted translumbar embolization.

J Vasc Surg Cases Innov Tech 2022 Jun 11;8(2):232-236. Epub 2022 Mar 11.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.

After endovascular aneurysm repair, type II endoleaks are encountered frequently, and warrant intervention when associated with aneurysmal sac expansion. Thus, the contemporary vascular surgeon must be able to manage them. The presented case illustrates our approach to percutaneous translumbar selective coil embolization of individual lumbar arteries feeding the type IIb endoleak. The use of specific imaging systems allows for needle track guidance to access the endoleak pocket. Treatment of the feeding vessels with detachable coils can be achieved with a direct route via the translumbar sheath. The benefits of this approach include avoidance of graft puncture, targeted therapy, and low puncture-related complications.
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http://dx.doi.org/10.1016/j.jvscit.2022.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9046119PMC
June 2022

Thirty-year single-center experience with arterial thoracic outlet syndrome.

J Vasc Surg 2022 Aug 1;76(2):523-530. Epub 2022 Apr 1.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.

Objective: Arterial thoracic outlet syndrome (ATOS) is rare. We present our 30-year experience with the management of ATOS at a high-volume referral center.

Methods: A retrospective review of all patients who had undergone primary operative treatment for ATOS from 1988 to 2018 was performed. ATOS was defined as subclavian artery pathology caused by extrinsic compression from a bony abnormality within the thoracic outlet.

Results: A total of 41 patients (45 limbs) underwent surgery for ATOS at a median age of 46 years (interquartile range [IQR], 34-58 years). Chronic symptoms (>6 weeks) were present in 31 limbs (69%). Of the 45 limbs, 13 (29%) presented with acute limb ischemia (ALI), requiring urgent brachial artery thromboembolectomy (BAT) in 9 and catheter-directed thrombolysis and thrombectomy (CDT) in 4. All patients underwent thoracic outlet decompression. 31 limbs (69%) required subclavian artery reconstruction. No perioperative deaths and only one major adverse limb event occurred. Patients with ALI underwent staged thoracic outlet decompression after initial BAT or CDT at a median of 23 days (IQR, 11-140 days). Of the 13 limbs with an initial presentation of ALI, 8 (62%) had recurrent thromboembolic events before thoracic outlet decompression subsequently requiring 10 additional BATs and 1 CDT. The cumulative probability of recurrent embolization at 14, 30, and 90 days was 8.33% (95% confidence interval [CI], 1.28%-54.42%), 16.67% (95% CI, 4.70%-59.06%), and 33.33% (95% CI, 14.98-74.20%), respectively. The median follow-up for 32 patients (35 limbs) was 13 months (IQR, 5-36 months). Subclavian artery/graft primary and secondary patency was 87% and 90%, respectively, at 5 years by Kaplan-Meier analysis. Of the 35 limbs, 5 (14%) had chronic upper extremity pain and 5 (14%) had persistent weakness. Preoperative forearm or hand pain and brachial artery occlusion were associated with chronic pain (P = .04 and P = .03) and weakness (P = .03 and P = .02). Of the 13 limbs that presented with ALI, 11 had a median follow-up after thoracic outlet decompression of 6 months (IQR, 5-14 months), including 9 (82%) with oral anticoagulation therapy. Anticoagulation therapy had no effect on subclavian artery patency (P = 1.0) or the presence of chronic symptoms (P = .93).

Conclusions: The presentation of ATOS is diverse, and the diagnosis can be delayed. Preoperative upper extremity pain and brachial artery occlusion in the setting of ALI were associated with chronic pain and weakness after thoracic outlet decompression. Delayed thoracic outlet decompression was associated with an increased risk of recurrent thromboembolic events for patients who presented with ALI. An early and accurate diagnosis of ATOS is necessary to reduce morbidity and optimize outcomes.
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http://dx.doi.org/10.1016/j.jvs.2022.03.870DOI Listing
August 2022

Aneurysms of the superior mesenteric artery and its branches.

J Vasc Surg 2022 07 8;76(1):149-157. Epub 2022 Mar 8.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.

Objective: Aneurysms of the superior mesenteric artery (SMA) and its branches are rare and account for only 6% to 15% of all visceral artery aneurysms. In the present report, we have described our 30-year experience with the management of aneurysms of the SMA and its branches at a high-volume referral center.

Methods: A retrospective review of all patients with a diagnosis of an aneurysm of the SMA or one of its branches from 1988 to 2018 was performed. Pseudoaneurysms and mycotic aneurysms were excluded. The clinical presentation, etiology, aneurysm shape and size, treatment modalities, and outcomes were analyzed. The growth rate of the aneurysms was estimated using linear regression.

Results: A total of 131 patients with 144 aneurysms were reviewed. The patients were primarily men (64%), with a median age of 60 years. Of the 144 aneurysms, 57 were fusiform, 30 were saccular, and 57 were dissection-associated aneurysms. Of the 131 patients, 41 had had an isolated SMA branch aneurysm. Degenerative aneurysms were the most common etiology (66%). A total of 35 patients (27%) were symptomatic at presentation. Of the 144 aneurysms, 111 had multiple computed tomography angiograms available, with a median follow-up of 43.6 months (interquartile range, 10.6-87.2 months). Only 18 aneurysms (16%) had had an estimated growth rate of ≥1.0 mm/y. The initial aneurysm size was significantly associated with the growth rate for the fusiform aneurysms (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.0-1.3]; P = .02) but not for the saccular (OR, 0.91; 95% CI, 0.76-1.1; P = 1.1) or dissection-associated (OR, 1.2; 95% CI, 0.91-1.5; P = .20) aneurysms. Acute abdominal pain (OR, 5.9; 95% CI, 1.6-22; P = .01) and chronic abdominal pain (OR, 3.7; 95% CI, 1.1-13; P = .04) were associated with aneurysm growth. Only two patients had a ruptured aneurysm, both of whom presented with rupture with no prior imaging studies. These two patients had a diagnosis of fibromuscular dysplasia and systemic lupus erythematosus, respectively. Of the 131 patients, 46 (34%) had undergone operative repair, including 36 open revascularizations and 8 endovascular procedures. The average aneurysm size for these 46 patients was 24.0 ± 8.6 mm. One patient died perioperatively, and nine patients experienced perioperative complications (25%). Of the 144 aneurysms, 91 were <20 mm, with an average size of 13.4 ± 3.1 mm. These 91 aneurysms had been followed up for a median of 120.8 months (interquartile range, 30.5-232.2 months), with no ruptures within this cohort during the follow-up period.

Conclusions: The present study represents one of the largest series on aneurysms of the SMA and its branches. Our results showed that aneurysms of the SMA are relatively stable. Patients with symptomatic and fusiform aneurysms had a greater risk of growth. Aneurysms <20 mm with a degenerative etiology can be safely monitored without treatment.
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http://dx.doi.org/10.1016/j.jvs.2022.02.047DOI Listing
July 2022

Impact of gap distance between fenestration and aortic wall on target artery instability following fenestrated-branched endovascular aortic repair.

J Vasc Surg 2022 07 16;76(1):79-87.e4. Epub 2022 Feb 16.

Division of Vascular and Endovascular Surgery, Advanced Aortic Research Program, Department of Cardiothoracic and Vascular Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Tex. Electronic address:

Objective: Target artery (TA) instability has been the most frequent indication for secondary intervention after fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms (TAAAs). The aim of the present study was to evaluate the effect of the gap distance between the endograft reinforced fenestration and TA origin at the aortic wall (fenestration gap [FG]) on target-related outcomes after FB-EVAR.

Methods: The clinical data and imaging studies of 430 patients enrolled in a prospective, nonrandomized study to evaluate FB-EVAR using manufactured stent grafts were reviewed. Of the 430 patients, 340 (79%) had had more than one vessel incorporated by fenestration. The FG was retrospectively measured on postoperative imaging studies and classified into three groups: no gap (FG, 0 mm), FG 1 to 4 mm, and FG ≥5 mm. The primary outcome was freedom from TA instability. The secondary end points included TA-related endoleak, TA secondary intervention, and TA patency.

Results: A total of 1558 renal-mesenteric TAs were incorporated by 1104 reinforced fenestrations and 454 directional branches (DBs), with a mean of 3.9 ± 0.5 vessels per patient. The mean FG was 2.8 ± 4.5 mm, with an FG of 0 mm for 646 TAs, 1 to 4 mm for 209 TAs, and ≥5 mm for 249 TAs. An FG of ≥5 mm was associated with significantly lower (P < .001) freedom from TA instability, type Ic or IIIc endoleak, and secondary interventions at 5 years. Compared with DBs, fenestrations with an FG of ≥5 mm had similar primary patency and freedom from TA instability but significantly lower freedom from type Ic or IIIc endoleak (91% ± 2% vs 95% ± 1%; log rank, P = .02) and secondary interventions (87% ± 3% vs 93% ± 2%; log-rank, P = .02) at 5 years. The independent predictors of TA instability included postdissection TAAAs (hazard ratio, 2.5; 95% confidence interval, 1.2-5.4) and FG ≥5 mm (hazard ratio, 1.6; 95% confidence interval, 1.2-1.8). TAs incorporated by reinforced fenestrations had higher primary (99% ± 0.8% vs 97% ± 1.0%; P = .039) and secondary (100% vs 98% ± 1.0%; P = .012) patency rates at 5 years compared with DBs, with the lowest primary patency observed for renal DBs (80% ± 6% vs 92% ± 2%; P = .008).

Conclusions: An FG of ≥5 mm was independently associated with an increased risk of TA instability, type Ic or IIIc endoleaks, and secondary interventions for patients treated by FB-EVAR using fenestrated designs. TAs incorporated by DBs had lower 5-year primary and secondary patency compared with those with reinforced fenestrations, with the lowest 5-year patency of 80% for renal branches. Compared with DBs, fenestrations with an FG of ≥5 mm carried a greater risk of type Ic or IIIc endoleak and secondary interventions. Independent predictors of TA instability included postdissection TAAAs and a greater FG. In contrast, dual antiplatelet therapy and larger TA diameters were protective.
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http://dx.doi.org/10.1016/j.jvs.2022.01.135DOI Listing
July 2022

Asymptomatic right internal carotid artery pseudoaneurysm and Eagle's syndrome.

J Vasc Surg 2022 02;75(2):695-696

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

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http://dx.doi.org/10.1016/j.jvs.2021.02.016DOI Listing
February 2022

Incidence, predictive factors, and outcomes of intraprocedure adverse events during fenestrated-branched endovascular aortic repair of complex abdominal and thoracoabdominal aortic aneurysms.

J Vasc Surg 2022 03 3;75(3):783-793.e4. Epub 2021 Nov 3.

Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex. Electronic address:

Objective: To evaluate the incidence of intraoperative adverse events (IAEs) and their impact on outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysm (TAAAs).

Methods: We reviewed the clinical and imaging data of 600 consecutive patients (445 males; mean age, 75 ± 8 years) who underwent FB-EVAR between 2007 and 2019 in a single institution. IAE was defined as any intraoperative complication or technical problem requiring additional and unplanned procedures, and was classified as access-related, target artery (TA)-related, or graft-related. End points included rates of IAEs, 30-day or in-hospital mortality, major adverse events, patient survival, freedom from secondary intervention, and TA instability.

Results: A total of 122 IAEs were identified in 105 patients (18%). IAEs were TA-related in 55 patients (9%), access-related in 46 patients (8%), and graft-related in seven patients (1%). Female sex was more frequent among patients with IAEs (44% vs 22%; P < .001). Patients with IAEs had smaller renal artery diameter (-0.4 mm, 5.4 ± 0.8 mm vs 5.8 ± 0.9 mm; P < .001), and were treated more often for TAAAs (72% vs 54%; P < .03). Technical success was achieved in 96.5% of patients and was lower for patients with IAEs (82% vs 99%; P < .001). Major adverse events were significantly more frequent among patients who had IAEs (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.21-3.25), most due to acute kidney injury (27% vs 11%; P < .001) including new-onset dialysis (5% vs 1%; P = .01). On multivariate logistic regression model, female sex (OR, 2.5; 95% CI, 1.5-4.0), TA stenosis >50% (OR, 2.0; 95% CI, 1.3-3.3), and Crawford Extent II TAAA (OR, 1.9; 95% CI, 1.1-3.3) were predictive of IAEs, whereas preloaded design (OR, 0.6; 95% CI, 0.4-0.9) and TA diameter (+1 mm; OR, 0.6; 95% CI, 0.4-0.9) were protective of IAEs. IAEs negatively affected secondary intervention (hazard ratio [HR], 1.6; 95% CI, 1.1-2.3) and TA instability (HR, 2.5; 95% CI, 1.2-5.4); however, IAEs did not affect patient survival (HR, 1.0; 95% CI, 0.7-1.4).

Conclusions: IAEs are common, occurring in nearly one of five patients treated with FB-EVAR for complex aortic aneurysms, and have a negative impact on clinical outcomes. IAEs were associated with female sex, TA diameter, and more extensive aortic disease.
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http://dx.doi.org/10.1016/j.jvs.2021.10.026DOI Listing
March 2022

Outcomes of balloon-expandable versus self-expandable stent graft for endovascular repair of iliac aneurysms using iliac branch endoprosthesis.

J Vasc Surg 2022 05 22;75(5):1616-1623.e2. Epub 2021 Oct 22.

The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex. Electronic address:

Purpose: The purpose of this study was to compare outcomes of internal iliac artery (IIA) stenting using balloon-expandable (BESG) or self-expandable stent grafts (SESG) during endovascular repair of aortoiliac aneurysms with iliac branch endoprosthesis (IBE; W. L. Gore, Flagstaff, Ariz).

Methods: We retrospectively reviewed all consecutive patients treated for aortoiliac aneurysms using IBE between 2014 and 2020. IIA stenting was performed using either the IIA side branch SESG or a Gore VBX BESG (W. L. Gore). Indications for use of BESGs were "up-and-over" IBE technique for type IB endoleak after prior endovascular aortic aneurysm repair (EVAR), short IIA length, and need for IIA extension into divisional branches (outside instructions for use). End points included technical success, freedom from buttock claudication, primary IIA patency, and freedom from IIA branch instability (eg, branch-related death or rupture, occlusion, disconnection, or reintervention for stenosis, kink, or endoleak), freedom from type IC/IIIC endoleak, and freedom from secondary interventions.

Results: There were 90 patients (86 males and 4 females) with a mean age of 74 ± 7 years treated by EVAR with 108 IBEs. Choice of stent was BESG in 43 and SESG in 65 targeted IIAs. BESGs were used more frequently in patients with prior EVAR (22% vs 2%; P = .003,), isolated IBEs (31% vs 2%; P < .001), and in patients with IIA aneurysms requiring stenting into divisional branches (36% vs 5%; P < .001). Technical success was similar for BESGs and SESGs (97% vs 100%; P = .40), respectively. The mean follow-up was 25 ± 16 months (range, 11-34 months). At 2 years, freedom from buttock claudication was 100% for BESG and 95 ± 3% for SESG (Log-rank 0.26), with no difference in primary patency (BESG, 100% vs SESG, 94 ± 4%; Log-rank 0.94). There were four (9%) IIA-related endoleaks in the BESG group and one (2%) in the SESG group (P = .08). Freedom from IIA branch instability was 87 ± 6% for BESG and 96 ± 3% for SESG at 2 years (Log-rank 0.043). Freedom from type IC/IIIC endoleak was 87 ± 7% for BESG and 98 ± 2% for SESG at the same interval (Log-rank 0.06). There was no difference in freedom from reinterventions for BESG and SESG (92 ± 6% vs 98 ± 2%; Log-rank 0.34), respectively.

Conclusions: BESGs were used more frequently during IBE procedures indicated for failed EVAR, isolated common iliac aneurysms, and IIA aneurysms requiring extension into divisional branches. Despite these differences and BESG being used outside instructions for use, both stent types had similar primary patency, freedom from buttock claudication, and freedom from reinterventions. However, BESGs were associated with higher rates of IIA-related branch instability.
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http://dx.doi.org/10.1016/j.jvs.2021.10.022DOI Listing
May 2022

Surgical and reconstructive outcomes in primary venous leiomyosarcoma.

J Vasc Surg Venous Lymphat Disord 2022 07 2;10(4):901-907. Epub 2021 Aug 2.

Division of Vascular Surgery, Mayo Clinic Rochester, Rochester, Minn.

Objective: Primary venous leiomyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL.

Methods: A retrospective review was performed of patients who had resection of PVL at three centers between 1990 and 2018. Patient demographics, comorbidities, intraoperative data, survival, and graft-related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

Results: Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the inferior vena cava (IVC) and 16 (23%) had peripheral PVL. The mean follow-up for the series was 55.0 months (range, 1-217 months). Fifty-one patients (96%) with IVC-PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within 30 days of surgery. Five patients (9%) required early reintervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within 30 days. Five-year survival was 57.5% for IVC-PVL and 70.0% for peripheral PVL. Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (P = .624) at 5 years.

Conclusions: PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions, suggesting that aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long-term outcomes.
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http://dx.doi.org/10.1016/j.jvsv.2021.07.010DOI Listing
July 2022

Midterm Outcomes of a Prospective, Nonrandomized Study to Evaluate Endovascular Repair of Complex Aortic Aneurysms Using Fenestrated-Branched Endografts.

Ann Surg 2021 09;274(3):491-499

Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.

Objective: The aim of this study was to investigate the midterm outcomes of fenestrated and branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs).

Summary Background Data: FB-EVAR has been associated with decreased morbidity compared to open repair, but there is limited midterm data.

Methods: A total of 430 patients (302 males, mean age 74 ± 8 years) treated by FB-EVAR were enrolled in a prospective, nonrandomized investigational device exemption study. Endpoints included 30-day mortality and major adverse events (MAEs), freedom from all cause and aortic-related mortality, target vessel patency, and freedom from secondary intervention and target vessel instability.

Results: There were 133 PRAs and 297 TAAAs with 1673 renal-mesenteric arteries incorporated by fenestrations or directional branches (3.9 ± 0.5 vessels/patient). At 30 days or within the hospital stay if longer than 30 days, there were 4 (0.9%) deaths. MAEs included new-onset dialysis in 8 patients (2%), permanent paraplegia or stroke in 10 patients each (2%), and respiratory failure requiring tracheostomy in 2 patients (0.5%). After a mean follow-up of 26 ± 20 months, there were 3 (0.7%) aortic-related deaths from SMA stent occlusion, gastrointestinal hemorrhage, or complications of open arch repair. At 5 years, freedom from all-cause and aortic-related mortality were 57% ± 5% and 98% ± 1%, respectively. Freedom from secondary intervention was 64% ± 4%, primary target vessel patency was 94% ± 1%, and freedom from target vessel instability was 89% ± 2% at same interval. One patient (0.2%) had nonfatal aneurysm treated using endovascular repair.

Conclusion: FB-EVAR is safe and effective for treatment of PRA and TAAAs with low rate of aortic-related mortality and aneurysm rupture on midterm follow-up.
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http://dx.doi.org/10.1097/SLA.0000000000004982DOI Listing
September 2021

Differences in procedural metrics and clinical outcomes among patients treated by fenestrated-branched endovascular repair of thoracoabdominal aortic aneurysms using infrarenal aortic versus iliac sealing zones.

J Vasc Surg 2021 11 18;74(5):1464-1471.e3. Epub 2021 May 18.

McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Tex. Electronic address:

Objective: The purpose of the present study was to assess the outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using infrarenal aortic vs iliac sealing zones.

Methods: We reviewed the clinical data of 430 consecutive patients enrolled in a prospective nonrandomized study to evaluate FB-EVAR from 2013 to 2020. The outcomes were analyzed for patients with extent I to IV thoracoabdominal aortic aneurysms who had undergone FB-EVAR with distal implantation in the native infrarenal aorta. The minimum anatomic criteria for the use of infrarenal aortic seal was a >3-cm length of parallel aorta with a diameter of 18 to 32 mm without excessive thrombus or calcification. A control group matched for the extent of aortic disease with an iliac artery seal was used to compare the following endpoints: 30-day mortality, major adverse events, freedom from type Ib endoleak (TIbE), freedom from secondary interventions, and changes in the infrarenal aortic diameter.

Results: A total of 110 patients (55 men; mean age, 73 ± 8 years) were included in the present study, 55 with an infrarenal aortic distal seal and 55 with the iliac arteries as the sealing zone. Both groups had similar clinical characteristics and aneurysm extent and diameter, except for a greater number of men and higher serum creatinine in the iliac seal group. Technical success was obtained in 106 patients (96%) and was greater for the iliac sealing zone group (100% vs 93%; P = .04). The use of the infrarenal aortic sealing zone was associated with shorter endovascular (148 ± 56 minutes vs 191 ± 61 minutes; P < .001) and fluoroscopy (76 ± 28 minutes vs 96 ± 32 minutes; P < .001) times and lower radiation exposure (cumulative air kerma, 1.4 ± 1.4 Gy vs 2.1 ± 2.0 Gy; P = .02; dose area product, 147 ± 75 Gy ∙ cm vs 208 ± 102 Gy ∙ cm; P = .006). One patient had died (1%) within 30 days. No differences were found in the major adverse events among the patients treated with infrarenal aortic vs iliac sealing zones (22% vs 18%; P = .63), including any spinal cord injury (13% vs 9%; P = .54) and grade 3 spinal cord injury (7% vs 7%; P = 1.0). The mean clinical follow-up was 24 ± 18 months. TIbE occurred in one patient in each group (P = 1.0). The 3-year freedom from TIbE and freedom from secondary intervention rate was 98% ± 2% and 67% ± 8% for the infrarenal aortic seal group and 97% ± 3% and 67% ± 8% for the iliac seal group, respectively (P = NS). Among the patients treated with infrarenal aortic sealing zones, the mean enlargement of the infrarenal aortic diameter was 5 ± 3.2 mm at 3 years. No late TIbE due to disease progression had developed in the infrarenal aorta.

Conclusions: Infrarenal aortic and iliac artery seal zones are safe and effective during FB-EVAR, provided the patients have suitable segments. The use of the infrarenal aortic sealing zone had modest procedural advantages such as shorter endovascular and fluoroscopy times and lower radiation exposure. No differences were found in the clinical outcomes or development of TIbEs.
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http://dx.doi.org/10.1016/j.jvs.2021.04.048DOI Listing
November 2021

Long-term fate of aortic branches in patients with aortic dissection.

J Vasc Surg 2021 08 14;74(2):537-546.e2. Epub 2021 Feb 14.

Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

Objective: Late morbidity and mortality related to aortic branches in patients with aortic dissection (AD) have not been well described. We investigated the fate of aortic branches in a population cohort of patients with newly diagnosed AD.

Methods: We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents with a diagnosis of AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging studies were included in the present analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). The secondary outcome was the diameter change in the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify the predictors of branch-related events. Univariate and multivariate linear regression models were used to assess the aortic branch growth rate.

Results: Of 77 total incident AD cases, 58 patients who had survived and had imaging follow-up studies available were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 patients (67%), 6 (10%) of whom had had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) had arisen from the true lumen, 33 (19%) from the false lumen, and 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95% confidence interval [CI], 32%-70%). A total of 31 branch-related events had occurred in 19 patients within 15 years, including 12 interventions (76% freedom; 95% CI, 63%-92%), 10 aneurysms (67% freedom; 95% CI, 50%-90%), 8 cases of malperfusion (76% freedom; 95% CI, 61%-94%), and 1 rupture (94% freedom; 95% CI, 84%-100%). No branch-related deaths had occurred. Type B AD (hazard ratio [HR], 3.5; 95% CI, 1.1-10.8; P = .033), patency of the aortic false lumen (HR, 6.8; 95% CI, 1.1-42.2; P = .038), and malperfusion syndrome at presentation (HR, 6.0; 95% CI, 1.3-28.6; P = .023) were predictors of late aortic branch-related events. The overall growth rate of aortic branches was 1.3 ± 3.0 mm annually. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase.

Conclusions: In patients with AD, aortic branch involvement was responsible for significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, and malperfusion syndrome at presentation resulted in a greater risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, especially in the case of a patent aortic false lumen or the presence of Marfan syndrome.
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http://dx.doi.org/10.1016/j.jvs.2021.01.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316268PMC
August 2021

Effect of aortic angulation on the outcomes of fenestrated-branched endovascular aortic repair.

J Vasc Surg 2021 08 4;74(2):372-382.e3. Epub 2021 Feb 4.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

Objective: To investigate the effect of aortic angulation on the early and midterm outcomes of fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms (PRAA).

Methods: We retrospectively reviewed the data of consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study (2013-2018). The infrarenal, suprarenal, and supraceliac aortic angles were measured on three-dimensional reconstructions of the preoperative computed tomography angiogram; a 45° cutoff was used for the analysis. End points were technical success, freedom from endograft-related complications (defined by type IA/IB/IIIA/IIIB/IIID endoleaks, and limb thrombosis); and freedom from target vessel instability (defined by branch-related death, occlusion, rupture or reintervention for stenosis, endoleak, or disconnection). Cox proportional hazard multivariable regression analyses were preformed to assess impact of covariates.

Results: There were 298 patients treated for 102 PRAAs (34%) and 196 TAAAs (66%) (78 extent IV, 118 extent I-III) with 1156 renal-mesenteric vessels incorporated. An angulation of >45° was present in the infrarenal aortic axis in 94 patients (32%), suprarenal axis in 39 (13%), and supraceliac axis in 93 (31%). A supraceliac angle of >45° was more common with extent I-III TAAAs (P = .01). Technical success was 97% and was not significantly related to aortic angulation; the total operating time and fluoroscopy time were significantly longer in patients with any aortic angulation of >45°. Freedom from endograft-related complications was 93% (95% confidence interval [CI], 90%-97%) at 42 months, and was not associated with infrarenal (HR, 1.0; 95% CI, 0.4-2.9; P = .976), suprarenal (HR, 1.7; 95% CI, 0.5-1.8; P = .428), or supraceliac (HR, 0.9; 95% CI, 0.3-2.6; P = .886) aortic angles of >45°. Overall freedom from target vessel instability was 92% (95% CI, 90%-94%) at 42 months. By multivariable analysis, target vessel instability was not affected by an infrarenal angle of >45° (HR, 1.5; 95% CI, 0.9-2.4; P = .135) and a supraceliac angle of >45° (HR, 0.9; 95% CI, 0.5-1.5; P = .627), but was associated with a suprarenal angle of >45° (HR, 5.6; 95% CI, 3.5-9.1; P < .001), even after adjustment for aneurysm extent and type of bridging stent. In this subgroup of patients, the use of directional branch vs fenestration (P = .10) and the type of bridging stent (P = .10) did not significantly impact target vessel instability.

Conclusions: Fenestrated-branched endovascular aneurysm repair can achieve excellent early and midterm results among patients with an aortic angulation of >45°, with no increase in rates of graft-related complications. However, increased aortic angulation was associated with longer operative and fluoroscopy times. The suprarenal aortic angle was the most important determinant of more target vessel events, independent of stent design or which bridging stent was selected.
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http://dx.doi.org/10.1016/j.jvs.2021.01.027DOI Listing
August 2021

Prospective Assessment of a Protocol Using Neuromonitoring, Early Limb Reperfusion, and Selective Temporary Aneurysm Sac Perfusion to Prevent Spinal Cord Injury During Fenestrated-branched Endovascular Aortic Repair.

Ann Surg 2021 Jan 7;Publish Ahead of Print. Epub 2021 Jan 7.

Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Texas Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota Department of Vascular Surgery, Cardiovascular Center, Semmelweis University, Budapest, Hungary Department of Neurology, Mayo Clinic, Rochester, Minnesota.

Objective: The aim of this study was to analyze the outcomes of a standardized protocol using routine CSFD, neuromonitoring, LL reperfusion, and selective TASP to prevent SCI during F-BEVAR.

Background: SCI is to be the most devastating complication for the patient, family, and surgeon, with impact on patient's quality of life and long-term prognosis. An optimal standardized protocol may be used to improve outcomes.

Methods: Patients enrolled in a prospective, nonrandomized single-center study between 2013 and 2018. A SCI prevention protocol was used for TAAAs or complex abdominal aneurysms with ≥5-cm supraceliac coverage including CSFD, neuromonitoring, LL reperfusion, and selective TASP. End-points included mortality and rates of SCI.

Results: SCI prevention protocol was used in 170 of 232 patients (73%) treated by F-BEVAR. Ninety-one patients (55%) had changes in neuromonitoring, which improved with maneuvers in all except for 9 patients (10%) who had TASP. There was one 30-day or in-hospital mortality (0.4%). Ten patients (4%) developed SCIs including in 1% (1/79) of patients with normal neuromonitoring and 10% (9/91) of those who had decline in neuromonitoring (P = 0.02). Permanent paraplegia occurred in 2 patients (1%). Factors associated with SCI included total operating time (odds ratio 1.5, 95% confidence interval 1.1-2.2, P = 0.02) and persistent changes in neuromonitoring requiring TASP (odds ratio 15.7, 95% confidence interval 2.9-86.2, P = 0.001).

Conclusion: This prospective nonrandomized study using a standardized strategy to prevent SCI was associated with low incidence of the SCI during F-BEVAR. Permanent paraplegia occurred in 1%.
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http://dx.doi.org/10.1097/SLA.0000000000004624DOI Listing
January 2021

Intraoperative posture and workload assessment in vascular surgery.

Appl Ergon 2021 Apr 21;92:103344. Epub 2020 Dec 21.

Department of Industrial and Manufacturing Systems Engineering, Iowa State University, Ames, IA, USA; Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA; Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Department of Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.
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http://dx.doi.org/10.1016/j.apergo.2020.103344DOI Listing
April 2021

Effect of renal function on patient survival after endovascular thoracoabdominal and pararenal aortic aneurysm repair.

J Vasc Surg 2021 07 16;74(1):13-19. Epub 2020 Dec 16.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

Background: Renal dysfunction can be a prohibitive risk for open repair of complex thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PRAAs). However, the effect of renal dysfunction from fenestrated and branched endovascular aneurysm repair (FB-EVAR) on outcomes is poorly defined. Our objective was to review the association of renal function on patient survival after FB-EVAR.

Methods: The present study reviewed the clinical data of consecutive patients enrolled in a prospective nonrandomized study to investigate FB-EVAR for PRAAs and TAAAs at a single institution with 1 year of follow-up (2013-2017). The patients were categorized by preoperative chronic kidney disease (CKD) classification, and the early- and long-term mortality was assessed.

Results: During the study period, 231 patients had undergone FB-EVAR for 80 PRAAs, 89 type I-III TAAAs, and 62 type IV TAAAs. The mean age was 74.6 ± 6.7 years, and 71% were men. Of the 231 patients, 126 had had CKD stage 1-2, 96 CKD stage 3, and 9 CKD stage 4-5 (all with baseline creatinine >2.0 mg/dL). Patients with CKD stage 4-5 had demographic data similar to those with normal renal function but had had slightly larger aneurysms (6.5 vs 7 cm; P = .15). The 30-day mortality was 0.5% (n = 1) for those with CKD 1-3 vs 0% for those with CKD 4-5 (P = .73). The 1- and 3-year survival analysis showed no major hazards (95% vs 88% and 84% vs 75%, respectively; log-rank P = .98) between the CKD 1-3 and CKD 4-5 groups. The median follow-up period was 2.6 years (interquartile range, 1.5-3.7 years). Two patients with CKD 4-5 had died during the follow-up period.

Conclusions: Although a small sample size for evaluation, selected patients with CKD 4-5 might have similar short- and long-term mortality compared with those with normal to moderate renal dysfunction after FB-EVAR. Although a major contraindication for open repair, renal dysfunction might not be as prohibitive for endovascular repair in well-selected patients.
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http://dx.doi.org/10.1016/j.jvs.2020.11.040DOI Listing
July 2021

Staged total arch replacement, followed by fenestrated-branched endovascular aortic repair, for patients with mega aortic syndrome.

J Vasc Surg 2021 05 13;73(5):1488-1497.e1. Epub 2020 Nov 13.

Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex. Electronic address:

Objective: The aim of the present study was to review the clinical outcomes of a staged approach using total arch replacement (TAR) with an elephant trunk or a frozen elephant trunk, followed by fenestrated-branched endovascular aortic repair (F-BEVAR) for patients with mega aortic syndrome.

Methods: We reviewed the clinical data and outcomes of 11 consecutive patients (8 men; mean age, 71 ± 7 years) treated by staged TAR and F-BEVAR from January 2014 to December 2018. The F-BEVAR procedures were performed under a prospective, nonrandomized, physician-sponsored investigational device exemption protocol. All patients had had mega aortic syndrome, defined by an ascending aorta, arch, and extent I-II thoracoabdominal aortic aneurysm. The endpoints were 30-day mortality, major adverse events (MAE), patient survival, freedom from reintervention, and freedom from target vessel instability.

Results: Of the 11 patients, 6 had developed chronic postdissection aneurysms after previous Stanford A (three A, two A, one A) dissection repair and 5 had had degenerative aneurysms with no suitable landing zone in the aortic arch. The thoracoabdominal aortic aneurysms were classified as extent I in four patients and extent II in seven. One patient had died within 30 days after TAR (9.0%). However, none of the remaining 10 patients who had undergone F-BEVAR had died. First-stage TAR resulted in MAE in three patients (27%), including one spinal cord injury. The mean length of stay was 12 ± 6 days. The mean interval between TAR and F-BEVAR was 245 ± 138 days with no aneurysm rupture during the interval. Second-stage F-BEVAR was associated with MAE in two patients (20%), including spinal cord injury in one patient from spinal hematoma due to placement of a cerebrospinal fluid drain. The mean follow-up period was 14 ± 10 months. At 2 years postoperatively, patient survival, primary patency, secondary patency, and freedom from renal-mesenteric target vessel instability was 80% ± 9%, 94% ± 6%, 100%, and 86% ± 8%, respectively. No aortic-related deaths occurred during the follow-up period. Four patients had required reintervention, all performed using an endovascular approach.

Conclusions: A staged approach to treatment of mega aortic syndrome using TAR and F-BEVAR is a feasible alternative for selected high-risk patients. Larger clinical experience and longer follow-up are needed.
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http://dx.doi.org/10.1016/j.jvs.2020.09.031DOI Listing
May 2021

Endovascular Arch Repair Using Inner Branch Stent-Graft With Transapical Access.

Ann Thorac Surg 2021 05 27;111(5):e323-e327. Epub 2020 Oct 27.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota.

Endovascular repair of aortic arch aneurysms has been considered in higher risk patients who are not ideally suited for open surgical or hybrid repair. A limitation of these devices is the 8- to 12-week delay for manufacturing, which does not allow treatment of symptomatic or rapidly expanding aneurysms. This report illustrates an urgent endovascular repair of an aortic arch aneurysm using a physician-modified endograft with 2 inner branches. Transapical access allowed better support and precision during device deployment, which was needed given the short proximal landing zone.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.089DOI Listing
May 2021

Comparison of Cerebral Embolic Events Between Right and Left Upper Extremity Access During Fenestrated/Branched Endovascular Aortic Repair.

J Endovasc Ther 2021 Feb 31;28(1):70-77. Epub 2020 Aug 31.

Advanced Aortic Research Program, University of Texas Health Science at Houston, McGovern Medical School, Houston, TX, USA.

Purpose: To evaluate the incidence and outcomes of cerebral embolic events when using right (RUE) vs left upper extremity (LUE) access for fenestrated/branched endovascular aneurysm repair (f/bEVAR).

Materials And Methods: A retrospective review was conducted of 290 consecutive patients enrolled in a physician-sponsored Investigational Device Exemption study to evaluate f/bEVAR between 2013 and 2018. Of these, 270 patients (93%) had an upper extremity access with 12-F sheaths, including 205 patients (mean age 75±8 years; 147 men) with LUE and 65 patients (mean age 73±8 years; 42 men) with RUE access. Outcome measures were technical success, procedural metrics, major adverse events (MAEs), any stroke or transient ischemic attack (TIA), and mortality.

Results: Technical success was higher (p=0.04) for LUE (99.6%) vs RUE access (98.4%). Patients treated via RUE access more often had extent I-III thoracoabdominal aortic aneurysms (57% vs 39%, p=0.03). Procedural metrics were similar for LUE vs RUE sides, including endovascular time (255±80 vs 246±83 minutes, respectively; p=0.23), fluoroscopy time (84±32 vs 90±35 minutes, respectively; p=0.80), and contrast volume (156±57 vs 153±56 mL, respectively; p=0.82). Total radiation exposure was significantly higher for LUE vs RUE access (2463±1912 vs 1757±1494 mGy, respectively; p=0.02). There were 2 deaths (1%) at 30 days or during hospital admission, both unrelated to access site complications. MAEs occurred in 32% of patients who had LUE and 26% of those who had RUE access (p=0.44). Five patients (2%) had embolic stroke and none had TIA. Embolic strokes were ipsilateral to the access side in 4 patients and affected the posterior circulation in 3. Two patients (1%) had hemorrhagic strokes. The incidence of stroke was 3% for LUE and 2% for RUE access (p>0.99).

Conclusion: Fenestrated/branched stent-graft repair was associated with low rates of cerebral embolic events and no significant difference between the right vs left upper extremity approach.
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http://dx.doi.org/10.1177/1526602820953511DOI Listing
February 2021

Effect of Blood Loss and Transfusion Requirements on Clinical Outcomes of Fenestrated-Branched Endovascular Aortic Repair.

Cardiovasc Intervent Radiol 2020 Nov 30;43(11):1600-1607. Epub 2020 Aug 30.

Advanced Aortic Research Program, University of Texas Health Science at Houston, McGoven Medical School, Houston, TX, USA.

Objective: The aim of this study was to evaluate the effect of blood loss and transfusion requirements on clinical outcomes of patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs).

Methods: We reviewed the clinical data of 370 consecutive patients (277 male, mean age 74 ± 10 years) treated by F-BEVAR between 2007 and 2017. Outcomes were estimated blood loss (EBL), use of intraoperative blood salvage (IOBS), transfusion of packed red blood cells (PRBCs), mortality, and major adverse events (MAEs).

Results: There were 189 patients (51%) treated for PRAs and 181 patients (49%) treated for TAAAs. IOBS was used in 194 patients (52%) and transfusion of PRBCs was needed in 137 (37%). Thirty-day mortality was 2.2% (8/370) and MAEs occurred in 123 patients (33%), including 74 patients (20%) who had EBL > 1L. EBL > 1L and transfusion of PRBCs were significantly higher (P < 0.05) in patients treated in the first half of clinical experience and in those with larger aneurysms, iliofemoral conduits, bilateral open surgical femoral access and Extent I-III TAAAs. Use of DrySeal sheaths (WL Gore, Flagstaff AZ) was associated with significantly lower (P < .05) EBL volume and with less transfusion of PRBCs. On multivariate analysis PRBCs > 1L, male gender and the last half of clinical experience were associated with MAEs/mortality.

Conclusions: F-BEVAR was associated with significantly higher volume of blood loss and transfusion requirements in patients treated in the early experience and in those who had iliofemoral conduits, open femoral surgical exposure or Extent I-III TAAAs.
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http://dx.doi.org/10.1007/s00270-020-02573-8DOI Listing
November 2020

Effect of celiac axis compression on target vessel-related outcomes during fenestrated-branched endovascular aortic repair.

J Vasc Surg 2021 04 27;73(4):1167-1177.e1. Epub 2020 Aug 27.

Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn. Electronic address:

Objective: To report the effect of median arcuate ligament (MAL) compression on outcomes and technical aspects of celiac artery (CA) stenting during fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms.

Methods: We retrospectively reviewed the clinical and anatomic data on 300 consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study from 2013 to 2018. From this group, 230 patients with CA incorporation by fenestration or directional branch were included. MAL compression was defined by preoperative computed tomography angiogram as a J-hook narrowing of the proximal CA at the level of the ligament; the shift angle between the downward and upward segments within the CA was measured. End points were technical success, rates of intraoperative or early (30-days) CA branch revision, and freedom from target vessel instability, defined by any death or rupture owing to target vessel complication, occlusion, or reintervention for stenosis, endoleak, or disconnection.

Results: CA incorporation was performed using fenestrations in 118 patients (51%) and directional branches in 112 (49%). MAL compression was present in 97 patients (42%), resulting in a stenosis of more than 50% in 48 (49%). MAL compression was more often present in patients with extent I to III TAAAs compared with extent IV TAAA-pararenal aortic aneurysms (56% vs 31%; P < .001). Technical success rate was 99%. Patients with MAL compression more often received a directional branch (65% vs 37%; P < .001), self-expanding bridging stent grafts (32% vs 16%; P = .007), adjunctive bare metal stents (46% vs 24%; P = .001), and coverage of the gastric artery (44% vs 22%; P < .001). An intraoperative (n = 6, 2.6%) or early (n = 1, 0.4%) revision of the CA branch was required in seven patients (3%) owing to dissection/occlusion (n = 2 [0.9%]), kinking/stenosis (n = 3 [1.3%]), stent dislodgement (n = 1 [0.4%]), or type IC endoleak (n = 1 [0.4%]). A shift angle of less than 120° was the most significant factor associated with CA branch revision (odds ratio, 10.9; 95% confidence interval, 2.3-88.9; P = .013). Freedom from CA branch instability was 97 ± 2% at 4 years, and this outcome was not associated with MAL compression (hazard ratio, 0.83; 95% confidence interval, 0.14-5.02; P = .588) or any other predictor.

Conclusions: MAL compression was more common in extent I to III TAAAs, and related to additional challenges for CA stenting in fenestrated-branched endovascular aneurysm repair. This process may include bare metal stenting, gastric artery coverage, or early revision, especially in presence of an angulation of less than 120°. However, durable results can be achieved for CA incorporation despite these difficulties.
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http://dx.doi.org/10.1016/j.jvs.2020.07.092DOI Listing
April 2021

Impact of intentional accessory renal artery coverage on renal outcomes after fenestrated-branched endovascular aortic repair.

J Vasc Surg 2021 03 21;73(3):805-818.e2. Epub 2020 Jul 21.

Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, Tex. Electronic address:

Objective: The objective of this study was to evaluate the impact of intentional coverage of accessory renal arteries (ARAs) on renal outcomes after fenestrated-branched endovascular aortic repair (FB-EVAR) for pararenal aortic aneurysms or thoracoabdominal aortic aneurysms.

Methods: We analyzed the clinical data of 296 patients enrolled in a prospective nonrandomized study to evaluate outcomes of FB-EVAR between 2013 and 2018. Patients with solitary kidneys, intraoperative loss of main renal arteries, or pre-existing stage V chronic kidney disease were excluded. Two groups were analyzed: patients with intentional ARA coverage; and controls, who had complete preservation. End points included 30-day mortality; major adverse events; acute kidney injury (AKI), defined by RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease); renal function deterioration (RFD), defined by >30% decline in baseline estimated glomerular filtration rate; and presence of renal infarcts.

Results: There were 254 patients (184 male; mean age, 75 ± 8 years) included in the study, 56 (22%) with intentional ARA coverage and 198 controls, of whom 16 had ARA preservation. ARA diameter was smaller in patients who had intentional coverage vs preservation (2.7 ± 0.9 mm vs 3.4 ± 0.2 mm; P < .001). There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. All ARAs intended to be incorporated were successfully stented. Patients with ARA coverage had a higher frequency of kidney infarction (75% vs 25%; P < .001). There were two (1%) deaths within 30 days, both among controls. Patients with ARA coverage had more major adverse events (32% vs 19%; P = .04) because of higher incidence of AKI (21% vs 9%; P = .02). None of the 16 patients who had ARA preservation developed AKI. At 3 years, freedom from RFD was lower for patients who had ARA coverage compared with controls (55% ± 9% vs 76% ± 5%; log-rank, P = .02). By multivariate analysis, predictors of AKI were ARA coverage (odds ratio, 2.8; 95% confidence interval [CI], 1.2-6.2; P = .01) and estimated blood loss >1 L (odds ratio, 3.8; 95% CI, 1.2-12.3; P = .03). Postoperative AKI (hazard ratio [HR], 4.4; 95% CI, 2.4-8.1; P < .001), renal reintervention for stenosis (HR, 3.2; 95% CI, 1.6-6.7; P = .002), aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.06; P < .001), and ARA coverage (HR, 2.0; 95% CI, 2.4-8.1; P = .02) were predictors of RFD.

Conclusions: Intentional ARA coverage during FB-EVAR was associated with a threefold increase in AKI and with lower freedom from RFD. Factors associated with RFD included postoperative AKI, renal reinterventions for stenosis, and ARA coverage. Incorporation of ARAs during FB-EVAR, when it is technically feasible, helps decrease risk of AKI and RFD.
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http://dx.doi.org/10.1016/j.jvs.2020.06.123DOI Listing
March 2021
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