Publications by authors named "Giuseppe Panuccio"

63 Publications

Fiber Optic RealShape (FORS) Technology for Endovascular Navigation in Severe Tortuous Vessels.

J Endovasc Ther 2022 Jan 12:15266028211070969. Epub 2022 Jan 12.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Purpose: The purpose of this study was to describe the use of a wire and catheters embedded with optical fiber (Fiber Optic RealShape [FORS]) to catheterize tortuous target vessels avoiding radiation.

Technique: A virtual biplane vies was simulated coupling traditional x-ray system, preoperative CT scan, and FORS system to treat an isolated hypogastric aneurysm. Despite the complex anatomy, catheterization of all target vessels was possible in 12 minutes with 19 seconds of fluoroscopy time (Radiation Exposure 3.8 mGy×cm). A minimal invasive endovascular exclusion of the aneurysm was achieved through selective coil-embolization of the iliolumbar artery and implantation of balloon expandable covered stents, thus preserving the perfusion of the superior gluteal artery.

Conclusion: FORS guidance allowed catheterization of a target vessel with challenging anatomy with a low radiation exposure.
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http://dx.doi.org/10.1177/15266028211070969DOI Listing
January 2022

Endovascular Treatment of Aortic Pathologies in Patients With Marfan Syndrome: Single-Center Experience.

J Endovasc Ther 2021 Dec 30:15266028211067733. Epub 2021 Dec 30.

Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Objectives: To study the outcome of endovascular treatment of aortic pathologies in patients with Marfan syndrome (MFS) at a single institution.

Methods: Consecutive MFS patients who underwent endovascular repair or hybrid procedures for aortic pathologies from January 2010 to May 2020 were identified. Several endovascular and hybrid strategies have been used. Technical success, short- and mid-term survival, complications, and re-interventions were retrospectively analyzed.

Results: During the study period, 24 patients with MFS (median age, 48 [13-78] years; 58% males) were treated. Indications for intervention were chronic aortic dissection with aneurysm degeneration in 16 patients (67%), acute type B aortic dissection in 4 patients (17%), aortic aneurysm without any dissection in 3 patients (13%), and aortic intramural hematoma in 1 patient (4%). Most patients were asymptomatic (83%), three (13%) were symptomatic and one (4%) had a contained rupture. The median aneurysm diameter was 56 (35-86) mm. Hybrid procedures were performed in 7 (29%) patients. Thoracic endovascular repair was performed in 12 (50%) patients, a fenestrated or branched endovascular aortic repair in 4 (17%) patients, and placement of an iliac artery stent-graft in 1 (4%) patient. Procedures were staged in 12 (50%) patients. Technical success was achieved in all patients. The median intensive care unit stay was 6 (range, 1-30) days, and the median hospital stay was 23 (range, 3-112) days. Early mortality was reported in 1 (4%) patient. Wound infection was seen in 7 (29%) patients and gastrointestinal complications in 3 (13%) patients. The median follow-up was 42 (range, 1-127) months. The cumulative survival rate was 87% at 24 months. The cumulative freedom from re-intervention was 77% at 12 months.

Conclusions: Endovascular treatment of aortic pathologies in patients with MFS appears feasible with acceptable early and mid-term outcomes in terms of mortality and re-intervention rates. Endovascular therapy plays an increasing role in MFS patients with aortic pathology.
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http://dx.doi.org/10.1177/15266028211067733DOI Listing
December 2021

Modular Endo-Bentall Procedure Using a "Rendez-Vous Access".

J Endovasc Ther 2021 Dec 29:15266028211065959. Epub 2021 Dec 29.

Department of Vascular Medicine, German Aortic Center Hamburg, University Heart & Vascular Center, Hamburg, Germany.

Purpose: The concept of a single endovascular valve-carrying conduit device was designated endo-Bentall, but published experience is limited to a single case. This technical note describes an alternative modular endo-Bentall technique and a novel access technique to implant it.

Technique: A 82-year-old woman with chest pain referred for a 10 cm symptomatic aneurysm of the distal arch and descending aorta. An ascending aortic aneurysm of 5.5 cm prevented endovascular aortic arch repair due to lack of a proximal landing zone. The technique is a modular approach combining a physician-modified endograft (PMEG) with 3 large fenestrations for coronary artery perfusion and a transcatheter aortic valve implantation (TAVI). A "rendez-vous access" with a transapical and transfemoral through-and-through wire offered rapid sequential deployment in a modular fashion of both components. The PMEG was deployed first, landing 5 mm deep in the left ventricular outflow tract (LVOT) and the transcatheter aortic valve was implanted few millimeters below. The endo-Bentall procedure was combined with endovascular aortic arch repair.

Conclusion: A modular endo-Bentall procedure combining a PMEG and TAVI is feasible and adaptable to emergent setting using the "rendez-vous access."
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http://dx.doi.org/10.1177/15266028211065959DOI Listing
December 2021

Safety and Effectiveness of TEVAR in Native Proximal Landing Zone 2 for Chronic Type B Aortic Dissection in Patients With Genetic Aortic Syndrome.

J Endovasc Ther 2021 Dec 12:15266028211061276. Epub 2021 Dec 12.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Objectives: The aim of this study is to report the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) in a native proximal landing zone (PLZ) 2 for chronic type B aortic dissection (TBAD) patients with genetic aortic syndrome (GAS).

Methods: A retrospective review of a single center database to identify patients with GAS treated with TEVAR in native PLZ 2 for chronic TBAD and thoracic false lumen aneurysm between February 2012 and February 2018 was undertaken.

Results: In total, 31 patients with GAS (24 Marfan syndrome [MFS], 5 Loeys-Dietz syndrome [LDS], and 2 vascular Ehlers-Danlos syndrome [vEDS]) were treated by endovascular repair. Nineteen patients were treated by TEVAR as index procedures with 8 patients (5 females, mean age = 55, range = 36-79 years old) receiving TEVAR in native PLZ 2. Left subclavian artery (LSA) perfusion was preserved in all 8 patients: by left common carotid artery-LSA bypass in 6 patients, chimney stenting of the LSA in 1 patient, and partial coverage of LSA ostium in 1 patient. Technical success was achieved in all patients (100%). There was no 30 day mortality (0%). The 30 day morbidity (0%) was free from major complications. The median follow-up was 40 months (range = 7-79). One patient died due to non-aortic-related cause. Native PLZ 2 was free from complications in MFS patients (5/8). Two patients with LDS developed type Ia endoleak with aneurysmal progression. One patient was treated by proximal extension with a double inner branched arch stent-graft landing in the replaced ascending aorta. The other one was treated with frozen elephant trunk.

Conclusion: Thoracic endovascular aortic repair in native PLZ 2 was safe and effective with no early or midterm PLZ complications in patients with MFS with chronic TBAD in this limited series. Native PLZ 2 is not safe in patients with LDS and should only be used in emergencies as a bridging to open repair.
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http://dx.doi.org/10.1177/15266028211061276DOI Listing
December 2021

Management of Ascending Aorta and Aortic Arch: Similarities and Differences Among Cardiovascular Guidelines.

J Endovasc Ther 2021 Dec 7:15266028211061271. Epub 2021 Dec 7.

Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany.

Background: Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence.

Methods: The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases.

Results: The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited.

Conclusion: In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.
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http://dx.doi.org/10.1177/15266028211061271DOI Listing
December 2021

Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies.

J Endovasc Ther 2021 Dec 1:15266028211061275. Epub 2021 Dec 1.

German Aortic Center Hamburg, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Purpose: To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms.

Technique: We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography.

Conclusion: Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.
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http://dx.doi.org/10.1177/15266028211061275DOI Listing
December 2021

Non-Standard Management of Target Vessels With the Inner Branch Arch Endograft: A Single-Center Retrospective Study.

J Endovasc Ther 2021 Nov 15:15266028211058682. Epub 2021 Nov 15.

Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center of Hamburg, Hamburg, Germany.

Purpose: The purpose of this study was to evaluate early and mid-term results of non-standard management of the supraaortic target vessels with the use of the inner branch arch endograft in a single high-volume center.

Material And Methods: A single-center retrospective study including all patients undergoing implantation of an inner branch arch endograft from December 2012 to March 2021, who presented a non-standard management of the supraaortic target vessels (any bypass other than a left carotid-subclavian or landing in a dissected target vessel). Technical success, mortality, reinterventions, endoleak (EL), and aortic remodeling at follow-up were analyzed.

Results: Twenty-four patients were included. In 17 (71%) cases, the non-standard management was related to innominate artery (IA) compromise (12 with IA dissection, 2 with short IA, 2 with short proximal aortic landing zone that required occlusion of IA, 1 with occluded IA after open arch repair). Two (8%) cases were related to an aberrant right subclavian artery (RSA), 1 patient (4%) due to the concomitant presence of a left vertebral artery (LVA) arising from the arch and an occluded left subclavian artery (LSA), and another patient presented with an occluded LSA distal to a dominant vertebral artery. Three (13%) cases were exclusively related to management in patients with genetic aortic syndromes. Twenty (83%) patients had a previous type A aortic dissection. Ten (42%) patients presented a thoracic or thoracoabdominal aortic aneurysm and 8 (33%) patients an arch aneurysm, 6 of them associated to false lumen (FL) perfusion. There were 2 (8%) perioperative minor strokes, and 1 patient with perioperative mortality. Seven patients presented an early type I endoleak, all resolved at follow-up. Seven patients required reinterventions during follow-up (7 reinterventions related to continuous false lumen perfusion, 3 related to Type Ia endoleak, 2 related to surgical bypass). All patients who presented with FL perfusion had complete FL thrombosis at follow-up. No patient presented aneurysm growth at follow-up.

Conclusions: The use of the inner branch arch endograft with a non-standard management of the supraaortic target vessels is a possible option. Despite a high reintervention rate, regression or stability of the aneurysmal diameter was achieved in all the patients with follow-up.
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http://dx.doi.org/10.1177/15266028211058682DOI Listing
November 2021

One-Year Results of ZBIS Iliac Branch Device With an Off-Label Connection Limb.

J Endovasc Ther 2021 Oct 28:15266028211054760. Epub 2021 Oct 28.

Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Purpose: The purpose of this article is to study 1-year results of Zenith branch iliac endovascular graft (ZBIS) with the off-label use of a 13 mm spiral Z limb to connect to the aortic main body.

Materials And Methods: A retrospective review from 2015 to 2019 of all iliac branch devices (IBDs) was performed at 1 institution that were connected to an aortic main body with a 13 mm spiral Z limb and had at least 1-year follow-up with computed tomography (CT). Primary endpoints are freedom from ZBIS separation from the connection limb, endoleak (EL), or reintervention at 1 year. Secondary endpoints are primary and secondary ZBIS patency, presence of any EL, and aortic reinterventions.

Results: Of 149 IBDs implanted in this period, 45 ZBIS in 35 patients were connected with a 13 mm limb and had a 1-year CT; 97% of patients had common iliac artery (CIA) aneurysms, 7% of patients had hypogastric artery (HA) aneurysms, and 30% of patients had bilateral ZBIS implantation. Technical success was 98%. In 84% of cases, the Advanta V12 was used as the HA mating stent; 56% of patients had an EL, mostly type II, which resolved spontaneously in 70% at 1 year, and 9% of ZBIS required reinterventions at 1 year (2 for thrombosis, 2 for type Ic EL from HA mating stent). One-year ZBIS primary patency and secondary patency were 96% and 100%, respectively. No EL was noted to be related to the 13 mm connection limb. No migration or separation of the devices occurred.

Conclusions: The use of 13 mm spiral Z limb to connect a ZBIS with the main body in our series yields a high technical success rate and good 12-month outcomes without device separation or migration.
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http://dx.doi.org/10.1177/15266028211054760DOI Listing
October 2021

Cerebral microbleeds following thoracic endovascular aortic repair.

Br J Surg 2021 Dec;109(1):46-52

German Aortic Centre, Department of Vascular Medicine, University Heart and Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Background: Stroke and neurological injury are a complication of thoracic endovascular aortic repair (TEVAR). Cerebral microbleeds (CMBs) are common in patients with white matter damage to the brain secondary to chronic vasculopathy. The aim of this study was to examine the occurrence of CMBs after TEVAR, and to evaluate their association with patient and procedural factors.

Methods: Patients who underwent TEVAR between September 2018 and January 2020 in two specialist European aortic centres were analysed. All patients underwent postoperative susceptibility-weighted MRI. The location and number of CMBs were identified, and analysed with regard to procedural aspects, clinical outcome, and Fazekas score as an indicator of pre-existing vascular leucoencephalopathy.

Results: Some 91 patients were included in the study. A total of 1531 CMBs were detected in 58 of 91 patients (64 per cent). In the majority of affected patients, CMBs were found bilaterally (79 per cent). Unilateral CMBs in the right or left hemisphere occurred in 16 and 5 per cent of patients respectively (P < 0.001). More CMBs were found in the middle cerebral than in the vertebrobasilar/posterior and anterior cerebral artery territories (mean(s.d.) 3.35(5.56) versus 2.26(4.05) versus 0.97(2.87); P = 0.045). Multivariable analysis showed an increased probability of CMBs after placement of TEVAR stent-grafts with a proximal diameter of at least 40 mm (odds ratio (OR) 6.85, 95 per cent c.i. 1.65 to 41.59; P = 0.007) and in patients with a higher Fazekas score on postoperative T2-weighted MRI (OR 2.62, 1.06 to 7.92; P = 0.037).

Conclusion: CMBs on postoperative MRI are common after endovascular repair in the aortic arch. Their occurrence appears to be associated with key aspects of the procedure and pre-existing vascular leucoencephalopathy.
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http://dx.doi.org/10.1093/bjs/znab341DOI Listing
December 2021

Bail-out technique to detach a locked Viabahn endoprosthesis in branched thoracic endovascular aortic repair.

J Vasc Surg Cases Innov Tech 2021 Dec 1;7(4):593-596. Epub 2021 Jul 1.

German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

A 69-year-old female patient presented with a 5.8 cm thoracoabdominal aortic aneurysm Crawford type II after partial arch replacement. She was treated by a branched thoracic endovascular aortic repair procedure using a branched arch endograft with one retrograde branch to the left subclavian artery. After deployment of a Viabahn as a bridging covered stent to the left subclavian artery, the deployment line did not detach and the delivery catheter could not be removed. With the use of a physician-modified sidehole catheter and balloon fixation, the pulling line could be released without displacement of the Viabahn endoprosthesis.
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http://dx.doi.org/10.1016/j.jvscit.2021.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8515410PMC
December 2021

How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study.

Eur J Vasc Endovasc Surg 2021 12 20;62(6):849-856. Epub 2021 Oct 20.

German Aortic Centre Hamburg, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

Objective: There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort.

Methods: This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes.

Results: In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay.

Conclusion: In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.
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http://dx.doi.org/10.1016/j.ejvs.2021.08.034DOI Listing
December 2021

Feasibility and Preliminary Patency of Prophylactic Hypogastric Artery Stenting for Prevention of Spinal Cord Ischemia in Complex Endovascular Aortic Repair.

Ann Vasc Surg 2021 Oct 13. Epub 2021 Oct 13.

Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Background: To report early results of feasibility and patency of prophylactic hypogastric artery (HA) stenting during complex endovascular aortic repair.

Methods: This is a single centre retrospective non comparative cohort study of all consecutive patients undergoing prophylactic HA stenting during fenestrated and/or branched EVAR (F/B EVAR) in order to prevent spinal cord ischemia (SCI). Endpoints included technical success and early outcomes in terms of morbidity, mortality and patency of the implanted stents.

Results: Between May 2014 and June 2019 prophylactic HA stenting was performed in 36 consecutive patients with significant HA stenosis during F/B EVAR to prevent SCI. 69.4% of patients presented with asymptomatic, 25% with symptomatic and 5.6% with ruptured aortic aneurysms. 55.6% were treated for thoracoabdominal aortic aneurysms, 44.4% for pararenal abdominal aortic aneurysms. In 13.9% aortic coverage was limited to the abdominal aorta. In 86.1% the aortic coverage was in the thoracoabdominal aortic segment. Unilateral HA stenting was performed in 91.7%, whereas 8.3% underwent bilateral stenting. Technical success was 100%. The primary patency of the implanted stents after a median follow-up time of 9.5 months was 97.5%. One intraprocedural bleeding from an HA branch occurred and was successfully treated by coil embolization. No further procedure-related complications occurred. 11.1% of the patients developed SCI.

Conclusions: HA stenting is feasible and safe with high rates of technical success and short-term patency.
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http://dx.doi.org/10.1016/j.avsg.2021.07.053DOI Listing
October 2021

Early outcomes of t-Branch off-the-shelf multibranched stent graft in urgent and emergent repair of thoracoabdominal aortic aneurysms.

J Vasc Surg 2022 Feb 1;75(2):416-424.e2. Epub 2021 Sep 1.

German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.

Objective: We compared the outcomes between elective, urgent, and emergent treatment of thoracoabdominal aortic aneurysms (TAAAs) using the t-Branch off-the-shelf multibranched stent graft (Cook Medical, Bloomington, Ind).

Methods: All consecutive patients treated for TAAAs using the t-Branch between September 2012 and June 2019 were included in the present study. The patients were divided into three groups according to the urgency of repair: (1) elective, (2) urgent, and (3) emergent. The periprocedural details and 30-day outcomes were analyzed. Survival and reinterventions were analyzed using Kaplan-Meier curves and log-rank tests.

Results: The t-Branch stent graft was used for 100 patients during the study period. Of the 100 patients, 30 (73% male; mean age, 65 ± 10 years) were treated electively, 49 (54% male; mean age, 72 ± 7 years) urgently, and 21 (81% male; mean age, 75 ± 9 years) emergently. Transfemoral access with a steerable sheath was used more frequently for target vessel catheterization in the elective group (57%) than in the urgent (8%) and emergent (5%) groups (P = .021). The total number of targeted vessels was 111 of 120 (93%) in the elective group vs 185 of 196 (94%) in the urgent group and 82 of 84 (98%) in the emergent group. The corresponding technical success rates were 97% (29 of 30), 98% (48 of 49), and 95% (20 of 21). The median intensive care unit stay was shorter in the elective group (3 days; range, 1-41 days) than in the urgent group (5 days; range, 1-41 days) and emergent group (11 days; range, 3-37 days; P = .004). The 30-day mortality rate was lower in the elective group (2 of 30; 7%) than in the urgent group (8 of 49; 16%) and emergent group (5 of 21; 24%; P = .049). The acute kidney injury rate was lower in the elective group (2 of 30; 7%) than in the urgent group (11 of 49; 22%) and emergent group (8 of 21; 38%; P = .002). The spinal cord ischemia rate was also lower in the elective group (5 of 30; 17%) than in the urgent group (5 of 49; 10%) and emergent group (8 of 21; 38%; P = .051). The median follow-up was 8 months (interquartile range, 3.2-18.5 months). The cumulative survival rate was 95%, 87%, and 87% at 6, 12, and 24 months, respectively. The cumulative freedom from reintervention during follow-up was 92%, 86%, and 77% at 6, 12, and 24 months, respectively.

Conclusions: The technical success of TAAA repair using t-Branch stent graft was not affected by an urgent or emergent presentation. However, the occurrence of worse periprocedural morbidity and mortality was significantly associated with an urgent or emergent presentation.
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http://dx.doi.org/10.1016/j.jvs.2021.07.237DOI Listing
February 2022

Iatrogenic coarctation caused by branched thoracic endovascular aortic repair treated with Palmaz XL stent and triple kissing balloon technique.

J Vasc Surg Cases Innov Tech 2021 Sep 4;7(3):433-437. Epub 2021 Jun 4.

German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

We have described a technique to treat iatrogenic coarctation caused by a branched thoracic endovascular aortic repair (TEVAR) procedure with a Palmaz XL stent (Palmaz Genesis; Cordis Corp, a Cardinal Health Company, Milpitas, Calif) and triple kissing balloons. A 42-year-old woman with Marfan syndrome had presented with aneurysmatic dilatation of the aortic arch 10 years after open aortic arch repair. After successful branched TEVAR, a significant coarctation just short of the left common carotid artery was noted with significant pressure gradient between the ascending and descending aorta. Branched TEVAR in previous open aortic arch replacement can result in iatrogenic coarctation that can be successfully treated using a Palmaz XL stent and triple kissing balloons.
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http://dx.doi.org/10.1016/j.jvscit.2021.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263522PMC
September 2021

Early outcomes of the t-Branch off-the-shelf multi-branched stent graft in 542 patients for elective and urgent aortic pathologies: A retrospective observational study.

J Vasc Surg 2021 12 23;74(6):1817-1824. Epub 2021 Jun 23.

Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland.

Objective: The t-Branch, a standardized off-the-shelf multi-branched stent graft has been used for the treatment of elective and urgent cases in aortic disease. The aim of this study was to assess the early outcomes in terms of technical success, mortality, and morbidity in >500 patients being treated with the t-Branch device.

Methods: A two-center retrospective observational study was undertaken including patients treated using the t-Branch (Cook Medical, Bloomington, IN) in elective or urgent settings for complex abdominal aortic aneurysm and thoraco-abdominal aortic aneurysm between 2014 and 2019 (early experience 2014-2016; late experience 2017-2019). Primary endpoints were technical success and early (30-day) mortality, and secondary endpoints were early morbidity, endoleak, and target vessel patency rates. Multivariable regression models were used to determine the independent association of risk factors with (1) mortality and (2) spinal cord ischemia.

Results: A total of 542 patients (mean age, 70.5 ± 8.5 years; 388 men [72%]; mean aneurysm diameter, 7.5 ± 2.5 cm) were included (63% elective; 90% thoraco-abdominal aortic aneurysm). The technical success rate was 97% (526/542) (elective, 96.7% [328/339] vs urgent, 97.6% [208/213]). The total 30-day mortality rate was 12.3% (8.5% in elective, 15% in symptomatic, and 30% in contained rupture). After multivariate regression analysis, the mortality rate was associated with older age (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.11; P < .001) and with lower baseline glomerular filtration rate (OR, 0.98; 95% CI, 0.98-0.99; P < .001). In elective cases, the mortality rate was associated with a history of coronary artery disease (OR, 0.26; 95% CI, 0.09-0.73; P < .011) and higher body mass index (OR, 0.87; 95% CI, 0.77-0.98; P < .027). In urgent cases, the mortality rate was associated with older age, (OR, 1.07; 95% CI, 1.02-1.13; P < .010) and lower baseline glomerular filtration rate (OR, 0.97; 95% CI, 0.95-0.99; P < .001). The spinal cord ischemia rate was 10.5% (6.5% temporary, 4% permanent) and was associated with the early study period (OR, 2.01; 95% CI, 1.03-3.89; P < .038). The renal impairment rate was 13%, the stroke rate was 2.5%, and the myocardial infarction rate was 1.8%, whereas the access complications rate was 7.7%. On early computed tomography angiography, the primary patency rate for the right renal artery was 99.6%, for the left renal artery was 100%, for the superior mesenteric artery was 99.4%, and for the coeliac trunk was 99.8%. The endoleak I and III rates were 2.7% (15/542) and 2.7% (15/542), respectively.

Conclusions: Elective and urgent use of the t-Branch multi-branched off-the shelf stent graft showed high technical success and early target vessel patency rates. Early mortality and morbidity rates were acceptable.
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http://dx.doi.org/10.1016/j.jvs.2021.05.041DOI Listing
December 2021

Endovascular Repair of Postdissection Thoracoabdominal Aortic Aneurysm in Patients With Vascular Ehlers-Danlos Syndrome.

J Endovasc Ther 2021 10 21;28(5):804-811. Epub 2021 Jun 21.

German Aortic Center, University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Purpose: To report endovascular repair of postdissection thoracoabdominal aortic aneurysm (TAAA) in 2 patients with vascular Ehlers-Danlos syndrome (vEDS).

Case Reports: . A 56-year-old vEDS male patient with a 50-mm type III TAAA [history of aortic root repair, hemiarch replacement, and thoracic endovascular aortic repair (TEVAR) for acute type A aortic dissection (TAAD) 7 years ago] was treated by a 2-stage procedure; first, cervical debranching of the left subclavian artery and second TEVAR and t-branch. The postoperative course was uneventful. Follow-up computed tomography angiography (CTA) 3.5 years postoperatively demonstrated aortic remodeling with patency of targeted visceral vessels and no endoleak. . A 47-year-old vEDS male patient presented with a TAAA (diameter of 67 mm). The patient had a history of aortic valve and arch replacement with elephant trunk for acute TAAD, and consequently a TEVAR and candy-plug procedure after a ruptured false lumen (FL) aneurysm of the descending thoracic aorta. He also had a surgical repair by an aorto-bi-iliac graft. Two years later, CTA demonstrated aneurysmal FL dilatation distally to the candy-plug and he was treated with fenestrated EVAR (F-EVAR).

Conclusion: Endovascular repair of postdissection TAAA was feasible and safe with good short-term outcome in 2 patients with vEDS.
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http://dx.doi.org/10.1177/15266028211025038DOI Listing
October 2021

Fenestrated and Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysm With More Than 4 Target Visceral Vessels due to Renovisceral Arterial Anatomical Variations: Feasibility and Early Results.

J Endovasc Ther 2021 10 26;28(5):692-699. Epub 2021 May 26.

German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany.

Purpose: This study describes technical success, feasibility, and early results of fenestrated and branched endovascular aortic repair (F/B-EVAR) for treatment of thoracoabdominal aortic aneurysms (TAAAs) or pararenal aneurysms with more than 4 target visceral vessels (TVs) due to renovisceral arterial anatomical variations.

Materials And Methods: Patients with TAAAs or pararenal aortic aneurysms who had more than 4 TVs due to renovisceral arterial anatomical variations of renal, celiac, and/or superior mesenteric arteries and received F/B-EVAR between January 2017 and September 2019 at a single aortic center were included in this study. We analyzed technical success, feasibility, and early outcomes.

Results: Twelve patients (mean age 70±10 years, 9 males) were included. The anatomical variations included 6 right accessory renal arteries, 8 left accessory renal arteries, and 1 celiac artery variant. Stent-grafts were fenestrated, branched or combined in 6, 5, or 1 patients, respectively. The mean operating time was 346±120 minutes, the mean fluoroscopy time was 80±29 minutes, and the mean radiation dose area product was 430±219 Gy·cm. The mean contrast volume was 129±45 mL. The total number of TVs was 64; 5 TVs in 9 patients, 6 in 2 patients, and 7 in 1 patient. Technical success was achieved in all cases. The mean intensive care unit stay was 6±5 days, and the mean total hospital stay was 14±10 days. One patient died early (30-day). Early morbidities included respiratory complication in 1 patient, renal insufficiency in 1 patient, and wound infection in 2 patients. No spinal cord ischemia, stroke, or bowel ischemia occurred. Early computed tomography angiography showed 100% patency of the bridging covered stents and TVs. The mean follow-up was 13±4.3 months. No mortality or adverse major event occurred during the follow-up. Two patients with developed type Ic endoleak related to 1 right renal artery and 1 celiac artery covered stent. Patency of the TVs during follow-up was 100%.

Conclusion: The use of F/B-EVAR for the treatment of TAAA with more than 4 TVs due to renovisceral arterial anatomical variations in our own experience is feasible and not related to increased morbidity and mortality.
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http://dx.doi.org/10.1177/15266028211016447DOI Listing
October 2021

"Powered Cheese Wire Technique" for Septal Fenestration in Complex Endovascular Repair for Chronic Thoracoabdominal Aortic Dissection.

J Endovasc Ther 2021 10 25;28(5):676-681. Epub 2021 May 25.

Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany.

Purpose: Endovascular repair of chronic thoracoabdominal aortic dissection with aneurysmal degeneration presents a therapeutic challenge when one or more visceral branches arise from the false lumen without an adjacent reentry. The chronic dissection flap can be thick and resistant to flap fenestration with standard techniques.

Technique: facilitates cutting of a dissection flap using electrical current on a noninsulated through-and-through wire segment. The mid-shaft of the guidewire is denuded and kinked to form the "flying V" configuration. This solution is based on the BASILICA procedure, which uses electrosurgery to split aortic valve tissue lengthwise prior to transcatheter aortic valve replacement to prevent coronary artery obstruction. We demonstrate the technique in a case of branched endovascular aortic repair of a complex thoracoabdominal dissecting aneurysm in which a renal artery from the false lumen was catheterized by creating a powered cheese wire fenestration.

Conclusion: The is an effective approach to access false lumen originating branches during endovascular aortic repair of chronic aortic dissections.
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http://dx.doi.org/10.1177/15266028211007474DOI Listing
October 2021

Aortic Remodeling After Custom-Made Candy-Plug for Distal False Lumen Occlusion in Aortic Dissection.

J Endovasc Ther 2021 06 26;28(3):399-406. Epub 2021 Feb 26.

German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Germany.

Purpose: To report a single-center experience with the use of a custom-made Candy-Plug (CP) for distal false-lumen (FL) occlusion in subacute and chronic aortic dissection (AD).

Materials And Methods: A retrospective single-center analysis was conducted on consecutive patients with subacute and chronic AD who were treated with a custom-made CP for distal FL occlusion using 3 design generations (CP I to CP III) from October 2013 to September 2019.

Results: A custom-made CP was used in 57 patients. Of these, 34 patients (29 males, mean age 62±10 years) were treated with a CP I vs 23 patients (16 males, mean age 59±17 years) with CP II/III. Technical success was achieved in 57 (100%) patients. Clinical success was achieved in 54 (95%) patients; 33 (97%) in CP I group vs 21 (91%) patients in CP II/III group, p=0.116. The mean hospital stay was 10±8 days (9±5 days in CP I group vs 13±9 days in CP II/III, p=0.102). The 30-day computed tomography angiography (CTA) confirmed successful CP placement at the intended level in all patients within both groups. Early complete FL occlusion was achieved in 50 (88%) patients; 30 (88%) patients in CP I group vs 20 (87%) in CP II/III group, p=0.894. Follow up CTA was available in 44 (77%) patients. Of these; 30/34 (88%) patients in CP I group with mean follow-up 29±17 months) vs. 14/23 (61%) patients with mean follow-up 14±5 months in CP II/III group. Thoracic aortic remodeling was achieved in 34/44 (77%) patients; 25/30 (83%) patients in CP I group vs 9/14 (64%) patients in CP II/III group, p=0.197. The aneurysm size remained stable in 9/44 (20%) patients; 5/30 (17%) patients in CP I group vs 4/14 (29%) patients in CP II/III group, p=0.741. The thoracic aneurysm increased size was seen in 1/44 (2%) patient. This patient was in CPII/III group.

Conclusion: CP technique using custom-made devices is technically feasible with a low mortality and morbidity, and a high rate of aortic remodeling. Both, the original design (CP I) and newer designs with a self-closing central sleeve (CP II and CP III) showed similar excellent outcomes.
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http://dx.doi.org/10.1177/1526602821996722DOI Listing
June 2021

Perioperative Outcome of Fenestrated and Branched Stent Grafting after Previous Open or Endovascular Abdominal Aortic Repair.

Ann Vasc Surg 2021 Jul 4;74:229-236. Epub 2021 Feb 4.

German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, Hamburg, Germany.

Background: To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoracoabdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair.

Methods: Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality.

Results: We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and 8 with a tube graft. Of these, 2 patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, 3 of them with additional type Ia endoleak, 2 with stent-graft migration and 2 with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P = 0.746). Eighteen patients (86%) had branched stent grafting in the post-open versus 11 (52%) in the post-endo group (P < 0.01). In 2 patients in the post-open group, 3 renal arteries were not catheterized due to severe ostial stenosis, resulting in technical success of 91% in the post-open and 100% in the post-endo fbEVAR group. Four patients (19%) in the post-open fbEVAR group died in hospital, 2 due to cerebral hemorrhage and 2 due to pneumonia, and none in the post-endo fbEVAR group (P = 0.101). There were 5 nonstent-graft-related reinterventions, 2 (10%) in the post-open fbEVAR group and 3 (14%) in the post-endo fbEVAR group (P = 0.844). After 12 months there were 4 events in the post-endo fbEVAR group: one renal artery stent occluded, one renal artery stent required relining because of disconnection and 2 type II endoleaks were embolized with coils. There were no reinterventions in the post-open fbEVAR group during 12 months.

Conclusions: Fenestrated and branched repair after previous open or endovascular abdominal aortic repair appears safe with high technical success rate. There is no difference in the technical success and in-hospital all-cause mortality rates between fbEVAR after previous open or endovascular abdominal aortic repair.
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http://dx.doi.org/10.1016/j.avsg.2020.12.047DOI Listing
July 2021

Female Sex and Outcomes after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Propensity Score Matched Cohort Analysis.

J Clin Med 2021 Jan 5;10(1). Epub 2021 Jan 5.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.

Objective: Previous studies have showed a potential disadvantage of female patients who underwent abdominal aortic aneurysm (AAA) repair. The current study aims to determine sex-specific perioperative and long-term outcomes using propensity score matched unselected nationwide health insurance claims data.

Methods: Insurance claims from a large German fund were used, covering around 8% of the insured German population. Patients who underwent endovascular aortic repair (EVAR) for intact AAA from 1 January 2011 to 30 April 2017 were included in the cohort. A 1:2 female to male propensity score matching was applied to adjust for confounding variables. Perioperative and long-term outcomes after 5 years were determined using matching and regression methods.

Results: Among a total of 3736 patients (19.3% females, mean 75 years) undergoing EVAR for intact AAA, we identified 1863 matched patients. Before matching, females were more likely to be previously diagnosed with hypothyroidism, electrolyte disorders, rheumatoid disorders, and depression, while males were more often diabetics. In the matched sample, 23.4% of the females and 25.8% of the males died during a median follow-up of 776 and 792 days, respectively. Perioperatively, females were more likely to exhibit acute limb ischemia (5.3% vs. 3.2%, = 0.031) and major bleeding (22.0% vs. 15.9%, = 0.001) before they were discharged to rehabilitation (5.5% vs. 1.5%, < 0.001) when compared to males. No statistically significant difference in perioperative (odds ratio 1.12, 95% CI 0.54-2.16) or long-term mortality (hazard ratio 0.91, 95% CI 0.76-1.08) was observed between sexes. This was also true regarding aortic reintervention rates after 1 year (2.0% vs. 2.9%) and 5 years (10.9% vs. 8.1%).

Conclusion: The current retrospective matched analysis of insurance claims revealed high early access-related morbidity in females when compared to their male counterparts. Short-term or long-term survival and reintervention outcomes were similar between sexes.
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http://dx.doi.org/10.3390/jcm10010162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796519PMC
January 2021

Management of Descending Thoracic Aortic Diseases: Similarities and Differences Among Cardiovascular Guidelines.

J Endovasc Ther 2021 Apr 13;28(2):323-331. Epub 2021 Jan 13.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.

Cardiovascular societies have developed recommendations regarding the management of thoracic aortic diseases. While improvements in treatment have been observed during the past decade in regard to patient selection, thoracic endovascular aortic repair (TEVAR) and associated techniques, and high-volume centralization, the broad expansion of TEVAR has raised considerations about its indications, appropriateness, limitations, and application. The aim of this systematic review was to assess the similarities and differences among current cardiovascular societies' guidelines for the management of thoracic aortic diseases. The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from January 2009 to May 2020. The initial search identified 990 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from cardiovascular societies published between 2010 and 2020. Selected controversial topics were analyzed, including diagnosis, imaging, spinal cord ischemia prevention, and management of the most important thoracic aortic pathologies. The analysis included data concerning the therapeutic approach in acute and chronic type B aortic dissection, penetrating aortic ulcer, intramural hematoma, thoracic aortic aneurysm, and traumatic aortic injury, as well a discussion of inflammatory aneurysms, aortitis, and genetic syndromes. The review presents consistent and controversial recommendations, as well as "gray zone" issues that need further investigation. There was significant overlap and agreement among the 5 societies regarding the management of thoracic aortic diseases. Especially in dissection and aneurysm management, TEVAR has established its role as the treatment of choice. However, robust evidence is still needed in many aspects of the management of thoracic aortic pathologies.
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http://dx.doi.org/10.1177/1526602820987808DOI Listing
April 2021

Transcaval embolization for type II endoleak after endovascular aortic repair of infrarenal, juxtarenal, and type IV thoracoabdominal aortic aneurysm.

J Vasc Surg 2021 07 1;74(1):38-44. Epub 2021 Mar 1.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart and Vascular Center, Hamburg, Germany.

Objective: This study aims to determine the outcomes of transcaval embolization (TCE) for type II endoleak after infrarenal endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/BEVAR).

Methods: A retrospective single-center cohort study of all consecutive TCE procedures between August 2015 and August 2019 was performed to investigate technical success, in-hospital morbidity, and 30-day mortality as well as clinical success during follow-up. The indication for TCE was an aneurysm sac growth of 5 mm or more owing to a type II endoleak after EVAR for infrarenal or F/BEVAR for juxtarenal and type IV thoracoabdominal aortic aneurysm.

Results: A total 25 TCE procedures in 24 patients (95.8% male) were included. Technical success was 96.0% (24/25); selective and nonselective TCE were performed in 48% of patients. The in-hospital morbidity and 30-day mortality were 0%. The median follow-up was 23.1 months (interquartile range, 10.9-40.1 months). Freedom from type II endoleak-related reintervention was 84.6% at 12 months. Comparing clinical success after TCE, reintervention was necessary in 16.7% of patients after nonselective and 20% of patients after selective TCE. Regarding TCE after EVAR vs F/BEVAR, reintervention was performed in 12.5% of EVAR and 33.3% of F/BEVAR patients during follow-up.

Conclusions: TCE is an acceptable treatment alternative for type II endoleak with aneurysm sac enlargement and can be used after EVAR for infrarenal abdominal aortic aneurysms and F/BEVAR for juxtarenal abdominal aortic aneurysms and type IV thoracoabdominal aortic aneurysms.
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http://dx.doi.org/10.1016/j.jvs.2020.12.067DOI Listing
July 2021

Comparison of transfemoral versus upper extremity access to antegrade branches in branched endovascular aortic repair.

J Vasc Surg 2021 05 26;73(5):1498-1503. Epub 2020 Nov 26.

German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Objective: We studied the outcomes of transfemoral access (TFA) vs upper extremity access (UEA) for branched endovascular aortic repair (BEVAR).

Methods: From January 2016 to October 2019, 152 consecutive patients underwent BEVAR under general anesthesia at a single institution. In 2018, an alternative approach to the antegrade branches using TFA compared with conventional UEA was introduced. The cohort was divided into TFA and UEA groups according to the access approach. The end points were technical success, adverse events (including perioperative stroke/transient ischemic attack), access complications, operation time, and radiation exposure.

Results: The TFA group included 60 patients (63% male; median age, 71 years; interquartile range [IQR], 65-76 years). The UEA group included 92 patients (67% male; median age, 73 years; IQR, 66-78 years). The number of target vessels (TVs) was similar in both groups (median, 4.0 TVs per procedure; range, 1-7 TVs for both). Technical success was greater in the TFA group (60 of 60 patients; 209 of 209 TVs) than in the UEA group (87 of 92 patients; 334 of 346 TVs; P < .01). The fluoroscopy time (median, 69 minutes; IQR, 48-87 minutes; vs 88 minutes; IQR, 65-104 minutes; P = .39) and contrast agent volume (median, 141 mL; IQR, 123-165 mL; vs median, 130 mL; IQR, 101-157 mL; P = .34) were similar in both groups. The radiation exposure (221 Gy × cm; IQR, 138-406 Gy × cm; vs median, 255 Gy × cm; IQR, 148-425 Gy × cm; P = .05) was lower and the operation time (median, 300 minutes; IQR, 240-356 minutes; vs median, 364 minutes; IQR, 290-475 minutes; P = .01) was shorter in the TFA group. Brachial access complications (0 of 60 vs 3 of 92 patients) and perioperative strokes/transient ischemic attacks (0 of 60 vs 8 of 92 patients) only occurred in the UEA group (P = .018).

Conclusions: The use of TFA to catheterize antegrade branches was associated with a lower rate of complications in the present study and has become our preferred approach for BEVAR.
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http://dx.doi.org/10.1016/j.jvs.2020.11.020DOI Listing
May 2021

Anatomical Suitability of the Aortic Arch Arteries for a 3-Inner-Branch Arch Endograft.

J Endovasc Ther 2021 Feb 1;28(1):14-19. Epub 2020 Sep 1.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.

Purpose: To analyze aortic arch anatomy of patients who were already treated with a 2-inner-branch arch endograft (2-IBAE) in order to assess the anatomical suitability of the supra-aortic arteries as target vessels for a 3-IBAE.

Materials And Methods: Three different configurations of the Cook Zenith Arch endograft were designed with distances of 110 mm (model 1), 90 mm (model 2), and 70 mm (model 3) between the orifices of the first and third inner branches. Preoperative measurements of the aortic arch anatomy from 104 consecutive patients treated electively with custom-made 2-IBAEs at 2 European centers between 2014 and 2019 were analyzed. A previously described standard methodology with a planning sheet was used. Data and measurements included the treatment indication for the aortic arch pathology, the type of landing zone, the type of arch, and the inner and outer lengths of the ascending aorta from the sinotubular junction to the innominate artery (IA). Additionally, the diameters and clock positions of the IA, left common carotid artery (LCCA), and left subclavian artery (LSA) were assessed, along with the distances between the IA and the LCCA, the IA and the LSA, and the distal landing zone.

Results: Type I was the most common arch configuration (75/104, 72%). The mean clock positions were 12:30±00:28 for the IA, 12:00±00:23 for the LCCA, and 12:15±00:29 for the LSA. The mean diameters were 14.2±2.2 mm for the IA, 8.8±1.8 mm for the LCCA, and 10.5±2 mm for the LSA. The mean distances between the IA and LCCA and between the IA and LSA were 14.7±5.8 mm and 33±9.4 mm, respectively. Model 2 (branch distance 90 mm) had the highest suitability (79%), while models 1 and 3 showed suitability rates of 73% and 68%, respectively. The most frequent exclusion criterion in all models was the diameter of the LSA, followed by the IA to LSA distance.

Conclusion: The suitability for a 3-IBAE among patients who had a 2-IBAE implanted is high, favoring a 90-mm distance between the retrograde LSA branch and baseline.
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http://dx.doi.org/10.1177/1526602820953634DOI Listing
February 2021

Management of Abdominal Aortic Aneurysm Disease: Similarities and Differences Among Cardiovascular Guidelines and NICE Guidance.

J Endovasc Ther 2020 Dec 19;27(6):889-901. Epub 2020 Aug 19.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.

The development of endovascular techniques has improved abdominal aortic aneurysm (AAA) management over the past 2 decades. Different cardiovascular societies worldwide have recommended the endovascular approach as the standard of care in their currently available guidelines. While endovascular treatment has established its role in daily clinical practice, a new debate has arisen regarding the indications, appropriateness, limitations, and role of open surgery. To inform this debate, the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched from 2010 to May 2020; the systematic search identified 5 articles published between 2011 and 2020 by 4 cardiovascular societies and the National Institute of Health and Care Excellence (NICE). Four debatable domains were assessed and analyzed: diagnostic methods and screening, preoperative management, indications and treatment modalities, and postoperative follow-up and endoleak management. The review addresses controversial proposals as well as widely accepted recommendations and "gray zone" issues that need to be further investigated and analyzed, such as screening in women, medical management, and follow-up imaging. While the recommendations for AAA management have significant overlap and agreement among international cardiovascular societies, the NICE guidelines diverge regarding the role of open repair in aortic disease, recommending conventional surgery in most elective cases.
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http://dx.doi.org/10.1177/1526602820951265DOI Listing
December 2020

Everything Flows, Nothing Stays Still.

Eur J Vasc Endovasc Surg 2021 02 5;61(2):227. Epub 2020 Aug 5.

German Aortic Centre Hamburg, Department of Vascular Medicine, University Heart & Vascular Centre, Hamburg, Germany.

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http://dx.doi.org/10.1016/j.ejvs.2020.06.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405874PMC
February 2021

Use of a Steerable Sheath for Antegrade Catheterization of a Supra-aortic Branch of an Inner-Branched Arch Endograft via a Percutaneous Femoral Access.

J Endovasc Ther 2020 Dec 7;27(6):917-921. Epub 2020 Jul 7.

German Aortic Center, Department of Vascular Medicine, University Heart & Vascular Center Hamburg, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

To describe the use of a steerable sheath from a femoral access for antegrade catheterization of the left common carotid artery (LCCA) in an inner-branched arch endograft. This technique is demonstrated in a patient with residual aortic dissection after replacement of the ascending aorta for acute type A aortic dissection. He presented 4 years later with aneurysmal degeneration of the thoracoabdominal aorta and a proximal tear located in the aortic arch. A 2-stage hybrid approach was devised to treat the patient. An axilloaxillary crossover graft (left to right) with plug occlusion of the innominate artery was performed initially. Later, a dual-branched custom-made device was implanted. To avoid an additional LCCA cutdown for retrograde branch access, an 18-F steerable sheath was used through a percutaneous femoral access. Two wires were delivered within the steerable sheath: the first one was directed into the left subclavian artery to stabilize the sheath position in the ascending aorta; the second wire was used to catheterize the first inner branch and the LCCA to deploy the covered bridging stent. Transfemoral access to catheterize antegrade branches for supra-aortic vessels is feasible using a large steerable sheath in branched endovascular arch repair.
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http://dx.doi.org/10.1177/1526602820939936DOI Listing
December 2020

Technical Aspects of Branched Thoracic Arch Graft Implantation for Aortic Arch Pathologies.

J Endovasc Ther 2020 Oct 20;27(5):792-800. Epub 2020 May 20.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Purpose: To describe the implantation steps and tips and tricks for the Inner Branch Arch Endograft designed to treat aortic arch aneurysm and chronic type A aortic dissection.

Technique: Anatomical suitability criteria should be met in order to use this device. The proximal segment of the graft lands in the ascending aorta distally to the sinotubular junction and the distal segment lands in the descending aorta. The device includes 2 inner branches; the proximal branch is used for a connection to the innominate artery (positioned slightly posterior at 12:30 o'clock), while the second branch is positioned slightly anterior at 11:30 o'clock and is used as a connection to the left common carotid artery. Access, implantation technique, deployment of the device, and catheterization of the branches are described thoroughly.

Conclusion: This Inner Branch Arch Endograft is an appealing alternative to treat aortic arch pathology, especially in patients unsuitable for open repair. Nevertheless, complex aortic arch repair is associated with a learning curve. Meticulous preoperative planning and a high level of concentration intraoperatively are mandatory.
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http://dx.doi.org/10.1177/1526602820925443DOI Listing
October 2020

Hypogastric Artery Stenting for Chronic Intermittent Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair.

J Endovasc Ther 2020 Oct 20;27(5):801-804. Epub 2020 May 20.

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Purpose: To report a case of chronic intermittent spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and its successful treatment using hypogastric artery stenting.

Case Report: A 79-year-old patient presented in May 2013 with a thoracic aortic aneurysm (TAA) and a contained rupture. He urgently underwent TEVAR that covered 274 mm of descending thoracic aorta without immediate postoperative signs of acute SCI. At 3-month follow-up, he reported repeating incidents of sudden lower extremity weakness leading to a fall with a humerus fracture. A neurological consultation revealed the tentative diagnosis of intermittent SCI caused by TEVAR and initially recommended a conservative approach. During the following year there was no clinical improvement of the symptoms. Computed tomography angiography showed a high-grade stenosis of the right hypogastric artery, which was stented in November 2014 to improve the collateral network of spinal cord perfusion. Following treatment, the patient had no further neurological symptoms; at 32 months after the reintervention, the imaging follow-up documented a patent stent and continued exclusion of the TAA.

Conclusion: Intermittent neurological symptoms after TEVAR should be suspected as chronic intermittent SCI. The improvement of collateral networks of the spinal cord by revascularization of the hypogastric artery is a viable treatment option.
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http://dx.doi.org/10.1177/1526602820925445DOI Listing
October 2020
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