Publications by authors named "Konstantinos Spanos"

160 Publications

Ascending aortic intramural hematoma: current concepts.

Curr Opin Cardiol 2022 Jul 16. Epub 2022 Jul 16.

Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Purpose Of Review: Type A intramural hematoma (TAIMH) is an acute aortic disease characterized by the presence of hematoma in the aortic media and involving the ascending aorta. Open repair seems to be the first treatment approach, although recent evidence highlights that the best management of TAIMH is controversial. This review will focus on the current concept for TAIMH management and factors affecting the decision making.

Recent Findings: Recent studies have evaluated the role of open and endovascular repair, as well as conservative management in patients with TAIMH. More specific imaging findings seem to affect decision making for urgent repair.

Summary: Despite TAIMH's acute nature, conservative management seems to represent a valid option for urgent approach, presenting similar mortality to open and endovascular repair. Comparative data are limited, however, in experienced centers, any approach may be applied with encouraging results. Endovascular management, which is mainly applied to manage retrograde TAIMH, is related to lower mortality and morbidity compared to open repair in this group of patients while aortic remodeling seems beneficial with this approach. Imaging findings, as ulcer-like lesions, hematoma thickness, concomitant dissection and aortic diameter, related to higher complication rate, set the indication for interventional management. Further research, including prospective data and registries, and ideally, randomized data may further clarify the best approach and factors indicating urgent repair.
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http://dx.doi.org/10.1097/HCO.0000000000000984DOI Listing
July 2022

The Impact of Iliac Artery Anatomy on Distal Landing Zone After EVAR During the 12-Month Follow-Up.

Ann Vasc Surg 2022 Jun 30. Epub 2022 Jun 30.

Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: Proximal sealing zone has been the main interest in endovascular abdominal aortic aneurysm repair (EVAR), although the distal landing zone remodeling may also affect EVAR durability. The aim of this study was to assess iliac anatomy and its potential impact on distal landing zone adverse events after EVAR during the 12-month follow-up.

Methods: A prospective data collection of patients treated with standard bifurcated EVAR devices for abdominal aortic aneurysm was undertaken between 2017 and 2019. Patients that received extension to the external iliac artery were excluded. Follow-up included computed tomography angiography (CTA) at the 1st and 12th month postoperatively. The common iliac artery (CIA) diameter was assessed in three levels: origin (just below the aortic bifurcation), distally (just above the iliac bifurcation) and the middle of the distance between these two landmarks. Iliac angle, tortuosity indexes, relining and oversizing were also analyzed. Distal landing zone-related adverse events were any limb related re-intervention, endoleak type Ib, graft migration, limb stenosis, or occlusion.

Results: In total, 268 iliac limbs (134 patients) were included. In all three levels, the mean iliac artery diameters increased at 12-month follow-up. At the origin of the CIA, the diameter increased from 18.7 ± 10.5 mm to 19.9 ± 9.4 mm (P = 0.04), at the middle portion of the CIA, the diameter changed significantly from 15.5 ± 5.1 mm to 17.4 ± 5.4 mm (P < 0.001) and at the distal CIA, from 14.6 ± 3.3 mm to 15.1 ± 3.9 mm (P = 0.03). The iliac angle remained stable (P = 0.14) while the CIA index decreased significantly from 1.17 ± 0.13 to 1.11 ± 0.09 (P < 0.001). The mean value of oversizing was 21.5 ± 14.5% and affected distal iliac diameter increase (P < 0.001). The composite outcome of distal landing zone adverse events was not associated to diameter changes at any level. In 57 cases, a distal iliac diameter ≥18 mm was recorded. The estimated oversizing was lower (16.3 ± 11.8%) compared to <18 mm arteries (22.5 ± 14.9%, P = 0.01). At 12-month follow-up, iliac diameters remained stable in the ≥18 mm group. Endoleak type Ib was more common in iliac arteries ≥18 mm [3 (5.3%) vs. 1 (0.5%) (P = 0.04)] at 12-months.

Conclusions: Post-EVAR iliac artery dilation does not seem to have an impact on distal landing zone adverse events during the 12-month follow-up. Aggressive oversizing may be related to iliac dilation. EVAR patients with iliac arteries ≥18 mm are at higher risk for ET Ib.
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http://dx.doi.org/10.1016/j.avsg.2022.06.011DOI Listing
June 2022

Anatomic variations of the recurrent laryngeal nerve according to the inferior thyroid artery and their clinical impact in patients undergoing thyroidectomy.

J Laryngol Otol 2022 Jun 20:1-24. Epub 2022 Jun 20.

Department of Anatomy, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1017/S0022215122001360DOI Listing
June 2022

Artificial intelligence application in vascular diseases.

J Vasc Surg 2022 May 31. Epub 2022 May 31.

Deontology and Bioethics Laboratory, Faculty of Nursing, School of Health Sciences, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1016/j.jvs.2022.03.895DOI Listing
May 2022

Sex specific outcomes after complex fenestrated and branched endovascular aortic repair A systematic review and meta-analysis.

Eur J Vasc Endovasc Surg 2022 May 19. Epub 2022 May 19.

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

Objectives: Females are at higher mortality risk after endovascular aortic repair. This study aimed to compare the 30-day and 12-month mortality, morbidity and re-intervention rates between sexes, treated with fenestrated or branched endovascular aortic repair (F/BEVAR).

Design: This meta-analysis was conducted according to PRISMA statement, and its protocol was registered to PROSPERO (CRD42021273418). A search of the English literature, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, until 30 July 2021, was performed.

Materials: Observational studies (2010-2021), with ≥20 patients, reporting on sex specific outcomes; mortality, acute kidney injury (AKI), spinal cord ischemia (SCI), and re-intervention, after F/BEVAR, were considered eligible.

Methods: Studies' bias was assessed using ROBINS-I and evidence quality using GRADE. The primary outcome was the sex specific 30-day mortality, AKI, SCI, and reintervention and secondary, survival and freedom from re-intervention at 12-months after F/BEVAR. The outcomes were summarized as odds ratio (OR) with 95% confidence intervals (CI).

Results: Four retrospective and one prospective study (2,421 patients; 26% females) were included. 30-day mortality was 12% in females, vs. 3% in males (OR, 2.65; 95% CI, 1.79, 3.92; Ι=0%). 30-day AKI, SCI and re-intervention rates were similar (OR, 1.45; 95% CI, 1.03, 2.03, Ι=0%; OR 1.86; 95% CI, 1.27, 2.74; Ι=38%; OR, 1.06; 95% CI, 0.66, 1.77; Ι=0%). 12-month survival rate was lower in females (OR, 0.95; 95% CI, 0.91, 0.99; Ι=38%). When excluding 30-day mortality, the 12-month survival showed no difference between sexes (OR, 0.99; 95% CI 0.95-1.02; Ι=32%). The 12-month freedom from re-intervention was similar between sexes (OR, 0.87; 95% CI, 0.75, 1.01; Ι=0%).

Conclusion: Female patients treated with F/BEVAR may present worse outcomes in terms of 30-day and 12-month survival. The high peri-operative mortality is still an issue. When excluding 30-day mortality, the 12-month survival is similar between sexes. Early morbidity and re-intervention rates seem comparable.
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http://dx.doi.org/10.1016/j.ejvs.2022.05.026DOI Listing
May 2022

Impact of true or false lumen renal perfusion after type B aortic dissection on renal volume.

J Cardiovasc Surg (Torino) 2022 Apr;63(2):124-130

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

Background: The aim of this study was to analyse the influence of true, false, and combined lumen perfusion of renal arteries on mid- and long-term kidney volume in patients with type B aortic dissection (TBAD).

Methods: Retrospective analysis of patients diagnosed with a TBAD between 2008 and 2015 in a single high-volume European center. The origin of the renal arteries was evaluated on a dedicated 3D workstation (TeraRecon Inc., San Mateo, CA, USA) and coded as either arising from the true lumen (TL), false lumen (FL) or from a combination of both (CL). Additional evaluated anatomical parameters were renal volume, length, width, and depth of the kidneys. Measurements were recorded at the time of diagnosis (T0) and at 1-month (T1), 6-months (T2), 18-months (T3) and 36-month of follow-up time (T4).

Results: A total of 131 renal arteries and kidneys were evaluated in 69 patients. Mean age was 64±13 years and 77% were male. The absolute number and percentage of assessed renal arteries/kidneys was 131 (100%) at T0, 89 (68%) at T1, 73 (56%) at T2, 57 (44%) at T3 and 43 (44%) at T4. At the time of diagnosis, 71.6% renal arteries originated from the TL, 19.1% from the FL and 9.2% from a CL. TEVAR was performed in 92.7% patients and nine patients had additional renal artery stenting. At T0 the mean renal volume was 212.1±70.9cm, 178±61.2 in women versus 222.2±70.6 in men (P=0.002). Forty-three percent of the patients had a renal volume reduction ≥15% from T0 to their last available CTA. Mixed model analysis showed a significant overall renal volume reduction of 13.7cm from T0 to T4 (P<0.05). No significant differences in renal-volume reduction were observed depending on origin of the renal artery, though an estimated reduction of renal volume from T0 to T4 of 40.8 cm was seen when the kidneys were perfused by a CL, while TL perfusion only caused a reduction of 15.6 cm and no relevant volume change over time was observed when the renal artery originated from FL. Alongside a renal volume reduction, mixed model analysis also showed a significant serum-creatinine increase, from 0.8618mg/at T0 to 1.38±0.56 mg/dL at T4 (P<0.001), as well as a significant glomerular filtration rate reduction over time, from > 60mL/min at T0 to 49±13 mL/min at T4 (P<0.001). A negative correlation was observed between creatinine values and renal volume change, while a positive correlation was observed between GFR and renal volume change (P<0.001).

Conclusions: There is a significant mid-term renal-volume reduction in patients with TBAD, independent of the origin of the renal arteries. Albeit not statistically significant, combined renal artery perfusion may lead to a greater volume reduction, potentially secondary to a relevant dynamic compression by the dissection membrane. Further multicentre studies are warranted to determine the effect on long-term renal function and on possible preventive strategies.
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http://dx.doi.org/10.23736/S0021-9509.21.12203-7DOI Listing
April 2022

Meta-analysis of Comparative Studies Between Self- and Balloon-Expandable Bridging Stent Grafts in Branched Endovascular Aneurysm Repair.

J Endovasc Ther 2022 Mar 16:15266028221083458. Epub 2022 Mar 16.

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

Purpose: Currently there is no robust evidence which type of bridging stent graft provides better outcomes after branched endovascular aortic repair (BEVAR). Self-expanding (SESG) and balloon-expandable (BESG) stent grafts are both commonly used to connect branches to their respective target vessels (TV). The aim of the current review was to evaluate the impact of the type of bridging stent grafts on TV outcomes during the mid-term follow-up after BEVAR.

Materials And Methods: The study protocol was registered to the PROSPERO (CRD42021274766). A search of the English literature was conducted, using PubMed and EMBASE databases via Ovid and Cochrane database via CENTRAL, from inception to June 30, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Only comparative studies on BEVAR reporting TV outcomes related to BESG vs SESG were considered eligible. Individual studies were assessed for risk of bias using the Newcastle Ottawa Scale. The of Recommendations, , Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcomes were primary patency, freedom from endoleak, TV instability, and re-intervention between BESG and SESG, used as bridging stents in branches. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis.

Results: Five out of 609 articles published from 2016 to 2020 were included in the analysis. In total, 1406 TV were revascularized, 547 (38.9 %) with BESGs and 859 with SESGs. The overall pooled primary patency (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.29-1.09; p=.256, I=4.24%) and freedom from branch-related endoleak (OR, 0.65; 95% CI, 0.17-1.48; p<.122, I=0.18%) did not differ between the stent types during the available follow-up (17 months, range = 12-35 months). In 4 studies (619 TV), SESG required fewer secondary interventions (OR, 1.04; 95% CI, 0.23-1.83; p=.009, I=0%) and TV instability rate was lower (OR, 0.99; 95% CI, 0.33-1.65; p=.003, I=0%) compared with BESG during the available follow-up.

Conclusion: BESG and SESG seem to perform similarly in terms of primary patency and branch-related endoleak during the mid-term follow-up. Current data from retrospective studies suggest that overall TV instability and re-intervention rates are favorable for SESG as bridging stent grafts in BEVAR.
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http://dx.doi.org/10.1177/15266028221083458DOI Listing
March 2022

Sarcopenia is a Prognostic Biomarker for Long-Term Survival after Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis.

Ann Vasc Surg 2022 Jul 12;83:358-368. Epub 2022 Mar 12.

Faculty of Medicine, Vascular Surgery Department, Larissa University Hospital, School of Health Sciences, University of Thessaly, Larissa, Greece; German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center Hamburg, Hamburg, Germany.

Background: Sarcopenia is the loss of muscle mass and strength. It manifests as decreased core muscle area in axial abdominal computed tomography scans. The predictive value of sarcopenia in outcome research has been widely discussed. A systematic review was conducted to assess sarcopenia as a biomarker in patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) and its association with long-term survival.

Methods: A systematic search of the English medical literature, published from 1991 to 2021, was conducted, using PubMed, EMBASE, and CENTRAL, as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA, 2020) guidelines. The study protocol was registered to the International Prospective Register of Systematic Reviews (CRD 42021260192). Observational studies reporting on sarcopenic and nonsarcopenic patients undergoing EVAR were included. The Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) risk of bias evaluation tool was used for the quality assessment. The outcomes were summarized as odds ratio (OR) along with their 95% confidence intervals (CI), through a paired meta-analysis. The primary outcome was 5-year survival following EVAR.

Results: Eleven observational studies, including 2,385 patients (89.6% males) treated with EVAR, between 1999 and 2018, were included in the qualitative synthesis. The mean age was 72.9 years (range 70-76.4 years). Nine of the studies reported on a negative prognostic value of sarcopenia on survival during a long-term follow-up. Six studies stratified their cohorts in sarcopenic versus nonsarcopenic patients (40.3% sarcopenic). The cutoff values (mm or mm/m) for defining sarcopenic patients were heterogeneous while ranging from 451 to 4,820 mm/m and 1,207 to 11,400 mm. Eight studies reported data on the mean follow-up duration, ranging from 27 to 101 months. Six studies reported on outcomes in terms of 5-year survival rates after EVAR, favoring nonsarcopenic over sarcopenic patients, with survival rates ranging from 58 to 93% and 24 to 60%, respectively. After a meta-analysis including 3 eligible studies, sarcopenia was associated with worse 5-year survival after EVAR (OR 0.77, 95% CI [0.58, 0.97], P < 0.001).

Conclusions: The available data derived from observational studies suggest an association between sarcopenia and worse long-term survival in patients treated with EVAR. There is a lack of a universally accepted definition for sarcopenia and future reporting standards should address this issue. Prospective studies are necessary to establish this negative prognostic value of sarcopenia on long-term survival.
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http://dx.doi.org/10.1016/j.avsg.2022.02.025DOI Listing
July 2022

Systematic review on transcaval embolization for type II endoleak after endovascular aortic aneurysm repair.

J Vasc Surg 2022 07 4;76(1):282-291.e2. Epub 2022 Mar 4.

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

Background: A persistent endoleak type II (ET II) after endovascular repair for aortic aneurysms is not always a benign condition and has been associated to sac expansion, rupture, and reintervention. A variety of different endovascular approaches are available for ET II treatment. The aim of this systematic review was to assess the currently available literature on transcaval embolization for ET II treatment after standard or complex endovascular aortic aneurysm repair.

Methods: This systematic review protocol was registered to the PROSPERO (CRD42021289686). The PRISMA guidelines and patient, intervention, comparison, outcome (P.I.C.O.) model was followed. A data search of the literature was conducted, using PubMed, EMBASE via Ovid, and CENTRAL databases, until September 30, 2021. Only studies reporting on ET II embolization using the transcaval approach after endovascular aneurysm repair were included. Studies reporting on different type of endoleak treatment or any other embolization approach were excluded. The quality of studies was assessed using the Newcastle-Ottawa Scale. Primary outcomes were technical success and freedom from ET II persistence during follow-up; secondary outcomes were any postoperative complication associated with the transcaval embolization and need for reintervention.

Results: The search yielded 2861 articles in total. Eight articles were included, reporting on 117 patients and 128 transcaval embolizations. The indication for treatment was ET II presence with sac expansion of more than 5 mm; in two studies, the presence of persistent endoleak has set the indication to intervene. The technical success was 91.4% (117/128); a variety of embolic materials were used, including coils, thrombin, and glue. Three cases of deep vein thrombosis were recorded and the remaining morbidity and mortality were null. Follow-up was ranging between 0 and 25 months. Out of 8 studies, persistent ET II rate was 12.8% and 18 reinterventions were performed (14.1%,), including 10 transcaval coil embolizations (56%). Sac expansion was reported in 11 cases, out of 3 studies (17%). Only one case of death, not associated with transcaval embolization, was recorded.

Conclusions: Transcaval embolization for ET II treatment presents a high technical success and low mortality in the early and mid-term period. ET II persistence rate is low during the available 12-month follow-up.
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http://dx.doi.org/10.1016/j.jvs.2022.02.032DOI Listing
July 2022

Proximal versus extensive repair in acute type A aortic dissection: an updated systematic review and meta-analysis.

Gen Thorac Cardiovasc Surg 2022 Apr 26;70(4):315-328. Epub 2022 Feb 26.

Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, W2 1NY, UK.

Objectives: Our aim was to compare the safety and efficacy of proximal repair (PR) versus extensive repair (ER) for acute type A aortic dissection (ATAAD).

Methods: A literature search in three databases was performed according to the PRISMA statement. Studies comparing PR versus ER for ATAAD were included. Random-effects meta-analyses were performed.

Results: A total of 27 studies incorporating 7113 patients (PR: 5080; ER: 2033) were included. Patients undergoing PR presented decreased in-hospital mortality (odds ratio [OR]: 0.67 [95% Confidence Interval (95% CI) 0.53-0.85]; p < 0.01) and post-operative bleeding (OR 0.75 [95% CI 0.60-0.95]; p = 0.02) compared to ER. Meta-regression analysis revealed that in-hospital mortality was not influenced by differences regarding the extent of dissection (p = 0.43). Cardiopulmonary bypass time (SMD:-0.93 [95% CI - 1.22, - 0.66]; p < 0.01) and length of hospital stay (SMD:-0.19 [95% CI - 0.34, - 0.05]; p = 0.01) were also lower in the PR group, while there was no difference in terms of renal failure and permanent neurological deficit. The ER approach demonstrated a lower post-discharge mortality compared to PR (OR 1.46 [95% CI 1.09, 1.97]; p = 0.01), while the post-discharge reoperation rate was comparable between the two groups. 1 and 3-year overall survival (OS) were comparable between PR and ER (OR 1.05, [95% CI 0.77-1.44]; p = 0.76) and (OR 1.27 [95% CI 0.86-1.86]; p = 0.23), respectively. The 5-year OS (OR 1.67 [95% CI 1.16-2.41]; p = 0.01) was in favor of the PR arm.

Conclusions: In patients with ATAAD, PR was associated with lower odds of in-hospital mortality but higher odds of late mortality. ER and PR demonstrated similar post-operative complication and reoperation rates.
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http://dx.doi.org/10.1007/s11748-022-01792-9DOI Listing
April 2022

Factors Associated With Noninfectious Fever After Endovascular Aortic Aneurysm Repair.

J Endovasc Ther 2021 Dec 29:15266028211065966. Epub 2021 Dec 29.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University Hospital of Larissa, University of Thessaly, Larissa, Greece.

Purpose: The post-endovascular abdominal aortic aneurysm repair (EVAR) inflammatory response, which is very often associated with fever, has been ascribed to a wide range of proinflammatory mediators and operative events. The aim of this study was to evaluate the impact of such factors in the development of fever of noninfectious origin after elective EVAR.

Materials And Methods: A retrospective analysis of prospectively collected data of patients treated with standard elective EVAR between February 2017 and December 2020 was undertaken. The database included patients' demographics and comorbidities, as well as laboratory inflammatory markers (white blood cell count, neutrophils, and C-reactive protein [CRP]) and anatomical characteristics (sac diameter, inferior mesenteric artery [IMA] patency and diameter, number of patent lumbar arteries, internal iliac artery [IIA] patency or occlusion). Intraoperative details, such as type of stent graft material and IIA overstenting, were also analyzed. Patients with infectious postoperative complications or previously receiving systemic anti-inflammatory medication were excluded. Statistical analysis was performed by SPSS 22.0 for Windows software (IBM Corp, Armonk, New York).

Results: From 332 patients treated with elective EVAR between 2017 and 2020, 268 patients (all men) were included in the analysis. The mean age was 72.1±7.5 years and the mean aneurysm diameter was 59.1±12.1 mm. Seventeen patients were excluded due to a known infection site. From the study cohort, 114 (42.5%) patients presented with fever. Multivariate regression analysis confirmed that the occlusion of IMA ≥5 mm (p<0.008) and higher CRP (p<0.001) were independent factors associated with postoperative fever. A subanalysis was performed only on patients with patent IMA before EVAR. In the multivariate regression analysis of this subgroup, IMA ≥5 mm (p=0.008), presence of dyslipidemia (p=0.037), and higher CRP (p<0.001) were related to fever.

Conclusion: Occlusion of an existing wide (≥5 mm) and patent IMA prior to EVAR may contribute to the development of post-EVAR pyrexia. The CRP is a reliable marker for post-EVAR fever. Further prospective studies are needed to corroborate these findings.
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http://dx.doi.org/10.1177/15266028211065966DOI Listing
December 2021

Uncomplicated type A intramural hematoma with extension to the descending thoracic aorta is best treated by thoracic endovascular aneurysm repair in most patients.

J Vasc Surg 2022 01;75(1):65-66

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

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http://dx.doi.org/10.1016/j.jvs.2021.08.048DOI Listing
January 2022

Gaps arising from randomized controlled trials on thrombolysis for proximal deep vein thrombosis of the lower limb.

J Vasc Surg Venous Lymphat Disord 2022 01;10(1):196-199.e2

Division of Vascular Surgery, Stony Brook Medicine, Stony Brook, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jvsv.2021.07.020DOI Listing
January 2022

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

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

J Endovasc Ther 2022 08 15;29(4):555-564. 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
August 2022

A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective settings.

J Vasc Surg 2022 03 3;75(3):1082-1088.e6. Epub 2021 Nov 3.

Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Objective: Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR), or open surgical (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings.

Methods: The protocol of the review was registered to the PROSPERO database (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE, and CENTRAL databases, from inception to March 5, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective settings, comparing EVAR and OSR, in the female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the (Risk Of Bias In Non-randomised Studies - of Interventions) ROBINS-I tool. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio, along with their 95% confidence intervals (CIs), through a paired meta-analysis.

Results: Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared with OSR (odds ratio [OR], 0.25; 95% CI, 0.23-0.27; P < .001; Ι = 86%). In addition, a reduced 30-day mortality was found in females that underwent elective EVAR compared with OSR (OR, 0.37; 95% CI, 0.33-0.41; P < .001; Ι = 48%). Despite the fact that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P < .001; Ι = 84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P < .001; Ι = 0%).

Conclusions: In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.
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http://dx.doi.org/10.1016/j.jvs.2021.10.040DOI Listing
March 2022

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

Correction to: Role of Endoluminal Techniques in the Management of Chronic Type B Aortic Dissection.

Cardiovasc Intervent Radiol 2021 Dec;44(12):2026

German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Hospital Hamburg Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

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http://dx.doi.org/10.1007/s00270-021-02949-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8626376PMC
December 2021

The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature.

Medicina (Kaunas) 2021 Sep 12;57(9). Epub 2021 Sep 12.

Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece.

Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, leading to an increased mortality rate. Novel randomized trials have added valuable information regarding cancer-associated thrombosis (CAT) management using direct oral anticoagulants (DOACs). The aim of this study is to present an overview of the current literature and recommendations in CAT treatment. A few randomized control trials (RCTs) have been integrated suggesting that DOACs may be effectively applied in CAT patients compared to low molecular weight heparins (LMWHs) with a decreased mortality and VTE recurrence rate. However, the risk of bleeding is higher, especially in patients with gastrointestinal malignancies. Real-world data are in accordance with these RCT findings, while in the currently available recommendations, DOACs are suggested as a reliable alternative to LMWH during the initial, long-term, and extended phase of treatment. Data retrieved from the current literature, including RCTs and "real-world" studies, aim to clarify the role of DOACs in CAT management, by highlighting their benefits and remarking upon the potential adverse outcomes. Current recommendations suggest the use of DOACs in well-selected patients with an increasing level of evidence through years.
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http://dx.doi.org/10.3390/medicina57090960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8471429PMC
September 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 02 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

Past Poliomyelitis with Limb Atrophy Is Not a Contraindication to EVAR.

Eur J Vasc Endovasc Surg 2021 Sep 13;62(3):386. Epub 2021 Aug 13.

Departments of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

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http://dx.doi.org/10.1016/j.ejvs.2021.06.017DOI Listing
September 2021

Clinical effect of accessory renal artery coverage after endovascular repair of aneurysms in abdominal and thoracoabdominal aorta.

J Vasc Surg 2021 12 29;74(6):2104-2113.e7. Epub 2021 Jun 29.

Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.

Background: The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms.

Methods: An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality.

Results: Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I = 0%).

Conclusions: ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.
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http://dx.doi.org/10.1016/j.jvs.2021.06.032DOI Listing
December 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

Treatment of Intramural Haematoma of the Ascending Aorta (Type A) Should be Selective.

Eur J Vasc Endovasc Surg 2021 07 20;62(1):7-8. Epub 2021 May 20.

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

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http://dx.doi.org/10.1016/j.ejvs.2021.04.012DOI Listing
July 2021

Reply.

J Vasc Surg 2021 06;73(6):2209-2210

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

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http://dx.doi.org/10.1016/j.jvs.2020.12.081DOI Listing
June 2021

Management of external jugular vein aneurysm: a systematic review.

Vascular 2022 Jun 22;30(3):590-595. Epub 2021 May 22.

Vascular Surgery Department, Larissa University Hospital, University of Thessaly, Larissa, Greece.

Introduction: Aneurysms of the jugular vein system are rare and high clinical suspicion is needed for diagnosis. External jugular vein aneurysms (EJVA) are considered innocent lesions that need treatment mainly for aesthetic reasons. The aim of this systematic review was to present current literature regarding diagnosis and management of EJVAs.

Methods: A literature review was conducted through the Pubmed/Medline and Scopus regarding articles referring on EJVA from 2000 to 2020. Using the PRISMA guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses), 30 articles were identified, according to inclusion criteria. Demographics, clinical characteristics, etiology, diagnostic imaging, complications, treatment, and histopathological findings were recorded and analyzed.

Results: Twenty-seven case reports and one case series were identified, including 30 patients and 31 EJVAs. One-third of patients (30.3%) were < 18 years old (mean age 32 years, range 1-72 years) and 54% of them were females. In 51% of the cases, the lesion was characterized as a true aneurysm after histological evaluation. The presence of a soft cervical mass was the most common clinical symptom, while Valsalva maneuver pointed out the presence of an EJVA in 66.7% of patients. Diagnosis was achieved using ultrasonography, computed tomography, or magnetic resonance imaging. Forty-three percent of the patients underwent more than one radiological examination. Twenty patients underwent surgical management. The primary indication of surgical treatment was aesthetic reasons (11/20, 55%). Thrombosis was the most common EJVA complication (11/30, 36.3%).

Conclusions: Differential diagnosis of neck mass should include EJVA. High clinical suspicion and adequate imaging are important for diagnosis. Open surgical approach is the more commonly applied therapeutic strategy.
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http://dx.doi.org/10.1177/17085381211013950DOI Listing
June 2022
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