BACKGROUND:The aim of this study was to gain insight in how patients with an abdominal aortic aneurysm (AAA) or peripheral arterial disease (PAD) experience shared decision-making (SDM) and to examine the role of health literacy (HL), specifically the domain of knowledge and information provision. METHODS:An original qualitative descriptive study was conducted using the principles of reflexive thematic analysis. Semi-structured interviews were conducted with purposively sampled vascular surgery patients from the University Medical Center Groningen and Ommelander Hospital Groningen between March and September 2024. Data collection and analysis followed an iterative approach, with interviews audio-recorded, transcribed, and analyzed inductively. Health literacy (Brief Health Literacy Screener), frailty (Groningen Frailty Indicator), and cognition (Mini-Cog) were assessed to contextualize findings. Data saturation was reached when no new insights emerged. Descriptive statistics were used for quantitative measures. RESULTS:Data saturation was reached after conducting 11 interviews. Four themes emerged regarding SDM and HL disease knowledge and information provision: 1) the decision; 2) desires, goals, and concerns; 3) information; and 4) disease knowledge. While some patients perceived active participation, most felt minimally involved, partly because their goals and concerns were not actively addressed by the treating physician. Patients generally regarded the vascular surgeon as their primary source of information. Knowledge levels and information needs varied between the included patients, influencing patient engagement in SDM. CONCLUSIONS:In this qualitative study, patients with AAA or PAD generally felt minimally involved in decision-making and often assumed that their vascular surgeon was unaware of their personal goals. Disease knowledge was typically limited, likely hindering patient participation in SDM.
BACKGROUND:The chimney technique may offer an alternative approach for managing juxta- and pararenal abdominal aortic aneurysms (AAA). This analysis presents the outcomes of the chimney technique and compares elective chimney and fenestrated endovascular aortic repair (FEVAR) findings in complex AAA. METHODS:The STROBE statement was followed to conduct a single-center retrospective analysis of patients who underwent chimney for complex AAA from January 1, 2016, to December 31, 2024. A comparison between elective chimney and FEVAR cases was also performed. Primary outcomes included technical success, mortality and survival. RESULTS:Seventy-two patients underwent chimney (94.4% males); 60 elective cases. Regarding the total chimney cohort, technical success was 98.6% and 30-day mortality 11.1%. Gutter endoleaks were detected in 6.9%; all resolved at 30 days. The mean follow-up was 36.8±5.8 months. Survival was 48.2% (standard error [SE] 9.5%) and freedom from reintervention was 87.3% (SE 6.5%) at 60 months. Forty-one elective FEVARs were compared to 60 elective chimney cases. Elective chimney patients had significantly larger aortic diameters (63 [Q1:56, Q3:78] mm vs. 56 [Q1:54, Q3:66] mm, P=0.02). Technical success (P=0.79) and 30-day mortality (P=0.30) were similar. The mean follow-up in elective chimney was longer compared to FEVAR (40.0±6.3 vs. 27.5±6.3 months; P=0.03). The estimated survival was consistently significantly lower in elective chimney cases (log rank; P=0.003) while freedom from reintervention was similar (P=0.88). CONCLUSIONS:The chimney technique demonstrated acceptable 30-day outcomes. Compared to elective chimney, 30-day FEVAR outcomes were similar, but FEVAR survival was significantly higher. The need for reintervention was equal.
BACKGROUND:Bridging stent grafts (BSG) are a critical component of fenestrated and branched endovascular aortic repair (f/bEVAR) but remain prone to structural failure due to continuous biomechanical stress. Early detection of stent wire fractures is clinically relevant, yet remains challenging with conventional computed tomography (CT) because of limited effective spatial resolution and metal-related blooming artifacts. The aim of the study is to evaluate whether photon-counting detector CT (PCCT) improves the detectability of structural defects in BSG compared with dual-energy CT (DECT). METHODS:An in vitro phantom model incorporating commercially available BSGs with predefined wire fractures was examined using PCCT and DECT across multiple Siemens IQ (dose/resolution) levels. Seven experienced human observers assessed defect visibility using a five-point Likert scale. Interobserver agreement was evaluated using Fleiss' kappa. Quantitative analysis was performed using relative full width at half maximum (FWHM) measurements, expressing defect width relative to stent diameter. RESULTS:PCCT demonstrated markedly superior visibility of stent fractures compared with DECT. Mean Likert scores were 4.66±0.43 for PCCT versus 2.56±0.62 for DECT (median 4.86 vs. 2.43; P<0.001). Ratings indicating good to excellent visibility (Likert 4-5) accounted for 94.7% of PCCT assessments but only 16.9% with DECT. Interobserver agreement was substantially higher for PCCT (κ=0.295) than for DECT (κ=0.004). Quantitative analysis revealed significantly larger relative FWHM values with PCCT (0.72±0.08) compared with DECT (0.60±0.12; P<0.001), consistent across stent types and IQ levels. PCCT achieved stable high detectability already at intermediate IQ levels, whereas DECT showed a gradual dose-dependent improvement. CONCLUSIONS:In this controlled experimental setting, PCCT substantially outperformed DECT in the detection of structural bridging stent graft failure, both in subjective and quantitative analyses. These findings suggest that structural BSG defects may be substantially underdetected with conventional CT and that PCCT enables a fundamentally improved level of detectability. This has potential implications for post-f/bEVAR surveillance and warrants further in vivo evaluation.
BACKGROUND:Target vessel outcomes affect fenestrated and branched endovascular aortic repair (f/bEVAR) durability. This systematic review and meta-analysis aimed to assess Viabahn balloon expandable (VBX) covered stent outcomes for bridging in f/bEVAR. METHODS:This systematic review was conducted according to PRISMA (PROSPERO: CRD420251034221). Database search was performed in PubMed, Cochrane Library and Embase. Studies between 2017-2025 reporting on f/bEVAR patients managed with bEVAR using the VBX for target vessel bridging were included. The risk of bias was assessed with ROBINS-I and the quality of evidence with GRADE. Target vessel technical success, instability (TVI), occlusion/stenosis, endoleak and reintervention rate were assessed as primary outcomes. RESULTS:Among 1728 studies, 16 were included (2214 patients, 5440 target vessels; 4406 branches, 993 fenestrations; 2918 bridged using VBX). Eight studies were at serious and eight at moderate risk of bias (ROBINS-I). Quality of evidence was 'very low' for all primary outcomes (GRADE). The median follow-up was 12.1 months (95% CI 9.1-15.1). Target vessel technical success was 98.9% (95% CI 97.3-99.5%; I2=0%), while TVI was 5.4% (95% CI 3.7-7.6%; I2=62%), occlusion/stenosis 3% (95% CI 1.8-4.9%; I2=62%), endoleak Ic/IIIc 2.9% (95% CI 2.2-3.7%; I2=0) and reintervention rate 3.1% (95% CI 1.6-6.1%; I2=54%). Analysis per vessel type revealed higher TVI for renal arteries. Subgroup analysis per incorporation type revealed higher technical success, but worse TVI, occlusion/stenosis and reintervention rate for branches. CONCLUSIONS:The VBX demonstrated high technical success and low complication rate. Target vessel incorporation with branches carried higher rates of complications compared to fenestrations.
BACKGROUND:Fenestrated endovascular aortic repair (FEVAR) is an established treatment for complex abdominal aortic aneurysms involving the renovisceral segment. Long-term durability remains dependent on bridging stent performance, yet prospective device-specific data remain limited. The fenCo study was designed to evaluate the clinical performance and safety of the iCover balloon-expandable covered stent (iVascular) used as a bridging stent during FEVAR. METHODS:fenCo is a prospective, multicenter, open-label, single-arm European clinical investigation conducted in 24 high-volume centers under Regulation (EU) 2017/745. The study aims to include 165 patients undergoing FEVAR for juxtarenal, pararenal, suprarenal, or thoracoabdominal aneurysms using an IFU-compliant fenestrated endograft. All target vessels are bridged exclusively using the iCover balloon-expandable covered stent. Follow-up is planned at discharge, 6 months, and 12 months, with optional extension to 5 years. RESULTS:The primary efficacy endpoint is bridging-stent patency at 12 months, defined as absence of binary restenosis (≥50% stenosis) or occlusion on imaging. The primary safety endpoint is freedom from target vessel instability, defined as a composite of aneurysm rupture, target vessel occlusion, component separation, branch-related endoleak, or branch-related reintervention. Secondary endpoints include technical success, endoleaks, reinterventions, mortality, aneurysm sac evolution, and renal outcomes. CONCLUSIONS:fenCo will provide prospective multicenter European data on the safety and performance of the iCover stent used as a bridging stent during FEVAR using predefined imaging-based and clinically adjudicated endpoints. The study is expected to strengthen the evidence base for bridging stent selection in complex endovascular aortic repair.
BACKGROUND:Bridging stent graft (BSG) durability remains a key limitation of fenestrated and branched endovascular aortic repair (f/bEVAR). This multicenter registry evaluated early and mid-term outcomes of the iCover balloon-expandable covered stent graft as a renovisceral BSG. METHODS:Consecutive adult patients undergoing f/bEVAR with implantation of at least one iCover BSG between February 2022 and December 2025 were retrospectively included from six Austrian tertiary aortic centers. Only renovisceral target vessels were analyzed. Endpoints included technical success, target vessel patency, BSG-related endoleaks, reinterventions, and survival. RESULTS:The cohort included 146 patients with a median age of 73.0 years (IQR, 67.0-76.0); 102 patients (69.9%) were male. A total of 494 iCover BSGs were implanted: 104 in the celiac artery, 137 in the superior mesenteric artery, and 253 in renal arteries. Technical success was achieved in 475 BSGs (96.2%). Nineteen technical failures occurred, including 11 renal and 8 visceral target vessels. Median follow-up was 376 days (IQR, 86-755). Target vessel patency was 482/489 evaluable target vessels (98.6%). iCover-related reintervention occurred in 17 patients (11.6%). Type Ic/IIIc endoleaks were observed in 15 (10.5%) patients. Estimated overall survival was 92.9% at 30 days, 86.7% at 1 year, and 84.1% at 2 years. CONCLUSIONS:In this national multicenter registry, iCover BSGs demonstrated high technical success and favorable early to mid-term patency. Branch-related endoleaks and reinterventions highlight the ongoing importance of renovisceral reconstruction durability after f/bEVAR.
BACKGROUND:This study aims to report the results of target vessels (TVs) bridged with more than one bridging stent-graft (BSG) in branched endovascular aneurysm repair (BEVAR) and assess the impact of hybrid configuration, BSG selection and relining on the outcomes. METHODS:Retrospective bicentric study including patients undergoing BEVAR for TAAA between January 2010-November 2025. Primary endpoints included primary patency and BSG-related endoleaks, reinterventions and target vessel instability (TVI). Endpoints were compared between TVs with one or more BSG, with or without hybrid configuration (balloon expandable stent-graft [BESG] + self-expandable stent-graft [SESG]), and with or without relining. A subanalysis in the subset of renal arteries (RAs) was also performed. RESULTS:Four hundred fifteen patients with 1081 vessels targeted with branches were included. 922 (85%) TVs were stented with one BSG and 159 (15%) with more than one device. Of those 159 TVs, 34 (21%) had a hybrid BESG+SESG configuration. Relining was performed in 250 (23%) TVs. Median follow-up was 20 months (IQR 8-45). In RAs, TVs with hybrid configuration presented better primary patency (Breslow P=0.004) and better freedom from TVI (Breslow P=0.019). Cox regression confirmed the type of BSG as an independent risk factor for primary patency and TVI with hybrid configuration performing better than BESG and SESG alone. CONCLUSIONS:Hybrid BESG+SESG configuration presented better primary patency and TVI in RAs targeted with branches in our series. The use of relining or combinations of more than one BSG without hybrid configuration did not show any significant improvement in TV related outcomes.
BACKGROUND:Transradial cardiac catheterization (TRC) and radial artery (RA) use during coronary artery bypass surgery (CABG) have become more frequent. Several studies have suggested decreased patency of the catheterized RA (c-RA). We sought to compare the patency of the c-RA versus the non-catheterized RA (nc-RA) in CABG patients. METHODS:Fifty-one patients undergoing CABG with bilateral RA grafting and who had prior TRC were retrospectively evaluated using cardiac computerized tomographic angiography (CTA) to assess for graft patency. Each patient had a c-RA and nc-RA utilized for CABG and thus each patient served as their own control. The right RA was used for cardiac catheterization in all patients. Patency rates were calculated based on the number of distal anastomoses. RESULTS:Average age was 58.6 years and 5 (10%) were female. There were no deaths in the 51 patients. The mean time from TRC to CABG was 16 (1-141) days and from CABG to follow up CTA was 618 (29-1787) days. The c-RA and nc-RA demonstrated no statistically significant differences in overall patency when grafted to only left sided target vessels (83% vs. 88%; P=0.51). The c-RA had a numerically lower patency than the nc-RA when grafted to right sided vessels (60% vs. 79%; P=0.39). Overall patency was not significantly different for the c-RA and nc-RA (79% vs. 86%; P=0.34). CONCLUSIONS:The c-RA and the nc-RA, demonstrated no statistically significant differences in overall patency suggesting that instrumentation of the RA may not be an absolute contraindication for use as a bypass graft during CABG.
BACKGROUND:The aim of this study is to compare early target vessel (TV) outcomes, procedural efficiency, and postoperative geometrical configuration of a dedicated flaring bridging stent graft with an established balloon-expandable covered stent graft in patients undergoing FEVAR or F/BEVAR. METHODS:This retrospective comparative cohort study included consecutive patients with FEVAR or F/BEVAR between September 2018 and February 2026. TVs treated with BeFlared were compared with TVs treated with BeGraft Peripheral. Primary endpoints were technical success and geometrical layout analysis. RESULTS:The study cohort comprised 225 patients and 831 TVs, including 159 treated with BeFlared and 672 treated with BeGraft Peripheral. Target-vessel distribution was comparable between groups. Technical success was 99.4% for BeFlared and 97.9% for BeGraft Peripheral (P=0.33). Thirty-day TVI occurred in 0.6% versus 2.1%, respectively (P=0.33). BeFlared was associated with shorter bridging stenting time (5.1 [4.3-6.2] vs. 7.5 [4.9-9.6] minutes; P<0.001) and shorter fluoroscopy time per vessel (4.4 [4.3-4.7] vs. 7.0 [5.9-8.6] minutes; P<0.001). Geometrical analysis showed a shorter and more standardized protrusion length with BeFlared (5.27±0.47 vs. 5.75±1.05 mm; P<0.001), a higher superior flaring angle (67.2±11.3 vs. 64.8±12.8 degrees; P=0.02), and a higher flaring ratio (0.96±0.03 vs. 0.94±0.04; P<0.001). CONCLUSIONS:In this retrospective comparison, the dedicated flaring bridging stent demonstrated comparable technical success and early TV outcomes to BeGraft Peripheral, while reducing bridging stenting and fluoroscopy time per vessel. Overall flaring geometry was broadly similar, with BeFlared showing more standardized protrusion length. Longer-term follow-up is required to determine whether these procedural and geometrical advantages translate into improved durability.
Target vessel incorporation with bridging balloon- and self-expandable stent grafts is an essential component to the long-term success of fenestrated and branched endovascular aortic repair (FB-EVAR). This narrative review summarizes contemporary evidence regarding bridging stent-graft performance and target vessel outcomes during FB-EVAR, with emphasis on analyses from sponsor-investigator investigational device exemption (SI-IDE) protocols and United States Aortic Research Consortium (US-ARC). FB-EVAR achieves high technical success and durable mid-term target vessel (TV) patency, with 5-year primary and secondary patency rates generally exceeding 90%. Target vessel instability (TVI) is mainly driven by TV-related complications such as stenosis, occlusion, and type Ic/IIIc endoleaks. Reinforced fenestrations tend to provide superior renal durability compared with directional branches, although most studies were biased by differences in aneurysm extent with predominance of directional branches in more extensive aneurysms. Furthermore, fenestrations are generally best suited for patients with narrow aortic luminal diameter and a fenestration-aortic wall gap distance <5 mm. US-ARC analyses also suggest that self-expandable and hybrid stent-graft constructs reduce the incidence of target events, primarily less endoleaks and reinterventions compared to balloon-expandable stent-grafts, while maintaining similar patency rates. Overall, most secondary interventions are minor and can be performed using percutaneous approach.
BACKGROUND:Pelvic venous disease (PeVD) and lymphedema are traditionally regarded as distinct clinical entities and are usually investigated and managed within separate clinical frameworks. However, both conditions may coexist in patients with chronic edema, raising the question of whether a venous-lymphatic interaction contributes to chronic edema and whether such a relationship is supported by current evidence. METHODS:A systematic-style review was performed of published literature on pelvic venous disorders, chronic venous disease, and lymphatic dysfunction. Evidence relating to pelvic venous reflux, central venous obstruction, lymphatic pathophysiology, imaging, and treatment outcomes was critically evaluated, with explicit distinction between established evidence, indirect associations, and hypotheses. RESULTS:The evidence base consists predominantly of observational studies and systematic or narrative reviews. Across published cohorts and reviews, the predominant reported outcome measure for reflux-dominant pelvic venous disease is pelvic pain, with pain improvement reported in approximately 70-80% of patients following embolization. In contrast, the predominant reported outcome measure for obstruction-dominant pelvic venous disease is edema, with subjective improvement reported in approximately 60% of patients following iliocaval with or without caval venous stenting, although edema outcomes are rarely quantified and are not distinguished from lymphedema in the available literature. Objective lymphatic dysfunction is frequently reported in advanced chronic venous disease, but pelvic venous pathology has not been systematically evaluated in relation to lymphatic dysfunction or lymphatic assessment. CONCLUSIONS:Current evidence does not establish a causal relationship between pelvic venous disease and lymphedema. While venous-lymphatic interaction is biologically plausible, the proposed surgical continuum should be regarded as hypothesis-driven rather than evidence-based. Routine pelvic venous intervention for lymphedema cannot be justified based on existing data, highlighting the need for integrated prospective studies combining venous and lymphatic assessment.
BACKGROUND:To perform a systematic review and meta-analysis of studies reporting the incidence of post-dissection aneurysms and need for secondary interventions after surgery for acute type A aortic dissections (ATAAD). METHODS:Following PRISMA guidelines, MEDLINE and CENTRAL databases were searched from inception to June 2023 for longitudinal studies reporting post-dissection aneurysmal formation and secondary interventions after surgery for ATAAD. The main outcome was the incidence of post-dissection aneurysms. Secondary outcomes included the incidence of post-dissection suture-line complications and secondary interventions related to aneurysmal complications. Additionally, the overall and aortic-related mortality during follow-up were pooled. RESULTS:One hundred and twenty-eight studies were included. The pooled calculated incidence of post-dissection aneurysmal formation after surgery for ATAAD was 10.24% (95% CI: 8.03-12.66). On sensitivity analysis considering only studies assessed having low risk of bias, incidence of post-dissection aneurysms increased to 24.9% (95% CI: 17.9-33.3). The incidence of suture line complications was 1.59% (95% CI: 0.98-22.30) and the incidence of late secondary interventions related to aortic aneurysmal complications was 12.00% (95% CI 10.12-14.00). Lastly, the calculated overall mortality was 17.53% (95% CI 14.71-20.53) and the aortic-related mortality was 1.59% (95% CI 1.08-2.18). CONCLUSIONS:The incidence of post-dissection aneurysmal formation in patients after previous surgery for acute type A aortic dissection in primarily untreated segments remains frequent. The reporting of this long-term issue has been broadly adopted in the aortic literature. Further studies are needed to assess the initial surgical strategy and its extent as well as a stringent follow-up protocol on early detection and intervention in these patients.
BACKGROUND:Since the introduction of Frozen Elephant Trunk in 2007, our center has refined surgical techniques, patient selection, and perioperative management. This study assesses how nearly two decades of institutional experience influenced indications, outcomes, and technical strategies. METHODS:This is a retrospective, single-center analysis of 417 patients undergoing Frozen Elephant Trunk between 2007 and 2024, stratified into three Periods (2007-2013; 2014-2019; 2020-2024). Indications included Stanford type A/B acute and chronic aortic dissections, residual dissections and degenerative aneurysms. Survival, freedom from thoracic endovascular aortic repair, and distal stent graft-related complications were assessed using Kaplan-Meier analysis. RESULTS:Across Periods, acute type A dissections increased significantly (10% to 29.4%, OR 2.24, 95% CI 1.27-3.96, P<0.001). Surgical refinements included shifting distal anastomosis from zone 3 to zone 2, transitioning from island to separate supra-aortic vessel reimplantation, and adopting the Thoraflex Hybrid prosthesis. Visceral ischemia time decreased significantly (60 [IQR29] to 32 [IQR11] minutes, MD 11.83, 95% CI 15.94-7.72, P<0.001), and spinal cord injury rates declined (12.8% to 2.8%, OR 0.23, 95% CI 0.07-0.77, P<0.001). Thirty-day mortality remained stable, while 5-year survival improved (75.2% to 91.3%, P=0.29). Distal stent graft-induced new entry increased in Period 3. Endovascular repair for graft kinking became more frequent consistent with increasingly complex anatomies. CONCLUSIONS:Progressive institutional experience with Frozen Elephant Trunk has broadened indications to more complex cases, reduced ischemia times, and improved neurological outcomes without compromising survival. Institutional learning is pivotal in optimizing outcomes and expanding applicability in complex aortic surgery.
Acute pulmonary embolism (PE) remains a leading cause of cardiovascular mortality worldwide. Effective management hinges on accurate risk stratification - classifying patients as high, intermediate, or low risk - to guide reperfusion strategies. This review evaluates the contemporary role of systemic thrombolysis, with a focus on the balance between rapid hemodynamic restoration and the risk of catastrophic hemorrhage. For high-risk PE characterized by hemodynamic instability, systemic thrombolysis remains the gold standard, offering a significant survival benefit that outweighs bleeding risks. Conversely, in intermediate-risk PE, it has been demonstrated that while full-dose thrombolysis prevents hemodynamic decompensation, it is associated with a significant increase in major bleeding and intracranial hemorrhage. Consequently, current guidelines generally support a "rescue thrombolysis" strategy rather than routine, up-front administration in this population. Encouragingly, recent small studies appear to demonstrate reduced-dose protocols that maintain efficacy while minimizing risk of major bleeding. While the acute effects of thrombolysis on hemodynamics are clear, there is conflicting evidence regarding the impact of thrombolysis on long-term sequelae such as chronic thromboembolic pulmonary hypertension (CTEPH). Ultimately, clinical decision-making must prioritize immediate hemodynamic risk while carefully evaluating contraindications to minimize adverse outcomes.
BACKGROUND:The pulmonary embolism response team (PERT) was first established in 2012 to aid in timely risk stratification and management of acute pulmonary embolism (PE). While this model has been widely adopted in many hospitals, only recently has sufficient data accumulated to allow systematic evaluation of whether PERTs produce measurable improvements in clinical outcomes. This review examines patient outcomes with PERT team implementation, in comparison to outcomes without PERT evaluation. METHODS:The PubMed database was searched for "pulmonary embolism response teams" and related Medical Subject Headings (MeSH). Eligible studies compared outcomes of PERT activation with non-PERT outcomes, and included at least ten patients. RESULTS:A total of 19,968 patients across 26 studies were included. Across the available literature, PERT implementation was associated with a trend toward lower mortality (8.2%, vs. 8.8% without PERT). PERT implementation was also associated with trends towards fewer recurrent deep venous thromboses (DVTs), shorter hospital and ICU length of stay (6.2 vs. 7.2 days total LOS, 2.1 vs. 2.8 days in ICU), and fewer bleeding events (7.0% vs. 7.3%). CONCLUSIONS:Current data is mostly observational and limited by significant variability in study design, however overall improved outcomes were seen for PERT compared to non-PERT patients. In hospitals with adequate capacity, PERT should be considered the standard of care for the management of acute pulmonary embolism. As the PERT model continues to evolve, continued optimization of PERT structure, consistency, and evidence-based activation will be critical to realizing its full potential in improving outcomes for patients with acute pulmonary embolism.
Pulmonary embolism (PE) is one of the leading causes of cardiovascular mortality in the United States. Even in those patients who get treatment in the acute phase, they are at risk of developing pulmonary hypertension, recurrent PE, which can lead to functional impairment and decreased survival. Interventional therapies for PE are reserved for unstable patients with high-risk PE or stable patients at high risk for decompensation. Several large-bore devices are currently approved for the treatment of PE and can provide expeditious thrombus removal without the need for lytic agents. Here, we review some of the large-bore catheter devices available for the treatment of acute PE.
