Introduction: Branched endovascular repair has shown consistently good outcomes, being sometimes the only available endovascular solution for aortic emergencies. However, in cases of limited proximal extension of the disease, such as juxtarenal or pararenal aneurysms, branched endografts usually cover a greater extent of the aorta than needed to establish a seal zone, thus increasing the risk for spinal cord ischemia (SCI) by unnecessarily covering segmental arteries. Our objective is to analyze a series of patients who underwent proximal shortening of an off-the-shelf (OTS) branched endograft to limit aortic coverage and preserve segmental arteries. Methods: Single-center retrospective study identifying all patients undergoing branched endovascular aortic repair (BEVAR) with a shortened t-Branch, through the removal of the first stent row, from April 2020 to March 2026. Perioperative technical success and complications were evaluated. Primary endpoints were technical success. Secondary endpoints were 30-day mortality, SCI, assessment of number of saved segmental arteries, and endograft migration at follow-up. Results: Fifteen patients underwent BEVAR with a shortened t-Branch endograft. All were urgencies, 60% being ruptured abdominal aortic aneurysms (AAAs). Thirteen (86%) cases were juxta/pararenal aortic aneurysms, and 3 (20%) had a previous endovascular aortic repair. In all cases, the proximal sealing stent of the t-Branch was removed, whereas in 2 cases, an additional large posterior fenestration at the second sealing stent was created. Technical success was 93%, with 1 severely stenotic renal artery not able to be catheterized and left unbridged. No endograft deployment complication (migration or malrotation) were experienced. There was 1 postoperative mortality in a patient with a ruptured AAA. Major complication rate was 27%, including 2 patients having SCI (one grade 2, one grade 3). A median of 2 segmental arteries were saved through the endograft modification. At a median follow-up of 1 year no endograft migration was observed. Conclusions: In urgent complex aortic repair for circumscribed anatomies such as juxta/pararenal aneurysms, the use of a modified OTS branched endograft proved to be a reproducible and safe technique, allowing the preservation of segmental arteries and possibly affecting favorably the spinal cord ischemic rates. Clinical Impact On-table shortening of the t-Branch endograft, optionally creating a big fenestration at the second sealing stent, is a feasible and reproducible option for urgent juxta/pararenal aortic aneurysm repair when custom-made devices are not available. The modification allowed sparing a median of two segmental arteries otherwise covered with a standard t-Branch, which might help mitigating the risk of spinal cord ischemia.
Purpose: Juxtarenal abdominal aortic aneurysms (JAAAs) present with a short infrarenal neck that does not permit standard endovascular aneurysm repair (EVAR). The AFX VELA cuff extension with its endoskeletal architecture may reduce type Ia endoleak (TIaEL) through passive sealing. We examined this hypothesis using a double-chimney benchtop model and a clinical cohort treated with VELA-based chimney EVAR (ChEVAR). Materials and Methods: A benchtop model compared gutter leakage volumes among VELA, Endurant II and Excluder C3 (5 trials per device). A retrospective single-centre cohort (January 2018-April 2024) included consecutive JAAA patients undergoing VELA-based ChEVAR with ≥12-month follow-up. Postoperative computed tomographic (CT) morphometry compared seal-zone geometry across the 3 platforms. Results: In the benchtop model, VELA showed a median gutter leakage of 5.0 mL/min (interquartile range [IQR], 4.0-11.0), whereas both comparators exceeded 500 mL/min and were right-censored. In the clinical cohort, 20 patients (55% male; median age 80.0 years) underwent ChEVAR for JAAAs with a median diameter of 53.5 mm and infrarenal neck length of 5.0 mm. Clinically successful sac exclusion was achieved in 19 of 20 patients (95%). Intraoperative TIaEL occurred in 5 patients: 1 major endoleak was sealed with adjunctive gutter coil embolisation, and 4 minor endoleaks resolved spontaneously on the 1-month CT angiogram. Over a median follow-up of 36.5 months, no persistent TIaEL was detected on follow-up imaging, and no chimney stent-graft (SG) occlusion occurred. One patient (5%) required an aortic-related reintervention for a type Ib endoleak. Estimated glomerular filtration rate (eGFR) decreased by ≥20% in 9 patients (45%), and 1 started dialysis at 4 years. On postoperative CT morphometry, relative gutter area was lowest with VELA, intermediate with Endurant II and highest with Excluder C3; circumferential apposition followed the inverse pattern. Conclusion: In the benchtop model, VELA produced consistently lower leakage than both comparators, with concordant CT morphometric evidence consistent with a passive sealing mechanism. In this cohort, VELA-based ChEVAR achieved clinically successful sac exclusion in 19 of 20 patients (95%) with no persistent TIaEL and no chimney SG occlusion. These findings support the feasibility of VELA-based ChEVAR when FEVAR is unavailable; multicentre prospective validation is required. Clinical Impact: Persistent type Ia endoleak (TIaEL) is a principal limitation of chimney EVAR (ChEVAR) compared with fenestrated EVAR (FEVAR). We report short-to mid-term outcomes of ChEVAR using the AFX VELA cuff extension, whose endoskeletal architecture is designed to promote passive sealing. Postoperative CT morphometry comparing the 3 devices (VELA, Endurant II and Excluder C3) showed a smaller relative gutter area and higher circumferential apposition with VELA, paralleling the benchtop pattern. VELA-based ChEVAR achieved clinically successful sac exclusion in 19 of 20 patients (95%), without persistent TIaEL detected on follow-up imaging. VELA-based ChEVAR appears feasible when FEVAR is unavailable; however, multicentre validation is required.
Purpose: To compare short- and long-term outcomes of bare-metal (BMS) vs covered (CS) balloon-expandable stents in transplant renal artery stenosis (TRAS). Materials and Methods: This retrospective study evaluated patients who underwent elective stent placement for TRAS between 2016 and 2023. Short-term efficacy was assessed by clinical improvement (resolution of resistant hypertension/hypervolemia) and reduction in serum creatinine (sCr) within 14 days post-procedure. Long-term outcomes included Doppler ultrasound parameters – peak systolic velocity (PSV), acceleration time (AT) and resistive index (RI) – and restenosis/occlusion rates requiring or not intervention. Graft survival at the latest follow-up was recorded. Results: A total of 40 patients (mean age 58 ± 13 years, 68% male) were treated with BMS (n = 31) or CS (n = 9). Clinical improvement was observed in 71% of BMS and 83% of CS patients ( P = 1.00). Median sCr decreased by 26% and 33% in BMS and CS patients, respectively ( P = .30). At a median follow-up of 29 months, there were no statistically significant differences between groups in median PSV reduction (47% BMS vs 47% CS; P = .44), AT improvement (36% BMS vs 25% CS; P = .38) or RI increase (15% BMS vs 33% CS; P = .12). In the BMS group, 2 cases of in-stent restenosis occurred (6.5%). In the CS group, 1 stent occlusion occurred (11%), resulting in graft loss. At final follow-up, overall graft survival was 85%. Conclusion: In this pilot study, BMS and CS showed no significant differences in TRAS outcomes. Further studies are warranted to better guide stent selection. Clinical Impact In transplant renal artery stenosis, balloon-expandable covered stents achieved clinical, biochemical and Doppler outcomes comparable to bare-metal stents, despite being used in more complex, atherosclerotic and longer lesions. This first direct comparison suggests that covered stents may be a reasonable option when heavy calcification, a friable wall or mural thrombus raise concern for embolisation or rupture, while bare-metal stents remain appropriate for most lesions. The single late covered-stent occlusion with graft loss highlights the need for careful platform selection and antiplatelet management. These pilot data should inform adequately powered multicentre registries rather than directly change practice.
