Background: Foot ulcers and minor amputations represent notable complications of peripheral arterial disease (PAD), and this risk is further heightened by concomitant diabetes. A comprehensive assessment should account for comorbid conditions, vascular status, and prior surgical interventions to inform optimal treatment strategies. The present study evaluates the impact of PAD and revascularization on the probability of major amputation following an initial minor amputation. Methods: We conducted a retrospective cohort study of patients undergoing minor lower extremity amputation at a single tertiary referral center between 2017 and 2023. Limbs were identified using five Current Procedural Terminology codes and followed for <= 1 year after the index procedure. Data collected included demographics, comorbidities, wound characteristics, Wound, Ischemia, and foot Infection stage when available, and attempted revascularization categorized as endovascular, open, or diagnostic only. The primary exposure was PAD. Primary outcomes were major amputation at 30 days, 6 months, and 1 year, and 1-year all-cause mortality. Kaplan-Meier analysis estimated 1-year amputation-free survival with comparisons by log-rank test. Time to major amputation was evaluated using Cox proportional hazards models. Multivariable logistic regression and limb-level generalized estimating equation models accounting for within-patient clustering were performed as secondary analyses. Results: A total of 973 limbs from 861 patients who underwent minor lower extremity amputation were included (mean age, 60.2 +/- 13.3 years; 32.8% female) with PAD present in 46.0% of limbs. Progression to major amputation occurred in 11.5% of limbs during follow-up, and the 1-year all-cause mortality rates was 10.8% among limbs with known survival status. Limbs with PAD had higher crude major amputation rates compared with non-PAD limbs (16.3% vs 7.3%; P < .001). Kaplan-Meier analysis demonstrated shorter amputation-free survival among limbs with PAD (324 +/- 5 days vs 348 +/- 3 days; log-rank P < .001). In multivariable Cox analysis, PAD was independently associated with increased hazard of major amputation (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.31-3.16; P = .002), along with dialysis-dependent end-stage renal disease (HR, 2.71; 95% CI, 1.64-4.47; P< .001), thrombophilia (HR, 2.48; 95% CI, 1.21-5.07; P = .013), and Black race (HR, 1.68; 95% CI, 1.09-2.59; P = .019). Atrial fibrillation was independently associated with a lower hazard of major amputation (HR, 0.37; 95% CI, 0.16-0.89; P = .026). Revascularization was attempted in 280 limbs (61.8% endovascular, 26.8% open, 11.4% diagnostic only). Major amputation rates did not differ by revascularization strategy (P = .199). The limb-level generalized estimating equation model confirmed these findings, with PAD (P = .004), dialysis-dependent end-stage renal disease (P < .001), and thrombophilia (P = .016) remaining significant. Other covariates, including age, coronary artery disease, hypertension, smoking status, and revascularization, were not associated with major amputation. Conclusions: PAD significantly increases the risk of major amputation following a minor foot amputation. Dialysis dependence, thrombophilia, and cerebrovascular disease further contribute to this heightened risk. Notably, the specific revascularization method performed did not affect outcomes. These findings emphasize the paramount importance of assessing PAD status and comorbidity profile during patient counseling.

OBJECTIVE:Branched endovascular aortic repair (BEVAR) has been increasingly used as a treatment option for thoracoabdominal aortic aneurysms, but the risk of renal artery (RA) branch occlusion remains a concern. The aim of this study was to evaluate the effect of RA diameter and stent length on renal outcomes after BEVAR. METHODS:Clinical data from consecutive patients enrolled in two prospective, nonrandomized, physician-sponsored investigational device exemption studies between 2017 and 2025 were reviewed. Patients treated by BEVAR using patient-specific or off-the-shelf company-manufactured devices with at least one RA directional branch were included. All RA branches were treated with Viabahn (W. L. Gore & Associates, Inc) self-expandable and/or balloon-expandable stent grafts. RA diameter was stratified as ≤5 or >5 mm and branch stent length as <60 or ≥60 mm. The primary end point was the cumulative incidence of RA branch occlusion per patient. Secondary end points were RA branch primary patency, cumulative incidence of RA target vessel instability (RA-TVI; defined as any occlusion, stenosis requiring reintervention, or type Ic/IIIc endoleak), and cumulative incidence of acute kidney injury (AKI) and/or new-onset dialysis, as defined by Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) criteria. RESULTS:A total of 154 patients (62% male, 71.7 ± 9.8 years old) underwent BEVAR with 250 RA directional branches. The diameter was ≤5 mm in 76 RA branches (30%) and >5 mm in 174 RA branches (70%), whereas RA branch stent length was <60 mm in 94 branches (38%) and ≥60 mm in 156 branches (62%). After a median follow-up of 52 months (75% interquartile range, 29-85 months), there were four (2.6%) patients with four RA branch occlusions. The cumulative incidence of RA branch occlusion per patient was 2 ± 1.2% and 2.8 ± 1.4% at 1 and 5 years, respectively. The incidence of RA branch occlusion was significantly higher in smaller RAs (≤5 mm: 9 ± 5% vs >5 mm: 1 ± 1%; P = .021) and longer RA branches (<60 mm: 2 ± 2.2% vs ≥60 mm: 3 ± 1.3%; P = .797) at 5 years. Similarly, RA primary patency was lower in smaller RAs (≤5 mm: 93 ± 3% vs >5 mm: 95 ± 3%; P = .093) and longer RA branches (<60 mm: 98 ± 1% vs ≥60 mm: 89 ± 5%; P = .097) during the same period. Most RA-TVI events (80%) occurred in the first year. At 5 years, the cumulative incidence of RA-TVI was similar by RA diameter (≤5 mm: 10 ± 3% vs 11 ± 3; P = .666) and RA branch stent length (<60 mm: 13 ± 5% vs ≥60 mm: 8 ± 3%; P = .574). AKI occurred in eight patients (5%), with only two patients (1%) requiring new-onset dialysis. There was no significant difference in the cumulative incidence of AKI or new-onset dialysis by RA diameter (<5 mm: 13.3 ± 8.7% vs ≥5 mm: 3.0 ± 2.1%; P = .06), but patients with longer RA branches had an increased risk at 5 years (<60 mm: 5.7 ± 1.1% vs ≥60 mm: 7.7 ± 0.8%; P = .042). CONCLUSIONS:The incidence of RA branch occlusion was low (2.6%) among patients treated with BEVAR using Viabahn self-expandable and/or balloon-expandable stent grafts, but the risk was higher among patients with smaller RAs and longer RA branches. Similarly, smaller RAs and longer RA branches had lower primary patency, with an increased cumulative incidence of RA-TVI for longer branches. Patients with longer RA branches had an increased incidence of AKI or new-onset dialysis at 5 years. These data provide a benchmark for comparison of custom BEVAR and T-branch devices with other multibranched thoracoabdominal aortic aneurysm stent graft designs.

BACKGROUND:This study aimed to investigate the outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) patients comparing individuals with and without a prior diagnosis of peripheral artery disease (PAD). METHODS:A single-center retrospective analysis was performed, including patients with the diagnosis of complex aortic aneurysms treated with an F/BEVAR procedure. The diagnosis of PAD was determined by an ankle-brachial index <0.9 or a toe-brachial index <0.7 in nondiabetic and diabetic patients, respectively. The ischemia grade of the WIFi classification was applied to categorize patients with PAD into "mild PAD" (grades 0 and 1) and "severe PAD" (grades 2 and 3), and both groups were compared with the non-PAD cases. The primary outcomes were 30-day and 5-year survival. The secondary outcomes included 30-day major adverse events (ischemic colitis, acute kidney injury [AKI], spinal cord ischemia [SCI]), long-term major complications such as myocardial infarction [MI], stroke, and kidney function deterioration, and aneurysm-related adverse events. RESULTS:Four hundred one patients (72.3% males; mean age, 71.7 ± 8.9 years) who underwent an F/BEVAR procedure between July 2012 and October 2023 were included in the study, 95 of whom (24%) presented a prior diagnosis of PAD (73 mild; 22 severe). In terms of demographics, aneurysm extent, aneurysm maximal diameter, and comorbidities, no significant difference was observed across the 3 groups, except for the history of tobacco use (P = 0.033) and prior diagnosis of diabetes (P = 0.036), which were significantly higher among the patients with severe PAD. The 30-day survival (P = 0.483) and 30-day major adverse events such as MI (P = 0.237), stroke (P = 0.222), AKI (P = 0. 566), and SCI(P = 0.183) were not significantly different across the groups. Ischemic colitis seemed to be more frequent among mild patients with PAD (P = 0.036), but the etiology might be multifactorial. Time-to-event analysis demonstrated that patients with severe PAD have a lower long-term survival when compared to the ones without this diagnosis (Log-rank P = 0.035). Cox regression analysis demonstrated that a prior diagnosis of severe PAD is associated with a significant increase in the probability of death at 5 years post-F/BEVAR (HR:2.15, P = 0.04). As for the aneurysm-related adverse events, there was no significant difference in terms of types I, II, and III endoleaks, access complications, target vessel occlusions, and freedom from secondary interventions across the groups. CONCLUSION:Significantly lower 5-year survival is observed in the F/BEVAR cases with a preoperative diagnosis of PAD and severe ischemic component. In addition, patients with PAD might present higher incidence of ischemic colitis post-F/BEVAR, but the origin of this adverse event might be multifactorial.

OBJECTIVES:Previous literature demonstrated an association between preoperative proteinuria and mortality after endovascular repair of juxtarenal aortic aneurysms. The aim of this study is to evaluate the association of preoperative proteinuria on 1- and 5-year survival after fenestrated/branched endovascular repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs), pararenal aortic aneurysms, and juxtarenal aortic aneurysms treated with patient-specific company-manufactured devices (CMDs) or off-the-shelf devices. The impact on kidney function after F/BEVAR was also analyzed. METHODS:A retrospective analysis was performed with prospectively collected data, including patients with complex anatomy aortic aneurysms who underwent F/BEVAR at a single institution from July 2012 to February 2024. All patients were treated with a company-manufactured device or off-the-shelf devices under a physician-sponsored investigational device exemption protocol. Patients were divided into two groups based on the preoperative urinalysis performed within 30 days before the index procedure: patients with trace or no proteinuria vs patients with proteinuria (1+, 30-100 mg/dL; 2+, 100-299 mg/dL; 3+, ≥300 mg/dL). Primary outcomes were 1-year and 5-year survival. Secondary outcomes were 30-day mortality, myocardial infarction, stroke/transient ischemic attack, acute kidney injury, and spinal cord ischemia. The follow-up protocol included imaging studies (chest, abdomen and pelvis computed tomography angiography, abdominal radiography, and renal-mesenteric duplex ultrasound examination) and laboratory analysis. Time-to-event analysis was performed with Kaplan-Meier plots compared through log-rank testing. Binary logistic regression model was designed to investigate predictors associated with 5-year survival after F/BEVAR. RESULTS:A total of 454 patients underwent the F/BEVAR procedure; patients were 71.5% male and 15.4% Black, with a mean age of 72 ± 5.2 years. Sixty-seven patients (14.7%) had preoperative proteinuria of ≥30 mg/dL. Patients with and without preoperative proteinuria were similar in terms of demographics, aneurysm extension, and comorbidities, except for chronic kidney disease and cerebrovascular disease, which were more prevalent in patients with proteinuria (P < .001 and P = .011, respectively). There was no significant differences observed in 30-day mortality, acute kidney injury, spinal cord ischemia, stroke/transient ischemic attack, or myocardial infarction rates. The survival analysis demonstrated a significantly lower 1-year (77.9 ± 5.4% vs 89.4 ± 1.6%; P = .004) and 5-year survival (33.8 ± 8.8% vs 65.2 ± 3.0%; P = .002) among the patients with proteinuria when compared with individuals presenting trace or no proteinuria. Patients with preoperative proteinuria had a risk of death almost two times higher (odds ratio, 1.95; 95% confidence interval, 1.27-2.99; P = .002) and a risk of developing kidney failure requiring dialysis at 5 years more than eight times higher (odds ratio, 8.28; 95% confidence interval, 2.62-26.13; P ≤ .001). Proteinuria was a better predictor of mortality than a preoperative estimated glomerular filtration rate of <60 mL/min/1.73 m2, which was not significantly associated with this adverse event (P = .060). CONCLUSIONS:The presence of significant proteinuria preoperatively is associated with reduced 1- and 5-year survival after F/BEVAR procedure in patients undergoing repair for complex anatomy aortic aneurysms. Preoperative proteinuria can be used to aid in preoperative risk assessment of either survival or kidney function deterioration after F/BEVAR.

The aim of this study was to compare the outcomes of F/BEVAR patients treated with and without concomitant endovascular hypogastric preservation. This single-center retrospective cohort included patients with a diagnosis of Crawford types I-IV thoracoabdominal aneurysms (TAAAs), suprarenal or juxtarenal aortic aneurysms treated with either a patient-specific company-manufactured device (CMD) or an off-the-shelf device. Patients were divided into 2 groups:F/BEVAR (group-A) and F/BEVAR + iliac device (group-B). Patients in group-B had their iliac artery aneurysm treated either with an IBD (Zenith Branch Endovascular Graft ZBIS–Iliac Bifurcation–by Cook Medical), an IBE (iliac branch endograft,IBE,by Gore), or with an investigational patient-specific manufactured iliac fenestrated graft (by Cook Medical). Patients with implanted iliac devices prior to the F/BEVAR or with parallel stenting into the iliac system were excluded from the study. Primary outcomes were 30-day survival, freedom from secondary interventions (SIs), and long-term patency of the IB graft. Secondary outcomes included perioperative adverse events considering the first 30 days post-intervention and long-term survival. Four hundred ten patients treated between July/2012-February/2023 were included, 391 in group-A and 19 in group-B. Four cases in group-B had bilateral implantation of iliac grafts. The two groups were similar in terms of demographics and comorbidities. There was no difference between the groups in terms of aneurysm extent (P = .759). Mean follow-up for groups A and B were 33.6 ± 22.6 and 23.8 ± 20.1 months, respectively (P = .06). For patients in group-B, a larger volume of contrast was used (P = .007) and the duration of the procedure was longer (P = .003), as well as fluoroscopy time (P = .002) (Table I). As for the perioperative variables, there was no significant difference between the groups in terms of major cardiovascular events (P = .240), and the 30-day mortality was 2% in group-A and 0% in group-B (P > .99). There were 11 cases of spinal cord ischemia (2.8%) in group-A, but none in group-B. Considering long-term results, time-to-event analyses did not demonstrate a significant difference in freedom from SI (Log-rank P = .945) or long-term survival (Log- rank P = .545) (Fig 1) between the groups. Primary patency of the iliac grafts was 94.4% at 1 and 3 years. The incidence of Type Ib endoleak in group-A was 2.3% and 0% in group-B (P > .99). F/BEVAR for complex aortic aneurysms can be safely performed concomitantly with the endovascular treatment of common iliac artery aneurysms using iliac branched or fenestrated grafts. Despite the longer duration of the procedures, longer fluoroscopy times, and higher doses of contrast, these patients do not present significant differences in terms of short and long-term outcomes when compared to the ones that were submitted to a F/BEVAR alone.TableMain aortic device typeDevice typeF/BEVAR (n = 391)F/BEVAR + IBD/IBE (n = 19)P valueCMD356 (91.1)17 (89.4)>.99p-branch22 (5.6)1 (5.3)>.99t-branch13 (3.3)1 (5.3)>.99Intraoperative dataVariablesF/BEVAR (n = 391)F/BEVAR + IBD/IBE (n = 19)P valueEBL281.1 ± 599.3258.3 ± 279.3.755Procedure duration, minutes246.6 ± 93.8309.7 ± 77.2.003Fluoroscopy time, minutes79.4 ± 43.3114.1 ± 40.9.002Air kerma, mGy1808.52159.3.384Contrast volume, mL94.2 ± 42.6145.66 ±70.3.007Early outcomes (first 30-day period)VariablesF/BEVAR (n = 391)F/BEVAR + IBD/IBE (n = 19)P value30-day mortality8 (2)0 (0)>.99AKI (RIFLE criteria)17(4.3)1(5.2).542Spinal cord ischemia11 (2.8)0 (0)>.99MACE45 (11.5)0 (0).24030-day secondary interventions18 (4.6)0 (0)>.99Access complications50 (12.7)0 (0).146Bowel ischemia5(1.3)1 (5.3).249Postopertive hospital stay length, days5.08 ± 6.27.39 ± 15.527AKI, Acute kidney injury; CMD, custom-manufactured device; EBL, estimated blood loss; MACE, major adverse cardiovascular events.Data are presented as the total number (%) or mean ± standard deviation. Open table in a new tab

The aim of this study was to analyze the 5-year incidence of target vessel occlusion (TVO) in fenestrated/branched endovascular aneurysm repair (F/BEVAR) cases, evaluating management, outcomes, and potential effects on long-term survival. A single-center, retrospective analysis was performed, including patients with the diagnosis of complex aortic aneurysms who underwent a F/BEVAR procedure. The occlusion of any of the target visceral arteries, either incorporated in the repair by a branch or fenestration, was included in this study if the vessel was stented during the index procedure. Patients who presented TVO were compared with the ones who did not have this adverse event with respect to demographics, aneurysm extension, aneurysm sac size, and 5-year risk of death. Four hundred and thirty-three F/BEVAR cases performed between July 2012 and May 2023 incorporating 1648 TV were included in the study (mean age, 72 ± 7.9 years; 72.2% males), with 20 individuals (4.6%; mean age, 68 ± 5.7 years; 72.2% males) subsequently presenting with occlusion of 24 target vessels(12 renal, 1 accessory renal, 1 hepatic, 6 celiac, and 4 superior mesenteric arteries [SMA]; occlusion rate, 1.45%). In terms of demographics, aneurysm extent (P = .155), or aneurysm maximum diameter (P = .140), there was no significant difference between the patients with and without TVO. Twenty of the occluded TVs (83.3%) were incorporated into the repair by fenestrations, and four (16.6%) by using branches. Balloon-expandable stents were used in 22 (91.6%) occluded vessels. Only 20.8% of the occluded TVs presented significant stenosis prior to the F/BEVAR procedure. Among the TVO cases, 85% were taking aspirin, 30% clopidogrel, and 5% were taking oral anticoagulants at the time of the occlusion event. Only 20% of the patients with TVOs were active smokers when the adverse event happened. The mean time-to-occlusion was 16.7 ± 16.5 months. Nine patients underwent a TVO-related secondary intervention (mostly percutaneous) involving 12 target vessels, and flow was reestablished in 58% of the arteries. The celiac artery occlusions were managed conservatively in all cases when patent SMA vessels were present. There was one TVO-related death secondary to mesenteric ischemia complications. The 5-year risk of death was not significantly different when patients that presented TVO were compared with the ones without this adverse event (P = .304). TVO is a rare adverse event after F/BEVAR, potentially occurring even in patients on antiplatelet therapy who are not active smokers. TVO-related secondary interventions have a relatively low rate of success. The conservative management of celiac artery occlusions appears to be tolerated in patients with patent SMA vessels. The occurrence of a TVO does not impact the 5-year mortality in F/BEVAR cases, possibly due to the infrequency of this adverse event.

The diagnosis and clinical features of thoracic outlet syndrome have long confounded clinicians, owing to heterogeneity in symptom presentation and many overlapping competing diagnoses that are "more common." Despite the advent and prevalence of high-resolution imaging, along with the increasing awareness of the syndrome itself, misdiagnoses and untimely diagnoses can result in significant patient morbidity. The authors aimed to summarize the current concepts in the clinical features and diagnosis of thoracic outlet syndrome.

The aim of this study was to investigate the outcomes of F/BEVAR patients comparing individuals with and without a prior diagnosis of peripheral arterial disease (PAD) A single-center retrospective analysis was performed, including patients with the diagnosis of complex aortic aneurysms treated with an F/BEVAR procedure, using either an off-the-shelf or a patient-specific device. The diagnosis of PAD was determined by an ankle- brachial index <0.9 or a toe-brachial index <0.7 in non-diabetic and diabetic patients, respectively. No individuals presenting active wounds or foot infection were included; therefore, only the ischemia grade of the WIFi classification was applied to categorize PAD patients into "mild PAD" (grades 0 and 1) and "severe PAD" (grades 2 and 3), and both groups were compared with the non-PAD cases. The primary outcomes were 30-day and long-term mortality. Secondary outcomes included 30-day major adverse events (bowel ischemia, acute kidney injury [AKI], spinal cord ischemia [SCI]), long-term major complications (myocardial infarction [MI], stroke, and kidney function deterioration), and aneurysm-related adverse events. Four hundred one patients (72.3% males; mean age, 71.7 ± 8.9 years) who underwent a F/BEVAR procedure between July/2012 and October/2023 were included in the study, 95 (24%) with a prior diagnosis of PAD (22 mild; 73 severe). In terms of demographics, aneurysm extent, aneurysm maximal diameter, and comorbidities, no significant difference was observed across the three groups, except for the history of tobacco use (P = .033) and prior diagnosis of diabetes (P = .036) that were significantly higher amongst the patients with severe PAD. The 30-day survival (P = .483) and 30-day major adverse events (Table I) such as MI (P = .237), stroke (P = .222), AKI (P = .566), and SCI (P = .183) were similar across the groups. However, when all PAD cases were compared with non-PAD patients, they presented a significantly higher incidence of postoperative mesenteric ischemia (3 cases in PAD group, 1 case in non-PAD group; P = .043). Despite a similar incidence of long-term complications such as MI (P = .330), stroke (P = .353), and kidney function deterioration requiring dialysis (p = .093) observed across the groups, time- to-event analysis demonstrated that patients with severe PAD have a lower long-term survival when compared to the ones without this diagnosis (Fig 1) (Log-rank P = .035). As for aneurysm-related adverse events, there was no significant difference in terms of types I, II, and III endoleaks, access complications, target vessel occlusions, and freedom from secondary interventions across the groups. Significantly lower 5-year survival is observed in the F/BEVAR cases with a preoperative diagnosis of PAD and severe ischemic component. In addition, patients with PAD might require a higher index of suspicion of mesenteric ischemia in the perioperative period.TableOutcomesCounts (percentages)P-valueMild PAD, n = 73 casesSevere PAD, n = 22 casesNon-PAD, n = 30630-day MI2 (2.73)0 (0)1 (0.32).23730-day stroke1 (1.37)2 (9.09)1 (0.32).222Spinal cord ischemia4 (5.47)0 (0)6 (1.96).183Long-term MI5 (6.84)1 (4.54)10 (3.26).330Long-term stroke5 6.84)3 (13.63)18 (5.88).353Long-term renal failure requiring dialysis5 6.84)7 (31.81)0 (0).093Spinal cord ischemia4 (5.47)0 (0)6 (1.96).183Types 1a + 1b endoleaks3 (4.11)0 (0)20 (6.53).519Type 2 endoleak16 (21.92)7 (31.81)108 (35.29).089Type 3 endoleaks12 (16.43)0 (0)30 (9.8).066 Open table in a new tab

The management of complex aortic pathology includes both open and endovascular therapeutic options, and the role of endovascular surgery is rapidly expanding. It is important to consider device limitations, anatomic considerations, and patient factors to better guide the choice of surgical therapy.

The aim of this study was to evaluate the outcomes of renal fenestrations with large gap distance compared to the results of renal branches This was a retrospective, single-center, non-randomized study including patients with a diagnosis of complex aortic aneurysm that underwent a fenestrated/branched endovascular repair (F/BEVAR) under a PSIDE protocol. Patients with at least one renal artery incorporated in the repair, either through a fenestration or a branch, were included in the analysis. Fenestrations were typically preferred over branches, especially for upward renal arteries, in an effort to optimize renal outcomes. Only large gap fenestrations (LGF) ≥5mm were included in the study and compared to branch outcomes including renal artery patency, renal instability (TVI), and renal-related secondary interventions. The branches were evaluated considering their tortuosity index (TI) (Figs 1 and 2). A TI >1.15 was previously established in the literature as a predictor of branch complications. One-hundred-fifty-six patients from a single institution (69.1% male; mean age, 71.22 ± 7.2 years), treated with F/BEVAR, were included in the analysis. The renal arteries were incorporated in the repair through 157 LGF (26 with 6 × 6 mm configuration; 131 with an 8 × 6 mm configuration) and 100 branches. Mean aneurysm diameter was similar in both groups (branches: 65 ± 14.0 mm, fenestrations: 64.1 ± 11.9 mm; P = .58). Mean renal artery diameter was 5.4 ± 1.1 mm in the branch group and 5.5 ± 1.5mm in the fenestration group (P = .91). The risk of TVI was significantly higher for LGF compared to renal branches (RR, 3.53; P = .0059). Similarly, the risk of TVI was significantly higher in LGF irrespective of fenestration configuration (6 × 6 mm: RR, 4.00; P = .0189; 8 × 6 mm: RR, 3.49; P = .007) compared to branches. Renal patency was not statistically different between LGF and branches (6 × 6 mm: P = .074; 8 × 6 mm: P = .973, all fenestrations P = .558). The same result was observed for secondary interventions (6 × 6 mm: P = .154; 8 × 6 mm: P = .112; all fenestrations P = .096). Mean branch tortuosity was 1.3 ± 0.2 mm. The risk of TVI was significantly higher in fenestrations associated with FG >5 mm when compared to renal branches associated with a TI >1.15 (6 × 6 mm fenestrations: RR, 3.80; P = .032; 8 × 6 mm fenestrations: RR, 3.32; P = .017). No difference was observed when both fenestration configurations were compared to the renal branches with TI >1.15 in terms of loss of renal patency and renal secondary interventions. The present results suggest that renal branches, even when associated with a high TI, are less detrimental to renal artery instability when compared to large gap renal fenestrations. Custom-manufactured device renal designs with large gap fenestrations should be avoided when possible in favor of branch configurations.Fig 2Illustration of tortuosity index (TI) measurement (3D image of a CT angiography): a = centerline length measurement; b: linear measurement; TI = a/b. H = head; F = feet.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: The best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services-linked data.Methods: A retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model.Results: A total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (+/- 4.6) years. Relative to mechanical Ben tall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies.Conclusions: In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement. (J Thorac Cardiovasc Surg 2023;165:554-65)

Patients with complicated paravisceral aortic aneurysms requiring urgent repair have limited surgical options. Such patients are typically treated with open repair or chimney visceral stent-grafts. Back-table creation of physician-modified endografts (PMEGs) is another method to produce custom devices for such patients. However, this process is challenging and time-consuming and can be imprecise. Therefore, we aimed to produce a rapid method for generating a template for PMEGs with an “off-the-shelf” option using sterilizable three-dimensionally (3D) printed aortic models for visceral vessel alignment. We generated centerline aortic projections from patient computed tomography angiograms using TeraRecon (Foster City, Calif) and 3mensio software (Pie Medical Imaging, Maastricht, The Netherlands) to provide branch vessel positions, as we would traditionally to create a PMEG. Three independent observers performed this analysis. We also rendered 3D surfaces from the same computed tomography angiograms in 3D Slicer and Blender and then printed models using sterilizable elastic 50A resin or flexible 80A resin and a FormLabs Form 2 (FormLabs, Somerville, Mass). We then deployed appropriately sized Cook Zenith endografts (Cook Medical, Bloomington, Ind) and demonstrated the relative positions of the 3D printed model to the centerline-generated measurements. For practical application in the setting of urgent aortic repair, the 3D printing process can be completed from scan to model in 10 to 12 hours. During our iterations of printing 3D aortic models, we found that the flexible and translucent resin enabled our deployment to capture the aortic contours and deformability and also allowed us to visualize the underlying graft struts for appropriate placement of fenestrations. The deployment of an endograft within a 3D printed model is presented in Fig 1, showing visible struts through the translucent resin to enable alignment. The visceral vessel positions generated from the example 3D model (red) and centerline projection (black) for the most angulated paravisceral aorta tested is shown in Fig 2. Centerline-generated positions were averaged, because the interobserver variability was low (median standard deviation 1.3 mm for longitudinal alignment). Significant deviation between the visceral vessel alignments was seen primarily in the setting of high angulation. 3D printed sterilizable aortic models for urgent PMEG generation is an exciting application of this technology. Our initial testing results have indicated that the visceral vessel position appeared well matched with the centerline in most cases. However, variability was demonstrated between the 3D printed model visceral vessel positions in cases with significant aortic angulation. Further testing is necessary to demonstrate the accuracy of PMEGs generated from 3D printed model in an in vivo setting and to determine whether the visceral vessel alignment produced from the printed models is potentially improved compared with centerline calculations.FigView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Purpose of review Vascular Ehlers–Danlos syndrome (vEDS) is the most severe form of EDS, affecting the synthesis of type III collagen. It is notable for decreased life expectancy and morbidity, including spontaneous vessel rupture. The present review summarizes recent findings that have improved the ability to manage and delineate the natural history of vEDS. Recent findings Recent EDS consortium guidelines for the diagnosis of vEDS have emerged and outlined clinical features and molecular diagnostic tools to help facilitate rapid diagnosis. Although medical interventions to help halt the disease progression remain limited, improved awareness of vEDS by patients and practitioners have resulted in increased average life expectancy. Early excitement with celiprolol has been tempered by a lack of high-quality studies. Likewise, the creation of multidisciplinary care teams and tertiary referral centers is helping improve outcomes. Unfortunately, there remain limitations in terms of the surgical management (including more advanced endovascular techniques) of these patients and the morbidity associated with these interventions. Summary Although new consensus guidelines have emerged to facilitate the diagnosis of those with vEDS, there remain limitations in terms of interventions and medical therapy that can be provided for these patients. Life expectancy does appear to be improving however with increased awareness and coordinated multidisciplinary efforts among medical geneticists, general practitioners, and interventionalists alike.

Purpose of review Vascular Ehlers-Danlos syndrome (vEDS) is the most severe form of EDS, affecting the synthesis of type III collagen. It is notable for decreased life expectancy and morbidity, including spontaneous vessel rupture. The present review summarizes recent findings that have improved the ability to manage and delineate the natural history of vEDS. Recent findings Recent EDS consortium guidelines for the diagnosis of vEDS have emerged and outlined clinical features and molecular diagnostic tools to help facilitate rapid diagnosis. Although medical interventions to help halt the disease progression remain limited, improved awareness of vEDS by patients and practitioners have resulted in increased average life expectancy. Early excitement with celiprolol has been tempered by a lack of high-quality studies. Likewise, the creation of multidisciplinary care teams and tertiary referral centers is helping improve outcomes. Unfortunately, there remain limitations in terms of the surgical management (including more advanced endovascular techniques) of these patients and the morbidity associated with these interventions. Although new consensus guidelines have emerged to facilitate the diagnosis of those with vEDS, there remain limitations in terms of interventions and medical therapy that can be provided for these patients. Life expectancy does appear to be improving however with increased awareness and coordinated multidisciplinary efforts among medical geneticists, general practitioners, and interventionalists alike.