Suitability of renal-mesenteric target arteries is an essential criterion for fenestrated-branched endovascular aortic repair (FB-EVAR). We describe a staged adjunctive technique of target vessel false lumen (FL) embolization to improve suitability for FB-EVAR in patients with chronic postdissection thoracoabdominal aortic aneurysms (PD-TAAA) and dissection extension into the superior mesenteric artery (SMA). Three patients with SMA dissection and ectasia (diameter > 12-14 mm) underwent staged FL embolization with pre-emptive stent placement to optimize SMA incorporation. Using bilateral transfemoral access with intravascular ultrasound guidance, the proximal SMA true lumen was stented with an 8 L × 39 mm VBX balloon-expandable stent graft (W. L. Gore & Associates) coupled with a 14 × 60 mm bare-metal self-expandable stent extending past the dissection flap reentrance. The SMA FL was then embolized using 15 mm IMPEDE-FX polymer plugs (Shape Memory Medical), followed by postdilatation with a 12 to 14 mm angioplasty balloon. FB-EVAR was completed as a second-stage procedure without complications. Follow-up computed tomography angiography confirmed successful target vessel incorporation without endoleak in all three patients. Staged adjunctive target vessel FL embolization is technically feasible and improves suitability for FB-EVAR in patients with postdissection thoracoabdominal aortic aneurysms and dissected SMA. Larger series and longer follow-up are needed to assess durability and secondary complications.

Teratomas are nonseminomatous germ cell tumors typically managed with platinum-based chemotherapy followed by resection of residual disease. We report the case of a 29-year-old man with metastatic nonseminomatous testicular cancer who developed a persistent 16 cm postchemotherapy retroperitoneal teratoma encasing the supraceliac and infrarenal aorta and involving the left renal hilum. He underwent open resection through a midline transperitoneal approach with mediastinal tumor resection, en bloc aortic resection, extended left nephrectomy, and juxtarenal aortic reconstruction using a rifampin-soaked polyester graft to achieve microscopically margin-negative (R0) complete resection. Postoperatively, he had transient renal dysfunction and a chyle leak requiring intervention. At the 3-year follow-up, he remained disease-free.

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.

Acute traumatic aortic injury (ATAI) is a rare but life-threatening consequence of blunt trauma that requires prompt diagnosis and accurate imaging assessment. This review presents an imaging-based approach to ATAI, with emphasis on computed tomography angiography (CTA) as the first-line modality for diagnosis, grading, treatment planning, and follow-up. CTA enables the detection of both direct and indirect signs while also allowing for the assessment of lesion severity, extent, and associated findings that may influence management. Familiarity with common mimics and anatomic variants improves diagnostic confidence and helps avoid false positive interpretations. Careful protocol optimization, including multiphasic acquisition, bolus timing, and postprocessing reconstructions, can further enhance image quality and diagnostic performance. Recognition of patient-related and technical CTA artifacts, along with strategies to reduce them, including the selective use of ECG-gated CTA, may further decrease diagnostic uncertainty. We also discuss the complementary roles of emerging CT technologies and magnetic resonance angiography in selected patients. Finally, we review current classification systems, imaging-guided management, post-treatment surveillance, and potential complications. Awareness of ATAI imaging findings, protocol optimization, and diagnostic pitfalls is essential for accurate interpretation and effective multidisciplinary care.

PURPOSE:Familial history of aortic disease has been associated with increased risk of aneurysm-related complications after standard endovascular aortic repair. The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) for complex aortic aneurysms in patients with or without familial aortic aneurysms (FAAs). MATERIALS AND METHODS:We reviewed the clinical data of consecutive patients enrolled in a prospective non-randomized study to investigate outcomes after FB-EVAR for treatment of complex aortic aneurysms between 2013 and 2022. Familial aortic aneurysm was defined as occurrence of an aortic aneurysm or dissections in a first- or second-degree relative and compared with patients with sporadic aortic aneurysms (SAAs). Endpoints included procedural metrics, 30-day mortality and major adverse events (MAEs), mid-term patient survival, freedom from reintervention and endoleak, and aneurysm sac shrinkage. RESULTS:There were 499 patients treated with FB-EVAR (70% males, mean age was 74±7.7 years) including 66 (13%) patients with FAAs and 434 (87%) with SAAs. Both groups had similar demographics, clinical characteristics, aneurysm extent, and prior history of aortic dissection or aortic repair. Patients with FAAs had longer fluoroscopy time (82 vs 71 minutes) and radiation exposure (1856 vs 1213 mGy; each p<0.05), with no difference in technical success (FAA, 94% vs SAA, 97%; p=0.51). There was no difference in 30-day mortality (1.5% vs 0.9%; p=1.00) and MAEs (23% vs 18%; p=0.44) among patients with FAA and SAA, respectively. Median follow-up was 28 months. At 3 years, patient survival, freedom from secondary interventions, and cumulative incidence of sac shrinkage were 76±2.5%, 74±2.5%, and 32±2.6% for all patients, respectively, with no difference between FAA and SAA groups. CONCLUSION:Fenestrated-branched endovascular aortic repair was performed with high technical success, low mortality, and low incidence of MAEs regardless of the presence of FAA. There was no difference in mid-term patient survival, secondary interventions, and sac changes among patients with or without family history of aortic disease.Clinical ImpactThis study demonstrates that fenestrated-branched endovascular aortic repair (FB-EVAR) can be performed with high technical success and comparable early and mid-term outcomes in patients with or without a familial history of aortic aneurysm, after exclusion of genetically triggered aortic diseases. These findings challenge the assumption that family history alone should preclude complex endovascular repair. Clinically, this supports broader use of FB-EVAR in carefully selected patients with familial aortic disease, emphasizing anatomical suitability rather than pedigree alone. The innovation lies in validating FB-EVAR as a safe alternative to open repair for this understudied population, informing patient selection, counseling, and surveillance strategies.

BACKGROUND:This study evaluated the role of target vessel (TV) lumen origin and fenestration gap (FG) distance between the endograft and the aortic wall on TV outcomes following fenestrated-branched endovascular aortic repair (FB-EVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAAs). METHODS:A multicenter review of prospectively and retrospectively collected data of patients undergoing FB-EVAR for PD-TAAAs between 2013 and 2023 was performed. Lumen origin was retrospectively analyzed on preoperative imaging studies and classified as true lumen (TL) only, false lumen (FL) only, or both TL and FL. The FG distance was retrospectively measured on postoperative imaging studies and included as a linear variable. Primary outcome measures were freedom from TV instability (TVI), stratified by TV lumen origin and FG distance. RESULTS:There were 688 patients treated with FB-EVAR; of these 74 patients (11%) (77% male; mean age, 67 ± 10 years) were treated for PD-TAAAs. Company manufactured, patient-specific devices were used in 45 patients (61%), multibranch off-the-shelf device was used in 16 (22%), and physician-modified endografts were used in 13 patients (18%). A total of 280 renal-mesenteric TVs were incorporated by 157 fenestrations (56%) and 123 (44%) directional branches (DBs), with a mean of 3.8 ± 0.5 vessels per patient. TL-TV origin was identified in 200 TVs (71%), FL in 44 TVs (16%), and both TL and FL in 36 TVs (13%). Technical success was achieved in 69 patients (93%) and was not affected by TV origin. Mean follow-up was 35 ± 27 months. Freedom from TVI at 4 years was not affected by lumen origin, including when stratified by fenestrations (87%, 78%, and 75% for TL, FL, and both TL and FL origins; P = .21) and DBs (84%, 53%, and 67% for TL, FL, and both TL and FL origins; P = .17). Similarly, there were no significant differences in TVI when comparing device designs (P = .58) or when comparing fenestrations and DBs (P = .97). Restricted cubic spline modeling demonstrated an accelerating increase in the estimated hazard at FG distances above ∼12 mm. Overall survival and freedom from aortic related mortality at 4 years were 52% and 98% for the entire cohort, with no changes associated with TV origin. CONCLUSIONS:FL-TV origin was not associated with increased rates of TVI or technical failure in patients undergoing FB-EVAR for PD-TAAAs, and thus, attempts should be made to incorporate all renal-mesenteric vessels when appropriate. Importantly, device design was not a predictor of TVI, and similar outcomes were obtained with different stent graft platforms.

INTRODUCTION:Intravascular ultrasound (IVUS) provides cross-sectional information on the intraluminal features of blood vessels, aiding procedural planning and postprocedural assessment of results. Although the use of IVUS in aortic procedures is increasing worldwide, consensus on best practices in aortoiliac interventions is still lacking. This study aims to obtain experts' consensus and define recommendations regarding applications of intravascular ultrasound in aortoiliac endovascular interventionsMethods:Delphi consensus methodology was performed over 3 rounds, using a panel of 27 experts. Each member was asked to grade (grade A-grade D) 26 statements regarding various applications of IVUS in aortoiliac surgery. Statements that passed the first round were proposed at the second round unmodified. Statements that failed the first round underwent stylistic modifications without altering their meaning and were proposed in the second and third rounds. Agreement and consistency were used to develop recommendations on the applications of IVUS in aortoiliac endovascular interventions. RESULTS:After 3 rounds, 17 recommendations were made (16 grade B, 1 grade A), whereas 8 statements were rejected, and the core team eliminated 1. Ten recommendations (58.8%) obtained grade IV (poor), 1 (5.9%) grade III (fair), 2 (11.8%) grade II (high), and 4 (23.5%) were classified as grade I (very high). CONCLUSIONS:Intravascular ultrasound is an important adjunct imaging technology in hybrid rooms. Most of the recommendations concerned the use of IVUS in aortic dissection. Other important recommendations for preoperative planning and evaluation of postoperative results were made in radioprotection, aortic aneurysms, and blunt thoracic aortic injury. Intravascular ultrasound assistance in aortoiliac occlusive disease is not routinely recommended at the present time.Clinical ImpactThis international expert-based Delphi consensus provides a comprehensive perspective on the current applications of intravascular ultrasound across various aspects of aortoiliac endovascular therapy. Clinical practice guidelines are currently lacking recommendations on the use of intravascular ultrasound (IVUS) as an adjunctive tool in aortoiliac endovascular surgery; therefore, this study aims to fill the current gap in the literature by assessing the role of IVUS across high-volume aortic centers and offering recommendations on possible IVUS applications in aortoiliac endovascular interventions. Areas of ongoing debate regarding IVUS are also highlighted in this article, to provide inputs for further research.

OBJECTIVE:This study aims to assess the association of surgeon and hospital volume on mortality following fenestrated and branched repair of aortic aneurysms (F/BEVAR) and identify minimum volume thresholds for repair. SUMMARY BACKGROUND DATA:While hospital volume is associated with outcomes after standard open and endovascular aortic repair, the volume-outcome relationship for F/BEVAR remains poorly defined. METHODS:We performed a retrospective cohort study using 100% Medicare fee-for-service claims (2016-2023) to identify adults undergoing F/BEVAR. We used locally estimated scatterplot smoothing (LOESS) and derivative-based methods to identify hospital- and surgeon-level annual volume thresholds associated with 30-day mortality. Multivariable logistic regression was used to assess the association between hospital and surgeon volume (separately) and 30-day mortality. RESULTS:There were 8015 patients who received F/BEVAR (mean age 76.1±6.8y, 27.7% female, 90.9% White race). Median annual hospital and surgeon volume was 2 cases (range: 1-70) and 1 case (range: 1-51), respectively. Overall, 350 (4.4%) of patients experienced mortality within 30 days. The LOESS plots identified inflection points at 9 cases/year for hospitals and 7 cases/year for surgeons. After adjusting for patient risk factors, there was a significant association of both low hospital volume (≤9 cases/year) (aOR 1.43, 95% CI: 1.02, 1.99) and low surgeon volume (≤7 cases/year) (aOR 1.51, 95% CI: 1.04, 2.18) with 30-day mortality after F/BEVAR. CONCLUSIONS:There is a significant volume-outcome relationship after F/BEVAR. As commercially available devices become available, volume thresholds may provide an opportunity to guide dissemination of the technology while ensuring acceptable patient outcomes.

Innovation in the treatment of ascending aorta and arch pathology with novel catheter-based and hybrid procedures has driven the need for a strategy to guide their safe application. The ARCH-ARC (Aortic Arch Academic Research Consortium) was established to pragmatically develop consistent clinical end points and to standardize definitions for use in studies of these new technologies. The ARCH-ARC team, consisting of independent international specialists in cardiac surgery, vascular surgery, vascular medicine, cardiology, neurology, radiology, and clinical trials, along with US Food and Drug Administration, industry, and contract research organization representatives, held virtual meetings from 2021 to 2025. Consensus was used to identify appropriate clinical end points and to standardize definitions of end points for endovascular, hybrid, and open surgical procedures in clinical trials in the ascending aorta and arch. Drawing on previous ARC work in cardiac, neurological, renal, and bleeding end points, the ARCH-ARC focused on definitions and end points related to aortic arch-specific anatomy, pathology, and procedures and clinical, device, and imaging. The adoption of the ARCH-ARC consensus definitions and end points will provide a template for consistent adjudication and event reporting and facilitate comparisons of clinical research studies involving devices for ascending aorta and arch pathology.

Endovascular aortic arch repair has seen increasing application for the treatment of complex aortic arch pathology in patients with suitable anatomy who are considered high risk for open surgical repair. Ongoing technical advancements have refined stent design, enabling total endovascular incorporation of the supra-aortic vessels. Despite these advances, the procedure remains highly complex and presents unique technical and physiologic challenges related to arch anatomy, device constraints, and cerebral protection. The risk of stroke remains high in several experiences and is the main limitation to widespread utilization in lower-risk groups. A comprehensive understanding of all aspects of the perioperative process is therefore essential to achieve a safe and effective repair. Several key considerations include meticulous patient selection, thoughtful device design, rigorous preoperative planning, precise procedural execution, and diligent postoperative follow-up. Currently available three-vessel arch branch devices remain under investigational protocols, and the outcomes reported thus far largely reflect experience at high-volume aortic centers. This review aims to summarize the current principles and key considerations required to successfully perform a three-vessel endovascular arch repair, with a focus on practical strategies to optimize clinical outcomes and ensure durable results.

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.

OBJECTIVE:Branched/fenestrated endovascular repair has become the mainstay treatment for thoracoabdominal aortic aneurysms (TAAAs) and pararenal aortic aneurysms (PAAs), yet little is known about its impact on patient quality of life (QoL). Long-term QoL trends in patients from the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE) multicenter, prospective pivotal trial were examined. METHODS:In enrolled patients with TAAA or PAA who underwent TAMBE repair, the RAND 36-Item Health Survey (SF-36) was collected at baseline and at 1, 3, 6, and 12 months postoperatively. QoL physical and mental domain scores were compared from baseline to 1 year in the overall cohort and in subgroups of aneurysm type, frailty risk, occlusion, or reintervention. Patient characteristics were summarized using descriptive statistics and mean QoL scores were compared across timepoints using paired t tests. RESULTS:The cohort of 121 patients had a mean age 73 years, 82.8% were male (n = 101), 83.6% were White (n = 102); 59.0% (n = 72) had an extent IV TAAA, 41.3% (n = 50) had a PAA, and 77.7% (n = 94) were low frailty risk. In this analysis, 13.2% of patients (n = 16) experienced a branch vessel/graft occlusion and 14.0% (n = 17) underwent a reintervention. All QoL domain scores decreased at 1 month postoperatively, predominantly in physical health limitations (P < .0001). All QoL domains recovered toward baseline by 3 months postoperatively, but then gradually declined to 1 year; differences were statistically significant compared with baseline (P ≤ .05). There was no mean QoL domain score difference at any time point among the aneurysm type, branch occlusion, or reintervention subgroups (P ≥ .071). Physical domain scores between frailty risks were significant (P ≤ .05). CONCLUSIONS:Patients experienced an immediate decrease in all QoL domains after undergoing a TAMBE procedure, especially physical health, but recovered by 3 months postoperatively. Aneurysm extent, branch occlusion, and reinterventions did not impact QoL trends. Patients who underwent endovascular TAAA/PAA TAMBE repair exhibited a gradual decrease in health-related QoL over the long term. This result may be representative of the comorbid and elderly population who require such operations.

OBJECTIVES:Endovascular repair options for pararenal aortic aneurysms (PRAs) and thoracoabdominal aortic aneurysms (TAAAs) include physician-modified endografts (PMEGs), and thoracoabdominal multibranch endoprosthesis (TAMBE). However, long-term renal artery performance of TAMBE is unknown. Thus, we aimed to compare renal artery outcomes between TAMBE and PMEG. METHODS:Patients who received TAMBE and PMEG at two aortic centers from 2015 to 2025 were reviewed. Aneurysm extent, branch stent size, antiplatelet regimen, laterality, and relining stents were compared by vessel level analysis. Primary outcome was freedom from target vessel instability (TVI). The secondary outcomes included primary patency, freedom from branch reintervention and branch endoleak. Cox proportional hazard regression was performed comparing PMEG and TAMBE RAs for TVI. RESULTS:We included 716 patients and 1339 RAs (633 patients/1180 RAs for PMEG and 83 patients/159 RAs for TAMBE groups). RAs in PMEG had higher 5-year freedom from TVI compared with TAMBE (89.5% vs 82.7%; P = .005), driven by higher freedom from branch reintervention (90.8% vs 82.5%; P = .002) and primary patency (93.7% vs 83.3%; P < .001), albeit with similar freedom from branch endoleak (93.9% vs 98.2%; P = .3). This finding was likely due to the higher freedom from TVI in the right renal artery (91.3% vs 77.9%; P = .002), but not left renal artery (87.6% vs 87.9%; P = .375). Subgroup analysis showed similar freedom from TVI in the TAAA patients (P = .691), whereas the PRA subgroup showed significantly lower freedom from TVI in the TAMBE compared PMEG group (P < .001). Cox regression, adjusting for aneurysm extent, branch stent size, relining, and dual antiplatelets, showed that the right RAs in TAMBE were more likely to develop TVI (hazard ratio, 4.2; P < .001) than PMEG. CONCLUSIONS:The right renal artery may be the principal site of failure for TAMBE, contributing to lower 5-year freedom from TVI compared with PMEG. TAAA appears to confer protection against renal TVI in TAMBE, compared with PRA. These findings warrant revisiting anatomical criteria and further optimization of renal bridging stent design for TAMBE.

OBJECTIVE:To describe indications and outcomes of open surgery performed for visceral and renal artery (RA) incorporation and revascularization before, during, or after fenestrated/branched endovascular aortic repair (F/BEVAR). METHODS:Retrospective review of patients who underwent F/BEVAR for complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms between 2007 and 2024 was conducted. Patients who underwent open surgical revascularization for the superior mesenteric artery (SMA), celiac artery, and/or RA as part of a planned or bailout procedure to the F/BEVAR were included. Access-related procedures, such as open surgical conduits, were excluded. Descriptive analysis was done to illustrate indications and outcomes of these hybrid procedures. RESULTS:A total of 861 patients underwent F/BEVAR during the study period, of whom 22 (2.5%) had a hybrid procedure and were included. The average age was 76 ± 6 years (range, 63-89 years), and 13 patients were male (59%). Most of the hybrid repairs were done in patients with thoracoabdominal aortic aneurysms (n = 17 [77%]) and electively (n = 20 [91%]). Three interventions (14%) were performed preoperatively, and 19 were performed intraoperatively (n = 3 [14%]) or postoperatively (n = 16 [72%]). Preoperative hybrid interventions included iliorenal bypass with syndactylization owing to multiple small accessory RA diameter in two patients, and ilio-SMA bypass for chronic mesenteric ischemia in one. Indication for post-F/BEVAR interventions included an inability to cannulate target arteries (n = 13 [59%]), complications from target artery dissection (n = 3 [14%]) or thrombosis (n = 2 [9%]), and complicated endoleak (n = 1 [4.5%]). Most of these interventions were done during the index admission (n = 15 [68%]), and included RA bypasses (n = 6 [27%]), retrograde SMA stenting (n = 5 [23%]), retrograde RA access and stenting (n = 4 [18%]), hepatic artery bypasses (n = 3 [14%]), and celiac artery ligation owing to complex endoleak in one patient (4.5%). Technical success was achieved in all cases, with one patient experiencing a postoperative complication (retroperitoneal hematoma requiring evacuation). The mean postoperative hospital length of stay was 15 ± 13 days. At a mean follow-up of 22 months (range, 0-93 months), primary patency rates of bypass grafts and stented target arteries via hybrid approach were 100% and 95%, respectively. Overall freedom from target-artery related reintervention was 95%, with only one patient requiring RA restenting. Freedom from aortic-related mortality was 100%. Finally, among 12 patients who had hybrid RA intervention, one patient with a solitary kidney who underwent retrograde access required permanent dialysis. CONCLUSIONS:Open surgical intervention is rarely necessary before, during, or after F/BEVAR. Nevertheless, when performed, it proves to be a useful adjunct to incorporate difficult anatomy and as a bailout procedure providing satisfactory long-term target artery patency with minimal risk.

OBJECTIVE:This retrospective analysis of prospectively collected observational cohort data aimed to investigate the impact of internal audit using imaging system procedure log analysis on radiation exposure during fenestrated and or branched endovascular aortic repair (FBEVAR). METHODS:Patients who underwent FBEVAR for complex aortic aneurysms by a single operator between January 2016 and January 2024 were analysed. Procedures were performed using a historical hybrid imaging platform (system I, January 2016 - June 2020) and a subsequent platform (system II, July 2021 - January 2024), stratified into phase 1 (pre-optimisation) and phase 2 (post-optimisation) after implementation of audit derived radiation reduction strategies. Procedural log analysis identified contributors to increased radiation dose, prompting optimisation. Endpoints included procedural metrics, air kerma (AK), and dose area product (DAP). RESULTS:Four hundred and ninety-one patients were included (system I: n = 346; system II: n = 145 [phase 1: n = 83; phase 2: n = 62]). The cohort after transition demonstrated greater anatomical complexity. Median AK increased from 0.9 Gy (interquartile range [IQR] 0.6, 1.6) in system I to 1.5 Gy (IQR 1.1, 2.0) in system II phase 1 (p < .001), with DAP increasing from 158 Gy·cm2 (IQR 111, 229) to 219 Gy·cm2 (IQR 167, 284) (p = .002). Following optimisation, AK decreased to 0.9 Gy (IQR 0.5, 1.4; p = .098 vs. system I) and DAP to 151 Gy·cm2 (IQR 101, 229; p = .32 vs. system I). In multivariable analysis, system II phase 1 was independently associated with increased AK and DAP compared with system I (AK: β = +425 mGy; 95% confidence interval 221 - 630; p < .001; DAP: β = +53 Gy·cm2; 95% confidence interval 24 - 82; p < .001), whereas no significant differences were observed in phase 2. CONCLUSION:A structured internal audit with targeted workflow and imaging optimisation mitigated radiation dose increases following hybrid platform transition, restoring exposure to baseline levels.