Abstract Aim To determine the short- and long-term outcomes of patients with complex abdominal aorta aneurysms (CAAAs) managed with fenestrated endovascular aneurysm repair (fEVAR) at a tertiary vascular unit. Method All patients undergoing fEVAR for elective CAAA between January 2013 and December 2021 were retrospectively identified. Primary outcomes were mortality rate and stent patency (assessed by CT imaging). Secondary outcomes included rates of reintervention. Follow-up intervals were at 30 days, 1 year, 3 years and 5 years. Descriptive statistics are reported. Results 61 patients were identified; 5 were excluded due to follow-up in a different health board. Of the 56 analysed, 49 (88%) were male and median age was 75 (IQR 68-83). The average number of fenestrations used per fEVAR graft was 3 (range 2-6). Mortality rate was 2% at 30-day, 9% at 1-year and 25% at 5-year. At 5-year follow-up, all patients (n = 11) had grafts with all fenestrations patents. There was an 11% (n = 6) reintervention rate in a 5-year period. Median time to reintervention was 12 months (range 5-36 months). Reintervention included 4 requiring embolization for a Type II endoleak, 1 patient required an iliac stent extension, and 1 patient required a renal stent. Conclusions With fEVAR being a relatively newly adopted technique, this data demonstrates technical success with low re-intervention rates when used for CAAAs. Future work should include organising a multi-centre study to gain a larger sample size to compare rates of fEVAR success in different centres.

OBJECTIVE:Endoleak remains the Achilles heel of endovascular aneurysm repair and the exclusion of Type II endoleaks, in particular, remains challenging. This systematic review presents the evidence for ethylene-vinyl-alcohol-copolymer liquid embolic agent as a monotherapy in the treatment of endoleaks. METHODS:A systematic literature search was performed for all studies reporting the use of liquid embolic agent as a sole agent in the treatment of endoleaks. Patient numbers, clinical details (endoleak type, route of delivery) and outcome in terms of survival, technical and clinical success with freedom from endoleak together with follow-up period were examined. RESULTS:Only 12 articles reporting the use of liquid embolic as the sole treatment modality for endoleaks in 174 patients were identified. All but 21 patients had a Type II endoleak. Transarterial embolization was attempted in 73% of patients with 48 patients having direct sac puncture. Technical success was high at 96%, but in patients with adequate imaging, the clinical success rate dropped to 79%. Complications were sparsely reported and follow-up ranged from 0 to 75 months. CONCLUSIONS:This review highlights the lack of data regarding the use of liquid embolic agent as a monotherapy with only 4 studies including more than 10 patients. Data from the largest series suggests a learning curve exists and no study reports on cost effectiveness. Technical success does not always translate into clinical success and with the largest series only reporting median 4-month follow-up no claims regarding durability can be made. In problematic Type II endoleaks, however, liquid embolic agent is a welcome addition to the treatment armamentarium.

Der C3-Gore-Excluder-Stentgraft (W.L. Gore & Associates, Flagstaff, Arizona, USA) erlaubt durch ein verändertes Design seines Delivery-Systems beim Einsetzen des Stentgrafts multiple Repositionierungen bei der EVAR. Um die Performance dieses Systems unter Real-World-Bedingungen zu erforschen, wurde vom Hersteller das Global Registry for Endovascular Aortic Treatment (GREAT) gegründet. Verhoeven et al. stellen die 1-Jahres-Ergebnisse aus 13 Zentren des europäischen C3-Moduls dieser Observationsstudie vor.

BACKGROUND:Effective abdominal aortic aneurysm (AAA) screening requires high uptake. The aim was to assess the independent association of screening uptake with rurality, social deprivation, clinic type, distance to clinic and season.METHODS:Screening across Grampian was undertaken by trained nurses in six community and three hospital clinics. Men aged 65 years were invited for screening by post (with 2 further reminders for non-responders). AAA screening data are stored on a national call-recall database. The Scottish postcode directory was used to allocate to all invited men a deprivation index (Scottish Index of Multiple Deprivation), a Scottish urban/rural category and distance to clinic. Multivariable analysis was undertaken.RESULTS:The cohort included 5645 men invited for screening over 12 months (October 2012 to October 2013); 42·6 per cent lived in urban areas, 38·9 per cent in rural areas and 18·5 per cent in small towns (uptake 87·0, 89·3 and 90·8 per cent respectively). Overall uptake was 88·6 per cent with 76 new AAAs detected: 15·2 (95 per cent c.i. 11·8 to 18·6) per 1000 men screened. Aberdeen city (large urban area) had the lowest uptake (86·1 per cent). Uptake declined with increasing deprivation, with the steepest decline in urban areas. On multivariable analysis, a 1-point increase in deprivation deciles was associated with a 0·08 (95 per cent c.i. 0·06 to 0·11) reduction in the odds of being screened (P < 0·001). Clinic type (community versus hospital), distance to clinic and season were not associated independently with uptake.CONCLUSION:Both urban residence and social deprivation were associated independently with uptake among men invited for AAA screening.

Objectives: The European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT) provides "real-world" outcomes for the new C3 Gore Excluder stent-graft, and evaluates the new deployment mechanism. This report presents the 1-year results from 400 patients enrolled in this registry.Methods: Between August 2010 and December 2012, 400 patients (86.8% male, mean age 73.9 +/- 7.8 years) from 13 European sites were enrolled in this registry. Patient demographics, treatment indication, case planning, operative details including repositioning and technical results, and clinical outcome were analyzed.Results: Technical success was achieved in 396/400 (99%) patients. Two patients needed intraoperative open conversion, one for iliac rupture, the second because the stent-graft was pulled down during a cross-over catheterization in an angulated anatomy. Two patients required an unplanned chimney renal stent to treat partial coverage of the left renal artery because of upward displacement of the stent-graft. Graft repositioning occurred in 192/399 (48.1%) patients, most frequently for level readjustment with regard to the renal arteries, and less commonly for contralateral gate reorientation. Final intended position of the stent-graft below the renal arteries was achieved in 96.2% of patients. Thirty-day mortality was two (0.5%) patients. Early reintervention (<= 30 days) was required in two (0.5%) patients. Mean follow-up duration was 15.9 +/- 8.8 months (range 0-37 months). Late reintervention (>30 days) was required in 26 (6.5%) patients. Estimated freedom from reintervention at 1 year was 95.2% (95% CI 92.3-97%), and at 2 years 91.5% (95% CI 86.8-94.5%). Estimated patient survival at 1 year was 96% (95% CI 93.3-97.6%) and at 2 years 90.6% (95% CI 85.6-93.9%).Conclusions: Early real-world experience shows that the new C3 delivery system offers advantages in terms of device repositioning resulting in high deployment accuracy. Longer follow-up is required to confirm that this high deployment accuracy results in improved long-term durability. (C) 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

AIM:The aim of this paper was to evaluate early outcome of the GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System in subjects with aortic neck anatomy outside IFU. METHODS:Individual patient data prospectively collected over a 2 year period from the Global Registry for Endovascular Aortic Treatment (GREAT). For each subject a minimum data set was collected containing demographic, pre/intra- and postoperative variables. Main outcome measures were successful exclusion of the AAA and occurrence of any major endoleak at 1 month. In this study, outside IFU was defined as aortic neck length less than 15 mm and/or aortic neck angle greater than 60 degrees. RESULTS:A total of 400 subjects, (86.6% male, mean age 73.9 years). Primary pathology was AAA in 94.2% with 98.2% undergoing EVAR as a primary procedure. Sixty-eight subjects underwent EVAR outside IFU (neck length <15 mm N.=32, neck angle >60˙N.=47 and neck length <15 mm and angle >60° N.=11). The graft was successfully deployed within 5 mm of its intended location in 63 (94%) cases utilising a total of 33 repositioning episodes. Eight aortic cuffs were used, 5 to treat a type 1 endoleak. At 30 days we recorded 2 type 2 endoleaks both successfully treated and 1 type 1b also successfully treated. There were 2 deaths, one in each group. CONCLUSION:GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System allows re-positioning to be performed safely in cases outside IFU. Repositioning is an effective operative manoeuvre and facilitates EVAR in challenging anatomy. Longer follow-up is required to evaluate the durability of these results at 30 days.

As a consequence of the introduction of the European Working Time Regulations and the New Deal, there has been a significant reduction in the number of hours worked by surgical trainees in the UK and Europe. A number of studies have highlighted how reduced working hours have negatively affected operative exposure in surgical specialties. Surgical training requires the accumulation of increasingly complex technical competencies. In order to produce a complete surgeon, these competencies must be complemented by non-technical skills. Traditionally, these have been acquired through ward and outpatient experience without strict time limitation. With reduced daytime clinical experience, not only will there be a reduction in technical skills training but inevitably reduced outpatient clinic (OPC) experience.

Objectives: It has been suggested that the Aberdeen Varicose Vein Questionnaire (AVVQ) could be used to help inform a patient pathway for referral and treatment of varicose veins. We aimed to determine 1) which patient and vein characteristics affected the AVVQ score, and 2) whether scores differed between those who were and were not offered treatment.Methods: Patients completed the AVVQ at the clinic prior to being seen. Treatment was offered to patients with symptoms, and duplex detected truncal incompetence by surgeons blinded to the score.Results: A total of 228 consecutive patients completed the AVVQ: 199 were valid questionnaires. On multivariate analysis, factors associated with a worse quality of life were female gender (p = .034, 3.14 mean unit increase in AVVQ), and bilateral varicose veins (10.25 unit increase, p < .001). For patients with C2 disease, only the presence of bilateral veins was significant. Overall, the AVVQ score was higher in those patients offered treatment than in those who were not (mean 20.3 [SD = 9.9] vs. 17.3 [SD = 10.3], p = .023), which equates to a 2.74 unit increase. This was not significant in patients with C2 disease.Conclusion: It is unlikely that a threshold AVVQ score could be used to aid referral of patients with C2 disease. The distribution of veins (unilateral vs. bilateral) must be adjusted for when reporting AVVQ scores. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objective: Recent interest has focussed on the role of biomarkers to predict outcome in patients undergoing major vascular surgery. We wished to determine if pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels could predict all-cause mortality (ACM; primary aim) and major adverse cardiac event (MACE) (secondary aim) in the medium-term follow-up in patients who have undergone elective major vascular surgery.Method: Patients who underwent major elective vascular surgery (n = 136) were followed up for up to 2 years. ACM and first MACE episode were identified from the case notes and the patient management system database of the hospital intranet.Results: One patient was lost to follow-up. In the mean follow-up of 654 days, 27 (20%) died and 23 (17%) patients suffered a MACE. Receiver operator curve (ROC) analysis showed that a pre-operative NT-pro-BNP level with a cut-off of 359 pg ml(-1) had a sensitivity and specificity of 73% each (area under the curve (AUC) 80%, p < 0.001) in predicting ACM and sensitivity of 74% and specificity of 71% (AUC 75%, p < 0.001) to detect a MACE. The overall 2-year survival rate was 84%, 93% in the <359 pg ml(-1) group and 68% in the >= 359 pg ml(-1) group (p < 0.001). Following multivariate analysis, pre-operative NT-pro-BNP at a value of >= 359 pg ml(-1) remained an independent predictor of ACM (odds ratio 3.6 (confidence interval (CI): 1.6-8.1), p = 0.002) Postoperative NT-pro-BNP was a predictor of mortality but not a MACE.Conclusion: This study has shown that pre-operative NT-pro-BNP is an independent predictor of ACM and MACE on medium-term follow-up. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

We report the case of 62-year-old male who underwent Endovascular Aneurysm Repair (EVAR) for a large infrarenal AAA. Following investigation for a contralateral benign epididymal cyst he was found to have a left testicular mass and underwent urgent orchidectomy. The histological features were of subacute testicular infarction secondary to cholesterol emboli following his EVAR. We believe this is the first reported case of subacute testicular infarction due to cholesterol emboli reported following EVAR. Clinicians should be aware of the risk of cholesterol embolisation following EVAR.

Cutting balloon angioplasty (CBA) has been used in the revascularisation of coronary arteries; however, more recently a role has been suggested in the salvage of failing infrainguinal grafts. We report a case of a vein graft aneurysm following treatment of a vein graft stenoses using CBA. This is a rare complication of cutting balloon angioplasty which may become more prevalent as this technique becomes more widespread.

Objectives: To report early clinical outcomes and learning experience following the introduction of endovenous laser ablation (EVLA) to an NHS vascular unit.Design: Prospective observational study.Results: Between February 2006 and January 2008, 631 consecutive patients underwent EVLA to 704 refluxing truncal veins - 579 GSV, 119 SSV and 6 straight segments of anterior accessory GSV. 275/631 (44%) patients had Local anaesthesia (LA) plus sedation, 237 (38%) had LA only and 119 (18%) had general anaesthesia. All were treated using the 810 nm diode laser. Adjuvant procedures on-table included foam sclerotherapy 129/704 (18%), multiple stab avulsions 53/704 (8%) and 3 limbs had both. Three-month follow-up with duplex examination is complete in 635/704 limbs (90%). Complete occlusion was noted in 610 veins (96%), 14 (2.2%) were partially occluded and 11 (1.7%) showed no occlusion. 193 (30%) of the 635 limbs seen at follow-up required further treatment for residual varicosities using foam sclerotherapy. There has been one non-fatal pulmonary embolus associated with EVLA and no other complications.Conclusions. EVLA is safe and technically effective. It has a defined learning curve requiring new operator skills which can be readily acquired. Crown Copyright (c) 2009 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery. All rights reserved.