Spinal cord ischemia (SCI) after surgery for acute type A aortic dissection is rare, and delayed paraplegia is particularly uncommon. A 76-year-old woman underwent emergency partial arch replacement for acute type A aortic dissection. Preoperative computed tomography scan showed that multiple intercostal arteries originated from the false lumen. On postoperative day 3, she developed acute paraplegia. Imaging demonstrated complete thrombosis of the false lumen, and spinal magnetic resonance imaging confirmed SCI. When spinal arteries originate from the false lumen, rapid thrombosis after entry closure may compromise spinal cord perfusion and lead to delayed SCI.

Objectives:This study aimed to identify anatomical predictors of aneurysm enlargement in patients with lumbar artery (LA)-related type 2 endoleak (T2EL) after endovascular aortic repair (EVAR). Methods:This retrospective observational cohort study included 59 patients with infrarenal abdominal aortic aneurysms who developed T2EL caused exclusively by LAs after EVAR between January 2019 and July 2024. Computed tomography-based anatomical parameters, including mural thrombus volume ratio, calcified volume ratio, aneurysm diameter, and LA anatomy, were analyzed. Results:During a median follow-up of 33 months, aneurysm enlargement occurred in 9 patients (15.3%). Patients with aneurysm enlargement had a significantly lower mural thrombus volume ratio (p <0.001). Female sex (hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.06-0.84; p = 0.026) and mural thrombus volume ratio (HR, 0.88 per 1% increase; 95% CI, 0.80-0.96; p = 0.003) were significantly associated with aneurysm enlargement, whereas LA anatomy was not. Receiver operating characteristic analysis identified an optimal cutoff value of 29.2% (area under the curve, 0.82). Conclusions:A low preoperative mural thrombus volume ratio was associated with aneurysm enlargement in patients with LA-related T2EL after EVAR. This parameter may serve as a practical imaging biomarker to support selective consideration of preemptive embolization.

ObjectiveContrast-induced nephropathy remains a significant concern in patients undergoing endovascular aneurysm repair (EVAR), particularly those with pre-existing renal impairment. This study aimed to evaluate the feasibility and safety of using a one-quarter diluted contrast agent during EVAR to reduce contrast volume without compromising imaging quality or clinical outcomes.MethodsWe retrospectively reviewed EVAR procedures performed between July 2022 and September 2024. A total of 96 patients were included, with 50 receiving undiluted contrast and 46 receiving a one-quarter diluted solution. All procedures were conducted using the same angiographic system and protocol. Pixel values and signal-to-noise ratios (SNRs) were measured from digital subtraction angiography (DSA) images. Subjective image quality was independently evaluated by three vascular surgeons using a standardized 5-point scale. Postoperative type I/III endoleaks were identified on contrast-enhanced CT or ultrasound within 30 days. Statistical comparisons were performed using Welch's t-test, Mann-Whitney U test, chi-square test, or Fisher's exact test, as appropriate.ResultsProcedural success was achieved in all cases. The diluted group achieved a 70% reduction in contrast volume (19.8 ± 11.5 mL vs 67.7 ± 30.5 mL; P < .001). Pixel values (2.87 ± 8.75 vs 2.99 ± 5.59; P = .936), SNRs, and surgeon-rated image quality were comparable between groups. The incidence of type I/III endoleaks (2.0% vs 4.3%; P = .606) and radiation parameters did not differ significantly.ConclusionsUse of a one-quarter diluted contrast agent during EVAR provided image quality and safety comparable to undiluted contrast while significantly reducing contrast volume. This technique may represent a practical strategy to mitigate renal risk in patients with impaired kidney function.

One of the complications after thoracic endovascular aortic repair (TEVAR) is stent graft-induced new entry (SINE). SINE occurs in 5% to 25% of aortic dissection cases treated with TEVAR and is thought to be associated with endograft oversizing and springback force. Although SINE typically occurs at the proximal or distal ends of the endograft, we report a rare case of managing a SINE formation within the main body of the stent graft, distinct from its landing zones. This unusual presentation highlights the importance of recognizing atypical SINE mechanisms and locations, which can lead to significant complications such as endoleak. TAKE-HOME MESSAGES: To prevent SINE after TEVAR, it is crucial to consider not only the landing zone and device sizing but also the entire aortic curvature where the stent graft will be deployed. Careful device selection and procedural planning are required.

BACKGROUND:Endovascular aneurysm repair (EVAR) is a minimally invasive treatment for abdominal aortic aneurysms. However, it poses challenges in chronic kidney disease (CKD) patients due to contrast-induced nephropathy (CIN). This case report presents a zero-contrast EVAR technique using noncontrast CT-derived volume rendering (VR) imaging and intravascular ultrasound (IVUS). CASE PRESENTATION:An 80-year-old male with CKD G4 underwent zero-contrast EVAR. Preoperative noncontrast CT-generated VR images were utilized for both surgical planning and intraoperative 3D roadmap, while intraoperative IVUS was used to identify key vascular landmarks, such as the renal arteries and internal iliac arteries bifurcation. This combination enabled precise vascular mapping and device placement without contrast agents. Preoperatively, renal function was serum creatinine (Cr) 2.64 mg/dL and estimated glomerular filtration rate (eGFR) 19.0 mL/min/1.73 m², indicating a high risk of CIN. At 6-month follow-up, postoperative evaluation confirmed stable renal function (Cr 2.82 mg/dL, eGFR 17.7 mL/min/1.73 m²) with no evidence of endoleaks. DISCUSSION:This case demonstrates the feasibility of zero-contrast EVAR using VR imaging and IVUS, mitigating CIN risks while maintaining accuracy. VR imaging enhanced intraoperative navigation with detailed visualization and color mapping of critical branches. IVUS complemented VR imaging by providing real-time spatial relationships. CONCLUSION:The combination of VR imaging and IVUS offers a viable alternative for zero-contrast EVAR, particularly in patients contraindicated for contrast agents. This renal-sparing technique expands EVAR options for high-risk populations.Clinical ImpactThis case presents a novel approach to zero-contrast endovascular aneurysm repair (EVAR) by combining non-contrast CT-derived volume rendering (VR) imaging and intravascular ultrasound (IVUS). This technique provides a renal-sparing solution for patients with chronic kidney disease (CKD) at high risk of contrast-induced nephropathy (CIN). By enabling accurate vascular mapping and device placement without contrast agents, procedural safety is enhanced. The innovation lies in integrating VR for visualization and IVUS for real-time intraluminal assessment, ensuring precision while avoiding contrast-related risks. This method may expand EVAR options and improve outcomes in CKD patients unsuitable for traditional contrast-based imaging.

Endovascular repair (EVAR) for abdominal aortic aneurysm and iliac aneurysm is a safe and valid treatment. However, it is associated with some different complications that may require reinterventions. Among these complications, abdominal endograft proximal collapse is an infrequent event. We report a case of acute type A aortic dissection and abdominal endograft proximal collapse in a patient previously treated with EVAR.

Background: This study investigated whether branched thoracic endovascular aortic repair (bTEVAR), a treatment for distal aortic arch diseases, could serve as an alternative to open aortic surgery (OAS). Methods: This single-center, retrospective, observational cohort study comprised 80 patients (bTEVAR, n = 28; TAR, n = 52) treated from October 2012 to June 2018. The median age and median follow-up periods were 73 years (interquartile range [IQR], 66-79 years) and 6.0 years (IQR, 2.8-9.7 years). Results: The patients in the bTEVAR group were older than those in the OAS group (p < 0.001), and the EuroSCORE2 was significantly higher in the bTEVAR group (6.6%) than in the OAS group (2.4%; p < 0.001). There were no 30-day or in-hospital mortalities in either group. Stroke was observed in four (5.0%) patients, all of whom were in the bTEVAR group (p = 0.013). However, no other significant differences were observed between the two groups in other early aortic events. Kaplan-Meier curves regarding the survival, aorta-related death, and aortic events showed no significant differences between the two groups. Conclusions: Although bTEVAR involves an older patient population and a higher surgical risk, the early and mid-term outcomes were comparable to those of OAS, except for cerebral infarction. However, because cerebral infarction significantly reduces a patient's quality of life, for bTEVAR to become more widespread, it is necessary to reduce the incidence of cerebral infarction.

This study aimed to investigate whether the efficacy of proximal landing zones (LZs) 0, 1, and 2 in hybrid thoracic endovascular aortic repair (TEVAR) without cardiopulmonary bypass (CPB) in elderly patients can broaden aortic arch surgical eligibility from the perspective of a lifetime loss. From April 2008 to March 2020, 254 patients who underwent LZs 0, 1, and 2 hybrid TEVAR without CPB were enrolled (zone 0 in 41, zone 1 in 82, and zone 2 in 131 patients). The patients had a median age of 73 years, with a median follow-up period of 5.8 years. The median operative time was 172 min, the median postoperative hospital stay was 11 days, and the discharge rate to home was 95.3

BACKGROUND:This study aimed to examine the outcomes of zones 1 and 2 landing hybrid thoracic endovascular aortic repair (TEVAR) and to examine risk factors associated with poor outcomes. METHODS:From April 2014 to March 2024, 96 patients underwent zones 1 and 2 landing hybrid TEVAR for aortic arch pathologies (median age: 78 years). The primary endpoint was major adverse aorta-related events (late rupture/dissection and/or aorta-related reintervention). The secondary endpoint was type 1a endoleak. Outcomes were analyzed by Kaplan-Meier and log-rank tests; risk factors by Cox regression. Median follow-up was 3.0 years. RESULTS:The 30-day mortality rate was 2.1% and the stroke rate was 4.2%. The aortic events rate at 7 years was 38.1%. In multivariate analysis, age (hazard ratio [HR] 1.06; 95% confidence interval [CI], 1.00-1.12; P = 0.023) and early era (HR 5.59; 95% CI, 1.23-25.3; P = 0.025) were significant risk factors for aortic events. Type 1a endoleak rates were significantly lower in the late-era group than in the early-era group (P = 0.003). The diameter of proximal landing zone in the early-era group was larger than that in the late-era group (P < 0.001); however, the oversizing rate of proximal stent grafts in the early-era group was smaller than that in the late-era group (P < 0.001). The aortic events and type 1a endoleak rates were significantly lower in the late-era group than in the early-era group (P = 0.003 and P = 0.011). CONCLUSION:To prevent type 1a endoleak and aortic events, strict patient selection including preoperative measurement and surgeon skill are required. Hybrid TEVAR should be performed in an experienced facility.

BACKGROUND:This study analyzed the risk factors for type 1a endoleak after hybrid thoracic endovascular repair (TEVAR) for aortic arch diseases based on preoperative patient characteristics and multidetector computed tomography measurements. METHODS AND RESULTS:In all, 213 patients who underwent proximal landing zone 1 and 2 hybrid TEVAR for aortic arch pathologies (zone 1, n=82 [38.5%]; zone 2, n=131 [61.5%]; median age 72 years) between May 2008 and February 2020 were enrolled in this study; the median follow-up period was 6.0 years. The rates of type 1a endoleak at 1, 3, 5, and 10 years were 1.4%, 1.4%, 4.1%, and 4.1%, respectively. Multivariate Cox proportional hazard regression analysis revealed that the angle of the aortic arch was a significant risk factor for type 1a endoleak (hazard ratio 1.08; 95% confidence interval 0.85-0.99; P=0.045). The estimated area under the curve in receiver operating characteristic curve analysis was 0.76, and the cut-off value of the aortic arch angle was 95°. CONCLUSIONS:It is essential to prevent type 1a endoleak, the most severe complication of hybrid TEVAR. The risk factor for type 1a endoleak in this study was a sharper angle of the aortic arch (≤95°). For patients at high risk of type 1a endoleak, it is necessary to consider alternative procedures depending on a patient's surgical risk.

PURPOSE:Hybrid thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is a minimally invasive procedure with improved results. This study aimed to clarify the effectiveness and expand the possibilities of zone 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. METHODS:This retrospective, single-center, observational cohort study included 213 patients (TBAD, n=69; thoracic arch aneurysm [TAA], n=144; median age, 72 years; median follow-up period, 6 years) from May 2008 to February 2020. The following conditions were satisfied before performing zone 1 and 2 landing TEVAR: TBAD; proximal landing zone (LZ): diameter <37 mm, length >15 mm, and nondissection area, proximal stent-graft: size ≤40 mm and oversizing rate: 10% to 20%, and TAA; proximal LZ: diameter ≤42 mm and length >15 mm, proximal stent-graft: size ≤46 mm and oversizing rate: 10% to 20%. Of the 69 patients in the TBAD group, 34 (49.3%) had patent false lumen (PFL), and 35 (50.7%) had false lumen partial thrombosis (FLPT), including ulcer-like projections. Emergency procedures were performed in 33 (15.5%) patients. RESULTS:There were no significant differences in the in-hospital mortality (TBAD: 1.5% vs TAA: 0.7%, p=0.544) or the in-hospital aortic complications (TBAD: n=1 vs TAA: n=5, p=0.666). Retrograde type A dissection was not observed in the TBAD group. The aortic event-free rates at 10 years were 89.7% (95% confidence interval [CI]: 78.7%-95.3%) and 87.9% (95% CI: 80.3%-92.8%) in the TBAD and TAA groups, respectively (log-rank p=0.636). In the TBAD group, the early and late outcomes were not significantly different between the PFL and FLPT groups. CONCLUSION:Satisfactory early and long-term results were obtained with zone 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD. CLINICAL IMPACT:This study aimed to clarify the effectiveness and expand the possibilities of zones 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Satisfactory early and long-term results in the TBAD and thoracic arch aneurysm (TAA) groups were obtained with zones 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.

Background: Hybrid thoracic endovascular aortic repair (TEVAR) without median sternotomy is increasingly being performed in high-risk patients with aortic arch disease. The outcomes of hybrid TEVAR were reported to be worse with a more proximal landing zone. This study aims to clarify the effectiveness of zone 1-landing hybrid TEVAR by comparing the outcomes of zone 2-landing hybrid TEVAR. Methods: From April 2008 to October 2020, 213 patients (zone 1: zone 1-landing hybrid TEVAR, n = 82, 38.5%; zone 2: zone 2-landing hybrid TEVAR, n = 131, 61.5%) were enrolled (median age, 72 years; interquartile range [IQR], 65–78 years), with a median follow-up period of 6.0 years (IQR, 2.8–9.7 years). Results: The mean logistic EuroSCORE was 20.9 ± 14.8%: the logistic EuroSCORE of the zone 1 group (23.3 ± 16.1) was significantly higher than that of the zone 2 group (19.3 ± 12.4%, p = 0.045). The operative time and hospital stay of the zone 1 group were significantly longer than those of the zone 2 group. On the other hand, the in-hospital and late outcomes did not differ significantly between the two groups. There were no significant differences in cumulative survival (66.8% vs. 78.0% at 10 years, Log-rank p = 0.074), aorta-related death-free rates (97.6% vs. 99.2% at 10 years, Log-rank p = 0.312), and aortic event-free rates (81.4% vs. 87.9% at 10 years, Log-rank p = 0.257). Conclusions: Zone 1- and 2-landing hybrid TEVAR outcomes were satisfactory. Despite the high procedural difficulty and surgical risk, the outcomes of zone 1-landing hybrid TEVAR were equal to those of zone 2-landing hybrid TEVAR. If the surgical risk is high, zone 1-landing hybrid TEVAR should not be avoided.

Background: Zone 0 landing thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch diseases has become a topic of interest. This study aimed to verify whether branced TEVAR (bTEVAR) is an effective and a more minimally invasive treatment by comparing the outcomes of bTEVAR and hybrid TEVAR (hTEVAR) in landing zone 0. Methods: This retrospective, single-center, observational cohort study included 54 patients (bTEVAR, n = 25; hTEVAR, n = 29; median age, 78 years; median follow-up period, 5.4 years) from October 2012 to June 2018. The logistic Euro-SCORE was significantly higher in the bTEVAR group than in the hTEVAR group (38% vs. 21%, p < 0.001). Results: There was no significant difference the in-hospital mortality between the bTEVAR and hTEVAR groups (0% vs. 3.4%, p = 1.00). The operative time (220 vs. 279 min, p < 0.001) and length of hospital stay (12 vs. 17 days, p = 0.013) were significantly shorter in the bTEVAR group than in the hTEVAR group. The 7-year free rates of aorta-related deaths (bTEVAR [95.5%] vs. hTEVAR [86.9%], Log-rank p = 0.390) and aortic reintervention (bTEVAR [86.3%] vs. hTEVAR [86.9%], Log-rank p = 0.638) were not significantly different. Conclusions: The early and mid-term outcomes in both groups were satisfactory. bTEVAR might be superior to hTEVAR in that it is less invasive. Therefore, bTEVAR may be considered an effective and a more minimally invasive treatment for high-risk patients.

ObjectiveHybrid thoracic endovascular aortic repair (TEVAR) is being accepted increasingly as a first line treatment for arch repair at the present authors’ institution. This study aimed to clarify the effectiveness of zones 0, 1, and 2 landing hybrid TEVAR.MethodsThis was a retrospective single centre case series. From April 2008 to March 2020, 348 patients (median age 72 years; interquartile range [IQR] 65, 77 years) were enrolled, with a median follow up period of 5.6 years (IQR 2.6, 8.7 years). The procedures included zone 0 in 135 patients (38.8%), zone 1 in 82 patients (23.6%), and zone 2 proximal landing zone (LZ) hybrid TEVAR in 131 patients (37.6%). The pathologies consisted of dissecting aortic aneurysms in 123 (35.3%) patients. Emergency procedures were performed in 39 (11.2%) patients.ResultsThe 30 day mortality (n = 2, 0.6%) and hospital deaths (n = 6, 1.7%) were registered. The stroke rate was 1.1% (n = 4), while early and late endoleak rates were 4.8% (n = 17) and 1.7% (n = 6), respectively. Type 1a endoleak and retrograde type A dissection occurred in seven (2.0%) and three (0.9%) patients, respectively. The cumulative survival, freedom from aorta related deaths, and freedom from aortic events in 10 years were 75.0%, 97.2%, and 84.1%, respectively. The freedom from aortic events in each landing zone in 10 years was 82.3%, 81.4%, and 87.9% for zones 0, 1, and 2, respectively. The 10 year survival rates were 82.5% and 73.6%; the 10 year aorta related death free rates were 94.9% and 98.6%, and the 10 year aortic event free rates were 82.3% and 85.5% in the zone 0 and zone 1 and 2 TEVAR, respectively.ConclusionSatisfactory early and long term results of hybrid arch repair at zones 0, 1, and 2 were achieved. To avoid complications and aortic events, the treatment strategy of hybrid arch repair for aortic arch pathologies should be tailored using accurate pre-operative assessment of the ascending aorta and the aortic arch.

PURPOSE:Zone 0 landing in thoracic endovascular aortic repair (TEVAR) has recently gained increasing attention for the treatment of high-risk patients. The aim of this study was to compare the outcomes of total endovascular aortic arch repair between branched TEVAR (bTEVAR) and chimney TEVAR (cTEVAR) in the landing zone (LZ) 0.MATERIALS AND METHODS:This was a single-center, retrospective, and observational cohort study. From January 2010 to March 2020, 40 patients (bTEVAR, n=25; cTEVAR, n=15; median age: 79 years) were enrolled in this study, with a median follow-up period of 4.1 years. These patients were considered unsuitable for open surgical treatment.RESULTS:All procedures were successful and no cases of conversion to open repair were noted during the 30-day postoperative period. The 30-day mortality was 2.5% (n=1; bTEVAR [0 of 25, 0%] vs cTEVAR [1 of 15, 6.7%]; p=0.375), the perioperative stroke rate was 10.0% (n=4; bTEVAR [4 of 25, 16.0%] vs cTEVAR [0 of 15, 0%], p=0.278), and type 1a endoleak rate was 15.0% (n=6; bTEVAR [0 of 25, 0%] vs cTEVAR [6 of 15, 40.0%], p=0.001). The risk factor for stroke was atheroma grade of ≥2 in the brachiocephalic artery (p<0.001). The risk factor for type 1a endoleak was cTEVAR (p=0.001). The 8-year survival rate was 49.9%. The aorta-related death-free rate and aortic event-free rate at 8 years were 94.4% (bTEVAR: 95.5% vs cTEVAR: 93.3%, p=0.504) and 60.7% (bTEVAR: 70.7% vs cTEVAR: 40.0%, p=0.048), respectively.CONCLUSIONS:Total endovascular aortic arch repair using bTEVAR and cTEVAR is feasible for the treatment of aortic arch diseases in high-risk patients who are unsuitable for open surgery. However, as the rate of stroke is high, strict preoperative evaluation to prevent stroke is needed. No rupture of the aneurysm was observed in cTEVAR, but patients should be selected carefully because of the high incidence of type 1a endoleak.

OBJECTIVES:Thoracic endovascular aortic repair (TEVAR) has been gradually extended to the aortic arch region, with improved results. However, the rates of strokes and endoleaks in a hybrid TEVAR remain high. The goal of this study was to clarify the effectiveness of a hybrid TEVAR with a zone 0 landing using our treatment strategy.METHODS:From April 2008 to March 2020, a total of 102 patients were enrolled in this study, with a median follow-up period of 3.2 years. The procedures included total debranching TEVAR with graft replacement of the ascending aorta in 62 patients, total debranching TEVAR with ascending aorta banding in 19 patients and total debranching TEVAR without ascending aorta banding in 21 patients.RESULTS:Thirty-day mortality and hospital deaths were 1.0% (n = 1) and 3.9% (n = 4), respectively. The rates of aortic complications and endoleaks during the first 30 days postoperatively were 8.8% (n = 9) and 4.9% (n = 5), respectively. There was no type 1a endoleak, whereas retrograde type A dissection occurred in 2 (2.0%) patients. The rate of late aortic events was 3.9% (n = 4); there were no late endoleaks or aneurysm ruptures. The 10-year survival rate was 73.7% [95% confidence interval (CI) 60.3-83.8%]. The 10-year rates of aorta-related deaths and aortic events when performing a competitive-risk analysis were 29.4% (95% CI 16.3-42.5%) and 7.2 (95% CI 23.0-51.4%), respectively.CONCLUSIONS:Satisfactory early and long-term results of a hybrid TEVAR with a zone 0 landing were achieved using our treatment strategy. When performing hybrid TEVAR in zone 0, postoperative aortic events may be reduced by accurate preoperative assessment of the ascending aorta.

Extended inferior vena cava (IVC) filter implantation time increases the risk of complications in patients. Here we present the case of a 72-year-old woman with IVC filter-induced thrombosis who underwent catheter-directed thrombolysis with prophylactic IVC filter placement. Two IVC filters were successfully retrieved 70 and 1858 days post placement. The decision to insert an IVC filter should be carefully considered with appropriate indications and all filters should be removed after the risk of deep vein thrombosis has resolved.

Purpose: To identify the optimal proximal landing zone for thoracic aortic endovascular repair (TEVAR) of aortic arch pathologies so as to avoid the bird-beak phenomenon that leads to type Ia endoleak. Materials and Methods: A retrospective single-center review was conducted of 164 patients (mean age 70.3±10.8 years, range 29–93; 127 men) who underwent repairs of the aortic arch using hybrid TEVAR from April 2008 to March 2017. The patients were divided into 2 groups according to the proximal landing zone: 43 zone 0 patients (26.2%) had total debranching TEVAR (n=18) or total endovascular aortic repair (n=25) while 121 patients (73.8%) had TEVAR landing in zones 1 (n=41) or 2 (n=80). Bird-beak configurations, endoleaks, and stent migrations were assessed on the postoperative and latest computed tomography angiography (CTA) scans. Overall survival and freedom from the bird-beak configuration, aorta-related death, and aortic events were estimated using the Kaplan-Meier method. Hazard ratios (HR) were calculated with the 95% confidence interval (CI). Results: All procedures were successful, without any 30-day mortality. There were 3 early complications (1.8%; all strokes) and 10 early endoleaks (6.1%; no type Ia). On the first postoperative CTA, 42 patients (25.6%) had a bird-beak configuration. The zone 0 patients had significantly fewer (p<0.001), shorter (p<0.004), and less angulated (p<0.001) bird-beak configurations than in zones 1–2. The mean follow-up period was 4.2 years (range 0.5–8.8). There were 18 late deaths (11.0%); only one was related to the aorta (rupture due to a type Ib endoleak in a zone 0 patient). The 5-year freedom from aorta-related death was not significantly different between groups (zone 0: 96.9% vs zones 1–2: 100%, p=0.080). On the latest CTA, 51 (31.0%) patients had a bird-beak configuration; of those, 22 (13.4%) showed >3-mm progression. The freedom from bird-beak configuration estimate was significantly higher in the zone 0 group (95.4%) vs zones 1–2 (57.8%; HR 0.10, 95% CI 0.02 to 0.31, p<0.001). There were 9 late endoleaks (4 type Ia; none in the zone 0 group). The rate of stent-graft migration was significantly lower in the zone 0 group (2.3% vs 14.1% in zones 1–2, p=0.035). Conclusion: Early and most late results in zone 0 TEVAR were equal to those in zones 1 and 2; however, there were no late type Ia endoleaks and fewer bird-beak configurations associated with zone 0 TEVAR, which suggests that zone 0 landing is advantageous for preventing these complications.

Endovascular repair can be an alternative to conventional surgery for arch and thoracoabdominal aneurysms; however, it has the limits of available stent-grafts in anatomy. We present the case of an 87-year-old woman who had dual aneurysms in the arch and thoracoabdominal regions. We considered that traditional open surgery was of extremely high risk, because she was an octogenarian and had multiple comorbidities. We successfully treated the aortic arch aneurysm and the thoracoabdominal aortic aneurysm using endovascular stent-grafts in a high-risk patient who was a poor candidate for the conventional open surgery.

BACKGROUND:Zone 0 landing hybrid thoracic endovascular aortic repair (TEVAR) includes a few moderately invasive surgical procedures. To reduce invasiveness, TEVAR with a branched aortic arch stent-graft can be considered. This study aimed to elucidate the effectiveness of performing TEVAR using a Bolton (Bolton Medical, Inc, Sunrise, Fla) branched endograft by analyzing early and midterm results. METHODS:We enrolled 28 patients (mean age, 78.4 years) who underwent TEVAR with the Bolton branched endograft in Osaka University Hospital between October 2012 and June 2018 with a mean follow-up period of 4.0 years. Double-side and single-side branched devices were used in 24 (85.7%) and 4 (14.3%) patients, respectively. RESULTS:All procedures were successful; no cases of endoleak or conversion to open repair were noted during the 30-day postoperative period. The perioperative stroke rate was 14.3% (4 out of 28); midterm stroke was not detected. All patients with perioperative stroke had atheroma grade ≥2 in the brachiocephalic artery. No type 1a endoleak was reported during the early or midterm results. The cumulative survival rate, aorta-related death-free rate, and aortic event-free survival rate at 5 years were 80.8%, 95.8%, and 81.6%, respectively. CONCLUSIONS:We achieved satisfactory early and midterm results by using a Bolton branched endograft for high-risk patients with arch pathologies except for high postoperative stroke. Although this treatment method is associated with postoperative stroke, performing strict evaluation of atheroma may prevent such complication. By preventing intraoperative stroke, TEVAR with this custom-made Bolton branched endograft may be considered a less-invasive treatment.