Percutaneous femoral arterial access is daily practice in a variety of medical specialties and enables physicians worldwide to perform endovascular interventions. The reported incidence of percutaneous femoral arterial access complications is 3–18% and often results from suboptimal puncture location due to insufficient visualization of the target vessel. The purpose of this proof-of-concept study was to evaluate the feasibility and the positional error of a mixed-reality (MR)-assisted puncture of the common femoral artery in a phantom model using a commercially available navigation system. In total, 15 MR-assisted punctures were performed. Cone-beam computed tomography angiography (CTA) was used following each puncture to allow quantification of positional error of needle placements in the axial and sagittal planes. Technical success was achieved in 14/15 cases (93.3%) with a median axial positional error of 1.0 mm (IQR 1.3) and a median sagittal positional error of 1.1 mm (IQR 1.6). The median duration of the registration process and needle insertion was 2 min (IQR 1.0). MR-assisted puncture of the common femoral artery is feasible with acceptable positional errors in a phantom model. Future studies should aim to measure and reduce the positional error resulting from MR registration.

Purpose: The objective of this systematic review was to report the cumulative incidence of endograft migration (EM), as well as the morbidity, reintervention rates, and mortality related to EM. This study aimed to provide evidence-based data on patient-relevant sequelae of EM after thoracic endovascular aortic repair (TEVAR) performed using contemporary aortic endografts. Materials and Methods: A systematic electronic search of literature in MEDLINE (via PubMed), Web of Science, and Cochrane Central Register of Controlled Trials was performed. The pooled synthesis of outcomes was performed using the inverse variance method. Results: Seven prospective non-randomized and 4 retrospective studies, including a total of 1783 patients presenting 70 EMs, were considered for the quantitative analysis. The pooled rate of EM was 4% (95% CI, 2%–7%; range, 0.2%–11%; I2=82%); pooled morbidity rate was 31% (95% CI, 12%–59%; range, 0%–100%; I2=64%) and pooled reintervention rate was 32% (95% CI, 15%–56%; range, 0%–100%; I2=55%). The pooled mortality rate due to EM was 5% (95% CI, 1%–21%; range, 0%–40%; I2=24%). Conclusion: For the first time, this meta-analysis provides pooled reference estimates of EM after TEVAR. Thus, the results hold the potential to further characterize EM after TEVAR. The clinical relevance of EM is underlined by its association with high rates of endoleak-related morbidity, reintervention, and mortality. Close standardized surveillance after TEVAR for early detection of EM and prophylaxis of its sequelae is essential.

Objective: The aim of this study was to report 10-year real-world single-center experience with the GORE TAG conformable thoracic aortic graft (CTAG), focusing on rupture-free survival, aortic-related reintervention, and device-related complications during midterm and long-term follow-up (FU). Methods: This retrospective study analyzes results of thoracic endovascular aortic repair (TEVAR) performed between January 2009 and December 2018. Out of 419 TEVAR procedures within this period, 194 patients (male 57.2%, 111/194), with a mean age of 65 ± 13 years, were treated with the CTAG device. Indication for TEVAR was a thoracic aortic aneurysm in 24.7% (48/194), type B aortic dissection in 32.5% (63/194), penetrating aortic ulcer 15.5% (30/194), and miscellaneous 27.3% (53/194). Emergently were operated 43.8% (85/194) patients. Median follow-up (FU) including computed tomography imaging was 43.5 months (Q1-Q3: 8.6–67.0) and was completed in 91.2% (177/194) of patients. Results: Overall survival rates were 75.8% (95% confidence interval [CI] = [0.76–0.70]) and 56.6% (95% CI = [0.57–0.50]) at 12 and 60 months, respectively. Cumulative incidence for aortic rupture was 11.9% (95% CI = [0.07–0.17]) at 60 and 90 months, respectively. Cumulative incidence for aortic-related reintervention was 27.5% (95% CI = [0.21–0.34]) at 60 and 90 months. Cumulative incidence for migration was 2.8% (95% CI = [0.004–0.05]) and 3.9% (95% CI = [0.007–0.07]) at 60 and 90 months, respectively. New endograft infections or material fatigue were not observed. Conclusions: The herein reported 10-year real-world single-center experience with the CTAG observed favorable long-term outcome. Thus, the device demonstrates appropriate persistent safety, efficacy, and clinical durability up to long-term FU in the treatment of diverse thoracic aortic pathologies.

Background The treatment of extensive thoracic/thoracoabdominal aortic pathologies with arch involvement remains a challenging task in aortic surgery. The introduction of the frozen elephant trunk (FET) technique offered a link between open surgery and thoracic endovascular aortic repair (TEVAR). Despite a decade of experience, data on the complementary use of these techniques are scant. The aim of this study was to evaluate TEVAR following FET in clinical reality. Methods Between November 2006 and June 2018, 20 patients (9 females; median age of 69 years) underwent endovascular second-stage completion after FET. The clinical outcomes, technical feasibility, and morphological findings were analyzed retrospectively. Results Eleven of the 20 interventions were intended “rendezvous procedures” in a multistage approach; 4 were elective reinterventions, and 5 were emergency complication repairs. The median interval between FET and TEVAR was 231 days (11 days–7.4 years). The technical success rate was 100%. During a median follow-up (FU) period of 58.3 months, the overall survival rate was 95%, with one in-hospital death. Neurological complications occurred in three cases (spinal cord injury: n = 1; stroke: n = 2). Computed tomography angiography showed overall regression in the median diameter of the proximal descending aorta (from 57 to 48.5 mm). Conclusion TEVAR as a second-stage intervention after FET is a feasible option, with satisfactory results at medium-term FU. In extensive thoracoabdominal aortic disease without proximal landing zones, the complementary use of both techniques in a multistage approach should be considered. ^* Both authors contributed equally to this work. Received: 08 August 2020 Accepted: 07 December 2020 Publication Date: 12 February 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

OBJECTIVES: Optimal treatment for patients with diseased proximal landing zones in acute/subacute Stanford type B dissection and intramural haematoma remains unclear. This study describes the preliminary outcomes of a localized endovascular treatment [spot-stent grafting (SSG)] of main entries/intramural blood pooling located downstream (aortic zones 4 and 5) using one single short device comprising diseased landing zones, looking particularly at the technical and morphological outcomes. METHODS: Patients undergoing thoracic endovascular aortic repair (TEVAR) for acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B between 1997 and 2018 were identified from a prospectively maintained institutional database. In a total of 183 cases, 22 patients (7 women; median age 62 years; range 35-79 years) received SSG. The primary study end point was technical success. The primary morphological end point was false lumen thrombosis/aortic remodelling. Secondary end points were TEVAR-related mortality/morbidity and reinterventions. The median follow-up was 28.5 months (5 days-15.6 years). RESULTS: The primary technical success rate was 100% (22/22). During follow-up, false lumen thrombosis was seen in 21 patients (95.5%) at a median of 6 days (0 days to 2.7 years) after the index procedure (limited/extended false lumen thrombosis: n = 9 vs 12). Aortic remodelling was achieved in 15 of 22 patients (68.2%) at a median of 360 days (3 days to 7.2 years). Limited/extended remodelling was observed in 8/15 and 7/15, respectively. Retrograde dissection or stent graft-induced new entry was not observed. No stroke or spinal cord injury occurred. Reinterventions were performed in 4/22 cases. The in-hospital mortality and 30-day mortality were 0%. Overall mortality during the follow-up period was 22.7% (5/22). CONCLUSIONS: This study shows favourable technical and morphological results for SSG in selected patients with acute/subacute aortic dissection Stanford type B/intramural haematoma Stanford type B. Patient allocation to SSG remains individual. Prospective large-scale long-term data may allow refinement of the application.

Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a “TEVAR-first” policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32–82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.