Abdominal aortic aneurysm (AAA) is a common cardiovascular disease resulting in morbidity and mortality in older adults due to rupture. Currently, AAA treatment relies entirely on invasive surgical treatments, including open repair and endovascular, which carry risks for small aneurysms (diameter < 55 mm). There is an increasing need for the development of pharmacological intervention for early AAA. Over the last decade, it has been increasingly recognized that intraluminal thrombus (ILT) is involved in the growth, remodeling, and rupture of AAA. ILT has been described as having both biomechanically protective and biochemically destructive properties. Platelets are the second most abundant cells in blood circulation and play an integral role in the formation, expansion, and proteolytic activity of ILT. However, the role of platelets in the ILT-potentiated AAA progression/rupture remains unclear. Researchers are seeking pharmaceutical treatment strategies (e.g., anti-thrombotic/anti-platelet therapies) to prevent ILT formation or expansion in early AAA. In this review, we mainly focus on the following: (a) the formation/deposition of ILT in the progression of AAA; (b) the dual role of ILT in the progression of AAA (protective or detrimental); (c) the function of platelet activity in ILT formation; (d) the application of anti-platelet drugs in AAA. Herein, we present challenges and future work, which may motivate researchers to better explain the potential role of ILT in the pathogenesis of AAA and develop anti-platelet drugs for early AAA.

Objectives: This study evaluated the feasibility and safety of total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft on zone 0 landing for aortic arch pathologies. Methods: Between June 2016 and October 2019, 37 consecutive patients underwent total endovascular arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and branch artery patency. Results: During the study period, 37 patients were treated with total endovascular aortic arch repair with surgeon-modified fenestrated stent-graft. Twenty-one (56.8%) patients were diagnosed with aortic dissections, 15 (40.5%) patients with aneurysms, and 1 (2.7%) patient required reintervention due to endoleak and sac expansion from previous thoracic endovascular aortic repair for thoracoabdominal aneurysm. The proximal landing zone for all patients were in zone 0, and all branch arteries of aortic arch were reconstructed. Technical success was achieved in 34 cases (91.9%). Three (8.1%) patients had fenestrations misaligned with target arteries, and the chimney technique was applied as a complementary measure. Thirty-day mortality rate was 5.4% (n=2). Thirty-day stroke rate was 5.4% (n=2). Thirty-day reintervention rate was 2.7% (n=1). At a median follow-up of 20 months (range, 3–49 months), 5 (13.5%) patients died, including 2 aortic-related deaths, 1 nonaortic-related death, and 2 deaths of unknown reason. One (2.7%) patient had stroke. Four patients (10.8%) had reintervention during the follow-up, including 2 cases of left subclavian artery occlusion and 2 cases of type II endoleak. The estimated survival (±SE) at 2 years was 72.4%±9.7% (95% CI 53.4%–91.4%). The estimated freedom from reintervention (±SE) at 2 years was 87.4%±5.9% (95% CI 75.84%–98.96%). Conclusions: Total endovascular aortic arch repair with surgeon-modified fenestrated stent-grafts on zone 0 landing is an alternate option for the treatment of aortic arch pathologies in experienced centers.

Endovascular therapy has emerged as a crucial therapeutic method for treating vascular diseases. Endovascular surgical robots have been used to enhance endovascular therapy. However, to date, there are no universal endovascular surgical robots that support molds of different types of devices for treating vascular diseases. We developed a novel endovascular surgical robotic system that can independently navigate the intravascular region, advance and retract devices, and deploy stents. This robot has four features: (1) The bionic design of the robot can fully simulate the entire grasping process; (2) the V-shaped relay gripper waived the need to redesign special guidewires and catheters for continuous rotation; (3) the handles designed based on the feedback mechanism can simulate push resistance and reduce iatrogenic damage; and (4) the detachable design of the grippers can reduce cross-infection risk and medical costs. We verified its performance by demonstrating six different types of endovascular surgeries. Early evaluation of the novel endovascular robotic system demonstrated its practicability and safety in endovascular surgeries.

Background: To assess the feasibility and first-in-human experience of a novel endovascular robotic system for treatment of lower extremity peripheral arterial disease (PAD). Methods: Between November 2021 and January 2022, consecutive patients with obstructive lower extremity PAD and claudication (Rutherford 2–5) with >50% stenosis demonstrated on angiography were enrolled in this study. Lower extremity peripheral arterial intervention was performed using the endovascular robotic system, which consisted of a bedside unit and an interventional console. The primary endpoints were technical success, defined as the successful manipulation of the lower extremity peripheral arterial devices using the robotic system, and safety. The secondary endpoints were clinical success, defined as 50% residual stenosis at the completion of the robot-assisted procedure without major adverse cardiac events and radiation exposure. Results: In total, 5 patients with PAD were enrolled in this study (69.2±6.0 years; 80% men). The novel endovascular robotic system successfully completed the entire procedure of endovascular treatment of lower extremity PAD. Conversion to manual operation, including advancement, retracement, rotation of the guidewires, catheters, sheaths, deployment, and release of the balloons and stent grafts, was not necessary. We achieved the criteria for clinical procedural and technical success in all patients. No deaths, myocardial infarctions, or ruptures occurred in the period up to 30 days after the procedure, and no device-related complications were observed. The robotic system operator had 97.6% less radiation exposure than that at the procedure table, with a mean of 1.40±0.49 μGy. Conclusions: This study demonstrated the safety and feasibility of the robotic system. The procedure reached technical and clinical performance metrics and resulted in significantly lower radiation exposure to the operators at the console compared with that at the procedure table. Clinical Impact: There were some reports about several robotic systems used in the peripheral arterial disease, but no robotic system was able to perform entire procedure of endovascular treatment of lower extremity peripheral arterial disease (PAD). To solve this problem, we designed a remote-control novel endovascular robotic system. It was the first robotic system that can perform entire procedure of endovascular treatment of PAD worldwide. A novelty retrieval report about this is provided in the supplementary materials. The robotic system is compatible with all commercial endovascular surgical devices currently available in the market, including guidewires, catheters and stent delivery systems. It can perform all types of motion, such as forward, backward, and rotation to meet the requirements of all types of endovascular procedures. During the operation, the robotic system can perform these operations in a fine-tuned manner, so it is easy to cross the lesions, which is the key factor influencing the success rate of the operation. In addition, the robotic system can effectively reduce the exposure time to radiation, thereby reducing the risk of occupational injury.

Objectives: This study evaluated the feasibility and safety of zone 1 thoracic endovascular aortic repair (TEVAR) with fenestrated surgeon-modified stent-graft (SMSG) for aortic arch pathologies. Methods: Between March 2016 and November 2020, 34 consecutive patients underwent zone 1 TEVAR with fenestrated SMSG for aortic arch pathologies. Outcomes included technical success, perioperative, and follow-up morbidity and mortality. Results: During the study period, 34 patients were treated with zone 1 TEVAR with fenestrated SMSG. Twenty-four (70.6%) patients presented with type B aortic dissections, 9 (26.5%) patients presented with aneurysms (7 located on the lesser curvature side of aortic arch), 1 (2.9%) patient presented with type Ia endoleak after previous TEVAR owing to traumatic aortic dissection. The proximal landing zone for all patients were in zone 1, and all supra-aortic trunks were reconstructed, except for one left subclavian artery. Technical success was achieved in all cases. The 30-day estimated survival (±SE) was 90.9% ± 5.0% [95% confidence interval (CI): 77.0%–97.0%]. The 30-day estimated freedom from reintervention (±SE) was 87.9% ± 5.7% (95% CI: 73.4%–95.3%). At a median follow-up of 48 months (range, 12–68 months), 2 patients died, including 1 aortic-related death and 1 non-aortic-related death. One patient had reintervention 13 months after the operation owing to type Ia endoleak. All supra-aortic trunks were patent. The estimated survival (±SE) during follow-up was 85.1% ± 6.2% (95% CI: 69.9%–93.6%). One (2.7%) patient had stroke. The estimated freedom from reintervention (±SE) during follow-up was 84.2% ± 6.5% (95% CI: 69.9%–93.5%). Conclusions: Zone 1 TEVAR with fenestrated SMSG is an alternate option for treatment of aortic arch pathologies in experienced centers.

Background: This study evaluated the feasibility and safety of thoracic endovascular aortic repair (TEVAR) for aortic arch penetrating atherosclerotic ulcer (PAU) using Castor single-branched stent-graft with zone 2 landing. Methods: Between May 2020 and April 2022, a total of 25 aortic arch PAU patients were treated by TEVAR with Castor single-branched stent-graft. Outcomes included technical success, perioperative and follow-up morbidity and mortality, and patency of left subclavian artery (LSA). Results: All patients had aortic arch PAU with intramural hematoma (IMH). The proximal landing zone for all patients was in zone 2, which was between the distal edge of the left common carotid artery and proximal edge of LSA, in all cases. Technical success was achieved in all cases. During hospitalization after the operation, 1 patient died of gastrointestinal bleeding, and 2 patients (8.0%) had ischemic stroke. At a median follow-up of 29 months (interquartile range [IQR], 24-30 months), 2 (8.0%) patients died, including 1 ischemic stroke and 1 hemorrhagic stroke. One patient (4.0%) had reintervention owing to retrograde type A aortic dissection (RTAD) 2 months after the operation, and was successfully treated with aortic root remodeling, ascending aorta and total aortic arch replacement and frozen elephant trunk procedure. No endoleak or LSA occlusion occurred. The maximal diameter of aorta at proximal (30.2±2.4 mm vs 31.2±3.0 mm; p>0.05) and distal (25.7±2.8 mm vs 24.5±2.3 mm; p>0.05) landing zone showed no significant difference before and after the operation. Conclusions: The TEVAR for aortic arch PAU using Castor single-branched stent-graft is a safe and efficient option with zone 2 landing. Clinical Impact: For patients with diagnosis of PAU with IMH, TEVAR with Castor single-branched stent-graft presents low mid-term mortality and morbidity rate, which should be considered as an optimal option when proximal landing zone is insufficient and revascularization of left subclavian artery (LSA) is needed. With Castor single-branched stent-graft, LSA could be revascularized easily and accurately.