Purpose: To describe how to use a steerable sheath from a femoral access to catheterize antegrade branches in a branched aortic stent-graft. Technique: Following femoral cutdown, a stent-graft with antegrade branches destined for renovisceral target vessels was deployed in the desired position. A steerable sheath with a tip that rotates up to 180° was introduced from the common femoral artery and navigated to the antegrade branches for consecutive catheterization of the target vessels and deployment of one or more bridging stents per branch. The technique is demonstrated in 4 patients who underwent successful complex abdominal and thoracoabdominal branched endovascular repairs with 1, 2, and 4 antegrade branches. Conclusion: Retrograde access for complex aortic endografts with antegrade branches using a steerable sheath appears feasible and effective and may serve as an alternative to upper extremity access.

During the last 20 years, a clear shift has been observed towards thoracic endovascular aortic repair for different aortic pathologies. However, total endovascular repair of the aortic arch remains technically demanding. Simultaneous perfusion of all supra-aortic arteries without longer cerebral ischemia time, whilst trying to avoid cerebral embolization, labels endovascular aortic arch repair with highest level of technical difficulty and surgical expertise. The aim of this article is to present an overview of the current technical options for endovascular aortic arch repair and their early results. Currently, early results are reported from four endovascular arch replacement techniques: hybrid repair, total endovascular approach, chimney grafts and in-situ fenestration. The early results of these different arch replacement techniques are promising, especially the total arch replacement with custom-made fenestrated or branched stent-grafts. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy.

Patients with peripheral artery disease (PAD) are at risk for amputation. The aim of this study was to assess the type of revascularisation prior to and the 30-day mortality rate after major amputation due to PAD. Retrospective analysis of consecutive patients undergoing major amputation for PAD between 01/2000 and 12/2017 at a tertiary referral center. The number and target level of ipsilateral revascularisations prior to amputation were analyzed per patient and over the years. There were three types of revascularisation (open, endovascular and combined treatment) at three levels: aortoiliac, femoropopliteal and infrapopliteal. Univariate and multivariate logistic regression models were used to assess the association of level of amputation and patient characteristics with 30-day mortality. 312 patients (65.7% male) with a mean age of 73.3 ± 11 years underwent 338 major amputations: 70 (21%) above/through knee and 268 (79%) below knee. A median of 2 (interquartile range, IQR 1-4) revascularisations were performed prior to amputation, with a slight decrease of 1.4% per year from 2000 to 2017 (incidence rate ratio of 0.986 0.974-0.998; Poisson regression analysis, p=0.021). 16% (53/338) of patients underwent primary amputation without revascularisation; this number remained relatively stable throughout the study period. The proportion of exclusively open treatment before amputation decreased substantially from 35% in 2006 to none in 2016, while exclusively endovascular revascularisations were performed increasingly from 17% in 2002 to 64% in 2016. Amputation occurred after a median of 9.5 months (IQR 0.9-67.6 months) if the first revascularisation was aortoiliac or femoropopliteal and after 2.1 months (IQR 0.5-13.8 months) if the first intervention was infrapopliteal (p<0.001) with no significant change over the years (normal linear regression, p=0.887). Thirty-day mortality was 8.9% (22/247) after below knee and 27.7% (18/65) after above/through knee amputation (adjusted OR 3.84, 95% CI 1.74-8.54, p=0.001) with a slight increase of mortality over the study period (adjusted OR 1.09, 95% CI 1.018-1.159, Poisson regression analysis, p= 0.021). The uni- and multivariate analysis of patient characteristics did not show an association with mortality, except higher ASA classification (adjusted OR 2.65, 95% CI 1.23-5.72, p= 0.012). Mortality, especially after above/through knee amputation, remains high over the past two decades. There is a clear shift towards endovascular treatment of patients with PAD prior to major amputation. In patients needing infrapopliteal revascularisations, amputation was performed much sooner than in those with aortoiliac or femoropopliteal interventions, with no improvement over the years. Strategies to extend limb salvage in these patients should be the focus of further research.

Purpose:To investigate the influence of flushing thoracic stent-grafts with carbon dioxide and perfluorocarbon on the amount of gas released during stent-graft deployment in thoracic endovascular aortic repair (TEVAR). Materials and Methods: Ten TX2 ProForm thoracic stent-grafts were deployed into a water-filled container with a curved plastic pipe and flushed sequentially with carbon dioxide, 20 mL of liquid perfluorocarbon (PFC), and 60 mL of saline. Released gas was measured using a calibrated setup. The volume of released gas was compared with the results of an earlier published reference group, in which identical stent-grafts were flushed with 60 mL saline alone as recommended in the instructions for use. Results: The average amount of gas released in the test group was 0.076 mL, significantly lower (p<0.001) than the mean 0.79 mL of gas released in the reference group. Big bubbles appearing at the tip of the sheath when deployment was started were seen in all grafts of the reference group but in only 2 of the test group stent-grafts. Small bubbles were less frequent in the test group. Conclusion: The amount of gas released from thoracic stent-grafts during deployment can be influenced by different flushing techniques. The use of PFC in addition to the carbon dioxide flushing technique reduces the volume of gas released during deployment of tubular thoracic stent-grafts to a few microliters. This significant effect is presumably based on the high solubility of carbon dioxide in perfluorocarbon and could be a potential future approach to lower the risk of cerebral injury and stroke from air embolism during TEVAR.

The aim of this study was to report on mid-term outcomes after endovascular aortic repair in patients with Marfan (MFS) or Loeys-Dietz (LDS) syndrome. We analyzed data from two European centers of patients with MFS and LDS undergoing endovascular aortic repair. Patients were analyzed based on (1) timing of the procedure (planned vs emergency procedure) and (2) the nature of the landing zone (safe vs non-safe). The primary end-point was freedom from reintervention. Secondary end-points were freedom from stroke, bleeding and death. A population of 419 patients with MFS (n = 352) or LDS (n = 67) was analyzed for the purpose of this study. Thirty-nine patients (9%) underwent endovascular aortic repair. Indications for TEVAR or EVAR were aortic dissection in 13 (33%) patients, aortic aneurysm in 22 (57%) patients and others (intercostal patch aneurysm, penetrating atherosclerotic ulcer, pseudoaneurysm, kinking of FET) in 4 (10%) patients. Thoracic endovascular repair was performed in 34 patients, abdominal endovascular aortic repair was performed in 5 patients. Mean age at 1^st TEVAR/EVAR was 48.5 ± 15.4y. Mean follow-up after 1^st TEVAR/EVAR was 5.9 ± 4.4 y. There was no statistically significant difference in the rate of re-interventions between patients with non-safe landing zone and the patients with safe proximal landing zone (P = 0.609). Furthermore, there was no increased probability for reintervention after planned endovascular intervention compared to emergency procedures (P = 0.916). Mean-time to reintervention, either open surgical or endovascular, after planned endovascular intervention was in median 3.9 y [95% CI 2.0–5.9y] and 2.0 y [95% CI -1.1–5.1y] (P = 0.23) after emergency procedures. Endovascular aortic repair in patients with MFS and LDS and a safe landing zone is feasible and safe. Endovascular treatment is a viable option when employed by a multi-disciplinary aortic team even if the landing zone is in native tissue.