Fenestrated and branched thoracic endovascular aortic repair (f/b-TEVAR) of the aortic arch is a viable approach in patients unsuitable for open repair. The aim is to summarise the published results of manufactured f/b-TEVAR devices for partial and total repair of the aortic arch, and to compare fenestrated vs. branched configurations. PubMed, Scopus and The Cochrane Library were searched for articles (2018 - 2021) about patients with elective/urgent/emergent aortic requiring a proximal landing zone in the aortic arch (zone 0 - 1 - 2) and treated by f/b-TEVAR. Systematic review and meta-analysis were performed according to the PRISMA guidelines. Open repair, supra-aortic trunk (SAT) debranching + standard TEVAR, and in situ/physician modified/parallel grafts were excluded. Primary outcomes were technical success and 30 day mortality. Secondary outcomes were 30 day major adverse events, and overall survival and procedure related endpoints during follow up. Out of 458 articles screened, 18 articles involving 571 patients were selected. Indications for intervention were chronic dissections (50.1%), degenerative aneurysms (39.6%), penetrating aortic ulcers (7.4%), and pseudoaneurysms (2%). f-TEVAR, b-TEVAR, and f + b-TEVAR were used in 38.4%, 54.1%, and 7.5% of patients, respectively. Overall, technical success was 95.9% (95% confidence interval [CI] 0.93 - 0.97; I² = 0%; p for heterogeneity (Het) = .77) and 30 day mortality was 6.7% (95% CI 0.05 - 0.09; I² = 0%; p Het = .66). No statistical differences were found comparing fenestrated vs. branched endografts, except for a higher rate of type I - III endoleaks in f-TEVAR (9.8% vs 2.6%; p = .034). Overall survival rate and freedom from aortic related death at the one year follow up ranged between 82 - 96.4% and 94 - 94.7%, respectively. Thirteen and five studies were considered at moderate and high risk of bias, respectively. f/b-TEVAR for the treatment of the aortic arch, nowadays show, according to experience in dedicated centres, a satisfactory level of technical success together with progressive lowered load in terms of early mortality. There are of several limitations, and further studies are needed to reach clearer conclusions.

OBJECTIVES: Our goal was to report outcomes of the endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) using the Cook Zenith t-Branch off-the-shelf multibranched endograft. METHODS: Between 2010 and 2020, we collected patients with TAAAs who received an urgent endovascular repair using the Cook Zenith t-Branch (had a rupture, symptoms or diameter >80 mm). Thirty-day mortality, spinal cord ischaemia (SCI) and clinical success were assessed as early outcomes. Freedom from reintervention, target visceral vessel patency and survival were considered during follow-up. RESULTS: Sixty-five cases were managed using the Cook Zenith t-Branch for 27 (42%) TAAA ruptures, 8 (12%) symptomatic TAAAs and 30 (46%) asymptomatic TAAAs with a diameter >80 mm. Crawford’s extent I–II–III and IV were noted in 54 (83%) and 11 (17%), respectively. Eleven (17%) patients had SCI with 3 (5%) cases of permanent paraplegia. Postoperative dialysis (P = 0.04) and ruptured TAAAs (P = 0.05) were associated with SCI. Sixteen (25%) patients had reinterventions within the first 30 days postoperatively. The 30-day mortality was 14% (9). Ruptured TAAAs (P = 0.05) and technical failures (P = 0.01) were correlated with in-hospital mortality. Clinical success was 78% (51 patients). The mean follow-up was 18 ± 14 months. Survival at 24 months was 47% with no late TAAA-related deaths. Patients with ruptured TAAAs had lower survival than those who did not have ruptured TAAAs (52% vs 60% at 1 year; P = 0.05). Target visceral vessel patency and freedom from reintervention at 24 months were 89% and 60%, respectively. CONCLUSIONS: An off-the-shelf multibranched endograft is safe and effective for treating urgent TAAAs. Postoperative SCI and 30-day mortality are satisfactory for this challenging clinical scenario. The early reintervention rate is not negligible. Midterm survival is low, especially in patients with a ruptured TAAA; therefore, accurate patient selection is mandatory.

Objective: To analyze the outcomes of urgent/emergent endovascular aortic repair of patients with free/contained ruptured thoracoabdominal aortic aneurysms (rTAAA). Background: Endovascular repair of rTAAA has been scarcely described in emergent setting. Methods: An international multicenter retrospective observational study (ClinicalTrials.govID:NCT05956873) from January 2015 to January 2023 in 6 European and 1 US Vascular Surgery Centers. Primary end points were technical success, 30-day and/or in-hospital mortality, and follow-up survival. Results: A total of 100 rTAAA patients were included (75 male; mean age 73 years). All patients (86 contained and 14 free ruptures) were symptomatic and treated within 24 hours from diagnosis: multibranched off-the-shelf devices (Zenith t-branch, Cook Medical Inc., Bjaeverskov, Denmark) in 88 patients, physician-modified endografts in 8, patient-specific device or parallel grafts in 2 patients each. Primary technical success was achieved in 89 patients, and 30-day and/or in-hospital mortality was 24%. Major adverse events occurred in 34% of patients (permanent dialysis and paraplegia in 4 and 8 patients, respectively). No statistical differences were detected in mortality rates between free and contained ruptured patients (43% vs 21%; P=0.075). Multivariate analysis revealed contained rupture favoring technical success [odds ratio (OR): 10.1; 95% CI: 3.0–33.6; P<0.001]. Major adverse events (OR: 9.4; 95% CI: 2.8–30.5; P<0.001) and pulmonary complications (OR: 11.3; 95% CI: 3.0–41.5; P80 mm (hazard ratio: 2.0; 95% CI: 1.0–30.5; P=0.037), technical failure (hazard ratio: 2.6; 95% CI: 1.1–6.5; P=0.045) and pulmonary complications (hazard ratio: 3.0; 95% CI: 1.2–7.9; P=0.021) were independent risk factors for follow-up mortality. Conclusions: Endovascular repair of rTAAA shows high technical success; the presence of free rupture alone appear not to correlate with early mortality. Effective prevention/management of postoperative complications is crucial for survival.

Background/Objectives: Carbon dioxide digital-subtraction angiography (CO₂-DSA) is an increasingly adopted technique in endovascular aortic repair (EVAR) and fenestrated/branched EVAR (F/B-EVAR); it is used to reduce the amount of iodinate contrast medium (ICM) and prevent postoperative renal function worsening (PO-RFW). Our aim is to report results from the literature on EVAR and F/B-EVAR procedures using CO₂-DSA, together with wider applications in aortic endovascular treatment. Methods: We performed a literature review by searching electronic databases for published data on CO₂-DSA during EVAR and F/B-EVAR procedures. The endpoints were postoperative renal function worsening (PO-RFW) and efficacy of intraoperative arterial visualization. Further, applications of CO₂ for thoracic endovascular aortic repair (TEVAR) were described. Results: Seventeen studies reporting results on CO₂-DSA in EVAR (644 patients) were retrieved. Overall, 372 (58%) procedures were performed with CO₂ alone, and 272 (42%) were performed with CO₂+ICM. Eight studies analyzed the effect of CO₂-DSA angiography on PO-RFW; four studies showed a significantly lower rate of PO-RFW compared to ICM. Five studies (153 patients) analyzed intraoperative arterial visualization with CO₂-DSA; renal and hypogastric arteries were effectively visualized in 69% and 99% of cases, respectively. The use of CO₂-DSA in F/B-EVAR has not been widely investigated. The largest series reported that PO-RFW was lower in the CO₂ vs. ICM group. Conclusions: Carbon dioxide is widely applied in modern aortic endovascular treatment. CO₂-DSA for EVAR and F/B-EVAR is an efficient technique for reducing PO-RFW while allowing acceptable arterial intraoperative visualization.