Current guidelines recommend diameter monitoring of small and asymptomatic abdominal aortic aneurysms (AAAs) due to the low risk of rupture. Elective AAA repair is recommended for diameters ≥ 5.5 cm in men and ≥ 5.0 cm in women. However, data supporting the efficacy of elective treatment for all patients above these thresholds are diverging. For a subgroup of patients, life expectancy might be very short, and elective AAA repair at the current threshold may not be justified. This study aimed to externally validate a predictive model for survival of patients with asymptomatic AAA treated with endovascular aneurysm repair (EVAR). This was a multicentre international retrospective observational cohort study. Data were collected from four European aortic centres treating patients between 2001 and 2021. The initial model included age, estimated glomerular filtration rate (eGFR), and chronic obstructive pulmonary disease (COPD) as independent predictors for survival. Model performance was measured by discrimination and calibration. The validation cohort included 1 500 patients with a median follow up of 65 months, during which 54.6% of the patients died. The external validation showed slightly decreased discrimination ability and signs of overfitting in model calibration. However, a high risk subgroup of patients with impaired survival rates was identified: octogenarians with eGFR < 60 OR COPD, septuagenarians with eGFR < 30, and septuagenarians with eGFR < 60 and COPD having survival rates of only 55.2% and 15.5% at five and 10 years, respectively. EVAR is a valuable treatment option for AAA, especially for patients unsuitable for open repair. Nonetheless, not all these patients will benefit from EVAR, and an individualised treatment recommendation should include considerations on life expectancy. This study provides a risk stratification to identify patients who may not benefit from EVAR under the present diameter threshold.

To investigate whether very low mammographic breast density (VLD), HER2, and hormone receptor status holds any prognostic significance within the different prognostic categories of the widely used Nottingham Prognostic Index (NPI). We also aimed to see whether these factors could be incorporated into the NPI in an effort to enhance its performance. This study included 270 patients with newly diagnosed invasive breast cancer. Patients with mammographic breast density of <10 % were considered as VLD. In this study, we compared the performance of NPI with and without VLD, HER2, ER and PR. Cox multivariate analysis, time-dependent receiver operating characteristic curve (tdROC), concordance index (c-index) and prediction error (0.632+ bootstrap estimator) were used to derive an updated version of NPI. Both mammographic breast density (VLD) (p < 0.001) and HER2 status (p = 0.049) had a clinically significant effect on the disease free survival of patients in the intermediate and high risk groups of the original NPI classification. The incorporation of both factors (VLD and HER2 status) into the NPI provided improved patient outcome stratification by decreasing the percentage of patients in the intermediate prognostic groups, moving a substantial percentage towards the low and high risk prognostic groups. Very low density (VLD) and HER2 positivity were prognostically significant factors independent of the NPI. Furthermore, the incorporation of VLD and HER2 to the NPI served to enhance its accuracy, thus offering a readily available and more accurate method for the evaluation of patient prognosis.

Background: Minimally Invasive Staged Segmental Artery Coil Embolization (MIS²ACE) is a novel technique of spinal cord preconditioning used to reduce the risk of paraplegia in thoracoabdominal aortic aneurysm (TAAA) repair. In this study, we report our experience with MIS²ACE, including both degenerative and post-dissection TAAA, while we attempt to systematically summarize relevant data available in the literature. Design: single-center observational study with systematic review of the literature and meta-analysis. Methods: Initial retrospective analysis of 7 patients undergoing MIS²ACE over 12 sessions with a subsequent systematic review of the literature and meta-analysis of the available published data (PROSPERO protocol number: CRD42023477411). Baseline patient and aneurysm characteristics, along with procedural technique and outcomes, were analyzed. One-arm pooling of proportions was used to summarize available published data. Results: We treated seven patients (5 males, 71%) with a median age of 69 years (IQR 55,69). According to the Crawford classification, five patients (1%) had extent II TAAA, and two (29%) had extent III TAAA. Five patients (71%) had post-dissection -TAAA; four of them were after Stanford type A dissection, and one had a chronic type B dissection. Three patients (43%) had connective tissue disease. Of the seven patients, six (86%) underwent previous aortic surgery, while the median aneurysm diameter was 58 mm (IQR 55,58). MIS²ACE was successful in 11 sessions (92%). The median number of embolized arteries was 4 (IQR 1,4). There were no periprocedural complications in any embolization. The median embolization-operation time interval was 37.0 days (IQR 31,78). Two patients had open and five endovascular treatment. There were no events of spinal cord ischemia either after MIS²ACE or after the aortic repair. Out of the 432 initially retrieved articles, we included two studies in the meta-analysis, including patients with MIS²ACE for spinal cord preconditioning in addition to our cohort. The prevalence of pooled postoperative spinal cord ischemia among MIS²ACE patients is 1.9% (95% CI −0.028 to 0.066, p = 0.279; 3 studies; 81 patients, 127 coiling sessions). Conclusions: While the current published data is limited, our study further confirms that MIS²ACE is a technically feasible and safe option for spinal cord preconditioning.

The risk of bridging stent occlusion after branched endovascular aortic repair (BEVAR) remains an issue. Currently, there is no clear recommendation on what kind of antithrombotic therapy should be installed after BEVAR. The aim of the study was to estimate the impact of postoperative antithrombotic therapy on bridging stent occlusion rate after elective BEVAR. An international multicenter retrospective analysis was performed in 4 European tertiary vascular units. All reno-visceral target vessels treated with bridging stents of patients undergoing elective BEVAR with the use of off-the-shelf or custom-made branched stent-grafts for pararenal aortic aneurysms (PAAs), type Ia endoleaks after previous EVAR, and thoracoabdominal aortic aneurysms (TAAA) between January 2014 and December 2022 were included. Primary outcome was freedom from bridging stent occlusion and its correlation with postoperative antithrombotic therapy. Secondary outcomes were overall survival and identifying target vessel and bridging stent characteristics, which may have a higher risk for bridging stent occlusion according to the PRINCE2SS recommendation. Follow-up information was obtained for all patients per 31st of December 2022. In total, 120 patients (90 male) with a median age of 72 (interquartile range [IQR]=67-77) years were included. Two hundred eighty-nine external and 127 internal branches were used for 416 target vessels. The median follow-up was 21 months (IQR=9-48) with a follow-up index of 1.0. During follow-up, 24 (5.8%) primary bridging stent occlusions (left renal artery [LRA]=10, right renal artery [RRA]=7, superior mesenteric artery [SMA]=3, truncus coeliacus [TC]=4) were found. The risk of renal bridging stent occlusion is significantly higher compared with visceral bridging stent, p=0.013. The occlusion rate was 7.8% for renal branches and 1.5% for visceral branches at 1 year and 10.6% and 3.7% at 5 years, respectively. The multivariable Cox proportional hazard model on bridging stent occlusion showed that there was no significant difference between the used antithrombotic strategies. No antithrombotic therapy was significantly associated with bridging stent occlusion, whereas no evidence for superiority of any other antithrombotic therapy was found. Overall, the bridging stents’ occlusion rate was low. We found a significantly higher occlusion rate in renal arteries compared with the visceral ones. Clinical Impact: Based on our study, no antithrombotic therapy is significantly associated with bridging stent occlusion, and no evidence of the superiority of other antithrombotic therapy exists. Nevertehless, due to the low number of bridging stent occlusions, this study can neither support nor reject the PRINCE2SS recommendations. Further studies with larger cohorts are needed to determine clear guideliness of the best antithrombotic treatment regimen after complex enfovascular aortic repair.

Background: The objective of this systematic review was to provide evidence-based data regarding the safety and efficacy of physician-modified endografts (PMEGs) for reno-visceral aortic pathologies. Methods: A systematic search of all the literature reported until February 2025 was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The main outcomes were technical success, major adverse events (MAE), mortality, bridging stents instability, device related re-intervention and type Ic/IIIc endoleak. Results: A total of 273 study titles were identified by the initial search strategy, of which 19 studies were considered eligible for inclusion in the meta-analysis. A total of 1585 patients (78%, male) were identified among the eligible studies. The median follow-up of the included studies was 14 months (ranged from 5 to 47 months). The overall technical success rate was 98.1% (95% CI 97.2%-98.8%, p<0.75, I ² =0%)(98.6% in elective cases, 95.1% for emergent/urgent cases). The overall MAE was 24.3% (95% CI, 19.1%-30.4% p<0.00, I ² =81%;) (elective group: 22.2%; emergent/urgent: 26%). The pooled 30-day mortality rate was 6.1% (95% CI 4.3%-8.6%, p=0.002, I ² =55%) (elective group: 4.8%; emergent/urgent: 15.6%). The pooled rate of early device-related re-intervention rate was 9.5% (95% CI 5.6%-15.7%, p=0.00, I ² =85%) (elective group: 8.9%; emergent/urgent:10.5%). The overall late pooled device-related re-intervention rate was 13.9% (95% CI 8.1%-22.8%, p=0.00, I ² =91%) (elective group: 14.6%; emergent/urgent: 15.6%). The pooled bridging stents instability during the early period was 1.9% (95% CI 1.1%-3.2%, p=0.00, I ² =80%). The late pooled late bridging stents instability was 1.5% (95% CI 1.1%-3.2%, p=0.00, I ² =74%). Conclusions: Physician-modified endografts represent a favorable alternative for treatment of reno-visceral pathologies. High technical success rate, low 30-day mortality and low re-intervention rate makes it an attractive solution for use in daily clinical practice. However, randomized studies with custom-made devices, larger sample sizes, and long-term follow-up are crucial for more robust and detailed analysis. Clinical Impact: This study provides detailed information on a physician-modified endografts for omplex endovascular treatemnt. As the custom-made endografts have been developed, the delivery time for them varies between countries and vascular surgery services, making the planning of the procedure difficult, especially in symptomatic patients with complex abdominal aortic aneurysms. The objective of this systematic review was to provide evidence-based data regarding the safety and efficacy of the physician-modified endografts (PMEGs) for complex endovascular treatment. Overall the results suggest that PMEGs represent a favourable alternative for complex endovascular treatment. High technical success rate, low 30-day mortality and low re-intervention rate makes it an attractive solution for use in daily clinical practice.

Bronchial artery aneurysm (BrAA) is a rare but potentially life-threatening condition, often associated with aortic pathology. We present a case of a 59-year-old man with a history of Stanford type A acute aortic dissection and subsequent aortic repairs. Surveillance imaging revealed a progressively enlarging right-sided BrAA originating from the false lumen. A staged approach was adopted, beginning with endovascular coil embolization using 18 detachable coils, followed by an open aortic repair. The procedure was successful, with complete aneurysm exclusion and no perioperative complications. This case underscores the technical challenges of BrAA embolization and highlights the efficacy of a multidisciplinary, staged treatment strategy.