Postimplantation syndrome (PIS) is a systemic inflammatory response occurring in early phase after abdominal aortic aneurysm (AAA) endovascular repair (EVAR). PIS can also occur after endovascular aneurysm sealing (EVAS) with Nellix system which prevent new onset of mural thrombus inside. Aim was to compare the incidence of PIS after EVAS and EVAR to evaluate the possible role of the new-onset thrombus inside the aneurysmal sac. Secondary aims were to assess the effect of AFX (Endologix) endoskeleton compared with other commercially available exoskeleton PTFE stent grafts on inflammatory response and its relationship with the clinical outcomes. From 2013 to 2017, data on 60 elective EVAS with Nellix system (Endologix, Irvine, CA, USA) and 110 EVAR with ePTFE devices (56 AFX devices and 54 other stent grafts) for AAA patients were retrospectively collected. PIS was defined as composite of body temperature ≥38 °C coinciding with leukocyte count >12,000/mL and hs-CPR >10 mg/L. New-onset thrombus volume after EVAR was calculated by: endograft volume - preoperative luminal volume=volume of new-onset thrombus, whereas post-EVAS thrombus volume was calculated from difference between AAA volume and volume of Nellix endobags, including balloon expandable stents. Nonparametric χ² distribution with corresponding P values were used to assess differences among categorical variables with regard to endograft type. Threshold of statistical significance was P<0.05. Subgroup analysis of outcomes by stent-graft design was performed using independent-samples t-test. EVAS with Nellix system was associated with lower incidence of PIS compared to EVAR using both AFX device and other endografts (8.3%, 30%, 35%, respectively, P=0.001). No significant new-onset of mural thrombus occurred following EVAS while an avarage new-onset thrombus of 21% and 14% was found in EVAR group A and group B, respectively. No statistically significant difference of PIS incidence was observed after endoskeleton AFX device deployment compared with other EVAR exoskeleton endografts. During follow-up, major complications were proportionally but not significantly (P=0.43) less frequent after EVAS (10.3%) than after EVAR and after EVAR using AFX device (8.9%) than after EVAR with other PTFE stent grafts (16.4%). The etiology and pathophysiology of PIS is not yet well understood. It is speculated that the type of the stent graft or the mural thrombus within the AAA may play a role in determing this inflammatory response. In this study, PIS was significantly less frequent after EVAS than EVAR. The lower inflammatory reaction observed after EVAS might be related to the endobags of Nellix system which completely seal the aneurysm sac reducing the new onset of mural thrombus. This could confirm the role of new-onset mural thrombus in the genesis of PIS. The systemic inflammatory response does not significantly differ after endoskeleton AFX device deployment compared with other EVAR exoskeleton stent grafts. PIS does not seem to have any significant prognostic implications in terms of major adverse events.

Introduction: A type 2 endoleak (EL2) remains the most prevalent complication of endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA). Methods: We conducted a retrospective, single-center analysis, including patients who underwent embolization for an isolated EL2 after EVAR. The study population was stratified into two groups: Group A, consisting of patients whose EL2 resolved after the first embolization procedure, and Group B, consisting of those with refractory EL2 (rEL2). The indication for EL2 treatment was aneurysmal sac growth amounting to >10 mm from the index EVAR. The indications for endograft explantation were the absence of high comorbidities and persisting aneurysmal sac expansion. Those with high comorbidities were subjected to another endovascular procedure or a conservative approach, the latter being preferred. The primary endpoint was EL2 resolution. The secondary endpoints were mid-term outcomes in terms of aneurysmal sac shrinkage, stability and expansion rates, and aneurysm-related complications. Results: Among 57 patients, 19 patients (33.3%) showed signs of EL2 after the first embolization, whereas 38 (66.6%) presented rEL2. Of these, 14 (36.8%) presented significant aneurysmal sac expansion: 8 patients underwent a secondary embolization, while an open conversion was performed in the remaining 6 patients (42.8%), 4 of whom, in an elective setting, showed a complete resolution of EL2, while 2 patients treated in an urgent setting died from a ruptured aneurysm. Among the patients treated with a secondary embolization, only 2 patients presented EL2 resolution, while the other 6 patients (75%) showed rEL2. Out of the 38 patients with rEL2, 24 patients did not undergo further interventions; of these, 11 (45.8%) presented sac expansion, and 16% developed type IA EL. Conclusions: A strict follow-up and possibly a more aggressive treatment should be considered in an elective setting for patients with rEL2.

Background: There is significant debate regarding the existence of sex-related differences in the presentation, treatment, and outcomes of men versus women affected by abdominal aortic aneurysm (AAA). The purpose of this study is to compare endovascular aneurysm repair (EVAR) of infrarenal AAAs with the current sex-neutral 5.0–5.5 cm-diameter threshold for intervention between the two sexes. Methods: Retrospective review of consecutive cases from a single teaching institution over a period of five years of patients who had undergone elective EVAR for AAAs between 5.0 and 5.5 cm in diameter. Outcomes of interest were compared according to sex. Results: Ninety-four patients were included in the analysis, with a higher prevalence of men (53%). Females were older at the time of repair, 78 ± 5.1 years, versus 71.7 ± 7 years (p < 0.01), and had higher incidence of underlying comorbidities, namely, arrhythmia, chronic kidney disease, and previous carotid revascularization. Women had higher incidence of immediate systemic complications (p = 0.021), post-operative AMI (p = 0.001), arrhythmia (p = 0.006), pulmonary oedema (p < 0.001), and persistent renal dysfunction (p = 0.029). Multivariate analysis for post-operative factors associated to mortality and adjusted for sex confirmed that AMI (p = 0.015), arrhythmia (p = 0.049), pulmonary oedema (p = 0.015), persistent renal dysfunction (p < 0.001), cerebral ischemia (p < 0.001), arterial embolism of lower limbs (p < 0.001), and deep-vein thrombosis of lower limbs (p < 0.001) were associated to higher EVAR-related mortality; a higher incidence of post-operative AMI (p = 0.014), pulmonary edema (p = 0.034), and arterial embolism of lower limbs (p = 0.046) were associated to higher 30-days mortality. In females there was also a higher rate of suprarenal fixation (p = 0.026), insertion outside the instruction for use (p = 0.035), and a more hostile neck anatomy with different proximal aortic diameter (p < 0.001) and angle (p = 0.003). Conclusions: A similar threshold of size of AAA for elective surgery for both males and females might not be appropriate for surgical intervention, as females tend to have worse outcomes. Further population-based studies are needed to guide on sex-related differences and intervention on AAA.

Objectives: This study aimed to evaluate whether gender-related anatomical differences in proximal aortic neck morphology affect the feasibility and outcomes of endovascular aortic aneurysm repair (EVAR) in women with abdominal aortic aneurysms (AAA). Methods: This study performed a retrospective analysis of patients electively treated by EVAR for infrarenal AAA between January 2019 and December 2023. Demographics, anatomical characteristics, and stent graft details were analyzed. The primary endpoint was technical success. Secondary endpoints included freedom from aortic and neck-related reinterventions, endoleak rate, and freedom from aneurysm-related mortality during follow-up. Technical aspects, including adherence to the instructions for use (IFUs), were retrospectively analyzed. Results: One-hundred-seventeen patients (fifty-six females; mean age 76.2 ± 5.3 years) underwent elective EVAR for AAA. Demographics and comorbidities were homogeneous across genders. Female patients (Group A) demonstrated a higher prevalence of hostile proximal aortic neck features, including neck length < 10 mm and angulation > 60° (p = 0.009, p = 0.029, respectively) and a higher frequency of off-label EVAR procedures (28.6% vs. 11.5%; p = 0.034). The overall technical success rate was 98.3%, with no significant differences between genders in terms of stent graft selection, use of suprarenal fixation, or incidence of type 1–3 endoleaks. The median follow-up period was 35.2 ± 12.7 months, showing comparable rates of neck-related reinterventions, open conversions, and aneurysm-related mortality between genders. Notably, off-label EVAR was identified as an independent risk factor for type 1A endoleaks, reinterventions, and aneurysm-related mortality (p < 0.00001, p < 0.0001, and p = 0.001, respectively). Conclusions: Female patients undergoing EVAR often present with hostile proximal aortic neck features and are treated at an older age than males. Despite these differences, technical success rates and mid- to long-term outcomes were comparable between genders, with no variation in stent graft selection or suprarenal fixation use. Effective procedural planning, device selection, and surgical expertise appear to mitigate historical gender-related anatomical challenges. Further large-scale studies are needed to confirm whether anatomical factors alone drive outcomes, irrespective of gender.

Objectives : the purpose of this study was to determine whether gender-related proximal neck anatomic variables influence the applicability and outcomes of aortic endografting in women with abdominal aortic aneurysms of similar size. Methods: this retrospective study includes all consecutive patients who underwent elective EVAR for abdominal aortic aneurysms (AAA) with a maximum diameter ranging from 5.0 to 6.0 cm between January 2019 and December 2023. Results: a total of 117 patients were consecutively enrolled between January 2019 and December 2023, comprising 56 females (47.9%) and 61 males (52.1%). Females were older than males (mean age: 78.2 vs. 74.3 years, respectively; p<0.001). Hostile anatomic features of the proximal aortic neck were observed more frequently in women than in men (33.9% vs. 16.3%; p<0.01), including neck length <10 mm (30.3% vs. 10%; p28 mm (10.7% vs. 3.3%; p60° compared to men, although this difference was not statistically significant (7.1% vs. 6.6%; p50% or a conical neck shape. Technical success was achieved in 98.2% of women and 98.3% of men. Similarly, no significant differences were found between sexes regarding proximal neck-related complications, re-interventions, or open conversions due to these complications.Due to the more challenging aortic neck anatomy, endografts with suprarenal fixation were used more frequently in women than in men (46.4% vs. 30%; p<0.01). Additionally, a significantly higher proportion of EVAR procedures performed outside the IFU were observed in women compared to men (26.7% vs. 18%; p<0.01). Univariate analysis revealed that off-IFU procedures were associated with a significantly higher risk of type IA endoleak and endoleak-related interventions (p<0.001). However, the rate of complications following off-label procedures did not significantly differ between men and women. Conclusions: A more complex and even hostile aortic neck anatomy was observed in women compared to men in our series, despite matched AAA sizes. The more challenging proximal neck features may have led to more frequent supra-renal fixation of the stent graft and off-label EVAR procedures performed in women than in men. Despite a statistically significant higher incidence of type 1A endoleaks following EVAR performed outside the IFU, the outcomes were comparable between genders. Accurate endograft selection and the availability of more versatile devices have improved the feasibility of EVAR, reducing complications related to proximal seal zones caused by the hostile aortic neck characteristics often associated with the female gender.