This study aimed to compare the peri-procedural success and complication rate within a large registry of intra-cardiac echocardiography (ICE)- vs. transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) procedures with a Watchmann FLX device. Data from 772 LAAO procedures, performed at 26 Italian centers, were reviewed. Technical success was considered as the final implant of a Watchmann FLX device in LAA; the absence of pericardial tamponade, peri-procedural stroke and/or systemic embolism, major bleeding and device embolization during the procedure was defined as a procedural success. One-year stroke and major bleeding rates were evaluated as outcome. ICE-guided LAA occlusion was performed in 149 patients, while TEE was used in 623 patients. Baseline characteristics were similar between the ICE and TEE groups. The technical success was 100% in both groups. Procedural success was also extremely high (98.5%), and was comparable between ICE (98.7%) and TEE (98.5%). ICE was associated with a slightly longer procedural time (73 ± 31 vs. 61.9 ± 36 min, p = 0.042) and shorter hospital stay (5.3 ± 4 vs. 5.8 ± 6 days, p = 0.028) compared to the TEE group. At one year, stroke and major bleeding rates did not differ between the ICE and TEE groups. A Watchmann FLX device showed high technical and procedural success rate, and ICE guidance does not appear inferior to TEE.

Thoracic endovascular aortic repair is established for complicated type B aortic dissection, but extension of disease toward the aortic arch and involvement of supra-aortic branches may require technically demanding, individualized solutions. We report a multistage endovascular strategy in a 56-year-old man who presented with acute Stanford type B aortic dissection, hypertensive crisis, right renal malperfusion, and bovine arch anatomy. Right renal artery stenting was followed by thoracic endovascular aortic repair because of persistent pain and rapid enlargement of the distal arch. At 1 year, computed tomography angiography (CTA) demonstrated aneurysmal progression with type IA and IB endoleaks. A custom-made fenestrated arch endograft was deployed to preserve the common origin of the brachiocephalic and left common carotid arteries. Device malrotation caused acute bilateral carotid hypoperfusion, which was successfully treated by bailout parallel stenting; one bridging stent migrated to the abdominal aorta. Five months later, distal endograft extension excluded the type IB endoleak, and the migrated stent was retrieved with a snare. Follow-up imaging showed exclusion of both endoleaks, patent carotid vessels, and stable renal function. This case illustrates both the versatility and the procedural hazards of total endovascular arch repair. Meticulous CTA planning, immediate availability of bailout strategies, multidisciplinary expertise, and structured imaging surveillance are essential when treating complex post-dissection arch disease.