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Objective: Abdominal aortic aneurysm (AAA) in a patient with an underlying heritable aortic disease (HAD) is rare, and evidence based recommendations for its management are lacking. This study aimed to generate a consensus from multidisciplinary specialists on the diagnosis, treatment, and surveillance of AAA associated with HAD and to define topics of interest for future research.

Methods: A Delphi consensus was designed involving European multidisciplinary specialists and reported using the ACcurate COnsensus Reporting Document (ACCORD) reporting guideline. Four rounds were carried out by email: the first two rounds to agree on the content of the questionnaire and the final two rounds to reach an agreement. Questions focused on the composition of the team, imaging, clinical suspicion, genetic testing, medical management, indications for surgical repair, surgical technique, surveillance, exercise, and quality of life. The level of agreement for each question was graded using a Likert type scale and classified into four categories: A (very strong), B (strong), C (fair), and D (no agreement).

Results: A total of 35 experts from 18 different hospitals and 10 different countries participated in the study: 19 vascular surgeons, 11 cardiologists, four geneticists, and one cardiac surgeon. Of the 97 statements of the final questionnaire, 16 were graded A (16%), 23 B (24%), five C (5%), 44 D (45%) and nine (9%) were invalid. The experts highlighted the need to develop personalised therapies for each pathology, as well as international multicentre databases to collect data on the natural course of AAA patients with HAD.

Conclusion: This Delphi process led to consensus on several aspects of care for patients with AAA and underlying HAD, providing guidance to manage them in a more standardised fashion. The agreements reached focus on multidisciplinary aortic teams, imaging and genetic diagnosis, treatment, and follow up. Furthermore, several topics for future research were identified.

Objective: The aim of this study was to describe the occurrence of branch thrombosis following endovascular treatment of aortic arch pathology using an arch branched device (ABD) and to determine whether this is influenced by clinical and geometric parameters.

Methods: In this retrospective observational study of patients treated with an ABD in three centres, the primary endpoint was thrombus formation within a branch during follow up. Secondary endpoints were technical success, serious adverse events (SAEs), early and late death, stroke, and re-interventions. Geometric measurements (tortuosity index and curvature) were determined on pre- and post-operative computed tomography angiograms.

Results: Thirty nine patients were treated and 68 antegrade branches were analysed (innominate artery, n = 27; common carotid artery [CCA], n = 40; left subclavian artery [LSA], n = 1). Thrombus was identified within seven branches (10%) on surveillance imaging (innominate artery, n = 6; CCA, n = 1; LSA, n = 0; p = .021) and was associated with a wider distal bridging stent diameter (median 14.0 mm [13.3, 15.3] vs. 8.7 mm [IQR 5.9]; p = .026), a higher degree of reversed tapering (4.3 mm [3.8, 5.2] vs. 1.2 mm [0.3, 3.1]; p = .023), use of polyethylene terephthalate (Dacron) covered (vs. expanded polytetrafluoroethylene) bridging stents (23% vs. 2%; p = .011), and higher body mass index (BMI) (32.1 kg/m2 [28.7, 36.2] vs. 25.7 kg/m2 [23.8, 29.2]; p = .029), but not with pre-operative or post-operative tortuosity index or curvature or alterations. Regarding secondary outcomes, the technical success rate was 97%, SAEs occurred in 15 patients (38%), early and late death rates were 8% and 23%, respectively, and early and late stroke rates were 5% and 23%, respectively.

Conclusion: The risk of developing branch thrombosis after endovascular intervention with an ABD is considerable, especially of innominate artery branches, characterised by Dacron covered large diameter bridging stents, and in patients with a high BMI. Large prospective studies are required to analyse factors associated with branch thrombosis.

Introduction: Abdominal aortic aneurysm (AAA) development is inversely associated with diabetes mellitus. Targeting glucose metabolism seems to be a beneficial strategy for preventing AAA growth. Several metabolism-related factors are associated with AAA development. This study aimed to analyse the expression of the so far unstudied proteins irisin, follistatin, activin A, and ghrelin (ligand and receptor) in human and murine aneurysmal tissue, to assess the involvement of these pathways in AAA.

Methods: Gene and protein expression was evaluated in aneurysmal and control tissue samples, by qPCR and immunohistochemistry. Vascular smooth muscle cells (VSMCs) were studied in vitro for expression. Circulating levels of the proteins of interest in human plasma samples were evaluated by ELISA.

Results: In human aneurysmal tissue, the proteins of interest were predominantly expressed by VSMCs in neovessels. Expression by human VSMCs was confirmed in vitro. In human plasma, the concentration of irisin was higher in AAA (+/− diabetes) compared to controls. Patients with AAA and type 2 diabetes treated with metformin had lower levels of follistatin and ghrelin.

Conclusion: This study demonstrates irisin, follistatin, and ghrelin as interesting proteins to be studied in the context of the observed negative association between AAA development and type 2 diabetes.

Objective: This retrospective, multicentre, observational study analysed patients who underwent endovascular repair for blunt traumatic aortic injury (BTAI) at four tertiary trauma referral centres over twenty years. It aimed to determine early and long term survival, to analyse aortic and device related complications, and to assess the re-intervention rate after endovascular repair for BTAI.

Methods: All patients treated from 1 January 2001 to 31 October 2021 were identified using local hospital registries and two national registries: the Swedish vascular registry (Swedvasc) and Swedish trauma registry (SweTrau). Patient, treatment, and follow up data were extracted from medical records and radiology data by review of congregated imaging. The report was structured according to the STROBE checklist.

Results: Ninety five patients were included: 80 were male (84%), the median age was 42 years (interquartile range [IQR] 27, 64), and median follow up time was 6.1 years (IQR 0.7, 12.4). The thirty day mortality rate was 16% (15 of 93), 40% of these were caused by traumatic brain injury and 33% by aortic related causes. Estimated overall survival was 57% (standard error 6.6) at fifteen years after index treatment. Aortic re-intervention procedures (re-stenting, coiling, or explantation) were performed in 14 of 86 patients (16%), six of whom underwent stent graft explantation. Seven of the 14 patients (50%) who underwent aortic re-intervention presented with symptoms and six of 14 had a device related complication. All complications that required aortic re-intervention were diagnosed within eighteen months of the index procedure. There was no association between injury grade and aortic re-intervention.

Conclusion: Thoracic endovascular aortic repair is an effective treatment for patients with BTAI needing intervention. It carries low rates of device related complications and death, and the long term outcomes are acceptable. As all aortic complications requiring re-intervention were identified during the first two years after index treatment, with half of the patients reporting symptoms, future follow up protocols should be adjusted accordingly.

Objective: A decline in abdominal aortic aneurysm (AAA) prevalence calls into question the credibility of general population screening of 65 year old men. Selectively targeting high risk individuals among this group could be more effective in preventing death from AAA rupture. This cross sectional study analysed risk factor data in a cohort of 65 year old men screened in the Swedish general population based AAA screening programme, with the aim of exploring the effectiveness of hypothetical targeted screening strategies.

Methods: All men attending AAA screening in four neighbouring counties in Sweden between 2006 and 2010 completed a health questionnaire on smoking habits and medical history. Abdominal aortic aneurysm was defined as measuring ≥ 30 mm. The sensitivity and specificity of different targeted screening strategies, with targeted subpopulations defined by duration of smoking with and without additional risk factors, were explored using receiver operating characteristic (ROC) curves.

Results: A total of 16 232 men were screened, with 236 (1.5%) screen detected AAAs. A strategy combining smoking, presence of coronary artery disease (CAD), or both was associated with the mathematically optimal balance between sensitivity and specificity (optimal threshold) in the ROC analysis. The optimal threshold corresponded to targeting men having smoked for thirty years or more, a history of CAD, or both, where 74.0% of all AAAs could be detected by screening 33.0% of the population, compared with general screening. Targeting men that have smoked for ten years or more indicated that 84.0% of all AAAs could be detected by screening 55.0% of the population. A simplified strategy of targeting ever smokers resulted in detecting 85.0% of all AAAs by screening 61.0% of the population.

Conclusion: Targeted screening of men at high risk of AAA, focusing on smoking history for inclusion, may be a safe and effective alternative to general population screening.

Objective: High risk, inoperable patients with ascending aortic disease are increasingly managed with thoracic endovascular aortic repair (TEVAR). The aim of this study was to assess the available literature on TEVAR confined to the ascending aorta (a-TEVAR), describing study and patient characteristics, procedural and stent graft details, and outcomes.

Data sources: This was a systematic review and meta-analysis. MEDLINE, Web of Science, and Scopus were systematically searched for eligible studies reporting on outcomes after a-TEVAR (PROSPERO ID: CRD42023440826). Eligible studies reported outcomes after a-TEVAR without adjunctive supra-aortic vessel treatment.

Review Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The ROBINS-I and Joanna Briggs Institute Critical Appraisal Checklist were used as quality assessment tools. A Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence certainty analysis was performed for the main outcomes. The main outcome was death. A proportional meta-analysis was performed with a mean and 95% confidence interval (CI) for the main outcomes. All articles were included up to 1 January 2024.

Results: Ninety four studies were included (19 cohort studies, 75 case reports or series), reporting on 259 patients (57.8% male). The mean age was 69.1 (95% CI 65.0 – 73.1) years and mean follow up 19.6 (95% CI 14.5 – 24.6) months. The most common comorbidity was prior cardiac or thoracic surgery (n = 191). The most frequent indications for a-TEVAR (52.1% urgent a-TEVAR) were type A aortic dissection (43.6%) and pseudoaneurysm (38.6%). The most commonly deployed stent grafts were Gore (44.5%), Cook (23.5%), and Medtronic (17.0%). The in hospital mortality rate was 7.3% (95% CI 4.7 – 11.2%), 30 day mortality rate 7.7% (95% CI 5.1 – 11.6%), and overall mortality rate 17.0% (95% CI 12.9 – 22.0%) during follow up. GRADE showed very low evidence certainty for all outcomes. Eighty eight complications were reported and there was a re-operation rate of 13.1% (95% CI 9.5 – 17.8%). In hospital and 30 day mortality rates for type A dissection were 12.4% (95% CI 7.5 – 19.7%) (n = 14) and 13.3% (95% CI 8.2 – 20.8%) (n = 15), respectively, and for pseudoaneurysm 4.0% (95% CI 1.6 – 9.8%) (n = 4) and 4.0% (95% CI 1.6 – 9.8) (n = 4), respectively.

Conclusion: Despite heterogeneous literature and very low GRADE evidence certainty, a-TEVAR seems technically feasible in high risk patients. In addition, there is need for a consensus on when and how to use a-TEVAR and a need for a specific endograft for use in the ascending aorta.

Purpose: Emergent repair of paravisceral aortic aneurysms (pAAs) with in situ laser fenestration (ISLF) technique is associated with renovisceral ischemia. We describe two strategies of temporary gutter endoleak creation to ensure renovisceral perfusion during ISLF.

Technique: Two patients (79- and 83-year-old) presented with symptomatic pAA. A Cook Zenith Alpha endograft (Cook Medical LLC, Bloomington, IN, USA) was used in both cases. All visceral vessels were prestented to serve as guide markers. Prior to the deployment of the endograft, a Cook Flexor 8F-sheath (Cook Medical LLC, Bloomington, IN, USA) was placed in the superior mesenteric artery (SMA) (patient #1), and a 5 mm × 200 mm angioplasty Armada balloon (Abbott, Green Oaks, Illinois, USA) was placed between the endograft and the aortic wall (patient #2). Angiograms after visceral coverage confirmed perfusion of the renovisceral arteries through the intentional gutter endoleaks. Thereafter, ISLF and bridging stenting for SMA and the renal arteries were performed before the removal of the sheath or balloon to stop the gutter endoleak. Both patients did not experience any kind of perioperative complications.

Conclusions: The above-described techniques for gutter endoleak creation during emergent pAA repair with ISLF can potentially reduce reno visceral ischemia and increase the ISLF technique’s safety.

Clinical Impact: The ISLF technique for pAA repair typically requires coverage of the visceral arteries with unpredictable ischemia time until laser fenestrations are established. The gutter endoleak technique reduces the renovisceral ischemia and potentially increases the safety of the ISLF repair.