OBJECTIVE: Revascularisation of the left subclavian artery (LSA) in zone 2 thoracic endovascular aortic repair (TEVAR) is traditionally performed with carotid-subclavian (CS) bypass. A thoracic branch endoprosthesis (TBE...OBJECTIVE: Revascularisation of the left subclavian artery (LSA) in zone 2 thoracic endovascular aortic repair (TEVAR) is traditionally performed with carotid-subclavian (CS) bypass. A thoracic branch endoprosthesis (TBE) has been developed for endovascular LSA revascularisation during zone 2 TEVAR. This single centre, retrospective cohort study aimed to compare the short and long term outcomes of TBE with TEVAR with CS bypass (CS-TEVAR) in patients requiring zone 2 arch repair. METHODS: One hundred and seventy-two patients underwent zone 2 CS-TEVAR and 66 patients underwent zone 2 TBE from January 2014 to May 2023. The primary outcome was in hospital death; long term outcomes included survival and freedom from type 1a or 1c endoleak. Propensity score matching identified 55 pairs of patients with similar baseline characteristics. Kaplan-Meier curves were plotted for long term survival on clinical follow up and endoleak on imaging follow up. RESULTS: Mean clinical follow up for the entire cohort was 3.5 ± 2.6 years. Technical success was 100%. In the propensity score matched cohort, there was no difference in in hospital death (1.8% vs. 1.8%; p = 1.0) or stroke (3.6% vs. 5.5%; p = .65) between TBE and CS-TEVAR. There was no difference in survival at 6 years (67.0 ± 10.0% vs. 76.0 ± 7.9%; p = .21). TBE patients had statistically significantly higher freedom from type 1a or 1c endoleak (97.9 ± 2.1% vs. 87.3 ± 4.9%; p = .04) on imaging follow up at 6 years. CONCLUSION: TBE demonstrated comparable short and long term outcomes compared with CS-TEVAR and is a reasonable alternative for zone 2 arch repair in suitable patients.
OBJECTIVE: This systematic review aimed to evaluate the safety, feasibility, and effectiveness of dedicated endovascular techniques for left subclavian artery (LSA) preservation during thoracic endovascular aortic repair...OBJECTIVE: This systematic review aimed to evaluate the safety, feasibility, and effectiveness of dedicated endovascular techniques for left subclavian artery (LSA) preservation during thoracic endovascular aortic repair (TEVAR) (PROSPERO CRD42024568126). DATA SOURCES: MEDLINE, Scopus, Embase, and Cochrane Library databases. REVIEW METHODS: A systematic literature search followed the PRISMA guidelines. Eligible studies reported on patients with aortic pathologies treated with a single branched or single fenestrated endograft, off the shelf or custom made, intended for preservation of the LSA. Risk of bias was assessed using the Cochrane ROBINS-I tool, and the certainty of evidence using the GRADE framework. A proportion meta-analysis was performed reporting pooled rates with 95% confidence intervals (CIs). RESULTS: Twenty-one studies (1 123 patients) published between 2015 and 2024 were included. The most common indication for treatment was type B aortic dissection, followed by thoracic aneurysm. Off the shelf devices were used in 23.7% and custom made devices in 76.3%. The pooled technical success rate was 98.75% (95% CI 97.89 - 99.49%) and 30 day mortality rate was 0.87% (95% CI 0.22 - 1.81%). The pooled 30 day stroke rate was 1.32% (95% CI 0.51 - 2.38%) and spinal cord ischaemia rate 0.06% (95% CI 0 - 0.59%). At 12 months, the pooled mortality rate was 2.5% (95% CI 1.27 - 4.02%). A subgroup analysis stratified by geographical region (Asian vs. European and North American studies) showed a higher incidence of stroke and 30 day cardiovascular events in European and North American studies, and higher 12 month target vessel occlusion rates in Asian studies. However, according to the GRADE classification, the overall certainty of the evidence was low. Considerable clinical and methodological heterogeneity and the use of devices not available outside Asia further limit the generalisability of the results. CONCLUSION: Despite the low evidence of the available data, the use of custom made and off the shelf single branched or fenestrated endografts for LSA preservation during TEVAR shows promising feasibility, safety, and durability in selected patients managed at high volume centres.
OBJECTIVE: Surveillance of abdominal aortic aneurysms (AAAs) traditionally relies on diameter measurements, yet up to 10% of ruptures occur below repair thresholds. The relationship between localised wall strain and futu...OBJECTIVE: Surveillance of abdominal aortic aneurysms (AAAs) traditionally relies on diameter measurements, yet up to 10% of ruptures occur below repair thresholds. The relationship between localised wall strain and future AAA growth remains unexplored. This study aimed to examine localised AAA wall strain patterns and their association with aneurysm growth. METHODS: This was a prospective study of patients with an infrarenal AAA under surveillance with conventional ultrasound. In a standard examination, ten second ultrasound videos (cineloops) were acquired in transverse plane with the curved array transducer at the maximum anteroposterior diameter during breath hold. From these cineloops, strain patterns were extracted and analysed via functional data analysis to assess changes over time and associations with annual AAA diameter growth. RESULTS: Two hundred and seventy-eight patients (median age 73 years; 238 men) across 1 117 clinic visits were included, with a median follow up of 2.3 years. Progressive vessel wall stiffening and increasingly homogeneous strain patterns were observed over time (p < .001). Baseline strain patterns were statistically significantly associated with future AAA growth (p = .006), especially in specific regions. In the posterior left and right vessel wall, a 5% point increase in strain corresponded to a 31.9% and 6.7% higher annual growth rate, respectively. Conversely, the same increase at the anterior middle wall was linked to a 33.3% reduction in annual growth rate. These associations remained statistically significant after adjusting for baseline diameter, age, sex, smoking, hypertension, and diabetes (p = .041). CONCLUSION: Ultrasound strain mapping identified biomechanical regions linked to AAA progression. Strain patterns were associated with future growth independently of diameter, supporting their potential utility in complementing diameter in AAA monitoring and risk stratification.
OBJECTIVE: Femoropopliteal in stent re-stenosis (ISR) remains a significant challenge following endovascular peripheral artery occlusive disease procedures, with Tosaka III lesions representing the most complex form of c...OBJECTIVE: Femoropopliteal in stent re-stenosis (ISR) remains a significant challenge following endovascular peripheral artery occlusive disease procedures, with Tosaka III lesions representing the most complex form of complete occlusive re-stenosis. Limited prospective, observational study data have focused on endovascular treatment of femoropopliteal Tosaka III ISR. METHODS: The FP-RESTORE study was a prospective, observational study involving 13 Chinese hospitals from April 2021. It enrolled 322 consecutive patients (353 limbs) with femoropopliteal Tosaka III ISR undergoing endovascular intervention. Primary endpoints were clinically driven target lesion revascularisation (CD-TLR) and major adverse limb events (MALE) at 24 months. Competing risk regression analysis was performed to identify independent predictors of adverse outcomes. RESULTS: Of the enrolled patients, the mean age was 71.6 ± 9.1 years, with 54.67% presenting Rutherford grade > 3. Average occlusive lesion length was 22.0 ± 10.5 cm, with suspected thrombotic components presenting in 46.74% of lesions. Technical success rates were 96.88%. Ankle brachial index (ABI) improved statistically significantly from 0.33 ± 0.2 to 0.77 ± 0.22 post-operatively; ABI improved by more than 0.2 after the procedure and this was observed in 85.8% of patients. The follow up rate was 86.0% with a median follow up duration of 24.5 months. At 24 months, the CD-TLR rate was 21.4% (95% confidence interval [CI] 16.82 - 25.93%) and MALE rate was 27.2% (95% CI 22.26 - 32.21%). The all cause mortality rate was 14.3%. Independent predictors of CD-TLR and MALE included multiple previous procedures and popliteal artery (P2 and P3) involvement. CONCLUSION: Endovascular treatment for femoropopliteal Tosaka III ISR achieved acceptable immediate and 24 month outcomes. Multiple previous procedures and popliteal artery involvement were key predictors of adverse events, suggesting valuable guidance for risk stratification and treatment modification in this challenging patient population.