Jan Brunkwall

Objective. To compare the demographics, comorbidities and risk factors in patients with abdominal aortic aneurysm (AAA) treated in three different communities; Germany, Tajikistan and Russian Federation. Methods. A retrospective comparative study including patients with an infrarenal AAA who were treated with either endovascular aneurysm repair (EVAR) or open repair (2011-2015) in Cologne, Dushanbe and Ryazan was done. A total number of 711 patients, 499 from Cologne, 46 from Dushanbe and 166 from Ryazan were included in the study. Demographic data including age, gender, body mass index (BMI), comorbidities (diabetes, coronary artery disease (CAD)), hypertension, cerebrovascular disease, chronic obstructive pulmonary disease (COPD, smoking), actual treatment as well as the diameter of the abdominal aorta were collected, retrospectively. Results. There was no statistically significant difference in AAA prevalence with respect to gender between the study centers. Similarly, the BMI did not differ significantly between these 3 centers. Though, the patients from Cologne were older than those from Dushanbe and Ryazan. Moreover, the number of patients treated due to ruptured aneurysm was significantly lower in Cologne in comparison to the other two centers (P<0.05). The AAA-diameter of patients in Ryazan and Dushanbe was greater than that found in Cologne. Regarding the actual medication that patients were presented with, antiplatelet-aggregation medication, statin and beta blockers were used significantly more often in Cologne. Patients from Tajikistan had COPD more often than patients from the other centers. Conclusion. The prevalence of comorbidities, risk factors as well as medication in patients with infrarenal abdominal aortic aneurysm is different in the various geographical regions. What this paper adds The study demonstrates that the prevalence of comorbidities, risk factors as well as medication in patients with infrarenal abdominal aortic aneurysm is different in the various geographical regions. These differences have been firstly demonstrated in patients from the Russian Federation and Tajikistan.

Objective: In the past years, a paradigm shift from best medical therapy to early thoracic endovascular aortic repair (TEVAR) has been observed in the treatment of uncomplicated type B aortic dissection (uTBAD). We aimed to analyze outcomes after TEVAR in the acute and subacute phase of uTBAD, focusing on aortic remodeling. Methods: Retrospective analysis of consecutive patients who underwent TEVAR for acute or subacute uTBAD in two tertiary referral centers from 2008 – 2017. Two assessors per center reviewed computed tomography scans of each patient at presentation, at one year and at the last follow-up using post-processing software. Results: Forty-nine patients were treated with TEVAR for uTBAD. The indication for TEVAR was the presence of multiple morphologic predictors of adverse aortic outcome. The most common predictors were a false lumen diameter of > = 22mm in 76% of patients, a primary entry tear of > = 10mm in 69% and a total aortic diameter of > = 40mm in 67%. There were no in-hospital deaths and no deaths at 1 year. The median follow-up was 40.6 months. Three-year cumulative survival was 94 % (46/49). Fourteen secondary interventions were performed in 10 patients (20 %) after a median of 4.2 months. TEVAR lead to remodeling of the descending thoracic aorta with a median reduction of the total aortic diameter of 4.5 mm within one year and stable diameters after three years. The median maximum false lumen diameter diminished from 26 mm to 15 mm in one year (at 3 years: 14.8 mm). Conclusion: In this cohort of selected patients with uTBAD and multiple morphologic predictors of worse aortic outcome, elective acute or subacute TEVAR was associated with a low mortality and positive aortic remodeling in the mid-term follow-up.

Objectives: To study the safety and feasibility of the E-liac Stent Graft System® in patients with aorto/iliac aneurysms. Methods: A prospective multicentric European registry of patients receiving the E-liac Stent Graft System® was conducted. Endpoints of the study included the technical success as well as periprocedural events and 30-day endoleaks, reinterventions, internal and external iliac artery patency and mortality. Results: Between July 2014 and June 2016, a total of 45 patients (93% men, mean age 72 years, range 53–90 years) were enrolled at 11 sites in four European countries. Five patients received an isolated iliac treatment. Thirty-seven patients were treated with a combination of an abdominal stent graft and a unilateral E-liac and three in combination with bilateral E-liac. All E-liac Stent Grafts (48) were implanted in the intended position and the internal iliac arteries were successfully bridged. Two patients did not receive clinical success, due to endoleak type Ia of the aortic stent graft. At 30-day follow-up, clinical success rate was 96%. Three successful endovascular reinterventions were performed within the 30-day follow-up: one due to a type Ia endoleak in the common iliac artery, one due to type Ia endoleak of the aortic stent graft, and one due to bilateral lower limb claudication provoked by stent graft limb stenosis. At 30-day, a 100% survival rate and complete absence of pelvic or buttock ischemia/claudication were reported. Primary patency at 30 days was 100% for the internal iliac artery and 98% for the external iliac artery with an assisted patency of 100% in the latter. Conclusions: The high clinical success rate, low rates of device-related reinterventions (2%), and excellent patency rate demonstrate the safety and feasibility of the E-liac Stent Graft System. Long-term results are awaited to state efficacy and durability. Clinical Trials.gov. Identifier no. NCT02209194.

Vaskuläre Anomalien stellen strukturelle Störungen und angeborene Fehler der vaskulären Morphogenese dar, die das gesamte arterielle und venöse Gefäßsystem betreffen können. Sie sind in zwei Hauptkategorien unterteilt: Tumoren, die eine endotheliale Hyperplasie aufweisen, und Malformationen, die einen normalen endothelialen Umsatz haben. Je nach Art und Komplexität reicht das Spektrum von einem einfachen „Muttermal“ bis zu lebensbedrohlichen Entitäten. Die relativ geringe Inzidenz (4–10 %) vaskulärer Anomalien unter der Allgemeinbevölkerung in Verbindung mit der Tatsache, dass ihr Management oft in den Zuständigkeitsbereich mehrerer medizinischer und chirurgischer Spezialitäten fällt, hat zu einer unzureichenden Expertise in der Beurteilung und Therapie dieser Bedingungen geführt. Identifikation, einheitliche Nomenklatur und multidisziplinärer Ansatz sind für das ordnungsgemäße Management von größter Bedeutung. Vascular anomalies represent a spectrum of structural disorders and inborn errors of vascular morphogenesis, which may affect the entire arterial and venous vascular tree. They are divided into two major categories: tumors, which exhibit endothelial hyperplasia and malformations, which have normal endothelial turnover unless disturbed. Depending on their nature and complexity they can range from a simple “birthmark” to life-threatening entities. The relatively low incidence (4–10%) of vascular anomalies among the general population combined with the fact that their management often falls within the purview of several different medical and surgical specialties, has traditionally resulted in insufficient expertise in the management of these conditions. Therefore, accurate identification, a uniform nomenclature and a multidisciplinary approach are paramount for correct management.

Objectives: To investigate the feasibility and the mid-term outcomes of the chimney-graft technique for the revascularization of supra-aortic branches in patients with thoracic aortic pathologies involving the aortic arch. Methods: A retrospective analysis of a prospectively maintained database between January 2010 and July 2016 was performed. Primary endpoints were 30-day and overall mortality. Secondary endpoints were technical success, target vessel patency, stroke/transitory ischemic attack and type I/III endoleak rate. Results: A total of 30 patients (80% male, median age 70.0 years) were treated using the chimney-graft technique for the supra-aortic branches. The indication was a degenerative aneurysm in nine patients (32%) and a type B Stanford aortic dissection and a penetrating aortic ulcer in the descending aorta in seven patients (23%), respectively. In six patients (20.0%), the indication was an type Ia endoleak after previous endovascular thoracic repair, whereas a pseudoaneurysm after previous open repair of the descending aorta was the indication in one patient (3%). Twenty-three patients (77%) were treated electively, five (17%) emergently and two (7%) urgently because of free rupture. Technical success was achieved in 90% of patients. The 30-day/in-hospital mortality was 17% (5/30). A retrograde dissection was presented in five patients. Four patients experienced a cerebrovascular event. Eight patients had type Ia endoleak and 10 had type II. During the median follow-up of 16 months (range: 0–56), four further patients died: one in respiratory insufficiency, one due to a ruptured abdominal aortic aneurysm, one in meningitis and the last one for unknown reason. The chimney-graft patency was 100%. According to the Kaplan–Meier curve, the estimated survival at one year was 66 ± 9%. Conclusions: The chimney-graft technique, despite a technically demanding strategy, is a useful tool as bailout procedure in our armamentarium for high-risk patients, unsuitable for open or hybrid repair.