Konstantinos Dakis

Proximal failure after endovascular aneurysm repair (EVAR) remains a major challenge in contemporary aortic surgery. Management requires a meticulous assessment of multiple factors, including patient anatomy, disease progression, aneurysm sac behavior, and endograft characteristics. Many patients facing failed EVAR tend to be older, frail, and often have serious cardiovascular issues, which complicates the decision-making process for clinicians. Open surgical conversion (OSC) is technically challenging due to the need for extensive surgical preparation and the frequent necessity for suprarenal or supraceliac aortic clamping. Consequently, perioperative morbidity and mortality remain considerable, particularly in urgent and emergent settings. Conversely, advanced endovascular techniques like fenestrated, branched, chimney, and physician-modified endografts have shown promising results, offering a lower physiological burden compared to OSC. Although there are ongoing discussions about long-term durability, current literature and our own institutional experience indicate that mid-term outcomes are encouraging. At our institution, we treated 38 patients with advanced endovascular methods for proximal failed EVAR. We achieved a 30-day survival rate of 94.7%, with target-vessel patency at 100% and an 88.1% rate of freedom from reintervention during a median follow-up of 20 months. Importantly, we did not observe any aortic-related deaths or recurrent type Ia endoleaks. These results advocate for an endovascular-first approach for most patients dealing with proximal failed EVAR, particularly through the use of custom-made fenestrated and branched devices. High-volume centers should be able to provide patients with the choice between the two strategies, after a thorough optimization process of patient physiological status, aortic anatomical criteria, surgical risk, patient disposition for long-term postoperative follow-up, and life prognosis.

Background and Objectives: Amyloidosis is a systemic disorder characterized by extracellular deposition of misfolded protein fibrils, most commonly light-chain (AL) or transthyretin-derived (ATTR) ones. Cardiac involvement is well recognized, but large-vessel complications, including thoracic aortic aneurysms (TAA) and dissections, are rare and under-reported. The aim of this review article is to provide insights into pathophysiology, clinical diagnosis and the therapeutic opportunities in amyloidosis-related thoracic aortic diseases. Methods and Materials: The PRISMA Extension for Scoping Reviews (PRISMA-ScR) Guidelines were followed. An extensive search of the available literature in the English language, published between 1 January 2000, and 31 December 2025, in three large-scale scientific databases was undertaken by two independent reviewers. The terms “amyloidosis”, “thoracic aorta”, “thoracic aortic aneurysm”, “aortic dissection”, and “aortopathy” were used both as specific items, as well as in MeSH Terms. Studies reporting on the pathophysiology, diagnosis, clinical manifestations, treatment options and prognosis of amyloid deposition on the thoracic aorta were included in the review. Because of the nature of the existing literature, only a narrative review was possible. Results: Twenty-nine studies were included. Owing to the rarity of reporting, data was derived mainly from case reports and series, as well as autopsy studies. Amyloid infiltration of the aortic wall has been associated with medial architectural disruption, degeneration of elastic fibers, impairment of vasa vasorum perfusion, and arterial stiffness, all of which could contribute to aneurysmal dilation and aortic lesions. Amyloidosis management combines targeted anti-plasma cell therapy with supportive care. In AL amyloidosis, melphalan–dexamethasone (MDex) was historically standard, but regimens such as cyclophosphamide, bortezomib, and dexamethasone (CyBorD) and bortezomib, melphalan, and dexamethasone (BMDex) achieve higher complete response rates. Immunotherapy with Daratumumab has shown high overall and complete response rates. Fibril-directed approaches, including doxycycline and epigallocatechin gallate, and monoclonal antibodies, are under evaluation. Acute management of large-vessel manifestations follows conventional protocols, but prognosis is often dominated by underlying cardiac and systemic involvement. Conclusions: Management of thoracic aortic involvement follows standard imaging surveillance and surgical criteria, though operative risk is increased. Multidisciplinary care, early recognition, and individualized risk stratification are essential to improve outcomes, particularly given frequent cardiac involvement.

Purpose: Iliac branch devices (IBDs) are indicated for the preservation of internal iliac artery (IIA) perfusion. Data on bridging stent choice in IBD are limited. The aim of this meta-analysis was to assess Advanta V12/iCast outcomes when used as bridging stent during IBD procedures. Methods: The English medical literature was systematically searched through PubMed, Scopus, and Cochrane Library (last search: 03.01.2025). The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was followed, and a predefined protocol was registered to PROSPERO. Randomized controlled trials and observational studies (2000–-2025) reporting on the Advanta V12/iCast-related outcomes were eligible. The ROBINS-I tool and Grading of Recommendations Assessment, Development and Evaluations (GRADE) were used to assess the risk of bias and quality of evidence. Primary outcomes were technical success, stenosis/occlusion, endoleak Ic/IIIc, and reintervention rates during follow-up. Data on the outcomes of interest were synthesized using proportional meta-analysis. Results: From 2698 study reports, 10 observational studies (510 targeted IIAs, 467 IIAs bridged with Advanta V12/iCast) were included. According to ROBINS-I, eight studies were of low and two were of moderate quality. Technical success was 98% (95% confidence interval (CI) = 93%–100%; I ² = 0%; certainty: very low). Regarding the 30-day outcomes, the occlusion/stenosis rate was 2% (95% CI = 0%–9%; I ² = 0%), the endoleak Ic/IIIc rate was 0.3% (95% CI = 0%–3%; I ² = 0%) and the reintervention rate was 1% (95% CI = 0%–3%; I ² = 0%). The mean follow-up among studies was 23.4 months (95% CI = 14.2–32.7). During follow-up, the occlusion/stenosis rate was 4% (95% CI = 1%–11%; I ² = 19%; certainty: very low), the endoleak Ic/IIIc overall rate was 5% (95% CI = 3%–8%; I ² = 0%; certainty: very low), and the reintervention rate was 5% (95% CI = 3%–9%; I ² = 0%; certainty: very low). Conclusions: The Advanta V12/iCast balloon-expandable covered stent showed low occlusion/stenosis, endoleak, and reintervention rates at 30 days and follow-up and appeared to be a reliable bridging stent choice in IBDs. Clinical Impact: The available literature on iliac branch devices does not provide adequate evidence supporting bridging stent selection. This systematic review and meta-analysis on the use of Advanta V12/iCast as bridging stent showed a high technical success rate of 98%, along with low occlusion/stenosis, endoleak Ic/IIIc and reintervention rates at 30 days, which were maintained below 5% during the total follow-up. These results reflect on the reliability of Advanta V12/iCast when used as bridging stent in iliac branch devices. However, the low quality of evidence should be considered upon result interpretation.

Background and Objectives: Proximal aortic neck-related complications severely impact the short- and long-term durability of endovascular aneurysm repair (EVAR). The Heli-FX EndoAnchor system provides proximal sealing zone reinforcement, aiming at both prevention and treatment of endograft migration and type Ia endoleak (EL Ia). The aim of this scoping review was to accumulate data on the prophylactic and therapeutic effect of EndoAnchors on patients undergoing index and revision EVAR for proximal neck complications. Methods and Materials: The PRISMA Extension for Scoping Reviews (PRISMA-ScR) Guidelines were followed. The literature published between 1 January 2009 and 1 September 2025 was searched by two independent reviewers. Studies reporting on morphological and clinical outcomes related to the proximal aortic neck were included. Main outcomes were Heli-FX EndoAnchor system technical success and procedural EVAR success, aortic neck dilation, endograft migration, EL Ia and proximal neck reinterventions. Results: Sixteen studies were included, with a total of 1164 patients. The mean follow-up ranged between 7 and 60 months. Eleven studies provided data on hostile proximal neck characteristics indicating Heli-FX EndoAnchors deployment. Technical success for prophylactic and therapeutic Heli-FX EndoAnchor application ranged between 85 and 100% as well as 86 and 100%, respectively. Procedural success for index and revision EVAR ranged between 85 and 100% as well as 45.4 and 100%, respectively. Residual EL Ia was reported in 103 patients following EndoAnchors deployment during index EVAR and revision cases. Secondary reinterventions related to the proximal sealing zone were reported in 39 patients (17 index EVAR, 19 revision). Mean aortic neck diameter increase between 2.5 and 4.6 mm was reported in four studies, while one study reported a mean >5 mm decrease. Conclusions: The Heli-FX EndoAnchor system was associated with high technical success, while procedural success was acceptable, amendable to neck-related characteristics, especially in revision cases for EL Ia treatment. Long-term data on morphological and clinical outcomes are warranted.

Background and Objectives: Accurate evaluation of vulnerable carotid atherosclerotic plaques remains essential for preventing ischemic stroke. Conventional imaging modalities such as ultrasound and computed tomography angiography (CTA) have limited capacity to identify histopathological features of plaque instability, including fibrous cap rupture, lipid-rich necrotic core, and intraplaque hemorrhage. Artificial intelligence (AI) techniques—particularly deep learning (DL) and radiomics—have recently emerged as valuable adjuncts to standard imaging, achieving AUC values of 0.83–0.99 across modalities in identifying vulnerable plaques. This scoping review summarizes the available evidence on the application of AI in the detection and assessment of vulnerable carotid plaques. Methods: A systematic search of the English-language literature was conducted in MEDLINE, SCOPUS, and CENTRAL from 2000 to 30 June 2025, following the PRISMA-ScR framework. Eligible studies applied AI-based approaches (machine learning, deep learning, or radiomics) to evaluate carotid plaque vulnerability using ultrasound, CTA, or MRI. Extracted outcomes included diagnostic performance, correlation with histopathology or neurological events, and predictive modeling for stroke risk. Results: Of 201 records screened, 12 studies met inclusion criteria (ultrasound = 6; CTA = 4; high-resolution MRI = 2; publication years 2021–2025). All reported receiver operating characteristic area-under-the-curve (ROC-AUC) values for endpoints related to plaque vulnerability (symptomatic versus asymptomatic status, presence of intraplaque hemorrhage or lipid-rich necrotic core, fibrous-cap surrogates, and, less frequently, short-term cerebrovascular events). For ultrasound, contrast-enhanced videomics achieved an AUC of 0.87 (10 centers; n = 205), B-mode texture/radiomics reached 0.87 (n = 150), and segmentation-assisted models 0.827 (n = 202); other ultrasound models reported AUCs of 0.88–0.91. For CTA, a symptomatic-plaque machine-learning model yielded AUC 0.89 ( n = 106); a perivascular-adipose-tissue (PVAT) radiomics nomogram achieved AUC 0.836 on external validation; a histology-referenced pilot attained AUC 0.987; and one mild-stenosis TIA model reported ROC performance. For high-resolution MRI (HR-MRI), radiomics-based models showed AUC 0.835–0.864 in single-modality cohorts and up to 0.984 with multi-contrast inputs. Across modalities, AUC ranges were: ultrasound 0.827–0.91, CTA 0.836–0.987 (external 0.836), and HR-MRI 0.835–0.984. Only two out of twelve studies performed external validation; calibration and decision-curve analyses were rarely provided, and most cohorts were single-center, limiting generalizability. Conclusions: AI demonstrates strong potential as a complementary tool for evaluating carotid plaque vulnerability, with high diagnostic performance across imaging modalities. Reported AUCs ranged from 0.83 to 0.99 based primarily on internal or hold-out validation, representing the upper bound of theoretical rather than real-world performance. Nonetheless, large prospective multicenter studies with standardized protocols, histopathological correlation, and external validation are required before clinical integration into stroke prevention pathways.

Objectives: New endografts have improved clinical outcomes in patients with abdominal aortic aneurysm (AAA) treated with the endovascular approach (EVAR). The purpose of this study is to evaluate the Endurant endograft for EVAR. Methods: A systematic search was conducted in PubMed, Scopus, and Cochrane for studies including patients treated with EVAR for unruptured AAA. This meta-analysis follows PRISMA guidelines (PROSPERO: CRD42024621517). A Kaplan–Meier-derived individual patient data analysis assessed the survival, the freedom from reintervention, the freedom from type Ia endoleak (ETIa), and the aneurysm-related mortality rates. The analysis reflects aggregated survival data, and the at-risk population decreases over time due to censoring and loss to follow-up. Kaplan–Meier survival curves were digitized to extract survival/mortality values at specific time points, and number-at-risk tables or total events were used to improve time-to-event accuracy. A subgroup analysis compared the outcomes of treatment within versus outside the instructions for use (IFU). Results: Twenty-six studies met our eligibility criteria, incorporating 5901 patients in terms of survival, with survival rates at 1, 5, and 10 years of follow-up at 94.4%, 71.6%, and 42.4%, respectively, while overall aneurysm-related mortality rates were 0.8%, 2.3%, and 7.6%, respectively. Freedom from secondary reintervention was 94.9% at 1 year, 81.9% at 5 years, and 43.7% at 10 years, while freedom from type Ia endoleak was 98.8%, 94.6%, and 85.6%, respectively. Comparing treatment within versus outside the IFU, in terms of survival (HR: 0.94, 95% CI: 0.75–1.16, p = 0.53), freedom from reintervention (HR: 0.85, 95% CI: 0.63–1.15, p = 0.29) and mortality due to aneurysm-related complication (HR: 0.79, 95% CI: 0.34–1.84, p = 0.58) revealed no statistically significant difference. Conclusions: The Endurant endograft provides acceptable rates of survival, freedom from secondary intervention, aneurysm-related mortality rates, and freedom from ETIa; however, continuous long-term follow-up surveillance is necessary.

Summary: Background: Arteriovenous grafts (AVG) can be the only bailout solution for patients who require kidney replacement therapy but are unsuitable for arteriovenous fistula (AVF) creation. Currently, high-level evidence on the effectiveness and safety of antithrombotic therapy in AVG patients is scarce. Materials and methods: Following the PICO (patient; intervention; comparator; outcome) model and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a data search of the English literature in PubMed, SCOPUS, Central Cochrane was conducted, until March 1st, 2023 (PROSPERO Protocol Number: CRD42023401785). Studies on humans with an AVG receiving any kind of antithrombotic medication, reporting on primary and secondary patency rates, and bleeding complications were included. Due to data heterogeneity, a descriptive report of the outcomes was undertaken. Results: Twelve studies, including 22,436 patients with end-stage renal disease (ESRD) and AVG were included, with patient recruitment spanning over a 41-year time-period (1982–2023). Antithrombotic factors included acetylsalicylic acid (ASA), clopidogrel, dipyridamole, warfarin, unfractioned heparin (UFH), and direct oral anticoagulants (DOACs). Ten studies reported on primary patency rates, and two on secondary patency rates. Primary and secondary patency rates (PPR, SPR) were reported better in four studies, similar in three and worse in one study, regarding patients receiving any kind of antiplatelet therapy. Anticoagulation therapy was not associated with increased PPR or SPR, except for one study on apixaban. Patients receiving single or combined antiplatelets versus patients receiving no treatment presented higher bleeding risk in two studies and similar bleeding risk in three studies. Anticoagulation therapy, excluding apixaban, was associated with higher bleeding risk in three studies, when compared to no anticoagulation. Conclusions: Data derived from the current literature were equivocal regarding the use of antiplatelet treatment in patients with AVG. Studies on anticoagulation therapy are confined. Randomized trials with confounder stratification remain crucial for robust long-term data.

Background/Objectives: Device selection during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) remains an important issue for ensuring endograft durability. This study evaluated the early and follow-up outcomes of elective EVAR with the Endurant platform. Methods: A single-center retrospective analysis was conducted including consecutive elective EVAR procedures with the Endurant II/IIs (2008 to 2024) device. Primary outcomes were technical success, mortality and major complications at 30 days. Survival, endoleak I/III and freedom from reintervention were secondary outcomes. Cox proportional hazards models were employed for risk-adjusted follow-up outcomes. Results: In total, 361 patients were included (72.7 ± 7 years; 96% males; mean AAA diameter 62 ± 14 mm); 92% received a bifurcated device, and 89% conformed to the instructions for use. Technical success was 99.7%. Intra-operative adjunctive procedures included 4.4% proximal cuffs and 1.7% endoanchors. The thirty-day mortality rate was 0.6%, and the major complication rate was 4.1%. Survival was 81% (SE 4.8%), 72% (SE 6.4%) and 52% (SE 9.2%) at 4, 6 and 8 years, with aneurysm-related mortality at 1.7%. Freedom from endoleak Ia was 76% (SE 7.3%) at 6 years, freedom from endoleak Ib was 79% (SE 7.4%) at 7 years and freedom from endoleak III was 94% (SE 3.7%) at 5 years. Freedom from reintervention was 71% (SE 6.1%) and 55% (SE 7.9%) at 5 and 7 years, respectively. No device-related co-factor affected long-term outcomes. Conclusions: Endurant II/IIs endograft is a safe and effective EVAR solution with excellent early outcomes and low long-term aneurysm-related mortality. The need for reintervention in the long term affected less than 50% of cases.