Simone Cuozzo

Background: Abdominal aortic aneurysm (AAA) is less prevalent in women, yet rupture occurs owing to smaller diameters, leading to higher mortality rates; moreover, higher mortality rates also occur in women after aneurysm repair procedures. Meanwhile, whether women derive comparable benefit from endovascular aneurysm repair (EVAR) remains uncertain, partly because of anatomical constraints, such as smaller-caliber access vessels and more angulated proximal necks. This review evaluates sex-specific perioperative and long-term outcomes after EVAR. Methods: This study was conducted as a systematic review with narrative synthesis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 framework. A comprehensive search was conducted in the PubMed/MEDLINE and Scopus databases for studies published between January 2000 and September 2025. Search strings combined controlled vocabulary and free-text terms for “abdominal aortic aneurysm”, “endovascular aneurysm repair”, and “sex” or “gender” or “female”. A predefined Population, Intervention, Comparison, Outcome (PICO) model was used to guide study selection. Comparative observational cohorts, registry or claims analyses, and EVAR-focused meta-analyses reporting sex-stratified outcomes were eligible. Articles were restricted to English. Outcomes included perioperative mortality, major complications, reintervention, and long-term survival. Given the heterogeneity and the availability of recent pooled analyses, quantitative synthesis favored adjusted estimates from high-quality meta-analyses and registries, and no new pooled meta-analysis was performed to avoid data duplication. Results: A total of 15 studies met the inclusion criteria, encompassing more than 500,000 EVAR procedures. Women consistently exhibited higher early mortality and morbidity after standard infrarenal EVAR. The largest EVAR-focused meta-analysis reported an odds ratio (OR) for 30-day mortality of 1.73 (95% confidence interval (CI) 1.32–2.26) and in-hospital mortality OR of 1.90 (1.43–2.53) for women versus men, with increased risks of limb ischemia (~2.4-fold), renal (OR ~1.7), and cardiac complications (OR ~1.7). Long-term all-cause mortality was higher in women (hazard ratio (HR) 1.23, 95% CI 1.09–1.38). Contemporary registry data indicated similar adjusted mortality but persistently greater access-related morbidity in women, including higher rates of limb ischemia (5.3% vs. 3.2%) and major bleeding (22.0% vs. 15.9%). Perioperative mortality and complications were approximately two-fold higher in women following complex EVAR, defined as fenestrated and/or branched endovascular repair (F/BEVAR) for juxtarenal, pararenal, suprarenal, or thoracoabdominal aneurysms. Additionally, survival remained inferior in those with a ruptured AAA (8-year survival: 36.7% vs. 49.5%). Conclusions: Women undergoing EVAR continue to experience higher perioperative morbidity and less favorable long-term outcomes compared with men, despite advances in device technology and perioperative care. These disparities largely reflect anatomical and physiological differences, delayed presentation, and underrepresentation in clinical trials and registries. This systematic review and narrative synthesis clarifies sex-specific differences in outcomes after standard infrarenal EVAR and complex F/BEVAR, integrating evidence from contemporary device eras. Sex-aware imaging, individualized access planning, and device design tailored to smaller anatomy are critical to achieving equitable outcomes in endovascular aortic repair.

Objective: Although open repair remains the standard of care for managing connective tissue disorders (CTDs), endovascular repair has emerged as an alternative, especially in patients with prior aortic surgery, using a “graft-to-graft” approach. Notwithstanding, long-term interaction between bridging stent-grafts and arterial wall of target vessels (TVs) remains under-investigated. We present a rare case of late-onset type IIIB/IIIC endoleaks in a symptomatic type V thoracoabdominal aortic aneurysm (TAAA) following fenestrated endovascular aneurysm repair (FEVAR) in a patient with Marfan syndrome (MFS), and a literature review. Methods: A 55-year-old woman with MFS and a history of multiple cardiovascular surgeries, including previous FEVAR using a graft-to-graft approach, presented with chest pain secondary to a large type V TAAA. Computed tomography angiography revealed type IIIB/IIIC endoleaks due to stent disconnection, stent fracture, and fabric tears involving renal and visceral arteries’ bridging stents. An urgent endovascular relining was performed with balloon-expandable stent-grafts, achieving enhanced stent protrusion and increased oversizing. The postoperative course was uneventful, with complete resolution of symptoms and no evidence of spinal cord ischemia. Follow-up imaging confirmed complete aneurysm exclusion and maintained patency of TVs. Additionally, a comprehensive literature review was conducted in accordance with PRISMA guidelines, using the search term “MFS,” “type IIIB/IIIC endoleak,” and “Fenestrated stent-graft” to investigate the rate of incident type III endoleak. Out of 43 identified reports, 8 studies met the inclusion criteria. Results: Although infrequent (4%–5.9%), type IIIB/IIIC endoleaks after FEVAR in MFS patients may be underreported. These endoleaks may result from under-investigated interactions between bridging stents and TVs, especially due to the inherent fragility of the aortic wall in CTDs. In redo cases, adjunctive strategies, such as increased stent protrusion and greater oversizing, may be necessary to prevent further disconnections. Conclusions: Endovascular therapy provides a viable option for managing MFS patients, particularly in challenging redo cases with prohibitive surgical risks. Lifelong aortic surveillance in specialized centers and extended and careful follow-up is essential to assess the risks and the true incidence of high-flow endoleaks, as well as the overall safety and durability of these interventions, especially given the progressive nature of CTDs. Clinical Impact: This study demonstrated the feasibility, safety, and time- and cost-effectiveness of single-disc vascular plug embolization for directional branches during urgent or emergent branched endovascular aortic aneurysm repair using off-the-shelf devices, even without elongation with balloon-expandable stent-grafts. This approach is particularly relevant in urgent scenarios, where minimizing procedural time is critical for optimizing patient outcomes, as well as in resource-limited settings, where efficient allocation of healthcare resources is essential.

Objective: The introduction of off-the-shelf (OTS) multibranch stent-grafts represented an advancement in the endovascular treatment of thoraco-abdominal aortic aneurysms (TAAAs), particularly in urgent settings. In certain cases (e.g, target vessel [TV] occlusion), unused directional branches (DBs) require proper occlusion with a vascular plug to prevent type III endoleaks. However, no standardized technique for DB closure has been established. We aim to evaluate the safety, feasibility, time-effectiveness and cost-effectiveness of using single-disk vascular plug (Amplatzer Vascular Plug [AVP]) for DB closure during urgent branched endovascular aneurysm repair (B-EVAR). Methods: Retrospective analysis of 16 patients (16/101, 15.8%) undergoing urgent B-EVAR with OTS devices requiring intentional occlusion of at least 1 DB using vascular plug due to unavailable TVs or anatomical constraints. Amplatzer Vascular Plugs were deployed in 2 different techniques: with or without DB elongation with balloon-expandable stent-grafts. Technical success, clinical outcomes, side branches plugging time, and plug-constrained length after its deployment were assessed. Results: Balloon-expandable stent-graft plus AVP were used to occlude 7 unused DBs (36.8%), whereas AVP without elongation was used in 8 (42.1%), with a median oversizing rate of 58.7%. The technical success rate was 100%, with no instances of plug migration or endoleak during a median follow-up of 20.9±14.4 months. Perioperative mortality rate was 25%, exclusively in patients with ruptured aneurysms. Clinical success was maintained in all patients, with no late reinterventions or DBs recanalization. Side-branch plugging time was significantly shorter when performed without elongation (3.9±0.6 vs. 6.4±1.3 minutes; p =.0003). Despite greater oversizing, even without elongation, the mean plug-constrained length (15.1±4.5 mm) did not exceed the shortest DB, effectively reducing the risk of complications associated with increased plug-constrained length while ensuring proper and secure deployment. Conclusions: Single-disk vascular plugs without DB elongation provide a safe, feasible, time-effective and cost-effective solution for DB closure during B-EVAR, with favorable outcomes and reduced procedural complexity, even in urgent setting. Multicenter studies are needed to validate these findings and establish standardized DB management techniques for challenging anatomical and urgent cases. Clinical Impact: Our study demonstrated the feasibility, safety, and time- and cost-effectiveness of single-disc vascular plug (AVP) embolization for directional branches during urgent or emergent branched endovascular aortic aneurysm repair using off-the-shelf devices, even without elongation using balloon-expandable stent-grafts. This technique simplifies the procedure, reducing complexity and potential complications. It is particularly advantageous in urgent scenarios, where minimizing procedural time is critical to improve patient outcomes and survival. Moreover, it offers significant benefits in resource-limited settings by ensuring efficient use of healthcare resources. Overall, this approach represents a practical, effective solution that can enhance procedural efficiency and broaden clinical applicability.

Objectives: This study aimed to evaluate whether gender-related anatomical differences in proximal aortic neck morphology affect the feasibility and outcomes of endovascular aortic aneurysm repair (EVAR) in women with abdominal aortic aneurysms (AAA). Methods: This study performed a retrospective analysis of patients electively treated by EVAR for infrarenal AAA between January 2019 and December 2023. Demographics, anatomical characteristics, and stent graft details were analyzed. The primary endpoint was technical success. Secondary endpoints included freedom from aortic and neck-related reinterventions, endoleak rate, and freedom from aneurysm-related mortality during follow-up. Technical aspects, including adherence to the instructions for use (IFUs), were retrospectively analyzed. Results: One-hundred-seventeen patients (fifty-six females; mean age 76.2 ± 5.3 years) underwent elective EVAR for AAA. Demographics and comorbidities were homogeneous across genders. Female patients (Group A) demonstrated a higher prevalence of hostile proximal aortic neck features, including neck length < 10 mm and angulation > 60° (p = 0.009, p = 0.029, respectively) and a higher frequency of off-label EVAR procedures (28.6% vs. 11.5%; p = 0.034). The overall technical success rate was 98.3%, with no significant differences between genders in terms of stent graft selection, use of suprarenal fixation, or incidence of type 1–3 endoleaks. The median follow-up period was 35.2 ± 12.7 months, showing comparable rates of neck-related reinterventions, open conversions, and aneurysm-related mortality between genders. Notably, off-label EVAR was identified as an independent risk factor for type 1A endoleaks, reinterventions, and aneurysm-related mortality (p < 0.00001, p < 0.0001, and p = 0.001, respectively). Conclusions: Female patients undergoing EVAR often present with hostile proximal aortic neck features and are treated at an older age than males. Despite these differences, technical success rates and mid- to long-term outcomes were comparable between genders, with no variation in stent graft selection or suprarenal fixation use. Effective procedural planning, device selection, and surgical expertise appear to mitigate historical gender-related anatomical challenges. Further large-scale studies are needed to confirm whether anatomical factors alone drive outcomes, irrespective of gender.

Article: Impact of frailty on outcomes of patients undergoing elective endovascular thoraco-abdominal aortic aneurysm repair - The Journal of Cardiovascular Surgery 2024 Oct 23 - Minerva Medica - Journals

Objectives : the purpose of this study was to determine whether gender-related proximal neck anatomic variables influence the applicability and outcomes of aortic endografting in women with abdominal aortic aneurysms of similar size. Methods: this retrospective study includes all consecutive patients who underwent elective EVAR for abdominal aortic aneurysms (AAA) with a maximum diameter ranging from 5.0 to 6.0 cm between January 2019 and December 2023. Results: a total of 117 patients were consecutively enrolled between January 2019 and December 2023, comprising 56 females (47.9%) and 61 males (52.1%). Females were older than males (mean age: 78.2 vs. 74.3 years, respectively; pppp<0.001). However, the rate of complications following off-label procedures did not significantly differ between men and women. Conclusions: A more complex and even hostile aortic neck anatomy was observed in women compared to men in our series, despite matched AAA sizes. The more challenging proximal neck features may have led to more frequent supra-renal fixation of the stent graft and off-label EVAR procedures performed in women than in men. Despite a statistically significant higher incidence of type 1A endoleaks following EVAR performed outside the IFU, the outcomes were comparable between genders. Accurate endograft selection and the availability of more versatile devices have improved the feasibility of EVAR, reducing complications related to proximal seal zones caused by the hostile aortic neck characteristics often associated with the female gender.

Objectives: This study aims to evaluate the technical and clinical outcomes of the E-nside stent graft for thoraco-abdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PAAA) endovascular treatment at our University Hospital Center. Methods: We conducted a retrospective analysis of patients electively treated by inner branched EVAR (iBEVAR) between 05/2021 and 03/2023. Demographic, procedural, and clinical data were analyzed. The technical success and clinical outcomes, such as access-site-related complications were reported. The perioperative and early mortality rate, freedom from aortic reintervention, target vessels’ (TVs) patency, and the endoleak rate were evaluated during the follow-up. The technical aspects (external iliac artery diameter, iliac tortuosity, extent of aortic coverage) were retrospectively analyzed. Results: Twenty-two patients were included (age 75.9 ± 5.5; 72.7% male). The aneurism extent was Crawford I = 4 (18.2%), III = 8 (36.4%), IV = 5 (22.7%), V = 1 (4.5%), and PAAA = 4 (18.2%). The mean aortic diameter was 63.5 ± 9.9 mm. The technical success was 95.5% (assisted primary success 100%). The clinical success was 86.4%. The perioperative and early freedom from all-cause mortality rates were 90.9% and 90%, respectively. No case of inter-stage aortic-related mortality was reported, and there was no permanent/temporary spinal cord ischemia (SCI). Seventy-eight out of 81 patent TVs were incorporated through a bridging stent (96.3%). The TV success was 95.1%. The mean external iliac artery (EIA) diameter was 7.5 ± 1.1 mm. Twelve patients (54.5%, including all female patients) were considered outside the instructions for use (IFU) due to narrow iliac arteries. One access-site-related complication was reported. Conclusions: Our experience confirms that E-nside has promising technical and clinical success rates, as well as a low reintervention rate, but it requires a significant compromise of the healthy aortic tissue and adequate iliac arteries that still represents a limitation, especially among women. Mid- to long-term studies and prospective registries are mandatory to evaluate the long-term efficacy and safety, as a comparison between E-nside and other alternative off-the-shelf solutions.

Objectives: We aim to evaluate technical and clinical outcomes with E-nside stent-graft for thoraco-abdominal aortic aneurysm (TAAA) and pararenal abdominal aortic aneurysm (PAAA) endovascular treatment at our University Hospital Center. Methods: Retrospective analysis of patients electively treated by inner branched EVAR (iBEVAR) between 05/2021 and 03/2023. Demographics, procedural and clinical data were analyzed. Technical success and clinical outcomes, such as access-site related complications were reported. Perioperative and early mortality rate, freedom from aortic reintervention, Target vessels (TVs) patency and endoleak rate were evaluated during the follow-up. Technical aspects (external iliac artery diameter, iliac tortuosity, extent of aortic coverage) were retrospectively analyzed. Results: Twenty-two patients included (age 75.9±5.5; 72.7% male). Aneurism extent was Craw-ford I=4 (18.2%), III=8 (36.4%), IV=5 (22.7%), V=1 (4.5%) and PAAA=4 (18.2%). Mean aortic di-ameter was 63.5±9.9mm. The technical success 95.5% (assisted primary success 100%). The clini-cal success 86.4%. Perioperative and early freedom from all-cause mortality rate 90.9% and 90%, respectively. No case of inter-stage aortic-related mortality reported, as no permanent/temporary spinal cord ischemia (SCI). Seventy-eight out of 81 patent TVs were incorporated through a bridging stent (96.3%). TV success 95.1%. Mean external iliac artery (EIA) diameter 7.5±1.1mm. Twelve patients (six women, 100%) were considered outside the instructions for use (IFU) due to narrow iliac arteries. One access-site related complication reported. Conclusions: Our experience confirms that E-nside has promising technical and clinical success rates, as low reintervention rate, but requires a great sacrifice of healthy aorta and adequate iliac arteries that still represent a limitation, especially among women. Mid- to long-term studies and prospective registries are mandatory to evaluate long-term efficacy and safety, as a comparison between E-nside and other alternative off-the-shelf solution.