Volume assessment of abdominal aortic aneurysms (AAAs) using 3-D ultrasound (US) is an innovative technique reporting good agreement with computed tomography angiography. One major limitation of the current 3-D US technique is a limited field of view, allowing full AAA acquisition in only 60% of patients. This study presents two new US acquisition protocols using magnetic field tracking, providing an “extended field of view” (XFoV-2-D and XFoV-3-D) with the aim of including both the aortic bifurcation and neck for full-volume assessment, and compares these methods with the current standard 3-D US protocol and with computed tomography angiography. A total of 20 AAA patients were included and underwent the current standard 3-D US protocol and the two novel 3-D US “extended field of view” protocols. Four patients were excluded from further analysis because of low image quality, leaving 16 patients eligible for analysis. Full AAA volume was achieved in 8 patients (50%) using the standard 3-D US protocol, in 11 patients (69%) with the XFoV-2-D protocol and in 13 patients (81%) with the XFoV-3-D protocol. In conclusion, this article describes two new and feasible US protocols applicable for full-AAA-volume estimation in most patients and should initiate further research into the added value of full volume in AAA surveillance.

Full-Volume Assessment of Abdominal Aortic Aneurysms by 3-D Ultrasound and Magnetic Tracking.

Penetrating atherosclerotic ulcer of the aorta

How vascular surgeons can learn ultrasound.

Objectives Endovascular Aneurysm Repair is an established treatment for abdominal aortic aneurysm which requires arterial access via the groin. Most centres perform percutaneous ultrasound-guided access into the common femoral artery for delivery of the stent graft. The profile of endovascular devices necessitates large sheath sizes, therefore formal closure of the arterial puncture site is required. Various percutaneous devices are available, with data lacking on efficacy and mid-term safety profile. We present outcomes from a single centre with the Perclose ProGlide™ (Abbott Vascular Devices, CA, USA) suture-mediated system, using the well described “pre-close” technique. Materials & methods Data were collected from operative records and electronic medical records. Patients undergoing standard (EVAR) or complex (F/B-EVAR) aneurysm repair between March 2015 and September 2019 were included. Complications were recorded per-patient and per-groin procedure. Results 266 patients were included; 182 (68.4%) standard infrarenal EVAR, 84 (31.6%) F/B-EVAR. There were a total of 484 groin procedures performed. Intraoperative Perclose ProGlide™ success was 98.1% (per patient) or 99.0% (per groin procedure). 30-day groin complication rate was 6.1% (per patient) or 3.1% (per groin procedure). There were no pre- or peri-operative factors which predicted the occurrence of groin complications. The rate of groin complications was not related to sheath size. Conclusions Our data support the use of percutaneous access with a pre-close technique for a variety of endovascular aneurysm repair procedures with both large- and small-bore access. The Perclose ProGlide™ system provides excellent mid-term complication-free and reintervention-free outcomes for groin procedures.

Mid-term follow-up of percutaneous access for standard and complex EVAR using the ProGlide device.

BACKGROUND: The GORE EXCLUDER Conformable Endoprosthesis with active control (CEXC) was developed to treat challenging aortic neck anatomy. This study investigated the clinical results and changes in endograft (ap)position during follow-up.METHODS: Patients treated with the CEXC between 2018 and 2022 were included in this prospective single-center study. Computed tomography angiography (CTA) follow-up was grouped into three categories: 0 to 6 (FU1), 7 to 18 (FU2), and 19 to 30 (FU3) months. Clinical end points were endograft-associated complications and reinterventions. CTA analysis included the shortest apposition length (SAL) between the endograft fabric and the first slice where circumferential apposition was lost, shortest fabric distance (SFD) between both renal arteries and the endograft fabric, and maximum infrarenal and suprarenal aortic curvature. FU2 and FU3 were compared with FU1 to establish changes.RESULTS: Included were 46 patients, of whom 36 (78%) had at least one hostile neck feature and 13 (28%) were treated outside instructions for use. Technical success was 100%. Median CTA follow-up was 10 months (2-20 months); 39 patients had a CTA available at FU1, 22 at FU2, and 12 at FU3. At FU1, the median SAL was 21.4 mm (13.2-27.4 mm), which did not significantly change during follow-up. No type I endoleaks, and one type III endoleak at an IBD occurred during follow-up. Two cases of endograft migration (SFD increase >10 mm) were seen during follow-up (one treated outside the instructions for use). Maximum infrarenal and suprarenal aortic curvature did not significantly change during follow-up.CONCLUSIONS: The use of the CEXC in challenging aortic necks enables stable apposition without significant changes in aortic morphology at short-term follow-up. 

Single-center results of the Gore Excluder Conformable Endoprosthesis with active control system in endovascular aneurysm repair

OBJECTIVES
Abdominal aortic aneurysms (AAAs) demonstrating hostile neck anatomy (HNA) are associated with increased perioperative risk and mortality. A number of these patients are not suitable for standard endovascular aneurysm repair (EVAR) and are high risk for open surgery. We present our experience with the first implantations in Scotland of a novel conformable aortic stent-graft designed to overcome some of the challenges of HNAs.


METHODS
From May 2018 to March 2022, 24 consecutive patients with non-ruptured AAAs demonstrating HNAs (neck length < 15 mm, or angulation > 60°) were treated with GORE Excluder Conformable AAA endoprosthesis (CLEVAR) (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) at a Scottish vascular centre. We assessed clinical outcomes and technical success of CLEVAR during deployment, primary admission and the post-operative period at 3- and 12-month clinical follow-up alongside CT angiography.


RESULTS
Twenty-four patients (20 males, mean age 75.6) were included. Primary technical success of proximal seal zones and CLEVAR deployment (no type 1/3 endoleaks, no conversion to open repair, AAA excluded and patient leaving theatre alive) was achieved in 100% of patients. All patients were alive and clinically stable at 3- and 12-month follow-up. There were five patients requiring re-intervention; at the 3-month follow-up, one patient (4.2%) developed a type 1b endoleak requiring graft limb extension, one patient developed a right common femoral artery dissection requiring open repair and one patient required a limb extension of the right iliac limb due to risk of developing a type 1b endoleak. At the 12-month follow-up, two patients required embolization of type 2 endoleaks and no patients demonstrated type 1 or type 3 endoleaks.Conclusions: In-hospital and post-operative 3- and 12-month clinical and angiographic outcomes demonstrate safety and efficacy with CLEVARs in treating unruptured AAAs with HNA. Further research involving larger heterogenous sample sizes is warranted to determine long-term clinical outcomes.

Novel conformable stent-graft repair of abdominal aortic aneurysms with hostile neck anatomy: A single-centre experience.

The One-Stop Aortic Surveillance Clinic.

EVAR continues to evolve. A certain proportion of recipients meet criteria for early discharge after surgery, making day case EVAR a possibility. We present our experience with a minimally-invasive arterial closure device prior to instituting a day-case EVAR programme.

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Challenges and Solutions in Day Case EVAR

Critical limb ischemia remains a therapeutic challenge and despite best efforts from the surgical and interventional team some of these patients will require major amputation Despite advances in anaesthesia surgical technique and critical care there remains a significant day mortality in this group Recent quality improvement frameworks have sought to improve outcomes and we present our experience with general and regional anaesthesia in this cohort of patients

Impact of Modality of Anesthesia on Major Amputation Surgery

We present a large contemporary series of patients presenting with unreconstructable critical limb ischaemia and requiring amputation. As well as being an insight into the challenges faced with the implementation of a quality improvement framework. We also feel the results will better inform the practising vascular surgeon and patients about the risks of limb loss in the 21st century.

Implementing a quality improvement framework for major amputation in a scottish health board (patterns of peri-operative mortality and amputation level) -

Bryce Renwick

Papers

Novel conformable stent-graft repair of abdominal aortic aneurysms with hostile neck anatomy: A single-centre experience.

The One-Stop Aortic Surveillance Clinic.

Challenges and Solutions in Day Case EVAR

Impact of Modality of Anesthesia on Major Amputation Surgery

Implementing a quality improvement framework for major amputation in a scottish health board (patterns of peri-operative mortality and amputation level) -