Safety and Efficacy of Endovascular Aortic Repair for Abdominal Aortic Aneurysms with a Hostile Neck Anatomy

Objective This study aimed to investigate the safety and efficacy of endovascular aortic repair(EVAR)for the treatment of an abdominal aortic aneurysm(AAA)with a hostile neck anatomy(HNA).Methods From January 1,2015 to December 31,2019,a total of 259 patients diagnosed with an AAA who underwent EVAR were recruited into this study.Based on the morphological characteristics of the proximal neck anatomy,the patients were divided into the HNA group and the friendly neck anatomy(FNA)group.The patients were followed up for up to 4 years.Results The average follow-up time was 1056.1±535.5 days.Type I endoleak occurred in 4 patients in the HNA group,and 2 patients in the FNA group.Neither death nor intraoperative switch to open repair occurred in either group.The time of the operation was significantly longer in the HNA group(FNA vs.HNA,99.2±51.1 min vs.117.5±63.8 min,P=0.011).There were no significant differences in short-term clinical success rate(P=0.228)or midterm clinical success rate(P=0.889)between the two groups.The overall mortality rate was 10.4%,and Kaplan-Meier survival analysis indicated that the two groups had similar cumulative survival rates at the end of the follow-up period(P=0.889).Conclusion EVAR was feasible and safe in patients with an AAA with a proximal HNA.The early and midterm results were promising;however,further studies are needed to verify the long-term effectiveness of EVAR.

Appearance of aseptic vascular grafts after endovascular aortic repair on[(18)F]fluorodeoxyglucose positron emission tomography/computed tomography

BACKGROUND Diagnosis of prosthetic vascular graft infection with[(18)F]fluorodeoxyglucose positron emission tomography/computed tomography(18F-FDG PET/CT)allows for early detection of functional changes associated with infection,based on increased glucose utilization by activated macrophages and granulocytes.Aseptic vascular grafts,like all foreign bodies,can stimulate an inflammatory response,which can present as increased activity on 18F-FDG PET/CT.Consequently,distinguishing aseptic inflammation from graft infection,though important,can be difficult.In the case of endovascular aneurysm repair(EVAR),a minimally invasive procedure involving the transfemoral insertion of an endoprosthetic stent graft,the normal postoperative appearance of these grafts on 18F-FDG PET/CT can vary over time,potentially confounding study interpretation.AIM To investigate the visual,semiquantitative,and temporal characteristics of aseptic vascular grafts in patients status post EVAR.METHODS In this observational retrospective cohort study,patients with history of EVAR who underwent 18F-FDG PET/CT for indications other than infection were identified retrospectively.All patients were asymptomatic for graft infection-no abdominal pain,fever of unknown origin,sepsis,or leukocytosis-at the time of imaging and for≥2 mo after each PET/CT.Imaging studies such as CT for each patient were also reviewed,and any patients with suspected or confirmed vascular graft infection were excluded.One hundred two scans performed on 43 patients(34 males;9 females;age=77±8 years at the time of the final PET/CT)were retrospectively reviewed.All 43 patients had an abdominal aortic(AA)vascular graft,40 patients had a right iliac(RI)limb graft,and 41 patients had a left iliac(LI)limb graft.Twentytwo patients had 1 PET/CT and 21 patients had from 2 to 9 PET/CTs.Grafts were imaged between 2 mo to 168 mo(about 14 years)post placement.Eight grafts were imaged within 6 mo of placement,including three that were imaged within three months of placement.The mean interval between graft placement and PET/CT for all 102 scans was 51±39 mo.PET/CT data was reconstructed with region-of-interest analysis of proximal,mid and distal portions of the grafts and background ascending aorta.Maximum standardized uptake value(SUVmax)was recorded for each region.SUVmax-to-background uptake ratios(URs)were calculated.Visual assessment was performed using a 2-pattern grading scale:Diffuse(homogeneous uptake less than liver uptake)and focal(one or more areas of focal uptake in any part of the graft).Statistical analysis was performed.RESULTS In total,there were 306 AA grafts,285 LI grafts,282 RI grafts,and 306 ascending aorta background SUVmax measurements.For all 102 scans,mean SUVmax values for AA grafts were 2.8-3.0 along proximal,mid,and distal segments.Mean SUVmax values for LI grafts and RI grafts were 2.7-2.8.Mean SUVmax values for background were 2.5±0.5.Mean URs were 1.1-1.2.Visual analysis of the scans reflected results of quantitative analysis.On visual inspection,98%revealed diffuse,homogeneous 18F-FDG uptake less than liver.Graft URs and visual pattern categories were significantly associated for AA graft URs(F-ratio=21.5,P<0.001),LI graft URs(F-ratio=20.4,P<0.001),and RI graft URs(F-ratio=30.4,P<0.001).Thus,visual patterns of 18F-FDG uptake corresponded statistically significantly to semiquantitative URs.The age of grafts showing focal patterns was greater than grafts showing diffuse patterns,87±89 vs 50±37 mo,respectively(P=0.02).URs were significantly associated with graft age for AA grafts(r=0.19,P=0.001).URs were also significantly associated with graft age for LI grafts(r=0.25,P<0.0001),and RI grafts(r=0.31,P<0.001).Quartiles of similar numbers of graft(n=25-27)grouped by graft age indicated that URs were significantly higher for 4th quartile vs 2nd quartile URs(F-ratio=19.5,P<0.001).When evaluating URs,graft SUVmax values within 10%-20%of the ascending aorta SUVmax is evident in aseptic grafts,except for grafts in the oldest quartiles.In this study,grafts in the oldest quartiles(>7 years post EVAR)showed SUVmax up to 30%higher than the ascending aorta SUVmax.CONCLUSION Characteristics of an aseptic vascular stent graft in the aorta and iliac vessels on 18F-FDG PET/CT include graft SUVmax values within 10%-20%of the ascending aorta background SUVmax.The SUVmax of older aseptic grafts can be as much as 30%above background.The visual uptake pattern of diffuse,homogeneous uptake less than liver was seen in 98%of aseptic vascular grafts,making this pattern particularly reassuring for clinicians.

Custom Made Fenestrated Stent Graft Collapse after Thoracic Endovascular Aortic Repair: A Case Report

We present a case of stent graft collapse after performing thoracic endovascular aortic repair with a custom-made fenestrated stent graft. The patient was a 70-year-old woman with an asymptomatic aneurysm of the distal aortic arch, and thoracic endovascular aortic repair was performed. The patient showed a blood pressure difference between the left arm and the right arm on postoperative day (POD) 17 prompting the performance of a chest computed tomography scan which revealed stent graft collapse. She then underwent staged debranching of thoracic endovascular aortic repair. Stent graft collapse is a rare but well-described complication of thoracic endovascular repair. Therefore, patients who undergo such a procedure should be carefully monitored for signs and symptoms, which suggest the possibility of stent collapse.

Antegrade in situ laser fenestration of aortic stent graft during endovascular aortic repair:A case report

BACKGROUND The endovascular repair of juxtarenal abdominal aortic aneurysms(JAAA)usually requires combination treatment with various stent graft modifications to preserve side branch patency.As a feasible technique,according to the situation,antegrade in situ laser fenestration still needs to be improved.CASE SUMMARY This report describes a case that was successfully treated with endovascular repair facilitated by antegrade in situ laser fenestration while maintaining renal arterial flow.Laser fenestration was performed using a steerable sheath positioned in the stent graft lumen in front of the renal artery ostium.With the bare stent region unreleased,renal artery perfusion could be maintained and accurate positioning could be achieved by angiography in real time.CONCLUSION This study suggests the feasibility and short-term safety of this novel antegrade in situ laser fenestration technique for select JAAA patients.

Thoracic Endovascular Aortic Repair for Cardiopulmonary Arrest Due to Aortic Dissection

Background and Aim: Reports on recovery from Stanford type A aortic dissection (TAAD) leading to cardiopulmonary arrest (CPA) are few. In retrograde TAAD (r-TAAD) cases, some authors reported the efficacy of thoracic endovascular aortic repair (TEVAR). However, only a few reports chose TEVAR for the treatment of r-TAAD resulting in cardiac arrest before hospital arrival. We report a case of r-TAAD presenting with cardiac arrest before hospital arrival not indicated for surgery but TEVAR as treatment. Case: A 65-year-old woman with a history of Marfan syndrome presented to the emergency department after a CPA. Sequential return of spontaneous circulation was achieved 27 min after CPA. Contrast-enhanced computed tomography showed retrograde r-TAAD with an entry tear to the false lumen in the thoracic descending aorta. Therefore, thoracic endovascular aortic repair (TEVAR) was performed with r-TAAD. Afterward, the clinical course was stabilized. This patient suggests that TEVAR is an effective option for the treatment of patients with hemodynamically unstable r-TAAD, even after CPA. Conclusion: TEVAR can lead to a successful recovery from cardiac arrest due to r-TAAD.

Thoracic endovascular aortic repair of chronic type B aortic dissection in 84 patients

Objective The optimal treatment for chronic type B dissection remains controversial. The purpose of this study was to report early and mid-term results of thoracic endovascular aortic repair (TEVAR) of chronic type B aortic dissection. Methods From June 2001 to September 2007, 84 patients with chronic type B aortic

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

Introduction:Blunt thoracic aortic injury(BTAI)is rare in elderly patients.As the population ages and life expectancy increases,the frequency of this injury will increase,while the treatment and outcomes remain unclear.Methods:We retrospectively analyzed the collected data of patients>60 years old with BTAI to investigate the mechanism of trauma;time interval from injury to diagnosis;type and timing of surgical intervention;aortic arch pattern;choice of left subclavian artery reconstruction;endograft to treat BTAI;length of the endovascular procedure;endoleaks;complications including stroke,paraplegia,and renal failure;length of hospital stay(LOS)and intensive care unit stay(L.ICUS);and 30-day mortality.Results:Five elderly trauma patients were found to have BTAI.Four(80%)were males,the cohort mean age was68 years,the major mechanism of trauma was fall injury,and the associated injury was thoracic trauma.All patients were transferred to our hospital,and emergency computed tomography angiography showed BTAI in each patient.The average time interval from injury to diagnosis was 2.7 days.Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair,while 3 patients underwent delayed endovascular repair.The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery;the aortic arch pattern was II(80.0%)in 4 cases and III in 1 case(20.0%).The choice of left subclavian artery reconstruction included chimney,double chimney,prefenestration,and chimney combined with in situ fenestration.Endografts to treat BTAI included the Ankura(Lifetech Scientific,Shenzhen,China)and the C-TAG(W.L.Gore&Associates,Flagstaff,AZ USA).The length of the endovascular procedure was 75.4 min;there were no endoleaks and no complications including stroke,paraplegia,or renal failure.The average LOS was25 days,and the average L.ICUS of 2 patients was 15 days,with no 30-day mortality.Conclusion:Elderly patients with fall injury should promptly exclude BTAI.Thoracic endovascular aortic repair(TEVAR)with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications.Because of the low incidence of this type of injury,we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

Application of multi-planar reconstruction technique in endovascular repair of aortic dissection

BACKGROUND Endovascular repair of aortic dissection is an effective method commonly used in the treatment of Stanford type B aortic dissection.Stent placement during the operation was one-time and could not be repeatedly adjusted during the operation.Therefore,it is of great significance for cardiovascular physicians to fully understand the branch status,position,angle,and other information regarding aortic arch dissection before surgery.AIM To provide more references for clinical cardiovascular physicians to develop treatment plans.METHODS Data from 153 patients who underwent endovascular repair of aortic dissection at our hospital between January 2021 and December 2022 were retrospectively collected.All patients underwent multi-slice spiral computed tomography angiography.Based on distinct post-image processing techniques,the patients were categorized into three groups:Multiplanar reconstruction(MPR)(n=55),volume reconstruction(VR)(n=46),and maximum intensity projection(MIP)(n=52).The detection rate of aortic rupture,accuracy of the DeBakey classification,rotation,and tilt angles of the C-arm during the procedure,dispersion after stent release,and the incidence of late complications were recorded and compared.RESULTS The detection rates of interlayer rupture in the MPR and VR groups were significantly higher than that in the MIP group(P<0.05).The detection rates of De-Bakey subtypesⅠ,Ⅱ,andⅢin the MPR group were higher than those in the MIP group,and the detection rate of typeⅢin the MPR group was significantly higher than that in the VR group(P<0.05).There was no statistically significant difference in the detection rates of typesⅠandⅡcompared to the VR group(P>0.05).The scatter rate of markers and the incidence of complications in the MPR group were significantly lower than those in the VR and MIP groups(P<0.05).CONCLUSION The application of MPR in the endovascular repair of aortic dissection has improved the detection rate of dissection rupture,the accuracy of anatomical classification,and safety.

Bicuspidization Using the Open-Sleeve Technique for Congenital Aortic Stenosis during Infancy

Congenital aortic stenosis(cAS)frequently requires intervention during the neonatal or infantile period.However,surgical repair is challenging because of the narrow surgical space.We performed bicuspidization using the open-sleeve technique for cAS with a unicuspid aortic valve in two patients.Postoperatively,the patients were doing well without reintervention for the aortic valve for 8 and 6 years,respectively.Their aortic annular diameter increased along with somatic growth.Bicuspidization for neonates or infancy can be performed safely using the open-sleeve technique as its midterm results have been satisfactory.

Totally percutaneous thoracic endovascular aortic repair with the preclosing technique： a case-control study

Background The conventional thoracic endovascular aortic repair （TEVAR） involves groin incisions under general or epidural anesthesia. As technology moves towards less invasive procedures, a total percutaneous approach is desirable.In this study, we describe a Preclosing technique and investigate its safety and efficacy for femoral access sites management, and evaluate its advantages as compared to those of traditional surgical cutdown approaches.Methods The Preclosing technique involves two or multiple 6 F Perclose Proglide devices deployed in the femoral artery before upsizing to a 20-25 F sheath. The sutures were secured to close the arteriotomy at the end of the procedure. The medical records of patients who underwent thoracic endovascular aortic repairs using the Preclosing technique between December 2009 and November 2010 （group A） were compared with those using surgical femoral cutdown from January 2008 to November 2009 （group B）. Outcome measures included rates of technical success, early complications, anesthesia method, procedure time, cardiac care unit （CCU） stay, time from procedure to discharge,hospital stay, procedure expense, hospital cost.Results Between the two groups, there were no significant differences in baseline characteristics, in the endograft models or profiles. The technical success rate was 100.0% （85/85） in group A vs. 97.4% （147/151） in group B （P 〈0.05）.There was no access-related mortality in both groups. Compared with group B, the incidence of early complications were fewer in group A, 9.4% （8/85） vs. 22.5% （34/151） （P 〈0.01）. Local anesthesia with conscious sedation was used more often in group A, 68.2% （58/85） vs. 51.7% （78/151） in group B （P〈0.01）. The procedure duration was shorter, （96±33）minutes in group Avs. （127±41） minutes in group B （P〈0.01）. The length of the CCU stay, the duration from procedure to discharge, and the hospital stay were both reduced in group A, （117.3±88.3） hours, （7.5±5.3） days and （15.3±6.8） days vs. （132.7±115.5） hours, （10.5±5.0） days and （19.5±7.8） days in group B （P〈0.01）. The procedure cost was RMB （109 000±30 000） Yuan in group A vs. RMB （108 000±25 000） Yuan in group B （P=NS）. The hospital cost was RMB （130 000±35 000） Yuan in group A vs. RMB （128 000±33 000） Yuan in group B （P=NS）.Conclusions Total percutaneous TEAVR with the Preclosing technique is safe and effective with meticulous technique and appropriate patient selection. The Preclosing technique decreases access-related complications, depends less on general anesthesia and the surgeon＇s cooperation, saves procedure time and shortens the CCU/hospital stay. With these advantages, the use of two percutaneous closure devices increases the hospital cost only slightly.

Safety and Necessity of Antiplatelet Therapy on Patients Underwent Endovascular Aortic Repair with Both Stanford Type B Aortic Dissection and Coronary Heart Disease

Background： Acute aortic dissection is known as the most dangerous aortic disease, with management and prognosis determined as the disruption of the medial layer provoked by intramural bleeding. The objective of this study was to evaluate the safety and necessity of antiplatelet therapy on patients with Stanford Type B aortic dissection （TBAD） who underwent endovascular aortic repair （EVAR）. Methods： The present study retrospectively analyzed 388 patients with TBAD who underwent EVAR and coronary angiography. The primary outcomes were hemorrhage, death, endoleak, recurrent dissection, myocardial infarction, and cerebral infarction in patients with and without aspirin antiplatelet therapy at 1 month and 12 months. Results： Of those 388 patients, 139 （35.8%） patients were treated with aspirin and 249 （64.2%） patients were not treated with aspirin. Patients in the aspirin group were elderly （57.0 ± 10.3 years vs. 52.5 ± 11.9 years, respectively, χ2 = 3.812, P 〈 0.001） and had more hypertension （92.1% vs. 83.9%, respectively, χ2 = 5.191, P = 0.023） and diabetes （7.2% vs. 2.8%, respectively, χ2 = 4.090, P = 0.043） than in the no-aspirin group. Twelve patients （aspirin group vs. no-aspirin group; 3.6% vs. 2.8%, respectively, χ2 = 0.184, P = 0.668） died at 1-month follow-up, while the number was 18 （4.6% vs. 5.0%, respectively, χ2 = 0.027, P = 0.870） at 12-month follow-up. Hemorrhage occurred in 1 patient （Bleeding Academic Research Consortium [BARC] Type 2） of the aspirin group, and 3 patients （1 BARC Type 2 and 2 BARC Type 5） in the no-aspirin group at 1-month follow-up （ χ2 = 0.005, P = 0.944）. New hemorrhage occurred in five patients in the no-aspirin group at 12-month follow-up. Three patients in the aspirin group while five patients in the no-aspirin group had recurrent dissection for endoleak at 1-month follow-up （2.3% vs. 2.2%, respectively, χ2 = 0.074, P = 0.816）. Four patients had new dissection in the no-aspirin group at 12-month follow-up （2.3% vs. 3.8%, respectively, χ2 = 0.194, P = 0.660）. Each group had one patient with myocardial infarction at 1-month follow-up （0.8% vs. 0.4%, respectively, χ2 = 0.102, P = 0.749） and one more patient in the no-aspirin group at 12-month follow-up. No one had cerebral infarction in both groups during the 12-month follow-up. In the percutaneous coronary intervention （PCI） subgroup, 44 （31.7%） patients had taken dual-antiplatelet therapy （DAPT, aspirin ＋ clopidogrel） and the other 95 （68.3%） patients had taken only aspirin. There was no significant difference in hemorrhage （0% vs. 1.1%, respectively,χ2 = 0.144, P = 0.704）, death （4.8% vs. 4.5%, respectively, χ2 = 0.154, P = 0.695）, myocardial infarction （2.4% vs. 0%, respectively,χ2 = 0.144, P = 0.704）, endoleak, and recurrent dissection （0% vs. 3.4%, respectively, χ2 = 0.344, P = 0.558） between the two groups at 12-month follow-up. Conclusions： The present study indicated that long-term oral low-dose aspirin was safe for patients with both TBAD and coronary heart disease who underwent EVAR. For the patients who underwent both EVAR and PCI, DAPT also showed no increase in hemorrhage, endoleak, recurrent dissection, death, and myocardial infarction.

Fenestrated endovascular aortic repair for juxtarenal abdominal aortic aneurysm

Background Endovascular stent-graft with fenestration can improve proximal sealing in patients with juxtarenal abdominal aortic aneurysm （JAAA）. The purpose of this study was to describe our primary experience and evaluate the safety and efficacy of fenestrated device for JAAA in high-risk patients. Methods Between March 2011 and May 2012, nine male patients （mean age, （79.6±8.6） years） with asymptomatic JAAAs underwent elective deployment of the Zenith fenestrated stent-grafts at a single institution. All patients were treated in the hybrid operating room under general anesthesia. Follow-up computed tomography angiography （CTA） was routinely performed before discharge, at 3, 6, and 12 months and annually thereafter. Results Procedural success was achieved in all cases. Total sixteen small fenestrations, two large fenestrations and eight scallops were used. Intra-operative complications occurred in four patients, which included one proximal type I endoleak, two type II endoleaks, and one renal artery dissection. The mean hospital stay was （8.9±1.4） days, mean blood loss was （360.5±46.8） ml, and mean iodinated contrast volume was （230.6±58.3） ml. The mean follow-up time was （7.6±4.2） months. The visceral graft patency was 100% until now. One patient had an increase of serum creatinine of more than 30%, but did not require dialysis. No patients died, no stent fractured, and migration were diagnosed during the follow-up. Conclusions The early results of fenestrated device for high-risk patients with complex JAAAs are satisfactory. However, long-term fenestrated graft durability and branch vessel patency remain to be determined.

Risk analysis of preoperative anemia in type B aortic dissection after thoracic endovascular aortic repair

Background Postoperative death of thoracic endovascular aortic repair （TEVAR） occurred in patients with type B aortic dissection （TBAD）. The prognostic value of anemia, an important problem during the perioperative period, is unknown. Methods According to predefined criteria, 184 TBAD patients underwent TEVAR were di-vided into two groups： non-anemia group and anemia group. Clinical data were compared between groups and multiple Cox proportional hazard regression analyses were performed to detect the risk factors of long-term mor-tality. Results After median 2.5 years follow-up, 21 patients died. Long-term mortality was significant higher in patients with anemia （23.9% vs. 8.1%, P=0.006）. Multivariate analyses showed that anemia was independently associated with increased risk of long-term mortality （HR=3.21, 95% CI： 1.31-7.89, P=0.011）. The ROC curve showed that hemoglobin level had predictive role for long-term mortality （AUC=0.742, P〈0.001）. The optimal cut-off was 130.2g/L, with sensitivity and specificity being 85.7% and 52.0%, respectively. Conclusions Admission anemia was independently associated with increased risk of long-term post-TEAVR mortality in TBAD pa-tients. Pre-TEAVR hemoglobin measure could be a risk assessment tool for TBAD patients undergoing TEAVR.

Predicting factors and adverse effect of non-infectious fever in patient with aortic dissection after endovascular aortic repair

Background Non-infectious fever in patients with aortic dissection after endovascular aortic repair （EVAR） is very common and can cause a series of adverse effects. However, the etiology and pathophysiology of non-infectious postoperative fever is seldom studied. Methods According to predefined criteria, 148 patients underwent EVAR were divided into two groups： non-infectious fever group and non-fever group. Clinical data were compared between groups and multiple logistic regressions were performed to detect the risk factors of non- infectious fever. Results A total of 54.1% （80/148） EVAR patients suffered non-infectious fever. Fever （37.3- 38 ℃ ） was almost universally presented in 57.5% patients. And 37.5% of the patients had fever ranging from 38.1 to 39 ℃ and 5% of the patients had fever above 39℃. Increased levels of D-dimer, white blood cell count （WBC）, procalcitonin （PCT）, C-reactive protein （CRP）, operation time duration and the length of stents and decreased levels of hemoglobin were presented in the non-infectious fever group as compared to non-fever group （P〈0.005）. Multiple logistic regression analysis revealed that D-dimer （OR=2.533, P=0.031 ）, PCT （OR= 3.307, P=0.009）, operation time duration （OR=2.631, P=0.021 ） and the length of stents （OR=2.851, P=0.015） were independently associated with non-infective fever EVAR. Furthermore, we also found that the duration of stay in CCU （3.2±2.2 vs. 2.5±2.0）, hospital time （8.6±2.2 vs. 7.5±2.3） and hospitalization expense （131.2 ±30.8 vs. 120.6 ±25.9 thousand yuan） were significant different between the two groups. Conclusions Increased levels of D-dimer, procalcitonin concentration, operation duration and the length of stents are risk factors for non-infectious fever of EVAR, which may prolong the duration of stay in CCU and hospital, and increase the hospitalization expense.

The impact of single-prophylactic antibiotic dministration on post-infection and outcome of endovascular aortic repair

Background It is unclear whether the efficacy of single prophylactic antibiotic administration has an impact on infection and death in patients with Aortic Dissection of Stanford B treated by Endovascular Aortic Repair （EVAR）. Methods According to whether or not received antibiotics prophylaxis, patients were divided into two groups： the single prophylactic antibiotic group （Group A） and non-prophylactic antibiotic group （Group B）. Procalcitonin （PCT） and other clinical data were obtained with follow-up for one year. Results A total of 201 patients were screened. Among which, 70 patients received single antibiotic administration and 131 patients did not. 31（44.3%） patients had fever in group A while 81（61.8%） patients had fever in group B after EVAR （P=0.017）. The PCT and C-reactive protein （CRP） were significantly different between the two group： 0.18 ± 0.31 vs. 0.76 ± 1.18（ng/mL） （P=0. 000）, 81.35 ± 31.83 vs. 105.02 ± 60.37（mg/mL） （P=0.000）, respectively. By comparison of incidences of postoperative infection, 4（5.7%） patients were infected in Group A while 26（19.8%） patients were infected in Group B （P=0.007）. In infected group, the PCT in group A was 1.04±0.82 while that in Group B was 2.67±1.28 （P=0.015）. In non-infected group, the PCT in group A was 0.12±0.14 while that in Group B was 0.29± 0.44 （P=0.005）. Finally, One-year mortality in group A was 2（2.9%） while that in Group B （P=0.037） was 15 （11.5%）. Conclusion Single prophylactic antibiotic administration can significantly reduce the incidences of postoperative infection and affect the prognosis after EVAR.

Incidental extravascular findings in computed tomographic angiography for planning or monitoring endovascular aortic aneurysm repair: Smoker patients, increased lung cancer prevalence?

AIM To validate the feasibility of high resolution computed tomography(HRCT) of the lung prior to computed tomography angiography(CTA) in assessing incidental thoracic findings during endovascular aortic aneurysm repair(EVAR) planning or follow-up.METHODS We conducted a retrospective study among 181 patients(143 men, mean age 71 years, range 50-94) referred to our centre for CTA EVAR planning or followup. HRCT and CTA were performed before or after 1 or 12 mo respectively to EVAR in all patients. All HRCT examinations were reviewed by two radiologists with 15 and 8 years experience in thoracic imaging. The results were compared with histology, bronchoscopy or follow-up HRCT in 12, 8 and 82 nodules respectively. RESULTS There were a total of 102 suspected nodules in 92 HRCT examinations, with a mean of 1.79 nodules per patient and an average diameter of 9.2 mm(range 4-56 mm). Eightynine out of 181 HRCTs resulted negative for the presence of suspected nodules with a mean smoking history of 10 pack-years(p-y, range 5-18 p-y). Eighty-two out of 102(76.4%) of the nodules met criteria for computed tomography follow-up, to exclude the malignant evolution. Of the remaining 20 nodules, 10 out of 20(50%) nodules, suspected for malignancy, underwent biopsy and then surgical intervention that confirmed the neoplastic nature: 4(20%) adenocarcinomas, 4(20%) squamous cell carcinomas, 1(5%) small cell lung cancer and 1(5%) breast cancer metastasis); 8 out of 20(40%) underwent bronchoscopy(8 pneumonia) and 2 out of 20(10%) underwent biopsy with the diagnosis of sarcoidosis.CONCLUSION HRCT in EVAR planning and follow-up allows to correctly identify patients requiring additional treatments, especially in case of lung cancer.

Follow-up of endovascular aortic aneurysm repair:Preliminary validation of digital tomosynthesis and contrast enhanced ultrasound in detection of medium- to long-term complications

AIM: To validate the feasibility of digital tomosynthesis of the abdomen(DTA) combined with contrast enhanced ultrasound(CEUS) in assessing complications after endovascular aortic aneurysm repair(EVAR) by using computed tomography angiography(CTA) as the gold standard.METHODS: For this prospective study we enrolled 163 patients(123 men; mean age, 65.7 years) referred for CTA for EVAR follow-up. CTA, DTA and CEUS were performed at 1 and 12 mo in all patients, with a maximum time interval of 2 d.RESULTS: Among 163 patients 33 presented complications at CTA. DTA and CTA correlated for the presence of complications in 32/33(96.96%) patients and for the absence of complications in 127/130(97.69%) patients; the sensitivity, specificity, positive predictive value(PPV), negative predictive value(NPV) and accuracy of DTA were 97%, 98%, 91%, 99%, and 98%, respectively. CEUS and CTA correlated for the presence of complications in 19/33(57.57%) patients and for the absence of complications in 129/130(99.23%) patients; the sensitivity, specificity, PPV, NPV and accuracy of CEUS were 58%, 99%, 95%, 90%, and 91%, respectively. Sensitivity, specificity and accuracy of combining DTA and CEUS together in detecting EVAR complications were 77%, 98% and 95%, respectively.CONCLUSION: Combining DTA and CEUS in EVAR follow-up has the potential to limit the use of CTA only in doubtful cases.

Procalcitonin could be a reliable marker in differential diagnosis of post-implantation syndrome and infection after percutaneous endovascular aortic repair

Background Thoracic endovascular aortic repair （TEVAR） is an emerging treatment moaality, wnicn nas been rapidly embraced by clinicians treating thoracic aortic disease. However, the clinical manifestations of systemic inflammatory response after TEVAR as post-implantation syndrome （PIS） resemble the perioperative infection. This study aimed to evaluate changes and diagnostic value of procalcitonin （PCT） and other traditional inflammatory markers for infections after TEVAR. Methods We conducted a prospective clinical study that enrolled 162 consecutive aortic dissection cases. who underwent TEVAR in our institution between July 2011 and November 2012. The PCT, C-response protein （CRP）, erythrocyte sedimentation rate （ESR） and blood routine examination were monitored before the operation and on days 1, 2, 3 and 5 after the operation. The diagnosis of infection was confirmed by the infection control committee with reference to Hospital Acquired Infection Diagnostic Criteria Assessment, released by the Ministry of Health of the People＇s Republic of China. Results Post endovascular repair of thoracic aorta, PCT changes significantly at different time points （X^2= 13.225, P=0.021）, without significant difference between the PIS group and the control group （0.24±0.04 vs.0.26±0.10, P=0.804）. PCT values were significantly higher in the first day after TEVAR than the preoperative levels （0.18±0.03 vs. 0.11±0.02, P 〈0.001）. Compared with PIS patients, the level of PCT, CRP, White blood cell （WBC） and neutrophil （NEU） in the infection patients elevated significantly （relatively X2=6.062, P=0.048; X2=6.081, P=0.048; X2=11.030, P=0.004; X2=14.632, P=0.001）. According to the ROC analysis, the PCT levels in the first day after TEVAR （AUC=0.785, P=0.012） had better predictive values of infection than WBC, NEU CRP and ESR （AUC=0.720, P=0.040; AUC=0.715, P=0.045; AUC=0.663, P=0.274; AUC=0.502, P=0.991）. The best predictive index was the changes of PCT between preoperative and postoperative （PCT）, which possess AUC as 0.803 （P=0.014）. And PCT=0.055 could be considered as an infection diagnosis cutoff value with a sensitivity of 83.3% and specificity 69.0%.

Endovascular repair of thoracic aortic dissection associated with right-sided aortic arch：report of four cases

Aortic dissection involving a right-sided aortic arch（RAA）is extremely rare with an incidence in adults of 0.04%to 0.1%^（[1]）.Thoracic aortic dissection associated with RAA is even a more uncommon and life-threatening condition.For complicated aortic dissection,conventional open surgical repair is considered a standard therapy^（[2]）.However,

Effect of Intravascular Ultrasound-assisted Thoracic Endovascular Aortic Repair for ＂Complicated＂ Type B Aortic Dissection

Background： Intravascular ultrasound （IVUS） examination can provide useful information during endovascular stent graft repair. However, its actual clinical utility in thoracic endovascular aortic repair （TEVAR） for type B aortic dissection （type B-AD） remains unclear, especially in complicated aortic dissection. We evaluated the effect of IVUS as a complementary tool during TEVAR. Methods： From September 2011 to April 2012, we conducted a prospective cohort study of 47 consecutive patients with ＂complicated＂ type B-AD diagnosed. We divided the patients into two groups： 1VUS-assisted TEVAR group and TEVAR using angiography alone group. The general procedure of TEVAR was performed. We evaluated the per±operative and follow-up events. Patient demographics, comorbidities, preoperative images, dissection morphology, details of operative strategy, intraoperative events, and postoperative course were recorded. Results： A total of 47 patients receiving TEVAR were enrolled. Among them （females, 8.51%; mean age, 57.38 i 13.02 years）, 13 cases （27.66%） were selected in the IVUS-assisted TEVAR group, and 34 were selected in the TEVAR group. All patients were symptomatic. The average diameter values of IVUS measurements in the landing zone were greater than those estimated by computed tomography angiography （31.82 ± 4.21 mm vs. 30.64 ± 4.13 ram, P 〈 0.001）. The technique success rate was 100%. Among the postoperative outcomes, statistical differences were only observed between the IVUS-assisted TEVAR group and TEVAR group for total operative time and the amount of contrast used （P = 0.013 and P 〈 0.001, respectively）. The follow-up ranged from 15 to 36 months for the IVUS-assisted TEVAR group and from 10 to 35 months for the TEVAR group （P = 0.646）. The primary endpoints were no statistical difference in the two groups. Conclusions： Intraoperative IVUS-assisted TEVAR is clinically feasible and safe. For the endovascular repair of ＂complicated＂ type B-AD, IVUS may be helpful for understanding dissection morphology arid decrease the operative time and the amount of contrast used.