Vandenberg, Jonathan

Objective To evaluate outcomes in patients with type 2 endoleak (T2E) and the impact of treatment outside the device instructions for use (IFU). Methods This retrospective single-center study included abdominal aortic aneurysms (AAA) patients who underwent EVAR (2011- 2024). Primary outcomes were 30-day and mid-term complications, reintervention, and mortality by T2E status. Propensity score matching was applied and secondary analysis stratified outcomes by IFU compliance, comparing within ( in IFU) or outside( out IFU) IFU in each T2E group. Results Among 154 EVAR patients (137 men (89.1%) and 17 women (11.0%); mean age 77.5 ± 7.6 years), 77 were T2E(−), and 77 were T2E(+). Baseline characteristics were similar. Thirty-day complications were comparable (T2E(−): 5, 6.4% vs T2E(+): 2, 2.56%, P = 0.72). The mean follow-up duration was 2.7 ± 2.4 years. Sac diameter change (Δ) decreased in the T2E(−) (7.7 ± 8.4 mm) and enlarged in the T2E(+) (1.79 ± 12.5 mm; P < 0.01). Mid-term graft-related complications (T2E(−): 3, 3.8% vs T2E(+): 49, 62.8%, P < 0.01) and reinterventions (T2E(−): 3, 3.8%, vs T2E(+): 20, 25.6% P < 0.01) were higher in the T2E(+) with no difference in mortality ( P = 1.00). These findings remained after excluding type 1 endoleaks. Among the T2E(+), those treated out IFU had longer hospital stays ( out IFU: 3.0 ± 2.8 days vs in IFU: 1.8 ± 2.0 days, P = 0.03), higher T1E ( out IFU: 3, 33.3% vs in IFU: 1, 4.34%, P < 0.01), higher rates of reintervention ( out IFU: 9, 100.0% vs in IFU:17; 24.6%, P < 0.01) and higher all-cause mortality than those within IFU criteria ( out IFU: 5, 55.0% vs in IFU: 13, 18.8%, P < 0.01). IFU status did not significantly affect outcomes in T2E(−) patients. Conclusions T2E is associated with sac growth and increased reinterventions, but not higher mortality. On subgroup analysis, those T2E(+) treated out IFU had longer hospitalizations, higher T1E rates, more reinterventions, and higher all-cause; but not aneurysmal-related mortality.

Objective: To evaluate the efficacy of regional anesthesia (RA) in enabling arteriovenous fistula (AVF) creation in patients with small-caliber veins who would typically receive arteriovenous grafts (AVG), and to compare access outcomes between AVF and AVG cohorts. Methods: We conducted a retrospective analysis of a prospectively maintained database from 2018 through 2024 involving patients with chronic kidney disease (CKD) requiring access creation. Eligible patients were those aged 18 years or older with inadequate veins for AVF creation based on initial ultrasound vein mapping. All patients underwent RA prior to the access creation and had a repeated intraoperative vein mapping at least 30 min after RA. Patients whose veins were sufficiently dilated and met the criteria for AVF creation underwent AVF formation; otherwise, an AVG was created. Outcomes included access maturation, patency rates, access failure, abandonment, and mortality. Statistical analysis was performed using R software, with significance set at p < 0.05. Results: Of the 106 patients, 67 (63.2%) underwent AVF creation post-RA due to sufficient vein dilation, while 39 (36.8%) received AVGs. Baseline vein diameters and comorbidities were comparable between groups. AVF maturation was achieved in 83.6% of AVF patients, with longer times to successful cannulation compared to AVG (median 187.0 vs 80.0 days, p = 0.037). Kaplan-Meier analysis revealed no difference in primary patency ( p = 0.97), but AVF patients had superior primary assisted ( p = 0.015) and secondary patency ( p = 0.033), and lower access failure rates ( p = 0.034) compared to AVG patients. Access abandonment and mortality rates did not differ significantly between groups. Conclusions: RA-induced venodilation enables the use of veins previously deemed inadequate for AVF creation, leading to improved access outcomes compared to AVG placement. Implementing RA may increase AVF utilization and enhance patient outcomes in hemodialysis access surgery.

We present an 81-year-old male with an extensive past medical history and an enlarging abdominal aortic aneurysm (AAA). Axial imaging showed dense aortoiliac calcification with a complete occlusion of the right common iliac and high-grade stenosis of the left common iliac artery (CIA). Shockwave Intravascular Lithotripsy and the pave-and-crack technique utilizing an endoconduit were used to dilate the left external iliac artery and the CIA to facilitate placement of an aortic stent graft and exclude the patient’s AAA. This method gives surgeons the ability to treat patients with AAAs endovascularly, despite a heavily diseased and/or diminutive iliac anatomy. We also present a contemporary literature review of the utilization of the pave-and-crack technique as well as tips and tricks of how we do it.

Abdominal aortic aneurysm (AAA) is a significant vascular condition characterized by the dilation of the abdominal aorta, presenting a substantial risk of rupture and associated high mortality rates. Current management strategies primarily rely on aneurysm diameter and growth rates to predict rupture risk and determine the timing of surgical intervention. However, this approach has limitations, as ruptures can occur in smaller AAAs below surgical thresholds, and many large AAAs remain stable without intervention. This review highlights the need for more precise and individualized assessment tools that integrate biomechanical parameters such as wall stress, wall strength, and hemodynamic factors. Advancements in imaging modalities like ultrasound elastography, computed tomography (CT) angiography, and magnetic resonance imaging (MRI), combined with artificial intelligence, offer enhanced capabilities to assess biomechanical indices and predict rupture risk more accurately. Incorporating these technologies can lead to personalized medicine approaches, improving decision-making regarding the timing of interventions. Additionally, emerging treatments focusing on targeted delivery of therapeutics to weakened areas of the aortic wall, such as nanoparticle-based drug delivery, stem cell therapy, and gene editing techniques like CRISPR-Cas9, show promise in strengthening the aortic wall and halting aneurysm progression. By validating advanced screening modalities and developing targeted treatments, the future management of AAA aims to reduce unnecessary surgeries, prevent ruptures, and significantly improve patient outcomes.