Jacobs, Christopher

Introduction Endovascular abdominal aortic aneurysm repair (EVAR) is the primary treatment for abdominal aortic aneurysm (AAA). Despite favorable early outcomes, lifelong surveillance is essential as endoleaks remain a major cause of reintervention. Among these, type II endoleaks (T2E) remain controversial regarding optimal management. This study aimed to identify factors associated with intervention for T2E using time-to-event analysis and predefined anatomic thresholds. Secondary objectives included comparing outcomes between T2E patients with (intT2E) and without (nointT2E) intervention. Methods A retrospective review of EVAR procedures from 2011-2024 was performed. Patients with newly diagnosed or persistent T2E were identified on completion and follow-up CT angiography. Patients were categorized as intT2E or nointT2E. Multivariable Cox regression evaluated time to first intervention, and logistic regression served as sensitivity analysis. Kaplan-Meier curves assessed freedom from intervention by inferior mesenteric artery (IMA) size. Results Among 207 EVAR patients, 78 (37.6%) developed T2E over a mean 3.4 ± 2.4 years. Nineteen (24.3%) required intervention. IntT2E patients were younger (74.9 ± 6.8 vs 78.3 ± 7.9 years, P = 0.02), had more frequent anticoagulation use (47.4% vs 20.3%, P = 0.02), larger IMAs (4.2 ± 0.6 vs 3.3 ± 0.7 mm, P < 0.01), and more lumbar arteries (6.0 ± 1.2 vs 5.0 ± 1.3, P = 0.02). IMAs >4 mm occurred in 68.4% of intT2E vs 8.5% of nointT2E ( P < 0.01). Mean sac growth was greater in intT2E (9.7 ± 5.3 mm vs −1.9 ± 6.5 mm, P < 0.01). Thirty-day complications following the index EVAR procedure, mid-term reinterventions, and overall mortality were similar between groups. Post-embolization, T2E resolved in 36.9%, with sac regression in 63.1%. Among embolized patients, 26.3% required a second embolization and one patient required 3 attempts without achieving resolution. IMA >4 mm independently predicted intervention (HR 7.18, 95% CI 1.97-26.16, P < 0.01). Logistic regression confirmed IMA >4 mm (OR 23.4, 95% CI 6.17-88.6, P < 0.01), >6 lumbar arteries (OR 4.2, 95% CI 1.10-15.98, P = 0.02), and anticoagulation (OR 3.4, 95% CI 1.17-10.6, P = 0.02) as predictors. Conclusions Approximately one-quarter of T2E patients required embolization. IMA >4 mm was the strongest predictor of intervention, while anticoagulation and increased lumbar artery number also increased risk. Management should prioritize risk-stratified surveillance and selective intervention.

Background: Patients with abdominal aortic aneurysms (AAA) often have comorbidities that make them poor candidates for open surgical repair (OSR). Endovascular aortic aneurysm repair (EVAR) circumvents the morbidity associated with OSR of AAA. Candidacy for EVAR is impacted by multiple factors, including the quality and size of vascular access vessels and involvement of visceral arteries, as seen in paravisceral abdominal aortic aneurysms (PVAAA). Additional challenges, such as obesity, can complicate vascular access during EVAR. PVAAA may be better suited for fenestrated EVAR (FEVAR) using a physician-modified endograft (PMEG). Materials and Methods: In this report, we describe the case of a 64-year-old female patient with a complex PVAAA in the setting of significant aortoiliac occlusive disease (AIOD) with intermittent claudication. We describe a successful staged FEVAR technique in which vascular access challenges were first addressed by recanalization of the iliac system with femoral conduit (FC) creation, followed by successful FEVAR using bilateral FC for deployment of the PMEG. Conclusion: Patients with PAAA have unique and complex pathology that are clinically challenging to address. It is not uncommon that these patients also have co-morbid conditions that make them less-than ideal candidates for open repair. Patients may also have other conditions such as AIOD which make EVAR complex. Staged approach with iliac recanalization and femoral conduit creation followed by FEVAR with PMEG is an effective treatment option for high-risk complex patients and can help avoid common complications such as groin infection and delay in FEVAR which may result in a catastrophic event such as interval AAA rupture.

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.

Vascular surgery has evolved from durable yet invasive open reconstructions to less traumatic endovascular techniques. While endovascular repair reduces perioperative morbidity, it introduces durability challenges and the need for lifelong surveillance. Laparoscopic surgery bridged some gaps but was hindered by steep learning curves and technical limitations. Robotic-assisted surgery represents a “third revolution”, combining the durability of open repair with the recovery and ergonomic benefits of minimally invasive approaches through enhanced 3D visualization, wristed instrumentation, and tremor filtration. This review synthesizes current evidence on robotic applications in vascular surgery, including aortic, visceral, venous, and endovascular interventions. Feasibility of robotic vascular surgery has been demonstrated in over 1500 patients across aortic, visceral, venous, and decompression procedures. Reported outcomes include pooled conversion rates of ~5%, 30-day mortality of 1–3%, and long-term patency rates exceeding 90% in aortoiliac occlusive disease. Similarly favorable outcomes have been observed in AAA repair, visceral artery aneurysm repair, IVC reconstructions, renal vein transpositions, and minimally invasive decompression procedures such as median arcuate ligament and thoracic outlet syndromes. Endovascular robotics enhances catheter navigation precision and reduces operator radiation exposure by 85–95%, with multiple series demonstrating consistent benefit compared to manual techniques. Despite these advantages, adoption is limited by high costs, lack of dedicated vascular instruments, absent haptic feedback on most platforms, and the need for standardized training. Most available evidence is observational and from high-volume centers, highlighting the need for multicenter randomized trials. Future directions include AI-enabled planning and augmented-reality navigation, which are the most feasible near-term technologies since they rely largely on software integration with existing systems. Other advances such as microsurgical robotics, soft-robotic platforms, and telesurgery remain longer-term developments requiring new hardware and regulatory pathways. Overcoming barriers through collaborative innovation, structured training, and robust evidence generation is essential for robotics to become a new standard in vascular care.

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.