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Patients with peripheral artery disease (PAD) have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic and undiagnosed. Coronary computed tomography angiography (CTA)-derived quantitative plaque analysis (CT-QPA) and fractional flow reserve (FFRCT) are established predictors of cardiovascular death in patients with symptomatic CAD. However, their prognostic value in patients with PAD with no symptoms of CAD undergoing peripheral vascular surgery is unknown. This study assessed the value of CT-QPA and FFRCT in predicting 5-year mortality in patients with vascular surgery with no known CAD. Patients with PAD with no evidence of CAD who were cleared for elective peripheral vascular surgery were enrolled in a prospective study of preoperative CTA and FFRCT to evaluate cardiac risk. Lesion-specific coronary ischemia was defined as FFRCT ≤ 0.80, with severe ischemia defined as FFRCT < 0.75. CT-QPA analysis provided quantitative data on total plaque volume (TPV) and plaque characteristics. Vascular surgery was performed on all patients with no perioperative mortality. Postoperatively, all patients received guideline-directed medical therapy with no elective coronary revascularization. The primary endpoint was all-cause death at 5 years, assessed by Cox regression analysis. Among 124 patients with PAD with no cardiac history or symptoms (mean age, 67 ± 8 years; 76% men), coronary plaque burden was high (median [TPV] 550 mm3 [IQR, 299-1156]), and 53% had asymptomatic (silent) coronary ischemia (FFRCT ≤ 0.80). During a 5-year follow-up, 32 patients (26%) died. Nonsurvivors had nearly twofold higher TPV compared with survivors (975 vs 458 mm3; P < .001), with significant increases in calcified (P < .001), noncalcified (P < .001), and low-attenuation plaque (P = .038). Five-year mortality in patients with TPV > 750 mm3 was 46% compared to 4% in those with TPV < 250 mm3 (log-rank P < .001). Both TPV ≥ 550 mm3 (hazard ratio, 3.6; 95% confidence interval, 1.6-7.9; P = .002) and FFRCT ≤ 0.80 (hazard ratio, 2.1; 95% confidence interval, 1.0-4.5; P = .045) were predictors of increased mortality risk. Five-year mortality in patients with both high plaque and coronary ischemia was 42% compared with only 10% in patients with low plaque and no ischemia (log-rank P = .006). In patients with PAD with no known CAD undergoing elective vascular surgery, coronary plaque burden and silent coronary ischemia detected by CT-QPA and FFRCT were predictors of a 5-year mortality. Coronary CTA with quantitative plaque and FFR analysis should be considered for comprehensive cardiac risk stratification in patients with vascular surgery, regardless of cardiac symptoms.
Seroma formation after common femoral artery (CFA) exposure is a recognized complication in vascular surgery, associated with delayed wound healing and graft-related morbidity. Reported seroma rates following CFA exposure using standard electrocautery range from 5% to 15% for cases requiring operative reintervention. The LigaSure bipolar vessel sealing system has demonstrated efficacy in sealing lymphatic channels in other surgical specialties, but its safety and impact in vascular groin surgery have not been well-characterized. We evaluated the safety, feasibility, and postoperative outcomes associated with LigaSure use during CFA exposure. We conducted a retrospective cohort study of consecutive patients undergoing open CFA exposure using LigaSure at a tertiary vascular referral center between June 2023 and November 2025, excluding any trauma cases. Demographic, clinical, operative, and postoperative outcome data were abstracted from the electronic medical record. The primary outcome was postoperative seroma formation, with clinical significance defined as the need for procedural or operative reintervention. Secondary outcomes included hematoma, surgical site infection, and fat necrosis. Observed outcome rates were descriptively compared with historically reported seroma rates after femoral artery exposure. Postoperative follow-up occurred during the index hospitalization and at scheduled outpatient visits. Twenty-eight patients were included. Cardiovascular comorbidities were prevalent: hypertension (86%), hyperlipidemia (75%), and diabetes (50%). Four patients (14.3%; 95% confidence interval [CI], 4.03%-32.67%) developed postoperative fluid collections: two seromas (7.1%; 95% CI, 0.88%-23.50%) and two hematomas (7.1%; 95% CI, 0.88%-23.50%), comparable with historically reported seroma rates of 5% to 15% after standard electrocautery. Critically, no patients required procedural drainage, operative reintervention, or graft excision, and no graft infections or fat necrosis were observed. Only one case of skin infection and one case of skin necrosis were noted. All fluid collections resolved with conservative management, yielding a final rate of 0% for seroma requiring operative reintervention. LigaSure use during CFA exposure was safe and feasible, with postoperative seroma rates comparable with those historically reported for standard electrocautery. Notably, 0% of seromas required procedural or operative reintervention, an important clinical consideration given the morbidity often associated with groin seromas in vascular surgery. Although a decrease in seroma incidence was not observed relative to historical benchmarks, the favorable safety profile and absence of clinically significant lymphatic complications requiring operative reintervention support LigaSure as a reliable adjunct for groin dissection. Larger prospective comparative studies are needed to further define its impact on clinically meaningful groin wound outcomes.
Bariatric artery embolization (BAE) is a minimally invasive therapy for obesity that has primarily been described with postprocedural inpatient monitoring. Whether this procedure can safely be performed without mandatory inpatient monitoring remains unknown. We, therefore, herein report on a retrospective case series evaluating the safety and feasibility of BAE in an ambulatory, vascular surgery office-based setting. As such, six consecutive patients with class II obesity or greater underwent BAE at a single QUAD A-accredited office-based laboratory between December 2024 and August 2025. Five patients were female with a median age of 71 (range, 50-82) and a median body mass index of 42.6 (range, 35.2-49.3). Technical success, defined as cessation of flow within the targeted gastric fundal arteries on completion angiography, was achieved in all. Procedural success, defined as same-day discharge without unplanned hospitalization, was achieved in all. No adverse events of Society of Interventional Radiology grade 1 or higher were observed during the median follow-up duration of 9 months (range, 4-15 months). These findings suggest that BAE can be performed safely and feasibly in an ambulatory, office-based setting in appropriately selected patients, supporting further prospective evaluation of the outpatient BAE model.
To demonstrate perioperative outcomes and short-term follow-up from a single-center experience using extra-anatomic carotid bypass and subsequent thoracic endovascular aortic repair using the Gore TAG thoracic branched endoprosthesis for the repair of proximal aortic arch pathologies with a zone 0 landing. This retrospective single-center case series reviews consecutive patients with zone 0 aortic pathology treated between October 2023 and December 2025. Patients were determined to be high risk for open intervention by a multidisciplinary board of cardiovascular and vascular surgeons who reviewed each case independently. All patients underwent a staged hybrid approach consisting of extra-anatomic carotid bypass followed by zone 0 thoracic endovascular aortic repair using the Gore TAG thoracic branched endoprosthesis. The primary outcome was technical success, defined as complete exclusion of aortic pathology with patent bypass grafts. Secondary outcomes included 30-day mortality, major adverse events, and early reintervention. Twenty-two consecutive patients (mean age, 66.7 years; 72.7% male) were treated. Indications included residual type A dissection after earlier open repair (50%), aortic arch aneurysm (27.3%), acute dissection (18.2%), and pseudoaneurysm (4.5%). Technical success was achieved in 100% of cases. Thirty-day mortality was 9.1% (2/22). Major adverse events included stroke in one patient (4.5%) and respiratory failure in two patients (9.1%). Dysphagia occurred in 27.3% and was self-limited in most cases. Early endoleaks were identified in 22.7%, with one requiring reintervention. A staged hybrid approach using extra-anatomic bypass and zone 0 thoracic branched endograft repair is feasible and reproducible in high-risk patients, with favorable short-term outcomes and acceptable morbidity.
Aortic remodeling after thoracic endovascular aortic repair (TEVAR) for complicated type B aortic dissection remains insufficiently characterized, particularly when the Provisional ExTension To Induce COmplete ATtachment (PETTICOAT) technique is applied. This study evaluated early geometric remodeling of the true and false lumens and the whole aorta following TEVAR with PETTICOAT using patient-specific computational modeling. A single-center retrospective review of 20 patients (16 men; age, 65 ± 11 years; nine acute, seven subacute, and four chronic) with type B aortic dissection treated with TEVAR and PETTICOAT was performed. Pre- and postintervention computed tomography angiography was used to extract centerlines and cross-sectional measurements along the entire aorta. Patient-specific computational simulations quantified changes in aortic arclength, curvature, cross-sectional area, and circumference across the ascending aorta, arch, descending thoracic aorta, and abdominal aorta. Remodeling was assessed by comparing geometric parameters from preoperative and the first available postoperative computed tomography angiography (mean interval from surgery, 82 ± 305 days; median, 14 days). In the first 30 days, one patient died, and the rest were free from reintervention. False lumen thrombosis was documented in 10 patients (50%) during early (<30 day) imaging and in 14 patients (70%) within 24-month surveillance. TEVAR with PETTICOAT produced significant true lumen expansion, including reduced curvature in the aortic arch and descending thoracic aorta (P < .05), and increased abdominal aortic arclength (13.1 ± 2.6 to 13.8 ± 2.3 cm; P < .05). True-lumen circumference increased at the arch (10.1 ± 1.7 to 10.5 ± 1.4 cm), descending thoracic aorta (7.1 ± 1.2 to 9.1 ± 1.2 cm), and abdominal aorta (5.7 ± 1.0 to 6.5 ± 1.0 cm; P < .05). The whole aorta circumference increased only in the descending thoracic segment (P < .05), whereas the false lumen cross-sectional area showed no significant change. TEVAR with the PETTICOAT technique results in measurable geometric remodeling in the first 30 days, most pronounced within the true lumen across thoracic and abdominal segments. Whole aorta and false lumen changes were limited, suggesting a preferential true lumen response to intervention.
Clinical presentation and operative outcomes in vascular Ehlers-Danlos syndrome (VEDS) are heterogeneous. We present two patients with genetically confirmed VEDS who exhibited markedly different iliac pathology phenotypes. One ruptured a common iliac artery at a near-normal diameter and the other tolerated a large aortoiliac aneurysm without rupture. The Aortic and Arterial Vulnerability Spectrum is a conceptual framework that characterizes aortic and arterial failure (dissection/rupture) along a continuum of underlying tissue vulnerability, integrating extracellular matrix (ECM) ultrastructure and clinical phenotypes beyond traditional diameter-based models. Using ultrastructural analysis of skin biopsy as a window into arterial integrity, we demonstrate distinct differences in ECM organization that paralleled the vascular phenotypes. Viewed through the Aortic and Arterial Vulnerability Spectrum, these cases show how genotype-driven vulnerability shapes surgical phenotype in VEDS and highlight ultrastructural skin analysis as a tool for ECM assessment and possibly biologic risk stratification.
Compared with the traditional open approach, minimally invasive vascular surgery techniques may offer benefits to patients undergoing lower-extremity arterial reconstruction. We sought to determine whether endoscopically-assisted in-situ lower-extremity bypass for chronic limb-threatening ischemia is as safe and effective as traditional approaches. From 2021 to 2024, we performed a retrospective cohort study of endoscopically-assisted femoropopliteal or femorotibial bypass on 10 patients in an academic hospital in Ontario, Canada. Patients were selected based on the presence of Rutherford grade 4 to 6 ischemia and anatomic suitability for in-situ bypass, aged over 18 years, and ability to tolerate surgery; no patients withdrew from the study but one died of unrelated causes before reaching the 1-year mark after surgery. We recorded patient demographics such as medical comorbidities (such as diabetes and coronary artery disease). We also documented outcomes (such as 1-year amputation-free survival, major adverse cardiac or limb events, and major revascularization). Follow-up with arterial duplex scanning was performed at 1 and 3 months, and then yearly after surgery; data were collected up to 1 year after surgery. The mean age of patients was 72.4 years, with 70% males. The amputation-free survival at 1-year was 80%. The 30-day mortality was 0.0%, whereas the 1-year mortality was 10.0%, with the only mortality being secondary to a new diagnosis of gastric cancer. At 1-year follow-up, the primary, primary-assisted, and secondary patency rates were 66.7%, 88.9%, and 100%, respectively. There were no major adverse cardiac events at 30-day or 1-year. No postoperative bleeding events requiring intervention or residual arteriovenous fistulas were identified on surveillance imaging. The median hospitalization length of stay was 4.4 days (1-11). Our outcomes suggest that endoscopically-assisted lower-extremity bypass for chronic limb-threatening ischemia is safe and effective in a select patient population with chronic limb-threatening ischemia.
Contralateral gate cannulation of the distal bifurcated component during thoracoabdominal branched endovascular repair can be challenging in patients with previous endovascular aneurysm repair (EVAR) because multiple indwelling and newly implanted stent graft components may crowd the distal aortic field and obscure wire behavior. We describe a trilumen catheter-assisted contralateral gate precannulation (TRIP) technique for distal bifurcated component during thoracoabdominal branched endovascular repair. A 81-year-old man presented 7 years after infrarenal EVAR with a type IA endoleak from a previous suprarenal fixation stent graft. Because of his operative risk, off the shelf endovascular thoracoabdominal branched endovascular repair was selected. After establishment of through-and-through access, placement of the aortic component, and completion of visceral branch stenting, attention was turned to distal bifurcated component deployment using the TRIP technique. Before deployment of the distal bifurcated component, a trilumen catheter was advanced from the upper-extremity sheath to the ipsilateral femoral sheath over the existing through-and-through wire. A 0.014-inch wire was introduced through the trilumen catheter and passed through the removable guidewire tube of the distal bifurcated component to precannulate the contralateral gate. After deployment of the distal bifurcated component, a 7F, 75-cm-long sheath was advanced over the precannulated wire through the contralateral gate. A 0.035-inch buddy wire was then introduced, snared from the contralateral femoral access, and exchanged to establish secure through-and-through access for contralateral limb delivery. The TRIP technique enabled confident contralateral gate access despite a crowded distal aortic configuration and may be useful during thoracoabdominal branched endovascular repair for type IA endoleak after previous EVAR when conventional gate cannulation is expected to be difficult.
A 75-year-old man with recurrent hemispheric stroke was found to have severe tandem cervical and intracranial internal carotid artery (ICA) stenoses and a hostile aortic arch. Transcarotid artery revascularization with flow reversal enabled safe carotid access for angioplasty and stenting of the cervical and intracranial ICA through the same access. Imaging confirmed excellent luminal restoration without complications, and follow-up ultrasound study showed <50% residual stenosis of the cervical ICA along with no new neurologic symptoms. This case demonstrates that transcarotid artery revascularization can facilitate single-session multilevel carotid revascularization in high-risk patients, offering a safe strategy when transfemoral access is unfavorable.
Intraluminal thrombus (ILT) is increasingly recognized as a dynamic factor in abdominal aortic aneurysm (AAA) progression. It can play a dual role-providing mechanical cushioning while simultaneously destabilizing the aortic wall through its biochemical activity. Fissuring and bleeding within the ILT remain underinvestigated but may serve as early indicators of wall failure, independent of aneurysm size. Our aim was to propose a novel biology-driven framework-the PACS-ILT classification (Proteolytic Activity and Clinical Stability of Intraluminal Thrombus)-to refine the assessment of rupture risk by integrating thrombus biology, imaging characteristics, and patient-specific factors. A targeted literature review of biomechanical and biochemical studies was conducted to inform the development of the PACS-ILT system. The weighting of individual parameters was guided by their reported impact on aortic wall vulnerability. The analysis indicates that diameter-based risk assessment alone does not capture the local pathophysiological changes of the aortic wall. Two key controllers of rupture risk beyond size were identified: (1) biomechanical effects, in which ILT thickness and morphology significantly influence wall stress distribution; and (2) biochemical effects, in which proteolytic activity, including matrix metalloproteinases and imbalances in their inhibitors, contributes to mural degradation. Integrating these findings with established clinical risk factors, the PACS-ILT algorithm stratifies rupture risk on a 1 to 5 scale (P1-P5). Scores are assigned across four domains: Geometric (G), Morphologic (M), Biochemical (B), and Clinical (C). A key insight is the recognition of "proteolytic hyperactivity" within thin ILTs, which may explain early rupture in small AAAs. Conversely, some larger aneurysms may remain relatively stable due to the "thrombus paradox," where a thick, mature ILT serves as a mechanical shield. PACS-ILT provides a conceptual, hypothesis-generating framework that moves AAA risk assessment beyond size alone toward a more dynamic, biology-informed approach. Future validation-incorporating computed tomography-based morphology, fluid-structure interaction, and computational fluid dynamics simulations-is required to confirm its utility in identifying "small-but-unstable" aneurysms and preventing catastrophic rupture.
Type II endoleaks are the most common complication after endovascular aneurysm repair typically arising from mesenteric and lumbar inflow vessels, whereas alternative collateral sources are less frequently recognized. We report a case of a deep circumflex iliac artery-mediated collateral causing persistent sac perfusion, identified on preprocedural imaging and confirmed angiographically. Targeted coil embolization resulted in occlusion of the culprit pathway with resolution of sac opacification. Follow-up imaging demonstrated a separate endoleak from a distinct collateral source without sac enlargement, consistent with flow redistribution. These findings highlight the importance of evaluating atypical collateral pathways.
Suitability of renal-mesenteric target arteries is an essential criterion for fenestrated-branched endovascular aortic repair (FB-EVAR). We describe a staged adjunctive technique of target vessel false lumen (FL) embolization to improve suitability for FB-EVAR in patients with chronic postdissection thoracoabdominal aortic aneurysms (PD-TAAA) and dissection extension into the superior mesenteric artery (SMA). Three patients with SMA dissection and ectasia (diameter > 12-14 mm) underwent staged FL embolization with pre-emptive stent placement to optimize SMA incorporation. Using bilateral transfemoral access with intravascular ultrasound guidance, the proximal SMA true lumen was stented with an 8 L × 39 mm VBX balloon-expandable stent graft (W. L. Gore & Associates) coupled with a 14 × 60 mm bare-metal self-expandable stent extending past the dissection flap reentrance. The SMA FL was then embolized using 15 mm IMPEDE-FX polymer plugs (Shape Memory Medical), followed by postdilatation with a 12 to 14 mm angioplasty balloon. FB-EVAR was completed as a second-stage procedure without complications. Follow-up computed tomography angiography confirmed successful target vessel incorporation without endoleak in all three patients. Staged adjunctive target vessel FL embolization is technically feasible and improves suitability for FB-EVAR in patients with postdissection thoracoabdominal aortic aneurysms and dissected SMA. Larger series and longer follow-up are needed to assess durability and secondary complications.
Inferior mesenteric artery (IMA) aneurysms are rare visceral artery aneurysms. We present the case of a 65-year-old man with multiple comorbidities who presented with rectal bleeding and was found to have a 7 cm IMA aneurysm with an associated IMA inferior mesenteric vein arteriovenous fistula. Given the aneurysm size and rupture risk, the patient underwent successful endovascular coil embolization with complete occlusion of the aneurysm and fistula on completion angiography. This case highlights the rare coexistence of an IMA aneurysm and an IMA inferior mesenteric vein arteriovenous fistula, for which the temporal and causal relationship remains uncertain, and supports the efficacy of endovascular coil embolization in high-risk patients.
Suture-mediated closure devices have enabled totally percutaneous endovascular aneurysm repair (EVAR). Although hemorrhagic access-site complications are well recognized, closure-device related common femoral artery (CFA) stenosis or dissection is less well described. We report the use of an endovascular bailout strategy for these complications and assess midterm outcomes. Between 2018 and 2023, a total of 751 consecutive percutaneous EVAR procedures were performed at a single tertiary center. Closure-device malfunction occurred in 66 cases (8.7%). Ten patients, representing 12 limbs (approximately 1.3% of all procedures), developed focal, flow-limiting CFA stenosis or dissection with controllable bleeding and were treated using an endovascular approach. Data were analyzed retrospectively from an institutional registry. Device selection was based on lesion characteristics. Technical success was achieved in all cases. Bare stents were used for focal dissection or intimal flap without bleeding, whereas covered stents were used in the presence of arterial injury or contrast extravasation. At a median follow-up of 2.5 years (interquartile range, 1.6-3.5 years), imaging, mainly computed tomography angiography, showed 100% primary patency. No clinically significant restenosis or occlusion was observed. Most other closure-device failures in the cohort were managed with adjunctive hemostasis or open repair, indicating that this group represents a specific subset of complications. Closure-device related CFA stenosis or dissection is an uncommon but distinct complication after percutaneous EVAR. When the lesion is focal, endovascular bailout can restore flow effectively and avoid surgical exploration. This approach fits within routine EVAR practice and provides durable results at midterm follow-up.
Chronic venous disease (CVD) of the lower extremities is associated with venous hypertension, leading to symptoms such as leg pain, heaviness, edema, and nocturnal cramps. These symptoms often worsen at night and may significantly impair sleep quality. Although endovenous ablation effectively relieves venous symptoms, its impact on sleep remains insufficiently investigated. This study aimed to assess the prevalence of poor sleep quality in patients with lower extremity CVD before and 1 month after endovenous ablation and to analyze changes in both global and component Pittsburgh Sleep Quality Index (PSQI) scores. A prospective observational study with a longitudinal pre-post design was conducted in 77 patients with lower extremity CVD undergoing endovenous ablation. Clinical severity and symptom burden were assessed using the Visual Analog Scale, Venous Clinical Severity Score, and Clinical, Etiologic, Anatomic, and Pathophysiologic classification. Sleep quality was evaluated using the PSQI. Assessments were performed at baseline and at 1-month follow-up. Changes between time points were analyzed using paired t-tests, Wilcoxon signed-rank test, and McNemar test. Among 77 patients with CVD, sleep quality improved significantly after endovenous ablation. The median PSQI score decreased from 6 (interquartile range, 5-10) at baseline to 5 (interquartile range, 4-7) at 1 month (P < .001). The proportion of patients with poor sleep quality (PSQI > 5) declined from 66.2% to 41.6%. Significant improvements were observed in subjective sleep quality, sleep latency, sleep duration, sleep disturbances, and daytime dysfunction, whereas habitual sleep efficiency and use of sleep medication did not change significantly. Endovenous ablation, frequently combined with phlebectomy, was associated with early improvements in sleep quality. However, given the observational design and lack of a control group, these findings should be interpreted with caution. The parallel reductions in Visual Analog Scale, Venous Clinical Severity Score, Clinical, Etiologic, Anatomic, and Pathophysiologic classification, and PSQI suggest that sleep impairment in CVD may reflect overall symptom burden rather than an independent disorder. Longer-term controlled studies incorporating objective sleep measures are warranted to confirm the durability and underlying mechanisms of these effects.
Iatrogenic innominate artery cannulation during subclavian central venous access is rare but potentially life-threatening, particularly when occurring near the carotid-subclavian bifurcation. A 76-year-old man with polytrauma-sustained inadvertent right subclavian-innominate cannulation. Standard catheter removal carried a high risk of uncontrolled hemorrhage. Endovascular repair was performed using a kissing-stent technique: a Gore Excluder iliac extension limb (W. L. Gore & Associates; 16 × 14.5 mm) was deployed via brachial access, and a 9-mm VIABAHN stent (W. L. Gore & Associates) was used off-label in the carotid artery and reinforced proximally with a balloon-expandable bare-metal stent. Completion angiography confirmed patency and exclusion of the entry site. Kissing-stent deployment, including the novel use of the Gore Excluder limb, safely preserved branch perfusion, ensured durable seal, and avoided sternotomy.
Tracheoinnominate fistula (TIF) is a rare but frequently fatal complication of tracheostomy. This study aims to describe a case series of TIFs associated with high-riding innominate arteries and bovine arch anatomy, and highlight anatomic variants as under-recognized risk factors that may warrant modified perioperative planning and surveillance. A focused literature review was conducted to contextualize known risk factors, operative approaches, and management strategies for TIFs. This retrospective case series at a single institution reviews three patients at risk for development of TIFs with one case of established TIF. Clinical presentation, imaging findings, arch anatomy, operative management, and outcomes were analyzed. All three patients demonstrated bovine arch anatomy with a high-riding innominate artery traversing the trachea at a more cephalad level than typical anatomy. Two patients presented with sentinel bleeding or tracheal erosion suggestive of impending TIF and were successfully managed with early surgical intervention, vascular control, and tissue interposition. One patient presented with a fully developed TIF and catastrophic hemorrhage requiring emergent innominate artery ligation and tracheal debridement, ultimately resulting in mortality. Imaging demonstrated loss of the normal fat plane between the trachea and innominate artery, correlating with intraoperative findings. Bovine arch anatomy may represent an underappreciated anatomic risk factor for TIF development due to its association with a high-riding innominate artery. Routine review of preoperative imaging, heightened surveillance, and consideration of preventative strategies in high-risk patients may improve early detection and reduce morbidity and mortality associated with this catastrophic complication.
Aortobronchial fistula is a rare but life-threatening cause of hemoptysis. We report the case of a 68-year-old man who developed an aortobronchial fistula 38 years after undergoing open repair of a blunt thoracic aortic injury from a plane crash. Initial thoracic endovascular aortic repair was performed covering the area of the previous open repair (zones III/IV) where fistulas typically form; however, persistent symptoms required extension with subsequent resolution of hemoptysis. Six years later, a suspected endograft infection following bronchitis was managed with antibiotics and chronic suppressive therapy. At 9-year follow-up, he remains stable. This case highlights the diagnostic challenges and late infection risk and supports thoracic endovascular aortic repair as a treatment option in selected high-risk patients.
Complex endovascular aortic repair (EVAR) frequently requires simultaneous femoral and upper-extremity access, particularly during multibranched endograft implantation, branched thoracic EVAR, and other procedures requiring target-vessel catheterization from the arm. In hybrid operating rooms, the arm-side operator often has a limited or obstructed view of the primary fluoroscopy monitor because of the image intensifier, patient position, equipment, radiation shielding, or distance from the main display. Although secondary monitors can be used, they may be small, poorly positioned, or difficult to align with the operator's working angle. We describe a simple wearable headset-assisted fluoroscopic visualization technique using commercially available components, including XREAL One Pro glasses (XREAL, Inc), a wireless high-definition multimedia interface transmission module, and a digital visual interface-to-high-definition multimedia interface connector. The system allows the live fluoroscopic image to be displayed as an individualized virtual monitor within the operator's field of view while preserving awareness of the operative field through a see-through display and adjustable shading. The headset can provide a stable three-degree-of-freedom or six-degree-of-freedom image as needed. This technique may be particularly useful for the arm-side operator during multibranch endograft procedures or branched thoracic EVAR, where precise wire, catheter, sheath, and bridging stent manipulation is required. Wearable headset-assisted fluoroscopic visualization may simplify hybrid operating room setup, reduce dependence on monitor positioning, and improve operator ergonomics. Further evaluation is needed to assess its effect on procedure efficiency, fluoroscopy time, radiation exposure, operator workload, and safety.
Thoracic endovascular aortic repair (TEVAR) is the preferred intervention for thoracic aortic pathology, offering favorable outcomes compared with open repair. Aortic graft infolding, although rare with an incidence of 0.4% to 3%, can pose significant clinical challenges. We present three patients who developed infolding post-TEVAR using the Terumo Relay Pro endograft, detailing their presentation, management, and outcomes. This case series, along with a review of the literature, provides insight into aortic endograft infolding after TEVAR and helps refine the risk stratification and management protocols.