Latest / European Society for Vascular Surgery / ESVS 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases - Part 2

Transcript

ESVS 2026 Clinical Practice Guidelines on the Management of Descending Thoracic and Thoraco-Abdominal Aortic Diseases - Part 2 · European Society for Vascular Surgery

• 0:05
  Hello and welcome back to the ESVS podcast. This
• 0:08
  is Susanne Stokmans and you are listening to
• 0:10
  part two of the Q &A series on the ESVS 2026
• 0:13
  Clinical Practice Guidelines on the Management
• 0:15
  of Descending Thoracic and Thoracobdominoaortic
• 0:18
  Diseases. In this episode, we move from the general
• 0:21
  principles discussed in part one to the C -specific
• 0:24
  management. We'll focus on acute thoracic aortic
• 0:27
  syndromes, chronic type B aortic dissection,
• 0:30
  and degenerative descending thoracic and thoracobdominal
• 0:33
  aortic aneurysms, conditions that make up a large
• 0:36
  part of daily aortic practice, where decision
• 0:38
  -making is often nuanced and time -critical.
• 0:41
  I'm very pleased to again welcome Professor Wanhainen,
• 0:44
  Dr. Fernandez -Prendes, and Professor Katsargyris
• 0:46
  Thank you and hello. Thank you. Thank
• 0:49
  you. Hello. let's start with acute type b dissections
• 0:52
  the guideline clearly maintains best medical
• 0:55
  treatment as the cortisone for uncomplicated
• 0:57
  acute type b aortic dissection with blood pressure
• 1:00
  aimed at reducing shear stress on the diseased
• 1:02
  aorta by lowering the systolic blood pressure
• 1:05
  to under 120 millimeters of mercury and maintaining
• 1:09
  a heart rate under 60 beats per minute recommendation
• 1:11
  37 plus 3a level c they said routine tvr is not
• 1:16
  indicated for uncomplicated acute type b aortic
• 1:19
  dissection outside clinical trials. Given the
• 1:22
  attention generated by trials such as ADSORB
• 1:24
  and INSTAD, which demonstrated improved aortic
• 1:27
  remodeling after early TVAR in uncomplicated
• 1:30
  acute type B dissections, some clinicians might
• 1:33
  have expected a more permissive recommendation.
• 1:35
  What were the key limitations of these trials
• 1:38
  that prevented the committee from endorsing routine
• 1:40
  early intervention? So trials like ABSORB and
• 1:43
  INSTEAD generated a lot of enthusiasm. And in
• 1:47
  some ways, it's because they showed to some extent
• 1:49
  improved overtake remodeling after TBAR. But
• 1:51
  one of the key issues is that this hasn't actually
• 1:54
  translated into a clear survival benefit. If
• 1:57
  we look at the limitations more closely, the
• 1:59
  ABSORB, although it included 17 different European
• 2:02
  countries, it was a relatively small trial with
• 2:05
  only about 60 patients and was simply underpowered
• 2:08
  to detect any differences in hard clinical endpoints.
• 2:11
  The INSTED and its long -term follow -up, the
• 2:14
  INSTED -XL, they managed to include 140 patients.
• 2:18
  And while they did show improved aortic remodeling
• 2:21
  and even signal towards fewer aortic -related
• 2:26
  deaths over time, there was no significant improvement
• 2:29
  in overall survival, even out to five years.
• 2:33
  So until we have adequately powered trials showing
• 2:37
  a clear benefit, not just in terms of aortic
• 2:40
  remodeling, but clinical endpoints for the patients,
• 2:44
  routine TVAR in uncomplicated type B aortic dissection,
• 2:48
  there is no evidence to sort of support that.
• 2:51
  Therefore, the negative recommendation. Okay,
• 2:54
  that's very clear. And are there any ongoing
• 2:56
  or upcoming trials that might realistically change
• 2:59
  this recommendation in the next guideline update?
• 3:01
  Yes. So I think this is a very exciting moment
• 3:05
  for these trials. There's currently three ongoing
• 3:09
  RCTs, the Sunday trial, the earnest trial and
• 3:12
  the improve AD. And they are based in different
• 3:17
  areas of the world. So the earnest is aiming
• 3:19
  to recruit. 470 patients, which is the lowest
• 3:23
  number of patients that they are aiming to recruit,
• 3:26
  up to 1 ,100 patients that the IMPROVE -AD is
• 3:30
  aiming to recruit. So much bigger than any of
• 3:34
  the prior trials. And the clinical endpoints,
• 3:37
  they vary. They're not the same, but they do
• 3:39
  all include mortality. to some level. So there's
• 3:43
  two that are including overall mortality, and
• 3:46
  then one which has included aortic -related mortality.
• 3:49
  So we hope that these much bigger trials with
• 3:52
  increased recruitment and hard clinical endpoints
• 3:56
  will be able to solve some of the questions regarding
• 3:59
  the role of... subacute T -bar for uncomplicated
• 4:02
  type B aortic dissection. The guideline discusses
• 4:05
  so -called high -risk features in acute type
• 4:07
  B dissection but ultimately identifies early
• 4:10
  aortic expansion or a large initial diameter
• 4:12
  as the most consistent predictors of late aneurysmal
• 4:15
  degeneration. This is reflected in Recommendation
• 4:18
  39, Class 2b, Level C. Selected patients with
• 4:22
  uncomplicated acute type B aortic dissections
• 4:25
  and suitable anatomy with early aortic expansion
• 4:27
  or large initial diameter over 4 cm may be considered
• 4:31
  for TVAR, preferably during the subacute phase.
• 4:34
  Why did other proposed markers such as false
• 4:36
  lumen diameter or entry -tier characteristics
• 4:38
  not translate into stronger or more definitive
• 4:41
  recommendations? So thank you for this question,
• 4:44
  which has caused quite a lot of controversy over
• 4:47
  the last years, I think, and has been greatly
• 4:50
  debated and discussed in various meetings. It
• 4:53
  all comes down to the evidence. And if we look
• 4:55
  at where these sort of high risk features originally
• 4:58
  come from, it's the 2020 SVS reporting standards
• 5:04
  on type B aortic dissection. And then they were
• 5:07
  also mentioned in the 2024 thoracic surgeons
• 5:10
  guidelines on on aortic pathologies. But the
• 5:13
  key question here is, would evidence exist for
• 5:17
  any of those other high -risk features? And the
• 5:20
  answer is that if you carefully look into the
• 5:23
  papers, which... prior guideline documents have
• 5:26
  sort of endorsed these high -risk features. They
• 5:28
  are based on retrospective studies, frequently
• 5:32
  with very few patients, variable endpoints, and
• 5:37
  just very inconclusive evidence. So the reason
• 5:41
  why these haven't translated into stronger or
• 5:45
  definitive recommendations is just because there
• 5:48
  is no evidence to suggest that any of these other
• 5:51
  than diameter greater than 40 millimeters, actually
• 5:54
  translates into a higher risk for the patient.
• 5:57
  And the guidelines suggest that in selected high
• 6:00
  -risk but uncomplicated patients... TFR should
• 6:02
  preferably be performed in the subacute phase
• 6:04
  rather than during the hyperacute period. From
• 6:07
  a practical standpoint, how do you define that
• 6:09
  subacute window and which factors would make
• 6:12
  you intervene earlier or conversely delay treatment
• 6:15
  even further? So the subacute period is defined
• 6:18
  as anything between 15 days and 90 days. And
• 6:21
  the thinking is that this is where patient and
• 6:24
  the lamella is going to be sufficiently stable,
• 6:27
  but not. so hard that it's not going to be sort
• 6:31
  of compliant. The reasons that would make me
• 6:34
  intervene earlier or should make somebody intervene
• 6:37
  earlier, I would say are just if the uncomplicated
• 6:41
  type B aortic dissection with maybe high risk
• 6:43
  features here progresses to a complicated type
• 6:46
  B aortic dissection. I don't think that there
• 6:48
  should be any other reason in the majority of
• 6:51
  patients to advance or do an urgent T -var or
• 6:55
  a T -var in the acute phase. unless there are
• 6:58
  signs of complication, because this has been
• 7:00
  shown to be associated with increased mortality
• 7:03
  and increased spinal cord ischemia risk. Regarding
• 7:06
  delaying a potential intervention, I think this
• 7:09
  is, as we mentioned, patient frailty, life expectancy,
• 7:13
  complexity of the required repair. I think they're
• 7:16
  all very important points to take into consideration.
• 7:19
  So one thing is thinking about doing a T -bar
• 7:21
  for a high -risk sort of 40 -millimeter aortic
• 7:24
  dissection in the subacute phase. And another
• 7:27
  thing is if you actually need to do extensive
• 7:30
  cervical debranching, for example. So those would
• 7:33
  be my things for postpartum. a repair. Before
• 7:37
  we move on, it's worth noting that the guideline
• 7:39
  also includes a dedicated section on endovascular
• 7:41
  and open surgical techniques for type B dissection,
• 7:44
  including adjunctive strategies such as false
• 7:46
  lumen management. We could easily fill an entire
• 7:48
  episode with that topic alone. We won't go into
• 7:51
  technical detail today, but it's certainly a
• 7:53
  section worth reading closely. Acute diabetes
• 7:56
  section is only one part of the acute thoracic
• 7:58
  aortic syndrome spectrum. The guideline also
• 8:01
  addresses intramural hematoma and penetrating
• 8:03
  aortic ulcer. From a practical clinical perspective,
• 8:06
  what do you see as the key differences between
• 8:08
  intramural hematoma and penetrating aortic ulcer
• 8:12
  in terms of diagnosis, initial management, and
• 8:15
  long -term follow -up? So I think those are great
• 8:17
  questions and things that we actually need more
• 8:21
  evidence on. Intramural hematoma has been defined
• 8:24
  as the presence of blood in the medial layer
• 8:26
  of the aortic wall and normally extends for a
• 8:29
  significant longitudinal part of the wall, whereas
• 8:32
  penetrating aortic ulcers are more focal disruptions
• 8:36
  of the intima and the patient population that
• 8:40
  is affected by them can vary between both of
• 8:43
  them. In terms of diagnosis, initial management,
• 8:45
  in long -term polio, I think that there is more
• 8:48
  uncertainty regarding the natural evolution of
• 8:52
  intramural hematomas. For example, reported rates
• 8:54
  of type B intramural hematoma progression in
• 8:57
  literature vary between 4 % and 50%, basically,
• 9:00
  so very large discrepancy. And I think that for
• 9:04
  both intramural hematoma and POW, when they present
• 9:07
  and if they are uncomplicated, conservative management
• 9:10
  is going to be indicated in both cases with follow
• 9:14
  -up. But the natural progression of the intramural
• 9:17
  hematoma, I feel like it's more unpredictable.
• 9:20
  Regarding penetrating aortic ulcers, I think
• 9:23
  a lot of them we see actually as incidental findings
• 9:26
  at the current moment with the amount of CTs
• 9:29
  that are being performed in asymptomatic patients.
• 9:32
  presentation can be quite different. But again,
• 9:34
  if they are uncomplicated, the initial management
• 9:38
  is going to be conservative and long -term follow
• 9:40
  -up, I think, is going to be dependent on the
• 9:43
  form of presentation and the extent of the disease
• 9:48
  or size of the penetrating aortic ulcer. In daily
• 9:52
  practice, management of intramural hematoma and
• 9:55
  POW can be challenging, especially when patients
• 9:57
  are initially treated conservatively. Which clinical
• 9:59
  or imaging features should in your most clearly
• 10:02
  lower the threshold for endovascular intervention.
• 10:05
  I think that's a great question and maybe not
• 10:07
  one that is going to be answered in the same
• 10:08
  way across different countries, maybe different
• 10:12
  positions. Obviously, I would say any signs of
• 10:15
  clinical progression. So if a patient turns from
• 10:18
  being uncomplicated to complicated or presents
• 10:20
  with subacute chest pain, thoracic pain without
• 10:23
  any other indication for it, that's an indication.
• 10:26
  And also radiological progression. So in terms
• 10:29
  of rapid growth or significant expansion or if
• 10:34
  it's an... hematoma, also just progression. Sometimes
• 10:38
  you see new sort of entry tears in the hematoma
• 10:41
  that are showing sort of activity. So I think
• 10:44
  those are all indications or aspects that can
• 10:48
  make you think about making, you know, an earlier
• 10:51
  intervention. I think the literature here is
• 10:53
  interesting and can be challenging to read. So
• 10:57
  for example, for penetrating aortic ulcer, I
• 11:00
  see papers treating a small uncomplicated pulse
• 11:04
  with excellent results. They conclude that therefore
• 11:07
  we should treat them. But I always come back
• 11:09
  to you. But was it necessary to treat? Was there
• 11:12
  an indication? And I think small, uncomplicated
• 11:15
  POWs, there are no evidence for the benefit of
• 11:18
  the patient to be treated at all. Most of all,
• 11:20
  I agree with the need of more evidence in these
• 11:23
  two pathologies. I do agree also with Anders
• 11:26
  and Carlotta, and the data are really limited
• 11:28
  in the available evidence. Obviously, if it is
• 11:32
  an uncomplicated POW, I wouldn't treat it personally,
• 11:35
  unless it showed signs becoming complicated,
• 11:39
  like... clinical deterioration and also radiological
• 11:42
  deterioration. And of course, we should not forget
• 11:45
  that the anatomy plays a role. If it is a relatively
• 11:48
  easy penetration of the culture with good proximal
• 11:51
  and ceiling zone, we can treat it with a short
• 11:53
  TIVA without having to do any cervical debranching.
• 11:56
  We may decide to be more aggressive if we have
• 11:58
  an indication. Otherwise, we may have more complex
• 12:01
  anatomies to be more kind of watchful waiting
• 12:05
  and see what happens. And recommendation 48,
• 12:08
  class 2A, level C, states that patients with
• 12:11
  complicated penetrating aortic ulcer or intramural
• 12:13
  hematoma of the thoracic aorta should be considered
• 12:16
  for TWAR. In this context, complicated includes
• 12:19
  signs of rupture, pseudoaneurysm formation, malperfusion,
• 12:23
  rapid expansion, or refractory or recurrent pain.
• 12:26
  This approach differs from acute diabetes section
• 12:29
  where complicated disease is essentially limited
• 12:31
  to rupture or malperfusion and where other so
• 12:34
  -called high -risk features play a much smaller
• 12:36
  role in triggering intervention. As we discussed
• 12:39
  earlier, could you explain why the guideline
• 12:41
  makes this distinction between these entities?
• 12:43
  Again, I will say what we were just discussing,
• 12:46
  that there is very, very little level of evidence
• 12:49
  with natural history and disease progression
• 12:51
  with both of these entities. So both of these
• 12:54
  recommendations are based on consensus. And the
• 12:57
  idea was to try and sort of limit or be as accurate
• 13:03
  as possible in terms of what complicated penetrating
• 13:07
  aortic ulcer or intramural hematoma actually
• 13:09
  is and try to in some ways limit over treatment
• 13:13
  of maybe small powers that as we discussed don't
• 13:17
  actually require an intervention just because
• 13:19
  there is very little evidence regarding the natural
• 13:23
  evolution. We need If I understand you correctly,
• 13:26
  we need more studies on conservatively managed
• 13:29
  intramural hematoma and PALS, right? Not treated,
• 13:33
  but conservatively managed and see the long -term
• 13:35
  outcome of those. I think we need to understand
• 13:38
  the natural evolution of both of these entities.
• 13:41
  And I feel that maybe intramural hematoma may
• 13:44
  be a more aggressive disease than PALS, just
• 13:47
  because of the way that we are seeing its natural
• 13:50
  presentation. And as we mentioned, penetrating
• 13:53
  aortic ulcer. A lot of them are now seen as incidental
• 13:57
  findings on CT imaging in asymptomatic patients
• 14:01
  that then, you know, you have follow up after
• 14:03
  five years, 10 years, and there is absolutely
• 14:05
  no progression. And I think this is quite frequent
• 14:09
  in our clinical practice. So, yes, absolutely,
• 14:12
  Anders. I think we need to understand the natural
• 14:14
  history of untreated intramural hematomas and
• 14:17
  PALS. That helps put the acute aortic syndromes
• 14:19
  into perspective. Let's now move on to chronic
• 14:22
  type B aortic dysplasia. section, where the challenge
• 14:24
  shifts from acute risk to long -term surveillance,
• 14:27
  timing of intervention, and patient selection.
• 14:29
  Recommendation 52, class 2A, level C, maintains
• 14:32
  a 60 mm diameter threshold for elective intervention
• 14:36
  in chronic type B dissection. Given the increasing
• 14:38
  availability and safety of advanced endovascular
• 14:41
  techniques, why did the committee decide not
• 14:43
  to lower this diameter threshold? There are some
• 14:45
  studies available on the natural history of thoracic
• 14:48
  and thoracoabdominal aortic aneurysms, suggesting
• 14:51
  that at a diameter around 6 cm, the risk of rupture
• 14:55
  increases significantly, and therefore preventive
• 14:58
  treatment should be considered at this diameter
• 15:00
  and thereafter. Obviously, endovascular techniques
• 15:03
  have evolved over the years and show very good
• 15:06
  early outcomes, but we should not forget that
• 15:09
  these techniques, especially in the case of a
• 15:11
  complex post -dissection thoracoabdominal aneurysm,
• 15:14
  complex techniques and require also often multiple
• 15:17
  interventions during follow -up. So it is clear
• 15:21
  that we need to balance also those issues against
• 15:23
  the risk of rupture of post -dissection thoracic
• 15:26
  abdominal aneurysm. And this is why, after all,
• 15:29
  we decided not to lower the threshold below six.
• 15:32
  Having said that, it is important to realize
• 15:34
  that aortic diameter alone can be influenced
• 15:37
  also by body size. Normalizing it by body surface
• 15:41
  area or body height may provide a more standardized
• 15:44
  measure of aortic size relative to an individual's
• 15:47
  body, which may be a better predictor, after
• 15:50
  all, of aortic aneurysm rupture and growth than
• 15:53
  simple aortic diameter. And this can be particularly
• 15:56
  useful in women. Thus, we have also a second
• 15:59
  recommendation, a lower diameter threshold equal
• 16:02
  or more than 5 .5 for repair that may be considered
• 16:06
  in some selected patients based on their aortic
• 16:09
  size index or in cases of significant growth.
• 16:12
  case. And the guideline discusses more complex
• 16:15
  endovascular strategies for chronic diabetes
• 16:17
  section, including fenestrated and branched repair
• 16:20
  and adjunctive techniques such as false lumen
• 16:22
  occlusion in recommendation 55 to 57. These approaches
• 16:26
  are generally supported by class 2A or 2B recommendations
• 16:30
  with level C evidence. Which of these strategies
• 16:32
  do you personally find most promising and where
• 16:35
  do you think the evidence is still too limited
• 16:36
  to justify wider adoption? The use of fenestrated
• 16:39
  and branched technology as a first -line treatment
• 16:42
  for post -disease. section for abdominal aneurysms
• 16:44
  is now recommended indeed with a class 2a recommendation
• 16:48
  and I do think that we have gradually obtained
• 16:50
  an important body of evidence from different
• 16:53
  centers around the world to be able to support
• 16:55
  such a recommendation. Outcomes are very promising
• 16:58
  at least in the early and mid term of follow
• 17:01
  -up and I do really believe that these techniques
• 17:03
  should be considered primarily for the treatment
• 17:06
  of this pathology. Now with regard to the techniques
• 17:09
  to manage and occlude the false lumen we have
• 17:12
  some data showing that they might be helpful
• 17:14
  as an adjunct to the primary management of the
• 17:17
  true lumen. And for the time being, we have a
• 17:19
  recommendation plus 2B, which is fine for now,
• 17:23
  I think, according to the data we have available.
• 17:25
  In my personal view, I think we may see an increasing
• 17:28
  use and role of these techniques in the future.
• 17:31
  And if we get more evidence about the longer
• 17:33
  -term efficacy of these false -lumen adjunctive
• 17:35
  techniques, we may even be able to change the
• 17:38
  class of this recommendation towards a stronger
• 17:41
  recommendation in the future guidelines. Let's
• 17:43
  see. I think false lumen occlusion has two benefits.
• 17:47
  It could either be part of a definitive treatment
• 17:50
  if you have a localized allotation in the thoracic
• 17:54
  aorta, or it could make it possible to stage
• 17:57
  the procedure. So you treat the most critical
• 18:00
  part first, and then you can wait maybe years
• 18:03
  before you have to extend it distally with a
• 18:06
  fenestrated device. So I agree with Thanos that
• 18:09
  you will probably see an increased use of this
• 18:11
  technique. And the guideline makes a strong class
• 18:13
  one. level C recommendation 59 for individualized
• 18:16
  long -term clinical follow -up and serial cross
• 18:19
  -sectional imaging after both endovascular and
• 18:21
  open repair of chronic type B dissection. Given
• 18:24
  the wide variation in disease extent, repair
• 18:26
  strategies, and patient fitness, how should clinicians
• 18:29
  practically tailor the intensity and duration
• 18:32
  of follow -up in daily practice? Indeed, given
• 18:34
  the high risk of late complications and disease
• 18:37
  progression requiring reinvention in these patients,
• 18:40
  long -term clinical and imaging follow -up is
• 18:43
  recommended after any type of chronic type B
• 18:46
  aortic dissection repair. And this is clear.
• 18:49
  Obviously, now we need to discuss some things.
• 18:52
  The frequency of imaging surveillance should
• 18:54
  be individualized based on factors such as extent
• 18:57
  and type of the repair, previous imaging findings,
• 19:00
  and life expectancy of every patient. We should
• 19:03
  try to find ways, obviously, to balance the risks
• 19:06
  against the benefits of frequent imaging surveillance,
• 19:09
  especially for young patients. Patients, for
• 19:11
  example, that have endovascular repair with a
• 19:14
  safe, so to say, proximal and distal landing
• 19:16
  zones, maybe in previous surgical grafts. may
• 19:19
  have, for example, less risk for later complications
• 19:23
  and may be considered for a less frequent cross
• 19:26
  -sectional imaging over time. On the other hand,
• 19:29
  patients with genetic autopathies may be more
• 19:32
  prone to progression of disease and we may need
• 19:34
  to restrict our surveillance protocol for these
• 19:37
  patients. Having said that, we need especially
• 19:40
  to be careful in younger patients to consider
• 19:43
  also MRA techniques instead of only CTA for some
• 19:46
  of our post -op controls. is medically acceptable
• 19:50
  in an attempt to reduce radiation burden in these
• 19:53
  patients that have also a longer life expectancy.
• 19:56
  So they will need many CTAs in their lives. Also
• 19:59
  patients showing stable or shrinking aneurysm
• 20:02
  sac behavior and overall a very good sac remodeling
• 20:05
  over the years might be considered for a less
• 20:09
  strict follow -up protocol after some point.
• 20:12
  Also with alternative modalities like combined
• 20:15
  ultrasound and some x -ray. particularly for
• 20:19
  pathology that is mainly confined in the paranal
• 20:22
  part of the aorta, for example. Thanos, can I
• 20:25
  ask you, do you agree that a default follow -up
• 20:27
  frequency could be annual follow -up, and then
• 20:30
  it can be upgraded or downgraded depending on
• 20:33
  all these individual factors? Yes, absolutely,
• 20:36
  Anders. I think we should do that, given that
• 20:39
  not every patient is the same, and there are
• 20:41
  several different factors that may affect our
• 20:43
  follow -up protocol. Some patients may need it
• 20:45
  more frequently than some patients. may indeed
• 20:47
  can be a more relaxed follow -up protocol. To
• 20:51
  round off this second episode, let's turn to
• 20:53
  degenerative descending thoracic and thoracobdominal
• 20:56
  aortic aneurysms, where the guideline clearly
• 20:58
  focuses on treatment strategy and technique.
• 21:01
  In this section, the guideline promotes an endovascular
• 21:03
  first strategy for both descending thoracic and
• 21:06
  thoracobdominal aortic aneurysm, as stated in
• 21:08
  Recommendation 64, Class 1, Level B, 65, Class
• 21:12
  2A, Level C. At the same time, Recommendation
• 21:14
  66, Class 2B, Level C, still leaves room for
• 21:18
  open repair in selected low -risk patients. In
• 21:21
  contemporary practice, how absolute is this endovascular
• 21:24
  first paradigm and which patients should you
• 21:27
  still actively consider for open surgical repair?
• 21:30
  I think that given the significantly lower perioperative
• 21:33
  mortality and morbidity of endovascular techniques
• 21:35
  in this complex pathology compared to open repair,
• 21:39
  endovascular repair should be indeed considered
• 21:41
  the first -line treatment in the thoracic and
• 21:43
  the thoracobdominal aorta. And if we look around,
• 21:46
  this is actually what is happening also in real
• 21:49
  life in most institutions nowadays. Now, open
• 21:52
  repair has still a role, particularly in some
• 21:54
  younger patients with genetic autopathy or in
• 21:57
  case of previous failed endovascular repair with
• 22:00
  multiple attempts to correct the problem by endovascular
• 22:03
  means, some extreme cases of infection or autoesophageal
• 22:06
  fistulas, and certainly in some cases where an
• 22:09
  endovascular solution is not possible at all
• 22:12
  for anatomical reasons. Also, in some less common
• 22:15
  scenarios of compression symptoms like pain due
• 22:19
  to vertebral erosion, an open repair may be considered
• 22:22
  in some anatomies if the patient, of course,
• 22:24
  is deemed fit for such a big procedure. And a
• 22:28
  very practical and sometimes controversial issue
• 22:30
  is celiac artery coverage during TVAR. Recommendation
• 22:34
  67 states that if celiac artery coverage is required
• 22:37
  to achieve an adequate seal, revascularization
• 22:39
  should be considered when collateral flow from
• 22:42
  the superior mesoteric artery is insufficient,
• 22:45
  preferably by endovascular means, class 2A, level
• 22:47
  C. In daily practice, how do you assess whether
• 22:50
  collateral circulation is truly adequate and
• 22:53
  where do you think clinicians most often underestimate
• 22:55
  the risk of visceral ischemia? Indeed, coverage
• 22:58
  of the celiac artery is not without risks and
• 23:01
  not without consequences in many cases. And to
• 23:04
  my opinion, every effort should be made to preserve
• 23:06
  the celiac artery if possible. Now, if this is
• 23:09
  not possible and celiac needs to be covered,
• 23:12
  collateral circulation should be assessed on
• 23:14
  preoperative CTA. If adequate collaterals through
• 23:18
  the gastroduodenal artery are demonstrated, then
• 23:21
  celiac artery coverage without revascularization
• 23:24
  may be considered. is, of course, if we have
• 23:27
  no definite conclusions from the CTA, we can
• 23:30
  use also a balloon occlusion technique of the
• 23:33
  celiac and then do an angiography through the
• 23:35
  SMA. And this may help us check if the collateral
• 23:38
  circulation is adequate or not. Only for cases,
• 23:41
  of course, that the CTA is not really very much
• 23:43
  helpful. A situation that one can underestimate
• 23:46
  the risk of visceral ischemia, to my opinion,
• 23:49
  and just say easily, let's cover the celiac,
• 23:52
  is when the celiac appears to be stenosed in
• 23:54
  the CTA, and this is due to compression of the
• 23:56
  median arcuate ligament. And actually, this is
• 23:59
  a very common imaging finding, to my opinion.
• 24:01
  Many patients come with these findings, and these
• 24:04
  are symptomatic. But even if we have this stenosis
• 24:06
  in the imaging, this does not necessarily mean
• 24:10
  that the celiac antegrade perfusion is really
• 24:12
  blocked or reduced. So this finding should not
• 24:15
  be interpreted very easily as a sign that we
• 24:18
  can easily sacrifice the celiac with artiva,
• 24:21
  as some clinicians may think. Because sometimes,
• 24:24
  if there is no good collateral circulation, we
• 24:26
  may end up with serious problems in visceral
• 24:29
  ischemia. And for thoraco -abdominal aneurysms,
• 24:31
  the guideline recommends fenestrated and branched
• 24:34
  endovascular repair as first -line therapy, but
• 24:36
  also makes some more nuanced recommendations
• 24:38
  regarding target vessel incorporation. Recommendations
• 24:41
  68 to 70, class 2A and 2B level C, suggest that
• 24:45
  fenestrations may be preferred over branches
• 24:48
  for the renal arteries when anatomy allows and
• 24:51
  that bridging stent choice should be individualized.
• 24:54
  From your perspective, which of these technical
• 24:56
  decisions have the greatest impact on long -term
• 24:59
  durability and re -intervention rates? I must
• 25:01
  say I am personally very happy that we decided
• 25:03
  also to include such technical recommendations
• 25:06
  because these are very important to my opinion.
• 25:10
  address some very important technical aspects
• 25:13
  and they have also an impact on long -term durability
• 25:16
  of these repairs. We do know that the Achilles
• 25:20
  heel of this fever and beaver procedures during
• 25:23
  follow -up are the target vessels and particularly
• 25:26
  the renal arteries that present with higher instability
• 25:29
  rates and higher occlusion rates. So every effort
• 25:32
  should be made to try to tailor the graph in
• 25:35
  such a way that we can reduce these complications
• 25:38
  from the target vessels and particularly from
• 25:40
  the renal arteries. Especially for the renal
• 25:42
  arteries, we have important evidence showing
• 25:44
  that fenestrations may have significantly better
• 25:47
  performance. latency rates compared to branches.
• 25:49
  And this, to my opinion, is something that we
• 25:51
  need to keep in mind and try to address therein
• 25:55
  a lot is with fenestrations if this is anatomically
• 25:57
  possible. Branches are, of course, technically
• 26:00
  easier in many cases and more forgiving than
• 26:03
  fenestrations in terms of achieving initial technical
• 26:06
  success. But still, I think that in cases we
• 26:09
  do expect to have a good opposition of the graph
• 26:12
  to the vessel wall, we need to take the extra
• 26:15
  effort and plan fenestrations for even if this
• 26:19
  means sometimes that we may have a more demanding
• 26:21
  procedure. Now, with regard to the bridging stance,
• 26:24
  again, the problem is more relevant with branches
• 26:27
  for the renal arteries. Here, we are still clearly
• 26:30
  lacking a dedicated ideal bridging stance, I
• 26:32
  would say. And I think we should really decide
• 26:35
  on a case -by -case basis, looking at each target
• 26:37
  vessel, the exact anatomy, not only of the target
• 26:40
  vessel itself, but also of the aortic lumen dimensions
• 26:43
  at the level of the target vessel and the different
• 26:46
  angulations. In some cases, for example, we need
• 26:48
  a high radial force at the level of the branch
• 26:51
  of the ground. But at the same time, we also
• 26:53
  need more flexibility and more conformability
• 26:56
  distally where the bridging stand seals into
• 26:59
  the target vessel. So in many cases, we should
• 27:02
  even consider a hybrid configuration of a balloon
• 27:06
  expandable stand approximately and a self -expanding
• 27:10
  distally in the target vessel. And this may be
• 27:13
  one choice we need to consider for now. And I'm
• 27:16
  talking, of course, for the difficult renal target
• 27:18
  vessels. Especially long branches to the renals
• 27:22
  are something that should be avoided. But if
• 27:25
  you have them, I think surveillance is important
• 27:28
  and early re -intervention if you suspect some
• 27:32
  problem, kinking. But also information to the
• 27:35
  patient that if they experience sudden pain,
• 27:38
  they need to seek medical attention immediately
• 27:40
  because there could be an occlusion that can
• 27:43
  be saved or fixed if they come in early. and
• 27:46
  this brings us to the end of this episode where
• 27:48
  we discussed acute thoracic aortic syndromes
• 27:51
  chronic diabetes section and degenerative aneurysmal
• 27:54
  disease there is much more in the guideline that
• 27:56
  we have not covered today so i would encourage
• 27:58
  all our listeners to read the complete guideline
• 28:00
  for additional detail and context in the next
• 28:03
  episode we will shift focus to rupture trauma
• 28:05
  and post -operative complications where decisions
• 28:08
  are often made under very different circumstances
• 28:10
  thank you to my guests and my listeners for being
• 28:12
  here today until next week bye bye bye Bye. Thank
• 28:16
  you.