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BackgroundUndifferentiated chest pain is one of the most common complaints in the acute care setting. Type B aortic dissection is an important cause of chest pain and a complex clinical entity, which carries significant morbidity and mortality and requires accurate clinical and radiological evaluation.MethodsImaging technologies have become an irreplaceable tool to establish the diagnosis of aortic dissection and to plan treatment strategies. Computed tomography is an important component in this process, replacing catheter-based angiography as the most commonly used preoperative and postoperative imaging modality for the thoracic aorta. The use of functional imaging methods, such as magnetic resonance imaging and echocardiography is evolving. These methods are able to provide the clinically relevant anatomical, hemodynamic and biomechanical information that is necessary for accurate diagnosis, risk stratification and patient selection for treatment.ConclusionAdvanced image acquisition equipment and expertise are increasingly available in a growing number of institutions and as a consequence, existing strategies for the management of type B dissection are rapidly evolving.

Endovascular embolization is a valid alternative solution for visceral artery aneurysm treatment. Imaging is crucial for anatomical assessments and treatment guidance. 3DRA can contribute to endovascular treatment in lieu of preoperative imaging.

Objective No bridging stent-graft (BSG) has been specifically designed for branched endovascular aortic repair (BEVAR) and therefore different “off-label” stent-grafts have been used. Recently, a third generation of balloon-expandable stent-graft has become available. Here we evaluate the outcomes of the BeGraft Peripheral Plus (B+) used as a BSG for internal/externalor inner branches during BEVAR. Materials and Methods Consecutive patients undergoing BEVAR using B+ as a BSG since its release in 2017 were included into the study. The primary endpoints were technical success and target vessel patency during follow-up. Secondary endpoints included the need for adjunct extension and relining of the BSG, branch instability rate, including occlusion, reinterventions for restonosis, kink, fracture, or endoleak (types 1 and 3). Results A total of 163 visceral branches in 46 patients were included with a median follow-up 15 months (4–36 months). Primary technical success was achieved in all visceral branches (69 inner branches and 94 internal/external branches) with the exception of 1 BSG that required serial dilatation until full expansion was achieved with overall branch patency was 98% at 2 years. An additional stent-graft was necessary in 35 branches (21%) following deployment of a B+ BSG to cover a longer bridging distance and optimize the distal and proximal sealing. Relining of B+ BSG was not routinely carried out during the index procedure and a self-expanding uncovered nitinol stent was necessary in only 3% of branches to smooth the distal transition zone between the BSG and target vessel. There were 4 events (2.4%) of branch related instability, including 2 occlusions and 2 late reinterventions for a partial in-stent-graft thrombosis. Conclusion Our study findings show satisfactory early outcomes of B+ as a BSG in BEVAR with low occlusion and reintervention rates. Extensions of BSG might be required to achieve adequate seal in the target vessels but routine relining BSG in branches was not required.

EVAR using stent grafts in the presence of an unfavourable neck has a high risk of complications. Medium-term survival in this group is low but mainly due to patient co-morbidities.

Secondary interventions in threatened distal bypass grafts are successful at maintaining graft patency and AFS when compared with nonthreatened grafts, and are associated with a low morbidity rate.

Aortic arch repair is a challenging intervention. Open surgical repair is still considered the gold standard, but in high-risk patients, it is not always a reasonable option, making endovascular approaches an enticing, when not the only available, alternative for treatment. The strategies more commonly adopted are surgical supra-aortic trunk (SAT) rerouting followed by deployment of a standard thoracic endoprosthesis, chimney techniques, custom-made scalloped, fenestrated, and branched devices, and in situ or physician-modified fenestrations. If we excluded techniques involving SAT rerouting where the arch anatomy is surgically modified in order to make deployment in the aortic arch of a standard thoracic endoprosthesis possible, in the other techniques, one or more SATs are incorporated in the thoracic endoprosthesis. In these cases, no matter what solution is adopted, because of the morphology of the aorta at this level, achieving an ideal sealing is extremely difficult, and endovascular treatments of the arch are burdened by an increased risk of type IA endoleaks. PubMed, EMBASE, and Cochrane Library were searched. We identified 1277 records. After reading titles, abstracts, and full texts, we excluded 1231 records. Exclusion criteria were low-quality evidence, abstracts, case reports, conference presentations, reviews, editorials, and expert opinions. A total of 48 studies were included, for a total of 3114 patients. A type IA endoleak occurred in 248 patients (7.7%) with a mean incidence of 18.8% in chimney procedures, 4.8% and 3%, respectively, in fenestrated and branched devices, and 2.2% in in situ fenestration. We excluded from our analysis scalloped technology that is used when the target vessel originates from a healthy landing zone and represents a different anatomical setting. Type IA endoleaks are a concern with all types of endovascular aortic arch repair, and they can compromise the outcomes of the procedure. The rate of type IA endoleaks appears to be significantly higher in chimney procedures. In order to maximize sealing, whenever possible, endovascular repair of the arch should be achieved with custom-made fenestrated devices. However, chimney configurations are still a valuable solution particularly in the emergency setting, although in such a procedure, to guarantee accurate postoperative management and follow-up, an imaging protocol could be useful.