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Objective: To present our early and midterm results using thoracic endovascular aortic repair (TEVAR) with a custom-made proximal scalloped stent graft to accommodate left common carotid artery (LCCA) and innominate artery (IA) in treating aortic lesions involving the arch. Materials and Methods: Between February 2014 and April 2017, select patients presenting with aortic arch lesions and short proximal landing zone were treated by proximal scalloped Relay Plus stent grafts. Patient demographics, operative details, clinical outcomes, and complications were analyzed. Results: Six patients (50% male) with a median age of 71 years (range, 60-82) underwent scalloped TEVAR using thoracic custom-made Relay Plus stent graft to preserve flow in the proximal supra-aortic trunks. Target vessels for the scallop were LCCA in 5 cases and IA in 1 case. The technical success rate was 100%, and proximal seal was achieved in all cases with no type I endoleaks on completion angiography. The median follow-up period was 20 (7-32) months. No conversion to open surgical repair and no aortic rupture occurred. One patient had a distal type I endoleak on the 6-month computed tomography (CT) scan, and 1 patient had a proximal type I endoleak on the 12-month CT scan. There was no stroke, paraplegia, retrograde type A dissection, or other aortic-related complication. We routinely used temporary rapid right ventricular pacing to obtain a near-zero blood pressure level during the graft deployment. No complications were observed related to the use of rapid pacing. Conclusion: When anatomy allows, proximal scalloped stent graft to accommodate LCCA and IA is a viable therapeutic option in treating aortic lesions involving the arch with short proximal landing zones. In addition, these findings represent a strong argument for the use of temporary rapid pacing during graft deployment.

Study design: This study was a search of studies that reported the effect of hospital or clinician volume on carotid endarterectomy (CEA) and stenting (CAS) outcomes restricted to European populations using MEDLINE, Embase, the Cochrane Library, Science Citation Index, and CINAHL from December 2014 to June 2016. Key findings: Eleven eligible studies were identified (233,411 participants): 5 from the UK, 2 from Sweden, 1 each from Germany, Finland, and Italy, and a combined German, Austrian, and Swiss population. Two large studies (179,736 patients) suggested an inverse relationship between hospital volume and mortality and combined mortality and stroke following CEA. An inverse relationship was also identified by 2 of 3 small studies of CEA. The evidence was less clear for CAS; multiple analyses in three studies did not identify convincing evidence of an association. Limited data are available on the relationship between clinician volume and outcome in CAS. Conclusion:The evidence from the largest and highest-quality studies included in this review support the centralization of CEA. Commentary: Although many studies have shown a correlation between hospital procedure volume and outcomes, many have also shown that the more important factor is the volume of the individual surgeon or interventionalist. This association makes sense particularly for CEA, where it would not be surprising that an outstanding vascular surgeon performing these operations at a small hospital where no one else performs CEAs obtained excellent results. It may be that the large-volume hospitals draw excellent surgeons and the hospital itself has little impact on outcomes. The other variable that has been shown to have a strong impact on CEA outcomes is the specialist performing the surgery. Several past studies have shown that vascular surgeons have better outcomes than general surgeons or neurosurgeons when performing CEA. The results of the current study are not surprising, but the plea for centralization of CEAs makes sense only if the surgeons at a particular hospital have been shown to obtain excellent results. On the other hand, it may be difficult to expect a surgeon, especially a board-certified vascular surgeon, to tell patients to travel 2 hours, or even to go across town, to a hospital that does more CEAs than his or her hospital does, when that individual has tracked his or her own results and met accepted standards in terms of low stroke and mortality rates.Stenting has high rate of restenosis in patients treated for Takayasu's arteritis