Planning and construction of fenestrated endografts for complex aortic anatomies where exact fit and positioning of the graft are paramount to allow cannulation of the aortic branches are challenging. In the current series, approximately one in five endografts was modified after prototype testing in an aortic model. Eventually, success rates were comparable between the groups of patients with a good primary prototype fit and those in which the endograft design was altered. Prototype testing in 3D aortic models is a valuable tool to test the fit of a custom-made endograft before implantation. This may help avoid potentially debilitating adverse events associated with misaligned fenestrations and unconnected aortic branches.

Background and Purpose— Even in patients with high-grade carotid stenosis, cardiovascular morbidity causes more deaths than strokes do. Despite successful low-density lipoprotein (LDL) cholesterol lowering, a significant risk of atherosclerotic cardiovascular disease remains, eventually rendering other lipid or lipoprotein ratios more efficient treatment targets. This study aimed to investigate the predictive value of the ratio of serum apolipoprotein A-II/B for overall mortality (primary outcome) of carotid surgery patients. Methods— This single-center, nonrandomized, prospective cohort study comprised 327 consecutive patients undergoing carotid endarterectomy for high-grade internal carotid artery stenosis. Baseline lipoprotein concentrations were measured, and patients were observed for the occurrence of the primary outcome until the census date (January, 2003 to January, 2012; median follow-up, 102.3 months). Results— The ratio of apolipoprotein A-II/B (hazard ratio, 0.74 per SD; confidence interval, 0.60–0.91; P =0.004) showed the highest association with the primary outcome compared with other lipid-risk parameters, significantly improving a prognostic model based on major cardiovascular risk factors, including LDL, high-density lipoprotein, and triglycerides in terms of overall performance, calibration, and discrimination. This led to a significantly improved reclassification of 8.9% of all patients (net reclassification improvement, 0.137; P =0.006 and integrated discrimination improvement, 0.041; P <0.001) and of 13.6% of patients with a serum baseline concentration of <100 mg/dL LDL (net reclassification improvement, 0.270; P =0.030 and integrated discrimination improvement, 0.061; P =0.002). Conclusions— Apolipoprotein A-II/B significantly improves risk prediction of overall survival, also in carotid surgery patients with lower LDL levels. Consequently, this ratio might provide an efficient diagnostic tool and eventually a treatment target for actual lipid-lowering therapies, which has to be addressed in future randomized controlled trials.

Our study identifies a high contralateral degree of ICAS as an independent predictor of preoperative ipsilateral TIA and stroke in patients with ipsilateral high-grade ICAS. Therefore, such patients might rather benefit from elective carotid surgery and intensive postoperative medical care.