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limb ischemia was similarly 13%. The reason for the greater presentation of acute limb ischemia and major amputation after stent graft thrombosis was likely due to obliteration of the collateral channels coming off the stented segment.The average lesion length in this study was 26 cm. After implantation of the stent-grafts, dual antiplatelet therapy was prescribed for 6 months, with a recommendation for maintenance for 12 months unless contraindicated. The patients underwent duplex ultrasound every 3 months after the procedure, which we agree is a useful surveillance tool for Viabahn stent-grafts. 2 Among the patients who had undergone reintervention in this study, 56% had undergone endovascular intervention, 29% had undergone surgical thrombectomy, and 15% had undergone bypass surgery. Because the patency was comparable between the surgical and endovascular intervention groups and because the perioperative complications were greater with surgery, the authors recommended endovascular intervention as the first-line strategy for revascularization of a thrombosed stent-graft. However, the 54% 1-year patency after reintervention in this study was poor. Although choosing the type of intervention can be difficult and depends on the acuity of the symptoms, performing autologous vein bypass (when possible) will yield better long-term results and avoid the potentially catastrophic complications of distal emboli associated with mechanical thrombectomy and thrombolysis of a thrombosed stent-graft.

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Objective: This study assessed early and midterm safety and efficacy of an off-the-shelf endovascular graft system (Ventana) in patients with pararenal or juxtarenal aneurysms.Methods: After Institutional Review Board approval, patients with infrarenal aneurysms adjacent to or involving the origin of one or both renal arteries were evaluated. Selection criteria included adequate access, nonaneurysmal infrasuperior mesenteric artery neck length Ն15 mm, and renal stenosis Յ70%. Evaluation was done at discharge, 1, 6 months, 1 year, and annually to 5 years. Core laboratory computed tomography evaluation was done for assessment of device integrity, patency, migration, endoleak, renal perfusion, and aneurysm morphology.Results: Between 2010 and 2012, six centers enrolled 30 consecutive patients with juxtarenal or pararenal aortic aneurysm. Patients (90% men; mean age, 73 years) had a mean aneurysm sac diameter of 5.8 cm, infrarenal neck length of 6 mm, and infrasuperior mesenteric artery neck diameter of 24 mm and length of 26 mm. A Ventana graft system with covered renal stents was implanted, preserving all visceral arteries. Complications included a compressed renal stent due to repeat ballooning and one extended renal cannulation time due to renal stenosis not seen on the computed tomography scan. Procedure time averaged 2 Ϯ 1.5 hours. Mean hospital stay was 3.8 days. No deaths occurred Յ30 days. One intervention on day 26 for limb occlusion was due to device kink. Three non-aneurysm-related deaths occurred during follow-up (mean, 8 months; range, 1-16 months). No rupture, conversion, stent fracture, migration, type III endoleak, or sac expansion was observed. Small type II endoleak was observed in six patients at 1 month and in three patients at 6 months. One reintervention for renal stenosis due to initial renal stent undersizing was done at 7 months. A type IA endoleak and renal occlusion, secondary to procedural device damage, led to reintervention on day 52 and dialysis at 5 months.Conclusions: The multicenter experience of the Ventana Fenestrated System supports its safety and midterm effectiveness for the endovascular repair of juxtarenal and pararenal aortic aneurysm. This off-the-shelf, integrated system permits endovascular treatment of juxtarenal or pararenal aortic aneurysms; however, further expanded clinical experience and longer-term follow-up are needed to more fully assess this device system. Objective: Due to lack of commercially available iliac branched devices, there have been descriptions of trifurcated techniques, homemade branch devices, and the double-barrel/snorkel approach to preserve hypogastric flow during endovascular aneurysm repair. We describe a novel technique mimicking a "preloaded" catheter to provide throughand-through wire access that eliminates the anatomic length restrictions of the aforementioned techniques, obviates the need for arm access, and can be performed without device modification.Methods: A 78-year-old man with comorbid factors of prior stroke after an emergency co...