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Sufali et al. Vessel Plus 2024;8:16 https://dx.doi.org/10.20517/2574-1209.2023.139 Page 3 of 14

METHODS
Study design and patient selection
Between January 2010 and March 2022, data on all consecutive patients receiving an endovascular repair of
a complex aortic pathology in a single tertiary center, were prospectively collected into a dedicated
electronic database. Once the anatomical feasibility for the endovascular treatment was established, the F/B-
EVAR was offered to subjects at high risk for open surgical repair, according to the SVS reporting
[18]
standards . The choice of the device configuration was made based on the patient’s vascular anatomy,
using either an off-the-shelf device or a custom-made device of the Cook Zenith platform (Cook Medical,
Cook Inc, Bloomington, IN, USA). All patients signed a dedicated consent for both the complex
endovascular procedure and the analysis of their anonymous data. For the present study, only patients with
a TAAA extent I to III (according to Crawford’s classification ), aged > 18 years, treated in an elective
[19]
setting with a custom-made or off-the-shelf thoracoabdominal stent-graft were included. The relative data
were extrapolated in a second electronic database and retrospectively analyzed. Exclusion criteria were
emergent/urgent setting, TAAA extent IV, pararenal and juxtarenal aortic aneurysm as underlying treated
pathology. The study was performed with the approval of the ethical review board of IRCCS - Azienda
Ospedaliero-Universitaria di Bologna, (T.Ev.AAA-155/2015/U/Oss).

SCI prevention protocol
For each patient, a SCI prevention protocol including intra/perioperative surgical, anesthesiological, and
neurological adjuncts was applied, as shown in Table 1.

Surgical measures
(1) Staging technique

In our series, a multi-staged TAAA repair was realized whenever possible. Depending on aortoiliac anatomy
and specific characteristics of the endografts of choice, a different staging technique was chosen. With
branched endograft, temporary aneurysm sac perfusion (TASP) was preferably adopted. TASP was
[20]
preferentially achieved leaving one of the directional branches patent into the aneurysm sac, generally the
one destined to the celiac trunk. In the case of stenotic target visceral vessel, the “bare branch” technique
was performed to guarantee the sac perfusion. This technique, which involves the connection of the target
visceral vessel (TVV) to the branch through a bare metal stent, prevents the thrombosis of the TVV during
the interstep period .
[21]

When a custom-made fenestrated-only device was used, the staging technique usually included a first
isolated thoracic step, possibly with supra-aortic surgical debranching, and subsequent deployment of the
fenestrated graft. In the case of bifurcated grafts, one of the two iliac limbs could serve as an unsealed
branch for aneurysm sack perfusion. In all cases, the aneurysm exclusion was completed within two or three
weeks.

(2) Collateral arterial network

Preservation of collateral spine network has always been pursued. Excluding urgent cases, revascularization
of subclavian and hypogastric arteries was performed, both in a surgical or endovascular fashion, prior to
extensive aortic coverage.