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\title{Valiant NAVION Stent Graft System Application: First Asian Case Series
Analysis}



\author[1]{Chi Ying Simon Chow}%
\author[1]{Yan Kit Ho}%
\author[1]{Takuya Fujikawa}%
\author[1]{Kevin Lim}%
\author[1]{Cheuk Man  Chu}%
\author[1]{Chun Ho Simon   Yu}%
\author[2]{Mohamad Bashir}%
\author[1]{Hung Leung Randolph Wong}%
\affil[1]{Prince of Wales Hospital}%
\affil[2]{Royal Blackburn Teaching Hospital}%


\vspace{-1em}



  
  \date{April 24, 2026}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background and aim of the study

The Valiant Navion\textsuperscript{TM} stent graft system is a
third-generation low profile thoracic endograft designed for thoracic
endovascular aortic repair. In this population analysis, we report on
the first Asian all-comers experience and outcomes who underwent
thoracic endovascular aortic repair with the use of this new stent graft
system.

Methods

Between May 2019 and October 2020, 21 patients with different aortic
pathologies were prospectively recruited and retrospectively analyzed.
Important clinical and device-related outcomes were evaluated. The
endpoints included short-term survival, technical success, access
failures, major vascular and clinical complications, endoleaks, and
hospital stay.

Results

The commonest indication of stenting was penetrating aortic ulcers
(28.6\%) and 6 (28.6\%) patients had emergency stenting performed for
aortic transection or rupture. 30 days of survival post-procedure was
recorded and complete. There were no major vascular complications.
Deployment accuracy was 100\%, and the technical success rate was 94.7\%
(18/19) with 1 patient having a type 2 endoleak on follow-up imaging. No
neurological complications were noted. The mean operative time was 95
+/- 73.6 mins and the mean fluoroscopy time was 16.2 +/- 10.8 mins. Mean
hospital stay for elective zone 2, 3 and 4 stenting was 5.3 +/- 3.8
days, and only 1 patient post zone 1 TEVAR required a brief (0.5 days)
ICU stay. All procedures were performed via the percutaneous
transfemoral route with 100\% success in percutaneous closure.

Conclusion

This first reported Asian case series demonstrated versatility, safety,
and efficacy of the Valiant NavionTM stent in Asian patients with
different aortic pathologies%
\end{abstract}%



\sloppy


Valiant NAVION Stent Graft System Application: First Asian Case Series
Analysis

Simon C.Y. Chow FRCS\textsuperscript{1}, Jacky Y.K. Ho
FRCS\textsuperscript{1}, Takuya Fujikawa FRCS\textsuperscript{1}, Kevin
Lim MRCS\textsuperscript{1}, C.M. Chu\textsuperscript{2} FRCR, Simon
C.H. Yu M.D. \textsuperscript{2}, Mohamad Bashir M.D. Ph.D.
MRCS\textsuperscript{3}, Randolph H.L. Wong FRCS\textsuperscript{1}

\textsuperscript{1} Division of Cardiothoracic Surgery, Department of
Surgery

The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32
Ngan Shing Street, Shatin, New Territories Hong Kong

\textsuperscript{2} Department of Imaging and Interventional Radiology

The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32
Ngan Shing Street, Shatin, New Territories Hong Kong

3. Department of Cardiovascular \& Endovascular Surgery, Blackburn
Teaching Hospital, Blackburn, UK.

Running Title: Valiant Navion endograft

Corresponding author

Dr Randolph H.L. Wong, MBChB, FRCS, FCSHK, FHKAM

Consultant and Chief

Division of Cardiothoracic Surgery, Department of Surgery

The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32
Ngan Shing Street, Shatin, New Territories Hong Kong

Email: wonhl1@surgery.cuhk.edu.hk

Declarations :

\textbf{Ethics approval and consent to participate :}

Ethical Statement: The authors are accountable for all aspects of the
work in ensuring that questions related to the accuracy or integrity of
any part of the work are appropriately investigated and resolved. This
cardiac surgical local registry was approved by Hong Kong

Hospital Authority and the Government of Hong Kong SAR to allow
collection, analysis, reporting, and outcome tracking of patient data
since its introduction in 2007.

\textbf{Consent for publication:}

No informed consent from patients was sought for this retrospective
analysis as there were no identifiers in this manuscript that could
disclose individual patient confidentiality. All patient data were
secured and kept confidential

\textbf{Availability of data and materials :}

The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.

\textbf{Competing interests}

The authors declare that they have no competing interests

\textbf{Funding}

The authors declare that there is no external funding support for this
study.

Abstract

Background and aim of the study

The Valiant Navion\textsuperscript{TM} stent graft system is a
third-generation low profile thoracic endograft designed for thoracic
endovascular aortic repair. In this population analysis, we report on
the first Asian all-comers experience and outcomes who underwent
thoracic endovascular aortic repair with the use of this new stent graft
system.

Methods

Between May 2019 and October 2020, 21 patients with different aortic
pathologies were prospectively recruited and retrospectively analyzed.
Important clinical and device-related outcomes were evaluated. The
endpoints included short-term survival, technical success, access
failures, major vascular and clinical complications, endoleaks, and
hospital stay.

Results

The commonest indication of stenting was penetrating aortic ulcers
(28.6\%) and 6 (28.6\%) patients had emergency stenting performed for
aortic transection or rupture. 30 days of survival post-procedure was
recorded and complete. There were no major vascular complications.
Deployment accuracy was 100\%, and the technical success rate was 94.7\%
(18/19) with 1 patient having a type 2 endoleak on follow-up imaging. No
neurological complications were noted. The mean operative time was 95
+/- 73.6 mins and the mean fluoroscopy time was 16.2 +/- 10.8 mins. Mean
hospital stay for elective zone 2, 3 and 4 stenting was 5.3 +/- 3.8
days, and only 1 patient post zone 1 TEVAR required a brief (0.5 days)
ICU stay. All procedures were performed via the percutaneous
transfemoral route with 100\% success in percutaneous closure.

Conclusion

This first reported Asian case series demonstrated versatility, safety,
and efficacy of the Valiant Navion\textsuperscript{TM} stent in Asian
patients with different aortic pathologies.

Abstract word count: 259

Keywords

Aorta, Thoracic aorta, Endovascular procedures, stents

Introduction

Thoracic endovascular aortic repair (TEVAR) is associated with reduced
morbidity and mortality compared to open surgery in the treatment of
multiple aortic pathologies {[}1{]} {[}2{]}. It is currently the
mainstay treatment for a wide variety of aortic diseases in patients
across all risk groups. However, not all patients are amenable to
standard TEVAR. Anatomic limitations still preclude a significant number
of patients from TEVAR and these include the absence of suitably sized
access vessels, aortic calcification, and tortuosity, as well as the
lack of adequate landing zones. The Valiant
Navion\textsuperscript{TM}stent graft system (Medtronic Inc. Santa Rosa,
Calif.) is a third-generation low profile TEVAR device designed to allow
smooth delivery via small-caliber vessels and provide better
conformability on deployment. In this case series, we evaluated the
short-term outcomes reflecting on our initial experience with the
Valiant Navion\textsuperscript{TM} stent graft system. To date, this is
the first reported Asian ``real world'' series on the use of the novel
Valiant Navion\textsuperscript{TM} stent graft.

Methods

Population Characteristics

The mean age of the population was 65.4 +/- 12.4 years, with a male
predominance of 90.5\%. The majority of the patients were smokers
(57.1\%) and suffered from hypertension (71.4\%). Table 1 displays the
baseline characteristics of our population.

Study Design:

Between May 2019 and October 2020, 21 patients underwent TEVAR with the
Valiant NavionTM endograft in the Prince of Wales Hospital, Hong Kong.
All patient data were prospectively collected and retrospectively
analyzed from the comprehensive Dendrite local cardiac and aortic
surgery registry. Patients with variable aortic pathologies were
included in the case series and relevant clinical and radiological data
were recorded and analyzed.

The wall-to-wall outer diameter of vessels was used to measure the
maximal aortic diameter (MAD) and the minimal iliofemoral access
diameter. Vessels with circumferential calcification at any site were
severely calcified. Any sequential aortic or vascular segments with
angulation of \textgreater{} 45 degrees between adjacent curves were
defined as tortuous vessels. TEVAR done within 1 day of admission were
emergency procedures. Outcomes of interest included short term survival
and important post TEVAR complications such as major vascular
complications, stroke, spinal cord injury (SCI), renal dialysis, and
endoleak. Procedural related death was defined as death during the index
hospital stay. Survival analysis included 30-day mortality rates.
Technical success was defined as successful access and deployment of the
stent-graft with no major vascular complications, mortality, and the
absence of endoleak on follow-up computed tomography (CT) scan.
Deployment accuracy was defined as stent deployment within 5mm of
intended proximal landing location on fluoroscopy and follow up CT scan.
Access failure was defined as the inability to insert the device due to
mechanical failure, or the need for anatomic exclusion of the
iliofemoral vessels for access. Major device-related complications
included aortic rupture, conversion to open surgery, need for salvage
procedure, endoleak, and mortality. Major access site-related
complications included access vessel dissection, pseudoaneurysm, limb
ischemia, and the need for unintended adjunctive procedures such as
conduits or cutdown. Neurological complications included stroke,
transient ischemic attack (TIA), and spinal cord ischemia (SCI).
Procedural related stroke was defined as a modified Rankin score (mRS)
of 2 or more or an increase in 1 category from baseline within index
episode of hospitalization. SCI was defined as new onset paraparesis or
paraplegia following TEVAR. Positive aortic remodeling did not apply to
transection cases and was defined as a complete penetrating aortic ulcer
(PAU) or stent- induced new entry (SINE) tear coverage, or MAD reduction
in aneurysmal disease. Thrombosis outside TEVAR stent in the absence of
aortic size reduction was not considered positive aortic remodeling. All
procedures were performed under general anesthesia in a state-of-the-art
hybrid theatre. TEVAR was jointly performed by cardiac surgeons and
interventional radiologists. For all patients, a proximal and distal
landing of 2 cm or more was mandatory. In zone 2 cases, a left
carotid-axillary artery bypass was performed for patients with the
dominant left vertebral artery. Zone 1 patients required double
de-branching with a carotid-carotid bypass and a left carotid-axillary
bypass. The left subclavian artery was not routinely embolized during
zone 2 TEVAR unless bypass was required or in the presence of type II
endoleak on completion aortogram. All grafts were deployed under strict
systolic blood pressure control \textless{} 100mmHg to prevent migration
and wind-socking phenomenon. All femoral access was performed
percutaneously and closed with percutaneous closure devices.

Ethical Approval:

The local registry was approved by the Hong Kong Hospital Authority and
the Government of Hong Kong SAR to allow collection, analysis,
reporting, and outcome tracking of patient data since its introduction
in 2007. No informed consent from patients was sought for this
retrospective analysis as there were no identifiers in this manuscript
that could disclose individual patient confidentiality. Patient
anonymity was preserved in this study and all patient data were kept
confidential and secured.

Statistical Analysis:

Continuous variables were reported as mean +/- standard deviations (SD).
Categorical variables were reported as frequencies and percentages. Data
analysis was performed with IBM SPSS Statistics Version 25.

Results

21 patients were recruited for this study. The commonest indication for
TEVAR was symptomatic penetrating aortic ulcers (PAU) (28.6\%) (Figure
1a,b \&c), followed by aortic transections (23.8\%) (Figure 2a \&b),
stent induced new-entry (SINE) tears (23.8\%), Thoracic aortic aneurysm
(19\%) and aortic rupture (4.8\%). All aortic transection cases were
grade 3 injuries, which required emergent stenting. The mean maximal
thoracic aortic diameter was 45.5 +/- 16.1 mm. Most patients had a MAD
of less than 50mm (71.4\%). The minimum iliofemoral access diameter was
9.7 +/- 1.57mm, and 14.3\% had access vessels smaller than 8mm. Severe
vessel tortuosity and calcification occurred in 14.3\% and 23.8\% of
patients, respectively. The mean follow-up period was 268 +/- 179 days.

Operative Characteristics

Table 2 displays the procedural characteristics. Most procedures were
done on an elective basis (71.4\%). TEVAR with zone 4 landing was most
commonly performed (52.4\%), followed by zone 2 landing (33.3\%) and
zone 3 landing (9.5\%). 1 patient had a zone 1 TEVAR (4.8\%). 28 stents
were utilized, and 7(33\%) patients had more than one stent. Most
patients did not require adjunctive bypass procedures. Head and neck
vessels debranching were performed in 2 patients, with 1 patient
requiring a double bypass with carotid-carotid bypass and left
carotid-axillary bypass (Figure 3a-d). The left subclavian artery was
embolized with Nester Embolization Coils (Cook Medical, Bloomington,
Indiana) in 3 patients (14.3\%) and 1 patient had coil embolization of
the aneurysmal sac. The overall mean operation time was 95 +/- 73.6mins,
and the mean operation time for zone 3 and 4 TEVAR was 75.1 +/- 20.1
mins. Mean fluoroscopy time was 16.2 +/- 10.8 mins, and 11.2 +/- 4.5
mins for zone 3 and 4 TEVAR alone. All patients had a percutaneous
femoral approach for TEVAR.

Outcomes

Table 3 displays the survival and procedural outcomes. The procedural
mortality was 0\%. None of the patients died within 30 days of the
procedure. There were no major vascular complications, stroke, dialysis,
or conversion to open surgery. 19 patients had a follow-up CT aortogram
at the time of the study. The technical success rate was 94.7\%, and 1
patient had type II endoleak found on a follow-up CT scan. There were no
cases of retrograde type A dissection (RTAD), SINE, and stent migration
up to the time of follow up. The mean overall hospital stay was 22.9 +/-
50.4 days. Excluding polytrauma and rupture cases, the mean hospital
stay was 5.8 +/- 4.12 days, and only 1 patient out of the 15 elective
TEVAR cases required half a day of ICU stay. On follow up CT scan for
non-transection cases, 73.3\% (10/15) patients had positive aortic
remodeling, while 20\% (3/15) had a static aortic appearance on CT. 1
patient (7.2\%) out of 15 patients had type II endoleak on follow up CT.

Discussion

This series represents the first reported all-comers, ``real world''
experience with the new Valiant Navion\textsuperscript{TM} stent graft
system (Medtronic Inc. Santa Rosa, Calif.) in an Asian population. The
Valiant Navion\textsuperscript{TM} stent graft system is a low- profile
evolution of the Valiant thoracic stent graft with
Captivia\textsuperscript{TM} delivery system {[}4,5{]}. Comparing to
prior generations of stent-grafts, the delivery system comes in smaller
outer diameters and has a shorter flexible, hydrophilic-coated taper tip
which facilitates navigation in small and tortuous vessels. The
stent-graft comes in outer diameters of 18, 20, and 22Fr. The
improvement in flexibility and trackability of the
Navion\textsuperscript{TM} Stent system theoretically reduces the
incidence of major vascular complications and facilitates a pure
percutaneous procedure. Femoral and iliac access limitations preclude
35\% of cases from TEVAR {[}6{]}. Anatomical drawbacks such as the size
of vessels, degree of calcification, and tortuosity are considered
unfavorable for transfemoral access of TEVAR. Indeed, the risks of major
vascular complications are reported to be around 15\% post TEVAR
{[}7-10{]}. In the Pivotal trial, the Navion\textsuperscript{TM} stent
graft system was implanted in 87 patients and 70.9\% of the studied
population had severe access artery tortuosity. Despite the challenging
access to anatomy, there were no cases of access failures. The Navion
study group reported 3.4\% access-related complications in 160 European
patients, which were all from cut-down procedures {[}11{]}. The rate of
femoral pseudoaneurysm and iliac vessel dissection was 0.86\%
respectively. In our center, the percutaneous femoral approach is
routine, and vessels are repaired with percutaneous closure devices. We
report a 100\% success rate in percutaneous closure of access sites with
no cases of the pseudoaneurysm, dissection, or limb ischemia. It is
worth noting, that despite our patients being predominantly Asian, the
mean minimal iliofemoral access was 9.7mm. A minority of patients (3/21;
14.3\%) had access vessels smaller than 8mm, and this can be explained
by the male predominance (90.5\%) in our studied population. The 3 cases
of small caliber iliofemoral access were all found in patients in shock
state with aortic transection and multisystem trauma. With the
low-profile delivery system, Navion\textsuperscript{TM} stent graft
allows for safe transfemoral access in shock patients with
vasoconstricted vessels, which is important and a significant advantage
especially in the setting of emergency TEVAR. No cutdown procedure was
required for access in all 5 of our transection cases. Around
one-quarter of our patients had circumferential calcification in the
access vessels, and we had no cases of limb ischemia secondary to
embolus and no cases of dissection. This can be attributed to the
hydrophilic smooth taper cone tip of the NavionTM Stent system, which
improves the trackability of the device during navigation to the
targeted landing sites.

Endoleaks post TEVAR can result in suboptimal aortic remodeling, lesser
sac regression rates, and repeat reinterventions {[}12-14{]}. The
complexity and variability in landing zones affect deployment accuracy
and success, and incomplete exclusion of diseased segments of the aorta
can result in endoleaks. The rate of endoleaks from TEVAR range from 3.4
\% to 42.2\% with type I endoleak being the commonest at 41.4\% followed
by type II and III endoleaks {[}15{]}. The
Valiant\textsuperscript{TM}Navion stent-graft comes with two proximal
stent-graft configurations, the FreeFlo, and the CoveredSeal device. The
Freeflo device has a bare stent proximal design, which allows for the
preservation of trans-vessel flow at the proximal landing zone, while
the CoveredSeal has a proximal graft fabric edge. The stent-graft is
mounted onto the delivery catheter and rarely shortens or changes length
during deployment. This allows for customization of the stent for
different landing zones and facilitates accurate landing, better
sealing, and conformability to optimize deployment accuracy and reduce
endoleaks. The improvement in conformability provides correct
positioning to avoid type 1 endoleaks. In our series, for all
pathologies, there was 100\% deployment accuracy and only one case of
endoleak due to a type II endoleak from a left subclavian artery with a
disproportionately large orifice which was not completely embolized with
coils. In the Pivotal trial, 2 out of 87 patients had endoleaks at 1
month (2.4\%), and in the Navion study group, there were no endoleaks at
a median follow up of 98 days. The latter study, similar to our series,
was all on types of pathologies, not limited to aneurysms, and 32.27\%
of patients had significant thoracic or abdominal aortic angulations of
more than 45 degrees. The Design of the Valiant
Navion\textsuperscript{TM} stent system is suitable for a wide range of
pathologies. The smaller stent option of 20mm in diameter, in
combination with the low-profile design, short nose cone, and simple
3-step deployment technique makes it an ideal stent for emergency
scenarios in patients who are vasoconstricted and in shock. The
CoveredSeal configuration has ``W'' shaped internal supporting stents,
which are fully enclosed within the graft. This aids in enhanced landing
zone apposition and sealing and reduces graft retroflexion. The
sinusoidally shaped elastic nitinol springs throughout the graft provide
improved conformability and flexibility, with a balanced radial force to
optimize vessel sealing. This factor, in combination with a greater
allowable distal tapering of 5-6 mm, prevents stent induced new entry
(SINE) tears and retrograde type A aortic dissection (RTAD), especially
in the setting of fragile aortas, such as aortas with intramural
hematoma. The Pivotal trial reported 1 case of RTAD and 1 case of arch
rupture, in our series, there were no cases of RTAD or SINE.

The improved design of the Valiant Navion\textsuperscript{TM} stent has
rendered TEVAR more operator-friendly without compromising short term
patient survival and procedural outcomes. In our series, the procedural
risk was low and survival outcomes were excellent. No patient died from
the procedure and there were no cases of stroke, new dialysis
requirement, spinal cord ischemia, respiratory failure, and conversion
to open surgery. A European study on the Navion stent reported a stroke
rate of 4.3\%, SCI rate of 2.6\%, and in-hospital mortality rate of
4.3\%. The Pivotal trial reported a 30-day survival rate of 97.7\% and a
stroke rate of 4.6\%. Our population is smaller compared to the two
stated trials above, but our results of superior survival and operative
outcomes affirmed the safety and feasibility of the
Navion\textsuperscript{TM} Stent graft system. The ease of deployment
has also facilitated shorter operation times, shorter fluoroscopy times,
and lower contrast doses, which obviate the need to utilize intensive
care unit resources post-TEVAR. 1 case of zone 1 TEVAR required a
half-day ICU stay, and excluding polytrauma patients with aortic
transections, none of the elective zone 2,3, and 4 TEVAR patients
required ICU stay. The mean hospital stay for elective cases was 5.3 +/-
3.8 days, and all elective zone 2, 3, and 4 TEVAR patients were
extubated immediately after the procedure. In our series, for standard
elective TEVAR, the mean operation time was 75.1 +/- 20.1 mins, with a
mean contrast dose of 63.6 +/- 19.5 mls and a mean fluoroscopy time of
11.2 +/- 4.5 mins. This is consistent with the findings of the Pivotal
trial, with a mean operative time of 88.7 mins, mean contrast dose of
96.2 ml, and fluoroscopy time of 12.2 mins. The ease to percutaneously
close TEVAR femoral wounds has diminished the need for open cut down
procedures, which also speeds up patient recovery.

Limitations

This non-comparative study is retrospective in nature and has inherited
intrinsic weaknesses such as recall and measurement bias. The population
is small, and the findings serve to highlight the safety, feasibility,
and versatility of the new Navion \textsuperscript{TM} stent graft
system in Asians. The findings are at best hypothesis-generating.
Besides, only short-term outcomes were demonstrated, and these patients
will be followed up for long term outcomes as controversies still exist
in the durability and high future reintervention rates of TEVAR

Conclusion

Our series, to date, is the first reported Asian series on the use of
the Navion\textsuperscript{TM} stent graft system in all-comers with all
pathologies. Most patients in our population had non-aneurysmal aortic
diseases such as aortic transection, SINE, and PAU. We did not encounter
a disproportionately high number of patients with small, calcified, and
tortuous vessels. Nonetheless, we have demonstrated the
Navion\textsuperscript{TM} stent system to be safe and effective across
various pathologies amongst Asians. The high rate of successful
percutaneous femoral access and stent deployment accuracy facilitates
shorter operative times, reduces procedural complications, and shortens
hospital stay.

Author contributions

Conception and design: SC, RW , JH

Administrative support: RW , SY, CM CHU

Provision of study materials or patients: All authors

Collection and assembly of data: SC, RW , JH

Data analysis and interpretation: All authors

Manuscript drafting and writing : SC, RW, JH

Critical Revision of article : all authors

Final approval of manuscript: All authors

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\par\null

Table 1. Baseline demographics\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Baseline demographics ( N= 21)\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Mean /frequencies +/- SD ( \%)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Age\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
65.4 +/- 12.4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Male\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
19/21 ( 90.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Hypertension\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
15/21 ( 71.4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Diabetes mellitus\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
3/21 ( 14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Smoker\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
12/21 ( 57.1\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
History of stroke\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
1/21 ( 4.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Follow up days\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
268.3 +/- 179 days Median: 236 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Indication for stenting\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Aortic transection\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
5/21 (23.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Aneurysm\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
4/21 ( 19.0\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Stent induced new entry tear\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
5/21 (23.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Penetrating aortic ulcers\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
6/21 (28.6\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Rupture\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
1/21 (4.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Pre op CT parameters\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Maximal thoracic aortic diameter (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
45.5 +/- 16.1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
or = 50mm\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
6/21 ( 28.6\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textless{} 50mm\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
15/21 ( 71.4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Minimum iliofemoral access diameter (mm)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
9.7 +/- 1.57\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\textless{} 8mm\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
3/21 ( 14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
8- 8.9mm\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
3/21 ( 14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
9 -- 9.9mm\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
6/21 ( 28.6\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
10-10.9mm\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
6 /21 ( 28.6\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
11 or above\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
3/21 (14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Iliofemoral tortuosity\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
3/21 ( 14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Severe circumferential calcium in any vascular segment\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
5/21 ( 23.8\%)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\emph{a : adjacent aortic curve angulation \textgreater{} 45 degrees}

Table 2. Procedural characteristics\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Procedural characteristics ( N = 21)\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Mean/frequencies ( \%)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Zone 1 landing\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
1/21 ( 4.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Zone 2 landing\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
7/21 ( 33.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Zone 3 landing\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
2/21 ( 9.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Zone 4 landing\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
11/21 ( 52.4\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Multiple stents ( \textgreater{} 1)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
7/21 ( 33.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Multiple procedure (including extra-anatomical bypass , branch vessel
embolization )\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
3/21 ( 14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Carotid -- carotid bypass\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1/21 ( 4.8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
left common carotid -- axillary bypass\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
2/21 (9.5\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Left subclavian coil embolization\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
3/21 ( 14.3\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Aneurysmal coil embolization\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
1/21 ( 4/8\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Operation time (mins)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
95 +/- 73.6\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Operation time for zone 3 \& 4 TEVAR (mins) (n =13)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
75.1 +/- 20.1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Contrast dose (mls) ( n= 17)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
79.4 +/- 60.4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Contrast dose for zone 3 and 4 TEVAR (mls) ( n = 10)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
63.6 +/- 19.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Fluoroscopy time (mins) (n= 11)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
16.2 +/- 10.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Fluoroscopy time (mins) for zone 3 and 4 (n=8)\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
11.2 +/- 4.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Percutaneous wound closure for femoral access\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
21/21 ( 100\%)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Access failure\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
0/21 (0\%)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 3. Outcomes\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Short term outcomes & Mean/frequencies ( \%)\tabularnewline
\midrule
\endhead
Procedural deaths & 0/21 (0)\tabularnewline
30 day mortality & 0/21 (0)\tabularnewline
Major vascular complications & 0/21 (0)\tabularnewline
Stroke & 0/21 (0)\tabularnewline
Dialysis & 0/21 (0)\tabularnewline
Conversion to open surgery / salvage procedure & 0/21 (0)\tabularnewline
Hospital stay (days)(n =21) & 22.9 +/- 50.4\tabularnewline
Hospital stay excluding polytrauma cases (days) (n=16) & 5.8 +/-
4.12\tabularnewline
Hospital stay for elective zone 2, 3 or 4 TEVAR excluding trauma case
(days) (n=13) & 5.3 +/- 3.8\tabularnewline
Mean time to follow up computed tomography scan (months) (N=19) & 3.6
+/- 3.24\tabularnewline
Endoleak & 1/19 (5.3\%)\tabularnewline
Stent induced new entry tear & 0/19\tabularnewline
Retrograde dissection & 0/19\tabularnewline
Stent migration & 0/19\tabularnewline
Procedural success \textsuperscript{a} & 18/19 (94.7\%)\tabularnewline
Deployment accuracy \textsuperscript{b} & 19/19 ( 100\%)\tabularnewline
Positive aortic remodelling \textsuperscript{c} ( n = 14) & 11/14 (
78.6\%)\tabularnewline
Absent aortic remodelling \textsuperscript{d} & 3/14
(21.4\%)\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{a} \emph{Defined as no major complications post
procedure , no endoleak, SINE, new dissection or migration on FU CT}

\textsuperscript{b} \emph{Defined as within 5mm of intended proximal
landing location on fluoroscopy and CT scan}

\textsuperscript{c} \emph{Not applicable to transection ; Defined as
complete PAU/SINE coverage / Size reduction of aneurysmal sac}

\textsuperscript{d} \emph{No change in size of aneurysmal sac despite
thrombosis outside stent or complete coverage of SINE/PAU}

Figure 1a\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1a. Penetrating aortic ulcer with saccular aneurysm.

Figure 1b\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 1b. Intraoperative angiogram showing zone 2 stenting of PAU.

Figure 1c\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 1c. Follow up CT scan of stented PAU with thrombosis of saccular
aneurysm sac.

Figure 2a\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Figure 2a. Grade 3 aortic transection with pseudoaneurysm and
mediastinal hematoma.

Figure 2b\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

Figure 2b. Follow up CT scan showing reduction in mediastinal hematoma
and coverage of pseudoaneurysm

Figure 3a\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

Figure 3a. Saccular aneurysm on CT scan.

Figure 3b\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}

Figure 3b. Patent carotid -carotid bypass and left carotid-axillary
bypass with zone 1 TEVAR.

\par\null

Figure 3c\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image8/image8}

\end{center}
\end{figure}

Figure 3c. Aneurysmal sac and left subclavian artery embolization.

Figure 3d.~\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image9/image9}

\end{center}
\end{figure}

Figure 3d. Post op CT showing coils in aneurysmal sac and zone 1 TEVAR
in situ

\selectlanguage{english}
\FloatBarrier
\end{CJK}\end{document}

