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Preliminary evidence supports the notion that COVID-19 patients may have an increased susceptibility to develop venous thromboembolism (VTE). However, the magnitude of this association still needs to be defined. Furthermore, clinical predictors of thrombogenesis, and the relationship with the inflammatory status are currently unknown. On this basis, we conducted a retrospective, observational study on 259 consecutive COVID-19 patients admitted to an academic tertiary referral hospital in Northern Italy between March 19th and April 6th, 2020. Records of COVID-19 patients with a definite VTE event were reviewed for demographic information, co-morbidities, risk factors for VTE, laboratory tests, and anticoagulation treatment. Twenty-five cases among 259 COVID-19 patients developed VTE (9.6%), all of them having a Padua score > 4, although being under standard anticoagulation prophylaxis since hospital admission. In the VTE subcohort, we found a significant positive correlation between platelet count (PLT) and either C reactive protein (CRP) (p p = 0.0013), while a significant inverse correlation was observed between PLT and mean platelet volume (p p p = 0.002 and p = 0.005, respectively). No significant difference was found in d-dimer levels between VTE and non VTE patients, while significantly higher levels of LDH (p = 0.04) and IL-6 (p = 0.04) were observed in VTE patients in comparison to non-VTE patients. In conclusion, our findings showed a quite high prevalence of VTE in COVID-19 patients. Raised inflammatory indexes and increased serum levels of pro-inflammatory cytokines should raise the clinical suspicion of VTE.

Preliminary evidence supports the notion that COVID-19 patients may have an increased susceptibility to develop venous thromboembolism (VTE). However, the magnitude of this association still needs to be defined. Furthermore, clinical predictors of thrombogenesis, and the relationship with the inflammatory status are currently unknown. On this basis, we conducted a retrospective, observational study on 259 consecutive COVID-19 patients admitted to an academic tertiary referral hospital in Northern Italy between March 19th and April 6th, 2020. Records of COVID-19 patients with a definite VTE event were reviewed for demographic information, co-morbidities, risk factors for VTE, laboratory tests, and anticoagulation treatment. Twenty-five cases among 259 COVID-19 patients developed VTE (9.6%), all of them having a Padua score 4, although being under standard anticoagulation prophylaxis since hospital admission. In the VTE subcohort, we found a significant positive correlation between platelet count (PLT) and either C reactive protein (CRP) (p 0.0001) or lactate dehydrogenase (LDH) (p = 0.0013), while a significant inverse correlation was observed between PLT and mean platelet volume (p 0.0001). Platelet-to-lymphocyte ratio significantly correlated with CRP (p 0.0001). The majority of VTE patients was male and younger compared to non-VTE patients (p = 0.002 and p = 0.005, respectively). No significant difference was found in D-dimer levels between VTE and non VTE patients, while significantly higher levels of LDH (p = 0.04) and IL-6 (p = 0.04) were observed in VTE patients in comparison to non-VTE patients. In conclusion, our findings showed a quite high prevalence of VTE in COVID-19 patients. Raised inflammatory indexes and increased serum levels of pro-inflammatory cytokines should raise the clinical suspicion of VTE.

In questo capitolo vengono descritti gli aspetti epidemiologici, diagnostici e terapeutici dell'arteriopatia ostruttiva degli arti inferiori, dei tronchi sovraaortici e delle arterie renali

Introduction The aim of this prospective observational registry was to study the outcome of symptomatic patients presenting with recent TIA or minor stroke and severe carotid stenosis, submitted to early percutaneous treatment by stenting. A secondary aim was to evaluate the biological activity of the symptomatic carotid plaques by serial serum and urinary markers (PAPP-A, hs-CRP, MMP-2/MMP-9, IL-6/IL-8, TNF alpha, CD40L) measured by enzyme-linked immunosorbent assay before and after treatment. Methods From May 2005 to June 2006, 57 patients were enrolled in this prospective registry. All patients underwent carotid stenting using a concentric filter for cerebral protection. The procedure was performed within 24–48hrs of the last attack in patients with TIA ( n =24, 42%) and between 14 and 30 days in patients with stroke ( n =33, 58%). Results Successful stent implantation was achieved in all cases (100%). Adverse events at 1 month were 1 death (1.7%) and 2 TIAs (3.5%). Some of the vulnerability markers, in particular those reflecting an active systemic inflammatory process of the plaque (PAPP-A, hs-CR, and IL-6), were significantly elevated at the time of enrolment, increased after stenting and decreased after 30 days. Conclusion Deferred CAS is feasible and safe in selected patients with symptomatic carotid stenosis. This preliminary study in a limited series of patients with unstable carotid plaques revealed that endovascular treatment has a satisfactory outcome considering the very high risk profile of the patient population. The evaluation of some biomarkers suggested an inflammatory role in the process of an unstable carotid plaque generating an acute cerebral event.

The equivalent currents method has proven to be particularly effective in the identification of plasma boundary in Tokamak fusion devices. Anyway, the ill‐posedness of the mathematical model to be inverted calls for the adoption of suitable regularization techniques to be adopted, in particular to reduce the influence of the measurement errors. In this paper the equivalent currents method is illustrated, together with some details on its application to the plasma identification. In addition, two algorithms for the optimal choice of the representation basis are presented, together with a discussion about the obtained numerical results.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Objective: The appropriateness of endovascular aneurysm repair (EVAR) of uncomplicated abdominal aortic aneurysm depends on the risk-benefit ratio, particularly in elderly patients with short life expectancy. The aim of this study was to assess the efficacy of EVAR in >80-year-old patients by evaluating their postoperative survival and analyzing the possible predictors of late mortality. Methods: All consecutive patients aged >80 years undergoing elective EVAR from 2006 to 2015 were prospectively evaluated. The 30-day mortality and long-term survival were assessed, and independent risk factors for mortality were determined by multivariate logistic and Cox analysis. Results: Of a total of 1135 EVARs performed in a 10-year period, 201 (18%) occurred in patients older than 80 years. The median age was 84 years (interquartile range, 3 years), and 85% were male. Thirty-four patients (17%) had a score of 4 according to the American Society of Anesthesiologists (ASA) classification. Overall 30-day mortality was 2% (n = 4); it was significantly higher in those with ASA score of 4 compared with ASA score 80-year-old patients is associated with an overall early mortality rate as low as 2%. In patients with no or only one risk factor, the survival rate warrants the treatment of abdominal aortic aneurysm; in contrast, patients with ASA score of 4 and PAOD have a significantly higher mortality rate and reduction of life expectancy.

Objective To evaluate the impact of renal artery (RA) anatomy on the renal outcome of fenestrated-branched endografts (FB-EVAR) for thoraco-abdominal aortic aneurysms (TAAA). Methods Between 2010 and 2016, all patients undergoing FB-EVAR for TAAA were prospectively collected. Anatomical, procedural, and post-operative data were retrospectively analysed. RA anatomy was assessed on volume rendering, multi planar and centre line reconstructions by dedicated software (3Mensio). RA diameter, length, ostial stenosis/calcification, orientation and aortic angles of the para-visceral aorta were evaluated. RA orientation was classified in four types: A (horizontal), B (upward), C (downward), D (downward + upward). RA revascularisation by fenestrations or branches was considered. Inability to cannulate and stent RA (RA loss), early RA occlusion (within three months), and composite RA events (one among RA loss, intra-operative RA lesion, RA related re-interventions, RA occlusion) were assessed. Results Seventy-three patients (male 77%; age 73 ± 6 years) with 39 (53%) type I, II, III and 34 (47%) type IV TAAA, underwent FB-EVAR, for a total of 128 RAs. The mean RA diameter and length were 6 ± 1 mm and 43 ± 12 mm, respectively. Type A, B, C, and D orientations were 51 (40%), 18 (14%), 48 (36%), and 11 (10%) RAs, respectively. Angulation of para-visceral aorta >45° was present in 14 cases (19%). Ostial stenosis and calcifications were detected in 20 (16%) and 16 (13%) RAs, respectively. Branches and fenestrations were used in 43 (34%) and 85 (66%) RAs, respectively. There were four (3%) intra-operative RA lesions (2 ruptures, 2 dissections). Ten (8%) RAs were lost intra-operatively because of the inability to cannulating and stenting. On univariable analysis, type B RA orientation (p = .001; OR 13.2; 95% CI 3.2–53.6), para-visceral aortic angle > 45° (p = .02; OR 4.9; 95% CI 1.3–18.5) and branches (p = .003; OR 9.0; 95% CI 1.9–46.9) were risk factors for intra-operative RA loss; type C RA orientation was a protective factor (p = .02; OR 0.1; 95% CI 0.01–0.9). On multivariable analysis, type B RA orientation (p = .03; OR 5.9; 95% CI 1.1–31.1) and branches (p = .03; OR 7.3; 95% CI 1.1–47.9) were independent risk factors for intra-operative RA loss. Fourteen patients suffered post-operative renal function worsening (> 30% of the baseline). The mean follow up was 19 ± 12 months. Four (3%) early RA occlusions occurred in three patients (2 single kidney patients required permanent haemodialysis). Type D RA orientation (p = .00; RR 17.8; 8.6–37.0) and branches (p = .004; RR 3.2; 2.4–4.1) were risk factors for early RA occlusion on univariable analysis. Five patients (7%) required early RA related re-interventions (recanalisation + relining 3; stent graft extension 1; parenchymal embolisation 1). No late RA occlusion or re-interventions were reported during follow up. Composite RA events occurred in 17 (13%) cases. Type B (p = .05; OR 3.9; 95% CI 1.1–15.7) or D (p = .006; OR 10.9; 95% CI 2.3–50.8) RA orientations and branches (p = .006; OR 5.7; 95% CI 1.6–20.3) were independent predictors of composite RA events on multivariable analysis. Conclusion Renal artery orientation significantly affects the early RA outcome of FB-EVAR for TAAA. Intra-operative RA loss is predicted by type B RA orientation and branches, while early RA occlusion is predicted by type D orientation and branches. The present data suggest that in TAAA, fenestrations should be the first choice for renal revascularisation in type B and D RA orientations.

Background: The cumulative amount of iodinated contrast medium necessary for endovascular repair (EVAR) planning, operative procedure, and subsequent follow-up is a threat for the onset of end-stage renal disease in patients with preoperative impaired kidney function. The purpose of this study was to describe a mini-invasive approach aimed to minimize the exposure of these patients to iodinated contrast medium and the subsequent risk of renal function worsening. Methods: From 2012 to 2015, all patients with abdominal aortic aneurysm (AAA) at high surgical risk and fit for standard EVAR (simple aortic-iliac anatomy: proximal and distal neck length ≥15 mm, no severe angulation), underwent EVAR through the following "near-zero contrast" approach, if their glomerular filtration rate (GFR) was

Background Carotid endarterectomy (CEA) intervention needs a specific training and a sufficient learning curve to obtain optimal results in terms of outcome. A formative program was settled up in a single academic center to optimize training of standard CEA procedures. This study aims to evaluate the 11-year results of the teaching CEA program. Methods The trainees CEA teaching program is carried on during the 5-year vascular surgery residency period, and it is stratified as follows: learning theory and intervention assistance (minimum 50 procedures per year) in the first and second residency year; performing CEA as second operator in the third and fourth residency year (minimum 50 procedures per year); CEA execution as first operator with attending supervision in the last residency year. All CEA procedures from 2005 to 2015 were retrospectively collected and the 30-day results were compared according to the expertise of the first operator: experienced vascular surgeons (EVSs) versus trainees. All CEA procedures were performed in general anesthesia, with routine shunting and patching. Results In the study period, 1,379 (361 [26.2%] symptomatic; 1,018 [73.8%] asymptomatic) CEAs were performed. Trainees performed 199 (14.4%) CEAs as first operator. Patients submitted to CEA by trainees were similar in terms of preoperative clinical characteristics except for the patients' age (trainees 72.4 years versus EVS 70.8 years, P = 0.02) and smoking history (trainees 30.7% versus EVS 24.1%, P = 0.04). The 30-day complication rates were similar in CEA performed by trainees versus EVS: stroke 0.5% vs. 1.1%, P = 0.5; death 0.0% vs. 0.5%, P = 0.6; stroke/death 0.5% vs. 1.7%, P = 0.24; hematoma 3.0% vs. 2.2%, P = 0.48; and cranial nerve injury 9.0% vs. 7.8%, P = 0.47, respectively. The intervention time was significantly longer in CEAs performed by trainees compared with EVS: 104 ± 1.9 min versus 98 ± 1.0 min, P = 0.02. Conclusions With a defined CEA teaching program, trainees can obtain results similar to those of more experienced surgeons in terms of clinical outcome at the price of an increased intervention time.

INTRODUCTION The best timing for carotid endarterectomy in patients with stroke is still matter of debate, particularly in case of significant cerebral ischemic lesion or neurological deterioration. The present review and meta-analysis aimed to report the best evidence in the outcome of patients submitted to urgent (

Purpose Generally the steal syndrome occurs in proximal arterial-venous fistulas and only exceptionally with distal vascular access because of the high number of arteries supplying the hand. We describe a rare case of steal syndrome of a proximalized distal radio-cephalic fistula stealing from both the radial and ulnar artery through the palmar arch. Methods An 86 year old man was admitted because of a cyanotic, swollen left hand with trophic lesions at the third finger. He had a latero-terminal radio-cephalic fistula performed in 2006 with subsequent proximalization performed four years later after failure of the first one. Duplex ultrasound examination showed a high flow within the fistula (2080 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch and an angiography excluded stenosis along the radial artery. Results We treated the steal syndrome through a plication technique that was performed with careful flow variations measurement, under duplex evaluation, during the surgical procedure. That procedure was effective to maintain the fistula flow and obtain the symptoms relief. The patient was evaluated the day after the intervention and after 10 weeks. The clinical examination highlighted the resolution of hand ischemia. The Duplex Ultrasound examination showed a lower flow within the fistula (1060 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch with a three-phase flow. Dialysis access from the fistula was never interrupted from immediately after surgery to the present date. Conclusions Plication is an effective technique for treatment of steal syndrome requiring a short operative time and it is related to satisfying post-operative results

Objective The objective of this study was to evaluate adverse events occurring during the lead period of custom-made fenestrated/branched endograft for juxtarenal/pararenal abdominal aortic aneurysm (j/p-AAA) and thoracoabdominal aortic aneurysm (TAAA). Methods Between 2008 and 2017, patients enrolled for custom-made fenestrated/branched endograft repair were prospectively collected. Anatomic, procedural, and postoperative data were retrospectively analyzed. Lead period was defined as the time between the endograft order to the manufacturer and implantation. Aneurysm diameter, target visceral vessel (TVV) severe stenosis (>75% of ostial lumen), and number of planned TVVs were evaluated at preoperative computed tomography angiography. Patency of TVVs was evaluated intraoperatively. Aneurysm rupture and TVV occlusion during the lead period were assessed. Results There were 141 custom-made fenestrated/branched endograft repairs planned. Of these, 133 patients (male, 87%; age, 73 ± 6 years) with complete available data were considered for the study. There were 75 (56%) j/p-AAAs and 58 (44%) TAAAs. The mean aneurysm diameter was 58 ± 6 mm (j/p-AAA, 56 ± 6 mm; TAAA, 67 ± 8 mm); 15 cases (11%) had >70-mm diameter. Planned TVVs were 431 (mean, 3 ± 1 TVVs/patient). The mean lead period was 89 ± 25 days, with five (3.8%) aneurysm ruptures (j/p-AAA, one; TAAA, four) occurring, two (1.5%) during manufacture and three (2.3%) with endograft available in the hospital (all three procedures were postponed because of cardiac or pulmonary comorbidities). In one TAAA rupture, the endograft was successfully implanted and the patient survived. Four of five ruptures had >70-mm diameter. On univariate analysis, chronic obstructive pulmonary disease (P = .01; odds ratio [OR], 2.6; 95% confidence interval [CI], 2.1-3.2) and aneurysm diameter >70 mm (P = .001; OR, 42; 95% CI, 4-411) were risk factors for aneurysm rupture during the lead period, with aneurysm diameter >70 mm being confirmed as an independent risk factor on multivariate analysis (P = .005; OR, 29.3; 95% CI, 2.8-308). Overall, eight endografts (6%) were not implanted (refusal, two; aneurysm rupture, four; death not related to aneurysm, two). In the remaining 125 patients (94%), 405 TVVs were planned. Of them, 46 (11%) had severe stenosis at preoperative computed tomography angiography. Twelve (3%) TVVs occluded in the lead period (renal arteries, five; celiac trunks, seven); six were recanalized and six were abandoned. Severe preoperative stenosis was a risk factor for TVV occlusion during the lead period (P = .000; OR, 1.3; 95% CI, 1.1-1.6). Conclusions In our series, custom-made design required a mean lead period of 89 days, which was determined by both manufacturing time and clinical reasons. During this delay, there is a high risk of both rupture in aneurysms >70 mm and TVV occlusion in severely stenosed vessels. These factors should be considered in the indication for custom-made fenestrated/branched endograft repair.

Objective Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. Methods Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. Results On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( PConclusions cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

Background Technical intraoperative complications (TICs) may occur during standard endovascular repair (EVAR) with possible effects on the outcome. This study evaluates the early and midterm effects of TICs on EVARs. Methods All EVARs (from 2012 to 2016) were analyzed to identify all TICs: (1) endoluminal defects (stenosis, dissection, rupture, compression of native arteries, or endograft); (2) type I-III endoleaks; (3) unplanned artery coverage; and (4) surgical access complications. Follow-up was performed by Doppler ultrasound/ontrast enhanced ultrasound/computed tomography scan at yearly intervals. The outcome was compared with that of uneventful cases (UCs) through Fisher's exact test and Kaplan-Maier curve. Results TICs occurred in 68 (18%) of 377 patients undergoing EVAR. Thirty-two endoluminal defects were relined endovascularly; 24 type I-III endoleaks were treated with cuff deployment/forced ballooning (23) and surgical conversion (1); 3 of 8 unplanned artery coverages were revascularized (2 renal and 1 hypogastric); 5 hypogastric coverages had an unsuccessful correction; and 4 access artery injuries were repaired. Although fluoroscopy time and contrast usage were significantly higher in the TIC group than those in the UC group (309 cases), 30-day outcome was similar for death (1.4% TIC vs 0% UC, P = 0.18), reintervention (0% TIC vs 0.3% UC, P = 1), type I-III endoleak (0% TIC vs 0.9% UC, P = 1), steno-occlusions (0% TIC vs 0.3% UC, P = 1), buttock claudication, and renal failure (0% in both groups). At 24 months, TIC and UC groups had similar survival (91.7 ± 8% vs 96.2 ± 2.1%, P = 0.5), freedom from reintervention (81.4 ± 9.9% vs 96 ± 2.2%, P = 0.49), overall complication rate (13.4 ± 7.6% vs 11.4 ± 3.5%, P = 0.49), type I-III endoleak (11.2 ± 7.5% vs 7 ± 2.9%, P = 0.8), buttock claudication (0% vs 2 ± 2% P = 0.6), and hemodialysis (0% in both). Midterm iliac leg occlusion was significantly higher in the TIC group (26.9 ± 12.3% vs 3 ± 2.1%, P = 0.01). Conclusion TICs may affect several aspects during EVAR, leading to the necessity of adjunctive maneuvers, which have no impact on early outcome but may cause an increased rate of midterm iliac leg occlusion.

Background To report early and mid-term results of endovascular treatments for type Ib endoleaks (IbEL) after endovascular aneurysm repair (EVAR) for aorto-iliac aneurysms (AAA). Methods Patients with IbEL after EVAR were retrospectively analyzed. Cases of IbEL treated in two centers from January 2009 to February 2017 were considered. Patients' demographics and comorbidities, interval between EVAR and IbEL diagnosis, type of endograft, site of sealing, oversize and length of iliac sealing zone, type of IbEL treatment were collected. Main endpoints were freedom from IbEL recurrence and freedom from reintervention. Results Thirty-five IbEL were treated in 29 patients (mean age: 76±7years; male: 100%). Mean time between EVAR and IbEL detection was 43±30months. IbEL was symptomatic in 4 (14%) and bilateral in 6 (21%). Endograft was bifurcated in 26 patients (90%) and aorto-uniiliac in 3 (10%). Distal landing zone was achieved in common and external iliac artery in 33 (94%) and 2 cases (6%), respectively. Mean oversize of endograft limb was 11±9%, mean length of sealing zone was 22±15 mm. Endovascular treatments included: 34 iliac extensions (8 cases [24%] with hypogastric artery coverage), and 1 embolization. Concomitant embolization of hypogastric artery was performed in 3 (9%) cases. Technical success was 100%, with no procedure-related complication. Considering patients with hypogastric exclusion, buttock claudication developed in 2/8 cases (25%). Mean follow-up was 20±19 months. Freedom from IbEL was 100% and no reintervention was necessity for IbEL during follow-up. At 12, 24 and 36 months, survival was 88%, 82% e 61%, respectively, with no IbEL-related death. Conclusions IbEL can be easily managed by endovascular means, typically with distal extensions with landing zones in the common or external iliac artery. Mid-term results are favourable, with no recurrent IbEL or reintervention.

Background Endovascular aortic repair (EVAR) is presently the preferred treatment for abdominal aortic aneurysm; however, it requires the injection of a contrast medium, which can hamper the renal function. Other nontoxic agents such as carbon dioxide (CO2) have been sporadically tested in this setting with uncertain results. The aim of the study is to investigate the efficacy of a new standardized CO2 injection method in standard EVAR procedures. Methods Between August and October 2016, 31 consecutive patients (median age 76.1 [interquartile range {IQR}: 7.4] years) were submitted to standard EVAR. Proximal and distal endograft landing zones were identified by the injection of 100 mL of CO2 at 300 mm Hg, through an 11 cm 10F femoral sheath by a specifically manufactured automated injection device (Angiodroid Srl, San Lazzaro, Bologna, Italy). Before EVAR deployment, a confirmative injection with a conventional contrast medium was accomplished. The possibility of precisely visualizing the proximal and distal landing zones by CO2 digital subtraction angiography (DSA) was evaluated considering the contrast medium injection obtained in the same procedure as a gold standard. Similarly, the possible presence of endoleak was assessed at the end of the procedure by the 2 techniques. Results CO2 DSA allowed to identify the juxtarenal landing zone of the endograft in 19/31 cases (61%) and the distal one in 31/31 (100%). In 12 (39%) cases, CO2 injection failed to visualize at least the lowest renal artery. This occurred in large aneurysms with scarce thrombotic apposition and a luminal volume greater than 95.9 (IQR: 25.2) mm3. Completion CO2 DSA detected type II endoleaks (ELIIs) in 10 cases compared with 2 of conventional contrast media. Conclusions The injection of nontoxic CO2 through an automated device allowed to perform EVAR procedures effectively, in the majority of cases. In some cases, a single injection of a minimum amount of conventional contrast medium can be used to overcome the lack of renal artery visualization by CO2. ELIIs are more frequently visualized with CO2 compared with standard contrast medium. Although the CO2 injection technique needs further amelioration particularly in the renal arteries detection, this technique appears promising and possibly substitutive of the standard contrast medium, with significant benefit for the renal function.

Background: The aim of the study was to evaluate the outcomes of duplex ultrasonography (DUS)–guided autologous vein bypass to paramalleolar (distal third of tibial arteries and peroneal artery) and inframalleolar arteries (dorsalis pedis, common plantar, medial, and lateral plantar arteries) in patients with critical limb ischemia (CLI) and extensive tibial artery disease Trans-Atlantic Inter-Society Consensus D. Methods: Between January 2007 and October 2016, all paramalleolar or inframalleolar bypasses performed in patients with CLI, planned only on the basis of DUS, were collected and analyzed retrospectively. DUS evaluation included arterial disease extension, inflow and outflow arteries' diameter, outflow vessels resistance, and autologous veins quality. Patient's demographics and clinical characteristics were assessed. Tissue loss was graded according to Texas University Wound Classification (TWC). Follow-up included periodic clinical and DUS examinations. Primary end points were technical success (TS) (patent bypass with distal anastomosis performed on the Duplex-selected runoff artery, without stenosis >30% and in line flow with the inframalleolar arteries at completion angiography and without hemodynamic bypass stenosis at postoperative DUS) and bypass patency (primary [PP], assisted [AP], and secondary [SP]). Secondary end points were perioperative and follow-up patient survival (PS), limb salvage (LS), and amputation-free survival (AFS). Descriptive statistics and Kaplan-Meier analysis were performed. Univariate and Multivariate Cox analyses were used to define risk factors. Results: Seventy-four bypasses in 73 patients with CLI (Rutherford 5–6 93.2%, TWC stage III in 63.5% and grade D in 48.6%) were performed in the study period (January 2007–October 2016). diabetes mellitus, coronary artery disease, and kidney disease were present in 67.6%, 60.8%, and 37.8% patients, respectively. Distal anastomosis was performed at the paramalleolar and inframalleolar arteries in 47.3% and 52.7%, respectively. Only autologous veins were used as conduit. TS was 98.6%. At 1-month, PP, AP, SP, PS, LS, and AFS were 87.8%, 91.9%, 93.2%, 95.9%, 94.6%, and 90.5%, respectively. The mean follow-up was 33.7 months; at 1-year, PP, AP, SP, PS, LS, and AFS were 54.4%, 71.4%, 75.1%, 89.9%, 84.3%, and 79.1%, respectively, and at 3-year, 42.3%, 63%, 66%, 67.5%, 80.6%, and 61%, respectively. At univariate and multivariate analyses, arterial hypertension was protective for PP (P = 0.035) while insulin-dependent diabetes was a negative predictor (P = 0.01); insulin-dependent diabetes was a negative predictor of LS (P = 0.002); TWC grade D was a negative predictor of AP (P = 0.047) and SP (P = 0.013). Age (P < 0.001) and major amputation (P = 0.014) resulted as negative predictors of PS. Conclusions: Bypass of the Duplex-selected paramalleolar and inframalleolar arteries in CLI has high TS and high rate of perioperative and late LS. Duplex evaluation and planning in CLI patients with extensive tibial arteries disease is associated with efficacy of surgical revascularization and high LS rates.

Introduction. Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS.Methods. A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohen’s concordance Index(K).Results. Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohen’sK: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohen’sK: 0.65) for ELII detection.Conclusion. CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.

Background Thoracoabdominal aortic aneurysms (TAAAs) after previous aortic open surgical repair (OSR) are challenging clinical scenarios. Redo-OSR is technically demanding, and standard endovascular repair is unavailable due to visceral vessel involvement. Fenestrated and branched endografts (FB-EVAR) are effective options to treat TAAAs in high surgical risk patients but dedicated studies on the FB-EVAR outcomes in patients with TAAAs with previous OSR are not available. The aim of the study was to evaluate the impact of previous OSR on TAAAs FB-EVAR outcomes. Methods Between 2010 and 2016, all TAAAs undergoing FB-EVAR were prospectively evaluated, retrospectively categorized in two groups, and then compared: group A–primary TAAAs and group B–TAAAs after previous OSR (abdominal, thoracic, or thoracoabdominal aneurysm). Early end points were technical success (absence of type I-III endoleak, target visceral vessel loss, conversion to OSR, intraoperative mortality), spinal cord ischemia (SCI), and 30-day mortality. Follow-up end points were survival, target visceral vessel patency, and freedom from reinterventions. Results Sixty-two patients (male: 74%; age: 72 ± 7 years) with 1 (1%) extent I, 14 (23%) extent II, 24 (39%) extent III, and 23 (37%) extent IV TAAA underwent FB-EVAR. The mean TAAA diameter and total target visceral vessels were 65 ± 13 mm and 226, respectively. Ninety branches and 136 fenestrations were planned. Thirty cases (48%) were clustered in group A and 32 (52%) in group B. Patients in group A and group B had similar preoperative clinical and morphologic characteristics, except for female sex (group A: 40% vs group B: 13%; P = .02). Technical success was 92% (group A: 90% vs group B: 94%; P = .6), SCI 5% (group A: 10% vs group B: 0%; P = .1) and 30-day mortality 5% (group A: 10% vs group B: 0%; P = .1). The mean follow-up was 17 ± 11 months with a total survival of 86%, 80%, and 60% at 6, 12, and 24 months, respectively and no differences in the two groups (group A: 83%, 83%, and 67% vs group B: 88%, 78%, and 55% respectively; P = .96). There was no late TAAA-related mortality. Target visceral vessel patency was 91%, 91%, and 91% at 6, 12, and 24 months, respectively (group A: 87%, 87%, and 87% vs group B: 95%, 95%, and 95%; P = .25). Freedom from reinterventions was 90%, 87%, and 87%, at 6, 12, and 24 months, respectively, and it was significantly lower in group A compared with group B (group A: 83%, 76%, and 76% vs group B: 96%, 96%, and 96% respectively; P = .002). Conclusions Previous open surgery repair does not significantly affect the early outcomes of FB-EVAR in TAAA, with encouraging results in terms of technical success, SCI, mortality, and lower reinterventions rate at midterm follow-up.

Background: Medical therapy for asymptomatic carotid artery stenosis (ACAS) may obviate the carotid revascularization, according to recent literature reports, but many studies also considered moderate carotid artery stenosis (50–69% NASCET). This study reviews the most recent series of ACAS focusing on ipsilateral transient ischemic attack (TIA) stroke and annual risk of stroke in patients with ACAS ≥70%, thereby also evaluating the adherence to best medical therapy (BMT). Methods: A systematic review consisting of all the series of patients with ACAS being treated medically was performed, which was published after 2005. The annual pooled risk of ipsilateral TIA-stroke and stroke in patients with ACAS ≥70% was calculated. A subgroup of studies with BMT defined as ≥90% of the patients in antiplatelet and statin therapy was performed. Results: Eleven studies, with the enrolling period from 1996 to 2009, were reviewed. Overall, 2185 patients were considered, with a follow-up from 2 to 13 years, for a total of 6834 patients/year. The pooled risk was 3.4%/year for ipsilateral TIA-stroke and 1.6%/year for stroke. Five studies, published from 2014, had BMT adherence, for a total of 1665 patients/year. The pooled risk was 3.5%/year for ipsilateral TIA-stroke and for stroke. Conclusion: The most recent series of ACAS ≥70% and BMT had an overall stroke rate which is relatively low; however, the risk of developing symptoms is still relevant (3.4%/year).

none 10 no Objective: Simulation may be a useful tool for training in endovascular procedures. The aim of this study was to evaluate the effect of endovascular repair of abdominal aortic aneurysms (EVAR) simulation in boosting trainees' learning curve. Design: Ten vascular surgery residents were recruited and divided in 2 groups (Trainee Group and Control group). At a first session (t0), each resident performed 2 simulated EVAR procedures using an endovascular simulator. After 2 weeks, each participant simulated other 2 EVAR procedures in a final session (t1). In the period between t0and t1, each resident in the Trainee Group performed 6 simulated EVAR procedures, whereas the Control Group did not perform any other simulation. Both quantitative and qualitative performance evaluations were performed at t0and t1. Quantitative evaluation from simulator metrics included total procedural time (TP), total fluoroscopy time (TF), time for contralateral gate cannulation (TG), and contrast medium volume (CM) injected. Qualitative evaluation was based on a Likert scale used to calculate a total performance score referred to skills involving major EVAR procedural steps. Results: All residents in the Trainee Group significantly reduced TP(48 ± 12 vs 32 ± 8 minutes, t0vs t1, p < 0.05), TF(18 ± 7 vs 11 ± 6 minutes, p < 0.05), and CM used over time (121 ± 37 vs 85 ± 26ml, p < 0.05), but not TG(5 ± 5 vs 3 ± 4 minutes, p = 0.284). In the Control Group metrics did not change significantly in any field (TP= 55 ± 11 vs 46 ± 10 minutes; TF= 25 ± 9 vs 21 ± 4 minutes; CM = 132 ± 51 vs 102 ± 42ml; TG= 6 ± 4 vs 8 ± 5 minutes, all p > 0.05). The average Trainee Group qualitative total performance score improved significantly (p < 0.05) after rehearsal sessions when compared with the Control Group. Conclusion: Simulation is an effective method to improve competence of vascular surgery residents with EVAR procedures. open Vento, Vincenzo; Cercenelli, Laura; Mascoli, Chiara; Gallitto, Enrico; Ancetti, Stefano; Faggioli, Gianluca; Freyrie, Antonio; Marcelli, Emanuela; Gargiulo, Mauro; Stella, Andrea Vento, Vincenzo; Cercenelli, Laura; Mascoli, Chiara; Gallitto, Enrico; Ancetti, Stefano; Faggioli, Gianluca; Freyrie, Antonio; Marcelli, Emanuela; Gargiulo, Mauro; Stella, Andrea

Objective Fenestrated and branched endovascular aneurysm repair (FB-EVAR) is a valid option to treat juxtarenal and pararenal abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. Because successful deployment depends on complex maneuvers, hostile iliac artery anatomy (HIA) can prejudice the FB-EVAR outcome. The aim of the study was to evaluate the impact of HIA on FB-EVAR outcome. Methods Between 2010 and 2015, all patients undergoing FB-EVAR were prospectively categorized according to iliac anatomy (friendly iliac artery anatomy [FIA] or HIA). HIA was defined as the presence of one of the following: severe (>90-degree) iliac angle, extensive (>50%) iliac circumferential calcification, hemodynamic iliac stenosis or obstruction, external iliac artery diameter

Background Carotid plaques with a high degree of calcification are usually considered at low embolic risk. However, since a precise evaluation of the extent of calcification is not possible preoperatively through duplex ultrasound and postoperatively by conventional histological examination due to the decalcification process, the relationship between the amount of calcium involvement and plaque vulnerability has not been evaluated yet. This study aims to correlate the extent of carotid plaque calcification with clinical, radiological, and histological complications. Methods Symptomatic and asymptomatic consecutive patients submitted to carotid endarterectomy between January to December 2014 were included in the study. The amount of carotid calcification was assessed at preoperative computed tomography (CT) through measurement of thickness and circumferential calcium extension and graded from 1 to 8 accordingly (Babiarz classification). Patients were then categorized into 2 groups (low-level group: grade 1–5; high-level group: grade 6–8) and correlated with clinical characteristics and ipsilateral cerebral ischemic lesions at CT. Vulnerability of the plaque was assessed histologically according with American Heart Association (AHA) Classification. Results were overall blindly correlated. Results One hundred five patients (81% male; age: 73 ± 8 years) were enrolled in the study. Forty (38%) were symptomatic and 43 (40%) had an ipsilateral focal lesion at preoperative cerebral CT. Thirty-six (38%) patients had high-level carotid calcification degree at CT scan. At histological analysis, 56 (56%) plaques were considered complicated (AHA type VI). Patients with high-level and low-level carotid calcification had similar epidemiological risk factors, preoperative neurological symptoms, and histological complications (17% vs. 15%, P = 0.76 and 50% vs. 55%, P = 0.62, respectively). The high-level calcification group showed a significantly higher incidence of ipsilateral cerebral lesions at preoperative CT (56% vs. 32%, P = 0.01). Conclusions A high level of calcification of the carotid plaque is not necessarily associated with lower vulnerability: the incidence of preoperative neurological symptoms and histological complications is similar in patients with and without extensive carotid plaque calcification. Cerebral ischemic lesions may be even more frequent in the presence of highly calcified plaques.

Background The influence of acute cerebral ischemic lesions (CILs) on the revascularization outcome of symptomatic carotid stenosis has been scarcely investigated in the literature. This study evaluated the effect of CILs and their volume on the results of carotid revascularization in symptomatic patients. Methods All patients with symptomatic carotid artery stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) between 2005 and 2014 were considered. CILs ipsilateral to the stenosis were identified in the preoperative cerebral computed tomography. The volume was quantified in mm 3 and correlated with 30-day rates of stroke and stroke/death by χ 2 , multivariate analysis, Pearson correlation, and receiver operating characteristic curves. Results A total of 489 symptomatic patients were treated by CEA (327 [67%]) or CAS (162 [33%]), 186 (38%) ≤2 weeks and 303 (62%) >2 weeks from symptom onset. CEA and CAS patients had statistically similar rates of stroke (3.3% vs 5.5%; P = .27) and stroke/death (3.8% vs 5.9%; P = .22). CILs were identified in 251 patients (53%) and were associated with similar stroke and stroke/death rate compared with patients without CIL (12 [4.8%] vs 8 [3.5%], P = .46; and 14 [5.6%] vs 8 [3.5%]; P = .26, respectively). The median CIL volume was 1000 mm 3 (interquartile range [IQR], 7000 mm 3 ). Patients with postoperative stroke and stroke/death had a significantly higher preoperative CIL volume of 5100 mm 3 (IQR, 31,000 mm 3 ) vs 1000 mm 3 (IQR, 7000 mm 3 ; P = .01) and 4500 mm 3 (IQR, 17,450 mm 3 ) vs 1000 mm 3 (IQR, 7000 mm 3 ; P = .03), respectively. The receiver operating characteristic curve analysis showed a volume of 4000 mm 3 was predictive of postoperative stroke with 75% sensitivity and 63% specificity. A CIL volume ≥4000 mm 3 was an independent risk factor for postoperative stroke, with a stroke rate of 9.3% (n = 9) vs 1.9% (n = 3) for a CIL volume of 3 (odds ratio, 4.6; 95% confidence interval, 1.1-19.1; P = .03). Conclusions CIL volume in symptomatic carotid stenosis seems to influence the 30-day outcome independently from the timing of carotid revascularization. A CIL volume of ≥4000 mm 3 could be considered a significant predictor for postoperative stroke after carotid revascularization.

none 8 no Objective: The aim of this paper was to report early and midterm results of endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) by the off-the-shelf multibranched Zenith t-Branch endograft (Cook Medical, Bloomington, Ind). Methods: Between January 2014 and April 2016, all patients with urgent TAAAs (asymptomatic with diameter >8 cm, symptomatic, or ruptured TAAAs) and aortoiliac anatomic feasibility underwent endovascular repair by t-Branch and were prospectively enrolled. Clinical, morphologic, intraoperative, and postoperative data were recorded. Follow-up was performed by duplex ultrasound, contrast-enhanced duplex ultrasound, and computed tomography angiography. Early end points were technical success (absence of type I or type III endoleak, loss of target visceral vessels [TVVs], conversion to open repair, or 24-hour mortality), spinal cord ischemia, and 30-day mortality. Follow-up end points were survival, TVV patency, type I or type III endoleaks, and freedom from reintervention. Results: Seventeen patients (male, 71%; age, 73 ± 6 years; American Society of Anesthesiologists class 3/4, 60%/40%) affected by type II (47%), III (29%), and IV (24%) TAAAs were enrolled. The indications for t-Branch were as follows: contained TAAA rupture, four (24%); symptomatic TAAA (pain or peripheral embolism), four (24%); and TAAA diameter ≥8 cm, nine (52%). The mean TAAA diameter was 80 ± 19 mm, with 63 TVVs. Fifteen patients (87%) needed adjunctive intraoperative procedures: 14 proximal thoracic endografts (thoracic endovascular aortic repair), 1 left carotid-subclavian bypass, 2 endovascular hypogastric branches, and 2 surgical iliac conduits. In four cases (24%), a significant malorientation (≥60 degrees) of the main body occurred during t-Branch deployment. Technical success was achieved in 14 cases (82%), with technical failures consisting of the loss of three renal arteries (TVV patency, 95%). Spinal cord ischemia occurred in one case (6%) with temporary paraparesis. The 30-day mortality was 6% (one patient with ruptured type II TAAA died on postoperative day 7 of respiratory failure). Renal function worsening occurred in four patients (25%), with one case requiring permanent hemodialysis. The mean follow-up was 11 ± 9 months. Survival at 1 month, 6 months, and 12 months was 94%, 82%, 82%, respectively. No TAAA-related mortality and TVV occlusion occurred in the follow-up. One type III endoleak was detected at 3 months and successfully treated. Freedom from reintervention at 1 month, 6 months, and 12 months was 88%, 82%, and 82%, respectively. Conclusions: The off-the-shelf multibranched endograft is a safe and effective therapeutic option for urgent total endovascular TAAA repair for which a custom-made endograft is not obtainable in due time. However, the complex anatomy of these aneurysms needs a number of adjunctive and complex intraoperative procedures to achieve a durable repair. none Gallitto, Enrico; Gargiulo, Mauro; Freyrie, Antonio; Pini, Rodolfo; Mascoli, Chiara; Ancetti, Stefano; Faggioli, Gianluca; Stella, Andrea Gallitto, Enrico; Gargiulo, Mauro; Freyrie, Antonio; Pini, Rodolfo; Mascoli, Chiara; Ancetti, Stefano; Faggioli, Gianluca; Stella, Andrea

Background Direct (DIR) or indirect (IND) revascularization of pedal angiosomes in patients with chronic limb-threatening ischemia (CLTI) has an unclear impact on limb salvage and healing. The aim of this study was to evaluate the outcomes of DIR and IND revascularization in patients with a peroneal bypass and tissue loss. Methods We conducted a retrospective study of a prospectively maintained database in two European university centers from 2004 to 2015. We extracted from this database all patients with CLTI and tissue loss who had received a bypass to the peroneal artery. All patients underwent angiography before bypass. Revascularization was considered DIR if the wound was in a peroneal angiosome. Wounds, ischemia, and infection were categorized according to the Wound, Ischemia, and foot Infection (WIfI) classification. Limb salvage and amputation-free survival were calculated using the Kaplan-Meier method. Cox regression was used to compare the role of patient characteristics, including diabetes, peroneal runoff, pedal arch angiosome, WIfI grade, chronic kidney disease, and diabetes, in amputation-free-survival. Results From January 2004 through October 2015, there were 120 peroneal bypasses performed in 120 patients with CLTI and foot tissue loss. Only 55 wounds (46%) could be ascribed to a peroneal angiosome. At 3 years, amputation-free survival in patients with DIR revascularization was 54.9% ± 7.3% compared with 56.5% ± 6.3% in patients with IND revascularization (P = .44), with no significant difference in wound healing. Amputation-free survival at 3 years in patients with two patent peroneal branches was 74.8% ± 6.9% compared with 45.0% ± 6.0% in patients with one patent peroneal branch (P = .003). Amputation-free survival at 3 years in patients with a patent pedal arch (Rutherford 0-1) was 73.0% ± 7.0% vs 45.7% ± 6.0% in patients with incomplete pedal arch (Rutherford 2-3; P = .0002). Amputation-free survival at 3 years in patients with grade 1 or grade 2 WIfI was 87.4% ± 8.3% compared with 48.4% ± 5.3% in patients with grade 3 or grade 4 WIfI (P = .001). Amputation-free survival at 3 years in patients with diabetes was 43.7% ± 6.2% compared with 73.1% ± 6.7% in patients without diabetes (P = .002). Wound healing at 6 months was not significantly improved by its location within or outside a peroneal angiosome. Cox regression analysis demonstrated that diabetes, patency of both peroneal branches, patency of pedal arch, and WIfI stage but not DIR angiosome revascularization were significant predictors of amputation-free survival. Conclusions Our results suggest that in patients with CLTI and tissue loss receiving a peroneal bypass, patency of both peroneal branches and pedal arch was associated with a better healing rate and a better amputation-free survival rate irrespective of wound angiosome location.

Background The aim of the study is to report early and follow-up outcomes of the endovascular treatment with iliac endografts for isolated iliac artery aneurysms (IIAAs). Methods Records of patients who underwent elective endovascular repair for IIAA (both primary and para-anastomotic) from 2005 to 2015 in 2 Italian centers were retrospectively examined. Demographic data, preoperative patient comorbidities, iliac aneurysm characteristics, contralateral iliac axis involvement, patency of hypogastric arteries and inferior mesenteric artery (IMA), and data of endovascular treatment were obtained for analysis. Early end points were technical success (TS), perioperative morbidity, clinical success (CS), freedom from reintervention (FFR) and survival. Follow-up end points were CS, FFR, survival, evolution of the aneurysmal sac, and endoleak (EL). Results Thirty-two IIAAs were treated through an endovascular approach in 30 patients (male 96.7%; mean age 74.2 years ± 7.6, range 55–86). Aneurysms were para-anastomotic in 11 (34.4%) cases. Mean diameter was 42.9 ± 15.6 mm (range 30–100). Twenty (62.5%) aneurysms involved exclusively the common iliac artery, 7 (21.9%) the hypogastric, and 5 (15.6%) both arteries. Ipsilateral hypogastric artery was stenotic or occluded in 4 (12.5%) and 1 (3.1%) patient, respectively. Contralateral hypogastric artery was occluded in 2 (6.3%) cases. IMA was patent in 9 (30%) patients. The ostium of the hypogastric artery was preserved in 5 cases (15.6%) and voluntarily covered in 27 (84.4%). Endovascular embolization of hypogastric artery was obtained with a plug device in 8 cases (25%). Hypogastric surgical revascularization was performed in 2 cases (6.3%). TS was 96.9%. Thirty-day morbidity was 6.3% (2/32). CS was 96.9% (1 endograft limb stenosis). Thirty-day FFR was 90.6% (1 transluminal angioplasty, 2 inguinal revisions). Thirty-day survival was 100%. At 1, 3, and 6 years, CS was 93.4%, 85.6%, and 85.6%, respectively (1 endograft limb thrombosis, 1 endograft limb stenosis, 1 hypogastric type II EL with sac enlargement). At 1, 3, and 6 years, FFR was 87.5%, 76.8%, and 76.8%, respectively (1 fibrinolytic therapy and stenting, 1 stenting, 1 surgical ligation of hypogastric artery). At 1, 3, and 6 years, survival was 100%, 96.3%, and 81.3%, respectively. No IIAA-related deaths were reported. During follow-up, aneurysmal diameter was unchanged in 12 cases (37.5%), decreased in 19 (59.4%), and increased in 1 (3.1%). Type II EL from hypogastric artery was detected in 3 cases (9.4%) and led to sac enlargement requiring surgical treatment in 1 case. Conclusions Endovascular treatment of isolated iliac aneurysm is safe and effective, providing that strict anatomical requirements are respected. Aneurysm embolization with vascular plugs was not associated with pelvic complications in this series. Endograft stenosis and thrombosis are the most frequent complications, which can be easily managed with endovascular approaches.

Background To report early and mid-term results of endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) by using Cook Zenith fenestrated/branched endografts (FB-EVAR) in high surgical risk patients unfit for open repair (OR). Methods Between January 2012 and April 2015, all the patients with TAAA, considered at high surgical risk for OR and treated by Cook Zenith FB-EVAR, were prospectively enrolled. Patients were studied using a thoracoabdominal computer tomography angiography (CTA) and dedicated software for advanced vessels analysis. Follow-up was performed by duplex ultrasound (DU), contrast-enhanced DU, and/or CTA. Early end points were the following: technical success (TS), spinal cord ischemia (SCI), and 30-day morbidity/mortality. Follow-up end points were the following: survival, TAAA-related mortality, target visceral vessels (TVV) patency, type I/III endoleaks, and freedom from reinterventions (FFRs). Results Thirty patients (male 77%, mean age 73 ± 7 years, American Society of Anesthesiologists 3/4 60%/40%) affected by TAAA type I (4%), II (21%), III (57%), and IV (18%) were enrolled. The mean aneurysm diameter was 66 ± 14 mm. The overall number of TVV was 107 (3.5 ± 0.9 vessels/patients). Custom-made and off-the-shelf endografts were used in 22 (73%) and 8 (23%) cases, respectively. The procedure was performed in multiple steps in 23 cases (77%). There were not intraoperative mortality and type I–III endoleaks, and the TVV patency was 97% (104/107). TS was 87%.There were 2 irreversible paraplegias (6.6%) and 1 reversible paraparesis (3.4%). Postoperative cardiac and pulmonary complications occurred in 2 (6.6%) and 2 (6.6%) patients, respectively. Renal function worsening (≥30% of the baseline level) was detected in 4 cases (13%). The 30-day mortality was 6.6%. Survival at 6, 12, and 24 months was 90%, 85%, and 68%, respectively. There was no TAAA-related mortality. The TVV patency at 3, 6, and 24 months was 95%, 90%, and 90%, respectively, and there were no type I–III endoleaks. FFRs at 6, 12, and 24 months was 88%. Conclusion The endovascular repair of TAAA by using Cook Zenith fenestrated/branched endografts is feasible with acceptable technical and clinical results at early to mid-term results in patients at high surgical risk unfit for OR.

We read with interest the paper from Corriere et al,1 published in the Journal of Vascular Surgery in October 2015, in which the authors state that patients rely mostly on health care provider recommendations when involved in a decision-making process. Although the authors write that few data exist on the willingness of patients to be involved in the approach toward a desired treatment, our study, published in the European Journal of Vascular and Endovascular Surgery, 2 shows a different attitude toward the involvement of patients in the decision-making process. In that study, we examined preferences of both patients and their caregivers through the technique of discrete choice analysis, which allows elicitation of preferences for health care interventions. We presented different hypothetical treatment scenarios to the patients through a written questionnaire and were able to evaluate which of the features of an open surgical procedure compared with those of an endovascular treatment. The rate of response was as high as 99% (patients, 98%; family caregivers, 99%), with 160 patients and 102 family caregivers entered into the study. From the respondents' choice between the possible answers, we could calculate which treatment characteristics can affect the preferences of the target subjects, whether a characteristic was considered negative or positive (direction of preferences), and how much one characteristic was more important than the others. With that methodology, we could establish that the risk of major complications and the risk of reinterventions were considered the most feared characteristic of the intervention for abdominal aortic aneurysm, no matter whether the patient was undergoing open or endovascular procedure or had been already undergone either one. The hypothetical cost of the intervention was also a significant issue for the patient. Our methodology and the aim of our work were different from those of the report by Corriere et al; however, we feel that our results should be taken into consideration when the attitudes of patients and their caregivers toward a vascular surgical procedure are analyzed. As a matter of fact, self-completion of the questionnaire, its extremely wide acceptance from both patients and caregivers, and the lack of a bias effect determined by a direct interview are important features of our study, which should be considered in future work on the subject. However, it is reasonable to hypothesize that the differences between the two studies might be related to philosophical differences between the patients comprising the populations of the two different countries.

Background Silent cerebral infarctions (SCIs) can be identified by preoperative computed tomography (CT) scans in patients with severe carotid stenosis being considered for carotid endarterectomy (CEA). It is unknown whether this finding has any effect on perioperative complications or long-term outcome. This study investigates the influence of SCI on early and late complications in asymptomatic patients undergoing CEA. Methods All consecutive CEAs undertaken for asymptomatic severe carotid stenosis from 2005 to 2013 were retrospectively evaluated for clinical and anatomic characteristics. SCI was defined as cerebral embolic infarcts in the anterior or middle cerebral artery territory, ipsilateral to the target carotid stenosis, identified on preoperative CT. The end points of the study were to compare the 30-day and long-term stroke and death rate after CEA in patients with and without SCI. All patients were followed yearly through duplex ultrasonography and clinical assessment. Statistical methods used were Cox regression (hazard ratio) and Kaplan-Meier for life-table analysis. Results A total of 743 CEAs were performed in asymptomatic patients during the study period of which all had CT scans, and 97 (13.1%) demonstrated SCI. All patient stroke and death outcomes at 30 days were 0.5% and 0.7%, respectively. Patients with SCI had a significantly higher 30-day stroke outcome (3.1% vs 0.2%; P = .001; odds ratio, 16.39; 95% confidence interval, 1.33-201.4; P = .02) but not death or stroke/death outcome (0% vs 0.8%; P = .19 and 3.1% vs 0.9%, P = .06, respectively) compared with those without SCI. In addition, at a mean follow-up of 44.3 ± 23.9 months, the patients with SCI had a significantly worse 5-year ipsilateral stroke or any stroke-/death-free survival compared with patients without SCI (86.7% vs 99.0%; P = .001; and 76.9% vs 87.7%; P = .004). SCI was confirmed as an independent predictor of late any stroke/death by Cox regression (hazard ratio, 2.45; 95% confidence interval, 1.29-4.67; P = .006). Conclusions Patients who have SCI in the presence of severe carotid stenosis and undergo CEA have significantly worse perioperative stroke and long-term stroke/death outcomes. This data would suggest that asymptomatic patients undergoing CEA who have CT scan evidence of a cerebral infarct have worse prognosis than those with normal CT scans.

We have read with interest the article by Wilensky et al. on “Outcomes after arterial endovascular procedures performed in patients with an elevated international normalized ratio,”1 reporting on the management of patients under oral anticoagulant therapy (OAT). Although the authors state that no studies were published before their series, the possibility of performing peripheral arterial procedures in patients with OAT was specifically addressed in 2 studies from our institution. Specifically in the articles by Pini et al.2 and Faggioli et al.,3 we have highlighted the results achievable in carotid stenting (CAS) procedures in patients with OAT. In both studies, not only the safety of the procedure was shown, but also the advantages over traditional surgical carotid endarterectomy (CEA) and bridging therapy. In the first paper, we have analyzed specifically 502 CAS performed in a 5-year period with 12 (2.4%) perioperative strokes, 1 (0.2%) death, no myocardial infarctions, and 4 (0.8%) access site bleeding period. Twenty patients (4.0%) under chronic OAT were submitted to CAS without perioperative bridging heparin therapy and no complications. Overall, patients under OAT had no significantly different outcome compared with patients without OAT.2 In the second paper, we have analyzed altogether 1,222 carotid revascularizations, with 711 CEAs (58.1%) and 511 CAS (41.9%). In the CEA group, 31 (4.4%) OAT patients were treated after OAT interruption and bridging heparin therapy. These patients had a significantly higher complication rate compared with patients not receiving OAT, including death, stroke, and hematoma. In CAS, the results were similar in patients receiving OAT (30[5.8%]) and patients not receiving OAT. Patients receiving unsuspended OAT who underwent CAS had better outcomes than OAT patients who underwent CEA after suppression of OAT and bridging therapy.3 As a matter of fact, our current practice includes stenting as a first option in OAT patients needing carotid revascularization. In this sense, although we advocate standard CEA as the gold standard procedure for symptomatic and asymptomatic carotid disease, there are subgroups of patients (i.e., OAT patients and patients with contralateral carotid occlusion) who benefit more from CAS.4

Objective Fenestrated endovascular aortic repair (fEVAR) is being used increasingly in the treatment of complex aortic aneurysms; however, this procedure can be associated with visceral and renal complications. Because the causes of possible renal function (RF) impairment have not been fully examined yet, we conducted a study to investigate whether there are risk factors associate with renal ischemic lesions (RILs) and if they influence RF in patients treated for complex aortic aneurysm with fEVAR. Methods We evaluated the clinical, anatomic, and technical characteristics of consecutive patients treated with fEVAR from 2008 to 2014. RIL were identified by postoperative computed tomography angiography and the volume of renal parenchyma involved quantified. A decrease in RF (>30% glomerular filtration rate reduction) was evaluated at discharge, and at the 6- and 12-month follow-ups. Results Among 53 patients, we analyzed 38 (72%) juxta/pararenal and 15 (28%) thoracoabdominal aortic aneurysms (33 [64%] with ≥3 fenestrations) and 102 renal arteries. Fifteen patients (30%) showed RIL, which was caused by accessory renal artery (ARA) coverage in 6 cases (38%), distal embolism in 6 (38%), renal artery thrombosis in 2 (18%), and iatrogenic embolization for intraoperative bleeding during fEVAR in 1 (6%). The volume of renal parenchyma involved was less than 25% in 10 (67%) and 25% to 50% in 5 (33%) cases. In no cases was more than 50% renal volume affected. On multivariate analysis, RIL predictors were the presence of ARA (odds ratio [OR], 8.00; 95% confidence interval [CI], 1.16-54.89; P = .03) and extensive thrombosis of the pararenal aorta (OR, 39.93; 95% CI, 3.36-474.23; P = .003). At discharge, chronic renal failure (CRF; OR, 4.80; 95% CI, 1.27-18.09; P = .01), diabetes (OR, 8.44; 95% CI, 1.33-53.51; P = .01), and extensive thrombosis of the pararenal aorta (OR, 5.50; 95% CI, 1.32-29.92; P = .01) were significantly associated with worsening RF. RIL, independent from volume, did not influence the postoperative RF. At 6 months and 1-year, preoperative CRF and perioperative declines in RF were identified as the only risk factors for worsening RF. Conclusions RIL is a common fEVAR complication and is primarily owing to ARA coverage and aortic thrombus embolization. However, RIL does not influence RF, which is predicted by preoperative CRF, diabetes, and extensive aortic thrombus.

Background.Neoangiogenesis is crucial in plaque progression and instability. Previous data from our group showed that Nestin-positive intraplaque neovessels correlated with histological complications. The aim of the present work is to evaluate the relationship between neoangiogenesis, plaque morphology, and clinical instability of the plaque.Materials and Methods.Seventy-three patients (53 males and 20 females, mean age 71 years) were consecutively enrolled. Clinical data and 14 histological variables, including intraplaque hemorrhage and calcifications, were collected. Immunohistochemistry for CD34 and Nestin was performed. RT-PCR was performed to evaluate Nestin mRNA (including 5 healthy arteries as controls).Results.Diffusely calcified plaques (13/73) were found predominantly in females(P=0.017), with a significantly lower incidence of symptoms (TIA/stroke(P=0.019)than noncalcified plaques but with the same incidence of histological complications(P=0.156)). Accordingly, calcified and noncalcified plaques showed similar mean densities of positivity for CD34 and Nestin. Nestin density, but not CD34, correlated with the occurrence of intraplaque hemorrhage.Conclusions.Plaques with massive calcifications show the same incidence of histological complications but without influencing symptomatology, especially in female patients, and regardless of the amount of neoangiogenesis. These results can be applied in a future presurgical identification of patients at major risk of developing symptoms.

BACKGROUND: Arteriovenous prosthetic graft (AVG) is an alternative hemodialysis vascular access choice; however, its performance is limited by a high rate of thrombosis. The aim of the study was to compare the long-term secondary patency of AVG in patients undergoing a surveillance program and the long-term secondary patency of AVG in patients with clinical assessment of AVG malfunction. METHODS: From 2009 to 2012, all patients with AVG entered in a duplex ultrasound (DUS) surveillance program (at 3 months and then every 6 months postoperatively) to assess AVG malfunction and/or stenosis (stenosis >50% and blood flow decrease [50% and blood flow decrease [

Background: Portal-superior mesenteric vein (PV/SMV) resection during pancreatic resection has been widely applied in clinical practice. Methods: From a prospective data base of pancreatic resections, patients undergoing PV/SMV resection and reconstruction with a cryopreserved arterial homograft were extracted with the aim of evaluating the safety, feasibility and reproducibility of the procedure. Data regarding patient demographics, preoperative staging, surgery, histopathology and postoperative outcomes were analyzed. Results: Five patients were extracted in the last year. Indications for this technique were type IV-V degree of vein involvement and a 3.5 cm median length of vein infiltration. Median operative and clamping times were satisfactory (385 and 27 min, respectively), postoperative outcomes were good and there was no graft infection, thrombosis or stenosis occurred postoperatively and during the follow-up period. Conclusion: The use of a cryopreserved arterial homograft for PV/SMV reconstruction after pancreatic resection seems to be a feasible, safe and easily reproducible surgical technique in high-volume specialized centers and can be added to the pool of surgical solutions in selected patients.