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Objective: We compared the early and mid-term outcomes of polytetrafluoroethylene covered stents (CSs) vs bare metal stents (BMSs) used in the kissing conformation for the reconstruction of the aortic bifurcation in aortoiliac obstructive disease. Methods: A multicenter cohort registry (2015-2019) collected data from 1306 patients who had undergone endovascular treatment of aortoiliac arterial obstructive disease. Only patients who had received bilateral iliac kissing stents for TransAtlantic Inter-Society Consensus (TASC) class C and D lesions were included in the present analysis. The 30-day outcomes, mid-term primary patency, and limb salvage rates were compared between the CSs and BMSs in matched patient cohorts after propensity score matching. The follow-up results were analyzed using Kaplan-Meier curves. Cox proportional hazards models were used to identify the predictors of primary patency. Results: A total of 336 patients were treated with kissing stents, 201 with CSs (60%) and 135 with BMSs (40%). In the unmatched cohort, patients receiving CSs were more likely to have critical limb ischemia (41% vs 30%; P = .038), complex iliac lesions, such as TASC D (90% vs 56%; P < .01), and iliac occlusions (59% vs 44%; P < .01). After propensity score matching, 220 patients were selected (110 with CSs and 110 with BMSs), without differences in the clinical presentation (critical limb ischemia, 41% vs 33%; P = .167), or anatomic complexity (TASC D, 66% vs 60%, P = .21; iliac occlusion, 48% vs 49%, P = .89). The 30-day mortality was 0%. The early medical (unmatched, 5% vs 4%, P = 1.00; matched, 5% vs 4%, P = .75) and surgical (unmatched, 5% vs 5%, P = 1.00; matched, 5% vs 3%, P = .72) complication rates were similar between the CSs and BMSs. However, the CSs resulted in a lower risk of intraoperative iliac rupture (0% vs 3.5%; P = .013) and greater ankle-brachial index improvement (0.43 ± 0.22 vs 0.36 ± 0.24; P = .02). At 36 months, the overall primary patency (92% ± 7% vs 92% ± 8%; P = .38), secondary patency (98% ± 3% vs 98% ± 4%; P = .50), and limb salvage (93% ± 9% vs 97% ± 5%; P = .20) rates were similar. In cases of moderate to severe iliac calcification, the CSs showed better results in the matched cohort (100% vs 89% ± 9%; P = .048). On multivariate analysis, CS use (hazard ratio [HR], 1.67; P = .45) did not significantly affect primary patency, but older age (HR, 0.93; P = .03) and kissing stent diameter ≥8 mm (HR, 0.25; P = .03) were significantly associated. Conclusion: In the present multicenter study, the use of kissing stents for the treatment of the aortic bifurcation provided good early and mid-term results. CSs were preferred for more complex lesions, were protective from iliac rupture, and allowed for greater ankle-brachial index improvement. The 3-year patency rates were similar between the CSs and BMSs. However, CSs showed improved results in the case of moderate to severe calcification.

Objectives: To analyze outcomes following endovascular treatment of total occlusion of the infrarenal aorta and aorto–iliac bifurcation in a multicenter Italian registry. Methods: It is a multicenter, retrospective, observational cohort study. From January 2015 to December 2018, 1306 endovascular interventions for aorto–iliac occlusive disease were recorded in the vascular registry. For this analysis, only patients treated for total occlusion of the infrarenal aorta and aorto–iliac bifurcation were included. Early (Results: A total of 54 (4.1%) patients met the inclusion criteria. Total percutaneous revascularization was possible in 41 (75.9%) patients and hybrid (endo plus open) intervention in 13 (24.1%) patients. The kissing-stent-graft technique was used in 45 (83.3%) cases, covered endovascular reconstruction of the aortic bifurcation (CERAB) in 5 (9.2%), and a unibody endograft deployed in 4 (7.4%). Technical success was 98.1% (n = 53). There were no episodes of intraoperative or perioperative vessel rupture. Conversion to open surgery was not necessary, and there were no in-hospital deaths. The median patient follow-up time was 16 months (interquartrile range [IQR], 6-27). The estimated primary patency rate was 95.8% ± 0.03 (95% confidence interval [CI]: 85.5-98.9) at 1 year, 91.4% ± 0.05 (95% CI: 76.2-97.2) at 2 years, and 85 ± 0.08 (95% CI: 64.5-94.6) at 3 years. Cox regression analysis demonstrated that sex (hazard ratio [HR]: 0.96; 95% CI: 0.15-6.23, p = 0.963), extent of the occlusion (HR: 0.28; 95% CI: 0.05-1.46, p = 0.130), calcium score (HR: 1.88; 95% CI: 0.31-11.27, p = 0.490), or type of endovascular reconstruction (HR: 0.80; 95% CI: 0.13-5.15, p = 0.804) did not affect primary patency. Secondary patency was 95.5% ± 0.04 (95% CI: 78.4-99.2) at 3 years. No patients required late conversion to open surgical bypass. Conclusions: Endovascular reconstruction for total occlusion of the infrarenal aorta and aorto–iliac bifurcation was successful using a combination of percutaneous and hybrid revascularization techniques. Estimated patency rates at 3 years of follow-up are promising and are unaffected by the extent of occlusion or type of revascularization.

Purpose: To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods: A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (

In-stent restenosis (ISR) is the most common long-term complication following carotid artery stenting (CAS), affecting 3.5% to 21% of patients after a mean follow-up of 18 months in published reports. Until now, the optimal management for ISR after CAS is still not clear, and different endovascular treatments along with various surgical options have been proposed. Moreover, surgical treatment for ISR in a previously operated patient of ipsilateral endarterectomy is a technically demanding procedure. In this report, we describe a case of severe carotid recurrent ISR, which occurred after CAS for postendarterectomy restenosis, that was successfully treated, in a straightforward way, with a carotid bypass using a Gore® Hybrid Vascular Graft.

Received January 27, 2014; accepted February 8, 2014.TO THE EDITORS:We report the unique course of a 54-year-old femalepatient after liver transplantation (LT) for Budd-Chiarisyndrome in 1999. Because of hepatic artery throm-bosis, early re-LT was performed with the classic infe-rior vena cava (IVC) reconstruction technique(suprahepatic and infrahepatic anastomoses). Thepatient suffered from severe ascites within 3 monthsof the surgery, and cavography showed 80% suprahe-patic caval stenosis at the diaphragmatic level with apeak gradient of 17 mm Hg. She was treated with sev-eral balloon dilatations and then with caval stenting

Background Multiple failed hemodialysis access and poor vascular anatomy can jeopardize an end-stage renal disease patient's survival, frequently leading to the urgent need for rapid and durable new vascular access. In these circumstances, the extensive use of central venous catheters (CVC) can led to serious complications, such as infection, thrombosis, and often vessel scarring with obstruction of the central veins. More recently, new self-sealing prosthetic grafts may be cannulated within a few days after implantation, avoiding the need for extensive CVC. However, similar to all synthetic arteriovenous grafts (AVG), the new grafts are prone to rapid and aggressive venous neointimal hyperplasia (VNH), which is responsible for outflow stenosis and access thrombosis. Endoluminal sutureless anastomosis has been demonstrated to have better hemodynamics at the venous outflow with a supposed reduction of VNH, thus potentially improving graft patency. Methods We report a case of a successful creation of a composite prosthetic access in a patient with severe comorbidities and nearly complete exhaustion of all vascular sites and with the need for immediate access for hemodialysis. Two relatively novel vascular expanded polytetrafluoroethylene prostheses were used jointly in this patient for a brachial-axillary AVG to allow early cannulation and with the aim of being less vulnerable to outflow stenosis. A multilayer self-sealing graft and a graft with a nitinol reinforced section, which permits endoluminal sutureless anastomosis, were sewed together to create a unique prosthesis with both features. Results The composite graft was cannulated 48 hr after implantation and continued to function well at 10 months of follow-up without signs of venous stenosis. Conclusions This simple technique allows the creation of a customized composite graft with self-sealing properties and improved hemodynamics at the venous outflow.

Congenital vascular malformations represent a wide number of diseases with a great variability of clinical features. The association between congenital vascular malformations and peripheral aneurysms is very rare. The present study reports a case of giant superficial femoral artery aneurysm (7-cm-long) associated with Parkes-Weber syndrome (capillary malformation, multiple arteriovenous fistulas [AVFs], skeletal hypertrophy of the affected limb) treated by positioning two covered self-expandable endoprostheses after embolization of AVFs with Gianturco coils. The peri- and postoperative course was uneventful and the postprocedural angiography showed the complete exclusion of the aneurysm sac. At last follow-up, after 87 months, the duplex scan and computed tomography scan showed regular patency of the vessels with thrombosis of the aneurysm sac and the presence of a large number of AVFs. The association between Parkes-Weber syndrome and peripheral aneurysms represents a very unusual entity. The lack of evidence does not allow the establishment of the most suitable treatment for this disease. Endovascular approach associated with previous embolization of AVFs may represent a valid alternative to traditional surgical repair, which is still burdened by a high percentage of complications and failures.

The popliteal artery (PA) entrapment syndrome, a rare cause of arterial thrombosis, is most often encountered in young male athletes. Here, we report a very unusual case of PA entrapment syndrome in a 14-year-old girl who presented with a 1-month history of calf claudication to our observation facility. Diagnostic work-up revealed obesity, sedentary lifestyle, and an aberrant accessory slip of the medial head of gastrocnemius around the PA. Arterial echo color Doppler ultrasonography and computed tomographic angiography studies were performed. Surgical treatment involved revascularization with resection of the medial head of gastrocnemius, the cause of the arterial entrapment, and enlargement angioplasty using an autologous saphenous vein patch, in combination with antiplatelet therapy, resulting in restitution ad integrum of the affected limb and, finally, an improved quality of life of the patient. This case underscores the importance of clinical suspicion, diagnosis, and treatment of lower-limb claudication in very young patients presenting with unusual symptoms. If missed, the condition may evolve dramatically. Prompt diagnosis and surgical treatment are key to complete recovery and the prevention of irreversible complications that may result in limb loss.