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Aim of this study is to evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open aortic repair (OAR) or endovascular aortic repair (EVAR) in patients under 70 years of age.A retrospective analysis of a prospectively collected database of patients with age under 70 years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into 2 groups: OAR and EVAR. Primary end points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications.One hundred ninety-one patients younger than 70 years old treated with elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65 ± 4 years) and 34 EVAR (94% males, mean age 66 ± 4 years). Hospital stay, 30-day mortality, and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs. 2.9%; P = 0.01) while minor complications were 32% in the OAR versus 21% in the EVAR group (P = 0.08). Median follow-up was 69 months for OAR (interquartile range [IQR] 53 months) vs. 79 months (IQR 51 months) for EVAR (P = 0.9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; P = 0.01) while AAA-related long-term mortality was similar in both subgroups (1.3% OAR and 3% EVAR; P = 0.8). At univariate analysis higher risk of reintervention was reported for conical necks in the EVAR group (P = 0.03) and for the concomitant presence of iliac aneurysms in both groups (P = 0.01).According to our data, EVAR in young patients is presenting an excessive rate of reintervention compared to OAR. The presence of conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in the OAR group. Open surgery should be considered the first option in younger patients with a long-life expectancy.

To report early and mid-term results of post-aortic dissection thoracoabdominal aneurysms (pD-TAAA) treated by complex endografting in three tertiary referral hospitals. A review of all patients with pD-TAAA unfit for open surgery treated with complex endovascular repair from 2012 to 2018 was performed. Simple thoracic endografts (TEVAR) were excluded. Staged procedures in case of extensive aortic coverage were always planned. In total, 21 patients (16 males, mean age 63 ± 10 years) with pD-TAAA underwent aortic repair by fenestrated or branched thoracoabdominal endografts for visceral vessels. Mean TAAA diameter was 61 ± 6.2 mm. Spinal cord drainage was performed in all patients. A staged approach was used in 12 (57%) cases. Technical success was achieved in 18 (86%) patients. No in-hospital deaths occurred. Two patients experienced transient post-procedural spinal cord ischemia. At 30 days, six type II endoleaks (29%), two type Ic endoleak (9.5%) and one type IIIc endoleak (5%) were reported. At a mean follow-up of 23 ± 13 months, no late aortic-related deaths occurred. Three patients underwent reintervention for type Ic and IIIc endoleaks. No visceral vessel occlusion was observed. Estimated freedom from reintervention at 12 and 24 months was 85.7 ± 0.7%. In 13 cases, TAAA diameter decreased at least 5 mm, while increased > 5 mm in only one case. Complete false lumen thrombosis was achieved in 18 patients (86%). Complex endografting for pD-TAAA showed favorable mid-term results. Staged and carefully planned endovascular procedures may represent a safe and effective therapeutic option in patients deemed at high risk of open repair.

Purpose: We present the results of unconventional endovascular treatment of a voluminous (65 mm) saccular visceral aortic aneurysm in a 78-year-old woman. Patient was deemed unfit for open surgery due to comorbidities. Fenestrated or branched endografting was also excluded due to the small diameter of the aorta, the severe stenosis at the origin of celiac trunk, and the anomalous origin of superior mesenteric artery arising infrarenally. Case Report: After a preliminary selective angiography of the superior mesenteric artery showing valid anastomotic network with celiac trunk branches, an aortic self-expandable bare stent (Jotec E-XL) was deployed in the visceral aorta. Aneurysm sac embolization (Penumbra detachable Ruby Coils) in a coil-jailing technique was performed. Finally, an aortic cuff endograft (Gore) was deployed immediately above the origin of the left renal artery to cover the wide neck of the saccular aneurysm and improve sac exclusion. Hospital stay was uneventful, computed tomography (CT) at 12-month demonstrated aneurysm shrinkage to 62 mm without images of endoleak. Literature review showed how this technique has successfully been applied to manage similar cases of postsurgical and posttraumatic saccular aortic aneurysms in high-risk patients; however, long-term results are still unknown. Conclusion: Coil-jail technique for the treatment of saccular aortic aneurysms can be considered an alternative when open surgery or conventional endovascular treatment is not feasible. Technical success and mid-term outcomes are promising but strict follow-up is recommended. Clinical Impact This study aims to share the unconventional endovascular treatment of a visceral aortic aneurysm in a patient unfit both for open and traditional endovascular surgery. To the best of our knowledge this is one of the first cases published in Literature, for this reason, a step-by-step video has been created to describe the procedure. Literature review was then performed to analyze midterm results of this technique. Despite being a treatment that is not recommended for conventional cases, the knowledge of endovascular devices and techniques may help to manage or simplify complex aortic diseases.

Background One of the most critical phases of carotid endarterectomy (CEA) is the carotid cross-clamping test, which is a concrete evaluation of efficacy of collateral cerebral perfusion. Some studies revealed a strong correlation between tolerance to carotid cross-clamping and postoperative transient ischemic attack (TIA)/stroke complications. The aim of the study is to make a global analysis of supra-aortic trunks (SAT) and circle of Willis (CoW) patency to predict the tolerance to carotid cross-clamping preoperatively. Methods We observed retrospectively 503 patients who underwent CEA under local anesthesia between January 2012 and 2017. We analyzed single preoperative risk factors, drug therapy, and vessels patency of the group of patients who did or did not present neurological symptoms at carotid cross-clamping. Afterward, we created a cerebral perfusion score (PTOT) to estimate the efficacy of collateral cerebral perfusion and we compared the results from both groups. The score ranges from 0 (hypothetical total occlusion of the SAT and CoW) to 0.65 in case of patency of all arterial districts. Moreover, we evaluated postoperative complication rates. Results Patients with previous neurological symptoms, female gender, and diabetes correlate with a lower tolerance to carotid cross-clamping (odds ratio: 2.57, 2.78, and 2.57, respectively; P value Conclusions The efficacy of cerebral mechanisms of compensation during carotid cross-clamping reflects the capability of the brain to adapt to ischemic insults, and this also correlates with the postoperative risk of TIA/stroke. It is possible to identify preoperatively patients with a higher risk of neurological intolerance at carotid cross-clamping. This score could be a useful method to make a further stratification of risk of neurological complications and eventually to prefer a general anesthesia and the use of shunt for those with PTOT

To evaluate the incidence and the time of onset of early micro-embolism after CAS (carotid artery stenting) with two different mesh-covered stents and to assess the role of DW-MRI (Diffusion-weighted magnetic resonance imaging) in their prediction. Single-institution prospective study including 50 patients (33 male, median age 74 years) who underwent CAS with Roadsaver® or CGuard™. All patients with primary stenosis (37/50, 74%) had carotid plaque DW-MRI pre-procedure, with both qualitative evaluation of the hyperintensity and ADC (apparent diffusion coefficient) measurement of the plaque. All patients had brain DW-MRI pre-procedure, at 1 h, 24 h and 30 days post-procedure to evaluate the appearance of hyperintense lesions over time. Imaging analysis was performed in a double-blinded fashion by two radiologists. There were no statistically significant differences between the two stents both in the incidence at 1 h (P = 0.23) and 24 h (P = 0.36) and in the volume of new DWI hyperintense brain lesions at 24 h (P = 0.27). Thirty-four new asymptomatic lesions in 19 patients (38%) were reported: 4 (11.8%) at 1 h, 30 (88.2%) at 24 h. The 30-day DWI-MR showed complete resolution of all lesions and no evidence of new lesion. The incidence of new lesions at 24 h resulted significantly higher in patients with DWI hyperintense carotid plaques (12/16, 75% vs. 0/21, 0%, P

To determine outcomes of postdissection thoracoabdominal aneurysms by either open or endovascular repair with fenestrated or branched endografts.A systematic review was conducted for open or endovascular repair of postdissection thoracoabdominal aneurysms, between January 2009 and February 2020. A meta-analysis was performed for postoperative complications and both early and late mortality and reinterventions.Fifteen noncomparative studies (eight endovascular repair and seven open repair) were suitable for meta-analysis. Overall, 1337 patients were included, 1068 in the open repair group (73% male; mean age 58 years) and 269 in the endovascular repair group (79% male; mean age 65 years). The 30-day mortality was 6% for open repair vs 3% for endovascular repair (P = .35), whereas the 30-day reintervention rate was 3% for open repair vs 1% for endovascular repair (P = .66). The only significant difference was reported for 30-day respiratory complication rate (30% open repair vs 2% endovascular repair; P .01). The incidence of spinal cord ischemia was 9% for open repair vs 8% for endovascular repair (P = .95). The mean follow-up was 44 months: 48 months (range, 10-72 months) after open repair and 17 months (range, 12-25 months) after endovascular repair (P .01). Late aortic reinterventions were more frequent after endovascular repair (11% vs 32%; P .001). The late overall mortality rate was 19% for open repair vs 7% for endovascular repair (P = .08), whereas aortic-related mortality was 7% for open repair vs 3% for endovascular repair (P = .22).In the absence of comparative studies, this meta-analysis showed that endovascular repair seems to be a viable alternative for patients unfit for open repair.

Endovascular repair of thoracoabdominal and juxtarenal aortic aneurysm has recently become a valuable alternative to open surgery especially in high-risk patients. Progressive improvements in graft materials and low-profile devices allow treatment of complex aneurysms even in adverse anatomical settings. However, all published experiences report risks of occlusion and reinterventions due to visceral stent-graft failures in the long term. The purpose of this systematic review is to analyze the results of currently used balloon expandable bridging stent-grafts and to evaluate the newest developments for fenestrated endovascular aortic repair (FEVAR) in juxtarenal endovascular repair. Data were retrieved from retrospective analyses, case series and case reports conducted from 2000 to September 2019. The literature analysis provided a list of the most commonly used balloon-expandable bridging stent-grafts for FEVAR. For each stent-graft a brief summary of structural characteristics and performances have been described. No randomized controlled trials (RCTs) or comparative data between the stent-grafts are available for this specific topic. Several balloon-expandable stent-grafts have been used as bridging stents during FEVAR but the ideal bridging stent-graft is far to be designed. The better understanding of the system FEVAR-native aorta and the strict collaboration and exchange of expertise between physicians and engineers are mandatory in order to increase the performances of these important components and to reduce re-interventions and complications in FEVAR.

The purpose of this study was to evaluate the long term results of endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysm (AAA) and ectatic common iliac arteries (CIAs).In a retrospective analysis of a prospectively collected database in two high volume centres, patients with AAAs undergoing elective standard EVAR were divided into two groups: those with both CIA diameters18 mm, and those with at least one ectatic iliac artery (CIA ≥ 18 mm). Patients with an intentional external iliac artery landing zone were excluded. Primary outcomes were survival and freedom from re-intervention. Secondary end points were EVAR failure and iliac related endoleak and iliac re-intervention.From 2000 to 2015, 648 patients were included in the study, 277 (43%) had at least one CIA ≥ 18 mm. Pre-operative risk factors were similar between the two groups, with the exception of chronic renal insufficiency (p = .010) and cerebrovascular events (p = .040), which were higher in the ectatic CIA group. At 30 days from primary procedure, there was a higher rate of type Ib endoleak in patients with ectatic iliacs (p = .020). A statistically significant increase in the incidence of late type Ib endoleak in patients with ectatic iliac arteries was confirmed at a mean follow up of 74.8 months (p = .01). The need for iliac related re-intervention was higher in patients with CIAs ≥18 mm (odds ratio 1.94; 95% confidence interval 1.1-3.2).Ectatic iliac arteries are considered suitable landing zones for EVAR, although there is an increased risk of secondary interventions in time mainly due to late CIA dilation and secondary type Ib endoleak. Patients receiving EVAR with flared iliac limbs may benefit a more intensive surveillance to avoid late failures.

Background:Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare and potentially life-threatening complication, with an incidence lower than 1%. Most of the cases described report PAs after carotid patch angioplasty and are associated with infection, often caused by Staphylococci. The management of PAs can be surgical, endovascular, or hybrid.Methods:We herein present the case of an infected carotid PA 27 days after an eversion CEA. We performed a common to internal carotid bypass with the interposition of great saphenous vein (GSV) associated with specific polyantibiotic therapy for 4 weeks. We searched the PubMed database for reviews and cases reports for patients who developed carotid PA after primary repair CEA in the period between 1969 and 2017.Results:We identified 21 cases of primary closure post-CEA PAs in the literature. In almost 60% of patients, infection was detected. Open surgery was performed in all the cases; in 1 case, an hybrid approach was preferred. In 52% of cases, a vein graft/patch or primary closure was chosen; in 3 cases, ligation was preferred, and in 1 case, a polyester graft was used.Conclusion:In our experience and with the evidence observed in the literature, open surgery with GSV interposition is the safest treatment in infected carotid PAs. The endovascular approach must be performed only in proven noninfectious cases. A bridge technique with the insertion of a stent followed by open surgery repair can be an option in emergency cases.

INTRODUCTION Endovascular treatment represents nowadays the preferred therapeutic approach for disabling femoro-popliteal arterial occlusive disease in fit patients. In the latest years, in order to improve short- and long-term outcomes, drug eluting devices have been developed. Drug coated balloons (DCB) and drug eluting stents (DES) are today employed in clinical practice, and several studies has been completed to assess their performance in different clinical scenarios. Objective of the present review and meta-analysis is to compare clinical results of different endovascular treatment modalities in the published literature in the last 10 years. EVIDENCE ACQUISITION A systematic review and meta-analysis following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement on the literature regarding direct comparisons between DCB, DES, bare metal stents (BMS) and Plain Old Balloon Angioplasty (POBA) has been conducted. Primary outcomes were considered Primary Patency and Target Lesion Revascularization (TLR) at 12 months. Analysis of late survival in different treatment groups was outside the scope of the present study and was therefore not included as main end point. EVIDENCE SYNTHESIS Meta analysis results confirm that DCB outperforms POBA in both primary patency (estimate OR=3.17, 95% CI: 2.10-4.76) and TLR (POBA estimate OR=3.59, 95% CI= 2.31-5.56). No clear evidences emerged comparing DES and BMS; however, DES were shown to fare better than BMS in terms of TLR when analyzing lesions

Background Today transdermal continuous oxygen therapy (TCOT) is used in wound care to promote healing by improving local hypoxia and preventing infection, and it has been described to reduce local inflammation over 1 month of administration. The present study aims to investigate the effects of this treatment on wound microcirculation through laser speckle contrast analysis (LASCA). Methods 20 adult patients (mean age: 76 ± 11.5 years) were prospectively enrolled. Inclusion criteria were presence of venous or mixed lower limb ulcers from three or more months without dimension reduction and without indication to surgery and weekly treatment by our outpatient clinic with silver dressings. Subjects underwent 1 month of TCOT (EPIFLO®) in addition to foam dressing. The primary endpoint was the comparison of ulcer and healthy skin perfusion through LASCA, performed before and after the treatment period. Secondary considered endpoints were wound area, wound area severity index and PUSH Tools 3.0 ulcer severity scales, and pain assessment (Numerical Rating Scale [NRS]). Results Before treatment, the wound area was significantly more perfused than healthy skin (+45%; P = 0.005). At the end of the study, this difference was not significant anymore (+20.5%; P = 0.11). Ulcer perfusion decreased (−12.5%, P = 0.047), whereas healthy skin perfusion did not vary significantly. A reduction of the wound dimension (median difference: 2 cm; P = 0.009) and pain (median difference: 2 NRS point; P Conclusions LASCA shows that 1 month of TCOT can help reduce hyperperfusion of ulcer bed in patients with chronic lower limb ulcers, strengthening the hypothesis that this treatment effectively contrasts inflammation. This could correlate with the area and pain reduction assessed; however, the absence of a control group in this study does not allow a generalization of this hypothesis. Larger, controlled trials are needed to properly assess the relationship between TCOT effects on wound microenvironment and effective healing process.

Endovascular treatment of carotid artery stenosis is a valuable alternative to open surgery, and the evolution of stent materials and cerebral protection devices significantly decreased postoperative neurological complications. Among these, the introduction of nitinol double-layer micromesh stent seems to guarantee a reduced perioperative and postoperative cerebral embolization. Long-term results are however still not available to make a global evaluation of these stents. We present the case of a 66-year-old female patient treated for asymptomatic carotid stenosis complicated by a symptomatic partial stent thrombosis occurred three months after carotid artery stenting.

Background Aortic aneurysm repair is a resolutive and effective surgical operation, which can be associated with severe postoperative complications. Procalcitonin (PCT) in clinical practice could play a role in early diagnosis and monitoring of therapy for complications, especially infections, making for timely and more effective interventions. Our aim was to investigate whether PCT could be a predictive marker in early diagnosis of infectious complications after open abdominal aortic surgery. Methods Eighty-three consecutive patients who underwent elective open aortic repair at our institution were enrolled. Blood samples were taken before surgery, and each day over the 7-day postoperative period, and measurement of serum PCT, C-reactive protein (CRP), and leukocytes levels were carried out. Data regarding clinical progress, instrumental examinations, and blood chemistry were prospectively collected. Results Postoperative infectious complications occurred in 24 patients. Within 30 days, 1 death occurred. In the study sample, we found a significant difference in PCT curves of patients with and without infectious complications, especially on third postoperative day (POD; P = 0.004). On analysis of the area under the curve (AUC curve), PCT was shown to be a fair predictor in distinguishing cases with infectious complications (AUC, 0.765 on third POD; CI, 0.638–0.877). Conversely, other inflammatory markers commonly used (leucocytes and CRP) had similar trends in patients with and without postoperative infections. Conclusions On the basis of the results collected in this pilot study, despite some limitations, PCT could be considered a better marker of infectious complications after open abdominal aortic repair, when compared with other routinely used parameters.

The objective of this study was to evaluate long-term results of self-expanding vs balloon-expandable hypogastric stent grafts in conjunction with iliac branch devices (IBDs) for aortoiliac aneurysm repair in a multicenter experience (pErformance of iLiac branch deVIces for aneurysmS involving the iliac bifurcation [pELVIS] Registry).All patients electively treated for aortoiliac aneurysm with the Cook IBD (Cook Medical, Bloomington, Ind) in nine European centers were reviewed. Clinical and imaging data were prospectively collected in each center, and a multicenter database was created and interrogated. The primary outcome was the primary patency of the IBDs. For the purpose of this investigation, three subgroups were identified: patients receiving a hypogastric balloon-expandable stent graft (BESg); those with a self-expanding stent graft (SESg); and those with any stent graft plus relining with a bare-metal stent (RESg).Between 2005 and 2017, there were 691 patients who underwent 747 elective endovascular repairs of aortoiliac aneurysms (n = 518 [75.0%]) or isolated iliac aneurysms (n = 173 [25.0%]) with Cook IBDs (n = 56 bilateral) in nine European centers. Mean age was 72 years (range, 41-93 years); 658 (95.2%) patients were male. In 364 patients (52.7%), BESg was used; in 127 (18.4%), SESg; and in 200 (28.9%), RESg. At 30 days, there were 3 (0.4%) perioperative deaths, 3 (0.4%) technical failures, 7 (1.0%) graft thromboses, 30 (4.3%) reinterventions, and 1 (0.1%) conversion to open repair. After a mean follow-up of 32 months (range, 0-128 months), 28 (3.7%) IBD occlusions and 17 (2.3%) IBD-related endoleaks occurred. In 10 patients, iliac diameter increased5 mm (1.4%). Overall primary patency was 99.2% at 1 month, 97.9% at 12 months, and 95.1% at 72 months. Primary patency was not significantly different in the BESg vs SESg or RESg cohorts (P = .4). During follow-up, there were 126 (18.2%) reinterventions, 93 (13.5%) of which were IBD related, including 11 (1.6%) conversions. Overall, freedom from reintervention and conversion was 90.4% at 12 months and 71.0% at 72 months. IBD-related reinterventions during follow-up in the three cohorts were not significantly different (P = .3) Overall survival was 71.3% at 72 months without differences between the subgroups. At multivariate analysis, aneurysmal hypogastric artery (P .001; Exp [B] = 4.44) and bilateral treatment (P = .02; Exp [B] = 1.87) were associated with an increase in late failure.In this wide real-world experience, long-term results of endovascular treatment of aortoiliac aneurysms with the IBD are favorable, with a low rate of late graft occlusion and aneurysm-related death. No significant differences in clinical outcomes were observed in patients receiving hypogastric BESg vs SESg or endovascular relining.

Objectives The traditional surgical approach to the treatment of the superficial venous insufficiency requires at least 12 h of post-operative monitoring and this often means the necessity of an overnight hospitalization. The introduction of new, less invasive techniques (i.e endovenous laser ablation) reduces the hospitalization stay in a Day Surgery setting. However, the increasing skills of the operators and the patient's selection, allows to propose endovenous laser ablation in an Outpatient setting. The aim of this study is to evaluate the activity of a single high-volume center. Method We enrolled 112 consecutive patients with great sapehous vein insufficiency and indication to endothermal laser ablation, 57 operations (51%) were performed in Day Surgery setting and 55 (49%) in Outpatient setting according to endovascular laser ablation's criteria. Past medical history, CEAP classification, VCSS score, type of symptoms and intervention's data were collected. Post-operative results (success and complications rates, patient's functional and aesthetic satisfaction) were evaluated at 7 and 30 days after intervention. A QoL questionnaire (CIVIQ) was submitted to the patients 30 days after surgery. Results We did not observe a statistically significant difference between the two groups concerning treatment results and complications onset. The QoL assessment did not differed significantly, except for over 65-year old patients undergoing outpatient treatment that showed a better QoL compared to those undergoing the same treatment in Day Surgery (p 0.05). Conclusions The endothermal laser ablation technique allows a safe, comfortable and faster management of the venous disease in Outpatient setting. This would further reduce the costs of the treatment while preserving the functional and aesthetic results and the low complication rate of the Day Surgery setting.

Pelvic arteriovenous malformation (AVM) is a rare condition mostly requiring a complex therapeutic strategy. The surgical approach is challenging and burdened by relatively high mortality and morbidity rates. No guidelines are available for the endovascular treatment of AVM because the literature is limited to small case series and case reports. We present a complex case of a pelvic AVM associated with an internal iliac artery aneurysm in a patient previously treated with a common to external prosthetic substitution for aneurysm and proximal ligation of internal iliac artery.

Background Many studies confirmed the role of early carotid endarterectomy (CEA) to prevent recurrent stroke or transient ischemic attack; however, the mid-long-term neurological benefit is still not completely investigated. The purpose of the study was to evaluate the role of early CEA on the perioperative and postoperative stroke/death complications of patients with a symptomatic carotid stenosis. Methods Ninety consecutive patients were referred to our center for a symptomatic carotid stenosis. They were divided into 2 groups according to the time to surgery: G1 within 2 weeks (39 patients) and G2 from 2 weeks to thereafter (51 patients). Neurological assessment was performed with the National Institutes of Health Stroke Scale (NIHSS) at presentation and at follow-up. Echo color Doppler ultrasound was performed at 1–6 months and then yearly. Results The presentation of neurological symptoms differed significantly between the 2 groups; in fact, minor stroke was more frequent in G1, whereas transient ischemic attack was more frequent in G2 (P value = 0.027). No significant differences emerged between the 2 groups on the surgical intervention or perioperative complications. The study showed a significant improvement of the neurological impairment (evaluated with a reduction of NIHSS score) of patients in G1 compared with G2 (P value = 0.01). Conclusions Neurological recovery after a symptomatic carotid stenosis is strictly correlated to the variable “time to surgery.” A higher sensitization of the general population on the early recognition of the symptoms and a strict collaboration with neurologists is mandatory to reduce time to CEA and improve clinical outcomes.

The superficial femoral artery (SFA) is a relatively rare location for lower limb aneurysmatic disease. In the literature, this disease is described an association between a relatively high growth rate and/or the rupture of aneurysms and chemotherapeutic agents. We report a case of the rupture of a giant SFA aneurysm in a patient during chemotherapy for acute lymphatic leukemia.

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly characterized by the origin of the right subclavian artery from the aortic arch distally to the left subclavian artery. We describe the case of a young patient with symptomatic ARSA treated by mediastinoscopy-assisted ligation at its origin and subclavian-carotid transposition.

Perfluoropentane (PFP)-based oxygen-loaded nanobubbles (OLNBs) were previously proposed as adjuvant therapeutic tools for pathologies of different etiology sharing hypoxia as a common feature, including cancer, infection, and autoimmunity. Here we introduce a new platform of oxygen nanocarriers, based on 2H,3H-decafluoropentane (DFP) as core fluorocarbon. These new nanocarriers have been named oxygen-loaded nanodroplets (OLNDs) since DFP is liquid at body temperature, unlike gaseous PFP. Dextran-shelled OLNDs, available either in liquid or gel formulations, display spherical morphology, ~600 nm diameters, anionic charge, good oxygen carrying capacity, and no toxic effects on human keratinocytes after cell internalization. In vitro OLNDs result more effective in releasing oxygen to hypoxic environments than former OLNBs, as demonstrated by analysis through oxymetry. In vivo, OLNDs effectively enhance oxy-hemoglobin levels, as emerged from investigation by photoacoustic imaging. Interestingly, ultrasound (US) treatment further improves transdermal oxygen release from OLNDs. Taken together, these data suggest that US-activated, DFP-based OLNDs might be innovative, suitable and cost-effective devices to topically treat hypoxia-associated pathologies of the cutaneous tissues.

Contrast-enhanced ultrasound (CEUS) has recently become one of the most versatile and powerful diagnostic tools in vascular surgery. One of the most interesting fields of application of this technique is the study of the carotid atherosclerotic plaque vascularization and its correlation with neurological symptoms (transient ischemic attack, minor stroke, and major stroke) and with the characteristics of the “vulnerable plaque” (surface ulceration, hypoechoic plaques, intraplaque hemorrhage, thinner fibrous cap, and carotid plaque neovascularization at histopathological analysis of the sample after surgical removal). The purpose of this review is to collect all the original studies available in literature (24 studies with 1356 patients enrolled) and to discuss the state of the art, limits, and future perspectives of CEUS analysis. The results of this work confirm the reliability of this imaging study for the detection of plaques with high risk of embolization; however, a shared, user-friendly protocol of imaging analysis is not available yet. The definition of this operative protocol becomes mandatory in order to compare results from different centers and to validate a cerebrovascular risk stratification of the carotid atherosclerotic lesions evaluated with CEUS.

Introduction: Carotid artery atherosclerosis is an established risk factor for cerebrovascular events. Core lipid-rich plaques are considered at a higher risk of embolization compared to fibrous or calcified lesions. Contrast enhanced ultrasound (CEUS) is effective for studying carotid plaques, providing a virtual histology [1]. Here we assess the behavior of non-surgical carotid plaques in terms of lipid variation over time. Methods: Eleven patients were enrolled (University of Turin) with a 50–69% (ECST) carotid asymptomatic stenosis. Seven patients were on statin therapy. All patients signed an informed consent and underwent standard carotid ultrasound (MyLab25 Gold, Esaote). A 1.5ml bolus of SonoVue (Bracco Spa) was injected; then a 5ml saline flush. Post-contrast Bmode images (180s after injection) were saved and analyzed offline. All patients repeated this protocol after 6 months. The plaques were segmented, intensity normalized [2], and characterized according to a previous method [3]. Results: We evaluated small cohorts according to lipid concentration changes, identifying four categories. One patient had a plaque showing no lipid variation; four patients showed a slight decrease; four patients a remarkable decrease; two patients an increase. Seven patients with a decrease in lipid concentration were on statin therapy, while both patients with an increase in lipids were not. Conclusions: A method for asymptomatic carotid plaque characterization using CEUS is presented. We focused on plaque lipid variations and the possible influence of statin therapy. We showed that carotid plaques are rarely stable, but rather continuously change composition over time and how statins could play an important role in this process.

Cerebral microembolization, one of the most frequent complications of carotid artery stenting, is associated with an increased risk of peri- and post-procedural stroke and transient ischemic attack and a mid-term risk of neurocognitive decline. A valuable tool to evaluate carotid plaque instability and risk of embolization is contrast-enhanced ultrasound. With this prospective study we sought to determine the correlation between contrast enhancement of the plaque and cerebral microembolization after carotid stent deployment and to evaluate the clinical impact of the neurological injury. Thirty-five consecutive patients with carotid artery stenosis and indications for endovascular stenting were enrolled. Before the procedure, patients were evaluated with contrast-enhanced ultrasound to define plaque enhancement (signal intensity). All endovascular procedures were performed under cerebral filter protection. Diffusion-weighted magnetic resonance imaging scans to detect microemboli were obtained before and 48 h after the stent deployment. The Ray auditory verbal learning test to assess neurocognitive function was administered before and 1 month after the procedure. Nineteen patients (54 %) developed new cerebral ischemic lesions after carotid artery stenting. Contrast enhancement of the plaque was greater in the patients with post-procedural microembolization than in those without it [maximum signal intensity 26 ± 7.7 vs. 21 ± 5.2, respectively, (p = 0.039), mean signal intensity, 20.7 ± 6.1 vs. 16.5 ± 5.3, respectively (p = 0.048)]. No correlation was found between neurocognitive test scores and microembolization or plaque enhancement. Contrast enhancement of the carotid plaque is strongly associated with post-procedural microembolization and for this reason it can be considered a reliable tool for an accurate selection of patients undergoing this endovascular treatment. However, the neurocognitive test scores performed in this study are not enough sensible to appreciate the impact of the neurological injury on the day life activities.

Ultrasound (US)-activated perfluoropentane-cored oxygen-loaded nanobubbles (OLNBs) were recently proposed as adjuvant therapeutic tools for pathologies of different etiology sharing hypoxia as a common feature (e.g. diabetes-associated chronic wounds, anaerobic infections, cancer). Here we introduce a new platform of oxygen nanocarriers, constituted of 2H,3H-decafluoropentane (DFP) as core fluorocarbon and chitosan as shell polysaccharide, and available either in liquid or gel formulations. Such oxygen-loaded nanodroplets (OLNDs) display spherical morphology, ∼700 nm diameters, cationic surfaces, good oxygen carrying capacity (without singlet oxygen generation after sterilization by ultraviolet-C rays), and no toxic effects on human keratinocytes. In vitro, OLNDs are more effective in releasing oxygen to hypoxic environments than former OLNBs, either with or without complementary US administration (f = 1 MHz; P = 5 W). In vivo, sonication of topically applied OLNDs appears essential to allow significant and time-sustained oxygen release. Taken together, the present data suggest that US-activated chitosan-shelled/DFP-cored OLNDs might be innovative, suitable and cost-effective devices to treat several hypoxia-associated pathologies of the cutaneous tissues.

Gianfranco Varetto,1 Caterina Guiot,2 Matteo Destro,1 Claudio Castagno,1 Luigi Contessa,1 Stefano Zan,1 Paolo Garneri,1 Pietro Rispoli11Division of Vascular Surgery, Department of Surgical Sciences, 2Department of Neuroscience, University of Turin, Turin, ItalyBackground: Endovenous laser ablation is a minimally invasive procedure in the treatment of great saphenous vein insufficiency. Procedural criteria (energy delivered according to the selected fluence) could affect outcome after treatment, potentially improving the success rate and reducing complications. However, the optimal values of the required energy per unit volume are not known, but on the basis of clinical experience, a range of optimal speed of retraction of the laser fiber catheter should exist and strictly depend on the actual vein dimensions.Methods: The study population included 21 patients. The equipment was a Diomed 30W® laser, wavelength 810 nm. Before treatment, three segments of the great saphenous vein were mapped and their diameter measured and recorded. The energy delivered to each segment was recorded as well as its relationship with vein diameter being evaluated for each vein segment.Results: A 100% success rate was observed at 12-month follow-up assessment, the discomfort complaint 1 week after endovenous laser ablation by 19% of patients was always low (2 or 3 on a scale of pain of 10). On the basis of the actual result, which greatly improves our previous clinical experience, a range of effective values of speed of retraction of the laser fiber catheter (and of the energy per unit volume) is assessed, which strictly depends on the diameter of each segment of the vein.Conclusion: The speed of retraction of the laser fiber catheter should be properly tailored, in order to deliver the right energy dose depending on the actual vein diameter. A real-time procedure can be easily performed using a simple mathematical nomogram.Keywords: EVLA, great saphenous vein, fluence

Gianfranco Varetto, Paolo Garneri, Claudio Castagno, Valentina Molinaro, Simone Quaglino, Matteo Ripepi, Emilio Benintende, Lorenzo Gibello, Stefano Zan, Luigi Contessa, Ugo Bertoldo, Pietro Rispoli Vascular Surgery, Department of Surgical Sciences, University of Turin, Turin, Italy Abstract: Venous ultrasonography is an indispensable tool in minimally invasive surgery for the treatment of varicose veins. However, the criteria for defining preoperative imaging parameters, outcome monitoring, and follow up are not well characterized. In this retrospective study, we reviewed the ultrasound periprocedural parameters and the outcomes in 274 patients (280 limbs) after endoluminal laser treatment, at early (

The aim of this study was to evaluate the incidence of acute kidney injury (AKI) after open and endovascular abdominal aortic aneurysm repair according to the Aneurysm Renal Injury Score classification.We retrospectively evaluated 431 patients undergoing elective open aortic repair (OAR; n = 285) or endovascular repair (n = 146) for infrarenal aortic aneurysm. All data regarding preoperative and postoperative serum creatinine concentrations and postoperative outcomes were assessed. Univariate and multivariate logistic regression models investigated the association between AKI and different risk factors and complications.The incidence of AKI was significantly higher after OAR (26.3% vs 5.5%; P .001). A significant share of patients who experienced AKI were restored to preoperative renal function at discharge (62.5% vs 77.5% in the endovascular and OAR groups, respectively; P = .37). Preoperative serum creatinine concentration was significantly higher in those patients who further developed AKI (1.25 vs 1.04 mg/dL; P .001). At the multivariate analysis, AKI was significantly associated with current smoking (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.19-3.52; P = .01), hypertension (OR, 2.46; 95% CI, 1.21-4.3; P = .01), chronic renal disease (OR, 2.53; 95% CI, 1.42-4.53; P .001), OAR (OR, 7.3; 95% CI, 3.25-16.42; P .001), and arrhythmias (OR, 3.16; 95% CI, 1.09-9.13; P = .03). AKI stage did not affect postoperative outcomes, except for a longer hospital stay in patients in stage 2 and stage 3 compared with stage 1.AKI is a common but often reversible complication, especially after OAR. There is an urgent need of a common classification for AKI after aortic surgery. New diagnostic markers for AKI should be evaluated in large-scale studies to assess their reliability.

Secondary aortoesophageal fistula is a relatively rare but very often lethal complication that may develop after thoracic endovascular aneurysm repair (TEVAR). The clinical syndrome is well explained by the Chiari triad: midthoracic pain and/or dysphagia, and sentinel minor hematemesis followed by massive hematemesis. The incidence of this serious complication has increased with the growing number of patients undergoing TEVAR. This case report describes a patient who was seen in the emergency department at this hospital because of fever, sepsis and thoracic pain radiating to the back and unresponsive to drug therapy, diagnosed with a secondary aortoesophageal fistula and subsequently treated with a two stage surgical procedure.

In June, 2010, a 66-year-old woman presented to us with a 2 month history of a bilateral pulsatile swelling in her groin. On examination she was in chronic atrial fi brillation. She had been on oral anticoagulant therapy since a mitral valve replacement in 1998. Her medical history also included arterial hypertension and bilateral varices along both great saphenous veins, but without oedema, skin dyschromia or phlebostatic ulcers. Physical examination showed abnormal bilateral pulsatile groin swelling, with holosystolic thrill and pulsating varices along the entire course of the great saphenous veins. Cardiac auscultation showed severe tricuspid insuffi ciency, although she was still in class 1 of the New York Heart Association (NYHA) classifi cation system. Doppler sonography showed bilateral incontinence of the saphenofemoral junction and the entire course of the great saphenous vein, with dilatation of the iliaco-caval segment and the suprahepatic veins associated with hepatomegaly. A reversed arteriallike pulsating fl ow was seen in the veins of the abdomen and of the limbs, and in particular in the great saphenous veins. Neither arteriovenous fi stula nor an apparent pulsatile fl ow transmitted by an artery was detected. The arterial trunks were normal. Transthoracic echocardiography showed an ejection fraction of 55%, confi rming the presence of severe tricuspid insuffi ciency (fi gure), with dilatation of the tricuspid annulus (44 mm), the inferior vena cava (39 mm), and the suprahepatic veins with reverse systolic fl ow. On the basis of clinical and sonography fi ndings, we diagnosed severe tricuspid insuffi ciency with reper cussions on the Lancet 2011; 378: 2138

This report describes the case of a 60-year-old woman with a history of hysterectomy for myomas, totally asymptomatic, with incidental evidence of a pelvic intracaval mass extending to the right atrium. She underwent a staged procedure (sternothomic and abdominal) through a thoracolaparotomic approach in circulatory arrest and deep hypothermia. Using a one-stage surgical approach, we were able to withdraw one portion of the mass from the right atrium and another from the abdominal inferior vena cava, thus minimizing the risk of unexpected venous or atrial wall injury during surgical manipulation.

Background Several fractal and non-fractal parameters have been considered for the quantitative assessment of the vascular architecture, using a variety of test specimens and of computational tools. The fractal parameters have the advantage of being scale invariant, i.e. to be independent of the magnification and resolution of the images to be investigated, making easier the comparison among different setups and experiments. Results The success of several commercial and/or free codes in computing the fractal parameters has been tested on well known exact models. Based on such a preliminary study, we selected the code Frac-lac in order to analyze images obtained by visualizing the angiogenetic process occurring in chick Chorio Allontoic Membranes (CAM), assumed to be paradigmatic of a realistic 2D vascular network. Among the parameters investigated, the fractal dimension Df proved to be the most robust estimator for CAM vascular networks. Moreover, only Df was able to discriminate between effective and elusive increases in vascularization after drug-induced angiogenic stimulations on CAMs. Conclusion The fractal dimension Df is likely to be the most promising tool for monitoring the effectiveness of anti-angiogenic therapies in various clinical contexts.

Pseudoaneurysms of the sovra-aortic trunks are uncommon lesions that usually have a post-traumatic etiology. The singular case of a patient who developed an innominate artery pseudoaneurysm (IAP) where a stent had been inserted 12 years earlier to manage severe innominate trunk stenosis is described. A chronic and large (8 cm in diameter) IAP was successfully treated in extracorporeal circulation and deep hypothermic circulatory arrest. The distal tract of the ascending aorta and the proximal aortic arch were substituted; total replacement of the innominate trunk with a singular 8-mm Dacron graft was necessary. We reviewed the literature about the reports of IAPs and the management of this singular lesion.

The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.

Primary aortoenteric fistula is a direct communication between the aorta and intestinal lumen and it represents a rare but potentially lethal complication of an abdominal aortic aneurysm. However, it may occur less frequently in a naive non-aneurysmatic aorta. Diagnosis is often difficult and delayed in most cases, unless there is a high level of clinical awareness. Urgent surgery is still the recommended treatment. We describe the case of primary aortoenteric fistula of a saccular aneurysm. A 55-year-old woman was referred to our center with hematemesis, melena, and severe anemia who was dignosed previously with unknown saccular abdominal aneurysm.