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The aim of this study was to compare the 2-year outcomes of de novo versus postendovascular lesion treatment of femoropopliteal occlusions included in a national, multicenter, observational, prospective registry based on the treatment of critical Limb-threatening IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE) registry.From January 2018 to December 2019, 541 patients from 43 centers have been enrolled in the LIMBSAVE registry. Of these patients, 460 were included in the present study: 341 (74.1%) with de novo lesions (DN group) and 119 (25.9%) with postendovascular treatment lesions (PE group). Initial outcome measures were assessed at 30 days after treatment. Furthermore, at the 2-year follow-up, the estimated outcomes of primary patency, primary-assisted patency, secondary patency, and limb salvage were analyzed with Kaplan-Meier curves and compared between groups with the log-rank test.Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation. However, compared with DN group, more patients in PE group had a great saphenous vein diameter of less than 3 mm (11.1% vs 21%; P = .007). Intraoperatively, both groups showed similar distal anastomosis sites: below-the-knee popliteal artery (63% DN group, 66.4% PE group) and tibial vessel (37% DN group, 33.6% PE group) (P = .3). The overall mean duration of follow-up was 11.6 months (range, 1-24 months). At the 2-year follow-up, there were no differences between the two groups in terms of primary patency (66.3% DN group vs 74.1% PE group; P = .9), primary-assisted patency (78.2% DN group vs 79.5% PE group; P = .2), secondary patency (85.1% DN group vs 91.4% PE group; P = .2), and limb salvage (95.2% DN group vs 95.1% PE group; P = .9).The LIMBSAVE registry did not show a worsening of overall patency and limb salvages rates at the 2-year follow-up in patients undergoing in situ saphenous bypass after a failed endovascular approach for long femoropopliteal occlusive disease. This finding is in contrast with what has been published in literature.

Introduction Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. Methods Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. Results Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. Conclusions Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.

Preliminary Observational Study on Cardiac Remodeling in Patients Undergoing Edge-to-Edge Trans-catheter Mitral Valve Repair with MitraClip Device Considering the current interest to the new trans-catheter mitral valve repair, it has been our aim to investigate the remodeling of left ventricular (LV), left atrium (LA) and right ventricular (RV) in a cohort of 24 patients with severe organic (13 cases) or functional (11 cases) mitral regurgitation (MR), on a 6 months follow-up. Their mean age was 78,54 ± 7,64 years, and STS score 4,69 ± 2,39 and EuroSCORE II of 5,10 ± 3,28%, and a corresponding ASA score of 3, due to age, co-morbidity and impaired cardiac function (NHIA III/IV). In our study we used advanced techniques of 3D- echocardiography, for the advantage of images independent from the cutting sections, probe angles, and operators skills: this method accuracy is comparable to that of cardiac magnetic resonance imaging. In detail, all enrolled patients underwent transthoracic 3D, spackle tracking imaging, to assess valve anatomy, and suitability for MitraClip treatment according to the EVEREST anatomic eligibility criteria. They were on optimized medications and, when necessary, previously treated with percutaneous angioplasty and stent implantation. Our results, in both functional and organic cases of MV regurgitation, can be summarized in a statically significant improvement of the NHYA class, reduction in the degree of MV and tricuspid valve insufficiency, decrease in LV end-diastolic diameter and diastolic volume, and mainly in a corrected direction of LV outflow towards the high pressure aortic system: so we explain the unchanged left ventricular ejection fraction. The LA remodeling was present with a significant reduction in LA volume only in patients without atrial fibrillation, while in its function there was a reduced peak strain. Regard the indicative parameters of afterload on the right heart chambers, the derived systolic pulmonary arterial pressure decreased, and in case of tricuspid regurgitation, a significant decrease in the maximal velocity of the blood flow was observed. There was also a statistically significant reduction in the right atrial area, and in RV size, both correlated with a reduced back flow in the RA. About the RV volumetric remodeling there was no statistically significant improvement in the end-diastolic RV volume, most probably of its better compliance towards a low pressure inflow. An improvement in RV systolic function parameters was obtained in terms of increased ejection fraction, decreased free wall strain, and decreased velocity at the tricuspid annular. In Conclusion, the clinical improvement observed after Mitral Clip repair consist in decreased overload to the left chambers, facilitating their reverse remodeling, and in the LV function. In perspective, we are planning to perform pre-operative models of MV repair, where we can calculate the reduced volume of regurgitated blood and the increase in the LVEF physiological outflow, in order to better tailor the indications to this procedure.

The aim was to demonstrate contemporary outcomes of in situ saphenous vein bypass using a valvulotome.Analysis of two year outcomes of a multicentre registry based on the treatment of critical Limb Ischaemia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE). Between January 2018 and December 2019, 541 patients in 43 centres were enrolled. In all patients an innovative valvulotome was used. Early outcomes were assessed. Two year outcomes according to Kaplan-Meier curves in terms of patency and limb salvage were evaluated. Associations between patient and procedure variables were analysed with univariable and multivariable analyses.In all cases, a valvulotome was able to lyse the valves. Vein injury due to the in situ technique was 3.5%. Thirty day mortality and major amputation rates were 3% and 0.9%, respectively. Mean follow up was 12.1 months. Two year estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 69.1%, 81.4%, 86.5%, and 94.5%, respectively. Multivariable analysis showed an association between pre-operative vein diameter3 mm and lower primary patency (hazard ration [HR] 14.3, p.001), primary assisted patency (HR 9.4, p = .002), secondary patency (HR 7.2, p = .007), and limb salvage (HR 7.8, p = .005) rates. Distal anastomosis to a tibial or foot vessel was also associated with lower primary patency (HR 4.8, p = .033), and primary assisted patency (HR 6, p = .011) rates. Use of a suprafascial tributary collateral as a graft was associated with lower primary patency (HR 6.7, p = .013), and primary assisted patency (HR 4.2, p = .042) rates.Vein diameter3 mm, distal anastomosis on a tibial or foot vessel, and use of a suprafascial tributary collateral as a graft were significantly associated with loss of patency and limb loss during follow up.

Endovascular treatment nowadays represents a valuable option in the treatment of ruptured abdominal aortic aneurysms (rAAAs). The aim of this study is to evaluate a 15-year, single-center experience with endovascular treatment of rAAAs and the role of the type of fixation in outcome.Retrospective analysis of all consecutive hemodynamically stable and unstable patients with a diagnosed rAAA treated at this hospital with an endovascular procedure between December 1999 and January 2015 was conducted. Patients with symptomatic aneurysms and impending ruptures were excluded. Predictive factors of immediate and overall major complications and survival were investigated. Study end points included technical and clinical success, mortality, and major adverse events.This study included 142 patients. Technical success was 97.1% within 30 days, 60 major adverse events were reported in 43 patients (30.3%), including 40 deaths (28.2%). Clinical success at 30 days was 59.9%. Predictive factors of 30-day mortality were chronic renal disease (odds ratio [OR] 3.44, P = 0.006), chronic obstructive pulmonary disease (OR 2.42, P = 0.032), hemodynamic instability at presentation (OR 4.57, P = 0.001), and the use of an aortic balloon (OR 23.4, P 0.001). The use of local anesthesia (OR 0.38, P = 0.017) had a protective influence. One-year survival was 52%. At a median follow-up of 44 months (range 0.5-152), overall survival was 39% (95% CI 30-48), with a median overall survival of 13 month (95% CI 6-36). Five-year survival was 23%. Predictive factors of long-term mortality were advanced age (85 years) (hazard ratio [HR] 2.0, P = 0.002), hemodynamic instability at admission (HR 1.90, P = 0.005), and the use of an aortic balloon (HR 4.56, P 0.001). The implantation of an anatomically fixated (AFIX) device was found to be protective against mortality (OR 0.41, P = 0.011).In this series, satisfactory rates of complications and survival were observed after endovascular repair of rAAAs. In addition to the well-known predictors of outcome, the type of fixation also seems to play a significant role, and the AFIX device was associated with improved longer term survival when its use was deemed feasible.

BACKGROUND The aim of this study was to assess clinical and contemporary costs associated with elective endovascular repair of intact descending thoracic aortic aneurysms (DTAA) into the mid-term follow-up. METHODS A retrospective review of a prospectively maintained clinical database including 29 consecutive patients from July 2005 to December 2009 treated with elective endovascular repair (TEVAR) or TEVAR and surgical infrarenal repair (hybrid) of intact DTAA was performed. Mean age was 74.5 years old (±7.1). Primary clinical endpoints include mortality and major morbidity. Additionally a comprehensive economic appraisal of individual in-hospital and follow-up costs was executed. Economic endpoints include in-hospital and follow-up costs and patient discharge status. Elective endovascular and open repairs' clinical and economical outcomes in contemporary literature were assessed for comparison according to PRISMA standards. RESULTS Immediate mortality was 6.9% (1/24 TEVAR and 1/5 hybrid). Three respiratory complications were recorded (11%; 2 TEVAR, 1 hybrid). Renal and cardiac complication rates were 7.4% (1 TEVAR, 1 hybrid) and 3.7% (1 TEVAR) respectively. Routine discharge home was achieved for 85% of patients (95.7% TEVAR, 25% hybrid). Three endoleaks were treated throughout the follow-up (2 TEVAR, 1 hybrid; mean 30.4 mo, ±19.9) rendering an 11% (3/27) reintervention rate. Average immediate cost was €21,976.87 for elective endovascular repair and €33,783.21 for elective endovascular hybrid repair. Additional reintervention and routine follow-up costs augmented immediate costs by 12.4%. CONCLUSIONS This study supports satisfying immediate clinical outcomes for TEVAR and TEVAR+surgical infrarenal procedures. Although limited by a small population size and difficulties in economic comparisons, this study presents the real world social and economic cost scenario for both elective TEVAR and TEVAR hybrid treatment of DTAA of both the in-hospital and at mid term follow-up periods.

BACKGROUND: This paper reports the 4-year safety and effectiveness of the INCRAFT® AAA Stent-Graft System (Cordis Corp., Milpitas, CA, USA), an ultra-low-profile device for the treatment of abdominal aortic aneurysms. METHODS: The INNOVATION Trial is the prospective, first-in-human, multicenter trial to evaluate the safety and effectiveness of the INCRAFT® System. Patients underwent annual clinical and computed tomography angiography examination as part of the study protocol. The IN CRAF T® AAA Stent-Graft System is a customizable tri-modular design, with an ultra-low profile (14-Fr) delivery system. Patient were treated under approved protocol, the prescribed clinical and imaging follow-up at annually through 5 years. Results analyzed and adjudicated by a clinical events committee, independent core laboratory, and a data safety and monitoring board. This manuscript reports results through 4 years of follow-up. RESULTS: A total of 60 patients were enrolled in the trial, all of whom were successfully treated. Follow-up rates at 1 and 4 years were 93% (56/60) and 85% (51/60), respectively. All-cause mortality at 4 years was 17.6% and no death was AAA-, device-, or procedure-related. The secondary reintervention rate at 1 year was 4.6%, primarily the result of stent thrombosis. In total, 10 patients required 13 post-procedure interventions within 4-years of follow-up (2 to repair a type I endoleak, 4 to repair a type II endoleak, 1 for stent thrombosis, 1 for renal stenosis, 1 for aneurysm enlargement, 2 for limb migration and 2 for prosthesis stenosis or occlusion). There were 4 cases (10%) of aneurysm enlargement reported at the 4 year follow-up. At 4 years, 38 out of 39 patients were free from type I and III endoleaks. There were no proximal type I or type III endoleaks at 4-year follow-up. Core laboratory evaluation of the postoperative imaging studies indicated absence of endograft migration while a single fracture was demonstrated without any clinical sequelae. CONCLUSIONS: The INCRAFT® AAA Stent-Graft System provides a minimally invasive and durable solution for patients undergoing EVAR that has been associated with a low frequency of device-related events through 4 years of follow-up.

Purpose: To report midterm outcomes of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the treatment of abdominal aortic aneurysm (AAA). Methods: Between September 2013 and July 2014, 64 AAA patients (mean age 76.6±6.8 years; 61 men) were treated with the EVAS system at 2 centers (only procedures performed at least 12 months prior to the analysis were included). Most patients were treated for a stable AAA, while 1 patient was treated for a ruptured aneurysm. Mean aneurysm diameter was 57.3±9.3 mm. The proximal neck measured a mean 21.5±3.3 mm in diameter and 27.0±12.1 mm long; the neck angle was 16.9°±19.3°. Eleven (17.2%) patients were treated outside the instructions for use (IFU). Results: Technical success was achieved in 63 (98.4%) of 64 patients; 1 type Ia endoleak was treated intraoperatively. One (1.6%) aneurysm-related death occurred at 4 months due to a secondary aortoenteric fistula. Overall, endoleaks occurred in 3 (4.7%) patients (2 type Ia, 1 type II). The estimated rates for 18-month overall survival, freedom from aneurysm-related death, and freedom from secondary interventions were 92.7%, 98.4%, and 95.0%, respectively. Patients treated outside the IFU had a significantly higher incidence of device-related complications (p=0.03). Conclusion: The use of the Nellix device in everyday clinical practice is safe and offers promising midterm results. The risk of secondary aortoenteric fistula requires further analysis. Longer follow-up is needed to assess the actual efficacy of the device, although the risk of migration with late endoleak seems low.

Optimal treatment for synchronous aortic aneurysms is still debated. Staged repair is advocated as the standard of care. Its disadvantage however is the consistent risk of rupture of the untreated aortic segment during recovery; moreover a considerable percentage of patients either refuse the second stage or is lost to follow-up. We present the case of a patient with a ruptured aortic arch aneurysm after open-surgery for a type III thoracoabdominal aortic aneurysm. Our therapeutic decision is described and discussed, with all the related advantages and disadvantages.

To evaluate the safety and efficacy of urgent carotid artery stenting (CAS) with technical modifications in patients with recent (24 hours) initial or recurrent (≥2 episodes in 24 hours) transient ischemic attacks (TIA) or with minor stroke.A single-center, prospective, observational study was begun in March 2005 to assess an urgent CAS protocol for the treatment of selected high-risk patients with carotid artery disease who presented within 24 hours of an initial or recurrent TIA or minor stroke. Up to June 2011, 78 patients (59 men; mean age 76 years) with TIA (n=57) or minor stroke (n=21) underwent urgent CAS (within 48 hours) for severe internal carotid artery stenosis. Outcome measures were major adverse cardiac and cerebrovascular events (MACCE), modifications in the National Institutes of Health Stroke Scale (NIHSS) values for minor stroke patients, and postoperative stroke and death rates.Technical and procedural success rates were 100% and 97.4%, respectively; 1 intraoperative minor stroke occurred due to stent thrombosis. At 30 days, 2 patients had recurrent minor stroke; one subsequently died after a hemorrhagic brain infarction. The MACCE rate was 3.8%. There were no cases of myocardial infarction or access-related complications. Of the 20 surviving minor stroke patients, 14 showed improvement in neurological deficit on the NIHSS scale at 30 days, while 5 remained stable and one was neurologically impaired.Urgent CAS in selected patients with symptomatic carotid stenosis was satisfactory in preventing the recurrence of TIA and stroke in this study. Urgent CAS with careful patient selection, contemporary tools (medical and technical), and expert technique may represent a possible solution for some patients with recent or recurrent TIA or minor stroke.

Posterior nutcracker syndrome (PNS) is a rare condition due to left renal vein (LRV) hypertension, caused by compression of the LRV between the vertebral column and the abdominal aorta. Diagnosis of PNS is challenging, as symptoms are variable and not specific. Therapeutic options are debated, and either conservative, open, or endovascular approaches have been advocated as both safe and effective. We report our experience with a case of PNS in a 17-year-old woman, who presented with a 2 year history of recurrent hematuria associated to severe left flank and back pain, successfully treated with anterior transposition of the LRV. (J Vasc Surg 2011;54:844-7.)

Pentraxin 3 (PTX3) plays cardioprotective and anti-atherogenic roles in murine models. PTX3 blood levels raise during early acute myocardial infarction (AMI). Neutrophils from healthy subjects physiologically contain PTX3 in secondary (also called specific) granules. In this study, we report that circulating neutrophils release preformed PTX3 in the early phase of AMI (within 6 h from the onset of clinical symptoms). Depletion of intracellular PTX3 correlates with increased plasma levels and with platelet–neutrophil heterotypic aggregates. Neutrophil PTX3 returns to normal values 48 h after the onset of symptoms; concentration does not vary in matched healthy controls or in patients with chronic stable angina. In vitro, recognition of activated P-selectin+ platelets causes the formation of neutrophil–platelet heteroaggregates and the release of neutrophil PTX3. Purified or membrane-bound P-selectin triggers PTX3 release from resting neutrophils. Released PTX3 binds to activated platelets in vitro. Moreover, PTX3 binds to a substantial fraction of platelets from patients in the circulating blood. PTX3-bound activated platelets have a reduced ability to 1) form heterotypic aggregates with neutrophils and monocytes; 2) activate neutrophils, as evaluated assessing the upregulation of leukocyte β2 integrins; 3) aggregate with other platelets; and 4) bind to fibrinogen. Our results suggest that neutrophils early release prestored PTX3 in patients undergoing AMI. PTX3 binds to activated circulating platelets and dampens their proinflammatory and prothrombotic action, thus possibly contributing to its cardioprotective effects.

OBJECTIVE: To evaluate the feasibility of the Adamkiewicz artery (AKA) detection by multidetector computed tomography (CT) data analysis without the need of a dedicated workstation, using low-cost hardware and the freeware OsiriX. METHODS: CT scans of 67 patients undergoing a thoracic or thoraco-abdominal aortic procedure between April 2006 and August 2008 were evaluated with respect to detection rate and AKA level and side using the OsiriX software version 3.2 on Mac OS X computer and compared to results obtained by standard workstation analysis, in a fully blinded analysis. The results were also compared with data compiled from a review of the English-language literature on this topic. RESULTS: (1) AKA identification showed a substantial agreement of 85.07% between the methods (k=0.636). (2) The comparison of AKA level showed a substantial agreement (weighted k=0.661), with consensus in 70.14%. (3) From the literature review, we found that recognition of the AKA was achieved in 466 of 555 cases (83.96%). (4) In 384 (83.3%) cases the AKA originated from a left intercostal artery. (5) The proposed method and literature-compiled data showed a similar AKA level distribution. CONCLUSIONS: Noninvasive AKA location with open-source software and low-cost hardware is feasible. The OsiriX software allows to effectively navigate through CT data not only to study the aorta, but also to detect the AKA, as in the case of the standard method and the literature data. Its availability and ease of use may contribute to make identification of the AKA part of the routine evaluation of CT scans in patients with aortic disease, even where dedicated workstations are not available, with potential benefits for planning therapeutic procedures. Objective: To evaluate the feasibility of the Adamkiewicz artery (AKA) detection by multidetector computed tomography (CT) data analysis without the need of a dedicated workstation, using low-cost hardware and the freeware OsiriX. Methods: CT scans of 67 patients undergoing a thoracic or thoraco-abdominal aortic procedure between April 2006 and August 2008 were evaluated with respect to detection rate and AKA level and side using the OsiriX software version 3.2 on Mac OS X computer and compared to results obtained by standard workstation analysis, in a fully blinded analysis. The results were also compared with data compiled from a review of the English-language literature on this topic. Results: (1) AKA identification showed a substantial agreement of 85.07% between the methods (k = 0.636). (2) The comparison of AKA level showed a substantial agreement (weighted k = 0.661), with consensus in 70.14%. (3) From the literature review, we found that recognition of the AKA was achieved in 466 of 555 cases (83.96%). (4) In 384 (83.3%) cases the AKA originated from a left intercostal artery. (5) The proposed method and literature-compiled data showed a similar AKA level distribution. Conclusions: Noninvasive AKA location with open-source software and low-cost hardware is feasible. The OsiriX software allows to effectively navigate through CT data not only to study the aorta, but also to detect the AKA, as in the case of the standard method and the literature data. Its availability and ease of use may contribute to make identification of the AKA part of the routine evaluation of CT scans in patients with aortic disease, even where dedicated workstations are not available, with potential benefits for planning therapeutic procedures.

Background Fast-track recovery programs have led to reduced patient morbidity and mortality after surgery. Minimally invasive surgery and anesthesia, with programs of early postoperative recovery are the main aspects of fast-track recovery programs. The optimization of pain control, early mobilization, and oral feeding allows for a rapid functional rehabilitation, which leads to minor morbidity and early discharge from the hospital to home. Methods We enrolled all nonemergent patients treated for elective abdominal aortic surgery for an aneurysm or obstructive disease from April 2000 to June 2014. The fast-track protocol was applied to all these patients. A transperitoneal aortic approach was used through a left subcostal incision and was complemented with epidural anesthesia–analgesia and a protocol of early rehabilitation. Results A total of 1,014 patients were treated for elective aortic surgery. For 980 patients (96.6%), clear liquids followed by a semisolid diet were tolerated starting on the afternoon of the day of intervention (day 0). Nine hundred eighty-seven patients (97.3%) began early ambulation on day 0, and for 81.2% of the population, regular colonic function returned within the second postoperative day. Seventeen deaths (1.7%) occurred. Nine hundred ten patients (89.7%) had no complications. The median hospital length of stay was 3 days for the entire series, and 80.4% of patients ( n = 815) were discharged to their homes between the second and fifth days after surgery. Conclusions The fast-track program can be efficiently and safely applied to aortic surgery and that this program improves surgical outcomes, allows for earlier discharge, and reduces costs.

To assess the midterm efficacy of a biodegradable poly-l-lactic acid (PLLA) stent in the treatment of superficial femoral artery (SFA) occlusive disease.Between June 2009 and April 2011, 35 de novo SFA lesions were treated with 43 biodegradable stents. This nonrandomized, retrospective, single-center study included patients with moderate or severe claudication, lower-limb rest pain, or ischemic ulceration restricted to the toes; symptoms were classified as Rutherford category 2 (48.6%), 3 (37.1%), 4 (8.6%), or 5 (5.7%). The population included 28 men and had a mean age of 71 years (range, 51-81 y). Follow-up included clinical examination and color-flow duplex imaging. Mean follow-up was 38.3 months (range, 30-58 mo).Technical success was reported in all patients (100%). There were no intraoperative or immediate (30 d) complications.. During follow-up, one in-stent occlusion and seven in-stent restenoses occurred, all of which were successfully treated with percutaneous transluminal angioplasty. Primary and secondary patency rates were 77.1% and 97.1% at 24 and 36 months, respectively. No stent recoil or stent fracture was encountered. Late follow-up (12 mo) by ultrasound confirmed total reabsorption of the stent structures. Clinical improvement (ie, an upward shift of at least two Rutherford categories) was achieved in all 35 patients.Midterm results for biodegradable PLLA stents for atherosclerotic SFA lesions were associated with high technical success and secondary patency rates, without stent recoil and vessel remodeling.

A 69-year-old man was admitted to our hospital for persistent fever, myalgias, articular pain, headache, and hypoaesthesia of the scalp. The clinical scenario was typical for giant-cell arteritis. During hospital stay, patient developed fugax amaurosis, stroke, and acute coronary syndrome. The definitive diagnosis of infective endocarditis, supported by transesophageal echocardiography, was confirmed only by culturing the material obtained during angiography and coronary thromboaspiration.

Objectives: Despite several advances in endoluminal salvage for failed endovascular abdominal aortic repair (EVAR), in our experience an increasing number of cases necessitate delayed open conversion (dOC). Methods: EVAR patients requiring delayed (>30 days) conversion were prospectively collected in a computerized database including demographics, details of aortoiliac anatomy, procedural and clinical success, and postoperative complications. Results: Between 2005 and 2011, 54 patients were treated for aortic stent-graft explantation. Indications included 34 type I and III endoleaks, 13 type II endoleaks with aneurysm growth, 4 cases of material failures, and 3 stent-graft infections. All fit-for-surgery patients with type I/III endoleak underwent directly dOC. Different surgical approaches were used depending on the type of stent-graft. Overall 30-day mortality was 1.9%. Overall morbidity was 31% mainly due to acute renal failure (13 cases). Mean hospitalization was 6 days (range, 5-27 days). Overall survival at mean follow-up of 19 months was 78%. Conclusions: In recent years, the use of EVAR has increased dramatically, including in young patients regardless of their fitness for open repair. dOC after endovascular abdominal aortic aneurysm seems to be a lifesaving procedure with satisfactory initial and mid-term results. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. OI tshomba, yamume/0000-0001-8316-4702; Bertoglio, Luca/0000-0001-6871-2176

Objective The goal of this article is to report the preliminary results of infrapopliteal percutaneous transluminal angioplasty stenting with the Nile Croco coronary bifurcated stent (Minvasys, Gennevilliers, France) for selected patients with critical limb ischemia (CLI). Methods From October 2006 to December 2010, 31 patients with CLI with below-the-knee TransAtlantic Inter-Society Consensus C and D lesions at the popliteal (n = 17, 54.8%) and distal tibioperoneal trunk (n = 14, 45.2%) bifurcations, with suboptimal primary percutaneous transluminal angioplasty results (residual stenosis >30%, elastic recoiling, or dissection), with at least two-vessel runoff to the foot (present or after percutaneous transluminal angioplasty), free of aortoiliac arterial disease, and at high surgical risk (more than three risk factors) were treated with the Nile Croco coronary bifurcated stent. Study end points included technical success, immediate and midterm primary and secondary patency rates, clinical improvement, and limb salvage. Results Technical success was achieved in all patients (100%) without any intraoperative complications. Early complications included an acute stent occlusion and an acute compartment syndrome for a collateral arterial branch perforation. Median follow-up was 12.1 months (range, 1-32). Primary and secondary patency rates were 96.7% and 86.2% (95% confidence interval [CI], 67.2%-94.6%) at 30 days and and 100% and 96.6% (95% CI, 78.0%-99.5%) at 1 year, respectively. Clinical improvement (an upward shift of at least two Rutherford categories) was achieved in 28 patients (90.3%). A major amputation was required in one patient (3.2%). The overall limb salvage rate at 1 year was 96.7% (95% CI, 78.6%-99.5%). Conclusions Preliminary data suggest that the Nile Croco bifurcated stent for below-the-knee angioplasty in selected patients with CLI is associated with high rates of technical success, early and midterm patency, and clinical improvement. Limb salvage rates are acceptable for this technically highly challenging anatomy, yet further studies with larger patient populations are necessary to validate these results.

Blunt aortic injury (BAI) involving an aberrant right subclavian artery (ARSA) is uncommon. The presence of an ARSA entails several treatment issues, in particular regarding the risk of perioperative posterior cerebral stroke. We report the case of a man with an ARSA who suffered from BAI. An initial conservative treatment with delayed open repair was chosen. A review of the published literature with discussion of the case is presented. The presence of an ARSA in patients with BAI can be considered a poor anatomy for endovascular repair, and suitable patients may benefit from delayed open repair.

Introduction: Recognition of acute mesenteric ischaemia (AMesI) in patients with aortic dissection (AoD) may be a challenge and exploratory laparotomy is often performed. Methods: We retrospectively analysed our experience with the use of diagnostic laparoscopy (DL) for the early detection of AMesI in patients with AoD, either undergoing medical treatment or after open/endovascular interventions. Results: Between 2004 and 2011, 202 consecutive AoDs were treated in our centre (71 acute type A AoD; 131 acute and chronic type B AoD). Among the 17 (8.4%) patients in which AMesI was suspected, nine (52.9%) were selected for DL Three DLs were performed during medical treatment of patients with acute type B AoD, six after treatment of AoD (both surgical and endovascular). Three second-look DLs were also performed. Eight DLs were negative, three showed AMesI and the patients underwent successful emergent revascularisation. One DL was not conclusive and laparotomy was required. Among the eight patients not submitted to DL, one case of bowel infarction was recorded. Conclusions: In our series DL was feasible and safe. The low invasiveness and repeatability were the main advantages. Although additional experience is mandatory, DL seems a promising technique for the detection of AMesI in patients with AoD. (C) 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Introduction: Recognition of acute mesenteric ischaemia (AMesI) in patients with aortic dissection (AoD) may be a challenge and exploratory laparotomy is often performed. Methods: We retrospectively analysed our experience with the use of diagnostic laparoscopy (DL) for the early detection of AMesI in patients with AoD, either undergoing medical treatment or after open/endovascular interventions. Results: Between 2004 and 2011, 202 consecutive AoDs were treated in our centre (71 acute type A AoD; 131 acute and chronic type B AoD). Among the 17 (8.4%) patients in which AMesI was suspected, nine (52.9%) were selected for DL Three DLs were performed during medical treatment of patients with acute type B AoD, six after treatment of AoD (both surgical and endovascular). Three second-look DLs were also performed. Eight DLs were negative, three showed AMesI and the patients underwent successful emergent revascularisation. One DL was not conclusive and laparotomy was required. Among the eight patients not submitted to DL, one case of bowel infarction was recorded. Conclusions: In our series DL was feasible and safe. The low invasiveness and repeatability were the main advantages. Although additional experience is mandatory, DL seems a promising technique for the detection of AMesI in patients with AoD. (C) 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. OI tshomba, yamume/0000-0001-8316-4702; Bertoglio, Luca/0000-0001-6871-2176

Visceral artery aneurysms (VAAs) represent approximately 1–2% of all vascular aneurysms. Improvements in imaging technology have led to increased aneurysm detection in asymptomatic patients. A timely proper diagnosis and management of VAAs is essential to avoid the risk of acute rupture and associated mortality. We present a case of an asymptomatic 59-year-old patient with superior mesenteric artery aneurysm, who was successfully treated with endovascular embolization of the aneurysmatic sac.

Background: Carotid endarterectomy (CEA) has been shown to be superior to medical therapy alone in the prevention of stroke only if it can be safely performed (ie, with a complication rate less than 3% in asymptomatic patients and less than 6% in symptomatic patients). Technical defects are the most common cause of neurological complications after CEA, and their correction has traditionally been performed through standard surgical techniques. Methods: From 1999, we started to treat intimal flaps, dissection, or partial thrombosis after CEA with carotid artery stenting (CAS). A retrospective analysis of the operating room registry and of the registry of our Interventional Cardiology laboratory was conducted in order to identify all the patients that underwent stenting of the internal carotid artery after CEA between January 2001 and June 2009. Results: During the time period considered, 5012 CEA were performed at our institution and a total of 34 patients (34/5012; 0.6%) were found to have received carotid stenting after CEA, both for symptomatic and asymptomatic defects. Immediate technical success was obtained in all patients. One major cerebrovascular adverse event (1/34; 3%) in the immediate perioperative period was recorded. At a mean follow-up of 18.6 months (range, 3-84 months; median, 12 months), we did not observe any neurological symptoms related to the treated carotid artery, nor hemodynamic in-stent restenosis. Long-term follow-up (ie, equal or greater than 4 years) was available for five patients: all patients remained event-free during the entire period. Conclusions: Our study adds to the assumption that CAS in post-CEA symptomatic and asymptomatic patients is safe and technically feasible, and represents a valid and quick alternative to standard surgical revision. Even if in a small group of patients, long-term results seem promising. (J Vase Surg 2010;52:1511-7.)

Purpose:To report a case of endovascular aneurysm repair (EVAR) in a patient with severe hemophilia B.Case report:A 63-year-old man with severe hemophilia B was referred for the treatment of a symptomatic infrarenal aortic aneurysm that had enlarged from 3.1 to 4.2 cm in diameter in the last 6 months. The patient was successfully treated with EVAR, associated with perioperative administration of titrated doses of high-purity factor IX concentrate. There were no perioperative complications, but a small type II endoleak was found on the initial postoperative computed tomographic scan; on the 6 month scan, the endoleak had not changed, and it is under intensive surveillance.Conclusion:This case demonstrates that endovascular abdominal aortic repair is safe and feasible in severe hemophilic patients managed perioperatively with deficient coagulant protein replacement.

To analyze the efficacy and durability of long-term tibioperoneal arterial stent placement for selected cases of symptomatic chronic limb ischemia (CLI).From January 2005 to June 2012, 168 limbs (155 patients) were treated with percutaneous transluminal angioplasty (PTA)/stent placement for de novo tibial stenosis or occlusion in at least one tibial artery. Most patients (92.9%) were classified with severe disease (Rutherford category 5/6). Concomitant interventions were performed in 58%. Bare metal (84%) and drug-eluting (16%) stents were used. Indications for stent placement were residual stenosis after PTA (30%), elastic recoiling, and dissection. Primary endpoints were freedom from symptomatic intrastent restenosis, target lesion revascularization (TLR), major amputation, and overall survival (OS).Technical success rate was 99%. Within 30 days, five deaths (3.2%) occurred, and a 1.8% (95% confidence interval [CI], 0.1%-27.2%) major adverse cardiac event rate, 3.6% (95% CI, 0.1%-22.1%) major adverse limb event rate, and 1.8% (95% CI, 0%-27.5%) amputation rate were recorded. Mean follow-up was 33 months (range, 1-96 mo). Symptomatic intrastent restenosis occurred in 20 limbs (12%) at a mean of 10.3 months ± 11.27; this was identified as a prognostic factor for limb loss (P = .045). TLR was necessary in 10.8% of limbs, for a limb salvage rate of 89.2%. OS was influenced by age (75 y; P.001), diabetes (P = .048), and renal insufficiency and/or dialysis (P.001). Estimated survival rate was 63% at 36 months (hazard ratio, 1.63; 95% CI, 54%-70%).Stent placement offers promising short- to long-term restenosis and patency rates, even in cases of multilevel symptomatic disease. Rigorous follow-up is vital.

Objectives This report evaluates the feasibility and efficacy of an endovascular blood flow blockage technique to prevent intracerebral embolization of plaque debris during carotid artery stenting. Methods Forty-two patients were enrolled in five clinical sites in Germany and Italy with either an asymptomatic internal carotid artery stenosis ≥75% (mean 87%) or a symptomatic stenosis ≥60% (mean 85%). Cerebral protection during the stenting procedure was achieved using an endovascular clamping technique, obtained by occlusion of the external and common carotid artery via two independently inflatable balloons integrated in the Mo.Ma ® system. Blood with particulate plaque debris was aspirated before flow was restored. The patient's clinical and the neurological status were assessed during intervention, at discharge, and at 3 months follow-up. Results Stenting was performed in all but one patient. The mean flow occlusion time was 10.6±6.5 min. Transient clamping intolerance was observed in five patients (12%). In two patients, neurological deficits persisted for 2 and 12 h, respectively. Two minor strokes (4,7%) occurred at 5 and 72 h after the procedure. No major strokes or deaths were observed at 3 months follow-up. Conclusions This first clinical experience with the Mo.Ma ® device substantiates the feasibility of endovascular clamping in preventing cerebral embolization during carotid artery stenting.

Popliteal artery aneurysms are the most common aneurysmal disease of the lower extremity. Although endovascular solutions are gaining consensus, open surgery with interposition grafting remains the standard of care. The great saphenous vein (GSV) is the most commonly used conduit and shows the best long-term results. However, optimal vein segments can sometimes be unavailable, thus leading to the use of unsuitable segments or prosthetic grafts. We report the cases of 3 patients who had bilateral popliteal aneurysms and only 1 GSV that was considered suitable for grafting, without alternative venous segments. All patients underwent staged treatment with the use of the GSV. After the first operation, the remaining GSV was cryopreserved and then reused for the contralateral limb. All patients had an uneventful outcome. No graft occlusions and no aneurysmal dilatations were detected at follow-up. Cryopreservation of autologous vein for staged treatment of bilateral popliteal aneurysms is feasible and seems to avoid the risk of residual GSV loss during the time inbetween the interventions.