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Objective: Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA., Methods: A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30 days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis., Results: A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed., Conclusions: Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background/objective: Target vessels related complications are one of the most important 'Achille's heel' of complex thoracoabdominal endovascular procedures. The aim of this report is to describe a case of spontaneous bridging stent-graft (BSG) delayed expansion in a patient treated for type III mega-aortic syndrome, associated with aberrant right subclavian artery and independent origin of the two common carotid arteries., Methods: The patient underwent different surgical procedures (ascending aorta replacement with carotid arteries debranching, bilateral carotid-subclavian bypass with subclavian origins embolization and TEVAR in zone 0, associated with a multibranched thoracoabdominal endograft deployment). Visceral vessels stenting was performed using balloon-expandable BSGs for celiac trunk, superior mesenteric artery and right renal artery, while for the left renal artery a 6 × 60 mm self-expandable BSG was deployed.The first follow-up (FU) by computed tomography angiography (CTA) showed a severe compression of the left renal artery BSG. Considering the challenging access to the directional branches (SAT's debranching and a tightly curve of the steerable sheath inside the branched main body), a conservative treatment was considered, performing a control CTA after 6-months., Results: Six months later, the CTA demonstrated a spontaneous expansion of the BSG, with a two-fold increase in the minimum stent diameter, excluding the need for new reinterventions such as angioplasty or BSG relining., Conclusions: Directional branch compression is a frequent complication during BEVAR; however, in this case, it spontaneously resolved after 6 months, without the need for secondary adjunctive procedures. Further studies on predictor factors for BSG related adverse events and regarding spontaneous delayed BSGs' expansion mechanisms are needed., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Simultaneous carotid artery stenosis (CS) and coronary artery disease (CAD) is a common condition among patients with several cardiovascular risk factors; however, its optimal management still remains under investigation, such as the assumption that carotid disease is causally related to perioperative stroke and that preventive carotid revascularization decrease the risk of this complication. Synchronous surgical approach to both conditions, performing carotid endarterectomy (CEA) before coronary artery bypass graft (CABG) during the same procedure, should still be considered in selective patients, in order to reduce the risk of perioperative stroke during coronary cardiac surgery. For the same purpose, staged approaches, such as CEA followed by CABG or CABG followed by CEA during the same hospitalization or a few weeks later have been described. Hybrid approach with carotid artery stenting (CAS) and CABG can also be an option in selected cases, offering a minimally invasive procedure to treat CS among patients whom CABG cannot be postponed. When carotid intervention is indicated in patients with concomitant CAD requiring CABG, a personalized and tailored approach is mandatory, especially in asymptomatic patients, in order to define the ideal surgical strategy. The aim of this paper is to summarize the current "state of the art" of the different approaches to carotid artery diseases in patients undergoing CABG.

Purpose: To demonstrate the feasibility and outcomes of using the microvascular plug (MVP) for intentional occlusion of directional branches (DB) during complex endovascular aortic procedures., Case Report: Two patients were treated with the off-the-shelf four-branched Zenith t-Branch thoracoabdominal stent-graft (Cook Medical, Bloomington, Ind). In both cases, the renal arteries (on one side in patient #1 and on both sides in patient #2, respectively) were occluded at time of index intervention. Preoperative planning included the intentional occlusion of each DB with one 7Q-MVP. Technical success was achieved in all cases and maintained at mid-term follow-up (12 months and 36 months, respectively)., Conclusions: Use of the MVP appears to be feasible and effective for intentional occlusion of DB during complex endovascular aortic repair. This novel and simple technique may present some unique technical advantages, allowing precise placement of the device while avoiding extension using a bridging stent and DB cannulation with larger sheaths., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The study reports retrospective evaluation of early outcomes from a multicentric experience with the Excluder conformable endograft with active control system (CEXC Device) in the treatment of abdominal aortic aneurysms. Its design allows more flexibility, given by proximal unconnected stent rows and a bending wire within the delivery catheter enables control of proximal angulation. This study specifically focuses on the severe neck angulation (SNA) subgroup (≥60°)., Methods: All patients treated with CEXC Device in nine vascular surgery centers of Triveneto area (Northeast Italy) between January 2019 and July 2022 were enrolled prospectively and analyzed retrospectively. Demographic and aortic anatomical characteristics were evaluated. Endovascular aneurysm repair in SNA were selected for analysis. Major investigated outcomes were technical success, endoleaks, morbidity, mortality, and reinterventions at 30 days and during follow-up. Endograft migration and postoperative aortic neck angulation changes were also analyzed., Results: A total of 129 patients were enrolled. An infrarenal angle of ≥60° was observed in 56 patients (43%) (SNA group) and their data analyzed. The mean patient age was 78.9 ± 5.9 years and median abdominal aortic aneurysm diameter 59 mm (range, 45-94 mm). Median aortic infrarenal neck length, angulation and diameter were 22 mm (range, 13-58 mm), 77° (range, 60°-150°), and 22.0 ± 3.5 mm respectively. Analysis revealed a technical success rate of 100% and perioperative major complication rate of 1.7%. Intraoperative and perioperative morbidity and mortality rates were 3.5% (one buttock claudication and one inguinal surgical cutdown) and 0%, respectively. No perioperative type I endoleaks were observed. The median follow-up was 13 months (range, 1-40 months). Five patients died during follow-up from aneurysm-unrelated causes. Two reinterventions occurred (3.5%): one conversion for a type IA endoleak and one sac embolization for a type II endoleak. Aneurysm sac shrinkage was observed in 15 patients (26%) and aneurysm stability in 35 patients (62%), respectively. Estimated freedom from reinterventions at 24 months was 92%. Aortic neck median postoperative angulation was 75° (range, 45°-139°)., Conclusions: The Triveneto Conformable Registry shows good early results of the CEXC device in severely angulated aortic infrarenal necks. These data need confirmation on longer follow-up and a wider cohort of patients to further increase endovascular aneurysm repair eligibility in SNA., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of this study was to present the short-term and 2-year outcomes after use of the Bentley BeGraft as bridging stent-graft (BSG) for reno-visceral target vessel (TV) during fenestrated endovascular aortic repair (FEVAR) from a contemporary multicentric experience., Methods: A retrospective review of all consecutive patients who underwent elective FEVAR at 7 institutions located in Italy from 2015 to 2021 was performed. The main outcomes of interest for this study were technical success and TV instability, defined in accordance with current reporting standards. Patients' survival was also assessed., Results: Overall, 81 patients received elective FEVAR during the study period. Mean age of patients was 78 years, and 89% were men. Most patients were treated for a juxta-pararenal abdominal aortic aneurysm (AAA) (68%), and 23% had already received an infrarenal aortic reconstruction. Most endografts had 3-vessel or 4-vessel design (27% and 55%, respectively), and a Cook endograft was used in 73% of cases. Overall, 266 Bentley BeGraft were implanted, of which 44 (16.5%) in the celiac trunk, 69 (26%) in the superior mesenteric artery, 79 (29.5%) in the right renal artery, and 74 (28%) in the left renal artery. Technical success was 94%, with 5 instances of technical failure that were recorded and required an additional intraoperative procedure. The early mortality rate was 4%, and acute kidney injury occurred in 14 cases with 1 requiring definitive hemodialysis. Survival at 6, 12, and 24 months in the overall cohort was 98.8%, 95.3%, and 83.4%, respectively. Freedom from TV instability at 6, 12, and 24 months in the overall cohort was 98.4%, 97.9%, and 97.2%, respectively. Events of TV instability included 3 cases of type 1C endoleak and 3 cases of type 3C endoleak, while no events of BSG fracture or thrombosis were noted. Five out of 6 cases of TV instability occurred in renal arteries, and they were all successfully treated by endovascular means., Conclusions: The data from this multicentric study show favorable short-term and 2-year outcomes of the Bentley BeGraft as BSG for reno-visceral TV during FEVAR, with low rates of TV-related endoleak and no stent occlusion up to 2 years., Clinical Impact: The data from this multicentric study show satsfactory outcomes up to two years of follow-up for the Bentley BeGraft when used for brdiging reno-visceral vessels during fenestrated endovascular aortic repair. Further research will be needed to identify predictors of stent-related reinterventions and ascertain the long-term durability.

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

Objective: To report the early and mid-term outcomes following open surgical conversion (OSC) after failed endovascular aortic repair (EVAR) using data from a multicentric registry., Methods: A retrospective study was carried out on consecutive patients undergoing OSC after failed EVAR at eight tertiary vascular units from the same geographic area in the North-East of Italy, from April 2005 to November 2019. Study endpoints included early and follow-up outcomes., Results: A total of 144 consecutive patients were included in the study. Endoleaks were the most common indication for OSC (50.7%), with endograft infection (24.6%) and occlusion (21.9%) being the second most prevalent causes. The overall rate of 30-day all-cause mortality was 13.9% (n = 20); 32 patients (22.2%) experienced at least one major complication. Mean length of stay was 13 ± 12.7 days. On multivariate logistic regression, age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.01-1-19; P = .02), renal clamping time (OR, 1.07; 95% CI, 1.02-1.13; P = .01), and suprarenal/celiac clamping (OR, 6.66; 95% CI, 1.81-27.1; P = .005) were identified as independent predictors of perioperative major complications. Age was the only factor associated with perioperative mortality at 30 days. Renal clamping time >25 minutes had sensitivity of 65% and specificity of 70% in predicting the occurring of major adverse events (area under the curve, 0.72; 95% CI, 0.61-0.82). At 5 years, estimated survival was significantly lower for patients treated due to aortic rupture/dissection (28%; 95% CI, 13%-61%), compared with patients in whom the indication for treatment was endoleak (54%; 95% CI, 40%-73%), infection (53%; 95% CI, 30%-94%), or thrombosis (82%; 95% CI, 62%-100%; P = .0019). Five-year survival rates were significantly lower in patients who received emergent treatment (28%; 95% CI, 14%-55%) as compared with those who were treated in an urgent (67%; 95% CI, 48%-93%) or elective setting (57%; 95% CI, 43%-76%; P = .00026). Subjects who received suprarenal/celiac (54%; 95% CI, 36%-82%) or suprarenal (46%; 95% CI, 34%-62%) aortic cross-clamping had lower survival rates at 5 years than those whose aortic-cross clamp site was infrarenal (76%; 95% CI, 59%-97%; P = .041). Using multivariate Cox proportional hazard, older age and emergency setting were independently associated with higher risk for overall 5-year mortality., Conclusions: OSC after failed EVAR was associated with relatively high rates of early morbidity and mortality, particularly for emergency setting surgery. Endoleaks with secondary sac expansion were the main indication for OSC, and suprarenal aortic cross-clamping was frequently required. Endograft infection and emergent treatment remained associated with poorer short- and long-term survival., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We evaluated the early and midterm outcomes of the Incraft (Cordis Corp, Bridgewater, NJ) ultra-low-profile endograft by analyzing data from the Triveneto Incraft Registry (TIR)., Methods: TIR is an independent multicenter cohort registry of 10 vascular surgery units in the Triveneto area (Northeast Italy). A prospective analysis of patients electively treated with Incraft from September 2014 to June 2019 was performed. The main outcomes were technical success, major 30-day complications, 30-day aneurysm-related death, freedom from reintervention, and mortality rate during follow-up and were analyzed using Kaplan-Meier curves. Univariable Cox regression was used to evaluate the associations between anatomic complexity factors and reintervention., Results: During the study period, 209 patients were included in the registry. Their mean age was 76.9 ± 7.7 years and the Society for Vascular Surgery comorbidity score was 0.97 ± 0.52. Most patients (n = 181; 86.6%) had presented with at least one complex anatomic factor: aortic neck angle α <135° in 31 patients (14.8%), conic neck in 17 patients (8.2%), iliac tortuosity index τ >1.5 in 102 (48.8%), iliac artery calcification >50% in 106 (50.7%), and external iliac artery <6 mm in 45 (21.5%). The concurrent presence of two or more complex iliac anatomic factors was present in 67 patients (32.1%). The technical success rate was 99.5%, and the early major complication rate was 1.5% (one limb occlusion, one iliac branch stenosis, one type III endoleak [EL]). No 30-day mortality was recorded. The mean follow-up period was 18.5 ± 13.2 months. The overall mortality was 9.5% (n = 18), none related to the aneurysm. The freedom from reintervention rate was 92.1%. Of these patients, six (3.2%) had been treated for type II EL embolization, one (0.5%) for type IA EL, four (2.1%) for iliac branch occlusion, and one (0.5%) for flow-limiting external iliac artery dissection. None of the single anatomic factors analyzed were predictive of reintervention. However, the association of two or more complex iliac anatomic factors was predictive of related reintervention (hazard ratio, 7.25; P = .014). The crude reintervention rate in this complex subgroup of patients was low (4 of 67; 6%)., Conclusions: Data from the TIR have demonstrated excellent early and midterm outcomes of endovascular aneurysm repair using the Incraft stent graft in patients with complex anatomy. The concurrent presence of two or more complex iliac anatomic factors still represent an issue for endovascular aneurysm repair success. However, the technical characteristics of this device resulted in low intervention rates, even for patients with these challenging issues., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim was to describe the outcomes of the Anaconda™ Fenestrated endograft Italian Registry for complex aortic aneurysms (AAAs), unsuitable for standard endovascular aneurysm repair (EVAR)., Methods: Between 2012 and 2018 patients with a proximal neck unsuitable for standard EVAR, treated with the fenestrated Anaconda™ endograft, were prospectively enrolled in a dedicated database. Endpoints were peri-operative technical success (TS) and evaluation of type Ia/b or 3 endoleaks (T1/3 EL), target visceral vessel (TVV) occlusion, re-interventions, and AAA related mortality at 30 days, six months, and later follow up., Results: One hundred twenty seven patients (74 ± 7 years, American Society Anesthesiology (ASA) II/III/IV: 12/85/30) were included in the study in 49 Italian Vascular Surgery Units (83 juxta/para-renal AAA, 13 type IV thoraco-abdominal AAA, 16 T1aEL post EVAR, and 15 short neck AAA). Configurations with one, two, three, and four fenestrations were used in 5, 56, 39, and 27 cases, respectively, for a total of 342 visceral vessels. One hundred and eight (85%) bifurcated and 19 (15%) tube endografts were implanted. In 35% (44/127) of cases the endograft was repositioned during the procedure, and 37% (128/342) of TVV were cannulated from brachial access. TS was 87% (111/127): five T1EL, six T3EL (between fenestration and vessel stent), and six loss of visceral vessels (one patient with a Type Ia EL had also a TVV loss) occurred. Thirty day mortality was 4% (5/127). Two of the five T1EL resolved spontaneously at 30 days. The overall median follow up was 21 ± 16 months; one T1EL (5%) occurred at six months and one T3EL (4%) at the three year follow up. Another two (3%) TVV occlusions occurred at six months and five (3%) at three years. The re-intervention rate at the 30 days, six months, and three year follow up was 5%, 7%, and 18 ± 5%, respectively., Conclusion: The fenestrated Anaconda™ endograft is effective in the treatment of complex AAA. Some structure properties, such as the re-positionability and the possibility of cannulation from above, are specific characteristics helpful for the treatment of some complex anatomies., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The recent technological evolution has also allowed for the treatment of juxtarenal aortic aneurysm (JAA) with an endovascular technique, but short- and long-term results must be compared with the results of open treatment, which is the gold standard. In this study, we analyzed the short- and long-term results of open surgical treatment (open repair) in patients with JAA in our series., Methods: From January 2006 to December 2016, 155 patients were treated for JAA with open repair; the data were analyzed retrospectively. The mean age was 71.17 years (standard deviation [SD] 7.1), and mean size of aneurysm was 6.15 cm (SD 1.1). The ASA classes 2, 3, and 4 were 20%, 74% and 6%, respectively. Follow-up included clinical visit and abdominal aorta Duplex scan after 1 and 6 months and annually. The mean follow-up interval was 48.6 (SD 32.4) months., Results: The mean surgical time was 256 min (SD 69), the mean stay in the intensive care unit was 1.6 days (SD 1.2), and the mean total hospital stay was 10.2 days (SD 4.3). Aortic cross-clamping was usually suprarenal (110, 71%); in 39 (25%), the aortic clamping was between the renal arteries, and 6 patients (4%) required a supraceliac cross-clamping. The mean renal ischemia time due to aortic clamping was 17 min (SD 3.5). In 32 patients (21%), the left renal vein was sectioned for performing proximal aortic anastomosis and then reconstructed. Twelve patients (8%) required a renal revascularization, and in 49 patients (32%), an hypogastric bypass was performed. The 30-day mortality rate was 0.6%, and only 1 patient died in the postoperative due to intestinal infarction. The postoperative morbidities occurred in 15 cases (10%). Six patients had dehiscence of the laparotomy without the involvement of the muscle, 4 patients had an asymptomatic small increase of the troponin, and in 3 patients, there was an increase in creatinine >1.8 mg/dL. No dialysis was performed. Two patients had peripheral embolism in the lower limbs. Twenty-six patients (15%) died in the follow-up, but causes have never been related to aortic disease., Conclusions: Open repair of JAA is still safe, effective, and durable also in the long-term period and even in patients with multiple cardiovascular risk factors., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We report a case of epithelioid angiosarcoma of the abdominal aortic wall after endovascular treatment for abdominal aortic aneurysm (EVAR). A 60-year-old male, treated 7 years before with EVAR, presented with abdominal back pain, general fatigue, and fever. It was assumed to be a graft infection with periaortic tissue compatible with an inflammatory reaction. The endograft was therefore completely removed and a Dacron silver aorto-bisiliac graft was implanted. After a few days the patient worsened, the angio-computed tomography scan showed a progressive increase of the periaortic mass and numerous small nodules in the abdomen were also detected. The patient was again brought to surgery, an axillo-bifemoral bypass was performed, and the aorto-bisiliac graft was removed but the patient died after surgery. The histological examination showed an aortic epithelioid angiosarcoma with peritoneal metastasis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Carotid artery pseudo-occlusion is a rare condition and its natural history and clinicopathological characteristics are not well defined. We reported our 7-year experience in the surgical treatment of carotid artery pseudo-occlusion to determine the real benefit of the surgical option., Methods: From January 2006 to December 2013, 1414 patients were treated for high-grade stenosis of the internal carotid artery, 33 (2.3%) presented with a carotid pseudo-occlusion (26 males and 7 females, mean age: 70 ± 10). Nineteen patients were symptomatic, and 14 asymptomatic. Carotid artery pseudo-occlusion was identified by duplex scan (segmental occlusion at the origin of internal carotid artery with very thin distal flow) and the diagnostic confirmation was obtained by angio-computed-tomography (CT) scan. The operation was performed under general anaesthesia and constant Electroencephalography (EEG) monitoring. The follow-up was performed by duplex scan at discharge, 30 days, 6 months and yearly., Results: Politetrafluoroetilene (PTFE) patch endarterectomy, eversion endarterectomy and carotid bypass were performed in 20 (61%), 10 (30%) and 3 patients (9%), respectively. No mortality or stroke was observed in postoperative period. Four patients presented with an asymptomatic postoperative thrombosis of the internal carotid artery. No restenosis was observed., Conclusions: Surgical treatment for carotid artery pseudo-occlusion is safe and effective., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To evaluate the outcome of surgical treatment of acute lower limb ischemia in elderly patients. The primary endpoints were early and midterm rates of survival and limb salvage., Methods: A retrospective analysis involving 76 consecutive patients observed for acute lower limb ischemia between March 2005 and December 2008 who underwent revascularization was conducted. A total of 44 patients (group A) of age >80 years (average age: 86.9 ± 4.5 years; 13 men and 31 women) had a site of obstruction at the level of abdominal aorta in one case (2.3%), common-external iliac artery/common femoral artery in 15 (34.1%), superficial femoral artery/popliteal artery in 26 (59.1%), and infrapopliteal arteries in two (4.5%), and embolectomy, thrombectomy, bypass, and angioplasty was performed in 24 (54.5%), 11 (25.0%), eight (18.2%), and one (2.3%) case(s), respectively. A total of 32 patients (group B) of age <80 years (average age: 67.2 ± 12.2 years; 19 men and 13 women) with an analogous site of obstruction at the level of abdominal aorta in one case (3.1%), common/external iliac artery/common femoral artery in 12 (37.5%), superficial femoral artery/popliteal artery in three (9.4%), and infrapopliteal arteries in 16 (50.0%) underwent the same aforementioned procedures in 10 (31.3%), 12 (37.5%), nine (28.1%), and one (3.1%) case(s), respectively., Results: At 30 days after surgery, survival and limb salvage were both 93.2% in group A versus 96.9% and 87.5%, respectively, in group B, whereas they were 93.2% and 65.8%, respectively, in group A versus 85.7% and 96.9%, respectively, in group B (p = 0.22 and p = 0.19, respectively) at the midterm control. The univariate and multivariate analyses showed that category 2b of acute ischemia (immediately-threatening) has a negative statistically significant influence on the survival rate (p = 0.01)., Conclusions: Limb salvage rates after surgical intervention for acute lower limb ischemia in the elderly population are comparable with those of the younger population, whereas survival rates are lower, but without statistical significance. The only factor that negatively influences the survival rate is the 2b clinical category of acute ischemia, regardless of the age of the patient., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate two anesthetic techniques for hemodynamic control during carotid TEA surgery and early post-surgery., Methods: Two study groups treated by carotid surgery were compared; the Fentanyl group consisted of 7 patients in ASA class 3, the Remifentanil-Sevoflorane group included 12 patients in ASA class 3. The double product was monitored on entry to the operating room, at 5, 15, 30 min after induction of anesthesia and tracheal intubation, and at 30 min after extubation. Time of extubation, re-awakening and attention levels during early post-surgery, and myocardial ischemia markers were monitored for 48 h after surgery in the Remifentanil group., Results: Statistical analysis using Student's "t"-test for paired data showed that the double product indicated better hemodynamic stability in the patients who received Remifentanil-Sevoflorane than in those who received Fentanyl., Conclusions: Compared with anesthesia using Fentanyl and with locoregional techniques, anesthesia with Remifentanil-Sevoflorane in carotid surgery provides a valuable alternative and secures good hemodynamic stability.

Background: Shunt insertion during carotid endarterectomy (CEA) is mandatory to avoid neurological damage due to clamping ischemia; however shunt insertion before plaque removal has many inconveniences (atheroembolism, intimal dissection, difficulty of endarterectomy). The aim of this study is to verify whether and how long shunt insertion may be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time consuming manoeuvres of CEA (peeling, patch angioplasty)., Methods: From July 1990 to February 1996 383 patients underwent 411 CEAs under general anesthesia with EEG continuous monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal. In 316 CEAs (76.9%) without EEG signs of cerebral ischemia (Group A) the mean clamping time was 10 min +/-4.8 (range 2-37 min). In 95 CEAs (23.1%) with EEG signs of cerebral ischemia (Group B) it was 7.3 min +/-3.5 (range 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion (mean 21 min, range 5-45 min)., Results: In the short term results (within 30 days) there was a relevant neurological complication rate of 0.96% (2 major stroke and 2 lethal stroke); at awakening we observed 5 RINDs (1.21% of total) 1 in a patient of Group A (0.31%) and the other 4 in patients of Group B (4.21%)., Conclusions: These data confirm the rationale of a delayed insertion of the shunt: actually the cerebral parenchyma may tolerate under general anesthesia a sufferance due to carotid clamping, EEG detectable, without neurological deficits for at least 7.3 min. This time is sufficient to perform the most difficult steps of CEA (plaque removal, distal intima checking) allowing shunt insertion in a clean operatory field, without inconveniences. Finally the shunt allows complementary time consuming steps, as patch angioplasty, with improvement of both short- and long-term results.

Background: The aim of this retrospective study is to analyze the short and long term results of two different surgical treatments in patients with subclavian lesions: common carotid-subclavian artery bypass (CSB) versus transposition of subclavian artery on the common carotid artery (SCT)., Methods: From 1981 until 1995, 40 non randomized patients with symptomatic subclavian steal underwent 20 CSBs and 20 SCTs. Risk factor rates were equally balanced in the two groups. Surgery was carried out routinely under general anesthesia, with electroencephalic continuous monitoring. Patency of revascularization was assessed by physical examination, brachial blood pressure determinations, ultrasound sonography and angiography whenever recurrence of symptoms developed or when the function of repair was in doubt. Patients were examined every year. In Spring 1996 (range 9-189 mos, average 7 years) a general clinical-instrumental follow-up was performed., Results: In the short term (<30 days) mortality was 5%: one death (5%) for pulmonary embolism in a patient with CSB and one for myocardial infarction in a patient with SCT. The early thrombosis rate was 5% (1 CSB and 1 common carotid artery distal to a patent SCT). During follow-up 10 patients (25%) died and 6 were lost. The six-year actuarial patency rate was 100% for SCT and 66% for CSB. Moreover there were 3 thromboses of the vertebral artery homolateral to patent CSBs., Conclusions: In conclusions SCT should be considered the surgical technical choice for the treatment of proximal subclavian artery lesions.

The aim of this study was to analyze and compare the perioperative hazards and late results of internal carotid endarterectomy (CEA) in patients with and without contralateral internal carotid artery occlusion. From March 1980 to April 1990, 375 consecutive patients underwent 439 CEAs at the First Department of Vascular Surgery of Padova Medical School. Patients were divided into two groups; group 1 (61 patients) had contralateral internal carotid artery occlusion and group 2 (314 patients) did not (378 CEAs, 64 bilateral). Indications for CEA were similar in both groups. The only significant difference in patient characteristics was a higher rate of previous stroke in group 1 (11% vs. 3%, p < 0.001). General anesthesia, continuous EEG monitoring, selective intraluminal shunt, and arteriotomy closure with a polytetrafluoroethylene patch (PTFE) were used routinely in both groups. An intraluminal shunt was inserted more frequently in group 1 than in group 2 (69% vs. 17%, p < 0.001). Major perioperative stroke occurred in one patient in each group (1.7% vs. 0.31%, respectively; NS). Early fatal stroke rates were 0% and 0.95% in groups 1 and 2, respectively (NS). All patients had neurologic examinations and duplex scans every 6 months (range 6 to 118 months; mean 42 months). Kaplan-Meier survival curves were virtually identical in the two groups; the majority of deaths were caused by myocardial infarction and cancer. There were no stroke-related deaths in group 1 as compared with 8.2% in group 2 (NS). New neurologic symptoms appeared in 4.7% of patients in group 1 and 6% in group 2 (NS) whereas the late stroke rates were 0% and 3.1%, respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Patients suffering from arteriosclerotic obliterating disease of the lower limbs that present with symptoms of rest pain, ulcers or more or less severe gangrene are considered as candidates for revascularization operation. Apart from the possible non relevance of individual symptoms, in some instances the revascularization operation is indicated solely on the basis of the angiographic evidence. Ascending thrombosis of the abdominal aorta, double or triple blocks, stenosis of the collateral circulation and, broadly speaking, any other situation that suggests a possible superimposition of an episode of acute ischaemia due to thrombosis in a condition of chronic obliterating arteriopathy are considered as absolute indication for revascularization operation. Patients whose conditions are not listed above are considered as stage II and indication for operation in this case is not absolute but relative or "luxury" since its purpose is only to improve the quality of life. The importance of the symptoms must be considered along with other factors, including the personal, social, working, sporting and psychological needs of the specific individual apart from the absence of general risks related to the patient's condition. The vascular surgeon's expertise is obviously fundamental in exactly evaluating the arteriography and in understanding the precise anatomic picture that varies in every single case: in fact, since the operation is optional and not a necessity, correction of the arterial lesions in only advisable when it is possible to carry out and operation that is broadly risk free and with good short and long term results, with reference to the patient's life expectancy.

From March 1980 to July 1988 a consecutive series of 256 patients (p.) underwent 301 carotid endarterectomy + patch with routine use of continuous intraoperative EEG monitoring and selective use of an intraluminal shunt (IS) for the presence of an atherosclerotic plaque concerning the internal carotid artery (ICA). Patients were divided in two groups: the first (42 p.) marked by contralateral ICA occlusion, the second (214 p.) without contralateral ICA occlusion (259 CEA). Immediate peroperative, long term and global (immediate and long term) outcomes were prospectively and comparatively studied. A temporary IS was inserted in 27 p. (64%) of the group I and in 38 p. (14%) of the group II. Immediate permanent postoperative neurological deficit occurred in 1 p. of group I (2.38%) and in 2 p. (0.9%) in group II. Immediate postoperative mortality was 0% and 0.9% in group I and II respectively. All p. had neurological valuation and Echo-Doppler of operated ICA and of the contralateral ICA every 6 months (middle follow-up 44 months). New neurological symptoms compared in 5.8% of p. of group I and in 5.23% of p. of group II with a stroke rate of 0% and 2.32% respectively. There were 2 restenosis of operated ICA, both of them in p. of group I, that underwent reoperation. In the two groups the principal causes of deaths were myocardial infarct and cancer; in the group I no death was due to stroke versus 1.86% in the group II.

From March 1980 to March 1987, at the Department of Vascular Surgery of the University of Padua, 217 patients underwent 252 carotid revascularizations with routine use of an intraluminal shunt (IS) for symptomatic (70%) or asymptomatic (30%) internal carotid artery (ICA) atherosclerotic stenosis. All carotid endarterectomies (CEs) were routinely performed with patch graft angioplasty to prevent restenosis. In the immediate post-operative period, no patient presented permanent or transient neurological deficits; no patient died. In the early post-operative course there was a 0.9% (2 patients) stroke rate and 0.4% (1 patient) mortality rate. These results suggest that the selective use of the IS on the basis of EEG changes is able to reduce the perioperative morbidity and mortality to nearly zero.

From March 1980 to July 1986 at the Department of Vascular Surgery of the University of Padua, 182 patients underwent 210 carotid revascularizations for atherosclerotic stenosis involving the carotid bifurcation (28 operations were bilateral). Carotid endarterectomies (CE) and patch graft angioplasty totalled 192 (166 patients); an enlarging patch graft angioplasty of the internal carotid artery (ICA) without CE was performed in 14 cases (13 patients); in the remaining four surgical procedures (3 patients), for technical reasons prohibiting CE, the operation consisted of a great saphenous vein bypass between a donor vessel and the ICA distal to the lesion. The preoperative symptoms in 182 patients were as follows: TIAs (98 cases, 54%), non-hemispheric symptoms (21 cases (12%) and fixed stroke or TIAIR (10 cases, 5%). Fifty-three patients (29%) were asymptomatic. In all cases, continuous EEG monitoring was employed. The operation was performed without a temporary intraluminal shunt in the patients showing tolerance to carotid clamping. The protection of the shunt was required only in patients with EEG changes (47 cases). The arteriotomy was routinely closed with a PTFE patch graft angioplasty. Early results of the operation were excellent: none of the patients presented permanent or transient neurological deficits in the immediate postoperative period and none of them died. All patients were reassessed with C.W. Doppler sonography and Duplex scanning in the postoperative period. In all cases, the success of the operation was demonstrated. Longterm follow-up (6-72 months, mean follow-up: 35 months) was done in 121 patients (142 operations): 107 patients were completely asymptomatic, 5 remained stable or slightly improved the preoperative status. Five patients had a new or recurrent TIAs, 3 suffered a stroke, one showed a recurrence of non-hemispheric symptoms. With the exception of two patients suffering a stroke, all had a second arteriography but none of these patients showed extracranial lesions. Two patients presented an asymptomatic restenosis of the ICA. Eight patients (8.8%) revealed a significant evolution of the disease of the contralateral unoperated ICA.(ABSTRACT TRUNCATED AT 400 WORDS)