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Cone-beam computed tomography (CBCT) is widely used for the technical assessment of standard and complex endovascular aortic interventions. Use of iodinated contrast in CBCT imaging might provide useful additional information; however, this also increases the procedural contrast dose, which may cause renal function deterioration, and the radiation exposure. We describe the technique and feasibility of carbon-dioxide (CO2)-enhanced CBCT for the technical assessment of standard and complex endovascular aortic repair. In our experience CO2-CBCT had no related adverse events and provided satisfactory imaging quality to assess endograft integrity, vessels patency, and was safely performed in case of severe chronic renal insufficiency.

The aim is to describe the technical feasibility, early outcomes, and graft stability of the Excluder iliac branch endoprosthesis (W.L. Gore & Associates) used as an infrarenal abdominal bifurcated endograft in cases unsuitable for standard endovascular aortic repair. The technique was used in 13 cases with abdominal and/or iliac aneurysms (n = 6), occlusive disease (n = 3), or complex aneurysms in association with a proximal fenestrated/branched endograft (n = 4). Technical success was 100%, and there were no adverse events, with 100% graft stability at 3 months. This case series demonstrates, in extremely selected cases, the feasibility and safety of Excluder iliac branch endoprosthesis used as an infrarenal aortic bifurcated device.

We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.

Background. Readmissions rates and costs were analysed over follow-up for patients who underwent open or endovascular procedures for aorto-iliac occlusive disease (AIOD). Methods. Patients who underwent aorto-bifemoral bypass (ABF) or covered kissing stent (CKS) for AIOD from May 2008 to February 2018 were compared in terms of readmission rates, related costs expressed in EUR, freedom from generic readmission (FFGR), and freedom from readmission for surgical reasons (FFRS). Results. ABF had a readmission rate of 16% and CKS of 18% (p = 0.999). The most common cause of readmission was prosthesis limb or stent occlusion. Time to readmission was longer for ABF (35 months [21–82] vs. 13.5 months [1–68.7] in the CKS group, p = 0.334). CKS group had higher cumulative re-hospitalisation, ICU stay, and reintervention costs (11569 ± 2216 SEM, 2405 ± 1125, 5264 ± 1230, respectively) and a trend for more readmissions in the first 36 months, without reaching significance. Conclusion. This study reports on a period of time exceeding ninety days. Even if not reaching significance, the CKS group presented a higher trend in readmissions till 36 months and a higher trend in readmission costs, while time-to-readmission was longer in the ABF group.

We describe the feasibility of a technique for temporary aneurysm sac reperfusion after endovascular single-stage thoracoabdominal aortic aneurysm exclusion, to be used in the case of postoperative spinal cord ischemia. Two cases were treated for impending rupture of a thoracoabdominal aortic aneurysm. Before completion of sac exclusion, a supplementary buddy wire (V-18 control guidewire; Boston Scientific) was advanced in parallel fashion from the left percutaneous femoral access into the aneurysmal sac on the posterior aspect of the endograft. Distal aneurysm exclusion was completed using the main superstiff guidewire, and the femoral access was closed with a percutaneous closure device (ProGlide; Abbott) in standard fashion, leaving in place the sole V-18 guidewire, draped in sterile fashion. In the case of spinal cord ischemia, the “safe-line” can be rapidly used for spinal reperfusion after trans-sealing exchange with a 6F, 65-cm-long Destination sheath (Terumo) connected to a 6F introducer on the contralateral femoral artery.

In the present report, we have described the use of intravascular lithotripsy angioplasty for heavily calcified occlusions of the infrarenal aorta and its bifurcation in two patients. In the first patient, two lithotripsy balloons in kissing conformation were simultaneously used to allow for dilatation of the distal aorta and its bifurcation with preservation of accessory renal artery patency, followed by stenting of the iliac arteries. For the second patient, the infrarenal aorta occlusion was first treated with a single lithotripsy balloon, followed by covered stenting. Intravascular lithotripsy could represent a valid endovascular adjunct to optimize outcomes in the treatment of coral reef aortas and aortic bifurcation occlusion.

Background. The aim of this study was to assess the incidence of two post-operative acute kidney injury (AKI) stages according to the Risk, Injury, Failure, Loss of function, End-stage (RIFLE) criteria in patients undergoing fenestrated endovascular aortic repair (FEVAR) for complex aortic aneurysms. Furthermore, we analyzed predictors of post-operative AKI and mid-term renal function deterioration and mortality. Methods. We included all patients who underwent elective FEVAR for abdominal and thoracoabdominal aortic aneurysms between January 2014 and September 2021, independently from their preoperative renal function. We registered cases of post-operative acute kidney injury (AKI) both at risk (R-AKI) and injury stage (I-AKI) according to the RIFLE criteria. Estimated glomerular filtration rate (eGFR) was noted preoperatively, at the 48th post-operative hour, at the maximum post-operative peak, at discharge, and then during follow-up approximately every six months. Predictors of AKI were analyzed with univariate and multivariate logistic regression models. Predictors of mid-term chronic kidney disease (CKD) (stage ≥ 3) onset and mortality were analyzed using univariate and multivariate Cox proportional hazard models. Results. Forty-five patients were included in the present study. Mean age was 73.9 ± 6.1 years and 91% of patients were males. Thirteen patients (29%) presented with a preoperative CKD (stage ≥ 3). Post-operative I-AKI was detected in five patients (11.1%). The aneurysm diameter, thoracoabdominal aneurysms and chronic obstructive pulmonary disease were identified as predictors of AKI in univariate analysis (OR 1.05, 95% CI [1.005–1.20], p = 0.030; OR 6.25, 95% CI [1.03–43.97], p = 0.046; OR 7.43, 95% CI [1.20–53.36], p = 0.031; respectively), yet none of these factors were significative on multivariate analysis. Predictors of CKD onset (stage ≥3) during follow-up on multivariate analysis were age (HR 1.16, 95% CI [1.02–1.34], p = 0.023), post-operative I-AKI (HR 26.82, 95% CI [4.18–218.10], p < 0.001) and renal artery occlusion (HR 29.87, 95% CI [2.33–309.05], p = 0.013), while aortic-related reinterventions where not significantly associated with this outcome in univariate analysis (HR 0.66, 95% CI [0.07–2.77], p = 0.615). Mortality was influenced by preoperative CKD (stage ≥3) (HR 5.68, 95% CI [1.63–21.80], p = 0.006) and post-operative AKI (HR 11.60, 95% CI [1.70–97.51], p = 0.012). R-AKI did not represent a risk factor for CKD (stage ≥ 3) onset (HR 1.35, 95% CI [0.45–3.84], p = 0.569) or for mortality (HR 1.60, 95% CI [0.59–4.19], p = 0.339) during follow-up. Conclusions. In-hospital post-operative I-AKI represented the main major adverse event in our cohort, influencing CKD (≥ stage 3) onset and mortality during follow-up, which were not influenced by post-operative R-AKI and aortic-related reinterventions.

The Thoracic Outlet Syndrome is a clinical potentially disabling condition characterized by a group of upper extremity signs and symptoms due to the compression of the neurovascular bundle passing through the thoracic outlet region. Because of the non-specific nature of signs and symptoms, to the lack of a consensus for the objective diagnosis, and to the wide range of etiologies, the actual figure is still a matter of debate among experts. We aimed to summarize the current evidence about the pathophysiology, the diagnosis and the treatment of the thoracic outlet syndrome, and to report a retrospective analysis on 324 patients followed for 5 years at the Padua University Hospital and at the Naples Fatebenefratelli Hospital in Italy, to verify the effectiveness of a specific rehabilitation program for the syndrome and to evaluate if physical therapy could relieve symptoms in these patients.

Background: This work aims to review recent literature on penetrating aortic ulcers (PAUs) and intramural hematomas (IMHs), in order to identify clinical and imaging factors connected to aortic-related adverse events (AAE). Methods: We performed a systematic review according to the Preferred Reporting Items for Systematic review and Metanalyses (PRISMA) guidelines. An electronic search was conducted on Medline and Embase databases. We included articles reporting on PAUs and/or IMHs localized in the descending thoracic and/or abdominal aorta and analyzing clinical and/or radiological markers of AAE. Results: Of 964 records identified through database searching, 17 were incorporated in the present review, including 193 and 1298 patients with type B PAUs and IMHs, respectively. The 30-days aortic-related mortality (ARM) was 4.3% and 3.9% for PAUs and IMHs. A total of 21% of patients with IMHs underwent intervention during the follow-up period, and 32% experienced an AAE. PAU markers of AAE were minimum depth (ranging from 9.5 to 15 mm) and diameter (≥12.5 mm). Maximum aortic diameter (MAD) cut-off values ranging from 38 to 44.75 mm were related to AAE for IMHs, together with ulcer-like projection (ULP) of the aortic wall. Conclusions: Despite data heterogeneity in the literature, this PAU- and IMH-focused review has highlighted the imaging and clinical markers of disease progression, thus identifying patients that could benefit from an early intervention in order to reduce the AAE rate.

Objectives: Surgical site infections (SSIs) in lower extremity vascular surgeries, post-groin incision, are not only common complications and significant contributors to patient mortality and morbidity, but also major financial burdens on healthcare systems and patients. In spite of recent advances in pre- and post-operative care, SSI rates in the vascular surgery field remain significant. However, compliant antibiotic therapy can successfully reduce the SSI incidence pre- and post-surgery. Methods: In October 2021, we conducted a systematic literature review using OVID, PubMed, and EMBASE databases, centered on studies published between January 1980 and December 2020. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta Analyses checklist. Inclusion/exclusion criteria have been carefully selected and reported in the text. For analyses, we calculated 95% confidence intervals (CI) and weighted odds ratios to amalgamate control and study groups in publications. We applied The Cochrane Collaboration tool to assess bias risk in selected studies. Results: In total, 592 articles were identified. After the removal of duplicates and excluded studies, 36 full-texts were included for review. Conclusions: The review confirmed that antibiotic therapy, administered according to all peri-operative protocols described, is useful in reducing groin SSI rate in vascular surgery.