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The aim of this paper was to report outcomes of endovascular aneurysm repair with percutaneous femoral access (pEVAR) using Prostar XL and Proglide closure systems (Abbot Vascular, Santa Clara, CA, USA), from the multicenter Italian Percutaneous EVAR (IPER) registry.Consecutive patients affected by aortic pathology treated by EVAR with percutaneous access (pEVAR) between January 2010 and December 2014 at seven Italian centers were enrolled in this multicenter registry. All the operators had an experience of at least 50 percutaneous femoral access procedures. Data were prospectively collected into a dedicated online database including patient's demographics, anatomical features, intra- and postoperative outcomes. A retrospective analysis was carried out to report intraoperative and 30-day technical success and access-related complication rate. Uni- and multivariate analyses were performed to identify factors potentially associated with an increased risk of percutaneous pEVAR failure.A total of 2381 accesses were collected in 1322 patients, 1249 (94.4%) male with a mean age of 73.5±8.3 years (range 45-97). The overall technical success rate was 96.8% (2305/2381). Major intraoperative access-related complications requiring conversion to surgical cut-down were observed in 3.2% of the cases (76/2381). One-month pEVAR failure-rate was 0.25% (6/2381). Presence of femoral artery calcifications resulted to be a significant predictor of technical failure (OR: 1.69; 95% CI: 1.03-2.77; P=0.036) at multivariate analysis. No significant association was observed with sex (P=0.28), obesity (P=0.64), CFA diameter (P=0.32), level of CFA bifurcation (P=0.94) and sheath size18 F (P=0.24). The use of Proglide was associated with a lower failure rate compared to Prostar XL (2.5% vs. 3.3%) despite not statistically significant (P=0.33).The results of the IPER registry confirm the high technical success rate of percutaneous EVAR when performed by experienced operators, even in presence of demanding anatomies. Femoral calcification represents the only predictor of percutaneous access failure.

Minimally invasive surgical solutions for patients with extensive aortic disease are eagerly awaited, since open repair is often associated with high rates of morbidity and mortality. In the last decade, the development of fenestrated and branched aortic endografts has offered a therapeutic option to patients deemed unsuitable for major surgery. Preliminary studies showed promising early results, while mid- and long- term data are scarce. The aim of this paper was to review current results of total endovascular repair of thoracoabdominal aortic aneurysms (TAAA) with a single model of endograft in the published literature. A literature search was conducted, and our two-center experience with fenestrated and branched endografts in the treatment of TAAA, with the Cook Zenith endograft, is presented. Early results show perioperative mortality rates ranging from 0% to 21%, spinal cord ischemia from 0% to 33.3%. At a mean follow up ranging from 9 to 19 months, reinterventions are needed in 3.3% to 25% of the cases, with a mid term visceral branch patency of 90% to 100%. Current experiences with total endovascular TAAA repair show promising results, in selected centers with large experience in complex aortic endografting. With increasing follow- up times, need for reintervention is growing, while aneurysm-related deaths remain rare. Long-term results are still lacking, but these encouraging data and further technological developments will support wider adoption of the technique.

Dilation of one or both common iliac arteries (CIAs) is a major concern in endovascular aneurysm repair (EVAR). One option for CIA aneurysm repair is hypogastric embolization followed by endograft extension into the external iliac artery. However, hypogastric occlusion does not always go unpunished and it may lead to ischemic complications. Aim of the paper was to evaluate early results with the Gore® Excluder® Iliac Branch Endoprosthesis (IBE) in the treatment of iliac aneurysms associated or not with abdominal aortic aneurysms.Between November 2013 and April 2014, in our Institution 7 Gore IBE were implanted in 5 patients. Technical success, 30-day mortality and complications were investigated.Technical success and branch patency was 100%. There was no 30-day mortality. In 1 of the 2 bilateral cases an endovascular relining with bare stents was required due to a compression of iliac legs at level of aortic bifurcation.Use of Gore IBE device in the treatment of aorto-iliac disease is feasible and safe. Late results are necessary to evaluate the performance of this endograft in the long term.

Introduzione al volume I Gonzaga fuori Mantova

Il contributo affronta lo studio del decennio trascorso in Sicilia da Ferrante Gonzaga, nella carica di viceré, analizzando da diversi puti di vista la committenza architettonica dello stesso e il ruolo della viceregina in un programma che sottintende la volontà di creare intorno a se una corte degna di un signore del Rinascimento, sul modello della natia corte mantovana.

Objective The objective of this study was to assess early and midterm results after endovascular aortic arch repair using a double inner branch stent graft (DIBSG) in patients with aortic arch aneurysm or dissection unfit for open surgery. Methods Between 2012 and 2018, there were 24 patients with aortic arch disease who were treated with a single model of a DIBSG (Terumo Aortic, Glasgow, United Kingdom) in nine Italian cardiovascular centers. We investigated technical success, mortality, occurrence of major complications, and need for reintervention in a multicenter, nonrandomized, retrospective fashion. Results The in-hospital mortality rate was 16.7%. Cerebrovascular events occurred in 25% of patients and major strokes in 12.5%. Two patients experienced a retrograde dissection (8.3%), whereas none reported any type I or type III endoleak. During a mean follow-up of 18 months (range, 1-60 months), one patient died of a nonaortic cause and one reported a nonarch-related major stroke. No late secondary intervention was needed during the follow-up. Excluding from the analysis the first six patients treated until 2014 as part of the learning curve, in-hospital mortality, major stroke, and retrograde dissection rates were 11.1%, 11.1%, and 5.6%, respectively. Conclusions Endovascular aortic arch repair using this model of DIBSG is feasible, and results are acceptable for a new technique in a high-risk subset of patients. Operative mortality suffers the effect of a learning curve, whereas midterm aorta-related survival is promising. Endovascular repair of aortic arch disease with a DIBSG should always be considered to give high-risk patients a chance of repair. Large-scale studies are needed to assess the long-term durability of this technique.

Objective The aim of this study was to investigate outcomes of patients treated with endovascular repair (ER) with the use of fenestrated and branched stent grafts or open surgery (OS) for thoracoabdominal aortic aneurysm (TAAA) in a current series of patients. Methods All TAAA patients undergoing repair at three centers between January 2007 and December 2014 were included in a prospective database. Patients were stratified according to treatment by ER or OS, and outcomes were compared using propensity score matching (1:1). Covariates included age, sex, aneurysm extent, hypertension, coronary disease, chronic pulmonary disease, diabetes, and renal function. The primary end points were mortality and paraplegia. Secondary end points included any spinal cord ischemia (SCI), renal and respiratory insufficiency, and a composite of these complications or death at 30 days. All-cause survival and freedom from reintervention were compared in the two groups. Results Of 341 patients, 84 (25%) underwent ER and 257 underwent OS (75%). After propensity score matching (65 patients per group), no significant differences were observed in rates of 30-day mortality (7.7% in ER and 6.2% in OS; P = 1) and paraplegia (9.2% and 10.8%; P = 1). Any SCI, renal insufficiency, and respiratory insufficiency were 12.3% and 20% ( P = .34), 9.2% and 12.3% ( P = .78), and 0% and 12.3% ( P = .006) in ER and OS, respectively. The incidence of the composite end point was significantly lower in ER patients (18.5% in ER vs 36.0% in OS; P =.03). According to Kaplan-Meier estimates, all-cause survival at 24 months was 82.8% in ER and 84.9% in OS, with rates unchanged at 42 months ( P = .9). Rates of freedom from reintervention were 91.0% vs 89.7% at 24 months and 80.0% vs 79.9% at 42 months in ER vs OS, respectively ( P = .3). Conclusions A propensity score analysis in patients with TAAA undergoing repair suggests an early benefit from ER compared with OS with regard to the composite end point because of reduced 30-day respiratory complications. No significant differences were found in SCI and renal insufficiency at 30 days and in survival and reintervention rates at midterm.