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Hypertension is a major risk factor for peripheral arterial atherosclerotic disease (PAD). Hypertension deteriorates arterial wall function and the morphology of all layers of arteries. Endothelial cell injury enhances permeability and promotes migration of cholesterol and monocytes into the vessel wall. Increased blood pressure (BP) through hyperplasia of smooth muscle cells initiates remodeling of the arterial wall that increases peripheral resistance. Further, hypertension, particularly in patients with dyslipidemia, provokes atherosclerosis in different vascular territories, including the lower legs. Guidelines recommend treatment of hypertension in patients with PAD to reach the target BP of <130/80 mmHg. However, systolic BP (SBP) <120 mmHg may worsen oxygen delivery to the diseased leg and is related to a higher rate of cardiovascular (CV) events. Therefore, there is a J-shape relationship between SBP and the rate of primary outcomes. Any class of antihypertensive drugs, including beta-blockers, can be used for the treatment of hypertension in patients with PAD. Angiotensin converting enzyme (ACE) inhibitors may have some additional benefit over other antihypertensive drugs including improvement of perfusion of the diseased leg and are recommended even in patients with critical limb ischemia. In conclusion: hypertensive patients with PAD are at increased risk for CV events and treatment of raised BP is indicated, but SBP <120 mmHg and DBP <70 mmHg may contribute to adverse limb outcomes and other CV events. Consequently, PAD patients may require a different BP target than those without PAD.

Adherence to the Mediterranean diet (MeD) has been associated with a reduced incidence of peripheral arterial disease (PAD)/lower extremity arterial disease (LEAD) in observational trials and in a randomized trial. In secondary prevention, a lower hazard ratio for composite major adverse cardiovascular events has been associated with better adherence to MeD in a relatively small, randomized trial. This has not been confirmed in a sub-analysis of a large interventional trial of dual antithrombotic treatment. The effects of vegetarian, vegan or low carbohydrate/ketogenic diets on the incidence and outcomes of PAD/LEAD are not known. While abdominal obesity is associated with diabetes mellitus and PAD/LEAD, the lowest incidence of PAD/LEAD has been found in subjects with a body mass index 25-29.9 kg/m 2 . Malnutrition is a negative prognostic factor for survival of patients with chronic limb threatening ischemia. Physical activity (PA) is an acute stressor, but habitual recreational PA results in beneficial adaptations and improved health. In observational studies, lower levels of exercise and lower physical fitness have been associated with more prevalent PAD/LEAD. In contrast to coronary artery disease, that shows a reverse J-shaped relationship between long-term endurance exercise and coronary atherosclerosis, such a relationship is not known for PAD/LEAD. A general recommendation for maintaining cardiovascular health is performing regular moderate-intensity exercise with some vigorous-intensity aerobic PA, and resistance exercise at least twice a week. Combinations of healthy behaviors are more effective in preventing PAD/LEAD than a single behavioral component. In treatment of PAD/LEAD causing intermittent claudication, supervised walking training is recommended among measures of first-line treatment, while unsupervised walking training should be considered as an alternative.

Introduction: Dyslipidemia is an established risk factor for cardiovascular diseases. We aimed to review its role in the pathogenesis of lower extremity arterial disease (LEAD), as well as the effect of lipid-lowering treatment on the progression of LEAD., Evidence Acquisition: PubMed/MedLine, EMBASE and Scopus were searched between January 1990 and January 2024 for articles investigating the role of dyslipidemias and hyperlipidemias in the pathogenesis of LEAD. A separate search focused on the effects of lipid-lowering therapy on patients with LEAD., Evidence Synthesis: There is evidence that dyslipidemias play a major role in the development of LEAD. All patients with LEAD should receive intensive lipid-lowering therapy for the reduction not only of claudication symptoms and amputation rates, but also of myocardial infarction and cardiovascular event rates., Conclusions: Vascular specialists should keep in mind the pivotal role of dyslipidemia in the pathogenesis and progression of LEAD.

Introduction: Stent-assisted, balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) is an extended downstream endovascular management technique for acute type B aortic dissection (TBAD), that aimed to achieve complete aortic remodeling. This systematic review aimed to assess the early and mid-term clinical outcomes with STABILISE in the management of TBAD., Evidence Acquisition: A literature search was performed on the Medline, Web of Science, Scopus, and SciELO databases, which returned 195 studies. Five studies were included. Data were extracted using predefined forms., Evidence Synthesis: In total, one hundred patients with acute or subacute TBAD managed with STABILISE were included. All studies reported a technical success of 100%. Thirty-day mortality was estimated at 4% (4/100) with no further deaths documented during an estimated mean follow-up of 12.7 months (range 12-15 months). Five percent developed spinal cord ischemia and another 5% developed visceral artery occlusions. One case of aortic rupture during time of balloon inflation was reported. Rare complications included delayed retrograde dissection (1%), aortobronchial fistula (1%), and renal failure (1%). One case of disconnection between stent-graft and bare stent was documented. Six percent of patients developed endoleak, predominately type I. Overall re-intervention rate was 21%, as reported in all studies. Complete obliteration of the false lumen in the thoracic aorta was achieved in 99% of patients and in the abdominal aorta in 96% of patients., Conclusions: STABILISE technique carries promising early and mid-term outcomes with high technical success and low mortality and morbidity. Excellent results on complete false lumen obliteration were observed. However, the heterogeneity among available studies' methodology does not permit firm conclusions, and further prospective analyses are needed to study the long-term outcomes of STABILISE.

Diabetes mellitus (DM) is a major risk factor for lower extremity arterial disease (LEAD) and about 20% of symptomatic patients with LEAD have DM. In subjects with DM, LEAD is a cause of morbidity and mortality. DM typically causes complications in the form of macro- and microangiopathy. In these patients, macroangiopathy manifests as atherosclerosis like in non-diabetic patients. However, its course is accelerated due to accompanying risk factors like hyperlipidemia and hypertension, with cumulative effects. Other factors are also relevant such as inflammation, endothelial dysfunction, platelet activation, blood rheological properties, hypercoagulability, and factors stimulating vascular smooth muscle cell proliferation. Additionally, DM is a risk factor for restenosis and amputation. DM is strongly associated with femoral-popliteal and tibial LEAD, which manifests earlier in patients with DM and may progress more rapidly to critical limb ischemia. Diabetic microangiopathy is characterized by arteriolosclerosis and interstitial fibrosis which additionally affects progression and outcomes of angiopathy of lower limbs. Glycemic control particularly decreases microangiopathic complications, while prevention of macrovascular complications requires treatment of accompanying risk factors like hypertension and dyslipidemia.

This study aims to provide an overview on contemporary open surgical approaches for the management of carotid artery stenosis. A comprehensive literature search was performed to identify and categorize open surgery intervention techniques for the management of carotid artery stenosis, focusing on the benefits and drawbacks of each technique. Five surgical techniques for carotid endarterectomy (CEA) have been described: CEA with primary closure, CEA with patch closure, CEA by eversion technique, CEA by modified eversion technique and CEA by partial eversion. Evidence has reported significantly higher rates of perioperative complications after CEA with primary closure, including 30-days stroke rate and late restenosis. Although more recent techniques have been reported to provide superior outcomes, electing the best surgical technique is still a matter of debate. Also, CEA using a mini-skin incision has been associated to lower risk of cranial/cervical nerve injury and shorter length of hospital stay. The selection of the surgical intervention should be tailored and have into consideration individual patient characteristics, clinical considerations, surgeon preference and surgical team expertise. Further large-scale randomized clinical trials are needed to support more robust decisions on the choice of contemporary open surgical approaches to manage carotid stenosis.

Introduction: Chronic venous disease (CVD) can lead to considerable morbidity and impact health-related quality of life (HRQoL). The aim of this review was twofold: (i) to provide a deeper understanding of how CVD affects HRQoL (physical, psychological and social functioning), and (ii) to review the impact of evidence-based veno-active drugs (VADs) on HRQoL., Evidence Acquisition: For the effect of CVD on HRQoL, information was gathered during an Expert Consensus Meeting, during which data were presented from both the patient and physician perspective assessed with validated quality-of-life measures. For the impact of VADs on HRQoL, a systematic literature review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases were searched for real world evidence or randomized-controlled trials (RCT) vs. placebo, reporting data on the influence of VADs on HRQoL in patients with CVD., Evidence Synthesis: CVD can negatively affect daily life in a number of areas related to pain, physical function and social activities. The impact of CVD on HRQoL begins early in the disease and for patients the emotional burden of the disease is as high as the physical burden. In contrast, physicians tend to overestimate the physical impact. The database search yielded 184 unique records, of which 19 studies reporting on VADs and HRQoL in patients with CVD met the inclusion criteria (13 observational and 6 RCTs). Micronized purified flavonoid fraction (MPFF) was the most represented agent, associated with 12/19 studies (2 RCTs and 10 observational). Of the 6 RCTs, only MPFF, aminaphthone and low-dose diosmin provided statistically significant evidence for improvement on HRQoL compared with placebo; for the other VADs improvements in HRQoL were not statistically different from placebo. MPFF was also associated with improvements in HRQoL in the observational studies, across all CEAP clinical classes, as monotherapy or in combination with other conservative therapy, and for all aspects of HRQoL: physical, psychological, and social. Real-world data for the other VADs were scarce. Ruscus extract, sulodexide and a semi-synthetic diosmin were each represented by a single observational study and these limited data were associated with statistically significant improvements compared with baseline in overall and subdomain scores across the range of CEAP clinical classes., Conclusions: CVD can impair patients' HRQoL significantly at all stages of the disease. MPFF has the greatest evidence base of clinical use in both RCT and real-world observational studies for effectiveness on HRQoL and is recognized by international guidelines. The complete video presentation of the work is available online at www.minervamedica.it (Supplementary Digital Material 1: Supplementary Video 1, 5 min, 194 MB).

Introduction: Presence of varices after operative treatment (PREVAIT) is a common finding after varicose vein surgery, and has been shown to significantly reduce the quality of life of those it affects. As such, long-term results after varicose vein interventions have to be taken into account when choosing a technique. This study aims to systematically review current evidence on the recurrence of varicose veins after three different techniques: conventional surgery (HLS), endovenous laser ablation (EVLA) and radiofrequency ablation (RFA)., Evidence Acquisition: A literature search was performed on the PubMed and Web of Science databases, which returned 546 studies. Fourteen studies were included. Data were extracted using predefined forms., Evidence Synthesis: A total of 2795 patients were included, for a total of 3056 legs treated. 503 legs (16.5%) were treated by HLS, 1791 (58.6%) by EVLA and 762 (25.0%) by RFA. PREVAIT was reported in 34.4% for patients treated by HLS, for a mean follow-up comprised between 18 months and 5 years; 16.6% by EVLA, for a mean follow-up between 112 days and 5 years and 6.7% of those treated by RFA, for a mean follow-up between 106 days and 5 years. Regarding patterns of recurrence, the development of new varicose veins was the most commonly reported mechanism of recurrence after HLS (range: 29.8-91%) and EVLA (range: 40-81.6%), but not RFA, where recanalization of the occluded saphenous trunk accounted for up to 67.0% of the cases. Only one study reported quality of life related recurrence, and included patients treated by HLS and EVLA, but not RFA. Aberdeen Varicose Vein Questionnaire (AVVQ) score, physical functioning domains of the SF-36 score and patient satisfaction were significantly worse in patients with clinical recurrence. Re-intervention rates after recurrence were reported in 5 studies, ranging between 7.7% and 37.7% for HLS and 0-57.0% for EVLA. Only one study reported data on re-intervention for RFA patients, which was 6.67%., Conclusions: Recurrence is a reliable indicator of long-term efficacy of a varicose vein treatment and appears to occur more frequently after HLS. Although there are several mechanisms of recurrence, the development of new varicose veins was the most commonly observed. There is clear heterogeneity among definitions of recurrence and follow-up periods in literature.

Atherosclerotic cardiovascular disease (ASCVD) is defined as coronary heart disease (CHD), cerebrovascular disease, or lower extremity arterial disease (LEAD) also named peripheral arterial disease (PAD). ASCVD is considered to be of atherosclerotic origin and is the leading cause of morbidity and mortality mainly for individuals with diabetes mellitus (DM). In this consensus document of the International Union of Angiology the authors discuss epidemiology, risk factors, primary and secondary prophylaxis, the correlation between diabetes mellitus and LEAD, conservative and surgical treatment.

Background: Chronic venous insufficiency (CVI) and diabetes mellitus (DM) pose significant burdens to patients and healthcare systems. While the two diseases share a number of commonalities in risk factors and pathophysiology, they are often assessed and managed separately. This can lead to a worsening of comorbidities and limitations in a patient's quality of life. This project aims to develop recommendations to enhance the identification and treatment of patients with concomitant CVI and DM., Methods: Using a modified Delphi method, a panel of experts developed 38 Likert Scale and two multiple choice questions across six key themes. These were used to form an online survey which was disseminated through a convenience sampling approach to CVI and DM healthcare professionals across Europe, Central America, South America, and the Middle East. The threshold for consensus was set at ≥75%., Results: A total of 238 responses were received. 27/38 statements attained >90% agreement, nine of 38 attained between 75-90%, and two failed to meet the threshold (<75%). The awareness around the impact of the two diseases was high, but a gap was highlighted in the identification of patients with concomitant CVI and DM., Conclusions: The high level of agreement shows that healthcare professionals are aware of the gaps in identification and treatment of patients with concomitant CVI and DM, and of the need to approach this as a combined therapy area. An algorithm is proposed to help the identification of at-risk patients and to provide recommendations on the management of patients with concomitant disease.

Vascular compression syndromes (VCS) are rare diseases, but they may cause significant symptoms interfering with the quality of life (QoL) of patients who are often in their younger age. Given their infrequent occurrence, multiform clinical and anatomical presentation, and absence of dedicated guidelines from scientific societies, further knowledge of these conditions is required to investigate and treat them using modern imaging and surgical (open or endovascular) techniques. This consensus document will focus on known VCS, affecting the arterial and venous system. The position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, will show an overview of pathophysiology, diagnostic, and therapeutical approaches for patients with VCS. Furthermore, this document will provide also unresolved issues that require more research that need to be addressed in the future.

Published scientific evidence demonstrate the current spread of healthcare misinformation in the most popular social networks and unofficial communication channels. Up to 40% of the medical websites were identified reporting inappropriate information, moreover being shared more than 450,000 times in a 5-year-time frame. The phenomenon is particularly spread in infective diseases medicine, oncology and cardiovascular medicine. The present document is the result of a scientific and educational endeavor by a worldwide group of top experts who selected and analyzed the major issues and related evidence-based facts on vein and lymphatic management. A section of this work is entirely dedicated to the patients and therefore written in layman terms, with the aim of improving public vein-lymphatic awareness. The part dedicated to the medical professionals includes a revision of the current literature, summing up the statements that are fully evidence-based in venous and lymphatic disease management, and suggesting future lines of research to fulfill the still unmet needs. The document has been written following an intense digital interaction among dedicated working groups, leading to an institutional project presentation during the Universal Expo in Dubai, in the occasion of the v-WINter 2022 meeting.

Background: Little data are available on real-life long-term treatments after a venous thromboembolism (VTE), and on recurrent VTE or bleeds events during treatments., Methods: We investigated the complications occurring during follow-up (FU) in VTE patients who had received the treatment decisions given by the clinical centers, active in 7 countries (China, Czechia, Poland, Portugal, Russia, Slovakia, Tunisia), which participated in the international, prospective, observational WHITE study., Results: FU information was collected in 1004 patients, recruited by 62 clinical centers (17 centers did not participate in FU collection). Extended treatments were proposed to 811 patients: direct oral anticoagulants (DOACs) (475), sulodexide (202), antiplatelet agents (73), vitamin K antagonists (VKAs) (45), low molecular weight heparin (LMWH) (16). All specific treatments were stopped in the remaining 193 patients. Patients who during FU used treatments different than those prescribed by the local investigators (263) or for other causes (26) were excluded from analysis. 50 primary events occurred throughout 1044 years FU in 715 patients, 4.8 incidence (×100 patient-years) [3.8 for recurrences, and 0.96 for bleeding (major or clinically relevant)]. Primary event incidence differed according to treatments (LMWH=33.3, antiplatelets =7.6, VKAs = 6.1, DOACs = 4.7, sulodexide = 4.2, all treatment stopped = 2.5), and differed across the involved countries., Conclusions: DOACs were the most used drugs for extended treatments. Overall, the rate of primary events during FU was low. The investigators identified patients at low risk of recurrence and high bleeding risk. Sulodexide use for secondary prevention deserves further studies.

Background: The efficacy and tolerability of the new micronized purified flavonoid fraction (MPFF) 1000 mg once-daily chewable formulation in comparison with the established MPFF 500 mg conventional tablet at the same daily dose are unknown., Methods: CHEWY was an international, multicenter, double-blind, double-dummy, randomized, parallel group, non-inferiority phase III study conducted in adult patients with symptomatic chronic venous disease (CVD). Patients were randomly allocated to MPFF 1000 mg chewable or MPFF 2x500 mg daily treatment. The primary efficacy endpoint for clinical non-inferiority (non-inferiority margin predefined at 1 cm) was lower limb discomfort (LLD) assessed by a 10 cm electronic visual analog scale (eVAS) at 8 weeks. Secondary endpoints included leg pain (LP), leg heaviness (LH), and quality of life (QoL) measured by the eCIVIQ-14 questionnaire. Overall acceptability was assessed at each visit by patient and investigator., Results: Three hundred and nine patients were randomized to MPFF 1000 mg chewable and 302 to MPFF 2x500 mg. After 8 weeks, LLD decreased from baseline by -3.6±2.4 cm and -3.6±2.5 cm in the MPFF chewable and 2x500 mg groups, respectively. Non-inferiority of the once-daily chewable formulation compared with twice daily tablets on improving LLD was demonstrated (adjusted between-group difference [Standard Error]) (E [SE]) = 0.00 (0.18) cm, 95%CI -0.35; 0.35, non-inferiority P value <0.0001. Decreases of similar magnitude were observed at 8 weeks for LP and LH in both treatment arms: -3.4±2.3 cm and -3.5±2.5 cm, respectively for LP, and -3.5±2.5 cm and -3.5±2.6 cm, respectively for LH. QoL (global score) improved by -21.0±17.2 and -22.5±20.1 in the MPFF 1000 mg chewable group and 2x500 mg groups, respectively (E [SE]=1.03 [1.20], 95%CI [-1.32; 3.38]), with similar improvements in the QoL subscore components in both groups. Treatment acceptability was high for both patients and physicians and tolerability similar to the tablet formulation., Conclusions: MPFF 1000 mg chewable was non-inferior to MPFF 2x500 mg tablets with respect to its effect on LLD. Both formulations were associated with improvements of similar magnitude in lower limb symptoms and QoL. The chewable formulation was observed to be well tolerated and well accepted. Once-daily MPFF chewable tablet offers patients with CVD a good alternative treatment regimen.

Introduction: Frozen elephant trunk (FET) technique was developed as an alternative to the conventional elephant trunk (cET) procedure for the repair of complex aortic arch pathology. However, short term results between these different procedures are sparsely described. This systematic review with meta-analysis aimed to compare short term outcomes between FET and cET in the repair of aortic arch pathology., Evidence Acquisition: PubMed, Web of Science and Scopus electronic databases were searched for studies comparing performance of FET and cET procedures in patients with aortic arch pathology. The primary outcome of interest was early mortality, defined as 30-day or in-hospital mortality. Secondary outcomes were stroke, and spinal cord ischemia (SCI). Meta-analysis utilizing the random-effects model was performed using Review Manager (RevMan) software, version 5.4., Evidence Synthesis: Ten studies, comprising 1481 patients with aortic arch pathology, were included. Meta-analysis demonstrated statistically significant reduction of early mortality (odds ratio [OR], 0.63; 95% CI, 0.41-0.97) in the FET group. For neurologic outcomes, no significant differences were noted in stroke risk between both groups (OR, 1.21; 95% CI, 0.83-1.75), but an increased risk of SCI was present in FET patients (OR, 2.07; 95% CI, 1.05-4.10)., Conclusions: FET appears to be associated with a significant lower early mortality, at costs of greater SCI risk. Larger studies are needed to provide confident recommendations towards preferential use of either procedure.

This position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, shows an overview of therapeutical approaches for patients with chronic limb-threatening ischemia (CLTI) and absence of 'standard' solutions for revascularization. The aim was to demonstrate the accurate management of the 'no-option' CLTI patient including the wound treatment and the rehabilitation, considering always the goal of the increase of quality of life of the patients.

Introduction: Venous thromboembolism (VTE) is a possible complication after varicose vein surgery, reported after both open and endovascular interventions. Nonetheless, there are no internationally accepted recommendations regarding postoperative VTE prevention strategies, with some authors advocating for its use, while others recommend against it. This study aims to systematically review current evidence on the efficacy and safety of chemothromboprophylactic strategies after varicose vein surgery., Evidence Acquisition: A literature search was performed on the MEDLINE, Scopus, SciELO and Web of Science databases, which returned 532 studies. Ten studies were included. Data were extracted using piloted forms., Evidence Synthesis: A total of 6929 patients were included for analysis, out of which 70.4% were treated by open surgery (N.=4878) and 29.6% by endovenous procedures (N.=2051; 79.1% EVLA; 20.9% RFA). VTE chemothromboprophylaxis was performed in 76.3% of the patients (N.=5284), from which 62.5% were treated by open surgery (N.=3301) and 37.5% by endovenous interventions (N.=1983). Among those treated by open surgery, reported deep venous thrombosis (DVT) rates ranged between 0-6.25%, while pulmonary embolism (PE) was reported in 0-0.07% of the cases. Regarding endovenous interventions, EHIT and DVT rates ranged between 0-2.5% and 0-0.9%, respectively, with no cases of PE described. The remaining 23.7% of the patients did not underwent VTE chemothromboprophylaxis (N.=1645), with DVT and PE rates after open surgery ranging between 0-5.17% and 0-1.48%, respectively. Only one study reported thrombotic complications after endovenous interventions in this subgroup of patients, with postoperative EHIT rates of 7.3%, and no information regarding PE or DVT. Bleeding complications were higher in patients undergoing chemothromboprophylaxis (0-10.2%) when compared to those who did not (0-0.18%), and were more frequent after endovenous interventions (0-10.2% versus 0-0.75% after open surgery)., Conclusions: VTE is a possible complication after both open and endovascular varicose vein procedures, although overall VTE complications occur less frequently after endovascular interventions. There's a clear heterogeneity regarding peri and postoperative chemoprophylaxis regimens used. Further studies are required to stratify risk factors and indications for chemothromboprophylaxis after varicose vein surgery.

Introduction: Chronic venous disease is a persistent venous drainage alteration caused by valvular incompetence and/or outflow obstruction. Disease management includes a variety of treatments, whose evidence and clinical performance in the mid-long term are variable. The objective of this umbrella review was to summarize efficacy data for pharmacological treatments including venoactive drugs from previously published reviews that included a meta-analytic component., Evidence Acquisition: Systematic database searches were conducted via Ovid SP on 13 August 2019, covering MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. Reviews that included a meta-analytic component of four or more clinical trials or observational studies reporting on the efficacy of systemic or topical pharmacological treatments for adults with chronic venous disease published since 2010 were eligible for inclusion., Evidence Synthesis: Eleven publications were included in this umbrella review. Change in ankle circumference was the most commonly reported outcome. Overall, several systemic treatments had significant effects compared with placebo on multiple efficacy outcomes, including measures of edema and pain. Out of them, Micronized Purified Flavonoid Fraction had the most comprehensive evidence of effectiveness on main symptoms and signs and on improving quality of life throughout chronic venous disease stages., Conclusions: Systemic pharmacotherapies represent a valuable therapeutic option in CVD management. As a result of this umbrella review, several gaps were identified with respect to research topics that warrant further investigation, particularly in the category of topical medications.

Introduction: Intermittent claudication (IC) stage of peripheral artery disease (PAD) is associated with significant impairment of quality of life. In the subset of patients with disabling IC refractory to best medical treatment (BMT), revascularization procedures may be considered. However, evidence comparing open revascularization surgery, endovascular treatment and BMT focusing on the impact on quality of life is very sparse. We aim to review clinical, anatomical and hemodynamic outcomes after bypass surgery compared to BMT and/or endovascular treatment in IC patients., Evidence Acquisition: We systematically reviewed controlled trials and comparative cohort studies assessing quality of life, walking performance, clinical/ symptomatic improvement, symptom recurrence, patency rates, Ankle-Brachial Index (ABI) improvement and adverse events after bypass surgery versus endovascular treatment/BMT in IC patients., Evidence Synthesis: Eleven studies involving 16,608 patients were included. Compared to BMT, bypass surgery was associated with a significantly greater improvement on Short-Form 36 (SF-36) physical functioning score (mean difference (MD), -14.0; 95% confidence interval [CI], -21.2 to -6.8), Walking Impairment Questionnaire (WIQ) walking distance score (MD, -0.23; 95% CI, -0.29 to -0.16) and SF-36 bodily pain score (MD, -13.0; 95% CI, -20.2 to -5.8). There were no significant differences between bypass and endovascular treatment regarding the three scores. Bypass surgery presented better primary patency rates at 1 (odds ratio [OR], 0.47; 95% CI, 0.29 to 0.76) and 5 years (OR, 0.44; 95% CI, 0.34 to 0.57) and better ABI improvement (MD, -0.07; 95% CI, -0.12 to -0.03) when compared to endovascular treatment. There were no statistically significant differences between bypass and endovascular patients regarding secondary patency rates, 30-day mortality and major amputation., Conclusions: Lower limb revascularization may be beneficial in patients with disabling and refractory IC when the primary goal is to improve quality of life and walking capacity. Bypass surgery is associated to better symptomatic status, long-term primary patency and ABI improvement when compared to endovascular surgery, especially in anatomically extensive disease. Further studies addressing patient-reported outcomes and including a BMT group are paramount for more robust evidence on IC treatment and, consequently, better decision making.

Background: There is general perception among vascular physicians that primary lower limb superficial chronic venous disease (CVD) can present in various clinical, anatomical and hemodynamical patterns. Nonetheless, and despite the diversity of classifications on this subject, none specifically addresses such patterns in an integrative form. In the authors opinion, an integrated anatomic and hemodynamic classification could prove a valuable tool for both patient stratification and treatment, as well as postoperative outcomes assessment and homogeneous comparison among groups. The purpose of this study was to collect expert opinion on the usefulness and applicability of a new integrated anatomic and hemodynamic classification for primary superficial venous disease, as well as the anatomic and hemodynamic variables to consider., Methods: A survey was administered via a web-based platform to a worldwide selected group of experts on vascular pathology. The survey included 27 questions and collected data on physician demographics and clinical experience (6 questions); usefulness and applicability of a new classification (6 questions); and anatomic and hemodynamic variables to consider (15 questions). A 5-point Likert Scale was used for categorization, and open-ended questions were included for commentary., Results: A total of 278 surveys were sent to experts worldwide, out of which 122 participated (response rate 43.9%). Most participants were European based (85.2%) vascular surgeons (85.2%), but experts from 39 countries across all continents were represented. 88.9% of the respondents agreed that primary varicose veins can be divided in different anatomic and hemodynamic patterns, although only 45.1% believe current classifications are appropriate to differentiate such patterns; 58.2% of respondents agree with an anatomical classification of varicose veins (VV) according to their area of distribution in the lower limb (anterior, posterior, medial, lateral), and 77.1% agree with a hemodynamic categorization of VV in 3 major patterns: VV related with saphenous insufficiency; VV related with pelvic insufficiency; isolated insufficient tributaries and perforator veins. There is general consensus that an integrated anatomic and hemodynamic classification for primary superficial venous disease would be of great use for patient stratification (80.3%), treatment selection (72.2%) and postoperative outcome assessment (70.5%); furthermore, 68.9% of the respondents would use the aforementioned classification, as long as it remained simple and easy to apply in a clinical practice daily basis., Conclusions: The results of the present survey demonstrate that vascular physicians involved in the treatment of primary superficial venous disease recognize the limitations on current varicose vein classifications and agree on the need for a more comprehensive classification for such pathology. Experts agree that an integrated anatomic and hemodynamic classification for primary superficial venous disease would be of great use for patient stratification, treatment selection and postoperative outcome assessment, as long as it remained simple and easy to apply in a clinical practice daily basis. Collected evidence provides significant insights on expert opinion on anatomic and hemodynamic variables to assess and may set the bases for a new classification. Further validations using methodologically solid strategies for expert consensus are required.

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement was to reconcile the conflicting views on the topic. A literature review was performed with a focus on data from recent studies. Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

Introduction: Hyperbaric oxygen therapy (HBOT) is increasingly being used in the treatment of as diabetic foot ulcers (DFU). However, definitive evidence regarding its beneficial effects is still scarce. The present systematic review aims to analyze the role of HBOT in the prevention of limb amputation along with improvement of ulcer healing in patients with lower limbs DFU., Evidence Acquisition: Three databases were searched: PubMed, Scopus, and ISI Web of Knowledge. The search was enrolled during October 2020. Both titles and abstracts were examined by two independent reviewers. Only randomized controlled trials (RCTs) reporting a comparison between standard DFU treatment and standard treatment associated with HBOT were included. In all studies eligibility was assessed and data regarding studies characteristics, methods and considered outcomes was obtained. Odds ratio (OR) was used to evaluate amputation and complete ulcer healing rates. Percentage of ulcer reduction at two weeks was evaluated using the inverse variance method, and the values were compared using mean difference values. Meta-analysis was done using a fixed-effect model if I 2 values were under 50%, and a random-effects model if not., Evidence Synthesis: Eleven RCTs were included, with a total of 668 patients studied. Patients undergoing HBOT had lower risk of amputation (OR 0.53 95% CI 0.32-0.90, I 2 =31%). No difference was found in minor amputations (OR 0.89 95% CI 0.35-2.24, I 2 =69%). Regarding, healing rates, HBOT patients had greater chances of ulcer healing (OR 4,00 95% CI 1.54-10.44, I 2 =70%). It has also shown higher percentage of ulcer area reduction after two weeks of treatment in the HBOT group (mean difference 23.19%; 95% CI 14.86-31.52; I 2 =0%)., Conclusions: The present review offers evidence that adjuvant HBOT decreases risk of major amputation while promoting wound healing when combined to standard treatment in the management of DFU. These findings may have clinical relevance in a selected group of patients, yet further larger studies are still needed.

Chronic venous disease and diabetes mellitus are highly prevalent and debilitating conditions affecting millions of individuals globally. Although these conditions are typically considered as separate entities, they often co-exist which may be important in both understanding their pathophysiology and determining the best treatment strategy. Diabetes mellitus is twice as common in patients with chronic venous disease compared with the general population. Notably, a large proportion of patients with diabetes mellitus present with venous disorders, although this is often overlooked. The etiology of chronic venous disease is multifactorial, involving hemodynamic, genetic, and environmental factors which result in changes to the venous endothelium and structural wall as well as inflammation. Inflammation, endothelial dysfunction and hyperfiltration or leakage, are commonly observed in diabetes mellitus and cause various diabetic microvascular complications. Both diseases are also influenced by the increased expression of adhesion molecules, chemokines, and cytokines, and are characterized by the presence of vessel hypertension. Consequently, despite differences in etiology, the pathophysiology of both chronic venous disease and diabetic microangiopathy appears to be driven by endothelial dysfunction and inflammation. Treatment strategies should take the co-existence of chronic venous disease and diabetic microangiopathy into account. Compression therapy is recommended in inflammatory conditions that have an edema component as seen in both chronic venous disease and diabetes mellitus. Lifestyle changes like weight loss and exercise, will improve metabolic state and lower inflammation and should be promoted in these patients. Additionally, both patient populations may benefit from venoactive drugs.

Introduction: Thoracic endovascular aortic repair (TEVAR) has been selectively used for uncomplicated acute type B aortic dissection (TBAD); however, not all cases will benefit from TEVAR. A search for high risk clinical and radiographic predictors for complications is ongoing. This systematic review and meta-analysis aimed to identify predictors of major adverse events during follow-up of uncomplicated TBAD, in order to identify who might benefit from elective TEVAR., Evidence Acquisition: A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) Statement., Evidence Synthesis: 16 studies were included in a qualitative synthesis and 10 in the meta-analysis. Several risk factors associated to major adverse events have been described, including: 1) aortic diameter ≥40 mm; 2) greater false lumen diameter (>22 mm); 3) patent false lumen; 4) primary entry tear >10 mm; and 5) greater number of false lumen vessels origin. Quantitative synthesis identified an aortic diameter ≥40 mm significantly associated with major adverse events (HR=3.56; P<0.00001). Reporting of false lumen status, aortic diameters and growth, and demographic data was not always congruent with the most recent recommendations by Society for Vascular Surgery and Society of Thoracic Surgeons, published in 2020., Conclusions: Acute and subacute patients with uncomplicated TBAD presenting with an aortic diameter ≥40 mm and solely treated with BMT have an increased hazard of developing major adverse events (HR), making them potential candidates for TEVAR. Remaining risk factors analysed have weaker evidence.

Introduction: Iliac venous stenting is an established treatment option for both post-thrombotic and non-thrombotic iliac venous obstructions. Nonetheless, there is still no consensus on the best medical practice regarding some of these interventions. One area of debate is the safety of extending venous stents across the inguinal ligament (IL), with contradictory results from various authors and overall poor-quality research. This review aims to summarise current knowledge on the effect of venous stent placement across the IL on primary patency., Evidence Acquisition: A literature search was performed on the MEDLINE, Scopus and Web of Science databases, which returned 531 studies. Eleven studies were included. Data were extracted using piloted forms, and, if necessary, authors were contacted to obtain further information., Evidence Synthesis: Two studies were prospective cohorts, whereas the remaining 9 were retrospective cohorts. Overall study quality was weak. Four studies showed a statistically significant association between stent placement across the IL and decreased primary patency. A multivariate analysis was performed in two of those studies, yet only one maintained statistical significance after multivariate analysis. Two studies reported 4 cases of stent fracture in total, and one study reported 5 cases of stent compression. All cases of stent fracture or compression occurred at the inguinal ligament., Conclusions: Although current expert opinion favors stent placement across the IL, there is still insufficient evidence to recommend for or against venous stenting across the IL. Further research is required on comparing alternatives for the treatment of iliac venous lesions that extend into the common femoral vein. Despite the establishment of venous stenting as a viable treatment option for both post-thrombotic and non-thrombotic iliac venous obstructions, there is an ongoing debate on the safety of extending such stents across the inguinal ligament. There are several publications on this subject, with conflicting results and overall poor-quality research. This is the first systematic review of published clinical evidence on the impact of venous stent placement across the IL on primary patency.

Peripheral artery disease (PAD) is one of the most frequent manifestations of atherosclerosis with high rates of morbidity and mortality. Platelets and coagulation are involved in the progression of atherosclerosis and thromboembolic complications. PAD patients have increased prothrombotic potential, which includes platelet hyperaggregability and increased pro-coagulant state. Therefore, antithrombotic treatment is of utmost importance for the prevention of cardiovascular events in this group of patients. Aspirin is the basic antiplatelet drug, but with limited efficacy in PAD. In contrast to coronary artery disease, its effect on the prevention of cardiovascular events in PAD has been limited proven. Particularly in asymptomatic PAD, there is no evidence for risk reduction with aspirin. Clopidogrel and ticagrelor are more effective than aspirin. Clopidogrel is thus an effective alternative to aspirin for prevention of cardiovascular events in symptomatic PAD. In patients who are non-responders to clopidogrel, ticagrelor is indicated. Dual antiplatelet treatment (DAPT) with aspirin and ticagrelor in patients with coronary artery disease and concomitant PAD significantly decreased the rate of major adverse cardiovascular events, including adverse limb events. However, in the CHARISMA Trial, aspirin and clopidogrel were not more effective than aspirin alone and increased bleeding complications. Therefore, DAPT seems effective only in PAD accompanied by coronary artery disease. Anticoagulant treatment for symptomatic PAD with vitamin K antagonists alone or in combination with aspirin is not more effective than single antiplatelet treatment but increases the rate of major bleeding. Low dose rivaroxaban combined with aspirin in PAD patients significantly reduces cardiovascular events, including limb-threatening ischemia and limb amputations. Anticoagulation and antiplatelet treatment after percutaneous or surgical revascularization of PAD improve the patency of treated vessels. Aspirin with or without dipyridamole improved patency of infra-inguinal by-pass grafts at one year. The combination of clopidogrel with aspirin was more effective than aspirin alone in the prevention of prosthetic graft occlusions in patients undergoing below-knee by-pass-grafting. Oral vitamin K antagonists were not more effective than aspirin in the prevention of infra-inguinal by-pass occlusion. The combination of low dose rivaroxaban and aspirin was effective in preventing major adverse cardiovascular events and adverse limb events after infrainguinal endovascular or surgical revascularization in patients with intermittent claudication. However, the data on antithrombotic treatment after revascularization for limb-threatening ischemia is scanty and inconclusive. In conclusion: Antithrombotic treatment of PAD is a cornerstone for the management of these patients. Antiplatelet drugs prevent the initiation and progression of atherosclerosis and are effective also in the prevention of thromboembolic events. Simultaneous use of antiplatelet and anticoagulation drugs is accompanied by an increased risk of bleeding. However, combined treatment with aspirin and low-dose rivaroxaban is more effective than single antithrombotic treatment and safer than full-dose combined treatment.

Introduction: Post-thrombotic syndrome (PTS) is the most common chronic complication of deep vein thrombosis. Recent studies suggested that iliac stenting in chronic obstructive venous disease is safe and effective. However, systematic reviews focusing on mid-term efficacy of iliac stenting in post-thrombotic syndrome are lacking. This systematic review aimed to analyze mid-term stent patency rates and clinical outcomes of iliac stenting in post-thrombotic syndrome., Evidence Acquisition: Two databases were searched: Pubmed/Medline and Scopus. Articles published between January 2000 and July 2020 were selected and titles and abstracts were independently reviewed. Eighteen articles were included for the qualitative analysis. From this initial set of articles, fourteen articles were included for the quantitative analysis., Evidence Synthesis: Overall, 1008 patients were included in this study. The pooled technical success rate was 96%. The pooled primary and secondary patency rates were 98.2% and 100% at 30 days, 78.1% and 94.5% at 12 months and 66.3% and 89.4% at 36 months, respectively. The rates of ulcer healing, pain and edema relief were 78.1%, 53.4% and 48.8%, respectively. The pooled rate of complications including intraoperative venous injury, back pain and stent fracture were 28%, 57.1%, and 5.9%, respectively., Conclusions: Iliac venous stenting in PTS presents durable mid-term patency rates, as well as significant symptomatic improvement. Therefore, endovascular treatment should be considered in symptomatic patients with PTS.

Introduction: Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to carotid endarterectomy (CEA) in atherosclerotic carotid artery disease, even though the risk for procedural stroke after CAS remains significantly higher. Recently, in order to reduce embolic cerebral events after CAS, a new generation of dual-layer stents (DLS) has been developed. This review aimed to perform a detailed analysis of the available evidence on safety and efficacy of DLS in both symptomatic and asymptomatic atherosclerotic carotid artery stenosis., Evidence Acquisition: A systematic review was conducted according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary endpoint was the 30-day rate of myocardial infarction (MI), stroke and death. Secondary outcomes included rate and timing of stent occlusion/restenosis., Evidence Synthesis: A total of 20 articles with 1193 patients were included. Thirty-day MI ranged from 0-5%, 30-day stroke ranged from 0-10.5% and 30-day mortality ranged from 0-10%. Stent occlusion rate ranged from 0-52.4%, the majority of which occurred intraprocedurally (N.=50; 61.7%), in emergency treated patients. The incidence of new ipsilateral cerebral ischemic lesions after CAS with DLS was reported in five studies, ranging from 5.5-37%., Conclusions: Despite the theoretic advantage of reducing the risk for procedural embolic events when compared to conventional stents, high quality evidence is scarce. Also, safety issues regarding DLS in the emergency setting have been raised, particularly for thrombotic complications. Additional data from well-designed Randomized Controlled Trials are needed to assert the true value of DLS.

The SARS-CoV-2 infection (COVID-19) is causing an ongoing pandemic and potentially fatal disease. Development of coagulopathy with thrombotic complications such as deep vein thrombosis and pulmonary embolism are emerging as factors for progression to severe disease and death. Also, a markedly increased level of D-dimer, a protein product of fibrin degradation, has been associated to mortality. Furthermore, activation of immune response due to virus infection may led to uncontrolled severe inflammation with damage to host cells and induction of endotheliitis and cellular apoptosis and pyroptosis. The use of low molecular weight heparin in early stage of the disease could prevent vascular complications and reduce the progression to severe stage of the disease. Aim of this paper was to summarize current evidence about vascular involvement in COVID-19 disease and potential antithrombotic therapy.

Introduction: Open repair remains the gold standard technique for popliteal aneurysm repair. However, the endovascular approach has gained increased popularity. Comparison between these techniques remain crucial to aid the physician choice, yet, data on mid-term outcomes lack in the literature. The present review aims to compare the limb salvage and reintervention rates in these different approaches., Evidence Acquisition: A comprehensive literature review was conducted to identify publications on endovascular treatment or open repair of popliteal artery aneurysms (PAAs). Primary endpoints were reintervention and limb salvage., Evidence Synthesis: Twenty-seven studies were selected for analysis describing a total of 5425 patients: 1651 PAAs underwent endovascular repair and 4166 PAAs were treated with open surgery. The technical success rates varied between 83.3% to 100% in the endovascular group and 79% to 100% in the open repair. For endovascular repair, the limb salvage at 1 year ranged between 84.2% and 100%, at 3 years between 88.9% and 100%; and at 5 years between 64.7% and 100%. The reintervention rate at 1 year ranged between 3.7% and 21%, at 3 years between 18.9% and 28%, and at 5 years between 34.5% and 38%. For open repair, the limb salvage varied between 94.3% and 100% at 1 year, 94.5% and 99% at 3 years, and 86.4% to 97% at 5 years. Regarding the reintervention rate, at 1 year was 12.8% and 13%, at 3 years 3.6% and 12%, and at 5 years varied between 15.7% and 30%., Conclusions: Both endovascular and open repair of popliteal aneurysms represent safe options for popliteal aneurysm repair. Yet, on mid-term, open repair is associated with greater limb salvage and fewer reintervention rates. Still, further studies are needed to access the long-term durability of this technique and its suitability in emergency settings.

Introduction: Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (r-EVAR) sometimes complicates with abdominal compartment syndrome (ACS) due to extensive retroperitoneal hematoma, with significant prognostic implications. This systematic review aimed to analyze the incidence of the syndrome and assess the impact of ACS on mortality. Mortality after decompressive laparotomy was also assessed., Evidence Acquisition: Two databases were searched: Medline and Web of Science. The search was conducted through October 2019. The titles and abstracts of the retrieved articles were independently reviewed. All studies reporting on the ACS incidence after r-EVAR were initially included. From each study, eligibility was determined and descriptive, methodological, and outcome data was extracted. The incidence was calculated with summary proportion. Odds ratio was used to compare the mortality rate. Meta-analysis was performed with fixed effect model when calculating the ACS incidence in r-EVAR patients and when assessing the impacts of ACS and DL in the mortality rate., Evidence Synthesis: A total of 46 studies were included, with a cumulative cohort of 3064 patients. Two hundred and fifty-two (8.2%) patients developed ACS. The ACS pooled incidence was 9% with a 95% confidence interval of [0.08; 0.11]. Among the 46 included studies, 19 studies reported data on the mortality rate, corresponding to 1825 of the 3064 patients. Of these, 169 (9.3%) had developed ACS and 94 (55.6%) of them died by multi organ failure. Among the 1656 patients without ACS, 328 died (19.8%). The mortality odds ratio meta-analysis was 6.25 with a 95% confidence interval of [4.44, 8.80]. Decompressive laparotomy was performed in 41 patients, decreasing mortality in 47%., Conclusions: ACS affects approximately 9% of patients submitted to r-EVAR, and significantly increases perioperative mortality. Close postoperative surveillance to clinical signs of ACS is vital in these patients.

Introduction: A paradoxical negative association between diabetes mellitus and abdominal aortic aneurysm (AAA) prevalence and growth is established. However, so far is not possible to determine whether this protection comes from the disease itself or the medication for Diabetes. The aim of this manuscript is to review the association between oral antidiabetic drugs and AAA incidence and growth., Evidence Acquisition: A search was conducted on PubMed and Scopus databases until December 2019 to identify publications reporting on the association between oral antidiabetic drugs (biguanides/metformin, sulfonylureas(SU), thiazolidinediones(TZD), dipeptidyl-peptidase 4(DPP-4) inhibitors, glucagon-like peptide 1(GLP-1) agonists, sodium-glucose transporter protein-2(SGLT2) inhibitors) and the outcomes AAA incidence and growth. Only data from human studies were considered, with a minimum of 3 months follow-up., Evidence Synthesis: Six studies enrolling 25,810 patients were included: one reporting on the AAA risk and five reporting on AAA growth. Metformin prescription was associated with a 28% reduction in AAA occurrence, while SU and TZD were associated with a 18% decrease in AAA risk. Regarding AAA enlargement, results were concordant for a slower expansion rate associated with metformin, with a decrease ranging from -0.30 mm/y to -1.30 mm/y, but not consistent for other antidiabetic drugs., Conclusions: Metformin seems to be associated with a decrease in AAA risk and enlargement rate. Evidence for the other classes is lacking. Studies evaluating the association between oral antidiabetic drugs and AAA progression, independently of the diabetic status, are needed.

Introduction: Post-thrombotic syndrome (PTS) and iliofemoral (IF) patency reduction are common complications of iliofemoral deep venous thrombosis (IFDVT). Recent studies suggested that endovascular treatment, such as catheter-directed thrombolysis (CDT) and pharmacomechanical thrombectomy (PMT) can effectively reduce the risk and morbidity of PTS in IFDVT patients. This article aims to review the current literature on the subject, focusing on the long-term outcomes of endovascular treatment techniques in IFDVT patients., Evidence Acquisition: A thorough systematic review of the literature was conducted using PubMed/Medline and Scopus, according to PRISMA statement guidelines. Forty articles were included, according to their scientific relevance, for the qualitative analysis. From this initial set of articles, nine articles were included for the quantitative analysis., Evidence Synthesis: Endovascular treatment with CDT or PMT is related to a decreased risk of PTS development, when compared to standard anticoagulation treatment (OR=0.71; 95% CI=0.54-0.92). Furthermore, IF patency presents superior rates in patients treated with CDT or PMT, instead of anticoagulation (OR=3.20; 95% CI=1.80 -5.71). There are no significant differences in the risk of PTS and IF patency between patients treated with CDT and PMT. Complications such as bleeding, pulmonary embolism and death, don't seem to differ between endovascular treatment and anticoagulation, as well as between CDT and PMT procedures., Conclusions: Endovascular techniques seem to have satisfactory long-term outcomes in IFDVT, regarding to PTS risk and IF patency. However, further investigation with prospective randomized clinical trials with large populations and long follow-ups is necessary.

Introduction: The feasibility of endovascular aneurysm repair (EVAR) is often challenged by the concurrent presence of common iliac artery aneurysms, which prevent the attainment of a successful distal sealing. The present review aims to portray the safety and efficacy of two internal iliac artery (IIA) preservation strategies in the endovascular treatment of aortoiliac aneurysms: the iliac branch extension device (IBED) and the parallel graft - "sandwich" technique (PG-ST)., Evidence Acquisition: A comprehensive literature review was conducted to identify publications on endovascular treatment of iliac aneurysmal disease using IBED or PG-ST. Primary endpoints were freedom from endoleak, IIA branch occlusion and secondary interventions., Evidence Synthesis: Twenty-eight studies were selected for analysis describing a total of 1316 patients, 1169 in the IBED group and 147 in the PG-ST group. The technical success rates were akin for IBED and PG-ST (83.9-100% versus 81.3-100%). The defined primary endpoints were reported by fourteen articles. Freedom from endoleak, IIA branch occlusion and reintervention, at 6 months, were as follows: 82-100% versus 86%, 90-94% versus 88%, and 90-98% versus 87%, respectively for IBED and PG-ST. Later outcomes were only recorded in the IBED group, and freedom from endoleak, IIA branch occlusion and reintervention, at 9 years, were 83%, 81-90%, and 64-75%, respectively., Conclusions: Both IBED and PG-ST have proven to be safe and valid approaches. However, while IBED has established as a durable procedure, mid-term data lacks on PGs performance and further studies are required to attest durability of the latter procedure.

Visceral arterial aneurysms and pseudoaneurysms are rare entities. Despite infrequent, these lesions are clinically important and potentially lethal, since 22% present as clinical emergencies and 8.5% result in death. As such, early detection and treatment is essential. Through this work, we aim to address both visceral arterial aneurysms and pseudoaneurysms, with particular focus on their epidemiology, etiology and risk factors, as well as report current diagnostic workups and treatment strategies. A full literature review was performed through a comprehensive electronic search of PubMed databases, including articles published until the end of November 2018 and using the following keywords: "visceral aneurysm," "pseudoaneurysm" and "endovascular treatment." From this research, 2043 articles had their abstract assessed, 359 were read integrally, 213 were excluded for not being directly related to the subject and 146 were included, according to the authors preference and scientific relevance in this work's context. Visceral arterial aneurysms and pseudoaneurysms have fairly similar clinical presentations and diagnostic workups. Differences reside mainly in their etiology and indications for treatment, since immediate treatment is recommended for pseudoaneurysms regardless of their size, while true aneurysms have specific treatment cutoffs. Despite a significant improvement on current diagnostic and treatment strategies, these lesions are still frequently diagnosed only upon rupture, with significant mortality rates. Endovascular strategies represent the first line of treatment on the majority of cases, although open surgery continues to play a role in specific conditions. Visceral arterial aneurysms and pseudoaneurysms are rare but potentially fatal and, as such, proper diagnosis and treatment is of capital importance. Due to its minimally invasive nature, endovascular therapies currently represent the standard of care in the majority of situations, although there are still solid indications for open surgery. Technique selection should be performed according to the clinical scenario and baseline anatomy.

Introduction: Lower limb varicose veins can be treated effectively with endovenous ablation procedures or with minimally invasive open techniques. However, these procedures may cause pain and discomfort, and surgical stripping can be associated with long recovery times. We investigated whether venoactive drugs (VAD) used to treat chronic venous disease (CVD), provide benefits to patients recovering from a surgical or endovenous varicose vein procedure., Evidence Acquisition: We conducted a systematic review of the literature to identify clinical trials investigating VAD therapy before, during, or after a surgical, endovenous, or sclerotherapy procedure for varicose veins. Records retrieved from the PubMed and Embase databases were screened for relevant studies. Full-length articles in English were obtained for analysis., Evidence Synthesis: We identified five clinical trials investigating the effects of VAD on recovery after surgery, endovenous ablation, or sclerotherapy. Studies were conducted in Russia, Italy, and Czech Republic and varied considerably in design, but all were unblinded open-label studies. All studies reported the use of micronized purified flavonoid fraction (MPFF); in one study, sulodexide was also used. Three studies reported significantly less post-procedural pain with MPFF treatment, with one reporting no significant effect. Two studies reported significant reductions in post-procedural bleeding with MPFF treatment. Three out of four studies reported greater symptomatic improvement with MPFF treatment., Conclusions: Appropriate treatment with MPFF may help reduce post-procedural pain, hemorrhage, and CVD-specific symptoms. While adjunct VAD treatment seems promising, high-quality placebo-controlled studies are needed to unequivocally demonstrate its benefits.

Introduction: Thoracic endovascular aortic repair (TEVAR) has been increasingly adopted in the treatment of intact thoracic aorta aneurysms (iTAA), offering a less invasive approach with good effectiveness. Women usually present with smaller aortas, while having greater aneurysm growth rates. How sex can affect mortality and re-interventions after TEVAR for iTAA is the aim of this review., Evidence Acquisition: A search was conducted on PubMed databases to identify studies with gender-specific data on outcomes after TEVAR for iTAA. Primary endpoints were 30-day (or in-hospital) and mid-term mortality. Secondary endpoints were 30-day and mid-term secondary interventions., Evidence Synthesis: Nine studies were included with a total of 4484 patients (2707 men and 1777 women). Thirty-day mortality ranged from 0% to 6% in female and from 1.1% to 5.3% for male patients. Three studies reported gender-specific mortality one year after TEVAR, ranging from 12% to 15.2% for female and from 8% to 16.8% in male patients. Six studies were found describing gender-related secondary intervention data., Conclusions: Mortality after TEVAR for iTAA seems to be similar between genders. While there was a tendency for higher mortality in women, specially at 30-days, statistically significant differences were reported in only two studies. Re-interventions rates were higher in men in 4 of 6 studies, probably due to increased rates of endoleak in men, but no statically significant difference was found. Further studies with larger female population and longer follow-up are needed to firmly confirm differences among genders.

Varicose vein surgery is among the most commonly performed surgical interventions. The standard treatment 'high ligation and stripping' has in many countries been replaced by endovenous techniques. However, there are many different techniques available. All have a different way of action and sometimes need different skills. The purpose of this review article is to give an update in those different endovenous ablation techniques. We describe the indications, technique, mechanisms of action, and results. We conclude that all different techniques can be used safely and are effective. Even on long term there seems to be no difference in outcome, even compared to high ligation and stripping.