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Background: Penumbra/Indigo aspiration thrombectomy Systems (Penumbra Inc.) in patients with acute lower limb ischemia (ALLI) is becoming a fundamental alternative to surgical and intra-arterial thrombolysis. The INDIAN UP trial represents the second phase of the Italian national multicenter trial evaluating the safety and effectiveness of the device in the treatment of ALLI., Methods: To assess vessel patency, the TIPI (Thrombo-aspiration In Peripheral Ischemia), is used. The TIPI flow in three different moments: at presentation, immediately after thromboaspiration, and after all adjuvant procedures. The primary outcome is the technical success of the thrombo-aspiration with the investigative system, defined as near complete or complete revascularization TIPI 2 - 3. Safety and clinical success rate were collected at one month follow-up., Results: A total of 250 patients were enrolled. The mean age was 72.2±13.1 years and 72.1% were male. Rutherford grade on enrolment was I in 10.8%, IIa in 34.9%, and IIb in 54.4%. Primary technical success (TIPI 2-3 flow) was achieved in 90.8% of patients. Adjunctive procedures were needed in 158 cases. After all interventions, assisted primary technical success was 96.4%. No systemic bleeding complications or device related serious adverse events were reported. At one month follow up, survival rate was 97.2%, limb salvage was 97.6%. Primary patency was 89.6% and 13 (5.4%) reinterventions were registered., Conclusions: The updated results of the INDIAN UP trial have confirmed the high value of the mechanical thromboaspiration device Indigo Penumbra in the treatment of ALLI in a large variety of clinical and anatomical settings.

Diabetic foot (DF) continues to present a significant challenge to the vascular surgeon. Despite great advances in the treatment of DF, including open revascularization and endovascular techniques, significant numbers of amputations are still performed. The effect of aggressive revascularization on ultimate limb salvage rates continues to be debated. In the US the amputation rate has increased from 19 to 30 per 100000 persons years over the last two decades primarily due to an increase in diabetes and advancing age. Despite advances in cardiovascular treatment, in patients over 85 year of age an amputation rate of 140 per 100000 persons/year has been reported with a primary amputation (PA) still carrying an excessively high mortality rate of 13-17%. Amputation has been historically regarded as a life saving therapeutic measure. At the time the advances of surgical techniques in revascularization, diagnostic modalities and effectiveness in antimicrobial agents have unintentionally designated amputation to be the last treatment option. Nowadays we have a variety of therapeutic options to correct, modify, or circumvent the obstructive vascular pathology, such as angioplasty, atherectomy, stenting, stent graft and the traditional open surgical approach using endarterectomy, patch angioplasty, or bypass revascularization and even sympathectomy to enhance cutaneous perfusion to the toes. However it is understandable that many older patients who have received multiple limb preservation procedures have spent most of the remaining days of their lives in and out of the hospital or in a long-term care facility where high technical and sophisticated wound care techniques can be provided.

Renal artery aneurysms (RAA) are rare (general population incidence is 0.09%). At this time, the appropriateness of the type of intervention ‑ surgical or endovascular ‑ is based on single center experiences rather than large randomized trials. Endovascular therapy offers less morbidity but surgery has excellent long-term results. In reality, the choice of the treatment relies on the operative risk. A patient with a RAA and good surgical risk should be offered open surgery. If the patient is deemed to be at high risk from surgery then the choice of the type of endovascular treatment (stent grafting, coil/glue embolization, multilayer stenting) should be based on the location and shape of the RAA. RAA should be treated by surgeons/interventionalists who have demonstrated expertise in renal artery procedures.

What distinguishes vascular surgeons from other specialists who treat patients with vascular disease is their ability to combine skills in both open and endovascular treatments. Open vascular surgery should be considered the "starting point" for endovascular surgery, since training and practice in vascular surgery require extensive knowledge of the basic science and a thorough education in general surgical techniques. In addition, surgeons must possess detailed specialized knowledge of the anatomy and physiology of arteries, veins and lymphatics and of the pathological processes which may affect them. This scientific and technical background is also imperative for endovascular surgery. Open vascular surgery can also be considered as a potential finishing point of endovascular surgery. In fact, open surgery is still often the only solution for complex cases considered unsuitable for an endovascular approach, or for different types of complications following endovascular treatments. As endovascular surgery is increasingly considered as the initial treatment option for many patients with vascular disease, it is crucial that vascular surgery training programs develop methods to maintain the open surgical skills of their trainees. The only way for vascular surgeons to remain the premier specialists to care for patients with vascular disease is for them to combine skills in both open and endovascular treatments.

The most efficient treatment for acute arterial embolism is operative embolectomy using Fogarty's balloon catheter, especially if a single large artery is involved. Unfortunately, although the early surgical success of arterial thromboembolectomy often seems acceptable, the early clinical outcome still remains unsatisfactory. This may be related to the incomplete restoration of perfusion (i.e., residual thrombus in distal vessels not reached by the balloon catheter thromboembolectomy), propagation of residual thrombi or presence of underlying steno-occlusive lesions. In such a situation a meticulous intraoperative assessment of the adequacy of clot removal is decisive. Residual thrombus, chronic atherosclerotic disease and even vessel injuries secondary to balloon catheter passage can be corrected by endovascular techniques (hybrid procedures). The combination of surgical and endovascular options may overcome the limitations that characterize the traditional approach, and it is likely that in the future many treatments will be a mix of techniques that can be performed by vascular surgeons in the operating room or in a dedicated endovascular suite. This review article summarizes the hybrid treatment options for acute arterial occlusion caused by either embolism or local thrombosis.

The rupture of an abdominal aortic aneurysm (rAAA) causes about 15000 deaths/year in the USA alone. Even though over the last 50 years progress in surgical techniques and in postoperative intensive care have been outstanding, the analysis of registries has shown either no decrease in the mortality rate for surgically treated rAAAs. Some reports asserted better out come for endovascular repair (EVAR) compared with surgery in case of rAAA. Despite this evidence, EVAR for rAAA remains prerogative of few centers worldwide. In conclusion only larger study or registry could assest the real role of EVAR in the management of rAAA.

Adventitial cystic disease (ACD) is an uncommon condition with only around 300 cases reported in the literature. ACD consists of a collection of gelatinous material within a cyst, that is adjacent or surrounding a vessel. In the last five years three cases of ACD have been observed: the first case was a 48-year-old man, ex nicotine abuser, with a four-month history of progressive claudication; the second case was a 55-year-old man, ex nicotine abuser, with ischemic heart failure and a one-year history of progressive claudication; the third case was a 70-year-old man, with diabetes, dislipidemia and current nicotine abuser with a few-day history of acute pain in the right leg. In two cases the cysts were incised and the contents evacuated. The adventitia was repaired and the wound closed. The first patient is currently asymptomatic after four years from surgery. The second one, at 21 months, follow-up, presented newly severe claudication. Duplex ultrasound scan and computed tomography angiography demonstrated a cranial progression of the lesions. This lesion was treated with bare stent, with complete regression of the symptoms. The third patient was treated with interposition of an autogenous saphenous vein. The patient is asymptomatic at the three-month follow-up. Even if ACD is quite rare, it should be taken in consideration in young patients with severe claudication and no- or poor comorbidities. The best treatment is the incision of the cysts and the advential reconstruction. Short lesions can be treated with endovascular therapy.

Aim: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair., Methods: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate., Results: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01)., Conclusion: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.

Aim: The aim of this study was to evaluate the technical success and clinical outcome of surgical revascularization, angioplasty and/or stenting for renal artery stenosis (RAS) in patients with renovascular hypertension (RVH). The secondary aim was to identify independent negative predictors of blood pressure control after successful renal revascularization., Methods: From January 1998 to July 2006, we treated 97 cases of RAS in 83 RVH patients. Inclusion criteria were RAS > or =80% associated with hypertension refractory to medical control with at least three drugs including a diuretic. Therapeutic options were surgical revascularization in 15 cases (11 renal endarterectomies, 4 aortorenal bypasses) and endoluminal treatment in 82 (14 balloon angioplasties, 68 stents)., Results: Technical success was 100% for both surgical and endovascular procedures; 13 cases of restenosis (> or =80%) were detected: 12 (14.6%) in the endoluminal group and one (6.6%) in the surgical group (P=0.68). During the follow-up period (average 37 months, range 6-94), blood pressure control improved in 43% of patients, disease stabilized in 37% and the natural course of RVH deteriorated in 20%. Multivariate Cox regression analysis showed that only a long history of antihypertensive drug use was a predictor of inefficacy of blood pressure control after revascularization (P<0.04)., Conclusion: The complete resolution of RVH associated with severe RAS appears unrealistic in several cases. Early and long-term results in terms of technical success and restenosis were acceptable and similar for surgical and endovascular renal intervention. An early diagnosis of RVH could improve the control of hypertension after successful renal revascularization.