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Alternative percutaneous approaches to the management of symptomatic aortic stenosis in elderly and high-risk patients have become more attractive and raised profound interest in recent years. The superiority of transcatheter aortic valve implantation (TAVI) compared with medical therapy for patients deemed unsuitable for surgery has recently been established by the PARTNER trial, and preliminary randomized data in high-risk patients have confirmed that TAVI is non-inferior to surgical valve replacement in terms of safety and effectiveness. This finding will probably lead to an exponential increase in TAVI procedures over the next decade. In the clinical setting of the percutaneous approach, the choice of a specific valve is crucial to optimize the success rate and minimize the procedure-related complications and requires accurate preprocedural diagnostic assessment. According to the high comorbidities of candidates currently undergoing a TAVI procedure, a tailored diagnostic framework in the elderly population is highly recommended. The present review discusses the role of echocardiography in the setting of multimodality imaging before the TAVI procedure and throughout the entire process, from patient selection to procedural guidance and post-procedural follow-up, suggesting a practical algorithm necessary for the best clinical outcome.

Background. Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia and circulatory arrest. Endovascular repair is an attractive, less invasive alternative that may change our therapeutic approach. The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms and to address the new problems in this area. Methods. In the last 5 years, we treated 21 patients for aortic arch pathology with an "off-pump" endovascular repair (18 men, 3 women, mean age 71.4 ± 7.2 years). We used 26 stent grafts (5 Gore Excluder TAG, 3 Endomed Endofit, 6 Medtronic Talent, 12 Cook Zenith TX1) with a mean of 1.2 graft/patient. Proximal fixation of endograft was achieved by means of aortic "de-branching" in 11 cases. In 10 cases the left subclavian artery was intentionally covered without revascularization. Follow-up included clinical examination, chest X-ray and computed tomography at discharge and at 6-month intervals thereafter. Results. Technical success was 85% (18/21). There was one in-hospital death (4.7%) due to endograft migration. We observed 2 cases of type I endoleak (9.5%). One surgical conversion was performed 2 weeks after the procedure, because of total collapse of the stent graft with rupture of three stents. No complications related to the coverage of the left subclavian artery were observed. At a mean follow-up of 18.7 ± 12.8 months, no mortality or morbidity including new-onset endoleak, stent-graft migration and thrombosis of supra-aortic grafts were recorded. Conclusions. Endovascular treatment of aortic arch pathology is feasible even in elderly patients. However, accurate placement in the arch and aneurysm sealing with the currently available devices, may be challenging due to the involvement of supra-aortic vessels, the anatomical curvature of the arch, the high blood flow, and substantial movement of the aorta with each heartbeat. BACKGROUND: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia and circulatory arrest. Endovascular repair is an attractive, less invasive alternative that may change our therapeutic approach. The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms and to address the new problems in this area.METHODS: In the last 5 years, we treated 21 patients for aortic arch pathology with an "off-pump" endovascular repair (18 men, 3 women, mean age 71.4 +/- 7.2 years). We used 26 stent grafts (5 Gore Excluder TAG, 3 Endomed Endofit, 6 Medtronic Talent, 12 Cook Zenith TX1) with a mean of 1.2 graft/patient. Proximal fixation of endograft was achieved by means of aortic "de-branching" in 11 cases. In 10 cases the left subclavian artery was intentionally covered without revascularization. Follow-up included clinical examination, chest X-ray and computed tomography at discharge and at 6-month intervals thereafter.RESULTS: Technical success was 85% (18/21). There was one in-hospital death (4.7%) due to endograft migration. We observed 2 cases of type I endoleak (9.5%). One surgical conversion was performed 2 weeks after the procedure, because of total collapse of the stent graft with rupture of three stents. No complications related to the coverage of the left subclavian artery were observed. At a mean follow-up of 18.7 +/- 12.8 months, no mortality or morbidity including new-onset endoleak, stent-graft migration and thrombosis of supra-aortic grafts were recorded.CONCLUSIONS: Endovascular treatment of aortic arch pathology is feasible even in elderly patients. However, accurate placement in the arch and aneurysm sealing with the currently available devices, may be challenging due to the involvement of supra-aortic vessels, the anatomical curvature of the arch, the high blood flow, and substantial movement of the aorta with each heartbeat.

Background. The aim of this study was to analyse perioperative morbidity and mortality in patients undergoing thoracic (TAA) and thoracoabdominal aortic aneurysm (TAAA) surgery at the Department of Vascular Surgery of IRCCS San Raffaele, Milan. Methods. The study included 258 patients (199 males and 59 females) with a mean age of 66 (range: 41-82 years) undergoing 259 operations for aneurysmectomy of TAA or TAAA between January 1988 and April 2000. Cerebral spinal fluid drainage (CSFD) was used in 166 cases (75% of TAAA, 53% of TAA; 183 patients (98 TAAA and 85 TAA) were operated on with the use of left atriofemoral bypass using a Biomedicus pump. Results. The overall mortality rate at 30 days was 33/259 (13%); a total of 26 deaths (11%) were recorded during elective surgery and 7 (32%) in patients undergoing emergency repairs. The following perioperative complications were reported: paraplegia/paraparesis in 20 cases (8%), respiratory failure requiring prolonged intubation in 62 cases (24%), cardiac complications (major arrhythmia, myocardial infarction) in 26 cases (10%), renal failure in 18 cases (7%), postoperative bleeding requiring redo surgery in 12 cases (5%), graft infection in 5 cases (2%). Conclusions. Morbidity and mortality consequent to TAAA and TAA surgery are still high. However, based on our experience, the use of atriodistal bypass, sequential cross-clamping and CFSD enables acceptable results to be achieved and reduces complications secondary to spinal cord and visceral ischemia without the need for expeditious clamping times. Background. The aim of this study was to analyse perioperative morbidity and mortality in patients undergoing thoracic (TAA) and thoracoabdominal aortic aneurysm (TAAA) surgery at the Department of Vascular Surgery of IRCCS San Raffaele, Milan. Methods. The study included 258 patients (199 males and 59 females) with a mean age of 66 (range: 41-82 years) undergoing 259 operations for aneurysmectomy of TAA or TAAA between January 1988 and April 2000. Cerebral spinal fluid drainage (CSFD) was used in 166 cases (75% of TAAA, 53% of TAA; 183 patients (98 TAAA and 85 TAA) were operated on with the use of left atriofemoral bypass using a Biomedicus pump. Results. The overall mortality rate at 30 days was 33/259 (13%); a total of 26 deaths (11%) were recorded during elective surgery and 7 (32%) in patients undergoing emergency repairs. The following perioperative complications were reported: paraplegia/paraparesis in 20 cases (8%), respiratory failure requiring prolonged intubation in 62 cases (24%), cardiac complications (major arrhythmia, myocardial infarction) in 26 cases (10%), renal failure in 18 cases (7%), postoperative bleeding requiring redo surgery in 12 cases (5%), graft infection in 5 cases (2%). Conclusions. Morbidity and mortality consequent to TAAA and TAA surgery are still high. However, based on our experience, the use of atriodistal bypass, sequential cross-clamping and CFSD enables acceptable results to be achieved and reduces complications secondary to spinal cord and visceral ischemia without the need for expeditious clamping times