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Chronic limb-threatening ischemia (CLTI) is characterized by rest pain and tissue loss, with an annual mortality rate of 20% and amputation rate of 40%, if not treated. Open bypass surgery is recommended in CLTI, depending on the availability of good quality venous material, outflow artery patency, and surgical expertise. The aim of the study is to analyze primary patency, limb salvage, and survival rate in patients undergoing popliteal-to-distal bypass.

Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch.

Extremity venous aneurysms result in the risk of pulmonary embolism (PE) and chronic venous insufficiency. At present, owing to the rarity of these aneurysms, no consensus for their treatment has been established. The purpose of the present study was to review the presentation, natural history, and contemporary management of extremity venous aneurysms.

Objective: To assess and compare the maturation rate of the native radiocephalic arteriovenous fistula (RC-AVF) created with and without a nitinol external support (VasQ™ Laminate Medical Technologies Ltd, Tel Aviv, Israel).Methods: Data of all consecutive patients who underwent the creation of native RC-AVFs at our center between October 2018 and January 2020 was prospectively collected and retrospectively analyzed. Selected patients who had a suitable vein and a radial artery with triphasic flow at preoperative duplex ultrasound exam and were selected for the creation of a radiocephalic fistula were included. Exclusion criteria were: malignant tumors, acute renal failure, previous upper limb revascularization, and septic status. Patency and maturation, vein, and artery diameter and blood flow rate were assessed at the following intervals: post-operatively, 24 h post-operatively, 1 month, 3 months, and 6 months post-operatively.Results: Forty-nine patients (31 males, mean age 65.7 years old) were included. Patients who received VasQ™ devices were 25 (VasQ group), the other 24 formed the control group. All patients underwent radio-cephalic AVF placement (21 on the wrist, 20 on the forearm, 8 on the proximal forearm). There were no perioperative complications and fatalities. At 1, 3, and 6 months, primary patency rates were 96 ± 4%, 96 ± 4%, 91 ± 6% (VasQ group) versus 87 ± 7%, 87 ± 7%, 80 ± 9% (control group, P 0.17), secondary patency rates were 96 ± 4%, 96 ± 4%, 91 ± 6% (VasQ group) versus 95 ± 4%, 90 ± 7%, 90 ± 7% (control group, P 0.79). A significantly larger vein diameter increase postoperatively (P 0.009) and a greater maturation rate (96% vs 74%, p0.044) were found in the VasQ group compared to the control group.Conclusions: The use of the VasQ™ device was associated with higher maturation rates and larger vein diameters postoperatively. The patency rates were slightly higher but not significantly. Further studies are needed to confirm these findings.

Purpose: The aim of this project is to explore practice patterns of experienced vascular specialists involved in the treatment of patients with arterial femoro-popliteal in-stent occlusion (ISO) and to understand key concepts and shared thoughts, throughout an international cross-sectional survey.Materials and Methods: The web-based survey was in English and included 31 questions. One-hundred experts were invited by email to fill in the survey anonymously on Google Forms using a dedicated link. Reminders were sent after the first 2 weeks. In addition to reporting of pooled responses, subanalyses of answers were also performed, according to country of origin (European vs non-European), years of experience (≤20 years vs >20 years), and type of institution (Academic/University vs Non-academic/Private).Results: A total of 77 physicians from 22 countries completed the survey. Most responders were males (70/77, 91%). Most of the participants were vascular surgeons (58/77, 75%). Endovascular therapy was the preferred option in patients presenting with either acute limb ischemia, disabling intermittent claudication, or chronic limb-threatening ischemia. Atherectomy/thrombectomy+Drug-Coated Balloon (DCB) was the preferred endovascular modality (32/77, 42%). No differences between country of origin, years of experience, and type of institution of the participants were found.Conclusions: The international SUrvey oN TReatment Of Occluded Femoro-Popliteal Stent (SUNROOF) survey has suggested that endovascular therapy is the preferred method for the treatment of femoro-popliteal ISO. This survey could represent a good starting point for future research on comparison between open and endovascular approach and different devices, which currently lacks good-level scientific evidence and appropriate guidelines.Clinical Impact The international SUNROOF survey included 31 questions. It was performed by 77 vascular physicians from 22 countries. More than a half of respondents considered an endovascular approach as the preferred treatment modality in acute limb ischemia, disabling intermittent claudication, or chronic limb-threatening ischemia. Most responders agreed they would intensify the follow-up protocol and anti-thrombotic medications regimen after a first in-stent occlusion episode. This survey could represent a good starting point for future research on comparison between open and endovascular approach and different devices, which currently lacks of good level scientific evidence and appropriate guidelines.

Introduction: Chimney technique (chimney graft in abdominal aortic aneurysm repair [ChEVAR]) can be used to treat patients with pararenal aortic aneurysm unfit for open surgery and not suitable for custom-made fenestrated endograft. Since almost 1 in 5 patients undergo a reintervention within 3 years, features associated with higher risk of complications need to be investigated to tailor the follow-up schedule to each patient. The aim of our study was to assess the impact of mural thrombus in the pararenal aorta on perioperative and follow-up complications after ChEVAR.Methods: All consecutive patients undergoing ChEVAR at our center from 2015 to 2022 were included in this retrospective study. Collected variables included number of target vessels, stent graft size, presence, and severity of mural thrombus in pararenal aorta, which was reported with a scoring system from 0 to 10 based on thrombus type, thickness area, and circumference Analyzed outcomes included perioperative and follow-up complications.Results: Thirty-one patients underwent ChEVAR during the study period. In 4 patients the indication for ChEVAR was type 1A endoleak after a previous endovascular aneurysm repair (EVAR). The number of target vessels was 1 in 17 patients (55%), 2 in 12 (39%), 3 in 1 (3%), and 4 in 1 (%). The mean mural thrombus score was 5.9. Complications were the following: type 1A endoleak in 4 cases (13%), chimney stent complications in 7 cases (23%) (including partial or total thrombosis, intrastent stenosis, displacement), renal function worsening during follow-up in 8 cases (26%). Overall survival was 90% at 2 years. Patients with severe mural thrombus showed lower freedom from ChEVAR-related complications (28% vs 59% at 2 years, p=0.023).Conclusions: The presence of severe pararenal aortic mural thrombus was associated with lower freedom from ChEVAR-related complications in patients undergoing ChEVAR for pararenal aortic aneurysm repair. Further research with a larger number of patients is required to confirm these results.Clinical Impact The analysis of severity of mural thrombus in pararenal aorta, which was reported with a scoring system from 0 to 10 based on thrombus type, thickness area and circumference, can be useful and can be represent an important predictor element for complications in patient submitted to Chimney tecnique; in fact the presence of severe pararenal aortic mural thrombus was associated with lower freedom from ChEVAR-related complications in patients undergoing ChEVAR for pararenal aortic aneurysm repair. Then, in patient with pararenal aortic aneurysm, a preoperative evaluation could be focused on severity of mural thrombus to minimize the complications in ChEVAR tecnique or to change the surgical strategy.

The aim of this study was to find out if intra-arterial intraoperative iloprost administration, in selected patients undergoing endovascular revascularization procedures, could lead to better results compared with a control group of patients with similar clinical background and risk factors.

Treatment of severe critical limb ischemia (CLI) due to superficial femoral artery (SFA) and below-the-knee (BTK) vessels’ involvement could be compromised by the lack of a great saphenous vein (GSV) suitable in its entire length. The purpose of this study is to assess the efficacy of a hybrid endovascular and open lower limbs arterial reconstruction in these patients with multilevel, advanced CLI.

Purpose:To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods:A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (<30 days) endpoints included mortality, thrombosis, and major complications. Late major outcomes were primary and secondary patency and freedom from reintervention as estimated by Kaplan-Meier analysis; estimates are given with the 95% confidence intervals (CIs). Associations between baseline variables and primary patency were sought with multivariate analysis; the results are presented as the hazard ratio (HR) and 95% CI. Results:Technical success was achieved in 708 (99%) lesions; in-hospital mortality was 0.6% (n=4). The median follow-up was 11 months (range 0–42). The estimated primary patency rate was 96% (95% CI 94% to 97%) at 1 year and 94% (95% CI 91% to 96%) at 2 years. The estimated secondary patency was 99% (95% CI 97% to 99%) at 1 year and 98% (95% CI 95% to 99%) at 2 years. The estimated freedom from reintervention was 98% (95% CI 96% to 99%) at 1 year and 97% (95% CI 94% to 98.5%) at 2 years. Cox regression analysis demonstrated that the application of a covered stent was associated with an increased need for reintervention (HR 1.4, 95% CI 1.10 to 1.74, p=0.005). Chronic obstructive pulmonary disease was associated with decreased primary patency (HR 3.7, 95% CI 1.25 to 10.8, p=0.018). Conclusion:Endovascular intervention with primary stent placement for aortoiliac occlusive disease achieved satisfactory 2-year patency regardless of the complexity of the lesion. Almost all TASC lesions should be considered for primary endovascular intervention if suitable.

The aim of this study is to retrospectively analyze the early and long-term outcomes of endovascular treatment of Trans-Atlantic Inter-Society Consensus II class C and D (TASC II) aortoiliac occlusive disease with an expanded polytetrafluoroethylene–covered stent graft.

We report the case of a patient with internal carotid artery (ICA) mycotic pseudoaneurysm secondary to Lemierre's syndrome, urgently treated. A 75-year-old man presented to E.R. with a left swelling lesion of the neck and complaining left visions lost since that morning, fever, hypotension, and dyspnea. Since 15 days before developing symptoms, he had sore throat and odynophagia treated with a broad coverage of antibiotic therapy for presumed streptococcal pharyngitis. Preoperative computed tomography angiography images revealed a circular lesion, involving the common carotid artery, carotid bulb, and the proximal part of the internal and external carotid arteries. A pseudoaneurysm of the ICA was detected, and the jugular vein was compressed. A Cormier carotid vein graft bypass was performed. Lemierre's syndrome is a rare syndrome, but it is rarer the carotid artery pseudoaneurysm secondary to Lemierre's syndrome. Surgical treatment is safe and durable in patients with severe infection involving the neck.

The aim of the study was to evaluate the diagnostic effectiveness of color Doppler ultrasound (CDUS) with superb microvascular imaging (SMI) compared to contrast-enhanced ultrasound (CEUS), computed tomography (CT) multislice angiography (64 slices), and angiography required for therapeutic reasons, for follow-up after endovascular aneurysm repair (EVAR).

The aims of this study were to determine the effect of failed prior endovascular treatment (EV) on early and midterm outcomes of subsequent lower extremity open surgical (OS) bypass.

We report the case of a 58-year-old man presented with bleeding ulcer of the left arm caused by a high-flow type-C arteriovenous malformation (AVM), feed by branches from both the subclavian arteries. He had been previously treated with AVM sclerotherapy, embolization, humeral artery endografting, and open surgery. We urgently performed coil embolization of the left vertebral artery, and we covered the huge subclavian artery by a thoracic endograft. Then, we embolized the right tyrocervical trunk. The result was an immediate interruption of bleeding. At 12 months, the patient had no neurologic complications, and the upper limb continued to decompress.

Objective In this study, we retrospectively evaluated our experience in minilaparotomy (MINI) and compared the results with conventional open repair (OPEN).Methods From January 2005 to December 2012, we surgically treated 234 consecutive patients with elective infrarenal abdominal aortic aneurysms, 195 men and 39 women, with a mean age of 74 years. Inclusion criteria for MINI were not ruptured abdominal aortic aneurysm, increased surgical risk, anatomical limits for endovascular repair, no previous surgical invasion of the abdominal cavity, and no requirement for concomitant abdominal surgical invasion. Surgical treatment was OPEN in 113 patients (48.3%) and MINI through an 8- to 14-cm incision in 121 patients (51.7%). Epidural anesthesia has been added in 26.5% and in 19.3% of the MINI and OPEN patients, respectively. Mortality, complications, aortic clamping time, operative time, need for postoperative morphine therapy, time to solid diet, and length of hospital stay were registered.Results The MINI has been performed in all patients selected, with 72 aortoaortic grafts and 49 aortobisiliac grafts. Early mortality was 1.6% versus 3.5% (P> 0.5); 1-, 3-, and 5-year mortality were 7% versus 9%, 19% versus 22%, and 29% versus 34% (P> 0.5); complications were 12.2% versus 26.6% (P> 0.05); mean (SD) clamping time was 48 (12) versus 44 (14) minutes (P> 0.5); mean (SD) operative time was 218.72 (41.95) versus 191.44 (21.73) minutes (P> 0.025); mean (SD) estimated intraoperative blood loss was 425.64 (85.95) versus 385.30 (72.41) mL (P> 0.1); mean (SD) morphine consumption in the group given epidural and the group not given epidural was 0 (2) and 2 (2) mg intravenously (IV) versus 2 (4) (P< 0.5) and 4 (3) mg IV (P> 0.1); mean (SD) ambulation was 2.1 (0.6) versus 4.1 (2.7) (P< 0.5); mean (SD) time to solid diet was 2.1 (0.4) versus 3.5 (1.6) (P< 0.5); and mean (SD) length of hospital stay was 4.9 (1.64) versus 7.35 (1.95) days (P> 0.05), in the MINI and OPEN groups, respectively. Postoperative hernia at 3 years was 18% versus 23% in the MINI and OPEN groups (P< 0.5), respectively.Conclusions The MINI gives the patients a significantly shorter period of recovery with the quality and safety of the OPEN. This experience suggested extending the indication to all surgical candidates without local limitations.

Objective In this study, we retrospectively evaluated our experience in minilaparotomy (MINI) and compared the results with conventional open repair (OPEN).Methods From January 2005 to December 2012, we surgically treated 234 consecutive patients with elective infrarenal abdominal aortic aneurysms, 195 men and 39 women, with a mean age of 74 years. Inclusion criteria for MINI were not ruptured abdominal aortic aneurysm, increased surgical risk, anatomical limits for endovascular repair, no previous surgical invasion of the abdominal cavity, and no requirement for concomitant abdominal surgical invasion. Surgical treatment was OPEN in 113 patients (48.3%) and MINI through an 8- to 14-cm incision in 121 patients (51.7%). Epidural anesthesia has been added in 26.5% and in 19.3% of the MINI and OPEN patients, respectively. Mortality, complications, aortic clamping time, operative time, need for postoperative morphine therapy, time to solid diet, and length of hospital stay were registered.Results The MINI has been performed in all patients selected, with 72 aortoaortic grafts and 49 aortobisiliac grafts. Early mortality was 1.6% versus 3.5% (P> 0.5); 1-, 3-, and 5-year mortality were 7% versus 9%, 19% versus 22%, and 29% versus 34% (P> 0.5); complications were 12.2% versus 26.6% (P> 0.05); mean (SD) clamping time was 48 (12) versus 44 (14) minutes (P> 0.5); mean (SD) operative time was 218.72 (41.95) versus 191.44 (21.73) minutes (P> 0.025); mean (SD) estimated intraoperative blood loss was 425.64 (85.95) versus 385.30 (72.41) mL (P> 0.1); mean (SD) morphine consumption in the group given epidural and the group not given epidural was 0 (2) and 2 (2) mg intravenously (IV) versus 2 (4) (P< 0.5) and 4 (3) mg IV (P> 0.1); mean (SD) ambulation was 2.1 (0.6) versus 4.1 (2.7) (P< 0.5); mean (SD) time to solid diet was 2.1 (0.4) versus 3.5 (1.6) (P< 0.5); and mean (SD) length of hospital stay was 4.9 (1.64) versus 7.35 (1.95) days (P> 0.05), in the MINI and OPEN groups, respectively. Postoperative hernia at 3 years was 18% versus 23% in the MINI and OPEN groups (P< 0.5), respectively.Conclusions The MINI gives the patients a significantly shorter period of recovery with the quality and safety of the OPEN. This experience suggested extending the indication to all surgical candidates without local limitations.

The long-term results of carotid artery stenting (CAS) for post-carotid endarterectomy (CEA) restenosis are disappointing (4-year patency rates: ∼75%). Since 1988, our group has offered carotid bypass (CB) as an alternative to redo CEA and later also to CAS in this setting. The aim of this retrospective study was to investigate early and late outcomes associated with CB in this population.

The purpose of this study was to compare midterm results of carotid-to-carotid bypass (CCB) after hybrid repair of aortic arch disease.

Eagle Syndrome (ES) is an often misdiagnosed syndrome due to its wide spectrum of signs and symptoms. Recent works have pointed out the relation between ES and some types of craniofacial pain often misdiagnosed with migraine or temporomandibular disorders. Moreover, the presence of Vascular ES as a cause of Carotid Artery Dissection in same cases of stroke as well as cause of intracranial venous hypertension resulting in migraine and other pains has been recently discussed. A multidisciplinary approach is mandatory to allow clinicians to better understand the pathophysiology and clinical main patterns of ES. The aim of the work is to perform a comprehensive review all the clinical patterns and available diagnostic tools to guide clinicians through lights and shadows of such an underestimated syndrome. Finally, a novel flow-chart for comprehensive diagnosis of ES is proposed, including “dynamic” imaging investigating the relationship between stiloyd processes and the neurovascular structures of the neck during head movements.

Objectives: To analyze outcomes following endovascular treatment of total occlusion of the infrarenal aorta and aorto–iliac bifurcation in a multicenter Italian registry.Methods: It is a multicenter, retrospective, observational cohort study. From January 2015 to December 2018, 1306 endovascular interventions for aorto–iliac occlusive disease were recorded in the vascular registry. For this analysis, only patients treated for total occlusion of the infrarenal aorta and aorto–iliac bifurcation were included. Early (<30 days) primary outcomes of interest were technical success and mortality. Late major outcomes were primary and secondary patency and freedom from conversion to open aortic surgery.Results: A total of 54 (4.1%) patients met the inclusion criteria. Total percutaneous revascularization was possible in 41 (75.9%) patients and hybrid (endo plus open) intervention in 13 (24.1%) patients. The kissing-stent-graft technique was used in 45 (83.3%) cases, covered endovascular reconstruction of the aortic bifurcation (CERAB) in 5 (9.2%), and a unibody endograft deployed in 4 (7.4%). Technical success was 98.1% (n = 53). There were no episodes of intraoperative or perioperative vessel rupture. Conversion to open surgery was not necessary, and there were no in-hospital deaths. The median patient follow-up time was 16 months (interquartrile range [IQR], 6-27). The estimated primary patency rate was 95.8% ± 0.03 (95% confidence interval [CI]: 85.5-98.9) at 1 year, 91.4% ± 0.05 (95% CI: 76.2-97.2) at 2 years, and 85 ± 0.08 (95% CI: 64.5-94.6) at 3 years. Cox regression analysis demonstrated that sex (hazard ratio [HR]: 0.96; 95% CI: 0.15-6.23, p= 0.963), extent of the occlusion (HR: 0.28; 95% CI: 0.05-1.46, p= 0.130), calcium score (HR: 1.88; 95% CI: 0.31-11.27, p= 0.490), or type of endovascular reconstruction (HR: 0.80; 95% CI: 0.13-5.15, p= 0.804) did not affect primary patency. Secondary patency was 95.5% ± 0.04 (95% CI: 78.4-99.2) at 3 years. No patients required late conversion to open surgical bypass.Conclusions: Endovascular reconstruction for total occlusion of the infrarenal aorta and aorto–iliac bifurcation was successful using a combination of percutaneous and hybrid revascularization techniques. Estimated patency rates at 3 years of follow-up are promising and are unaffected by the extent of occlusion or type of revascularization.

In 80% of the patients presenting with deep-venous thrombosis (DVT), a risk factor can be identified. An absent or hypoplastic infrarenal vena cava is a rare risk factor for DVT in young adults. In these cases, the prevalence of congenital anomalies of the inferior vena cava (IVC) is estimated at 0.5% of the general population, up to 5% in young people. The association with coagulopathy increases the risk of DVT. We report a case of a young man who presented with a massive caval and iliofemoral-popliteal thrombosis in presence of the agenesis of retrohepatic inferior vena cava and atresia of the left renal vein. Open thrombectomy and caval reconstruction with a polytetrafluoroethylene graft were performed. Surgical option with vein reconstruction was preferred to prevent new episodes of thrombosis and the risk of acute renal failure.

Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC.

Aneurysms of the extracranial internal carotid arteries are rare. They may provoke symptoms of adjacent neurovascular structure compression, cerebral embolization, or rupture. An 81-year-old woman was found to have a saccular aneurysm of 2.2?cm in diameter in the left internal carotid with concomitant kinking. She underwent resection of the aneurysm and the kinked arterial area, followed by end-to-end anastomosis of the internal carotid artery.

We describe a technique for rescue surgery of autologous arterovenous fistula (AVF), using Bovine Mesenteric Vein (BMV), which may be used in patients with autologous AVF malfunction caused by steno-occlusion on the arterial side or by fibrosis of the first portion of the vein. To preserve the autologous AVF, we replaced the diseased portion of the artery, or the first centimeters of the vein, by a segment of BMV, with the aim of saving the patency and functionality of the access. We used this technique in 16 cases. All patients underwent hemodialysis treatment immediately after the procedure. Infection or aneurismal dilatation of the graft in implanted BMV was never observed.

Aortic dissection involving the arch can be complicated by extension to the supra-aortic branches. Carotid dissection may be symptomatic or asymptomatic at the time of surgery. Dissection or re-dissection of repaired carotid may happen later, with symptoms occurring days after the surgical repair, increasing the morbidity and mortality of those patients. We report a case of a patient with type A aortic dissection involving the aortic arch and extending to the supra-aortic branches. During surgery the dissection was seen extending to the distal carotid arteries with tears in the inner wall. After use of surgical glue as a sealant, seeing the persistent fragility and the presence of spiral form tears in the internal wall of the carotid arteries, intraoperative stenting of the common carotid arteries was performed using two stents to prevent carotid re-dissection and ischemic stroke in the postoperative period. In patients with aortic dissection and extension into the carotid arteries, especially with presence of tears of the inner wall, after use of a glue as a sealant of the two dissected layers, if the repaired artery wall results are still fragile, use of intraoperative carotid stenting may be of help in preventing late re-dissection.

Spontaneous subcapsular renal hematoma is a rare condition in clinical practice. It is caused by renal cysts, benign and malignant renal tumors, vascular lesions, and antiplatelet or anticoagulant therapy. In this paper we report an unusual case of rupture of a renal cyst of a 66-year-old male patient during an aortic and iliac endovascular procedure for a massive calcified atheroma above the iliac bifurcation. We suspected that the bolus of high weight molecular heparin given during the procedure caused the rupture of the cyst. According to the literature, this is the first case of renal cyst rupture during an endovascular aortic procedure after administering a high weight molecular heparin bolus.