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Blunt thoracic aortic injury (BTAI) is a devastating condition that commonly occurs in healthy and young patients. Endovascular treatment is the first choice; however, it has also been demonstrated to alter cardiovascular haemodynamics. The aim of this systematic review was to describe the cardiovascular modifications after thoracic endovascular aortic repair (TEVAR) for BTAI.PubMed (MEDLINE), Scopus, and Web of Science were systematically searched for eligible studies reporting on modifications in aortic stiffness, blood pressure, cardiac mass, and aortic size.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies.A total of 12 studies reporting on 265 patients were included. Severe heterogeneity existed among the included studies with regard to demographics, BTAI grade, endograft specifications, reported outcomes, and the method of evaluation. Regarding aortic stiffness, two studies found a significant increase in pulse wave velocity (PWV) in patients after TEVAR compared with a control group, while one did not find a significant increase in PWV and augmentation index after3 years of follow up. Five studies reported an increase in the incidence of post-TEVAR hypertension up to 55% (range 34.8% - 55.0%) vs. baseline. One study found a statistically significant increase in left ventricular mass and left ventricular mass index during follow up. Nine studies report data regarding aortic dilatation or remodelling after TEVAR. One found a 2.4 fold faster growth rate in ascending aortic diameter vs. controls, while other studies described significant changes in aortic size at different locations along the aorta and endograft after TEVAR.This systematic review highlights adverse cardiac and aortic modifications after TEVAR for BTAI. The results stress the need for lifelong surveillance in these patients and the necessity of developing a more compliant endograft to prevent cardiovascular complications in the long term.

A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents.The Web of Science, Pubmed, and Embase databases were searched from inception to July 2021. The corresponding authors of excluded articles were contacted to obtain additional data for possible inclusion.The main outcomes included ischaemic complications (stroke, transient ischaemic attack [TIA], and transcranial Doppler [TCD] measured micro-emboli), haemorrhagic complications (haemorrhagic stroke, neck haematoma, and re-operation for bleeding), and composite outcomes. Pooled estimates using odds ratios (ORs) were combined using a random or fixed effects model based on the results of the chi square test and calculation of IIn total, 47 411 patients were included in 11 studies, with 14 345 (30.2%) receiving DAPT and 33 066 (69.7%) receiving aspirin only. There was no significant difference in the rates of peri-operative stroke (OR 0.87, 95% confidence interval [CI] 0.72 - 1.05) and TIA (OR 0.78, 95% CI 0.52 - 1.17) despite a significant reduction in TCD measured micro-emboli (OR 0.19, 95% CI 0.10 - 0.35) in the DAPT compared with the aspirin monotherapy group. Subgroup analysis did not reveal any significant difference in ischaemic stroke risk between patients with asymptomatic and symptomatic carotid artery stenosis. DAPT was associated with an increased risk of neck haematoma (OR 2.79, 95% CI 1.87 - 4.18) and re-operation for bleeding (OR 1.98, 95% CI 1.77 - 2.23) vs. aspirin. Haemorrhagic stroke was an under reported outcome in the literature.This meta-analysis found that CEA while on DAPT increased the risk of haemorrhagic complications, with similar rates of ischaemic complications, vs. aspirin monotherapy. This suggests that the risks of performing CEA on DAPT outweigh the benefits, even in patients with symptomatic carotid stenosis. The overall quality of studies was low, and improved reporting of CEA outcomes in the literature is necessary.

Background Despite the great evolution of endograft devices for thoracic endovascular aortic repair (TEVAR), threatening related complication such as graft migration and endoleaks still occur during follow up. The Drag Forces (DF), that is the displacement forces that play a role in graft migration and endoleaks caused by the blood flow against the thoracic graft, can be studied by means of Computational Fluid Dynamics (CFD). Method A general review of papers found in current literature was performed. CFD studies available on the topic of thoracic aortic diseases and DF were analyzed. All anatomic, hemodynamics or graft related factors which could have an impact on DF were reported. Results Different factors deeply influence DF magnitude in the different site of the Ishimaru's zones classification: angulation, tortuosity and length of the landing zone, graft diameter, length and deployment position, blood pressure, pulse waveform, blood viscosity and patient heart rate have been related to the magnitude of DF. Moreover, also the three-dimensional orientation of DF is emerging as a fundamental issue from CFD studies. DF can be divided in sideways and upward components. The former, even of higher magnitude in zone 0, maintain always an orthogonal orientation and does not change in any type of aortic arch; the latter result strictly related to the anatomic complexity of the aortic arch with values up to four times higher in zone 3. Conclusion Different DF magnitude and orientation could explain how TEVAR have higher rate of migration and endoleaks when we face with more complex aortic anatomies. All these aspects should be foreseen during the planning of TEVAR procedure. In this field, collaboration between physicians and engineers is crucial, as both parts have a primary role in understanding and describing hidden aspects involved in TEVAR procedures.

Objective: The characteristics and outcomes of patients undergoing vascular surgery hospitalised and managed in Lombardy are described with a comparison of patients tested positive for COVID-19 (CV19-pos) vs. those tested negative (CV19-neg). Methods: This was a multicentre, retrospective, observational cohort study which involved all vascular surgery services in Lombardy, Northern Italy. Data were retrospectively merged into a combined dataset covering the nine weeks of the Italian COVID-19 pandemic phase 1 (8 March 2020 to 3 May 2020). The primary outcome was freedom from in hospital death, secondary outcomes were re-thrombosis rate after peripheral revascularisation, and freedom from post-operative complication. Results: Among 674 patients managed during the outbreak, 659 (97.8%) were included in the final analysis: 121 (18.4%) were CV19-pos. CV19-pos status was associated with a higher rate of complications (OR 4.5; p < .001, 95% CI 2.64 – 7.84), and a higher rate of re-thrombosis after peripheral arterial revascularisation (OR 2.2; p = .004, 95% CI 1.29 – 3.88). In hospital mortality was higher in CV19-pos patients (24.8% vs. 5.6%; OR 5.4, p < .001;95% CI 2.86 – 8.92). Binary logistic regression analysis identified CV19-pos status (OR 7.6; p < .001, 95% CI 3.75 – 15.28) and age > 80 years (OR 3.2; p = .001, 95% CI 1.61 – 6.57) to be predictors of in hospital death. Conclusion: In this experience of the vascular surgery group of Lombardy, COVID-19 infection was a marker of poor outcomes in terms of mortality and post-operative complications for patients undergoing vascular surgery treatments.

Background Arterial traumas of the extremities are quite rare in civilian records; nevertheless, patients with trauma of limbs are admitted daily in emergency departments worldwide. The up-to-date information about epidemiology and treatment (open vs. endovascular surgery) comes from war records and it is not always easy getting data on mortality and morbidity in these patients. The aim of this study is to analyze the approach (open or endovascular) and the outcome of patients with vascular trauma of upper limbs (from the subclavian artery) and/or lower limbs (distal to the inguinal ligament), in the greater Milan area. Methods A retrospective analysis was conducted on data recorded by the emergency departments of two hospitals of the greater Milan between 2009 and 2017. We collected all patients with arterial injuries of the limbs in terms of demography, injury patterns, clinical status at admission, therapy (open or endovascular approach), and outcomes in terms of limb salvage and survival. Results We studied 52 patients with vascular trauma of extremities. The main mechanism of trauma was road accident (48.1%), followed by criminal acts (32.7%), self-endangering behavior (13.5%), work (3.8%), and sport accidents (1.9%). Associated lesions (orthopedic, neurological, and/or venous lesions of the limbs) were present in 39 patients (75%). All patients underwent emergency surgery, forty-six patients (88.5%) by open repair (polytetrafluoroethylene or greater saphenous vein bypass grafts, arterial suture or ligation), whereas endovascular approach was used only in 6 patients (11.5%), all treated with embolization. The overall postoperative mortality rate was 5.7% (3 patients). Among survivors, we report 5 major amputations of the lower limbs, 3 of them after bypass graft infection, and 2 after graft failure. The rate of limb salvage was 90.4%. Conclusions Isolated arterial trauma of the extremities are rare, usually they occur in the setting of multiple trauma patients. Despite progresses in surgical techniques, there are still controversies in diagnosis and treatment of these patients. We treated most cases with open surgery (n = 46), choosing endovascular approach (embolization performed mainly by interventional radiologists) in difficult anatomic districts. We believe that, during decision-making of the surgical strategy, it is important to consider the anatomical site of lesions and the general condition of the patients. Moreover, in case of multiple trauma, we suggest a multidisciplinary approach to provide the best medical care to the victims.

Increased aortic stiffness (AoS) has been recognised as a risk factor in the development of cardiovascular disease. The aim of this systematic review and meta-analysis was to assess the impact of aortic repair on AoS.PubMed, Scopus, and Web of Science were searched systematically for relevant studies evaluating the consequences of endovascular and open aortic repair on AoS.The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement was followed to perform the research process. Papers containing data on AoS before and after both thoracic (TEVAR) and abdominal (EVAR) endovascular repair, as well as open surgical repair (OSR), were included for detailed evaluation. A fixed effects model was used to perform analysis. The Newcastle-Ottawa Scale was calculated for each included study.The first article cluster comprised 367 papers. After removal of duplicates and the adoption of inclusion/exclusion criteria, 14 articles remained, 13 of which were selected for meta-analysis. Ten studies analysed EVAR and three analysed TEVAR. Five of the selected papers were case control studies, with OSR adopted in four of these as the EVAR comparator. Several graft types were used in the endovascular group. AoS increased after TEVAR and EVAR, in terms of pulse wave velocity (PWV), even though several spatial levels and measurement modalities were adopted. No differences were described after OSR, although no pooled data could be analysed.EVAR and TEVAR both demonstrated a significant increase in AoS measurement (PWV). Although the heterogeneity and the low number of available studies limit the strength of the results, this review highlights the potential deleterious endograft role in the cardiovascular system although further studies are needed to achieve robust evidence. Further studies are needed to improve the mutual interaction between aorta and endograft, minimising their impact on the native aortic wall properties.

The aim was to identify pre-operative color Doppler ultrasound (CDUS) variables predictive of post-operative endovenous heat induced thrombosis (EHIT) after radiofrequency ablation (RFA) of the saphenous veins.This was a single centre, observational study with retrospective analysis of consecutive patients treated from December 2010 to February 2017.Pre-operatively, the diameter of the sapheno-femoral junction (dSFJ), distance between superficial epigastric vein and SFJ (dSEV-SFJ) [corrected], maximum great saphenous vein (GSV) diameter (mdGSV), diameter of the saphenous-popliteal junction (dSPJ), and mean small saphenous vein (SSV) diameter (adSSV) were measured. All patients received low molecular weight heparin (LWMH) at a prophylactic dose for a week. Post-operatively, CDUS was performed after 72 h, 1 week, and 3 months.Venous interventions on 512 patients were performed: 449 (87.7%) underwent RFA of the GSV (Group 1), and 63 (12.3%) of the SSV (Group 2). At Day 3 post-operatively, CDUS documented 100% complete closure of the treated saphenous vein segment. Overall, 40 (7.8%) cases of post-operative EHIT were identified: 29 in Group 1, and 11 in Group 2 (6.4% vs. 17.5%, p = .005). Deep venous thrombosis or pulmonary embolism did not occur in either group. At the 1 month follow up, all cases of EHIT regressed. In Group 1, on multivariate analysis, dSEV-SFJ [corrected] (OR, 1.13, p = .036; 95% CI 1.01-1.27) was the only statistically significant predictor for EHIT. A dSEV-SFJ [corrected] distance of 4.5 mm yielded an 84% of sensitivity for EHIT prediction with a 72.4% positive predictive value. In Group 2, univariate analysis did not identify independent risk factors for EHIT occurrence.EHIT was higher than previously reported. The dSEV-SFJ [corrected] was the most significant predictor for EHIT in the GSV group. A greater distance between the tip of the radiofrequency catheter and the SFJ may decrease the risk of developing this complication.

Background Extra-anatomic bypass (EAB) remains a viable alternative for lower limb revascularization if aorto-bifemoral bypass and endovascular therapy are contraindicated. Among EAB, perigraft seroma (PS) occurs in about 4% of cases. Diagnostic and therapeutic management, as well as standardized treatment paradigm, are still not well defined. The aim of this study is to report 5 PS cases in EAB and to review the literature about similar cases. Methods We retrospectively reviewed EAB performed during the period 2002–2015. Among these, PS cases were analyzed. A similar description for all cases found in the literature through research on the major international databases (PubMed, Scopus, EMBASE) was conducted. Results During the study period, 797 bypasses—528 (66.3%) anatomical and 269 (33.7%) extra-anatomical—were performed. Among the latter, 169 femoro-femoral (FF), 20 axillo-femoral (AXF), 22 axillo-bifemoral (AxBF), and 58 aortouni-iliac endoprosthesis (AUI) + FF bypasses were performed. Five cases (1.86%) of PS in EAB population were detected: 3 after AxBF and 2 after AUI + FF. Although we initially preferred percutaneous drainage, a surgical choice with graft explant and replacement were imposed by the high recurrence rate. Literature analysis identified 20 additional cases (11 after AxBF, 7 after AXF and one after AUI + FF). Conclusions Our case series and the literature confirm that the most widely used therapy is the surgical drainage with primary or secondary replacement of the graft of a different material. Percutaneous drainage has proved to be ineffective because not conclusive and potential to increase risk of graft infection. Careful follow-up, even years after surgery, remains necessary for PS diagnosis and management, to prevent complications and potential infection.