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To ascertain whether simulated endovascular procedures are comparable to real life operating room (OR) procedures, particularly with regard to irradiation time.This was a retrospective study comparing simulation with clinical data. Fluoroscopy time and overall operation time were compared between simulated abdominal aortic endovascular repair (EVAR) and iliac procedures that were performed, respectively, from 2016 to 2019 and from 2015 to 2019, and clinical EVAR and iliac procedures performed in the OR between January 2018 and November 2021.Within the defined periods, 171 simulated procedures (91 EVAR, 80 iliac) and 199 clinical procedures (111 EVAR, 88 iliac) were performed. For both EVAR and iliac procedures, median total procedure time was much longer during real surgery (Simulated endovascular procedures are comparable with real life OR procedures, particularly with regard to irradiation time when integrated in a dedicated curriculum.

The respiratory syndrome COVID-19 has had a devastating effect on health, economy, and social life worldwide. The healthcare system of industrialised countries has been at times submerged by the pandemic, leading to some of the most challenging choices in health resource distribution experienced by this generation. During local COVID-19 prevalence surges, access to operating theatres and intensive care facilities for all but the most urgent surgery has been severely restricted. The workforce and intensive care have been redeployed to deal with the flood of COVID-19 cases. Associated with this limited access to elective theatre, disease specific case prioritisation has been required. Society and healthcare providers tend to be very aware of the need to perform early surgery for cancer diagnoses, and the associated high morbidity and mortality of vascular patients is less well recognised. The high mortality of vascular patients infected with COVID-19 and particularly the risk of pulmonary complications was not widely understood at the start of the pandemic; moreover, there was a high geographical variability in the severity of the COVID-19 distribution, and a standardisation of the hospital strategies was not possible.1, 2, 3, 4

To co-register conventional computed tomography angiography (CTA), with ex vivo micro-computed tomography (microCT) and histology of popliteal atherosclerotic plaques. Improving the non-invasive imaging capabilities may be valuable to advance patient care with peripheral arterial obstructive disease towards lesion and individual based treatment.In this prospective observational study, 12 popliteal arteries from 11 symptomatic patients who had undergone transfemoral amputations for chronic limb threatening ischaemia and who had pre-operative CTA, were analysed ex vivo by microCT and histology. A total of 353 histological cross sections were co-registered with microCT and CTA, and classified as: lipid rich (LP, n = 26), fibrous (FP, n = 80), or calcific (CP, n = 247) plaques. CTA and microCT plaque density was calculated in 791 regions of interest as Hounsfield units (HU).CTA and microCT could identify plaque components that were confirmed by histology such as fibrous tissue (FP), lipid pool/core (LP), and calcification (CP). MicroCT densities were 77.8 HU for FP (IQR 52.8, 129.5 HU), -28.4 HU for LP (IQR -87.1, 13.2 HU), and 3826.0 HU for CP (IQR 2989.0, 4501.0 HU). CTA densities of the three components of the plaque were: 78.0 HU for FP (IQR 59.5, 119.8 HU), 32.5 HU for LP (IQR 15.0, 42 HU), and 641.5 HU for CP (IQR 425.8, 1135 HU). The differences were statistically significant between the HU densitometric characteristics among the three groups (p .0001) for both imaging modalities. Overall, microCT performed better diagnostically than conventional CTA for the three types of plaques: areas under the receiving operator characteristics curve were greater for microCT than CTA for FP (0.97 vs. 0.90), for LP (0.88 vs. 0.67), and for CP (0.97 vs. 0.90).CTA and microCT can be used to identify histological atherosclerotic plaque components, with better diagnostic performance for microCT. This study demonstrates the feasibility of using microCT to assess plaque morphology lesions in a manner that approaches histology thus becoming a useful tool for ex vivo assessment of atherosclerosis and towards lesion based treatment.

Objective There have only been a few studies on the stiffness and load bearing characteristics of guidewires used to deliver devices during endovascular procedures, particularly endovascular aneurysm repair. The aim of this study was to compare the load bearing characteristics of typical stiff and floppy wires, including in the context of consistency for each wire type. Methods Two sets of stiff guidewires (Lunderquist Extra-Stiff and Amplatz Super Stiff [0.035” × 260 cm]), were compared with a floppy hydrophilic guidewire (Radifocus Stiff M [0.035” × 260 cm]). Radial stiffness was defined as the force (newtons [N]) needed to deform the wires on an electromechanical dynamometer. Tests were repeated with three runs on three sets of the same wire to check for consistency. Data were logged on proprietary dynamometric software and peak load values assessed per wire. Peak deformation forces (PDFs) from straight configuration to midwire deformation at 15 mm was translated into Microsoft Excel for statistical analysis in Minitab 19 for Windows. Results There was good agreement within each wire set, with no difference in PDFs from runs for each wire (p > .10). Mean ± standard deviation PDFs were 7.83 ± 0.23 N for the Lunderquist, 9.87 ± 0.92 N for the Amplatz, and 7.84 ± 0.52 N for the Radifocus wires. The Amplatz wire exhibited the greatest resistance to deformation vs. both the Lunderquist and Radifocus wires (p < .001, one way analysis of variance). Both Amplatz and Radifocus wires had non-linear deformation characteristics. Conclusion This study confirmed that the represented hydrophilic wire is more deformable than the stiff wires. The Amplatz wire has complex construction features that yielded surprising baseline stiffness characteristics. The linear stiffness characteristics of the Lunderquist wire possibly contribute to it being the preferred choice for large endograft delivery., Highlights • A range of stiff and floppy wires are used in endovascular procedures. • Very few studies have assessed wire stiffness characteristics. • No study has undertaken external quality assurance analyses of wire stiffness. • This study confirms consistent wire stiffness characteristics. • Predictable Lunderquist wire stiffness supports its choice for device delivery.

European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

Resumen El trasplante renal es el mejor metodo para suplir la funcion renal y en la actualidad tiene tasas de supervivencia del injerto del 92,2% y del 76,8% a 1 y 5 anos, respectivamente. Las complicaciones vasculares secundarias a la cirugia explican algunas de las perdidas de los trasplantes renales y pueden producirse en todas las fases, desde la extraccion renal hasta varios anos despues del trasplante. Las pruebas de imagen, en particular la ecografia Doppler, desempenan un papel importante en su prevencion, diagnostico y seguimiento. La mayoria de las complicaciones vasculares que se producen durante el primer mes se deben a un defecto tecnico durante la confeccion de las anastomosis vasculares o a un problema de posicionamiento del injerto. Es esencial una tecnica quirurgica rigurosa y una apreciacion de la reperfusion del injerto en todas las fases de la intervencion. Las complicaciones mas graves son las rupturas arteriales, a menudo de origen septico, que pueden poner en peligro la vida. La estenosis de la arteria del injerto es la complicacion postoperatoria tardia mas comun, hoy en dia tratada por metodos endovasculares. El conocimiento, la prevencion y el tratamiento de estas complicaciones vasculares deben estar dentro del ambito de competencia de un cirujano vascular.

International audience; Objective: Compliance is considered to be a major property influencing the long term performances of synthetic vascular substitutes that could play a role in anastomotic false aneurysm and intimal hyperplasia stenosis onset. Over the last decades, manufacturers have tried to develop substitutes that mechanically mimic arterial properties and avoid a compliance mismatch at the anastomoses in particular. However, data are missing about how initial compliance properties could change with time. The goal of this study was to evaluate how the compliance of vascular grafts evolves under cyclic loading conditions in vitro.Methods: The compliance of three different models of commercially available textile polyethylene terephthalate (PET) grafts was evaluated. Tests were performed with and without their original coating. Compliance was assessed with a specific device dedicated to measure the deformations undergone by a graft under cyclic pressure loading conditions, using image analysis software. In each experiment, image analysis was performed under 60 and 140 mmHg pressure loading conditions at loading start (H0) and after three, six, and 24 h (H3, H6, H24) loading time. Average radial, longitudinal, and volumetric compliance was calculated from the obtained images.Results: Twenty-four samples were tested. Results demonstrate that all values decreased significantly within only a few hours. On average, the loss of compliance after 3 h of cyclic loading ranged on average from 35% for longitudinal compliance to 39% for radial compliance and 37% (p < .050) for volume compliance. After 24 h, the loss of radial, longitudinal and volume compliance was respectively 63 ± 3%, 60.5 ± 2% and 61 ± 7%.Conclusion: In this in vitro model, PET graft compliance has already decreased significantly within 3 h. The rapid loss of compliance identified in this experimental study helps explain the mismatch mentioned in clinical observations.

Objective Occupational exposure is a growing concern among the endovascular specialist community. Several types of imaging equipment are available, such as mobile C arms or hybrid rooms, and some have been shown to deliver higher levels of radiation. A literature review was conducted to identify studies reporting dose data during standard (EVAR) and complex abdominal aortic endovascular repair (fenestrated/branched EVAR [F/BEVAR]). Methods A search of the MEDLINE and the Cochrane databases was performed by two independent investigators using the medical subject heading terms “aortic aneurysms”, “radiation”, and “humans” over a search period of 10 years. Studies with full text available in English and reporting radiation data independently from the imaging equipment type were included. Experimental studies were excluded. Results The lowest dose–area product levels during EVAR and F/BEVAR were identified in hybrid rooms, while the highest were with fixed systems. When adherence to the as low as reasonably achievable principles was stipulated by the authors, dose reports tended to be among the lowest. Several studies, especially of F/BEVAR, report concerning levels of radiation for both patients and staff. Conclusion Modern imaging equipment type, team involvement with radiation management, and the support of recent imaging technologies such as fusion help to reduce the dose delivered during standard and complex EVAR. Investment in modern imaging technology should be considered in every centre providing endovascular management of aortic aneurysms.

Riassunto Il trapianto renale e il miglior metodo per ripristinare la funzionalita renale e presenta attualmente dei tassi di sopravvivenza dell’organo trapiantato del 92,2% e del 76,8% a, rispettivamente, uno e cinque anni. Le complicanze vascolari secondarie all’intervento chirurgico spiegano una parte della perdita dei trapianti renali e possono verificarsi in tutte le fasi, dal prelievo renale a diversi anni dopo il trapianto. L’imaging e, in particolare, l’ecografia Doppler svolgono un ruolo importante nella loro prevenzione, nella loro diagnosi e nel loro follow-up. La maggior parte delle complicanze vascolari che si verificano durante il primo mese e dovuta a un difetto tecnico durante il confezionamento delle anastomosi vascolari o a un problema di posizionamento dell’organo trapiantato. Una tecnica chirurgica rigorosa e un apprezzamento della ricolorazione dell’organo in tutte le fasi dell’intervento sono essenziali. Le complicanze piu gravi sono le rotture arteriose spesso di origine settica, che possono essere pericolose per la vita. La stenosi dell’arteria del rene trapiantato e la piu frequente complicanza postoperatoria tardiva, il cui trattamento si basa attualmente sui metodi endovascolari. La conoscenza, la prevenzione e le modalita di gestione di queste complicanze vascolari devono far parte del dominio di competenza di un chirurgo vascolare.

ObjectiveA significant decrease in aneurysm related survival is observed at long term follow up after infrarenal endovascular aneurysm repair (EVAR) compared with open repair. Therefore, longer term results with new generation endografts are essential. The aim of this post-approval French multicentre prospective observational study (EPI-ANA-01) was to evaluate the technical success and five year mortality and secondary intervention rates of the third generation AnacondaTM endograft.MethodsFrom June 2012 to October 2013, 176 consecutive unruptured infrarenal abdominal aortic aneurysms were included (160 male patients, mean age 75.3 ± 8.4 years). Survival, freedom from type Ia endoleak, limb events, and re-interventions were estimated using the Kaplan–Meier method. Anatomical and clinical characteristics were compared according to the occurrence of migration, conversion, adverse limb events, endoleak, and sac enlargement.ResultsThe primary technical and clinical success rates were 98.3% and 94.9%, respectively. A hostile neck was identified in 33.9% of patients and 10.7% were treated outside instructions for use (IFU). An early post-operative (≤30 days) mortality rate of 1.7% was observed. At one and five years, respectively, the overall survival rate was 94.9% and 65.9% (aneurysm related in four patients [2.3%]) and the clinical success rate was 90.9% and 70.6%. Secondary interventions were performed in 35 of 176 patients (19.9%). The overall limb occlusion rate was 7.9% and the aneurysm sac diameter decreased significantly (pre-operative diameter 53.9 ± 8.6 mm vs. 42.3 ± 14.7 mm at five years; p < .001). Patients treated outside the instructions for use (IFU) had significantly higher rates of migration, surgical conversion, and aneurysm sac expansion (p = .03).ConclusionThe Anaconda endograft provides high technical success and satisfactory five year aneurysm exclusion and clinical success rates. However, implantation outside the IFU should be avoided, as it leads to significantly worse outcomes, and caution over the risk of limb occlusion and distal embolisation should be observed.

Objectives The objective of this study was to comprehensively evaluate the pathology of acute and chronic femoral stenting in symptomatic atherosclerotic patients and to understand the causes of stent failure (SF) using multimodality imaging including micro–computed tomography. Background Although the pathology of coronary stenting has been well studied, the pathology of lower extremity femoral stenting remains poorly understood. Methods Twelve stented femoral lesions removed at surgery (n = 10) and at autopsy (n = 2) were obtained from 10 patients (median age 74 years; interquartile range [IQR]: 66 to 82 years) with histories of peripheral artery disease (critical limb ischemia in 7) (7 men and 3 women). All specimens underwent radiography, micro–computed tomography, and histological assessment. Results The median duration of implantation was 150 days (IQR: 30 to 365 days), the median stent diameter was 5.90 mm (IQR: 5.44 to 7.16 mm), and the median stent length was 39.5 mm (IQR: 27 to 107.5 mm). Of the 12 stented lesions, 2 had drug-eluting stents, and 10 had bare-metal stents. SF was observed in 8 of 12 lesions. The major cause of SF was acute thrombosis (6 of 8), but causes varied (delayed healing, stent underexpansion, false lumen stenting, and fracture), and 2 had restenosis. Stent fractures were observed in 3 cases by micro–computed tomography. Both drug-eluting stents, implanted for >1 year, showed delayed healing with circumferential peristrut fibrin deposition and SF. Conclusions This histological study is the first to examine the pathological cause of SF. Stent thrombosis was the major cause of SF. Delayed healing was a common feature of bare-metal stents implanted for 1 year, showed delayed healing.

Introduction Common femoral artery aneurysm is a rare condition and can be treated by open or endovascular surgery. There is a general understanding that open surgery is the recommended option because of the anatomical location and the biomechanical constraints posed by hip flexion. Report The case of a 66 year old man treated with an endograft for an asymptomatic abdominal aortic aneurysm followed by the implantation of a nitinol covered stent graft (Fluency™, Bard Peripheral Vascular, Temple, AZ) for a 25 mm diameter left common femoral artery aneurysm is reported. Two years later, follow up revealed a rupture of the nitinol covered stent graft, requiring an open iliofemoral reconstruction. Discussion Systematic analysis with protocolised cleaning, and macroscopic and microscopic evaluation (Keyence VHX-600 digital microscope) of the explanted nitinol covered stent graft showed membrane perforation at the level of an acute angle formed by the struts.

Early diagnosis and prompt management of acute mesenteric ischaemia (AMI) are key to survival but remain extremely difficult, due to vague and non-specific symptoms. Serum lactate (SL) is commonly presented as a useful biomarker for the diagnosis or prognosis of AMI. The aim of our study was test SL (1) as a diagnostic marker and (2) as a prognostic marker for AMI.This was an ancillary multicentre case-control study. Patients with AMI at intensive care unit (ICU) admission were included (AMI group) and matched to ICU patients without AMI (control group). SL was measured and compared on day 0 (D0) and day 1 (D1). Diagnosis and prognosis accuracy were assessed by receiver operating characteristic (ROC) and their area under the curve (AUC).Each group consisted of 137 matched ICU patients. There was no significant difference of SL between the two groups at D0 or at D1 (p = 0.26 and p = 0.29 respectively). SL was a poor marker of AMI: at D0 and D1, AUC were respectively 0.57 [0.51; 0.63] and 0.60 [0.53; 0.67]. SL at D0 and D1 correctly predicted ICU mortality, independently of AMI (AUC D0: 0.69 [0.59; 0.79] vs. 0.74 [0.65; 0.82]; p = 0.51 and D1: 0.74 [0.64; 0.84] vs. 0.76 [0.66; 0.87]; p = 0.77, respectively, for control and AMI groups].SL has no specific link with AMI, both for diagnosis and prognosis. SL should not be used for the diagnosis of AMI but, despite its lack of specificity, it may help to assess severity.

Introduction The detection of acquired arteriovenous fistulas (AVFs) is mostly incidental. However, the modification of haemodynamic conditions secondary to AVFs can lead to dramatic systemic complications, including cardiac complications. In this report, two unusual cases of congestive heart failure secondary to acquired AVF are presented. Report A 40 year old man with past history of gunshot wound of the right flank complained of severe right limb swelling and shortness of breath. An AVF between the right external iliac artery and external iliac vein responsible for the cardiac failure was diagnosed. A 40 year old woman with past history of spinal surgery complained of breathlessness and lower limb oedema. She presented with recurrent episodes of ascites and dyspnoea. An AVF between the right common iliac artery and the common iliac vein responsible for high output cardiac failure was diagnosed. Open surgery was performed in both patients and treatment of the AVFs led to the resolution of all symptoms. Follow up at four and three years, respectively, was uneventful in both cases. Discussion Although rare, heart failure secondary to an AVF can be encountered. These rare cases highlight the significance of careful inquiry into the patient's medical history and meticulous follow up physical examinations for patients with injuries in close proximity to vessels., Highlights • The diagnosis of iatrogenic arteriovenous fistula (AVF) is usually delayed. • Heart failure due to iatrogenis AVF is rare. • Routine physical examination can allow correct diagnosis and appropriate treatment.

Objective: Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments. Methods: Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft. Results: The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m2 (range, 23-26.4 kg/m2). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs. Conclusions: Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair. Keywords: Robotic vascular surgery, Hybrid graft, Iliac aneurysm, Laparoscopic

Objective Type B acute aortic syndrome (AAS) encompasses aortic dissection (AD) and intramural haematoma (IMH), the diagnosis, evolution, and treatment of which are subject to controversies. The aim of this pilot investigation was to assess the ability of specific magnetic resonance imaging (MRI) criteria to differentiate AD from IMH and predict optimal aortic remodeling following AAS. Methods In this retrospective study, all patients presenting between 2008 and 2015 with type B AAS, who had diagnostic MRI following admission, were included. Three MRI criteria were proposed to identify IMH: (i) no visualised entry tear; (ii) no contrast uptake in the aortic lesion on the first pass angiographic run; (iii) no contrast uptake in the aortic lesion on the equilibrium phase T1 sequence. On each patient's diagnostic and follow up imaging studies, the volume of (i) false lumen/IMH, (ii) total aorta, and (iii) true lumen were calculated. Using the Wilcoxon signed rank test, the evolution of these volumes according to the presence or absence of the aforementioned criteria were compared. Results Of 39 patients, in seven all MRI criteria were positive (group IMH) and 32 had one or more negative criteria (group AD). Patients with IMH and AD were similar with respect to sex, age, and delay between onset of symptoms and diagnostic and follow up imaging studies. Eighteen patients had a follow up imaging study after a mean period of 11.2 months: six in the IMH group and 12 in the AD group. Lesion volume decrease and relative true lumen volume increase were statistically significant in group IMH (p = .046 and p = .046, respectively), whereas there was a statistically significant increase of lesion volume (p = .008) in the AD group. Conclusion This pilot study proposed three simple MRI criteria to differentiate between AD and IMH. Once prospectively and clinically validated, this could have substantial therapeutic benefits as IMH are likely to heal spontaneously.

Objective The aim of this paper was to provide recommendations for diagnosis and management in the setting of infection following open or endovascular reconstructions of the supra-aortic trunks. Methods A review of the Medline database was performed from 1997 to 2017 by a combined strategy of MeSh terms. Results The literature search identified 49 publications: 36 studies addressing prosthetic material infections and 13 studies addressing stent infections. A total of 140 cases of prosthetic material infections were reported, mostly involving carotid patches. Surgical treatment was mostly based on complete removal of the infected material followed by in situ arterial reconstruction (86 cases, 62.3%). Peri-operative complications included cranial nerve injury in 17 cases (12.5%), stroke in eight (6.7%), bleeding in four (2.9%), re-infection in five (3.6%), and cardiac failure in three cases (2.2%). Stent infections were reported in 12 patients: eight carotid stents, three subclavian stents and one tandem brachiocephalic subclavian stent. Treatment was not described for one case, was conservative in one case, consisted of stent removal with venous reconstruction in six cases, stent removal without reconstruction because of carotid thrombosis in two cases, and carotid embolisation in two cases. Complications included intra-operative death in one case (9.1%), stroke in two (18.2%), reinfection in one (9.1%), bleeding in one (9.1%), and cardiac failure in one case (9.1%). Conclusion Appropriate pre-operative imaging is mandatory and treatment modality should be determined by patient condition. Complete removal of the infected material, followed by in situ arterial reconstruction with venous material seems advisable, despite high morbidity. However, alternative strategies may be considered for fragile and high risk patients. A multidisciplinary approach is mandatory to ensure optimum results.

Objective/background The aim of this study was to investigate whether antioxidant therapy might decrease oxidative stress related deleterious effects in the setting of critical limb ischaemia (CLI). Methods Twenty Swiss mice were submitted to sequential right femoral and iliac ligatures; the left limb served as control. The mice were assigned to two groups: in the first group (no-treatment group, n = 10) no treatment was administered; in the second group (N-acetyl cysteine [NAC] group, n = 10) NAC was administered by dissolution in drinking water for 4 weeks, starting on day 7, when CLI was effective. Clinical and functional scores were assessed by two blinded investigators. Mice were killed on day 40 and mitochondrial respiratory chain complex activities, calcium retention capacity, oxidative stress, and histological analysis were analysed. Results Ischaemic muscles in the no-treatment group showed significantly impaired mitochondrial respiration and calcium retention capacity, with increased production of reactive oxygen species; but no statistical difference was noticed when comparing ischaemic muscles in the NAC group (n = 10) to contralateral muscles (n = 10) and to control muscles in the no-treatment group (n = 10). Ischaemic muscles in the no-treatment group exhibited myopathic features such as wider range in fibre size, rounded shape, centrally located nuclei, and smaller cross sectional areas, but none of these features were observed in contralateral muscles or in NAC-group muscles (ischaemic or controls). Conclusion Targeting inhibition of oxidative stress may be a potential therapeutic strategy for muscle protection in CLI and might be considered as potential adjunctive therapy to revascularisation procedures.

Background The purpose of this study was to report midterm outcomes of open repair (OR) or endovascular repair (ER) of popliteal artery aneurysms (PAAs) and assess if outcomes of patients have changed in the endovascular era. Methods This monocentric and retrospective study included all consecutive patients treated for PAA between January 2004 and December 2016. Before 2010, all patients underwent OR, but ER was available since 2010, and the choice between OR or ER was made on the basis of clinical presentation and preoperative morphological assessment. Survival, primary patency, primary-assisted patency, secondary patency, and limb salvage rates were assessed regarding the surgical way of treatment (OR or ER) or regarding the period of time (before 2010 or since 2010). Results A total of 153 PAA were treated in 126 patients (103 limbs in OR and 50 limbs in ER). Mean follow-up was 3.8 years. Five-year survival was 97.7% for OR and 88.7% for ER. Five-year primary patency was 77.8% and 29.5% for OR and ER, respectively, primary-assisted patency 85.0% and 49.7%, respectively, and secondary patency 92.8% and 79.6%, respectively. Five-year limb salvage was 89.5% for OR and 87.9% for ER. No outcome difference was observed between patients who underwent surgery before or after ER was available. Conclusions Results of OR and ER in the setting of PAA are satisfactory. Outcomes of patients did not change in the endovascular era.

Background Superficial femoral artery (SFA) remote endarterectomy offers the advantage of preserving anatomy and geometry of the native artery, but the risk of restenosis still exists. The particular role of the adductor canal (AC) in mechanical constraints has been highlighted. The aim of this study was to assess if a surgical protocol associating remote SFA endarterectomy and AC freeing would modify the SFA geometrical changes during physiological limb flexion. Methods From January 2015 to March 2015, 10 patients (Rutherford 3–5) with unilateral SFA occlusion were included. Functional postoperative assessments were performed through duplex ultrasound (DUS) examinations with flow velocity measurements in both straight and flexed positions and anatomical measurements through 3-dimensional computed tomography angiography (CTA) reconstructions with arterial angulations examination. Functional results were compared with similar findings in healthy volunteers, and anatomical results were compared with contralateral limb findings. Results Mean occlusion length was 243.0 ± 17.7 mm. Technical success was achieved in all cases. No difference of peak flow velocities was noticed between operated patients and volunteers. CTA results showed that limb flexion induced SFA shortening in all segments, with a maximal value for the popliteal artery (PA) (10.4 ± 4.4%). Comparisons between the operated and contralateral limbs showed that angles were less sharp during bending in the operated limb. Conclusions This preliminary study demonstrates that freeing the AC modifies the biomechanical properties of the SFA. These results could potentially help in proposing future hybrid techniques that could improve technical performances for SFA occlusive disease treatment.

Objectives: The IN.PACT Global Study is the largest prospective, multicenter, independently adjudicated trial to evaluate a paclitaxel drug-coated balloon in patients with lifestyle-limitin...

Ischemia-reperfusion, which is characterized by deficient oxygen supply and subsequent restoration of blood flow, can cause irreversible damage to tissue. The vascular surgeon is daily faced with ischemia-reperfusion situations. Indeed, arterial clamping induces ischemia, followed by reperfusion when declamping. Mechanisms underlying ischemia-reperfusion injury are complex and multifactorial. Increases in cellular calcium and reactive oxygen species, initiated during ischemia and then amplified upon reperfusion are thought to be the main mediators of reperfusion injury. Mitochondrial dysfunction also plays an important role. Extensive research has focused on increasing skeletal muscle tolerance to ischemia-reperfusion injury, especially through the use of ischemic conditioning strategies. The purpose of this review is to focus on the cellular responses associated with ischemia-reperfusion, as well as to discuss the effects of ischemic conditioning strategies. This would help the vascular surgeon in daily practice, in order to try to improve surgical outcome in the setting of ischemia-reperfusion.

Objective Endovascular recanalization is considered first-line therapy for chronic central venous occlusion (CVO). Unlike arteries, in which landmarks such as wall calcifications provide indirect guidance for endovascular navigation, sclerotic veins without known vascular branching patterns impose significant challenges. Therefore, safe wire access through such chronic lesions mostly relies on intuition and experience. Studies have shown that magnetic resonance venography (MRV) can be performed safely in these patients, and the boundaries of occluded veins may be visualized on specific MRV sequences. Intraoperative image fusion techniques have become more common to guide complex arterial endovascular procedures. The aim of this study was to assess the feasibility and utility of MRV and intraoperative cone-beam computed tomography (CBCT) image fusion technique during endovascular CVO recanalization. Methods During the study period, patients with symptomatic CVO and failed standard endovascular recanalization underwent further recanalization attempts with use of intraoperative MRV image fusion guidance. After preoperative MRV and intraoperative CBCT image coregistration, a virtual centerline path of the occluded segment was electronically marked in MRV and overlaid on real-time two-dimensional fluoroscopy images. Technical success, fluoroscopy times, radiation doses, number of venograms before recanalization, and accuracy of the virtual centerline overlay were evaluated. Results Four patients underwent endovascular CVO recanalization with use of intraoperative MRV image fusion guidance. Mean (± standard deviation) time for image fusion was 6:36 ± 00:51 mm:ss. The lesion was successfully crossed in all patients without complications. Mean fluoroscopy time for lesion crossing was 12.5 ± 3.4 minutes. Mean total fluoroscopy time was 28.8 ± 6.5 minutes. Mean total radiation dose was 15,185 ± 7747 μGy/m 2 , and mean radiation dose from CBCT acquisition was 2788 ± 458 μGy/m 2 (18% of mean total radiation dose). Mean number of venograms before recanalization was 1.6 ± 0.9, whereas two lesions were crossed without any prior venography. On qualitative analysis, virtual centerlines from MRV were aligned with actual guidewire trajectory on fluoroscopy in all four cases. Conclusions MRV image fusion is feasible and may improve success, safety, and the surgeon's confidence during CVO recanalization. Similar to arterial interventions, three-dimensional MRV imaging and image fusion techniques could foster innovative solutions for such complex venous interventions and have the potential to affect a great number of patients.

Introduction - Commercially available fenestrated and branched endografts (FBE) using reinforced nitinol ring fenestrations represent the endovascular treatment of choice for thoraco-abdominal aortic aneurysm (TAAA). In situ laser fenestration (INLF) emerges as an innovative and immediately available alternative, which could be less deleterious than mechanical in situ fenestration. However, biomechanical features of INLF are poorly known. Therefore, the aim of this study was to experimentally evaluate the textile damages secondary to INLF. Methods - In a first step, an in vitro bench study consisted in a microscopic textile analysis of textile damages following INLF with various standard endografts. We compared INLF to mechanical fenestration using an 18G needle in two clinical scenarios (with or without tension applied to the fabric, corresponding to a 90mmHg blood pressure). The subsequent hole was dilated using a non-compliant balloon followed by a cutting balloon and stabilized by a balloon-expandable covered stent. Tear and burst strength tests were performed to determine the loss of textile mechanical strength. Leak tests at the stent-fenestration junctions were implemented using a water column. In a second step, an in vivo study evaluating the feasibility and the damages secondary to INLF was performed at the level of the thoraco-abdominal aorta in sheep. Results - In total, 24 stent-graft textile samples (8 Cook, 8 Medtronic and 8 Vascutek) were analyzed in vitro. Primary fenestrated holes morphology differed between mechanical and INLF with all types of textiles, in both clinical scenarios. Following mechanical fenestration, the hole created, resulted in spacing fabric filaments whereas one circular with cauterized edges were observed after INLF. Tear and burst strength tests results, highlighted a 26±4% textile mechanical strength loss after in situ fenestration. A non-significant decrease of 7% of mechanical resistance was observed following INLF compared to mechanical fenestration (p=0.21). For each in situ fenestration technique, a substantial leak rate persisted at the stent-fenestration junction, even after ballooning. This was found both in in vitro and in vivo analyses. Regarding the in vivo study, 14 INLF were performed in 10 sheep using the Vascutek Anaconda, the Cook Zenith Alpha, the Medtronic Endurant II and the Gore Excluder stent-graft textiles in 4, 3, 2 and 1 cases respectively. Technical success of INLF was 80% but all INLF had a satisfactory final morphology once the first hole was successfully created. Mean visceral and renal ischemia durations were 10±2 and 15±3 minutes, respectively. Although sheep aortas were not aneurysmal, no endoleak was detected at completion angiography. Aortic explants demonstrated that failed INLF led to substantial damages of the textile and the native arterial wall. Conclusion - This study demonstrates that in situ fenestration creates substantial textile damages with all available stent-graft textiles, whatever the technique used. However, initial technical success can be obtained in vivo, perhaps thanks to blood viscosity. Complementary fatigue tests are needed to conclude on the long-term effects of INLF, and its non-inferiority to reinforced fenestrations used in commercially available FBE.

During the most aggressive phase of the COVID-19 outbreak in Italy, the Regional Authority of Lombardy identified a number of hospitals, named Hubs, chosen to serve the whole region for highly specialised cases, including vascular surgery. This study reports the experience of the four Hubs for Vascular Surgery in Lombardy and provides a comparison of in hospital mortality and major adverse events (MAEs) according to COVID-19 testing.Data from all patients who were referred to the Vascular Surgery Department of Hubs from 9 March to 28 April 2020 were collected prospectively and analysed. A positive COVID-19 polymerase chain reaction swab test, or symptoms (fever 37.5 °C, upper respiratory tract symptoms, chest pain, and contact/travel history) associated with interstitial pneumonia on chest computed tomography scan were considered diagnostic of COVID-19 disease. Patient characteristics, operative variables, and in hospital outcomes were compared according to COVID-19 testing. A multivariable model was used to identify independent predictors of in hospital death and MAEs.Among 305 included patients, 64 (21%) tested positive for COVID-19 (COVID group) and 241 (79%) did not (non-COVID group). COVID patients presented more frequently with acute limb ischaemia than non-COVID patients (64% vs. 23%; p .001) and had a significantly higher in hospital mortality (25% vs. 6%; p .001). Clinical success, MAEs, re-interventions, and pulmonary and renal complications were significantly worse in COVID patients. Independent risk factors for in hospital death were COVID (OR 4.1), medical treatment (OR 7.2), and emergency setting (OR 13.6). COVID (OR 3.4), obesity class V (OR 13.5), and emergency setting (OR 4.0) were independent risk factors for development of MAEs.During the COVID-19 pandemic in Lombardy, acute limb ischaemia was the most frequent vascular disease requiring surgical treatment. COVID-19 was associated with a fourfold increased risk of death and a threefold increased risk of major adverse events.

Background Delayed graft function (DGF) is an early postoperative complication of kidney transplantation (KT) predisposing to acute rejection and lower graft survival. Intraoperative arterial hypotension and hypovolemia are associated with DGF. Central venous pressure (CVP) is used to estimate volemia but its reliability has been criticized. Pleth variability index (PVI) is a hemodynamic parameter predicting fluid responsiveness. The aim of this study was to examine the relationship between intraoperative PVI and CVP values and the occurrence of DGF. Methods This was a prospective, noninterventional, observational, single-center study. All consecutive patients with KT from deceased donors were included. Recipients received standard, CVP, and PVI monitoring. Intraoperative hemodynamic parameters were recorded from recipients at 5 time points during KT. Results Forty patients were enrolled. There was a poor correlation between PVI and CVP values ( r 2 = 0.003; P = .44). Immediate graft function and DGF patients had similar hemodynamic values during KT, with the exception of PVI values, which were significantly higher in the DGF group. In particular, a PVI >9% before unclamping of the renal artery was the only predictive parameter of DGF in our multivariate analysis ( P = .02). Conclusions This study suggests that PVI values >9% during KT are associated with the occurrence of DGF.

Resume Les dissections aortiques de type B sont des pathologies graves avec une survie a 5 ans comprise entre 60 et 80 %. Bien que relevant classiquement d’un traitement medical, une chirurgie peut s’averer necessaire au stade aigu/subaigu ou chronique dans les formes compliquees de la maladie. L’imagerie, principalement tomodensitometrique, est indispensable dans la selection des patients a operer, la preparation de l’intervention et le suivi post-therapeutique. Les points essentiels de son interpretation doivent donc etre connus des specialistes en charge de ces patients. La malperfusion d’organe est la complication aigue la plus frequente, confirmee par l’imagerie et/ou la biologie. La dilatation anevrysmale du faux chenal est la complication chronique la plus frequente, avec prise en charge chirurgicale indiquee generalement au-dela de 55 mm de diametre axial. Le traitement endovasculaire tend a supplanter la chirurgie ouverte : il necessite des mesures precises et un reperage des portes d’entrees (interet de l’angio-IRM 4D).

Background Mechanical tests assessing Nitinol stents used for the superficial femoral artery (SFA) are designed without taking into account their deployment environments. The objectives of this study were (1) to create normal and pathologic femoral artery models, (2) to run mechanical tests reproducing the stresses of the SFA, and (3) to study and compare Nitinol stents in those conditions. Methods Femoral artery models with identical mechanical properties to the SFA were created using the 3-dimensional printing technology. Those models were designed with and without an asymmetric focal 50% stenosis. Three mechanical tests (bending–compression, bending–compression–torsion, and multiple bending tests) were created and 1 flexible stent was tested, of 6 and 7-mm diameter. Three samples of the stent, LifeStent (Bard®), were deployed and tested in the models. Stents alone were evaluated in the same conditions. The analysis focused on the comparison of rheologic curves, level of kink, and the energy deployed for each stent to kink. Results In the 3 tests, all stents deployed in the models presented a kink during their evaluation. When tested alone, during the compression–bending and bending–compression–torsion tests, no plicature was observed. During the multiple bending test, the energy deployed to plicature for the stent tested alone was of 1.4 ± 0.10 and 2.84 ± 0.1 J compared with 9.7 ± 0.6 and 8.25 ± 0.6 J when deployed in the model for the Lifestent 6 × 80 and 7 × 80 mm, respectively. For all of these 3 tests, 6-mm diameter stents exhibited a level of kink and energy of kink higher than 7 mm stents. The behavior of the stents changed in the stenosed model whatever diameter is taken into account. Analysis of the rheologic curves showed a decrease in the inflection of the curve related to the plication. In the bending–compression test, the presence of a stenosis lead to an early plication of the model, with less deployed kinking energy whereas in the bending, compression, and torsion test, this earliness was absent. Conclusions This study permitted the creation of a mechanical test platform evaluating Nitinol stents in bending situations. It tends to confirm the mechanical deleterious effect of excessive oversizing. This study confirms the necessity to evaluate Nitinol stents in their deployment environments.

Objective/Background The aim of this study was to evaluate long-term outcomes following surgery for popliteal artery entrapment syndrome. Methods A retrospective study of all patients that underwent surgery for popliteal artery entrapment syndrome between January 2003 and December 2009 was performed. Patient demographic data, clinical features, imaging modalities, and surgical management were recorded. The primary outcome was 5 year patency. Results Eighteen patients (25 limbs) underwent surgery. The mean age at the time of surgical procedure was 35 (median 35 years; range 15–49). Presentation was bilateral in seven patients (39%). Diagnosis was made using various imaging modalities, including position stress test, Duplex ultrasonography, computed tomography angiography, magnetic resonance imaging and conventional angiography. In four limbs the popliteal artery was compressed and undamaged (16%), and treatment consisted of musculo-tendinous division alone. In 16 limbs the popliteal artery was damaged with lesions limited to the popliteal artery (64%) where treatment consisted of venous interposition. In five limbs lesions extended beyond the popliteal artery (20%) and procedures included one below knee femoro-popliteal bypass, three femoro-posterior tibial bypasses, and one popliteo-posterior tibial bypass. Musculo-tendinous division was associated with vascular reconstruction in 19 limbs (90%). Mean follow up was 82 months (median 81 months, range 60–120). Five year patency was 84%. Conclusion Long-term outcomes of surgical procedures performed for popliteal artery entrapment syndrome can be considered satisfactory.

The aim was to report the midterm outcome for nonagenarians with critical limb ischemia (CLI) and to identify factors affecting survival or limb salvage rates.Nonagenarians who underwent endovascular surgery (ES), open surgery (OS), or primary amputation (PA) for CLI between 2005 and 2014 were included. Cox regression model identified factors affecting survival and limb salvage.ES was performed in 116 patients (119 limbs), OS in 73 patients (73 limbs), and PA in 54 patients (57 limbs). Mean follow-up was 10.38 months. There was no difference in survival between ES, OS, and PA groups: survival rate was 51.2% at 1 year and 38.9% at 2 years after ES, 48.3% at 1 year and 39.6% at 2 years after OS, and 50.6% at 1 years and 40.8% at 2 years after PA (P = 0.58). There was no difference in limb salvage between ES and OS groups: limb salvage rate was 88.2% and 77.8% at 1 and 2 years after ES and 87.3% and 77.6% at 1 and 2 years after OS. Coronary artery disease (hazard ratio [HR] 1.54; confidence interval [CI] 1.04-1.08; P = 0.01) was risk factor for death. Fully dependent state was risk factor for death (HR 4.2; CI 3.55-4.87; P0.001) and major amputation (HR 5.3; CI 1.32-1.67; P0.001). In fully dependent patients, 1-year and 2-year survival rate was 28.9% and 20.6%, respectively, and 1-year and 2-year limb salvage rate was 61.2% and 44.5%, respectively.With acceptable early and late mortality, limb salvage and maintenance of functional status and level of independent living, revascularization in nonagenarians is effective as long as the patient is not fully dependent.

Background Use of the forearm basilic vein for the creation of an arteriovenous fistula has been codified as second-choice vascular access for hemodialysis in the last clinical guidelines of the Society for Vascular Surgery in 2008. Poor literature data on this technical option and on its evaluation and outcomes led us to initiate a retrospective single-center study. Methods We analyzed the outcomes of every arteriovenous fistula using the forearm basilic vein created in our department. It is a retrospective study in which we collected data prospectively by contacting dialysis centers, nephrologists, and patients. Primary end point was primary patency rate at 1 year. Secondary end points were secondary patency rate at 1 year, time of maturation, and Doppler flow measurement before the first puncture. Results From February 2004 to June 2014, 49 forearm basilic arteriovenous fistulas were created: 33 ulnar-basilic and 16 radial basilic arteriovenous fistulas. Initial technical success rate was 98%. Functional success rate was 60%. Primary and secondary patency rates at 1 year were respectively 21% and 48%. Median time of maturation was 81 days, and mean Doppler flow measurement was 678 mL/min. Ulnar-basilic fistulas had a statistically significant shorter time of maturation than radial basilic fistulas ( P ≤ 0.05). Conclusions Despite poor primary patency rate and a long time of maturation, forearm basilic arteriovenous fistula has satisfactory secondary patency rate and keeps all the advantages of a distal-located vascular access concerning complications. It is worth its second-choice place in the current algorithm of creation of vascular access for hemodialysis.

Ischemia/reperfusion, which is characterized by deficient oxygen supply and subsequent restoration of blood flow, can cause irreversible damages to tissue. Mechanisms contributing to the pathogenesis of ischemia reperfusion injury are complex, multifactorial and highly integrated. Extensive research has focused on increasing organ tolerance to ischemia reperfusion injury, especially through the use of ischemic conditioning strategies. Of morbidities that potentially compromise the protective mechanisms of the heart, diabetes mellitus appears primarily important to study. Diabetes mellitus increases myocardial susceptibility to ischemia reperfusion injury and also modifies myocardial responses to ischemic conditioning strategies by disruption of intracellular signaling responsible for enhancement of resistance to cell death. The purpose of this review is twofold: first, to summarize mechanisms underlying ischemia reperfusion injury and the signal transduction pathways underlying ischemic conditioning cardioprotection; and second, to focus on diabetes mellitus and mechanisms that may be responsible for the lack of effect of ischemic conditioning strategies in diabetes.

Introduction La complication majeure de l’anevrisme de l’aorte abdominale (AAA) est la rupture. Les recommandations retiennent une indication chirurgicale pour les AAA presentant un diametre maximal transverse (DMT) superieur ou egal a 5,5 cm ou les AAA a croissance rapide et reposent sur des etudes de population mais n’integrent pas le risque individuel du patient. Les etudes biomecaniques A. Particularites anatomiques des AAA rompus : les facteurs de risques anatomiques de rupture sont l’absence de tortuosites et l’asymetrie de diametre. Le DTM indexe a la surface corporelle est un facteur predictif de rupture chez la femme. Les techniques d’imagerie actuelles ne permettent pas encore une prediction fiable du risque de rupture des AAA. B. Caracteristiques biomecaniques et structurelles de la paroi arterielle anevrismale : les caracteristiques structurelles de la paroi anevrismale : il existe une rigidite accrue de la paroi anevrismale avec une augmentation relative du collagene et de la substance fondamentale et une diminution de la composante elastique et cellulaire musculaire. Les calcifications modifient les proprietes mecaniques de la paroi. Les faces laterales presenteraient plus de micro-vaisseaux, de cellules inflammatoires, d’activite des proteases et une presence plus elevee de cytokines que les parois anterieures et posterieures. Il existe des differences de structure histologique en fonction du sexe. Les caracteristiques mecaniques de la paroi anevrismale : la paroi de l’AAA est plus rigide et moins elastique que la paroi aortique normale. L’epaisseur de la paroi des AAA rompus serait superieure et la resistance a la rupture inferieure a celle des AAA non-rompus. Le role du thrombus intra-luminal (TIL) Le TIL est considere comme un facteur de risque de croissance rapide de l’AAA. L’epaisseur du TIL anterieur est correlee avec l’apoptose des cellules musculaires lisses vasculaires et la degradation de la composante elastine et a la concentration en MMP-2 dans la paroi aortique. L’epaisseur du TIL diminue la stabilite de la paroi aortique et augmente le risque de rupture. Le TIL presente des caracteristiques mecaniques propres qui expliquent l’augmentation du risque de rupture. Le role du TIL n’a cependant pas ete confirme en clinique. Les modeles mathematiques de prediction de la rupture Les premiers modeles de prediction ont montre que le Peak Wall Stress (PWS) etait significativement superieur pour les AAA en rupture imminente que pour les AAA asymptomatiques. Le PWS calcule pour chaque AAA serait un meilleur facteur predictif de rupture que le DTM. Ces modeles mathematiques doivent inclure un maximum de variables qui influencent significativement le risque de rupture pour pouvoir gagner en precision. Le principe de ne plus considerer unique le DMT de l’AAA pour predire le risque individuel de rupture s’impose de plus en plus comme realiste.