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Background Despite promising early results, mid-term failures of the Nellix endovascular aneurysm sealing (EVAS) system (Endologix Inc, Irvine, Calif) have been reported at higher than expected rates. The management of proximal endoleaks and migration differs from those after conventional endovascular aortic aneurysm repair (EVAR) owing to the peculiar design of the Nellix device. In the present study, we report a monocentric experience in the management of EVAS complications using various techniques. We also performed a comprehensive review of the relevant literature on both open surgical and endovascular management of proximal failure of EVAS from the MEDLINE database. Methods We retrospectively analyzed the reinterventions for type Ia endoleak and migration after elective infrarenal EVAS at our institution. We collected preoperative, intraoperative, and follow-up data. Open and endovascular techniques are described. Overall survival, aortic-related mortality, and the technical success rate (rate of exclusion of endoleaks) with endovascular techniques were the primary outcomes. Results We performed 101 infrarenal elective EVAS procedures from 2013 to 2018. Of the 101 patients, 20 (19.8%) had required reintervention for proximal sealing failure. The indications were type Ia (Is2, Is3) endoleak, migration >5 mm, sac expansion >5 mm, and secondary rupture. Of the 20 patients, 6 (30%) were treated with endovascular techniques—2 with a chimney Nellix-in-Nellix application and 4 with proximal relining with a covered stent. The remaining 14 patients (70%) were treated with late open conversion (OC). The average time from EVAS to reintervention was 36.1 months (range, 3-65 months). Six patients (30%) had undergone OC in an emergent setting because of secondary rupture. The technical success rate for the patients treated with endovascular reinterventions was 100%. The 30-day mortality was 20% (4 of 20), all emergent cases (four of six emergent repairs; 67%). The overall survival for the 20 patients was 75% (n = 15) at a mean follow-up of 15.1 months (range, 2-47 months). One patient had died after 7 months of non–aortic-related causes. Conclusions The high reintervention rate of the Nellix graft mandates careful evaluation for its further use with the revised instructions for use, and it should not be used off-label. OC remains the strategy of choice when managing Nellix proximal sealing failures in fit patients. Chimney Nellix-in-Nellix application and transcatheter embolization are feasible alternative techniques. Proximal relining also appears to be an effective alternative to more complex interventions, although it requires further studies for validation.

Summary Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding UK Medical Research Council and Health Technology Assessment Programme.

Background Acute lower limb ischemia (ALLI) poses a major threat to limb survival. For many years, surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution to the management of ALLI. It seems that the newly designed endovascular thrombectomy devices may shift treatment recommendations toward endovascular options. This protocol study aims to collect evidence supporting the latest hypothesis. Objective The devices under investigation are the Penumbra/Indigo Systems (Penumbra Inc). The objective of this clinical investigation is to evaluate, in a controlled setting, the early safety and effectiveness of the devices and to define the optimal technique for the use of these systems in patients with confirmed peripheral acute occlusions. Methods This study will be an interventional prospective trial of patients with a diagnosis of ALLI treated with Penumbra/Indigo devices. This project is intended to be a national platform where every physician invited to participate could register his or her own data procedure. The primary outcome is the technical success of thromboaspiration with the Indigo System. Assessment of vessel patency will be recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications before and after use of the device. Clinical success at follow-up is defined as an improvement of Rutherford classification at 1-month follow-up of one class or more as compared to the preprocedure Rutherford classification. Secondary endpoints include the following: (1) safety rate at discharge, defined as the absence of any serious adverse events; (2) primary patency at 1 month, defined as a target lesion without a hemodynamically significant stenosis or reocclusion on duplex ultrasound (>50%) and without target lesion reintervention within 1 month; and (3) limb salvage at 1 month. Results The study is currently in the recruitment phase and the final patient is expected to be treated by the end of March 2019. A total of 150 patients will be recruited. Analyses will focus on primary and secondary endpoints. Conclusions These new endovascular thrombectomy devices that are specifically designed for peripheral intervention in this difficult set of patients, as those under investigation in the proposed registry, may offer improved clinical outcomes with lower rates of major systemic and local complications. Following completion of this study, it is expected that the value of the Indigo Thrombectomy System in the treatment of ALLI will be better defined. As a result, a shift of treatment recommendations toward endovascular options may be observed in the near future. International Registered Report Identifier (IRRID) DERR1-10.2196/9972

International audience; Flow-induced vibrations in a pressurized water reactor (PWR) core can cause fretting wear in fuel rods. These vibrations can compromise safety of a nuclear reactor. So, it is necessary to know the random fluctuating forces acting on the rods which cause these vibrations. In this paper, simplified 3D models like square spacer grid, circular spacer grid and symmetric mixing vanes have been used inside an annular pipe. Hydrodynamic and wall pressure characteristics are evaluated using large eddy simulations (LES). Structured meshes are generated as far as possible. Simulations are compared with an experiment. Results show that the grid and vanes have a combined effect: grid accelerates the flow whereas the vanes contribute to the swirl structures. Spectral analysis of the simulations illustrate vortex shedding phenomenon in the wake of spacer grids. This initial study opens up interesting perspectives towards improving the modeling strategy and understanding the complex phenomenon inside a PWR core. (C) 2017 Elsevier B.V. All rights reserved.

Despite the improvement in diagnostic and therapeutic strategies, the treatment of thoracoabdominal aneurysms is still burdened with a high incidence of peri/postoperative morbidity and mortality. The multilayer flow modulator is a new and promising technique for the treatment of such disease; however, some limits are still evident. We report the case of a 76-year-old woman affected by a symptomatic thoracoabdominal aneurysm treated with multiple Cardiatis multilayer flow modulators complicated by aortic arch rupture on the fifth postoperative day, with subsequent patient death.

Background The endovascular treatment of an abdominal aortic aneurysm (AAA) is a treatment with low risk and good reported results. This retrospective study analyzed experience with patients requiring surgical conversion after endovascular abdominal aortic aneurysm repair (EVAR). Methods A total of 26 patients underwent open conversion (OC) after EVAR (18 endografts implanted at the authors' center and 8 in other centers). Patients were divided into 2 groups: early conversion if OC was performed within 30 days from the primary EVAR, and late conversion if OC was performed at least 30 days after EVAR. The authors analyzed all data on OC and the postoperative course. Results In this series, OC was performed for 22 endoleaks (13 type I, 5 type II, 2 type III, and 2 type V, which in 5 cases these were associated with AAA ruptures), 2 renal artery coverages, and 2 endograft infections. Six (23%) patients underwent early conversion with a mortality rate of 50%, and 20 (77%) had late conversion with a mortality rate of 20%. The overall mortality rate after OC, occurring before hospital discharge or within 30 days, was 26.9% (7 of 26). Conclusions Endoleaks remain the weak point of endografts and can result in aneurysm rupture/death. Urgent OC and infections engender a high mortality. Elective OC can be performed with very low mortality and acceptable morbidity. Lifelong surveillance is necessary to detect and treat endoleaks.

To report midterm failure of tandem peripheral multilayer stents used to treat a common hepatic artery aneurysm (HAA) that had a good early result.A 71-year-old man with multiple comorbidities had a 3.4-cm HAA treated with 2 Cardiatis peripheral multilayer stents (8×100 and 9×60 mm) that overlapped by 3 cm. At the 12-month follow-up, the stents were patent, with signs of collateral patency and full thrombosis of the aneurysm sac without expansion. At the 18-month visit, the sac had expanded to 4.5 cm without signs of revascularization, but there was an initial stent dislocation; a wait and watch approach was elected. On the 24-month imaging, the HAA had enlarged to 6 cm, with disconnection of the 2 stents. A new multilayer stent (9×100 mm) was positioned to "bridge" the gap; however, the proximal part of the new stent did not correctly expand despite multiple attempts to overcome the infolding. The 3 stents became completely thrombosed, but thanks to rich mesenteric collaterals, perfusion of the proper hepatic artery was adequate.The multilayer peripheral stent appears to be an alternative for the treatment of visceral aneurysms in patients with a high surgical risk, but it is not a conventional stent. There are unknowns about its function, behavior, and application. Therefore, more experience is needed to validate the effectiveness of the multilayer stent.

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

The objective of this study was to evaluate the results of the off-label use of the Nellix endograft (Endologix, Irvine, Calif) for the treatment of short-neck aneurysms and juxtarenal aortic aneurysms (JAAs) compared with the outcomes of patients with infrarenal abdominal aortic aneurysms treated in accordance with the manufacturer's instructions for use.Data available from patients treated with the Nellix endograft from September 2013 to January 2016 were reviewed to create a case-control analysis (1:2). Fourteen elective patients with a short-neck aneurysm or JAA (10 mm) and mild aortic neck angulation (35 degrees) were included. As a control group, 28 elective patients who had been treated in accordance with instructions for use were included. Patients were matched for age, sex, aortic diameter, and aortic neck angulation. The final cohort group included 42 patients: 14 in the JAA off-label group (5 with aortic neck length ≤4 mm and 9 with necks of 5 to 10 mm) and 28 in the control group. Technical and clinical success, freedom from any secondary intervention, any type of endoleak, and aneurysm-related death were evaluated.There were no significant differences between the two groups in terms of comorbidity, intraoperative time, radiation time, contrast agent volume, and perioperative mortality and morbidity. Two patients of the JAA group subsequently underwent open repair (14%), both with aortic neck length 4 mm (2/5; 40%), for type Ia endoleak. Two of the control group also subsequently underwent open repair (7%). At a mean follow-up of 22 ± 3.9 months, freedom from any reintervention was 85% for the JAA off-label group vs 92% for the control group (log-rank test, P = .33).The off-label use of the Nellix endograft for the treatment of JAA showed a higher rate of subsequent conversion to open repair for JAA patients (aortic neck length ≤4 mm), underlining the need for a proximal sealing zone. Longer term data are needed to verify the possible use of the Nellix endograft in selected short-neck aneurysms with aortic neck length5 mm.

Objective Because of advances in technology and experience of the operator, endovascular aneurysm repair (EVAR) has supplanted open repair to treat abdominal aortic aneurysm (AAA). The low 30-day mortality and morbidity of EVAR make the endovascular approach particularly suitable for patients at high surgical risk. However, endoleak or endograft migration requiring secondary intervention or open surgical conversion is a limitation of EVAR. The Nellix system (Endologix, Inc, Irvine, Calif) has been designed to seal the entire AAA to overcome these limitations with EVAR. We report the results of a retrospective, multicenter study with endovascular aneurysm sealing (EVAS) aimed to assess technical success, procedure-related mortality, complications, and reinterventions. Methods This study included patients selected for elective treatment with the Nellix device per the endovascular repair protocol at 16 Italian vascular centers. All patients were enrolled in a postoperative surveillance imaging program including duplex ultrasound investigations, computed tomography, and magnetic resonance controls following local standards of care. Results From 2013 to 2015, there were 335 patients (age, 75.5 ± 7.4 years; 316 men) who underwent elective EVAS. In 295 cases (88.0%), EVAS was performed under standard instructions for use of the Nellix system. Preoperative aneurysm diameter was 55.5 ± 9.4 mm (range, 46-65 mm). The inferior mesenteric artery and lumbar arteries emerging from the AAA were patent in 61.8% and 81.3% of cases, respectively. Chimney grafts were electively carried out in eight cases (2.4%). One (0.3%) intraprocedural type IB endoleak was observed and promptly corrected. Device deployment was successful in all patients, with no perioperative mortality. Early (≤30 days) complications included 1 (0.3%) type IA endoleak, 2 (0.6%) type II endoleaks (0.6%), 2 (0.6%) stent occlusions (0.6%), 3 (0.9%) distal embolizations, and 2 (0.2%) femoral artery dissections. Six (2.9%) patients underwent reinterventions. At 1-year follow-up, complications included 3 (1.1%) type II endoleaks, 4 (1.4%) type IA endoleaks, 1 (0.3%) type IB endoleak, 2 (0.7%) distal stent migrations, 5 (1.8%) distal embolizations, and 1 (0.3%) stent occlusion. Twelve patients (3.7%) underwent reinterventions, including four (1.4%) surgical conversions due to aortoduodenal fistula (1), endograft infection (1), and type IA endoleak that was unsuccessfully treated percutaneously (2). Two AAA-related deaths occurred. Freedom from aneurysm-related reintervention was 98.3% at 1-month and 94.7% at 12-month follow-up. Conclusions The preliminary results of this real-world multicenter study showed that EVAS with Nellix for the management of AAAs appears feasible. This device platform is associated with acceptable procedure-related mortality and low overall complication and reintervention rates. Definitive conclusions on the value of this novel device await long-term follow-up data.

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Purpose: To report midterm outcomes of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the treatment of abdominal aortic aneurysm (AAA). Methods: Between September 2013 and July 2014, 64 AAA patients (mean age 76.6±6.8 years; 61 men) were treated with the EVAS system at 2 centers (only procedures performed at least 12 months prior to the analysis were included). Most patients were treated for a stable AAA, while 1 patient was treated for a ruptured aneurysm. Mean aneurysm diameter was 57.3±9.3 mm. The proximal neck measured a mean 21.5±3.3 mm in diameter and 27.0±12.1 mm long; the neck angle was 16.9°±19.3°. Eleven (17.2%) patients were treated outside the instructions for use (IFU). Results: Technical success was achieved in 63 (98.4%) of 64 patients; 1 type Ia endoleak was treated intraoperatively. One (1.6%) aneurysm-related death occurred at 4 months due to a secondary aortoenteric fistula. Overall, endoleaks occurred in 3 (4.7%) patients (2 type Ia, 1 type II). The estimated rates for 18-month overall survival, freedom from aneurysm-related death, and freedom from secondary interventions were 92.7%, 98.4%, and 95.0%, respectively. Patients treated outside the IFU had a significantly higher incidence of device-related complications (p=0.03). Conclusion: The use of the Nellix device in everyday clinical practice is safe and offers promising midterm results. The risk of secondary aortoenteric fistula requires further analysis. Longer follow-up is needed to assess the actual efficacy of the device, although the risk of migration with late endoleak seems low.

Entre 2000 et 2010, 32 patients (17 hommes ; âge moyen : 64,7 [extremes 18-85 ans) avec des anevrysmes d’arteres viscerales (AAVs) ont ete traites dans notre centre. Le site de la maladie anevrismale etait : l’artere splenique (18), l’artere hepatique (5), l’artere mesenterique superieure (3), l’artere pancreatico-duodenale (3), le tronc cœliaque (2), et (1) l’artere gastroduodenale. Six patients (18,75%) se sont presentes avec une rupture anevrysmale. Neuf cas ont recu un traitement endovasculaire. Le succes technique primaire etait obtenu chez six patients. Les echecs incluaient un cas d'occlusion de stent immediate, une migration de stent, et une tentative d'embolisation. Dans 24 cas, le traitement chirurgical etait realise avec succes. Le taux de survie global etait de 90,6% (en urgence : 75% ; electif : 95,8%). Les resultats etait corrects apres une periode de suivi de 34,7 mois (extremes : 2-117 mois). En raison du risque potentiel de rupture, les AAVs devraient etre traite. Une nouvelle technologie endovasculaire basee sur un stent multicouche a pu nous fournir une alternative au traitement des AAVs, garantissant la thrombose du sac anevrysmal et la perfusion correcte des organes. Cependant, cette nouvelle technologie n'est pas adaptee a tous les anevrysmes et necessite une formation specifique et une courbe d'apprentissage. Chez les sujets avec un faible risque chirurgical, la chirurgie garantit une reparation definitive et durable avec une bonne perfusion d'organe.

Objectifs Le thrombus libre flottant de l'artere carotide interne (TLF-ACI) est rare et sa vraie incidence est inconnue. L'etiologie la plus commune est la complication d'une plaque atheromateuse, mais plusieurs conditions medicales peuvent etre responsables. Le but de cette etude etait d'analyser retrospectivement notre experience de l'endarteriectomie carotidienne dans la gestion des TLF-ACI et d'analyser les resultats. Methodes Une revue retrospective a ete faite sur tous les patients admis pendant les 9 dernieres annees avec un diagnostic de TLF-ACI. La demographie, les manifestations cliniques, les modalites diagnostiques, les indications chirurgicales, les details operatoires, les suites postoperatoires, et le suivi ont ete enregistres dans la base de donnees de l'hopital. Resultats Entre janvier 2000 et decembre 2008, dans notre unite, 2.572 endarteriectomies carotidiennes ont ete faites pour lesion de l'artere carotide. Un total de 16 patients (16 sur 2.572 ; 0,62%) ont ete traites pour un TLF-ACI. En tout, 87,5% (14 sur 16) patients avaient eu des symptomes neurologiques. Tous les patients ont eu un examen duplex. Dans 75% (12 de 16) de cas, des examens diagnostiques additionnels ont ete faits : angiographie numerique en soustraction (ANS), angiographie par resonance magnetique, ou scanner. Le duplex et l'ANS ont detecte le TLF-ACI dans 62,5% et 100% des cas, respectivement. Le scanner et l'angiographie par resonance magnetique n'ont pas fourni de diagnostic chez la majorite des patients (33,4% et 66,7%, respectivement). La presence d'un TLF-ACI a ete confirmee en peroperatoire dans tous les cas. Le taux cumulatif d'AVC apres chirurgie etait de 6,3% (un sur 16). Parmi tous les patients sortis, 68,75% montraient une amelioration des symptomes neurologiques, 12,5% etaient asymptomatiques, 12,5% n'avaient aucun changement des symptomes, et 6,25% des cas etaient aggraves. Au suivi de 30 jours, le taux de survie etait de 93,7% et 75% des patients avaient une amelioration des symptomes neurologiques, 12,5% etaient asymptomatiques, et 6,25% etaient morts. En tout, 6,25% des patients ont ete perdus de vue. Conclusion Les patients avec TLF-ACI sont habituellement symptomatiques et se presentent en urgence. Le duplex demeure l'examen diagnostic de reference pour detecter les TLF-ACI. Nous ne pouvons pas affirmer que la chirurgie precoce est superieure a l'anticoagulation provisoire et/ou a l'intervention differee en raison de l'absence d'un groupe controle. Cependant, nos resultats retrospectifs suggerent que l'intervention rapide est une alternative sure dans le traitement des TLF-ACI.

Introduction Cette etude retrospective unicentrique sequentielle comparait les resultats de l’endarteriectomie carotidienne (EAC) sous anesthesie generale a l’EAC sous anesthesie generale. Methodes De Novembre 2002 a Octobre 2004, 428 EACs etaient realisees dans notre unite vasculaire. Deux groupes etaient formes : groupe AG (anesthesie generale) : 219 patients operes sous anesthesie generale ; groupe AL (anesthesie locale) : 209 patients operes sous anesthesie locale. Resultats Il n’y avait aucun deces dans les deux groupes. Apres chirurgie, trois accidents vasculaires constitues etaient notes dans le groupe AG et trois dans le groupe AL (AG 1,36% vs. AL 1,43%, p = 0,9540) ; Apres EAC, il y avait trois AITs dans le groupe AG et aucun dans le groupe AL (AG 0,42% vs. AL 0%, p = 0,2634). Conclusion La morbi-mortalite n’etait pas influencee par le type d’anesthesie utilisee en chirurgie carotidienne. Aucune difference statistique n’etait detectee en termes de taux de complications neurologiques et cardio-pulmonaires entre l’AG et l’AL.

The early risk of stroke after transient ischemic attack (TIA)/stroke is of the order of 5-10% at 1 week and 10-20% at 3 months. Even if carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery stenosis, the timing of carotid intervention after acute stroke is not yet codified. The authors want to determinate whether early CEA is safely carried out in the first few hours (48 hours) successive to the nondebilitating neurological event and whether the outcome (TIA/stroke/death) in these cases is comparable with the results of those treated by delayed/deferred surgery (range, 48 hours-24 weeks).In 4 years, the authors performed 1,184 CEA (285 symptomatic). Five groups were formed from 285 symptomatic patients, according to interval between TIA/stroke onset and performance of CEA: G1, less than 48 hours; G2, 48 hours-2 weeks; G3, 2-4 weeks; G4, 4-8 weeks; G5, 8-24 weeks. Surgery was never performed on patients with disabling neurological deficit (modified Rankin Scale, 5) at the time of admittance, cerebral lesions greater than 3 cm at magnetic resonance/computed tomography scan, presence or suspect of parenchymal hemorrhage associated with ischemic damage, condition considered unfit for surgery (American Society of Anesthesiology classification grade V), and occlusion of the cerebral middle artery. Neurological and diagnostic examinations (duplex-scanning and computed tomography/magnetic resonance scan) were used in determining the selection for early CEA.Cumulative TIA/stroke/death rate after CEA was 3.8% (11/285) and at 30 days was 2.8% (8/285). The cumulative TIA rate after CEA and at 30 days was 0% (0/285). The cumulative stroke rate after CEA was 3.5% (10/285) and at 30 days was 2.4% (7/285). The cumulative death rate after CEA and at 30 days was 0.3% (1/285). Stroke rate after CEA in each group was: G1 4.2% (3/70); G2 3.2% (2/61); G3 0% (0/22); G4 3.4% (1/29); G5 3.8% (4/103). Any statistically significant difference between G1 and the other four groups was not detected with regard to postoperative stroke: G1 (4.2%) versus G2 (3.2%), p = 0.7641; G1 (4.2%) versus G3 (0%), p = 0.7648; G1 (4.2%) versus G4 (3.4%), p = 0.8473; G1 (4.2%) versus G5 (3.8%), p = 0.8952. No hemorrhagic stroke was detected after early CEA. The type of anesthesia and the use of a shunt didn't show any significant difference between the five groups.The analysis of these records suggests that early CEA in the acute post stroke phase, for patients clinically selected, does not result in greater complications than when performed delayed or deferred . Furthermore, the advantage of early CEA is the reduction of recurrent strokes, as untreated patients present a higher incidence of neurological events.

Objectif Le risque precoce de survenue d’un accident vasculaire cerebral apres un accident ischemique transitoire (AIT)/accident vasculaire cerebral (AVC) varie entre 5 et 10% a une semaine et 10 et 20% a trois mois. Bien que l’endarteriectomie carotidienne (EAC) soit le traitement de choix des stenoses symptomatiques de l’artere carotide interne, le delai de realisation des interventions carotidiennes apres un accident vasculaire aigu n’est toujours pas codifie. Les auteurs ont voulu determiner si une EAC precoce pouvait etre realisee de maniere sure au cours des premieres heures ( Methodes En quatre ans, les auteurs ont effectue 1184 EAC (285 symptomatiques). Cinq groupes ont ete formes a partir des 285 patients symptomatiques, selon l’intervalle separant la survenue de l’AIT (accident cerebral) et la realisation de l’EAC : G1, moins de 48 heures ; G2, 48 heures-2 semaines ; G3, 2-4 semaines ; G4, 4-8 semaines ; G5, 8-24 semaines. La chirurgie n’a jamais ete effectuee lorsque les patients presentaient des deficits neurologiques invalidants (echelle de Rankin modifiee, 5) a l’admission, des lesions cerebrales superieures a 3 cm sur l’IRM ou le scanner, presence ou suspicion d’hemorragie parenchymateuse associee aux lesions ischemiques, patients consideres comme mauvais candidats a la chirurgie (classification de l’American Society of Anesthesiology grade V) et en cas d’occlusion de l’artere cerebrale moyenne. Des examens neurologiques et diagnostiques (echographie Doppler et scanner/IRM) ont ete utilises pour selectionner les candidats a l’EAC precoce. Resultats Le taux cumulatif AIT/AVC/deces apres EAC a ete de 3,8% (11/285) et de 2,8% (8/285) a 30 jours. Le taux cumulatif d’AIT apres EAC et a 30 jours a ete de 0% (0/285). Le taux cumulatif d’AVC apres EAC a ete de 3,5% (10/285) et a 30 jours de 2,4% (7/285). Le taux cumulatif de deces apres EAC et a 3 jours a ete de 0,3% (1/285). Le taux d’AVC apres EAC dans chaque groupe a ete : G1 4,2% (3/70) ; G2 3,2% (2/61) ; G3 0% (0/22) ; G4 3,4% (1/29) ; G5 3,8% (4/103). Il n’a pas ete montre de difference statistiquement significative entre les groupes G1 et les quatre autres groupes concernant la survenue d’un AVC post-operatoire : G1 (4,2%) versus G2 (3,2%), p = 0,7641 ; G1 (4,2%) versus G3 (0%), p = 0,7648 ; G1 (4,2%) versus G4 (3,4%), p = 0,8473 ; G1 (4,2%) versus G5 (3,8%), p = 0,8952. Il n’y a eu aucun accident hemorragique compliquant une EAC precoce. Le type d’anesthesie et l’utilisation d’un shunt n’etaient pas significativement differents entre les 5 groupes. Conclusions L’analyse de ces donnees suggere qu’une EAC precoce dans la phase suivant un evenement neurologique aigu, chez les patients cliniquement selectionnes, ne semble pas augmenter le risque de complications comparee a la chirurgie retardee ou differee. De plus, l’avantage de l’EAC precoce est de reduire les taux de recidive d’evenement neurologique, les patients non traites en presentant une plus forte incidence.

Endometrial cancer is the most common malignancy of the female genital tract in industrialized countries. The traditional treatment of endometrial cancer is based on a surgical approach. In recent years, systemic endocrine therapy has demonstrated good efficacy in recurrent or metastatic setting, delaying progression, ameliorating quality of life and palliating symptoms. Areas covered: Phase I and II studies on selective estrogen receptor down-regulators used for the treatment of endometrial cancer treatment have been reviewed. The pharmacokinetic and pharmacodynamic features of selective receptor down-regulators have been also investigated. Expert opinion: Selective estrogen receptor down-regulators may exhibit clinical efficacy in the treatment of gynecological malignancies due to their pure estrogen receptor antagonist properties. However, up to now data are still limited and some unsolved questions remain. Fulvestrant has poor oral bioavailability and low pharmacodynamic characteristics. Further trials are required to examine new selective estrogen receptor down-regulator agents with better pharmacodynamic and pharmacokinetic profiles.

This paper deals with the modelling of degradation phenomena for works of art under the action applied by external agents. The analysis is based on a suitable development of the methods of the kinetic theory for active particles. The model consists in an evolution equation for the probability distribution of the degradation stage. The interpretation of empirical data provides the identification of the parameters of the model and a quantitative prediction of degradation events.

The Lunar Atmosphere Dust Environment Explorer (LADEE) was a small explorer class spacecraft that was launched on Sept 7, 2013. After completing all of the mission objectives, LADEE was de-orbited and successfully impacted the moon's surface on April 17, 2014. In order to reduce costs and leverage previous research and development, LADEE utilized the “common modular bus” design. The physical construction utilized a low-cost, rapidly prototyped design and the same philosophy drove the development of the software base. To achieve this goal, a Model Based Design approach was utilized to develop the On-board Flight SoftWare (OFSW), and coincident with this, a model-based multipurpose simulator was created of the LADEE spacecraft and its mission environment. The spacecraft simulator was designed to have sufficient fidelity that it could be used to test the required modes and responses of the OFSW. A faster-than-real-time Workstation SIMulator (WSIM) version of the LADEE simulator was used to develop and test the software control algorithms in the Simulink environment. The automatic code generation feature in Simulink was used to port the simulation to several real-time environments to support Processor-in-the-Loop (PIL) and Hardware-in-the-Loop (HIL) testing, verification and validation. Since the simulation interface was designed to be compatible with the command interface employed by the LADEE mission operation team, the WSIM, PIL and HIL simulators were used for both personnel training (nominal and off-nominal operations) prior to the mission and to perform command sequence verification during the mission. This approach resulted in time and budget savings, and allowed changes to the model to be quickly propagated through all the simulation target environments. The mode- based design approach also allows the simulation framework to be generalized and reused to model future small-satellite missions.

We report a case of a metachronous common iliac artery and the internal iliac artery (IIA) aneurysm developed 8 years after an aortobi-femoral bypass for treatment of abdominal aortic aneurysm associated at chronic occlusion of the right iliac axis. To exclude the metachronous aneurysm on the left iliac axis and to maintain the pelvic circulation, an external to IIA endografts were positioned ("U stent-graft technique"). At 6-month follow-up, the computed tomography scan showed patency of the endografts, of the bypass and of the IIA, without endoleak, or other adverse events.

Objective We compared the outcomes and the durability of endovascular recanalization (EVR) with the Viabahn (W. L. Gore and Associates, Flagstaff, Ariz) covered stent graft vs traditional aortobifemoral or aortofemoral bypass grafting for complex aortoiliac occlusions. Methods Between 2008 and 2014, 11 unilateral iliac occlusions and 11 aortobiiliac occlusions were treated by EVR. Also collected were data from the last 21 consecutive patients treated in the same period by aortofemoral (n = 6) or aortobifemoral (n = 15) bypass grafting. In accordance with the TransAtlantic Inter-Society Consensus II (TASC II) document, only patients with type D lesions were considered. Kaplan-Meier estimates for patency were calculated, and Cox proportional hazard modeling was performed. Results The difference in risk factors between the groups was not significant. General anesthesia was required in 100% of the surgical group, and local or locoregional anesthesia was used for EVR. Suprarenal aortic cross-clamping was required in nine of the open surgical procedures (41%). A brachial percutaneous approach was performed in all patients undergoing EVR, and technical success was 100% in both groups. All of the attempts at EVR were successful. At the 2-year follow-up, primary patency did not differ significantly between the endovascular (91%) and surgical (95%) groups. This was seen in the univariate model (hazard ratio [HR], 0.27; 95% confidence interval [CI], 0.02-2.95; P = .28) and in the multivariate model (HR, 0.77; 95% CI, 0.06-10.07; P = .84) for group (HR, 0.58; 95% CI, 0.04-7.72; P = .68), age (HR, 0.89; 95% CI, 0.73-1.08; P = .24), symptoms (HR, 1.98; 95% CI, 0.42-9.46; P = .39), and occlusion (HR, 3.22; 95% CI, 0.51-20.35; P = .21). The average hospital length of stay was shorter for patients treated with ERV than for those treated with open surgery (3.9 ± 2.2 vs 5.8 ± 3.1 days, respectively; P = .03). The complication rate was 4% for EVR vs 18% in the surgical group (P = .32). Conclusions At 2 years of follow-up, the results of endoluminal bypass grafting with the Viabahn stent to treat complex aortoiliac disease are promising. Longer-term results are needed to fully evaluate the potential benefits and longer-term patency.

Objective This study was undertaken to evaluate the effect of exposure to multiple antenatal steroid courses on short-term neonatal morbidity and 2-year infant neurodevelopmental outcome. Study design This was a prospective observational study of 201 preterm singleton infants who received 1 or more courses of corticosteroids to prevent complications of prematurity and were delivered between 24 and 34 weeks' gestation at a single institution. Neurodevelopmental outcome of the infants was evaluated at 2 years corrected age. Logistic regression analysis was used to perform multivariate analyses of associations and trends. Results One hundred thirty-eight subjects (68.7%) received at least 1 complete course of betamethasone, whereas 63 (31.3%) patients were treated with dexamethasone. The prevalence of multiple steroid doses exposure was 26.8% (37/138) in betamethasone and 52.4% (33/63) in dexamethasone group. The prevalence of infant leukomalacia, including both prolonged echogenicity and cystic leukomalacia, was 25.9% (34/131) after a complete corticosteroid course, 40% (6/15) after 1, 42.3% (12/28) after 2, and 44.4% (12/27) after more than 2 additional courses, respectively (adjusted P for trend=.011). In the same categories of steroid exposure, the corresponding prevalences of 2-year infant neurodevelopmental abnormalities were 18% (20/111), 21.4% (3/14), 29.2% (7/24), and 34.8% (8/23), respectively (adjusted P for trend=.038). Multivariate study of first grade interaction suggested that the risk of leukomalacia and 2-year infant neurodevelopmental abnormalities associated with multiple doses exposure was confined to dexamethasone. In fact, compared with betamethasone, exposure to multiple doses of dexamethasone was associated with an increased risk of leukomalacia (19/33 compared with 11/37; odds ratio [OR]=3.21, 95% CI=1.07-9.77) and overall 2-year infant neurodevelopmental abnormalities (12/28 compared with 6/35; OR=3.63, 95% CI=1.03-13.58). Conclusion In this study, multiple antenatal courses of dexamethasone but not betamethasone were associated with an increased risk of leukomalacia and 2-year infant neurodevelopmental abnormalities.

Introduction Intravascular ultrasound (IVUS) can be used as a quality control technique following carotid artery stenting (CAS). Report An asymptomatic 79-year-old female, with 70% right internal carotid artery (ICA) stenosis, underwent CAS. ICA IVUS evaluation was performed before and after CAS. Angiogram post-CAS showed good results while IVUS detected a flap protrusion across the stent. We treated the flap protrusion with another stent placement. A second IVUS evaluation did not show any further procedural defects. Discussion IVUS can be a useful tool to perform quality control following CAS.

We wished to analyze our initial experience with the Cardiatis Multilayer Stent for visceral artery aneurysms. Two males with a hepatic artery aneurysm (34 mm and 48 mm in diameter, respectively) were treated, via a percutaneous femoral approach, with multilayer stents. We deployed the stent in front of the aneurysm neck, covering the hepatic artery branches. At 12 months, a computed tomography scan showed thrombosis of the aneurysmal sac and patency of all the branches of the hepatic artery. The Multilayer Stent appears to be a viable alternative for the treatment of visceral artery aneurysms in patients at high surgical risk, but long-term follow-up is needed.

Objectives: It is still controversial whether hormone replacement therapy (HRT) can affect the onset of uterine myomas or their growth in postmenopause. It is likely that some therapeutic schedules can influence the myometrial growth differently, due to a more potent stimulation of the uterine receptors. The aim of the present study is to evaluate the effects of two different hormonal treatment schedules on the risk of uterine myoma onset or progression. Methods: In a 2 year prospective randomised study we compared an oral cyclic association of oestradiol valerate and cyproterone acetate versus a sequential combination of transdermal E 2 and per oral medrossiprogesterone acetate on 240 postmenopausal women with and without uterine myomas. Results: Among the patients without uterine myomas treated with the transdermal-oral combination we noted the onset of myomas in 5% of cases after 24 months of treatment, while no new uterine formation was observed for the orally treated women (P < 0.01). Among the patients with uterine myomas at the begining of the study, in the group transdermally treated we found a mean increase in myoma volumes of 25.3% in the following 24 months, which was significantly different compared with the initial volume of myomas. On the other hand, women treated with the oral combination showed no significant modification of myoma volumes at the end of the study. Conclusions: Percutaneous-oral schedule of HRT seems to affect the growth of uterine myomas more than a single oral combination of oestradiol valerate and cyproterone acetate.

Background. We sought to evaluate the long-term safety and efficacy of cyclic combined estradiol valerate and cyproterone acetate. Methods. A six-year, single center, open study was performed of forty-eight recently postmenopausal women. We evaluated biochemical markers of bone turnover, bone mineral content, bone mineral density, serum lipids, climacteric symptoms, and bleeding throughout the six-year period. Ultrasound evaluation of the endometrium was performed yearly for the first two years. Results. Markers of bone turnover were decreased over the study period, while bone mineral content and density remained unchanged. High density lipoprotein cholesterol levels were increased with unchanged blood pressure over the six years. Menopausal symptoms showed significant improvements within 6 months. Endometrial scan results never required hysteroscopic evaluation. Conclusion. Sequentially combined estradiol valerate and cyproterone acetate can be used for an indefinite number of years in women with recent natural menopause. Cyproterone acetate provides adequate endometrial protection and cycle control while allowing estradiol valerate to exert its positive effects on lipid profile, bone metabolism, and climacteric symptoms.

The distinctive features of mountain pastoral families in the past, and their adaptations to environmental and economic constraints, have been the subject of many comparative studies. Less effort has been invested in exploring the role of the family in today’s pastoral economy and identifying structural and cultural continuities within the dramatic changes of the last decades. Our ethnographic fieldwork in several valleys of the Italian Western Alps revealed that, contrary to some expectations, families do retain a central economic and productive role and are instrumental in keeping pastoral farming alive. Some present-day herders belong to families that have continuously engaged in pastoralism for a long time; in other cases, younger generations have returned to pastoral work their parents abandoned for jobs in industry or the service sector; in still other cases, ‘‘new highlanders’’ have turned to pastoralism and become the heirs of local pastoral knowledge. Family structures have changed considerably, and their size and composition as well as their entrepreneurial choices depend on a delicate balance between market demands, domestic strategies to keep or attain the right household size and composition, and the availability of local resources. Access to communal resources to which some pastoral families are entitled by their local origin may prove crucial to the success of their enterprises.

Percutaneous closure of an atrial septal defect has been increasingly used, and complications have been rare. We report the case of a 63-year-old man who had undergone endovascular closure of a secundum atrial septal defect months earlier. The occluder was later found in the abdominal aorta.

Purpose This study examined the reliability and validity of the Test of Infant Motor Performance Screening Items (TIMPSI) in infants with type I spinal muscular atrophy (SMA). Methods After training, 12 evaluators scored 4 videos of infants with type I SMA to assess interrater reliability. Intrarater and test-retest reliability was further assessed for 9 evaluators during a SMA type I clinical trial, with 9 evaluators testing a total of 38 infants twice. Relatedness of the TIMPSI score to ability to reach and ventilatory support was also examined. Results Excellent interrater video score reliability was noted (intraclass correlation coefficient, 0.97-0.98). Intrarater reliability was excellent (intraclass correlation coefficient, 0.91-0.98) and test-retest reliability ranged from r = 0.82 to r = 0.95. The TIMPSI score was related to the ability to reach (P ≤ .05). Conclusion The TIMPSI can reliably be used to assess motor function in infants with type I SMA. In addition, the TIMPSI scores are related to the ability to reach, an important functional skill in children with type I SMA.

OBJECTIVE: Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections. METHOD: We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients. RESULTS: The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1–56), and the survival rate was 77.8%. The endoleaks’ rate was 3.7% (1/27), due to a stent-graft migration. CONCLUSION: Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.

Atherosclerosis can be thought of as a complex process involving many aspects of the patient’s life, ranging from sex, age, and genetics to lifestyle and nutrition. In the last 10 years, there has been a wide expansion of the “-omics” sciences. Such sciences have proven very effective and accurate in the analysis of complex systems, where the analysis of many factors might help a better understanding of the system itself. Among all the “-omics” sciences, metabolomic and metabonomic are gaining increasing interest. Metabonomics quantitatively measures living systems undergoing the effects of diseases. Unlike genomics and proteomics, metabonomics focuses on the multiparameter evaluation of a living complex system by studying its overall physiological profile. Metabonomics can be thought of as a multiparameter profiling technique of each individual.

A 69-year-old man was referred to our facility owing to the sudden onset of a compression-like pain in the right leg, without limb-threatening acute ischemia. The duplex scan examination, followed by a selective leg angiography, showed the presence of a peroneal artery aneurysm. A diagnosis of mycotic aneurysm was made on the basis of the patient’s clinical condition, positive blood cultures, and the unusual location of the lesion. Endovascular repair was performed by using a coil embolization and covered stent release. The patient was discharged in good general condition with complete pain relief. In previously published data, only four cases of peroneal artery aneurysm with a mycotic etiology have been reported. In this case, the endovascular treatment was safe and resolutive.

Surgical treatment for steno-obstructive pathology of the extracranial carotid artery is today the gold standard for the prevention of cerebral ischemic disease associated to the manifestation of atherosclerosis. During the 1990s, a number of randomised trials incontrovertibly demonstrated the advantages which are derived from carotid endarterectomy with respect to medical therapy alone, in patients with symptomatic or asymptomatic stenosis. As a whole, these ­trials ­indicated a perioperative rate of major adverse events (stroke, mortality and MACE) of about 9%. Many projects have since been conducted in the field of carotid surgery, and today the reported complication rates are lower than 3%, with excellent long-term results (North American Symptomatic Carotid Endarterectomy Trial Collaborators, N Engl J Med 325(7):445–534, 1991; Mayberg et al., JAMA 266(23):3289–945, 1991). The results of new arising techniques, such as carotid stenting, must be compared with these complication rates in order to have a clear benchmark for a more objective future dissemination.

Five patients were treated for ruptured visceral artery aneurysms during the last 9 years, including two splenic and three pancreaticoduodenal aneurysms. The average size of aneurysm was 2.6 cm (range: 1.5-5 cm). All patients underwent open surgical treatment. There was one operative death. After a mean follow-up of 46.6 months, there were no cases of mortality or secondary complications. The authors conclude that operative treatment of ruptured visceral artery aneurysms is durable.

Congenital vascular malformations represent a wide number of diseases with a great variability of clinical features. The association between congenital vascular malformations and peripheral aneurysms is very rare. The present study reports a case of giant superficial femoral artery aneurysm (7-cm-long) associated with Parkes-Weber syndrome (capillary malformation, multiple arteriovenous fistulas [AVFs], skeletal hypertrophy of the affected limb) treated by positioning two covered self-expandable endoprostheses after embolization of AVFs with Gianturco coils. The peri- and postoperative course was uneventful and the postprocedural angiography showed the complete exclusion of the aneurysm sac. At last follow-up, after 87 months, the duplex scan and computed tomography scan showed regular patency of the vessels with thrombosis of the aneurysm sac and the presence of a large number of AVFs. The association between Parkes-Weber syndrome and peripheral aneurysms represents a very unusual entity. The lack of evidence does not allow the establishment of the most suitable treatment for this disease. Endovascular approach associated with previous embolization of AVFs may represent a valid alternative to traditional surgical repair, which is still burdened by a high percentage of complications and failures.

Background Free-floating thrombus in the internal carotid artery (FFT-ICA) is a rare condition and its real incidence is unknown. The most common etiology is a complication of an atherosclerotic plaque, but several medical conditions can be responsible. The purpose of this study was to retrospectively analyze our experience with carotid endarterectomy in the management of FFT-ICA and also to analyze the patient outcome. Methods A retrospective review was performed of all patients admitted during the past 9 years with a diagnosis of FFT-ICA. Patient demographics, clinical manifestations, diagnostic modalities, surgical indications, operative details, postoperative courses, and follow-up information were recorded from the hospital database. Results Between January 2000 and December 2008, in our Unit, 2,572 carotid endarterectomies were performed for carotid artery disease. A total of 16 patients (16 of 2,572; 0.62%) were treated for an FFT-ICA. In all, 87.5% (14 of 16) of patients had neurological symptoms. All patients underwent a duplex scan. In 75% (12 of 16) of cases, additional diagnostic tests were performed: digital subtraction angiography (DSA), magnetic resonance angiography, or computed tomographic scan. Duplex scan and DSA detected the FFT-ICA in 62.5% and 100% of cases, respectively. Computed tomographic scan and magnetic resonance angiography failed to provide a diagnosis in majority of the patients (33.4% and 66.7%, respectively). The presence of FFT-ICA was confirmed intraoperatively in all cases. The cumulative stroke rate after surgery was 6.3% (one of 16). Of the total number of patients discharged, 68.75% showed an improvement of neurological symptoms, 12.5% were asymptomatic, 12.5% had no changes in symptoms, and 6.25% of cases worsened. At 30-day follow-up, the survival rate was 93.7% and 75% of patients showed an improvement of neurological symptoms, 12.5% were asymptomatic, and 6.25% died. In all, 6.25% of patients were lost to follow-up. Conclusion Patients with FFT-ICA are usually symptomatic and present with an acute emergency. DSA remains the gold standard diagnostic test in FFT-ICA detection. We cannot assert that early surgery is superior to temporary anticoagulation and/or delayed intervention because of the absence of a comparison group. However, our retrospective results suggest that prompt intervention seems to be a safe alternative in FFT-ICA treatment.

Between 2000 and 2010, 32 patients (17 males; mean age: 64.7 [range: 18-85] years) with visceral artery aneurysms (VAAs) were treated in our center. The site of aneurysmal disease was: splenic artery (18), hepatic artery (5), superior mesenteric artery (3), pancreaticoduodenal artery (3), celiac axis (2), and gastroduodenal (1). Six patients (18.75%) presented with an aneurysm rupture. Nine cases received an endovascular treatment. Primary technical success was achieved in six patients. Failures included one case of immediate stent occlusion, one stent migration, and one failed attempt of embolization. In 24 cases, the surgical treatment was performed successfully. The total survival rate was 90.6% (in urgency: 75%; in election: 95.8%). A follow-up period of 34.7 months (range: 2-117 months) showed good results. Because of the potential risk of rupture, VAAs should be treated. A new endovascular technology based on a multilayer stent could provide us with a new alternative to VAA treatment, guaranteeing both aneurysmatic sac thrombosis and the correct perfusion of the organs. However, this new technology is not suitable for all aneurysms and requires a specific training and learning curve. In subjects with a low surgical risk, surgery guarantees a definitive and long-lasting repair with a good organ perfusion.

True aneurysms of tibial artery are rare occurrences and their rupture is really rare. We report the case of a 59-year-old man who, after an episode of bacterial endocarditis, presented a posterior tibial aneurysm formation evolved in rupture. To our knowledge, this is the first case of a true giant aneurysm rupture of the posterior tibial artery (diameter, 6 cm). The treatment consisted of aneurysmectomy and surgical arterial ligation. A follow-up of 24 months was performed with good results.

We report the case of a 54-year-old man with acute stroke caused by left internal carotid artery (ICA) occlusion secondary to pleural mesothelioma, discovered later. The cranial computed tomography scan revealed a left hemisphere ischemic lesion. At neurological examination, the modified National Institutes of Health Stroke Scale (mNIHSS) score was 9. The carotid duplex scan (DS) showed a complete thrombotic occlusion of the left ICA. The patient underwent emergency carotid thrombectomy. The screening tests revealed thrombocytosis, hyperfibrinogenemia, increased C-reactive protein values, and multiple left pleural mesothelioma nodularity confirmed at the immunohistochemical investigation. After surgery, the patient's neurological symptoms improved, with an mNIHSS score of 3. At 30 and 120 days, the DS follow-up showed regular patency of the ICA.

Background This sequential retrospective monocentric study compares the results between general and local anesthesia for carotid endarterectomy (CEA). Methods Between November 2002 and October 2004, 428 CEAs were performed in our vascular unit. Two groups were formed: group GA (general anesthesia): 219 patients operated under general anesthesia; group LA (local anesthesia): 209 patients operated under local anesthesia. Results No mortality was found in both groups. After surgery, three strokes were detected in group GA and three in group LA (GA 1.36% vs. LA 1.43%, p = .9540); After CEA, there were three TIAs in GA group and none in LA group (GA 0.42% vs. LA 0%, p = .2634). Conclusion The morbi-mortality was not influenced by the type of anesthesia used for carotid surgery. No statistical difference was detected in the perioperative neurological and cardiopulmonary complication rates between GA and LA.

BACKGROUND: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. METHODS: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. FINDINGS: A primary outcome occurred in 84 (4.8%) patients assigned to surgery under general anaesthesia and 80 (4.5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0.94 [95% CI 0.70 to 1.27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. INTERPRETATION: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. FUNDING: The Health Foundation (UK) and European Society of Vascular Surgery.

The Nellix device (Endologix, Irvine, CA), has been designed with a brand new concept to seal the abdominal aortic aneurysms, minimizing endoleaks and reducing reinterventions. We present the first open conversion of a Nellix endograft due to aortoduodenal fistula of a 74-year-old male patient treated for an abdominal aortic aneurysms of 62-mm diameter.

In logistics and industrial production managers must deal with the impact of stochastic events to improve performances and reduce costs. In fact, production and logistics systems are generally designed considering some parameters as deterministically distributed. While this assumption is mostly used for preliminary prototyping, it is sometimes also retained during the final design stage, and especially for estimated parameters (i.e. Market Request). The proposed methodology can determine the impact of stochastic events in the system by evaluating the chaotic threshold level. Such an approach, based on the application of a new and innovative methodology, can be implemented to find the condition under which chaos makes the system become uncontrollable. Starting from problem identification and risk assessment, several classification techniques are used to carry out an effect analysis and contingency plan estimation. In this paper the authors illustrate the methodology with respect to a real industrial case: a production problem related to the logistics of distributed chemical processing.

A Hermitian-Fourier numerical method for solving the Navier-Stokes equations with one non-homogeneous direction had been presented by Schiestel and Viazzo. An extension of the method is devised for solving problems with two non-homogeneous directions. This extension is indeed not trivial since new algorithms will be necessary, in particular for pressure calculation. The method uses Hermitian finite differences in the non-periodic directions whereas Fourier pseudo-spectral developments are used in the remaining periodic direction. Pressure-velocity coupling is solved by a simplified Poisson equation for the pressure correction using direct method of solution that preserves Hermitian accuracy for pressure. The turbulent flow after a backward facing step has been used as a test case to show the capabilities of the method. The applications in view are mainly concerning the numerical simulation of turbulent and transitional flows

We report a case of abdominal endograft proximal collapse due to acute type B aortic dissection in a patient previously treated with endovascular repair (EVAR) for an infrarenal abdominal aortic aneurysm. Patient underwent axillobifemoral bypass grafting, in emergency. The postoperative computed tomography scan showed reexpansion of the occluded endograft. The patient died after 2 days with evidence of progression of the thrombosis of the false lumen and with involvement of renal, visceral, and medullar artery. EVAR collapse associated to acute type B aortic dissection is a challenging condition, which requires aggressive approach.

A 59-year-old male, referred to our center with a ruptured aortic aneurysm, underwent urgent endovascular repair and femoro-femoral crossover bypass. An endograft infection because of Aspergillus fumigatus occurred about 20 days after surgery. We removed the endograft and femoral prosthesis and we then performed an aorto-bi-iliac bypass with autogenous reversed superficial femoral veins. Five days after surgery, the patient died. Microbiological examination and postmortem examination showed the presence of A. fumigatus in femoral prosthesis, aortic wall, and periaortic exudate.