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Coronary artery calcium (CAC) scoring has emerged as a marker of the burden of atheromatous disease and has been included in scoring systems. The practice of myocardial revascularization, considering percutaneous procedures or surgical strategies, is dramatically changing over years and the prognostic significance of CAC scoring is gradually being conceived. In this interdisciplinary scenario, vessel specific calcium scoring, mapping of coronary calcification and its integration with functional assessment of coronary artery disease might change the future decisions in the catheterization lab and operative theaters. This article summarizes CAC evaluation techniques and its implications in clinical practice.

Purpose to evaluate the impact of bi- and 3-dimensional preoperative aortic morphological features and their immediate postoperative variations on the outcome of abdominal aortic aneurysms (AAA) treated by endovascular exclusion with standard devices (EVAR). Materials and Methods Double centre retrospective analysis of prospectively collected registry data of EVAR patients. For all patients, preoperative and 30-day computed tomographic angiography images (CTA) were reviewed. Preoperative maximum AAA diameter >59 mm and volume >159 cm 3 , and any 30-day postoperative increasing at CTA, were considered as potentially influencing the outcome. The outcome measures were: primary technical success; 30-day, 1-year, and mean follow-up reintervention, all-cause and AAA-related mortality rates, and also endoleak-related reinterventions. Results Three hundred and thrity-three patients were enrolled. Mean preoperative and 30-day AAA diameter and volume were 50.4 mm ± 11.8 vs. 49.1 mm ± 12.1, and 112.9 cm3 ± 79.5 vs. 112.1 cm3 ± 80.5, respectively. Primary technical success was achieved in all cases. At 34.9 months follow-up, cumulative reintervention rate was 12.0%, mortality rates 7.2%, without AAA-related deaths. Endoleak-related reintervention rate was 7.5%. At uni- and multi-variate analysis, preoperative AAA diameter >59 mm, and AAA volume >159 cm 3 were significantly associated to reintervention (P = 0.012; P = 0.002), and reintervention and death (P = 0.002; P = 0.001) during follow-up. Additionally, any increase in postoperative AAA diameter or volume was significantly associated with reintervention (P = 0.001, P = 0.001) and reintervention and death (P = 0.006, P = 0.001). Endoleak-related reintervention were also significantly associated with all of the analysed morphological parameters (P = 0.019, P = 0.005, P = 0.005, and P = 0.002, respectively). Conclusions Patients with larger baseline AAA size and volume as well as unfavourable early remodelling of the sac are associated to worse long-term EVAR outcome.

Objectives This study sought to evaluate 30-day safety and efficacy of dual-layer mesh-covered carotid stent systems for carotid artery stenting (CAS) in the clinical practice. Background When compared with carotid endarterectomy, CAS has been associated with a higher rate of post procedural neurologic events; these could be related to plaque’s debris prolapsing through stent’s mesh. Consequently, the need for increased plaque coverage has resulted in the development of dual-layer mesh-covered carotid stent systems. Methods From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system in 20 centers. The primary endpoint was stroke up to 30 days; secondary endpoints were technical and procedural success; external carotid artery occlusion; and in-hospital and 30-day transient ischemic attack (TIA), acute myocardial infarction (AMI), and death rates. Results Symptoms were present in 131 (17.87%) patients. An embolic protection device was used in 731 (99.72%) patients. Procedural success was 100%, technical success was obtained in all but 1 (99.86%) patient, who died in hospital due to a hemorrhagic stroke. Six TIAs, 2 minor strokes, and 1 AMI occurred during in-hospital stay, and external carotid artery occlusion was evident in 8 (1.09%) patients. Between hospital discharge and 30-day follow-up, 2 TIAs, 1 minor stroke, and 3 AMIs occurred. Therefore, the cumulative stroke rate was 0.54%. Conclusions This real-world registry suggests that use of CGuard embolic prevention system in clinical practice is safe and associated with a minimal occurrence of adverse neurological events up to 30-day follow-up.

Objective With the increasing use of endovascular aortic repair (EVAR), open repair after aortic stent grafting is of growing interest. The surgical conversion treatment may be a very challenging process with high mortality and in hospital complications rates. Aim of the study was to present our experience in patients with EVAR failure treated by minimally invasive open conversion (MOC) and its technical aspects. Methods A retrospective study was conducted on a prospectively compiled computerized database of consecutive patients treated by minimally invasive open conversion (MOC) at our Institution between May 2014 and June 2018. Indications for treatment were endoleaks with sac growth at least >5mm in the last 6 months and failure of previous endovascular tentative for aneurysm sealing. Demographics of the patients, reason for conversion, previous endovascular procedures, surgical outcomes, and survival were reviewed. MOC was performed by a small abdominal incision, infrarenal clamping and partial explantation of the endograft in all patients. Results A total of 10 patients were treated during the study period. The mean interval to MOC after EVAR was 45.1 months (range, 14-128). Indications for MOC included type Ia endoleak in three patients (30%), persistent type II EL in four (40%) and type III EL in one patient (10%), indeterminate or type V EL in two (20%). At 30-days no deaths or re-interventions were reported and major complication rate was 10% (one post-operative pneumonia). At mean follow-up of 22.9±15.9 months no re-interventions were described. Death rate was (20%) with one aneurysm-related death (10%) for graft infection 32 months after MOC and one (10%) cardiac event at 18 months. Conclusions Despite the potential high risk of open conversion, MOC appears to be a safe surgical solution for EVAR failure. This potentially challenging operation may be improved with minimally invasive techniques that are presented.

Residual type B aortic dissection (R-TBAD) is a challenging kind of disease affecting an increasing number of patients. Management of R-TBAD has not been specifically addressed in current literature and many of those patients are not eligible for endovascular treatment. Aim of the study was to evaluate the efficacy and feasibility of a specifically conceived procedure the "saguaro branched graft technique" to treat R-TBAD distal to a proximal stent-graft.Data of patients treated between 2015 and 2019 were prospectively collected and retrospectively analyzed. Indication for surgery was R-TBAD with chronic malperfusion, aortic enlargement55 mm or rapid growth, and symptomatic aortic enlargement. A Dacron graft with four branches has been tailored on the back table by implanting two bifurcated grafts to a tube or bifurcated graft. After left thoracoabdominal incision the proximal endograft has been used as a solid starting point for the distal branched graft. Sequential revascularization of the visceral vessels was performed step by step by suturing each artery outside the aneurysm before opening the distal aorta, while a continued retrograde aortic and visceral perfusion was maintained by a left pump atrio-femoral bypass. After that all visceral branches had been regularly perfused from above, the thoraco-abdominal aorta was open and repaired. Outcome measures were 30-day mortality and 30-day major complications as were long-term all-cause mortality, aorta-related mortality, reintervention and patency rates of the branches.Thirteen patients with R-TBAD were treated during the study period. Indication for surgery was chronic malperfusion in one patient (7.7%), aortic enlargement55 mm or rapid growth in 9 patients (69.2%), persistent pain with aortic enlargement ≥50 mm in 3 patients (23.1%). All patients were considered not eligible for endovascular repair. At 30-days no deaths or re-interventions occurred and major complications including acute cardiovascular events and renal function impairment were not reported; one patient (7.7%) developed postoperative paraplegia. At a mean follow-up period of 19.6±10.2 (range, 8-48) months, reintervention and mortality rates were null. Visceral malperfusion and late-onset renal failure were not reported, and all visceral branches were still patent.Despite the potential high risk of open surgery, the "saguaro branched graft technique" appears to be a safe surgical solution for R-TBAD.

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a ‘one-size-fits-all’ procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Objective: Prior research on median arcuate ligament syndrome has been limited to institutional case series, making the optimal approach to median arcuate ligament release (MALR) and resulting outcomes unclear. In the present study, we compared the outcomes of different approaches to MALR and determined the predictors of long-term treatment failure. Methods: The Vascular Low Frequency Disease Consortium is an international, multi-institutional research consortium. Data on open, laparoscopic, and robotic MALR performed from 2000 to 2020 were gathered. The primary outcome was treatment failure, defined as no improvement in median arcuate ligament syndrome symptoms after MALR or symptom recurrence between MALR and the last clinical follow-up. Results: For 516 patients treated at 24 institutions, open, laparoscopic, and robotic MALR had been performed in 227 (44.0%), 235 (45.5%), and 54 (10.5%) patients, respectively. Perioperative complications (ileus, cardiac, and wound complications; readmissions; unplanned procedures) occurred in 19.2% (open, 30.0%; laparoscopic, 8.9%; robotic, 18.5%; P < .001). The median follow-up was 1.59 years (interquartile range, 0.38-4.35 years). For the 488 patients with follow-up data available, 287 (58.8%) had had full relief, 119 (24.4%) had had partial relief, and 82 (16.8%) had derived no benefit from MALR. The 1- and 3-year freedom from treatment failure for the overall cohort was 63.8% (95% confidence interval [CI], 59.0%-68.3%) and 51.9% (95% CI, 46.1%-57.3%), respectively. The factors associated with an increased hazard of treatment failure on multivariable analysis included robotic MALR (hazard ratio [HR], 1.73; 95% CI, 1.16-2.59; P = .007), a history of gastroparesis (HR, 1.83; 95% CI, 1.09-3.09; P = .023), abdominal cancer (HR, 10.3; 95% CI, 3.06-34.6; P < .001), dysphagia and/or odynophagia (HR, 2.44; 95% CI, 1.27-4.69; P = .008), no relief from a celiac plexus block (HR, 2.18; 95% CI, 1.00-4.72; P = .049), and an increasing number of preoperative pain locations (HR, 1.12 per location; 95% CI, 1.00-1.25; P = .042). The factors associated with a lower hazard included increasing age (HR, 0.99 per increasing year; 95% CI, 0.98-1.0; P = .012) and an increasing number of preoperative diagnostic gastrointestinal studies (HR, 0.84 per study; 95% CI, 0.74-0.96; P = .012) Open and laparoscopic MALR resulted in similar long-term freedom from treatment failure. No radiographic parameters were associated with differences in treatment failure. Conclusions: No difference was found in long-term failure after open vs laparoscopic MALR; however, open release was associated with higher perioperative morbidity. These results support the use of a preoperative celiac plexus block to aid in patient selection. Operative candidates for MALR should be counseled regarding the factors associated with treatment failure and the relatively high overall rate of treatment failure.

Background Thoracic outlet syndrome is an important clinical entity, which usually affects young patients and working cohort, causing disability if unrecognized and untreated. Although treatment is commonly conservative, in patients with more severe disease, surgical treatment is often required for decompression. Purpose of this paper was to evaluate the surgical and clinical outcomes of patients who underwent first rib resection through transaxillary approach for thoracic outlet syndrome (TOS) during a period of 30 years. Methods A retrospective study was conducted on a prospectively compiled, computerized database between January 1988 and December 2018 including patients affected by TOS surgically treated in two Italian centers, by the same surgeon. Patients with neurogenic and vascular TOS were included in the present analysis. The surgical approach for TOS decompression was the first rib resection using the Roos' transaxillary approach, with small variations in technique. Outcome measures considered for analysis were primary technical success, 30-day and mean follow-up re-intervention, pneumothorax, nerve injury and symptoms recurrence rates. Results One hundred three patients were treated: 89 (86.4%) women and 14 (13.6%) man; median age was 32.6±10.2 years (range 9-53). Prominent symptoms were neurogenic in 60 patients (58.2%), venous in 32 (31.1%), and arterial in 11 (7.76%) patients. In 49 patients (47.5%) with prominent neurogenic symptoms, concomitant symptoms of vascular TOS were also presents. Thirteen (12.6%) patients had cervical rib and sixteen cases (15.5%) had bilateral TOS. Technical success was achieved in all cases, and no other surgical access or secondary approach was necessary. Three patients (2.9%) presented with hand ischemia and also needed an arm vein bypass after rib resection. One (0.9%) intraoperative arterial injury was reported and nerve injury rate was 1.8%. At 30-day re-intervention rate was 0.9%: one patient experienced hemothorax solved by thoracoscopic drainage. Restrict pneumothorax was reported in 42 patients (40.8%) treated through pleural drainage. At mean follow-up of (93±9 months) partial symptoms recurrence was present in 6 patients (5.8%). Conclusions In our experience first rib resection through the transaxillary approach is a safe and feasible procedure associated with an acceptable rate of peri-operative morbidity and satisfactory long-term relief of symptoms.

The aim of the present study was to evaluate the impact of the aortic bifurcation (AB) morphological characteristics, analyzed on computed tomography angiography (CTA), on outcomes of patients with abdominal aortic aneurysms (AAAs), treated by endovascular aneurysm repair (EVAR) in a single-center experience. A retrospective analysis was conducted using a prospectively collected database. Morphological features considered as potentially impacting outcomes were maximum AB diameter (ABmax), minimum diameter (ABmin), mean diameter (ABaverage), AB area (ABarea), and AB calcification (ABcalcification) and thrombosis (ABthrombosis). Outcome measures were perioperative, 30-day, and midterm AAA-related reinterventions and all-cause mortalities. Investigators reviewed 306 preoperative CTA scans. Maximum aortic diameter was 51.4 ± 12.4 mm (range 40–110), and mean ABmax was 24.2 ± 8.8 mm (range 10–60), ABmin 17.0 ± 5.4 mm (range 4–40), ABaverage 20.6 ± 6.5 mm (range 9–47.5), and ABarea 35.2 ± 24.2 mm2 (range 6–176). ABcalcification ≥ 50% was present in 63 patients (20.6%), and ABthrombosis ≥ 50% in 102 patients (33.3%). Technical success was obtained in all cases, without perioperative reintervention or death. At 30-day follow-up, the reintervention rate was 3.3%, and mortality rate was 1.3%. At a mean follow-up period of 35 ± 28.6 (range, 1–72) months, reintervention and mortality rates were 6.5 and 4.9%, respectively. None of the analyzed thresholds were predictive of adverse outcomes. At multivariate analysis, association of a narrowed AB with severe calcification of the distal aorta showed a significant differences in terms of reinterventions (p = 0.009). Our limited experience seems to reveal that a cutoff of ≤ 20 mm for AB diameter, as in current guidelines, is ineffective in predicting outcomes after EVAR.

Background To evaluate the impact of iliac artery's diameters, tortuosity, and peripheral vascular patency on outcome of elective endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) in 2 high volume vascular centers' experience. Methods A retrospective study was conducted on a prospectively collected database between 2010 and 2012. Anatomical features at pre-operative computed tomography (CTA) considered as potentially influencing outcomes were: iliac diameters, tortuosity (expressed as a ratio), and calcifications, bilateral internal iliac artery (IIA) patency, and presence of Trans-Atlantic Inter-Societies Consensus (TASC) II C/D femoro-popliteal occlusive disease (PAD). Outcome measures were reintervention and mortality rates at follow-up. Results Two-hundred-eighty-nine patients' CTA preoperative images were reviewed with a mean of 1148±328 images per patient analyzed. Mean common iliac artery (CIA) diameters calculated in the narrowest point were 12.8±4 mm and 12.9±3.9 mm, and mean external iliac artery (EIA) diameters were 7.7±1.6 mm 7.8±1.7 mm, respectively on right and left side. Mean tortuosity ratios were 0.8±0.1 (0.40-0.91) and 0.8±0.1 (0.49-0.99), respectively on right and left side. PAD was present in 31 patients (10.7%). Technical success was achieved in all case, and bilateral IIA patency was preserved in 229 (79.2%) patients. No in hospital and 30-day mortality and complications were recorded. At a mean follow-up of 26 months, 30 reinterventions were required in 26 patients (8.9%), and 22 (7.6%) non AAA-related deaths were noted. Right EIA diameter ≤5 mm (P=0.0012, OR 5.2, 95% CI 1.73-15.57), and femoro-popliteal steno-obstructive disease (P=0.03, OR 3.06, 95% CI 1.02-9.20) were significantly related to reinterventions during follow-up. Iliac tortuosity ratio and calcification were not significant predictors of adverse events. Conclusions This preliminary experience suggests that diameters of access vessels and the presence of femoro-popliteal steno-obstructive disease could affect the outcome of EVAR.

To report a case of acute arm ischemia and prosthetic shoulder infection treated by extra-anatomical great saphenous vein graft with external vascular scaffolding. A 65 year-old man with multiple surgical interventions for soft tissue sarcoma of the right shoulder, local radiotherapy with residual brachial plexus neuropraxia, was referred to our attention for signs of arm ischemia. Two weeks before, the patient was submitted to prosthetic shoulder replacement complicated with prosthetic infection. Considering the mechanism of vascular injury, an open surgical revascularization was planned with a deliberate avoidance of the natural anatomic pathway to reduce the risk of graft infection. Consequently, after the complete removal of infected shoulder prosthesis and placement of antibiotic spacer, an axillarbrachial artery bypass using great saphenous vein was performed using a new braided cobalt chrome kink resistant external vascular support to prevent compression, also considering the extra-anatomical position of the graft. At 12 months’ follow-up, patient was in good clinical condition with complete resolution of arm ischemia; computed tomographic angiography and duplex scan revealed patency of the graft with excellent distal perfusion. The new external vascular support seems to be useful and feasible for preventing compression of extra-anatomical venous bypass.

To describe results of AFX unibody stent-graft treatment for TransAtlantic Inter-Society Consensus (TASC) D aortoiliac occlusive disease (AIOD) with coexistent abdominal aortic aneurysm (AAA).A retrospective analysis was conducted of 21 consecutive patients (mean age 73.6±6.4 years; 17 men) with TASC D AIOD plus AAA (diameter3.5 cm) treated electively using the AFX stent-graft. Common iliac artery (CIA) and external iliac artery (EIA) stenosis or occlusion was reported. Outcome measures were technical and clinical success, improvement in ankle-brachial index (ABI), and improvement in Rutherford category. Immediate and midterm patency, AAA exclusion, major adverse events (MAE), and mortality were also evaluated.After AFX deployment (100% technical success), 18 EIAs required adjunctive stenting (none required in the CIA). One patient required a reintervention for closure device failure. At 30-day follow-up, no death or MAE was recorded. Improvement in ABI was registered in all patients (mean 0.91±0.11), with 100% primary patency. At a mean follow-up of 25.2±11.1 months, primary patency was maintained in all cases. No death or amputation occurred; 2 patients had a myocardial infarction. Improvement in ABI was maintained (0.88±0.13) as well as Rutherford category.This study examined the use of the AFX unibody stent-graft for the treatment of TASC D AIOD with concomitant AAA. The AFX stent-graft appears to be a safe and effective solution for these complex lesions, with low morbidity and mortality.

Background The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. Methods Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. Results MS-CEA patients were more frequently male ( P = 0.03), presented more frequently with symptomatic lesions ( P = 0.007), longer lesions ( P = 0.01), and had common ICA bypass implantation ( P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1–144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups ( P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group ( P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up ( P = 0.24). Conclusions MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

Elongation, coils, and kinks of carotid vessels are rare conditions, and these are often asymptomatic. Rarely, kinking may provide functional symptoms, requiring surgical correction. We report an unusual case of internal carotid artery kinking causing pharynx compression with dysphagia. Patient underwent carotid-carotid bypass graft. His dysphagic symptom improved markedly at 1-month follow-up control.

We report a case of acute limb ischemia (ALI) due to a thromboembolism from a persistent sciatic artery (PSA) pseudoaneurysm precipitated by a fractured stent. Patient, previously treated for ALI by fibrinolysis and stent implantation, presented with a PSA pseudoaneurysm (undetected during first hospitalization), stent fracture (SF), and occlusion of vessels below the knee. Fibrinolysis was performed, restoring direct flow to the foot. A week later, an endovascular procedure was attempted to reline SF and exclude the PSA pseudoaneurysm by deployment of two 13 × 100-mm peripheral endografts (Viabahn; W.L. Gore & Associates, Flagstaff, AZ). At 1-year follow-up, patient was asymptomatic without further clinical events.

Purpose: Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center. Methods: We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction. Results: From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR ( P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR ( P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction ( P < .05). Conclusions: Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate.

We report a case of a compassionate treatment of a ruptured thoracoabdominal aortic aneurysm in a 92-year-old patient. The patient was admitted to our emergency department for acute onset of pain irradiating to the back. Computed tomography angiography showed the presence of a thoracoabdominal aortic aneurysm with a contained rupture at infrarenal level. Given the presence of a relative healthy visceral aorta, we decided to treat the patient by Ovation (Endologix, Irvine, CA) implantation in an off-label fashion. Procedure was performed by bilateral percutaneous access. Completion angiography showed the good stent-graft apposition with complete aneurysm exclusion. The patient was discharged on the third postoperative day. The 1-month follow-up confirmed the good procedural result; aneurysm was completely excluded without further thoracic dilatation.

Background To preliminary report on epidemiology, risk factors, diagnosis, treatments, and outcomes in a multicenter series of patients treated for endovascular aortic repair (EVAR) infection and detected by an Italian National enquiry. Methods From June 2012, 26 cases of abdominal aortic endograft infection were collected by a National Enquiry and recorded in the Italian National Registry of Infection in EVAR. Cases collected were available for patients submitted to EVAR implantation from January 2004 to June 2013. Results Mean time from EVAR treatment to infection diagnosis was 20.5 ± 20.3 months (range, 1–72). In 6 cases (23.1%), an aortoenteric fistula (AEF) was detected. Positive microbiologic cultures were found in 20 patients (76.9%). More than 1 infectious agent was found in 6 cases (19.2%). EVAR infection treatment was conservative in 4 cases, endovascular in 2. Endograft excision was performed in 10 cases by conventional treatment (aortic stump + extra-anatomic bypass) and in 10 cases by in situ reconstruction (cryopreserved allograft or rifampin-soaked silver Dacron graft). A 30-day mortality was 38.4% (10 of 26 cases), 3 patients died from 2 to 24 months after infection treatment, accounting for a mean time from infection treatment to death of 1.25 ± 0.62 months. Mortality rates were 50% in all treatment groups. In those survived (13 of 26 cases) recurrence-free follow-up after infection treatment was 27.9 ± 22.4 months (range, 2–74). Four patients with AEF died in the first month after treatment (66.6%). Suprarenal endografts required supraceliac aortic cross-clamping for removal. Supraceliac cross-clamping was burdened by higher mortality rates than infrarenal cross-clamping (71.4% vs. 30.7%). Conclusions EVAR infection diagnosis is burdened by extremely high mortality rates. Prospective registries could help monitoring outcomes in EVAR infection patients and, possibly, developing new surveillance protocols in patients at high risk of recurrence.

A 62-year-old man presented with fever, abdominal pain, and malaise 13 months after emergency endovascular aortic repair. Computed tomographic angiograms showed a periprosthetic fluid and gas collection, so infection was diagnosed. Open conversion was performed, involving endograft explantation and in situ aortic reconstruction. Cultures and the explanted prosthesis were positive for carbapenemase-producing Klebsiella pneumoniae, resistant to colistin. Because of the sparse data on endograft infections caused by this pathogen, we placed the patient on an empiric double-carbapenem regimen for 4 weeks. Symptomatic recovery occurred after 21 days. On the 30th day, we deployed a stent to treat a new pseudoaneurysm. Three years later, the patient had no signs of persistent or recurrent infection. We think that this is the first report of aortic endograft infection caused by colistin-resistant, carbapenemase-producing K. pneumoniae.

ObjectiveThe purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms.MethodsThis prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging.ResultsBetween January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%).ConclusionsDue to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA.

We report a case of an early type Ia endoleak after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm by Ovation Stent Graft implantation and spontaneously resolved without further reintervention. The patient presents a conical aortic neck, but EVAR was performed within the instruction for use proposed by manufactory. At completion angiography, a low-flow type Ia endoleak was present and left untreated. Computed tomographic angiography performed on the third postoperative day showed infolding of the 2 sealing rings. The patient was dismissed without further treatment. At 3-month follow-up, the leak appeared spontaneously sealed with partial expansion of the 2 rings.

s 403 Results: At five years, 7.3% (CI 2.7e11.9%) of the elective intended to treat patients with EVAR had an increase in aneurysm diameter. 38.2 % of patients were registered with endoleaks during the follow up period but only 5.7 % had secondary procedures.13 % of patients had secondary procedures for other reasons 12.2 % of patients had early and 6.5 % late complications during the follow up period. Aneurysm rupture was seen in 1.6 % of patients. During the 5 years of follow up there was no statistical difference in standardized mortality ratio in patients treated with elective EVAR compared to the general population. The 1 year mortality of those electively treated with open AAA repair and EVAR was 7.6%, and 6.3 % respectively. There was no statistically significant difference seen in 1 year mortality between elective open operation and elective EVAR. Conclusion: Adhering to proven indications for use of EVAR gives a low long-term risk for increased diameter, low mortality rate and low rate of secondary procedures in treated aortic aneurysms compared to other published results. With this approach no statistical difference in standardized mortality was seen in patients treated with EVAR compared to the general population. This is the case even if the risk for AAA rupture after treatment will still not be entirely excluded with EVAR. The strict application of EVAR does not increase the mortality from AAA even if the number of open repairs will increase. Hypogastric Artery Management during EVAR W. Mansour, L. Capoccia, P. Sirignano, N. Montelione, E. Sbarigia, F. Speziale Vascular and Endovascular Surgery e “Sapienza” University of Rome, Italy Introduction: Hypogastric artery (HA) revascularization in patients affected by abdominal aortic aneurysm (AAA) and submitted to endovascular repair (EVAR) is open to debate. Aim of our study is to analyze the outcomes in patients undergoing EVAR with exclusion of one or both hypogastric arteries. Methods: In a prospective series of EVAR patients needing HA exclusion, we retrospectively reviewed our results in terms of peri-operative (30 day) and follow up rates of intestinal and spinal cord ischemia, buttock claudication (BC), skin necrosis, and sexual dysfunction (SD) in male patients. In case of aneurysms involving a single common iliac artery or iliac bifurcation, the unilateral HA was excluded by coil embolization, vascular plug deployment or simple coverage by endograft. In case of aneurysms involving both iliac arteries revascularization of at least one hypogastric artery was attempted. Techniques of hypogastric salvage included branch devices, flow modulator stents, sandwich, and periscope and bell bottom techniques. Results: From January 2008 to December 2014, 427 patients underwent elective EVAR; among those 104 (24.3%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH) as many single hypogastric arteries were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH): 16 of those (51.6%) had one HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both hypogastric arteries were excluded (group BHE). No 30 day or follow up aneurysm related mortality, intestinal or spinal cord ischemia were recorded. At 30 days skin necrosis was observed in 2 patients. BC, and SD rates in group UH were 17.8% and 8.2% respectively; in group BH, BC and SD rates were significantly greater in group BHE than in group BHR (53.3% vs. 18.5% and 46.4% vs. 12.5%, respectively; p < 0.05). At a mean 18.6 months follow up (range 4-e47), in group BHE, BC and SD rates were persistently higher than in group UH and BHR (respectively, 40% and 46.6% vs. 8.2% and 6.8% in UH, and 6.2% and 12.5% in BHR, p < 0.05). Data analysis disclosed that HA coil embolization was significantly associated with 30 days BC and SD (OR 3.92; 95% CI 1.27e12.1; p < 0.05). Conclusion: Our results suggest that at least one HA should be salvaged in case of bilateral involvement. Unilateral HA exclusion seems to be related to acceptable complication rates at follow up. Coil embolization seems to be related to a higher peri-operative complications rate respect to plug or coverage. Glycated Haemoglobin Influences the Growth Rate of Abdominal Aortic Aneurysms. A Sub Study from the Population based VIVA Randomised Screening Trial K.L. Kristensen, M.D. Thomsen, L.M. Rasmussen, J.S. Lindholt Odense University Hospital, Denmark Introduction: Several studies have reported a paradoxically negative association between abdominal aortic aneurysms (AAA) and diabetes with a reduced prevalence and progression rate by almost half. However, reason remains unsolved and could be due to elevated blood sugar level, systemic level of insulin, medication or other factors. This study aimed to evaluate the role of elevated blood sugar, as glucose can induce cross-links in the extracellular matrix. Methods: The cohort study was based on “VIVA”, the randomised clinically controlled screening trial of men aged 65 e74 in Central Denmark Region. The screening included a questionnaire, ankle brachial index measurement and measurement of the abdominal aorta by ultrasound. Furthermore, follow up for up to five years were offered to AAA cases below 5 cm in diameter, while those above were referred for surgical evaluation. At follow up, full blood samples were drawn for glycated haemoglobin (HbA1c) and analysed. We defined diabetes as HbA1c above 47 mmol/mol or an already verified diagnosis. The analyses were performed both as a conventional case-control study, comparing patients with AAA with and without diabetes, and as a cohort study concerning growth rate. Results: At baseline, we found 619 (3.3 %) AAAs. 114 were lost to follow up or referred for vascular evaluation. In addition, full blood samples were only possible at 9 of the 13 screening locations leaving 346 AAA patients. Sixty-nine (20%) had defined diabetes (38 with known diagnosis, 31 with high Hba1c). Compared with the patients without defined DM, the patients with diabetes differed in comorbidity seeing as they had more angina (20.9 vs. 13.0%), peripheral arterial disease (39.1 vs. 25.7%), and hypertension (71.0 vs. 50.4%). Median baseline aortic diameter was 35.4 vs. 34.0 mm with and without diabetes respectively (p 1⁄4 0.83), while the median growth-rate was 1.66 vs. 2.66 mm/year with and without diabetes respectively (p < 0.000). We found a significant association between AAAs growth rate and HbA1c (Spearman’s rho: -0.159, p 1⁄4 0.004), but no association between the maximal antero-posterior AAA diameter and HbA1c (Spearman’s rho: -0.088, p 1⁄4 0.112). Conclusion: Exploring the association between AAA and diabetes, we found an inverse relation between the growth rate of AAAs and the level of HbA1c indicating that long lasting elevated blood sugar impairs aneurysmal progression, probably by inducing cross links in the extracellular matrix. Prosthetic Vascular Graft Infections: Cultures from NPWT Foams Are of No Value A.U. Scherrer, G. Bloemberg, R. Zbinden, C. Fuchs, Z. Rancic, D. Mayer, B. Hasse and the VASGRA Cohort University Hospital of Zurich, Zurich, Switzerland Introduction: In recent years prosthetic vascular graft infections are increasingly operated in a graft-preserving manner together with the use of negative pressure wound therapy (NWPT). The use of NPWT in vascular graft infection shortens the time to complete wound healing, has a high success rate, and the complication rate is low. During NWPT either polyurethaneor polyvinyl alcohol containing sponges are exchanged on a regular basis. The aim of this study was to compare bacteria retrieved from the NWPT-sponges with the bacteria detected by conventional methods in order to examine if microorganisms from NPWTW sponges help to determine the bacterial burden of vascular wounds. Methods: Diagnostic accuracy of NPWT sponges was assessed. The standard of reference was a microbiological culture, obtained after open biopsy or graft explantation. We calculated sensitivity, specificity, positive predictive (PPV) and negative predictive values (NPV). Results: 109 negative pressure wound therapy treatment cycles were performed among 104 patients with prosthetic vascular graft infections.

Purpose: To evaluate the midterm outcomes of chimney and/or periscope grafts (CPGs) in patients presenting type I endoleak after a previous endovascular aneurysm repair (EVAR). Methods: Between June 2002 and April 2014, 24 consecutive patients (mean age 73.9±9.2 years; 23 men) presenting a type I endoleak were addressed with CPGs to extend the proximal and/or distal landing zone and to maintain side branch perfusion. Indication for treatment was a type Ia endoleak in 23 (96%) patients and a type Ib endoleak in one. Median interval from the previous EVAR to endoleak treatment with CPGs was 52.2±48.9 months (range 0.2–179). All patients had proximal/distal landing zones precluding any standard endovascular reintervention. Measured outcomes included technical success and perioperative mortality and morbidity. Technical success was defined as a procedure completed as intended, with no secondary procedures within 30 days. Midterm outcomes included survival, CPG patency, endoleaks, and freedom from reintervention. Results: Technical success was 96%; a single patient required an additional procedure to seal a recurrent type Ia endoleak. Intraoperative revascularization of all 55 target vessels (2.3/patient) with CPGs was successful. One (4%) patient died within 30 days. Estimated survival at 12, 24, and 36 months was 83%; estimated CPG patency at the same intervals was 94%. Over a mean follow-up of 23.4±29 months, 6 (25%) reinterventions were performed; of these, 4 were secondary to type I endoleak. Aneurysm diameters reduced from 88.3±26 to 85.5±33 mm (p=0.49) over the mean follow-up. Conclusion: The CPG technique is a safe and effective tool for treatment of type I endoleak after previous EVAR. The CPG technique is feasible even in nonelective patients, with excellent outcomes in terms of patency. Close imaging follow-up is warranted to rule out recurrent or de novo endoleaks.

Purpose: To evaluate the impact of two-dimensional and three-dimensional preoperative morphologic features analyzed on computed tomography (CT) angiography on midterm outcome in patients with abdominal aortic aneurysms (AAAs) treated with endovascular aneurysm repair (EVAR). Materials and Methods: A retrospective analysis was conducted using a prospectively collected database. Morphologic features considered as potentially influencing outcomes were maximum aortic diameter, thrombus area, overall aneurysm volume, and intrasac thrombus volume. Outcome measures were all perioperative and midterm AAA-related reinterventions and all-cause mortality. Results: Investigators reviewed 191 preoperative CT angiography scans. Mean maximum aortic diameter was 58 mm; thrombus area, 49.6%; aortic volume, 159.36 cm 3 ; and thrombus volume, 58.6%. Technical success was achieved in all cases. No reintervention was required in the perioperative period, and there was no perioperative mortality. At a mean follow-up of 32 months 16.8 (range, 3–66 mo), mortality rate was 9.4%, AAA-related death was 0, and reintervention rate was 8.9%. Causes of reintervention included type I endoleak (n ¼ 3 [1.6%]), type II endoleak (n ¼ 7 [3.7%]), type III endoleak (n ¼ 1 [0.5%]), endograft limb thrombosis (n ¼ 4 [2.1%]), and access vessel thrombosis (n ¼ 2; 1%). Greater thrombus area (4 60%) and thrombus volume (4 59%) were predictors for reintervention (P ¼ .005 and P ¼ .0034). Greater maximum aortic diameter (4 59 mm) and aortic volume (4 159 cm 3 ) were related to higher reintervention rate without statistical significance (P ¼ .62 and P ¼ .12). Aortic volume was a predictor of any adverse event, reintervention, and all-cause mortality after EVAR (P ¼ .03). Conclusions: Thrombus area and volume are related to higher rates of reintervention. Maximum aortic diameter was related to a higher reintervention rate, but this was not significant.

To report a case of pararenal aortic aneurysm (PAAA) with narrowed iliac arteries treated by the chimney technique combined with the INCRAFT® AAA stent graft system. A 75-year-old man was diagnosed with a 55-mm PAAA. Patient was judged unfit for open repair and for standard endovascular aneurysm repair (EVAR) due to its clinical and anatomical requirements. Custom-made fenestrated device (FEVAR) was excluded due to the presence of narrowed and heavily calcified iliac axes. Consequently, patient underwent auspicious endovascular aneurysm repair with the INCRAFT System and chimney grafts in the superior mesenteric artery and both renal arteries. At 12 months' follow-up, patient was in good clinical condition, with preserved renal function. Computed tomographic angiography revealed inceptive shrinkage of the aneurysm with patency of aortic and visceral grafts even in the presence of a low-flow type Ia endoleak. Chimney grafts (CGs) combined with the low-profile INCRAFT System seem to be feasible for treating PAAA, in high-risk patients unfit for standard EVAR or FEVAR devices.

Concomitant aortic aneurismal pathology and vertebral erosion are seldom reported in literature. The differential diagnosis between a primary vertebral disease affecting the aortic wall and a primary aortic pathology causing a vertebral disruption is quite difficult. We report on a patient presenting with increasing lumbar pain and neurologic lower limbs deficit due to a vertebral erosion accompanied by aortic rupture treated by emergent endovascular aortic repair procedure and then staged vertebral fixation. Microbiological tests on intraoperative periaortic fluid collection samples showed no clear sign of infection and clinical conditions progressively improved. At 12-month follow-up, the patient is in good clinical condition, with a small residual walking impairment and no clinical, laboratory, or imaging sign of aortic endograft infection.

We report a case of superficial femoral artery (SFA) stent fractures (SF) with atypical symptoms and site of disruption. Patient was hospitalized for sudden onset of right thigh pain, nonrelated to steno-obstructive disease. Preoperative ultrasound suspected and computed tomographic angiography (CTA) confirmed multiple proximal SFA SFs with concurrent pseudoaneurysms. A peripheral endograft was deployed covering the entire SFA, achieving a complete "relining" with exclusion of the pseudoaneurysm. Pain disappeared and postoperative control demonstrated good patency of the SFA. After 1 month, patient reported no further events and CTA revealed patency of the endograft and exclusion of the pseudoaneurysm. At 1 year follow-up, Viabahn is patent with no further symptoms reported by the patient.

All patients (n 1⁄4 1177) Wound (0-3) 1.1 (0.9-1.3) 1.7 (1.3-2.3) 1.2 (1.0-1.4) Ischemia (1-3) 1.5 (1.2-1.8) 3.5 (2.0-6.5) 1.2 (0.9-1.4) Infection (0 3) 1.2 (1.0 1.3) 1.7 (1.3-2.1) 1.2 (0.9-1.4) Composite (2-9) 1.2 (1.1-1.2) 1.8 (1.5-2.0) 1.2 (1.0-1.3) Mean (0-3) 1.4 (1.2-1.6) 4.5 (3.1-6.5) 1.2 (1.0-1.5) Clinical stage (1-4) 1.1 (0.9-1.3) 2.2 (1.6-3.1) 1.1(0.9-1.2) Bypass only (n 1⁄4 592) Wound (0-3) 1.3 (1.1-1.5) 1.6 (1.2-2.3) 1.3 (1.0-1.6) Laura Capoccia, Maria Antonietta Panico, DaniloMenna, Pasqualino Sirignano, Wassim Mansour, Nunzio Montelione, Chiara Pranteda, Martina Formiconi, Francesco Speziale. “Sapienza” University of Rome, Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy; Maria Antonietta Panico, Vascular and Endovascular Surgery Division, Rome, Italy; Danilo Menna, Vascula and Endovascular Surgery Division, Rome, Italy; Policlinico Umberto I, Rome, Italy