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

BACKGROUND: To highlight clinical practice among referral (Hub, HH) or satellite (Spoke, SH) hospitals Vascular Surgery Units (VSUs) in Lombardy, during the COVID-19 pandemic "phase 1" period (March 8 - May 3, 2020). METHODS: The Vascular Surgery Group of Regione Lombardia Register, a real-word, multicenter, retrospective register was interrogated. All patients admitted with vascular disease were included. Patients' data on demographics, COVID-19 positivity, comorbidities and outcomes were extrapolated. Two cohorts were obtained: patients admitted to HH or SH. Primary endpoint was 30- day mortality rate. Secondary outcomes were 30-day complications and amputation (in case of peripheral artery disease [PAD]) rates. Univariate and multivariate analysis were used to compare HH and SH groups and predictors of poor outcomes. RESULTS: During the study period, 659 vascular patients in 4 HH and 27 SH were analyzed. Among these, 321 (48.7%) were admitted to a HH. No difference in COVID-19 positive patients was described (21.7% in HH vs 15.9% in SH; p=.058). After 30 days from intervention, HH and SH experienced similar mortality and no-intervention-related complication rate (12.1% vs 10.0%; p=.427 and 10.3% vs 8.3%; p=.377, respectively). Conversely, in HH postoperative complications were higher (23.4% vs 16.9%, p=.038) and amputations in patients treated for PAD were lower (10.8% vs 26.8%; p

The possibility of coming to a “good death” is a challenging issue that crosses ethical and religious beliefs, cultural assumptions, as well as medical expertise. The provision of palliative care for relieving patients’ pain is a practice that reshapes the path to the event of death and gives form to a particular context of awareness, recalling the notion proposed by Glaser and Strauss. This decision redesigns the relationships between patients, practitioners and caregivers and introduces a new pattern of collaboration between them. Our study focuses on the implications of the collaboration between practitioners and caregivers, starting from the assumption that the latter may provide support to their loved ones and to the practitioners, but need to be supported too. We provide a qualitative analysis of this collaboration based on an empirical research that took place in four different settings of provision of palliative care, reporting the contrast between the affective engagement of caregivers and the professional approach of practitioners. We claim that this ambivalent collaboration, while embedded in contingent and incommensurable experiences, brings to the fore the broader understanding of the path to a “good death,” outlining its societal representation as a collective challenge.

To evaluate the incidence of in-stent restenosis (ISR) at 12-month follow-up, in patients treated with new dual-layer Roadsaver (Terumo Corp, Tokyo, Japan) carotid artery stent (CAS). Thirteen patients underwent CAS and received a Roadsaver. Neurological examination was performed in all patients. Carotid stenosis was revealed by Doppler ultrasound (DUS) and multidetector CT (MDCT) scan. Four patients presented a peak systolic velocity (PSV) between 130 and 150 cm/s, six a PSV between 150 and 180 cm/s, and three a PSV > 180 cm/s. MDCT gave further anatomic information. Direct stenting was performed in 11 (84.6%) cases, whereas in 2 (15.4%) cases predilatation was required. In all cases postdilatation was performed. Technical and clinical success and safety were evaluated. Stent patency was evaluated during the 12-month follow-up. Technical success was achieved in all cases. In three patients a nonsignificant residual stenosis

Warfarin-related nephropathy is an unexplained acute kidney injury, and may occur in patients with supratherapeutic INR, in the absence of overt bleeding. Similar findings have been observed in rats treated with dabigatran etexilate. We conducted a prospective study in dabigatran etexilate-treated patients to assess the incidence of dabigatran-related nephropathy and to investigate the possible correlation between dabigatran plasma concentration (DPC) and worsening renal function. One hundred and seven patients treated long term with dabigatran etexilate for non-valvular atrial fibrillation (NVAF) were followed up for 90 days. DPC, serum creatinine (SCr) and serum cystatin C were prospectively measured. Ninety five patients had complete follow-up data and were evaluable for primary endpoint. Eleven patients had supratherapeutic DPC, defined as DPC higher than 200 ng/ml at study enrolment, but at the end of follow-up no patient showed a persistent increase in SCr. No patients experienced acute kidney injury. Our study shows that no persistent renal detrimental effect is associated with dabigatran treatment. An increase in SCr during dabigatran treatment is reversible and it seems to be unrelated to dabigatran itself.

Introduction In the treatment of patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), it is unclear which combination of antithrombotic drugs is preferable and which is the optimal duration of treatment. Areas covered The authors review the available evidence in this area resulting from single studies and meta-analyses. In the absence of direct head-to-head comparisons between different non-vitamin K oral anticoagulants (NOAC), the authors review the available studies with NOACS in these patients and derived indirect comparisons. Expert opinion In patients with AF who undergo PCI, a dual antithrombotic strategy which includes a NOAC plus single antiplatelet therapy with a P2Y12 inhibitor (preferably clopidogrel) should be considered as the preferred treatment option in most cases. Oral anticoagulation associated with dual antiplatelet therapy (triple antithrombotic therapy) should be offered for no longer than 30 days to patients with very high thrombotic and low hemorrhagic risk. It is unclear whether the dual antithrombotic strategy should be continued beyond 12 months in patients at high risk of thrombotic events. Additional data from adequately powered controlled studies are needed to support the long-term efficacy of this strategy and to establish the best patient-tailored approach in this complex scenario.

Background: Cancer patients experience multiple symptoms throughout the course of the disease. We aimed to provide a comprehensive analysis of the symptom burden in patients with advanced cancer at admission to specialist palliative care (PC) services and seven days later to estimate the immediate impact of PC intervention. Patient and methods: The analysis was based on an observational, prospective, multicenter study (named DEMETRA) conducted in Italy on new patients accessing network specialist PC centers during the period May 2017&ndash, November 2017. The prevalence and intensity of symptoms were assessed at baseline and after seven days using three tools including the Edmonton Symptom Assessment System (ESAS). Results: Five PC centers recruited 865 cancer patients. Thirty-three different symptoms were observed at the baseline, the most frequent being asthenia (84.9%) and poor well-being (71%). The intensity of the most frequent symptoms according to ESAS ranged from 5.5 for asthenia to 3.9 for nausea. The presence and intensity of physical symptoms increased with increasing levels of anxiety and depression. After seven days, prevalence of nausea and breathlessness as well as intensity of almost all symptoms significantly decreased. Conclusions: The study confirmed the considerable symptom burden of patients with advanced cancer. PC intervention has significantly reduced the severity of symptoms, despite the patients&rsquo, advanced disease and short survival.

Background: Dependency in older ages is increasing. Many older persons receive care while living in the community. We aimed to identify the predictive value of four clinical measurements to predict home care intensity in older patients following discharge from hospital to home care over 90days. Methods: We included 425 inpatients from the “Frailty Department–Local Palliative Care Network” of the local social health authority (ASST) Lecco, Italy (mean age 75.4years, SD 14.5; female 75.5%). Changes in Health, End-stage disease, and Signs and Symptoms, light version (CHESS-Lite), activities of daily living (ADL), frailty, and the Service Urgency Algorithm. Receiver operative curves were used to calculate thearea under the curve (AUC) for predicting Home Care Intensity coefficient (ratio of the number of days when any home care was provided 90days post-discharge). The interRAI Contact Assessment Instrument was used to calculate these measures. Results: Analysis was stratified using six different home care intensity score cut-offs. CHESS-Lite had a higher AUC for predicting home care intensity at all cut-off levels but was best for predicting the highest level of home care intensity (≥ 0.8) where the AUC was 0.71 (0.64–0.79). The frailty index also had an acceptable AUC. ADL had the lowest AUC. Conclusions: Health instability measured with CHESS-Lite has a high predictive value for identifying home care intensity in geriatric patients after discharge from hospital to home, especially in persons with higher home care intensity scores. Geriatric patients with high health instability should be focused on at discharge to prioritize assessment and initiate timely services for home care support.

Background: The aim of this study was to investigate the effect of the time interval from clinical presentation of arteriovenous graft thrombosis and the thrombectomy procedure by the AngioJet system in terms of technical and clinical success and to identify factors influencing success. Methods: A total of 60 consecutive patients (35 men and 25 women; mean age = 52 ± 7.89 years) who had undergone percutaneous thrombectomy by the AngioJet device from 2016 to 2019 were retrospectively enrolled. Demographics and fistula data, previous treatments, time from clinical onset of thrombosis to intervention, procedural details and complications were recorded. Technical and clinical success and primary and secondary patency rates were calculated. One-way analysis of variance was performed to test any correlation between patient-related and fistula/procedure-related variables and technical/clinical success. Odds ratio and relative risk were also calculated when necessary. Results: Technical success and clinical success were 95% and 91.7%, respectively. Post-interventional primary and secondary patency rates at 1 year were 72.5% and 84.3%, respectively. Complication rate was 6.7%. One-way analysis of variance showed that clinical success was higher in patients with no previous treatment (p = 0.015). Furthermore, clinical success was significantly associated with door to angiographic bed time (p = 0.002): p-value for the 24-h and the 72-h cut-off was 0.012 and 0.006, respectively. Conclusion: Percutaneous rheolytic thrombectomy is safe and effective for thrombosed arteriovenous grafts, with acceptable primary and secondary patency rates. Higher clinical success was found in patients never treated before and when the procedure was carried out within 24 h from the clinical onset of thrombosis.

Several arrhythmogenic substrates may generate narrow QRS complex tachycardia, frequently encountered in clinical practice. Some narrow QRS complex tachycardias, however, are sustained by an uncommon arrhythmogenic mechanism. Although rare, these forms should be taken into account in the differential diagnosis to avoid misdiagnosis and improper patient management. Dual atrioventricular node physiology can be responsible for different uncommon forms of narrow QRS complex tachycardia, also nonreentrant in mechanism. A ventricular origin also is possible, if the tachycardia site is located in the upper ventricular septum with fast ventricular propagation to the specific conduction system and narrowing of the QRS complex.

Symptomatic obstruction related to malignant involvement of large veins may occur in central veins both in the thoracic and pelvic regions, and in the abdominal region of the body. Both cases represent a therapeutic challenge, and endovascular revascularization, consisting of angioplasty and stent placement, is safe and effective. Superior vena cava stenting has become widespread in the management of occlusive venous disease. The percutaneous placement of large expandable metal stents allows rapid restoration of normal blood flow in the majority of patients, thus improving symptoms. Published data on the diagnosis and treatment of symptomatic cancer-related iliocaval obstructions are limited and mainly consist of case reports and small case series. The present review reports the current state of endovascular treatment for both superior vena cava occlusion and iliac compression syndrome in cancer patients.

The purpose of this study was to evaluate the safety and efficacy of uninterrupted and interrupted direct oral anticoagulant (DOAC) administration in patients undergoing pulmonary vein isolation (PVI).The optimal periprocedural management of DOACs in patients undergoing PVI is not well defined, and different strategies are used.A systematic search of PubMed/MEDLINE, Ovid/MEDLINE, and EMBASE was performed. Three strategies for periprocedural DOAC administration were considered: uninterrupted, mildly interrupted (12 h), and interrupted (≥12 h). Primary endpoints were major bleeding (MB) and thromboembolic (TE) complications; pooled weighted mean incidence (WMI) was calculated using a random-effects model. A secondary endpoint was the WMI of overall bleeding (OB).The analysis included 43 studies for a total of 8,362 patients. DOACs showed similar safety and efficacy in the 3 subgroups. The WMI of MB was 1.02%, 1.49%, and 1.17% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively; the WMI of TE complications was 0.16%, 0.46%, and 0.49% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively, with no heterogeneity. OB appeared to be higher in uninterrupted (6.33%) and mildly interrupted (8.62%) groups compared with the interrupted (3.53%), with substantial heterogeneity among studies. No interaction was found between the incidence of MB and TE complications and different DOACs.In patients undergoing PVI, these 3 anticoagulation strategies may have similar safety and efficacy in terms of MB and TE complications. OB appears to be higher in uninterrupted and mildly interrupted strategies compared with the interrupted strategy. No substantial differences were observed among DOACs regarding the incidence of MB and TE complications.

Objective: The aim of this study was to illustrate the characteristics of patients with palliative care (PC) needs, early identified by general practitioners (GPS), and to analyze their care process in home PC services. Background: Early identification and service integration are key components to providing quality palliative care (PC) services ensuring the best possible service for patients and their families. However, in Italy, PC is often provided only in the last phase of life and for oncological patients, with a fragmented service. Methods: Multicenter prospective observational study, lasting in total 18 months, implemented in a sample of Italian Home Palliative Care Units (HPCUs), enrolling and monitoring patients with limited life expectancy, early identified by 94 GPS. The study began on March 1, 2014 and ended on August 31, 2015. Results: Nine hundred thirty-seven patients, out of a total pool of 139,071, were identified by GPS as having a low life expectancy and PC needs. Of these, 556 (59.3%) were nononcological patients. The GPS sent 433 patients to the HPCUs for multidimensional assessment, and 328 (75.8%) were placed in the care of both settings (basic or specialist). For all patients included in the study, both oncological and nononcological patients, there was a high rate of death at home, around 70%. Discussion: This study highlights how a model based on early identification, multidimensional evaluation, and integration of services can promote adequate PC, also for noncancer patients, with a population-based approach.

To evaluate safety, technical and clinical success of embolization of type Ia endoleak (T1a EL) using ethylene–vinyl alcohol copolymer as embolic agent alone or in combination with other materials. Five patients presented T1a EL after endovascular repair of aortic aneurysms (EVAR) with radiological evidence of expanding sac size; in particular, three had contained rupture. In one patient, proximal cuff insertion was previously performed, in three patients proximal cuff was urgently inserted but T1a EL persisted; one patient, previously treated with Ovation Abdominal Stent Graft System, was directly proposed for endovascular treatment. In all cases, endovascular embolization was successfully performed and the transfemoral approach was always chosen; in one case it failed and translumbar approach by direct puncture of the sac was required. Used embolization agents were glue, ethylene–vinyl alcohol copolymer (Onyx) and coils in three cases, n-butyl cyanoacrylate and Onyx in one case, Onyx and coils in the last case. Technical success rate was 100% as well as clinical success. No major or minor complication, including non-target embolization, was registered. Clinical success was 100% until today and the sac diameter remained stable in four patients and decreased in one. Onyx may be considered a suitable embolic agent in the treatment of patients with type Ia endoleaks after EVAR, after failure of conventional treatments such as prolonged balloon inflation of the aortic neck or deployment of large bare stent.

Pulmonary Embolism (PE) incidence increases with age. Data on mortality and prognosis in elderly patients with suspected PE are lacking. (1) To assess 30- and 90-day mortality in subjects with PE from an elderly population seen in the emergency department (ED); (2) to test the prognostic accuracy of a simplified Pulmonary Embolism Severity Index (sPESI) coupled to a highly sensitive cardiac Troponin T (hs-cTnT) level. A retrospective cohort study was performed, including patients evaluated in the ED of Vimercate Hospital for clinically suspected PE from 2010 to 2012. Study population: n = 470, 63.4 % women, mean age ± SD 73.06 ± 16.0 years, 40 % aged ≥80 and 77.7 % ≥65 years old, confirmed PE: 22.6 % (106 cases). Within 30 and 90 days, mortality among patients with confirmed PE was 14.2 % (8.8–22.0) and 20.8 % (16.5–41.7). In subjects aged ≥80 years, 30-day mortality was 18.9 % among patients with confirmed PE, and 12.6 % among those with PE excluded (p = 0.317). Ninety-day mortality rates were 29.7 and 19.9 %, respectively (p = 0.193). In patients with confirmed PE, Negative Predictive Value of sPESI was 94.1 % (80.3–99.3) for 30 days and 88.2 % (72.3–96.7) for 90-day mortality. Adding the hs-cTnT level to sPESI did not improve its performance. (1) In an elderly population referring to the ED with clinically suspected PE, mortality was high both in subjects with and without confirmed PE; (2) the ability of sPESI and hs-cTnT to predict PE mortality seems to be lower than reported in studies based on data from younger populations. Better risk stratification tools will be necessary to improve clinical management in this setting.

Introduction D-dimer is commonly used in the workup of suspected Pulmonary Embolism (PE), but its specificity decreases with age. We evaluated whether using a higher cutoff value for D-dimer could increase the test specificity without reducing its sensitivity for ruling-out PE in elderly and very elderly patients presenting to the Emergency Department (ED). Material and Methods All patients with D-dimer and pulmonary Computed Tomography Angiography (CTA) performed in the ED of Vimercate Hospital, from 2010 through 2012 for clinical suspicion of PE were included in this retrospective cohort study. Results Study population 481 patients (63.4% women, mean age 73.0 ± 16.1 years, confirmed PE 22.5%). In very elderly patients (aged 80 or more years, n = 191), compared with standard 490 ng/mL D-dimer threshold, both higher fixed (1000 ng/mL) and age-adjusted cutoffs increase the specificity of D-dimer for the exclusion of PE maintaining a Negative Predictive Value of 100%. Potentially avoided CTAs were 12(6.3%) using 1000 ng/mL cutoff and 10(5.2%) age-adjusted. In very elderly patients the Number Needed to Test was incalculable for the standard cutoff (0 cases), 16 for 1000 ng/mL and 19 for age-adjusted. In patients with PE, index episode mortality was 6.5%, and death occurred only in subjects with D-dimer values above 1000 ng/mL and age-adjusted thresholds. Conclusion For very elderly patients with suspected PE in ED, both higher fixed D-dimer (1000 ng/mL) and age-adjusted thresholds increase test specificity for excluding PE without reducing its sensitivity, leading to a safe reduction in the number of CTAs.