Search

Bone marrow‐derived cells contribute to tissue repair, but traffic of hematopoietic stem/progenitor cells (HSPCs) is impaired in diabetes. We therefore tested whether HSPC mobilization with the CXCR4 antagonist plerixafor improved healing of ischemic diabetic wounds. This was a pilot, phase IIa, double‐blind, randomized, placebo‐controlled trial (NCT02790957). Patients with diabetes with ischemic wounds were randomized to receive a single subcutaneous injection of plerixafor or saline on top of standard medical and surgical therapy. The primary endpoint was complete healing at 6 months. Secondary endpoints were wound size, transcutaneous oxygen tension (TcO2), ankle‐brachial index (ABI), amputations, and HSPC mobilization. Twenty‐six patients were enrolled: 13 received plerixafor and 13 received placebo. Patients were 84.6% males, with a mean age of 69 years. HSPC mobilization was successful in all patients who received plerixafor. The trial was terminated after a preplanned interim analysis of 50% of the target population showed a significantly lower healing rate in the plerixafor vs the placebo group. In the final analysis data set, the rate of complete healing was 38.5% in the plerixafor group vs 69.2% in the placebo group (chi‐square P = .115). Wound size tended to be larger in the plerixafor group for the entire duration of observation. No significant difference was noted for the change in TcO2 and ABI or in amputation rates. No other safety concern emerged. In conclusion, successful HSPC mobilization with plerixafor did not improve healing of ischemic diabetic wounds. Contrary to what was expected, outside the context of hematological disorders, mobilization of diabetic HSPCs might exert adverse effects on wound healing., We randomized patients with diabetic ischemic wounds to receive stem cell mobilization with the CXCR4 antagonist plerixafor or placebo. Despite the fact that plerixafor successfully mobilized hematopoietic stem cells, no significant difference was observed between the two groups in the rates of wound healing and in surrogate measures of perfusion.

BACKGROUND We compared the outcomes of open surgical repair (OSR) versus endovascular aortic repair (EVAR) with parallel graft technique (PG) in patients with juxtarenal abdominal aortic aneurysm (JAAA) excluded from fenestrated endovascular aortic repair (FEVAR) due to clinical, anatomical, technical or manufacturing time reasons. METHODS A single-center analysis of consecutive patients who underwent elective and urgent (within 24-48 hours) repair of JAAA from January 2010 to January 2019 was performed. Two groups were compared: patients excluded from FEVAR and respectively treated by OSR or by PG for JAAA. Perioperative clinical, anatomic and operative data were collected in a dedicated database. The endpoints were primary technical success, changes in renal function, early and long-term mortality, freedom from aortic related reinterventions (ARRs) and aortic related mortality (ARM). RESULTS Overall, 118 consecutive patients were treated for JAAA, 32 of whom (27.1%) with FEVAR. Eighty-six patients were enrolled in the study (OSR group, N.=61; PG group, N.=25). The mean age was 77.4±6.5 years for PG group and 71.1±6.7 years for OSR group (P=0.0001); the average comorbidity score of the Society for Vascular Surgery was higher for patients treated by PG (10.2±4.8 vs. 5.5±0.4, P=0.0001), with no differences for hypertension and renal score. After propensity score matching, 42 patients (27 OSR, 15 PG) without differences in the preoperative risk factors were selected. Conical shape and neck mural thrombus were respectively more represented in the OSR group (95.1% vs. 56.0%; 63.9% vs. 36.0%). Aortic clamp site was supraceliac for 12 patients (19.7%), suprarenal for 21 (34.4%) and trans-renal for 28 patients (45.9%). In the PG group, 16 patients (64%) were treated with a single renal chimney. Primary technical success was similar in the two groups (100.0% vs. 92.0%, P=0.08), with a higher rate of procedure achieved by assisted technical success for the PG group after propensity score matching analysis (20.0% vs. 0%, P=0.04). Deterioration of renal function occurred for both groups of patients, with a significant creatinine increasing 12 months after surgery in the PG group compared with OSR group (1.72±0.66 vs. 1.18±0.40, P=0.006). Multiple logistic regression shows no independent predictor of peri-operative medical complication among demographics and pre-operative relevant clinical factors between the two cohorts. No difference in terms of early mortality was observed between the groups (1.6% vs. 0%, P=1.00). At 5 years, overall survival was lower for patients treated by PG (53.5% vs. 70.2%, P=0.007), such as freedom from ARRs (64.6 vs. 90.5%, P=0.03). Freedom from ARM at 5 years did not show significant differences among the two groups (100% vs. 98.4%, P=1.00). CONCLUSIONS PG represents a feasible procedure for patients excluded from FEVAR due to clinical, anatomical, technical or device manufacturing time reasons, ensuring low rates of ARM. However, ARRs during the follow-up remain the Achilles heel of this technique. OSR is still the most durable procedure in the endovascular era, allowing the treatment of proximal "hostile necks" with low rates of reoperation and a similar impact on the renal function compared to PG.

Background The purpose of this study was to evaluate how a multidisciplinary approach, including patients and familiar genetic counseling, preoperative succinate-dehydrogenase (SDH) gene mutation analysis, preoperative adjunctive endovascular procedures (PAEPs) and postoperative rehabilitative team may affect the outcomes in patients who underwent surgery for carotid body tumors (CBTs). Methods Fifty-seven consecutive CBT resections were performed from January 1995 to December 2019 in a single center institution. Two groups of patients were compared: group A (1995–2003; n = 10) and group B (2004–2019; n = 47), treated before and after the establishment of a multidisciplinary approach to CBTs. Group A and group B were evaluated retrospectively and prospectively for SDH mutations, respectively. PAEPs (external carotid artery stenting, percutaneous transfemoral embolization or direct percutaneous puncture of the tumor with simultaneous embolization) were performed only in patients of group B, when the size of the tumor exceeded the 45 mm. Primary endpoints were blood loss (BL) and cranial nerve injuries. Secondary endpoint was the number of new silent masses (NSMs) discovered after genetic evaluation. Results SDH mutations were found in 2 patients of group A and in 11 patients of group B. There were no significant differences in mass diameter between the groups. A significant difference regarding the surgical procedure time was observed in the 2 groups, with a higher time in the group A (Group A: 180 ± 77.3; Group B: 138 ± 54.5, P= 0.04). BL was significantly lower in group B (203 ± 69.5 mL vs. 356 ± 102 mL; P = 0.0001), as well as for patients underwent PAEPs vs. those underwent direct surgery (n = 15, 149 ± 53 mL vs. n = 42, 273 ± 88 mL; P = 0.0001). No differences between transient and persistent cranial nerve injuries were observed between the 2 groups. Carotid reconstruction was necessary for 2 patients of group A (n = 2 vs. n = 0; P = 0.02). Unilateral tumor recurrence was detected in 7 patients, with a significantly higher rate (P ≤ 0.002) in patients carrying SDH mutations compared to those without SDH mutation (wild-type). SDH mutations detected in the groups lead to discover 7 NSMs (group A n = 1 vs. group B n = 6; P = 1.00). Conclusion The impact of the multidisciplinary team suggests that surgical resection still remains the gold standard for the treatment of CBTs, but the use of PAEPs in selected cases may reduce surgical procedure time, BL and the need for reconstructive carotid surgery. Genetic counseling and SDH gene analysis allow to diagnose NSMs in asymptomatic patients. Larger studies should be considered to evaluate the effectiveness of postoperative rehabilitative program.

Both open surgical repair (OSR) and endovascular repair (EVAR) are characterized by possible early and long-term effects on renal function. In particular, contrast-induced nephropathy, endoluminal manipulation of juxtarenal aorta, the use of endografts with transrenal fixation, and the repeated contrast dye administration during follow-up may affect renal function in patients treated with EVAR. Furthermore, the use of endovascular techniques to treat juxtarenal and pararenal aneurysms (Chimney technique, fenestrated and branched endografts) raises additional concerns due to the need for renal artery cannulation and stenting. This chapter aims to review more than 10 years’ experience in the study of renal function following aortic surgery, with particular attention to long-term outcomes.

The aim of our study was to identify patients' characteristics that predicted a higher chance of arteriovenous graft patency in patients undergoing Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) implantation for hemodialysis access. The GHVG is a polytetrafluroethylene (PTFE) prosthesis with a nitinol-reinforced section (NRS) at the venous end. METHODS: All consecutive patients undergoing GHVG implantation for hemodialysis access at 10 tertiary referral centers between December 2013 and January 2018 were included in the study and compared with a control group of patients undergoing standard PTFE graft implantation. Selection of patients for hybrid graft implantation was based on the impossibility of autogenous vascular access creation. RESULTS: There were 145 patients included in the GHVG group and 218 in the PTFE group. In the GHVG and the PTFE groups, the mean age was 67 ± 13 years and 65 ± 13 years, and male patients totaled 52% and 46%, respectively. The technical success was 99%. The mean duration of the intervention was 100 minutes (median, 95 minutes; interquartile range, 80-120 minutes). The brachial-axillary configuration was used in the majority of cases (n = 78 [54%]). The 5-cm NRS length was prevalent (n = 108 [75%]). The median NRS oversize was 14% (interquartile range, 0%-21%). Mean follow-up was 13 months (range, 0-55 months). Seventy-one patients (49%) underwent at least one reintervention. Primary, assisted primary, and secondary patency estimates at 12 months were 44% ± 5%, 47% ± 5%, and 65% ± 4% for the GHVG group and 41% ± 4%, 53% ± 4%, and 75% ± 3% for the control group, respectively (P = NS). One-year survival was 90% ± 3%. On multivariable Cox regression analysis, hypotension (P < .001; hazard ratio [HR], 5.8; confidence interval [CI], 2.6-13) and diabetes (P = .024; HR, 1.9; CI, 1.1-3.2) were significant predictors of GHVG loss. A larger graft size was protective against GHVG loss (P = .042; HR, 0.73; CI, 0.54-0.99). The 10-cm-long graft showed a tendency toward improved patency but did not reach statistical significance (P = .074; HR, 0.48; CI, 0.21-1.07). CONCLUSIONS: Diabetes and hypotension were predictors of loss of hybrid arteriovenous access. Smaller diameters of NRS were more prone to thrombosis, whereas the 10-cm length seemed to perform better than the 5-cm one.

Renal artery aneurysms (RAAs) are localized dilatations of the renal artery or its branches, exceeding twice the diameter of the native artery. They are uncommon and their treatment is often a challenge for the vascular surgeon.

The optimal vascular access for elderly patients remains a challenge due to the difficult balance between risks and benefits in a population with increased comorbidity and decreased survival. Long dependence to central vein catheter, patient comorbidities, life expectancy, and complication rates are important influencing the indications for arteriovenous fistula or an arteriovenous graft. Although central vein catheters are simpler way to start a hemodialysis treatment, elderly patients are also at higher risk of death from infection or other complications associated with them more than for younger patients. The discussion revolves around the following key questions: What are the limiting factors for a vascular access in the elderly patients? Central venous catheter—is it still an option for elderly patients? Is still the autologous arteriovenous fistula playing a pivotal role as hemodialysis access in the elderly patients? Are there any real surgical contraindication to perform a vascular access in elderly patients? Is the old age a limiting factor for the vascular access management?

Background and aims Diabetes is traditionally associated with vascular calcification, but the molecular mechanisms are largely unknown. We herein explored the relationships among carotid plaque calcification, composition and gene expression, and how these are modified by diabetes. Methods We collected carotid endoarterectomy specimen from 59 patients, of whom 23 had diabetes. We analysed histology with pentachromic staining, calcification with Alizarin red and Von Kossa's staining, chemical calcium extraction and quantification, as well as gene expression by quantitative PCR. Results We detected no differences in the extent of plaque calcification and in plaque composition between diabetic and non-diabetic patients. In non-diabetic plaques, calcium content was directly correlated with the area occupied by muscle/fibrinoid tissue and inversely correlated with collagen, but such correlations were not seen in plaques from diabetic patients. While consistent correlations were found between calcium content and RUNX2 (direct), as well as Osteopontin (inverse), diabetes modified the association between plaque calcification and inflammatory gene expression. Only in diabetic plaques, calcium content was inversely correlated with MCP1 and IL1b, whereas the direct correlation with TNF-alpha expression seen in non-diabetic plaques was lost in diabetes. Conclusions Though plaque composition and calcification were not quantitatively affected, diabetes modified the relationships between plaque calcium, composition and inflammation. These results suggest that the mechanisms and the clinical significance of atherosclerotic calcification in diabetic may be different than in non-diabetic patients.

We investigated the in vivo pressor effects of the potent vasoconstrictor Urotensin II (UII). We randomized normotensive Sprague-Dawley rats into 4 groups that received a 7-day UII infusion (cases) or vehicle (controls). Group 1 received normal sodium intake; Group 2 underwent unilateral nephrectomy and salt loading; Group 3 received spironolactone, besides unilateral nephrectomy and salt loading; Group 4 only received spironolactone. UII raised BP transiently after a lag phase of 12-36 hours in Group 1, and progressively over the week in Group 2. Spironolactone did not affect blood pressure, but abolished both pressor effects of UII in Group 3, and left blood pressure unaffected in Group 4. UII increased by 7-fold the renal expression of renin in Group 2, increased aldosterone synthase expression in the adrenocortical zona glomerulosa, and prevented the blunting of renin expression induced by high salt. UII raises BP transiently when sodium intake and renal function are normal, but progressively in salt-loaded uninephrectomized rats. Moreover, it increases aldosterone synthase and counteracts the suppression of renin induced by salt loading. This novel action of UII in the regulation of renin and aldosterone synthesis could play a role in several clinical conditions where UII levels are up-regulated.

Background In cases of multilevel obstructive atherosclerotic disease, hybrid procedures of concomitant iliac artery stenting and femoro-popliteal bypass (IS-FPB) may represent a valid approach, but results are still unclear. The aim was to evaluate early and long-term outcomes of concurrent IS-FPB. Methods This retrospective study included 75 patients (76 limbs) treated with concomitant IS-FPB between January 2010 and June 2016. All patients were prospectively enrolled in a dedicated database. Long-term patency and limb salvage rates were reported using Kaplan-Meier curves. Clinical presentation, lesion sites and extension, distal runoff, type of stent, and bypass were evaluated for their association with patency using univariate and multivariate analysis. Results Mean age was 72.2 ± 9.4 years; the Society for Vascular Surgery comorbidity score was 1.14 ± 0.61. A covered stent (CS) was implanted in 41 (54%) iliac arteries and a bare-metal stent in 35 (46%); a polytetrafluoroethylene graft was used for bypass in 44 limbs (58%) while 32 limbs (42%) had great saphenous vein bypass. Technical success was 99%; the 30-day cumulative surgical complications rate was 6%, mortality 2%, and morbidity 1%. At 42 months, primary patency of the entire ilio-femoral axis was 65.2% (95% confidence interval [CI], 53–86%). This finding was primarily related to femoro-popliteal bypass occlusion (primary patency, 69.5%), rather than iliac stent loss of patency (primary patency, 94.6%). Secondary patency was 77.6% and limb salvage 89.9%. Univariate analysis demonstrated that Rutherford category 5/6 was a negative predictor of FPB patency (P = 0.04), whereas common femoral artery endarterectomy (P = 0.03) and the use of a CS (P = 0.02) were positive predictors. Multivariate analysis finally indicated that the use of CS to treat iliac obstructive disease was an independent predictor of patency (hazard ratio, 0.15; 95% CI, 0.03–0.64; P = 0.01). Conclusions Concurrent IS-FPB has acceptable early and long-term results. Even if further studies are needed, the use of a CS for the iliac obstruction seem to provide better outcomes in the hybrid treatment of these cases of multilevel disease.

Purpose: To define the risk for type II endoleak (EII) after endovascular aneurysm repair (EVAR) based on preoperative anatomical characteristics. Methods: Between January 2008 and December 2015, 189 patients (mean age 78.4 +/- 7.6 years; 165 men) underwent standard EVAR. Mean aneurysm diameter was 5.7 +/- 0.7 cm and mean volume 125.2 +/- 45.8 cm(3). Patients were assigned to the at-risk group (n=123, 65%) when at least one of the following criteria was present: patency of a >3-mm inferior mesenteric artery (IMA), patency of at least 3 pairs of lumbar arteries, or patency of 2 pairs of lumbar arteries and a sacral artery or accessory renal artery or any diameter patent IMA; otherwise, patients were entered in the 'low-risk" group (n=66, 35%). EII rates and freedom from EII reintervention were compared using Kaplan-Meier curves. Preoperative clinical and anatomical characteristics were evaluated for their association with EII and EII reinterventions using multiple logistic regression analysis; results are presented as the odds ratio (OR) and 95% confidence interval (CI). Results: Freedom from endoleak was lower in the at-risk group compared with the low-risk group at 36 months after EVAR (p=0.04). Freedom from EII-related reinterventions was significantly lower in the at-risk group (80% vs 100%, p=0.001) at 48 months. Based on the multiple regression analysis, the at-risk group had a higher likelihood of both EII (OR 9.91, 95% CI 2.92 to 33.72, p

Objectives The aim was to compare outcomes of self expanding PTFE covered stents (CSs) with bare metal stents (BMSs) in the treatment of iliac artery occlusions (IAOs). Methods Between January 2009 and December 2015, 128 iliac arteries were stented for IAO. A CS was implanted in 78 iliac arteries (61%) and a BMS in 50 (49%). After propensity score matching, 94 limbs were selected and underwent stenting (47 for each group). Thirty day outcomes and midterm patency were compared; follow-up results were analysed with Kaplan–Meier curves. Results Overall, iliac lesions were classified by limb as TASC B (19%), C (21%), and D (60%). Technical success was 98%. Comparing CS versus BMS, the early cumulative surgical complication rate (12% vs. 12%, p = 1.0) and 30 day mortality rate (2% vs. 2%, p = 1.0) were equivalent. At 36 months (average 23 ± 17), overall primary patency was similar between CS and BMS (87% vs. 66%, p = .06), and this finding was maintained after stratification by TASC B ( p = .29) and C ( p = .27), but for TASC D, CSs demonstrated a higher patency rate (CS, 88% vs. BMS, 54%; p = .03). In particular, patency was in favour of CSs for IAOs > 3.5 cm in length ( p = .04), total lesion length > 6 cm ( p = .04), and IAO with calcification > 75% of the arterial wall circumference ( p = .01). Conclusions Overall, the use of self expanding CS for IAOs has similar early and midterm outcomes compared with BMS. Even if further confirmatory studies are needed, CSs seem to have higher midterm patency rates than BMSs for TASC D lesions, IAOs with a total lesion length > 6 cm, occlusion length > 3.5 cm, and calcification involving > 75% of the arterial wall circumference. These specific anatomical parameters may be useful to the operator when deciding between CS and BMS during endovascular planning.

OBJECTIVE: The aim of this study was to evaluate outcomes of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) in patients considered at risk for type II endoleak (EII), using a sac volume-dependent dose of fibrin glue and coils. METHODS: Between January 2012 and December 2014, 126 patients underwent EVAR. Based on preoperative computed tomography evaluation of anatomic criteria, 107 patients (85%) were defined as at risk for EII and assigned to randomization for standard EVAR (group A; n = 55, 44%) or EVAR with intraoperative sac embolization (group B; n = 52, 42%); the remaining 19 patients (15%) were defined as at low risk for EII and excluded from the randomization (group C). Computed tomography scans were evaluated with OsiriX Pro 4.0 software to obtain aneurysm sac volume. Freedom from EII, freedom from EII-related reintervention, and aneurysm sac volume shrinkage at 6, 12, and 24 months were compared by Kaplan-Meier estimates. Patients in group C underwent the same follow-up protocol as groups A and B. RESULTS: Patient characteristics, Society for Vascular Surgery comorbidity scores (0.99 ± 0.50 vs 0.95 ± 0.55; P = .70), and operative time (149 ± 50 minutes vs 157 ± 39 minutes; P = .63) were similar for groups A and B. Freedom from EII was significantly lower for group A compared with group B at 3 months (58% vs 80%; P = .002), 6 months (68% vs 85%; P = .04), and 12 months (70% vs 87%; P = .04) but not statistically significant at 24 months (85% vs 87%; P = .57). Freedom from EII-related reintervention at 24 months was significantly lower for group A compared with group B (82% vs 96%; P = .04). Patients in group B showed a significantly overall mean difference in aneurysm sac volume shrinkage compared with group A at 6 months (-11 ± 17 cm(3) vs -2 ± 14 cm(3); P < .01), 12 months (-18 ± 26 cm(3) vs -3 ± 32 cm(3); P = .02), and 24 months (-27 ± 25 cm(3) vs -5 ± 26 cm(3); P < .01). Patients in group C had the lowest EII rate compared with groups A and B (6 months, 5%; 12 months, 6%; 24 months, 0%) and no EII-related reintervention. CONCLUSIONS: This randomized study confirms that sac embolization during EVAR, using a sac volume-dependent dose of fibrin glue and coils, is a valid method to significantly reduce EII and its complications during early and midterm follow-up in patients considered at risk. Although further confirmatory studies are needed, the faster aneurysm sac volume shrinkage over time in patients who underwent embolization compared with standard EVAR may be a positive aspect influencing the lower EII rate also during long-term follow-up.

Objective This study compared early and midterm outcomes of polytetrafluoroethylene-covered stents (CSs) vs bare-metal stents (BMSs) in the primary treatment of severe TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) C and D iliac artery obstructive lesions. Methods Between January 2009 and June 2014, 128 patients underwent stenting of 167 iliac arteries; CSs were implanted in 82 iliac arteries (49%) and BMSs in 85 (51%). All patients were prospectively enrolled in a dedicated database. Thirty-day outcomes, mid-term patency, limb salvage, and survival were compared, and follow-up results were analyzed with Kaplan-Meier curves. Clinical presentation, lesion site, extension, and laterality were evaluated for their association with patency in the two groups using multiple logistic regressions. Results Patients were a mean age of 70 ± 10.3 years, The Society for Vascular Surgery comorbidity score was 0.89 ± 0.57, with no differences after stratification by CS and BMS ( P = .17). Iliac lesions were classified by limb as TASC II C in 86 (51%) and D in 81 (49%). Comparing CS and BMS, technical success was 99% in both groups ( P = 1.0); the 30-day cumulative surgical complications rate (7.3% vs 4.7%; P = .53), mortality (1.8% vs 0%; P = .45), and morbidity (1.8% vs 1.4%; P = .99) were equivalent. At 24 months (average 22 months; range, 30 days-56 months), primary patency of CS vs BMS was similar (93% vs 80%; P = .14), and this finding was maintained after stratification by TASC II C (97% vs 93%; P = .59) and D (88% vs 61%; P = .07); secondary patency was 98% vs 92% ( P = .22), and limb salvage was 99% and 95% ( P = .35) respectively. Multivariate analysis indicated that BMS in long-segment stenosis involving the common and external iliac arteries was a negative predictor of patency (odds ratio, 0.16; 95% confidence interval, 0.04-0.62; P = .007); within this subgroup of TASC II D lesions, primary patency at 24 months was significantly higher for CS than for BMS (88% vs 57%; P = .03). Conclusions Overall, the use of CSs for severe iliac lesions has similar early and midterm outcomes compared with BMS. In a subcategory of TASC II D lesions with long-segment severe stenosis of both the common and external iliac arteries, CS should be considered as the primary line of treatment.

Objectives: The aim was to describe and analyze the management of hemothorax (HTX) and the occurrence of respiratory complications after endovascular repair of thoracic aortic rupture (TEVAR). Methods: This was a multicenter study with retrospective analysis. Between November 2000 and December 2012, all patients with confirmed HTX due to rupture of the descending thoracic aorta treated with TEVAR were included. Respiratory function (acid base status, Pao(2), Paco(2), lactate, and respiratory index) was monitored throughout hospitalization. Primary endpoints were survival and post-operative respiratory complications. Results: Fifty-six patients were treated. The mean age was 62 21 years (range 18-92 years). Etiology included traumatic rupture (n = 23, 41%), atherosclerotic aneurysm (n = 20, 36%), Debakey type II la dissection (n = 8, 14%), and penetrating aortic ulcer (n = 5, 9%). The primary technical success of TEVAR was 100%. The in hospital mortality rate was 12.5% (n = 7). Hemothorax was drained in 21 (37.5%) cases. In hospital respiratory complications occurred in 23 (41%) patients who required a longer intensive care unit stay (days 2.3 +/- 0.7 vs. 1.9 +/- 0.8, p = .017), and hospitalization (26 +/- 17 vs. 19 +/- 17, p = .021). Those who developed post-Operative respiratory complications had lower pre-operative PO2 values (mmHg, 80 +/- 24 vs. 91 +/- 21, p =.012). Respiratory complications and in hospital mortality did not differ among aortic pathologies (p = .269 and p = 1.0, respectively), nor did in hospital mortality differ between patients with and without respiratory complications (13% vs. 12%; p = .990). Conclusions: Thoracic aortic rupture still has a high mortality rate. Respiratory complications have not been eliminated by endovascular repair. HTX evacuation may have had a positive influence on the survival in these patients. Although traumatic and degenerative ruptures are two significantly different scenarios, survival and respiratory outcomes were similar and were not affected by the underlying aortic disease. (C) 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. OI Castelli, Patrizio/0000-0002-0709-6936 Objectives: The aim was to describe and analyze the management of hemothorax (HTX) and the occurrence of respiratory complications after endovascular repair of thoracic aortic rupture (TEVAR). Methods: This was a multicenter study with retrospective analysis. Between November 2000 and December 2012, all patients with confirmed HTX due to rupture of the descending thoracic aorta treated with TEVAR were included. Respiratory function (acid base status, Pao(2), Paco(2), lactate, and respiratory index) was monitored throughout hospitalization. Primary endpoints were survival and post-operative respiratory complications. Results: Fifty-six patients were treated. The mean age was 62 21 years (range 18-92 years). Etiology included traumatic rupture (n = 23, 41%), atherosclerotic aneurysm (n = 20, 36%), Debakey type II la dissection (n = 8, 14%), and penetrating aortic ulcer (n = 5, 9%). The primary technical success of TEVAR was 100%. The in hospital mortality rate was 12.5% (n = 7). Hemothorax was drained in 21 (37.5%) cases. In hospital respiratory complications occurred in 23 (41%) patients who required a longer intensive care unit stay (days 2.3 +/- 0.7 vs. 1.9 +/- 0.8, p = .017), and hospitalization (26 +/- 17 vs. 19 +/- 17, p = .021). Those who developed post-Operative respiratory complications had lower pre-operative PO2 values (mmHg, 80 +/- 24 vs. 91 +/- 21, p =.012). Respiratory complications and in hospital mortality did not differ among aortic pathologies (p = .269 and p = 1.0, respectively), nor did in hospital mortality differ between patients with and without respiratory complications (13% vs. 12%; p = .990). Conclusions: Thoracic aortic rupture still has a high mortality rate. Respiratory complications have not been eliminated by endovascular repair. HTX evacuation may have had a positive influence on the survival in these patients. Although traumatic and degenerative ruptures are two significantly different scenarios, survival and respiratory outcomes were similar and were not affected by the underlying aortic disease. (C) 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. OI Castelli, Patrizio/0000-0002-0709-6936

Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center's experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.

OBJECTIVES We sought to establish whether a reduction in endothelial progenitor cells (EPCs) has a putative role in peripheral vascular disease (PVD) of type 2 diabetic patients. BACKGROUND Peripheral vascular disease is a common and severe complication of diabetes mellitus. Impaired collateralization of diabetic vasculopathy has been extensively shown, but causes leading to its pathogenesis are not fully understood. Recently, EPCs have been found to contribute to vascular repair and angiogenesis. Diabetes has been associated with low levels of circulating EPCs, but no data are available in the literature on the relationship between EPCs and PVD in diabetes. METHODS Flow cytometric analysis was used to quantify circulating progenitor cells (CPCs, CD34+) and EPCs (CD34+KDR+) in 51 patients and 17 control subjects. RESULTS The CPCs and EPCs from diabetic patients were reduced by 33% and 40%, respectively, compared with healthy subjects (p < 0.001). An inverse correlation was found between the number of EPCs and the values of fasting glucose (r = -0.49, p = 0.006). Peripheral vascular disease was associated with a 47% reduction in EPCs (p < 0.0001) and EPC levels directly correlated with the ankle-brachial index (r = 0.70, p = 0.01). The subgroup of diabetic patients with PVD also had reduced CPCs by 32% (p = 0.037), whereas patients with ischemic foot lesions had the lowest levels of both EPCs and CPCs (p = 0.02). CONCLUSIONS Our data demonstrate decreased EPC levels in diabetic patients and, for the first time, show that PVD is associated with an extensively low number of EPCs. Depletion of circulating EPCs in diabetic patients may be involved in the pathogenesis of peripheral vascular complications.

A new endovascular procedure is reported to treat bilateral common iliac artery (CIA) aneurysms extending to both iliac bifurcations.The left internal iliac artery (IIA) was first embolised, two overlapped Viabahn endografts were delivered from the right IIA to the distal aorta and, finally, CIA aneurysms excluded using iliac contralateral leg and extension endografts from the distal aorta to both external iliac arteries, applying a combined 'chimney-graft/double-barrel' technique.This procedure may extend the limits of conventional iliac endografting by preserving blow flow to at least one IIA using off-label commercially available devices, avoiding associated open surgical procedures. © 2010 European Society for Vascular Surgery.

Objectives Endovascular treatment of distal abdominal aortic aneurysms (D-AAA) and bilateral common iliac artery aneurysms (BCIAA) may present technical challenges for standard EVAR. Parallel iliac leg endografts (ILEs) of standard aortic devices and covered stents have been successfully employed to treat patients with D-AAA and BCIAA. The perioperative and long-term results of this straightforward endovascular technique are presented. Methods Beginning in 2009, patients deemed unfit for open surgery underwent parallel endografts D-AAA and BCIAA exclusion. Avoiding the use of a main body, ILEs are simultaneously delivered from both femoral arteries, landing parallel into the aortic neck (parallel grafts: PG). Distal landing zones including external iliac arteries (EIAs) are reached using appropriate ILEs. A third parallel covered stent graft (Viabahn, Gore) is delivered from a left brachial approach to maintain prograde blood flow to one internal iliac artery (IIA) when needed. Results Eighteen patients were successfully treated using parallel endografts, nine for BCIAA and nine for D-AAA. All D-AAA presented an irregular saccular shape, including three penetrating aortic ulcers and two pseudoaneurysms of previous aortic grafts. Prograde flow to one IIA was successfully maintained using a Viabahn graft in five patients with BCIAA. Mean aneurysm size was 50 mm in D-AAA and 43 mm in BCIAA. One patient required a perioperative ILE extension to treat a type Ib endoleak. One patient suffered a minor stroke 24 hours after the procedure. Two type II endoleaks were observed postoperatively. Five patients died of non-aneurysm related causes during follow-up. No new endoleaks, graft displacements or occlusions were observed during follow-up (median: 26 months, range 12–42 months). Conclusions Successful exclusion of D-AAA and BCIAA was achieved in high-risk patients using parallel endografts, allowing antegrade blood flow to one IIA when needed. Commercially available endografts were used in a simple and effective approach, with excellent follow-up results.

ObjectiveThis single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center.MethodsFrom January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was 60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up.ResultsThirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter

Objective Consistent long-term follow-up data of thoracic endovascular repair (TEVAR) for acute blunt thoracic aortic injury (BTAI) are largely absent at this time. The late outcomes of TEVAR for BTAI are the focus of this study to evaluate the durability of this type of repair. Methods The records of 46 consecutive cases of TEVAR for BTAI from November 2000 to August 2012 were reviewed. Patient demographics, lesion characteristics, procedure details, and outcomes were recorded. We performed a clinical and body computed tomography angiography follow-up at 1, 6, and 12 months after the intervention; thereafter, it was done on a yearly basis if device-related defects were ruled out. Results There were 35 (76.1%) males. Mean age was 39 ± 18 years (range, 17-92). Indications for intervention were BTAI at the aortic isthmus in 73.9% (n = 34) of the cases, and in the proximal one-half of the descending thoracic aorta in the remaining 26.1% (n = 12). Pseudoaneurysm or free rupture accounted for 44 (95.6%) cases. Primary technical success was obtained in all cases. All patients survived the intervention, open conversion was never required, and no patient required reintervention. In-hospital mortality was 6.5% (n = 3). Mean follow-up was 66 ± 46 months (range, 1-144; median, 72). No patient was lost during this period. All patients who were discharged from the hospital are still alive. Aortic hematoma or hemothorax were completely reabsorbed in 42 (97.7%) cases. Endoleak or modifications of the native aorta were never detected; endograft-related complication was observed in one (2.3%) case only. An asymptomatic collapse was observed at a 36-month follow-up and was managed conservatively. Conclusions Midterm follow-up of TEVAR for acute BTAI is feasible with satisfactory late outcomes. In our experience, TEVAR is a durable and definitive treatment for BTAI.

ObjectiveRecent studies have shown that progressive renal dysfunction may develop in patients after endovascular aneurysm repair (EVAR). Data are conflicting about the effect of EVAR on renal function compared with open repair (OR). The purpose of this study was to compare the effects of EVAR, both with transrenal fixation (TRF) and infrarenal fixation (IRF), vs OR on renal function detected with renal perfusion scintigraphy (RPS).MethodsA prospective study was carried out from January 2003 to December 2007. Exclusion criteria included factors that could influence post-procedural renal function as: preoperative creatinine clearance level 60%, renal accessory artery planned to be covered by the endograft, single functioning kidney, hemodialysis, and kidney transplant. To evaluate renal function, an RPS was performed preoperatively, at 30 days, at 6 and 12 months, and then yearly. The glomerular filtration rate (GFR) was estimated with the Gates method.ResultsDuring the study period, 403 patients were enrolled; 243 (60%) had OR and 160 (40%) EVAR; among these, 83 (51%) had a TRF and 77 (48%) an IRF; 55 patients were excluded from the study. No statistical differences were observed between groups for demographics and risk factors. Statistically significant differences emerged between OR and EVAR for early postoperative death (4% vs 0%; P = .01). Follow-up ranged from 54 to 126 months (mean, 76 months) for OR and from 54 to 124 months (mean, 74 months) for EVAR (P = NS). Kaplan-Meier analysis survival rate at 9 years was 70% for OR and 58% for EVAR with a risk of secondary procedure of 9% and 34%, respectively (P < .0001). A deterioration of the GFR was observed during the follow-up in both groups with a decrease after 9 years of 11% in the EVAR group and 3% in the OR group respective to baseline (P < .001). A remarkable difference emerged on renal function between EVAR patients who required a secondary procedure compared with the other EVAR patients (P < .005). No significant differences emerged between TFR and IRF for GFR decline during the follow-up period.ConclusionsAfter EVAR, there is a continuous decline in renal function with respect to OR, regardless of fixation level and independently of pre-existing renal insufficiency. The risk of GFR impairment after EVAR should be taken into consideration in selecting patients with preoperative renal insufficiency.

PURPOSE To describe modification of the Viabahn Padova Sutureless (ViPS) technique for challenging anastomosis between a prosthetic graft and a circumferentially calcified target artery. TECHNIQUE The technique is demonstrated in a 75-year-old man with complete superficial femoral artery (SFA) occlusion and reconstitution of a circumferentially calcified above-knee popliteal artery. A 7-mm Viabahn endoprosthesis with its constraining string was withdrawn from its delivery system; the string at the proximal edge of the stent was gently cut with a scalpel, causing the proximal part of the stent to deploy, while the undeployed distal tip with its smooth profile retained its commercial orientation. The proximal end was subsequently sutured to a 7-mm polytetrafluoroethylene (PTFE) graft. After surgical exposure, the popliteal artery was transected, and the undeployed distal portion of the Viabahn was inserted into the distal segment, supported by a stiff guidewire. By pulling the constraining string, the stent was deployed in a "non-reversed" fashion and subsequently dilated to achieve optimal apposition. Finally, the proximal end of the PTFE graft was tunneled under the sartorius muscle and sutured to the common femoral artery. CONCLUSION This modification to the ViPS technique using a "non-reversed" method of Viabahn stent preparation allows a safer and more accurate deployment of the endoprosthesis in the calcified target artery.

Ischemic recruitment of endothelial progenitor cells (EPCs) in involved in compensatory angiogenic in animal models, but this still needs to be substantiated in humans. We enrolled 12 patients, who underwent surgical correction of abdominal aortic aneurysm without atherosclerosis of leg arteries (n = 4) or lower limb atherosclerosis obliterans (AO; n = 8). We measured VEGF, SDF-1, lactate and CD34 + KDR + EPCs in the arterial and venous circulation of lower limbs. We found that, irrespectively of AO stage and lactate production, there was no consistent arterio-venous gradient of EPC, VEGF and SDF-1. Notably, in 4/8 patients, EPCs were more abundant in the vein than in the artery. EPC gradient was directly correlated with VEGF gradient and inversely correlated with SDF-1 gradient. In conclusion, we failed to show any consistent gradient of EPCs across ischemic limbs in relation to severity of atherosclerosis obliterans, but we speculatively suggest that a bidirectional traffic of EPCs in and out the ischemic tissue might be regulated by VEGF and SDF-1.

Rationale: Acquisition of a procalcific phenotype by resident or circulating cells is important for calcification of atherosclerotic plaques, which is common in diabetes. Objective: We aim to identify and characterize circulating calcifying cells, and to delineate a pathophysiological role for these cells in type 2 diabetes. Methods and Results: We demonstrate for the first time that a distinct subpopulation of circulating cells expressing osteocalcin and bone alkaline phosphatase (OC + BAP + ) has procalcific activity in vitro and in vivo. The study of naïve patients with chronic myeloid leukemia indicated that OC + BAP + cells have a myeloid origin. Myeloid calcifying OC + BAP + cells (MCCs) could be differentiated from peripheral blood mononuclear cells, and generation of MCCs was closely associated with expression of the osteogenic transcription factor Runx2. In gender-mismatched bone marrow–transplanted humans, circulating MCCs had a much longer half-life compared with OC − BAP − cells, suggesting they belong to a stable cell repertoire. The percentage of MCCs was higher in peripheral blood and bone marrow of type 2 diabetic patients compared with controls but was lowered toward normal levels by optimization of glycemic control. Furthermore, diabetic carotid endoarterectomy specimens showed higher degree of calcification and amounts of cells expressing OC and BAP in the α-smooth muscle actin–negative areas surrounding calcified nodules, where CD68 + macrophages colocalize. High glucose increased calcification by MCCs in vitro, and hypoxia may regulate MCC generation in vitro and in vivo. Conclusions: These data identify a novel type of blood-derived procalcific cells potentially involved in atherosclerotic calcification of diabetic patients.

A left renal artery aneurysm (RAA) was incidentally discovered in a 50-year-old hypertensive woman at renal artery duplex scan. The computed tomography angiography scan confirmed an eccentric, 2-cm large aneurysm localized on a prehilar branch with a very twisted and coiled main renal artery. The selective digital subtraction angiography allowed a better understanding of the local complex anatomy; a covered stent was placed with the complete exclusion of the aneurysm. Even if open surgery still represents the treatment of choice, endoluminal approach has been reported as an effective procedure especially in consideration of its low invasiveness. The exclusion by covered stent can be a safe alternative to coil embolization in case of distal RAAs as well.

Objective— Peripheral arterial disease (PAD) is a threatening complication of diabetes. As endothelial progenitor cells (EPCs) are involved in neovasculogenesis and maintenance of vascular homeostasis, their impairment may have a role in the pathogenesis of diabetic vasculopathy. This study aimed to establish whether number and function of EPCs correlate with PAD severity in type 2 diabetic patients. Methods and Results— EPCs were defined by the expression of CD34, CD133 and KDR, and quantified by flow cytometry in 127 diabetic patients with and without PAD. PAD severity has been assessed as carotid atherosclerosis and clinical stage of leg atherosclerosis obliterans. Diabetic patients with PAD displayed a significant 53% reduction in circulating EPCs versus non-PAD patients, and EPC levels were negatively correlated with the degree of carotid stenosis and the stage of leg claudication. Moreover, the clonogenic and adhesion capacity of cultured EPCs were significantly lower in diabetic patients with PAD versus patients without. Conclusions— This study demonstrates that EPC decrease is related to PAD severity and that EPC function is altered in diabetic subjects with PAD, strengthening the pathogenetic role of EPC dysregulation in diabetic vasculopathy. EPC count may be considered a novel biological marker of peripheral atherosclerosis in diabetes.

Objectives Conversion of a previous endovascular aneurysm repair (EVAR) with suprarenal fixation is a challenging situation even in the elective setting. The outcomes of a technique based on preservation of the first proximal covered stent of the endograft, used as a “neo-neck” for proximal anastomosis, are presented. Methods From 2001 to 2014, nine patients underwent elective conversion of a previous suprarenally fixed EVAR. After supraceliac clamping, the aneurysm sac was opened and the endograft identified; the fabric was cut beyond the first covered stent together with its native aortic wall in order to create a “neo-neck.” An aortic balloon was inflated into the visceral aorta to avoid back bleeding. A Dacron bifurcated tube graft (Intergard, Maquet) was then sutured to the neo-neck mimicking endobanding, passing the stitches into the aortic wall and the first covered stent. Results The mean age was 68 years (range, 52–84 years). The stent grafts removed were four Zenith (Cook Medical), three Endurant (Medtronic), and two E-vita (Jotec). The indication for conversion was type 1A ( n = 2), type 2 ( n = 2), and type 3 ( n = 1) endoleak, complete endograft thrombosis ( n = 2), and abdominal pain with sac enlargement with no radiological sign of endoleak ( n = 2). Blood loss was 1,428 mL (range 500–3,000 mL); the visceral ischemic time to perform the proximal anastomosis was 23.5 min ± 2.3 min). The post-operative complication rate was 11% ( n = 1/9) related to a case of sac wall bleeding requiring re-intervention; mortality at 30 days was 0%. At 22 months (range, 8–41) the computed tomography angiogram demonstrated no signs of leaks or anastomotic pseudoaneurysm. Conclusion Preservation of the proximal covered stent of an endograft with suprarenal fixation used as an infrarenal “neo-neck” with incorporation of the aorta to the suture line during elective surgical explantation simplifies the procedure, and can be achieved with very low early morbidity and mortality; furthermore, it seems to be durable over mid-term follow up.

Diagnosis of carotid body tumor (CBT) was made in a 36 years old woman. The pre-operative examination included genetic analysis of the succinate dehydrogenase that showed a mutation in his subunit D responsible of multiple paraganglioma at slow growth. Subsequently a thoraco-abdominal CT and indium 111 octreotide body scan were performed and another paraganglioma was detected in the anterior mediastinum. CBT was surgically removed; differently the thoracic lesion due to his benign genetic profile was not treated. During a 3-years follow-up the thoracic paraganglioma as expected, didn't increase. Genetic analysis of succinate dehydrogenase, should be performed in the management of CBT.