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Objective: Recent 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). Methods: A 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 <65 mL/min for men and 60 mL/min for women, renal artery stenosis >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. Results: During 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. Conclusions: After 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. [Copyright &y& Elsevier]

Objective: The goal of this study was to evaluate the role of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) using a standard dose of coils and fibrin glue in the prevention of type II endoleak (EII). Methods: Two groups were compared: 83 patients underwent standard EVAR during the period 2008-2009 (group A) and 79 patients underwent EVAR during the period 2010-2011 (group B). Computed tomography scans were evaluated with Osirix Pro 4.0 software to obtain aneurysm sac volume. EII rates at the first computed tomography scan follow-up, as well as midterm freedom from EII and freedom from related reintervention, were compared. Preoperative number of patent aortic side branches (inferior mesenteric artery, lumbar arteries, accessory renal arteries), sac thrombus, and sac volume were evaluated for their association with EII in the two groups using multiple logistic regressions. Results: Patient characteristics, Society for Vascular Surgery comorbidity scores (0.85 ± 0.44 vs 0.82 ± 0.46; P = .96), and operative time (185 ± 52 vs 179 ± 49; P = .92) were similar for groups A and B. The first computed tomography scan (≤3 months) revealed a significantly larger number of EIIs in group A than in group B (23% vs 10%; P = .02). Spontaneous EII resolution occurred in 65% of patients in group A and in 79% in group B (P = 1.0), whereas sac volume increased in 25% and 10% (P = .63) of cases, respectively. At 18 months (range, 6 months to 4.4 years), overall mean differences in sac volume shrinkage (27 ± 12 cm3 vs 25 ± 12 cm3; P = .19) and freedom from EII (92% vs 96%; P = .33) were similar, whereas freedom from reintervention was significantly lower in group A (93% vs 99%; P = .03) than in group B. Multivariate analysis showed preoperative aneurysm sac volume >125 cm3 to be the only independent significant predictor of EII (odds ratio, 4.0; 95% confidence interval, 1.5-10.5; P = .005). Conclusions: Although further confirmatory studies are needed, sac embolization during EVAR may be a valid approach to preventing EII and its complications during short- and midterm follow-up. More aggressive intraoperative embolization should be considered for patients with a preoperative aneurysm sac volume >125 cm3. [Copyright &y& Elsevier]

We describe a new surgical technique performed in a heart-transplanted patient who underwent transcatheter repair of combined ascending aortic pseudoaneurysm and aortic arch aneurysm. The endografts were deployed through a left ventricular transapical approach by using a left mini-thoracotomy after previous debranching of the brachiocephalic vessels. [Copyright &y& Elsevier]

We present a hybrid endovascular approach to a 6.5-cm aneurysm of the right-sided aortic arch with an aberrant left subclavian artery arising from a Kommerell diverticulum, connected to the left pulmonary artery through the ligamentum arteriosum. The two-step procedure consisted of a bilateral carotid-subclavian bypass, followed by an ascending aorta-bicarotid bypass and completed by an endovascular exclusion of the aneurysms by covering the whole aortic arch and its branches. The patient had no complications and is asymptomatic 21 months after surgery. Hybrid procedures may be helpful in complex aortic arch pathologies, reducing complications of challenging open surgery. [Copyright &y& Elsevier]

Objective: The purpose of the study was to evaluate the results of reoperative surgery and carotid artery stenting (CAS) in cases of recurrent carotid artery stenosis (RCS) and to compare the results of all RCS (reoperative surgery + CAS) with primary carotid endarterectomy (CEA) performed during the study period. Summary Background Data: Consensus has not yet been established on the best treatment for RCS. Recently CAS has emerged as a potential alternative to carotid endarterectomy. Methods: A 6-year (Jan 2000-Dec 2005) prospective study was performed. Eligible patients were those with symptomatic or asymptomatic RCS ≥80% at a preoperative angiography or angio-computed tomography. The carotid plaques were classified at a preoperative ultrasonographic scan, according to the five type classification proposed by Geroulakos (Br J Surg 1993;80:1274-7). Patients with type 1 and 2 carotid plaque were not considered for CAS. Results: 56 patients were enrolled. Fifteen patients with a type 1-2 plaque underwent reoperative surgery, 41 with type 3-4 plaque underwent CAS. In 90.6% of primary closure a type 3-4 carotid plaque was found; a type 1-2 was observed in 84.5% of the polytetrafluoroethylene patch closure group. No statistical difference for the 30-day and the 6 year stroke-free rate was observed; similarly no differences emerged between all RCS (reoperative surgery + CAS) performed and primary CEA. Conclusions: CAS is an acceptable alternative to surgery in the management of RCS. An accurate patient selection is required. Restenosis after CEA and direct closure is mostly associated with fibrous material. In these cases CAS might be the best choice. [Copyright &y& Elsevier]

Purpose: The aim of this prospective randomized study was to evaluate the relative risks and advantages of using the Hemobahn graft for popliteal artery aneurysm (PAA) treatment compared with open repair (OR). The primary end point was patency rate; secondary end points were hospital stay and length of surgical procedure. Methods: The study was a prospective, randomized clinical trial carried out at a single center from January 1999 to December 2003. Inclusion criteria were an aneurysmal lesion in the popliteal artery with a diameter ≥2 cm at the angio-computed tomography (CT) scan, and proximal and distal neck of the aneurysm with a length of >1 cm to offer a secure site of fixation of the stent graft. Exclusion criteria were age <50 years old, poor distal runoff, contraindication to antiplatelet, anticoagulant, or thrombolytic therapy, and symptoms of nerve and vein compression. The enrolled patients were thereafter prospectively randomized in a 1-to-1 ratio between OR (group A) or endovascular therapy (ET) (group B). The follow-up protocol consisted of duplex ultrasound scan and ankle-brachial index (ABI) measured during a force leg flexion at 1, 3, and 6 months. Group B patients underwent an angio-CT scan and plain radiography of the knee with leg flexion (>120°) at 6 and 12 months, and then yearly. Results: Between January 1999 and December 2003, 30 PAAs were performed: 15 OR (group A) and 15 ET (group B). Bypass and exclusion of the PAA was the preferred method of OR; no perioperative graft failure was observed. Twenty stent grafts were placed in 15 PAAs. Endograft thrombosis occurred in one patient (6.7%) in the postoperative period. The mean follow-up period was 46.1 months (range, 12 to 72 months) for group A and 45.9 months (range, 12 to 65 months) for group B. Kaplan-Meier analysis showed a primary patency rate of 100% at 12 months for OR and 86.7% at 12 months with a secondary patency rate of 100% at 12 and 36 months for ET. No statistical differences were observed at the log-rank test. The mean operation time (OR, 155.3 minutes; ET, 75.4 minutes) and hospital stay (OR, 7.7 days; ET, 4.3 days) were statistically longer for OR compared with ET (P < .01). Conclusion: We can conclude, with the power limitation of the study, that PAA treatment can be safely performed by using either OR or ET. ET has several advantages, such as quicker recovery and shorter hospital stay. [Copyright &y& Elsevier]

To report the early and mid-term outcomes following open surgical conversion (OSC) after failed endovascular aortic repair (EVAR) using data from a multicentric registry. A retrospective study was carried out on consecutive patients undergoing OSC after failed EVAR at eight tertiary vascular units from the same geographic area in the North-East of Italy, from April 2005 to November 2019. Study endpoints included early and follow-up outcomes. A total of 144 consecutive patients were included in the study. Endoleaks were the most common indication for OSC (50.7%), with endograft infection (24.6%) and occlusion (21.9%) being the second most prevalent causes. The overall rate of 30-day all-cause mortality was 13.9% (n = 20); 32 patients (22.2%) experienced at least one major complication. Mean length of stay was 13 ± 12.7 days. On multivariate logistic regression, age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.01-1-19; P =.02), renal clamping time (OR, 1.07; 95% CI, 1.02-1.13; P =.01), and suprarenal/celiac clamping (OR, 6.66; 95% CI, 1.81-27.1; P =.005) were identified as independent predictors of perioperative major complications. Age was the only factor associated with perioperative mortality at 30 days. Renal clamping time >25 minutes had sensitivity of 65% and specificity of 70% in predicting the occurring of major adverse events (area under the curve, 0.72; 95% CI, 0.61-0.82). At 5 years, estimated survival was significantly lower for patients treated due to aortic rupture/dissection (28%; 95% CI, 13%-61%), compared with patients in whom the indication for treatment was endoleak (54%; 95% CI, 40%-73%), infection (53%; 95% CI, 30%-94%), or thrombosis (82%; 95% CI, 62%-100%; P =.0019). Five-year survival rates were significantly lower in patients who received emergent treatment (28%; 95% CI, 14%-55%) as compared with those who were treated in an urgent (67%; 95% CI, 48%-93%) or elective setting (57%; 95% CI, 43%-76%; P =.00026). Subjects who received suprarenal/celiac (54%; 95% CI, 36%-82%) or suprarenal (46%; 95% CI, 34%-62%) aortic cross-clamping had lower survival rates at 5 years than those whose aortic-cross clamp site was infrarenal (76%; 95% CI, 59%-97%; P =.041). Using multivariate Cox proportional hazard, older age and emergency setting were independently associated with higher risk for overall 5-year mortality. OSC after failed EVAR was associated with relatively high rates of early morbidity and mortality, particularly for emergency setting surgery. Endoleaks with secondary sac expansion were the main indication for OSC, and suprarenal aortic cross-clamping was frequently required. Endograft infection and emergent treatment remained associated with poorer short- and long-term survival. [ABSTRACT FROM AUTHOR]

Covered stent grafts are currently used for arterial aneurysm exclusion, aortic dissection, or peripheral occlusive disease. A new indication to endograft was applied to perform resection of the thoracic aorta for infiltration of an adjacent lung cancer into the vessel wall, avoiding a major vascular intervention for aortic graft interposition associated with tumor resection. [Copyright &y& Elsevier]