Search

Aims: Conflicting data exist on the impact on outcome of the use of different stent types during carotid artery stenting (CAS). The aim of this study was to evaluate clinical outcomes according to different carotid stent design among the population of the European Registry of Carotid Artery Stenting (ERCAS)., Methods and Results: The present study was conducted in 1,604 patients who underwent neuroprotected CAS in ERCAS. All types of commercially available carotid stent were used. Open-cell design stents were classified according to free cell area into <7.5 mm2 or >7.5 mm2. A total of 713 closed-cell, 456 hybrid-cell, 238 <7.5 mm2 open-cell, and 197 >7.5 mm2 open-cell stents were implanted. Overall, the 30-day stroke and death rate was 1.37%. At 30 days, 19 strokes occurred (1.18%): eight in the group of patients treated with a closed-cell (1.12%), two in those with a hybrid-cell (0.44%), three in those with a <7.5 mm2 open-cell (1.26%), and six in those treated with a >7.5 mm2 open-cell stent (3.05%) (p=0.045)., Conclusions: Data of the present study suggest that, in the setting of neuroprotected CAS performed in high-volume centres by properly trained operators, the use of an open-cell design stent with a free cell area >7.5 mm2 may be associated with an increased 30-day stroke risk.

Background: Although international guidelines recommend cilostazol as first-line therapy for peripheral arterial disease (PAD) because it improves the symptoms and quality of life, it remains an underused agent for amputation-free survival. The objective of this study was to evaluate the practice among Italian physicians of the use of cilostazol in patients suffering from peripheral arterial disease (PAD)., Methods: For the present study, a cross-sectional survey was carried out. Physicians specialized in the medical and/or surgical treatment of PAD and who prescribe cilostazol regularly were invited to a phone interview. A nationally-representative probability sample of hospital-based physicians who diagnose and treat patients with PAD was randomly selected among the members of the Italian Physicians' Association., Results: Out of a total of 641 physicians contacted, 250 of them (39%) accepted to take part in this survey. Reasons of survey refusal were the non-attitude to prescribe cilostazol (45%), or unspecified motivations (16%). Among the 250 physicians participating the survey: 120 were vascular surgeons, 80 internal medicine doctors, 50 angiologists. Cilostazol was suggested in 79% of patients with symptomatic intermittent claudication, and in 30% of patients who had undergone revascularization. The majority of physicians stated to prescribe cilostazol at recommended dosage of 100 mg bid (46.4%). The principal reason to suggest a reduced drug dosage was to limit early side effect at the time of treatment onset, but the increase to the full dose of cilostazol is suggested by 91.3% of interviewed within 4 weeks. Sixty-three percent of physicians affirmed to prescribe cilostazol as a continuous treatment for a mean of 4 months, while a lifelong treatment was suggested by 17.6% of participants., Conclusions: Among physicians who habitually prescribe cilostazol adherence to the recommended drug dosage and length of treatment is high. The prescription of cilostazol is particularly appreciated in patients with symptomatic intermittent claudication, even before any non-invasive diagnosis of PAD, and before any invasive therapy. Finally a relevant number of physicians regularly prescribe cilostazol also after revascularization, advocating the anti-restenotic properties of the drug.

Aim: To validate the feasibility of digital tomosynthesis of the abdomen (DTA) combined with contrast enhanced ultrasound (CEUS) in assessing complications after endovascular aortic aneurysm repair (EVAR) by using computed tomography angiography (CTA) as the gold standard., Methods: For this prospective study we enrolled 163 patients (123 men; mean age, 65.7 years) referred for CTA for EVAR follow-up. CTA, DTA and CEUS were performed at 1 and 12 mo in all patients, with a maximum time interval of 2 d., Results: Among 163 patients 33 presented complications at CTA. DTA and CTA correlated for the presence of complications in 32/33 (96.96%) patients and for the absence of complications in 127/130 (97.69%) patients; the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of DTA were 97%, 98%, 91%, 99%, and 98%, respectively. CEUS and CTA correlated for the presence of complications in 19/33 (57.57%) patients and for the absence of complications in 129/130 (99.23%) patients; the sensitivity, specificity, PPV, NPV and accuracy of CEUS were 58%, 99%, 95%, 90%, and 91%, respectively. Sensitivity, specificity and accuracy of combining DTA and CEUS together in detecting EVAR complications were 77%, 98% and 95%, respectively., Conclusion: Combining DTA and CEUS in EVAR follow-up has the potential to limit the use of CTA only in doubtful cases.

Endovascular aortic repair (EVAR) for abdominal aortic aneurysms (AAA) is the preferred first treatment option in case of patients with advanced age and/or fit anatomy owing to shorter length of in hospital staying, less complications or laparotomy-related re-interventions, and lower initial costs. Although it is a less-invasive intervention, EVAR entails a risk similar to that of open aortic procedures for medical comorbidities, and a perioperative clinical evaluation is mandatory to minimize the early and late cardiovascular risk. In this brief review the determinants of cardiac risk (functional capacity, cardiac evaluation, non-invasive tests, bio markers and "specialist" cardiac tests) as well the most widely used predictive risk scores were analyzed. Taking into account that a preoperative cardiovascular assessment is conditioned by the urgency of the repair, in everyday practice rarely the patient undergoes over a complete and exhaustive cardiac assessment with the exclusion of few selected cases that do not represent the rule. Moreover most of models focused on perioperative mortality, tailored for open repair and then adjusted to EVAR or specifically retailed for this procedure show both differences and remarkable similarities. None defines the patient's cardiac risk "alone" (angina, recent myocardial infarction, chronic heart failure, arrhythmias). Actually they measure a "global" medical risk for they take into account of various comorbidities, such as previous stroke, kidney failure, including dialysis, diabetes, COPD, etc. that contribute to intra and perioperative mortality/morbidity and that may be heavier for prognosis.

Background and Objectives: A variant located at the end of HDAC9 gene within clusters of DNAse I sensitivity zones and histone modification hotspots has been associated with large vessel stroke and could be linked to plaque instability. The aim of the study is to define if an altered expression of HDAC9, TWIST1 and FERD3L genes could be involved in plaque vulnerability., Methods: Histological classification and gene expression analysis were performed in 6 stable and 16 unstable plaques obtained from asymptomatic patients undergoing endarterectomy. Gene expression was analysed by real-time PCR., Results and Conclusions: TWIST1 gene expression resulted higher in stable plaques (P < 0.02). HDAC9 gene expression followed a similar trend (P = 0.11). These results highlighting the significant correlation between TWIST and HDAC9 gene expression suggest that both genes may contribute to plaque stability in a coordinated way.

Endovascular repair of abdominal aortic aneurysms has become a milestone in the treatment of patients with abdominal aortic aneurysm. Technological improvement allows treatment in more and more complex cases. This review summarizes all grafts available on the market. A complete review of most important trial on this topic is provided to the best of our knowledge, and technical tips and tricks for standard cases are also included.

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives. To compare durability and survival after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) in young patients. Material and Methods. A retrospective study was conducted between 2005 and 2014 on all consecutive patients of 60 years of age or younger. Measures considered for analysis were reintervention related to AAA, laparotomy and access vessel injury during EVAR, and all-cause mortality during hospitalization and follow-up. Results. Seventy out of 119 patients were treated by OR (58.8%) and 49 (41.2%) by EVAR, 9 in off-label fashion (18.3%). Technical success was achieved in all cases. No AAA-related death was recorded. Overall in-hospital mortality was zero and the reintervention rate was 2.5% (3/119: 1/70 OR, 2/49 EVAR, p = 0.36). There is no death at 30-day or 1-year follow-up. Thirty-day reintervention rate was 1.6% (2/119; 0/70 OR, 2/49 EVAR, p = 0.16), while the 1-year rate was 2.5% (3/119; 1/70 OR, 2/49 EVAR, p = 0.36). At the mean follow-up of 56.8 ± 42.7 months, mortality and reintervention rates were 5.8% (7/119; 3/70 OR, 4/49 EVAR, p = 0.38) and 10% (12/119; 8/70 OR, 4/49 EVAR, p = 0.39), respectively. The overall reintervention rate, mortality, and freedom from adverse events did not differ between the two groups. No differences in outcome were recorded between patients treated by EVAR in on-label versus off-label fashion. Conclusion. Our (albeit limited) experience suggests that, in an unselected young patient population undergoing elective AAA repair, OR or EVAR can be performed safely with similar immediate and long term outcomes.

Objective: Aortic neck dilation has been reported after endovascular aneurysm repair (EVAR) with self-expanding devices. With a core laboratory analysis of morphologic changes, this study evaluated midterm results of aortic neck evolution after EVAR by endograft with no chronic outward force., Methods: This was a multicenter registry of all patients undergoing EVAR with the Ovation endograft (TriVascular, Santa Rosa, Calif). Inclusion criteria were at least 24 months of follow-up. Standard computed tomography (CT) scans were reviewed centrally using a dedicated software with multiplanar and volume reconstructions. Proximal aortic neck was segmented into zone A (suprarenal aorta/fixation area), zone B (infrarenal aorta, from lowest renal artery to the first polymer-filled ring), and zone C (infrarenal aorta, at level of the first polymer-filled ring/sealing zone). Images were analyzed for neck enlargement (≥2 mm), graft migration (≥3 mm), endoleak, barb detachment, neck bulging, and patency of the celiac trunk and superior mesenteric and renal arteries., Results: Inclusion criteria were met in 161 patients (mean age, 75.2 years; 92% male). During a mean follow-up period of 32 months (range, 24-50), 17 patients died (no abdominal aortic aneurysm-related death). Primary clinical success at 2 years was 95.1% (defined as absence of aneurysm-related death, type I or type III endoleak, graft infection or thrombosis, aneurysm expansion >5 mm, aneurysm rupture, or conversion to open repair). Assisted primary clinical success was 100%. CT scan images at a minimum follow-up of 2 years were available in 89 cases. Patency of visceral arteries at the level of suprarenal fixation (zone A) was 100%. Neither graft migration nor barb detachment or neck bulging was observed. None of the patients had significant neck enlargement. The mean change in the diameter was 0.18 ± 0.22 mm at zone A, -0.32 ± 0.87 mm at zone B, and -0.06 ± 0.97 mm at zone C. Changes at zone B correlated significantly with changes at zone C (correlation coefficient, 0.183; P = .05), whereas no correlation was found with zone A (correlation coefficient, 0.000; P = 1.0)., Conclusions: No aortic neck dilation occurred in this series at CT scan after a minimum 24-month follow-up. This may suggest that aortic neck evolution is not associated with EVAR at midterm follow-up when an endograft with no chronic outward radial force is implanted., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to present open surgical conversion with graft salvage or "semiconversion" as a definitive and safe treatment for untreatable and persistent type II endoleaks causing sac enlargement after endovascular aneurysm repair., Methods: Between January 2001 and December 2014, 25 of 1623 endovascular aortic repair (EVAR) patients were selected as candidates for open semiconversion. The indication was persistent type II endoleak in 13 patients (12 of whom received previous attempts of embolization), type I and II endoleak in 2 patients, and sac growth without imaging evidence of endoleak in the other 10. After the infrarenal aorta was prepared (via a retroperitoneal access, whenever possible), the technique consisted of performing a banding of the neck with Teflon (DuPont, Wilmington, Del), a sacotomy to remove the thrombus or the hygroma, or both, and then suturing all of the feeding vessels that were found. Proximal and distal fenestrations were performed to avoid sac repressurization., Results: The semiconversion was performed after a mean of 74 months after the initial EVAR. The mean aneurysm size at the time of the EVAR was 6.0 cm (range, 5.0-9.5 cm), and the mean aneurysm size at the time of the semiconversion was 7.7 cm (range, 5.5-11.5 cm). The overall aneurysm size increase was 38%, and the average growth rate was 8.2% per year. One patient had a stable aneurysm size but was treated because of an emergency condition. Technical success was 100%, with resolution of the endoleak and no perioperative deaths. Four cardiac deaths were registered at 12, 26, 30, and 60 months (mean follow-up, 42 months; range, 1-80 months)., Conclusions: Graft salvage appears to be a valid option compared with open repair when considering treatment of persistent type II endoleak. This case series shows that semiconversion is a safe and effective treatment for otherwise untreatable type II endoleak., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Marfan syndrome is the most prevalent connective tissue disorder, with an autosomal dominant inheritance with variable penetrance. This paper aims to summarize epidemiology and treatment for type B dissection in Marfan patients.

Aim: A new stent was designed, conceived for being placed externally around blood vessels to perform vessel banding in a much simple and fast way. In fact it requires the dissection of a single segment of the aortic wall, as its mechanical features allow it to slide on the tunica adventitia. After previous tests (ex vivo and in vivo test), the new stent has been evaluated in vivo long-term study., Methods: In female pig of average weight of 60 kg, after placement of endoprosthesis in infrarenal abdominal aorta, immediately below renal arteries, aortic banding was performed with new stent at the level of each end of endoprosthesis, identified under fluoroscopic guidance. Pigs were followed up for six months, and acetylsalicylic acid was administrated: 100 mg once a day. After six months, histological evaluation of explanted abdominal aorta was performed., Results: New stent made the aortic banding simple and fast. Postoperative course was uneventful. Histological results were similar to previous 10-week survival tests and not damages of aortic wall were observed., Conclusion: Positive outcome of three last long-term survival tests, as of all those ex vitro and in vivo tests previously performed, makes conceivable further scientific investigation and trials.

According to the World Health Organization, every year, 5 million peoples die for stroke and another 5 million are permanently disabled. Although there are many causes of acute stroke, a common treatable cause of acute stroke is atheromatous narrowing at the carotid bifurcation. Carotid endarterectomy is still the standard of car, even if carotid artery stenting (CAS) has become an effective, less invasive alterantive. Unfortunately, CAS procedure is not yet perfect; regardless the use of an embolic protection device (EPD), percutaneous treatment has been correlated with a risk of cerebral ischemic events related to distal embolization. The objective of the IRON-Guard Registry is to evaluate the clinical outcome of treatment by means of stenting with the C-Guard (InspireMD, Boston, MA, USA) in subjects requiring CAS due to significant extracranial carotid artery stenosis with a physician-initiated, Italian, prospective, multicenter, single-arm study. A total of 200 enrolled subjects divided over different centers are planned to be enrolled. CAS will performed by implanting of C-Guard stent. Procedure will be performed according to the physician's standard of care. Standard procedures will be followed based on the Instructions for Use, for the C-Guard device of Inspire. The primary endpoint of this study is the 30-day rate of major adverse events (MAE), defined as the cumulative incidence of any periprocedural (≤30 days postprocedure) death, stroke or myocardial infarction. Secondary endpoints are rate of late ipsilateral stroke (31 through 365 days), system technical success, device malfunctions, major adverse events (MAEs), serious device-related and procedure-related adverse events, target lesion revascularization, and in-stent restenosis rates.

Endovascular repair of abdominal aortic aneurysm has become a milestone in the treatment of patients with abdominal aortic aneurysm.Technological improvement allows treatment in more and more complex cases. This review summarizes all grafts available in the market. At the best of our knowledge a complete review of most important trial on this topic are provided and at least technical tips and tricks for standard cases are recapitulated.

Patients undergoing major surgery are at risk for postoperative cognitive dysfunction (POCD). The consciousness of the POCD arises new ethical and medico-legal issues that should be identified, managed and, if possible, prevented. Elderly patients still represent a real challenge for physicians and medical science. This challenge can be surmounted not only through technical progress but also by safeguarding the correct ethical behavior at the base of each relationship between a patient and his physician. Effective communication with the elderly patient is a prerequisite for clear and complete information, involving family members and caregivers when necessary. In every case, the identification of patients with pre-existing risk factors of POCD, shortening the period of time preceding the surgery and a proper technique of the procedure as well as physical and intellectual exercises, nutrition and medication play an important role in decreasing the incidence of neurocognitive deficits in the elderly.

Although traditional surgical repair by aneurysm exclusion and bypass is still considered the gold standard in the treatment of popliteal artery aneurysms (PAAs), the endovascular repair (ER) has been gaining great interest in the last decades. ER offers several advantages over open bypass, including lower morbidity and mortality, and faster functional recovery, but some concerns about migration, occlusion, or fracture remain when a stent graft is deployed across a joint that undergo constant flexion. This review summarizes the current evidence on ER for PAAs. Level I evidence is still very limited, while the majority of published data come from retrospective studies. Moreover the heterogeneity of PAA morphology seems to play a major role in the outcomes after popliteal endografts placement, so that many anatomical criteria should be taken into account to determine which patient is best treated endovascularly. In conclusion, while it is unlike that endovascular treatment may displace open surgical bypass in the near future, it indeed does provide a feasible option for selected patients with high surgical risk and good anatomical features.

Isolated spontaneous dissection of the superior mesenteric artery is extremely rare. In December 2012, a 45-year-old man, without significant comorbidities, presented at the emergency room of another hospital with abdominal pain. The patient was treated with medical therapy and discharged on resolution of the pain. Three months later he returned to the emergency room with a new onset of pain. CT-angiography (CTA) showed an isolated SMA dissection associated with aneurysmal dilatation. The patient was referred to our attention. We attempted endovascular exclusion of the dissecting aneurysm in May 2013. We deployed a self-expandable nitinol stent (BostonSC Adapt 4-9×32 mm) in order to simultaneously repair the dissection, preserve the branches and exclude the aneurysm. Postoperative course was uneventful and the patient was discharged on postoperative day 2. At 10-month follow-up CTA showed excellent positioning of the stent, patency of the visceral branches and shrinkage of the aneurysm., (© Acta Chirurgica Belgica.)

Objectives: Arterovenous grafts (AVGs) present a feasible solution for creating a vascular access in patients who are unsuitable for autogenous fistula (AVF). The aim of this study is to assess the prevention rate of vein stenosis, placing a graft on an arterialized vein (GAV) instead of an anastomized AVG in a native vein (GNV)., Methods: This was a cohort study conducted from January 2009 to November 2012. All consecutive patients who underwent AVG in our institution were included. All patients requiring a secondary intervention were also referred to our centre. Patients underwent ultrasound follow up at first and the every month. A Kaplan-Meier method was used; a Log-rank test was used to identify whether significant difference existed between GAV and GNV (p < 0.05)., Results: Forty-six grafts were placed. Twenty patients had arterialized receiving veins (group A), while 26 patients received an AVG immediately because they lacked autogenous veins suitable for fistula (group B).The average follow-up period was 16.1 months (range 0-41). The group A 41 months-patency rate was 84.3%, while group B was 43.7% (p = 0.06). Secondary patency was similar in the two groups., Conclusions: Vein arterialization seems to prevent venous stenosis improving AVG-patency rate. More data are needed; however, the borderline p value encourages new studies., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Stent fracture has been well documented in the Literature and in the majority of cases arises from the exposition of the stent to unfavourable stresses and biomechanical forces. We report a case of carotid false aneurysm after stent placement for post-surgery restenosis. Stent fracture is a clinical reality that sometimes should be considered prior to stent deployment and may require monitoring or treatment after occurrence., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: To evaluate the 24-month outcome of stenting in Trans-Atlantic Inter-Society Consensus (TASC) A & B and TASC C & D iliac lesions in a controlled setting., Methods: The BRAVISSIMO study is a prospective, nonrandomized, multicenter, multinational, monitored registry including 325 patients with aortoiliac lesions. The end point is the primary patency at 24 months, defined as a target lesion without a hemodynamically significant stenosis on duplex ultrasound (>50%, systolic velocity ratio >2.0). A separate analysis for TASC A & B versus TASC C & D population is performed., Results: Between July 2009 and September 2010, 190 patients with TASC A or B and 135 patients with TASC C or D aortoiliac lesions were included. The demographic data were comparable for TASC A & B cohort and TASC C & D cohort. Technical success was 100%. Significantly more balloon-expandable stents were deployed in TASC A & B lesions, and considerably more self-expanding stents were placed in TASC C & D (P = 0.01). The 24-month primary patency rate after 24 months for the total population was 87.9% (88.0% for TASC A, 88.5% for TASC B, 91.9% for TASC C, and 84.8% for TASC D). No statistically significant difference was shown when comparing these groups. The 24-month primary patency rates were 92.1% for patients treated with the self-expanding stent, 85.2% for patients treated with the balloon-expandable stent, and 75.3% for patients treated with a combination of both stents (P = 0.06). Univariate and multivariable regression analyses using Cox proportional hazards model identified only kissing stent configuration (P = 0.0012) and obesity (P = 0.0109) as independent predictors of restenosis (primary patency failure). Interestingly, as all TASC groups enjoyed high levels of patency, neither TASC category nor lesion length was predictive of restenosis., Conclusion: The 24-month data from this large, prospective, multicenter study confirm that endovascular therapy may be considered the preferred first-line treatment option of iliac lesions, irrespectively of TASC lesion category., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The prevalence of endograft infections (EI) after endovascular abdominal aortic aneurysm repair is below 1%. With the growing number of patients with aortic endografts and the aging population, the number of patients with EI might also increase. The diagnosis is based on an association of clinical symptoms, imaging, and microbial cultures. Angio-computed tomography is currently the gold-standard technique for diagnosis. Low-grade infection sometimes requires nuclear medicine imaging to make a correct diagnosis. There is no good evidence to guide management so far. In the case of active gastrointestinal bleeding, pseudoaneurysm, or extensive perigraft purulence involving adjacent organs, an invasive treatment should always be attempted. In the other cases (the majority), when there is not an immediate danger to the patient's life, a conservative management is started with a proper antimicrobial therapy. Any infectious cavity can be percutaneously drained. Management depends on the patient's condition and a tailored approach should always be offered. In the case of a patient who is young, has a good life expectancy, or in whom there is absence of significant comorbidities, a surgical attempt can be proposed. Surgical techniques favor, in terms of mortality, patency, and reinfection rate, the in situ reconstruction. Choice of technique relies on the center and the operator's experience. Long-term antibiotic therapy is always required in all cases, with close monitoring of the C-reactive protein.

Implantation of a vascular prosthesis increases surgical site infection risk by producing a microenvironment conducive to bacterial attachment and biofilm formation, which sustains bacterial colonization and protects encased organisms from host defenses and antimicrobial therapy. Many maneuvers are used in an attempt to reduce infection in arterial reconstructions, but there are no clear guidelines on the most appropriate or effective. As well, there is no good evidence to guide management. A general principle is that indication for removal of the entire infected graft is mandatory when a suture line is involved in the infectious process, an infected anastomotic aneurism and a suture-line hemorrhage is evident, or when a graft-enteric fistula is diagnosed. Conservative, non-resectional management of graft infection is still a respectable solution for selected patients, as those with significant comorbidities, or those where the implanted aortic graft is in a location that precludes excision without causing a high likelihood of morbidity and/or mortality. Anyway, definitive management depends on the patient's condition and a tailored approach should be always offered. Surgical techniques favor in terms of mortality, patency and reinfection rate the in situ reconstruction. Currently, the choice of the technique used relies on center and operator's experience. This article summarizes the incidence of graft infection, analyze the predisponding factors to graft infection, and review current strategies for prevention and treatment of prosthesis and endograft infection.

In recent years the number of carotid revascularization has increased steadily. This increased has inevitably resulted in an increase (relative) in complications, both after carotid endarterectomy (CEA) and carotid stenting (CAS), despite the technical evolutions of new available materials and the expertise of the operators. So, complications which may potentially require operative intervention, although not very frequent, are possible. However, after diagnosis, immediate management should be undertaken in order to avoid sequelae which are often irreversible and potentially fatal. To minimize this risk, it's important that these procedures are performed by skilled operators in high-volume Centers of activity. The aim of this review is to assess local complications which can lead to re-interventions after CEA and CAS.

Background: Endovascular aneurysm repair (EVAR) has fast become the therapeutic strategy of choice for abdominal aortic aneurysms (AAAs). Nowadays, the most important limit to the effectiveness of this technique is represented by complex anatomical situations, especially regarding the morphology of the proximal sealing zone. The aim of this study was to evaluate the 2-year outcome of unselected, real-world patients with "off-label" (off-L) proximal necks treated in 2 high-volume Italian vascular centers., Methods: A double-center study was conducted on a prospectively compiled computerized database between January 2010 and December 2011. One hundred and ninety-six consecutive elective surgery patients were analyzed and divided into 2 groups ("on-label" [on-L] and "off-L" necks) on the basis of their aortic neck anatomy. The neck was classified as an "off-L neck" in the presence of: (1) a noncylindrical neck, (2) an angulated neck, (3) a short neck, and (4) an enlarged neck. The end points were 30-day and 2-year technical and clinical success, evaluated in terms of freedom from reintervention and death., Results: One hundred and thirty-three elective patients were treated by standard EVAR in the presence of an "off-L" proximal neck anatomy. Technical success was achieved in all cases in both groups. Six (9.5%) unplanned adjunctive procedures were necessary in the on-L group and 16 (12%) in the off-L group (P = ns). Perioperative endoleaks, reinterventions, stent-graft migration rates, and AAA-related deaths were null. A multivariate analysis was performed to evaluate the subgroups of patients with 2 or > 2 anatomic factors that indicate a challenging neck. In patients with 2 such factors, a significant difference was observed in terms of intraoperative adjunctive procedures, intraoperative endoleaks, and all-cause mortality: 26.7% vs. 9.9% (P = 0.048), 6.7% vs. 0.5% (P = 0.023), and 13.3% vs. 1.1% (P = 0.0012), respectively. The same differences became increasingly evident when analyzing patients with > 2 criteria: 50% vs. 10% (P = 0.0022), 16.7% vs. 0.5% (P < 0.001), and 16.7% vs. 1.0% (P = 0.01). No AAA-related deaths or AAA ruptures were reported in either group at the end of the 2-year follow-up. High-flow endoleaks, stent-graft migration, and, consequently, reintervention were more frequent in the off-L group, but none of these parameters reached statistical significance., Conclusions: Our experience seems to show that the off-L use of EVAR could be considered effective for the treatment of patients unfit for open surgery. In patients with more than one anatomical proximal neck feature contraindicating open surgery, the rate of immediate complications and reinterventions was higher, but this did not affect the clinical benefit and success at 2-year follow-up., (Copyright © 2014 Elsevier Inc. All rights reserved.)

We report a clinical evolution of a 85-years old male admitted to our Emergency Department for ruptured abdominal aortic aneurysm (rAAA). One month later a huge type I proximal endoleak was detected and corrected by proximal aortic extension. We decided to fix the stent-graft to the aortic wall using EndoAnchors. However, an asymptomatic type III endoleak due to controlateral limb disconnection was detected at the followed schedulated CT angio and corrected by a relining of the endograft. The patient is now in good clinical condition with no evidence of endoleaks at 1-year follow-up., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

One hundred and fifty-three authors, 45 Italian scientific societies, and two Italian patients' associations participated in drafting the Italian Stroke Organization document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of the Italian Stroke Organization document, the main trials on carotid endoarterectomy and stenting were critically reviewed in order to formulate recommendations for these procedures. Recommendations are presented here for the referral of patients to either carotid endarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic., (© 2013 The Authors. International Journal of Stroke © 2013 World Stroke Organization.)

Background: The choice of carotid stent systems depends primarily on the anatomy of the carotid artery, the lesion morphology, and the patient's risk factors. Design improvements in devices, in terms of crossing profile and the ability to precisely position the stent, may greatly contribute to the procedural success without compromising acute clinical outcomes., Methods and Results: The primary objective of this clinical registry was to evaluate the early safety and efficacy of a novel open-cell carotid stent system in an "all comer" population suitable for carotid artery stenting. The primary end point was the composite of ipsilateral stroke and "all-cause mortality" within 30 days after the procedure. Secondary end points entailed the rates of myocardial infarction and other clinical complications within the first 30 days following the procedure and up to the 6-month follow-up. Unsuccessful placement and/or withdrawal of the delivery system, as well as device-related complications involving the carotid artery and the rate of nonlesion-related embolisms, were evaluated relative to other currently available carotid stents. The 30-day composite death/stroke rate was 2.8% (3 of 106) while the overall stent system performance was similar to commonly used carotid stent systems., Conclusions: The utilized open-cell carotid stent system had favorable lesion crossing and positioning characteristics without compromising the 30-day composite death/stroke rate.

Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery. Cardiologists, surgeons and anaesthesiologists have contributed equally to its creation. On the basis of clinical and angiographic data, the individual thrombotic risk has been defined. All surgical interventions have been classified according to their inherent haemorrhagic risk. A consensus on the optimal antiplatelet regimen in the perioperative phase has been reached on the basis of the ischaemic and haemorrhagic risk. Aspirin should be continued perioperatively in the majority of surgical operations, whereas dual antiplatelet therapy should not be withdrawn for surgery in the case of low bleeding risk. In selected patients at high risk for both bleeding and ischaemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be taken into consideration.

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Vascular and endovascular procedures are typically very "clean" procedures, with a very low infection rate. However, these complications, although rare, are unfortunately associated with a high rate of morbidity and mortality. The first rule to effectively treat the infection is always prevention, but when the infection has been established the only solution is given by an early diagnosis and proper medical care and often surgical treatment. The hardest thing is to obtain is an early and correct diagnosis, especially for low-grade infections. The purpose of our work was to strengthen the conviction that only an integrated work as a team will enable effective and quick management of this serious complication.

Objective: Surgical arterial thromboembolectomy (TE) is an efficient treatment for acute arterial thromboemboli of lower limbs, especially if a single large artery is involved. Unfortunately, residual thrombus, propagation of thrombi, chronic atherosclerotic disease, and vessel injuries secondary to balloon catheter passage may limit the clinical success rate. Intraoperative angiography can identify any arterial imperfection after TE, which may be corrected simultaneously by endovascular techniques (so-called "hybrid procedures," HP). The aim of this study is to compare outcomes of surgical TE vs HP in patients with acute lower limb ischemia (ALLI)., Methods: From 2006 to 2012, 322 patients with ALLI were admitted to our department. Patients received urgent surgical treatment using only a Fogarty balloon catheter (TE group = 112) or in conjunction with endovascular completion (HP group = 210). In-hospital complications, 30-day mortality, primary and secondary patency, reintervention rate, limb salvage, and overall survival rates were calculated using the Kaplan-Meier method and compared by log-rank test., Results: HPs (n = 210) following surgical TE consisted of angioplasty (PTA) ± stenting in 90 cases, catheter-directed intra-arterial thrombolysis + PTA ± stenting in 24, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting in 67, vacuum-based accelerated thromboaspiration by mechanical devices in 9, and primary covered stenting in 12. Estimated primary patency was 90.4% vs 70.4% at 2-year and 87.1% vs 66.3% at 5-year follow-up, respectively, for HP and TE patients (hazard ratio, 3.1; 95% confidence interval, 1.78-5.41; P < .01). A hazard ratio of 2.1 for limb salvage was noted for the HP group (95% confidence interval, 1.01-4.34; P = .03). Estimated freedom from reintervention at 1 year was 94.4% for HP vs 82.1% for TE patients, and 89% vs 73.7% at 5 years, respectively (P = .04)., Conclusions: HPs for ALLI may represent the tools that, when applied to specific clinical scenarios, hold the potential to reduce the morbidity previously associated with acute arterial occlusion., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Aim: The aim of this paper was to evaluate the influence of a challenging neck on mid-term results using the Endurant I stent-graft system in high risk patients., Methods: A retrospective study was conducted on a prospectively compiled database of 72 elective patients with challenging neck treated with the Endurant I system (Endurant Stent Graft, Medtronic AVE, Santa Rosa, CA, USA). These patients were compared to a control group (65 patients) without significant neck problems. The endpoints were mid-term 2-years technical, clinical success and the event free survival of all treated patients., Results: Mean age was 76.12 years; 76.6% of patients were males. Risk factors and preoperative variables did not differ significantly between the two groups. Only 4 (5.5%) patients of the study group vs. 2 (3.1%) in the control group developed type I endoleak during the follow-up. Three (4.1%) study group patients developed type III endoleak vs. 2 (3.1%) in the control group. All these patients required an adjunct procedure of relining with a new endograft. No type II endoleaks requiring adjunctive endovascular procedures were detected in our series. The 2-year event free survival rate did not differ statistically between the two groups (P=0.425)., Conclusion: Treatment with the Endurant stent-graft is technically feasible and safe, yielding satisfactory results even in challenging anatomies. Mid-term results are promising and challenge current opinion concerning the negative influence of challenging neck anatomy on EVAR especially after a longer follow-up.

When Juan Parodi implanted an endograft in a human body for the first time on September 7, 1990 in Buenos Aires, Argentina, the delivery system of the handmade device was primitive, extremely rigid, and had a bulky profile of 27 French (F). Since then, stent-graft technology has evolved rapidly, limitations of earlier-generation devices have been overtaken, and endovascular aneurysm repair (EVAR) eligibility has increased enormously. Nevertheless (still) challenging aortoiliac anatomy such as short and complex proximal aortic neck seal zones and narrow access vessels are responsible for EVAR ineligibility in up to 50% of cases. The Ovation Prime abdominal stent-graft system (TriVascular, Inc., Santa Rosa, CA, USA) is a trimodular device designed with the aortic body delivered via a flexible, hydrophilic-coated, ultra-low profile catheter (14-F outer diameter - OD). The aortic body is provided with a suprarenal nitinol stent with anchors that provide active fixation, while a network of rings and channels that are inflated with a low-viscosity radiopaque polymer during stent-graft deployment, provides effective sealing. The previous EVAR technology aimed to both anchor and seal using stents combined with fabric, with neither optimized for their roles and each forced to compete for the same space within their delivery catheters, which inevitably led to larger profile of the delivery system. The technical revolution of the Ovation endograft includes the idea to truly uncouple the stages of stent-graft fixation and seal during the procedure. In the Ovation endograft platform, stent and fabric are not competing the same space within the delivery system and an ultra-low profile delivery can be achieved without compromise. With such a low-profile delivery catheter, approximately 90% of men and 70% of women with abdominal aortic aneurysm have access vessel diameters considered fit for endovascular repair. The aim of this review paper was to analyze the main properties of Ovation endograft, to emphasize the advantage of the ultra-low profile device, and to sum up current literature.

Background: A major debate in cerebrovascular medicine today is over the choice of the best treatment to implement for stenosis of the carotid artery. Carotid artery stenting is a less invasive technique than endarterectomy for the treatment of carotid stenosis, and is becoming more widely performed, particularly on patients with carotid artery stenosis who present also with comorbidities. To address the aspects related to the use of carotid artery stenting, an Italian multidisciplinary task force comprising the most representative scientific societies concerned with carotid artery disease was set up to provide neurologists, radiologists, cardiologists, vascular surgeons, and all those involved in stroke prevention and treatment with an updated, evidence-based consensus document., Summary: The task force followed a structured methodology to assess the literature on carotid stenosis in order to provide a summary of the main issues related to carotid artery stenting, including the definition of the grade of symptomatic carotid artery stenosis, indications for intervening on the carotid artery stenosis, establishing whether to perform either a surgical or an endovascular procedure, the training, credentialization, and competency needed by physicians to perform carotid artery stenting, acceptable complication rates and risk certification for carotid artery stenting, management of stented patients, durability of carotid artery stenting, and future tasks. Here, we outline the main findings of this effort., Key Messages: As for any guideline or consensus statement, each point is valid as long as the evidence on which it is based remains up to date. In a fast-evolving field of medicine such as that of carotid artery stenosis management, and in particular carotid artery stenting, the stimulation of continuous and fruitful discussion among all professionals involved is mandatory. We hope that this document may provide a standardized basis for the application of carotid artery stenting as implemented today., (© 2014 S. Karger AG, Basel.)

Patients affected by critical limb ischemia (CLI) represent a complex and high risk clinical problem, and a multidisciplinary approach is often demanded. The amputation rate in patients affected by CLI is still high. Introduction of endovascular procedure shook up the CLI concept of treatment. The increasing experience of Vascular Surgeons in endovascular technique forced these specialist to match classic surgical skills and endovascular tools in order to achieve the best treatment for each patients. The combination of the two techniques identifies the hybrid procedure. Aim of this paper is to define indication, necessity and results of the hybrid procedure in patients suffering from CLI.

The treatment of the critical limb ischemia (CLI) and diabetic foot (DB) is still object of discussion and the gold standard for revascularization has not yet been identified. In these two decades the introduction of endovascular procedures had a large impact on the surgical revascularization and were added to the practice of vascular surgeons in patients who cannot be candidates for a bypass. This may be due to significant comorbidities, a reduced life expectancy, infection or gangrene in the possible sites of distal anastomoses, the unavailability of suitable veins, or the absence of an adequate "landing zone" for the distal part of the bypass. Various studies have evaluated the role of PTA in DF and CLI that resulted favourable in terms of feasibility, technical efficacy, the reduced number of complications, and limb salvage rates. Anyway, long-term patency is better after bypass surgery than after angioplasty, which is burdened by a high restenosis rate. In our experience we tried to practice endovascular approach as a first choice. If the procedure cannot be concluded safely, we continue the intervention surgically or use a hybrid approach. The endovascular-first strategy seems to be the future regardless of comorbidity of the patient and the degree of pathology. The vascular surgeon remains the only specialist that can decide the correct intervention without pressure or been forced and, last but not least, the only one who can independently perform hybrid interventions.

"For the best vascular care to every patient, every day" is the goal of our practice, but is it a possible goal? Where are we now? The general idea is that we are pursuing the right way. The evolution of our discipline in the last two decades has been extraordinary and we reaffirm that we are the leaders in diagnose and treatment of the arterial pathology. Unfortunately, we can find some cases in which reality has to be faced as hardly as it can be, remembering us that we still have to go further with our job. The delay in the diagnose and treatment could lead to a permanent deficit and a money loss for the national health system due to prolonged hospitalization, multiple re-hospitalizations, loss of working capacity. This must be avoided. We strongly suggest that a vascular surgeon should be present in all the Emergency Room and should be routinely involved in the management of patients. The routine use of dedicated interdisciplinary protocols should be strongly advocated. Vascular surgery, as medical specialty, should be recognized as single specialty in all countries and as "peculiar" by the National Authority as well as Neurosurgery and Cardiac Surgery.

Interventional procedures on peripheral vessels are the field of a novel specialty dedicated to the diagnosis and minimally invasive endovascular treatment of diseases involving the cerebral, thoracic and abdominal arteries (including renal and visceral arteries), as well as the peripheral arteries (femoro-popliteal arteries and the arteries below the knee). At present, physicians with three different types of medical training, each involving particular strengths and characteristics, specialize in endovascular treatment of patients with peripheral arterial disease: vascular surgeons, interventional radiologists and interventional cardiologists. Treatment of high-risk patients in terms of anatomical and clinical (serious comorbidities) complexity raised the need for the interventional cardiologist to face issues related to technical aspects of the procedure, multilevel pathology management and adequate indication. To achieve this goal, interventional cardiologists require particular facilities and clinical skills. The objectives of this position paper from the Italian Society of Interventional Cardiology (SICI-GISE) are (i) to define the theoretical background and practical training required to ensure that interventional cardiologists maintain high-quality standards also in the field of treatment of peripheral arterial disease, by establishing shared rules and drafting papers; (ii) to standardize the procedures of interventional cardiology operational units that treat patients with peripheral arterial disease in Italy on the basis of scientific evidence, and (iii) to establish common requirements in terms of facilities and regulations.

Background: Carotid artery stenting (CAS) is currently considered a valid alternative to carotid endarterectomy (CEA) for the prevention of stroke in high-risk patients. One of the most important issues for both of these techniques is carotid restenosis. The aim of our study was to evaluate the incidence of post-CEA and post-CAS restenosis in a large cohort of patients in a single high-volume center., Methods: Between December 2000 and December 2010, 2453 CEA and 2628 CAS procedures were performed in the Vascular and Endovascular Surgery Unit at our institution. The mean age of patients was 73.8 years (range 55‒89 years), 78% of whom were men. Indications for carotid revascularization were: presence of symptomatic carotid artery stenosis of >70%, or asymptomatic stenosis of at least 80%, especially in patients with vulnerable plaques., Results: Mild and long-term results after CEA and CAS were similar. The overall perioperative neurologic complication rate (minor and major stroke) was similar in the 2 groups. At 1-year follow-up the restenosis rate after CEA was 1.58%. In-stent restenosis after CAS occurred in 1.67% of the procedures. All but 3 arteries had been treated for postsurgical restenosis. All lesions were approached secondarily with endovascular procedures. Statistical analysis demonstrated that post-CEA restenosis was the most important predictive factor for the development of in-stent restenosis after CAS., Conclusions: This review of our 10-year experience confirms that patients who develop restenosis after CEA are also prone to developing in-stent restenosis after CAS., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aim: Acute limb ischemia (ALI) is not infrequently associated with limb loss (10-30%) or death of the affected patient (15-30%). These results can be even worse in elderly population. The aim of this study is to quantify safety and efficacy of early revascularization in over 90 years old patients with acute limb ischemia., Methods: This is a prospective registry lasting from January 2012 to January 2013. We include all consecutive over 90 years patients treated for ALI (N.=15). A careful preoperative Duplex scan (DS) were performed in each patient. All patients underwent surgery by Fogarty's embolectomy, and endovascular completion procedure if needed (N.=3)., Results: We performed 18 revascularizations (15 lower limbs, 3 upper limbs) in 15 patients (2 staged bilateral femoral, 1 simultaneous bilateral femoral). The mean follow-up was 124 days (4-365). Technical success was obtained in 16 cases (88.9%). At disharge mortality was 5.9% (1 case), and amputation rate was 6.2% (1 pt). The Kaplan-Meier curves at 1 year revealed an estimated freedom from death, amputation and re-occlusion of 76.5%, 88.2%, and 71.3%, respectively., Conclusion: The over 90 years old patient represent a challenging case for vascular surgeon. Vascular procedures involve high mortality rate but emergent revascularization by Fogarty Embolectomy in ALI is safe and effective even in older patient.

Purpose: To analyze the feasibility and outcomes of an inguinal field block (IFB) for femoral artery exposure in patients undergoing elective endovascular aneurysm repair (EVAR)., Methods: Between January 2004 and June 2012, 784 patients (597 men; mean age 76 years) underwent elective EVAR via surgical cutdown to the common femoral arteries. The data from these procedures were retrospectively analyzed to determine the technical feasibility of IFB, need for conversion to general anesthesia, mortality, and complication rate., Results: IFB was successfully performed in 768 (97.9%) patients. Conversion from IFB to general anesthesia was necessary in 11 (1.4%) patients owing to patient discomfort (n=3, 0.4%), anxiety (n=5, 0.6%), and persistent patient movement (n=3, 0.4%). The remaining 5 (0.7%) patients underwent EVAR under general anesthesia because they refused IFB. Technical success of EVAR was 99.7%; the mean operation time was 84 minutes and the radiation time was 13 minutes. The mean hospital stay was 3.7 days; no patient required intensive care. At 6 months, there were no reports of local/systemic complications related to IFB, such as infection, seroma, hematoma, nerve injury, or allergic/toxic reactions., Conclusion: Our study demonstrated that performing EVAR with femoral cutdown under IFB is a feasible, safe, and effective surgical and anesthetic combination, with very little need for conversion to general anesthesia.

A 62 year old man, suffering from arterial hypertension and no other significant comorbidities come to our attention for the presence of an asymptomatic 29 mm left common iliac artery (CIA) aneurysm and bladder cancer. Given the young age of the patient, we opted for endovascular treatment that would allow to maintain the patency of the hypogastric artery. In June 2011, the patient underwent an endovascular exclusion of the left iliac artery aneurysm corrected by multilayer stent placement (Cardiatis 16x120mm) and post-dilatation with 14x40 mm balloon (Medtronic Reliant). At the 3 months follow-up, a CT-angio was made, showing a Type I endoleak with complete perfusion of the aneurismal sac. We analysed the CT-Angio using OsiriX and at the 3D reconstruction a poor adhesion of the stent to the proximal neck was detected. We decided to intervene by implanting two balloon-expendable covered stents (Atrium Adventa; 16x40 mm) The aneurysm sac remained stable for 9 months but at 12 months follow-up the aneurysm presented a diameter of 39mm. Due to the increase of the aneurysm sac, we decided to implant a stent-graft 16-10x95+10-10x80 mm (Medtronic Endurant) with complete exclusion of the aneurysm and internal iliac artery occlusion. At one month follow-up the patient is completed asymptomatic with no endoleak at the Duplex scan and at the CT-Angio.