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Late distal type I endoleak (ELIB) hampers the outcome of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA); however, only few dedicated experiences have been reported in the literature. The aim of the study was to evaluate the incidence, presentation and treatment of late ELIB and to identify possible anatomical and technical predictors. All patients undergoing elective EVAR between 2008 and 2013 were collected prospectively. Follow up was by post-operative computed tomography angiography (CTA) performed within 30 days and CTA and/or duplex ultrasound (DUS) at six or 12 months and yearly thereafter. Patients with late ELIB, defined as distal type I endoleak detected more than six months after the primary intervention without endoleak on the intra-operative completion angiogram and on the post-operative CTA, were retrospectively selected (G1) and compared with a control group with no ELIB (G2) homogeneous for clinical conditions, endograft implanted, and timing of follow up. The minimum follow up required for inclusion in the study was 24 months. Pre-operative morphological aorto-iliac features and EVAR implant details were evaluated, and measurements performed after centre lumen line reconstructions using dedicated software. The differences between G1 and G2 were analysed using the chi-square test, the Student t test, and logistic regression. Six hundred and sixteen patients were submitted to EVAR. ELIB was detected in 14 cases (2.3%) (G1) at a median follow up of 32.8 (IQR 48) months. In three of the 14 cases ELIB was symptomatic (AAA rupture, 2; pain, 1); in the remaining 11 cases it was asymptomatic and found incidentally at routine follow up. Treatment was by open repair in one case and by endovascular iliac leg extension in 13 cases. Hypogastric exclusion was necessary in two of 14 cases. Thirty patients were included in G2, with a median follow up of 41.2 (25) months. Common iliac artery length <4 cm (OR 5.3, 95% CI 1.1–29.5, p =.05), diameter > 15 mm (OR 3.5, 95% CI 1.2–10.9, p =.03), and severe thrombotic apposition (>50% of circumference) (OR 5, 95% CI 1.2–19.2, p =.02), at the iliac sealing zone were significant predictors of ELIB, on univariable analysis; oversizing of the iliac leg diameter < 10% and distal sealing > 1 cm above the hypogastric origin were independently associated with ELIB (OR 5.4, 95% CI 1.3–21.5, p =.01 and OR 6.6, 95% CI 1.1–39.3, p =.03, respectively), on multivariable analysis. The present data underline that ELIB is a non-negligible occurrence during long term EVAR follow up and requires further interventions, most often by endovascular solutions. According to the ELIB risk factors identified in this study, an iliac leg diameter oversize >10% and extensive common iliac artery coverage (<1 cm above the hypogastric origin) would be suggested to prevent this complication. [ABSTRACT FROM AUTHOR]

Purpose: To compare perioperative and long-term outcomes of endovascular aneurysm repair (EVAR) with flared limbs (FLs) vs iliac branch devices (IBDs) for common iliac artery aneurysm to determine possible differences in outcome.Materials and Methods: From 2012 to 2017, all patients with standard EVAR with FLs and aortoiliac anatomy fit for implantation of IBDs were retrospectively selected and compared with patients with standard EVAR and IBDs. The study included 150 patients with 162 iliac treatments: 105 (65%) FLs and 57 (35%) IBDs. Iliac complications (ICs), including internal iliac artery (IIA) loss, limb thrombosis, and type 1b or type 3 endoleak, were considered at 30 days and in the follow-up period.Results: Procedural time and volume of contrast medium were significantly higher in IBD vs FL procedures (90 min ± 33 vs 70 min ± 25, P = .01; 130 mL ± 40 vs 80 mL ± 20, P = .01). Perioperative rate of ICs was similar between IBDs and FLs (0% vs 3.8% [4 IIA loss], P = .25). During 35-month median follow-up, there were 10 ICs, all in FLs group (4 IIA perioperative loss, 4 type 1b endoleak, 2 limb occlusion). By Kaplan-Meier analysis, survival free of ICs was significantly higher in IBD group after 4 years of follow-up (1 y 100% vs 96%, P = .36; 2 y 100% vs 94%, P = .14; 3 y 100% vs 91%, P = .07; 4 y 100% vs 87%, P = .03; 5 y 100% vs 78%, P = .02).Conclusions: IBDs and FLs have similar perioperative results. IBDs require longer procedural time and greater contrast medium volume; however, they are associated with lower ICs after 4 years of follow-up. [ABSTRACT FROM AUTHOR]

Carotid endarterectomy (CEA) in patients with asymptomatic carotid stenosis (ACAS) remains a subject of debate. Current recommendations are based on randomized trials conducted over 20 years ago and improvements in medical therapies may have reduced the risk of cerebral ischemic events (CIE). This study presents a mid-term analysis of results from an ongoing prospective observational study of ACAS patients to assess their CIE risk in a real-world setting. This is a prospective observational cohort study of patients with ACAS >60 % (NASCET criteria) identified in a single duplex ultrasonography (DUS) vascular laboratory (trial registered: NCT04825080). Patients were not considered for CEA due to their short life expectancy (<3 year) or absence of signs of plaque vulnerability (ulceration, ipoechogenic core). Patient enrollment started in January 2019 and ended in March 2020 with a targeted sample size of 300 patients.A 5-year follow-up was scheduled. Clinical characteristics, risk factors, and medical therapies were documented, and, when necessary, the best medical therapy (BMT), involving antiplatelet agents, blood pressure control, and statins, was recommended during clinical visits. The primary endpoint was to asses CIEs (including strokes, transient ischemic attacks, amaurosis-fugax) ipsilateral to ACAS along with plaque progression rate and patients survival. Follow-up involved annual clinical visit and carotid DUS examination, complemented by telephone interviews at six-month intervals. The study included 307 patients, with an average age of 80 ± 7 years, of whom 55 % were male. Contralateral stenosis exceeding 60 % was present in 61 (20 %) patients. Seventy-seven percent of patients were on BMT. At a mean follow-up of 41±9 months, 7 ispilateral strokes and 9 TIAs occurred, resulting in 14 CIEs (2 patients experienced both TIA and stroke). According to Kaplan–Meier analysis, the 4-year CIE rate was 6±2 %, with an annual CIE rate of 1.5 %. Fifty-eight (19 %) patients had a stenosis progression which was associated with a higher 4-year estimated CIE rate compared to patients with stable plaque (10.3 % vs 3.2 %, P=.01). Similarly, a contralateral carotid stenosis >60 % was associated with a higher 4-year estimated CIE rate: 11.7 % vs 2.9 %, P=.002. These factors were independently associated with high risk for CIE at the multivariate COX analysis: Hazard Ratio (HR): 3.2; 95 % Confidence Interval: 1.1-9.2 and HR: 3.6; 95 % CI: 1.2-10.5. The mid-term results of this prospective study suggest that the incidence of CIE in ACAS patients should not be underestimated, with plaque progression and contralateral stenosis serving as primary predictors of CIEs. [ABSTRACT FROM AUTHOR]

Objective: Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors.Methods: Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting.Results: On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02).Conclusions: cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome. [ABSTRACT FROM AUTHOR]

Objective To evaluate the impact of renal artery (RA) anatomy on the renal outcome of fenestrated-branched endografts (FB-EVAR) for thoraco-abdominal aortic aneurysms (TAAA). Methods Between 2010 and 2016, all patients undergoing FB-EVAR for TAAA were prospectively collected. Anatomical, procedural, and post-operative data were retrospectively analysed. RA anatomy was assessed on volume rendering, multi planar and centre line reconstructions by dedicated software (3Mensio). RA diameter, length, ostial stenosis/calcification, orientation and aortic angles of the para-visceral aorta were evaluated. RA orientation was classified in four types: A (horizontal), B (upward), C (downward), D (downward + upward). RA revascularisation by fenestrations or branches was considered. Inability to cannulate and stent RA (RA loss), early RA occlusion (within three months), and composite RA events (one among RA loss, intra-operative RA lesion, RA related re-interventions, RA occlusion) were assessed. Results Seventy-three patients (male 77%; age 73 ± 6 years) with 39 (53%) type I, II, III and 34 (47%) type IV TAAA, underwent FB-EVAR, for a total of 128 RAs. The mean RA diameter and length were 6 ± 1 mm and 43 ± 12 mm, respectively. Type A, B, C, and D orientations were 51 (40%), 18 (14%), 48 (36%), and 11 (10%) RAs, respectively. Angulation of para-visceral aorta >45° was present in 14 cases (19%). Ostial stenosis and calcifications were detected in 20 (16%) and 16 (13%) RAs, respectively. Branches and fenestrations were used in 43 (34%) and 85 (66%) RAs, respectively. There were four (3%) intra-operative RA lesions (2 ruptures, 2 dissections). Ten (8%) RAs were lost intra-operatively because of the inability to cannulating and stenting. On univariable analysis, type B RA orientation ( p =.001; OR 13.2; 95% CI 3.2–53.6), para-visceral aortic angle > 45° ( p =.02; OR 4.9; 95% CI 1.3–18.5) and branches ( p =.003; OR 9.0; 95% CI 1.9–46.9) were risk factors for intra-operative RA loss; type C RA orientation was a protective factor ( p =.02; OR 0.1; 95% CI 0.01–0.9). On multivariable analysis, type B RA orientation ( p =.03; OR 5.9; 95% CI 1.1–31.1) and branches ( p =.03; OR 7.3; 95% CI 1.1–47.9) were independent risk factors for intra-operative RA loss. Fourteen patients suffered post-operative renal function worsening (> 30% of the baseline). The mean follow up was 19 ± 12 months. Four (3%) early RA occlusions occurred in three patients (2 single kidney patients required permanent haemodialysis). Type D RA orientation ( p =.00; RR 17.8; 8.6–37.0) and branches ( p =.004; RR 3.2; 2.4–4.1) were risk factors for early RA occlusion on univariable analysis. Five patients (7%) required early RA related re-interventions (recanalisation + relining 3; stent graft extension 1; parenchymal embolisation 1). No late RA occlusion or re-interventions were reported during follow up. Composite RA events occurred in 17 (13%) cases. Type B ( p =.05; OR 3.9; 95% CI 1.1–15.7) or D ( p =.006; OR 10.9; 95% CI 2.3–50.8) RA orientations and branches ( p =.006; OR 5.7; 95% CI 1.6–20.3) were independent predictors of composite RA events on multivariable analysis. Conclusion Renal artery orientation significantly affects the early RA outcome of FB-EVAR for TAAA. Intra-operative RA loss is predicted by type B RA orientation and branches, while early RA occlusion is predicted by type D orientation and branches. The present data suggest that in TAAA, fenestrations should be the first choice for renal revascularisation in type B and D RA orientations. [ABSTRACT FROM AUTHOR]