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To report a case of pararenal aortic aneurysm (PAAA) with narrowed iliac arteries treated by the chimney technique combined with the INCRAFT ® AAA stent graft system. A 75-year-old man was diagnosed with a 55-mm PAAA. Patient was judged unfit for open repair and for standard endovascular aneurysm repair (EVAR) due to its clinical and anatomical requirements. Custom-made fenestrated device (FEVAR) was excluded due to the presence of narrowed and heavily calcified iliac axes. Consequently, patient underwent auspicious endovascular aneurysm repair with the INCRAFT System and chimney grafts in the superior mesenteric artery and both renal arteries. At 12 months' follow-up, patient was in good clinical condition, with preserved renal function. Computed tomographic angiography revealed inceptive shrinkage of the aneurysm with patency of aortic and visceral grafts even in the presence of a low-flow type Ia endoleak. Chimney grafts (CGs) combined with the low-profile INCRAFT System seem to be feasible for treating PAAA, in high-risk patients unfit for standard EVAR or FEVAR devices., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We report a case of acute limb ischemia (ALI) due to a thromboembolism from a persistent sciatic artery (PSA) pseudoaneurysm precipitated by a fractured stent. Patient, previously treated for ALI by fibrinolysis and stent implantation, presented with a PSA pseudoaneurysm (undetected during first hospitalization), stent fracture (SF), and occlusion of vessels below the knee. Fibrinolysis was performed, restoring direct flow to the foot. A week later, an endovascular procedure was attempted to reline SF and exclude the PSA pseudoaneurysm by deployment of two 13 × 100-mm peripheral endografts (Viabahn; W.L. Gore & Associates, Flagstaff, AZ). At 1-year follow-up, patient was asymptomatic without further clinical events., (Copyright © 2017 Elsevier Inc. All rights reserved.)

To report rationale of a physician-initiated study: Expanding Indications for Treatment with Standard EVAR in Patients with Challenging Anatomies, a Multi-Centric Prospective Evaluation - EXTREME.

Although proof-based medicine has generated much valid evidence for the drawing up of guidelines and recommendations for best clinical practice in symptomatic and asymptomatic carotid stenosis, whether and when it is better to employ endarterectomy or stenting as the intervention of choice still remain matters of debate. Moreover, guidelines have been targeted up to now to the 'representative' patient, as resulting from the statistical analyses of the studies conducted on the safety and efficacy of both interventions as well as on medical therapy alone. The Italian Stroke Organization (ISO) and Stroke Prevention and Awareness Diffusion (SPREAD) group has thus decided to update its statements for an 8th edition. To this end, a multidisciplinary team of authors representing Italian scientific societies in the neurology, neuroradiology, vascular and endovascular surgery, interventional cardiology, and general medicine fields re-examined the literature available on stroke. Analyses and considerations on patient subgroups have allowed to model the risks/benefits of endarterectomy and stenting in the individual. Accordingly, the guideline's original methodology has been revised to follow the new SIGN (Scottish Intercollegiate Guideline Network) Grade-like approach, integrating it with new considerations on Precision, or Personalized Medicine. Therefore, this guideline offers recommendations on precision medicine for the single patient, and can be followed in addition to the more standard guidelines.

Dolphins emit short ultrasonic pulses (clicks) to acquire information about the surrounding environment, prey and habitat features. We investigated Delphinidae activity over multiple temporal scales through the detection of their echolocation clicks, using long-term Passive Acoustic Monitoring (PAM). The Istituto Nazionale di Fisica Nucleare operates multidisciplinary seafloor observatories in a deep area of the Central Mediterranean Sea. The Ocean noise Detection Experiment collected data offshore the Gulf of Catania from January 2005 to November 2006, allowing the study of temporal patterns of dolphin activity in this deep pelagic zone for the first time. Nearly 5,500 five-minute recordings acquired over two years were examined using spectrogram analysis and through development and testing of an automatic detection algorithm. Echolocation activity of dolphins was mostly confined to nighttime and crepuscular hours, in contrast with communicative signals (whistles). Seasonal variation, with a peak number of clicks in August, was also evident, but no effect of lunar cycle was observed. Temporal trends in echolocation corresponded to environmental and trophic variability known in the deep pelagic waters of the Ionian Sea. Long-term PAM and the continued development of automatic analysis techniques are essential to advancing the study of pelagic marine mammal distribution and behaviour patterns.

We report a case of a compassionate treatment of a ruptured thoracoabdominal aortic aneurysm in a 92-year-old patient. The patient was admitted to our emergency department for acute onset of pain irradiating to the back. Computed tomography angiography showed the presence of a thoracoabdominal aortic aneurysm with a contained rupture at infrarenal level. Given the presence of a relative healthy visceral aorta, we decided to treat the patient by Ovation (Endologix, Irvine, CA) implantation in an off-label fashion. Procedure was performed by bilateral percutaneous access. Completion angiography showed the good stent-graft apposition with complete aneurysm exclusion. The patient was discharged on the third postoperative day. The 1-month follow-up confirmed the good procedural result; aneurysm was completely excluded without further thoracic dilatation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: The aim of this review is to assess if late mortality after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is a real problem, and whether it could be an issue in the case of medical litigation., Material and Methods: A review of all English language literature was performed on PubMed web-site, looking for all papers reporting EVAR long-term mortality rate. EVAR performances were reviewed also from an ethical and medico-legal point of view, based on current Italian laws., Results: Mono-centric studies, and international registers suggest that today EVAR offers similar (if not better) results than open repair (OR) in the treatment of AAAs with standard and complex anatomies, even if performed outside the devices-specific instructions for use. In contrast, large randomized trials, and consequently current guidelines, suggest that EVAR still has an ancillary role compared to OR, only to be used for highly selected patients. Recently, specific litigation cases on surgical options related to the treatment of aortic aneurysms has developed. The informed consent process needs to include not only mortality and major complications related to the procedure but also the chance of patients' outcomes. For those reasons, the generic nature of informed consent has been criticized., Conclusions: No conclusive data is currently available to assess the initial question of late mortality after EVAR but results are still improving. In the meantime, widespread use of EVAR as first choice for treating AAA may only be acceptable in high-volume centres validating their results by a strict follow up protocol.

Background: Extreme complex aortic anatomies still represent the major limit of endovascular aneurysms repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Aim of this study was to evaluate results of EVAR with Ovation® stent-graft in extremely complex aortic anatomies., Methods: A single center study was retrospectively conducted on a prospectively compiled computerized database between July 2012 and July 2014. Twenty-one elective patients with atherosclerotic AAA were included. All patients were judged unfit for or refused an open approach. In all of them, extremely complex anatomies features contraindicated EVAR by common endografts. Patients' outcomes were evaluated on the basis of anatomical features: challenging proximal aortic neck (non-cylindrical, short, severely angulated, enlarged, thrombosed) and challenging iliac artery accesses (angulated and narrowed). Technical and clinical successes were defined as the absence of intraoperative surgical conversion and aneurysm related mortality, respectively. Reintervention, morbidity and mortality rates during follow-up were also recorded., Results: All patients were male; mean age was 75.6±7.2 years. In 14 patients (66.7%) neck length was <10 mm, a non-cylindrical neck was present in 15 patients (71.4%) and a severe neck thrombosis was registered in 13 patients (61.9%). Only 1 patient (4.8%) had no iliac tortuosity, 9 (42.8%) patients had severe tortuosity at least on one iliac access and 7 (33.3%) on both. Technical and clinical successes were achieved in all cases. Neither death nor reinterventions were observed in the present series. At a mean follow-up of 9±5 (3-27) months, only one patient presented an iliac leg occlusion., Conclusions: Our limited and preliminary experience seems to show that Ovation® stent-graft may widen the range of AAAs suitable for standard EVAR. Early results, even in patients with challenging anatomies, are encouraging but a longer follow-up is mandatory.

A 62-year-old man presented with fever, abdominal pain, and malaise 13 months after emergency endovascular aortic repair. Computed tomographic angiograms showed a periprosthetic fluid and gas collection, so infection was diagnosed. Open conversion was performed, involving endograft explantation and in situ aortic reconstruction. Cultures and the explanted prosthesis were positive for carbapenemase-producing Klebsiella pneumoniae, resistant to colistin. Because of the sparse data on endograft infections caused by this pathogen, we placed the patient on an empiric double-carbapenem regimen for 4 weeks. Symptomatic recovery occurred after 21 days. On the 30th day, we deployed a stent to treat a new pseudoaneurysm. Three years later, the patient had no signs of persistent or recurrent infection. We think that this is the first report of aortic endograft infection caused by colistin-resistant, carbapenemase-producing K. pneumoniae.

Purpose: Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center., Methods: We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction., Results: From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR (P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR (P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction (P < .05)., Conclusions: Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate., (© The Author(s) 2016.)

Objective: This study investigated the frequency, clinical features, therapeutic options, and results of aortoenteric fistulas (AEFs) developing after endovascular abdominal aortic repair (EVAR)., Methods: Eight Italian centers with an EVAR program participated in this retrospective multicenter study and collected data on AEFs that developed after a previous EVAR., Results: A total of 3932 patients underwent EVAR between 1997 and 2013 at the participating centers. During the same period, 32 patients presented with an AEF during EVAR follow-up, 21 with original EVAR performed for atherosclerotic aneurysmal disease (ATS group) and 11 with the original EVAR performed for a postsurgical pseudoaneurysm (PSA group). The incidence of AEF development after EVAR was 0.46% in the ATS group and 3.9% in the PSA group. Anastomotic PSA as the indication to EVAR (P < .0001) and urgent/emergency EVAR (P = .01) were significantly associated with AEF development. Median time between EVAR and the AEF diagnosis was 32 months (interquartile range, 11-75 months) for the ATS group and 14 months (interquartile range, 10.5-21.5 months) for the PSA group. Among five AEF patients treated conservatively, two (40%) died, at 7 and 15 months, and the remaining three were alive at a median follow-up of 12 months. The AEF was treated surgically in 27 patients, including aortic stent graft explantation in all cases, in situ aortic reconstruction in 14 (52%), and extra-anatomic bypass in 13 (48%). Perioperative mortality was 37% (10 of 27). No additional aortic-related death was recorded in operated-on patients at a median follow-up of 28 months., Conclusions: Late AEFs rarely occur during EVAR follow-up, but the risk is significantly increased when EVAR is performed for PSA after previous aortic surgery and EVAR is performed as an emergency. Conservative and surgical treatment of post-EVAR AEF are both associated with high mortality. However, beyond the perioperative period, surgical correction of AEFs appears to be durable at midterm follow-up., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

We report a case of an early type Ia endoleak after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm by Ovation Stent Graft implantation and spontaneously resolved without further reintervention. The patient presents a conical aortic neck, but EVAR was performed within the instruction for use proposed by manufactory. At completion angiography, a low-flow type Ia endoleak was present and left untreated. Computed tomographic angiography performed on the third postoperative day showed infolding of the 2 sealing rings. The patient was dismissed without further treatment. At 3-month follow-up, the leak appeared spontaneously sealed with partial expansion of the 2 rings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The coral reef aorta (CRA) is a rare syndrome commonly referred to a distribution of calcified plaques in the visceral part of the aorta. Because those plaques can cause malperfusion of the lower limbs, visceral ischemia or renovascular hypertension, surgical treatment is recommended. Transaortic endarterectomy is accepted as a standard repair and it is often performed through an extensive thoracoabdominal approach. CRA has been reported in association with polidistrectual atherosclerotic disease, such as Leriche syndrome. When these 2 conditions coexist, surgical invasivity increases raising several issues concerning the type of surgical access and the revascularization techniques. We report the case of a patient with CRA and Leriche syndrome treated by simultaneous aortic endarterectomy and aortibifemoral bypass at our institution. Intervention was performed through left lumbotomy at 10th intercostal space extended by a left pararectal abdominal incision with section of 11th rib. Through extraperitoneal access visceral vessels were isolated. Aortic cross-clamping was performed at supraceliac and infrarenal levels and a longitudinal arteriotomy was performed on the posterolateral wall of visceral aorta for an overall 4-cm extension. Aortic endarterectomy was then performed and complete plaque excision was easily achieved. Superior mesenteric artery angioplasty was then performed by a DeBakey dilator, gaining an optimal backflow. The aortotomy was then closed with running 3-0 polypropylene suture. Subsequently, through a transperitoneal access an aortobi-femoral bypass was performed by a Dacron knitted graft. Postoperative course was uneventful. At a 6-month follow-up, the patient is in good clinical condition with normal patency of visceral vessels., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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.

The sperm whale (Physeter macrocephalus) emits a typical short acoustic signal, defined as a "click", almost continuously while diving. It is produced in different time patterns to acoustically explore the environment and communicate with conspecifics. Each emitted click has a multi-pulse structure, resulting from the production of the sound within the sperm whale's head. A Stable Inter Pulse Interval (Stable IPI) can be identified among the pulses that compose a single click. Applying specific algorithms, the measurement of this interval provides useful information to assess the total length of the animal recorded. In January 2005, a cabled hydrophone array was deployed at a depth of 2,100 m in the Central Mediterranean Sea, 25 km offshore Catania (Ionian Sea). The acoustic antenna, named OνDE (Ocean noise Detection Experiment), was in operation until November 2006. OνDE provided real time acoustic data used to perform Passive Acoustic Monitoring (PAM) of cetacean sound emissions. In this work, an innovative approach was applied to automatically measure the Stable IPI of the clicks, performing a cepstrum analysis to the energy (square amplitude) of the signals. About 2,100 five-minute recordings were processed to study the size distribution of the sperm whales detected during the OνDE long term deep-sea acoustic monitoring. Stable IPIs were measured in the range between 2.1 ms and 6.4 ms. The equations of Gordon (1991) and of Growcott (2011) were used to convert the IPIs into measures of size. The results revealed that the sperm whales recorded were distributed in length from about 7.5 m to 14 m. The size category most represented was from 9 m to 12 m (adult females or juvenile males) and specimens longer than 14 m (old males) seemed to be absent.

We report a case of superficial femoral artery (SFA) stent fractures (SF) with atypical symptoms and site of disruption. Patient was hospitalized for sudden onset of right thigh pain, nonrelated to steno-obstructive disease. Preoperative ultrasound suspected and computed tomographic angiography (CTA) confirmed multiple proximal SFA SFs with concurrent pseudoaneurysms. A peripheral endograft was deployed covering the entire SFA, achieving a complete "relining" with exclusion of the pseudoaneurysm. Pain disappeared and postoperative control demonstrated good patency of the SFA. After 1 month, patient reported no further events and CTA revealed patency of the endograft and exclusion of the pseudoaneurysm. At 1 year follow-up, Viabahn is patent with no further symptoms reported by the patient., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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.

Purpose: To evaluate the impact of two-dimensional and three-dimensional preoperative morphologic features analyzed on computed tomography (CT) angiography on midterm outcome in patients with abdominal aortic aneurysms (AAAs) treated with endovascular aneurysm repair (EVAR)., Materials and Methods: A retrospective analysis was conducted using a prospectively collected database. Morphologic features considered as potentially influencing outcomes were maximum aortic diameter, thrombus area, overall aneurysm volume, and intrasac thrombus volume. Outcome measures were all perioperative and midterm AAA-related reinterventions and all-cause mortality., Results: Investigators reviewed 191 preoperative CT angiography scans. Mean maximum aortic diameter was 58 mm; thrombus area, 49.6%; aortic volume, 159.36 cm(3); and thrombus volume, 58.6%. Technical success was achieved in all cases. No reintervention was required in the perioperative period, and there was no perioperative mortality. At a mean follow-up of 32 months ± 16.8 (range, 3-66 mo), mortality rate was 9.4%, AAA-related death was 0, and reintervention rate was 8.9%. Causes of reintervention included type I endoleak (n = 3 [1.6%]), type II endoleak (n = 7 [3.7%]), type III endoleak (n = 1 [0.5%]), endograft limb thrombosis (n = 4 [2.1%]), and access vessel thrombosis (n = 2; 1%). Greater thrombus area (> 60%) and thrombus volume (> 59%) were predictors for reintervention (P = .005 and P = .0034). Greater maximum aortic diameter (> 59 mm) and aortic volume (> 159 cm(3)) were related to higher reintervention rate without statistical significance (P = .62 and P = .12). Aortic volume was a predictor of any adverse event, reintervention, and all-cause mortality after EVAR (P = .03)., Conclusions: Thrombus area and volume are related to higher rates of reintervention. Maximum aortic diameter was related to a higher reintervention rate, but this was not significant., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

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.

Background: Although rare, popliteal artery aneurysms (PAAs) are the most commonly observed peripheral arterial aneurysms. Surgical repair is considered the gold standard, even if with debated results. The aim of our study is to evaluate the outcome of endovascular treatment of PAAs using the Viabahn peripheral endograft (W. L. Gore and Associates, Inc., Flagstaff, AZ) in 2 high-volume Italian centers., Methods: All consecutive PAA patients treated by endovascular procedures between January 2004 and December 2013 were retrospectively reviewed. True atherosclerotic aneurysms, symptomatic and asymptomatic, were included in the analysis. All patients were treated by high-skilled vascular surgeons. The outcome measures were graft thrombosis, reintervention rate, and limb salvage at early and long-term follow-up., Results: Fifty-three PAAs were treated. Patients were more frequently male (98.1%) with a mean age of 73.6 ± 7.8 years. Twelve patients (22.6%) were symptomatic and in 8 of them a local fibrinolysis was required before definitive surgery. Mean PAA diameter was 30.9 ± 10.9 mm (range 17-60). Fifty-two patients (98.1%) had at least 1 patent runoff vessel. Technical success was achieved in all patients. Overall, 80 stent grafts were deployed and in 21 patients (39.6%) more than 1 stent graft was deployed. In-hospital mortality rate and 30-day reinterventions were null. At a mean follow-up of 37.4 ± 29.3 months, primary patency, secondary patency, and limb salvage were respectively 73.6%, 92.4%, and 100%., Conclusion: In our limited, retrospective experience, the endovascular treatment of PAA by Viabahn stent graft allowed satisfactory technical and clinical results even at long-term follow-up., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Duodenal obstruction caused by abdominal aortic aneurysm was first described by Osler in 1905 and is named "aortoduodenal syndrome." This condition has always been treated by open surgical repair. We report the first case of aortoduodenal syndrome successfully treated by endovascular aneurysm repair. A 74-year-old male patient referred to our hospital complaining postprandial vomit, reporting a consistent weight loss in the latest weeks. Enhanced computed tomography scans showed a small saccular abdominal aortic aneurysm compressing duodenum and inferior vena cava without any other evident pathological finding. As the patient underwent a successful endovascular treatment of the abdominal aortic aneurysm, symptoms immediately resolved so that he started back to feed and progressively gained body weight. Despite aortoduodenal syndrome is generally caused by large abdominal aortic aneurysm, this condition has to be suspected also in case of small abdominal aortic aneurysm. Differently from what has been reported in literature, endovascular aneurysm repair could be effective in the treatment of aortoduodenal syndrome., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Purpose: To retrospectively review all patients undergoing late open conversion (LOC) after endovascular aneurysm repair (EVAR) in order to identify any clinical or technical predictors of poor outcome., Methods: Twenty-six consecutive patients (24 men; mean age 74.7 ± 8.3 years) underwent LOC between June 2006 and April 2013 at our institution. The mean interval from index EVAR to LOC was 40.4 ± 29.2 months (range 5-93 months). The indication for LOC was endoleak in 14 (54%) patients and infection in 12 (46%): 2 (8%) patients with endoleak had a ruptured aneurysm and 6 (23%) patients with infection had a recurrent secondary aortoesophageal fistula (sAEF)., Results: In all 12 cases of infection and in 12 of 14 endoleaks, the entire endograft was explanted. A rifampin-soaked Dacron silver graft was implanted in all patients with infection. Patients with any infection and with recurrent AEF required more blood units than patients with endoleak (6.40 vs. 1.86, p = 0.045; 6.76 vs. 1.86, p = 0.0036, respectively). Compared with endoleak, the duration of conversions in the setting of infection (274 vs. 316 minutes, p = 0.42) and recurrent sAEF (274 vs. 396 minutes, p = 0.021) was longer. All patients with recurrent sAEF died at a mean 3.0 ± 2.5 days after LOC from proximal anastomosis disruption and hemorrhagic shock (n = 2), myocardial infarction (n = 2), acute stroke (n = 1), or persistent sepsis (n = 1). Perioperative mortality was significantly higher in patients with endograft infection (6/12, p = 0.002) and in cases of supraceliac cross-clamping (4/6, p = 0.003). The association of infection with supraceliac cross-clamping was a strong predictor for perioperative mortality (p < 0.001)., Conclusion: In our experience, endograft infection led to greater perioperative mortality after LOC. Recurrent aortoenteric fistula in association with supraceliac cross-clamping is a strong predictor of poor outcome. Patients surviving the perioperative period may have good chances of long-term survival., (© The Author(s) 2015.)

Endovascular repair (EVAR) for abdominal aortic aneurysms (AAAs) is becoming the standard of practice in most vascular centers, even if some concerns remain about the occurrence of early and long-term failure and reintervention. A rare but potential catastrophic event is represented by retrograde type B aortic dissection (RTBAD). We report 2 cases of RTBAD after 425 standard EVARs performed in our institution. Both patients were treated for AAA without perioperative complication, and in both the patients, the presence of a preexisting disease of the thoracic aortic wall (ulcerated plaque in 1 case and aortic ectasia in the other) may have played an important role in the rapid evolution toward an early onset of the dissection. Only few cases of type B dissection after EVAR have been reported in literature, and the etiology of this complication remains uncertain. For the first time, our experience highlights the possible etiologic role of preexisting lesions of the thoracic aorta. In these cases, the only possible strategy may be to carefully study the entire aorta before an EVAR procedure, eventually switching the indication to an open surgical repair or carrying out a more aggressive management, treating the defects of the thoracic aorta., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Endovascular treatment of abdominal aortic aneurysm (EVAR) represents a good alternative to open surgery, also in patients who present inflammatory abdominal aortic aneurysm, resulting in reduction of the inflammatory process in many cases. Instead, the onset of periaortic inflammation after EVAR is a rare event with an unclear pathogenesis, time of onset, and clinical presentation. This is a case report of a very early onset of periaortitis after EVAR with inferior vena cava involvement and stretching, resulting in lower limb swelling and back pain, treated by corticosteroid drug with a good remission of the pathology., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.

We report the case of a 76-year-old man presented with three saccular aneurysms at the aortic arch and descending thoracic aorta. A two-staged hybrid approach was performed. A left common carotid-to-left subclavian artery bypass and a custom-made fenestrated endograft were used for the two proximal aneurysms. The endograft deployment was complicated by the unadverted coverage of the left common carotid artery ostium, promptly corrected with the chimney technique. The endovascular treatment was completed with the third endovascular aneurysm exclusion 5 months after the first procedure to reduce the risk of spinal cord ischemia. Yearly follow-up computed tomography scan confirmed aortic arch and descending thoracic aorta aneurysms exclusion with supra-aortic vessels, bypass, and stent patency. Endovascular repair of the aortic arch aneurysm with a fenestrated endograft is safe and feasible in selected patients. Complications may be solved with total endovascular approach. Long term follow-up remains mandatory., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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.)

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.)

One of the most discussed issues in abdominal aortic surgery in kidney-transplanted patients is represented by organ protection during aortic cross-clamping. We report the case of a kidney-transplanted woman who underwent surgical correction for an abdominal aortic aneurysm after she refused any endovascular approach. To maintain kidney perfusion, during surgical aortic reconstruction, a biopump was chosen. Nowadays, abdominal aortic aneurysm endovascular repair, when feasible, allows avoiding cross-clamping-related renal ischemia, although a potential risk for contrast-induced nephrotoxicity still exists. When open surgical repair is chosen, several different techniques to protect the transplanted organ have been proposed, with different potential advantages and results. In the case we reported, the use of biopump allowed an effective protection from ischemia, minimizing perioperative stress and complications., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Concomitant aortic aneurismal pathology and vertebral erosion are seldom reported in literature. The differential diagnosis between a primary vertebral disease affecting the aortic wall and a primary aortic pathology causing a vertebral disruption is quite difficult. We report on a patient presenting with increasing lumbar pain and neurologic lower limbs deficit due to a vertebral erosion accompanied by aortic rupture treated by emergent endovascular aortic repair procedure and then staged vertebral fixation. Microbiological tests on intraoperative periaortic fluid collection samples showed no clear sign of infection and clinical conditions progressively improved. At 12-month follow-up, the patient is in good clinical condition, with a small residual walking impairment and no clinical, laboratory, or imaging sign of aortic endograft infection., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Pseudoaneurysm after carotid endarterectomy (CEA) is a rare complication, with an incidence lower than 1%. Infection as a cause of carotid pseudoaneurysm is uncommon, and is mostly caused by staphylococci. An 81-year-old woman, treated with right carotid endarterectomy 7 years earlier, presented with a diagnosis of right carotid pseudoaneurysm. The patient was neurologically asymptomatic; clinical status, laboratory, and imaging findings were negative for infection. She was referred to surgical treatment consisting of patch excision and a carotid polytetrafluoroethylene bypass grafting. During intervention a purulent fluid collection was discovered, and therefore an inverted great saphenous vein carotid bypass was performed. The postoperative course was normal. Microbiological examination on the purulent fluid collection and excised patch showed the presence of Staphylococcus epidermidis. Carotid pseudoaneurysms after CEA often arise in asymptomatic patients. Despite this common clinical presentation, an infective origin must always be taken into account before any intervention is planned., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy., Methods: Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis., Results: MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24)., Conclusions: MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The aim of this study was to assess the relationship between serum levels of S100β and neuron-specific enolase (NSE), postoperative diffusion-weighted magnetic resonance imaging (DW-MRI) and Mini-Mental State Examination (MMSE) score in asymptomatic patients affected by ≥ 70% carotid stenosis submitted to carotid endarterectomy (CEA) or carotid artery stenting (CAS), and to compare MMSE scores and DW-MRI findings at follow-up evaluations. Between April 2008 and April 2009, 60 patients were submitted to carotid intervention. All patients underwent DW-MRI and MMSE preoperatively, at 24 hours postoperatively, at 6 months and at 12 months. Neurobiomarkers were assessed for each patient at six time-points. Thirty-two patients were submitted to CEA and 28 to CAS. No mortality was observed. One CAS patient presented with an ischemic stroke. In six CAS patients and one CEA patient, new subclinical ischemic lesions were detected at postoperative DW-MRI (21.4% versus 3%, P = 0.03). In CAS patients, new DW-MRI lesions were significantly associated with MMSE score decline (P = 0.001). At 12 months, patients presenting with new postoperative ischemic lesions showed lower MMSE scores (P = 0.08). CAS patients showed increasing neurobiomarker levels compared with CEA patients (P = 0.02). In conclusion, microembolization effects may persist over time, so it should be avoided whenever possible. Carotid revascularization procedures should be evaluated and compared not only with respect to death/stroke but also to microembolism rates.

Objective: The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms., Methods: This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging., Results: Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%)., Conclusions: Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Rationale: In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure., Aims: Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions., Design: Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups: urgent carotid endarterectomy (within 48 hours) and delayed carotid endarterectomy ( operated between 48 hours and 15 days after onset of symptoms) Risk factors will be evaluated at enrollment. TIA will be classified by ABCD2 scoring system,and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores. The study will last 90 days per patient,starting from their initial symptom,and the follow-up will be performed by an indipendent neurologist. A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups., Outcomes: Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones. Secondary end-points are: Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups., (© 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.)

The treatment of Aortic Aneurysm disease is a growing procedure due to increase of life expectancy in Western Countries and relative incidence. In the past ten years we observed a progressive growth of endovascular over open surgery procedures with a related decline in rupture related deaths. Endo Vascular Aortic Repair [EVAR] is a well known technique of treatment of abdominal aortic aneurysms, that has changed the surgical approach to abdominal aortic aneurysms, as it is performed with low perioperative morbility and mortality rate and shorter hospital stay. However although EVAR offers immediate advantages over open surgical repair, it carries the need of close lifelong surveillance due to specific possible complications including rupture, endoleaks, graft migration and enlargement of aneurysm sac size. Contrast Enhanced Computed Tomography [CTA] is actually considered the standard reference in EVAR followup. However CTA carries high costs, radiation exposure and potential renal impairment. In the last five years several studies have been published on the role of Contrast Enhanced UltraSound [CEUS] in EVAR follow-up asserting high accuracy of this evaluation technique with absence of renal impairment, without radiation risk and at low costs. Especially since introduction of second generation Contrast Agents this evaluation technique is gaining popularity in EVAR follow-up surveillance. The diffusion of CEUS investigations by using new generation of contrast medium with appropriate software represents without any doubt an important step in the EVAR surveillance and could open up new strategies in the evaluation of endovascular aortic procedures gaining a fundamental role in EVAR follow-up.

To present a rare case of association of abdominal aorta rupture and flexion-distraction fracture of thoracolumbar spine and to review the literature on this condition. In non-penetrating abdominal traumatic injuries with flexion-distraction fractures of the thoracolumbar spine, rupture of the abdominal aorta is an extremely rare occurrence but its outcome is potentially lethal. This association of skeletal and vascular lesions mainly affects young patients and involves the thoraco-lumbar junction and the portion of the aorta that lies in front of it. The authors analyze the pertinent literature and describe a case, operated in two sittings, of a traumatic lesion of the aorta attributable to a fracture of L1, focusing on mechanism of damage, diagnosis and surgical treatment. At 2-year follow-up examination, there were no neurological deficits. A review of the pertinent literature has shown that mortality can be reduced by a meticulous clinical and radiological work-up for a correct diagnosis followed by surgical repair of any damaged vessels. The possibility of performing a rapid diagnosis by means of total-body CT-scan plus CT-angiography allows repair of vascular damage, stabilization of the patient's hemodynamic conditions and, subsequently, surgical treatment of the vertebral fracture.

Atheromatous plaques are dynamic structures undergoing continuous remodeling. Duplex ultrasound is now an accepted technique to classify the severity of arterial stenoses. It gives information about the ultrasonic echogenicity of tissue, the plaque surface and the velocity of blood flowing through vessels with the latest equipment. We report the case of a 59-year-old male patient with left hemispheric stroke and a 50% left carotid artery stenosis whose remodeling and reabsorption developed throughout three months from the onset of symptoms. Plaque surface and structural echomorphology assessment and standardization, along with the degree of carotid stenosis, might be helpful in identifying patients most likely to benefit from carotid endarterectomy.

Objectives: This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event., Methods: The study involved patients with acute neurologic impairment, defined as ≥ 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis ≥ 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation ≥ 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or ≥ 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging., Results: Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 ± 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 ± 3.41 on admission and 3.11 ± 3.62 at discharge in the entire group (P < .01). Patients with an NIHSS score of ≥ 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 ± 1.03 preoperatively vs 1.31 ± 1.7 postoperatively, NIHSS ≥ 8 10.32 ± 1.94 vs 4.03 ± 3.67; P < .001)., Conclusions: In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis ≤ 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance < or = 40 mL/min (p = .03) and female sex (p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.

Objective: Subclinical alterations of cerebral function can occur during or after carotid revascularization and can be detected by a variety of standard tests. This comparative study assessed the relationship among serum levels for two biochemical markers of cerebral injury, postoperative diffusion-weighted magnetic resonance imaging (DW-MRI), and neuropsychometric testing in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) for high-grade asymptomatic carotid stenosis., Methods: Forty-three consecutive asymptomatic patients underwent carotid revascularization by endarterectomy (CEA, 20) or stenting (CAS, 23). They were evaluated with DW-MRI and the Mini-Mental State Examination (MMSE) test preoperatively and 5 points (P = .001). Analysis of S100beta and NSE levels showed a significant increase at 24 hours in CAS patients compared with CEA patients (P = .02). The MMSE score at 6 months showed a nonsignificant increase vs the postoperative score in both groups., Conclusions: Biochemical markers measurements of brain damage combined with neuropsychometric tests and DW-MRI can be used to evaluate silent injuries after CAS. The mechanisms of rise in S100beta and NSE levels at 24 hours after CAS may be due to increased perioperative microembolization rather than to hypoperfusion. Further studies are required to assess the clinical significance of those tests in carotid revascularization.

We describe the occurrence of monolateral aseptic sialadenitis following non-iodinated contrast medium (ICM) administration for a carotid artery stenting procedure in a 71-year-old man. The mechanism for iodide-induced sialadenitis may be idiosyncratic or related to toxic accumulation of iodide. The risk for sialadenitis is directly related to serum iodide levels (> 10 mg/100 mL) and inversely related to normal renal function so that in renal impairment, ICM can be eliminated through alternative pathways such as the salivary glands and other excretory organs.

This multidisciplinary guideline provides an overview of the current evidence on the benefits obtained by endoarterectomy and stenting for the surgical treatment of patients with symptomatic and asymptomatic carotid stenosis. A hundred forty-six authors, 37 Italian scientific societies and two Italian patients' associations participated in drafting the Stroke Prevention and Educational Awareness Diffusion (SPREAD) document, which has become the national guideline for the prevention and treatment of stroke in Italy. For the surgical therapy section of this document, the main trials on carotid endoarterectomy and stenting were critically reviewed following The Scottish Intercollegiate Guideline Network Oxford Centre for Evidence-Based Medicine methodology in order to formulate recommendations and syntheses for these procedures. The final document was peer reviewed and approved by all the participants. Recommendations and syntheses are presented for the referral of patients to either carotid endoarterectomy or stenting on the basis of whether carotid stenosis is symptomatic or asymptomatic, on the presence of various risk factors such as degree of arterial narrowing, and on concomitant pathology (cardiopathy and acute stroke).

Objectives: Type II endoleak is the most common complication after endovascular aneurysm repair and require close surveillance. Hence, the need to validate new techniques as alternative to helical CT-scan, the reference standard. The aim of this study is to evaluate the efficacy of Cadence Contrast Pulse Sequencing ultrasound technique with second generation contrast agents in detecting endoleaks, and to compare the results with data obtained from CTA., Methods: 30 patients with endovascular stent grafts, during their regular follow-up consisting in serial CT and ultrasound exams performed at discharge, at one and six months and at one year thereafter, previous informed consent, were enrolled in a prospectic double blind study design in order to compare triphasic helical CT-scan to another adjunctive ultrasound investigation (Cadence CPS technique with Sono Vue). No more than 15 days occurred between the two examinations. In the study were evaluated only data obtained from the comparison of the two concomitant investigations, independently from the follow-up. Variables analysed were changes in the maximum diameter of the aneurysmal sac, presence and type of endoleak, if detected. In the case of disagreement between the two diagnostic tools angiography was performed., Results: One patient dropped out because of violation of the study protocol (a stroke occurred in the time interval between the two investigations). Both exams visualised patency and proper graft placement in all the remaining patients. Aneurysmal diameters with both investigations overlapped (r(s):0.98). In 21 patients no endoleak was detected with a significant aneurysmal sac shrinkage (P<0.001). In seven patients both methods confirmed presence of endoleak. Ultrasonography detected all type of endoleaks, while CT-scan was uncertain in one. Moreover, in one patient CT-angiography showed an increased aneurysmal diameter without other evidence, while a contrast ultrasound investigation disclosed a type II low-flow endoleak, confirmed by angiography., Conclusions: The Cadence Contrast Pulse Sequencing with echo contrast agent is an ultrasound technique that substantially improves the ultrasound diagnostic reliability.