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OBJECTIVE To evaluate trends and differences in Near Infrared Spectroscopy (NIRS) monitoring during carotid endarterectomy (CEA) in patients affected by asymptomatic and symptomatic carotid artery stenosis, to predict postoperative neurological complications (PNCs). METHODS NIRS data of CEAs performed in a University Hospital were retrospectively reviewed. All the interventions were performed under general anesthesia and patients with intraoperative complications were excluded. Mean regional Oxygen Saturation Index (rSO2), pre-clamp values (mean baseline value, MBv and Single Mark Baseline value, SMBv) were collected and compared to the lowest rSO2 values during carotid cross-clamp (LSO2v) calculated within 3 minutes (percentage drop, PD). ROC curve analysis with Youden's Test was performed to determine the best threshold value of PD, in order to identify PNCs in both asymptomatic and symptomatic groups. RESULTS Between 2007 and 2015, a total of 399 CEAs were consecutively performed with NIRS monitoring. Three-hundred-seventy-two CEAs in 355 patients were reviewed. Asymptomatic stenoses were 291 (81.9%), eleven (2.9%) PNC were registered (5 in asymptomatic and 6 in symptomatic group). Asymptomatic and symptomatic diseases had different MBv (69.5±7.5 vs71.8±6.9, respectively; p=.011) and similar rSO2 value during carotid clamping (63.7±8.0vs63.7±6.7, respectively: p=.958). Asymptomatic patients experiencing PNCs had a greater PD than non-PNCs group (20.5±10.2% versus 12.5±7.6%, respectively using MBv as baseline value; p = .002), in contrast, in symptomatic patients, in which a low PD was associated with PNCs, it does not reach statistical significance (using MBv, 12.6±5.4% versus 14.8±6.7%, respectively; p = .476). In order to detect PNCs, ROC analysis revealed an optimal PD cut-off value of -17% in asymptomatic CEAs. (Sensibility (Se) 0.80, Specificity (Sp) 0.76, PPV 0.05, NPV 0.99, Youden's index 0.56; p=.020) In symptomatic a threshold value of -9% was found, without reaching statistical significance. CONCLUSIONS NIRS as cerebral monitoring during CEA can predict PNCs in asymptomatic stenosis. Asymptomatic and symptomatic groups differ in baseline and intraprocedural cut-off values to detect an augmented PNCs risk.

A relatively high mortality of severe coronavirus disease 2019 (COVID-19) is worrying, and the application of heparin in COVID-19 has been recommended by some expert consensus because of the risk of disseminated intravascular coagulation and venous thromboembolism. However, its efficacy remains to be validated.Coagulation results, medications, and outcomes of consecutive patients being classified as having severe COVID-19 in Tongji hospital were retrospectively analyzed. The 28-day mortality between heparin users and nonusers were compared, as was a different risk of coagulopathy, which was stratified by the sepsis-induced coagulopathy (SIC) score or D-dimer result.There were 449 patients with severe COVID-19 enrolled into the study, 99 of them received heparin (mainly with low molecular weight heparin) for 7 days or longer. D-dimer, prothrombin time, and age were positively, and platelet count was negatively, correlated with 28-day mortality in multivariate analysis. No difference in 28-day mortality was found between heparin users and nonusers (30.3% vs 29.7%, P = .910). But the 28-day mortality of heparin users was lower than nonusers in patients with SIC score ≥4 (40.0% vs 64.2%, P = .029), or D-dimer 6-fold of upper limit of normal (32.8% vs 52.4%, P = .017).Anticoagulant therapy mainly with low molecular weight heparin appears to be associated with better prognosis in severe COVID-19 patients meeting SIC criteria or with markedly elevated D-dimer.

OBJECTIVES: Feasibility and results of cardiovascular hub-spoke networks to face COVID19 pandemic. The COVID-19 pandemic in Italy had the primary outbreak in the northern part of the country forcing the regional health care system to expand the availability of beds in the wards and intensive care units and to institute a Hub and Spoke hospital network to ensure assistance continuity for urgencies and emergencies. We report a descriptive analysis of the activity of the first 30 days of the Hub center. METHODS: Role of our Hub center was to guarantee 24/24h 7/7days cardiovascular surgical care for an area of 3.145.312 inhabitants’ area. Hub-spoke reorganization permitted a significant increase of ICU and ward beds availability for COVID patients needing hospitalization in all peripheral centers. Records of all consecutive patients admitted were collected and analyzed. RESULTS: a total of 100 patients were evaluated in the study period . Hub and spoke cooperation have been successful, all patients affected by cardiovascular urgencies or emergencies found a highly specialized hospital and was evaluated and treated. Global reduction of elective and non-deferrable interventions in spoke centers was achieved for both vascular and cardiac surgery while we detected a significant increase of urgent vascular interventions for acute limb ischemia. We did not observe an increase of in-hospital mortality in non-infected patients. CONCLUSION: Hub and spoke network for cardiovascular pathology is an effective way to face healthcare needs during the pandemic.

Objectives: We describe the clinical characteristics and outcomes of patients with three acute cardiovascular events (MACE) and coronavirus 2019 (COVID-19) infe

Objective The aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic. Methods We performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early ( Results We evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%]; P Conclusions In our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.

Purpose A rare complication of high energy traumatism of the lower limbs could be the development of post traumatic pseudoaneurysm (PSA) of the tibial arteries associated with arteriovenous fistula (AVF). Symptomatology could be challenging and leading to misdiagnosis. Methods Endovascular treatment with covered stent deployment or coil embolization has been now replaced by open surgery. Report (Results) Coil embolization of a post-traumatic peroneal PSA + AVF in not compound tibia and fibular fractures of the leg was performed. Conclusion This case highlights the possible use of coil embolization for PSA and AVF treatment and reviewed the recent literature on this issue.

BACKGROUND The aim of this study was to evaluate the effect of chronic kidney disease (CKD), assessed by preoperative estimated glomerular filtration rate (eGFR) and serum creatinine (Cr), on postoperative outcomes and long-term survival in asymptomatic patients undergoing carotid endarterectomy (CEA). METHODS We examined data about patients that underwent CEA between January 2002 and September 2014 in our Institution. Retrospective analysis to assess preoperative comorbidities and postoperative complications was performed. Modification of Diet in Renal Disease (MDRD) formula was used to calculate eGFR. Patients were divided into four groups based on values of preoperative eGFR: group A (≥90 mL/min/1.73 m2), group B (89-60 mL/min/1.73 m2), group C (59-30 mL/min/1.73 m2) and group D (≤29 mL/min/1.73 m2), and into two groups based on preoperative Cr values: group 1 (

The treatment of hepatitis C virus in monoinfected and HIV-coinfected patients has greatly changed over recent years as a result of the introduction of direct-acting antiviral agents (DAAs), which have revolutionized clinical outcomes and led to sustained virological response rates above 90-95%. The discovery of new molecules and the subsequent competition between pharmaceutical companies, together with the negotiated price policies pursued by many national health systems, have led to a gradual reduction in the cost of DAAs, and expand their use to an increasing number of patients, including those with mild liver damage. However, the cost of branded DAAs is still too high for many developing countries, and many patients are still left without therapy. In this context, the availability of generic DAAs certainly provides a major opportunity for further cost savings in industrialized countries and will ensure broader access to treatment elsewhere. However, their more widespread use must not lead to a reduction in pharmaceutical quality because this could result in serious clinical consequences, including high rat failures, and selection of drug resistance. It is therefore essential that all generic formulations of DAAs are pre-qualified by the World Health Organization, and that real-life studies are carried out to verify their pharmacokinetic bioequivalence (ideally in patients, and not just in healthy volunteers) and clinical effectiveness. In this regard, lessons from expanding access programs in the HIV field would be very helpful.