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Background The aim of this study was to compare early and long-term outcomes of endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) in patients aged ≤ 65 years. Methods Data of patients aged ≤65 years undergoing infrarenal abdominal aortic aneurysm repair, between 2005 and 2013, were retrospectively reviewed. All EVAR procedures were performed according to the instruction for use, and only OSR procedures with an infrarenal aortic cross-clamping were included in the study. Results In this group of 115 patients (EVAR: 58 patients, 51% and OSR: 57 patients, 49%), EVAR and OSR patients had similar comorbidities, except for obesity (EVAR: 38% vs. OSR: 19%; P = 0.03). A stay in the intensive care unit (ICU) was necessary in 19% of patients with EVAR versus 79% with OSR (P = 0.001), and the amount of blood transfusion was 236 ± 31 mL for EVAR versus 744 ± 98 mL for OSR (P = 0.001). The hospital stay was 4 ± 2 days for EVAR versus 9 ± 6 days for OSR (P = 0.03). The overall 30-day mortality was 1% (EVAR: 0% vs. OSR: 2%; P = 0.30). Five patients (4%) required reinterventions within 30 days (EVAR: 0% vs. OSR: 8%, P = 0.001). The mean follow-up was 86 ± 38 months. Freedom from reintervention at 10 years after EVAR was 81% versus OSR 74%; (P = 0.77). Late reinterventions were reported in 13 patients (23%) with OSR and in 10 patients (17%) with EVAR. Postoperative retrograde ejaculation occurred more often in patients with OSR (31%) versus EVAR (2%) (P = 0.001). During the follow-up, cancer was found in 19 (17%) patients with no difference between EVAR and OSR (P = 0.83). The global survival at 10 years was 72% (EVAR: 79% vs. OSR: 70%; P = 0.94). Conclusions In this study, EVAR was associated with a shorter hospital stay, less need for the ICU, and less early reinterventions than OSR. Survival and reinterventions during the follow-up were not significantly different between EVAR and OSR. According to these results, EVAR may be considered for patients aged ≤65 years with a favorable anatomy.

Background: Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symp-toms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. Methods: A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were per-formed in Helsinki University Hospital between January 2013 and December 2018. First, infor-mation about patients' baseline characteristics, indications and details of surgery and technical/ hemodynamic success, and complications and mortality were obtained from the vascular regis-try and patients records. Secondarily, a prospective assessment of mid-term patency was per-formed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed.Results: One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n = 144 occlusions recanalized). Primary technical success was somewhat lower in lesions > 90 mm (87.1%) compared to lesions shorter than 90 mm (95.7%; c2 P = 0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant resid-ual stenosis remained in 1.2% of cases. Median operative time was 4 hr 34 min (interquartile range 2 hr 43 min) and median estimated blood loss was 743 mL (interquartile range 500 mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any ma-jor cardiovascular event or stroke perioperatively. Primary patency at 30 day, 6 months, 1 year, and 2 years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoc-cluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. Conclusions: Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this pop-ulation often suffers from universal atherosclerosis. The involvement of the aorta represents a sig-nificant determinant of worse long-term patency, although it did not preclude technical success.

To report outcomes following endovascular revascularisation for severe aorto-iliac occlusive disease (AIOD) using covered (CS) or bare metal (BMS) stent(s).This was a retrospective cohort study including patients who underwent treatment with CS or BMS for AIOD between November 2012 and March 2020 in 12 European centres. Outcome measures included death, freedom from target lesion revascularisation (TLR), major amputation, and major adverse cardiac and cerebrovascular events (MACCE).Overall, 252 patients (53% males; mean age 65 ± 10 years) were included (102 with a bare metal and 150 with a covered aortic stent); 122 (48%) presented with chronic limb threatening ischaemia (CLTI). Severe arterial calcification was noted in65% of patients, 70% presented with Trans-Atlantic Societies Consensus (TASC) D lesions, 32% and 46% had aortic or iliac chronic total occlusion (CTO), respectively. Median follow up was 17 months (range 6 - 40; none lost to follow up). Median inpatient stay was two days (range two to four). During the first 30 days, two patients died (both with covered aortic stents, because of cardiovascular events), none required TLR, two (1%) patients had a major amputation (all presented with CLTI), and three (1%) had a MACCE. At 17 months, mortality (BMS 14% vs. CS 7%, hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.42 - 2.26, p = .94, log rank test) and TLR (11% vs. 10%, HR 1.98, 95% CI 0.89 - 4.43, p = .095) did not differ statistically significantly between the two groups; only three patients had a major limb amputation during late follow up (all with a covered stent). In a multivariable model, the use of an aortic CS did not influence TLR. In a conditional Cox regression, however, the concomitant use of aortic and iliac CSs was associated with improved freedom from TLR.Endovascular reconstruction with aortic CSs or BMSs for severe AIOD showed comparable midterm performance. The use of both aortic and iliac CSs seems to be associated with reduced TLR.

Introduction Preserving pelvic circulation is crucial to minimize the risk of spinal cord and colonic ischemia, especially during the endovascular treatment of extended thoraco-abdominal aneurysm (TAAA) after previous open repair (OR). Case report A 78-years-old patient, previously treated for AAA with OR and reimplantation of inferior mesenteric artery (IMA), has presented with 9-cm type-III TAAA and underwent to a multi-stage endovascular procedure. Two thoracic endografts, t-Branch and a straight endograft by Cook Zenith platform were deployed. Renal and superior mesenteric arteries were cannulated and revascularized. Through the left axillary access, a 5F-vertebral catheter was delivered over a 0.035-inch guidewire to selectively catheterize IMA. A post-anastomotic stenosis was stented to advance the sheath and the parallel-graft (Viabahn 7 × 150-mm, Gore) into the artery. Thus, a bifurcated endograft was deployed inside the previous OR. According to the Sandwich-Technique, the stentgraft was deployed parallel and outside the bifurcated device, inside the straight one and 2-cm into the IMA and then reinforced by a bare-metal-stent (Protege EverFlex™ 7 × 120-mm, Medtronic). Finally, a kissing ballooning of iliac endografts and parallel-graft was performed. The procedure was completed five days later, by stenting the celiac trunk. Post-operative course was uneventful. The 36-months CTA showed the patency of the IMA with no complications. Conclusion The combination of t-Branch and Sandwich-Technique for IMA could be employed to treat extended TAAA with previous OR and reimplanted IMA thus minimizing the risk of colonic and spinal cord ischemia.

Background Fenestrated/branched endografts for aortic repair (FB-EVAR) are valid options to treat thoracoabdominal aortic aneurysms (TAAAs). Successful repair requires manipulation of target visceral vessels (TVVs) with possible splanchnic ischemia. The aim of the study was to evaluate the clinical impact of splanchnic ischemia occurring in FB-EVAR for TAAA. Methods Between 2010 and 2015, patients with TAAAs undergoing FB-EVAR were prospectively enrolled. Clinical, morphological, procedural, and 30-day data were evaluated. Splanchnic ischemia was defined as the presence of splanchnic ischemic lesions (SILs) visible at perioperative computed tomography angiography. Preoperative, postoperative, and 30-day hepatic/pancreatic/renal laboratory functions were analyzed. End points were incidence of SILs, laboratory splanchnic functions worsening (≥25% of baseline), and presence of related clinical/morphological and procedural risk factors. Results Thirty-six patients (male: 78%; age: 73 ± 7 years) with 27 (75%) type I-III and 9 (25%) type IV TAAA who underwent FB-EVAR for a total of 127 TVV (branches: 47–60%; fenestrations: 53–67%). Fourteen SILs occurred in 12 (33%) patients: 4 (29%) in pancreas, 3 (21%) in spleen, 2 (14%) in bowel, 5 (36%) in kidney. The cause was embolic in 79% and thrombotic in 21%. No preoperative clinical/morphological data or procedural data were correlated with SIL. Pancreatic, hepatic, or renal function worsening occurred at 24 hr in 16 (44%), 16 (44%), and 9 (25%) cases, respectively. Overall, SILs were associated with increased values of C-reactive protein (CRP) (17.9 ± 0.4 vs. 9.9 ± 9.0 mg/dL; P = 0.03) and bilirubin (1.2 ± 2.3 vs. 1.0 ± 0.5 mg/dL; P = 0.02) at 24 hr. Specifically, SIL of the celiac trunk and superior mesenteric and renal arteries' parenchyma were associated with the significant laboratory function changes 24 hr. SIL of the superior mesenteric artery was associated with increased 30-day mortality (50% vs. 7 %; P = 0.002). Pancreatic, hepatic, or renal function worsening occurred at 30 days in 2 (6%), 0 (0%), and 4 (12%) cases, with similar laboratory tests in patients with and without SIL. Conclusions SIL can be frequently detected after FB-EVAR for TAAA and appears mainly of embolic origin. No clinical, morphological, or procedural predictors could be identified in our series. Postoperative laboratory changes of CRP, bilirubin, activated partial thromboplastin time, and amylases are associated with SIL but disappear without clinical consequences within 30 days. However, SIL occurring in the superior mesenteric artery are associated with an increased 30-day mortality.

Objective: We compared the early and mid-term outcomes of polytetrafluoroethylene covered stents (CSs) vs bare metal stents (BMSs) used in the kissing conformation for the reconstruction of the aortic bifurcation in aortoiliac obstructive disease. Methods: A multicenter cohort registry (2015-2019) collected data from 1306 patients who had undergone endovascular treatment of aortoiliac arterial obstructive disease. Only patients who had received bilateral iliac kissing stents for TransAtlantic Inter-Society Consensus (TASC) class C and D lesions were included in the present analysis. The 30-day outcomes, mid-term primary patency, and limb salvage rates were compared between the CSs and BMSs in matched patient cohorts after propensity score matching. The follow-up results were analyzed using Kaplan-Meier curves. Cox proportional hazards models were used to identify the predictors of primary patency. Results: A total of 336 patients were treated with kissing stents, 201 with CSs (60%) and 135 with BMSs (40%). In the unmatched cohort, patients receiving CSs were more likely to have critical limb ischemia (41% vs 30%; P = .038), complex iliac lesions, such as TASC D (90% vs 56%; P < .01), and iliac occlusions (59% vs 44%; P < .01). After propensity score matching, 220 patients were selected (110 with CSs and 110 with BMSs), without differences in the clinical presentation (critical limb ischemia, 41% vs 33%; P = .167), or anatomic complexity (TASC D, 66% vs 60%, P = .21; iliac occlusion, 48% vs 49%, P = .89). The 30-day mortality was 0%. The early medical (unmatched, 5% vs 4%, P = 1.00; matched, 5% vs 4%, P = .75) and surgical (unmatched, 5% vs 5%, P = 1.00; matched, 5% vs 3%, P = .72) complication rates were similar between the CSs and BMSs. However, the CSs resulted in a lower risk of intraoperative iliac rupture (0% vs 3.5%; P = .013) and greater ankle-brachial index improvement (0.43 ± 0.22 vs 0.36 ± 0.24; P = .02). At 36 months, the overall primary patency (92% ± 7% vs 92% ± 8%; P = .38), secondary patency (98% ± 3% vs 98% ± 4%; P = .50), and limb salvage (93% ± 9% vs 97% ± 5%; P = .20) rates were similar. In cases of moderate to severe iliac calcification, the CSs showed better results in the matched cohort (100% vs 89% ± 9%; P = .048). On multivariate analysis, CS use (hazard ratio [HR], 1.67; P = .45) did not significantly affect primary patency, but older age (HR, 0.93; P = .03) and kissing stent diameter ≥8 mm (HR, 0.25; P = .03) were significantly associated. Conclusion: In the present multicenter study, the use of kissing stents for the treatment of the aortic bifurcation provided good early and mid-term results. CSs were preferred for more complex lesions, were protective from iliac rupture, and allowed for greater ankle-brachial index improvement. The 3-year patency rates were similar between the CSs and BMSs. However, CSs showed improved results in the case of moderate to severe calcification.

Objectives: To analyze outcomes following endovascular treatment of total occlusion of the infrarenal aorta and aorto–iliac bifurcation in a multicenter Italian registry. Methods: It is a multicenter, retrospective, observational cohort study. From January 2015 to December 2018, 1306 endovascular interventions for aorto–iliac occlusive disease were recorded in the vascular registry. For this analysis, only patients treated for total occlusion of the infrarenal aorta and aorto–iliac bifurcation were included. Early (Results: A total of 54 (4.1%) patients met the inclusion criteria. Total percutaneous revascularization was possible in 41 (75.9%) patients and hybrid (endo plus open) intervention in 13 (24.1%) patients. The kissing-stent-graft technique was used in 45 (83.3%) cases, covered endovascular reconstruction of the aortic bifurcation (CERAB) in 5 (9.2%), and a unibody endograft deployed in 4 (7.4%). Technical success was 98.1% (n = 53). There were no episodes of intraoperative or perioperative vessel rupture. Conversion to open surgery was not necessary, and there were no in-hospital deaths. The median patient follow-up time was 16 months (interquartrile range [IQR], 6-27). The estimated primary patency rate was 95.8% ± 0.03 (95% confidence interval [CI]: 85.5-98.9) at 1 year, 91.4% ± 0.05 (95% CI: 76.2-97.2) at 2 years, and 85 ± 0.08 (95% CI: 64.5-94.6) at 3 years. Cox regression analysis demonstrated that sex (hazard ratio [HR]: 0.96; 95% CI: 0.15-6.23, p = 0.963), extent of the occlusion (HR: 0.28; 95% CI: 0.05-1.46, p = 0.130), calcium score (HR: 1.88; 95% CI: 0.31-11.27, p = 0.490), or type of endovascular reconstruction (HR: 0.80; 95% CI: 0.13-5.15, p = 0.804) did not affect primary patency. Secondary patency was 95.5% ± 0.04 (95% CI: 78.4-99.2) at 3 years. No patients required late conversion to open surgical bypass. Conclusions: Endovascular reconstruction for total occlusion of the infrarenal aorta and aorto–iliac bifurcation was successful using a combination of percutaneous and hybrid revascularization techniques. Estimated patency rates at 3 years of follow-up are promising and are unaffected by the extent of occlusion or type of revascularization.

Background The endovascular treatment of peripheral artery obstructive disease in Trans-Atlantic Inter-Society (TASC) C and D lesions involving the aortic bifurcation is a matter of debate. The aim of this study is to evaluate the technical and clinical success of kissing stenting in this context and to analyze predictors of outcome. Methods All patients treated for aortoiliac TASC C and D lesions with kissing stenting (from 2012 to 2017) in a 6-year period were retrospectively analyzed. Preoperative anatomical features were evaluated by reviewing computed tomography angiography images to identify severe iliac calcifications (SICs) versus not SIC (NSICs). Primary end points were as follows: technical success (TS), procedural success, primary patency (PP), and clinical success (CS). Secondary end points were as follows: secondary patency, assisted patency, survival, mid-term procedure-related complications, and risk factors that affected TS and mid-term results. Results In a 6-year period, 51 patients fulfilled the inclusion criteria. TS was achieved in 49 (96.1%) cases. Thirty-one patients (60.8%) received a dual antiplatelet therapy (DAPT) for at least 1 month after the procedure. 30-day CS was 94.1%. Median follow-up was 45.7 months (IQR: 24.5, 8–86 range). The CS was 92.6% at 3 years, with a PP of 86.8% and a secondary patency of 93.2% at 3 years. Six (13.2%) iliac axis occluded during the first follow-up year. NSIC was statistically and independently associated with a lower PP (73% vs. 96%, P = 0.03); DAPT was statistically and independently associated with higher PP than single antiplatelet therapy (96% vs. 75%, P = 0.03); these results were confirmed by Cox regression analysis (HR: 0.14, 95%, IC: 0.01–0.89, P = 0.05 for DAPT analysis; HR: 6.8, 95%, IC: 1.21–59, P = 0.05 for NSIC analysis). Conclusions Endovascular treatment for TASC C–D is an effective technique. Postoperative stent occlusion is higher in patients with no DAPT and it usually occurs during the first postoperative year. Preoperative NSIC lesions are associated with reduced PP at 3 years of follow-up.

Background The aim of this study was to report early/mid-term-up outcomes of fenestrated endografting (FEVAR) for juxta-renal aneurysms (j-AAAs). Methods Between 2008 and 2019, all consecutive j-AAAs treated by FEVAR were prospectively collected and retrospectively analyzed. Early endpoints were technical success, renal function worsening and 30-day mortality. Follow-up endpoints were survival, freedom from re-interventions (FFRs) and target visceral vessels (TVVs) patency. Results Among 240 cases of FB-EVAR, 98(41%) were j-AAAs. Endografts with 1,2,3,4 and 5 fenestrations were planned in 3(3%), 25(26%), 35(36%), 33(34%) and 2(1%) cases, respectively. Overall, 360 TVVs were treated by fenestrations and scallops. Technical success was achieved in 97(99%) cases. The only failure was 1 type III endoleak requiring renal artery relining. No TVVs were lost. Renal function worsening was reported in 22(22%) and 12(12%) cases at 24-hour and 30-day, respectively. One patient required hemodialysis and died within 30-day (1%). This was the only case of 30-day mortality. The mean follow-up was 36±32months. Aneurysm sac shrinkage or stability was observed in 55(56%) and 41(42%) cases, respectively. Two (2%) patients with persistent type II endoleak had sac enlargement and required re-interventions. Freedom from reinterventions at 5-year was 86%. An asymptomatic celiac trunk occlusion (accommodated by a scallop) occurred at 24-month in a case with a severe preoperative stenosis. No late renal arteries occlusions or type I-III endoleaks occurred. TVVs-patency was 96% at 5-year. Renal function worsening was reported in 10(10%) patients during follow-up. Survival at 5-year was 73%, with no j-AAA related mortality. Chronic obstructive pulmonary disease (COPD) (P=0.007; OR:4.8; 95% CI: 1.5-15.3) and postoperative renal function worsening (P=0.028; OR:1,1; 95% CI: 1.1-1.2) were independent predictor for mortality at the multivariate analysis. Conclusions FEVAR for j-AAAs is safe and effective at early and long-term follow-up. According with these results, it could be proposed as the first line treatment in high risk patients if anatomically fit. Long term survival is reduced in the presence of preoperative COPD and postoperative renal function worsening.

Background To evaluate early/midterm outcomes of a specific configuration of a bridging stent graft—that is a distal self-expandable (SE) stent graft combined with proximal balloon-expandable (BE) one—in hostile renal artery (RA) anatomy in branched thoracoabdominal aneurysm (TAAA) repair. Methods Between 2010 and 2019, all TAAAs undergoing fenestrated and branched endografting (FB-EVAR) were prospectively collected. Preoperative, procedural, and postoperative data of RAs accommodated by branch design and patent at the completion angiography were retrospectively analyzed. Hostile RA anatomy included upward (type B) and downward + upward (type D) orientations. Type B and D RAs treated by the combination of an SE + BE stent graft as a bridging stent (BE + SE group) were compared with RAs treated by a BE stent graft only (BE group). RA occlusion, reinterventions, and branch instability were assessed. Results Over a total of 112 TAAAs undergoing FB-EVAR, 189 RAs were treated by fenestrations (113–60%) and branches (76–40%). Among the 66 (86%) RAs accommodated by branch and patent at completion angiography, 55 had a type B/D orientation. BE stent grafts were used in 15/55 (27%) RAs and SE + BE in 40/55 (73%). At a median follow-up of 12 (8) months, 5/55 (9%) RAs occluded: 4/15 (27%) in the BE group and 1/40(2.5%) in the SE + BE group (P: 0.017). RA patency was 83 ± 5% at 24 months. The SE + BE group had higher patency than the BE group (90 ± 5% vs. 68 ± 5% at 12 months; P: 0.039). Overall freedom from RA-related reinterventions was 87 ± 5% at 24 months. Six (9%) RAs required reinterventions: 4/15 (27%) in the BE group and 2/40 (5%) in the BE + SE group (P: 0.041). RAs managed by an SE + BE stent graft had lower reinterventions than RAs treated by a BE stent graft only (93 ± 5% vs. 76 ± 5% at 12 months; P: 0.01). Freedom from branch instability was 78 ± 5% at 24 months, with 8 overall cases (12%) occurring—5/15 (33.3%) in the BE group versus 3/40 (7.5%) in the SE + BE group (P: 0.02). RAs managed by an SE + BE stent graft had lower branch instability than RAs treated only by a BE stent graft (BE: 68 ± 5% vs. SE + BE: 80 ± 5% at 12 months; P: 0.02). Conclusions In hostile renal anatomy, the combination of a distal SE and proximal BE stent graft as a bridging stent in branched endografting is safe and effective with lower rates of occlusion, reinterventions, and branch instability at midterm follow-up compared with a BE stent graft alone.

Adventitial cystic disease is a rare nonatheromatous cause of popliteal artery disease. We report the case of a 49-year-old male patient who presented with left calf claudication caused by adventitial cystic disease. Popliteal artery resection followed by autologous vein graft interposition and Percutaneous Transluminal Angioplasty (PTA) stenting led to recurrence. The patient was finally successfully treated by bypass with autologous vein. No postoperative complications occurred, and patency was preserved at 33-month follow-up. Several different treatment options are possible; however, a primary radical surgical treatment with extra-anatomical medial bypass with autologous vein seems preferable.

Background The aim of this study is to evaluate the preliminary outcomes of the Gore® Viabahn® balloon-expandable endoprosthesis (VBX) as bridging stent for fenestrated/branched aortic endograft. Methods Between April and June 2018, patients undergoing fenestrated and branched-endovascular aortic repair were prospectively collected. Anatomical, procedural, and postoperative data of patients treated with VBX as bridging stents to connect fenestrations/branches to target visceral vessels (TVVs) were analyzed. Technical success and any TVV-related adverse event were assessed before discharge, at 30 days, and after 6 months of follow-up. Results Fifteen patients undergoing fenestrated and branched-endovascular aortic repair for juxta/pararenal aneurysms (11), proximal type I endoleak after endovascular aortic repair (1), and thoracoabdominal aneurysms (3) were included in the study. Overall, 60 TVVs—celiac trunk (n = 14), superior mesenteric artery (n = 13), renal arteries (n = 30), hypogastric artery (n = 3)—were accommodated by fenestrations (n = 51), branches (n = 7), and scallops (n = 2). The bridging stent graft was a VBX in 40 (67%) TVVs. A renal artery dissection was successfully managed by a self-expandable bare metal stent. Overall, relining of a bridging stent graft was required in 2 TVVs revascularized by fenestrations (superior mesenteric artery: n = 1, renal artery: n = 1). One intraoperative type III endoleak from renal fenestration was detected and successfully sealed by an adjunctive flaring maneuver. Technical success was achieved in all cases. At 5-day, 1 VBX (1/40: 2.5%) lost its sealing in a renal artery revascularized by a branch (type II thoracoabdominal aortic aneurysm) and required reintervention and relining with a self-expandable stent graft. No TVV occlusion or reintervention occurred Conclusions According to these preliminary results, the Gore Viabahn VBX balloon-expandable endoprosthesis can be safely used as bridging stent graft for fenestrated or branched endografts. A longer follow-up with a larger case load is necessary in order to validate this preliminary experience.

Purpose: To report the results of endovascular treatment of iliac and complex aortoiliac occlusive disease (AIOD) in a multicenter Italian registry. Materials and Methods: A retrospective, multicenter, observational cohort study analyzed 713 patients (mean age 68±10 years; 539 men) with isolated iliac and complex aortoiliac lesions treated with primary stenting between January 2015 and December 2017. Indications for treatment were claudication in 406 (57%) patients and critical limb ischemia in 307 (43%). According to the TransAtlantic Inter-Society Consensus II (TASC) classification, the lesions were categorized as type A (104, 15%), type B (171, 24%), type C (170, 24%), and type D (268, 37%). Early (

Background: The aim of the study was to evaluate the outcomes of duplex ultrasonography (DUS)–guided autologous vein bypass to paramalleolar (distal third of tibial arteries and peroneal artery) and inframalleolar arteries (dorsalis pedis, common plantar, medial, and lateral plantar arteries) in patients with critical limb ischemia (CLI) and extensive tibial artery disease Trans-Atlantic Inter-Society Consensus D. Methods: Between January 2007 and October 2016, all paramalleolar or inframalleolar bypasses performed in patients with CLI, planned only on the basis of DUS, were collected and analyzed retrospectively. DUS evaluation included arterial disease extension, inflow and outflow arteries' diameter, outflow vessels resistance, and autologous veins quality. Patient's demographics and clinical characteristics were assessed. Tissue loss was graded according to Texas University Wound Classification (TWC). Follow-up included periodic clinical and DUS examinations. Primary end points were technical success (TS) (patent bypass with distal anastomosis performed on the Duplex-selected runoff artery, without stenosis >30% and in line flow with the inframalleolar arteries at completion angiography and without hemodynamic bypass stenosis at postoperative DUS) and bypass patency (primary [PP], assisted [AP], and secondary [SP]). Secondary end points were perioperative and follow-up patient survival (PS), limb salvage (LS), and amputation-free survival (AFS). Descriptive statistics and Kaplan-Meier analysis were performed. Univariate and Multivariate Cox analyses were used to define risk factors. Results: Seventy-four bypasses in 73 patients with CLI (Rutherford 5–6 93.2%, TWC stage III in 63.5% and grade D in 48.6%) were performed in the study period (January 2007–October 2016). diabetes mellitus, coronary artery disease, and kidney disease were present in 67.6%, 60.8%, and 37.8% patients, respectively. Distal anastomosis was performed at the paramalleolar and inframalleolar arteries in 47.3% and 52.7%, respectively. Only autologous veins were used as conduit. TS was 98.6%. At 1-month, PP, AP, SP, PS, LS, and AFS were 87.8%, 91.9%, 93.2%, 95.9%, 94.6%, and 90.5%, respectively. The mean follow-up was 33.7 months; at 1-year, PP, AP, SP, PS, LS, and AFS were 54.4%, 71.4%, 75.1%, 89.9%, 84.3%, and 79.1%, respectively, and at 3-year, 42.3%, 63%, 66%, 67.5%, 80.6%, and 61%, respectively. At univariate and multivariate analyses, arterial hypertension was protective for PP (P = 0.035) while insulin-dependent diabetes was a negative predictor (P = 0.01); insulin-dependent diabetes was a negative predictor of LS (P = 0.002); TWC grade D was a negative predictor of AP (P = 0.047) and SP (P = 0.013). Age (P < 0.001) and major amputation (P = 0.014) resulted as negative predictors of PS. Conclusions: Bypass of the Duplex-selected paramalleolar and inframalleolar arteries in CLI has high TS and high rate of perioperative and late LS. Duplex evaluation and planning in CLI patients with extensive tibial arteries disease is associated with efficacy of surgical revascularization and high LS rates.

Purpose To describe an endovascular technique to close a renal artery fenestration during fenestrated endograft implant for a pararenal abdominal aortic aneurysm (p-AAA) without interfering with other visceral vessels. Report A 76-year-old man with p-AAA underwent repair by a 4 fenestrations custom-made endograft. At the intraprocedural angiography, the right renal artery was occluded. To avoid a high-flow endoleak from fenestration, we performed the following technique: a 9F-steerable sheath was used to advance a 7F sheath through the fenestration into aneurism. A balloon-expandable covered stent was deployed across the fenestration and then occluded by 2 vascular plugs. At the completion angiography, there was no endoleak from the right renal fenestration, and at 6-month period, p-AAA remained completely excluded. Conclusions The present technique can be a safe and effective therapeutic option to propose in cases of impossible target visceral vessels cannulation during p-AAA repair using a custom-made device to avoid the aneurysmal sac perfusion.