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In February 2017, the “Programma Mattone Internazionale Salute” (ProMis), that is the Italian Program for Internationalization of Regional Health Systems of the Ministry of Health (MoH), presented the first version of its Position Paper on Health Tourism, which embeds a first shared approach to the recommendations expressed by the European Committee of Regions (CoR) on “Age-Friendly” tourism. The CoR stresses the importance of local and regional authorities in the coordination of multi-sectoral policies such as healthcare, social assistance, transport, urban planning and rural development in relation to the promotion of mobility, security, accessibility of services, including health care and social services. “Age-friendly” tourism is an example of an innovative tourist offer that strives to meet the health needs of the entire “traveling” population, with an integrated and cross-sector approach that involves various organizations operating in sectors such as healthcare, accessibility and transport. The aim of the workshop was to explore the interest of the stakeholders to participate in a systemic action in the field of “health” tourism, and to identify priority implementation areas that offer opportunities to take advantage of validated, innovative experiences that strengthen the accessibility to health and social services in regional, national and international contexts. This effort provides the opportunity to take advantage of aligning the European Structural and Investment Funds (ESIF) to the development of tourism, coherently with the needs and resources of local and regional health authorities.

May-Thurner syndrome (MTS) is an anatomically variable condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine with subsequent development of a left deep vein thrombosis (DVT). Although this syndrome is rare, its true prevalence is likely underestimated. Mainly, clinical symptoms and signs include, but are not limited to, pain, swelling, venous stasis ulcers, skin pigmentation changes and post-thrombotic syndrome. Correct treatment is not well established and is based on clinical presentation. Staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement followed by angioplasty/stenting of the left iliac vein appears to be the best option in MTS patients with extensive DVT. The aim of this review is to present in a simple and didactic form all variable clinical presentations of MTS and to outline possible management within the current guidelines.

Introduction: Adiponectin is a protein secreted by the adipose tissue with pleiotropic effects on metabolism. This adipokine play different anti-atherogenic action, such as the improvement of endothelial function and anti-inflammatory status in arterial walls. Two receptors ubiquitously expressed, AdipoR1 and AdipoR2, are involved in its action which. In obesity a mechanism of adiponectin resistance was demonstrated. Aim: To verify if adiponectin-resistance occurs in human atherosclerotic plaques. Methods: RNA from 49 carotid atherosclerotic plaques (advanced lesions), their respective adjacent regions (witha low grade lesions) and 7 healthy arteries (iliac and mesenteric) was extracted, reverse-transcribed and used for real-time PCR by specific TaqMan assays (Applied Biosystems). In vitro experiments for gene regulation studies were performed on primary Human Aortic Endothelial Cells and Smooth Muscle Cells (Lonza) co-cultured with the macrophage cell line THP-1. Results: Expression levels of AdipoR1 were lower in advanced plaques as well as in their respective adjacent regions than in healthy arteries (p = 0.020 and p = 0.001 respectively). AdipoR2 levels gradually decreased from healthy arteries to plaque adjacent regions and to advanced plaques (all comparisons p\0.0001). In both cell types, expression of AdipoR1 was not affected by the co-culture with THP-1. The presence of THP-1 decreased AdipoR2 expression in Smooth Muscle Cells (p = 0.040), whereas a not statistically significant decrease was observed in Endothelial Cells. Conclusions: We demonstrated a decreased expression of adiponectin receptors in initial and advanced plaques, suggesting a mechanism of adiponectin-resistance during atherosclerotic process. A local adiponectin-resistance could be a main cause of the lack of atheroprotective effects mediated by adiponectin. Presence of macrophages could be a contributory cause of AdipoR2 decrease.

May-Thurner syndrome (MTS) is an anatomically variable condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine with subsequent development of a left deep vein thrombosis (DVT). Although this syndrome is rare, its true prevalence is likely underestimated. Mainly, clinical symptoms and signs include, but are not limited to, pain, swelling, venous stasis ulcers, skin pigmentation changes and post-thrombotic syndrome. Correct treatment is not well established and is based on clinical presentation. Staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement followed by angioplasty/stenting of the left iliac vein appears to be the best option in MTS patients with extensive DVT. The aim of this review is to present in a simple and didactic form all variable clinical presentations of MTS and to outline possible management within the current guidelines.

Aims: Atherosclerosis is an inflammator y disease which molecular mechanisms are not been completely investigated. Our aim is to perform a wide expression study of inflammation related genes in human atherosclerotic plaques. Methods: The Human Inflammation Array (Applied Biosystems) was used to perform the mRNA quantification of 92 inflammation-related genes in 12 atherosclerotic plaques, their respective adjacent regions (with a lower grade lesion) and 7 healthy ar teries. The principle of the array is the real-time PCR amplification with a TaqMan probe specific for each gene. Data analysis was performed with SDS 2.3 software with the comparative Ct method using the gene beta-2-microglobulin as housekeeping and one of analysed samples as calibrator. Results: The mRNA levels of 42 genes result to be differently expressed:13 genes were up-regulated in atherosclerotic plaques respect to control ar teries whereas 29 were down-regulated. Their expression levels show an increasing or a decreasing trend from healthy ar teries to plaque adjacent regions and to advanced plaques. These genes belong to many different functional classes. In particular, we observed the dys-regulation of genes encoding for enzymes involved in the arachidonic acid metabolism that lead to generation of prostaglandins and leukotrienes. Conclusions: This is the first study in which the expression of a wide panel of inflammation-related genes was investigated. Results clarify the mechanisms of inflammation involvement during atherosclerotic process and highlight newpossible target for anti-inflammator y therapy in cardiovascular disease.

Background: A 74-year-old male patient complaining of crescendo TIAs, hypertension and hyperlipidaemia. Investigation: Duplex ultrasound scan MR angiography. Diagnosis: Pseudoaneurysm stemming from the ICA. Treatment: An open or endovascular procedure for the right pECCA repair, or a left CEA or CAS.

Aim. The aim of this study was to evaluate the impact of intraoperative cell salvage (ICS) on the early outcome after open repair (OR) of ruptured abdominal aortic aneurysm (rAAA). Methods. This is a retrospective review of 73 consecutive patients who underwent emergency OR of infiarenal rAAA with ICS between 2005 and 2008 (Group tr), compared to 5l repairs from 21lll2-2ll1l4 with no ICS (Group II). In addition, a transfusion protocol of platelets and tiesh frozen plasma (FFP) administration on admission and during surgerv was adopted in patients in Group I to maintain coagulation conrpetence. Results. ICS reduced bank blood demand by 63.6Vc (from I I to 4 units, P

Objective: To assess the etiology, management and outcome of iliac pseudoaneurysms following renal transplantation. Methods: Eleven patients who underwent repair between 1982 and 2007 were identified. Five (Group 1) presented pseudoaneurysm at the anastomosis of the donor renal and native iliac arteries, and six (Group 2) presented iliac pseudoaneurysm following transplant nephrectomy. Intraoperative cultures and immunohistochemical examinations were obtained from all surgical cases to determine the existence of a relationship between infection or transplant rejection and pseudoaneurysm formation. Results: Endovascular repair (EVR) was used to treat three patients, while eight patients underwent open repair (OR). Transplant nephrectomy was needed in all cases but one after anastomotic pseudoaneurysm repair. After pseudoaneurysm excision, arterial reconstruction was performed in all cases, with a limb salvage rate of 100%. At 30 days, no patients died in the EVR subgroup. In the OR subgroup, one patient died of sepsis (12.5%). Cultures taken from the pseudoaneurysm wall and content grew Candida albicans and E. coli in two febrile patients. Pathologic evaluation of donor renal arteries revealed evidence of chronic rejection in three patients (60%) in Group 1, and in two (33.3%) in Group 2. No patients in either Group presented late infection, failure of vascular reconstruction nor pseudoaneurysm recurrence. The follow-up ranges from 20 to 89 months. Conclusions: The etiology of pseudoaneurysms in this location is multifactorial, however, an association with chronic rejection must be considered. Though rare, the development of pseudoaneurysms at the donor renal-external iliac artery anastomosis results in high rates of transplant nephrectomy. Less invasive endovascular techniques offer a new therapeutic option in this challenging scenario notwithstanding the fact that they require further validation. © 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Background. The Study Aimed To compare the endovascular stent-graft technique with open repair of anastomotic aortic aneurysms following aorto-femoral reconstructions. Methods. Nine patients (mean age = 62.7 years; ASA II: 5 patients, ASA III: 3 patients ASA IV: 1 patient) were treated with standard open repair (group 1) and 14 patients at high surgical risk (mean age=71.8 years; ASA II: 2 patients, ASA III: 3 patients, ASA IV: 9 patients) were treated by endovascular stent-grafting (group II), in both groups for non-infected anastomotic aneurysms located in the abdominal aorta. One patient in the surgical group had frank and 1 had covered rupture of the aneurysm sac. In addition, 1 anastomotic iliac aneurysm was excluded by means of a tube graft and 7 anastomotic femoral aneurysms were repaired by surgery. Results. Surgical treatment was resection of the anastomotic aortic aneurysm and replacement with a new graft. The operative morbidity rate was 25%; mortality rate 14.3% (1 out of 7) for patients with intact aneurysm and 50% (1 of 2) for patients with ruptured aneurysm. All endovascular interventions were completed satisfactorily, with no open conversion; an acute graft thrombosis occurred in 1 patient (7.1%), who required a femoro-femoral crossover graft. There were no procedure-related deaths, and complications (14.3%) included 1 perioperative transient cerebral ischemia and 1 case of postoperative jaundice. During a mean follow-up period of 3.8 years (14-81 months) and 4.3 years (11-79 months), respectively, re-operation has been required in 14.3 % of patients after standard operative repair and in 21.4% after endovascular repair for treatment of limb occlusion or graft migration. There was 1 late conversion to open repair 46 months after the initial procedure. The late mortality rates were almost identical (28.6 % versus 21.4%) in the two groups. Conclusions. Endoluminal repair is a less invasive treatment method and provides benefits to elderly, high-risk patients. Because of concerns related to its long-term effectiveness, elective standard surgical repair can still play a role for younger, lower-risk patients.

Background The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded on October 1, 2018, to enhance cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic arteriopathy has been selected as the very first topic to be investigated by the federation. Methods MeFAVS members were asked to reply to a questionnaire on the management of diabetic ischemic foot. Results were collected and analyzed statistically. The questionnaire consisted of 15 multiple choice answers regarding diabetic foot (DF) diagnosis and treatment. The questionnaire was submitted to 21 centers on April 20, 2019. Results Response rate was 62%. The survey revealed that vascular surgeons, diabetologists, and wound care nurses made-up the core of the diabetic teams present in 76.9%, 69.3%, and 92.3% of the centers, respectively. Diabetic teams were most often led by vascular surgeons (53.8%) and diabetologists (42.2%), but only in 7.9% of cases by nurses. Duplex ultrasonography and computed tomographic angiography were the most commonly available tools used to assess diabetic peripheral arterial disease (PAD). Surgical wound care was undertaken by vascular surgeons in the majority of cases, and only in 46.2% of the cases to orthopedic or plastic surgeons, while nonsurgical wound care was handled by specialized nurses (76.6%) and diabetologists (53.8%). First-line revascularization was preferred over conservative treatment (61.5% vs 53.8%) and endovascular strategy (45.3%) over open (33.7%) or hybrid (21.0%) surgery. Vascular surgeons and interventional radiologists were found to be the most common performers of endovascular revascularization (92.3% and 53.8%, respectively). Amputations had an overall rate of 16.6% (range 4–30%) and a mean reintervention rate of 22.5%, and were usually performed by vascular surgeons for both minor and major interventions (84.6%) followed by orthopedic surgeons (15.4% minor and 30.8% major). The availability of a DF clinic (84.6%) and endovascular (53.8%) and open surgery (46.2%) capabilities were considered fundamental to reduce amputation rates. Conclusions Especially since the introduction and spreading of new endovascular techniques for the treatment of DF, it is a common consensus amongst vascular surgeons that a standardized approach to the discipline is necessary in order to improve outcomes such as amputation-free survival and mortality and it is with this perspective and purpose that transnational cooperation amongst vascular professionals and residents in training are aiming for greater proficiency in endovascular and open surgery.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

This article describes how innovations are exploited in Campania (Italy) to improve health outcomes, quality of life, and sustainability of social and healthcare services. Campania's strategy for digitalization of health and care and for healthy aging is based on a person-centered, life-course, “One Health” approach, where demographic change is considered capable of stimulating a growth dynamic linked to the opportunities of combining the “Silver Economy” with local assets and the specific health needs of the population. The end-users (citizens, patients, and professionals) contribute to the co-creation of products and services, being involved in the identification of unmet needs and test-bed activity. The Campania Reference Site of the European Innovation Partnership on Active and Healthy Aging is a flexible regional ecosystem to address the challenge of an aging population with a life-course approach. The good practices, developed in the context of research and innovation projects and innovative procurements by local stakeholders and collaborations with international networks, have been allowing the transfer of innovative solutions, knowledge, and skills to the stakeholders of such a multi-sectoral ecosystem for health.

Introduction: Anastomotic pseudoaneurysm following renal transplantation is uncommon. Indications for repair, treatment options and outcomes remain controversial. Report: We present 6 renal transplant recipients with large anastomotic pseudoaneurysms. Five of the patients underwent open repair while one had a stent-grafting and delayed transplant nephrectomy for a ruptured pseudoaneurysm. A transplant nephrectomy was needed in all cases but one. Arterial reconstruction enabled limb salvage in all cases. One patient died of sepsis postoperatively. No patient presented late infection, failure of vascular reconstruction, nor pseudoaneurysm recurrence. Conclusions: Surgical excision of anastomotic pseudoaneurysms results in high rates of allograft loss. Less invasive techniques have a place in selected cases. © 2009 European Society for Vascular Surgery.

Objective— Many gene products involved in oxidation and inflammation are implicated in the pathogenesis of atherosclerosis. We investigated paraoxonase 2 (PON2), 5-lipoxygenase (5-LO), and 5-LO activating protein (FLAP) expression and malondialdehyde (MDA) levels in carotid lesions to assess their involvement in plaque formation. Methods and Results— We measured gene expression and MDA levels in atherosclerotic plaques from 59 patients undergoing carotid endarterectomy, and in plaque-adjacent tissue from 41/59 patients. Twenty-three fetal carotids and 6 mammary arteries were also investigated. Real-time polymerase chain reaction and immunohistochemistry revealed decreased PON2 expression in plaques versus adjacent regions ( P P P P P P P Conclusions— We demonstrate that PON2 mRNA and protein are decreased in plaques versus plaque-adjacent tissue, mammary arteries, and fetal carotids. Our data indicate that the protective effect of PON2 could fail during atherosclerosis exacerbation; this was confirmed by the increase of MDA levels. The increase of 5-LO and FLAP mRNA expression confirms their role as inflammatory markers associated to atherosclerosis.

L’articolo tratta le problematiche relative alle vie di accesso ed all’approccio terapeutico delle patologie ostruttive dei vasi sanguigni situati al di sopra del legamento inguinale.

Aim. To eval¬u¬ate the effi¬ca¬cy of ¬intra-arte¬ri¬al throm¬bol¬y¬sis and adjunc¬tive endo¬vas¬cu¬lar pro¬ce¬dures for infra¬in¬gui¬nal ¬native ¬artery chron¬ic occlu¬sions, ¬that ¬result in a ¬recent wors¬en¬ing of symp¬toms ¬because of throm¬bo¬sis super¬im¬posed on under¬ly¬ing path¬o¬log¬ic ¬lesions. Methods. Intra-arte¬ri¬al cath¬e¬ter-direct¬ed throm¬bol¬y¬sis ¬with urok¬i¬nase 300000 IU ¬bolus fol¬lowed by 70000 IU /h for 24-48 ¬hours was admin¬is¬tered to 54 ¬patients affect¬ed ¬with low¬er ¬limb ische¬mia. Twenty-¬three ¬patients (25 ¬limbs) pre¬sent¬ed ¬severe clau¬di¬ca¬tio and 31 -patients (34 ¬limbs) crit¬i¬cal leg ische¬mia; sub¬acute (14 ¬days-3 ¬months) symp¬toms ¬were ¬present in 60.9% and 77.4% , respec¬tive¬ly. After suc¬cess¬ful throm¬bol¬y¬sis, endo¬vas¬cu¬lar pro¬ce¬dures (i.e., angio¬plas¬ty, endo¬lu¬mi¬nal stent¬ing, endo¬pros¬the¬sis place¬ment) ¬were per¬formed in 72% and 67.6%, respec¬tive¬ly. In addi¬tion, infra¬in¬gui¬nal autog¬e¬nous ¬vein recon¬struc¬tion was per¬formed in 5 ¬patients ¬with crit¬i¬cal leg ische¬mia. Results. Initial clin¬i¬cal improve¬ment was ¬seen in 76% of 25 extrem¬ities in ¬group I, ¬with a 30-day pri¬mary paten¬cy and ¬relief of clau¬di¬ca¬tio in 68%. Arterial rec¬a¬nal¬iza¬tion was ¬achieved in 23 (67.6%) and res¬to¬ra¬tion of ¬flow in tar¬get ves¬sels for sub¬se¬quent ¬bypass in 5 (14.7%) of 34 extrem¬ities in ¬group II. The 30-day ¬limb-sal¬vage was 73.5%; ¬limb ¬loss includ¬ed 2 ampu¬ta¬tions (5.9%) as a ¬result of infec¬tion and/or necro¬sis in dia¬bet¬ic ¬patients, ¬despite ana¬tom¬ic paten¬cy at the endo¬vas¬cu¬lar pro¬ce¬dure ¬site. Relief of ische¬mia was ¬achieved in 56% of clau¬di¬cants (¬mean fol¬low-up, 42 ¬months) and ¬limb sal¬vage in 52.9% of ¬patients ¬with crit¬i¬cal ische¬mia (¬mean fol¬low-up, 36 ¬months). Conclusion. Thrombolysis and adjunc¬tive endo¬vas¬cu¬lar pro¬ce¬dures are an accept¬able ther¬a¬peu¬tic ¬option for the treat¬ment of wors¬en¬ing man¬i¬fes¬ta¬tions of chron¬ic occlu¬sive dis¬ease of the femor¬o¬pop¬li¬teal arte¬ri¬al seg¬ment.

Purpose:To describe a unique case of misdiagnosed leiomyosarcoma of the common femoral artery presenting with signs and symptoms of high-grade stenosis, which was treated with stent placement.Case Report:A 31-year-old woman with a history of diabetes and hyperlipidemia had recurrent claudication and showed significant in-stent restenosis of the common femoral artery in a postoperative angiogram at 5 months. The patient's clinical stage remained unchanged after repeat percutaneous intervention, and leiomyosarcoma was diagnosed from surgical specimens. The patient underwent resection and repair of the involved artery. She has survived 30 months with no further evidence of local recurrence or systemic metastatic disease.Conclusions:Endovascular repair may cause a long delay in the diagnosis of an arterial leiomyosarcoma mimicking peripheral occlusive disease.

A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: Case report and review of the literature.