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Background: Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI). Methods: Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included. Follow-up: One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated. Results: Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66–80) and 79 (71–85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics. Conclusion: Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

Background: Identifying sex-related differences/variables associated with 30-day/1-year mortality in patients with chronic limb-threatening ischemia (CLTI). Methods: Multicenter/retrospective/observational study. Database sent to all-the-Italian vascular surgeries to collect all-the¬-patients operated for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot not included. Follow-up: 1-year. Data on demographics/comorbidities, treatments/outcome, and 30-day/1-year mortality investigated. Results: Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) yrs for men/women, respectively (p75 (HR3.63, p=.003) associated with 30-day mortality. Age >75 (HR2.14, p

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study. Each received a 13-point questionnaire investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs. 2019 (9161 patients): post-EVAR surveillance, hospitalization for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased (1484 (16.2%) vs. 1014 (14.3%), p = 0.0009; 1401 (15.29%) vs. 959 (13.52%), p = 0.0006; and 1558 (17.01%) vs. 934 (13.17%), p < 0.0001, respectively), while admissions for revascularization or major amputations for chronic limb-threatening ischemia and urgent revascularization for symptomatic carotid stenosis significantly increased (1204 (16.98%) vs. 1245 (13.59%), p < 0.0001; 355 (5.01%) vs. 358 (3.91%), p = 0.0007; and 153 (2.16%) vs. 140 (1.53%), p = 0.0009, respectively). Conclusions: The suspension of elective procedures during the COVID-19 pandemic caused a significant reduction in post-EVAR surveillance, and in the hospitalization of asymptomatic carotid stenosis revascularization and Rutherford 3 peripheral arterial disease. Consequentially, we observed a significant increase in admissions for urgent revascularization for symptomatic carotid stenosis, as well as for revascularization or major amputations for chronic limb-threatening ischemia.

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study conducted through cross-sectional survey. Each received a 13-point questionnaire, investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs 2019 (9161 patients): post-EVAR surveillance, treatment for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased [1484 (16.2%) vs 1014 (14.3%), p=0.0009; 1401 (15.29%) vs 959 (13.52%), p=0.0006; and 1558 (17.01%) vs 934 (13.17%), p

Objective The Gore Excluder Iliac Branch Endoprosthesis (IBE) was developed to preserve perfusion in the hypogastric artery after endovascular repair of aorto-iliac aneurysms. This study reports the 12 month technical and clinical outcomes of treatment with this device. Methods This study was a physician initiated international multicentre, prospective cohort study. The primary endpoint was primary patency of the hypogastric branch at 12 months. Secondary endpoints included technical and clinical outcomes. Patients with an indication for elective treatment with the Gore Excluder IBE were enrolled between March 2015 and August 2018. Baseline and procedural characteristics, imaging data, physical examinations and questionnaire data (Walking Impairment Questionnaire [WIQ], EuroQol-5-Dimensions [EQ5D], International Index of Erectile Function 5 [IIEF-5]) were collected through 12 month follow up. Results One hundred patients were enrolled of which 97% were male, with a median age of 70.0 years (interquartile range [IQR] 64.5 – 75.5 years). An abdominal aortic aneurysm (AAA) above threshold for treatment was found in 42.7% and in the remaining patients the iliac artery diameter was the indication for treatment. The maximum common iliac artery (CIA) diameter on the Gore Excluder IBE treated side was 35.5 mm (IQR 30.8 – 42.0) mm. Twenty-two patients received a bilateral and seven patients had an isolated IBE. Median procedural time was 151 minutes (IQR 117 – 193 minutes) with a median hospital stay of four days (IQR 3 – 5 days). Primary patency of the IBE at 12 month follow up was 91.3%. Primary patency for patients treated inside and outside the instructions for use were 91.8% and 85.7%, respectively (p = .059). Freedom from secondary interventions was 98% and 97% at 30 days and 12 months, respectively. CIA and AAA diameters decreased significantly through 12 months. IIEF-5 and EQ5D scores remained stable through follow up. Patency of the contralateral internal iliac artery led to better IIEF-5 outcomes. WIQ scores decreased at 30 days and returned to baseline values through 12 months. Conclusion Use of the Gore Excluder IBE for the treatment of aorto-iliac aneurysms shows a satisfactory primary patency through 12 months, with significant decrease of diameters, a low re-intervention rate, and favourable clinical outcomes.

The expansion of coronavirus disease 2019 (COVID-19) prompted measures of disease containment by the Italian government with a national lockdown on March 9, 2020. The purpose of this study is to evaluate the rate of hospitalization and mode of in-hospital treatment of patients with chronic limb-threatening ischemia (CLTI) before and during lockdown in the Campania region of Italy. The study population includes all patients with CLTI hospitalized in Campania over a 10-week period: 5 weeks before and 5 weeks during lockdown ( n = 453). Patients were treated medically and/or underwent urgent revascularization and/or major amputation of the lower extremities. Mean age was 69.2 ± 10.6 years and 27.6% of the patients were women. During hospitalization, 21.9% of patients were treated medically, 78.1% underwent revascularization, and 17.4% required amputations. In the weeks during the lockdown, a reduced rate of hospitalization for CLTI was observed compared with the weeks before lockdown (25 vs 74/100,000 inhabitants/year; incidence rate ratio: 0.34, 95% CI 0.32–0.37). This effect persisted to the end of the study period. An increased amputation rate in the weeks during lockdown was observed (29.3% vs 13.4%; p < 0.001). This study reports a reduced rate of CLTI-related hospitalization and an increased in-hospital amputation rate during lockdown in Campania. Ensuring appropriate treatment for patients with CLTI should be prioritized, even during disease containment measures due to the COVID-19 pandemic or other similar conditions.

Background Endovascular aneurysm repair (EVAR) is currently accepted as an alternative to open repair for the treatment of abdominal aortic aneurysm (AAA). Approximately 40–60% of AAA patients are not considered eligible for EVAR due to unfavorable anatomy. There is currently no consensus on the definition of “hostile” aortic neck for EVAR procedure. Methods An Expert Panel (EP), made up of 9 Italian vascular surgeons from high-volume centers (>50 EVAR procedures/year), was assembled to share their opinion about the definition of hostile aortic neck anatomy for EVAR procedure. The process included a review of the current literature by the EP, a face-to-face meeting, and an on-line survey completed by the EP prior to and following the face-to-face meeting, using the Delphi method. Results Of the 66 reviewed studies, only 38 (58%) reported at least 1 aortic neck hostility criterion. Five anatomic parameters were identified, namely, aortic neck length, aortic neck angulation, aortic neck diameter, conical neck, and presence of circumferential calcification. Based on the results of the first survey round, these criteria and related definitions were discussed in depth during the face-to-face meeting. For 3 parameters (aortic neck diameter, aortic neck angulation, conical neck), the agreement among the EP members was already high during the first survey round while for the remaining 2 (aortic neck length, circumferential calcification) it remarkably increased from the first to the second survey round. For each of these criteria, as well as combinations of at least 2 of these criteria, specific threshold values were identified above or below which a standard EVAR approach was not considered ideal by the EP due to high/moderate risk of complications. Conclusions EP agreed on the definition of 5 aortic neck hostility criteria, according to which they gave their opinion on the feasibility and risks of a standard EVAR approach. Further agreement will be needed and examined on the best nonstandard EVAR technique which may be offered in the presence of different combinations of hostility criteria.

Major adverse cardiac events, defined as death or myocardial infarction, are common causes of perioperative mortality and major morbidity in patients undergoing non-cardiac surgery. Reduction of perioperative cardiovascular risk in relation to non-cardiac surgery requires a stepwise patient evaluation that integrates clinical risk factors, functional status and the estimated stress of the planned surgical procedure. Major guidelines on preoperative cardiovascular risk assessment recommend to establish, firstly, the risk of surgery per se (low, moderate, high) and the related timing (elective vs. urgent/emergent), evaluate the presence of unstable cardiac conditions or a recent coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), assess the functional capacity of the patient (usually expressed in metabolic equivalents), determine the value of non-invasive and/or invasive cardiovascular testing and then combine these data in estimating perioperative risk for major cardiac adverse events using validated scores (Revised Cardiac Risk Index (RCRI) or National Surgical Quality Improvement Program (NSQIP)). This stepwise approach has the potential to guide clinicians in determining which patients could benefit from cardiovascular therapy and/or coronary artery revascularization before non-cardiac surgery towards decreasing the incidence of perioperative morbidity and mortality. Finally, it should be highlighted that there is a need to implement specific strategies in the 2019 Coronavirus disease (COVID-19) pandemic to minimize the risk of transmission of COVID-19 infection during the preoperative risk assessment process.

Background Acute lower limb ischemia (ALLI) poses a major threat to limb survival. For many years, surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution to the management of ALLI. It seems that the newly designed endovascular thrombectomy devices may shift treatment recommendations toward endovascular options. This protocol study aims to collect evidence supporting the latest hypothesis. Objective The devices under investigation are the Penumbra/Indigo Systems (Penumbra Inc). The objective of this clinical investigation is to evaluate, in a controlled setting, the early safety and effectiveness of the devices and to define the optimal technique for the use of these systems in patients with confirmed peripheral acute occlusions. Methods This study will be an interventional prospective trial of patients with a diagnosis of ALLI treated with Penumbra/Indigo devices. This project is intended to be a national platform where every physician invited to participate could register his or her own data procedure. The primary outcome is the technical success of thromboaspiration with the Indigo System. Assessment of vessel patency will be recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications before and after use of the device. Clinical success at follow-up is defined as an improvement of Rutherford classification at 1-month follow-up of one class or more as compared to the preprocedure Rutherford classification. Secondary endpoints include the following: (1) safety rate at discharge, defined as the absence of any serious adverse events; (2) primary patency at 1 month, defined as a target lesion without a hemodynamically significant stenosis or reocclusion on duplex ultrasound (>50%) and without target lesion reintervention within 1 month; and (3) limb salvage at 1 month. Results The study is currently in the recruitment phase and the final patient is expected to be treated by the end of March 2019. A total of 150 patients will be recruited. Analyses will focus on primary and secondary endpoints. Conclusions These new endovascular thrombectomy devices that are specifically designed for peripheral intervention in this difficult set of patients, as those under investigation in the proposed registry, may offer improved clinical outcomes with lower rates of major systemic and local complications. Following completion of this study, it is expected that the value of the Indigo Thrombectomy System in the treatment of ALLI will be better defined. As a result, a shift of treatment recommendations toward endovascular options may be observed in the near future. International Registered Report Identifier (IRRID) DERR1-10.2196/9972

The antiphospholipid syndrome (APS), either primary or secondary form, is considered an autoimmune disease with the presence of at least 1 clinical and 1 laboratory abnormalities as defined by the Sydney criteria. Clinical criteria include vascular thrombosis of venous, artery, small vessel in any organ, and recurrent pregnancy pathologies. Mesenteric ischemia is a rare and threatening manifestation of APS. We herein report a case of a 34-year-old pregnant woman referred to our Emergency Room with thoracic and abdominal acute pain. Her past medical history was remarkable for positivity to antiphospholipid antibodies, deep vein thrombosis of the right lower limb, chronic occlusion of celiac trunk, and superior mesenteric artery and recurrent abortions. Imaging revealed acute occlusion of inferior mesenteric artery (IMA). Both a surgical and endovascular thrombectomy were ineffective to obtain durable IMA patency and so the patient underwent antegrade aorta-inferior mesenteric bypass with saphenous vein and resection of an ischemic ileal loop. The medical treatment at discharge was lifelong oral anticoagulant associated with double antiplatelet therapy. To the best of our knowledge, this is the first case reporting a young pregnant woman with APS and mesenteric ischemia submitted to several attempts of revascularization. Aggressive oral anticoagulant and antiplatelet long-term therapy is advised. Moreover, we recommend strict follow-up in those patients in order to early diagnose thrombotic recurrence.

From January 1979 to December 1991, 92 revascularizations of the V3 segment of the vertebral artery were performed in 91 patients through a direct transposition of this artery into the internal carotid artery (ICA). These cases represented 15.1% of 610 vertebral revascularizations and 38.8% of 280 distal vertebral revascularizations performed during this period at our institution. The sex ratio of this population was 0.59, and the mean age was 59.4 +/- 13.2 years (range 14 to 82 years). Preoperative ischemic symptoms were vertebrobasilar in 87 (94.6%) cases, exclusively hemispheric in one (1.1%), and absent in the remaining four (4.3%). One of these four patients had asymptomatic severe multivessel occlusive disease and three others underwent resection of a spinal tumor involving the vertebral foraminal canal. In 31 (33.7%) cases significant carotid occlusive disease was also present. The distal V3 segment of the artery was directly transposed into the ICA in all cases in this series. In 24 (26.1%) cases the ICA was endarterectomized during the same operation. There were no deaths or strokes in this series but there were two (2.2%) transient ischemic attacks-one vertebrobasilar and the other hemispheric. However, eight (8.7%) transposed vertebral arteries were totally occluded at early follow-up. At 1 month, among the 87 patients with vertebrobasilar insufficiency, 44 (50.6%) were cured, 31 (35.6%) were improved, and 12 (13.8%) remained unchanged. Among the 12 who were unchanged, eight (66.7%) had occlusion or stenosis of the distal transposition at the time of discharge. At 5 years, the primary patency rate in the series was 89.1% +/- 7.2%. At the time of the last follow-up, among the 87 patients with vertebrobasilar insufficiency, 50 (57.5%) were cured, 25 (28.7%) were improved, two (2.3%) had remained unchanged since the operation, two (2.3%) suffered a relapse, and eight (9.2%) exhibited vertebrobasilar symptoms of varying severity and therefore could not be considered improved. Direct transposition of the V3 segment of the vertebral artery into the ICA is a simple, safe, and reliable technique for revascularization of the distal cervical vertebral artery.

From January 1979 to December 1993, of 2723 carotid revascularizations performed on our service, 168 (6.2%) were isolated carotid eversion endarterectomies (CEEs) for atherosclerotic occlusive disease. Since 10 of these procedures were bilateral, there were 158 patients total (88 men and 70 women). Twenty-six (16.5%) had diabetes, 54 (34.2%) had coronary disease, and 107 (67.7%) had hypertension. The mean age was 68.9±8.9 years (range 38 and 85 years). Preoperative ischemic symptoms were hemispheric in 93 (55.4%) patients, retinal in 31 (18.4%), and vertebrobasilar in 37 (22%). They consisted of one or more strokes in 44 (26.2%) patients and one or more transient ischemic attacks in 99 (58.9%); 25 (14.9%) patients were asymptomatic. The operated lesion contained atherosclerotic stenotic plaque in all cases. The lesion was tightly stenotic (>75%) and hemodynamically significant in 93 (55.4%) cases and irregular or ulcerated in all others. In 86 (51.2%) patients a coil or kink of the distal internal carotid artery was also present. The contralateral carotid artery was totally occluded in eight (4.7%) patients and tightly stenotic in seven (4.2%). All patients were operated on under deep general anesthesia; they were given systemic heparin and normal blood pressure was maintained. After freeing and cross-clamping of the carotid bifurcation, the end of the common carotid artery or the ostium of the internal carotid artery was sectioned. The section allowed a deep-plane endarterectomy through eversion and excellent control over the endarterectomized surface and its extremities. Since January 1989 completion arteriography has been routinely performed after CEE. There were three (1.9%) postoperative deaths in the series (two due to ipsilateral ischemic stroke and one due to contralateral ischemic stroke in the context of congestive heart failure) and two (2.9%) nonlethal ischemic strokes (one ipsilateral and one contralateral). All CEEs were controlled using arteriography in 60 (35.7%) cases or duplex scanning in all others, and in all except one patency was confirmed in the postoperative period. The mean follow-up was 53 months (5 to 160 months). At 5 years the primary patency rate was 99.4%±1.2% and the ipsilateral ischemic stroke-free rate was 93.2%±5.7%. CEE is a fast, safe, easy, and satisfactory technique that avoids the stenotic consequences of a longitudinal arteriotomy and does not necessitate a patch. Provided that completion arteriography is possible, CEE should be used more often, especially when the carotid artery is elongated.

Purpose: Dissatisfaction with conventional methods of treatment of infected infrarenal aortic prosthetic grafts and excellent long-term results reported by heart surgeons after allograft replacement for management of infections involving the ascending aorta have prompted us to investigate allograft replacement in the management of arterial infections. Methods: From October 1988 to April 1992, 43 consecutive patients with infected infrarenal aortic prosthetic grafts underwent in situ replacement with preserved allografts obtained from cadavers as part of a program to retrieve multiorgan transplant tissue. Thirty-four patients had isolated prosthetic infections, whereas nine had aortoenteric fistulas. One patient had a concomitant below-knee amputation for septic arthritis of the ankle as a result of septic emboli. Nineteen patients had nonvascular-associated procedures, including 17 intestinal procedures. Results: Five patients (12%) died after operation: four of general causes and one of rupture of the native aorta as a result of persistent infection. Three patients successfully underwent repeat operation for allograft-related complications (one case each of occlusion, septic rupture, and graft-enteric fistula). All surviving patients were discharged after control angiography showed patent allografts. Two patients were unavailable for follow-up. The other 36 patients have been monitored with serial duplex and computed tomography scanning for a mean follow-up of 13.8 months (range 1 to 42 months). There were four late deaths: three were unrelated to the vascular operation, and one may have been caused by late persistent or recurrent infection. Nine patients (26%) have had pathologic changes in the allograft, with three (9%) requiring repeat operation. There were no early or late postoperative amputations in the entire series. Conclusions: Although complete protection against persistent or recurrent infection has not been achieved and late deterioration may be expected, in situ allograft replacement seems to be a major advance in the management of infected infrarenal aortic prosthetic grafts. (J VASC SURG 1993;17:349-56.)

We report a case in which an allogenic aortic graft was used to treat the last one of a series of infectious graft complications. The original operation was a Dacron aortobifemoral bypass for aortoiliac occlusive disease in an institution other than ours. The patient was referred for the treatment of the infection of the prosthetic implant. We inserted a prosthetic bypass from the left axillary to the left deep femoral artery, as well as a crossover autogenous saphenous vein graft from the prosthesis to the right deep femoral artery; in the same operation the infected intraabdominal prosthesis was removed with closure of the proximal aortic stump. Subsequent stenosis of the vein graft made it necessary to insert a prosthetic bypass between the descending thoracic aorta and the two deep femoral arteries. Infection of the last named prosthesis made it necessary to remove it and replace it with a tailored allogenic arterial allograft between the infrarenal abdominal aorta and both deep femoral arteries. The patient had an uneventful recovery as the infection was controlled and both lower limbs were salvaged. Eighteen months later the allograft was patent without any signs of degeneration. Further clinical experience under appropriate conditions may prove the use of allografts effective in the treatment of selected cases of aortic prosthetic infection. (J VASC SURG 1991;14:98-102.)

Between October 1988 and May 1994, all aortoiliac graft infections seen in the authors' service were treated by in situ arterial allografting after resection of any infected graft or tissue. Some 83 consecutive cases were treated; there were 68 isolated primary prosthetic infections (82%) and 15 aortoenteric fistulae (18%). Emergency arterial allografting was performed in five cases (6%), elective allografting in 64 cases (77%) and elective allografting after emergency palliative revascularization using a temporary prosthetic graft in 14 cases (17%). Arterial allografts were harvested from cadavers as part of a programme to retrieve multiorgan transplant tissue. Fifteen patients (18%) died either intra- or postoperatively. Three died during the operation, one from septic shock and two from uncontrollable coagulopathy. Twelve patients died in the early postoperative period, from from septic shock, two from myocardial infarction, two from pneumonia, one from a pulmonary embolism, one from an intestinal infarction, one from recurrence of a duodenal fistula and one from disruption of the native aorta at the suture line. Three patients presented with an early complication directly related to the use of the allograft. Eleven early survivors of the series died during follow-up. Among these late deaths, only one could likely be allograft-related. In four patients, the aortic segment of the allograft was mildly dilated on late computed tomography scan; three were reoperated on for disruption of the extra-abdominal segment of their allograft. All four cases were managed with simple suture of the allograft or with the use of a new allograft. Fifteen patients exhibited 19 late occlusive lesions of their allograft; 17 of these lesions had to be treated either with transluminal angioplasty or with surgery using autogenous or allograft material. In all but one case, secondary patency could be achieved through these additional procedures. Late occlusive disease was more prevalent in the femoral segment of the allograft than in the iliac or, moreover, the aortic segment. There were no late amputations in this series. Copyright © 1996 The International Society for Cardiovascular Surgery.

From October 1973 to April 1985, 81 patients with aneurysms of the descending thoracic or thoracoabdominal aorta underwent surgery. Eight (10%) of these patients were treated by exclusion-bypass. The aneurysm was located in the descending aorta alone in five cases, and in the descending thoracic and thoracoabdominal aorta in three cases. In all cases, the proximal anastomosis of the bypass was performed on the ascending aorta. The site of the distal anastomosis was the supraceliac aorta in two cases, the infrarenal aorta in three cases and the iliac arteries in three other cases. Exclusion was bipolar, at each end of the aneurysm, in six cases, and unipolar, ie. proximal interruption only, in two cases. Two patients died during the first postoperative month, one of rupture of the distal portion of the aortic arch, the second, after onset of secondary paraplegia. There were no other spinal, cardiac or cerebral complications. One patient died three months postoperatively of intercurrent pulmonary infection. The five other surviving patients whose mean follow-up period is 48.1 +/- 25 months, are alive and enjoying good health. Resection and grafting as advocated by Crawford, is the usual treatment proposed for aneurysms of the descending thoracic and thoracoabdominal aorta. Exclusion-bypass may however be preferred in the following cases: elderly patients with compromised respiratory status, aneurysms of the descending thoracic aorta, either voluminous, of infectious origin or associated with aneurysm of the infrarenal abdominal aorta.