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Introduction: Acute limb ischemia (ALI), classified according to Rutherford’s classification (RC), is a vascular emergency burdened by high rates of mortality and morbidity. The need of new and different prognostic values for ALI has emerged, and, among all, the neutrophil-to-lymphocyte ratio (NLR) has been proven as a strong outcome predictor in vascular disease. The aim of this study is to investigate the role of preoperative NLR in predicting clinical outcomes in patients presenting acute limb ischemia. Material and Methods: A single-center retrospective study was conducted between January 2015 and December 2019. Demographic and clinical characteristics, procedural technical aspects, postoperative and early (up to 30-day) outcomes were recorded. All enrolled patients were categorized into low- and high-NLR at baseline, using a cut-off value of 5. Study outcomes were 30-day all-cause mortality and amputation rates. Results: A total of 177 ALI patients were included in the final analysis (6 RC I, 44 RC IIA, 108 RC IIB, and 19 RC III), 115 males (65%), mean age 78.9 ± 10.4 years. Mean NLR at hospital presentation was 6.65 ± 6.75 (range 0.5–35.4), 108 (61.1%) patients presented a low-NLR, 69 (38.9%) a high-NLR. Immediate technical success was achieved in 90.1% of cases. At 30 days, freedom from amputation and freedom from death rates were 87.1% and 83.6%, respectively. At the univariate analysis, amputation (p &lt, 0.0001, OR: 9.65, 95%CI: 3.7–25.19), mortality (p = 0.0001, OR: 9.88, 95%CI: 3.19–30.57), and cumulative event rates (p &lt, 0.001, OR: 14.45, 95%CI: 6.1–34.21), were significantly different between the two groups according to NLR value. Multivariate analysis showed that a high baseline NLR value was an independent predictor of unfavorable outcomes in all enrolled patients. Consistently, at ROC analysis, a preoperative NLR &gt, 5 was strongly associated with all outcome occurrences. Conclusion: Preoperative NLR value seems to be strongly related to ALI outcomes in this unselected population. The largest series should be evaluated to confirm present results.

The aim of this study is to evaluate the role of preoperative ischemic brain lesion (IBL) volume, assessed by Diffusion-weighted magnetic resonance brain imaging (DW-MRI) with RAPID® processing, and surgery timing in predicting post-operative neurological outcomes in symptomatic carotid stenosis (SCS) patients treated with carotid endarterectomy (CEA).All patients with SCS who underwent CEA between January 2010 and June 2020 were considered. IBLs ipsilateral to the stenosis were identified in the preoperative magnetic resonance brain (MRI). The volume was quantified in mL and correlated with 30-day rates of stroke and stroke/death by χ2 and receiver operating characteristic (ROC) curve.One hundred thirty-four patients were surgically treated for SCS during the entire study period. CEA procedures were defined as emergent, urgent, or elective if performed within 48 hr, between 48 hr and 14 days, or after 14 days from symptoms onset, respectively. Cumulative new ipsilateral stroke rate was 4,5%, with a statistically higher neurological complications in emergent patients compared to urgent and elective patients (10,6%, 1,47% and 0% respectively, P 0,039). ROC curve analysis showed a volume of 10 mL was predictive of postoperative stroke with 100% sensitivity and 80% specificity. An IBL volume10 mL was an independent risk factor for postoperative stroke. In fact, the perioperative neurological complication rate was significantly different in high-IBL volume patients (10 mL) compared with low-IBL volume patients (10 mL) (P 0,003) CONCLUSIONS: The present study suggests that the optimal timing for CEA is between 48 hr and 14 days. Furthermore, the present study suggests that the presence of the IBL, by itself, is not definitively related with an unsatisfactory neurological outcome. However, an IBL higher than 10 mL should be as a reliable threshold value adverse neurological result in SCS patients.

To describe the case of a young female patient, affected by Systemic Lupus Erythematous, hospitalized for severe SARS-CoV-2 infection pneumonia and presenting a treatment-resistant acute upper limb ischemia. Two days after hospital admission, the patient suffered sudden right upper limb pain associated with mild functional impairment. At physical examination, radial and ulnar pulses were absent, and no flow signal was detected at duplex ultrasound scan. Therefore, an acute limb ischemia diagnoses was posed. Despite several surgical and endovascular revascularization attempts, the patient underwent an above the elbow amputation in 10th postoperative day from first surgical embolectomy, and she died for respiratory failure 25 days after hospitalization. Our case of acute upper limb ischemia seems to confirm that clinical manifestation and fate of thrombotic disorder in COVID-19 patients could be precipitated by concomitant autoimmune diseases.

Blockchain has been considered a breakthrough technology-but does your company need it? In this article, the authors discuss the advantages and disadvantages of blockchain technology using examples from the insurance sector, which can be generalized and applied to other sectors.

Aims The aim of the present study was to evaluate periprocedural and 30-day outcomes in a prospective series of patients treated with the CGuard Embolic Prevention System (EPS). Methods and results From April 2015 to June 2016, a physician-initiated prospective multicentre study was performed in 200 consecutive patients admitted for protected carotid artery stenting (CAS) and treated using the CGuard EPS in twelve vascular centres. Outcome measures were: technical success, periprocedural (0-24 hours) and post-procedural (24 hours-30 days) major and minor strokes, death, acute myocardial infarction (AMI), transient ischaemic attack (TIA), and external carotid occlusion. In three centres, consecutive diffusion-weighted magnetic resonance cerebral imaging (DW-MRI) was performed ≤72 hours prior to and within 72 hours after the intervention. A distal embolic protection device was employed in 182 patients (91%). Technical success was 100%. No death, AMI or major stroke occurred periprocedurally. There were two TIAs and five periprocedural minor strokes (2.5%), including one thrombosis solved by surgery. In the remaining patients (199/200; 99.5%) one-month follow-up duplex ultrasound revealed optimal technical results. Post-procedural clinical follow-up was uneventful. No external carotid artery occlusion occurred. New post-procedural DW-MRI lesions were detected in 12 patients out of 61 (19.6%), including bilateral in five (8.2%) and isolated ipsilateral in six (9.8%), whereas one patient (1.6%) had contralateral only lesions. Conclusions Multicentre multi-specialty use of the CGuard EPS in routine clinical practice was associated with no major periprocedural neurologic complications and a total elimination of post-procedural neurologic complications by 30 days.

Background The objective of the study was to report immediate and midterm results of an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) using the Ovation stent graft. Methods A double-center retrospective study was conducted on a prospectively collected database between 2012 and 2015. One hundred fifty-six elective patients were included. The outcome measures considered for analysis were primary technical success, 30-day and midterm reinterventions, and all-cause and AAA-related mortality rates. The presence of an aortic neck ≤10 mm, and of a noncylindrical aortic neck, as well as a narrowed aortic bifurcation was defined as an aortic bifurcation average diameter (AB average ) ≤ 18 mm or an AB area ≤ 20 mm 2 , and an external iliac artery diameter ≤5 mm was considered as independent factors potentially influencing the outcome. Results Male patients totaled 128 (82.1%), and mean age was 74.83 ± 6.76 years (range: 56–91). Mean aortic diameter was 57.15 ± 8.77 mm, mean diameter at inferior renal artery level + 13 was 24.44 ± 3.31 mm, and mean aortic neck length was 18.77 ± 8.45 mm. Fifty-four patients (34.6%) had an aortic neck ≤10 mm, and cylindrical aortic neck shape was present in 34 patients (21.8%). Regarding the aortic bifurcation (AB), 31 patients (19.9%) presented AB average ≤ 18 mm, and 35 (22.4%) an AB area ≤ 20 mm 2 . Technical success was achieved in all cases. At 30-day follow-up, 2 type I endoleaks (1.3%) were detected. One patient was successfully treated endovascularly by proximal aortic cuff implantation, while the other patient refused further treatment. Three-month unscheduled computed tomographic angiography shows endoleak resolution and complete aneurysm seal. One patient suffered from a limb graft occlusion, managed by medical treatment. At a mean follow-up time of 20.4 ± 8.8 (1–60) months, 6 reinterventions were reported, including 2 embolizations for type II endoleak and 4 for iliac and femoral vessel occlusive disease. Log-rank test on preoperative anatomical features showed no significant differences in terms of freedom from reinterventions, and P values were 0.653 for aortic neck length ≤10 mm, 0.309 for noncylindrical aortic neck length shape, 0.520 for AB average ≤ 18 mm, 0.604 for AB area ≤ 20 mm 2 , and 0.421 for external iliac artery diameter ≤5 mm. Conclusions Our initial experience suggests that in an unselected patient population undergoing AAA repair, EVAR by Ovation stent graft can be performed safely with satisfactory immediate and midterm outcomes.

The aim of the present study was to evaluate the impact of the aortic bifurcation (AB) morphological characteristics, analyzed on computed tomography angiography (CTA), on outcomes of patients with abdominal aortic aneurysms (AAAs), treated by endovascular aneurysm repair (EVAR) in a single-center experience. A retrospective analysis was conducted using a prospectively collected database. Morphological features considered as potentially impacting outcomes were maximum AB diameter (ABmax), minimum diameter (ABmin), mean diameter (ABaverage), AB area (ABarea), and AB calcification (ABcalcification) and thrombosis (ABthrombosis). Outcome measures were perioperative, 30-day, and midterm AAA-related reinterventions and all-cause mortalities. Investigators reviewed 306 preoperative CTA scans. Maximum aortic diameter was 51.4 ± 12.4 mm (range 40–110), and mean ABmax was 24.2 ± 8.8 mm (range 10–60), ABmin 17.0 ± 5.4 mm (range 4–40), ABaverage 20.6 ± 6.5 mm (range 9–47.5), and ABarea 35.2 ± 24.2 mm2 (range 6–176). ABcalcification ≥ 50% was present in 63 patients (20.6%), and ABthrombosis ≥ 50% in 102 patients (33.3%). Technical success was obtained in all cases, without perioperative reintervention or death. At 30-day follow-up, the reintervention rate was 3.3%, and mortality rate was 1.3%. At a mean follow-up period of 35 ± 28.6 (range, 1–72) months, reintervention and mortality rates were 6.5 and 4.9%, respectively. None of the analyzed thresholds were predictive of adverse outcomes. At multivariate analysis, association of a narrowed AB with severe calcification of the distal aorta showed a significant differences in terms of reinterventions (p = 0.009). Our limited experience seems to reveal that a cutoff of ≤ 20 mm for AB diameter, as in current guidelines, is ineffective in predicting outcomes after EVAR.

Blockchain is receiving increasing attention from academy and industry, since it is considered a breakthrough technology that could bring huge benefits to many different sectors. In 2017, Gartner positioned blockchain close to the peak of inflated expectations, acknowledging the enthusiasm for this technology that is now largely discussed by media. In this scenario, the risk to adopt it in the wake of enthusiasm, without objectively judging its actual added value is rather high. Insurance is one the sectors that, among others, started to carefully investigate the possibilities of blockchain. For this specific sector, however, the hype cycle shows that the technology is still in the innovation trigger phase, meaning that the spectrum of possible applications has not been fully explored yet. Insurers, as with many other companies not necessarily active only in the financial sector, are currently requested to make a hard decision, that is, whether to adopt blockchain or not, and they will only know if they were right in 3–5 years. The objective of this paper is to support actors involved in this decision process by illustrating what a blockchain is, analyzing its advantages and disadvantages, as well as discussing several use cases taken from the insurance sector, which could easily be extended to other domains.

Acute limb ischemia (ALI) is a pathological condition resulting from a sudden blood interruption (or, at least, from an important reduction in flow) limiting tissues’ survival. ALI is always a serious event requiring immediate diagnosis and treatment, also considering the high associated amputation risk. The most frequent causes of acute limb ischemia are embolism, thrombosis, and trauma. Clinical findings are grouped together in a series mnemonic note as “6P of Pratt”: pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis. Those in concert with duplex ultrasound assume a primary and crucial role in diagnostic and preoperative evaluation of ALI patients. Treatment for ALI largely depends on the clinical presentation according to Rutherford’s classification. When indication for surgery is posed, several open, endovascular, and hybrid procedures are developed to restore blood flow in acute patients.

To describe results of AFX unibody stent-graft treatment for TransAtlantic Inter-Society Consensus (TASC) D aortoiliac occlusive disease (AIOD) with coexistent abdominal aortic aneurysm (AAA).A retrospective analysis was conducted of 21 consecutive patients (mean age 73.6±6.4 years; 17 men) with TASC D AIOD plus AAA (diameter3.5 cm) treated electively using the AFX stent-graft. Common iliac artery (CIA) and external iliac artery (EIA) stenosis or occlusion was reported. Outcome measures were technical and clinical success, improvement in ankle-brachial index (ABI), and improvement in Rutherford category. Immediate and midterm patency, AAA exclusion, major adverse events (MAE), and mortality were also evaluated.After AFX deployment (100% technical success), 18 EIAs required adjunctive stenting (none required in the CIA). One patient required a reintervention for closure device failure. At 30-day follow-up, no death or MAE was recorded. Improvement in ABI was registered in all patients (mean 0.91±0.11), with 100% primary patency. At a mean follow-up of 25.2±11.1 months, primary patency was maintained in all cases. No death or amputation occurred; 2 patients had a myocardial infarction. Improvement in ABI was maintained (0.88±0.13) as well as Rutherford category.This study examined the use of the AFX unibody stent-graft for the treatment of TASC D AIOD with concomitant AAA. The AFX stent-graft appears to be a safe and effective solution for these complex lesions, with low morbidity and mortality.

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

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

Objectives.To compare durability and survival after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) in young patients.Material and Methods.A retrospective study was conducted between 2005 and 2014 on all consecutive patients of 60 years of age or younger. Measures considered for analysis were reintervention related to AAA, laparotomy and access vessel injury during EVAR, and all-cause mortality during hospitalization and follow-up.Results.Seventy out of 119 patients were treated by OR (58.8%) and 49 (41.2%) by EVAR, 9 in off-label fashion (18.3%). Technical success was achieved in all cases. No AAA-related death was recorded. Overall in-hospital mortality was zero and the reintervention rate was 2.5% (3/119: 1/70 OR, 2/49 EVAR,p=0.36). There is no death at 30-day or 1-year follow-up. Thirty-day reintervention rate was 1.6% (2/119; 0/70 OR, 2/49 EVAR,p=0.16), while the 1-year rate was 2.5% (3/119; 1/70 OR, 2/49 EVAR,p=0.36). At the mean follow-up of 56.8 ± 42.7 months, mortality and reintervention rates were 5.8% (7/119; 3/70 OR, 4/49 EVAR,p=0.38) and 10% (12/119; 8/70 OR, 4/49 EVAR,p=0.39), respectively. The overall reintervention rate, mortality, and freedom from adverse events did not differ between the two groups. No differences in outcome were recorded between patients treated by EVAR in on-label versus off-label fashion.Conclusion.Our (albeit limited) experience suggests that, in an unselected young patient population undergoing elective AAA repair, OR or EVAR can be performed safely with similar immediate and long term outcomes.

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

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

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

Blockchain technology is receiving an ever-increasing attention. In this work, we present pros and cons of this technology, by taking the point of view of (IT) professionals evaluating whether to embrace this technology or not for their business. Use cases selected from a particular domain represented by the insurance sector are analyzed, and several application guidelines that can be generalized and applied to other sectors are identified.

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

All patients (n 1⁄4 1177) Wound (0-3) 1.1 (0.9-1.3) 1.7 (1.3-2.3) 1.2 (1.0-1.4) Ischemia (1-3) 1.5 (1.2-1.8) 3.5 (2.0-6.5) 1.2 (0.9-1.4) Infection (0 3) 1.2 (1.0 1.3) 1.7 (1.3-2.1) 1.2 (0.9-1.4) Composite (2-9) 1.2 (1.1-1.2) 1.8 (1.5-2.0) 1.2 (1.0-1.3) Mean (0-3) 1.4 (1.2-1.6) 4.5 (3.1-6.5) 1.2 (1.0-1.5) Clinical stage (1-4) 1.1 (0.9-1.3) 2.2 (1.6-3.1) 1.1(0.9-1.2) Bypass only (n 1⁄4 592) Wound (0-3) 1.3 (1.1-1.5) 1.6 (1.2-2.3) 1.3 (1.0-1.6) Laura Capoccia, Maria Antonietta Panico, DaniloMenna, Pasqualino Sirignano, Wassim Mansour, Nunzio Montelione, Chiara Pranteda, Martina Formiconi, Francesco Speziale. “Sapienza” University of Rome, Vascular and Endovascular Surgery Division, Department of Surgery “Paride Stefanini”, Policlinico Umberto I, “Sapienza” University of Rome, Roma, Italy; Maria Antonietta Panico, Vascular and Endovascular Surgery Division, Rome, Italy; Danilo Menna, Vascula and Endovascular Surgery Division, Rome, Italy; Policlinico Umberto I, Rome, Italy

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