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The aim of this study was to evaluate whether the scrupulous hygiene rules and the restriction of contacts during the lockdown owing to the COVID-19 pandemic affected the rate and severity of surgical site infections (SSI) after vascular exposure in the groin at two Italian University Hospitals.Starting from March 2020, strict hygiene measures for protection of health care workers (HCW) and patients from COVID-19 infection were implemented, and partly lifted in July 2020. The main exposure for analysis purposes was the period in which patients were operated. Accordingly, study subjects were divided into two groups for subsequent comparisons (preCOVID-19 era: March-June 2018-2019 versus COVID-19 era: March-June 2020). The primary endpoint was the occurrence of superficial and/or deep SSI within 30 days after surgery. The Centers for Disease Control and Prevention definitions were used to classify superficial and deep SSI.A total of 194 consecutive patients who underwent vascular exposure in the groin were retrospectively analyzed. Of those, 60 underwent surgery from April 1, 2018 to June 30 of the same year; 83 from April 1, 2019 to June 30 of the same year; and 51 from April 1, 2020 to June 30 of the same year. The mean age of the study cohort was 75 years and 140 (72%) were males. Patients who were operated in the COVID-19 era were less likely to develop SSI (10% vs. 28%; P = 0.008), including both deep SSI (4% vs. 13%; P = 0.04) and superficial SSI (6% vs. 15%; P = 0.05). After multivariate adjustments, being operated in the COVID-19 era was found to be a negative predictor for development of an SSI (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.09-0.76; P 0.001) or deep SSI (OR = 0.21; 95% CI = 0.03-0.98; P 0.001). Operative time was also found as independent predictor for the development of deep SSI (OR = 1.21; 95%CI = 1.21-1.52; P = 0.02). Using binary logistic regression, there were no independent predictors of superficial SSI that could be identified.Vascular exposure in the groin carries a non-negligible risk of SSI. In this study, we provided important insights that are simple and easily viable precautions (such as the universal use of surgical masks both for patients and health care professionals during wound care, the widespread diffusion of hand sanitizers, and the reduction of the number of visitors in the surgical wards) could be promising and safe tools for SSI risk reduction.

The aims of this study were as follows: i) to identify the prevalence of sarcopenia in patients undergoing elective endovascular aortic repair (EVAR) for intact abdominal aortic aneurysm; ii) to assess its association with perioperative morbidity and long-term survival; and iii) to estimate its diagnostic accuracy for prediction of 5-year mortality following the intervention.We performed a retrospective review of all patients who underwent elective EVAR from January 1, 2010 through December 31, 2019. The lean psoas muscle area (LPMA; cmThe study cohort eventually comprised 338 patients who underwent elective EVAR for intact abdominal aortic aneurysm. In the overall population, 154 patients (45.5%) were classified as sarcopenic. At baseline, patients with sarcopenia were older (mean age: 78 ± 5 versus 75 ± 7 y, P 0.001) and had lower proportion of males (73.5% versus 93.5%, P 0.001). At 5 y, the estimated survival rates were 52% versus 74% in sarcopenic and nonsarcopenic patients, respectively (P 0.001). Using multivariate Cox proportional hazard regression, an independent association was identified between sarcopenia and all-cause mortality in the whole cohort (hazard ratio: 2.63, 95% confidence interval: 1.43-3.36, P = 0.009).Sarcopenia, defined as LPMA350 as measured on preoperative computed tomography angiography, can be highly prevalent in patients undergoing elective EVAR. Although the intervention remains safe in the short term, presence of sarcopenia was significantly associated to lower long-term survival irrespective of patients' age or gender.

OBJECTIVES The aim of this study was to assess the approaches to reno-visceral target vessels (TVs) cannulation during branched-fenestrated endovascular aortic repair, determine the evidence base that links these approaches to clinical outcomes and identify literature gaps. METHODS A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English (PubMed, Cochrane and EMBASE databases; last queried, 31 June 2022) were systematically reviewed and analysed. Data were reported as descriptive narrative or tables, without any statistical analysis nor quality assessment. RESULTS Fourteen retrospective articles were included. Seven articles studied the use of upper extremity access (UEA) during branched-fenestrated endovascular aortic repair, 3 studied the use of steerable sheaths and 4 included both approaches. A left UEA was used in 757 patients (technical success: 99%, stroke rate: 1–3%) and a right UEA in 215 patients (technical success: 92–98%, stroke rate: 0–13%). Seven studies (1066 patients) described a surgical access only (technical success: 80–99%, stroke rate: 0–13%), while 3 studies (146 patients) described a percutaneous access only (technical success: 83–90%, stroke rate: 3%) and lastly 4 studies compared UEA versus use of steerable sheaths from the transfemoral approach (TFA) (UEA: 563 patients, technical success: 95–98%, stroke rate: 1–8%; TFA: 209 patients, technical success: 98–100%, stroke rate: 0–1%). CONCLUSIONS Both UEA and TFA as cannulation approaches were associated with high technical success and low perioperative complications. Currently, there is a paucity of high-quality data to provide definitive indication. Optimal UEA in terms of side (left versus right) and approach (surgical versus percutaneous) needs further study.

Introduction: The aim of this study was to present the short-term and 2-year outcomes after use of the Bentley BeGraft as bridging stent-graft (BSG) for reno-visceral target vessel (TV) during fenestrated endovascular aortic repair (FEVAR) from a contemporary multicentric experience. Methods: A retrospective review of all consecutive patients who underwent elective FEVAR at 7 institutions located in Italy from 2015 to 2021 was performed. The main outcomes of interest for this study were technical success and TV instability, defined in accordance with current reporting standards. Patients’ survival was also assessed. Results: Overall, 81 patients received elective FEVAR during the study period. Mean age of patients was 78 years, and 89% were men. Most patients were treated for a juxta-pararenal abdominal aortic aneurysm (AAA) (68%), and 23% had already received an infrarenal aortic reconstruction. Most endografts had 3-vessel or 4-vessel design (27% and 55%, respectively), and a Cook endograft was used in 73% of cases. Overall, 266 Bentley BeGraft were implanted, of which 44 (16.5%) in the celiac trunk, 69 (26%) in the superior mesenteric artery, 79 (29.5%) in the right renal artery, and 74 (28%) in the left renal artery. Technical success was 94%, with 5 instances of technical failure that were recorded and required an additional intraoperative procedure. The early mortality rate was 4%, and acute kidney injury occurred in 14 cases with 1 requiring definitive hemodialysis. Survival at 6, 12, and 24 months in the overall cohort was 98.8%, 95.3%, and 83.4%, respectively. Freedom from TV instability at 6, 12, and 24 months in the overall cohort was 98.4%, 97.9%, and 97.2%, respectively. Events of TV instability included 3 cases of type 1C endoleak and 3 cases of type 3C endoleak, while no events of BSG fracture or thrombosis were noted. Five out of 6 cases of TV instability occurred in renal arteries, and they were all successfully treated by endovascular means. Conclusions: The data from this multicentric study show favorable short-term and 2-year outcomes of the Bentley BeGraft as BSG for reno-visceral TV during FEVAR, with low rates of TV-related endoleak and no stent occlusion up to 2 years. Clinical Impact The data from this multicentric study show satsfactory outcomes up to two years of follow-up for the Bentley BeGraft when used for brdiging reno-visceral vessels during fenestrated endovascular aortic repair. Further research will be needed to identify predictors of stent-related reinterventions and ascertain the long-term durability.

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.

The aim of this study was to develop and validate a risk prediction model for "PREdiction of long-term MortalitY for patients with severe asYmptomatic de-novo carotid StEnosis undergoing Carotid EndArterectomy (PREMYData were collected retrospectively from a dedicated database on consecutive patients who underwent elective CEA for severe (70% according to NASCET criteria) asymptomatic carotid stenosis at two Italian University Hospitals from 2008 through 2016. Internal validation of the score was performed after random sampling in a 3:1 fashion. The primary endpoint of the PREMYA total of 901 patients were included in the derivation cohort while the validation cohort included 313 patients. By performing multivariable logistic regression with backward elimination, a parsimonious model was derived A risk score incorporating 8 risk factors was generated and found to be highly predictive of long-term mortality in the derivation (OR, 1.38; 95% CI 1.28 - 1.41; p0.001) and validation (OR 1.29, 95% CI 1.21 -1.37, p0.001) cohorts. The discrimination power in ROC curve analysis was C= 0.775 (95% CI 0.74-.80), while the optimism-corrected AUC in bootstrapped samples was 0.761 (P.001). A strong correlation was found between predicted mortality rates and actual mortality rates in the validation cohort (r = 0.71, p0.001).This study describes development, evaluation, and validation of a risk prediction model (PREMY

Introduction The aim of our paper was to describe the complementary role of different technical solutions for secondary endovascular repair of recurring lesions and peri-operative complications after open aortic repair (OAR). Methods We describe our clinical experience of secondary endovascular repair after OAR. We included in the analysis all consecutive patients who presented recurring lesions and peri-operative complications after OAR and underwent secondary endovascular repair between January 1, 2015 and June 31, 2018. Both elective and non-elective cases were captured. Early end-points were technical success, 30-day mortality, 30-day major adverse events and 30-day vascular access complications. Late end-points were survival and freedom from secondary interventions. Results Three different techniques were used in six patients: two cases of fenestrated-branched endovascular aortic repair (F-BEVAR), two cases of parallel-graft EVAR (pg-EVAR) and two cases of off-label use of standard devices. Technical success was 100%. One patient died within 30 days from acute pulmonary embolism. One patient developed acute kidney injury not requiring renal replacement therapy while the remaining four patients were free from 30-day major adverse events and. The cumulative rate of 30-day vascular access complications was 0%. All the five patients who survived the index hospitalization had ≥12 months clinical and imaging follow-up. At the longest individual follow-up, they all were alive and free from secondary interventions. Computed tomography angiography showed in all cases sustained clinical success. Conclusions Secondary endovascular repair of recurring lesions and peri-operative complications after OAR is safe and feasible and offers a minimally invasive effective treatment option when a re-do surgical operation would be associated with a considerable risk to the patient. Different solutions are available (including F-BEVAR, pg-EVAR, and off-label use of standard devices) and are complementary rather than competitive. Careful pre-operative assessment as well as familiarity with advanced techniques are essential to achieve satisfactory outcomes.

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory.

Introduction The aim of the study was to evaluate the short-term and mid-term technical and clinical outcomes of the Bolton Treo endograft in subjects with abdominal aortic aneurysm (AAA) requiring endovascular aortic repair (EVAR) and assess if presence of hostile proximal neck would represent a risk factor for increased failure rates. Methods A retrospective review of all consecutive patients who had undergone elective or non-elective EVAR with the Bolton Treo endograft at five institutions located in the North-East of Italy (January 2016-December 2020) was performed. The main exposure variable for this study was presence of hostile (HAN) or friendly (FAN) aortic neck. Results A total of 137 consecutive patients were treated with the Bolton Treo endograft at participating institutions; of these 63 (46%) presented HAN while 74 (54%) had FAN. At baseline, no significant differences were observed in the distribution of demographics and comorbidities between study groups. Two type Ia endoleaks (EL) were detected at completion angiography, all in patients with HAN but none in patients with FAN (3% vs 0%, p=.04), but no type III EL were identified in the whole cohort. The median duration of follow-up in the study cohort was 30 months (IQR 22-34 months) and was similar between study groups (p=.87). At three-years, survival estimates were 89% and 91% (p=.82) in patients with HAN and FAN, respectively. At three years, patients with HAN had significantly lower freedom from type IA endoleak as compared with patients with FAN (87% vs 94%, p=.02). No significant differences were found between study groups in the three-year estimates of freedom from reinterventions (80% vs 86%, p=.28). Using cox proportional hazards, presence of type II EL (HR 3.15, 95%CI 1.18-8.5, p=.02) and presence of type IA EL (HR 4.22, 95%CI 1.39-12.85, p=.01) were found as independent predictors for reinterventions in univariate analysis, although they were no longer significant in the multivariate model. Freedom from sac increase >5mm at three years were not significantly different between study groups (92% vs 91%, p=.95). Conclusions Within a contemporary multicentric real-world experience, EVAR with the Bolton Treo endograft shows a satisfactory safety profile in the immediate postoperative phase and acceptable outcomes during mid-term follow-up. Presence of HAN is correlated with development of type Ia EL (either early following stent-graft implantation or late after EVAR) which, in turn, may represent a significant factor leading to reinterventions.

A 65-year-old man, with previous open surgical repair of an infrarenal abdominal aortic, presented with acute complicated (paraplegia) Type B aortic dissection. He successfully underwent endovascular repair of the descending thoracic and abdominal aorta. Following the procedure, the neurological manifestations resolved. As he had a concomitant aneurysm of the right hypogastric artery (HGA), we executed a 10-minute balloon occlusion of this artery with evoked potential measurements to assess the risk of spinal cord ischemia after exclusion of the right HGA. The examination was interpreted as negative, and we proceeded with coil embolization of the right HGA and subsequent placement of an endograft landing distally within the external iliac artery. The postoperative course was totally uneventful, and the patient was discharged home 4 days after the operation. Computed tomography angiography follow-up at 1, 6, 12 and 24 months showed patency of all endografts without any signs of endoleak and effective remodeling of the descending thoracic aorta with volume reduction of the false lumen.

After successful endovascular aortic repair (EVAR), abdominal aortic aneurysms (AAA) sac will undergo negative remodeling (i.e., shrinkage) as a measure of successful exclusion. Determinants of shrinkage after EVAR are not fully known. In 84 post-EVAR patients, time course of AAA diameter after repair and occurrence of endoleaks (ELs) have been correlated with clinical history, medications, anthropometric data, vascular anatomy, and matrix metalloprotease (MMP) genetic variants (namely MMP-1 rs1799750, MMP-3 rs35068180, MMP-9 rs2234681, rs917576, rs917577, MMP-12 rs652438, and TIMP1 rs4898). During follow-up, 41 ELs were detected in 37 patients (44%, 10.4 events/100 pt./y), accounting for AAA dilation or reduced shrinkage (P < .001). High-flow ELs (type 1 and/or 3) occurrence was associated with warfarin use, MMP9 rs17577 polymorphism, and unfavorable anatomy, while low-flow type 2 ELs occurred more often in TIMP1 rs4898 non-T carriers. In EL-free patients, AAA diameter decreased for the first three years, (-4, -3 and - 2 mm/year respectively) and remained stable thereafter. Shrinkage between two measurements (n = 120) was associated with smaller AAA diameter at the baseline, peripheral arterial disease (PAD), patients’ older age at intervention, and G-/G- genotype in MMP1 rs1799750 (binary logistic regression, P = .0001). Aneurysmal sac shrinking occurs for few years after EVAR, only in patients without EL, and is related to older age, PAD, smaller aneurysm size and putative lower MMP1 expression while EL occurrence prevents such a remodeling and is mainly related to local-acting factors like unfavorable anatomy, anticoagulation, and MMP9 and TIMP1 genetic polymorphisms.

Objectives The aim of this study was to report on the safety and feasibility of secondary relining with focal flaring of novel-generation balloon-expandable covered stents for endovascular treatment of significant diameter mismatch in the aorto-iliac territory. Significant diameter mismatch was defined as >20% difference in the nominal diameter between the intended proximal and distal landing zones. Methods Patient A was an 84-year-old man with prior abdominal aortic aneurysm open repair with a straight 20 mm Dacron tube. He presented with a right common iliac artery aneurysm (Ø88 mm) with contained rupture. The Gore Viabahn endoprosthesis (9 mm × 5 cm) was inserted proximally about 15 mm above the occluded ostium of the internal iliac artery. Subsequently, the BeGraft Aortic® (16 mm × 48 mm) was inserted proximally up to the common iliac artery origin; its proximal portion was flared to 22 mm. Patient B was a 77-year-old man with prior endovascular abdominal aortic aneurysm repair with a Medtronic Endurant stent-graft. He presented with occlusion of the right limb of the aortic endoprosthesis and thrombosis that extended down to the level of the superficial femoral artery. After mechanical thrombectomy, two Gore Viabahn endoprosthesis (first one, 8 mm × 10 cm; second one, 10 mm × 15 cm) were inserted into the right iliac limb. Subsequently, the BeGraft Aortic® (12mm × 39mm) was inserted proximally up to the gate of the aortic stent-graft; its proximal portion was flared to 16 mm. Results Technical success and clinical success were achieved in both patients. Imaging follow-up (6 months for Patient A, 12 months for Patient B) showed correct placement of all stent-grafts without any graft-related adverse event. The patients remained free from new reinterventions or recurrent symptoms. Patient A died 8 months after the index procedure from acute respiratory failure after community acquired pneumonia. Conclusion Secondary relining with focal flaring of novel-generation balloon-expandable covered stents for endovascular treatment of significant diameter mismatch in the aorto-iliac territory is safe and feasible. Although mid-term results seem to be effective, longer follow-up is warranted to establish durability of the technique.

Purpose: To report an alternative approach for rescue of an occluded aortofemoral bypass using the Gore Excluder Iliac Branch Endoprosthesis (IBE). Case Report: A 52-year-old man presented with acute right limb ischemia because of displaced and occluded iliac stents and was treated with aortofemoral bypass. On the third postoperative day, there was early bypass failure due to distal embolization from aortic thrombus. After fluoroscopy-guided balloon thrombectomy of the bypass, an endovascular bailout strategy was used. The Gore Excluder IBE was deployed below the renal arteries (with the external iliac limb opening in the surgical prosthesis and the gate opening within the aortic lumen). After antegrade catheterization of the gate, a Gore Viabahn endoprosthesis was inserted as the bridging endograft and deployed so that it landed just above the preimplanted aortoiliac kissing stents without overlapping them. Completion angiography showed technical success without complications; results were sustained at 1-year follow-up. Conclusion: The Gore Excluder IBE may represent a versatile solution for the rescue of complex cases when open surgery would be associated with a considerable risk. This off-label application of a well-recognized endovascular device is safe and feasible and may prove useful as a valuable alternative in properly selected patients.

Background We sought to evaluate the midterm results of parallel-graft-endovascular aneurysm repair (pg-EVAR) for complex aortic anatomy in high-risk candidates for open surgical repair of abdominal aortic aneurism (AAA). Methods Clinical and radiographic information on 35 patients treated by pg-EVAR between March 2010 and December 2015 was retrospectively reviewed and analyzed. All patients presented with symptomatic aneurysms and were treated within 3 days of clinical presentation. Primary end points included primary chimney graft patency, overall survival, and freedom from all reintervention. Results Overall, 55 chimney grafts were placed into 47 renal arteries and 8 superior mesenteric arteries in 35 patients. An endurant stent graft was used as the main body component in all cases. At 36 months, primary chimney graft patency was 88%, overall survival of patients was 71%, and the rate of freedom from all reintervention was 78%. Conclusions Considering our midterm results, pg-EVAR seems to be a safe and effective treatment for patients with complex anatomies and at poor risk for open repair.

Purpose We present a novel application of custom-made stent-grafts (CMSGs) with inner branches to incorporate target vessels (TVs) as an alternative to fenestrations or directional branches for secondary treatment after stent-graft migration of previous infrarenal endovascular aortic repair (EVAR). Case report Two consecutive patients with stent-graft migration of previous EVAR were electively treated at our institution from January 1, 2018 through December 31, 2018. Stent-graft migration was defined as radiologic evidence of stent-graft displacement >10mm. In both cases, a proximal type I endoleak was noted and the residual infrarenal aorta above the previous endograft was unsuitable as proximal landing zone for a non-fenestrated cuff. Repair was planned by means of a CMSG with four inner branches. The procedures were conducted in two-stage fashion to minimize the risk of spinal cord ischemia. The procedures were technically successful with a total of eight TVs stented. Both patients did not suffer from any early (i.e. up to 30 days) major adverse events and no access-site complications were noted. At one-year follow-up, computed tomography angiography (CTA) showed regular placement of the CMSGs, widely patent TVs, absence of any type I or III endoleak, and stable sac size. No late reinterventions were recorded. Conclusion Secondary treatment of stent-graft migration after previous EVAR is safe and feasible using CSMGs with four inner branches. This technique is effective as showed by stable sac size and 100% freedom from TVI at mid-term imaging follow-up. Larger cohorts and longer follow-up are needed to confirm the preliminary results.

The aortoaortic concept for endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) is nearly forgotten but may constitute a valuable option for focal pathologies. Herein, we describe our experience using custom-made (CM) unibody conical endografts for saccular AAAs with narrow (≤20 mm wide) aortic bifurcation (AB) in three patients. Given the narrow AB, the option for a bifurcated stent graft was reputed not optimal. Therefore, we decided to further suggest the construction of a CM unibody conical stent graft with respect to unique anatomical characteristics of the patients. Technical success rate was 100%, and computed tomography angiography at first-month follow-up showed complete sealing proximally and distally with excellent conformability of the endografts in all the cases. All the patients were free from any-type endoleak (EL) and had no evidence of any endograft-related complication (i.e., fracture, thrombosis, or migration) or required any reintervention at their longest follow-up. We conclude that in the proper anatomic setting, the use of CM unibody conical endografts for elective EVAR of saccular AAAs with narrow AB is technically feasible with excellent short-term safety regarding ELs or migration.

Objectives Our goal was to identify anatomical and physiological factors that could predict the amount of cerebrospinal fluid (CSF) drainage in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease. Methods All consecutive elective endovascular procedures performed for descending thoracic or thoracoabdominal aortic disease between January 2015 and December 2017 were included in the study. Routine use of CSF drainage was established in all patients. The goal of drainage was to reach a spinal fluid pressure of 10-12 mmHg by draining in 5-15-ml aliquots. The number of visible intercostal and lumbar segmental arteries (SAs) was evaluated before and after endovascular repair. The covering ratio of SAs was calculated as covered preoperative SAs/total preoperative SAs. Results Twenty-four consecutive patients were included in the final analysis. The indication for the intervention was a descending thoracic aneurysm in 13 cases, a thoracoabdominal aneurysm in 4 cases and a chronic type B dissection in 7 cases. The procedure performed was thoracic endovascular aortic repair in 20 cases and fenestrated endovascular aneurysm repair in 4 cases. None of the patients developed spinal cord ischaemia. The mean volume of CSF drained was 46 ml. The mean length of aortic coverage was 231 mm. The mean number of total preoperative SAs and of covered preoperative SAs was, respectively, 22 and 9. The volume of CSF drained was significantly correlated with all these variables (length of aortic coverage, total visible SAs and covered SAs), but the most powerful correlation was individuated with the covering ratio of SAs. Conclusions Our findings suggest that the percentage of intercostal and lumbar SAs covered by placement of a stent graft can predict the volume of CSF drained in patients undergoing elective endovascular repair of descending thoracic and thoracoabdominal aortic disease.

Subclavian artery aneurysms (SAAs) are rare but potentially life- and limb-threatening. We present the case of a 69-year-old man with a true right SAA; the vertebral artery branched off the aneurysm and was the dominant one. A hybrid (combined open surgical and endovascular) repair was performed; the vertebral artery was anastomosed end to side to the common carotid artery through a right supraclavicular incision, then using a percutaneous high brachial artery access, a covered stent was deployed to exclude the SSA. The procedure was technically successful, and computed tomography angiography at 24 months showed regular placement of the endograft with blood flow within it and absence of any endograft-related complication (i.e., stent fracture/thrombosis/displacement or any-type detectable endoleak). This hybrid treatment is safe and feasible with good midterm results and may represent a valuable, less invasive alternative to conventional open surgical approaches.

Objectives Contrast enhanced ultrasound (CEUS) has been suggested as an imaging tool for detection of asymptomatic carotid atherosclerotic disease (ACAD) at high risk of cerebral embolisation. The objective of this study was to evaluate CEUS and immunohistochemical (IHC) patterns in ACAD (i.e., without any neurologic symptoms in the last 6 months) and their correlations with histology. Methods CEUS analysis was classified on a semiquantitative basis using a three-point classification scale. Plaque morphology was assessed using the American Heart Association (AHA) classification of atherosclerotic plaques, then accordingly assigned as non-vulnerable (AHA Type IV/V) or vulnerable (AHA Type VI). IHC analysis for intra-plaque neo-angiogenesis (IPN) was identified by CD34/VEGF immunostaining and classified on a semiquantitative basis using a four-point classification scale. Both CEUS and IHC analyses were performed and scored by single observers. Results Fifty-eight consecutive asymptomatic patients (mean age 73 years, 33 males) undergoing carotid endarterectomy were included in the final analysis. Nineteen had AHA Class IV/V plaques, and the remaining 39 had AHA Class VI plaques. There were two main findings of the study: (a) histologically proven vulnerable plaques compared with histologically proven non-vulnerable plaques had denser IPN (p = .004), but did not show more pronounced contrast enhancement; (b) the correlation between IHC analysis and CEUS analysis was significant for both vulnerable and non-vulnerable plaques (p = .04 and p = .01, respectively), but it was direct for AHA Type IV/V plaques and inverse for AHA Type VI plaques. Conclusions The main findings of the study were that histologically proven vulnerable plaques (i.e., AHA Class VI) as compared with histologically proven non-vulnerable plaques (i.e., AHA Class IV/V) had denser neo-vascularisation, but not more pronounced contrast enhancement.

OBJECTIVE: The objective of this study was to assess whether functional genetic polymorphisms of matrix metalloproteinases (MMPs) 1, 3, 9, and 12 are associated with arterial enlargements or aneurysms of the thoracic aorta or popliteal arteries in patients with abdominal aortic aneurysm (AAA). METHODS: The associations between MMP1 (-1607 G in/del, rs1799750), MMP3 (-1171 A in/del rs35068180), MMP9 (13-26 CA repeats around -90, rs2234681, rs917576, rs917577), and MMP12 (G/T missense variation, rs652438) polymorphisms and enlargements or aneurysms of the thoracic aorta and popliteal arteries were tested in 169 consecutive AAA patients. RESULTS: Thoracic aorta enlargement or aneurysm (TE/A; maximum diameter, >35 mm) was detected in 34 patients (20.1% prevalence). MMP9 rs2234681 microsatellite was the only genetic determinant of TE/A in AAA patients (P = .003), followed by hypercholesterolemia and antiplatelet use. Carriers of both alleles with ≥22 CA repeats had a 5.9 (95% confidence interval, 1.9-18.6; P < .0001) increased odds of TE/A, and a score considering all three variables showed 98% negative predictive value and 30% positive predictive value for thoracic aortic aneurysm detection. Eighty-two popliteal artery enlargements or aneurysms (diameter >10 mm) occurred in 55 patients (33.1% prevalence). Carriers of MMP12 rs652438 C allele showed an 18% (P = .006) increased diameter in popliteal arteries and a 2.8 (95% confidence interval, 1.3-6; P = .008) increased odds of popliteal artery enlargement or aneurysm compared with TT genotype. CONCLUSIONS: Among patients with AAA, carriers of homozygous ≥22 CA repeats in MMP9 rs12234681 and of C allele in MMP12 rs652438 have a substantial risk of carrying thoracic and popliteal enlargements, respectively.

We report the unusual case of a pseudoaneurysm of the superior gluteal artery (SGA) as a complication of a bone marrow biopsy. A 75-year-old man presented with pain and swelling of the left buttock 1 month after a bone marrow biopsy of the left iliac crest. The patient was treated by percutaneous ultrasound-guided thrombin injection (UGTI). The procedure was successful without any complication and the patient was discharged at home the same day. Follow-up at 3 months after the procedure confirmed the complete thrombosis of the pseudoaneurysm sac. At the best of our knowledge, UGTI of a pseudoaneurysm of the SGA has never been reported since now in the English literature.

We report our experience with the urgent treatment of two high-risk patients with infected femoral artery pseudoaneurysms (IFAPs) with the placement of a self-expandable covered stent (SECS). In both cases, there was no perioperative mortality and the aneurysm exclusion was successful without early or late stent thrombosis/stent fracture nor acute or chronic limb ischemia or limb loss. There was no recurrence of local or systemic infection during the follow-up period. Endovascular therapy represents a feasible treatment option for IFAPs in those patients for whom the risk of open surgical repair would be prohibitive, especially under urgent circumstances.

Genetic variants of matrix metalloproteases (MMPs)-1, -3, and 9, together with clinical variables, might predict the growth rate (GR) of abdominal aortic aneurysm (AAA). Genotyping of MMP-1 (-1,607 G+/G-), MMP-3 (- 1,171 6A/5A), and MMP-9 microsatellite (13-26 cytosine-adenosine repeats around -90) from peripheral blood was performed in 137 AAA patients with two AAA diameter measurements (at least 3 months to 1 year apart). When the same technique (either ultrasound or computed tomography) was used for the two measurements, yearly GR was estimated and compared with MMP genotype and clinical features by linear and binary logistic regression. Collectively, 36 patients provided 94 observations, with a median GR of 3 mm/year (interquartile range, 0-5.8); GRs in carriers of MMP-1 polymorphism G-/G-, G-/G+, and G+/G+ genotype were 0.3, 3.5, and 4.7mm/year, respectively (p = 0.008). In linear logistic regression, the main determinant of GR was growth arrest (GA, i.e., GR = 0, occurring in 32 observations, 34%). In turn, GA occurred mainly in G-/G- MMP-1 genotype (odds ratio, 3.9; 95% confidence interval, 1.6-9.7; p = 0.002), while variables accounting for GR > 0 were MMP-1 G + /G+ genotype, intake of any antihypertensive drug, and MMP-3 6A/6A genotype. Carriers of none, one, or two/three of these conditions accounted for a GR of 3, 4, and 9 mm/year, respectively (p = 0.001). MMP-1 (-1,607 G+/-) variant is associated to differential GR in AAA: homozygous G deletion variant shows higher GA prevalence and lower GR, while carriers of G + /G+ MMP-1 genotype, together with intake of antihypertensive drugs, and 6A/6A in MMP-3 present cumulative GR increase.

Papillary fibroelastoma is the second most frequent primary tumor of the heart. We report the case of a cardiac papillary fibroelastoma, arising from the interatrial septum, symptomatic from distal embolization to lower limb arteries. Such a clinical presentation is extremely infrequent for cardiac papillary fibroelastomas. Moreover, the site of origin not from cardiac valves and the pathogenetic mechanism underlying the clinical manifestation both represent peculiar additional findings of our case.

Internal jugular vein hemangioma, also called pyogenic granuloma, is a rare tumor. Such a neoformation was accidentally discovered and excised in a middle-aged man. Histologic and immunohistochemical investigations were performed, and this case is compared with the poor amount of similar ones described in the literature.