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Purpose To describe the early results and mid-term patency rates of external iliac artery (EIA) stenting using self-expanding covered stents. Methods We conducted a multicenter retrospective study (2015–2021), including patients receiving primary endovascular treatment of external iliac artery occlusive disease with self-expanding covered stents. All patients were treated with the Viabahn (W.L Gore & Associates, Inc., Flagstaff, AZ–USA) stent. Patency and limb salvage rates were estimated with Kaplan–Meier curves. Results Ninety-three patients (mean age, 69 ± 9 years; 81% males) were treated for disabling claudication in 44%, rest pain in 28%, and tissue loss in 28%. TASC C/D lesions were present in 72% and iliac complete occlusion in 30%. Mean lesion length was 6.9 ± 2.4 cm; 30% had moderate/severe EIA calcifications; and the mean iliac tortuosity index was 1.17 ± 0.13. Technical success was 100%. There was one perioperative death (1.4%) and procedural complication rate was 6.5%. At 42 months (mean, 25 months), primary patency was 89.8% (95%CI 83–98); the presence of EIA tortuosity (tortuosity index > 1.25, 87.7 ± 11% vs 89.9 ± 8%; P = .6) or severe calcifications (87.6 ± 9% vs 96.0 ± 8%; P = .400) had no significant impact. After univariate analysis, the use of a stent with diameter P Conclusions The use of self-expanding covered stents provided excellent early and mid-term results in the treatment of obstructive disease of the EIA, also in cases of high EIA tortuosity and high grade of calcifications. The use of a

Background. The aim of this study was to assess the incidence of two post-operative acute kidney injury (AKI) stages according to the Risk, Injury, Failure, Loss of function, End-stage (RIFLE) criteria in patients undergoing fenestrated endovascular aortic repair (FEVAR) for complex aortic aneurysms. Furthermore, we analyzed predictors of post-operative AKI and mid-term renal function deterioration and mortality. Methods. We included all patients who underwent elective FEVAR for abdominal and thoracoabdominal aortic aneurysms between January 2014 and September 2021, independently from their preoperative renal function. We registered cases of post-operative acute kidney injury (AKI) both at risk (R-AKI) and injury stage (I-AKI) according to the RIFLE criteria. Estimated glomerular filtration rate (eGFR) was noted preoperatively, at the 48th post-operative hour, at the maximum post-operative peak, at discharge, and then during follow-up approximately every six months. Predictors of AKI were analyzed with univariate and multivariate logistic regression models. Predictors of mid-term chronic kidney disease (CKD) (stage ≥ 3) onset and mortality were analyzed using univariate and multivariate Cox proportional hazard models. Results. Forty-five patients were included in the present study. Mean age was 73.9 ± 6.1 years and 91% of patients were males. Thirteen patients (29%) presented with a preoperative CKD (stage ≥ 3). Post-operative I-AKI was detected in five patients (11.1%). The aneurysm diameter, thoracoabdominal aneurysms and chronic obstructive pulmonary disease were identified as predictors of AKI in univariate analysis (OR 1.05, 95% CI [1.005–1.20], p = 0.030; OR 6.25, 95% CI [1.03–43.97], p = 0.046; OR 7.43, 95% CI [1.20–53.36], p = 0.031; respectively), yet none of these factors were significative on multivariate analysis. Predictors of CKD onset (stage ≥3) during follow-up on multivariate analysis were age (HR 1.16, 95% CI [1.02–1.34], p = 0.023), post-operative I-AKI (HR 26.82, 95% CI [4.18–218.10], p < 0.001) and renal artery occlusion (HR 29.87, 95% CI [2.33–309.05], p = 0.013), while aortic-related reinterventions where not significantly associated with this outcome in univariate analysis (HR 0.66, 95% CI [0.07–2.77], p = 0.615). Mortality was influenced by preoperative CKD (stage ≥3) (HR 5.68, 95% CI [1.63–21.80], p = 0.006) and post-operative AKI (HR 11.60, 95% CI [1.70–97.51], p = 0.012). R-AKI did not represent a risk factor for CKD (stage ≥ 3) onset (HR 1.35, 95% CI [0.45–3.84], p = 0.569) or for mortality (HR 1.60, 95% CI [0.59–4.19], p = 0.339) during follow-up. Conclusions. In-hospital post-operative I-AKI represented the main major adverse event in our cohort, influencing CKD (≥ stage 3) onset and mortality during follow-up, which were not influenced by post-operative R-AKI and aortic-related reinterventions.

The aim of this study was to describe a single center preliminary experience with the use of a specific balloon expandable stent-graft for the treatment of innominate artery (IA) obstructive lesions.We report our experience with four male patients treated with Gore Viabahn balloon (Gore Medical, Flagstaff, AZ, USA) expandable stent-graft for different types of IA stenosis: three patients were symptomatic for vertebrobasilar insufficiency, while one patient was asymptomatic for cerebrovascular symptoms. The stent grafts were deployed using retrograde (N.=2) or antegrade approach (N.=2), aiming to cover the entire lesions length and to slightly protrude into the aortic arch. Post-dilatation was performed with a compliant balloon. One patient presented a tandem lesion (IA and right internal carotid artery) and after the stenting of the IA he was treated also with a carotid artery stenting during the same procedure.Technical success was achieved in all patients. No perioperative or postoperative complications had been reported and the neurological disorders disappeared for the three symptomatic patients. After a mean clinical and radiological follow-up of 24±5 months, all the stents were patent and perfectly adapted to the vessels.This preliminary clinical experience shows that the use of the Gore Viabahn balloon (Gore Medical) expandable stent-graft seems safe and feasible for the treatment of the IA obstructive lesions, also in presence of irregular plaques and hostile anatomies for an endovascular treatment. Larger experiences and long-term data are mandatory.

To describe prevalence, risk factors, and clinical impact of coronary artery disease (CAD) in patients with asymptomatic bilateral carotid stenosis.We conducted a single-center retrospective cohort study on consecutive patients referred for bilateral carotid stenosis70% (2014-2021). All patients underwent systematic coronary angiography. Depending on anatomic and clinical characteristics, patients were addressed to combined carotid endarterectomy (CEA)+coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or stenting (CAS), or staged bilateral CEA under cardiac best medical therapy. Cumulative 30-days stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed.One-hundred-sixty-seven patients with bilateral carotid stenosis70% received preoperative coronary angiography, identifying a severe CAD in 108 cases (65.1%). Echocardiography abnormalities (OR 2.07, 95%CI 1.03-5.78; P=.04) or prior coronary intervention (OR 11.94, 95%CI 2.99-63.81; P=.001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% in patients with severe CAD and 1.7% in those without severe CAD (P=.262). The cumulative stroke rate was 1.8%, 1.8% in cases with severe CAD and 1.7% in cases without severe CAD (P=1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% in patients without severe CAD (P=.33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention were at higher risk of perioperative stroke/MI (OR 1.24, 95%CI 1.00-2.83; P=.04). At 10 years, overall survival was 67.1% (95%CI 57-79) and freedom from cardiovascular mortality was 78.5% (95%CI 69-89). Patients with untreatable CAD maintained a higher risk of 10-years mortality (HR 5.5, 95%CI 1.6-19.9; P.01).The prevalence of CAD in patients with bilateral carotid stenosis is high, especially in those with abnormal echocardiography findings. CAD is potentially treatable in 80% of cases, and a staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate in these patients. The presence of an untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions in this subset of patients.

Purpose: To investigate early- and long-term outcomes of endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) in young and low surgical risk patients. Methods: The global registry for endovascular aortic treatment (GREAT) was queried for all patients with AAA undergoing standard EVAR; patients were excluded if had previous AAA repair or underwent concomitant procedures. Young patients were defined if age 11) risk. Young versus older patients and low-risk versus average/high-risk patients were compared. The primary endpoints were early (30 days) major adverse events (MAEs), 5-year freedom from overall mortality, aortic-related mortality, and freedom from device-related reinterventions. Time-to-event endpoints were calculated by Kaplan–Meier curves. Results: Of 3217 included patients, 182 (6%) were Conclusion: In this real-world registry, EVAR was more often offered in cases with suitable anatomy in young and low-risk patients. Low operative risk, rather than young age alone, predicted excellent early outcomes and low 5-year mortality, aortic-related mortality, and reintervention rates.

To assess outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of Extent I-III thoracoabdominal aortic aneurysms (TAAAs) without prophylactic cerebrospinal fluid drainage (CSFD).Prophylactic CSFD has been routinely used during endovascular TAAA repair, but concerns about major drain-related complications gave led to revising this paradigm.We reviewed a multicenter cohort of 541 patients treated for Extent I-III TAAAs by FB-EVAR without prophylactic CSFD. Spinal cord injury (SCI) was graded as ambulatory (paraparesis) or non-ambulatory (paraplegia). Endpoints were any SCI, permanent paraplegia, response to rescue treatment, major drain-related complications, mortality, and patient survival.There were 22 Extent I, 240 Extent II and 279 Extent III TAAAs. Thirty-day mortality was 3%. SCI occurred in 45 patients (8%), paraparesis occurring in 23 (4%) and paraplegia in 22 patients (4%). SCI was more common in patients with Extent I-II compared to Extent III TAAAs (12% vs. 5%, P=0.01). Rescue treatment included permissive hypertension in all patients, with CSFD in 22 (4%). Symptom improvement was noted in 73%. Twelve patients (2%) had permanent paraplegia. Two patients (0.4%) had major drain-related complications. Independent predictors for SCI by multivariate logistic regression were sustained peri-operative hypotension (OR 4.4, 95% CI 1.7-11.1), patent collateral network (OR 0.3, 95% CI 0.1-0.6), and total length of aortic coverage (OR 1.05, CI 95% 1.01-1.10). Patient survival at 3-years was 72±3%.FB-EVAR of Extent I-III TAAAs without CSFD has low mortality and low rates of permanent paraplegia (2%). SCI occurred in 8% of patients, and rescue treatment improved symptoms in 73% of them.

We aimed to investigate predictors of intervention of acute type B aortic penetrating ulcer (PAU) and intramural hematoma (IMH). We conducted a retrospective chart review of all patients admitted for acute type B PAU or IMH in a tertiary referral hospital. Indications to intervention were "complicated" (rupture, impending rupture, malperfusion) or "high risk for unfavorable outcome" (refractory hypertension and/or pain despite best medical treatment, morphologic aortic evolution, transition to a new aortic syndrome, or increase in IMH/PAU depth5 mm) during the acute/subacute phase. The primary outcomes were overall mortality, aortic-related mortality, and freedom from intervention. Time-dependent outcomes were estimated with Kaplan-Meier curves. Cox proportional hazards models were used to identify predictors of intervention and mortality. There were 54 acute aortic syndromes, 37 PAUs and 17 IMHs. Mean age was 69 ± 14 years and 33 patients (62.2%) were male. Six (11.5%) patients had complicated aortic syndromes and underwent urgent repair. Two (3.7%) additional patients developed an impending rupture during the acute phase. Eleven (21.1%) patients were classified as at "high risk" during the initial hospitalization. Overall, 22 (40.7%) patients required an aortic intervention during the initial admission (n = 16, 72.7% during the acute phase; n = 6, 27.3% during the subacute phase). In-hospital mortality was 5.5% (1 PAU and 2 IMH), and was aorta-related in all cases. For IMH, disease extension in3 aortic zones (HR 1.94, 95%CI 1.17-32.6; p = 0.038) and presence of ulcer-like projections (ULPs) (HR 1.23, 95%CI 1.02-9.41; p = 0.042) were associated with the need for intervention. There were no aortic-related deaths or intervention during the chronic phase. PAU width20 mm (HR 1.68, 95%CI 1.07-16.08; p = 0.014), PAU depth15 mm (HR 6.74, 95%CI 1.31-34.18; p = 021), PAU depth/total aortic diameter0.3 (HR 4.31, 95%CI 1.17-20.32; p = 0.043), and location at the level of the paravisceral aorta (HR 2.24, 95%CI 1.23-4.70; p = 0.035) were significantly associated with need for intervention. Six additional (16.2%) PAUs required intervention during the chronic phase owing to PAU growth. Maximum aortic diameter35 mm was significantly associated with intervention (HR 1.45, 95%CI 1.00-2.32; p = 0.037). Acute symptomatic type B IMHs and PAUs are characterized by a high risk of complications during the first month from presentation. Morphologic features associated with intervention were IMH with ULPs or extension in more than 3 aortic zones, as well as PAUs with depth15 mm, width20 mm, or depth/aortic diameter ratio0.3. A strict follow-up protocol or consideration for early intervention within 30 days from presentation should be taken into account for these high-risk patients. During the chronic phase imaging follow-up is particularly important for PAUs in order to identify progression to saccular aneurysms.

We report a case of Kommerell's diverticulum (KD) treated with a total endovascular approach, maintaining supra-aortic trunk (SAT) patency. A 75 year-old female with aneurysmal KD was deemed unsuitable for open surgery. Landing zone 2 was unfeasible; therefore, we planned an endovascular approach with landing in zone 1, chimney to left subclavian artery and periscope to right subclavian artery. Postoperatively she was free from complications, with complete exclusion of KD and SAT patency at 3-year follow-up.

The purpose of the study is to perform a postimplantation geometrical analysis and to evaluate early and mid-term outcomes of new-generation balloon-expandable covered stents, used in the kissing conformation to treat obstructive lesions involving the aortic bifurcation.A single-center retrospective review of all patients who underwent endovascular reconstruction of the aortoiliac bifurcation for obstructive disease, with the use of Viabahn balloon expandable stents (VBX; W. L. GoreAssociates, Flagstaff, AZ) deployed in the kissing conformation, from March 2018 to June 2019 was carried out. Two same-size kissing VBXs were simultaneously deployed from the distal aorta (1.5-2 cm above the aortic bifurcation) to the common iliac arteries; a kissing post-ballooning using compliant balloons was routinely performed to flare the proximal part of the VBX, to adapt to the aortic diameter and morphology. A postoperative computed tomography (CT) angiogram was obtained for all patients for the geometrical assessment. "Precision" of deployment was measured as protrusion mismatch, intended as the longitudinal distance between the stents' proximal ends. "Conformability" was measured as radial mismatch (area and volume of the "dead space" between the stented lumen and the aortic wall) and D-ratio (ratio of the major and minor axes in the axial view). Symmetry was measured as the ratio between the minor diameter of the 2 kissing stents at the same level.Twenty-eight patients (56 limbs) underwent endovascular treatment with kissing VBXs for Trans-Atlantic Inter-Society Consensus II C (n = 10, 36%) or D (n = 18, 64%) lesions involving the aortic bifurcation. Two 8-mm diameter ("8L") VBX stents were used in most cases (n = 32, 57%). At the postoperative CT, the mean protrusion mismatch was 0.8 ± 1.7 mm and was5 mm in all cases. The mean radial mismatch area was 20.4 ± 10.6 mmThe use of kissing VBX stents may represent a valid option for the treatment of obstructive lesions involving the aortic bifurcation, with excellent early and mid-term outcomes and achievement of optimal stents geometry.

The aim was to determine the clinical impact of routine cardiology consultation before carotid endarterectomy (CEA) in neurologically asymptomatic patients, in terms of early and long term cardiovascular events.A single centre retrospective review of consecutive patients receiving CEA from 2007 to 2017 for asymptomatic carotid stenosis was performed. Two groups were compared: patients operated on from 2007 to 2012 received a pre-operative cardiology consultation only in selected cases (group A); from 2012 to 2017 patients received a routine pre-operative cardiology consultation (group B). In hospital death, myocardial infarction (MI), heart failure, dysrhythmias, and stroke were compared. A multiple logistic regression was performed to identify predictors of peri-operative complications. Long term overall survival and freedom from fatal cardiovascular events were compared.In total, 878 CEAs were performed in group A and 1094 in group B. Patients in group B were more likely to have had a previous coronary intervention (0.5% vs. 5.1%; p .001), and to be on dual antiplatelet (4.6% vs. 9.5%; p = .001), statin therapy (60.3% vs. 72.4%; p .001), and a higher number of cardiac drugs (1.77 ± 1.22 vs. 1.92 ± 1.23; p = .01) at the time of CEA. In hospital mortality was 0.1% for both groups (p = 1.0), and there were no significant differences regarding neurological complications (0.8% vs. 0.3%; p = .20); group B had a significant reduction in overall cardiac complications (3.4% vs. 1.9%; p = .05) and MI (1.6% vs. 0.6%; p = .05). Multivariable analysis confirmed that routine cardiology consultation was an independent predictor of MI (odds [OR] ratio 0.61; p = .04) and overall reduction in cardiac complications (OR 0.28; p = .01). At five years, overall survival was similar (84.2% vs. 82.4%; p = .72), but patients in group B had a significantly lower mortality from cardiovascular events (92.0% vs. 95.8%; p = .04).Routine cardiology consultation before elective CEA in patients with asymptomatic carotid stenosis reduced peri-operative cardiac complications and long term fatal cardiovascular events. This approach may be considered to maximise the risk/benefit ratio of CEA in asymptomatic patients.

To assess the prevalence of atherosclerotic carotid artery disease (ACAD) in patients undergoing transcatheter aortic valve implantation (TAVI) and postoperative cerebrovascular accidents (CVAs) and evaluate its prognostic impact on postoperative CVAs.A retrospective review of all consecutive patients with severe symptomatic aortic valve stenosis (AVS) who underwent TAVI was conducted at a single tertiary university hospital (January 2008-December 2018). Patients with AVS scheduled for TAVI and concomitant carotid stenosis were evaluated for prophylactic carotid revascularization (carotid endarterectomy [CEA] or carotid artery stenting [CAS]).Seven hundred and seventy one consecutive patients (mean age: 80 years, 52% males) were treated by TAVI procedures. Carotid stenosis70% was detected in 69 patients (9%); it was unilateral in 47 (68%) and bilateral in 22 (32%) patients. Prophylactic carotid revascularization was performed before TAVI in 45 patients (31%): in 63.1% of patients (30/47) with unilateral carotid stenosis70% and in 68.1% (15/22) with bilateral carotid stenosis70%. Postoperative CVA following TAVI procedures were recorded in 25 patients (3.2%): 22 cases of stroke (2.8%) and 3 cases of transient ischemic attack (0.4%). At a multiple logistic regression, only bilateral carotid stenosis70% (odds ratio [OR] 1.16, confidence interval [CI] 95% 1.03-1.31; P = 0.0009) was found as independent predictors of periprocedural CVA.In patients with severe symptomatic AVS undergoing TAVI, carotid stenosis was frequently observed. Unilateral carotid stenosis70% did not show a significant association with early CVA following TAVI. However, in the cohort of patients with bilateral carotid stenosis70%, a significant association with postoperative CVA was observed.

Background: We aimed to identify predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU). Methods: We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN-USA, residents diagnosed with AD, IMH, and PAU (1995–2015). The endpoints were aortic diameter change, freedom from clinical disease progression (any related intervention, aortic aneurysm, new aortic syndrome, rupture or death) and disease resolution (complete spontaneous radiological disappear). Linear regression was used to assess aortic growth rate; predictors of disease progression were identified with Cox proportional hazards. Results: Of 133 incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included. Overall median follow-up was 8.1 years. Aortic diameter increase occurred in 40 ADs (87%, median 1.0 mm/year), 5 IMHs (42%, median 0.2 mm/year) and 14 PAUs (50%, median 0.4 mm/year). Symptomatic presentation (P = 0.045), connective tissue disorders (P = 0.005), and initial aortic diameter >42 mm (P = 0.013) were associated with AD growth rate. PAU depth >9 mm (P = 0.047) and female sex (P = 0.013) were associated with aortic growth rate in PAUs and IMHs. At 10 years, freedom from disease progression was 22% (95% CI 12–41) for ADs, 44% (95% CI 22–92) for IMHs, and 46% (95% CI 27–78) for PAUs. DeBakey I/IIIB AD (HR 3.09; P = 0.038), initial IMH aortic diameter (HR 1.4; P = 0.037) and PAU depth >10 mm (HR 3.92; P = 0.018) were associated with disease progression. No AD spontaneously resolved; resolution rate at 10 years was 22% (95% CI 0–45) for IMHs and 11% (95% CI 0–23) for PAUs. Conclusions: Aortic growth and clinical disease progression are observed in most patients with aortic syndromes, while spontaneous resolution is uncommon. Predictors of aortic growth and disease progression may be used to tailor appropriate follow-up and eventual early intervention.

Background: We aimed to assess the effect of surgeons’ shunting practice and shunt use on the early outcomes of carotid endarterectomy (CEA) in recently symptomatic patients. Methods: We conducted a retrospective observational study based on a multicenter national prospective database. The Vascular Quality Initiative database (2010–2019) was queried for CEAs performed within 14 days after an ipsilateral stroke or transient ischemic attack. Surgeons were gauged as routine shunters if they shunted in >95% of CEAs, otherwise were classified as selective shunters. In-hospital stroke and death rates were compared between routine and selective shunters, stratifying by type of index event (transient ischemic attack versus stroke) and timing of CEA (≤2 versus >2 days). Results: Thirteen thousand four hundred sixty-nine CEAs were performed after a transient ischemic attack (43%) or stroke (57%), 3186 (24%) by routine shunters, and 10 283 (76%) by selective shunters. Comparing routine and selective shunters, in-hospital stroke (1.9% versus 2.4%; P =0.09) and death (0.4% versus 0.5%; P =0.73) rates were similar. A lower stroke rate (1.5% versus 4.2%; P =0.02) was achieved by routine shunters for CEA performed P P P =0.57). Awake anesthesia was adopted in 7.8% of cases by selective shunters and in 0.8% by routine shunters, without impact on the perioperative stroke rate (1.8% versus 2.3%; P =0.349). Conclusions: In this large national cohort, the overall outcomes of CEA were similar between routine and selective shunters. A lower postoperative stroke rate was achieved by routine shunters in CEA performed

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

To investigate geometrical determinants of target vessels instability in fenestrated endovascular aneurysm repair (FEVAR), using a computed tomography angiogram postimplantation analysis.We retrospectively reviewed single-center data on consecutive patients undergoing FEVAR (2014-2021). The geometrical analysis consisted in the assessment of bridging stent lengths and diameters, stent conformation, and graft misalignment. Bridging stent length was categorized in three components: protrusion length (PL) into the main endograft, bridging length (BL) between the fenestration and the origin of the target vessel, and sealing length (SL) of apposition in the target vessel. The conformation was measured as the flare ratio (the ratio of maximum to minimum bridging stent diameter within the PL). Horizontal misalignment was measured as the angle between the fenestration and the target vessel ostium on computed tomography angiography axial cuts. The primary end point was freedom from target vessel instability; secondary end points were target vessels primary patency and freedom from related endoleaks. Time-dependent outcomes were estimated as Kaplan-Meier curves; Cox proportional hazards were used to identify the predictors of target vessel instability.There were 46 patients (juxta/pararenal: n = 34 [74%]; thoracoabdominal: n = 11 [26%]), with 147 target arteries incorporated through a bridging stent. Freedom from target vessel instability was 87% (95% confidence interval [CI], 80-94) at 42 months. Primary patency was 98% (95% CI, 96-100) and freedom from endoleak was 85% (95% CI, 76-93). PL (hazard ratio [HR], 1.08; 95% CI, 0.22-5.28; P = .923), sealing length (HR, 0.95; 95% CI, 0.87-1.03; P = .238), and flare ratio (HR, 4.66; 95% CI, 0.57-37.7; P = .149) were not associated with target vessel instability. By multivariate analysis, a BL of more than 5 mm (HR, 4.98; 95% CI, 1.13-21.85; P = .033) was significantly associated with instability. Patients with a BL 5 mm or more had a significantly greater degree of horizontal misalignment (21 ± 12° vs 9 ± 13°; P = .011).An optimal geometrical conformation between the bridging stent and the main endograft at the level of target vessels is warranted to improve the midterm outcomes of FEVAR. A BL of more than 5 mm was associated with a greater risk of target vessel instability, likely as a result of a less accurate endograft alignment. The sizing and planning of FEVAR should be performed to maintain a BL of less than 5 mm.

BACKGROUND We compared the outcomes of open surgical repair (OSR) versus endovascular aortic repair (EVAR) with parallel graft technique (PG) in patients with juxtarenal abdominal aortic aneurysm (JAAA) excluded from fenestrated endovascular aortic repair (FEVAR) due to clinical, anatomical, technical or manufacturing time reasons. METHODS A single-center analysis of consecutive patients who underwent elective and urgent (within 24-48 hours) repair of JAAA from January 2010 to January 2019 was performed. Two groups were compared: patients excluded from FEVAR and respectively treated by OSR or by PG for JAAA. Perioperative clinical, anatomic and operative data were collected in a dedicated database. The endpoints were primary technical success, changes in renal function, early and long-term mortality, freedom from aortic related reinterventions (ARRs) and aortic related mortality (ARM). RESULTS Overall, 118 consecutive patients were treated for JAAA, 32 of whom (27.1%) with FEVAR. Eighty-six patients were enrolled in the study (OSR group, N.=61; PG group, N.=25). The mean age was 77.4±6.5 years for PG group and 71.1±6.7 years for OSR group (P=0.0001); the average comorbidity score of the Society for Vascular Surgery was higher for patients treated by PG (10.2±4.8 vs. 5.5±0.4, P=0.0001), with no differences for hypertension and renal score. After propensity score matching, 42 patients (27 OSR, 15 PG) without differences in the preoperative risk factors were selected. Conical shape and neck mural thrombus were respectively more represented in the OSR group (95.1% vs. 56.0%; 63.9% vs. 36.0%). Aortic clamp site was supraceliac for 12 patients (19.7%), suprarenal for 21 (34.4%) and trans-renal for 28 patients (45.9%). In the PG group, 16 patients (64%) were treated with a single renal chimney. Primary technical success was similar in the two groups (100.0% vs. 92.0%, P=0.08), with a higher rate of procedure achieved by assisted technical success for the PG group after propensity score matching analysis (20.0% vs. 0%, P=0.04). Deterioration of renal function occurred for both groups of patients, with a significant creatinine increasing 12 months after surgery in the PG group compared with OSR group (1.72±0.66 vs. 1.18±0.40, P=0.006). Multiple logistic regression shows no independent predictor of peri-operative medical complication among demographics and pre-operative relevant clinical factors between the two cohorts. No difference in terms of early mortality was observed between the groups (1.6% vs. 0%, P=1.00). At 5 years, overall survival was lower for patients treated by PG (53.5% vs. 70.2%, P=0.007), such as freedom from ARRs (64.6 vs. 90.5%, P=0.03). Freedom from ARM at 5 years did not show significant differences among the two groups (100% vs. 98.4%, P=1.00). CONCLUSIONS PG represents a feasible procedure for patients excluded from FEVAR due to clinical, anatomical, technical or device manufacturing time reasons, ensuring low rates of ARM. However, ARRs during the follow-up remain the Achilles heel of this technique. OSR is still the most durable procedure in the endovascular era, allowing the treatment of proximal "hostile necks" with low rates of reoperation and a similar impact on the renal function compared to PG.

BACKGROUND The role of shunting during carotid endarterectomy (CEA) in symptomatic patients is unclear. The aim was to evaluate early outcomes of CEA with routine "delayed" shunt insertion, for patients with symptomatic carotid stenosis. METHODS we conducted a single-center retrospective review of symptomatic patients undergoing CEA (2009-2020). All CEAs were performed under general anesthesia using a standardized technique, based on delayed routine shunt insertion after plaque removal. Primary endpoints were 30-days mortality and stroke. A logistic regression was performed to identify clinical and procedural factors predictors of post-operative stroke. A literature systematic review was conducted using the terms "carotid endarterectomy" "stroke", "transient ischemic attack", "symptomatic carotid stenosis", and "shunt". RESULTS two-hundred-sixty-three CEAs were performed for TIA (n=178, 47%) or acute ischemic stroke (n=85, 32%). Mean delay of surgery was 6±19 days, and early CEA (

To evaluate the effectiveness of a program to reduce work-related musculoskeletal disorders (WRMSD) among surgeons.Surgeons are at high risk of WRMSD due to many physical and psychosocial factors.This study is a multicenter randomized clinical trial (UMIN000028557) conducted from January to August 2015. Following cluster randomization by surgical division, surgeons were allocated to 2 groups. The NPP group (No Preventive Program) underwent no intervention, while the PP group (Preventive Program) followed ergonomic principles in the operating room and specific physical exercises supervised by a physical therapist. A multiple logistic regression was performed to identify baseline WRMSD risk factors. WRMSD assessment was based on 1 ad hoc and 3 validated questionnaires: Nordic Musculoskeletal Questionnaire (NMQ), Numerical Rating Scale (NRS), and Short Form 36 Health Survey (SF-36). Follow-up was planned after 3 and 6 months.One hundred forty-one surgeons matched the inclusion criteria and were randomized in the PP (n = 65) and NPP (n = 76) groups. At the initial analysis, physical activity was the only modifiable independent risk factor for WRMSD (OR, 2.44; P = 0.05). The PP group showed a significant improvement in the item "General Health" (GH) regarding quality of life at 3 (NPP: 70.5 ± 15.2 vs PP: 75.9 ± 14.1; P = 0.04) and 6 months (70.6 ± 13.4 vs 75.3 ± 13.0; P = 0.04). The PP group had a significant reduction of low back pain (66.2% vs 50.0%; P = 0.04) and analgesic consumption (30.9% vs 15.5%; P = 0.03) after 6 months.This study demonstrated the effectiveness of a global program based on the application of ergonomics in the operating room and specific physical exercises.

Background The aim was to describe a single-center experience with the Conformable GORE TAG Thoracic Endoprosthesis (C-TAG) with active control system, specifically designed to evaluate the accuracy of proximal and distal deployment and its capability to adapt to the aortic wall. Methods This is a single-center prospective study including all patients treated with the C-TAG with active control system for thoracic aorta pathologies from September 2017 to May 2018. Proximal and distal accuracy of deployment was measured as the distance between “intended” and “actual landing” zone measured on the digital subtraction angiography images. Mean lack of wall apposition was measured at postoperative computed tomography (CT) angiogram images as the distance between the proximal or distal graft radiopaque ring marker and the point of graft aortic complete apposition, using parasagittal multiplanar reconstructions. Results Eleven cases were treated: 6 atherosclerotic aneurysms (5 descending and 1 arch), 1 dissecting aneurysm, 2 type B acute dissections, 1 thoracic pseudoaneurysm, and 1 Kommerell diverticulum. The proximal deployment was in landing zone 3 in 6 cases (54%), 2 in 2 cases (18%), 1 in 1 case (9%), and 0 in 2 (18%). The distal landing was in zone 4 in 1 case (9%), zone 5 in 9 cases (81%), and in 1 case (9%), it was in zone 6 with intentional coverage of the celiac trunk. Rapid pacing was used only in 2 cases. Mean accuracy of deployment was 1.8 ± 1.3 mm for the proximal and 0.7 ± 1 mm for the distal landing zones. Mean lack of wall apposition was 1.1 ± 1.9 mm at the proximal landing zone and 0.6 ± 1.8 mm at the distal landing zone. Conclusions The C-TAG with active control system offers accurate deployment both at the proximal and at the distal levels. The conformability, staged deployment, and angulation control allow good adaptation to aortic arch and precise deployment.

Purpose: To report preliminary outcomes of Viabahn Balloon-Expandable Endoprosthesis (VBX) stent-graft as bridging stent for renal arteries in fenestrated endovascular aneurysm repair (FEVAR). Materials and Methods: Between 2018 and 2019, patients undergoing FEVAR at 3 referral Italian university hospitals were prospectively collected. During the study period, VBX was the first-line choice as bridging stent for renal arteries. Procedural and anatomical data were analyzed, including renal artery (RA) configuration. A dedicated software (3Mensio, Vascular Imaging, Bilthoeven, The Netherlands) was used and RA anatomy classified as follow: upward-oriented in case of any angle >30° above the horizontal or transverse axis perpendicular to the aortic axis, downward-oriented if there was an angle >30° measured below the transverse axis and downward + upward in case of an angle 90°. Primary endpoints were technical success, defined as complete deployment of the fenestrated endograft without target vessel (TV) loss, limb stenosis or occlusion and type I or III endoleak, and freedom from target artery instability (TAI), defined by target vessel-related death, occlusion, rupture or reintervention for stenosis, endoleak or disconnection. Secondary endpoints were target artery patency rate and freedom from reinterventions. Results: A total of 26 elective FEVAR for juxta/pararenal aneurysm (20), thoracoabdominal type II (3) and type IV (3) were included. Fifty-one RA were planned for revascularization. Of these, 32 were downward, 10 horizontal, 6 upward, 4 were downward + upward. Technical success was achieved in 88.5% (23/26) of patients and 94.2% (48/51) of the TVs. One occlusion (2.1%) occurred within 30 days in a patient with previous endovascular aortic repair and suprarenal fixation. During follow-up (median 10 months), there was 1 type IC endoleak after 6 months (2.1%) in a patient with upward plus downward arterial orientation. Freedom from TAI was 96.1% (CI = 0.89 to 1.04) at first month and 92.3% (CI = 0.82 to 1.03) at 6 months. No aneurysm-related mortality and renal insufficiency occurred during follow-up. Conclusion: The use of VBX as bridging stent of RA in FEVAR is safe and feasible. Previous EVAR and tortuosity of RA may be a challenging on target vessel fate.

Made available in DSpace on 2022-04-28T19:47:00Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-10-01 Introduction: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. Methods: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. Results: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) Conclusion: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material. University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine the Ronald Reagan UCLA Medical Center University of California Los Angeles SSM Healthcare Semmelweis University Keck School of Medicine University of Southern California University of North Carolina School of Medicine University of Arizona the Indiana University Health Physicians Vascular Surgery Michigan Medicine University of Michigan University Heart Center Hamburg University Medical Center Hamburg-Eppendorf Penn State Heart and Vascular Institute Milton S. Hershey Medical Center Johns Hopkins Hospital The Heart Hospital Baylor Plano the Cardiovascular Surgery Clinic University of Messina National & Kapodistrian University of Athens University of Patras Keio University University of Pennsylvania Vancouver General Hospital & University of British Columbia Mayo Clinic Christiana Health System University of Chicago Harborview Medical Center University of Washington Washington University Stanford University CHU de Poitiers Baylor College of Medicine MedStar Georgetown University Hospital SSM Health St. Louis University Faculdade de Medicina de Botucatu-Unesp Beth Israel Deaconness Medical Center Brigham and Women's Hospital St. Joseph's Hospital Massachusetts General Hospital Robert Wood Johnson Medical School Rutgers University Vita-Salute University School of Medicine San Raffaele Scientific Institute Kaiser Permanente University Heart Center Freiburg-Bad Krozingen Freiburg University of Virginia Medical Center University of Siena Kyung Hee University Gustave Dron Hospital Centro Hospitalar de Lisboa Norte Wexner Medical Center Ohio State University Uppsala University University Hospital of Trieste University Hospital of Verona University Hospital of Padova University of Alabama University of California Davis University of Florida Michael E. DeBakey Department of Surgery Baylor College of Medicine University Hospital University of Missouri Faculdade de Medicina de Botucatu-Unesp

To investigate the effect of aortic angulation on the early and midterm outcomes of fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms (TAAA) or pararenal aortic aneurysms (PRAA).We retrospectively reviewed the data of consecutive patients enrolled in a prospective nonrandomized physician-sponsored investigational device exemption study (2013-2018). The infrarenal, suprarenal, and supraceliac aortic angles were measured on three-dimensional reconstructions of the preoperative computed tomography angiogram; a 45° cutoff was used for the analysis. End points were technical success, freedom from endograft-related complications (defined by type IA/IB/IIIA/IIIB/IIID endoleaks, and limb thrombosis); and freedom from target vessel instability (defined by branch-related death, occlusion, rupture or reintervention for stenosis, endoleak, or disconnection). Cox proportional hazard multivariable regression analyses were preformed to assess impact of covariates.There were 298 patients treated for 102 PRAAs (34%) and 196 TAAAs (66%) (78 extent IV, 118 extent I-III) with 1156 renal-mesenteric vessels incorporated. An angulation of45° was present in the infrarenal aortic axis in 94 patients (32%), suprarenal axis in 39 (13%), and supraceliac axis in 93 (31%). A supraceliac angle of45° was more common with extent I-III TAAAs (P = .01). Technical success was 97% and was not significantly related to aortic angulation; the total operating time and fluoroscopy time were significantly longer in patients with any aortic angulation of45°. Freedom from endograft-related complications was 93% (95% confidence interval [CI], 90%-97%) at 42 months, and was not associated with infrarenal (HR, 1.0; 95% CI, 0.4-2.9; P = .976), suprarenal (HR, 1.7; 95% CI, 0.5-1.8; P = .428), or supraceliac (HR, 0.9; 95% CI, 0.3-2.6; P = .886) aortic angles of45°. Overall freedom from target vessel instability was 92% (95% CI, 90%-94%) at 42 months. By multivariable analysis, target vessel instability was not affected by an infrarenal angle of45° (HR, 1.5; 95% CI, 0.9-2.4; P = .135) and a supraceliac angle of45° (HR, 0.9; 95% CI, 0.5-1.5; P = .627), but was associated with a suprarenal angle of45° (HR, 5.6; 95% CI, 3.5-9.1; P .001), even after adjustment for aneurysm extent and type of bridging stent. In this subgroup of patients, the use of directional branch vs fenestration (P = .10) and the type of bridging stent (P = .10) did not significantly impact target vessel instability.Fenestrated-branched endovascular aneurysm repair can achieve excellent early and midterm results among patients with an aortic angulation of45°, with no increase in rates of graft-related complications. However, increased aortic angulation was associated with longer operative and fluoroscopy times. The suprarenal aortic angle was the most important determinant of more target vessel events, independent of stent design or which bridging stent was selected.