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Vela X is a pulsar wind nebula in which two relativistic particle populations with distinct spatial and spectral distributions dominate the emission at different wavelengths. An extended $2^\circ \times 3^\circ$ nebula is seen in radio and GeV gamma rays. An elongated cocoon prevails in X-rays and TeV gamma rays. We use 9.5 years of data from the Fermi Large Area Telescope (LAT) to disentangle gamma-ray emission from the two components in the energy range from 10 GeV to 2 TeV, bridging the gap between previous measurements at GeV and TeV energies. We determine the morphology of emission associated to Vela X separately at energies < 100 GeV and > 100 GeV, and compare it to the morphology seen at other wavelengths. Then, we derive the spectral energy distribution of the two gamma-ray components over the full energy range. The best fit to the LAT data is provided by the combination of the two components derived at energies < 100 GeV and > 100 GeV. The first component has a soft spectrum, spectral index $2.19\pm0.16^{+0.05}_{-0.22}$, and extends over a region of radius $1.36^\circ\pm0.04^\circ$, consistent with the radio nebula. The second component has a harder spectrum, spectral index $0.9\pm0.3^{+0.3}_{-0.1}$, and is concentrated over an area of radius $0.63^\circ\pm0.03^\circ$, coincident with the X-ray cocoon that had already been established to account for the bulk of the emission at TeV energies. The spectrum measured for the low-energy component corroborates previous evidence for a roll-over of the electron spectrum at energies of a few tens of GeV possibly due to diffusive escape. The high-energy component has a very hard spectrum: if the emission is produced by electrons with a power-law spectrum the electrons must be uncooled, and there is a hint that their spectrum may be harder than predictions by standard models of Fermi acceleration at relativistic shocks. (Abridged), Accepted for publication in A&A

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Background: Increased artery intima-media thickness (IMT) was found in adults with classical congenital adrenal hyperplasia (CAH). No data are available in patients with non-classical (NC) CAH. Aims: To evaluate IMT in adolescents with classical and NC CAH and to compare the results with those recorded in a control population. Patients and Methods: 18 adolescents with either classical (Subgroup A1) or NC CAH (Subgroup A2) were compared with 16 controls (Group B). All subjects underwent IMT ultrasonography measurement at different sites; results were correlated with clinical, metabolic and insulin resistance (IR) data. Results: When compared with Group B, both subgroups exhibited higher IMT values at all sites. No differences were found between classical and NC CAH. Univariate analysis of factors impacting on IMT of CAH patients demonstrated that: a) abdominal aorta (AA) IMT was positively correlated with cumulative glucocorticoid doses, triglyceride serum levels and diastolic blood pressure SDS and negatively with androstenendione and ACTH levels; b) common carotid (CC) IMT was positively associated with triglycerides and triglyceride / HDL ratio. At multiple regression analysis the independent positive predictors of AA and CC IMTs were respectively triglyceride levels and triglyceride / HDL ratio. Conclusions: a) even adolescents with NC CAH and not only those with classical form may be at higher risk of artery alterations; b) this risk is not necessarily associated with either obesity or waist/height ratio or dyslipidemia; c) an important role in the pathogenesis of artery alterations in CAH may be played by intermittent iatrogenic hypercortisolism and secondary IR.

Viene valutata una nuova tendenza a fare ricorso a Cad 3D nel settore della progettazione di stampi ad iniezione, utilizzando programmi dedicati. La valutazione delle motivazioni che stanno portando verso questi nuovi metodi di progetto è accompagnata da riscontri di interviste compiute sul campo e dalla diretta applicazione di software di tipologia differente.

Aims of the study were: 1. to evaluate the results of surgical treatment of type IV thoraco-abdominal aneurysms (TAA), with relationship to other types, 2. to evaluate results obtained with an approach different from the traditional thoraco-phreno laparatomy, with specific attention to postoperative respiratory function.We have retrospectively compared type IV TAA with all other types of thoraco-abdominal aneurysms electively treated between January 1st, 1994 and May 31st, 2003. Data on perioperative mortality, spinal cord ischemia and renal failure (both temporary and permanent) occurring in the first 30 postoperative days were considered. Protection from spinal cord ischemia was accomplished through liquor drainage and prostaglandin E1 (PGE1) infusion. When the aneurysm extension was limited to the celiac axis an extrapleuric access with removal of XI rib was performed. In this subgroup of patients we have considered postoperative recovery time of respiratory function (intubation time, number of days in intensive care unit, postoperative pulmonary complications) postoperative renal failure, perioperative mortality and morbidity.Seventy-eight TAA have been treated in the period of time of the study. Twenty cases were type IV TAA (25.6%) of which 2 due to chronic dissection. Cumulative postoperative mortality has been 19.2%. The single perioperative death in the group of type IV TAA (5%) occurred in post-operative day 15 for multiple organ failure. No spinal cord ischemia occurred in this group. Temporary renal failure occurred in 3 cases (15%) with one case requiring dialysis. In 10 cases (50%) an extrapleuric access with removal of XI rib was performed, with adequate control of the proximal aorta. Postoperative respiratory failure requiring and intubation time longer than 12 hours occurred in 2 cases (20%). In the remaining 8 cases the mean intubation time was 5.3 hours (range 4-8 hrs). Tracheostomy was not necessary in any case. Mean time of intensive care unit stay was 3.5 days (range 0-15 days).The appropriate treatment of type IV TAA leads to low mortality and morbidity with results similar to those of pararenal aneurysms rather than those of other TAA forms. Left extrapleuric access when feasible allows faster recovery of a normal respiratory function.

Authors underscore the importance of research in vascular surgery progress and approach some basic aspects on the correct conduction of an experimental research in vascular surgery fields and in particular on synthetic prosthesis of different diameter. Some important aspects of the current Italian law on animal experimentation are shown because they could cause new changes either on methodology or animal selection. Finally some experimental models adopted in the department of experimental surgery of the Rizzoli Orthopaedic Institutes on vascular prosthesis are described.

OBJECTIVE: The objective of this study was to evaluate early and late results of the Anaconda aortic endograft (Vascutek, Terumo, Inchinnan, Scotland) in a single-center experience. METHODS: From September 2005 to March 2012, patients underwent endovascular aortic repair for abdominal aortic aneurysm (AAA) with Anaconda endograft were prospectively enrolled in a dedicated database. Demographic and aortoiliac morphological data were considered. Preoperative planning was based on thoracoabdominal and pelvic computed tomography angiography. Follow-up included duplex ultrasound or computed tomography angiography at 1, 6, and 12 months and yearly thereafter. Primary end points were technical success, early and late primary and primary assisted clinical success (CS), overall and AAA-related survival and freedom from reinterventions. Secondary end points were endoleaks (ELs), steno-obstructive iliac leg complications, and AAA shrinkage. RESULTS: An Anaconda endograft was implanted in 177 patients (male 94%; mean age, 73.3 ± 7.4 years; American Society of Anesthesiologists class III-IV, 85% and 9%, respectively). The mean AAA diameter, neck length, and diameter were 55 ± 9.7 mm, 26.7 ± 10 mm, and 23 ± 2.3 mm, respectively. There was an aortic neck angle >60° in 44 (25%) patients. Iliac angles >90° were observed in 152 (43%) iliac axes. Technical success was 98.9%. Early CS was 96%. Mean follow-up was 33 ± 23.3 months. Late assisted CS was 97.7%. Survival at 12, 24, and 36 months was 96.4%, 89%, and 86.2%, respectively. There was only one case of late AAA-related mortality. Freedom from reintervention was 94%, 92%, and 85% at 12, 24, and 36 months, respectively. Three (1.7%) conversions occurred during follow-up. There were 14.1% ELs at the completion angiography (EL Ia, 1.1%; EL II, 13%). Late ELs were 20.2% (EL Ia, 1.1%; EL Ib, 2.2%; EL II, 16.9%). Iliac leg complications occurred in 5.6% of the cases. An AAA shrinkage >5 mm was observed in 130 (73.4%) patients. In 7 (4%) cases there was an AAA enlargement >5 mm. CONCLUSIONS: Data in our series demonstrate that the Anaconda endograft has good early and late results in the treatment of AAAs.

Objective/background The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO. Methods All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect. Results Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs ( p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7–14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57–2.11]; OR: 1.22 [0.60–2.49], respectively). Conclusion CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.

Introduction Chronic oral anticoagulant therapy (OAT) is of widespread use, and usually its management in patients undergoing carotid artery stenting (CAS) is through perioperative bridging heparin therapy. Aim of the present study is to analyze a single center experience of CAS in patients maintaining OAT without perioperative bridging heparin therapy. Materials and methods A retrospective evaluation of consecutive patients submitted to CAS was performed. Clinical anatomical characteristics and chronic OAT were evaluated to find a correlation with stroke, death, myocardial infarction and bleeding from the access site by Chi-square, Fisher's tests and regression analysis. Results 502 CAS were performed in a 5-year period. Twelve (2.4%) strokes, 1 (0.2%) death, no myocardial infarctions and 4 (0.8%) access site bleeding occurred in the perioperative period. In the overall population the presence of type 3 or bovine aortic arch was associated with stroke (5.5% vs. 1.5% p = 0.02), and preoperative neurological ischemic symptoms were correlated with higher incidence of the composite event of stroke/death (4.8% vs. 1.4%, p = 0.05). Twenty patients (4.0%) under chronic OAT were submitted to CAS without perioperative bridging heparin therapy with no complications. Overall, patients under OAT had no significantly different outcome compared with patients without OAT. Conclusions OAT without perioperative bridging heparin therapy is safe and effective. This data could be useful in the management of patients with chronic OAT submitted to CAS.

Background: The best strategy in the treatment for ruptured abdominal aortic aneurysm (RAAA) is an ongoing matter of debate. Differently from several retrospective studies, recent randomized controlled trials (RCTs) failed to demonstrate the superiority of endovascular repair (EVAR) over open repair (OPEN). The aim of the present study was to compare 30-day mortality of EVAR and OPEN in RAAA according to different study designs through a systematic review and meta-analysis. Methods: A systematic literature search of all series comparing the outcome of EVAR and OPEN in RAAA was performed. Studies on symptomatic aneurysms without frank ruptures were excluded. The analyses evaluated the effect of the study design on EVAR versus OPEN 30-day mortality. The pooled mortality risk was expressed as odds ratio (OR) with a 95% confidence interval (CI) by random effect model. Results: Four different study designs were evaluated. 1) Patients allocation in EVAR or OPEN was ‘‘unbiased’’ (3 studies, 2 RCTs): there was no superiority treatment in EVAR versus OPEN (OR, 1.58; 95% CI, 0.82e3.06; P ¼ 0.17). 2) Patients submitted to EVAR were compared with a historical OPEN group (2 studies): no difference between EVAR and OPEN (OR, 3.55; 95% CI, 0.47e26.62; P ¼ 0.22). 3) EVAR was the preferential treatment and OPEN was confined to patients with unsuitable anatomy for endovascular procedures (18 studies): in this type of study OPEN had a higher risk of 30-day mortality (OR, 2.18; 95% CI, 1.61e2.96; P < 0.00001). 4) The 30-day mortality after EVAR introduction in centers using both EVAR and OPEN was compared with the only OPEN treatment (7 studies): the latter had higher mortality compared with the protocol with both EVAR and OPEN options (OR, 2.26; 95% CI, 1.41e3.63; P ¼ 0.0007). Conclusions: Only few studies are available to compare EVAR and OPEN in an ‘‘unbiased’’ cohort, with no significant differences between the 2 treatments. However, after the introduction of EVAR and OPEN protocols, the overall mortality for RAAA was reduced compared with the only OPEN option, suggesting a beneficial effect of EVAR in selected cases.

AIM: Endovascular therapy (ET) is the treatment of choice for critical limb ischemia (CLI) and tibial arteries disease (TAD) in focal lesions with restorable run-off; ankle and foot bypass (BPG) is indicated in patients unfit for ET with foot or ankle arteries suitable for surgery. The aim of this study was to evaluate limb salvage (LS), primary patency (PP) and survival (S) of patients underwent BPG in the era of ET for TAD and to define the correlated prognostic factors. METHODS: Between February 2000 and November 2008, patients with CLI and TAD were collected prospectively in a data-base (demographics, Fontaine's stage, Texas University Wound Classification [TUC]of ulcers, risk-factors, TAD, techniques of foot revascularization and surgical factors). BPG was performed in tibial arteries occlusion longer than 4 cm or focal occlusion without line-flow to pedal arteries. Clinical and Duplex-ultrasound follow-up was performed at discharge, 1, 3, 6 months and every 6 months. LS, PP, and S rates were assessed with Kaplan-Meier method; factors influencing outcomes were sought by multivariate Cox proportional hazards model analysis. RESULTS: A total of 410 revascularizations were performed in patients with CLI and TAD; BPG in 153 patients (mean age:69.3±10.6, male/female=117/36, diabetes mellitus=75.2\% hyperlypidemia=54.9\%, hypertension=87.6\%, renal disease=32.7\%, coronary arteries disease=51.6\%, Fontaine stage IV=96.1\%, TUC grade-III=65.4\%, TUC stage-D=51\%). All autologous grafts in 96.7\% (non-reversed saphenous vein=74.5\%, reversed=7.2\%, composite vein graft=12.4\%, arm's veins=2.6\%). LS and S after 1 month were 88.2\% and 97.1\%, respectively. Mean follow-up was 23 months. At 12 and 36 months: LS 76.7\% and 70.9\%, PP 62.3\% and 52.9\%, S 91.5\% and 74.6\%. LS was negatively associated with age (HR=1.041 [95\%CI=1.005-1.079]), infected ulcers (HR=3.377 [95\%CI=1.571-7.258]), run-off arteries diameter

To evaluate the feasibility and clinical efficacy of endovascular treatment of the infrapopliteal arteries (IPA) in hemodialysis patients with critical limb ischemia (CLI).Between January 2005 and December 2010, patients undergoing hemodialysis who were treated with endovascular treatment of IPA were prospectively collected and evaluated with regard to demographics, clinical risk factors (including duration of hemodialysis), presentation of CLI, lesion type, target arteries, and treatment type. Follow-up was performed on clinical and duplex ultrasonographic evaluation at 1, 3, 6, and 12 months and annually thereafter. End points included technical success, limb salvage, primary and assisted patency, and survival and were calculated using the Kaplan-Meier method. Risk factors were analyzed by Fisher exact test for categorical data and the Mann-Whitney U test for nonparametric quantitative data.Thirty-nine patients (29 men; mean age: 70.6 ± 11 years) with 46 limbs and 91 target tibial arteries were treated. The mean duration of hemodialysis was 5.5 years. A trophic lesion was present in 95.7\% of the limbs. The intent-to-treat was made on 47 (51.6\%) tibial artery stenoses, 21 (23.1\%) obstructions

ObjectiveMajor postoperative complications such as stroke and myocardial infarction are usually carefully evaluated in the analysis of carotid revascularization performance. Although transient ischemic attacks (TIAs) are often left unreported, they also may influence long-term outcome. The aim of our study was to evaluate the influence of postoperative TIA in the long-term survival of patients submitted to carotid revascularization.MethodsAll consecutive patients submitted to either carotid artery stenting or carotid endarterectomy for symptomatic or asymptomatic carotid stenosis from 2005 to 2012 were retrospectively analyzed. Patients were stratified according to their postoperative (30-day) neurologic course (no symptoms, TIA, or stroke). Kaplan-Maier with log-rank analysis was performed to compare the 5-year survival of patients with postoperative TIA, stroke, or neither; factors affecting the 5-year mortality were evaluated by multivariable Cox proportional hazards models.ResultsOver a total of 1390 carotid revascularizations (carotid endarterectomy, n = 868 [62.4%]; carotid artery stenting, n = 522 [37.6%]), neurological perioperative complications occurred in 67 (4.7%) cases (38, 2.7% TIA; 29, 2.0% stroke). At 5-year follow-up, overall survival was significantly lower in patients with postoperative TIA (78.4 ± 8.0% vs 97.4 ± 0.6%; P < .001) and postoperative stroke (68.2 ± 14.4% vs 97.4 ± 0.6%; P = .03) compared with patients without neurological complications. By means of multivariate Cox analysis, postoperative TIA and stroke were independent predictors of decreased survival (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.01-9.72; P = .04, and HR, 3.87; 95% CI, 1.13-13.19; P = .03, respectively), other than age >80 years, postoperative myocardial infarction, and chronic renal failure (HR, 2.07; 95% CI, 1.41-4.90; P = .01; HR, 4.33; 95% CI, 2.74-23.79; P = .04; HR, 2.54; 95% CI, 1.04-6.19; P = .04, respectively).ConclusionsTIAs are significant events, possibly determined by a wider extent of atherosclerotic disease, with important effects on long-term mortality similar to that in strokes. Different from most trials evaluating the outcomes of revascularization techniques, the incidence of perioperative TIA should be accurately considered in the analysis.

Purpose To assess the influence of oral anticoagulant therapy conversion to heparin (OAT-CH) on carotid endarterectomy (CEA) outcomes and the influence of unmodified oral anticoagulant therapy (OAT) on carotid artery stenting (CAS) and to compare the outcomes of CEA in OAT-CH with CAS in ongoingOAT. Materials and Methods The 30-day results from all patients who underwent CEA and CAS in a 6-year period were analyzed for stroke, death, myocardial infarction (MI), and hematoma of the access site requiring surgical evacuation. We evaluated the influence of OAT-CH in CEA and the influence of OAT in CAS and compared CEA and CAS outcomes in patients receiving OAT-CH andOAT. Results Among 1,222 carotid revascularizations, there were 711 CEAs (58.1%) and 511 CAS procedures (41.9%). In the CEA group, 31 (4.4%) patients were treated with OAT-CH, and these patients had a significantly higher complication rate compared with patients not receiving OAT, including death (1 [3.2%] vs 4 [0.6%]; P = .04), stroke (4 [12.9%] vs 10 [1.4%]; P = .001), and hematoma (3 [9.6%] vs 11 [1.6%]; P = .02). In CAS, the results were similar in patients receiving OAT (30 [5.8%]) and patients not receiving OAT. Patients receiving OAT who underwent CAS had better outcomes than patients receiving OAT-CH who underwent CEA, including stroke, death, MI, and hematoma combined (0 [0.0%] vs 7 [22.5%]; P =.01). Conclusions OAT management significantly influences the results of carotid revascularization. Because CAS with unmodified OAT had a significantly better outcome than CEA with OAT-CH, carotid revascularization strategies should favor CAS rather than CEA in this setting.

Carotid endarterectomy (CEA) in the early period after the onset of cerebral neurologic symptoms seems to be useful in the prevention of recurrent stroke while safety is still under debate. Asymptomatic carotid artery stenosis could be associated with silent cerebral ischemic events (CIEs) detectable on cerebral computed tomographic (CT) scans, but is not clear if (or how) silent cerebral lesions could influence the outcome of CEA. The aim of our work was to analyze the outcome of CEA according to the timing and type of neurologic symptoms and to evaluate the outcome of CEA in asymptomatic patients with silent cerebral events detected with preoperative cerebral CT scans.Consecutive patients who underwent CEA between January 2006 and December 2010 were collected in a dedicated database and divided into a symptomatic group (with CEA performed within 2 weeks, 2-4 weeks, and 4-24 weeks after occurrence of the symptoms) and an asymptomatic group (with either positive-according to the classification of Stevens et al.-or negative preoperative cerebral CT scan) to evaluate the perioperative outcome in terms of CIEs, myocardial infarction (MI), and death. Results were compared using the chi-squared test, analysis of variance, and multivariate analysis.During the study period, 610 CEAs were performed, resulting in 16 (2.6\%) CIEs (10 [1.6\%] strokes and 6 [1.0\%] transient CIEs), 6 (1.0\%) MIs, and 3 (0.5\%) deaths. Symptomatic patients (n = 162; 22.6\%) were independently associated with a higher incidence of stroke and MI compared with asymptomatic patients (7 [5.1\%] vs. 3 [0.7\%]; P < 0.002; 2 [1.4\%] vs. 4 [0.9\%]; P < 0.02; respectively). The analysis of CEA outcome according to the timing of revascularization found no differences among groups within 2 weeks (5 [7.9\%]), 2-4 weeks (no events), and after 4 weeks (6 [7.4\%]); in the same manner, the type of preoperative symptom was not associated with significant differences in outcome. Preoperative positive cerebral CT scans were present in 88 (19.6\%) asymptomatic patients and were associated with a higher incidence of perioperative CIEs (7 [7.9\%] vs. 2 [0.5\%]; P = 0.001), transient CIEs (4 [4.5\%] vs. 2 [0.5\%]; P = 0.004), and stroke (3 [3.0\%] vs. 0 [0.0\%]; P = 0.001).Although symptomatic patients have a higher risk of perioperative complications compared with asymptomatic patients, early CEA after symptom onset does not influence the results. Asymptomatic patients with positive CT scans who undergo CEA have a higher rate of neurologic complications.

Introduction. High-sensitivity C-Reactive Protein (hsCRP) levels are correlated with vulnerable carotid plaques, although their impact on the outcome of carotid revascularization is unknown. The aim of our study was to investigate the correlation between hsCRP and embolization during carotid artery stenting (CAS). Methods. Patients with symptomatic carotid stenosis were submitted to CAS with distal protection filters. Serum hsCRP was analysed prior to CAS and patients were divided into two groups: Class I, patients presenting hsCRP

To evaluate the role of 3-projection completion angiography in defining endograft limb stenosis after endovascular aneurysm repair (EVAR) and to determine the role of adjunctive stenting in reducing the risk of endograft limb occlusion.In our center, stent-graft limb dilation was routinely done after endograft deployment in patients with preoperatively identified severe iliac axis angulation to reduce the incidence of limb stenosis. Completion angiography was then routinely performed in anteroposterior (AP) and 45° right and left oblique projections to identify perioperative endograft limb stenosis after the stiff guidewires were removed. Adjunctive stenting was used in iliac limbs with postangioplasty residual stenosis >50\%. From January 2005 to November 2010, 302 EVAR patients (296 men; mean age 74.25 ± 7.04 years, range 53-90) with 589 stent-graft limbs (aortomonoiliac stent-graft in 15 patients) who had a minimum 6 months of follow-up and a nonstenotic aortic bifurcation were selected for this study. Patient demographics, clinical risk factors, iliac anatomical features, procedure data, and limb patency were analyzed. Primary endpoints were the incidence of limb stenosis >50\% and any associated risk factors; the secondary endpoint was the primary patency of stent-graft limbs with adjunctive stenting.On 3-projection completion angiography, 40 (6.8\%) limbs presented limb stenosis and were treated with adjunctive stenting; in only 28 (70\%) of these cases was the >50\% limb stenosis evident on the AP view. According to the degree of preoperative iliac angulation, limb stenosis occurred in mild (50\%.

Introduction. Thalidomide has been associated with both venous and arterial thrombotic events.Case Presentation. A 66-years old man during thalidomide therapy for myeloma experienced acute right arm ischemia, emergently treated with thrombectomy and, on postoperative day one left side weakness with right internal carotid thrombosis.Discussion. Because of the increased risk of arterial thrombosis complication, prophylactic therapy with ASA or anticoagulation during thalidomide administration is mandatory.

Introduction The aim of this prospective observational registry was to study the outcome of symptomatic patients presenting with recent TIA or minor stroke and severe carotid stenosis, submitted to early percutaneous treatment by stenting. A secondary aim was to evaluate the biological activity of the symptomatic carotid plaques by serial serum and urinary markers (PAPP-A, hs-CRP, MMP-2/MMP-9, IL-6/IL-8, TNF alpha, CD40L) measured by enzyme-linked immunosorbent assay before and after treatment. Methods From May 2005 to June 2006, 57 patients were enrolled in this prospective registry. All patients underwent carotid stenting using a concentric filter for cerebral protection. The procedure was performed within 24–48hrs of the last attack in patients with TIA ( n =24, 42%) and between 14 and 30 days in patients with stroke ( n =33, 58%). Results Successful stent implantation was achieved in all cases (100%). Adverse events at 1 month were 1 death (1.7%) and 2 TIAs (3.5%). Some of the vulnerability markers, in particular those reflecting an active systemic inflammatory process of the plaque (PAPP-A, hs-CR, and IL-6), were significantly elevated at the time of enrolment, increased after stenting and decreased after 30 days. Conclusion Deferred CAS is feasible and safe in selected patients with symptomatic carotid stenosis. This preliminary study in a limited series of patients with unstable carotid plaques revealed that endovascular treatment has a satisfactory outcome considering the very high risk profile of the patient population. The evaluation of some biomarkers suggested an inflammatory role in the process of an unstable carotid plaque generating an acute cerebral event.

Objective To evaluate the peri-operative results of Anaconda™ endograft in the first 49 cases treated in a single centre. Methods The study was carried out prospectively on cases of infrarenal abdominal aortic aneurysm (AAA) treated with Anaconda™ endograft. The characteristics of the proximal aortic neck and of the iliac access vessels were considered. The following operative results were assessed: the main body oversizing, the need to correct the positioning of the main body, the use of iliac extensions, the use of ballooning, the covering of patent hypogastric arteries, the presence of endoleaks and the need for conversion. Peri-operative (30 days) mortality and morbidity were also considered. Results Of the 49 cases treated, 44 were males with a mean age of 73 years (range: 55–89 yrs; SD ± 7 yrs). The mean diameter of the AAA was 56 mm (range 45–91 mm; SD ± 11); 4 cases had common iliac aneurysms with a diameter >3 cm. The mean neck diameter and length were 23 mm (range 19–28 mm; SD ± 3) and 25 mm (range 15–50 mm; SD ± 10) respectively. An aortic neck angle between 40° and 70° was present in 10 cases (20%) (mean 58°; SD ± 15°), and 20 cases (41%) had iliac tortuosity with an angle greater than 60° (mean 85°; SD ± 25°). There were no cases of conversion or intra-operative death. One (2%) peri-operative death occurred, for reasons not related to the endograft. There were two cases of iliac limb thrombosis. CT at one month showed 12 cases (25%) of type II endoleak. There were no cases of type I or type III endoleaks. Conclusions The preliminary data of this series demonstrates that the Anaconda™ endograft has good peri-operative results in the treatment of infrarenal AAAs with a neck length not less than 15 mm.

BMJ Publishing Group Limited 2004

Objectives. In order to confirm a possible link, suggested by a recent study, between atherosclerosis and tympanosclerosis, and which could theoretically open new frontiers in the early diagnosis of vascular atherosclerotic diseases starting from a rather simple and rapid examination such as otoscopy, we further investigated this hypothesis in a population affected by atherosclerotic disease of the carotid artery. Material and Methods. Fifty patients submitted to carotid endoarteriectomy were examined. Previous otologic diseases and otosurgical procedures had been excluded. The presence of tympanosclerosis was defined if 20% of the eardrum at least appeared interested by tympanic plaques. The study group was compared to a sex and age matched control group randomly chosen inside our hospital with a negative history for vascular and otologic diseases. Results. Tympanosclerosis was observed in 18/50 patients (36%) of the study group compared to 6/50 cases of the control group (12%). This difference was statistically significant (p= 0.005). In both groups the incidence of this finding was similar in both sexes. Conclusions. Our results confirm the reported analogies between tympanosclerosis and atherosclerosis. Although further investigations are needed, promising implications may be supposed in the diagnostic and therapeutic evaluation of this kind of ear patients.

Objective: Factors influencing the choice between endovascular (endovascular aneurysm repair, EVAR) and open repair (OPEN) of abdominal aortic aneurysm (AAA) are of increasing interest. We quantified their importance among the different subjects involved in the treatment. Methods: Pre- and postoperative patients (pts), their relatives and vascular surgeons completed questionnaires evaluating six treatment characteristics: anaesthesia; recovery time to basic everyday activities; risk of re-intervention at 5 years (RR); complexity of follow-up; risk of major complications; and additional cost of intervention (AC). Through a discrete choice experiment, hypothetical scenarios of treatment were obtained and the relative importance (RI) of each characteristic was determined through a conditional logistic regression model. Results: A total of 160 pts, 102 relatives and 30 surgeons from nine centres completed the questionnaires. Major complications and re-intervention risk were the most important characteristics (RI = 56.0% and 27.2%, respectively) for all the respondent categories. Pts and their relatives considered very important also a possible out-of-pocket AC. Recovery time and type of anaesthesia were among the least important characteristics, including hospital additional cost for surgeons. The different categories of respondents showed different opinions towards different treatment characteristics depending also on possible previous treatment. Conclusion: Preferences for AAA treatment characteristics differ between groups of involved subjects. Understanding individuals' preferences could help in optimising treatment benefits. © 2011 European Society for Vascular Surgery.

Spinal cord ischemia is a rare but catastrophic complication after endovascular treatment of infrarenal aortic aneurysm: only 14 cases are reported in the literature. A patient with a 6 cm infrarenal aortic aneurysm extending to both common iliac arteries and high surgical risk was submitted to endovascular repair with exclusion of both hypogastric arteries and surgical revascularization of the right hypogastric artery. The patient presented paraplegia, apallesthesia and superficial hyposensitivity immediately after the procedure. A spinal cord drainage was positioned with little improvement of superficial sensitivity. We undertook a systematic review of the literature on this topic.