Search

Background Isolated post dissection infrarenal and iliac aneurysm is a rare condition that often requires surgical treatment. Surgical repair should involve the replacement of the aneurysmal segments and a wide fenestration in the residual proximal untreated abdominal aorta. However, in these patients proximal aortic clamping may be challenging. Indeed, infrarenal clamping may hamper an appropriate fenestration in the proximal dissecting lamella, and suprarenal or supraceliac clamping can be dangerous and highly demanding, especially in acute and subacute patients. Here we report our initial experience with a balloon endoclamping technique. Material and Methods Our technique includes 1) direct aortic true lumen catheterization, 2) balloon endoclamping of the proximal thoracic aorta, 3) wide fenestration of the infrarenal aorta followed by external clamp positioning, 4) infrarenal aorta and iliac artery reconstruction. Results Between October 2018 and November 2019, 4 patients (male n = 4, median age 57 years) underwent postdissection iliac aneurysm repair in our institution. All patients had previously undergone emergent thoracic aorta repair. Postoperative courses were uneventful in all cases. At a median FU of 13 months, all patients remain well, with stable diameters in visceral aorta. Conclusions In our initial experience, proximal aortic endoclamping appeared to be a safe technique associated with promising results. This approach may facilitate proximal aortic clamping and allow for a wide aortic fenestration. Further larger clinical trials are needed to validate our preliminary observations.

The aim of this study was to evaluate the long-term outcomes of endovascular aneurysm repair with flared iliac limb grafts in patients with abdominal aortic aneurysm (AAA) and aneurysmal common iliac arteries (CIAs).This is a multicenter, retrospective, observational cohort study that involves four tertiary referral hospitals between May 1, 2005, and April 30, 2019. Primary outcomes were freedom from aneurysm-related mortality (ARM), and freedom from iliac-related reintervention.We studied 995 aneurysmal iliac limbs in 795 (85.2%) patients who met the inclusion criteria. Median AAA diameter was 55mm (IQR: 51-60). Early mortality occurred in 3 (0.4%) patients. The median of follow-up time was 52 months (IQR: 26-88). Estimated freedom from ARM was 99±0.002% (95% CI: 99-99.9) at 1 year, and 99±0.004% (95% CI: 97.9-99.6) at 5-years. Chronic obstructive pulmonary disease (HR=6.4, 95% CI: 1.7-24.0, P=0.006), chronic kidney disease (HR=5.5, 95% CI: 1.4-21.9, P=0.016), and the presence of an aneurysmal left CIA (HR=5.3, 95% CI: 1.0.5-27.4, P=0.044) was associated with ARM. There were 42 (7.3%) late iliac-related events (limb occlusion, N.=5; iliac-related endoleaks, N.=37). Estimated freedom from iliac-related reintervention was 98±0.003% (95% CI: 97-99) at 1 year, and 95±0.01% (95% CI: 92.7-96.7) at 5-years, which was associated with an aneurysmal right CIA (HR=2.2, 95% CI: 1.3-3.9; P=0.005), and age ≥78 years (HR=1.9, 95% CI: 1.01-1.3; P=0.039).EVAR flared iliac limb grafts showed a high rate of freedom from ARM and a low reintervention rate. Owing to these results, it can be a durable and stable alternative for patients aged78 years.

Complex aortic pathology still represents an open issue in contemporary endovascular management, with continuous technological advancement being introduced in practice over time aiming to improve outcomes. Thus far, the dualism between the fenestrated and branched configuration for visceral artery revascularization is yet unsolved, with each approach having its own pros and cons. The inner branched technology for endovascular aneurysm repair (iBEVAR) aims to take the best out of both strategies, offering wide applicability and stable bridging stent sealing. The objective of this study was to evaluate the early outcomes obtained with a single manufacturer custom-made inner-branched endograft in a multicenter Italian experience.All patients consecutively treated with E-xtra design devices in three Italian facilities were enrolled. Anatomic characteristics and perioperative data were analyzed. The main objective was to asses technical and clinical success after iBEVAR. Secondary end points were overall survival, aortic-related mortality, target visceral vessel (TVV) patency, and freedom from target vessel instability during follow-up.From 2016 to 2021, 45 patients were treated with an E-xtra design device revascularizing at least one visceral vessel through an inner branch. The mean age at the time of the procedure was 71.1 ± 9.3 years and 77.8% were males. The total number of target visceral arteries to be bridged with an inner branch was 159. The extent of aortic repair was thoracoabdominal in 91.1% of the cases. Technical success was achieved in 93.3% of the procedures (42/45) with all failures owing to a type I endoleak at final angiography. Each TVV was successfully connected to the graft's main body as planned without complications. Following their intervention, five patients developed spinal cord ischemia and in three of these cases symptoms persisted after discharge (6.7%). At 30 days clinical success was 93.3% (42/45). No death as well as no TVV thrombosis occurred within 30 days from the primary procedures. The mean follow-up was 22.8 ± 14.2 months. The Kaplan-Meier estimate of overall survival and TVV patency at 36 months were 83.9% and 95.9%, respectively.Inner branches seem to be a promising technology in the complex aortic repair landscape, with an applicability ranging from type II thoracoabdominal aneurysm to type I endoleak repair after infrarenal endografting. Whether iBEVAR could offer results comparable with those provided by fenestrated/branched endovascular aneurysm repair in terms of target vessel patency and stent stability is yet to be established and further studies are, therefore, needed.

Background: This guideline (GL) on carotid surgery as updating of "Stroke: Italian guidelines for Prevention and Treatment" of the ISO-SPREAD Italian Stroke Organization-Group, has recently been published in the National Guideline System and shared with the Italian Society of Vascular and Endovascular Surgery (SICVE) and other Scientific Societies and Patient's Association. Methods: GRADE-SIGN version, AGREE quality of reporting checklist. Clinical questions formulated according to the PICO model. Recommendations developed based on clinical questions by a multidisciplinary experts' panel and patients' representatives. Systematic reviews performed for each PICO question. Considered judgements filled by assessing the evidence level, direction, and strength of the recommendations. Results: The panel provided indications and recommendations for appropriate, comprehensive, and individualized management of patients with carotid stenosis. Diagnostic and therapeutic processes of the best medical therapy, carotid endarterectomy (CEA), carotid stenting (CAS) according to the evidences and the judged opinions were included. Symptomatic carotid stenosis in elective and emergency, asymptomatic carotid stenosis, association with ischemic heart disease, preoperative diagnostics, types of anesthesia, monitoring in case of CEA, CEA techniques, comparison between CEA and CAS, post-surgical carotid restenosis, and medical therapy are the main topics, even with analysis of uncertainty areas for risk-benefit assessments in the individual patient (personalized medicine [PM]). Conclusions: This GL updates on the main recommendations for the most appropriate diagnostic and medical-surgical management of patients with atherosclerotic carotid artery stenosis to prevent ischemic stroke. This GL also provides useful elements for the application of PM in good clinical practice.

An 85-year-old woman came to our emergency department because of back pain and dysphagia that started a few hours before. As relevant in history, the patient had an active follicular lymphoma treated with bendamustine (90 mg/m2 every 28 days up to three cycles). A saccular aneurysm of the upper wall

Situs inversus totalis (SIT) refers to a mirror-image reversal of the internal organ position. The coexistence of abdominal aortic aneurysm and SIT is extremely rare; very short series have been reported; therefore its prevalence has never been estimated. The presence of anatomical anomalies could increase operative risk. The authors describe a case of successfully repaired pararenal abdominal aortic aneurysm with a right retroperitoneal approach in situs inversus totalis.

Background Endovascular abdominal aortic aneurysm repair (EVAR) is considered the primary option for abdominal aortic aneurysm but the management of concomitant wide or aneurysmal iliac arteries (CIAs) is still controversial. Methods We retrospectively evaluated mid-term results of patients receiving standard EVAR combined with bell-bottom technique (BBT) using Medtronic Endurant endograft between January 2009 and December 2018. Patients were followed up by CT scan performed 1 month after the procedure and by duplex ultrasound annually (with or without contrast medium) followed by CT scan in case of evolution. Results Seventy-one patients (67 males; mean age of 77,1 years) with abdominal aortic aneurysm and wide or aneurysmal common iliac artery (distal landing zone diameter up to 25 mm and length more than 20 mm) were treated with standard EVAR and BBT (107 limbs) using Endurant stent graft. The median aortic diameter was 56,1 mm (31.0-85.0). Technical success was obtained in 100%. Mean procedural time was of 100.1 min. No 30 days’ mortality, renal failure or limb ischaemia occurred. The median follow-up was of 36.56 months (1–136). 5-year aneurysm related mortality was not found. At 5 years, the number of all-cause deaths was seven. The freedom from secondary intervention was 91.6% at 5 years. Three patients (4.4%) were treated for iliac related complications at 5 years: internal iliac artery aneurysm, iliac obstruction, type 1b endoleak, all successfully treated by endovascular technique. Conclusions According with this study BBT using Endurant stent graft is effective and safe with good mid-term results, with low rate of iliac related complications and no aneurysm related mortality.

High-grade carotid stenosis can affect cognition, but the relationship between stenosis correction and cognitive outcome is not fully understood, yet. The aim of this study was to evaluate the predictors of post-operative neurocognitive functioning in patients with symptomatic severe internal carotid artery (ICA) stenosis undergoing carotid endarterectomy (CEA).Patients with history of transient ischemic attack within the past 6 months and ipsilateral high-grade stenosis of ICA undergoing CEA were prospectively enrolled. Cerebral hemodynamics was assessed by means of the cerebral vasomotor reactivity (CVR) to hypercapnia measured through transcranial Doppler ultrasonography. Coloured Progressive Matrices plus Complex Figure Copy Test, and phonemic plus categorical (ca) Verbal Fluency tests were performed to assess right and left hemisphere cognitive functions, respectively. Cerebral hemodynamics and cognitive functions were assessed before and 6 months after CEA.One hundred and eighty-one patients were included. The mean age was 73.2 (6.9) years and 121 (66.9%) were males. At 6 months from CEA, the scores obtained in the cognitive tests exploring the re-vascularized hemisphere's functions and ipsilateral cerebral hemodynamics were improved. At multivariate linear regression analysis, the 6-month change in cognitive performance was inversely associated with age [ß = -0.17, 95% confidence interval (CI) -0.22 to -0.12; p .001] and CVR value obtained before CEA on the side of ICA stenosis (ß = -6.25, 95% CI -7.40 to -5.10; p .001).In patients with symptomatic high-grade ICA stenosis, age and cerebral hemodynamic status before CEA predicted the neurocognitive performance changes after surgical stenosis correction.

Background Catastrophic events have been correlated to increased incidence of cardio-vascular events, but no correlation between RAA and seismic activities have ever been investigated. Methods Hospital admissions related to RAA between January 2014 and December 2016 were retrospectively assessed in nine vascular centers of central Italy and correlated with date-matched seismic events. Correlation between RAA presentation and seismic event was first evaluated by Linear Regression analysis. Incidence of RAA events, mortality rate, and type of intervention were analyzed during seismic days (SD) and compared to outcomes during non-seismic days (nSD). Results A total of 376 patients were admitted with a diagnosis of RAA, and a total of 783 seismic events were reviewed. Twenty patients died before intervention (untreated). Open surgery was performed in 72.8%, endovascular treatment in 27.2%. General mortality at 30 days was 26.6% (30.5% for open surgery; 21.6% for endovascular treatment; P=0.24). Linear regression analysis between RAA and seismic periods revealed a significant correlation (slope=0.11±0.04, equation: y = 0.1143 x + 3.034, P=0.02). Incidence of RAA was 0.34 event per day during the entire period, 0.32 during nSD and 0.44 during SD (P=0.006). During seismic days, patients with RAA were older (80.5 years during SD vs. 77 years during nSD, P=0.12), were in poorer general condition at admission and remained untreated more frequently (8% SD vs. 4.7% nSD, P=0.3), and had a higher mortality rate at 30 days (46.2% SD vs. 27.2% nSD, P=0.012). Conclusions During seismic days, the incidence of RAA is higher in comparison to non-seismic days. Patients with rupture during seismic days have a higher risk of death.

Background In vascular surgery with aortic cross-clamping, ischemia/reperfusion injury induces systemic haemodynamic and microcirculatory disturbances. Different anaesthetic regimens may have a varying impact on tissue perfusion. The aim of this study was to explore changes in microvascular perfusion in patients undergoing elective open abdominal aortic aneurysm repair under balanced or total intravenous anaesthesia. Methods Prospective observational study. Patients undergoing elective open infrarenal abdominal aortic aneurysm repair received balanced (desflurane + remifentanil, n = 20) or total intravenous anaesthesia (TIVA, propofol + remifentanil using target-controlled infusion, n = 20) according to the clinician’s decision. A goal-directed haemodynamic management was applied in all patients. Measurements were obtained before anaesthesia induction (baseline) and at end-surgery and included haemodynamics, arterial/venous blood gases, sublingual microvascular flow and density (incident dark field illumination imaging), peripheral muscle tissue oxygenation and microcirculatory reactivity (thenar near infrared spectroscopy with a vascular occlusion test). Results The two groups did not differ for baseline characteristics, mean aortic-clamping time and requirement of vasoactive agents during surgery. Changes in mean arterial pressure, systemic vascular resistance index, haemoglobin and blood lactate levels were similar between the two groups, while the cardiac index increased at end-surgery in patients undergoing balanced anaesthesia. The sublingual microcirculation was globally unaltered in the TIVA group at end-surgery, while patients undergoing balanced anaesthesia showed an increase in the total and perfused small vessel densities (from 16.6 ± 4.2 to 19.1 ± 5.4 mm/mm2, p

We treated an 89-year-old patient affected by a descending thoracic aorta lesion due to a rib fracture with a penetrating costal stump. An urgent combined thoracic and endovascular surgical approach was performed, removing the rib fragment and positioning an aortic endoprosthesis simultaneously. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage or periaortic hemorrhage.

ObjectiveTo evaluate in patients with TIA and ipsilateral high-grade internal carotid artery (ICA) stenosis whether changes in cognitive performance and cerebral hemodynamics occurred after carotid endarterectomy (CEA) and to explore their relationship.MethodsParticipants were patients who underwent CEA, had TIA within the last 6 months, and had an ipsilateral severe ICA stenosis. Coloured Progressive Matrices (CPM) plus Complex Figure Copy Test (CFCT) and phonemic (ph) plus categorical (ca) Verbal Fluency (VF) tests were performed to assess right and left hemisphere cognitive functions, respectively. Hemodynamics was assessed with transcranial Doppler ultrasonography by means of the cerebral vasomotor reactivity (CVR) to hypercapnia.ResultsA total of 137 patients were included. Before CEA, patients with right ICA obtained lower scores on the CPM and CFCT; patients with left ICA stenosis performed worse on the phonemic and categorical VF tests. The CVR was decreased on the side of the stenosis. At 6 months from CEA, CVR and cognitive performance were significantly improved. The performance change in cognitive tests exploring the revascularized hemisphere was positively associated with the ipsilateral CVR variation (CPM: R2 for linear regression = 0.759, adjR2 = 0.737; CFCT: R2 = 0.734, adjR2 = 0.710; (ph)VF: R2 = 0.774, adjR2 = 0.749; (ca)VF: R2 = 0.732, adjR2 = 0.703).ConclusionCognitive performance was enhanced at 6 months since CEA, and the improvement was related to the CVR increase. Cerebral hemodynamics may be an independent and potentially reversible determinant of cognitive dysfunction in severe carotid artery disease.

Coral reef aorta (CRA) is a rare condition featured by rock-hard calcifications that grow into the lumen of the thoracoabdominal aorta. Patients suffering from CRA may present severe downstream ischemic and embolic events involving the viscera and the lower limbs. In these patients, open surgical repair is the first choice of treatment. We present a case of a 70-year-old woman with acute presentation of bilateral limb ischemia and abdominal pain. An angio-computed tomography (CT) scan showed the subocclusion of the distal thoracic aorta due to a severe calcified coarctation with intraluminal thrombosis, a chronic occlusion of the superior mesenteric and celiac trunk arteries, a hypertrophic inferior mesenteric artery associated with signs of partial left kidney ischemia. The patient underwent urgent endovascular repair. A soft dilatation of the coarctation using a 7-mm noncompliant balloon was initially performed; a 21-mm conformable thoracic stent graft was subsequently deployed and increasingly dilated using progressively larger angioplasty balloons. The procedure was uneventful and the aortic gradient was reduced to zero. A postoperative CT scan revealed the proper deployment of the graft with no residual stenosis. Endovascular approach with the covered thoracic stent graft could be an accurate technique to treat CRA in the emergency setting. It allows for a primary protected balloon angioplasty and, in case of aortic-graft recoiling, a subsequent placement of covered or uncovered balloon-expandable stent graft can be safely and easily performed.

We treated a 73-year-old female patient with a giant thoracic proximal aortic aneurysm above a previous multibranched thoracoabdominal graft without a distal neck for a standard endovascular approach. A procedure with sandwich technique was performed using the new Valiant Navion Evo Thoracic Endograft® to preserve visceral graft. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage with patency of visceral graft.

Objectives: The treatment of deep vein thrombosis (DVT) of the lower limbs during pregnancy remains controversial. There are a lot of problems related to anticoagulant therapy for the safety of the fetus; the use of caval filters rarely appears in the literature and it is not yet codified. So the choice of the right treatment is often difficult. The authors review their experience with a prophylactic use of a temporary caval filter for patients with proximal DVT of the last period of pregnancy, in order to avoid the inherent risk of major pulmonary embolism during delivery and postpartum. Methods: Ten women with proximal DVT were treated. The diagnosis was performed by Doppler ultrasonography (DU) and magnetic resonance (MR). At the end of pregnancy, a temporary caval filter (eight Prolyser and two Tempofilter) was percutaneously inserted under X-ray control. The patients were then subjected to a planned caesarean section. After 15 days, all filters were removed after a phlebography to check the absence of clots. Results: The mean time of X-ray exposure was about 1 min and 30 s. None of the patients suffered a major pulmonary embolism. All fetuses were born without problems or malformations. There were no complications related to the filters. No caval thrombosis or filters clots were found at the phlebography. The follow-up registered no pulmonary embolism episodes. Conclusions: The use of a temporary caval filter in pregnancy is safe and does not introduce any additional risk. It could be suggested for pregnant patients with proximal DVT beginning in the last period of pregnancy.

IntroductionAneurysmal degeneration of autologous saphenousvein (ASV) used in femoro-distal revascularization isa fairly frequent but not always predictable event andinvolves a high risk of thrombosis of the bypass itself.Treatment involves repair, removal and replacementor endovascular treatment. If replacement is necessaryfor revascularization with the distal anastomosisbelow the knee, results with heterologous grafts aredisappointing. More favourable results can beachieved with cryopreserved homologous veins(CHV) or arterial allografts.

Our aim in this observational, prospective, noncontrolled study was to detect, in 29 patients who underwent abdominal aortic aneurysm (AAA) surgery, correlations between the incidence of postoperative organ failure and intraoperative changes in arterial and portal blood lactate; changes in intramucosal sigmoid pH (pHi); differences between sigmoid Pco(2) and arterial Pco(2) (DeltaCO(2)); and hemoglobin (Hb). Hb, arterial blood lactate concentrations, pHi, and DeltaCO(2) (air tonometry) were recorded at the start of anesthesia (T0), before aorta clamping (T1), 30 minutes after clamping (T2), and at the end of surgery (T3). Portal venous lactate concentrations were recorded at T1 and T2. Patients were stratified into two groups: group A patients had no postoperative organ failure, and group B patients had one or more organ failures. As compared with group A (n = 16), group B patients (n = 13) had a lower pHi value at T2 and T3 and a higher DeltaCO(2) at T3. A pHi value of7.15 was a predictor of organ failure, with a sensitivity of 92.3%, a specificity of 68.8%, and positive and negative predictive values of 70.6% and 91.7%, respectively, whereas a DeltaCO(2) value of28 mm Hg predicted later organ failure with a sensitivity of 92.3%, a specificity of 62.5%, and positive and negative predictive values of 66.6% and 90.9%, respectively. Portal venous lactate concentrations were larger in group B at T2 (P0.001), and an increaseor=5 g/dL predicted later postoperative organ failure with a sensitivity of 92.3%, a specificity of 100%, and positive and negative predictive values of 100% and 94.1%, respectively. The comparison of the receiving operator characteristic curves to test the discrimination of each variable and the logistic regression analysis revealed that the increase in portal lactate was the best predictor for the development of postoperative organ failure. Hb concentration was significantly smaller in group B at T0 (13.8 +/- 1.0 g/dL versus 12.2 +/- 2.2 g/dL) and T2 (10.9 +/- 1.2 g/dL versus 9.1 +/- 1.9 g/dL). In conclusion, both pHi and DeltaCO(2) are reasonably sensitive prognostic indices of organ failures after AAA surgery, but they are less specific and accurate than portal venous lactate.

Extracranial carotid artery aneurysm is a rare condition with relatively significant morbidity and mortality. When surgery is not indicated, endovascular techniques are emerging as the preferred treatment. However, even this approach may be contraindicated due to anatomic factors. We present a case of a high-lying extracranial carotid artery aneurysm with challenging anatomy unsuitable for conventional or endovascular repair. After resecting the aneurysm, the carotid artery was revascularized using the new Gore Hybrid Vascular Graft (W. L. Gore & Associates, Flagstaff, Ariz). This straightforward procedure turned out to be safe and further reduced the cerebral ischemic time.