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Background: Identifying sex-related differences/variables associated with 30-day/1-year mortality in patients with chronic limb-threatening ischemia (CLTI). Methods: Multicenter/retrospective/observational study. Database sent to all-the-Italian vascular surgeries to collect all-the¬-patients operated for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot not included. Follow-up: 1-year. Data on demographics/comorbidities, treatments/outcome, and 30-day/1-year mortality investigated. Results: Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) yrs for men/women, respectively (p75 (HR3.63, p=.003) associated with 30-day mortality. Age >75 (HR2.14, p

We report on a case of severe cystic adventitial disease involving the popliteal artery in a man aged 42, who in 2009 underwent surgical resection of the cyst and the tract of the involved artery. The arterial reconstruction was then performed with an autogenous graft, using a reversed small saphenous vein interposition. The surgical specimen was histologically examined. The postoperative course was uneventful, and the patient was discharged on the 8th day. Currently, on an 11-year long clinical follow-up, the patient is healthy, and the graft is patent. A pictorial essay of the clinical and pathological findings of the case is presented, along with a brief discussion covering the main issues relevant to the disease manifestations and diagnosis, clinical differential diagnoses, and the treatment options. The pertinent world literature has been reviewed as well.

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study conducted through cross-sectional survey. Each received a 13-point questionnaire, investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs 2019 (9161 patients): post-EVAR surveillance, treatment for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased [1484 (16.2%) vs 1014 (14.3%), p=0.0009; 1401 (15.29%) vs 959 (13.52%), p=0.0006; and 1558 (17.01%) vs 934 (13.17%), p

Purpose: Common femoral artery (CFA)-occlusive disease has traditionally been treated with open surgery, yet nowadays the frailty of patients has induced to find new techniques of revascularisation by endovascular means. So far, intravascular lithotripsy (IVL) has shown promising results in several lower limbs arterial districts. The purpose of this article is to report our experience with IVL for severely calcified peripheral arterial disease (PAD) of the CFA. Methods: From November 2018 and October 2020, 10 consecutive patients (12 limbs) treated with IVL were prospectively enrolled in a dedicated database. Inclusion criteria were CFA localization of PAD, with a severe degree of calcification, a lesion length ≥10 mm, and a degree of stenosis ≥70% (severe). The only admitted adjunctive treatment was drug-coated balloon (DCB) angioplasty. Primary outcomes were technical and procedural success, clinical success, and target lesion revascularisation (TLR). Secondary outcomes were target extremity revascularisation (TER) and major adverse events (MAEs). Results: All patients underwent IVL with associated DCB angioplasty. The median percentage of achieved stenosis reduction was 55.5% (interquartile range [IQR] 50-60.75), with a technical and procedural success of 100%. Over the study period, TLR only occurred in one limb (8.3%), with a mean upgrade in Rutherford class of 2.7 ± 0.77. No target vessel and access site complications were reported, as well as no distal embolization. One death and one major amputation occurred over the follow-up period, both in the same patient. Conclusions: Based on our experience, IVL for selected cases of severely calcified CFA disease, associated with DCB angioplasty, may be considered a safe and effective technique. Of course, a long-term follow-up and a larger series of patients are needed to validate our results.

Chimney/snorkel endovascular aneurysm repair (Ch-EVAR) enables the minimally invasive treatment of abdominal aortic aneurysm in anatomically challenging and high-risk surgical cases. Here, we present the case of a 77-year-old man with an abdominal aortic aneurysm associated with crossed fused renal ectopia and an ectopic renal artery arising directly from the aneurysm sac. After successful implementation of Ch-EVAR, computed tomography angiography at 18 months revealed no endoleaks, patency of the parallel graft, and normal renal vascularization and function. This report underscores the feasibility of Ch-EVAR in a case with high anatomic complexity. Keywords: Abdominal aortic aneurysm, Chimney endovascular aneurysm repair, Crossed fused renal ectopia

Objectives This study describes our experience of total laparoscopic juxtarenal abdominal aortic aneurysm (JAAA) repair. Methods Between February 2002 and October 2007, we performed 148 total laparoscopic AAA repairs, including a subset of 13 patients who underwent a laparoscopic JAAA repair. Median age was 70 years (range, 50-81years). Median aneurysm size was 55 mm (range, 50-80 mm). Eight patients were in American Society of Anesthesiologist class II, and five were in class III. We used laparoscopic transperitoneal left retrorenal approaches and suprarenal clamping in all patients. Results We implanted tube grafts in nine patients and bifurcated grafts in four. No conversions to open repair were required. Median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). No patients died. One patient had a postoperative coagulopathy with hemorrhagic syndrome. Five patients had moderate systemic complications, including four renal insufficiencies without dialysis and one grade I ischemic colitis. Liquid diet was reintroduced after 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days). Median lengths of stay were 48 hours (range, 12-336 hours) in the intensive care unit and 10 days (range, 4-30 days) in the hospital. With a median follow-up of 19 months (range, 1-36 months), patients had complete recovery without graft anomalies. Conclusion Total laparoscopic JAAA repair is feasible and worthwhile for patients. Prior experience in laparoscopic aortic surgery is essential to perform these challenging procedures. Despite these encouraging results, a greater experience is required to ensure the benefit of this technique compared with open repair.

En todas las disciplinas, la cirugia videoscopica implica: una vision del campo quirurgico en dos dimensiones, la ausencia de sensacion tactil y una instrumentacion especifica Los cirujanos integran enseguida la vision bidimensional a medida que adquieren experiencia. Las principales dificultades surgen durante las suturas arteriales. La ausencia de sensacion tactil dificulta en gran medida la realizacion de los distintos tiempos quirurgicos. En las vias de acceso a la aorta abdominal, el cirujano debe orientarse solo en funcion de los planos y de las referencias anatomicas. Ya no es posible dirigir la diseccion hacia los troncos arteriales ayudandose de la palpacion de las estructuras y, sobre todo, de la palpacion de los latidos arteriales. Al contactar con los troncos arteriales, el cirujano no tiene el mismo control de las zonas de calcificacion o de fragilidad de la pared arterial antes de realizar los pinzamientos y las anastomosis. Otra especificidad del acceso aortico mediante videoscopia es la utilizacion de una tecnica para mantener la exposicion porque, al contrario de la cirugia tradicional, no se dispone de separadores o de valvas para mantener la masa visceral. En noviembre de 2000, los autores de este articulo desarrollaron una tecnica nueva totalmente videoscopica para el tratamiento de las lesiones oclusivas aortoiliacas (LOAI) graves. A partir de esta experiencia, se ha desarrollado el tratamiento totalmente videoscopico de los aneurismas de la aorta abdominal (AAA). La cirugia videoscopica de los AAA consta de dos etapas tecnicas esenciales: la exposicion de la aorta abdominal seguida del desbridamiento-injerto.

PurposeThis study was designed to identify differences in the per- and postoperative outcomes between total laparoscopic and open surgical repair of abdominal aortic aneurysms (AAA).MethodsWe reviewed 30 patients who underwent total laparoscopic AAA repair between July 2003 and December 2004 (group I). This group was matched in a case-control fashion by AAA morphology and American Society of Anesthesiologists class with a group of 30 patients who underwent conventional AAA repair between April 1997 and May 2004 (group II). Proportions and categoric data were compared with a χ2 test. Continuous data were compared with a Mann-Whitney test.ResultsThe two groups had comparable characteristics of age and cardiovascular risk factors. The number of tube and bifurcated grafts was 13 for group I and 17 for group II. Median operative time was 255 minutes (range, 170 to 410 minutes) in group I and 200 minutes (range, 130 to 410) in group II (P

An extra-anatomic bypass initiating from the ascending aorta, namely the ventral aorta, is a possible alternative for lower limb revascularization. However, acceptance of this technique is limited by the need of a median sternotomy and clamping of the ascending aorta. We report a new technique for the ventral aorta using a total videoscopic approach of the ascending aorta, which avoids the need for a median sternotomy. We discuss the advantages and perspectives of this new approach.

The primary difficulties with laparoscopic infrarenal aortic surgery are the exposure of the abdominal aorta and the performance of laparoscopic anastomoses. With training in videoscopic sutures, performance of laparoscopic anastomoses is possible. Sutureless anastomotic devices or Robot-assisted sutures are also promising techniques for the performance of laparoscopic anastomoses. Stable exposure of the abdominal aorta remains essential to perform total laparoscopic aortic repair. Laparoscopic transperitoneal left retrocolic approach allows a stable and reproducible aortic exposure during the performance of laparoscopic repair for abdominal aortic aneurysm (AAA) and aorto-iliac occlusive disease (AIOD). However, the left retrocolic approach is not always possible or could be difficult. In these cases, we use a transperitoneal left retrorenal approach.

We report our initial experience with total laparoscopic repeat aortic surgery between June 2002 and October 2003. There were 4 patients, 3 men and 1 woman, ages 83, 67, 49, and 61 years, respectively. First operations were performed to treat aortoiliac occlusive disease. Repeat aortic surgery was indicated to treat para-anastomotic aneurysms (n = 2) and graft occlusion (n = 2). All patients underwent total laparoscopic surgery. There were no postoperative deaths. Only 1 patient had postoperative complications that required complementary surgical treatment. All patients were alive with patent revascularization after a mean follow-up of 14, 17, 20, and 12 months, respectively.

Laparoscopy is a minimally invasive alternative for type II endoleak repair after endovascular aneurysm repair. However, control of lumbar and median sacral arteries is considered technically difficult due to the dense inflammatory tissue surrounding the aorta. We describe a technical tip that avoids close dissection of the aneurysm sac. After the transperitoneal approaches we commonly use during laparoscopic aortic surgery, the aneurysm is drawn rightward to access the plane of the anterior longitudinal ligament. This technique allows a direct exposure of the lumbar and median sacral arteries, which are all methodically dissected and ligated along the anterior wall of the spine without close dissection of the aneurysm sac. In our experience, this technical tip was always feasible and simplified laparoscopic type II endoleak repair.

Herein, we report a 26-year-old patient with lymphangiomatosis of the spleen associated with multiple lymphatic and venous malformations. This patient underwent excision of a large lymphatic malformation of the left abdominal wall during childhood. A venous malformation of her left lower limb was excised during adolescence. Additional lymphatic malformations were found in the soft tissue of her left thigh at the age of 20. During hospitalization for a huge vulvar hemangioma at the age of 26, she was incidentally found to have asymptomatic splenomegaly, for which she underwent splenectomy. Examination of the spleen revealed diffuse involvement by a lymphatic anomaly predominantly forming small cystic spaces. Lymphangiomatosis of the spleen is rare and is classically separated into an isolated or pure form and a generalized form when it is associated with involvement of other viscera and/or multiple soft-tissue planes. This patient was affected by a borderline form of splenic lymphangiomatosis with limited somatic involvement of the superficial soft tissues and blood vessels. Notably, all the additional vascular malformations in this patient were left sided, and at this time there was no additional involvement of internal organ. No hereditary or known syndrome was identified.

Vascular complications after liver transplantation are relatively rare. Thrombosis of the host-transplant arterial anastomosis is the most frequently encountered vascular complication whereas only a few observations of infected anastomotic aneurysms, often leading to death by massive bleeding or loss of the transplant, have been reported. We report herein the case of a patient with an infected false anastomotic aneurysm of the hepatic artery associated with dissection of the celiac artery following orthotopic liver transplantation in a 35-year-old man who had received a liver transplantation for end-stage liver disease secondary to posthepatitis cirrhosis in March 1989. Starting at day 30, he had signs of infection associated with hemocultures positive for Staphylococcus aureus. A subhepatic collection was found on sonography and CT scan and also cultured positive for the same germ. Arteriograms demonstrated a celiac artery dissection associated with a false anastomotic aneurysm of the hepatic artery. Surgical treatment consisted of arterial reconstruction using a saphenous vein graft between the right renal artery and the hepatic artery of the transplant, followed by resection of the hepatic artery aneurysm and the celiac artery. Hepatic ischemia was 12 min. The immediate postoperative course was uneventful and postoperative angiograms showed that the reconstruction was patent at 5 years.

Objective We describe the laparoscopic transperitoneal direct approach to the abdominal aorta. Operative technique The patient is placed in the right lateral decubitus position, which allows dropping of the small bowel into right side of the abdomen. Anatomical exposure of the abdominal aorta follows the same steps as in open surgery. Discussion Laparoscopic transperitoneal direct approach allows a reproducible exposure of the abdominal aorta. This technique was useful when retrocolic and/or retrorenal approaches were not possible because of previous left nephrectomy.

Between January 1, 1979, and December 31, 1988, 149 infrapopliteal polytetrafluoroethylene (PTFE) bypasses were performed in 145 patients with chronic, critical, limb-threatening ischemia. These operations represented 27.9% of 534 infrapopliteal bypasses performed during the same period. There were 92 males and 53 females. Mean age was 71.8 +/- 12.3 years. Signs and symptoms of critical ischemia were gangrene, ulceration, and isolated rest pain in 101 (69%), 23 (15.3%), and 25 (16.7%) cases, respectively. A composite (PTFE-saphenous vein) graft was used in 53 (35%) cases. In 96 prosthetic bypasses the distal anastomosis was performed using vein patch angioplasty in 65 (44%) cases and directly in 31 (21%). The in-hospital mortality rate was 3.3%. Patency, limb salvage, and patient survival rates were plotted according to the actuarial method and the curves obtained were compared using the log-rank test. Actuarial survival rates were 68% +/- 5% and 57% +/- 7% at 3 and 5 years, respectively. Primary patency and lower limb salvage rates were 41% +/- 5% and 68% +/- 6% at 3 years and 35% +/- 9% and 65% +/- 10% at 5 years, respectively. There was no statistically significant difference noted in primary patency rates at 3 years according to the type of bypass (composite or all-prosthetic: 36% vs. 44%), the type of distal anastomosis (direct or vein patch angioplasty: 43% vs. 45%), the site of distal anastomosis (upper or lower half of the leg: 38% vs. 46%), lateral or medial placement of the bypass (39% vs. 43%), or according to whether or not it was a repeat operation (40% vs. 44%). In conclusion, patency rates using infrapopliteal PTFE bypasses are low. Certain technical approaches, although they do not seem to improve patency, definitely increase the feasibility of bypass and in our opinion decrease the risk of early failure in unfavorable anatomic settings. The limb salvage rates following infrapopliteal PTFE and composite bypass are encouraging and justify the use of routine distal revascularization, even in the absence of autogenous vein graft.

Endovascular repair of chronic aortic dissections (CAD) intend to promote false lumen thrombosis (FLT). This article describes a technique using Amplatzer vascular plugs (AVPs) for entry tear closure of CAD. A 70-year-old man presented with a type II dissecting thoracoabdominal aneurysm. Computed tomography scan showed a very tight true lumen, partial FLT, and 2 entry tears at the level of the left subclavian artery and the visceral aorta, respectively. During a first procedure, aortic debranching was performed using the ascending aorta as bypass inflow. In a second intervention entry tears were closed using AVPs protected by short stent grafts. Technical success was achieved. No paraplegia occurred. Eighteen months later, FLT was complete and aortic diameter decreased. Entry tear closure using AVPs is feasible and allows FLT. Further reports are needed to determine if stent-graft protection of AVPs is mandatory, which may simplify technical aspects of the procedure.

Between 1984 and 1989, 29 iliac renal artery bypasses were performed in 29 patients (mean age 67.8 years) with severe renovascular disease due to atheroma. The indication for renal artery reconstruction was hypertension in all patients, which was associated with kidney failure in 16 cases. In six cases, reconstruction was performed after failure or complications of percutaneous transluminal angioplasty. The bypass was constructed with polytetrafluoroethylene in 24 cases (83%) and vein graft in five cases (17%). There was no postoperative mortality. All bypasses were found to be patent on duplex scanning or digital subtraction arteriograms. One patient was lost to follow-up. Mean follow-up was 23.2 months. One patient died of acute kidney failure, probably related to occlusion of the bypass. Hypertension improved in 22 cases (79%), was cured in two cases (7%), and remained unchanged in four (14%). Renal function remained unchanged in six cases (40%) and improved in nine (60%). Iliac-to-renal artery bypass seems to be the surgical renal revascularization modality best adapted to high-risk patients or those who have severe atheroma. Additionally, this technique enables rapid treatment of failures or complications of percutaneous transluminal angioplasty of the renal artery.

Objectives We describe our experience with a new technique of total laparoscopic bypass surgery to treat aortoiliac occlusive lesions. Material and methods From November 2000 to December 2003, 93 total laparoscopic bypass procedures were performed to treat TASC (TransAtlantic Inter-Society Consensus document) grade C or D aortoiliac occlusive lesions. We also reimplanted 2 inferior mesenteric arteries, and performed 3 prosthesis–superior mesenteric bypasses and 2 suprarenal aorta endarterectomies. Our technique includes a sloping right lateral decubitus installation, which enables a simple transperitoneal left retrocolic or retrorenal approach to the infrarenal abdominal aorta. In patients with a hostile abdomen a retroperitoneal videoscopic approach was used. Aorta-prosthesis laparoscopic anastomoses are performed simply, which averts any trauma to the suture material. Results Patients included 76 men and 17 women, with median patient age 61 years (range, 38-79 years). The approach to the aorta was always possible, in particular, in obese patients. It enabled stable aortic exposure during performance of the laparoscopic aorta-prosthesis anastomosis. Median operative time was 240 minutes (range, 150-450 minutes). Median aortic clamping time measured to unclamping of the first prosthetic limb was 67.5 minutes (range, 30-135 minutes). Median duration of aorta-prosthesis anastomosis was 30 minutes (range, 12-90 minutes). The longest durations were mainly observed during the learning curve. Thirty-day postoperative mortality was 4% (4 of 93 patients). Two patients died of myocardial infarction. One patient with American Society of Anesthesiologists grade 4 disease operated on to treat critical ischemia died of multiple organ system failure, and 1 patient died of colonic ischemia. Major nonlethal postoperative complications were observed in 4 patients, and included lung atelectasia in 2 patients, graft infection in 1 patient operated on emergently to treat aortic occlusion, and secondary spleen rupture at day 5 in 1 patient. Median hospital stay was 7 days (range, 2-57 days). With a mean follow-up of 19 months (range, 1-37 months), complete recovery was observed in 89 patients, and all grafts were patent. One patient had kinking of a prosthetic limb at the groin, and in 1 patient Staphylococcus epidermidis graft infection developed, which was treated with in situ replacement with a rifampin-bonded graft. Conclusion Total laparoscopic aortic bypass is feasible. In patients with TASC C and D aortoiliac occlusive lesions, short-term outcomes are comparable to those with conventional aortic bypass. After the initial learning curve, laparoscopic technique may reduce the operative trauma of aortic bypass.

Objectives We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. Material and methods Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach. Results We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent. Conclusion These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.

The development of laparoscopic aortic surgery has led us to develop new approaches to the abdominal aorta. Transperitoneal approaches are not always possible and can be difficult, as is the case with open surgery. In these difficult cases, a left retroperitoneal laparoscopic (retroperitoneoscopic) approach (LRPA) is necessary. We describe the LRPA we used for total laparoscopic aortoiliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA) repairs.

Elective bilateral exposure of iliac arteries during endovascular or laparoscopic aneurysm repair is commonly performed through two retroperitoneal incisions in the iliac fossa. Larger incisions are necessary when simultaneous external and common iliac exposures are needed. We describe a new technique using a single incision for bilateral approach of the iliac arteries. Exposure of iliac arteries through this bilateral anterior paramedian retroperitoneal approach allows the introduction of endografts, crossover ilioiliac bypass, implantation of graft limbs for bifurcated bypass grafting, reconstruction of internal iliac arteries, and ligature of iliac arteries.