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Non-contrast computer tomography detects the presence of hyperdense middle cerebral artery sign (HMCAS). Studies on the prognostic value of HMCAS among patients undergoing mechanical thrombectomy (MT) are conflicting. A retrospective analysis of consecutive patients with acute ischemic stroke due to middle cerebral artery occlusion, presenting with or without HMCAS, who underwent MT, was performed. We enrolled 191 patients (HMCAS +, n = 140; HMCAS -, n = 51). Prevalence of successful recanalization was significantly higher in patients with HMCAS than in those without HMCAS (92.1% versus 74.5%, p = 0.001). Patients with HMCAS had a better clinical outcome than those HMCAS - (54.3% versus 37.3%, p = 0.037, for three-month favorable outcome; 62.9% versus 39.3%, p = 0.004, for major neurological improvement at discharge; 8.6% versus 19.6%, p = 0.035, for in-hospital mortality; 14.3% versus 27.5%, p = 0.035, for intracranial hemorrhage; 2.9% versus 17.6%, p = 0.001, for symptomatic intracranial hemorrhage). Multivariate analyses confirmed that HMCAS represents an independent predictor of three-month favorable outcome (OR 2.48, 95% CI 1.10-5.58, p = 0.028), major neurological improvement at discharge (OR 2.40, 95% CI 1.09-5.20, p = 0.030), in-hospital mortality (OR 0.29, 95% CI 0.010-0.81, p = 0.018), presence of ICH (OR 0.49, 95% CI 0.25-0.97, p = 0.042) and presence of SICH (OR 0.16, 95% CI 0.04-0.63, p = 0.009). HMCAS presence predicts favorable outcome in patients undergoing MT. This result may indicate that hyperdense clots are more likely to respond to MT than isodense ones. This effect is mediated by reduction in hemorrhagic transformation.

We report a patient who presented with paraplegia after ascending aorta and arch replacement using the frozen elephant trunk technique. Immediate postoperatively cerebrospinal fluid drainage allowed successful reversal of spinal cord injury. Early awakening of patients following a frozen elephant trunk technique is mandatory because it allows recognition and treatment of this complication by prompt cerebrospinal liquor drainage.

Investigations have shown that infection from the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is responsible also for initiating severe inflammatory responses that can lead macrovascular and microvascular thrombosis. Several studies have already described acute limb ischemia and peripheral arterial disease in critically ill patients with Coronavirus disease 2019 (Covid-19), as well as coronary artery disease and ischemic stroke as a manifestation usually associated with respiratory distress. However, what still remains unclear is how long inflammation and thrombotic derangements can last after recovery from the symptoms of Covid-19. Hence, in this article we report 3 cases of arterial thrombotic sequalae after this viral infection. To the best of our knowledge, this is the first cases' series that had described different delayed vascular arterial complications, which occurred after the index infection, with a negative nasopharyngeal swab and Covid-19 systemic symptoms resumption. A better understanding of the coagulopathy in Covid-19 could have an essential role to guide prevention and treatment of arterial thromboembolic events, both during and after the viral infection. Further investigations are required to confirm these data and to estabilish the type, dose and duration of anticoagulant/antiplatelet therapy not just during but also after Covid-19 infection.

Mediastinal teratoma rarely causes pericarditis. We report a case of a 22-year-old young female admitted to the emergency department for inspiratory chest pain and fever with severe pericardial effusion, unexepectable the cause of pericarditis was a mediastinal teratoma.

Pulmonary sequestrations are rare congenital malformations. They are often located in the lower lobes, and they are supplied by an aberrant systemic vessel arising from the thoracic aorta or abdominal arteries. These pulmonary malformations are divided into intra- and extralobar sequestrations, depending on the respective lack or presence of an independent pleural covering. Pulmonary sequestration can be asymptomatic or lead to recurrent pulmonary infections. The goal of this study was to analyse the feasibility and safety of a hybrid sequential approach. We report a small series of intralobar pulmonary sequestrations, from November 2017 to December 2018, successfully treated with a hybrid minimally invasive approach consisting of endovascular embolization of the aberrant arterial branch followed by video-assisted thoracoscopic lobectomy the day after. Thoracic pain following endovascular embolization was noted in all cases. Patients were discharged early in the absence of major postoperative complications. Prolonged air leak was observed in only 1 case. Despite the presence of sequestration-related pulmonary inflammation, in our experience, hybrid treatment for intralobar pulmonary sequestration is a safe and reproducible approach in terms of postoperative complications and hospital stay., Pulmonary sequestrations (PS) are rare malformation of the lung, wherein a portion of the lung’s parenchyma is supplied by an aberrant vessel arising from the thoracic or abdominal aorta.

Objectives This study sought to evaluate 30-day safety and efficacy of dual-layer mesh-covered carotid stent systems for carotid artery stenting (CAS) in the clinical practice. Background When compared with carotid endarterectomy, CAS has been associated with a higher rate of post procedural neurologic events; these could be related to plaque’s debris prolapsing through stent’s mesh. Consequently, the need for increased plaque coverage has resulted in the development of dual-layer mesh-covered carotid stent systems. Methods From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system in 20 centers. The primary endpoint was stroke up to 30 days; secondary endpoints were technical and procedural success; external carotid artery occlusion; and in-hospital and 30-day transient ischemic attack (TIA), acute myocardial infarction (AMI), and death rates. Results Symptoms were present in 131 (17.87%) patients. An embolic protection device was used in 731 (99.72%) patients. Procedural success was 100%, technical success was obtained in all but 1 (99.86%) patient, who died in hospital due to a hemorrhagic stroke. Six TIAs, 2 minor strokes, and 1 AMI occurred during in-hospital stay, and external carotid artery occlusion was evident in 8 (1.09%) patients. Between hospital discharge and 30-day follow-up, 2 TIAs, 1 minor stroke, and 3 AMIs occurred. Therefore, the cumulative stroke rate was 0.54%. Conclusions This real-world registry suggests that use of CGuard embolic prevention system in clinical practice is safe and associated with a minimal occurrence of adverse neurological events up to 30-day follow-up.

Background: Treatment of cerebral aneurysms using hemodynamic implants such as endosaccular flow disruptors and endoluminal flow diverters has gained significant momentum during recent years. The intended target zone of those devices is the immediate interface between aneurysm and parent vessel. The therapeutic success is based on the reduction of aneurysmal perfusion and the subsequent formation of a neointima along the surface of the implant. However, a subset of aneurysms–off-centered bifurcation aneurysms involving the origin of efferent branches and aneurysms arising from peripheral segments of small cerebral vessels–oftentimes cannot be treated via coiling or implanting a hemodynamic implant at the neck level for technical reasons. In those cases, indirect flow diversion–a flow diverter deployed in the main artery proximal to the parent vessel of the aneurysm–can be a viable treatment strategy, but clinical evidence is lacking in this regard. Materials and Methods: Five neurovascular centers contributed to this retrospective analysis of patients who were treated with indirect flow diversion. Clinical data, aneurysm characteristics, anti-platelet medication, and follow-up results, including procedural and post-procedural complications, were recorded. Results: Seventeen patients (mean age: 60.5 years, range: 35–77 years) with 17 target aneurysms (vertebrobasilar: n = 9) were treated with indirect flow diversion. The average distance between the flow-diverting stent and the aneurysm was 1.65 mm (range: 0.4–2.4 mm). In 15/17 patients (88.2%), perfusion of the aneurysm was reduced immediately after implantation. Follow-ups were available for 12 cases. Delayed opacification (OKM A3: 11.8%), reduction in size (OKM B1-3: 29.4%) and occlusion (D1: 47.1%) were observable at the latest investigation. Clinically relevant procedural complications and adverse events in the early phase and in the late subacute phase were not observed in any case. Conclusion: Our preliminary data suggest that indirect flow diversion is a safe, feasible, and effective approach to off-centered bifurcation aneurysms and distant small-vessel aneurysms. However, validation with larger studies, including long-term outcomes and optimized imaging, is warranted.

Background and Purpose: Flow diverting stents are designed to divert blood flow from the aneurysm sac, allowing for eventual occlusion following endovascular therapy. This case series reports clinical experience using the Silk Vista Baby (SVB, Balt Extrusion, Montmorency, France), a flow diverter (FD) designed to treat intracranial aneurysms in small, distal vessels.Methods: All patients who underwent treatment with SVB at the University Hospital “Santa Maria della Misericordia” of Udine between July 2018 and September 2020 were retrospectively identified. Baseline patient and aneurysm characteristics, intraprocedural technical outcomes, periprocedural complications, modified Rankin Scale (mRS) at discharge, magnetic resonance imaging (MRI) results at 3-month follow-up, and angiographic results at 6-month follow-up were collected.Results: A total of 18 patients (55.6% [10/18] male; mean age 62.6 years, range: 42–77 years) were retrospectively identified, receiving treatment for 22 aneurysms. Most patients were symptomatic (14/18, 77.8%) and approximately half had subarachnoid hemorrhage (10/18, 55.6%). Sufficient aneurysm coverage was achieved in 88.9% (16/18) of patients with a single device. Mortality did not occur (0/18, 0%); adverse device-related events included side branch occlusion (1/18, 5.6%) and in-stent thrombosis (1/18, 5.6%). At discharge, 77.8% (14/18) had an mRS of 0. In most cases, patients showed complete occlusion (10/15, 66.7%) or a small aneurysmal remnant (3/15, 20.0%) upon MRI; upon angiography, most showed complete occlusion (10/13, 76.9%) or only a small aneurysmal remnant (2/13, 15.4%).Conclusion: This case series showed that the SVB FD is safe and feasible to use in patients with aneurysms in small, distal vessels. Additional randomized, prospective studies with larger cohorts are needed for the SVB.

Coronavirus disease 2019 poses a serious threat to public health. The protocol developed at the Azienda Sanitaria Universitaria Friuli Centrale (Italy) is based on clinical data, laboratory tests, chest echography and HRCT. Several therapeutic options are considered, since patients vary in disease severity, evolution and co-morbidities and because so far there are no clear indications about therapeutic strategy based on randomized clinical trial. In this protocol chest echography has a central role in categorizing patient status, follow-up and decision-making.

We report a patient who presented with paraplegia after ascending aorta and arch replacement using the frozen elephant trunk technique. Immediate postoperatively cerebrospinal fluid drainage allowed successful reversal of spinal chord injury. Early awakening of patients following a frozen elephant technique is mandatory because it allows recognition and treatment of this complication by prompt cerebrospinal liquor drainage.

The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry.DLS have been proved to be safe and efficient during short-term follow-up. Recent data have raised the concern that the benefit of CAS performed with using a DLS may be hampered by a higher restenosis rate at 1 year.From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system at 20 centers. The primary endpoint was the occurrence of death and stroke at 1 year. Secondary endpoints were 1-year rates of transient ischemic attack, acute myocardial infarction, internal carotid artery (ICA) restenosis, in-stent thrombosis, and external carotid artery occlusion.At 1 year, follow-up was available in 726 patients (99.04%). Beyond 30 days postprocedure, 1 minor stroke (0.13%), four transient ischemic attacks (0.55%), 2 fatal acute myocardial infarctions (0.27%), and 6 noncardiac deaths (1.10%) occurred. On duplex ultrasound examination, ICA restenosis was found in 6 patients (0.82%): 2 total occlusions and 4 in-stent restenoses. No predictors of target ICA restenosis and/or occlusion could be detected, and dual-antiplatelet therapy duration (90 days vs 30 days) was not found to be related to major adverse cardiovascular event or restenosis occurrence.This real-world registry suggests that DLS use in clinical practice is safe and associated with minimal occurrence of adverse neurologic events up to 12-month follow-up.

Background The treatment of patients with thromboembolic symptoms due to a popliteal artery aneurysm (PAA) is still controversial with poor results in terms of primary patency. The aim of our pilot study was to evaluate whether improving the outflow with an endovascular pretreatment consisting in thromboaspiration and angioplasty could positively ameliorate the primary patency of the subsequent femoropopliteal (FP) bypass in symptomatic patients with at least one below the knee (BTK) patent vessel. Methods This is a single-center pilot case-control study that involves patients treated at the Vascular and Endovascular Surgery Unit of Udine, Italy, from January 2015 to November 2019. The inclusion criteria were the presence of thromboembolic symptoms due to PAA distal embolization, associated with the presence of a patent PAA >20 mm and a poor runoff (no more than one patent BTK artery). The case group was treated in a two-step approach: the first step consisted in thromboaspiration followed by BTK angioplasty, when appropriate, and the second one consisted in performing the surgical FP bypass. The control group moved on directly to the open surgical intervention. Results The case group was composed of 11 patients, 10 males and 1 female, with a mean age of 69.3 ± 10.8 years. The mean PAA dimension was 32.6 ± 9.9 mm. Particularly, 9 patients were operated on through the medial vascular approach and 2 through the posterior one. The grafts used were 10 polytetrafluoroethylene (PTFE) and 1 great saphenous vein (GSV) in situ. The control group was composed of 11 male patients with a mean age of 75.5 ± 8.7 years, and the mean PAA dimension was 29.8 ± 13.4 mm. All the FP bypasses were approached medially, and the materials used were 10 PTFE and 1 reversed GSV. The median follow-up was 31.5 ± 12.6 months. Primary patency in the case group was 72.7% within one year; on the contrary, it was 27.3% in the control group. The amputation rate was 0% in the case group, 27.3% in the controls. By comparing the 2 groups, we found a higher and significant risk (P = 0.0261) of early FP bypass occlusion and major limb amputation in the control group. Conclusions This pilot study shows encouraging results; the endovascular approach is a safe and repeatable procedure which, improving the runoff in thromboembolic symptomatic PAA, seems to guarantee a better FP graft primary patency.

Objective The aim was to evaluate the short term safety and effectiveness of the Penumbra/Indigo aspiration thrombectomy Systems (Penumbra Inc.) in patients with acute lower limb ischaemia. (ALLI). Recently, endovascular vacuum assisted thrombectomy devices, similar to those used in the management of acute ischaemic stroke, have become available for peripheral arteries, but data are still scarce. Methods To assess vessel patency, a modified Thrombolysis in Myocardial Infarction (TIMI) classification, called TIPI (Thrombo-aspiration In Peripheral Ischaemia), is proposed. The TIPI flow is assessed at presentation, immediately after treatment with the study device, and after all adjuvant procedures. The primary outcome is the technical success of the thrombo-aspiration with the investigative system, defined as near complete or complete revascularisation TIPI 2 – 3. Safety and clinical success rate were collected at one month. Results One hundred and fifty patients were enrolled. The mean age was 72.4 years and 73.3% were male. Rutherford grade on enrolment was I in 16%, IIa in 40.7%, and IIb in 43.3% with a mean ankle brachial index of 0.19. Primary technical success (TIPI 2 – 3 flow) was achieved in 88.7% of patients. Adjunctive procedures included angioplasty/stenting of chronic atherosclerotic lesions (n = 39), thrombolysis (n = 31), covered stenting (n = 15), and supplementary Fogarty embolectomy (n = 6). After all interventions, assisted primary technical success was 95.3% (TIPI 2 – 3 in 143/150). No systemic bleeding complications or device related serious adverse events were reported. At one month follow up, one death, and one below the knee amputation were recorded. Primary patency was 92% (138/150), and the re-intervention rate was 7.33%, resulting in an assisted primary and secondary patency of 94% and 99.33%, respectively. Conclusion Results from the INDIAN registry reveal that mechanical thrombectomy using the Indigo system is safe and effective for revascularisation of ALLI as a primary therapy.

Background: Admission hyperglycemia impairs outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). Since hyperglycemia in AIS represents a dynamic condition, we tested whether the dynamic patterns of hyperglycemia, defined as blood glucose levels &gt, 140 mg/dl, affect outcomes in these patients. Methods: We retrospectively analyzed data of 200 consecutive patients with prospective follow-up. Based on blood glucose level, patients were distinguished into 4 groups: (1) persistent normoglycemia, (2) hyperglycemia at baseline only, (3) hyperglycemia at 24-h only, and (4) persistent (at baseline plus at 24-h following MT) hyperglycemia. Results: AIS patients with persistent hyperglycemia have a significantly increased risk of poor functional outcome (OR 6.89, 95% CI 1.98&ndash, 23.94, p = 0.002, for three-month poor outcome, OR 11.15, 95% CI 2.99&ndash, 41.52, p = 0.001, for no major neurological improvement), mortality (OR 5.37, 95% CI 1.61&ndash, 17.96, p = 0.006, for in-hospital mortality, OR 4.43, 95% CI 1.40&ndash, 13.97, p = 0.01, for three-month mortality), and hemorrhagic transformation (OR 6.89, 95% CI 2.35&ndash, 20.21, p = 0.001, for intracranial hemorrhage, OR 5.42, 95% CI 1.54&ndash, 19.15, p = 0.009, for symptomatic intracranial hemorrhage) after endovascular treatment. These detrimental effects were partially confirmed after also excluding diabetic patients. The AUC-ROC showed a very good performance for predicting three-month poor outcome (0.76) in-hospital mortality (0.79) and three-month mortality (0.79). Conclusions: Our study suggests that it is useful to perform the prolonged monitoring of glucose levels lasting 24-h after MT.

Chylothorax is a serious complication of transthoracic esophagectomy. Intraoperative thoracic duct (TD) identification represents a possible tool for preventing or repairing its lesions, and it is most of the time difficult, even during high-definition thoracoscopy. The aim of the study is to demonstrate the feasibility of using near-infrared fluorescence-guided thoracoscopy to identify TD anatomy and check its intraoperative lesions during minimally invasive esophagectomy. A 0.5 mg/kg solution of indocyanine green (ICG) was injected percutaneously in the inguinal nodes of 19 patients undergoing minimally invasive esophagectomy in a prone position, before thoracoscopy. TD anatomy and potential intraoperative lesions were checked with the KARL STORZ OPAL1® Technology. In all of the 19 patients where transthoracic esophagectomy was feasible, the TD was clearly identified after a mean of 52.7 minutes from injection time. The TD was cut for oncological radicality in two patients, and it was successfully ligated under the ICG guide. No postoperative chylothorax or adverse reactions from the ICG injection occurred. The TD identification with indocyanine green fluorescence during minimally invasive esophagectomy is a simple, effective, and non-time-demanding tool; it may become a standard procedure to prevent postoperative chylothorax.

Objectives: This study sought to evaluate 30-day safety and efficacy of dual-layer mesh-covered carotid stent systems for carotid artery stenting (CAS) in the clinical practice. Background: When compared with carotid endarterectomy, CAS has been associated with a higher rate of post procedural neurologic events; these could be related to plaque's debris prolapsing through stent's mesh. Consequently, the need for increased plaque coverage has resulted in the development of dual-layer mesh-covered carotid stent systems. Methods: From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system in 20 centers. The primary endpoint was stroke up to 30 days; secondary endpoints were technical and procedural success; external carotid artery occlusion; and in-hospital and 30-day transient ischemic attack (TIA), acute myocardial infarction (AMI), and death rates. Results: Symptoms were present in 131 (17.87%) patients. An embolic protection device was used in 731 (99.72%) patients. Procedural success was 100%, technical success was obtained in all but 1 (99.86%) patient, who died in hospital due to a hemorrhagic stroke. Six TIAs, 2 minor strokes, and 1 AMI occurred during in-hospital stay, and external carotid artery occlusion was evident in 8 (1.09%) patients. Between hospital discharge and 30-day follow-up, 2 TIAs, 1 minor stroke, and 3 AMIs occurred. Therefore, the cumulative stroke rate was 0.54%. Conclusions: This real-world registry suggests that use of CGuard embolic prevention system in clinical practice is safe and associated with a minimal occurrence of adverse neurological events up to 30-day follow-up.

The Djumbodis system is a metallic stent designed to prevent false lumen dilatation after repair of acute aortic dissection. Although the exact number of Djumbodis stents inserted worldwide could not be ascertained from a review of the literature, available data indicate 9 specific device-related complications from 4 patient series and 3 case reports: stent deformity or fracture (4), progressive enlargement of the distal false lumen (3) and distal pseudoaneurysm (1); a further patient with pseudoaneurysm of the distal suture line is added from personal observation. The present review confirms the inability of the Djumbodis stent to provide reduction and/or elimination of the false lumen after repair of type A dissection, highlighting peculiar device-related complications. Current survivors with a Djumbodis stent should undergo close follow-up to prevent possible catastrophic events due to device failure.

Aims The aim of the present study was to evaluate periprocedural and 30-day outcomes in a prospective series of patients treated with the CGuard Embolic Prevention System (EPS). Methods and results From April 2015 to June 2016, a physician-initiated prospective multicentre study was performed in 200 consecutive patients admitted for protected carotid artery stenting (CAS) and treated using the CGuard EPS in twelve vascular centres. Outcome measures were: technical success, periprocedural (0-24 hours) and post-procedural (24 hours-30 days) major and minor strokes, death, acute myocardial infarction (AMI), transient ischaemic attack (TIA), and external carotid occlusion. In three centres, consecutive diffusion-weighted magnetic resonance cerebral imaging (DW-MRI) was performed ≤72 hours prior to and within 72 hours after the intervention. A distal embolic protection device was employed in 182 patients (91%). Technical success was 100%. No death, AMI or major stroke occurred periprocedurally. There were two TIAs and five periprocedural minor strokes (2.5%), including one thrombosis solved by surgery. In the remaining patients (199/200; 99.5%) one-month follow-up duplex ultrasound revealed optimal technical results. Post-procedural clinical follow-up was uneventful. No external carotid artery occlusion occurred. New post-procedural DW-MRI lesions were detected in 12 patients out of 61 (19.6%), including bilateral in five (8.2%) and isolated ipsilateral in six (9.8%), whereas one patient (1.6%) had contralateral only lesions. Conclusions Multicentre multi-specialty use of the CGuard EPS in routine clinical practice was associated with no major periprocedural neurologic complications and a total elimination of post-procedural neurologic complications by 30 days.

Background: Arteriovenous fistula is a relatively frequent complication after partial nephrectomy. The timing of this complication is generally limited to the perioperative period. In this study, we describe a case of arteriovenous fistula after imperative right partial nephrectomy occurred 2 years after surgery. Case Presentation: A 69 year-old man previously treated with left partial nephrectomy and concomitant right partial nephrectomy for synchronous bilateral renal cell carcinoma developed a right 5 cm arteriovenous fistula 2 years after the procedure. An arteriographic study of right renal vessel with concomitant embolization of the tributary artery branch was performed with the resolution of the fistula and preservation of renal function. Conclusion: Late arteriovenous fistula is a rare complication after partial nephrectomy that may occur in bleeding and affects renal function especially in solitary kidney. Radiological approach for its treatment is feasible in expert hands.

Recent clinical trials demonstrated that mechanical thrombectomy (MT) using second-generation endovascular devices has beneficial effects in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, it remains controversial if intravenous thrombolysis (IVT) prior to MT is superior compared to direct mechanical thrombectomy (DMT). The aims of this study were to compare short and long-term outcomes between IVT + MT and DMT patients. We prospectively recruited AIS patients with LVO in the anterior or posterior circulation eligible for MT with and without prior IVT. Modified Rankin Scale (mRS) and mortality were assessed at baseline, at discharge, 90-days and 1-year after stroke. Favorable outcome was defined as a mRS score ≤2. Of the 66 patients included, 33 (50%) were in IVT + MT group and 33 (50%) were in DMT group. Except for a higher prevalence of patients using anticoagulants at admission in DMT group, baseline characteristics did not differ in the two groups. Procedural characteristics were similar in IVT + MT and DMT group. Rate of favorable outcome was significantly higher in IVT + MT patients than DMT ones both 90-days (51.5 vs. 18.2%; p = 0.004) and 1-year (51.5 vs. 15.2%; p = 0.002) after stroke. DMT patients were six times more likely to die during the 1-year follow-up compared to IVT + MT patients. This study suggests that bridging therapy may improve short and long-term outcomes in patients eligible for endovascular treatment. Further studies with larger patient numbers and randomized design are needed to confirm our findings.

Background Gastrointestinal perforation (GIP) is a rare complication after adult liver transplant (LT) associated with high morbidity and mortality. Limited data are available about clinical risk factors and underlying pathogenic mechanisms. Methods The retrospective study included all GIP cases from a consecutive cohort of 361 LT recipients during the period 2005-2017. Clinical variables were investigated as potential risk factors for GIP, and radiologic and histopathologic evaluations were undertaken to identify any causative mechanism. Results A total of 22 patients developed at least 1 episode of GIP (prevalence 6.1%) at a median time of 18.5 [interquartile range, 12.5-28.5] days after LT. The perforations occurred in the small bowel (63.6%), transverse colon (27.3%), right colon (22.7%), left colon (9.1%), and stomach (9.1%). A total of 27.3% of patients developed multiple sites of GIP, and in 31% GIP recurred after curative surgery. The 30-day mortality rate after relaparotomy was 40%. A history of previous abdominal surgery (odds ratio, 2.5) and early post-LT relaparotomy due to other complications (odds ratio, 2.6) were significant risk factors for GIP. No thromboembolic or steno-occlusive complications of any splanchnic vessel were detected at computed tomography scan, while histopathology examination on perforated gastrointestinal segments excluded cytomegalovirus infection, graft-vs-host disease, and inflammatory bowel disease. In all the cases, ischemic necrosis with aspecific microangiopathy and microembolization were the pathologic features detected. Conclusions GIP is a severe complication after LT with frequent multiple gastrointestinal involvement and recurrence after curative surgery. The pathologic underlying mechanism is usually microvascular ischemia. Clinical risk factors are history of previous abdominal surgery and early post-LT relaparotomy.

Background Acute lower limb ischemia (ALLI) poses a major threat to limb survival. For many years, surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution to the management of ALLI. It seems that the newly designed endovascular thrombectomy devices may shift treatment recommendations toward endovascular options. This protocol study aims to collect evidence supporting the latest hypothesis. Objective The devices under investigation are the Penumbra/Indigo Systems (Penumbra Inc). The objective of this clinical investigation is to evaluate, in a controlled setting, the early safety and effectiveness of the devices and to define the optimal technique for the use of these systems in patients with confirmed peripheral acute occlusions. Methods This study will be an interventional prospective trial of patients with a diagnosis of ALLI treated with Penumbra/Indigo devices. This project is intended to be a national platform where every physician invited to participate could register his or her own data procedure. The primary outcome is the technical success of thromboaspiration with the Indigo System. Assessment of vessel patency will be recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications before and after use of the device. Clinical success at follow-up is defined as an improvement of Rutherford classification at 1-month follow-up of one class or more as compared to the preprocedure Rutherford classification. Secondary endpoints include the following: (1) safety rate at discharge, defined as the absence of any serious adverse events; (2) primary patency at 1 month, defined as a target lesion without a hemodynamically significant stenosis or reocclusion on duplex ultrasound (>50%) and without target lesion reintervention within 1 month; and (3) limb salvage at 1 month. Results The study is currently in the recruitment phase and the final patient is expected to be treated by the end of March 2019. A total of 150 patients will be recruited. Analyses will focus on primary and secondary endpoints. Conclusions These new endovascular thrombectomy devices that are specifically designed for peripheral intervention in this difficult set of patients, as those under investigation in the proposed registry, may offer improved clinical outcomes with lower rates of major systemic and local complications. Following completion of this study, it is expected that the value of the Indigo Thrombectomy System in the treatment of ALLI will be better defined. As a result, a shift of treatment recommendations toward endovascular options may be observed in the near future. International Registered Report Identifier (IRRID) DERR1-10.2196/9972

Kommerell's diverticulum is a rare congenital anomaly, consisting in aneurysmal dilatation at the origin of an aberrant subclavian artery. Depending on concomitant anatomical characteristics, different endovascular and open surgical procedures have been proposed. The following report describes the first single-stage hybrid repair of a type I Kommerell's diverticulum associated with an aortic arch aneurysm and anomalous origin of the brachiocephalic vessels by total aortic arch replacement with a composite frozen elephant trunk prosthesis and endovascular treatment of the right subclavian artery. This hybrid procedure may represent an alternative to more challenging open repairs when totally endovascular approach is unfeasible.

Objectives: Vertebral osteomyelitis (VO) is a compelling clinical entity for clinicians because of its insidious and indolent course, which makes diagnosis difficult. Methods: All patients with a suspected diagnosis of VO were analyzed over an 8-year period (January 2009 to January 2017). The UDIPROVE protocol (UDIne PROtocol on VErtebral osteomyelitis) was applied in all cases. The primary endpoint was the performance of the UDIPROVE protocol to obtain the causal bacteria of infection. Results: During the study period, 133 episodes of confirmed VO were observed. The etiology of infection was obtained in 73.6% of cases: 70.5% were gram-positive, 16.3% were gram-negative, and 13.2% were mycobacteria. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed that for tubercular VO, the median standard uptake value (SUV) was higher when compared with VO caused by other bacteria. Clinical cure at the end of therapy was reported in 85.7% of patients. Previous antimicrobial therapy and a delay of more than 5 days in performing biopsy were associated with an undiagnosed etiology of VO. Targeted antibacterial therapy and follow-up with FDG-PET/CT were associated with clinical cure at the end of therapy, while the involvement of more than two vertebrae and inadequate drainage were associated with failure. Conclusions: Rigorous application of the UDIPROVE protocol allowed the causative pathogens of VO to be obtained – at about twice the rate reported in the literature. The use of FDG-PET/CT for the follow-up of infection was more reliable when compared to magnetic resonance imaging (MRI). Keywords: Vertebral osteomyelitis, Vertebral biopsy, C-reactive protein, FDG-PET/CT, MRI

OBJECTIVES Transjugular intrahepatic portosystemic shunt (TIPS) is adopted to treat refractory complications of portal hypertension, such as variceal bleeding and ascites. This study aimed to assess predictors of hepatic encephalopathy (HE) development and cumulative transplant-free survival after TIPS placement in patients with cirrhosis complicated by refractory ascites and major gastroesophageal bleeding. MATERIALS AND METHODS Sixty-three cirrhotic patients who underwent TIPS positioning as a secondary prophylaxis of major upper gastroesophageal bleeding (N=30) or to control refractory ascites (N=33) were enrolled. RESULTS After a median follow-up of 26 months following TIPS insertion, only 1/30 (3.3%) patients developed reoccurrence of bleeding. Complete control of refractory ascites was recorded in 19/23 (82.6%) patients. Within the first month after TIPS placement, 34/63 (53.9%) patients developed clinically significant HE, which was associated with the baseline presence of type 2 hepatorenal syndrome (P=0.022). At the end of 90 months of follow-up, 35 (55.6%) patients were alive, 12 (19.0%) patients underwent liver transplantation, and 16 (25.4%) patients died. Independent predictors of transplant-free survival were a model for end-stage liver disease score up to 15 (P

Treatment of thoracoabdominal aortic aneurysms with endovascular or conventional surgical techniques is burdened by high risk in older patients. Furthermore, the standard hybrid approach might be not feasible in case of severe atherosclerotic disease of the peripheral vessels. This report describes an alternative hybrid procedure which consists of an innovative mini-invasive thoracic approach combined with laparotomy to perform antegrade revascularization of the visceral arteries from the ascending aorta, followed by endovascular treatment.

Endovascular therapy (EVT) represents the gold standard treatment in patients affected by acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Prior antiplatelet (APT) therapy might increase the risk of bleeding and modify the clinical outcome of AIS patients treated with EVT. Thus, we compared effectiveness and safety of EVT in Caucasian patients with and without previous use of APT agents. We recruited consecutive patients admitted to Udine University Hospital with AIS undergoing EVT from January 2015 to December 2017. The following outcomes were documented: successful recanalization, 3-month favorable outcome, symptomatic intracranial hemorrhage (sICH), parenchymal hematoma (PH), and 3-month mortality. The study population included 100 patients (mean age 70.1 &plusmn, 11.2 years, 58% males). At time of admission, 34 patients were taking APT agents. Patients on APT pretreatment were older, had more vascular risk factors, and showed higher levels of serum creatinine than APT na&iuml, ve patients. Moreover, prior APT therapy was associated with a higher rate of pre-stroke disability and a more severe stroke at admission. Patients pretreated with APT had higher rates of successful recanalization (91.2% vs. 74.2%, p = 0.04). Prevalence of 3-month unfavorable outcome and 3-month mortality was significantly higher in APT-pretreated patients than in those without APT pretreatment. However, these associations were not confirmed on multivariable analyses. Prevalence of sICH and PH did not differ in the two groups. APT pretreatment is associated to successful recanalization rate, without increasing the risk of intracranial bleeding in patients with LVO undergoing EVT.

Carotid artery stenting (CAS) is a minimal invasive procedure used to resolve carotid occlusion that can be affected by peri-procedural complications. Statin use before CAS has shown to reduce peri-procedural risk and improve survival, though time-dependent cofactors that influence mortality has not been considered. The aim of this study was to evaluate long-term survival of patients who undergo CAS considering new occurred major adverse cardiovascular event (MACE) as time-dependent cofactor. In this study, 171 high cardiovascular risk patients (age 72 &plusmn, 8 years, 125 males) were enrolled after CAS procedure and were followed for a median of 8.4 years. Death occurred in 44% of patients with a mean time to death of 69 &plusmn, 39 months and MACE in 34% with a mean time of 35 &plusmn, 42 months. In patients who used or not statins at baseline, death occurred in 33% and 65%, respectively (p &lt, 0.001). Survival analysis showed that statin use reduced risk of death (hazard ratio HR 0.36, 95% confidence interval CI 0.23&ndash, 0.58, p &lt, 0.0001). Including MACE as time-dependent variable did not change beneficial effects of statins. Additionally, statin use was associated with a protective effect on MACE (HR 0.48, 95% CI 0.27&ndash, 0.85, p = 0.012), particularly, the prevalence of stroke was reduced by 59% (p = 0.018). In multivariate analysis, effects of statins were independent of demographic and anthropometric variables, prevalence of cardiovascular risk factors, renal function, antiplatelet use, and MACE occurrence. In conclusion, use of statins before CAS procedure is associated with increased long-term survival and reduced MACE occurrence. This evidence supports the hypothesis that statin use before CAS might be beneficial in high risk patients.

Introduction Hepatic artery thrombosis still represents a major complication after liver transplantation responsible for graft failure, possibly resulting in the need for retransplantation. Case Report We describe a case of a patient undergoing liver transplant complicated by hepatic artery thrombosis, successfully treated with an endovascular approach using the Indigo System. This new system allows mechanical fragmentation and aspiration of the thrombus, with no injection of any thrombolytic agents, thereby reducing the risk of bleeding. Hepatic artery flow was immediately restored, with no complications for the patient and the graft. Discussion The Indigo System appears to be a safe, affordable, and manageable technique for endovascular management of late hepatic artery thrombosis after liver transplant.

Transplant renal artery stenosis (TRAS) is a vascular complication occurring during the first 2 years after kidney transplantation, with an incidence and a prevalence ranging from 1% to 23%, and from 1.5% to 4%, respectively. Detection of TRAS is the key, since most stenoses may progress to renal graft loss, however it may be difficult to detect due to its nonspecific clinical manifestations. Although Doppler ultrasound has become a primary imaging technique, digital subtraction angiography (DSA) remains the gold standard for diagnosing TRAS. We present a case of delayed graft function following kidney transplantation complicated by a lateral by-pass with prosthesis upstream and downstream of renal anastomosis, TRAS criteria were unclear using Doppler ultrasound, contrast-enhanced computed tomography-scan, and DSA. Only contrast-enhanced ultrasound (CE-US), observing a delayed and pulsating contest impregnation of renal parenchyma, supported the hypothesis of TRAS that was confirmed by the measurement of trans-anastomosis pressure gradient during DSA. Keywords: Transplant renal artery stenosis (TRAS), Kidney transplantation (KT), Doppler ultrasound (DUS), Digital subtraction angiography (DSA), Contrast-enhanced ultrasound (CE-US)

Background Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE). Methods This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014. Results For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases. Conclusions pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.

BACKGROUND AND AIMS: Conventional surgery of the thoracic aorta is frequently associated with significant mortality and morbidity. Here we present treatment of surgical pathologies of the thoracic aorta using a less invasive endovascular approach. METHODS: From January 2000 to May 2004, 51 patients (mean age 62.7 +/- 12.8 years, 36 men) underwent endovascular repair of thoracic aortic lesions in our institution. All patients underwent computed tomography scan at discharge, 6 and 12 months and annually thereafter. Clinical follow-up was carried out by outpatient clinic visit or by telephone contact with the patients or their referring physicians. Mean follow-up was 15.8 months. RESULTS: The 30-day mortality rate was 3.8%, one death in the group of chronic (1.9%) and one in the group of acute lesion (1.9%). The survival rate in the follow-up period was 92.4% at 6 months. Computed tomography angiography confirmed exclusion of the lesion in 25 out of 27 chronic patients, whereas type I and II endoleaks were detected in two patients treated with a secondary procedure. In addition, two patients with an acute type B aortic dissection presented with early endoleaks. The overall rate of complications was 10%. No other endoleaks or deaths were observed at later follow-up. CONCLUSIONS: The early and mid-term results of endovascular stent-grafting for the treatment of chronic and acute thoracic aortic diseases showed a good outcome and low rate of complications. Stent-grafting of the thoracic aorta is still an investigational procedure that needs further validation.