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This paper offers a practical overview of the contemporary management of patients with peripheral arterial disease presenting intermittent claudication (IC), including clinical and instrumental diagnosis, risk factors modification, medical management, and evidence-based revascularization indications and techniques. Decision making represents a crucial element in the management of the patient with IC; for this, we think a review of this type could be very useful, especially for non-vascular specialists.

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. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included. Follow-up: One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were 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) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics. Conclusion: Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

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

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

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 The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded on October 1, 2018, to enhance cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic arteriopathy has been selected as the very first topic to be investigated by the federation. Methods MeFAVS members were asked to reply to a questionnaire on the management of diabetic ischemic foot. Results were collected and analyzed statistically. The questionnaire consisted of 15 multiple choice answers regarding diabetic foot (DF) diagnosis and treatment. The questionnaire was submitted to 21 centers on April 20, 2019. Results Response rate was 62%. The survey revealed that vascular surgeons, diabetologists, and wound care nurses made-up the core of the diabetic teams present in 76.9%, 69.3%, and 92.3% of the centers, respectively. Diabetic teams were most often led by vascular surgeons (53.8%) and diabetologists (42.2%), but only in 7.9% of cases by nurses. Duplex ultrasonography and computed tomographic angiography were the most commonly available tools used to assess diabetic peripheral arterial disease (PAD). Surgical wound care was undertaken by vascular surgeons in the majority of cases, and only in 46.2% of the cases to orthopedic or plastic surgeons, while nonsurgical wound care was handled by specialized nurses (76.6%) and diabetologists (53.8%). First-line revascularization was preferred over conservative treatment (61.5% vs 53.8%) and endovascular strategy (45.3%) over open (33.7%) or hybrid (21.0%) surgery. Vascular surgeons and interventional radiologists were found to be the most common performers of endovascular revascularization (92.3% and 53.8%, respectively). Amputations had an overall rate of 16.6% (range 4–30%) and a mean reintervention rate of 22.5%, and were usually performed by vascular surgeons for both minor and major interventions (84.6%) followed by orthopedic surgeons (15.4% minor and 30.8% major). The availability of a DF clinic (84.6%) and endovascular (53.8%) and open surgery (46.2%) capabilities were considered fundamental to reduce amputation rates. Conclusions Especially since the introduction and spreading of new endovascular techniques for the treatment of DF, it is a common consensus amongst vascular surgeons that a standardized approach to the discipline is necessary in order to improve outcomes such as amputation-free survival and mortality and it is with this perspective and purpose that transnational cooperation amongst vascular professionals and residents in training are aiming for greater proficiency in endovascular and open surgery.

Background: Endovascular aneurysm repair (EVAR) has become an accepted alternative to open repair (OR) for the treatment of abdominal aortic aneurysm (AAA) despite “hostile” anatomies that may reduce its effectiveness. Guidelines suggest refraining from EVAR in such circumstances, but in clinical practice, up to 44% of EVAR procedures are performed using stent grafts outside their instruction for use (IFU), with acceptable outcomes. Starting from this “inconsistency” between clinical practice and guidelines, the aim of this contribution is to report the technical results of the use of EVAR in challenging anatomies as well as the ethical aspects to identify the criteria by which the “best interest” of the patient can be set. Materials and Methods: A literature review on currently available evidence on standard EVAR using commercially available endografts in patients with hostile aortic neck anatomies was conducted. Medline using the PubMed interface and The Cochrane Library databases were searched from 1 January 2000 to 6 May 2021, considering the following outcomes: technical success; need for additional procedures; conversion to OR; reintervention; migration; the presence of type I endoleaks; AAA-related mortality rate. Results: A total of 52 publications were selected by the investigators for a detailed review. All studies were either prospective or retrospective observational studies reporting the immediate, 30-day, and/or follow-up outcomes of standard EVAR procedures in patients with challenging neck anatomies. No randomized trials were identified. Fourteen different endo-grafts systems were used in the selected studies. A total of 45 studies reported a technical success rate ranging from 93 to 100%, and 42 the need for additional procedures (mean value of 9.04%). Results at 30 days: the incidence rate of type Ia endoleak was reported by 37 studies with a mean value of 2.65%; 31 studies reported a null migration rate and 32 a null conversion rate to OR; in 31 of the 35 studies that reported AAA-related mortality, the incidence was null. Mid-term follow-up: the incidence rate of type Ia endoleak was reported by 48 studies with a mean value of 6.65%; 30 studies reported a null migration rate, 33 a null conversion rate to OR, and 28 of the 45 studies reported that the AAA-related mortality incidence was null. Conclusions: Based on the present analysis, EVAR appears to be a safe and effective procedure—and therefore recommendable—even in the presence of hostile anatomies, in patients deemed unfit for OR. However, in order to identify and pursue the patient’s best interest, particular attention must be paid to the management of the patient’s informed consent process, which—in addition to being an essential ethical-legal requirement to legitimize the medical act—ensures that clinical data can be integrated with the patient’s personal preferences and background, beyond the therapeutic potential of the proposed procedures and what is generically stated in the guidelines.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Introduction: Acute limb ischemia (ALI), classified according to Rutherford’s classification (RC), is a vascular emergency burdened by high rates of mortality and morbidity. The need of new and different prognostic values for ALI has emerged, and, among all, the neutrophil-to-lymphocyte ratio (NLR) has been proven as a strong outcome predictor in vascular disease. The aim of this study is to investigate the role of preoperative NLR in predicting clinical outcomes in patients presenting acute limb ischemia. Material and Methods: A single-center retrospective study was conducted between January 2015 and December 2019. Demographic and clinical characteristics, procedural technical aspects, postoperative and early (up to 30-day) outcomes were recorded. All enrolled patients were categorized into low- and high-NLR at baseline, using a cut-off value of 5. Study outcomes were 30-day all-cause mortality and amputation rates. Results: A total of 177 ALI patients were included in the final analysis (6 RC I, 44 RC IIA, 108 RC IIB, and 19 RC III), 115 males (65%), mean age 78.9 ± 10.4 years. Mean NLR at hospital presentation was 6.65 ± 6.75 (range 0.5–35.4), 108 (61.1%) patients presented a low-NLR, 69 (38.9%) a high-NLR. Immediate technical success was achieved in 90.1% of cases. At 30 days, freedom from amputation and freedom from death rates were 87.1% and 83.6%, respectively. At the univariate analysis, amputation (p &lt, 0.0001, OR: 9.65, 95%CI: 3.7–25.19), mortality (p = 0.0001, OR: 9.88, 95%CI: 3.19–30.57), and cumulative event rates (p &lt, 0.001, OR: 14.45, 95%CI: 6.1–34.21), were significantly different between the two groups according to NLR value. Multivariate analysis showed that a high baseline NLR value was an independent predictor of unfavorable outcomes in all enrolled patients. Consistently, at ROC analysis, a preoperative NLR &gt, 5 was strongly associated with all outcome occurrences. Conclusion: Preoperative NLR value seems to be strongly related to ALI outcomes in this unselected population. The largest series should be evaluated to confirm present results.

The aim of this study is to evaluate the role of preoperative ischemic brain lesion (IBL) volume, assessed by Diffusion-weighted magnetic resonance brain imaging (DW-MRI) with RAPID® processing, and surgery timing in predicting post-operative neurological outcomes in symptomatic carotid stenosis (SCS) patients treated with carotid endarterectomy (CEA).All patients with SCS who underwent CEA between January 2010 and June 2020 were considered. IBLs ipsilateral to the stenosis were identified in the preoperative magnetic resonance brain (MRI). The volume was quantified in mL and correlated with 30-day rates of stroke and stroke/death by χ2 and receiver operating characteristic (ROC) curve.One hundred thirty-four patients were surgically treated for SCS during the entire study period. CEA procedures were defined as emergent, urgent, or elective if performed within 48 hr, between 48 hr and 14 days, or after 14 days from symptoms onset, respectively. Cumulative new ipsilateral stroke rate was 4,5%, with a statistically higher neurological complications in emergent patients compared to urgent and elective patients (10,6%, 1,47% and 0% respectively, P 0,039). ROC curve analysis showed a volume of 10 mL was predictive of postoperative stroke with 100% sensitivity and 80% specificity. An IBL volume10 mL was an independent risk factor for postoperative stroke. In fact, the perioperative neurological complication rate was significantly different in high-IBL volume patients (10 mL) compared with low-IBL volume patients (10 mL) (P 0,003) CONCLUSIONS: The present study suggests that the optimal timing for CEA is between 48 hr and 14 days. Furthermore, the present study suggests that the presence of the IBL, by itself, is not definitively related with an unsatisfactory neurological outcome. However, an IBL higher than 10 mL should be as a reliable threshold value adverse neurological result in SCS patients.

Monocytes are a heterogeneous cell population distinguished into three subsets with distinctive phenotypic and functional properties: “classical” (CD14++CD16-), “intermediate” (CD14++CD16+), and “nonclassical” (CD14+CD16++). Monocyte subsets play a pivotal role in many inflammatory systemic diseases including atherosclerosis (ATS). Only a low number of studies evaluated monocyte behavior in patients affected by cardiovascular diseases, and data about their role in acute aortic dissection (AAD) are lacking. Thus, the aim of this study was to investigate CD14++CD16-, CD14++CD16+, and CD14+CD16++ cells in patients with Stanford-A AAD and in patients with carotid artery stenosis (CAS).Methods. 20 patients with carotid artery stenosis (CAS group), 17 patients with Stanford-A AAD (AAD group), and 17 subjects with traditional cardiovascular risk factors (RF group) were enrolled. Monocyte subset frequency was determined by flow cytometry.Results. Classical monocytes were significantly increased in the AAD group versus CAS and RF groups, whereas intermediate monocytes were significantly decreased in the AAD group versus CAS and RF groups.Conclusions. Results of this study identify in AAD patients a peculiar monocyte array that can partly explain depletion of T CD4+ lymphocyte subpopulations observed in patients affected by AAD.

The aim of this study was to evaluate CD25+ and Lag3+ T regulatory subpopulations in patients with critical carotid artery stenosis (CAS) and Stanford-A acute aortic dissection (AAD). CD25+ and Lag3+ were measured in 36 patients affected by CAS and 24 patients with Stanford type A AAD. Based on neurological symptoms, patients affected by CAS were further divided in 25 asymptomatic (CAS-A) and 11 symptomatic (CAS-S) subjects. Twenty-five patients with traditional cardiovascular risk factors (RF), matched for age and sex, were used as control group. Interleukin (IL)-10, IL-6 and transforming growth factor-β-levels were also measured. CD25+ T cells were significantly increased in CAS-S versus CAS-A (p > 0.05), AAD (p > 0.05) and RF (p > 0.05). Moreover, a significant increase in Lag3+ Tregs was observed in CAS e CAS-S versus AAD (p

To describe the case of a young female patient, affected by Systemic Lupus Erythematous, hospitalized for severe SARS-CoV-2 infection pneumonia and presenting a treatment-resistant acute upper limb ischemia. Two days after hospital admission, the patient suffered sudden right upper limb pain associated with mild functional impairment. At physical examination, radial and ulnar pulses were absent, and no flow signal was detected at duplex ultrasound scan. Therefore, an acute limb ischemia diagnoses was posed. Despite several surgical and endovascular revascularization attempts, the patient underwent an above the elbow amputation in 10th postoperative day from first surgical embolectomy, and she died for respiratory failure 25 days after hospitalization. Our case of acute upper limb ischemia seems to confirm that clinical manifestation and fate of thrombotic disorder in COVID-19 patients could be precipitated by concomitant autoimmune diseases.

Aim of this paper is to report an unusual case of iliac artery acute thrombosis following a laparoscopic elective surgery for hiatal hernia repair and observed during a medical malpractice litigation. A 69-year-old woman submitted to laparoscopic hiatal hernia repair developed a lower limb ischemia in 5th postoperative day due to common iliac and popliteal arteries acute occlusion. Patient was urgently treated with iliac embolectomy with Fogarty's catheter, and femoral endarterectomy, followed on 1st post-operative day by external iliac artery stenting and multiple attempts of popliteal artery recanalization. After 4 years of follow-up, despite symptoms at rest were disappeared, a severe (, Highlights • Although rare, retrospective studies and surveys report an incidence ranging from 0.04% to 0.5%, direct major vascular injuries are well-known potential complications of laparoscopic surgery. • In the great majority of cases, iliac lesion become clinically evident as haemorrhagic lesions. • This is the first case of acute limb ischemia due to laparoscopic surgery related iliac lesion evaluated during a medical malpractice litigation.

Simple Summary Bacterial biofilms cause infections that are often resistant to antibiotic treatments. Research about the formation and elimination of biofilms cannot be undertaken without detailed imaging techniques. In this review, traditional and cutting-edge microscopy methods to study biofilm structure, ultrastructure, and 3-D architecture, with particular emphasis on conventional scanning electron microscopy and variable pressure scanning electron microscopy, are addressed, with the respective advantages and disadvantages. When ultrastructural characterization of biofilm matrix and its embedded bacterial cells is needed, as in studies on the effects of drug treatments on biofilm, scanning electron microscopy with customized protocols such as the osmium tetroxide (OsO4), ruthenium red (RR), tannic acid (TA), and ionic liquid (IL) must be preferred over other methods for the following: unparalleled image quality, magnification and resolution, minimal sample loss, and actual sample structure preservation. The first step to make a morphological assessment of the effect of the various pharmacological treatments on clinical biofilms is the production of images that faithfully reflect the structure of the sample. The extraction of quantitative parameters from images, possible using specific software, will allow for the scanning electron microscopy morphological evaluation to no longer be considered as an accessory technique, but a quantitative method to all effects. Abstract Several imaging methodologies have been used in biofilm studies, contributing to deepening the knowledge on their structure. This review illustrates the most widely used microscopy techniques in biofilm investigations, focusing on traditional and innovative scanning electron microscopy techniques such as scanning electron microscopy (SEM), variable pressure SEM (VP-SEM), environmental SEM (ESEM), and the more recent ambiental SEM (ASEM), ending with the cutting edge Cryo-SEM and focused ion beam SEM (FIB SEM), highlighting the pros and cons of several methods with particular emphasis on conventional SEM and VP-SEM. As each technique has its own advantages and disadvantages, the choice of the most appropriate method must be done carefully, based on the specific aim of the study. The evaluation of the drug effects on biofilm requires imaging methods that show the most detailed ultrastructural features of the biofilm. In this kind of research, the use of scanning electron microscopy with customized protocols such as osmium tetroxide (OsO4), ruthenium red (RR), tannic acid (TA) staining, and ionic liquid (IL) treatment is unrivalled for its image quality, magnification, resolution, minimal sample loss, and actual sample structure preservation. The combined use of innovative SEM protocols and 3-D image analysis software will allow for quantitative data from SEM images to be extracted; in this way, data from images of samples that have undergone different antibiofilm treatments can be compared.

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.

Vascular graft infection (VGI) is a rare but severe complication of vascular surgery that is associated with a bad prognosis and high mortality rate. An accurate and prompt identification of the infection and its extent is crucial for the correct management of the patient. However, standardized diagnostic algorithms and a univocal consensus on the best strategy to reach a diagnosis still do not exist. This review aims to summarize different radiological and Nuclear Medicine (NM) modalities commonly adopted for the imaging of VGI. Moreover, we attempt to provide evidence-based answers to several practical questions raised by clinicians and surgeons when they approach imaging in order to plan the most appropriate radiological or NM examination for their patients.

Introduction: The aim of the present study is to report the outcome of patients presenting an isolated type II endoleak (TIIEL) requiring reintervention and to identify clinical and anatomical characteristics potentially implicated in refractory TIIEL occurrence and fate. Materials and Methods: A multicenter retrospective study on TIIEL requiring reintervention was conducted between January 2003 and December 2020. Demographic and clinical characteristics, procedural technical aspects, reinterventions, and outcomes were recorded. TIIEL determining sac expansion greater than 10 mm underwent a further endovascular procedure aiming to exclude aneurismal sac. Redo endovascular procedures were performed via endoleak nidus direct embolization and/or aortic side branches occlusion. TIIELs responsible for persisting aneurysmal sac perfusion 6 months after redo endovascular procedures were classified as “refractory” and submitted to open conversion. Results: A total of 102 TIIEL requiring reintervention were included in the final analysis. Eighty-eight (86.27%) patients were male, the mean age was 77.32 ± 8.08 years, and in 72.55% of cases the American Society of Anaesthesiologists (ASA) class was ≥3. The mean aortic diameter was 64.7 ± 14.02 mm, half of treated patients had a patent inferior mesenteric artery (IMA), and 44.11% ≥ 3 couples of patent lumbar arteries (LA). In 49 cases (48.03%) standard endovascular aneurysm repair (EVAR) procedure was completed without adjunctive maneuvers. All enrolled patients were initially submitted to a further endovascular procedure once TIIEL requiring reintervention was diagnosed; 57 patients underwent LAs or IMA embolization (55.87%), 42 transarterial aneurismal sac embolization (41.17%), and three (2.96%) laparoscopic ostial ligations of the inferior mesenteric artery. During a mean follow-up of 15.22 ± 7.57 months (7–48), a redo endovascular approach was able to ensure complete sac exclusion in 52 cases, while 50 patients presented a still evident refractory TIIEL and therefore a surgical conversion or semiconversion was conducted. At the univariate analysis refractory TIIEL patients were significantly different from those who did not develop the complication in terms of preoperative clinical, morphological characteristics, and initial EVAR procedures: coronary artery disease occurrence (p = 0.005, OR: 3.18, CI95%: 1.3–7.2); preoperative abdominal aortic aneurysm (AAA) sac diameter (p = 0.0055); IMA patency (p = 0.016, OR: 2.64, CI95%: 1.18–5.90); three or more patent LAs; isolated standard EVAR without adjunctive procedures (p > 0.0001; OR: 9.48, CI95%: 3.84–23.4). Conclusions: Our experience seems to demonstrate that it is reasonable to try to preoperatively identify those patients who will develop a refractory TIIEL after EVAR and those with a TIIEL requiring reintervention for whom a simple endovascular redo will not be enough, needing surgical conversion.

The occlusion of superficial femoris artery (SFA) is a common feature in peripheral vascular disease, so the profunda femoris artery (PFA) is a crucial collateral pathway for the perfusion of the lower limb. The purpose of this study is to discuss the safety, clinical, and hemodynamic efficacy of profundoplasty on the basis of limb salvage, patency, and freedom from reintervention rates. Furthermore, this study aims to identify the risk factors linked to the failure of the procedure.The study is based on a retrospective analysis of prospectively collected data of identified patients who underwent profundoplasty from March 2005 to October 2015. All patients showed a hemodynamic stenosis, extended from the posterior wall of the common femoral artery (CFA) into the origin of the PFA and concomitant occlusion of SFA. Endarterectomy with patch angioplasty was performed in all cases. In patients with concomitant iliac occlusive disease, a hybrid treatment was carried out to restore an adequate inflow through an endovascular approach.Seventy-four profundoplasty were performed during the study period. Isolate profundoplasty was performed in 56 cases (75.7%), while in the remaining 18 cases (24.3%), concomitant endovascular treatment of iliac lesions was performed. Hemodynamic success was achieved in 90.5% of the cases. The mean ankle-brachial index significantly improved, rising from 0.36 ± 0.17 preoperatively to 0.57 ± 0.20 postoperatively (P 0.001). The median follow-up period was 33 months. Primary patency rate was 98.5% at 12, 36, and 60 months. Freedom from reintervention rate was 97% at 1 year and 95.3% at 3 and 5 years. Limb salvage rate was 96.9% at 1 year and 92.7% at 3 and 5 years. Survival rates were 86%, 60%, and 47.4% at 1, 3, and 5 years, respectively. Multivariate analysis identified Rutherford class 5 or 6 lesions as the strongest predictors of major amputation or reintervention (odds ratio, 9.37; confidence interval: 0.98-89.27; P = 0.05).Profundoplasty is a durable, safe, and effective procedure in terms of clinical and hemodynamic results for patients characterized by occlusion of SFA and stenosis of CFA extended to profunda ostium. For patients with Rutherford category 5 and 6 ischemia, the only profundoplasty does not seem to be adequate, and concomitant distal bypass should be necessary to improve limb salvage and decrease reintervention rate.

A 77-year-old male patient presented with a symptomatic, 66-mm pararenal aortic aneurysm. The patient was classified as unsuitable for open surgery due to significant comorbidities. Fenestrated or branched endografts were contraindicated due to the poor iliac access (6 mm diameter). A double Nellix with chimney endovascular aneurysm sealing (ChEVAS) technique was selected to exclude the pararenal aortic aneurysm and to preserve renal arteries and the superior mesenteric artery. Technical preplanning considered the ideal proximal landing zone to be close to the origin of the almost occluded celiac trunk and the distal common iliac arteries as the ideal distal landing zone. The total length of the aorta to cover was estimated as >180 mm, requiring 2 aortic EVAS systems, bilaterally overlapped. Technical success was achieved, and the patient was discharged on postoperative day 8 in good general condition. Successful aneurysm exclusion and target vessel patency without endoleak or stent-graft kinking or migration were confirmed at angio-computed tomography at 6 months.

Acute aortic occlusion is a rare but potentially devastating clinical event, which requires a prompt diagnosis and emergency treatment. Only 5 cases of native thoracic aorta acute occlusion have so far been reported with different pathologic causes. The clinical features depend on the level of occlusion. Sometimes the diagnosis could be misinterpreted as a stroke or other diseases of the central nervous system. This could lead to a delay in the diagnosis and revascularization procedure, followed by a morbidity or mortality increase. Open surgery has been considered the first-line approach. This study is of a female patient suffering from acute descending thoracic aorta occlusion undergoing, for the first time to our knowledge, endovascular surgical treatment.

Peripheral arterial disease (PAD) is one of the most common disabling diseases of the elderly. Critical limb ischemia (CLI) represents the most severe progression of PAD, threatening leg amputation. Revascularization is critical for limb salvage, prolonging survival, and improving the quality of life of patients with PAD. The ‘best vessel’ approach has been the traditional strategy used by surgeons when deciding the target vessel for intervention. Recently, angiosome-targeted revascularization to maximize healing of ischemic tissue lesions of the foot has gained popularity. However, this “idealized” anatomic concept has many theoretical and practical flaws, which make it difficult to generalize in patients with CLI. Many factors, such as quality of target vessel, role of pedal arch, extensive tissue loss and angiosome variability, need to be taken into consideration and this necessitates a more individualized approach for each patient.

Background ST2 represents an interesting biomarker associated with the progression of atherosclerotic disease. Methods This study aims to detect different ST2 serum concentrations, and intraplaque ST2 expression, in patients with symptomatic and asymptomatic carotid artery stenosis. Results The analysis of ST2 expression in the atheromatous plaque did not show any significant difference between symptomatic and asymptomatic patients (39.61 ± 35.97 vs. 38.49 ± 35.26; P = ns). ST2 serum concentrations of asymptomatic and symptomatic patients were statistically different with a concentration of 11.04 ± 8.95 ng/mL and 13.91 ± 8.01 ng/mL, respectively (P = 0.037). We observed statistical difference in serum ST2 levels between asymptomatic and symptomatic patients for cerebrovascular acute disease. No differences have been obtained in intraplaque ST2 expression. Conclusions Soluble serum ST2 levels can be a useful biomarker to identify patients at risk for cerebrovascular events.

Background: Atherosclerosis is a multifactorial disease characterized by an immune-inflammatory remodeling of the arterial wall. Treg and Th17 subpopulations are detectable inside atherosclerotic plaque; however, their behavior in symptomatic carotid artery stenosis (CAS) is not fully elucidated. The aim of this study was to evaluate Th17 and Treg subsets and their ratio in patients affected by symptomatic and asymptomatic CAS. Methods: 14 patients with symptomatic CAS (CAS-S group), 41 patients with asymptomatic CAS (CAS-A group), 32 subjects with traditional cardiovascular risk factors (RF group), and 10 healthy subjects (HS group) were enrolled. Th17 and Treg frequency was determined by flow cytometry and by histology and immunohistochemistry. Interleukin (IL)-10, IL-17, and metalloproteinase (MMP)-12 levels were measured by ELISA. Results: Th17 were significantly increased in CAS-A versus RF and versus HS. Tregs were significantly increased in CAS-S versus CAS-A. Tregs/Th17 ratio was significantly reduced in CAS-A versus RF and versus HS, whereas it was significantly increased in CAS-S versus CAS-A. Conclusions: The results of this study suggest that Th17 are related to the late stages of CAS but not to plaque instability. Moreover, Treg expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with brain injury. KEY MESSAGESTregs expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with CD4+ effector depletion and brain ischemic injury.Th17 lymphocytes are related to the late stages of CAS but not to plaque instability. Tregs expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with CD4+ effector depletion and brain ischemic injury. Th17 lymphocytes are related to the late stages of CAS but not to plaque instability.

This study aimed to evaluate the postoperative incidence of recurrent varicose veins (vv) and the possibility to differentiate the different types of recurrence.Patients who underwent surgery for saphenofemoral junction (SFJ) incompetence, great saphenous vein (GSV) varicosity and at least one perforator incompetence and varicosity of tributaries between January 1998 and December 2003 were selected for the study. Surgery consisted in SFJ flush ligation, GSV stripping, perforator vein ligature, and phlebectomies. Patients were assessed by detailed interview, clinical examination, and color duplex imaging after 10 years. The differentiation in recurrent, residual and progressive vv was done by comparison of the pre-and intraoperative and the phlebographic documentation in particular with the findings on follow-up..353 patients (400 legs) were analyzed at 120 ± 21 months. At follow up the vv were classified as recurrent in 23,75%, residual in 23,25%, and progressive in 21% of cases. Nine patients (1.9%) were reoperated after 70 ± 33 months, and 17 (3.5%) underwent sclerotherapy during follow-up.Recurrent, residual, and progressive vv can be clearly differentiated with the presented methodology. The authors suggest a revised definition (NEVVAS- new vv after surgery) because the term recurrent and the known acronyms do not embrace exactly the three types of vv after surgery. Since residual and many recurrent vv are due to avoidable technical or tactical errors, it is important to classify them properly in order to avoid these complications.Neovarices, NEVVAS (New Varicose Veins After Surgery), Neovascularization, Recurrent varicose veins, Residual varicose veins, Progressive varicose veins.Obiettivo di questo studio è di riconoscere l’esatta incidenza di varici recidive dopo chirurgia e di vedere se sono differenziabili le recidive vere dalle varici residue e dalle varici dovute ad una progressione della malattia varicosa.Per questo studio furono selezionati tutti i pazienti operati per un’insufficienza primaria della crosse con varicosità della VGS (Vena grande safena) e delle tributarie e con almeno una perforante insufficiente tra gennaio 1998 e dicembre 2003. La tecnica operatoria, cosidetta tecnica radicale secondo Babcock Cockett, consisteva in una legatura e resezione a raso della crosse safenofemorale, stripping della VGS, legatura e sezione di almeno una perforante e di flebectomie multiple. La differenziazione in varici residue, recidive e progressive avenne attraverso il confronto dei dati rilevati pre ed intra operatoriamente ed i risultati del controllo al follow-up. I reperti al follow-up vennero confrontati in particolare con la situazione flebografica preoperatoria.353 pazienti (400 arti) furono controllati a 120±21 mesi dall’intervento (percentuale di follow-up dell’88,6%). All’esame clinico furono diagnosticate vv (vene varicose) in 182 estremità (46%), confermate tutte all’ecocolordoppler. L’ecocolordoppler evidenziò altri 84 arti (20,5%) con vv, non visibili all’esame clinico. Pertanto l’incidenza totale (obiettività clinica e/o ecografica) di vv era del 66,5%, che si compone nel 23,25% di vv residue, nel 23,75% di vv recidive e nel 21% di vv progressive. In 11 casi (2,8%) la classificazione non era possibile per dati imprecisi o per flebografie mancanti.Il presente lavoro ha dimostrato come si possano distinguere nettamente tre entità diverse di vv dopo chirurgia applicando uno schema di documentazione preciso e prospettico basato su un parametro diagnostico affidabile. L’incidenza di varici recidive „vere“ era del 23,75%. Di consequenza viene proposto di sostituire il termine generale „vv recidive“ (REVAS) e di usare un acronimo piu confacente, denominato NEVAS (new varices after surgery- nuove varici dopo chirurgia). La classificazione dei diversi tipi ha un’importanza non solo scientifica e teorica, ma acquista significato clinico e profilattico se si considera che una varice residua può essere evitata con maggiore attenzione al mappaggio, con maggiore precisione nell’approccio ai punti di fuga e nella valutazione causale degli stessi. Le vv recidive invece debbono indurre il chirurgo a rivedere la sua tecnica e la precisione della stessa. Per la varice progressiva, spesso tralasciata in letteratura, purtroppo rimane solo la profilassi generale per l’insufficineza venosa cronica.

The study evaluated macrophage cytokines and macrophage metalloprotease (MMP)-12 levels in patients with Stanford-A acute aortic dissection (AAD) and in patients with critical carotid artery stenosis (CAS) compared with patients matched for age, sex, and traditional cardiovascular risk factors (RF). The aim was to identify possible early serum markers of risk for atherosclerotic complications.We selected 65 patients: 23 AAD patients, 21 CAS patients, 21 RF, and 10 healthy subjects (HS). In each patient and control serum, levels of interleukin (IL)-6, IL-8, tumour necrosis factor (TNF)-α, monocyte chemoattractant protein (MCP)-1, vascular endothelial growth factor (VEGF), and MMP-12 were assessed by ELISA.A significant increase of MMP-12, IL-6, and IL-8 levels in AAD versus CAS was found. Moreover, MMP-12 was shown to be significantly higher in AAD versus RF, but not in CAS versus RF. A significant increase of IL-6, IL-8, MCP-1, TNF-α, and VEGF levels was observed both in AAD and CAS versus RF.The results suggest that MMP-12 may be considered to be a specific marker of Stanford-A AAD. Furthermore, the study confirmed that in AAD and CAS macrophage cytokines play a key role in the progression of the atherosclerotic disease towards complications.

Objectives: The aim of the study was to determine whether the release by macrophages of matrix metalloproteinase (MMP)-12 and vascular endothelial growth factor (VEGF) - leading to inflammation, matrix degradation and neoangiogenesis - represents an effective pathway that underlies aortic wall remodeling in Stanford type A acute aortic dissection (AAD). Methods: Twenty-one consecutive patients with no genetic predisposition, with Stanford type A AAD were selected. In each patient, the levels of serum VEGF, MMP-12, serum interleukin (IL)-6, IL-8 and monocyte chemoattractant protein (MCP)-1 were evaluated using enzyme-linked immunosorbent assay. Ascending aortic specimens were collected for immunohistochemical identification of any presence of inflammatory infiltrate, VEGF and CD31 expression. Results: A significant increase in serum VEGF (p = 0.044), MMP-12 (p = 0.007), IL-6 (p = 0.0001), IL-8 (p = 0.0001) and MCP-1 (p = 0.0001) levels was observed in the AAD group compared to the control group. Furthermore, all AAD samples were positive for VEGF in the tunica media and showed vessel growth and immune-inflammatory infiltrate. A large number of cases (62.79%) showed inflammation at the edge of the dissection and approximately half (51.42%) showed neovessels growing at the edge of the dissection. Conclusions: The results suggest that VEGF-mediated angiogenesis and matrix degradation play a role in AAD. Finally, we believe that MMP-12 should be considered a marker of AAD.

Purpose: To evaluate the long-term results of endovascular and hybrid treatment in patients with Trans-Atlantic Inter-Society Consensus (TASC) II type “C” and “D” aortoiliac lesions and to highlight, in contrast to TASC II guidelines, the importance to analyze individually the lesions of a single iliac axis. Methods: From January 2008 to December 2012, 50 patients with TASC II type C and D aortoiliac lesions underwent endovascular or hybrid treatment. In 38 patients (76%), the lesions were treated by endovascular approach, while in 12 (24%) patients surgical treatment was adopted. All patients underwent a postoperative surveillance program at 1, 3, and 6 months for the first year and every 6 months thereafter. Results: Technical success was achieved in all patients (100%). The postoperative complication rate was 4%. Primary patency rate was 93.3% at 1 year, 90.2% at 2 years, and 86.6% at 3 years. Cumulative secondary patency rate was 97.7% at 1, 2, and 3 years. Survival after 1 and 2 years was 94.8% and after 3 years was 91.1%. Limb salvage was 100% for the entire period of follow-up. Conclusions: In contrast to TASC II guidelines, the endovascular or hybrid treatment should be considered a valid approach for type C and D lesions. The hybrid treatment, in selected cases, is an effective method to improve the runoff, which plays a key role in the success of the treatment of multilevel stenoocclusive lesions. In TASC II C to D iliac lesions, a specific overview of each axis is necessary in order to select the most appropriate treatment.

The purpose of the popliteal aneurysm surgical treatment is the prevention of thromboembolic events or the increase of the aneurysm size. Our prospectively collected data were analyzed with the aim to identify factors that could characterize the immediate and long-term success of the treatment, with particular regards to quality of life in terms of early recovery. From July 2004 to September 2012, 36 patients affected by 39 popliteal aneurysms have been treated. A total of 16 posterior accesses, 5 medial accesses, 12 above and below the knee joint medial accesses, and 6 endovascular accesses have been performed. Functional recovery, quality of life, as well as primary and secondary patency have been compared for different access. A complete sac excision before the graft repair has been obtained for all patients subjected to posterior or medial access with section of the goose foot tendons. The posterior access functional recovery has been compared with that of the patients subjected to medial access in terms of motility (p = 0.0001). The average follow-up was 27 months; the primary patency was 87 % and the secondary one 96 %. The limb salvage rate was 100 %. The posterior access offers a better aneurysm exposure and a better functional recovery.