Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry.

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.

Outcome Analysis From a Multicenter Registry on Unibody Stent-Graft System for the Treatment of Spontaneous Infrarenal Acute Aortic Syndrome (MURUSSIAS Registry).

PURPOSE: This study reports the outcomes from a Multicenter Registry on unibody stent-graft system for the treatment of spontaneous infrarenal acute aortic syndrome (MURUSSIAS registry). MATERIALS AND METHODS: The retrospective MURUSSIAS registry included spontaneous infrarenal acute aortic dissection (IAAS) managed with the unibody stent-graft system (AFX endovascular AAA system; Endologix Inc., Irvine, California) outside the current instruction for use. IAAS considered aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU). Indications to IAAS treatment were symptoms, associated dilated abdominal aorta (>3 cm), rapidly-growing (>0.5 cm/6 months) aorta, IAAS disease progression. Measured results were technical success, early (within 30 days) and midterm outcomes (after 30 days), including mortality, complications, symptoms recurrence, type I/III endoleak occurrence, stent-graft patency, survival, and freedom from reintervention. The mean follow-up was 22.12 ± 17 months. RESULTS: The MURUSSIAS registry included 83 patients from 7 participating centers. IAAS indication to treatment were symptoms in 42 (51%). In 14 (17%) patients, the infrarenal aortic length was <80 mm, and in 28 (34%), the aortic bifurcation diameter was <16 mm. Technical success was 100%. Mortality occurred early in 1 (1%) and at the midterm in 3 (4%) patients. Complications occurred early in 10 (12%) patients (1 severe, 3 moderates, and 6 mild) and at midterm in 2 (2%) (2 moderate). No symptoms' recurrence or type I/III endoleaks were registered. The 36-month estimated survival and freedom from reinterventions were 89% and 92%, respectively. CONCLUSIONS: The MURUSSIAS registry is the largest collection of spontaneous IAAS managed endovascularly using the AFX endovascular AAA system. The IAAS peculiar anatomic features were fitted with the used technique with excellent results. This treatment strategy might be considered in IAAS unless specifically-designed endovascular solutions will be available also in the emergent setting. Further studies are required to assess the longer-term performances and the stability of the reported technique. CLINICAL IMPACT: The lack of specifically designed devices for infrarenal acute aortic syndrome (IAAS) disease remains an issue principally for its specific anatomic features. The MURUSSIAS registry retrospectively examined the outcomes of spontaneous IAAS treated using the unibody stent-graft system in a spontaneous national study; and reports the largest available data on this topic. The use of the unibody stent-graft system showed to fit the anatomic peculiarities of IAAS with excellent outcomes. This IAAS treatment strategy should be considered unless specifically designed endovascular solutions will be available.

A Case of Multilevel Aortic Disease Treated Using Cardiatis Multilayer Flow Modulator.

A recent systematic review and meta-analysis shows that synchronous and metachronous thoracic and abdominal aortic aneurysms are present in 19.2% of cases. The management remains controversial: elective simultaneous TEVAR and EVAR could increase morbidity due to increased aortic coverage during a single procedure, longer operative times, increased blood loss, and greater contrast exposure. Conversely, simultaneous thoracic endovascular aortic repair (TEVAR) and endovascular aneurysms repair (EVAR) prevent the need for two interventions, reduces future access site complications, and obviates interval aortic complications. We present a case of a multilevel aortic disease treated in three stages: EVAR, TEVAR, and exclusion of an increasing aortic visceral penetrating aortic ulcer through a multilayer flow modulator endograft with an optimal result.

The role of cord blood platelet gel in the management of a diabetic foot with tendon exposure.

Diabetic foot infection is frequent in diabetic patients and is due to neuropathy, trauma or peripheral arterial disease. The presence of an abscess requires urgent drainage and specific antibiotic therapy. Patients with critical limb ischemia need revascularization and, subsequently the intervention of a plastic surgeon is often required in cases of exposure of tendons and ligaments. During the COVID-19 pandemic, a patient was refered to our department with an abscess on the dorsum of the left foot. After urgent drainage with tendon exposure, he started specific antibiotic therapy and underwent tibial vessels angioplasty. After infection healing cord blood platelet gel was applied, accelerating the healing process, with injection of its liquid part into the exposed tendons, thus retaining the vital functions of the tendons.

Stent-Graft Relining Using the Altura Endograft for Type Ia and IIIb Endoleaks after Kissing Iliac Arteries Stent.

A 79 years old man, affected by serious comorbidities, occurred to the Emergency Room of our Hospital complaining abdominal pain. He was previously submitted to kissing iliac arteries stent for iliac aneurysms. An urgent CT scan showed a type Ia and a type IIIb endoleaks with left common iliac artery enlargement, occlusion of both hypogastric arteries and inferior mesenteric artery, and a severe stenosis of the right iliac external artery. We opted for a relining with a two-piece D-shaped Altura endograft for the aorta, with bilateral iliac components, landing at the level of the external iliac arteries. Postoperative course was uneventful with no endoleak or endograft migration on CT scan control at 6 months.

A Case of Late Type Ia Endoleak After Endovascular Aneurysm Sealing Using the Nellix System: Proximal Extension with Triple Chimney and Gutter Endoleak Embolization.

An 87-year-old man, who submitted to endovascular aneurysm sealing (EVAS) on 2017, presented a type Ia endoleak 2 years later, with enlargement of the aneurysmal sac. We planned an endovascular procedure of correction consisting of a proximal extension through two covered stent grafts deployed into the previous Nellix stent grafts, with associated triple chimney. However, 3 months later, he had a further 5 mm aneurysmal sac enlargement. He was submitted to angiography with coil embolization of gutters, obtaining a successfully result. At 1 and 3 months, he is free from endoleak, with a stable aneurysmal diameter.

Use of cord blood platelet gel to enhance healing of deep surgical site dehiscences after peripheral bypass.

Surgical site dehiscence after lower limb revascularization through bypass represents a serious postoperative complication, especially in diabetic and obese patients, with subsequent risk of early graft failure, infection, sepsis, hemorrhage, major amputation and sometimes death. To prevent bypass exposure and subsequent complications, physicians recur to reoperation, antibiotic therapy, advanced dressing and vacuum-assisted closure therapy. To improve the process of wound healing, cord blood platelet gel can be used to fill deep and large wounds. Growth factors released from platelets in the cord blood platelet gel stimulate the process of healing and allow patients to be followed up in Outpatient Surgery, thus reducing hospital stay and costs, while providing excellent results.

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience.

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid-subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid-subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.

Endovascular Treatment of Juxtarenal Abdominal Aortic Aneurysms Recurring to the "Vent Technique".

BACKGROUND: Juxtarenal abdominal aortic aneurysms represent 15-20% of all abdominal aortic aneurysms (AAAs). The gold standard of treatment is represented by open surgical repair (OSR). Patients judged unfit for OSR could be submitted to fenestrated endovascular aortic repair (FEVAR) or the chimney technique. FEVAR requires 3-4 weeks for endograft production, a minimal length of 4 mm for proximal aortic neck and a large access vessels diameter, with high costs. The traditional chimney technique, feasible also in urgent cases, has a risk of type IA endoleak due to the space created between covered stents introduced into visceral arteries and the endograft. METHODS: In the present article, we report our experience about juxtarenal AAA (jAAA) treatment in 5 patients, recurring to uncovered bare metal stents associated with the ultralow profile Ovation endograft. RESULTS: No intraoperative complications or type IA endoleaks were recorded. Primary clinical success at 1 month was also 100%. During a mean follow-up period of 12.1 ± 3.6 months (range, 9-15 months), no complications related to aneurysm were recorded. CONCLUSIONS: The technique reported represents a valid endovascular option for jAAA treatment in patients at high risk for OSR. With respect to FEVAR, urgent patients should also be treated. With respect to traditional Ch-EVAR, the risk of type IA endoleak is reduced, with a lower rate of reoperation during follow-up. Preliminary clinical results are promising.

Successfully Kissing Stent of Innominate Artery and Left Common Carotid Artery Subsequent to Blunt Injury, in the Setting of a Bovine Aortic Arch.

Blunt injuries of the great vessels arising from the aortic arch are usually fatal. The innominate artery lesions represent the most common site of injury after the aortic isthmus distal to the left subclavian artery. Injuries are usually located at the origin of the vessel from the aortic arch, especially in patients with bovine aortic arch. Open traditional repair is a successful but invasive treatment, with long hospital stay and different possible complications. Although a bovine aortic arch presents an increased technical challenge, it is possible to achieve a complete and safe repair of the innominate artery injuries through a total endovascular treatment, with important reduction of risks and complications related to operation, compared to traditional open repair. We report the case of a 62-year-old man in our hospital with a posttraumatic pseudoaneurysm of the innominate artery in the setting of a bovine aortic arch, associated with a transection of the descending thoracic aorta. In the urgent setting, the patient was submitted to a kissing stent of innominate artery-left common carotid artery and deployment of thoracic endoprosthesis to exclude the aortic transection, with good final result.

Endovascular Treatment of a Carotid Pseudoaneurysm Using the New Double-Layer Micromesh Stent (Roadsaver®).

Pseudoaneurysm (PA) formation after carotid endarterectomy (CEA) is a very uncommon but dangerous complication, potentially responsible for cerebral embolism or rupture. Therefore, the PA treatment is imperative. Until few years ago, the treatment of choice was represented by open surgical repair, with a higher mortality and morbidity rate than primary operation. Actually, the advancements in endovascular procedures allow the surgeon the possibility to recur to a less invasive approach in the presence of an adequate anatomy, reducing the risk of cranial nerve injuries. We present a case of post-CEA PA successfully treated using the double-layer micromesh stent (Roadsaver®; Terumo, Tokyo, Japan), with almost immediate thrombosis of the aneurysmal sac.

Haemorrhage from varicose veins and varicose ulceration: A systematic review.

Varicose veins (VVs) and varicose ulceration (VU) are usually considered non-life-threatening conditions, but in some cases they can lead to major complications such as fatal bleeding. The aim of this systematic review is to evidence the most updated information on bleeding from VV and VU. As evidence acquisition, we planned to include all the studies dealing with "Haemorrhage/Bleeding" and "VVs/VU". We excluded all the studies, which did not properly fit our research question, and with insufficient data. As evidence synthesis, of the 172 records found, after removing of duplicates, and after records excluded in title and abstract, 85 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 68 articles because of the following reasons: (1) not responding properly to our research questions; (2) insufficient data; the final set included 17 articles. From literature searching, we identify the following main issues to be discussed in the review: epidemiology and predisposing factors, pathophysiology and forensic aspects, first aid. It has been estimated that deaths for bleeding due to peripheral venous problems account up to 0.01% of autopsy cases. From a pathological point of view, venous bleeding may arise from either acute or chronic perforation of an enlarged vein segment through the weakened skin. From a forensic point of view, in cases of fatal haemorrhage the death scene can even simulate non-natural events, due to crime or suicide. In most cases, incorrect first aid led to fatal complications. Further investigation on epidemiology and prevention measures are needed.

Endovascular Aortic Repair Complications and the Power of Endovascular Solutions.

We report the case of a 75-year-old man submitted to traditional endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysm. He presented a late type II endoleak 6 months after operation, initially without sac enlargement. One year later, a computed tomography scan control demonstrated a sac expansion >10 mm, also responsible for a secondary proximal type I endoleak. The patient was submitted to transarterial embolization of lumbar arteries through left internal iliac artery, followed by type I endoleak correction with a proximal cuff deployment. Intraoperative angiography revealed no signs of endoleak. Six months later, a sudden enlargement of the sac was detected, with evidence of type III endoleak, probably consequence of the lumbar arteries embolization, promptly corrected through an aortoaortic endograft. In conclusion, even if a conservative approach for type II endoleak without sac enlargement is proposed, sometimes a sudden sac enlargement could be responsible for catastrophic events in the absence of strict follow-up. The sac embolization during EVAR could reduce the incidence of type II endoleak during follow-up, with reoperation and hospital cost reduction.

Endovascular and open surgical treatment of complications after endovascular aortic aneurysm repair: A single-center experience.

While endovascular aortic aneurysm repair (EVAR) has proven to be a safer alternative to open surgical repair for infrarenal abdominal aortic aneurysms (AAA) repair, the development of stent-graft complications mandates follow-up computed tomography imaging to minimize AAA-related mortality. In this single-institution report, adverse EVAR events identified in 150 consecutive patients are detailed. Early morbidity was low (<3%), with only 1 patient death on post-procedure day 2. After discharge (mean follow-up of 24 months), 2 patients died from cancer and one AAA-related mortality occurred after open conversion for stent-graft migration. Although computed tomography imaging detected no EVAR endoleak at 30 days, 19 patients developed an endoleak, including three Type I and four Type III leaks. Our institutional series review confirmed that EVAR of infrarenal AAA is a safe and valid alternative to open surgical repair, but sac embolization at the primary procedure in patients judged to be at high risk for Type II endoleak should be considered.

Unstable atherosclerotic plaque in the common carotid artery: Diagnosis and treatment strategy.

The indication for carotid artery stenosis treatment is based primarily on the severity of internal carotid stenosis. There is increasing evidence that unstable plaques in the extracranial carotid artery can be responsible for ischemic stroke or transient ischemic attacks as the source of emboli, even if in the presence of a moderate stenosis. Physicians should be aware that morphological characteristics of the carotid plaques that indicate recent intra-plaque hemorrhage might require intervention in the absence of severe stenosis. This report details a patient with an unstable plaque in the common carotid artery who met clinical criteria for intervention because of the risk for future stroke.

Percutaneous drug-eluting balloon angioplasty to treat dialysis access stenosis.

A common complication of arteriovenous fistula for hemodialysis is development of conduit stenosis, which compromises function and can result in access thrombosis. Possible treatment options include open repair and endovascular therapy, with the latter preferred due to lower morbidity and similar outcomes. Recurrence of conduit stenosis is common and, based on the pathophysiology of this lesion, the application of drug-coated balloon angioplasty is attractive. In this report, the application of drug-eluting balloon angioplasty for dialysis access stenosis in 18 consecutive patients is detailed and primary patency rates of 82% at 1 year and 68% at 2 years were calculated.

Traumatic Anterior Knee Dislocation with Popliteal Artery Injury: The Importance of a Prompt Diagnosis and Treatment to Obtain Lower Limb Salvage.

We report a case of traumatic anterior dislocation of the left knee in association with disruption of the soft tissues including knee ligaments, popliteal artery, and common peroneal nerve, resulting in lower limb acute ischemia. All components of this complex trauma were recognized and treated promptly. First, he was submitted to closed reduction of the dislocated knee under general anesthesia; right after he underwent superficial femoro-tibioperoneal trunk bypass using a reversed saphenous contralateral vein recurring to a posterior approach through a popliteal S-shaped incision; rehabilitation program was initiated early; a second and final reconstructive orthopedic operation was carried out in a different center. The present case is important in 2 aspects. First, it reports a very rare occurrence of simultaneous anterior dislocation of the knee associated with vascular insult and common peroneal nerve injury, which was rarely reported in the current literature; second, it highlights that with timely intervention and a team approach, excellent results could be achieved.

Preliminary Results of Aorfix™ Stent Graft to Treat Infrarenal Abdominal Aortic Aneurysms with Severe Proximal Aortic Neck Angulation.

BACKGROUND: We report a preliminary experience about endovascular aortic repair (EVAR) of infrarenal abdominal aortic aneurysm (iAAA) with severe proximal aortic neck angulation (NA) using the Aorfix™ stent graft. METHODS: Data of consecutive patients with iAAA with severe proximal NA submitted to endovascular repair between September 2012 and December 2014 in 2 Italian centers of Vascular and Endovascular Surgery were retrospectively reviewed, and outcomes were analyzed using the software JMP 5.1.2. RESULTS: A total of 26 patients were treated. Median proximal NA was 87.5° (range 68-108°), and 3 patients were treated outside the instruction for use of Aorfix because of a proximal NA > 90°. Eleven patients (42.3%) had severe iliac tortuosity. The primary success rate was 92.3%, as 2 patients required intraoperative correction of a type Ia endoleak. Within 30 days, a right limb occlusion was successfully resolved with endovascular recanalization. The median follow-up period was 14 months (range 1-48 months): 1 patient died for neoplasm and 1 patient presented a type II endoleak from lumbar arteries at 3 months, which is still under surveillance. No other complications were reported during the follow-up period. CONCLUSIONS: Preliminary results with the Aorfix stent graft seemed to be promising in the aim of reducing endoleak and migration rates in presence of iAAA with severe proximal aortic NA.

Functional chronic venous disease: A systematic review.

Objectives Functional chronic venous disease is an underestimated syndrome quite present in the general population. It affects up to 20% of the general population and is based on the presence of venous symptoms without instrumental evidence of anatomic and morphologic damage. The aim of this review article is to provide the reader with the most updated information on this phenomenon. Methods Medline and Scopus databases were searched without time limit using the key-word: 'Functional chronic venous disease of legs', C0s patients. We decided to include all the studies conducted about functional chronic venous disease. Randomised trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Only publications in English were considered. We excluded all the studies with insufficient statistical analysis, possible biases and contradictions, not clear end-points, inconsistent or arbitrary conclusions. Results Of the 326 records found, after removal of 68 duplicates, 143 matched our inclusion criteria. After reading the full-text articles, 133 manuscripts were excluded. Ten full text articles were assessed for eligibility and four studies were excluded because of the following reasons: (a) no specific or important content and (b) insufficient data; the final set included six articles. Conclusions Functional chronic venous disease is a complex syndrome and further evidences are needed in order to assess the pathophysiology, the morbidity and the correct treatment of this venous dysfunction.