Current state of education in venous diseases within vascular surgery training programs in Italy: A national web-based survey among residents.

BACKGROUND: To analyze the perception of vascular surgery trainees from Italian schools of Vascular Surgery regarding the level of practical and theoretical education in venous diseases. METHODS: An anonymous electronic survey was sent to Italian vascular surgery residents affiliated with 19 universities, asking about their training and experience in the management of venous diseases. The survey gathered information on the residents' personal and demographic details, their university's teaching program, operative experience in phlebology, as well as their confidence levels in performing various venous procedures, with the goal of analyzing the training and learning programs provided by Italian vascular surgery schools. RESULTS: The analysis showed that 28% of programs do not include phlebology in the curriculum, and more than 40% of residents are unable to independently perform venous duplex ultrasound or treat venous ulcers. Additionally, most residents (over 70%) have limited weekly exposure to phlebology cases, with only 5% having access to a dedicated phlebology operating room. The vast majority of residents (96%) expressed a strong desire to deepen their knowledge and skills in this field, particularly in areas such as endovascular ablation techniques, venous duplex ultrasound, and management of deep venous disease. CONCLUSIONS: The survey reveals significant limitations in phlebology education and hands-on experience within the current training programs, highlighting the need to standardize and enhance venous disease management education in order to ensure that future vascular surgeons are adequately equipped to provide high-quality care for patients with a wide range of venous disorders.

Discussing on the Aortic Coverage in Type B Aortic Dissection Treatment: A Comprehensive Scoping Review.

OBJECTIVE: The objective of this study is to investigate and address the question surrounding the determination of the optimal endograft length of coverage during TEVAR for type B aortic dissection (TBAD), with a particular emphasis on the distal landing zone (DLZ). DATA SOURCES: MEDLINE, Scopus, and Web of Science databases were used. METHODS: The PRISMA-ScR statement was followed. RESULTS: Several variables can contribute to the length of coverage during TEVAR in TBAD patient. Baseline patient's characteristics, TBAD-related features, the type of endoprosthesis, and postoperative graft behaviour may contribute to the choice of coverage. CONCLUSIONS: No robust data have been published regarding the optimal length of TEVAR. Therefore, reporting the percentage of covered aorta and improving computational studies should be valorised to improve postoperative outcomes.

The Other Side of Chronic Venous Disorder: Gaining Insights from Patients' Questions and Perspectives.

Venous disorders encompass a diverse range of manifestations and diseases, impacting a significant portion of the population. While life-threatening conditions are uncommon in non-thrombotic disorders, like telangiectasias or uncomplicated varicose veins (VVs), these conditions still have a substantial impact on affected individuals. Ensuring that patients are well informed about their venous disorder is a crucial step in their treatment journey. Providing them with valuable information regarding the disease's natural progression and available therapeutic options plays a pivotal role in optimizing their care. When patients are diagnosed with venous disorders, they often have numerous questions and concerns they want to discuss with their healthcare providers. Addressing these inquiries not only improves patients' knowledge and understanding but also influences their treatment compliance and overall outcomes. Therefore, it is of utmost importance to provide comprehensive explanations that address any doubts, uncertainties, and areas of confusion that patients may have. This report aims to present a concise, practical, and informative guide to venous disorders, focusing specifically on the common questions frequently raised by patients in everyday clinical practice. By serving as a valuable resource for healthcare professionals working in the field of venous diseases, this guide equips them with the necessary tools to effectively address patients' concerns and provide optimal care. By bridging the gap between patients' inquiries and medical expertise, this guide strives to enhance therapeutic outcomes and improve the overall management of venous disorders, ultimately empowering patients in their treatment journey.

High intensity focused ultrasound in treating great saphenous vein incompetence: Perioperative and 1-year outcomes.

BACKGROUND: To investigate the use of high intensity focused ultrasound (HIFU) for great saphenous vein (GSV) incompetence. MATERIAL AND METHODS: Patients with GSV incompetence underwent HIFU. The primary endpoint was the rate of GSV target segment shrinkage or closure after 1 year. RESULTS: Out of 188 limbs treated, the GSV treated segment shrinkage/closure rate at 1 week, 3 months, 6 months, and 12 months was 93.3%, 98.2%, 97.6%, and 98.3%, respectively. CONCLUSION: These preliminary results suggest that HIFU holds promise for the treatment of GSV incompetence. Further trials are needed to compare it with other techniques and assess long-term outcomes.

Three-year follow-up analysis of automated microfoam preparation system for great saphenous vein incompetence and varicose veins sclerotherapy treatment.

BACKGROUND: To describe the treatment of patients with great saphenous vein (GSV) incompetence and varicose veins (VVs), utilizing an Automated Microfoam Preparation System (AMPS, Varixio®, VB Devices, Barcelona, Spain). METHODS: Adults between January and June 2021 were included. The AMPS system was used for foam preparation. Sclerotherapy treatment followed international recommendations. The primary endpoint was GSV closure rate after 36 months. RESULTS: 164 patients were enrolled. During the 7-day follow-up period, all GSVs showed complete closure, which was maintained at the 1-year mark. No major complications were reported. A cumulative complete GSV recanalization rate of 6.1% and a partial recanalization rate of 26.8% after 36 months were noted. Some patients (9.7%) required additional treatment. A higher BMI was associated with complete recanalization. CONCLUSION: The AMPS offers an easy-to-use and standardized procedure, potentially enhancing treatment outcomes if compared with manual preparation. Caution is advised when treating obese patients.

Empty vein ablation (EVA) technique: an in-vivo animal model to assess the effects of sclerosing agent concentration and wall contact time on intima and media tunicae structure.

BACKGROUND: Sclerotherapy is a cornerstone of the treatment of chronic venous disease, despite some technical aspects (e.g., sclerosant liquid agent concentration [SLAC] and contact time between sclerosant agent and vein wall [ctSA/VW]) to maximize outcomes remain an unsolved problem and a source of debate. An innovative three-balloon catheter has been developed to allow sclerotherapy in empty vein conditions (Empty Vein Ablation technique, EVA), revolutionizing the definition of SLAC and ctSA/VW. Aim of this experimental study is to analyze EVA effects on intima and media vessel tunicae using different SLAC and ctSA/VW in an in-vivo animal model. METHODS: Two adult sheep were treated by EVA using jugular and common iliac vein axes (eight vein segments). Different SLAC (polidocanol 0.5% or 1%) and different ctSA/VW (3 or 5 minutes) were combined for testing residual circumferential intima percentage and media thickness after EVA. RESULTS: Intact circumferential residual intima after the treatment was 21.3±4.9%, 18.2±7.4%, 15.7±2.4% and 8.9±2.0% using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.945; control sample: 97.6%). Media thickness after the treatment was 121.6±35.3 µm, 110.9±7.8 µm, 96.1±30.4 µm and 79.1±34.1 µm using 0.5% (3 min), 0.5% (5 min), 1% (3 min) and 1% (5 min), respectively (R2=0.990; control sample 125.7 µm). No significant modifications were detected analyzing the adventitia in all samples. CONCLUSIONS: EVA proved to be effective in venous wall destruction even with a very low SLAC and ctSA/VW (0.5% in 3 minutes), in quite large caliber veins. Direct comparisons with foam/liquid sclerotherapy should be done to confirm therapeutic effectiveness of these results, despite EVA has provided a maximized and controlled SA/VW contact time and ratio.

A study protocol for evaluating aortic stiffness modifications in patients treated with endovascular aortic repair.

BACKGROUND: Arterial stiffness, particularly aortic stiffness (AoS), is associated with an increased risk of cardiovascular disease. Endovascular repair for abdominal (EVAR) and thoracic (TEVAR) aortic disease may increase AoS. This study protocol aims to assess changes in AoS before and after interventions for aortic disease. METHODS: Patients scheduled for EVAR or TEVAR during a three-year period will be enrolled. An indirect AoS indicator, carotid-to-femoral pulse wave velocity (cf-PWV) will be measured non-invasively using applanation tonometry and reported with others perioperative data before and after the endovascular treatment. Moreover, cardiological data will be collected through echocardiography. RESULTS: Fifty EVAR and 50 TEVAR will be enrolled. We will primarily analyze changes in cf-PWV. To ensure the reliability of our findings, we will also include supplementary data such as clinical information, morphological data, and functional echocardiographic data. CONCLUSIONS: By examining AoS modifications before and after endovascular aortic repair, this study aims to enhance our understanding of how arterial stiffness changes following endoprosthesis deployment. The findings from the applied protocol are expected to be informative for innovative graft designs with minimized mechanical mismatch with the aortic wall and with improved vascular hemodynamic, aligning with the current trend in improving patient outcomes. Moreover, understanding these modifications is important for predicting and improving long-term cardiovascular outcomes in patients undergoing such interventions.

Type III aortic arch angulation increases aortic stiffness: Analysis from an ex vivo porcine model.

Objective: The relationship among increased aortic arch angulation, aortic flow dynamics, and vessel wall stiffness remains unclear. This experimental ex vivo study investigated how increased aortic arch angulation affects aortic stiffness and stent-graft induced aortic stiffening, assessed by pulse wave velocity (PWV). Methods: Porcine thoracic aortas were connected to a circulatory mock loop in a Type I and Type III aortic arch configuration. Baseline characteristics and blood pressures were measured. Proximal and distal flow curves were acquired to calculate PWV in both arch configurations. After that, a thoracic stent-graft (VAMF2626C100TU) was deployed in aortas with adequate proximal landing zone diameters to reach 10% t0 20% oversizing. Acquisitions were repeated for both arch configurations after stent-graft deployment. Results: Twenty-four aortas were harvested, surgically prepared, and mounted. Cardiac output was kept constant for both arch configurations (Type I: 4.74 ± 0.40 and Type III: 4.72 ± 0.38 L/minute; P = .703). Compared with a Type I arch, aortic PWV increased significantly in the Type III arch (3.53 ± 0.40 vs 3.83 ± 0.40 m/second; P < .001), as well as blood pressures. A stent-graft was deployed in 15 aortas. After deployment, Type I arch PWV increased (3.55 ± 0.39 vs 3.81 ± 0.44 m/second; P < .001) and Type III arch PWV increased although not significantly (3.86 ± 0.42 vs 4.03 ± 0.46 m/second; P = .094). Type III arch PWV resulted the highest and significantly higher compared with the Type I arch after stent-graft deployment (3.81 ± 0.44 vs 4.03 ± 0.46 m/second; P = .023). Conclusions: Increased aortic arch angulation-as in a Type III arch-is associated with higher aortic PWV and blood pressures and this may negatively influence cardiovascular health.

Patients' Radiation Exposure During Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: To investigate associations between patient characteristics, intraprocedural complexity factors, and radiation exposure to patients during endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Elective standard EVAR procedures between January 2015 and December 2020 were retrospectively analyzed. Patient characteristics and intraprocedural data (i.e., type of device, endograft configuration, additional procedures, and contralateral gate cannulation time [CGCT]) were collected. Dose area product (DAP) and fluoroscopy time were considered as measurements of radiation exposure. Furthermore, effective dose (ED) and doses to internal organs were calculated using PCXMC 2.0 software. Descriptive statistics, univariable, and multivariable linear regression were applied to investigate predictors of increased radiation exposure. RESULTS: The 99 patients were mostly male (90.9%) with a mean age of 74 ± 7 years. EVAR indications were most frequently abdominal aortic aneurysm (93.9%), penetrating aortic ulceration (2.0%), focal dissection (2.0%), or subacute rupture of infrarenal abdominal aortic aneurysm (2.0%). Median fluoroscopy time was 19.6 minutes (interquartile range [IQR], 14.1-29.4) and median DAP was 86,311 mGy cm2 (IQR, 60,160-130,385). Median ED was 23.2 mSv (IQR, 17.0-34.8) for 93 patients (93.9%). DAP and ED were positively correlated with body mass index (BMI) and CGCT. Kidneys, small intestine, active bone marrow, colon, and stomach were the organs that received the highest equivalent doses during EVAR. Higher DAP and ED values were observed using the Excluder endograft, other bi- and tri-modular endografts, and EVAR with ≥2 additional procedures. Multivariable linear regression analysis revealed that BMI, ≥2 additional procedures during EVAR, and CGCT were independent positive predictors of DAP and ED levels after accounting for endograft type. CONCLUSIONS: Patient-related and procedure-related factors such as BMI, ≥2 additional procedures during EVAR, and CGCT resulted predictors of radiation exposure for patients undergoing EVAR, as quantified by higher DAP and ED levels. The main intraprocedural factor that increased radiation exposure was CGCT. These data can be of importance for better managing radiation exposure during EVAR.

Role of Preoperative Embolization in Surgical Management of Carotid Body Tumors: A Systematic Review and Meta-Analysis.

The objective of this study is to evaluate the effect of preoperative embolization on carotid body tumor resection. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. PubMed, Scopus, and Web of Science were screened for studies published between 2010 and 2022. Primary outcomes investigated were intraoperative blood loss, operative time, length of hospital stay, and perioperative complications such as transient ischemic attack (TIA)/stroke, vascular injury, and cranial nerve injury (CNI). A random effects model was used in cases where study heterogeneity was high. Overall, 25 studies were included in the systematic review, involving 1649 patients: 23 studies were eligible for meta-analysis. The incidence of vascular injury was significantly less in the preoperative embolization group (odds ratio (OR) = 0.60; 95% CI: 0.42-0.84; P = .003). There was no statistically significant difference between the two groups regarding intraoperative blood loss, operative time, length of hospital stay, incidence of TIA/stroke, and CNI. Subgroup analyses did not demonstrate significant difference between Shamblin I, II, and III subgroups regarding operative time. This meta-analysis found preoperative embolization to be significantly beneficial in reducing incidence of vascular injury.

Sex-Specific Morphometric Analysis of Ascending Aorta and Aortic Arch for Planning Thoracic Endovascular Aortic Repair: A Retrospective Cohort Study.

OBJECTIVE: In many studies on aortic disease, women are underrepresented. The present study aims to assess sex-specific morphometric differences and gain more insight into endovascular treatment of the ascending aorta (AA) and arch. METHODS: Electrocardiogram-gated cardiac computed tomography scans of 116 consecutive patients who were evaluated for transcatheter aortic valve replacement were retrospectively reviewed. Measurements of the AA and aortic arch were made in multiplanar views, perpendicular to the semi-automatic centerline. Multiple linear regression analysis was performed to identify predictors affecting AA and aortic arch diameter in men and women. Propensity score matching was used to investigate whether sex influences aortic morphology. RESULTS: In both sexes, body surface area (BSA) was identified as a positive predictor and diabetes as a negative predictor for aortic diameters. In men, age was identified as a positive predictor and smoking as a negative predictor for aortic diameters. Propensity score matching identified 40 pairs. Systolic and diastolic mean diameters and AA length were significantly wider in men. On average, male aortas were 7.4% wider than female aortas, both in systole and diastole. CONCLUSIONS: The present analysis demonstrates that, in women, increased BSA is associated with increased aortic arch diameters, while diabetes is associated with decreased AA and arch diameters. In men, increased BSA and age are associated with increased AA and arch diameters, while smoking and diabetes are associated with decreased AA and arch diameters. Men were confirmed to have 7.4% greater AA and arch diameters than women. CLINICAL IMPACT: Men had 7.4% greater ascending aorta and arch diameters than women in a retrospective cohort, gated computed tomography-based study of 116 patients. Sex-specific differences in ascending aortic and arch size should be considered by aortic endovascular device manufacturers and physicians when developing ascending and arch endografts and planning aortic interventions.

Utilizing numerical simulations to prevent stent graft kinking during thoracic endovascular aortic repair.

Numerical simulations of thoracic endovascular aortic repair (TEVAR) may be implemented in the preoperative workflow if credible and reliable. We present the application of a TEVAR simulation methodology to an 82-year-old woman with a penetrating atherosclerotic ulcer in the left hemiarch, that underwent a left common carotid artery to left subclavian artery bypass and consequent TEVAR in zone 2. During the intervention, kinking of the distal thoracic stent graft occurred and the simulation was able to reproduce this event. This report highlights the potential and reliability of TEVAR simulations to predict perioperative adverse events and short-term postoperative technical results.

Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community.

OBJECTIVE: The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years. METHODS: IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents. RESULTS: Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index. CONCLUSIONS: IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.

Outcomes After Endovascular Aortic Intervention in Patients With Connective Tissue Disease.

Importance: Endovascular treatment is not recommended for aortic pathologies in patients with connective tissue diseases (CTDs) other than in redo operations and as bridging procedures in emergencies. However, recent developments in endovascular technology may challenge this dogma. Objective: To assess the midterm outcomes of endovascular aortic repair in patients with CTD. Design, Setting, and Participants: For this descriptive retrospective study, data on demographics, interventions, and short-term and midterm outcomes were collected from 18 aortic centers in Europe, Asia, North America, and New Zealand. Patients with CTD who had undergone endovascular aortic repair from 2005 to 2020 were included. Data were analyzed from December 2021 to November 2022. Exposure: All principal endovascular aortic repairs, including redo surgery and complex repairs of the aortic arch and visceral aorta. Main Outcomes and Measures: Short-term and midterm survival, rates of secondary procedures, and conversion to open repair. Results: In total, 171 patients were included: 142 with Marfan syndrome, 17 with Loeys-Dietz syndrome, and 12 with vascular Ehlers-Danlos syndrome (vEDS). Median (IQR) age was 49.9 years (37.9-59.0), and 107 patients (62.6%) were male. One hundred fifty-two (88.9%) were treated for aortic dissections and 19 (11.1%) for degenerative aneurysms. One hundred thirty-six patients (79.5%) had undergone open aortic surgery before the index endovascular repair. In 74 patients (43.3%), arch and/or visceral branches were included in the repair. Primary technical success was achieved in 168 patients (98.2%), and 30-day mortality was 2.9% (5 patients). Survival at 1 and 5 years was 96.2% and 80.6% for Marfan syndrome, 93.8% and 85.2% for Loeys-Dietz syndrome, and 75.0% and 43.8% for vEDS, respectively. After a median (IQR) follow-up of 4.7 years (1.9-9.2), 91 patients (53.2%) had undergone secondary procedures, of which 14 (8.2%) were open conversions. Conclusions and Relevance: This study found that endovascular aortic interventions, including redo procedures and complex repairs of the aortic arch and visceral aorta, in patients with CTD had a high rate of early technical success, low perioperative mortality, and a midterm survival rate comparable with reports of open aortic surgery in patients with CTD. The rate of secondary procedures was high, but few patients required conversion to open repair. Improvements in devices and techniques, as well as ongoing follow-up, may result in endovascular treatment for patients with CTD being included in guideline recommendations.