Total Endovascular Aortic Replacement in Post-Dissecting Thoraco-Abdominal Aortic Aneurysm with A New Inner Branched Device.

To describe a new inner-branched device used to treat two cases of chronic post-dissection aortic thoraco-abdominal aneurysms (PD-TAAAs) after ascending aortic surgery. A 67-year-old male who had undergone an ascending aorta and arch surgical replacement and a 70-year-old male with a previous Bentall procedure for acute type A aortic dissection were admitted at our department with a PD-TAAA diagnosis. Both patients were defined unfit for open surgery by a multidisciplinary team and a totally percutaneous endovascular repair was planned. A prophylactic cerebro-spinal fluid drainage was applied and at least one hypogastric artery was targeted for salvage in order to reduce the risk of spinal cord ischemia. A new inner branch device by Jotec® (GmbH/ Criolife; Hechingen, Germany/Kennesaw, Georgia) was implanted. A TEVAR and a standard EVAR completed the procedures and a double barrel technique was performed in order to achieve the preservation of the selected hypogastric artery. In both patients the complete technical success was achieved. The postoperative period was uneventful and the patients were discharged on the 6th and 7th postoperative day, respectively. The triple-phase angio-CT performed at 6 months showed the complete false lumen exclusion and the patency of the endografts and of the target visceral vessels. The total endovascular treatment of PD-TAAAs is a fascinating technique with encouraging results in experienced centers. Inner branched devices may expand the field of application of this new technology. More data are required to evaluate mid- and long-term results.

Soft and flexible piezoelectric smart patch for vascular graft monitoring based on Aluminum Nitride thin film.

Vascular grafts are artificial conduits properly designed to substitute a diseased blood vessel. However prosthetic fail can occur without premonitory symptoms. Continuous monitoring of the system can provide useful information not only to extend the graft's life but also to optimize the patient's therapy. In this respect, various techniques have been used, but all of them affect the mechanical properties of the artificial vessel. To overcome these drawbacks, an ultrathin and flexible smart patch based on piezoelectric Aluminum Nitride (AlN) integrated on the extraluminal surface of the prosthesis is presented. The sensor can be conformally wrapped around the external surface of the prosthesis. Its design, mechanical properties and dimensions are properly characterized and optimized in order to maximize performances and to avoid any interference with the graft structure during its activity. The sensorized graft is tested in vitro using a pulsatile recirculating flow system that mimics the physiological and pathological blood flow conditions. In this way, the ability of the device to measure real-time variations of the hemodynamics parameters has been tested. The obtained high sensitivity of 0.012 V Pa-1 m-2, joint to the inherent biocompatibility and non-toxicity of the used materials, demonstrates that the device can successfully monitor the prosthesis functioning under different conditions, opening new perspectives for real-time vascular graft surveillance.

Italian Percutaneous EVAR (IPER) Registry: outcomes of 2381 percutaneous femoral access sites' closure for aortic stent-graft.

AIM: The aim of this paper was to report outcomes of endovascular aneurysm repair with percutaneous femoral access (pEVAR) using Prostar XL and Proglide closure systems (Abbot Vascular, Santa Clara, CA, USA), from the multicenter Italian Percutaneous EVAR (IPER) registry. METHODS: Consecutive patients affected by aortic pathology treated by EVAR with percutaneous access (pEVAR) between January 2010 and December 2014 at seven Italian centers were enrolled in this multicenter registry. All the operators had an experience of at least 50 percutaneous femoral access procedures. Data were prospectively collected into a dedicated online database including patient's demographics, anatomical features, intra- and postoperative outcomes. A retrospective analysis was carried out to report intraoperative and 30-day technical success and access-related complication rate. Uni- and multivariate analyses were performed to identify factors potentially associated with an increased risk of percutaneous pEVAR failure. RESULTS: A total of 2381 accesses were collected in 1322 patients, 1249 (94.4%) male with a mean age of 73.5±8.3 years (range 45-97). The overall technical success rate was 96.8% (2305/2381). Major intraoperative access-related complications requiring conversion to surgical cut-down were observed in 3.2% of the cases (76/2381). One-month pEVAR failure-rate was 0.25% (6/2381). Presence of femoral artery calcifications resulted to be a significant predictor of technical failure (OR: 1.69; 95% CI: 1.03-2.77; P=0.036) at multivariate analysis. No significant association was observed with sex (P=0.28), obesity (P=0.64), CFA diameter (P=0.32), level of CFA bifurcation (P=0.94) and sheath size >18 F (P=0.24). The use of Proglide was associated with a lower failure rate compared to Prostar XL (2.5% vs. 3.3%) despite not statistically significant (P=0.33). CONCLUSION: The results of the IPER registry confirm the high technical success rate of percutaneous EVAR when performed by experienced operators, even in presence of demanding anatomies. Femoral calcification represents the only predictor of percutaneous access failure.

Endovascular treatment of aorto-iliac aneurysms: four-year results of iliac branch endograft.

INTRODUCTION: The aim of this report was to analyse early and mid-term outcomes of endovascular treatment (endovascular aneurysm repair, EVAR) for aorto-iliac aneurysms with the use of an iliac branch device (IBD). REPORT: A total of 85 EVAR procedures with IBD were electively carried out in 81 patients between September 2007 and August 2012. Technical success was obtained in 98.7% of the cases. The mean follow-up duration was 20.4 months (SD ± 15.4). There was one IBD occlusion (1.2%). Estimated 48 months' survival, freedom from re-intervention and branch occlusion were 76.7%, 88.3% and 98%, respectively. CONCLUSIONS: EVAR for aorto-iliac aneurysms using IBD is an effective procedure with low complication and re-intervention rates at mid-term follow-up.

A multicentric experience with open surgical repair and endovascular exclusion of popliteal artery aneurysms.

INTRODUCTION: The aim of this study was to analyse early and follow-up results of the treatment of popliteal artery aneurysms (PAAs) performed with open surgical repair or with endovascular exclusion with endografts in a multicentric retrospective registry involving seven Italian vascular centres. MATERIALS AND METHODS: We retrospectively collected data concerning 178 open surgical interventions (OR group) and 134 endovascular exclusions (ER group) for PAAs performed between January 2000 and December 2011. Early and follow-up results were analysed in terms of mortality, graft patency, reintervention and limb preservation. RESULTS: OR patients were more frequently symptomatic (64%, 115 cases) than patients in the ER group (34%, 51 cases; p < 0.001), had more frequently acute limb ischaemia (23% and 6.5%, respectively; p < 0.001) and had more frequently a run-off score <2 (39% and 26%, respectively, p = 0.03). In the OR group there were no perioperative deaths; six thromboses (3.3%) and one amputation occurred. In the ER group mortality was 1.5%; 13 thromboses (9.7%) and one amputation (0.5%) occurred. Mean duration of follow-up was 30.6 ± 27.5 months. In the OR group primary and secondary patency, freedom from reintervention and limb preservation rates at 48 months were 63.5% (standard error (SE) 0.05), 76.5% (SE 0.05), 72.5% (SE 0.06) and 89.7% (SE 0.05), respectively. The corresponding figures in the ER group were 73.4% (SE 0.04), 85% (SE 0.04), 75% (SE 0.04) and 97% (SE 0.04), respectively. CONCLUSIONS: In this large multicentric retrospective registry, open and endovascular treatment of PAAs are used in different patients with regard to clinical and anatomical characteristics. Both treatments are feasible and safe, providing satisfactory early and long-term results.

Comparison of open and endovascular treatments of post-carotid endarterectomy restenosis.

AIM OF THE STUDY: To compare early and long term results of open and endovascular treatment of post-carotid endarterectomy (CEA) restenosis in a single centre experience. METHODS: From January 2005 to December 2011, ninety-nine consecutive interventions for primary severe post-CEA restenosis were performed: in 41 cases (41%, Group 1) open repair was carried out, whereas the remaining 58 patients (59%, group 2) underwent an endovascular treatment. Data concerning these interventions were prospectively collected in a dedicated database containing main pre, intra and postoperative variables. Early results in terms of 30-day stroke and death rates were analysed and compared with χ(2) test. Follow-up results were analysed with Kaplan Meier curves and compared with log-rank test. RESULTS: Mean time from primary CEA was 75 months in group 1 and 42 months in group 2 (p = 0.002; 95% CI 12-52). There were no differences between the two groups in terms of demographic data, comorbidities, risk factors for atherosclerosis, preoperative clinical status or degree of stenosis on the operated side. In group 1 interventions consisted of redo-CEA in 37 patients and of carotid bypass in the remaining 4; all the patients in group 2 underwent stent placement with cerebral protection device. No perioperative deaths and ipsilateral neurological events occurred in both groups. One patient in group 1 suffered from a non-fatal acute myocardial infarction. Other six patients (14.5%) experienced transient cranial nerve injuries, with complete regression at 1-month follow-up; two patients had postoperative dysphagia due to neck haematoma, which was medically managed. Neither access-related nor systemic complications were recorded in group 2. Follow-up was available in 98% of the patients with a median duration of 24 months (range 3-72). There were no differences in terms of 4-year estimated survival and stroke-free survival, whereas patients in group 1 were more likely to develop severe (>80%) secondary restenosis (28.3% and 6.5%, respectively, p = 0.01, log rank 6.3) and to undergo secondary reintervention (22% and 11%, respectively p = 0.01, log rank 6). CONCLUSIONS: despite the selection limits and bias of this study, in our experience open and endovascular surgery provided similar perioperative results in the management of post-CEA restenosis. Long term outcomes are similar, too, despite a slight increase in secondary restenosis and recurrent reinterventions among open surgery patients, warranting further studies and analysis.

A 20-year experience with surgical management of true and false internal carotid artery aneurysms.

AIM OF THE STUDY: The aim of this study was to retrospectively analyse early and late results of surgical management of internal carotid artery (ICA) true and false aneurysms in a single-centre experience. MATERIALS AND METHODS: From January 1988 to December 2011, 50 consecutive interventions for ICA aneurismal disease were performed; interventions were performed for true ICA aneurysm in 19 cases (group 1) and for ICA post-carotid endarterectomy (CEA) pseudo-aneurysm in the remaining 31 (group 2). Early results (<30 days) were evaluated in terms of mortality, stroke and cranial nerves' injury and compared between the two groups with χ(2) test. Follow-up results (stroke free-survival, freedom from ICA thrombosis and reintervention) were analysed with Kaplan-Meier curves and compared with log-rank test. RESULTS: All the patients in group 1 had open repair of their ICA aneurysm; in group 2 open repair was performed in 30 cases, while three patients with post-CEA aneurysm without signs of infection had a covered stent placed. There were no perioperative deaths. Two major strokes occurred in group 1 and one major stroke occurred in group 2 (p = 0.1). The rates of postoperative cranial nerve injuries were 10.5% in group 1 and 13% in group 2 (p = 0.8). Median duration of follow-up was 60 months (range 1-276). Estimated 10-year stroke-free survival rates were 64% in group 1 and 37% in group 2 (p = 0.4, log rank 0.5); thrombosis-free survival at 10 years was 66% in group 1 and 34% in group 2 (p = 0.2, log rank 1.2), while the corresponding figures in terms of reintervention-free survival were 68% and 33%, respectively (p = 0.2, log rank 1.8). CONCLUSIONS: Surgical treatment of ICA aneurismal disease provided in our experience satisfactory early and long-term results, without significant differences between true and false aneurysms. In carefully selected patients with non-infected false aneurysm, the endovascular option seems to be feasible.

Alterations of haemorheological parameters in patients with peripheral arterial disease.

Peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis. Advances on the development of such vascular disease have described with a number of novel risk factors. Hyperviscosity, due to alterations of blood cells and plasma components, may play a role on the pathogenesis of the disease. Aim of this study was to evaluate the possible association between hemorheological variables and PAD. The hemorheological variables [whole blood viscosity (WBV), erythrocyte deformability index (DI), plasma viscosity (PLV)] were analyzed in 90 patients and in 180 healthy subjects. WBV and PLV were measured by a Rotational Viscosimeter and DI by a filtrometer. DI and PLV were significantly different in patients as compared to controls. To investigate the possible association between these parameters and the disease we divided the study population into tertiles. At the univariate analysis, we found a significant association between the highest tertiles of PLV, of DI and the disease. A model adjusted for traditional risk factors showed an association between highest tertiles of PLV and PAD. After adjustment for confounding parameters highest tertiles of PLV remained to be significantly associated with the disease. Our data indicate that an alteration of plasma viscosity may modulate the predisposition to PAD.

Results from an Italian multicentric registry comparing heparin-bonded ePTFE graft and autologous saphenous vein in below-knee femoro-popliteal bypasses.

AIM: The aim of this study was to evaluate early and follow-up results of below-knee bypasses performed with a bioactive heparin-treated ePTFE graft in patients with peripheral arterial obstructive disease (PAOD) in a multicentric retrospective registry involving seven Italian vascular centers and to compare them with those obtained in patients operated on with autologous saphenous vein (ASV) in the same centres in the same period of time. METHODS: Over a nine-year period, ending in 2010, a heparin bonded prosthetic graft (Propaten Gore-Tex, W.L. Gore & Associates Inc, Flagstaff, AZ, USA) was implanted in 556 patients undergoing below-knee revascularization for PAOD (HePTFE group). In the same period of time 394 below-knee bypasses with ipsilateral ASV were performed (ASV group). Data concerning these interventions were retrospectively collected in a multicenter registry with a dedicated database. Early (<30 days) results were analyzed in terms of graft patency, major amputation rates and mortality. Follow-up results were analyzed in terms of primary and secondary graft patency, limb salvage and survival. RESULTS: Among patients of HePTFE group, 413 had critical limb ischemia (74%); the corresponding figure for ASV group was 84% (332 interventions, P<0.001). Eighty-nine patients in HePTFE group (16%) and 207 patients in ASV group (52.5%; P<0.001) had distal tibial anastomosis. Patients in HePTFE group had more frequently adjunctive procedures performed at distal anastomotic sites in order to improve run-off status. Thirty-day death rate was 1.9% in HePTFE group and 0.5% in ASV group (P=0.08). The rates of perioperative thromboses and amputations were 6% and 3.5% in HePTFE group, and 5% and 1.7% in ASV group, without significant differences between the two groups. Mean duration of follow-up was 28.5±22.1 months; 921 patients (97%) had at least one postoperative clinical and ultrasonographic control. Estimated 48-month survival rates were 81% in HePTFE group and 74% in ASV group (P=0.7, log rank 0.1). Primary patency rate at 48 months was significantly better in ASV group (61%) than in HePTFE group (44.5%; P=0.004, log rank 8.1). The rates of secondary patency at 48 months were 57% in HePTFE group and 67.5% in ASV group (P=0.1, log rank 1.9); the corresponding values in terms of limb salvage in patients with critical limb ischemia were 77% and 79.5% (P=0.3, log rank 0.9), respectively. CONCLUSION: Data from this large, retrospective registry confirmed that the indexed heparin-bonded ePTFE graft provides satisfactory early and mid-term results in patients undergoing surgical below-knee revascularization. While autologous saphenous vein maintains its superiority in terms of primary patency, secondary patency and limb salvage rates are comparable.

Urgent carotid endarterectomy in patients with recent/crescendo transient ischaemic attacks or acute stroke.

OBJECTIVES: Objective of this study was to review the results of urgent carotid endarterectomy (CEA) performed in patients with recent (< 24 h) or crescendo (at least 2 episodes in 24 h) transient ischaemic attack (TIA) or with acute stroke in a single centre experience. MATERIALS AND METHODS: From January 2000 to December 2008, 75 patients underwent urgent CEA for severe internal carotid artery stenosis and recent/crescendo TIA (51 patients, TIA group) or acute stroke (24 patients, stroke group). In patients with acute stroke the intervention was proposed on the basis of clinical and instrumental features (patient conscious, patency of middle cerebral artery, no lesions or limited brain infarction at CT scan) according to neurologists' suggestion. Data from all the interventions were prospectively collected in a dedicated database, which included main pre-, intra- and postoperative parameters. Independent neurological assessment with National Institute of Health Stroke Scale (NIHSS) score calculation was performed before the operation and within the 30th postoperative day. Early (< 30 days) results were evaluated in terms of mortality, modifications in NIHSS values and stroke and death rates. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6 and 12 months and yearly thereafter. Follow-up results (survival, occurrence of ipsilateral stroke in TIA group, recurrence of stroke in stroke group) were analysed by Kaplan-Meier curves. RESULTS: Among patients presenting with TIA, 28 had crescendo TIAs and 23 had a recent TIA; In stroke group, two patients had a stroke in evolution, eight patients had a recent major non-disabling stroke and 14 patients had a recent minor stroke. Preoperative mean value of NIHSS score in stroke group was 4.7 (SD 3.2). There were 2 perioperative (< 30 days) deaths, both in stroke group, in one case due to acute respiratory failure and to fatal stroke in the other one (preoperative NIHSS value 9, postoperative 17), with a cumulative 30-day mortality rate of 2.7%, significantly higher in stroke group (8.3%) than in TIA group (no death, p = 0.03). No postoperative cerebral haemorrhage occurred. In TIA group one postoperative major stroke occurred, with a 30-day stroke and death rate of 1.9%. In surviving patients of stroke group NIHSS value improved in 13 cases, with a mean improvement of 2 points (SD 0.9); in 8 cases the value remained unchanged, while in the remaining case it increased from 2 to 4. Mean postoperative NIHSS score in stroke group was 3.9 (SD 3.7), significantly reduced in comparison with preoperative value (p < 0.001). Mean duration of follow-up was 34 months (SD 28.1). No ipsilateral stroke in patients of TIA group occurred; in stroke group a recurrent fatal stroke at 1 postoperative month was recorded. Estimated 48-month stroke-free survival rate TIA group was 95% and 79% in stroke group (p = 0.02). CONCLUSIONS: Urgent CEA in patients with recent/crescendo TIA provided in our experience excellent results, with low rates of perioperative and late stroke. In selected patients with acute stroke early surgery seems to provide acceptable results.

Endovascular repair of a ruptured popliteal artery aneurysm associated with popliteal arteriovenous fistula.

Popliteal artery aneurysms (PAAs) represent the most common peripheral arterial aneurysm and are a significant cause of patient morbidity and limb loss. Complications of PAA include distal embolisation, thrombosis and, rarely, rupture. Whereas open surgical repair remains the gold standard, endovascular exclusion has been demonstrated to be a valid alternative in selected patients. We present an unusual case of ruptured PAA associated with popliteal vein arteriovenous fistula that was successfully treated with an endovascular approach. In our opinion, higher-risk patients as well as patients presenting with rupture may constitute a subgroup warranting an endovascular approach whenever possible.

Carotid artery disease: novel pathophysiological mechanisms identified by gene-expression profiling of peripheral blood.

OBJECT: The pathogenesis of carotid artery stenosis (CAS) as well as the mechanisms underlying the different localisation of the atherosclerotic lesions remains poorly understood. We used microarray technology to identify novel systemic mediators that could contribute to CAS pathogenesis. Moreover, we compared gene-expression profile of CAS with that of patients affected by abdominal aortic aneurysm (AAA), previously published by our group. METHODS AND RESULTS: By global gene-expression profiling in a pool of 10 CAS patients and 10 matched controls, we found 82 genes differentially expressed. Validation study in pools used for profiling and replication study in larger numbers of CAS patients (n = 40) and controls (n = 40) of 14 genes by real-time polymerase chain reaction (RT-PCR) confirmed microarray results. Fourteen out of 82 genes were similarly expressed in AAA patients. Gene ontology analysis identified a statistically significant enrichment in CAS of differentially expressed transcripts involved in immune response and oxygen transport. Whereas alteration of oxygen transport is a common tract of the two localisations, alteration of immune response in CAS and of lipid metabolic process in AAA represents distinctive tracts of the two atherosclerotic diseases. CONCLUSIONS: We describe the systemic gene-expression profile of CAS, which provides an extensive list of potential molecular markers.

Hybrid treatment of aortic arch aneurysms.

AIM: Aim of this study was to retrospectively analyze the experience of a single center in the hybrid treatment of aortic arch aneurysms. METHODS: From January 2005 to August 2008 a hybrid treatment for complex aortic aneurysms (aortic arch, thoracoabdominal aorta or thoracic and abdominal segments at the same time) was performed in 34 patients. In 11 cases a hybrid exclusion of an aortic arch aneurysm was carried out. Perioperative results in terms of morbidity and mortality were assessed. Follow-up examination consisted of computed tomography scan and chest X-ray at discharge, 6 and 12 months, and yearly thereafter. Mid-term survival and graft-related complications were analyzed. RESULTS: All the patients were males with a mean age of 74 years, range 68-81. Intraoperative technical success was achieved in all the cases. At 30 days one patient died for an acute stroke. The overall 30-day mortality rate was 9.1%. One frenic nerve paralysis and one acute re-spiratory failure with pneumonia were observed with an overall 30-day major morbidity rate of 18.2%. During follow-up (mean duration 19.3 months, range 1-36) no death, reintervention, conversion, aneurysm-related complication or graft thrombosis were recorded. CONCLUSION: Hybrid approaches to the treatment of complex aortic lesions involving the arch can be successfully used. However, perioperative complications remain still not irrelevant and long-term efficacy has to be proved.

Protein Z-dependent protease inhibitor and protein Z in peripheral arterial disease patients.

SUMMARY INTRODUCTION: Protein Z is a vitamin K-dependent protein that serves as a cofactor for the inhibition of activated factor X by the serpin protein Z-dependent protease inhibitor (ZPI). Protein Z plasma levels have been shown to be reduced in patients with peripheral arterial disease (PAD), but ZPI levels have not yet been reported. The aim of this study was to more fully assess the protein Z-ZPI system in individuals with atherosclerosis selected by the presence of symptomatic PAD. MATERIALS AND METHODS: Protein Z and ZPI levels were determined in 95 PAD patients (73 males; 22 females) [median age: 73 years (range, 50-86 years)] and in 190 controls comparable for age and gender. Protein Z was measured using a commercial immunoassay, and ZPI was measured with a homemade immunoassay and a functional assay. RESULTS: Protein Z antigen, ZPI antigen and ZPI function were found to be significantly lower in PAD patients with respect to controls [protein Z, median 72.5% (range: 3.4-123.7%) vs. 90.7% (range: 32.1-203.2%), P < 0.0001; ZPI antigen, 86.1% (range: 25.1-149.5%) vs. 93.2% (range: 48.9-171.3%), P = 0.004; ZPI function, 83.5% (range: 21.1-135.2%) vs. 97.2% (range: 50.5-175.5%), P < 0.0001]. The lowest tertiles of protein Z antigen [odds ratio (OR) 5.4, 95% confidence interval (CI) 2.2-13.5, P < 0.0001] and ZPI function (OR 2.4, 95% CI 1.1-5.5, P = 0.03) were associated with PAD on multivariate analysis after adjustment for age, gender, and traditional cardiovascular risk factors. A significant inverse relationship was also observed between protein Z and ZPI levels and the number of traditional cardiovascular risk factors and the clinical severity of disease (Fontaine stage). CONCLUSIONS: Low levels of protein Z antigen and protein Z activity are significantly associated with the occurrence and severity of atherosclerotic PAD.

Gene expression profiling of peripheral blood in patients with abdominal aortic aneurysm.

OBJECT: Abdominal aortic aneurysm (AAA) pathogenesis remains poorly understood. This study investigated the gene expression profile of peripheral blood from patients with AAA using microarray technology. METHODS AND RESULTS: We determined gene expression profiles in pooled RNA from 10 AAA patients and 10 matched controls with arrays representing 14,000 transcripts. Microarray data for selected genes were confirmed by real-time PCR in two different AAA (n=36) and control (n=36) populations and integrated with biochemical data. We identified 91 genes which were differentially expressed in AAA patients. Gene Ontology analysis indicated a significant alteration of oxygen transport (increased hemoglobin gene expression) and lipid metabolism [including monoglyceride lipase and low density lipoprotein receptor-related protein 5 (LRP5) gene]. LRP5 expression was associated inversely with serum lipoprotein(a) [Lp(a)] concentration. CONCLUSIONS: Increased expression of hemoglobin chain genes as well as of genes involved in erythrocyte mechanical stability were observed in the AAA RNA pools. The association between low levels of LRP5 gene expression and increased levels of Lp(a) in AAA patients suggests a potential role of LRP5 in Lp(a) catabolism. Our data underline the power of microarrays in identifying further molecular perturbations associated with AAA.

Genetic analysis of 56 polymorphisms in 17 genes involved in methionine metabolism in patients with abdominal aortic aneurysm.

BACKGROUND: Previous studies suggested an association between abdominal aortic aneurysm (AAA) and hyperhomocysteinaemia, a complex trait determined by genetic and environmental factors. Our hypothesis was that polymorphisms in genes directly or indirectly involved in methionine metabolism may contribute to AAA susceptibility. METHOD: We studied 56 polymorphisms in MTHFR, MTR, MTRR, CBS, MTHFD1, SLC19A1, NNMT, TCN2, AHCY, BHMT, BHMT2, FOLH1, TYMS, ENOSF1, SHMT1, PON1, PON2 genes according to their demonstrated/putative function, localisation in promoter or regulatory and coding regions and/or heterozygosity values >0.300. Polymorphisms were evaluated by using a primer extension based microarray technology in 423 AAA patients and 423 matched controls. RESULTS: All polymorphisms resulted in Hardy-Weinberg equilibrium in patients and controls. At the multiple logistic regression analysis adjusted for traditional cardiovascular risk factors (sex, age, hypertension, smoking habit, dyslipidaemia, diabetes) and chronic obstructive pulmonary disease (COPD), rs8003379 MTHFD1 (odds ratio (OR) 0.41, 95% confidence interval (CI) 0.26 to 0.65) and rs326118 MTRR (OR 0.47, 95% CI 0.29 to 0.77) polymorphisms resulted in independent susceptibility factor for AAA. CONCLUSIONS: After haplotype reconstruction, logistic regression analyses adjusted for traditional risk factors and COPD showed a significant association among AAA and AHCY, FOLH1, MTHFD1, MTR, NNMT, PON1 and TYMS haplotypes. Our findings offer new insights into the pathogenesis of AAA.

Below-knee revascularization in patients with critical limb ischemia: long-term comparison of redo vs primary interventions.

AIM: The aim of this study was to evaluate the authors' experience in below-knee revascularization in patients with critical limb ischemia, comparing long-term outcomes in primary and secondary interventions. METHODS: From January 2000 to December 2006, 140 consecutive below-knee revascularizations in patients with critical limb ischemia were performed at the Department of Vascular Surgery of the University of Florence (Italy). In 105 patients (75%) a primary intervention was performed (Group 1). Early and long-term results in terms of survival, patency and limb salvage were compared with those obtained in the remaining 35 patients (25%) secondarily operated on in the same period for a late (>30 days) bypass graft thrombosis (Group 2). RESULTS: One patient died in the early postoperative period. Thirty-day thrombosis and amputation rates were poorer in Group 2 than in Group 1 (17.1% and 4.8%, P=0.02; 37.1% and 16.2%, P=0.01, respectively). Mean duration of follow-up was 25.1 months. At 60 months there were no differences between the two groups in terms of survival (90.1% in Group 1 and 90.9% in Group 2; P=NS), primary patency (43.5% in Group 1 and 31.9% in Group 2; P=NS) and secondary patency (48.4% in Group 1 vs 43.8% in Group 2; P=NS). Estimated 60-month limb salvage rate was significantly poorer in Group 2 than in Group 1 (64.1% and 77.7%, respectively; P=0.05). In Group 2 prosthetic graft material significantly affects 60-month limb salvage rate. CONCLUSION: Redo below-knee revascularization in patients with critical limb ischemia provides acceptable long-term results in terms of primary and secondary patency; however, limb salvage appeared to be slightly worse in patients undergone redo surgery.

The treatment of isolated iliac artery aneurysm in patients with non-aneurysmal aorta.

OBJECTIVES: The aim of the study was to evaluate early and mid-term results of surgical repair of isolated iliac artery aneurysm (IAA) in patients with non aneurysmal abdominal aorta. METHODS: From January 1996 to December 2006, 34 patients with IAA had elective surgery. In 32 cases open repair was performed. Two patients had endovascular repair using a tube endoprosthesis and internal iliac artery coil embolization. The diameters of the abdominal aorta and iliac arteries were measured preoperatively and during follow-up. Early and late results in terms of mortality, major morbidity, reinterventions and graft-related complications were recorded. Mean pre and postoperative diameters of abdominal aorta were compared. RESULTS: The site of the IAA was the common iliac artery in 29 cases (10 bilateral), internal iliac artery in 4 cases and external iliac artery in 1 case. Preoperative mean abdominal aortic diameter was 22.2mm (SD 7.6). There were no perioperative deaths and two major complications (retroperitoneal bleeding and limb ischemia) occurred. At the median follow-up time of 24 months survival was estimated as 91%. No reinterventions, graft thrombosis and graft related complications occurred. There were no cases of abdominal aorta aneurysm development. Mean aortic diameter at the most recent imaging was 23.1mm, which was not significantly different from preoperative values (p=0.2). CONCLUSIONS: Surgical treatment of IAAs provides good early and mid-term results. During mid-term follow-up the diameter of abdominal aorta remains stable, suggesting IAA may be a localized aneurysmal disease.