Early Experience with Ovation Alto Stent-Graft.

BACKGROUND: Alto is the latest generation of the Ovation stent-graft platform for endovascular aneurysm repair (EVAR). Its ultra-low profile and its proximal sealing zone close to the lowest renal artery (≥7 mm) increase standard EVAR eligibility. We report early clinical and technical outcomes with the Alto stent-graft in our University Hospital Center after CE Mark approval in August 2020. METHODS: Seven patients (all male, mean age 76.1 ± 6.2 years) underwent EVAR with Ovation Alto stent-graft between June 2021 and February 2022. All the EVAR procedures were performed by a team of vascular surgeons experienced on EVAR with previous generation of Ovation platform. Follow-up consisted of duplex ultrasound examination at 1, 3, and 6 months and of a 1-month control computed tomography angiography (CTA). Patients treated gave consent to participate in this case series and publication. A descriptive analysis of variables was performed. SPSS (version 25) and Excel were used for statistical analysis. RESULTS: Most of the patients had a fusiform abdominal aortic aneurysm (n = 5; 71.4%). The median maximal transversal aortic diameter was 5.06 cm (range, 3.98-6.99). Because of hostile aortic neck anatomy, on-label EVAR was considered feasible only with Ovation Alto stent-graft. Narrow iliac arteries (<6 mm) were also present in 2 cases. All procedures were performed according to the instruction for the use of the device. Technical success was achieved in all cases. No type IA/IB/III endoleak occurred at completion angiography. No distal migration (>10 mm) but 2 distal displacements (≥2 mm) were observed at control CTA. During follow-up, duplex ultrasound and CTA showed no type I/III endoleak, no stent-graft migration (>10 mm), and no proximal aortic neck variations (P = not statistically significant). Three patients (42.8%) are under strict surveillance because of low-flow type II endoleak not associated with sac variations. CONCLUSIONS: Our early experience shows promising technical and clinical success with Alto stent-graft. The proximal relocation of the proximal sealing rings and the ultra-low profile delivery system allow on-label EVAR in a wider range of aortic anatomies. Notwithstanding, further studies, meta-analysis, and prospective registries are mandatory to evaluate mid- and long-term efficacy and safety of this latest Ovation platform.

Surgery for late type Ia/IIIb endoleak from a fabric tear and stent fracture of AFX2 stent graft.

Technical improvements and labeling updates of the AFX2 stent graft (Endologix Inc, Irvine, CA) seemed to have solved the known issues of its previous generation (AFX Strata). Although most endograft failures after endovascular abdominal aortic aneurysm repair will be managed endovascularly, a small subset of patients will still require secondary open conversion. Partial or complete endograft removal can be required, mainly dependent on the characteristics of the stent graft previously placed. We have report a case of secondary open conversion for late type Ia/IIIb endoleak due to stent fracture and fabric tear of the AFX2 stent graft 3 years after endovascular abdominal aortic aneurysm repair.

Could Gender Impact on Immediate and Long-term Carotid Artery Stenting Outcome? Insight from an Italian Single Center Experience.

BACKGROUND: Carotid artery stenting (CAS) has become a valid alternative to carotid endarterectomy in stroke prevention. However, female gender is still considered as an independent risk factor for CAS procedures, potentially limiting immediate and long-term benefits. Aim of present study was to evaluate gender differences in CAS submitted patients from an Italian high-volume center. MATERIAL AND METHODS: a retrospective monocentric study has been conducted on 568 patients (366 males and 202 females), submitted to CAS, between January 2000 and December 2019. Besides gender sex, clinical anatomical, and procedural data were collected as possible factors determining the outcome, when associated to sex gender itself. Primary endpoint of this study consisted in evaluating the technical and procedural success ratio, and the incidence of major and minor stroke, transient ischemic attack, acute myocardial infarction (AMI) peri-procedurally and at medium and long term, between the male and the female population. Secondary endpoint of this study consisted in evaluating the percentage ratio of minor complications happening peri-procedurally in both genders. RESULTS: Male patients were more likely to be octogenarians, clinical history of coronary artery disease, and smokers, while diabetes was more frequent in female patients. Anatomical and plaque morphology features were not different between the two groups. Technical success was obtained in all but two patients (99,6%), while procedural success was 95% (538/566 patients). During the peri-procedural time, no major stroke, 16 minor strokes (2,81%, 2,45% males vs. 3,45% females, P= 0,48), and 11 transient ischemic attack (2,18% males vs. 1,48% females, P= 0,56) were recorded. At a medium follow-up 57 months, 32 stroke (8 major strokes, 24 minor strokes) episodes (5,6%, males 5,7% vs. females 5,4%, P= 0,88), 24 AMIs (4,2%, males 4,6% vs. females 3,46%, P= 0,5;), 13 restenosis (2,8%, males 2,4% vs. females 1,9%, P= 0,71) and 223 deaths (39,2%, males 34,9% vs. females 47%, P= 0,0048) were noted. CONCLUSIONS: Our results showed no differences in immediate, and long-term CAS outcomes between gender. Larger, prospective studies are required to assess the real importance and significance of gender in determining CAS procedures' benefit and outcome.

Infrarenal Abdominal Aortic Aneurysm Endovascular Treatment: Long-term Results From a Single-Center Experience in an Unselected Patient Population.

BACKGROUND: The aim of the present study was to evaluate early-, mid-, and long-term outcomes in an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) with different commercially available off-the-shelf devices. MATERIALS AND METHODS: A retrospective study was conducted on a prospectively compiled computerized database on patients presenting an infrarenal AAA treated between January 2008 and December 2015 in a high-volume Italian tertiary referral Center. Demographic, clinical, and specific morphological features were considered as potentially influencing the outcomes and the type of the implanted device. Outcome measures were procedure-related reintervention, AAA-related, and all-cause mortality rates at 30-day, 12-month, and long-term follow-up. Reinterventions considered for the analysis were AAA rupture, graft infection, type I or III endoleaks, type II endoleaks with sac enlargement > 5 mm, graft stenosis or occlusions, procedures related to renal or visceral ischemia, and reintervention for access vessel injury. RESULTS: Of 498 EVAR procedures performed for elective infrarenal AAA treatment during the entire study period, 479 patients were enrolled, the mean age was 73.5 ± 7.34 years (range 51-91), and 416 (86.84%) were men. The mean maximum AAA diameter was 52.02 ± 8.04 mm (range 39-90.2), a maximum AAA diameter ≥59 mm was recorded in 107 patients (22.33%), and an aortic neck length was <10 mm in 137 (28.60%). Technical success was achieved in all patients. At a mean follow-up of 52.97 ± 26.16 months (range 1-120), overall reintervention and death rates were 8.14% and 20.04%, respectively, without AAA-related deaths. At univariate analysis, hypertension was the only demographical variable found to be associated with higher risk of reintervention, P = 0.04 (OR: 2.34; CI 95%: 1.00-5.42). Furthermore, male sex (P = 0.02; OR: 2.62; CI 95%: 1.09-6.27) and chronic renal insufficiency (P = 0.003; OR: 2.08; CI 95%: 1.27-3.42) were associated with higher mortality rates. AAA diameter ≥59 mm was statistically associated with a higher rate of both reintervention and mortality: P < 0.001 (OR: 9.05; CI 95%: 4.52-18.11) and <0.001 (4.00; 2.46-6.49), respectively. CONCLUSIONS: Our experience seems to suggest that EVAR could be safely and effectively performed in an unselected patients' population, with encouraging results up to a ten-year follow-up.

Peri-procedural brain lesions prevention in CAS (3PCAS): Randomized trial comparing CGuard™ stent vs. Wallstent™.

BACKGROUND: Aim of this study was to evaluate peri-procedural incidence of new diffusion-weighted-magnetic-resonance-imaging (DWMRI) brain lesions in CAS patients treated by carotid mesh stent (CGuard™) or closed-cell stent (Wallstent™). METHODS: Consecutive patients with asymptomatic carotid stenosis ≥ 70% were submitted to preoperative DW-MRI scan, to exclude the presence of preoperative silent cerebral lesions. Patients were randomized to CGuard or Wallstent. DWMRI was performed immediately after the intervention and at 72-hour postoperatively. Moreover, pre and postoperative Mini-Mental-State-Examination Test (MMSE) and a Montreal-Cognitive-Assessment (MoCA) test were conducted, and S100ß and NSE neurobiomarkers were measured at 5-time points (preoperatively, 2, 12, 24, and 48 h postoperatively). RESULTS: From January 2015 to October 2016, sixty-one consecutive eligible patients were submitted to preoperative DWMRI scan. Three patients were excluded because of preoperative silent cerebral lesions. In 29 CGuard patients, 1 developed a minor stroke and 8 silent new lesions were observed in the 72 h-DWMRI (31%): 4 lesions were ipsilateral, and 4 lesions were contra or bilateral. In 29 Wallstent patients, 7 clinically-silent new lesions were found in the 72 h-DWMRI (24.1%; p = 0.38). In 4 cases lesions were ipsilateral and in 3 cases contra or bilateral. S100B values doubled at 48 h in 24 patients, and among them 12 presented new DWMRI lesions. 48-h S100B increase was significantly related to 72-h DWMRI lesions (p = 0.012). CONCLUSIONS: In our experience both stents showed an acceptable rate of subclinical neurological events with no significant differences at 72-hour DWMRI between groups. Bilateral/contralateral lesions suggest that periprocedural neurological damage may have extra-carotid sources.

Abdominal Aortic Aneurysm Repair: Results from a Series of Young Patients.

Objectives. To compare durability and survival after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) in young patients. Material and Methods. A retrospective study was conducted between 2005 and 2014 on all consecutive patients of 60 years of age or younger. Measures considered for analysis were reintervention related to AAA, laparotomy and access vessel injury during EVAR, and all-cause mortality during hospitalization and follow-up. Results. Seventy out of 119 patients were treated by OR (58.8%) and 49 (41.2%) by EVAR, 9 in off-label fashion (18.3%). Technical success was achieved in all cases. No AAA-related death was recorded. Overall in-hospital mortality was zero and the reintervention rate was 2.5% (3/119: 1/70 OR, 2/49 EVAR, p = 0.36). There is no death at 30-day or 1-year follow-up. Thirty-day reintervention rate was 1.6% (2/119; 0/70 OR, 2/49 EVAR, p = 0.16), while the 1-year rate was 2.5% (3/119; 1/70 OR, 2/49 EVAR, p = 0.36). At the mean follow-up of 56.8 ± 42.7 months, mortality and reintervention rates were 5.8% (7/119; 3/70 OR, 4/49 EVAR, p = 0.38) and 10% (12/119; 8/70 OR, 4/49 EVAR, p = 0.39), respectively. The overall reintervention rate, mortality, and freedom from adverse events did not differ between the two groups. No differences in outcome were recorded between patients treated by EVAR in on-label versus off-label fashion. Conclusion. Our (albeit limited) experience suggests that, in an unselected young patient population undergoing elective AAA repair, OR or EVAR can be performed safely with similar immediate and long term outcomes.

Clinical and Functional Impact of Hypogastric Artery Exclusion During EVAR.

PURPOSE: Hypogastric artery (HA) revascularization during endovascular aneurysm repair (EVAR) is still open to debate. Moreover, exclusion-related complication rates reported in literature are not negligible. The aim of this study is to present and analyze the outcomes in patients undergoing EVAR with exclusion of 1 or both HAs at our academic center. METHODS: We retrospectively reviewed our results in patients submitted to EVAR and needing HA exclusion, in terms of perioperative (30-day) and follow-up rates of intestinal and spinal cord ischemia, buttock claudication, buttock skin necrosis, and sexual dysfunction. RESULTS: From January 2008 to December 2014, a total of 527 patients underwent elective standard infrarenal EVAR; among those 104 (19.7%) had iliac involvement needing HA exclusion. In 73 patients with unilateral iliac involvement (70.1%, group UH), many single HAs were excluded. Thirty-one patients (29.9%) had bilateral iliac involvement (group BH), of which 16 (51.6%) had 1 HA excluded with revascularization of the contralateral one (group BHR); in the remaining 15 patients (48.4%) both HAs were excluded (group BHE). No 30-day or follow-up aneurysm-related mortality, intestinal, or spinal cord ischemia were recorded. At 30 days, skin necrosis was observed in 2 patients. Buttock claudication and sexual dysfunction rates were significantly greater in group BHE than in group BHR (P < .05). At a mean 18.6 months follow-up (range: 4-47), buttock claudication and sexual dysfunction rates in group BHE were persistently higher than that in groups UH and BHR (P < .05); HA coil embolization was significantly associated with buttock claudication and sexual dysfunction (P < .05). CONCLUSIONS: Whenever anatomically feasible, at least 1 HA should be salvaged in case of bilateral involvement. In case of unilateral HA exclusion, the rate of complications is not negligible. Coil embolization is related to a higher complication rate.

Preliminary Results from a National Enquiry of Infection in Abdominal Aortic Endovascular Repair (Registry of Infection in EVAR--R.I.EVAR).

BACKGROUND: To preliminary report on epidemiology, risk factors, diagnosis, treatments, and outcomes in a multicenter series of patients treated for endovascular aortic repair (EVAR) infection and detected by an Italian National enquiry. METHODS: From June 2012, 26 cases of abdominal aortic endograft infection were collected by a National Enquiry and recorded in the Italian National Registry of Infection in EVAR. Cases collected were available for patients submitted to EVAR implantation from January 2004 to June 2013. RESULTS: Mean time from EVAR treatment to infection diagnosis was 20.5 ± 20.3 months (range, 1-72). In 6 cases (23.1%), an aortoenteric fistula (AEF) was detected. Positive microbiologic cultures were found in 20 patients (76.9%). More than 1 infectious agent was found in 6 cases (19.2%). EVAR infection treatment was conservative in 4 cases, endovascular in 2. Endograft excision was performed in 10 cases by conventional treatment (aortic stump + extra-anatomic bypass) and in 10 cases by in situ reconstruction (cryopreserved allograft or rifampin-soaked silver Dacron graft). A 30-day mortality was 38.4% (10 of 26 cases), 3 patients died from 2 to 24 months after infection treatment, accounting for a mean time from infection treatment to death of 1.25 ± 0.62 months. Mortality rates were 50% in all treatment groups. In those survived (13 of 26 cases) recurrence-free follow-up after infection treatment was 27.9 ± 22.4 months (range, 2-74). Four patients with AEF died in the first month after treatment (66.6%). Suprarenal endografts required supraceliac aortic cross-clamping for removal. Supraceliac cross-clamping was burdened by higher mortality rates than infrarenal cross-clamping (71.4% vs. 30.7%). CONCLUSIONS: EVAR infection diagnosis is burdened by extremely high mortality rates. Prospective registries could help monitoring outcomes in EVAR infection patients and, possibly, developing new surveillance protocols in patients at high risk of recurrence.

Preoperative Intrasac Thrombus Load Predicts Worse Outcome after Elective Endovascular Repair of Abdominal Aortic Aneurysms.

PURPOSE: To evaluate the impact of two-dimensional and three-dimensional preoperative morphologic features analyzed on computed tomography (CT) angiography on midterm outcome in patients with abdominal aortic aneurysms (AAAs) treated with endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: A retrospective analysis was conducted using a prospectively collected database. Morphologic features considered as potentially influencing outcomes were maximum aortic diameter, thrombus area, overall aneurysm volume, and intrasac thrombus volume. Outcome measures were all perioperative and midterm AAA-related reinterventions and all-cause mortality. RESULTS: Investigators reviewed 191 preoperative CT angiography scans. Mean maximum aortic diameter was 58 mm; thrombus area, 49.6%; aortic volume, 159.36 cm(3); and thrombus volume, 58.6%. Technical success was achieved in all cases. No reintervention was required in the perioperative period, and there was no perioperative mortality. At a mean follow-up of 32 months ± 16.8 (range, 3-66 mo), mortality rate was 9.4%, AAA-related death was 0, and reintervention rate was 8.9%. Causes of reintervention included type I endoleak (n = 3 [1.6%]), type II endoleak (n = 7 [3.7%]), type III endoleak (n = 1 [0.5%]), endograft limb thrombosis (n = 4 [2.1%]), and access vessel thrombosis (n = 2; 1%). Greater thrombus area (> 60%) and thrombus volume (> 59%) were predictors for reintervention (P = .005 and P = .0034). Greater maximum aortic diameter (> 59 mm) and aortic volume (> 159 cm(3)) were related to higher reintervention rate without statistical significance (P = .62 and P = .12). Aortic volume was a predictor of any adverse event, reintervention, and all-cause mortality after EVAR (P = .03). CONCLUSIONS: Thrombus area and volume are related to higher rates of reintervention. Maximum aortic diameter was related to a higher reintervention rate, but this was not significant.

Contralateral occlusion increases the risk of neurological complications associated with carotid endarterectomy.

Objective. To report on the incidence and factors associated with the development of perioperative neurological complications following CEA in patients affected by carotid stenosis with contralateral occlusion (CO) and to compare results between those patients and the whole group of patients submitted to CEA at our vascular division from 1997 to 2012. Methods. Our nonrandomized prospective experience including 1639 patients consecutively submitted to CEA was retrospectively reviewed. 136 patients presented a CO contralateral to the treated carotid stenosis. Outcomes considered for analysis were perioperative neurological death rates, major and minor stroke rates, and a combined endpoint of all neurological complications. Results. CO patients more frequently were male, smokers, younger, and symptomatic (P < 0.001), presented with a preoperative brain infarct and associated peripheral arterial disease (P < 0.0001), and presented with higher perioperative major stroke rate than patients without CO (4.4% versus 1.2%, resp., P = 0.009). Factors associated with the highest neurological risk in CO patients were age >74 years and preoperative brain infarct (P = 0.03). The combination of the abovementioned factors significantly increased complication rates in CO patients submitted to CEA. Conclusions. In our experience CO patients were at high risk for postoperative neurological complications particularly when presenting association of advanced age and preoperative brain infarction.

Abdominal aortic rupture and spondylodiscitis: emergent EVAR and staged spinal fixation.

Concomitant aortic aneurismal pathology and vertebral erosion are seldom reported in literature. The differential diagnosis between a primary vertebral disease affecting the aortic wall and a primary aortic pathology causing a vertebral disruption is quite difficult. We report on a patient presenting with increasing lumbar pain and neurologic lower limbs deficit due to a vertebral erosion accompanied by aortic rupture treated by emergent endovascular aortic repair procedure and then staged vertebral fixation. Microbiological tests on intraoperative periaortic fluid collection samples showed no clear sign of infection and clinical conditions progressively improved. At 12-month follow-up, the patient is in good clinical condition, with a small residual walking impairment and no clinical, laboratory, or imaging sign of aortic endograft infection.

Mandibular subluxation as an adjunct in very distal carotid arterial reconstruction: incidence of peripheral and cerebral neurologic sequelae in a single-center experience.

BACKGROUND: The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. METHODS: Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. RESULTS: MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). CONCLUSIONS: MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

Silent stroke and cognitive decline in asymptomatic carotid stenosis revascularization.

The aim of this study was to assess the relationship between serum levels of S100ß and neuron-specific enolase (NSE), postoperative diffusion-weighted magnetic resonance imaging (DW-MRI) and Mini-Mental State Examination (MMSE) score in asymptomatic patients affected by ≥ 70% carotid stenosis submitted to carotid endarterectomy (CEA) or carotid artery stenting (CAS), and to compare MMSE scores and DW-MRI findings at follow-up evaluations. Between April 2008 and April 2009, 60 patients were submitted to carotid intervention. All patients underwent DW-MRI and MMSE preoperatively, at 24 hours postoperatively, at 6 months and at 12 months. Neurobiomarkers were assessed for each patient at six time-points. Thirty-two patients were submitted to CEA and 28 to CAS. No mortality was observed. One CAS patient presented with an ischemic stroke. In six CAS patients and one CEA patient, new subclinical ischemic lesions were detected at postoperative DW-MRI (21.4% versus 3%, P = 0.03). In CAS patients, new DW-MRI lesions were significantly associated with MMSE score decline (P = 0.001). At 12 months, patients presenting with new postoperative ischemic lesions showed lower MMSE scores (P = 0.08). CAS patients showed increasing neurobiomarker levels compared with CEA patients (P = 0.02). In conclusion, microembolization effects may persist over time, so it should be avoided whenever possible. Carotid revascularization procedures should be evaluated and compared not only with respect to death/stroke but also to microembolism rates.

The need for emergency surgical treatment in carotid-related stroke in evolution and crescendo transient ischemic attack.

OBJECTIVE: The purpose of this study was to examine the safety of emergency carotid endarterectomy (CEA) in patients with carotid stenosis and unstable neurological symptoms. METHODS: This prospective, single-center study involved patients with stroke in evolution (SIE) or fluctuating stroke or crescendo transient ischemic attack (cTIA) related to a carotid stenosis ≥ 50% who underwent emergency surgery. Preoperative workup included National Institute of Health Stroke Scale (NIHSS) neurological assessment on admission, immediately before surgery and at discharge, carotid duplex scan, brain contrast-enhanced head computed tomography (CT) or magnetic resonance imaging (MRI). End points were perioperative (30-day) neurological mortality, NIHSS score variation, and hemorrhagic or ischemic stroke recurrence. Patients were evaluated according to clinical presentation (SIE or cTIA), timing of surgery, and presence of brain infarction on neuroimaging. RESULTS: Between January 2005 and December 2009, 48 patients were submitted to emergency surgery. CEAs were performed from 1 to 24 hours from onset of symptoms (mean, 10.16 ± 7.75). Twenty-six patients presented an SIE with a worsening NIHSS score between admission and surgery, and 22 presented ≥ 3 cTIAs with a normal NIHSS score (= 0) immediately before surgery. An ischemic brain lesion was detected in four patients with SIE and eight patients with cTIA. All patients with cTIA presented a persistent NIHSS normal score before and after surgery. Twenty-five patients with SIE presented an NIHSS score improvement after surgery. Mean NIHSS score was 5.30 ± 2.81 before surgery and 0.54 ± 0.77 at discharge in the SIE group (P < .0001). One patient with SIE had a hemorrhagic transformation of an undetected brain ischemic lesion after surgery, with progressive neurological deterioration and death (2%). CONCLUSIONS: Due to the absence of randomized controlled trials of CEA for neurologically unstable patients, data currently available do not support a policy of emergency CEA in those patients. Our results suggest that a fast protocol, including CT scans and carotid duplex ultrasound scans in neurologically unstable patients, could help identify those that can be safely submitted to emergency CEA.

SPREAD-STACI study: a protocol for a randomized multicenter clinical trial comparing urgent with delayed endarterectomy in symptomatic carotid artery stenosis.

RATIONALE: In patients with >50% carotid artery stenosis (as measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria) suffering a transient ischemic attack or a minor ipsilateral stroke, carotid endarterectomy exerts maximum benefits, when performed within the first 15 days from the initial ischemic symptom. It is also known that the probability of a major stroke spikes within the first few days after a transient ischemic attack/minor stroke and then flattens out in the following days and weeks. It could be hypothesized that urgent carotid endarterectomy has greater benefit than delayed procedure. AIMS: Demonstrate that urgent carotid endarterectomy is more effective than delayed interventions. DESIGN: Centers employing neurolgist/stroke physicians and vascular surgeons will enroll TIA or minor stroke patients with >50 % carotid artery stenosis (Nascet criteria), randomized in two groups: urgent carotid endarterectomy (within 48 hours) and delayed carotid endarterectomy ( operated between 48 hours and 15 days after onset of symptoms) Risk factors will be evaluated at enrollment. TIA will be classified by ABCD2 scoring system,and minor stroke by National Institutes of Health Stroke Scale (NIHSS) scores. The study will last 90 days per patient,starting from their initial symptom,and the follow-up will be performed by an indipendent neurologist. A total of 456 patients (228 / group) is needed to observe an absolute difference of 10% between groups. OUTCOMES: Primary end-point is reduction in all types of stroke, AMI or death in urgent endarterectomy groupo compared to delayed ones. Secondary end-points are: Reduction of ipsilateral ischemic stroke in group 1 with respect to Group 2 Identification of predictive risk factors and Confirmation of no different rate for hemorragic/ischemiccomplications between groups.

From embolization to remodeling: the need for early carotid endarterectomy in symptomatic carotid plaques.

Atheromatous plaques are dynamic structures undergoing continuous remodeling. Duplex ultrasound is now an accepted technique to classify the severity of arterial stenoses. It gives information about the ultrasonic echogenicity of tissue, the plaque surface and the velocity of blood flowing through vessels with the latest equipment. We report the case of a 59-year-old male patient with left hemispheric stroke and a 50% left carotid artery stenosis whose remodeling and reabsorption developed throughout three months from the onset of symptoms. Plaque surface and structural echomorphology assessment and standardization, along with the degree of carotid stenosis, might be helpful in identifying patients most likely to benefit from carotid endarterectomy.

Urgent carotid endarterectomy to prevent recurrence and improve neurologic outcome in mild-to-moderate acute neurologic events.

OBJECTIVES: This study evaluated the safety and benefit of urgent carotid endarterectomy (CEA) in patients with carotid disease and an acute stable neurologic event. METHODS: The study involved patients with acute neurologic impairment, defined as ≥ 4 points on the National Institutes of Health Stroke Scale (NIHSS) evaluation related to a carotid stenosis ≥ 50% who underwent urgent CEA. Preoperative workup included neurologic assessment with the NIHSS on admission or immediately before surgery and at discharge, carotid duplex scanning, transcranial Doppler ultrasound imaging, and head computed tomography or magnetic resonance imaging. End points were perioperative (30-day) neurologic mortality, significant NIHSS score improvement or worsening (defined as a variation ≥ 4), and hemorrhagic or ischemic neurologic recurrence. Patients were evaluated according to their NIHSS score on admission (4-7 or ≥ 8), clinical and demographic characteristics, timing of surgery (before or after 6 hours), and presence of brain infarction on neuroimaging. RESULTS: Between January 2005 and December 2009, 62 CEAs were performed at a mean of 34.2 ± 50.2 hours (range, 2-280 hours) after the onset of symptoms. No neurologic mortality nor significant NIHSS score worsening was detected. The NIHSS score decreased in all but four patients, with no new ischemic lesions detected. The mean NIHSS score was 7.05 ± 3.41 on admission and 3.11 ± 3.62 at discharge in the entire group (P < .01). Patients with an NIHSS score of ≥ 8 on admission had a bigger score reduction than those with a lower NIHSS score (NIHSS 4-7; mean 4.95 ± 1.03 preoperatively vs 1.31 ± 1.7 postoperatively, NIHSS ≥ 8 10.32 ± 1.94 vs 4.03 ± 3.67; P < .001). CONCLUSIONS: In patients with acute neurologic event, a high NIHSS score does not contraindicate early surgery. To date, guidelines recommend treatment of symptomatic carotid stenosis ≤ 2 weeks from onset of symptoms to minimize the neurologic recurrence. Our results suggest that minimizing the time for intervention not only reduces the risk of recurrence but can also improve neurologic outcome.

Factors influencing outcome after open surgical repair of juxtarenal abdominal aortic aneurysms.

The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance < or = 40 mL/min (p = .03) and female sex (p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.