Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting.

PURPOSE: Aim of the study was to evaluate the influence of sex in asymptomatic patients undergoing carotid artery stenting (CAS). MATERIALS AND METHODS: A retrospective observational study was conducted from January 2006 to December 2020. A total of 438 consecutive patients with asymptomatic carotid artery stenosis >70% underwent transfemoral CAS and were stratified in males (M) and females (F). Periprocedural 30-day outcomes were: stroke, death, and myocardial infarction (MI). Follow-up outcomes were: death and stroke rates (primary) and freedom from restenosis (FFR) and reintervention rates (secondary). Follow-up data were analyzed at 1, 5, and 10 years. Data were analyzed with χ2 test and Fisher's exact test and follow-up outcomes with Kaplan-Meier curves. The log-rank test was used to determine differences between the groups and univariate analysis to identify the association between risk factors and intraoperative details with mortality and restenosis rates. RESULTS: A total of 462 procedures were performed (M: n=321, 69.4%), in which 24 CAS were bilateral (5.5%). Mean age was 71.9±7.6 years (M: 72.1±7.8; F: 71.7±7.3). Periprocedural outcomes were: stroke rate 2.2% (n=10; M: n=5, 1.6%; F: n=5, 3.5%; p=0.176), mortality rate 0.6% (M: n=3, p=0.334), and stroke/death rate 2.8% (n=13; M: n=8, 2.5%; F: n=5, 3.5%; p=0.528); no cardiac events (MI) were recorded. A not-disabling (minor) stroke was detected in 3 males (0.9%), while a disabling (major) stroke was reported in 7 patients (1.7%) of whom 5 were ischemic events (M: n=2, 0.6%; F: n=3, 2.2%) and 2 were cerebral hemorrhages (F: 1.3%, p=0.046). Mean follow-up was 73.66±40.83 months (M: 72.66; F: 76.01; p=0.246). Overall survival rate was 96.1% (95% confidence interval [CI]: 93-98), 81.8% (95% CI: 77-86), and 45.5% (95% CI: 38-53) at 1, 5, and 10 years, respectively (p=0.236). The overall stroke rate was 0.3% (freedom from stroke [FFS]: 99.7%; 95% CI: 98-100), 0.9% (FFS: 99%; 95% CI: 98-100), and 4.3% (FFS: 95.7%; 95% CI: 89-98; M: n=6; F: n=2; p=0.774). Stroke-related mortality rate was 0.7% (FFS: 99.3%; 95% CI: 97-100) and 2.9% (FFS: 97.1%; 95% CI: 91-99) at 5 and 10 years, respectively, without differences between the groups (M: n=4; F: n=2; p=0.763). Overall FFR rate was 97.4% (95% CI: 95-99), 93.4% (95% CI: 90-96), and 89.5% (95% CI: 84-93; p=0.322). Two severe symptomatic restenosis (>70%, M) required a new endovascular revascularization. CONCLUSION: The sex variable does not influence outcomes of CAS in asymptomatic patients at short- and long-term follow-up, although females show a worst incidence of periprocedural major strokes. Carotid artery stenting may be safely proposed when a careful patient selection is applied. CLINICAL IMPACT: The sex variable has been advocated as a considerable factor that could influence the outcomes of transfemoral carotid artery stenting (CAS). Literature data are contrasting, even if different papers mainly reported that CAS is associated to worst outcomes in female patients. Our study shows that the sex-variable does not influence outcomes of CAS in asymptomatic patients at short and long-term follow-up, although females had a worst incidence of periprocedural major strokes. CAS may be safely proposed when a careful patient selection is applied.

Outcomes of Endovascular Reconstructive Techniques in Trans-Atlantic Inter-Society Consensus II C-D Aortoiliac Lesions.

BACKGROUND: To describe the outcomes of the endovascular reconstruction of TASC C/D lesions involving the infrarenal aorta and aortic bifurcation with different techniques. METHODS: This is an observational, retrospective, single-center study. In a 5-year period, we selected all the patients treated with an endovascular procedure for an aorto-iliac TASC C/D lesion involving the infrarenal aorta and/or the aortic bifurcation. Early (<30 days) outcomes were mortality, major amputation, and thrombosis. Late mid-term (1 and 3 years) outcomes were primary, assisted primary and secondary patency, limb salvage rate, and freedom from reintervention. RESULTS: A total of 87 patients were treated during the index period. Kissing covered stent (cKS), covered reconstruction of aortic bifurcation (CERAB), and unimodular bifurcated AFX Unibody stent-graft (Bif-SG) implantation were performed in 35 (40.4%), 26 (29.8%), and 26 (29.8%) cases, respectively. Bif-SG group included 11 (11/26, 42.3%) patients treated for abdominal aortic aneurysm associated with the obstruction of the aortic bifurcation. Technical success was achieved in all cases and no ruptures or conversions to open surgery were recoded. Median follow-up age was 18 months (interquartile range [IQR], 8-34). Overall primary patency rate was 91.2% (95% confidence interval [CI]: 81.3-95.9) at 1 year and 83.5% (95% CI: 69.6-91.4) at 3 years. Assisted primary patency was 96.9% (95% CI: 87.8-99.2) at 1 and 3 years. Secondary patency was 97.8% (95% CI: 85.5-99.6) at 3 years. Limb salvage rate was 98.6% (95% CI: 90.1-99.7) at 1 and 3 years and, freedom from reintervention was 98.4% (95% CI: 88.9-99.7) at 1 year and 87% (95% CI: 66.1-95.4) at 3 years. Univariate analysis did not identify any factor affecting primary patency rate. CONCLUSIONS: Endovascular reconstruction in severe aorto-iliac obstructions using advanced techniques offered promising mid-term patency rates and profiles of safety. The variety of reconstructive configurations allows surgeons to customize on patients' anatomies the type of revascularization.

Hypogastric Artery Salvage Using an Unibody Bifurcated Aorto-Iliac Graft Associated to Double-Barrel Technique in Spontaneous Isolated Abdominal Aortic Dissection.

A 54-year-old male patient was admitted with acute left lower limb ischemia (ALI). Computed tomography (CT) angiogram showed an isolated abdominal aortic dissection (IAAD) with a single entry tear just proximal to the aortic bifurcation and an intramural hematoma (IMH) extending to the descending thoracic aorta. The IAAD involved the left iliac bifurcation, with a flow limiting dissection flap into the internal iliac artery (IIA) and external iliac artery (EIA) thrombosis with femoro-popliteal embolization. A surgical thrombectomy of the femoral arteries was performed. An unibody bifurcated endograft was deployed into the true lumen to cover the entry tear, and a double-barrel technique was employed to restore the flow into the EIA and to preserve the IIA patency. The postoperative period was complicated by a compartment syndrome of the calf, requiring a fasciotomy. Follow-up imaging after 12 months showed complete resolution of the IAAD and patency of the stented vessels.

Endovascular Bailout Repair After Intraprocedural Thrombosis of a Bifurcated Unimodular Stent-graft During Aorto-iliac Revascularization in a Patient with Sars CoV-2 Infection.

To describe a case of endovascular bailout strategy during stent-graft thrombotic complication in an endovascular procedure for complex TASC II D aortoiliac lesion. A 77-year-old patient was admitted at our institution with bilateral lower limb rest pain due to aortoiliac obstructive disease in a previous aortobifemoral bypass grafting with an asymptomatic Sars-CoV-2 infection. We planned an anatomic reconstruction of the aortoiliac segment with an unimodular bifurcated stent-graft. During the procedure, we observed a preocclusive thrombosis of the aortic portion requiring endovascular thrombectomy with vacuum assisted system followed by a successfully kissing-stent endolining. The post-operative period was uneventful and patient was discharged on the 14th post-operative day. Endovascular thrombectomy may be a helpful strategy during thrombotic complication of complex reconstructions of obstructive aortoiliac disease avoiding surgical conversion to laparotomy.

How the First Year of the COVID-19 Pandemic Impacted Patients' Hospital Admission and Care in the Vascular Surgery Divisions of the Southern Regions of the Italian Peninsula.

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study. Each received a 13-point questionnaire investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs. 2019 (9161 patients): post-EVAR surveillance, hospitalization for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased (1484 (16.2%) vs. 1014 (14.3%), p = 0.0009; 1401 (15.29%) vs. 959 (13.52%), p = 0.0006; and 1558 (17.01%) vs. 934 (13.17%), p < 0.0001, respectively), while admissions for revascularization or major amputations for chronic limb-threatening ischemia and urgent revascularization for symptomatic carotid stenosis significantly increased (1204 (16.98%) vs. 1245 (13.59%), p < 0.0001; 355 (5.01%) vs. 358 (3.91%), p = 0.0007; and 153 (2.16%) vs. 140 (1.53%), p = 0.0009, respectively). Conclusions: The suspension of elective procedures during the COVID-19 pandemic caused a significant reduction in post-EVAR surveillance, and in the hospitalization of asymptomatic carotid stenosis revascularization and Rutherford 3 peripheral arterial disease. Consequentially, we observed a significant increase in admissions for urgent revascularization for symptomatic carotid stenosis, as well as for revascularization or major amputations for chronic limb-threatening ischemia.