Celiac Artery Coverage After Thoracic Endovascular Aortic Procedure: A Meta-Analysis of Early and Late Results.

BACKGROUND/AIM: Clinical outcomes of celiac artery (CA) coverage during aortic procedures are often contradicting and the fate of this additional maneuver is still unclear. This study summarizes the results of available literature and aims to clarify the impact of CA coverage during thoracic endovascular aneurysm repair (TEVAR) in patients with inadequate distal sealing zone. METHODS: Prospective and retrospective, observational original articles focused on CA coverage during elective/urgent TEVAR for descending thoracic aortic pathology (DTAP) were included. PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials database were examined to identify articles published from January 2007 to December 2020, according to PRISMA guidelines. Early and late visceral (any sign or symptom reported) and neurological (both transient and permanent) complications were considered as primary outcomes. Onset of any endoleak, type IB endoleak, need of reintervention, and TEVAR-related mortality were considered as secondary outcomes. RESULTS: A total of 5618 articles were extracted for analysis and 13 studies were finally included in the synthesis. A total of 178 CAs were covered during 2653 TEVAR (7%). Spinal cord ischemia was 8% (95% CI, 5-14%, I2 0%) Any endoleak and type IB endoleak was observed in 12% (95% CI, 6-21%, I2 17%) and 5% (95% CI, 2-11%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reoperation was necessary in 8% (95% CI, 4-14%, I2 0%), the majority of which (14/18, 78%) performed for distal sealing failure; mortality rate was 9% (95% CI, 5-14%, I2 0%). Out of 178 patients, 168 (94%) were available for follow-up, ranged 12 to 42 months. Visceral complications, any endoleak, and type IB endoleak were identified in 15% (95% CI, 10-23%, I2 45%), 20% (95% CI, 13-29%, I2 8%), and 8% (95% CI, 4-15%, I2 0%), respectively. Thoracic endovascular aneurysm repair-related reintervention was required in 8% (95% CI, 4-14%, I2 0%). Mortality rate was 17% (95% CI, 12-25%, I2 4%). CONCLUSIONS: Celiac artery coverage in DTAP should be regarded as a "bailout" procedure especially in urgent/emergent settings but requires caution in elective cases. Even if transient visceral ischemia is frequent, life-threatening complications are rare. Early and late mortality rates are similar to standard TEVAR although the risk of type IB endoleak and reintervention may be an issue.

National Institutes of Health stroke scale score at admission can predict functional outcomes in patients with ischemic stroke undergoing carotid endarterectomy.

OBJECTIVE: The aim of present study was to evaluate the prognostic effect of the National Institutes of Health stroke scale (NIHSS) score for patients who had undergone acute carotid endarterectomy (CEA) and assess the clinical and morphologic factors that could predict for worse outcomes. METHODS: The data from 183 consecutive patients who had undergone CEA after ischemic stroke were analyzed from January 2015 to January 2021. The patients were divided into two groups using the NIHSS score cutoff of 4. Functional dependence was assessed at hospital discharge and 90 days after discharge. RESULTS: Of the 183 patients, 102 (55.7%) had had a minor stroke (group A; NIHSS score of ≤4) and 81 (44.3%) had had a moderate to major stroke (group B; NIHSS score >4). Groups A and B showed significant differences in their intracranial anatomic features, including the presence of an incomplete circle of Willis (7.8% vs 17.3%; P = .05), cerebral ischemic lesion volume ≥4000 mm3 (5.9% vs 24.7%; P ≤ .001), and a high Alberta stroke program early computed tomography score of 8 to 10 (75.5% vs 44.4%; P ≤ .001). The overall rate of combined perioperative stroke, myocardial infarction, and death was 1.1%, with no strokes recorded during the interval to CEA. Patients in group A had a lower rate of functional dependence at discharge (4.9% vs 35.8%; P ≤ .001) and at 90 days after the index stroke event (2.5% vs 19.6%; P ≤ .001) compared with those in group B. Using multivariate binary logistic regression, an admission NIHSS score >4 was significantly associated with higher odds of functional dependence at discharge (odds ratio, 7.9; 95% confidence interval, 2.7-18.5; P ≤ .001) and at 90 days (odds ratio, 10.4; 95% confidence interval, 2.7-19.3; P = .002). CONCLUSIONS: An NIHSS score >4 at admission increased the risk of a higher modified Rankin scale score at both hospital discharge and 90 days after the index stroke event. Acute CEA was safe and feasible for patients with ischemic stroke, even if they had previously undergone intravenous thrombolysis.

Sheath-Anchoring for Rail Guidewire Technique to Advance and Deploy Thoracic Endograft in Hostile Anatomy.

BACKGROUND: To describe a bailout technique to advance and precisely deploy thoracic endograft in the ascending aorta in case of difficulty crossing the aortic arch. CASE REPORTS: A 73-year-old man presented with a large ruptured aneurysms in the descending aorta. During the TEVAR, stent-graft passage through the aortic arch was impossible due to the severe tortuosity of the aorta. The problem has been resolved using the sheath-anchoring rail guidewire (SARG) technique. RESULTS: Through an axillary access, a snare was used to capture the stiff wire from the femoral access. A sheath was advanced over the stiff wire to the ascending aorta and placed there. By exploiting the grip of the sheath on the stiff in the ascending aorta, it was possible to handle the tension, move the delivery system through the arch and carefully deploy the graft. CONCLUSION: The SARG is a simple and quick learning technique which can be useful for Physicians dealing with complex aortic arch anatomy.

Impact of Cone Beam Computed Tomography in Advanced Endovascular Aortic Aneurysm Repair Using Last Generation 3D C-arm.

BACKGROUND: To report the early outcomes of cone beam computed tomography (CBCT) using last generation 3D C-arm in patients undergone advanced endovascular aortic aneurysm repair (AdEVAR) and to identify risk factors that may predict any un-planned procedures. METHODS: Patients undergone AdEVAR between December 2017 and December 2018 were enrolled. Final CBCT was performed in all patients after digital subtraction angiography. Primary end points were the incidence of any positive findings and the following unplanned procedures intended as any endovascular manoeuvre performed to fix such technical defect. The secondary endpoints were comparison of outcomes between patients with positive findings undergone unplanned procedure (Group A) versus patients without findings (Group B). RESULTS: 132 patients underwent endovascular treatment for aortic aneurysm. Of these, 22 (33%) fenestrated-branched endovascular aneurysm repairs (F-BEVAR), 21 (29%) EVAR with iliac branch devices, 19 (26%) abdominal and 10 (14%) thoracic EVAR were included in the study. Unplanned procedures after CBCT were necessary in 22 patients (31%). Patients in both groups were similar excepted for BMI >25 kg/m2 (55% vs. 26%), hostile iliac anatomy (64% vs. 32%) and previous aortic treatment (73% vs. 32%) (P < 0.05). The odds ratios for unplanned procedure in case of previous aortic treatment was 6.76 (95% CI, 1.97-23.16; P = 0.002). CONCLUSION: The use of CBCT, especially in challenging scenarios, can reveal technical defects and may potentially limit the need for late reintervention. Patients undergone previous aortic surgery should be carefully evaluated and routine CBCT should be performed.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia.

OBJECTIVE: The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI). METHODS: This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan-Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement. RESULTS: Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford's category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different (p = .006). Group 1 had significantly lower amputation rate at 36 months (p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40-36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02-0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07-16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02-0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015-29.95, p = .002) were the significant independent predictors of LCI. CONCLUSION: The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

Early and Long-term Results of ePTFE (Gore TAG®) versus Dacron (Relay Plus® Bolton) Grafts in Thoracic Endovascular Aneurysm Repair.

BACKGROUND: The aim of this study is to compare early and late results of an expanded polytetrafluoroethylene (ePTFE-Gore TAG®, group A) mesh structured endograft versus a Dacron one (Relay Plus® Bolton, group B) in thoracic endovascular aneurysm repair (TEVAR). METHODS: A prospective database was used to extract information from anonymous patients who underwent TEVAR for descending thoracic aortic aneurysms (DTAAs) between February 2005 and February 2019 at 3 referral university hospitals. Cases treated by means of ePTFE endograft (Gore TAG, group A) and Dacron graft (Relay Plus Bolton, group B) in elective and urgent settings were included. Early and late outcomes were compared. RESULTS: A total of 129 consecutive patients were included (115 men and 14 women). ePTFE-Gore TAG® and Dacron-Relay Plus® Bolton were used in 56 (43.4%) and 73 (56.5%) patients, respectively. Preoperative characteristics of patients were similar. Technical success was 100%. Urgent procedures were 22.4%. Mean aortic coverage and partial debranching were 217.5 ± 91.3 and 37.2%, respectively. Early mortality and spinal cord ischemia (SCI) were 8.5% and 2.3%, respectively, without differences between the 2 groups. Early reintervention was required in 5.4% (group A) and 11% (group B), P = 0.29. Median follow-up was 32 months (interquartile range 12-55 months, range 1-156 months), similar between the 2 groups. Type I endoleak (EL), type II EL, and type III EL were observed in 16.3%, 10.9%, and 3.1% of cases, respectively, without significant differences between the groups. The rate of sac shrinkage was 28.6% in group A vs. 39.7% in group B (P = 0.19). Freedom from reintervention in group A versus group B at 6, 12, 24, and 36 months was 94.0% vs. 97.1%, 94.0% vs. 95.5%, 90.8% vs. 86.9%, and 81.1% vs. 80.4%, respectively (log-rank 0.35, Breslow 0.54). Rate of survival at 6, 12, 24, and 36 months was 96.0% vs. 94.2%, 89.3% vs. 86.8%, 76.5% vs. 77.5%, and 63.3% vs. 64.2%, respectively (log-rank 0.30, Breslow 0.57). CONCLUSIONS: ePTFE-Gore TAG and Dacron-Relay Plus Bolton in DTAA presented similar early and late results in terms of mortality, SCI, EL, and TEVAR-related reinterventions. Effectiveness of TEVAR procedure was confirmed by the high rate of sac shrinkage and it was not influenced by endograft fabric.

Carotid Endarterectomy with Modified Eversion Technique: Results of a Single Center.

BACKGROUND: Carotid endarterectomy (CEA) has a wide range of approaches based on personal expertise and preference. We evaluated our outcome with CEA with modified eversion technique (meCEA) under local anesthesia and whether the surgeon's experience could influence it. METHODS: at our Institution, 837 patients underwent CEA across 8 years. Although the surgical technique was standardized, 2 groups were considered further: meCEA performed by a single Senior Operator (Group A) and meCEA performed by 4 young Consultants (Group B). RESULTS: A selective shunting policy was needed in 5.1%, together with general anesthesia. Overall operative time was 63.9 ± 15.1 minutes (61.4 ± 12.5 and 66 ± 16.9 minutes in Group A and Group B respectively; P < 0.001) and cross-clamp time 19.3 ± 2.9 minutes (19.0 ± 3.2 vs. 19.5 ± 2.8, P = 0.009). At 30 days, 0.7% TIA and 0.8% strokes were recorded. No differences (p = N.S.) between the 2 study groups in terms of postoperative neurological complications, with postoperative ipsilateral strokes always < 1%. At a median imaging follow-up of 22.5 months, the overall percentage of restenosis was 3.7%, with no difference between the 2 groups (P = 0.954). Twenty-two patients (2.6%) underwent reintervention for significant restenosis, and none of them had an ipsilateral stroke or TIA. Freedom from reintervention for restenosis at 24 months was 97.9% in Group A and 95.9% in Group B, with no between-group difference (P = 0.14). At the median survival follow-up of 37 months, the overall survival rate at 24 months was 97.9%in Group A, and 97.9% in Group B, with no between-group difference (P = 0.070). CONCLUSIONS: In our experience, CEA with a modified technique is safe and achieves comparable outcomes to those of other established techniques. The reported short cross-clamp time, also in less experienced hands, is an additional strength.

Bridging Stents in Fenestrated and Branched Endovascular Aneurysm Repair: A Systematic REVIEW.

BACKGROUND: Concern exists about durability of stent grafts used to bridge aortic grafts to visceral and renal arteries during fenestrated and branched endovascular aneurysm repair (F/B-EVAR). There are no guidelines regarding the ideal technique for joining target vessels (TVs). METHODS: We systematically reviewed data published from 2014 to 2019 using PRISMA guidelines and PICO models. Keywords were searched in MEDLINE, EMBASE, and Cochrane Library. All articles were screened by two authors (a third author in case of discrepancies). Only original articles regarding F/B-EVAR in complex aortic aneurysm, reporting the number and type of TVs mated, the onset of bridging stent complications, and reinterventions on TVs were included. Analysis included quality assessment scoring, types of stent grafts, and complications related to bridging stents. RESULTS: 19 studies were included with 2,796 patients and 9556 TV; 4,797 renal arteries (50.2%), 4,174 visceral arteries (43.6%), and undefined TV (n = 585; 6.1%) were bridged. Balloon-expandable stent-grafts (B-EXP) were used in 40.9% and self-expandable (S-EXP) in 22.7% and undefined stents in 36.3%. The included studies had quality assessment scores ranging between 11/15 and 15/15, with high grade of accordance on reporting general results, but a low grade of accordance on reporting detailed data. Despite study heterogeneity, high-volume analysis confirmed a higher rate of complication in renal arteries than visceral arteries, 6% (95% CI 4-8) vs. 2% (95% CI 1-3), respectively. The rate of reinterventions was similar, 3% (95% CI 2-4) and 2% (95% CI 1-3). S-EXP versus B-EXP stent complication was 4% (95% CI 2-7) vs. 3% (95% CI 2-5), respectively. CONCLUSIONS: This systematic review underlines the low grade of accordance in reporting detailed data of bridging stents in F/B-EVAR. Renal TVs were more prone to complications, with an equivalent reintervention rate to visceral TVs. As to B-EVAR, the choice of B-EXP over S-EXP is still uncertain.

Management of distal aneurysm of the superior mesenteric artery by percutaneous ultrasound-guided Onyx injection: A case report.

OBJECTIVES: The aim of this article is to report an alternative approach for the management of a distal aneurysm of superior mesenteric artery using direct percutaneous ultrasound-guided Onyx injection. METHODS: We report a rare case of symptomatic superior mesenteric artery aneurysm. A 78-year-old man presents with pain and pulsating mass in the right umbilical region of the abdomen. The patient was treated by percutaneous ultrasound-guided Onyx injection after several failing transarterial embolization attempts. RESULTS: The procedure was successful without any complication, and the patient wasdischarged to home the day after procedure. Follow-up at 60 months confirmed the complete thrombosis of the aneurysm sac. Ultrasound-guided Onyx injection for distal superior mesenteric artery aneurysm could provide an alternative to transcatheter arterial embolization or open surgery. Anatomical assessment of collaterals and knowledge of abdomen anatomy could play important roles in preventing bowel ischemia and minimizing the risk of procedural complication. CONCLUSION: Ultrasound-guided Onyx injection of superior mesenteric artery aneurysm is a feasible, effective, and cost-saving technique that can be used when endovascular approach is not possible or has failed.

Preliminary Experience with Prophylactic Thoracic Endovascular Aortic Repair in Patients Affected by Advanced Esophageal Cancer.

Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer (AEC). Esophageal malignancy is the third most common cause of aortoesophageal fistula, after thoracic aortic aneurysm and ingestion of foreign body. The involvement of aortic wall often contraindicates chemoradiotherapy (CRT) treatment, thus reducing life expectancy of these patients. Thoracic endovascular aortic repair (TEVAR) is a well-described mini-invasive technique that can be also applied for coverage of the aortic lumen in case of invasion by esophageal cancer. Only few cases have been published with this atypical indication. Between 2016 and 2018, in our tertiary hospital 3 patients affected by AEC involving the thoracic aorta were treated by means of prophylactic TEVAR. All procedures were uneventful, and all patients were reconsidered fit for preoperative or definitive CRT.

Surgical Treatment of Symptomatic Aortic Aneurysm in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Case Report and Review of the Literature.

Vasculitis is an heterogeneous group of syndromes, which shares inflammation of blood vessel wall as the main feature. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis, with few or no immune deposits, predominantly affecting small vessels (i.e., capillaries, venules, arterioles, and small arteries), associated with ANCAs specific for myeloperoxidase or proteinase 3. Clinical manifestations may be heterogeneous but an involvement of lungs and kidneys frequently occurs. AAV of large vessels is a very rare condition whose standard therapy is medical approach. Surgical revascularization has been described in selected patients after medical failure or in emergent settings. We report the case of a patient affected by symptomatic infrarenal aortic aneurysm related to AAV, who underwent in-situ reconstruction by means of cryopreserved homograft.

Technical Success and Long-Term Results with Excluder/C3 Endoprosthesis in Narrow Aortic Bifurcations: First Italian Multicentre Experience.

BACKGROUND: This study aims at evaluating technical success and long-term results using Gore Excluder/C3 endoprosthesis in patients with narrow aortic bifurcation (NAB; inner aortic diameter < 18 mm). METHODS: Clinical and anatomical data were collected retrospectively from patients treated in 2 high-volume Italian vascular centers between 2005 and 2017. A total of 1325 endovascular aneurysm repair procedures were performed, of which 195 involved Excluder/C3 Gore endoprosthesis. One hundred forty-one patients had a regular aortic bifurcation (RAB; maximum inner diameter ≥ 18 mm), whereas 54 presented with NAB (<18 mm). Technical success and procedural time were considered as primary outcomes. Secondary outcomes were perioperative complications, long-term graft-related complications and reintervention rates. RESULTS: Demographic data and risk factors were similar in the 2 groups. The mean diameter of aortic bifurcation was 29.8 ± 10.4 mm in RAB versus 17.1 ± 0.9 mm in NAB. Technical success was 100% in both groups. Incidence of intraoperative kinking/stenosis of limb graft was significantly higher in NAB (40.7% vs. 12.8%; P < 0.001), which was treated by means of kissing balloon technique (KiBaTe) and selective stenting. Time of procedure was similar. Post-operative complications rate was similar in both the groups (9.5% in RAB versus 4.2% in NAB, P = 0.180). Mean follow-up period was 40.0 months (range, 1-130). No significant difference was registered in long-term graft-related complications between RAB and NAB (38.3% vs. 38.8%; P = 0.939). Reintervention rate after 70 months was 21.8% vs. 24.6% in RAB and NAB, respectively (log rank = 0.517). Primary patency at 6, 12, and 48 months was 99.3% vs. 100%, 99.3% vs. 100%, and 98.5% vs. 97.9%, respectively (log rank = 0.497). Assisted primary patency was 98.6% vs. 96.0%, 97.8% vs. 96.0%, and 97.8% vs. 96.0%, respectively (log rank = 0.789). Secondary patency was 100% in both the groups. CONCLUSIONS: Endovascular aneurysm repair of NAB using Gore Excluder/C3 graft can be considered safe and effective in early and late follow-up. Intraoperative graft kinking is frequent in NAB and KiBaTe is recommended to prevent occlusive complications.

Thoracic Aortic Pseudoaneurysm after Esophageal Perforation and Mediastinitis Caused by Accidental Ingestion of a Mutton Bone: A Case Report on Staged Endoscopic and Endovascular Treatments.

BACKGROUND: Esophageal perforation involving the thoracic aorta is a rare but potentially life-threatening event. Esophageal wall dehiscence, aortoesophageal fistula, mycotic aneurysms, or mediastinitis may complicate this challenging condition, and a multidisciplinary approach is mandatory. Aggressive endoscopic and medical therapy followed by thoracic endovascular aneurysm repair (TEVAR) may be a valuable approach to reduce the mortality rate of this catastrophic event. CASE REPORT: A 79-year-old man presented at the emergency department with a 2-day history of worsening dysphagia and fever, suddenly appeared after consuming mutton meat. Esophagogastroduodenoscopy and computed tomography (CT) scan at admission showed a bone fragment penetrating the esophagus very close to the thoracic aorta, associated with signs of mild mediastinitis. After endoscopic removal of the bone, an esophageal fistula occurred. A conservative approach by means of endoscopic clipping of the esophageal perforation, nasojejunal tube for enteral nutrition and broad spectrum antibiotic therapy was preferred at this stage. Control chest X-ray with oral water-soluble contrast (Gastrografin) and repeat CT at 10- and 20-day follow-up showed a complete resolution of the esophageal fistula and mediastinitis. On the other hand, an increase of the aortic pseudoaneurysm was noted. This was treated by means of TEVAR. Subsequent clinical evolution was uneventful, and the patient was discharged in optimal clinical conditions with a 4-week course of home antibiotic therapy. The 6-month follow-up was uneventful. CONCLUSIONS: Foreign body esophageal perforation causing mediastinitis and aortic pseudoaneurysm is a very rare and challenging situation that requires a strict follow-up and an intensive multidisciplinary approach. A staged approach, first by endoscopy followed by endovascular treatment, may be safe and effective in selected patients.

Treatment of popliteal artery aneurysms by means of cryopreserved homograft.

BACKGROUND: Autologous saphenous vein is considered the gold standard conduit in the femoral-popliteal revascularization for popliteal artery aneurysms (PAAs). In several cases, it may be absent or unsuitable for length or diameter and so it may be considered unfit for a conduit. In such patients, a synthetic graft or the endovascular correction can be useful, but results are controversial. In this retrospective case series, we have analyzed the safety and efficacy of the cryopreserved homograft (CHg) as a conduit in the PAA revascularization. METHODS: In the period between January 2005 and December 2013, 54 PAAs have been treated with an arterial CHg. Indications to surgery were asymptomatic aneurysm with >25-mm diameter in 30 cases (55.6%), ischemic symptoms in 20 (37%), and compressive symptoms in 4 (7.4%). An urgent treatment was performed in 8 cases (14.8%) for severe ischemic symptoms. All cases have been operated by the same vascular team: a posterior surgical approach was preferred whenever possible (33 cases, 61.1%). All patients received a clinical and radiologic follow-up, and all data were collected in a specific database. A >10-mm diameter increase of the conduit was considered significant for an aneurysmatic degeneration. RESULTS: The primary outcomes were complications and reoperation rate, limb salvage, and primary and secondary patency. Secondary outcome was the incidence of aneurysmatic degeneration of the CHg. Mean diameter of the homografts was 6.3 mm (range, 4-8 mm). In the 30-day postoperative period, 7 PAAs (13%) developed a complication: 3 wound infections, 3 graft thrombosis, and 1 anastomotic bleeding. Six cases needed a reoperation: 2 surgical revascularizations, 2 wound debridement, and 1 anastomotic hemostasis; 1 major amputation was necessary for graft failure after the revascularization. Mean follow-up was 34.8 months (range, 1-96). Five cases (9.3%) developed a graft complication with 4 reoperations necessary (7.4%): 2 grafts required a percutaneous transluminal angioplasty for a perigraft stenosis and 2 underwent a femorodistal bypass in CHg for severe ischemic symptoms after CHg occlusion. Another one CHg occlusion was treated conservatively because it was clinically asymptomatic. Primary patency was 96.3%, 93.9%, and 88.3% at 12, 36, and 60 months, respectively; secondary patency was 98.1% at 12, 36, and 60 months. Freedom from amputation resulted in 98.1%. No aneurysmatic degeneration was observed. Univariate and multivariate analysis showed urgent surgery to be independent risk factors for complications, reoperations, and CHg occlusion (P < 0.05). CONCLUSIONS: In this retrospective study, the use of CHg showed to be safe and effective in the surgery of PAAs, either in the short or in the long-term follow-up. Urgent surgery can be considered predictive of graft failure. In our experience, CHg can be considered a good alternative conduit to the autologous saphenous vein.

Hybrid rescue technique after failure of a standard multibranched stent graft.

A 78-year-old woman presented with type IIIC and IIID endoleaks after endovascular treatment for a thoracoabdominal aortic aneurysm. Mating between the ruptured segments of superior mesenteric artery stent graft was performed. After failed attempts at relining the right renal artery stent graft, a hybrid approach was used to connect the side branch to the target vessel: a stent graft was deployed into the side branch of the main graft and it was temporarily occluded with a balloon. After opening the sac, a stent graft was deployed into the right renal artery and the two stent grafts were connected with a running suture. Follow-up examination performed 1 month postoperatively by computed tomography imaging confirmed the effectiveness of this treatment.

Red Blood Cell Distribution Width Predicts 1-month Complications after Percutaneous Transluminal Angioplasty.

BACKGROUND: The identification of patients at higher risk of developing percutaneous transluminal angioplasty (PTA)-related complications is pivotal for achieving better clinical outcomes. We carried out a single-center, observational, retrospective study to explore whether in-hospital changes of red blood cell distribution width (RDW) may help predicting early development of PTA-related complications. METHODS: The study population consisted of all consecutive patients who underwent PTA for severe peripheral artery occlusive disease (PAOD) during a 2-year period. RDW was measured at hospital admission and discharge, and the delta was calculated. Patient follow-up was routinely performed 1-month after hospital discharge, and was based on thoughtful medical assessment and arterial ultrasonography. The control population consisted of 352 ostensibly healthy subjects. RESULTS: The final PTA group consisted of 224 patients. Hemoglobin was lower, whilst mean corpuscular volume (MCV) and RDW were higher in PAOD cases than in controls. Overall, 11 PAOD patients (4.9%) developed clinically significant PTA-related complications 1-month after hospital discharge. Patients who developed 1-month PTA-related complications had lower hemoglobin concentration, but higher RDW and delta RDW than those who did not. Patients with delta RDW >1 had 60% higher risk of developing 1-month PTA-related complications and 88% higher risk of developing early reocclusion. Overall, RDW exhibited an area under the curve (AUC) of 0.68 and 0.74 for predicting 1-month PTA-related complications and early reocclusion, respectively. CONCLUSIONS: The results of this study suggest that RDW may play a role for guiding the clinical decision making of PTA patients immediately after hospital discharge.

Is There Any Role for Super-Extended Limphadenectomy in Advanced Gastric Cancer? Results of an Observational Study from a Western High Volume Center.

BACKGROUND: Although the Japan Clinical Oncology Group (JCOG) 9501 trial did not find that prophylactic D3 lymphadenectomy led to any survival advantage over D2 lymphadenectomy, it did find that the prognosis of subserosal and N0 gastric cancer patients improved. The aim of this retrospective observational study was to compare survival after D2 or D3 lymphadenectomy in different patient subgroups. METHODS: The study considered all of the patients who underwent D2 or D3 lymphadenectomy at a high-volume center in Verona (Italy) between 1992 and 2011. After excluding patients with Bormann IV or neuroendocrine tumors, early gastric cancers, or non-curative resections, the analysis involved 301 R0 patients: 100 who underwent D2, and 201 who underwent D3 lymphadenectomy. Post-operative deaths and deaths due to recurrences were considered as terminal events in the survival analysis. RESULTS: The D2 patients were significantly older than the D3 patients at baseline (69.8 ± 2.3 vs. 62.2 ± 10.7 years). The median number of retrieved nodes was 29 (interquartile range: 24.5-39) after D2, and 43 (34-52) after D3. The five-year disease-related survival rate was similar after D2 (44%, 95% confidence interval (CI) 34-54%) and D3 (41%, 34-48%) (p = 0.766). A Cox model controlling for sex, age, tumor site, Laurén histology, and T and N stages showed that the risk of cancer-related death after D3 was similar to that recorded after D2 (hazard ratio 0.97, 95% CI 0.67-1.42). There was a significant interaction between the T status and the extension of the lymphadenectomy (p = 0.012), with the prognosis being better after D2 in T2 and T4b patients, and after D3 in T3 patients. CONCLUSIONS: The findings of this study suggest that D3 lymphadenectomy is not routinely indicated for patients with advanced gastric cancer, although differences in survival after D3 across T tiers deserve further consideration.

Clinical pathways in gastric cancer care.

The diagnostic-therapeutic pathways (DTPs) are emerging as useful instruments for clinical management of complex diseases as gastric cancer, whose treatment is challenging and requires a multidisciplinary approach. However, the DPTs of patients with gastric cancer are still not defined yet. The aim of this study was to define the optimal DPT to be applied for patients with gastric cancer in the Veneto region. Rather than defining the ideal DTPs a priori, we conducted a preliminary research by analyzing the differences in the actual DPTs for patients with gastric cancer among different hospitals (hub and spokes) in Veneto. Then, the final DPT was elaborated based on the current available best clinical evidences; however, also the areas of homogeneity among the actual DPTs of the included centers as well as the critical issues that had emerged by our preliminary analysis were taken into account for pathway design. High heterogeneity in actual DTPs of patients with gastric cancer was observed among the analyzed centres. Moreover, some of the major criticisms have been found at crucial points of the current pathways. Based on these data, a reference path that is applicable to the whole-regional health network was constructed. The reference DTP is focused on multidisciplinary team management of patients with gastric cancer. Clinical pathways are essential tools to properly manage complex diseases such as gastric cancer. As such, more efforts should be done to implement their use.

Red blood cell distribution width (RDW) is an independent predictor of post-implantation syndrome in patients undergoing endovascular aortic repair for abdominal aortic aneurysm.

BACKGROUND: This observational, retrospective study aims establishing the role of red blood cell distribution width (RDW) for identifying abdominal aortic aneurism (AAA) patients at risk of developing post-implantation syndrome (PiS) after endovascular aneurysm repair (EVAR). METHODS: The study population consisted of all patients undergoing EVAR for AAA at the University Hospital of Verona (Italy), between June 1, 2016 and May 31, 2018. Blood samples for measuring hemoglobin, mean corpuscular volume (MCV) and RDW were collected at hospital admission and the day after EVAR. The primary endpoint was PiS development. Delta variations were calculated as the ratio between values measured after and before EVAR. RESULTS: The final study population consisted of 124 patients (10 women and 114 men; median age, 75 years), 55 of whom developed PiS. In patients with or without PiS hemoglobin significantly decreased after EVAR, whilst RDW significantly increased in patients with PiS and decreased in those without. Age, sex, hypertension, diabetes and renal failure were similar in patients who developed PiS or not, whilst a positive history of coronary artery disease was more frequent in PiS patients. Although hemoglobin and MCV changes after EVAR did not differ in patients with or without PiS, delta RDW was higher in those with PiS. The rate of patients with delta RDW >1 was significantly higher in patients with PiS that in those without (61.8% vs. 34.8%; P=0.002). In multivariate analysis, delta RDW remained independently associated with PiS (ß coefficient, 2.023; P=0.001). A delta RDW >1 after EVAR was associated with ~3-fold enhanced risk of PiS (odds ratio, 3.04; P=0.003) and exhibited a good prognostic performance (area under the curve, 0.69; P<0.001). CONCLUSIONS: Calculation of delta RDW after EVAR seems an efficient prognostic tool for stratifying the risk of developing PiS, especially in the early postoperative period.