Thoracic endovascular repair for blunt traumatic thoracic aortic injury: Long-term results.

OBJECTIVE: This study aims to evaluate the endoprosthesis complications in patients undergoing TEVAR for blunt traumatic thoracic aortic injury, through long-term clinical and diagnostic follow-up. METHODS: During the study interval (November 2000-October 2020), a total of 38 patients (63% male; average age 37.5 years) with thoracic aortic injury underwent thoracic endovascular aortic repair. Patients underwent routine follow-up with clinical examination and radiological evaluation (CT-angiography or MRI-angiography plus chest radiograph), scheduled at 1 month, at 6 months (only in the cases of thoracic aortic dissection), at 1 year after the procedure and every 1 year thereafter. RESULTS: Technical success was achieved in 38 procedures (100%). The TEVAR-related mortality rate was 0%. No immediate major complications related to the endovascular procedure were observed. The median duration of diagnostic follow-up was 80 months. A total of four procedure-related complications (10.5%) were identified at the follow-up. Three (7.9%) distal infoldings and collapses of the thoracic endoprosthesis and one (2.6%) type Ia endoleak were observed. No thrombosis of the prosthesis, nor signs of aortic pseudocoarctation were identified. No further complications related to endograft (endoleaks, infections, rupture, partial or complete thrombosis) occurred. No changes in the native aorta, stenosis, or increases in the endograft's diameters were observed. A total of 20 patients (52.6%) underwent MRI-angiography examinations, while a total of 34 patients (89.5%) underwent chest radiographs at the follow-up. In all cases, CT-angiography examinations were performed at the follow-up. CONCLUSIONS: Procedure-related complications were observed within one year of TEVAR, limiting concerns related to the durability of the prosthesis. No morphological changes in the aorta were observed despite long-term follow-up. The consequences of lifelong surveillance in terms of radiation exposure deserve special consideration, especially in younger patients treated for TAI.

The use of the Amplatzer Vascular Plug in the prevention of endoleaks during abdominal endovascular aneurysm repair: A systematic literature review on current applications.

OBJECTIVES: The Amplatzer Vascular Plug (AVP) is a vascular occlusion device designed to provide optimal embolization in several fields of the endovascular surgery. A full literature review was conducted to analyze AVPs in comparison with coils for the prevention of endoleaks during endovascular abdominal aortic aneurysm repair. METHODS: A systematic review was designed under PRISMA statement guidelines for systematic reviews and meta-analyses. The results were updated with a subsequent electronic search using Medline and Scopus databases up to December 2019. RESULTS: Eighteen articles making this comparison were found. In 79.7% of the cases, the target vessel was the internal iliac artery; in 1.6%, the common iliac artery; and in 16.7%, the inferior mesenteric artery. Risk of complications (buttock claudication, groin hematoma, endoleaks, and erectile dysfunction) after AVP was low. A cost comparison revealed that the mean cost for coils was around US$2262, while the average cost for the AVP was US$310. CONCLUSIONS: The AVP is an effective and safe device for occluding peripheral vessels, proved to have lower complications rates. Compared with coil embolization, the AVP technique is potentially associated with lower procedural costs.

PredyCLU: A prediction system for chronic leg ulcers based on fuzzy logic; part II-Exploring the arterial side.

Peripheral arterial disease (PAD) and its most severe form, critical limb ischaemia (CLI), are very common clinical conditions related to atherosclerosis and represent the major causes of morbidity, mortality, disability, and reduced quality of life (QoL), especially for the onset of ischaemic chronic leg ulcers (ICLUs) and the subsequent need of amputation in affected patients. Early identification of patients at risk of developing ICLUs may represent the best form of prevention and appropriate management. In this study, we used a Prediction System for Chronic Leg Ulcers (PredyCLU) based on fuzzy logic applied to patients with PAD. The patient population consisted of 80 patients with PAD, of which 40 patients (30 males [75%] and 10 females [25%]; mean age 66.18 years; median age 67.50 years) had ICLUs and represented the case group. Forty patients (100%) (27 males [67.50%] and 13 females [32.50%]; mean age 66.43 years; median age 66.50 years) did not have ICLUs and represented the control group. In patients of the case group, the higher was the risk calculated with the PredyCLU the more severe were the clinical manifestations recorded. In this study, the PredyCLU algorithm was retrospectively applied on a multicentre population of 80 patients with PAD. The PredyCLU algorithm provided a reliable risk score for the risk of ICLUs in patients with PAD.

Single-Center Experience and Preliminary Results of Intravascular Ultrasound in Endovascular Aneurysm Repair.

BACKGROUND: Intravascular ultrasound (IVUS) has been introduced as diagnostic adjunct to provide new insights into the diagnosis and therapy of vascular disease. Herein, we compared the outcomes of conventional endovascular aneurysm repair (EVAR) and EVAR with IVUS in patients presenting with infrarenal abdominal aortic aneurysm using a propensity-matched cohort. METHODS: From May 2013 to August 2017, 221 patients were retrospectively analyzed. Of that, 122 patients were eligible for inclusion and underwent propensity score matching. Perioperative mortality and morbidity, renal function impairment, endoleak incidence, mean contrast medium usage, operative time, radiation exposure (including fluoroscopy time, dose-area product [DAP], and digital subtraction angiography [DSA] runs), survival, and freedom from reintervention were the outcomes measured. RESULTS: After matching, 52 patients were included, 26 in the conventional EVAR group and 26 in the EVAR with IVUS group. No perioperative mortality or type I/III endoleak were registered. One perioperative lymphatic fistula and one iliac limb occlusion were observed. In the EVAR with IVUS group, a significant reduction of contrast medium (92 [vs. 51 ± 17] vs. 51 [20-68] mL; P = 0.003) and radiation exposure including fluoroscopy time (12 [9-16] vs. 20 [12-25] min; P = 0.001), DAP (15 [9-21] vs. 32 [16-44] G*cm2; P = 0.002), and DSA runs (2 [1-3] vs. 3 [2-4]; P = 0.04) was reported. No differences were observed in terms of glomerular filtration rate (86 [45-121] vs. 90 [38-117] mL/min; P = 0.14) and operation time (176 [124-210] vs. 179 [120-210]; P = 0.48). Survival at 36 months was 93% for standard EVAR and 92% for EVAR with IVUS (P = 0.845). Freedom from reintervention at 36 months was 85.5% in both the groups (P = 0.834). CONCLUSIONS: In this preliminary experience, the use of IVUS during EVAR was feasible with no registered postoperative complications. A significant reduction of contrast medium usage and radiation exposure was observed with the use of IVUS. The IVUS is an adjunctive tool to consider in the vascular surgeon armamentarium, especially in centers where advanced radiological tools of imaging fusion are not available.

Early experience with a modified preloaded system for fenestrated endovascular aortic repair.

OBJECTIVE: Preloaded endovascular delivery systems expand the anatomic eligibility for complex aortic repair by requiring only one iliac access vessel and providing a stable platform for guiding sheaths into challenging target vessels. This article reports the lessons learned and early clinical outcomes using a modified preloaded delivery system for fenestrated endovascular aneurysm repair (FEVAR) in three aortic centers in Europe. METHODS: From October 2015 to March 2016, consecutive patients presenting with extensive aortic aneurysm treated with a modified preloaded FEVAR were prospectively enrolled from three high volume European aortic centers. The new design is a modification of previous designs of preloaded fenestrated stent grafts and of the p-branch device platform. The technical details of implantation are described and perioperative outcomes, including the learning curve, are collected and reported. RESULTS: All patients (30 patients; 80% men; 70.2 years old) presented for nonurgent repair of either a type Ia endoleak (3/30; 10%), a type I-II-III thoracoabdominal (8/30; 27%), or a type IV thoracoabdominal or pararenal (19/30; 63.%) aneurysm repair of a mean size of 64 ± 13 mm using a custom made device. Primary technical success was achieved in 28 of 30 patients (93%) and assisted primary technical success in 29 of 30 patients (97%). The two technical failures included open conversion to repair a ruptured iliac artery and restenting of a dissected superior mesenteric artery which was recognized hours after the index procedure had finished. The mean procedure time was 277 ± 153 minutes, fluoroscopy time 79 ± 36 minutes, dose area product 112 ± 90 Gy cm2, and contrast volume 87 ± 46 mL. All renal fenestrations were successfully stented without type III endoleak on completion angiogram; the preloaded guiding sheaths were used for 53 of 58 renal arteries (91%). Challenges related to learning to the use of the modified preloaded system were experienced early and had no clinical consequences. Major complications occurred in seven cases (23%), including two perioperative deaths because of stroke and sepsis following primary conversion attributable to iliac rupture. There were no target vessel occlusions or type I/III endoleaks found on postoperative imaging. CONCLUSIONS: Based on early experience, the modified preloaded system can be safely and effectively used during FEVAR, with good technical result and a short period of learning. This device expands treatment to patients with compromised iliac access, thus, additional patients and more follow-up will be required to determine unique risks of operating in this patient population.

Symptomatic Deep Femoral Artery Pseudoaneurysm Endovascular Exclusion. Case Report and Literature Review.

Deep femoral artery pseudoaneurysms (DFAPs) are rare and generally occur after penetrating trauma or surgical procedures. A 36-year-old obese man presented with pain in correspondence of the anterior-lateral thigh after 6 months from gunshot wound. Duplex and computed tomography (CT) showed a bilobed right DFAP (maximal diameter 12.9 cm). The patient was managed urgently, under local anesthesia, by placement in the distal DFA of a Viabahn 8 × 100-mm stent graft (W L Gore & Associates, Inc). The postoperative course was uneventful, and the 24-month CT showed regular stent-graft patency and 20-mm DFAP shrinkage. The literature review reported 8 cases of DFAPs; of these 6 were managed by endovascular mean (3 stent-graft implantations and 3 coil embolization). The remaining 2 cases were managed surgically (one of these after failed coil embolization). In conclusion, the use of covered stent graft was effective to treat a DFAP localized in the medium DFA. This tool allowed maintaining the native DFA patency and the preservation of its main branches.

Practical points of attention beyond instructions for use with the Zenith fenestrated stent graft.

Fenestrated stent grafting for endovascular repair (F-EVAR) aims to treat patients with abdominal aortic aneurysms that are unsuitable for standard EVAR because of a short or absent infrarenal neck. F-EVAR has been used initially in patients with higher surgical risk with pararenal abdominal aortic aneurysms, but F-EVAR is now increasingly considered a treatment alternative to open surgery in anatomically suitable patients. F-EVAR has benefitted from ongoing technical refinements and accumulating clinical experience but remains a relatively complex procedure. Correct indication, accurate preoperative planning, and meticulous execution are the key to long-term success. Considering the growing interest in F-EVAR worldwide, including the United States, we discuss current indications and provide advice for planning and technical execution on the basis of the senior authors' 13 years of experience.

Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications.

Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.

Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry.

BACKGROUND: Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI). METHODS: Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included. FOLLOW-UP: One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated. RESULTS: Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics. CONCLUSION: Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

Proximal type I endoleak after previous EVAR with Palmaz stents crossing the renal arteries: treatment using a fenestrated cuff.

PURPOSE: To report the use of a fenestrated cuff for endovascular treatment of a proximal type I endoleak after previous endovascular aneurysm repair (EVAR) that included 2 suprarenal cuffs and 2 Palmaz stents. CASE REPORT: A 71-year-old man had been treated for an infrarenal abdominal aortic aneurysm with a Powerlink stent-graft, 2 additional proximal cuffs with suprarenal fixation, and 2 Palmaz stents extending over the renal arteries. Follow-up demonstrated a type I endoleak and an increase in aneurysm size. A 2-stage endovascular approach featuring a fenestrated cuff was undertaken. Prior to the endoleak repair procedure, both renal arteries were catheterized and the Palmaz stent struts dilated. When the customized fenestrated cuff was available, it was successfully positioned with covered stents in the fenestrations, completely excluding the proximal type I endoleak. CONCLUSION: Fenestrated stent-grafting is a viable alternative to open repair after failed EVAR, even when previously implanted bare metal stents cross the renal orifices.

Selective crossectomy combined with mechanochemical ablation in the treatment of great saphenous vein insufficiency: Early results of a single center experience.

BACKGROUND: Selective crossectomy and mechanochemical ablation (MOCA) of great saphenous vein (GSV) have been used, for years, individually in the treatment of chronic venous insufficiency. In this paper, we focus on the advantages of a combination of the two techniques, in order to prevent complications and recurrence. METHODS: A preoperative clinical and instrumental screening phase was conducted for the purpose of dividing patients into three groups: "Saph+Cross" group (51/139 patients) underwent saphenectomy and crossectomy; "MOCA" group (44/139 patients) underwent MOCA of GSV with Flebogrif® device; "MOCA + Cross" group (44/139 patients) subjected to both MOCA and crossectomy procedures.Recurrence rate, defined as total recanalization of GSV and/or onset of neosaphena and/or new varicose veins, was used as a primary outcome. Secondary outcomes were procedural time and intra- and post-procedural complications. RESULTS: We conducted a 1-, 6-, and 12-month follow-up with Duplex scan. The recurrence rates were 3.9%, 21.8%, and 4.5% for "Saph+Cross," "MOCA," and "MOCA+Cross," respectively, with a significant difference for the comparison between "MOCA" and "Saph+Cross" (MOCA vs Saph+Cross: OR 5.35, CI95% [0.98; 54.6], p-value .040).The sub-analysis of primary outcome highlighted a lower recanalization rate of GSV when combining the crossectomy with MOCA procedure (2.2% MOCA+Cross vs 15.9% MOCA; 0.12 OR, [0.002; 1.02] CI95%, p-value .029).Among the secondary outcomes, "MOCA" showed a shorter procedural time than the other groups (Saph+Cross: 51.3 ± 11.4; MOCA: 45.1 ± 7.5; MOCA+Cross: 50.4 ± 10; p-value .027). No significant differences were noted in terms of intra- and post-procedural complications. CONCLUSIONS: The results showed that patients treated with saphenectomy and crossectomy have a lower recurrence rate compared to MOCA alone and MOCA + crossectomy procedures.The association of crossectomy with MOCA significantly reduces the recanalization rate of GSV, and it is also characterized by a higher free survival from recurrence (SSF) than with MOCA alone.

Abdominal Aortic Aneurysm: Natural History, Pathophysiology and Translational Perspectives.

An abdominal aortic aneurysm (AAA) is a degenerative pathology that affects the infrarenal segment of the aorta, leading to its progressive dilatation and eventually rupture. The infrarenal segment is involved in 80% of the aortic aneurisms, and represents alone 30% of all aneurysms. The natural history of the disease is characterized by the progressive increase of the aortic diameter associated with proportionally higher risk of rupture, particularly for cases with diameter greater than 5.5 cm. In case of rupture the mortality rate is very high, independently from the endovascular or surgical treatment. The most important risk factors are older age, smoking, hypertension, dyslipidemia, and family history of AAA. The most frequent form is "atherosclerotic", but infectious, collagen disease-related, immune dysregulation-related, and post-traumatic AAA have also been described. Albeit multiple pathogenetic hypotheses have been proposed, the role of metallo-proteinases in the degeneration of the aortic wall seem to play a central role. Early detection of AAA is crucial for the identification and treatment before the onset of potentially life-threatening complications. Moreover, the individual risk stratification is fundamental for the clinical management and follow-up. The growing knowledge about the pathophysiology of AAA has the potential to lead to significant translational advances. The challenge for the next years is to employ bioinformatic and genetic models, also based on artificial intelligence and machine learning approach, to develop novel screening methods and to stratify individuals at higher-risk or in the early stages of AAA.

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.

Novel biomarkers in cardiovascular surgery.

Cardiovascular disease includes health problems related to the heart, arteries and veins and is a significant healthcare problem worldwide. Cardiovascular disease may be acute or chronic and relapses are frequent. Biomarkers involved in this field may help clinicians and surgeons in diagnosis and adequate decision making. Relevant articles searched in the following databases Medline, Scopus, ScienceDirect, were retrieved and analysed. Several biomarkers have been identified and we analyzed those of most importance from a clinical and surgical point of view. Biomarkers can better identify high-risk individuals, facilitate follow-up process, provide information regarding prognosis and better tailor the most appropriate surgical treatment.

Single staged hybrid approach for multilevel aortic-iliac-femoral-popliteal disease.

INTRODUCTION: Multilevel peripheral arterial disease (MPAD) is the main cause of critic limb ischemia (CLI). Vascular interventions are required to increase distal blood flow and reduce the risk of lower limb amputation. PRESENTATION OF CASE: We report a case of complex hybrid revascularization in a patient presenting a Rutherford V MPAD involving the infrarenal aorta, iliac, femoral and popliteal segments. The simultaneous hybrid intervention consisted of an endovascular aortic stent-graft placement and a surgical above-the-knee prosthetic femoro-popliteal bypass. In the same operation a renal stenting was performed due to a significant renal artery stenosis associated to a systemic hypertension non-responder to medical management. DISCUSSION: Hybrid interventions can be performed simultaneously or staged with benefit given by the complementary role of endovascular and surgical treatments allowing the correction of eventually inadequate results of both approaches. Reports of simultaneous hybrid treatments are limited but, despite the complexity of such procedures, primary success rate is reported high. Also in the reported case, a complex simultaneous treatment in a patient presenting MPAD in association to a significant and symptomatic renal artery disease was feasible in the same operation. CONCLUSION: Hybrid procedure are safe with high degree of efficacy in terms of revascularization procedure, reduced morbidity and shorter intensive care and hospital stay. In our experience, the use of hybrid procedure is technically feasible and allowed the treatment of MPAD with a good outcomes.

Renewed endovascular repair for recurrent acute abdominal aortic aneurysm.

The aim of the study was to describe the successful endovascular management of a patient who was admitted urgently with a second episode of acute abdominal aortic aneurysm (AAA) 30 months after emergency endovascular abdominal aortic aneurysm repair (eEVAR) for a ruptured AAA. The patient, an 84 year-old male physician, presented with severe acute abdominal and back pain. Contrast-enhanced computer tomography scanning showed type III endoleak owing to complete disconnection of both graft limbs and the prosthetic main body. Treatment consisted of acute stent-grafting with two bridging stent-grafts to seal the endoleak and reline the graft. The patient is alive and well 6 months postoperatively. This case indicates the need for follow-up after eEVAR, but also that complications can be managed endovascularly.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery.

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Extra-anatomic iliac to superior mesenteric artery bypass after bridge endovascular treatment for chronic mesenteric ischemia. A case report.

UNLABELLED: A 60 year old patient presenting chronic mesenteric Ischemia (CMI) was managed with superior mesenteric artery (SMA) stenting as bridge therapy to conventional open surgery. At 5 months follow-up, the SMA stent occluded. During this bridge period the patient gained his general condition and the body mass index (BMI) increased from 18 to 22. The patient was managed subsequently with iliac-SMA bypass in C-loop configuration. At 6 months follow-up the bypass is patent, the patient has no CMI symptoms and his BMI is 25. The endovascular approach did not preclude a subsequent conventional open surgery and it can be safely employed as bridge therapy. An improved patient clinical condition, also during a limited bridge period, can improve the conventional open surgery outcomes. KEY WORDS: Body Mass Index(BMI), Mesenteric artery, Mesenteric ischemia.

Unexpected complication with the new C3 excluder: cause and treatment.

The new C3 Gore Excluder delivery system enables both up/downward and rotational repositioning of the device before complete deployment. This contributes to more precise proximal landing and permits facilitation of the contralateral gate cannulation. During separate deployment, the position of the ipsilateral limb can also be readjusted. We have used the modified C3 delivery system in more than 50 patients, and in most cases, we were able to utilize the repositioning options of the device to achieve optimal fixation and sealing. However, we present a case where our attempt to readjust the position of the ipsilateral limb led to upward migration of the main body with coverage of the left renal artery origin. The latter was secured with a bare stent implantation.