Enhanced recovery protocols after surgery: A systematic review and meta-analysis of randomized trials in cardiac surgery.

BACKGROUND: Previous meta-analyses combining randomized and observational evidence in cardiac surgery have shown positive impact of enhanced recovery protocols after surgery (ERAS) on postoperative outcomes. However, definitive data based on randomized studies are missing, and the entirety of the ERAS measures and pathway, as recently systematized in guidelines and consensus statements, have not been captured in the published studies. The available literature actually focuses on "ERAS-like" protocols or only limited number of ERAS measures. This study aims at analyzing all randomized studies applying ERAS-like protocols in cardiac surgery for perioperative outcomes. METHODS: A meta-analysis of randomized controlled trials (RCTs) comparing ERAS-like with standard protocols of perioperative care was performed (PROSPERO registration CRD42021283765). PRISMA guidelines were used for abstracting and assessing data. RESULTS: Thirteen single center RCTs (N = 1704, 850 in ERAS-like protocol and 854 in the standard care group) were selected. The most common procedures were surgical revascularization (66.3%) and valvular surgery (24.9%). No difference was found in the incidence of inhospital mortality between the ERAS and standard treatment group (risk ratio [RR] 0.61 [0.31; 1.20], p = 0.15). ERAS was associated with reduced intensive care unit (standardized mean difference [SMD] -0.57, p < 0.01) and hospital stay (SMD -0.23, p < 0.01) and reduced rates of overall complications when compared to the standard protocol (RR 0.60, p < 0.01) driven by the reduction in stroke (RR 0.29 [0.13; 0.62], p < 0.01). A significant heterogeneity in terms of the elements of the ERAS protocol included in the studies was observed. CONCLUSIONS: ERAS-like protocols have no impact on short-term survival after cardiac surgery but allows for a faster hospital discharge while potentially reducing surgical complications. However, this study highlights a significant nonadherence and heterogeneity to the entirety of ERAS protocols warranting further RCTs in this field including a greater number of elements of the framework.

Challenges in Diagnosis of Non-A Non-B Acute Aortic Dissection.

BACKGROUND: Non-A non-B (NANB) aortic dissections are uncommon and frequently unrecognized diseases. However, their proper identification is crucial given the unpredictable behavior of the dissected aorta with potential mortality and increased morbidity. We investigate the accuracy of radiological computed tomography angiography (CTA) reports in the diagnosis of acute NANB and the risk related to delayed recognition or misdiagnosis. METHODS: The pretreatment contrast CTA of all consecutive patients admitted with acute aortic dissection (AAD) in a University Hospital in London (UK) between January 2017 and May 2023 were reviewed to retrospectively verify the accuracy of CTA reports in the diagnosis of NANB AAD (B1-2D The risk related to the delayed diagnosis (morbidity, mortality, and hospital readmissions) were evaluated as secondary outcomes. The study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. RESULTS: Overall, 588 aortic CTAs were reviewed for a total of n = 393 (66.8%) type A AADs, n = 171 (29%) type B AADs and n = 25 (4.3%) NANB AADs (n = 16, 64% men, mean age 60.56, standard deviation ± 14.6 years). While no case of misdiagnosis was identified in Type A or B AAD groups, in NANBs only about a third of cases (n = 9, 36%) were immediately indicated as "NANB" (n = 2, 8%) or "B with retrograde extension into the arch" (n = 7, 28%), n = 8 cases (32%) were described generically as "arch dissections" (n = 6, 24%) or "type A and B" AAD (n = 2, 8%). The remaining 32% of patients received a diagnosis that did not include mention of the arch, as n = 6 (24%) cases were reported to be "type A″ and n = 2 (8%) to be "type B″ AADs. Despite the heterogeneity of terms used to describe NANB AAD, no case of cardiac tamponade, new onset malperfusion nor neurological complications were reported, and no sudden death nor home-discharge and readmission while waiting for the proper diagnosis. CONCLUSIONS: The heterogeneity of terms used to describe NANB aortic dissection highlights the need for increased awareness, adoption of in guideline based classification systems, and further education to better understand and correctly address this challenging entity, minimizing misdiagnosis in ambiguous or difficult cases.

Aortic Outcome after Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch.

OBJECTIVE: To evaluate the outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD)). METHODS: This retrospective observational study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. All cases of NANB AAD (B 1-2 D) treated at our institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodeling were analyzed. RESULTS: Among 519 cases of acute aortic syndrome, n = 22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n = 16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly 2 days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7 (31.8%) needed emergent operation for risks of impending aortic rupture or retrograde aortic dissection extension, and 4 (26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of false lumen thrombosis (100% vs 55.5%, P = 0.033), and a significant positive aortic remodeling in zone 3 (P < 0.001) and 4 (P = 0.038) were reported in operated versus medically managed patients. CONCLUSIONS: The best treatment for NANB is not established. We advocate for medical stabilization with an operative approach that favors open surgery in the acute post dissection period, promotes aortic remodeling, and carries acceptable risk in centers where FET is performed routinely.

Diagnostic performance of White Blood Cell SPECT imaging against intra-operative findings in patients with a suspicion of prosthetic valve endocarditis.

AIM: The objective of this study was to evaluate the diagnostic performance of white blood cells (WBC)-SPECT imaging in patients with suspicion of prosthetic valve endocarditis (PVE) against intra-operative findings. METHODS: 36 consecutive patients who underwent cardiac surgery 30 days after WBC-SPECT imaging were identified retrospectively. Clinical, imaging, and biological results were collected from reports. WBC-SPECT results were classified as positive or negative and, if positive, the intensity of signal graded as intense or mild. Lesions observed during cardiac surgery were collected from surgeons' reports. RESULTS: The 20 patients with positive WBC-SPECT study had confirmed PVE intra-operatively. Patients with intense signal on WBC-SPECT had high prevalence of abscesses (83%) compared to patients with only mild signal (12%). The three patients with negative WBC-SPECT but confirmed PVE had longer duration of antibiotic treatment before imaging and had no perivalvular abscess. Sensitivity, specificity, positive predictive and negative values, and accuracy of WBC-SPECT were measured at 87%, 100%, 100%, 81%, and 92%, respectively. Addition of WBC-SPECT results to the modified Duke score helped re-classify correctly 25% of patients from possible to definite PVE. CONCLUSION: In patients with suspicion of PVE, WBC-SPECT imaging provides excellent diagnostic performance against intra-operative findings.

A tentative I/O curve with consciousness: Effects of multiple simultaneous ambiguous figures presentation on perceptual reversals and time estimation.

This study was aimed at investigating mechanisms of consciousness using bistable perception. In 4 experimental conditions, 1, 2, 4 or 8 Rubin's face-vase ambiguous figures were presented for 3 min.In Experiment 1, 40 subjects looked at the center of the screen and pressed a specific key correspondent to the figure where they perceived a reversal. In Experiment 2, 32 subjects controlled with eye-tracker performed a similar task in which they pressed the spacebar whenever they perceived a reversal in any of the figures.At the end of each condition subjects estimated its duration. Results showed that changing the number of figures does not alter the number of reversals, producing a flat I/O curve between the two parameters. Estimated time lapse showed a negative correlation with the number of reversals. These findings are discussed considering the relationships between bistable perception, attention, and consciousness, as well as the time perception literature.

The Results of The Interposition Graft-Technique in Treatment of High Flow Vascular Access.

OBJECTIVE: High-flow (HF) vascular access (VA) is a fearsome condition potentially responsible for cardiac or pulmonary complications, steal syndrome and hand ischemia. The present study was conducted to report the results achieved in a group of patients undergoing interposition-graft technique to treat HF. MATERIALS AND METHODS: An analysis of clinical, ultrasound and echocardiography data collected from the review of medical charts was performed. Flow reduction, complications and need for secondary interventions were investigated. RESULTS: Among a total 498 hemodialysis access interventions performed during a 6-years period, 30 patients (n 15, 50% male, median age 63.5, range 42-91 years) presented with high-flow (median flow 1.9 L/min, range 1.5-4 L/min). 18 patients were asymptomatic (60%); 6 (20%) suffered from a severe distal hand ischemia; 5 (16.6%) developed signs of congestive heart failure and 1 patient (3.3%) presented with pulmonary hypertension. In twenty patients (66.7%) the access was preserved by the interposition of a 6 mm polytetrafluroethylene (PTFE) prosthesis. This approach was used as a primary flow reduction technique in 16 patients (80%) or the failure of a previously attempted procedure in 4 cases. No intraoperative complications were observed. Post-operative median VA flow was 1.1 L/min (range 0.900-2 L/min), with a median flow reduction of 0.770 L/min (range 0.100-2.8 L/min). At a median follow-up of 9 months (range 1-42), 95% (n 19) of patients were free from recurrences. CONCLUSION: In treatment of HF-VA graft interposition demonstrated satisfactory results at the mid-term follow-up. More data are needed to affirm this technique as the preferential one.

The Fate of Hemodialysis Vascular Access After Kidney Transplantation: Why Ligation Should Not Be Systematically Performed?

BACKGROUND: After renal transplant, the haemodialysis (HD) vascular access (VA) is often maintained in the event of graft failure but evidence to recommend the systematic ligation/maintenance are lacking. We investigate the effects of VA preservation/ligation in successfully transplanted patients. METHODS: A retrospective analysis of all patients undergoing successful renal transplantation after HD were conducted. Patients with a functioning VA, those undergoing ligation or presenting with post-transplantation spontaneous thrombosis were included. Demographics, comorbidities, reasons for ligation, need for secondary interventions, complications and return in dialysis were assessed. RESULTS: Out of 542 HD patients, 114 (76, 66.7% male, median age 50 years, range 20-70) were included. Eight (7%) accesses thrombosed in a mean of 1.4 days (range 1-3) after transplant; 42 (36.8%) fistulas were ligated and 64 (56.1%) preserved. The reasons for ligation were patient's request (35, 83.3%), steal syndrome (5, 11.9%), heart failure (1, 2.4%) and aneurysmal degeneration (1, 2.4%).During a mean follow-up of 724.9 days (range 80-1082) 25 patients developed complications over the maintained access (40% of stenosis; 32% high flow and 28% thrombosis); 18 (15.8%) needed reoperation; 17 (15%) required further HD. Multivariate analysis showed that coronary artery disease (OR= 12.566 [2.056-76.805], P < 0.06) or age >60 years (OR=0.181 [0.044-0.735], P = 0.017) were risk factor for complications over unused VA. CONCLUSIONS: The ligation of a functioning VA after renal transplant should evaluated on an individualized basis. Patients with pre-existing cardiovascular disease or aged >60 years should be monitored closely up as they are at higher risk of complications.

Late onset infection of covered and bare metal arterial stents.

OBJECTIVE: The objective was to present the case of a late covered iliac stent late infection and report a comprehensive literature review on diagnosis and outcomes in this setting. METHODS: A comprehensive review of the literature was performed through MedLine by two independent reviewers from 1990 to 2020 on reported cases of arterial stent late onset infection over arterial stents. The data about on the risk factors, clinical presentation, treatment and outcomes were collected. RESULTS: Twenty-two studies were selected as pertinent for the analysis, totalling 24 patients including the indexed case. Infection occurred at a median of 22 months postoperatively (range 2-120 months) over a bare metal stent in 66.7% (n 16) of cases versus 33.3% (n 8) over a covered stent. Clinical presentation included local symptoms (local pain, oedema, petechiae or skin rash) in 21 (87.5%) cases and non-specific systemic symptoms (fever, sepsis, chills and leucocytosis) in 8 cases (33.3%). In 4 cases (16.7%), patients presented with haemorrhagic shock upon arterial rupture. The bacteria most frequently encountered were S. aureus (54.2% of cases). Several factors were supposed to be responsible for the infection including among which procedure-related (non-aseptic technique, lack of prophylactic antibiotics and repetitive punctures at the access site) or related to pre-existing patient's clinical conditions (immunosuppression, diabetes and concurrent infection) have been considered responsible for the infection. Treatment consisted in antibiotics alone (2 patients, 8.3%) or in association with surgical explant, both with or and without revascularization (n 21, 87.5%). In one case, an endovascular coiling was performed. Complications occurred in 29.2% (n 7) of cases and included the need for amputation, bowel resection, endocarditis, pulmonary failure or pneumonia. Overall, three patients (12.5%) died from a septic shock or multi-organ failure. CONCLUSIONS: Intravascular stent infection is a rare but fearsome condition associated with high morbidity and mortality.

Puncture Site Necrosis Over Hemodialysis Native and Prosthetic Vascular Accesses.

BACKGROUND: The aim of this study was to detail our experience in the management of skin necrosis/ulceration over hemodialysis vascular accesses. METHODS: We collected demographics and operative data about patients undergoing surgery for skin necrosis over native or prosthetic vascular accesses. The different procedural techniques used and outcomes achieved were analyzed. RESULTS: Over a six-year period (2013-2019), 593 hemodialysis accesses were created and 16 patients (50%, 8 male; median age 63.6 years, range 42-87; 12 native and 4 prosthetic accesses) were emergently/urgently treated for skin necrosis with danger of rupture (n 9), minor active bleeding (n 4) or life-threatening hemorrhage (n 3). Underlying causes were local infection, aneurysm/pseudo-aneurysm formation and venous stenosis. Most accesses were preserved. Rescue procedures consisted in excision of skin necrosis in association with aneurysmorrhaphy (n 1, 6.3%), simple closure of the venous breach (n 2, 12.5%) or resection and direct re-anastomosis (n 7, 43.8%). Concomitant endoluminal dilatation of venous outflow was needed in 7 (43.8%) cases. No intraoperative complications were observed. At a median of 13 months (range 1-39), 90% of rescued accesses were still functional. CONCLUSIONS: Skin necrosis/ulceration over vascular access requires prompt surgical intervention ahead the risk of life-threatening hemorrhage. The rescue of a functional access is possible in most patients and provides an efficient dialysis in postoperative period.

True Aneurysm of Ovarian and Uterine Arteries:a Comprehensive Review.

BACKGROUND: Gonadal artery aneurysm represents an extremely rare condition often unrecognized until rupture. METHODS: A literature review was undertaken on Pubmed from 1990 to 2020 to identify reported cases of ovarian and uterine artery aneurysms, including the index case presented here. Data about the clinical presentation, diagnostic approach, and treatment were collected. RESULTS: Twenty-one articles reporting on data about 22 patients, including the index case, were included. The patients's median age was 46.7 years (range 30-80) and aneurysm maximal diameter 2.6 cm (range 0.75-5 cm). Except for one asymptomatic patient, the aneurysm's clinical presentation was abdominal/back pain in the majority of cases (n = 20, 90.9%). Rupture with retroperitoneal hematoma occurred in 16 cases (72.7%) and hemorrhagic shock in one case (4.5%). No history of vaginal bleeding was reported in any case. The majority of the aneurysms were diagnosed in women of childbearing age: in 50% (n = 11) of cases during the peripartum period and in 22.7% (n = 5) of cases during the postmenstruation period. The remaining cases (n = 6, 27.3%) were detected during the postmenopausal period. The majority of patients (n = 15, 68.2%) were emergently treated with an endovascular approach by embolization, achieving the total exclusion of the aneurysm in 86.7% of cases (13 patients). In 7 cases (31.8%), surgical ligation was performed, of which 2 (9.1%) were for the failure of a primarily attempted coils embolization. The spontaneous thrombosis of the uterine aneurysm was noted 3 months after the initial diagnosis in one patient. CONCLUSIONS: The Gonadal artery aneurysms are unrecognized entities until an acute rupture occurs. Endovascular treatment by embolization is progressively becoming the first-line treatment with satisfactory results.

Surgical Treatment of Carotid Webs in Symptomatic Young Adults.

BACKGROUND: Carotid webs are possibly responsible for ischemic stroke in young adults. We aim to report a case series study about surgical treatment of this uncommon condition. METHODS: We performed a retrospective analysis on clinical, imaging, pathological, operative data, and outcomes about consecutive patients affected with carotid ischemic stroke due to carotid webs in a single institution. RESULTS: During a three-year period, a total of 123 patients were treated for carotid stroke, in five cases (4%) (median age 48.4 years, range 44-53, 2 men and 3 women, median NIHSS score 8.4, range 4-17) due to a carotid web. Patients were all Caucasian excepting for one. No severe comorbidities were detected. Preoperatively thrombectomy of middle cerebral artery was needed in three cases. Surgical treatment consisted in web resection and carotid end-to-end anastomosis (3 cases) or web excision and patch angioplasty (2 cases). In-hospital NIHSS score improved postoperatively of more than 2 points (median 3.6, range 2-7) in all cases. No major complications were detected. One patient experienced a local hematoma treated conservatively. At a mean follow-up of 18 months (range 1-35 months), no recurrent stroke nor myocardial infarction nor death were remarked. CONCLUSIONS: In young patients presenting with ischemic stroke without neither conventional stroke risk factors nor other possible sources of embolism, a carotid web should be suspected. Surgery guarantees excellent results in prevention of recurrences.

Tailoring Hemodialysis Vascular Access in Diabetic Patients.

BACKGROUND: The objective of the study was to investigate which kind of native arterious-venous fistula guaranteed the best results in diabetic patients. METHODS: A retrospective case-control study with prospective follow-up was conducted on all consecutive patients undergoing creation of the first native vascular access (VA) at our Institution between January 2011 and December 2016. Patients were divided into 2 groups: diabetics (group A) and nondiabetics (group B), and results were evaluated in accordance with site chosen for VA creation. Primary outcomes were maturation and primary patency rate. Secondary outcomes were complications, rate of functional fistulas, and mortality. RESULTS: A total of 410 patients (n 155, 37.8% female; n 255, 62.2% male; mean age 64.21 ± 14.85 years, range 58-78) were divided into 2 nonstatistically different groups (group A: n 170, 41.5% and group B: n 240, 58.5%). Maturation and primary patency were statistically different for antebrachial (P = 0,038 and P = 0.044, respectively), but not for brachial access (P = 1 and P = 0.080, respectively) at 3 years. Hyperflow and steal syndrome rate did not differ between the 2 sites and groups. At a mean follow-up of 42.86 months (range 1-72), 5 patients died. Diabetics demonstrated the higher rate of overall complications at the long-term follow-up. CONCLUSIONS: Diabetes mellitus plays a detrimental role in maturation and primary patency of antebrachial fistula; however, brachial fistula results do not differ between diabetic and nondiabetic patients. More robust data and longer-term results from randomized studies are needed to affirm brachial fistula as preferential access in diabetic patients.

Extracorporeal Membrane Oxygenation to Support Life-Threatening Drug-Refractory Electrical Storm.

OBJECTIVES: Despite rapid implementation of anti-arrhythmic treatment and sedation and controlling the triggering event, rare patients develop treatment-refractory electrical storm and their hemodynamic instability prevents emergency catheter ablation. In that context, venoarterial extracorporeal membrane oxygenation could rapidly restore hemodynamics and tissue perfusion and reduce myocardial oxygen consumption, until adequate anti-arrhythmic drug levels are reached to safely perform catheter ablation. DESIGN: Retrospective, multicenter study over an 8-year period. SETTING: Two French tertiary care centers. PATIENTS: Eighty-three consecutive adults with venoarterial extracorporeal membrane oxygenation-supported treatment-refractory electrical storm (median [interquartile range] age, 55 yr [48-63 yr]). MEASUREMENTS AND MAIN RESULTS: Fifty-nine percent of these patients had acute ischemic cardiomyopathy and 66% underwent cardiopulmonary resuscitation prior to venoarterial extracorporeal membrane oxygenation initiation, with 18% cannulated during it. Fifty patients (60%) had ventricular tachycardia and/or ventricular fibrillation alternating with short periods of sinus rhythm and 33 (40%) had refractory ventricular tachycardia and/or ventricular fibrillation. Twelve patients (15%) underwent safe catheter ablation under venoarterial extracorporeal membrane oxygenation. After a median of 3 days (1-13 d) on extracorporeal membrane oxygenation support, 37 patients (45%) were successfully weaned off and 42% were alive 6 months post-ICU admission. Multivariable analysis retained ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm (odds ratio, 0.18; 95% CI, 0.06-0.52; p = 0.002) and age less than 50 years (odds ratio, 0.32; 95% CI, 0.18-0.89; p = 0.002) as being independent protective factors with 6-month survival, regardless of the underlying electrical storm cause. CONCLUSIONS: Among venoarterial extracorporeal membrane oxygenation-supported drug-refractory electrical storm patients, 42% survived 6 months post-ICU admission. Ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm and age less than 50 years were independently associated with better survival.

Symptomatic Aortic Mural Thrombus Treatment and Outcomes.

BACKGROUND: To report results achieved in treatment of symptomatic aortic mural thrombus in a single institution. MATERIALS AND METHODS: A retrospective analysis of data about 97 patients presenting with acute onset lower limb ischemia (Rutherford stage II-III), upper limb ischemia, and mesenteric ischemia surgically treated between January 2011 and December 2018 in the Vascular and Endovascular Unit of Foch Hospital (Suresnes, France) was conducted. Only patients affected with primary aortic mural thrombus (PAMT) as source of embolism were included. RESULTS: A total of 9 patients (mean age 51 years, range 28-69; 55.5%, n 5 men and 44.5% n 4 women) were affected with PAMT. Three (33.3%) patients presented a concomitant renal embolism (22.2% of acute renal failure). Thrombus was located at the level of thoracic aorta (4 patients), visceral aorta (2 patients), or infrarenal aorta (3 patients). PAMT was sessile or pedunculated in 5 (55.5%) and 4 (44.4%) patients, respectively. Treatment consisted of anticoagulation in all patients in association with surgical exclusion of the PAMT, distal thrombectomy alone, or in addition to distal bypass. At a median follow-up of 22 months (range 1-57 months) no patients died, 4 patients (44.4%) recovered well, and 5 patients (55.5%) experienced recurrence/thrombus persistency and needed secondary interventions. The best results and absence of recurrences were achieved in patients undergoing immediate exclusion of the PAMT. CONCLUSIONS: PAMT is an uncommon source of embolism, and no guidelines are at disposal in its management. An aggressive approach with anticoagulation and exclusion of thrombus seems to be efficacious in preventing recurrences limiting complications and optimizing outcomes.

Early Carotid Endarterectomy for Symptomatic Stenosis of Internal Carotid Artery in Patients Affected by Transient Ischemic Attack or Minor-to-Moderate Ischemic Acute Stroke: A Single-Center Experience.

BACKGROUND: In the setting of carotid transient ischemic attack (TIA) or minor/moderate ischemic stroke, early surgical endarterectomy (CEA) seems to decrease the number of recurrences. The aim of the present study was to report a single-center experience with early surgical carotid revascularization in patients affected by TIA and minor/moderate ischemic acute stroke. METHODS: A retrospective data collection was carried out on all consecutive patients surgically treated for an extracranial internal carotid artery (ICA) hemodynamic NASCET stenosis in the Vascular Unit of Foch Hospital, in Suresnes (France) between January 2011 and July 2016. All patients undergoing ICA endarterectomy for symptomatic carotid stenosis (SCS) within 48 hours and 14 days after the acute neurologic onset were included in the present study. Outcomes were evaluated by a prospective follow-up. Primary outcomes were the rate of postoperative ipsilateral stroke and myocardial infarction (MI) and the death/stroke/MI at 30-day and at the long-term follow-up. Secondary outcomes were local and systemic complications' rate. Outcomes were stratified according to NIHSS score and comorbidities, and a univariate analysis and multivariate analysis were performed to define any correlation between preoperative data and postoperative outcomes. RESULTS: A total of 249 consecutive patients (45.4%, 113 symptomatic vs. 54.6%, 136 asymptomatic) underwent CEA for hemodynamically significant ICA stenosis at our institution. According to inclusion criteria, 72 patients affected by SCS (27.7% women vs. 72.3% men; median age 71.9 years, range: 42-89; median preoperative NIHSS score 3, range 1-17) were enrolled in the present study. Median delay for surgery was 4 days (range: 2-14). No in-hospital stroke, nor myocardial infarction nor death were detected during in-hospital post-operative period. The combined death/stroke/MI rate was 0% and 5.5 % at 30-days at 6 years follow-up respectively. In-hospital NIHSS score improved post-operatively of more than 2 points (range 0-15) in 47.2% of cases. A total of 10 patients (13.8%) experienced a local complication (hematoma, permanent or regressive nerve injury). No systemic complications (renal/respiratory failure, urinary tract infection, pneumoniae) were registered. At long-term follow-up a total of four patients (5.5%) died and six patients (8.3%) were lost. The stratification of outcomes according to NIHSS status, sex, comorbidities and preoperative surgical procedure did not show any statistical relation neither at 30 days nor at the long term-follow up. Diabetes was statistically correlated to a higher rate of complication at the long-term follow-up (P 0.049). CONCLUSIONS: In properly selected patients affected by minor/moderate ischemic acute stroke and TIA early carotid endarterectomy can be performed without any worsening of neurological status.

Early EEG for Prognostication Under Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND/OBJECTIVES: Tools for prognostication of neurologic outcome of adult patients under venoarterial ECMO (VA-ECMO) have not been thoroughly investigated. We aimed to determine whether early standard electroencephalography (stdEEG) can be used for prognostication in adults under VA-ECMO. METHODS: Prospective single-center observational study conducted in two intensive care units of a university hospital, Paris, France. Early stdEEG was performed on consecutive adult patients treated with VA-ECMO for refractory cardiogenic shock or refractory cardiac arrest. The association between stdEEG findings and unfavorable outcome was investigated. The primary endpoint was 28-day mortality. The secondary endpoint was severe disability or death at 90 days, defined by a score of 4-6 on the modified Rankin scale. RESULTS: A total of 122 patients were included, of whom 35 (29%) received cardiopulmonary resuscitation before VA-ECMO cannulation. Main stdEEG findings included low background frequency ≤ 4 Hz (n = 27, 22%) and background abnormalities, i.e., a discontinuous (n = 20, 17%) and/or an unreactive background (n = 12, 10%). Background abnormalities displayed better performances for prediction of unfavorable outcomes, as compared to clinical parameters at time of recording. An unreactive stdEEG background in combination with a background frequency ≤ 4 Hz had a false positive rate of 0% for prediction of unfavorable outcome at 28 days and 90 days, with sensitivities of 8% and 6%, respectively. After adjustment for confounders, a lower background frequency was independently associated with unfavorable outcome at 28 days (adjusted odds ratio per 1-Hz increment, 95% CI 0.71, 0.52-0.97), whereas no such independent association was observed at 90 days. CONCLUSION: Standard EEG abnormalities recorded at time of VA-ECMO initiation are predictive of unfavorable outcomes. However, the low sensitivity of these parameters highlights the need for a multimodal evaluation for improving management of care and prognostication.

Open Surgery and Endovascular Techniques in Treatment of Acute Abdominal Arteriovenous Fistulas.

Acute abdominal arteriovenous fistulas in the setting of ruptured abdominal aortic aneurysms are a life-threatening condition; thus, a prompt diagnosis is required for proper treatment. Open, endovascular, and hybrid repair have been proposed for their management, with pros and cons for each method. In particular, the evolution of endoluminal techniques guarantees an increasing feasibility of these procedures, and a significant reduction in morbidity and mortality rates was usually associated with open surgery. Nevertheless, some concerns still remain regarding the midterm and long-term follow-up. The aim of this article was to review and compare the reported clinical and technical results of conventional open surgery and endoluminal techniques in this scenario and to report the case of an acute aorto-iliac fistula due to a ruptured common iliac artery aneurysm into the iliac vein that was managed by endovascular repair at our institution.

Re-hospital admission, morbidity and mortality rate in patients undergoing tunnelled catheter implantation for haemodialysis.

OBJECTIVE: Despite the effort to increase the proportion of patients starting dialysis on native accesses, many of them are still dialyzed on tunnelled catheter. Catheter-related complications are often serious and responsible for re-hospital admission, high morbidity and mortality. Several multicenter trials have reported results in the use of tunnelled dialysis catheter (TDC). However, few single-center studies have been published to verify the outcome from real-world experience. This study presents our center's experience in managing such patients in the context of relevant literature. METHODS: Demographics and operative data were retrospectively collected from medical charts. A prospective follow-up was performed to investigate complications, number of re-hospitalizations and mortality. Kaplan-Meier estimate was used to evaluate catheter primary patency and patients' overall survival. RESULTS: Among a total 298 haemodialysis accesses interventions, 105 patients (56 men, 53.3% and 49 women, 46.7%) with a median age of 65 years (range 32-88 years) were included in the study. All insertions were successful with an optimal blood flow achieved during the first session of dialysis in all cases. A catheter-related complication was detected in 33.3% (n=35) patients (48.6% infections; 28.6% TDC dysfunction; 14.3% local complications; 5.7% accidental catheter retractions; 2.8% catheter migrations). At a median follow-up of 10.5±8.5 months, a total of 85 patients (80.9%) was re-hospitalized, in 28 cases (26.7%) for a catheter-related cause. The median catheter patency rate was 122 days. At the last follow-up, 39 patients (37.1%) were still dialyzed on catheter, 30(28.6%) were dialyzed on an arteriovenous fistula and 7(6.7%) received a kidney transplantation. Two patients (2%) were transferred to peritoneal dialysis and two patients (2%) recover from renal insufficiency. Mortality rate was 23.8% (25 patients). Causes of death were myocardial infarction (n=13, 52%), sepsis (n=9, 36%); one patient (4%) died from pneumonia, one (4%) from uremic encephalopathy and one (4%) from massive hematemesis. CONCLUSION: TDCs may represent the only possible access in some patients, however they are burned with a high rate of complications, re-hospital admission and mortality. Results from this institutional experience are in line with previously published literature data in terms of morbidity and mortality. The present results reiterate once more that TDC must be regarded as a temporary solution while permanent access creation should be prioritized. Strict surveillance should be held in patients having TDC for the early identification of complications allowing the prompt treatment and modifying the catheter insertion site whenever needed.

Endovascular Stent-Graft Repair of True and False Aneurysms of the Splenic Artery.

OBJECTIVE: In treatment of aneurysms (SAAs) and pseudoaneurysms (SAPs) of the splenic artery, endovascular coil embolization is the approach most commonly used as it is minimally invasive and safe. However, it carries a significant rate of primary failure (up to 30%) and might be complicated by splenic infarction. The use of stent grafts might represent a valuable alternative when specific anatomical criteria are respected. We report a comprehensive review on technical and clinical outcomes achieved in this setting. Methods: We performed a comprehensive review of the literature through the MedLine and Cochrane databases (from January 2000 to December 2023) on reported cases of stenting for SAAs and SAPs. Outcomes of interest were clinical and technical success and related complications. The durability of the procedure in the long-term was also investigated. Results: Eighteen papers were included in the analysis, totalling 41 patients (n = 20 male 48.8%, mean age 55.5, range 32-82 years; n = 31, 75.6% SAAs). Mean aneurysm diameter in non-ruptured cases was 35 mm (range 20-67 mm), and most lesions were detected at the proximal third of the splenic artery. Stent grafting was performed in an emergent setting in n = 10 (24.3%) cases, achieving immediate clinical and technical success rate in 90.2% (n = 37) of patients regardless of the type of stent-graft used. There were no procedure-related deaths, but one patient died in-hospital from septic shock and n = 2 (4.9%) patients experienced splenic infarction. At the last available follow-up, the complete exclusion of the aneurysm was confirmed in 87.8% of cases (n = 36/41), while no cases of aneurysm growing nor endoleak were reported. None of the patients required re-intervention during follow-up. Conclusions: When specific anatomical criteria are respected, endovascular repair of SAAs and SAAPs using stent grafts appears to be safe and effective, and seems to display a potential advantage in respect to simple coil embolization, preserving the patient from the risk of end-organ ischemia.