The Role of Early Revascularization and Biomarkers in the Management of Diabetic Foot Ulcers: A Single Center Experience.

Diabetic neuropathy and Peripheral Arterial Disease (PAD) are the main etiological factors in foot ulceration. Herein, we report our experience of diabetic foot ulceration (DFU) management, with an analysis of the relationship between the rate of lower extremity amputation, in persons with infected DFU, after revascularization procedures performed to prevent major amputation. This study highlights the role of different biomarkers, showing their usefulness and potentiality in diabetic foot ulcer management, especially for the early diagnosis and therapy effectiveness monitoring. A retrospective analysis, from September 2016 to January 2021, of diabetic patients presenting diabetic foot with DFU, was performed. All patients were treated with at least one vascular procedure (endovascular, open, hybrid procedures) targeting PAD lesions. Outcomes measured were perioperative mortality and morbidity. Freedom from occlusion, primary and secondary patency, and amputation rate were registered. A total of 267 patients, with a mean age of 72.5 years, were included in the study. The major amputation rate was 6.2%, minor amputation rate was 17%. In our experience, extreme revascularization to obtain direct flow reduced the rate of amputations, with an increase in ulcer healing.

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

Simultaneous Hybrid Treatment of Multilevel Peripheral Arterial Disease in Patients with Chronic Limb-Threatening Ischemia.

BACKGROUND: Hybrid treatments (HT) aim to reduce conventional open surgery invasiveness and address multilevel peripheral arterial disease (PAD). Herein, the simultaneous HT treatment in patients with chronic limb-threatening ischemia (CLTI) is reported. METHODS: Retrospective analysis, for the period from May 2012 to April 2018, of patients presenting multilevel PAD with CLTI addressed with simultaneous HT. The outcomes of these interventions were measured the following metrics: early technical successes (within 30 days following treatment) and late technical successes (30 days or more following treatment) and included mortality, morbidity symptoms recurrence, and amputation. Survival and patencies were estimated. The median follow-up was 43.77 months. RESULTS: In the 45 included patients, the HT consisted of femoral bifurcation patch angioplasty followed by an endovascular treatment in 38 patients (84.4%) and endovascular treatment followed by a surgical bypass in 7 patients (15.6%). Technical success was 100% without perioperative mortality. Eight (17.8%) patients presented early complications without major amputations. During the follow-up, seven (15.6%) deaths occurred and six patients (13.3%) experienced symptoms recurrence, with five of those patients requiring major amputation. An estimated survival time of 5 years, primary patency, and secondary patency was 84.4%, 79.2%, and 83.3% respectively. CONCLUSIONS: Hybrid treatments are effective in addressing patients presenting with multilevel PAD and CLTI. The common femoral artery involvement influences strategy selection. Larger studies with longer-term outcomes are required to validate the hybrid approach, indications, and results.

Efficacy and one-year outcomes of Luminor® paclitaxel-coated drug-eluting balloon in the treatment of popliteal artery atherosclerosis lesions.

PURPOSE: Reporting outcomes with a new generation paclitaxel eluting balloon (Luminor®; iVascular, Vascular, S.L.U., Barcelona, Spain) in the popliteal district. Endovascular treatment of popliteal artery atherosclerotic disease is still debated without definitive evidences. METHODS: From January to June 2019, patients' data presenting popliteal artery atherosclerotic diseases and treated with the Luminor® (iVascular) drug eluting balloon (DEB) were prospectively collected. Critical limb ischemia (CLI) or severe claudication associated with popliteal artery stenosis >50% were the inclusion criteria. Measured outcomes were technical success, early and late results; including mortality, morbidity, symptoms recurrence, amputation, ankle-brachial index (ABI), survival, primary patency, secondary patency, freedom from restenosis. Median follow-up was 22.43 ± 4 (mean:21.58; IQR:20-24) months. RESULTS: Of the 33 included patients, 28 (85%) were diagnosed with CLI, with a mean preoperative run-off score of 5.39 (r:0-10; SD:3) and a chronic popliteal occlusion in 21 (64%). Technical success was achieved in all cases. Perioperative mortality was observed in 1 (3%) patient and perioperative complications in 2 (6%). During the follow-up were reported 2 symptoms recurrence; a significant ABI increase (0.57; IQR:0.41-0.47 vs. 0.69; IQR:0.50-0.67; P < 0.01); 1 (3%) major and 2 (6%) minor amputations. Estimated 24 months survival, primary patency, secondary patency, and freedom from restenosis were 97%, 96.9%, 100%, and 93.8% respectively. CONCLUSIONS: In this prospective study, the use of the Luminor® (iVascular) was safe and effective in addressing atherosclerotic popliteal artery lesions. Larger studies with longer term-outcomes are required to assess the durability of this device in the popliteal artery.

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.

Simultaneous endovascular treatment of synchronous symptomatic acute type B aortic dissection and large infrarenal aortic aneurysm. Technical tips and case report.

INTRODUCTION: Data from the literature suggest that in patients with acute type B aortic dissection (ATBAD), associated with AAA, rupture risk is higher at the confluence tract than isolated lessions. Herein, we report a case of ATBAD and AAA managed with simultaneous intervention. CASE PRESENTATION: We report a complicated case of a symptomatic patient presenting with a type B aortic dissection and false lumen extension into superior mesenteric artery (SMA) with an infrarenal abdominal aortic aneurysm (AAA). Severe back pain and hypertension were the patient's initial complaints. This patient underwent endovascular repair with a thoracic and infrarenal aortic endograft. DISCUSSION: AAA rupture has been detected at admission in three-fourths of patients with ATBAD that extended to or involved a coexisting unoperated atherosclerotic aneurysms. Prompt surgical intervention is essential to deal with this dreadful aortic emergency. CONCLUSION: In our experience a totally endovascular solution to treat a complicated ATBAD plus AAA was a rapid solution with low invasivity, no complication and complete healing of patients.

Endovascular Treatment of Spontaneous and Isolated Infrarenal Acute Aortic Syndrome with Unibody Aortic Stent-Grafts.

INTRODUCTION: Spontaneous acute aortic syndrome (IAAS) is rarely localized in the infrarenal aorta. The endovascular approach is preferred over conventional open surgery with fewer complications. However, dedicated endovascular devices for IAAS treatment are unavailable. The aim was to report a large single-center experience using unibody stent-grafts to address IAAS. METHODS: From April 2016 to March 2019, a retrospective analysis of patients presenting spontaneous and isolated IAAS was performed. Patients addressed with the unibody stent-graft (AFX endovascular AAA system; Endologix Inc., Irvine, CA) were included in the study. Indications to IAAS treatment were persistent symptoms and/or dilated abdominal aorta (>3 cm). The measured outcomes were technical success; early outcomes (<30 days) including mortality, morbidity, symptoms recurrence, and endoleak occurrence; and late outcomes (>30 days) including mortality, symptoms recurrence, endoleak occurrence, stent-graft patency, and survival. Median follow-up was 23.77 ± 10 months. RESULTS: Twenty-one patients with IAAS were included. Indications to treatment were symptoms in 14 (67%) patients and dilated abdominal aorta in 7 (33%). Technical success was achieved in all cases. No perioperative mortality and 1 (4.8%) early femoral access complication was encountered. During the follow-up were registered 1 (4.8%) aortic unrelated death and 1 (4.8%) stent-graft limb stenosis. The 36 months estimated survival and freedom from reintervention were 92% (CI: 37-43; SE: 1.7) and 94% (CI: 37-44; SE: 1.7), respectively. CONCLUSIONS: The endovascular treatment of IAAS with unibody stent-graft (AFX endovascular AAA system; Endologix Inc.) is safe and effective with promising mid-term outcomes. The use of unibody stent-grafts expands the endovascular indication, despite the usual anatomic IAAS features. Larger studies with longer follow-up are required to validate the outcomes of the reported technique.

A rare case of infrarenal aortic coarctation in a young female.

INTRODUCTION: Infrarenal abdominal aortic coarctation (AAC) is an extremely rare disease. It can be associated with renal artery stenosis determining secondary renal hypertension. PRESENTATION OF CASE: We report a case of AAC in young female patient presenting systemic hypertension non-responder to medical treatment. Diagnostics revealed the involvement of the right renal artery as the cause of hypertension. The management consisted of percutaneous renal artery stenting and close surveillance for the aortic segment. The treatment was uneventful with resolution of the hypertensive condition. DISCUSSION: AAC etiology is unknown. There are no studies comparing the long-term treatment outcome in adult patients. The long-term prognosis depends mainly on blood pressure control and the underlying disease. In the reported case the treatment of the renal lesion was adequate to control the secondary hypertension. This approach does not preclude future intervention in the aortic segment and provides a fast-recovery and less invasive approach to the major clinical manifestation. CONCLUSION: In this case the treatment of the specific vascular lesion was adequate to address the main clinical hypertensive manifestation. This less-invasive approach did not preclude future intervention in the aortic segment where the evolution of the disease is unknown.

Endovascular Treatment of Spontaneous Internal Carotid Artery Dissection with Proximal Embolic Protection Device.

BACKGROUND: The aim of this study was to report the feasibility and outcomes with the endovascular treatment of spontaneous internal carotid artery dissections (ICADs) using a proximal embolic protection device (EPD). METHODS: This is a retrospective analysis of patients treated for spontaneous symptomatic ICAD using a proximal EPD from January 2017 to December 2018. Indication for treatment was the presence of neurologic symptoms. Early outcomes measured included technical success, perioperative mortality, and major cardiovascular or cerebrovascular complications. Late outcomes were recurrent neurologic symptoms, patency, and reinterventions. RESULTS: A total of 4 male patients with ICAD were included. A preoperative cerebral computed tomography positive for cerebral ischemic events was reported in all cases. In 3 patients, the neurologic symptoms consisted of a transient ischemic attack; the remaining patient presented an amaurosis fugax and aphasia. In 2 patients, ICAD was associated with a carotid significant stenosis. In all patients, the reported approach was feasible with no complications and complete anatomic dissection resolution. At a mean follow-up of 18 months, all stents are patent and no restenosis recurrence or complications were registered. CONCLUSIONS: The use of proximal EPDs allowed the treatment of ICAD under flow arrest, minimizing the risk of stroke during the endovascular maneuvers. Larger series are required to validate this treatment strategy.

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.

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.

Endovascular treatment of large and wide aortic neck: case report and literature review.

Large (24-34 mm) and wide (≥35 mm) aortic necks are a contraindication to endovascular aneurysm repair (EVAR). A 63-year-old man, unfit for conventional surgery, presented a 79 mm abdominal aortic aneurysm with 36.5 mm aortic neck and a 62 mm right common iliac artery aneurysm. He was treated endovascularly with standard commercially available stent-graft using the so-called 'funnel technique'; by placing a thoracic stent-graft inside a bifurcated device to achieve proximal sealing. The completion angiography and the 6 months follow-up with computed tomography showed no stent-graft migration, limb occlusion or endoleak. The literature review reported 179 cases of large aortic neck managed with EVAR, all cases treated with standard devices. Conversely a wide aortic neck was reported in 9; in 2 cases were employed custom-made devices and in 7 standard stent-graft. The use of EVAR with commercially available stent-grafts is feasible and it represents an option especially in non-elective setting.

Stent-assisted detachable coil embolization of wide-necked renal artery aneurysms.

Renal artery aneurysms (RAAs) are rare with an estimated incidence of 0.1% in the general population, and they represent approximately 25% of all visceral aneurysms. The gold standard of treatment is open surgery, but it is associated with a high risk of nephrectomy, mortality, and morbidity. Less invasive endovascular therapies are becoming increasingly common for the treatment of RAAs. Here, we aimed to report three cases of wide-necked complex renal artery aneurysms treated endovascularly using stent-assisted coil embolization with self-expandable stent nitinol Solitaire AB and Concerto Axium coils. In addition, we describe the use of the waffle-cone technique in a case of wide-necked saccular RAA involving the renal artery bifurcation. Technical success was achieved in all three cases with no early or late complications and no recurrences.

Use of the directional atherectomy for the treatment of femoro-popliteal lesions in patients with critical lower limb ischemia.

Femoro-popliteal PTA for the treatment of critical limb ischemia is frequently associated with unsatisfactory procedural success rates while directional atherectomy (DCA) has improved success rate since claudicant patients undergoing percutaneous treatment of femoro-popliteal obstructive disease. The aim of this prospective study is to evaluate the safety, efficacy and procedural success of DCA, at one year, in the percutaneous treatment of femoro-popliteal obstructive disease in patients with critical limb ischemia. METHODS: From March 2012 to March 2013 18 consecutive patients with critical limb ischemia were treated with DCA (Turbohawk/Covidien-ev3 Endovascular Inc., North Plymouth, Minnesota, USA) for the treatment of femoro-popliteal obstructive disease. Patients were evaluated at 12 months. RESULTS: Technical and procedural success was achieved in every patient. No in-hospital major adverse cardiovascular events occurred. Primary endpoint: freedom from any amputation was obtained in all patients. Secondary endpoints: clinical (Rutherford class improvement) and hemodynamic success (Ankle-brachial index improvement) was achieved in all patients. CONCLUSION: The use of DCA for the treatment of femoro-popliteal obstructive disease is a safe and effective therapeutic strategy for patients with critical limb ischemia. The data included in our study should be considered hypothesis-generating in order to design of a randomized trial comparison with conventional PTA.

Cinical outcomes of Endurant II stent-graft for infrarenal aortic aneurysm repair: comparison of on-label versus off-label use.

PURPOSE: We aimed to compare the outcomes of the Endurant II (Medtronic) stent-graft used under instructions for use versus off-label in high-risk patients considered unfit for conventional surgery. METHODS: Data from patients treated with the Endurant II stent-graft between December 2012 and March 2015 were retrospectively analyzed. Sixty-four patients were included. Patients were assigned to group A if treated under instructions for use (n=34, 53%) and to group B if treated off-label (n=30, 47%). Outcome measures included perioperative mortality and morbidity, survival, freedom from reintervention, endoleak incidence, in-hospital length of stay, and mean stent-graft component used. Mean follow-up was 22.61±12 months (median, 21.06 months; range, 0-43 months). RESULTS: One perioperative mortality (1.6%) and one perioperative complication (1.6%) occurred in group B. At two months follow-up, one iliac limb occlusion (1.6%) occurred in group A. No type I/III endoleaks were recorded. A type II endoleak was identified in three cases (4.7%). Overall survival at three years was 89% (97% for group A, 82% for group B; P = 0.428). Reintervention-free survival at three years was 97% for both groups (P = 0.991). A longer in-hospital stay was observed in group B (P = 0.012). CONCLUSION: The Endurant II (Medtronic) new generation device was safe in off-label setting at mid-term follow-up. The off-label use of the Endurant II (Medtronic) is justified in patients considered unfit for conventional surgery. Larger studies are required in this subgroup of patients.

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.

Spontaneous symptomatic common carotid artery pseudoaneurysm: case report and literature review.

Spontaneous common carotid artery pseudoaneurysm (CCAP) is rare but potentially lethal disease. A 78-year-old man presented with pain in correspondence of right neck side and slight right eye ptosis. No previous surgery, trauma, or venous catheterizations in the neck region were reported. The computed tomographic angiography (CTA) showed a 4-cm saccular CCAP. The patient was managed emergently with surgical CCAP excision. At 6-month follow-up, the patient is neck pain-free with complete ptosis regression, and the CTA shows no pathologic findings. The literature review reported 7 cases of pseudoaneurysm of carotid district. All these cases were managed by surgical approach, and in 1 case, an endovascular embolization procedure was associated before. The CTA was used in all cases but angiography in only one. In these cases, the surgical repair with pseudoaneurysm evacuation is still the treatment of choice.

Late Complication after Superficial Femoral Artery (SFA) Aneurysm: Stent-graft Expulsion Outside the Skin.

A 78-year-old man presented with a 7-cm aneurysm in the left superficial femoral artery, which was considered unfit and anatomically unsuitable for conventional open surgery for multiple comorbidities. The patient was treated with stent-graft [Viabhan stent-graft (WL Gore and Associates, Flagstaff, AZ)]. Two years from stent-graft implantation, the patient presented a purulent secretion and a spontaneous external expulsion through a fistulous channel. No claudication symptoms or hemorrhagic signs were present. The pus and device cultures were positive for Staphylococcus aureus sensitive to piperacillin/tazobactam. Patient management consisted of fistula drainage, systemic antibiotic therapy, and daily wound dressing. At 1-month follow-up, the wound was closed. To our knowledge, this is the first case of this type of stent-graft complication presenting with external expulsion.

Endograft connector technique to treat popliteal artery aneurysm in a morbid obese patient.

Surgical repair of popliteal artery aneurysm in morbid obese patients poses additional challenges. We report a morbid obese patient who had a 59 mm right popliteal artery aneurysm which was successfully treated with the endograft connector technique. This technique was used to perform the distal anastomosis of the below-knee femoro-popliteal bypass. A 10 mm Dacron graft was used as a main graft bypass and an 11 mm/10 cm stentgraft as endograft connector. Following the respective tunnel of the Dacron graft, an end-to-side proximal anastomosis was performed at distal femoral artery. The aneurysm exclusion was obtained through a proximal and a distal ligation. Postoperative duplex showed adequate bypass patency. Knee x-rays demonstrated no signs of stent kinking/fractures. The postoperative course was uneventful and the patient was discharged home on fourth day post operative. The six-month computed tomography scan and the 12-month duplex control showed a patent bypass with no signs of stenosis.

Carotid artery stenting in patients with brain meningioma.

The association between carotid artery stenosis and brain meningioma is rather rare. Indeed, data in literature about this association are scarce and potential risks of carotid artery stenting using different protection devices are not known. We describe the endovascular treatment of severe carotid stenosis in two patients with intracranial meningioma.