Carotid Artery Stenting versus Carotid Endarterectomy in Terms of Neuroprotection DW-MRI Detected and Neuropsychological Assessment Impairment.

BACKGROUND: Carotid artery stenting (CAS) versus carotid endarterectomy (CEA) is well issue known, but the purpose of this study is to compare CAS versus CEA in terms of asymptomatic Diffusion-weighted magnetic resonance imaging (DW-MRI) demonstrated microembolic scattering of infarction and neuropsychological assessment impairment. METHODS: We performed a prospective, observational, cohort study on 211 consecutive carotid revascularizations at our institution. Patients were divided into 2 different cohorts: CEA was performed in n = 116 patients (Group A); CAS was performed in n = 95 (Group B). Adverse events were collected at 30 days and 6 months postoperative. Differences in terms of DW-MRI demonstrated microembolic scattering of infarction were analyzed and considered significative for P ≤ 0.05. Secondary objectives were: major and minor stroke, neuropsychological assessment impairment, death, myocardial infarction (MI). RESULTS: CEA was associated with a significative decreased rate of asymptomatic DW-MRI demonstrated microembolic scattering of infarction (13.8% vs. 51%; P = 0.0001) and of 6 months neuropsychological assessments impairment (0.8 vs. 7.4) (P = 0.04) in asymptomatic patients. There was no significant difference between 2 groups in terms of comorbidities. Stroke rates were similar at 30 days (1.7% CEA vs. 4.1% CAS) and 6 months (2.6% CEA vs. 5.3% CAS P = 0.32). There were no differences in terms of central neurological events, death, transient ischemic attack, MI between the groups. The composite end point of stroke/death/MI at 6 months postoperatively was 2.6% vs. 6.3% (P = 0.19). CONCLUSIONS: According to these results, CEA achieved better outcomes compared to patients treated by CAS with distal filter in terms of asymptomatic microembolic event and impairment National Institutes of Health Stroke Scale scale and neuropsychological assessments. Limitations of the study lead to limited conclusions only in the specific population and not generalized. Further, comparative randomized studies are warranted.

Simultaneous aortoiliac kissing Endovascular stenting for management of isolated monolateral common iliac artery aneurysm with no proximal landing zone.

BACKGROUND: Isolated iliac artery aneurysm (IIAA) is an uncommon finding. It, accounts for 0.03% of all patients and 2% of all abdominal aneurysm. Endovascular approach represents the treatment of choice for most patients with IIAA. We reported our experience on iliac aneurysm with no proximal landing zone by simultaneous aortoiliac kissing endovascular (S.A.K.E.) covered stenting. METHODS: This is a retrospective analysis of nine consecutive patients with IIAA with no proximal landing zone, who underwent endovascular kissing covered stenting (Gore®Viabahn®VBX) The median aneurysm diameter was 4.1 cm, with a median 3-mm proximal neck length. In 3/9 aneurysms involving the internal iliac arteries the origin of the internal iliac artery was covered after its embolization and a stent graft extending to the external iliac artery (EIA) was placed. All stents were flared with semi-compliant balloon. RESULTS: Iliac aneurysm exclusion was obtained in all cases (100%), no graft migration or endo-leak were recorded. The median operative time was 28 min; the median fluoroscopy time was 9 min and a median 70 mL of contrast was used. At a median 24-month follow-up, all patients are alive, and no endo-leak or migration, infection, distal embolization, limb loss were observed. Moderate buttock claudication was experienced in 1/9 patients with internal iliac artery embolization. In 6/9 patients a shrinkage of the aneurysmal sac was recorded after 1 year. DISCUSSION: Endovascular management of IIAAs cases has been reported in literature and it was confirmed to be safe and successful. The IAA usually progresses into expansion which eventually leads into rupture. Adequate long proximal and distal landing zones were the most important feature related to better outcomes. Short proximal neck (˂10 mm) represents a real challenge for iliac aneurysm treatment and, nowadays, a classical bifurcated aortoiliac endograft deployment represents the treatment of choice. Endovascular repair of isolated CIA aneurysms with no proximal neck is safe and successful using the SAKE stenting technique with VBX adequately flared and it represents effective and minimally invasive alternative to aortobiliac endograft implantation in the treatment of these aneurysms. To the best of our knowledge, this is the first report which describes this approach in the treatment of IIAA with no adequate proximal landing zone. Our approach overcomes the need to aortic bifurcation graft implantation and reduces procedure time, contrast dose and radiation exposure. It also preserves relevant collaterals vessels thanks to inferior mesenteric artery and lumbar arteries sparing. A proximal aortic bifurcation endograft allows proximal sealing to be regained. Large population study with longer follow-up are needed to establish this approach as a new standard.

Are Small Popliteal Aneurysm so Innocent?

BACKGROUND: We recently recorded 5 lower limb ischemia related to a small (diameter≤20 mm) popliteal artery aneurysm (PAA) thrombosis hence we performed a retrospective data analysis on small symptomatic PAA management from our database. METHODS: We performed a retrospective cohort study on 48 acute leg ischemia from aneurysm's thrombosis. All of them underwent surgical distal thrombectomy and bypass creation. Patients were divided into 2 different cohorts: GROUP A (diameter ≥20 mm) and GROUP B (diameter ≤20 mm). Differences in terms of the limb salvage (end-point: the amputation rate) was analyzed and considered significative for P ≤ 0.05. Secondary objectives were: vessel runoff recovery and patency rate. Adverse events were collected at 12 and 24 months postoperative. RESULTS: Two-year overall amputation rate was: 22.9% (11/48); 21.8% (7/32) in GROUP A and 25% (4/16) in GROUP B (RR:0.87, CI:0.29-2.55, p.80). The mean age was 68 ± 13 years, No statistically significant differences were identified in term of primary and secondary patency (RR:0.95, CI:0.55-1.6, p.85 and (RR:0.95, CI:0.53-1.7, p.88 respectively) no differences were found in terms of comorbidities. Patients' follow-up ranged from 8 to 36 months. In 90% of those amputated patients, the length of ischemia exceeded 4 days. Amputation rate was correlated with one runoff vessel recovery, only. CONCLUSION: s According these results small PAA are not as innocent as it is often presumed and was associated with not negligible incidence of limb loss due to thrombosis or distal embolizations also if compared to larger aneurysm. The immediate surgery is mandatory also when the ischemia exceeds 2 days.

Isolated popliteal artery lesion due to giant cell vasculitis post COVID-19 mRNA vaccine and COVID-19 asymptomatic infection.

OBJECTIVE: Giant cell arteritis (GCA) is a rare granulomatous vasculitis, affecting medium and large vessels, usually in old patients. The incidence of GCA has been higher during current COVID-19 pandemia and COVID-19 is recognized for its immune dysregulation. Lower limbs involvement is uncommon but can be limb threatening, resulting in limb loss. METHOD: A 43-year-old man presented with a sudden pain in his right calf and foot associated with pallor and hypothermia, and there was objective evidence of ischemia. Symptoms began few days after he received the first dose of a COVID-19 mRNA vaccine and COVID-19 asymptomatic infection 20 days after vaccination. He had no history of any signs of claudication pre-COVID or limb trauma and was very fit.Enhanced computed tomography and magnetic resonance imaging (MRI)suggest diagnosis of popliteal artery cystic adventitial disease. We resected the affected popliteal artery with interposition using a right great saphenous vein graft, through a posterior approach. On the fourth postoperative day, he was discharged.Histopathological examination revealed patchy intramural inflammatory infiltrates composed of lymphocytes and rare multinucleated giant cells at the internal lamina and adventitia consistent with a diagnosis of GCA. CONCLUSION AND RESULT: Our case represents the first reported case of isolated popliteal GCA following vaccination with a COVID-19 mRNA vaccine and COVID-19 infection. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing risk factors and recurrent and repetitive microtrauma in popliteal fossa (the patient is a professional runner). Our case suggests the need for further studies about real world incidence of GCA associated vaccination and COVID-19 infection. Currently, data is limited regarding this relationship. We continue to encourage COVID-19 vaccination, even in elderly patients because the benefits of vaccination far outweigh any theoretical risk of immune dysregulation following administration.

Common carotid artery endovascular clamping for neuroprotection during carotid stenting: Flow-gate system as an innovative treatment approach.

OBJECTIVES: We here report our clinical experience in CAS management through common carotid artery endovascular clamping with FlowGate2 system. METHODS: Forty-five patients were enrolled with de novo asymptomatic internal carotid artery stenosis ≥70%. Cerebral protection during the stenting procedure was achieved using a unique endovascular clamping technique developed in our Institution which includes: (a) the occlusion of the common carotid artery only, through inflatable balloons integrated in the FlowGate2 Balloon Guide Catheter system; (b) flow inversion connecting catheter to 16 G blood cannula previously placed in arm vein; (c) after the placement of the stent, the flow inversion is maintained for 30 s to allow debris washout. The related primary end-point was the rate of Diffusion-weighted imaging magnetic resonance (DWI) micro-embolic scattering of infarction. The patient's clinical and the neurological status were assessed prior, during and after intervention, at discharge. RESULTS: Transient clamping intolerance was observed in two patients (2/45; 4%). One minor stroke (1/45; 2%) occurred 8 hr the procedure with DWI ipsilateral micro-embolic lesions. No major strokes or deaths were observed at 3 months follow-up. DWI demonstrated ipsilateral micro-embolic scattering of infarction, in one asymptomatic patient. In all patients, no worst changes in NIHSS scale assessment were recorded at 1, 3, and 6 months. CONCLUSIONS: Our data confirmed the efficacy of FlowGate2 in terms of neuroprotection during CAS. To our knowledge, these are the first published data on this innovative approach developed in our institution. A large controlled trial is ongoing to confirm preliminary evidences.

Outcomes of endovascular repair of abdominal aortic aneurysms in narrow aortic bifurcations using the ultra-low profile "INCRAFT" device: A retrospective multicenter study.

OBJECTIVE: Although the long-term results of endovascular aortic repair (EVAR) with low-profile devices in patients with hostile iliac anatomies have been published, there are no reported results specifically for narrow aortic bifurcations (NAB). This study investigated the outcomes of EVAR with the INCRAFT device in NAB (<16 mm). METHODS: This multicenter retrospective study involved five vascular surgery centers. From November 2014 until June 2018, 127 patients were treated with the INCRAFT device. The patient population was divided into two groups based on aortic bifurcation diameter. They were designated as the (1) standard aortic bifurcation (SAB) group (>16 mm) and the (2) the NAB group (<16 mm). Primary end points were the differences between the two groups in terms of technical success, survival at 30 days, iliac limb patency, and reinterventions. RESULTS: The SAB group included 96 patients and the NAB group included 31 patients. The mean aortic bifurcation diameter was 25.5 mm in the SAB group and 13.2 mm in the NAB group. It is noteworthy that, in the NAB group, 21.8% of patients had aortic bifurcations with focal calcific lesions (less than one-third of the circumferential length of the bifurcation) and 48.3% showed extensive calcifications (two-thirds of the circumferential length of the bifurcation), for 29.9% of the patients in the NAB group the aortic bifurcation had a circumferential highly calcific lesion (complete occlusion of the circumferential length of the bifurcation). Technical success was 98.9% in the SAB group and 96.7% in the NAB group (P = .1). The need for iliac component stenting was not significantly different between the groups (SAB 2.0% vs NAB 3.2%; P = .07). The 1-year survival was 97.9% and 96.7% in the SAB and NAB groups, respectively, with no aneurysm-related mortality. The mean follow-up was 18.4 months and 15.3 months in the SAB and NAB groups, respectively. The iliac primary patency was 98.9 % in the SAB group and 96.8% in the NAB group (P = .088), and the primary assisted patency was 100% in both groups. CONCLUSIONS: EVAR with INCRAFT in NABs showed acceptable results. In this multicenter study, the results were comparable in terms of technical success and iliac patency rate between patients with SABs and NABs.

Retroperitoneal Hematoma Caused by Suprarenal Stent Perforation Two Years after Ovation Abdominal Stent-Graft Implantation.

Retroperitoneal hematoma due to late perforation of aortic wall endograft deployment is a rare but, potentially, fatal event. We report a case of symptomatic retroperitoneal hematoma due to aortic perforation by free flow barbs of Ovation Prime stent graft. The patient was successfully treated by celiac trunk embolization and aortic cuff placement. The patient was discharged with no further treatment. At 3-month follow-up, no complications were detected.

Endovascular Treatment with Two Overlapping Micromesh-Covered Stents and Balloon Guide Catheter for Symptomatic Carotid Pseudoaneurysm Ten Years after Eversion Endarterectomy.

Pseudoaneurysm is a rare complication after carotid endarterectomy. Herein, we report a successful endovascular exclusion of a symptomatic carotid pseudoaneurysm occurred ten years after an eversion carotid endarterectomy by means of 2 overlapping micromesh stents (InspireMD C-Guard™) and balloon guide catheter (FlowGate2 Balloon Guide Catheter) used as a proximal protection device.

Carotid artery stenting with flow inversion cerebral protection and MicroNet-covered stent.

BACKGROUND: The study aims to evaluate the association of proximal flow-inversion cerebral protection and MicroNet-covered CGuard stents in reducing early and late embolic events in carotid artery stenting procedures. METHODS: From 2018 to 2023, we performed 204 procedures in 180 patients with flow inversion cerebral protection and CGuard stents at the Vascular Surgery Unit of Sant'Eugenio Hospital in Rome. Cerebral protection was achieved with a Flow-Gate2 catheter connected to a peripheral vein. The tip balloon is inflated in the CCA to obtain an effective endoclamping, the pressure difference between the carotid bifurcation and the venous compartment ensures a constant back flow with wash-out in the venous compartment. Inclusion criteria were: life expectancy of >12 months, target lesions indicating treatment according to ESVS Guidelines, increased surgical risk due to comorbidities or anatomic issues. ECD follow-up was performed immediately postoperatively, at 30 days, 6 and 12 months, and subsequently annually. RESULTS: The treatment protocol was successfully implemented in 99% of cases. No major strokes occurred, while one minor stroke (0.5%) occurred within 8 hours of the procedure, regressing in the following months. One perioperative death (0.5%) due to cerebral hemorrhage occurred three hours after the procedure. All patients remained asymptomatic, with no short or medium-term neurological score deterioration. One hemodynamically significant restenosis (0.5%) was detected at the 6-month follow-up. All patients completed the 6 months follow-up, though 6 (3%) were lost at the 12-month appointment. CONCLUSIONS: Our prospective monocentric study has demonstrated the effectiveness and safety of the FlowGate2 flow inversion cerebral protection system in association with MicroNet covered CGuard stent.

Role of mini access during carotid endarterectomy: a prospective observational study.

BACKGROUND: Data from literature confirmed the non-trivial risk associated with carotid revascularization. The purpose of this study is to evaluate carotid endarterectomy (CEA) via a mini-invasive access (3-6 cm longitudinal) incision as a viable alternative to the traditional access via a cutaneous incision (˃6 cm) in terms of nerve sparing and neck pain/disability for patients. METHODS: We performed a prospective, observational, cohort study on 796 consecutive patients who underwent CEAs. A number of 730 patients was included in the final analysis. Patients entered in two different cohorts: CEA with 3-6 cm incision was performed in N.=398 (Group A); CEA with>6 cm incision was performed in N.=398 (Group B). Entire data set is available from 382 in group A and 348 in group B. Adverse events were recorded at 30 days, 3 and 6 months after surgery. The primary purpose of this study was to identify the incidence of cranial nerve injuries and related pain (by Northwick Park Neck Pain Questionnaire [NPq]) in both groups. Differences between groups were exploratory, only, and considered significative for P≤0.05. Secondary objectives were: death, major and minor stroke, transient ischemic attack (TIA), myocardial infarction (MI) and main duration of operation. RESULTS: The cumulative incidence of transient deficit of peripheral nerve in group A was 1.7% at 30 days and 19.4% in group B (RR: 0.10, 95% CI 0.07-0.1, P=0.0001) suggesting a possible benefit from mini-skin incision on nerve injuries reduction. Cranial nerve permanent injuries were identified in 0.17% of mini-incision group and 0.23% of standard group. Exploratory comparison did not demonstrate significative differences between the groups (RR: 0.72, 95% CI 0.19-2.71, P=0.63). The median NPq postoperative score was 40% in GROUP A and 79% in GROUP B (exploratory difference 39%, 95% CI 32.22-45.20%, P=0.0001, χ2: 114.007). At 6 months, NPq was 20% and 42%, respectively; exploratory differences were still present. The need to prolong the mini-incision in GROUP A to preserve the surgical outcome was 1.3%, only. CONCLUSIONS: According to these results the mini skin incision allows a sufficient vessels exposure for dissection, endarterectomy, reconstruction of carotid artery and shunt positioning, minimizing surgical invasiveness, decreasing the incidence of temporary cervical nerve dysfunction and improving the aesthetic result with significative less pain suffered by the patients. Transverse cervical and great auricular nerves sparing decreased postoperative hypo-paresthesia in the neck, improving patient's satisfaction. These data suggest that this procedure can be considered safe. Exploratory analysis suggested that it could possibly be considered a safety alternative to standard carotid endarterectomy. A randomized controlled trial is ongoing for definitive conclusions.

Electromyographic and Stabilometric Analysis of the Static and Dynamic "Standing Bird Dog" Exercise.

(1) Background: The "bird dog" exercise is considered one of the most effective therapeutic exercises for lumbopelvic rehabilitation and the prevention and treatment of low back pain. The "standing bird dog" (SBD) exercise, executed in a single-leg stance, constitutes a natural and challenging variation in the "bird dog"; nevertheless, this exercise has not yet been investigated. This study provides a stabilometric and electromyographic analysis of the SBD performed in static and dynamic conditions and in ipsilateral and contralateral variations; (2) Methods: A time-synchronized motion capture system, wireless electromyography sensors, and triaxial force platform were used to analyze the selected SBD exercises; (3) Results: In dynamic conditions, the gluteus maximum, multifidus, lumbar erector spinae, and gluteus medius reached a mean activation level higher than in the static condition, with peak activation levels of 80%, 60%, 55%, and a 45% maximum voluntary isometric contraction, respectively. In the static condition, balance control was more challenging in the mediolateral compared to the anteroposterior direction. In the dynamic condition, the balance challenge was higher in the anteroposterior direction and higher than the static condition in both directions; (4) Conclusions: The SBD was proved to be effective for strengthening the hip and lumbar extensor muscles and provided a powerful challenge to single-leg balance control in both mediolateral and anteroposterior directions.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document.

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient's underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Hey surgeons! It is time to lead and be a champion in preventing and managing surgical infections!

Appropriate measures of infection prevention and management are integral to optimal clinical practice and standards of care. Among surgeons, these measures are often over-looked. However, surgeons are at the forefront in preventing and managing infections. Surgeons are responsible for many of the processes of healthcare that impact the risk for surgical site infections and play a key role in their prevention. Surgeons are also at the forefront in managing patients with infections, who often need prompt source control and appropriate antibiotic therapy, and are directly responsible for their outcome. In this context, the direct leadership of surgeons in infection prevention and management is of utmost importance. In order to disseminate worldwide this message, the editorial has been translated into 9 different languages (Arabic, Chinese, French, German, Italian, Portuguese, Spanish, Russian, and Turkish).

Spinal cord protection during aortic cross clamping: retrograde venous spinal cord perfusion, distal aortic perfusion, and cerebrospinal fluid drainage.

OBJECTIVE: We investigated retrograde venous spinal cord perfusion (RVP), with the established adjuncts cerebrospinal fluid drainage (CSFD), and distal aortic perfusion (DAP) in the canine model. We then examined the clinical feasibility of RVP, DAP, and CSFD. DESIGN: Canine study: Twenty dogs were randomized to four treatment groups. All animals underwent 60 min of complete aortic cross-clamp. Group 1 was the control and received only aortic cross-clamp; group 2 DAP and CSFD; group 3 DAP, CSFD, and RVP; and group 4 CSFD plus RVP. Human study: Five patients underwent aortic graft replacement of the descending or thoracoabdominal aorta, while receiving CSFD, DAP, and RVP. RESULTS: Canine study: All animals in groups 1 and 4 awoke paralyzed. One animal each in groups 2 and 3 were paraparetic, with the remaining dogs neurologically intact. Groups 2 and 3 differed from groups 1 and 4 at p < 0.0001. Human study: No mortality or permanent complications were observed in this group. CONCLUSION: While RVP did not reduce neurologic injury, neither did it increase morbidity. In humans the method is technically feasible and free from major problems. Further animal studies and randomized trials are underway at our center.