Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol.

BACKGROUND: Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury. METHODS: We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study. RESULTS: The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall. CONCLUSIONS: Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.

Next-Generation Sequencing of microRNAs in Small Abdominal Aortic Aneurysms: MiR-24 as a Biomarker.

BACKGROUND: Small abdominal aortic aneurysms (AAAs) are asymptomatic but can potentially lead to rupture if left undetected. To date, there is a lack of simple nonradiologic routine tests available for diagnosing AAAs. MicroRNAs (miRNAs) have been proven to be good-quality biomarkers in several diseases, including AAA. METHODS: An attempt to identify a panel of circulating miRNAs with differential expression in AAAs via next-generation sequencing (NGS) was performed in serum samples: small AAAs (n = 3), large AAAs (n = 3), and controls (n = 3). For miR-24, validation with real-time polymerase chain reaction (PCR) was undertaken in a larger group (n = 80). RESULTS: In the NGS study, 23 miRNAs were identified as differentially expressed (with statistical significance) in small AAAs in comparison with controls. Among them, miR-24 showed the largest upregulation with 23-fold change (log2FC 4.5, P = 0.024). For large AAAs compared with controls, and small AAAs compared with large AAAs, a panel of 33 and 131 miRNAs showed statistically significant differential expression, respectively. Based on the results of the NGS stage, a literature search was performed, and information regarding AAA pathogenesis, coronary artery disease, and peripheral arterial disease was documented where applicable: miR-24, miR-103, miR-193a, miR-486, miR-582, and miR-3663. Of these 6 miRNAs, miR-24 was chosen for further validation with real-time PCR. Additionally, in the NGS study analysis, 17 miRNAs were common between the small-large AAAs, small AAAs-controls, and large AAAs-controls comparisons: miR-7846, miR-3195, miR-486-2, miR-3194, miR-5589, miR-1538, miR-3178, miR-4771-1, miR-5695, miR-6504, miR-1908, miR-6823, miR-3159, miR-23a, miR-7853, miR-496, and miR-193a. Interestingly, in the validation stage with real-time PCR, miR-24 was found downregulated in small and large AAAs compared with controls (fold-changes: 0.27, P = 0.015 and 0.15, P = 0.005, respectively). No correlation was found between average Ct values, aneurysm diameter, and patients' age. CONCLUSIONS: Our findings further highlight the importance of miR-24 as a potential biomarker as well as a therapeutic target for abdominal aneurysmal disease. Future research and validation of a panel of miRNAs for AAA would aid in diagnosis and discrimination between diseases with overlapping pathogeneses.

Long-term outcomes of the Endurant endograft in patients undergoing endovascular abdominal aortic aneurysm repair.

OBJECTIVE/BACKGROUND: To investigate the long-term outcomes after endovascular aneurysm repair (EVAR) in a real-world setting using the Endurant endograft (EG). METHODS: 184 EVAR candidates treated with the Endurant family EGs in a single vascular center were prospectively enrolled from January 2009 to December 2016. Kaplan-Meir estimates of long-term standardized primary and secondary outcome measures were performed. Per protocol, subgroup comparison analysis was performed in three groups: patients treated within instructions for use (in-IFU) vs patients treated outside IFU (outside-IFU), EVAR in patients receiving the Endurant proximal diameter 32 or 36 mm EG vs those receiving the <32 mm diameter EG and EVAR with various Endurant EG versions. RESULTS: The mean follow-up was 75.09 ± 37.9 months (range: 4.1-172 months). The median age of the patients was 72.96 ± 7.03 years (range: 55-88 years). A total of 177 patients were male (96.2%). Compliance with IFU was followed in 107 patients (58.2%). Overall survival was 69.5% and 48% at 5 and 8 years, respectively. Of the 102 all-cause deaths, 7 (6.9%) were aneurysm related. Six of these postimplant deaths occurred in patients presented with aneurysm rupture from type Ia or/and type Ib endoleak. At 5, 8, and 10 years of observation, freedom from aneurysm rupture, open surgical conversion, type I/III endoleak, any type of endoleak, aneurysm-related secondary intervention probabilities, and neck-related events were as follows: 98.1%, 95%, and 89.4%; 95.1%, 91.2%, and 85.7%; 93.6%, 87.3%, and 83.9%; 83.4%, 74%, and 70.9%; 89.8%, 76.7%, and 72%; and 96.3%, 90%, and 87.6%, respectively. Corresponding clinical success was 90%, 77.4%, and 68.4%, respectively. Patients treated outside-IFU had significantly higher risk of aneurysm rupture, open surgical conversion probability, occurrence of type I/III endoleak, and chance of reinterventions and lower clinical success probabilities compared with the in-IFU counterparts at 5 and 8 years. This statistical difference remained when type Ia endoleak or endoleak of any type was considered independently. In addition, it was stronger in patients having extreme anatomic boundaries (>1 hostile anatomic condition), when aneurysm-related death, aneurysm rupture, and clinical success at 5 years were considered. Overall proximal migration and limb occlusion were recorded in 1.1% and 4.9% of the patients, respectively. Overall reintervention rate was 17.4%. An increase in aneurysm sac diameter was observed in 12.5% of patients and was not related to IFU status. The Endurant version or the proximal EG diameter had no significant association with the chance of any complication or adverse event. CONCLUSIONS: The data confirmed the durability of the Endurant EG, achieving promising long-term outcomes in a real-world setting. However, its positive performance must be interpreted with caution in patients treated off-label especially those with extreme anatomic boundaries. In this cohort, some of EVAR advantages might be lost in the late future. Further similar studies are warranted.

Customizing foam sclerotherapy of the great saphenous vein: A proposed algorithm to enhance technical efficacy.

OBJECTIVES: The catheter-directed foam sclerotherapy (FS) and the suggested perivenous tumescent application for great saphenous vein (GSV) diameter reduction are suggested to improve technical and clinical results; yet, their use is reported rather indiscriminately. Our aim is to introduce an algorithm categorising the use of technical modalities accompanying ultrasound-guided FS of the GSV and present the technical efficacy of FS through a 5 F × 11  cm sheath placed at the knee level. METHODS: Representative cases of GSV insufficiency were chosen to describe our methodology. RESULTS: Sole sheath-directed FS can achieve complete GSV occlusion proximally at a level comparable to the catheter-directed technique. We apply perivenous 4°C cold tumescent to GSV >6 mm even in the standing position to ensure diameter reduction of the proximal GSV as close to the saphenofemoral junction. We use long catheters only to overcome large varicosities above the knee level that could otherwise compromise the adequate foam infusion from the sheath tip. When GSV insufficiency extends along the entire limb and severe skin lesions preclude the antegrade distal catheterisation, the sheath-directed FS in the thigh can be concomitantly combined with retrograde FS from catheterisation just below the knee. CONCLUSIONS: A topology-oriented methodology with sheath-directed FS is technically feasible and avoids indiscriminate use of more complex modalities.

Safety and Efficacy of Intentional Celiac Artery Coverage in Endovascular Management of Thoracoabdominal Aortic Diseases: A Systematic Review and Meta-analysis.

PURPOSE: Thoracic endovascular aortic aneurysm repair (TEVAR) has emerged as an attractive alternative option in the treatment of thoracoabdominal aortic aneurysm (TAAA) diseases, reporting lower morbidity and mortality rates compared with open or hybrid repair. A challenging situation arises when the aneurysm involves the celiac artery (CA), precluding a safe distal landing zone. We investigated the safety and efficacy of CA coverage in the treatment of complex TAAA diseases during endovascular management. MATERIALS AND METHODS: A review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The electronic bibliographic sources searched were MEDLINE and SCOPUS databases. Primary outcomes of interest were perioperative and 30-day mortality. Any type of endoleak, mesenteric ischemia, perioperative spinal cord ischemia, and reintervention rates were secondary end points. A random-effects meta-analysis was performed. Summary statistics of event risks were expressed as proportions and 95% confidence interval (CI). RESULTS: Ten observational cohort studies published between 2009 and 2020, reporting a total of 175 patients, were eligible for quantitative synthesis. Indications for TEVAR were primary TAAAs in 82% of patients, aortic dissection in 14% of patients, type Ib endoleak after previous endograft deployment in 3% of patients, and penetrating aortic ulcer in 1 patient. Reintervention rate was 9% (95% CI, 4%-20%) and spinal cord ischemia was 7% (95% CI, 4%--12%). Type II endoleak was the predominant type of endoleak in 10% of patients (95% CI, 4%-22%), followed by type I endoleak in 5% of patients (95% CI, 2%-12%) and type III endoleak in 1% (95% CI, 0%-16%) of patients. Mesenteric ischemia occurred in 6% of patients (95% CI, 3%-10%). Thirty-day mortality was 5% (95% CI, 2%-13%) and the pooled estimate for overall mortality was 21% (95% CI, 14%-31%). CONCLUSIONS: Celiac artery coverage during TEVAR is a challenging but feasible option for the treatment of TAAA diseases, providing acceptable morbidity and mortality rates. Demonstration of adequate visceral collateral pathways before definitive CA coverage is the sine quo non for the success of the technique.

Superficialization Methods of Arteriovenous Fistula in Obese Patients: A Review of the Literature.

BACKGROUND: The creation of an arteriovenous fistula in obese patients with end-stage-renal-disease, might not lead to a successful hemodialysis session, partly due to excess adipose tissue overlapping the enlarged vein. This review summarizes the available evidence on superficialization methods in studies dealing with obese patients. METHODS: An English-language literature search was undertaken in the MEDLINE/SCOPUS databases looking for publications that described procedures of salvaging autologous arteriovenous access in upper extremities of obese patients. Perioperative outcomes including technical and clinical success, mean vein depth reduction, wound complications and patency rates were compared within all identified techniques. RESULTS: We identified 12 prospective and 8 retrospective studies. A total of 1149 patients with a mean age 57.2 (range: 49-68) years and a mean BMI 35.8 (range: 28.2-40.8) kg/m2 underwent mainly radial-cephalic and brachial-cephalic arteriovenous fistula superficialization procedures [transposition, 54%; elevation, 11.1%; lipectomy, 26.1%; liposuction, 2.4%; implantation of a venous window needle guide device, 6.4%]. Technical success was similar between all methods (≥96%). However, successful cannulation was lower after liposuction and elevation (81.5% and 78.1% respectively). Transposition achieved lower mean vein depth reduction and clinical success when compared with lipectomy (4.9 mm vs. 8.8 mm and 90% vs. 92.7% respectively). Transposition and liposuction had the lowest and highest complication rate respectively (1.6% vs. 40.8%). Primary and secondary patency rates were lower with liposuction (51.8% and 76.6% respectively), while lipectomy and elevation achieved the highest primary patency rates (68.3% and 71.6% respectively) at 12 months. CONCLUSIONS: In obese patients, all superficialisation techniques report high technical success rates. Although limited by the design of individual published studies and lack of a standard for reporting outcomes, these results lead to satisfactory postoperative and early outcomes. In aggregate, lipectomy and transposition are more clinically effective and more durable procedures.

Network meta-analysis of trials comparing first line endovascular treatments for arteriovenous fistula stenosis.

OBJECTIVE: We investigated the comparative effectiveness of different endovascular treatments for patients with failing autogenous arteriovenous fistulas (AVFs) with outflow vein stenosis. METHODS: The Medline (via PubMed) and SCOPUS databases were searched. We performed a systematic review and network meta-analysis of randomized controlled trials that had investigated the effectiveness of plain balloon angioplasty (PBA), cutting balloon angioplasty, and drug-coated balloon angioplasty (DCBA) to treat vein stenoses in autogenous AVFs. Studies of central vein stenosis were excluded. The main outcome measures were the failure rates at 6 months and 1 year after treatment. RESULTS: Eleven randomized controlled trials were included, with 814 patients, 395 of whom had undergone PBA. The network meta-analysis showed that DCBA at 6 months was significantly more effective than PBA (odds ratio, 0.39; 95% confidence interval, 0.18-0.81) and ranked as the best treatment option, although the difference was not statistically significant compared with cutting balloon angioplasty (odds ratio, 0.65; 95% confidence interval, 0.20-2.12). The differences among the three treatments at 1 year were not statistically significant. Additional conventional pairwise meta-analyses did not find significant differences at 1 year. CONCLUSIONS: In failing AVFs with outflow stenosis, DCBA was significantly superior to PBA, with improved 6-month failure rates. However the effectiveness of DCBA in the long term deserves further investigation.

Editor's Choice - Network Meta-Analysis of Carotid Endarterectomy Closure Techniques.

OBJECTIVE: There is discordance between reviews comparing eversion endarterectomy (EvE) with conventional carotid endarterectomy (CEA) mostly because under this term various "closure" techniques are included, from direct closure to a wide spectrum of patches with different materials. DATA SOURCES: MEDLINE (via PubMed) and SCOPUS. REVIEW METHODS: This was a systematic review of the Medline (via PubMed) and SCOPUS databases for randomised controlled trials (RCTs) comparing different CEA closure techniques. Network meta-analysis (NMA) was performed with a frequentist approach. The primary and the secondary outcome measures were the 30 day combined stroke and death rate and the late restenosis rate, respectively. RESULTS: Twenty-three RCTs were finally included in the NMA with a total of 4440 patients randomised, representing seven different techniques (primary carotid closure, n = 753; EvE, n = 431; vein patch closure, n = 973; polytetrafluoroethylene [PTFE] patch, n = 948; Dacron patch, n = 828; bovine pericardium patch, n = 249; and polyurethane patch, n = 258). NMA showed that EvE had a decreased 30 day combined stroke and death rate vs. all other methods of arterial closure, with the exception of PTFE and bovine pericardium patching. Additionally, EvE was associated with the lowest restenosis rate vs. all other methods of arterial closure after CEA. EvE was significantly superior to Dacron patches with regard to late restenosis, with the prediction intervals (PIs) lying completely on the beneficial side (risk ratio 0.06; PI 0.01-0.58) and increasing confidence of this comparison. Rare catastrophic complications of vein patch blow out or synthetic patch infection were reported in 0.2% of the total (n = 9/4 400) and no comparisons were made. CONCLUSION: EvE and patching with bovine pericardium or PTFE is associated with a lower incidence in both short term and late undesired outcomes following CEA and seems to represent the best choice compared with other carotid closure techniques. These results may support the vascular surgeon's choice of technique/patch material.

The "Pull, Cast, and Fix" Technique for Bypass in the Midpopliteal (P2) Arterial Segment in Chronic Femoropopliteal Occlusions.

Femoropopliteal bypass operations can be difficult when the occlusive disease involves the superficial femoral artery and the popliteal arterial segment above the knee joint (supragenicular artery, P1). In case of lack of suitable vein graft or when the surgeon wishes to spare to infrapopliteal segment, the choice of the midpopliteal artery as anastomotic site becomes challenging because of its location. Moreover, totally endovascular recanalization procedures in such cases can be complex and demanding, whereas other reported hybrid revascularization techniques require advanced technical skills and raise significantly the cost. Therefore, we present our suggestion of a "pull, cast, and fix" technique to encounter these challenges and facilitate a successful bypass with a synthetic graft in the upper midpopliteal (P2) segment, combing a secure endarterectomy and anastomosis even under marginal visualization by means of securing the lumen with a soft feeding tube after the artery has been pulled via a Satinsky vascular clamp. Accordingly, the procedure is accomplished with placement of a flexible self-expandable stent in the midpopliteal artery through the synthetic graft.

Unmasking the Coronary-Subclavian Steal Syndrome: The Culprit Lies in the Subclavian Artery. A Report of a Case and Review of the Literature.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

Late Basilic Vein Superficialization Combined with Revision Using Distal Inflow (RUDI) Operation to Treat a Symptomatic High Flow Fistula.

BACKGROUND: Vascular access (VA)-related high flows (HF) are common with brachial artery based fistulas. Flow-reduction procedures are indicated in symptomatic patients or asymptomatic ones with flows >2 L/min. However concomitant issues increase their complexity. We describe a case of a patient suffering congestive heart failure as a result of HF brachial-basilic fistula >3 L/min. A simultaneous late basilic vein transposition and revision using distal inflow (RUDI) was performed. METHODS: A large diameter untransposed arterialized basilic vein was carefully and completely mobilized up to the proximal upper arm. After harvesting an autologous great saphenous vein (GSV) segment, a new inflow anastomosis was performed in the proximal ulnar artery. At the final stage, and after tunneling the mobilizing basilic vein in a subcutaneous semicircular configuration, an end-to-end anastomosis joining the two stumps (basilic vein outflow portion and GSV inflow arterial portion) was performed. A decision-making process in order to reach this complex option is discussed. Results Access flow and cardiac output were greatly attenuated following our approach. After a mean follow-up of 9 months no VA complications were observed, with flow still detected below 2 L/min. All cardiac symptoms and ultrasound investigations improved. CONCLUSION: Multiple VA issues including HF pose a risk for abandonment and a challenge for the vascular surgeon. An effort toward increasing the "upper extremity life span" is advised.

Multicenter Mid-term Results After Endovascular Aortic Aneurysm Repair with the Incraft® Device.

OBJECTIVES: Durability after endovascular aortic aneurysm repair (EVAR) is considered an ongoing topic of investigation and was always a point of concern with smaller profile devices. Recently released five-year clinical trial results using the Incraft® ultralow profile device are encouraging. However, additional real-life experience will need to assist these initial findings. Herein, we investigated the outcomes after EVAR, in real world practice using the Incraft® endograft (EG). MATERIAL AND METHODS: Seventy-seven patients with infrarenal abdominal aortic aneurysms (AAA) ≥50 mm in diameter treated with the Incraft® device in three vascular centers were enrolled from November 2015 to July 2018. Follow-up was completed in August 2020. Selection of EVAR using the Incraft® device was individualized according to aorto-iliac morphologic features, comorbidities, history of previous abdominal surgery and preference of the patient. At the early phase of the study, we specifically opted for preferential use of this low profile EG mainly in cases of small and tortuous iliac vessels (more challenging access routes). At later stages, it was used according to surgeon preference and not specifically in complex anatomies (real-world conditions). End-points included technical success, perioperative complications, 30-day survival, endoleg patency, presence of endoleaks, sac enlargement >5 mm and clinical success. RESULTS: The primary technical success rate was 97.4% before the addition of an aortic cuff and iliac extension for a type Ia and type Ib endoleak respectively, and the repair of a maldeployment iliac component (primary-assisted and secondary technical success, 100%). Intraoperative small type II endoleaks (visible in final angiogram) were noted in 19 patients (24.7%). There were no intraoperative deaths from AAA rupture, primary conversions or conversions to aortounilateral grafts. Two complications occurred, necessitating hybrid techniques for repair (replaced of a dislodged endoleg and distal external iliac artery hemostasis). No deaths were reported within 30 days. Occlusion of an endoleg, was observed in two patients, 6 and 14 months respectively after implantation (2.6%), and were treated by femoral-femoral PTFE bypass after unsuccessful endovascular recanalization. The latter required open conversion, 3 mo later, to repair compromised flow to the inflow iliac axis. Three patients (3.9%) experienced sac enlargement >5 mm in diameter compared with the 1-month CT scan. All of these had type II endoleaks and two received embolization procedures. Eleven patients died from causes unrelated to AAA repair. Clinical success was 97.3%, 92.8% and 89.4% through 1, 2 and 3 years respectively. CONCLUSIONS: EVAR with the Incraft® device might be considered a reliable option in real-world conditions and not specifically only in complex iliac anatomies.

Five-Year Management of Vascular Injuries of the Extremities in the "Real-World" Setting in Northeastern Greece: The Role of Iatrogenic Traumas.

BACKGROUND: Vascular trauma comprises a diagnostic and surgical challenge. Aim of this study was to present the vascular traumas treated in our Tertiary Hospital during the last 5 years. METHODS: We retrospectively reviewed the surgical records of our vascular department and documented the site and type of vascular injuries of the extremities along with the concurrence of musculoskeletal injuries. The type and outcome of surgical interventions were also recorded. RESULTS: Fifty-eight cases of vascular trauma were recorded (39 in the upper and 19 in the lower extremities). Overall, iatrogenic traumas accounted for 41.3% of cases. The arterial injuries of the upper limb were blunt and penetrating in 27% and 67%, respectively. The most affected artery in the upper limb was the radial artery (37.8%), followed by the ulnar artery (27%) and the brachial artery (24.3%). Orthopedic injuries were recorded in 19% of patients. Management involved simple revascularization, bypass operations, patch arterioplasty and endovascular management in 48.7%, 33.3%, 5.1%, and 5.1%, respectively. The most affected site in the lower extremity was the common femoral artery (36.8%) followed by the popliteal artery (21%). Bone fractures were reported in 5 cases (26.3%). The surgical management involved bypass, simple revascularization, patch arterioplasty in 42.1%, 26.3%, and 21%, respectively. Endovascular management was performed in 10.5%. CONCLUSIONS: A considerable percentage of iatrogenic vascular injuries was recorded, affecting both the upper and lower limbs. Despite the trend toward centralization of vascular services, a basic service of vascular surgery should be available in most sites to ensure that patients with vascular injuries receive fast and appropriate care.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR.

BACKGROUND: Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. MATERIALS AND METHODS: A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. RESULTS: From January 2003 to January 2020, 38 male patients (mean age, 75 ± 7 years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6 ± 33.8 months (range, 17-120). Mean diameter of the aneurysms was 82.2 ± 22.1 mm before OpC compared with 62.9 ± 13 mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P = 0.04 and P = 0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P = 0.02 and P = 0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6 ± 39.8 months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). CONCLUSIONS: Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Lysed Erythrocyte Membranes Promote Vascular Calcification.

BACKGROUND: Intraplaque hemorrhage promotes atherosclerosis progression, and erythrocytes may contribute to this process. In this study we examined the effects of red blood cells on smooth muscle cell mineralization and vascular calcification and the possible mechanisms involved. METHODS: Erythrocytes were isolated from human and murine whole blood. Intact and lysed erythrocytes and their membrane fraction or specific erythrocyte components were examined in vitro using diverse calcification assays, ex vivo by using the murine aortic ring calcification model, and in vivo after murine erythrocyte membrane injection into neointimal lesions of hypercholesterolemic apolipoprotein E-deficient mice. Vascular tissues (aortic valves, atherosclerotic carotid artery specimens, abdominal aortic aneurysms) were obtained from patients undergoing surgery. RESULTS: The membrane fraction of lysed, but not intact human erythrocytes promoted mineralization of human arterial smooth muscle cells in culture, as shown by Alizarin red and van Kossa stain and increased alkaline phosphatase activity, and by increased expression of osteoblast-specific transcription factors (eg, runt-related transcription factor 2, osterix) and differentiation markers (eg, osteopontin, osteocalcin, and osterix). Erythrocyte membranes dose-dependently enhanced calcification in murine aortic rings, and extravasated CD235a-positive erythrocytes or Perl iron-positive signals colocalized with calcified areas or osteoblast-like cells in human vascular lesions. Mechanistically, the osteoinductive activity of lysed erythrocytes was localized to their membrane fraction, did not involve membrane lipids, heme, or iron, and was enhanced after removal of the nitric oxide (NO) scavenger hemoglobin. Lysed erythrocyte membranes enhanced calcification to a similar extent as the NO donor diethylenetriamine-NO, and their osteoinductive effects could be further augmented by arginase-1 inhibition (indirectly increasing NO bioavailability). However, the osteoinductive effects of erythrocyte membranes were reduced in human arterial smooth muscle cells treated with the NO scavenger 2-phenyl-4,4,5,5-tetramethylimidazoline-1-oxyl 3-oxide or following inhibition of NO synthase or the NO receptor soluble guanylate cyclase. Erythrocytes isolated from endothelial NO synthase-deficient mice exhibited a reduced potency to promote calcification in the aortic ring assay and after injection into murine vascular lesions. CONCLUSIONS: Our findings in cells, genetically modified mice, and human vascular specimens suggest that intraplaque hemorrhage with erythrocyte extravasation and lysis promotes osteoblastic differentiation of smooth muscle cells and vascular lesion calcification, and also support a role for erythrocyte-derived NO.

"Evidence-based Tweeting" in Vascular Surgery.

The use of social media for academic or research purposes is still in infancy. However, the potential of dissemination of medical knowledge through these electronic platforms is dynamically increasing. We performed a search on Twitter® collecting tweets containing the keywords "peripheral arterial disease" and "abdominal aortic aneurysm" separately and including 3 types of emitters. Our aim was to assess the dissemination of these 2 major vascular entities across the social networking and their effect on the medical and general population. The results show that people talk about their experiences of hospitals and care quality on Twitter® more than health care providers or commercial industries in critical diseases that arise more concern. Twitter® could become a successful channel through which physicians, patients, and health care providers interact, engage, and disseminate medical knowledge.

Composite Contralateral Axillobifemoral Bypass for Ipsilateral Axillobifemoral Bypass Infection.

We report an innovative technique in an 82-year-old patient with a patent but infected right axillobifemoral (AxBF) bypass performed 7 years ago owingto critical limb ischemia who underwent a semielective de novo left-sided composite AxBF bypass consisting of a central prosthetic polytetrafluoroethylene segment and distal autologous limbs to the femoral regions (femoral crossover bypass vein to the right limb using the femoral vein and jump graft to the left femoral limb using the great saphenous vein.) Although AxBF bypass is not considered the "gold standard" surgical composite revascularization procedure in the suprainguinal region, it can constitute an acceptable intervention in selected cases.

Correlation of Baseline Plasma and Inguinal Connective Tissue Metalloproteinases and Their Inhibitors With Late High-Pressure Endoleak After Endovascular Aneurysm Repair: Long-term Results.

Purpose: To investigate whether plasma and connective tissue matrix metalloproteinases (MMP) and their inhibitors (TIMP) may predict late high-pressure endoleak after endovascular aneurysm repair (EVAR). Materials and Methods: Samples of inguinal fascia and blood were collected in 72 consecutive patients (mean age 73.1 years; 68 men) undergoing primary EVAR with the Endurant stent-graft. Baseline plasma levels of MMP-2, MMP-9, TIMP-1, and TIMP-2 and baseline MMP-2 and MMP-9 activity estimated using gelatin zymography (GZ) were compared between patients who developed late endoleak in follow-up and those who did not. Subgroup analyses were performed between patients with (n=18) and without inguinal hernias and between patients with moderate-diameter (50-59 mm; n=45) or large-diameter (≥60 mm; n=27) abdominal aortic aneurysms (AAA) at primary EVAR. Results: The mean follow-up period was 63.1 months (range 7.5-91.5), during which time 13 (18.1%) patients developed type I (6 Ia and 5 Ib) or 2 type III endoleaks. Only GZ-analyzed proMMP-9 concentrations were higher in the endoleak group than in patients without endoleak (mean difference 8.44, 95% CI -19.653 to -1.087, p=0.03). The patients with primary inguinal hernia at presentation had significantly higher tissue TIMP-2 values (0.8±0.7 vs 0.5±0.4, p=0.018) but lower plasma total (pro- + active) MMP-9 values (11.9±7.8 vs 16.2±7.4, p=0.042) than patients without hernias at the time of EVAR. Patients with AAAs ≥60 mm had significantly higher mean tissue homogenate levels of total (pro- + active) MMP-9 (p=0.025) and total (pro- + active) MMP-2 (p=0.049) as well as higher proMMP-9 (p=0.018) and total (pro- + active) MMP-9 (p=0.021) levels based on GZ compared to patients with moderate-diameter AAAs. Regression analysis revealed a significant association between total (pro- + active) MMP-9 plasma samples and the presence of hernia (OR 0.899, 95% CI 0.817 to 0.989, p=0.029) and between GZ-analyzed proMMP-9 and late endoleak (OR 1.055, 95% CI 1.007 to 1.106, p=0.025). GZ-analyzed proMMP-9 and active MMP-9 were strong predictors of late endoleak in patients with hernia (p=0.012 and p=0.044, respectively) and in patients with AAAs ≥60 mm (p=0.018 and p=0.041 respectively). Conclusion: Inguinal fascial tissue proMMP-9 significantly predicted late endoleak. ProMMP-9 and active MMP-9 biomarkers are significantly associated with late endoleak in hernia patients and in patients with AAAs ≥60 mm. Considering the clinical association between hernia and AAA and the fact that the AAA wall connective tissue environment remains exposed to systemic circulation after EVAR, inguinal fascia extracellular matrix dysregulation and altered MMP activity may reflect similar changes in AAA biology, leading to complications such as endoleak.

Short Term Success of Treatments to Salvage Thrombosed or Failing Synthetic Arteriovenous Grafts in End Stage Renal Disease: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials.

OBJECTIVE: There is currently uncertainty regarding the ideal treatment to salvage thrombosed or failing synthetic arteriovenous grafts (AVGs) in patients with end stage renal disease. Therefore, a systematic review up to December 2018 and network meta-analysis of randomised control trials (RCTs) that compared three month failure risk of available treatments was carried out. METHODS: Medline, Scopus, Embase, and the Cochrane Library were the data sources. Pairwise meta-analyses were based on random effects models. Network meta-analysis was conducted within a frequentist framework with a multivariable random effects approach to model treatment effects across studies. The metric of choice was the odds ratio (OR) along with the associated 95% confidence interval (CI). RESULTS: Sixteen two arm RCTs were included involving 2011 patients who were randomised to six different treatments (plain balloon angioplasty, open surgical repair, stents, stent grafts, drug eluting balloons (DEBs), and cutting balloons). The network of RCTs had a star like geometry with plain balloon angioplasty being the common comparator. There were no significant differences between treatments with regards to risk of failure at three months with the exception of stent graft use that significantly reduced the risk of failure compared with plain balloon angioplasty (OR 0.53, 95% CI 0.34-0.84). Based on surface under the cumulative ranking curve (SUCRA) values, the best interventions to salvage thrombosed or failing AVGs were DEB and stent grafts. CONCLUSIONS: Stent graft seems to perform better than plain balloon angioplasty in terms of saving thrombosed or failing AVGs. However, this network meta-analysis was limited by the lack of closed loops and thus unable to assess consistency between direct and indirect evidence. The efficacy of DEBs as a promising treatment deserves further investigation and new RCTs are required.

A Rare Case of Tibioperoneal Arterial Trunk Entrapment Caused by a Fibular Osteochondroma.

BACKGROUND: Osteochondromas or exostoses are the most common benign tumors of the bones, which appear during the growth period. The involvement of lower extremities is common, particularly in metaphyseal structures of the femur and humerus and around the knee joint. However, the incidence of the development of the tumor at the proximal fibula is rare. The most common signs and symptoms of the disease are pain, pulsatile mass, limb swelling, neurologic sequelae, bursa formation with subsequent bursitis, and impairment of the developmental growth. Vascular complications are rare, yet osteochondromas can cause catastrophic arterial complications threatening the life of the patient if they occur and can include vessel perforation and thrombosis, arterial thromboembolic events, and pseudoaneurysm formation. METHODS: We report a case of a 24-year-old male patient presenting with tibioperoneal arterial trunk entrapment caused by a massive osteochondroma derived from the proximal fibula. A combined vascular-orthopedic approach was initiated with the excision of the tumor, in which the neurovascular structures (tibial nerve, popliteal artery and vein, anterior tibial artery, and tibioperoneal trunk) were carefully recognized and protected. RESULTS: The postoperative course of the patient was uneventful. CONCLUSIONS: High clinical suspicion of a vascular complication should be raised by physicians when investigating a young patient with a suspected osseous tumor in the popliteal fossa and symptomatology of concurrent peripheral arterial disease. Prompt surgical management is crucial for the salvage of the affected limb in cases of arterial involvement. Furthermore, quick surgical exposure of the mass and regular postoperative follow-up check minimizes the risk of irreparable impairments and tumor recurrence.