Carotid endarterectomy in asymptomatic octogenarians: Outcomes at 30 days and 5 years.

BACKGROUND: The following study investigated the 30-day and 5-year relative survival rate and freedom from neurological events in asymptomatic carotid stenosis (ACS) octogenarians who had undergone elective carotid endarterectomy (CEA). METHODS: Between January 2008 and June 2014, a retrospective review was conducted on ACS patients who had undergone elective CEA. The patients' sample was divided into two groups: Group A (GA) included octogenarians and Group B (GB) included younger patients. The GA patients were subjected to a risk-scoring system and follow-up. The two groups were compared analysing the following primary endpoints: 30-day mortality, stroke, stroke/death and acute myocardial infarction (AMI); GA patients' survival rate and freedom from neurological events at 5 years. The 30-day secondary endpoints included carotid shunting, redo surgical, need for general anaesthesia with preserved consciousness (GAPC) conversion and length of hospital stay. RESULTS: We identified 620 patients with ACS, of them 144 (23.2%) belonged to the GA and 476 (76.8%) belonged to the GB. No statistical difference between the two groups was found regarding the primary and secondary endpoints. One hundred nineteen of 144 GA patients (82.6%) underwent the follow-up; the median follow-up was 78.3 months. The GA patients' 5-year survival rate was 62%, while freedom from cerebral events was 94.9%. Analysis regarding GA patients' 5-year survival rate revealed a significantly lower percentage among the patients with a severe risk score compared with those with a moderate risk score (respectively, 29.5% vs 67.7%; p = .005). The multivariate analysis showed that chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were independently associated with lower survival. CONCLUSIONS: The 30-day outcomes of CEA in octogenarians are comparable to those in younger patients. Comprehensive life expectancy and preoperative score, rather than age alone, should be taken into account before performing CEA on octogenarian patients, considering the short- and long-term efficacy in stroke prevention.

Endovascular Treatment of Persistent Sciatic Artery Occlusion: Case Report and Literature Review.

Persistent sciatic artery (PSA) is a rare congenital anatomic variant of the lower limb vascular system with highly variable presentations. The management of lower limb ischemia due to PSA disease is not specifically recommended in guidelines, and surgical by-pass is usually the most described treatment. We reported a case of a 46-year-old patient with bilateral PSA and right chronic limb-threatening ischemia due to PSA occlusion at the PSA-popliteal junction which was successfully treated with percutaneous transluminal balloon angioplasty. In addition to this case report, a systematic review of the literature regarding the endovascular management of PSA stenosis and occlusion was conducted.

Intraoperative contrast-enhanced ultrasound for early diagnosis of endoleaks during endovascular abdominal aortic aneurysm repair.

BACKGROUND: The aim of this study was to evaluate the feasibility and utility of intraoperative contrast-enhanced ultrasound (CEUS) for early detection of endoleaks (ELs) during endovascular abdominal aortic aneurysm repair (EVAR) compared with completion digital subtraction angiography. METHODS: Patients undergoing elective EVAR from January 2017 to April 2018 were consecutively enrolled in this prospective study. After endograft deployment, two-digital subtraction angiography (2DSA) with orthogonal C-arm angulations (anteroposterior and sagittal view) were routinely performed. After the endovascular treatment of clear, high-flow type I/III ELs detected by 2DSA, intraoperative CEUS was carried out in sterile conditions on the surgical field before guidewire removal. Presence and type of EL were evaluated with 2DSA and CEUS. CEUS was performed with the vascular surgeon blinded to the 2DSA findings. The primary end point was the level of agreement between 2DSA and CEUS to detect any type of EL and type II EL. Agreement between two diagnostic methods was calculated using Cohen's kappa. The secondary end point was utility of CEUS for intraoperative adjunctive procedure guidance. RESULTS: Sixty patients were enrolled (mean age, 78 ± 6 years; 90% male). 2DSA revealed 11 ELs (18%; 1 type IA, 10 type II), and CEUS 25 ELs (42%; 2 type IA, 23 type II). 2DSA and CEUS were in agreement in 39 cases (65%; 32 no ELs, 7 type II ELs). CEUS detected 17 ELs not identified by 2DSA (28%; 2 type IA, 15 type II); 2DSA detected three ELs not identified by CEUS (5%; 3 type II). In one case, 2DSA and CEUS detected type II and type IA ELs, respectively. For EL and type II EL detection, Cohen's kappa was 0.255 and 0.250, respectively (both "fair agreement"). Intraoperative adjunctive sac embolization was performed under CEUS control in 4 cases and technical success was 100%. CONCLUSIONS: Intraoperative CEUS during EVAR is feasible and can detect a greater number of ELs than 2DSA, in particular type II ELs. Further studies are necessary to assess the reliability of this intraoperative diagnostic examination. In type II ELs, CEUS may represent an additional, useful tool for intraoperative sac embolization guidance.

Systematic Review and Meta-Analysis of the Outcome of Different Treatments for Type 1a Endoleak After EVAR.

BACKGROUND: Insufficient evidence is available to recommend a particular strategy for the treatment of type 1a endoleaks (T1aELs) after endovascular abdominal aneurysm repair (EVAR). The aim of this study was to report outcomes of the different treatment modalities proposed for persistent and late-occurring T1aEL after EVAR. METHODS: A systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library) was undertaken until August 2018. Studies about treatment of T1aEL after EVAR (excluding intraoperative treatments during the first EVAR) presenting a series of 5 or more patients with extractable outcome data (at least intraoperative and/or early results) were included. Meta-analyses of proportions were performed using a random-effects model. RESULTS: A total of 39 nonrandomized studies were included (714 patients; 88.1% males, 95% confidence interval [CI] 84.5-91.7; weighted mean age 75.76 years, 95% CI 74.11-77.4). Overall estimated technical success (TS) and clinical success (CS) rates were 93.2% (95% CI 90.5-95.8) and 88.2% (95% CI 84.5-91.9), respectively. Two hundred eighteen patients underwent proximal extension (98.1% TS, 95% CI 96.3-99.8), 131 chimney EVAR (93.9% TS, 95% CI 89.9-97.9), 97 fenestrated EVAR (86.2% TS, 95% CI 77.3-95.1), 90 open conversion (96.5% TS, 95% CI 93-100), 71 embolization (95.2% TS, 95% CI 90.4-100), 35 endostapling (57.2% TS, 95% CI 14.1-100), and 72 conservative treatment (75.4% CS, 95% CI 56.4-94.5). Estimated overall 30-day mortality was 3.2% (95% CI 1.7-4.7), and it was higher for patients undergoing open surgery (6.6%, 95% CI 1.7-11.5). Overall, endoleak resolution during the mean follow-up of 19.4 months (95% CI 15.45-23.36) was maintained in 91% of the patients (95% CI 87.7-94.3). CONCLUSIONS: T1aEL repair appeared generally feasible, with good early to midterm outcomes. Different treatments are available, and the choice should be based on endoleak characteristics, aortic anatomy, and the patient's surgical risk. Conservative treatment and endoleak embolization should be considered only in selected cases, such as low-flow endoleaks and unfit patients.

Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: A Systematic Review and Meta-analysis.

BACKGROUND: The detection of intraprosthetic thrombus (IPT) deposits is a common finding during follow-up for endovascular abdominal aneurysm repair (EVAR); however, its clinical significance is still debated. The aim of this study was to determine if IPT represents a risk factor for thromboembolic events (TEs; endograft or limb thrombosis, or distal embolization) after EVAR. METHODS: A systematic review of English literature was undertaken until November 2017. Studies providing 2-group comparison (patients with IPT development on postoperative computed tomography angiography versus patients without IPT) with extractable outcome data (TE related to IPT and/or risk factors for IPT development) were included. Meta-analysis was performed when comparative data were given in 2 or more articles. RESULTS: Five single-center studies (808 patients) were analyzed. IPT detection at any time during follow-up occurred in 20.8% (168/808) of patients. Extractable data for postoperative TE were available in 4 studies (613 patients): on comparative meta-analysis, IPT was not significantly associated with TE occurrence during follow-up (odds ratio 2.25, 95% confidence interval [CI] 0.50-10.1; P = 0.29). IPT is generally detected during the first year after EVAR (maximum reported median: 12 months, range: 1.2-23). Polyester graft material (odds ratio 2.34, 95% CI 1.53-3.58; P < 0.001) and aorto-uni-iliac configuration of the endograft (odds ratio 3.27, 95% CI 1.66-6.44; P = 0.001) were confirmed as risk factors for IPT formation on meta-analysis. The literature systematic review suggests that IPT formation may be also associated with long main bodies and large necks. CONCLUSIONS: IPT detection on postoperative computed tomography angiography was not significantly associated with the occurrence of TE over time. The aorto-uni-iliac configuration and the use of polyester fabric for endografts were confirmed as risk factors for IPT development.

A systematic review of treatment modalities and outcomes of type Ib endoleak after endovascular abdominal aneurysm repair.

Objectives To collect specific literature on type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm, reporting data on diagnosis, treatment, and follow-up results. Methods Publications about type Ib endoleak after aorto-iliac endografting for abdominal aortic or iliac aneurysm were searched in PubMed, Web of Science, and Scopus. Considered studies were in English and published until 3 November 2016. Research methods and reporting were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were: (1) reporting on abdominal aortic or iliac aneurysm as primary diagnosis; (2) reporting on distal endoleak after aorto-iliac endografting. Patient data, data on endovascular treatment, endoleak, reintervention, and follow-up were collected by two independent authors. Results Included studies were 11 (five original articles, six case reports), corresponding to 29 patients and 30 type Ib endoleak. Excluding missing data (2/30, 6.7%), type Ib endoleak was treated intra-operatively, within six months and after six months in six cases (21.4%), eight cases (28.6%), and fourteen cases (50%), respectively. Treatment of type Ib endoleak was endovascular in 27 cases (90%) (7 embolizations + extender cuffs, 10 extender cuffs, 8 embolizations without extender cuff, 1 Palmaz stenting and 1 iliac branched endograft), hybrid in 1 case (3.3%) and surgical in 2 cases (6.6%). Buttock claudication occurred in two cases (6.7%). One-month mortality was 3.4% (2/29) without events due to type Ib endoleak. In 14 cases (46.7%), median follow-up was six months (interquartile range: 2.75-14; range: 0.75-53). Type Ib endoleak persisted or reappeared in three cases (10%), all after endovascular treatment. Two of these (2/3, 66.7%) needed endovascular reintervention. No death during follow-up was reported. Conclusions Few specific data are available in literature about type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm. About 50% of type Ib endoleak occurred after six months from the endovascular abdominal aneurysm repair procedure. Treatment is mainly endovascular and distal endograft extension is the main and effective treatment. Buttock claudication is the most frequent complication in case of exclusion of internal iliac artery. Persistent type Ib endoleak is possible, and adjunctive endovascular procedures are necessary.

Early and mid-term results in the endovascular treatment of popliteal aneurysms with the multilayer flow modulator.

Background The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres. Methods We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications. Results Twenty-three consecutive patients (19 males, age 72 ± 11) with 25 popliteal artery aneurysms (mean diameter 23 mm ± 1, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6 ± 16.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient. Conclusions Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.

Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair.

OBJECTIVE: The aim of this study was to report the technical aspects and outcomes of late open conversion (LOC) after endovascular aneurysm repair (EVAR) in a single center by using exclusively infrarenal clamping of the endograft as an alternative to suprarenal or supraceliac aortic clamping. METHODS: A retrospective analysis of EVAR requiring late explantation (>30 days) from January 1996 to October 2016 was performed. Patients' demographics, type of endograft, duration of implantation, reason for removal, extent of stent graft removal, type of reconstruction, 30-day mortality, postoperative complications, and long-term survival were obtained for analysis. RESULTS: During the study period, 28 patients required LOC. The mean age at conversion was 75.11 ± 6.65 years; 26 of 28 (92.86%) were male. Grafts were excised after a median of 41.4 months (range, 5.97-112.67 months), with 21 of 28 explantations (75%) performed electively. Multiple types of EVAR devices have been explanted; suprarenal fixation was present in 75% of the cases. The indication for LOC was the presence of an endoleak in 27 cases (20 type I, 4 type II associated with aneurysm growth, 3 type III, and 3 endotensions; in 3 cases, multiple types of endoleak were present) and graft thrombosis in 1 case. All patients underwent a transperitoneal approach with infrarenal clamping. No patient required revascularization of visceral or renal vessels. Complete removal of the stent graft was performed in 8 of 28 cases, partial removal in the remaining 20 cases (with conservation of the proximal portion in 16 of 20 cases). Technical success was 100%. Overall 30-day mortality was 7.14% (2/28). The 30-day mortality was 9.5% in elective patients and 0% in the urgent setting; this difference was not statistically significant (P = .56). Postoperative kidney injury rate was 7.7% (2/26). Mean follow-up was 47.37 ± 55.67 months (range, 0.23-175.07 months). The estimated 5-year survival rate was 78%. No aneurysm-related death or additional procedure occurred during follow-up. CONCLUSIONS: LOC after EVAR using infrarenal clamping of the endograft is a feasible and effective technique, with satisfactory postoperative mortality and morbidity. This method allows simplification of the surgical technique and may avoid renal and visceral complications related to suprarenal or supraceliac clamping.

Perioperative and Late Outcomes after Endovascular Treatment for Isolated Iliac Artery Aneurysms.

BACKGROUND: The aim of the study is to report early and follow-up outcomes of the endovascular treatment with iliac endografts for isolated iliac artery aneurysms (IIAAs). METHODS: Records of patients who underwent elective endovascular repair for IIAA (both primary and para-anastomotic) from 2005 to 2015 in 2 Italian centers were retrospectively examined. Demographic data, preoperative patient comorbidities, iliac aneurysm characteristics, contralateral iliac axis involvement, patency of hypogastric arteries and inferior mesenteric artery (IMA), and data of endovascular treatment were obtained for analysis. Early end points were technical success (TS), perioperative morbidity, clinical success (CS), freedom from reintervention (FFR) and survival. Follow-up end points were CS, FFR, survival, evolution of the aneurysmal sac, and endoleak (EL). RESULTS: Thirty-two IIAAs were treated through an endovascular approach in 30 patients (male 96.7%; mean age 74.2 years ± 7.6, range 55-86). Aneurysms were para-anastomotic in 11 (34.4%) cases. Mean diameter was 42.9 ± 15.6 mm (range 30-100). Twenty (62.5%) aneurysms involved exclusively the common iliac artery, 7 (21.9%) the hypogastric, and 5 (15.6%) both arteries. Ipsilateral hypogastric artery was stenotic or occluded in 4 (12.5%) and 1 (3.1%) patient, respectively. Contralateral hypogastric artery was occluded in 2 (6.3%) cases. IMA was patent in 9 (30%) patients. The ostium of the hypogastric artery was preserved in 5 cases (15.6%) and voluntarily covered in 27 (84.4%). Endovascular embolization of hypogastric artery was obtained with a plug device in 8 cases (25%). Hypogastric surgical revascularization was performed in 2 cases (6.3%). TS was 96.9%. Thirty-day morbidity was 6.3% (2/32). CS was 96.9% (1 endograft limb stenosis). Thirty-day FFR was 90.6% (1 transluminal angioplasty, 2 inguinal revisions). Thirty-day survival was 100%. At 1, 3, and 6 years, CS was 93.4%, 85.6%, and 85.6%, respectively (1 endograft limb thrombosis, 1 endograft limb stenosis, 1 hypogastric type II EL with sac enlargement). At 1, 3, and 6 years, FFR was 87.5%, 76.8%, and 76.8%, respectively (1 fibrinolytic therapy and stenting, 1 stenting, 1 surgical ligation of hypogastric artery). At 1, 3, and 6 years, survival was 100%, 96.3%, and 81.3%, respectively. No IIAA-related deaths were reported. During follow-up, aneurysmal diameter was unchanged in 12 cases (37.5%), decreased in 19 (59.4%), and increased in 1 (3.1%). Type II EL from hypogastric artery was detected in 3 cases (9.4%) and led to sac enlargement requiring surgical treatment in 1 case. CONCLUSIONS: Endovascular treatment of isolated iliac aneurysm is safe and effective, providing that strict anatomical requirements are respected. Aneurysm embolization with vascular plugs was not associated with pelvic complications in this series. Endograft stenosis and thrombosis are the most frequent complications, which can be easily managed with endovascular approaches.

Hybrid Treatment of Acute Abdominal Aortic Thrombosis Presenting with Paraplegia.

Acute thrombotic or embolic occlusion of the abdominal aorta is a rare vascular emergency associated with high morbidity and mortality rates. Classically, the clinical presentation is a severe peripheral ischemia with bilateral leg pain as the predominant feature. Aortic occlusion presenting as an isolated acute onset of paraplegia due to spinal cord ischemia is very rare and requires improved awareness to prevent adverse outcomes associated with delayed diagnosis. We report the case of a 54-year-old man who presented with sudden paraplegia due to the thrombotic occlusion of the infrarenal aorta involving the first segment of the common iliac arteries on both sides; emergent transperitoneal aorto iliac thrombectomy combined with the endovascular iliac kissing-stent technique were performed achieving perioperative complete regression of the symptoms.

Endovascular stent grafting of a posterior tibial artery pseudoaneurysm secondary to penetrating trauma: case report and review of the literature.

Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed.

Complete sustained reversal of cyclic ST-segment elevation (coronary cyclic flow variations) by low-dose intravenous nitroglycerin during acute coronary syndrome.

BACKGROUND: Recurrent ST-segment elevations in acute coronary syndromes have been attributed to coronary cyclic flow variations (CCFVs) possibly due to coronary vasospasm and unstable platelet aggregation in partially occluded arteries. METHODS: We describe the case of a patient with an acute myocardial infarction, recurrent ST-segment elevations and diffuse disease of the left anterior descending artery. RESULTS: The post-angiography 12-lead continuous ECG monitoring revealed cyclic anterior ST-segment elevations that were completely abolished with continuous intravenous infusion of low-dose isosorbide-dinitrate. CONCLUSION: The complete and sustained response to low-dose nitrate suggests that vasoconstriction plays a crucial role to provoke CCFVs. This case underlines the importance of continuous 12-lead ECG monitoring with ST-segment trend analysis in the CCU.

Clinical, electrocardiographic and echocardiographic features in patients with major arterial vascular disease assigned to surgical revascularization.

BACKGROUND: Preoperative cardiac assessment may essentially contribute to estimate the operative risk in vascular surgery.This study was undertaken to depict the clinical conditions and cardiac status in patients before elective major vascular surgery. PATIENTS AND METHODS: 143 patients with asymptomatic critical aortic abdominal aneurysm, 119 with high-grade carotid stenosis, and 138 with advanced symptomatic ischemia due to peripheral artery disease were assigned to surgical revascularization. Preoperatively, all subjects completed detailed medical history, physical and laboratory examinations, electrocardiogram, and transthoracic echocardiography. RESULTS: In patients with peripheral artery disease we identified more smokers (p < 0.05), diabetes (p < 0.01), hypertriglyceridemia (p < 0.05), previous myocardial infarction (p < 0.01); the asymptomatic aortic abdominal aneurysm group had a higher body mass index (p < 0.05), diastolic hypertension (p < 0.05), and most had left ventricular anterior hemiblocks (p < 0.001). Patients with critical carotid stenosis were older (p < 0.01), with greater systolic hypertension (p < 0.01), and with a less compromised left ventricular systolic function. CONCLUSIONS: Patients with peripheral artery disease were mostly affected by severe metabolic diseases and by worst cardiac conditions; patients with asymptomatic abdominal aortic aneurysms were of robust physique, and often had left ventricular anterior hemiblocks. Patients with critical carotid stenosis were older and had less cardiomyopathies.

The Utility of Intraoperative Contrast-enhanced Ultrasound for Immediate Treatment of Type Ia Endoleak during EVAR: Initial Experience.

Objectives Type Ia endoleak (EL) after endovascular abdominal aortic repair (EVAR) may be misdiagnosed at completion angiography. Intraoperative contrast-enhanced ultrasound (CEUS) may play a role in early detection and immediate treatment of type Ia EL. Methods From January 2017 to April 2018, patients treated with EVAR underwent intraoperative CEUS. After endograft deployment and ballooning, digital subtraction angiography (DSA) and intraoperative CEUS were performed in a blinded fashion. All cases of type Ia EL at DSA or CEUS were considered. Results Type Ia EL detected at intraoperative CEUS and undetected at DSA was defined in 2 patients. The former was solved with intraoperative re-ballooning; in the latter case, a Palmaz stent deployment was required. The resolution of type Ia EL was detected at intraoperative CEUS control and post-operative computed tomography angiography (CTA). In another patient, the DSA detected a type Ia EL, but intraoperative CEUS reveal a type II EL from lumbar arteries. Post-operative CTA confirm the type II EL. Conclusions The reported cases prove the clinical utility of the intraoperative CEUS, permitting the early identification of 2 type Ia EL. In addition, the intraoperative CEUS is useful in case of dubious type Ia EL at DSA, avoiding unnecessary intraoperative adjunctive procedure or post-operative CTA.

Prevalence, risk factors and clinical impact of intraprosthetic thrombus deposits after EVAR.

BACKGROUND: The aim was to define the prevalence, the evolution and the clinical relevance of the intraprosthetic thrombus deposit (IPT) after endovascular abdominal aortic repair (EVAR). METHODS: Patients treated with EVAR from 2009 to 2017 for abdominal aortic aneurysm were retrospectively considered. Patients with at least one postoperative computed tomography angiography (CTA) performed after a 3-month follow-up were included. Postoperative medical therapy (antiplatelet and/or oral anticoagulant) were recorded. Aorto-iliac anatomical characteristics were measured on pre-operative CTA, while structural and dimensional endograft features were extracted from instructions for use. IPT was defined as intra-endograft thrombus with minimum thickness of 2mm and longitudinally extended for minimum 4 mm, and was assessed in all postoperative CTA. Primary endpoints were freedom from IPT occurrence, risk factors for IPT and evolution of IPT. Secondary endpoints were the prevalence of overall and IPT-related tromboembolic events (TEE: main-body or limb occlusion, distal embolization) during follow-up and its correlation with IPT. RESULTS: Two-hundred twenty-one patients (mean age 76±7 years; male 94%) were included. Deployed endografts were: aorto-biiliac 96%, aorto-uniiliac 3%, aortic tube 1%; dacron 90%, ePTFE 10%. Mean follow-up was 30±25 months. Overall IPT prevalence was 36% (80/221). At 6, 12, 24 and 48 months, overall estimated freedom from IPT occurrence was 86%, 80%, 60% and 52%, respectively (Kaplan-Meier analysis). At Cox uni-variate analysis, postoperative medical therapy has no influence on IPT; aorto-iliac anatomical risk factors for IPT were larger neck diameter (P<0.001), severe neck thrombus (P=0.043), higher percentage of sac thrombus (P<0.001), hypogastric occlusion/coverage (P=0.040); endograft risk factors were proximal diameter ≥30mm (P<0.001), longer main body (P=0.002), dacron fabric (P=0.025), higher ratio between main body area/gate areas and main body area/distal iliac areas (P<0.001 and P<0.001, respectively). At Cox multi-variate analysis, independent risk factors for IPT were larger neck diameter (P=0.003), higher percentage of sac thrombus (P=0.005) and longer main body (P=0.028). During follow-up, IPT disappeared in 14 cases (18%). Overall TEE prevalence was 4% (8/221) and overall estimated freedom from TEE occurrence at 6, 12, 24 and 48 months was 99%, 99%, 95.3%, 94.1%, respectively (Kaplan-Meier analysis). TEE was IPT-related in 5/8 cases (63%). No statistical correlation were found between IPT and TEE. CONCLUSIONS: The development of intraprosthetic graft thrombus (IPT) is a frequent event after EVAR. The risk of IPT is closely correlated with the proximal aortic neck size, the presence of intra-aneurysmal sac thrombus, and the length of the endograft main body. However, there was no statistical correlation between the presence of IPT and TEE.

Twelve years of experience in carotid endarterectomy with general anesthesia and preserved consciousness.

BACKGROUND: Carotid endarterectomy (CEA) can be performed both under general anesthesia (GA) or local anesthesia (LA) with good results. General anesthesia with preserved consciousness (GAPC) using remifentanil infusion has been already reported in literature and could potentially merge the advantages of GA and LA overcoming the disadvantages of this last technique. Although the good results of GAPC reported in literature, this technique is not widespread in clinical practice. The aim of this study was to report the perioperative results of CEA under GAPC in a large series of consecutive patients. METHODS: This is a retrospective, single center, observational study including all patients treated for CEA under GAPC in our institution between January 2008 and October 2019. Primary endpoints were neurological complications rate, mortality rate in the perioperative period, need to GAPC conversion to GA during surgery and evaluation of the technique with a specific questionnaire regarding patients' satisfaction. Secondary endpoints were myocardial infarction (MI) rate, other perioperative complications rate, rate of intraoperative shunting and need of reintervention in the perioperative period. RESULTS: In the considered period 1290 CEA under GAPC were performed and included in this study. Neurological complications rate was 2.01%, mortality rate in the perioperative period was 0.07%, need of GAPC conversion to GA rate during surgery was 0.46% and patients satisfaction regarding the technique were high with a mean vote of 9.1 in a 0 to 10 scale. In the perioperative period MI rate was 0.23%, other perioperative complications rate was 1.39%, intraoperative shunting rate was 7.1% and reintervention rate after surgery was 2.4%. CONCLUSIONS: CEA under GAPC may combine the advantages of LA and GA, with a very low rate of conversion to GA during surgery and good patients' satisfaction. Moreover, it does not increase neurological, cardiologic and systemic complications. For these reasons CEA under GAPC could represents a valid alternative to GA or LA.

Endovascular repair of an abdominal aortic aneurysm using bifurcated stent-graft in a patient with bilateral external iliac artery occlusion.

Abdominal aortic aneurysm (AAA) in association with external iliac artery (EIA) occlusion is a rare entity which may limit endovascular aortic aneurysm repair (EVAR) feasibility. We describe the case of an 84-year-old man affected by a 64mm infrarenal inflammatory abdominal aortic aneurysm with complete bilateral occlusion of EIA and patency of both common and internal iliac arteries. The common femoral arteries (CFA) were patent, and the patient was asymptomatic for lower limb claudication. The treatment was performed by EVAR using a bifurcated stent-graft after the recanalization of the left EIA, achieving technical success.

Extracranial Internal Carotid Artery Aneurysms: case report of a saccular wide-necked aneurysm and review of the literature.

PURPOSE: To describe a case of atherosclerotic Extracranial internal Carotid Artery Aneurysm (ECAA) with an unique "diverticulum-like" morphological structure, surgically treated and to review the experiences of major referral centers. CASE REPORT: A 76-year-old woman presented with persistent dysphagia and transient hypophonia caused by a growing pulsatiling mass of the neck; duplex ultrasonography and angio-CT scan demonstrated a wide-necked, saccular aneurysm at the origin of the right Internal Carotid Artery (ICA). A total aneurysmectomy with patch angioplasty of the aneurysm of the neck on the carotid wall was successfully performed. No perioperative complications were encountered; at one year follow-up the patient was asymptomatic without any neurological complication and with carotid patency. CONCLUSIONS: Open surgery remains the gold standard for the treatment of extracranial internal carotid artery aneurysms in terms of patency and reduced risk of adverse complications; endovascular procedures may, in selected cases, provide a valuable additional tool in the armoury of the physician.

Carotid endarterectomy with mini-invasive access in locoregional anaesthesia.

AIM: To assess the validity of a carotid endarterectomy (CEA) with a mini-invasive access via a 3-7 cm cutaneous incision in locoregional anaesthesia as a viable alternative to the traditional access with a cutaneous incision longer than 7 cm. MATERIALS AND METHODS: We carried out a retrospective analysis of 76 consecutive patients (Group A) who had undergone carotid CEA in locoregional anaesthesia with cervical mini-access (3-7 cm incision), compared to a preceding series of 95 patients (Group B) who had undergone the same operation through a traditional access (incision > 7 cm). All patients in Group A were examined solely by means of duplex ultrasound scanning. RESULTS: No mortality occurred in Group A and the morbidity rate was as follows: 1.3% strokes, 2.6% minor neurological events and 6.5% transitory deficit of peripheral nerves. In Group B, the mortality rate was 1%, with the following morbidity rate: 2% strokes, 1% minor neurological events and 7.3% transitory deficit of peripheral nerves. Statistical analysis revealed the two groups as being compatible for age, sex, associated pathologies and type of surgery. No statistically significant differences emerged between the two series of patients with regards to neurological morbidity or operative mortality. CONCLUSIONS: In addition to being more aesthetically pleasing, mini-invasive access is a viable alternative to the traditional access for patients undergoing carotid CEA in locoregional anaesthesia.