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OBJECTIVE: Complex endovascular procedures are now recognized as the gold standard treatments for extensive aortic diseases. Bridging stents (covered stents used to couple the aortic graft to the visceral vessels) play a pivotal role, yet there is currently no dedicated device available on the market. The aim of the study was to evaluate the mid-term performance of the Gore Viabahn balloon-expandable (VBX) stent graft as a bridging stent for target visceral vessels (TVV). METHODS: Data from all consecutive patients undergoing fenestrated and branched endovascular aortic repair (F/BEVAR) and receiving the VBX stent graft as a bridging stent between July 2018 and September 2022 were prospectively collected and subsequently analyzed retrospectively. Primary endpoints included freedom from TVV instability and freedom from TVV-related reinterventions, both overall and in comparison between branched and fenestrated graft configurations. Secondary endpoints were overall survival, procedure and TVV-related (in an intent-to-treat basis) technical success, freedom from type IC/IIIC endoleak, and freedom from TVV patency loss. RESULTS: Sixty-three patients were treated with a F/BEVAR using VBX as bridging stent, of those 47 (74.6%) presented an atherosclerotic aneurysm, 7 (11.1%) a post-dissecative aneurysm and 9 (14.3%) an anastomotic pseudoaneursym or a type IA endoleak in a previous EVAR. Included in the aortic repair were 231 out of 243 (95.1%) total visceral vessels. The intra-operative requirement of 13 additional VBX determined a TVV-related technical success of 94.4%. Mean follow-up was 26.1 ± 16.4 months. Estimated overall survival at 36-months was 73 ± 7.5%. Estimated rates at 36-months for freedom from type IC/IIIC endoleaks and TVV primary patency were 90.6 ± 3.9% and 99 ± 0.7%, respectively. Estimated rate at 36-months for freedom from TVV-instability was 92.1 ± 3% and did not differ between branched and fenestrated configurations, while freedom from TVV-related reinterventions was 90.6 ± 3.1% and significantly in favor of fenestrations (69.4% versus 96.8%, p< .001). Multivariate analyses confirmed fenestrated configuration as a protective factor against TVV-related reinterventions (HR: .079; 95% CI: .016 - .403). CONCLUSION: The VBX stent graft proves to be a reliable bridging stent for complex aortic procedures involving both fenestrated and branched endografts. While immediate results are deemed satisfactory, they favor fenestrations regarding need of reinterventions through 3-years. The success of the procedure heavily relies on a thorough understanding of the unique characteristics of this stent.
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OBJECTIVES: The aim of this study was to evaluate the effectiveness of protein-based tissue adhesive (Bioglue®) in reducing time to haemostasis in patients undergoing peripheral vascular surgery. METHODS: From January to December 2021, 100 consecutive patients from 4 centres have been treated with open peripheral vascular surgery including upper and lower limb interventions. Patients have been allocated in each centre into control with no use of Bioglue® (Group no-Bio, 50 patients) or use of Bioglue® (Group Bio, 50 patients) by a block randomization method 10:10 until the required sample size was reached. Perioperative parameters including time to haemostasis, number of adjunctive stitches, and in-hospital bleeding have been analysed and compared in the two groups by means of mean independent-samples tT -test and Gehan-Breslow-Wilcoxon test. RESULTS: Both groups were homogeneous in terms of demographic data, preoperative risk factors, and preoperative medical therapy except for a higher percentage of active smokers in Group Bio (52% vs. 24%, p = 0.004). Femoral endarterectomy was most common in Group Bio (44% vs. 24%, p = 0.03), whilst the percentage of lower limb vein bypasses was higher in Group no-Bio (50% vs. 36%, p = 0.03). Bovine pericardium was the preferred material in Group Bio (20 cases, 40%), whilst autologous vein is mostly used in Group no-Bio (26 cases, 52%) (p = 0.01). Time to haemostasis was faster in Group Bio (4.4 vs. 9.6 minutes, p < 0.001). The need for adjunctive stitches was higher in Group no-Bio (8 cases, 16%, Group Bio vs. 25 cases, 50%, Group no-Bio; p < 0.001). The overall rate of in-hospital bleeding, including those requiring reintervention, was not different between the two groups (9 cases, 18%, Group Bio vs. 7 cases, 14%, Group no-Bio; p = 0.39). CONCLUSIONS: The protein-based tissue adhesive Bioglue® reduced time to haemostasis and need for adjunctive stitches in peripheral vascular surgery. However, it did not affect the overall rate of perioperative bleedings. Further studies with larger sample sizes are needed to validate these outcomes.
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BACKGROUND: The aim of this study was to retrospectively analyse perioperative and long-term outcomes of carotid endarterectomy (CEA) performed in symptomatic patients in a high-volume academic vascular centre, stratifying them according to the type of preoperative symptoms and the timing of surgery with respect to the indexed neurological event. METHODS: From January 2014 to December 2020, 1,369 consecutive CEAs were performed at our institution. Data concerning these interventions were prospectively collected in a dedicated database including data concerning preoperative assessment, surgical details, perioperative (<30 days) outcomes, and long-term outcomes. A retrospective analysis of the database was performed, and 213 interventions performed in symptomatic patients were found. We identified 2 subgroups of patients: patients with stable neurological symptoms (not recent transient ischemic attack (TIA) or stable major disabling stroke, stable group, and 157 patients) and patients with unstable neurological symptoms (recent TIA, crescendo TIAs, stroke in evolution, acute/recent minor stroke, unstable group, and 56 patients). Perioperative outcomes were analysed in terms of mortality, major neurological events, and local or systemic complications The results were compared using the χ2 test; these were also analysed on the basis of the presenting symptom (isolated TIA, crescendo TIA, stroke in evolution, acute/recent minor stroke, stabilized stroke) and the timing of the intervention relative to the onset of the symptom. Long term results were analysed using the life-table analysis and Kaplan-Meier curves in terms of survival, stroke-free survival, absence of neurological symptoms, and absence of significant restenosis. RESULTS: Overall, 30-day stroke and death rate were 4.2%. (3.1% vs. 7%, P = 0.2). Two deaths occurred at 30 days, both in the stable group (mortality 1.2%, P = 0.4 compared to the unstable group), but no fatal strokes were recorded in the overall sample. No differences were found in terms of new perioperative neurological events and local complications between the 2 groups. We found a trend toward poorer perioperative results in patients operated on within 48 hr from the indexed event and in patients operated on for stroke in evolution or acute/recent stroke, whereas we found a trend toward better results in favour of patients operated on between 8 and 14 days (P = 0.08). The median duration of follow-up was 24.8 months (range 1-78); at 5 years we did not find significant differences in terms of survival and stroke-free survival rates between 2 groups. CONCLUSIONS: In our experience, carotid surgery in symptomatic patients provided satisfactory results, particularly in patients with stable neurological status. Among unstable patients, the rate of complications significantly increases, mainly among treated in the very early (<48 hr) period for stroke in evolution or acute/recent stroke. Once the perioperative risk is overcome, the results in the long-term setting are similarly good, both in stable and in unstable patients.
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Estenosis Carotídea , Endarterectomía Carotidea , Ataque Isquémico Transitorio , Accidente Cerebrovascular , Humanos , Endarterectomía Carotidea/efectos adversos , Ataque Isquémico Transitorio/etiología , Estudios Retrospectivos , Estenosis Carotídea/cirugía , Resultado del Tratamiento , Factores de Tiempo , Accidente Cerebrovascular/etiología , Factores de RiesgoRESUMEN
OBJECTIVE: To compare the outcomes of heparin bonded expanded polytetrafluoroethylene (HePTFE) and autologous saphenous vein (ASV) in patients undergoing below-knee (BK) femoro-popliteal bypass for critical limb ischemia (CLI). DESIGN: Retrospective single-centre matched case-control study. METHODS: From 2003 to 2019, 275 consecutive BK bypasses for CLI were performed, 109 with the ASV and 166 with a HePTFE graft. All the baseline characteristics that were reliably measured and were potentially relevant in the decision-making process were included as confounders in a logistic regression model and the factors that were significantly different between the two groups then used to perform a propensity matching analysis. Propensity score-based matching was performed in a 1:1 ratio to compare outcomes. Arterial hypertension, hyperlipemia, the need for tibial anastomosis at the distal level and the run-off status were the covariates included in the matching. Follow-up outcomes were estimated by Kaplan-Meier methods and compared with log rank test. RESULTS: After propensity matching, 101 HePTFE bypasses were matched with 101 ASV bypasses. The median duration of follow-up was 37 months (range 1-192). The 5-year survival rate was 67.5% (standard error (SE) 0.05) in the HePTFe group and 64.5% (SE 0.06) in the ASV group (p = 0.8, log rank 0.04). Primary patency rates were 38% (SE 0.06) in the HePTFE group and 41% (SE 0.06) in the ASV group (p = 0.7, log rank 0.3). Also assisted primary patency and secondary patency rates did not differ in the two groups. Amputation-free survival was 53% (SE 0.05) in the HePTFE group and 58% (SE 0.06) in the ASF group (p = 0.6, log rank 0.2). CONCLUSIONS: HePTFE provided 5-year similar results to those obtained with use of the ASV in equivalent patients with CLI undergoing below-knee or tibial bypass.
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Implantación de Prótesis Vascular , Heparina , Anticoagulantes/uso terapéutico , Prótesis Vascular , Estudios de Casos y Controles , Isquemia Crónica que Amenaza las Extremidades , Materiales Biocompatibles Revestidos , Humanos , Isquemia/cirugía , Recuperación del Miembro , Politetrafluoroetileno , Puntaje de Propensión , Diseño de Prótesis , Estudios Retrospectivos , Vena Safena/cirugía , Vena Safena/trasplante , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To report a rare case of giant aortic coarctation (CoA)-related descending thoracic aneurysmal degeneration, complicated by an acute aortic dissection. CASE REPORT: A 57-year-old man referred with acute chest pain to the emergency department. A computed tomography angiography (CTA) revealed a CoA with a giant post-stenotic descending thoracic aneurysm (14 cm) and a concomitant left subclavian artery (LSA) aneurysm, complicated by an acute type B aortic dissection. A single-stage hybrid procedure was planned in an urgent setting. Initially, a left common carotid-to-left subclavian artery (LCCA-LSA) bypass was performed to gain a suitable proximal landing zone, the procedure was then completed with 3 thoracic endografts and 1 aortic dissection stent through a percutaneous femoral approach. The patient was discharged in postoperative day 8th without complications; the CTA performed at 1 month demonstrated patency of supra-aortic and visceral vessels, dilation of CoA site and exclusion of the false lumen. CONCLUSIONS: CoA is a congenital malformation rarely found in adults that may represent a challenge for the surgeon, especially when combined with a complication like an acute aortic dissection. This case shows that a hybrid approach is a safe and feasible treatment option even in such complex anatomies.
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Aneurisma de la Aorta Torácica , Aneurisma de la Aorta , Coartación Aórtica , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aneurisma de la Aorta Torácica/cirugía , Coartación Aórtica/complicaciones , Coartación Aórtica/diagnóstico por imagen , Coartación Aórtica/cirugía , Aortografía , Prótesis Vascular , Humanos , Masculino , Persona de Mediana Edad , Stents , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of the present study was to assess early and long-term results of open surgical interventions for popliteal artery aneurysms (PAAs) with the use of heparin-bonded expanded polytetrafluorethylene (HePTFE) in a single center, retrospective, non-comparative cohort study. METHODS: A retrospective analysis of a prospectively maintained dataset, including 207 open interventions for PAAs between 2002 and 2022, was performed and 170 procedures carried on with the use of a HePTFE graft were found. Perioperative results were analyzed in terms of mortality, graft thrombosis and amputation rates. Follow-up results were analyzed in terms of survival, primary and secondary patency, freedom from amputation, freedom from reintervention with life-table analysis and Kaplan Meier curves. Follow-up results were considered as primary outcomes, whereas perioperative results were considered as secondary outcomes. RESULTS: In 82 interventions (48%) the PAA was asymptomatic. In 140 cases a medial approach was used, while in 30 cases a posterior approach was preferred. The level of the distal anastomosis was the p3 tract of the popliteal artery in 89% of the cases. One perioperative death occurred; early thromboses occurred in eight cases and the overall perioperative amputation rate was 2.8%. The median duration of follow-up was 48 months (range 1-251). Estimated survival rate at 10 years was 55% (standard error, SE, 0.065). The 10-year rates of primary and secondary patency and freedom from amputation were 40.8% (SE 0.06), 47.6% (SE 0.065) and 93.4% (SE 0.04), respectively. The estimated freedom from reintervention rate at 10 years was 57% (SE 0.05). CONCLUSIONS: The results of this large monocentric experience showed that open surgical repair of PAAs with HePTFE is a safe procedure, with low rates of perioperative complications, and excellent results in the long-term setting.
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Aneurisma , Implantación de Prótesis Vascular , Aneurisma de la Arteria Poplítea , Humanos , Heparina/efectos adversos , Prótesis Vascular , Estudios Retrospectivos , Estudios de Cohortes , Implantación de Prótesis Vascular/efectos adversos , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Aneurisma/diagnóstico por imagen , Aneurisma/cirugía , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/cirugíaRESUMEN
BACKGROUND: Evaluation of the impact of aneurysm sac behavior in terms of either stability or shrinkage after endovascular aneurysm repair (EVAR) on long-term clinical outcomes. METHODS: A retrospective study was conducted on 1483 consecutive patients who underwent EVAR from 1999 to 2021 at our institution. 1037 patients met inclusion criteria (1037/1483, 69.9%): abdominal aortic or aorto-iliac aneurysm, elective surgery, follow-up (FU) ≥12 months. Patients who had sac stability (330/1037, 31.8%) and patients who demonstrated sac shrinkage (542/1037, 52.2%) at FU were compared; patients who presented sac increase at FU were excluded (165/1037, 16%). PRIMARY ENDPOINTS: rupture rates, need for surgical conversion, and long-term aneurysm-related mortality. Secondary endpoints: all type endoleak rates and long-term reintervention rates. RESULTS: Mean FU was 61.2 months (IQ 26-85.7 months). In terms of comorbidities, the group of patients with stable sac showed greater association with polidistrectual atherosclerotic manifestations. Estimated 12-year survival was 42.9% in the stable sac group and 65% in the shrinked group (P<0.001), although there were no significant differences in terms of freedom from aneurysm-related death (97.3% vs. 95.4% estimated at 12 years, P=0.493). Patients with sac stability had higher rates of rupture (2.1% vs. 0.6%, P=0.035) and surgical conversion (2.1% vs. 0.6%, P=0.035). The stable sac group had significantly higher rates of all type endoleak during FU (45.8% vs. 24%, P<0.001). Estimated 12-year freedom from reintervention rates were 56.2% and 83.9% respectively (P<0.001). CONCLUSIONS: After more than 20 years of EVAR experience it is probably time to reconsider the procedure clinical success parameters as a patient with a stable sac cannot be considered healed.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Endofuga/cirugía , Procedimientos Endovasculares/efectos adversos , Humanos , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
In March 2020, Italy was the first European country to be hit severely by the first wave of coronavirus disease 2019 (COVID-19) and to put in place moderate-high containment measures. 594 Italian expatriates participated in a cross-sectional mixed-methods survey focusing on the period that goes from the beginning of March 2020 to the beginning of April 2020. The survey aimed to describe the experiences of participants when it comes to conflicting beliefs and behavior with the Italian or host country communities in relation to COVID-19, using the Intragroup Cognitive Dissonance (ICD) framework. We explored: (1) COVID-19 risk perception (assessed for themselves, the Italian community, and the host country community); (2) COVID-19 risk meta-perception (participants' perception of the Italian and host country communities' risk perception); (3) intensity of emotions (assessed for themselves); (4) national group identification (assessed for themselves in relation to the Italian and host country communities) before and after the first wave of COVID-19 in Italy. An inductive thematic analysis of three open-ended questions allowed an in-depth understanding of the experiences of Italian expatriates. Results describe the ICD of participants with the Italian or host country communities, expressed as a difference between COVID-19 risk-perception and risk meta-perception. ICD predicts that when a dissonance of beliefs and behavior is experienced within an individual's group, a shift in identification with another more consonant group will happen, if identity enhancing strategies with the dissonant group are unsuccessful. Our findings showed that when the ICD was experienced with the host country community, this was solved through a disidentification strategy and mediated by negative emotions. Identity enhancing strategies with the host country community were unsuccessfully enacted as described by the qualitative answers of participants referring to episodes of racism, ridicule, and to a Cassandra experience: predicting a catastrophic future without being believed. Unexpectedly, participants experiencing the ICD with the Italian community did not enact a disidentification strategy. An increase in virtual contacts, enhanced sense of belonging, a stronger identification baseline, and different features of the two ICDs can be responsible for these results. This study sheds light on the relevance of ICD in natural settings and on international communities, during global crises.
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Hybrid operating room represents nowadays an important tool in the management of a constantly increasing number of complex surgical procedures which necessitate appropriate settings in order to be performed safely. We herein present the peculiarities and applications of such a versatile operating environment which is capable of guaranteeing the best performances in terms of equipment and imaging tools respecting the standards of asepsis that a simple angiographic room could not offer. In particular, we focus on its relevance in the field of complex vascular pathology, and on the importance of setting an appropriate management process in order to make the most of its potentialities without sacrificing the not negligible costs connected to it.
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BACKGROUND: The etiology of delayed-onset spinal cord injury (SCI) following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) is still unclear and may be related to multiple factors. Extravascular factors, such as lumbar spinal stenosis (LSS), may play a significant role in the selection of patient at risk of SCI. In this report we describe a case of paraplegia following thoracic endovascular aortic repair (TEVAR) in a patient suffering from severe and symptomatic LSS and undergoing staged endovascular repair of a TAAA. CASE PRESENTATION: A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm. The patient complained of buttock and thigh claudication in the absence of defects in the pelvic perfusion; a spinal magnetic resonance angiography (MRA) showed a severe narrowing of the lumbar canal.. After 24 h from first-step procedure (TEVAR) paraplegia was detected. A cerebrospinal fluid (CSF) drainage was then placed with incomplete recovery. CONCLUSIONS: Stenotic damage to the spinal cord is thought to be the result of direct compression of the neural elements and ischemic disruption of arterial and venous structures surrounding the spinal cord. This comorbidity may constitute an additional anatomic risk factor in those patients currently recognized as prognostically associated to the development of SCI.