Prevalence of Abdominal Aortic Aneurysms in the General Population and in Subgroups at High Cardiovascular Risk in Italy. Results of the RoCAV Population Based Study.

OBJECTIVES: Prevalence data on abdominal aortic aneurysm (AAA) in women, subjects younger than 65 years and in subgroups carrying specific risk factors are scarce. AAA prevalence was evaluated in an Italian population including women and younger subjects, stratifying for the presence of cardiovascular disease (CVD) risk factors and CVD risk score. MATERIALS AND METHODS: A population based cross-sectional study was conducted between 2013 and 2016. Men aged 50-75 and women aged 60-75 years, resident in the city of Varese (northern Italy), were randomly selected from the civil registry. A vascular surgeon performed an abdominal aortic ultrasound scan at four sites using the leading edge to leading edge method. CVD risk score was computed using the ESC-SCORE algorithm. The age and gender specific prevalence was estimated, stratifying by the presence of CVD and cardiovascular risk factors. RESULTS: Among the 3755 subjects with a valid ultrasound measurement, 63 subjects with an AAA were identified (5 referred for surgical intervention), among whom 34 were not previously known (30 men 1.3%, 95% CI 0.9-1.8; 4 women 0.3%, 95% CI 0.1-0.8). Considering age classes in men only, the highest prevalence of screen detected AAA was found in subjects aged 65-70 (1.2%; 95% CI 0.4-2.5) and 70-75 (2.5%; 95% CI 1.4-4.0) years. Among 65-75 year old men, the highest AAA prevalence was found in subjects with a previous myocardial infarction (MI 4.9%, 95% CI 2.0-9.9) and in ever-smokers reporting more than 15 pack years of smoking (4.1%, 95% CI 2.5-6.3). Among the younger subjects, those having an ESC-SCORE higher than 5% or a previous CVD (MI or stroke) showed a prevalence of 1.4% (95% CI 0.3-4.2; prevalence including subaneurysms 6.7%, 95% CI 3.7-11.0%). CONCLUSIONS: In the study population, both a general screening program in 65-75 year old men and an approach targeted to subgroups at higher risk merit evaluation in a cost-effectiveness study. In 50-64 year old men, strategies for population selection should consider CVD risk stratification tools.

Outcome Analysis of Carotid Cross-Clamp Intolerance during Carotid Endarterectomy under Locoregional Anesthesia.

BACKGROUND: To analyze the predictors and describe the outcomes of cross-clamp intolerance (CCI) and the results of the use of carotid endarterectomy (CEA) with shunting or a shift strategy to immediate carotid artery stenting (CAS) in this setting. METHODS: Between January 2008 and December 2015, 385 patients were elected for single-sided, isolated CEA under locoregional anesthesia. In case of CCI, CEA with shunt was used selectively, whereas indication to immediate conversion to CAS was the immediate onset and severe persistent deterioration of the neurologic status, and/or local technical difficulties to perform endarterectomy. Primary outcome was prevention of death and all early (<30 days) perioperative cerebrovascular events. RESULTS: We treated 169 (43.9%) symptomatic lesions; urgent (≤48 hours) intervention was performed in 85 (22.1%) cases. Carotid CCI occurred in 45 (11.7%) patients. CEA with shunt was used in 16, whereas CAS in 27 (7.0%, 2 refused further treatment). Multivariable analysis identified hypertension (odds ratio [OR]: 2.93, 95% confidence interval [CI]: 1.01-8.52; P = 0.049) and symptomatic lesions (OR: 2.34, 95% CI: 1.11-4.93; P = 0.025) as significant predictors of CCI. In-hospital mortality rate was 0.5%; none occurred in CCI group. Postoperative cerebrovascular event rate was 2.3% (n = 9). At multivariable analyses, only CCI (OR: 6.60, 95% CI: 1.65-26.36; P = 0.008) was significantly associated with postoperative cerebrovascular events, with no significant different clinical outcomes between CEA and CAS. CONCLUSIONS: Hypertension and symptomatic carotid stenosis were significant predictors of CCI, which was found to be predictive for postoperative cerebrovascular events. In selected patients with CCI, CAS had satisfactory, similar results of CEA.

A comparison between aortobifemoral bypass and aortoiliac kissing stents in patients with complex aortoiliac obstructive disease.

OBJECTIVE: The aim of this study was to retrospectively compare early and late results of aortobifemoral bypass and endovascular recanalization with the kissing stent technique in the management of TransAtlantic Inter-Society Consensus II (TASC II) C and D lesions in the aortoiliac district in a multicenter study. METHODS: From January 2006 to December 2013, 210 open and endovascular interventions for TASC II class C and D aortoiliac obstructive lesions were performed at three Italian teaching hospitals. In all the cases, the intervention was performed for aortic and bilateral iliac involvement. An aortobifemoral bypass was performed in 82 patients (group 1); in the remaining 128, an endovascular recanalization with the kissing stent technique was carried out (group 2). Early results in the two groups were compared with the χ2 test. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. Univariate and multivariate (forward Cox regression) analysis to identify potentially significant predictors of primary patency in the whole study group was performed. RESULTS: Patients in group 2 were more frequently female and more frequently had diabetes and arterial hypertension than patients in group 1. The indication for surgical intervention was the presence of critical limb ischemia in 29 cases in group 1 (35%) and in 31 cases in group 2 (24%; P = .07). Technical success in group 2 was 98.5%; two patients required immediate conversion to open surgery for iliac rupture. There was one perioperative death in group 1 (mortality rate, 1%; P = .2 in comparison with group 2). Four perioperative thromboses occurred, two in group 1 and two in group 2 (in one case requiring conversion to open surgical intervention), and no amputations at 30 days were recorded. Cumulative postoperative local and systemic complications occurred in 17 patients in group 1 (20.5%) and in 9 patients in group 2 (7%; P < .001). Mean duration of follow-up was 38 months (range, 1-96 months). Survival rates at 6 years were 65.5% (standard error [SE], 0.08) in group 1 and 83.5% (SE, 0.08) in group 2 (P = .08; log-rank, 2.2). At the same time interval, primary, assisted primary, and secondary patency rates were similar; reintervention rates were 6% in group 1 (SE, 0.05) and 11% in group 2 (SE, 0.04; P = .3; log-rank, 0.8). Univariate and multivariate analysis showed that only the presence of critical limb ischemia was independently associated with poorer primary patency during follow-up (hazard ratio, 2.4; 95% confidence interval, 0.9-6.4; P = .05). CONCLUSIONS: In this multicenter experience, endovascular repair of aortoiliac complex lesions with the kissing stent technique provided similar satisfactory early and late results to those obtained with open surgery.

Production of IL-8, VEGF and Elastase by Circulating and Intraplaque Neutrophils in Patients with Carotid Atherosclerosis.

OBJECTIVES: Polymorphonuclear neutrophils (PMN) in atherosclerotic plaques have been identified only recently, and their contribution to plaque development is not yet fully understood. In this study, production of elastase, interleukin (IL)-8 and vascular endothelial growth factor (VEGF) by PMN was investigated in subjects with carotid stenosis undergoing carotid endarterectomy (CEA). METHODS: The study enrolled 50 patients (Pts) and 10 healthy subjects (HS). Circulating PMN (cPMN) isolated from venous blood (in both Pts and HS) and from plaques (pPMN, in Pts) were cultured, alone or with 0.1 µM fMLP. Elastase, IL-8 and VEGF mRNA were analyzed by real-time PCR. In CEA specimens, PMN were localized by immunohistochemistry. RESULTS: In both Pts cPMN and pPMN, IL-8 mRNA was higher at rest but lower after fMLP (P<0.01 vs HS), and VEGF mRNA was higher both at rest and after fMLP (P<0.01 vs HS), while elastase mRNA was not significantly different. On the contrary, protein production was always higher in cPMN of HS with respect to values measured in cells of Pts. In CEA specimens, CD66b+ cells localized to areas with massive plaque formation close to neovessels. Pts with soft and mix plaques, as defined by computed tomography, did not differ in cPMN or pPMN IL-8, VEGF or elastase mRNA, or in intraplaque CD66b+ cell density. However, Pts with soft plaques had higher white blood cell count due to increased PMN. CONCLUSIONS: In Pts with carotid plaques, both circulating and intraplaque PMN produce IL-8, VEGF and elastase, which are crucial for plaque development and progression. These findings suggest mechanistic explanations to the reported correlation between PMN count and cardiovascular mortality in carotid ATH.

Outcomes of endovascular repair for blunt thoracic aortic injury.

OBJECTIVE: Consistent long-term follow-up data of thoracic endovascular repair (TEVAR) for acute blunt thoracic aortic injury (BTAI) are largely absent at this time. The late outcomes of TEVAR for BTAI are the focus of this study to evaluate the durability of this type of repair. METHODS: The records of 46 consecutive cases of TEVAR for BTAI from November 2000 to August 2012 were reviewed. Patient demographics, lesion characteristics, procedure details, and outcomes were recorded. We performed a clinical and body computed tomography angiography follow-up at 1, 6, and 12 months after the intervention; thereafter, it was done on a yearly basis if device-related defects were ruled out. RESULTS: There were 35 (76.1%) males. Mean age was 39 ± 18 years (range, 17-92). Indications for intervention were BTAI at the aortic isthmus in 73.9% (n = 34) of the cases, and in the proximal one-half of the descending thoracic aorta in the remaining 26.1% (n = 12). Pseudoaneurysm or free rupture accounted for 44 (95.6%) cases. Primary technical success was obtained in all cases. All patients survived the intervention, open conversion was never required, and no patient required reintervention. In-hospital mortality was 6.5% (n = 3). Mean follow-up was 66 ± 46 months (range, 1-144; median, 72). No patient was lost during this period. All patients who were discharged from the hospital are still alive. Aortic hematoma or hemothorax were completely reabsorbed in 42 (97.7%) cases. Endoleak or modifications of the native aorta were never detected; endograft-related complication was observed in one (2.3%) case only. An asymptomatic collapse was observed at a 36-month follow-up and was managed conservatively. CONCLUSIONS: Midterm follow-up of TEVAR for acute BTAI is feasible with satisfactory late outcomes. In our experience, TEVAR is a durable and definitive treatment for BTAI.