Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft.

OBJECTIVE: The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). METHODS: Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. RESULTS: Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. CONCLUSIONS: The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair.

Inner branched complex aortic repair outcomes from a national multicenter registry using the E-xtra design platform.

BACKGROUND: Complex aortic pathology still represents an open issue in contemporary endovascular management, with continuous technological advancement being introduced in practice over time aiming to improve outcomes. Thus far, the dualism between the fenestrated and branched configuration for visceral artery revascularization is yet unsolved, with each approach having its own pros and cons. The inner branched technology for endovascular aneurysm repair (iBEVAR) aims to take the best out of both strategies, offering wide applicability and stable bridging stent sealing. The objective of this study was to evaluate the early outcomes obtained with a single manufacturer custom-made inner-branched endograft in a multicenter Italian experience. METHODS: All patients consecutively treated with E-xtra design devices in three Italian facilities were enrolled. Anatomic characteristics and perioperative data were analyzed. The main objective was to asses technical and clinical success after iBEVAR. Secondary end points were overall survival, aortic-related mortality, target visceral vessel (TVV) patency, and freedom from target vessel instability during follow-up. RESULTS: From 2016 to 2021, 45 patients were treated with an E-xtra design device revascularizing at least one visceral vessel through an inner branch. The mean age at the time of the procedure was 71.1 ± 9.3 years and 77.8% were males. The total number of target visceral arteries to be bridged with an inner branch was 159. The extent of aortic repair was thoracoabdominal in 91.1% of the cases. Technical success was achieved in 93.3% of the procedures (42/45) with all failures owing to a type I endoleak at final angiography. Each TVV was successfully connected to the graft's main body as planned without complications. Following their intervention, five patients developed spinal cord ischemia and in three of these cases symptoms persisted after discharge (6.7%). At 30 days clinical success was 93.3% (42/45). No death as well as no TVV thrombosis occurred within 30 days from the primary procedures. The mean follow-up was 22.8 ± 14.2 months. The Kaplan-Meier estimate of overall survival and TVV patency at 36 months were 83.9% and 95.9%, respectively. CONCLUSIONS: Inner branches seem to be a promising technology in the complex aortic repair landscape, with an applicability ranging from type II thoracoabdominal aneurysm to type I endoleak repair after infrarenal endografting. Whether iBEVAR could offer results comparable with those provided by fenestrated/branched endovascular aneurysm repair in terms of target vessel patency and stent stability is yet to be established and further studies are, therefore, needed.

Editor's Choice - Early Outcomes of a Novel Off the Shelf Preloaded Inner Branch Endograft for the Treatment of Complex Aortic Pathologies in the ItaliaN Branched Registry of E-nside EnDograft (INBREED).

OBJECTIVE: The aim of this study was to investigate the early outcomes of a novel off the shelf pre-loaded inner branched thoraco-abdominal endograft (E-nside) in the treatment of aortic pathologies. METHODS: Data from a physician initiated national multicentre registry on patients treated with the E-nside endograft, were prospectively collected and analysed. Pre-operative clinical and anatomical characteristics, procedural data, and early outcomes (90 days) were recorded in a dedicated electronic data capture system. The primary endpoint was technical success. Secondary endpoints were early mortality (90 days), procedural metrics, target vessel patency, endoleak rate, and major adverse events (MAEs) at 90 days. RESULTS: In total, 116 patients from 31 Italian centres were included. Mean ± standard deviation (SD) patient age was 73 ± 8 years and 76 (65.5%) were male. Aortic pathologies included degenerative aneurysm in 98 (84.5%), post-dissection aneurysm in five (4.3%), pseudoaneurysm in six (5.2%), penetrating aortic ulcer or intramural haematoma in four (3.4%), and subacute dissection in three (2.6%). Mean ± SD aneurysm diameter was 66 ± 17 mm; aneurysm extent was Crawford I - III in 55 (50.4%), IV in 21 (19.2%), pararenal in 29 (26.7%), and juxtarenal in four (3.7%). The procedure setting was urgent in 25 (21.5%) patients. Median procedural time was 240 minutes (interquartile range [IQR] 195, 303), with a median contrast volume of 175 mL (IQR 120, 235). The endograft's technical success rate was 98.2% and the 90 day mortality rate was 5.2% (n = 6; 2.1% for elective repair and 16% for urgent repair). The 90-days cumulative MAE rate was 24.1% (n = 28). At 90 days, there were 10 (2.3%) target vessel related events (nine occlusions and one type IC endoleak) and one type 1A endoleak requiring re-intervention. CONCLUSION: In this real life, non-sponsored registry, the E-nside endograft was used for the treatment of a broad spectrum of aortic pathologies, including urgent cases and different anatomies. The results showed excellent technical implantation safety and efficacy, as well as early outcomes. Longer term follow up is needed to better define the clinical role of this novel endograft.

Balloon Endoclamping for Postdissection Infrarenal Aorto-Iliac Aneurysm Repair.

BACKGROUND: Isolated post dissection infrarenal and iliac aneurysm is a rare condition that often requires surgical treatment. Surgical repair should involve the replacement of the aneurysmal segments and a wide fenestration in the residual proximal untreated abdominal aorta. However, in these patients proximal aortic clamping may be challenging. Indeed, infrarenal clamping may hamper an appropriate fenestration in the proximal dissecting lamella, and suprarenal or supraceliac clamping can be dangerous and highly demanding, especially in acute and subacute patients. Here we report our initial experience with a balloon endoclamping technique. MATERIAL AND METHODS: Our technique includes 1) direct aortic true lumen catheterization, 2) balloon endoclamping of the proximal thoracic aorta, 3) wide fenestration of the infrarenal aorta followed by external clamp positioning, 4) infrarenal aorta and iliac artery reconstruction. RESULTS: Between October 2018 and November 2019, 4 patients (male n = 4, median age 57 years) underwent postdissection iliac aneurysm repair in our institution. All patients had previously undergone emergent thoracic aorta repair. Postoperative courses were uneventful in all cases. At a median FU of 13 months, all patients remain well, with stable diameters in visceral aorta. CONCLUSIONS: In our initial experience, proximal aortic endoclamping appeared to be a safe technique associated with promising results. This approach may facilitate proximal aortic clamping and allow for a wide aortic fenestration. Further larger clinical trials are needed to validate our preliminary observations.

Emergency Endovascular Treatment of Coral Reef Aorta with an Unconventional Technique.

Coral reef aorta (CRA) is a rare condition featured by rock-hard calcifications that grow into the lumen of the thoracoabdominal aorta. Patients suffering from CRA may present severe downstream ischemic and embolic events involving the viscera and the lower limbs. In these patients, open surgical repair is the first choice of treatment. We present a case of a 70-year-old woman with acute presentation of bilateral limb ischemia and abdominal pain. An angio-computed tomography (CT) scan showed the subocclusion of the distal thoracic aorta due to a severe calcified coarctation with intraluminal thrombosis, a chronic occlusion of the superior mesenteric and celiac trunk arteries, a hypertrophic inferior mesenteric artery associated with signs of partial left kidney ischemia. The patient underwent urgent endovascular repair. A soft dilatation of the coarctation using a 7-mm noncompliant balloon was initially performed; a 21-mm conformable thoracic stent graft was subsequently deployed and increasingly dilated using progressively larger angioplasty balloons. The procedure was uneventful and the aortic gradient was reduced to zero. A postoperative CT scan revealed the proper deployment of the graft with no residual stenosis. Endovascular approach with the covered thoracic stent graft could be an accurate technique to treat CRA in the emergency setting. It allows for a primary protected balloon angioplasty and, in case of aortic-graft recoiling, a subsequent placement of covered or uncovered balloon-expandable stent graft can be safely and easily performed.

Treatment of a Proximal Giant Thoracic Aortic Aneurysm in Preview Open Repair of Thoracoabdominal Aortic Aneurysm, Sandwich Technique with Valiant Navion Evo Thoracic Endograft®.

We treated a 73-year-old female patient with a giant thoracic proximal aortic aneurysm above a previous multibranched thoracoabdominal graft without a distal neck for a standard endovascular approach. A procedure with sandwich technique was performed using the new Valiant Navion Evo Thoracic Endograft® to preserve visceral graft. Postoperative angio-computed tomography scan demonstrated the correct position of the endoprosthesis without any leakage with patency of visceral graft.

Use of the Gore Hybrid Vascular Graft in a challenging high-lying extracranial carotid artery aneurysm.

Extracranial carotid artery aneurysm is a rare condition with relatively significant morbidity and mortality. When surgery is not indicated, endovascular techniques are emerging as the preferred treatment. However, even this approach may be contraindicated due to anatomic factors. We present a case of a high-lying extracranial carotid artery aneurysm with challenging anatomy unsuitable for conventional or endovascular repair. After resecting the aneurysm, the carotid artery was revascularized using the new Gore Hybrid Vascular Graft (W. L. Gore & Associates, Flagstaff, Ariz). This straightforward procedure turned out to be safe and further reduced the cerebral ischemic time.

Multiple giant intercostal and lumbar artery aneurysms.

This case report presents a 49-year-old male with multiple intercostal and lumbar aneurysms of the thoraco-abdominal aorta, complicating a history of aortic surgeries and comorbidities. Following emergent surgical repair of a ruptured lumbar aneurysm, a multidisciplinary team opted for staged interventions, mitigating risks and optimizing outcomes. Treatment stages involved surgical ligation and endovascular embolization, aiming to minimize complications, particularly spinal cord ischaemia. This case underscores the challenges of managing complex and rare aortic pathology, highlighting the importance of multidisciplinary care and close follow-up to mitigate risks.

Partial Deployment to Save Space for Vessel Cannulation When Treating Complex Aortic Aneurysms with Narrow Paravisceral Lumen Is Also Feasible Using Inner-Branched Pre-Cannulated Endografts.

Introduction: The aim of this paper is to propose a sequential deployment technique for the E-nside off-the-shelf endograft that could potentially enhance target visceral vessel (TVV) cannulation and overstenting in narrow aortic anatomies. Methods: All data regarding patients consecutively treated in two aortic centers with the E-nside graft employing the partial deployment technique were included in the study cohort and analyzed. To execute the procedure with partial endograft deployment, the device should be prepared before insertion by advancing, under fluoroscopy, all four dedicated 400 cm long 0.018″ non-hydrophilic guidewires until their proximal ends reach the cranial graft's edge. Anticipating this guidewire placement prevents the inability to do so once the endograft is partially released, avoiding potentially increased friction inside the constricted pre-loaded microchannels. The endograft is then advanced and deployed in the standard fashion, stopping just after the inner branch outlets are fully expanded. Tip capture is released, and the proximal end of the device is opened. Visceral vessel bridging is completed from an upper access in the desired sequence, and the graft is fully released after revascularizing one or more arteries. Preventing the distal edge of the graft from fully expanding improves visceral vessel cannulation and bridging component advancement, especially when dealing with restricted lumina. Results: A total of 26 patients were treated during the period December 2019-March 2024 with the described approach. Procedure was performed in urgent settings in 14/26 cases. The available lumen was narrower than 24 mm at the origin of at least one target vessel in 11 out of 26 cases performed (42.3%). Technical success was obtained in 24 out of 26 cases (92.3%), with failures being due to TVVs loss. No intraoperative death or surgical conversion was recorded, and no early reintervention was needed in the perioperative period. Clinical success at 30 days was therefore 80.7%. Conclusions: The described technique could be considered effective in saving space outside of the graft, allowing for safe navigation and target vessel cannulation in narrow visceral aortas, similar to what has already been reported for outer-branched endografts.

Diet and lifestyles of young women of childbearing age: an Italian survey.

BACKGROUND: Daily lifestyles play a pivotal role in influencing the preconception health of women in their childbearing years. The aim of this cross-sectional study is to delineate, within the Italian context, the lifestyles of young women of childbearing age, that may have repercussions on their preconception health. METHODS: From July 2020 until April 2021, an anonymous online questionnaire was administered to a sample of 340 women aged 18-25 years attending secondary grade schools and universities in Italy. RESULTS: Over the course of the preceding three days, 90.29% of women had meat, 45.59% had fish. 28.24%, 38.82% and 18.53% of women reported tobacco, alcohol and drugs consumption, respectively. The mean amount of folic acid taken through foods consumed was 341 µg/day. Only 53.53% of women did sports. Smokers were more frequently consuming alcohol and drugs. Women who never did sports, were more likely to use drugs. CONCLUSIONS: Young women in our sample had suboptimal dietary habits. It is imperative to advocate for policies and interventions that endorse healthy dietary patterns and physical activity, improve knowledge and discourage young women from smoking, alcohol consumption and drug use.

Frozen elephant use in type a dissection: fundamentals, innovations, and pitfalls.

INTRODUCTION: Type A acute aortic dissection (TA-AAD) is a great challenge for aortic surgeons. The establishment of a standardized surgical approach, particularly the determination of whether and when to address the aortic arch and the distal aorta in the same operation as the proximal aorta, is still unclear. AREAS COVERED: Frozen elephant trunk (FET) has emerged as a valuable treatment for TA-AAD over the last decade. Here, we discuss the fundamentals and pitfalls of frozen elephant trunk procedures and present the latest innovations. EXPERT OPINION: FET has the potential to simplify arch reconstruction in patients with complex arch tears and rupture, optimize perfusion in the distal true lumen for those with a compressed true lumen and malperfusion, address distal reentry tears, and promote false lumen thrombosis and late aortic remodeling. Nevertheless, FET is still associated with non-negligible mortality and morbidity rates. Patient selection, surgical expertise, and postoperative care remain crucial determinants in ensuring successful outcomes. Recent innovations in FET surgery involve the development of techniques to minimize or avoid hypothermic circulatory arrest and new FET devices with different arch branch configurations aiming to facilitate subsequent aortic reinterventions. We believe that both these advancements have the potential to improve patient outcomes.

EASY-NET Program: Effectiveness of an Audit and Feedback Intervention in the Emergency Care for Acute Conditions in the Lazio Region.

The EASY-NET network program (NET-2016-02364191)-effectiveness of audit and feedback (A&F) strategies to improve health practice and equity in various clinical and organizational settings), piloted a novel and more structured A&F strategy. This study compared the effectiveness of the novel strategy against the sole periodic dissemination of indicators in enhancing the appropriateness and timeliness of emergency health interventions for patients diagnosed with acute myocardial infarction (AMI) and ischemic stroke in the Lazio Region. The efficacy of the intervention was assessed through a prospective quasi-experimental design employing a pre- and post-intervention (2021-2022) comparison with a control group. Participating hospitals in the Lazio Region, where professional teams voluntarily engaged in the intervention, constituted the exposed group, while the control group exclusively engaged in routine reporting activities. Effectiveness analysis was conducted at the patient level, utilizing regional health information systems to compute process and outcome indicators. The effectiveness of the intervention was evaluated using difference-in-difference models, comparing pre- and post-intervention periods between exposed and control groups. Estimates were calculated in terms of the difference in percentage points (PP) between absolute risks. Sixteen facilities for the AMI pathway and thirteen for the stroke pathway participated in the intervention. The intervention yielded a reduction in the proportion of 30-day readmissions following hospitalization for ischemic stroke by 0.54 pp in the exposed patients demonstrating a significant difference of -3.80 pp (95% CI: -6.57; -1.03; 5453 patients, 63.7% cases) in the exposed group compared to controls. However, no statistically significant differences attributable to the implemented A&F intervention were observed in other indicators considered. These results represent the first evidence in Italy of the impact of A&F interventions in an emergency setting, utilizing aggregated data from hospitals involved in the Lazio Region's emergency network.

Knowledge, attitudes and behaviours of a sample of Italian paediatricians towards RSV and its preventive strategies: a cross-sectional study.

BACKGROUND: Respiratory Syncytial Virus (RSV) infection mainly affects newborns, infants and young children aged < 2 years. Since an RSV vaccine is in the European Medicines Agency's waitlist validation, nowadays the prevention only includes passive immunization with monoclonal antibodies (mAb). In the present study we aimed at investigating Italian paediatricians' knowledge, attitudes and behaviours towards RSV and its prevention. METHODS: From February to May 2023, an anonymous online questionnaire, with answers based on the Likert scale, was administered to a sample of Italian paediatricians' members of the Italian Society of Paediatrics. Descriptive and inferential statistical analyses were performed using STATA 17. RESULTS: The paediatricians who answered the questionnaire were 507, mostly women (70.6%), aged 30-45 (33.1%), employed in hospitals in 66.6% of cases. The 10.8% of respondents reported that RSV is transmitted only among children younger than 2 years of age and 80.33% of participants that school-age children are not at risk of developing severe forms of RSV disease. The 25% of participants thought that active immunization is currently available to prevent RSV infection and 35.7% that does not exist passive immunization to prevent RSV for infants and newborns aged < 2 years. The 97.5% of physicians managed bronchiolitis cases and 65.6% of participants did not prescribe the administration of mAb. Higher age, seniority and RSV knowledge score were found to be associated with having a higher mAb knowledge score (p < 0.001) and having a higher RSV knowledge was associated with a higher mAb knowledge score (p < 0.001). The logistic regression model found that the odds of a positive attitude towards mAB knowledge score increased by over 3 times (OR 3.23, 95% CI [1.41, 7.40], p = 0.006) for being female and the odds of a positive attitude towards mAB knowledge score increased by almost 10 times (OR 9.73, 95% CI [3.06, 30.89], p < 0.001) for a one-unit increase in RSV knowledge score. CONCLUSIONS: Paediatricians' limited knowledge or awareness could represent a barrier to the implementation of preventive strategies against RSV infection. Strategies to improve paediatricians' education on RSV prevention are, therefore, crucial.

T-next: a new custom-made Thoraflex graft to simplify proximal and distal aortic reinterventions.

Secondary root and distal thoraco-abdominal endovascular aortic re-interventions can be challenging after frozen elephant trunk. We obtained from the TERUMO Aortic custom-made platform a Thoraflex graft with a modified disposition of the arch branches that facilitate secondary proximal and distal reinterventions. Here we describe the graft and our first implant.

Normothermic frozen elephant trunk without circulatory arrest.

We describe our technique for total aortic arch replacement with stenting of the descending thoracic aorta allowing normothermic cardiopulmonary bypass and avoiding hypothermic circulatory arrest. Supplementary information: The online version contains supplementary material available at 10.1007/s12055-023-01536-1.

Arch vessels' switch in frozen elephant trunk: a new technique to facilitate the second-stage endovascular thoraco-abdominal aorta repair.

In patients with extensive thoraco-abdominal aortic disease, staged hybrid repair involving open total aortic arch replacement and endovascular thoraco-abdominal aorta repair with branched stent graft has emerged as a valuable treatment option. However, total arch replacement with the available branched vascular grafts often results in acute angulation between the reimplanted vessels and the aortic arch hampering antegrade catheterization of the thoraco-abdominal aorta during the second endovascular stage. Here, we present our 'switch technique' for arch vessels' reimplantation to facilitate antegrade aortic catheterization of the thoraco-abdominal aorta and visceral vessels.

Knowledge, attitudes, and health status of childbearing age young women regarding preconception health - an Italian survey.

Introduction: Preconception health is a public health issue, concerning aspects that could have repercussions on pregnancy outcomes. Despite the importance, often there is a lack of knowledge, particularly among young women. This cross-sectional study aims to evaluate knowledge, attitudes and health status of young women regarding preconception health in the Italian context. Methods: From July 2020 until April 2021 a validated questionnaire (systematic review, Delphi procedure and pilot study) was administered to a sample of 340 women aged 18 to 25 years, without previous pregnancy and not planning it, attending secondary grade schools and universities. It collected information on knowledge, physical, sexual and mental health. T-test and analysis of variance (ANOVA) were used to determine a significant difference in knowledge mean score (KMS) among different groups. Results: KMS was 67.6% (SD = 18.1). Participants with Italian nationality, enrolled in a health-field university, with a full-time job, a family income higher than 35,000 €/year and teachers or health providers as information source, had a significantly higher KMS. Only 15.9% of women who saw a gynaecologist in the last year (47.7%) asked about preconception health. 56.5% knew that folic acid is effective in reducing the risk of neural tube defects, while 5.9% was taking it. 82.3% was living in stressing environment. Gender-based discrimination at work, school or family was felt by 25.1%, while 38.2% experienced at least one type of violence. Conclusions: Promoting preconception health by improving knowledge, attitudes and behaviours may be an impactful possibility to improve women's, children's, and communities' health.

Normothermic frozen elephant trunk: our experience and literature review.

Background and Objective: The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. Methods: A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. Key Content and Findings: Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. Conclusions: The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.

Case report: A hybrid technique for a safe nephrectomy in a giant kidney angiomyolipoma.

Background: Giant angiomyolipoma is usually associated with genetic syndromes and complications (spontaneous rupture and bleeding, hematuria, hypertension) and mass-related symptoms (flank and abdominal pain). Case presentation: We present a case of a 20-year-old woman suffering from tuberous sclerosis who was referred to our hospital with a giant angiomyolipoma causing abdominal pain. A contrast-enhanced computed tomography showed a left angiomyolipoma, measuring 28 cm × 17 cm × 27 cm. After a multidisciplinary team discussion, the patient was submitted for a nephrectomy. Percutaneous temporary occlusion of the main renal artery was achieved through an endovascular balloon catheter. Through the balloon catheter guidewire, 2,500 IU of heparin was infused to reduce the risk of tumor vein thrombosis and venous embolism. This allowed a safe kidney manipulation through a left thoracoabdominal approach. The postoperative course was uneventful. Pathology showed a 40 cm × 30 cm × 9 cm and 10 kg AML. One year after surgery, the patient is on follow-up, and her estimated glomerular filtration is 120.5 ml/min/1.73 m2. Conclusion: The present case showed that the endovascular control of the main renal artery could be considered a useful approach to safely managing huge renal masses when renal hilar control is expected to be very difficult.

The value of surgical admissions for malignant uterine cancer. A comparative analysis of robotic, laparoscopic, and laparotomy surgery in a university hospital.

Background: Robotic surgery for malignant uterine cancer raises issue of economic sustainability for providers. The objective of this study was to assess the value of surgical admissions for malignant uterine cancer in a University Hospital through an analysis of their costs and outcomes by comparing three different surgical approaches (laparotomy, laparoscopic, and robotic surgery). Methods: Hospitalizations between 1 January 2019 and 31 October 2021 for malignant uterine cancer surgery were selected and stratified. For each surgical approach, mean values (with 95% confidence intervals, CI) were calculated for cost items. Moreover, 30-day readmission frequency was calculated for the three approaches compared to each other. ANOVA and Student's t-test and relative risk (RR) were used for statistical analysis. A break-even analysis was carried out by evaluating the volume of robotic and non-robotic surgical admissions. Results: A total of 1,336 hospitalizations were included in the study, 366 with robotic, 591 with laparoscopic, and 379 with laparotomy surgery. Robotic surgery, compared to laparoscopic and laparotomy ones, showed a statistically significant difference (p < 0.001) in the economic margin, which was largely negative (-1069.18 €; 95%CI:-1240.44--897.92 €) mainly due to devices cost, and a lower percentage of 30-day readmissions (1.4%; 95%CI: 0.2-2.6%), with a statistically significant difference only vs. laparotomy (p = 0.029). Laparoscopic compared to laparotomy surgery showed a significantly (p < 0,001) more profitable economic margin (1692.21 €; 95%CI: 1531.75 €-1852.66 €) without a significant difference for 30-day readmissions. Break-even analysis showed that, on average, for each malignant uterine cancer elective surgery performed laparoscopically, 1.58 elective robotic surgeries are sustainable for the hospital (95% CI: 1.23-2.06). Conclusion: Break-even analysis could be a useful tool to support hospital management in planning and governance of malignant uterine cancer surgery. Systematic application of this tool will allow defining over time right distribution of robotic, laparoscopic, and laparotomy surgeries' volumes to perform to ensure both quality and economic-financial balance and therefore value of uterine oncological surgery. Concerning research, this study paves the way for a multicentric study, the extension of outcomes of malignant uterine surgery to be considered and assessed, and the future inclusion of other therapeutic interventions in the analysis.