Long-term Outcome Comparison of 2 Techniques for Embolization of Splenic Artery Aneurysms.

PURPOSE: The aim of the study is to analyze our single-center experience in endovascular treatment of splenic artery aneurysms (SAAs) with transcatheter coil embolization, comparing long-term outcomes of packing and sandwich techniques. MATERIALS AND METHODS: Between January 2010 and December 2021, 28 patients with certain diagnosis of non-ruptured asymptomatic SAA were treated with 2 different embolization techniques (packing, n=10, and sandwich, n=18). Early outcomes assessed were technical success, overall mortality, mean hospital stay, post-embolization syndrome rate, and freedom from splenectomy rate. Estimated 5-year outcomes in terms of freedom from sac reperfusion, and freedom from reintervention were evaluated and compared between the 2 different embolization techniques. RESULTS: The mean SAA diameter was 2.8±0.8 cm. Overall technical success rate was 100%. Intraoperative and 30-day mortality rates were 0 in both groups. One patient in the sandwich group required a postoperative splenectomy. The mean follow-up period was 58.3±44.5 months. Estimated overall 5-year survival was 86.7%. Five-year freedom from sac reperfusion was 100% in the sandwich group, and 85.7% in the packing group, with no difference between the 2 groups (p=0.131), whereas freedom from reintervention was 100% in the sandwich group, and 75% in the packing group with a statistically significant difference (p=0.049; log-rank=3.750). CONCLUSIONS: Embolization of SAAs seemed to be safe and effective with 100% of technical success rate and good perioperative results. Both sandwich and packing techniques yielded promising results also in the long-term period. CLINICAL IMPACT: Transcatheter coil embolization of splenic artery aneurysms seems to be a safe and effective procedure with a 100% technical success and satisfactory perioperative outcomes. Sandwich and packing techniques offer good results in the long-term period. Freedom from reintervention seems to be optimal and comparable between the 2 techniques.

Early and Midterm Outcomes of Endovascular Aneurysm Repair With Zenith Alpha Abdominal Stent-Graft: Results From a Multicenter Retrospective Tuscany Registry.

PURPOSE: Zenith Alpha Abdominal (Cook Medical, Bloomington, IN, USA) is one of the new-generation low-profile stent-grafts with demonstrated satisfactory early and midterm clinical outcomes for endovascular treatment of abdominal aortic aneurysms (AAAs). The aim was to evaluate early and midterm results of this device in the framework of a multicenter regional retrospective registry, with the analysis of morphological factors affecting outcomes, including different limb configurations. MATERIALS AND METHODS: Between January 2016 and November 2021, 202 patients with AAA underwent elective endovascular aneurysm repair (EVAR) with implantation of a Zenith Alpha Abdominal in 7 centers. Early (30 day) outcomes in terms of technical and clinical success were assessed. Estimated 5 year outcomes were evaluated in terms of survival, freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and graft infection evaluation by life-table analysis (Kaplan-Meier test). A comparative analysis between different limb configurations (Zenith Spiral Z AAA iliac legs, codes ZISL vs ZSLE) was performed in terms of limb graft occlusion. RESULTS: The 30 day technical and clinical success rates were 97.5% and 99.5%, respectively. Median follow-up period was 25.5 months (interquartile range [IQR]: 12-43.25). The 5 year survival rate was 73.6%. The estimated 5 year outcomes in terms of freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and freedom from graft infection were 88.6% (95% CI [confidence interval]: 83.4%-93.1%), 95.8% (95% CI: 92.7%-97.1%), 93.6% (95% CI: 90.2%-96.8%), 87% (95% CI: 83.3%-91.6%), and 97.7% (95% CI: 95.1%-98.9%), respectively. About limb configuration, no differences were found in terms of 5 year freedom from limb graft occlusion (ZSLE 93.4% [95% CI: 89.8%-95.5%] vs ZISL 94.3% [95% CI: 90.1%-95.9%], p=0.342; log-rank 0.903). CONCLUSION: Zenith Alpha Abdominal in elective EVAR offered satisfactory early and 5 year outcomes with low complication rates. Limb graft occlusion continued to be an issue. Limb configuration did not affect outcomes. CLINICAL IMPACT: The authors describe satisfactory early and 5 year outcomes of Zenith Alpha Abdominal in elective endovascular aortic repair in the framework of a multicenter regional retrospective registry. At 5 years freedom from type I endoleak was 88.6%, and rate of endograft infections and conversions to open repair were very low. in the present study. Hot topic about about Zenith stent-graft still remains the limb graft occlusion with a 30-day overall rate of 2%, and estimated 5-year freedom from limb graft occlusion of 93.6%. Limb graft configuration did not affect limb graft occlusion rate. A standardized protocol including iliac stenting should be adopted to reduce kimb graft occlusion.

Comparison of long occlusive femoropopliteal de novo versus previous endovascularly treated lesions managed with in situ saphenous bypass.

BACKGROUND: The aim of this study was to compare the 2-year outcomes of de novo versus postendovascular lesion treatment of femoropopliteal occlusions included in a national, multicenter, observational, prospective registry based on the treatment of critical Limb-threatening IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE) registry. METHODS: From January 2018 to December 2019, 541 patients from 43 centers have been enrolled in the LIMBSAVE registry. Of these patients, 460 were included in the present study: 341 (74.1%) with de novo lesions (DN group) and 119 (25.9%) with postendovascular treatment lesions (PE group). Initial outcome measures were assessed at 30 days after treatment. Furthermore, at the 2-year follow-up, the estimated outcomes of primary patency, primary-assisted patency, secondary patency, and limb salvage were analyzed with Kaplan-Meier curves and compared between groups with the log-rank test. RESULTS: Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation. However, compared with DN group, more patients in PE group had a great saphenous vein diameter of less than 3 mm (11.1% vs 21%; P = .007). Intraoperatively, both groups showed similar distal anastomosis sites: below-the-knee popliteal artery (63% DN group, 66.4% PE group) and tibial vessel (37% DN group, 33.6% PE group) (P = .3). The overall mean duration of follow-up was 11.6 months (range, 1-24 months). At the 2-year follow-up, there were no differences between the two groups in terms of primary patency (66.3% DN group vs 74.1% PE group; P = .9), primary-assisted patency (78.2% DN group vs 79.5% PE group; P = .2), secondary patency (85.1% DN group vs 91.4% PE group; P = .2), and limb salvage (95.2% DN group vs 95.1% PE group; P = .9). CONCLUSIONS: The LIMBSAVE registry did not show a worsening of overall patency and limb salvages rates at the 2-year follow-up in patients undergoing in situ saphenous bypass after a failed endovascular approach for long femoropopliteal occlusive disease. This finding is in contrast with what has been published in literature.

Factors Affecting Patency of In Situ Saphenous Vein Bypass: Two Year Results from LIMBSAVE (Treatment of critical Limb Ischaemia with infragenicular Bypass adopting in situ SAphenous VEin technique) Registry.

OBJECTIVE: The aim was to demonstrate contemporary outcomes of in situ saphenous vein bypass using a valvulotome. METHODS: Analysis of two year outcomes of a multicentre registry based on the treatment of critical Limb Ischaemia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE). Between January 2018 and December 2019, 541 patients in 43 centres were enrolled. In all patients an innovative valvulotome was used. Early outcomes were assessed. Two year outcomes according to Kaplan-Meier curves in terms of patency and limb salvage were evaluated. Associations between patient and procedure variables were analysed with univariable and multivariable analyses. RESULTS: In all cases, a valvulotome was able to lyse the valves. Vein injury due to the in situ technique was 3.5%. Thirty day mortality and major amputation rates were 3% and 0.9%, respectively. Mean follow up was 12.1 months. Two year estimated primary patency, primary assisted patency, secondary patency, and limb salvage were 69.1%, 81.4%, 86.5%, and 94.5%, respectively. Multivariable analysis showed an association between pre-operative vein diameter < 3 mm and lower primary patency (hazard ration [HR] 14.3, p < .001), primary assisted patency (HR 9.4, p = .002), secondary patency (HR 7.2, p = .007), and limb salvage (HR 7.8, p = .005) rates. Distal anastomosis to a tibial or foot vessel was also associated with lower primary patency (HR 4.8, p = .033), and primary assisted patency (HR 6, p = .011) rates. Use of a suprafascial tributary collateral as a graft was associated with lower primary patency (HR 6.7, p = .013), and primary assisted patency (HR 4.2, p = .042) rates. CONCLUSION: Vein diameter < 3 mm, distal anastomosis on a tibial or foot vessel, and use of a suprafascial tributary collateral as a graft were significantly associated with loss of patency and limb loss during follow up.

Percutaneous glue embolization of arteriovenous fistula of in situ saphenous vein bypass graft: Case report and literature review.

OBJECTIVES: Arteriovenous fistulas (AVFs) of an in situ saphenous vein bypass can be managed surgically or through endovascular coil embolization. The complications associated with the surgical wounds required for side branch ligature can be minimized through selective vein ligature and interrupted small incisions, but endovascular methods are time-consuming and limited by vein size. In this case report, we describe percutaneous ultrasound (US)-guided balloon-assisted direct glue injection as an alternative treatment strategy for AVF closure. METHODS: We treated a patient with a delayed AVF in a femoral-popliteal in situ saphenous vein bypass. The patient came to our attention for the recurrence of chronic limb-threatening ischemia (CTLI) 4 years after the initial bypass creation. Ultrasound and computed tomography angiography (CTA) showed a double tandem graft in significant stenosis below an AVF connected with the deep venous system. Treatment included percutaneous angioplasty of the bypass stenosis and contemporary AVF closure via ultrasound-guided glue injection. RESULTS: We successfully performed endovascular angioplasty with a drug-eluting balloon of the bypass stenosis and ultrasound-guided fistula embolization with cyanoacrylate Glubran 2. Angiography after the procedure showed bypass graft patency, no residual stenosis, and complete closure of the AVF. Results were confirmed with US. CONCLUSIONS: Percutaneous embolization using glue could be a useful technique for AVF closure. It is a minimally invasive method that reduces the need for skin incisions during in situ saphenous grafting or endovascular revascularization.

Bifurcated bypass in severe chronic limb threatening ischaemia.

OBJECTIVES: Revascularization according to the angiosome concept is of proven importance for limb salvage in chronic limb threatening ischaemia but it is not always practicable. Bifurcated bypasses could be considered as an option when an endovascular approach is not feasible or has already failed and a single bypass would not allow direct revascularization of the ischaemic area. Bifurcated bypasses are characterized by landing on two different arteries, the main artery (in direct continuity with the foot vessels) and the secondary one (perfusing the angiosome district). The aim of this study is to evaluate the safety and effectiveness of bifurcated bypass in chronic limb threatening ischaemia. METHODS: Thirty-five patients were consecutively treated with a bifurcated bypass for chronic limb threatening ischaemia from January 2014 to December 2019 in a single vascular surgery centre. Data from clinical records and operative registers were collected prospectively in an electronic database and retrospectively analysed. Primary and primary assisted bypass patency, amputation-free survival, morbidity and mortality rates at 12 and 24 months were analysed. RESULTS: Mean follow-up period was 25.1 months (range 2-72 months). Thirty-six bifurcated bypasses were performed on 35 patients (age 75.3 ± 7.2 years; 69.4% were male). According to Wound, Ischemia, foot Infection classification 22.2% belonged to stage 3 and 77.8% to stage 4 and the mean Rutherford's class was 5.1 ± 0.7. Immediate technical success was 100%. Early mortality and morbidity rates were respectively 5.5%, and 33.3%; foot surgery was performed in 50% of cases with wound healing in all patients. Primary patency and primary assisted bypass patency were 96.7% and 100% at 6 months; 85.2% and 92% at 12 months, 59.9% and 73.4% at 24 months, respectively. Amputation-free survival at 12 and 24 months was, respectively, 95.6% and 78.8%. Overall survival rates at 12 and 24 months were respectively 94.4% and 91.6%. CONCLUSIONS: Bifurcates bypass can provide good results in patients with chronic limb threatening ischaemia without endovascular option, especially in diabetic ones. Bifurcated bypass is a complex surgical solution, both to be planned and performed, and it is quite invasive for frail patients that should be accurately selected.

Hand-assisted laparoscopic surgery versus endovascular repair in abdominal aortic aneurysm treatment.

OBJECTIVE: Hand-assisted laparoscopic surgery (HALS) for the treatment of abdominal aortic aneurysm (AAA) has shown promising initial results compared with traditional surgery, but its efficacy remains highly debated. The aim of this monocentric, retrospective study was to investigate differences in morbidity, mortality, and reintervention rates between endovascular aneurysm repair (EVAR) and HALS, in the medium- and long-term follow-up in a highly selected population. METHODS: We treated 977 patients consecutively for nonurgent AAA from January 2006 to December 2013; among them, 615 (62.9%) underwent open surgery, 173 (17.7%) HALS, and 189 (19.3%) EVAR. For this study, only patients treated with HALS or EVAR were considered. A subsequent selection process was carried out to identify the patients with clinical characteristics and aneurysm morphology amenable to either of these treatments. The final study cohort included 229 patients; 92 (40.2%) underwent HALS and 137 (69.8%) received EVAR. The two populations were homogeneous for clinical and demographic characteristics. RESULTS: The mean duration of follow-up was 57 ± 28 months (50 ± 24 months in the EVAR group and 67 ± 29 months in the HALS group; range, 2-110 months). No deaths and no statistically significant differences in severe complications or reinterventions were observed over the perioperative period (30 days). Length of stay was significantly shorter after EVAR, because the need for and length of stay in the intensive care unit were decreased. Three postoperative deaths (in-hospital mortality >30 days: HALS, 2.2%; EVAR, 0.7%; P = .7268) occurred owing to respiratory failure (two patients, one in each group) and multiorgan failure secondary to a bowel ischemia (one patient in the HALS group). Other deaths in the study population were not related to the procedure. In both groups, the major causes of death were cancer (24 cases [36.9%]), cardiovascular causes unrelated to AAA (16 [24.6%]), and chronic obstructive lung disease (10 [15.4%]). In the long-term follow-up period, there was a difference in the overall survival in favor of HALS when compared with EVAR (P = .011). CONCLUSIONS: This retrospective, single-center study shows that, within a population of similar clinical and anatomic characteristics, treatment of AAA with EVAR or HALS does not result in significant differences in early morbidity and mortality. EVAR presents significantly shorter hospital and intensive care unit length of stay, whereas HALS presents a lower aneurysm-related reintervention rate and lower perioperative cost. The strict patient selection in this trial, as is generally the case with AAA treatment, is likely the key to success for both of these techniques.

Colonic Ischemia after Standard Endovascular Abdominal Aortic Aneurysm Repair, a Rare but Dangerous Complication.

Colonic ischemia (CI) after abdominal aortic aneurysm repair, although rare, is associated with severe prognosis. Endovascular aneurysm repair (EVAR) is becoming the standard of practice in most vascular centers, and it also may reduce CI incidence in comparison with conventional open repair. We report 2 cases of fatal CI after 636 standard EVAR procedures performed at our institution, from January 1998 to December 2017. Both patients were electively treated by highly skilled operators. In one patient, presenting early CI, EVAR procedure was complicated by intraoperative common iliac artery rupture. The other one, presenting CI in seventh postoperative day, had a history of previous left hemicolectomy. In both patients, CI with leakage of fecal material in the abdominal cavity was confirmed by surgical exploration. Only few cases of CI after EVAR have been reported in literature, and the etiology of this complication remains uncertain. While saving the inferior mesenteric artery is almost impossible during standard EVAR, the preservation of hypogastric arteries could play an important role, especially after colonic surgery, but other factors should also be considered. Our preliminary, although limited experience, seems to suggest that in CI developing, intraoperative persistent hypotension and hypogastric branches distal embolization have both a role that should be better addressed.

Open Surgical Management of Hypogastric Artery during Aortic Surgery: Ligate or Not Ligate?

BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with 43% of cases with common iliac artery aneurysms and an extension of prosthetic replacement distal to the iliac bifurcation is needed. The decision about preserving the hypogastric artery (HA) is a source of discussion, in particular when only one HA is interested. The low risk of pelvic ischemia, even if existing, has to be compared with the greater technical difficulty of the vascular reconstruction. The aim of this study is to evaluate retrospectively the perioperative results in patients who underwent ligation or reconstruction of the HA during open surgical procedures for AAA. METHODS: Over a period of 11 years (January 2002 to December 2012), 1,487 patients were treated electively for AAA. In 235 cases (15.8%), the aneurysm involved the iliac bifurcation with need to extend distally the prosthetic reconstruction; among them, 63 patients were subjected to HA ligation (26.8%, group 1) and 172 to HA bypass (73.2%, group 2). Indication for ligation was the presence of extended HA aneurysm in 34 cases (54%) and heavy calcification of HA in 29 (46%). RESULTS: Perioperative mortality and morbidity rates were, respectively, 1.6% (1/63) and 7.9% (5/63) in group 1 and 1.2% (2/172) and 6.4% (11/172) in group 2 (P = 0.902 and 0.689). The incidence of buttock claudication was significantly higher in group 1 (6/63, 9.5% vs. 4/172, 2.3% P = 0.025), while there were no significant differences in other complications of pelvic ischemia. In group 2, higher intraoperative blood loss (754 ± 721 vs. 996 ± 608 mL, P = 0.011), longer operating time (283.2 ± 104.7 vs. 302 ± 109 min, P = 0.053), and longer postoperative length of stay (PLOS) (5.8 ± 2.2 vs. 6.7 ± 3.6 days, P = 0.049) occurred. CONCLUSIONS: HA bypass during open surgery for AAA is a safe procedure. If compared with ligation, it reduces the risk of buttock claudication without increasing perioperative morbidity and mortality. However, the increased complexity of the intervention involves an increase in blood loss, operating time, and PLOS.

Kissing intravascular lithotripsy in iliac in-stent restenosis related to underexpanded stents.

Intravascular lithotripsy (IVL) has been used for the treatment of native highly calcified arterial lesions. No data are available in the literature about its use in the treatment of noncoronary in-stent restenosis (ISR). We report the case of kissing IVL in highly calcified iliac ISR related to underexpansion of stents previously deployed in the common iliac arteries. The procedures were performed with a combined percutaneous right femoral and surgical left axillary access. This case demonstrates the safety and effectiveness of IVL even for the treatment of iliac ISR when other "standard" techniques cannot be used to obtain a satisfactory outcome. This technique needs to be evaluated further with multicenter experiences and adequate population sizes.

Mid-term outcomes of sartorius flap reconstruction in groin infection following vascular procedures or intravenous drug injections.

BACKGROUND: In this study, the early and mid-term outcomes of sartorius flap reconstruction after the development of a prior groin infection were investigated. METHODS: From January 2017 until June 2023, 44 patients from 2 centers in Italy underwent sartorius flap reconstruction after the development of a prior groin infection. Thirty-day outcome measures including major morbidity, amputation-free survival, and mortality were assessed. At 2-year follow-up, estimated outcomes of freedom from hemorrhagic complications, freedom from recurrent infection, freedom from reintervention, and amputation-free survival were analyzed using Kaplan-Meier curves. RESULTS: In 35 cases (79.5%) a previous vascular procedure was performed, whilst in the remaining 9 cases (20.5%) the patient was an intravenous drug abuser. Thirty-day mortality and major amputation rates were 4.5%, and 2.3%, respectively. Overall 30-day wound healing rate was 56.8% (25 cases). The overall median duration of follow-up was 12 months (IQR 4-24). Complete wound healing was obtained in 36 cases (81.8%) after a median period of 1 month (IQR 1-3). The 2-year Kaplan-Meier estimates of freedom from hemorrhagic complications, freedom from recurrent infection, freedom from reintervention, and amputation-free survival were 82.1%, 70%, 71.9%, and 97.7%, respectively. Multivariate analysis confirmed the association of female sex with recurrent infection (HR 3.4, P=.05). CONCLUSIONS: Sartorius flap reconstruction after the development of a prior groin infection following vascular procedures or intravenous drug injections yielded acceptable mid-term outcomes in terms of freedom from hemorrhagic complications, and freedom from recurrent infection. Female sex seemed to affect the rate of recurrent infection.

Intraoperative Predictors and Proposal for a Novel Prognostic Risk Score for In-Hospital Mortality after Open Repair of Ruptured Abdominal Aortic Aneurysms (SPARTAN Score).

(1) Background: Several mortality risk scores have been developed to predict mortality in ruptured abdominal aortic aneurysms (rAAAs), but none focused on intraoperative factors. The aim of this study is to identify intraoperative variables affecting in-hospital mortality after open repair and develop a novel prognostic risk score. (2) Methods: The analysis of a retrospectively maintained dataset identified patients who underwent open repair for rAAA from January 2007 to October 2023 in three Italian tertiary referral centers. Multinomial logistic regression was used to calculate the association between intraoperative variables and perioperative mortality. Independent intraoperative factors were used to create a prognostic score. (3) Results: In total, 316 patients with a mean age of 77.3 (SD ± 8.5) were included. In-hospital mortality rate was 30.7%. Hemoperitoneum (p < 0.001), suprarenal clamping (p = 0.001), and operation times of >240 min (p = 0.008) were negative predictors of perioperative mortality, while the patency of at least one hypogastric artery had a protective role (p = 0.008). Numerical values were assigned to each variable based on the respective odds ratio to create a risk stratification for in-hospital mortality. (4) Conclusions: rAAA represents a major cause of mortality. Intraoperative variables are essential to estimate patients' risk in surgically treated patients. A prognostic risk score based on these factors alone may be useful to predict in-hospital mortality after open repair.

Secondary endovascular procedures improve overall patency and limb salvage in patients undergoing in situ saphenous vein infragenicular bypass.

BACKGROUND: Secondary interventions strongly improves patency and limb salvage rates in patients undergoing infrainguinal vein bypass. The aim of this study was to evaluate the influence of secondary endovascular procedures performed during the follow-up on patency and limb salvage in patients with critical limb-threatening ischemia (CLTI) undergoing in situ saphenous vein infragenicular bypass. METHODS: From January 2018 to December 2019 541 patients in 43 centers have been enrolled into the LIMBSAVE registry (treatment of critical Limb IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique). In all patients a strict surveillance program with Duplex scan was established (1, 3, 6, 9, 12, 18, 24 months). During the follow-up indications for endovascular procedures were anastomotic stenoses, improvement of run-in (iliac stenosis) or run-off (tibial vessels' stenoses or occlusions). Two-year estimated outcomes in terms of overall patency, and limb salvage were analyzed by life-table analysis (Kaplan-Meier test). Outcomes obtained in patients undergoing endovascular procedure (Group-endo) were compared by means of Gehan-Breslow-Wilcoxon Test with those obtained in patients with no secondary endovascular procedure during the follow-up (Group-no endo). RESULTS: Two groups were homogeneous in terms of demographics and intraprocedural details. Overall mean duration of follow-up was 12.1 months (range 1-24). During the follow-up period (>30 days) 55 endovascular procedures were performed in 49 patients (9.1%) (Group-endo). Most of endovascular procedures (37/55, 67.3%) was performed to treat stenoses at proximal or distal anastomosis. Secondary endovascular procedures (40/55, 72.7%) were predominantly performed within 6 months from the index procedure. Estimated 2-year overall patency (97.9% vs. 85.2%, P=0.05), and limb salvage (100% vs. 93.9%, P=0.05) rates were significantly better in Group-endo. CONCLUSIONS: Secondary endovascular procedures in patients with CLTI undergoing in situ saphenous infragenicular bypass significantly improve the rates of overall patency and limb salvage in the mid-term period.

Successful extreme foot revascularization with plaque cracking (percutaneous direct needle puncture of calcified plaque) technique of medial tarsal artery.

The percutaneous direct needle puncture of calcified plaque technique is a valuable method to allow for extreme revascularization of occluded below-the-ankle vessels. We report the case of an antegrade recanalization technique from the peroneal artery to medial plantar artery to achieve external "cracking" of a calcified plaque of the medial tarsal artery.

Chronic Limb-Threatening Ischemia and the Need for Revascularization.

BACKGROUND: Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones. METHODS: We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis. RESULTS: Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue. CONCLUSIONS: The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

Intraoperative predictors of in-hospital mortality after open repair of ruptured abdominal aortic aneurysms.

BACKGROUND: Several models and scores have been released to predict early mortality in patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA). These scores included above all preoperative factors and they could be useful to deny surgical repair. The aim of the study was to evaluate intraoperative predictors of in-hospital mortality in patients undergoing open surgical repair (OSR) for a rAAA. METHODS: Between January 2007 and December 2020, 265 patients were admitted at our tertiary referral hospital for a rAAA. Two-hundred-twenty-two patients underwent OSR. Intra-operative factors were analyzed by means of univariate analysis (step 1). Associations of procedure variables with in-hospital mortality rates were sought based on a multivariate Cox regression analysis (step 2). RESULTS: Overall, in-hospital mortality rate was 28.8% (64 cases). Multivariate Cox regression analysis reported that operation time >240 minutes (P=0.032, OR 2.155, CI 95% 1.068-4.349), and hemoperitoneum (P<0.001, OR 3.582, CI 95% 1.749-7.335) were negative predictive factors for in-hospital mortality. Patency of at least one hypogastric artery (P=0.010; OR 0.128, CI 95% 0.271-0.609), and infrarenal clamping (P=0.001; OR 0.157, CI 95% 0.052-0.483) had a protective role in reducing in-hospital mortality rate. CONCLUSIONS: Operation time >240 minutes, and hemoperitoneum affected in-hospital mortality in patients undergoing OSR for rAAA. Patency of at least one hypogastric artery, and infrarenal clamping had a protective role. Further studies are needed to validate these outcomes. A validated predictive model could be useful to help the physicians in communication with patients' relatives.

Preoperative factors affecting long-term mortality in patients survived to ruptured abdominal aortic aneurysm repair.

BACKGROUND: Aim of this study was to retrospectively evaluate preoperative factors affecting long-term mortality in patients survived to surgical repair for ruptured abdominal aortic aneurysms (rAAAs). METHODS: From January 2007 to December 2021, 444 patients have been treated for symptomatic or ruptured aortoiliac aneurysms in two tertiary referral centers. Only 405 with diagnosis of rAAA at computed tomography were included in the present study. Initial outcome measures were assessed during at 30 and 90 days post-treatment. Estimated 10-year survival of patients survived after 90 days from the index procedure was evaluated with Kaplan-Meier Test. Uni- and multivariate analyses of the preoperative factors affecting 10-year survival in survivor patients was performed by means of log-rank and multivariate Cox regression analysis. RESULTS: Among included patients, 94 (23.3%) underwent endovascular aortic repair (EVAR) and 311 (76.8%) open surgical repair (OSR). Intraoperative death occurred in 29 patients (7.2%). At 30 days, overall death rate was 24.2% (98/405 cases). Hemorrhagic shock (HR 15.5, 95% CI 3.5 to 41.1, P<0.001) was an independent predictor for 30-day mortality. The overall rate of 90-day mortality was 32.6%. In survivors estimated survival rates at 1, 5, and 10 years were 84.2%, 58.2%, and 33.3%, respectively. Type of treatment (OSR vs. EVAR) did not affect long-term freedom from AAA-related death (HR 0.6, P=0.42). In survivor patients, multivariate analysis confirmed the association between late mortality and female sex (HR 4.7, 95% CI 3.8 to 5.9, P=0.03), age >80 years (HR 28.5, 95% CI 25.1 to 32.3, P<0.001), and chronic obstructive pulmonary disease (HR 5.2, 95% CI 4.3 to 6.3, P=0.02). CONCLUSIONS: Late freedom from AAA-related death was not affected by the type of treatment (EVAR vs. OSR) in patients undergoing urgent repair for rAAA. In survivors, female gender, elderly age, and chronic obstructive pulmonary disease negatively affected long-term survival.

Non-reversed bifurcated vein graft improves time to healing in ischemic patients undergoing lower limb distal bypass.

BACKGROUND: Bifurcated vein grafts have been described in reconstructive microsurgery. No comparative studies have been published in lower limb arterial revascularization. The aim of this study was to compare non-reversed bifurcated vs. single vein graft in patients with critical limb-threatening ischemia (CLTI) undergoing lower limb distal bypass. METHODS: Between January 2015 and December 2021 193 CLTI patients have been treated at our center with vein bypass, and distal anastomosis on infrapopliteal vessels; 137 patients (71%) received a single graft (Group SIN), and 56 patients (29%) had a bifurcated bypass (Group BIF). Primary outcomes measures were time to healing, primary patency, primary assisted patency, secondary patency, and limb salvage. Two-year outcomes according to Kaplan-Meier curves were evaluated and compared. RESULTS: Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation except for an elderly age in Group BIF (77.5 vs. 71.5 years; P<0.001). Intraoperative technical success was achieved in all patients. Overall median duration of follow-up was 19 months (interquartile range 9-36). Wound healing did not differ between the two groups (77.4% Group SIN vs. 73.2% Group BIF; P=0.33). Mean time to healing was faster in Group BIF (2.4 vs. 6.8 months; P<0.001). At 2-year follow-up there were no differences between the two groups in terms of primary patency (71.4% Group SIN vs. 54% Group BIF; P=0.10), primary assisted patency (81.7% Group SIN vs. 76.4% Group BIF; P=0.53), secondary patency (85.1% Group SIN vs. 80.9% Group BIF; P=0.79), and limb salvage (92.3% Group SIN vs. 87.2% Group BIF; P=0.64). CONCLUSIONS: Bifurcated graft improved time to healing in CLTI patients undergoing infrapopliteal non-reversed vein bypass. Two-year overall patencies and limb salvage did not differ accordingly to vein graft configuration (single vs. bifurcated).

Emergent management of diabetic foot problems in the modern era: Improving outcomes.

Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage ("time is tissue"). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.