Covered Endovascular Reconstruction of Aortic Bifurcation Facilitated by Intravascular Lithotripsy With Shockwave Balloon: A Case Report.

Aortoiliac occlusive disease (AIOD) is a specific form of peripheral artery disease (PAD) that affects the infrarenal aorta and iliac arteries. Patients with PAD commonly suffer from intermittent claudication (IC), a condition characterized by cramping pain during or after exercise that is relieved by rest. The first-line therapy for IC involves medical management, foot care, and structured exercise programs while revascularization therapy, which can be endovascular, surgical, or a combination of both, is generally reserved for patients with claudication who do not respond adequately to initial therapies. We present the clinical case of a 58-year-old female with hypertension, dyslipidemia, and a smoking habit who was referred to our hospital (Misericordia Hospital, Grosseto, Italy) due to bilateral IC of the buttocks and thighs. Computed tomography (CT) angiography revealed a 90% tight stenosis of the infrarenal abdominal aorta just above the iliac bifurcation with diffuse calcifications. After a careful evaluation of the patient's condition and anatomical characteristics of the atherosclerotic disease, the vascular team decided to perform covered endovascular reconstruction of aortic bifurcation (CERAB) with previous intravascular lithotripsy (IVL) with shockwave balloon using intravascular ultrasound (IVUS) as guidance, because of severe aortic luminal calcifications. We performed successful CERAB, and the patient was discharged in good clinical condition on the fifth day of hospitalization with an indication to follow optimal medical therapy. At the one-month clinical follow-up, the patient reported the disappearance of claudication with marked improvement in quality of life. This first described case of IVUS-guided IVL-facilitated CERAB demonstrates the efficacy and safety of IVL in calcific aortic disease and shows the usefulness of IVUS as guidance in peripheral calcium debulking procedures.

Endovascular Aortic Repair With the E-Tegra Device: Preliminary Outcomes From a Multicenter National Registry.

PURPOSE: Endovascular aortic repair (EVAR) is currently expanding its feasibility thanks to design innovations, but hostile proximal necks and narrow iliac arteries are still a constraint, as expressed by the Instructions for Use (IFU) of most devices. Our aim is to report the preliminary results of the E-Tegra endograft in infrarenal abdominal aortic aneurysms (AAAs) performed in 15 high-volume centers. MATERIALS AND METHODS: The e-Tegra Italian endoGraft REgistry (TIGRE) is a prospectively maintained database of consecutive EVAR with the E-Tegra stent-graft across 15 participating centers between March 2021 and March 2023. The registry records baseline clinical data, anatomic measurements of the abdominal aorta, perioperative and postoperative outcomes, with a scheduled follow-up period of 3 years for all patients. This is a preliminary analysis of the first results updated to January 2024. The primary endpoints are technical and clinical success, perioperative mortality, freedom from endograft rupture, and aortic-related mortality. The secondary endpoints are freedom from reintervention, and any type of endoleak (EL). The results were analyzed in relation with the anatomic characteristics of the AAAs, namely, iliac axes tortuosity and proximal neck hostility. RESULTS: The registry included 147 consecutive EVAR (138 elective and 9 in emergent setting), 7 of which were associated with an iliac branch implantation. Ninety patients had at least 1 criterion of anatomical hostility, and 25 were treated outside the device IFU. Primary technical success was achieved in 146 cases (99.3%) and assisted success in 147 (100%), with no perioperative mortality. After a median follow-up period of 20 months, no aneurysm-related mortality occurred. Reinterventions were 5: 2 for type IB EL and 3 for type II ELs with aneurysm sac increase. Five more type II ELs with aneurysm sac stability are under observation. No differences in terms of reinterventions were noted between aneurysms with standard and hostile anatomy. CONCLUSION: The E-Tegra endograft is safe and effective in treating AAAs with standard and hostile anatomy, with a low rate of complications and reinterventions, although longer-term outcomes and larger numbers are needed to compare its performances related to specific anatomic criteria. CLINICAL IMPACT: This multi-center nationwide Registry reports a real-world experience of EVAR performed with the E-Tegra abdominal endograft across 15 high-volume Centers, providing early- and mid-term device-specific results, which will help vascular surgeons in endograft selection. In particular, this study focuses on clinical results obtained in treating aneurysms with hostile anatomy, analyzing the performances of the E-Tegra endograft in cases of hostile proximal necks and narrow or tortuous iliac axes.

Grasping tiny objects.

In grasping studies, maximum grip aperture (MGA) is commonly used as an indicator of the object size representation within the visuomotor system. However, a number of additional factors, such as movement safety, comfort, and efficiency, might affect the scaling of MGA with object size and potentially mask perceptual effects on actions. While unimanual grasping has been investigated for a wide range of object sizes, so far very small objects (<5 mm) have not been included. Investigating grasping of these tiny objects is particularly interesting because it allows us to evaluate the three most prominent explanatory accounts of grasping (the perception-action model, the digits-in-space hypothesis, and the biomechanical account) by comparing the predictions that they make for these small objects. In the first experiment, participants ( N = 26 ) grasped and manually estimated the height of square cuboids with heights from 0.5 to 5 mm. In the second experiment, a different sample of participants ( N = 24 ) performed the same tasks with square cuboids with heights from 5 to 20 mm. We determined MGAs, manual estimation apertures (MEA), and the corresponding just-noticeable differences (JND). In both experiments, MEAs scaled with object height and adhered to Weber's law. MGAs for grasping scaled with object height in the second experiment but not consistently in the first experiment. JNDs for grasping never scaled with object height. We argue that the digits-in-space hypothesis provides the most plausible account of the data. Furthermore, the findings highlight that the reliability of MGA as an indicator of object size is strongly task-dependent.

The Ability to Look Beyond: The Treatment of Peripheral Arterial Disease.

This paper offers a practical overview of the contemporary management of patients with peripheral arterial disease presenting intermittent claudication (IC), including clinical and instrumental diagnosis, risk factors modification, medical management, and evidence-based revascularization indications and techniques. Decision making represents a crucial element in the management of the patient with IC; for this, we think a review of this type could be very useful, especially for non-vascular specialists.

The Role of the Profundoplasty in the Modern Management of Patient with Peripheral Vascular Disease.

BACKGROUND: The occlusion of superficial femoris artery (SFA) is a common feature in peripheral vascular disease, so the profunda femoris artery (PFA) is a crucial collateral pathway for the perfusion of the lower limb. The purpose of this study is to discuss the safety, clinical, and hemodynamic efficacy of profundoplasty on the basis of limb salvage, patency, and freedom from reintervention rates. Furthermore, this study aims to identify the risk factors linked to the failure of the procedure. METHODS: The study is based on a retrospective analysis of prospectively collected data of identified patients who underwent profundoplasty from March 2005 to October 2015. All patients showed a hemodynamic stenosis, extended from the posterior wall of the common femoral artery (CFA) into the origin of the PFA and concomitant occlusion of SFA. Endarterectomy with patch angioplasty was performed in all cases. In patients with concomitant iliac occlusive disease, a hybrid treatment was carried out to restore an adequate inflow through an endovascular approach. RESULTS: Seventy-four profundoplasty were performed during the study period. Isolate profundoplasty was performed in 56 cases (75.7%), while in the remaining 18 cases (24.3%), concomitant endovascular treatment of iliac lesions was performed. Hemodynamic success was achieved in 90.5% of the cases. The mean ankle-brachial index significantly improved, rising from 0.36 ± 0.17 preoperatively to 0.57 ± 0.20 postoperatively (P < 0.001). The median follow-up period was 33 months. Primary patency rate was 98.5% at 12, 36, and 60 months. Freedom from reintervention rate was 97% at 1 year and 95.3% at 3 and 5 years. Limb salvage rate was 96.9% at 1 year and 92.7% at 3 and 5 years. Survival rates were 86%, 60%, and 47.4% at 1, 3, and 5 years, respectively. Multivariate analysis identified Rutherford class 5 or 6 lesions as the strongest predictors of major amputation or reintervention (odds ratio, 9.37; confidence interval: 0.98-89.27; P = 0.05). CONCLUSIONS: Profundoplasty is a durable, safe, and effective procedure in terms of clinical and hemodynamic results for patients characterized by occlusion of SFA and stenosis of CFA extended to profunda ostium. For patients with Rutherford category 5 and 6 ischemia, the only profundoplasty does not seem to be adequate, and concomitant distal bypass should be necessary to improve limb salvage and decrease reintervention rate.

Hypothermia during Carotid Endarterectomy: A Safety Study.

BACKGROUND: CEA is associated with peri-operative risk of brain ischemia, due both to emboli production caused by manipulation of the plaque and to potentially noxious reduction of cerebral blood flow by carotid clamping. Mild hypothermia (34-35°C) is probably the most effective approach to protect brain from ischemic insult. It is therefore a substantial hypothesis that hypothermia lowers the risk of ischemic brain damage potentially associated with CEA. Purpose of the study is to test whether systemic endovascular cooling to a target of 34.5-35°C, initiated before and maintained during CEA, is feasible and safe. METHODS: The study was carried out in 7 consecutive patients referred to the Vascular Surgery Unit and judged eligible for CEA. Cooling was initiated 60-90 min before CEA, by endovascular approach (Zoll system). The target temperature was maintained during CEA, followed by passive, controlled rewarming (0.4°C/h). The whole procedure was carried out under anesthesia. RESULTS: All the patients enrolled had no adverse events. Two patients exhibited a transient bradycardia (heart rate 30 beats/min). There were no significant differences in the clinical status, laboratory and physiological data measured before and after CEA. CONCLUSIONS: Systemic cooling to 34.5-35.0°C, initiated before and maintained during carotid clamping, is feasible and safe. TRIAL REGISTRATION: ClinicalTrials.gov NCT02629653.

Emergent fully endovascular treatment of a free ruptured thoracoabdominal aneurysm.

To present a case of successful emergency complete endovascular repair of a ruptured type IV thoracoabdominal aortic aneurysms (TAAA) through chimney technique with off-the-shelf devices. A 64-year-old man with a free ruptured type IV TAAA. Open access was obtained at both common femoral arteries, both axillary arteries, and left common carotid artery. Covered stent grafts were located undeployed into the target arteries. An endoprosthesis was released in the suprarenal aorta, and soon after, covered stents were deployed in renal arteries and superior mesenteric artery. Type Ib and II endoleaks required an adjunctive endovascular treatment. Total endovascular repair with chimney technique may be the only life-saving option in patients unfit for open surgery and is effective in sealing the aneurysm and maintaining blood flow to the aortic branches.

Endovascular treatment of common carotid artery dissection via the superficial temporal artery.

PURPOSE: To describe the endovascular treatment of an iatrogenic common carotid artery (CCA) dissection using the superficial temporal artery (STA) as the principal access. TECHNIQUE: An 83-year-old man with a post-carotid endarterectomy left CCA dissection was admitted for a transient ischemic attack involving the left cerebral hemisphere that occurred despite proper anticoagulation. After excluding redo surgery and transfemoral stenting (owing to a partially compromised aortobifemoral bypass graft), stenting of the left CCA dissection was planned using a right transbrachial approach, with the left STA as an additional access. However, intraoperative angiography showed an acute angle between the innominate artery and left CCA, so the STA was used as the primary access route owing to its straight course and 4-mm diameter. The 9-x40-mm self-expanding stent was inserted via a 5-F sheath in the STA and deployed directly at the CCA dissection. The procedure was successful, and all vessels involved were patent at 6-month follow-up. CONCLUSION: In selected cases, the superficial temporal artery may represent a valid alternative approach for the endovascular treatment of short CCA dissections.