Cardiac risk after elective endovascular repair for infrarenal abdominal aortic aneurysm: Results from the Italian Collaborators for EVAR multicenter registry.

OBJECTIVE: Major adverse cardiac events (MACEs) were common complications after endovascular aortic repair (EVAR) causing significant postoperative morbidity and mortality. The aim of the study was to evaluate the cardiac risk after elective EVAR for uncomplicated noninfected infrarenal abdominal aortic aneurysm in a large multicenter cohort. METHODS: This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study conducted by four academic tertiary referral hospitals from January 2018 to March 2021. Baseline, perioperative, and postoperative information of elective EVARs was evaluated. The primary outcome was the incidence of MACEs after EVAR, which was defined as acute coronary syndrome, non-ST-elevation myocardial infarction, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, and revascularization as well as cardiovascular death. Secondary outcomes were 1-year overall survival (all-cause mortality) and freedom from aorta-related mortality. Comparative analysis was conducted between MACE and overall population, and univariate and multivariate logistic regression analyses were used to analyze factors associated with the risk of the MACE occurrence and early 1-year mortality. RESULTS: The study has enrolled 497 patients (35 females, 7%) with a mean age of 75.3 ± 7.8 years. The MACE rate was 6.4% (32/497, events/patients), and the majority of the events were recorded in the postoperative period (24/32, 75%; overall 24/497, 4.8%). One-year survival from all-cause mortality was 94% (95% confidence interval [CI]: 91-96), and the MACE population showed a significantly lower survival estimation rate (Overall - MACEs, 95.8% [95% CI: 93-97] - 67.9% [95% CI: 47-82], log-rank 41.950, P = .0001). Freedom from aorta-related mortality was 99.3% (95% CI: 98-100). The perioperative need for red blood cell transfusions was strongly related to the MACE occurrence (odds ratio: 2.67, 95% CI: 1.52-4.68, P = .001) and 1-year mortality (hazard ratio: 2.14, 95% CI: 1.48-3.09, P = .0001). CONCLUSIONS: MACEs represent a common complication in the postoperative and early period after elective EVAR. Blood loss requiring red blood cell transfusions is associated with increased postoperative MACEs and early mortality, suggesting that all the efforts should be carried out to reduce the bleeding during and after elective interventions.

Outcomes of Endovascular Reconstructive Techniques in Trans-Atlantic Inter-Society Consensus II C-D Aortoiliac Lesions.

BACKGROUND: To describe the outcomes of the endovascular reconstruction of TASC C/D lesions involving the infrarenal aorta and aortic bifurcation with different techniques. METHODS: This is an observational, retrospective, single-center study. In a 5-year period, we selected all the patients treated with an endovascular procedure for an aorto-iliac TASC C/D lesion involving the infrarenal aorta and/or the aortic bifurcation. Early (<30 days) outcomes were mortality, major amputation, and thrombosis. Late mid-term (1 and 3 years) outcomes were primary, assisted primary and secondary patency, limb salvage rate, and freedom from reintervention. RESULTS: A total of 87 patients were treated during the index period. Kissing covered stent (cKS), covered reconstruction of aortic bifurcation (CERAB), and unimodular bifurcated AFX Unibody stent-graft (Bif-SG) implantation were performed in 35 (40.4%), 26 (29.8%), and 26 (29.8%) cases, respectively. Bif-SG group included 11 (11/26, 42.3%) patients treated for abdominal aortic aneurysm associated with the obstruction of the aortic bifurcation. Technical success was achieved in all cases and no ruptures or conversions to open surgery were recoded. Median follow-up age was 18 months (interquartile range [IQR], 8-34). Overall primary patency rate was 91.2% (95% confidence interval [CI]: 81.3-95.9) at 1 year and 83.5% (95% CI: 69.6-91.4) at 3 years. Assisted primary patency was 96.9% (95% CI: 87.8-99.2) at 1 and 3 years. Secondary patency was 97.8% (95% CI: 85.5-99.6) at 3 years. Limb salvage rate was 98.6% (95% CI: 90.1-99.7) at 1 and 3 years and, freedom from reintervention was 98.4% (95% CI: 88.9-99.7) at 1 year and 87% (95% CI: 66.1-95.4) at 3 years. Univariate analysis did not identify any factor affecting primary patency rate. CONCLUSIONS: Endovascular reconstruction in severe aorto-iliac obstructions using advanced techniques offered promising mid-term patency rates and profiles of safety. The variety of reconstructive configurations allows surgeons to customize on patients' anatomies the type of revascularization.

Acute Distress Respiratory Syndrome and Cardiac Shock after AngioJet Thrombectomy for Acute Occlusion of an Aortic Endograft.

Partial thrombosis or total occlusion of aortic or limb graft are possible complications after endovascular aneurysm repair. Different strategies for therapeutic management are available; these include open surgical techniques or endovascular treatments. The choice of the treatment depends on the patient's clinical conditions and on the timing of the thrombosis. Bypass still remains the first choice in case of chronic occlusion but in the last 10 years, the use of percutaneous mechanical/rheolytic thrombectomy systems is increasing. These devices can be used in case of acute or subacute onset of native arterial and venous thrombosis or embolism and in case of graft occlusion. AngioJet is a percutaneous rheolytic mechanical thrombectomy system. Through a pressurized saline solution jet, a low-pressure zone is made up and the thrombus is fragmented and aspirated by the device. Different transient adverse effects caused by lysis of the thrombus are described such as hemoglobinuria but in some cases the release of high doses of the thrombus degradation products such as heme and adenosine diphosphate can lead to fatal consequences for the patient. We reported a case of an acute onset of acute distress respiratory syndrome, pulmonary edema, cardiac shock, and renal failure following AngioJet thrombectomy in an 81-year-old man with an acute occlusion of an aortic endograft.

Effectiveness and use of avalanche airbags in mortality reduction among winter-recreationists.

BACKGROUND/OBJECTIVE: The number of backcountry skiers and snowboarder surged in the last years, especially during the COVID-19 pandemic, as ski resorts shut down. Inevitably, this led to an increase in avalanche-related injuries and death. As avalanche rescue device, avalanche airbags are increasingly becoming part of the standard winter mountaineering equipment. This study provides a review of the available data and an updated perspective on avalanche airbags, discussing their function and efficacy to reduce mortality and their limitations. RESULTS: Causes of death in individuals caught by avalanches are multiple. Airbags seem to reduce mortality by decreasing the chances of critical burial, the most determining risk factor. However, there is a scarcity of reliable scientific research on the topic, and the way in which airbags reduce mortality and to what extent is still debated. Several elements seem to influence airbags efficacy, and their use still yields several limitations linked to manufacturing, proper use, users education and risk compensation. CONCLUSIONS: Avalanche airbags seem to be an important tool in reducing mortality in the backcountry expeditions. However, more research and standardized data collection are needed to fill the knowledge gap, and mountain communities should promote adequate education of winter-recreationists on how to prevent and react to an avalanche and on the correct use of airbags in combination with already available tools such as transceivers, probes and shovels; and manufacturing companies should ensure higher efficacy of the survival avalanche equipment for better prevention of burial, asphyxia and trauma.

Endovascular Bailout Repair After Intraprocedural Thrombosis of a Bifurcated Unimodular Stent-graft During Aorto-iliac Revascularization in a Patient with Sars CoV-2 Infection.

To describe a case of endovascular bailout strategy during stent-graft thrombotic complication in an endovascular procedure for complex TASC II D aortoiliac lesion. A 77-year-old patient was admitted at our institution with bilateral lower limb rest pain due to aortoiliac obstructive disease in a previous aortobifemoral bypass grafting with an asymptomatic Sars-CoV-2 infection. We planned an anatomic reconstruction of the aortoiliac segment with an unimodular bifurcated stent-graft. During the procedure, we observed a preocclusive thrombosis of the aortic portion requiring endovascular thrombectomy with vacuum assisted system followed by a successfully kissing-stent endolining. The post-operative period was uneventful and patient was discharged on the 14th post-operative day. Endovascular thrombectomy may be a helpful strategy during thrombotic complication of complex reconstructions of obstructive aortoiliac disease avoiding surgical conversion to laparotomy.

Broken Trust. Confidence Gaps and Distrust in Latin America.

Latin American societies show lower levels of political trust when compared to other regions of the world. The lack of trust in institutions can led to ineffective management of public affairs, social crises, lack of transparency, economic problems and even difficulties in countering pandemics. The objective of this work is to build an index (LADI) that provides a measure of the level of perceived distrust in the institutions of the different Latin American countries and its variations over the period from 2008 to 2018. The data used for this analysis are of a subjective nature and come from the series of surveys provided by Latinobarómetro. To develop the analysis, we have used a quantitative approach of a partially non-compensatory aggregative type, known as Adjusted Mazziotta and Pareto Index. The results show a generalized increase of distrust in the years 2017 and 2018 for several Latin American countries. On the other hand, in countries where the rule of law is more consolidated, a best perception of the functioning of democracy emerges.