How the First Year of the COVID-19 Pandemic Impacted Patients' Hospital Admission and Care in the Vascular Surgery Divisions of the Southern Regions of the Italian Peninsula.

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study. Each received a 13-point questionnaire investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs. 2019 (9161 patients): post-EVAR surveillance, hospitalization for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased (1484 (16.2%) vs. 1014 (14.3%), p = 0.0009; 1401 (15.29%) vs. 959 (13.52%), p = 0.0006; and 1558 (17.01%) vs. 934 (13.17%), p < 0.0001, respectively), while admissions for revascularization or major amputations for chronic limb-threatening ischemia and urgent revascularization for symptomatic carotid stenosis significantly increased (1204 (16.98%) vs. 1245 (13.59%), p < 0.0001; 355 (5.01%) vs. 358 (3.91%), p = 0.0007; and 153 (2.16%) vs. 140 (1.53%), p = 0.0009, respectively). Conclusions: The suspension of elective procedures during the COVID-19 pandemic caused a significant reduction in post-EVAR surveillance, and in the hospitalization of asymptomatic carotid stenosis revascularization and Rutherford 3 peripheral arterial disease. Consequentially, we observed a significant increase in admissions for urgent revascularization for symptomatic carotid stenosis, as well as for revascularization or major amputations for chronic limb-threatening ischemia.

Open vascular surgery training in the endovascular era: 5-year experience with cadaver laboratory.

BACKGROUND: Vascular cadaver laboratory (CAD LAB) courses included vascular exposure techniques and simulations of open procedures. Aim of the study was to demonstrate the benefit of cadaver laboratory (CAD LAB) courses to improve trainees' experience in open surgical vascular procedures. METHODS: Between 2014 and 2020, 162 vascular surgeons or medical trainees (mean age 28 years) participated in vascular CAD LAB courses in Italy and France. Outcomes were measured using the Linkert survey, performed pre- and postcourse to evaluate self-efficacy/confidence, surgical experience, and resident perception of the course with a range score from 0 to 5 for each point. Anatomical knowledge improvement was measured using a questionnaire with multiple answers pre- and postcourse. The course was considered to have yielded a positive result if the postcourse Linkert Survey Score increased by ≥2 points, or in the case of an increase of at least 30% above the baseline value of the multiple questionnaires. RESULTS: Postcourse questionnaires were positive for all outcomes evaluated. Participants' perception of the usefulness of the CAD LAB evaluation was 4.8 out of 5. For the vascular CAD LAB, participant anatomical knowledge improved overall from an average of 55% to 93% (P<0.001), and self-efficacy/confidence improved from 2.3 to 4.5 out of 5 (P<0.001). Regarding the different operative procedures, the greatest self-efficacy/confidence improvement was recorded in carotid endarterectomy and aortic procedures (+50% and +66% respectively; P<0.001). The city location (Italy vs. France) did not affect the results. CONCLUSIONS: CAD LAB courses were shown to be effective in increasing participants' self-efficacy, confidence, and anatomical knowledge in open vascular surgical procedures.

Patient-specific haemodynamic simulations of complex aortic dissections informed by commonly available clinical datasets.

Patient-specific computational fluid-dynamics (CFD) can assist the clinical decision-making process for Type-B aortic dissection (AD) by providing detailed information on the complex intra-aortic haemodynamics. This study presents a new approach for the implementation of personalised CFD models using non-invasive, and oftentimes minimal, datasets commonly collected for AD monitoring. An innovative way to account for arterial compliance in rigid-wall simulations using a lumped capacitor is introduced, and a parameter estimation strategy for boundary conditions calibration is proposed. The approach was tested on three complex cases of AD, and the results were successfully compared against invasive blood pressure measurements. Haemodynamic results (e.g. intraluminal pressures, flow partition between the lumina, wall shear-stress based indices) provided information that could not be obtained using imaging alone, providing insight into the state of the disease. It was noted that small tears in the distal intimal flap induce disturbed flow in both lumina. Moreover, oscillatory pressures across the intimal flap were often observed in proximity to the tears in the abdominal region, which could indicate a risk of dynamic obstruction of the true lumen. This study shows how combining commonly available clinical data with computational modelling can be a powerful tool to enhance clinical understanding of AD.

Outcome After Crossing Femoropopliteal Chronic Total Occlusions Based on Optical Coherence Tomography Guidance.

AIMS: The crossing of chronic total occlusions (CTOs) is the key step for an endovascular treatment. The Ocelot system is a novel device that combines a steerable drilling tip with optical coherence tomography (OCT) technology. It provides intraluminal imaging to help the crossing of CTOs in the femoropopliteal segment. Aim of the study was to determine early and midterm results after recanalization with this device. METHODS AND RESULTS: During a period of 16 months, 84 CTOs were treated using the Ocelot system and prospectively registered. The primary end points were technical success and the primary and secondary patency of the lesion. Risk factors associated with early and midterm results were also analyzed. In all, 58 (69.0%) lesions were treated for intermittent claudication, 26 (31.0%) for critical limb ischemia, 34 (40.5%) were classified as Trans-Atlantic Inter-Society Consensus II D lesions, and 22 (26.2%) showed severe calcifications. The technical success rate was 72.6%. During 36 months of follow-up (mean 25.9), there were 10 reinterventions. The primary and secondary patency at 36 months were 54.2% and 68.1%, respectively. CONCLUSIONS: In our experience, the Ocelot system would appear to be a safe and effective tool for increasing the applicability of endovascular techniques. However, the midterm results did not show drastic improvement.

Spot Stenting of Supra-aortic Branch Vessels for Residual Type A Dissection.

The purpose of this report was to describe the exclusion of the false lumen in a residual type A aortic dissection (TAAD) by the deployment of 2 covered stents: one in the right common carotid artery (RCCA) and one in the left subclavian artery (LSA). A 77-year-old female, already treated with ascending aorta replacement for acute TAAD, was referred to our center for a 97-mm post-dissection arch aneurysm. A computed tomography angiography (CTA) showed false lumen patency by reperfusion from secondary tears located at the level of RCCA and LSA. No primary aortic tear was noted. Under local anesthesia and by transfemoral percutaneous approach, the tears at the level of RCCA and LSA were covered by a 9-mm Viabahn stent graft (Gore, Flagstaff, AZ), and a 10-mm V-12 stent graft (Maquet, Rastatt, Germany), respectively. The false lumen was finally occluded by the deployment of a 6-mm vascular plug at the level of LSA re-entry tear, by left transbrachial puncture. The procedure was completed uneventfully. Twelve-month CTA showed exclusion of the false lumen, patency of all supra aortic trunks, and initial shrinkage of the aneurysm. Spot stenting of secondary re-entry tears, already described for visceral branches, seems to be safe and effective also for supra-aortic trunks in selected patients.

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications.

OBJECTIVES: To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS: Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS: Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS: ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy.

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC).

PURPOSE: To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). METHODS: A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. RESULTS: In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). CONCLUSION: Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Cystic adventitial disease of the popliteal artery. A case report and review of the literature.

Cystic adventitial disease is a rare form of non-atherosclerotic stenosis and one of the main causes of claudication in young and middle-aged men. Approximately 200 case reports are available in the literature to date. It is generally located in the popliteal artery, although it may be found in other arteries and even in veins. The aetiology is still unclear: most authors believe that the cyst may originate from a synovial ganglion close to the adjacent hip joint capsule. Patients affected by adventitial cystic degeneration are often young male non-smokers with intermittent calf claudication. The treatment of choice is surgical removal of the cyst or reconstruction with autologous vein or synthetic graft interposition. Percutaneous US-guided cystic aspiration is a recent easy and safe alternative method for treating the disease but may result in local recurrence. We report the case of a 51-year-old male patient with clinically intermittent claudication of the right leg. The arteriogram showed complete occlusion of the right proximal popliteal artery and no evidence of atherosclerotic disease in other vessels. The diagnosis was made at the time of surgery. Surgical exploration revealed a gelatinous material involving the popliteal artery. It was excised and evacuated and a segment of greater saphenous vein interposed. Ultrasound examination 12 months later showed graft patency and absence of local recurrence.