Elective Surgical Repair of Popliteal Artery Aneurysms with Posterior Approach vs. Endovascular Exclusion: Early and Long Term Outcomes of Multicentre PARADE Study.

OBJECTIVE: The aim of this study was compare elective surgical repair of popliteal artery aneurysms (PAAs) via a posterior approach vs. endovascular exclusion, analysing early and five year outcomes in a multicentre retrospective study. METHODS: Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs that underwent open repair with posterior approach or endovascular repair in 37 centres was investigated. An aneurysm length of ≤ 60 mm was considered the only inclusion criterion. A total of 605 patients were included; 440 PAAs (72.7%) were treated via a posterior approach (open group) and the remaining 165 PAAs (27.3%) were treated using covered stents (endo group). Continuous data were expressed as median with interquartile range. Thirty day outcomes were assessed and compared. At follow up, primary outcomes were freedom from re-intervention, secondary patency, and amputation free survival. Secondary outcomes were survival and primary patency. Estimated five year outcomes were compared using log rank test. RESULTS: At 30 days, no differences were found in major morbidity, mortality, graft occlusion, or re-interventions. Three patients (0.7%) in the open group experienced nerve injury. The overall median duration of follow up was 32.1 months. At five year follow up, freedom from re-intervention was higher in the open group (82.2% vs. 68.4%; p = .021). No differences were observed in secondary patency (open group 90.7% vs. endo group 85.2%; p = .25) or amputation free survival (open group 99.0% vs. endo group 98.4%; p = .73). A posterior approach was associated with better survival outcomes (84.4% vs. 79.4%; p = .050), and primary patency (79.8% vs. 63.8%; p = .012). CONCLUSION: Early and long term outcomes following elective repair of PAAs measuring ≤ 60 mm via a posterior approach or endovascular exclusion seem comparable. Nerve injury might be a rare but potential complication for those undergoing open surgery. Endovascular repair is associated with more re-interventions.

Endograft Thrombosis as an Indication for Open Conversion after Endovascular Aneurysm Repair in a Multicenter Experience over 25 Years.

BACKGROUND: To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. METHODS: This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The end points were as follows: 30-day mortality and major postoperative complications. Follow-up data included survival and aortic-related complications. RESULTS: Sixteen patients (mean age: 68.6 ± 8.5 years) were included. The median elapsed time between EVAR and OC was 26.46 months (interquartile range: 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, and complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were aorto-bi-iliac grafts in 8 cases (50%), 7 aortobifemoral bypass grafts (43.8%), and 1 aortoaortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). The overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years, and 41.7% at 3 years. CONCLUSIONS: OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seems to be associated with high short-term mortality.

Multicentre experience of antegrade thoracic endovascular aortic repair for the treatment of thoracic aortic diseases.

OBJECTIVES: The goal of this multicentre retrospective cohort study was to evaluate technical success and early and late outcomes of thoracic endovascular repair (TEVAR) with grafts deployed upside down through antegrade access, to treat thoracic aortic diseases. METHODS: Antegrade TEVAR operations performed between January 2010 and December 2021 were collected and analysed. Both elective and urgent procedures were included. Exclusion criteria were endografts deployed in previous or concomitant surgical or endovascular repairs. RESULTS: Fourteen patients were enrolled; 13 were males (94%) with a mean age of 71 years (interquartile range 62; 78). Five patients underwent urgent procedures (2 ruptured aortas and 3 symptomatic patients). Indications for treatment were 8 (57%) aneurysms/pseudoaneurysms, 3 (21%) dissections and 3 (21%) penetrating aortic ulcers. Technical success was achieved in all procedures. Early mortality occurred in 4 (28%) cases, all urgent procedures. Median follow-up was 13 months (interquartile range 1; 44). Late deaths occurred in 2 (20%) patients, both operated on in elective settings. The first died at 19 months of aortic-related reintervention; the second died at 34 months of a non-aortic-related cause. Two patients (14%) underwent aortic-related reinterventions for late type I endoleak. The survival rate of those having the elective procedures was 100%, 84% and 67% at 12, 24 and 36 months, respectively. Freedom from reintervention was 92%, 56% and 56% at 12, 24 and 36 months, respectively. CONCLUSIONS: Antegrade TEVAR can seldom be considered an alternative when traditional retrograde approach is not feasible. Despite good technical success and few access-site complications, this study demonstrates high rates of late type I endoleak and aortic-related reinterventions.

Plug-Based Embolization Techniques of Aortic Side Branches during Standard and Complex Endovascular Aortic Repair.

Vascular plugs are an evolving family of vessel occluders providing a single-device embolization system for large, high-flow arteries. Nitinol mesh plugs and polytetrafluoroethylene membrane plugs are available in different configurations and sizes to occlude arteries from 3 to 20 mm in diameter. Possible applications during complex endovascular aortic procedures are aortic branch embolization to prevent endoleak or to gain an adequate landing zone, directional branch occlusion, and false lumen embolization in aortic dissection. Plugs are delivered through catheters or introducers, and their technical and clinical results are comparable to those of coil embolization. Plugs are more accurate than coils as repositionable devices, less prone to migration, and have fewer blooming artifacts on postoperative computed tomography imaging. Their main drawback is the need for larger delivery systems. This narrative review describes up-to-date techniques and technology for plug embolization in complex aortic repair.

Comparative outcomes of aortobifemoral bypass with or without previous endovascular kissing stenting of the aortoiliac bifurcation.

OBJECTIVE: The aim of this multicenter national study was to compare the outcomes of primary open surgery by aorto-bifemoral bypass (ABFB) with those performed after a failed endovascular treatment (EVT) by kissing stent technique for complex aortoiliac occlusive disease (AIOD) lesions (TransAtlantic Inter-Society Consensus [TASC] II C and D). METHODS: All consecutive ABFB cases carried out at 12 vascular surgery centers between 2016 and 2021 were retrospectively collected and analyzed. Data included patients' baseline demographics and clinical characteristics, procedural details, perioperative outcomes, and follow-up results (survival, patency, amputation). The study cohort was divided into two groups based on indications for ABFB: primary treatment vs secondary treatment after EVT failure. RESULTS: Overall, 329 patients underwent ABFB during the study period (71% males; mean age, 64 years), of which 285 were primary treatment and 44 were after prior EVT. At baseline, no significant differences were found between study groups in demographics and clinical characteristics. TASC C and D lesions were similarly represented in the study groups (TASC C: 22% vs 78%; TASC D: 16% vs 84%). No major differences were found between study groups in terms of procedural details, early mortality, and perioperative complications. At 5 years, primary patency rates were significantly higher for primary ABFB (88%; 95% confidence interval [CI], 93.2%-84%) as compared with ABFB after prior EVT (69%; 95% CI 84.9%-55%; log rank P value < .001); however, the 5-year rates of secondary patency (100% vs 95%; 95% CI, 100%-86%) and limb salvage (97%; 95% CI, 99%-96 vs 97%; 95% CI, 100%-94%) were similar between study groups. CONCLUSIONS: Surgical treatment of TASC C/D AIOD with ABFB seems to be equally safe and effective when performed after prior EVT, although primary ABFB seemed to have higher primary patency rates. Despite the need for more frequent reinterventions, secondary patency and limb salvage rates were similar. However, future large prospective trials are required to confirm these findings.

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM).

The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended.

An International Expert-Based CONsensus on Indications and Techniques for aoRtic balloOn occLusion in the Management of Ruptured Abdominal Aortic Aneurysms (CONTROL-RAAA).

OBJECTIVE: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA). METHODS: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts' responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final study report. The consistency of each round's answers was also graded using Cohen's kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa. RESULTS: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making. CONCLUSIONS: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology. CLINICAL IMPACT: This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge.

Twenty-Five Year Multicentre Experience of Explantation of Infected Abdominal Aortic Endografts.

We report a multicenter experience of open conversions (OC) for aortic endograft infections (AEI). We retrospectively analyzed all patients who underwent OC for AEI after endovascular aneurysm repair (EVAR), from 1997 to 2021 in 12 Italian centers. The endpoints were as follows: mortality (30-days, in-hospital), major postoperative complications. Follow-up data included: survival, aortic-related complications, infection persistence or reoccurrence. Fifty-eight patients (mean age: 73.8 ± 6.6 years) were included. Median time from EVAR to OC was 14 months (interquartile range 7-45). Thirty-five patients (60.3%) were symptomatic at presentation. Aortic reconstruction was anatomic in 32 patients (55.2%), extra-anatomic in 26 (44.8%). Thirty-day mortality was 31% (18/58). Six additional patients died after 30 days during the same hospitalization (in-hospital mortality: 41.4%). Most common post-operative complications included respiratory failure (38.6%) and renal insufficiency (35.1%). During 28.1 ± 4 months follow-up, 4 aneurysm-related deaths were recorded. Infection re-occurred in 29.4% of the patients. Estimated survival was 50% at 1 year, and 30% at 5 years, and was significantly lower for patients who underwent extra-anatomic reconstructions (37 vs 61% at 1 year, 16 vs 45% at 5 years; log-rank P = .021). OC for AEI is associated with high early mortality. The poor mid-term survival is influenced by aortic complications and infection re-occurrence.

Emergent endovascular treatment options for thoracoabdominal aortic aneurysm.

For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade.

Predicting early mortality following single-stage coronary artery or valve surgery and carotid endarterectomy.

BACKGROUND: Surgical management of coexisting cardiac disease and extra-cranial carotid artery disease is a controversial area of debate. Thus, in this challenging scenario, risk stratification may play a key role in surgical decision making. AIM: To report the results of single-stage coronary/valve surgery (CVS) and carotid endarterectomy (CEA), and to identify predictive factors associated with 30-day mortality. METHODS: This was a multicenter, retrospective study of prospectively maintained data from three academic tertiary referral hospitals. For this study, only patients treated with single-stage CVS, meaning coronary artery bypass surgery or valve surgery, and CEA between March 1, 2000 and March 30, 2020, were included. Primary outcome measure of interest was 30-day mortality. Secondary outcomes were neurologic events rate, and a composite endpoint of postoperative stroke/death rate. RESULTS: During the study period, there were 386 patients who underwent the following procedures: CEA with isolated coronary artery bypass graft in 243 (63%) cases, with isolated valve surgery in 40 (10.4%), and combination of coronary artery bypass grafting and valve surgery in 103 (26.7%). Postoperative neurologic event rate was 2.6% (n = 10) which includes 5 (1.3%) transient ischemic attacks and 5 (1.3%) strokes (major n = 3, minor n = 2). The 30-day mortality rate was 3.9% (n = 15). Predictors of 30-day mortality included preoperative left heart insufficiency (odds ratio [OR]: 5.44, 95% confidence interval [CI]: 1.63-18.17, p = .006), and postoperative stroke (OR: 197.11, 95% CI: 18.28-2124.93, p < .001). No predictor for postoperative stroke and for composite endpoint was identified. CONCLUSIONS: Considering that postoperative stroke rate and mortality was acceptably low, single-stage approach is an effective option in such selected high-risk patients.

Occult endoleaks revealed during open conversions after endovascular aortic aneurysm repair in a multicenter experience.

BACKGROUND: An occult endoleak (OE) may be the underlying cause of aneurysm sac expansion after endovascular aneurysm repair (EVAR). The aim of this study is to describe intraoperative findings of OE during surgical endograft explantations. METHODS: This is a retrospective, multicenter analysis of all open conversions (OC) after EVAR from 1997 to 2020 in 12 vascular centers. We excluded patients with a preoperative diagnosis of endograft infection, endograft thrombosis, and thoracic-EVAR. An OE was defined as an endoleak revealed during OC not shown on preoperative imaging, which was likely the real cause for sac enlargement. We reported the number of OE, and we described the type of OE in relation to the initial alleged or associated endoleak. A separate analysis of patients with an initial diagnosis of endotension was also performed. RESULTS: An OE was found in 32/255 patients (12.5%). In the 78.1% of the cases (25/32) a type II endoleak hid a type I or III endoleak. Endotension was the initial diagnosis of 26/255 patients (10.2%). In 4/26 cases (15.4%), a type I or II OE was revealed. In 5/26 cases (19.2%) an endograft infection was found intraoperatively. In 2/26 cases we found an angiosarcoma. Fifteen cases of endotension (57.7%) remained unexplained. CONCLUSIONS: OE represent a not negligible cause of EVAR failure. A type II endoleak associated with sac enlargement may actually conceal a higher-flow endoleak. In most of the cases, the initial diagnosis of endotension remains unexplained. However, endotension sometimes conceals severe underlying pathologies such as infections.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE).

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Long-term outcomes of endovascular aortic repair with flared iliac limb endografts in patients with abdominal aortic aneurysm and aneurysmal common iliac arteries.

BACKGROUND: The aim of this study was to evaluate the long-term outcomes of endovascular aneurysm repair with flared iliac limb grafts in patients with abdominal aortic aneurysm (AAA) and aneurysmal common iliac arteries (CIAs). METHODS: This is a multicenter, retrospective, observational cohort study that involves four tertiary referral hospitals between May 1, 2005, and April 30, 2019. Primary outcomes were freedom from aneurysm-related mortality (ARM), and freedom from iliac-related reintervention. RESULTS: We studied 995 aneurysmal iliac limbs in 795 (85.2%) patients who met the inclusion criteria. Median AAA diameter was 55mm (IQR: 51-60). Early mortality occurred in 3 (0.4%) patients. The median of follow-up time was 52 months (IQR: 26-88). Estimated freedom from ARM was 99±0.002% (95% CI: 99-99.9) at 1 year, and 99±0.004% (95% CI: 97.9-99.6) at 5-years. Chronic obstructive pulmonary disease (HR=6.4, 95% CI: 1.7-24.0, P=0.006), chronic kidney disease (HR=5.5, 95% CI: 1.4-21.9, P=0.016), and the presence of an aneurysmal left CIA (HR=5.3, 95% CI: 1.0.5-27.4, P=0.044) was associated with ARM. There were 42 (7.3%) late iliac-related events (limb occlusion, N.=5; iliac-related endoleaks, N.=37). Estimated freedom from iliac-related reintervention was 98±0.003% (95% CI: 97-99) at 1 year, and 95±0.01% (95% CI: 92.7-96.7) at 5-years, which was associated with an aneurysmal right CIA (HR=2.2, 95% CI: 1.3-3.9; P=0.005), and age ≥78 years (HR=1.9, 95% CI: 1.01-1.3; P=0.039). CONCLUSIONS: EVAR flared iliac limb grafts showed a high rate of freedom from ARM and a low reintervention rate. Owing to these results, it can be a durable and stable alternative for patients aged >78 years.

Multicenter comparison between open conversions and semi-conversions for late endoleaks after endovascular aneurysm repair.

OBJECTIVE: The aim of this study is to compare early and follow-up outcomes of late open conversions (LOC, with complete or partial endograft explantation) and semi-conversions (SC, with endograft preservation) after endovascular aneurysm repair in a multicenter experience. METHODS: All LOC and SC performed from 1997 to 2020 in 11 vascular centers were compared. Endograft infections or thrombosis were excluded. Primary endpoints were early mortality and long-term survival estimates. Secondary endpoints were differences in postoperative complication rates and conversion-related complications during follow-up. RESULTS: In the considered period, 347 patients underwent surgery for endovascular aneurysm repair complications. Among these, 270 were operated on for endoleaks (222 LOC, 48 SC). The two groups were homogeneous in terms of American Society of Anesthesiologists score (LOC, 3.2 ± 0.7; SC, 3 ± 0.5; P = .128) and main endograft characteristics (suprarenal fixation, bifurcated/aorto-uni-iliac configuration). The mean age was 75 ± 8 years for LOC and 79 ± 7 years for SC (P = .009). Reasons for LOC were: 62.2% (138/222) type I endoleak, 21.6% (48/222) type II endoleak, 7.7% (17/222) type III endoleak, and 8.5% (19/222) endotension. Indications for SC were: 64.6% (31/48) type II endoleak, 33.3% (16/48) type I endoleak, and 2.1% (1/48) type III endoleak. Thirty-day mortality was 12.2% (27/222) in the LOC group, and 10.4% (5/48) in the SC group (P = .73). Postoperative complication rate was higher in the LOC group (45.5% vs 29.2%; P = .04). The estimated survival rate after LOC was 80% at 1 year and 64% at 5 years; after SC, it was 72% at 1 year and 37% at 5 years (log-rank P = .01). During the median follow-up of 21.5 months (interquartile range, 2.4-61 months), an endoleak after SC was found in the 38.3% of the cases; sac growth was recorded in the 27.7% of SC patients. CONCLUSIONS: SC has an early benefit over LOC in terms of reduced postoperative complications but has a significantly inferior mid-term survival. The high rates of persistent and/or recurrent endoleaks reduce SC durability.

Combined endovascular and open treatment to prevent increase in afterload in anastomotic pseudoaneurysm and aortobronchial fistula after surgery for aortic coarctation.

We report the treatment of a patient who had presented with hemoptysis due to an aortobronchial fistula from an anastomotic pseudoaneurysm after extra-anatomic bypass for aortic coarctation. An aortobronchial fistula can often result from an aortic pseudoaneurysm and is associated with high mortality if not treated. We decided to use combined endovascular and open surgical treatment and obtained a satisfactory intraoperative result. The perioperative outcome and first follow-up visit were favorable. In recent years, endovascular repair of pathologic aortic conditions has increased; thus, we have placed the present case within the context of the relevant medical literature.

Investigating the Link between Alpha-1 Antitrypsin Deficiency and Abdominal Aortic Aneurysms.

BACKGROUND: Alpha-1-Antitrypsin (AAT) is one of the major plasmatic protease inhibitors. In the last decade, an association between Alpha-1-Antitrypsin Deficiency (AATD) and Abdominal Aortic Aneurysms (AAA) has been hypothesized. Multiple factors may be involved in AAA's etiopathogenesis, and an underlying structural defect of the extracellular matrix (ECM) is always present. AATD could be a reasonable risk factor for AAA because it is related to protease/antiprotease imbalance and enhanced ECM degradation of the vessel wall. METHODS: We performed genotyping of 138 patients hospitalized in the Vascular Surgery Division of the ASST-Spedali Civili di Brescia, Italy, for nontraumatic rupture of AAA. The second purpose was to observe the distribution of main nongenetic risk factors for AAA between patients with and without AATD. RESULTS: Out of 138 patients, 22 were found with AATD: 16 MS, 1 SS, 3 MZ, and 2 with a new rare AAT variant. When compared to the general Italian population, our cohort's frequency of deficient S allele was significantly higher (7.8 vs. 2.2% respectively, P < 0.01), whereas the deficient Z allele was similar (1.1 vs. 1.3% respectively, P > 0.05). Although we found no differences in age, gender, hypertension, diabetes, and smoke habits between AAA patients with and without AATD, hyperlipidemia was significantly less frequent in patients with AATD (46.4 vs. 12.5% respectively, P < 0.05). CONCLUSIONS: In our AAA patients' cohort, the S allele frequency was higher than in the general Italian population. Our results support the hypothesis that AATD might be a risk factor for AAA.

Regional Survey in Lombardy, Northern Italy, on Vascular Surgery Intervention Outcomes During The COVID-19 Pandemic.

OBJECTIVE: The characteristics and outcomes of patients undergoing vascular surgery hospitalised and managed in Lombardy are described with a comparison of patients tested positive for COVID-19 (CV19-pos) vs. those tested negative (CV19-neg). METHODS: This was a multicentre, retrospective, observational cohort study which involved all vascular surgery services in Lombardy, Northern Italy. Data were retrospectively merged into a combined dataset covering the nine weeks of the Italian COVID-19 pandemic phase 1 (8 March 2020 to 3 May 2020). The primary outcome was freedom from in hospital death, secondary outcomes were re-thrombosis rate after peripheral revascularisation, and freedom from post-operative complication. RESULTS: Among 674 patients managed during the outbreak, 659 (97.8%) were included in the final analysis: 121 (18.4%) were CV19-pos. CV19-pos status was associated with a higher rate of complications (OR 4.5; p < .001, 95% CI 2.64 - 7.84), and a higher rate of re-thrombosis after peripheral arterial revascularisation (OR 2.2; p = .004, 95% CI 1.29 - 3.88). In hospital mortality was higher in CV19-pos patients (24.8% vs. 5.6%; OR 5.4, p < .001;95% CI 2.86 - 8.92). Binary logistic regression analysis identified CV19-pos status (OR 7.6; p < .001, 95% CI 3.75 - 15.28) and age > 80 years (OR 3.2; p = .001, 95% CI 1.61 - 6.57) to be predictors of in hospital death. CONCLUSION: In this experience of the vascular surgery group of Lombardy, COVID-19 infection was a marker of poor outcomes in terms of mortality and post-operative complications for patients undergoing vascular surgery treatments.

Differences in hub and spoke vascular units practice during the novel Coronavirus-19 (COVID-19) outbreak in Lombardy, Italy.

BACKGROUND: To highlight differences in clinical practice among referral (hub, HH) or satellite (spoke, SH) hospital vascular surgery units (VSUs) in Lombardy, during the COVID-19 pandemic "phase 1" period (March 8 - May 3, 2020). METHODS: The Vascular Surgery Group of Regione Lombardia Register, a real-word, multicenter, retrospective register was interrogated. All patients admitted with vascular disease were included. Patients' data on demographics, COVID-19 positivity, comorbidities and outcomes were extrapolated. Two cohorts were obtained: patients admitted to HH or SH. Primary endpoint was 30-day mortality rate. Secondary outcomes were 30-day complications and amputation (in case of peripheral artery disease [PAD]) rates. Univariate and multivariate analysis were used to compare HH and SH groups and predictors of poor outcomes. RESULTS: During the study period, 659 vascular patients in 4 HH and 27 SH were analyzed. Among these, 321 (48.7%) were admitted to a HH. No difference in COVID-19 positive patients was described (21.7% in HH vs. 15.9% in SH; P=0.058). After 30 days from intervention, HH and SH experienced similar mortality and no-intervention-related complication rate (12.1% vs. 10.0%; P=0.427 and 10.3% vs. 8.3%; P=0.377, respectively). Conversely, in HH postoperative complications were higher (23.4% vs. 16.9%, P=0.038) and amputations in patients treated for PAD were lower (10.8% vs. 26.8%; P<0.001) than in SH. Multivariate analysis demonstrated in both cohorts COVID-19-related pneumonia as independent predictor of death and postoperative complications, while age only for death. CONCLUSIONS: HH and SH ensured stackable results in patients with vascular disease during COVID-19 "phase 1." Despite this, poor outcomes were observed in both HH and SH cohorts, due to COVID-19 infection and its related pneumonia.

Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy.

Importance: There are limited data on mortality and complications rates in patients with coronavirus disease 2019 (COVID-19) who undergo surgery. Objective: To evaluate early surgical outcomes of patients with COVID-19 in different subspecialties. Design, Setting, and Participants: This matched cohort study conducted in the general, vascular and thoracic surgery, orthopedic, and neurosurgery units of Spedali Civili Hospital (Brescia, Italy) included patients who underwent surgical treatment from February 23 to April 1, 2020, and had positive test results for COVID-19 either before or within 1 week after surgery. Gynecological and minor surgical procedures were excluded. Patients with COVID-19 were matched with patients without COVID-19 with a 1:2 ratio for sex, age group, American Society of Anesthesiologists score, and comorbidities recorded in the surgical risk calculator of the American College of Surgeons National Surgical Quality Improvement Program. Patients older than 65 years were also matched for the Clinical Frailty Scale score. Exposures: Patients with positive results for COVID-19 and undergoing surgery vs matched surgical patients without infection. Screening for COVID-19 was performed with reverse transcriptase-polymerase chain reaction assay in nasopharyngeal swabs, chest radiography, and/or computed tomography. Diagnosis of COVID-19 was based on positivity of at least 1 of these investigations. Main Outcomes and Measures: The primary end point was early surgical mortality and complications in patients with COVID-19; secondary end points were the modeling of complications to determine the importance of COVID-19 compared with other surgical risk factors. Results: Of 41 patients (of 333 who underwent operation during the same period) who underwent mainly urgent surgery, 33 (80.5%) had positive results for COVID-19 preoperatively and 8 (19.5%) had positive results within 5 days from surgery. Of the 123 patients of the combined cohorts (78 women [63.4%]; mean [SD] age, 76.6 [14.4] years), 30-day mortality was significantly higher for those with COVID-19 compared with control patients without COVID-19 (odds ratio [OR], 9.5; 95% CI, 1.77-96.53). Complications were also significantly higher (OR, 4.98; 95% CI, 1.81-16.07); pulmonary complications were the most common (OR, 35.62; 95% CI, 9.34-205.55), but thrombotic complications were also significantly associated with COVID-19 (OR, 13.2; 95% CI, 1.48-∞). Different models (cumulative link model and classification tree) identified COVID-19 as the main variable associated with complications. Conclusions and Relevance: In this matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without COVID-19. These data suggest that, whenever possible, surgery should be postponed in patients with COVID-19.