The Use of Pressure Recording Analytical Method in Patients Undergoing Endovascular Repair for Abdominal Aortic Aneurysm: The Impact on Clinical Decisions for the Appropriate Postoperative Setting and Cost-effective Analysis.

OBJECTIVE: To analyze the use of the Pressure Recording Analytical Method (PRAM), an hemodynamic monitoring system, in evaluating intraoperative and postoperative hemodynamic instability in patients undergoing endovascular repair for abdominal aortic aneurysm, and to evaluate if the decision to refer patients to a ordinary ward or to a Cardiac Step-Down Unit (CSDU) after the intervention on the basis of intraoperative hemodynamic monitoring could be more cost-effective. MATERIALS AND METHODS: After preoperative clinical evaluation, 44 patients were divided in this non-randomised study into two groups according to their postoperative destination: Group 1-ward (N=22) and Group 2-CSDU (N=22). All patients underwent monitoring with PRAM during the intervention and in the 24 postoperative hours, measuring several indices of myocardial contractility and other hemodynamic variables. RESULTS: According to the variability of two parameters, Stroke Volume Variation and Pulse Pressure Variation, patients were classified as stable or unstable. Unstable patients showed a significant alteration in several hemodynamic indices, in comparison to stable ones. According to the intraoperative monitoring, eight high risk patients could have been sent to an ordinary ward due to their stability, with a reduction in the improper use of CSDU and, consequently, in costs. CONCLUSIONS: Hemodynamic monitoring with PRAM can be useful in these patients, both for intraoperative management and for the choice of the more appropriate postoperative setting, possibly reducing the improper use of CSDU for hemodynamically stable patients who are judged to be at high risk preoperatively, and re-evaluating low surgical risk patients with an unstable intraoperative pattern, with a possible reduction in costs.

Tuning Local Order in Starch Nanoparticles Exploiting Nonsolvency with "Green" Solvents.

Starch is a renewable biopolymer that can be sourced from agricultural waste and used to produce nanoparticles (SNPs). In particular, amorphous SNPs have potential application in numerous fields, including the consolidation of weakened paintings in the cultural heritage preservation. Starch dissolution followed by nanoprecipitation in nonsolvents is an advantageous synthetic route, but new methodologies are needed to feasibly control the physicochemical properties of the SNPs. Here, we explored nanoprecipitation by nonsolvency using a set of "green" solvents to obtain amorphous SNPs, rather than starch nanocrystals already reported in the literature. The effect of the nonsolvent on the ordering of polymer chains in the obtained SNPs was studied. The recovery of local order (e.g., isolated V-type helices) after dissolution was shown to depend on the type of solvents used in the dissolution and precipitation steps, while long-range order (extended arrays of helices) is lost. Aqueous dispersions of the SNPs provided effective consolidation of powdery painted layers, showing that the selection of particle synthetic routes can be dictated by sustainability and scalability criteria. These "green" formulations are candidates as new consolidants in art preservation, and the possibility of tuning local order in amorphous starch assemblies might also impact fields like food chemistry, pharmaceutics, and nanocomposites, where SNPs with tunable amorphousness are more advantageous than nanocrystals.

An Augmented Vision of Our Medical and Surgical Future, Today?

Incorporating consumer electronics into the operating room, we evaluated the Apple Vision Pro (AVP) during limb preservation surgeries, just as we evaluated Google Glass and FaceTime more than a decade ago. Although AVP's real-time mixed-reality data overlay and controls offer potential enhancements to surgical precision and team communication, our assessment recognized limitations in adapting consumer technology to clinical environments. The initial use facilitated intraoperative decision-making and educational interactions with trainees. The current mixed-reality pass-through resolution allows for input but not for highly dexterous surgical interactions. These early observations indicate that while AVP may soon improve aspects of surgical performance and education, further iteration, evaluation, and experience are needed to fully understand its impact on patient outcomes and to refine its integration into clinical practice.

Tailoring the properties of poly(vinyl alcohol) "twin-chain" gels via sebacic acid decoration.

HYPOTHESIS: The development of gels capable to adapt and act at the interface of rough surfaces is a central topic in modern science for Cultural Heritage preservation. To overcome the limitations of solvents or polymer solutions, commonly used in the restoration practice, poly(vinyl alcohol) (PVA) "twin-chain" polymer networks (TC-PNs) have been recently proposed. The properties of this new class of gels, that are the most performing gels available for Cultural Heritage preservation, are mostly unexplored. This paper investigates how chemical modifications affect gels' structure and their rheological behavior, producing new gelled systems with enhanced and tunable properties for challenging applications, not restricted to Cultural Heritage preservation. EXPERIMENTS: In this study, the PVA-TC-PNs structural and functional properties were changed by functionalization with sebacic acid into a new class of TC-PNs. Functionalization affects the porosity and nanostructure of the network, changing its uptake/release of fluids and favoring the uptake of organic solvents with various polarity, a crucial feature to boost the versatility of TC-PNs in practical applications. FINDINGS: The functionalized gels exhibited unprecedented performances during the cleaning of contemporary paintings from the Peggy Gugghenheim collection (Venice), whose restoration with traditional solvents and swabs would be difficult to avoid possible disfigurements to the painted layers. These results candidate the functionalized TC-PNs as a new, highly promising class of gels in art preservation.

A Novel Transmittance Vis-NIR Hyper-Spectral Imaging Scanner for Analysis of Photographic Negatives: A Potential Tool for Photography Conservation.

This work illustrates a novel prototype of a transmittance hyperspectral imaging (HSI) scanner, operating in the 400-900 nm range, and designed on purpose for non-invasive analysis of photographic materials, such as negatives, films and slides. The instrument provides high-quality spectral data and high-definition spectral images on targets of small size (e.g., 35 mm film strips) and is the first example of HSI instrumentation specifically designed for applications in the photographic conservation field. The instrument was tested in laboratory and on a set of specimens selected from a damaged photographic archive. This experimentation, though preliminary, demonstrated the soundness of a technical approach based on HSI for large-scale spectroscopic characterization of photographic archival materials. The obtained results encourage the continuation of experimentation of HSI as an advanced tool for photography conservation.

Conformational changes and location of BSA upon immobilization on zeolitic imidazolate frameworks.

The location and the conformational changes of proteins/enzymes immobilized within Metal Organic Frameworks (MOFs) are still poorly investigated and understood. Bovine serum albumin (BSA), used as a model protein, was immobilized within two different zeolitic imidazolate frameworks (ZIF-zni and ZIF-8). Pristine ZIFs and BSA@ZIFs were characterized by X-ray diffraction, small-angle X-ray scattering, scanning electron microscopy, confocal laser scanning microscopy, thermogravimetric analysis, micro-FTIR and confocal Raman spectroscopy to characterize MOFs structure and the protein location in the materials. Moreover, the secondary structure and conformation changes of BSA after immobilization on both ZIFs were studied with FTIR. BSA is located both in the inner and on the outer surface of MOFs, forming domains that span from the micro- to the nanoscale. BSA crystallinity (ß-sheets + α-helices) increases up to 25 % and 40 % due to immobilization within ZIF-zni and ZIF-8, respectively, with a consequent reduction of ß-turns.

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.

A case report of pudendal arteries angioplasty with sirolimus drug-coated balloon and drug-eluting stent associated with intracavernous autologous peripheral blood mononuclear cells injection for untreatable vasculogenic erectile dysfunction.

BACKGROUND: Erectile dysfunction (ED) is a prevalent health problem that seriously impacts men's quality of life. The potential treatment of ED by percutaneous approach has emerged with valid angiographic results and a significant improvement in symptoms and quality of life. In addition, cell-based regenerative therapies aiming at enhancing neovascularization have been successfully performed with peripheral blood mononuclear cells (PBMNCs) in diabetic patients affected by critical limb ischaemia. CASE SUMMARY: We report a case of a young insulin dependent (ID) diabetic patients who suffered of severe vasculogenic erectile dysfunction associated with a poor response for more than 1 year to oral phosphodiesterase-5 inhibitors (PDE5i) and intracavernous (IC) phosphodiesterase type 1 (PDE1) therapy. At selective angiography of the pelvic district, a severe atherosclerotic disease of the internal iliac and pudendal artery was evident with absence of distal vascularization of the cavernous bodies. The patient was treated by mechanical revascularization with drug-coated balloon and drug-eluting stent placement associated with IC injection of autologous PBMNCs. Immediate and 1-year clinical and angiographic follow-up are described. DISCUSSION: Percutaneous revascularization with drug-coated balloon and drug-eluting stent associated with IC autologous PBMNCs cells injection is a safe and effective procedure to restore normal erectile function in diabetic patients affected by severe vasculogenic ED not responding to conventional oral drug therapies.

Jin Shofu Starch Nanoparticles for the Consolidation of Modern Paintings.

Matte, porous, and weakly bound paint layers, typically found in modern/contemporary art, represent an unsolved conservation challenge. Current conservation practice relies on synthetic or natural adhesives that can alter dramatically the optical properties of paints. Alternatively, we propose a novel nanostructured consolidant based on starch, a renewable natural polymer. We synthesized starch nanoparticles (SNPs) to boost their penetration into the porous painted layers; upon solvent evaporation, the particles were expected to adhere to the pigments thanks to their large surface area and abundant -OH groups. The SNPs were formulated through a bottom-up approach, where gluten-removed Jin Shofu wheat starch was gelatinized and then precipitated in a nonsolvent. The low gelatinization temperature of wheat starch is likely key to favor disassembly in alkali and reassembly in the nonsolvent. The synthesis conditions can be tuned to obtain amorphous SNPs of ca. 50 nm with acceptable polydispersity. The particles swell in water to form nanosized gel-like fractal domains (as observed with cryogenic electron microscopy), formed by the organization of smaller units in polymer-rich and -deficient regions. Aqueous and hydroalcoholic particles' dispersions were assessed on aged ultramarine blue mock-ups that mimic degraded modern/contemporary paints. The consolidation effectiveness was evaluated with a specifically designed in-house protocol: the SNPs distribute across the paint section and strongly increase pigments' cohesion while preserving the original optical properties of the painted layer, as opposed to dispersions of bulk starch that simply accumulate on the paint surface, forming superficial glossy films. The Jin Shofu SNPS proved to be a new promising tool for the consolidation of weakened paintings, opening perspectives in the formulation and application of consolidants for modern and contemporary art.

A pilot study of the enhanced recovery after surgery protocol in aortic surgery.

OBJECTIVE: We tested the outcomes with the use of the enhanced recovery after surgery protocol in patients who had undergone open abdominal aortic aneurysm (AAA) repair (enhanced recovery after vascular surgery [ERAVS] protocol). We compared them with those obtained for patients who had undergone endovascular aneurysm repair (EVAR) and for a historical control group of standard open AAA repair in a prospective, single-center pilot study. METHODS: From June to December 2019, all patients who were candidates for open AAA repair at our department were enrolled in the ERAVS protocol (ERAVS group; 17 patients). During the same period, 18 patients had undergone EVAR (EVAR group). The historical control group of standard open AAA repair included 32 patients who had undergone surgery during the 6 months before the study period (standard protocol open repair [OR] group). The three groups were compared on an "on-treatment" basis (prospectively for the ERAVS and EVAR groups and retrospectively for the OR group) in terms of the time to discharge (TTD), interval to the resumption of oral intake, time to ambulation, resumption of bowel function, and postoperative pain. Comparisons were performed using the one-way analysis of variance test, Tukey post hoc test for quantitative data, and χ2 test for qualitative data. RESULTS: The ERAVS protocol was successfully applied for all but one patient (feasibility rate, 94%). The mean TTD was 5.1 days in the ERAVS group, 3.5 days in the EVAR group, and 8.4 days in the OR group [P < .001; F(2,64) = 11.3], with a significant difference between the OR and ERAVS and EVAR groups (P = .1 and P < .001, respectively) but not between the EVAR and ERAVS groups (P = .4). The ERAVS group had intervals to the resumption of oral intake and ambulation similar to those of the EVAR group. In contrast, these were significantly longer for the OR group. The mean time to the resumption of bowel function was similar in the ERAVS and OR groups (2.6 and 2.9 days, respectively; P = .6). In the ERAVS group, the mean value of the maximum referred pain using the numeric rating scale was 3.75 (range, 1-6). The corresponding values for the EVAR and OR groups were 2.6 (range, 0-6) and 4.9 [range, 1-8; F(2,62) = 15.4; P < .001]. The post hoc test showed a significant difference between the OR group and the ERAVS and EVAR group (P = .01 and P < .001, respectively) but not between the ERAVS and EVAR groups (P = .07). CONCLUSIONS: In our early experience, the ERAVS protocol appeared to be effective in reducing the TTD and improving the postoperative outcomes compared with the OR group, without significant differences compared with the EVAR group.

GLASS (Global Limb Anatomic Staging System): a critical appraisal.

BACKGROUND: THE Global Vascular Guidelines (GVGs) propose a new Global Anatomic Staging System (GLASS) resulting in three stages of complexity for intervention. The aim of this study was to retrospectively classify a large cohort of CLTI patients according to the GLASS, evaluating its distribution in a real-world setting. METHODS: Retrospective, single center, observational study enrolling all consecutive CLTI patients submitted to infra-inguinal endovascular revascularization in our institution, between June 2014 and September 2019. Patients were categorized according to the GLASS for femoro-popliteal (FP), infra-popliteal (IP) and infra-malleolar grading. FP and IP grades were merged to get the final GLASS stage for each limb. RESULTS: The study included 1995 CLTI patients who underwent 2850 endovascular procedures in which 6009 arterial lesions were successfully treated. The FP segment was classified as: 1292 (45.3%) grade 0, 475 (16.6%) grade 1, 159 (5.6%) grade 2, 209 (7.4%) grade 3, and 715 (25.1%) grade 4. The IP segment was classified as: 1529 (53.6%) grade 0, 183 (6.4%) grade 1, 80 (2.8%) grade 2, 207 (7.3%) grade 3, and 851 (29.9%) grade 4. The combination of FP and IP grading led to GLASS stages: 922 (32.3%) stage 1, 375 (13.2%) stage 2, 1472 (51.6%) stage 3. CONCLUSIONS: The distribution of the FP, IP and final GLASS grading was mainly grouped at the two extremes, letting the intermediate grades rather scarce. The majority of patients present with an absent or severely diseased pedal arch, stressing the need to incorporate infra-malleolar disease into the GLASS.

A Novel Scoring System for Small Artery Disease and Medial Arterial Calcification Is Strongly Associated With Major Adverse Limb Events in Patients With Chronic Limb-Threatening Ischemia.

PURPOSE: To evaluate the roles of small artery disease (SAD) and medial arterial calcification (MAC) in patients with chronic limb-threatening ischemia (CLTI) and to identify any correlation between these factors and peripheral artery disease (PAD) or outcomes after treatment. MATERIALS AND METHODS: A retrospective review was conducted of 259 limbs with tissue loss among 223 CLTI patients (mean age 72.2±11.4 years; 194 men) having an angiographic foot vessel study, foot radiography, and at least 6 months of follow-up after intervention. SAD and MAC were quantified using a 3-level score (0=absent, 1=moderate, 2=severe) based on angiography for SAD and foot radiographs for MAC. The MAC score was validated and compared with the SAD score, evaluating their associations with PAD distribution and clinical outcomes. RESULTS: Based on the MAC score, the 259 limbs were classified as 55 group 0 (21.2%), 89 group 1 (34.4%), and 115 group 2 (44.4%). The SAD score stratified the 259 limbs as 67 group 0 (25.9%), 76 group 1 (29.3%), and 116 group 2 (44.8%). Interobserver reproducibility of the MAC score was high (correlation coefficient 0.96). Sensitivity and specificity of the MAC score in detecting SAD was 100% and 98.1%, respectively, in SAD groups 0 and 2 vs 99.1% and 92.7%, respectively, for SAD group 1. PAD was more proximal in MAC and SAD groups 0 and more distal in groups 1 and 2. Both MAC and SAD scores were able to predict clinical endpoints. Multivariable analysis demonstrated that the MAC score represents an independent risk factor for adverse limb events. CONCLUSION: SAD and MAC must be considered expressions of the same obstructing disease, able to adversely impact the fate of CLTI patients. SAD and MAC scores are powerful prognostic indicators of major adverse limb events in CLTI patients.

How Good Are RGB Cameras Retrieving Colors of Natural Scenes and Paintings?-A Study Based on Hyperspectral Imaging.

RGB digital cameras (RGB) compress the spectral information into a trichromatic system capable of approximately representing the actual colors of objects. Although RGB digital cameras follow the same compression philosophy as the human eye (OBS), the spectral sensitivity is different. To what extent they provide the same chromatic experiences is still an open question, especially with complex images. We addressed this question by comparing the actual colors derived from spectral imaging with those obtained with RGB cameras. The data from hyperspectral imaging of 50 natural scenes and 89 paintings was used to estimate the chromatic differences between OBS and RGB. The corresponding color errors were estimated and analyzed in the color spaces CIELAB (using the color difference formulas ΔE*ab and CIEDE2000), Jzazbz, and iCAM06. In CIELAB the most frequent error (using ΔE*ab) found was 5 for both paintings and natural scenes, a similarity that held for the other spaces tested. In addition, the distribution of errors across the color space shows that the errors are small in the achromatic region and increase with saturation. Overall, the results indicate that the chromatic errors estimated are close to the acceptance error and therefore RGB digital cameras are able to produce quite realistic colors of complex scenarios.

Foot Angiosomes: Instructions for Use.

In the last 15 years an abundance of literature has demonstrated that angiosome-targeted revascularization, either endovascular or open, can lead to better clinical results in patients with chronic limb-threatening ischemia. According to this literature, the angiosome concept should guide our treatment strategy in every chronic limb-threatening ischemia patient. However, in our daily practice, its application is often difficult or impossible. Most foot wounds spread over multiple angiosomes and, moreover, the value of an angiosome-guided revascularization approach can vary according to vascular anatomy, collateral vessel network, type of revascularization, and wound. The aim of this article is to explore values and limits of the angiosome concept, and to propose some "instructions for use" regarding its application in our daily practice.

Hyper-Spectral Imaging Technique in the Cultural Heritage Field: New Possible Scenarios.

Imaging spectroscopy technique was introduced in the cultural heritage field in the 1990s, when a multi-spectral imaging system based on a Vidicon camera was used to identify and map pigments in paintings. Since then, with continuous improvements in imaging technology, the quality of spectroscopic information in the acquired imaging data has greatly increased. Moreover, with the progressive transition from multispectral to hyperspectral imaging techniques, numerous new applicative perspectives have become possible, ranging from non-invasive monitoring to high-quality documentation, such as mapping and characterization of polychrome and multi-material surfaces of cultural properties. This article provides a brief overview of recent developments in the rapidly evolving applications of hyperspectral imaging in this field. The fundamentals of the various strategies, that have been developed for applying this technique to different types of artworks are discussed, together with some examples of recent applications.

Hybrid Foot Vein Arterialization in No-Option Patients With Critical Limb Ischemia: A Preliminary Report.

PURPOSE: To describe a preliminary experience in treating no-option critical limb ischemia (CLI) patients with a hybrid foot vein arterialization (HFVA) technique combining open plus endovascular approaches. MATERIALS AND METHODS: Between May 2016 and January 2018, 35 consecutive patients (mean age 68±12 years; 28 men) with 36 no-option CLI limbs underwent HFVA in our center. All limbs had grade 3 WIfI (Wound, Ischemia, and foot Infection) ischemia, and the wound classification was grade 1 in 4 (11%) limbs, grade 2 in 4 (11%), and grade 3 in 28 (78%). Surgical bypass was done on the medial marginal vein or a posterior tibial vein, followed by endovascular removal of foot vein valves and embolization of foot vein collaterals. A "tension-free" surgical approach was used to treat foot lesions. RESULTS: At a mean follow-up of 10.8±2 months, limb salvage was achieved in 25 (69%) limbs and wound healing in 16 (44%); 9 patients presented an unhealed wound. Eleven (31%) patients underwent a major amputation (2 below the knee and 9 thigh). One patient with an unhealed wound and open bypass died of myocardial infarction. CONCLUSION: HFVA is a promising technique able to achieve acceptable rates of limb salvage and wound healing in no-option patients generally considered candidates for an impending major amputation. Further studies are needed to standardize the technique and better identify patients who can benefit from this approach.

[Multidisciplinary approach to diabetic foot: a challenge of expertises]. / La gestione multidisciplinare del piede diabetico: una sfida di competenze.

The diabetic foot represents one of the most dangerous complications of diabetic disease, and it is characterized by the presence of infection, ulceration, or necrosis of the foot tissues associated with various degrees of neuropathy or ischemia. If not correctly and promptly treated, it leads to high rates of major amputations. Although in Italy diabetics are about 5% of the population, more than 50% of major amputations are performed in diabetic patients. Compared to non-diabetic patients, diabetic peripheral artery disease localizes more distally, mostly in the below-the-knee vessels, is typically bilateral with multi-level involvement, and presents earlier onset and more aggressive course. The primary target of revascularization, either surgical or percutaneous, is the reconstitution of a direct flow line up to the suffering tissues, essential condition for healing. Revascularization alone, however, is not sufficient, it must be integrated in a multidisciplinary context, where the internal, infectious, surgical and orthopedic aspects of treatment can drive the patient on a personalized route towards limb salvage and recovery of walking.

Anterolateral retrograde access to the distal popliteal artery and to the tibioperoneal trunk for recanalization of femoropopliteal chronic total occlusions.

OBJECTIVES: To describe and assess the safety of a technique for the percutaneous retrograde access to either the P3 segment of the popliteal artery or the tibioperoneal trunk (TPT) through the anterior muscle compartment of the leg to treat distal femoropopliteal chronic total occlusion (CTO). METHODS: After a failed antegrade attempt of endovascular recanalization of a femoropopliteal CTO, 41 symptomatic patients (29 men; mean age of 75.8 ± 8.4 years) underwent a percutaneous retrograde access by means of the puncture of the TPT in 15 cases (36.6%) and of the P3 tract of popliteal artery in 26 cases (63.4%). The puncture was performed on the anterolateral aspect of the proximal leg through the anterior muscle compartment with the patient in a standard supine position. Access to the vessel was obtained with a sheathless approach. After retrograde recanalization and guidewire rendezvous, the distal wire was retrieved proximally and a standard antegrade endovascular intervention was carried out. RESULTS: Retrograde access was achieved successfully in all patients. Recanalization was carried out in 16 cases (39.0%) with an endoluminal technique and in 25 cases (61.0%) in a subintimal fashion. Hemostasis was successfully attained in 31 patients (75.6%) by inflating a blood pressure cuff at the calf. In 11 cases (26.8%), the hemostasis was accomplished instead by means of a low-pressure ballooning as a bailout strategy for small residual bleedings. The transcutaneous oximetry at the 1-month follow-up from the procedure was significantly increased compared with the preprocedural values (10.4 ± 6.8 vs 42.4 ± 18.7 mm Hg; P < .01). No early or late postoperative access-related complications were observed at a mean follow-up of 12.6 ± 9.5 months. CONCLUSIONS: After a failed antegrade approach, the anterolateral retrograde puncture of the P3 or of the TPT is a valuable and safe technique to treat femoropopliteal CTOs in selected patients, regardless the distal spread of the lesion to the popliteal artery.