Stent-assisted balloon-induced intimal disruption and relamination in complicated chronic residual type B aortic dissection after frozen elephant trunk treatment.

CASE REPORT: a 77-year-old man presented to our Emergency Department for worsening dyspnea. A chest CT scan showed a type A aortic dissection with a dilatation of the ascending and descending aorta. After evaluating the case with cardiac surgeons, it was decided to perform an aortic arch replacement through the frozen elephant trunk technique. Three months after cardiac surgery, a TC scan showed a residual 58 mm dissecting aneurysm of the descending thoracic aorta and a collapse of the true lumen so we decided to perform an endovascular treatment of the thoracoabdominal aorta according to the STABILISE technique. Due to the impossibility of cannulating the left renal artery (originating from the false lumen), a partial dilation of the dissecting stent was performed at the origin of the renal arteries, maintaining the communication between true and false lumen at the level of the aortic bifurcation. DISCUSSION: the STABILISE technique can be applied safely and effectively even in selected cases of residual chronic aortic dissection, constituting a safe and effective alternative to open thoracoabdominal surgery. CONCLUSIONS: the presence of a proximal artificial neck without proximal tears in the aortic arch can be a great advantage for subsequent endovascular interventions. It is therefore desirable to design a common surgical strategy within an aortic team to achieve a more favorable preoperative anatomy. KEY WORDS: Chronic dissection, Frozen elephant trunk, STABILISE.

Vascular plug oversizing to treat an endoleak after hybrid surgery of the aortic arch.

A patient with prior ascending aortic replacement for a type A acute dissection and a bovine arch presented with an asymptomatic chronic dissecting innominate artery aneurysm extending to both carotid arteries. As the patient refused redo open surgery, we performed a hybrid procedure with reverse extra-anatomic aortic arch debranching and a fenestrated endograft. The aneurysm was still partially perfused due to an endoleak and corrected 1 week later with vascular plugs.

An infection-oriented approach for thoracic endovascular aortic repair in a SARS-CoV-2 positive patient. A case report.

CASE REPORT: A 64-year-old woman presented to our emergency department during the outbreak of the covid-19 emergency in Italy with syncope, anosmia, mild dyspnoea and atypical chest and dorsal pain. A chest CT scan showed an acute type B aortic dissection (ATBAD) and bilateral lung involvement with ground-glass opacity, compatible with interstitial pneumonia. Nasopharyngeal swabs resulted positive for SARS-CoV-2. For the persistence of chest pain, despite the analgesic therapy, we decided to treat her with a TEVAR. Patient's chest and back pain resolved during the first few days after the procedure. No surgical or respiratory complications occurred and the patient was discharged 14 days after surgery. DISCUSSION: By performing the operation under local anesthesia, it was possible to limit both the staff inside the operatory room and droplet/aerosol release. Since we had to perform the operation in a hemodynamics room, thanks to the limited extension of the endoprosthesis and the good caliber of the right vertebral artery we were able to reduce the risk of spinal cord ischemia despite the lack of a revascularization of the left subclavian artery. CONCLUSIONS: A minimally invasive total endovascular approach allows, through local anesthesia and percutaneous access, to avoid surgical cut down and orotracheal intubation. This, combined with a defined management protocol for infected patients, seems to be a reasonable way to perform endovascular aortic procedures in urgent setting, even in a SARSCoV- 2 positive patient. KEY WORDS: COVID-19, Dissection, TEVAR.

Sizes of endografts for endovascular aortic repair: do few fit most?

AIM: The endoprostheses for the endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAA), are currently available in many sizes in reference to the aortic diameters of the proximal neck, but often not all of them are really used. Aim of our work was to review in our experience the most frequent proximal aortic diameters of main bodies that were used, among all those available for EVAR, with respect to the native proximal aortic neck. METHODS: All the sizes of main bodies of the different endografts used for EVAR from 2000 to 2016 were retrospectively counted. For each endograft, we calculated the number of times each size of main bodies' proximal diameter was used. The mean diameter of the proximal aortic neck was also calculated for each group of main bodies. RESULTS: From 2000 to 2016, 607 patients underwent EVAR for infrarenal AAA. Overall, mean diameter of the proximal aortic neck was 23.4 ± 0.5 mm (median 23.1 mm, IQR 22.2-23.7 mm). The most frequently used main bodies had a 28 mm, 26 mm and 25 mm proximal diameter (161/607, 26.5%; 147/607, 24.2%; 122/607, 20.1% respectively), for a mean proximal neck diameter of 23.2 ± 0.5 mm, 22.2 ± 0.4 mm and 22.1 ± 0.2 respectively. The least frequently used main bodies had a 21 mm and a 36 mm proximal diameter (3/607 times each, 0.5%), for a mean proximal neck diameter of 18.1 ± 0.2 mm and 32.4 ± 0.8 mm respectively. CONCLUSIONS: In our experience, the most frequently used main bodies had a 25, 26 and 28 mm proximal diameters. KEY WORDS: Abdominal aortic aneurysm, EVAR, Sizing endografts.

Endovascular repair of thoracic and thoraco-abdominal aortic lesions.

BACKGROUND: We report our "real-world" experience of endovascular repair of thoracic/thoraco-abdominal aortic lesions in patients treated from May 2002 to May 2017. METHODS: Data of all consecutive treated patients were retrospectively collected in a database and analyzed. Patients were divided into 4 groups: atherosclerotic thoracic/thoraco-abdominal aneurysms (TAA/TAAA) and floating thrombus (group A); acute complicated type B dissection (TBD), penetrating aortic ulcers (PAU) and intra-mural hematomas (IMH) in group B; chronic TBD evolving in TAA (group C); traumatic injuries (group D). Mortality, reinterventions and occurrence of neurological complications, both at 30 days and in the long term, were analyzed as primary outcomes for each group. RESULTS: Ninety-four patients were treated complessively, most for a TAA (55.3%). Thirty-days deaths and neurological complications were observed in group A only (5 cases each, 5.3%). A reintervention was necessary in 6 patients (6.4%) of group A. At 5 years, in group A survival was 62.8%±6.3% and freedom from neurological complication was 88.3%±4.2%. Neither deaths nor neurological complications were recorded in the other groups. No late aortic ruptures were recorded. Freedom from reintervention in group A was 54.7%±7.6% at 5 years and a reintervention was needed in all patients of group D. Overall, the main cause for reintervention was a type I endoleak. CONCLUSIONS: The endovascular repair of thoracic/thoraco-abdominal aortic lesions had acceptable mortality and neurological complication rates, both at 30 days and in the long term. Reinterventions in the long term occurred more frequently after TAA/TAAA and traumatic injuries, and were mainly required for a type I endoleak. KEY WORDS: Endovascular thoracic repair, Endovascular thoraco-abdominal repair, Thoracic aneurysms.

Sealing Devices in Chimney Aortic Repair (CH EVAS) Versus Chimney Aortic Repair with Conventional Devices (CH EVAR): A Systematic Review.

AIM: The aim of this study was to review the literature about the occurrence of postoperative type I endoleak (EL) and chimney graft thrombosis (CGT) after the use of sealing devices in chimney endovascular aortic repair (Ch EVAS), compared to chimney EVAR using conventional devices (Ch EVAR). METHODS: A systematic review of the literature on PubMed and MEDLINE with the terms "Chimney" and "Parallel grafts" was performed. The review was set up following the PRISMA guidelines. Case series about the use of the chimney/snorkel technique during endovascular repair of juxtarenal/pararenal aneurysms (AAA) were considered. Only papers with full text available in English and reporting complete data with at least 1 month of follow-up about at least 5 cases were included in the analysis. RESULTS: In total, 90 papers were assessed for eligibility. According to the inclusion criteria, only 25 papers could be analyzed (20 in the Ch EVAR group and 5 in the Ch EVAS group). A type I EL occurred in 9.3% after Ch EVAR (95% CI 7.1-12.2%) and in 8.3% after Ch EVAS (95% CI 3.5-18.5%), being not significantly different. CGT occurred in 10.7% of cases after Ch EVAR (95% CI 8.8-13%) and in 8.8% of cases after Ch EVAS (95% CI 3.3-21.3%), being also not significantly different. CONCLUSIONS: The reported rate of type I EL and CGT occurring after Ch EVAR tended to be slightly higher than those reported after Ch EVAS, even if the difference was not statistically significant.

Use of venoactive drugs after surgery for varicose veins: a preliminary study.

BACKGROUND: The aim of this paper was to assess the use of venoactive drugs (VADs) after surgery for chronic venous disease in our operative unit in terms of patients' compliance to the therapy and a possible effect on the postoperative pain and quality of life (QoL). METHODS: Data of consecutive patients who underwent surgery were retrospectively analyzed. All patients, through telephone interview 90 days after the operation, were asked about taking the VAD (either sulodexide or MPFF) which was recommended during the postoperative period. Data were collected about the duration of therapy, the intensity of perceived pain (0-10 scale) at 1st, 7th and 30th postoperative days (POD), the length of rest from their daily activities and QoL during the first postoperative month (through Italian SF-12 questionnaire). P values <0.05 were considered significant. Results of patients who took the VAD were compared to those of patients who did not take the VAD (case-controlled study). RESULTS: A total of 132 patients were operated on (43 with endovenous radiofrequency ablation, RFA; 43 with stripping or crossectomy; 46 with phlebectomies). The proportion of patients who took VADs was two thirds, similar among the three groups. Of those, 24% took VADs for less than 30 days. No significant differences were recorded between those who took and those who didn't take any drugs in terms of intensity of pain at 1st, 7th and 30th POD, days of rest from daily activities and QoL. CONCLUSIONS: Irrespectively of the groups, about one third of the patients did not take the recommended VAD postoperatively. No significant difference was recorded between those who took the therapy and those who did not in terms of intensity of postoperative pain, length of rest from daily activities and QoL.

Varicose veins: new trends in treatment in a Vascular Surgery Unit.

AIM: Less invasive techniques such as foam sclerotherapy, endovenous laser or radiofrequency ablation have recently been introduced as a valid alternative to surgery for the treatment of varicose veins (VVs). We retrospectively reviewed our experience in the treatment of VVs with particular attention to how our therapeutic approach has changed over the last years. MATERIAL OF STUDY: Data of all patients consecutively treated from September 1st 2013 to July 31st 2015 for both primitive and recurrent VVs were retrospectively collected and analyzed. Statistical analysis was performed using the software JMP 5.1.2 (SAS Institute). RESULTS: A total of 409 legs in 378 patients were treated. The percentage of stripping of the great saphenous veins (GSV) for primary VVs has decreased over the years (67% in 2013 vs 15.2% in 2015), differently from what happened to the percentage of RFA of the GSV (14.3% vs. 31.5% respectively in 2013 and in 2015) and to the percentage of legs treated with the A.S.V.A.L. technique (8.7% vs. 31.5% respectively in 2013 and in 2015). Likewise, in 2013 most procedures were performed using spinal anesthesia (77.5%), while in 2015 the most used anesthetic techniques were both the local anesthesia and the local anesthesia with conscious sedation (35.9% and 29.3% respectively). Postoperative course was uneventful in all cases but seven (1.7%). At follow-up (median 16.9 months, IQR 7.5-22.6 months), neither major adverse events nor deaths were recorded. CONCLUSIONS: During the years of our experience, we observed a trend towards a less invasive approach for the treatment of VVs, with safe and effective results. KEY WORDS: Ablation Radiofrequency, Stripping, Varicose veins.

A 16-year experience of carotid artery stenting for carotid artery stenosis.

AIM: We report our experience of carotid artery stenting (CAS) for the endovascular treatment of significant carotid stenosis over 16 years. MATERIALS AND METHODS: Data of all consecutive patients who came for a significant carotid artery stenosis from January 1st 1999 to August 31st 2015 were retrospectively collected and analyzed. Primary outcomes were the occurrence of death and major cerebrovascular events (MCE) both at 30-day and at long-term. RESULTS: In our experience CAS was a safe and effective technique, with acceptable mortality and neurological complication rates, both at 30 days and in the long term. KEY WORDS: Carotid stenting, Carotid stenosis, Long-term follow-up.