Reallocation of Carotid Surgery Activity with the Support of Telemedicine in a COVID-Free Clinic during COVID-19 Pandemic.

The aim of this study is to report the reallocation of carotid surgery activity with the support of telemedicine in a COVID-free clinic during COVID-19 pandemic. Patients with symptomatic carotid stenosis or asymptomatic vulnerable plaques were reallocated to a COVID-free private clinic which began to cooperate with the National Health System during the emergency. Quick training of staff nurses was performed. Surgeons moved to the COVID-19 free clinic. Remote cerebral monitoring was performed with the support of telemedicine. Twenty-four patients underwent standard carotid endarterectomy with eversion technique. Five patients (20.8%) had recently symptomatic stenosis, and the remaining 19 patients (79.2%) had a risky asymptomatic carotid stenosis. No technical issue with remote cerebral monitoring was detected. In the early postoperative period, no neurological/systemic complication was observed. Three patients under dual antiplatelet therapy (12.5%) had neck hematoma. All patients were discharged the day after surgery. In our preliminary experience, reallocation in a COVID-free clinic allowed us to maintain a functioning carotid surgery activity during COVID-19 pandemic. A multidisciplinary approach and support of telemedicine were crucial. Training of unskilled nurse staff was necessary.

Nineteen-year outcomes with the Anaconda stent graft system from two tertiary centers.

OBJECTIVE: The Anaconda stent graft device presents peculiar and unique features in its design and deployment sequence, available on the market for many years with minor modifications, among different generations. The aim of this study was to assess the long-term, real-life, outcomes obtained in two high-volume centers with this endograft for infrarenal aortic aneurysms treatment over a period of 19 years. METHODS: All patients treated with the investigated device between 2000 and 2019, with at least 1 year of follow-up, were entered into a prospective database and data were reviewed retrospectively. The long-term results were assessed according to the Kaplan-Meier method. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late reintervention, freedom from late conversion to open repair, freedom from late limb occlusion, and freedom from late EVAR failure. RESULTS: A total of 260 consecutive patients were treated during the study period. Technical success was achieved in 98.5% (256/260) of the cases. Two perioperative deaths (0.8%) and four major complications (1.5%) were recorded. At a mean follow-up of 54 ± 38 months (summary follow-up index = 0.86), the late survival estimate was 94.8% at 1 year, 75.2% at 5 years, 50.5% at 10 years, and 43.3% at 13 years, with no case of late AAA rupture or late AAA-related death. Late freedom from conversion was 99.2% at 1 year, 96.9% at 5 years, 94.0% at 10 years, and 94.0% at 13 years. Freedom from late limb thrombosis was 96.8% at 1 year and 91.0% at 5, 10, and 13 years. Estimates of freedom from late reintervention was 95.6% at 1 year, 87.0% at 5 years, 77.4% at 10 years, and 77.4% at 13 years. Estimates of limb thrombosis at 11 years were significantly different in patients receiving or not intraoperative iliac kissing balloon maneuver with noncompliant angioplasty catheters (98.0% vs 88.4%; P = .029). CONCLUSIONS: The Anaconda stent graft demonstrated effective and durable outcomes for AAA treatment over a 19-year period, with no case of late AAA rupture or AAA related death in the studied population. Late limb occlusion was the leading cause of reintervention; however, a positive prevention strategy was found in intraoperative kissing balloon, which was associated with significant reduced rate of iliac thrombosis over time.

Staged in situ aorto-iliac hybrid technique: an original technique to treat complex juxtarenal and iliac aneurysms.

BACKGROUND: To report a novel staged hybrid technique to treat complex juxtarenal abdominal aortic aneurysm (JAAA) associated with at least one iliac artery aneurysm (IA) with no adequate distal fixation zone. METHODS: The novel technique herein described has two main "staged" steps. The first step consists in creating an adequate distal fixation zone by endovascular means; after hypogastric embolization an iliac stent-graft has placed from 5 mm above the aortic bifurcation to the external iliac artery. The second step is the surgical resection of the JAAA and graft placement sutured distally to the stent-graft which was always performed the day after. RESULTS: The five cases included (mean age 74 years), were rejected for fenestrated or branched endovascular aortic repair or iliac branch devices. Four tube grafts and one aorto-bi-iliac graft were sutured to one stent-graft (N.=3), two stent-grafts in iliac kissing configuration (N.=1) and to a main body of a bifurcated stent-graft (N.=1). Mean follow-up duration was 14 (4-27) months with no mortality. Technical success was obtained in all cases (2 suprarenal clamping). Postoperative complications included two pleural effusions, two transient gluteal intermittent claudications, and one renal failure. CONCLUSIONS: The technique herein described seems to be a feasible and cost-effective alternative treatment for selected concomitant complex JAAAs and IAs unsuitable for totally endovascular treatment.

Design of a sensorized guiding catheter for in situ laser fenestration of endovascular stent.

PURPOSE: The in situ fenestration of a standard endograft is currently limited by difficulties in targeting the fenestration site under fluoroscopic control and by the lack of a safe method to perforate the graft. Evidence in the literature suggests the use of a 3 D electromagnetic navigator to accurately guide the endovascular instruments to the target and a laser to selectively perforate the graft. The aim of this work is to provide design guidelines to develop a sensorized catheter to guide the laser tool to the fenestration site and conduct preliminary testing of the feasibility of the proposed solution. Matherials and methods: Different catheter designs were delineated starting from engineering considerations, then prototypes were preliminarily tested to collect surgeon opinions and to steer the design process toward the preferred solution reported by the user. Finally, mechanical simulations were performed with CathCAD, a design software system for the development of composite tubing for endovascular catheters. RESULTS: Based on surgeon feedback, a 9-French steerable catheter with a stabilization system was designed. CathCAD simulations allowed us to define the construction parameters (e.g., materials and geometric constrains) for the fabrication of composite tubes with mechanical properties (flexural, axial, and torsional rigidities) compatible with target values in the literature for guiding catheters. CONCLUSION: The presented results preliminarily demonstrate the clinical reasonability and feasibility of the designed tool in terms of mechanical properties. Further mechanical tests and extensive in vitro clinical trials are required prior to animal testing.

Open Surgical Management of Hypogastric Artery during Aortic Surgery: Ligate or Not Ligate?

BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with 43% of cases with common iliac artery aneurysms and an extension of prosthetic replacement distal to the iliac bifurcation is needed. The decision about preserving the hypogastric artery (HA) is a source of discussion, in particular when only one HA is interested. The low risk of pelvic ischemia, even if existing, has to be compared with the greater technical difficulty of the vascular reconstruction. The aim of this study is to evaluate retrospectively the perioperative results in patients who underwent ligation or reconstruction of the HA during open surgical procedures for AAA. METHODS: Over a period of 11 years (January 2002 to December 2012), 1,487 patients were treated electively for AAA. In 235 cases (15.8%), the aneurysm involved the iliac bifurcation with need to extend distally the prosthetic reconstruction; among them, 63 patients were subjected to HA ligation (26.8%, group 1) and 172 to HA bypass (73.2%, group 2). Indication for ligation was the presence of extended HA aneurysm in 34 cases (54%) and heavy calcification of HA in 29 (46%). RESULTS: Perioperative mortality and morbidity rates were, respectively, 1.6% (1/63) and 7.9% (5/63) in group 1 and 1.2% (2/172) and 6.4% (11/172) in group 2 (P = 0.902 and 0.689). The incidence of buttock claudication was significantly higher in group 1 (6/63, 9.5% vs. 4/172, 2.3% P = 0.025), while there were no significant differences in other complications of pelvic ischemia. In group 2, higher intraoperative blood loss (754 ± 721 vs. 996 ± 608 mL, P = 0.011), longer operating time (283.2 ± 104.7 vs. 302 ± 109 min, P = 0.053), and longer postoperative length of stay (PLOS) (5.8 ± 2.2 vs. 6.7 ± 3.6 days, P = 0.049) occurred. CONCLUSIONS: HA bypass during open surgery for AAA is a safe procedure. If compared with ligation, it reduces the risk of buttock claudication without increasing perioperative morbidity and mortality. However, the increased complexity of the intervention involves an increase in blood loss, operating time, and PLOS.

Efficacy and safety of a novel vascular closure device (Glubran 2 seal) after diagnostic and interventional angiography in patients with peripheral arterial occlusive disease.

PURPOSE: To prospectively evaluate safety and efficacy of a novel vascular closure device (Glubran 2 Seal) after peripheral angiography in patients with peripheral arterial occlusive disease (PAOD). METHODS: From December 2010 to June 2011, all consecutive patients with PAOD undergoing peripheral angiography were prospectively enrolled onto the study after percutaneous antegrade or retrograde puncture of the common femoral artery. After angiography, the Glubran 2 Seal device was used to achieve hemostasis. The following data were registered: technical success and manual compression duration, patients' discomfort (scale 0-5), operators' technical difficulty (scale 0-5), and vascular complications. The site of hemostasis was evaluated by clinical inspection and color-coded Duplex ultrasound performed 1 day and 1 month after the procedure. RESULTS: One hundred seventy-eight patients were enrolled (112 male, mean age 70.8 years) with a total of 206 puncture sites, including 104 (50.5 %) antegrade accesses. The device was successful in 198(96.1 %) of 206 procedures, with 8 cases of manual compression lasting longer than 5 min (maximum 20 min). No major vascular complications were observed, resulting in 100 % procedural success. Minor complications occurred in seven procedures (3.4 %), including two cases of pseudoaneurysms, successfully treated by ultrasound-guided glue injection. The mean ± standard deviation score for patients' discomfort was 0.9 ± 0.7, whereas the mean score for operators' difficulty was 1.2 ± 0.9. CONCLUSION: In patients with PAOD, the Glubran 2 Seal represents a simple, painless, and efficient vascular closure device, able to achieve hemostasis both in antegrade and retrograde accesses.

[Left paraduodenal hernia: a case report and review of the literature]. / Ernia paraduodenale sinistra: case report e review della letteratura.

Paraduodenal hernia is a rare internal congenital hernia due to an embryological abnormality. It is often associated with non-specific abdominal symptoms. In this report the authors describe the case of a woman who was referred to the emergency ward for intestinal obstruction. Preliminary examinations (x-ray and computed tomography scan) failed to yield a clear diagnosis. The patient underwent a surgical procedure and a left paraduodenal hernia was diagnosed. A sound knowledge of embryological anatomy is essential for safe, effective surgical treatment of such internal hernias. A review of the literature confirms that this congenital abnormality is rare and that its diagnosis is the most difficult step in its therapeutic management.