Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications.

Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery.

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Perioperative care in open aortic vascular surgery: A consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery.

The Society for Vascular Surgery and the Enhanced Recovery After Surgery Society formally collaborated and elected an international, multidisciplinary panel of experts to review the literature and provide evidence-based recommendations related to all the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites) for aortic aneurysm and aortoiliac occlusive disease. Structured around the Enhanced Recovery After Surgery core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

Modifications in Near Infrared Spectroscopy for Cerebral Monitoring During Carotid Endarterectomy in Asymptomatic and Symptomatic Patients.

BACKGROUND: To evaluate trends and differences in Near Infrared Spectroscopy (NIRS) monitoring during carotid endarterectomy (CEA) in patients affected by asymptomatic and symptomatic carotid artery stenosis, to predict postoperative neurological complications (PNCs). METHODS: NIRS data of CEAs performed in a University Hospital were retrospectively reviewed. All the interventions were performed under general anesthesia and patients with intraoperative complications were excluded. Mean regional Oxygen Saturation Index (rSO2), pre-clamp values (mean baseline value, MBv and Single Mark Baseline value, SMBv) were collected and compared to the lowest rSO2 values during carotid cross-clamp (LSO2v) calculated within 3 min (percentage drop, PD). ROC curve analysis with Youden's Test was performed to determine the best threshold value of PD, in order to identify PNCs in both asymptomatic and symptomatic groups. RESULTS: Between 2007 and 2015, a total of 399 CEAs were consecutively performed with NIRS monitoring. Three-hundred-seventy-two CEAs in 355 patients were reviewed. Asymptomatic stenoses were 291 (81.9%), eleven (2.9%) PNC were registered (5 in asymptomatic and 6 in symptomatic group). Asymptomatic and symptomatic diseases had different MBv (69.5 ± 7.5 vs. 71.8 ± 6.9, respectively; P = 0.011) and similar rSO2 value during carotid clamping (63.7 ± 8.0 vs. 63.7 ± 6.7, respectively: P = 0.958). Asymptomatic patients experiencing PNCs had a greater PD than non-PNCs group (20.5 ± 10.2% vs. 12.5 ± 7.6%, respectively using MBv as baseline value; P = 0.002), in contrast, in symptomatic patients, in which a low PD was associated with PNCs, it does not reach statistical significance (using MBv, 12.6 ± 5.4% vs. 14.8 ± 6.7%, respectively; P= 0.476). In order to detect PNCs, ROC analysis revealed an optimal PD cut-off value of -17% in asymptomatic CEAs. (Sensibility (Se) 0.80, Specificity (Sp) 0.76, PPV 0.05, NPV 0.99, Youden's index 0.56; P = 0.020) In symptomatic a threshold value of -9% was found, without reaching statistical significance. CONCLUSIONS: NIRS as cerebral monitoring during CEA can predict PNCs in asymptomatic stenosis. Asymptomatic and symptomatic groups differ in baseline and intraprocedural cut-off values to detect an augmented PNCs risk.

Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms?

INTRODUCTION: Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. METHODS: Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. RESULTS: Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. CONCLUSIONS: Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.

COVID-19 and acute limb ischemia: a systematic review.

INTRODUCTION: The main goal of this systematic review was to analyze the outcomes of acute limb ischemia (ALI) in patients suffering from the novel Coronavirus: COVID-19 (SARS-CoV-2). EVIDENCE ACQUISITION: A systematic review on Medline and Embase was conducted up to May 15, 2021. All papers were sorted by abstract and full text by two independent authors. Systematic reviews, commentaries, and studies that did not distinguish status of COVID-19 infection were excluded from review. Patient demographics were recorded along with modality of treatment (endovascular and/or surgical). We analyzed 30-day outcomes, including mortality. Primary outcome was to evaluate clinical characteristic of ALI in patients affected by SARS-CoV-2 in term of location of ischemia, treatment options and 30-day outcomes. EVINDENCE SYNTHESIS: We selected 36 articles with a total of 194 patients. Most patients were male (80%) with a median age of 60 years old. The treatment most used was thromboembolectomy (31% of all surgical interventions). A total of 32 patients (19%) were not submitted to revascularization due to critical status. The rate of technical success was low (68%), and mortality rate was high (35%). CONCLUSIONS: This review confirms that SARS-CoV-2 is associated with a high risk of ALI. Further studies are needed to investigate the association and elucidate potential mechanisms, which may include a hypercoagulable state and hyperactivation of the immune response. Furthermore, management of ALI is not standardized and depends on patient condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

Use of a Steerable Sheath for Antegrade Catheterization of a Supra-aortic Branch of an Inner-Branched Arch Endograft via a Percutaneous Femoral Access.

Purpose: To describe the use of a steerable sheath from a femoral access for antegrade catheterization of the left common carotid artery (LCCA) in an inner-branched arch endograft. Technique: This technique is demonstrated in a patient with residual aortic dissection after replacement of the ascending aorta for acute type A aortic dissection. He presented 4 years later with aneurysmal degeneration of the thoracoabdominal aorta and a proximal tear located in the aortic arch. A 2-stage hybrid approach was devised to treat the patient. An axilloaxillary crossover graft (left to right) with plug occlusion of the innominate artery was performed initially. Later, a dual-branched custom-made device was implanted. To avoid an additional LCCA cutdown for retrograde branch access, an 18-F steerable sheath was used through a percutaneous femoral access. Two wires were delivered within the steerable sheath: the first one was directed into the left subclavian artery to stabilize the sheath position in the ascending aorta; the second wire was used to catheterize the first inner branch and the LCCA to deploy the covered bridging stent. Conclusion: Transfemoral access to catheterize antegrade branches for supra-aortic vessels is feasible using a large steerable sheath in branched endovascular arch repair.

Acute Hemispheric Stroke: Full Remission Following Surgical Thrombectomy.

INTRODUCTION: Carotid occlusion because of embolisation or as a distal extension of thrombus formation in an ulcerated plaque can be the cause of a devastating stroke, caused by sudden occlusion of the internal carotid artery (ICA). Often, invasive treatments are not an option because of the limited time frame. In rare situations of acute stroke onset and admission to therapy within six hours however, aggressive recanalisation may be considered. This technical note demonstrates surgical transcatheter embolectomy of intra-extra cranial ICA by reducing inflow by placing a clamp on the common carotid artery (CCA) before puncture cranial to the clamp. PATIENT AND TECHNIQUE: A 67 year old man was admitted as an emergency seven hours after an acute hemispheric stroke with paraplegia of his left arm and full consciousness. An immediate duplex scan showed more than 90% stenosis of the carotid bifurcation with low echolucent plaque material extending proximally up to the intracranial ICA. CT angiography confirmed the stenosis and a sub-occlusive thrombosis of the ICA up to the M1 segment of the middle cerebral artery (MCA). Because the onset of clinical symptoms was more than six hours previously, the patient was not within the clinical window for endovascular therapy. Following interdisciplinary consensus, surgical over the wire thrombectomy with endarterectomy with complete removal of the thrombus and subsequent thrombo-endarterectomy of the carotid bifurcation and bovine patch plasty was performed. The patient was discharged with statin and antiplatelet treatment on the second post-operative day with full remission of symptoms. CONCLUSIONS: Immediate surgical transcatheter recanalisation of acute intra-extracerebral ICA thrombus with inflow reduction can be a valid procedure to improve cerebral circulation, leading to full remission of stroke symptoms.

Successful Fat Grafting in a Patient With Thromboangiitis Obliterans.

Thromboangiitis obliterans, or Buerger disease, is a rare nonatherosclerotic segmental inflammatory vasculitis that generally affects young tobacco smokers. Although no surgical treatment is available, the most effective way to halt the disease's progress is smoking cessation. In this case report, a 29-year-old smoker showed up to emergency department with gangrene of his fifth left toe and extensive plantar ulceration. After investigative angiography, he was diagnosed with Buerger disease. On November 2017, he underwent fifth left toe amputation and hyperbaric therapy. Five months after amputation, the patient was rehospitalized because of surgical wound dehiscence, wide ulceration, and pain. He was treated with lipofilling using the Coleman technique. Two weeks after the fat grafting procedure, the patient suspended pain control medication, and after 2 months, the surgical wound was almost healed. Fat grafting (lipofilling) is mostly used in plastic surgery; it offers regenerative effects, with minimal discomfort for the patient. This case report demonstrates a successful alternative use of lipofilling for this unique condition and opens up new options for use of this technique in other fields.

Concomitant Renal Artery and Aortic Aneurysm: Is Endovascular Surgery the Correct Approach?

Our case illustrates the concomitant presence of a giant aneurysm of the left renal artery at the ostium and an abdominal aortic aneurysm, in presence of a complex aortic anatomy. Type of approach and timing of the treatment is still not well established for the rare coexistence of these 2 pathologies. In case of surgical high-risk patients, endovascular therapy is considered now the best choice to exclude arterial and aortic aneurysms although there are chances to do further interventions in the follow-up. For this reason, we simultaneously treated both the aneurysms through an embolization with plugs and coils of renal aneurysm and endovascular exclusion of aortic aneurysm; in the follow-up, renal function of the patient worsened until hemodialysis and we saw the reperfusion of renal aneurysm and the onset of endoleak I type A from above the aortic and renal aneurysm and B from iliac legs of the previous endograft. We performed a parallel graft technique on visceral vessels to exclude the refilling of both aneurysms and preserve visceral vascularization. Follow-up at 12 months showed the complete exclusion of the aneurysms and the patency of stents in celiac trunk and superior mesenteric artery.

Carotid artery stenting in the elderly. Are there differences between open and closed cell stents?

INTRODUCTION: We reviewed our experience of carotid artery stenting (CAS) in patients older than 75 years treated with open or closed cell stents. The aim of our paper is to evaluate if there are differences between the two groups in term of clinical outcomes, neurological impairment and survival. MATERIAL AND METHODS: CAS consecutively performed from March 2000 and December 2016 in elderly patients were rectrospectively collected. We classified them into two groups: closed cells (group A) and open cells stent (group B). Perioperative and long term events were observed (death, major cerebrovascular and cardiovascular events, in-stent restenosis). RESULTS: We collected 429 CAS, 259 (60.37%) male with median age of 79 years (range 77-82). Group A collects 247 (57.98%) patients, 142 (33.3%) in group B. The other 40 patients were treated with hybrid stents or just ballooning. In perioperative period we had not death but 2 patients (0.8%) in group A had a transient ischemic attack (TIA) due to immediate stent thrombosis, 2 patients (1 per group) had an ipsilateral major stroke and 8 patients had a TIA (3 in group A and 5 in group B). Median follow up was 686 days (IQR 267-1299 days). Freedom from complications at 12, 36 and 60 months was 99.4 ± 0.5%, 97 ± 1.5% and 90.08 ± 4.3% respectively. Survival at 12, 36 and 60 months was 77.4 ± 7.5%, 51.6 ± 8.9% and 16.1± 6.6% respectively. CONCLUSION: Our data show CAS as a safe procedure also for people older than 75 years in terms of perioperative and long term complications and cerebral events without any significant difference between the different type of stent. Further studies are requested to better clarify its role in symptomatic patients. KEY WORDS: Carotid stenting, Carotid treatment, Old people.

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.

Relevance of inflammation and matrix remodeling in abdominal aortic aneurysm (AAA) and popliteal artery aneurysm (PAA) progression.

Aneurysm is a multifactorial degenerative disease characterized by focal dilatation of blood vessels. Although abdominal aortic (AAA) and popliteal aneurysms (PAA) are the most common dilatative vascular diseases and share some features, a comparison between the different anatomical sites and the relative pathophysiological differences has not been established. In order to gain deeper insights to AAA and PAA, we have characterized the role of matrix remodelling, vascular cells phenotype depletion and the inflammatory process in both diseases. Results show a more extensive presence of T-cell, B-cell and monocyte-macrophage infiltration in AAA with respect to PAA. Concurring with this aspect, IL-6, IL-8 and MCP-1 are 10-fold increased in AAA. Moreover, MMP-9, and metalloproteinase inhibitor 3 (TIMP3) resulted up-regulated in AAA tissues. Regarding the catalytic activity, which is tightly related to the oxidative stress, we found an up-regulation of superoxide dismutase [Mn] mitochondrial (SODM), glutathione peroxidase 3 (GPX3) and peroxiredoxin-1 (PRDX1). Histological analyses clearly showed a massive elastin fragmentation in AAA. This may enhance the inflammatory response, which has a prevalent role in AAA, while PAA is mainly guided by a loss of the contractile phenotype. These findings suggest insight in these potentially devastating diseases in term of their progression, aiming to identify potential specific markers respectively for AAA and PAA treatment.

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.