Inflow Artery Aneurysmal Degeneration After Long Term Native Arteriovenous Fistula for Haemodialysis.

OBJECTIVE: Inflow arterial aneurysms are a rare but serious complication after long term arteriovenous fistulae (AVF), probably due to arterial wall remodelling after an increase in flow and shear stress, and kidney transplantation with immunosuppressive therapy. This study aimed to describe the outcomes of surgical treatment and long term follow up in a large cohort. METHODS: This prospective cohort study collected data from patients with a true inflow artery aneurysm after AVF creation that was surgically repaired between 2010 and 2022. Anastomotic and infected aneurysms or post-puncture pseudoaneurysms were excluded. Demographic data, access characteristics, symptoms, treatment strategies, and long term follow up were recorded; patency was estimated using Kaplan-Meier survival analysis. RESULTS: During the study period, 28 patients (64% men, mean age 60.1 years) were treated surgically for aneurysmal degeneration of the axillary or brachial (n = 23) or radial (n = 5) artery after an AVF (10 distal, 18 proximal) performed a mean of 18.3 ± SD 7.9 years previously. Most AVFs were ligated or thrombosed, while all patients except one had previously received kidney transplants. Most of the cases (n = 18) were symptomatic: 13 with pain or swelling, four with distal embolisation, and one rupture. They were repaired by aneurysm partial excision and graft interposition (11 great saphenous vein, six ipsilateral basilic vein, three cephalic vein, and two PTFE graft), ligation (n = 3), or direct end to end anastomosis (n = 3). No major complications occurred before discharge, after a mean hospital stay of 2.4 days. After a mean follow up of 4.8 ± 3.3 years, three cases presented complications: two recurrent proximal brachial aneurysms were repaired with an additional proximal interposition graft (one with further late infected pseudoaneurysm) and an asymptomatic post-traumatic graft thrombosis. Five year primary and secondary patency was 84% and 96%, respectively. CONCLUSION: Aneurysmal degeneration of the inflow artery is an unusual complication during long term follow up of AVFs. Aneurysm excision and, in general, autogenous graft interposition using the saphenous or ipsilateral arm vein is a safe and effective strategy.

Impact of Target Visceral Vessel Anatomical Configuration on Early Complications Following Endovascular Repair of Thoracoabdominal Aortic Aneurysms.

BACKGROUND: Fenestrated and branched endovascular aortic repair (fEVAR-bEVAR) is a viable treatment option for thoracoabdominal aortic aneurysms but target visceral stent (TVS) endoleak and thrombosis remain a limiting factor. This study aims to evaluate TVS anatomy impact on 1-year risk of thrombosis and endoleak. METHODS: Patients treated with fEVAR-bEVAR for thoracoabdominal aneurysms between 2008 and 2020 in our centre were enrolled. We recorded comorbidities, operative details, 1-month postoperative CT scan (anatomical reference), and TVS behaviour: thrombosis and endoleak at 1-year follow-up. For each TVS, different points were identified using a centre-lumen-line: (A) TVS origin, (B) end of branch/fenestration, (C) visceral vessel entry, (D) end of TVS, (E) 1-cm distally. We analyzed TVS tortuosity ((centre-lumen-line/straight distance)-1, in %), image vector analysis of each segment in 2D (antero-posterior, left-right) and 3D (craneo-caudal displacement), and centre-lumen-line analysis (bending in ABC and CDE). Three independent observers performed a blind analysis, and anatomical differences between bEVAR/fEVAR, and cases with/without 1-year thrombosis and TVS endoleak, were compared using Kaplan-Meier curves (Log-Rank test), and t-test/Wilcoxon signed-ranks test respectively. RESULTS: Fifty-four patients (72 ± 713 years mean age; 182 TVS: 50 branches, 132 fenestrations) met the inclusion criteria. bEVAR cases had longer stents, with more caudal 3D angulation, and greater ABC angulated segment. After excluding bEVAR cases (low case number), 97 fEVAR TVS were analyzed. Five thrombosis and 7 endoleaks were observed. While anatomical configuration showed no association to thrombosis, it was related to endoleak: these cases presented more tortuous stents (5.97% ± 0.10, 21.40% ± 0,22, P = 0.011), with more angulated centre-lumen-line at ABC segment (5.69° ± 15.77°, 7.18° ± 7.77°, P = 0.012), and more upward-pointing stents in the origin of the stent (AB: 89.07° ± 24.46°, 109.09° ± 16.56°, P = 0.012; BC: 87.86° ± 21.10°, 113.11° ± 22.23°, P = 0.026). CONCLUSIONS: Anatomical configuration of the TVS is associated with type III endoleak, but not thrombosis, at 1-year following fEVAR. Cases with endoleak presented more tortuous stents, with a more angulated exit from the endograft, and upward-pointing of the origin of the stent.

Linoleic Acid Status in Cell Membranes Inversely Relates to the Prevalence of Symptomatic Carotid Artery Disease.

BACKGROUND AND PURPOSE: The red blood cell fatty acid composition objectively reflects the long-term dietary intake of several fatty acids. In patients undergoing carotid endarterectomy, we explored whether red blood cell status of selected fatty acids related to symptomatic carotid artery disease. METHODS: We included patients with symptomatic (n=22) and asymptomatic (n=23) carotid artery disease. We determined all-C18:1 trans, linoleic acid (LA, C18:2n6), alpha-linolenic acid (C18:3n3), and the omega-3 index (sum of eicosapentaenoic [C20:5n3] and docosahexaenoic [C22:6n3] acids) in both red blood cells and carotid plaque phospholipids by gas-chromatography. RESULTS: In a multivariate logistic regression analysis, we only observed a significant association for LA, whose red blood cell status was inversely related to symptomatic carotid artery disease (odds ratio, 0.116 [95% CI, 0.022-0.607], P=0.011, for each 1-SD increase). A similar result was observed for LA in carotid plaque phospholipids. CONCLUSIONS: Cell membrane enrichment in LA, which reflects its intake, was inversely related to symptomatic carotid disease. This increases evidence supporting a favorable role of dietary LA in vascular health.

Diagnostic yield of 18F-FDG PET/CT in suspected diagnosis of vascular graft infection: A prospective cohort study.

BACKGROUND: Prosthetic vascular graft infection (PVGI) is a severe complication associated with high morbidity and mortality. Clinical diagnosis is complex, requiring image testing such as CT angiography or leukocyte scintigraphy, which has considerable limitations. The aim of this study was to know the diagnostic yield of PET/CT with 18F-Fluorodeoxyglucose (18F-FDG) in patients with suspected PVGI. METHODS: We performed a prospective cohort study including 49 patients with suspected PVGI, median age of 62 ± 14 years. Three uptake patterns were defined following published recommendations: (i) focal, (ii) patched (PVGI criteria), and (iii) diffuse (no PVGI criterion). RESULTS: Sensitivity, specificity, and positive and negative predictive values for 18F-FDG-PET/CT were 88%, 79%, 67%, and 93%, respectively. 18F-FDG-PET/CT identified 14/16 cases of PVGI showing a focal (n = 10) or patched pattern (n = 4), being true negative in 26/33 cases with either a diffuse pattern (n = 16) or without uptake (n = 10). Five of the seven false-positive cases (71%) showed a patched pattern and all coincided with the application of adhesives for PVG placement. CONCLUSIONS: 18F-FDG-PET/CT is a useful technique for the diagnosis of PVGI. A patched pattern on PET/CT in patients in whom adhesives were applied for prosthetic vascular graft placement does not indicate infection.

Climatic influence on the risk of abdominal aortic aneurysm rupture.

Our aim is to examine the effects of climatic conditions on the incidence of ruptured abdominal aortic aneurysms (rAAA) in Catalonia, Spain. We combined clinical data from the Public Health official registries in Catalonia, Spain (HD-MBDS) of all rAAA with local climatic data obtained from the closest meteorological station (69 stations, National Meteorological Service: MeteoCat) from 2008 to 2017. We analyzed the median, maximum, minimum, and variability of atmospheric pressure (hPa) and air temperature (°C), solar irradiation (MJ/m2), humidity (%), accumulated precipitation (mm), median wind, and maximum flaw direction and velocity (°, m/s), recorded on the days of events, the previous day, and mean results for 3, 7, and 30 days before, as well as seasonality. Seventy-five control days were randomly selected in a 1-year period around every rAAA day at the same meteorological station, and compared. A total of 717 days and locations with rAAA were identified, and 53,775 controls were randomly selected. For the rAAA days, there were significantly lower temperatures, lower solar global irradiation, and higher mean humidity levels in all time periods (p < 0.001, p < 0.001, p < 0.05); higher atmospheric pressure variability during 1 week and 1 month before (p = 0.011, p = 0.007); and they often occurred during autumn/winter (57.6%, p < 0.001). Logistic regression identified low mean temperatures on the days of ruptures and high mean humidity the week before as independent rupture predictors. In conclusion, low median temperatures the same day and high humidity during 1 week before were identified as independent predictors of rAAA occurrence. The role of climate on pathophysiologic mechanisms may require further investigation.

Influence of On-Call Vascular Surgery Team and Off-Hour Effect on Survival after Ruptured Abdominal Aortic Aneurysm.

BACKGROUND: Ruptured abdominal aortic aneurysms (rAAAs) represent a life-threatening emergency and carry a high community and in-hospital mortality, despite treatment and protocol advances. Identifying prognostic factors like the presence of on-call vascular surgery teams at first hospital admissions or times of hospital admissions can modify hospital protocols and mechanisms to ameliorate general outcomes. The aim of this study is to analyze the influence of on-call vascular surgery teams and off-hour admissions on survival after rAAAs in Catalonia, Spain. METHODS: We used data from public health official registries (based on registration of the minimum basic data set) to collect diagnosed cases of rAAAs (ICD-9-CM [International Classification of Diseases, Ninth Revision, Clinical Modification] 441.3) between January 2008 and December 2017. Variables included patient comorbidities, aneurysm treatment and type (endovascular treatment: ICD-9-CM 39.7 or open surgery: ICD-9-CM 398.44 and 39.25), in-hospital mortality, initial hospital admissions and transfers, days and times of admission, and final treatment received. We compared intervention rates and mortalities in all samples and operated cases, in patients initially admitted into tertiary vascular centers (with on-call vascular surgery teams) and community centers (without on-call vascular surgery teams), and the "off-hour effect" (night [22:00 hr to 8:00 hr] or weekend admissions [Friday to Sunday]) in mortality and type of surgery (open or endovascular repair). RESULTS: Of 717 patients with rAAAs (92% men), 561 (78.2%) were initially admitted into tertiary vascular centers and 156 (21.8%) into community centers. The rate of operated cases and global mortality was higher when cases were initially admitted into tertiary vascular centers (388, 69.2% vs. 46, 29.5%; P < 0.001 and 63.6% vs. 88.5%, P < 0.001, respectively), but when surgery was performed (excluding palliative nonoperated cases), the postoperative mortality in both groups was comparable (47.4% vs. 60.9%, P = 0.085), in both univariate and multivariate analysis. On the other hand, patients admitted during night hours (210, 29.3%) did not reveal noteworthy differences in the overall mortality (68.6% vs. 69.2%, P = 0.860) or postoperative mortality compared to those admitted during day hours (61.0% vs. 60.4%, P = 0.880). Weekend admissions neither showed worse results (280, 39.1%, admitted during weekend: overall mortality 70.4% vs. 68.2%, P = 0.541 and postoperative mortality 51.2% vs. 47.3%, P = 0.436). No significant dissimilarities were seen either in the use of endovascular or open repair at night (42.2% vs. 46.1%, P = 0.457) or weekend (41.8% vs. 47%, P = 0.287). CONCLUSIONS: Patients with rAAAs initially admitted into tertiary vascular centers have better overall survival rates than those initially admitted into community centers, mainly because of higher rates of rejected cases in community centers. No differences were seen in terms of mortality or type of surgery in the off-hour admitted cases (night hours or during weekends).

The best in vitro conditions for two and three parallel stenting during endovascular aneurysm repair.

OBJECTIVE: The aim of this study is to identify which endograft-parallel stent combinations and which degree of oversizing result in the most adequate fit in a juxtarenal abdominal aneurysmal neck, when using a double or triple parallel-stent (chimney) technique. METHODS: In vitro silicon, juxtarenal, abdominal aortic aneurysmal neck models of different diameters, with two and three side-branches (simulating both the renal and superior mesenteric arteries), were constructed. Two different endografts of three diameters each, with two or three parallel stents (of 6 mm and 6 mm; or 6 mm, 6 mm, and 8 mm) were tested (Endurant-II endograft [Medtronic Inc, Santa Rosa, Calif] with balloon-expandable BeGraft stent [Bentley InnoMed, Hechingen, Germany] and an Excluder endograft [W. L. Gore and Associates, Flagstaff, Ariz] with self-expanding Viabahn stent [W. L. Gore and Associates]), applying three endograft-oversizing degrees: recommended (15%), excessive (30%), and over-excessive (40%). After remodeling, using the kissing-balloon technique at 37°C (98.6°F), 36 endograft-stent-oversizing models were scanned by computed tomography. The area of the gutters, parallel-stent compression, and main endograft infolding were recorded. RESULTS: Increasing oversizing (15%, 30%, and 40%) revealed a nonsignificant propensity toward smaller gutters and similar parallel-stent compression, but it significantly augmented infolding, more in three parallel-stent models (0%, 0%, 67% and 0%, 33%, 83% of cases; P = .015 and .018, for two and three parallel-stent models; n = 36) and mainly for the Excluder-Viabahn combination. The Excluder-Viabahn showed significantly smaller gutters, but with higher stent compression, than Endurant-BeGraft combinations for both two and three parallel stents (8.2 mm2, 22.6 mm2; P = .002 and 14.4 mm2, 23.3 mm2; P = .009 gutter area; and 18%, 2%; P < .001 and 15%, 2%; P = .007 relative stent area compression, respectively). CONCLUSIONS: Better endograft stent apposition was usually attained when using 30% oversizing during two and three parallel-stent techniques. Higher oversizing was related to nonsignificant smaller gutters but higher rates of infolding. Smaller gutters, but higher stent compression and risk of infolding, were achieved with the Excluder-Viabahn than with the Endurant-BeGraft combination.

Parallel-Stenting Technique in a Sandwich Configuration for Hypogastric Artery Preservation during Endovascular Aneurysm Repair: An In Vitro Study.

BACKGROUND: The aim of the study was to identify the best conditions in iliac sandwich procedure for hypogastric artery preservation during endovascular aneurysm repair, testing different devices, different oversizing (OS) degrees as well as different methods to measure it. METHODS: Four external iliac devices (16-mm Endurant and 12-mm Aorfix limb extensions; 11- and 13-mm Viabahn endografts) were tested with 2 distinct internal iliac stent grafts (8-mm Advanta V12 and 8-mm Viabahn) inside different proximal silicon iliac limb models (10, 12, 14, 16, and 18 mm), simulating an iliac sandwich procedure for hypogastric preservation. After remodeling all devices in a saline bath at 37°C, the combinations were computed tomography scanned. Gutter size, parallel-stent compression, and inadequate parallel-stent deployment or infolding were recorded. Oversizing between both parallel stents and the iliac limb models were examined in terms of added diameter, perimeter, and area being additionally compared. RESULTS: All three sizing methods (diameter, perimeter, and area) were highly correlated (diameter OS to perimeter and area OS correlation coefficient 0.998 and 0.997, respectively, P < 0.001 for both); thus, diameter OS was used for further comparisons. Increasing diameter OS (< 30%, 30-55%, 55-75%, and > 75%) showed a significant tendency toward smaller gutters (38.9, 12.2, 5.4, and 2.6 mm2, respectively, P < 0.001) but also increasing parallel-stent compression (13.5%, 28.9%, 43.9%, and 55.1%, P < 0.001) and infolding (0%, 0%, 38%, and 60%, P < 0.001). There were no significant differences between the analyzed devices. CONCLUSIONS: In iliac sandwich procedures, better apposition is usually achieved when using 30-55% diameter OS; higher OS is related to smaller gutters but higher rates of malpositioning and parallel-stent compression. No clear recommendations in material selection can be performed. All sizing methods are highly correlated and predictable.

Aortic Arch and Thoracic Aorta Curvature Remodeling after Thoracic Endovascular Aortic Repair.

BACKGROUND: The objective of this study was to analyze the original curvature of the aortic arch and thoracic aorta, and how it is modified after the placement of a thoracic endograft. METHODS: We retrospectively analyzed all patients primarily treated for thoracic aortic aneurysms and blunt traumatic aortic injuries by means of an endograft sealed into the aortic arch (zones, Z1-Z3) in 2 different centers (Vascular Surgery Division, Hospital Clinic, UB; and Vascular and Endovascular Surgery Department, Hospital Vall d'Hebron, UAB; Barcelona, Spain), between 2010 and 2015. The last preoperative and early (1-month) postoperative computed tomography angiography (CTA) was obtained for all cases, and an accurate 3-dimensional (3D) center lumen line was created, from the aortic valve to the renal arteries. Angles in 2-dimensional (2D; XY-plane) and 3D (referred to cranial-caudal Z-axis) were analyzed in: the distal ascending aorta, aortic arch, and thoracic aorta (at 5, 10, 15, and 20 cm from the brachiocephalic trunk [BCT]) and celiac trunk (CT). Changes in preoperative-postoperative CTA were compared independently for both diseases. Thirty-six cases were included (20 aneurysms, 16 blunt traumatic injuries; mean age, 69.5 and 42.5 years). RESULTS: After placement of an aortic endograft (sealed in Z1-Z2 in 30% of aneurysms and 75% of traumatic injuries; mean endograft length: 22.6 cm and 11.3 cm, respectively), a global left anterior displacement of the ascending aorta was observed (2D examination: -13.1° and -7.5°, P = 0.049 and 0.041, respectively). The 3D examination showed an average increase of the aortic angle at 5 and 10 cm from the BCT in the whole sample (+4.0°, +4.9° in reference to the vertical; P = 0.017, 0.001), softening the curvature of the proximal descending thoracic aorta. In addition, in traumatic injuries, a decrease in the aortic arch angle was observed (-3.5°, P = 0.030). CONCLUSIONS: Placement of an endograft into the aortic arch and proximal thoracic aorta engenders a softening of the proximal descending thoracic aorta curvature, increasing its angle from the vertical. In blunt traumatic aortic injuries (with shorter and more proximally sealed endografts), an additional decrease of the aortic arch angle (3.5° more vertical), was observed.

Safety of adjuvant open axillary access during complex thoracoabdominal aortic endovascular procedures.

BACKGROUND: Endovascular treatment of aortic diseases with complex anatomy may require an additional upper extremity arterial access (like axillary access) for support during aortic navigation and allowing the use of larger sheaths for thoracoabdominal antegrade access. The objective of this study is to evaluate the safety of the open axillary approach as adjuvant access in complex thoracoabdominal aortic endovascular interventions. METHODS: A monocentric retrospective study was performed, including all patients with a complex aortic endovascular procedure (fEVAR, bEVAR, chEVAR or TEVAR), elective or urgent, with open surgical exposure of the axillary artery as adjuvant access, between 2012 and 2022. Demographic data, diagnosis and urgency criteria, type of aortic intervention, size of axillary sheath, use of through-and-through maneuver, and features by computed tomography angiography (CTA) of the axillary artery and aortic arch were recorded. The appearance of local and aortic postoperative complications were described, and possible prognostic factors were analyzed. RESULTS: Forty-eight patients (38 men) were included, median age 78 years (range 50-87), 33 with intact thoracoabdominal aneurysms, eight previous EVAR endoleaks and seven aortic aneurysm ruptures. 28 fEVAR/bEVAR, 17 chEVAR and three TEVAR procedures with axillary access were performed. Left infraclavicular axillary access was the most common approach (94%), along with a 12 French (F) median sheath (range 7-20). Eight (16.7%) local complications were identified: three bleedings, one hematoma, three focal dissections in the subclavian artery, and one brachial embolism, all successfully resolved. The only factor related to local complications was small axillary diameter (median 10.7 vs. 14.6 mm; P<0.001), a subclavian/sheath ratio less than one was associated to more local complications (P=0.02). Regarding aortic complications, two (4.1%) type B asymptomatic aortic dissections with left juxta-subclavian tear were found, attributed to local manipulation, occurring only in urgent procedures (P=0.032). CONCLUSIONS: The use of open axillary access as an adjuvant approach in complex aortic endovascular surgery, although it is very useful and usually safe, can be associated with subclavian or even aortic complications (not reported until now), especially in cases with small subclavian diameters and urgent cases.

Compressive symptoms due to thrombosed or hypertrophic collateral circulation in infrarenal inferior vena cava agenesis.

Agenesis of the infrarenal segment of inferior vena cava is an uncommon and often asymptomatic congenital abnormality with an approximate incidence of 0.005-1% in the general population. Presentation of this condition as deep venous thrombosis associated with symptoms secondary to thrombosis or hypertrophy of collateral vessels is a rare clinical form. Two cases of this rare form are described, and an analysis of the related literature is presented. The first case was that of a 35-year-old man with symptoms of acute obstructive pyelonephritis with no apparent cause and swelling of the lower limb. The second case involved a 30-year-old man with lower limb swelling associated with paresthesia and motor deficit. Both patients were found to have infrarenal inferior vena cava agenesis associated with iliofemoral deep venous thrombosis and compression of anatomic structures by collateral vessels (ureteral compression due to thrombosis of an ectatic gonadal vein and L5 nerve root compression due to a hypertrophic epidural venous plexus). Patients were conservatively managed with anticoagulation therapy, with a favorable outcome and no recurrence in either case. In a young patient with iliac deep venous thrombosis of uncertain etiology, and particularly in those with atypical associated symptoms (mainly abdominal or neurologic), it is important to investigate congenital vena cava anomalies and carry out diagnostic imaging studies. Anticoagulation therapy is currently considered the best treatment option for this condition, but it should be individualized. The need for long-term anticoagulation should also be assessed in each case.

Autologous forearm arteriovenous loop vascular access, an option to be considered.

BACKGROUND: Autologous arteriovenous fistula is usually the vascular access of choice for hemodialysis in patients with chronic kidney disease. Autologous forearm loops with cephalic or basilic vein are an alternative in those cases with a suitable forearm vein but with an unsuitable radial artery; however they are rarely used and there is little reported evidence of their usefulness. Our objective is to report our results on the creation of autogenous forearm loops as vascular access for hemodialysis. METHODS: We present a prospective cohort study of autogenous forearm loop arteriovenous fistula created between 2010 and 2022, in patients with stage 4-5 chronic kidney disease. Demographic data, surgical details, vein used, follow up to 24 months, maturation, utilization, primary, assisted, and secondary patency estimations with Kaplan-Meier curves, as well as complications during follow-up, were recorded. RESULTS: During the study period, 22 autologous forearm loops were created, 14 of them with cephalic, and 8 with basilic vein. Most (59%) of the patients were men, 19 were already on dialysis and the rest started during follow-up. Sixteen patients had previous vascular accesses. One patient was lost during follow-up. Six-week maturation rate was 61.9% and utilization rate was 57.1%. 6, 12, and 24 months primary and secondary patencies were 75.4%, 59.2%, 41.5% and 85.0%, 69.5%, 56.9% respectively. In five patients an access-induced distal ischemia was diagnosed, four successfully treated and only one patient lost the access. No cases of infection or other major complications were reported. CONCLUSION: Autologous forearm loops have acceptable maturation (61.9%) and patency rates at follow-up (56.9% 2-years secondary patency). Although rarely used, they are a vascular access alternative that should be considered to preserve the proximal vasculature of the arm for future accesses.

Innominate artery aneurysm with hemoptysis and airway compression in a patient with bovine aortic arch.

We present the case of a 63-year-old man with a bovine aortic arch variation, who presented episodes of mild hemoptysis secondary to a 4.5-cm (diameter) aneurysm of the innominate artery that compressed the trachea and obliterated the right subclavian artery. Surgery, performed through a median sternotomy, consisted of a bypass from the ascending aorta to both common carotid arteries using a Dacron graft, and exclusion of the aneurysm by ligature and direct thrombin injection. Computed tomography angiography at 30 days showed a patent bypass, successful aneurysm exclusion, and improvement of the tracheal compression. The patient is currently asymptomatic at 12 months following the procedure.

Transcervical carotid stenting with flow reversal is a safe technique for high-risk patients older than 70 years.

BACKGROUND: Recent evidence regarding carotid revascularization advises against carotid angioplasty and stenting (CAS) in patients aged >70 years with conventional risk for carotid endarterectomy (CEA). The poor outcome of transfemoral CAS in this age group may be explained by the anatomic characteristics of the aortic trunk and supra-aortic vessels in elderly patients, as well as by a high prevalence of aortic arch atheromatosis. Transcervical CAS with flow reversal for cerebral protection avoids these unfavorable characteristics. This study analyzed the short-term and middle-term results of transcervical CAS with flow reversal in patients aged >70 years at high risk for CEA. METHODS: Between January 2006 and January 2011, 219 cases of >70% carotid artery stenosis in high-risk patients aged >70 years (55.7% asymptomatic and 44.3% symptomatic) were treated by transcervical CAS. All patients underwent complete neurologic examination by a stroke neurologist before and after the procedure. Primary end points were stroke, death, or myocardial infarction (MI), technical success, and complications at 30 days. During follow-up, we analyzed the rate of restenosis ≥50% and ipsilateral stroke. Data were collected prospectively and outcome was analyzed in all cases, including technical failures. RESULTS: The 30-day combined stroke/death/MI rate was 2.2% (stroke, 1.8%; stroke/death, 2.2%; and MI, 0.45%). In symptomatic patients, stroke/death/MI was 5.1% (stroke, 4.1%; stroke/death, 5.1%). None of the asymptomatic patients suffered stroke, MI, or death postoperatively. Technical success was 96.3% (four inability to cross lesion, two major common carotid dissections, one failed preangioplasty, one stent thrombosis). One cervical hematoma required surgical drainage. At follow-up (18.8 ± 16.9 months), cumulative (standard error) incidence of >70% restenosis was 3% (1%) at 1 year and 8% (3%) at 2 and 3 years. Only one patient experienced ipsilateral stroke during follow-up. Overall survival (standard error) was 94% (2%) at 1 year and 90% (3%) at 2 and 3 years. CONCLUSIONS: In our experience, transcervical CAS with flow reversal is a safe technique for treating carotid stenosis in patients aged >70 years. We believe that avoiding the aortic arch and tortuous supra-aortic vessels is responsible for the favorable results in this study.

Relationship between plasma homocysteine and the morphological and immunohistochemical study of carotid plaques in patients with carotid stenosis over 70%.

BACKGROUND: Several clinical and epidemiological studies describe hyperhomocysteinemia as an independent cardiovascular risk factor. Implication of cellular immunity in atherosclerosis also seems clear. This study aimed to analyze the association among plasma hyperhomocysteinemia, neurological clinical events, and the morphology and immunocytology of carotid plaques in patients with carotid stenosis >70% receiving surgical treatment. METHODS: Sixty-two patients with carotid stenosis >70% receiving surgical treatment were studied; 58% had a history of stroke in the ipsilateral carotid territory. Plasma homocysteine concentrations were determined by considering pathological values >12.4 µmol/L. Histopathological (stable and unstable plaques) and immunohistochemical (macrophages, T lymphocytes, and active T lymphocytes counts) studies were performed. Hyperhomocysteinemia prevalence was calculated in this population, as were the possible relationships between homocysteine plasma concentrations, and the carotid plaque type and the cell types in it. The relationship between this risk factor and the presence of a neurological event relating to carotid stenosis was also investigated. RESULTS: Hyperhomocysteinemia prevalence was 43.5%, with a mean value of 11.8 µmol/L (median; range = 2-41.8 µmol/L). No significant differences were found between homocysteine levels and the plaque's morphological characteristics, or between the cell types analyzed. Elevated concentrations of homocysteine were not significantly higher in patients with a history of stroke. CONCLUSION: The present study confirms high hyperhomocysteinemia prevalence in patients with extracranial cerebrovascular disease, although no relationship between plaque complication phenomena and this cardiovascular risk factor was observed.

Blood glucose monitoring during hospitalisation: Advanced practice nurse and semi-automated insulin prescription tools.

INTRODUCTION: Hyperglycemia is very common in hospitalized patients and is associated with worse clinical outcomes. AIMS: We implemented a clinical and educational program to improve the overall glycemic control during hospital admission, and, in patients with HbA1c > 8%, to improve their metabolic control after hospital admission. METHODS: Non-critical patients admitted to cardiovascular areas between October-2017 and February-2019. The program was led by an advanced nurse practitioner (ANP) and included a semiautomated insulin prescription tool. Program in 3 phases: 1) observation of routine practice, 2) implementation, and 3) follow-up after discharge. RESULTS: During the implementation phase the availability of HbA1c increased from 42 to 81%, and the ANP directly intervened in 73/685 patients (11%), facilitating treatment progression at discharge in 48% (de novo insulin in 36%). One-year after discharge, HbA1c in patients who were admitted during the observation phase with HbA1c > 8% (n = 101) was higher than similar patients admitted during implementation phase (8,6 ±â€¯1,5 vs. 7,3 ±â€¯1,2%, respectively, p < 0,001). We evaluated 47710 point of care capillary blood glucose (POC-glucose) in two 9 months periods (one before, one during the program) in cardiology and cardiovascular surgery wards. POC-glucose ≥250 mg/dl (pre vs. during: cardiology 10,7 vs. 8,4%, and surgery 7,4 vs. 4,5%, both p < 0,05) and <70 mg/dl (2,3 vs. 0,8% y 1,5 vs 1%, p < 0,05), respectively, improved during the program. CONCLUSIONS: The program allowed improving inpatient glycemic control, detect patients with poor glycemic control, and optimize metabolic control 1-year after discharge.

FEVAR/BEVAR have limitations and do not always represent the preferred option for juxtarenal reconstruction.

Following the definition given by the recent ESVS guidelines, juxtarenal abdominal aortic aneurysm (JAAA) is defined as an aneurysm extending up to but not involving the renal arteries, necessitating suprarenal aortic clamping for open surgery, i.e. a short neck (<10 mm). JAAA repair always represents a challenge intervention, either by open or endovascular means, mostly related to the renal arteries involvement. Concerning endovascular repair, different options can be considered. Among them, fenestrated endografts (FEVAR) should be considered as a first option1, due to their reported safety and efficacy. However, when the anatomy is not favorable or when FEVAR devices are not available in an emergency setting for instance, other alternatives can be considered like parallel graft or chimney technique (ChEVAR). Do nothing is the last alternative when medical and anatomical circumstances are absolutely poor. In the following pages, we will review the limitations of FEVAR and branched endografts, the better indications and anatomical conditions for a successful repair with ChEVAR technique and its current clinical results reported in the literature.