A Pilot Study of Endovascular Repair for Ruptured Aortic Aneurysms With the Use of Carbon Dioxide Angiography Alone.

INTRODUCTION: Endovascular aortic repair (EVAR) of a ruptured abdominal aortic aneurysm (rAAA) has become a common approach. Hemorrhagic shock associated with the use of iodinated contrast medium (ICM) increases the risk of acute kidney injury (AKI). Theoretically, eliminating ICM from EVAR can decrease that risk. The aim of this pilot study was to analyze the feasibility and safety of emergent EVAR performed with the exclusive use of carbon dioxide (CO2) for a rAAA. METHODS: Since 2021, all consecutive rAAAs with hemorrhagic shock and suitable anatomical criteria for a standard endograft have been treated by EVAR with the exclusive use of CO2 using an automated CO2 injector (Angiodroid SpA, San Lazzaro di Savena, Italy). RESULTS: Eight percutaneous EVARs were performed under local anesthesia. Median age was 78 (interquartile range [IQR]=6) years, 5 patients were male. The technical success was 100%, the 30-day mortality was 25% (n=2), the median amount of administered CO2 was 400 (IQR=60) ml. The median change in serum creatinine level between admission, post-operative and 30-day values was an increase of 0.14 mg/dL and a decrease of 0.11 mg/dL, respectively. Post-operative AKI occurred in the two patients who died. All 6 surviving patients showed sac shrinkage >5 mm, and no reinterventions at a median follow-up of 10 months. CONCLUSIONS: Endovascular repair of rAAA with the exclusive use of CO2 as contrast agent is technically feasible and safe. Further studies are needed to determine whether CO2 increases survival rate and limits the progression of renal dysfunction after endovascular repair of rAAA. CLINICAL IMPACT: The recorded rate of post-operative AKI after endovascular repair of rAAA performed with the use of CO2 found in this pilot study was significantly lower than the one reported in the literature with the use of ICM. Our hyphotesis is that the use of CO2 during rEVAR might increase survival rate and limits the progression of renal dysfunction.

Benefits and Role of Carbon Dioxide Angiography in Case of Misalignment Between Fenestration and Target Vessel During Fenestrated Endovascular Aneurysm Repair.

PURPOSE: To report the benefits and the role of carbon dioxide (CO2) angiography in case of misalignment between fenestration and target vessel during fenestrated endovascular aneurysm repair (F-EVAR). TECHNIQUE: During F-EVAR, misalignment between fenestration and target vessel is a potentially catastrophic complication. In 2 patients, we experienced that one of the target vessels were not visible during standard angiography in different projections after positioning a fenestrated graft and even after cannulation of the corresponding fenestration. In both cases, the graft was sealed to the aortic wall but not in the predictable position. Consequently, acute occlusion of the target vessel was hypothesized. However, CO2 angiography was useful to evaluate patency of the target vessel clarifying the relative position of the fenestration versus the target vessel. Rescue maneuvers were feasible under the guidance of CO2 angiography in order to obtain the cannulation of both renal arteries. In both cases, the procedure was successfully accomplished. CONCLUSION: In case of misalignment of a fenestration during F-EVAR and non-visualization of the target vessel with standard angiography, CO2 angiography could have the unique and complementary role of clarifying the patency and position of the target vessel. In addition, CO2 could guide the rescue maneuvers.

Timing to Carotid Endarterectomy Affects Early and Long Term Outcomes of Symptomatic Carotid Stenosis.

BACKGROUND: The aim of this study is to evaluate early and long-term outcomes according to the timing to carotid endarterectomy (CEA) of symptomatic carotid stenosis. METHODS: Consecutive CEAs with selective shunting for symptomatic carotid stenosis ≥50% performed between 2009 and 2020. Patients had acute neurological impairment on presentation, defined as <5 points on the National Institutes of Health Stroke Scale (NIHSS). We grouped patients according to time between index event and CEA: the first group was operated between 0 and 2 days, the second group between 3 and 7 days, the third group between 8 and 14 days and the last group after 15 days. Thirty-day neurological status improvement was defined as a decrease (≥1) in the 30-day NIHSS score versus NIHSS score immediately before surgery. RESULTS: Five hundred CEAs were performed. The perioperative combined stroke and mortality rate was 3.6% (18/500), representing a perioperative mortality rate of 0.2 (n = 1) and stroke rate of 3.4% (n = 17). Overall freedom from stroke was 95% at 1 year, 89 % at 6 years, and 88% at 10 years. Annual stroke rate was 0.6% after the 30-day period. Thirty-day improvement in neurologic status occurred in 103 patients (20.6%), while in 380 (76%) neurologic status was unchanged, and 17 (3.4%) experienced worsening of their neurologic status. Patients treated within 7 days from the index event had significant benefit (OR = 2.6) in the 30-day neurological improvement versus those treated after 7 days from the index event. Timing to CEA <2 days increased significantly the risk of late stroke (OR = 9.7). CONCLUSIONS: The ideal timing for performing CEA is between 3 and 7 days from the index event if NIHSS <5 as it is associated with the best rates of improvement in neurological status and durability in the long term. Very early CEA (<48 hrs) was associated with increased late stroke occurrence.

Results of Iliac Branch Devices in Octogenarians Within the pELVIS Registry.

Purpose: To evaluate if the elderly could benefit from the implantation of iliac branch devices (IBDs) to preserve the patency of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation. Materials and Methods: From January 2005 to April 2017, 804 patients enrolled in the pELVIS registry underwent endovascular aneurysm repair with 910 IBDs due to aneurysmal involvement of the iliac bifurcation. Among the 804 patients, 157 (19.5%) were octogenarians (mean age 82.9±2.5 years; 157 men) with 171 target IIAs for preservation. Outcomes at 30 days included technical success, death, conversion to open surgery, and major complications. Outcomes evaluated in follow-up were patency of the IBD and target vessels, type I and type III endoleaks, aneurysm-related reinterventions, aneurysm-related death, and overall patient survival. Kaplan-Meier analyses were employed to evaluate the late outcome measures; the estimates are presented with the 95% confidence interval (CI). Results: Technical success was 99.4% with no intraoperative conversions or deaths (1 bridging stent could not be implanted, and the IIA was sacrificed). Perioperative mortality was 1.9%. The overall perioperative aneurysm-related complication rate was 8.9% (14/157), with an early reintervention rate of 5.1% (8/157). Median postoperative radiological and clinical follow-up were 21.8 months (range 1-127) and 29.3 months (range 1-127), respectively. Estimated rates of freedom from occlusion of the IBD, the IIA, and the external iliac artery at 60 months were 97.7% (95% CI 96.1% to 99.3%), 97.3% (95% CI 95.7% to 98.9%), and 98.6% (95% CI 97% to 99.9%), respectively. Estimated rates of freedom from type I and type III endoleaks and device migration at 60 months were 90.9% (95% CI 87% to 94.3%), 98.7% (95% CI 97.5% to 99.8%), and 98% (95% CI 96.4% to 99.6%), respectively. Freedom from all cause reintervention at 60 months was 87.4% (95% CI 82.6% to 92.2%). The estimated overall survival rate at 60 months was 59% (95% CI 52.4% to 65.6%). Conclusion: IBD implantation in octogenarians provided acceptable perioperative mortality and morbidity rates, with satisfying long-term freedom from IBD-related complications and should be considered a feasible repair option for selected elderly patients affected by aneurysms involving the iliac bifurcation.

Bilateral Use of Iliac Branch Devices for Aortoiliac Aneurysms Is Safe and Feasible, and Procedural Volume Does Not Seem to Affect Technical or Clinical Effectiveness: Early and Midterm Results From the pELVIS International Multicentric Registry.

OBJECTIVE: To evaluate early and follow-up outcomes following bilateral use of iliac branch devices (IBD) for aortoiliac endografting and assess the impact of center volume. We used data from the pELVIS international multicentric registry. METHODS: For the purpose of this study, only those patients receiving concomitant bilateral IBD implantation were analyzed. To assess the impact that procedural volume of bilateral IBD implantation could have on early and follow-up outcomes, participating institutions were classified as Site(s) A if they had performed >10 and/or >20% concomitant bilateral IBD procedure, otherwise they were classified as Site(s) B. Endpoints of the analysis included early (ie, 30-day) mortality and morbidity, as well as all-cause and aneurysm-related mortality during follow-up. Additional endpoints that were evaluated included IBD-related reinterventions, IBD occlusion or stenosis requiring reintervention (ie, loss of primary patency), and IBD-related type I endoleak. RESULTS: Overall, 96 patients received bilateral IBD implantation (out of 910 procedures collected in the whole pELVIS cohort), of whom 65 were treated at Site A (ie, Group A) and 31 were treated at Site(s) B (ie, Group B). In total, only 1 death occurred within 30 days from bilateral IBD implantation, and 9 patients experienced at least 1 major complication without any significant difference between subjects in Group A versus those in Group B (10.8% vs 6.5%, p=0.714). In the overall cohort, the 2-year freedom from IBD-related type I endoleaks and IBD primary patency were 96% and 92%, respectively; no significant differences were seen in those rates between Group A or Group B (95% vs 100%, p=0.335; 93% vs 88%, p=0.470). Freedom from any IBD-related reinterventions was 83% at 2 years, with similar rates between study groups (85% vs 83%, p=0.904). CONCLUSIONS: Within the pELVIS registry, concomitant bilateral IBD implantation is a safe and feasible technique for management of aortoiliac aneurysms in patients with suitable anatomy. Despite increased technical complexity, effectiveness of the repair is satisfactory with low rates of IBD-related adverse events at mid-term follow-up. Procedural volume does not seem to affect technical or clinical outcomes after bilateral use of IBD, which remains a favorable treatment option in selected patients.

The Italian USL Toscana Centro model of a vascular hub responding to the COVID-19 emergency.

BACKGROUND: Spreading of the COVID-19 pandemic in Italy forced health facilities to drastically change their organization to face the overwhelming number of infected patients needing hospitalization. The aim of this paper is to share with all the vascular community the protocol developed by the USL (Unità Sanitaria Locale) Toscana Centro for the reorganization of the Vascular Surgery Unit during the COVID-19 emergency, hoping to help other institutions to face the emergency during the hard weeks coming. METHODS: The USL Toscana Centro is a public Italian health care institution including four districts (Empoli, Florence, Pistoia, Prato) with 13 different hospitals, serving more than 1,500,000 people in a 5000 km2 area. The USL adopted a protocol of reorganization of the Vascular Surgery Unit during the first difficult weeks of the epidemic, consisting in the creation of a Vascular Hub for urgent cases, with a profound reorganization of activities, wards, surgical operators, operating blocks, and intensive care unit (ICU) beds. RESULTS: All 13 hospitals are now COVID-19 as the first days of April passed. The San Giovanni di Dio Hospital (Florence) has more than 80 COVID-19 patients in different settings (ICU, medical and surgical ward), which at the time of writing is almost one-third of the total hospital capacity (80/260 beds). It has been identified as the Surgical Hub for urgent vascular COVID-19 cases. Therefore, the elective surgical and office activities were reduced by 30% and 80%, respectively, and reserved to priority cases. A corner of the whole operating block, well separate from the remaining operating rooms, was rapidly converted into one operating room and six ICU beds dedicated to COVID patients. The COVID-19 surgical path now includes an emergency room for suspected COVID-19 patients directly connected to an elevator for the transfer of COVID patients in the COVID operating block and dedicated COVID-19 ward and ICU beds. CONCLUSIONS: Rapid modification of hospital settings, a certain "flexibility" of the medical personnel, a stepwise shutdown of vascular surgical and office activity, and the necessity of a strong leadership are mandatory to cope with the tsunami of the COVID-19 outbreak.

A propensity score-matched comparison of two commercially available iliac branch devices in patients with similar clinical and anatomic preoperative features.

OBJECTIVE: The objective of this study was to compare the perioperative and midterm results of Zenith Bifurcated Iliac Side (ZBIS; Cook Medical, Bloomington, Ind) and Gore Iliac Branch Endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, Ariz) iliac branch devices (IBDs) in treatment of dilated iliac bifurcations in patients with similar anatomic and clinical preoperative features. METHODS: Between July 2007 and May 2018, 190 IBDs were implanted at two high-volume Italian vascular and endovascular centers. Among the series, preoperative propensity score matching based on preoperative anatomic and clinical factors was performed, and two homogeneous groups were created: group 1, 35 Cook ZBIS IBD implants; and group 2, 35 Gore IBE devices. Early results were analyzed in terms of technical success, death, conversion to open surgery, and occurrence of major local and systemic complications. Follow-up results were analyzed in terms of patency of the IBD, freedom from type I and type III endoleaks, aneurysm-related reintervention, and aneurysm-related death. RESULTS: Technical success was achieved in all implants from both groups. Perioperative IBD-related complications and major complications occurred in one case from group 1 (P = .49). No perioperative mortality was recorded in the two groups. Mean postoperative follow-up was 46.7 months in group 1 (standard deviation, ± 36.3) and 20.8 months in group 2 (standard deviation, ± 15.9; P < .0001). None of the IBDs or target hypogastric arteries occluded during follow-up in this series. Estimated 36-month freedom from type I and type III endoleaks was 97% (standard error [SE], 0.03) in group 1 and 87% (SE, 0.09) in group 2 (P = .34; log-rank, 0.9). Estimated freedom from IBD-related reintervention was 97% (SE, 0.03) in group 1 and 93% (SE, 0.06) in group 2 (P = .81; log-rank, 0.05). The estimated rates of overall survival at 36 months from the IBD implantation were 95% (SE, 0.04) in group 1 and 88% (SE, 0.08) in group 2 (P = .03; log-rank, 4.7); freedom from aneurysm-related death was 100% in group 1 and 93% (SE, 0.06) in group 2 (P = .19; log-rank, 1.7). CONCLUSIONS: The propensity score-matched comparison between the Cook ZBIS and Gore IBE devices showed similar, satisfying perioperative and midterm results in the experience of two high-volume Italian vascular centers.

Results of the multicenter pELVIS Registry for isolated common iliac aneurysms treated by the iliac branch device.

OBJECTIVE: We evaluated the short- and long-term results of off-label use of iliac branch devices (IBDs) in isolated common iliac artery aneurysms compared with the manufacturer-recommended configuration with additional extension in the infrarenal aorta based on the pELVIS Registry (pErformance of iLiac branch deVIces for aneurysmS involving the iliac bifurcation). METHODS: Between January 2005 and April 2017, 804 patients underwent endovascular aneurysm repair with 910 IBDs owing to aneurysmal involvement of the iliac bifurcation in nine high-volume European vascular centers. Among this cohort, 231 IBDs were implanted in 207 patients to treat an isolated common iliac aneurysm; 91 IBDs (group 1) were implanted without proximal aortic extension in the infrarenal aorta, and in the remaining cases (n = 140; group 2) an aortic bifurcated stent graft was deployed proximally as stated in the instructions for use. Primary outcomes were IBD and target hypogastric artery occlusions, type I and III endoleaks, procedure-related reinterventions, and aneurysm-related deaths. RESULTS: Technical success was achieved in 90 cases (98.9%) in group 1 versus 137 cases (97.8%) in group 2 (P = .55). The overall aneurysm-related early reintervention rate for the two groups was 4.4% (4 of 91) and 2.1% (3 of 140), respectively (P = .33). The 30-day mortality was 1.1% in group 1 (n = 1), and 0% in group 2 (P = .21). The median postoperative follow-up in groups 1 and 2 were 34.1 months (range, 1-108 months) and 17.5 months (range, 1-90 months), respectively. The estimated rates of freedom from IBD occlusion at 60 months were 86% in group 1 and 83% in group 2 (P = .69). The estimated rates of freedom from target hypogastric artery occlusion at 60 months were 98.3% in group 1 and 91.3% in group 2 (P = .45). The estimated freedom from reintervention rates at 60 months for types I, types III, and IBD stenosis-occlusion were 78.2% in group 1 and 79.9% in group 2 (P = .79). The estimated freedom from all cause reintervention at 60 months was 64.5% in group 1 and 66.1% in group 2 (P = .44). The estimated freedom from aneurysm-related death at 60 months was 97.9% in group 1 and 100% in group 2 (P = .83). CONCLUSIONS: Single IBD placement for isolated common iliac artery aneurysms seems to be a safe and effective treatment option, when a proper anatomic patient selection is provided. Major benefits are represented by the decrease in X ray exposure, overall procedural time, and use of contrast medium, without affecting perioperative and long-term results in comparison with more extensive procedures.

A Propensity Matched Comparison for Open and Endovascular Treatment of Post-carotid Endarterectomy Restenosis.

OBJECTIVES: To compare results of open and endovascular management of post-carotid endarterectomy (CEA) restenosis. METHODS: This was a retrospective single centre matched case control study. From 2005 to 2015, 148 consecutive interventions for post-CEA restenosis were performed: 80 cases received carotid artery stenting (CAS) and 68 cases received redo CEA. Propensity score based matching was performed in a 1:1 ratio to compare outcomes. Coronary artery disease, degree of the carotid restenosis, timing of the re-intervention with respect to the primary intervention (greater or less than 24 months) and the presence of ipsilateral brain lesions were the covariates included in the matching. Peri-operative outcomes were analysed with χ2 tests, while late results were estimated by Kaplan-Meier methods. RESULTS: After propensity matching, 32 CAS interventions were matched with 32 redo CEAs. There were no peri-operative deaths or strokes. Cranial nerve palsy occurred in seven patients in the redo CEA group. Median duration of follow-up was 36 months (interquartile range 24-60; range 6-120). The estimated 5 year survival rate was 94% in the CAS group and 72% in the redo CEA group (p=.1, log rank 2.4). There were no significant differences between the groups in terms of stroke free survival. In the CAS group, no severe restenosis were found, while in the redo CEA group eight patients had severe restenosis or occlusion of the operated carotid artery. Freedom from secondary restenosis at 4 years was 100% in the CAS group and 72.5% in the redo CEA group (p=.005, log rank 7.9). The corresponding figures in terms of freedom from secondary re-intervention were 100% and 83%, respectively (p=.02, log rank 4.8). CONCLUSIONS: CAS and redo CEA in patients with post-CEA restenosis provided similar peri-operative results in a sample of equivalent patients. CAS patients had better follow-up results in terms of secondary restenosis and re-interventions. Further analysis is required with a larger number of patients and a longer follow-up time.

Endovascular Treatment with Primary Stenting of Acutely Thrombosed Popliteal Artery Aneurysms.

BACKGROUND: Only anecdotal cases concerning primary stenting of thrombosed popliteal artery aneurysm (PAA) without a preoperative intra-arterial thrombolysis are reported. We report our series of 6 patients treated with this technique. METHODS: Six male patients, aged between 63 and 88, came to our attention in the last 10 years for acute limb ischemia due to thrombosis of a PAA. In all the cases, immediate digital subtraction angiography was performed, the occlusion was crossed with an angiographic guidewire, and once an adequate distal landing zone was identified in the distal popliteal artery, a primary stenting was performed. RESULTS: Technical success was achieved in all the cases. One perioperative thrombosis leading to major amputation occurred, and the patient died 4 days later. The mean follow-up of the remaining 5 patients was 28.6 months, with a primary patency rate of 60% and a secondary patency rate of 80%. CONCLUSIONS: Urgent primary stenting of acutely thrombosed PAAs is feasible and can represent an alternative solution to classical surgical approaches.

Reintervention rate after infrarenal aortic aneurysm repair is lower for open than endovascular repair with aneurysm sac shrinkage: a fifteen-year study.

BACKGROUND: The aim of this study was to report long-term results of infrarenal abdominal aortic aneurysm (AAA) in a single tertiary Hospital. METHODS: One thousand seven hundred seventy-seven consecutive AAA repairs (2003-2018) were included. Primary outcomes were all-cause mortality, AAA-related mortality, reinterventions rate. Open repair (OSR) was offered in case the patient had a functional capacity ≥4 metabolic equivalents (MET), and a predicted >10 year life expectancy. Endovascular repair (EVAR) was offered in case of hostile abdomen, presence of anatomic feasibility for standard endovascular graft, and <4 MET. Sac shrinkage was defined as a reduction of both anterior-posterior and latero-lateral diameter of the sac of at least 5 mm at the last follow-up vs. the first post- operative follow-up imaging. RESULTS: Eight hundred twenty-eight (47%) OSRs and 949 (53%) EVARs were performed 90.6% (N.=1610) were male, mean age was 73.8 years. Mean follow-up was 79 (SD: 51) months. 30-day mortality was 0.7% (N.=6) and 0.6% (N.=6) for OSR and EVAR respectively (P=1). Long-term survival was better for OSR as expected by the selection criteria used (P<0.001), while AAA-related death was similar in the OSR vs. EVAR group (P=0.37); 664 (70%) sac shrinkages occurred at the last follow-up in the EVAR group. Freedom from reintervention was 97% and 96% at 1 year, 96.5% and 88.4% at 5 years, 95.8% vs. 81.7% at 10 years, and 94.6% vs.72.3% at 15 years for OSR and EVAR, respectively (P<0.001). The reintervention rate was significantly lower in the sac shrinkage vs. no-sac shrinkage subgroup and but higher than the OSR (P≤0.001). Any statistical difference was found for the survival outcome in case of sac shrinkage (P=0.1). CONCLUSIONS: Open repair of an infrarenal AAA had a lower reintervention rate than EVAR even in case of a shrinked sac at a long-term follow-up. Further studies with greater sample size are needed.

Outcomes of popliteal artery aneurysms treated by ligation and in-situ saphenous vein bypass.

BACKGROUND: Modality of elective repair (open or endovascular) of popliteal artery aneurysms (PAAs) is still debated. About open repair no strict evidence exists about the best surgical technique. The aim of this study was to report a 20-year experience with ligation and in-situ saphenous vein bypass for the elective treatment of PAAs. METHODS: A retrospective review of consecutive patients who underwent elective open surgical PAA repair in our center between January 2001 and April 2020 was performed. Ninety-two limbs in 84 patients underwent a PAA ligation and in-situ saphenous bypass. Early (30 day) outcomes were assessed. Estimated 5-year outcomes according to Kaplan-Meier curves in terms of primary patency, primary assisted patency, secondary patency, and limb salvage were evaluated. Associations of patient and procedure variables with patency and limb salvage outcomes were sought with multivariate analysis. RESULTS: Patients were predominantly male (80/84, 95.2%) with a mean age of 73.1 years (range 50-89). In all cases technical success was obtained. The mean hospital stay was 5.8 days (range 2-27). Thirty-day overall mortality (N.=1) and major amputation (N.=1) rates were both 1.2%. Mean duration of follow-up was 31.3 months (range: 1-168). At 5 years estimated rates of primary patency, primary assisted patency, secondary patency, and limb salvage were 76.3%, 81.5%, 89.9%, and 96.6%, respectively. On multivariate analysis the associations were: primary patency with PAA diameter >30 mm (P=0.007), and poor run-off status (P<0.001); primary assisted patency with poor run-off status (P<0.001); secondary patency with poor run-off status (P=0.04). Major amputation had no independent predictors of poor outcomes. CONCLUSIONS: Elective surgical treatment of PAAs with ligation and in-situ saphenous vein bypass is safe, effective and durable with good 5-year outcomes in terms of overall patency and limb salvage. Poor run-off status seemed to be an independent predictor of worse patency rates. This surgical technique should be cautiously applied in patients with PAAs with a diameter >30 mm.

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.

An unexpected intraoperative finding of cystic adventitial degeneration of the common femoral artery.

Herein we present a rare case of cystic adventitial degeneration involving the common femoral artery (CFA) of a 71-year-old patient, an unusual site of presentation of the disease. The most commonly affected district is the popliteal artery, and only a few cases of CFA involvement are described in literature. The history and comorbidities of the patient oriented us initially towards the diagnosis of an atherosclerotic obstructive disease. It was only intraoperatively indeed that a diagnosis of cystic adventitial arterial degeneration was made, subsequently confirmed by microscopic examination. Our case shows how both clinical and instrumental diagnosis of cystic adventitial disease can be challenging, given its non-specific presentation and low incidence. Suspicion of cystic adventitial degeneration is recommended in patients with sudden appearance of symptoms and with an isolated lesion of the affected artery without other involvement of the vascular tree.

Open surgical conversion for Type II endoleak following hybrid treatment of a giant aneurysm of aberrant right subclavian artery.

Type II endoleak following hybrid treatment of aneurysms of aberrant subclavian arteries (AARSA) and requiring reintervention is rare. A retroesophageal AARSA with a 70 mm diameter was treated with left and right carotid to subclavian bypasses and thoracic endografting to exclude its ostium. The distal neck was embolized with a vascular plug. At 22 months postoperatively, an angio-computed tomography (CT) scan performed for worsening of dysphagia showed the presence of a Type II endoleak from bronchial arteries with significant sac enlargement. An open surgical repair with thoracotomy, aneurysmorraphy and ligature of the feeding vessels was successfully performed.