Objective Methods to Assess Aorto-Iliac Calcifications: A Systematic Review

Vascular calcifications in aorto-iliac arteries are emerging as crucial risk factors for cardiovascular diseases (CVDs) with profound clinical implications. This systematic review, following PRISMA guidelines, investigated methodologies for measuring these calcifications and explored their correlation with CVDs and clinical outcomes. Out of 698 publications, 11 studies met the inclusion criteria. In total, 7 studies utilized manual methods, while 4 studies utilized automated technologies, including artificial intelligence and deep learning for image analyses. Age, systolic blood pressure, serum calcium, and lipoprotein(a) levels were found to be independent risk factors for aortic calcification. Mortality from CVDs was correlated with abdominal aorta calcification. Patients requiring reintervention after endovascular recanalization exhibited a significantly higher volume of calcification in their iliac arteries. Conclusions: This review reveals a diverse landscape of measurement methods for aorto-iliac calcifications; however, they lack a standardized reproducibility assessment. Automatic methods employing artificial intelligence appear to offer broader applicability and are less time-consuming. Assessment of calcium scoring could be routinely employed during preoperative workups for risk stratification and detailed surgical planning. Additionally, its correlation with clinical outcomes could be useful in predicting the risk of reinterventions and amputations.

Systematic Review and Meta-Analysis of the Outcome of Different Treatments for Innominate Artery Stenosis or Occlusion

The present study reported the outcomes of different treatments for innominate artery (IA) atherosclerotic stenosis or occlusion. We performed a systematic review of the literature (4 database searched; last search February 2022), including articles with ≥5 patients. We performed meta-analyses of proportions for different postoperative outcomes. Fourteen studies were included (656 patients; 396 underwent surgery, 260 endovascular procedures). IA lesions were asymptomatic in 9.6% (95% CI 4.6-14.6). Overall estimated technical success (TS) rate was 91.7% (95% CI 86.9-96.4); weighted TS rate was 86.8% (95% CI 75-98.6) in the surgical group (SG), 97.1% (95% CI 94.6-99.7) in the endovascular group (EG). Postoperative stroke in SG was 2.5% (95% CI 1-4.1) and 2.1% in EG (95% CI .3-3.8). Overall, 30-day occlusion was estimated .9% (95% CI 0-1.8) in SG and .7% (95% CI 0-1.7) in EG. Thirty-day mortality was 3.4% (95% CI .9-5.8) in SG and .7% (95% CI 0-1.7) in EG. Estimated mean follow-up after intervention was 65.5 months (95% CI 45.5-85.5) in SG and 22.4 months (95% CI 14.72-30.16) in EG. During follow-up, restenosis in SG were 2.8% (95% CI .5-5.1) and 16.6% (95% CI 5- 28.1) in EG. In conclusion, the endovascular approach seems to offer good short to mid-term outcomes, but with a higher rate of restenosis during follow-up.

Systematic review and meta-analysis of incidence, indications, and outcomes of early open conversions after EVAR for abdominal aortic aneurysms

INTRODUCTION

The purpose of this study is to report incidence, indications, and outcomes of early open conversions (EOC) after endovascular aortic repair (EVAR), defined as surgical conversion performed within 30 days from the initial EVAR.

EVIDENCE AQUISITION

A systematic review of the literature was performed (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search April 2023). Articles reporting EOC after EVAR comprising at least five patients were included. Meta-analyses of proportions were performed using a random-effects model.

EVIDENCE SYNTHESIS

Seventeen non-randomized studies, published between 1999 and 2022, were included. A total of 35,970 patients had previously undergone EVAR, of these 438 patients underwent EOC. Estimated incidence of EOC was 1.4% (95% CI 1.1-1.4; I2=81.66%). Specifically, in the works published before 2010 the incidence was 1.8% (95% CI 1.3-2.4; I2=74.25) while for subsequent ones it was 0.9% (95% CI 0.6-1.1; I2=69.82). Weighted mean age was 74.91 years (95% CI 72.42-77.39; I2=83.11%). Estimated rate of cause determining EOC were: access issue in 27.7% of patients (95% CI 13.8-41.6; I2=88.14%), incorrect placement of the endograft in 20.1% (95% CI 10.2-30.0; I2=76,9%), problems with "delivery system" in 9.0% (95% CI 4.9-13.1; I2=0%), aorto-iliac rupture in 8.6% (95% CI 4.5-12.6; I2=0%), endoprosthesis migration in 7.9% of cases (95% CI 3.3-12.4; I2=22.96%), failure in engaging the contralateral gate in 4.8% (95% CI 1.6-8; I2=0%), "kinking" or "twisting" of endoprosthesis in 3.3% (95% CI 0.6-5.9; I2=0%), graft thrombosis in 3.2% (95% CI 0.6-5.7; I2=0%), type Ia endoleak in 2.9% (95% CI 0.4-5.4; I2=0%), type III endoleak in 2.8% (95% CI 0.3-5.3; I2=0%) and endograft infection in 2.7% (95% CI 0.3-5.2; I2=0%). Intraoperative conversion rate was 91.1% (95% CI 85.8-96.4; I2=66.01%). Early mortality rate after EOC was 14.5% (95% CI 9.1-19.9; I2=48.31%). Mean length of stay (LOS) was 11.94 days (95% CI 6.718-17.172; I2=92.34%).

CONCLUSIONS

The incidence of EOC seems to decrease over time. Causes of EOC were mainly related to access problems and incorrect positioning of the endograft. Most of the EOC were performed intraoperatively carrying a high mortality rate.

Surgical Medical Education via 3D Bioprinting: Modular System for Endovascular Training

There is currently a shift in surgical training from traditional methods to simulation-based approaches, recognizing the necessity of more effective and controlled learning environments. This study introduces a completely new 3D-printed modular system for endovascular surgery training (M-SET), developed to allow various difficulty levels. Its design was based on computed tomography angiographies from real patient data with femoro-popliteal lesions. The study aimed to explore the integration of simulation training via a 3D model into the surgical training curriculum and its effect on their performance. Our preliminary study included 12 volunteer trainees randomized 1:1 into the standard simulation (SS) group (3 stepwise difficulty training sessions) and the random simulation (RS) group (random difficulty of the M-SET). A senior surgeon evaluated and timed the final training session. Feedback reports were assessed through the Student Satisfaction and Self-Confidence in Learning Scale. The SS group completed the training sessions in about half time (23.13 ± 9.2 min vs. 44.6 ± 12.8 min). Trainees expressed high satisfaction with the training program supported by the M-SET. Our 3D-printed modular training model meets the current need for new endovascular training approaches, offering a customizable, accessible, and effective simulation-based educational program with the aim of reducing the time required to reach a high level of practical skills.

Blood-brain barrier damage associates with glia-related cytokines in the cerebrospinal fluid of patients with Multiple Sclerosis

BACKGROUND

The presence of Blood-Brain Barrier (BBB) dysfunction is defined by albumin quotient (QALB) and characterize a group of Multiple Sclerosis (MS) patients at clinical onset. We evaluated the concentration in cerebrospinal fluid (CSF) of 87 cytokines, to better characterize the CSF inflammatory pattern in presence of BBB damage.

MATERIALS AND METHOD

In an exploratory cohort, CSF cytokines were evaluated by means of Multiplex technology (Bio-Plex Pro-Human Cytokine, GF and Diabetes 27-Plex Panel, Bio-Plex Pro-Human Chemokines 40-Plex Panel, Bio-Plex Pro-Human Inflammation Assays 37-Plex Panel) in a cohort of Other Not Inflammatory Neurological Disorders (ONIND) and in cohort of patients with MS, stratified according to BBB damage into QALB+ and QALB- MS patients. In the validation cohort, we evaluated the relevant molecules in a cohort of MS patients, stratified again into QALB+ and QALB-, including also Neurofilament Light (NfL) and Chitinase 3-like 1 (CHI3L1) CSF concentration.

RESULTS

While MIP-1α, CXCL-13, and CCL-22 CSF concentrations were higher in both MS groups compared to ONIND, in QALB+ MS CSF concentrations of CXCL-9 (17.85 ± 4.69 pg/mL), CXCL-10 (476.5 ± 324.3 pg/mL), and IL-16 (96.08 ± 86.17 pg/mL) were higher than in QALB- MS (8.98 ± 5368 pg/mL, p < 0.005, 281.0 ± 180.9 pg/mL, p < 0.05, and 47.35 ± 36.87 pg/mL, p < 0.005, respectively) and ONIND (8.98 ± 5368 pg/mlL, p < 0.005, 281.0 ± 180.9 pg/mL, p < 0.005, and 47.35 ± 36.87 pg/mL, p < 0.001, respectively). A strong correlation was observed between CXCL-9 and CXCL-10 in all MS groups (all r>0.75, all p < 0.001). In the validation cohort again CXCL-10 CSF concentration were higher in QALB+ MS than in QALB- MS (94.25 ± 64.75 vs 153.8 ± 99.52, p < 0.05), while no difference was observed in serum. CSF NfL (1642 ± 1963 vs 3231 ± 3492 pg/mL, p < 0.05) and CHI3L1 (183.9 ± 86.62 vs 262 ± 137.5 ng/mL, p < 0.05) were increased in QALB+ MS.

CONCLUSIONS

BBB damage in MS is linked to a specific CSF cytokines pattern (CXCL-9, CXCL-10, IL-16), that are also involved in astrocyte-microglia interaction. To what extent their continuous production in the CNS may mark a more severe disease course merits to be investigated.

Acute Type B Aortic Dissection Complicated With Spinal Cord Ischemia and Paraplegia Treated With Endovascular Scissor Technique

Spinal cord ischemia leading to paraplegia is a rare, life-limiting complication of acute type B aortic dissection. We report a case of spinal cord ischemia occurred in a young woman treated with endovascular scissor technique in urgent setting. The patient had an uneventful post-procedural course. After 4 months, computed tomography angiography confirmed false lumen reperfusion and major symptoms were regressed. In selected cases, this procedure is a tool to improve false lumen perfusion in type B dissections, and demonstrated to be helpful in our case of spinal cord ischaemia.

Endovascular and Surgical Venous Arterialization for No-Option Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis

BACKGROUND

Chronic limb-threatening ischemia (CLTI) is known for its high rates of major amputation and mortality. Conventional revascularization techniques often fail in CLTI patients due to the heavily diseased arteries. Foot vein arterialization (FVA) has been proposed as an alternative technique to provide arterial blood to the foot by using the disease-free venous bed.

OBJECTIVES

This systematic review and meta-analysis aimed to determine outcomes of surgical FVA (sFVA) and percutaneous FVA (pFVA) at 6 and 12 months post-procedure.

DATA SOURCES

PubMed, Scopus, Web of Science, and the Cochrane Library databases were searched to identify papers reporting clinical outcomes of sFVA and pFVA published between January 1966 and March 2023.

METHODS

Databases were searched for eligible studies. A meta-analysis was performed to evaluate the limb salvage rate, overall survival rate, and wound healing rate at 6 and 12 months.

RESULTS

A total of 27 studies were included, with 753 patients and 793 limbs. Of the included studies, 16 analyzed the sFVA technique and 11 the pFVA technique. Of the included patients, 86.3% were Rutherford 5/6 in the sFVA group versus 98.4% in the pFVA group. The pooled limb salvage rate at 6 and 12 months was 78.1% and 74.1% in the sFVA group and 81.7% and 78.6% in the pFVA group, respectively. Wound healing rates were not reported in the sFVA group. In the pFVA group, the pooled wound healing rates were 48.1% and 64.5% at 6 and 12 months, respectively.

CONCLUSION

This study showed promising results after FVA among a large population of CLTI patients. In high-risk patients, pFVA is a feasible option with favorable limb salvage and wound healing rates.

Single-Stage Procedure of Transcatheter Aortic Valve Replacement and Endovascular Aneurysm Repair Under Local Anaesthesia and Percutaneous Access

PURPOSE

Abdominal aortic aneurysms (AAA) are observed in 6% of patients with concomitant aortic valve stenosis (AS) requiring aortic valve replacement. Optimal management of these concomitant pathologies is still debated.

CASE REPORT

An 80-year-old man presented with acute heart failure due to a severe AS. Past medical history included AAA under regular surveillance. A thoracic and abdominal computed tomography angiography (CTA) confirmed a 6 mm increase of AAA over an 8-month period (max 55 mm). A multidisciplinary team prescribed a simultaneous endovascular approach of transcatheter aortic valve implantation (TAVI) followed by endovascular aneurysm repair (EVAR) under local anaesthesia with bilateral femoral percutaneous access. No intra or post-procedural complications were registered; technical success was confirmed by completion angiography and post-operative ultrasound. The patient was discharged on postoperative day 5. A 2-month post-operative CTA confirmed ongoing technical success.

CONCLUSION

Combined TAVI and EVAR under local anaesthesia for AS and AAA was associated with reduced hospital stay and technical success at 2 months from intervention in this case report.

Twenty-Five Year Multicentre Experience of Explantation of Infected Abdominal Aortic Endografts

We report a multicenter experience of open conversions (OC) for aortic endograft infections (AEI). We retrospectively analyzed all patients who underwent OC for AEI after endovascular aneurysm repair (EVAR), from 1997 to 2021 in 12 Italian centers. The endpoints were as follows: mortality (30-days, in-hospital), major postoperative complications. Follow-up data included: survival, aortic-related complications, infection persistence or reoccurrence. Fifty-eight patients (mean age: 73.8 ± 6.6 years) were included. Median time from EVAR to OC was 14 months (interquartile range 7-45). Thirty-five patients (60.3%) were symptomatic at presentation. Aortic reconstruction was anatomic in 32 patients (55.2%), extra-anatomic in 26 (44.8%). Thirty-day mortality was 31% (18/58). Six additional patients died after 30 days during the same hospitalization (in-hospital mortality: 41.4%). Most common post-operative complications included respiratory failure (38.6%) and renal insufficiency (35.1%). During 28.1 ± 4 months follow-up, 4 aneurysm-related deaths were recorded. Infection re-occurred in 29.4% of the patients. Estimated survival was 50% at 1 year, and 30% at 5 years, and was significantly lower for patients who underwent extra-anatomic reconstructions (37 vs 61% at 1 year, 16 vs 45% at 5 years; log-rank P = .021). OC for AEI is associated with high early mortality. The poor mid-term survival is influenced by aortic complications and infection re-occurrence.

Carotid endarterectomy in asymptomatic octogenarians: Outcomes at 30 days and 5 years

BACKGROUND

The following study investigated the 30-day and 5-year relative survival rate and freedom from neurological events in asymptomatic carotid stenosis (ACS) octogenarians who had undergone elective carotid endarterectomy (CEA).

METHODS

Between January 2008 and June 2014, a retrospective review was conducted on ACS patients who had undergone elective CEA. The patients' sample was divided into two groups: Group A (GA) included octogenarians and Group B (GB) included younger patients. The GA patients were subjected to a risk-scoring system and follow-up. The two groups were compared analysing the following primary endpoints: 30-day mortality, stroke, stroke/death and acute myocardial infarction (AMI); GA patients' survival rate and freedom from neurological events at 5 years. The 30-day secondary endpoints included carotid shunting, redo surgical, need for general anaesthesia with preserved consciousness (GAPC) conversion and length of hospital stay.

RESULTS

We identified 620 patients with ACS, of them 144 (23.2%) belonged to the GA and 476 (76.8%) belonged to the GB. No statistical difference between the two groups was found regarding the primary and secondary endpoints. One hundred nineteen of 144 GA patients (82.6%) underwent the follow-up; the median follow-up was 78.3 months. The GA patients' 5-year survival rate was 62%, while freedom from cerebral events was 94.9%. Analysis regarding GA patients' 5-year survival rate revealed a significantly lower percentage among the patients with a severe risk score compared with those with a moderate risk score (respectively, 29.5% vs 67.7%; p = .005). The multivariate analysis showed that chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were independently associated with lower survival.

CONCLUSIONS

The 30-day outcomes of CEA in octogenarians are comparable to those in younger patients. Comprehensive life expectancy and preoperative score, rather than age alone, should be taken into account before performing CEA on octogenarian patients, considering the short- and long-term efficacy in stroke prevention.

Occult endoleaks revealed during open conversions after endovascular aortic aneurysm repair in a multicenter experience

BACKGROUND

An occult endoleak (OE) may be the underlying cause of aneurysm sac expansion after endovascular aneurysm repair (EVAR). The aim of this study is to describe intraoperative findings of OE during surgical endograft explantations.

METHODS

This is a retrospective, multicenter analysis of all open conversions (OC) after EVAR from 1997 to 2020 in 12 vascular centers. We excluded patients with a preoperative diagnosis of endograft infection, endograft thrombosis, and thoracic-EVAR. An OE was defined as an endoleak revealed during OC not shown on preoperative imaging, which was likely the real cause for sac enlargement. We reported the number of OE, and we described the type of OE in relation to the initial alleged or associated endoleak. A separate analysis of patients with an initial diagnosis of endotension was also performed.

RESULTS

An OE was found in 32/255 patients (12.5%). In the 78.1% of the cases (25/32) a type II endoleak hid a type I or III endoleak. Endotension was the initial diagnosis of 26/255 patients (10.2%). In 4/26 cases (15.4%), a type I or II OE was revealed. In 5/26 cases (19.2%) an endograft infection was found intraoperatively. In 2/26 cases we found an angiosarcoma. Fifteen cases of endotension (57.7%) remained unexplained.

CONCLUSIONS

OE represent a not negligible cause of EVAR failure. A type II endoleak associated with sac enlargement may actually conceal a higher-flow endoleak. In most of the cases, the initial diagnosis of endotension remains unexplained. However, endotension sometimes conceals severe underlying pathologies such as infections.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Multicentre Comparison between Open Conversions and Semi-Conversions for Late Endoleaks after EVAR

OBJECTIVES

The aim of this study is to compare early and follow-up outcomes of late open conversions (LOC, with complete or partial endograft explantation) and semi-conversions (SC, with endograft preservation) after EVAR in a multicentre experience.

MATERIALS AND METHODS

All-LOC and SC performed from 1997 to 2020 in 11 vascular centres were compared. Endograft infections or thrombosis were excluded. Primary endpoints were early mortality, and long-term survival estimates. Secondary endpoints were differences in: postoperative complication rates, conversion-related complications during follow-up.

RESULTS

In the considered period, 347 patients underwent surgery for EVAR complications. Among these, 270 were operated on for endoleaks (222 LOC, 48 SC). The 2 groups were homogeneous in terms of ASA score (3.2±0.7 LOC, 3±0.5 SC; P=.128) and main endograft characteristics (suprarenal fixation, bifurcated/aorto-uni-iliac configuration). Mean age was 75±8 at LOC and 79±7 at SC (P=.009). Reasons for LOC were: 62.2% (138/222) type I endoleak, 21.6% (48/222) type II, 7.7% (17/222) type III, 8.5% (19/222) endotension. Indications for SC were: 64.6% (31/48) type II endoleak, 33.3% (16/48) type I, 2.1% (1/48) type III. Thirty-day mortality was 12.2% (27/222) in the LOC group, and 10.4% (5/48) in the SC group (P=.73). Postoperative complication rate was higher in the LOC group (45.5% vs. 29.2%, P=.04). The estimated survival rate after LOC was 80% at 1 year and 64% at 5 years; after SC 72% at 1 year and 37% at 5 years (log-rank P=.01). During the median follow-up of 21.5 months (inter-quartile range 2.4-61), an endoleak after SC was found in the 38.3% of the cases; sac growth was recorded in the 27.7% of SC patients.

CONCLUSIONS

SC have an early benefit over LOC in terms of reduced postoperative complications, but a significantly inferior mid-term survival. The high rates of persistent and/or recurrent endoleaks reduce SC durability.

Multiple sclerosis epidemiological trends in Italy highlight the environmental risk factors

Italy is definitely a high-risk country for multiple sclerosis (MS). Over the last 50 years, several epidemiological studies, including longitudinal surveys, have disclosed that MS incidence and prevalence in Italy mainland and Islands (Sardinia and Sicily) have progressively increased, picturing a semi-parabolic curve. Based on the comprehensive scrutiny of 58 papers, we conclude that the latitude risk gradient does not fit to the Italian map of MS. The genetic heterogeneity of the Italian ethnicities, that likely forms the basis of MS predisposition, does not account for the dramatic increase of MS incidence and prevalence observed in Italy over the last half century that, rather, seems better explained by the effect of environmental factors.

The Utility of Intraoperative Contrast-enhanced Ultrasound for Immediate Treatment of Type Ia Endoleak during EVAR: Initial Experience

Objectives:

Type Ia endoleak (EL) after endovascular abdominal aortic repair (EVAR) may be misdiagnosed at completion angiography. Intraoperative contrast-enhanced ultrasound (CEUS) may play a role in early detection and immediate treatment of type Ia EL.

Methods:

From January 2017 to April 2018, patients treated with EVAR underwent intraoperative CEUS. After endograft deployment and ballooning, digital subtraction angiography (DSA) and intraoperative CEUS were performed in a blinded fashion. All cases of type Ia EL at DSA or CEUS were considered.

Results:

Type Ia EL detected at intraoperative CEUS and undetected at DSA was defined in 2 patients. The former was solved with intraoperative re-ballooning; in the latter case, a Palmaz stent deployment was required. The resolution of type Ia EL was detected at intraoperative CEUS control and post-operative computed tomography angiography (CTA). In another patient, the DSA detected a type Ia EL, but intraoperative CEUS reveal a type II EL from lumbar arteries. Post-operative CTA confirm the type II EL.

Conclusions:

The reported cases prove the clinical utility of the intraoperative CEUS, permitting the early identification of 2 type Ia EL. In addition, the intraoperative CEUS is useful in case of dubious type Ia EL at DSA, avoiding unnecessary intraoperative adjunctive procedure or post-operative CTA. (www.actabiomedica.it)

Endovascular Treatment of Persistent Sciatic Artery Occlusion: Case Report and Literature Review

Persistent sciatic artery (PSA) is a rare congenital anatomic variant of the lower limb vascular system with highly variable presentations. The management of lower limb ischemia due to PSA disease is not specifically recommended in guidelines, and surgical by-pass is usually the most described treatment. We reported a case of a 46-year-old patient with bilateral PSA and right chronic limb-threatening ischemia due to PSA occlusion at the PSA-popliteal junction which was successfully treated with percutaneous transluminal balloon angioplasty. In addition to this case report, a systematic review of the literature regarding the endovascular management of PSA stenosis and occlusion was conducted.

High rates of sustained virological response despite premature discontinuation of directly acting antivirals in HCV-infected patients treated in a real-life setting

In routine clinical practice, hepatitis C virus-infected patients can prematurely discontinue the prescribed regimen for several reasons. The aim of our study was to investigate sustained virological response (SVR12) rates in patients who prematurely discontinued directly acting antiviral (DAA) regimens and to assess the shortest effective duration of DAA able to lead to SVR12. We retrospectively collected the SVR rates of patients, registered in the NAVIGATORE-Lombardia Network database from January 2015, who discontinued DAAs before the predefined end of treatment. Overall, we included 365 patients, males were the majority (213, 58.4%), mean age was 60.5 years, and 53 (14.5%) patients were HIV-co-infected. Liver cirrhosis was observed in 251 (68.8%) subjects, and the most represented genotypes were 1b (n = 168, 46%) and 3 (n = 59, 16.2%). DAA was discontinued a median of 1 (IQR 1-4) weeks before the predefined EOT, with 164 (44.9%) patients stopping DAAs at least 2 weeks before the planned schedule. In patients with F0-F3 liver fibrosis, lower rates of SVR12 were observed in patients treated for <4 weeks: 50% (n = 2/4) vs. 99.1% (n = 109/110) for ≥4 weeks, p = 0.003. In patients with liver cirrhosis, lower rates of SVR12 were observed in patients treated <8 weeks: 83.3% (n = 25/30) vs. 94.6% (n = 209/221) for ≥8 weeks, p = 0.038. Despite premature discontinuation of DAA, high SVR12 rates were observed in a real-life setting for treatment lasting at least 4 weeks in patients with liver fibrosis F0-F3 and 8 weeks in those with liver cirrhosis. On this basis, feasibility of reducing DAA treatment duration should be explored in randomized clinical trials.

Loss of Prosthetic Aortic Valve during TAVI Procedure: Endovascular Treatment in Emergent Setting

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has proven over the years to be a viable alternative to open surgery. A rare but severe complication is represented by the valve migration. We report a case of TAVI complication due to the loss of the prosthetic valve in the abdominal aorta treated by endovascular approach.

METHODS

An 88-year-old patient with severe aortic valve stenosis, symptomatic for dyspnea was proposed for a TAVI because considered at high risk for surgery. During the TAVI procedure, the undeployed device (Edwards SAPIEN 3 - Edwards Lifesciences, Irvine, CA, USA) detached from its delivery system. Several attempts to withdraw the valve fluctuating in the aorta into its supporting system were performed without success. An emergency endovascular treatment was promptly planned to obtain the exclusion from the flow of the embolized valve. Under local anaesthesia, through the percutaneous femoral access already present, a tube aortic endograft (Endurant^TM II, Medtronic, Santa Rosa, CA; ETTF2828C70EE) was successfully introduced and deployed in the infrarenal aorta without any related complications. The embolized valve was completely covered by the endgraft and thus fixed to the aortic wall. The first postoperative computer tomography angiography (CTA) confirmed the correct placement of the endograft, the exclusion of the valve from the flow and the patency of the great vessels. No perioperative or postoperative complications were recorded. The patient was discharged on the ninth postoperative day with the indication to a new attempt of TAVI, through transapical access.

CONCLUSIONS

In case of intraprocedural loss of an undeplyed valve during TAVI, the valve fixing through endograft deployment in infrarenal aorta is a possible solution.

Twelve years of experience in carotid endarterectomy with general anesthesia and preserved consciousness

BACKGROUND

Carotid endarterectomy (CEA) can be performed both under general anesthesia (GA) or local anesthesia (LA) with good results. General anesthesia with preserved consciousness (GAPC) using remifentanil infusion has been already reported in literature and could potentially merge the advantages of GA and LA overcoming the disadvantages of this last technique. Although the good results of GAPC reported in literature, this technique is not widespread in clinical practice. The aim of this study was to report the perioperative results of CEA under GAPC in a large series of consecutive patients.

METHODS

This is a retrospective, single center, observational study including all patients treated for CEA under GAPC in our institution between January 2008 and October 2019. Primary endpoints were neurological complications rate, mortality rate in the perioperative period, need to GAPC conversion to GA during surgery and evaluation of the technique with a specific questionnaire regarding patients' satisfaction. Secondary endpoints were myocardial infarction (MI) rate, other perioperative complications rate, rate of intraoperative shunting and need of reintervention in the perioperative period.

RESULTS

In the considered period 1290 CEA under GAPC were performed and included in this study. Neurological complications rate was 2.01%, mortality rate in the perioperative period was 0.07%, need of GAPC conversion to GA rate during surgery was 0.46% and patients satisfaction regarding the technique were high with a mean vote of 9.1 in a 0 to 10 scale. In the perioperative period MI rate was 0.23%, other perioperative complications rate was 1.39%, intraoperative shunting rate was 7.1% and reintervention rate after surgery was 2.4%.

CONCLUSIONS

CEA under GAPC may combine the advantages of LA and GA, with a very low rate of conversion to GA during surgery and good patients' satisfaction. Moreover, it does not increase neurological, cardiologic and systemic complications. For these reasons CEA under GAPC could represents a valid alternative to GA or LA.

Surgical and Endovascular Management of Isolated Internal Iliac Artery Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVES

The purpose of this paper is to report the different modalities for the treatment of isolated internal iliac artery aneurysms (IIIAA), as well as their outcomes.

METHODS

We performed a systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search: April 2020). We included articles reporting on the outcomes for IIIAA interventions comprising at least 5 patients. Studies were included when presenting extractable outcome data regarding intraoperative and/or early results. We performed meta-analyses of proportions for different outcomes, using random effects model.

RESULTS

Thirteen non-randomized studies were included (192 patients with 202 IIIAA). IIIAA were symptomatic in the 18.1% (95%CI 9.3-26.9; I² 54.46%, P = .019). Estimated mean IIIAA diameter was 46.28 mm (95%CI 39.72-52.85; I² 88.85%, P < .001). Open repair was performed in 21/202 cases. Endovascular treatments were: embolization (81/181), embolization and hypogastric artery coverage (79/181), hypogastric artery coverage by stent-grafting (15/181), stent-grafting in the hypogastric artery (6/181). Overall estimated technical success (TS) rate was 91.6% (95% CI 86.8-95.5; I² 45.82%, P = .031). TS rate was 94.5% for open surgery (95%CI 85.3-100; I² 0%, P = .907), and 89.7% for endovascular repair (95%CI 83.8-95.6; I² 55.43%, P = .006). Estimated overall 30-day mortality was 3.1% (95%CI 0.8-5.4; I² 0%, P = .969). Mortality rates after open surgery and endovascular repair were 8.2% (95%CI 3.4-19.8; I² 0%, P = .545) and 2.8% (95%CI 0.5-5.1; I² 0%, P = .994), respectively. Estimated mean follow-up was 32.63 months (95%CI 21.74-43.53; I² 94.45%, P < .001). During this timeframe, IIIAA exclusion was preserved in 92.8% of the patients (95%CI 89.3-96.2; I² 0%, P = .797). Buttock claudication occurred in 13.9% of the patients (95%CI 8.7-19.2; I² 0%, P = .622).

CONCLUSIONS

IIIAA are frequently large, and symptomatic at presentation. Several treatments are proposed in literature, open and endovascular, both with good results. The endovascular treatment is the preferred method of treatment in literature, since it offers good short- to mid-term results and low early mortality. Buttock claudication after hypogastric artery exclusion is a common complication.

Author Correction: In-vivo vascular application via ultra-fast bioprinting for future 5D personalised nanomedicine

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Floating Stent-Graft as a Support to Bridge an Unfavorable Renal Artery During Postdissection TAAA Repair Using a Multibranched Thoracoabdominal Endograft

Purpose: To report an unusual endovascular technique to manage unfavorable renal artery anatomy encountered in an urgent case of symptomatic postdissection thoracoabdominal aortic aneurysm (TAAA) treated with an off-the-shelf multibranched device. Technique: The technique is demonstrated in a 77-year-old woman who had a history of previous open abdominal aortic aneurysm repair and an emergent procedure to implant a thoracic endograft and an aortic bare Z-stent (PETTICOAT) for acute Stanford type B dissection 7 years prior. The patient presented with a symptomatic, rapidly growing, postdissection TAAA. Endovascular treatment with a Zenith t-Branch was planned. After standard catheterization techniques failed in the left renal artery, a bailout maneuver was utilized to place a "floating" Viabahn stent-graft in the aneurysm sac to create sufficient support to deliver the bridging stent-grafts through the bare stent to the target left renal artery. The procedure was successful in excluding the TAAA and preserving perfusion to all target vessels. No neurological complications occurred. Six-month imaging follow-up confirmed the patency of the bridging stents. Conclusion: Remodeling changes after complex endovascular TAAA procedures often require the use of innovative techniques and materials during secondary procedures. In this case, the presence of a post-PETTICOAT bare aortic stent and hostile target artery anatomy increased the technical difficulty of t-Branch implantation. A "floating" stent-graft could be useful to reach challenging target vessels by providing additional support to bridging stent advancement and deployment.

Complete Relining in Type 3 Endoleak with AFX Endograft Billowing and Severe Kinking: A Case Report

BACKGROUND

Type 3 endoleak (T3E) is usually treated by endovascular relining. The procedure can be technically complex in cases of endografts with kinking of innermost stents. We report a case of T3E in an AFX (Endologix, Irvine, CA, USA) endograft with sac enlargement, billowing, and severe kinking of the main body stents, managed with a complete relining endovascular procedure.

METHODS

A 69-year-old man with severe comorbidities and prior aorto-bi-iliac AFX endograft completed by an Endurant II cuff (Medtronic, Santa Rosa, CA, USA) for a 63-mm asymptomatic infrarenal aneurysm was admitted to our department for a T3E with 7-mm sac enlargement. The computed tomography angiography (CTA) showed perfusion of the aneurysmal sac, AFX fabric disconnection from its stent (billowing), and severe stent kinking of the main body without a residual lumen. A digital subtraction angiography confirmed the T3E. A complete relining was performed by deploying a bifurcated Endurant II through the AFX stents.

RESULTS

The 1-year CTA proved the resolution of the endoleak with a stable aneurysmal sac diameter.

CONCLUSIONS

In case of T3E with severe main body stent kinking and graft billowing, an endovascular procedure with a complete aorto-bi-iliac relining through inner stents may be considered.

Outcomes of Surgical and Endovascular Treatment for Arterial Lesions in Intravenous Drug Abusers

BACKGROUND

The objective of this study is to report an 18-year single-center experience in the surgical and endovascular treatment of arterial complications due to self-injection in drug abuser patients.

METHODS

This retrospective single-center study was conducted analyzing a prospectively collected database including all endovascular or surgical procedures performed from January 2007 to December 2019 for any arterial complication due to self-injection in drug abuser patient. Collected data were patient demographic and comorbidity, site and type of arterial lesion (pseudoaneurysm [PA], arteriovenous fistula [AVF]), signs of systemic or local infection, and procedural data (endovascular/surgical treatment). End points were rate of postoperative complications, reintervention rate, limb salvage, and patients' early and long-term survival.

RESULTS

In 11 patients (median age 36 years, range 27-47; male 73%), 13 arterial lesions were treated: 10 (77%) PA, 2 (15%) PA associated with AVF, and 1 (8%) isolated AVF. Arterial lesion involved common femoral artery in 5 (38%), superficial femoral artery in 4 (31%), profunda femoral artery in 1 (8%), brachial artery in 2 (15%), and subclavian artery in 1 (8%). Signs of infections were present in 9 of the 13 cases (69%). The treatment was surgical in 11 (85%) cases: 7 interposition graft (6 great saphenous vein, 1 arterial cryopreserved homograft), 2 direct reconstruction, 1 patch plasty with pericardium bovine patch, and 1 arterial ligation. Endovascular treatment was performed in 2 cases: 1 noninfected PA of the superficial femoral artery, and 1 55-mm PA of the postvertebral segment of the right subclavian artery with clinical sign of hemodynamic instability. At 1 month, postoperative complication rate was 8% (one lower limb claudication after superficial femoral artery ligation). Reintervention rate was 8% (interposition graft rupture for repeated self-injections). Limb salvage and patient survival were both 100%. Median follow-up was 5 years (range 1 month to 11.3 years); surgical group: median 8.2 years (range 2 months to 11.3 years); endovascular group: median 3.5 months (range 1-6). During follow-up, neither complications nor reinterventions occurred, and limb salvage was 100% for both groups. At 2, 4, and 6 years, overall estimated patient survival was 91%, 81%, and 81%, respectively, with no procedure-related death.

CONCLUSIONS

After surgical or endovascular management of arterial lesions due to self-injection in drug abuser patients, complications occur mainly in the postoperative period. During follow-up, the surgical procedures have low rate of complications, reinterventions, and procedure-related mortality, whereas for the endovascular treatment the mid-term outcomes remain unknown.

Prevalence, risk factors and clinical impact of intraprosthetic thrombus deposits after EVAR

BACKGROUND

The aim was to define the prevalence, the evolution and the clinical relevance of the intraprosthetic thrombus deposit (IPT) after endovascular abdominal aortic repair (EVAR).

METHODS

Patients treated with EVAR from 2009 to 2017 for abdominal aortic aneurysm were retrospectively considered. Patients with at least one postoperative computed tomography angiography (CTA) performed after a 3-month follow-up were included. Postoperative medical therapy (antiplatelet and/or oral anticoagulant) were recorded. Aorto-iliac anatomical characteristics were measured on pre-operative CTA, while structural and dimensional endograft features were extracted from instructions for use. IPT was defined as intra-endograft thrombus with minimum thickness of 2mm and longitudinally extended for minimum 4 mm, and was assessed in all postoperative CTA. Primary endpoints were freedom from IPT occurrence, risk factors for IPT and evolution of IPT. Secondary endpoints were the prevalence of overall and IPT-related tromboembolic events (TEE: main-body or limb occlusion, distal embolization) during follow-up and its correlation with IPT.

RESULTS

Two-hundred twenty-one patients (mean age 76±7 years; male 94%) were included. Deployed endografts were: aorto-biiliac 96%, aorto-uniiliac 3%, aortic tube 1%; dacron 90%, ePTFE 10%. Mean follow-up was 30±25 months. Overall IPT prevalence was 36% (80/221). At 6, 12, 24 and 48 months, overall estimated freedom from IPT occurrence was 86%, 80%, 60% and 52%, respectively (Kaplan-Meier analysis). At Cox uni-variate analysis, postoperative medical therapy has no influence on IPT; aorto-iliac anatomical risk factors for IPT were larger neck diameter (P<0.001), severe neck thrombus (P=0.043), higher percentage of sac thrombus (P<0.001), hypogastric occlusion/coverage (P=0.040); endograft risk factors were proximal diameter ≥30mm (P<0.001), longer main body (P=0.002), dacron fabric (P=0.025), higher ratio between main body area/gate areas and main body area/distal iliac areas (P<0.001 and P<0.001, respectively). At Cox multi-variate analysis, independent risk factors for IPT were larger neck diameter (P=0.003), higher percentage of sac thrombus (P=0.005) and longer main body (P=0.028). During follow-up, IPT disappeared in 14 cases (18%). Overall TEE prevalence was 4% (8/221) and overall estimated freedom from TEE occurrence at 6, 12, 24 and 48 months was 99%, 99%, 95.3%, 94.1%, respectively (Kaplan-Meier analysis). TEE was IPT-related in 5/8 cases (63%). No statistical correlation were found between IPT and TEE.

CONCLUSIONS

The development of intraprosthetic graft thrombus (IPT) is a frequent event after EVAR. The risk of IPT is closely correlated with the proximal aortic neck size, the presence of intra-aneurysmal sac thrombus, and the length of the endograft main body. However, there was no statistical correlation between the presence of IPT and TEE.

Comparison of three therapeutic regimens for genotype-3 hepatitis C virus infection in a large real-life multicentre cohort

BACKGROUND & AIMS

In the direct-acting antiviral era, treatment of genotype-3 HCV (HCV-GT3) is still challenging. Real-life comparisons between recommended regimens, sofosbuvir (SOF)+daclatasvir (DAC), SOF/velpatasvir (VEL), glecaprevir/pibrentasvir (GLE/PIB), are scarce. We aimed at filling this data gap.

METHODS

Sustained virological response 12 weeks after treatment completion (SVR12) was assessed for all HCV-GT3 patients consecutively treated within the Lombardia web-based Navigatore HCV-Network; differences in SVR12 across regimens were evaluated by logistic regression.

RESULTS

Of the 2082 subjects with HCV-GT3, 1544 were evaluable for comparisons between regimens: SOF + DAC (1023, 66.2%), SOF/VEL (369, 23.9%), GLE/PIB (152, 9.8%). Patients treated with former regimens were more frequently male, cirrhotic, HIV-positive, pretreated, used ribavirin in their regimen, and had lower baseline HCV-RNA. SVR12 was similar across groups: 94.8% in SOF + DAC, 97.6% in SOF/VEL, 96.7% in GLE/PIB (P = .065). At univariate analysis, SVR12 was associated with female gender (97.9% vs 94.8%, P = .007) and lower median pretreatment Log₁₀ HCV-RNA (5.87 vs 6.20, P = .001). At multivariate logistic regression analysis, treatment with SOF/VEL was associated with a higher likelihood of SVR12 than SOF + DAC, but only in the absence of ribavirin (98% vs 90.3%). Female gender and lower pretreatment HCV-RNA were independently associated with SVR12.

CONCLUSIONS

In a large real-life setting of HCV-GT3-infected patients with a high proportion of cirrhosis, the success rate was remarkable. The slight advantage of SOF/VEL on SOF + DAC was significant only without ribavirin. The current prescription shift towards novel regimens (ie SOF/VEL and GLE/PIB) in easier-to-treat patients allows ribavirin-free and shorter schedules without mining SVR12 in this <<difficult-to-treat>> genotype.

In-vivo vascular application via ultra-fast bioprinting for future 5D personalised nanomedicine

The design of 3D complex structures enables new correlation studies between the engineering parameters and the biological activity. Moreover, additive manufacturing technology could revolutionise the personalised medical pre-operative management due to its possibility to interplay with computer tomography. Here we present a method based on rapid freeze prototyping (RFP) 3D printer, reconstruction cutting, nano dry formulation, fast freeze gelation, disinfection and partial processes for the 5D digital models functionalisation. We elaborated the high-resolution computer tomography scan derived from a complex human peripheral artery and we reconstructed the 3D model of the vessel in order to obtain and verify the additive manufacturing processes. Then, based on the drug-eluting balloon selected for the percutaneous intervention, we reconstructed the biocompatible eluting-freeform coating containing 40 nm fluorescent nanoparticles (NPs) by means of RFP printer and we tested the in-vivo feasibility. We introduced the NPs-loaded 5D device in a rat's vena cava. The coating dissolved in a few minutes releasing NPs which were rapidly absorbed in vascular smooth muscle cell (VSMC) and human umbilical vein endothelial cell (HUVEC) in-vitro. We developed 5D high-resolution self-dissolving devices incorporating NPs with the perspective to apply this method to the personalised medicine.

Intraoperative contrast-enhanced ultrasound for early diagnosis of endoleaks during endovascular abdominal aortic aneurysm repair

BACKGROUND

The aim of this study was to evaluate the feasibility and utility of intraoperative contrast-enhanced ultrasound (CEUS) for early detection of endoleaks (ELs) during endovascular abdominal aortic aneurysm repair (EVAR) compared with completion digital subtraction angiography.

METHODS

Patients undergoing elective EVAR from January 2017 to April 2018 were consecutively enrolled in this prospective study. After endograft deployment, two-digital subtraction angiography (2DSA) with orthogonal C-arm angulations (anteroposterior and sagittal view) were routinely performed. After the endovascular treatment of clear, high-flow type I/III ELs detected by 2DSA, intraoperative CEUS was carried out in sterile conditions on the surgical field before guidewire removal. Presence and type of EL were evaluated with 2DSA and CEUS. CEUS was performed with the vascular surgeon blinded to the 2DSA findings. The primary end point was the level of agreement between 2DSA and CEUS to detect any type of EL and type II EL. Agreement between two diagnostic methods was calculated using Cohen's kappa. The secondary end point was utility of CEUS for intraoperative adjunctive procedure guidance.

RESULTS

Sixty patients were enrolled (mean age, 78 ± 6 years; 90% male). 2DSA revealed 11 ELs (18%; 1 type IA, 10 type II), and CEUS 25 ELs (42%; 2 type IA, 23 type II). 2DSA and CEUS were in agreement in 39 cases (65%; 32 no ELs, 7 type II ELs). CEUS detected 17 ELs not identified by 2DSA (28%; 2 type IA, 15 type II); 2DSA detected three ELs not identified by CEUS (5%; 3 type II). In one case, 2DSA and CEUS detected type II and type IA ELs, respectively. For EL and type II EL detection, Cohen's kappa was 0.255 and 0.250, respectively (both "fair agreement"). Intraoperative adjunctive sac embolization was performed under CEUS control in 4 cases and technical success was 100%.

CONCLUSIONS

Intraoperative CEUS during EVAR is feasible and can detect a greater number of ELs than 2DSA, in particular type II ELs. Further studies are necessary to assess the reliability of this intraoperative diagnostic examination. In type II ELs, CEUS may represent an additional, useful tool for intraoperative sac embolization guidance.

Endovascular repair of an abdominal aortic aneurysm using bifurcated stent-graft in a patient with bilateral external iliac artery occlusion

Abdominal aortic aneurysm (AAA) in association with external iliac artery (EIA) occlusion is a rare entity which may limit endovascular aortic aneurysm repair (EVAR) feasibility. We describe the case of an 84-year-old man affected by a 64mm infrarenal inflammatory abdominal aortic aneurysm with complete bilateral occlusion of EIA and patency of both common and internal iliac arteries. The common femoral arteries (CFA) were patent, and the patient was asymptomatic for lower limb claudication. The treatment was performed by EVAR using a bifurcated stent-graft after the recanalization of the left EIA, achieving technical success.

Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: A Systematic Review and Meta-analysis

BACKGROUND

The detection of intraprosthetic thrombus (IPT) deposits is a common finding during follow-up for endovascular abdominal aneurysm repair (EVAR); however, its clinical significance is still debated. The aim of this study was to determine if IPT represents a risk factor for thromboembolic events (TEs; endograft or limb thrombosis, or distal embolization) after EVAR.

METHODS

A systematic review of English literature was undertaken until November 2017. Studies providing 2-group comparison (patients with IPT development on postoperative computed tomography angiography versus patients without IPT) with extractable outcome data (TE related to IPT and/or risk factors for IPT development) were included. Meta-analysis was performed when comparative data were given in 2 or more articles.

RESULTS

Five single-center studies (808 patients) were analyzed. IPT detection at any time during follow-up occurred in 20.8% (168/808) of patients. Extractable data for postoperative TE were available in 4 studies (613 patients): on comparative meta-analysis, IPT was not significantly associated with TE occurrence during follow-up (odds ratio 2.25, 95% confidence interval [CI] 0.50-10.1; P = 0.29). IPT is generally detected during the first year after EVAR (maximum reported median: 12 months, range: 1.2-23). Polyester graft material (odds ratio 2.34, 95% CI 1.53-3.58; P < 0.001) and aorto-uni-iliac configuration of the endograft (odds ratio 3.27, 95% CI 1.66-6.44; P = 0.001) were confirmed as risk factors for IPT formation on meta-analysis. The literature systematic review suggests that IPT formation may be also associated with long main bodies and large necks.

CONCLUSIONS

IPT detection on postoperative computed tomography angiography was not significantly associated with the occurrence of TE over time. The aorto-uni-iliac configuration and the use of polyester fabric for endografts were confirmed as risk factors for IPT development.

Two-year real-life efficacy, tolerability and safety of dimethyl fumarate in an Italian multicentre study

BACKGROUND

Dimethyl-fumarate (DMF) demonstrated efficacy and safety in relapsing-remitting multiple sclerosis (MS) in randomized clinical trials.

OBJECTIVES

To track and evaluate post-market DMF profile in real-world setting.

MATERIALS AND METHODS

Patients receiving DMF referred to Italian MS centres were enrolled and prospectively followed, collecting demographic clinical and radiological data.

RESULTS

Among the 735 included patients, 45.4% were naïve to disease-modifying therapies, 17.8% switched to DMF because of tolerance, 27.4% switched to DMF because of lack of efficacy, and 9.4% switched to DMF because of safety concerns. Median DMF exposure was 17 months (0-33). DMF reduced the annual relapse rate (ARR) by 63.2%. At 12 and 24 months, 85 and 76% of patients were relapse-free. NEDA-3 status after 12 months of DMF treatment was maintained by 47.5% of patients. 89 and 70% of patients at 12 and 24 months regularly continued DMF. Most frequent adverse events (AEs) were flushing (37.2%) and gastro-enteric AEs (31.1%).

CONCLUSION

Our post-market study corroborated that DMF is a safe and effective drug. Additionally, the study suggested that naïve patients strongly benefit from DMF and that DMF improved ARR also in patients who were horizontally switched from injectable therapies due to tolerability and efficacy issues.

Surgical Treatment of a High-Flow Femoro-Femoral Arteriovenous Fistula in an Intravenous Drug Abuser

BACKGROUND

We report the surgical treatment of a high-flow femoro-femoral arteriovenous fistula (AVF), a rare complication of intravenous drug abuse.

METHODS

A 36-year-old woman with history of intravenous heroin and cocaine abuse presented with right lower limb edema, inguinal bruit, and heart failure. Duplex ultrasound examination (DUS) and computed tomography angiography showed a large, high-flow AVF involving the common femoral vein and the superficial femoral artery, which is associated with thrombosis of the great saphenous vein and an important inflammation in the right groin, without active bleeding. Under general anesthesia, the patient underwent open surgical repair of the AVF through a right-groin cutdown. The 3-cm-long AVF was repaired with the interposition of a bovine pericardium patch that is sewn from inside the femoral vein through a longitudinal venotomy with a continuous 5-0 polypropylene suture.

RESULTS

The venotomy was repaired with a 5-0 polypropylene running suture. No perioperative or postoperative complications were recorded. The inguinal bruit resolved, the arteries recovered good pulsatility, and the lower limb edema promptly reduced. A 6-month DUS confirmed the patency of the femoral arteries and veins and the absence of AVF or infection signs in the right groin.

CONCLUSIONS

Surgical repair of femoro-femoral AVF in drug abusers by biologic patch interposition is a challenging, but feasible, and effective technique with encouraging midterm results in terms of patency and resistance to infections.

Early and mid-term results in the endovascular treatment of popliteal aneurysms with the multilayer flow modulator

Background The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres. Methods We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications. Results Twenty-three consecutive patients (19 males, age 72 ± 11) with 25 popliteal artery aneurysms (mean diameter 23 mm ± 1, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6 ± 16.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient. Conclusions Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.

Hyperthyroidism and Concurrent Thyroid Cancer

Aims and Background

The aim of this study was to analyze the frequency of coexisting hyperthyroidism and thyroid malignancy in endemic goiter areas and review the current literature on the subject.

Methods

During the period January 1984 to June 1998, 1853 patients were examined for hyperthyroidism at the Spedali Civili Hospital of Brescia, Italy; 512 (27.6%) subjects underwent surgery. Of these patients 108 (21%) had Graves’ disease, 251 (49%) multinodular toxic goiter (MTG) and 153 (30%) uninodular toxic goiter (UTG).

Results

Malignancy was found in 24 (4.7%) patients: 19 females and 5 males with a mean age of 52.2 years (range, 21-76 years). The frequency of cancer in Graves’ disease was 6.4%, 5 females and 2 males; in MTG 3.9%, 2 females and 8 males, and in UTG 4.4%, 7 females and 1 male.

Conclusions

Our data confirm previous reports on the frequency of thyroid cancer in hyperthyroidism. This association is more relevant than previously suspected. The frequent coexistence of hyperthyroidism and neoplasia, demonstrated by our study and the most recent literature, underlines the importance of studying and excluding the possibility of neoplastic degeneration by means of a systematic approach.

One-year experience in carotid endarterectomy combining general anaesthesia with preserved consciousness and sequential carotid cross-clamping

Background and aim of the work: We report 1-year single-centre experience in carotid endarterectomy (CEA) combining general anaesthesia with preserved consciousness (GAPC) and standardized carotid sequential cross-clamping, for our protocol effectiveness evaluation in reduction of perioperative stroke, death or cardiologic complications. Methods: We considered all patients who underwent CEA in 2016. All patients underwent superficial cervical plexus block and GAPC with Remifentanil. The surgical technique consisted of common carotid artery (CCA) cross-clamping, carotid bifurcation isolation, external (ECA) and internal carotid artery (ICA) cross-clamping. After CCA cross-clamping, we performed a neurological tolerance test (NTT); this allowed selective shunting only for positive NTT. Primary end-points were: transient ischemic attack (TIA)/stroke, myocardial infarction, death in perioperative period. Secondary end-points were: carotid shunting, peripheral cranial nerves injuries (PCNI), GAPC intolerance, other complications, reintervention in perioperative period, length of hospital stay. Results: 104 consecutive patients underwent CEA with this protocol in the considered period. Twenty-seven (25.9%) patients were symptomatic. Mean clamping time was 48±13.5 minutes. Five cases (4.8%) requested internal carotid artery shunting. No TIA/stroke, myocardial infarction or death were recorded in the perioperative period. PCNI were observed in 19 cases (18.2%) in the immediate post-operative period; 16 of them (84.2%) showed complete or partial resolution at discharge. Only one patient (0.9%) showed GAPC intolerance. No other complication occurred. Three patients (2.9%) underwent reintervention for neck haematoma drainage. Mean hospital stay were 3±0.9 days. Conclusions: GAPC associated with sequential carotid cross-clamping appeared to be safe and effective in prevention of major neurological and cardiologic complications during CEA. (www.actabiomedica.it)

Ruptured Abdominal Aortic Aneurysm in a Patient with Congenital Fused Pelvic Kidney: A Case Report of Emergency Endovascular Treatment

A 90-year-old male developed acute onset of abdominal and lumbar pain due to the rupture of an 11-cm abdominal aortic aneurysm. A congenital fused pelvic kidney perfused by three renal arteries arising from iliac axes was detected. In an emergent setting, an aorto-uni-iliac endograft was deployed through right femoral surgical access with occlusion of the upper right renal artery. An occluder device was placed in the common iliac artery above the renal artery through left femoral access. A femorofemoral crossover bypass completed the procedure. The patient developed acute renal failure, with no dialysis necessity. One-month computed tomography angiography showed procedure success.