Few authors report cases of retropharyngeal carotid stenosis treated with stenting, while no surgical interventions are described. We report two cases of critical retropharyngeal carotid stenosis treated by stenting and endarterectomy. Case #1: A patient with critical, asymptomatic stenosis of the right internal carotid artery with retropharyngeal course documented on computed tomography (CT) angiography: a right carotid artery stenting (CAS) procedure was planned. A CGuard 8 x 40 mm (Inspire MD) stent was placed by a percutaneous, right transfemoral approach. Case #2: A patient with symptomatic stenosis of the right internal carotid artery. CT image reconstructions showed tortuous carotids with a retropharyngeal course. The term commonly used to describe this rare anatomical configuration is 'kissing carotids', as both carotids are located close to the midline (Fig.1). Case #1: The postoperative course was uneventful, and the patient was discharged on the first postoperative day. Case #2: Carotid stenting was also planned in this case. However, the procedure proved unsuccessful due to the inability to cross the tortuosity of the supra-aortic vessels, and the need to ensure good stability of the devices. A carotid endarterectomy was therefore performed with the support of the otolaryngologist surgeon. Carotid artery exposure was performed according to the Paul André approach, and carotid endarterectomy with the eversion technique was performed (Fig. 2). The postoperative course was uneventful, and the patient was discharged on the second postoperative day in the absence of focal neurological deficits. Both approaches proved successful in the treatment of these retropharyngeal carotid stenoses. It is useful to be aware of the existence of this anatomical variant when observing CT images to better plan the intervention.

In the last decade, Internal Jugular Vein (IJV) obstructive disease has been gaining increasing attention due to different confounding symptoms that impair patients’ quality of life and cannot be explained by other established causes. The most common clinical symptoms associated with IJV stenosis are tinnitus and sleep disturbances (60.5%), headache (48.8%), visual disturbances (39.5%), hearing disorders (39.5%) and anxiety or depression (37.5%). We report a complex case of a woman with a wide range of severe neurological inexplicable disorders. Using Duplex Ultrasound, an IJV occlusion was successfully diagnosed and the patient was then treated using endovascular techniques. IJVs occlusion and outflow alteration were detected by the means of Duplex Ultrasound (DUS) demonstrating the need of a carefully assessment of neck vessels in patients with drug-resistant neurological symptomatology as headache, tinnitus and sleep disturbances.

Background: Endovascular aortic repair (EVAR) is generally performed with bi/trimodular stent-grafts requiring retrograde contralateral gate cannulation (CGC). In the case of tricky CGC, an increased EVAR procedural time and radiation exposure have been reported. Herein, we compare the outcomes of conventional CGC and CGC using the speed gate cannulation (SGC) technique in standard EVAR for a propensity-matched cohort. Methods: A total of 371 patients were retrospectively analyzed. Inclusion criteria were fulfilled in 172 patients who underwent propensity score matching. Primary outcomes included operative time, CGC time, mean contrast medium, fluoroscopy time, and CGC fluoroscopy time. Results: After matching, 78 patients were included in each group (SGC vs. standard). Primary outcomes registered a significant reduction in CGC time (4 [1–6] vs. 8 [6–14] min; p = 0.001) and fluoroscopy time (12 [9–16] vs. 17 [12–25] min). Conclusions: In this preliminary experiment, the use of SGC was feasible with no significant registered postoperative complications. A significant reduction in contrast medium usage, radiation exposure, and CGC time was observed with the use of SGC. SGC is a simple adjunctive technique, and its use should be considered in standard EVAR, especially in emergency scenarios, where time is of the essence.

Stenosis of the internal carotid artery may be responsible for 10%–20% of all strokes or transient ischemic attacks. Stroke is the third leading cause of death and the most common cause of permanent disability in western countries. Until the introduction of carotid artery stenting (CAS), carotid endarterectomy (CEA) was the only surgical solution to the potential embolic and thrombotic load of the carotid plaque. Over the past few years, medical therapy has made enormous progress because of the introduction of new drugs and the widespread and more effective control of vascular risk factors. The choice of treatment between CEA, CAS, or medical therapy alone for any individual patient with carotid stenosis remains a controversial issue. However, a simple complete method to independently stratify the peri-interventional neurologic outcomes of patients undergoing CAS is still lacking. CEA has been used to treat carotid disease for greater than 50 years. Over this period, CEA was validated by large multicenter randomized clinical trials as an effective method for stroke prevention. Indication for CEA with defined outcomes has markedly improved and technical aspects have evolved but an ideal surgical technique has yet to be determined. Consequently, as a practical matter, most vascular surgeons use a number of technical variations for CEA in their clinical practice and adapt their preference to each particular situation. About carotid artery stenting (CAS), in the last years evolution in both stents and protection devices as well as in carotid stenting techniques, resulted in an important reduction in stroke rate in patients undergoing CAS procedure. But carotid stenting, although a mature technique regularly applied with excellent outcomes in high-volume centers by expert operators, is struggling to find the consensus of the scientific community. A key issue in limiting periprocedural events to the lowest possible is to select the appropriate device for the appropriate patient anatomy and clinical syndrome. An important element of this concept is the recognition of high-risk cases for CAS dependent primarily on the skill of the interventional vascular specialist, a factor that is substantially more relevant in the field of CAS than other areas of percutaneous intervention. Evaluation of different types of interventions, medical therapy, carotid endarterectomy (CEA) or CAS and their continuous evolutions, a tailored approach to the patient is considered now the best treatment in carotid artery stenosis.

Abstract Background Cell therapy with autologous peripheral blood mononuclear cells (PB-MNCs) may help restore limb perfusion in patients with diabetes mellitus and critical limb-threatening ischemia (CLTI) deemed not eligible for revascularization procedures and consequently at risk for major amputation (no-option). Fundamental is to establish its clinical value and to identify candidates with a greater benefit over time. Assessing the frequency of PB circulating angiogenic cells and extracellular vesicles (EVs) may help in guiding candidate selection. Methods We conducted a prospective, non-controlled, observational study on no-option CLTI diabetic patients that underwent intramuscular PB-MNCs therapy, which consisted of more cell treatments repeated a maximum of three times. The primary endpoint was amputation rate at 1 year following the first treatment with PB-MNCs. We evaluated ulcer healing, walking capability, and mortality during the follow-up period. We assessed angiogenic cells and EVs at baseline and after each cell treatment, according to primary outcome and tissue perfusion at the last treatment [measured as transcutaneous oxygen pressure (TcPO2)]. Results 50 patients were consecutively enrolled and the primary endpoint was 16%. TcPO2 increased after PB-MNCs therapy (17.2 ± 11.6 vs 39.1 ± 21.8 mmHg, p < .0001), and ulcers healed with back-to-walk were observed in 60% of the study population (88% of survivors) during follow-up (median 1.5 years). Patients with a high level of TcPO2 (≥ 40 mmHg) after the last treatment showed a high frequency of small EVs at enrollment. Conclusions In no-option CLTI diabetic patients, PB-MNCs therapy led to an improvement in tissue perfusion, a high rate of healing, and back-to-walk. Coupling circulating cellular markers of angiogenesis could help in the identification of patients with a better clinical benefit over time.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry.DLS have been proved to be safe and efficient during short-term follow-up. Recent data have raised the concern that the benefit of CAS performed with using a DLS may be hampered by a higher restenosis rate at 1 year.From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system at 20 centers. The primary endpoint was the occurrence of death and stroke at 1 year. Secondary endpoints were 1-year rates of transient ischemic attack, acute myocardial infarction, internal carotid artery (ICA) restenosis, in-stent thrombosis, and external carotid artery occlusion.At 1 year, follow-up was available in 726 patients (99.04%). Beyond 30 days postprocedure, 1 minor stroke (0.13%), four transient ischemic attacks (0.55%), 2 fatal acute myocardial infarctions (0.27%), and 6 noncardiac deaths (1.10%) occurred. On duplex ultrasound examination, ICA restenosis was found in 6 patients (0.82%): 2 total occlusions and 4 in-stent restenoses. No predictors of target ICA restenosis and/or occlusion could be detected, and dual-antiplatelet therapy duration (90 days vs 30 days) was not found to be related to major adverse cardiovascular event or restenosis occurrence.This real-world registry suggests that DLS use in clinical practice is safe and associated with minimal occurrence of adverse neurologic events up to 12-month follow-up.

OBJECTIVES The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry. BACKGROUND DLS have been proved to be safe and efficient during short-term follow-up. Recent data have raised the concern that the benefit of CAS performed with using a DLS may be hampered by a higher restenosis rate at 1 year. METHODS From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system at 20 centers. The primary endpoint was the occurrence of death and stroke at 1 year. Secondary endpoints were 1-year rates of transient ischemic attack, acute myocardial infarction, internal carotid artery (ICA) restenosis, in-stent thrombosis, and external carotid artery occlusion. RESULTS At 1 year, follow-up was available in 726 patients (99.04%). Beyond 30 days postprocedure, 1 minor stroke (0.13%), four transient ischemic attacks (0.55%), 2 fatal acute myocardial infarctions (0.27%), and 6 noncardiac deaths (1.10%) occurred. On duplex ultrasound examination, ICA restenosis was found in 6 patients (0.82%): 2 total occlusions and 4 in-stent restenoses. No predictors of target ICA restenosis and/or occlusion could be detected, and dual-antiplatelet therapy duration (90 days vs 30 days) was not found to be related to major adverse cardiovascular event or restenosis occurrence. CONCLUSIONS This real-world registry suggests that DLS use in clinical practice is safe and associated with minimal occurrence of adverse neurologic events up to 12-month follow-up. (C) 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

History of the team approach to management of the diabetic foot chronicles the emergence of the specialties of vascular surgery and wound healing. The partnership between the diabetologist, vascular surgeon, and podiatrist can be seen as a natural marriage that complements the skills and knowledge of each partner and results in more successful limb salvage and functional outcomes. Diabetic foot patients are among the most complex and vulnerable of all diabetes patients, with high morbidity and mortality. Specialized diabetic foot clinics of the 21st century should be equipped to coordinate revascularization procedures, to aggressively treat infections, and to manage medical comorbidities within a multidisciplinary forum. History has taught us that optimal management of diabetic foot complications is best provided in a hospital-based diabetic foot clinic. It is common experience that clinic must be available to manage emergencies and equipped to perform urgent investigations, wound debridement, and to initiate immediate parenteral antibiotic therapy. It must also be able to obtain rapid vascular, podiatric, and orthopaedic opinions and to arrange for emergency admissions to the hospital However, aside daily experience do we have evidences that multidisciplinary team (MDT) has an impact in the management of individuals with diabetic foot? In 2017, Buggy A. et al tried to explore the delivery of a diabetic foot MDT in detail and to identify if its existence leads to more positive diabetic foot outcomes. Thus, their systematic review explored the following question: What is the impact of the MDT in the management of individuals with DFUs? Their review counted 19 eligible studies in which the impact of the multidisciplinary team in the management of the diabetic foot compared with those who did not receive multidisciplinary care was assessed. They found some positive effects of the MDT on DFUs, namely; amputation rate, severity of amputation and resource use. MDT care also appears to improve mortality and quality of life of people with this condition. MDTs was heterogeneous; they were constituted for the most by diabetologist-endocrinologists, vasculargeneral surgeon and/or orthopaedics, podiatrists and nurses. Even if it is impossible to perform a correct statistical analysis because of the high heterogeneity of data and results, it is notable that MDTs where Vascular Surgeon was absent had the highest major amputation rates (9, 5-47%, mean 34%) compared to the groups where Vascular Surgeon was included (419%, mean 12, 5%). That data is without statistical weight but it is the mirror of what we live daily; in our daily practice we are used to see frequently diabetic patients with terrific diabetic foot gangrene sent by small peripheral centres where the Vascular Surgeon is not available. That is the reason why we strongly recommend an integrated, coordinate, multidisciplinary care. To date, in literature, different combinations of team members are described (in absence of comparisons among different team compositions) and some studies do not discuss how the team was formed. However we believe that a foot care team would consist ideally of a diabetologist, a vascular surgeon, an, a specialised nurse, a podiatrist, an educator and a plaster technician. In particular, it would be advisable that the multidisciplinary team leader for diabetic foot care would be a diabetologist because diabetic foot is a chronic complication of diabetes and poor vascular supply due to arterial disease involving small as well as large vessels is strongly influenced by the underlying pathology. Evidence on the need for an integrated approach to the management of diabetes: the surgical perspective

Objective: In cases of juxtarenal abdominal aortic aneurysm (jAAA), endovascular aneurysm repair (EVAR) involves the use of custom-made fenestrated stent grafts, which usually need large-diameter access vessels, superior costs, and a certain time between graft planning and delivery. We report our preliminary experience using the bare renal stent technique (called vent) in combination with the ultralow-profile stent graft Ovation (Endologix, Irvine, Calif) to seal jAAAs in patients evaluated to be unfit for open surgery and not suitable for fenestrated endograft. Methods: A single-center retrospective review of jAAAs treated by Ovation vent technique from January 2015 to December 2018 was conduced. The vent procedure consisted of a modified, off-label deployment of the sealing ring of the ultralow-profile Ovation stent graft close to renal orifices in combination with short bare-metal stents. The exclusion criterion was a diameter >31 mm at the level of the lowest renal artery. Early technical and clinical results, estimated midterm survival, renal artery patency, freedom from type IA endoleak, freedom from reintervention, and freedom from neck enlargement (>2 mm) were reported. Results: Overall, 38 patients had jAAA and were considered unfit for open repair and not eligible for fenestrated EVAR. The proximal neck was <5 mm in all cases (mean, 3.3 +/- 1.2 mm). Vent renal stents were implanted bilaterally in 16 patients. Primary technical success was 94.7% (36/38), with satisfactory cannulation of all renal arteries and sealing of the aneurysm in all but two cases because of type IA endoleaks that were treated immediately with success. Primary clinical success at 1 month was 100%. During amedian follow-up period of 22.4 +/- 3.6 months (range, 1-46 months), no abdominal aortic aneurysm-related deaths occurred, and no patient was lost to follow-up. The survival curve at 1 year and 2 years was, respectively, 96.4% and 91.6% (standard error, 0.57%). There were no cases of neck dilation or endograft migration. Freedom from reintervention at 12 months and 24 months was 100% and 89.5%, respectively (standard error, 0.7%); freedom from type IA endoleak was 100% and patency of the renal artery was 100% at 2 years. Conclusions: The described technique includes the use of a low-profile stent graft with a polymer ring sealing technology combined with bare renal stents that are not competing for the same room. This early experience shows that the vent technique is safe and feasible and increases the range of treatment of those patients with jAAA who are unfit for open repair and for fenestrated EVAR because of several anatomic constraints.

An 87-year-old female patient underwent transcatheter aortic valve replacement with a self-expandable 27-mm Portico valve (Abbott Vascular, Santa Clara, California). An extremely unfavorable horizontal aortic root hampered the intervention. No pre-dilation or post-dilation was performed. Final

Foot ulcers associated with Diabetes mellitus require immediate attention due to risk of amputation if left untreated. Herein we focus on the mitigating risk factors and physiopathology of the diabetic foot, recounting our own surgical approach and revascularization procedures.

Nowadays patients affected by deep vein thrombosis (DVT) and pulmonary embolism (PE) are studied widely but the challenge for physicians is when and how they are to be treated. Most patients present serious comorbidities that can potentially make treatment difficult. An increasing cohort of patients cannot be treated with systemic fibrinolysis but fortunately today, physicians can utilize a number of different instruments to resolve acute DVT and PE.

BACKGROUND:Acute lower limb ischemia (ALLI) poses a major threat to limb survival. For many years, surgical thromboembolectomy was the mainstay of treatment. Recent years have brought an endovascular revolution to the management of ALLI. It seems that the newly designed endovascular thrombectomy devices may shift treatment recommendations toward endovascular options. This protocol study aims to collect evidence supporting the latest hypothesis.OBJECTIVE:The devices under investigation are the Penumbra/Indigo Systems (Penumbra Inc). The objective of this clinical investigation is to evaluate, in a controlled setting, the early safety and effectiveness of the devices and to define the optimal technique for the use of these systems in patients with confirmed peripheral acute occlusions.METHODS:This study will be an interventional prospective trial of patients with a diagnosis of ALLI treated with Penumbra/Indigo devices. This project is intended to be a national platform where every physician invited to participate could register his or her own data procedure. The primary outcome is the technical success of thromboaspiration with the Indigo System. Assessment of vessel patency will be recorded using the Thrombolysis in Myocardial Infarction (TIMI) score classifications before and after use of the device. Clinical success at follow-up is defined as an improvement of Rutherford classification at 1-month follow-up of one class or more as compared to the preprocedure Rutherford classification. Secondary endpoints include the following: (1) safety rate at discharge, defined as the absence of any serious adverse events; (2) primary patency at 1 month, defined as a target lesion without a hemodynamically significant stenosis or reocclusion on duplex ultrasound (>50%) and without target lesion reintervention within 1 month; and (3) limb salvage at 1 month.RESULTS:The study is currently in the recruitment phase and the final patient is expected to be treated by the end of March 2019. A total of 150 patients will be recruited. Analyses will focus on primary and secondary endpoints.CONCLUSIONS:These new endovascular thrombectomy devices that are specifically designed for peripheral intervention in this difficult set of patients, as those under investigation in the proposed registry, may offer improved clinical outcomes with lower rates of major systemic and local complications. Following completion of this study, it is expected that the value of the Indigo Thrombectomy System in the treatment of ALLI will be better defined. As a result, a shift of treatment recommendations toward endovascular options may be observed in the near future.INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/9972.