INTRODUCTION:Arteriovenous (AV) hemodialysis accesses are hampered by the risk of thrombosis. Due to lack of evidence, current guidelines do not suggest routine assessment of AV access blood flow (Qa) for surveillance. This study aims to analyze the association between postoperative Qa and thrombosis risk, in distal and proximal autologous AV fistulae (dAVF and pAVF), and AV grafts (AVGs). METHODS:This retrospective cohort study included all AV accesses created in San Paolo Hospital (Milan, IT) between 2013 and 2022, with a postoperative Qa measurement available within 30 days from creation. Thrombosis-free survival curves were plotted using the Kaplan-Meier method. The association between Qa and thrombosis risk was studied by multivariate Cox proportional hazard models. Nonlinearity was assessed using natural splines. RESULTS:A total of 218 AV accesses (92 dAVF, 76 pAVF, and 50 AVG) were created in 191 patients. During a median follow-up time of 1.35 years, 66 AV access thrombosis occurred. In dAVF, Qa showed a significant nonlinear association with thrombosis risk, with nadir at Qa of 1,289 mL/min and an exponential risk increase for Qa <800 mL/min. In dAVF with a Qa<1,289 mL/min, there was a 43% increase in the risk of thrombosis every 100 mL/min decrease in Qa (aHR 1.43 [1.11-1.83], p 0.005). In pAVF and AVG, Qa was not associated with thrombosis risk. CONCLUSION:Postoperative Qa shows a nonlinear association with thrombosis risk in dAVF, suggesting that this may be a useful tool to identify high-risk dAVF allowing closer surveillance or preventive interventions.

Abstract Background and Aims The use of arteriovenous (AV) access for hemodialysis (HD) is hampered by the risk of dysfunction and thrombosis. Various factors affect the risk of AV access thrombosis, such as age, female sex, hematocrit, vessels’ diameter and anatomy, and patients’ comorbidities (e.g. diabetes mellitus, thrombophilia, chronic inflammatory disease). Previous studies have reported contradictory results on the prognostic value of intraoperative blood flow (Qa) measurements. Finally, only few studies have investigated the association between postoperative Qa measurements and thrombosis risk. Therefore, current guidelines report that there is not enough evidence to suggest routine assessment of AV access Qa for surveillance. This study aimed to analyze the association between Qa, measured at the first post-operative visit (within 30 days from creation), and thrombosis risk, in distal and proximal autologous AV fistulae (dAVF and pAVF), and AV grafts (AVG). Method This retrospective cohort study included all AV accesses created in San Paolo Hospital (Milan, IT) between January 1st 2013 and December 31st 2022, with a post-operative Qa measurement available within 30 days from the date of creation. AV accesses were classified as dAVF, pAVF and AVG. Qa was measured by ultrasound as the product of the cross-sectional area and the time-averaged mean velocity, in the feeding artery. The thrombosis-free survival of dAVF, pAVF and AVG was plotted using the Kaplan Meier method. The association between Qa and the risk of thrombosis was studied by Cox proportional hazard models, adjusted for patient's age and sex. Non-linearity was assessed using natural splines. Results A total of 218 AV accesses (92 dAVF, 76 pAVF, and 50 AVG) were created in 191 patients. At baseline, patients had a median age of 69 years, 70% were male, 42% were already on HD treatment, and overall, they had a high prevalence of hypertension, diabetes mellitus and cardiovascular comorbidities. At first post-operative visit, median Qa was 922 [698, 1278] ml/min, 1260 [917, 1825] ml/min, and 1665 [1195, 2508] ml/min, respectively for dAVF, pAVF, and AVG (p &lt;0.001). During a median follow up time of 1.35 [0.55, 2.62] years, 66 AV access thrombosis occurred. The thrombosis-free survival rates for dAVF, pAVF and AVG were 84%, 97%, and 51% at 1 year, and 63%, 66%, and 19% at 5 years (Fig. 1). For dAVF we found a significant L-shaped association between Qa measured at the first post-operative visit and thrombosis risk, with the lowest risk found at Qa of 1289 ml/min and an exponential risk increase for dAVF with Qa &lt;800 ml/min (Fig. 2). Particularly, for dAVF with Qa &lt; 1289 ml/min, we found a 39% increased risk of thrombosis for every 100 ml/min decrease in Qa (aHR 1.39, 95% CI 1.10-1.75, p 0.006). In pAVF, Qa showed a trend of inverse linear association with the risk of thrombosis, although not reaching statistical significance (aHR 1.06, 95% CI 0.96-1.17, p 0.24, for every 100 ml/min decrease in Qa). In AVG, Qa was not associated with the risk of thrombosis (aHR 1.01, 95% CI 0.97-1.06, p 0.57, for every 100 ml/min decrease in Qa). Conclusion In our cohort we found that Qa, measured at the first post-operative visit, is associated with the risk of thrombosis in dAVF, but not in pAVF and AVG. In particular, in dAVF the association is non-linear with the lowest risk in our cohort found at Qa equal to 1289 ml/min, with an exponentially increasing risk for Qa &lt;800 ml/min. Our findings suggest that post-operative flow assessment may be a useful tool to identify dAVF at higher risk of thrombosis and allow a closer monitoring or possible preventive interventions.

Review of MEDLINE (PubMed), EMBASE, and the Cochrane Library between January 1, 1990, and December 31, 2018. Five articles identified risk factors predicting death or complications after prophylactic carotid endarterectomy (CEA) with long-term results of ≥3 years: the Alococer Score, which includes age >80 years, glomerular filtration rate of <30, chronic obstructive pulmonary disease (COPD), diabetes, history of coronary intervention; the Morales Score, which includes age, sex, diabetes, COPD, history of myocardial infarction or coronary intervention, lack of preoperative antiplatelet therapy; the Conrad Score, which includes age, diabetes, COPD, coronary artery disease, lack of preoperative statins, neck radiation, creatinine of >1.5 mg/dL; the Wallaert Score (Vascular Study Group of New England), which includes age >80 years, diabetes, smoking, contralateral carotid artery stenosis, COPD, congestive heart failure; and the Carmo Score, which includes age >80 years, COPD, diabetes, and creatinine of >1.5 mg/dL. Although each model is simple and easy to use, weight difference between factors leads to controversial results. Risk scoring systems may be a valuable tool to predict 3- and 5-year mortality in asymptomatic patients undergoing CEA. However, each score has limitations.

Objective: The goal of this study was to analyze our 10-year experience in the treatment of aneurysms of the collateral circulation secondary to steno-occlusions of the celiac trunk (CT) or superior mesenteric artery (SMA). Methods: In the last 10 years, 32 celiac-mesenteric aneurysms were detected (25 true aneury sms and seven pseudoaneurysms) in 25 patients with steno-occlusion of the CT or SMA. All cases were diagnosed and treated at our center, with either surgical or endovascular approach. As open surgery, we performed aneurysmectomy and revascularization; as endovascular treatment we performed both the embolization (or graft exclusion) of the aneurysm sac, and embolization of afferent and efferent arteries. Results: Sixteen patients (64%) underwent endovascular treatment, accounting for 66% of aneurysms (21/32). Six patients (24%) and seven associated aneurysms (22%) underwent open surgery. Three asymptomatic patients (12%), representing a total of four aneurysms (12%), were not treated. For endovascular procedures, the technical success rate was 90%, with a 56% clinical success rate. For open surgery, clinical and technical success were achieved in five patients (83%) and six procedures (86%), respectively. Sixty-eight percent of patients (17/25) were treated in an emergency setting, using either endovascular (88%) or open (12%) approaches. Although technical success was achieved in more than 85% of these procedures for both approaches, clinical success was reached less frequently among patients with an acute presentation (P = .041). Regardless of the type of treatment, CT or SMA revascularization during the first procedure did not show an increased rate of clinical success (P = .531). However, we reported four cases of visceral ischemia after an endovascular approach without revascularization, with three open surgical corrections required. The mean follow-up was 41 months (range, 0-136 months). Conclusions: Neither of the approaches described qualifies as a standard optimal choice. We suggest a tailored therapeutic approach based on the clinical conditionat the time of diagnosis and specific vascular anatomy.

The present review was conducted to describe current published risk scoring systems to predict late mortality after carotid endarterectomy (CEA). The aim of the study is to identify simple, clinical, and reproducible tools to predict life expectancy in patients with asymptomatic carotid artery stenosis candidates to CEA and therefore which patients may benefit from surgery, reaching the goal of life expectancy >3 to 5 years, recommended by guidelines. Advantages, disadvantages, feasibility, simplicity, and reproducibility of each selected score were analyzed. Rigorous statistical analysis and validation of the score are essential components to produce a calibrated and usable score. Future studies should address the impact of using these tools in CEA candidates for asymptomatic disease.

We evaluated the evolution of chronic medical therapy in patients admitted for carotid endarterectomy (CEA) over a 13-year period and to analyze the difference in medical treatment between symptomatic and asymptomatic patients. A retrospective study was conducted on patients treated between 2002 and 2015. The use of antiplatelets (acetylsalicylic acid [ASA], ticlopidine, and clopidogrel), oral anticoagulant therapy (OAT), statins and antihypertensives (angiotensin-converting enzyme inhibitors [ACE-I]/angiotensin receptor blockers [ARBs], β-blockers [BB]) administration was evaluated. During the study period, 852 CEAs were performed in 681 (79.9%) asymptomatic patients. Prescription rate increased significantly for ASA (+29.2%), clopidogrel (+10.3%), statins (+60.8%), ACE-I/ARBs (+31.1%), and BB (+19.3%; all Ptrend < .05). No significant modification was observed for ticlopidine and OAT (ticlopidine use was abandoned in the recent years, but this difference was not significant due to the small numbers). A lower medication intake was recorded for symptomatic patients when compared with asymptomatic patients, except for OAT and clopidogrel. Our analysis suggests that medical therapy has changed over the years for patients with carotid stenosis. Although this is a big step toward best medical therapy, preoperative drug therapy remains suboptimal in symptomatic patients.

Objective: Recent improvement of best medical treatment for carotid stenosis has sparked a debate on the role of surgery-identification of patients who may benefit from carotid endarterectomy (CEA) is crucial to avoid overtreatment. An expected 5-year postoperative survival is one of the main selection criteria. The aim of this study was the development of a score for predicting survival of asymptomatic patients after CEA. Methods: Our score was derived from a retrospective analysis of 648 consecutive asymptomatic patients from a single hospital. External validation of the score was then performed on a second cohort of 334 asymptomatic patients from two different hospitals in the same area. Factors associated with reduced postoperative survival within the derivation cohort (DC) were identified and tested for statistical significance. Each selected factor was assigned a score proportional to its beta coefficient: 1 point for chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and lack of statin treatment; 4 points for age 70 to 79 years and creatinine concentration >= 1.5 mg/dL; 8 points for age >= 80 years and dialysis. The DC was divided into four groups based on individual scores: group 1, 0 to 3 points; group 2, 4 to 7 points; group 3, 8 to 11 points; and group 4, >= 12 points. Group-specific survival curves were calculated. The validation cohort (VC) was stratified according to the score. Survival of each of the four risk groups within the VC was compared with its analogue from the DC. Results: Median follow-up of the DC and VC was, respectively, 56 and 65 months. Intercohort comparison of 5-year survival was 84.7% +/- 1.7% vs 85.2% +/- 2% (P = .41). Group-specific 5-year survival within the DC was 97% +/- 1.5% (group 1), 88.4% +/- 2.2% (group 2), 69.6% +/- 4.7% (group 3), and 48.1% +/- 13.5% (group 4; P < .0001). Five-year survival within the VC was 95.5% +/- 2% (group 1), 89.5% +/- 2.7% (group 2), 65% +/- 6.1% (group 3), and 44.8% +/- 14.1% (group 4; P < .0001). Intercohort comparison of group-specific survival curves showed close similarity throughout the groups. Conclusions: Our score is a simple clinical tool that allows a quick and reliable prediction of survival in asymptomatic patients who are candidates for CEA. This selective approach is crucial to avoid unnecessary surgery on patients who are less likely to survive long enough to experience the benefits of this preventive procedure.

The residual stump after excision of an infected aortic graft may be subject to acute blowout due to chronic mechanical stress on a weak arterial wall. We present a case of late aortic stump disruption that required revision after 12 months from graft removal. Our strategy consisted of avoiding reexposure of the pararenal aorta by creating a new supraceliac stump with healthy aortic wall after antegrade visceral debranching. This case confirms the need for long-term surveillance of aortic stumps. The use of a supraceliac approach minimizes the risk of intraoperative blowout and postoperative disruption.

operatively with suturing of the graft proximally due to poor proximal seal without endoleaks.

Background: To evaluate the role of an ultrasound (US) debridement system to treat conservatively patients with poor medical conditions who presented with infection of a prosthetic vascular graft in the lower extremities.Methods: Data of all patients who underwent debridement of the grafts and/or surrounding tissue using an ultrasonic generator (Genera, Italia Medica, Milan, Italy) were recorded and retrospectively reviewed. Based on cultures, patients received specific antibiotic therapy. Partial graft removal, sartorius muscle flap rotation, or negative pressure wound treatment (NPWT) was selectively used. Early and late morbidity and mortality and recurrence were analyzed.Results: Thirteen patients (median age, 72 years; range, 57-92 years; 8 men) were treated (12 Szilagyi grade III and 1 grade II infections) with US debridement without removing the graft (8 cases) or with partial excision and "in situ" reconstruction with a silver prosthetic graft (5 cases). Sartorius flap rotation was associated in 6 and NPWT in 1 case. One patient died perioperatively because of pulmonary edema because of sepsis secondary to treatment failure. Estimated freedom from reinfection was 90.9 +/- 9% at 6 months and 77.9 +/- 14% at 1 and 2 years. Estimated limb survival was 78.7 +/- 13% at 6 months, 65.6 +/- 16% at 1 year, and 52.5 +/- 18% at 2 years.Conclusions: US debridement proved to be a valuable aid in the treatment of patients with infected grafts and poor medical conditions. Used in conjunction with antibiotics, it allowed us to be more conservative without compromising the chance of success.

Purpose: To describe the treatment of a noninfected saccular anastomotic false aneurysm (AFA) of the abdominal aorta with the use of a single “sandwiched” coil. Case Report: A 65-year-old man presented with a saccular AFA of the distal anastomosis exactly at the level of the aortic bifurcation 1 month after open abdominal aortic aneurysm repair. Endograft exclusion was not attempted because an aortouni-iliac configuration would have sacrificed a patent iliac axis. Coil embolization was the preferred strategy. Use of 3-dimensional rotational angiography and 3-dimensional roadmap was necessary to cannulate the neck of the AFA. Complete thrombosis and shrinkage of the sac was achieved by “sandwich coiling” of the neck after deployment of a single pushable hydrogel-coated coil. Imaging at 9 months postprocedure showed no sign of the aneurysm sac. Conclusion: This novel technique can be used for selected saccular AFAs with a narrow neck. In such cases, sandwich coiling may avoid sacrifice of a patent iliac axis.

Background: Long-term results of the posterior approach (PA) for the treatment of popliteal artery aneurysms are lacking in the literature. We reviewed our experience during a 13-year period in patients with popliteal artery aneurysms, comparing those treated through a PA with those operated on through a standard medial approach (MA).Methods: Clinical data of all patients treated between February 1998 and October 2011 were retrospectively reviewed and outcomes analyzed. The Kaplan-Meier method was used to estimate survival, and chi(2), Wilcoxon, and log-rank tests were used for analysis.Results: A total of 77 aneurysms were treated in 65 patients (64 men). Mean age was 68 years (range, 48-96 years). Thirty-six aneurysms were asymptomatic (47%). Mean sac diameter was 2.8 +/- 1 cm. A PA was used in 43 PAAs (55%) and an MA in 34. The PA and MA patients differed significantly in age (median being older), smoking history (more frequent in PA), and renal insufficiency and cerebrovascular disease (higher for MA). In 42 cases the aneurysm was symptomatic (54.5%) for chronic limb ischemia, with intermittent claudication in 18 patients, acute ischemia in 17, blue toe syndrome in 3, compression on adjacent structures in 3, and rupture with severe acute pain in 1. All PA repairs consisted of aneurysmectomy with an interposition graft with end-to-end anastomoses; among MA repairs, 22 interposition grafts and 12 bypasses were performed. A polytetrafluoroethylene graft was used in 54 cases. Five patients had an early thrombosis (two PA and three MA). No perioperative deaths occurred. Two patients sustained a permanent (PA) and a temporary (MA) peroneal nerve lesion. There were no early amputations. The median in-hospital stay was longer for MA (10 days) than for PA (7 days; P =.02). Median follow-up was 58.8 months (range, 5 days-166 months). Nine patients died during follow-up of unrelated causes. The 5-year primary and secondary patency rates were 59.6% +/- 8.6% and 96.5% +/- 3.4%, respectively, for PA, and 65.1% +/- 11.1% and 79.4% +/- 9.7%, respectively, for MA (P =.53 for primary patency rate and P =.22 for secondary patency rate). Limb salvage was 100% at 5 years and 93.3% +/- 6.4% at 10 years for PA and 91.1% +/- 6.3% at both time points for MA (P =.28).Conclusions: PA and MA both achieved satisfactory results in primary and secondary patency rates, as well as limb salvage, during long-term follow-up. The differences between the two groups were small and not statistically significant. PA was burdened by similar postoperative nerve and wound complications compared with MA. The in-hospital stay after PA was significantly lower.

This article reviews the arterial access sites used in the treatment of peripheral arterial disease, including common femoral, superficial femoral, and popliteal arterial puncture. The optimal approach and techniques for arterial puncture will be described and technical tips and tricks will be discussed. An overview of the currently available vascular closure devices will also be presented. Indications, contraindications, and complications will be discussed. Results of the use of vascular closure devices compared with manual compression will be presented.

Primary aorto-enteric fistula (PAEF) develops between the native aorta and the gastro-intestinal tract, in the presence of an abdominal aortic aneurysm. It is a rare, life-threatening condition and appears to be less frequent than secondary aorto-enteric fistula, which is associated with previous aortic prosthetic reconstruction. When untreated, the overall mortality rate is almost 100%. Diagnosis may be challenging until the occurrence of a massive haemorrhage. In the presence of gross contamination, patients tend to a worse prognosis. Extra-anatomical bypass and repair of the enteric tract is the treatment of choice in case of gross contamination. In situ reconstruction is often reported in cases of mild bacterial contamination. Endovascular treatment has recently become a valid option in haemodynamically unstable patients, but a staged approach, with delayed surgical treatment, seems advisable.

The popliteal vein is the most frequent site of venous aneurysm. Surgical treatment is indicated above a 2.5 cm diameter to prevent complications, notably deep venous thrombosis and pulmonary embolism (PE). Here we report a case of recurrent episodes of severe PE, leading to cardio-circulatory shock caused by a popliteal vein aneurysm (PVA) despite oral anticoagulant therapy. When surgical correction of the aneurysm was performed, we found an ulcerative lesion in the inner aspect of the vein that was acting as a thrombogenic focus' inside the aneurysm. An accurate inspection of the intimal wall is always important during surgery of PVA, particularly when tangential resection is performed.

OBJECTIVE:The aim of the study was to assess the outcomes of carotid endarterectomy (CEA) performed in an urgent setting on acutely symptomatic patients selected through a very simple protocol. METHODS:From January 2002 to January 2012, 193 symptomatic patients underwent CEA. Of these, 90 presented with acute symptoms, and after a congruous carotid stenosis was identified, underwent urgent operations (group 1): 27 patients had transient ischemic attack (group 1A), 52 patients had mild to moderate stroke (group 1B), and 11 patients had stroke in evolution (group 1C). The remaining 103 patients with a nonrecent neurologic deficit were treated by elective surgery in the same period (group 2). End points were 30-day neurologic morbidity and mortality. RESULTS:The median delay of urgent CEA (U-CEA) from deficit onset was 48 hours (interquartile range, 13-117 hours). Groups 1 and 2 were comparable in demographics. Acute patients showed a higher rate of stroke at presentation (70% vs 37%; P = .001) and of history of coronary artery disease (30% vs 13.5%; P = .007). Acute patients sustained six postoperative strokes (6.6%). Neurologic outcomes were correlated to clinical presentation: no strokes occurred in group 1A patients, and 5.8% group 1B patients and 27.3% group 1C patients had postoperative stroke (P < .01). Postoperative mortality was 4.4% for U-CEA: one fatal myocardial infarction, one intracranial hemorrhage, and two thromboembolic strokes. Elective patients sustained four postoperative strokes (3.9%), with one death (0.9%) as a consequence of hyperperfusion cerebral edema. U-CEAs performed ≤48 hours from symptom onset had a lower postoperative stroke rate than those performed >48 hours (4.4% vs 8.8%; P = .3). Among patients presenting with a stroke (group 1B), the National Institutes of Health Stroke Scale (NIHSS) assessment at discharge showed improvement in 79% (although only 25% had ≥4 points in reduction), stability in 17%, and deterioration in 4%. Patients with moderate stroke were slightly better in NIHSS improvement than those with mild stroke (median NIHSS variation at discharge, -3 vs -1; P = .001). CONCLUSIONS:Our results with U-CEA confirm that this population has a higher risk profile compared with elective surgery. The type of acute presentation is correlated with perioperative risk. U-CEA was safe when performed on patients presenting with transient ischemic attack. An acceptable complication rate was achieved for patients with minor to moderate strokes. The poorest outcomes occurred in patients presenting with stroke in evolution: U-CEA in these patients should be offered with extreme caution, although we are aware that a conservative treatment may not grant a better prognosis.