OBJECTIVE:Standard carotid endarterectomy (CEA) is usually performed with patch closure or eversion. However, sometimes a 'modified' carotid artery revascularization (MCAR) technique is required if the lesion is complex, extended and anatomically or technically challenging. MCAR is defined as carotid artery bypass; otherwise, it is the combination of common carotid artery (CCA) primary suture or patch angioplasty, associated with internal carotid artery (ICA) patch closure or eversion. The aim of this study was to evaluate the outcomes of MCAR during complex carotid procedures, comparing them with standard CEA.METHODS:A retrospective analysis of asymptomatic patients who underwent CEA during a 16-year period (June 2005 to June 2021) was performed. Patients were divided into three different groups: ECEA (eversion CEA), PCEA (CEA with patch angioplasty) and MCAR. Primary endpoints were relevant neurological complication rate (RNCR), death within 30 days, freedom from ipsilateral stroke, reintervention rates and freedom from carotid artery restenosis.RESULTS:A total of 1,752 patients were included (ECEA: 699; PCEA: 948; MCAR: 105) in the study. Patients treated with MCAR were significantly older and had a higher SVS score for arterial hypertension compared with ECEA and PCEA groups. A long plaque in the CCA was the most common indication for MCAR (40.1%); inadequate distal plaque-end or distal dissection (25.7%) was the second most prevalent indication. Overall perioperative RNCR, defined as minor and major stroke, was 0.7% (ECEA: 0.4%; PCEA: 0.7%; MCAR: 1.9%; p = 0.22), without any significant difference among the three groups. However, patients treated with MCAR had a significantly higher rate of global central neurological complications (defined as transient ischaemic attack, minor stroke and major stroke) than the other cohorts (ECEA: 0.7%; PCEA: 1.2%; MCAR: 3.8%; p = 0.02). One patient (0.05%) died perioperatively of a major cerebral infarction. Long-term follow-up (66.7 ± 43.9) showed a significantly lower rate of freedom from ipsilateral stroke for the MCAR group (96.8%) compared with ECEA and PCEA groups (99.8% and 98.9%, respectively, p = 0.03). Similar reintervention rates (ECEA: 2.7%; PCEA: 3.3%; MCAR: 3.8%; p = 0.74) and freedom from carotid restenosis rates (ECEA: 1.3%; PCEA: 2.6%; MCAR: 1.9%; p = 0.16) were observed.CONCLUSIONS:Patients who underwent ICA revascularization with MCAR showed risks of perioperative death, major or minor stroke (<2%), reintervention rates and carotid restenosis rates that are comparable with PCEA or ECEA groups. Nevertheless, the MCAR group showed a significantly higher rate of global central neurological complications (considering together TIA, minor stroke and major stroke) than patients treated with standard CEA. MCAR techniques appear to be effective alternatives to standard CEAs, with an acceptable surgical risk. However, these should be performed mainly in selected cases, for example, in complex anatomy (detected in a non-negligible percentage of patients by preoperative imaging), or in the case of unexpected intraoperative technical issues.

BACKGROUND/OBJECTIVE:Target vessels related complications are one of the most important 'Achille's heel' of complex thoracoabdominal endovascular procedures. The aim of this report is to describe a case of spontaneous bridging stent-graft (BSG) delayed expansion in a patient treated for type III mega-aortic syndrome, associated with aberrant right subclavian artery and independent origin of the two common carotid arteries. METHODS:The patient underwent different surgical procedures (ascending aorta replacement with carotid arteries debranching, bilateral carotid-subclavian bypass with subclavian origins embolization and TEVAR in zone 0, associated with a multibranched thoracoabdominal endograft deployment). Visceral vessels stenting was performed using balloon-expandable BSGs for celiac trunk, superior mesenteric artery and right renal artery, while for the left renal artery a 6 × 60 mm self-expandable BSG was deployed.The first follow-up (FU) by computed tomography angiography (CTA) showed a severe compression of the left renal artery BSG. Considering the challenging access to the directional branches (SAT's debranching and a tightly curve of the steerable sheath inside the branched main body), a conservative treatment was considered, performing a control CTA after 6-months. RESULTS:Six months later, the CTA demonstrated a spontaneous expansion of the BSG, with a two-fold increase in the minimum stent diameter, excluding the need for new reinterventions such as angioplasty or BSG relining. CONCLUSIONS:Directional branch compression is a frequent complication during BEVAR; however, in this case, it spontaneously resolved after 6 months, without the need for secondary adjunctive procedures. Further studies on predictor factors for BSG related adverse events and regarding spontaneous delayed BSGs' expansion mechanisms are needed.

BACKGROUND:To evaluate the outcome of surgical treatment of acute lower limb ischemia in elderly patients. The primary endpoints were early and midterm rates of survival and limb salvage. METHODS:A retrospective analysis involving 76 consecutive patients observed for acute lower limb ischemia between March 2005 and December 2008 who underwent revascularization was conducted. A total of 44 patients (group A) of age >80 years (average age: 86.9 ± 4.5 years; 13 men and 31 women) had a site of obstruction at the level of abdominal aorta in one case (2.3%), common-external iliac artery/common femoral artery in 15 (34.1%), superficial femoral artery/popliteal artery in 26 (59.1%), and infrapopliteal arteries in two (4.5%), and embolectomy, thrombectomy, bypass, and angioplasty was performed in 24 (54.5%), 11 (25.0%), eight (18.2%), and one (2.3%) case(s), respectively. A total of 32 patients (group B) of age <80 years (average age: 67.2 ± 12.2 years; 19 men and 13 women) with an analogous site of obstruction at the level of abdominal aorta in one case (3.1%), common/external iliac artery/common femoral artery in 12 (37.5%), superficial femoral artery/popliteal artery in three (9.4%), and infrapopliteal arteries in 16 (50.0%) underwent the same aforementioned procedures in 10 (31.3%), 12 (37.5%), nine (28.1%), and one (3.1%) case(s), respectively. RESULTS:At 30 days after surgery, survival and limb salvage were both 93.2% in group A versus 96.9% and 87.5%, respectively, in group B, whereas they were 93.2% and 65.8%, respectively, in group A versus 85.7% and 96.9%, respectively, in group B (p = 0.22 and p = 0.19, respectively) at the midterm control. The univariate and multivariate analyses showed that category 2b of acute ischemia (immediately-threatening) has a negative statistically significant influence on the survival rate (p = 0.01). CONCLUSIONS:Limb salvage rates after surgical intervention for acute lower limb ischemia in the elderly population are comparable with those of the younger population, whereas survival rates are lower, but without statistical significance. The only factor that negatively influences the survival rate is the 2b clinical category of acute ischemia, regardless of the age of the patient.

Evaluer les résultats du traitement chirurgical de l'ischémie aiguë de membre inférieur chez les patients âgés. Les critères d'évaluation primaires étaient des taux de survie précoces et à moyen terme et de sauvetage de membre. Une analyse rétrospective de 76 patients consécutifs traités pour ischémie aiguë de membre inférieur entre mars 2005 et décembre 2008 qui avaient subi une revascularisation, a été menée. Un total de 44 patients (groupe A) d'âge >80 ans (âge moyen : 86,9 ± 4,5 ans ; 13 hommes et 31 femmes) avaient une thrombose au niveau de l'aorte abdominale dans un cas (2,3%), de l'artère iliaque commune-externe/artère fémorale commune dans 15 cas (34,1%), de l'artère fémorale superficielle/artère poplitée dans 26 cas (59,1%), et des artères sous-poplitées dans deux cas (4,5%), et une embolectomie, une thrombectomie, un pontage, et une angioplastie ont été réalisés chez 24 (54,5%), 11 (25,0%), 8 (18,2%), et 1 (2,3%) cas, respectivement. Un total de 32 patients (groupe B) d'âge <80 ans (âge moyen : 67,2 ± 12,2 ans ; 19 hommes et 13 femmes) avec une thrombose de l'aorte abdominale dans un cas (3,1%), de l'artère iliaque commune /externe/artère fémorale commune dans 12 cas (37,5%), de l'artère fémorale superficielle/ artère poplitée dans trois cas (9,4%), et des artères sous-poplitées dans 16 cas (50,0%) ont subi les mêmes procédures dans 10 (31,3%), 12 (37,5%), 9 (28,1%), et 1 (3,1%) cas, respectivement. À 30 jours après la chirurgie, les taux de survie et de sauvetage de membre étaient tous les deux de 93,2% dans le groupe A contre 96,9% et 87,5% dans le groupe B, respectivement, tandis qu'ils étaient de 93,2% et 65,8%, respectivement, dans le groupe A contre 85,7% et 96,9%, respectivement, dans le groupe B (p = 0,22 et p = 0,19, respectivement) au contrôle à moyen terme. Les analyses univariées et multivariées ont prouvé que le type 2b de l'ischémie aiguë (menace-immédiate) influençait négativement de façon statistiquement significative le taux de survie (p = 0,01). Le taux de sauvetage de membre après que intervention chirurgicale pour ischémie aiguë de membre inférieur chez une population âgée serait comparable à ceux d'une population plus jeune, alors que les taux de survie sont inférieurs, mais sans significativité statistique. Le seul facteur qui influence négativement le taux de survie est le type 2b clinique de l'ischémie aiguë, indépendamment de l'âge du patient.

OBJECTIVES:To verify in our experience if fibrin glue injection into the aneurysm sac, made at the end of endovascular aneurysm repair (EVAR), can reduce type II endoleak rates.METHODS:Between January 2005 and February 2008, 38 patients underwent EVAR for an unruptured abdominal aortic aneurysm. The first 20 consecutive patients (Group A) had standard EVAR while the last 18 patients (Group B) had EVAR with fibrin glue injection into the sac, regardless of type II endoleak's presence.RESULTS:There was no statistically significant difference between the two groups concerning the surgical time and the time of X-ray exposure (P=0.30 and 0.54, respectively). Type II endoleak rate was significantly higher in Group A compared to Group B (6 cases, 30% vs. 1 case, 5.5%, respectively, P=0.05). Primary short-term clinical success was 95% and 100%, respectively. At 12 months, selective lumbar embolization was performed in two patients in Group A and in one patient in Group B. Patients in Group A had less computed tomography (CT) studies than patients in Group B (2.0 vs. 1.2, respectively, P=0.024).CONCLUSIONS:Fibrin glue injection is a safe procedure and seems to reduce type II endoleak rates. Patients who received this procedure had fewer CT examinations, with reduced health-care costs.

Objectives: The aim of this study is to assess the immediate and mid-term results of hypogastric artery bypass (HAB) in open repair of abdominal aortic aneurysm (AAA). Methods: The clinical data of 24 patients with an average age of 70.4 years [standard deviation (S.D.)+/- 8.1 years] with AAA treated between January 2005 and December 2008 with HAB during open repair of aortoiliac aneurysm were reviewed. Eighteen patients received unilateral and six bilateral hypogastric bypasses, using a segment of Dacron graft prosthesis. Concomitant hypogastric eversion endarterectomy was associated in six cases (25%). Follow-up was complete in all the 24 patients and averaged 16.2 months (range 1-35). Postoperative imaging protocol involved a conventional Echocolordoppler and CT-scan. With respect to the operating time, the blood loss, the intensive care unit (ICU) and the length of ward admission (LWA) stay, we compared the 24 patients who underwent hypogastric bypass (group A) with the 50 patients who had bifurcated graft without hypogastric bypass (group B). Results: Between the two groups, statistically different results were demonstrated only with respect to the duration of operation (h) (group A 5.19 +/- 1.38 vs. group B 4.39 +/- 1.32, P=0.0195). No statistical differences were noted for ICU stay (h) (group A median 21.50 vs. group B median 21.3, range 1 degrees-3 degrees quartile 19.75-23.50) and LWA stay (days) (group A median 8.50, range 1 degrees-3 degrees quartile 7.00-11.50 vs. group B median 8.0, range 1 degrees-3 degrees quartile 7.00-9.00). There were no operative deaths, bowel or intestinal ischemia in the early postoperative period between the two groups. In group A, one patient had transient renal failure and one patient had an acute coronary syndrome. In group B, one patient had a peripheral ischemia who required tibioperoneal embolectomy. The patency of the hypogastric grafts was demonstrated in all cases. Conclusions: In our experience, direct revascularization of the hypogastric artery to ensure pelvic vascularization in aortoiliac surgery appears a safe procedure. (C) 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Occlusion of the contralateral internal carotid artery (ICA) is considered to have a significant impact on the outcome of carotid endarterectomy (CEA). The purpose of this study was to review one center's experience concerning CEA opposite an occluded ICA, to see whether results differed from those obtained in patients with patent contralateral ICA in terms of relevant neurologic complication rate (RNCR, fatal + disabling stroke), stroke-free rate, and survival rate. From January 1997 to December 2002, 1,381 patients underwent a total of 1,445 CEAs at the Department of Vascular Surgery of Padua University. Patients were divided into two groups: group A included 144 patients with occlusion of the contralateral ICA and group B consisted of 1,237 patients with a patent contralateral ICA. There was no postoperative mortality in patients of group A, while in group B, two patients died as a result of myocardial infarction and cardiac failure and one died as a direct result of perioperative stroke. Postoperative disabling strokes occurred in one (0.7%) patient in group A and 10 (0.8%) patients in group B (p > 0.5). At 72 months, there were no statistical differences between the two groups in terms of RNCR, stroke-free rate, and late death. Our results show that contralateral carotid occlusion does not reduce the safety of CEA. The efficacy in terms of RNCR, stroke-free rate, and late survival is no different in patients with contralateral carotid occlusion.