BACKGROUND:Management of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) in zone 2 remains debated, as intentional coverage without revascularization increases the risk of cerebrovascular accident and spinal cord ischemia. Among available strategies, physician-modified endografts (PMEGs) have emerged as a practical, fully endovascular option for LSA preservation. METHODS:The study reports the single-center experience at San Raffaele University Hospital, Milan, with PMEGs for TEVAR involving the distal aortic arch and the proximal descending thoracic aorta. In addition, a review of the current literature on PMEG-based LSA revascularization was conducted, including studies published between 2016 and 2024 addressing technical success, neurologic events, and mid-term patency. RESULTS:Fourteen consecutive patients operated between February 2023 and October 2024, all in urgent or emergent settings, were included in this study. PMEG implantation achieved 93% technical success with no 30-day mortality, stroke, or spinal cord ischemia. At a mean follow-up of 18.4 months, LSA patency was 92.3%, with a single reintervention for branch occlusion. Consistently, literature data demonstrate >90-95% technical success, stroke rates of 0-5%, and durable (>95%) LSA patency up to 3 years. CONCLUSIONS:Initial experience with PMEG-based LSA revascularization seems to offer a valuable, fully endovascular alternative for Zone-2 TEVAR in urgent or emergent cases that can't wait for standard custom-made device manufacturing. Meticulous imaging-guided planning and standardized modification protocols are essential for durable outcomes. While long-term data remain limited, accumulating evidence supports PMEGs as an effective bridge between conventional hybrid approaches and dedicated branched endografts.

BACKGROUND:Late open surgical conversion (LOC) after endovascular aneurysm repair (EVAR) has been considered a high-risk operation. This study compared patient characteristics, procedural details, and short- and long-term outcomes between LOC after EVAR and primary open surgical repair (OSR) in a high-volume center. METHODS:This single-center, retrospective, nonrandomized study included all consecutive patients undergoing elective OSR for abdominal aortic aneurysm or LOC after EVAR between January 2012 and May 2024. Exclusion criteria were Crawford extent IV thoracoabdominal, isolated iliac, or mycotic aneurysms, prior stent-graft infection, and aortoenteric fistula; emergency operation for rupture was also excluded. Infrarenal, juxtarenal, and pararenal abdominal aortic aneurysms were included. Primary end points were in-hospital mortality and major perioperative complications such as cardiac events, pulmonary complications, intestinal ischemia, and renal dysfunction according to the Acute Kidney Injury Network (AKIN) criteria. Secondary end points were reintervention and overall survival during follow-up. In contemporary practice, the proximal free-flow, when present and possibly the first covered stent, and the iliac limbs are generally preserved during conversion procedures. Patient demographics, intraoperative variables, and outcomes were compared between the LOC and OSR groups. Propensity score matching (1:2 ratio) was performed using age, smoking status, hypertension, coronary artery disease, diabetes, chronic obstructive pulmonary disease, and aortic diameter. Survival and reintervention-free survival were assessed using Kaplan-Meier analysis. RESULTS:A total of 1266 patients were included (LOC: 87; OSR: 1179), with a mean age of 75.7 ± 6.8 years in the LOC group vs 70.7 ± 7.5 years in the OSR group (P < .001). After propensity score matching, 87 LOC and 174 OSR patients were analyzed. In-hospital mortality did not differ between groups in either the unmatched (0.0% vs 0.7%; P = .44) or matched cohorts (0.0% vs 1.1%; P = .32). Thirty-day reintervention rates were also similar (unmatched: 0.0% vs 2.3%, P = .15; matched: 0.0% vs 1.7%; P = .22). Pulmonary complications were more frequent in LOC patients before matching (6.9% vs 2.3%; P = .01) but comparable after matching (6.9% vs 4.6%; P = .44). AKIN stage 1 renal dysfunction occurred more often in LOC patients in both unmatched and matched cohorts (P < .001 and P = .01, respectively), whereas higher AKIN stages, cardiac events, and bowel ischemia showed no significant differences. At a median follow-up of 68 months, overall survival was significantly lower in LOC patients (unmatched: 56.9 ± 40.4 vs 70.4 ± 34.9 months; P < .001; matched: 56.9 ± 40.4 vs 72.1 ± 40.4 months; P = .01). Reintervention-free survival showed a similar trend. CONCLUSIONS:Elective LOC after EVAR can be performed safely in high-volume centers, with perioperative and long-term outcomes comparable to primary OSR. Prospective multicenter studies are needed to confirm these findings and guide best practices. Preservation of the proximal bare-metal stent and initial covered stent may have helped reduce complications.

BACKGROUND:Fenestrated endovascular aortic repair (FEVAR) is an established and effective treatment for thoracoabdominal aortic aneurysms (TAAAs). Although secondary endovascular interventions are not uncommon during follow-up, device-related failures causing type III endoleaks are rare but potentially life-threatening. When these defects occur within the visceral segment, standard relining techniques may be unfeasible, requiring alternative endovascular strategies to avoid open conversion. CASE PRESENTATION:A 73-year-old man, previously treated with a custom-made FEVAR, presented 3 years after the index procedure with severe back pain. Urgent computed tomography angiography revealed a large endoleak in the visceral segment, associated with aneurysm sac expansion and contained rupture. After relining of the superior mesenteric artery and the left renal artery, a type III endoleak originating from a small fabric defect between these vessels was identified and selectively catheterized. The defect was successfully treated by deploying an Amplatzer Vascular Plug IV across the graft tear. RESULTS:Completion angiography demonstrated near-complete exclusion of the endoleak. Follow-up imaging confirmed progressive aneurysm sac shrinkage and full endoleak resolution at 1 year, with preserved visceral and renal perfusion. CONCLUSION:In selective settings, plug embolization represents a practical and durable bailout option for type III endoleaks caused by small fabric disruptions after FEVAR, especially when conventional relining is not feasible. This approach enables rapid hemodynamic stabilization and offers favorable mid-term outcomes in high-risk patients.Clinical ImpactType IIIb endoleaks caused by fabric disruption after FEVAR are rare but potentially catastrophic complications that may lead to aneurysm rupture and require urgent treatment. When the defect is located within the fenestrated visceral segment, conventional relining techniques may be technically unfeasible or risk compromising target vessel perfusion. This report describes a novel bailout strategy based on selective catheterization of the graft defect and deployment of an Amplatzer Vascular Plug IV directly across the fabric tear. The technique allowed exclusion of the endoleak and preservation of visceral branch patency, expanding the endovascular armamentarium.

Background: Radiofrequency ablation (RFA) and mechanochemical ablation (MOCA) have emerged as less invasive alternatives to traditional surgical interventions, offering reduced recovery times and comparable efficacy. This study aims to compare the efficacy, safety, and patient-reported outcomes between RFA and MOCA in treating SSV insufficiency. Materials and methods: this is a retrospective, nonrandomized study that involved patients who underwent either RFA or MOCA between 2015 to 2019. Data collected included demographics, clinical grading, procedural specifics, and follow-up outcomes. The primary endpoint was the comparison of freedom from recanalization and freedom from reinterventions rates, while secondary endpoints focused on recurrences rates and clinical outcomes assessed by revised clinical severity score (rVCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ). Results: A total of 132 limbs were treated (n=72 RFA; n=60 MOCA). Baseline demographics and clinical severity were comparable between groups. At 5 years, freedom from recanalization rate was significantly higher in the RFA group compared to the MOCA group (91.7% vs 66%; p=.0014). Clinical recurrence rates at 5 years were 11.7% for RFA and 22% for MOCA (p=.0023), while freedom from reintervention rates were 93.3% and 72.7%, respectively (p=.0011). Although both groups showed clinical improvement over time, patients treated with MOCA exhibited a significant worsening in rVCSS and AVVQ at 3 and 5 years compared to the RFA group (p<.0001). Conclusions: RFA demonstrates greater long-term stability, lower recurrence and reintervention rates compared to MOCA, suggesting it may be a preferable option for SSV insufficiency treatment in terms of durability and patient outcome.

Background: Radiofrequency ablation (RFA) and mechanochemical ablation (MOCA) have emerged as less invasive alternatives to traditional surgical interventions, offering reduced recovery times and comparable efficacy. This study aims to compare the efficacy, safety, and patient-reported outcomes between RFA and MOCA in treating SSV insufficiency. Materials and methods: this is a retrospective, nonrandomized study that involved patients who underwent either RFA or MOCA between 2015 to 2019. Data collected included demographics, clinical grading, procedural specifics, and follow-up outcomes. The primary endpoint was the comparison of freedom from recanalization and freedom from reinterventions rates, while secondary endpoints focused on recurrences rates and clinical outcomes assessed by revised clinical severity score (rVCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ). Results: A total of 132 limbs were treated (n=72 RFA; n=60 MOCA). Baseline demographics and clinical severity were comparable between groups. At 5 years, freedom from recanalization rate was significantly higher in the RFA group compared to the MOCA group (91.7% vs 66%; p=.0014). Clinical recurrence rates at 5 years were 11.7% for RFA and 22% for MOCA (p=.0023), while freedom from reintervention rates were 93.3% and 72.7%, respectively (p=.0011). Although both groups showed clinical improvement over time, patients treated with MOCA exhibited a significant worsening in rVCSS and AVVQ at 3 and 5 years compared to the RFA group (p<.0001). Conclusions: RFA demonstrates greater long-term stability, lower recurrence and reintervention rates compared to MOCA, suggesting it may be a preferable option for SSV insufficiency treatment in terms of durability and patient outcome.

OBJECTIVE:The aim of this study was to assess the effectiveness of mechanochemical ablation (MOCA) for the treatment of small saphenous vein (SSV) incompetence at 3 and 5 years, building on preliminary results that showed feasibility, safety, and high occlusion rates at 1 year follow up. METHODS:Sixty patients who underwent MOCA for SSV incompetence at a single centre between January 2017 and December 2019 were included. Clinical and radiological data were reviewed retrospectively from a prospectively maintained database. Primary endpoints were SSV recanalisation and re-intervention at 3 and 5 years. Additional outcome measures included Venous Clinical Severity Score (VCSS), quality of life (QoL) using the Aberdeen Varicose Vein Questionnaire (AVVQ) and the visual analogue scale to assess pain during long term follow up, and signs and symptoms of chronic venous disease. Uni- and multivariable analyses were performed to identify risk factors for SSV recanalisation. RESULTS:Fifty patients completed the full 5 year follow up. Freedom from recanalisation was 84.7% at 3 years and 66.5% at 5 years. Freedom from re-intervention at the same time points was 86.7% and 72.6%, respectively. Although the VCSS and AVVQ scores decreased during the first year, a progressive increase was observed over the follow up period. The median VCSS increased significantly at 3 and 5 years. The AVVQ score increased from a median (interquartile range [IQR]) of 5.0 (IQR 3.0, 7.0) at 1 year to 8.2 (IQR 5.0, 11.0) at 3 years and 10.1 (IQR 6.0, 14.0) at 5 years (p < .001). Multivariable analysis identified body mass index > 25 kg/m2 and pre-operative SSV diameter > 6 mm as significant risk factors for SSV recanalisation. CONCLUSION:Treatment of SSV incompetence with MOCA had high 5 year recanalisation and re-intervention rates. Additionally, a progressive decrease in QoL and deterioration of patient reported outcomes over time were found, as reflected by rising VCSS and AVVQ scores.

Thoracic outlet syndrome (TOS) secondary to chronic sternoclavicular (SC) joint pseudoarthrosis is a rare but clinically significant condition. We report the case of a 50-year-old male who developed chronic SC joint instability and neurogenic TOS 2 years after a conservatively treated SC fracture. Preoperative Doppler ultrasound showed dynamic venous outflow impairment. Surgical treatment included clavicular calloclasia, adhesiolysis, anterior scalenectomy, SC joint reduction and fixation, and anchorage stabilization. At 2-month follow-up, the patient achieved complete pain relief, full functional recovery, and resolution of neurological and vascular symptoms. Early surgical management can restore stability and prevent neurovascular complications.

Early cellular alterations in abdominal aortic aneurysm (AAA) are scarcely investigated. Aortic remodeling inflammation-related suggested the CXCR2/CXCL1/IL-8 axis as a therapeutic target. This study investigates CXCR1/CXCR2 antagonism in primary human aortic endothelial (HAOEC) and smooth muscle cells (HAOSMC) conditioned with IL-8 or serum from patients with AAA (sPT). Ladarixin (10 μM Lad or 25 μM) served as an inhibitor. Readouts included RT-qPCR for CXCL1, CXCL8, CXCR2, MMP9, NFKB1, and VEGF-A; zymography for MMP9 activity confocal microscopy for F-actin and mitochondria; NADPH/NADH diaphorase histochemistry for redox activity; and ATP assay. In HAOEC, IL-8 downregulated CXCR2, increased MMP9 activity, and induced cytoskeletal and mitochondria disorganization without altering NADH/NADPH diaphorases but increasing ATP release. At concentration of 10 μM Lad rescued cell organization and gene expression. sPT upregulated CXCL8, CXCR2, and MMP9, decreased NADH/NADPH diaphorases, and altered cytoskeleton and mitochondria organization in HAOEC. At concentration of 10 μM Lad (partially) and 25 μM Lad reverted gene upregulation and mitochondria distribution; both doses increased diaphorase and released ATP. HAOSMC were scantily susceptible to IL-8 and weakly responsive to sPT, slightly upregulating CXCR2 and VEGF-A but increasing proMMP9 gelatinolysis. Ladarixin recovered proMMP9 activity and modulated CXCL1. AAA-like vascular cell alterations involve multiple inflammatory factors and are modulable by inhibition of IL-8 receptors. The results underline careful dose calibration.

Objective: The Stent-Assisted Balloon-Induced Intimal Disruption and Relamination in Aortic Dissection Repair (STA-BILISE) technique was proposed for treating type B aortic dissections (TBADs), using bare metal stents and balloon inflation to intentionally rupture the lamella and allow full expansion of the true lumen (TL) and finally promote aortic remodeling. A systematic review was conducted to assess the current evidence and treatment indications and compare outcomes of the STABILISE technique. Methods: A literature search in PUBMED and Cochrane Library was performed, and articles that were published up to June 2024 reporting on the STABILISE technique were included (randomized controlled trials, prospective and retrospective studies). Case series with less than four patients were excluded. Titles, abstracts, and full texts were evaluated by two authors independently. Primary outcomes included technical success and 30-day mortality. Secondary outcomes were mortality and complications during the available follow-up. Continuous variables were presented as means 6 standard deviation or median and interquartile range, and categorical variables were expressed as numbers (percentages). Results: Twenty-nine studies were evaluated: 10 studies, totaling 284 patients, were included. Of these patients, 92 of 284 (32%) were acute, 61 of 284 (21.4%) were subacute, and 65 of 284 (22.8%) were chronic TBADs. In 66 of 284 cases (23.2%), the setting of TBAD was not available. Two hundred thirty-six patients were male (236/284; 83.1%). In 85 patients (85/284; 29.9%), supra-aortic trunk debranching was required to provide an appropriate proximal landing zone. Carotid to carotid bypass debranching was performed in all Ishimaru's zone 1 cases, whereas left carotid-subclavian bypass was performed in 42 of 64 cases (42/65; 65.6%) who underwent aortic zone 2 coverage. One patient died intraoperatively, with an estimated mortality rate of 0.3% (1/284). In 10 studies, nine deaths overall were recorded (9/284; 3.1%). The type of balloon used, the number of inflations, and any additional maneuvers that were carried out during the procedure were never mentioned in the literature. The reintervention rate was 16.9% (48/284 patients). Spinal cord ischemia rate was available in eight studies, resulting in eight patients (8/261; 3.1%). All studies reported on the available follow-up for a median of 29 months. Technical success was reported in all studies, accounting for 280 patients (280/284; 98.6%), for an overall follow-up in 247 patients (247/284; 86.9%). Conclusions: The STABILISE technique is safe and effective in promoting aortic remodeling over time. Additional research is required to investigate the technique's safety in a larger patient population and to assess the long-term behavior of the post-dissected aorta. (JVS-Vascular Insights 2025;3:100170.)

OBJECTIVE:Sarcopenia is gaining interest in the pre-operative evaluation of patients with thoraco-abdominal aortic aneurysm (TAAA). Lean psoas muscle area (LPMA) has emerged as a way to measure sarcopenia and is a possible predictor of outcomes in endovascular TAAA repair. The aim of this study was to analyse the correlation between LPMA and outcomes of open TAAA repair. METHODS:Between 2018 and 2022, all consecutive elective patients who underwent open TAAA repair with an available adequate pre-operative computed tomography angiogram (CTA) were analysed retrospectively. The CTA data were used to measure LPMA. Pre- and post-operative variables were collected from all patients. Primary endpoints were death and major adverse events (MAEs) at 30 days and 90 days. The secondary endpoint was follow up mortality rate. Primary and secondary endpoints were correlated with LPMA. RESULTS:A total of 179 patients were included, and 61.5% (110/179) were treated for extent II and III TAAA. Death at 30 days and 90 days was 6.1% and 8.9%, respectively. At a median follow up of 38 months (range: 12 - 60), the mortality rate was 17.2%. The proportion of patients with MAE occurrence at 30 days and 90 days was 29.1% and 37.4%, respectively. The median LPMA was 330 cm2/Hounsfield unit (HU) (interquartile range 264, 442) and was significantly higher in men than in women (p = .001). Patients were divided according to the LPMA value into sarcopenic (< 350 cm2/HU) and non-sarcopenic (> 350 cm2/HU) groups, and in four quartiles. No statistically significant correlation between LPMA and death or MAEs was observed at 30 days and 90 days, and at follow up, but a trend towards an increased mortality rate was observed in patients with sarcopenia at 30 days (10%; 9/90) compared with patients without sarcopenia (2.2%, 2/89) (p = .059). CONCLUSION:In this series of patients who underwent open TAAA repair, LPMA was found to be ineffective as an independent predictor of morbidity and mortality. Further studies are needed to clarify the role of this parameter as a predictor of adverse outcomes.

ObjectiveRecurrent varicose veins (RVVs) following open surgical procedures are common and present significant treatment challenges. Redo open surgery (rOS) presents risks leading to a need for alternative treatment options. This study compares the safety and efficacy of ultrasound-guided foam sclerotherapy (UGFS), used to treat recurrent reflux and remove neovascular and tributary venous networks in the thigh, to redo open surgery (rOS) for the treatment of C2r.Materials and methodsA retrospective review was conducted on 133 patients with symptomatic C2r treated between 2018 and 2020. Of these, 91 patients received UGFS-based mini-invasive treatment (Group A), and 42 underwent rOS (Group B). Data were collected during perioperative, intraoperative, and postoperative times. Clinical outcomes were assessed using the CEAP and rVCSS scoring systems. Follow-up occurred within 1 week, at 1-6 months, and annually thereafter.ResultsUGFS showed a significantly shorter average procedure time (21 ± 7 minutes) compared to rOS (47 ± 13 minutes, p < .001) and time spent in the hospital (3 ± 0.5 hours vs 16 ± 2 hours, p < .001). Both groups achieved high technical success rates. The anterior saphenous vein (ASV) was found to be incompetent in 32 patients (24%). In Group A, it was treated with radiofrequency ablation (RFA) in 10 cases and with foam sclerotherapy in 11. In contrast, all ASV cases in Group B were managed with surgical stripping. UGFS patients experienced a more rapid clinical improvement within the first-week post-treatment (p < .001). The freedom from recurrences was 88.9% in the Group A, and 87.8% in the Group B at 3-year (p = .85). The freedom from reintervention was 90.9% in the Group A, and 88.5% in the Group B at 3-year (p = .89).ConclusionsUGFS is a safe and effective alternative to rOS for treating C2r, offering significant advantages in shorter procedure times, faster recovery, and similar medium-term outcomes. This approach provides a viable option for C2r patients seeking effective treatment with reduced recovery periods.

Aortic coarctation (CoA) is a congenital vascular anomaly characterized by luminal narrowing of the aorta, representing approximately 5–8% of all congenital heart defects, and is frequently associated with a bicuspid aortic valve and additional vascular malformations. The clinical spectrum is broad, ranging from severe neonatal heart failure to asymptomatic systemic hypertension in adulthood, with the severity of presentation directly influencing the timing of diagnosis and therapeutic intervention. Over recent decades, management strategies have transitioned from conventional surgical techniques—such as end-to-end anastomosis, subclavian flap aortoplasty, and patch augmentation—to endovascular modalities including balloon angioplasty and stent implantation, with covered stents now constituting the preferred approach in most cases. Nonetheless, late complications remain clinically significant. Post-coarctation aneurysms (pCoAA), particularly following patch aortoplasty, have been reported in up to 50% of patients and necessitate lifelong imaging surveillance. Re-coarctation persists as a therapeutic challenge, especially in neonates, with recurrence risk influenced by anatomical factors and the initial repair method. Optimal outcomes require an individualized, anatomy-tailored approach that judiciously integrates surgical, endovascular, and hybrid techniques. Lifelong surveillance remains essential to mitigate long-term risks, including systemic hypertension, aneurysm formation, and the need for re-intervention.

OBJECTIVE:To develop a simple preoperative risk score and assess its performance to predict the occurrence of spinal cord ischemia (SCI), in patients undergoing open surgical repair of thoracoabdominal aortic aneurysm (TAAA). METHODS:A retrospective analysis was conducted on patients who underwent elective TAAA open repair between 2016 and 2020. A preoperative risk score (0-6 points) was constructed based on six binary variables: TAAA extent II, body mass index of ≥30, smoking history, preoperative diuretic use, age >70 years, and history of chronic kidney disease. Each variable contributed 1 point. The score was applied retrospectively to the study cohort. Discriminative performance was assessed by receiver operating characteristic analysis, and the area under the curve (AUC) was calculated with a 95% confidence interval (CI). Sensitivity and specificity were calculated using the optimal cut-off based on the Youden index. RESULTS:Among the 246 patients, SCI occurred in 33 patients (13.4%). The incidence of SCI increased progressively with higher preoperative scores: 0/71 (95% CI, 0.0-5.1) for a score of 0, 1/93 (95% CI, 0.03-5.9) for a score of 1, 4/47 (95% CI, 2.4-20.4) for a score of 2, 8/15 (95% CI, 26.6-78.7) for a score of 3, and all patients with scores of 4 (11/11; 95% CI, 71.5-100) and 5 (9/9; 95% CI, 66.4-100). The optimism-corrected AUC was 0.902 (apparent AUC, 0.919) after bootstrapping internal validation. At the Youden-optimal cut-off of ≥2, sensitivity was 92.1%, specificity 78.9%, positive predictive value 42.7%, and negative predictive value 98.3%. Decision curve analysis confirmed a clinical benefit across a wide range of threshold probabilities. CONCLUSIONS:This preoperative risk score, derived from a single-center cohort and internally assessed with bootstrap resampling, offers a simple tool to estimate SCI risk in patients undergoing open TAAA repair. These preliminary findings may support risk stratification and patient counseling, but external validation will be required before broader clinical use can be recommended.

Summary: Background: This study aimed to assess the safety of the third-generation ClosureFast catheter for radiofrequency ablation (RFA) in the treatment of great saphenous vein (GSV) reflux in patients presenting to a dedicated vein center. Materials and methods: All consecutive patients with incompetent GSV who underwent RFA between December 2023 and May 2024 were retrospectively analyzed. The primary study endpoints were technical success and postoperative complication rate at 30 days. Secondary study endpoints were freedom from GSV recanalization and recurrent varicose vein (RVV) rate over the follow-up. The improvement in symptoms (measured by the Venous Clinical Severity Score [VCSS]) was evaluated. Results: During the study period, 50 limbs were treated in 50 consecutive patients (mean age 55.8±13.4 years; 56% women; CEAP 2-4; VCSS >5). The technical success rate was achieved in 100% of cases. There was no significant incidence of 30-day complications. There were no instances of deep venous thrombosis or puncture site thermal injury. One patient (2%) had hyperpigmentation; two patients (4%) had ecchymosis; 4 patients (8%) had pain. At a mean follow-up of 2.9±1.4 months, GSV occlusion and freedom from reintervention rates were both 100% within 1 week and 30 days respectively. No patients had RVV over the follow-up. The VCSS score had decreased a median of 3.5 (IQR: 2.4–5) points from baseline (p<0.01). The mean CEAP class had decreased to 1.59 points from baseline, reflecting a shift towards milder disease categories (C0–C2). Conclusions: The third generation of RFA is safe and effective to ablate the GSV with a low complication rate in the perioperative period. However, durability over the follow-up and further studies with larger cohorts of patients are still needed to confirm these outcomes.

BACKGROUND:Thoracoabdominal aortic aneurysm (TAAA) open surgical repair (OSR) is a highly complex procedure associated with significant mortality and morbidity. Despite advancements in surgical techniques and organ protection strategies, TAAA OSR remains a challenge. This study analyzes nearly 35 years of experience at a single center, with a focus on the evolution of surgical approaches and adjuncts, particularly the use of left heart bypass (LHBP) for organ perfusion maintenance. METHODS:This retrospective study was performed on all the patients who underwent elective TAAA OSR at our institution between 1989 and 2024. Patients were divided into two groups: Group 1 (1989-2009), where adjuncts were used selectively, and Group 2 (2010-2024), where a systematic multimodal approach was implemented. Preoperative, intraoperative, and postoperative data were analyzed to assess the impact of evolving surgical techniques, adjuncts, and patient outcomes. Key adjuncts included cerebrospinal fluid drainage (CSFD), motor and somatosensory evoked potentials (MEP&SSEP), LHBP, renal perfusion strategy, and rotational thromboelastometry. RESULTS:In total, 1211 patients underwent elective TAAA OSR, with 455 patients in Group 1 and 756 in Group 2. A modified surgical approach was employed in the two groups, with significant differences in terms of sites of aortic cross-clamping, techniques for vessel reconstruction, and approach in the management of intercostal artery. In addition, significant differences between the groups were observed for what concern the use of adjuncts. Regarding the outcomes, Group 2 demonstrated a significantly lower 30-day mortality rate (7.5% in Group 2 vs. 13.4% in Group 1; P=0.001), and a reduction in permanent spinal cord ischemia (SCI) (7.4% in Group 2 vs. 11.9% in Group 1; P=0.012). Additionally, Group 2 exhibited trends toward reduced respiratory failure and renal complications, but these differences were not statistically significant. CONCLUSIONS:This single-center experience highlights the evolution of TAAA OSR over 35 years, demonstrating a significant reduction in mortality and SCI with the use of a comprehensive, multimodal approach. Although there were improvements in postoperative complications, further advancements are needed in this complex field to optimize outcomes. The ongoing refinement of surgical techniques and adjuncts continues to play a crucial role in improving patient care.

Background The frozen elephant trunk (FET) technique has become a cornerstone in managing complex aortic arch disease. However, commercial FET systems may be unavailable in emergent situations, necessitating alternative solutions. First-in-Human/Early Reports Summary In a 57-year-old man with an acute arch aneurysm with dissection, we replicated the FET configuration by back-table modification of a standard thoracic stent graft and combining it with a surgical graft. This novel approach, the “C-tag Endograft SanRaffaele Arrangement to Re-create a frozen Elephant trunk” (CESARE), provides a rapid, adaptable solution for emergent aortic arch repair with FET when commercial devices are unavailable. Discussion The modified device was prepared in 65 minutes and was deployed under moderate hypothermic circulatory arrest, with uneventful recovery and excellent early imaging. Novelty CESARE is a rapid, customizable, and widely accessible alternative to FET. Take-Home Message This technique enables effective arch repair when standard FET prostheses are unavailable.

Background Systemic sclerosis (SSc) is characterized by macro and microvasculopathy, including splanchnic circulation. Chronic mesenteric ischemia (CMI) is a potentially severe condition which can complicate SSc gastrointestinal vasculopathy. Doppler ultrasound (DUS) may be a non-invasive procedure for identifying CMI in symptomatic SSc patients. Objectives To investigate the capacity of DUS to detect early CMI and the effect of the endovascular approach on CMI-related symptoms. Methods DUS of splanchnic arteries was performed in symptomatic SSc patients, during routinary outpatient visits. Results In 6 out of 72 SSc symptomatic patients, DUS suggested a splanchnic vessels stenosis which was confirmed by computed tomography angiography (CTA). After multidisciplinary evaluation in 3 patients a revascularization was performed. Three-monthly clinical and DUS follow-up was negative in all patients. Conclusion CDU is a useful screening tool for CMI in SSc patients. Revascularization of stenotic mesenteric arteries seems to be a safe and effective procedure.

BACKGROUND:The aim of this paper was to compare the patient characteristics, procedural details, 30-day postoperative outcomes of carotid artery stenting (CAS) performed through radial access versus femoral access. METHODS:This is a single-center, retrospective, non-randomized study conducted on 613 consecutive patients who underwent elective CAS between January 2015 and January 2025. Patients were divided into two groups based on access route: radial (N.=167) and femoral (N.=446). The following were considered as the primary endpoints: 1) the occurrence of one of TIA/stroke/death; and 2) the overall perioperative complications rate. Secondary endpoints included access-site complications, procedure duration, and single complication rate. RESULTS:No significant differences were observed between the two groups in pre/intraoperative variables, except for the rate of symptomatic carotid stenosis (radial 22% vs. femoral 15%, P=0.030) and the use of dual-layer stents (radial 87% vs. femoral 75%, P<0.001). The TIA/Stroke/death rate (radial 1.8% vs. femoral 4.4%, P=0.119), overall perioperative complication rate (radial 5.4% vs. femoral 10%, P=0.057), and access-site complications (radial 0.6% vs. femoral 2%, P=0.217) were comparable between groups. However, the mean procedure time was significantly shorter in the radial group (36±15 minutes vs. 42±18 minutes, P<0.001). CONCLUSIONS:Percutaneous radial access in CAS procedures was more frequently performed in symptomatic patients and with the use of newer low-profile dual-layer micromesh platforms. Radial access was associated with shorter procedural times and a trend toward lower perioperative complication rates, though the latter did not reach statistical significance.