Chronic limb-threatening ischemia (CLTI) represents the end-stage form of peripheral arterial disease (PAD) and is associated with a very poor prognosis and high risk of limb loss and mortality. It can be considered very similar to a terminal cancer disease, reflecting a large impact on quality of life and healthcare costs. The aim of this study is to offer an overview of the relationship between CLTI, limb salvage, and mortality, with a focus on the need of a fast-track team-based management that is a driver to achieve better survival results. This review can be useful to improve management of this growing impact disease, and to promote the standardisation of care and communication between specialist and non-specialist healthcare professionals.

Arteriovenous grafts (AVG) present a feasible solution for creating a vascular access in patients who are unsuitable for autogenous fistulas (AVF). The quite poor outcomes associated with AVG are largely due to neointimal hyperplasia in the venous anastomosis. The aim of this study was to assess the patency rate of GORE Hybrid Vascular Grafts (HG) in vascular access for hemodialysis. This was a cohort study conducted from March 2013 to November 2016. All consecutive patients in whom an HG was implanted in our institution were included. Indications for HG were primary lack of native veins suitable for a direct fistula and secondary lack of native veins due to failure of a previous fistula. In patients suffering segmental occlusions or aneurysmatic lesions (prosthetic interpositions) a standard stretch graft was used. All patients requiring a secondary intervention were also referred to our center. Patients underwent ultrasound follow-up at 1, 3, and 6 months and then every 6 months. Outcomes were primary and cumulative (assisted and secondary) patency at 6, 12, and 24 months (Kaplan-Meier analysis). Patency was evaluated as no evidence of venous stenosis at duplex examination in functional accesses. Graft closures caused by pseudoaneurysm, death, infections, transplants, or related to proximal anastomosis were excluded from the data analysis. There were 29 grafts placed in 29 patients. In 22 patients, a 5-cm-long nitinol reinforced section (NRS) graft was used, in the other seven, the 10-cm NRS was selected. No patients suffered pseudoaneurysms and surgical closure; graft infections requiring excision were not recorded. Median follow-up was 17 months (2-43). Primary patency was 58.8%, 58.8%, and 50.4% at 6, 12, and 24 months respectively. Cumulative patency was 85.6% at 6 months and 71.4% at 12 and 24 months. Seven clotted grafts were recorded, in one case a central venous catheter was deployed, in the other six cases the clot was managed surgically and then an endovascular completion was done with stent graft deployment to treat the venous residual stenosis and to extend the NRS. Use of GORE Hybrid Vascular Graft seems to be effective in prevention of vein stenosis in AVG. Interestingly the majority of clotting events occurred in the first 6 months after access creation. Our data suggest to intensify follow-up protocol in this period to improve stenosis detection and treatment and to reduce the occurrence of thrombosed grafts. More data are needed to confirm our findings.

Introduction: The Endovascular Correction (EC) has emerged in recent years as a possible alternative to surgical revision (SR) in case of bleeding complications after Peripheral Bypass (PB). The purpose of this study is to evaluate the efficacy and safety of EC compared to SR in case of bleeding complications of PB. Methods: From January 2004 to December 2014, we have undergone surgery 32 patients for acute bleeding in previous PB (25 venous bypass, in situ or reversed, 6 PTFE bypass and 1 composite bypass). The cause of the bleeding was in 14 cases the dehiscence of proximal anastomosis, in 11 cases of distal anastomosis and in 7 cases the rupture of the graft. All patients postoperatively underwent anticoagulation or antiplatelet therapy, antibiotic therapy and close ultrasound follow-up. Patency rate, Limb Salvage rate and Survival rate in the short term were assessed by Kaplan-Meier curves. Results: Of the 32 patients treated for acute bleeding in previous PB, 11 underwent endovascular correction with a technical success of 100% (no need for reintervention), while in 21 patients was performed a surgical revision. Among the latter, in 4 cases (19.1%) an early bleeding occurred, and endovascular correction was promptly performed solving the bleeding in the absence of sequelae (then a total of 15 patients were treated by endovascular correction). The 12-months patency, limb salvage and survival rates were respectively 71.4%, 88.2% and 88.2% in the SR group and 80%, 93.3% and 100% in the EC. Conclusion: This topic underlines that endovascular correction after peripheral bypass bleeding is an attractive alternative to surgery, but there are still few data to change the gold standard treatment. Randomized Clinical Trials comparing the two treatment options are warranted.

BACKGROUND:Although international guidelines recommend cilostazol as first-line therapy for peripheral arterial disease (PAD) because it improves the symptoms and quality of life, it remains an underused agent for amputation-free survival. The objective of this study was to evaluate the practice among Italian physicians of the use of cilostazol in patients suffering from peripheral arterial disease (PAD).METHODS:For the present study, a cross-sectional survey was carried out. Physicians specialized in the medical and/or surgical treatment of PAD and who prescribe cilostazol regularly were invited to a phone interview. A nationally-representative probability sample of hospital-based physicians who diagnose and treat patients with PAD was randomly selected among the members of the Italian Physicians' Association.RESULTS:Out of a total of 641 physicians contacted, 250 of them (39%) accepted to take part in this survey. Reasons of survey refusal were the non-attitude to prescribe cilostazol (45%), or unspecified motivations (16%). Among the 250 physicians participating the survey: 120 were vascular surgeons, 80 internal medicine doctors, 50 angiologists. Cilostazol was suggested in 79% of patients with symptomatic intermittent claudication, and in 30% of patients who had undergone revascularization. The majority of physicians stated to prescribe cilostazol at recommended dosage of 100 mg bid (46.4%). The principal reason to suggest a reduced drug dosage was to limit early side effect at the time of treatment onset, but the increase to the full dose of cilostazol is suggested by 91.3% of interviewed within 4 weeks. Sixty-three percent of physicians affirmed to prescribe cilostazol as a continuous treatment for a mean of 4 months, while a lifelong treatment was suggested by 17.6% of participants.CONCLUSIONS:Among physicians who habitually prescribe cilostazol adherence to the recommended drug dosage and length of treatment is high. The prescription of cilostazol is particularly appreciated in patients with symptomatic intermittent claudication, even before any non-invasive diagnosis of PAD, and before any invasive therapy. Finally a relevant number of physicians regularly prescribe cilostazol also after revascularization, advocating the anti-restenotic properties of the drug.

Data from randomized controlled trials (RCTs) demonstrated significant differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in terms of early neurological outcomes (from 0 to 30 days), although mid- and long-term neurological results are indistinguishable. CAS in symptomatic standard risk patients is coupled with a higher risk of any stroke, and death or any stroke at 30 days, while the rates of disabling or major stroke do not vary remarkably between treatments. Since the micro-embolization through the stent struts is the primary suspected cause of suspected early postoperative neurological complications (i.e., non-disabling stroke), surgical technology has focused on the production of a new generation of stents with a double layer of mesh to reduce the "free area" of the cells, and on new cerebral protection devices. Another major determinant of early negative outcomes is believed to be the intraluminal manipulation occurring during carotid engagement from the aortic arch, the crossing maneuvers at the level of the culprit lesion and vessel trauma during angioplasty. To address these subject matters, new embolic protection devices and innovative strategies have been developed, consequently. This review is designed to furnish the current status of CAS results, to update the ongoing RCTs comparing CAS vs. CEA outcomes, and to recapitulate the features and clinical outcomes for a new carotid stent design, the so called "mesh-stents", and new embolic protection tools.

Endovascular repair of abdominal aortic aneurysms has become a milestone in the treatment of patients with abdominal aortic aneurysm. Technological improvement allows treatment in more and more complex cases. This review summarizes all grafts available on the market. A complete review of most important trial on this topic is provided to the best of our knowledge, and technical tips and tricks for standard cases are also included.

Endovascular repair of abdominal aortic aneurysms has become a milestone in the treatment of patients with abdominal aortic aneurysm. Technological improvement allows treatment in more and more complex cases. This review summarizes all grafts available on the market. A complete review of most important trial on this topic is provided to the best of our knowledge, and technical tips and tricks for standard cases are also included.

To evaluate the feasibility and image quality assessment of optical coherence tomography (OCT) for the in vivo examination of de novo lesions or restenosis of lower limb arteries, before and after endovascular treatment. OCT was performed in 15 consecutive patients with peripheral arterial obstructive disease (PAD) of femoropopliteal segments undergoing endovascular treatment. Images were acquired before treatment, immediately after balloon angioplasty, and after bailout stenting and postdilatation, if necessary (range, 2-6 scans per patient). Two independent physicians judged blinded sets of OCT images for image quality, artifact frequency, discriminability of the vessel wall layers, and plaques on a predefined 1 to 10 scale. The proportions of specific agreement and κ values were calculated. Twenty-two arterial lesions of the femoropoplitel arterial segment were studied, for a total of 58 OCT acquisitions. No procedural or in-hospital complications related to OCT images acquisition occurred. The technical success of OCT pullbacks was 94.8% (55 of 58). The images obtained were of high quality (mean value, 8.3 of 10), both with good interobserver and intra-observer agreement (respectively, κ = 0.85 and κ = 0.94). OCT image quality improved with decreasing vessel diameter and decreased with the presence of multiple collateral vessels. OCT images after endovascular treatment revealed innovative features, such as intimal tears, flaps and residual dissection, intimal or subintimal guidewire passage, as well as plaque prolapse through the stent cell and malapposition in case of stenting. Intravascular OCT appears to be feasible and safe in femoropopliteal arterial segments, permitting the acquisition of high-quality images that might increase our understanding in the application of endovascular technique to the femoropopliteal arterial segments, as well as influencing our clinical policies.

Implantation of a vascular prosthesis increases surgical site infection risk by producing a microenvironment conducive to bacterial attachment and biofilm formation, which sustains bacterial colonization and protects encased organisms from host defenses and antimicrobial therapy. Many maneuvers are used in an attempt to reduce infection in arterial reconstructions, but there are no clear guidelines on the most appropriate or effective. As well, there is no good evidence to guide management. A general principle is that indication for removal of the entire infected graft is mandatory when a suture line is involved in the infectious process, an infected anastomotic aneurism and a suture-line hemorrhage is evident, or when a graft-enteric fistula is diagnosed. Conservative, non-resectional management of graft infection is still a respectable solution for selected patients, as those with significant comorbidities, or those where the implanted aortic graft is in a location that precludes excision without causing a high likelihood of morbidity and/or mortality. Anyway, definitive management depends on the patient's condition and a tailored approach should be always offered. Surgical techniques favor in terms of mortality, patency and reinfection rate the in situ reconstruction. Currently, the choice of the technique used relies on center and operator's experience. This article summarizes the incidence of graft infection, analyze the predisponding factors to graft infection, and review current strategies for prevention and treatment of prosthesis and endograft infection.