Aim. We report our experience of thirteen years of treatment of significant carotid artery stenosis.Methods. Data of all consecutive patients who came to our Division for a significant carotid artery stenosis from January 1999 to January 2012 were collected about patients' demographic, cardiovascular risk factors, neurological symptoms and treatment (carotid endarterectomy, carotid artery stenting or best medical therapy). Retrospective review was performed and the occurrence of death, major cerebrovascular events (major stroke, minor stroke) and myocardial infarction (MI) were recorded both at 30-day and at long-term. Analysis was performed among groups by means of JMP 5.10 (R).Results. Of 1824 patients who were admitted to our Department for a significant carotid stenosis, 582 were unsuitable for surgery and underwent carotid artery stenting (CAS, Group A). Three hundred and seventy-three of them were symptomatic (64.1%). Carotid endarterectomy (CEA) was performed in 1030 patients (Group B), 741 (71.9%) of them were symptomatic. The remaining patients (Group C) were treated using best medical therapy (BMT). At 30-day CEA compared to CAS and BMT was associated with higher risk of MI (2.1% vs. 0.2%, and 0.4% respectively, P<0.05), most of all in asymptomatic patients. CEA had a higher risk of cranial nerve injuries than CAS (3.3% vs. 0%, P<0.001). Both risk of death and major neurological complications were similar among the three groups in both symptomatic and asymptomatic patients. At long-term, risk of stroke after CEA was similar to that after CAS, both for symptomatic and asymptomatic patients, while risk of 1-year stroke in Group C was higher than in Group A (P<0.001) and in Group B (P<0.001), for both symptomatic and asymptomatic patients. Risk of long-term MI was similar among the three groups. Mortality at long term in symptomatic patients was higher after CAS than after CEA (P=0.001). Also long-term mortality in Group C was higher than in Group A and B (both P<0.001) but only for asymptomatic patients. A procedure that lasted for more than 60 minutes, patients who had no prior Magnetic Resonance Angiography (MRA) or Computed Tomographic Angiography (CTA) study of the aortic arch were independent risk factors for major neurological complications after CAS. Symptomatic patients were likely to have more major neurological complications in the long term if they were treated with BMT only.Conclusion. In our experience, CAS offered a valid alternative for both symptomatic and asymptomatic patients who were poor candidates for CEA, with results that compared favourably to those of CEA both at 30-day and at long-term. Patients who couldn't be operated on neither with CAS nor with CEA had a lower risk of MI at 30-day but a higher risk of stroke during the first year, especially if they had previously experienced neurological symptoms.

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization.Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012.Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD +/- 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%.Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions.Clinical trial: ISRCTN21144362. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Endovascular treatment of atherosclerotic femoropopliteal lesions is increasing, primarily because peripheral artery disease is very common and tends to recur after the first procedure, secondly because new techniques are becoming available. PTA and stenting are no longer the only treatments available and although there is still no agreement on the gold standard for the treatment of infrainguinal lesions, some studies have been conducted in order to give an answer. This review takes into account recent studies and clinical data to support the use of directional atherectomy.

Aim. We report our preliminary experience with the use of the TriVascular Ovation endograft system for the treatment of abdominal aortic aneurysms (AAA).Methods. Data from patients treated for AAA using the Ovation endograft at two centers from January 2011 to September 2012 were retrospectively collected and reviewed. Main outcomes included primary success, survival, complications, and device-related events at 30-days.Results: Thirty-seven patients (male: 95%, mean age: 76 yr) were treated for AAA (mean diameter: 54 mm) with the Ovation endograft, mainly using local or regional anesthesia (86.5% of cases). Percutaneous femoral access was utilized in 73% of cases. Primary success was achieved in 89.2% of cases, as 4 adjunctive procedures were required including two distal extensions (type 1b endoleak and iliac limb disconnection resulting in type III endoleak) and two bypass surgeries (limb graft occlusion and gate cannulation failure). No deaths, major complications, endoleaks, AAA enlargement, AAA rupture, stent fracture, migration, or endovascular or surgical reintervention were reported at 30-days.Conclusion. Our initial experience with the Ovation endograft demonstrated encouraging 30-day results for the treatment of AAA.

AIM:Open surgical repair (OSR) and endovascular techniques (ET) are both described in the literature for treating visceral artery aneurysms (VAAs). Aim of this study is to report a two-center experience of patients treated for a VAA using either OSR or ET, analyzing perioperative outcomes.METHODS:Clinical data of 32 VAAs in 32 patients treated between January 2001 and May 2011 were retrospectively reviewed and outcomes analyzed.RESULTS:Eighteen patients were men (56.3%). Median age was 64 years (range 26-79). Sixteen aneurysms were symptomatic: half of them were ruptured causing hemoperitoneum or gastrointestinal bleeding. ET were employed in 19 cases (59%) using covered stents (7 patients), coil embolization (5), plug placement (1), thrombin injection (2) and multiple associated techniques (4). OSR consisted in aneurysmectomy with end to end anastomoses (5 patients) or interposition graft (1), aneurysm ligation (4), splenectomy (2). One patient died during open surgery for hemoperitoneum due to VAA rupture (3%). OSR and ET had similar perioperative complication rates (5.2% vs. 15.3%, P=0.76). OSR had a longer in-hospital stay than ET (8 vs. 4 days, P=0.04). The presence of pancreatitis and alcohol abuse were more frequent in patients who presented with VAAs rupture. Clinical presentation with hemoperitoneum or aneurysm rupture were associated with higher mortality, regardless of the type of treatment.CONCLUSION:Both OSR and ET offered a safe way to treat VAAs in our experience.

Aim. We report a case of ulnar and palmar arch artery aneurysm in a 77 years old man without history of any occupational or recreational trauma, vasculitis, infections or congenital anatomic abnormalities. We also performed a computed search of literature in PUBMED using the keywords "ulnar artery aneurysm" and "palmar arch aneurysm".Case report. A 77 years old male patient was admitted to hospital with a pulsing mass at distal right ulnar artery and deep palmar arch; at ultrasound and CT examination a saccular aneurysm of 35 millimeters at right ulnar artery and a 15 millimeters dilatation at deep palmar arch were detected. He was asymptomatic for distal embolization and pain. In local anesthesia ulnar artery and deep palmar arch dilatations were resected. Reconstruction of vessels was performed through an end-to-end microvascular repair. Histological examination confirmed the absence of vasculitis and collagenopaties. In postoperative period there were no clinical signs of peripheral ischemia, Allen's test and ultrasound examination were normal. At follow-up of six months, the patient was still asymptomatic with a normal Allen test, no signs of distal digital ischemia and patency of treated vessel with normal flow at duplex ultrasound.Conclusion. True spontaneous aneurysms of ulnar artery and palmar arch are rare and can be successfully treated with resection and microvascular reconstruction.

Aim. endovascular procedures for thoracic aorta are widely used in different pathologies: aneurysms, acute and chronic dissections, penetrating aortic ulcers, intramural hematomas, blunt trauma. The aim of this study is to present the Italian experience in the RESTORE I Registry.Methods. RESTORE is a perspective, non randomized, European multicentric Registry designed to evaluate technical and clinical outcome from patients treated with Relay (TM) stent-graft. Threre hundred and four patients were enrolled all over Europe. Italy contributed with 146 patients (48%) in 8 major referral centres. The purpose of the registry was to collect data about patients undergoing thoracic graft endoprosthesis with Relay (TM) Bolton. Including indications were degenerative acute and chronic aneurysm, type B acute and chronic dissections, intramural hematomas, penetrating aortic ulcers, pseudoaneurysms and blunt trauma.Results. Patients were 120 males (82.2%) and 26 females; 102 patients (70.3%) were classified as ASA class III or more. The most common aortic pathology treated was aneurysms (63.0%), followed by dissection (22.6%). Technical success was achieved in 144 patients (98.6%); 139 patients (95.21%) reported no endoleaks at discharge. No neurologic complications were found in 136 patients (93.15%): a overall spinal cord ischemia rate of 5.48% and a overall stroke rate of 1.37%. The 30-day mortality rate was 18.6% (8/43) in the acute group and 9.7% (10/103) in the chronic one. At 2 years the overall survival rate due to any cause was 68.54%.Conclusion. Realy (TM) is a safe and accurate graft to treat different thoracic aorta pathologies with acceptable mortality and morbidity and with low stroke rate.

Endovascular treatment of abdominal aortic aneurysm (AAA) involves placement of an endoluminal graft inside the aneurysmal sac in order to exclude it from blood circulation and thereby prevent the risk of aneurysmal sac rupture. A possible complication is endoleak, i.e. persistent blood flow outside the lumen of the endograft into the aneurysmal sac. The protocol for treatment monitoring includes abdominal computed tomography (CT) and color Doppler ultrasound (US). The aim of this case report is to present our experience in two cases of endoleak in which diagnosis and treatment were carried out using color Doppler US.

Objectives. The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers.Methods. Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N = 16) and abdominal infrarenal aorta (N = 2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months).Results. Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in thefollow-up periodfor reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure.Conclusion. Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients.

AIM:The aim of the study was to report a 20-year single Institution experience, with the early and late outcomes of surgical treatment of inflammatory abdominal aortic aneurysms.METHODS:In a 20-year period, 2 275 consecutive patients underwent elective surgical repair for non-rupture abdominal aortic aneurysm. Fifty-two patients (2.3%) were classified as inflammatory abdominal aortic aneurysms. Early and late outcomes were analyzed.RESULTS:One patient died in the perioperative period, giving a mortality rate of 1.92%. One patient died from a pseudoaneurysm rupture 7 months after operation. Three patients developed an aortic pseudoaneurysm in the follow-up period (mean 12.1 years, range 1-20 years) and underwent a redo operation.CONCLUSION:Overall surgical outcome of these patients, in terms of short-term and long-term is good. A high rate of pseudoaneurysm formation was observed.

Adventitial cystic disease of the popliteal artery constitutes an infrequent cause of claudication in non-atherosclerotic young or middle-aged population. Here, we report the case of a 43-year-old female with adventitial cystic disease of the popliteal artery causing left lower leg claudication, detected by duplex scanning. The angio-CT showed the "dog-leg" sign, typical of the aneurysm of the popliteal artery. Surgery was performed through the posterior approach. The cyst and the affected segment of the artery were successfully excised and replaced with an autogenous saphenous vein graft. In 1 year follow-up the graft is patent and the patient is completely asymptomatic.

We report a case of early stent failure in a patient with chronic mesenteric ischemia and its treatment with a retrograde aorto-mesenteric by-pass. The patient was initially treated with angioplasty and stenting. Seven months after the procedure complete thrombosis of the stent was achieved. A retrograde aorto-mesenteric by-pass was performed. After two years the patient remains asymptomatic and color Duplex scan confirm the patency of the graft.

BACKGROUND: The aim of this study is to assess differences between axial computed tomography and duplex ultrasound, based on measurements of maximal aortic diameter in patients with abdominal aortic aneurysms. METHODS: From January 2002 until December 2004, 322 patients were admitted with an abdominal aortic aneurysm. All of them underwent abdominal duplex ultrasound scanning and computed tomography by separate laboratories in order to determine the maximal aortic diameter. The computed tomography technologists were blinded to all duplex results and vice versa. RESULTS: Mean computed tomography maximal aortic diameter was 56.17 mm and mean duplex maximal aortic diameter was 53.44 mm. Computed tomography measurements were greater than duplex in 97.83% of the patients. CONCLUSIONS: Axial computed tomography consistently overestimates the maximal aortic diameter measurements in patients with abdominal aortic aneurysms compared with duplex ultrasound.

AIM:This retrospective single Institution study, aims to evaluate the performance of duplex scanning on admission of patients with carotid artery disease to avoid unnecessary carotid endarterectomies.METHODS:From 1 January 1997 until 31 Decem-ber 2004, 1 504 patients were admitted to our Institution to undergo carotid endarterectomy. A duplex scan on admission was performed in all of them.RESULTS:A total of 1 369 from these patients (91%) underwent surgery, while 135 (9%) were dismissed because there was no indication for surgical treatment. They were put in conservative treatment and periodic duplex control appointments.CONCLUSIONS:In 9% of the patients, unnecessary carotid endarterectomy was avoided.

AIM:The aim of this retrospective, single institution study was to describe our 4-year experience with the endovascular repair of isolated iliac artery aneurysms.METHODS:Between May 1997 and June 2001, 16 patients (15 males; mean age 64+/-9 years), were treated with covered stent grafts. Twelve of the endovascular procedures were performed under epidural and 4 under local anaesthesia. The percutaneous approach was employed in 13 cases and the femoral artery had to be exposed in 3 cases that demanded simultaneous revascularization of the peripheral circulation (n=2) or required a 16 F sheath to employ a Baxter Lifepath stent graft (n=1). The mean size of the iliac aneurysms was 4.5 cm (range 3.5 to 5.2 cm). Four aneurysms involved the hypogastric ostium in absence of any distal neck.RESULTS:All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and were followed from 3 to 52 months (mean 18 months). No procedural deaths and no acute or late graft thrombosis occurred. The perioperative complications included 1 dissection of the external iliac artery that required a further endovacular procedure and 1 case of endovascular leak fed to the hypogastric artery. A CT scan 4 months later showed spontaneous thrombosis of aneurysm and no further leakage. Two patients had undergone combinated femoro-popliteal arterial bypass.CONCLUSION:In our early clinical experience the use of self-expandable covered stent graft successful treated isolated iliac artery aneurysms. Endovascular repair is a safe and effective technique with good midterm results in patients at standard and high risk.

Endovascular treatment of abdominal aortic aneurysm (AAA) involves placement of an endoluminal graft inside the aneurysmal sac in order to exclude it from blood circulation and thereby prevent the risk of aneurysmal sac rupture. A possible complication is endoleak, i.e. persistent blood flow outside the lumen of the endograft into the aneurysmal sac. The protocol for treatment monitoring includes abdominal computed tomography (CT) and color Doppler ultrasound (US). The aim of this case report is to present our experience in two cases of endoleak in which diagnosis and treatment were carried out using color Doppler US.