Editor's Choice – European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease

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Documenting the Recovery of Vascular Services in European Centres Following the Initial COVID-19 Pandemic Peak: Results from a Multicentre Collaborative Study

Objective: To document the recovery of vascular services in Europe following the first COVID-19 pandemic peak. Methods: An online structured vascular service survey with repeated data entry between 23 March and 9 August 2020 was carried out. Unit level data were collected using repeated questionnaires addressing modifications to vascular services during the first peak (March – May 2020, “period 1”), and then again between May and June (“period 2”) and June and July 2020 (“period 3”). The duration of each period was similar. From 2 June, as reductions in cases began to be reported, centres were first asked if they were in a region still affected by rising cases, or if they had passed the peak of the first wave. These centres were asked additional questions about adaptations made to their standard pathways to permit elective surgery to resume. Results: The impact of the pandemic continued to be felt well after countries’ first peak was thought to have passed in 2020. Aneurysm screening had not returned to normal in 21.7% of centres. Carotid surgery was still offered on a case by case basis in 33.8% of centres, and only 52.9% of centres had returned to their normal aneurysm threshold for surgery. Half of centres (49.4%) believed their management of lower limb ischaemia continued to be negatively affected by the pandemic. Reduced operating theatre capacity continued in 45.5% of centres. Twenty per cent of responding centres documented a backlog of at least 20 aortic repairs. At least one negative swab and 14 days of isolation were the most common strategies used for permitting safe elective surgery to recommence. Conclusion: Centres reported a broad return of services approaching pre-pandemic “normal” by July 2020. Many introduced protocols to manage peri-operative COVID-19 risk. Backlogs in cases were reported for all major vascular surgeries

Editor's Choice - Asymptomatic Carotid Stenosis and Cognitive Impairment: A Systematic Review

Objective: The aim was to evaluate the relationship between asymptomatic carotid stenosis (ACS) of any severity and cognitive impairment and to determine whether there is evidence supporting an aetiological role for ACS in the pathophysiology of cognitive impairment. Data sources: PubMed/Medline, Embase, Scopus, and the Cochrane library. Review methods: This was a systematic review (35 cross sectional or longitudinal studies) RESULTS: Study heterogeneity confounded data interpretation, largely because of no standardisation regarding cognitive testing. In the 30 cross sectional and six longitudinal studies (one included both), 33/35 (94%) reported an association between any degree of ACS and one or more tests of impaired cognitive function (20 reported one to three tests with poorer cognition; 11 reported four to six tests with poorer cognition, while three studies reported seven or more tests with poorer cognition). There was no evidence that ACS caused cognitive impairment via silent cortical infarction, or via involvement in the pathophysiology of lacunar infarction or white matter hyperintensities. However, nine of 10 studies evaluating cerebral vascular reserve (CVR) reported that ACS patients with impaired CVR were significantly more likely to have cognitive impairment and that impaired CVR was associated with worsening cognition over time. Patients with severe ACS but normal CVR had cognitive scores similar to controls. Conclusion: Notwithstanding significant heterogeneity within the constituent studies, which compromised overall interpretation, 94% of studies reported an association between ACS and one or more tests of cognitive impairment. However, "significant association" does not automatically imply an aetiological relationship. At present, there is no clear evidence that ACS causes cognitive impairment via silent cortical infarction (but very few studies have addressed this question) and no evidence of ACS involvement in the pathophysiology of white matter hyperintensities or lacunar infarction. There is, however, better evidence that patients with severe ACS and impaired CVR are more likely to have cognitive impairment and to suffer further cognitive decline with time

Cystic Adventitial Disease of the Popliteal Artery: Radical Surgical Treatment After Several Failed Approaches. A Case Report and Review of the Literature

Adventitial cystic disease is a rare nonatheromatous cause of popliteal artery disease. We report the case of a 49-year-old male patient who presented with left calf claudication caused by adventitial cystic disease. Popliteal artery resection followed by autologous vein graft interposition and Percutaneous Transluminal Angioplasty (PTA) stenting led to recurrence. The patient was finally successfully treated by bypass with autologous vein. No postoperative complications occurred, and patency was preserved at 33-month follow-up. Several different treatment options are possible; however, a primary radical surgical treatment with extra-anatomical medial bypass with autologous vein seems preferable

Total Endovascular Repair of Contained Ruptured Thoracoabdominal Aortic Aneurysms

Background: To report perioperative and 1-year results of total endovascular repair of contained ruptured thoracoabdominal aortic aneurysms (TAAAs). Methods: Between 2015 and 2017, preoperative, procedural, and postoperative data of patients with radiographic evidence of contained ruptured TAAAs treated by endovascular repair were prospectively collected. Only patients with stable hemodynamic parameters were enclosed. Primary endpoints were 30-day/in-hospital mortality, spinal cord ischemia (SCI), postoperative cardiopulmonary complications, and new onset of hemodialysis. Secondary endpoints were endoleaks, reinterventions, and overall follow-up survival. Results: Twelve patients underwent endovascular repair for contained ruptured TAAAs. According with the Crawford/Safi's classification, 6 type II (50%), 3 type III (25%), 1 type IV (8%), and 2 type V (17%) TAAAs were treated. All patients were symptomatic. Overall, 34 target visceral vessels were planned to be revascularized. The mean time from admission to treatment was 48 hours (range 4\u201396), with 4 patients operated within 24 hours. Five patients (42%) were treated by T-branch, 3 (25%) by custom-made fenestrated/branched endografts, 3 (25%) by parallel graft technique, and 1 (8%) by standard thoracic endovascular aortic repair covering a stenotic celiac trunk. The 30-day and in-hospital mortality was 17% and 25%, respectively. Two patients (17%) developed SCI. Cardiac and pulmonary complications were reported in 1 (8%) and 3 (25%) cases, respectively. One patient (8%) needed permanent hemodialysis. Two endoleaks (17%) were detected at the postoperative computed tomography angiography (1 low-flow gutter endoleak and 1 type III endoleak). Four patients (33%) required re-interventions within 30 postoperative days. The mean follow-up was 12 months (range 1\u201322). No late target visceral vessels occlusion, endoleak, or reintervention occurred in this series. Overall, 7/12 (59%) patients were alive, and no cases of TAAA-related mortality occurred during follow-up. Conclusions: According to our results, endovascular repair of contained ruptured TAAAs is feasible by a flexible approach in selected patients with anatomical suitability and stable hemodynamic conditions. Although early mortality and morbidity are significant, with frequent reintervention necessity, subsequent follow-up is free from reinterventions and TAAA-related mortality

VAscular and Endovascular Consensus Update 2017

Data form randomised controlled trials shown endovascular aneurysm repair (EVAR) to be associated with lower 30-day morbidity than the open repair. the faesibility and effectivfeness of EVAR depend on specific anatomic aortioiliac features. after proximal neck atonomy, the challenging iliac-femoral access (small diameter, severe angulations/tortuosity, exstensive calcification and occlusive disease) represent the second excluding factor for EVAR

The Clinical Impact of Splanchnic Ischemia on Patients Affected by Thoracoabdominal Aortic Aneurysms Treated with Fenestrated and Branched Endografts

Background: Fenestrated/branched endografts for aortic repair (FB-EVAR) are valid options to treat thoracoabdominal aortic aneurysms (TAAAs). Successful repair requires manipulation of target visceral vessels (TVVs) with possible splanchnic ischemia. The aim of the study was to evaluate the clinical impact of splanchnic ischemia occurring in FB-EVAR for TAAA. Methods: Between 2010 and 2015, patients with TAAAs undergoing FB-EVAR were prospectively enrolled. Clinical, morphological, procedural, and 30-day data were evaluated. Splanchnic ischemia was defined as the presence of splanchnic ischemic lesions (SILs) visible at perioperative computed tomography angiography. Preoperative, postoperative, and 30-day hepatic/pancreatic/renal laboratory functions were analyzed. End points were incidence of SILs, laboratory splanchnic functions worsening ( 6525% of baseline), and presence of related clinical/morphological and procedural risk factors. Results: Thirty-six patients (male: 78%; age: 73 \ub1 7 years) with 27 (75%) type I-III and 9 (25%) type IV TAAA who underwent FB-EVAR for a total of 127 TVV (branches: 47\u201360%; fenestrations: 53\u201367%). Fourteen SILs occurred in 12 (33%) patients: 4 (29%) in pancreas, 3 (21%) in spleen, 2 (14%) in bowel, 5 (36%) in kidney. The cause was embolic in 79% and thrombotic in 21%. No preoperative clinical/morphological data or procedural data were correlated with SIL. Pancreatic, hepatic, or renal function worsening occurred at 24 hr in 16 (44%), 16 (44%), and 9 (25%) cases, respectively. Overall, SILs were associated with increased values of C-reactive protein (CRP) (17.9 \ub1 0.4 vs. 9.9 \ub1 9.0 mg/dL; P = 0.03) and bilirubin (1.2 \ub1 2.3 vs. 1.0 \ub1 0.5 mg/dL; P = 0.02) at 24 hr. Specifically, SIL of the celiac trunk and superior mesenteric and renal arteries' parenchyma were associated with the significant laboratory function changes 24 hr. SIL of the superior mesenteric artery was associated with increased 30-day mortality (50% vs. 7 %; P = 0.002). Pancreatic, hepatic, or renal function worsening occurred at 30 days in 2 (6%), 0 (0%), and 4 (12%) cases, with similar laboratory tests in patients with and without SIL. Conclusions: SIL can be frequently detected after FB-EVAR for TAAA and appears mainly of embolic origin. No clinical, morphological, or procedural predictors could be identified in our series. Postoperative laboratory changes of CRP, bilirubin, activated partial thromboplastin time, and amylases are associated with SIL but disappear without clinical consequences within 30 days. However, SIL occurring in the superior mesenteric artery are associated with an increased 30-day mortality