Medial Artery Calcification (MAC) and Small Artery Disease (SAD) in patients with critical limb ischemia: definition of predisposing factors, development of a prognostic score, histopathological definition, and evaluation of lower limb vein arterialization outcomes as a revascularization technique.

Questo studio si concentra sull'ischemia critica cronica dell'arto inferiore (CLTI), una patologia globale con gravi complicanze e impatto sociale elevato. Recentemente, la "Medial Artery Calcification" (MAC) è emersa come fattore prognostico significativo nei pazienti con CLTI e malattia grave dei vasi del piede, ma le informazioni sono principalmente retrospettive. Questa tesi esplora la relazione tra MAC e CLTI in tre sezioni. Nella sezione clinica, 248 pazienti sono stati divisi in gruppi MAC per valutare l'impatto prospettico sulla guarigione e sul salvataggio dell'arto. Nella sezione isto-patologica, campioni arteriosi di 26 pazienti sottoposti ad amputazione maggiore sono stati analizzati per comprendere la relazione tra MAC, aterosclerosi e occlusione vascolare. Nella sezione di arterializzazione, 16 pazienti sottoposti all'arterializzazione delle vene del piede (AVP) sono stati esaminati per valutare i risultati clinici prospettici. I risultati della sezione clinica indicano che la presenza di MAC severa è associata a risultati clinici peggiori nei pazienti affetti da CLTI. L'analisi isto-patologica mostra una prevalenza elevata di MAC rispetto all'aterosclerosi, con una associazione importante tra MAC e iperplasia intimale. L'AVP presenta risultati promettenti nei pazienti affetti da CLTI. In conclusione, la MAC influisce sui risultati clinici della CLTI, e l'AVP potrebbe essere una strategia efficace di trattamento.This study focuses on chronic limb-threatening ischemia (CLTI), a global pathology with severe complications and significant societal impact. Recently, Medial Artery Calcification (MAC) has emerged as a significant prognostic factor in patients with CLTI and severe foot vessel disease, but the information is primarily retrospective. This thesis explores the relationship between MAC and CLTI in three sections. In the clinical section, 248 patients were divided into MAC groups to prospectively assess the impact on limb healing and salvage. In the histopathological section, arterial samples from 26 patients undergoing major amputation were analyzed to understand the relationship between MAC, atherosclerosis, and vascular occlusion. In the arterialization section, 16 patients undergoing foot vein arterialization (AVP) were examined to prospectively evaluate clinical outcomes. Results from the clinical section indicate that the presence of severe MAC is associated with worse clinical outcomes in CLTI patients. Histopathological analysis reveals a high prevalence of MAC compared to atherosclerosis, with a significant association between MAC and intimal hyperplasia. AVP shows promising outcomes in CLTI patients. In conclusion, MAC influences CLTI clinical outcomes, and AVP may be an effective treatment strategy

Surgical treatment of a high-flow femoro-femoral arteriovenous fistula in an intravenous drug abuser

Background: We report the surgical treatment of a high-flow femoro-femoral arteriovenous fistula (AVF), a rare complication of intravenous drug abuse. Methods: A 36-year-old woman with history of intravenous heroin and cocaine abuse presented with right lower limb edema, inguinal bruit, and heart failure. Duplex ultrasound examination (DUS) and computed tomography angiography showed a large, high-flow AVF involving the common femoral vein and the superficial femoral artery, which is associated with thrombosis of the great saphenous vein and an important inflammation in the right groin, without active bleeding. Under general anesthesia, the patient underwent open surgical repair of the AVF through a right-groin cutdown. The 3-cm-long AVF was repaired with the interposition of a bovine pericardium patch that is sewn from inside the femoral vein through a longitudinal venotomy with a continuous 5–0 polypropylene suture. Results: The venotomy was repaired with a 5–0 polypropylene running suture. No perioperative or postoperative complications were recorded. The inguinal bruit resolved, the arteries recovered good pulsatility, and the lower limb edema promptly reduced. A 6-month DUS confirmed the patency of the femoral arteries and veins and the absence of AVF or infection signs in the right groin. Conclusions: Surgical repair of femoro-femoral AVF in drug abusers by biologic patch interposition is a challenging, but feasible, and effective technique with encouraging midterm results in terms of patency and resistance to infections

Endovascular treatment for restenosis of carotid venous bypass graft: a clinical case report

Restenosis after open carotid surgery (OCS) represents an issue that experts are very often facing nowadays, both after carotid endoarterectomy(CEA) and carotid bypass(CB). Yet, even if from one side carotid artery stenting (CAS) is currently recommended by most guidelines as treatment of choice for carotid restenosis after CEA, on the other side little is known regarding the best treatment of restenosis after CB. This clinical case report is aimed to empathize the endovascular treatment as an effective therapeutic option for restenosis after OCS

Surgical and Endovascular Management of Isolated Internal Iliac Artery Aneurysms: A Systematic Review and Meta-Analysis

Objectives: The purpose of this paper is to report the different modalities for the treatment of isolated internal iliac artery aneurysms (IIIAA), as well as their outcomes. Methods: We performed a systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search: April 2020). We included articles reporting on the outcomes for IIIAA interventions comprising at least 5 patients. Studies were included when presenting extractable outcome data regarding intraoperative and/or early results. We performed meta-analyses of proportions for different outcomes, using random effects model. Results: Thirteen non-randomized studies were included (192 patients with 202 IIIAA). IIIAA were symptomatic in the 18.1% (95%CI 9.3-26.9; I-2 54.46%, P = .019). Estimated mean IIIAA diameter was 46.28 mm (95%CI 39.72-52.85; I-2 88.85%, P < .001). Open repair was performed in 21/202 cases. Endovascular treatments were: embolization (81/181), embolization and hypogastric artery coverage (79/181), hypogastric artery coverage by stent-grafting (15/181), stent-grafting in the hypogastric artery (6/181). Overall estimated technical success (TS) rate was 91.6% (95% CI 86.8-95.5; I-2 45.82%, P = .031). TS rate was 94.5% for open surgery (95%CI 85.3-100; I-2 0%, P = .907), and 89.7% for endovascular repair (95%CI 83.8-95.6; I-2 55.43%, P = .006). Estimated overall 30-day mortality was 3.1% (95%CI 0.8-5.4; I-2 0%, P = .969). Mortality rates after open surgery and endovascular repair were 8.2% (95%CI 3.4-19.8; I-2 0%, P = .545) and 2.8% (95%CI 0.5-5.1; I-2 0%, P = .994), respectively. Estimated mean follow-up was 32.63 months (95%CI 21.74-43.53; I-2 94.45%, P < .001). During this timeframe, IIIAA exclusion was preserved in 92.8% of the patients (95%CI 89.3-96.2; I-2 0%, P = .797). Buttock claudication occurred in 13.9% of the patients (95%CI 8.7-19.2; I-2 0%, P = .622). Conclusions: IIIAA are frequently large, and symptomatic at presentation. Several treatments are proposed in literature, open and endovascular, both with good results. The endovascular treatment is the preferred method of treatment in literature, since it offers good short- to mid-term results and low early mortality. Buttock claudication after hypogastric artery exclusion is a common complication

Significance and Risk Factors for Intraprosthetic Mural Thrombus in Abdominal Aortic Endografts: a Systematic Review and Meta-Analysis

The detection of intraprosthetic thrombus (IPT) deposits is a common finding during follow-up for endovascular abdominal aneurysm repair (EVAR); however, its clinical significance is still debated. The aim of this study was to determine if IPT represents a risk factor for thromboembolic events (TE; endograft or limb thrombosis, or distal embolization) after EVAR