The Ability to Look Beyond. The Treatment of Peripheral Arterial Disease

This paper offers a practical overview of the contemporary management of patients with peripheral arterial disease presenting intermittent claudication (IC), including clinical and instrumental diagnosis, risk factors modification, medical management, and evidence-based revascularization indications and techniques. Decision making represents a crucial element in the management of the patient with IC; for this, we think a review of this type could be very useful, especially for non-vascular specialists

Early and long-term outcomes of carotid stenting and carotid endarterectomy in women

Background: The role of carotid revascularization in women remains intensely debated because of the lower benefit and higher perioperative risks concerning the male counterpart. Carotid artery endarterectomy (CEA) and stenting (CAS) represent the two most valuable stroke prevention techniques due to large vessel disease. This study investigates the early and late outcomes in female sex in a real-world everyday clinical practice.Methods: Data were retrospectively analyzed from a single-center database prospectively compiled. A total of 234 procedures, both symptomatic and asymptomatic, were identified (98 CEAs and 136 CASs). Perioperative risks of death, cerebral ischemic events, and local complications were analyzed and compared between the two groups. Long-term outcomes were evaluated in overall survival, freedom from ipsilateral stroke/transient ischemic attack, and freedom from restenosis (>50%) and reintervention.Results: Women who underwent CAS and CEA did not differ in perioperative ischemic cerebral events (2.2 vs. 0%, p = 0.26) and death (0.8 vs. 0%, p = 1). Other perioperative and 30-day outcomes were similarly distributed within the two groups. Kaplan-Meier curves between CAS and CEA groups highlighted no statistical differences at 6 years in overall survival (77.4 vs. 77.1%, p = 0.47) of ipsilateral stroke/transient ischemic attack (94.1 vs. 92.9%, p = 0.9). Conversely, significant differences were showed in 6 years freedom from restenosis (93.1 vs. 83.3%, p = 0.03) and reinterventions (97.7 vs. 87.8%, p = 0.015).Conclusion: Our results revealed that both CEA and CAS have acceptable perioperative risk in women. Long-term outcomes highlighted favorable indications for both procedures, especially for CAS, which seemed to be an excellent alternative to CEA in female patients when performed by well-trained operators

The polymer-based technology in the endovascular treatment of abdominal aortic aneurysms

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta that progressively grows until it ruptures. Treatment is typically recommended when the diameter is more than 5 cm. The EVAR (Endovascular aneurysm repair) is a minimally invasive procedure that involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. For years, stent grafts' essential design was based on metallic stent frames to support the fabric. More recently, a polymer-based technology has been proposed as an alternative method to seal AAA. This review underlines the two platforms that are based on a polymer technology: (1) the polymer-filled endobags, also known as Endovascular Aneurysm Sealing (EVAS) with Nellix stent graft; and (2) the O-ring EVAR polymer-based proximal neck sealing device, also known as an Ovation stent graft. Polymer characteristics for this particular aim, clinical applications, and durability results are hereby summarized and commented critically. The technique of inflating endobags filled with polymer to exclude the aneurysmal sac was not successful due to the lack of an adequate proximal fixation. The platform that used polymer to create a circumferential sealing of the aneurysmal neck has proven safe and effective

Primary leiomyosarcoma of the inferior vena cava

1. Leiomyosarcoma of the IVC (IVCLMS) is a very rare retroperitoneal tumor, accounting for only about 0.5 % of adult soft tissue sarcomas. 2. Complete R0 surgical resection of surrounding involved organs is the mainstay of treatment, with medical oncological treatments (CT, RT, and CHRT) incom- pletely verified and partially ineffective. 3. IVC ligation should be abandoned considering the high risk of leg edema and local/peripheral complications. 4. IVCresectionandcompletereconstructionisthetreatmentofchoice,bothusing homologous and prosthetic graft implants. 5. Survival is poor, but radical resection can allow long disease-free intervals and adequate cumulative survivals

Management of abdominal aortic aneurysm in nonagenarians: a single-centre experience

Objective In the last decades, life expectancy has increased worldwide considerably. Traditionally, very elderly patients have been considered too frail to undergo major vascular interventions. Considering that abdominal aortic aneurysm is an age-related disease, there is an increasing need of a correct management of the disease even in nonagenarians, but data are still scarce. The purpose of this single-centre study is to report early and mid-term outcomes of all-comer abdominal aortic aneurysm patients in their 10th decades of age. Methods A retrospective review of our prospectively maintained database identified a total of 33 patients aged >= 90 presenting with abdominal aortic aneurysm between 2014 and 2019. Elective and emergency repairs were both considered. Early technical success and mortality rate at 30 days were considered as primary outcomes. Mid-term clinical success was reported, and overall survival, freedom from aneurysm-related death, re-interventions and endoleaks were estimated with the Kaplan-Meier method, stratified for elective of emergency repair and type of treatment. Results The mean age was 91.7 (range 90-96), and 63.6% were male. Mean abdominal aortic aneurysm diameter was 67.4 +/- 16.8 mm. Sixteen patients were admitted for rupture abdominal aortic aneurysm: three untreated, five underwent open and seven underwent endovascular aneurysm repair (EVAR), with an early mortality rate of 100, 100 and 42.8%, respectively. Eighteen (60%) patients were asymptomatic, and all underwent elective EVAR, with an early mortality rate of 0%. At one-month follow-up, clinical success was 84% in EVAR group. At a median follow-up of 22.4 +/- 14.5 months, no abdominal aortic aneurysm-related death was registered. Freedom from all cause of mortality was 77.3, 59.4 and 40.7% at one, two and three years. Freedom from endoleaks was 95.4% at one month and 61.7% at one and three years. Freedom from reintervention was 85.8% at three years. Conclusion Elective EVAR in nonagenarians is associated with acceptable early and mid-term outcomes. Age by itself should not be considered an exclusion criterion for treatment

The relation between neutrophil/lymphocyte and platelet/lymphocyte ratios with mortality and limb amputation after acute limb ischaemia

ObjectiveAcute limb ischaemia is still considered a significant event, with considerable early- and long-term amputation and mortality risk. Our study aims to investigate the predictive role of pre-operative neutrophil/lymphocyte and platelet/lymphocyte ratios in terms of mortality and amputation risk in patients with acute limb ischaemia.MethodsPre-operative blood samples of all patients admitted with acute limb ischaemia were used to calculate neutrophil/lymphocyte and platelet/lymphocyte ratios. Population was subdivided into quartiles by platelet/lymphocyte ratio and neutrophil/lymphocyte ratio values, and Kaplan-Meier life tables were obtained for overall survival and limb salvage. The optimal neutrophil/lymphocyte ratio and platelet/lymphocyte ratio cut-offs were obtained from receiver operating characteristic curves with all-cause mortality and all kinds of amputation. Stepwise multivariate analysis was performed in order to identify independent risk and protective factors for mortality and amputations.ResultsA total of 168 patients were included in the analysis. Receiver operating characteristic curves identified cut-off values for neutrophil/lymphocyte ratio and platelet/lymphocyte ratio: neutrophil/lymphocyte ratio >= 5.57 for mortality; neutrophil/lymphocyte ratio >= 6.66 and platelet/lymphocyte ratio >= 269.9 for all amputations. Kaplan-Meier analysis revealed that survival rate in group neutrophil/lymphocyte ratio <5.57 was 83.4%, 78.9%, 73.7%, and 59.8%, respectively, at 12, 24, 36, and 48 months; in neutrophil/lymphocyte ratio >= 5.57 group was 62.4%, 51.3%, 47.8, and 43.7%, respectively (p < 0.0001). Freedom from all amputations was significantly higher in case of neutrophil/lymphocyte ratio and platelet/lymphocyte ratio below the identified cut-off values (p < 0.0001). Neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were found as independent risk factors.ConclusionNeutrophil/lymphocyte ratio and platelet/lymphocyte ratio are reliable markers for stratification of mortality and limb amputations in patients with acute limb ischaemia. The inexpensive nature and ready availability of these biomarkers' values reinforced their usefulness in everyday clinical practice

The Polymer-Based Technology in the Endovascular Treatment of Abdominal Aortic Aneurysms

An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta that progressively grows until it ruptures. Treatment is typically recommended when the diameter is more than 5 cm. The EVAR (Endovascular aneurysm repair) is a minimally invasive procedure that involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. For years, stent grafts’ essential design was based on metallic stent frames to support the fabric. More recently, a polymer-based technology has been proposed as an alternative method to seal AAA. This review underlines the two platforms that are based on a polymer technology: (1) the polymer-filled endobags, also known as Endovascular Aneurysm Sealing (EVAS) with Nellix stent graft; and (2) the O-ring EVAR polymer-based proximal neck sealing device, also known as an Ovation stent graft. Polymer characteristics for this particular aim, clinical applications, and durability results are hereby summarized and commented critically. The technique of inflating endobags filled with polymer to exclude the aneurysmal sac was not successful due to the lack of an adequate proximal fixation. The platform that used polymer to create a circumferential sealing of the aneurysmal neck has proven safe and effective

Mini-skin incision for carotid endarterectomy: neurological morbidity and health-related quality of life

Background: Cranial and cervical nerve (CCN) injury is recognized as a possible complication after carotid endarterectomy (CEA), which may result in minor local neurologic deficiencies and significant discomfort for the patient. The aim of this study is to investigate the effect of a mini-skin incision (<5 cm) on the CCN injury after CEA in comparison to standard longitudinal incision of 12-15 cm in a high volume center, and to evaluate health-related quality of life (HRQOL) outcomes in those patients who had undergone both types of the skin incision.Methods: From January 2013 to December 2019, 446 CEAs (47.3%) were performed through a standard neck incision of 12-15 cm (group A), while 496 (52.7%) were performed through a mini-skin incision (<5 cm) (group B). Sixty-two patients underwent standard neck incision on one side and mini-skin incision on the other side (subgroup B). The main outcome measures were stroke, death, CCN injuries, cervical hematoma rates, and reinterventions. The HRQOL was assessed at baseline and after 30 days using Medical Outcomes Study Short-Form 36 and 6 disease-specific modified Likert scales.Results: The stroke and death rate at 30 days was 1.12% in group A and 1% in group B (P = 1). The incidence of CCN deficits was significantly lower in group B (5.1%) in comparison to group A (13.4%) (P < 0.001). The cervical hematoma was more common after standard incision (4.9% vs. 1.2%, P = 0.02). HRQOL at 1 month showed that the outcomes after mini-skin incision were significantly better for less difficulty with eating/swallowing and neck pain (P < 0.01).Conclusions: CEA through a small incision (<5 cm) may reduce CCN complications without additional perioperative neurologic risks. As validated by patients with bilateral disease who experienced both surgical techniques, mini-skin incision is also associated with better HRQOL at 1 month, particularly with regard to eating/swallowing and neck pain

Latinos’ Views of Chronic Disease and Minor Depression

Background: There are notable health disparities among Latinos in the US associated with chronic diseases (e.g., diabetes) and depression. Further, chronic diseases and minor depression tend to co-occur among Latino populations. This paper reports findings from a community-based participatory research study using dyadic focus groups with Latinos who have chronic disease and minor depression and their family members. The goal of this study was to better understand barriers and facilitators to chronic disease self-management among underserved Latinos living with both chronic illness and minor depression and their families using a socio-ecological approach.Methods: In total, five focus groups were conducted with individuals with chronic disease (n=25) and four with nominated family members (n=17). All focus groups were digitally recorded and transcribed by a professional transcription agency in Spanish. Transcripts were imported into Atlas.ti V 6.2 software program and analyzed in Spanish by a team of bilingual researchers using content analysis. Qualitative results are presented thematically by level of analysis or behavioral influence (i.e., individual, family, and community levels) and barriers and facilitators are discussed within each level.Results: Results revealed individual, family, and community level barriers (e.g., transportation, expressed emotion, and lack of health care providers) and facilitators to managing chronic disease and minor depression (e.g., acceptance, family support, and Spanish speaking support groups). Conclusion: Findings have important implications for the understanding of chronic disease management for Latinos and emphasize the need to use evidence based approaches that address barriers and facilitators across the social-ecological continuum

A Mixed-Methods Design Informed by CBPR for the Adaptation of an EBI for Latinos with Minor Depression and Chronic Disease

Background: A mixed methods design informed by community-based participatory research (CBPR) offers advantages to a single research approach by engaging community and academic partners in collecting context-rich and empirical data to inform the translation of evidence-based interventions (EBI). Purpose: This multiphase study sought to translate research findings for the adaptation of an EBI, self-management program (Tomando) for Latino individuals with chronic illness and minor depression (ICD). This presentation focuses on the mixed methods, CPPR approach used to guide phase I of the research. Methods: Mixed methods employed include: a) focus groups with ICD and family members and b) key stakeholder semi-structured interviews followed by a survey. A community-academic team informed key decisions about research design, recruitment, and presentation of findings. Results: Methodological issues arose regarding the heterogeneity of focus group members (e.g., rural versus urban, combining genders) and presence of illness in family members. Recruitment efforts indicated that depression was not well understood or endorsed by potential participants who exhibited depressive symptomatology. Other challenges include the limited health literacy of participants, the need for bi-lingual/bi-cultural staff to conduct and analyze research, and the need for a more diverse community sampling frame. Community partners; however, provided an insider perspective to overcome methodological challenges and the impact of stigma associated with depression on recruitment. Conclusion: This CBPR approach allowed for the identification of practical solutions to methodological challenges while demonstrating important strategies for informing and influencing the translation of EBIs aimed at reducing or eliminating health disparities into practice