Carotid Artery Disease in the Era of Biomarkers: A Pilot Study

The intima-media thickness (IMT) and its irregularities or ulcerations in the common carotid artery (CCA) are useful tools as sentinel biomarkers for the integrity of the cardiovascular system. Total homocysteine and lipoprotein levels are the most commonly used elements in cardiovascular risk stratification. Duplex ultrasound (DUS), associated with serum biomarkers, can be used simply to assess the degree of atherosclerotic disease and cardiovascular risk. This study highlights the role of different kinds of biomarkers, showing their usefulness and potentiality in multi-district atherosclerotic patients, especially for early diagnosis and therapy effectiveness monitoring. A retrospective analysis performed from September 2021 to August 2022, of patients with carotid artery disease, was performed. A total of 341 patients with a mean age of 53.8 years were included in the study. The outcomes showed an increased risk of stroke in patients with significative carotid artery disease, nonresponsive to therapy, monitored through a series of serum biomarkers (homocysteine, C-reactive protein, and oxidized LDL). In this reported experience, the systematic use of DUS in association with the multiple biomarkers approach was effective for the early identification of patients at higher risk of disease progression or inefficient therapy

Standard carotid endarterectomy versus carotid artery stenting with closed-cell stent design and distal embolic protection: does the age matter?

Carotid artery endarterectomy (CEA) is considered the gold standard for treatment of symptomatic and asymptomatic carotid disease. Carotid artery stenting (CAS) is a less invasive approach and therefore could be considered a viable alternative to CEA, especially in high-risk patients or those with relative contraindications to CEA (i.e. actinic stenosis, post-CEA restenosis, previous neck or tracheostomy surgery, contralateral laryngeal nerve paralysis, etc.). Methods – The aim of this study is to evaluate the short- and medium-term outcomes of CAS performed with a single type of closed-cell stent design and distal filter protection by comparing the procedure with CEA based upon 3 endpoints: overall survival rate, stroke free survival rate and restenosis free survival rate. The same endpoints were also evaluated in 2 different age groups, more and less than 70 years, to show possible age-based differences on outcomes. Among 105 patients (77 males, 28 females), 74 were submitted to CEA and 31 were subject to CAS. In all cases the same self-expanding stent with closed-cell design (XACT Carotid Stent, Abbott Vascular) and the same distal embolic protection device (Emboshield NAV, Abbott Vascular) were employed. Results – At 12 months, no statistically significant difference was observed in overall survival rates (CEA 93.2% vs CAS 93.5%, p=0.967) and restenosis free survival rates (CEA 94.5% vs CAS 96.8%, p=0.662). An increased stroke free survival rate was observed in the CEA group when compared to the CAS group (CEA 100.0% vs CAS 93.5%, p=0.028). The age-based endpoints didn’t show any significant difference. Conclusion - These results suggest that CEA still remains the gold standard of treatment for carotid stenosis given its greater efficacy in the prevention of stroke CAS. However, CAS could be considered as an alternative treatment to CEA to be used in select cases only

Insight from an Italian Delphi Consensus on EVAR feasibility outside the instruction for use: the SAFE EVAR Study

BACKGROUND: The SAfety and FEasibility of standard EVAR outside the instruction for use (SAFE-EVAR) Study was designed to define the attitude of Italian vascular surgeons towards the use of standard endovascular repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) outside the instruction for use (IFU) through a Delphi consensus endorsed by the Italian Society of Vascular and Endovascular Surgery (Societa Italiana di Chirurgia Vascolare ed Endovascolare - SICVE). METHODS: A questionnaire consisting of 26 statements was developed, validated by an 18 -member Advisory Board, and then sent to 600 Italian vascular surgeons. The Delphi process was structured in three subsequent rounds which took place between April and June 2023. In the first two rounds, respondents could indicate one of the following five degrees of agreement: 1) strongly agree; 2) partially agree; 3) neither agree nor disagree; 4) partially disagree; 5) strongly disagree; while in the third round only three different choices were proposed: 1) agree; 2) neither agree nor disagree; 3) disagree. We considered the consensus reached when >70% of respondents agreed on one of the options. After the conclusion of each round, a report describing the percentage distribution of the answers was sent to all the participants. RESULTS: Two -hundred -forty-four (40.6%) Italian Vascular Surgeons agreed to participate the first round of the Delphi Consensus; the second and the third rounds of the Delphi collected 230 responders (94.3% of the first -round responders). Four statements (15.4%) reached a consensus in the first rounds. Among the 22 remaining statements, one more consensus (3.8%) was achieved in the second round. Finally, seven more statements (26.9%) reached a consensus in the simplified last round. Globally, a consensus was reached for almost half of the proposed statements (46.1%). CONCLUSIONS: The relatively low consensus rate obtained in this Delphi seems to confirm the discrepancy between Guideline recommendations and daily clinical practice. The data collected could represent the source for a possible guidelines' revision and the proposal of specific Good Practice Points in all those aspects with only little evidence available

A case of symptomatic popliteal vein aneurysm

We describe a case of a 44 year-old man with a subcutaneous swelling in the left popliteal fossa. The patient complained pain posteriorly to the left knee since several months and presented with a saccular aneurysm of the left popliteal vein (PVA) with reflux clearly evidenced at duplex ultrasound scan (DUS), but in absence of thrombus inside and without clinical signs of embolism. The patient was treated surgically by aneurysmectomy with lateral venorrhaphy according to Aldridge technique and a duplex ultrasound scan after six months revealed a complete patency of the left popliteal vein. According to literature evidences and our center experience, the surgical treatment of the popliteal vein aneurysm represents the gold standard in order to prevent the possible complications like development of thrombus inside the aneurysmatic vein and the consequent embolic risk and it is recommended in all case of a symptomatic saccular type of whatever diameter, and in fusiform type >20 mm, with or without thrombus

The experience of two vascular centers in the use of supera stent for femoropopliteal lesions

BACKGROUND: Endovascular interventions are increasing in the treatment of long femoro-popliteal lesions. Standard laser-cut nitinol stents offer an acceptable midterm patency rate but still controversial in the longterm period, particularly in the setting of complex lesions. The Supera interwoven nitinol stent is designed to have superior radial strength and fractures resistance. METHODS: From January 2016 to July 2018, 32 patients (19 M / 13 F) with femoro-popliteal occlusion were treated at two italian vascular surgery centers. The majority of patients (24/32) were affected by critical limb ischemia (class IV-VI Rutherford). RESULTS: Thirty-eight Supera stents were successfully deployed. The mean length of the femoro-popliteal lesions was 102 ± 25 mm. The primary latency at 30 days was 100% without any stent fracture. During a mean follow-up of 19 months, two patients experienced an intrastent restenosis treated with a drug eluting balloon. In four cases occurred an occlusion of the stent: only two patients were successfully treated with intra-arterial trombolysis. The primary patency rate was 83% at nineteen months. One major amputation was necessary thus determining an overall limb salvage rate of 97%. CONCLUSIONS: The use by vascular surgeons of this relatively new device is feasible in the treatment of long femoro-popliteal lesions. Our results in this small population of diseased patients not suitable for surgery are promising

Carotid Artery Disease in the Era of Biomarkers: A Pilot Study

The intima-media thickness (IMT) and its irregularities or ulcerations in the common carotid artery (CCA) are useful tools as sentinel biomarkers for the integrity of the cardiovascular system. Total homocysteine and lipoprotein levels are the most commonly used elements in cardiovascular risk stratification. Duplex ultrasound (DUS), associated with serum biomarkers, can be used simply to assess the degree of atherosclerotic disease and cardiovascular risk. This study highlights the role of different kinds of biomarkers, showing their usefulness and potentiality in multi-district atherosclerotic patients, especially for early diagnosis and therapy effectiveness monitoring. A retrospective analysis performed from September 2021 to August 2022, of patients with carotid artery disease, was performed. A total of 341 patients with a mean age of 53.8 years were included in the study. The outcomes showed an increased risk of stroke in patients with significative carotid artery disease, nonresponsive to therapy, monitored through a series of serum biomarkers (homocysteine, C-reactive protein, and oxidized LDL). In this reported experience, the systematic use of DUS in association with the multiple biomarkers approach was effective for the early identification of patients at higher risk of disease progression or inefficient therapy

Endovascular treatment of a wide-necked renal artery aneurysm with a flow diverter stent

Renal artery aneurysm (RAA) is a rare, often asymptomatic disease (0.1% incidence in general population) and can be incidentally diagnosed during an abdominal imaging workup. The traditional, gold standard of treatment is open surgery, carrying with it, however, a high risk of nephrectomy, mortality, and collateral morbidity. The endovascular approach is currently the most valid alternative to treating RAAs reducing, as it does, the risks associated with the surgical approach/open surgery. Herein we report on our experience with a case of wide-necked RAA treated with the Pipeline Vantage (Medtronic) flow diverter stent. Wide-neck aneurysms are defined as having neck diameters greater than 4 mm. Our choice of endovascular treatment was preferred over the surgical option notwithstanding the large size of the neck and the involvement of the branching vessels

A case of large renal aneurysm treated with a combined endovascular-laparoscopic approach

A 67-year-old man with pain in his right flank and hematuria over the last few weeks was admitted to our hospital due to right renal calculi revealed by an ultrasound examination of the urinary tract. An abdominal x-ray drew attention to the presence of structures of an uncertain interpretation, that mimicked multiple calculi in the right kidney and renal pelvis, but CT-scan identified a large saccular aneurysm of 76 mm with renal pelvis involvement and urinary statis of the right renal artery. A combined endovascular and laparoscopic surgical approach was chosen. The patient underwent endovascular embolization of the renal artery with an Amplatzer Vascular Plug followed by a video laparoscopic nephrectomy. After few days of hospitalization, the patient was in good general status and was discharged. A review of the literature has highlighted the unicity of our surgical approach, especially within the context of traditional vascular and general surgical practice, due to multidisciplinary consultation

Selective crossectomy combined with mechanochemical ablation in the treatment of great saphenous vein insufficiency: Early results of a single center experience

Background: Selective crossectomy and mechanochemical ablation (MOCA) of great saphenous vein (GSV) have been used, for years, individually in the treatment of chronic venous insufficiency. In this paper, we focus on the advantages of a combination of the two techniques, in order to prevent complications and recurrence. Methods: A preoperative clinical and instrumental screening phase was conducted for the purpose of dividing patients into three groups: "Saph+Cross" group (51/139 patients) underwent saphenectomy and crossectomy; "MOCA" group (44/139 patients) underwent MOCA of GSV with Flebogrif® device; "MOCA + Cross" group (44/139 patients) subjected to both MOCA and crossectomy procedures.Recurrence rate, defined as total recanalization of GSV and/or onset of neosaphena and/or new varicose veins, was used as a primary outcome. Secondary outcomes were procedural time and intra- and post-procedural complications. Results: We conducted a 1-, 6-, and 12-month follow-up with Duplex scan. The recurrence rates were 3.9%, 21.8%, and 4.5% for "Saph+Cross," "MOCA," and "MOCA+Cross," respectively, with a significant difference for the comparison between "MOCA" and "Saph+Cross" (MOCA vs Saph+Cross: OR 5.35, CI95% [0.98; 54.6], p-value .040).The sub-analysis of primary outcome highlighted a lower recanalization rate of GSV when combining the crossectomy with MOCA procedure (2.2% MOCA+Cross vs 15.9% MOCA; 0.12 OR, [0.002; 1.02] CI95%, p-value .029).Among the secondary outcomes, "MOCA" showed a shorter procedural time than the other groups (Saph+Cross: 51.3 ± 11.4; MOCA: 45.1 ± 7.5; MOCA+Cross: 50.4 ± 10; p-value .027). No significant differences were noted in terms of intra- and post-procedural complications. Conclusions: The results showed that patients treated with saphenectomy and crossectomy have a lower recurrence rate compared to MOCA alone and MOCA + crossectomy procedures.The association of crossectomy with MOCA significantly reduces the recanalization rate of GSV, and it is also characterized by a higher free survival from recurrence (SSF) than with MOCA alone