Trattamento endovascolare della patologia dell'arco aortico

Il miglior approccio per il trattamento delle patologie dell’arco dell’aorta rimane attualmente oggetto di dibattito non essendo ancora supportato da solide evidenze. La maggior parte dei dati relativi ai risultati post-operatori riguardo ai pazienti sottoposti ad interventi chirurgici per patologia dell’arco dell’aorta, si basa su un numero esiguo di casi, su trattamenti eterogenei e follow-up limitati. L’aorta ascendente e l’arco aortico costituiscono un segmento peculiare dell’aorta toracica per quanto riguarda l’anatomia, la fisiologia, la patologia e l’approccio terapeutico. La posizione anatomica all’interno del mediastino e la presenza delle principali branche arteriose responsabili della perfusione del cuore e dell’encefalo rendono conto delle forti difficoltà tecniche nell’approccio chirurgico a questa porzione dell’aorta, e delle importanti complicanze che possono associarsi a tali interventi. Per questo motivo la terapia chirurgica è spesso riservata solo ai pazienti in buone condizioni generali e con un rischio operatorio accettabile. Inoltre tale segmento vascolare riveste un ruolo particolare poiché rappresenta da sempre una ‘’zona di confine’’ tra la cardiochirurgia e la chirurgia vascolare, richiedendo pertanto una stretta collaborazione e sinergia tra diverse figure professionali quali il cardiochirurgo, il chirurgo vascolare, il cardio-anestesista, il cardiologo interventista, il radiologo interventista, il perfusionista e l’ecocardiografista, all’interno di strutture sanitarie attrezzate ed altamente specializzate, ovvero i cosiddetti ‘’centri di eccellenza”. L’intervento di sostituzione dell’aorta ascendente fu eseguito per la prima volta a Houston nel 1952 da DeBakey e Cooley1, senza l’utilizzo della circolazione extracorporea. Gli stessi descrissero nel 1956 il primo caso di sostituzione dell’aorta ascendente in circolazione extracorporea (bypass cardio-polmonare)2, mentre solo nel 1957 riportarono i risultati favorevoli dell’intervento di sostituzione dell’arco aortico3. Il gruppo di Houston che faceva capo a questi due grandi chirurghi, giustamente considerati pioneri della chirurgia dell’aorta toracica, contribuì negli anni seguenti alla diffusione di tali tecniche chirurgiche verso il resto del globo. Durante i successivi cinquanta anni, lo sviluppo dell’imaging radiologico, il progresso delle tecniche chirurgiche ed anestesiologiche, nonchè l’avvento dei metodi di circolazione extracorporea e dei sistemi di protezione cerebrale, hanno permesso di trattare la maggior parte dei pazienti con un significativo miglioramento dei tassi di mortalità e morbilità, i quali tuttavia rimangono ancora oggi tra i più alti rispetto alla media degli interventi chirurgici. Per cercare di ridurre ulteriormente l’invasività e le complicanze perioperatorie della chirurgia dell’aorta ascendente e dell’arco aortico, nell’ultimo decennio, sono stati studiati e sviluppati approcci differenti, meno invasivi, che includessero l’utilizzo delle tecniche endovascolari maturate negli altri distretti aortici (aorta toracica discendente, toracoaddominale e addominale), adattando queste ultime alla particolare anatomia dell’arco. Queste procedure, riportate per la prima volta nel 1998,4 che possono combinare la chirurgia tradizionale con quella endovascolare (procedure ibride) o che possono utilizzare tecniche endovascolari complesse (ad esempio con l’utilizzo di endoprotesi ramificate, o con tecniche “chimney”), hanno dimostrato di poter ridurre sensibilmente la mortalità e la morbilità perioperatoria. Tuttavia, attualmente è prematuro trarre delle conclusioni sull’effettiva efficacia a lungo termine di tali procedure. Obiettivo di questo studio è quello di valutare i risultati a medio termine delle procedure endovascolari a carico dell’arco aortico

Results of Iliac Branch Devices in Octogenarians Within the pELVIS Registry

Purpose:To evaluate if the elderly could benefit from the implantation of iliac branch devices (IBDs) to preserve the patency of the internal iliac artery (IIA) in aneurysms involving the iliac bifurcation.Materials and Methods:From January 2005 to April 2017, 804 patients enrolled in the pELVIS registry underwent endovascular aneurysm repair with 910 IBDs due to aneurysmal involvement of the iliac bifurcation. Among the 804 patients, 157 (19.5%) were octogenarians (mean age 82.9 +/- 2.5 years; 157 men) with 171 target IIAs for preservation. Outcomes at 30 days included technical success, death, conversion to open surgery, and major complications. Outcomes evaluated in follow-up were patency of the IBD and target vessels, type I and type III endoleaks, aneurysm-related reinterventions, aneurysm-related death, and overall patient survival. Kaplan-Meier analyses were employed to evaluate the late outcome measures; the estimates are presented with the 95% confidence interval (CI).Results:Technical success was 99.4% with no intraoperative conversions or deaths (1 bridging stent could not be implanted, and the IIA was sacrificed). Perioperative mortality was 1.9%. The overall perioperative aneurysm-related complication rate was 8.9% (14/157), with an early reintervention rate of 5.1% (8/157). Median postoperative radiological and clinical follow-up were 21.8 months (range 1-127) and 29.3 months (range 1-127), respectively. Estimated rates of freedom from occlusion of the IBD, the IIA, and the external iliac artery at 60 months were 97.7% (95% CI 96.1% to 99.3%), 97.3% (95% CI 95.7% to 98.9%), and 98.6% (95% CI 97% to 99.9%), respectively. Estimated rates of freedom from type I and type III endoleaks and device migration at 60 months were 90.9% (95% CI 87% to 94.3%), 98.7% (95% CI 97.5% to 99.8%), and 98% (95% CI 96.4% to 99.6%), respectively. Freedom from all cause reintervention at 60 months was 87.4% (95% CI 82.6% to 92.2%). The estimated overall survival rate at 60 months was 59% (95% CI 52.4% to 65.6%).Conclusion:IBD implantation in octogenarians provided acceptable perioperative mortality and morbidity rates, with satisfying long-term freedom from IBD-related complications and should be considered a feasible repair option for selected elderly patients affected by aneurysms involving the iliac bifurcation

Gender associated differences in determinants of quality of life in patients with COPD: a case series study

BACKGROUND: The influence of gender on the expression of COPD has received limited attention. Quality of Life (QoL) has become an important outcome in COPD patients. The aim of our study was to explore factors contributing to gender differences in Quality of Life of COPD patients. METHODS: In 146 men and women with COPD from a pulmonary clinic we measured: Saint George's Respiratory Questionnaire (SGRQ), age, smoking history, PaO(2), PaCO(2), FEV(1), FVC, IC/TLC, FRC, body mass index (BMI), 6 minute walk distance (6MWD), dyspnea (modified MRC), degree of comorbidity (Charlson index) and exacerbations in the previous year. We explored differences between genders using Mann-Whitney U-rank test. To investigate the main determinants of QoL, a multiple lineal regression analysis was performed using backward Wald's criteria, with those variables that significantly correlated with SGRQ total scores. RESULTS: Compared with men, women had worse scores in all domains of the SGRQ (total 38 vs 26, p = 0.01, symptoms 48 vs 39, p = 0.03, activity 53 vs 37, p = 0.02, impact 28 vs 15, p = 0.01). SGRQ total scores correlated in men with: FEV(1)% (-0.378, p < 0.001), IC/TLC (-0.368, p = 0.002), PaO(2 )(-0.379, p = 0.001), PaCO(2 )(0.256, p = 0.05), 6MWD (-0.327, p = 0.005), exacerbations (0.366, p = 0.001), Charlson index (0.380, p = 0.001) and MMRC (0.654, p < 0.001). In women, the scores correlated only with FEV(1)% (-0.293, p = 0.013) PaO(2 )(-0.315, p = 0.007), exacerbations (0.290, p = 0.013) and MMRC (0.628, p < 0.001). Regression analysis (B, 95% CI) showed that exercise capacity (0.05, 0.02 to 0.09), dyspnea (17.6, 13.4 to 21.8), IC/TLC (-51.1, -98.9 to -3.2) and comorbidity (1.7, 0.84 to 2.53) for men and dyspnea (9.7, 7.3 to 12.4) and oxygenation (-0.3, -0.6 to -0.01) for women manifested the highest independent associations with SGRQ scores. CONCLUSION: In moderate to severe COPD patients attending a pulmonary clinic, there are gender differences in health status scores. In turn, the clinical and physiological variables independently associated with those scores differed in men and women. Attention should be paid to the determinants of QoL scores in women with COPD

The sac evolution imaging follow-up after endovascular aortic repair:An international expert opinion-based Delphi consensus study

Objective: Management of follow-up protocols after endovascular aortic repair (EVAR) varies significantly between centers and is not standardized according to sac regression. By designing an international expert-based Delphi consensus, the study aimed to create recommendations on follow-up after EVAR according to sac evolution. Methods: Eight facilitators created appropriate statements regarding the study topic that were voted, using a 4-point Likert scale, by a selected panel of international experts using a three-round modified Delphi consensus process. Based on the experts' responses, only those statements reaching a grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement &lt;5%) were included in the final document. Results: One-hundred and seventy-four participants were included in the final analysis, and each voted the initial 29 statements related to the definition of sac regression (Q1-Q9), EVAR follow-up (Q10-Q14), and the assessment and role of sac regression during follow-up (Q15-Q29). At the end of the process, 2 statements (6.9%) were rejected, 9 statements (31%) received a grade B consensus strength, and 18 (62.1%) reached a grade A consensus strength. Of 27 final statements, 15 (55.6%) were classified as grade I, whereas 12 (44.4%) were classified as grade II. Experts agreed that sac regression should be considered an important indicator of EVAR success and always be assessed during follow-up after EVAR. Conclusions: Based on the elevated strength and high consistency of this international expert-based Delphi consensus, most of the statements might guide the current clinical management of follow-up after EVAR according to the sac regression. Future studies are needed to clarify debated issues.</p

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 &gt;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

Give more data, awareness and control to individual citizens, and they will help COVID-19 containment.

The rapid dynamics of COVID-19 calls for quick and effective tracking of virus transmission chains and early detection of outbreaks, especially in the "phase 2" of the pandemic, when lockdown and other restriction measures are progressively withdrawn, in order to avoid or minimize contagion resurgence. For this purpose, contact-tracing apps are being proposed for large scale adoption by many countries. A centralized approach, where data sensed by the app are all sent to a nation-wide server, raises concerns about citizens' privacy and needlessly strong digital surveillance, thus alerting us to the need to minimize personal data collection and avoiding location tracking. We advocate the conceptual advantage of a decentralized approach, where both contact and location data are collected exclusively in individual citizens' "personal data stores", to be shared separately and selectively (e.g., with a backend system, but possibly also with other citizens), voluntarily, only when the citizen has tested positive for COVID-19, and with a privacy preserving level of granularity. This approach better protects the personal sphere of citizens and affords multiple benefits: it allows for detailed information gathering for infected people in a privacy-preserving fashion; and, in turn this enables both contact tracing, and, the early detection of outbreak hotspots on more finely-granulated geographic scale. The decentralized approach is also scalable to large populations, in that only the data of positive patients need be handled at a central level. Our recommendation is two-fold. First to extend existing decentralized architectures with a light touch, in order to manage the collection of location data locally on the device, and allow the user to share spatio-temporal aggregates-if and when they want and for specific aims-with health authorities, for instance. Second, we favour a longer-term pursuit of realizing a Personal Data Store vision, giving users the opportunity to contribute to collective good in the measure they want, enhancing self-awareness, and cultivating collective efforts for rebuilding society

Investigación y aportación al estudio del diseño y elaboración del plan de autoprotección de una estación ferroviaria metropolitana

[ES] El principal problema que se encuentra a la hora de elaborar el plan de autoprotección de una explotación ferroviaria metropolitana es la inexistencia de normativa específica de carácter nacional que regule dicha actividad. Además, la normativa existente no se ajusta a este tipo de explotación y por tanto no se puede utilizar, al menos en su totalidad. En la investigación se realiza la recopilación y estudio de la normativa en materia ferroviaria tanto a nivel nacional como internacional para, posteriormente, diseñar y utilizar la metodología más adecuada que permita llevar a cabo su elaboración. También, y dirigido especialmente al trabajo de campo y en particular para la toma de datos, se emplea la metodología Investigación ¿ Acción con el objetivo de mejorar la recogida de información y la futura implantación del Plan. La metodología y el modelo obtenidos en el estudio se aplican a la elaboración del Plan Director de Autoprotección (PDA) de una explotación ferroviaria metropolitana de de la ciudad de Valencia y provincia. Los problemas encontrados y las soluciones y recomendaciones propuestas permiten valorar y mejorar el diseño de los planes de autoprotección en instalaciones de características similares.[EN] The main problem encountered while developing an autoprotection plan for a metropolitan railway operation is the lack of specific national regulations for this activity. In addition, the current regulations do not fit this kind of exploitation and therefore cannot be used, at least in its entirety. In this research investigation the collection and study of the rules on subway transit rail is performed both nationally and internationally to design and use the most appropriate methodology that allows drawing an autoprotection plan. Also, and directed especially to field work and particularly for data collection, Action research methodology is used in order to improve the collection of information and the future implementation of the Plan. The methodology and the model obtained in the study are applied to the development of the Planning Guidelines of an Autoprotection Plan (PGAP) of a metropolitan railway operation of Valencia City and province. The problems encountered, and proposed solutions and recommendations are useful for assessing and improving the design of autoprotection plans in facilities with similar characteristics.[CA] El principal problema que es troba a l'hora d'elaborar el pla d'autoprotecció d'una explotació ferroviària metropolitana és la inexistència de normativa específica de caràcter nacional que regule la dita activitat. A més, la normativa existent no s'ajusta a este tipus d'explotació i per tant no es pot utilitzar, almenys en la seua totalitat. En la investigació es realitza la recopilació i estudi de la normativa en matèria ferroviària tant a nivell nacional com internacional per a, posteriorment, dissenyar i utilitzar la metodologia més adequada que permeta dur a terme la seua elaboració. També, i dirigit especialment al treball de camp i en particular per a la presa de dades, s'empra la metodologia Investigació - Acció amb l'objectiu de millorar l'arreplegada d'informació i la futura implantació del Pla. La metodologia i el model obtinguts en l'estudi s'apliquen a l'elaboració del Pla Director d'Autoprotecció (PDA) d'una explotació ferroviària metropolitana de la ciutat de València i província. Els problemes trobats i les solucions i recomanacions proposades permeten valorar i millorar el disseny dels plans d'autoprotecció en instal·lacions de característiques semblants.Ferrer Gómez, C. (2012). Investigación y aportación al estudio del diseño y elaboración del plan de autoprotección de una estación ferroviaria metropolitana. http://hdl.handle.net/10251/19215Archivo delegad

Endovascular arch replacement with a dual branched endoprosthesis

Background: In the light of current evidence, endovascular repair of aortic arch pathologies with custom-made devices should be considered a valid alternative to decrease operative mortality and morbidity associated with open or hybrid repair. Currently, two double inner branch devices are available on the market. Some papers from multicenter experiences have been published about the use of Cook device. We report our single-center experience with Bolton double branch stent graft in the treatment of aortic arch disease.Methods: Between 2013 and 2016, nine high-risk patients with arch pathology were treated in our center with a Bolton custom-made branched device. Among these, two with a single branch model were excluded, leaving a subgroup of seven patients of this study.Results: Out of the seven male patients (mean age, 76; range, 70-85) included in the study, two (28%) died perioperatively after stroke (14%) and retrograde dissection (14%), respectively. No other death, major complications, including aneurysmal diameter evolution and branch related complications, or secondary intervention was recorded at a mean follow up of 24 [6-53] months.Conclusions: Despite the small sample size, our results are in line with the early experiences published on this technique. Endovascular repair of aortic arch disease with custom-made branched devices should always be considered to give high-risk patients a chance of repair