Long Term Benefits of EVAR in the Modern Era: The Importance of Looking at Stent Graft Durability without Forgetting the Right Pathophysiology

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Quantitative flood hazard assessment methods: A review

Flood hazard assessment is a fundamental step in flood risk mapping. Quantitative assessment requires hydrodynamic modelling of the flooding process in order to calculate the spatial distribution of suitable flood hazard indicators representative of flooding intensity and frequency, hence its potential to result in harm. Flood hazard indicators are usually defined by combining relevant flooding parameters, mainly flood depth and flow velocity, but also flooding arrival time, flooding duration, sediment or contamination load, and so forth. A flood hazard classification is commonly introduced to assign a hazard level to areas potentially subject to flooding. This article presents a systematic review of quantitative methods proposed in the scientific literature or prescribed by government authorities to assess the hazard associated with natural or anthropic flooding. Flood hazard classification methods are listed and compared by specifying their underlying approach (heuristic, conceptual, empirical), the exposed element which they were designed for (people, buildings, vehicles, etc.), and their fields of application (river overflow, dam-break, levee breach, debris flow). Perspectives and future challenges in quantitative flood hazard analysis are also discussed. This review aims to help modellers and practitioners to select the most suitable flood hazard assessment method for the case study of interest

Frequency and type of interval adverse events during the waiting period to complex aortic endovascular repair

Objective: The aim of the present study was to evaluate the frequency and type of adverse events that can occur during the waiting period to complex aortic endovascular repair. Methods: We performed a retrospective study of all elective patients with complex aortic aneurysms (including pararenal, suprarenal, thoracoabdominal, and aortic arch aneurysms) that had required a custom-made device (CMD) from Cook Medical (Bloomington, Ind) at a tertiary referral vascular center (November 2010 to May 2020). The waiting period was defined as the interval between the date of the stent-graft order and the date of the procedure or cancellation. Interval adverse events were defined as any event that had occurred during the waiting period and led to either mortality, aneurysm rupture, or cancellation of the planned procedure. Results: A total of 235 patients (mean age, 72 years; 25% female) had had a CMD graft ordered (201 planned as a single-stage procedure). The median waiting time until surgery was 106 days (interquartile range [IQR], 77-146 days) in the whole cohort and 101 days (IQR, 77-140 days) for the single-stage cohort. The planned procedure was performed electively in 219 patients (93%), with an overall 30-day elective mortality of 2% (n = 5). A total of 16 interval adverse events occurred during the waiting period. Of these 16 events, 10 were aneurysm ruptures and 6 were cancellations of the procedure owing to non–aneurysm-related deaths (3% of the entire cohort). A total of 10 interval deaths were registered (4.2%), 4 of which were aneurysm related. The risk of rupture during the waiting period (Kaplan-Meier) was 6.1% ± 2.3% at 180 days. The median interval from the stent-graft order to aneurysm rupture was 101 days (IQR, 54-200 days). Of the 10 aneurysm ruptures that had occurred, 6 had undergone emergent repair, with 0% mortality at 30 days (one open repair, one t-Branch, one physician-modified endograft, two cases for which the CMD was already available, one case for which a different CMD was available). Conclusions: The median waiting time from the stent-graft order to implantation was ∼15 weeks. During this waiting period, a substantial proportion of patients could experience adverse events, either related to aneurysm rupture or underlying comorbidities. The risk of rupture during the waiting period exceeded the risk of perioperative mortality. Thus, efforts to decrease this risk could significantly improve the outcomes. A combination of different techniques might play a vital role in reducing the mortality after cases of interval rupture

Emergent endovascular treatment options for thoracoabdominal aortic aneurysm

For a long time, parallel grafting, physician-modified endografts, and, more recently, in situ fenestration were the only go-to endovascular options for ruptured thoracoabdominal aortic aneurysm, offered mixed results, and depended mainly on the operator's and center's experience. As custom-made devices have become an established endovascular treatment option for elective thoracoabdominal aortic aneurysm, they are not a viable option in the emergency setting, as endograft production can take up to 4 months. The development of off-the-shelf (OTS) multibranched devices with a standardized configuration has allowed the treatment of ruptured thoracoabdominal aortic aneurysm with emergent branched endovascular procedures. The Zenith t-Branch device (Cook Medical) was the first readily available graft outside the United States to receive the CE mark (in 2012) and is currently the most studied device for those indications. A new device, the E-nside thoracoabdominal branch endoprosthesis OTS multibranched endograft (Artivion), has been made commercially available, and the GORE EXCLUDER thoracoabdominal branch endoprosthesis OTS multibranched endograft (W. L. Gore and Associates) is expected to be released in 2023. Due to the lack of guidelines on ruptured thoracoabdominal aortic aneurysm, this review summarizes the available treatment options (ie, parallel grafts, physician-modified endografts, in situ fenestrations, and OTS multibranched devices), compares the indications and contraindications, and points out the evidence gaps that should be filled in the next decade

A scoping review on the approaches for cannulation of reno-visceral target vessels during complex endovascular aortic repair

OBJECTIVES: The aim of this study was to assess the approaches to reno-visceral target vessels (TVs) cannulation during branched-fenestrated endovascular aortic repair, determine the evidence base that links these approaches to clinical outcomes and identify literature gaps. METHODS: A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English (PubMed, Cochrane and EMBASE databases; last queried, 31 June 2022) were systematically reviewed and analysed. Data were reported as descriptive narrative or tables, without any statistical analysis nor quality assessment. RESULTS: Fourteen retrospective articles were included. Seven articles studied the use of upper extremity access (UEA) during branched-fenestrated endovascular aortic repair, 3 studied the use of steerable sheaths and 4 included both approaches. A left UEA was used in 757 patients (technical success: 99%, stroke rate: 1-3%) and a right UEA in 215 patients (technical success: 92-98%, stroke rate: 0-13%). Seven studies (1066 patients) described a surgical access only (technical success: 80-99%, stroke rate: 0-13%), while 3 studies (146 patients) described a percutaneous access only (technical success: 83-90%, stroke rate: 3%) and lastly 4 studies compared UEA versus use of steerable sheaths from the transfemoral approach (TFA) (UEA: 563 patients, technical success: 95-98%, stroke rate: 1-8%; TFA: 209 patients, technical success: 98-100%, stroke rate: 0-1%). CONCLUSIONS: Both UEA and TFA as cannulation approaches were associated with high technical success and low perioperative complications. Currently, there is a paucity of high-quality data to provide definitive indication. Optimal UEA in terms of side (left versus right) and approach (surgical versus percutaneous) needs further study

HDL cholesterol protects from liver injury in mice with intestinal specific LXRα activation

Background and aims: Liver X receptors (LXRs) exert anti-inflammatory effects even though their hepatic activation is associated with hypertriglyceridemia and hepatic steatosis. Selective induction of LXRs in the gut might provide protective signal(s) in the aberrant wound healing response that induces fibrosis during chronic liver injury, without hypertriglyceridemic and steatogenic effects. Methods: Mice with intestinal constitutive LXRα activation (iVP16-LXRα) were exposed to intraperitoneal injection of carbon tetrachloride (CCl4) for 8 weeks, and in vitro cell models were used to evaluate the beneficial effect of high-density lipoproteins (HDL). Results: After CCl4 treatment, the iVP16-LXRα phenotype showed reduced M1 macrophage infiltration, increased expression M2 macrophage markers, and lower expression of hepatic pro-inflammatory genes. This anti-inflammatory effect in the liver was also associated with decreased expression of hepatic oxidative stress genes and reduced expression of fibrosis markers. iVP16-LXRα exhibited increased reverse cholesterol transport in the gut by ABCA1 expression and consequent enhancement of the levels of circulating HDL and their receptor SRB1 in the liver. No hepatic steatosis development was observed in iVP16-LXRα. In vitro, HDL induced a shift from M1 to M2 phenotype of LPS-stimulated Kupffer cells, decreased TNFα-induced oxidative stress in hepatocytes and reduced NF-kB activity in both cells. SRB1 silencing reduced TNFα gene expression in LPS-stimulated KCs, and NOX-1 and IL-6 in HepG2. Conclusions: Intestinal activation of LXRα modulates hepatic response to injury by increasing circulating HDL levels and SRB1 expression in the liver, thus suggesting this circuit as potential actionable pathway for therapy

Covid-19 infection in children, infants and pregnant subjects: An overview of recent insights and therapies

Background: The SARS-CoV-2 pandemic has involved a severe increase of cases worldwide in a wide range of populations. The aim of the present investigation was to evaluate recent insights about COVID-19 infection in children, infants and pregnant subjects. Methods: a literature overview was performed including clinical trials, in vitro studies, reviews and published guidelines regarding the present paper topic. A descriptive synthesis was performed to evaluate recent insights and the effectiveness of therapies for SARS-CoV-2 infection in children, infants and pregnant subjects. Results: Insufficient data are available regarding the relationship between COVID-19 and the clinical risk of spontaneous abortion and premature foetus death. A decrease in the incidence of COVID-19 could be correlated to a minor expression of ACE2 in childrens’ lungs. At present, a modulation of the dose-effect posology for children and infants is necessary. Conclusions: Pregnant vertical transmission has been hypothesised for SARS-CoV-2 infection. Vaccines are necessary to achieve mass immunity for children and also pregnant subjects

Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes

The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient’s quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs

Outcomes of “Anterior Versus Posterior Divisional Branches of the Hypogastric Artery as Distal Landing Zone for Iliac Branch Devices”: The International Multicentric R3OYAL Registry

Objective: The aim of this multicentric registry was to assess the outcomes of “anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL).” Methods: The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability. Results: A total of 171 patients were included in the study, of which 50 received bilateral implantation of iliac branch devices (IBDs). This resulted in a total of 221 incorporated IIAs included in the final analysis, of which 40 were anterior divisional branches and 181 were posterior divisional branches. Technical success was high in both groups (anterior division: 98% vs posterior division: 100%, P =.18). Occurrence of any adverse event was noted in 14% of patients in both groups (P = 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test =.215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test =.009; secondary patency: 81% vs 97%, log-rank test <.001). Conclusions: The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA. Clinical Impact: The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA