Pazienti ad alto rischio in patologia carotidea: endoarterectomia vs. trattamento endovascolare

Le procedure endovascolari, introdotte negli anni \u201970 per il trattamento a minima invasivit\ue0 di lesioni vascolari di difficile accesso o ad elevato rischio chirurgico (lesioni vascolari intracraniche, angiodisplasie, etc.), hanno avuto negli anni \u201980 e soprattutto nell\u2019ultimo decennio un\u2019evoluzione \u201cesplosiva\u201d nel trattamento di pressoch\ue9 tutte le patologie arteriose, sia di tipo ostruttivo che dilatativo,dei diversi territori vascolari (1, 2). Negli anni \u201990, per molte patologie arteriose si \ue8 verificata un\u2019inversione di tendenza e per esse \ue8 diventato approccio di prima scelta la procedura endovascolare, sostituendosi quasi completamente all\u2019intervento chirurgico o integrandosi con esso per permettere di ottenere risultati pi\uf9 duraturi nel tempo. Pertanto, negli ultimi anni, le procedure percutanee hanno avuto un rapido sviluppo e si \ue8 tentato di applicare tali metodiche a tutti gli ambiti della patologia vascolare; questo anche in considerazione del continuo e progressivo sviluppo di nuovi materiali. L\u2019applicazione delle tecniche endovascolari al distretto sovraortico, e alle arterie carotidi in particolare, \ue8 sicuramente quella che ha pi\uf9 faticato ad affermarsi, soprattutto in considerazione del rischio di embolizzazione del sistema nervoso centrale e agli ottimi risultati attualmente raggiunti dalla chirurgia carotidea (3). L\u2019ictus ischemico cerebrale rappresenta la terza causa di morte, dopo le malattie cardiovascolari e le neoplasie; si pensi che studi della letteratura riportano l\u2019ictus come responsabile del 26,3% delle morti in Giappone, del 9,4% in Italia e del 6,3% negli USA (4). La mortalit\ue0 a 30 giorni dall\u2019ictus raggiunge il 20%, mentre la sopravvivenza a 1 e a 5 anni \ue8 rispettivamente del 52% e del 30%. Fra coloro che superano un ictus 2/3 presentano deficit neurologici permanenti, la met\ue0 sopravvive per almeno 5 anni e 1/3 richiedono una riabilitazione in centri specializzati; solo il 36% ritorna ad un\u2019attivit\ue0 lavorativa e il 4% rimane non autosufficiente (5). L\u2019infarto cerebrale ischemico \ue8 responsabile di oltre l\u201980% dei casi d\u2019ictus nella popolazione, di cui solo il 16-20% \ue8 d\u2019origine cardioembolica, mentre la patogenesi della grande maggioranza di tali eventi \ue8 da ricondursi alla presenza di placche aterosclerotiche a livello dei principali vasi cerebroafferenti ed in particolare a livello della biforcazione carotidea.Non disponibil

Human IgG Antinuclear Antibodies Induce Pregnancy Loss in Mice by Increasing Immune Complex Deposition in Placental Tissue: In Vivo Study

Problem A threefold higher prevalence of antinuclear antibodies (ANA) has been reported in patients with recurrent pregnancy loss (RPL). Nevertheless, the role of ANA in reproductive failure is still unclear. The aim of this study was to investigate the role of ANA during early pregnancy in vivo. Method of study We used pregnant mice treated with immunoglobulin G (IgG) obtained from normal healthy subjects (NHS); ANA+ sera of patients with RPL; and ANA+ sera from women with uncomplicated pregnancies (HW). Placental immunohistochemical/immunofluorescence staining was performed to detect complement and immune complex deposition. ELISA was performed to evaluate complement levels. Results ANA+ IgG from RPL women significantly increased embryo resorption rate, reduced C3, and increased C3a serum levels compared to NHS IgG or ANA+-HW IgG. Increased C3 deposition and increased immune complex staining in placental tissues from mice treated with ANA+-RPL IgG fraction compared to NHS- and ANA+-HW-IgG-treated mice were found. Conclusion ANA+ IgG injection in mice is able to induce fetal resorption and complement activation. The presence on placental tissues of immune complexes and complement fragments suggests the complement activation as a possible mechanism of placental damage

Mid-term results on a new self-expandable covered stent combined with branched stent-grafts: insights from a multicenter Italian registry

Objective: To investigate the technical periprocedural and mid-term outcomes of endovascular repairs with multibranched (BEVAR) or iliac-branch devices (IBD) combined with a new self-expanding covered stent. Methods: The COBRA (COvera in BRAnch) registry is a physician-initiated, multicenter, ambispective, observational registry (ClinicalTrials.gov Identifier: NCT04598802) enrolling patients receiving a BEVAR or IBD procedure mated with Bard Covera Plus (Tempe, Arizona, USA) covered stent, designed to evaluate the outcomes of the covered stent mated with patient-specific and off-the-shelf branched stent-graft. Primary endpoints were technical success, branch instability, and freedom from aortic and branch-related reintervention within 30 days and at follow-up. Preoperative characteristics, comorbidities, and outcomes definition were graded according to the Society for Vascular Surgery reporting standards. Results: Two hundred eighty-four patients [76 years (70-80); 79% males] in 24 centers were enrolled for a total of 708 target vessels treated. The CSs were mated with an off-the-shelf graft in 556 vessels (79%) and a custom-made graft in 152 (21%). Three-hundred-seven adjunctive relining stents in 277 vessels (39%) were deployed, of which 116 (38%) proximal, 66 (21%) intrastent and 125 (41%) distal. Adjunctive relining stent placement was more frequent when landing in a vessel branch instead of the main trunk (59%vs39%, p=.031), performing a percutaneous access (49%vs35%, p<.001), using a stent with a diameter ≥8mm (44%vs36%, p=.032) and a length ≥80mm (65%vs55%, p=.005), when a post-dilatation was not performed (45%vs29%, p<.001) and when an inner-branch configuration was used (55%vs35%, p<.001). Perioperative technical bridging success was 98%. Eight patients (3%) died in the perioperative period. Two deaths (1%) were associated with renal branch occlusion followed by acute kidney injury and paraplegia. Follow-up data were available for 638 vessels (90%) at a median of 32 months (Q1, Q3: 21,46). A branch instability was reported in 1% of branches. Forty-six (17%) patients died during follow-up, nine (3%) of them due to aortic-related causes. Primary patency rates at one year, two and three years were 99% (581/587), 99% (404/411), and 97% (272/279) respectively. Branch instability was associated with patient-specific devices (9% vs 4%, p=.014) and intrastent adjunctive stent placement (12% vs 2%, p=.003), especially when a bare metal balloon-expandable stent was used (25%vs3%, p<.001). Conclusions: The use of this new self-expanding covered stent mated with branched endografts proved to be safe and feasible with high technical procedural success rates. Low rates of branch instability were observed at mid-term follow-up. Comparative studies with other commercially available covered stents are warranted

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia

This editorial assembles endovascular specialists from diverse clinical backgrounds and nationalities with a global call to address key challenges to enhance revascularization in chronic limb-threatening ischemia (CLTI) patients.- Dedicated below-the-ankle (BTA) angiography and revascularization is underutilized in ischemic foot treatment. Existing guidelines do not address comprehensive BTA vessel analysis. CLTI trials also often lack data on in-line arterial flow to the ischemic lesion and BTA vessel evaluation, hindering outcome assessment.- Dedicated multi-planar angiographic evaluation of the distal microcirculation is key: Direct arterial flow or good-quality collaterals are crucial in influencing wound healing and need to be assessed diligently to the level of the distal ischemic wound territory, termed “woundosome.”- An important primary emphasis of future trials should be on validating technologies and strategies for assessing tissue perfusion before, during, and after revascularization undertaken to heal tissue loss in CLTI patients. This will allow determination of a potentially significant delta in tissue perfusion prior to and following intervention at the “woundosome” level. Once changes in arterial perfusion have been identified as positively correlated to wound healing, these could serve as a much-needed novel primary technical outcome measure for patients with tissue loss undergoing surgical, hybrid, or endovascular revascularization

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 (Società 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