Endovascular stenting of the ascending aorta for type A aortic dissections in patients at high risk for open surgery

Background: Open repair is the gold standard for type A aortic dissection (TAAD). Endovascular option has been proposed in very limited and selected TAAD patients. We report our experience with endovascular TAAD repair. Methods: Inclusion criteria were: (1) entry tear in the ascending aorta; (2) proximal landing zone of at least 2 cm; (3) distance between entry tear and brachio-cephalic trunk of at least 0.5 cm; (4) no signs of cardiac tamponade or severe aortic regurgitation and (5) no signs of aortic branches ischaemia. Patients with cardiac revascularisation from ascending aorta were excluded. Results: From April 2009 to June 2012, 37 patients with TAAD were admitted to our hospital. As many as 28 underwent surgical repair and 9 were considered at high surgical risk in a multidisciplinary meeting. Four met our inclusion criteria for an endovascular approach. Two of them had previous ascending aortic repair for TAAD and one had aortic valve replacement. Technical success was achieved in 100% of the patients. No mortality was registered during a median follow-up of 15 months (range 4-39 months), no migration of the graft and complete false lumen thrombosis of the ascending aorta in three patients. Conclusion: Endovascular treatment of TAAD is challenging but feasible in a selected subset of patients. Further research remains mandatory. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

The Gore Hybrid Vascular Graft in renovisceral debranching for complex aortic aneurysm repair

Objective This study reports our initial experience with the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) for staged hybrid open renovisceral debranching and endovascular aneurysm repair in patients affected by thoracoabdominal aortic aneurysms and pararenal abdominal aortic aneurysms (PAAAs). Methods Between December 2012 and December 2013, we analyzed outcomes of 13 patients who underwent open surgical debranching of renovisceral vessels for thoracoabdominal aortic aneurysm and PAAAs. All patients were considered at high risk for conventional surgery. Inclusion criterion was treatment by open surgical debranching of at least one visceral artery (renal artery, superior mesenteric artery [SMA], or celiac trunk [CT]) using the GHVG. In a second step, the aortic stent graft was implanted to exclude the aneurysm. If required, parallel grafts to the remaining visceral arteries were deployed in the same procedure. One patient had a symptomatic descending thoracic aortic aneurysm and another had a ruptured PAAA. Perioperative measured outcomes were immediate technical success rate, mortality, and morbidity. Median follow-up was 24.8 months (range, 0-15; mean, 8.2; standard deviation, 4 months). Results All open surgical debranching of renovisceral vessels were completed as intended. GHVG was used to revascularize 20 visceral vessels in 13 patients with a mean of 1.54 vessels per patient. Six renal arteries (30%; 2 right and 4 left), 9 SMAs (45%), and 5 CTs (25%) were debranched. In nine of 13 (66%) patients, other renovisceral arteries were addressed with chimney/periscope, Viabahn Open Revascularization Technique, and end-to-side anastomosis. Two of 13 patients (15%) died of bowel ischemia. Neither patient had GHVG revascularization to the SMA or CT. Perioperative complications occurred in three patients (23%; 1 renal hematoma, 1 respiratory insufficiency, and 1 small-bowel ischemia related to a SMA GHVG thrombosis). At 24 months, estimated survival was 85%, and estimated primary and secondary patency were 94% and 100%, respectively. Conclusions This limited series extracted from a more consistent hybrid procedure experience showed a mortality rate similar to most recent reports. Technical feasibility and the short-term patency rate of the GHVG for renovisceral debranching during staged hybrid open and endovascular procedures were satisfactory. Use of GHVGs may represent a useful revascularization adjunct to minimize visceral ischemia in these challenging patients

Helsinki-Vantaan lentoaseman tilannekuvakeskus : Häiriö- ja poikkeamatilanteiden eteneminen lentoasemalla

Tämän opinnäytetyön tavoitteena oli selvittää, miten Finavian ylläpitämällä Helsinki-Vantaa lentoasemalla tapahtuvat häiriö- ja poikkeamatilanteet vaikuttavat lentoasemalla toimiviin Finavian omiin organisaatioihin sekä lentoasemalla toimiviin viranomaisiin. Häiriö- ja poikkeamatilanteella tarkoitetaan lentoaseman normaaliin toimintaan häiritsevästi vaikuttavaa tapahtumaa, esimerkiksi sähkökatkoa. Työ tehtiin Helsinki-Vantaa lentoaseman tilannekuvakeskuksen päällikön pyynnöstä. Tilannekuvakeskuksessa huomattiin, että vaikka häiriö- ja poikkeamatilanteessa toiminta eri tahojen kanssa on ollut kitkatonta ja sujuvaa, ei toisen organisaation sisällä tapahtuvasta toiminnasta ollut kuvaa. Työn avulla selvitettiin, onko häiriö- tai poikkeamatilanteella vaikutusta eri organisaatioiden ja viranomaisten toimintaan. Opinnäytetyö auttaa rakentamaan kokonaiskäsitystä poikkeamatilanteiden aiheuttamasta toiminnasta koko lentoaseman alueella. Tätä kautta voidaan myös lisätä ymmärrystä eri organisaatioiden ja viranomaisten välillä. Opinnäytetyö toteutettiin yhteistyössä Helsinki-Vantaa lentoaseman tilannekuvakeskuksen kanssa. Työn edetessä rakennetta muokattiin yhteistyössä tilaajan kanssa niin, että se palvelisi mahdollisimman tarkoituksenmukaisesti eri organisaatioita. Työ toteutettiin tekemällä laadullinen tutkimus, jonka runkona oli puolistrukturoitu haastattelu. Haastatteluita kertyi yhteensä 19 kappaletta ja haastateltavia 21. Haastateltavina olivat Finavian eri organisaatioiden johtajia tai päälliköitä ja lentoaseman toimintaan liittyvien viranomaisten lentoaseman toimipisteiden päälliköt. Työstä rajattiin pois kaupalliset yritykset, koska haastatteluiden määrä olisi kasvanut liian suureksi. Lentoaseman tilannekuvakeskus on luonut useita valmiita toimintamalleja erilaisiin häiriö- ja poikkeamatilanteisiin. Tilannekuvakeskuksen päällikkö valitsi näistä häiriö- ja poikkeamatilanteista ne, jotka ovat todennäköisiä tai merkittäviä ja vaikuttavat haitallisesti lentoaseman toimintaan. Erilaisia häiriö- ja poikkeamatilanteita valikoitui 17 kappaletta. Näiden tilanteiden vaikutuksia ja toimintamalleja käsiteltiin haastatteluissa. Haastatteluissa saatu informaatio liitettiin tilannekuvakeskuksen toimintamalleihin ja luotiin jokaiseen valittuun poikkeamatilanteeseen kronologinen kuvaus eri organisaatioiden toiminnasta. Opinnäytetyöstä on myöhemmin tarkoitus tehdä pelkistetympi käsikirja Finavian ja viranomaisten käyttöön.The aim of this study was to find out how to Finavia’s Helsinki-Vantaa airport take place in crisis and emergency situations and how they affecting operating at the airport Finavia's own organizations as well as authorities operating at the airport. The work was done at the request of the Head of the Helsinki-Vantaa airport operation center. The airport operation center noted that although the crisis and emergency situations operation with various parties has been smooth, but nobody didn’t have a picture how these crisis and emergency situations was handled in the another organizations. The work purpose was to find out whether the fault or deviation situation could affect the functioning of the various organizations and public authorities. The thesis helps to build the overall understanding of the actions caused by the deviation of situations throughout the airport. This period may also increase the understanding of the different organizations and authorities. The research was conducted in cooperation with the Helsinki-Vantaa airport operation center. As work progresses, the structure was modified in cooperation with the client so that it would serve as appropriately as possible the different organizations. The work was carried out by qualitative research, whose backbone was the semi-structured interview. Interviews were a total of 19 tracks and 21 interviewees were interviewed leaders or managers in different organizations and Finavia's airport activities related to airport authorities, heads of offices. Work were excluded trading companies, because the number of interviews had grown too large. The airport operation center has created a number of ready-made models for different crisis and emergency situations. Head of the Centre chose a snapshot of the crisis and emergency situations, those who are likely or significant and adversely affect the operation of the airport. 17 various types of crisis and emergency situations was selected. Effects and models of these situations addressed in the interviews. The information obtained in the interviews attached a airport operation center’s operational models and was created for each selected deviation situation chronological description of the activities of various organizations. The thesis is later to be made simpler manual for use by Finavia and the authorities

Role of human tissue kallikrein in gastrointestinal stromal tumour invasion

Background: Human tissue kallikrein (hK1) generates vasodilator kinins from kininogen and promotes angiogenesis by kinin-dependent and kinin-independent mechanisms. Here, we investigate the expression and functional relevance of hK1 in human gastrointestinal stromal tumour (GIST).<p></p> Methods: Vascularisation and hK1 expression of GIST samples were assessed by immunohistochemistry. In two GIST cell lines, hK1 expression was assessed by PCR, and hK1 protein levels and activity were measured by ELISA and an amidolytic assay, respectively. The effect of hK1 silencing, inhibition or overexpression on GIST cell proliferation, migration and paracrine induction of angiogenesis was studied. Finally, local and systemic levels of hK1 were assessed in mice injected with GIST cells.<p></p> Results: Human tissue kallikrein was detected in 19 out of 22 human GIST samples. Moreover, GIST cells express and secrete active hK1. Titration of hK1 demonstrated its involvement in GIST invasive behaviour, but not proliferation. Furthermore, hK1 released by GIST cells promoted endothelial cell migration and network formation through kinin-dependent mechanisms. Gastrointestinal stromal tumour implantation in nude mice resulted in local and systemic hK1 expression proportional to tumour dimension.<p></p> Conclusions: Human tissue kallikrein is produced and released by GIST and participates in tumour invasion. Further studies are needed to validate hK1 as a diagnostic biomarker and therapeutic target in GIST

Endovascular Abdominal Aortic Aneurysm Repair With Ovation Alto Stent Graft: Protocol for the ALTAIR (ALTo endogrAft Italian Registry) Study

Background: Since 2010, the Ovation Abdominal Stent Graft System has offered an innovative sealing option for abdominal aortic aneurysm (AAA) by including a sealing ring filled with polymer 13 mm from the renal arteries. In August 2020, the redesigned Ovation Alto, with a sealing ring 6 mm closer to the top of the fabric, received CE Mark approval. Objective: This registry study aims to evaluate intraoperative, perioperative, and postoperative results in patients treated by the Alto stent graft (Endologix Inc.) for elective AAA repair in a multicentric consecutive experience. Methods: All consecutive eligible patients submitted to endovascular aneurysm repair (EVAR) by Alto Endovascular AAA implantation will be included in this analysis. Patients will be submitted to EVAR procedures based on their own preferences, anatomical features, and operators experience. An estimated number of 300 patients submitted to EVAR with Alto stent graft should be enrolled. It is estimated that the inclusion period will be 24 months. The follow-up period is set to be 5 years. Full data sets and cross-sectional images of contrast-enhanced computed tomography scan performed before EVAR, at the first postoperative month, at 24 or 36 months, and at 5-year follow-up interval will be reported in the central database for a centralized core laboratory review of morphological changes. The primary endpoint of the study is to evaluate the technical and clinical success of EVAR with the Alto stent graft in short- (90-day), mid- (1-year), and long-term (5-year) follow-up periods. The following secondary endpoints will be also addressed: operative time; intraoperative radiation exposure; contrast medium usage; AAA sac shrinkage at 12-month and 5-year follow-up; any potential role of patients' baseline characteristics, valuated on preoperative computed tomography angiographic study, and of device configuration (number of component) in the primary endpoint. Results: The study is currently in the recruitment phase and the final patient is expected to be treated by the end of 2023 and then followed up for 5 years. A total of 300 patients will be recruited. Analyses will focus on primary and secondary endpoints. Updated results will be shared at 1- and 3-5-year follow-ups. Conclusions: The results from this registry study could validate the safety and effectiveness of the new design of the Ovation Alto Stent Graft. The technical modifications to the endograft could allow for accommodation of a more comprehensive range of anatomies on-label

Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft

Objective: The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). Methods: Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. Results: Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm >80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (<25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. Conclusions: The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

La fortezza di Lucera: un cantiere tra svevi e angioini, attraverso un sistema integrato di fonti. Il contributo archeologico delle fonti indirette

Negli ultimi decenni l’ampliamento del campo di osservazione a tutti quei sistemi di informazione che possono allargare la domanda storica ha comportato la dilatazione del concetto di ‘fonte archeologica’. Un ‘organismo edilizio’ racchiude in sé una varietà di indicatori specifici, indagabili attraverso distinti linguaggi e metodologie, che costituiscono spesso una delle più immediate espressioni dell’economia, delle trasformazioni sociali e della mobilità, umana e materiale, a livello territoriale. Nell’ambito di un progetto finalizzato alla ricostruzione storica del paesaggio ‘globale’ medievale della Capitanata e rivolto in particolare all’analisi dei siti fortificati, in quanto luoghi privilegiati da cui osservare i processi di trasformazione insediativa e da cui indagare le basi economiche della vita sociale, il complesso fortificato svevo-angioino di Lucera (FG) è stato oggetto di mirate indagini archeologiche finalizzate ad individuare gli indicatori materiali presenti nelle murature. La costruzione in laterizio di gran parte della cinta fortificata angioina del complesso lucerino ha promosso l’osservazione, attraverso il metodo della mensioconologia, delle dinamiche di sfruttamento dell’argilla quale risorsa edilizia nel centro di Lucera. Si è posto in evidenza come il mattone a partire dalla seconda metà del XIII secolo, proprio con la costruzione della fortificazione angioina, sembri assumere fino ad età moderna. La ricca disponibilità di fonti indirette tratte dai Registri della Cancelleria angioina in relazione al cantiere della fortificazione lucerina, una serie documentaria (384 documenti) riferibile ad un preciso arco cronologico (1269-1284) e relativa alle decisioni, ai modi e ai ruoli del costruire, ha tuttavia ampliato lo spettro multidisciplinare della ricerca e contribuito a porre in connessione i dati statistici relativi alla produzione dei mattoni nel XIII secolo con le probabili maestranze preposte alla fabbricazione. La pluralità di fonti, che connota l’architettura medievale, consente di identificare differenti elementi e di porli in relazione, individuando un percorso privilegiato per una ricostruzione dell’intero ciclo economico dell’edilizia, dallo sfruttamento delle risorse alla diffusione delle tecniche. A tal fine il comparto territoriale prescelto sta progressivamente rivelando un potenziale osservatorio privilegiato per innescare un rinnovamento negli studi sulla edilizia storica in Italia meridionale

Archeologia del cantiere bassomedievale in Italia meridionale: status quaestionis, problemi, prospettive

Il contributo si propone di illustrare lo stato degli studi sui caratteri materiali dei cantieri bassomedievali nel Sud Italia, attraverso casi i più rappresentativi, così da metterne in luce, pur in un quadro di sensibile ritardo negli studi e a fronte di diversi problemi interpretativi, il potenziale conoscitivo. Gli indicatori osservati sono: le fondazioni, i sistemi di protezione e rinforzo strutturale, i presidi antisismici, i materiali impiegati in edilizia e la loro lavorazione e finitura, l’apprestamento di opere provvisionali, la fabbricazione della calce e la preparazione della malta, i segni lapidari. Lo studio consente di riconoscere prassi di antica tradizione, che spesso affondano le loro radici nei saperi costruttivi di età romana, mantenuti in vita sul lungo periodo, e l’emergere contestuale di nuove tendenze, nella scelta di determinati materiali e apparecchiature murarie, nella produzione dei leganti, nel tipo di ponteggi, nelle modalità organizzative dei cantieri, frutto di dinamiche complesse, innescate probabilmente dalla convivenza e dal confronto nel Sud Italia bassomedievale fra diverse culture architettoniche e tecnico-costruttive, spesso espressione di esperienze maturate in un areale geografico ampio che spazia dall’Oriente bizantino alla Sicilia islamica, al Nord Europa.The contribution aims to illustrate the material features of the Late Medieval construction sites in Southern Italy, through more representative cases, so as to highlight the cognitive potential, even in a context of considerable delay in studies and in the presence of various interpretative problems. The markers observed are: foundations; systems of protection and structural reinforcement; possible seismic equipment; materials used in buildings, their working and finishing; the set-up of provisional works; the manufacture of lime and the preparation of mortar: lapidary signs. The study allows us to recognize, hypothetically, practices of ancient tradition, which often have their roots in the constructive knowledge of the Roman age, kept alive in the long term, and contextual emergence of new trends, in the choice of materials and masonry techniques, in the production of mortars, in the type of scaffolding, in the organization of construction sites; the new practices may be the result of complex dynamics, probably triggered by the coexistence and confrontation in Southern Italy of different architectural and technical-constructive cultures, often the expression of experiences gained in a wide geographical area ranging from the Byzantine East to Islamic Sicily, to Northern Europe