How the First Year of the COVID-19 Pandemic Impacted Patients’ Hospital Admission and Care in the Vascular Surgery Divisions of the Southern Regions of the Italian Peninsula

Background: To investigate the effects of the COVID-19 lockdowns on the vasculopathic population. Methods: The Divisions of Vascular Surgery of the southern Italian peninsula joined this multicenter retrospective study. Each received a 13-point questionnaire investigating the hospitalization rate of vascular patients in the first 11 months of the COVID-19 pandemic and in the preceding 11 months. Results: 27 out of 29 Centers were enrolled. April-December 2020 (7092 patients) vs. 2019 (9161 patients): post-EVAR surveillance, hospitalization for Rutherford category 3 peripheral arterial disease, and asymptomatic carotid stenosis revascularization significantly decreased (1484 (16.2%) vs. 1014 (14.3%), p = 0.0009; 1401 (15.29%) vs. 959 (13.52%), p = 0.0006; and 1558 (17.01%) vs. 934 (13.17%), p < 0.0001, respectively), while admissions for revascularization or major amputations for chronic limb-threatening ischemia and urgent revascularization for symptomatic carotid stenosis significantly increased (1204 (16.98%) vs. 1245 (13.59%), p < 0.0001; 355 (5.01%) vs. 358 (3.91%), p = 0.0007; and 153 (2.16%) vs. 140 (1.53%), p = 0.0009, respectively). Conclusions: The suspension of elective procedures during the COVID-19 pandemic caused a significant reduction in post-EVAR surveillance, and in the hospitalization of asymptomatic carotid stenosis revascularization and Rutherford 3 peripheral arterial disease. Consequentially, we observed a significant increase in admissions for urgent revascularization for symptomatic carotid stenosis, as well as for revascularization or major amputations for chronic limb-threatening ischemia

Endovascular Management of Suprarenal Aortic Pseudoaneurysm. Are Custom – Made Devices and Chimps Tecniques Safe and Effective Options for These Complex Lesions?

Introduction: Non-traumatic pseudoaneurysm of suprarenal aorta is an infrequent disease; however, it represents for vascular surgeon a challenging lesion. Open surgery for decades was the only treatment option, but at the moment endovascular therapy may be considered as an alternative in high risk patientsMethods: We describe three different endovascular op- tions in three patients who was reffered to our Institution in the last year. In the first case, a custom-made fenes- trated 2-hole tube endograft was implanted for a para- renal pseudoaneurysm. It seemed to be a plaque rupture in the posterior wall of the aorta, just in the room between the two renal arteries in an asymptomatic patient. The remaining part of the aorta was quite normal and a tube graft was planned. In the second case, a customized fenestrated 3-hole bifurcated endograft was implanted for a right aorto-renal pseudoaneurysm. The patient had undergone one month before a coil embolization of the aneurysm and right renal covered stent in urgent setting. After the urgent treat- ment the patient was discharged asymptomatic and a custom-made endograft was planned. At the moment of the second intervention the pseudoaneurysm was enlarged and it was impossible to cannulate the renal stent. The procedure was completed with a plug in the right renal fenestration. In the third case, a symptomatic post-pancreatitis supra-renal aortic pseudoaneurysm was treated with Chimney/Periscope/Snorkel (CHIMPS) tecnique. An Aorto-uni-iliac (AUI) endograft with two Chimney grafts for visceral trunks and two periscope grafts for renal ar- teries was implanted. The AUI choice was necessary for the conic profile from suprarenal to infrarenal segment of the aorta. Results: Technical success was obtained in all cases with a complete exclusion of pseudoaneurismal sac, patency of visceral arteries and absence of endoleaks at completion angiography. Clinical success was obtained in 2 of 3 cases, because the patient with aorto-renal lesion died in the postoperative period for multiple organ failure. A 6-month CT scan confirmed complete exclusion of pseudoaneurysm in absence of any complications in the remaining two patients. Conclusion: The endovascular treatment of complex aortic pseudoaneurysm may be effective, with a high technical success rate even in urgency situations. Although early re- sults are promising, more cases and long-term results are required to understand the safety and effectiveness in long term follow-u

Different Techniques in Endovascular Treatment of Obstructive Aortoiliac Disease

Objectives: Obstructive aortoiliac disease must be considered a chal- lenging treatment lesion for vascular surgeons. The aim of our study was to evaluate the outcomes of endovascular treatment of these lesions in terms of early and midterm Results, comparing standard iliac stenting with more complex techniques, including kissing stent, covered recon- struction of aortic bifurcation and bifurcated endograft deployment . Methods: A retrospective review was conducted of 116 patients treated for aortoiliac disease with endovascular technique from March 2015 to December 2018 at our institution. We considered in our study 64 patients with obstructive disease and divided our series in standard stenting group (32 patients) and complex technique group (32 patients). In the complex group, 21 kissing stents, 6 bifurcated endografts, and 5 covered reconstruction of aortic bifurcations were included. For each group, we analyzed comorbidities, and morphologic preoperative and intraopera- tive details. Early Results were analyzed in terms of 30-day thrombosis, amputation, and death. Follow-up results were analyzed by life-table an- alyses (Kaplan-Meier curves) in terms of primary and secondary graft patency, assisted primary patency, freedom from reintervention, amputa- tion-free survival, and overall survival. Univariate Cox regression analysis was performed to identify risk factors and intraoperative details associ- ated with primary stent graft patency. The median follow-up was 12 months. Results: The mean age was 64 6 11 years. At 30 days, we did not record any cases of amputations or deaths. The rate of thrombosis was of 3.1 and 9.4 (c2 1,067; P 1⁄4 .3) in the standard stenting and complex technique groups, respectively. During follow-up, primary patency in both groups was quite similar (82% vs 90%; log-rank 0.088; P 1⁄4 .7; Fig), secondarypatency and limb salvage for patients with critical limb ischemia, freedom from reintervention, and overall survival did not differ in the two groups. Univariate analysis did not find any factors affecting primary patency. Conclusions: In our experience, endovascular treatment of obstructive aortoiliac disease offered satisfactory early and mid term Results. Com- plex techniques, although they are more technically demanding and time consuming strategies, may be performed with similar results to those obtained in standard stenting procedures

Italian COLT Registry: A Multicenter Experience

Objective: The objective was to evaluate early and midterm results of elective and urgent endovascular treatment of complex thoracoabdomi- nal aortic diseases with the custom-made multibranched COLT endog- raft system (JOTEC, Hechingen, Germany). Methods: Thirteen patients (12 men and 1 woman; mean age, 72 years) were treated with the custom-made multibranched COLT endograft sys- tem from June 2018 to December 2019 in three different Italian institu- tions. The complex thoracoabdominal aortic diseases were divided as follows: 3 ruptured post-dissection aneurysms; 10 thoracoabdominal aortic aneurysms. One patient was treated for an impending rupture af- ter an endoprosthesis migration. All patients were assigned to American Society of Anesthesiologists class 3 or class 4. The median aneurysm diameter was 74 mm. All procedures were performed under general anesthesia, with femoral and axillary percutaneous approach. The spinal catheter for cerebrospinal fluid drainage was used in all the elective cases. Emergent and urgent procedures were completed in one step; all the others were divided in two stages. Self-expanding covered stents were implanted as bridging stent grafts to connect the target visceral vessels (TVVs) with the main body. Balloon-expandable covered stents were used to fix the bridging stent proximally, and distal relining with bare self-expandable metal stents was employed to provide a good land- ing zone when a tortuous anatomy was present. The technical success was defined as the absence of type I and type III endoleak at the end of the procedure and patency of all TVVs. The presence of spinal cord ischemia, procedure-related reinterventions, presence of any type ofendoleak, freedom from reinterventions, overall survival, and 30-day mor- tality were also evaluated. Results: Technical success was achieved in 85% of procedures; 52 TVVs were involved, and 2 TVVs (1 celiac trunk and 1 right renal artery) were embolized in urgent settings. No cases of spinal cord ischemia or aorta- related mortality were recorded. We registered two early deaths, one on postoperative day 6 and the other after 10 days due to myocardial infarction. Two late deaths, after 2 months and 4 months, were related to cerebral hemorrhage and pneumonia. The mean follow-up was 6 months. No type I or type III endoleaks and no bridge stent occlusion were recorded. Freedom from reinterventions was 100%. The estimated survival rate was 79.1%. Conclusions: The use of the COLT stent graft in thoracoabdominal dis- ease appears to be feasible and safe in elective and urgent settings. The use of self-expanding covered stents as bridging stent grafts, combined with a proximal fixing with balloon-expandable covered stents and a se- lective distal relining, seems to provide good early and midterm results. Long-term follow-up is necessary to confirm these result