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

Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures

Objective: To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. Methods: A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. Results: Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 – 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 – 12.1; p =.026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 – 9.6; p =.019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 – 20.7; p =.001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 – 9.0; p =.013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 – 13.8; p =.037), and aortic arch procedure (OR 7.3, 95% CI 1.7 – 31.1; p =.007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p <.001). Conclusion: AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure

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

Il mercato antiquariale nella Venezia di Ruskin. L'arte medievale in Germania

I primi viaggi di Ruskin a Venezia cadono durante la dominazione austriaca, una lunga fase che vede una dispersione di materiali medievali veneziani che sono divenuti oggetto d’interesse per un mercato che risponde a sollecitazioni diverse: privati collezionisti, amatori e turisti stranieri che cercano “souvenir” ma anche committenze elevate finalizzate alla costituzione di musei e luoghi evocativi. È questo il caso dell’imponente acquisto negli anni Quaranta ( committente Federico Guglielmo di Prussia) di sculture antiche e medievali in Italia che andranno a costituire un importante nucleo per il museo di arte medievale e bizantina dei musei di stato in corso di costruzione. Tra queste si trova un gruppo interessante di opere veneziane acquistate tutte presso un unico commerciante veneziano (Pajaro). Anche il fratello di Federico Gugliemo, Carlo, acquista arte veneziana per ricreare nel castello di Glienicke un chiostro veneziano. Ancora: la Friedenkirche a Potsdam viene ornata da un mosaico acquistato a Murano dalla demolita chiesa di san Cipriano. Frammenti e opere intere vanno quindi a costituire raccolte destinate al pubblico e alla sua educazione, oppure a impreziosire edifici neomedievali o evocativi. Una spoliazione che va in direzione opposta all’attenzione di Ruskin. L’occhio e la mano di Ruskin ci hanno consegnato documentazione grafica e visiva di un patrimonio in contesto. I suoi scritti sono animati dalla attenzione ad ogni frammento, come testimonianza di un fare che è anche storia. Delle esportazioni delle opere medievali resta traccia anche nella reazione di veneziani (Seguso in primis) e si può cogliere non solo negli scritti ma nelle azioni successive la crescita di una attenzione e una sensibilità per un patrimonio che verrà sentito come identitario. Dopo l’annessione all’Italia pur non cessando l’azione del mercato e le vendite possiamo riscontrare una dinamica non solo di attenzione e forte impegno nel restauro di monumenti significativi, ma anche la costituzione di musei dove trovano posto i frammenti emersi da restauri e le sculture decontestualizzate in nome di un nuovo spirito e di una attenzione di cui Ruskin è stato attivo promotore e protagonista

Ipazia, l'intellettuale

Il saggio si divide in cinque parti. Nella prima («Ipazia, o della faziosità degli Alessandrini») la vita e la morte di Ipazia vengono ricostruite (attraverso le notizie di Suida, Esichio di Mileto, Damascio, Socrate Scolastico, Giovanni di Nikiu et al.) nel contesto delle violente agitazioni e degli scontri ideologici e religiosi nell'Egitto del IV e V secolo. La seconda sezione (La fortuna di Ipazia) analizza la grande fortuna che la figura e la vicenda di Ipazia riscossero nella letteratura e nel pensiero europeo tra Seicento e Ottocento (da Voltaire a Monti, da John Toland a Diodata Saluzzo Roero), pur nelle diverse prospettive assunte in area protestante e in area cattolica, in campo illuminista o nelle correnti romantiche. Nella terza parte (Giudizio e pregiudizio delle fonti), constatata l'esistenza di due versioni della vicenda di Ipazia, una cristiana e una pagana, ciascuna delle quali declinata in chiave moderata o oltranzista, si rilevano i tratti idealizzanti attribuiti, nelle fonti, alla sua figura, e il retroterra ideologico del loro formarsi. La quarta parte del saggio (Sinesio, Ipazia e la «philosophia») approfondisce l'indagine sugli studi e sull'attività didattica di Ipazia, soprattutto attraverso le testimonianze del suo allievo Sinesio. L’interesse di Ipazia per la "geometria" e l’astronomia, ma anche l'esoterismo di parte del suo insegnamento e gli elementi teurgici che vi si colgono, inducono ad attribuire alla sua figura di scienziata e filosofa un complementare e dominante carisma sacerdotale: il genere di philosophia del quale fu cultrice deve inquadrarsi nel rapporto fra la donna e il sacro, coerentemente con quella concezione della preminenza femminile nell'ambito soprarazionale che è lascito della spiritualità tardoantica. È alla luce di queste considerazioni che si valuta, nella parte conclusiva del saggio, il «martirio» di Ipazia. Le accuse convergenti, da parte pagana e cristiana, sul suo carnefice, il vescovo Cirillo, da un lato confermano la sua responsabilità nel selvaggio assassinio, pur negata finora dalla chiesa cattolica, e d’altro lato paradossalmente concorrono alla trasfigurazione cristiana della donna, obliterando la connotazione concretamente politica e sociale della sua vicenda.This essay is divided into five parts. In the first (Hypatia, or the Partisan Spirit of the Alexandrians), the author reconstructs the circumstances of Hypatia’s life and death from the writings of Suida, Hesychius of Miletus, Damascius, Socrates Scholasticus, John of Nikiu and others) in the context of the violent upheavals and ideological and religious strife in 4th and 5th century Egypt. The second section (Hypatia’s Influence) analyses the enormous fortune Hypatia’s character and circumstances had in European literature and thought from the 17th to 19th centuries (from Voltaire to Monti, John Toland to Diodata Saluzzo Roero), despite the different perspectives adopted in Protestant and Catholic cultures, Enlightenment circles, and Romantic currents. In the third part (The Judgment and Prejudice of the Sources), given the existence of two versions of the Hypatia affair - one Christian and one pagan - each then interpreted in a moderate or fundamentalist key, the author highlights the idealising traits attributed to the figure of Hypatia in the sources, and the ideological background of their development. The fourth section of the essay (Synesius, Hypatis, and “Philosophia”) investigates in more depth Hypatia’s study and teaching, especially through the testimony of her pupil, Synesius. Hypatia’s interest in "geometry" and astronomy, and the exotericism - along with theurgic elements - of some aspects of her teaching, suggest the attribution of a complementary and dominant priestly charisma to her character as scientist and philosopher. The genre of philosophia she cultivated must form part of the relationship between women and the sacred, in line with the concept of female pre-eminence within the sphere of the super-rational, which is an legacy of the spirituality of Late Antiquity. It is in light of these considerations that the author evaluates, in the concluding part of the essay, Hypatia’s “martyrdom.” Both Christian and Pagan accusations, converging on her executioner, Bishop Cyril, confirm, on the one hand, his responsibility in the brutal murder – still unacknowledged by the Catholic Church - and on the other, contribute paradoxically to the Christian transfiguration of Hypatia, cancelling out the concrete political and social connotations of her life and experience