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

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 &gt;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 (&lt;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

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 (Societa 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 &gt;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

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

Ancora sulla Cronografia di Psello

Il contributo difende gli interventi filologico-esegetici sul testo di Psello, proposti dall’autrice, dalle critiche avanzate da Rosario Anastasi nella sua recensione (“Orpheus” 7 [1986], pp. 432-438) ai volumi degli Imperatori di Bisanzio (Chronographia) pubblicati dalla Fondazione Valla, di cui l’autrice ha curato la traduzione italiana affiancandola a un lavoro di indagine critica sul testo pselliano parzialmente esposto nel precedente saggio Indagini ermeneutiche e critico-testuali sulla Cronografia di Psello oltreché testimoniato nell'apparato critico dell'edizione in oggetto. This essay contains the author’s defence of her proposed philological and exegetical comments and revisions to Psellos’ text in response to criticisms advanced by Rosario Anastasi in his review (Orpheus 7 [1986], pp. 432-38) on the volumes of the Imperatori di Bisanzio (Chronographia) published by the Fondazione Valla. The author translated and edited the first Italian version, along with the critical analysis of the Psellos text presented in part in her earlier essay Indagini ermeneutiche e critico-testuali sulla Cronografia di Psello, as well as in the critical apparatus of the edition in question

Il volto giovanile di Bessarione

Il contributo, corredato da tavole illustrative, si interroga sulle sembianze giovanili di Bessarione, quali appaiono attestate nella Flagellazione di Piero della Francesca, che ritrae un presumibile Bessarione trentenne, in abiti da delegato ecclesiastico bizantino al concilio di Ferrara-Firenze del 1438-39. Se da un lato la fisionomia del personaggio ritratto è congruente con quella attestata dalle quattro più attendibili raffigurazioni del suo aspetto senile — fornite in seguito da Paolo Romano, Gioacchino de Gigantibus, Pedro Berruguete e probabilmente Giusto di Gand — d’altro lato il cruciale quesito su quale possa essere stata la fonte iconografica di Piero — che dipinse i tratti del giovane delegato bizantino a vent’anni di distanza dal concilio fiorentino — è oggetto di una ricognizione iconografica che, riconducendo ipoteticamente il modello cui Piero dovette rifarsi agli schizzi tracciati da Pisanello a Ferrara nell’agosto del 1438, apre la strada a ulteriori interrogativi sulla committenza della tavola di Urbino. Al di là delle ipotesi, l’indagine storica e prosopografica è volta a individuare, nelle rappresentazioni delle fattezze bessarionee, una unitarietà e una coerenza fisionomica generalmente sconosciute al Bessarion pictus. This illustrated study investigates the presumptive representations of the young Bessarion, which appear in Piero della Francesca’s Flagellation of Christ, portraying the thirty year old intellectual and diplomat in his attire as Byzantine ecclesiastical delegate to the Council of Ferrara-Florence of 1438-39. While the physiognomy of the portrayal is consistent with that of the four most credible representations of Bessarion’s later years – those of Paolo Romano, Gioacchino de Gigantibus, Pedro Berruguete and, most probably, Justus van Gent — the crucial question of the iconographic source used by Piero, who painted the young Byzantine delegate twenty years after the Florentine Council, is the subject of this investigation. Locating the possible model Piero must have drawn on in sketches made by Pisanello in August 1438 at Ferrara, this investigation opens the way to further questions concerning the commission of the Urbino painting. Beyond the various conjectures, the historical and prosopographical investigation aims to identify the most reliable physiognomic characteristics in the representations of the Bessarion pictus, which have been generally unacknowledged

Byzantinische Kultur. Eine Aufsatzsammlung. III. Die materielle Kultur

Per esercitare oggi un meditato giudizio storico su ciò che troppo spesso viene liquidato come “scontro di civiltà” tra oriente islamico e occidente cristiano, è essenziale non solo recuperare e ravvivare una memoria attiva di Bisanzio, una coscienza collettiva dei suoi grandi lineamenti storico-politici e storico-culturali — che abbiamo visto trattati nei primi due volumi del corpus degli scritti di Peter Schreiner — ma anche e forse soprattutto analizzare la formula della sua civiltà multietnica, scomporre nei suoi più minuti ingredienti la ricetta della convivenza, nei suoi primari elementi il millenario processo di integrazione. Per farlo, è indispensabile discernere con attenzione e precisione quelli che solo superficialmente possono essere considerati costituenti “minori” dello studio di ciò che chiamiamo civiltà: gli elementi di quella che definiamo la sua cultura materiale, ossia, secondo il titolo di questo terzo volume dell’opera di Schreiner, die materielle Kultur. Stiamo parlando dell’economia affrontata non solo e non tanto nei suoi aspetti teorici — peraltro difficilmente coglibili nella tradizione scritta bizantina — ma anche e soprattutto nelle sue declinazioni concrete ed empiriche, nelle sue ramificazioni sottili, insinuate nelle pieghe della vita quotidiana, esemplificate nelle varie e molteplici modalità in cui giorno per giorno, in ogni singola e distinta parte dell’impero, si svolgevano, anzitutto, quei continui scambi tra popoli che ne definivano l’identità

Bessarion Venetus

L’amore di Bessarione per Venezia, da lui considerata quasi alterum Byzantium, si concretizzò nella donazione libraria volta a insediare nella città una biblioteca statale e pubblica. Il lascito bessarioneo, che avrebbe costituito il nucleo della futura Biblioteca Marciana, rimase tuttavia inaccessibile per oltre ottant’anni dopo la morte del cardinale Niceno, il che conferma la tendenziale diffidenza di una parte almeno dell’aristocrazia veneziana nei confronti della figura di Bessarione così come del progetto da lui coltivato di un «salvataggio occidentale di Bisanzio». Questo atteggiamento si riverberò anche sull’iconografia bessarionea: i ritratti veneziani di Bessarione, in primis quello notissimo di Gentile Bellini, ne restituiscono un’immagine grottesca, quasi caricaturale. Più fededegna appare invece l’immagine serbata nei ritratti espressi dalle corti “amiche” di Roma, Napoli, Urbino – dove Bessarione operò in vecchiaia – e di Ferrara – da cui provengono alcune sue raffigurazioni giovanili. La sequenza di volti del cardinale che si snoda attraverso queste quattro corti permette una comparazione fisionomica, fra l’altro, del suo più caratteristico attributo: il naso, forse ingrossato in vecchiaia da una malattia infettiva deformante. Il trattamento iconografico del naso di Bessarione – ora esasperato, ora ingentilito – se da un lato rende difficile stabilire un identikit certo del personaggio, d’altro lato certamente rispecchia le mutevoli attitudini dei committenti dei dipinti nei suoi confronti. Il saggio è corredato da tavole che riproducono alcuni dei ritratti bessarionei citati nel testo. Bessarion’s love for Venice, which he considered quasi alterum Byzantium, materialised in his library donation to establish a state public library in the city. However, the Bessarion donation, the nucleus of the future Marcian Library, remained inaccessible for over eighty years beyond the Nicene Cardinal’s death. This confirms the general diffidence of at least a part of the Venetian aristocracy toward Bessarion as well as his plan to “save Byzantium in the West.” This attitude is borne out also in the iconography of Bessarion: the Venetian portraits of the cardinal, in primis the most well-known by Gentile Bellini, reveal a grotesque image, almost a caricature. The images captured in portraits produced in the “friendly” courts of Rome, Naples, Urbino, where Bessarion resided in old-age, and Ferrara, source of more youthful portrayals, seem to be more accurate. The sequence of depictions of the cardinal originated in these four courts offer comparison of his physiognomy, especially that of his most characteristic feature: his nose, perhaps deformed in later years by swelling caused by an infectious disease. If the iconography of Bessarion’s nose – sometimes grotesquely exaggerated, sometimes refined – on the one hand makes it difficult to establish a reliable identikit, on the other most certainly reflects the changeable attitudes towards him of the patrons of the paintings. The essay includes plates with reproductions of some of the portraits mentioned in the text

Orthodoxy on Sale: the Last Byzantine, and the Lost Crusade

This conference paper reconstructs and summarises the various aspects and stages of the plan to “save Byzantium in the West,” of which Aeneas Sylvius Piccolomini, Bessarion, and Thomas Palaeologus were protagonists, underscoring with particular attention the doctrinal and ideological implications. Thomas, sovereign in pectore of the New Byzantium to be founded on the Peloponnese once delivered from the Turks by the crusade called by Pius II at the Council of Mantua in 1459, brought the head of St. Andrew, missionary on the Peloponnese and patron of the Eastern Church, with him to Italy soon after – probably at Bessarion’s suggestion. The transfer of St. Andrew’s head was a solemn event, filled with symbolism and commemorated in important artistic commissions. The idea of a crusade against the Turks by the Western powers under the aegis of the papacy had been planned for the first time soon after the Council of Ferrara and Florence, Bessarion’s move to the unionist faction, and the subsequent, though virtual and realpolitiker, union of the churches. After the failure of the Varna Crusade, however, the pope continued to promote the plan to found a “New Byzantium” in Morea, based on the realistic political proposals laid down by Georgius Gemistus Pletho and the school of Mystras. The project was supported by a clan of pro-Byzantine signorie, related through the Malatesta to the Palaeologi, but the greater objective was the reunification of the First and Second Rome into one legal entity under the primary influence of the papacy. The expectations and the crucial political, ideological, and religious connections are to be found mirrored allegorically in Benozzo Gozzoli’s Cavalcata dei Magi and Piero della Francesca’s Flagellation. However, after Pius II’s announcement at Mantua, international support for his expedition against the Turks began to wane quickly and the plan reached its epilogue with the death of the pontiff, the staunchest supporter until his end in Ancona. Lost in the West, inheritance of the Byzantine imperial title passed to Russia, thanks to the marriage – orchestrated with Machiavellian skill by Bessarion – between the last Palaeologian princess, Zoe, and Ivan III (the Great) Vasilyevich of Moscow. The divine right of the basileia and the concomitant bequest of orthodoxy, manipulated for decades, came to be absorbed into the Empire of the Third Rome. Il contributo ricostruisce e riassume, sotto forma di relazione congressuale, i vari aspetti e momenti del piano di "salvataggio occidentale di Bisanzio", che ebbe per protagonisti Enea Silvio Piccolomini, Bessarione e Tommaso Paleologo, sottolineandone in particolare le implicazioni ideologiche e dottrinali. Tommaso, sovrano in pectore della Nuova Bisanzio che avrebbe dovuto costituirsi nel Peloponneso una volta liberato dai turchi grazie alla crociata indetta da Pio II al Concilio di Mantova del 1459, recò con sé poco dopo in Italia, dietro probabile suggerimento di Bessarione, la reliquia della testa di Sant'Andrea, evangelizzatore del Peloponneso e patrono della Chiesa d’Oriente. La traslazione del capo di Sant’Andra fu un evento solenne e carico di simbolismi, commemorato, fra l’altro, in importanti committenze artistiche. L'idea di una crociata antiturca delle potenze occidentali sotto l’egida del papato si era concretizzata per la prima volta poco dopo il concilio di Ferrara-Firenze, il passaggio di Bessarione all'ala unionista e la conseguente, ancorché virtuale e “realpolitica”, unione delle chiese. Dopo il fallimento, tuttavia, della Crociata di Varna, ad essere caldeggiato dal papa restò il progetto di fondazione di una “Nuova Bisanzio” in Morea, basato sulle realistiche proposte politiche elaborate da Giorgio Gemisto Pletone e dalla scuola a Mistrà. Il progetto era appoggiato da un clan di signorie filo-bizantine, imparentate attraverso i Malatesta con i Paleologhi, ma la sua posta più alta era la prospettiva di una riunificazione della Prima e della Seconda Roma in una sola entità giuridica dominata dal papa. Le aspettative e i cruciali intrecci politici, ideologici, religiosi di quest'epoca si rispecchiano, in maniera allegorica, nel Corteo dei Magi di Benozzo Gozzoli e nella Flagellazione di Piero della Francesca. Tuttavia, dopo l’annuncio di Pio II a Mantova, andarono rapidamente scemando le adesioni internazionali al suo piano di spedizione antiturca, che vide il suo epilogo con la morte del pontefice, fino all'ultimo suo strenuo sostenitore, ad Ancona. Persa all'Occidente, l'eredità giuridica del titolo imperiale di Bisanzio passò alla Russia, grazie al matrimonio – machiavellicamente orchestrato da Bessarione – tra l'ultima principessa paleologa, Zoe, e Ivan III Vasilevič di Mosca. L'ideologia della basileia di diritto divino e l'ortodossia, manipolata per decenni, vennero riassorbite nell’impero della Terza Roma