Demographic, Clinical and Hematological Predictors of Carotid Atherosclerotic Plaque Histology

Aims: This retrospective observational study was aimed to identify hematological predictors of histological heterogeneity of carotid atherosclerotic plaques (CAPs). Results: The mean values of all demographic, clinical and haematological parameters did not differ between patients with or without symptomatic CAD. In univariate analysis, intraplaque hemorrhage was associated with male sex (r=0.18; p=0.032), superficial thrombosis with low hemoglobin (r=- 0.18; p=0.033), fibrosis with enhanced RDW (r=0.24; p=0.005), presence of foam cells with high WBC count (r=0.22; p=0.001), neovascularisation with high WBC count (r=0.17; p=0.048), whilst the presence of inflammatory infiltrate was also associated with high WBC count (r=0.17; p=0.043). Conlusions: The results of this retrospective observational study confirm that some traditional and inexpensive hematological parameters such as WBC count, hemoglobin and RDW may help identifying patients with more severe forms of CAD

An International Expert-Based CONsensus on Indications and Techniques for aoRtic balloOn occLusion in the Management of Ruptured Abdominal Aortic Aneurysms (CONTROL-RAAA)

Objective: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA). Methods: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts’ responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final study report. The consistency of each round’s answers was also graded using Cohen’s kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa. Results: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making. Conclusions: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology. Clinical Impact This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge

Guidelines on the diagnosis, treatment and management of visceral and renal arteries aneurysms: a joint assessment by the Italian Societies of Vascular and Endovascular Surgery (SICVE) and Medical and Interventional Radiology (SIRM)

: The objective of these Guidelines is to provide recommendations for the classification, indication, treatment and management of patients suffering from aneurysmal pathology of the visceral and renal arteries. The methodology applied was the GRADE-SIGN version, and followed the instructions of the AGREE quality of reporting checklist. Clinical questions, structured according to the PICO (Population, Intervention, Comparator, Outcome) model, were formulated, and systematic literature reviews were carried out according to them. Selected articles were evaluated through specific methodological checklists. Considered Judgments were compiled for each clinical question in which the characteristics of the body of available evidence were evaluated in order to establish recommendations. Overall, 79 clinical practice recommendations were proposed. Indications for treatment and therapeutic options were discussed for each arterial district, as well as follow-up and medical management, in both candidate patients for conservative therapy and patients who underwent treatment. The recommendations provided by these guidelines simplify and improve decision-making processes and diagnostic-therapeutic pathways of patients with visceral and renal arteries aneurysms. Their widespread use is recommended

Endovascular repair of an unusually complex anastomotic pseudoaneurysm of an aorto-bisiliac graft

BACKGROUND: Anastomotic pseudoaneurysm is an underestimated complication of aorto-iliac grafts. CASE REPORT: This case report describes an unusual presentation of a pseudoaneurysm with a particularly complex anatomy involving both the left iliac branches, which hindered the interpretation of diagnostic studies and therapeutic management in a patient with multiple comorbidities. CONCLUSIONS: The manuscript describes a successful management of such a complication by means of an elective endovascular approach

Treatment of popliteal artery aneurysms by means of cryopreserved homograft

Autologous saphenous vein is considered the gold standard conduit in the femoral-popliteal revascularization for popliteal artery aneurysms (PAAs). In several cases, it may be absent or unsuitable for length or diameter and so it may be considered unfit for a conduit. In such patients, a synthetic graft or the endovascular correction can be useful, but results are controversial. In this retrospective case series, we have analyzed the safety and efficacy of the cryopreserved homograft (CHg) as a conduit in the PAA revascularization

Endovascular treatment of abdominal aortic aneurysms with the Powerlink Endograft System: Influence of placement on the bifurcation and use of a proximal extension on early and late outcomes

ObjectiveWe evaluated the influence of placement of the bifurcated Powerlink endograft (Endologix Inc, Irvine, Calif) on the aortic bifurcation, with the addition of a proximal extension, in the endovascular treatment (EVAR) of selected patients with atherosclerotic abdominal aortic aneurysms (AAAs).MethodsFrom September 1999 to June 2007, 205 patients were treated with the bifurcated Powerlink endograft for atherosclerotic AAA at two Italian centers with shared protocols. Patients were retrospectively divided in two groups according to treatment with the bifurcated graft only (n = 126), or its placement on the bifurcation with the addition of a proximal extension (n = 79) at the initial procedure. Study end points included postoperative complications, secondary procedures, immediate and late conversion, migration, endoleak, death, and aneurysmal sac behavior.ResultsOverall technical success was 98.5%. Additional procedures were performed in 18%, and postoperative complications occurred in 11.2% (systemic, 8.3%; local, 2.9%). Median follow-up was 42.4 months (range, 6-94 months). Secondary procedures were recorded in 11.2%, migration in 3.9%, type I proximal endoleak in 7.8%, and late conversions in 2.4%. Placement on the bifurcation and the addition of an extension were associated with a higher incidence of postoperative complications (7.1% vs 17.7%, P = .020). A reduced incidence of endoleak (19% vs 8.9%, P = .048), secondary procedures (14.3% vs 6.3%, P = .04), and migration (6.3% vs 0%, P = .024) were observed in the group with a proximal extension. Analysis of single variables reveals that migration was significantly influenced by placement of the graft on the bifurcation (47% vs 0%, P < .001). Both placement on the bifurcation and the addition of an extension positively influenced the type I proximal endoleak rate (3.8% vs 35.3% P < .001) and the need for a secondary intervention (6.3% vs 35.3% P < .001) Two aneurysm ruptures and five cases of late conversion occurred in the group treated with a bifurcated graft only (4%, P = .52, P = .159). Analysis of aneurysm sac behavior was not statistically significant: enlargement, 4.1% vs 1.3% (P = .158); reduction, 34.1% vs 40.5% (P = .542).ConclusionThe placement of the bifurcated Powerlink endograft on the aortic bifurcation with a proximal extension for complete sealing seems to improve late outcomes, particularly secondary procedures, migration, and endoleak development. Larger prospective studies with longer follow-up are necessary to confirm these promising results

Surgical Treatment of Symptomatic Aortic Aneurysm in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Case Report and Review of the Literature

Vasculitis is an heterogeneous group of syndromes, which shares inflammation of blood vessel wall as the main feature. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis, with few or no immune deposits, predominantly affecting small vessels (i.e., capillaries, venules, arterioles, and small arteries), associated with ANCAs specific for myeloperoxidase or proteinase 3. Clinical manifestations may be heterogeneous but an involvement of lungs and kidneys frequently occurs. AAV of large vessels is a very rare condition whose standard therapy is medical approach. Surgical revascularization has been described in selected patients after medical failure or in emergent settings. We report the case of a patient affected by symptomatic infrarenal aortic aneurysm related to AAV, who underwent in-situ reconstruction by means of cryopreserved homograft

Red blood cell distribution width predicts 1-month complications after percutaneous transluminal angioplasty

Background: The identification of patients at higher risk of developing percutaneous transluminal angioplasty (PTA)-related complications is pivotal for achieving better clinical outcomes. We carried out a single-center, observational, retrospective study to explore whether in-hospital changes of red blood cell distribution width (RDW) may help predicting early development of PTA-related complications.Methods: The study population consisted of all consecutive patients who underwent PTA for severe peripheral artery occlusive disease (PAOD) during a 2-year period. RDW was measured at hospital admission and discharge, and the delta was calculated. Patient follow-up was routinely performed 1-month after hospital discharge, and was based on thoughtful medical assessment and arterial ultrasonography. The control population consisted of 352 ostensibly healthy subjects.Results: The final PTA group consisted of 224 patients. Hemoglobin was lower, whilst mean corpuscular volume (MCV) and RDW were higher in PAOD cases than in controls. Overall, 11 PAOD patients (4.9%) developed clinically significant PTA-related complications 1-month after hospital discharge. Patients who developed 1-month PTA-related complications had lower hemoglobin concentration, but higher RDW and delta RDW than those who did not. Patients with delta RDW &gt;1 had 60% higher risk of developing 1-month PTA-related complications and 88% higher risk of developing early reocclusion. Overall, RDW exhibited an area under the curve (AUC) of 0.68 and 0.74 for predicting 1-month PTA-related complications and early reocclusion, respectively.Conclusions: The results of this study suggest that RDW may play a role for guiding the clinical decision making of PTA patients immediately after hospital discharge

Thoracic Aortic Pseudoaneurysm after Esophageal Perforation and Mediastinitis Caused by Accidental Ingestion of a Mutton Bone: A Case Report on Staged Endoscopic and Endovascular Treatments

Background Esophageal perforation involving the thoracic aorta is a rare but potentially life-threatening event. Esophageal wall dehiscence, aortoesophageal fistula, mycotic aneurysms, or mediastinitis may complicate this challenging condition, and a multidisciplinary approach is mandatory. Aggressive endoscopic and medical therapy followed by thoracic endovascular aneurysm repair (TEVAR) may be a valuable approach to reduce the mortality rate of this catastrophic event. Case Report A 79-year-old man presented at the emergency department with a 2-day history of worsening dysphagia and fever, suddenly appeared after consuming mutton meat. Esophagogastroduodenoscopy and computed tomography (CT) scan at admission showed a bone fragment penetrating the esophagus very close to the thoracic aorta, associated with signs of mild mediastinitis. After endoscopic removal of the bone, an esophageal fistula occurred. A conservative approach by means of endoscopic clipping of the esophageal perforation, nasojejunal tube for enteral nutrition and broad spectrum antibiotic therapy was preferred at this stage. Control chest X-ray with oral water-soluble contrast (Gastrografin) and repeat CT at 10- and 20-day follow-up showed a complete resolution of the esophageal fistula and mediastinitis. On the other hand, an increase of the aortic pseudoaneurysm was noted. This was treated by means of TEVAR. Subsequent clinical evolution was uneventful, and the patient was discharged in optimal clinical conditions with a 4-week course of home antibiotic therapy. The 6-month follow-up was uneventful. Conclusions Foreign body esophageal perforation causing mediastinitis and aortic pseudoaneurysm is a very rare and challenging situation that requires a strict follow-up and an intensive multidisciplinary approach. A staged approach, first by endoscopy followed by endovascular treatment, may be safe and effective in selected patients

Value of Perioperative Chest X-ray for the Prediction of Sternal Wound Complications after Cardiac Surgery in High-Risk Patients: A "Work in Progress" Analysis

Background: Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods: Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results: SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p &lt; 0.001); proximal sternal height (PSH) was the only independent protective factor (O.R. 0.58; p &lt; 0.001), with a cut-off value of 11.7 mm (sensitivity 70.5%, specificity 71.0%; ROC area under the curve (AUC) = 0.768, p &lt; 0.001). Diabetes mellitus (O.R. 3.5; p &lt; 0.001) and COPD (O.R. 21.3; p &lt; 0.001) were independent predictors for MG1-SSI; indexed proximal sternal height (iPSH) was as a protective factor (O.R. 0.26; p &lt; 0.001) with a cut-off of 5.97 mm (sensitivity 70.2%, specificity 69.0%; ROC AUC = 0.739, p &lt; 0.001). No other radiological measurements were independently correlated with SD or MG1-SS (p = N.S.). Conclusion: PSH and iPSH at preoperative chest X-ray may act as indicators of high risk for sternal wound complications, allowing for early preventative measures