Off-label use of interwoven carotid stent in common femoral artery occlusion after surgery.

Open surgery is the gold standard for treating common and deep femoral arterial lesions. Nevertheless, significant data have emerged in recent years supporting an endovascular strategy for this peculiar anatomic region, despite certain disadvantages, including the requirement for strong compression resistance and excellent flexibility and conformability when stents are implanted. We present a case of critical limb ischemia due to total common and deep femoral arteries occlusion after endarterectomy that resulted in a very tapered lesion. It was successfully treated with percutaneous angioplasty and off-label application of an interwoven nitinol Roadsaver carotid artery stent, which demonstrated good adaptability.

PBMNCs Treatment in Critical Limb Ischemia and Candidate Biomarkers of Efficacy.

When in critical limb ischemia (CLI) the healing process aborts or does not follow an orderly and timely sequence, a chronic vascular wound develops. The latter is major problem today, as their epidemiology is continuously increasing due to the aging population and a growth in the incidence of the underlying diseases. In the US, the mean annualized prevalence of necrotic wounds due to the fact of CLI is 1.33% (95% CI, 1.32-1.34%), and the cost of dressings alone has been estimated at USD 5 billion per year from healthcare budgets. A promising cell treatment in wound healing is the local injection of peripheral blood mononuclear cells (PBMNCs). The treatment is aimed to induce angiogenesis as well to switch inflammatory macrophages, called the M1 phenotype, into anti-inflammatory macrophages, called M2, a phenotype devoted to tissue repair. This mechanism is called polarization and is a critical step for the healing of all human tissues. Regarding the clinical efficacy of PBMNCs, the level of evidence is still low, and a considerable effort is necessary for completing the translational process toward the patient bed site. From this point of view, it is crucial to identify some candidate biomarkers to detect the switching process from M1 to M2 in response to the cell treatment.

Peripheral artery disease, the 'lost syndrome' during lockdown for COVID-19: A report of three cases.

The recent coronavirus disease 2019 (COVID-19) pandemic has significantly increased the burden placed on healthcare systems worldwide. This health emergency has led to changes being implemented in the organization of health institutions and has shifted the focus on pandemic management. This has led to marked changes being made in the treatment of patients without COVID-19, and has resulted in more difficult access to healthcare, with ensuing delays in diagnosis and treatment. Vascular diseases, including peripheral artery disease (PAD), require prompt treatment in the majority of cases in order to save affected limbs. Moreover, COVID-19 may result in acute arterial and venous complications, which need to be promptly recognized and treated. The present study describes three paradigmatic clinical cases of hospitalized patients, which are representative of the different forms of the 'lost syndrome' caused by either the direct effect of COVID-19 or by the effects of COVID-19 on the healthcare system and lifestyle factors. Prophylaxis against arterial and venous thrombotic events is crucial in patients with COVID-19, particularly those with a marked inflammatory state. On the other hand, the COVID-19 pandemic has diminished the access to healthcare system for patients with other chronic pathologies, with potential severe consequences for vulnerable patient groups, such as those with PAD and cardiovascular diseases. For these patients, the authors' experience over the last few months suggests that more suitable measures need to be adopted to avoid additional severe consequences on public health. In addition, it is necessary to identify pathways that will allow these patients to have rapid access to treatment with marked improvements in outcome.

In Situ Treatment of Branch Renal Artery Aneurysms With Pantaloon Vein Graft.

INTRODUCTION: The optimal method of operative management of complex renal artery aneurysms (RAAs) involving distal branches (BRAAs) remains unclear. When more than 1 artery is involved within the BRAA, endovascular techniques are not advisable and an ex vivo approach is often preferred. In this study, we introduce an alternative surgical in situ technique to treat BRAAs. METHODS AND SURGICAL TECHNIQUE: Five aneurysms involving the main or second-order bifurcation of the renal artery (RA) were treated in 4 patients at our institute between November 2012 and January 2017. The treatment of the BRAAs was based on resection of the aneurysm wall and reconstruction with autologous Pantaloon vein graft (PVG): a "Y-shaped" bypass created on-bench with autogenous great saphenous vein. Sequential clamping/reperfusion of the kidney allows to reduce renal function impairment. RESULTS: No perioperative mortality or morbidity was observed, including none nephrectomy. In all the cases, aneurysms were treated with an in situ technique as previously planned. All the grafts were patent at the follow-up time (mean 64.1 ± 11.7 months). Renal function was preserved in all the cases. Vascularization of the renal parenchyma was satisfactory both on arterial echo Doppler and contrast-medium ultrasound in all the cases. Average cross-clamping times of the main RA and of a single branch RA were 15.8 ± 1.7 and 17.7 ± 4.6 minutes, respectively. Mean total operating time was 266.3 ± 18.9 minutes. CONCLUSION: The PVG with sequential clamping applied in the surgical treatment of BRAAs permits to reduce the ischemic effects to the renal parenchyma. To our knowledge, these are the first cases described in which BRAAs are treated with a PVG and our experience suggests that it is a feasible technique, with good long-term results and without severe adverse events recorded.

[Endovascular treatment of a celiac trunk aneurysm: a case report and review of the literature]. / Trattamento transradiale di aneurisma complesso del tripode celiaco: descrizione di un caso e revisione della letteratura.

Celiac trunk aneurysms are uncommon vascular lesions; treatment is usually an open surgical operation; in the medical literature, only few cases of celiac aneurysm treated with endovascular technique are reported; coil positioning or stent-graft placement are described using a femoral vascular access as first choice.Here we describe the case of a 57-year-old man with an asymptomatic large celiac trunk aneurysm involving the origin of the splenic, left gastric and hepatic arteries. The patient was treated in an elective clinical setting with a totally endovascular procedure performed through the left radial artery. First, two vascular plugs were put into splenic and gastric artery, respectively, to prevent type II endoleak, then the aneurysm was closed using a balloon expandable stent-graft into the celiac trunk-hepatic axis. The procedure was completed without any complication. The computed tomography angiography scan confirmed total occlusion of the aneurysm and normal blood flow in the visceral arteries.This case shows that endovascular technique is effective and safe also for the treatment of very complex vascular lesions, and radial access could be considered the preferred choice to minimize access-related vascular complications.

Totally Percutaneous Aneurysm Sac Embolization During Endovascular Aneurysm Repair.

PURPOSE: To describe a sac embolization technique modification for type II endoleak prevention that makes a totally percutaneous approach feasible during endovascular aneurysm repair (EVAR) using the Excluder stent-graft. TECHNIQUE: Percutaneous access of the common femoral arteries is obtained and 2 suture-mediated closure systems are placed on each side. A 16-F or 18-F sheath is placed for delivery of the Excluder stent-graft main body and a 16-F sheath is used on the contralateral side. After the stent-graft and contralateral limb component are delivered to their intended positions, a standard 0.035-inch hydrophilic guidewire is placed into the aneurysm sac through the same 16-F sheath. Then a 5-F, straight, 65-cm-long catheter is advanced over the standard wire into the sac in parallel with the contralateral limb. The contralateral limb is deployed, the standard guidewire is removed; coils are released through the 5-F catheter into the sac, followed by injection of 5 to 10 mL of double-component fibrin glue. CONCLUSION: Totally percutaneous, nonselective sac embolization during EVAR, with a single access on each femoral artery, is feasible and helpful to physicians who wish to perform intraoperative sac embolization without relevant changes in their usual EVAR procedure.

Hepatitis B vaccination at three months of age: a successful strategy?

Vaccination of infants, children and adolescents against the hepatitis B virus (HBV) is mandatory in Italy. It is crucial to assess whether vaccinated subjects have protective antibody level during adulthood when the risk of HBV infection increases due to lifestyle or occupational exposure. Two groups of students attending to University of Padova Medical School were enrolled between 2004 and 2011 and HBV antibodies and antigens were measured. The first group (Group A) comprised students vaccinated at three months of age and the second group (Group B) comprised students vaccinated after the first year of life. The follow-up was 18.0 (Group A) and 17.9 (Group B) years. The students vaccinated at three months of age had a higher rate of non-protective antibodies (47.2%) comparing to those vaccinated after the first year of life (17.0%, P<0.0001) with a significantly lower antibody level (P<0.001). The rate of non-protective antibodies was inversely related to vaccination age. The results clearly show that children vaccinated after the first year of life are better protected against HBV. On the other hand, both groups show a good immunological memory as evidenced by the achievement of protective antibody level after the booster dose in 97.8% of subjects.

Modification of the Viabahn Padova sutureless technique for challenging anastomosis between a prosthetic graft and a circumferentially calcified target artery.

PURPOSE: To describe modification of the Viabahn Padova Sutureless (ViPS) technique for challenging anastomosis between a prosthetic graft and a circumferentially calcified target artery. TECHNIQUE: The technique is demonstrated in a 75-year-old man with complete superficial femoral artery (SFA) occlusion and reconstitution of a circumferentially calcified above-knee popliteal artery. A 7-mm Viabahn endoprosthesis with its constraining string was withdrawn from its delivery system; the string at the proximal edge of the stent was gently cut with a scalpel, causing the proximal part of the stent to deploy, while the undeployed distal tip with its smooth profile retained its commercial orientation. The proximal end was subsequently sutured to a 7-mm polytetrafluoroethylene (PTFE) graft. After surgical exposure, the popliteal artery was transected, and the undeployed distal portion of the Viabahn was inserted into the distal segment, supported by a stiff guidewire. By pulling the constraining string, the stent was deployed in a "non-reversed" fashion and subsequently dilated to achieve optimal apposition. Finally, the proximal end of the PTFE graft was tunneled under the sartorius muscle and sutured to the common femoral artery. CONCLUSION: This modification to the ViPS technique using a "non-reversed" method of Viabahn stent preparation allows a safer and more accurate deployment of the endoprosthesis in the calcified target artery.

The peritoneum as a natural scaffold for vascular regeneration.

OBJECTIVE: The peritoneum has the same developmental origin as blood vessels, is highly reactive and poorly thrombogenic. We hypothesize that parietal peritoneum can sustain development and regeneration of new vessels. METHODS AND RESULTS: The study comprised two experimental approaches. First, to test surgical feasibility and efficacy of the peritoneal vascular autograft, we set up an autologous transplantation procedure in pigs, where a tubularized parietal peritoneal graft was covered with a metal mesh and anastomosed end-to-end in the infrarenal aorta. Second, to dissect the contribution of graft vs host cells to the newly developed vessel wall, we performed human-to-rat peritoneal patch grafting in the abdominal aorta and examined the origin of endothelial and smooth muscle cells. In pig experiments, the graft remodeled to an apparently normal blood vessel, without thrombosis. Histology confirmed arterialization of the graft with complete endothelial coverage and neointimal hyperplasia in the absence of erosion, inflammation or thrombosis. In rats, immunostaining for human mitochondri revealed that endothelial cells and smooth muscle cells rarely were of human origin. Remodeling of the graft was mainly attributable to local cells with no clear evidence of c-kit+ endothelial progenitor cells or c-kit+ resident perivascular progenitor cells. CONCLUSIONS: The parietal peritoneum can be feasibly used as a scaffold to sustain the regeneration of blood vessels, which appears to occur through the contribution of host-derived resident mature cells.

ViPS (Viabahn Padova Sutureless) technique: preliminary results in the treatment of peripheral arterial disease.

BACKGROUND: To describe early results of a novel technique (ViPS, Viabahn Padova Sutureless) that connects a vascular prosthetic graft to a target artery in a sutureless fashion. METHODS: A consecutive series of five patients with peripheral arterial occlusive disease (Rutherford class IV and V) underwent six ViPS procedures (one bilateral) for limb revascularization. Angiography in all cases demonstrated complete superficial femoral artery (SFA) occlusion with reconstitution of a circumferentially calcified above-knee popliteal artery. Ultrasonography revealed no adequate vein for autogenous bypass creation. In all cases, a previous attempt of SFA endovascular recanalization was unsuccessful. A Viabahn (W.L. Gore, Flagstaff, AZ) endoprosthesis was partially deployed, and its proximal end was sutured to a polytetrafluoroethylene graft. After surgical exposure, the circumferentially calcified popliteal artery, which could not be safely sutured, was transected and the undeployed distal portion of the Viabahn was inserted into the popliteal artery supported by a stiff guidewire. The distal portion of the Viabahn graft was then deployed 2.5 cm into the popliteal artery with optimal apposition. The proximal end of the polytetrafluoroethylene graft was then sutured to the common femoral artery. The distal portion of the Viabahn was ballooned to ensure apposition with the popliteal artery. RESULTS: The mean time for surgical modification of the device was 6.6 minutes with a mean time for ViPS anastomosis deployment of 7 seconds. Mean operative time for ViPS procedure was 61 minutes (range: 48-74). Completion angiogram in all cases demonstrated a patent graft with no sign of dissection. The patients' symptoms resolved in all cases, with complete ulcer healing occurring in five patients within 3 weeks. Follow-up imaging (mean = 2.6 months, range: 1-5) with eco-color-Doppler and computed tomography angiogram demonstrated a patent graft with no loss of device integrity in all cases. CONCLUSION: The ViPS technique is simple, easily performed, and provides an alternative for bypass creation, particularly in cases where challenging arterial anastomoses are required. Furthermore, this technique has the potential to reduce operative time and is accomplished using common commercially available devices.

ViPS technique as a novel concept for a sutureless vascular anastomosis.

OBJECTIVE: To describe a novel technique (Viabhan Padova Sutureless [ViPS]) that connects a vascular prosthetic graft to a target artery in a sutureless fashion. METHODS: The patient was a 74-year-old male with complete superficial femoral artery (FA) occlusion and reconstitution of a circumferentially calcified above-knee popliteal artery (ANPA). The proximal end of a surgeon-modified 7-mm Viabahn endoprosthesis was sutured to a 7-mm polytetrafluoroethylene graft (PTFEg). After surgical exposure, the ANPA was transected, and the undeployed distal portion of the Viabahn was inserted, supported by a stiff guidewire. The distal portion of the Viabahn graft was then deployed and ballooned with optimal apposition. Finally, the proximal end of the PTFEg was sutured to the common FA. RESULTS: Operative time was 60 minutes. Completion angiogram and the computed tomography angiogram at 6 months demonstrated a patent graft. CONCLUSION: The ViPS technique provides an alternative for bypass creation when challenging arterial anastomoses are required.

Endovascular treatment as first line approach for infrarenal aortic occlusive disease.

INTRODUCTION: The purpose of this study was to report the early and late results of primary stenting for focal atherosclerotic lesions of the infrarenal aorta. METHODS: A retrospective analysis of 52 consecutive patients treated for infrarenal occlusive aortic disease with primary stenting between January 2002 and November 2009 was performed. Original angiographic imaging, medical records, and noninvasive testing were reviewed. Primary stenting was the first line of treatment. Perioperative technical success and Kaplan-Meier estimates for patency and survival were calculated. RESULTS: The majority of the patients (43) were treated for severe claudication (Rutherford III; 82.7%), 5 for ischemic rest pain (Rutherford IV; 9.6%), and 4 for minor tissue loss (Rutherford V; 7.7%). Aortic stenosis was found in 40 cases (76.9%) and occlusion in 12 (23%). Perioperative hemodynamic success was 100%. All patients had an improvement of ankle brachial index (ABI) >0.10. Clinical improvement was found in 96%. Early surgical revision was necessary for aortic rupture in 1 patient. One death occurred for pneumonia. The mean follow-up time was 39.4 ± 27.2 months. Ten reinterventions (19%) were needed for symptom recurrence. The estimated assisted primary patency at 9 years was 96% and the mean survival time was 86.6 months. CONCLUSION: Primary stenting offers safe and durable results and should be considered as the first line of treatment for focal aortic lesions.

Stent graft exclusion of a renal artery aneurysm at hilum in a case with complex anatomy.

A left renal artery aneurysm (RAA) was incidentally discovered in a 50-year-old hypertensive woman at renal artery duplex scan. The computed tomography angiography scan confirmed an eccentric, 2-cm large aneurysm localized on a prehilar branch with a very twisted and coiled main renal artery. The selective digital subtraction angiography allowed a better understanding of the local complex anatomy; a covered stent was placed with the complete exclusion of the aneurysm. Even if open surgery still represents the treatment of choice, endoluminal approach has been reported as an effective procedure especially in consideration of its low invasiveness. The exclusion by covered stent can be a safe alternative to coil embolization in case of distal RAAs as well.