Bypass vs endovascular treatment for occluded femoro-popliteal stents in patients with critical limb-threatening ischemia.

OBJECTIVE: The aim of the study was to compare the early and medium-term outcomes of bypass vs endovascular treatment of occluded femoro-popliteal stents in patients with chronic limb-threatening ischemia (the OUT-STEPP multicentric registry). METHODS: Between January 2016 and December 2021, 317 patients in 14 centers underwent treatment for a symptomatic occlusion of femoro-popliteal stent/stents. One hundred sixty-one patients were included into the present study: 46 (28.6%) underwent open bypass surgery (Group OPEN), and 115 (71.4%) underwent endovascular revascularization (Group ENDO). Early (30 days) results were assessed and compared between the two groups. Estimated 5-year outcomes were evaluated and compared with the log rank test. RESULTS: At 30 days, no differences were found in terms of major adverse cardiovascular events, acute kidney injury, reinterventions, major amputation, and all-cause mortality between the two groups. The need for blood transfusions was higher for patients in Group OPEN (17; 36.9% vs 13; 11.3%; P < .001). The mean length of intensive care unit stay and the mean hospital stay were higher for patients in Group OPEN ([0.3 ± 0.9 vs 0 days; P < .001] and [9.7 ± 5.8 vs 3.3 ± 1.4 days; P < .001], respectively). The overall median duration of follow-up was 33.1 months (interquartile range, 14-49.5 months). At 5 years, there were no differences between the two groups in terms of survival (68.7% Group OPEN vs 68.8% Group ENDO; P = .27; log-rank, 1.21), primary patency (56.3% Group OPEN vs 67.8% Group ENDO; P = .39; log-rank, 0.75), secondary patency (59.1% Group OPEN vs 77.8% Group ENDO; P = .24; log-rank, 1.40), absence of target lesion restenosis (56.8% Group OPEN vs 62.7% Group ENDO; P = .42; log-rank, 0.65), and limb salvage (77.2% Group OPEN vs 90.4% Group ENDO; P = .17; log-rank, 1.87). CONCLUSIONS: Both bypass and endovascular treatment provided safe and effective restoration of patency for femoro-popliteal in-stent occlusion in patients with chronic limb-threatening ischemia. Open surgery was associated with longer stay in hospital and increased use of blood transfusions. At 5 years, no significant differences were found in the rates of overall patency or limb salvage between bypass and endovascular treatment.

Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry.

BACKGROUND: Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI). METHODS: Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included. FOLLOW-UP: One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated. RESULTS: Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics. CONCLUSION: Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.

Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms?

INTRODUCTION: Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. METHODS: Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. RESULTS: Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. CONCLUSIONS: Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.

Insulin resistance, serum uric acid and metabolic syndrome are linked to cardiovascular dysfunction in pediatric obesity.

INTRODUCTION: Childhood obesity is associated with cardiovascular abnormalities but little is known on the potential correlation between early cardiovascular and metabolic alterations. AIM: Aims of this study were 1) to evaluate early cardiovascular abnormalities in a large population of obese children and adolescents compared with a normal weight counterpart, 2) to investigate their potential association with insulin resistance (IR), serum uric acid (sUA) and metabolic syndrome (MetS). METHODS: This was a single-center case-control study. Eighty obese (OB) subjects (6-16years) and 20 normal weight (NW) matched controls were consecutively recruited. In the whole population we performed an anthropometric and a cardiovascular assessment. OB patients also underwent an OGTT and biochemical evaluations. RESULTS: OB children showed greater left atrial (LA) and ventricular (LV) dimensions and mass and higher carotid artery intima-media thickness (CIMT), compared with NW controls. The BMI z-score, waist circumference, IR and sUA were positively related with LA and LV dimensions and mass. OB subjects with MetS (46.3%) showed greater LA diameter (p=0.001) and LV area (p=0.01) and volume (p=0.04) compared with OB children without MetS. LA diameter and LV dimensions and mass were significantly dependent on the number of criteria for MetS. Mets, sUA and IR were significant predictors of left heart dimensions and mass in obese children. CONCLUSIONS: Obesity and MetS are associated with abnormal cardiovascular response during childhood. Hyperuricemia can be an early marker of cardiovascular dysfunction and the routine determination of circulating levels of sUA should be implemented during risk stratification among pediatric age.

Endovascular Treatment of Aorto-Iliac-Femoral Anastomotic Pseudoaneurysms: A Multicentric Study.

PURPOSE: The purpose of this study was to assess the effectiveness of anastomotic pseudoaneurysms (APAs) endovascular treatment following aorto-iliac-femoral surgical reconstruction. BASIC PROCEDURES: We retrospectively evaluated 54 patients who underwent aorto-iliac-femoral bypass (72 APAs). Follow-up was performed with echo-color-Doppler and/or computed tomography angiography at 1, 3, and 6 months after the procedure and then yearly. We compared clinical success in terms of mortality between aortic APAs and nonaortic APAs (iliac-femoral-popliteal). MAIN FINDINGS: Immediate technical success was 100%. No periprocedural complications occurred. Six patients died during follow-up due to causes not related to APA and 5 due to sepsis at 3 months after the procedure. Thirty-day mortality was 9% overall, and we did not register any statistically significant different between aortic APA and nonaortic APA groups. During a mean follow-up of 25.5 months (range: 3-72), we registered 3 occlusions of stent-graft leg, respectively, at 3 days, 7 days, and 24 months after the procedure, 2 type I endoleaks and 1 type III endoleak. Primary clinical success rate was 87.2%, and secondary clinical success was 95.7%. CONCLUSIONS: Endovascular treatment resulted as a valid alternative to open surgery and could be proposed as the treatment of choice for APAs especially in patients with a high surgical risk.

Abdominal aortic aneurysm treatment: minimally invasive fast-track surgery and endovascular technique in octogenarians.

BACKGROUND: We conducted a retrospective study on patients aged over eighty who underwent elective surgery for an abdominal aortic aneurysm between January 2006 and December 2010. We compared our results with fast-track abdominal aortic surgery (OPEN group) and with endovascular aneurysm repair (EVAR group). METHODS: We followed 97 consecutive octogenarians affected by abdominal aortic aneurysm who underwent elective surgery. A total of 55 patients were enrolled in the OPEN group (56.7%) and 42 were enrolled in the EVAR group (43.3%). RESULTS: Eight patients (14.5%) in the OPEN group and six patients in the EVAR group (14.2%) received transfusions. None of the patients required admission to the intensive care unit. In total, 53 patients (98%) in the OPEN group and 34 patients (80%) in the EVAR group were able to get up and walk in the afternoon after the end of surgery. The recovery of intestinal transit was on day 2 in the OPEN group and on day 1 in the EVAR group. Patients in both groups were discharged on average on the fourth postoperative day. There were no perioperative mortalities in the OPEN and the EVAR groups. CONCLUSIONS: Minimally invasive treatment with the fast-track protocol and EVAR are both valid options in octogenarian patients because we obtained comparable results in terms of resumption of feeding, early ambulation, days of hospitalization, perioperative rate of mortality and morbidity.

Fast-track in abdominal aortic surgery: experience in over 1,000 patients.

BACKGROUND: Fast-track recovery programs have led to reduced patient morbidity and mortality after surgery. Minimally invasive surgery and anesthesia, with programs of early postoperative recovery are the main aspects of fast-track recovery programs. The optimization of pain control, early mobilization, and oral feeding allows for a rapid functional rehabilitation, which leads to minor morbidity and early discharge from the hospital to home. METHODS: We enrolled all nonemergent patients treated for elective abdominal aortic surgery for an aneurysm or obstructive disease from April 2000 to June 2014. The fast-track protocol was applied to all these patients. A transperitoneal aortic approach was used through a left subcostal incision and was complemented with epidural anesthesia-analgesia and a protocol of early rehabilitation. RESULTS: A total of 1,014 patients were treated for elective aortic surgery. For 980 patients (96.6%), clear liquids followed by a semisolid diet were tolerated starting on the afternoon of the day of intervention (day 0). Nine hundred eighty-seven patients (97.3%) began early ambulation on day 0, and for 81.2% of the population, regular colonic function returned within the second postoperative day. Seventeen deaths (1.7%) occurred. Nine hundred ten patients (89.7%) had no complications. The median hospital length of stay was 3 days for the entire series, and 80.4% of patients (n = 815) were discharged to their homes between the second and fifth days after surgery. CONCLUSIONS: The fast-track program can be efficiently and safely applied to aortic surgery and that this program improves surgical outcomes, allows for earlier discharge, and reduces costs.