Appropriateness of Duplex ultrasound assessment on venous system of the legs: a two-month preliminary analysis.

AIM: The goal of this study is to evaluate the appropriateness to prescribe venous ultrasound of lower limbs. MATERIAL OF STUDY: Over a two months period, 1005 Duplex scans were performed by our Vascular Surgery Unit; out of the total, 225 exams were conducted on venous system of lower limbs. We retrospectively analyzed appropriateness of prescription (according to Lombardy District indications), urgency of prescription, time-lapse between application for the exams and its execution, positive or negative results, National Health System's sustained cost. RESULTS: During the above mentioned period, 87,5% of the exams were conducted as normal screening with no urgency characteristics, 61 exams (27%) were combined with arterial duplex of the same district. General Practitioners' requests accounted for 76,8% while only 9,7% were from vascular surgeons. Following indications of appropriateness, 117 exams (52%) were judged as appropriate. Combining appropriateness and result (χ2 test) we found that if the indication was inappropriate the negative result rate was 90,75%; in the group of exams prescribed with an urgent request the rate of appropriateness raised to 60,7% of whose 94.1% were pathologically positive. DISCUSSION: There is no evidence in Literature about appropriateness of prescription of Duplex ultrasound for vascular districts. While Lombardy District recently published guidelines for prescription, neither vascular surgeon societies nor National Health Service ever provided any indication. CONCLUSION: Nowadays there is increasing demand for appropriateness in healthcare. This study delivered such significant data to make it a pivotal study for an extended analysis during 2016. KEY WORDS: Appropriateness, Vascular Duplex Ultrasound, Venous System.

Varicose veins: new trends in treatment in a Vascular Surgery Unit.

AIM: Less invasive techniques such as foam sclerotherapy, endovenous laser or radiofrequency ablation have recently been introduced as a valid alternative to surgery for the treatment of varicose veins (VVs). We retrospectively reviewed our experience in the treatment of VVs with particular attention to how our therapeutic approach has changed over the last years. MATERIAL OF STUDY: Data of all patients consecutively treated from September 1st 2013 to July 31st 2015 for both primitive and recurrent VVs were retrospectively collected and analyzed. Statistical analysis was performed using the software JMP 5.1.2 (SAS Institute). RESULTS: A total of 409 legs in 378 patients were treated. The percentage of stripping of the great saphenous veins (GSV) for primary VVs has decreased over the years (67% in 2013 vs 15.2% in 2015), differently from what happened to the percentage of RFA of the GSV (14.3% vs. 31.5% respectively in 2013 and in 2015) and to the percentage of legs treated with the A.S.V.A.L. technique (8.7% vs. 31.5% respectively in 2013 and in 2015). Likewise, in 2013 most procedures were performed using spinal anesthesia (77.5%), while in 2015 the most used anesthetic techniques were both the local anesthesia and the local anesthesia with conscious sedation (35.9% and 29.3% respectively). Postoperative course was uneventful in all cases but seven (1.7%). At follow-up (median 16.9 months, IQR 7.5-22.6 months), neither major adverse events nor deaths were recorded. CONCLUSIONS: During the years of our experience, we observed a trend towards a less invasive approach for the treatment of VVs, with safe and effective results. KEY WORDS: Ablation Radiofrequency, Stripping, Varicose veins.

A 16-year experience of carotid artery stenting for carotid artery stenosis.

AIM: We report our experience of carotid artery stenting (CAS) for the endovascular treatment of significant carotid stenosis over 16 years. MATERIALS AND METHODS: Data of all consecutive patients who came for a significant carotid artery stenosis from January 1st 1999 to August 31st 2015 were retrospectively collected and analyzed. Primary outcomes were the occurrence of death and major cerebrovascular events (MCE) both at 30-day and at long-term. RESULTS: In our experience CAS was a safe and effective technique, with acceptable mortality and neurological complication rates, both at 30 days and in the long term. KEY WORDS: Carotid stenting, Carotid stenosis, Long-term follow-up.

Tips About the Cordis INCRAFT Endograft.

BACKGROUND: Recently, the new Cordis INCRAFT abdominal aortic aneurysm (AAA) Stent-Graft System ultra low-profile device has been introduced in the clinical practice of endovascular aortic repair (EVAR) for the treatment of infrarenal AAAs (iAAAs). In our operative unit, it has been used since November 2014. We report our initial experience with the use of this novel device. We further discuss some technical aspects about the use of the endograft. METHODS: Data of all patients undergoing elective EVAR in our Division of Vascular Surgery using the Cordis INCRAFT AAA Stent-Graft System from November 2014 till now were retrospectively collected in a database and outcomes reviewed. Follow-up data were analyzed to evaluate primary success, survival, complications, and device-related events. Statistical analysis was performed using JMP(®) 5.1.2 (SAS Institute Inc., Cary, NC). Continuous variables are reported as mean ± standard deviation, and categorical variables are presented as n (%). RESULTS: From November 2014 till now in our institution, a total of 10 patients (7 male; mean age, 76.3 years old; range, 65-87 years) underwent elective exclusion of an iAAA with a challenge iliac anatomy (minimum access vessel, 6.7 mm) using Cordis INCRAFT endoprosthesis. There were 9 AAA and a left common iliac artery aneurysm 50 mm in diameter, involving the internal iliac artery. Primary success was achieved in 90% as 1 patient presented an immediate type Ia endoleak which was resolved by the placement of a proximal aortic cuff. There was 1 intraoperative acute leg ischemia requiring a left popliteal Fogarty thrombectomy. Three patients (30%) presented a postimplantation syndrome. No other complications occurred neither during in-hospital stay (mean, 3.4 days; range, 2-4 days) nor during follow-up. CONCLUSIONS: In our experience, the Cordis INCRAFT AAA System was a safe and effective device. Our reflections about technical aspects of the use of this device will probably find their answer when further studies will report shared experiences and results about using this type of endograft.

New technologies in vascular surgery: San Donato's experience in the last decades.

The Department of Vascular Surgery I at IRCCS Policlinico San Donato has been part of the Cardiovascular Center "Edmondo Malan" since the end of the 1980s. Surgical activity of the Department has always been designed to prevent and treat vascular diseases such as aneurysms of the thoracic and abdominal aorta and peripheral vessels, carotid artery stenosis, peripheral arterial disease, and chronic venous insufficiency. Excellent results have been achieved with the endovascular treatment of both symptomatic and asymptomatic carotid artery stenosis also by using innovative devices. Another point of interest regards the endovascular treatment of more complex thoraco-abdominal aortic aneurysms. We report our experience in the last decades.

Early experience with Ovation endograft system in abdominal aortic disease.

OBJECTIVE: We describe our initial experience with the use of the TriVascular Ovation endograft system for the treatment of abdominal aortic aneurysms (AAA). METHODS: We retrospectively reviewed data from patients treated for AAA using the Ovation endograft at two institutions from January 2011 to September 2012. Main outcomes included primary success, survival, complications, and device-related events. The mean follow-up period was 10 months (range 1-22 months). RESULTS: Thirty-seven patients (male: 95%, mean age: 76 yr) were treated for AAA (mean diameter: 54 mm) with the Ovation endograft. Local or regional anesthesia was used in 86.5% of cases. Percutaneous access was utilized in 73% of cases. Primary success was 89.2% (33/37). Four adjunctive procedures were required including two distal extensions (type 1b endoleak and iliac limb disconnection resulting in type III endoleak) and two bypass surgeries (limb graft occlusion and gate cannulation failure). No deaths or major complications were reported during the procedure or in follow-up. No type I, III, or IV endoleak, AAA enlargement, AAA rupture, stent fracture, migration, or endovascular or surgical reintervention were reported during the follow-up period. Type II endoleak was observed in two patients. Asymptomatic narrowing of both iliac limbs was observed in one patient at 6 months. CONCLUSIONS: Our initial experience with the Ovation endograft demonstrated encouraging results in patients with AAA.

Hybrid endovascular and surgical approach for mycotic pseudoaneurysms of the extracranial internal carotid artery.

OBJECTIVES: Mycotic pseudoaneurysms of the extracranial internal carotid artery are rare, and their management often represents a challenge, but treatment is necessary due to the high risk of rupture and distal brain embolization. Systemic antibiotics associated with open surgical excision of the infected tissues and carotid reconstruction using autologous grafts are the treatment of choice. The use of endovascular techniques still remains controversial in infective fields; however, it can be an attractive alternative in high-risk patients or more often as a "temporary" solution to achieve immediate bleeding control for a safe surgical reconstruction. METHODS: We discuss the unusual case of an extracranial right internal carotid artery mycotic pseudoaneurysm following methicillin-resistant Staphylococcus aureus infection, in a patient with poor general conditions. RESULTS AND CONCLUSION: The lesion was successfully treated using a hybrid endovascular and surgical procedure.

Straight aortic endograft in abdominal aortic disease.

BACKGROUND: We describe our 8-year experience with the use of endovascular techniques (ET) for the treatment of abdominal aortic aneurysms (AAA) through a straight endograft. METHODS: We retrospectively reviewed data of all patients who were treated for AAA using ET in two centres from 1998 to 2012 and who received a single straight endograft (group A) or a double straight tube (group B). Outcomes were analyzed to assess survival, absence of endoleak and absence of reintervention for both groups. Log-rank and Chi-Square were used as appropriate to make comparison between the two groups. P values < .05 were considered statistically significant. RESULTS: Fifty-three patients from 1998 to May 2012 were treated for AAA using a straight endograft. In 28 cases (52.8%) a single aortic straight tube was used (Group A), while in the remaining cases a "double trombone technique" was used (Group B). CONCLUSIONS: In our experience the endovascular repair of AAA using straight aortic endografts was a safe and effective technique. Reintervention and endoleaks were slightly more frequent in patients who had received a single endograft compared to patients who were treated using the "trombone technique".

Long-term results of carotid artery stenting in patients 80 years and older.

INTRODUCTION: We report our experience about carotid artery stenting (CAS) in patients 80 years and older. MATERIALS AND METHODS: Out of 582 patients who underwent CAS at our institution from January 1999 to June 2010, 102 patients (group A) were 80 years or older. The clinical data of these patients were retrospectively reviewed, outcomes analyzed, and compared with those of younger patients who underwent CAS during the same period (group B). RESULTS: Outcomes of group B were similar to those of group A, both at 30 days and at long term. Male gender, symptoms, and not using an embolic protection device were related to long-term complications in both groups. Occurrence of bradycardia/asystole during CAS was a risk factor for long-term myocardial infarction for group A only. CONCLUSIONS: CAS can be safely performed in patients 80 years or older, with results that compare favorably to those of younger patients.

Ruptured hemiarch and descending thoracic aorta aneurysm: hybrid treatment.

Ruptured aortic arch aneurysm is a life threatening disease. Surgical repair has an high perioperative mortality rate and totally endovascular treatment is a challenge. Hybrid repair has been proposed as a valuable approach. We report the case of a patient with a contained rupture of aortic arch aneurysm. We treated him with a debranching of supraortic vessels with carotid-carotid and carotid-subclavian bypass and deployment of two enodgrafts in two different times. We consider hybrid treatment for arch and hemiarch a feasible option for aortic arch aneurysms in non emergent and in an emergency setting with an improvement in perioperative morbidity and mortality.

Delayed endovascular treatment of descending aorta stent graft collapse in a patient treated for post- traumatic aortic rupture: a case report.

BACKGROUND: We report a case of delayed endovascular correction of graft collapse occurred after emergent Thoracic Endovascular Aortic Repair (TEVAR) for traumatic aortic isthmus rupture. CASE PRESENTATION: In 7th post-operative day after emergent TEVAR for traumatic aortic isthmus rupture (Gore TAG® 28-150), a partial collapse of the endoprosthesis at the descending tract occurred, with no signs of visceral ischemia. Considering patient's clinical conditions, the graft collapse wasn't treated at that time. When general conditions allowed reintervention, the patient refused any new treatment, so he was discharged.Four months later the patient complained of severe gluteal and sural claudication, erectile disfunction and abdominal angina; endovascular correction was performed. At 18 months the graft was still patent. DISCUSSION AND CONCLUSION: Graft collapse after TEVAR is a rare event, which should be detected and treated as soon as possible. Delayed correction of this complication can be lethal due to the risk of visceral ischemia and limbs loss.