Role of monogenic diabetes genes on beta cell function in Italian patients with newly diagnosed type 2 diabetes. The Verona Newly Diagnosed Type 2 Diabetes Study (VNDS) 13.

We tested the hypothesis that common genetic variability of beta-cell genes responsible for monogenic diabetes may affect beta cell function in type 2 diabetes mellitus (T2DM). We studied 794 drug- naïve GAD-negative patients with newly diagnosed T2DM (age: median=59 years; I.Q. range: 52-66; body mass index: 29.3 kg/m2; 26.6-32.9). Beta-cell function was assessed by state-of-art mathematical modeling of glucose/C-peptide curves during a 240'-300' frequently sampled oral glucose tolerance test, to provide the beta-cell responses to the rate of increase in glucose concentration (derivative control: DC) and to glucose concentration (proportional control: PC). Forty-two single nucleotide polymorphism (SNPs), selected to cover over 90% of common genetic variability, were genotyped in nine monogenic diabetes genes: HNF4A, GCK, HNF1A, PDX1, HNF1B, NEUROD1, KLF11, KCNJ11 and ABCC8. Allelic variants of four SNPs (rs1303722 and rs882019 of GCK, rs7310409 of HNF1A and rs5219 of KCNJ11) were significantly associated with DC of beta-cell secretion (all P < 0.036). Allelic variants of four other SNPs (rs2868094 and rs6031544 of HNF4A, and rs1801262 and rs12053195 of NEUROD1) were associated with PC of beta-cell secretion (P < 0.02). In multivariate models, GCK, HNF1A and KCNJ11 SNPs explained 2.5% of the DC variability of beta-cell secretion, whereas HNF4A and NEUROD1 SNPs explained 3.6% of the PC variability of beta-cell secretion. We conclude that common variability of monogenic diabetes genes is significantly associated with an impaired beta-cell function in patients with newly diagnosed T2DM; thereby, these genes might be targeted by specific treatments in T2DM.

Accuracy of CGM Systems During Continuous and Interval Exercise in Adults with Type 1 Diabetes.

BACKGROUND: continuous glucose monitoring systems (CGMs) play an important role in the management of T1D, but their accuracy may reduce during rapid glucose excursions. The aim of study was to assess the accuracy of recent rt-CGMs available in Italy, in subjects with T1D during 2 sessions of physical activity: moderate continuous (CON) and interval exercise (IE). METHOD: we recruited 22 patients with T1D, on CSII associated or integrated with a CGM, to which a second different sensor was applied. Data recorded by CGMs were compared with the corresponding plasma glucose (PG) values, measured every 5 minutes with the glucose analyzer. To assess the accuracy of the CGMs, we evaluated the Sensor Bias (SB), the Mean Absolute Relative Difference (MARD) and the Clarke error grid (CEG). RESULTS: a total of 2355 plasma-sensor glucose paired points were collected. Both average plasma and interstitial glucose concentrations did not significantly differ during CON and IE. During CON: 1. PG change at the end of exercise was greater than during IE (P = .034); 2. all sensors overestimated PG more than during IE, as shown by SB (P < .001) and MARD (P < .001) comparisons. Classifying the performance according to the CEG, significant differences were found between the 2 sessions in distribution of points in A and B zones. CONCLUSIONS: the exercise affects the accuracy of currently available CGMs, especially during CON, suggesting, in this circumstance, the need to maintain blood glucose in a "prudent" range, above that generally recommended. Further studies are needed to investigate additional types of activities.

Haplotypes of the genes (GCK and G6PC2) underlying the glucose/glucose-6-phosphate cycle are associated with pancreatic beta cell glucose sensitivity in patients with newly diagnosed type 2 diabetes from the VNDS study (VNDS 11).

BACKGROUND: Elevated fasting plasma glucose has been associated with increased risk for development of type 2 diabetes (T2D). The balance between glucokinase (GCK) and glucose-6-phosphate catalytic subunit 2 (G6PC2) activity are involved in glucose homeostasis through glycolytic flux, and subsequent insulin secretion. AIM: In this study, we evaluated the association between the genetic variability of G6PC2 and GCK genes and T2D-related quantitative traits. METHODS: In 794 drug-naïve, GADA-negative, newly diagnosed T2D patients (VNDS; NTC01526720) we performed: genotyping of 6 independent tag-SNPs within GCK gene and 5 tag-SNPs within G6PC2 gene; euglycaemic insulin clamp to assess insulin sensitivity; OGTT to estimate beta-cell function (derivative and proportional control; DC, PC) by mathematical modeling. Genetic association analysis has been conducted using Plink software. RESULTS: Two SNPs within GCK gene (rs882019 and rs1303722) were associated to DC in opposite way (both p < 0.004). Two G6PC2 variants (rs13387347 and rs560887) were associated to both parameters of insulin secretion (DC and PC) and to fasting C-peptide levels (all p < 0.038). Moreover, subjects carrying the A allele of rs560887 showed higher values of 2h-plasma glucose (2hPG) (p = 0.033). Haplotype analysis revealed that GCK (AACAAA) haplotype was associated to decreased fasting C-peptide levels, whereas, the most frequent haplotype of G6PC2 (GGAAG) was associated with higher fasting C-peptide levels (p = 0.001), higher PC (ß = 6.87, p = 0.022) and the lower 2hPG (p = 0.012). CONCLUSION: Our findings confirmed the role of GCK and G6PC2 in regulating the pulsatility in insulin secretion thereby influencing insulin-signaling and leading to a gradual modulation in glucose levels in Italian patients with newly diagnosed T2D.

Assessment of simple strategies for identifying undiagnosed diabetes and prediabetes in the general population.

BACKGROUND AND AIMS: The rising tide of diabetes mellitus (DM) and prediabetes (PDM) is urgently calling for strategies easily applicable to anticipate diagnosis. We assessed the effectiveness of random capillary blood glucose (RCBG), administration of a validated DM risk questionnaire, or the combination of both. MATERIALS AND METHODS: RCBG measurement and/or questionnaire administration were offered to all individuals presenting at gazebos organized during the World Diabetes Day or similar public initiatives on diabetes awareness. Subjects with suspicious DM or PDM were invited to the Diabetes Center (DC) for laboratory confirmation (fasting plasma glucose and HbA1c). RESULTS: Among 8563 individuals without known diabetes undergoing RCBG measurement, 341 (4%) had suspicious values. Diagnosis of DM was confirmed in 36 (41.9%) of the 86 subjects who came to the DC and PDM was found in 40 (46.5%). Among 3351 subjects to whom the questionnaire was administered, 480 (14.3%) had suspicious scores. Diagnosis of DM was confirmed in 40 (10.1%) of the 397 who came to the DC and PDM was found in 214 (53.9%). These 3351 subjects also had RCBG measurement and 30 out of them had both tests positive. Among them, 27 subjects came to DC and DM was diagnosed in 17 (63.0%) and PDM was found in 9 (33.3%). CONCLUSIONS: These data suggest that RCBG definitely outperforms the questionnaire to identify unknown DM and PDM. RCBG measurement, with questionnaire as an adjunctive tool, appears to be a simple, fast, and feasible opportunistic strategy in detecting undiagnosed DM and PDM.

Estimated peak systolic pulmonary artery pressure in young non-complicated patients with type 1 diabetes.

OBJECTIVE: Right ventricle and pulmonary artery pressure have always received less attention in type 1 diabetes than left ventricle. The aim of this study is to compare the right heart performance and the estimated peak systolic pulmonary artery pressure (EPSPAP) in young type 1 diabetes patients with healthy controls. PATIENTS AND METHODS: Subjects affected by type 1 diabetes without cardiovascular and respiratory diseases (n=93) and healthy controls (n=56) were evaluated with a comprehensive transthoracic echocardiography. The pulmonary peak systolic arterial pressure was calculated with an established formula based on pulmonary artery acceleration time. RESULTS: The left ventricle's function was found to be normal in all the subjects under study. The estimated peak systolic pulmonary artery pressure was significantly higher in patients with type 1 diabetes compared to the controls (38.5 ± 8.6 vs. 35.4 ± 6.7, p = 0.019). The highest value of EPSPAP was observed in smoking female patients with type 1 diabetes. Basal and mid cavity diameter of the right ventricle were higher in patients with type 1 diabetes. Factors associated with EPSPAP were sex, body mass index, mid cavity diameter and, with an inverse correlation, HDL-cholesterol. CONCLUSIONS: The present study suggests that young, uncomplicated patients with type 1 diabetes have a higher estimated peak systolic pulmonary artery pressure. Further studies are needed to define the mechanisms underlying this alteration and its clinical consequences.

Increased aortic stiffness index in patients with type 1 diabetes without cardiovascular disease compared to controls.

PURPOSE: Increased arterial stiffness is an early sign of endothelial dysfunction. Nevertheless, measures of the elastic properties of the aortic root in patients with type 1 diabetes are still lacking. The aim of this study was to compare aortic root stiffness index in type 1 diabetes and healthy controls. METHODS: Ninety-three patients with type 1 diabetes without cardiovascular diseases were recruited and compared to 33 healthy controls. Aortic root elastic properties were estimated by measuring the systolic and diastolic diameters on M-mode acquisition. RESULTS: None of the subjects showed alterations of either systolic or diastolic echocardiographic parameters. Patients with type 1 diabetes had a very low prevalence of chronic complications and their metabolic control was good. Significantly increased aortic stiffness index was found in type 1 diabetes compared to controls, and the same different pattern was found in men and women. The presence of type 1 diabetes and increased pulse pressure was significantly associated with aortic stiffness index in a multivariate linear analysis. CONCLUSION: This study strongly suggests that patients with type 1 diabetes develop aortic root stiffness in the absence of cardiovascular diseases. This alteration may be part of a more generalized arterial dysfunction in type 1 diabetes.

Heavy Physics Contributions to Neutrinoless Double Beta Decay from QCD.

Observation of neutrinoless double beta decay, a lepton number violating process that has been proposed to clarify the nature of neutrino masses, has spawned an enormous world-wide experimental effort. Relating nuclear decay rates to high-energy, beyond the standard model (BSM) physics requires detailed knowledge of nonperturbative QCD effects. Using lattice QCD, we compute the necessary matrix elements of short-range operators, which arise due to heavy BSM mediators, that contribute to this decay via the leading order π^{-}→π^{+} exchange diagrams. Utilizing our result and taking advantage of effective field theory methods will allow for model-independent calculations of the relevant two-nucleon decay, which may then be used as input for nuclear many-body calculations of the relevant experimental decays. Contributions from short-range operators may prove to be equally important to, or even more important than, those from long-range Majorana neutrino exchange.

A per-cent-level determination of the nucleon axial coupling from quantum chromodynamics.

The axial coupling of the nucleon, gA, is the strength of its coupling to the weak axial current of the standard model of particle physics, in much the same way as the electric charge is the strength of the coupling to the electromagnetic current. This axial coupling dictates the rate at which neutrons decay to protons, the strength of the attractive long-range force between nucleons and other features of nuclear physics. Precision tests of the standard model in nuclear environments require a quantitative understanding of nuclear physics that is rooted in quantum chromodynamics, a pillar of the standard model. The importance of gA makes it a benchmark quantity to determine theoretically-a difficult task because quantum chromodynamics is non-perturbative, precluding known analytical methods. Lattice quantum chromodynamics provides a rigorous, non-perturbative definition of quantum chromodynamics that can be implemented numerically. It has been estimated that a precision of two per cent would be possible by 2020 if two challenges are overcome1,2: contamination of gA from excited states must be controlled in the calculations and statistical precision must be improved markedly2-10. Here we use an unconventional method 11 inspired by the Feynman-Hellmann theorem that overcomes these challenges. We calculate a gA value of 1.271 ± 0.013, which has a precision of about one per cent.

Detecting Stealth Dark Matter Directly through Electromagnetic Polarizability.

We calculate the spin-independent scattering cross section for direct detection that results from the electromagnetic polarizability of a composite scalar "stealth baryon" dark matter candidate, arising from a dark SU(4) confining gauge theory-"stealth dark matter." In the nonrelativistic limit, electromagnetic polarizability proceeds through a dimension-7 interaction leading to a very small scattering cross section for dark matter with weak-scale masses. This represents a lower bound on the scattering cross section for composite dark matter theories with electromagnetically charged constituents. We carry out lattice calculations of the polarizability for the lightest "baryon" states in SU(3) and SU(4) gauge theories using the background field method on quenched configurations. We find the polarizabilities of SU(3) and SU(4) to be comparable (within about 50%) normalized to the stealth baryon mass, which is suggestive for extensions to larger SU(N) groups. The resulting scattering cross sections with a xenon target are shown to be potentially detectable in the dark matter mass range of about 200-700 GeV, where the lower bound is from the existing LUX constraint while the upper bound is the coherent neutrino background. Significant uncertainties in the cross section remain due to the more complicated interaction of the polarizablity operator with nuclear structure; however, the steep dependence on the dark matter mass, 1/m(B)(6), suggests the observable dark matter mass range is not appreciably modified. We briefly highlight collider searches for the mesons in the theory as well as the indirect astrophysical effects that may also provide excellent probes of stealth dark matter.

Hemothorax Management After Endovascular Treatment For Thoracic Aortic Rupture.

OBJECTIVES: The aim was to describe and analyze the management of hemothorax (HTX) and the occurrence of respiratory complications after endovascular repair of thoracic aortic rupture (TEVAR). METHODS: This was a multicenter study with retrospective analysis. Between November 2000 and December 2012, all patients with confirmed HTX due to rupture of the descending thoracic aorta treated with TEVAR were included. Respiratory function (acid base status, Pao2, Paco2, lactate, and respiratory index) was monitored throughout hospitalization. Primary endpoints were survival and post-operative respiratory complications. RESULTS: Fifty-six patients were treated. The mean age was 62 ± 21 years (range 18-92 years). Etiology included traumatic rupture (n = 23, 41%), atherosclerotic aneurysm (n = 20, 36%), Debakey type IIIa dissection (n = 8, 14%), and penetrating aortic ulcer (n = 5, 9%). The primary technical success of TEVAR was 100%. The in hospital mortality rate was 12.5% (n = 7). Hemothorax was drained in 21 (37.5%) cases. In hospital respiratory complications occurred in 23 (41%) patients who required a longer intensive care unit stay (days 2.3 ± 0.7 vs. 1.9 ± 0.8, p = .017), and hospitalization (26 ± 17 vs. 19 ± 17, p = .021). Those who developed post-operative respiratory complications had lower pre-operative PO2 values (mmHg, 80 ± 24 vs. 91 ± 21, p = .012). Respiratory complications and in hospital mortality did not differ among aortic pathologies (p = .269 and p = 1.0, respectively), nor did in hospital mortality differ between patients with and without respiratory complications (13% vs. 12%; p = .990). CONCLUSIONS: Thoracic aortic rupture still has a high mortality rate. Respiratory complications have not been eliminated by endovascular repair. HTX evacuation may have had a positive influence on the survival in these patients. Although traumatic and degenerative ruptures are two significantly different scenarios, survival and respiratory outcomes were similar and were not affected by the underlying aortic disease.

The VO(2)-on kinetics in constant load exercise sub-anaerobic threshold reflects endothelial function and dysfunction in muscle microcirculation.

To propose a test to evaluate endothelial function, based on VO(2) on-transition kinetics in sub-anaerobic threshold (AT) constant load exercise, we tested healthy subjects and patients with ischemic-hypertensive cardiopathy by two cardiopulmonary tests on a cycle ergometer endowed with an electric motor to overcome initial inertia: a pre-test and, after at least 24 h, one 6 min constant load exercise at 90 % AT. We measured net phase 3 VO(2)-on kinetics and, by phase 2 time constant (tau), valued endothelial dysfunction. We found shorter tau in repeated tests, shorter time between first and second test, by persisting endothelium-dependent arteriolar vasodilatation and/or several other mechanisms. Reducing load to 80 % and 90 % AT did not produce significant changes in tau of healthy volunteers, while in heart patients an AT load of 70 %, compared to 80 % AT, shortened tau (delta=4.38+/-1.65 s, p=0.013). In heart patients, no correlation was found between NYHA class, ejection fraction (EF), and the two variables derived from incremental cycle cardio-pulmonary exercise, as well as between EF and tau; while NYHA class groups were well correlated with tau duration (r=0.92, p=0.0001). Doxazosin and tadalafil also significantly reduced tau. In conclusion, the O(2) consumption kinetics during the on-transition of constant load exercise below the anaerobic threshold are highly sensitive to endothelial function in muscular microcirculation, and constitute a marker for the evaluation of endothelial dysfunction.

An anatomical review of spinal cord blood supply.

Knowledge of the spinal cord (SC) vascular supply is important in patients undergoing procedures that involve the thoracic and thoracoabdominal aorta. However, the SC vasculature has a complex anatomy, and teaching is often based only on anatomical sketches with highly variable accuracy; historically, this has required a "leap of faith" on the part of aortic surgeons. Fortunately, this "leap of faith" is no longer necessary given recent breakthroughs in imaging technologies and postprocessing software. Imaging methods have expanded the non-invasive diagnostic ability to determine a patient's SC vascular pattern, particularly in detecting the presence and location of the artery of Adamkiewicz. CT is the imaging modality of choice for most patients with thoracic and thoracoabdominal aortic disease, proving especially useful in the determination of feasibility and planning of endovascular treatment. Thus the data set required for analysis of SC vascular anatomy is usually already available. We have concentrated our efforts on CT angiography, which offers particularly good imaging capabilities with state-of-the-art multidetector scanners. Multidetector row helical CT provides examinations of an extensive range in the craniocaudal direction with thin collimation in a short time interval, giving excellent temporal and spatial resolution. This paper provides examples of the SC vasculature imaging quality that can be obtained with 64 row scanners and appropriate postprocessing. Knowledge of the principal anatomical features of the SC blood supply of individual patients undergoing open or endovascular thoracoabdominal procedures has several potential benefits. For open surgery, analysis of the SC vasculature could tell us the aortic region that feeds the Adamkiewicz artery and thus needs to be reimplanted. For endovascular procedures, we can determine whether the stent-graft will cover the Adamkiewicz artery, thus avoiding unnecessary coverage. CT data can also be used to stratify risk of SC ischemia and guide the selective use of spinal cord injury prevention strategies.

Open treatment of extent IV thoracoabdominal aortic aneurysms.

AIM: Extent IV thoracoabdominal aortic aneurysm (TAAA) open repair is considered relatively safer to repair than other extents of TAAA in terms of both perioperative mortality and spinal cord ischemia. Our purpose is to report our experience and to perform a literature review regarding extent IV TAAA open repair in order to provide an updated benchmark for comparison with any other alternative strategy in this aortic segment. METHODS: From 1993 to 2015 we performed 736 open repairs for TAAA (177 extent I, 196 extent II, 141 extent III, 222 extent IV). In extent IV group there were 164 men (73.9%) and the mean age was 67.4±9.3 years (range 32-84). The aneurysm etiology was degenerative in 198 patients (95.6%). Twelve patients (5.4%) underwent emergent operation. Totally abdominal approach was used in 22.0% of the cases. Until 2006 left heart bypass (LHBP) and cerebrospinal fluid drainage (CSFD) were almost never performed during extent IV repair. Since 2006 we changed our approach with a more aggressive use of LHBP (22.9%) and CSFD (43.4%) in 83 consecutive extent IV. Renal arteries perfusion was performed with 4 °C Ringer's solution until 2009 and with 4 °C Custodiol solution since September 2009 to date. Literature search was performed on several databases (PubMed, BioMedCentral, Embase, and the Cochrane Central Register of clinical trials). Research was updated on March 1th 2015. RESULTS: Perioperative mortality in our overall group of TAAA and in the extents IV was 10.7% and 4.9%, respectively (P=0.01); spinal cord ischemia rate 11.4% and 2.7%, respectively (P=0.0001). In the extents IV treated between 2006 and 2015 we observed a further trend of outcomes improvement with a rate of perioperative mortality and spinal cord ischemia of 1.2%, and 2.4%, respectively. Database searches yielded a total of 767 articles. Excluding non-pertinent titles or abstracts, we retrieved in complete form and assessed 27 studies according to the selection criteria. Nine studies were further excluded because of our prespecified exclusion criteria. The final 18 manuscripts included a total of 2098 patients. In this group median mortality rate was 4.8% (interquartile range 3-6) and the mean incidence of spinal cord ischemia was 1.56±1.54%. CONCLUSION: Perioperative outcomes after extent IV TAAA open repair were significantly better compared to our overall TAAA series. A more aggressive use of CSFD, LHBP and renal perfusion with Custodiol solution allowed a further trend of outcomes improvement in our series of extent IV TAAA open repair. Literature analysis confirmed during extent IV open repair very satisfactory perioperative outcomes with rates of mortality and spinal cord ischemia dropped to under 5% and 2%, respectively.

Redo surgery in ascending aorta and aortic arch.

AIM: Reinterventions following previous ascending aorta and aortic arch repair are uncommon, but technically challenging and often burdened with high morbidity and mortality. The aim of this article is to present a single-center experience in the treatment of this complex pathology, using different surgical approaches. METHODS: Between 1999 and 2014, 17 patients (14 males, mean age 73±16 years) underwent ascending aorta and aortic arch redo surgery at our Department. A prospectively maintained database including thoracic aortic procedures was reviewed retrospectively to collect data on redo patients. RESULTS: In 13 cases the index procedure was an endovascular or hybrid procedure on the aortic arch performed at our Department, for an in-house reintervention rate of 6.9% (13/188). In 10 cases the cause of reintervention was stent-graft distal migration, treated by means of endovascular relining in all cases, associated with adjunctive supra-aortic trunks debranching via sternotomy in 6 cases. In 5 cases the cause of reintervention was retrograde ascending aortic dissection, in 1 case ascending aortic anastomotic pseudoaneurysm following supra-aortic trunk debranching, and in 1 case mediastinitis following implantation of an endovascular plug previously used to treat an ascending aortic pseudoaneurysm. In these last 7 cases, all patients were treated by means of ascending and arch surgical replacement under deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP). No 30-day mortality was observed. Major perioperative morbidity included 1 paraplegia, 1 minor stroke, 1 bleeding requiring reintervention, and 3 cases of respiratory failure requiring prolonged intubation (2) or tracheostomy (1). CONCLUSION: In our experience, incidence of serious complications requiring reinterventions following ascending aorta or aortic arch repair is not negligible. Redo surgery in ascending aorta and aortic arch is feasible in high-volume and experienced centers, as it often requires hybrid repair via midline sternotomy, or surgical replacement under DHCA and ACP.

Technical features of the INCRAFT™ AAA Stent Graft System.

The INCRAFT® AAA Stent Graft System is the advanced endovascular aneurysm repair (EVAR) technology for the treatment of infrarenal abdominal aneurysms. This new system is designed to address the unmet needs of current endografts by combining unique features and adding new refinements compared to existing endografts delivered through a flexible 14-Fr ultra-low system. The INCRAFT® AAA Stent Graft System introduces innovative features without deviating from proven stent-graft design principles. It is a three-piece modular system, made of low porosity polyester and segmented nitinol stents. However, the introduction of cap-free delivery and partial proximal repositioning enhances the ability of the device to better match individual aortoiliac anatomy with a high deliverability and placement accuracy in a easy to use system. Moreover, the INCRAFT® System allows a "customization" of the implant during the procedure with bilateral in-situ length adjustment features. The present data from the ongoing clinical trials confirm excellent results with this system, but postmarket studies will be necessary to verify the effectiveness of this system in the real-world setting.

Open repair for juxtarenal aortic aneurysms.

Abdominal aortic aneurysms (AAAs) are classified as juxtarenal if their proximal extent is next to the origin of the renal arteries but does not involve them. An AAA is suprarenal if it extends above at least one renal artery and ends below the celiac axis. Juxtarenal AAAs need inter-renal or suprarenal clamping, with the aortic reconstruction usually made at the infrarenal level. Aneurysms requiring suprarenal clamping, often supraceliac, and the reconstruction (direct attachment or bypass) of at least one renal artery, are often defined as suprarenal AAAs. Endovascular aortic repair (EVAR) is feasible in most of cases of infrarenal AAAs and has been shown to be as effective as open repair (OR) in reducing aneurysm-related mortality and perioperative mortality with shorter length of stay. However, the feasibility of standard EVAR with an on-label use of commercially available devices is limited in the juxtarenal aorta. In our series, approximately, 20% to 30% of patients with an AAA are considered not eligible for standard EVAR owing to their anatomy, and in the most of the cases are patients with juxtarenal AAAs. Fenestrated and branched endografts and newer "off the shelf" techniques (such as chimney, periscope, sandwich) have been recently described, all with the purpose of widening the therapeutic range of EVAR to the treatment of aneurysms with involvement of renal and visceral arteries. However, safety, efficacy, long-term results, and cost-effectiveness of these expensive techniques have still to be carefully assessed. For these reasons, the OR is currently still considered the gold standard for treatment of juxtarenal AAAs, reserving endovascular strategies mainly for high-risk patients having comorbidities or other contraindications for conventional repair. If compared to open repair of infrarenal AAAs, juxtarenal AAA OR is technically more complex and might require specific organ-protection strategies in order to minimize ischemia-reperfusion injury to kidneys and visceral organs. Because of the complexity of the surgical procedure and of the multiple clinical problems, an optimal operative strategy for the treatment of juxtarenal AAAs has not been established yet. The choice of the surgical access, clamping level, methods of organ protection and their impact on renal, respiratiry, cardiac and gastrointestinal morbidity are still debated issues.

Open repair for infrarenal AAA: technical aspects.

The aim of this study was to describe the technique and report our single center experience of abdominal aortic aneurysm (AAA) open surgical repair over the last 17 years. From 1993 to 2010, a total of 4347 open surgical procedures for repair of AAA were performed in our center. The details of 3857 (88.7%) patients undergoing infrarenal AAA open repair were analyzed; mean age at the time of surgery was 71.8 years ranging from 58 to 89 years. Among all repairs, 23.7% (914) were performed in women and 24.3% (937) in octogenarians; 3587 (93.0%) procedures were performed for degenerative aneurysms, 146 (3.8%) for inflammatory aneurysms, 100 (2.6%) for dissecting aneurysms, and 19 (0.5%) for other pattern of disease. In 162 cases (4.2%) surgery was performed for ruptured aneurysm. In most cases (N.=2596; 67.3%) infrarenal AAA open repair was performed by means of aorto-aortic bypass using a tube graft. A total of 1261 patients were treated using a bifurcated graft: 417 (33.1%) aorto-iliac bypasses, 530 (42.0%) aorto-femoral bypasses and 314 (24.9%) aorto-iliac-femoral bypasses were performed. In elective aorto-aortic bypass, mean aortic clamping time was 21.3+6.7 minutes. The average duration of the procedure was 126+84 minutes (range, 42-410 minutes). Mean intraoperative bleeding was 803.4+422.7 mL (range 250-3,100). Overall intraoperative mortality was 0.2%. Intraoperative mesenteric ischemia was observed in 3% of cases, all treated with inferior mesenteric artery reimplantation. The rate of intraoperative lower limbs ischemia was 2.2%. One intraoperative acute type A aortic dissection occurred. The overall 30-day mortality was 0.6%. Permanent renal function impairment occurred in 4.3% of cases. The rate of pulmonary complications was 9.8%. Other complications were myocardial infarction, congestive heart failure, late ischemic colitis, late leg ischemia, wound infection, urinary tract infection, and sepsis. Although endovascular techniques have emerged as a less invasive alternative to open repair, short- and long-term outcomes associated to the surgery of infrarenal AAAs remain satisfactory for a large range of patients.

Analysis of stroke after TEVAR involving the aortic arch.

OBJECTIVE: To analyse the incidence of stroke after thoracic endovascular aortic repair (TEVAR) for aortic arch disease. METHODS: In the last decade, 393 patients received TEVAR at our Institution; in 143 cases the aortic arch was involved (32 zones '0', 35 zones '1' and 76 zone '2'). The left subclavian artery (LSA) was revascularised selectively in 75 cases; the proximal LSA was ligated or occluded with a plug in 55 cases before endograft (EG) deployment. RESULTS: Initial clinical success, perioperative mortality, spinal cord ischaemia and stroke in TEVAR patients with or without arch involvement were, respectively, 86.7% vs. 94.4%, 4.2% vs. 2.4%, 2.1% vs. 3.6% and 2.8% vs. 1.2%. The stroke rate was 9.4% (P < 0.02) in 'zone 0', 0% in 'zone 1' and 1.3% in 'zone 2' with scans showing severe atheroma and/or thrombus in all cases. Stroke was observed in patients with 2.6% or without 2.9% LSA revascularisation; however, it was never observed in patients in whom the LSA was occluded before EG deployment and in 4.5% of patients in whom it was patent at the time of EG deployment. CONCLUSIONS: Stroke after TEVAR is not infrequent especially when the arch is involved. Careful patient selection together with a strategy to reduce embolisation such as occlusion of supra-aortic trunks before EG deployment may play a beneficial role.