COVID-19 induced aorto duodenal fistula following evar in the so called "negative" patient.

OBJECTIVES: Since October 2019, SARS-CoV-2 pandemic represents a challenge for the international healthcare system and for the treatment and survival of patients. We normally focus on symptomatic patients, and symptoms can range from the respiratory to the gastrointestinal system. In addition, we consider patients without fever and respiratory symptoms, with both a negative RT nasopharyngeal swab and lung CT, as a "Covid-19 negative patient." In this article, we present a so called Covid-19 "negative" patient, with an unsuspected vascular clinical onset of the viral infection. METHODS: An 80 y.o. man, who previously underwent endovascular aortic repair for an infrarenal abdominal aortic aneurysm, presented to our department with an atypical presentation of an aorto-enteric fistula during the pandemic. While in hospital, weekly nasopharyngeal swab tests were always negative for SARS-CoV-2. However, the absence of aortic endograft complications, the gross anatomy of duodenal ischemic injury, and the recent history of the patient who lived the last months in Bergamo, the Italian city with the highest number of COVID-19 deaths, lead the senior Author to suspect an occult SARS-CoV-2 infection. The patient underwent to resection of the fourth portion of the duodenum and the first jejunal loop, with subsequent duodenum-jejunal latero-lateral anastomosis and the direct suture of the aortic wall. The intestinal specimen was investigated as suspected SARS-CoV-2 bowel infection by the means of immune-histochemistry (IHC). An ileum sample obtained in the pre-COVID-19 era was used as a control tissue. RESULTS: The histological analysis of the bowel revealed sustained wall ischemia and liponecrosis of the duodenal wall, with intramural blood vessels thrombosis. Blood vessel endotheliitis and neo-angiogenesis were also observed. Finally, the IHC was strongly positive for SARS-CoV-2 RNA and for HLA-G presence, with a particular concentration both in blood vessels and in the intestinal villi. The control tissue sample was not positive for both SARS-CoV-2 and HLA-G. CONCLUSIONS: Coronavirus pandemic continues to be an international challenge and more studies and trials must be done to learn its pathogenesis and its complications. As for thromboembolic events caused by SARS-COV-2, vascular surgeons are involved in treatment and prevention of the complications of this syndrome and must be ready with general surgeons to investigate atypical and particular cases such as the one discussed in this article.

SARS-COV-2 Pandemic for Patients with Chronic Obstructive Peripheral Arterial Disease: Impact of Interruption to Access According to Gender in a Single Center Experience.

BACKGROUND: This retrospective study aims to evaluate the impact of interrupted services for peripheral arterial disease (PAD) patients and especially women in a single north-eastern Italian center over a period of 3 months prior to the pandemic, during the first (2020) and the second (2021) wave of contagion in northern Italy. METHODS: Patients with PAD at Rutherford stages 3 to 6 that required revascularization between March 2019 and March 2021 were classified into 3 groups, according to the period of treatment: the prepandemic period, the pandemic-20 period, and the pandemic-21 period. RESULTS: Twenty-eight patients were treated in the prepandemic period, 21 in the pandemic-20 period, and 39 in the pandemic-21 period. It was observed that in the both pandemic periods patients presented with more severe stages of limb ischemia, Rutherford 5 and 6 stages. During pandemic-20, patients underwent mostly open surgery, followed by hybrid procedures. No differences were observed between the 3 groups in major amputations, length of hospital stay, type of discharge, limb salvage and mortality. During long-term follow-up, limb salvage appeared to be significantly better in the pandemic-21 group. The gender analysis revealed a significantly reduced female proportion of overall treated patients in 2020 and 2021 compared to the prepandemic period. In the pandemic-20 this difference appears even more evident since treatments on females represented 19% of the total while in the same period of the previous year the male/female percentage was comparable (54% vs. 46%). The women admitted presented higher stages of disease and tended to have a longer hospital stay than men. At 12-month follow-up, limb salvage was similar between the 2 genders but was slightly worse in women. CONCLUSIONS: An efficient reorganization of the vascular surgery services during the pandemic period guaranteed the quality and standard of treatment offered in the preceding periods. Among patients suffering from PAD the impact of the pandemic was greater for the female gender. It is therefore important that in addition to a reorganization of hospital services to provide adequate care for patients with ACOP in the pandemic period, greater information and awareness of women.

Superficial Femoral Artery Access for Infrainguinal Antegrade Endovascular Interventions in the Hostile Groin: A Prospective Randomized Study.

BACKGROUND: In a hostile groin, it may be difficult to perform antegrade endovascular procedures at the lower extremities using the ipsilateral common femoral artery as vascular access; therefore, the use of the ipsilateral superficial femoral artery (SFA) could be a useful alternative. In this study, we evaluated the feasibility and safety of ultrasound-guided SFA puncture versus traditional SFA cutdown to achieve arterial access. METHODS: This prospective observational randomized study examined patients with symptomatic peripheral arterial disease who required endovascular interventions at the lower extremities. A hostile groin was defined as a high femoral bifurcation, obesity, and surgical scarring due to previous surgical interventions. A 6-Fr sheath (12 cm long; ULTIMUM EV INTRODUCER; Abbott, Plymouth, MN, USA) was used in all procedures. In the percutaneous group, the puncture was performed under ultrasound guidance and hemostasis was performed using a percutaneous closure device (PCD) (ANGIO-SEAL VIP 6-Fr; Terumo Medical Corporation, Somerset, NJ, USA). The primary end points were technical success and perioperative complications. The secondary end points were the time required for the management of vascular access and the type of anesthesia administered. RESULTS: Between 2020 and 2021, 107 patients who underwent antegrade revascularization were enrolled. SFA was achieved in 50 cases by the femoral cutdown technique (c-group) and in 57 cases by percutaneous ultrasound-guided puncture (p-group). In the c-group, the time from incision to sheath introduction and the time of suturing the artery and wound closure was 35 ± 8 min. In the p-group, the time from skin puncture and sheath placement plus that from the sheath removal and hole closure with the PCD was 6 ± 3 min. For the c-group versus p-group, the following variables were as follows: high bifurcation, 10 vs. 6 cases (P = 0.2); severe obesity, 33 vs. 40 cases (P = 0.46); and previous surgical groin interventions, 7 vs. 9 cases (P = 0.53), respectively. The technical success rates were 100% vs. 96.49% for the c-group versus p-group, respectively (P = 0.63). Two percutaneous puncture failures were managed using the cutdown technique. In the p-group, 2 postprocedural hematomas were recorded, with only one requiring surgical treatment and 2 with SFA occlusion to intravascular cap hemostatic dislocation, which were subjected to surgical revision. A total of 3 percutaneous procedures in the p-group required surgical revision versus none in the c-group (P = 0.1). Within 3 months, complications consisted of 6 cases of surgical wound complications in the c-group versus none in the p-group (P = 0.009). All procedures in the p-group versus 72% of patients in the c-group were managed with local anesthesia (P < 0.0001). CONCLUSIONS: The femoral cutdown technique seems to be a safe and successful approach for achieving vascular access in cases of hostile groin. Ultrasound-guided puncture and PCD make SFA puncture a successful and safe alternative with an acceptable complications rate. Moreover, it reduces the time required to manage vascular access and can be performed mainly under local anesthesia.

Segmental saphenous ablation for chronic venous disease treatment.

BACKGROUND: Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno-femoral junction ablation. METHODS: This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA.Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction. RESULTS: At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2-10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06-17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction. CONCLUSION: Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

The Effects of Thermal Water Physical Exercise in Patients with Lower Limb Chronic Venous Insufficiency Monitored by Bioimpedance Analysis.

BACKGROUND: Lower limb chronic venous diseases (CVD) lead to possible edema. The aim of the present investigation was to study the effect of thermal aquatic standardize exercise on lower limb edema control in CVD patients assessed by bioimpedance analysis (BIA). METHODS: Seventeen patients (34 legs) affected by CVD clinical class CEAP C3, 4c, Ep, As, Pr were included. All the cohort performed a standardized exercise protocol in thermal water environment for a total of five sessions. BIA, leg volume, and heart rate at rest were measured. RESULTS: After the five exercise sessions, BIA showed a significant percentage of extracellular water (ECW) reduction from 42.1 ± 5.8 to 41.24 ± 5.5%; p < 0.001. Moreover, an improvement of resistance (p < 0.0009) and reactance (p < 0.009) was assessed. At the same time, the leg volume reduction rate was 15.7%, p <0.0001. A moderate-strong correlation was found between % ECW and leg volume variation (R = 0.59, p < 0.01). Finally, a significant HR at rest reduction was recorded, p < 0.0001. CONCLUSION: The investigated exercise protocol significantly affects the lower limb volume, and BIA parameters related to the tissue drainage improvement. The correlation founded between the ECW rate and volume variations suggest the possible use of BIA as a biomarker for monitoring the treatments aimed to reduce edema in CVD.