Guidelines on prevention, diagnosis and treatment of thoracic and thoracoabdominal aortic pathology: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The aim of these Guidelines was to refresh and enhance the earlier 2015 Italian Guidelines regarding Thoracic and Thoracic - Abdominal Aortic Disease, aligning them with the National Guidelines System (SNLG) to assist all healthcare professionals in adopting the most appropriate treatment approach for this condition. The update utilized the GRADE-SIGN version methodology, adhering to the AGREE checklist for quality reporting. The initial step involved crafting clinical questions in the PICO (Population, Intervention, Comparison, Outcome) format to base the Recommendations on. Following this, systematic literature reviews were conducted for each PICO question or for related clusters of questions, leading to article selection and evaluation of their methodological quality via qualitative checklists. Subsequently, a Considered Judgment form was completed for each clinical question, assessing the overall evidence to facilitate the conversion from evidence level to recommendation strength and direction. These guidelines outline the best practices for managing thoracic-abdominal aortic disease, with a focus on screening and monitoring. They explore medical treatments and criteria for surgical intervention, including a thorough preoperative analysis of the patient's history and an assessment of surgical risks. Following the determination of surgical necessity, the guidelines compare traditional open surgery with endovascular procedures, paying particular attention to define new recommendations where there were not. Systematic literature reviews were executed for each PICO question. Considered judgments were made through evaluating the evidence level, and the recommendations, direction and strength. The document concludes by outlining protocols for both immediate and prolonged postoperative care. Recent literature has not only validated and refined previous recommendations but also introduced new ones on emerging topics

Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures

Objective: To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices. Methods: A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques. Results: Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 – 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 – 12.1; p =.026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 – 9.6; p =.019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 – 20.7; p =.001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 – 9.0; p =.013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 – 13.8; p =.037), and aortic arch procedure (OR 7.3, 95% CI 1.7 – 31.1; p =.007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p <.001). Conclusion: AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure

Editor's Choice – European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Diseases of the Mesenteric and Renal Arteries and Veins

Publisher Copyright: © 2025 The AuthorsObjective: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with diseases of the mesenteric and renal arteries and veins, in succession to the first 2017 guidelines, with the aim of assisting physicians and patients in selecting the best management strategy. Methods: These guidelines are based on scientific evidence and expert opinion. By summarising and evaluating the best available evidence, recommendations for the diagnosis and treatment of patients have been formulated. The recommendations are graded according to the new ESVS clinical practice guidelines class of recommendation grading system, where the strength (class) of each recommendation is graded from I to III, and the letter A to C marks the level of evidence. Results: A total of 102 recommendations have been issued on the management of chronic arterial mesenteric ischaemia, median arcuate ligament syndrome, acute arterial mesenteric ischaemia, non-occlusive mesenteric ischaemia, venous mesenteric thrombosis and ischaemia, occlusive disease of the renal arteries and veins, visceral artery aneurysms, and spontaneous isolated dissection of the visceral arteries. Conclusion: These 2025 ESVS clinical practice guidelines provide comprehensive and up to date advice to physicians and patients on the management of diseases of the mesenteric and renal arteries and veins.publishersversionpublishe

Use of an Off the Shelf Inner Branch Thoraco-abdominal Endograft for the Treatment of Juxtarenal and Pararenal Aortic Aneurysms

Objective: To investigate outcomes of an off the shelf pre-loaded inner branched endograft (E-nside) for the treatment of juxtarenal and pararenal abdominal aortic aneurysms (JP-AAAs). Methods: Data from a multicentre registry (INBREED), including patients treated with the E-nside endograft, were collected and analysed prospectively. Patients treated for JP-AAA were included. Pre-operative clinical and anatomical characteristics, procedural data, and 30 day and one year outcomes were recorded. Endpoints were technical success, 30 day death, major adverse events (MAEs), and one year freedom from target vessel instability. Results: Of 185 consecutively treated patients, 47 (25.4%) had a JP-AAA (juxtarenal n&nbsp;= 10, 21%; pararenal n&nbsp;= 37, 79%) and were included in the study; 183 target vessels were incorporated through an inner branch. Procedural setting was emergency or urgent in 18 patients (38%) owing to a contained aortic rupture (n&nbsp;= 2, 4%), symptomatic aneurysm (n&nbsp;= 4, 9%), or aneurysm &gt; 70 mm (n&nbsp;= 12, 26%). The mean length of aortic coverage above the coeliac trunk was 116 ± 7 mm. Technical success was 100% and 30 day mortality rate 4% (n&nbsp;= 2 urgent cases). The 30 day cumulative MAE rate was 26% (n&nbsp;= 12): two stroke (4%); and seven spinal cord ischaemia (15%), with six in an elective setting (21%) and one in an urgent setting (6%), and five leading to permanent paraplegia or paraparesis (10%). Freedom from target vessel instability was 99% after 30 days and 97 ± 3% after one year. Conclusion: Use of an off the shelf inner branched device for treating JP-AAA was feasible in urgent and elective settings, with high technical success and satisfactory target vessel stability at one year. In the treatment of JP-AAA, stroke and spinal cord ischaemia may be associated with arm access and the increased aortic coverage that the design brings

Outcomes of off-the-shelf preloaded inner branch device for urgent endovascular thoraco-abdominal aortic repair in the ItaliaN Branched Registry of E-nside EnDograft

Objective: The aim of this study was to report the outcomes of endovascular urgent thoracoabdominal aortic (TAAA) repair, using an off-the-shelf preloaded inner branch device (E-nside; Artivion). Methods: Data from a physician-initiated national multicenter registry, including patients treated with E-nside endograft (INBREED) were prospectively collected (2020-2024); only urgent cases were included in this study. Primary outcomes were technical success and mortality at 30 days. Secondary outcomes were spinal cord ischemia rate, stroke rate, major adverse events (MAE) as also branch instability at 12 months. Results: Of 185 patients enrolled in the INBREED, 64 (34.5%) were treated in a urgent setting and were included in the study. Reason for urgent repair was presence of aneurysm-related symptoms in 31 patients (48.4%), a contained rupture in eight (12.5%), and a large aneurysm &gt;80 mm in 25 (39.1%). Extent of repair was I to III in 32 patients (50%) and IV in 32 (50%); 18 (28%) had a narrow (&lt;25 mm) paravisceral aortic lumen. An adjunctive proximal thoracic endograft was deployed in 29 patients (45.3%); a distal bifurcated abdominal endograft was used in 33 (51.5%). Two hundred forty-nine target vessels (97.2%) were successfully incorporated through an inner branch from an upper arm (81.2%) or femoral (18.8%) access. A balloon expandable stent was used in 184 (75.7%) target vessels, a self-expandable stent in 59 (24.3%). Mean time for target vessel bridging was 39.9 ± 28.4 minutes per target vessel. Thirty-day cumulative major adverse event (MAE) rate was 28%, and mortality occurred in five patients (9.1%). There was one postoperative stroke (1.6%), and the spinal cord ischemia (SCI) rate was 8% (n = 5). For the 249 target vessels successfully incorporated through an inner branch, 1-year freedom from target vessel instability was 93% ± 3% after 1 year. Conclusions: The E-nside represents a valid solution for the urgent treatment of TAAAs, including symptomatic and ruptured TAAAs, as well as large asymptomatic TAAAs that cannot wait for a custom-made device. The preloaded inner branches and available proximal and distal graft diameters might be useful in urgent settings and provided satisfactory early and 1-year results, in terms of both endograft and target vessel stability. Further studies are required to assess the clinical role of E-nside for urgent TAAA repair

Insight from an Italian Delphi Consensus on EVAR feasibility outside the instruction for use: the SAFE EVAR Study

BACKGROUND: The SAfety and FEasibility of standard EVAR outside the instruction for use (SAFE-EVAR) Study was designed to define the attitude of Italian vascular surgeons towards the use of standard endovascular repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) outside the instruction for use (IFU) through a Delphi consensus endorsed by the Italian Society of Vascular and Endovascular Surgery (Societa Italiana di Chirurgia Vascolare ed Endovascolare - SICVE). METHODS: A questionnaire consisting of 26 statements was developed, validated by an 18 -member Advisory Board, and then sent to 600 Italian vascular surgeons. The Delphi process was structured in three subsequent rounds which took place between April and June 2023. In the first two rounds, respondents could indicate one of the following five degrees of agreement: 1) strongly agree; 2) partially agree; 3) neither agree nor disagree; 4) partially disagree; 5) strongly disagree; while in the third round only three different choices were proposed: 1) agree; 2) neither agree nor disagree; 3) disagree. We considered the consensus reached when &gt;70% of respondents agreed on one of the options. After the conclusion of each round, a report describing the percentage distribution of the answers was sent to all the participants. RESULTS: Two -hundred -forty-four (40.6%) Italian Vascular Surgeons agreed to participate the first round of the Delphi Consensus; the second and the third rounds of the Delphi collected 230 responders (94.3% of the first -round responders). Four statements (15.4%) reached a consensus in the first rounds. Among the 22 remaining statements, one more consensus (3.8%) was achieved in the second round. Finally, seven more statements (26.9%) reached a consensus in the simplified last round. Globally, a consensus was reached for almost half of the proposed statements (46.1%). CONCLUSIONS: The relatively low consensus rate obtained in this Delphi seems to confirm the discrepancy between Guideline recommendations and daily clinical practice. The data collected could represent the source for a possible guidelines' revision and the proposal of specific Good Practice Points in all those aspects with only little evidence available

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Orthodoxy on Sale: the Last Byzantine, and the Lost Crusade

This conference paper reconstructs and summarises the various aspects and stages of the plan to “save Byzantium in the West,” of which Aeneas Sylvius Piccolomini, Bessarion, and Thomas Palaeologus were protagonists, underscoring with particular attention the doctrinal and ideological implications. Thomas, sovereign in pectore of the New Byzantium to be founded on the Peloponnese once delivered from the Turks by the crusade called by Pius II at the Council of Mantua in 1459, brought the head of St. Andrew, missionary on the Peloponnese and patron of the Eastern Church, with him to Italy soon after – probably at Bessarion’s suggestion. The transfer of St. Andrew’s head was a solemn event, filled with symbolism and commemorated in important artistic commissions. The idea of a crusade against the Turks by the Western powers under the aegis of the papacy had been planned for the first time soon after the Council of Ferrara and Florence, Bessarion’s move to the unionist faction, and the subsequent, though virtual and realpolitiker, union of the churches. After the failure of the Varna Crusade, however, the pope continued to promote the plan to found a “New Byzantium” in Morea, based on the realistic political proposals laid down by Georgius Gemistus Pletho and the school of Mystras. The project was supported by a clan of pro-Byzantine signorie, related through the Malatesta to the Palaeologi, but the greater objective was the reunification of the First and Second Rome into one legal entity under the primary influence of the papacy. The expectations and the crucial political, ideological, and religious connections are to be found mirrored allegorically in Benozzo Gozzoli’s Cavalcata dei Magi and Piero della Francesca’s Flagellation. However, after Pius II’s announcement at Mantua, international support for his expedition against the Turks began to wane quickly and the plan reached its epilogue with the death of the pontiff, the staunchest supporter until his end in Ancona. Lost in the West, inheritance of the Byzantine imperial title passed to Russia, thanks to the marriage – orchestrated with Machiavellian skill by Bessarion – between the last Palaeologian princess, Zoe, and Ivan III (the Great) Vasilyevich of Moscow. The divine right of the basileia and the concomitant bequest of orthodoxy, manipulated for decades, came to be absorbed into the Empire of the Third Rome. Il contributo ricostruisce e riassume, sotto forma di relazione congressuale, i vari aspetti e momenti del piano di "salvataggio occidentale di Bisanzio", che ebbe per protagonisti Enea Silvio Piccolomini, Bessarione e Tommaso Paleologo, sottolineandone in particolare le implicazioni ideologiche e dottrinali. Tommaso, sovrano in pectore della Nuova Bisanzio che avrebbe dovuto costituirsi nel Peloponneso una volta liberato dai turchi grazie alla crociata indetta da Pio II al Concilio di Mantova del 1459, recò con sé poco dopo in Italia, dietro probabile suggerimento di Bessarione, la reliquia della testa di Sant'Andrea, evangelizzatore del Peloponneso e patrono della Chiesa d’Oriente. La traslazione del capo di Sant’Andra fu un evento solenne e carico di simbolismi, commemorato, fra l’altro, in importanti committenze artistiche. L'idea di una crociata antiturca delle potenze occidentali sotto l’egida del papato si era concretizzata per la prima volta poco dopo il concilio di Ferrara-Firenze, il passaggio di Bessarione all'ala unionista e la conseguente, ancorché virtuale e “realpolitica”, unione delle chiese. Dopo il fallimento, tuttavia, della Crociata di Varna, ad essere caldeggiato dal papa restò il progetto di fondazione di una “Nuova Bisanzio” in Morea, basato sulle realistiche proposte politiche elaborate da Giorgio Gemisto Pletone e dalla scuola a Mistrà. Il progetto era appoggiato da un clan di signorie filo-bizantine, imparentate attraverso i Malatesta con i Paleologhi, ma la sua posta più alta era la prospettiva di una riunificazione della Prima e della Seconda Roma in una sola entità giuridica dominata dal papa. Le aspettative e i cruciali intrecci politici, ideologici, religiosi di quest'epoca si rispecchiano, in maniera allegorica, nel Corteo dei Magi di Benozzo Gozzoli e nella Flagellazione di Piero della Francesca. Tuttavia, dopo l’annuncio di Pio II a Mantova, andarono rapidamente scemando le adesioni internazionali al suo piano di spedizione antiturca, che vide il suo epilogo con la morte del pontefice, fino all'ultimo suo strenuo sostenitore, ad Ancona. Persa all'Occidente, l'eredità giuridica del titolo imperiale di Bisanzio passò alla Russia, grazie al matrimonio – machiavellicamente orchestrato da Bessarione – tra l'ultima principessa paleologa, Zoe, e Ivan III Vasilevič di Mosca. L'ideologia della basileia di diritto divino e l'ortodossia, manipolata per decenni, vennero riassorbite nell’impero della Terza Roma

Tommaso Paleologo al Concilio di Firenze

Il contributo intreccia analisi iconografica e lettura storica del Corteo dei Magi di Benozzo Gozzoli per soffermarsi sui suoi protagonisti e soprattutto sul giovane e biondo “capocaccia” che reca, in sella e al guinzaglio, due ghepardi. L’identificazione dei tre Magi con i capidelegazione bizantini, “portatori” al Concilio di Firenze del “dono” dell’Unione delle Chiese – il patriarca Giuseppe II, il basileus Giovanni VIII e il suo fratello minore Demetrio, raffigurati secondo l’effettivo ordine di arrivo dei rispettivi cortei in città – è resa inequivoca dalla presenza di ritratti di personaggi del loro seguito (tra cui si riconoscono con certezza almeno Giorgio Gemisto Pletone, Isidoro di Kiev, Giovanni Argiropulo, Teodoro Gaza) oltre che da quella di platonici occidentali e dello stesso papa Pio II. Vi è però anche un “quarto Mago”: nella figura del biondo capocaccia affiancato da due ghepardi può riconoscersi un’immagine idealizzata dell’altro fratello minore di Giovanni VIII, l’ultimogenito Tommaso, o comunque una memoria della sua presenza al Concilio, rivelata peraltro dalle testimonianze storiografiche, finora ignote o ignorate, di Giorgio Sfrantze e Pero Tafur. Tommaso, l’ultimo dei principi Paleologhi era d’altronde al centro del progetto di “salvataggio occidentale di Bisanzio” che Pio II avrebbe esposto ufficialmente al Concilio di Mantova del 1459: in occasione di questo concilio gli affreschi celebrativi del concilio fiorentino di vent’anni prima erano stati commissionati a Benozzo da Piero de’ Medici. Se dopo la conclusione del summit di Mantova l’immagine realistica di un più maturo Tommaso Paleologo si ritroverà nelle committenze di Pio II e dei suoi eredi (nei due ritratti marmorei di Paolo Romano, eseguiti dopo la venuta di Tommaso a Roma, e in quello dipinto da Pinturicchio nella Libreria Piccolomini del Duomo di Siena), i tratti idealizzati e simbolici del misterioso “giovane con ghepardi” del Corteo di Benozzo possono confrontarsi con quelli dell’altrettanto enigmatica figura di giovane biondo raffigurato nel “proscenio” della Flagellazione di Piero della Francesca