Domenico Baccellieri

Summary: Background: Pelvic venous disorders (PeVD) are associated with chronic pelvic pain and varicose veins due to venous insufficiency and pooling in the pelvis. Despite increasing interest, there is a lack of widely accepted diagnostic algorithms and validated criteria, which complicates diagnosis and management. This study aimed to develop and validate a diagnostic and therapeutic algorithm for PeVD using expert consensus. Materials and methods: An independent Advisory Board (AB) of 11 Italian specialists (gynaecologist, radiologists, vascular surgeons, and angiologists) was convened. A literature review informed the development of a draft algorithm. Three Delphi survey rounds were conducted, with online and in-person discussions, and a consensus threshold set at ≥70%. Results: All 11 AB members completed the first two survey rounds, and eight completed the third. The median number of diagnosed and treated PeVD cases per expert was 20 and 12 per year, respectively. The group agreed on classifying PeVD into Pelvic Congestion Syndrome (PCS) and compressive/obstructive syndromes. Endovascular therapy was recognised as standard of care: pelvic embolisation for PCS, stenting for obstructive lesions, and combined approaches when both are present. Clinical success was defined as subjective symptom improvement assessed 3–6 months post-procedure. Treatment failure warranted re-evaluation and possible reintervention. Surgical treatment was considered only when conservative and endovascular options failed (37.5% agree, 50% neutral). Conclusions: This Delphi-based consensus produced a validated, multidisciplinary algorithm for the diagnosis and treatment of PeVD. It highlights the need for standardised clinical pathways, but further validation by a broader expert community is warranted.

Summary: Background: Radiofrequency ablation (RFA) and mechanochemical ablation (MOCA) have emerged as less invasive alternatives to traditional surgical interventions, offering reduced recovery times and comparable efficacy. This study aims to compare the efficacy, safety, and patient-reported outcomes between RFA and MOCA in treating SSV insufficiency. Materials and methods: this is a retrospective, nonrandomized study that involved patients who underwent either RFA or MOCA between 2015 to 2019. Data collected included demographics, clinical grading, procedural specifics, and follow-up outcomes. The primary endpoint was the comparison of freedom from recanalization and freedom from reinterventions rates, while secondary endpoints focused on recurrences rates and clinical outcomes assessed by revised clinical severity score (rVCSS), and Aberdeen Varicose Vein Questionnaire (AVVQ). Results: A total of 132 limbs were treated (n=72 RFA; n=60 MOCA). Baseline demographics and clinical severity were comparable between groups. At 5 years, freedom from recanalization rate was significantly higher in the RFA group compared to the MOCA group (91.7% vs 66%; p=.0014). Clinical recurrence rates at 5 years were 11.7% for RFA and 22% for MOCA (p=.0023), while freedom from reintervention rates were 93.3% and 72.7%, respectively (p=.0011). Although both groups showed clinical improvement over time, patients treated with MOCA exhibited a significant worsening in rVCSS and AVVQ at 3 and 5 years compared to the RFA group (p<.0001). Conclusions: RFA demonstrates greater long-term stability, lower recurrence and reintervention rates compared to MOCA, suggesting it may be a preferable option for SSV insufficiency treatment in terms of durability and patient outcome.

Background: High-risk pulmonary embolism (PE) complicated by floating right atrial thrombi (RAT) carries a significantly increased mortality risk, often requiring urgent intervention beyond systemic thrombolysis (ST). However, current guidelines lack specific recommendations for managing persistent RAT following ST. Catheter-directed therapies (CDTs) have emerged as a promising alternative in this setting. We report a novel single-session, multidisciplinary approach combining mechanical thrombectomy of both RAT and iliofemoral deep vein thrombosis (DVT) using the Penumbra Indigo Lightning System. Case summary: A 74-year-old woman presented with syncope and signs of cardiogenic shock. Imaging confirmed high-risk PE with floating RAT and extensive iliofemoral DVT. Initial treatment with ST led to partial haemodynamic recovery but persistent RAT. A multidisciplinary Pulmonary Embolism Response Team elected to perform percutaneous thrombectomy. Under transoesophageal echocardiography and fluoroscopic guidance, mechanical aspiration of the right atrial thrombus was successfully performed using the Penumbra Indigo Lightning 12 F catheter. In the same session, intravascular ultrasound-guided aspiration of iliofemoral DVT was achieved, with confirmation of complete thrombus removal and exclusion of the May–Thurner syndrome. The patient had an uneventful recovery, with restored right ventricular function and no recurrent thromboembolism or post-thrombotic syndrome at follow-up. Discussion: This case demonstrates the feasibility and safety of a combined single-session catheter-directed approach for simultaneous treatment of RAT and DVT following ST failure. The integration of multidisciplinary decision-making, advanced aspiration technology, and intravascular imaging may optimize outcomes in complex PE cases and supports expanding the role of CDTs in rescue settings.

Summary: The number of endovascular interventional procedures for catheter-based therapy (CBT) of acute venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), has been increasing over the past years. The development of more efficient thrombectomy systems for CBT of VTE has potentially enhanced the efficacy of interventional treatment of VTE. Nevertheless, indications for CBT of VTE, i.e. catheter-directed thrombolysis (CDT) or catheter-based mechanical thrombus removal, need to be established based on existing data and expert consensus. Vascular experts should be involved in the decision-making process on CBTs in patients with acute VTE, and thrombus removal procedures should be performed in centers with experience in interventional treatment of VTE. This guideline document of the European Society of Vascular Medicine (ESVM) provides recommendations on indications and management of CBT in acute VTE and is endorsed by the European national societies of Vascular Medicine.

Early cellular alterations in abdominal aortic aneurysm (AAA) are scarcely investigated. Aortic remodeling inflammation-related suggested the CXCR2/CXCL1/IL-8 axis as a therapeutic target. This study investigates CXCR1/CXCR2 antagonism in primary human aortic endothelial (HAOEC) and smooth muscle cells (HAOSMC) conditioned with IL-8 or serum from patients with AAA (sPT). Ladarixin (10 μM Lad or 25 μM) served as an inhibitor. Readouts included RT-qPCR for CXCL1, CXCL8, CXCR2, MMP9, NFKB1, and VEGF-A; zymography for MMP9 activity confocal microscopy for F-actin and mitochondria; NADPH/NADH diaphorase histochemistry for redox activity; and ATP assay. In HAOEC, IL-8 downregulated CXCR2, increased MMP9 activity, and induced cytoskeletal and mitochondria disorganization without altering NADH/NADPH diaphorases but increasing ATP release. At concentration of 10 μM Lad rescued cell organization and gene expression. sPT upregulated CXCL8, CXCR2, and MMP9, decreased NADH/NADPH diaphorases, and altered cytoskeleton and mitochondria organization in HAOEC. At concentration of 10 μM Lad (partially) and 25 μM Lad reverted gene upregulation and mitochondria distribution; both doses increased diaphorase and released ATP. HAOSMC were scantily susceptible to IL-8 and weakly responsive to sPT, slightly upregulating CXCR2 and VEGF-A but increasing proMMP9 gelatinolysis. Ladarixin recovered proMMP9 activity and modulated CXCL1. AAA-like vascular cell alterations involve multiple inflammatory factors and are modulable by inhibition of IL-8 receptors. The results underline careful dose calibration.