DEDICATIONAfter studying medicine at Hanover Medical School and philosophy and social psychology at the Leibniz University Hanover, Omke E. Teebken joined the Christian Albrechts University in Kiel at the end of the 1990s as a research fellow at the Clinic for Cardiovascular Surgery headed by Professor Dr Axel Haverich, whom Omke E. Teebken later followed back to Hanover.In Hanover, besides working as a clinician, Omke E.Teebken was particularly active scientifically, contributing to the establishment of the then newly founded Leibniz Laboratories for Biotechnology and Artificial Organs (LEBAO). His work focused on regenerative medicine and tissue engineering, and subsequently he wrote his habilitation thesis in in this field. After basic training in cardiac surgery, he specialised clinically in vascular surgery and played a pioneering role in the development of this field. Before being appointed director of the Clinic for Vascular Surgery e Endovascular Surgery at the Peine Clinic in 2016, Omke E. Teebken headed the Vascular Surgery e Endovascular Surgery Division of the Department of Cardiothoracic, Thoracic, Transplantation and Vascular Surgery at Hanover Medical School. Professor Teebken was a highly appreciated, committed, and competent colleague and teacher.On 8 April 2019, Professor Teebken passed away after a short and severe illness. He was member and author of the ESVS guideline writing committee, an esteemed colleague, and friend.We will always honor his memory.

Among the various risk factors involved in the development and progression of carotid atherosclerosis, the oxidation of LDL has been proposed to play a relevant role. LDL oxidation has been investigated in 94 patients with severe carotid atherosclerosis undergoing elective carotid artery endarterectomy and in 42 matched control subjects. LDL oxidation was evaluated in all patients as (1) the susceptibility to in vitro oxidation, (2) vitamin E concentration and its efficiency in LDL, and (3) the presence of autoantibodies against oxidatively modified lipoprotein to monitor the occurrence of the oxidative processes taking place in vivo. No difference was detected between control subjects and patients concerning vitamin E concentration and the kinetics of conjugated diene formation in isolated LDL exposed to CuSO 4 . However, vitamin E efficiency was lower (9.6±4.2 versus 30.2±7.6 min/ nmol vitamin E) and the duration of the vitamin E-independent lag phase was longer (105.5±16.5 versus 58± 11.8 minutes) in the patient group. Autoantibodies against oxidatively modified lipoproteins were measured with an ELISA method using native LDL, Cu 2+ -oxidized LDL (oxLDL), or malondialdehyde-derivatized LDL (MDA-LDL) as antigens. To monitor cross-reactivity of the antibodies detected with other C arotid atherosclerosis, ranging from intima-media thickening to the appearance of more advanced lesions such as fibrotic and complicated plaques, affects about 25% of the whole population.

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Background The aim of this study was to report the experience of one of the major “hubs” for vascular surgery in Lombardy, Italy, during the first 7 weeks after total lockdown due to COVID-19 pandemic. Methods Data from all patients treated at our Department since the decision of the regional healthcare authorities of Lombardy to centralize surgical specialties creating a hub/spoke system (March 9, 2020) were prospectively collected and compared with a retrospectively collected cohort from the same period of year 2019. Primary study end point was defined as primary clinical success. Secondary end points were defined as in-hospital mortality and/or any in hospital major adverse event or lower limb amputation. Results One hundred sixteen patients were treated (81 men, 70%; median age: 71 years, IQR 65–81). Thirty-two patients (28%) were addressed from spoke hospitals directly referring to our hub, 19 (16%) from hospitals belonging to other hub/spoke nets, 48 (41%) came directly from our emergency department, and 17 (15%) were already hospitalized for COVID-19 pneumonia. Acute limb ischemia was the most observed disease, occurring in 31 (26.7%), 12 (38.7%) of whom were found positive for COVID-19 pneumonia on admission, whereas 3 (9.7%) became positive during hospitalization. Chronic limb ischemia was the indication to treatment in 24 (20.7%) patients. Six (5.2%) patients underwent primary amputation for irreversible ischemia. Aortic emergencies included 21 cases (18.1%), including 13 (61.9%) symptomatic abdominal aortic or iliac aneurysms, 4 (19.0%) thoracoabdominal aortic aneurysms, 2 (9.5%) cases of acute type B aortic dissection (one post-traumatic). Seventeen (14.7%) patients were admitted for symptomatic carotid stenosis (no COVID-19 patients); all of them underwent carotid endarterectomy. Seventeen (14.7%) cases were treated for other vascular emergencies. Overall, at a median follow-up of 23 ± 13 days, primary clinical success was 87.1% and secondary clinical success was 95.9%. We recorded 3 in-hospital deaths for an overall mortality rate of 2.6%. Compared with the 2019 cohort, “COVID era” patients were older (72 vs. 63 years, P = 0.002), more frequently transferred from other hospitals (44% vs. 21%, P = 0.014) and more frequently with decompensated chronic limb threatening ischemia (21% vs. 3%, P = 0.015); surgical outcomes were similar between the 2 cohorts. Conclusions Since its appearance, SARS-CoV-2 has been testing all national healthcare systems which founds themselves facing an unprecedented emergency. Late referral in the pandemic period could seriously worsen limb prognosis; this aspect should be known and addressed by health care providers. Vascular surgical outcomes in pre-COVID and COVID era were comparable in our experience.

Objective During the most aggressive phase of the COVID-19 outbreak in Italy, the Regional Authority of Lombardy identified a number of hospitals, named Hubs, chosen to serve the whole region for highly specialised cases, including vascular surgery. This study reports the experience of the four Hubs for Vascular Surgery in Lombardy and provides a comparison of in hospital mortality and major adverse events (MAEs) according to COVID-19 testing. Methods Data from all patients who were referred to the Vascular Surgery Department of Hubs from 9 March to 28 April 2020 were collected prospectively and analysed. A positive COVID-19 polymerase chain reaction swab test, or symptoms (fever > 37.5°C, upper respiratory tract symptoms, chest pain, and contact/travel history) associated with interstitial pneumonia on chest computed tomography scan were considered diagnostic of COVID-19 disease. Patient characteristics, operative variables, and in hospital outcomes were compared according to COVID-19 testing. A multivariable model was used to identify independent predictors of in hospital death and MAEs. Results Among 305 included patients, 64 (21%) tested positive for COVID-19 (COVID group) and 241 (79%) did not (non-COVID group). COVID patients presented more frequently with acute limb ischaemia than non-COVID patients (64% vs. 23%; p < .001) and had a significantly higher in hospital mortality (25% vs. 6%; p < .001). Clinical success, MAEs, re-interventions, and pulmonary and renal complications were significantly worse in COVID patients. Independent risk factors for in hospital death were COVID (OR 4.1), medical treatment (OR 7.2), and emergency setting (OR 13.6). COVID (OR 3.4), obesity class V (OR 13.5), and emergency setting (OR 4.0) were independent risk factors for development of MAEs. Conclusion During the COVID-19 pandemic in Lombardy, acute limb ischaemia was the most frequent vascular disease requiring surgical treatment. COVID-19 was associated with a fourfold increased risk of death and a threefold increased risk of major adverse events.

Heparin resistance is an uncommon phenomenon defined as the need for high-dose unfractionated heparin (UFH) of more than 35,000 IU/day to achieve the target activated partialthromboplastin time ratio or the failure to achieve the desired activated clotting time after a full UFH dose. This rare phenomenon is being more commonly observed in Covid-19 patients in a hypercoagulable state. We describe a Covid-19 patient confirmed by reversetranscriptase polymerase chain reaction assay, with acute limb ischemia, who developed heparin resistance. The patient was managed by the departments of vascular surgery, anesthesia and intensive care, and the

Coronavirus pandemic started in China in December 2019 and spread worldwide infecting more than two million people causing more than 100,000 deaths. 1 The first case of COVID-19 infection in Italy was reported in a small center in Lombardy on 20 February 2020 and then the infection was able to spread to all Italian regions. Lombardy resulted as the most affected area due to its high density of population and the high number of old age citizens. The regional healthcare authorities decided to create dedicated COVID-19 hospitals and to identify a Hub/ Spoke system for vascular emergencies, where four large centers (Hubs) would provide service to whole region for emergency cases. San Raffaele Hospital was identified as Hub for cardiovascular emergencies and simultaneously as referral center for COVID-19 patients. At our hospital, six divisions of Medicine were converted to COVID-19 patient care and more than 30 new intensive care unit (ICU) beds were set up. A dedicated emergency room with "COVID free" access was prepared in 24 h in order to create different pathways for non-infected patients. Elective cases were suspended and consequently all cases of chronic venous disorders postponed, continuous vascular diagnostic service was exclusively maintained for emergency cases with acute deep vein thrombosis (DVT). Interesting patterns have emerged: during the initial days, the patient reluctance to mix-up in hospitals with COVID-19 patients determined a reduction of all vascular emergencies. After two weeks, a sensible increase of arterial limb ischemia was observed requiring both open and endovascular interventions as well as an increase of DVT cases. Two patients with acute ilio-caval DVT were treated by means of thrombectomy and stenting; one case of secondary iliofemoral DVT due to extrinsic abdominal compression from a lymphoma was managed conservatively because unsuitable for thrombolysis or venous thrombectomy.

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