Objectives Previous literature has suggested an association between AAA and the presence of elevated plasma homocysteine levels (HCY). Homocysteine can stimulate elastolysis in the arterial media via activation of elastase and matrix metalloproteinases. No evidence in the literature exists correlating aneurysm expansion and HCY. The study objective is to identify whether the rate of AAA expansion is related to HCY.Methods 108 patients undergoing surveillance for AAA were identified at our vascular surgical unit. AAA size and growth rate were assessed by serial ultrasongraphic measurements. Fasting total HCY levels were measured using fluorescence polarisation immunoassays. Demographic details and atherosclerotic risk factors were noted all AAA patients. A multivariate analysis was performed for growth rate vs. HCY, hypertension and hypercholesterolaemia. The correlation between AAA growth rate, AAA size and HCY levels were calculated.Results 60% of patients with AAA had some degree of hyperhomocysteinaemia (Ͼ15 mol/l). Multivariate analysis showed HCY to be the only significant factor affecting AAA growth rate. A positive correlation was demonstrated between HCY levels and AAA growth rate using a linear regression model (Rϭ0.28, pϭ0.003). Median growth rate among patients with hyper-HCY was double that of patients with normal HCY (0.5 mm/month vs. 0.25 mm/month, pϭ0.003). A growth rate of Ͼ10 mm/year was seen in 25% of hyper HCY patients and in only 2% of patients with normal HCY. In addition patients with hyper HCY and larger AAAs (Ͼ4 cm) had a growth rate twice as fast as patients with hyper HCY and AAAs Ͻ4 cm.Conclusions A correlation between HCY and growth rate exists, although this is weak due to the multifactorial aetiology of AAAs. Hyper-HCY patients have faster expansion rates than patients with normal HCY, with significant numbers demonstrating rapid expansion (Ͼ10 mm/year) and therefore an increased risk of rupture.

This paper evaluates the protocol adopted during the emergency phase of the COVID-19 pandemic to maintain elective activity in a vascular surgery unit while minimising the risk of contamination to both patients and physicians. All elective patients were submitted to nasopharyngeal swabs; all emergency patients were considered as possibly contaminated, in order to minimise contamination possibilities to other patients and hospital professionals. This approach should be considered in an emergency situation in high risk areas.Objective: This study aimed to evaluate the protocol adopted during the emergency phase of the COVID-19 pandemic to maintain elective activity in a vascular surgery unit while minimising the risk of contamination to both patients and physicians, and the impact of this activity on the intensive care (IC) resources. Methods: The activity of a vascular surgery unit was analysed from 8 March to 8 April 2020. Surgical activity was maintained only for acute or elective procedures obeying priority criteria. The preventive screening protocol consisted of nasopharyngeal swabs (NPS) for all patients and physicians with symptoms and for unprotected contact infected cases, and serological physician evaluations every 15 days. Patients treated in the acute setting were considered theoretically infected and the necessary protective devices were used. The number of patients and the possible infection of physicians were evaluated. The number and type of interventions and the need for post-operative IC during this period were compared with those in the same periods in 2018 and 2019. Results: One hundred and fifty-one interventions were performed, of which 34 (23%) were acute/emergency. The total number of interventions was similar to those performed in the same periods in 2019 and 2018: 150 (33, of which 22% acute/emergency) and 117 (29, 25% acute/emergency), respectively. IC was necessary after 6% (17% in 2019 and 20% in 2018) of elective operations and 33% (11) of acute/emergency interventions. None of the patients treated electively were diagnosed with COVID-19 infection during hospitalisation. Of the 34 patients treated in acute/emergency interventions, five (15%) were diagnosed with COVID-19 infection. It was necessary to screen 14 (47%) vascular surgeons with NPS after contact with infected colleagues, but none for unprotected contact with patients; all were found to be negative on NPS and serological evaluation. Conclusion: A dedicated protocol allowed maintenance of regular elective vascular surgery activity during the emergency phase of the COVID-19 pandemic, with no contamination of patients or physicians and minimal need for IC resources.

Objectives:To evaluate frequency, clinical and etiological features, short- and long-term outcomesofearly recurrent TIA.Methods:Prospective observational cohort study enrolling all consecutive patients with TIAreferred to our emergency department (ED) and diagnosed by a vascular neurologist. Expedite assessment and best secondary prevention were performed within 24h. Primary endpoints were stroke and a composite outcome including stroke, acute coronary syndrome and vascular death at 3, 12 and,for a subset of patients, 60 months; secondary outcomeswere TIA relapse, cerebral hemorrhage, new onset atrial fibrillation and death from other causes. Concordance between index TIA and subsequent stroke etiologies was also evaluated.Results:A total of 1035 patients (822 single TIA, 213 recurrent TIA =21%) were enrolled from August2010 to December 2017. Capsular warning syndrome and large-artery atherosclerosis showed the strongest relationship with early recurrent TIA. The risk of stroke was significantly higher in the early recurrent TIA subgroup at each follow-upand most stroke episodes occurred within 48h of index TIA. TIA with lesion, dysarthria and leukoaraiosiswere 3- and 12-month independent predictors of stroke incidence after early recurrent TIA subgroup. Index TIA and subsequent stroke etiologies showed substantial concordance. An ABCD3 score>6 predictedahigher risk of stroke rcurrenceover the entire follow-up.Conclusions:Our study was the first to evaluate long-term outcome after early recurrentTIA. Our observations support the importance of promptly detecting and treating patients with earlyrecurrent TIAs in order to reduce the high early and long-term risk of poor clinical outcomes.