International Angiology最新文献

Background: The impact of carotid endarterectomy (CEA) on symptomatic patients with mild high-risk carotid stenosis has not been really investigated and it is not well-defined. This multicenter retrospective study aims to assess the safety and effectiveness of CEA in patients with 50% or less stenosis with symptoms despite best medical therapy.

Methods: Between January 2018 and December 2024, all consecutive patients presenting with carotid-related neurological symptoms and a ≤50% high risk carotid stenosis submitted to CEA in eight high-volume vascular centers were included in the present study. All patients underwent duplex ultrasonography and computed tomography angiography to identify plaque morphological features. All patients were checked for alternative possible source of brain embolism.

Results: Twenty-nine patients with high-risk embolic plaques determining ≤50% stenosis and carotid-related neurological symptoms underwent CEA. The majority of plaques were Gray-Weale 1 or 2 (79.3%) and with ulcerated cap (79.3%). Symptoms reported at onset and during hospitalization up to CEA were 8 (27.5%) TIA, 8 (27.5%) crescendo TIA, 10 (34.4%) minor strokes, 3 (34.4%) strokes in evolution. Ischemic brain lesions of less of 25 mm were detected in 12 patients (41.3%). No perioperative stroke, death, myocardial infarction or cerebral hemorrhage occurred in this series. Only one TIA was detected due to a surgical defect that was promptly corrected. No patient experienced recurrent neurologic events related to the revascularized hemisphere during follow-up (mean 35.6 months).

Conclusions: Despite the limited number of patients included in the study, CEA has been shown to be safe and effective in preventing recurrent neurological ischemic events in highly selected patients with mild carotid high-embolic-risk plaque stenosis treated at high-volume institutions. Further studies are required to identify the most appropriate diagnostic tools and the precise carotid plaque features associated with high-embolic risk.

Background: The aim of this study was to evaluate the feasibility, safety, and radiographic outcomes of vascular plug embolization for high-flow type I endoleaks after endovascular repair of abdominal aortic aneurysms.

Methods: This single-center retrospective case series included 10 patients who underwent endovascular repair of abdominal aortic aneurysms. These patients were subsequently diagnosed with high-flow type I endoleaks, either during the index endovascular repair of abdominal aortic aneurysms at completion angiography or during a staged procedure prompted by the evidence of a persistent type I endoleak on follow-up contrast-enhanced computed tomography. Each patient received endovascular embolization using vascular plugs. The collected data comprised patient demographics, clinical characteristics, complications, device number and size, and procedural details. Contrast-enhanced computed tomography was scheduled at 1, 3, 6, and 12 months and annually thereafter for up to 5 years.

Results: Seven patients (70.0%) had type Ia endoleaks and three (30.0%) had type Ib endoleaks. Twelve vascular plugs were implanted with 100% technical success and complete occlusion of all type I endoleaks. Imaging follow-up was available in eight patients; during 6-52 months of observation, no recurrent type I endoleak was detected on contrast-enhanced computed tomography.

Conclusions: Vascular plug embolization of high-flow type I endoleaks after endovascular repair of abdominal aortic aneurysm is feasible and safe. The technical success rate is high with durable radiographic exclusion on early to mid-term follow-up.

Introduction: Chronic venous disease (CVD) is a widespread disease characterized by various clinical manifestations. This manuscript is Part II of a systematic literature review and meta-analysis assessing the effects of micronized purified flavonoid fraction (MPFF) on lower limb symptoms and signs in patients with CVD at all stages of the disease. Part I examined symptoms and Part II presented herein focused on signs.

Evidence acquisition: A systematic literature review was conducted in November 2023 to identify studies investigating the efficacy of MPFF oral treatment (1000 mg daily for at least 1 month) on venous symptoms and signs in patients with CVD at all stages (C0s-C6). Databases searched included Medline, Embase, and Cochrane. Eligible studies included randomized controlled trials (RCTs) and non-RCTs (non-randomized comparative, single-arm, and observational studies) evaluating venous signs: edema, redness, ulcer healing and disease severity assessed by venous clinical severity score (VCSS). A single-group random-effects meta-analysis was used to estimate the mean change in sign intensity and the proportion of sign improvement or complete resolution from baseline to the final assessment.

Evidence synthesis: Out of 387 identified articles, 56 studies were included in the analysis, among which 33 reported CVD signs in 24,617 MPFF-treated patients. Included participants were mainly females (84.1%) with a mean age (±SD) of 48.6 (±8.8) years, and overweight with a mean BMI of 26.3 (±4.5) kg/m². Significant reductions were observed in mean [95% confidence interval] ankle and calf circumferences (-7.6 mm [-9.1 to -6.2] and -8.0 mm [-11.2 to -4.8], respectively, P<0.001). Venous ulcers were healed in 48.9% [30.3% to 67.8%] or regressed in 73.4% [63.3% to 82.3%] of the patients (P<0.001). Significant improvements were also shown in redness and VCSS score (P<0.001). Twelve studies had a high risk of bias, while sensitivity analyses did not change the study results. Heterogeneity level was frequently high among studies.

Conclusions: This comprehensive meta-analysis provides additional evidence supporting the effectiveness of MPFF in improving clinical signs of CVD across all stages of the disease.

Background: Recently, day case peripheral endovascular interventions have gained momentum due to constantly optimizing results, based on technological and pharmacological advancements. Despite this, some hospitals, especially in rural areas with limited access to the emergency services, have not fully adopted this model. We evaluate the safety and feasibility of same-day discharge after endovascular procedures in north wales hospitals.

Methods: A study was conducted of patients who underwent day-case peripheral arterial endovascular interventions during two distinct 12-month periods: April 2019 to March 2020 and April 2021 to March 2022. Data were sourced from a prospectively maintained interventional radiology database. We defined procedural technical success as the successful distal arterial access and crossing of the target lesion. The primary endpoint was safe same-day discharge, and the secondary endpoint was any adverse event related to the intervention. Patient's demographics, clinical information (including indication: claudication versus critical limb ischemia), primary procedure details, technical success, procedural complications, and unplanned admissions were recorded. Patient's records were evaluated at a minimum of 12 months post procedure.

Results: Over 24-month period, 221 patients underwent 237 peripheral arterial interventions as day case. The mean age was 70 years with male female ratio of 2:1. The indications for intervention were claudication (55%) and critical limb ischemia (45%). The mean distance to hospital from home address was 23.6 kilometers. The most common artery undergoing treatment was the superficial femoral artery (51%). The procedure technical success rate was 90%. There were 12 (5%) complications with three (1.3%) patients requiring open surgery. The unplanned hospital admissions rate was 7.2%. The primary endpoint of safe same-day discharge was achieved in 92.8% of cases.

Conclusions: Same day discharge following peripheral endovascular interventions is safe and feasible even in a rural setting. With a low rate of complications and unplanned admissions this model of care can be adopted universally.

Background: Endovenous ablation techniques (EVA) have become increasingly common and have taken the place of surgical treatment for truncal vein incompetence. We set out to investigate and identify outcome, complications, and incidence of recurrence, and possible causes of truncal recurrence in patients treated with Endovenous Laser Ablation (EVLA).

Methods: A cohort study of 307 consecutive patients (119M/188F) with varicose veins and great saphenous vein incompetence, (C3-C6), were treated with EVLA. Clinical and duplex ultrasound assessment was performed for all patients. Post-procedure patients were placed in compression stockings for 2 weeks, and given enoxaparin for DVT prophylaxis. Patients were also assessed for deep venous thrombosis (DVT), and successful obliteration.

Results: Median initial vein diameter was 6.9 (range 3.7-12.6) mm, and the median ablation energy was 57.8 (range 44.3 to 83.1) J/cm in all 307 patients. Complete truncal occlusion was noted in 301 patients. Truncal occlusion was demonstrated in all patients at initial and 2-week scan, however six patients with were noted to have developed truncal recurrence observed at 6-weeks to 3-months. The median energy delivered was 40.9 (range 35.6 to 41.7) J/cm, significantly less compared to non-recurrent GSV (P=0.02). We observed multiple tiny arteriovenous fistulae with arterialized signals within the lasered vein that became confluent, resulting in truncal recurrence.

Conclusions: Venous re-canalization after EVLA occurs as a result of neovascularization. This takes the form of multiple tiny AV fistulae, that eventually join and becomes a confluent reflux. The triggers for this phenomenon are unclear, but probably related to linear endovenous energy density.

Introduction: Chronic venous disease (CVD) significantly impacts patients' quality of life through leg symptoms and signs. This systematic literature review and meta-analysis, published in two separate articles, evaluated the effects of micronized purified flavonoid fraction (MPFF), a venoactive drug, on CVD symptoms and signs by analyzing data from a wide spectrum of clinical studies in patients with CVD at all stages of the disease. Part I presented herein, focused on symptoms, and Part II on signs.

Evidence acquisition: A systematic review was conducted in November 2023 using PRISMA guidelines. Medline, Embase, and Cochrane databases were searched. Eligible studies included prospective randomized controlled trials (RCTs) and non-RCTs investigating the effects of oral MPFF treatment (1000 mg, daily for at least 1 month) on venous leg symptoms and signs in patients with CVD at all stages (C0s-C6). In the present analysis, primary outcomes were the main venous symptoms including pain, heaviness, discomfort, cramps, feeling of swelling, and burning sensation. Secondary outcomes were pruritus, paresthesia, fatigue, and global symptoms. Patient level of satisfaction with treatment was also assessed. A single-group random-effects meta-analysis was used to estimate the mean change in symptom intensity and the proportion of complete symptom resolution from baseline to the last post-baseline value.

Evidence synthesis: Out of 387 articles, 56 studies were included in the analysis, among which 51 studies involving 39,878 MPFF-treated patients, reported CVD symptoms. Significant reductions in symptom intensity scores were observed for all outcomes (P<0.001), except for fatigue. Improvement of symptoms was further supported by the resolution of pain, heaviness, cramps, discomfort, and burning sensation observed in pooled estimated proportion of patients (76.2%, 61.5%, 80.5%, 69.8%, and 67.2%, respectively; all P<0.001). The overall level of patient satisfaction was estimated to be more than 90%. Twenty studies had high risk of bias, while sensitivity analyses did not change the study results. Heterogeneity level was frequently high among studies.

Conclusions: This systematic review and meta-analysis provide strong evidence of consistent and clinically significant improvements in venous leg symptoms associated with the use of the venoactive drug MPFF, across all stages of CVD.

Background: Leg ulcers associated with chronic venous disease (CVD) are characterized by prolonged healing and high recurrence. This study describes the effectiveness and tolerability of venoactive drugs (VAD) combined with compression as part of conservative therapy for active venous leg ulcers among patients treated in routine clinical practice.

Methods: This prospective, multicenter, observational, 6-month study recruited patients diagnosed with Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class C6 and active venous ulcer area, 5-30 cm². VAD pharmacotherapy was at the discretion of the treating physician and consistent with national guidelines at the time of the study. Primary outcome was the proportion of patients with a healed venous ulcer at 6 months. Change from baseline in the mean Venous Clinical Severity Score (VCSS), the proportion of patients with a reduction in CEAP clinical class, and Quality of life (QoL - Chronic Venous Insufficiency Questionnaire [CIVIQ-14]) were also assessed.

Results: The study enrolled 349 patients: 66.8% were women; mean age was 61.0±12.7 years; and mean Body Mass Index (BMI) was 27.9±4.1 kg/m². Mean duration of the reference venous ulcer was 18.3±23.0 weeks and mean ulcer area was 9.2±6.9 cm². All patients were prescribed VAD at baseline, most commonly micronized purified flavonoid fraction (MPFF) (98.3% patients). Compression therapy was prescribed to 91.1% of patients. After 6 months, venous ulcers had completely healed in 69.6% of patients; 13.5% had experienced complete healing at 3 months. Mean physician-assessed VCSS decreased from 15.5±4.1 at baseline to 9.7±4.5 at 6 months (P<0.001). There was a progressive decrease in mean reference ulcer area from 9.2±6.9 cm² at baseline to 1.2±2.8 cm² at 6 months. QoL was significantly improved with a reduction in mean CIVIQ-14 global index score from 53.9±20.5 at baseline to 24.5±16.3 at 6 months (P<0.001). Treatment was well tolerated.

Conclusions: Combined treatment with VAD and compression therapy was associated with complete venous leg ulcer healing in 70% of patients with a mean time to healing of 7.4 months. A significant improvement in QoL compared with baseline was also observed.

Background: Peripheral artery disease (PAD) increases cardiovascular (CV) mortality risk. Dual therapy (DT) with aspirin and rivaroxaban reduces major CV adverse events and limb ischemia. An analysis of patients at high CV risk undergoing DT was conducted in a real-world setting. Major adverse events and bleedings were collected, comparing results with COMPASS and XATOA trials.

Methods: A retrospective, observational, monocentric analysis was performed. Major-adverse-cardiovascular-events (MACE) and major-adverse-limb-events (MALE) defined the effectiveness of DT, whereases safety was assessed recording major and minor bleedings, according to the ISTH criteria. Blood pressure (BP), low-density-lipoprotein (LDL) levels, Rutherford's classes, Ankle-Brachial-Index (ABI) and Toe-Brachial-Index (TBI) were also evaluated.

Results: Fifty-seven patients were considered from 2021 to 2024. The average follow-up was 24.5±10.1 months. The cumulative risk at 32 months of MACE, MALE and major or minor bleedings were 4.3%, 11% and 17.7% respectively. Comparing results with COMPASS and XATOA studies, there were more MALE, more minor bleedings and less MACE in DOLOMITI. There were more smokers, diabetics, hypertensives, patients with hypercholesterolemia, and patients with a history of limb revascularization in DOLOMITI. No differences in BP values were noticed at baseline and final valuations in DOLOMITI, whereases a reduction in LDL levels, an improvement in Rutherford's class, ABI and TBI resulted significative.

Conclusions: Low-dose rivaroxaban and acetylsalicylic acid have shown efficacy in reducing MACE in real-world contexts, with acceptable MALE events and bleeding risk. DT maximizes benefits by optimizing CV risk factors and improving PAD symptoms, but targeted studies are needed.

Background: Mesenteric vein thrombosis (MVT) is a rare clinical entity that occurs secondary to other diseases in approximately 90% of cases. Early diagnosis and treatment of intestinal hypoperfusion can be lifesaving for the patient. Here, we present a case series of MVT in our department over the past decade, highlighting how they were treated and the need for intervention in cases of intestinal ischemia, as well as the long-term results of newer anticoagulants.

Methods: Retrospective study of patients with MVT during the period 2013-2023 who were hospitalized in our department. We present the clinical presentation, the diagnostic process and the therapeutic measures, the follow-up of the patients to this day, and their outcomes.

Results: Eleven patients suffering from MVT were admitted to our surgical department during the study, with a mean age of 59.7 years. Three of them had an extension of the thrombus into the portal vein. In total, six patients were taken to the operating room and underwent either thrombolysis (N.=3) or enterectomy (N.=3). The rest were treated conservatively with heparin or warfarin. Mortality was estimated at 18% (2/11), positive thrombophilia screening was found in six patients (66.6%, 6/9), while 4/11 were diagnosed with malignant disease. Three patients voluntarily discontinued their treatment 3 months after the episode; however, despite that, they did not develop a new thrombotic event.

Conclusions: Due to its rarity, the management of MVT has not been established with protocols based on thorough research. The initial conservative treatment, and the subsequent decision for surgical intervention, depending on the patient's clinical course, are still the pillars of treatment. In the long term, the newer anticoagulants and a finite course of treatment seem to be non-inferior to traditional treatment options. However, large-scale multicenter studies are needed to confirm the results.

Since the late 1950s, grafts and endografts have been constructed from a variety of materials and have been designed to be implanted in several different ways. However, despite the level of safety, effectiveness and versatility these devices reached, failures still exist. METHODS: Material surveillance through a dedicated explant analysis program is the cornerstone towards improving knowledge about vascular grafts and endografts behavior in humans. Major lessons learned from explant analysis have already been published few years ago, but this review provides an update by summarizing the recent findings of a dedicated explant analysis program over the past five years. Recent findings include vascular grafts degradation, devices calcifications, mechanisms of endografts failure. Two mechanisms of vascular grafts degradation have been reported: a decrease in the density of the meshing and local ruptures of the polyethylene terephthalate fibers. The degradation occurred preferentially in some grafts zones where the textile was weakened during manufacturing process. Calcification of vascular grafts and endografts have also been reported, and may contribute to device failure, as calcification reduces compliance, increases stiffness and generated a compliance mismatch. Concerning mechanisms of endografts failure, it has been shown that the polymer used in the endobags of the Nellix EndoVascular Aneurysm Sealing (EVAS) System could lose weight and volume upon dehydration. Accordingly, the polymer deteriorated and failed to retain its weight, volume and shape, undergoing fragmentation, explaining the high rate of migration observed with this device. Endoleaks have also been investigated and endograft fabric damages responsible for endoleaks have been demonstrated. This review highlights that despite continuous improvement of vascular and endovascular devices, failure still exists. Accordingly, continuous material surveillance is mandatory in order to provide the latest information on the mechanisms responsible for degradation and implement knowledge concerning the biological and mechanical behavior of grafts and endografts.