Journal of Vascular Surgery最新文献

Objective: Adequate exposure of the anterior and lateral spinal columns, requiring mobilization of major vascular structures, is critical to instrumented lumbar spine surgery. Anterior lumbar interbody fusion (ALIF) has traditionally been the primary approach, but oblique lumbar interbody fusion (OLIF) is increasingly used. We aimed to compare intraoperative and postoperative vascular outcomes between ALIF and OLIF approaches.

Methods: A retrospective chart review identified all patients who underwent ALIF or OLIF for lumbar spine surgery between January 2017 and July 2023 at a single tertiary care center. Primary outcomes included frequency and level of vascular injury, as well as estimated blood loss. Secondary outcomes included operative times and other intra- and perioperative parameters. Adjusted analyses were performed using inverse probability of treatment weighting based on propensity scores.

Results: A total of 292 procedures were included (222 ALIF, 70 OLIF). Rates of vascular injury were similar between ALIF and OLIF after inverse probability of treatment weighting (ALIF vs OLIF: 9.5% vs 9.4%, P = .98) as well as similar blood loss overall (155 [28] cc vs 323 [178] cc, P = .16). Injuries at L4-L5 were more frequent in ALIF (5.3% vs 0%), and L5-S1 injuries were higher during OLIF (2.6% vs 7.7%, P = .015). Procedure duration was longer for OLIF than for ALIF (132 [6] minutes vs 260 [14] minutes, P < .001). No differences were observed in other postoperative outcomes, including injuries to surrounding structures, surgical site infections, and length of hospital stay.

Conclusions: In this cohort, ALIF and OLIF approaches demonstrated comparable rates of vascular injury and estimated blood loss overall; however, the level of injury differed between the procedures, with more distal injuries at L5-S1 during OLIF. OLIF procedures were also associated with longer procedure times. Both approaches remain safe and effective options for lumbar spine access when performed in high-volume centers.

Objective: Treatment of acute type B aortic dissection (TBAD) is highly variable across institutions, specialties, and practice parameters, with optimal medical therapy (OMT) accepted as both the standard of care and control group for randomized trials. In 2018, our institution developed an acute aortic protocol to standardize care during index acute TBAD presentation. This study aimed to quantify the impact of our institutional protocol.

Methods: A single-center, retrospective cohort study was performed to include patients who were admitted with acute TBAD over a 12-year period, comparing outcomes before and after protocol initiation. Acute TBAD was defined as a new dissection on imaging with primary, isolated pathology, discovered within 2 weeks of symptom onset. Patients with acute aortic syndrome variants were excluded. Primary outcomes included survival, freedom from aortic surgery, and progression to complicated status. Secondary outcomes included length of stay and periadmission use of oral antihypertensive medications. We used χ² and t tests for categorical and continuous variables, respectively; Kaplan-Meier and log-rank tests were used to assess time to event data.

Results: A total of 146 patients were admitted with acute TBAD surrounding protocol implementation: 73 pre protocol and 73 post protocol. Despite no difference in long-term survival (67 vs 88%; P = .16), postprotocol patients had better freedom from aortic surgery (45% vs 75%; P < .001). Additionally, the postprotocol cohort had a lower rate of all (42 vs 22%; P = .01) and aortic-specific (22 vs 8%; P = .004) surgery during primary acute TBAD admission. Protocol initiation resulted in lower rates of progression to complicated dissection at 72 hours (19 vs 5%; P = .03).

Conclusions: Implementation of a standardized OMT protocol decreased disease progression in the acute phase and 5-year need for aortic surgery. These data suggest that thoughtful discussions regarding future clinical trial protocolization of OMT and societal standardizations for management are warranted.

Objective: To report outcomes of endovascular repair of complex (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) by an off-the-shelf mutibranched thoracoabdominal endograft (T-Branch; Cook Medical).

Methods: This single-center, retrospective study analyzed all consecutive CAAAs and TAAAs managed in elective and urgent setting by T-Branch, between 2014 and 2024. Outcomes were reported according to the Society for Vascular Surgery reporting standards. Technical success (TS), spinal cord ischemia (SCI), and 30-day mortality were assessed as early outcomes. Freedom from reinterventions, target artery (TA) instability, and survival were assessed during follow-up.

Results: Of 130 cases, 71 (55%) and 59 (45%) patients were managed in urgent and elective setting, respectively. One hundred fifteen (89%) cases were TAAAs, and 15 (11%) were juxtarenal/pararenal aneurysms. Sixty-seven (52%) cases were performed outside the manufacturer's instructions for use (IFUs). TS was achieved in 118 (91%) cases (elective: 90% vs urgent: 92%) without difference between cases inside and outside IFUs (inside: 92% vs outside: 90%; P = .7). There were 10 (8%) SCI events (elective: 2% vs urgent: 13%) with 3 (2%) cases of paraplegia (elective: 2% vs urgent: 3%). Ruptured TAAAs (P = .02; odds ratio [OR]: 9; 95% confidence interval [CI]: 1.4-58.9) and postoperative mesenteric events (P = .01; OR: 30; 95% CI: 2.1-424.2) were risk factors for SCI. Twelve (9%) patients died within 30 days (elective: 7% vs urgent: 11%). Urgent setting (P = .03; OR: 5; 95% CI: 1.5-30.2), iliac conduit (P = .05; OR: 5; 95% CI: 1.3-9.2), and postoperative cardiac morbidity (P = .001; OR: 15; 95% CI: 1.6-18.5) were risk factors for 30-day mortality. The mean follow-up was 39 ± 22 months. Estimated 3-year freedom from TA occlusion, instability, and reinterventions was 89%, 92%, and 70%, respectively. Urgent TAAA repair (P = .003; hazard ratio [HR]: 2; 95% CI: 1.1-4.2) and Crawford's extent I-III (P = .04; HR: 3; 95% CI: 1.1-5.9) were risk factors for follow-up reinterventions. Estimated 3-year survival was 64%. Urgent TAAAs (P = .03; HR: 3; 95% CI: 1.4-5.8), paraplegia (P = .04; HR: 10; 95% CI: 1.1-86.1), and major adverse events (P = .003; HR: 2; 95% CI: 1.1-3.8) were risk factors for follow-up mortality.

Conclusions: Endovascular repair of CAAAs and TAAAs by T-Branch is effective with excellent early outcomes and satisfactory midterm TA instability, reinterventions, and survival. Predictors of early/midterm failures were identified, and they should be considered to optimize patient selection and postoperative management.

Objective: Postoperative hypotension following transcarotid artery revascularization (TCAR) is associated with greater intensive care unit (ICU) utilization, longer inpatient length of hospital stay (LOS), and increased in-hospital mortality. This study's aim was to identify key intraoperative and anatomic factors contributing to postoperative hypotension in the setting of TCAR for asymptomatic carotid stenosis. Identification and risk stratification of such high-risk patients is an important aspect of perioperative care to mitigate this occurrence and ensuing complications.

Methods: This was a retrospective, single-institutional analysis of TCAR procedures performed in 94 patients with asymptomatic carotid stenosis. The primary endpoint was the development of postoperative hypotension. Secondary outcomes were rates of ICU utilization, LOS, and postoperative transient ischemic attack or stroke.

Results: Ninety-four patients met inclusion criteria for this study. Baseline demographics between the two groups were comparable. Postoperative hypotension was more common in the post-stent dilation (PSD) group (75.0% vs 34.8%; P < .001). Among patients with postoperative hypotension, there were greater rates of ICU utilization and incidence of prolonged inpatient LOS (>1 day). However, only 19.0% of patients with postoperative hypotension following PSD required vasopressors, with a median duration of 15.9 hours. Patients that experienced postoperative hypotension had a significantly higher measured calcium volume percent (17% vs 6.5%; P = .006). Median carotid bulb dilation index was similar across groups (1.30 vs 1.30; P = .577). On multivariate logistic regression, PSD was the only factor significantly associated with postoperative hypotension (odds ratio, 4.01; 95% confidence interval, 1.36-12.78; P = .014).

Conclusions: Patients with increased vessel calcification required PSD more frequently to achieve adequate luminal gain. However, PSD was the sole intraoperative factor associated with postoperative hypotension when adjusting for covariates. This suggests that intraprocedural carotid bulb manipulation exerts increased transient distension on baroreceptors in instances of PSD, thus conferring a higher risk of this complication. The risks and benefits of post-stent balloon dilation for increased luminal gain and stent expansion should be carefully considered in these patients.

Background: Endovascular repair of large diameter infrarenal and complex abdominal aortic aneurysms has been associated with worse outcomes. Whether these associations also apply to thoracoabdominal aortic aneurysms (TAAAs) remains unclear.

Methods: We identified all patients who underwent endovascular repair for intact TAAAs between July 2010 and July 2024 in the Vascular Quality Initiative. A TAAA was defined as having a proximal aneurysm extent between zones 2 and 6, with at least one renal or visceral artery treated. Locally estimated scatterplot smoothing curves were used to visualize the relationship between preoperative aneurysm diameter and perioperative mortality, which informed the sex-specific definition of large aneurysms. Aneurysm size was categorized based on maximum diameter as follows (females/males): large (>60 mm/>65 mm), small (<50 mm/<55 mm), and medium (50-60 mm/55-65 mm). Perioperative outcomes were assessed using logistic regression models, and 5-year mortality was evaluated using adjusted Kaplan-Meier methods and Cox regression. Both large and small aneurysms were compared with medium-sized aneurysms.

Results: A total of 1309 patients were included; of these, 54% underwent repair for medium-sized aneurysms, 37% for large aneurysms, and 9.1% for small aneurysms. The median follow-up was 345 days. After adjustment, compared with medium-sized aneurysms, large aneurysms were associated with 31% higher odds of any perioperative complication (adjusted odds ratio, 1.31; 95% confidence interval, 1.00-1.72; P = .046) and nearly twice the hazard of 5-year mortality (adjusted hazard ratio, 1.94; 95% confidence interval, 1.43-2.62; P < .01). The odds of perioperative mortality and in-hospital reintervention were similar between medium-sized and large aneurysms. No significant differences in perioperative outcomes or 5-year mortality were observed between patients with small and medium-sized aneurysms.

Conclusions: After endovascular repair for TAAAs, compared with medium-sized aneurysms, large aneurysms (>60 mm in females, >65 mm in males) were associated with higher odds of any complication and higher 5-year mortality. Patients with small aneurysms (<50 mm in females, <55 mm in males) demonstrated similar perioperative outcomes and 5-year mortality compared with those with medium-sized aneurysms. These findings highlight the need to optimize management strategies for patients with large TAAAs and emphasize the importance of improved screening programs to enable earlier detection.

Objective: To conduct a multicenter pilot program, My Peripheral Arterial Disease (My PAD), for the collection of patient-reported outcomes (PROs) from patients undergoing peripheral vascular intervention (PVI) within the Vascular Quality Initiative.

Methods: Ten centers within the Society for Vascular Surgery Vascular Quality Initiative PVI Registry collected health-related quality-of-life (HR-QoL) surveys using a modified version of the Vascu-QoL-6 (VQ-6) and the EuroQoL-5D-5L (EQ-5D-5L) at three time periods: preoperative, early follow-up (1-3 months), and late follow-up (9-15 months) from April 1, 2021 to June 30, 2024. A variety of workflows including automated emails to patients were used. Survey completion rates and HR-QoL score changes were analyzed using paired Wilcoxon tests.

Results: Among 5845 eligible PVI procedures, 440 (7.5%) had a completed preoperative PRO. Of the patients who filled out a preoperative surveys, 247 (56.1%) had an early survey, and 104 (23.6%) completed all three time points. Successful collection of surveys varied across centers (preoperative 0.2%-29%, early follow-up 27%-89% of preoperative, and late follow-up 5%-60% of preoperative). Mean EQ-5D-5L scores significantly improved from preoperative to early follow-up (-2.7, P < .01) and preoperative to late follow-up (-2.9, P < .01) in the subset of 104 patients. VQ-6 scores increased from preoperative to early follow-up (+5.4, P < .01) and preoperative to late follow-up (+4.9, P < .01). Meaningful improvements in VQ-6 scores were observed for patients with claudication (N = 104) and chronic limb-threatening ischemia (N = 143) at early follow-up. No overall drop-off was observed at late follow-up (mean EQ-5D-5L + 0.5, P = .12 and VQ-6 - 0.6, P = .22).

Conclusions: The My PAD pilot study demonstrates that the collection of PROs in the form of HR-QoL surveys is possible but challenging. Successful collection of PROs requires substantial resources and hands-on effort by motivated and dedicated vascular practices. PRO collection provided clinically meaningful insight with an improvement in HR-QoL scores after endovascular revascularization. Future efforts should focus on supporting multimodal implementation, including data collection directly from patient, integrated data collection within electronic medical records, and aligning financial incentives in an effort to make patient-centered outcomes a routine part of PAD quality assessment.

Objective: To evaluate the evolution of peripheral venoarterial extracorporeal membrane oxygenation access and the impact of adjuncts such as ultrasound guided access, distal perfusion catheters, and decannulation use on vascular complications, involvement, and outcome.

Methods: A retrospective chart review of patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation was performed at a large tertiary center using patients identified from a prospectively maintained extracorporeal life support registry. The primary end point was limb ischemia requiring fasciotomy or amputation. Secondary outcomes included limb ischemia, femoral pseudoaneurysm, artery dissection, hematoma, groin wound complication, and lymph leak.

Results: Of the patients in the extracorporeal life support registry from 2017 to 2024, 447 patients met inclusion criteria for this study. The mean age of the patients at the time of cannulation was 54.8 ± 15.1 years, 28.8% of the patients were female, and the body mass index was 29.5 ± 6.8. Indication for placement on venoarterial extracorporeal membrane oxygenation was most commonly cardiogenic shock (59.4%) and cardiac arrest (39.8%). The median duration of extracorporeal membrane oxygenation support was 4 [1, 7] days, with 50.7% of patients surviving decannulation. Of the entire cohort (N = 447), 8 (1.8%) patients experienced amputation (4 of 447, 0.9%) or fasciotomy (7 of 447, 1.5%). Also, 91 of 447 (20.3%) patients experienced secondary vascular complications. On multivariate analysis, peripheral artery disease was a risk factor for vascular complication (odds ratio, 2.19; 95% confidence interval, 1.34-3.59; P < .01). The overall primary and secondary vascular outcomes were not significantly different between the distal perfusion catheter and nondistal perfusion catheter groups or between the early group (2017-2022) and contemporary group (2023-2024). There was, however, a significant increase in ultrasound guidance use (73% vs 88%, P < .01), distal perfusion placement (81.3% vs 90%, P = .02), and Fogarty balloon use at decannulation (26% vs 65%), and a significant decrease in limb ischemia (8.2% vs 3.5%, P = .049) in the contemporary time period.

Conclusions: This study presents a granular single-institution analysis of peripheral venoarterial extracorporeal membrane oxygenation cannulation practices and associated lower extremity vascular outcomes over an 8-year period. A significant reduction in limb ischemia in the contemporary cohort may reflect adaptations in practice patterns, with increased use of adjuncts such as ultrasound guidance, distal perfusion catheters, and Fogarty balloon thrombectomy at decannulation.