Journal of Vascular Surgery最新文献

Background: Acute type A aortic dissection (ATAD) can cause visceral malperfusion. Central aortic repair may resolve malperfusion, but some require further intervention. This study aimed to review outcomes after ATAD presenting with visceral malperfusion and to evaluate the predictive value of true lumen (TL) morphologies in preoperative computed tomography scan for persistent superior mesenteric artery (SMA) ischemia after central repair.

Methods: Open surgical repair of ATAD performed between 2008 and 2023 at our institution was reviewed retrospectively. Patients with central repair first approach were included for analysis. Patients with inadequate computed tomography scan data to assess luminal morphology were excluded. TL morphology was reviewed at the diaphragm level and categorized as concave or convex. The malperfusion pattern, static vs dynamic, was assessed at SMA orifices. Data were analyzed using a contingency table and parametric and nonparametric methods.

Results: A total of 543 open ATAD repairs were performed. Of these, 263 patients were eligible under the inclusion criteria and, subsequently, analyzed. The mean age was 57±14, and 83 (31%) patients were female. SMA malperfusion developed in 42 (16%) of the 263 patients, including 26 patients with dynamic obstruction, 6 patients with static obstruction, and 10 patients with dynamic and static obstruction. Regarding dissection flap morphology, 78 patients (30%) exhibited concave morphology, while 185 patients (70%) had convex morphology. TL diameter was significantly larger in convex than concave (concave: 6 mm vs convex: 16 mm; P < .0001). The prevalence of clinically significant SMA malperfusion was higher in concave-shaped TL (concave 41% vs convex 5%; P < .0001). Dynamic SMA obstruction was more frequently observed in the concave group (concave 72% vs convex 30%; P < .001). However, significantly more patients with convex-shaped TL required bowel resection than concave (concave 13% vs convex 70%; P < .001). The operative mortality was higher in the convex group, although statistically insignificant (concave 19% vs convex 50%; P = .0059).

Conclusions: Central repair first strategy could resolve more than 80% of SMA malperfusion in ATAD when the TL is concave-shaped at the level of the diaphragm. Convex-shaped TL morphology was associated with less incidence of SMA malperfusion but was more frequently associated with static obstruction and higher incidence of bowel resection. The morphology evaluation of the TL at the diaphragm level may be simple and beneficial for surgical planning for ATAD presenting with SMA malperfusion.

Background: Endovascular treatment of the common femoral artery (CFA) and its bifurcation is currently recommended for patients with hostile groin (prior femoral bifurcation open surgery, history of radiotherapy) or severe comorbidities (advanced age, frailty, obesity). Preliminary results have shown favorable outcomes. Among the different endovascular techniques (atherectomy, intravascular lithotripsy, plain balloon angioplasty, drug-coated balloon angioplasty, stenting), stents are mainly used but the best type of stent to use is still debated. The aim of this study was to assess the value of balloon-expandable stents (BES) and self-expandable stents (SES) for stenosis of the femoral bifurcation.

Methods: Consecutive patients with stenosis of the CFA and its bifurcation were included from 2016 to 2022. Demographic data, the type of stent used, procedural data, and angiographic variables were collected. Groups were defined according to the type of stent implanted. Primary patency was defined as a binary end point based on a duplex ultrasound peak systolic velocity ratio of ≤2.4 as assessed by duplex ultrasound examination, in the absence of clinically driven target lesion revascularization (TLR) or bypass of the target lesion. Secondary outcomes were clinical sustained improvement, freedom from TLR at 12 months, mean ankle-brachial index improvement, primary-assisted patency, and secondary patency.

Results: A total of 90 procedures conducted in 77 patients were included in this study, 26 in the SES group and 64 in the BES group. The most common symptomatology according to the Rutherford classification was class 2, 3, and 4 (28%, 48%, and 8%, respectively). The type of lesions in the CFA, assessed using the Azema classification, were comparable between both groups (SES/BES group type 2: 31%/27%; type 3: 54%/62%). At 12 months, the primary patency rates for SES and BES were 88% (26/26 patients) and 72% (58/64 patients) (P = .10). At 12 months, freedom from TLR rates for SES and BES were 97% vs 81%, respectively (P = .13).

Conclusions: SES for CFA stenosis show a trend toward better patency and freedom from TLR rates at 12 months. However, controlled studies are warranted to further investigate the significance of this trend.

Background: Obesity represents a prevalent and escalating health concern among vascular surgery patients. Evidence pertaining to the influence of body mass index (BMI) on clinical outcomes after fenestrated-branched endovascular aneurysm repair (B/FEVAR) remains unclear. This study aims to assess the effect of obesity on short- and midterm clinical outcomes among individuals undergoing B/FEVAR.

Methods: This was a single-center retrospective analysis of all patients who underwent B/FEVAR from 2007 to 2020, with a median follow-up of 3.3 years (interquartile range, 1.6-5.3 years). Obesity was defined as a BMI of ≥30 kg/m². Patients were divided into nonobese (NO) and obese cohorts according to their BMI. Outcomes were compared between the two groups subsequently.

Results: A total of 264 patients, 96 obese and 168 NO, were included. Patients with obesity were younger (72.8 ± 6.9 years vs 76.0 ± 7.3 years; P < .001), but had a higher prevalence of diabetes mellitus (27.1% vs 12.0%; P = .01) and dyslipidemia (80.2% vs 68.5%; P = .03). Both cohorts had similar rates of percutaneous access (37.5% for obese vs 35.1%; P = .7), and no significant differences in the rate of conversion to open access (8.3% for obese vs 4.2% for NO; P = .16). Technical success was similar between the cohorts (89% for obese vs 86%; P = .59). Major adverse events (MAEs) were higher in the NO group (13.1% vs 4.2%; P = .02). Patients in the obese cohort suffered more access site related infections (7.3% vs 1.2%; P = .01). All-cause mortality over 5 years was significantly higher in the NO group (35.1% vs 21.9%; P = .02). No statistical differences were found in spinal cord injury or dialysis requirement rates. Furthermore, on follow-up at 5 years, endoleak, branch instability, and reintervention rates were not statistically different between the two cohorts.

Conclusions: Patients with obesity are on average younger; however, they were more likely to suffer access site infections compared with NO patients. They had increased survival rates on follow-up, although rates of reinterventions and endoleaks were similar between the two cohorts. Our study demonstrates that, despite higher comorbidities, patients with obesity had similar intraoperative success with decreased postoperative mortality; however, access site infections remains a significant clinical concern.