Journal of Vascular Surgery最新文献

Objective: Prior studies have emphasized the importance of compliance with preoperative dual antiplatelet therapy (DAPT) in patients undergoing transcarotid artery revascularization (TCAR). This investigation examines differences in perioperative outcomes after TCAR in those receiving a loading dose of antiplatelet medications on the day of the procedure vs those already maintained on DAPT.

Methods: Consecutive TCAR procedures from the Vascular Quality Initiative (2016-2022) were identified. Patients were divided into (1) those on preoperative DAPT (aspirin and P2YI2 antagonist) taken at least within 36 hours of the procedure (61.9%); (2) those on at least one antiplatelet medication who received a supplemental dose of another antiplatelet within 4 hours before the procedure (AP + loading, 37.1%); and (3) patients receiving only a loading dose (of aspirin or P2Y12 antagonist) without prior use of antiplatelet therapy (1%). In-hospital and 30-day outcomes were compared between the three groups using univariable and multivariable analyses.

Results: A total of 22,310 patients were on DAPT; 13,392 were on at least one antiplatelet and received a supplemental dose (AP + loading) and 361 patients received a loading dose on the day of the intervention. On univariable analysis, there was no significant difference in in-hospital or 30-day outcomes between the three groups, except for an increased rate of in-hospital stent thrombosis/occlusion in patients loaded with antiplatelet medications on the day of TCAR (n = 2 [0.6%]), compared with those maintained on DAPT (n = 23 [0.1%]) and patients in the AP + loading group (n = 26 [0.2%]) (P = .01). After adjusting for baseline differences between the three groups, no significant association was observed between the groups and in-hospital stroke/death or bleeding complications. However, compared with patients maintained on DAPT, patients receiving antiplatelet loading had higher odds of stent thrombosis/occlusion (odds ratio, 1.92; 95% confidence interval, 1.08-3.4; P = .03). Among patients in the AP + loading group, those maintained on aspirin preoperatively and receiving another antiplatelet loading on the day of the intervention were more likely to have stent thrombosis.

Conclusions: This study demonstrates that administering loading or supplemental doses of antiplatelet medication(s) to rapidly achieve therapeutic levels on the day of TCAR is not associated with higher rates of in-hospital stroke or bleeding complications. However, an increase in stent thrombosis or occlusion was noted in patients receiving a loading dose or supplementation of antiplatelet medications and warrants further investigation. In elective cases, it might be safer to delay intervention until patients receive adequate DAPT regimen, especially if patients are not maintained on P2Y12 inhibitors preoperatively.

Objective: Popliteal artery entrapment syndrome (PAES) results from an anomalous relationship between the popliteal artery and the myofascial structures of the popliteal fossa. The long-term treatment outcomes are not well-known because of the rarity of the disease. This study aimed to establish a nationwide collective dataset and analyze treatment outcomes.

Materials and methods: The Korean Rare Vascular Ailment Research Experts performed nationwide retrospective data collection on PAES from 2003 to 2023. Fourteen tertiary medical centers participated, and data from 111 limbs of 96 patients who received invasive treatment with sufficient baseline and follow-up data were used for statistical analysis.

Results: The median age was 37.5 years (range, 14-82 years), and 92.8% were male. Eighty-one percent of the patients presented with claudication, and 13.5% with rest pain. The popliteal arteries were stenotic in 24.3% and occluded in 75.6%. A total of 109 open surgeries and two endovascular treatments were performed. The primary patency rates at 1, 5, and 9 years were compared according to the surgery type: musculotendinous section (MTS) only group (n = 25), 94.7%, 94.7%, and 94.7%; MTS with in situ revascularization group (n = 55), 90.1%, 77.0%, and 77.0%; and bypass surgery group (n = 29), 88.6%, 82.7%, and 68.9%, respectively. In multivariate analysis for the loss of primary patency, bypass using PTFE graft (hazard ratio, 9.676; 95% confidence interval, 1.032-90.736; P = .047) was a statistically significant risk factor.

Conclusion: Patients with early-stage PAES treated with MTS alone showed excellent long-term primary patency. When arterial reconstruction was needed in PAES, MTS with in situ revascularization and bypass surgery showed comparable long-term primary patency. However, bypass surgery using PTFE graft should be avoided due to the high risk of occlusion.

Objective: The thoracic branch endoprosthesis (TBE) (W.L. Gore) offers an off-the-shelf single option for thoracic endovascular aortic repair (TEVAR) of aortic arch pathology with sealing in zones 0 to 2. This study reports the early outcomes of TBE-TEVAR for acute indications.

Methods: Clinical data, imaging, and outcomes of patients treated with TBE-TEVAR at seven institutions were retrospectively reviewed (March 2017 to March 2024). Patients treated for complicated aortic dissection, symptomatic aneurysm/pseudoaneurysm, or blunt traumatic aortic injury by urgent/emergent repair were included. End points were 30-day mortality, major adverse events (mortality, myocardial infarction, prolonged intubation, stroke, paraplegia, dialysis, or bowel ischemia), and technical success.

Results: Of 356 patients treated by TBE-TEVAR, 107 (69.0% male; mean age, 60 ± 15 years) underwent repair for acute indications including 70 dissections (65%), 21 symptomatic aneurysms/pseudoaneurysms (20%), and 16 blunt traumatic aortic injuries (15%). Eight patients (8%) had repair immediately after open ascending repair of a type A dissection. Proximal sealing was in zone 2 in 91 patients (89%) and zone 0 to 1 in 11 patients (11%) who required cervical debranching. Technical success was achieved in all (99%) except one patient with acute dissection and aneurysmal degeneration requiring staged repair. At 30 days, two patients (2%) died, and 19 patients (18%) developed major adverse events, including stroke in six patients (6%) and paraplegia in six patients (6%). Five patients (5%; all Zone 2) had retrograde dissections, all treated for acute or subacute dissection, with no mortality. Mean follow-up was 55 ± 171 days, and 96 patients (94%) had follow-up imaging. Type IA or III endoleak occurred in seven patients (7%), retrograde branch occlusion in one (1%), and eleven (10%) required reintervention. Cumulative aortic-related mortality was three (3%) from aortic rupture.

Conclusions: Urgent/emergent TEVAR with the Gore TBE device in acute pathology offers low mortality, stroke, and paraplegia risk. Longer follow-up is needed to assess effectiveness of the repair.

Objective: We assessed if age was an effect modifier in a pooled analysis of two randomized trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) in asymptomatic patients, CREST and ACT 1.

Methods: We analyzed data from 2544 patients aged <80 yearas with ≥70% asymptomatic carotid stenosis randomized to CAS or CEA (n_CREST = 1091; n_{ACT 1} = 1453) who were recruited between 2000 and 2013. Age was considered in four strata (<65, 65-69, 70-74, and 75-79 years). The primary outcome was any stroke, myocardial infarction, or death during the peri-procedural period, or ipsilateral stroke afterwards. The secondary outcome of any stroke or death during the peri-procedural period or ipsilateral stroke within 4 years was also analyzed.

Results: For the primary outcome, there were no CAS vs CEA treatment differences within any age stratum (P > .05). For the secondary outcome of stroke or death, those randomized to CAS age 75 to 79 yearas were at approximately four times greater risk compared with those randomized to CEA (10% vs 2%; hazard ratio, 4.41; 95% confidence interval, 1.31-14.83). No treatment differences between CAS and CEA were detected for the three younger age strata, <65, 65 to 69, and 70 to 74 years (P > .05). For patients randomized to CAS, the risk of the primary endpoint for those aged 75 to 79 years was higher than the risk for those age <65 years (11% vs 4%; hazard ratio, 2.90; 95% confidence interval, 1.52-5.53), without significant differences between other strata (P > .05). For those randomized to CEA, there were no differences between age strata (P > .1).

Conclusions: This pooled analysis of 2544 asymptomatic patients in CREST and ACT 1 shows a higher stroke or death risk for CAS compared with CEA in only the oldest age group, 75 to 79 years. For patients randomized to CAS, there was an increased risk for patients aged 75 to 79 years. No increased risk by age was found for patients randomized to CEA. Hence, the clinical management of asymptomatic patients above age 75 years must be individualized to optimize outcomes in the context of advances in CAS since 2013.

Objective: This study aimed to develop a prediction tool to identify abdominal aortic aneurysms (AAAs) at increased risk of rupture incorporating demographic, clinical, imaging, and medication data using artificial intelligence (AI).

Design: A development and validation study for individual prognosis using AI in a case-control design.

Methods: From two Danish hospitals, all available ruptured AAA cases between January 2009 and December 2016 were included in a ratio of 1:2 with elective surgery controls. Cases with previous AAA surgery or missing preoperative scans were excluded. Features from computed tomography angiography scans and hospital records were manually retrieved. The sample was divided randomly and evenly into developmental and internal validation groups. A SHapley Additive exPlanations Feature Importance Rank Ensembling (SHAPFire) AI tool was developed using a gradient boosting decision tree framework. The final SHAPFire AI model was compared with models using (1) solely infrarenal anterior-posterior diameter and (2) all available features.

Results: The study included 637 individuals (84.8% men, mean age 73 ± 7 years, 213 ruptured AAAs). The SHAPFire AI incorporated 20 of 68 available features, and aneurysm size, blood pressure, and relationships between height and weight were given highest rankings. The receiver operating characteristic curve for the SHAPFire AI model displayed a significant increase in accuracy identifying ruptured AAA cases compared with the conventional model based solely on diameter with areas under the curves of 0.86 ± 0.04 and 0.74 ± 0.03 (P = .008), respectively. SHAPFire AI was comparable in performance with the model using all features.

Conclusions: This study successfully developed a SHAPFire AI tool to identify AAAs at increased risk of rupture with significantly higher accuracy than diameter alone. External validation of the model is warranted before clinical implementation.

Objective: Wound, Ischemia, and foot Infection (WIfI) staging was established to provide objective classification in patients with chronic limb-threatening ischemia (CLTI) and to predict 1-year major amputation risk. Our goal was to validate WIfI staging using data from the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial.

Methods: Data from the BEST-CLI Trial, a prospective randomized trial comparing surgical revascularization (OPEN) and endovascular revascularization (ENDO), were used to assess the association of WIfI stage on long-term outcomes in an intention-to-treat analysis. Patients were prospectively allocated to two cohorts, which included patients with and without adequate single-segment greater saphenous vein, respectively. The primary outcome of this analysis was major amputation.

Results: There were 1568 patients analyzed, representing 86% of the entire trial population; of these 35.5%, 29.6%, and 34.9% were categorized as WIfI stage 4, WIfI stage 3, and WIfI stage 1/2, respectively. There were 1223 patients (606 OPEN, 617 ENDO) and 345 patients (OPEN 172, ENDO 173) in cohorts 1 and 2, respectively. On unadjusted Kaplan-Meier analysis, WIfI clinical stages 4 and 3, compared with WIfI stage 1/2, were associated with higher rates of major amputation (21.4%, 16.2% vs 10.7%), death (33.5%, 35.7% vs 24.6%), amputation/death (44.9%, 44.5% vs 31.3%), major adverse limb events (MALEs)/death (34.4%, 33.9% vs 29.5%), and reintervention/amputation/death (69.9% vs 69% vs 60.4%) (P < .05 for all) at 3 years. On risk-adjusted analysis, compared with WIfI stage 1/2, major amputation was associated with WIfI stage 4 (hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.44-2.96; P < .001) and WIfI stage 3 (HR, 1.62; 95% CI, 1.1-2.37; P = .013) stages. Death was associated with WIfI stage 4 (HR, 1.3; 95% CI, 1.03-1.63; P = .027) and WIfI stage 3 (HR, 1.42; 95% CI, 1.13-1.79; P = .003). MALE/death was associated with WIfI stage 4 (HR, 1.29; 95% CI, 1.02-1.63; P = .036. Reintervention amputation/death was associated with WIfI stage 4 (HR, 1.28; 95% CI, 1.09-1.50; P = .03) and WIfI stage 3 (HR, 1.22, 99% CI 1.03-1.43) ; P = .018). When examining OPEN vs ENDO revascularization by each WIfI stage, OPEN intervention was favored in cohort 1 for MALE/death for each stage.

Conclusions: In BEST-CLI, WIfI stage was strongly associated with major amputations, death, and MALEs/death after revascularization for CLTI. Cohort 1 patients, with an adequate preoperative single segment greater saphenous vein, had lower MALE/death with OPEN intervention across all WIfI stages. This validation of WIfI score in a prospective multicenter trial reinforces its importance in shared-decision making, informed consent, and prognostication.

Background: Heart failure is common in patients receiving hemodialysis. A high-flow arteriovenous fistula (AVF) may represent a modifiable risk factor for heart failure and death. Currently, no tools exist to assess the risk of developing a high-flow AVF (>2000 mL/min). The aim of this study was to use machine learning to develop a predictive model identifying patients at risk of developing a high-flow AVF and to examine the relationship between blood flow, heart failure, and death.

Methods: Between 2011 and 2020, serial AVF blood flows were measured in 366 prevalent hemodialysis patients at two tertiary hospitals in Australia. Four prediction models (deep neural network and three separate tree-based algorithms) using age, first AVF flow, diabetes, and dyslipidemia were compared to predict high-flow AVF development. Logistic regression was used to assess the relationship between AVF blood flow, heart failure, and death.

Results: High-flow AVFs were present in 31.4% of patients. The bootstrap forest predictive model performed best in identifying those at risk of a high-flow AVF (under the curve, 0.94; sensitivity 86%; specificity 83%). Heart failure before vascular access creation was identified in 10.2% of patients with an additional 24.9% of patients developing heart failure after AVF creation. Long-term mortality after access formation was 27%, with an average time to death after AVF creation of 307.5 ± 185.6 weeks. No univariable relationship using logistic regression was noted between AVF flow and incident heart failure after AVF creation or death. Age, flow at first measurement of >1000 mL/min, time to highest AVF flow, and heart failure predicted death after AVF creation using a general linear model.

Conclusions: Predictive modelling techniques can identify patients at risk of developing high-flow AVF. No association was seen between AVF blood flow rate and incident heart failure after AVF creation. In those patients who died, time to highest AVF flow was the most important predictor of death after AVF creation.

Objective: Open surgery is the gold standard for patients a connective tissue disorder (CTD). Thoracic endovascular aortic repair (TEVAR) is used in emergencies and patient-specific situations. Limited data on durability of TEVAR in patients with CTD exist. The purpose of this study was to investigate the durability, complications, and outcomes of TEVAR in patients with CTD.

Methods: This single-center retrospective study included 40 patients with CTD who underwent TEVAR for thoracoabdominal aortic aneurysm or aortic dissection from February 2014 to April 2021. CTDs included Marfan syndrome, Loey-Dietz syndrome, and nonspecific CTD-related diagnoses. Primary outcomes included aortic-related morbidities, time to and type of postoperative reinterventions, and time to open/hybrid conversion. Time to conversion and reintervention was calculated using Kaplan-Meier estimation. Predictors of reintervention and open/hybrid conversion were evaluated using Cox proportional hazards models.

Results: The median age was 53 years with 52.5% of the patients being female. Marfan syndrome was diagnosed in 57.5%, Loey-Dietz syndrome in 2.5%, and 40% had a diagnosed nonspecific or other CTD. Thirty-two (80%) had prior aortic interventions. Thoracic aneurysm existed in 52.5% and dissection in 82.5%. The average maximum thoracic aortic diameter was 55.2 mm. There were two mortalities within the first month. Of the remaining 38 patients, 71.1% had aneurysm-related morbidities, including 81.5% with aneurysmal degeneration and 33.3% with endoleak. Overall, 62.5% required reintervention. Of those, median time to reintervention was 9.1 months, including redo-TEVAR/extension in 32%, ascending/arch repair in 24%, open thoracoabdominal aortic repair in 56%, and false lumen embolization in 16%. Open conversions and reintervention were most likely to occur within the first year, with freedom of open conversion of 67.2% at 1 year, and 59.7% at 2 and 3 years, and freedom of reintervention of 49.8%, 36.0%, and 30.0% at 1, 2, and 3 years, respectively.

Conclusions: This study suggests that TEVAR for patients with CTD can be performed safely; however, patients are at high risk for aortic-related morbidities and reintervention. Reinterventions and open conversion are common and more likely to occur within 1 year. TEVAR should remain limited in this population until more durable outcomes are possible.

Objective: The current medical landscape lacks comprehensive data regarding the impact of preoperative smoking status on both short and long-term outcomes for patients undergoing carotid endarterectomy (CEA). This study seeks to elucidate the influence of smoking cessation on in-hospital and long-term outcomes in this patient population.

Methods: Data were collected from the Vascular Quality Initiative for all asymptomatic patients who underwent CEA from 2016 to 2023. Outcomes were compared across three different smoking status groups: never smoke (NS), current smoker (CS), and quit >30 days ago. Our primary outcomes included in-hospital stroke, death, and myocardial infarction. Secondary outcomes included 1-year and 3-year death. We used inverse probability of treatment weighting to balance the following preoperative factors: age, gender, race, ethnicity, body mass index, diabetes, coronary artery disease, prior congestive heart failure, renal dysfunction, chronic obstructive pulmonary disease, hypertension, prior coronary artery bypass grafting/percutaneous coronary intervention, prior CEA/carotid artery stenting, degree of stenosis, urgency, anesthesia type, and medications.

Results: The final analysis included 85,237 CEA cases with 22,343 NS (26.2%), 41,731 who quit >30 days ago (49.0%) , and 21,163 CS (24.8%). Notably, NS tended to be older and more likely to be female. In contrast, patients who quit >30 days ago were more likely to have comorbidities, including obesity, coronary artery disease, prior congestive heart failure, and CKD, as well as prior procedures. Patients who are CS were more likely to have chronic obstructive pulmonary disease and stenosis of >80%. After inverse probability of treatment weighting, we found no statistical difference for in-hospital stroke, death, myocardial infarction outcomes across the three groups. However, the long-term outcomes revealed quit >30 days ago and CS compared with NS had higher odds of 1-year death (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.2-1.5; P < .001; OR, 1.4; 95% CI, 1.2-1.6; P < .001) and 3-year death (OR, 1.5; 95% CI, 1.3-1.6; P < .001; OR, 1.5; 95% CI, 1.4-1.7; P < .001), respectively. There was no significant difference in midterm mortality outcomes between those who quit >30 days ago and CS.

Conclusions: In this large national study, we found that smoking status did not emerge as a substantial determinant of adverse short-term outcomes for asymptomatic patients undergoing CEA. However, smoking did adversely affect midterm mortality in these patients. In light of these findings, our study suggests that delaying CEA for smokers may not be warranted. It is crucial to recognize that the complex relationship between smoking and surgical outcomes requires further exploration and validation through additional prospective studies.