Journal of Vascular Surgery最新文献

Objective: This study aimed to evaluate indications and outcomes of open surgical conversion (OSC) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm using a multicenter registry in Japan.

Methods: Thirteen vascular centers retrospectively reviewed patients who underwent OSC after prior EVAR between 2006 and 2024. Baseline characteristics, indications, procedural details, and outcomes were analyzed. The primary end point was 30-day mortality. Secondary end points were overall survival, aneurysm-related survival, and freedom from retreatment.

Results: A total of 208 patients (85.6% males; median age, 78 years) were included. The median abdominal aortic aneurysm diameter was 62 mm. The median interval from initial EVAR to OSC was 5.2 years. Indications for OSC were type II endoleak with sac enlargement (47.1%), type I endoleak (23.1%), type V endoleak with sac enlargement (13.0%), infection (10.1%), and type III endoleak (9.6%). The most frequently used stent graft was the Excluder, followed by Endurant and Zenith. Complete stent graft removal was performed in 41 patients, partial removal in 51, and 116 underwent OSC with stent graft preservation. Thirty-eight patients (18.3%) presented with rupture and 48 (23.1%) underwent urgent OSC. The 30-day mortality rate was 4.3% in the overall cohort, 2.4% in nonruptured cases, and 13.2% in ruptured cases. Rupture was a risk factor for 30-day mortality (hazard ratio, 5.93; 95% confidence interval, 1.59-22.1; P = .008). At 10 years, overall survival and aneurysm-related mortality were 58.4% and 14.8%, respectively, and freedom from retreatment rate was 87.5% at 10 years.

Conclusions: Type II endoleak was the leading common indication for OSC after EVAR in this multicenter retrospective study in Japan. Rupture at OSC markedly increased 30-day mortality, even in patients with type II endoleak. Further studies are needed to refine elective indications for OSC to prevent aneurysmal rupture and avoid treatment delay.

Background: In October 2023, Medicare expanded coverage for carotid stenting to include standard-risk beneficiaries, prompting substantial debate surrounding the potential impact on procedure use, most notably, for transfemoral carotid artery stenting (TFCAS). Since this coverage expansion, it remains unknown whether there has been a concordant change in carotid stenting use and resultant long-term stroke risk. Therefore, our objective was to document trends in procedure use of TFCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in response to the coverage expansion and compare the respective long-term stroke risks.

Methods: We performed a retrospective study using Truveta electronic health record data. Truveta provides daily updated electronic health record data from >800 hospitals and 100 million patients. We studied patients who underwent TCAR, CEA, or TFCAS from January 2016 to December 2024. We calculated the procedure rate for each quarter and performed an interrupted time series (ITS) analysis to assess the change from Q3 2023 (Medicare policy change) to Q4 2024. We used Kaplan-Meier analysis and Cox regression to compare the long-term stroke risk among asymptomatic patients.

Results: We identified 6473 TCAR patients (65.9% asymptomatic), 36,224 CEA patients (61.6% asymptomatic), and 11,626 TFCAS patients (50.1% asymptomatic). The procedure rate per 100,000 patients from Q3 2023 (Medicare policy change) to Q4 2024 decreased by 39.3% for TCAR (ITS P < .001) and 38.4% for CEA (ITS P = .035). The procedure rate increased by 2.1% for TFCAS (ITS P = .365). Among asymptomatic patients, the freedom from stroke at 8 years for TCAR, CEA, and TFCAS was 87.2% (95% confidence interval [CI], 84.0%-90.5%), 86.3% (95% CI, 85.5%-87.2%), and 79.8% (95% CI, 77.6%-82.0%), respectively. Compared with CEA, the adjusted hazard ratio of stroke was 0.83 (95% CI, 0.72-0.97) after TCAR and 1.41 (95% CI, 1.27-1.56) after TFCAS.

Conclusions: TFCAS use has remained largely unchanged since the Medicare coverage expansion, refuting any perception that the Medicare policy shift would substantially impact real-world carotid practice. Interestingly, TCAR and CEA rates have decreased over time, despite having a lower long-term stroke risk. These findings highlight the need for longitudinal procedure use surveillance to ensure optimal outcomes among patients undergoing carotid revascularization.

Background: The optimal anesthetic strategy for carotid artery stenting (CAS) remains uncertain. General anesthesia (GA) ensures immobility and airway control but may increase hemodynamic instability, whereas monitored anesthesia care or local anesthesia permits real-time neurological assessment. This multicenter study evaluated the association between anesthetic modality and clinical outcomes after CAS.

Methods: Data were prospectively collected from 15 comprehensive stroke centers in the United States between January 2023 and December 2024. Adults undergoing CAS for atherosclerotic carotid stenosis were included. Propensity score matching (1:2 nearest neighbor, without replacement) was performed using preprocedural National Institutes of Health stroke scale to balance baseline differences between GA and non-GA cohorts. The primary outcomes were 30-day procedure-related mortality, ischemic or hemorrhagic stroke, and myocardial infarction. Logistic regression identified independent predictors of mortality.

Results: Among 888 patients (222 GA, 666 non-GA), the groups were well-balanced after matching (220 vs 668). Overall complication rates were low (6%-7%). Thirty-day mortality was 4.1% with GA vs 1.8% with non-GA (P = .14). In regression, non-GA was associated with lower all-cause mortality (odds ratio, 0.11; 95% confidence interval, 0.01-0.85; P = .03). Functional recovery was superior with non-GA (mean 30-day modified Rankin Scale 1.25 vs 1.60; P = .012). Length of stay was shorter in the non-GA group (5.2 days vs 6.2 days; P = .021).

Conclusions: Both anesthetic approaches were safe, but non-GA was associated with slightly better functional outcomes and lower mortality rates. When clinically feasible, monitored anesthesia care or local anesthesia may offer superior periprocedural safety and recovery in CAS.

Objective: Pediatric vascular surgery is infrequent, heterogeneous, and lacks standardized care models. We sought to characterize the full spectrum of pediatric vascular surgery consultations, interventions, multidisciplinary involvement, and long-term outcomes within an integrated academic health system over a 20-year period.

Methods: We performed a retrospective cohort study of all pediatric patients (aged <18 years) evaluated by vascular surgery from 2004 to 2024 at a single tertiary academic center with an affiliated children's hospital. Demographics, consultation characteristics, operative details, and longitudinal outcomes were abstracted from the electronic health record. Interventions were categorized as arterial, aortic, or venous. Descriptive statistics were used.

Results: A total of 342 pediatric patients were evaluated by vascular surgery across inpatient and ambulatory (clinic-based) settings during the study period. The patients were 51.5% male and had a median age of 14.2 years (interquartile range, 10.2-16.4 years). Inpatient consultations accounted for 54.1%, and 60.0% were urgent or emergent. Most consultations (62.0%) did not require operative intervention. Vascular interventions were performed in 129 patients (37.7%), predominantly by vascular surgeons (91.5%). Arterial interventions (n = 81) included trauma repairs, renal artery reimplantation, decompression or entrapment syndromes, patch angioplasty, and 31 bypasses. Autogenous conduit was used in 96.8% of bypasses and demonstrated primary vein graft patency was 72.4% at a median 5-year follow-up, with no failures attributable to somatic growth. Aortic interventions (n = 10) included thoracic endovascular repair for blunt thoracic aortic injury (n = 4) and varied abdominal reconstructions (n = 5), all with durable early and midterm outcomes; one late embolic event occurred after thoracic endovascular repair. Venous interventions (n = 37) most commonly included thoracic outlet decompression (n = 12), dialysis access surgery (n = 6), and oncological vascular assistance (n = 4). Reinterventions occurred primarily in dialysis access patients. The overall median follow-up was 4.6 years. Of 85 patients who reached adulthood, 32.9% successfully transitioned to adult vascular surgery care.

Conclusions: Pediatric vascular surgery represents a high-acuity, consult-driven practice with a broad disease spectrum and excellent operative safety when intervention is required. However, substantial gaps in longitudinal surveillance and transition to adult care persist, even within an integrated health system. Structured pediatric vascular care pathways and formal transition strategies are needed to ensure durable, lifelong outcomes.

Objective: The purpose of this study was to evaluate the impact of left renal vein (LRV) division in patients undergoing open abdominal aortic aneurysm (AAA) repair.

Methods: This systematic review and meta-analysis was registered in the PROSPERO register of systematic reviews (CRD42025640222) and conducted in accordance with Cochrane's guidelines for systematic review and meta-analysis. The PubMed, EMBASE, and Cochrane databases were searched systematically for studies comparing outcomes of patients who underwent open AAA repair with and without LRV division. Two authors screened the search results and collected data of interest independently, according to the PRISMA protocol. The primary outcome was 30-day mortality and secondary outcomes were short and long-term renal function. Risk ratios (RRs) and mean differences (MDs) with corresponding 95% confidence intervals (CI) were estimated using a random effects model. Significance was defined as a P value of <.05.

Results: A total of 190 studies were screened for inclusion, of which nine studies (8 cohort studies and 1 case-control study) met the inclusion criteria. These studies included a total of 1324 patients, 350 of whom underwent LRV division and 974 patients who did not. Meta-analysis revealed no significant difference in 30-day mortality (28/205 vs 123/512; RR, 0.90; 95% CI, 0.63-1.29; P = .42; I² =0%), acute kidney injury (RR, 1.74; 95% CI, 0.39-7.83; P = .33; I² = 69%), need for dialysis (4/178 vs 10/473; RR, 1.61; 95% CI, 0.54-4.84), discharge estimated glomerular filtration rate (MD, -0.32; 95% CI, -2.57 to 1.92; P = .60; I² = 0%), and discharge serum creatinine (MD, -0.01; 95% CI, -0.02 to 0.01; P = .29; I² = 0%). LRV division was associated with an increase in postoperative serum creatinine (MD, 0.08; 95% CI, 0.04-0.11; P = .009; I² = 0%) compared with patients with the LRV left intact.

Conclusions: Among patients undergoing AAA open surgical repair, our results demonstrate that LRV division is not associated with an increase in 30-day mortality or worse renal function.

Objective: Open bypass with single segment great saphenous vein is the optimum procedure for chronic limb-threatening ischemia (CLTI). However, many CLTI patients require revascularization after a prior failed lower extremity bypass or endovascular therapy (ET). Hence in this study, we aimed to investigate outcomes of bypass vs ET in patients with prior bypass as well as in those with prior ET.

Methods: The Vascular Quality Initiative database was queried for CLTI patients who underwent infrainguinal open or endovascular revascularization after a prior lower extremity bypass or ET from 2016 to 2023. Patients with prior ipsilateral major amputation (MA), or concomitant procedures were excluded. Two well matched (SD<0.1) propensity score-matched (PSM) cohorts (1:1) were produced for patients who underwent 1-prior bypass and 2-prior ET. Cox regression, Kaplan Meier survival analysis, and Log Rank test were used to analyze one-year outcomes of bypass vs ET in both groups. Outcomes include mortality, MA, reintervention, and major adverse limb events [MALE (reintervention or MA)].

Results: A total of 53,793 patients were included. In the group with prior bypass, 3499 (60%) underwent ET and 2338 (40%) had another bypass. While in the prior ET group, 39,738 (82.9%) had another ET and 8218 (17.1%) had a bypass. PSM produced two well matched cohorts in each group [prior bypass 1047 pairs; prior ET 5603 pairs]. After matching, there was no significant difference in any of the outcomes between bypass and ET after a prior bypass. There was a trend of lower one-year mortality with bypass after a prior bypass (HR, 0.79; 95% CI, 0.61-1.03; P = .078]. However, in patients with prior ET, bypass was associated with lower hazard of mortality (HR, 0.82; 95% CI, 0.73-0.91; P < .001), reintervention (HR, 0.73; 95% CI, 0.63-0.83; P < .001), and MALE/death (HR, 0.91; 95% CI, 0.84-0.98; P = .015] at one year compared with ET.

Conclusions: This real-world multi-institutional study revealed that outcomes of revascularization after a prior lower extremity bypass are not associated with procedure type. However, in patients with prior ET, open lower extremity bypass is associated with lower hazard of mortality and reintervention as well as better MALE-free survival compared with secondary endovascular intervention.

Objective: To evaluate morphological and clinical outcomes after false lumen occluder (FLO) implantation for postdissection thoracoabdominal aortic aneurysm and to investigate the impact of adjunctive false lumen embolization on aortic remodeling.

Methods: A retrospective single-center study included 71 patients (median age, 64 years; interquartile range, 58-70 years; 77.5% male) with chronic type B aortic dissection treated between June 2018 and December 2024 with third-generation FLO implantation during thoracic endovascular aortic repair (TEVAR) or fenestrated/branched repair. Aortic, true lumen (TL), and false lumen (FL) volumes were quantified using three-dimensional reconstructions on Aquarius software. FLO remodeling was defined as compression of the occluder with a crescent shape on follow-up imaging. Aortic remodeling (FL regression) was defined as a ≥10% reduction in FL volume, stability as ±10% change, and enlargement as >10% increase compared with baseline. Associations between clinical, anatomical, and procedural variables and remodeling outcomes were analyzed using nonparametric and mixed effects models.

Results: Across 268 imaging examinations, total aortic and FL volumes decreased significantly over time, whereas the TL volume expanded (all P < .001). The median total aortic volume declined from 796 cm³ at 1 month to 706 cm³ at 4 years, and the FL volume decreased from 501 cm³ to 296 cm³, whereas TL volume increased from 287.5 cm³ to 358 cm³. Median follow-up was 13.3 months (interquartile range, 5.6-36.5 months). Aortic remodeling occurred in 83.1% of patients, FL stability in 12.7%, and enlargement in 4.2%. Regression was more frequent in younger patients (P = .048) and those with smaller baseline diameters and volumes (P = .043 and P = .034). Adjunctive embolization was strongly associated with TL expansion (χ² = 5.8; P = .016) and FLO remodeling (χ² = 5.2; P = .022), and showed a trend toward increased aortic remodeling (χ² = 4.8; P = .056) without added mortality or morbidity. No cases of spinal cord ischemia occurred. FLO size (≥40 mm vs <40 mm) and position (thoracic, diaphragmatic, or abdominal) did not influence outcomes. FLO remodeling was strongly correlated with concurrent FL reduction (χ² = 20.8; P < .001) and may represent a radiologic marker of procedural success.

Conclusions: FLO implantation provided durable aortic remodeling in chronic type B aortic dissection, and adjunctive embolization enhanced remodeling efficacy by eliminating residual perfusion without increasing risk. The absence of spinal cord ischemia and the identification of FLO remodeling as a surrogate of success highlight the value of this combined, low-risk strategy for long-term aortic stability.

Background: While historically amaurosis fugax was clinically categorized similarly to ipsilateral hemispheric transient ischemic attack (TIA) or stroke, it remains unclear whether transient monocular blindness confers comparable risk to patients in contemporary practice. The purpose of this analysis was to compare postoperative stroke risk among patients undergoing carotid endarterectomy (CEA) for amaurosis, compared with patients with TIA, stroke, or asymptomatic carotid stenosis.

Methods: We studied patients who underwent CEA in the Vascular Quality Initiative (VQI) (2016-2024) and performed a subgroup analysis among patients with linked Medicare claims data (2016-2019). The primary exposure was baseline symptom status, classified as amaurosis, TIA, stroke, or asymptomatic. The primary outcome was stroke. Logistic regression was used to compare the likelihood of in-hospital stroke across the four groups for all examined VQI patients, and Kaplan-Meier analysis and Cox regression was used among patients with linked Medicare data.

Results: We identified 177,859 carotid stenosis patients who underwent CEA (amaurosis, 7.0%; TIA, 12.1%; stroke, 25.4%; and asymptomatic, 55.5%). The in-hospital stroke risk was 0.8% for amaurosis, compared with 1.4%, 2.0%, and 0.7% for TIA, stroke, and asymptomatic presentations, respectively. Compared with asymptomatic patients, the adjusted odds ratio of stroke was 1.17 (95% confidence interval [CI], 0.93-1.46; P = .18) for patients with amaurosis and was 1.76 (95% CI, 1.51-2.06; P < .01) and 2.30 (95% CI, 2.05-2.59; P < .01) for those with TIA and stroke, respectively. We identified 31,010 patients with linked Medicare claims data (amaurosis, 6.0%; TIA, 10.7%; stroke, 21.9%; and asymptomatic, 61.4%). The 3-year stroke risk was 6.1% for patients with amaurosis, compared with 12.4%, 16.0%, and 5.0% for patients with TIA, stroke, and those who were asymptomatic, respectively (log-rank: P < .001). Compared with asymptomatic patients, the adjusted hazard ratio of stroke was 1.15 (95% CI, 0.91-1.45; P = .21) for patients with amaurosis and was 2.03 (95% CI, 1.74-2.36; P < .01) and 2.80 (95% CI, 2.50-3.14; P < .01) for patients with TIA and stroke, respectively.

Conclusions: Patients undergoing CEA in the setting of amaurosis fugax had a statistically similar perioperative and 3-year stroke risk compared with asymptomatic patients. By contrast, hemispheric TIAs or stroke conferred greater risks longitudinally. These findings suggest that it may be appropriate to reconsider the historical risk perception associated with transient monocular blindness to a less severe phenotype and can inform preoperative decision-making for patients considering CEA.