Journal of Vascular Surgery最新文献

Background: Age remains an important factor in decision making and operative outcomes in patients with CLTI. Prior studies have used arbitrary age categories. Our aim is to identify an evidence-based age cut-off to differentiate patient outcomes between open and endovascular therapy (ET) in the BEST-CLI trial.

Methods: The BEST-CLI trial dataset was queried to include all patients who underwent open surgical bypass or ET. Patients' age on the day of the index revascularization was identified as a continuous variable. Restricted cubic splines were generated to examine the moderating effect of age on the outcomes of procedure type in cohort 1 (bypass with SSGSV vs ET) and cohort 2 (bypass with an alternative conduit vs ET). Four separate spline models for each cohort were generated corresponding to our outcomes of interest: major amputation (above-ankle), all-cause mortality, major adverse limb events (MALE defined as above-ankle amputation or major reintervention), and MALE/Death.

Results: Our study included 1,780 patients, with mean age of 67.2±9.7 (range 27.9-94.1). In cohort 1, the MALE/death spline model showed lower hazard for SSGSV compared to ET across all ages, however, the upper limit of the HR confidence interval approaches 1.0 at age 72. There was no age inflection point identified with regards to mortality. Amputation risk was lower with SSGSV compared to ET up to around the age of 57, beyond which there was no difference between the two treatment modalities. Furthermore, the risk of MALE was consistently lower with SSGSV for patients up to age 83. On the other hand, in cohort 2, age was not found to be an effect modifier in revascularization outcomes or survival among patients undergoing bypass with an alternative conduit compared to ET.

Conclusions: In this study, we confirmed that bypass with SSGSV was associated with superior MALE-free survival compared to ET up to the age of 72, beyond which there was no significant difference in outcomes between the two strategies. MALE was significantly higher for ET for patients up to age 83. Patients' age was not found to favor one revascularization method over the other if the bypass was performed using an alternative conduit. Further studies are needed to compare the effectiveness of revascularization strategies among older patients with CLTI.

Objective: Previous studies have suggested unique challenges in treating women with thoracoabdominal aortic aneurysms (TAAA) compared to their male counterparts. We sought to examine the real-world outcomes of complex endovascular repair (cEVAR) for TAAA in women and men.

Methods: Patients undergoing cEVAR for type I-IV TAAAs between 2014-2020 were identified using the Vascular Quality Initiative (VQI) database. Demographic, preoperative, and intraoperative variables, as well as postoperative outcomes were compared between women and men. One-year survival following cEVAR was compared between women and men using the long-term follow up data from VQI.

Results: A total of 1128 patients underwent cEVAR for type I-IV TAAAs during the study period, of whom 417 (37%) were females. Women had more extensive aneurysms (84.7% vs 72.4% type I-III TAAA; P<0.001) and were more likely to present with symptomatic aneurysm (26.1% vs 18.4%; P=0.002) compared to men. Women were less likely to be on secondary cardiovascular preventative medications, including aspirin (59.4% vs 67.4%; 0.019) and statins (65.1% vs 73.1%; P=0.012), more likely to be current smokers (36.1% vs 30.7%; P=0.052), and treated at higher maximum diameter threshold (7.7 vs 4.6mm above recommended repair size; P<0.001). While there were no differences in operative time, women were more likely to have undergone a staged repair (22.3% vs 16.6%; P=0.018) and have complicated iliofemoral access (19.2% vs 10.3%; P<.001) with higher incidence of access complications (8.9% vs 5.2%; P=0.016) compared to men. Thirty-day rates of mortality (11.8% vs 6.6%; P=0.003) and overall complication (35.7% vs 25.7%; P<.001), including permanent spinal cord ischemia (5.5% vs 2.8%; P=0.022) primarily among patients with type II TAAAs (7.8 vs 3.0%; P=0.025), were all higher for women compared to men. One-year survival following cEVAR for TAAAs were significantly lower for women compared to men (74 vs 82%; P=0.001), driven by the higher 30-day mortality rate in women. Female sex was an independent risk factor for both 30-day and 1-year mortality.

Conclusions: This study demonstrated that women had higher 30-day morbidity and mortality and lower 1-year survival following cEVAR of type I-IV TAAA compared to men. There were significant differences in presentation, anatomic features, and implementations of secondary cardiovascular preventative management, all likely affecting the differences in outcomes between women and men. Future studies are warranted to better understand these differences and optimize sex-specific approach to management of TAAAs in women.

Introduction: The rapid expansion in endovascular techniques has placed vascular surgeons among those most exposed to occupational medical radiation. There are a number of emerging novel No-radiation and Low-radiation ('No-Lo') imaging techniques in various stages of development within vascular surgery, which may significantly reduce occupational radiation exposure during endovascular procedures. This scoping review aims to identify, evaluate and discuss these emerging technologies.

Methods: A systematic search of the literature published from March 2009 to May 2025 was performed using the following databases: PubMed, Embase and Scopus. To identify novel 'No-Lo' vascular imaging techniques, articles were limited only to those relating to vascular surgery. Well-established modalities such as magnetic resonance imaging and intravascular ultrasound were not included. The review was conducted in accordance with the PRISMA-ScR extension criteria for scoping reviews.

Results: A total of 87 studies were included in this scoping review. Seven predominant categories of 'No-Lo' radiation imaging techniques were identified: Movement Tracking, Electromagnetic Navigation, Image Fusion, Augmented Reality, Fiber Optic Technology, Optical Coherence Tomography, Magnetic Particle Imaging, and Robotic Surgery. Each modality demonstrated the potential to reduce radiation exposure in vascular and endovascular surgery, however presented limitations with regards to cost, scalability, ergonomics, and accessibility.

Conclusion: Many promising 'No-Lo' techniques are still in various trial stages and require further results from real clinical settings to elucidate their full potential and identify possible limitations. However, their emergence in clinical use in the near future may have profound implications. It is hoped that ongoing innovation and development of 'No-Lo' technologies may one day unshackle endovascular surgery from the unwanted, but currently necessary, dependence on ionising radiation.

Objectives: Vascular Ehlers-Danlos Syndrome (VEDS) is a rare autosomal dominant disorder due to pathogenic alterations in type III collagen structure and production which results in increased risk of aortopathy and arteriopathy. Given the documented sex-related differences in aortic and other arterial aneurysms and dissections in non-VEDS populations, the potential influence of sex on the incidence of aortopathy, arteriopathy, and mortality in individuals with VEDS was examined.

Methods: A cross-sectional analysis on a cohort of 557 individuals with VEDS with COL3A1 pathogenic variants was performed as part of the VEDS Collaborative Natural History Study. Primary outcomes were all-cause mortality and time to first aortopathy or arteriopathy diagnosis. Statistical analysis was performed utilizing student t-test (continuous data), Pearson χ2 test (categorical data), and log-rank test (Kaplan-Meier survival data). Data were analyzed using STATA version 16 for Windows (STATA Inc., College Station, TX).

Results: Males comprised 44.5% of the cohort (n=248) and females 55.7% (n=309). At enrollment, the mean age of males was younger than females (35.8 ± 16.6 vs 39.2 ± 16.0 years; p=.017). Mean age at genetic diagnosis did not differ (30.8 ± 17.9 vs 33.5 ± 17.7 years; p=.110). Aortopathy and iliac or visceral arteriopathy were more frequent in males (74.2% vs 57.9%; p<.001), whereas females had higher rates of carotid-cavernous fistulae and spontaneous coronary artery dissections. The mean age at first aortopathy or arteriopathy diagnosis trended younger in males (34.4 vs 37.3 years; p=.057), confirmed by Kaplan-Meier analysis (p<.001). Males also had higher all-cause mortality (32.3% vs 20.4%; p=.001) and a trend toward increased aortic-related mortality (53.8% vs 38.1%; p=.063).

Conclusions: Males presented at younger ages with earlier disease onset and higher all-cause mortality. The distribution of vascular pathology varied by sex: aortopathy and iliac or visceral arteriopathy were more common in males, while carotid-cavernous fistulae and spontaneous coronary artery dissection occurred more frequently in females.

Objectives: The Multimorbidity Weighted Index (MWI) quantifies both cumulative disease burden and its impact on physical functioning. This study examined the association between MWI and short-term outcomes of arteriovenous fistula (AVF) creation for hemodialysis (HD) access.

Methods: We performed a retrospective review of AVFs created between January 2011 to December 2019 of national Vascular Quality Initiative data linked to United States Renal Data Systems data. The primary exposure was multimorbidity as measured by the MWI. MWI was dichotomized as above/below median. The primary outcome was functional AVF use within 6 months. Multivariable logistic regression was performed with age, sex, race, cannulation site and MWI as covariates.

Results: A total of 9023 patients were included. The mean age was 65 and the cohort was predominantly male and identified as White. Median follow up was 14 months (IQR 3, 33). The median MWI was 8.3. Of the 9023 AVF created, 5578 (61.8%) were used within 6 months of creation and median time to first use was 4 months (IQR 3,5). Upper arm AVFs were more likely to be used within 6 months than forearm (62.7% vs. 59.4%, P = 0.004). Of the 5578 patients who used their access within 6 months, 2199 (39.4%) required at least one revision prior to first AVF use, with most undergoing one (73.8%) or two (21.3%) revisions. Patients with MWI greater than the median (>MED) compared to patients with MWI less than or equal to the median (MED (35 months vs. 50 months, P < 0.001). On multivariable analysis, MWI >MED, female sex, Black race, and age > 80 were associated with decreased odds of AVF use within 6 months. An MWI >MED, Female sex, Asian and Black race, and upper arm cannulation site were associated with increased odds of undergoing a revision prior to first AVF use.

Conclusions: Patients undergoing AVF creation have a high MWI. In this cohort, higher MWI was associated with increased mortality, lower likelihood of AVF use within 6 months, and greater odds of revision prior to first AVF use. The MWI may be a valuable adjunct to guide vascular access planning and shared decision-making.

Objective: Type II endoleak (T2EL) is the most common complication after endovascular aneurysm repair (EVAR). It is typically considered benign because of frequent spontaneous resolution. However, limited evidence exists on whether early T2EL, detected at 1-month post-EVAR, can reliably predict adverse aortic outcomes during follow-up.

Methods: Between January 2009 and December 2024, 444 patients underwent EVAR for aortoiliac aneurysms at two centers. Patients whose main indication was iliac aneurysm, those with non-degenerative or ruptured aneurysms, and those without 1-month imaging or with type I/III endoleak at that time were excluded. The final cohort comprised 292 patients with a degenerative large fusiform abdominal aortic aneurysm. The patients were categorized into T2EL and non-T2EL groups based on 1-month imaging findings. The primary outcome was aneurysm sac expansion (≥5 mm increase); the secondary outcomes were endoleak-related reintervention, open conversion, and all-cause mortality.

Results: Of the 292 patients, 65 (22.3%) had T2EL and 227 did not at 1-month post-EVAR. The median follow-up durations were 31.1 and 25.3 months in the T2EL and non-T2EL groups, respectively (P=0.475). Sac expansion occurred in 21 (32.3%) and 16 (7.0%) of the patients in the T2EL and non-T2EL groups, respectively (P<0.001). Endoleak-related reintervention was performed in 12 (18.5%) patients with T2EL and 9 (4.0%) without T2EL (P<0.001). All-cause mortality occurred in 19 (29.2%) patients with T2EL and 68 (30.0%) without T2EL (P=0.282). In multivariable analysis, T2EL at 1 month was independently linked to sac expansion (hazard ratio [HR], 4.75; 95% confidence interval [CI], 2.09-10.78; P<0.001) and endoleak-related reintervention (HR, 3.08; 95% CI, 1.10-8.61; P=0.032).

Conclusion: Early T2EL identified at 1-month post-EVAR was significantly related to sac expansion and endoleak-related reintervention during follow-up. Although it was not associated with the increased all-cause mortality, its presence should be closely monitored. These findings supported the prognostic value of T2EL at 1 month in predicting adverse aortic outcomes after EVAR.

Objective: Transcatheter arterialization of the deep veins (TADV) has been demonstrated to be safe and effective among no-option chronic limb-threatening ischemia (CLTI) patients, who lack suitable treatment alternatives. This study reports clinical and economic outcomes based on pooled data from PROMISE I and II trials of TADV for no-option compared to propensity-matched standard of care (SoC) patients from the concurrent CLariTI natural history registry.

Methods: PROMISE I and II were single-arm, multicenter, prospective studies evaluating the safety and efficacy of TADV in no-option CLTI patients, assessed by an independent committee. Both the PROMISE and CLariTI cohorts included patients with Rutherford disease class 5 or 6. Propensity score matching (PSM) was performed on 118 TADV patients and 132 SoC patients based on age, sex, diabetes status, and Rutherford classification. Patients on dialysis at baseline were excluded from analysis. One-year clinical outcomes including limb salvage, overall survival, and amputation-free survival (AFS), were analyzed using Cox regression and Kaplan-Meier methods. Cost-effectiveness of TADV vs. SoC was evaluated using a decision-analytic Markov model, projecting outcomes over a lifetime horizon. One-year clinical event rates previously discussed were relied upon in conjunction with contemporary U.S. cost data, including the incorporation of the new technology add-on payment (NTAP) granted for TADV. The resulting incremental cost-effectiveness ratio (ICER), reported in Dollars per quality-adjusted life year (QALY) gained, was evaluated against established willingness-to-pay thresholds. Extensive scenario and sensitivity analyses were performed.

Results: After matching, 228 patients (114 matched pairs) were analyzed. At one year, compared to matched SoC, patients treated with TADV demonstrated superior limb salvage rates (74.6% vs. 57.8%, p=0.003), survival rates (86.4% vs. 71.1%, p=0.013), and AFS rates (64.9% vs. 39.1%, p<0.001). Over lifetime and under the base case assumptions, TADV (vs. SoC) provided an additional 1.15 QALYs (2.32 vs. 1.17), with increased costs of $24,738 ($101,235 vs. $76,497), and a projected survival gain of 2.33 life years. The base case ICER was $21,600 per QALY gained. TADV demonstrated to be highly cost-effective across the range of sensitivity analyses explored, including scenarios considering application of the NTAP.

Conclusion: TADV with the LimFlow System resulted in significantly improved limb salvage, survival, and AFS at one year compared to the SoC. Based on projections using a previously validated health-economic model, these improvements were shown to translate to meaningful lifetime benefits that help to justify the upfront cost of TADV, rendering it a cost-effective intervention for no-option CLTI patients.

Objectives: This study aimed to evaluate the incidence, degree, and potential predictors of rotational deviation in custom-made triple-branch endografts (Cook Medical, Bloomington, IN, USA) deployed in the aortic arch, and to assess its impact on technical and clinical outcomes.

Methods: This single-center retrospective study included 75 patients who underwent total endovascular aortic arch repair using custom-made Cook triple-branch devices between October 2018 and April 2025. Endograft rotational deviation was assessed by comparing intended and actual branch positions using clock-face orientation with three-dimensional centerline reconstruction. Anatomic variables, including arch, aortic and iliac tortuosity, and device specifications were analyzed to identify potential predictors of rotation. Patients were stratified into three groups based on total rotation: <20°, 20-40°, and >40°.

Results: Most patients (74.7%) had minimal rotation (<20°), while 17.3% had moderate (20-40°) and 8% severe (>40°) rotation. No significant differences in arch anatomy, aortic diameter, or graft dimensions were associated with rotation. However, higher iliac tortuosity index (p = 0.041) and smaller BCT branch diameter (p < 0.001) were significantly correlated with severe rotation. Arch tortuosity index did not significantly (p=0.088) impact graft rotation. Technical success was 96%, unaffected by rotational deviation. Although early stroke incidence was higher in patients with severe rotation (33.3%), this did not reach statistical significance (7.1% vs 0% in mild and moderate rotation, p = 0.089). Midterm outcomes, including mortality and reintervention, were comparable across groups.

Conclusions: The delivery system of the triple-branch Cook CMD demonstrates excellent precision, with limited graft rotation in the majority of cases. While there was a trend towards arch tortuosity in device rotation, iliac tortuosity was significantly associated with rotational deviation. Preoperative assessment of such anatomical factors may enhance procedural planning and reduce intraoperative challenges.

Background: In 2024, numerous scholars introduced the concept of "woundosome" in an editorial, highlighting the necessity of prioritizing perfusion and microcirculation function within patient wound areas. Building upon this foundation, we systematically compared this concept with the previously established angiosome theory.

Methods: A comprehensive search was performed across the Cochrane Central Register of Controlled Trials, Embase, and PubMed. Twenty-five relevant studies met the inclusion criteria, including four investigations employing wound blush (WB). We implemented a Bayesian network meta-analysis to evaluate angiosome-related studies and reviewed the literature on WB. Within the framework of the network meta-analysis, therapeutic efficacy was compared among direct revascularization (DR), indirect revascularization (IR), and indirect revascularization with collateral vessels (IRc). Primary outcome measures encompassed wound healing rate (WHR), amputation-free survival (AFS), and limb salvage rate (LSR).

Results: The network meta-analysis revealed that the DR was significantly higher than IR in WHR outcomes at 3, 6, and 12 months, as well as in the overall analysis. Additionally, IRc demonstrated a significant advantage over IR in both the 12-month and overall analyses. The SUCRA values for WHR indicated that DR achieved the highest ranking at 3-, 6-, and 12-months post-surgery. IRc SUCRA values at 6 months, 12 months, and in the overall analysis were comparable to those of DR. In terms of AFS, DR showed significantly higher results than IR at 6 months, 12 months, and in the overall analysis. LSR analysis indicated that both DR and IRc were significantly superior to IR at 12 months and in the overall analysis. The SUCRA curves for AFS and LSR revealed that DR and IRc had similar SUCRA values and higher compared to IR. In the second part of the study, we reviewed research related to wound blush (WB). Our findings indicated that WHR, LSR, and AFS were significantly higher in the WB+ group compared to the WB- group. The benefit of LSR in WB+ patients persisted for over three years, while there was no significant difference in DR/IR between the two groups. Notably, the proportion of DR patients in the WB+ group was higher than in the WB- group, suggesting that DR may increase the likelihood of WB+.

Conclusions: For endovascular treatment of CLTI disease, DR and IRc exhibit comparable efficacy across all three endpoints and are both superior to IR. WB reflects a focus on wound microcirculation and appears to better inform intraoperative decision-making and predict favorable clinical outcomes.