Journal of Vascular Surgery最新文献

Objective: To evaluate the impact of aneurysmal sac regression versus failure to regress on perioperative and long-term outcomes after endovascular aortic aneurysm repair (EVAR).

Methods: Article screening was conducted using Medline, Embase, and the Cochrane databases. The primary outcome was overall survival; secondary outcomes included reintervention-free survival, endoleak during follow-up, aneurysmal rupture and reintervention during follow-up. End points were compared using risk ratio (RR) for binary outcomes and hazard ratio (HR) for long-term outcomes. For all outcomes, 95% confidence intervals were calculated. Subgroup analysis was done for studies including F/BEVAR patients and for studies comparing sac regression to sac stability. A trial sequential analysis was done for the short-term outcomes. Heterogeneity was assessed through the I² statistic. GRADE assessment of the findings was performed.

Results: Twenty-seven studies comprising 36,822 patients were included. Sac regression was associated with improved overall survival in the overall analysis (HR 0.70; 95% CI 0.61-0.80; p < .00001). In the F/BEVAR subgroup, sac regression was associated with a numerically lower hazard of death; however, this association did not reach statistical significance (HR 0.87; 95% CI 0.49-1.53; p = .62). This association persisted for endoleak during follow-up, with lower risk observed in the overall analysis (RR, 0.55; 95% CI, 0.41-0.72; p < .0001) and in the F/BEVAR subgroup (RR, 0.55; 95% CI, 0.41-0.75; p = .0001). Patients with sac regression also demonstrated better reintervention-free survival (HR, 0.37; 95% CI, 0.27-0.53; p < .00001) and a lower incidence of reintervention during follow-up and aneurysm rupture; however, these latter outcomes were not statistically significant within the F/BEVAR subgroup. Statistical significance persisted across all outcomes in the subgroup analysis comparing sac regression with stable sac.

Conclusion: Sac regression after EVAR confers superior outcomes compared with failure to regress. Our findings underscore the importance of sac behaviour as a key indicator in post-EVAR surveillance and long-term risk stratification.

Objective: To evaluate sex-specific differences in clinical outcomes following thromboelastography with platelet mapping (TEG-PM)-guided antiplatelet therapy compared with standard empiric dual antiplatelet therapy (DAPT) in patients undergoing peripheral artery disease (PAD) revascularization.

Methods: This prospective cohort study enrolled 443 consecutive patients undergoing lower extremity revascularization at Massachusetts General Hospital (2020-2025). Patients received either TEG-PM-guided antiplatelet adjustment (n=147; 46 female, 101 male) or standard empiric DAPT (n=296; 102 female, 194 male). TEG-PM testing was performed preoperatively and at serial intervals post-procedure (1 month, 3 months, and 6 months post-procedure), with antiplatelet therapy adjusted accordingly. Clinical outcomes were followed through 12 months. The primary outcome was major amputation (above-ankle) at 12 months. Secondary outcomes included thrombotic events, all-cause mortality, and amputation-free survival (AFS). Sex-stratified analyses and treatment x sex interaction testing were performed.

Results: Women receiving TEG-guided therapy demonstrated significantly lower major amputation rates compared to men within the same treatment arm (2.2% vs 16.8%; p=0.013; OR=0.110, 95% CI: 0.014-0.852), representing an 87% relative risk reduction (RRR) with a number needed to treat (NNT) of 7. In contrast, no significant sex difference was observed in the standard care arm (18.6% vs 21.1%; p=0.614). The treatment x sex interaction approached statistical significance (OR=0.129; p=0.060), suggesting differential treatment response by sex. Women in the TEG-guided arm also demonstrated superior amputation-free survival compared to men (8.7% vs 22.8% events; 62% RRR). TEG-guided therapy reduced thrombotic events overall (5.4% vs 19.3%; log-rank p<0.001; HR=0.312, 95% CI: 0.156-0.624), with similar benefit observed in both sexes. Subgroup analyses demonstrated consistent female benefit across high-risk populations including patients with diabetes, chronic kidney disease, and chronic limb-threatening ischemia.

Conclusions: TEG-PM-guided thromboprophylaxis appears to provide greater protection against major amputation in women compared to men following peripheral revascularization. The 87% relative risk reduction in amputation observed in women, with an NNT of 7, represents a clinically meaningful benefit. These findings suggest that a precision medicine approach to antiplatelet therapy may help address the historical outcomes gap between women and men with PAD. Routine TEG-PM monitoring should be considered, particularly in female patients undergoing lower extremity revascularization.

Objective: Branched/fenestrated endovascular repair has become the mainstay treatment for thoracoabdominal (TAAA) and pararenal (PAA) aortic aneurysms, yet little is known about its impact on patient quality of life (QoL). Long-term QoL trends in patients from the GORE® EXCLUDER® Thoracoabdominal Branch Endoprosthesis (TAMBE) multicenter, prospective pivotal trial were examined.

Methods: In enrolled patients with TAAA or PAA who underwent TAMBE repair, the RAND 36-Item Health Survey (SF-36) was collected at baseline and at 1-, 3-, 6-, and 12-months post-operatively. QoL physical and mental domain scores were compared from baseline to 1 year in the overall cohort and in subgroups of aneurysm type, frailty risk, occlusion, or reintervention. Patient characteristics were summarized using descriptive statistics and mean QoL scores were compared across timepoints using paired t-tests.

Results: The cohort of 121 patients were a mean age 73 years, 82.8% (n=101) male, 83.6% (n=102) White; 59.0% (n=72) had an Extent IV TAAA, 41.3% (n=50) had a PAA, and 77.7% (n=94) were low frailty risk. In this analysis, 13.2% (n=16) of patients experienced a branch vessel/graft occlusion and 14.0% (n=17) underwent a reintervention. All QoL domain scores dropped at 1-month post-operatively, predominantly in physical health limitations (P<0.0001). All QoL domains recovered towards baseline by 3 months post-operatively but then gradually declined to 1 year; differences were statistically significant compared to baseline (p≤0.05). There was no mean QoL domain score difference at any time point among the aneurysm type, branch occlusion, or reintervention subgroups (P≥0.071). Physical domain scores between frailty risks were significant (P≤0.05).

Conclusions: Patients experienced an immediate drop in all QoL domains post-TAMBE procedure, especially physical health, but recovered by 3 months post-operatively. Aneurysm extent, branch occlusion or reinterventions did not impact QoL trends. Patients who underwent endovascular TAAA/PAA TAMBE repair exhibited a gradual decline in health-related QoL over the long term. This may be representative of the comorbid and elderly population who require such operations.

Objective: A free-floating thrombus in the carotid artery (cFFT) is a high-risk vascular condition for stroke. Treatment recommendations are lacking. This systematic review aimed to identify the safety and effectiveness of existing management strategies for cFFT.

Methods: PubMed and Embase were systematically searched from inception to May 2025, using search terms including "free-floating thrombus" and "carotid", and treatment strategies. Eligible studies reported on treatment and clinical outcomes. Two authors independently screened eligible literature and extracted data. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) score. Primary endpoints were the composite of any non-fatal stroke and all-cause death (death/stroke) at short (<30 days) and long-term (beyond 30 days) follow-up after initial treatment.

Results: Literature search revealed eleven studies, encompassing 179 patients with cFFT. These studies were predominantly of low-quality, with a mean MINORS score of nine for non-comparative studies and fifteen for comparative studies, notably, no randomized controlled studies were identified. Twenty treatment strategies were identified, grouped as antithrombotic medication (AM; n=120/179, 67.0%), or AM combined with endovascular treatment (EVT) (n=20/179, 11.2%), carotid endarterectomy (CEA) (n=38/179, 21.2%), and combined EVT + CEA (n=1/179, 0.6%). Sequential treatments were analyzed by timing: those initiated before 30 days contributed to short-term outcomes, and those thereafter to long-term outcomes. Short-term combined death/stroke rates were reportedly highest with AM alone (n=8/120, 6.7%), followed by EVT (n=1/20, 5.0%) and CEA (n=1/38, 2.6%). The AM group reported a short-term all-cause death rate of 5.0% (n=6/120) and non-fatal stroke rate of 1.7% (n=2/120). Long-term outcomes occurred solely in the AM group, yielding a death/stroke rate of 6.5% (n=3/46), comprising two deaths (n=2/46, 4.3%) and one stroke (n=1/46, 2.2%).

Conclusion: The published literature on cFFT is limited and lacks high-quality studies. This review suggests that all currently reported treatment strategies are associated with a considerable risk for stroke or death. Anticoagulation alone appears inadequate, thereby challenging current ESVS guideline recommendations, whereas the results for CEA suggest it may represent a more favorable option in patients amenable to surgery. These findings should be interpreted with caution given the small number of patients included. Nevertheless, our data may help inform the design of future studies and contribute to the development of more standardized treatment strategies.

Background/purpose: TCAR has been proposed as an alternative for both transfemoral carotid artery stenting and carotid endarterectomy. TFCAS has been associated with increased risk in heavy calcified lesions. Therefore, this study will analyze the effect of calcium burden (percentage of circumference calcification, thickness, and/or the length) on TCAR early and late clinical outcome.

Patient population and methods: This is a retrospective review of prospectively collected data of patients who had TCAR enrolled in the TCAR Surveillance Project (SVS/VQI) in our institution. Preoperative CTAs were reviewed to determine three calcium variables: 1. degree of circumferential calcification, classified into 0 to <25%, ≥25% to <50%, ≥50% to <75% and ≥75%; 2. calcification thickness in mm (measured as the largest thickness); and 3. lesion length calcification. The primary outcome was 30-day perioperative stroke/death rate, while secondary outcome included the combined 30-day stroke, death, and MI rate. Late outcome included stroke/death rate and late in-stent restenosis (>50% or >80%). Kaplan Myer Analysis was used to estimate freedom of stroke, stroke and death, and ≥50% restenosis rates according to calcium classification.

Result: This study analyzed 313 procedures (304 patients) with a mean age of 71 years and mean follow-up of 29.4 months (1 month - 108 months). Circumference calcification were: 0-25% in 37%, 26-50% in 24%, 51.75% in 18%, and >75% in 20% (0-50% in 62% and 51-100% in 38%). Calcification thickness of 1mm or less was noted in 22%, 1-2mm in 27%, 2-3mm in 26%, 3-4mm in 18%, and >4mm in 7% (<2mm in 49% and ≥2mm in 51%) while calcification length of <5mm in 10%, 5 - <10mm in 4%, 10 - <15mm in 15%, 15 - <20mm in 20%, 20 - <25mm in 26%, and ≥25mm in 24%(<20mm in 50%, and ≥20mm in 50%). The overall 30-day perioperative stroke rate was 2.0% and stroke/death/MI of 3.5%. The 30-day perioperative stroke rate according to calcium circumference (<50% vs ≥50%) was 1.7% vs 2.9% (p 0.674); length (<20mm vs ≥20mm) was 2.1% vs 2.2% (p 1); and thickness (<2mm vs ≥2mm) was 1.5% vs 2.9% (p 0.6841). For all stroke rates early and late for calcium circumference (<50% vs ≥50%) were 4.2% vs 4.9% (p 0.771); length (<20mm vs ≥20mm) were 6% vs 3% (p 0.242); and thickness (<2mm vs ≥2mm) were 3.8% vs 5.2% (p 0.599). Rates for >50% restenosis for calcium circumference (<50% vs ≥50%) were 7.9% vs 8.8% (p 0.821); length (<20mm vs ≥20mm) were 7.5% vs 9.0% (p 0.663); and thickness (<2mm vs ≥2mm) were 7.6% vs 8.8% (p 0.825). Kaplan Myer Analysis showed that the rates of freedom from stroke, stroke and death, and ≥50% restenosis at 1, 2, and 3 years according to calcification circumference, thickness, and length were similar.

Conclusion: This study showed no significant effect of calcium burden on TCAR early and late outcomes.