Journal of Vascular Surgery最新文献

Background: Systemic unfractionated heparin (UFH) is routinely administered as procedural anticoagulation during carotid artery procedures. However, Type I, II, and IV hypersensitivity to heparin can occur amongst patients with carotid artery disease who require carotid endarterectomy (CEA) or carotid artery stenting (CAS). While rapid-acting non-heparin alternatives are available, their use for procedural anticoagulation in patients with suspected heparin hypersensitivity undergoing carotid intervention has not been thoroughly studied.

Objective: To evaluate the safety of non-heparin anticoagulant use in carotid artery interventions.

Methods: A PRISMA-structured scoping review was done to evaluate the outcomes of carotid interventions performed with non-heparin intraoperative anticoagulation. To do so, primary literature published between 1993 and 2025 was obtained using structured searches of PubMed, OVID Medline, and OVID Embase. Studies were included if they assessed major adverse cardiovascular events (MACE) and excessive bleeding associated with non-heparin anticoagulation in CEA and CAS, and were excluded if they did not have a primary focus on surgical outcomes or were not original research. Data on study characteristics, patient population, intervention, and clinical outcomes were extracted and summarized using a narrative synthesis to identify trends in the incidence and type of complication for a given alternative anticoagulant relative to UFH.

Results: A total of 90 deduplicated citations were identified, of which 21 met the criteria for inclusion. Eleven studies evaluated bivalirudin, six evaluated argatroban, and four evaluated LMWH. The bivalirudin literature included three case reports describing its use in CEA, as well as two randomized controlled trials (RCTs) and six retrospective cohort studies on its use in CAS. Bivalirudin was found to be safe for carotid procedures and was associated with reduced bleeding compared to UFH. Argatroban use was described in five case reports of CEA and one of CAS, none of which reported adverse events. Finally, two prospective RCTs, a retrospective cohort study, and a case series compared different LMWHs with UFH in CEA and found no significant difference in thrombotic or hemorrhagic events between the two treatment groups but did note a lower risk of embolism with LMWH.

Conclusion: In patients with suspected UFH hypersensitivity requiring carotid intervention, bivalirudin appears to be a safe alternative, while argatroban and LMWH may represent acceptable options based on limited available evidence. Bivalirudin, in particular, is associated with reduced perioperative bleeding and no increase in periprocedural complications.

Introduction: Immune checkpoint inhibitors (ICIs) has revolutionized cancer therapy and improved survival across multiple malignancies. Although associations with cardiovascular events have been described, the relationship between ICIs and peripheral artery disease (PAD) remains unclear. The study aimed to determine whether ICI treatment is associated with PAD, chronic limb-threatening ischemia (CLTI), or lower extremity amputation (LEA) in patients with cancer.

Methods: We conducted a retrospective multicenter cohort study using the TriNetX Analytics platform to identify cancer patients treated with ICIs or non-ICI therapies between 2005-2025. Propensity score matching (1:1) was performed to balance baseline characteristics. Outcomes included PAD, CLTI, LEA within five years. Kaplan-Meier (KM) analyses assessed survival probabilities, and hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox Models. Subgroup analyses evaluated outcomes across different ICI classes and within at-risk groups with hypertension, hyperlipidemia, diabetes, or smoking history.

Results: The matched cohort included 66,766 patients treated with ICIs and 66,766 controls. KM showed a lower 5-year PAD-free survival in the ICI group (73.6% vs. 81.7%, P < 0.001). In multivariable analysis, although the risk of CLTI and LEA were similar, ICI treatment was associated with increased risk of PAD (HR 1.59, 95% CI: 1.53-1.64). Consistently, an increased risk of PAD was demonstrated across all ICI classes: programmed cell death protein 1 (PD-1) inhibitors (HR 1.56, 95% CI: 1.47-1.55), programmed cell death ligand 1 (PD-L1) inhibitors (HR 1.48, 95% CI: 1.36-1.61), cytotoxic T-lymphocyte associated protein 4 (CTLA-4) inhibitors (HR 1.58, 95% CI: 1.43-1.74). Among at-risk patients (N = 27,932), KM showed a lower 5-year PAD-free survival in the ICI group (70.3% vs 80.2%, P < 0.001) and ICI treatment was associated with increased risk of PAD (HR 1.64, 95% CI: 1.58-1.71) and LEA (HR 1.85, 95% CI: 1.32-2.61). Furthermore, increased risk of PAD was demonstrated across each ICI class among at-risk patients: PD-1 inhibitors (HR 1.64, 95% CI: 1.57-1.71), PD-L1 inhibitors (HR 1.64, 95% CI: 1.51-1.78), CTLA-4 inhibitors (HR 1.82, 95% CI: 1.60-2.06).

Conclusions: In this multicenter cohort of adults with cancer, ICI therapy appears to be associated with increased risks of PAD and LEA, particularly among individuals with pre-existing vascular risk factors. These findings suggest that ICI may contribute to PAD and highlight the need for vascular assessment and monitoring in patients receiving ICIs.

Objective: This study aimed to investigate the impact of ultrasound-guided popliteal sciatic nerve block (PSNB) on the outcomes of endovascular therapy (EVT) for below-the-knee (BTK) lesions in patients with chronic limb-threatening ischemia (CLTI).

Methods: This single-center retrospective observational study enrolled 180 consecutive patients with CLTI (median age, 75 [IQR, 43-95] years; male, 77.8%; diabetes mellitus, 66.7%; dialysis, 52.8%) who underwent EVT for BTK lesions between July 2024 and June 2025. PSNB was introduced at our institution in March 2025. We compared 73 consecutive patients treated with PSNB from March to June 2025 (PSNB group) with 107 consecutive patients treated without PSNB from July 2024 to February 2025 (non-PSNB group). The endpoints included technical success, procedure time, failure rate of digital subtraction angiography (DSA) due to leg motion, contrast volume, radiation exposure (cumulative dose-area product), and PSNB-related complications. Propensity score matching was performed to reduce the baseline differences.

Results: Propensity score matching extracted 65 pairs with no significant baseline differences between the groups. There was no significant difference in technical success between the PSNB and non-PSNB groups (96.9% vs. 96.9%, p > 0.99). The total room time was comparable (57 [IQR, 28-157] min vs. 60 [IQR, 22-190] min, p = 0.26), but the procedure time from puncture to sheath removal was significantly shorter in the PSNB group (46 [IQR, 14-149] min vs. 53 [IQR, 18-184] min, p = 0.02). The median duration required to perform PSNB was 7 [IQR, 2-15] min. The failure rate of DSA imaging due to leg movement was significantly lower in the PSNB group (18.5% vs. 53.8%, p < 0.001). Although contrast volume tended to be lower in the PSNB group (51 [IQR, 0-210] ml vs. 65 [IQR, 13-241] ml, p = 0.22), the cumulative dose-area product was significantly lower in the PSNB group (7.1 [IQR, 1.7-32.7] Gy·cm² vs. 8.6 [IQR, 2.5-69.6] Gy·cm², p = 0.02). No PSNB-related complications were observed.

Conclusions: Ultrasound-guided PSNB appears to be a safe and effective adjunct during EVT for BTK lesions in CLTI, contributing to reduced procedure time, improved imaging success by minimizing leg movement, and decreased radiation exposure.

Objective: Arteriovenous fistulae (AVF) are necessary for hemodialysis in patients with end-stage kidney disease (ESKD) but are frequently complicated by thrombosis, stenosis, and need for revision. Glucagon-like peptide-1 receptor agonist (GLP-1RA) are increasingly used in type 2 diabetic patients with kidney disease, with recent evidence of both cardiovascular and renoprotective effects, yet their influence on AVF outcomes is unknown. The aim of this study was to investigate the impact of GLP-1RA on AVF outcomes in patients with ESKD.

Methods: We conducted a multicenter, retrospective cohort study utilizing the TriNetX Research Network. This included 37,694 patients with ESKD who underwent open AVF creation from January 2017 to October 2022, with a minimum of one year follow-up. Patients started on new GLP-1RA therapy were matched 1:1 to non-GLP-1RA controls using propensity scores accounting for patient demographics, comorbidities, medication history, and diagnoses. Primary outcomes included the risk of fistula thrombosis, stenosis, infection, percutaneous angioplasty, and open revision over one year. Secondary outcomes included dialysis catheter intervention, major adverse cardiovascular events (MACE), and all-cause mortality. Cox proportional hazards regression and survival analyses were performed.

Results: After matching, 1,239 well-matched pairs were created. Patients started on GLP-1RA therapy were associated with a lower risk of fistula thrombosis (HR, 0.77; 95% CI, 0.60-0.97; log-rank p=0.03), stenosis (HR, 0.82; 95% CI, 0.71-0.95; log-rank p=0.01), infection (HR, 0.61; 95% CI, 0.41-0.90; log-rank p=0.01), dialysis catheter intervention (HR, 0.63; 95% CI, 0.53-0.76; log-rank p<0.01), and open revision (HR, 0.57; 95% CI, 0.47-0.69; log-rank p<0.01) at one year. No significant effects were observed for percutaneous angioplasty (HR, 0.88; 95% CI, 0.75-1.05; log-rank p=0.15), MACE (HR, 0.99; 95% CI, 0.88-1.11; log-rank p=0.86), or all-cause mortality (HR, 0.79; 95% CI, 0.59-1.05; log-rank p=0.10. The protective effects of GLP-1RA were more prominent among male patients and in those with HgbA1c ≥7%, BMI ≥35 kg/m², or eGFR ≤30 mL/min/1.73 m². These protective effects were also seen as early as twelve weeks after AVF creation and persisted through three years, at which point GLP-1RA use was associated with improved survival (HR, 0.81; 95% CI, 0.68-0.96; log-rank p=0.02).

Conclusions: In patients with ESKD undergoing AVF creation, new GLP-1RA therapy was associated with reduced access complications, fewer dialysis catheter intervention, and improved long-term survival. These findings suggest that GLP-1RA use may promote a favorable environment following access creation, allowing AVF to mature.

Objective: Fragmentation of care (FOC) is referred to as receipt of care across multiple unaffiliated health systems (HS). We evaluated whether FOC was associated with outcomes in patients with uncomplicated type B aortic dissection (uTBAD).

Methods: The Healthcare Cost and Utilization Project State Inpatient Databases, for California (2018-2021), New York/Maryland/Florida (2016-2020) were queried using International Classification of Disease-10th (ICD-10) edition to identify patients who underwent medical management for uTBAD. Patient's hospital affiliation and its linkage to a HS during follow up were verified using the American Hospital Association data (AHA). FOC was defined as receipt of care across multiple unaffiliated, AHA defined HS, care delivered among transitions within the same HS was not classified as FOC. Univariate analyses were conducted to compare outcomes between patients with and without FOC, employing Chi-square or Fisher's exact tests as appropriate. Multivariable logistic regression models were constructed to investigate associations between FOC and outcomes. Model validation was performed using Hosmer-Lemeshow test, and receiver operating characteristic curve analysis.

Results: Among 5,476 patients included in the analysis, FOC was observed in 3,046 (55.6%). Baseline characteristics between those with and without FOC differed significantly. During follow-up, while mortality rates were similar between groups, FOC group had significantly more computed tomography scans, higher rates of aortic interventions, and elevated complication rates. Furthermore, total costs were markedly higher with FOC. Multivariable analysis also showed that FOC was associated with increased aortic interventions [TEVAR: OR 1.47, 95%CI 1.26-1.74] and complication rates (renal failure [OR 1.3, 95% CI 1.17-1.50], paraplegia [OR 1.60, 95% CI 1.07-2.42], and stroke [OR 1.31, 95%CI 1.09-1.58]) during follow-up. Total costs were 31% higher in the FOC group (p<0.001).

Conclusions: FOC in uTBAD patients is associated with increased likelihood of intervention with higher post-procedural complications and elevated healthcare costs. Coordinated care within a single HS should be prioritized to improve outcomes and reduce healthcare cost.

Objective: Chronic Limb-Threatening Ischemia (CLTI) patients with diabetes mellitus (DM) have increased risk for major amputation despite surgical revascularization. As demonstrated in the BEST-CLI trial, autologous great saphenous vein (GSV) remains the standard for revascularization in CLTI. However, alternative conduits such as autologous arm vein (AAV) and non-autologous biologic (cryovein) were infrequently used in the trial. Using the Vascular Quality Initiative (VQI), this study examined the outcomes of patients with DM undergoing infrainguinal bypass with AAV and cryovein for CLTI.

Methods: The prospectively collected VQI database was retrospectively queried for all patients with DM undergoing infrainguinal bypass for CLTI between 2010 and 2023. Patients were stratified into three cohorts according to the type of graft they received. Baseline characteristics and outcomes for the AAV and cryovein cohorts were compared individually to the GSV group. The primary outcome was amputation-free survival, while long-term freedom from index limb reintervention and freedom from major adverse limb events (MALEs) were analyzed as secondary outcomes.

Results: Out of 17,701 patients with diabetes undergoing bypass, 87.0% (N=15,393) received GSV, 3.5% (N=616) received AAV, and 9.6% (N=1,692) received cryovein. There was no difference in perioperative mortality and early thrombosis between AAV and GSV groups. Patients in the cryovein cohort, however, demonstrated significantly higher rates of perioperative graft occlusion (3.8% vs 1.5%, P<0.001) and major amputation (4.1% vs 1.9%, P<0.001) compared to GSV patients, with no difference in mortality. KM analyses demonstrate that amputation-free survival rates at 5 years were decreased for patients receiving cryovein as compared to those receiving GSV (55.8% vs 70.4%; p<0.001). Patients receiving AAV exhibited similar rates of amputation-free survival (69.0% vs 70.4%; p=0.9) and freedom from MALEs (66.4% vs 68.4%, p=0.5) compared to GSV patients at 5 years, while cryovein patients experienced significantly more MALEs (55.0% vs 68.4%, p<0.001). Following multivariate regression analysis, cryovein was independently associated with increased amputation or death (HR=1.64, 95% CI: 1.4-1.8) when compared to GSV, while AAV demonstrated no difference (HR=0.91, 95% CI: 0.7-1.1).

Conclusions: AAV is an effective alternative conduit to GSV in patients with DM undergoing infrainguinal bypass for CLTI. Cryovein has inferior outcomes to GSV but seem to offer acceptable limb salvage in patients with no other options for conduit.

On November 3^rd, 2021, the Circulatory System Devices Panel of the Medical Device Advisory Committee met to discuss the role of real-world evidence in measuring the safety and long-term effectiveness of endovascular stent grafts used to treat abdominal aortic aneurysms. The panel concluded that long-term surveillance after endovascular aortic aneurysm repair (EVAR) was necessary, and 10-year outcomes in real-world practice should be collected and reported to stakeholders. In collaboration with endograft manufacturers, a multidisciplinary group created the Long-Term EVAR Assessment and Follow-up (LEAF) surveillance program. This program leverages registry-based data sources and data from a national health care system, Medicare claims-based linkages, enhanced registry data entry and targeted clinical and imaging follow-up to better surveil long-term device performance after EVAR. In this practice management guideline, we discuss the role of the VQI-VISION and Kaiser Permanente in this process, the methodology of linking registry-level and Medicare claims data for long-term device surveillance, the development of LEAF and key points for the future and additional possible applications to cardiovascular procedures. This guideline can inform the processes behind developing long-term device monitoring protocols which can serve as a benchmark report for the iterative expansion for future surveillance programs.