Journal of Vascular Surgery最新文献

Objective: The VOYAGER PAD clinical trial demonstrated that low-dose rivaroxaban (LDR; 2.5mg twice daily) reduces major adverse limb events (MALE) at the expense of increased bleeding rates in patients undergoing lower extremity revascularization for peripheral artery disease (PAD). However, it's unclear whether LDR therapy is associated with similar outcomes in real-world practice. This retrospective cohort study was designed to evaluate the effectiveness and safety of LDR therapy following peripheral vascular intervention (PVI) for patients with PAD.

Methods: The Merative MarketScan database was used to identify patients 40-90 years old who underwent lower extremity PVI between 2017 and 2024. Pharmacy claims were used to identify LDR use within 30-days post-PVI and patient adherence to therapy within 1-year while excluding those receiving therapeutic anticoagulation. For patients prescribed LDR, the proportion of days covered (PDC) was determined and those greater or equal to 80% of PDC were classified as adherent. After performing a propensity-subclass weighted analysis on the use of LDR, we used cox proportional hazards models to estimate the risk-adjusted incidence of MALE and bleeding complications following PVI.

Results: We identified 88,792 patients, of which 1,285 (1.5%) were prescribed LDR within 30-days post-PVI. However, only 547 (43%) of these patients were adherent to LDR within the year after revascularization. After propensity weighted analysis, patients on LDR were well matched to those not on therapy based on age, sex, comorbidities and demographics. While non-adherent patients had no significant improvement in MALE outcomes, those adherent to LDR therapy had a 70% lower likelihood of major amputation at 1-year after revascularization (HR:0.30; 95% CI:0.10-0.91; P=.03). There was an increased likelihood of experiencing a bleeding complication (HR: 1.85; 95%CI:1.24-2.76; p=.002) associated with LDR use relative to the non-LDR control group.

Conclusions: Following the publication of VOYAGER PAD, the use of low-dose rivaroxaban remains low and patient adherence is variable. However, clinical outcomes in real world practice are similar if adherence to LDR is maintained following PVI. Further work is needed to define the optimal patient with PAD who should receive LDR following revascularization.

Objective: General population based screening of women for AAA is not recommended. A selective screening approach, targeting high-risk women with a history of smoking may detect most AAAs and be effective. The aim of this population-based cross-sectional study was to evaluate a pragmatic screening strategy selectively targeting women with a history of smoking.

Methods: Between 2018 and 2022 all 70 year-old women in a defined catchment area, the county of Dalarna in central Sweden, were invited by letter to a one time ultrasound examination of the aorta. The letter of invitation encouraged women with a smoking history of 20 years or more to attend. No women were excluded. Prevalence of AAA (≥30 mm), sub-AAA (25-29 mm), self-reported comorbidity and smoking habits were recorded. The results were compared with the outcome from a previous general population-based screening program study of 70-year-old women conducted in the neighboring counties of Dalarna and Uppsala in central Sweden.

Results: A total of 9061 women were invited to selective screening, 42.6%, (95%CI 41.5- 43.6%) attended after the invitation to the selective strategy vs 74.2% (95%CI 73.2-75.2 %) in the previous general screening study (p<0.001). In the selective screening cohort 71% reported a history of smoking vs 44% in the general screening cohort (p<0.001). The prevalence of screening-detected AAA was 0.8% (95%CI 0.6-1.1%) in the selective screening cohort vs 0.4% (95%CI 0.2- 0.6%) in the general general screening cohort (p<0.001) and the corresponding prevalence of sub-aneurysm was 1.1% (95%CI 0.8-1.5%) vs 0.6% (95%CI 0.4-0.8%), p=0.0039.. Screening-detected AAAs in the total population (attenders and non-attenders) were similar between strategies: 0.3% (95% CI 0.2-0.5%) for targeted screening versus 0.2% (95% CI 0.2-0.4%) for general screening (p=0.23).

Conclusion: Targeted AAA screening of high-risk women with a long-term smoking history doubles prevalence (0.8%) compared with general screening, halves the number of women needing screening, and maintains the detection rate. Further studies should assess the clinical impact and cost-effectiveness of this approach.