Objective: This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI).
Methods: This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence.
Results: A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031).
Conclusions: Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.
{"title":"Endovascular revascularization vs open surgical revascularization as the first strategy for arterial acute mesenteric ischemia: A systematic review and meta-analysis.","authors":"Yadong Shi, Boxiang Zhao, Yangyi Zhou, Liang Chen, Haobo Su, Jianping Gu","doi":"10.1016/j.jvs.2024.07.084","DOIUrl":"10.1016/j.jvs.2024.07.084","url":null,"abstract":"<p><strong>Objective: </strong>This paired meta-analysis aimed to compare the mortality and morbidity of endovascular revascularization (EVR) and open surgical revascularization (OSR) as the first strategy for arterial acute mesenteric ischemia (AMI).</p><p><strong>Methods: </strong>This systematic review and meta-analysis were performed in accordance with the PRISMA statement. A systematic search strategy was performed to identify eligible studies using the following databases: PubMed, Embase, and Cochrane Library database from inception to December 31, 2023, with restriction to the English language. The end search date was January 2, 2024. The primary outcome was short-term mortality. Secondary outcomes included bowel resection, second-look laparotomy, and short bowel syndrome. The counterenhanced funnel plot and the Peters' test were used to assess bias. Outcomes were reported as odds ratio (OR) with a 95% confidence interval (CI) using the Mantel-Haenszel method. The GRADE classification was used to estimate the certainty of evidence.</p><p><strong>Results: </strong>A total of 11 studies (1141 patients) comparing EVR vs OSR for arterial AMI were identified and analyzed. The mean patient age was 61.9 to 73.6 years and 45.1% of the patients were male. Compared with OSR, EVR as the first treatment may not decrease short-term mortality (OR, 0.79; 95% CI, 0.50-1.25; P = .31; very low certainty) and second-look laparotomy (OR, 1.00; 95% CI, 0.30-3.36; P = .99; very low certainty). However, EVR may be associated with decreased bowel resection (OR, 0.42; 95% CI, 0.20-0.88; P = .022; very low certainty) and short bowel syndrome (OR, 0.39; 95% CI, 0.21-0.75; P = .005; very low certainty). The metaregression revealed that the mortality regarding EVR vs OSR was not impacted significantly by thrombotic etiology (-0.002; 95% CI, -0.027 to 0.022; P = .85), whereas it was impacted significantly by publication year (0.076; 95% CI, 0.069-0.145; P = .031).</p><p><strong>Conclusions: </strong>Compared with OSR, EVR as the first treatment for arterial AMI may not decrease short-term mortality or second-look laparotomy. Future multicenter randomized controlled trials are needed urgently to confirm these results.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1883-1893.e2"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141788509","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-06-27DOI: 10.1016/j.jvs.2024.06.164
Alexandra A Sansosti, Jose Munoz, Andrew N Lazar, Ariela L Zenilman, Ambar Mehta, Imad Aljabban, Panpan Chen, Adam P Johnson, Jeffrey J Siracuse, Virendra I Patel, Nicholas J Morrissey
Objective: The frequency of atherectomy in lower extremity arterial disease has increased substantially over the past several years, specifically in the office-based laboratory (OBL) setting, yet the efficacy compared with other interventions and the consequences of distal embolization remain unknown. Embolic protection devices (EPDs) have been used at varying rates depending on physician and practice setting. Previous studies have described lesion characteristics to consider when weighing the benefits and drawbacks associated with device use. Our study focuses on the use of atherectomy and EPDs in femoropopliteal arterial disease to better characterize resource use trends and postoperative outcomes in the inpatient and OBL interventional settings.
Methods: We conducted a retrospective analysis on endovascular interventions performed for femoral-popliteal occlusive disease that were entered into the Vascular Quality Initiative data registry between 2017 and 2021. A one:one greedy match, adjusted analysis based on inpatient or OBL location of procedure was used to compare the groups. Hierarchical logistical regression with selective use of principal component analysis was used to further explore the differences in EPD use and immediate postoperative outcomes. A proportional hazard model was used to demonstrate differences in reintervention rates up to 2 years postoperatively between patients who underwent atherectomy in the inpatient vs OBL treatment setting.
Results: 2849 matched pairs were inlcuded in the final analysis. In our cohort, there was 22% EPD use overall, 40% in the hospital setting and 4.4% in the OBL setting (P < .001). Among the patients with available follow-up information, OBL intervention setting increased probability of reintervention by 18% at 2 years postoperatively compared with the inpatient setting; however, there was no difference associated with EPD placement and rate of reintervention.
Conclusions: Use of EPDs in the OBL setting compared with the hospital setting is dramatically decreased; however, no increased incidence of postoperative complications was seen compared to procedures performed in the hospital setting when controlling for patient and lesion characteristics. Patients with available follow-up data were more likely to undergo ipsilateral reintervention between 6 months and 2 years postoperatively if atherectomy was done in the OBL setting. Dedicated studies are encouraged to ensure patient safety, effective resource allocation, and long-term efficacy of OBL atherectomy as an ever-growing number of peripheral arterial procedures are transitioned to the OBL setting.
{"title":"Practice patterns in utilization of atherectomy and embolic protection devices in inpatient and outpatient treatment settings.","authors":"Alexandra A Sansosti, Jose Munoz, Andrew N Lazar, Ariela L Zenilman, Ambar Mehta, Imad Aljabban, Panpan Chen, Adam P Johnson, Jeffrey J Siracuse, Virendra I Patel, Nicholas J Morrissey","doi":"10.1016/j.jvs.2024.06.164","DOIUrl":"10.1016/j.jvs.2024.06.164","url":null,"abstract":"<p><strong>Objective: </strong>The frequency of atherectomy in lower extremity arterial disease has increased substantially over the past several years, specifically in the office-based laboratory (OBL) setting, yet the efficacy compared with other interventions and the consequences of distal embolization remain unknown. Embolic protection devices (EPDs) have been used at varying rates depending on physician and practice setting. Previous studies have described lesion characteristics to consider when weighing the benefits and drawbacks associated with device use. Our study focuses on the use of atherectomy and EPDs in femoropopliteal arterial disease to better characterize resource use trends and postoperative outcomes in the inpatient and OBL interventional settings.</p><p><strong>Methods: </strong>We conducted a retrospective analysis on endovascular interventions performed for femoral-popliteal occlusive disease that were entered into the Vascular Quality Initiative data registry between 2017 and 2021. A one:one greedy match, adjusted analysis based on inpatient or OBL location of procedure was used to compare the groups. Hierarchical logistical regression with selective use of principal component analysis was used to further explore the differences in EPD use and immediate postoperative outcomes. A proportional hazard model was used to demonstrate differences in reintervention rates up to 2 years postoperatively between patients who underwent atherectomy in the inpatient vs OBL treatment setting.</p><p><strong>Results: </strong>2849 matched pairs were inlcuded in the final analysis. In our cohort, there was 22% EPD use overall, 40% in the hospital setting and 4.4% in the OBL setting (P < .001). Among the patients with available follow-up information, OBL intervention setting increased probability of reintervention by 18% at 2 years postoperatively compared with the inpatient setting; however, there was no difference associated with EPD placement and rate of reintervention.</p><p><strong>Conclusions: </strong>Use of EPDs in the OBL setting compared with the hospital setting is dramatically decreased; however, no increased incidence of postoperative complications was seen compared to procedures performed in the hospital setting when controlling for patient and lesion characteristics. Patients with available follow-up data were more likely to undergo ipsilateral reintervention between 6 months and 2 years postoperatively if atherectomy was done in the OBL setting. Dedicated studies are encouraged to ensure patient safety, effective resource allocation, and long-term efficacy of OBL atherectomy as an ever-growing number of peripheral arterial procedures are transitioned to the OBL setting.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1806-1812.e4"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141469085","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-06-11DOI: 10.1016/j.jvs.2024.06.007
Ilse Torres Ruiz, Xin Yee Ooi, Lauren Harry, Cuneyt Koksoy, Zachary S Pallister, Ramyar Gilani, Joseph L Mills, Charles J Bailey, Jayer Chung
<p><strong>Objective: </strong>The impact of sex upon outcomes in acute limb ischemia (ALI) remains disputed. We aim to quantify the effect of sex upon amputation-free survival (AFS) after a percutaneous-first approach for ALI.</p><p><strong>Methods: </strong>This was a two-center retrospective review of ALI managed via a percutaneous-first approach. Demographics, comorbidities, and clinical characteristics were analyzed. The Kaplan-Meier and Cox regression were used to estimate AFS, limb salvage, and overall survival.</p><p><strong>Results: </strong>Over 9 years, 170 patients (n = 87, 51% males; median age, 67 [interquartile range (IQR), 59-77 years) presented with ALI. Rutherford classification was I in 56 (33%); IIa in 85 (50%); IIb in 20 (12%), and III in 9 (5%). Thirty-day mortality, major amputation rate, and fasciotomy rates were 8% (n = 13); 6.5% (n = 11), and 4.7% (n = 8), respectively. Among revascularized limbs, 92% were patent at 30 days. Length of stay was 7 days (IQR, 3-11 days). Complications included 13 bleeding episodes (8%), four cases of atrial fibrillation (2%), and three re-thrombosis/clot extension events (1.7%). No differences were noted in complication rates when stratified by sex. Females were older than males (median age, 70 [IQR, 62-79] vs 65 [IQR, 56-76 years]; P = .02) and more likely to present with atrial fibrillation (20.5% vs 8%; P = .02) and hyperlipidemia (72% vs 57%; P = .04). Females also more frequently presented with multi-level thrombotic/embolic burden compared with males (56% vs 43%; P = .03) and required both aspiration thrombectomy and thrombolysis (27% vs 14%; P = .02). Kaplan-Meier estimated median AFS, limb salvage, and overall survival were 425 days (IQR, 140-824 days); 314 days (IQR, 72-727 days); and 342 days (IQR, 112-762 days). When stratified by sex, females had worse survival (median, 270 days [IQR, 92-636 days] vs 406 days [IQR, 140-937 days]; P = .005) and limb salvage (median, 241 days [IQR, 88-636 days] vs 363 days [IQR, 49-822 days]; P = .04) compared with males. Univariate Cox regression showed female sex (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.04-2.05; P = .03), multi-level thrombotic/embolic burden (HR, 1.64; 95% CI, 1.17-2.31; P = .004), and Rutherford class (HR, 1.37; 95% CI, 1.08-1.73; P = .009) predicted major amputation/death. By multivariable Cox regression, multi-level thrombotic/embolic burden (HR, 1.54; 95% CI, 1.09-2.17; P = .01), Rutherford class (HR, 1.34; 95% CI, 1.07-1.69; P = .01), and female sex (HR, 1.45; 95% CI, 1.03-2.05; P = .03) were each independently predictive of major amputation/death.</p><p><strong>Conclusions: </strong>A percutaneous-first strategy is safe and efficacious in the overall ALI population. Similar to prior works, female vs male patients with ALI in our cohort have higher rates of mortality and major amputation. In our multivariable model, multi-level thrombotic/embolic burden was independently associated with a greater than 45%
简介性别对急性肢体缺血（ALI）预后的影响仍存在争议。我们旨在量化性别对急性肢体缺血经皮先行术后无截肢存活率（AFS）的影响：方法：由两家中心对采用经皮先入法治疗的 ALI 进行回顾性研究。对人口统计学、合并症和临床特征进行了分析（表 I）。采用卡普兰-梅耶（Kaplan-Meier）和考克斯回归（Cox regression）估算AFS、肢体存活率和总存活率：九年来，共有 170 名患者（87 人，51% 为男性；中位年龄 67，IQR 59，77 岁）出现 ALI。卢瑟福分级为 I 级的有 56 人（33%），IIa 级的有 85 人（50%），IIb 级的有 20 人（12%），III 级的有 9 人（5%）。30天死亡率、主要截肢率和筋膜切开率分别为8%（13例）、6.5%（11例）和4.7%（8例）。在接受血管再通的肢体中，92%在30天内是通畅的。住院时间为 7 天（IQR 3-11）。并发症包括 13 例出血（8%）、4 例心房颤动（2%）和 3 例血栓再形成/血块扩展事件（1.7%）。按性别分层后，并发症发生率无差异。女性比男性年龄大（中位年龄 70 IQR 62 79 岁 vs 65 IQR 56 76 岁；P=0.02），更容易出现心房颤动（20.5% vs 8%，P 0.02）和高脂血症（72% vs 57%，P = 0.04）。与男性相比，女性也更常出现多层次血栓/栓塞负担（56% 对 43%；P=0.03），并且需要抽吸血栓切除术和溶栓治疗（27% 对 14%；P 0.02）。Kaplan-Meier估计的AFS、肢体挽救和总生存期中位数分别为425（IQR 140，824天）、314（IQR 72，727天）和342（IQR 112，762天）。按性别分层后，女性的存活率（中位数 270 IQR 92, 636 对 406 IQR 140, 937 天；P=0.005）和肢体挽救率（中位数 241 IQR 88, 636 对 363 IQR 49, 822 天；P=0.04）均低于男性。单变量 Cox 回归显示，女性性别（HR = 1.46 95% CI 1.04-2.05；p=0.03）、多级血栓/栓塞负担（HR 1.64 95% CI 1.17-2.31；p=0.004）和卢瑟福分级（HR 1.37 95% CI 1.08-1.73；p=0.009）可预测大截肢/死亡。通过多变量Cox回归，多级血栓/栓塞负担（HR 1.54 95% CI 1.09-2.17；p=0.01）、卢瑟福分级（HR 1.34 95% CI 1.07-1.69；p=0.01）和女性性别（HR = 1.45 95% CI 1.03-2.05；p=0.03）均可独立预测大截肢/死亡：结论：在所有ALI患者中，经皮先入策略安全有效。与之前的研究相似，在我们的队列中，女性 ALI 患者的死亡率和大截肢率高于男性。在我们的多变量模型中，多层次血栓/栓塞负担与最后一次随访时主要截肢/死亡风险增加 45% 以上有独立关联。有必要进行进一步的前瞻性分析，以阐明导致女性 ALI 患者多层次血栓/栓塞负担发生率较高的潜在因素，并根据患者性别和血栓负担程度进一步确定 ALI 的最佳经皮首诊方法。
{"title":"Multilevel thrombotic or embolic burden and its role in sex-related outcomes in acute limb ischemia.","authors":"Ilse Torres Ruiz, Xin Yee Ooi, Lauren Harry, Cuneyt Koksoy, Zachary S Pallister, Ramyar Gilani, Joseph L Mills, Charles J Bailey, Jayer Chung","doi":"10.1016/j.jvs.2024.06.007","DOIUrl":"10.1016/j.jvs.2024.06.007","url":null,"abstract":"<p><strong>Objective: </strong>The impact of sex upon outcomes in acute limb ischemia (ALI) remains disputed. We aim to quantify the effect of sex upon amputation-free survival (AFS) after a percutaneous-first approach for ALI.</p><p><strong>Methods: </strong>This was a two-center retrospective review of ALI managed via a percutaneous-first approach. Demographics, comorbidities, and clinical characteristics were analyzed. The Kaplan-Meier and Cox regression were used to estimate AFS, limb salvage, and overall survival.</p><p><strong>Results: </strong>Over 9 years, 170 patients (n = 87, 51% males; median age, 67 [interquartile range (IQR), 59-77 years) presented with ALI. Rutherford classification was I in 56 (33%); IIa in 85 (50%); IIb in 20 (12%), and III in 9 (5%). Thirty-day mortality, major amputation rate, and fasciotomy rates were 8% (n = 13); 6.5% (n = 11), and 4.7% (n = 8), respectively. Among revascularized limbs, 92% were patent at 30 days. Length of stay was 7 days (IQR, 3-11 days). Complications included 13 bleeding episodes (8%), four cases of atrial fibrillation (2%), and three re-thrombosis/clot extension events (1.7%). No differences were noted in complication rates when stratified by sex. Females were older than males (median age, 70 [IQR, 62-79] vs 65 [IQR, 56-76 years]; P = .02) and more likely to present with atrial fibrillation (20.5% vs 8%; P = .02) and hyperlipidemia (72% vs 57%; P = .04). Females also more frequently presented with multi-level thrombotic/embolic burden compared with males (56% vs 43%; P = .03) and required both aspiration thrombectomy and thrombolysis (27% vs 14%; P = .02). Kaplan-Meier estimated median AFS, limb salvage, and overall survival were 425 days (IQR, 140-824 days); 314 days (IQR, 72-727 days); and 342 days (IQR, 112-762 days). When stratified by sex, females had worse survival (median, 270 days [IQR, 92-636 days] vs 406 days [IQR, 140-937 days]; P = .005) and limb salvage (median, 241 days [IQR, 88-636 days] vs 363 days [IQR, 49-822 days]; P = .04) compared with males. Univariate Cox regression showed female sex (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.04-2.05; P = .03), multi-level thrombotic/embolic burden (HR, 1.64; 95% CI, 1.17-2.31; P = .004), and Rutherford class (HR, 1.37; 95% CI, 1.08-1.73; P = .009) predicted major amputation/death. By multivariable Cox regression, multi-level thrombotic/embolic burden (HR, 1.54; 95% CI, 1.09-2.17; P = .01), Rutherford class (HR, 1.34; 95% CI, 1.07-1.69; P = .01), and female sex (HR, 1.45; 95% CI, 1.03-2.05; P = .03) were each independently predictive of major amputation/death.</p><p><strong>Conclusions: </strong>A percutaneous-first strategy is safe and efficacious in the overall ALI population. Similar to prior works, female vs male patients with ALI in our cohort have higher rates of mortality and major amputation. In our multivariable model, multi-level thrombotic/embolic burden was independently associated with a greater than 45% ","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1796-1803"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141317658","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Endovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported, without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients.
Methods: All consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points.
Results: A total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 years) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01].
Conclusions: F/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.
{"title":"Long-term results of fenestrated and branched endovascular aneurysm repair for complex abdominal and thoracoabdominal aortic aneurysms in young and fit patients.","authors":"Ciro Ferrer, Enrico Gallitto, Ottavia Borghese, Marcello Lodato, Antonio Cappiello, Piergiorgio Cao, Mauro Gargiulo, Rocco Giudice","doi":"10.1016/j.jvs.2024.07.090","DOIUrl":"10.1016/j.jvs.2024.07.090","url":null,"abstract":"<p><strong>Background: </strong>Endovascular repair of complex abdominal aortic aneurysms (CAAAa) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated and branched devices (F/BEVAR) represents the first-line treatment in old or unfit patients. Currently, the widespread diffusion of these techniques has led to a progressive increase of complex endovascular procedures also in younger and fitter patients, but the related results have been only minimally reported, without long-term data. We investigated the long-term results of F/BEVAR for CAAA and TAAA repair in young and fit patients.</p><p><strong>Methods: </strong>All consecutive patients, aged ≤70 years, who underwent F/BEVAR for CAAA and TAAA over the last 13 years at two tertiary institutions were included in the study. All subjects presented a low to intermediate risk according to the Society for Vascular Surgery clinical comorbidity grading system. The primary end points were technical and clinical success and late overall and aortic-related survival. Major complications and specific target vessel-related outcomes were investigated as secondary end points.</p><p><strong>Results: </strong>A total of 183 patients (155 males [84.7%]; mean age, 64.5 ± 5.7 years; range, 33-70 years) underwent F/BEVAR during the study period, for a total of 167 degenerative (91.3%) and 16 postdissection (8.7%) aneurysms, including 44 (24%) juxtarenal, 33 (18%) pararenal, and 106 (58%) TAAAs. Technical and clinical success were achieved in 176 patients (96.2%) and 171 patients (93.4%), respectively. Four patients (2.2%) died perioperatively, of which two (1.1%) operated in emergency. Postoperatively, five patients (2.7%) presented permanent grade 3 spinal cord injury and three (1.6%) renal failure needing permanent dialysis. The mean follow-up was 65.7 ± 39.6 months (range, 1-158 months). The estimated overall and aortic-related survival at 12, 60, and 120 months was 94.0%, 85.1%, 72.2%, and 97.8%, 97.8%, 96.2%, respectively, and reintervention and branch instability-free survival at the same time points were 84.4%, 71.8%, 71.8%, and 93.2%, 86.3%, 72.2%, respectively. An aneurysm growth of >5 mm was detected in six patients (3.3%), and a sac shrinkage of >5 mm was achieved in 118 cases (64.5%). The Cox regression analysis demonstrated the need for unplanned procedure as the only risk factor for overall mortality (odds ratio, 3.331; 95% confidence interval, 1.397-7.940; P < .01].</p><p><strong>Conclusions: </strong>F/BEVAR in young and fit patients led to low perioperative mortality and major morbidity rates and a favorable overall survival rate in the long-term, making this technique particularly appealing in such a subgroup of patients. The availability of long-term data derived from the results of young patients, may additionally provide helpful information to redefine the indications for treatment and allow future targeted device and technique improvements.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1639-1649"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141860214","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-08-10DOI: 10.1016/j.jvs.2024.07.101
Mohammed Hamouda, Shaima Alqrain, Sina Zarrintan, Kevin Yei, Andrew Barleben, Mahmoud B Malas
<p><strong>Objective: </strong>The Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis.</p><p><strong>Methods: </strong>All patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ<sup>2</sup> tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality.</p><p><strong>Results: </strong>A total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834).</p><p><strong>Concl
{"title":"Transcarotid artery revascularization outperforms transfemoral carotid artery stenting regardless of aortic arch type or degree of atherosclerosis.","authors":"Mohammed Hamouda, Shaima Alqrain, Sina Zarrintan, Kevin Yei, Andrew Barleben, Mahmoud B Malas","doi":"10.1016/j.jvs.2024.07.101","DOIUrl":"10.1016/j.jvs.2024.07.101","url":null,"abstract":"<p><strong>Objective: </strong>The Centers for Medicare and Medicaid Services now approve reimbursement for transfemoral carotid artery stenting (TFCAS) in the treatment of standard-risk patients with carotid artery occlusive disease. TFCAS in patients with complex aortic arch anatomy is known to be challenging with worse outcomes. Transcarotid artery revascularization (TCAR) could be a preferable alternative in these patients owing to avoiding the aortic arch and using flow reversal during stent deployment. We aim to compare the outcomes of TCAR vs TFCAS across all aortic arch types and degrees of arch atherosclerosis.</p><p><strong>Methods: </strong>All patients undergoing carotid artery stenting between September 2016 and October 2023 were identified in the Vascular Quality Initiative database. Patients were stratified into four groups: Group A (mild atherosclerosis and type I/II arch), Group B (mild atherosclerosis and type III arch), Group C (moderate/severe atherosclerosis and type I/II arch), and Group D (moderate/severe atherosclerosis and type III arch). The primary outcome was in-hospital composite stroke or death. Analysis of variance and χ<sup>2</sup> tests analyzed differences for baseline characteristics. Logistic regression models were adjusted for potential confounders, and backward stepwise selection was implemented to identify significant variables for inclusion in the final models. Kaplan-Meier survival estimates, log rank test, and multivariable Cox regression models analyzed hazard ratios for 1-year mortality.</p><p><strong>Results: </strong>A total of 20,114 patients were included (Group A: 12,980 [64.53%]; Group B: 1175 [5.84%]; Group C: 5124 [25.47%]; and Group D: 835 [4.15%]). TCAR was more commonly performed across the four groups (72.21%, 67.06%, 74.94%, and 69.22%; P < .001). Compared with patients with mild arch atherosclerosis, patients with advanced arch atherosclerosis in Group C and Group D were more likely to be female, hypertensive, smokers, and have chronic kidney disease. Patients with type III arch in Group B and Group D were more likely to present with stroke preoperatively. On multivariable analysis, TCAR had less than one-half the risk of stroke/death and 1-year mortality compared with TFCAS in the patients with the mildest atherosclerosis and simple arch anatomy (Group A) (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.31-0.61; P < .001; hazard ratio, 0.42; 95% CI, 0.32-0.57; P < .001). Group B patients with similar atherosclerosis but more complex arch anatomy had 70% lower odds of stroke/death with TCAR compared with TFCAS (OR, 0.30; 95% CI, 0.12-0.75; P = .01). Similar findings were also evident in patients with more severe atherosclerosis and simple arch anatomy (OR, 0.66; 95% CI, 0.44-0.97; P = .037). There was no significant difference in odds of stroke/death in patients with advanced arch atherosclerosis and complex arch (Group D) (OR, 0.91; 95% CI, 0.39-2.16; P = .834).</p><p><strong>Concl","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1736-1745.e1"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141971356","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-07-16DOI: 10.1016/j.jvs.2024.07.026
Lucas Mota, Anusha Jayaram, Winona W Wu, Eve M Roth, Jeremy D Darling, Allen D Hamdan, Mark C Wyers, Lars Stangenberg, Marc L Schermerhorn, Patric Liang
Background: Patient travel distance to the hospital is a key metric of individual and social disadvantage and its impact on the management and outcomes following intervention for chronic limb-threatening ischemia (CLTI) is likely underestimated. We sought to evaluate the effect of travel distance on outcomes in patients undergoing first-time lower extremity revascularization at our institution.
Methods: We retrospectively reviewed all consecutive patients undergoing first-time lower extremity revascularization, both endovascular and open, for CLTI from 2005 to 2014. Patients were stratified into 2 groups based on travel distance from home to hospital greater than or less than 30 miles. Outcomes included reintervention, major amputation, restenosis, primary patency, wound healing, length of stay, length of follow-up and mortality. Kaplan-Meier estimates were used to determine event rates. Logistic and cox regression was used to evaluate for an independent association between travel distance and these outcomes.
Results: Of the 1293 patients were identified, 38% traveled >30 miles. Patients with longer travel distances were younger (70 years vs 73 years; P = .001), more likely to undergo open revascularization (65% vs 41%; P < .001), and had similar Wound, Ischemia, foot Infection stages (P = .404). Longer distance travelled was associated with an increase in total hospital length of stay (9.6 days vs 8.6 days; P = .031) and shorter total duration of postoperative follow-up (2.1 years vs 3.0 years; P = .001). At 5 years, there was no definitive difference in the rate of restenosis (hzard ratio [HR], 1.3; 95% confidence interval [CI], 0.91-1.9; P = .155) or reintervention (HR, 1.4; 95% CI, 0.96-2.1; P = .065), but longer travel distance was associated with an increased rate of major amputation (HR, 2.1; 95% CI, 1.2-3.7; P = .011), and death (HR, 1.6; 95% CI, 1.2-2.2; P = .002). Longer travel distance was also associated with higher rate of nonhealing wounds (HR, 2.3; 95% CI, 1.5-3.5; P = .001).
Conclusions: Longer patient travel distance was found to be associated with a lower likelihood of limb salvage and survival in patients undergoing first-time lower extremity revascularization for CLTI. Understanding and addressing the barriers to discharge, need for multidisciplinary follow-up, and appropriate postoperative wound care management will be key in improving outcomes at tertiary care regional specialty centers.
{"title":"The impact of travel distance in patient outcomes following revascularization for chronic limb-threatening ischemia.","authors":"Lucas Mota, Anusha Jayaram, Winona W Wu, Eve M Roth, Jeremy D Darling, Allen D Hamdan, Mark C Wyers, Lars Stangenberg, Marc L Schermerhorn, Patric Liang","doi":"10.1016/j.jvs.2024.07.026","DOIUrl":"10.1016/j.jvs.2024.07.026","url":null,"abstract":"<p><strong>Background: </strong>Patient travel distance to the hospital is a key metric of individual and social disadvantage and its impact on the management and outcomes following intervention for chronic limb-threatening ischemia (CLTI) is likely underestimated. We sought to evaluate the effect of travel distance on outcomes in patients undergoing first-time lower extremity revascularization at our institution.</p><p><strong>Methods: </strong>We retrospectively reviewed all consecutive patients undergoing first-time lower extremity revascularization, both endovascular and open, for CLTI from 2005 to 2014. Patients were stratified into 2 groups based on travel distance from home to hospital greater than or less than 30 miles. Outcomes included reintervention, major amputation, restenosis, primary patency, wound healing, length of stay, length of follow-up and mortality. Kaplan-Meier estimates were used to determine event rates. Logistic and cox regression was used to evaluate for an independent association between travel distance and these outcomes.</p><p><strong>Results: </strong>Of the 1293 patients were identified, 38% traveled >30 miles. Patients with longer travel distances were younger (70 years vs 73 years; P = .001), more likely to undergo open revascularization (65% vs 41%; P < .001), and had similar Wound, Ischemia, foot Infection stages (P = .404). Longer distance travelled was associated with an increase in total hospital length of stay (9.6 days vs 8.6 days; P = .031) and shorter total duration of postoperative follow-up (2.1 years vs 3.0 years; P = .001). At 5 years, there was no definitive difference in the rate of restenosis (hzard ratio [HR], 1.3; 95% confidence interval [CI], 0.91-1.9; P = .155) or reintervention (HR, 1.4; 95% CI, 0.96-2.1; P = .065), but longer travel distance was associated with an increased rate of major amputation (HR, 2.1; 95% CI, 1.2-3.7; P = .011), and death (HR, 1.6; 95% CI, 1.2-2.2; P = .002). Longer travel distance was also associated with higher rate of nonhealing wounds (HR, 2.3; 95% CI, 1.5-3.5; P = .001).</p><p><strong>Conclusions: </strong>Longer patient travel distance was found to be associated with a lower likelihood of limb salvage and survival in patients undergoing first-time lower extremity revascularization for CLTI. Understanding and addressing the barriers to discharge, need for multidisciplinary follow-up, and appropriate postoperative wound care management will be key in improving outcomes at tertiary care regional specialty centers.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1766-1775.e3"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141723821","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-08-13DOI: 10.1016/j.jvs.2024.05.063
Ruojia Debbie Li, Carol Barry, Beatriz Ibanez Moreno, Kellie R Brown, Rabih Chaer, Thomas S Huber, Andrew Jones, Jason T Lee, Bruce A Perler, Malachi G Sheahan, Bernadette Aulivola
Objective: Implicit bias is a potential factor in the severity of examinee rating during oral examinations. Ratings may be impacted by examinee characteristics, such as gender, that are independent of examinee knowledge base, clinical judgment, or test-taking ability. The effects of examiner-examinee gender concordance in the Vascular Surgery Certifying Examination (VCE) have not been previously studied. We explored whether examiner ratings and likelihood of passing the examination were influenced by gender concordance among examiners and examinees.
Methods: Data collected from examinees who first attempted the VCE between 2018 and 2023 were analyzed. There were 1005 examinees (69.3% male and 30.1% female) and 121 examiners (71.9% male, and 28.1% female). Linear mixed-effects models and generalized linear mixed-effects models were used to evaluate the effects of examinee and examiner gender on VCE ratings and likelihood of passing the examination.
Results: Examiner-examinee gender concordance had no significant impact on examiner ratings or likelihood of passing the examination. In addition, examinee gender alone had no significant impact on VCE rating or pass rates. Only Vascular Qualifying Examination scores explained more than 1% of the variance in total VCE scores for the gender model (F(1, 1003.5) = 71.08, P < .01, R2 = 3%). Vascular Qualifying Examination scores were positively related to total VCE scores.
Conclusions: Although implicit bias has the potential to impact examiner scoring, there is no evidence that this is the case with respect to gender in the VCE of the American Board of Surgery.
{"title":"Examiner-examinee gender concordance does not impact ratings on the American Board of Surgery Vascular Surgery Certifying Examination.","authors":"Ruojia Debbie Li, Carol Barry, Beatriz Ibanez Moreno, Kellie R Brown, Rabih Chaer, Thomas S Huber, Andrew Jones, Jason T Lee, Bruce A Perler, Malachi G Sheahan, Bernadette Aulivola","doi":"10.1016/j.jvs.2024.05.063","DOIUrl":"10.1016/j.jvs.2024.05.063","url":null,"abstract":"<p><strong>Objective: </strong>Implicit bias is a potential factor in the severity of examinee rating during oral examinations. Ratings may be impacted by examinee characteristics, such as gender, that are independent of examinee knowledge base, clinical judgment, or test-taking ability. The effects of examiner-examinee gender concordance in the Vascular Surgery Certifying Examination (VCE) have not been previously studied. We explored whether examiner ratings and likelihood of passing the examination were influenced by gender concordance among examiners and examinees.</p><p><strong>Methods: </strong>Data collected from examinees who first attempted the VCE between 2018 and 2023 were analyzed. There were 1005 examinees (69.3% male and 30.1% female) and 121 examiners (71.9% male, and 28.1% female). Linear mixed-effects models and generalized linear mixed-effects models were used to evaluate the effects of examinee and examiner gender on VCE ratings and likelihood of passing the examination.</p><p><strong>Results: </strong>Examiner-examinee gender concordance had no significant impact on examiner ratings or likelihood of passing the examination. In addition, examinee gender alone had no significant impact on VCE rating or pass rates. Only Vascular Qualifying Examination scores explained more than 1% of the variance in total VCE scores for the gender model (F(1, 1003.5) = 71.08, P < .01, R<sup>2</sup> = 3%). Vascular Qualifying Examination scores were positively related to total VCE scores.</p><p><strong>Conclusions: </strong>Although implicit bias has the potential to impact examiner scoring, there is no evidence that this is the case with respect to gender in the VCE of the American Board of Surgery.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1854-1860"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141982605","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-12-01Epub Date: 2024-06-18DOI: 10.1016/j.jvs.2024.06.021
Micah J Rubin, Nalani A Wakinekona, Margaret A Reilly, Bethany Canales, Rodney Sparapani, Mitchell Dyer, Melina R Kibbe, Neel A Mansukhani
Objective: To examine sex in human vascular surgery research by quantifying the inclusion and analysis of sex-based data in high-impact vascular surgery journals.
Methods: A bibliographic review of original articles published in the European Journal of Vascular and Endovascular Surgery, Journal of Vascular Surgery, JVS: Venous and Lymphatic Disorders, Journal of Endovascular Therapy, and Annals of Vascular Surgery from January 1, 2018, to December 31, 2020, and from January 1, 2023, to December 31, 2023, was conducted. Abstracted data included sex-based data analysis, inclusion of sex as a variable in multivariable analysis, inclusion of sex as an independent variable, and a discussion of sex-based results.
Results: Of the 3762 articles that included human, animal, or cell subjects, 249 (6.6%) did not state sex. Of those 249 articles, 183 included human subjects, 55 included animal subjects, and 11 used cell lines as the subjects. These were removed from analysis as well as the remaining 68 articles with animal subjects. In addition, 23 researched a sex-specific pathology and were removed from analysis. Of the remaining 3422 articles included in our study, 42.3% analyzed sex, 46.9% included sex in multivariable analysis, 4.8% included sex as an independent variable, and 26.6% included a discussion of sex. There were no significant differences in all four sex variables between 2018, 2019, and 2020. Between 2018-2020 and 2023, there were significant increases in all four sex variables. Multicenter studies had significantly higher rates of independent analysis of sex over single-center studies (7.4% vs 3.3%, P < .001). There was no significant difference in independent analysis of sex between U.S.-based and non-U.S.-based studies. Only 191 articles (5.6%) had 90% or greater matching of men and women in their study.
Conclusions: Equitable inclusion and analysis of sex is rare in vascular surgery research. Less than 5% of articles included an independent analysis of data by sex, and few studies included males and females equally. Clinical research is the basis for evidence-based medicine; therefore, it is important to strive for equitable inclusion, analysis, and reporting of data to foster generalizability of clinical research to men and women.
{"title":"Reporting and analysis of sex in vascular surgery research.","authors":"Micah J Rubin, Nalani A Wakinekona, Margaret A Reilly, Bethany Canales, Rodney Sparapani, Mitchell Dyer, Melina R Kibbe, Neel A Mansukhani","doi":"10.1016/j.jvs.2024.06.021","DOIUrl":"10.1016/j.jvs.2024.06.021","url":null,"abstract":"<p><strong>Objective: </strong>To examine sex in human vascular surgery research by quantifying the inclusion and analysis of sex-based data in high-impact vascular surgery journals.</p><p><strong>Methods: </strong>A bibliographic review of original articles published in the European Journal of Vascular and Endovascular Surgery, Journal of Vascular Surgery, JVS: Venous and Lymphatic Disorders, Journal of Endovascular Therapy, and Annals of Vascular Surgery from January 1, 2018, to December 31, 2020, and from January 1, 2023, to December 31, 2023, was conducted. Abstracted data included sex-based data analysis, inclusion of sex as a variable in multivariable analysis, inclusion of sex as an independent variable, and a discussion of sex-based results.</p><p><strong>Results: </strong>Of the 3762 articles that included human, animal, or cell subjects, 249 (6.6%) did not state sex. Of those 249 articles, 183 included human subjects, 55 included animal subjects, and 11 used cell lines as the subjects. These were removed from analysis as well as the remaining 68 articles with animal subjects. In addition, 23 researched a sex-specific pathology and were removed from analysis. Of the remaining 3422 articles included in our study, 42.3% analyzed sex, 46.9% included sex in multivariable analysis, 4.8% included sex as an independent variable, and 26.6% included a discussion of sex. There were no significant differences in all four sex variables between 2018, 2019, and 2020. Between 2018-2020 and 2023, there were significant increases in all four sex variables. Multicenter studies had significantly higher rates of independent analysis of sex over single-center studies (7.4% vs 3.3%, P < .001). There was no significant difference in independent analysis of sex between U.S.-based and non-U.S.-based studies. Only 191 articles (5.6%) had 90% or greater matching of men and women in their study.</p><p><strong>Conclusions: </strong>Equitable inclusion and analysis of sex is rare in vascular surgery research. Less than 5% of articles included an independent analysis of data by sex, and few studies included males and females equally. Clinical research is the basis for evidence-based medicine; therefore, it is important to strive for equitable inclusion, analysis, and reporting of data to foster generalizability of clinical research to men and women.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":"1871-1882"},"PeriodicalIF":3.9,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141432182","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-20DOI: 10.1016/j.jvs.2024.11.017
Joachim Sejr Skovbo, Nicklas Sindlev Andersen, Lasse Møllegaard Obel, Malene Skaarup Laursen, Andreas Stoklund Riis, Kim Christian Houlind, Axel Cosmus Pyndt Diederichsen, Jes Sanddal Lindholt
Objective: This study aimed to develop a prediction tool to identify abdominal aortic aneurysms (AAA) at increased risk of rupture incorporating demographic, clinical, imaging, and medication data using artificial intelligence (AI).
Design: A development and validation study for individual prognosis using AI in a case-control design.
Methods: From two Danish hospitals, all available ruptured AAA cases between January 2009 and December 2016 were included in a ratio of 1:2 with elective surgery controls. Cases with previous AAA surgery or missing pre-operative scans were excluded. Features from computed tomography angiography scans and hospital records were manually retrieved. The sample was divided randomly and evenly into developmental and internal validation groups. A SHapley Additive exPlanations Feature Importance Rank Ensembling (SHAPFire) AI tool was developed using a gradient boosting decision tree framework. The final SHAPFire AI model was compared with models using 1) solely infrarenal anterior-posterior-diameter, and 2) all available features.
Results: The study included 637 individuals (84.8% men, mean age 73±7 years, 213 ruptured AAAs). The SHAPFire AI incorporated 20 of 68 available features, and aneurysm size, blood pressure, and relationships between height and weight were given highest rankings. The receiver operating characteristic curve for the SHAPFire AI model displayed a significant increase in accuracy identifying ruptured AAA cases compared to the conventional model based solely on diameter with areas under the curves of 0.86±0.04 and 0.74±0.03 (P=0.008), respectively. SHAPFire AI was comparable in performance with the model using all features.
Conclusion: This study successfully developed a SHAPFire AI tool to identify AAAs at increased risk of rupture with significant higher accuracy than diameter alone. External validation of the model is warranted before clinical implementation.
研究目的本研究旨在开发一种预测工具，利用人工智能（AI）结合人口统计学、临床、影像学和药物治疗数据，识别破裂风险增加的腹主动脉瘤（AAA）：设计：在病例对照设计中使用人工智能进行个体预后的开发和验证研究：丹麦两家医院2009年1月至2016年12月期间的所有AAA破裂病例与择期手术对照病例的比例为1:2。既往接受过 AAA 手术或术前扫描缺失的病例被排除在外。人工检索计算机断层扫描血管造影扫描和医院记录的特征。样本被随机平均分为开发组和内部验证组。使用梯度提升决策树框架开发了 SHapley Additive exPlanations Feature Importance Rank Ensembling（SHAPFire）人工智能工具。最终的 SHAPFire AI 模型与 1）仅使用脐下前后径的模型和 2）使用所有可用特征的模型进行了比较：研究共纳入 637 人（84.8% 为男性，平均年龄为 73±7 岁，213 例 AAA 破裂）。SHAPFire AI纳入了68个可用特征中的20个，其中动脉瘤大小、血压以及身高和体重之间的关系排名最高。SHAPFire AI 模型的接收器操作特征曲线显示，与仅基于直径的传统模型相比，SHAPFire AI 模型识别破裂 AAA 病例的准确性显著提高，曲线下面积分别为 0.86±0.04 和 0.74±0.03 (P=0.008)。SHAPFire AI与使用所有特征的模型性能相当：本研究成功开发了一种 SHAPFire AI 工具，用于识别破裂风险增加的 AAA，其准确性明显高于单纯的直径识别。在临床应用之前，有必要对该模型进行外部验证。
{"title":"Individual risk assessment for rupture of abdominal aortic aneurysm using artificial intelligence.","authors":"Joachim Sejr Skovbo, Nicklas Sindlev Andersen, Lasse Møllegaard Obel, Malene Skaarup Laursen, Andreas Stoklund Riis, Kim Christian Houlind, Axel Cosmus Pyndt Diederichsen, Jes Sanddal Lindholt","doi":"10.1016/j.jvs.2024.11.017","DOIUrl":"https://doi.org/10.1016/j.jvs.2024.11.017","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to develop a prediction tool to identify abdominal aortic aneurysms (AAA) at increased risk of rupture incorporating demographic, clinical, imaging, and medication data using artificial intelligence (AI).</p><p><strong>Design: </strong>A development and validation study for individual prognosis using AI in a case-control design.</p><p><strong>Methods: </strong>From two Danish hospitals, all available ruptured AAA cases between January 2009 and December 2016 were included in a ratio of 1:2 with elective surgery controls. Cases with previous AAA surgery or missing pre-operative scans were excluded. Features from computed tomography angiography scans and hospital records were manually retrieved. The sample was divided randomly and evenly into developmental and internal validation groups. A SHapley Additive exPlanations Feature Importance Rank Ensembling (SHAPFire) AI tool was developed using a gradient boosting decision tree framework. The final SHAPFire AI model was compared with models using 1) solely infrarenal anterior-posterior-diameter, and 2) all available features.</p><p><strong>Results: </strong>The study included 637 individuals (84.8% men, mean age 73±7 years, 213 ruptured AAAs). The SHAPFire AI incorporated 20 of 68 available features, and aneurysm size, blood pressure, and relationships between height and weight were given highest rankings. The receiver operating characteristic curve for the SHAPFire AI model displayed a significant increase in accuracy identifying ruptured AAA cases compared to the conventional model based solely on diameter with areas under the curves of 0.86±0.04 and 0.74±0.03 (P=0.008), respectively. SHAPFire AI was comparable in performance with the model using all features.</p><p><strong>Conclusion: </strong>This study successfully developed a SHAPFire AI tool to identify AAAs at increased risk of rupture with significant higher accuracy than diameter alone. External validation of the model is warranted before clinical implementation.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":""},"PeriodicalIF":3.9,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142693091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-11-20DOI: 10.1016/j.jvs.2024.11.016
Whitney L Teagle, Andrew S Warren, Marc Schermerhorn, Thomas F O'Donnell, Elina Quiroga, Kirsten D Dansey, Sara L Zettervall
Objective: Prior studies have found disparities in outcomes by sex following repair of abdominal aortic aneurysms. However, little is known about the disparities in outcomes following endovascular repair of complex abdominal aortic aneurysms. This study aims to assess differences in presentation and outcomes by sex following endovascular repair of complex abdominal aortic aneurysms.
Methods: All patients treated via endovascular approach for complex abdominal aortic aneurysms treated in the Vascular Quality Initiative database from 2014-2022 were included. Demographics, comorbidities, and operative details were compared by sex. Perioperative outcomes and long-term survival were then assessed using univariable and adjusted analysis.
Results: 4671 patients were treated for complex abdominal aortic aneurysms, including 74% men and 26% women. Women had higher rates of chronic obstructive pulmonary disease (46% vs. 38%, p<0.001), but lower rates of coronary artery disease (20% vs. 32%, p<0.001) and lower baseline creatinine (0.9 vs. 1.1, p<0.001). Women more commonly presented symptomatic (18% vs. 9%), ruptured (2.9% vs. 2.0%), and had more thoracoabdominal aneurysms (vs. juxtarenal) (38% vs. 26%) on presentation than men (all p<0.001). Women had higher thirty-day mortality (5.2% vs. 2.8%, p<0.001) and long-term mortality (p<0.001) compared to men. This trend persisted after adjustment for thirty-day mortality (OR 1.5, CI: 1.0-2.2) but not long-term survival (HR 1.2, CI: 0.96-1.4). Prior to adjustment, major morbidities were also more common among women, including cardiac complications (12% vs. 10%, p=0.024), respiratory complications (7.0% vs. 4.2%, p<0.001), intestinal ischemia (2.8% vs. 1.5%, p=0.005), stroke (2.6% vs. 1.2%, p=0.002), and spinal cord ischemia (5.3% vs. 3.3%, p=0.002). Prolonged length of stay exceeding 7 days was also more common among women (25% vs. 14%, p<0.001). Only prolonged length of stay (OR 1.7, CI: 1.4-2.1) was more common among women following adjustment. Rather, non-elective repair (OR 1.9, CI: 1.5-2.3) and thoracoabdominal extent (OR 1.3, CI: 1.1-1.6) was associated with late mortality.
Conclusions: Women experience higher morbidity and mortality following endovascular repair of complex abdominal aortic aneurysms, primarily due to urgent presentations and more extensive aneurysms at time of repair. These findings highlight the critical need for improved screening and earlier intervention in women, which may help mitigate this inequality and improve outcomes.
{"title":"Women have Higher Morbidity and Mortality Following Repair of Complex Aortic Aneurysms Due to Symptomatic Presentation and More Extensive Aneurysms.","authors":"Whitney L Teagle, Andrew S Warren, Marc Schermerhorn, Thomas F O'Donnell, Elina Quiroga, Kirsten D Dansey, Sara L Zettervall","doi":"10.1016/j.jvs.2024.11.016","DOIUrl":"https://doi.org/10.1016/j.jvs.2024.11.016","url":null,"abstract":"<p><strong>Objective: </strong>Prior studies have found disparities in outcomes by sex following repair of abdominal aortic aneurysms. However, little is known about the disparities in outcomes following endovascular repair of complex abdominal aortic aneurysms. This study aims to assess differences in presentation and outcomes by sex following endovascular repair of complex abdominal aortic aneurysms.</p><p><strong>Methods: </strong>All patients treated via endovascular approach for complex abdominal aortic aneurysms treated in the Vascular Quality Initiative database from 2014-2022 were included. Demographics, comorbidities, and operative details were compared by sex. Perioperative outcomes and long-term survival were then assessed using univariable and adjusted analysis.</p><p><strong>Results: </strong>4671 patients were treated for complex abdominal aortic aneurysms, including 74% men and 26% women. Women had higher rates of chronic obstructive pulmonary disease (46% vs. 38%, p<0.001), but lower rates of coronary artery disease (20% vs. 32%, p<0.001) and lower baseline creatinine (0.9 vs. 1.1, p<0.001). Women more commonly presented symptomatic (18% vs. 9%), ruptured (2.9% vs. 2.0%), and had more thoracoabdominal aneurysms (vs. juxtarenal) (38% vs. 26%) on presentation than men (all p<0.001). Women had higher thirty-day mortality (5.2% vs. 2.8%, p<0.001) and long-term mortality (p<0.001) compared to men. This trend persisted after adjustment for thirty-day mortality (OR 1.5, CI: 1.0-2.2) but not long-term survival (HR 1.2, CI: 0.96-1.4). Prior to adjustment, major morbidities were also more common among women, including cardiac complications (12% vs. 10%, p=0.024), respiratory complications (7.0% vs. 4.2%, p<0.001), intestinal ischemia (2.8% vs. 1.5%, p=0.005), stroke (2.6% vs. 1.2%, p=0.002), and spinal cord ischemia (5.3% vs. 3.3%, p=0.002). Prolonged length of stay exceeding 7 days was also more common among women (25% vs. 14%, p<0.001). Only prolonged length of stay (OR 1.7, CI: 1.4-2.1) was more common among women following adjustment. Rather, non-elective repair (OR 1.9, CI: 1.5-2.3) and thoracoabdominal extent (OR 1.3, CI: 1.1-1.6) was associated with late mortality.</p><p><strong>Conclusions: </strong>Women experience higher morbidity and mortality following endovascular repair of complex abdominal aortic aneurysms, primarily due to urgent presentations and more extensive aneurysms at time of repair. These findings highlight the critical need for improved screening and earlier intervention in women, which may help mitigate this inequality and improve outcomes.</p>","PeriodicalId":17475,"journal":{"name":"Journal of Vascular Surgery","volume":" ","pages":""},"PeriodicalIF":3.9,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142693107","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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