Journal of Vascular Surgery最新文献

Objective: The aim of this study was to assess the optimal thresholds of surgical intervention for Behcet's disease (BD) aortic or peripheral artery pseudoaneurysms.

Methods: This was a retrospective single-center study of 2138 BD patients, including 96 vascular BD patients (4.5%) with 151 pseudoaneurysms between January 2002 and December 2021. Factors associated with mortality were assessed using Cox regression model. Growth rate of each pseudoaneurysm was calculated based on available imaging data in linear mixed effect model.

Results: Patients in surgical group (2/56) had significantly lower aneurysm-related mortality than those in medical treatment group (10/33) (chi-square = 10.34; p = 0.0013). Surgical intervention (p = 0.009) and diameter of BD pseudoaneurysm (p = 0.006) were independently associated with BD aneurysm-related mortality. Rapid growth of BD pseudoaneurysm was achieved once diameter exceeded 4.0 cm for aortic pseudoaneurysm, or 2.5 cm for peripheral artery pseudoaneurysm, accompanied with high risk of rupture (Overall rupture rate: BD aortic pseudoaneurysm, ≥4.0 cm vs. < 4.0 cm: 63.6% vs. 15.4%; BD peripheral artery pseudoaneurysm, ≥2.5 cm vs. < 2.5 cm: 50.9% vs. 0).

Conclusions: This study verified the critical role of surgical intervention in reducing the mortality rate of patients with BD pseudoaneurysms. BD aortic pseudoaneurysms larger than 4.0 cm in diameter and peripheral artery pseudoaneurysms larger than 2.5 cm in diameter require prompt surgical intervention due to the remarkable increase in the growth rate and greater risk of rupture and death.

Objective: Non-home discharge (NHD) contributes to poor patient quality of life and healthcare costs. Prior Vascular Study Group of New England database-based analysis developed a novel risk score, outlined in Table 1, for NHD following infrainguinal lower extremity bypass (LEB). Still, it has yet to be validated in an external dataset. This study hypothesized that the LEB NHD risk score would be externally validated using unique single institutional data.

Methods: A single institutional quaternary center electronic data warehouse was queried for elective LEB cases from 2012-2020. The primary endpoint was NHD, defined as discharge to a skilled nursing facility or acute rehabilitation center. This analysis excluded inpatient deaths. A previously developed risk score was applied (table 1). The risk score's predictive ability for NHD was assessed using a logistic regression, c-statistic, and Hosmer-Lemeshow test. The risk score was then categorized as low risk (score <5), moderate risk (score 5-9), and high risk (score >9) for NHD.

Results: Among 242 included patients, NHD occurred in 22% of cases. The mean age of this cohort was 69. The cohort was 38% female and 26.4% non-white. The NHD proportion by risk category was 34% in high-risk, 26% in moderate-risk, and 4% in low-risk cases. High-risk cases represented 17% of the population and 27% of all NHD. On logistic regression, higher-risk groups had significantly higher odds of NHD than the low-risk category (moderate risk OR:8.8, CI 2.02-38.4, p=0.004, high risk OR: 13.0, CI:2.7-63.1, p=0.001). The risk score successfully predicted NHD with a c-statistic of 0.702 and Hosmer-Lemeshow p=0.748, suggesting the model fit the data.

Conclusion: A novel non-home discharge risk score was validated in an external single institutional dataset. This risk score could be used to provide better pre-operative counseling and streamline post-discharge planning. Future studies should prospectively validate the NHD risk score.

Objective: Perioperative stroke after carotid artery stenting (CAS) is rare. However, the degree of disability and long-term effects from a post-operative stroke remain unclear. Our goal was to assess the degree of disability from a stroke after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) for asymptomatic carotid artery disease, and the associated one-year impact on subsequent neurological events and mortality.

Methods: The Vascular Quality Initiative CAS registry (2016-2023) was queried for CAS performed for asymptomatic disease. Patients with a post-operative stroke had their disability stratified by modified Rankin score (mRS) of 0-1 (mild), 2-3 (moderate), 4-5 (severe), and 6 (deceased). Post-operative stroke-related disability based on mRS for those recorded at discharge and its association with long-term outcomes were analyzed.

Results: There were 23,435 TCAR and 7,487 TFCAS procedures performed for asymptomatic disease. Among TCAR patients, the periprocedural stroke and stroke/death rates were 0.8% and 1.03%, respectively, with disability distributed as 33.6% mild, 31% moderate, 28.9% severe, and 7.5% deceased. Among TFCAS patients, the periprocedural stroke and stroke/death rates were 0.92% and 1.19%, respectively, with disability distributed as 37.7% mild, 31% moderate, 27.5% severe, and 2.9% deceased. Multivariable analysis demonstrated that severe early postoperative disability was associated with increased one-year mortality (HR 11.04, 95% CI 6.9 - 17.7, P=.001) and increased subsequent neurological event/death (HR 10.82, 95% CI 6.93 - 16.9, P=.001). Patients with a stroke after TFCAS had a higher risk of one-year mortality (HR 1.27, 95% CI 1.10, 1.47, P=.001) and neurological event/death (HR 1.27, 1.11,1.45, P<.001), as compared to patients with a stroke after TCAR. Among patients who undergo a CAS procedure for asymptomatic disease, hypertension was associated with a higher likelihood of developing severe disability (OR 4.2, 95% CI 1.03-17.32, p =0.045), while pre-operative aspirin (OR 0.51, 95% CI 0.30-0.87, p =0.01) or P2Y12 inhibitor use (OR 0.45, 95% CI 0.27-0.74, p=0.11) was associated with a lower likelihood of developing severe disability.

Conclusion: The majority of patients who undergo TCAR and TFCAS for asymptomatic carotid artery disease that suffered a periprocedural stroke had substantial disability. Patients with strokes from TFCAS have worse one-year outcomes, as compared to patients with stroke following TCAR. These findings should help guide patient-provider discussion regarding the surgical management of asymptomatic carotid stenosis, the risks of CAS interventions, as well as aid in the prognostication of postoperative stroke.

Objectives: This study aimed to evaluate technical factors influencing stent graft occlusion following endovascular repair of internal iliac artery aneurysms (IIAAs), with a specific focus on the longitudinal length of unsupported stent graft segments and connecting stent grafts.

Methods: A retrospective single-center analysis was performed on 61 IIAAs treated with endovascular techniques between 2010 and 2022. Anatomical and technical factors, including the unsupported stent graft length within the aneurysm sac (Distance A) and the length of the distal sealing zone (Distance B), were assessed. Statistical analyses were conducted to identify factors associated with stent graft occlusion, Type Ib endoleaks, and clinical outcomes.

Results: The primary technical success rate was 90.2%, with a stent graft occlusion rate of 23% documented over a mean follow-up period of 25.7 months. A longer unsupported stent graft length (Distance A) was significantly associated with increased risk of occlusion (53.7 mm vs. 37.0 mm in non-occluded cases, p = .017). Occlusion rates were also higher in cases with a greater number of connecting stent grafts used to extend the iliac branched device (IBD) to healthy vessel segments (p = .015). Type Ib endoleaks occurred in 6.6% of cases and were significantly associated with shorter distal sealing zones (≤15 mm, OR 18.0). Despite these technical challenges, clinical success was achieved in 83.3% over the follow-up period, with low rates of ischemic complications. Buttock claudication occurred in 12.9% of cases, and erectile dysfunction was reported in one patient.

Conclusions: Endovascular repair of IIAAs is effective and provides a viable option for patients unfit for open surgery. However, it carries risks of stent graft occlusion and endoleaks, particularly when the unsupported stent graft length is extended or when multiple connecting stents are used. Optimizing graft configurations and minimizing unsupported segments may reduce occlusion risks. Furthermore, ensuring an adequate distal sealing zone length is critical to minimizing the occurrence of Type Ib endoleaks. These findings highlight the importance of careful procedural planning and technical considerations to improve long-term outcomes and enhance durability in endovascular management of IIAAs.

Objective: This study aimed to determine whether age affects thromboelastography (TEG) coagulation profiles among elderly patients with peripheral arterial disease (PAD). We hypothesized that TEG parameters would not significantly differ between age groups when controlled for anticoagulation regimen.

Methods: This was a prospective, single-institution, observational study that included patients aged 65 years and older who underwent open or endovascular lower extremity revascularization for PAD from December 2020 through December 2023. 158 patients were grouped into categories: age 65-74 and age 75+ and anticoagulation regimen (single antiplatelet [50%], dual antiplatelet [15%], therapeutic anticoagulation [27%], none [8%]). Objective TEG coagulation profiles were collected preoperatively and were compared among patient groups. One-way ANOVA analysis was used to compare three or more groups of continuous data, and chi-squared analysis or Fisher's exact test were used to compare categorical data.

Results: Among 158 patients (36.4% female, median age 74.5±6.6 years), there were no significant differences in TEG parameters (reaction time, maximum amplitude, lysis at 30 minutes, angle, ADP% aggregation, ADP% inhibition) between age groups when stratified by anticoagulation regimen (all p>0.05). Thrombosis rates were similar between age groups (21.1% vs. 20.6%, p=0.936), but mortality was significantly higher in the 75+ group (20.6% vs. 5.6%, p=0.005).

Conclusions: Objective coagulation parameters do not appear to vary significantly among age groups within the elderly population when controlled for antiplatelet/anticoagulant regimen. TEG profiles may be used to guide anticoagulation management among elderly patients. Further studies can help elucidate the full utility of TEG profiles for coagulation surveillance among elderly patients.

Objective: Historically, the medical profession is a male dominated field. While the number of women entering surgical specialties is rising, this increase is not proportionate to the composition of medical school graduates, which are now 50% female. This study aimed to investigate the specialty and gender of practitioners performing common vascular procedures.

Methods: Medical claims data was obtained from the Center for Medicare and Medicaid Services (CMS). Claims were linked to provider characteristics in the National Plan and Provider Enumeration System (NPPES) using national physician identifier (NPI). The study included final billing records from inpatient claims 2017-2021. Procedures of interest were identified by the primary International Classification of Disease 10 Procedure Coding System (ICD-10 PCS) codes. Provider taxonomy, gender, tenure, and region were derived from National Plan and Provider Enumeration System using their NPI.

Results: Among all specialties, board certified vascular surgeons (VS) performed the highest percentage of open infrarenal aortic interventions (68.6%), endovascular aorta repairs (EVAR, 65.2%), carotid endarterectomies (CEA, 59.1%), endovascular carotid interventions (32.4%), open arteriovenous fistulas (AVF, 60.3%), endovascular AVF (59.3%), open infrainguinal interventions (71.4%), and endovascular infrainguinal interventions (45.7%). For the two categories where VS performed less than half of the procedures, the next most common specialties were neurology/neurosurgery (17.9%) and interventional cardiology (10.8%) for endovascular carotid interventions and interventional cardiology (11.1%) and interventional radiology (10.3%) for endovascular infrainguinal interventions. Over the five-year period, the percentage of procedures performed by vascular surgeons increased for all categories except endovascular AVF. Analyzing by gender, the majority of all procedures were performed by male physicians, which ranged from 88.3% (endovascular AVF) to 94.7% (endovascular carotid intervention). Over the five-year interval, however, all specialties had a significant increase in the percentage of vascular procedures performed by females (P<0.05) except thoracic/cardiac surgery. Among all specialties, vascular surgery had the greatest absolute increase in female performed interventions (P<0.05).

Conclusion: While the majority of vascular interventions are still performed by male practitioners, the proportion of procedures conducted by females is increasing. Among all specialties, vascular surgery has both the highest proportion and greatest absolute increase of vascular procedures performed by women. Future recruitment efforts should focus on continuing to reduce this disparity.

Background: The recent National Coverage Decision surrounding carotid stenting and shared decision-making (SDM) has ushered in an era of patient-centric carotid care. However, historical carotid intervention endpoints have lacked patient-centered nuances to inform clinical decisions. Accordingly, we aimed to create a comprehensive novel, patient-centric textbook outcome (TO) to inform treatment paradigms.

Methods: We developed a novel composite TO for patients who underwent carotid revascularization reflecting a combination of patient centric outcomes derived from previous patient interviews and the published literature. We defined a TO to include freedom from postprocedural neurologic events, myocardial infarction, cranial nerve injury, return to the OR, reperfusion syndrome, or access site complications. The endpoint also included discharge on postprocedural day 1, home discharge, and 30-day survival. We measured the risk of a TO versus non-TO among asymptomatic patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), or transfemoral carotid artery stenting (TF-CAS) in the VQI from 2016-2023.

Results: We studied 72,778 patients who underwent carotid revascularization, 70.3% CEA, 21.0% TCAR, and 8.7% TF-CAS. The mean age across all patients was 71.6±8.4 years, 39.9% were female, and 91.7% were white. A TO was achieved in 76.9% of patients, and was 76.7% after CEA, 76.5% after TCAR, and 79.1% after TF-CAS (p<.001). postprocedural length of stay was 2 days or more in 21.0% of patients, and was 21.1% after CEA, 21.6% after TCAR, and 18.4% after TF-CAS (p<.001). Postprocedural neurologic events occurred in 1.0% of patients after CEA, 1.3% after TCAR, and 1.4% after TF-CAS (p=.037). A sensitivity analysis of the TO that did not include postprocedural length of stay demonstrated a non-TO in 5.9% of patients after CEA, 5.5% after TCAR, and 6.3% after TF-CAS (p=.070). Patients who did not achieve a TO had inferior 5-year survival compared to patients who did have a TO across all three cohorts (log-rank P<.001).

Conclusions: This novel patient-centric endpoint demonstrated that a substantial percentage of patients fail to achieve a TO in current practice, and that failure to achieve a TO was associated with inferior 5-year survival. These findings are particularly important in light of the recent Medicare mandate for a SDM approach to carotid care delivery and may help to best align patient preferences with procedure type.