Journal of Vascular Surgery最新文献

Background: According to the latest Society for Vascular Surgery (SVS) guidelines, carotid revascularization for asymptomatic individuals should be offered if the perioperative stroke/death rate does not exceed 3%. Heart failure (HF) has been associated with reduced survival rates following carotid revascularization, which may significantly impact the risk-benefit decision of treating asymptomatic patients with HF. This study aimed to evaluate the 30-day postoperative risks in asymptomatic patients with newly diagnosed and/or decompensated HF undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS).

Methods: Asymptomatic patients who underwent CEA and CAS were identified in the ACS-NSQIP targeted databases from 2011-2023. HF was defined as newly diagnosed HF and/or an acute exacerbation of chronic HF within 30 days of the surgery A 1:3 propensity-score matching was used to balance preoperative differences between HF and non-HF patients. Patients who underwent CEA and CAS were analyzed separately. Thirty-day postoperative outcomes were examined.

Results: There were 23,274 patients who underwent CEA, where 601 (2.58%) had HF, who were matched to 1,803 non-HF patients. Among 1,361 patients who underwent CAS, 87 (6.38%) had HF and were matched to 222 non-HF counterparts. HF patients had a much higher comorbidity burden. After CEA, HF patients had higher risks of stroke/mortality (4.83% vs 2.55%, p=0.01), cardiac (6.66% vs 3.38%, p<0.01), pulmonary (4.49% vs 2.44%, p=0.02), and renal complications (1.66% vs 0.44%, p=0.01), as well as sepsis (1.50% vs 0.44%, p=0.02), distal embolization (0.50% vs 0.00%, p=0.02), unplanned operation (5.99% vs 3.49%, p=0.01), prolonged hospital stay (p<0.01), and 30-day readmission (13.14% vs 8.65%, p<0.01). After CAS, HF patients had similarly high risks of stroke/mortality (5.75% vs. 3.60%, p=0.53).

Conclusion: For newly diagnosed and/or decompensated HF patients with asymptomatic carotid stenosis, the 30-day postoperative stroke/mortality risks after both CEA and CAS greatly exceed the SVS guideline recommendations. Coupled with the substantially higher risk of other major complications, the decision to pursue surgical revascularization in asymptomatic patients with HF should be approached with extreme caution, and conservative management may be prioritized.

Objective: To conduct a "Noise Audit" of the Vascular Quality Initiative (VQI) Peripheral Vascular Intervention (PVI) Registry to analyze variation in device selection for similar patients and anatomies.

Methods: We conducted a retrospective cohort study analysis of the VQI PVI Registry. Eight clinical-based, and seven lesion-based scenarios were developed, and the VQI was queried for all procedures matching these descriptions from December 2010 to December 2021. All patients undergoing PVI for either claudication or chronic limb threatening ischemia (CLTI) were included. Device selection was then identified for each procedure, with a treatment hierarchy to designate the primary device class along with a separate accounting of specialty balloons including drug coated and lithoplasty devices. Variability was then quantified in each mock patient scenario using the most commonly used device as the reference standard.

Results: The number of patients matching the criteria for each mock scenario ranged from 223-1,379 across eight clinical and from 6,166-26,241 in seven lesion-based scenarios. The most commonly used device in a given patient scenario was used between 32% and 72% of procedures in the clinical based scenarios, and between 34% and 67% of procedures in the lesion-based scenarios. Variation in device selection and use of specialty balloons were found to be significant across all patient scenarios (P <0.0001).

Conclusion: Noise in PVI device selection and use of drug coated balloons in the VQI was significant across 15 mock scenarios. This indicates that similar patients with similar vascular pathologies are receiving vastly different devices and confirms that future comparative effectiveness studies are required to more effectively combat this systemic source of Noise in device selection.

Background: BEST-CLI established the superiority of single-segment great saphenous vein (ssGSV) conduits for revascularization in patients with CLTI; however, the generalizability of these data is unknown. Thus, we aimed to validate the long-term results of open surgical bypass (BPG) versus angioplasty with or without stenting (PTA/S) using the BEST-CLI inclusion and randomization criteria.

Methods: All patients undergoing a first-time lower extremity revascularization for CLTI at our institution from 2005 to 2022 were retrospectively reviewed. To approximate BEST-CLI, one-to-one propensity score matching was used. Cohort 1 included BPG with ssGSV versus PTA/S; Cohort 2 included BPG without ssGSV versus PTA/S. Primary outcomes included wound healing, major amputation, major reintervention, major amputation/death (Amputation/Death), and major adverse limb events (MALE) or Death (MALE/Death) and were evaluated using Kaplan-Meier estimates and log-rank tests.

Results: Of 1,946 limbs undergoing a first-time intervention for CLTI between 2005-2022, 765 underwent BPG and 1181 underwent PTA/S. After matching, 862 fit Cohort 1 (431 BPG and 431 PTA/S) and 274 fit Cohort 2 (137 BPG and 137 PTA/S). Both cohorts exhibited a median follow-up of 2.7 years. In Cohort 1, major reintervention and MALE/death were both noted to be significantly lower following ssGSV BPG, as compared to PTA/S (at 7 years: 11% vs. 24%, p=.001 and 72% vs. 78%, p=.03, respectively). These findings correlated with a 53% and 28% reduction in the aforementioned adjusted events (HR 0.47, 95% CI [0.30-0.74] and 0.82 [0.69-0.98], respectively). These significant differences in major reintervention and MALE/Death were not noted in Cohort 2 (at 7 years: 25% vs. 24%, p=.92 and 82% vs. 80%, p=.31, respectively). Further, neither Cohort demonstrated significant differences in complete wound healing (at 6 months, Cohort 1: 47% vs. 40%, p=.32; Cohort 2: 40% vs. 38%, p=.12), major amputation (at 7 years: Cohort 1: 15% vs. 15%, p=.89; Cohort 2: 35% vs. 25%, p=.86), or Amputation/Death (at 7 years, Cohort 1: 70% vs. 66%, p=.99; Cohort 2: 78% vs. 76%, p=.45).

Conclusions: Patients undergoing revascularization using single-segment great saphenous vein demonstrate significantly lower rates of major reintervention and MALE/Death compared with those undergoing endovascular interventions for CLTI. However, similar outcomes are not seen among patients undergoing revascularization without a suitable ssGSV. These findings correlate with those demonstrated in BEST-CLI, suggesting generalizability.

Introduction: In 2015, Society for Vascular Surgery guidelines on claudication management were released spanning optimal medical management, procedural, and post-procedure recommendations. Uptake of guidelines and changes to clinical practice over time remain unknown. This study hypothesized that guideline aligned practice increased after guideline release.

Methods: The Vascular Quality Initiative Peripheral Vascular Intervention (VQI PVI) dataset was queried for years 2010-2021 for cases of claudication from occlusive disease. Only the initial procedure was considered, and subsequent interventions were excluded. The primary endpoint was care aligned with the 2015 SVS claudication treatment guidelines that were possible to evaluate in the VQI PVI dataset. Guideline aligned practice before 2016 was compared to after 2016. A hierarchical regression was used to control for hospital level variation introduced by changing VQI membership during the study timeframe.

Results: A majority of the 2015 SVS guideline GRADE 1-A recommendations can be assessed using the VQI PVI dataset. Overall, 93,654 cases were included, 30.9% before 2016 and 69.1% after guideline release. After controlling for hospital level variation, guideline aligned care improved for preoperative smoking cessation, aspirin, clopidogrel, and statin use, and post operative medical therapy with antiplatelet, dual antiplatelet and statin therapy. Guideline aligned care did not change over time for aorto-iliac stent use, covered stent use in calcified aortoiliac disease, or superficial femoral artery stenting for 5-15cm lesions. Guideline aligned care worsened for isolated infrapopliteal treatments and use of bare metal stents for 5-15 cm SFA occlusions. Secondary analysis identified an association between area deprivation index and increased odds of smoking and decreased odds of meeting post-discharge optimal medical therapy.

Conclusion: While guideline aligned care improved after guideline release for medical management of claudication, procedural elements did not improve. Those with social deprivation were less likely to receive guideline aligned care for medical management representing a future area of study and improvement. High GRADE recommendations can be tracked using the VQI PVI dataset and should be monitored to help improve care.

Background: Infrainguinal bypass for chronic limb-threatening ischemia (CTLI) in octogenarians is considered a high-risk procedure due to the presumed associated frailty of the patient population. However, the alternative which is major amputation may not be a better option. This study retrospectively compares the outcomes of bypass versus major amputation for functionally independent and partially dependent patients.

Methods: Patients greater than and equal to 80 years old who underwent non-emergent infrainguinal bypasses for CTLI presenting with rest pain/tissue loss were selected from the targeted NSQIP database 2011-2022. Patients with major amputations (CPT codes 27880, 27882, 27590, 27592) for atherosclerosis by ICD9/10 codes were selected from the general database. We stratified the patients based on functional status (independent or partially dependent) and compared outcomes of bypass versus amputation within each group. Multivariable logistic regression was performed for 30-day mortality, major organ dysfunction, length of stay (LOS), and discharge destinations.

Results: There were 2,419 patients who underwent a bypass and 1,326 patients who underwent an amputation in the independent functional group. Patients with bypass were generally healthier. Multivariable analysis revealed that having a bypass was associated with significantly higher major adverse cardiac events (aOR: 1.7; p<0.01), bleeding requiring transfusion (aOR: 4.3; p<0.01), and wound complications (aOR: 1.7; p<0.01). There was no significant difference in mortality, renal complications, or sepsis. Additionally, bypass patients had longer operation time (p<0.01) and return to the operating room (aOR: 2.7; p<0.01). However, bypass patients were more likely to be discharged to home rather than to a facility (aOR: 4.2; p<0.01). Similar outcomes were observed for partially dependent patients, except that bypass patients had a longer LOS (12.40 ± 9.86 vs. 10.78 ± 9.94 days; p<0.01).

Conclusion: Bypass for limb salvage for octogenarians does incur higher morbidities than amputation but does not increase mortality. The immediate higher morbidities of bypass should be weighed against a better chance of home discharge, which could potentially imply less functional decline.

Objectives: Endovascular aneurysm repair (EVAR) for large infrarenal abdominal aortic aneurysms (AAA) has been associated with worse outcomes compared to EVAR for smaller AAAs. Whether these findings apply to complex AAAs (cAAA) remains uncertain.

Methods: We identified all intact complex EVAR (cEVAR) from 2012-2024 in the Vascular Quality Initiative. cEVAR was defined as having a proximal extent between zones 6-9 and at least one side branch/fenestration/chimney/parallel grafting. Aneurysm size was defined as follows: large: >65 mm (males), >60 mm (females); medium: 55-65 mm (males), 50-60 mm (females); and small: <55 mm (males), <50 mm (females). We assessed perioperative death, any complication, and in-hospital reintervention using logistic regression and mid-term mortality using adjusted Kaplan-Meier methods and Cox regression. Medium-sized aneurysms were compared to large and small aneurysms.

Results: Of 3,426 patients, 22.6% had large, 60.4% medium, and 17.0% had small aneurysms. As compared to medium and small aneurysms, large aneurysms demonstrated higher rates of perioperative death (4.8% vs. 2.6% vs. 0.5%), any complication (33.3% vs. 23.6% vs. 19.4%), and in-hospital reintervention (6.2% vs. 4.0% vs. 2.6%) (all p<.05). Median follow-up was 445 days. One-year mortality rates were higher in large aneurysms (12.3% vs. 7.8% vs. 3.8%; p<.001). After adjustment, when compared with medium-sized aneurysms, large aneurysms were associated with a significantly higher risk of perioperative death (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], [1.09-2.72]), any complication (aOR, 1.44; [1.18-1.76]), and mid-term mortality (adjusted hazard ratio [aHR], 1.50; [1.19-1.88]), but not in-hospital reintervention (aOR, 1.46; [0.99-2.13]). While small aneurysms, as compared with medium-sized aneurysms, did not demonstrate a difference in any complication (aOR, 0.87; [0.68-1.10]), in-hospital reintervention (aOR, 0.77; [0.42-1.33]), and mid-term mortality (aHR, 0.78; [0.57-1.08], they did demonstrate a lower risk of perioperative death (aOR, 0.26; [0.06-0.71]).

Conclusions: In cEVAR for cAAA, large aneurysms, compared with medium-sized aneurysms, were associated with higher rates of perioperative death, any complication, and mid-term mortality, with in-hospital reintervention trending toward a statistically significant higher risk. While these results align with expectations, they emphasize the importance of effectively managing patients with large cAAAs and highlight the need for future research to determine whether patients might benefit more from medical therapy or open repair.

Background: PAD affects >12 million Americans and poses significant financial burdens on patients, but the relationship between delayed/forgone (D/F) care and resource use in this population is unknown. We sought to assess the relationship between D/F care, resource use, and health care expenditures among patients with PAD.

Methods: Adults with PAD in the US were identified in the Medical Expenditure Panel Survey for years 2007-2017. Unweighted counts of reasons for D/F care were tabulated. Proportions of patients with ≥1 emergency department (ED), ≥1 inpatient, ≥1 outpatient, and >5 office-based encounters were compared using Rao-Scott adjusted Chi-Squared tests. Annual per capita total, out-of-pocket (OOP), ED, inpatient, outpatient, office-based visit, and prescription medication expenditures were compared using two-part econometric models.

Results: The study cohort included 2,926,654 patients with PAD. Among the 264,172 (9%) of patients with PAD reporting D/F care, 41.2% of patients cited financial barriers as the primary reason for D/F care. There were greater proportions of patients with ≥1 ED visits (52% vs 31%, P<0.001), ≥1 outpatient hospital visits (56% vs 43%, P=0.004), and >5 office-based visits (81% vs 71%, P=0.04) among those reporting D/F care versus those who did not. Patients with D/F care had $7,742 (95% CI $3,170-$12,314, P=0.001) greater per capita total and $5,156 (95% CI $692-$9,619, P=0.02) greater per capita inpatient expenditures per year than patients without D/F care.

Conclusions: D/F care is associated with increased resource use and health care expenditures among patients with PAD. Further work is needed to elucidate the underlying causes of D/F care and mitigate financial burdens on PAD patients.

Objective: Low-profile endografts have reported increased rates of limb graft occlusions. The INCRAFT stent graft system is an ultra-low profile endograft for the exclusion of infrarenal abdominal aortic aneurysms. Our aim was to report thromboembolic events (TE) in patients treated with the INCRAFT device and its association with risk factors.

Methods: A retrospective study was performed of 80 patients treated with the INCRAFT endograft between February 2015 and December 2022 at a single institution. All available imaging studies were reviewed by two reviewers independently. TE included intraprosthetic thrombus (IPT), limb graft occlusion (LGO) and distal embolization. A regression analysis was performed to evaluate possible risk factors associated with the development of TE. These included tortuous access vessels, IPT, access vessel diameter and the ratio between the cross-sectional area of the mainbody to the bilateral limb grafts.

Results: Limb occlusions occurred in 7 patients (9%) and 12 limbs (7.5%) resulting in a primary and secondary patency at one, three and five years of 96% and 99%, 94% and 97% and 89% and 93%, respectively. IPT was found in 36% of patients and affected endograft limbs in 93%. Ten distal occlusions in 8 patients (10.0%) were considered to origin from IPT, which led to symptomatic occlusions of below-the-knee vessels in all patients. Freedom from IPT at one, three and five years was 80%, 61%, and 43%, respectively. Age ≤70 years and access vessel diameter ≥10 mm were associated with IPT development. IPT was significantly associated with LGO (OR 77.10, p=0.003).

Conclusion: Thromboembolic events are frequent after treatment with the INCRAFT endograft with a limb graft occlusion rate of 9% per patient and IPT found in 36% of patients. IPT was more common in patients ≤70 years and was a significant risk factor for LGO.

Introduction/aim: The partial deployment technique (PDT) is an unconventional option of T-branch deployment to allow target arteries (TAs) cannulation/stenting from the upper arm access, in case of narrow (NPA: <25mm) or severely angulated (APA: >60°) aorta. Aim of this study was to report outcomes of the endovascular repair of complex aortic (c-AAAs) and thoracoabdominal (TAAAs) aneurysms by T-branch and PDT.

Methods: All consecutive patients underwent urgent endovascular repair of c-AAAs and TAAAs by T-branch (Cook-Medical, Bloomington, IN, US) and PDT from 2021 to 2023 were analyzed. Technical success (TS), 30-days mortality, TAs-instability within 30-days and 1-year as well as reinterventions were assessed as primary endpoints. Time of intraoperative pelvic/lower limb ischemia, spinal cord ischemia (SCI) and perioperative stroke were assessed as secondary endpoints.

Results: Thirty-three cases were analyzed. There were 6(18%) type I endoleaks in failed EVAR, 9(28%) juxta/para-renal aneurysms, 6(18%) post-dissection and 12(36%) degenerative TAAAs, respectively. The median para-visceral aortic lumen diameter was 23(IQR:19-27) mm and 10(30%) cases had APA. Out of 128 TAs, 111(87%) were cannulated/stented with distally captured aortic graft. The median time of pelvic/lower limb ischemia was 120 (IQR:90-150) minutes. TS was achieved in all patients. One (3%) patient suffered SCI and there were no cases of stroke. An asymptomatic renal artery occlusion was detected at postoperative imaging which was recanalized by thrombus-aspiration/relining. This was the only case of TAs-instability (1/128-0.8%) and reintervention (1/33-3%) within 30-day. Two (6%) patients died within 30-days. Median follow-up was 14(IQR:6-22) months. One (3%) case of bilateral renal artery occlusion occurred at 6-months. No superior mesenteric artery or celiac trunk events occurred, with an overall TAs-instability rate of 2% (3/128). Eighteen (55%) patients completed the radiological follow-up at 1-year with no new case of TAs-instability. Freedom from TAs-instability was 91% at 1-year.

Conclusion: T-branch by PDT seems to be safe and effective in the management of c-AAAs/TAAAs with NPA or APA. Results were satisfactory in terms of TS and mid-term TAs-instability, suggesting a possible enlargement of the anatomical feasibility criteria for outer branches in urgent cases.