Journal of Vascular Surgery最新文献

Objective: This study aimed to evaluate indications and outcomes of open surgical conversion (OSC) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) using a multicenter registry in Japan.

Methods: Thirteen vascular centers retrospectively reviewed patients who underwent OSC after prior EVAR between 2006 and 2024. Baseline characteristics, indications, procedural details, and outcomes were analyzed. Primary endpoint was 30-day mortality. Secondary endpoints were overall survival (OS), aneurysm-related survival, and freedom from retreatment.

Results: A total of 208 patients (85.6% males, median age 78 years) were included. Median age was 78 years, 85.6% were male, and median AAA diameter was 62mm. Median interval from initial EVAR to OSC was 5.2 years. Indications for OSC were type 2 endoleak with sac enlargement (47.1%), type 1 endoleak (23.1%), type 5 endoleak with sac enlargement (13.0%), infection (10.1%), and type 3 endoleak (9.6%). The most frequently used stent graft was Excluder, followed by Endurant and Zenith. Complete stent graft removal was performed in 41 patients, partial removal in 51, and 116 underwent OSC with stent graft preservations. Thirty-eight patients (18.3%) presented with rupture, and 48 (23.1%) underwent urgent OSC. Thirty-day mortality was 4.3% in overall cohort, 2.4% in non-ruptured cases, and 13.2% in ruptured cases. Rupture was a risk factor for the 30-day mortality (hazard ratio, 5.93; 95% confidence interval, 1.59-22.1; P = .008). At 10 years, OS and aneurysm-related mortality were 58.4% and 14.8%, respectively, while freedom from retreatment rate was 87.5% at 10 years.

Conclusion: Type 2 endoleak was the leading common indication for OSC after EVAR in this multicenter retrospective study in Japan. Rupture at OSC markedly increased 30-day mortality, even in patients with type 2 endoleak. Further studies are needed to refine elective indications for OSC to prevent aneurysmal rupture and avoid treatment delay.

Background: In October 2023, Medicare expanded coverage for carotid stenting to include standard-risk beneficiaries, prompting substantial debate surrounding the potential impact on procedure utilization, most notably, for transfemoral carotid stenting (TFCAS). Since this coverage expansion, it remains unknown whether there has been a concordant change in carotid stenting utilization and resultant long-term stroke-risk. Therefore, our objective was to document trends in procedure utilization of TFCAS, transcarotid artery revascularization (TCAR), and carotid endarterectomy (CEA) in response to the coverage expansion and compare the respective long-term stroke-risks.

Methods: We performed a retrospective study using Truveta electronic health record (EHR) data. Truveta provides daily updated EHR data from over 800 hospitals and 100 million patients. We studied patients who underwent TCAR, CEA, or TFCAS from January 2016 to December 2024. We calculated the procedure rate for each quarter and performed an interrupted time series (ITS) analysis to assess the change from Q3 2023 (Medicare policy change) to Q4 2024. We used Kaplan-Meier analysis and Cox-regression to compare the long-term stroke-risk among asymptomatic patients.

Results: We identified 6,473 TCAR patients (65.9% asymptomatic), 36,224 CEA patients (61.6% asymptomatic), and 11,626 TFCAS patients (50.1% asymptomatic). The procedure rate per 100,000 patients from Q3 2023 (Medicare policy change) to Q4 2024 decreased by 39.3% for TCAR (ITS p-value: <.001) and 38.4% for CEA (ITS p-value: .035). The procedure rate increased by 2.1% for TFCAS (ITS p-value: .365). Among asymptomatic patients, the freedom from stroke at 8 years for TCAR, CEA, and TFCAS was 87.2% (95%CI: 84.0%-90.5%), 86.3% (95%CI: 85.5%-87.2%), and 79.8% (95%CI: 77.6%-82.0%), respectively. Compared to CEA, the adjusted hazard ratio of stroke was 0.83 (95%CI: 0.72-0.97) after TCAR, and 1.41 (95%CI: 1.27-1.56) after TFCAS.

Conclusions: TFCAS utilization has remained largely unchanged since the Medicare coverage expansion, refuting any perception that the Medicare policy shift would substantially impact real-world carotid practice. Interestingly, TCAR and CEA rates have decreased over time, despite having a lower long-term stroke-risk. These findings highlight the need for longitudinal procedure utilization surveillance to ensure optimal outcomes among patients undergoing carotid revascularization.

Background: The optimal anesthetic strategy for carotid artery stenting (CAS) remains uncertain. General anesthesia (GA) ensures immobility and airway control but may increase hemodynamic instability, whereas monitored or local anesthesia (MAC/LA) permits real-time neurological assessment. This multicenter study evaluated the association between anesthetic modality and clinical outcomes following CAS.

Methods: Data were prospectively collected from 15 comprehensive stroke centers in the United States between January 2023 and December 2024. Adults undergoing CAS for atherosclerotic carotid stenosis were included. Propensity score matching (1:2 nearest-neighbor, without replacement) was performed using preprocedural NIHSS to balance baseline differences between GA and non-GA cohorts. The primary outcomes were 30-day procedure-related mortality, ischemic or hemorrhagic stroke, and myocardial infarction. Logistic regression identified independent predictors of mortality.

Results: Among 888 patients (222 GA, 666 non-GA), the groups were well-balanced after matching (220 vs. 668). Overall complication rates were low (6-7%). Thirty-day mortality was 4.1% with GA versus 1.8% with non-GA (p = 0.14). In regression, non-GA was associated with lower all-cause mortality (OR 0.11, 95% CI 0.01-0.85, p = 0.03). Functional recovery was superior with non-GA (mean 30-day mRS 1.25 vs 1.60, p = 0.012). Length of stay was shorter in the non-GA group (5.2 vs 6.2 days, p = 0.021).

Conclusions: Both anesthetic approaches were safe, but non-GA was associated with slightly better functional outcomes and reduced mortality. When clinically feasible, MAC or local anesthesia may offer superior peri-procedural safety and recovery in carotid artery stenting.

Objective: Pediatric vascular surgery is infrequent, heterogeneous, and lacks standardized care models. We sought to characterize the full spectrum of pediatric vascular surgery consultations, interventions, multidisciplinary involvement, and long-term outcomes within an integrated academic health system over a 20-year period.

Methods: We performed a retrospective cohort study of all pediatric patients (<18 years) evaluated by vascular surgery from 2004-2024 at a single tertiary academic center with an affiliated children's hospital. Demographics, consultation characteristics, operative details, and longitudinal outcomes were abstracted from the electronic health record. Interventions were categorized as arterial, aortic, or venous. Descriptive statistics were used.

Results: A total of 342 pediatric patients were evaluated by vascular surgery across inpatient and ambulatory (clinic-based) settings during the study period. The patients were 51.5% male and had a median age of 14.2 years [IQR 10.2-16.4]). Inpatient consultations accounted for 54.1%, and 60% were urgent or emergent. Most consultations (62.0%) did not require operative intervention. Vascular interventions were performed in 129 patients (37.7%), predominantly by vascular surgery (91.5%). Arterial interventions (n=81) included trauma repairs, renal artery reimplantation, decompression or entrapment syndromes, patch angioplasty, and 31 bypasses. Autogenous conduit was used in 96.8% of bypasses and demonstrated primary vein graft patency was 72.4% at a median 5-year follow-up, with no failures attributable to somatic growth. Aortic interventions (n=10) included TEVAR for blunt thoracic aortic injury (n=4) and varied abdominal reconstructions (n=5), all with durable early and midterm outcomes; one late embolic event occurred after TEVAR. Venous interventions (n=37) most commonly included thoracic outlet decompression (n=12), dialysis access surgery (n=6), and oncologic vascular assistance (n=4). Reinterventions occurred primarily in dialysis access patients. Overall median follow-up was 4.6 years. Of 85 patients who reached adulthood, 32.9% successfully transitioned to adult vascular surgery.

Conclusions: Pediatric vascular surgery represents a high-acuity, consult-driven practice with a broad disease spectrum and excellent operative safety when intervention is required. However, substantial gaps in longitudinal surveillance and transition to adult care persist, even within an integrated health system. Structured pediatric vascular care pathways and formal transition strategies are needed to ensure durable, lifelong outcomes.