Journal of Vascular Surgery最新文献

Objective: Elderly patients with chronic limb-threatening ischemia (CLTI) undergoing revascularization are prone to delirium and prolonged hospitalization. Preoperative prehabilitation may prevent delirium and reduce the length of stay. This study investigates the effect of multimodal prehabilitation on delirium incidence in elderly patients with CLTI undergoing revascularization.

Methods: A comparative observational cohort study conducted in a large teaching hospital (intervention cohort n = 101, retrospective control cohort n = 207) and a university hospital (prospective control cohort n = 48) from 2020 to 2023. Patients aged ≥65 years undergoing revascularization were included, with acute treatment or severe cognitive impairment as exclusion criteria. The 3-week prehabilitation program included screening of general health and presence of delirium risk factors by a vascular nurse practitioner, screening and provision of personalized, home-based exercises by a physiotherapist, provision of nutritional advice by a dietician, and, if indicated, comprehensive geriatric assessment by a geriatrician, assessment of self-reliance and home situation by a prearranged homecare nurse, guidance and support for smoking cessation by a quit smoking coach, and anemia treatment. Primary outcome was 30-day delirium incidence, analyzed using regression models adjusting for potential confounders (age, physical impairment, history of delirium, preoperative anemia, and revascularization type). Secondary outcomes were length of stay, postoperative complications, 30-day mortality, and patient experiences.

Results: Median age was 76 years (interquartile range, 71-82 years). Delirium incidence was lower in the prehabilitation cohort (n = 2/101; 2%) compared with controls (n = 23/255; 9%; odds ratio, 0.21; 95% confidence interval, 0.05-0.89; P = .04). Adjusted analysis showed a non-significant delirium reduction (odds ratio, 0.28; 95% confidence interval, 0.06-1.3; P = .097). The prehabilitation cohort had a significantly shorter length of stay (2 [interquartile range (IQR), 1-5] vs 4 [IQR, 2-9] days; P ≤ .001), and fewer minor complications (14% vs 26%; P=.01). No differences were present in major complications and 30-day mortality. Patients reported high compliance and satisfaction (median score, 8/10 [IQR, 7-9]).

Conclusions: Prehabilitation among elderly patients with CLTI is safe and has the potential to yield multiple beneficial effects on general outcomes following revascularization, while also achieving high levels of patient satisfaction. Further validation and consideration of implementation in surgical settings is recommended.

Objective: The aim of this study was to compare perioperative and 5-year outcomes following endovascular (FEVAR) and open repair (OAR) of complex abdominal aortic aneurysms (cAAAs) in males and females separately, given the known sex-related differences in perioperative outcomes.

Methods: We studied all elective cAAA repairs between 2014 and 2019 in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry. We stratified patients based on sex. We calculated propensity scores for assignment to either OAR or FEVAR. Covariates including age, race, diameter, baseline comorbidities, proximal extent of repair, annual center volumes, and annual surgeon volumes were introduced into the model for estimating propensity scores. Within matched cohorts, perioperative outcomes and 5-year outcomes (mortality, reinterventions, and ruptures) were evaluated using multivariable logistic and Cox regression models.

Results: We identified 2825 patients, of whom 29% were female. Within both the sexes, OAR was more commonly performed (OAR vs FEVAR: males: 53% vs 47%; females: 63% vs 37%). After matching, among males (n = 1326), FEVAR was associated with lower perioperative mortality (FEVAR vs OAR: 2.3% vs 5.1%; P < .001). However, FEVAR was associated with comparable 5-year mortality (38% vs 28%; hazard ratio [HR], 1.2; 95% confidence interval [CI], 0.92-1.4; P = .22) and a higher hazard of 5-year reintervention (19% vs 3.7%; adjusted HR, 4.5; 95% CI, 2.6-7.6; P < .001). Among females (n = 456), FEVAR and OAR showed similar perioperative mortality (8.3% vs 7.0%; P = .73). At 5 years, FEVAR was associated with higher hazards of mortality (43% vs 32%; adjusted HR, 1.5; 95% CI, 1.03-2.2; P = .034) and reintervention (20% vs 3.0%; adjusted HR, 4.8; 95% CI, 2.1-11; P < .001) compared with OAR.

Conclusions: Among males, FEVAR was associated with favorable perioperative outcomes compared with OAR, although these advantages attenuate over time. However, among females, FEVAR was associated with similar perioperative outcomes, eventually leading to higher reinterventions and possibly higher mortality within 5 years. Future efforts should focus on determining the factors associated with these sex disparities to improve outcomes following FEVAR in females. Based on current evidence, females undergoing elective cAAA repair should be selected with due caution, especially for endovascular repair.

Objective: The aim of this study was to evaluate the patency of bridging covered stents (BCS) bridged to inner branches in custom-made thoracoabdominal endografts.

Methods: This was a single-center retrospective study identifying all patients undergoing fenestrated or branched endovascular aortic repair (f/b EVAR) in whom the reno-visceral target vessels (TVs) were bridged with a BCS to an inner branch of a custom-made (CMD) endograft. Technical success and perioperative complications were noted. Follow-up BCS patencies were evaluated, and in patients with follow-up, two groups based on BCS were created, a group with BCS occlusion and a group with BCS patent. Univariable and multivariable analyses were performed to analyze factors related to visceral and renal bridging stent occlusion.

Results: From 2019 through 2022, 69 patients undergoing complex aortic repair had at least one TV bridged to an inner branch built into a CMD endograft. Eighty-six percent of the grafts had only inner branches, whereas 14% had a mix of fenestrations for the visceral TVs and inner branches for the renal arteries. Twenty-five percent of patients presented as urgent and received an endograft originally designed for another patient and available on our shelf at the time. A total of 245 TVs were connected to inner branches: celiac trunk (CT), 54; superior mesenteric artery (SMA), 59; and renal artery (RA), 132. Technical success was 99%. There was a 23% complication and 9% perioperative mortality rate. At follow-up, we identified 6% of visceral and 14% of renal BCS occlusions. The primary patency for RA BCS was 83% at 12 months and 58% at 24 months. For the CT-SMA BCS, Kaplan-Maier showed a patency of 99% and 96% at 12 and 24 months. In the univariate analysis, a misaligned TV ostium (P = .001), the postoperative BCS diameter on postoperative computed tomography angiography (P = .02), and the preoperative infrarenal aortic angle >60° (P = .007) were correlated with RA BCS occlusion. In the multivariate analysis, only the misaligned TV ostium (P = .002) and infrarenal angle >60° (P = .01) were significantly correlated.

Conclusions: In our series of complex aortic repair, the incorporation of inner branches to bridge TVs is associated with a high renal BCS occlusion rate. Improper alignment of the branches with the TV ostium and acute aortic angles might play a significant role. Further research on this technology is needed.

Objective: Proximal ExTension to Induce COmplete ATtachment (PETTICOAT), which uses downstream bare metal stents for structural support, demonstrates potential, yet its adoption is limited by variable outcomes. This study elucidates the potential of PETTICOAT in aortic dissection, emphasizing the determinants that guide patient selection.

Methods: A retrospective analysis of 60 patients who underwent full PETTICOAT for aortic dissections was conducted. A multivariate logistic regression model identified predictors of favorable aortic remodeling. Patients underwent standardized follow-up with computed tomography scans to assess size, volumetric changes, and anatomical conditions. Selection criteria included full PETTICOAT application and a minimum of 3 months of follow-up. Demographics, preoperative conditions, and procedural details were collected and analyzed.

Results: The analysis identified predictors of favorable aortic remodeling, including age >60 years, a larger downstream aorta stent graft, a smaller abdominal aorta (<450 mm²), and oral angiotensin II receptor blocker administration. Over a median 47.5 months of follow-up, survival rates in the favorable remodeling (97.3%) and unfavorable groups (100%) were similar. Downstream aortic event-free survival rates did not differ significantly (89.2% vs 73.9%), although the unfavorable group had a relatively higher incidence of distal stent-induced new entries (26.1% vs 8.1%).

Conclusions: The PETTICOAT concept effectively enhances aortic remodeling in complex aortic dissections. Predictors for favorable remodeling, including age, stent graft sizing, aortic diameter, and angiotensin II receptor blocker therapy, offer insights for optimizing patient selection. This approach improves survival outcomes, mitigates risks associated with untreated aortic segments, and provides a minimally invasive solution for aortic dissections. Despite some outcome variations, the technique holds promise for addressing the challenges of aortic dissections, with the potential for further refinement in patient selection and technique application.