Journal of Vascular Surgery最新文献

Objective: The purpose of this study is to evaluate the impact of left renal vein (LRV) division in patients undergoing open abdominal aortic aneurysm repair (AAA) repair.

Methods: This is a systematic review and meta-analysis registered in PROSPERO register of systematic reviews (CRD42025640222) and conducted in accordance to Cochrane's guidelines for systematic review and meta-analysis. PubMed, EMBASE, and Cochrane databases were systematically searched for studies comparing outcomes of patients who underwent open AAA repair with and without LRV division. Two authors screened the search results and collected data of interest independently, according to the PRIMA protocol. The primary outcome was 30-day mortality and secondary outcomes were short and long-term renal function. Risk ratio (RR) and mean difference (MD) with corresponding 95% confidence interval (CI) were estimated using a random-effects model. Significance was defined as a p-value <0.05.

Results: A total of 190 studies were screened for inclusion, of which nine studies (8 cohort studies and 1 case-control study) met the inclusion criteria. These studies included a total of 1,324 patients, 350 of whom underwent LRV division, while 974 patients did not. Meta-analysis revealed no significant difference in 30-day mortality (28/205 versus 123/512, RR= 0.90, 95% CI 0.63-1.29; p=0.42, I²=0%), AKI (RR=1.74, 95% CI 0.39-7.83; p=0.33, I²=69%), need for dialysis (4/178 versus 10/473, RR=1.61, 95% CI 0.54-4.84), discharge eGFR (MD=-0.32, 95% CI -2.57-1.92, p=0.60, I²=0%), and discharge serum creatinine (sCr) (MD=-0.01, 95% CI -0.02-0.01, p = 0.29, I² = 0%). LRV division was associated with an increase post operative sCr (MD=0.08, 95% CI 0.04-0.11, p=0.009, I²=0%) compared to patients with the LRV left intact.

Conclusions: Among patients undergoing AAA open surgical repair, our results demonstrate that LRV division is not associated with an increase in 30-day mortality or worse renal function.

Objectives: Open bypass with single segment great saphenous vein is the optimum procedure for chronic limb threatening ischemia (CLTI). However, many CLTI patients require revascularization after a prior failed lower extremity bypass or endovascular therapy (ET). Hence in this study, we aimed to investigate outcomes of bypass vs ET in patients with prior bypass as well as in those with prior ET.

Methods: The Vascular Quality Initiative (VQI) database were queried for CLTI patients who underwent infrainguinal open or endovascular revascularization after a prior lower extremity bypass or ET from 2016 to 2023. Patients with prior ipsilateral major amputation (MA), or concomitant procedures were excluded. Two well matched (SD<0.1) propensity score-matched (PSM) cohorts (1:1) were produced for patients who underwent 1-prior bypass and 2-prior ET. Cox regression, Kaplan Meier survival analysis, and Log Rank test were used to analyze one-year outcomes of bypass vs ET in both groups. Outcomes include mortality, major amputation (MA), reintervention, and major adverse limb events [MALE (reintervention or MA)].

Results: A total of 53,793 patients were included. In the group with prior bypass, 3,499 (60%) underwent ET and 2,338 (40%) had another bypass. While in the prior ET group, 39,738 (82.9%) had another ET and 8,218 (17.1%) had a bypass. PSM produced two well matched cohorts in each group [prior bypass 1,047 pairs; prior ET 5,603 pairs]. After matching, there was no significant difference in any of the outcomes between bypass and ET after a prior bypass. There was a trend of lower one-year mortality with bypass after a prior bypass [HR=0.79, 95%CI 0.61-1.03, p=0.078]. However, in patients with prior ET, bypass was associated with lower hazard of mortality [HR=0.82, 95%CI 0.73-0.91, p<0.001], reintervention [HR=0.73 95%CI 0.63-0.83, p<0.001], and MALE/death [HR=0.91, 95%CI 0.84-0.98, p=0.015] at one year compared to ET.

Conclusions: This real-world multi-institutional study revealed that outcomes of revascularization after a prior lower extremity bypass are not associated with procedure type. However, in patients with prior ET, open lower extremity bypass is associated with lower hazard of mortality and reintervention as well as better MALE-free survival compared to secondary endovascular intervention.

Objective: To evaluate morphological and clinical outcomes after False Lumen Occluder (FLO) implantation for post-dissection thoracoabdominal aortic aneurysm (PD-TAAA) and to investigate the impact of adjunctive false lumen embolization on aortic remodeling.

Methods: A retrospective single-center study included 71 patients (median age 64 years, IQR 58-70; 77.5% male) with chronic type B aortic dissection (cTBAD) treated between June 2018 and December 2024 with third-generation FLO implantation during thoracic endovascular aortic repair (TEVAR) or fenestrated/branched repair (F/BEVAR). Aortic, true lumen (TL), and false lumen (FL) volumes were quantified using three-dimensional reconstructions on Aquarius software. FLO remodeling was defined as compression of the occluder with a crescent shape on follow-up imaging.Aortic remodeling (false lumen regression) was defined as a ≥10% reduction in FL volume, stability as ±10% change, and enlargement as >10% increase compared with baseline. Associations between clinical, anatomical, and procedural variables and remodeling outcomes were analyzed using non-parametric and mixed-effects models.

Results: Across 268 imaging examinations, total aortic and FL volumes decreased significantly over time, while TL volume expanded (all p<0.001). Median total aortic volume declined from 796 cm³ at 1 month to 706 cm³ at 4 years, and FL volume decreased from 501 cm³ to 296 cm³, while TL volume increased from 287.5 cm³ to 358 cm³. Median follow-up was 13.3 (5.6-36.5) months.Aortic remodeling occurred in 83.1% of patients, FL stability in 12.7%, and enlargement in 4.2%. Regression was more frequent in younger patients (p=0.048) and those with smaller baseline diameters and volumes (p=0.043 and p=0.034).Adjunctive embolization was strongly associated with TL expansion (χ²=5.8, p=0.016) and FLO remodeling (χ²=5.2, p=0.022), and showed a trend toward increased aortic remodeling (χ²=4.8, p=0.056) without added mortality or morbidity. No cases of spinal cord ischemia occurred. FLO size (≥40 vs <40 mm) and position (thoracic, diaphragmatic, or abdominal) did not influence outcomes. FLO remodeling was strongly correlated with concurrent FL reduction (χ²=20.8, p<0.001) and may represent a radiologic marker of procedural success.

Conclusions: FLO implantation provided durable aortic remodeling in cTBAD, while adjunctive embolization enhanced remodeling efficacy by eliminating residual perfusion without increasing risk. The absence of spinal cord ischemia and the identification of FLO remodeling as a surrogate of success highlight the value of this combined, low-risk strategy for long-term aortic stability.

Background: While historically, amaurosis fugax was clinically categorized similarly to ipsilateral hemispheric transient ischemic attack (TIA) or stroke, it remains unclear whether transient monocular blindness confers comparable risk to patients in contemporary practice. The purpose of this analysis was to compare postoperative stroke risk among patients undergoing CEA for amaurosis, compared to patients with TIA, stroke, or asymptomatic carotid stenosis.

Methods: We studied patients who underwent CEA in the VQI (2016-2024) and performed a subgroup analysis in patients with linked Medicare claims (2016-2019). The primary exposure was baseline symptom status, classified as amaurosis, TIA, stroke or asymptomatic. The primary outcome was stroke. Logistic regression was used to compare the likelihood of in-hospital stroke across the four groups for all examined VQI patients, and Kaplan-Meier estimation and Cox-regression was used among patients with linked Medicare data.

Results: We identified 177,859 carotid stenosis patients who underwent CEA (7.0%-amaurosis, 12.1%-TIA, 25.4%-stroke, 55.5%-asymptomatic). The in-hospital stroke rate was 0.8% for amaurosis, compared to 1.4%, 2.0%, and 0.7% for TIA, stroke, and asymptomatic presentations, respectively. Compared to asymptomatic patients, the adjusted odds ratio of stroke was 1.17 (95%CI:0.93-1.46; p=0.18) for patients with amaurosis and was 1.76 (95%CI:1.51-2.06; p<0.01), and 2.30 (95%CI:2.05-2.59; p<0.01) for those with TIA, and stroke, respectively. We identified 31,010 patients with linked Medicare data (6.0%-amaurosis, 10.7%-TIA, 21.9%-stroke, 61.4%-asymptomatic). The 3-year stroke risk was 6.1% for amaurosis patients, compared to 12.4%, 16.0%, and 5.0% for patients with TIA, stroke, and those who were asymptomatic, respectively (log-rank: p<0.001). Compared to asymptomatic patients, the adjusted hazard ratio of stroke was 1.15 (95%CI:0.91-1.45; p=0.21) for patients with amaurosis and was 2.03 (95%CI:1.74-2.36; p<0.01), and 2.80 (95%CI: 2.50-3.14; p<0.01) for patients with TIA, and stroke, respectively.

Conclusions: Patients undergoing CEA in the setting of amaurosis fugax had a statistically similar perioperative and long-term stroke risk compared to asymptomatic patients. By contrast, hemispheric TIAs or stroke conferred greater risks longitudinally. These findings suggest that it may be appropriate to reconsider the historical risk perception associated with transient monocular blindness to a less severe phenotype and can inform preoperative decision making for patients considering CEA.

Background: Suicidal ideation (SI) during surgical training is poorly understood and may be attributed to a variety of personal and environmental risk factors. The purpose of this study was to evaluate the incidence of SI among vascular surgery trainees.

Methods: Data were collected from a confidential, voluntary survey administered after the 2020-2024 Vascular Surgery In-Training Exam as part of the SECOND trial (Surgical Education Culture Optimization through targeted interventions based on National comparative Data Trial). SI was assessed with the following question: "In the past 12 months, have you had thoughts of taking your own life?" Positive screens prompted presentation of the National Suicide Hotline. Descriptive statistics were used to evaluate demographic and learning environmental factors associated with suicidality.

Results: A total of 3272 survey results were collected from 2020 to 2024. Seventy-four respondents (2.3%) reported positive SI. In considering the most recent year of responses (2024), demographic variables were comparable between trainees who did and did not screen positive for SI. However, trainees who screened positive were more likely to report negative learning environment factors, including pressure to under-report hours (31% vs 6%), lack of a sense of belonging among trainees (15% vs 4%), sexual harassment (46% vs 10%), and perception of program unresponsiveness (38% vs 5%), among other factors.

Conclusions: Although low rates of SI limit more detailed statistical analysis, this remains the most comprehensive evaluation among vascular surgery trainees. Although rates remain low, they are associated with burnout. Modifiable learning environmental factors, such as harassment, program responsiveness, and trainee camaraderie, may be potential areas for intervention.

Objective: To assess spontaneous endoleak (EL) resolution rate and its associated factors in patients without aneurysm sac enlargement undergoing imaging surveillance with computed tomography angiography (CTA) following complex endovascular aneurysm repair procedures (coEVAR).

Methods: A retrospective analysis of 230 consecutive patients at a single institution was undertaken. In patients with type I/III/mixed EL at predischarge CTA without aneurysm sac enlargement, CTA surveillance was scheduled in 6 months after index procedure. Indication for secondary re-intervention was given provided aneurysm sac enlargement of more than 5 mm in 6 months or more than 10 mm after 12 months. Primary endpoint was EL resolution rate during follow-up. Secondary endpoints were patient-related, periprocedural and morphological factors of spontaneous EL resolution over time.

Results: Predischarge CTAs have revealed ELs of any type in 75% of patients. Type I ELs did not resolve spontaneously over time. Type III ELs resolved spontaneously in 83% of cases at 24 months after index procedure, with most resolution events being observed during the first 12 postinterventional months. Amongst mixed ELs, a combination of II/III ELs was found to resolve spontaneously over time (50% at 12 months). Spontaneous resolution between small (< 9.37 ml) and big (> 9.37 ml) volume ELs was compared, demonstrating at first no difference at 12 months and a tendency of faster EL resolution thereafter for small volume ELs. Maximum aortic diameter (P = 0.011), aneurysm sac shrinkage (P = < 0.001) and history of PAD (P = 0.007) were found to be independent predictive factors of EL remission. No aneurysm sac rupture has been observed.

Conclusions: Provided stable aneurysm sac dynamics, CTA surveillance might be considered for patients presenting type III EL or mixed type II/III EL at predischarge CTA scan.

Objective: To evaluate the 5-year long-term outcomes of in situ laser fenestration (ISLF)-assisted thoracic endovascular aortic repair (TEVAR) for acute type A dissection involving zone 0 with all three supra-aortic branches reconstructed.

Methods: This single-center, retrospective consecutive series (2014-2021) included 152 zone 0 acute type A dissection patients treated with three-branched ISLF-assisted TEVAR. In the same timeframe, 286 contemporaneous patients at our institution were treated mainly with open or hybrid repair (not analyzed here). The primary end point was immediate technical success. Secondary end points included branch-stent patency at 1, 2, and 5 years and complete false-lumen thrombosis in the stent-covered segment at 1, 2, and 5 years, as well as postoperative complications.

Results: ISLF-assisted TEVAR with triple-branch reconstruction was performed in all 152 patients; immediate technical success was 95.4%. Within 30 days, 6 deaths (3.9%), 11 strokes (7.2%), 5 cases of spinal cord ischemia (3.3%), and 4 proximal stent-induced dissections (2.6%) were observed; no distal stent-induced dissections occurred. Long-term follow-up was available in 94.7% of patients (144/152). At a mean of 60 months (range, 12-72 months), branch-stent patency was 96.1% at 1 year, 95.0% at 2 years, and 94.7% at 5 years. Complete false-lumen thrombosis in the covered segment was 89.6%, 84.7%, and 82.6% at 1, 2, and 5 years, respectively. Over 5 years, all-cause mortality was 7.9% (n = 12) and reintervention 12.5% (n = 18).

Conclusions: In this single-center cohort, ISLF-assisted TEVAR for zone 0 acute type A dissection achieved high immediate technical success and acceptable complication rates with sustained branch patency over 5 years. These findings support the feasibility and safety of a standardized cerebral protection and device strategy, while prospective multicenter controlled studies are needed to confirm generalizability and comparative effectiveness.

Background: Carotid artery injuries carry a high risk of morbidity and mortality. Owing to their variable presentation, management paradigms are not standardized. Our goal was to report the outcomes of penetrating carotid artery injuries.

Methods: All patients over the age of 18 with penetrating common carotid artery or internal carotid artery injury between 2010 and 2021 were retrospectively identified from our prospectively maintained database.

Results: Forty-six patients were identified. The median patient age was 29 years. The majority were male (82.6%) and Black (80.4%). Sixteen of the 46 patients with penetrating injuries presented neurologically intact. Ten underwent operative repair with one having a new neurological deficit; six were managed conservatively with one new neurological deficit. Thirty of the 46 patients with a penetrating injury presented with neurological deficits. Of the 23 managed operatively, 9 had a stroke, 6 improved neurologically, and 8 died (3 from other injuries). Only seven penetrating injuries were treated medically: one had a stroke, four improved, and two died from other injuries. Overall, 12 patients had a new stroke. Factors not significantly associated with stroke included age, Injury Severity Score, time to repair, sex, artery involved, and operative vs medical management. Presence of avulsion/transection was found to be significantly associated with stroke (odds ratio, 5.40; 95% confidence interval, 1.26-23.2; P = .0024).

Conclusions: Patients who present with avulsion or transection of the carotid artery after penetrating trauma have a significant risk of stroke. This risk is not significantly associated with the mechanism of injury or subsequent management. Patients who present neurologically intact rarely deteriorate regardless of treatment.