Journal of Vascular Surgery最新文献

Objective: Branched/fenestrated endovascular repair has become the mainstay treatment for thoracoabdominal (TAAA) and pararenal (PAA) aortic aneurysms, yet little is known about its impact on patient quality of life (QoL). Long-term QoL trends in patients from the GORE® EXCLUDER® Thoracoabdominal Branch Endoprosthesis (TAMBE) multicenter, prospective pivotal trial were examined.

Methods: In enrolled patients with TAAA or PAA who underwent TAMBE repair, the RAND 36-Item Health Survey (SF-36) was collected at baseline and at 1-, 3-, 6-, and 12-months post-operatively. QoL physical and mental domain scores were compared from baseline to 1 year in the overall cohort and in subgroups of aneurysm type, frailty risk, occlusion, or reintervention. Patient characteristics were summarized using descriptive statistics and mean QoL scores were compared across timepoints using paired t-tests.

Results: The cohort of 121 patients were a mean age 73 years, 82.8% (n=101) male, 83.6% (n=102) White; 59.0% (n=72) had an Extent IV TAAA, 41.3% (n=50) had a PAA, and 77.7% (n=94) were low frailty risk. In this analysis, 13.2% (n=16) of patients experienced a branch vessel/graft occlusion and 14.0% (n=17) underwent a reintervention. All QoL domain scores dropped at 1-month post-operatively, predominantly in physical health limitations (P<0.0001). All QoL domains recovered towards baseline by 3 months post-operatively but then gradually declined to 1 year; differences were statistically significant compared to baseline (p≤0.05). There was no mean QoL domain score difference at any time point among the aneurysm type, branch occlusion, or reintervention subgroups (P≥0.071). Physical domain scores between frailty risks were significant (P≤0.05).

Conclusions: Patients experienced an immediate drop in all QoL domains post-TAMBE procedure, especially physical health, but recovered by 3 months post-operatively. Aneurysm extent, branch occlusion or reinterventions did not impact QoL trends. Patients who underwent endovascular TAAA/PAA TAMBE repair exhibited a gradual decline in health-related QoL over the long term. This may be representative of the comorbid and elderly population who require such operations.

Objective: A free-floating thrombus in the carotid artery (cFFT) is a high-risk vascular condition for stroke. Treatment recommendations are lacking. This systematic review aimed to identify the safety and effectiveness of existing management strategies for cFFT.

Methods: PubMed and Embase were systematically searched from inception to May 2025, using search terms including "free-floating thrombus" and "carotid", and treatment strategies. Eligible studies reported on treatment and clinical outcomes. Two authors independently screened eligible literature and extracted data. Study quality was assessed with the Methodological Index for Non-Randomized Studies (MINORS) score. Primary endpoints were the composite of any non-fatal stroke and all-cause death (death/stroke) at short (<30 days) and long-term (beyond 30 days) follow-up after initial treatment.

Results: Literature search revealed eleven studies, encompassing 179 patients with cFFT. These studies were predominantly of low-quality, with a mean MINORS score of nine for non-comparative studies and fifteen for comparative studies, notably, no randomized controlled studies were identified. Twenty treatment strategies were identified, grouped as antithrombotic medication (AM; n=120/179, 67.0%), or AM combined with endovascular treatment (EVT) (n=20/179, 11.2%), carotid endarterectomy (CEA) (n=38/179, 21.2%), and combined EVT + CEA (n=1/179, 0.6%). Sequential treatments were analyzed by timing: those initiated before 30 days contributed to short-term outcomes, and those thereafter to long-term outcomes. Short-term combined death/stroke rates were reportedly highest with AM alone (n=8/120, 6.7%), followed by EVT (n=1/20, 5.0%) and CEA (n=1/38, 2.6%). The AM group reported a short-term all-cause death rate of 5.0% (n=6/120) and non-fatal stroke rate of 1.7% (n=2/120). Long-term outcomes occurred solely in the AM group, yielding a death/stroke rate of 6.5% (n=3/46), comprising two deaths (n=2/46, 4.3%) and one stroke (n=1/46, 2.2%).

Conclusion: The published literature on cFFT is limited and lacks high-quality studies. This review suggests that all currently reported treatment strategies are associated with a considerable risk for stroke or death. Anticoagulation alone appears inadequate, thereby challenging current ESVS guideline recommendations, whereas the results for CEA suggest it may represent a more favorable option in patients amenable to surgery. These findings should be interpreted with caution given the small number of patients included. Nevertheless, our data may help inform the design of future studies and contribute to the development of more standardized treatment strategies.

Background/purpose: TCAR has been proposed as an alternative for both transfemoral carotid artery stenting and carotid endarterectomy. TFCAS has been associated with increased risk in heavy calcified lesions. Therefore, this study will analyze the effect of calcium burden (percentage of circumference calcification, thickness, and/or the length) on TCAR early and late clinical outcome.

Patient population and methods: This is a retrospective review of prospectively collected data of patients who had TCAR enrolled in the TCAR Surveillance Project (SVS/VQI) in our institution. Preoperative CTAs were reviewed to determine three calcium variables: 1. degree of circumferential calcification, classified into 0 to <25%, ≥25% to <50%, ≥50% to <75% and ≥75%; 2. calcification thickness in mm (measured as the largest thickness); and 3. lesion length calcification. The primary outcome was 30-day perioperative stroke/death rate, while secondary outcome included the combined 30-day stroke, death, and MI rate. Late outcome included stroke/death rate and late in-stent restenosis (>50% or >80%). Kaplan Myer Analysis was used to estimate freedom of stroke, stroke and death, and ≥50% restenosis rates according to calcium classification.

Result: This study analyzed 313 procedures (304 patients) with a mean age of 71 years and mean follow-up of 29.4 months (1 month - 108 months). Circumference calcification were: 0-25% in 37%, 26-50% in 24%, 51.75% in 18%, and >75% in 20% (0-50% in 62% and 51-100% in 38%). Calcification thickness of 1mm or less was noted in 22%, 1-2mm in 27%, 2-3mm in 26%, 3-4mm in 18%, and >4mm in 7% (<2mm in 49% and ≥2mm in 51%) while calcification length of <5mm in 10%, 5 - <10mm in 4%, 10 - <15mm in 15%, 15 - <20mm in 20%, 20 - <25mm in 26%, and ≥25mm in 24%(<20mm in 50%, and ≥20mm in 50%). The overall 30-day perioperative stroke rate was 2.0% and stroke/death/MI of 3.5%. The 30-day perioperative stroke rate according to calcium circumference (<50% vs ≥50%) was 1.7% vs 2.9% (p 0.674); length (<20mm vs ≥20mm) was 2.1% vs 2.2% (p 1); and thickness (<2mm vs ≥2mm) was 1.5% vs 2.9% (p 0.6841). For all stroke rates early and late for calcium circumference (<50% vs ≥50%) were 4.2% vs 4.9% (p 0.771); length (<20mm vs ≥20mm) were 6% vs 3% (p 0.242); and thickness (<2mm vs ≥2mm) were 3.8% vs 5.2% (p 0.599). Rates for >50% restenosis for calcium circumference (<50% vs ≥50%) were 7.9% vs 8.8% (p 0.821); length (<20mm vs ≥20mm) were 7.5% vs 9.0% (p 0.663); and thickness (<2mm vs ≥2mm) were 7.6% vs 8.8% (p 0.825). Kaplan Myer Analysis showed that the rates of freedom from stroke, stroke and death, and ≥50% restenosis at 1, 2, and 3 years according to calcification circumference, thickness, and length were similar.

Conclusion: This study showed no significant effect of calcium burden on TCAR early and late outcomes.

Objective: The VOYAGER PAD clinical trial demonstrated that low-dose rivaroxaban (LDR; 2.5mg twice daily) reduces major adverse limb events (MALE) at the expense of increased bleeding rates in patients undergoing lower extremity revascularization for peripheral artery disease (PAD). However, it's unclear whether LDR therapy is associated with similar outcomes in real-world practice. This retrospective cohort study was designed to evaluate the effectiveness and safety of LDR therapy following peripheral vascular intervention (PVI) for patients with PAD.

Methods: The Merative MarketScan database was used to identify patients 40-90 years old who underwent lower extremity PVI between 2017 and 2024. Pharmacy claims were used to identify LDR use within 30-days post-PVI and patient adherence to therapy within 1-year while excluding those receiving therapeutic anticoagulation. For patients prescribed LDR, the proportion of days covered (PDC) was determined and those greater or equal to 80% of PDC were classified as adherent. After performing a propensity-subclass weighted analysis on the use of LDR, we used cox proportional hazards models to estimate the risk-adjusted incidence of MALE and bleeding complications following PVI.

Results: We identified 88,792 patients, of which 1,285 (1.5%) were prescribed LDR within 30-days post-PVI. However, only 547 (43%) of these patients were adherent to LDR within the year after revascularization. After propensity weighted analysis, patients on LDR were well matched to those not on therapy based on age, sex, comorbidities and demographics. While non-adherent patients had no significant improvement in MALE outcomes, those adherent to LDR therapy had a 70% lower likelihood of major amputation at 1-year after revascularization (HR:0.30; 95% CI:0.10-0.91; P=.03). There was an increased likelihood of experiencing a bleeding complication (HR: 1.85; 95%CI:1.24-2.76; p=.002) associated with LDR use relative to the non-LDR control group.

Conclusions: Following the publication of VOYAGER PAD, the use of low-dose rivaroxaban remains low and patient adherence is variable. However, clinical outcomes in real world practice are similar if adherence to LDR is maintained following PVI. Further work is needed to define the optimal patient with PAD who should receive LDR following revascularization.

Objective: General population based screening of women for AAA is not recommended. A selective screening approach, targeting high-risk women with a history of smoking may detect most AAAs and be effective. The aim of this population-based cross-sectional study was to evaluate a pragmatic screening strategy selectively targeting women with a history of smoking.

Methods: Between 2018 and 2022 all 70 year-old women in a defined catchment area, the county of Dalarna in central Sweden, were invited by letter to a one time ultrasound examination of the aorta. The letter of invitation encouraged women with a smoking history of 20 years or more to attend. No women were excluded. Prevalence of AAA (≥30 mm), sub-AAA (25-29 mm), self-reported comorbidity and smoking habits were recorded. The results were compared with the outcome from a previous general population-based screening program study of 70-year-old women conducted in the neighboring counties of Dalarna and Uppsala in central Sweden.

Results: A total of 9061 women were invited to selective screening, 42.6%, (95%CI 41.5- 43.6%) attended after the invitation to the selective strategy vs 74.2% (95%CI 73.2-75.2 %) in the previous general screening study (p<0.001). In the selective screening cohort 71% reported a history of smoking vs 44% in the general screening cohort (p<0.001). The prevalence of screening-detected AAA was 0.8% (95%CI 0.6-1.1%) in the selective screening cohort vs 0.4% (95%CI 0.2- 0.6%) in the general general screening cohort (p<0.001) and the corresponding prevalence of sub-aneurysm was 1.1% (95%CI 0.8-1.5%) vs 0.6% (95%CI 0.4-0.8%), p=0.0039.. Screening-detected AAAs in the total population (attenders and non-attenders) were similar between strategies: 0.3% (95% CI 0.2-0.5%) for targeted screening versus 0.2% (95% CI 0.2-0.4%) for general screening (p=0.23).

Conclusion: Targeted AAA screening of high-risk women with a long-term smoking history doubles prevalence (0.8%) compared with general screening, halves the number of women needing screening, and maintains the detection rate. Further studies should assess the clinical impact and cost-effectiveness of this approach.