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 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. The primary end point was 30-day mortality. Secondary end points were overall survival, aneurysm-related survival, and freedom from retreatment.

Results: A total of 208 patients (85.6% males; median age, 78 years) were included. The median abdominal aortic aneurysm diameter was 62 mm. The median interval from initial EVAR to OSC was 5.2 years. Indications for OSC were type II endoleak with sac enlargement (47.1%), type I endoleak (23.1%), type V endoleak with sac enlargement (13.0%), infection (10.1%), and type III endoleak (9.6%). The most frequently used stent graft was the 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 preservation. Thirty-eight patients (18.3%) presented with rupture and 48 (23.1%) underwent urgent OSC. The 30-day mortality rate was 4.3% in the overall cohort, 2.4% in nonruptured cases, and 13.2% in ruptured cases. Rupture was a risk factor for 30-day mortality (hazard ratio, 5.93; 95% confidence interval, 1.59-22.1; P = .008). At 10 years, overall survival and aneurysm-related mortality were 58.4% and 14.8%, respectively, and freedom from retreatment rate was 87.5% at 10 years.

Conclusions: Type II 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 II 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 use, most notably, for transfemoral carotid artery stenting (TFCAS). Since this coverage expansion, it remains unknown whether there has been a concordant change in carotid stenting use and resultant long-term stroke risk. Therefore, our objective was to document trends in procedure use 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 data. Truveta provides daily updated electronic health record data from >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 6473 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 < .001) and 38.4% for CEA (ITS P = .035). The procedure rate increased by 2.1% for TFCAS (ITS P = .365). Among asymptomatic patients, the freedom from stroke at 8 years for TCAR, CEA, and TFCAS was 87.2% (95% confidence interval [CI], 84.0%-90.5%), 86.3% (95% CI, 85.5%-87.2%), and 79.8% (95% CI, 77.6%-82.0%), respectively. Compared with 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 use 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 use surveillance to ensure optimal outcomes among patients undergoing carotid revascularization.