Journal of vascular surgery. Venous and lymphatic disorders最新文献

Objective: To quantify how ablation distance from the saphenofemoral or saphenopopliteal junction (SFJ/SPJ) and treatment of the small saphenous vein (SSV) relate to endothermal heat-induced thrombosis (EHIT) grade ≥2, and to evaluate predictive performance and a data-driven ranking of risk factors.

Methods: We conducted a retrospective multi-center cohort study at six high-volume vascular centers in Japan between January 2012 and May 2025. Of 1,307 enrolled patients, 1,191 were eligible after exclusions for prior ipsilateral intervention, active deep vein thrombosis, pregnancy, or incomplete EHIT assessment. The primary outcome was EHIT grade ≥2, defined according to the unified AVF/SVS classification as thrombus extension into the adjacent deep vein with <50% intraluminal occlusion. We used mixed-effects logistic regression with a random intercept for center. Model-based risk curves stratified by SSV status were compared with observed event rates across prespecified distance categories. Gradient boosting with SHAP values yielded a data-driven ranking.

Results: EHIT grade ≥2 occurred in 58 of 1,191 patients, or 4.9%. Each 1-cm increase in distance was associated with lower odds of EHIT grade ≥2: OR 0.53; 95% CI 0.33-0.87; p=0.011. SSV treatment showed a nonsignificant trend toward higher odds: OR 2.12; 95% CI 0.95-4.76; p=0.068. The random-effects standard deviation was 0.673, and the intraclass correlation was approximately 12%, indicating meaningful between-center variability. Predicted curves showed higher risk at shorter distances with a steeper gradient for SSV, and these patterns corresponded to observed rates across short (≤1.5 cm), intermediate (>1.5 to ≤2.5 cm), and long (>2.5 cm) categories. A two-variable model using distance and SSV achieved an AUC of 0.744; 95% CI 0.685-0.802. Adding age, BMI, and vein diameter produced only a modest improvement: AUC 0.767; 95% CI 0.715-0.819. SHAP analysis based on Gradient boosting revealed that ablation distance was the dominant contributor with a monotonic increase in risk at shorter values, followed by BMI, age, vein diameter, and SSV. Device type and comorbidities such as hypertension and diabetes showed only limited impact.

Conclusions: Ablation distance is the dominant determinant of EHIT grade ≥2, with risk rising as distance shortens, particularly in SSV cases. Model-based estimates aligned with real-world event rates, and a simple two-variable approach using distance and SSV provided strong discrimination. These findings support procedural strategies that prioritize securing adequate distance, especially when treating the SSV.

Introduction: Superior vena cava (SVC) syndrome is a rare but severe medical condition due to obstruction of the venous return to the heart through the innominate veins and the SVC. Lung cancer is the most common malignant cause, while central vein thrombosis due to intravenous lines and pacemaker wires as well as mediastinal fibrosis are the frequent benign etiologies.

Methods: This review is based on a review of published literature reporting the results of endovenous management of Superior vena cava (SVC) syndrome.

Results: Endovenous treatment, with balloon angioplasty and immediate stenting has become the first line of treatment of all causes of symptomatic SVC syndrome. Various stents have been used, including balloon and self-expanding stents, woven, braided, and laser-cut nitinol stents, as well as open- and closed-cell designs. However, no single type has demonstrated superiority in comparative clinical studies. Evidence increasingly suggests that covered stents are safer for SVC obstruction, offering patency rates comparable to non-covered stents while reducing the risk of lethal complications such as rupture and pericardial tamponade. For patients with malignant disease, fabric-covered stents may also reduce tumor ingrowth. Open surgery remains a viable option using spiral saphenous vein graft, femoral vein, and expanded polytetrafluoroethylene graft for those who are not candidates for endovascular interventions or fail after repeat interventions.

Conclusions: Stent placement is a safe and effective first-line treatment for symptomatic SVC syndrome of both malignant or benign etiologies, with likely better outcomes and less complications associated with using covered stents.

Objective: To characterize the contemporary academic landscape surrounding the Caprini Venous Thromboembolism (VTE) Risk Assessment Model (RAM), including its application patterns, reported performance, evolving scholarly perspectives, and dominant refinement strategies.

Methods: A scoping review was conducted following the PRISMA-ScR framework. PubMed, Web of Science, Embase, and the Cochrane Library were systematically searched for studies published between January 1, 2021, and December 31, 2025, using terms including "Caprini score," "venous thromboembolism," and "risk assessment." Eligible studies reported on the validation, application, or modification of the Caprini RAM in adult patients. Data on study characteristics, predictive performance metrics (e.g., area under the curve [AUC]), author conclusions, and model refinement details were extracted.

Results: From 754 identified records, 275 studies met the inclusion criteria. Analysis of 275 studies with codable author perspectives revealed a distribution of supportive (113 studies, 41.1%), neutral (96 studies, 34.9%), and critical (66 studies, 24.0%) stances. Fifty-two studies providing paired AUC data reported a mean baseline Caprini score AUC of 0.702 (SD 0.104), compared to a mean AUC of 0.832 (SD 0.080) for refined or new models. The mean AUC improvement was 0.130 (SD 0.117), with a median improvement of 0.105 (IQR 0.106); improvements were observed in 98.1% of these comparisons. Critical perspectives frequently cited poor accuracy in specific populations (e.g., medical inpatients) and operational complexity. In response, 111 studies proposed refinements categorized into four domains: integration of biomarkers (33 studies), development of specialty-specific/simplified models (45 studies), application of artificial intelligence/machine learning (23 studies), and optimization of assessment processes (30 studies).

Conclusion: This review quantifies a fragmented scholarly discourse on the Caprini RAM, reflecting its validated utility in certain contexts alongside recognized limitations driving extensive model refinement. The significant performance gains reported for refined models, particularly in specialties where the original score underperforms, highlight the ongoing evolution of VTE risk assessment toward more precise and context-adapted tools.

Objective: Topical Oxygen therapy (tOT) is a novel treatment method capable of expediting granulation tissue formation in patients with non-healing lower extremity venous leg ulcers (VLUs). tOT provides cyclic oxygen with compression and is able to be administered at home, unlike chamber-based oxygen therapy. Although previous randomized prospective trials have demonstrated effectiveness of tOT in treating ulcers of diabetic etiology, its ability to promote healing in refractory venous ulcers requires additional exploration. Thus, we investigated preliminary outcomes of tOT administration in treatment-resistant VLUs.

Methods: We conducted a single-center retrospective review of treatment outcomes among 31 patients with 32 total extremities with VLUs following longitudinal administration of tOT. All patients received managed Medicaid approval for tOT after each ulcer failed to resolve following multiple alternative therapies, including Unnaboot compression, sclerotherapy, thermal ablation, iliac vein stenting, and debridement. Patient response to tOT was determined by assessing mid-treatment progression of ulcer length and width, in addition to final ulceration status at the conclusion of therapy. Mean treatment length, total ulcer duration, peak ulcer length, and peak ulcer width were determined for each patient and compared between healed and unhealed VLUs.

Results: Average age across all individuals was 73±19 years (range 27-99). 14 (45%) patients were male, with a racial breakdown of 18 (58%) White, 5 (16%) Hispanic, 6 (19%) Black, and 2 (6%) Asian patients. Comorbid conditions included hypertension in 31 (100%) patients, hyperlipidemia in 15 (48%), and diabetes in 12 (39%). 4 (13%) patients demonstrated a former history of smoking while 3 (10%) patients were currently using tobacco products during the study period. Total duration across all VLUs was 1075±1004 days. Average duration of tOT was 265±233 days, while average pre-treatment ulcer duration was 718±842 days. Mean ulcer length was 7.6±6.8 cm and mean ulcer width was 5.7±5.0 cm (range 2-24 cm for both). Following tOT administration, 11 (34%) VLUs healed entirely, 9 (28%) ulcers improved but did not completely heal, 8 (25%) remained unchanged, and 4 (13%) worsened despite treatment. Median time to healing among the 11 VLUs which healed completely was 121 days. For ulcers that did not heal, the mean duration of tOT was 333±261 days. No differences were observed in the pretreatment VLU duration (p=0.54), maximum length (p=0.50) or maximum width (p=0.80) of healed versus unhealed VLUs.

Conclusions: 20 (62.5%) of the 32 refractory VLUs treated with tOT either decreased in size or healed entirely after failing multiple previous therapies. 3 (27.3%) of the 11 ulcers which healed completely recurred following topical oxygen therapy.

Objectives: This study aimed to evaluate how the choice of intervention modality for pulmonary embolism (PE) influenced by patient and hospital characteristics. We compared catheter-directed thrombolysis (CDT), percutaneous mechanical thrombectomy (PMT), and surgical embolectomy.

Methods: Utilizing the Maryland statewide database from the Health Services Cost Review Commission (HSCRC), we analyzed interventions for PE over a 6-year period (FY 2019-2024), focusing on CDT, PMT, and surgical embolectomy. Key hospital factors including trauma center status, hospital size, Leapfrog safety ratings, ECMO availability, and PE volume, were assessed for their association with intervention choice. Patient characteristics were assessed for their association with intervention choice including demographics, comorbidities, and health insurance status. Univariate and multivariate statistics were performed to assess the relationship between patient and hospital characteristics and PE interventions.

Results: Over time the utilization of PMT increased with a concomitant decrease in utilization of CDT. CDT was more commonly performed in trauma centers, smaller hospitals, Leapfrog B-D rated hospitals, and hospitals with lower PE volumes. In contrast, PMT was more frequently performed in non-trauma centers, non-ECMO programs, larger hospitals, Leapfrog A rated hospitals, and hospitals with higher PE volumes. Surgical embolectomy was primarily performed in high-volume centers equipped with cardiac surgery and ECMO capabilities. African-American patients and those with higher social vulnerability index were more likely to undergo CDT. Comorbidity profiles increased progressively from CDT to PMT to surgical embolectomy. Surgical embolectomy patients were generally younger and more likely to be on Medicaid, while PMT/CDT patients were more commonly covered by Medicare. Patients undergoing surgery had higher rates of transfer from other facilities. There were no significant differences in rates of non-routine discharge or mortality across the interventions. In the multivariate model, presence of a cardiac surgery program was associated with increased odds of PMT.

Conclusions: PMT has been adopted at a higher rate than CDT in Maryland over the past 6 years, potentially due to benefits such as reduced length of stay and ICU requirements. Our findings demonstrate that both patient and hospital characteristics influence the modality of PE intervention. These results highlight significant disparities based on race, social vulnerability, and hospital characteristics that warrant systemic attention.

Objective: Funding for research in varicose vein disease has traditionally been poor despite its negative impact and high prevalence affecting millions of people. To identify high yield topics that would benefit from dedicated research and funding, the AVF Research Committee hosted a Research Priorities Retreat for C2 disease. We hypothesized that an open forum of brief presentations, open panel discussions, and forced rank surveys would identify scientific priorities in C2 disease and provide a foundation for designing future research efforts.

Methods: The initial list of topics for discussion and potential speakers was reviewed by members of the 2024 AVF Research Committee based on recently published guidelines on C2 disease and on scientific experience. All participants were required to participate synchronously during the virtual event. The format prioritized high yield topics, opportunities for robust discussion and transparency for registered AVF members. A force rank survey was administered before and after the retreat to committee members, panel speakers, and discussions. In addition, registrants who attended were also given the opportunity to rank topics after discussion.

Results: The speakers, discussants and committee members (N=12) who ranked topics immediately before and after the retreat represented a multidisciplinary team from vascular surgery, interventional radiology, vascular medicine, and phlebology with clinical and scientific doctorate experience. understanding the underlying etiologies, the biological mechanisms, and identifying new medical therapies were considered the highest research priorities, followed by ways to achieve healthcare equity for patients with C2 disease.

Conclusion: This study represents a multidisciplinary effort by the AVF Research Committee to identify research priorities in C2 disease. The retreat was carefully planned and transparently executed, providing a mechanism to inform future research efforts of the AVF. Future biologic therapies to target and improve the treatment of varicose veins and health care equity were the top priorities in post event ranking. The resulting document may provide guidance for investigators hoping to pursue research in C2 varicose vein disease.

Objective: This study aimed to evaluate the effectiveness and safety of dehydrated human amnion/chorion membrane (dHACM) allograft for venous leg ulcers (VLUs) and to identify clinical factors associated with early healing within 12 weeks.

Methods: This single-center retrospective cohort study included 52 patients with CEAP C6 VLUs treated with dHACM at Shimokitazawa Hospital between February 2023 and June 2025. The primary outcomes were complete epithelialization and recurrence-free survival. Kaplan-Meier analysis was used to estimate healing rates. Early healing (within 12 weeks) was analyzed using univariate and multivariable Firth-penalized logistic regression, with directional consistency confirmed using univariate Cox proportional hazards analysis. Sensitivity analyses were performed by altering early-healing thresholds to 81 and 90 days. Variables with odds ratios (ORs) approximating 1.0 were further evaluated using predefined clinical equivalence margins (OR 0.80-1.25). Adverse events (AEs) were retrospectively assessed according to WHO-UMC criteria.

Results: Among the 52 patients, 43 (82.7%) achieved complete healing, and the 12-week healing rate was 52.1%. Early healing occurred in 26 patients (50.0%). Multivariable analysis identified higher body mass index (BMI) (adjusted OR, 0.847; 95% CI, 0.739-0.948) and infection (adjusted OR, 0.253; 95% CI, 0.060-0.913) as independent inhibitory factors, while independence in activities of daily living (ADL) showed a tendency toward promoting healing. Cox analysis demonstrated consistent directional results. Sensitivity analyses using alternative thresholds (81 and 90 days) confirmed the robustness of key predictors. Ulcer area (OR 0.999) and disease duration (OR 1.002) were within the predefined equivalence margins, indicating minimal clinical impact. Recurrence occurred in six patients (14.0%), with recurrence-free survival rates of 90.5% at 1 year and 80.5% at 2 years. A total of 58 AEs were observed in 33 patients (63.5%), most of which were mild and self-limiting; only two mild local reactions were considered possibly related to dHACM treatment.

Conclusion: Despite being a descriptive study without a control group, favorable healing outcomes, low recurrence, and acceptable safety were observed in treatment-refractory venous leg ulcers managed with dHACM under Japan's stringent reimbursement criteria. Higher BMI and infection were major predictors of delayed early healing, whereas ulcer area and disease duration had limited influence. These findings suggest that dHACM represents a valuable therapeutic option for patients with hard-to-heal VLUs.

Background: The optimal surgical strategy for treating chronic venous disease with concomitant deep and superficial reflux but without iliac/proximal obstruction remains unclear. This study aimed to compare clinical symptoms, health-related quality-of-life, and ulcer outcomes between superficial venous surgery alone and combined deep-superficial surgery (performed concurrently or in stages).

Methods: In this single-center retrospective cohort, 229 patients were grouped by treatment and received superficial-only (n = 138), concurrent deep + superficial (n = 49), or staged deep + superficial (n = 42) interventions. Outcomes were Venous Clinical Severity Score (VCSS), Chronic Venous Insufficiency Questionnaire-20 (CIVIQ-20) at baseline and follow-up (1, 3, and 6 months, and last follow-up), ulcer outcomes (n = 59) assessed by healing rates and Kaplan-Meier time-to-healing analysis, duplex valve competence after deep intervention, and complications. Analyses used Welch one-way analysis of variance with Games-Howell post hoc and log-rank testing.

Results: Baseline characteristics were comparable (baseline VCSS 8.6±3.3, 9.6±4.0, and 9.0±3.9; P = .32). Between-group differences in VCSS were significant at 1 month (P = .012), 6 months (P < .001), and last follow-up (P = .017). Staged treatment reduced VCSS vs superficial-only at 1 month (mean difference [MD], -1.47; P_adj = .008); both concurrent and staged strategies showed lower VCSS vs superficial-only at 6 months (MD, -0.98 and -1.01; P_adj = .003 and .001) and last follow-up (MD, -0.76 and -0.68; P_adj = .025 and .033). The CIVIQ-20 at the last-follow-up was lower with concurrent and staged strategies vs superficial-only (MD, -2.83 [P_adj < .001]; MD, -2.40 [P_adj = .010]). Internal valvuloplasty (n = 77) demonstrated lower VCSS at 1 to 6 months and last follow-up vs superficial-only (all P_adj ≤ .026) and a lower CIVIQ-20 score. Among 59 active ulcers, 89.8% healed overall; healing proportions did not differ (P = .310), but time to healing differed by Kaplan-Meier analysis (log-rank P = .038). Duplex after deep intervention showed reflux normalization (<0.5 seconds) in 94.5% to 98.9% at 1 to 6 months; complications were minor, with no symptomatic deep vein thrombosis/pulmonary embolism or major bleeding.

Conclusions: In patients with chronic venous disease with concomitant deep and superficial reflux but no iliac obstruction, adding deep reflux correction (concurrent or staged) was associated with greater and more durable symptom relief and better quality of life than superficial-only surgery, with high duplex-confirmed competence and low complication rates; ulcer healing time may be accelerated.