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

Objective: This study aimed to evaluate the accuracy and reproducibility of information provided by ChatGPT, in response to frequently asked questions about radiofrequency ablation (RFA) for varicose veins.

Methods: This cross-sectional study was conducted at The Aga Khan University Hospital, Karachi, Pakistan. A set of 18 frequently asked questions regarding RFA for varicose veins were compiled from credible online sources and presented to ChatGPT twice, separately, using the new chat option. Twelve experienced vascular surgeons (with >2 years of experience and ≥20 RFA procedures performed annually) independently evaluated the accuracy of the responses using a 4-point Likert scale and assessed their reproducibility.

Results: Most evaluators were males (n = 10/12 [83.3%]) with an average of 12.3 ± 6.2 years of experience as a vascular surgeon. Six evaluators (50%) were from the UK followed by three from Saudi Arabia (25.0%), two from Pakistan (16.7%), and one from the United States (8.3%). Among the 216 accuracy grades, most of the evaluators graded the responses as comprehensive (n = 87/216 [40.3%]) or accurate but insufficient (n = 70/216 [32.4%]), whereas only 17.1% (n = 37/216) were graded as a mixture of both accurate and inaccurate information and 10.8% (n = 22/216) as entirely inaccurate. Overall, 89.8% of the responses (n = 194/216) were deemed reproducible. Of the total responses, 70.4% (n = 152/216) were classified as good quality and reproducible. The remaining responses were poor quality with 19.4% reproducible (n = 42/216) and 10.2% nonreproducible (n = 22/216). There was nonsignificant inter-rater disagreement among the vascular surgeons for overall responses (Fleiss' kappa, -0.028; P = .131).

Conclusions: ChatGPT provided generally accurate and reproducible information on RFA for varicose veins; however, variability in response quality and limited inter-rater reliability highlight the need for further improvements. Although it has the potential to enhance patient education and support healthcare decision-making, improvements in its training, validation, transparency, and mechanisms to address inaccurate or incomplete information are essential.

Objective: Nutcracker syndrome is a rare condition that involves mechanical compression of the left renal vein, leading to chronic and debilitating left flank pain. The etiology of the pain is misdiagnosed frequently, and patients usually require long-term opioid use to manage their pain. Multiple therapeutic options for nutcracker syndrome have been described in the literature but the reports are limited by small numbers of patients, and the lack of convincing data demonstrating consistently improved outcomes. Here we report the largest series to date of patients undergoing renal autotransplantation for the treatment of nutcracker syndrome.

Methods: We performed a multicenter retrospective cohort review of patients 105 patients with nutcracker syndrome who underwent renal autotransplantation as a primary or salvage therapy.

Results: During the overall study period, 93.1% of patients treated with autotransplantation had durable, complete flank pain relief at 12 months with both open and robotic surgical approach. After autotransplantation, a statistically significant decrease in the percentage of patients using opioids from 48.6% to 17.0% was demonstrated at 12 months. In those patients using opioids before autotransplantation, a statistically significant decrease in morphine milligram equivalents was demonstrated from an alarming 68.9 ± 15.0 per day to 25.0 ± 11.02 morphine milligram equivalents per day.

Conclusions: Our findings suggest that renal autotransplantation, as a primary treatment or a salvage treatment, in patients with nutcracker syndrome provides durable pain relief and a marked decrease in chronic opioid use regardless of surgical approach.

Objective: Venous thromboembolism (VTE) is a preventable cause of hospitalization-related morbidity and mortality. VTE prevention requires accurate risk stratification. Federal agencies mandated VTE risk assessment for all hospital admissions. We have shown that the widely used Caprini (30 risk factors) and Padua (11 risk factors) VTE risk-assessment models (RAMs) have limited predictive ability for VTE when used for all general hospital admissions. Here, we test whether combining the risk factors from all 23 available VTE RAMs improves VTE risk prediction.

Methods: We analyzed data from the first hospitalizations of 1,282,014 surgical and non-surgical patients admitted to 1298 Veterans Affairs facilities nationwide between January 2016 and December 2021. We used logistic regression to predict VTE within 90 days of admission using risk factors from all 23 available VTE RAMs. Area under the receiver operating characteristic curves (AUC), sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) were used to quantify the predictive power of our models. The metrics were computed at two diagnostic thresholds that maximized (1) the value of sensitivity + specificity-1; and (2) PPV and were compared using McNemar's test. The Delong-Delong test was used to compare AUCs.

Results: After excluding those with missing data, 1,185,633 patients (mean age, 66 years; 93% male; and 72% White) were analyzed, of whom 33,253 (2.8%) had a VTE (deep venous thrombosis [DVT], n = 19,218, 1.6%; pulmonary embolism [PE], n = 10,190, 0.9%; PE + DVT, n = 3845, 0.3%). Our composite RAM included 102 risk factors and improved prediction of VTE compared with the Caprini RAM risk factors (AUC composite model: 0.74; AUC Caprini risk-factor model: 0.63; P < .0001). When the sum of sensitivity and specificity-1 was maximized, the composite model demonstrated small improvements in sensitivity, specificity and PPV; NPV was high in both models. When PPV was maximized, the PPV of the composite model was improved but remained low. The nature of the relationship between NPV and PPV precluded any further gain in PPV by sacrificing NPV and sensitivity.

Conclusions: Using a composite of 102 risk factors from all available VTE RAMs, we improved VTE prediction in a large, national cohort of >1 million general hospital admissions. However, neither model has a sensitivity or PPV that permits it to be a reliable predictor of VTE. We demonstrate the limits of currently available VTE risk prediction tools; no available RAM is ready for widespread use in the general hospital population.

Objective: The diagnosis of abdominal lymphatic malformations (ALMs) is often overlooked in clinical practice. However, reports in the literature about ALMs are limited to case reports and series with small sample sizes. This study aimed to review our currently available data to describe the clinical characteristics of ALMs and evaluate the risk factors for acute abdomen caused by ALMs.

Methods: We reviewed the records of patients with ALMs who were diagnosed between December 2008 and January 2023 in our institution. The associations between acute abdomen and ALMs were analyzed based on single-factor and multivariate logistic regression analyses.

Results: This study included 345 patients with pathologically confirmed ALMs, with a slight female predominance of 1:1.4. Approximately 39.1% (135/345) of patients were asymptomatic, and 24.6% (85/345) presented with acute abdomen. Among the ALMs in the cohort, 42.6% (147/345) were retroperitoneal lymphatic malformations (LMs). The maximal lesion dimensions in patients with acute abdomen and nonacute abdomen were 10.0 cm and 7.8 cm, respectively, with no significant difference based on multivariate analyses. Children were more likely to develop acute abdomen than adults were (P = .002; odds ratio, 5.128; 95% confidence interval, 1.835-14.326). ALMs accompanying acute abdomen were more common for lesions involving the small intestinal mesentery (P = .023; odds ratio, 2.926; 95% confidence interval, 1.157-7.400).

Conclusions: ALMs are rare with an insidious onset, and retroperitoneal LMs are the most common ALMs, followed by jejunal mesenteric LMs. Our retrospective analysis suggested that young age and small intestinal mesenteric lymphatic malformation are independent risk factors for acute abdomen with ALMs.

Objective: The short-term anatomical success rates of mechanochemical ablation using the Clarivein device (Merit Medical) in the treatment of great saphenous vein (GSV) incompetence are high. However, the anatomical success rates seem to drop over time. The aim of this study was to determine the long-term outcomes of GSV treatment using the Clarivein and to assess whether specific anatomical features better correlate with clinical or quality of life (QoL)-related outcomes.

Methods: This is a single-center, prospective cohort study in follow-up of a multicenter, randomized controlled trial using Clarivein with liquid polidocanol for the treatment of GSV incompetence. The primary outcome was anatomical success (AS), defined as complete occlusion or a recanalized segment, irrespective of reflux, of <10 cm in length. In addition, reflux-free anatomical success (RF-AS) was determined, and defined as complete occlusion or a recanalized segment with <10 cm of reflux. Clinical success was assessed using the Venous Clinical Severity Score (VCSS), and QoL was assessed using the Dutch version of the Aberdeen Varicose Vein Questionnaire (DAVVQ) and the 36-Item Short Form Health Survey (SF-36). Subgroup analyses were performed based on whether AS or RF-AS was achieved or not.

Results: A total of 109 patients (115 limbs) were included. The mean follow-up time was 8.4 ± 0.9 years (range, 5.5-10.3 years). AS was seen in 60.5% of limbs, and RF-AS was seen in 72.8% of limbs. Compared with baseline, the overall mean VCSS improved from 5.3 ± 2.4 to 4.1 ± 2.4, and the overall median DAVVQ score from 13.5 (interquartile range [IQR], 8.7-20.0) to 10.5 (IQR, 5.3-16.2) (P < .001). Improvement in VCSS was only significant in patients with successful treatment: from 5.5 ± 2.7 to 3.7 ± 2.5 (P < .001) if AS was achieved and from 5.0 ± 1.7 to 4.5 ± 1.9 (P = .20) if AS was not achieved. The same results were found for DAVVQ scores: improvement from13.5 (IQR, 8.7-20.6) to 10.3 (IQR, 3.0-14.5) (P < .01) if AS was achieved and from 12.9 (IQR, 8.3-19.3) to 10.8 (IQR, 6.7-18.2) (P = .35) if AS was not achieved. Regarding the overall SF-36 scores, the domains of vitality, mental health, and general health worsened significantly.

Conclusions: In over 8 years of follow-up, the anatomical success rate after the treatment of GSV incompetence using the Clarivein device decreased to 60.5%. However, clinical scores and disease-specific QoL still improved significantly compared with baseline. We found no convincing evidence that the absence of reflux correlates better with clinical and QoL-related outcomes compared with recanalization irrespective of reflux.

Background: The deep femoral vein generally has individual differences in origin, course, tributary, caliber, and quantity. However, systematic research on deep femoral vein variations remains insufficient. Given this, this study used anatomical observation to reveal the types and ratios of variations in the deep femoral vein and its tributaries.

Methods: This study selected 63 gross specimens of intact lower extremities and dissected their 126 lower limbs layer by layer to explore variations in the deep femoral vein and its tributaries.

Results: A total of 15 lower limbs exhibit variations in the deep femoral vein and its tributaries, of which 93% were unilateral. No correlation was found between the mutations and gender. They can be generally classified into three types: variations in the small saphenous vein branch of the deep femoral vein (7.14%), variations in the popliteal vein branch of the deep femoral vein (3.96%), and multiple deep femoral vein variations (0.79%).

Conclusions: Variations in the deep femoral vein and its tributaries are not rare and can achieve a variation rate of 11.9%. Moreover, 93% of the variations involve tributaries of the deep femoral vein, among which 60% occur in the small saphenous vein branch, and approximately 30% are related to the popliteal vein branch. The variation diversity can lay a theoretical foundation for clinical diagnosis and treatment.

Objective: Advanced pneumatic compression devices (APCDs) have been shown to be effective in treatment of lower extremity lymphedema in the home setting. However, adherence to self-care has been poor, and APCDs require patients to remain immobile during treatment. We evaluated the safety and efficacy of a novel nonpneumatic compression device (NPCD) for treating lower extremity lymphedema vs an APCD.

Methods: A randomized, crossover head-to-head study was performed at nine sites in 2023. Patients were randomized to either the NPCD or a commercially available APCD. Patients used the randomly assigned initial device for 90 days with a 4-week washout period before a comparable 90-day use of the second device.

Results: A total of 71 patients (108 affected limbs) with lower extremity lymphedema were analyzed. Compared with the APCD, the NPCD was associated with a greater mean decrease in limb edema volume (a mean limb volume decrease of 369.9 ± 68.19 mL [P < .05] vs 83.1 ± 67.99 mL [P < .05]). Significant improvement in Quality of Life was achieved for NPCD and but not for APCD treatment (score improvement of 1.01 ± 0.23 [P < .05] for NPCD vs 0.17 ± 0.18 [P > .05] for APCD). Patients reported greater adherence (81% vs 56%; P < .001) and satisfaction with the NPCD (78% vs 22%) compared with APCD. No device-related adverse events were reported.

Conclusions: The novel NPCD is an effective treatment for decreasing limb volume in patients with lower extremity lymphedema. The NPCD was more effective than an APCD and resulted in superior limb volume decrease, greater improved quality of life, adherence, mobility, and patient satisfaction.

Objective: Hand arteriovenous malformations (AVMs) are extremely difficult to manage for their functional importance and cosmetic disfiguration. A single-center retrospective study was conducted to identify long-term outcomes of multidisciplinary team management of hand AVMs.

Methods: Institutional review board approved this retrospective study. Multidisciplinary vascular anomalies center data was reviewed from 1995 to 2023. Patient demographics, Schobinger's AVM stage, sclerotherapy details, surgical history, and adverse events after sclerotherapy were reviewed.

Results: A total of 150 patients with hand AVMs visited our hospital from 1995 to 2023, with a mean age of 33 years (range, 1-75 years), and 91 were females. Forty-four patients were Schobinger stage II, and 106 were stage III. Sclerotherapy was performed on 101 patients (67%) with 320 sessions. Angiographic devascularization rates after sclerotherapy were: 16 with 100%, 30 with over 90%, 34 with 50% to 90%, 15 with 0% to 50%, and six showed aggravation. Sclerotherapy-related adverse events occurred in 123 of 320 sessions (39%), with 112 minor and 11 major events. Fifteen patients (15%) eventually underwent amputation surgery a mean of 1618 days after sclerotherapy for necrosis (n = 3) and delayed complications (n = 12). Thirteen patients (9%) underwent primary surgical amputation for ulcers or bleeding (all Schobinger stage III). Thirty-six patients (24%) were followed without any procedure.

Conclusions: Multidisciplinary management of hand AVMs shows varied long-term outcomes. Although sclerotherapy is effective for many patients, it carries a significant risk of adverse events. The necessity for amputation in some cases highlights the severity of advanced AVMs and the need for individualized treatment approaches.

Objective: Several studies have shown that, in the short term, treatment outcomes following endothermal ablation of varicose veins without the prescription of post procedural compression are not inferior to outcomes when compression is routinely prescribed. This follow-up to our randomized controlled trial (RCT) published in 2020 explores whether the non-inferiority persists into the medium to long term.

Methods: All 94 patients from the RCT were recalled at 27 months after their initial radiofrequency ablation (RFA) procedure. The procedural details, randomization, and inclusion and exclusion criteria were described in the original RCT paper. Consent was obtained for further venous duplex ultrasound scan at 27 to 61 months after the initial procedure. The successful target vein closure at this juncture represented our primary outcome. Secondary outcomes include disease severity, measured using the Aberdeen Varicose Vein Severity Score (AVSS) and the Revised Venous Clinical Severity Score (RVCSS), post-procedural pain measured using Likert scale, and number of days taken for patients to return to work or normal activities.

Results: Thirty-one of 48 patients (64.6%) in the compression group and 29 of 46 patients (63%) in the no-compression group were evaluated. The mean duration of follow-up was 43 and 42 months in the compression and no-compression group, respectively. The target vein occlusion rate evaluated at this longer-term follow up were 80.7% and 79.3% in the compression and no-compression groups, respectively. There was no significant difference between the two groups (P = .37). Secondary outcomes of quality of life and disease severity measured using AVSS and RVCSS showed no significant difference between the two groups (post-procedural AVSS mean score 5.2 in the compression group vs 8.3 in the no-compression group [95% confidence interval (CI), -7.3 to 1.1; P = .14]; post-procedural RVCSS mean score 1.5 in the compression group vs 1.8 in the no-compression group [95% CI, -1.1 to 0.7; P = .59]). Patient satisfaction was similar in both groups (mean score 6.4 in the compression group vs 5.9 in the no-compression group [95% CI, -0.22 to 1.17; P = .18]), and the number of days taken for patients to return to work were also comparable (mean of 11.9 days in the compression group vs 12.6 days in the no-compression group [95% CI, -7.7 to 6.2; P = .83]).

Conclusions: This study provided some evidence to support no additional benefit of compression use after RFA at a longer term follow-up of 3 years. However, larger, suitably powered studies would be beneficial to confirm this.