Vasa-european Journal of Vascular Medicine最新文献

Acute heparin-induced thrombocytopenia (HIT) type II requires the immediate discontinuation of heparin and initiation of a non-heparin anticoagulant. Lifelong avoidance of heparin is generally recommended due to the risk of recurrence. Therefore, anticoagulation management in endovascular procedures remains challenging, as heparin is the preferred anticoagulant and evidence on alternative strategies is limited. This narrative review outlines an institutional approach aligned with current guidelines and examines the available data on non-heparin anticoagulants in this setting. Current evidence may support the use of bivalirudin among non-heparin anticoagulants for peripheral endovascular interventions due to indirect evidence of its use during percutaneous coronary intervention in patients with acute HIT. However, bivalirudin is often not available due to drug shortage and not approved for HIT in Europe. This leaves argatroban as the main alternative, particularly in patients with renal impairment. Data on non-heparin anticoagulation for HIT were extrapolated from other types of intervention and from small retrospective studies. In selected cases of patients with remote or subacute HIT B and negative antibodies, intraoperative heparin may be considered if alternative anticoagulants are not practical, particularly in emergency situations, even in this approach is controversial and not discussed in current guidelines regarding peripheral endovascular procedures. In the absence of robust evidence, anticoagulation strategies should be individualized and patients adequately informed. Further studies are necessary to optimize anticoagulant management among patients with HIT undergoing peripheral endovascular interventions.

Atherosclerotic plaques represent a typical deterioration of arterial wall in atherosclerotic process and are the source of cardiovascular events. Plaque progression and composition represent a major risk for cardiovascular events. Therefore, recently many studies have assessed changes in plaque characteristics and their response to various treatment modalities. In the last two decades, improvement in plaque imaging modalities that can assess plaque volumes and composition enable to follow plaque characteristics in a non-invasive way. Clinical trials utilizing arterial imaging modalities have shown that reducing LDL cholesterol to low levels can reduce atherosclerotic plaque burden and favourably modify plaque composition. These outcomes have been achieved with statin therapy and newer lipid-lowering strategies such as protein convertase subtilisin/kexin type 9 inhibitors. Also, some anti-inflammatory drugs and other anti-atherosclerotic medications can lead to significant reduction in plaque burden. However, the data assessing association of plaque regression to reduction of cardiovascular events are limited. Therefore, the aim of this narrative review is to elucidate the possibilities and the role of plaque assessment and if it might offer the potential to guide personalized management of patients at risk for cardiovascular events in the future.

Risk factor-based algorithms give a good estimate of cardiovascular (CV) risk at the population level but are often inaccurate at the individual level. Detecting preclinical atherosclerotic plaques in the carotid and common femoral arterial bifurcations by ultrasound is a simple, non-invasive way of detecting atherosclerosis in the individual and thus more accurately estimating his/her risk of future CV events. The presence of plaques in these bifurcations is independently associated with increased risk of CV death and myocardial infarction, even after adjusting for traditional risk factors, while ultrasonographic characteristics of vulnerable plaque are mostly associated with increased risk for ipsilateral ischaemic stroke. The predictive value of carotid and femoral plaques for CV events increases in proportion to plaque burden and especially by plaque progression over time. Assessing the burden of carotid and/or common femoral bifurcation plaques enables reclassification of a significant number of individuals with low risk according risk factor-based algorithms into intermediate or high CV risk and intermediate risk individuals into the low- or high CV risk. Ongoing multimodality imaging studies, supplemented by clinical and genetic data, aided by machine learning/ artificial intelligence analysis are expected to advance our understanding of atherosclerosis progression from the asymptomatic into the symptomatic phase and personalize prevention.

Background: Over the past decade the increasing adoption of endovascular-first strategies has significantly altered the landscape in the treatment of peripheral arterial disease (PAD), raising concerns about the continuation and future development of high-quality surgical training, particularly in regard to tibial and pedal bypass procedures. This study aims to assess the current surgical and endovascular experience among the community of German vascular surgery program directors. Materials and methods: This study consisted of a questionnaire-based survey among German vascular surgeons who are licensed to provide further training in vascular surgery (in 2024). The aim was to assess participant's clinical experience, technical approaches to bypass surgery, decision making algorithms to revascularization procedures, and perceived adequacy of training in vascular surgery. Results: A total of 272 (77.7%) of the 350 invited surgeons responded, including 19 females (7.0%). The majority of the participants worked at academic teaching hospitals (79.8%), while 9.2% were in university hospitals and 11.0% worked at non-teaching hospitals. The median number of below-the-knee bypasses performed per career was 524 (IQR 286-1002), including 57 (IQR 20-129) pedal bypasses. Academic teaching hospitals reported the highest number of bypasses (601 vs. 300 in university hospitals) and non-teaching hospitals reported the highest number of endovascular procedures (786 vs. 301). Although the majority reported high confidence levels in performing said procedures, a considerable heterogeneity existed in technical aspects such as intraoperative anticoagulation, clamping technique, and post-surgical quality control. There was no association between institution type and technical aspects. One-third of respondents were over 60 years of age and therefore close to retirement age. Conclusions: This survey provided valuable insights into the delivery of vascular surgery programs in Germany, revealing a high variability in surgical experience, techniques, and training exposure. With an aging workforce and the further evolution of endovascular techniques, structured mentorship programs and standardized training curricula are essential to tackle the challenge of ensuring vascular surgeons remain proficient in tibial and pedal bypass surgery.

Background: Duplex ultrasound assessment with the patient standing is standard for diagnosing chronic venous insufficiency (CVI). However, assessments are often performed with patients in tilted or supine positions due to age or physical limitations. This study aimed to evaluate the influence of the patient's positioning on venous diameters and venous valve function. Patients and Methods: Monocentric, prospective cohort study in 30 patients with CVI of the great saphenous vein (GSV). 18 contralateral limbs without GSV insufficiency were defined as the control group. With duplex ultrasound, we measured GSV diameters at different anatomic points. Moreover, we analyzed the occurrence of venous reflux (>0.5s) with the patient in a lying position (0°), on the tilting table in 30° and 70° positions, and with the patient standing (90°). Results: A linear relationship was found between patient inclination and diameters in varicose GSVs. Average diameters in limbs with CVI increased from lying to standing by 39-42%, while average diameters in healthy GSVs increased by 20-23%. In ≥97% of the patients, pathological venous reflux findings observed in the standing position were also detected in the 70° tilted position, with no statistically significant differences between these two positions. Conclusions: For duplex ultrasound examination of the GSV in cases of suspected CVI, it can be recommended to position the patient on a table tilted at 70°. This position provides results comparable to those obtained in the standing position while enhancing patient safety and examiner comfort.

Peripheral artery disease (PAD) is a growing health problem, with symptoms ranging from intermittent claudication to chronic limb-threatening ischemia (CLTI). Balloon angioplasty in below-the-knee (BTK) PAD lesions is the mainstay treatment procedure but still a challenging one, given the heterogeneity in the patient population, multivessel and multilevel involvement, small-vessel size, long lesions (up to 40 cm), calcium burden, and lower flow rates with or without impaired runoff. The technical success of balloon angioplasty is often subverted by flow-limiting dissections, recoil with early restenosis. This review will explore current guidelines, revascularization anatomical planning, interventional approaches, and possible solutions to avoid the feared dissection, recoil and restenosis that our patients currently face.

Lipedema is a chronic disease characterized by the disproportionate and symptomatic accumulation of fat in the lower limbs and arms. Women with lipedema experience heaviness, fatigue and pain, leading to impairments in daily activities and reduced quality of life. Conservative treatment mainly focuses on lifestyle modifications, along with compression therapy and manual lymphatic drainage. Exercise training could also play a pivotal role in the management of lipedema. The aim of this systematic review was to explore the effectiveness of exercise training in women with lipedema. A comprehensive literature search was conducted in Embase, MEDLINE, Cochrane CENTRAL, Web of Science, CINAHL on June 23, 2025. The main outcomes were pain, fatigue and other symptoms, quality of life, anthropometric characteristics, lower limb volumes and/or circumference, and functional performance. The search strategy identified 523 studies, of which six were included in this review. Studies included 115 women with lipedema. Exercise training seems to improve pain and other symptoms, quality of life, limb volumes and/or circumference, and functional performance. The effects seem to be greater when combined with ongoing compression therapy. However, the effects of exercise training on the different outcomes varied among the studies, probably related to the high heterogeneity, different training approaches, and small sample sizes. Exercise training might be a promising therapeutic care option in women with lipedema, and the effects seem to be greater when combined with ongoing compression therapy. Appropriately designed and adequately powered studies are needed to further explore the benefits of exercise in these patients. (PROSPERO Registration No.: CRD42024604164).