Vasa-european Journal of Vascular Medicine最新文献

Vessel preparation has emerged as a key feature in endovascular treatment strategies as treated lesions are increasingly complex. While treatment algorithms have been presented, a practical systematic case-based approach, entailing contemporary vessel preparation tools, would provide assistance for vascular specialists in the daily routine. Based on patient characteristics, including clinical presentation, age and comorbidities and lesion specific parameters, team-based and patient-centered decisions are necessary for successful treatment. In addition, pre- and procedural imaging, lesion specific characteristics, such as the presence of chronic total occlusions, lesion length and calcification or the presence of thrombus are evaluated. Furthermore, run-off vessels serving as potential conduits for retrograde puncture in case of failed antegrade crossing need to be considered. Based on lesion-specific variables and the type of crossing (intraluminal versus subintimal), options for lesion preparation techniques, including plain-old-balloon angioplasty (POBA), specialty balloons, atherectomy, intravascular lithotripsy and/or thrombectomy are selected prior to the definitive treatment of the lesion. The selection of such vessel preparation strategies depends on the current scientific evidence, guidelines and expert opinion statements. Treatment of patients with intermittent claudication or chronic limb threatening ischemia (CLTI) are now discussed, where a recently published lesion preparation algorithm is applied. By the establishment of this algorithm in daily practice, harmonization of endovascular practice and further improvements in vessel and patient specific outcomes are anticipated.

Background: Pulmonary embolism (PE) can result in high mortality. Early risk stratification and treatment are critical for individualized management. In patients with intermediate-high-risk (IHR) PE, guidelines recommend to consider a percutaneous catheter-directed treatment (CDT). While different techniques are available, comparisons between treatments regarding right ventricular (RV) function and outcome are still scarce. This study aimed to compare changes in RV function as well as outcomes in patients with IHR PE after CDT with ultrasound-assisted thrombolysis (USAT) as compared to large-bore mechanical thrombectomy (MT). Patients and methods: This is a retrospective, single-center study in IHR PE, diagnosed in accordance with the ESC Guidelines. All patients underwent a CDT either with USAT (EKOS, Boston Scientific) or MT (FlowTriever System, Inari). Right heart function (RV/LV ratio, TAPSE) was assessed via transthoracic echocardiography before and after CDT as well as interventional characteristics and postinterventional hospital stay were compared. Results: From June 2022 to April 2024, 26 patients (35% female; aged 61.2±15.2 years) were diagnosed with IHR PE and underwent CDT. 14 patients (53.8%) were treated with USAT and 12 patients (46.2%) with MT. The mean procedural time was 40.4±19.8 minutes for USAT and 104±32.2 minutes for MT. RV/LV ratio was improved in both groups (change from baseline USAT -0.48±0.25; MT -0.36±0.13). TAPSE increased by 6.95±3.7 mm in USAT and by 9.8±4.6 mm in MT. Major bleeding (defined as BARC ≥ 3a) occurred only in three patients of the USAT group. The 90-day mortality rate was 0% in both groups. Conclusions: In patients with IHR PE both USAT and MT lead to an improved RV function without mortality within 90 days. Further randomized data have to discriminate the differential impact of novel tools for the treatment of IHR PE.

The number of endovascular interventional procedures for catheter-based therapy (CBT) of acute venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), has been increasing over the past years. The development of more efficient thrombectomy systems for CBT of VTE has potentially enhanced the efficacy of interventional treatment of VTE. Nevertheless, indications for CBT of VTE, i.e. catheter-directed thrombolysis (CDT) or catheter-based mechanical thrombus removal, need to be established based on existing data and expert consensus. Vascular experts should be involved in the decision-making process on CBTs in patients with acute VTE, and thrombus removal procedures should be performed in centers with experience in interventional treatment of VTE. This guideline document of the European Society of Vascular Medicine (ESVM) provides recommendations on indications and management of CBT in acute VTE and is endorsed by the European national societies of Vascular Medicine.

Background: We investigated the safety and efficacy of rivaroxaban as routine thromboprophylaxis after endovenous thermal ablation (EVTA). Patients and methods: Adhering to the PRISMA 2020 guidelines, we conducted a systematic review for studies published up to April 2024. Primary endpoints included endovenous heat-induced thrombosis (EHIT) class ≥ II, deep vein thrombosis (DVT), major and minor bleeding and the composite endpoint of major thromboembolic complications including any incidents of EHIT ≥ III, DVT or pulmonary embolism (PE). Results: Eight retrospective case series, encompassing 1666 patients, and 2049 truncal veins were included. The pooled EHIT ≥ II, DVT, and major thromboembolic complications estimates were 0.73% (95% CI: 0.37-1.42), 0.51% (95% CI: 0.22-1.17) and 0.71% (95% CI: 0.27-1.89). The crude and pooled major and minor bleeding estimates were 0% (0/885) and 2.60% (95% CI: 1.05-6.33). The pooled early truncal and great saphenous vein (GSV) occlusion outcomes were 99.03% (95% CI: 96.88-99.70) and 98.74% (95% CI: 92.07-99.81). The pooled and crude superficial thrombophlebitis and PE estimates were 2.86% (95% CI: 0.88-8.89) and 0% (0/579). While the comparative analysis between rivaroxaban and low molecular weight heparins (LMWH)/fondaparinux displayed improved outcomes favouring rivaroxaban in terms of DVT, risk ratio (RR), 0.60 (95% CI: 0.12-3.07) and truncal occlusion, odds ratio (OR), 1.43 (95% CI: 0.31-6.55) outcomes did not reach statistical significance. Meta-regression analysis including rivaroxaban treatment durations spanning from three to ten days displayed a negative association between duration of treatment and both truncal, (β = -0.4740, p<0.01) and GSV, (β = -0.4583, p<0.01) occlusion in the early pos-operative period. Conclusions: The results of this review underscore the potential safety of rivaroxaban as thromboprophylaxis in the context of endovenous thermal ablation. The observed inverse relationship between anticoagulation duration and occlusion outcomes should be interpreted with caution, highlighting the need for further research.

Background: Atherosclerotic cardiovascular disease (ASCVD) encompasses a diverse range of disease manifestations including coronary, lower extremity peripheral (PAD), carotid, or extensive (e.g., polyvascular) arterial disease. However, a paucity of data exists with regard to the prevalence, shared risk factors, and rate of prescribed secondary preventive medications in different ASCVD subgroups. We sought to investigate this from a population-based perspective using data derived from the contemporary Hamburg City Health Study (HCHS). Patients and methods: In the population-based HCHS participants between 45 and 74 years were recruited at random. In the current cross-sectional analysis of the first 10,000 participants enrolled between February 2016 and November 2018, participants were stratified by the arterial vascular bed affected by atherosclerosis, e.g., carotid artery disease, lower extremity PAD, or coronary artery disease, as well as a combination of at least two entities (polyvascular disease). Baseline characteristics including risk factor profiles, prescribed preventive medications as well as cardiovascular risk scores (ESC SCORE 2, Stroke score) were compared. Results: A total of 6,324 individuals with complete cardiovascular screening data were included. Overall, 2,258 (35.7%), 732 (11.6%) and 174 (2.8%) participants were diagnosed with isolated carotid artery disease, lower extremity PAD, or coronary artery disease, respectively. In 739 (11.7%) participants polyvascular disease was noted. Across the subgroups, different patterns of risk factor profiles were documented. Participants with polyvascular disease were the oldest, most often unemployed, diabetic, and current smokers. Individuals with coronary artery disease or polyvascular disease were noted to have the highest cardiovascular risk scores and highest rates of prescribed preventive medications. Conclusions: In this contemporary population-based analysis, different risk factor profiles, cardiovascular risk scores and prescribed secondary preventive medications were noted according to the diseased vascular bed. Our findings suggest differences between best medical treatment which could be targeted to improve cardiovascular event rates in patients with ASCVD.

Background: Optimal pharmacotherapy is a cornerstone for the treatment of patients with symptomatic peripheral artery disease (PAD). Our aim was to evaluate the impact of adjunct medical therapy, including lipid-lowering and antiplatelet treatment in patients undergoing open or endovascular revascularization due to common femoral artery occlusive disease (CFAOD). Patients and methods: Consecutive patients undergoing either endovascular or open revascularization due to CFAOD were analyzed. Pharmacotherapy before and after treatment was registered and its impact on the following post-procedural outcomes: (i) all-cause mortality and (ii) major adverse limb events (MALE), including major amputation and clinically driven target lesion revascularization (CD-TLR), were systematically analyzed. Results: Patients undergoing endovascular therapy (n=225) were older and exhibited more comorbidities such as diabetes mellitus and heart failure and had more frequently chronic limb threatening ischemia (CLTI) compared to those undergoing open repair (n=662). During 1.73 (0.9-3.3) years of follow-up, 96 (10.8%) deaths and 118 (13.3%) MALE occurred. After endovascular therapy, more patients received clopidogrel (70.2% versus 41.5%) and statins (92.0% versus 74.9%), (p<.001 for both). By multivariable analysis, statin perscription was associated with lower death rates (Odds Ratio (OR)= 0.43, 95%CI=0.25-0.73, p<.002), whereas clopidogrel was associated with lower MALE rates (OR=0.65, 95%CI=0.43-0.97, p=.04). These effects were primarily driven by patients undergoing open repair (effect of statins) and by patients with chronic limb threatening ischemia (effect of clopidogrel). Conclusions: Statin and clopidogrel treatment are important components of the post-procedural treatment of patients with PAD undergoing revascularisation due to CFAOD. Especially statins need to be prescribed based on current national and international guidelines independent of the revascularization type in every patient to reduce death rates.

Background: Coral reef aorta (CRA) is a rare and therapeutically challenging condition characterized by heavily calcified paravisceral aortic stenosis, leading to severe clinical manifestations. Open surgery is associated with substantial perioperative morbidity and mortality, while standard endovascular approaches often face technical limitations. This multicentre study aimed to evaluate the feasibility and safety of intravascular lithotripsy (IVL) combined with aortic and/or reno-visceral vessel (RVV) stenting for the treatment of paravisceral CRA. Patients and methods: Patients with paravisceral CRA treated with IVL between 2021 and 2025 across six vascular centres were retrospectively analysed. The primary endpoint was technical success. Secondary endpoints included IVL-related complications, perioperative mortality, freedom from reintervention, clinical improvement, and aortic lumen gain at the site of maximum stenosis. Results: A total of 16 patients were included. Presenting symptoms were claudication (n=15), renal failure (n=9), mesenteric ischemia (n=4), and cardiac failure (n=2). IVL alone was performed in 3 patients (18.8%), while 13 patients (81.2%) underwent adjunctive aortic and/or RVV stenting. Technical success was achieved in all cases. There were no IVL-related complications or perioperative deaths. All patients demonstrated clinical improvement and significant aortic lumen gain. During a median follow-up of 5 (1-11.5) months, two elective reinterventions were required. No patients were lost to follow-up. Conclusions: In our cohort, IVL combined with aortic and/or RVV stenting appeared to be a feasible and safe endovascular strategy for the management of paravisceral CRA. The approach offers high technical success with low perioperative morbidity, mortality, and reintervention rates.

Background: Open thoracoabdominal aortic aneurysm (TAAA) repair for Crawford extent II aneurysms carries substantial risks. This study compares outcomes of open TAAA repair following prior thoracic endovascular aortic repair (TEVAR) with conventional open extent II repair. Patients and methods: A retrospective analysis of 91 patients (2006-2024) divided into prior TEVAR (n=29) and conventional repair Crawford extent II repair without previous TEVAR (n=62). Primary endpoints included mortality and complications; secondary endpoints assessed survival and reinterventions. This study was designed according to STROBE criteria. Results: The prior TEVAR group (n=29) had a mean age of 61.5±10.7 years and 72.4% were male, while the conventional extent II repair group (n=62) had a mean age of 63.2±9.8 years and 69.4% were male. Prior TEVAR patients underwent open repair for extent II (13.8%), III (58.6%), or IV (27.6%) aneurysms. In-hospital mortality was lower in the prior TEVAR group (6.9% vs. 25.8%, p =.07), as were rates of spinal cord ischemia (3.4% vs. 8.1%, p =.55), acute kidney injury (24.1% vs. 35.5%, p =.28), and massive transfusion (24.1% vs. 30.6%, p =.54). Pulmonary complications occurred less frequently after TEVAR (69.0% vs. 82.3%, p =.25). Kaplan-Meier analysis revealed no significant survival difference (log-rank p=.05), with 5-year survival rates of 94% (prior TEVAR) and 61% (conventional). Aortic reintervention rates were also similar (10.5% vs. 18.8%, p=.69). Conclusions: Open TAAA repair following prior TEVAR may offer clinically meaningful advantages over conventional open type II repair with acceptable survival rates; however, these findings should be interpreted cautiously given the study's retrospective design and small sample size. Staged hybrid approach could be a viable strategy for managing complex aortic pathologies.

Background: Over the last years, the discussion about gender equality has reached surgery. Among all the different aspects being discussed, the question of the necessity of implementing a women's quota arises regularly. Materials and methods: In 2022 a questionnaire was answered by members of the German Society for Vascular Surgery and Vascular Medicine. Relevant career and family-life related demographic aspects as well as their personal opinion on the need for a women's quota were evaluated. Results: 540 vascular surgeons participated in the survey. Significantly more male surgeons were in a committed relationship. Significantly more partners of female colleagues had full-time jobs, and significantly less women stated that they were the main earners in the relationship. Male surgeons had significantly more children. In general, men held higher positions and significantly more male surgeons were enrolled as head of department. Significantly more women favoured a women's quota for e.g. head of department positions, senior surgeon positions, scientific committees and scientific panels at scientific conferences. Regarding the level of such a quota, 43% of participating female surgeons and 19.5% of males suggested a 50% quota, whereas 59% of male and 30% of female surgeons did not see the need of a women's quota at all. Conclusions: The present survey shows the imbalance between men and women in vascular surgery in Germany in terms of career development and family life. Persistent disadvantages for women were shown. Women's quotas could be helpful, but are certainly no reasonable "stand-alone-approach": a general change of mindset is needed here.

Background: Type II endoleaks (T2EL) remain the most common complication after endovascular aneurysm repair (EVAR). Aneurysm sac regression is a predictor for better treatment outcomes compared to sac stability and growth. T2EL are associated with aneurysm sac regression and prophylactic embolization of the sac or side branches may result in lower T2EL incidence. This review aims to assess the current evidence on whether prophylactic treatment strategies provide improved clinical outcomes after EVAR. Materials and methods: A systematic search was performed of the Scopus, PubMed and Web of Science databases. Original studies reporting prophylactic embolization to prevent endoleaks were included and a meta-analysis was performed on important clinical outcome parameters; T2EL incidence, sac remodelling and T2EL related reinterventions. Results: A total of 1,870 publications were identified. After screening and quality assessment by two reviewers, data were extracted from 29 studies and analysed. T2EL incidence was significantly lower in the embolization group; odds ratio 0.29 [0.19-0.45, 95% confidence interval] at 6 months, 0.20 [0.13-0.31] at 12 months and 0.28 [0.14-0.55] at 24 months. Sac growth was significantly lower in the embolization group with odds ratios of 0.08 [0.01-0.59], 0.16 [0.05-0.53] and 0.24 [0.11-0.52] at 6, 12 and 24 months, respectively. Sac shrinkage was significantly higher in the embolization group with odds ratios of 0.42 [0.28-0.63], 0.49 [0.32-0.77] and 0.28 [0.16-0.50] at 6, 12 and 24 months, respectively. Reintervention rates were lower in the embolization group, although not statistically significant. Conclusions: The results from this review and meta-analysis show that prophylactic embolization, either through non-selective sac filling or selective side branch embolization, result in better clinical outcomes at 6, 12 and 24 months. Prophylactic embolization seems promising in increasing sac regression rates and reducing T2EL incidence, but more data about other clinical outcome parameters is required.