Vasa-european Journal of Vascular Medicine最新文献

Background: Experience on endovascular inferior mesenteric artery (IMA) revascularisation for atherosclerotic chronic mesenteric ischaemia (CMI) is limited and its clinical benefit remains uncertain. Patients and methods: This retrospective single-centre study included 12 patients with CMI who underwent endovascular IMA revascularisation between January 2014 and January 2024. Indications were: (1) IMA stenosis with endoscopically confirmed colonic ischaemia, (2) IMA stenosis with retrograde filling of a proximally occluded superior mesenteric artery ineligible for revascularisation, and (3) overall improvement of collateralisation in critical CMI due to multi-vessel disease. Technical success, clinical success and primary clinical patency were assessed. Procedure-related adverse events, symptom recurrence, mortality and survival rates were also analysed. Results: Seven isolated IMA interventions and five IMA revascularisations as part of a multi-vessel approach were performed. Balloon-expandable stents were used in 11 cases; one patient underwent balloon angioplasty with intravascular lithotripsy. Technical success was 83% (10/12); two cases had >50% residual stenosis due to annular aortic calcification impeding stent expansion. Median final residual stenosis was 27% (IQR 23.5). Four minor procedure-related adverse events occurred. Clinical success was 92% (11/12). Median follow-up was 17 months (IQR 20.7). The all-cause mortality rate was 25% (3/12). The mesenteric ischaemia-related mortality rate was 8% (1/12). The symptom recurrence rate was 33% (4/12). At 6 and 12 months, primary clinical patency rates were 71% and 54%, and survival rates were 83% and 72%. Conclusions: Endovascular IMA revascularisation is a viable treatment for CMI in selected scenarios where other options are inappropriate. Despite the specific calcification pattern at the IMA origin predisposing to residual stenosis, most patients had symptom resolution and acceptable clinical patency with low recurrence and mortality rates. However, 33% of patients had early symptom recurrence requiring treatment. It remains difficult to assess whether IMA revascularisation is curative or a bridge to open revascularisation.

Background: To report the clinical outcomes of endovascular therapy in nonagenarians treated for symptomatic peripheral arterial disease (PAD). Patients and methods: This is a retrospective analysis of 81 nonagenarians (mean age 93±2.4 years) treated by endovascular therapy for chronic limb threatening ischemia (CLTI) or claudication between December 2017 and August 2023. The composite of amputation and/or death (amputation-free survival; AFS) was the primary endpoint. Technical success, mortality, major limb amputation, risk for Major Adverse Cardio-Cerebro-vascular Events (MACCE) and re-intervention during follow-up were additionally analysed. Results: Most patients presented with CLTI (n=75, 93%). Popliteal artery interventions were most frequently performed (n=59, 73%), followed by superficial femoral artery (n=57, 70%), tibial (n=49, 61%), aortoiliac (n=11, 14%) and common femoral artery (n=7, 9%) procedures. The technical success rate was 100% and the in-hospital mortality was 1% (n=1). At 24 months the AFS was 23.5%, while the major amputation and mortality rates were 4.9% and 75.3% respectively. In the same period the rate of MACCE was 74.1% and the freedom from re-intervention rate amounted to 85.2% The cox regression analysis revealed a lower AFS among males (HR:1.8, 95% CI: 1.06-3.03, p=0.03) and a higher risk for MACCE in patients on warfarin (HR:3.1, 95% CI:1.26-7.59, p=0.01). Conclusions: Despite the high technical success and the low amputation rates, a very high mortality rate at follow up was observed among nonagenarians undergoing endovascular procedures for PAD. Male gender and Warfarin administration increased the risk for adverse events.

Background: Ankle-brachial-index (ABI) calculation is the recommended method in diagnosing peripheral artery disease (PAD) but its use is limited due to medial artery calcification (MAC) which leads to incompressibility of lower limb arteries and results in false elevated ABI values. Measurement of systolic acceleration time (AT) by duplex ultrasound is being discussed as an alternative, but whether coexisting MAC influences AT values remains unknown. Patients and methods: In a prospective clinical study healthy subjects, patients with MAC and patients with PAD with and without MAC were examined. In all 238 participants ABI calculation for posterior tibial artery (ATP) and anterior tibial artery (ATA) was performed by continuous wave (CW) Doppler ultrasonography, followed by measurement of AT derived from velocity-time spectra of ATP, ATA, and brachial artery (AB) by colour-coded duplex sonography. We introduced an innovative parameter to quantify PAD severity: the absolute difference value of AT (DAT), calculated as the absolute difference between crural AT and brachial AT. This parameter aims to minimize confounding effects of cardiac conditions on AT measurements. Results: It was found that a coexisting MAC does not have a significant impact on AT values (p>.05). According to the findings of this study PAD is present in patients with AT >95ms (sensitivity (Se): 85%, specificity (Sp): 87%) or in patients with DAT >20ms (Se: 82%, Sp: 84%). Conclusions: Both AT and DAT are suitable quantitative parameters for PAD diagnosis and severity assessment in patients with coexisting MAC, providing valuable alternatives when ABI is unreliable.

Background: We investigated the safety and efficacy of antiplatelet therapy in preventing native arteriovenous fistula (AVF) dysfunction. Patients and methods: A systematic review was conducted in accordance with the PRISMA 2020 guidelines. Randomized controlled trials (RCTs) evaluating the effects of antiplatelet therapy following native AVF creation were eligible for inclusion. The primary endpoint was AVF primary patency. Secondary endpoints included AVF maturation, abandonment, and overall bleeding. Results: Twelve RCTs, comprising 2,491 patients, were incorporated in the analysis. The included studies assessed aspirin, clopidogrel, ticlopidine, and dypiridamole across various dosing regimens. The postoperative administration of antiplatelets, regardless of the specific drug or dose, was associated with improved AVF primary patency compared to controls or placebo, odds ratio (OR) 2.28 (95% CI: 1.42-3.65). Subgroup analysis showed no significant differences for aspirin 100mg daily or clopidogrel 75mg daily compared to controls/placebo, with ORs of 1.08 (95% CI: 0.76-1.54) and 2.16 (95% CI: 0.95-4.91), respectively. In contrast, ticlopidine 250mg twice daily significantly improved patency, OR 3.48 (95% CI: 1.46-8.26). Additionally non-statistically significant differences were identified between the antiplatelet and control/placebo groups in terms of maturation, OR 1.58 (95% CI: 0.81-3.09), AVF abandonment, risk ratio (RR) 0.93 (95% CI: 0.58-1.50), or overall bleeding RR 1.18 (95% CI: 0.77-1.81). Finally, meta-regression analysis of the antiplatelet groups pooled estimates revealed a negative association between maturation and follow-up duration (β =-0.1235, p<.01), and treatment duration and abandonment outcomes (β =-0.065, p<.01). Conclusions: This review demonstrated the safety and efficacy of antiplatelet therapy in preserving AVF patency, with ticlopidine and clopidogrel emerging as the primary contributors to this outcome. These findings suggest the potentially beneficial role of adenosine diphosphate (ADP) receptor antagonists in maintaining AVF patency.

Background: Current guidelines on the follow-up after infrainguinal bypass recommend clinical examination with history, pulse palpation and ankle-brachial-index assessment. Depending on the guideline, duplex ultrasound may or may not be recommended due to the lack of evidence. Data on this topic is sparse, especially after prosthetic bypass. Patients and methods: In a retrospective single-centre analysis, ultrasound surveillance examinations of 181 patients after femoropopliteal prosthetic bypass were analysed. Flow-velocities and flow-patterns of the inflow, anastomoses, the bypass as well as the outflow vessels were evaluated. The primary endpoint was primary patency, while primary-assisted and secondary patency as well as amputation-free survival were secondary endpoints. Results: By applying the Fine-Gray Model five ultrasound criteria were identified to increase the risk of loss of primary patency. A monophasic flow-pattern of the bypass as well as the popliteal artery showed a hazard-ratio of 2.0 (95% CI: 1.26-3.1, p=.003) and 1.7 (95% CI: 1.09-2.64, p=.02), respectively. A peak systolic velocity <60cm/sec of the deep femoral artery was significantly associated with loss of primary patency (p=.025). Decrease of inflow velocity as well as the deep femoral artery during follow-up were also significantly connected to loss of primary patency (p<.001). Primary-assisted and secondary patency as well as amputation-free survival were significantly associated with the waveform in the bypass and the popliteal artery (p<.001, p=.011, p=.031, p=.013). Conclusions: Ultrasound surveillance after femoropopliteal prosthetic bypass can identify factors associated with lower patency rates and amputation-free survival. These findings can help detect patients at higher risk of bypass occlusion and may improve their outcome.

Background: Infrapopliteal lesions account for one-third of peripheral artery disease (PAD) cases; however, its endovascular treatment data are insufficient. Although paclitaxel-coated drug-coated-balloons (DCBs) reduce restenosis and the need for re-interventions in femoropopliteal arteries, their effectiveness in below-the-knee (BTK) vessels is uncertain. This study evaluated the real-world effectiveness and safety of paclitaxel-coated DCBs in BTK vessels. Patients and methods: This retrospective single-centre study included consecutive patients treated with paclitaxel-coated Luminor™ DCB in BTK arteries between August 2017 and March 2022. The follow-up extended to 60 months. Data were retrieved from archives, phone interviews and physician inquiries. Results: Seventy-nine patients (65.5% male; mean age 74.9±9.2 years) underwent 84 interventions with 114 DCBs. The overall and treated lesion lengths averaged 102.1±80.3 and 117.2±75.5 mm, respectively. The median preoperative Rutherford score was 5 [interquartile range (IQR), 5-5; n=80]. The ankle-brachial index (ABI, 0.8±0.4-1.0±0.2, P=.002) and toe-brachial index (TBI, 0.3±0.3-0.6±0.2, P=.039) significantly improved post-intervention. The wound, ischaemia and foot infection score components showed median value reductions from the pre- to the postinterventional assessment: wound, from 1 (IQR, 1-2) to 1 (0-1); ischaemia, from 1 (IQR, 0-2) to 0 (0-1); and foot infection, from 1 (IQR, 0-2) to 0 (0-1). Kaplan-Meier analysis revealed 25 major adverse limb events, 17 re-interventions, 15 major adverse cardiac events, and 8 major amputation events over 5 years. Re-intervention-free survival was lower in men than in women (P=.036). Diabetic status or renal function was not significantly different. The 3-year mortality was 46.4%. Conclusions: This study highlights the clinical benefit of infrapopliteal paclitaxel-coated DCBs in real-world patients. ABI and TBI improvements reflect ischaemia relief. Wound-healing trends suggest reduced ischaemia and infection within 3 days, but requires longer follow-up. High mortality rates emphasise the effect of comorbidities and multidisciplinary care requirements.

Background: The benefit-risk profile of thoracic endovascular aortic repair (TEVAR) in patients with type B aortic intramural hematoma (IMH) has not been well established yet. This study aimed to evaluate the outcomes of TEVAR compared with medical management (MM) in this population. Patients and methods: PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched to identify studies comparing TEVAR with MM in patients with type B IMH. Results: Sixteen studies involving 1528 patients were included in this meta-analysis. Compared with the MM group, the TEVAR group displayed similar incidences of in-hospital death [RR (95%CI): 0.73 (0.32-1.66), p=.45] and aortic-related death [RR (95%CI): 0.70 (0.31-1.58]), p=.39]. The risk of all-cause death was comparable between the two groups [RR (95%CI): 0.62 (0.36-1.07), p=.08]. Meanwhile, TEVAR was superior to MM in promoting IMH regression [RR (95%CI): 1.51(1.26-1.81), p<.001] and reducing IMH progression [RR (95%CI): 0.15 (0.08-0.29), p<.001], dissection [RR (95%CI): 0.26 (0.12-0.60), p=.002], and secondary intervention [RR (95%CI): 0.22 (0.08-0.60), p=.003]. Conclusions: In patients with type B IMH, the incidences of in-hospital death, aortic-related death and all-cause death during follow-up were comparable between the TEVAR group and the MM group. However, TEVAR was superior to MM in promoting IMH regression and reducing IMH progression, dissection, and secondary intervention. Further randomized controlled trials are needed to clarify the role of TEVAR in this population.

Background: Patients having emergency surgery due to ischemia caused by a popliteal artery aneurysm (PAA) have worse outcomes in all endpoints (operation time, major adverse limb events (MALE), amputation-free survival) than after elective treatment, mostly due to a limited crural vessel runoff. This study investigates the relationship between PAA diameter, volume, and luminal thrombus load in relation to the preoperative crural runoff. Patients and methods: Retrospective single-centre evaluation of surgically treated patients with PAA and semi-automated quantitative CT analysis of PAA morphologies (diameter, volume and intraluminal thrombus volume). Primary endpoints were the correlations these characteristics with the number of patent crural vessels. Results: A total of 89 PAAs (61 patients, median age 75, IQR 12; 94.4% male) were identified, of which 47.2% were symptomatic with 18 acute limb ischemia (ALI). The diameter at surgery was 33.8 ± 12.1mm and the volume 68.5 ± 13.6mm³. A median of two lower leg vessels were patent (elective 3 [1, 2, 3] vs. emergency 1 [1, 2], p=0.1) upon preoperative CTA. 77 PAAs underwent elective surgery, five PAAs (5.6%) received endovascular treatment. The surgical complication rate was 23.6% without immediate or early occlusion. The follow-up was 42.5 [39-45] months. The overall mortality rate was 11.2% and the primary patency rate 73.9%. While the total aneurysm volume correlated well with the diameter (r=0.77, p<0.01), the intraluminal thrombus volume (ILT) showed the clearest correlation with the crural runoff (r=-0.34, p=0.01). No correlation between the diameter and crural runoff was observed (r=-0.17, p=0.1). A reduced crural run-off was significantly associated with impaired amputation-free survival (p=0.01). A subgroup analysis (n=21) with sequential CTs showed a tendency towards greater increase of thrombus volume compared to plain diameter during PAA growth. The thrombus volume index (=ILT/total PAA volume) was significantly higher in emergency patients (p=0.01), while diameters tended to be smaller (p=0.57). Conclusions: The increasing intraluminal thrombus volume correlates most distinctly with a reduced crural runoff in PAAs and should therefore be considered prognostically important, especially in the presence of an increased growth rate compared to the diameter.