Vascular最新文献

BackgroundVascular graft infection (VGI) is a devastating complication that necessitates immediate diagnosis to reduce morbidity and mortality. In 2016, The Management of Aortic Graft Infection Collaboration (MAGIC) proposed a diagnostic algorithm for identifying aortic graft infection which uses clinical, radiological, and laboratory findings to determine risk. The purpose of this study was to retrospectively validate the MAGIC criteria for VGI diagnosis and potentially broaden its application.MethodsAn IRB approved retrospective cohort study was performed with 28 suspected VGI patients from our institution. A blinded chart review categorized patients based on MAGIC criteria into "infected," "suspected infection," or "insufficient evidence" groups. Due to the MAGIC criteria's placement of a third outcome, "suspected infection," the results were dichotomized into two systems whereby "suspected infection" patients were considered as infected (S = I) or uninfected (S = NI). Both dichotomized systems from the MAGIC criteria were then compared to the clinical diagnosis (with surgical evidence when possible) from which sensitivity and specificity were calculated.ResultsA total of 15 patients (54%) presented with definitive VGI, two patients (7%) presented with suspicion for VGI, and 11 patients (39%) presented with insufficient evidence to suspect VGI; placement in these categories were determined by the MAGIC criteria at entry to the study. When using clinical diagnoses, 17 out of 28 had VGI (61%). When using the categorization system S = I, sensitivity was 88.2% and specificity of 100%, for S = NI, sensitivity dropped to 76.4%, but specificity remained at 100%. These results were recomputed using only 25 of the 28 patients who were good surgical candidates. Using this new surgical threshold and smaller cohort to compare MAGIC against, sensitivity was calculated to be 93.3% with a specificity of 100% when S = I. When S = NI, the sensitivity was calculated to be 86.7% with specificity remaining at 100%.ConclusionsThe MAGIC criteria provide excellent specificity and reasonable sensitivity for diagnosis of VGI for peripheral and aortic revascularization.

ObjectivesFemoral vein transposition (tFV) is a complex procedure that provides high patency rates for patients with exhausted upper-limb vascular access. Traditionally, the procedure involves a long single incision in the thigh to harvest the femoral vein, but this approach is associated with increased risks of local complications such as infections and haematomas. Skip incisions have shown to lower complication rates and shorten maturation times. We present an optimised, minimally invasive technique that transposes the femoral vein through three short skip incisions on the anterior thigh.MethodsWe present the technical details and outcomes of three patients who underwent femoral vein transposition (tFV) for haemodialysis access. Additionally, we conducted a literature review on lower-limb vascular access options for haemodialysis.ResultsPre-operative clinical and ultrasound assessments confirmed femoral vein transposition (tFV) eligibility. The procedure involved three short skip incisions along the medial thigh to harvest the femoral vein. Subcutaneous tunnelization was performed through the anterior thigh. The arteriovenous anastomosis was sized at 3-4 mm to minimise the risk of lower-limb steal syndrome. The average procedure duration was 120 min. Postoperative recovery was uneventful, with patients discharged an average of 6 days after surgery. Wound healing was satisfactory, and the access was cannulated approximately 3 weeks post-procedure.ConclusionsThis method reduces wound complications and significantly improves the comfort of patients and dialysis nursing staff by enhancing cannulation access and increasing the availability of puncture sites, thereby improving the overall patient care experience.

BackgroundPatients suffering from lower extremity venous ulcers typically undergo prolonged dressing changes, entailing extended treatment cycles and significant costs, creating an urgent need for effective continuous care. There is scarce literature reporting on the preferences and requirements for wound care within continuous care services for such conditions. Discrete choice experiments serve as an innovative method to elicit patient preferences, where the development of attributes and levels is a critically important process.ObjectiveTo identify attributes and levels patients with venous leg ulcers consider when making decisions about continued care services for venous leg ulcers.MethodsIn this study, we employed four steps to devise service features (i.e., attributes) and their potential manifestations (i.e., levels). Firstly, we conducted a systematic literature search with articles screened and content compiled by two researchers to identify possible service attributes. Secondly, we conducted in-depth interviews with patients suffering from venous leg ulcers to gather personal experiences and expectations for quality care, and used Nvivo11.0 for data management. Thirdly, focus group discussions were held to assess general viewpoints from various perspectives. Finally, expert meetings were organized to refine our research tools further. To narrow down the attributes to a manageable number for the discrete choice experiment, focus groups and expert meetings performed ranking exercises, calculating the average importance scores by dividing the total score by the number of participants and ranking attributes from highest to lowest average scores.ResultsThrough literature reviews, qualitative data acquisition, expert meetings, and ranking exercises, a total of six attributes were finalized, each with two to three levels. The attributes included: 1) service cost (Ave score: 4.7); 2) Mode of service delivery (Ave score: 4.5); 3) Service type (Ave score: 4.4); 4) Consistency of caregiver (Ave score: 4.4); 5) Category of service providers (Ave score: 4.3); and 6) Appointment scheduling (Ave score: 4.3). These attributes encompassed key aspects related to wound care in the continuous care services for patients with venous leg ulcers.ConclusionsThe mixed-methods approach adopted in this study has proven particularly suitable for identifying, refining, and selecting attributes and levels for discrete choice experiments. By leveraging the advantages and limitations of the four steps, and especially through qualitative data analysis, a more profound and comprehensive understanding of the attributes and levels was achieved. This approach has facilitated the practicality and accuracy in attribute construction, enhancing the overall efficacy of the DCE design.

BackgroundPeripheral artery disease (PAD) outcomes often rely on the expertise of individual vascular units, introducing potential subjectivity into disease staging. This retrospective, multicenter cohort study aimed to demonstrate the ability of artificial intelligence (AI) to provide disease staging based on inter-institutional expertise by predicting limb outcomes in post-interventional pedal angiograms of PAD patients, specifically in comparison to the inframalleolar modifier in the Global Limb Anatomic Staging System (IM GLASS).MethodsWe used computer vision (CV) based on the MobileNetV2 model, implemented via TensorFlow.js library, for transfer learning and feature extraction from 518 pedal angiograms of PAD patients with known 3-month limb outcomes: 218 salvaged limbs, 140 minor amputations, and 160 major amputations.ResultsAfter 43 epochs of training with a learning rate of 0.001 and a batch size of 16, the model achieved a validation accuracy of 95% and a test accuracy of 93% in differentiating salvaged limbs from amputations. In manual testing with 45 angiograms excluded from the training, validation, and test processes, the AI predicted mean limb salvage probabilities of 96% for actual salvaged limbs, 27% for minor amputations, and 17% for major amputations (p-value < .001). The correlation coefficient between the CV model-predicted outcome and the actual outcome for these 45 angiograms was 0.7, nearly five times higher than that between the IM GLASS pattern and the actual outcome (0.14).ConclusionComputer vision can analyze angiograms and predict disease outcomes, demonstrating a significant correlation between predicted and actual limb salvage rates, outperforming IM GLASS segmentation by a vascular specialist. It has the potential to provide immediate and precise treatment results during vascular interventions, tailored to (inter)institutional expertise, and enhance individualized decision-making.

ObjectivesMal-deployment of the thoracic endovascular aortic repair (TEVAR) stent graft during a frozen elephant trunk (FET) procedure for an acute type A aortic dissection (ATAAD) leads to devastating complications. We report a hemiarch replacement with TEVAR stent graft covering the aortic arch vessels salvaged through an endovascular approach.MethodsA 69-year-old man with ATAAD in 2018, status post-hemiarch repair with TEVAR, presented in 2023 with progressive dizziness/syncope and lower extremity hypertension with inability to tolerate anti-hypertensives. A CT scan revealed TEVAR stent graft coverage of the brachiocephalic, left common carotid (LCA), and left subclavian artery (LSA), with retrograde flow into the arch vessels through a false lumen fed by a dissection fenestration at the aortic bifurcation. Given an elevated peri-operative death and stroke risk with an open arch revision, we performed an in situ anterograde laser fenestration of his FET with LCA and LSA stenting via the Culotte technique.ResultsOn 1 year follow-up, the patient's dizziness has resolved, and he has maintained normotension via anti-hypertensives.ConclusionLaser fenestration and the Culotte technique can be used to salvage a TEVAR causing coverage of the arch vessels, showing that endovascular techniques can be a safe alternative for rescuing mal-positioned FETs.

ObjectivesCarotid stenosis plays a significant role in stroke burden. Surgical intervention in the form of carotid endarterectomy or carotid artery stenting is an important stroke risk reduction strategy. Careful patient selection with identification of high-risk individuals is crucial to operative planning given perioperative risks including stroke, myocardial infarction, and death. Machine learning (ML) is a subset of artificial intelligence (AI) consisting of mathematical algorithms that can learn from datasets to perform particular tasks. These algorithms offer a tool for prediction of patient outcomes by analysis of preoperative data leading to improved patient selection. This systematic review aims to assess the use of artificial intelligence in risk stratification for carotid endarterectomy and carotid artery stenting.MethodsPubMed, Web of Knowledge, EMBASE, and the Cochrane Library were systematically searched to identify any articles utilising artificial intelligence in predicting surgical outcomes in carotid endarterectomy or carotid artery stenting. After duplicate removal, all studies underwent independent title and abstract screening followed by quality assessment using the PROBAST tool. Data extraction was then carried out for synthesis and comparison of study outcomes including accuracy, area under receiver operator curve (AUC), sensitivity, and specificity.ResultsAfter duplicate processing, a total of 100 articles underwent title and abstract screening resulting in 11 clinical studies published between 2008 and 2023 that fit eligibility criteria. Surgical outcomes assessed included haemodynamic instability, shunt requirement, hyperperfusion syndrome, stroke, myocardial infarction, and death. Artificial intelligence models were able to accurately predict major adverse cardiovascular events (AUC 0.84), postoperative haemodynamic instability (AUC 0.86), shunt requirement (AUC 0.87), and postoperative hyperperfusion syndrome (AUC 0.95). However, many studies had a high risk of bias due to lack of external validation.ConclusionThis systematic review highlights the potential application of machine learning in prediction of surgical outcomes in carotid artery intervention. However, use of these tools in a clinical setting requires further robust study with use of external validation and larger patient datasets.

ObjectivesNon-pneumatic compression devices (NPCDs) rely on shape-memory alloy technology that allows patients to ambulate and remain active during lymphedema treatment. This study examines the effect of the NPCD on foot and ankle swelling.MethodsThis was a prospective, non-randomized study of patients with phlebolymphedema (venous insufficiency-related lymphedema) treated with a novel NPCD for 4 weeks. Ankle and foot circumference (cm), and volume measurements (ml water displacement using immersion) of the foot and ankle were obtained at enrollment, 2-weeks, and 4-weeks, and ambulation was tracked with a wearable exercise monitoring device.ResultsThis study included 13 patients (21 limbs). A significant reduction in circumference (ankle (-0.84 ± 0.22 cm, p < .01) and metatarsal bed (-0.55 ± 0.95, p < .01)) and volume (foot/ankle (-52 ± 22 mL, p = .032)) was observed. Patients reported a mean of 8100 steps per day (±6100).ConclusionsNPCD results in significant reduction in edema in the foot and ankle despite garments lacking a foot piece. Patients remained mobile while adhering to therapy.

PurposeTo report the 10-year follow-up of a patient managed with a custom-made fenestrated endograft, including a large fenestration for the preservation of a celiac trunk (CT) anatomic variation.Case reportIn 2014, a 75-year-old female was treated endovascularly for descending thoracic and visceral aortic pseudoaneurysms (PA). Due to a celiac trunk (CT) anatomic variation, consisting of separate origins of the hepatic and splenic artery, a custom-made four-fenestrated endograft was planned, including a large fenestration (18 × 10 mm) for CT preservation. Balloon-expandable covered stents bridged all target vessels (TVs), except the large fenestration, which was left unstented. Imaging at 10 years showed patency of TVs, no signs of instability or device migration and complete PA exclusion.ConclusionUsing a patient-specific device for complex endovascular aortic repair provided favorable extended follow-up outcomes. An unstented large fenestration remained patent during 10 years of follow-up. This case highlights the importance of individualized approach in complex aortic pathologies.

ObjectivesWe aim to evaluate the safety and effectiveness of the Zenith Dissection Endovascular System (ZDES; Zenith TX2 Dissection Endovascular Graft with Pro-Form and Zenith Dissection Endovascular Stent), which uses a proximal stent graft along with a distal bare metal stent compared to traditional stent grafts in the repair of acute, complicated Type B Aortic Dissection (AcTBAD).MethodsThis retrospective study reviews the medical charts of 32 patients with AcTBAD repaired at a single urban academic medical center. 16 of these AcTBAD cases were repaired with the ZDES (87.5% male; mean age, 63.1 years), and 16 were repaired with stent grafts (62.5% male; mean age, 60.6 years). Outcomes include 30-day morbidity, false lumen thrombosis and aneurysmal degeneration at 6 months and 1 year, thirty-day and three-year mortality, and freedom from secondary surgical intervention.ResultsTwelve total postoperative adverse events occurred in the ZDES group compared to 37 in the stent graft group (p = .046). The notable adverse events included renal insufficiency (p = .04) and refractory pain (p = .002). At the 6-month follow-up, complete or partial false lumen thrombosis was noted in 100% of patients (16/16) in the ZDES group and 56.3% of patients (9/16) in the stent graft group (p < .01). At the 12-month follow-up, complete or partial thrombosis of the false lumen was noted in 1 additional patient in the stent graft group for a total of 62.6% of patients (10/16; p = .018). Growth (>5 mm) of the maximum transaortic diameter at 12 months was noted in 33.3% of patients (5/15) in the ZDES group and 54% of patients (7/13) in the stent graft group (p = .45). Thirty-day mortality occurred in one patient in the ZDES group and no patients in the stent graft group (p = 1.0). Three-year mortality occurred in four patients in the stent graft group and no patients in the ZDES group (p = .11). Although more patients in the ZDES group underwent secondary intervention to address aortic growth, there were no differences between the two groups in freedom from any secondary intervention at 365 days post-procedure (p = .13).ConclusionsPatients treated with ZDES had fewer post-procedural adverse events. Although the use of the ZDES had favorable false lumen thrombosis at 6 and 12 months, the device was not associated with a statistically significant change in transaortic diameter. Our single institution study demonstrated that ZDES has favorable clinical outcomes, but further investigation is needed to better understand aortic remodeling in the distally stented regions. Additionally, further research is necessary to explore the incidence of endoleaks associated with ZDES to optimize long-term patient outcomes.

ObjectivesAnemia is known to be prevalent in patients with diabetic foot ulcers, but such was not documented in those who required lower extremity amputations (LEAs). In this high-risk population, preoperative anemia could be an additional risk factor for postoperative morbidity and mortality. This study attempts to address the knowledge gap related to the preoperative hemoglobin (Hg) level and anemia prevalence in patients admitted for diabetic LEA.MethodsUsing a cross-sectional design, the primary outcomes were defined as the mean preoperative Hg level and anemia frequency. Mean differences and sex-based results were calculated and compared between three categories: major, midfoot, and forefoot amputation groups. Correlation between Hg level and serum creatinine was set as a secondary outcome.ResultsA total of 141 patients comprising 192 amputation cases were included. The mean Hg value for the whole sample was 10.6 ± 1.8 g/dl. Only 18 patients (9.7%) had a normal Hg level and 174 (90.3%) were anemic: 90 cases (46.8%) with mild anemia, 76 (40.8%) with moderate anemia, and 8 cases (4.3%) with severe anemia. No significance was found between mean Hg values of the three groups or between sex groups. A significant negative correlation between the levels of serum creatinine and Hg was found (p = .037).ConclusionsAn overwhelming majority of patients admitted for diabetic LEA were anemic. Since anemia could impede limb perfusion and induce higher postoperative mortality rate, adjusting this confounder could be justified. Future research should aim to evaluate the impact of preoperative blood component transfusion on postoperative complications following diabetic LEA.