European Journal of Vascular and Endovascular Surgery最新文献

Objective: Over a dozen ruptured abdominal aortic aneurysm (rAAA) mortality risk prediction models currently exist; however, lack of external validation limits their applicability. This study aimed to evaluate the accuracy of eight common rAAA mortality risk prediction models in a large, contemporary, external validation cohort.

Methods: A retrospective review of rAAA repairs at a multicentre integrated regional healthcare system with large central quaternary referral facility (2010 - 2020) was performed. Eight models were used to predict 30 day post-operative death, including the Updated Glasgow Aneurysm Score (GAS), Vascular Study Group of New England rAAA Risk Score, Harborview Preoperative rAAA Risk Score, Modified Harborview Risk Score, Vancouver Scoring System (VSS), Artificial Neural Network Score, Dutch Aneurysm Score, and Edinburgh Ruptured Aneurysm Score. The models were assessed for discrimination, calibration, and clinical utility using receiver operating characteristic curves (area under the curve [AUC]), Hosmer-Lemeshow χ² test, Brier scores, and decision curve analysis. The proportion of unexpected survivors (survival despite > 80% predicted 30 day mortality) to expected deceased was compared across calculators, and both groups were compared using the model demonstrating the highest unexpected survival frequency.

Results: A total of 315 rAAA repairs were included (mean age 73.6 ± 10.0 years; 72.1% male; 49.8% open repair) with a 30 day mortality rate of 32.1%. Three models had fair discrimination (AUC ≥ 0.70), with GAS having the highest AUC (0.74, 95% confidence interval 0.68 - 0.79). All models demonstrated poor to adequate calibration. Using VSS, unexpected survivors (n= 25) had less pre-operative shock (72% vs. 96%; p=.050) and statistically significantly less coagulopathy (median international normalised ratio 1.2 [interquartile range 1.1, 1.5] vs. 1.8 [1.3, 2.2]; p= .015) compared with expected deceased (n=23).

Conclusion: Current rAAA risk prediction models demonstrated fair discrimination and poor to adequate calibration. These findings suggest that existing risk prediction models have not sufficiently captured important physiological characteristics associated with rAAA mortality and should be cautiously applied to clinical practice.

Objective: To assess the prevalence and risk factors for the occurrence of myocardial injury (MIn) in patients undergoing carotid revascularisation and to assess whether elevated troponin levels can predict the occurrence of adverse cardiac events and short term mortality.

Methods: This prospective, multicentric cohort study included 527 patients subjected to carotid revascularisation from June to October 2023. High sensitive cardiac troponin I and/or T were assessed pre-operatively, and 8 and 24 hours post-operatively. Myocardial injury was defined as at least one value of cardiac troponin above the 99th percentile upper reference limit.

Results: A total of 440 patients (83.5%) underwent carotid endarterectomy and 87 (16.5%) patients underwent carotid artery stenting (85 under local infiltrative and two under general anaesthesia). Of the 527 patients, 87 (16.5%) were operated under general, 355 (67.4%) under regional anaesthesia, and the remaining 85 (16.1%) received local anaesthetic infiltration. Pre-operatively, MIn was noted in 7% of patients, and the overall prevalence of post-operative MIn was 12.3%. Age ≥ 81 years, pre-operative haemoglobin 10 - 13.9 g/dL and glomerular filtration rate 15 - 30 mL/min/1.73 m² were independent predictors for the occurrence of post-operative MIn (OR 2.84, 95% CI 1.17 - 6.91, p = .021; OR 1.95, 95% CI 1.01 - 3.76, p = .046; OR 11.46, 95% CI 2.37 - 55.33, p = .002, respectively). Myocardial infarction (MI) developed in seven patients (1.3%), more frequently in those who had MIn 8 hours and 24 hours following surgery (71.4% vs. 10.4%, p = .001; 71.4% vs. 10.2%, p = .001, respectively).

Conclusion: Myocardial injury is common in patients undergoing carotid revascularisation; to reduce the rate of MIn, special attention should be paid to those patients with risk factors identified in the present study. Long term (one and two year) follow up of the TROPICAR patients will provide additional insight into the association between peri-operative MIn and MI/mortality.

Objective: The aim of this study was to assess the results of an off the shelf inner branched thoraco-abdominal endograft for treating aortic pathologies, with a specific focus on comparing outcomes between antegrade and retrograde approaches for target vessel (TV) cannulation.

Methods: This was a national, physician initiated, multicentre, observational study. Data from a registry on patients treated with the E-nside endograft were prospectively gathered. Patients were divided into two groups based on the type of endovascular approach for TV cannulation. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Results: From September 2020 to February 2024, 166 procedures were collected, of which 128 (77.1%) utilised a TV cannulation with an antegrade upper extremity approach, while 38 (22.9%) employed a retrograde femoral approach. There were no statistically significant differences in terms of bridging stent choice (balloon expandable only, 69.4% vs. 73.7%; self expandable only, 12.9% vs. 7.9%; mixed configurations, 17.7% vs. 18.4%; p = .68). The mean operative time ± standard deviation was longer in case of retrograde approach (282 ± 90 minutes vs. 313 ± 155 minutes; p = .006), but fluoroscopy time, dose area product, and the amount of contrast medium injected were similar. Six cases of post-operative stroke were reported in the antegrade group (4.7% vs. 0%; p = .17). The 30 day TV related technical success was 94.5% and 94.7%, respectively, for antegrade and retrograde approaches (p = .96). Mean follow up was 14.4 ± 11.3 months (median 12.5 months). Kaplan-Meier estimates (with 95% confidence interval [CI]) at twelve months revealed similar overall survival (87.7%, 95% CI 81 - 95% vs. 91.1%, 95% CI 82 - 100%; log rank = .009, p = .92). Competing risk analysis revealed similar one year estimates of TV instability and TV related re-intervention between groups both in patient centred and TV centred analyses.

Conclusion: A total transfemoral retrograde approach for TV cannulation of inner branches proved to be effective and was not associated with any neurological events.

Objective: This study aimed to create a novel prediction model (AMPREDICT MoRe) that predicts death and re-amputation after dysvascular amputation, which overcomes prior implementation barriers by using only predictors that are readily available in the electronic health record (EHR).

Methods: This was a retrospective cohort study of 9 221 patients with incident unilateral transmetatarsal, transtibial, or transfemoral amputation secondary to diabetes and/or peripheral arterial disease identified in the Veterans Affairs Corporate Data Warehouse between 1 October 2015 and 30 September 2021. The prediction model evaluated factors falling into several key domains: prior revascularisation; amputation level; demographics; comorbidities; mental health; health behaviours; laboratory values; and medications. The primary outcome included four categories: (i) no death/no re-amputation (ND/NR); (ii) no death/re-amputation (ND/R); (iii) death/no re-amputation (D/NR); and (iv) death/re-amputation (D/R). Multinomial logistic regression was used to fit one year post-incident amputation risk prediction models. Variable selection was performed using LASSO (least absolute shrinkage and selection operator), a machine learning methodology. Model development was performed using a randomly selected 80% of the data, and the final model was externally validated using the remaining 20% of subjects.

Results: The final prediction model included 23 predictors. The following outcome distribution was observed in the development sample: ND/NR, n = 4 254 (57.7%); ND/R, n = 1 690 (22.9%); D/NR, n = 1 056 (14.3%); and D/R, n = 376 (5.1%). The overall discrimination of the model was moderately strong (M index 0.70), but a deeper look at the c indices indicated that the model had better ability to predict death than re-amputation (ND/NR vs. ND/R, 0.64; ND/NR vs. D/NR, 0.78; grouped ND vs. D, 0.79 and NR vs. R, 0.67). The model was best at distinguishing individuals with no negative outcomes vs. both negative outcomes (ND/NR vs. D/R, 0.82).

Conclusion: The AMPREDICT MoRe model has been successfully developed and validated, and can be applied at the time of amputation level decision-making. Since all predictors are available in the EHR, a future decision support tool will not require patient interview.