European Journal of Vascular and Endovascular Surgery最新文献

Objective: To define and characterise the epidemiology, management, and outcomes of vascular trauma in the UK and Ireland following the introduction of a national major trauma network.

Methods: A retrospective observational study of The Trauma Audit and Research Network registry. Patients with traumatic vascular injury between 2013 and 2020 were analysed (n = 8 357). Demographics, injury descriptors, severity score, patient management, and outcomes were analysed.

Results: The case volume increased 40.2% between 2013 (n = 780) and 2020 (n = 1 094). Median patient age was 40.6 years, and over two thirds (n = 5 758) of injuries occurred following blunt trauma. Over one half of patients were admitted in haemorrhagic shock, two thirds presenting outside normal working hours (17:00 - 08:00). From nearly 9 000 vessel injuries, 7 136 (80.6%) were arterial; the aorta was the most frequently involved vessel (n = 1 115). Interventions were carried out in 3 338 (39.9%) patients, 2 639 (73.8%) via open surgery, with a median time to theatre of 3.3 hours. Interventional radiology procedures included 616 embolisations and 319 primary stentings. The aorta was the most common site for intervention outside the extremities, 250 (88.3%) of which were stented. Overall and early mortality rates significantly fell during the study from 15.9% and 8.1% in 2013 to 11.1% and 2.9% in 2020 (r = -0.82, r = -0.90, p < .010), respectively. Median critical care length of stay was 5 days; overall hospital stay for all patients was 12 days.

Conclusion: Following the transition towards major trauma networks, overall and early vascular trauma mortality significantly reduced. Co-operative development of national vascular and trauma registries to capture data relevant to quality improvement activity is needed to inform and shape future practice.

Objective: Inguinal incision is the most common vascular surgery incision and is associated with a high rate of surgical site infections (SSIs). The objective of this study was to determine whether intradermal suture leads to a lower SSI rate compared with metal staples.

Methods: A multicentre, open label, superiority randomised controlled trial was conducted from March 2018 until November 2021 in three Finnish hospitals (ClinicalTrials.gov ID: NCT03468621). Patients with scheduled elective vascular surgery with isolated exposure of the femoral vessels from a longitudinal incision, i.e., femoral endarterectomy, femoral cutdown for endovascular aortic repair, and femoropopliteal or femorofemoral crossover bypass procedure using synthetic graft, were screened for eligibility. Patients were randomised with 1:1 allocation to undergo skin closure with metal staples or continuous intradermal suture. The primary outcome was 30 day SSI rate. SSI was defined according to the US Centers for Disease Control and Prevention (CDC). Secondary outcomes included incision dehiscence and lymphatic leak or seroma.

Results: A total of 300 patients aged 54 - 94 years were enrolled (mean age ± standard deviation, 73.4 ± 8.0 years; 217; 72.3% male), with 148 patients randomised to skin closure with intradermal suture and 152 patients to skin closure with metal staples. The SSI rate was 10.1% (15/148) after intradermal suture and 15.8% (24/152) after metal staples (relative risk [RR] 0.64, 95% confidence interval [CI] 0.35 - 1.17; p = .15). The rate of seroma and lymph leak was 12.8% (19/148) and 21.1% (32/152) in the intradermal suture and metal staple groups, respectively (RR 0.6, 95% CI 0.4 - 1.0; p = .060). The rate of inguinal incision complications (infection or dehiscence) was 13.5% (20/148) and 19.7% (30/152) in the intradermal suture and metal staple groups, respectively (RR 0.7, 95% CI 0.4 - 1.2; p = .15).

Conclusion: In patients undergoing elective vascular surgery with primary isolated exposure of the femoral vessels, skin closure with intradermal suture did not reduce the SSI rate compared with the use of metal staples.

Objective: The aim of this study was to report the findings of transcranial duplex (TCD) evaluation of petrous internal carotid artery (ICA) flow during transcarotid artery revascularisation (TCAR). Thirty day clinical results were also evaluated.

Methods: A two centre database of all consecutive patients who had TCD evaluation of the petrous segment of the ICA during TCAR with a modified approach using the Neuroguard IEP (Contego Medical, Raleigh, NC, USA) three in one device and selective flow reversal was reviewed retrospectively. This novel carotid stent has an integrated embolic protection (IEP) system, and the procedure has been termed TCAR-IEP. The study primary endpoint was the achievement or not of flow reversal, and secondary endpoints were procedural technical success and 30 day stroke and or death.

Results: Between January and May 2023, 22 consecutive patients (mean age 72 years; 16 [73%] males) underwent TCAR-IEP with concomitant TCD evaluation of the ipsilateral petrous ICA. In 16 of these patients (73%) there was a sufficient temporal bone window to allow for an adequate peri-operative duplex scan of the petrous segment of the ICA. After common carotid artery (CCA) clamping and side port opening for pressure differential augmentation and despite the presence of retrograde flow in an 8 F carotid artery sheath in all patients, only eight patients (50%) demonstrated flow reversal in the ipsilateral petrous ICA. Technical success was 100%. No major strokes or death were observed in the first 30 days post-intervention.

Conclusion: In this study, distal ICA flow reversal was not present during TCAR for a significant proportion of patients despite retrograde flow being visually observed in the CCA sheath. Addition of distal embolic protection in all patients appears reasonable for effective stroke risk reduction.

Objective: The aim of this study was to evaluate and compare methods that identify patients at low risk of developing complications after endovascular aortic aneurysm repair (EVAR) and thus would not require surveillance in the first post-operative years.

Methods: This was a retrospective, single centre, cohort study including all patients after elective infrarenal EVAR with both immediate post-operative and one year computed tomography angiography (CTA) imaging. Patients were categorised by adherence to instructions for use (IFU), adequate seal, and absence of endoleak (method A1), and without high risk features (method A2) on the first post-operative CTA. Additionally, these patients were dichotomised based on aneurysm sac shrinkage at one year (> 5 mm maximal diameter reduction, method B). Outcomes were graft related adverse events and all cause death. Negative predictive value (NPV) was utilised to compare risk classifications.

Results: Of 422 eligible patients, 297 underwent the required imaging for classification: 140 (47.1%) and 109 (36.7%) patients were classified as low risk based on methods A1 and A2, respectively, while 147 (49.5%) were assumed low risk based on method B. The five year cumulative incidence of adverse events in low risk patients according to method A1 was 14.6% (95% confidence interval [CI] 8.5 - 20.9%), similar to method A2 (16.1%, 95% CI 8.8 - 23.4%) and method B (15.4%, 95% CI 9.3 - 21.5%). The five year median NPV for adverse events of method A1 was 85.2% (95% CI 79.7 - 90.8%), comparable with method A2 (83.8%, 95% CI 76.9 - 90.3%; p = .37) and method B (84.7%, 95% CI 79.4 - 89.5%; p = .87). Significantly higher NPVs were found by combining method A1 or A2 with method B, with median values ≥ 95% up to four years after EVAR. The five year NPV for death did not differ between methods (five year NPV_{method A1}, 81.7%, 95% CI 76.6 - 86.5%).

Conclusion: Refraining from imaging in the first five years after EVAR in patients treated within IFU and with a favourable post-operative CTA would have failed to detect important complications at an early stage. It is proposed to combine the post-operative CTA and sac shrinkage at one year in order to stratify post-EVAR surveillance. No benefit was found in considering the high risk features suggested in the European Society for Vascular Surgery (ESVS) guidelines.