European Journal of Vascular and Endovascular Surgery最新文献

Objective: The incidence and related factors of spontaneous occlusion of a patent inferior mesenteric artery (IMA) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) without pre-emptive embolisation remain unclear. This study aimed to elucidate the incidence, clinical implications and predictors of spontaneous IMA occlusion after EVAR.

Methods: This was a single centre, retrospective cohort study. Patients who underwent elective EVAR between 2007 and 2022 were categorised into three groups (group 1, spontaneous IMA occlusion; group 2, patent IMA with no type II endoleak (T2EL) from IMA; group 3, T2EL from IMA). Endpoints were the incidence of spontaneous IMA occlusion, sac enlargement, freedom from re-intervention, and overall survival after EVAR.

Results: Of 372 cases of elective EVAR for AAA, 230 who had patent IMA pre-operatively were analysed, after excluding 127 with pre-occluded IMA and 15 who underwent pre-emptive IMA embolisation. Spontaneous IMA occlusion occurred in 101 patients (43.9%). Sac enlargement rate was lower in group 1 than in groups 2 and 3. Freedom from re-intervention rate was higher in group 1 than in group 3 but did not differ between groups 1 and 2. Multivariate analysis revealed the absence of antiplatelet therapy, pre-operative higher haematocrit, absence of concomitant iliac artery aneurysm, posterior thrombus in the sac, and use of Endurant as predictors associated with spontaneous IMA occlusion. Spontaneous IMA occlusion was observed in 7.1% and 77.5% of patients with zero and four or five predictors, respectively.

Conclusion: Spontaneous IMA occlusion occurred in nearly half of cases and was associated with positive clinical outcomes. In patients with a high prediction of spontaneous IMA occlusion, pre-emptive IMA embolisation may be omitted.

Objective: While ambulatory capacity is a readily assessable clinical indicator of functional status, its association with outcomes after endovascular aneurysm repair (EVAR) remains underexplored. This study aimed to investigate the association between pre-operative ambulatory status and outcomes following elective EVAR.

Methods: A retrospective review of the multi-institutional Vascular Quality Initiative database was conducted for all patients who underwent elective infrarenal EVAR from 2009 - 2022. Patients were categorised into independent ambulation and impaired ambulation groups. A propensity score matched analysis was performed to produce two well matched cohorts in a 1:1 ratio without replacement. The primary outcome was 30 day death. Secondary outcomes included one year survival and in hospital major complications.

Results: Among 11 474 patients, 10 539 (91.8%) were independently ambulatory pre-operatively. Propensity score matching resulted in 885 matched pairs. The impaired ambulation group, although older (mean 77.6 vs. 76.3 years; p = .001), showed comparable baseline characteristics. Post-operatively, the impaired ambulation group had higher cumulative in hospital complications and death as well as 30 day death. Even after adjustment for age, impaired pre-operative ambulation was associated with increased in hospital and 30 day death (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.26 - 3.95; p = .006). Multivariable analysis demonstrated increasing cumulative risk of 30 day death in the setting of impaired pre-operative ambulatory status with age > 75 years requiring post-operative red blood cell transfusion > 2 units (HR 5.75, 95% CI 2.09 - 15.88; p < .001). Beyond 30 days, impaired pre-operative ambulation was not associated with increased one year death (HR 1.09, 95% CI 0.81 - 1.48; p = .570).

Conclusion: Among patients who underwent elective infrarenal EVAR in this matched analysis, impaired pre-operative ambulatory capacity was associated with an increased risk of in hospital and 30 day death, further compounded by advanced age and post-operative transfusion. As such, a threshold higher than the traditional size criteria should be considered in shared decision making when determining options for the management of abdominal aortic aneurysm in this high risk cohort.

Objective: The prevalence of chronic limb threatening ischaemia (CLTI) is increasing worldwide, resulting in the need for more patients undergoing revascularisation, especially for below the knee pathology. Nevertheless, prospective data on below the knee endovascular interventions are lacking. The aim of the study was to provide large scale, real world data on procedural and short term outcomes of popliteal and infrapopliteal endovascular interventions in patients with CLTI.

Methods: This study is an analysis of the first 1 000 interventions of the Dutch Chronic Lower Limb-Threatening Ischemia Registry (THRILLER). It includes all patients with CLTI undergoing popliteal or infrapopliteal endovascular revascularisation in seven hospitals in the Netherlands. The primary outcomes were limb salvage and amputation free survival (AFS) at three months estimated with the Kaplan-Meier method. Secondary outcomes were procedural complications and primary patency.

Results: Between February 2021 and July 2023, 1 000 endovascular procedures were performed in 840 patients (947 limbs), treating 486 popliteal and 1 209 tibial lesions. Wound, Ischemia, and foot Infection (WIfI) stages 1 - 4 were present in 16.8%, 17.2%, 25.4%, and 40.6% of the limbs, respectively. Technical success was hampered by arterial perforation, acute thrombosis, and distal embolisation in 8.7%, 1.0%, and 2.3% of the interventions, respectively. Limb salvage was 100.0%, 96.9%, 94.9%, and 86.1% (p < .001), whereas AFS was 96.9%, 93.2%, 86.6%, and 76.4% for WIfI stages 1 - 4 at three months (p < .001), respectively. Primary patency at the 6 - 8 week visit was 86.4% for popliteal and 74.3% for tibial lesions, respectively.

Conclusion: THRILLER presents a large prospective database on outcomes of CLTI endovascular interventions. Popliteal and infrapopliteal endovascular revascularisation for CLTI is safe. Interventions with initial technical success have high rates of limb salvage and survival at three months. The WIfI classification provides a reliable instrument to predict limb salvage and AFS independently at three months.