European Journal of Vascular and Endovascular Surgery最新文献

Objective: This study aimed to retrospectively apply a modified Global Limb Anatomic Staging System (GLASS) framework of infrainguinal arterial disease to patients enrolled in the Best Endovascular vs. Best Surgical Therapy in patients with Critical Limb Ischemia (BEST-CLI) trial to assess its validity for limb based outcomes and its utility in guiding the choice between endovascular therapy (ENDO) and open surgical bypass (OPEN).

Methods: This was a secondary analysis of the BEST-CLI clinical trial dataset. The BEST-CLI trial randomised 1 830 patients with chronic limb threatening ischaemia to ENDO or OPEN revascularisation. Baseline arterial anatomy from case report form data was evaluated using a modified GLASS construct to classify femoropopliteal and infrapopliteal disease severity. Kaplan-Meier analyses and Cox proportional hazards models were used to assess associations between modified GLASS stage, treatment modality, and outcomes including major adverse limb events (MALEs), re-intervention, and amputation.

Results: Modified GLASS stages 1, 2, and 3 were assigned to 12.4%, 24.5%, and 63.1% of trial participants, respectively. The technical failure rate in patients in the ENDO group was 11.1%, 15.4%, and 17.5% in modified GLASS stages 1, 2, and 3, respectively. In ENDO, higher GLASS stage was associated with worse MALE free survival and increased re-intervention risk. No association between GLASS stage and limb based outcomes was observed in OPEN. When comparing ENDO vs. OPEN using Cox models with inverse propensity weighting, OPEN conferred superior limb outcomes in modified GLASS stage 2 and 3 patients, with fewer major re-interventions (hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.15 - 0.40; p < .001 and HR 0.37, 95% CI 0.29 -0.47; p < .001) and amputations (HR 0.57, 95% CI 0.38 - 0.87; p = .009 and HR 0.62 95% CI 0.47 - 0.81; p = .001). Modified GLASS stage was not associated with all cause death in either group.

Conclusion: This study validated GLASS, even in a modified format, as a predictor of limb based outcomes in endovascular therapy and highlighted its limited relevance in predicting outcomes after open bypass. GLASS should be incorporated into clinical decision making and trial designs, particularly to guide the revascularisation strategy in patients with complex occlusive disease (GLASS stage 3).

Objective: To compare high ligation and stripping (HLS), endovenous laser ablation (EVLA), and ultrasound guided foam sclerotherapy (UGFS) for symptomatic great saphenous vein (GSV) reflux in the long term, given the limited comparative data beyond ten years.

Methods: Patients with symptomatic GSV reflux were randomised (1:1:1) to undergo HLS, EVLA, or UGFS. One hundred and ninety-six patients treated at Helsinki University Hospital were invited to 14 year follow up. Primary outcomes were above knee GSV reflux and GSV re-intervention rates. Secondary outcomes included quality of life.

Results: Of 233 randomised patients, 214 were included. UGFS increased the risk of GSV reflux recurrence compared with both HLS (risk ratio [RR] 11.7, 95% confidence interval [CI] 1.6 - 85.6) and EVLA (RR 5.0, 95% CI 1.5 - 16.6; 30.8% [12 of 39] after UGFS vs. 2.6% [1 of 38] and 6.1% [3 of 49] after HLS and EVLA, respectively; overall p < .001). UGFS was associated with a higher risk of GSV re-interventions compared with HLS (RR 4.3, 95% CI 1.8 - 10.2) and EVLA (RR 6.9, 95% CI 2.6 - 18.4; 56.4% for UGFS vs. 13.2% for HLS and 8.2% for EVLA; overall p < .001). Neovascularisation rates did not differ between the treatments (29.0%, 22.5%, and 23.1% for HLS, EVLA, and UGFS, respectively; overall p = .76). Aberdeen Varicose Vein Questionnaire scores were comparable across the groups (median [interquartile range] 8.9 [3.7, 13.3] in HLS, 6.1 [0.8, 12.2] in EVLA, and 8.8 [4.1, 13.4] in UGFS, with median differences of +2.8 [HLS vs. EVLA], +0.1 [HLS vs. UGFS], and -2.7 [EVLA vs. UGFS]; overall p = .21).

Conclusion: UGFS demonstrated inferior outcomes in terms of GSV recurrent reflux and re-intervention rates compared with both HLS and EVLA, whereas HLS and EVLA showed comparable performance across these outcomes. Long term quality of life was comparable across all groups.

Objective: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with descending thoracic and thoraco-abdominal aortic pathologies, in succession to the 2017 version, with the aim of assisting physicians and patients in selecting the best management strategy.

Methods: The guidelines are based on scientific evidence complemented with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS grading system, where the strength (class) of each recommendation is graded from I to III and the level of evidence from A to C.

Results: One hundred and twenty-nine recommendations have been issued across the following main topics: (1) acute thoracic aortic syndrome; (2) chronic type B aortic dissection; (3) descending thoracic and thoraco-abdominal aortic aneurysms; (4) ruptured descending thoracic and thoraco-abdominal aortic aneurysms; and (5) blunt thoracic aortic injury. Additional topics include genetic aortopathy, floating thrombus and shaggy aorta, inflammatory aortitis, mycotic aortic aneurysms, coarctation of the aorta, aberrant subclavian artery, and service standards such as surgical volume, imaging, risk assessment, and optimisation. Special considerations include pregnancy, left subclavian artery revascularisation, spinal cord ischaemia, stroke prevention, vascular access, and the patient's perspective. A final chapter addresses unresolved issues.

Conclusion: These clinical practice guidelines provide comprehensive, up to date advice to clinicians and patients on the management of descending thoracic and thoraco-abdominal aortic pathologies.