European Journal of Vascular and Endovascular Surgery最新文献

Objective: This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting.

Data sources: PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022.

Review methods: Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence.

Results: Thirty nine studies reporting outcomes in 1 539 patients were included in the meta-analysis. Primary patency up to one year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after one year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low.

Conclusion: Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to one year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after one year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programs.

Objective: Segmenting the aorta into zones based on anatomical landmarks is a current trend to better understand interventions for aortic dissection or aneurysm. However, comprehensive reference values for aortic zones are lacking. The aim of this study was to establish reference values for aortic size using a fully automated deep learning based segmentation method.

Methods: This retrospective study included 704 healthy adults (mean age 50.6 ± 7.5 years; 407;57.8%] males) who underwent contrast enhanced chest computed tomography (CT) for health screening. A convolutional neural network (CNN) was trained and applied on 3D CT images for automatic segmentation of the aorta based on the Society for Vascular Surgery and Society of Thoracic Surgeons classification. The CNN generated masks were reviewed and corrected by expert cardiac radiologists.

Results: Aortic size was significantly larger in males than in females across all zones (zones 0 - 8, all p < .001). The aortic size in each zone increased with age, by approximately 1 mm per 10 years of age, e.g., 25.4, 26.7, 27.5, 28.8, and 29.8 mm at zone 2 in men in the age ranges of 30 - 39, 40 - 49, 50 - 59, 60 - 69, and ≥ 70 years, respectively (all p < .001).

Conclusion: The deep learning algorithm provided reliable values for aortic size in each zone, with automatic masks comparable to manually corrected ones. Aortic size was larger in males and increased with age. These findings have clinical implications for the detection of aortic aneurysms and other aortic diseases.

Objective: This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented.

Methods: In this single centre prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m², functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure.

Results: Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were four days (IQR 3, 5), 190 minutes (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were blood transfusion, re-intervention, and ileus over three days. Overall survival was: 98.2% at one year, 85.0% at five years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at one year, 94.1% at five years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals.

Conclusion: The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol in other vascular centres.

Objective: Emergent complex abdominal aortic diseases are challenging to treat. During in situ laser fenestration (ISLF), aortic branches are covered and flow is restored with in situ fenestration of the stent graft, with promising midterm results. This study aimed to expand on the limited body of knowledge of midterm outcomes of ISLF in renovisceral aortic pathology in a multicentre setting.

Methods: Retrospective pooled data on consecutive ISLF cases of visceral aortic stent grafts undertaken from 2018 - 2023 in three aortic centres were analysed. Technical success was defined as successful vascularisation with a bridging stent graft and acceptable final angiographic series without signs of endoleak related to the bridging stent graft. Target vessel instability was defined as an endoleak related to the bridging stent graft, disconnection, kink, stenosis, occlusion of bridging stent, re-intervention on bridging stent graft, or rupture or death related to the bridging stent graft.

Results: A total of 65 ISLFs were performed in 34 patients, with a mean age 74 years. The procedure was acute in 79%, and 35% were ruptures. Pre-stenting was performed on 56 target vessels (86%). Four patients (12%) died within 30 days; all presented with a rupture. Technical success was achieved in 61 of 65 (94%) ISLFs. All failed cannulations were in the renal arteries: three due to difficult angulations and one dissected during cannulation. Median follow up was 16 (interquartile range 5, 22) months. Cumulative survival at six months, one year, and two years was 88%, 80%, and 72%, respectively. In total, six (10%) target vessel instabilities were detected: two (3%) type III endoleaks, and four (7%) stent stenosis; all required re-lining. Freedom from target vessel instability at six months until the end of follow up was 89%. On the latest follow up scan, all successfully deployed ISLF bridging stents were patent (primary assisted patency 100%, 61 of 61) without signs of endoleak type 3.

Conclusion: In situ laser fenestration is a promising tool for emergent endovascular procedures in complex anatomies.

Objective: Major amputation and death are significant outcomes after lower limb revascularisation for chronic limb threatening ischaemia (CLTI), but there is limited evidence on their association with the timing of revascularisation. The aim of this study was to examine the relationship between time from non-elective admission to revascularisation and one year outcomes for patients with CLTI.

Methods: This was an observational, population based cohort study of patients aged ≥ 50 years with CLTI admitted non-electively for infra-inguinal revascularisation procedures in English NHS hospitals from January 2017 to December 2019 recorded in the Hospital Episode Statistics database. Outcomes were death and ipsilateral major amputation rate at one year. Logistic regression models were fitted to explore the relationship between time to revascularisation and death, adjusted for patient and admission factors. For major amputation, multinomial logistic regression models were used to account for the competing risk of death.

Results: A total of 10 183 patients (median age 75 years) were included in the analysis, of which 67.1% (n = 6 831) were male and 57.6% had diabetes. In patients with tissue loss, the unadjusted one year mortality rate was 30.0% (95% confidence interval [CI] 28.9 - 31.0%), and for every one day increase in time from admission to revascularisation, the adjusted odds of one year mortality increased by 3% (odds ratio 1.03, 95% CI 1.02 - 1.04). In the absence of tissue loss, the unadjusted one year mortality rate was 19.9% (95% CI 18.4 - 21.4%) and there was no evidence of an association with time to revascularisation. There was also no significant association between the time to revascularisation and risk of ipsilateral major amputation at one year irrespective of tissue loss.

Conclusion: Patients undergoing infra-inguinal revascularisation during non-elective admissions for CLTI have high one year major amputation and mortality rates. Longer time from admission to revascularisation was independently associated with higher mortality in patients with tissue loss, but not in those without.