European Journal of Vascular and Endovascular Surgery最新文献

Objective: Although sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective treatments, their use may be associated with increased risk of lower limb amputation. Moreover, no studies have reported on their clinical safety and efficacy in patients with chronic limb threatening ischaemia (CLTI). Therefore, this multicentre retrospective observational study evaluated their clinical efficacy in diabetic patients with CLTI who underwent endovascular therapy (EVT).

Methods: Eligible patients with diabetes and CLTI were retrospectively identified between January 2021 and December 2023 from a multicentre Japanese registry of EVT. These patients were divided into two groups based on whether they received treatment with SGLT2 inhibitors. The clinical safety and efficacy of SGLT2 inhibitors was evaluated after propensity score matching (PSM). The primary outcome was freedom from major amputation within 1 year. Secondary endpoints were amputation free survival, all cause mortality, wound healing, cardiovascular mortality, and infection related mortality within 1 year.

Results: Among 257 patients, 51 matched pairs were analysed after PSM, with no baseline differences between groups. One year freedom from major amputation was similar (94.0% vs. 86.8%; p = .30), whereas amputation free survival was statistically significantly higher in the SGLT2 inhibitor group (88.3% vs. 71.3%; p = .030). All cause mortality was also lower with SGLT2 inhibitors (4.7% vs. 18.7%; p = .030). Wound healing (82.8% vs. 69.7%; p = .49), cardiovascular mortality (0.0% vs. 7.0%; p = .070), and infection related mortality (2.2% vs. 6.1%; p = .31) did not differ statistically significantly between the groups.

Conclusion: SGLT2 inhibitors may not be associated with an increased risk of major lower limb amputation in patients with CLTI undergoing EVT. These agents may be associated with improved clinical outcomes in this population.

Objective: The aim of this study was to determine whether patients with ≥ 10 mm aneurysm sac regression are suitable for a less intensive surveillance regimen after endovascular aneurysm repair (EVAR).

Methods: In this retrospective single centre study, all patients who underwent elective standard EVAR between 2004 and 2018 were included. All available follow up imaging was retrospectively assessed, and aneurysm sac diameters were compared with the first post-operative computed tomography angiography. Patients were divided into two groups: patients with < 10 mm aneurysm sac regression and patients with ≥ 10 mm aneurysm sac regression. The primary endpoint was any EVAR related complication, defined as aneurysm rupture, type I or III endoleak, type II endoleak requiring re-intervention, or loss of seal that required intervention.

Results: A total of 263 patients were included in this analysis, of which 166 patients (63.1%) developed ≥ 10 mm aneurysm sac regression in the first 4 years after EVAR. Among the 166 patients who achieved aneurysm sac regression of ≥ 10 mm, 11 (6.6%) developed an EVAR related complication during a median (interquartile range) follow up of 64 (47, 85) months. The estimated 5 year freedom from developing an EVAR related complication after reaching ≥ 10 mm sac regression was 94.4% (95% confidence interval 90.9 - 98.1%). When imaging would be postponed by 2, 3, or 5 years after ≥ 10 mm aneurysm sac regression, a cumulative delay in diagnosis of EVAR related complications would have occurred in two (1.2%), three (1.8%), and five (3.0%) patients, respectively.

Conclusion: Once the aneurysm sac diameter after EVAR had regressed ≥ 10 mm, patients experienced a very low rate of development of EVAR related complications. In these patients, it is safe to increase surveillance intervals.

Objective: It is unclear how malignant neoplasms affect limb prognosis in patients with peripheral arterial disease (PAD). The purpose of this study was to clarify the association between malignant neoplasms and limb outcomes in patients with PAD complicated by chronic limb threatening ischaemia (CLTI).

Methods: Data for patients who underwent revascularisation between 2013 - 2015 were collected from the JAPAN Chronic Limb Threatening Ischaemia Database (JCLIMB), established as a part of the National Clinical Database. All patients included in this study had PAD with CLTI and were followed for two years. The prevalence of malignant neoplasms at the time of revascularisation was examined. Overall survival, cardiovascular death, primary patency, and major adverse limb events (MALE) were also investigated.

Results: A total of 2 891 patients were included in the study. The patients underwent surgical revascularisation including hybrid treatment in 1 709 cases, and endovascular treatment in 1 182 cases. Overall, 62 patients (2.1%) had malignant neoplasms at revascularisation (malignancy bearing group). Primary patency and MALE free rates did not differ between patients with and without malignant neoplasms, regardless of treatment type. Overall survival was significantly poorer in the malignancy bearing than in malignancy free groups. Cardiovascular mortality was not significantly different between the malignancy bearing and malignancy free groups, regardless of treatment modality.

Conclusion: Approximately 2% of patients with PAD complicated by CLTI had a malignant neoplasm at the time of revascularisation. The presence of malignant neoplasms did not impact post-operative limb prognosis in patients with CLTI. Therefore, even if diagnosed with malignant neoplasms, there is no need to avoid performing optimal revascularisation for CLTI, including surgical revascularisation, provided the patient's condition and life prognosis are acceptable.

Objective: Endovascular thoracoabdominal aortic aneurysm (TAAA) repair can impair spinal cord perfusion, leading to paraplegia. The mechanisms driving this devastating complication are poorly understood. This study aimed to interrogate the cerebrospinal fluid (CSF) proteome in patients after TAAA repair to identify biomarkers that herald permanent paraplegia. It also aimed to investigate a potential therapeutic target identified by proteomics using an in vivo model of ischaemic spinal cord injury (iSCI).

Methods: CSF was collected for proteomic analysis from patients before and following TAAA repair. A differentially expressed protein identified in human paraplegic subjects was subsequently interrogated in a rodent model of iSCI. The protein composition of CSF was analysed using tandem mass tag proteomics. Neurological examinations were carried out by a blinded neurologist and T2 weighted magnetic resonance imaging (MRI) was used to measure spinal cord volume/oedema. A rodent model of iSCI was used to investigate a clinically relevant therapeutic target informed by proteomic findings.

Results: CSF analysis was taken from 37 patients, all of whom had aneurysm repair using a custom branched/fenestrated device (median age 73.5 years (range 67 - 78); 27 males, ten females; Crawford classification: six type I, 11 type II, 15 type III, three type IV, and two type V). Five patients remained permanently paraplegic and seven recovered from transient paraplegia. CSF of patients who remained paraplegic contained approximately fourfold more aquaporin-4 (AQP4) (41.8 ± 19.2 ng/mL, n = 5) than those who recovered from paraplegia (10.8 ± 1.3 ng/mL, n = 7; p = .01), or did not develop paraplegia (10.8 ± 1.2 ng/mL, n = 25; p = .004). Permanently paraplegic patients had CSF AQP4 levels > 15 ng/mL and this was associated with greater cord oedema on T2 weighted magnetic resonance imaging (1.77 ± 0.19 vs. 1.03 ± 0.36; p = .03). In a rodent model of iSCI, AQP4 inhibition preserved spinal neurons and glia in the dorsal horn and intermediate zones of white matter (p = .004) and protected against ischaemia induced paraplegia (p < .001).

Conclusion: The AQP4 level in the CSF of a patient represents a prognostic marker of permanent paraplegia after TAAA repair and highlights a novel therapeutic target. These findings represent a conceptual advance in the management of iSCI.