European Journal of Vascular and Endovascular Surgery最新文献

Objective: Recent evidence suggests an association between air pollution exposure and abdominal aortic aneurysm (AAA) rupture. It is unclear whether environmental factors also influence the rate at which AAAs grow. This study aimed to determine how environmental factors contribute to aneurysm growth using a prospective cohort study design.

Methods: This study used data from the UK Aneurysm Growth Study (UKAGS), a national cohort of men with AAA representative of the UK population in AAA surveillance. Participant records were linked with environmental exposure data from a validated land use regression model, including nitrogen dioxide (NO₂) concentrations (micrograms per cubic metre), particulate matter of diameter < 2.5 μm (PM_2.5) concentrations (micrograms per cubic metre), satellite measures of greenness (normalised difference vegetation index, enhanced vegetation index, and tree cover density), Ordnance Survey derived greenspace, and noise pollution exposure (decibels) from three sources (aircraft, railway, and road), over a 10 year period (2010 - 2019) with a 25 × 25 m grid cell resolution. Linear mixed effect growth modelling was used to explore the association with AAA growth.

Results: Environmental data were available for 3 360 (86%) participants. Mean follow up ± standard deviation was 5.64 ± 2.47 years. There were no statistically significant associations between NO₂, PM_2.5, and transport noise pollution with AAA growth in adjusted models, whereas relationships with greenspace measures were inconsistent.

Conclusion: The link between environmental factors and AAA growth remains unclear. Potential issues include use of those participating in a screening programme (who may be healthier than the general population and less susceptible to environmental influences). Managing traditional risk factors, especially smoking, remains key to clinical care.

Objective: In patients with chronic limb threatening ischaemia (CLTI), pedal artery angioplasty (PAA) is widely known to improve wound healing, but inframalleolar revascularisation may worsen arterial lesion morphology and lead to wound recurrence after healing. This retrospective cohort study aimed to clarify the effects of PAA on wound recurrence after wound healing.

Methods: Consecutive limbs with CLTI (n = 534) secondary to infrapopliteal and pedal artery disease that underwent endovascular therapy (EVT) and achieved complete wound healing at eight cardiovascular centres in Japan were analysed (March 2021 - December 2023). Limbs were divided into two groups according to whether PAA was performed (n = 89) or not (n = 445).

Results: Propensity score matching extracted 160 matched limbs that had no remarkable intergroup differences in patient and lesion characteristics. The wound recurrence rate at 1 year was statistically significantly higher in the PAA group than in the non-PAA group (51.4% vs. 23.5%; p < .001). Low serum albumin level, haemodialysis, good pedal artery type before EVT, and low small artery disease score showed significant interaction effects on wound recurrence, favouring non-PAA over PAA. Subanalysis of changes in plantar arch artery morphology before EVT and during repeat angiography at the time of wound recurrence showed statistically significantly more frequent deterioration of plantar arch artery morphology in the PAA group than in the non-PAA group (p = .020).

Conclusion: This study showed a significantly higher wound recurrence rate and more frequent deterioration of plantar arch artery morphology after PAA than after a non-PAA treatment in patients with CLTI.

Objective: Simultaneous treatment of tributaries alongside saphenous trunk ablation is considered the standard practice for managing symptomatic varicose disease. Nevertheless, uncertainty persists regarding the optimal timing of tributary treatment. This study aimed to compare early outcomes of concomitant vs. staged tributary treatment performed as an adjunct to saphenous trunk endovenous laser ablation (EVLA).

Methods: This was a multicentre, non-blinded, parallel arm, randomised controlled trial (NCT04774939). Patients with symptomatic varicose disease and great, small, or anterior saphenous vein reflux requiring treatment were randomised to isolated laser ablation (ILA) or laser ablation with foam sclerotherapy (LA+FS). Patients randomised to ILA received isolated EVLA of the saphenous trunk, and those randomised to LA+FS received saphenous trunk EVLA with concomitant ultrasound guided foam sclerotherapy (UGFS) of tributaries. The primary outcome was the need for additional tributary intervention at 3 months, as determined by the patient. A power analysis, set to detect a 29.8% difference in additional intervention rates, allowing a 14% dropout rate (α = 0.05, β = 0.20), indicated a required sample size of 66 patients.

Results: At 3 months, 20.7% of patients post ILA compared with 0.0% post LA+FS pursued additional UGFS of tributaries (p < .001). The median (interquartile range [IQR]) procedure time was shorter for ILA compared with LA+FS (median 46 minutes [IQR 41, 55] vs. 55 minutes [49, 63]; p < .001), with a higher 3 month Venous Clinical Severity Score following ILA (median 2.0 [IQR 1.0, 3.0] vs. 1.0 [IQR 0.0, 2.0]; p <.001). Complication rates and 3 month quality of life were similar across the groups.

Conclusion: Despite some early clinical advantages seen with concomitant tributary treatment, isolated EVLA met the main therapeutic objectives in most patients, thereby representing an acceptable but slightly less effective alternative to concomitant tributary treatment in the short term. Extended follow up is needed to assess the durability of these results.

Objective: There has been major controversy regarding the long term risk of death associated with the use of paclitaxel coated devices in the lower limbs. The authors performed a contemporary systematic review and meta-analysis.

Data sources: Data sources included published literature and repositories of regulatory agencies.

Review methods: All cause mortality was analysed on the intention to treat principle. Because of violation of proportional hazards, reconstructed patient level survival data (R² = 0.999) were fitted with piecewise Cox models and flexible generalised survival models with natural splines and shared frailty terms. Survival differences were summarised with the non-parametric statistical tests of the difference and the ratio of restricted mean survival time lost (RMTL).

Results: In total, 34 randomised studies with 7 486 subjects and 25 465 person years were included, more than twice the size of the latest industry sponsored meta-analysis for regulatory purposes. In the long term, there were 575 deaths amongst 4 231 patients in the paclitaxel arms (13.6% crude risk) vs. 367 deaths amongst 3 255 patients in the control arms (11.3% crude risk), with an average hazard ratio (HR) of 1.18 (95% confidence interval [CI] 1.03 - 1.35; p = .015). The RMTL ratio (non-parametric analogue of HR) was 1.21 times (95% CI 1.07 - 1.38; p = .003) at five years. The absolute RMTL difference was 0.08 years (95% CI 0.03 - 0.13; p = .004) at five years. The HR significantly varied over time, displaying a dynamic temporal pattern. Soon after treatment, HR progressively increased and became significantly higher before the end of the first year and for most of the second year (HR 1.45; 95% CI 1.11 - 1.89; p = .007), before declining towards unity (neutral) again up to five years. There was modest between trial heterogeneity (θ = 0.083; p = .017) and level of certainty by Grading of Recommendations Assessment, Development and Evaluation was moderate.

Conclusion: There is a significant, dynamic increase in all cause mortality following application of paclitaxel coated devices in the femoropopliteal artery.

Objective: Lower limb amputation profoundly impairs health related quality of life (HRQoL), yet comparative data across indications and amputation levels are scarce. This study evaluated EQ-5D-3L outcomes in patients with and without ischaemia undergoing major vs. minor lower extremity amputations.

Methods: In this retrospective cohort at a German level 1 trauma centre, patients (during 2010 - 2020) were classified by indication (ischaemia vs. trauma/tumour/infection) and amputation level (major vs. minor). Between 2023 and 2024, EQ-5D-3L interviews assessed five HRQoL dimensions. Multivariable linear regression identified independent predictors of EQ-5D index scores.

Results: Of 1 075 eligible patients, 276 (25.7%) completed EQ-5D: 176 with ischaemia (124 minor and 53 major) and 100 with other indications (55 minor and 44 major). Mobility limitations were more frequent in major vs. minor amputees for both ischaemia (71.7% vs. 62.1%) and other indications (75.0% vs. 41.8%). Self care was least affected (ischaemia majors 47.2% no problems; minors 60.5%; other majors 51.2%; minors 80.0%). Pain/discomfort was reported by 77.4% of ischaemia majors and 52.8% of ischaemia minors, and by 68.2% and 58.2% of other majors and minors, respectively. Anxiety/depression impairment was intermediate across groups. In patients with ischaemia, higher American Society of Anesthesiologists (ASA) score (β = -6.05, p = .001) and dialysis status (β = 3.47, p = .15) strongly predicted EQ-5D, whereas amputation level did not (β = -2.50, p = .32). In patients without ischaemia, coronary heart disease (β = -10.47, p < .001) and major amputation (β = -8.47, p = .006) were key negative predictors.

Conclusion: HRQoL impairments after lower limb amputation vary by indication and level, with comorbidity burden, especially ASA score and coronary disease, exerting greater influence than amputation level alone. These findings support multidisciplinary optimisation of systemic health in amputation care.

Objectives: To evaluate clinical outcomes and duplex ultrasound changes following venous arterialisation (VA) in patients with no option chronic limb threatening ischaemia (CLTI).

Methods: A retrospective analysis was conducted on 23 patients with no option CLTI who underwent VA procedures with standardised pedal duplex ultrasound assessments at baseline, one week, three months, and six months. Pedal venous maturation (PVM) was defined as the presence of dilated terminal pedal veins with colour Doppler signal and arterialised waveforms. PVM was correlated with VA patency, wound healing, and amputation free survival.

Results: At six months, amputation free survival was 85%; three patients underwent below the knee amputation and one was lost to follow up. PVM developed in the lateral plantar vein of 62% (19 of 22) of patients at a mean of 112.5 ± 60.6 days (range, 5 - 225 days). Once present, PVM persisted in 100% (19 of 19) of cases, including ten patients with VA occlusion. Wound healing occurred in 86% (19 of 22) of patients, including 100% (19 of 19) of those with PVM (p < .001). Healing was minor in 14% and major in 73%. All three patients who ultimately required amputation (at a mean of 152.7 ± 7 days) failed to achieve PVM. In contrast, 100% of patients with PVM remained amputation free at six months (p < .001).

Conclusion: PVM strongly correlated with wound healing and limb preservation following VA in patients with no option CLTI. PVM may serve as a physiological marker for successful revascularisation and guide postprocedure surveillance strategies.

Objective: To report peri-operative and midterm outcomes following open surgical, endovascular, and hybrid revascularisation for acute lower limb ischaemia (ALLI) using contemporary techniques and to provide adjusted comparative analyses accounting for key baseline differences.

Methods: This was a multicentre, retrospective study including patients treated for ALLI (January 2016 - November 2024) across 20 international vascular centres. Patients underwent open surgery (56%), endovascular treatment (20%), or hybrid procedures (24%). Primary outcome was major amputation and or death at the latest follow up. Secondary outcomes included peri-operative mortality, amputation, acute kidney injury, and re-intervention. Multivariable Cox regression analyses adjusted for age, sex, Rutherford stage, and chronic kidney disease were performed. A Fine-Gray competing risk model accounted for death as a competing event for major amputation.

Results: A total of 1 259 patients (51% men; mean age 72 ± 14 years; no popliteal aneurysms) from 19 European centres and one centre in New Zealand were included. At 30 days, peri-operative mortality was 11% (open 12%, endovascular 3%, hybrid 7%; p = .04), and major amputation occurred in 9% (open 10%, endovascular 8%, hybrid 7%; p = .41). Median follow up was 36 months (range 8 - 49 months). At 3 years, estimated mortality was 22.9% (standard error [SE] 1.5%) after open, 11.5% (SE 1.9%) after endovascular, and 19.6% (SE 2.2%) after hybrid procedures. Adjusted analyses demonstrated that endovascular treatment was associated with a lower risk of the composite outcome of major amputation and or death compared with open surgery (hazard ratio 0.69, 95% confidence interval [CI] 0.53 - 0.89; p = .005). For major amputation, the Fine-Gray competing risk analysis showed a reduced subdistribution hazard with endovascular treatment (subdistribution hazard ratio 0.71, 95% CI 0.33 - 0.99; p = .006).

Conclusion: Endovascular ALLI intervention was associated with lower long term amputation risk compared with open surgery, with comparable survival. These findings support endovascular treatment as a safe alternative in patients with ALLI.

Objective: Peripheral arterial disease (PAD) is rising globally, impacting healthcare systems. However, in Hungary, and indeed in the Central Eastern European region, which represents an important historical and socioeconomic block, little is known about recent evolution of this disease and the accompanying therapeutic interventions. This study investigated trends over the past decade among patients with PAD in Hungary, focusing on patients with intermittent claudication (IC) and chronic limb threatening ischaemia (CLTI) undergoing revascularisation.

Methods: Data for patients undergoing revascularisation for IC or CLTI were extracted from the Hungarian Vascular Registry (HUNVASC) from 2011 to 2019 and analysed. Patients were grouped into three time periods: period 1 (2011 - 2013), period 2 (2014 - 2016), period 3 (2017 - 2019) for comparison of characteristics, interventions, and clinical outcomes. In hospital death was the primary outcome of interest.

Results: Among 28 587 patients with PAD undergoing revascularisation, IC accounted for 16 908 and CLTI for 11 679 cases. From period 1 to period 3, the proportion of revascularised IC patients increased from 55.2% to 61.6%, while CLTI decreased from 44.8% to 38.4%. There was a general increase in disease burden over time, and patients with CLTI presented with more comorbidities than those with IC. Endovascular procedures were more common in IC. Open interventions declined from 77.6% to 60.0% with a concomitant rise in endovascular and hybrid methods. The in hospital mortality rate remained consistent at 1.4% and did not change considerably with time. Predictors of mortality included CLTI, ischaemic heart disease, chronic kidney disease, chronic pulmonary disease, older age, and open revascularisation.

Conclusion: This study showed that patients with CLTI had a higher comorbidity burden and higher rates of open interventions and post-operative complications compared with patients with IC. Although open procedures are declining, it remains the primary method of revascularisation irrespective of the disease cohort. Despite increasing patient comorbidities over time, post-operative mortality rates have not changed significantly.