JVS-vascular insights最新文献

英文中文

Real-world outcomes of above-knee amputation: Investigating the impact of peripheral arterial disease 膝上截肢的实际结果：外周动脉疾病的影响

JVS-vascular insights

Pub Date : 2026-01-01 DOI: 10.1016/j.jvsvi.2026.100353

Micah Thomas BS , Aaron Ebeweber MS , Maham Rahimi MD, PhD

Objective

Above-knee amputation (AKA), or transfemoral amputation, represents a highly morbid surgical procedure, typically performed in patients with irreversible limb compromise due to peripheral arterial disease, diabetes, trauma, or malignancy. Despite prior declines, U.S. incidence of AKA has risen 4% annually since 2012, paralleling an aging population and evolving comorbid risk profiles. Given its profound functional, psychosocial, and systemic implications, a contemporary understanding of real-world outcomes is essential. This study evaluated demographic characteristics, preoperative comorbidities, and postoperative complications of patients undergoing AKA using the TriNetX global health research network, comparing large-scale patient data with published literature to identify gaps between controlled research and clinical practice.

Methods

A retrospective cohort analysis was performed using deidentified electronic health records within TriNetX, identifying approximately 23,000 patients who underwent AKA via Current Procedural Terminology codes 27590, 27594, and 27596. Demographics, preoperative comorbidities, and postoperative outcomes—including stroke, myocardial infarction, infection, venous thromboembolism, contralateral limb amputation, and mortality—were assessed longitudinally and compared with systematically reviewed literature cohorts (n = 56-2879 patients). Statistical comparisons were conducted using two-proportion z tests (P < .05).

Results

TriNetX patients were younger (70 vs 75 years) and more often male (61.3% vs 47.4%) than literature cohorts. Compared with literature, TriNetX showed higher rates of chronic kidney disease (39% vs 23.9%) and end-stage renal disease (16% vs 12.9%) but lower rates of smoking, stroke, congestive heart failure, and diabetes. Major postoperative complications accumulated progressively: stroke (11.6%), myocardial infarction (14.1%), deep vein thrombosis (6.6%), pulmonary embolism (6.1%), and contralateral limb amputation (54.2%) by 11 years. All-cause mortality reached 19.9% at 1 year and 34.6% at 20 years.

Conclusions

AKA represents a sentinel event signaling advanced systemic vascular disease and high long-term morbidity and mortality. TriNetX data reveal substantial cerebrovascular, cardiovascular, and contralateral limb complications exceeding prior reports. These findings support multidisciplinary postamputation pathways emphasizing cardiovascular risk reduction, thromboembolic prophylaxis, wound management, and proactive contralateral limb surveillance to improve survival and quality of life.

目的：膝上截肢（AKA）或经股截肢是一种高度病态的外科手术，通常用于因外周动脉疾病、糖尿病、创伤或恶性肿瘤导致的不可逆肢体损害患者。尽管之前有所下降，但自2012年以来，美国的AKA发病率每年上升4%，与人口老龄化和不断变化的合并症风险概况相一致。鉴于其深刻的功能、社会心理和系统影响，对现实世界结果的当代理解至关重要。本研究利用TriNetX全球健康研究网络评估了接受AKA患者的人口统计学特征、术前合并症和术后并发症，并将大规模患者数据与已发表的文献进行比较，以确定对照研究与临床实践之间的差距。方法使用TriNetX内未识别的电子健康记录进行回顾性队列分析，通过现行程序术语代码27590、27594和27596确定约23,000名接受AKA的患者。人口统计学、术前合并症和术后结局（包括卒中、心肌梗死、感染、静脉血栓栓塞、对侧肢体截肢和死亡率）进行纵向评估，并与系统回顾的文献队列（n = 56-2879例患者）进行比较。采用双比例z检验进行统计学比较（P < 0.05）。结果与文献组相比，strinetx组患者更年轻（70岁vs 75岁），男性居多（61.3% vs 47.4%）。与文献相比，TriNetX显示慢性肾病（39% vs 23.9%）和终末期肾病（16% vs 12.9%）的发生率较高，但吸烟、中风、充血性心力衰竭和糖尿病的发生率较低。术后主要并发症逐渐累积：中风（11.6%）、心肌梗死（14.1%）、深静脉血栓形成（6.6%）、肺栓塞（6.1%）和对侧截肢（54.2%）。1年时全因死亡率为19.9%，20年时为34.6%。结论：saka是一个前哨事件，预示着晚期全身性血管疾病和高长期发病率和死亡率。TriNetX数据显示大量脑血管、心血管和对侧肢体并发症超过先前的报道。这些发现支持多学科截肢后途径，强调心血管风险降低、血栓栓塞预防、伤口管理和主动对侧肢体监测，以提高生存率和生活质量。

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引用次数: 0

Improved maturation of two-stage over single-stage basilic vein transposition for first-time hemodialysis access creation: A multilevel model 两期比单期基底静脉转位在首次血液透析通路创建中的成熟程度提高：一个多层次模型

JVS-vascular insights

Pub Date : 2026-01-01 DOI: 10.1016/j.jvsvi.2025.100345

Max Zhu MD, Joel Kruger MD, Joshua T. Geiger MD, MS, Irina Kanzafarova MD, Jose Aldana MD, Adam Doyle MD, Doran S. Mix MD, Michael C. Stoner MD, Karina A. Newhall MD, MS

Objective

Successful brachiobasilic arteriovenous fistula (BBAVF) creation can be performed in single or two stages, with evidence supporting either approach. Although surgeon and practice pattern often influence surgical approach, little is known about the role of practice patterns in maturation and reintervention-free fistula survival.

Methods

We conducted a retrospective study using the Vascular Quality Initiative from 2011 to 2022, including patients undergoing BBAVF procedures for first-time hemodialysis access with at least 4 weeks of follow-up. The primary outcome was fistula maturation. Our analysis incorporated a multilevel model, clustering by surgeon effects. Secondary analysis examined 1-year freedom from the composite outcome of access reintervention, fistula abandonment, or death, using Cox proportional hazards modeling and Kaplan-Meier survival analysis. Likelihood ratio testing was used to analyze model fit.

Results

Among 6417 patients, 1347 (21%) underwent single-stage and 5043 (79%) underwent two-stage BBAVF creation. Overall maturation was 60.6%. On univariable analysis, two-stage fistulas had higher maturation (62.3% vs 54.3%, P < .001) and 1-year reintervention-free fistula survival (50.5% vs 47.9%, P = .008). Multilevel adjusted analysis demonstrated that two-stage procedures were associated with higher maturation rates (odds ratio: 1.4, 95% confidence interval: 1.1-1.6, P = .001) and lower 1-year composite reintervention, abandonment, or death risk (hazard ratio: 0.88, 95% confidence interval: 0.8-0.98, P = .018). Clustering by surgeon random effects significantly improved model fit for maturation rate (likelihood ratio: 66.9, P < .001) and 1-year reintervention, abandonment, or death (likelihood ratio: 4774.7, P < .001).

Conclusions

Two-stage BBAVF creation was associated with superior maturation and 1-year reintervention-free fistula survival, even after adjusting for surgeon practice patterns. With other patient factors equal, a two-stage approach should be considered for first-time BBAVF creation.

目的成功的肱基底动静脉瘘（bbbavf）的形成可以分单期或两期进行，并有证据支持这两种方法。尽管外科医生和实践模式经常影响手术入路，但实践模式在成熟和无再干预瘘管存活中的作用知之甚少。方法：采用血管质量倡议（Vascular Quality Initiative）于2011年至2022年进行了一项回顾性研究，包括首次接受BBAVF手术进行血液透析的患者，随访时间至少4周。主要结果为瘘管成熟。我们的分析纳入了一个多层模型，根据外科医生的影响进行聚类。二级分析采用Cox比例风险模型和Kaplan-Meier生存分析，检查了1年无通路再干预、瘘管放弃或死亡的复合结局。采用似然比检验分析模型拟合。结果在6417例患者中，1347例（21%）接受单期治疗，5043例（79%）接受两期治疗。总体成熟度为60.6%。在单变量分析中，两期瘘管具有更高的成熟度（62.3% vs 54.3%, P < 001）和1年无再干预瘘管生存率（50.5% vs 47.9%, P = 0.008）。多水平调整分析表明，两阶段手术与较高的成熟率（优势比：1.4,95%可信区间：1.1-1.6,P = 0.001）和较低的1年复合再干预、放弃或死亡风险相关（风险比：0.88,95%可信区间：0.8-0.98,P = 0.018）。外科医生随机效应聚类显著改善了成熟率（似然比：66.9,P < 0.001）和1年后再干预、放弃或死亡（似然比：4774.7,P < 0.001）的模型拟合。结论：即使在调整了外科医生的实践模式后，两期bbbavf的形成与更高的成熟度和1年无再干预瘘管存活相关。在其他患者因素相同的情况下，应考虑采用两阶段方法治疗首次bbbavf。

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引用次数: 0

Analysis of physician-modified endograft utilization using online databases and social media 利用在线数据库和社交媒体分析医师改良内移植物的使用情况

JVS-vascular insights

Pub Date : 2026-01-01 DOI: 10.1016/j.jvsvi.2025.100314

Rob Tatum MD , Michael Nooromid MD , Paul DiMuzio MD , Babak Abai MD

Background

To characterize the present landscape of physician-modified endograft (PMEG) use and the impact of an institution's investigational device exemption (IDE) status on endograft use by analyzing publication trends and social media coverage.

Methods

We used the social media platform X and three online bibliographic databases to perform a keyword search using the following terms: PMEG, physician-modified endograft, and laser fenestration. Data extracted from X and online articles included authorship, IDE protocol status, pertinent clinical outcome measures, and others. An internet search was performed to determine which institutions offered revascularization with a custom-made device within an IDE protocol and which institutions were performing PMEGs without an IDE. Data were compared using standard methods.

Results

Our search identified 177 X posts and 315 published articles between 2017 and 2024. We found that 61% (109/177) of X post authors were male, and the most frequently mentioned device was Cook (n = 21) followed by Gore (n = 12) and AFX (n = 2). There were 306 articles published in peer-reviewed journals, and 217 articles described at least 10 procedures. An IDE was mentioned in 3.9% of X posts (7/177). Sixty-seven percent of posts (119/177) mentioned a thoracoabdominal repair compared with 18% (32/177) mentioning arches and 15% (26/177) not indicating repair type. Of the 74 posts mentioning the number of branch grafts, 35% (26/74) were three-branch, and 65% (48/74) were four-branch repairs. Of the X posts, 64% (114/177) were related to procedural technique followed by 20% meeting presentations (34/177), 14% education (n = 24), and 2% mentorship (n = 5). The most frequently observed complication was endoleak (n = 8), followed by aneurysmal degeneration (n = 3) and stent migration (n = 1). Among published articles, most institutions were academic (n = 236) and urban (n = 209). Of the 274 articles for which author training history was available, most institutions were in the United States (n = 238) and urban (n = 211). The most frequently reported outcome was endoleak (n = 249), followed by need for reintervention (n = 199), stent migration (n = 57), and aneurysmal degeneration (n = 41). Only 31% of institutions (97/315) had an IDE; the remaining 69% (218/315) were performing PMEGs without an IDE. Of the 144 articles indicating commercial device use, Cook was the most frequently reported platform (n = 97) followed by Gore (n = 47).

Conclusions

PMEG has become a broadly used treatment option for patients with complex thoracoabdominal aortic disease at non-IDE centers. A less restrictive regulatory environment may expand patient access to custom-made devices without sacrificing patient safety standards. Collaboration is needed between vascular surgeons, device manufacturers, and lawmakers to achieve this goal.

通过分析出版趋势和社交媒体报道，描述医生改良内移植物（PMEG）使用的现状，以及一个机构的研究器械豁免（IDE）状态对内移植物使用的影响。方法利用社交媒体平台X和3个在线文献数据库进行关键词检索：PMEG、医师改良内移植物和激光开窗。从X和在线文章中提取的数据包括作者身份、IDE协议状态、相关临床结果测量等。通过互联网搜索，确定哪些机构在IDE协议下使用定制设备进行血运重建，哪些机构在没有IDE的情况下进行pmeg。采用标准方法对数据进行比较。结果在2017年至2024年期间，我们检索了177x篇帖子和315篇发表的文章。我们发现61%（109/177）的X篇文章作者是男性，最常被提及的设备是Cook (n = 21)，其次是Gore （n = 12）和AFX （n = 2）。在同行评议的期刊上发表了306篇文章，其中217篇文章描述了至少10种治疗方法。在X个帖子中有3.9%（7/177）提到了IDE。67%的帖子（119/177）提到胸腹修复，18%（32/177）提到弓，15%（26/177）没有指出修复类型。在74篇提到树枝移植数量的文章中，35%（26/74）为三支修复，65%（48/74）为四支修复。在X个帖子中，64%（114/177）与程序技术相关，其次是20%的会议演讲（34/177），14%的教育（n = 24）和2%的指导（n = 5）。最常见的并发症是内漏（n = 8），其次是动脉瘤变性（n = 3）和支架移位（n = 1）。在发表的文章中，大多数机构是学术机构（236篇）和城市机构（209篇）。在有作者培训历史的274篇文章中，大多数机构在美国（238）和城市（211）。最常见的报道结果是内漏（n = 249），其次是需要再干预（n = 199），支架移位（n = 57）和动脉瘤变性（n = 41）。只有31%的机构（97/315）拥有IDE；其余69%（218/315）在没有IDE的情况下执行pmeg。在144篇关于商业设备使用的文章中，Cook是最常被报道的平台（n = 97），其次是Gore （n = 47）。结论spmeg已成为非ide中心复杂胸腹主动脉疾病患者广泛使用的治疗选择。限制较少的监管环境可以在不牺牲患者安全标准的情况下扩大患者使用定制设备的机会。为了实现这一目标，血管外科医生、设备制造商和立法者之间需要合作。

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