Annals of vascular surgery最新文献

Background: Due to the rarity of median arcuate ligament syndrome (MALS), surgical approaches to median arcuate ligament release (MALR) have been understudied. This series aimed to review robot-assisted laparoscopic MALR from a quaternary care center.

Methods: This is a single center cohort study of adult patients who underwent robot-assisted laparoscopic MALR between March 2015 and June 2023. Clinicopathologic data was abstracted from the electronic medical record for patients with at least 30 days of follow-up. Our primary outcome was symptom improvement which was assessed via review of the medical record from post-operative patient visits with a provider. Bivariate analyses were performed using Fisher's exact test.

Results: Twenty patients were identified. The mean age of patients at the time of surgery was 41.65 (±16.02) and 16 (80%) of the patients were female. Many patients had concomitant diagnoses of gastrointestinal illnesses including Crohn's/IBS (40%) and GERD (35%). DSM-5 psychiatric illnesses were diagnosed in 13 (65%) patients. The most frequently encountered pre-operative chronic symptoms included post-prandial pain (90%), chronic abdominal pain (85%), and unintended weight loss (85%). Post-operatively, 10 patients experienced complete resolution of unintended weight loss (p=0.0031), and significant improvement in chronic MALS symptoms including abdominal pain, post-prandial pain, nausea, and unintended weight loss. The median follow-up time was 1.63 (0.97 - 2.69) years. Operative characteristics include mean operative time of 133.25 ±25.91 minutes, median estimated blood loss of 20 (8.75 - 25.00) mL, and no significant changes in inspiratory or expiratory celiac artery peak systolic velocity between measurements before and after R-MALR. Patients had a median length of stay of 2 (1-3) days. 2 of 20 patients (10%) experienced a return to the OR for an injury to the gastroesophageal junction and pseudoaneurysm of the left gastric artery. There were no mortalities within 30 days of operation.

Conclusion: Our single institution experience offers evidence that robot-assisted laparoscopic median arcuate ligament release can be a safe and effective option for medium-term relief of MALS symptoms.

Objective: To study the effect of endovascular treatment of the thoracic aorta on cardiac geometry and evaluate the effects of stent placement on hemodynamics and cardiovascular biomechanics.

Methods: Articles were selected through the use of online databases such as PubMed, Scopus, and Web of Science, investigating the use of engineering methods (computational analysis and simulations using 3D models of cardiovascular structures obtained from medical imaging) to study the effects of pre- and post-treatment TEVAR (Thoracic Endovascular Aortic Repair) in terms of left ventricular mass variation and assessment of fluid dynamics parameters such as Wall Shear Stress (WSS), flow variations, and velocity. The quality of the included studies was assessed using the Newcastle-Ottawa Scale.

Results: A total of eleven studies were considered: three reported data on left ventricular mass variation, five reported flow and velocity variations, and six provided information on Wall Shear Stress (WSS). A high discrepancy in results and methodology for conducting the analyses was observed. Overall, an increase in left ventricular mass was observed in patients undergoing TEVAR, while an improvement in flow conditions and stress was noted following the exclusion of the pathological aortic zone CONCLUSIONS: To summarize, TEVAR can result in changes in vascular structures. However, the current literature on this topic is limited and the analysis methods used vary in terms of methodology, treated pathology, and follow-up duration. To successfully integrate computational simulations and engineering evaluations of medical images into clinical practice, it is crucial to standardize the analysis methods.

Introduction: Early detection of abdominal aortic aneurysms (AAA) is a mainstay of diagnosis, with Endovascular aortic repair (EVAR) emerging as the primary mode of repair. Maximum diameter measurement remains central to risk assessment; however, recent studies suggest AAA volumetric analysis may be more sensitive to true size changes. We compare the utility of volume and diameter in AAA size assessment and further investigating related clinical factors.

Methods: We retrospectively reviewed all patients who underwent EVAR at our institution between August 2017 and March 2023 with available pre- and post-operative CT angiograms. AAA total aneurysm and lumen volume were measured using semiautomatic segmentations. Maximum diameter, clinical variables were extracted from the medical record. Direct comparison of volume to diameter was completed using percent change from baseline. A subgroup of patients with long-term follow-up data (>231 days between scans) were used for additional analyses.

Results: Of 116 patients, 69 (59.5%) were included in the long-term patient cohort. Post-intervention, percent change volume and percent change diameter had a moderate positive correlation (r_s=0.6662), and average AAA percent change did not differ between volume and diameter (1.5% vs -1.8%, respectively; p=0.1654). Volumetric analysis was more likely to detect aneurysm sac enlargement (p=0.0315). On univariable analysis, increase in volume and diameter was associated with older age and endoleak. A diameter decrease was associated with metformin therapy.

Conclusion: Aneurysm volume is more likely to detect AAA enlargement than diameter. The benefit of early detection of high-risk aneurysms may translate to changes in surveillance and ultimately decrease aneurysm-related mortality.

Objectives: Endovascular aortic aneurysm repair (EVAR) is utilized to treat abdominal aortic aneurysms, while patients with short infrarenal necks can undergo fenestrated EVAR (FEVAR). Previous studies have demonstrated decreased aortic neck dilation for FEVAR compared to EVAR. Sac regression is a marker of success after EVAR, however, little is known regarding changes in sac volumetrics. This study compares aortic sac regression after EVAR vs FEVAR using volumetric analysis.

Methods: A retrospective review of prospectively collected data from 120 patients who underwent EVAR was performed. Thirty patients underwent FEVAR (Cook Medical Inc, Bloomington, IN) and 90 patients underwent EVAR (30 each with Endurant [Medtronic, Dublin, Ireland], Excluder [Gore, Flagstaff, AZ], and Zenith [Cook]). Demographic data were analyzed. Using three-dimensional reconstruction software, pre- and post-operative aneurysm sac volumes were measured, in addition to aneurysm characteristics.

Results: There were no differences in demographic or preoperative comorbidities. Preoperatively, FEVAR had greater percentage of thrombus within the sac by volume compared to EVAR (51.5% vs 39.1%, p=0.0002), and greater overall sac volume (240.8 ± 100.4 vs 188.2 ± 82.4cm³, p=0.005). EVAR patients had greater number of lumbar arteries (7.26 ± 1.68 vs 5.31 ± 1.93, p<0.000001). On postoperative follow-up, FEVAR cases had greater sac regression compared to standard EVAR (-22.75 ± 25.7% vs -5.98 ± 19.66%, p=0.00031). The percentage of sac regression was greater when measured by volume compared to maximum diameter for FEVAR (-22.75 ± 25.7% vs -13.90 ± 15.4%, p=0.01) but not EVAR (-5.98 ± 19.7% vs -4.51 ± 15.2%, p=0.246). Those in the top tertile of percent volume of thrombus (>48.5%) were more likely to experience greater than 10% sac regression by volume (55% vs 33.3%, p=0.015). On multivariate analysis, FEVAR was associated with sac regression greater than 10% by volume (OR 4.325, 95% CI 1.346-13.901, p=0.014), while endoleak (OR 0.162, 95% CI 0.055-0.479, p<0.001) and two patent hypogastric arteries (OR 0.066, 95% CI 0.005-0.904, p=0.042) were predictive against.

Conclusion: Fenestrated EVAR is associated with greater sac regression compared to EVAR on volumetric analysis. This difference may be attributable to decreased endotension within the aneurysm resulting from less aortic neck dilatation, while the greater proportion of thrombus may be a protective factor from growth. Patients being evaluated for EVAR with borderline neck anatomy should be considered for FEVAR given increased sac regression.

Objectives: Cerebral hyperperfusion syndrome (CHS) is a rare but serious complication following carotid artery revascularization. Considering the varying rates observed among carotid endarterectomy (CEA), Transfemoral Carotid Artery Stenting (TFCAS), and Transcarotid Artery Revascularization (TCAR), identifying the predictors and complications of CHS is essential for improving patient outcomes. This study utilizes a national database to investigate the predictors and complications of CHS following carotid revascularizations.

Methods: We conducted a retrospective analysis of all patients undergoing CEA, TFCAS, and TCAR for carotid artery stenosis in the VQI database from 2020 to 2023. Multivariate logistic regression was applied to identify CHS predictors, which were used to develop a risk score calculator. Moreover, we compared the stroke and mortality rates following CHS among the three revascularization techniques.

Results: The final cohort in our study included 59,130 (53%) CEA, 14,064 (13%) TFCAS, and 37,565 (34%) TCAR. There were 281 cases of CHS (0.25%), and TFCAS was associated with the highest rate of CHS (0.78% vs. 0.22% vs. 0.15%; p < 0.001). After adjusting for potential confounders, TFCAS was associated with almost three-fold higher risk compared to CEA (aOR=2.87[ 95%CI:1.65-4.9] P<0.001). On the other hand, TCAR was comparable to CEA. Other predictors of CHS included uncontrolled hypertension, insulin-dependent diabetes, symptomatic status, prior carotid procedure, urgent intervention, and postoperative blood pressure medication. These predictors were used to develop an interactive CHS risk calculator (C-statistic = 0.8). Among patients who developed CHS, TFCAS was associated with a 70% higher risk of in-hospital stroke (aOR[adjusted odds ratio]=1.7[ 95%CI:1.4-2] P<0.001) and almost triple the risk of in-hospital death (aOR=2.9[ 95%CI:2.3-3.8] P<0.001). TCAR and CEA were comparable except for a slight risk of in-hospital stroke after TCAR (aOR=1.2[ 95%CI:1-1.3] P=0.03).

Conclusion: In this multi-institutional national study, we have demonstrated that the type of carotid revascularization significantly influences the risk of CHS and subsequent stroke and mortality, with TFCAS associated with the highest risk. Uncontrolled hypertension was associated with a two-fold increased risk of CHS, underscoring the importance of tight blood pressure control. We were able to provide a prediction model for CHS based on preoperative factors. Prospective use of this risk calculator might benefit in postoperative monitoring.