Annals of vascular surgery最新文献

Introduction: Lower extremity access remains a last resort for many patients needing dialysis. The role antiplatelets or anticoagulants (AC) play on their patency is unknown. We sought to identify the effects of antiplatelet or AC therapy prescribed at discharge on patency and survival in patients undergoing creation of lower extremity dialysis access.

Methods: All patients in the Vascular Quality Initiative dialysis module with a lower extremity AV fistula (AVF) or AV graft (AVG) created from 2011-2023 were retrospectively analyzed. Medications prescribed at discharge were organized into aspirin (ASA), clopidogrel, dual antiplatelet (DAPT), and single antiplatelet plus anticoagulation (SAPT+AC). Univariable Kaplan-Meijer (KM) and multivariable regression analyses were utilized to assess impact of discharge medication on survival and primary/secondary patency.

Results: 1,190 patients underwent lower extremity dialysis access creation with 151 (12.7%) receiving AVFs and 1,039 (87.3%) receiving AVGs. Of AVF patients, 41 (27.2%) were discharged on no medication, 50 (33.1%) on aspirin, 5 (3.3%) on clopidogrel, 9 (6.0%) on DAPT, and 46 (30.5%) on SAPT+AC. Following AVG creation, 348 (33.5%) of patients were discharged on no medications, 271 (26.1%) on aspirin, 59 (5.7%) on clopidogrel, 62 (6.0%) on DAPT, and 299 (28.8%) on SAPT+AC. KM analyses showed no difference in survival, primary patency, or secondary patency based on medication following AVF. Multivariable analysis showed improved secondary patency with clopidogrel alone (HR 0.08, CI 0.01-0.96, p = 0.04). Aspirin, DAPT, and SAPT + AC use showed no significant difference.

Conclusion: This analysis suggests SAPT is protective for lower extremity AVG with clopidogrel alone showing statistically significant protection. This suggests that clopidogrel as SAPT is a viable option for prolonging AVG patency if prescribed at discharge. Further study on antiplatelet usage following lower extremity dialysis access creation is warranted.

Background: Prophylactic postoperative vasopressors (PPV) are used to induce hemodynamic augmentation to prevent spinal cord ischemia (SCI) in patients undergoing thoracic endovascular aortic repair (TEVAR). However, the scientific evidence on its effectiveness and safety is limited. This study aims to investigate the safety and effectiveness of PPV in patients undergoing TEVAR in a multi-institutional real-world setting.

Methods: All TEVAR patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database between March 1, 2012, and January 28, 2023, were identified. Univariable and multivariable analyses were performed to assess the association between the use of PPV and the rates of postoperative 30-day mortality, Major Adverse Cardiovascular Events (MACE, defined as new onset of postoperative myocardial infarction (MI), congestive heart failure (CHF), dysrhythmias, or stroke), SCI, and other adverse events for patients undergoing TEVAR.

Results: Out of 25,549 reviewed patients, 11,342 underwent TEVAR, matching the study criteria, and were analyzed. 2,420 patients (21.3%) received PPV. Patients who received PPV had significantly higher rates of 30-day mortality (9.3% vs 2.1%, p<0.001), MACE (18.2% vs 7.4%, p<0.001), postoperative SCI (2.6% vs 1.3%, p<0.001), and other adverse events. After adjusting for confounders, the use of PPV was associated with significantly increased odds of 30-day mortality (OR, 3.23, 95%CI: 2.58-4.04, p<0.001), MACE (OR, 2.18, 95%CI: 1.89-2.51, p<0.001), postoperative SCI (OR, 1.46, 95%CI: 1.05-2.01, p=0.022) and other adverse events.

Conclusions: PPV was associated with significantly higher odds of 30-day mortality, MACE, SCI, and other adverse outcomes. The role of PPV should be re-evaluated, and the decision for administration should be made on an individualized basis, considering patient comorbidities and risk factors. A prospective study is required to confirm these findings.

Objective: To analyze the impact of sex on the occurrence of death, stroke and myocardial infarction at 30 days and at 1 year after either carotid endarterectomy (CEA) or carotid artery stenting (CAS) for the treatment of significant carotid stenosis on the real-world dataset coming from TriNetX.

Methods: A retrospective multicenter cohort study was built within the TriNetX platform (TriNetX LLC, Cambridge, MA) to investigate cohorts of patients aged 18 years or older diagnosed with carotid artery occlusion or stenosis receiving either CEA or CAS from 1 January 2010 to 19 June 2025. Patients were also classified as symptomatic, thus delineating four cohorts: symptomatic CAS, symptomatic CEA, asymptomatic CAS and asymptomatic CEA. The primary outcome was identified as the occurrence of death from all causes, stroke and myocardial infarction, within each of the four cohorts of patients, comparing male versus female patients. These outcomes were evaluated both individually and as a composite outcome within 1 month and 1 year after the intervention.

Results: Results of 59340 procedures of carotid revascularization (5599 CAS and 53741 CEA) from 2010 ongoing were analyzed, being 22574 on female patients (38.0%). At 30 days, the propensity-matched score analysis adjusted for age did not show any significant difference for the risk of all the outcomes between males and females both in the cohort of patients who underwent CEA as well as in that of patients who underwent CAS, neither in symptomatic nor in asymptomatic patients. At one year, no significant differences were recorded between men and women for the all the outcomes in both the cohorts, except for a lower survival of symptomatic female patients who underwent CAS (86.7% vs. 93.8%, p=0.013).

Conclusions: At 30 days and at long-term follow-up no differences were recorded between male and female patients undergoing CAS or CEA, except for a lower 1-year survival of symptomatic female patients who underwent CAS.

Objective: Type IA and type II endoleaks remain among the most frequent and clinically relevant complications following endovascular aneurysm repair (EVAR). These events compromise aneurysm exclusion, may cause sac enlargement, and are associated with an increased risk of late rupture. The ability to identify morphological features predisposing to endoleak formation and to apply targeted preventive strategies could substantially improve the long-term durability of EVAR.

Design: Single-centre retrospective cohort study METHODS: We analysed 250 consecutive patients who underwent EVAR for infrarenal abdominal aortic aneurysm between 2000 and 2019. Patients were divided into two periods reflecting the evolution of graft technology and the adoption of preventive measures: Period 1 (2000-2014) and Period 2 (2015-2019). Pre-operative computed tomography angiography (CTA) was reviewed for aortic neck length and angulation, thrombus burden, and the patency and calibre of lumbar arteries and the inferior mesenteric artery (IMA). In Period 2, selective embolisation of patent branch vessels and the use of fenestrated endografts for short or angulated necks were implemented. Primary outcomes were freedom from type I and II endoleaks and freedom from re-intervention.

Results: Three-year freedom from any endoleak was significantly higher in Period 2 (85% vs 70%, p = .03), as was freedom from re-intervention (90% vs 75%, p = .02). Short proximal necks (<10 mm; HR 3.2, 95% CI 1.8-5.6), large patent lumbar or mesenteric arteries (>3 mm; HR 2.7, 95% CI 1.5-4.9), and sac thrombus involving >50% of the circumference (HR 1.9, 95% CI 1.1-3.3) were independent predictors of type I or II endoleaks. Preventive interventions were protective (HR 0.6, p = .04).

Conclusions: Comprehensive pre-operative morphological assessment enables accurate identification of patients at increased risk for endoleak development. A patient-specific, anatomy-driven strategy significantly improves long-term endoleak-free and re-intervention-free survival after EVAR.

Thoracic outlet syndrome (TOS) encompasses a group of disorders caused by compression of the brachial plexus or subclavian vessels as they pass from the neck to the upper limb. Among its variants, pectoralis minor syndrome (PMS) is increasingly recognized as a distinct cause of neurovascular compression beneath the pectoralis minor muscle. PMS typically presents with anterior chest wall pain, paresthesia, weakness, or upper-limb swelling, closely resembling neurogenic or vascular TOS. Diagnosis relies on detailed history and physical examination, with ultrasound-guided pectoralis minor block serving as a key confirmatory and prognostic test. At the same time, dynamic ultrasonography or venography provides supportive evidence when vascular involvement is suspected. Most patients respond to conservative management, which includes posture correction, stretching of the pectoralis minor, physical therapy, and botulinum toxin injection. In contrast, refractory cases benefit from surgical pectoralis minor tenotomy, which offers durable symptom relief with minimal complications. Early recognition and precise localization of compression are essential to guide effective treatment and prevent unnecessary thoracic outlet procedures. This study provides a comprehensive review of PMS, detailing its etiologies, clinical features, diagnostic strategies, differential diagnoses, and treatment options to improve recognition and optimize management of this underdiagnosed condition.

Background: Management of peripheral vascular disease often requires multiple interventions and hospital admissions, affecting patients' mental and psychological health. This study compares the effect of open and endovascular interventions for revascularisation with major lower limb amputations (MLLA) on patients' depression and anxiety scores.

Materials and methods: A prospective study of patients who underwent open or endovascular revascularization interventions or MLLAs at a tertiary referral centre between January and June 2021 was conducted. Data was collected on demographics, length of stay, co-morbidities including previous psychological issues, previous revascularisation or amputation, presence or absence of peri-operative pain and re-hospitalisation. Patients were asked to fill in the hospital anxiety and depression scale (HADS) 1-week pre and 6-8 weeks post interventions, and outcomes were statistically analysed.

Results: A total of 122 patients (73 revascularisations vs. 49 amputations) were included in the study; 57.4% had diabetes, 43.4% had hypertension, 31.1% had ischaemic heart disease, and 42.6% had previous re-vascularisation interventions. The median and interquartile range of inpatient admission days was 10 (5-21) and 14 (9-21) for re-vascularisation and amputation groups, respectively (p=0.04). Median pre-operative depression scores were 6 (range 2-8) and 8 (range 5-11), and post-operative scores were 4 (range 2-7) and 9 (range 8-13) for the revascularisation and amputation groups, respectively. Median pre-operative anxiety scores were 6 (range 2-10) and 11 (6-13), and post-operative scores were 5 (range 2-9) and 9 (5-11) for the revascularisation and amputation groups, respectively. All pre- and postoperative scores were significantly different between the two intervention groups (p<0.05, 95% confidence interval).

Conclusion: Amputation negatively affects the patient's mental and psychological health as compared to revascularization.

Background: To evaluate, in light of existing population-based studies, whether endovascular abdominal aortic aneurysm repair (EVAR) increases the long-term incidence of abdominal cancer compared with open surgical repair.

Methods: A literature search was conducted using PubMed, Scopus, and Web of Science. Studies comparing endovascular abdominal aortic aneurysm repair and open technique were included. No date limitation was applied. The findings of the studies were evaluated using a random-effects or fixed-effects model depending on the presence of heterogeneity (I² > 25%).

Results: A total of 9734 articles were found after a database search. After reviewing the article titles and abstracts, two articles with 57,597 patients that met the inclusion criteria were included in the meta-analysis. Although our analysis showed that open surgery appeared to be associated with a lower incidence of abdominal cancer compared to EVAR, this result was not statistically significant (OR: 0.61; 95% CI 0.12-3.23; p=0.56).

Conclusions: A meta-analytic review of the available data revealed no statistically significant difference in abdominal cancer incidence between EVAR and open surgical repair. Although the hazard ratio for developing abdominal cancer after EVAR appeared modestly increased in individual cohort analyses, the absolute incidence of abdominal cancer remained low in both treatment groups. Given significant heterogeneity and the inclusion of only two retrospective studies in the analysis, these findings should be considered hypothesis-generating rather than transformative for clinical practice.

Objectives: Appropriate allocation of consult service resources is essential to reduce burnout. This study analyzed vascular surgery consults to compare referring services' perceived urgency with actual need for urgent therapy.

Methods: A randomized sample of 1,279 consults for patients >18 years from 2019-2023 was retrospectively reviewed. Consults were evaluated for indication and whether surgery occurred inpatient or outpatient. Perceived urgency was designated STAT or routine by the referring team placing the consult. "True" urgency was defined by whether a vascular procedure occurred during the same hospitalization. Agreement was defined as matched perceived and true urgency. Logistic regression identified predictors of agreement by vascular pathology, consulting service, and time of day, adjusting for race, sex, and age.

Results: Overall, 67.0% of consults demonstrated agreement between perceived and true urgency. Routine consults were accurate in 77.6% of cases, versus 22.1% of STAT consults resulting in inpatient intervention (p < .001). Agreement was lowest for peripheral arterial disease (PAD), acute limb ischemia (ALI), and compartment syndrome (p < .05), and higher for aneurysmal, mesenteric ischemia, cerebrovascular, and venous disease (p < .05). ICU consults had lower agreement (aOR 0.53, p < .001), while medicine consults had higher agreement (aOR 1.41, p < .05) compared to the emergency department. Agreement was lowest for consults placed between 0000-0259 and 1500-1759.

Conclusions: Discrepancies exist between perceived and true urgency of vascular consults, particularly from the ICU and for PAD, ALI, and compartment syndrome, highlighting an opportunity for targeted education to improve inpatient workflow.

Objectives: Open surgical repair for thoracoabdominal aortic aneurysms (TAAAs) is associated with substantial perioperative morbidity and mortality, especially in elderly or comorbid patients. Hybrid repair-visceral debranching combined with thoracic endovascular aortic repair (TEVAR) -was introduced at our institution in 2007 to reduce operative stress while maintaining durable outcomes. This study evaluates the long-term results of this approach over a 19-year experience.

Methods: We retrospectively analyzed 78 patients who successfully underwent hybrid TAAA repair and were discharged between 2007 and 2025. Long-term outcomes focused on aneurysm-related events and the need for reintervention.

Results: Fifty-four patients (69.2%) were male, with a mean age of 73 years (range, 44-89). Twenty-two patients (28.2%) were ≤70 years, 26 (33.3%) were in their seventies, and 30 (38.5%) were in their eighties. Overall survival was 67.0% ± 5.4% at 5 years and 30.9% ± 6.3% at 10 years. Freedom from aneurysm-related events was 98.5% ± 1.5% at 5 years and 77.2% ± 9.4% at 10 years. Freedom from reintervention was 85.0% ± 4.6% at 5 years and 54.8% ± 10.0% at 10 years. Aneurysm enlargement occurred in 29 patients (41.4%), and 17 patients (21.8%) underwent reintervention for endoleaks (type I: 5, type II: 4, type III: 8). Endoleak was the only factor significantly associated with aneurysm enlargement.

Conclusion: Despite the need for late reintervention, hybrid repair provides a high aneurysm-related event-free rate at 10 years when endoleaks are appropriately managed. Hybrid repair remains a valuable treatment option for high-risk patients, particularly in centers without full endovascular capability and in patients who are anatomically unsuitable for total endovascular repair.