Annals of vascular surgery最新文献

Introduction: The main treatment for Chronic Mesenteric Ischemia (CMI) is revascularization, typically achieved through stent angioplasty of the superior mesenteric artery, and in certain cases, the celiac trunk. However, long-term outcomes using bare-metal stents have been less than satisfactory. Therefore, we aimed to compare the performance of covered stents (CS) versus bare-metal stents (BMS) in patients treated for CMI.

Methods: Pubmed, Embase and Cochrane Central Register of Controlled Trials databases were systematically searched for studies of patients with CMI who underwent stenting procedures using BMS or CS. The main outcomes were primary patency and freedom from reintervention. Statistical analysis was performed using R version 3.6.

Results: One randomized clinical trial and five observational studies were included. In the pooled analysis, patients undergoing the covered stenting approach haOd a higher primary patency (HR 0.40; 95%CI 0.23-0.68; p<0.01). Additionally, CS also demonstrated significantly superior freedom from reintervention when compared to BMS patients (HR 0.30; 95% CI 0.13-0.71; p<0.01).

Conclusion: In patients undergoing transluminal angioplasty with stent placement both in the celiac trunk and superior mesenteric artery, the use of CS indicated superior primary patency and a higher rate of freedom from reintervention compared to BMS. These findings indicate superior outcomes with CS and may suggest their use as the preferred stent option in patients with CMI. However, these findings should be interpreted cautiously due to the limited number of studies, the moderate to serious risk of bias in the included data, and the significant heterogeneity observed. Further high-quality clinical trials are necessary to validate these results and strengthen the evidence base for clinical practice.

Objectives: Brachial artery injury due to displaced supracondylar fracture (SC) of the humerus in children may present with pink pulseless hand (PPH), denoting a well perfused hand without radial pulse, or acute hand ischemia. Some reports state that brachial artery reconstruction is not necessary in children with persisting PPH, but the reports on long-term consequences such as intermittent claudications, growth retardation and ischemic contracture in children with pulseless hand are scarce and often misinterpreted. The objective of our analysis was to assess the long-term outcomes of children with brachial artery injury associated with SC fracture.

Methods: A retrospective review was performed and data on all children treated for SC fracture with brachial artery injury from 2010 to 2022 were collected. Functional outcomes, brachial artery patency and complications were analyzed.

Results: Overall, 10 patients with acute ischemia or PPH persisting after fracture reduction/fixation were identified, and all underwent brachial artery exploration (age range 3-10 years). Six patients underwent immediate exploration after fracture reduction and fixation: three due to signs of acute ischemia, and three for persisting PPH. Two patients underwent vascular surgery for PPH that persisted for more than 48 hours following fracture reduction. Two patients were discharged and later developed intermittent claudications/critical ishemia requiring revascularization. Mean follow up was 3.5 years (ranged 2-6 years). There were no postoperative complications. All patients had a palpable radial pulse, patent brachial artery on the last follow-up examination and no signs of ischemic contracture.

Conclusion: Brachial artery reconstruction after SC fracture with brachial artery injury is a safe procedure that offers excellent long-term patency. Revascularization should be done in all patients with persistently absent radial pulse to avoid chronic hand and forearm ischemia.

Objectives: The population in the U.S., and across the world is aging rapidly which warrants an assessment of the safety of surgical approaches in elderly individuals to better risk stratify and inform surgeons' decision making for optimal patient care. This review is designed to assess the risk of 30-day mortality and other outcomes of interest among the octogenarians undergoing fenestrated or branched endovascular aortic aneurysm repair (F/BEVAR) for thoracoabdominal aortic aneurysms (TAAAs).

Methods: The review protocol was registered in the PROSPERO database (CRD42023435673). A systematic review of the English literature was performed using literature databases PubMed and Scopus from inception till May 2024. The review was designed on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting 30-day mortality following F/BEVAR. The risk of bias was evaluated utilizing the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for the overall mortality was computed, and a p-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I² statistics.

Results: Nine studies were found fit for the meta-analysis per inclusion and exclusion criteria. Of these seven studies, three exclusively reported F/BEVAR for Type IV TAAA. Based on a random effects model, a 30-day mortality for octogenarians undergoing F/BEVAR for any type of TAAA was found to be higher (OR, 1.73; 95% CI, 1.13-2.63, p=0.250), however was not statistically difference as compared to non-octogenarians. This insignificance was pertinent, when a meta-analysis with similar model was computed for Type IV TAAA (OR, 1.89; 95% CI, 0.75-4.77, p= 0.163). Other outcomes including spinal cord ischemia, kidney injury, transient ischemic attack or stroke, non-home discharge, and all-cause reintervention were all found not to be statistically significant in the older population.

Conclusions: No statistical difference was observed for the risk of 30-day mortality in octogenarians versus non-octogenarians undergoing F/BEVAR for TAAA. This finding was consistent in sub-group meta-analysis of F/BEVAR for Type IV TAAAs, and all other outcomes. Factors pertaining to patient's health, and the system factors like surgeon's skills and postoperative care should be weighed when performing F/BEVAR in older patients. Further research is imperative to assess and better understand the impact of comorbidities on surgical outcomes.

Background and objectives: Post-embolization syndrome (PES), characterized by pain, fever, nausea, and vomiting, is a common but non-serious adverse event following arterial embolization, negatively impacting patient satisfaction with the procedure. This study aimed to evaluate the efficacy of dexamethasone-based prophylactic therapy in preventing PES, as well as to assess the effects of its dosage and timing of administration.

Methods: A systematic search was conducted across three databases, two trial registries, and citation searches to identify relevant studies. Data related to postoperative pain, fever, nausea, and vomiting were extracted and meta-analyzed using a random-effects model and the Mantel-Haenszel method. Meta-regression was performed to examine the role of dexamethasone dose and timing of administration as mediators.

Results: Dexamethasone-based prophylactic therapy significantly reduced the risk of postoperative pain (RR=0.58, 95% CI: 0.48-0.69; P<0.00001), fever (RR=0.36, 95% CI: 0.22-0.61; P<0.00001), nausea (RR=0.52, 95% CI: 0.41-0.67; P<0.00001), and vomiting (RR=0.54, 95% CI: 0.36-0.82; P=0.004) compared to placebo or no treatment. A higher dose of dexamethasone was associated with a significantly lower incidence of postoperative pain (P=0.038). Regarding timing, postoperative and continuous (extending throughout the perioperative period) administration, was more effective than preoperative administration (P=0.024; P=0.007). A dosage of 6-12 mg was particularly effective in reducing the risk for all four symptoms.

Conclusion: Dexamethasone effectively prevents PES in patients undergoing arterial embolization. An optimal protocol may involve a divided dose regimen within the range of 6-12 mg, extending throughout the recovery period for maximum benefit.

Background: Thoracic Endovascular Aortic Repair (TEVAR) reduced mortality for blunt aortic injury (BAI) from 30-50% to < 10%; however, penetrating traumatic aortic injury (PAI) remains highly lethal (>40% mortality). This study's goal is to determine outcomes of TEVAR for PAI.

Methods: Patients undergoing TEVAR for traumatic aortic injuries were identified from the Vascular Quality Initiative database from 2011-2022. Patients with blunt and penetrating injuries were compared based on pre-operative characteristics, injury severity, and post operative outcomes.

Results: TEVAR was performed for 1,867 patients with traumatic aortic injuries of which 1808 (96.9%) patients had BAI, and 59 (3.1%) had PAI. The majority of injuries being treated were either grade 3 (pseudoaneurysm) (55.3%) or grade 4 (transection) (16.4%). PAI patients had a higher proportion of grade 4 injuries compared to BAI (36.4% vs. 16.5%, p=0.001). The majority of PAI were in zones 4-5 (61.1% vs. 14.2%, p<0.001), whereas the majority of BAI were in zone 3 (66.5% vs. 16.7%, p<0.001). Overall, the mortality rate was 8.2% (N=154). In hospital mortality was 8.5% in the PAI group and 8.2% in the BAI group (p=0.813). There was no significant difference in major complication rates between PAI and BAI patients.

Conclusions: PAI occurs more commonly in zones 4-5 of the thoracic aorta and often presents with higher grade aortic injury when compared to BAI. TEVAR for PAI provides excellent in-hospital survival, especially compared to historical mortality rates around 40%. An endovascular first approach may lead to improved survival for PAI.

Background: Although guidelines have established endovenous laser ablation (EVLA) as the first-line option for patients with varicose veins (VVs) in chronic Great saphenous vein (GSV) insufficiency, however, Chronic Vein Insufficiency (CVI) remains a significant healthcare burden. Endovenous microwave ablation (EMA) is a promising alternative. This review aims to analyze the Endovenous Microwave Ablation versus Endovenous Laser Ablation for Varicose Veins in Chronic Great Saphenous Vein Insufficiency METHODS: Randomized controlled trials (RCTs) and cohort studies across PubMed, Scopus, Science Direct, and the Cochrane Library up to November 11, 2024 was searched. Risk of bias was evaluated using Cochrane Risk of Bias Tool for RCT and Newcastle-Ottawa Scale (NOS) for Cohort studies. Meta-analysis was done using RevMan 5.4.0 using an inverse-variance random-effects model with Duval and Tweedie trim-and-fill sensitivity analysis.

Results: Overall, a total of 2 RCTs and 1 cohort study included. In treating GSV VVs, EMA has proven to have shorter duration of operation significantly compared to EVLA (MD: -6.62 [95% CI: -11.91, -1.32, p = 0.01]) although heterogeneity is high. EMA have similar profiles in efficacy compared to EVLA (Aberdeen score of QoL, VAS Score, length of hospital stays, and recanalization rate in 6-months). In terms of safety, the incidence of ecchymosis was found to be lower in the EMA group compared to the EVLA group significantly (OR: 0.58). Other safety profiles were found to be similar.

Conclusion: EMA might lower operating time, potentially reducing procedure risks, and is equally effective as EVLA in treating VVs in chronic GSV insufficiency. Further research comparing these techniques with extended follow-up periods (over 12 months) and standardized study methodologies are still needed.

Objective: Chronic limb-threatening ischemia (CLTI) requires revascularization whenever it is possible. The great saphenous vein represents the surgical conduit of choice. However, it is not always available, in particular in multi-operated patients. In such cases, alternative efficient biological conduits are needed but data remains limited. This study aims at evaluating the performance of cold stored venous allografts provided by Bioprotec® society.

Methods: Prospective multi-center cohort. The primary endpoint was limb salvage rate at one year following revascularization with cold stored venous allografts. Follow-up based on clinical examination and duplex-scan. Uni- and multivariate analyses were performed to analyze predictive factors of endpoints.

Results: Overall, 39 patients (40 limbs) were included between 2018 and 2021. Patients had a median of 2 [0-6] revascularizations prior to inclusion. A total of 97 grafts were used (median of 3 [1-4] grafts per procedure). In the postoperative period (30 days) no death and 4 major amputations were noted. The median length of follow-up was 13.4 [0.7-31.1] months. The six-months, one-year and two-year freedom from major amputation rates were 79% [95% CI: 68-93], 75% [95% CI 62-91] and 68% [95% CI: 51-90], respectively. The six months, one-year and two-year survival rates were 95% [88-100], 83% [95% CI: 71-98] and 79% [95% CI: 65-96], respectively. Primary patency rates were 77% [95% CI: 64-91] at six months, and 47% [95% CI: 32-70] at one and two years. Secondary patency rates were 82% [95% CI: 70-95] at 6 months and 50% [95% CI: 34-73] at one and two years. The analysis identified the number of previous revascularizations as a significant risk factor for graft patency (Hazard Ratio: 1.59; 95% Confidence Interval: 1.13-2.24).

Conclusion: Revascularization of CLTI patients with previous failed interventions is highly challenging. The use of cold stored venous allograft showed encouraging limb salvage rate despite modest patency rates and thus may represent an alternative to other substitute in some selected cases. More studies are necessary to identify the potential of CSVA in CLTI patients.

Background: Nonocclusive mesenteric ischemia (NOMI), a subtype of acute mesenteric ischemia, is primarily caused by mesenteric arterial vasoconstriction and decreased vascular resistance, leading to impaired intestinal perfusion.Commonly observed after cardiac surgery, NOMI affects older patients with cardiovascular or systemic diseases, accounting for 20-30% of acute mesenteric ischemia cases with a mortality rate of ∼50%. This review explores NOMI's pathophysiology, clinical implications in aortic dissection, and the unmet needs in diagnosis and management, emphasizing its prognostic significance.

Methods: A comprehensive literature review was conducted using multiple electronic databases to extract relevant data and information.

Results: NOMI is a life-threatening condition characterized by mesenteric vasoconstriction and reduced splanchnic blood flow, often triggered by cardiac surgery, haemodialysis, or hypotensive episodes. Epidemiological studies highlight its prevalence in ICU settings, with a high mortality rate linked to delayed diagnosis and systemic hypoperfusion. Risk factors include advanced age, vasopressor use, and inflammatory markers. Biomarkers such as I-FABP, citrulline, and D-lactate show potential for early detection but lack robust clinical validation. Management includes fluid resuscitation, vasodilators, and surgical intervention for bowel necrosis. Emerging endovascular approaches show promise but are limited to select cases without bowel infarction. This review underscores the critical need for timely diagnosis, risk factor identification, and tailored interventions to improve outcomes.

Conclusion: NOMI remains poorly understood despite advances in surgical and perioperative care. Its pathophysiology, linked to cardiopulmonary bypass and intraoperative factors, requires heightened clinical vigilance. Limited evidence underscores the need for a multidisciplinary approach involving surgeons, radiologists, and anaesthetists to improve diagnosis, management, and outcomes in aortic surgery patients. Figure 1. Schematic illustration of morphological and haemodynamic patterns of mesenteric ischaemia. The aortic type (A) and branch type (B) cause significant malperfusion, while mild compression of the true lumen (TL) or double tract perfusion do not cause malperfusion. AB-AO abdominal aorta, FL false lumen, SMA superior mesenteric artery. Reproduced from Orihashi et al. [REF] with copyright permission obtained.