Annals of vascular surgery最新文献

Objective: This study compared clinical features, risk factors, and outcomes between cancer and non-cancer patients with hospital-acquired pulmonary embolism (HA-PE).

Methods: A retrospective analysis of 287 HA-PE patients (186 non-cancer and 101 cancer) was conducted using R for statistical analysis and outcome comparison.

Results: Cancer was found to be the most significant risk factor for all-cause mortality in HA-PE patients (hazard ratios [HR] 4.36, 95% confidence intervals [CI] 2.78-6.86, p < 0.001). During follow-up, patients with cancer demonstrated significantly higher all-cause mortality (55.45% vs. 33.33%, p < 0.001) and shorter median survival time (12.6 vs. 28.5 months, p < 0.001) compared with non-cancer patients. Distant metastasis (HR 2.54, 95% CI 1.12-5.77, p = 0.026) was identified as an independent risk factor for death in cancer patients with HA-PE. In contrast, anticoagulation therapy alone (HR 0.30, 95% CI 0.10-0.88, p = 0.028), and pulmonary artery thrombectomy (HR 0.06, 95% CI 0.01-0.34, p = 0.001) initiated after HA-PE onset were associated with a significant reduction in mortality risk.

Conclusion: HA-PE patients with concomitant cancer, especially those with distant metastases, have an extremely poor prognosis with a markedly increased risk of mortality. Clinically, greater emphasis should be placed on thromboprophylaxis and early intervention in this population, with proactive use of anticoagulation and, when indicated, adjunctive interventions such as pulmonary artery thrombectomy to substantially improve survival outcomes.

Background: This study evaluates impact of converting from local to general anesthesia on Transcarotid Artery Revascularization (TCAR) outcomes and identifies risk factors predictive of conversions.

Methods: 58,960 TCAR cases from the Vascular Quality Initiative (2018-2024) were categorized by anesthesia type: 6,831 local/regional (LRA), 51,851 general (GA), and 278 conversions from LRA to GA. In-hospital outcomes were compared using multivariate logistic regression, with stroke/death as the primary endpoint. Preoperative predictors of conversion were also assessed.

Results: Converted patients were oldest, more often obese, and more likely to undergo urgent procedures. Compared to LRA, conversion was associated with increased odds of in-hospital stroke/death (aOR = 3.01; 95% CI, 1.54-5.36; P < 0.001), stroke/death/MI (aOR = 2.92; 95% CI, 1.58-5.00; P < 0.001), and prolonged hospital stay (aOR = 1.38; 95% CI, 1.05-1.80; P = 0.020). Compared to GA, converted patients had higher odds of stroke/death (aOR = 2.95; 95% CI, 1.55-5.09; P < 0.001) and stroke/death/MI (aOR = 2.75; 95% CI, 1.52-4.57; P < 0.001). Compared to LRA, GA was only associated with longer hospital stay. Age and urgent procedures were significant preoperative predictors of conversion to GA (P < 0.05).

Conclusions: Conversion from LRA to GA during TCAR is associated with higher rates of stroke, death, and MI compared to LRA or initial GA. Age and urgent TCAR procedures were identified as critical preoperative factors influencing conversion risk. These findings underscore the importance of meticulous preoperative risk assessment and optimal anesthesia selection to minimize conversions and enhance safety in TCAR.

Background: Supraceliac aortic cross-clamping can induce remote organ injury, particularly affecting the lungs through ischemia-reperfusion mechanisms. Pulmonary endothelial dysfunction plays a central role in acute lung injury, potentially involving degradation of the endothelial glycocalyx. Unfractionated heparin (UFH), routinely used during aortic surgery, is known for its anti-inflammatory, glycocalyx-protective properties and protective effects on lung parenchyma. This study aimed to evaluate the role of UFH in preventing remote lung injury following aortic cross-clamping.

Methods: Rats underwent 40 min of supraceliac aortic cross-clamping followed by 3 hr of reperfusion and were randomized to receive UFH or saline (n = 10/group). Plasma glycocalyx degradation products (Syndecan-1, Heparan Sulfate) and inflammatory cytokines were measured. Lung tissue was analyzed for cytokine expression, heparanase activity, and histological injury. Pulmonary endothelial glycocalyx was assessed by electron microscopy. Blood gas analysis evaluated systemic metabolic response.

Results: UFH did not significantly affect systemic cytokine levels (GM-CSF, IFN-gamma, IL-1a, IL-1b, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, and TNF-a), glycocalyx degradation products, blood gas parameters, or histological lung injury scores. Lactate levels were higher in the UFH group (P < 0.05). Lung heparanase activity was significantly reduced with UFH (P < 0.001). Electron microscopy seemed to identify better-preserved and more regularly distributed pulmonary endothelial glycocalyx in the UFH group, with less intraluminal shedding compared to controls.

Conclusion: Although UFH did not reduce lung injury or systemic inflammation after aortic cross-clamping, it was associated with lower pulmonary heparanase activity and seemed to improved preservation of the endothelial glycocalyx. These findings suggest a potential endothelial-protective effect of UFH that warrants further investigation.

Objective: Currently, carotid blowout syndrome (CBS) is mainly treated with endovascular treatments, including embolization and stent grafting. However, the optimal treatment strategy remains a topic of debate. This paper aims to thoroughly assess the overall efficacy of endovascular therapies for CBS and to systematically compare the clinical outcomes and complications between embolization and stent grafting.

Methods: Medline, EMBASE, and the Cochrane Library were searched from inception to April 28, 2024. The comparison between embolization and stent grafting was determined based on the primary or secondary outcomes. Recurrent bleeding and complications were the primary outcomes. Secondary outcomes included postoperative mortality and 1-year mortality. Newcastle-Ottawa scale was used to evaluate the methodological quality of the cohort studies.

Results: There were no randomized studies among the total of 31 studies included in the analysis, which comprised 16 single-arm and 15 two-arm studies and involved 1,824 patients. The Newcastle-Ottawa Scale evaluation produced an average score of 7.19, reflecting medium to high quality across the studies. The pooled results from these cohort studies revealed a significantly higher risk of postoperative rebleeding [odds ratio (OR) = 2.18, 95% confidence interval (CI) 1.24-3.83; P = .01] and complications (OR = 1.91, 95%CI 1.15-3.19; P = .01) in the stent grafting group compared to the embolization group. However, there were no statistically significant differences in the risks of postoperative mortality (OR = 1.27, 95%CI 0.73-2.23; P = .40) or 1-year mortality (OR = 0.77, 95%CI 0.41-1.45; P = .42) between the stent grafting and embolization groups. Given that the included studies are primarily cohort studies, further prospective, multicenter research is necessary to validate these findings.

Conclusion: Patients with CBS in the stent grafting group demonstrated a significantly higher risk of postoperative rebleeding and complications compared to those in the embolization group. While embolization is a feasible approach for treating CBS, its long-term outcomes remain uncertain.

Objective: Juxtarenal abdominal aortic aneurysms (JRAAAs) represent 16% of all AAAs and pose challenges due to their proximity to the renal arteries. Standard EVAR is unsuitable, necessitating advanced techniques such as fenestrated EVAR (FEVAR) and chimney EVAR (ChEVAR), which carry increased risks. Octogenarians are an expanding demographic, but evidence on JRAAA repair outcomes in this group is limited. This study evaluates outcomes of JRAAA repair in octogenarians using data from the Dutch Surgical Aneurysm Audit (DSAA).

Methods: This nationwide retrospective cohort study analyzed DSAA data on elective JRAAA repairs (2016-2023). Outcomes in octogenarians were compared between open surgical repair (OSR) and complex endovascular aneurysm repair (cEVAR). In addition, outcomes in octogenarians were compared with those in non-octogenarians, stratified by treatment modality. The primary endpoints were textbook outcome (TO) and failure-to-rescue (FTR); secondary endpoints included 30-day mortality and postoperative complications.

Results: Among 1,655 patients, 237 (14%) were octogenarians. Octogenarians had TO in 57% of cases, with higher rates following cEVAR than OSR (66% vs. 41%; p=0.010). Complication rates were significantly lower with cEVAR (24% vs. 53%; p<0.001), as were ICU admissions (38% vs. 89%; p<0.001). FTR occurred in 7%, and 30-day mortality rates did not differ significantly between cEVAR and OSR (6% vs. 9%; p=0.072).

Conclusion: Octogenarians undergoing JRAAA repair are at greater risk of dying and experiencing complications compared to non-octogenarians. cEVAR demonstrates fewer complications, reduced resource utilization, and more favorable perioperative outcomes compared to OSR, supporting its role as a safer alternative. Individualized risk assessment and further research on predictive models and cost-effectiveness are crucial for optimizing management in this high-risk group.