Annals of vascular surgery最新文献

Background: Venous thromboembolism (VTE) is a significant morbidity following major open abdominal surgery. While there are clear recommendations for perioperative and post-discharge VTE chemoprophylaxis in general surgery, guidance for vascular patients is unclear. We compared the incidence of VTE in vascular versus general surgery cases and then investigated the timing of VTE in vascular patients.

Methods: Two cohorts of major open abdominal surgery, vascular (open abdominal aortic aneurysm and aortoiliac reconstruction) and general, were compared in ACS-NSQIP database. There were significant preoperative differences between cohorts that were corrected using 1:1 propensity matching and logistic regression. Thirty-day outcomes included incidence and timing of VTE (in-hospital and post-discharge), mortality, and major morbidities.

Results: After propensity matching, there were 14,983 and 15,075 patients had vascular and general surgery, respectively. VTE rate was significantly lower in vascular. The distribution of in-hospital and post-discharge VTE was similar in both groups. Over the last 10 years, the overall incidence of VTE has decreased for both general and vascular surgery, with a corresponding decrease in in-hospital VTE but no change in post-discharge VTE. VTE occurrence showed a bimodal distribution with 76.92% of VTE occurring in early period (<14 days) and 23.08% occurring in late period (>14 days), which coincided with in-hospital (77.91%) and post-discharge (22.09%), respectively.

Conclusion: Although VTE incidence after vascular procedures has decreased, in-hospital VTE may be further reduced if pre-induction subcutaneous heparin is given. Furthermore, 22% VTE developed post-discharge in vascular patients, which suggests post-discharge VTE prophylaxis should be considered in selected high-risk patients.

Objective: Fever is a classic symptom in postoperative period, but to our knowledge no study shows exclusively the occurrence of fever after open aortic repair (OAR) and explores the difference between explained and unexplained fever.

Methods: Patients who underwent an OAR between March 2018 to April 2023 in Reims University Hospital were enrolled retrospectively. The primary endpoint was the rate of fever after OAR, which was classed in explained fever group (eFG) or unexplained fever group (uFG). Secondary outcomes were to compare fever characteristics, length of hospitalization, and mortality all causes at day 30 and day 90 between groups.

Results: The occurrence of fever was 23,8% after OAR, and 52% of them were unexplained. Date of occurrence of fever was at mean 3,3 days in uFG versus 7,8 days in eFG (p=0,0051). Sixty-six percent of eFG had a diagnosis of pneumopathy. The duration of hospitalization was longer in eFG vs. uFG (25 vs. 15 days) and no statistical difference was found for the mortality in both groups. After at mean 806 days of follow-up in uFG, there was no occurrence of vascular graft infection.

Conclusions: Fever after OAR occurred in a quarter of OAR patients and half of them were unexplained. Unexplained fever occurred earlier than eFG.

Background: Penetrating carotid artery injuries (CAI) are rare with high morbidity and mortality. We aimed to perform a systematic review of the published literature to evaluate the workup and management of penetrating CAI.

Methods: Studies of acute management of adult trauma patients with penetrating common or internal carotid artery injuries on MEDLINE or EMBASE from 1946 through July 2024 were included following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement methodology. Exclusion criteria was case series with <5 patients, review articles, animal studies, cadaver studies, non-English language, and age<18. Risk of bias was assessed with Oxford Level of Evidence and findings evaluated via GRADE.

Results: Our systematic review identified 4737 studies, of which 35 were included. Preoperative evaluation transitioned to screening CTA of the neck in the absence of hard signs. Management now includes endovascular and nonoperative in select cases: nonoperative for some small intraluminal injuries and stenting or embolization for surgically inaccessible lesions. Repair or revascularization was preferred in all but neurologically devastated comatose patients, in which, ligation was deemed acceptable. Temporary intravascular shunting (TIVS) with a takeback for definitive revascularization was associated with a 100% stroke or death. Postoperative antiplatelet or anticoagulation therapy and follow-up was non-standardized with a shift toward antiplatelet therapy for all injuries described more recently.

Conclusions: Penetrating CAI remain challenging with a shift toward less invasive initial workup with CTA and management including endovascular and nonoperative in select cases. TIVS with delayed revascularization and ligation were both associated with poor outcomes. Postoperative antiplatelet therapy has become increasingly common and postoperative surveillance is not standardized.

Objective: Pigs have long been employed as an animal model for knee-related diseases. However, vascular anatomy around the pig knee is rare. The objective of this study was to explore the vascular anatomy around the pig knee from the perspective of comparative medicine.

Materials and methods: Fifteen fresh cadaveric hindlimbs of hybrid pigs were used in this study. The femoral artery was infused with red- or black-colored latex. The origination, course, and branches of the arteries around the pig knee were observed.

Results: The femoral artery around the pig knee has the following branches: the saphenous artery, the first descending geniculate artery, the second descending geniculate artery, several muscular branches, and the caudal femoral artery. The popliteal artery gives off the following branches: the medial sural artery, lateral sural artery, and five articular branches. The caudal tibial artery was very thin, whereas the cranial tibial artery was strong and gave off a cranial recurrent tibial artery running toward the knee joint.

Conclusion: With the help of two classic veterinary anatomy books, we described the vascular anatomy around the pig knee from the perspective of comparative medicine, which was useful for vessel-related studies using pig knees and was conducive to academic communication.

Introduction: The Rutherford Classification for chronic limb-threatening ischemia (CLTI) is used to categorize peripheral artery disease severity through history and physical examination. This study investigated whether higher Rutherford Classification correlates with worse clinical outcomes and could serve as a predictive tool.

Methods: In this prospective single-center study , 252 patients undergoing lower extremity revascularization were followed for three years (2020-2023). Rutherford classification was determined at presentation. Outcomes included reintervention for stenosis/occlusion, amputation rates, and mortality. Statistical analysis used chi-squared tests for categorical data and one-way ANOVA for continuous data.

Results: Higher Rutherford classifications (3-6) showed increased reoperation rates versus lower classifications (28.2% vs 10.3%, p=0.043), with the largest increase between classes 2 and 3 (4.7% to 26.8%). Amputation rates were significantly higher in classifications 4-6 versus 0-3 (31.9% vs 7.2%, p<0.001), particularly between classes 4 and 5 (19.0% to 37.6%). Mortality rates were also higher in classes 4-6 versus 0-3 (22.6% vs 7.2%, p<0.001).

Discussion: Rutherford Classification effectively predicts major adverse outcomes, with marked increases at specific classification transitions suggesting critical thresholds for risk stratification. Early intervention may be warranted in higher classifications. These findings support its use as a valuable prognostic tool in preoperative planning and patient counseling.

Conclusion: This study validates Rutherford Classification as an effective tool for predicting adverse outcomes in CLTI patients. The clear correlation between higher classifications and increased complications supports its use in clinical decision-making, risk stratification, and determining optimal timing for surgical intervention.

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.