Vascular and endovascular surgery最新文献

BackgroundCarotid endarterectomy (CEA) is recommended as the standard revascularization strategy for patients with carotid stenosis, whereas carotid artery stenting (CAS) is generally reserved for high-risk surgical candidates. However, evidence comparing the safety and efficacy of both approaches in real-world practice remains heterogeneous.MethodsWe retrospectively analyzed 202 patients (mean age: 71.1 ± 8.5 years; 152 males, 75.2%) who underwent carotid revascularization at a single center between October 2016 and April 2025. Patients with symptomatic moderate-to-severe stenosis (50-99%) and asymptomatic severe stenosis (70-99%) were included. Based on the revascularization strategy, patients were divided into CEA (n = 67) and CAS (n = 135) groups. Periprocedural (30-day), 1 and 3-year outcomes including stroke, myocardial infarction (MI), and all-cause mortality were evaluated.ResultsAmong patients, periprocedural stroke occurred in 4.5% of CEA patients and 2.2% of CAS patients (P = 0.653), MI in 1.5% and 0%, (P = 0.720), and all-cause mortality in 4.5% and 0.7% (P = 0.208) respectively. At 1-year follow-up, MI was significantly more frequent after CEA compared with CAS (8.6% vs 1.5%, P = 0.029), whereas stroke (8.6% vs 5.3%, P = 0.387) and all-cause mortality (10.3% vs 12.9%, P = 0.622) did not differ significantly. At 3 years, rates of stroke (12.3% vs 5.3%), MI (10.3% vs 3.8%), and all-cause mortality (22.4% vs 15.9%) were numerically higher in the CEA group, although these differences were not statistically significant. Subgroup analyses according to symptomatic status demonstrated no significant differences in 30-day, 1 or 3-year rates of stroke, MI, or all-cause mortality between the CEA and CAS groups.ConclusionIn this single-center experience, CAS achieved peri-procedural and short-term outcomes comparable to CEA, despite being performed in a more frail and comorbid patient population. These findings suggest that CAS may represent a safe and effective alternative to CEA in high-risk surgical candidates when performed by experienced operators within a multidisciplinary framework.

ObjectiveVascular closure devices (VCDs) are frequently employed to achieve hemostasis at the femoral puncture site, offering an alternative to traditional manual compression. However, a rare yet significant complication is common femoral artery (CFA) occlusion caused by suture-mediated VCDs. The optimal management of this complication remains unclear, with open surgical repair traditionally regarded as the standard of care. This paper aims to share our clinical experience in managing CFA occlusions caused by suture-mediated VCDs and to introduce our preferred endovascular treatment strategy.MethodsAt our institution, approximately 250 femoral artery hemostasis procedures using suture-mediated VCDs are performed annually. Over the past 10 years, we encountered 6 cases of CFA occlusion following the use of such devices. This corresponds to an incidence rate of approximately 0.24%. In all cases, endovascular management was selected as the primary treatment modality over open surgical intervention. Our endovascular approach consisted of initial balloon angioplasty, with adjunctive stenting performed when residual stenosis exceeded 50%.ResultsEndovascular treatment was technically successful in all 6 cases, with no major procedural complications. The mean degree of stenosis prior to balloon angioplasty was 91.9%, including 3 cases of long segmental occlusion. Balloon angioplasty alone was sufficient in 4 cases, while the remaining 2 required additional stenting to address significant residual stenosis. Final angiography demonstrated an average residual stenosis of 25.1%. During the follow-up period (mean duration: 37.8 months), no patients reported symptoms of lower extremity ischemia.ConclusionThis case series highlights the feasibility and efficacy of endovascular management as a first-line approach for CFA occlusion caused by suture-mediated VCDs. When diagnosis is delayed, long segmental occlusion with considerable thrombus burden may limit the effectiveness of balloon angioplasty alone, necessitating adjunctive stenting. Therefore, timely diagnosis and intervention are essential to optimize outcomes in these cases.

IntroductionBlunt trauma to the external iliac artery (EIA) is rare but potentially fatal. Endovascular stent-graft placement is used to control hemorrhage and restore limb perfusion. However, the safety profile and potential complications associated with stent-graft treatment are not well documented. We report a case of EIA injury following blunt trauma complicated by stent-graft deployment into a false lumen, successfully managed with an endovascular rescue technique.Case ReportAn 88-year-old man sustained blunt pelvic trauma with active extravasation from the left EIA. Initially, a covered stent-graft was deployed, which inadvertently caused arterial occlusion due to placement within a false lumen. A rescue procedure was performed using an endovascular approach, where a guidewire was advanced through the perigraft space and snared to establish a pull-through technique. Over this, a second stent-graft was deployed within the perigraft space, restoring flow through the true lumen. Follow-up computed tomography images confirmed successful recanalization and persistent exclusion of the false lumen.ConclusionThis case highlights the potential for stent-graft misplacement in EIA trauma and the importance of ensuring access to the true lumen. Accessing the perigraft space and placing an additional stent-graft represents a new therapeutic approach to achieve recanalization in similar complex vascular injuries.

BackgroundAortic dissection following endovascular aneurysm repair (EVAR) may be iatrogenic or a de-novo event. This study aims to systematically review all cases of dissection following EVAR to identify complications specific to each scenario and develop a management algorithm depending on the clinical presentation.MethodsA comprehensive literature search of MEDLINE, Embase, and CENTRAL databases was performed for all studies relating to dissection following EVAR or fenestrated/branched EVAR (F/BrEVAR). Data collected included timing (differentiating iatrogenic and de-novo events), entry tear location, endograft involved, complications, management, and subsequent outcomes. Due to limited data availability, descriptive data was collected and outcomes compared depending on dissection type and timing. Risk of bias was assessed using a standardised tool for case reports.Results46 patients in 37 studies were included. Complications included endograft compression (52.2%), endoleak (15.2%), and rupture (13.0%). Compression was less likely in endografts with proximal fixation (41.9%), compared to those without (69.2%). Type A dissection after EVAR required cardiac surgery with a high mortality (20.0%). In Type B dissection, 2 cases were diagnosed intra-operatively during F/BrEVAR, 1 died. 8 were diagnosed <4 weeks post-operatively, all managed medically with no complications or mortality. 31 were diagnosed >4 weeks, with mortality of 25.8% and high rates of endograft compression (58.1%), endoleak (16.1%), and rupture (19.4%).ConclusionAortic dissection following EVAR may cause endograft compression, endoleak, or rupture, with significant mortality. Complications are more frequent following Type A dissection and late Type B dissection. Early Type B dissection may be amenable to medical management.

ObjectiveThe study was performed to examine clinical outcomes of bypass surgery for recurrent superficial femoral artery (SFA) occlusive lesions after endovascular treatment (EVT).MethodPatients who underwent bypass surgery for a recurrent SFA lesion after EVT at 4 Japanese vascular centers from 2015 to 2020 were analyzed retrospectively. The primary endpoint was graft patency (primary, assisted primary, and secondary).ResultsA total of 46 patients were included in the study. The patients had high rates of hypertension (85%), diabetes (70%), and chronic kidney disease (63%). Clinical presentation before EVT was intermittent claudication in 16 cases (35%) and chronic limb-threatening ischemia in 30 cases (65%). Initial EVT was performed for complex SFA lesions (lesion length, 200 [125-260] mm; reference vessel diameter, 5.3 [4.7-6.0] mm; chronic total occlusion, 50%; poor below-the-knee runoff vessel, 60%). The final device was a bare-nitinol stent in 26 cases (56%), stent graft in 9 (20%), and drug-eluting stent in 7 (15%). A total of 46 surgical reconstructions (above-the-knee femoropopliteal bypass, 15 (33%); below-the-knee femoropopliteal bypass, 7 (15%); tibial bypass, 24 (52%)) were performed using autologous vein grafts (72%) and prosthesis grafts (28%) in a median period of 300 [145-556] days from initial EVT. The median procedure time was 201 [159-299] min. No case had early graft occlusion or hospital death within 30 days. The median follow-up period was 27 (12.7-49.2) months. The 3-year primary, assisted primary, and secondary graft patencies were 57%, 70%, and 77%, respectively; the 3-year limb salvage was 84%; and the 3-year survival was 66%.ConclusionMedium term outcomes were acceptable in patients with bypass surgery for a recurrent SFA lesion after EVT.

BackgroundThirty-day hospital readmissions are a critical healthcare quality metric used to evaluate hospital performance and patient outcomes. Vascular surgery readmission rates are among the highest and most costly. Accurate data on patient readmissions is essential for improving care quality and reimbursement processes. The accuracy of readmission data, often derived from quality metric programs like NSQIP and Vizient, is challenged by misclassification or improper capture of readmissions.MethodsWe conducted a single-institution retrospective analysis using the NSQIP and Vizient registries to identify patients who underwent vascular surgery between 2018 and 2023 and were subsequently readmitted to our institution within 30 days. Demographic, procedural, and readmission data were reviewed to identify factors associated with procedure-related vs non-procedure related readmissions. Logistic regression was employed to determine variables that significantly predicted procedure-related readmissions.ResultsAmong 2375 vascular surgery operations captured by NSQIP and Vizient during the study period, 219 patients (9.2%) were readmitted within 30 days. Of these, 89 (40.6%) were procedure-related and 130 (59.4%) were non-procedure-related. Baseline demographics, comorbidities, and perioperative characteristics were largely similar between groups, although patients with non-procedure-related readmissions were more likely to be functionally dependent (39.2% vs 22.5%, P = 0.009) and current smokers (30.8% vs 20.2%, P = 0.08). In multivariable logistic regression, functional dependence (OR 0.41, 95% CI 0.19-0.88, P = 0.022) and current smoking within 1 year (OR 0.48, 95% CI 0.23-0.99, P = 0.047) were independently associated with lower odds of procedure-related readmission, suggesting that these patients are more likely to return for medical decompensation rather than surgical complications.ConclusionsVascular surgery readmissions are frequent and costly, and factors such as functional health status and pre-existing complications should be considered in prevention strategies. Accurate documentation and coding, combined with targeted transitional care interventions, will be essential to reduce unnecessary readmissions and to ensure fair institutional benchmarking under current quality metric programs.

ObjectivesTo evaluate the clinical, hematological, and anatomical outcomes of rotational atherectomy (RA) combined with drug-coated balloon (DCB) angioplasty compared to DCB alone in patients with femoropopliteal arterial disease, with particular emphasis on inflammatory markers and mid-term vessel patency.MethodsThis retrospective, single-center study included patients who underwent endovascular treatment for femoropopliteal lesions using either RA combined with DCB (RA + DCB) or DCB alone. Demographic characteristics, lesion morphology, neutrophil-to-lymphocyte ratio (NLR), and Doppler ultrasonography (DUS) findings were compared between the two groups. Primary outcomes were residual stenosis, ankle-brachial index (ABI), and mid-term vessel patency. Secondary outcomes included postprocedural NLR changes and clinical symptom evolution during follow-up.ResultsA total of 150 patients were included, with 75 treated using RA + DCB and 75 with DCB alone. There were no significant differences in baseline demographics or comorbidities between groups. The RA + DCB group demonstrated a higher prevalence of TASC A lesions and left lower extremity involvement. Postprocedural lymphocyte counts were significantly higher, and NLR values were significantly lower in the RA + DCB group. Additionally, this group exhibited lower residual stenosis rates and significantly higher patency rates at 6 and 12 months. Greater clinical improvement and a higher proportion of asymptomatic patients were observed in the RA + DCB group during follow-up.ConclusionsRA combined with DCB offers superior vascular and clinical outcomes vs DCB alone, likely due to improved lesion preparation and reduced inflammation. NLR may serve as both a prognostic biomarker and indicator of treatment efficacy in peripheral arterial interventions.

BackgroundIdentifying the aetiology of ischemic stroke can be challenging, especially when critical findings are overlooked. Stroke assessment often relies on standardised guidelines, primarily focused on carotid stenosis severity (>50%) as an intervention criterion. However, this approach may neglect high-risk plaque features. This case report highlights the importance of integrating diagnostic findings with clinical presentation to guide management.Case presentationA 68-year-old male presented with sudden-onset transient right arm weakness. Initial imaging, including MRI and CT angiography, revealed a subtle diffusion-weighted imaging (DWI) abnormality in the left hemisphere and moderate carotid atherosclerosis (<50%) that did not meet guideline criteria for endarterectomy. Despite antiplatelet and anticoagulant therapy, the patient experienced multiple recurrent ischemic episodes. Due to the persistence of symptoms, the multidisciplinary team (MDT) recommended advanced vessel wall MRI, which identified intraplaque haemorrhage and plaque ulcerations in the left internal carotid artery-critical findings missed on conventional imaging. This led to a decision to perform carotid endarterectomy. Histology confirmed atheromatous disease with intraplaque haemorrhage. Following surgery, the follow-up scans showed no new infarcts with no clinical recurrence.DiscussionThis case underscores the limitations of relying solely on carotid stenosis degree in stroke management and highlights the importance of identifying high-risk plaque characteristics. Advanced vessel wall imaging proved instrumental in guiding treatment, while MDT collaboration ensured a tailored approach. The findings emphasise the need to prioritise carotid stenosis characteristics over stenosis degree alone when guiding clinical decisions to optimise outcomes in ischemic stroke management.

BackgroundObstructive sleep apnea (OSA) is a recognized risk factor for aortic dissection development due to its association with arterial hypertension, negative intrathoracic pressures during respiratory efforts, and further development of aortic false lumen. However, the impact of OSA on the outcomes of type A aortic dissection (TAAD) repair has not been extensively investigated. Therefore, this study aimed to perform a population-based analysis of the impact of OSA on in-hospital outcomes following TAAD repair.MethodsPatients who underwent TAAD repair were identified in National Inpatient Sample from the last quarter of 2015-2020. Multivariable logistic regressions were employed to compare the in-hospital outcomes between patients with and without OSA, where demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status were adjusted for.ResultsThere were 465 (10.86%) and 3817 (89.14%) patients with and without OSA who underwent TAAD repair. Patients with and without OSA had comparable in-hospital mortality (9.89% vs 15.75%, aOR = 0.744, 95 CI = 0.535-1.035, P = .08). Patients with OSA had a higher risk of diaphragmatic paralysis (0.86% vs 0.21%, aOR = 4.821, 95 CI = 1.405-16.539, P = .01) but lower risks of pericardial complications (12.04% vs 19.02%, aOR = 0.675, 95 CI = 0.501-0.909, P = .01) and cardiogenic shock (11.40% vs 18.21%, aOR = 0.643, 95 CI = 0.472-0.875, P = .01). All other in-hospital outcomes were comparable.ConclusionWhile OSA is a known risk factor for the development of TAAD, it does not appear to significantly affect short-term surgical outcomes. Future research should focus on stratifying OSA by duration and severity and examining the long-term prognosis of these patients.

Background: Endovascular Aneurysm Repair (EVAR) is a proven, safe, and effective treatment; however, its application may be limited by the potential adverse effects of iodinated contrast medium (ICM), which can exacerbate renal function and may be contraindicated in patients with renal insufficiency. Purpose: This review aims to provide an overview of "zero-iodine contrast EVAR," which uses CO₂ exclusively, as a strategy to mitigate the risk of acute kidney injury (AKI) associated with ICM. Research design: A systematic literature review was conducted in PubMed, Embase, and Cochrane databases following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify EVAR cases performed using carbon dioxide. The Medical Subject Headings (MeSH) terms used were "endovascular repair AND abdominal aortic aneurysm AND contrast medium" and "endovascular repair AND abdominal aortic aneurysm AND carbon dioxide," with inclusion criteria limited to articles in English published until December 2024. Results: The literature search yielded 1167 papers. After removing duplicates, titles and abstracts were screened, and 68 papers underwent full-text review. A total of 16 studies were included in the analysis, encompassing 1625 patients. Of these, 837 patients underwent EVAR with ICM, and 788 patients underwent EVAR with CO₂. Of these, 510 patients were treated with EVAR using CO₂ exclusively. Conclusions: Although this method still faces inherent limitations due to the physicochemical characteristics of CO₂, its use, when combined with additional technical precautions, enables the achievement of zero-contrast results in standard EVAR procedures.