Vascular and endovascular surgery最新文献

PurposePaclitaxel is a chemotherapeutic agent which may be administered locally to an arterial lesion via a drug-coated balloon or drug-eluting stent. We report an allergic reaction to locally administered paclitaxel.Case SummaryA 75 year-old woman underwent a right external iliac to superior mesenteric artery bypass and presented a year later with evidence of iliac artery stenosis, which was repaired via angioplasty and stenting. Two years later, the patient presented again with restenosis. She underwent balloon angioplasty of affected vessels with an IN.PACT Admiral® 6 × 40 drug-coated (Paclitaxel) balloon. The patient presented to her local hospital a week later with severe pruritis and a rash, for which she received a dose of parenteral steroid. Despite the patient's denial of changes in medication or environmental changes, she continued to experience hypersensitivity symptoms which required recurrent courses of oral prednisone, diphenhydramine, and cetirizine before finally resolving.ConclusionTo our knowledge, a severe allergic reaction to paclitaxel has not been reported when administered locally using either a drug-coated balloon or a drug-eluting stent. This case emphasizes that severe allergic reactions can occur. Because the drug is embedded in the arterial tissue, it cannot be easily removed, and such allergic reactions should be treated with systemic corticosteroids and antihistamines. The allergic reaction should be self-limited as the drug is eliminated over time.

IntroductionCarotid endarterectomy (CEA) is a cornerstone in stroke prevention for patients with carotid stenosis, with closure techniques including primary, patch angioplasty, and eversion. The aim of this paper is to present a 10-year analysis of outcomes in patients undergoing primary repair and selective patch angioplasty in CEA.MethodsA retrospective, single-center study including all consecutive patients undergoing elective CEA at our institution between 2014 and 2023. The Primary outcomes were technical success and 30-day overall survival, ipsilateral ischemic stroke, reintervention, and major adverse cardiac events (MACE) rates. The secondary outcomes were >30-day ipsilateral ischemic stroke, reintervention and primary patency. All outcomes were analyzed in relation to the carotid closure technique (primary closure, patch angioplasty, or eversion). A Generalized Linear Mixed Model (GLMM) was used to assess the association between closure technique and both early and late outcomes. Kaplan-Meier estimates were used to analyze follow-up outcomes depending on the closure technique.ResultsA total of 625 CEA procedures were performed on 577 patients [mean age: 71 ± 9 years; 30.7% female], comprising 87.4% primary repairs, 10.4% patch angioplasty, and 2.2% eversion CEA. Technical success was achieved in (n = 615, 98.4%) of the procedures, with no significant difference between repair types (P value .947). The mean follow-up duration was 60 ± 38.45 months. Early (<30-day) ipsilateral stroke and reintervention did not differ significantly across carotid repair groups. GLMM analysis showed that congestive heart failure (CHF) was a significant predictor of increased risk for stroke and MACE (OR: 8.870, CI 95% 2.046-38.451, P = .005) (OR: 7.037, CI 95% 1.902-26.038, P = .005), respectively. Regional anesthesia significantly lowered the risks of stroke (OR: 0.216, CI 95% .065-.721, P = .014) and MACE (OR: 0.380, CI 95% .158-.914, P = .032). Long-term (>30-day) ipsilateral stroke and 2-year primary patency were comparable across the groups. GLMM analysis of >30-day stroke revealed no statistically significant differences between patch and primary CEA (OR: 1.947, 95% CI: .321-11.819, P = .363). Neither age >80 years (n = 94, 15%) nor female sex (n = 177, 30.7%) were significantly associated with increased stroke risk (age: OR 0.524, 95% CI: 0.021-7.013, P = .415; sex: OR 0.524, 95% CI: 0.087-3.152, P = .370). The analysis of 2-year patency outcomes revealed no significant associations between patch vs primary CEA, sex, or age greater than 80 years. KM analysis revealed 3-year survival rates of 93% for primary repair, 99% for patch angioplasty, and 90% for eversion (P = .5). Stroke-free survival at 3 years was 95%, 94%, and 100%, respectively (P = .3).ConclusionNo significant differences were observed in early or late stroke, mortality, or 2-year patency on adjusted

ObjectiveThis study aimed to compare 30-day postoperative outcomes of carotid body tumor (CBT) resections performed by vascular surgeons vs otolaryngologists, examining complication rates, operation time, and hospital stay duration.MethodsA retrospective cohort analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2020. Patients undergoing CBT resection were identified using CPT code 60605. Only cases performed by vascular surgeons or otolaryngologists were included. The primary outcome was any major postoperative complication, with secondary outcomes including operation time and hospital length of stay. Multivariable logistic and linear regression models adjusted for confounders including age, sex, modified Charlson Comorbidity Index (mCCI), race, surgical setting, and emergency status.ResultsA total of 718 patients (545 vascular surgery, 173 otolaryngology) were included. Patients operated on by vascular surgeons were older (58 vs 51 years, p < .001), had a significantly higher incidence of hypertension (51% vs 36%; p < .001) and mCCI (1.78 ± 1.47 vs 1.25 ± 1.36; p < .001). Otolaryngology surgeries had significantly longer mean operative times (203 vs 145 min, p < .001) and a higher, though not statistically significant, rate of major complications (5.3% vs 2.3%, p = .07). Adjusted multivariable analysis showed otolaryngology specialty was independently associated with increased odds of severe adverse events (aOR: 2.99; 95% CI: 1.15-7.56; p = .021) and longer operation time (aβ: 61; 95% CI: 46-75; p < .001), but not with reoperation rates.ConclusionWhile both specialties achieved generally safe outcomes, CBT resections performed by otolaryngologists were associated with longer operative times and higher odds of major complications. These differences may reflect variations in case complexity, patient selection, or surgical expertise, warranting further prospective research into multidisciplinary and specialty-specific outcomes for CBT surgery.

PurposeThis case report aims to describe the rare and severe complication of carotid artery stent expulsion via an oropharyngeal fistula (OCF) in a 59-year-old male with head and neck cancer. The study emphasizes the unique interplay between oropharyngeal cancer and carotid artery blowout and highlights a novel presentation of OCF in a patient with advanced comorbidities.CaseA 59-year-old male with oropharyngeal squamous cell carcinoma, carotid artery stenosis, and multiple comorbidities underwent chemotherapy, pseudoaneurysm embolization, and carotid artery stenting. Four months after carotid artery stent placement, the patient expelled the carotid stent through an oropharyngeal fistula. Imaging confirmed a chronic fistula and occlusion of the right carotid artery. Remarkably, the patient remained hemodynamically stable due to collateral circulation, allowing for safe discharge without further intervention.ConclusionsThis case illustrates an exceedingly rare presentation of carotid artery stent expulsion through an oropharyngeal fistula in a patient with severe carotid stenosis and head and neck cancer. This case underscores the importance of vigilance in patients with high-risk comorbidities undergoing vascular interventions for head and neck cancers. It also adds to the literature by highlighting a potential, albeit rare, complication of carotid stenting in the context of oropharyngeal malignancy.

ObjectivesIn recent years, the widespread use of vascular imaging and increased workups for atherosclerotic disease have led to more frequent detection. Although the true incidence remains unclear, the number of renal artery aneurysms identified through imaging has increased. Ruptured renal aneurysms are extremely rare and can be life-threatening without emergency treatment. However, only a few studies have focused on its treatment. In this report, we present a case of a ruptured renal pseudoaneurysm treated with endovascular therapy.Case DescriptionA female patient who had previously undergone surgery for a ruptured abdominal aortic aneurysm (rAAA) presented with progressive left-sided lower back pain. Computed tomography revealed a ruptured left renal pseudoaneurysm near the AAA replacement. Chimney endovascular aneurysm repair (Ch-EVAR) was performed immediately. Completion angiography demonstrated no endoleak and preserved flow into the left renal artery. The patient was discharged 4 days post-Ch-EVAR.ConclusionsThis case offers valuable perspectives on managing ruptured renal aneurysms. Ch-EVAR represents a feasible treatment option for such cases. Following treatment for aortic emergencies such as rAAA, careful long-term follow-up is necessary.

ObjectiveTo demonstrate the demographic profile and postoperative outcomes among a large single-center series of patients undergoing carotid endarterectomy for carotid web.BackgroundCarotid artery web (CaW) is a shelf-like intraluminal lesion at the carotid bulb that produces stagnant flow and can result in cerebrovascular ischemia among young and otherwise healthy individuals. While there is no consensus on the ideal management strategy for CaW with ipsilateral stroke, emerging evidence favors open surgical intervention. We present a large single-center experience of carotid endarterectomy for CaW.MethodsSingle-center retrospective review of all patients admitted between January 2016 and September 2023 with acute ischemic stroke, had CT angiography findings consistent with CaW- shelf-like projection at the level of the carotid bulb- and underwent carotid endarterectomy. The main outcome variables were ipsilateral stroke or transient ischemic attack during the follow-up period.ResultsTwenty-three patients who underwent carotid endarterectomy for CaW were identified. The median age was 41 years old [IQR 38 - 47], 19 were female (82%), and 21 were African American (91%). One patient was originally managed with medical therapy alone and presented with recurrent stroke. All patients underwent carotid endarterectomy at a median of 29 days after presentation. Patch angioplasty was used in 16 (70%) patients, 15 with bovine pericardial patch and one with collagen-impregnated polyester patch. The arteriotomy was closed primarily in the other 7 patients. Eleven (48%) patients had mobile thrombus associated with the web present on imaging or surgical exploration. No new cerebrovascular events occurred in the follow-up period, a median of 154 days.ConclusionCarotid endarterectomy is an established procedure that can be applied to the treatment of carotid web in the setting of associated ipsilateral cerebrovascular ischemia. The procedure is associated with minimal complications and demonstrates an absence of recurrent ischemic events at short and medium-term follow-up.

Objective: The Pedal Medial Arterial Calcification (pMAC) score is a radiographic tool that quantifies arterial calcification in the foot, providing a novel approach to predict outcomes in chronic limb-threatening ischemia (CLTI). This study investigates the association of pMAC scores with clinical outcomes in patients undergoing major lower limb amputations (MLLA). Methods: This retrospective study analyzed data from the National Vascular Registry (NVR) for the Southeast Wales Vascular Network (SEWVN) from July 2022 to June 2024. Patients undergoing MLLA with available preoperative radiographs were included. pMAC scores were categorized into low (0-1), medium (2-3), and high (4-5). Cox proportional hazards regression assessed the impact of pMAC on time to amputation, while additional analyses evaluated its association with revascularization outcomes and systemic comorbidities. Results: A total of 119 patients were included after excluding cases with insufficient imaging. Higher pMAC scores were associated with male gender (P = 0.009) and chronic kidney disease (P = 0.017), though not with preoperative blood test parameters. Each unit increase in pMAC score was associated with a 22% higher risk of amputation over time (HR = 1.22, P = 0.049). Medium pMAC scores correlated with shorter time to MLLA (P = 0.0516). Revascularization type did not significantly impact time to amputation (P = 0.66). Conclusions: pMAC predicts amputation risk in CLTI patients, independent of revascularization type. Integrating pMAC into clinical workflows may refine risk stratification and guide postoperative care. Prospective validation is warranted to establish its role in vascular surgery decision-making.

BackgroundMechanical thrombectomy (MT) is the gold standard treatment for acute ischemic stroke (AIS) patients with large vessel occlusion. Direct cervical carotid puncture is a recognized approach in unfavorable aortic arch anatomy. However, manual compression/ surgical closure of the access site can be challenging if the International Normalized Ratio (INR) is high and the patient is taking anticoagulation.Case SummaryWe present a case of Stanford type A (STA) aortic dissection (status post Bentall procedure) presenting with acute ischemic stroke (AIS) with left M2-MCA thrombotic occlusion. Conventional transfemoral or transradial approach for MT was deferred due to replaced ascending aorta & arch debranching and a residual thoraco-abdominal aortic dissection flap. Risk of soft tissue blood loss was high with open neck access (surgical cut down) due to high INR of 2.9. So, MT was performed through direct left common carotid artery (CCA) puncture achieving mTICI 3 flow. Due to high INR, manual compression was deferred, puncture site haemostasis was achieved with use of collagen based Obtura vascular closure device (VCD). Patient made substantial neurological recovery with no puncture site complications and MRS-0 at discharge.ConclusionObtura femoral VCD can be an alternative haemostatic device for direct carotid puncture mechanical thrombectomy for AIS.

PurposeThe purpose of this study was to compare the effectiveness and safety of drug eluting stents with percutaneous transluminal angioplasty and bare-metal stents in below the knee peripheral artery disease. Methods: The systematic review was registered in Research Registry. A literature search was performed across four databases: PubMed, Medline/Embase, Cochrane Review, and Web of Science for eligible comparative studies. The primary outcomes examined were mortality, major amputation (above the ankle), minor amputation (below the ankle), and clinically driven target lesion revascularization (CD-TLR). A random effects model was used when pooling outcomes to account for heterogeneity.Main FindingsA total of 7 studies were included in this systematic review and meta-analysis. All subjects were treated for below the knee lesions and CLTI was confirmed as Rutherford ≥4 in 669/955 (70.0%). Among the studies, 572 were treated with a drug eluting stents and 477 treated with non-DES modalities. Pooled analysis showed that DES significantly reduced minor amputations and CD-TLR, O.R = 0.56 [0.32, 0.96], and O.R = 0.38 [0.25, 0.60], respectively. In subgroup analysis, paclitaxel eluting stents were not associated with either survival or major amputation. Everolimus/sirolimus eluting stent use was associated with reduced CD-TLR, O.R = 0.36 [0.21, 0.61].ConclusionThis study suggests that Drug-Eluting Stents (DES), irrespective of type, provide protection against minor amputations and CD-TLR. However, they do not seem to have a significant impact on overall survival rates or the risk of major amputations.

ObjectiveInterventionalists have noted significant venous luminal gain with nitinol venous stents although post-placement lumen shape differed from the circular shape observed with elgiloy stents. The goal of this study was to determine the characteristics of a stented vein lumen that correspond with clinical outcomes, and to identify metrics that might be relevant for stent design by assessing aspect ratio (AR), lumen diameter (LD), lumen area (LA), and stent shape (symmetry and eccentricity) post-implant.MethodsThis post-hoc analysis evaluated patients from the VIVO US Study (NCT01970007) with pre- and post-stent intravascular ultrasound (IVUS) imaging. Patient characteristics, Venous Clinical Severity Score (VCSS) and Venous Disability Score (VDS) were collected in the study. LD, LA, and stent geometry were measured by the core laboratory. Data were analyzed for linear association between core-laboratory assessed pre and post stent LD, LA, AR, stent eccentricity and symmetry index, and VCSS and VDS change.ResultsIVUS imaging was available for 29 patients (2 sites) enrolled in the VIVO US Study (55.2% women; mean age: 59.8 ± 17 years). The cohort had post-thrombotic (48.3%), nonthrombotic iliac vein lesion (44.8%) or acute deep vein thrombotic (6.9%) disease. Mean lesion length was 111.8 ± 60.9 mm. Eleven stents extended below the inguinal ligament. Median minimum LD and LA significantly increased after stent placement (P < 0.001); median lumen AR changed from 2.0 pre-stent to 1.4 post-stent (P < 0.001). Mean VCSS improved from baseline to 12 months (7.6 ± 4.3 to 3.7 ± 2.6). No statistically significant linear relationships were identified between VCSS / VDS change and a specific characteristic of LA, LD, or AR.ConclusionsMeasures of lumen change pre and post iliofemoral vein nitinol stent placement reflect disease and stent characteristics. After stent placement, minimum LD and LA increased and AR decreased. Stented lumen shape or size with Zilver Vena did not impact 1-year clinical improvement by VCSS.