Vascular and endovascular surgery最新文献

ObjectiveTo evaluate the impact of introducing a surgeon-led emergency endovascular aneurysm repair (EVAR) service on patient outcomes and cost efficiency in the management of ruptured abdominal aortic aneurysms (rAAA) at a UK tertiary vascular center.MethodsA retrospective cohort study was conducted, including all patients presenting with rAAA between January 2019 and December 2023. Patients were categorized into two time periods: before (Period A: 2019-2020) and after (Period B: 2021-2023) the introduction of the emergency EVAR service. Outcomes assessed included 30-day and one-year mortality, length of hospital stay, complication rates, and return-to-theatre rates. Cost-effectiveness analysis was conducted using incremental cost-effectiveness ratio (ICER) calculations based on Quality-Adjusted Life Years (QALYs).ResultsA total of 71 patients with ruptured abdominal aortic aneurysm were identified, of whom 58 underwent surgical repair (OSR or EVAR). In Period A, all patients (n = 17) underwent open surgical repair. In Period B, 24 received OSR (58.5%) and 17 received EVAR (41.5%). The 30-day mortality rate was significantly lower in the EVAR group (5.9%) compared to OSR in both periods (63.3% and 50%, respectively; P = .001). The one-year mortality rate remained unchanged for EVAR but increased for OSR (P = .00075). Return-to-theatre rates were significantly higher in OSR patients (P = .044). ICER calculations showed EVAR to be cost-effective (-£202 526 per QALY within one year).ConclusionThe introduction of a surgeon-led emergency EVAR service significantly improved early survival rates and reduced reintervention rates in rAAA patients while demonstrating cost-effectiveness compared to OSR.

ObjectiveRestenosis limits the benefit of below-the-knee (BTK) endovascular therapy (EVT). Restenosis may be attributable to limited information from digital subtraction angiography. A promising alternative is intravascular ultrasound (IVUS). However, data regarding the association between post-EVT IVUS-detected lesions and the risk for future major adverse limb events (MALE) after BTK EVT are scarce.DesignProspective single-arm observational pilot study.MethodsPatients scheduled for BTK EVT were eligible. Altogether, 50 patients were included after informed consent. IVUS was performed in treated BTK vessels to analyze vessel characteristics and, if present, lesions. Lesions were defined as; significant stenoses (≥50%), substantial vessel wall irregularities (highly calcified multisided sharp wall irregularities without significant stenosis and over a longer track post-PTA), any dissections, and incorrect stenting. Follow-up included duplex ultrasound (DUS) after 3, 6 weeks, and 3 and 6 months after EVT by trained independent nurses blinded to IVUS findings. Primary endpoint was MALE, including restenosis/occlusions and major amputation.ResultsIn total, 33/50 (66%) participants had at least one lesion following IVUS. Compared to the group without any lesions, no difference in baseline characteristics was found. Lesions contained mostly significant stenosis (52%) or wall irregularities (20%). Within 6 months, 28 (56%) participants experienced MALE, including 23 restenosis/occlusion. In total, 21/28 (75%) participants with MALE had a lesion on IVUS imaging. Participants with MALE had a higher incidence of any lesions on IVUS compared with the no-lesion group (64% vs 41%), leading to a sensitivity of 0.75 and specificity of 0.45.ConclusionThis study suggests a good sensitivity for IVUS in detecting post-treatment lesions leading to MALE. However, a well-powered study is warranted to confirm these results. Ultimately, a randomized trial should assess the effect of interventions for IVUS-detected lesions post-EVT on reduction of risk of future MALE. However, the first needs are standardized reporting definitions, categorization of IVUS-detected lesions, and standardization of operating procedures.

Background: A pulmonary arteriovenous malformation (PAVM) is an abnormal connection between the pulmonary arterial and venous systems, resulting in a pathologic right-to-left shunt. PAVMs worsen during pregnancy due to physiologic changes, yet no treatment guidelines exist for newly diagnosed PAVMs in pregnancy.Case: We report a case of a previously asymptomatic 19-year-old G1 who was incidentally found to have a low oxygen saturation during routine prenatal care at 34 5/7 weeks of gestation. She was diagnosed with a complex, left-sided PAVM. Through the close collaboration of the interventional radiology and high-risk obstetric teams, antenatal embolization was successfully performed, allowing for the prolongation of pregnancy. The patient experienced spontaneous rupture of membranes at 36 1/7 weeks and underwent a successful Cesarean delivery at this time.Conclusion: Embolization of a complex PAVM in the third trimester of pregnancy was successfully and safely achieved by a skilled multidisciplinary team. In comparable clinical scenarios, clinicians should carefully assess maternal and fetal risks-such as neonatal prematurity, radiation exposure, and PAVM-related complications-to guide optimal management.

Aortic pleomorphic sarcomas are rare, aggressive vascular tumors often presenting with nonspecific symptoms that delay diagnosis. We describe a 53-year-old male who presented with isolated lower extremity claudication. Examination revealed absent pulses in the left leg, and duplex vascular ultrasound showed monophasic flow. CT angiography demonstrated a 48 mm infrarenal abdominal aortic aneurysm extending to the iliac bifurcation, a bulge in the left common iliac artery, and high-grade stenosis in a short segment. The patient underwent surgical repair with a Y-graft. Histopathological analysis confirmed undifferentiated pleomorphic sarcoma with a high Ki67 index (65%) and absence of specific immunohistochemical markers. Postoperative PET-CT revealed metastatic disease involving lungs, liver, and bones. The patient subsequently received systemic chemotherapy. This case highlights the diagnostic challenges of undifferentiated pleomorphic sarcoma when they present with isolated ischemic symptoms rather than signs of malignancy Early recognition through imaging and histopathology is essential, as surgical resection remains the cornerstone of treatment despite poor prognosis.

ObjectivesThoracic Endovascular Aortic Repair (TEVAR) is now the standard of care for management of aortic injury from trauma. Long term outcomes stratified by the severity of the aortic injury are limited.MethodsThis is a single center retrospective analysis of all patients undergoing TEVAR for trauma between January 2008-November 2023. Long term outcomes of mortality and re-intervention were stratified and compared based on the blunt thoracic aortic injury score. Kaplan Meier analysis was used to compute one year and 5-year survival.ResultsA total of 104 patients (age 42 ± 15 years; 72 males; 69%) underwent TEVAR for trauma. Most repairs were for grade 3 (59 patients, 57%) or grade 4 (30 patients, 29%) blunt aortic injuries. The remaining patients included grade 1 (1 patient, 1%), grade 2 (14 patients; 13%). Grade 4 injuries were not associated with higher rate of concomitant neurologic injuries (P = 0.33) or death (P = 0.74). Eighty-seven percent patients had a mean follow up of 4.2 ± 3.3 years. Two patients died due to aortic related causes within 30 days (intra-operative hemorrhage in one patient, graft collapse in one patient who had an unsuccessful exploratory thoracotomy). Overall, one year survival was 92%, and 5-year survival was 88% by Kaplan Meier analysis. Patients with neurologic injury trended toward higher mortality in Kaplan Meier analysis but this was not statistically significant (log rank = 0.22). The grade of injury was not significant for long term survival (log rank = 0.81). Early reintervention was required in 2% patients with none required in long-term. Age>40 (P = 0.17), female sex (P = 0.34) and graft diameter>26 mm (P = 0.41) were not significant for re-intervention. None of the patients experienced endoleaks or spinal cord ischemia.ConclusionsTEVAR is a durable repair for patients with BTAI requiring no re-intervention after one year follow-up. CT surveillance of TEVAR in setting of trauma should be limited to 1 and 5 years after surgery. Long term survival is not related to severity of BTAI.

BackgroundIn 2022, the United States Medical Licensing Examination (USMLE) Step 1 transitioned to a pass/fail format, removing a long-standing objective measure from residency applications. This shift led applicants and/or residency program directors to place increased emphasis on alternative metrics such as research output (RO), though how much programs value this remains unclear. This study explores RO trends among vascular surgery applicants from 2014-2024 and compares them by applicant type and across other competitive surgical specialties.MethodsNRMP Charting Outcomes in the Match reports (2014-2024) were reviewed. The mean number of abstracts, presentations, and peer-reviewed publications (RO) was collected for matched and unmatched U.S. MD seniors applying to vascular surgery. RO data for Doctor of Osteopathic Medicine (DO) and non-U.S. international medical graduate (IMG) applicants were also reviewed for completeness.ResultsRO among matched U.S. MD vascular surgery applicants rose by 54.7%, from 7.0 in 2014 to 12.8 in 2024. The most marked increase occurred between 2018 and 2022 (8.3 to 12.4; +67%), with growth plateauing thereafter after 2022. In contrast, RO among matched DO and IMG applicants declined: DO applicants dropped from 21.3 in 2022 to 9.0 in 2024, and IMG applicants from 60.3 in 2020 to 38.3 in 2024. However, 2024 sample sizes were small, 137 matched U.S. MDs vs only 3 DOs and 6 IMGs, limiting direct comparisons.ConclusionWhile RO among vascular surgery applicants surged after Step 1 became pass/fail, the recent plateau suggests a transient response rather than ongoing growth, differing from trends in other surgical subspecialties. These findings raise concerns about equity and added pressure on underrepresented applicants. Further research is needed to clarify RO's actual role in residency selection and inform fairer evaluation practices.

PurposeLong-term survival after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm remains a clinical concern, particularly in elderly patients with comorbidities. This study aimed to compare different machine learning (ML) models that capture complex, nonlinear relationships among clinical variables to predict 5-year all-cause mortality following EVAR.MethodsWe retrospectively analyzed 142 patients who underwent elective EVAR between 2013 and 2018. Predictive models for 5-year mortality were developed using 3 supervised ML algorithms: Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Support Vector Classification (SVC). Each model was trained on the entire dataset and internally validated through 5-fold cross-validation. Model performance was evaluated using accuracy, sensitivity, specificity, precision, F1 score, and area under the curve (AUC) based on the training set and 5-fold cross-validation. Feature importance was assessed for RF and XGBoost.ResultsThe RF demonstrated the most consistent performance (training AUC 0.80; cross-validation AUC 0.77 ± 0.07). XGBoost achieved the highest training accuracy (0.85) but had lower cross-validation AUC (0.68 ± 0.05). SVC showed stable but modest performance. Key predictors identified by RF and XGBoost included poor nutritional status, octogenarian status, compromised immunity, and active cancer.ConclusionsTree-based ML models, especially RF, may effectively predict long-term survival after EVAR. Incorporating key clinical predictors into preoperative assessment may enhance risk stratification. Future studies should explore external validation and integration with time-to-event models such as Cox proportional hazards, to enhance prognostic accuracy.

IntroductionAcute aortic occlusion (AAO) is a rare, life-threatening condition presenting with severe ischemia and requiring urgent intervention. While traditional open surgical approaches, including aortobifemoral and axillobifemoral bypasses, are well-established, endovascular techniques such as Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) have emerged as promising alternatives in select cases. This case introduces a novel modification termed Lysis Assisted CERAB (LA CERAB), combining thrombolysis and CERAB to manage acute graft occlusions.MethodsSingle-institution case report highlighting the utility of the LA CERAB technique in select patients.ResultsA 67-year-old male presented two years post-open aortobiiliac aneurysm repair with acute abdominal pain and bilateral limb ischemia without motor impairment. Initial CTA demonstrated complete thrombosis of his graft. He underwent percutaneous bilateral transfemoral catheter-directed thrombolysis. Post-thrombolysis angiography showed graft patency but significant residual thrombus. Subsequent LA CERAB successfully re-lined the graft, secured residual thrombus, and restored perfusion. The patient had an uneventful recovery, discharged home on therapeutic anticoagulation. Follow-up CTA at 2 months demonstrated sustained graft patency. This case highlights its applicability to acute presentations and adds to a growing body of literature on acute aortic graft occlusion interventions.ConclusionThe LA CERAB technique can serve as a novel, minimally invasive approach for select AAO patients presenting with high morbidity risks for transition open surgery. This case underscores patient-specific considerations in treatment strategy selection, illustrating how individualized surgical approaches can achieve favorable immediate and sustained clinical outcomes for future patients.

Background: Patients with abdominal aortic aneurysms (AAA) often have comorbidities that make them poor candidates for open surgical repair (OSR). Endovascular aortic aneurysm repair (EVAR) circumvents the morbidity associated with OSR of AAA. Candidacy for EVAR is impacted by multiple factors, including the quality and size of vascular access vessels and involvement of visceral arteries, as seen in paravisceral abdominal aortic aneurysms (PVAAA). Additional challenges, such as obesity, can complicate vascular access during EVAR. PVAAA may be better suited for fenestrated EVAR (FEVAR) using a physician-modified endograft (PMEG).Materials and Methods: In this report, we describe the case of a 64-year-old female patient with a complex PVAAA in the setting of significant aortoiliac occlusive disease (AIOD) with intermittent claudication. We describe a successful staged FEVAR technique in which vascular access challenges were first addressed by recanalization of the iliac system with femoral conduit (FC) creation, followed by successful FEVAR using bilateral FC for deployment of the PMEG.Conclusion: Patients with PAAA have unique and complex pathology that are clinically challenging to address. It is not uncommon that these patients also have co-morbid conditions that make them less-than ideal candidates for open repair. Patients may also have other conditions such as AIOD which make EVAR complex. Staged approach with iliac recanalization and femoral conduit creation followed by FEVAR with PMEG is an effective treatment option for high-risk complex patients and can help avoid common complications such as groin infection and delay in FEVAR which may result in a catastrophic event such as interval AAA rupture.

BackgroundVaricose vein surgery increases the risk of venous thromboembolism (VTE). Although pharmacological thromboprophylaxis is commonly used postoperatively, its efficacy and optimal regimen remain unclear. This study systematically reviews the effectiveness and safety of various anticoagulant strategies.MethodsA comprehensive literature search was conducted across PubMed, Embase, EBSCO, and Web of Science databases to identify relevant studies. Eligible studies were screened and selected based on predefined inclusion and exclusion criteria. A network meta-analysis was performed to compare different anticoagulant agents and prophylaxis durations indirectly. Additionally, a random-effects meta-analysis was conducted to calculate the relative risk (RR) and 95% confidence intervals (CI) for VTE and bleeding outcomes.ResultsA total of 11 studies, including 7359 patients who underwent either endovenous or open surgical procedures for varicose veins, met the inclusion criteria. Meta-analysis results indicated that pharmacological thromboprophylaxis was associated with a lower risk of VTE compared to no prophylaxis (RR = 0.49, 95% CI: 0.12-1.99, P < 0.01); however, this difference was not statistically significant. Similarly, there was no significant difference in bleeding risk between patients who received anticoagulant prophylaxis and those who did not (RR = 2.03, 95% CI: 0.82-5.07, P = 0.81). Furthermore, network meta-analysis revealed no significant differences in the incidence of thromboembolic events or bleeding risk across various prophylaxis durations (3, 5, and 10 days) or among different anticoagulants, including low-molecular-weight heparin (LMWH), rivaroxaban, heparin, apixaban, and sulodexide.ConclusionsPostoperative anticoagulant prophylaxis for VTE following varicose vein surgery appears to be safe; however, its effectiveness in reducing VTE incidence remains uncertain. The lack of significant differences in outcomes across different prophylaxis durations and anticoagulant types highlights the need for further high-quality, large-scale randomized controlled trials to establish the optimal prophylactic strategy, including the appropriate agent, dosage, and duration.