Annals Of Vascular Surgery[JOURNAL]
Sun
200 papers
The Influence of Gender on the Outcomes of Revascularization for Aortoiliac Occlusive Disease.
de Athayde Soares R, Lorenzoni GS, Pinheiro VG … +4 more , Peixoto Aleixo FA, Dutra de Souza Matos B, Pecego CS, Sacilotto R
Ann Vasc Surg · 2026 Jul · PMID 41903846 · Publisher ↗
BACKGROUND: The objective of the present study was to assess the impact of gender on outcomes following endovascular treatment of AIOD, focusing on patency, limb salvage, reintervention rates, and survival. METHODS: This...
BACKGROUND: The objective of the present study was to assess the impact of gender on outcomes following endovascular treatment of AIOD, focusing on patency, limb salvage, reintervention rates, and survival. METHODS: This retrospective cohort study of prospectively collected data included consecutive patients with AIOD who underwent aortoiliac angioplasty between January 2017 and January 2024. Two groups were analyzed: (1) female patients, (2) male patients. Eligible patients presented with critical limb-threatening ischemia or disabling claudication. Regression cox was performed to evaluate the factors related to primary patency, major amputation, and overall survival. Among several factors analyzed, covered versus bare-metal stents and common femoral endarterectomy were evaluated. RESULTS: A total of 108 endovascular procedures were attempted. Technical success was achieved in 103 patients (95.4%), who comprised the study cohort. The female group predominated with 57 patients (55.3%) and the male group with 46 patients (44.7%). Arterial hypertension was the most prevalent comorbidity (79.6%), with higher prevalence at female group than male group (87.7% vs. 69.6%, P = 0.021), followed by dyslipidemia (63.1%), diabetes mellitus (54.4%), and ischemic heart disease (28.2%), with higher prevalence at male group than female group (65.3% vs. 34.5%, P = 0.005). Concomitant common femoral endarterectomy (CFE) was performed in 11 patients (10.7%; 13% male group and 8.8% female group; P = 0.48). The perioperative mortality rate was 11.7%, with no significant differences among groups (P = 0.82). Primary patency at 1,000 days was 80.1% at male group and 78.1% at female group (P = 0.43). Limb salvage rates at 1000 days were 95.5% at male group and 95.5% at female group, P = 0.57. Cox regression analysis identified bare-metal stent use as a predictor of reduced primary patency (HR 15.99, 95% CI 2.07-122.996; P = 0.008). Conversely, CFE was a protective factor for better primary patency (HR 0.123, 95% CI 0.020-0.778; P = 0.026). CONCLUSION: In conclusion, female and male patients with AIOD submitted to endovascular treatment had similar outcomes regarding patency, limb salvage rates, overall survival, and freedom from target-lesion reintervention. Moreover, covered stent use was associated with higher primary patency and lower reintervention rates compared with bare-metal stents, and concomitant CFE was a protective factor for better primary patency.
Carotid Endarterectomy Reduces Systemic Inflammatory Burden: A Prospective Analysis of Preoperative and Postoperative Biomarker Dynamics.
Beyaz MO, Kaya S, Beyaz GK … +1 more , Tas SK
Ann Vasc Surg · 2026 Jul · PMID 41903845 · Publisher ↗
BACKGROUND: Carotid atherosclerosis is a chronic inflammatory disease in which cytokines, particularly interleukin (IL)-6 (IL-6), IL-1β, and tumor necrosis factor-α (TNF-α), lead to endothelial dysfunction, plaque destab...
BACKGROUND: Carotid atherosclerosis is a chronic inflammatory disease in which cytokines, particularly interleukin (IL)-6 (IL-6), IL-1β, and tumor necrosis factor-α (TNF-α), lead to endothelial dysfunction, plaque destabilization, and thromboembolic events. While carotid endarterectomy (CEA) effectively reduces the risk of stroke, its effect on systemic inflammatory biomarkers has not been fully characterized. In this study, we aimed to comprehensively evaluate the changes in inflammatory biomarker profiles after CEA and identify patient subgroups showing different inflammatory responses. METHODS: This prospective observational study included 87 consecutive patients who underwent CEA between January 2024 and June 2025 at Hatay Mustafa Kemal University Hospital. Ten inflammatory biomarkers (C-reactive protein [CRP], IL-6, TNF-α, IL-10, IL-1β, tumor necrosis growth factor [TGF]-β, fibrinogen, neutrophil-lymphocyte ratio [NLR], white blood cell count [WBC], and procalcitonin)] were measured from peripheral venous blood samples collected preoperatively (24 h before surgery) and postoperatively (48-72 h after surgery). Serum was obtained after centrifugation for cytokine analysis. Wilcoxon signed-rank tests were used for preoperative and postoperative comparisons; Mann-Whitney U-tests were used for subgroup analyses; and Spearman coefficients were used for correlations. RESULTS: All 10 biomarkers were significantly reduced in the postoperative period (all P < 0.001). The greatest reductions occurred in IL-6 (-29.3%), NLR (-28.6%), IL-1β (-28.1%), procalcitonin (-27.5%), and CRP (-26.2%), with high effect sizes (Cohen's d > 2.0). Symptomatic patients and those with unstable plaques showed significantly greater reductions in inflammation compared to asymptomatic patients and those with stable plaques (P < 0.05 for CRP, IL-6, fibrinogen, NLR, and IL-1β). IL-6 showed a strong correlation with stenosis severity (ρ = 0.602, P < 0.001). Interestingly, baseline CRP (P = 0.024), IL-6 (P = 0.049), and fibrinogen (P = 0.004) levels were lower in patients who developed restenosis. CONCLUSION: CEA delivers significant and consistent reductions in systemic inflammatory biomarkers and shows greater effects in high-risk inflammatory phenotypes. These findings support the anti-inflammatory benefit of carotid revascularization beyond mechanical plaque clearance and suggest potential for inflammatory biomarker-guided patient selection.
Do Arterial Allografts Outperform Venous in Cryopreserved Bypass for Limb Salvage? A Systematic Review and Meta-Analysis of Infrainguinal Revascularization Outcomes.
Buongiovanni G, Murigu A, Wong KHF … +5 more , Settembrini A, Nava G, Dainese L, Trabattoni P, Hinchliffe RJ
Ann Vasc Surg · 2026 Aug · PMID 41903844 · Publisher ↗
BACKGROUND: Cryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding...
BACKGROUND: Cryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding comparative outcomes by allograft type (arterial vs venous) and clinical indication (infectious vs noninfectious settings). This systematic review and meta-analysis summarizes outcomes and key evidence gaps. METHODS: A systematic search of studies reporting infrainguinal reconstructions with cryopreserved arterial or venous allografts was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (International Prospective Register of Systematic Reviews: CRD42024579097). Primary outcomes were 1-year primary patency, overall survival, and cumulative major amputation. Random-effects single-arm meta-analyses were performed with subgroup analyses by graft type and infection status. Risk of bias was assessed using Risk Of Bias In Nonrandomized Studies - of Interventions and certainty of evidence using Grading of Recommendation Assessment, Development, and Evaluation (GRADE). Secondary outcomes, including reintervention and graft-related complications, were narratively summarized. RESULTS: Forty-two studies (2,237 patients; 2,170 limbs) were included: 25 were at serious risk of bias and 17 at moderate. Pooled 1-year primary patency was 51.1% (95% confidence interval [CI] 40.9-61.4%), overall survival 85.0% (95% CI 81.1-88.9%), and cumulative major amputation 20.2% (95% CI 15.7-24.7%). Arterial grafts had higher patency (67.6%; 95% CI 54.3-80.9%) than venous (39.6%; 95% CI 30.2-49.0%). Reconstructions for infection had superior patency (70.4%; 95% CI 55.2-85.6%) compared with noninfectious indications (44.2%; 95% CI 32.8-55.5%). GRADE certainty was very low. CONCLUSION: Cryopreserved allografts enable limb salvage in complex chronic limb-threatening ischemia but show modest 1-year patency and substantial heterogeneity. Arterial conduit and use in infection were associated with superior early patency; robust comparative studies are required to optimize graft selection.
Smoking Status Predicts Mortality after Carotid Endarterectomy for Symptomatic Disease but Not after Carotid Stenting or Transcarotid Revascularization.
Basilious M, Akosman I, Sarad N … +6 more , Jethmalani N, Agrusa CJ, Ellozy SH, Connolly PH, Stern JR, DeRubertis BG
Ann Vasc Surg · 2026 Aug · PMID 41903843 · Publisher ↗
OBJECTIVE: To assess the impact of smoking on mortality after interventions for symptomatic carotid stenosis. METHODS: The Vascular Quality Initiative database was reviewed from 2003 to 2021 to identify patients undergoi...
OBJECTIVE: To assess the impact of smoking on mortality after interventions for symptomatic carotid stenosis. METHODS: The Vascular Quality Initiative database was reviewed from 2003 to 2021 to identify patients undergoing interventions for symptomatic carotid artery stenosis with carotid endarterectomy (CEA), transfemoral carotid stenting (TFCAS), or transcarotid artery revascularization (TCAR). Patients were grouped as never, former (quit ≥1 month prior), or active smokers (smoking within 1 month). Propensity matching adjusted for demographics, comorbidities, preoperative medications, and additional risk factors. Primary outcomes were 30-day and 1-year mortality; secondary outcomes included 30-day transient ischemic attack, stroke, and other complications. Multivariate logistic regression identified independent predictors of mortality. RESULTS: We identified 27,693 patients who underwent carotid artery interventions for symptomatic stenosis (CEA = 18,867; TFCAS = 5,388; TCAR = 3,438). After propensity score matching, no significant differences persisted in preoperative demographics and risk factors. After CEA, active smokers exhibited similar rates of 30-day mortality (1.19% vs. 0.89%, P = 0.338), but significantly higher rates of 1-year mortality (5.43% vs. 3.78%, P = 0.005) compared to never smokers. Active smokers also had an increased rate of 1-year mortality compared to former smokers (5.73% vs. 4.57%, P = 0.012). Mortality did not differ by smoking status after TFCAS or TCAR. There was an increased rate of overall complications in former smokers over never smokers undergoing TCAR (8.27% vs. 5.19%, P = 0.041), otherwise no other significant differences were noted in any of the secondary outcomes. On multivariate logistic regression analysis, both active smoking (odds ratio 1.395, 95% confidence interval: 1.11-1.67) and former smoking (odds ratio 1.321, 95% confidence interval: 1.12-1.56) were predictive of 1-year mortality following CEA. CONCLUSION: Both active and former smoking are independently associated with increased 1-year mortality following CEA for symptomatic carotid artery stenosis, but not after TFCAS or TCAR. Active smoking was associated with higher 1-year mortality than former smoking, highlighting the importance of smoking cessation in patients with carotid disease.
Two-Year Comparative Outcomes of Four Early Clot Removal Techniques for Deep Vein Thrombosis.
Ozsoy O, Ugur M, Caglar Karakaya H … +1 more , Turhan M
Ann Vasc Surg · 2026 Aug · PMID 41903842 · Publisher ↗
BACKGROUND: Despite full adherence to treatment, patients with acute iliofemoral deep vein thrombosis (IFDVT) remain at high risk for developing postthrombotic syndrome (PTS). Consequently, endovascular strategies such a...
BACKGROUND: Despite full adherence to treatment, patients with acute iliofemoral deep vein thrombosis (IFDVT) remain at high risk for developing postthrombotic syndrome (PTS). Consequently, endovascular strategies such as early thrombus removal and catheter-directed thrombolysis (CDT) have been developed. In this study, we compared the long-term effectiveness of endovascular thrombectomy techniques and CDT available at our institution. METHODS: We retrospectively analyzed 91 adults with acute IFDVT who underwent endovascular interventions between 2019 and 2023. Patients were stratified into four groups (G1, G2, G3, G4): CDT (n = 27), AngioJet rheolytic (n = 27), AngioJet Power Pulse (n = 17), and Mantis rotational thrombectomy (n = 20). The primary outcome was the development of PTS at 24 months, assessed using Villalta and the venous clinical severity score. Secondary outcomes included complications, major and minor bleeding events, and recurrent thrombosis. RESULTS: Among the 91 patients, the mean age was 51.2 ± 18.1 years, 51.6% were male, and the mean body mass index was 27.6 ± 3.7 kg/m. At 24 months, PTS assessed by the Villalta score showed no significant differences among groups (P = 0.279). In G1, 51.9% had no PTS, 29.6% mild, 14.8% moderate, and 3.7% severe; in G2, 59.3% had no PTS, 29.6% mild, 3.7% moderate, and 7.4% severe; in G3, 64.7% had no PTS, 5.9% mild, 11.8% moderate, and 17.6% severe; and in G4, 70% had no PTS, 20% mild, 0% moderate, and 10% severe. Major bleeding occurred in 0-7.4% of patients, minor bleeding in 7-18.5%, and acute kidney injury in 5-35.3%, with no cases of perioperative mortality or pulmonary embolism. Recurrence was observed in G1 (3.7%) and G3 (23.5%), with a statistically significant difference between groups (P = 0.004). CONCLUSION: In conclusion, our study found no significant differences among endovascular techniques regarding PTS development. All methods were generally safe, although recurrence rates varied across techniques.
Causal Machine Learning for Personalized Surgical Decision-Making in Aortic Dissection: A National Fairness-Aware Clinical AI Framework.
Hassan AA, Elshami MI, Shaban Soliman AA … +11 more , Abdo Ibrahim MI, Hassan Ali MH, Aboumansour MH, Abuelela EZ, Awad FM, Elbnawany MM, Aly Elbosraty EE, Mohamed Moustafa AY, Elsabagh HM, Aboheif MM, Ali Aboelsaad HY
Ann Vasc Surg · 2026 Aug · PMID 41903841 · Publisher ↗
BACKGROUND: Most machine learning (ML) models for aortic dissection predict mortality but do not address treatment-effect heterogeneity, fairness, or bedside implementation. We developed a causal-inference-informed frame...
BACKGROUND: Most machine learning (ML) models for aortic dissection predict mortality but do not address treatment-effect heterogeneity, fairness, or bedside implementation. We developed a causal-inference-informed framework integrating prediction, heterogeneous treatment-effect estimation, fairness auditing, and individualized risk-benefit profiling. METHODS: Using 2016-2022 Healthcare Cost and Utilization Project National Inpatient Sample discharge data, we analyzed 45,112 aortic dissection hospitalizations. Five ML models, plus a weighted ensemble, were trained on 2016-2019 data (n = 24,475) and temporally tested on 2020-2022 data (n = 20,624). CausalForestDML estimated surgery-associated heterogeneous effects with specification-based robustness analyses. We audited fairness across race/ethnicity, insurance status, and income, and performed internal-external geographic validation. RESULTS: In-hospital mortality was 11.0% (n = 4,940). The ensemble achieved an area under the receiver operating characteristic curve (AUROC) of 0.845, with stable COVID-era performance. Calibration varied substantially across models (Brier 0.076-0.161). Causal forest estimated heterogeneous surgery-associated treatment effects (interpreted as observational associations), with 39.5% of patients aged ≥80 years showing negative conditional average treatment effects versus 18.5% aged 65-80; however, all average treatment effect (ATE) 95% confidence intervals crossed zero. Dissection type-stratified analysis showed distinct patterns for Type A (ATE +0.4 pp) versus Type B (ATE +0.8 pp). Fairness was consistent across the 3 largest racial groups (AUROC 0.820-0.862). Model discrimination was preserved with race excluded (AUROC 0.834 vs. 0.836). Geographic validation preserved discrimination (0.832 ± 0.007). CONCLUSION: This framework supports risk stratification and hypothesis generation regarding treatment-effect heterogeneity, but not causal treatment recommendations. Clinical deployment requires prospective testing and independent external validation.
Supervised In-Person versus Home-Based Exercise in Peripheral Artery Disease: A Pilot Comparative Study.
Lara M A, Martínez-Huenchullán S, Jara D C … +9 more , Zárate B C, Bustos A S, Bustamante M J, Agurto L, Flores S, Burgos N, Prieto P, Zapata M M, Núñez V C
Ann Vasc Surg · 2026 Jul · PMID 41895602 · Publisher ↗
BACKGROUND: Peripheral artery occlusive disease (PAD) causes intermittent claudication and functional impairment. Exercise is a primary therapeutic strategy, yet comparisons between supervised in-person and remote home-b...
BACKGROUND: Peripheral artery occlusive disease (PAD) causes intermittent claudication and functional impairment. Exercise is a primary therapeutic strategy, yet comparisons between supervised in-person and remote home-based programs are limited. This pilot study compared both modalities on physical function and quality of life in individuals with PAD. METHODS: Fifteen adults under 65 years with PAD were assigned to an in-person group (n = 8) or a home-based group (n = 7). Both completed an 8-week aerobic and resistance-training program (3 60-min sessions/week). Vascular function (PVR 2CP), body composition, physical function (1-min STST, 6MWT), muscle oxygen saturation (SmO), medication adherence (Morisky-Green), physical activity (IPAQ), and quality of life (EQ-5D VAS) were assessed. RESULTS: Participants were mostly men (60%) with multiple comorbidities. No baseline differences were observed. Adherence was higher in the in-person group (91.7% vs. 41%). The in-person group showed significant improvements in 6MWT distance (+51 m; P < 0.05), PVR, pain-free walking, and lower-limb strength/endurance (1-min STST; P < 0.05). The home-based group showed no significant functional changes. Pain-free walking improved in both groups, with greater gains in the in-person modality. Hemodynamic measures remained stable, medication adherence was unchanged, and quality of life showed slight improvement in both groups. Physiological responses during the 6MWT displayed expected exercise-related patterns without group differences. CONCLUSION: Supervised in-person exercise produced meaningful improvements in functional capacity, strength, endurance, and PVR values. These benefits underscore the effectiveness of this supervised in-person protocol for individuals with PAD in our local context.
Saphenous Vein Arterialization for Limb Salvage in Unreconstructable Peripheral Arterial Disease: Long-Term Results.
Shoemaker H, Lau DL, Safran BA … +1 more , Brewer MB
Ann Vasc Surg · 2026 Aug · PMID 41895601 · Publisher ↗
BACKGROUND: Chronic limb-threatening ischemia (CLTI) is the end stage of peripheral arterial disease, characterized by ischemic rest pain, nonhealing ulcers, or gangrene. Up to 40% of patients lack distal targets for rev...
BACKGROUND: Chronic limb-threatening ischemia (CLTI) is the end stage of peripheral arterial disease, characterized by ischemic rest pain, nonhealing ulcers, or gangrene. Up to 40% of patients lack distal targets for revascularization, often resulting in major amputation. Great saphenous vein arterialization (GSVA) with distal pedal vein valve disruption is a promising limb salvage technique. We report 12-month amputation, pain, and wound healing for patients with CLTI treated with GSVA between 2019 and 2024. METHODS: From October 2019 to August 2024, 20 limbs in 15 patients with unreconstructable CLTI underwent GSVA. The GSV was used in situ and anastomosed to the most distal patent artery, with central valvulotomy and peripheral valve disruption. Outcomes were assessed through chart review on August 2025. RESULTS: GSVA was technically successful in all cases without major operative complications. Patients were predominantly male (87%) with mean age 63 years; 87% had diabetes. Follow-up of ≥12 months was available for 14 of 15 patients (19 of 20 limbs). One patient died 327 days post-GSVA without undergoing amputation. Among the 19 limbs with 12-month follow-up, below knee amputation (BKA)-free survival was 53% (10 of 19). Over total study follow-up, BKA-free survival was 55% (11 of 20). In limbs without BKA, 91% demonstrated wound healing and pain improvement. Most amputations (8 of 9) occurred within 1.5 months of GSVA. CONCLUSION: GSVA with pedal valve disruption offers a viable limb salvage option for patients with unreconstructable CLTI, achieving >50% BKA-free survival at 1 year and substantial wound healing. Larger studies are needed to refine patient selection and optimize outcomes.
Alterations in Arterial Stiffness and Cardiac Function Following Complex Endovascular Repair of Pararenal and Thoracoabdominal Aortic Aneurysms.
Tsotsios M, Katsargyris A, Moulakakis KG … +5 more , Oikonomou E, Tsigkou V, Hasemaki N, Siasos G, Klonaris C
Ann Vasc Surg · 2026 Jul · PMID 41895600 · Publisher ↗
BACKGROUND: Previous studies have demonstrated significant changes in arterial stiffness and secondary cardiac effects following endovascular repair of infrarenal or thoracic aortic aneurysms. However, data remain scarce...
BACKGROUND: Previous studies have demonstrated significant changes in arterial stiffness and secondary cardiac effects following endovascular repair of infrarenal or thoracic aortic aneurysms. However, data remain scarce regarding the impact of more extended complex fenestrated and branched endovascular aortic repair (F/BEVAR) for pararenal and thoracoabdominal aortic aneurysms. This study aimed to investigate alterations in arterial stiffness and cardiac function following F/BEVAR. METHODS: A total of 41 patients undergoing F/BEVAR for pararenal or thoracoabdominal aortic aneurysms were prospectively enrolled. Arterial stiffness was evaluated by measuring the carotid-femoral pulse wave velocity (cfPWV). Cardiac function was assessed by left ventricular global longitudinal strain, left atrial volume index, peak atrial longitudinal strain, left ventricular end-diastolic volume, and N-terminal pro-B-type natriuretic peptide. Measurements were obtained preoperatively and at 1 and 6 months postoperatively. RESULTS: Arterial stiffness increased significantly postoperatively. CfPWV increased from 10.85 ± 2.27 preoperatively to 15.30 ± 3.70 m/s at 1 month (P < 0.001) and remained elevated at 14.54 ± 3.90 m/s (P = 0.22), at 6 months. Ventriculoarterial coupling increased (cfPWV/global longitudinal strain ratio - 0.60 ± 0.23 to - 0.79 ± 0.29 m/s%; P < 0.001). Left atrial volume index increased (30.4 ± 13.7 to 33.1 ± 13.6 ml/m; P < 0.001), left ventricular end-diastolic volume increased (74.3 ± 21 to 77.1 ± 20.1 mL; P < 0.001), and peak atrial longitudinal strain decreased (30.1 ± 9.7 to 27 ± 8.8%; P = 0.06) at 1 month. N-terminal pro-B-type natriuretic peptide levels increased transiently (341 ± 204 to 1,266 ± 786 pg/mL; P < 0.01) at 1 month follow-up, but seemed to be improved at the second examination. All cardiac markers were elevated at 1-month follow-up and most of them continued to deteriorate at 6 months. A high percentage of aortic coverage seemed to deteriorate the cfPWV measurements. CONCLUSION: Endovascular repair of complex aortic aneurysms with F/BEVAR is associated with a significant increase in arterial stiffness and measurable changes in cardiac function. Further research is necessary to better understand the potential implications of these extensive endovascular procedures for the cardiac function in the long-term. In view of these findings, long-term cardiovascular monitoring should be considered for patients undergoing extensive endovascular aortic repair.
Management of Inferior Mesenteric Artery Aneurysms Based on a Comprehensive Review of all Reported Cases in the Last 50 Years.
Balakrishnan N, Akfaly EM, Jabeen N … +5 more , Brovold C, Osborne Z, Beckermann J, Weis TL, Sen I
Ann Vasc Surg · 2026 Jul · PMID 41895599 · Publisher ↗
BACKGROUND: Inferior mesenteric artery aneurysms (IMAAs) are rare, and their clinical behavior and management outcomes are poorly understood. METHODS: We performed a retrospective review of all published cases of IMAA fr...
BACKGROUND: Inferior mesenteric artery aneurysms (IMAAs) are rare, and their clinical behavior and management outcomes are poorly understood. METHODS: We performed a retrospective review of all published cases of IMAA from 1861 to 2025. Demographics, aneurysm size, treatment outcomes, and follow-up were analyzed. RESULTS: A total of 70 studies (74 patients; 63 male, mean age 59 ± 16) report clinical details of patients with IMAA. Presentation was with abdominal pain in 18 (24%). The most common etiology was atherosclerosis in 45 patients (61%). Overall, the mean IMAA diameter was reported in 63 studies (66 cases) and was 3 ± 1.8 cm. Surgical intervention was performed in 61 patients (82%); in this group, the mean IMAA diameter was 3.3 ± 2 cm. Indication for intervention (when reported) included IMAA enlargement to over 1.5 cm in 35 (47%) or rupture in 16 (22%). Open surgery included IMA bypass/reimplantation in 29 (39%) with ligation/embolization in the rest. Early postprocedural mortality was reported in 4 patients. Median postoperative follow-up was 8 months. Late mortality was reported following repair in 1 patient at 4 years unrelated to the aneurysm (myocardial infarction). Nine (12%) patients were managed nonoperatively; the mean IMAA diameter was 2.5 ± 1.5 cm and the median reported follow-up was 6 months. With nonoperative management; 3/6 patients with IMAA size greater than 1.5 cm experienced fatal rupture between 2 and 14 weeks. CONCLUSION: IMAAs repair should be considered at a size greater than 1.5 cm.
PCSK9 Inhibitors in Peripheral Arterial Disease: A Systematic Review.
Bandukwala LM, Curley D, Bontinis A … +2 more , Bontinis V, Shalhoub J
Ann Vasc Surg · 2026 Jul · PMID 41895598 · Publisher ↗
BACKGROUND: Dyslipidaemia is a key modifiable risk factor for peripheral arterial disease (PAD), and statin therapy for lipid-lowering is well established in its management. Proprotein convertase subtilisin/kexin type-9...
BACKGROUND: Dyslipidaemia is a key modifiable risk factor for peripheral arterial disease (PAD), and statin therapy for lipid-lowering is well established in its management. Proprotein convertase subtilisin/kexin type-9 (PCSK9) inhibitors lower lipids and cardiovascular risk; however, their impact on limb-based outcomes in PAD remains uncertain. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating PCSK9 inhibitor therapy in patients with PAD were eligible for inclusion. RESULTS: Four studies met the inclusion criteria and were included in the review, comprising three randomized controlled trials (RCTs) and 1 prospective case series, with a total of 3,770 patients. The majority of included participants were derived from a large multicenter RCT, FOURIER, which contributed 3,642 patients from its PAD subgroup. In the FOURIER PAD subgroup, Evolocumab significantly reduced major adverse limb events (MALEs) compared with placebo in patients receiving background statin therapy (Hazard Ratio 0.58; 95% Confidence Interval 0.38-0.88). Smaller studies in patients with PAD and chronic limb-threatening ischemia reported improvements in amputation-free survival, wound healing, walking performance, and markers of endothelial function and atherosclerotic burden. CONCLUSION: PCSK9 inhibitors appear to provide limb-related benefits in patients with PAD, without ill-effects. These benefits include decrease in MALEs and improvements in functional and physiological parameters, and may extend beyond lipid lowering alone. However, current evidence is limited, heterogeneous, and exploratory. Dedicated, adequately powered randomized trials focusing on clearly defined limb outcomes are needed to clarify the role of PCSK9 inhibitors in PAD management.
An Artificial Intelligence Application for Standardized Expert-Level Interpretation of Vascular Clinical Practice Guidelines.
Alexiou VG, Vassiliou A, Sumpio BE … +2 more , Geroulakos G, Kakkos SK
Ann Vasc Surg · 2026 Jul · PMID 41895597 · Publisher ↗
BACKGROUND: Clinical practice guidelines (CPGs) are often complex and subject to the reader's interpretation. The aim was to develop and validate an artificial intelligence (AI)-driven application for standardized interp...
BACKGROUND: Clinical practice guidelines (CPGs) are often complex and subject to the reader's interpretation. The aim was to develop and validate an artificial intelligence (AI)-driven application for standardized interpretation of CPGs. The application was named "VascLink-AI," reflecting the clinical focus and traceable nature of the tool. METHODS: A comparative study to benchmark AI performance against established clinical standards. The 2017 European Society of Cardiology/European Society for Vascular Surgery Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases were vectorised into a knowledge graph. A large language model was locked to this graph, returning structured, citation-anchored answers. Performance was tested on 41 committee-answered vignettes. The app's answers and the committee's answers were scored for accuracy, completeness, clarity, relevance, adaptability, and evidence justification by an automated evaluator (GPT-4o) and 2 independent human experts. Inter-rater reliability and consensus scores were compared. A noninferiority analysis was performed. RESULTS: The application achieved high alignment with the expert intent, with composite scores favoring the app for both raters: automated 90.5% versus 77.8%, P < 0.001; human consensus 94.2% versus 86.2%, P < 0.001. Reliability analysis revealed an "agreement gap"; human raters' agreement on committee answers was negligible (Kappa = -0.018), but reached a moderate level on AI answers (Kappa = 0.450). The application was found to be noninferior to the experts across all 12 evaluated metrics (all P < 0.001). CONCLUSION: This study demonstrates how AI can grow from a general research aid into a traceable, guideline-restricted framework capable of delivering advice that matches human expert interpretation of societal guidelines.
Subcutaneous Port Implantation Without Tunneling Site Anesthesia: A Feasible and Efficient Approach?
Bolgen C, Karluka I
Ann Vasc Surg · 2026 Jul · PMID 41895596 · Publisher ↗
BACKGROUND: The study examines whether omitting local anesthesia at the tunneling site during subcutaneous port catheter implantation is associated with differences in patient comfort and procedural outcomes through pain...
BACKGROUND: The study examines whether omitting local anesthesia at the tunneling site during subcutaneous port catheter implantation is associated with differences in patient comfort and procedural outcomes through pain assessment during tunneling. METHODS: The study included 243 patients who underwent subcutaneous port catheter placement at one interventional radiology unit. Patients received local anesthesia through three injection sites-vascular access, tunneling, and port pocket (n = 121)-or through two sites-vascular access and port pocket only (n = 122). The primary outcome was tunnel-site pain assessed by visual analog scale. Secondary outcomes included patient satisfaction, complication rates, procedure duration, additional anesthetic requirements, and total anesthetic consumption. Between-group differences were evaluated using appropriate statistical tests with P < 0.05 as the significance threshold. RESULTS: No statistically significant difference was observed in mean pain levels during tunneling between the three-region and two-region groups (4.1 ± 2.3 vs. 3.8 ± 2.1; mean difference 0.3; 95% confidence interval: -0.35 to 0.95; P = 0.361). No statistically significant difference in patient satisfaction was observed between groups [median 4 (interquartile range [IQR]: 3-5) versus median 4 (IQR: 4-5), P = 0.135]. Procedure duration showed no statistically significant difference (22.3 ± 4.5 vs. 21.7 ± 4.2 minutes, P = 0.517). Additional analgesia was required in 20.7% vs. 15.6% of patients (P = 0.302). Both groups demonstrated similarly low overall complication rates (7.4% vs. 6.6%, P = 0.791), with no significant differences in bleeding/hematoma (2.5% vs. 1.6%, P = 0.682), vasovagal reactions (1.7% vs. 0.8%, P = 0.621), or procedure interruptions (0.8% vs. 0.8%, P = 0.999). CONCLUSION: No statistically significant differences were observed in pain scores, patient satisfaction, procedure duration, or complication rates between the two approaches. These findings suggest that omitting tunnel-site anesthesia may be feasible when a blunt-tip stylet is employed.
Machine Learning Models Used to Predict Abdominal Aortic Aneurysm Growth and Rupture: A Systematic Review and Critical Appraisal.
Aljobeh A, Parthasarathy P, Liao J … +4 more , Kartsonis W, Saltz M, Saltz J, Tassiopoulos A
Ann Vasc Surg · 2026 Aug · PMID 41895595 · Publisher ↗
BACKGROUND: Abdominal aortic aneurysm (AAA) rupture remains a major cause of mortality, and diameter-based surveillance is an imperfect predictor of risk. Some aneurysms rupture below operative thresholds, whereas others...
BACKGROUND: Abdominal aortic aneurysm (AAA) rupture remains a major cause of mortality, and diameter-based surveillance is an imperfect predictor of risk. Some aneurysms rupture below operative thresholds, whereas others remain stable despite exceeding them. Machine learning (ML) may improve risk stratification by integrating geometric, hemodynamic, radiomic, and clinical data. We performed a systematic review to evaluate ML models predicting AAA growth and rupture, characterize their performance, and assess readiness for clinical translation. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant search of PubMed/MEDLINE, Embase, and Web of Science (through March 2025) identified studies developing preoperative ML models for AAA growth or rupture. Data extraction followed the CHecklist for Critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies checklist. Risk of bias and applicability were assessed using the Prediction model Risk of Bias ASsessment Artificial Intelligence Tool, and reporting quality was assessed using Transparent Reporting of a multivariable prediction model for Individual Prognosis Artificial Intelligence. RESULTS: Eighteen studies met inclusion criteria: 13 addressed growth (n = 745 patients) and five rupture (n = 1,394). Growth models commonly employed support vector machines, convolutional neural networks, and gradient boosting, incorporating diameter, intraluminal thrombus thickness, tortuosity, wall shear stress, radiomics, and clinical variables. The area under the curve for growth prediction ranged from 0.79 to 0.93, with root mean square errorof 0.94-2.4 mm. Rupture models used diverse classifiers with similar multimodal inputs and area under the curve from 0.75 to 0.91. Although internal performance was promising, external validation was uncommon. PROBAST + AI demonstrated low risk of bias in 61% of studies but frequent applicability concerns. Transparent Reporting of a multivariable prediction model for Individual Prognosis Artificial Intelligence revealed inconsistent reporting, particularly regarding transparency and fairness. CONCLUSION: ML models show promise for improving AAA risk prediction. Clinical implementation will require standardized feature definitions, robust external validation, and prospective evaluation of impact on decision-making.
The VascGSI Score: Development and Temporal Validation of a Predictive Scoring System for Groin Surgical Site Infection Following Vascular Surgery.
Nikolić D, Pasternak J, Manojlović V … +3 more , Budinski S, Nikolić MB, Batinić N
Ann Vasc Surg · 2026 Jul · PMID 41895594 · Publisher ↗
BACKGROUND: To develop and temporally validate a predictive scoring system (VascGSI Score) for groin surgical site infection (SSI) after vascular surgery. METHODS: Retrospective cohort study reported per the TRIPOD state...
BACKGROUND: To develop and temporally validate a predictive scoring system (VascGSI Score) for groin surgical site infection (SSI) after vascular surgery. METHODS: Retrospective cohort study reported per the TRIPOD statement (Collins et al., 2015). A tertiary referral vascular center serving a defined geographic region. From 12,180 femoral-access procedures (2010-2024), 2,156 percutaneous excluded. Of 10,024 with groin incision, 1,282 excluded. Final cohort: 8,742 incisions in 7,218 patients. Derivation 2010-2020 (n = 6,394); temporal validation 2021-2024 (n = 2,348). Groin SSI within 90 days per Centers for Disease Control and Prevention/National Healthcare Safety Network criteria. Twenty-eight a priori candidate predictors. Multiple imputation (multivariate imputation by chained equations, m = 20). Logistic regression with generalized estimating equation confirmation. PERFORMANCE: area under the receiver operating characteristic curve (AUC), calibration, decision curve analysis (5-30%), and net reclassification index/integrated discrimination improvement. Bootstrap (n = 1,000) and temporal validation. RESULTS: Groin SSI occurred in 846/8,742 incisions (9.7%). Ten predictors were retained: diabetes (4 pts), prior femoral exploration/obesity/chronic kidney disease/operative time >180 min/immunosuppression/smoking (3 each), prosthetic graft/chronic limb-threatening ischemia/female sex (2 each). Generalized estimating equation confirmed all predictors (<5% odds ratio change). Derivation AUC 0.831 (0.812-0.850); bootstrap-corrected 0.819. Temporal validation AUC 0.808 (0.778-0.838). Calibration slopes 0.96/0.91. Risk tiers: low (0-6) 3.2%, moderate (7-13) 11.8%, high (14-20) 24.6%, and very high (>20) 41.1%. CONCLUSION: The VascGSI Score demonstrated good discrimination and calibration in temporal validation. Its incremental value over existing models requires confirmation in multicenter prospective studies before clinical implementation.
Prophylactic Absorbable Antibiotic Beads in Groin Reconstruction Following Vascular Procedures.
Jeong LD, Zhang TD, Bald M … +5 more , Anderson L, Moody JP, Curwick LP, Beck AW, Myers RP
Ann Vasc Surg · 2026 Jul · PMID 41895593 · Publisher ↗
BACKGROUND: Postsurgical complications following vascular procedures requiring a groin incision are common due to factors such as preexisting comorbidities and are complicated by the frequent use of synthetic grafts. Whi...
BACKGROUND: Postsurgical complications following vascular procedures requiring a groin incision are common due to factors such as preexisting comorbidities and are complicated by the frequent use of synthetic grafts. While negative pressure wound therapy and muscle flap coverage are interventions that have been shown to improve vascular graft salvage rates in the groin, use of absorbable antibiotic beads (AABs) may offer another useful adjunct to reduce adverse outcomes. This study evaluated the outcomes in patients receiving AABs during groin reconstruction following vascular procedures at a large tertiary-care hospital. METHODS: A retrospective review was performed of all patients undergoing vascular surgery in the groin followed by reconstruction by the Plastic and Reconstructive Surgery service from January 2018 to March 2024. Patients were grouped by whether prophylactic AABs were placed during groin reconstruction. RESULTS: Among 63 cases, 20 received AABs. Bivariate analysis showed significantly lower reoperation rates in the AAB group (P = 0.046). Multivariable analysis revealed AAB was associated with a significantly lower odds of composite major complications (P = 0.015), 30-day readmissions (P = 0.012), and reoperation (P = 0.003) following groin reconstruction. AAB use was not a significant predictor for length of stay, composite minor complications, postoperative packed red blood cells transfusions, long-term wound care, or surgical site infection. CONCLUSION: Use of AABs during groin reconstruction was associated with improved outcomes, including significantly lower rates of reoperations, readmission, and major complications suggesting a potential benefit in managing complex groin wounds.
Causal Effect of Multicohort Circulating Proteome on the Risk of Aortic Aneurysm: A Mendelian Randomization Study.
Ding M, Li Y, Yao S … +1 more , Wang K
Ann Vasc Surg · 2026 Aug · PMID 41895592 · Publisher ↗
BACKGROUND: The pathogenesis of aortic aneurysm (AA) remains unclear, and there are no effective therapeutic drugs or targets. Circulating plasma proteins are considered biomarkers of AA and potential therapeutic targets...
BACKGROUND: The pathogenesis of aortic aneurysm (AA) remains unclear, and there are no effective therapeutic drugs or targets. Circulating plasma proteins are considered biomarkers of AA and potential therapeutic targets for AA. This study aimed to systematically evaluate the causal effects of plasma proteins on AA using a multicohort Mendelian randomization (MR) approach. METHODS: Protein quantitative trait loci (pQTLs) was obtained from 9 published proteome genome-wide association studies (GWASs) and AA GWAS data from the FinnGen cohort. Independent pQTLs were selected as instrumental variables (IVs). Two-sample MR analysis was performed using inverse-variance weighted, MR-Egger regression, weighted median, weighted mode, and simple mode methods. Heterogeneity and pleiotropy were assessed using Cochran's Q test, I statistic, MR-Egger intercept, MR-PRESSO, and Leave-one-out analysis. Steiger filtering was used to test the causal direction. Colocalization analysis and pQTL-expression quantitative trait loci overlap assessment were conducted to validate the findings. Pathway enrichment and drug target analyses were performed to explore the biological and clinical implications of the MR results. RESULTS: A total of 8,285 pQTLs for 4,421 proteins were retained as IVs. Using cis-pQTLs for IVs, MR analysis identified 154 proteins associated with thoracic aortic aneurysm (TAA; 76 protective and 78 risk factors) and 211 proteins with abdominal aortic aneurysm (AAA; 112 protective and 99 risk factors) Using cis-pQTLs combined with trans-pQTLs as IVs, MR analysis identified 236 proteins associated with TAA and 309 proteins with AAA. A subset of these associations survived false discovery rate (FDR) correction (FDR <0.05), representing the most robust findings. Comparison of the TAA and AAA proteomic profiles revealed both shared proteins (e.g., AHSG, MMP7, RARRES2, THBS2, CCL25) and condition-specific proteins (e.g., OVCA2, STAT3, and HPSE for TAA; PLAU, LPA, SERPING1, and SMPDL3A for AAA), reflecting the distinct embryonic origins and pathological drivers of these 2 conditions. Steiger filtering confirmed the expected direction of effect from circulating proteins to AA. Colocalization analysis found evidence of shared causal variants between multiple proteins and AA. Pathway enrichment analysis revealed involvement in stress response, immune regulation, cytokine-cytokine receptor interaction, and metabolic processes. Nearly two-thirds of the associated proteins were classified as druggable or potentially druggable targets. CONCLUSION: This study identified a large number of potentially novel pathogenic proteins and therapeutic targets for AA, providing important references for elucidating the molecular pathogenesis of AA and advancing drug development. These findings warrant further validation through experimental studies and prospective clinical investigations.
Adherence to Instructions for Use and Mid-Term Outcomes of Endovascular Repair in Thoracic Aortic Disease from the Gore Global Registry for Endovascular Aortic Treatment (GREAT).
Meisenbacher K, Hagedorn MN, Böckler D … +3 more , Feito Y, Bischoff MS, GREAT Investigators
Ann Vasc Surg · 2026 Jul · PMID 41895591 · Publisher ↗
BACKGROUND: To examine whether adherence to device instructions for use (IFU) impacts outcomes after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) and penetrating aortic ulcer...
BACKGROUND: To examine whether adherence to device instructions for use (IFU) impacts outcomes after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) and penetrating aortic ulcer (PAU). METHODS: This retrospective analysis of the prospective, multicenter Gore Global Registry for Endovascular Aortic Treatment (GREAT) (NCT01658787) included 939 patients treated with GORE® TAG® or Conformable TAG® devices between 2010 and 2016. For the present study, we evaluated 334 elective patients with DTAA or PAU who underwent TEVAR in proximal landing zones 2-4, with 5 years of follow-up (FU). Patients were categorized as treated inside IFU (iIFU) or outside IFU (oIFU). Primary outcomes included survival, aortic-related mortality, serious adverse events (SAEs), and device-/procedure-related complications. Secondary outcomes included endoleak, reintervention (RI), and device integrity. Cox proportional hazards models assessed associations between IFU status and outcomes. RESULTS: Among 334 patients (median age, 71 years; 41% female), 208 (62%) were treated iIFU and 128 (38%) oIFU. The most common deviations were inadequate proximal landing zone (56%) and distal diameter mismatch (47%). Baseline demographics and comorbidities were similar, although coronary heart disease was more prevalent in iIFU patients. Over 5 years, survival (56.1% vs. 62.8%, P = 0.50), aortic-related mortality (4.3% vs. 4.7%, P = 0.90), SAEs (64.3% vs. 61.4%, P = 0.60), and device-/procedure-related SAEs (24.0% vs. 26.7%, P = 0.60) did not differ significantly between iIFU and oIFU groups. Endoleaks were infrequent, with no significant differences by IFU status, though type III endoleaks occurred only in oIFU patients (1.6%). Device migration, fracture, or compression was rare. RIs occurred in 15% of iIFU and 20% of oIFU patients (P = 0.30). Cox analysis demonstrated a significantly increased hazard for "other" RIs in oIFU patients (hazard ratio, 2.38; 95% confidence interval, 1.13-5.02; P = 0.022), whereas risks for device-/procedure-related RIs, endoleaks, or mortality were not significantly different. CONCLUSION: Elective TEVAR is frequently performed oIFU, largely due to proximal landing zone and distal diameter constraints. In this multicenter registry, oIFU treatment was not associated with significantly worse survival, aortic-related mortality, or major device-related complications over 5 years. However, the increased risk of secondary RIs highlights the need for careful patient selection, structured FU, and further prospective research to define which anatomic deviations can be safely tolerated in clinical practice.
Use of Alternative Endograft for Popliteal Artery Aneurysm Endovascular Repair: A Single Center Experience in Italy With the Wrapsody™ Cell-Impermeable Endoprosthesis.
Marazzi G, Udini M, Oggianu C … +1 more , Leo E
Ann Vasc Surg · 2026 Aug · PMID 41895590 · Publisher ↗
BACKGROUND: To describe clinical outcomes associated with the off-label use of the Wrapsody™ Cell-Impermeable Endoprosthesis (CIE) for endovascular popliteal artery aneurysm (PAA) repair. METHODS: This was a retrospectiv...
BACKGROUND: To describe clinical outcomes associated with the off-label use of the Wrapsody™ Cell-Impermeable Endoprosthesis (CIE) for endovascular popliteal artery aneurysm (PAA) repair. METHODS: This was a retrospective analysis of patients with PAA treated (September 2021-October 2024) with the WRAPSODY CIE. Clinical outcomes of interest included successful device placement, complete exclusion of the aneurysm at 30 days, aneurysm shrinkage, primary patency, reintervention with secondary patency, and complications. Patients were followed for a range of 4-48 months. RESULTS: Eighteen patients were analyzed (17 males and 1 female). The mean age of patients treated was 73 years. The mean aneurysm length was 6.8 cm. All devices were successfully placed, no major complications were observed. Aneurysm shrinkage was achieved in 8 patients. One patient presented a small type II endoleak from a genicular artery. Early primary patency at 4 months was 100%, late patency at 16 months was 85.7%. One patient underwent endovascular reintervention for acute intrastent thrombosis 12 months postprocedure, without the possibility of recanalization and secondary patency. Another endograft occluded chronically, without symptoms; therefore, the patient was treated with medical therapy. CONCLUSION: These results indicate that the WRAPSODY CIE used may be a safe and effective intervention for endovascular popliteal artery aneurysm repair and may help physicians optimize care for PAA.
GLP-1 Receptor Agonist Use Is Associated with Venous Ulcer Healing and Fewer Wound Infections.
Go CC, Annie F, Drabish K … +1 more , Eslami MH
Ann Vasc Surg · 2026 Aug · PMID 41895589 · Publisher ↗
BACKGROUND: Chronic venous leg ulcers are a prevalent and debilitating complication of chronic venous insufficiency. Up to 20% of patients with venous ulcers are diabetic, and up to 50% struggle with obesity. Glucagon-li...
BACKGROUND: Chronic venous leg ulcers are a prevalent and debilitating complication of chronic venous insufficiency. Up to 20% of patients with venous ulcers are diabetic, and up to 50% struggle with obesity. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are an established class of agents used primarily for the treatment of type 2 diabetes and obesity. Studies have repeatedly demonstrated that their use is associated with reductions in major adverse cardiac events (MACEs) and major adverse limb events (MALEs), but their effects on venous ulcer healing have not yet been investigated. METHODS: Data were sourced from the TriNetX Research Network, encompassing 101 health care organizations. We utilized a 1:1 propensity-matched study to compare patients with an active venous ulcer and started on GLP-1 RAs (group 1) with those who were not started on GLP-1 RAs (group 2). To control for differences in the cohorts, we controlled for age, race, sex, diabetes status, smoking history, and baseline weight. Outcomes included wound healing, inpatient admission, MACE, and MALE, which were identified using International Classification of Diseases, Tenth Revision codes. Patients with arterial insufficiency defined by an abnormal ankle-brachial index were excluded. RESULTS: We identified 381,512 patients with venous ulcers between October 1, 2022, and December 31, 2023. After propensity matching, we arrived at a study population of 38,834 matched pairs. Patients in group 1 were found to have a higher starting mean weight (247 ± 68.2 vs. 216 ± 64.2, P = 0.001) and hemoglobin A1c (7.7 ± 0.8 vs. 7.2 ± 0.8, P < 0.01). At the 1-year follow-up period, group 1 exhibited more weight loss (240 ± 65.0 vs. 212 ± 63.5, P < 0.01), fewer nonhealing ulcers (0.61% vs. 0.92%, P < 0.01), and fewer inpatient admissions for wound-related infection (18.4% vs. 30.8%, P < 0.01). Both MACEs and MALEs were decreased in group 1. Multivariate analysis found GLP-1 RAs to be significantly associated with decreased risk of persistence of wounds, soft tissue infections, inpatient admissions, MACEs, and MALEs. CONCLUSION: The use of GLP-1 RAs is associated with improved venous ulcer healing. Patients with venous ulcers treated with GLP-1 RAs are also less likely to be admitted to the hospital with wound-associated complications and suffer MACEs.
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