Annals Of Vascular Surgery[JOURNAL]
Sun
200 papers
Impact of a Substantial Oversizing Strategy in Chimney Endovascular Aneurysm Repair on Aortic Neck Behavior and Clinical Outcomes Compared with Open Repair for Challenging Aortic Necks.
Takeuchi Y, Morikage N, Mizoguchi T … +5 more , Samura M, Harada T, Kurazumi H, Suehiro K, Hamano K
Ann Vasc Surg · 2026 Jun · PMID 42349642 · Publisher ↗
PURPOSE: This study aimed to compare early and long-term outcomes of chimney endovascular aneurysm repair (chEVAR) using a polyester endograft with a substantial oversizing strategy versus open repair (OR) for abdominal...
PURPOSE: This study aimed to compare early and long-term outcomes of chimney endovascular aneurysm repair (chEVAR) using a polyester endograft with a substantial oversizing strategy versus open repair (OR) for abdominal aortic aneurysms (AAAs) with challenging proximal necks, and to elucidate key determinants of successful chEVAR. MATERIALS AND METHODS: We retrospectively analyzed patients undergoing chEVAR (n = 112) or OR (n = 51) for AAAs with short-neck infrarenal, juxtarenal, or pararenal anatomy between May 2005 and October 2023. Primary endpoints were 30-day/in-hospital mortality and major adverse events (MAEs). Secondary endpoints included freedom from aneurysm-related adverse events and mortality, reintervention, and long-term survival. ChEVAR-specific analyses assessed freedom from type Ia endoleak (T1aEL), predictors of T1aEL, aneurysm sac behavior, and longitudinal proximal neck dilatation. RESULTS: In-hospital mortality tended to be lower with chEVAR (1.8% vs. 7.8%, P = .057), and 30-day MAEs were significantly reduced (10.7% vs. 37.3%, P < .001). Five-year freedom from aneurysm-related adverse events was higher for chEVAR (64.9% vs. 60.5%, P = .015). Freedom from aneurysm-related mortality, reintervention, and overall survival were similar. Three-year freedom from T1aEL was 97.5%. Predictors of T1aEL included bare metal chimney stents, multiple chimneys, larger neck diameter, shorter neck length, and reverse taper neck. Mean annual neck dilatation rate was 0.13 at the infrarenal level. Patients with or without significant neck dilatation (≥ 0.20; 4th quartile) had similar T1aEL rates. CONCLUSION: ChEVAR demonstrated favorable early outcomes and comparable long-term results compared to OR. Chimney EVAR can be performed successfully without increasing the incidence of T1aEL, even in the presence of significant neck dilatation, provided that appropriate anatomical selection is applied.
Contemporary Outcomes of Staged versus Primary Major Amputation for Severe Foot Infection.
Kim Y, Yu J, Tran LM … +4 more , Cui CL, Kozak B, Assaf E, Chun TT
Ann Vasc Surg · 2026 Jun · PMID 42349641 · Publisher ↗
BACKGROUND: Lower extremity amputation is a necessary, life-saving intervention for patients with severe foot infection. Previous studies have suggested that a staged amputation (SA) approach to severe foot infections ma...
BACKGROUND: Lower extremity amputation is a necessary, life-saving intervention for patients with severe foot infection. Previous studies have suggested that a staged amputation (SA) approach to severe foot infections may be associated with higher technical success and lower mortality rates, when compared with primary amputations (PA). In this study, we examined our single-center experience comparing outcomes between SA and PA in patients presenting with unsalvageable severe foot infection. METHODS: Institutional medical records were retrospectively reviewed for all lower extremity amputations performed for severe foot infection at a single academic medical center, from January 2020 to December 2023. Per institutional practice, patients presenting with systemic illness and requiring urgent infectious source control were typically managed with a staged approach. Patients undergoing PA were compared with those managed with a staged approach. The primary outcome was post-amputation survival, analyzed using Kaplan-Meier survival curves. Secondary outcomes included stump-related complications, 30-day hospital readmission, and unplanned reoperation rates. RESULTS: A total of 228 patients undergoing major amputation were included in the final cohort. Of these, 169 (74.1%) underwent SA and 59 (25.9%) underwent PA. Median follow-up was 1.3 years. Baseline demographics and comorbidity profiles were comparable between the two groups. Rates of amputation stump infection (8.9% vs. 13.6%, p=0.30) and wound necrosis (8.3% vs. 5.1%, p=0.42) were comparable between SA and PA cohorts. There were no differences in median postoperative hospital length of stay (9 days [IQR 6-19] vs. 8 days [IQR 5-14], p=0.141), 30-day hospital readmission (20.7% vs. 20.3%, p=0.95), unplanned reoperation (20.7% vs. 22.0%, p=0.83), or non-home discharge rates (64.5% vs. 59.3%, p=0.60). One-year and three-year survival rates were 71.8% (±3.7%) and 50.9% (±4.9%) after SA, and 73.8% (±6.1%) and 41.6% (±9.5%) after PA, respectively (log-rank p=0.48). On multivariable analysis, factors associated with post-amputation mortality included advanced age (hazard ratio [HR] 1.03 per year, 95% confidence interval [CI] 1.01-1.05, p<0.001), chronic kidney disease (HR 1.74, 95% CI 1.06-2.84, p=0.03), and end-stage renal disease (HR 1.86, 95% CI 1.09-3.17, p=0.02). Notably, SA strategy was not associated with increased mortality risk compared to PA (HR 0.81, 95% CI 0.50-1.29, p=0.37). CONCLUSIONS: Patients undergoing major lower extremity amputation for severe, unsalvageable foot infection face poor long-term survival. In our experience, both staged and selective primary amputation strategies yielded comparable postoperative outcomes and survival rates. These findings support an individualized, patient-centered approach to amputation strategy selection.
Long-term graft and patient survival following endovascular intervention for renal artery stenosis in transplanted kidneys: a single-center experience.
Hegazi M, Kabutey NK, Redfield RR … +6 more , Ichii H, Reddy U, Kuo IJ, Fujitani RM, Chau AH, Chen SL
Ann Vasc Surg · 2026 Jun · PMID 42349640 · Publisher ↗
INTRODUCTION: Transplant renal artery stenosis (TRAS) is a recognized etiology of allograft dysfunction and potential graft loss. Endovascular therapy via carbon dioxide angiography (COA) and angioplasty/stenting represe...
INTRODUCTION: Transplant renal artery stenosis (TRAS) is a recognized etiology of allograft dysfunction and potential graft loss. Endovascular therapy via carbon dioxide angiography (COA) and angioplasty/stenting represents an opportunity to mitigate allograft failure in transplant patients with progressive TRAS. We present our institutional experience with COA and endovascular interventions in treating TRAS. METHODS: A retrospective review was performed of all renal transplant patients who underwent COA for suspected TRAS between March 2017 and July 2024. The diagnosis of TRAS was based on duplex ultrasound (DUS) and unexplained graft dysfunction in the absence of ureteral obstruction, infection, or acute rejection. Pre and post-intervention creatinine (Cr), DUS velocities, and freedom from dialysis at 6 months, 1 year, and 5 years were examined. Statistical analysis was performed using Wilcoxon signed-rank test. RESULTS: 19 patients were identified who underwent 23 endovascular procedures for transplant renal artery stenosis, comprising 1.7% of all transplant patients in that time frame. 3 patients underwent diagnostic COA without intervention and were excluded from analysis. The remaining 16 patients (56% male) had a mean age of 52 years. Time from transplant to TRAS intervention averaged 196 days (range 55-726). Anastomotic PSV pre-and post-intervention averaged 426 cm/s (sd=235) and 263 cm/s (sd=124), (p=0.015), respectively. TRAS was resolved or improved based on DUS in 12 of 16 patients; the median balloon size used for angioplasty was 3.5mm (range 2.5-5mm). Pre- to post-intervention Cr decreased from mean 3.2 (sd=1.4) to 1.6 (sd=0.5) (p<0.001). 14 (75%) patients were free from dialysis at 6 months from TRAS intervention. At the 5-year follow-up period, 6 transplanted kidneys were still functioning, and 100% of those functioning at 1 year were still functioning at 5 years, with no TRAS re-intervention after the first year. In our cohort, patient survival was 100%. CONCLUSION: Juxta-anastomotic TRAS associated with rapidly progressive allograft dysfunction can be successfully salvaged with a high rate of success with COA and angioplasty/stenting. This can lead to high rates of long-term allograft and patient survival.
Aortoesophageal Fistula: Mending the Lethal Connection - A Systematic review and meta-analysis.
Hantash NA, El Beyrouti H, Alghzawi Y … +9 more , Lafi L, Al Dyrawi TZ, Aldeeb OM, Nashwan OM, Abuqtaish RM, Fakeh S, Bohan P, Al Thani H, Halloum N
Ann Vasc Surg · 2026 Jun · PMID 42349639 · Publisher ↗
BACKGROUND: Aortoesophageal fistula (AEF) is a rare, life-threatening condition with limited high-quality evidence to guide management. METHODS: We conducted a systematic review and meta-analysis of PubMed and Scopus thr...
BACKGROUND: Aortoesophageal fistula (AEF) is a rare, life-threatening condition with limited high-quality evidence to guide management. METHODS: We conducted a systematic review and meta-analysis of PubMed and Scopus through December 2025, evaluating survival and complication outcomes according to treatment strategy and morphological severity. Patients were categorized into five groups: TEVAR alone, staged TEVAR followed by surgery, primary open or hybrid surgery, TEVAR with esophageal stenting, and supportive/palliative care. Outcomes were pooled as proportions with 95% confidence intervals. RESULTS: A total of 167 reports representing 528 patients were included. Overall 30-day mortality was 31.2% (95% CI 27.0-35.7) and one-year mortality 41.2% (95% CI 36.2-46.4). Infection occurred in 32.6%, reintervention in 20.2%, and recurrence in 13.2%. Staged TEVAR followed by surgery showed favorable survival (30-day 12.7%, one-year 26.1%) but high infection (66.7%) and reintervention (43.2%) rates. TEVAR with esophageal stenting had the lowest early mortality (5.0%) but frequent reintervention (54.5%) and one-year mortality of 33.3%. TEVAR alone demonstrated the lowest one-year mortality among definitive strategies (25.5%) but notable recurrence (26.9%). Primary open or hybrid surgery carried higher early and late mortality, while supportive/palliative care had the worst outcomes. Morphological severity correlated strongly with mortality, infection, reintervention, and recurrence, with Type IV lesions showing particularly poor prognosis. CONCLUSIONS: Despite contemporary management, AEF carries high early and late mortality. Definitive strategies, particularly staged TEVAR followed by surgery, offer improved survival but increased complications. Morphology-guided, individualized management is recommended.
Impact of bypass versus PTA on foot perfusion in patients with peripheral artery disease.
Umbgrove JL, Peul RC, Koning S … +7 more , Kruiswijk MW, van der Aa LE, Planting I, van den Hoven P, van Rijswijk CSP, Vahrmeijer AL, van der Vorst JR
Ann Vasc Surg · 2026 Jun · PMID 42349638 · Publisher ↗
INTRODUCTION: Revascularization in patients with PAD relies on open or endovascular approach. Current evidence favoring open/endovascular approach focuses on clinical endpoints, however, there is little evidence on the a...
INTRODUCTION: Revascularization in patients with PAD relies on open or endovascular approach. Current evidence favoring open/endovascular approach focuses on clinical endpoints, however, there is little evidence on the actual quantitative improvement in foot perfusion. This study aims to investigate the effect of PTA compared to bypass surgery on arterial foot perfusion using near-infrared fluorescence (NIRF-imaging) with indocyanine green (ICG). MATERIAL AND METHODS: This retrospective cohort study compared foot perfusion of patients with an occlusion of the superficial femoral artery or proximal popliteal artery who underwent PTA or bypass surgery. Perfusion measurements were conducted by NIRF-imaging pre- and post-interventional. The intervention groups were compared on delta (Δ) normalized maximum slope (MaxSlope) and Δ time to maximum intensity (Tmax). NIRF-parameters were also compared to clinical outcomes. RESULTS: Thirty-five patients were included (17 PTA vs. 18 bypass surgery group). The bypass surgery group showed a significantly higher improvement compared to the PTA group in median Δ MaxSlope (+0.73%/s PTA vs. 4.40%/s bypass surgery, p=0.002) and median Δ Tmax (-14.50s PTA vs. -56.55s bypass surgery, p=0.005). In patients with improvement of clinical symptoms, median Δ Tmax improved by 31.90 seconds compared to a Δ Tmax increase of 5.80 seconds (p=0.207). Median Δ MaxSlope improved by +2.14%/s in the group with clinical improvement, compared to a decrease of -1.29%/s in the group without clinical improvement (p=0.041). CONCLUSION: Bypass surgery seems to lead to a greater improvement in post-interventional arterial perfusion of the foot compared to PTA in patients with an occlusion. Furthermore, improvement in NIRF-imaging parameters appears to be an indicator of a positive clinical outcome.
Hospital Volume and Outcomes After Elective Abdominal Aortic Aneurysm Repair: A Systematic Review and Dose-Response Meta-Analysis.
Coutinho ML, Delgado LM, D'Oria M … +5 more , Scali ST, Hanna L, Zerati AE, de Luccia N, Leão PP
Ann Vasc Surg · 2026 Jun · PMID 42349637 · Publisher ↗
INTRODUCTION: Procedural volume has been associated with outcomes after abdominal aortic aneurysm (AAA) repair, yet the magnitude and shape of the volume-outcome relationship remain uncertain. This systematic review and...
INTRODUCTION: Procedural volume has been associated with outcomes after abdominal aortic aneurysm (AAA) repair, yet the magnitude and shape of the volume-outcome relationship remain uncertain. This systematic review and dose-response meta-analysis evaluated the association between hospital and surgeon procedural volume and outcomes following elective AAA repair. METHODS: MEDLINE, Embase, and the Cochrane Library were systematically searched from inception to February 9, 2026. Studies evaluating the association between procedural volume and outcomes after elective AAA repair were included. Dose-response meta-analyses were performed using restricted cubic spline models to assess potential linear and non-linear associations between procedural volume and outcomes. RESULTS: Eleven observational studies were analyzed. Higher hospital procedural volume was significantly associated with lower overall mortality, with a predominantly linear relationship (n = 202,212; β = -0.0102, p = 0.011). Hospitals at the 90th percentile of procedural volume had 35% lower odds of mortality compared with those at the 10th percentile (OR 0.65; 95% CI 0.44-0.96). A significant inverse association was also observed between hospital volume and failure-to-rescue after open repair (n = 60,096; β = -0.0407, p = 0.0006), although the P90 versus P10 contrast was not statistically significant due to wide confidence intervals. CONCLUSION: Higher hospital procedural volume is associated with lower mortality after elective AAA repair and reduced failure-to-rescue after open repair. These findings suggest that institutional experience plays an important role in outcomes after AAA repair, supporting strategies aimed at centralizing care in higher-volume centers.
Contemporary Outcomes In Chronic Limb-Threatening Ischemia: The Role of the Social Vulnerability Index.
Hart JP, Davies MG
Ann Vasc Surg · 2026 Jun · PMID 42342214 · Publisher ↗
OBJECTIVE: Health disparities have been shown to influence the outcomes of vascular surgery interventions. This study aimed to analyze the association of the Social Vulnerability Index (SVI) with the outcomes of patients...
OBJECTIVE: Health disparities have been shown to influence the outcomes of vascular surgery interventions. This study aimed to analyze the association of the Social Vulnerability Index (SVI) with the outcomes of patients undergoing a lower extremity intervention for chronic limb-threatening ischemia (CLTI). METHODS: This is a retrospective cohort study. Between 2018 and 2023, all patients undergoing a primary intervention (bypass, BYP; endovascular interventions, EV; or major amputation, AMP) for CLTI presenting with WIfI stages 1-5 were analyzed. Patients presenting acutely and/or with prior vascular procedures on the limb in question were excluded. Patient addresses were geocoded, and estimated Social Vulnerability Index (SVI) scores were assigned. The cutoff for high-risk versus low-risk social vulnerability was an SVI >75th percentile. SVI consists of 4 distinct disparity domains that allow for subgroup analysis: socioeconomic status, minority status and language, household composition and disability, and housing and transportation. Short-term objective performance goals, Amputation-free survival (AFS; survival without major amputation), and freedom from major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated. RESULTS: 1974 patients (55% male, age 64±12years, mean ± SD) underwent either EV (57%), a BYP (29%), or AMP (14%). The median follow-up of 4.1 years. Patient distribution by SVI quartiles (from less social disparity to greater social disparity) was as follows: Q1 (11%), Q2 (21%), Q3 (32%), and Q4 (37%). The incidence of diabetes, obesity, and end-stage Renal disease increased as SVI increased (P=0.03). Access to primary care also diminished as the SVI quartile increased. When dichotomized into low-risk (n=1263) and high-risk SVI (n=711) groups, 30-day MACE (5% vs. 11%; low-risk vs. high-risk SVI, respectively; P=.03, 30-day MALE (7% vs. 18%; P=.01), and 30-day Amputation (4% vs. 9%; P=.01) were significantly increased in the high-risk SVI group. Patients in high SVI group had significantly lower survival (55±9% vs. 31±8%, low vs. high SVI respectively, mean ± SEM; P= .003), lower freedom from MALE (61±7% vs. 31±8%; P=.001) and lower AFS at 5 years (49±5% vs. 21±6%; P= .001). CONCLUSIONS: Social vulnerability as measured by socioeconomic status, minority status and language, household composition, disability, housing, and transportation influences short-term and long-term outcomes after intervention for CLTI. Assessing and addressing domains in social disparity risk may improve outcomes before major lower extremity intervention.
Surgical Treatment Outcomes of Abdominal Aortic Endograft Infection: A Dual-Center Retrospective Study.
Wang X, Diao Y, Qi B … +7 more , Wu Z, Lian L, Zhang Z, Jin S, Chen X, Li Y, Feng H
Ann Vasc Surg · 2026 Jun · PMID 42342213 · Publisher ↗
OBJECTIVE: Abdominal aortic endograft infection (AAEI) is a rare but life-threatening complication following endovascular aneurysm repair (EVAR). This study aimed to report surgical outcomes of AAEI from two specialized...
OBJECTIVE: Abdominal aortic endograft infection (AAEI) is a rare but life-threatening complication following endovascular aneurysm repair (EVAR). This study aimed to report surgical outcomes of AAEI from two specialized Chinese vascular centers and analyze prognostic risk factors. METHODS: A dual-center retrospective cohort study enrolled 41 patients who underwent complete infected graft excision and revascularization for AAEI between February 2018 and September 2025. Clinical data were collected and analyzed via Kaplan-Meier survival analysis and univariate COX regression. RESULTS: This cohort included 40 males and 1 female (mean age: 64.22±9.12 years). Complete removal of the infected graft was performed in all cases, with revascularization achieved via EAB (n=39) or ISR (n=2). Median follow-up time was 12 months. All-cause mortality was 29.3%, non-fatal complication rate was 39.0% and reintervention rate was 17.1% (7/41). Elevated WBC (P=0.01, HR=3.90) and enteric fistula (P=0.04, HR=3.21) worsened survival; Advanced age showed a trend towards significance (P=0.09). CRP level and renal artery stent coverage had no significant prognostic impact (P>0.05). CONCLUSION: EAB is a feasible and practical option for high-risk AAEI patients, particularly at centers lacking biological grafts. Enteric fistula, elevated preoperative WBC and advanced age predict poor survival. Large prospective multicenter trials are needed to refine individualized treatments for AAEI..
Isolated Endovascular Repair of the Ascending Aorta: Early Outcomes and Temporal Trends from a National Multicenter Registry.
Baghbani A, Dominguez G, Tanaka A … +3 more , Saqib NU, Estrera AL, Wang SK
Ann Vasc Surg · 2026 Jun · PMID 42342212 · Publisher ↗
OBJECTIVE: Endovascular repair of the ascending aorta has emerged as a minimally invasive alternative for high-risk patients with zone 0 aortic pathology who are unsuitable for conventional open repair. This study evalua...
OBJECTIVE: Endovascular repair of the ascending aorta has emerged as a minimally invasive alternative for high-risk patients with zone 0 aortic pathology who are unsuitable for conventional open repair. This study evaluated perioperative outcomes, midterm durability, and temporal era effects associated with ascending thoracic endovascular aortic repair (TEVAR) using the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) database. METHODS: The SVS-VQI TEVAR registry was queried through April 2026 to identify patients undergoing endovascular repair confined to zone 0. Procedures were performed across 28 participating VQI centers by 36 operators. Patients with proximal or distal landing zones extending beyond zone 0 were excluded. Baseline characteristics, procedural variables, perioperative outcomes, and midterm survival were analyzed. Kaplan-Meier analysis was used to estimate overall survival and freedom from stroke, endoleak, and aortic reintervention. Temporal era effects were evaluated by comparing early and contemporary procedural cohorts. RESULTS: A total of 55 patients underwent ascending TEVAR confined to zone 0. Median age was 75 years, and most patients had significant cardiovascular comorbidity. Overall technical success was achieved in 52 patients (94.5%). Median operative duration was 110 minutes, and median hospital stay was 4 days. Perioperative mortality was 14.5%, whereas stroke occurred in 1.8% of patients. Freedom from stroke was 97.5% at both 1 and 3 years. Freedom from aortic reintervention was 91.5% at 1 year and 83.2% at 3 years. Perioperative mortality decreased significantly from 25.9% in the early cohort to 3.6% in the contemporary cohort (P=.025), suggesting improved outcomes with increasing procedural experience. CONCLUSIONS: Ascending TEVAR confined to zone 0 is feasible with acceptable perioperative outcomes, low stroke and endoleak rates, and favorable midterm durability in selected high-risk patients. Significant improvement in outcomes over time highlights the importance of institutional experience and multidisciplinary expertise.
Local hemodynamic changes and branch outcomes associated with inner branched versus outer branched stent grafts.
Erhart P, Bresler AM, Peters AS … +3 more , Böckler D, Abramowitz S, Yoon WJ
Ann Vasc Surg · 2026 Jun · PMID 42342211 · Publisher ↗
BACKGROUND: This study compared the hemodynamic performance and branch outcomes of outer branched (t-Branch) and inner branched (E-nside) stent-graft designs. METHODS: Patient-specific computational fluid dynamics (CFD)...
BACKGROUND: This study compared the hemodynamic performance and branch outcomes of outer branched (t-Branch) and inner branched (E-nside) stent-graft designs. METHODS: Patient-specific computational fluid dynamics (CFD) simulations were performed on patients who underwent four-vessel branched endovascular aortic repair (BEVAR) with E-nside (n=12) or t-Branch (n=11) between November 2013 and March 2024, using three-dimensional reno-visceral aortic geometry models reconstructed from pre- and post-implantation computed tomography (CT) images. Hemodynamic parameters at the branches (23 celiac artery [CA], 23 superior mesenteric artery [SMA], 23 right renal artery [RRA], 23 left renal artery [LRA]) were compared along with the clinical outcome data. RESULTS: E-nside and t-Branch showed comparable all-four-bridging stent patency (patient-level p=1.0; stent-level p=.46) and reintervention rates (patient-level p=1.0; stent-level p=1.0). There were no significant differences in either peak flow changes (Δ) (CA, p=.69; SMA, p=.26; RRA, p=.1; LRA, p=.21) or peak pressure Δ (CA, p=.26; SMA, p=.38; RRA, p=.35; LRA, p= .35) in all branches between the groups. While post-implantation changes in time-averaged wall shear stress (TAWSS) in the main aortic segment were not significantly different between endograft strategies (E-nside 6.4 dynes/cm vs t-Branch 9.2 dynes/cm, p=.1), aortic displacement force (DF) differed significantly (E-nside 4.9 N vs t-Branch 8.1 N, p=.002). CONCLUSION: Despite geometric differences, the t-Branch and E-nside devices showed similar outcomes for patency and reintervention, with CFD simulation analysis indicating no significant impact on local branch hemodynamics. However, the t-Branch may be associated with higher DF in the device's aortic segment compared to the E-nside.
Lower Extremity Access Versus HeRO Graft: Choosing Dialysis Access in Patients with Central Venous Stenosis.
Mehta V, Curry J, DeVirgilio C … +1 more , Bowens N
Ann Vasc Surg · 2026 Jun · PMID 42342210 · Publisher ↗
BACKGROUND: In patients with central venous stenosis, it is controversial whether an upper extremity Hemodialysis Reliable Outflow (HeRO) graft or lower extremity access is preferable. Furthermore, lower extremity grafts...
BACKGROUND: In patients with central venous stenosis, it is controversial whether an upper extremity Hemodialysis Reliable Outflow (HeRO) graft or lower extremity access is preferable. Furthermore, lower extremity grafts are contraindicated in patients with significant peripheral artery disease (PAD). The purpose of this study was to compare outcomes of HeRO grafts with lower extremity dialysis access in patients with central venous stenosis. METHODS: We performed a retrospective analysis of patients with central venous stenosis undergoing lower extremity dialysis access or HeRO graft placement at a large safety-net hospital from 2015 to 2022. Primary outcomes were 1-year primary patency, secondary patency, and mortality. Secondary outcomes were 30-day postoperative outcomes. RESULTS: There were 25 patients included in this study. There was a higher rate of peripheral arterial disease in the patients undergoing HeRO graft placement, although not significant (33% vs 6%, p=0.12). One year mortality was significantly higher for patients who underwent HeRO graft (55% vs 6%, p=0.006). 1-year primary patency was higher for lower extremity access, although not significant (44% vs 25%, p=0.21). There was no difference in secondary patency at 1 year between HeRO grafts and lower extremity access (56% vs 44%, p=0.57). DISCUSSION: Although our results are limited by small sample size, upper extremity HeRO grafts appear to have similar outcomes compared to lower extremity AV access in terms of primary and secondary patency. Thus, HeRO grafts are an acceptable alternative to lower extremity access in patients with central venous stenosis, particularly in patients who have peripheral artery disease who may not be candidates for lower extremity access.
The Influence of Procedure Setting on Tibial Endovascular Arterial Intervention Practice Patterns in the Medicare Population.
Potluri VK, Chawla K, Dossani H … +5 more , Patel SG, Nguyen K, Patel M, Silva MB, Blecha M
Ann Vasc Surg · 2026 Jun · PMID 42342209 · Publisher ↗
OBJECTIVE: The purpose of this study is to investigate the influence of practice location on the type of tibial endovascular arterial intervention performed in the Medicare population. Further, stratification of the freq...
OBJECTIVE: The purpose of this study is to investigate the influence of practice location on the type of tibial endovascular arterial intervention performed in the Medicare population. Further, stratification of the frequency of the performance of each type of intervention between the primary subspecialty stakeholders in endovascular lower extremity care is investigated. METHODS: A retrospective analysis of claims data from the Centers for Medicare and Medicaid Service's (CMS) Physician/Supplier Procedure Summary files for each year between 2011 and 2022 was conducted. Physicians were grouped into 1 of 4 categories: radiologists, cardiologists, vascular surgeons, or other. Claims data was tabulated for all Current Procedural Terminology (CPT) codes corresponding to endovascular therapy in the tibial arterial segment. These CPT codes encompass the interventions of angioplasty alone (CPT 37228), atherectomy with or without angioplasty (CPT 37229), stent placement with or without angioplasty (CPT 37230), and atherectomy in combination with stent placement (CPT 37231). Chi-Squared testing was utilized for univariable comparisons. RESULTS: Atherectomy procedures were performed at a nearly two-fold higher rate in outpatient-based facilities (OBL) relative to hospital-based facilities (59.1% of procedures vs. 31.3%, OR 1.87, P<.0001). After 2011 atherectomy rapidly accelerated with a per annum increase from 18,000 cases to over 45,000 per year. In 2011, balloon angioplasty was performed twice as frequently as atherectomy. By the year 2016 atherectomy with angioplasty eclipsed angioplasty. When analyzing location of service, the escalation in atherectomy occurred entirely in the OBL setting as the total number of atherectomies remained stable year over year between 2011 and 2022. Vascular surgeons performed tibial atherectomy at the lowest rate, but within an absolute rate of 1% relative to other disciplines for atherectomy without stent placement and within an absolute rate of 3% relative to other disciplines for tibial atherectomy with stent placement. Amongst all OBL cases, vascular surgery (41.5%) and Cardiology (31.9%) performed the highest proportion of procedures relative to Interventional Radiology (22.0%) and Other Subdisciplines (4.5%), P<.001. CONCLUSIONS: There was a rapid acceleration in the performance of tibial atherectomy between 2011 and 2022. This was driven entirely by OBL based atherectomy performed at essentially equal rates across subdisciplines. Patients treated in the OBL setting were nearly twice as likely to be treated with atherectomy relative to those in hospital settings. Future reimbursement models for infra-inguinal endovascular arterial interventions should carefully identify to-facility cost of devices utilized and create an equivalent reimbursement to cost margin across clinically equivalent methods of treatment.
Balloon-assisted maturation is strongly associated with inferior functional patency rates of arteriovenous fistulas.
Yang H, Lai Q, Gao X … +3 more , Chen L, Zhang X, Wan Z
Ann Vasc Surg · 2026 Jun · PMID 42342208 · Publisher ↗
BACKGROUND: Balloon-assisted maturation (BAM) is used to salvage non-maturing arteriovenous fistulas (AVFs). This study compared long-term patency between naturally matured AVFs and those matured through the BAM and iden...
BACKGROUND: Balloon-assisted maturation (BAM) is used to salvage non-maturing arteriovenous fistulas (AVFs). This study compared long-term patency between naturally matured AVFs and those matured through the BAM and identified factors associated with patency. METHODS: This retrospective cohort study included adult patients who achieved AVF maturation between 2018 and 2020, divided into the unassisted maturation (UM) group (N = 1008) and the BAM group (N = 499). Functional primary patency (creation to first post-maturation reintervention) and cumulative functional patency (creation to abandonment) were analyzed. Cox regression and age-stratified analyses were performed to identify factors influencing patency. RESULTS: The UM group had significantly greater 1-, 3-, and 5-year functional primary patency rates (88.0%, 70.4%, and 62.5%, respectively) than the BAM group (63.8%, 37.0%, and 24.2%; all P < 0.001). Cumulative patency rates were also significantly greater in the UM group at 1, 3, and 5 years (98.9% vs. 95.0%, 95.1% vs. 85.6%, and 93.6% vs. 76.9%, respectively; all P < 0.001). Multivariate analysis revealed that BAM independently increased the risk of reintervention (HR = 2.738; P < 0.001) and abandonment (HR = 3.517; P < 0.001). Male sex (HR = 0.762; P = 0.019) and underweight (HR = 1.297; P = 0.040) were also influencing factors of reintervention. Age-stratified analysis revealed that among patients ≤ 55 years, diabetes and coronary heart disease additionally increased reintervention risk, whereas in patients > 55 years, upper arm AVF additionally increased abandonment risk. CONCLUSIONS: BAM is strongly associated with inferior long-term functional patency of AVFs.
Long-term Outcomes of Endovascular Versus Open Repair for Traumatic Thoracic Aortic Injury: A Single-Center Experience.
Son SA, Cho JY
Ann Vasc Surg · 2026 Jun · PMID 42342207 · Publisher ↗
BACKGROUND: Traumatic thoracic aortic injury (TTAI) carries high early mortality. Thoracic endovascular aortic repair (TEVAR) has increasingly replaced open repair, however, long-term comparative data remain limited. Thi...
BACKGROUND: Traumatic thoracic aortic injury (TTAI) carries high early mortality. Thoracic endovascular aortic repair (TEVAR) has increasingly replaced open repair, however, long-term comparative data remain limited. This study compared long-term outcomes after open repair versus TEVAR for TTAI. METHODS: This single-center retrospective cohort study included 95 consecutive patients with TTAI treated between January 2003 and August 2024. Patients with traumatic ascending aortic injury, those managed non-operatively, or those not undergoing repair were excluded. Forty-two patients underwent open repair and 53 underwent TEVAR. Primary endpoints were procedure-related complications and in-hospital mortality. Secondary endpoints were long-term all-cause and aorta-related mortality and aorta-related event rates. RESULTS: The mean follow-up duration was 129.3 ± 58.8 months. Age and injury severity score were similar between groups. Postoperative acute kidney injury (47.6% vs. 18.9%; p = 0.003) and bowel ischemia (7.1% vs. 0.0%; p = 0.048) occurred more frequently after open repair. One patient (2.4%) in the open repair group developed spinal cord ischemia; no cases occurred after TEVAR. Rates of cerebral complications (4.8% vs. 1.9%; p = 0.445) and in-hospital mortality (7.1% vs. 11.3%; p = 0.490) did not differ significantly between open repair and TEVAR. Long-term cumulative all-cause mortality (21.4% vs. 18.9%; p = 0.915) and aorta-related mortality (2.4% vs. 1.9%; p = 0.868) were comparable, as were freedom from aorta-related events (p = 0.813). CONCLUSIONS: Open repair for TTAI was associated with higher procedure-related morbidity, particularly acute kidney injury and bowel ischemia, whereas long-term survival and aorta-related event rates were similar between open repair and TEVAR. These findings support the use of TEVAR as the preferred treatment modality when anatomically feasible, although larger multicenter studies are needed to better define its long-term efficacy.
Association between lactate-to-albumin ratio and 28-day in-hospital poor outcomes in acute limb Ischemia: a multicenter cohort study.
Feng Y, An H, Wu M … +9 more , Lu J, Geng Y, Gao X, Zhao Z, Li Y, Wang S, Rong Z, Chen Z, Yang Y
Ann Vasc Surg · 2026 Jun · PMID 42342206 · Publisher ↗
OBJECTIVE: The lactate-to-albumin ratio (LAR) is a novel prognostic marker in conditions such as respiratory failure and sepsis, but its value in acute lower limb ischemia (ALI) remains unclear. METHODS: ALI patients wer...
OBJECTIVE: The lactate-to-albumin ratio (LAR) is a novel prognostic marker in conditions such as respiratory failure and sepsis, but its value in acute lower limb ischemia (ALI) remains unclear. METHODS: ALI patients were retrospectively enrolled from our hospital and the MIMIC-IV database. LAR was the exposure of interest, and the primary outcome was in-hospital adverse events, defined as death or amputation within 28 days. RESULTS: In the inner cohort, 18 patients experienced adverse events and 93 did not. In the MIMIC cohort, 73 had adverse events and 154 served as controls. Multivariable Cox regression in both cohorts showed that higher LAR was independently associated with increased risk of in-hospital adverse events. LAR demonstrated moderate discrimination, with an AUC of 0.762 in the inner cohort and 0.647 in the MIMIC cohort. Subgroup analyses found no significant interactions in the inner cohort. In the MIMIC cohort, the association between LAR and adverse events was stronger in patients without atrial fibrillation (HR = 1.69) than in those with atrial fibrillation (HR = 1.25). CONCLUSION: LAR was independently associated with in-hospital death or amputation in patients with ALI.
Impact of Chronic Kidney Disease Severity and Drug-Coated Devices on 2-Year Clinically Driven Target Lesion Revascularization After Femoropopliteal Endovascular Intervention.
Pan J, Peng Y, Yu Q … +4 more , Zheng J, Yong X, Zhu J, Yuan S L
Ann Vasc Surg · 2026 Jun · PMID 42342205 · Publisher ↗
OBJECTIVE: This study evaluated the association of eGFR-based renal function severity and drug-coated device use with 2-year clinically driven target lesion revascularization (CD-TLR) after femoropopliteal endovascular i...
OBJECTIVE: This study evaluated the association of eGFR-based renal function severity and drug-coated device use with 2-year clinically driven target lesion revascularization (CD-TLR) after femoropopliteal endovascular intervention. METHODS: Patients who underwent femoropopliteal endovascular intervention at three centers between January 2018 and June 2023 were retrospectively reviewed. Renal function was stratified into eGFR-based categories: Stage I, eGFR ≥90 mL/min/1.73 m; Stage II, eGFR 60-89 mL/min/1.73 m; Stage III, eGFR 30-59 mL/min/1.73 m; and Stage IV/severe renal dysfunction, defined as eGFR <30 mL/min/1.73 m or dialysis dependence. Drug-coated devices included drug-coated balloons and drug-eluting stents. The primary endpoint was 2-year CD-TLR. Predictors of CD-TLR were assessed using Cox proportional hazards regression models. RESULTS: A total of 589 patients were included; 229 patients (38.9%) were treated with drug-coated devices and 360 patients (61.1%) with conventional devices. Severe renal dysfunction/Stage IV was associated with a higher risk of 2-year CD-TLR compared with Stage I (hazard ratio [HR], 5.43; 95% confidence interval [CI], 2.80-10.51; P<0.001). Drug-coated device use was associated with a lower risk of 2-year CD-TLR compared with conventional-device treatment (HR, 0.56; 95% CI, 0.35-0.91; P=0.020). In secondary outcome analysis, patients with severe renal dysfunction/Stage IV had worse overall survival. CONCLUSION: More advanced renal dysfunction was associated with an increased risk of 2-year CD-TLR after femoropopliteal endovascular intervention. Drug-coated device use was associated with a lower risk of CD-TLR in the overall cohort. Findings in the severe renal dysfunction subgroup should be interpreted cautiously because of the retrospective design, small subgroup size, and potential treatment-selection bias.
Increasing Technical Complexity of EVAR Conversion Over Time Is Not Associated With Worse Outcomes at a High-Volume Aortic Treatment Center.
Fassler MJ, Scali ST, Stinson GP … +9 more , Jacobs CR, Back MR, Berceli SA, Cooper MA, Jacobs BN, Shah SK, Shahid Z, Upchurch GR, Huber TS
Ann Vasc Surg · 2026 Jun · PMID 42342204 · Publisher ↗
OBJECTIVES: Open conversion after endovascular aneurysm repair(EVAR-c) remains a treatment strategy for EVAR failure. However, little is known regarding the evolution of EVAR-c practice. Advancements in surveillance and...
OBJECTIVES: Open conversion after endovascular aneurysm repair(EVAR-c) remains a treatment strategy for EVAR failure. However, little is known regarding the evolution of EVAR-c practice. Advancements in surveillance and endovascular salvage may influence failure phenotypes, referral-timing, and reconstructive complexity. We hypothesized that patients undergoing EVAR-c at aortic referral centers present increasingly later and with greater complexity. METHODS: EVAR-c procedures(n=294) from a single center were stratified into equivalent eras by volume(Era-1:10/2002-7/2015;Era-2:8/2015-5/2020;Era-3:6/2020-1/2025;N=98 each). The primary outcome was temporal change in operative complexity variables across eras. Secondary outcomes included 30-day mortality, interval to conversion, failure phenotype, length of stay, and complications. RESULTS: Age was similar across eras(median 73[IQR 67-80] vs. 76[68-80] vs. 72[67-77] years)); however, contemporary cohorts had more total comorbidities(median 3[IQR 2-5] vs. 4[3-5] vs. 4[3-5];p=.046). Time from EVAR to conversion increased (34[9-63] vs. 58[34-89] vs. 75[31-120]months;p<.001). Operative complexity increased over time, with greater use of retroperitoneal exposure(67% vs. 77% vs. 87%;p=.006) and renal/visceral bypass(7% vs. 21% vs. 46%;p<.001). Multivariable modeling confirmed increasing complexity over time(≥2-features: OR 1.11/year, 95%CI 1.05-1.17; ≥3-features: OR 1.19/year, 95%CI 1.12-1.28; both p<.001). Elective 30-day mortality declined numerically(8% vs. 3% vs. 3%;p=.5), while non-elective mortality remained unchanged(21% vs. 21% vs. 15%;p=.8). Major complications, length of stay, and mid-term survival were similar. CONCLUSIONS: EVAR-c has evolved toward later referral and greater operative complexity, reflecting progressive endograft failure in the contemporary EVAR population. Despite increasing complexity, perioperative outcomes remained stable. These findings support the role of specialized aortic centers in managing EVAR-c.
Beyond the Cuff: Deep Learning-Based Analysis of Handheld Doppler Signals to Detect Masked Peripheral Ischemia in Diabetic Patients with Normal Ankle-Brachial Index.
Aydin E, Kurt D
Ann Vasc Surg · 2026 Jun · PMID 42342203 · Publisher ↗
OBJECTIVE: The Ankle-Brachial Index (ABI) remains the primary screening tool for Peripheral Arterial Disease (PAD). However, its diagnostic performance is severely compromised in patients with diabetes mellitus due to me...
OBJECTIVE: The Ankle-Brachial Index (ABI) remains the primary screening tool for Peripheral Arterial Disease (PAD). However, its diagnostic performance is severely compromised in patients with diabetes mellitus due to medial arterial calcification (MAC), leading to falsely normal or elevated results. We aimed to evaluate the efficacy of a smartphone-based Deep Learning (DL) model analyzing handheld Doppler spectrograms to identify "masked" ischemia in symptomatic diabetic patients with pseudo-normal ABI. METHODS: In this prospective study, 120 participants were stratified into three cohorts: Group 1 (Masked Ischemia; n=40), symptomatic diabetic patients with false-normal ABI (0.90-1.30) but PAD confirmed via imaging; Group 2 (Overt PAD; n=40) with ABI <0.90; and Group 3 (Healthy Controls; n=40). Doppler audio signals were converted into Mel-Spectrograms. To account for intra-patient clustering, all diagnostic accuracy metrics and their 95% Confidence Intervals (CIs) were adjusted using Generalized Estimating Equations (GEE). To ensure robustness and eliminate data leakage, a Convolutional Neural Network (CNN) was trained using patient-level Leave-One-Patient-Out Cross-Validation (LOPOCV). Explainable AI (Grad-CAM) was utilized to visualize pathophysiologically relevant spectral features. RESULTS: As expected from the study design, ABI did not discriminate Group 1 from healthy controls (p=0.454). In contrast, accounting for intra-patient dependency via the GEE framework, the AI model successfully identified pathological flow in 37/40 patients in Group 1, achieving a cluster-adjusted sensitivity of 92.5% (95% CI: 80.1% - 97.4%) (p<0.001 vs. ABI). For the total cohort (n=480 signals), the model demonstrated a cluster-adjusted global accuracy of 95.8 %, a sensitivity of 93.7 %, and a specificity of 95.0 % . ROC analysis confirmed diagnostic superiority (AUC: 0.96 vs. 0.51; p<0.001). Notably, the AI-predicted risk score showed a strong positive correlation with duplex-derived Acceleration Time (AT) (r=0.78, p<0.001), validating its physiological relevance. CONCLUSIONS: Deep learning analysis of handheld Doppler signals demonstrated incremental diagnostic value in identifying peripheral ischemia where traditional pressure-based measurements face limitations. By shifting from mechanical pressure to flow-based hemodynamics, this point-of-care technology bridges a critical diagnostic gap and may reduce delayed diagnoses and subsequent limb loss in high-risk diabetic populations.
Thoracic Endovascular Repair for Retrograde Type A Aortic Dissection: True Lumen Device Sizing.
Onishi R, Okamoto T, Shimada A … +9 more , Takamatsu Y, Okoshi Y, Suzuki S, Okubo Y, Nagasawa A, Domae K, Mishima T, Shiraishi S, Tsuchida M
Ann Vasc Surg · 2026 Jun · PMID 42342202 · Publisher ↗
BACKGROUND: Optimal device sizing for retrograde type A aortic dissection during TEVAR remains challenging because the true lumen at the proximal landing zone is frequently compressed and elliptical. This study evaluated...
BACKGROUND: Optimal device sizing for retrograde type A aortic dissection during TEVAR remains challenging because the true lumen at the proximal landing zone is frequently compressed and elliptical. This study evaluated the clinical outcomes and investigated how true lumen morphology influences device selection. METHODS: Between October 2012 and December 2022, 34 retrograde type A aortic dissection patients underwent TEVAR. Patients with major cardiac or neurological complications were excluded. We retrospectively analyzed the clinical and anatomical outcomes, focusing on postoperative remodeling. Preoperative CT evaluated the relationship between the proximal landing true lumen morphology and device sizing. RESULTS: The mean patient age was 62.7 ± 10.9 years. Emergency TEVAR was performed in 21 patients (61.8%) on the day of onset. Perioperative complications included one spinal cord infarction and no cerebral infarctions. Five patients required additional procedures for a residual entry flow. During the follow-up, the ascending aortic false lumen disappeared in 30 patients (88%). One in-hospital death occurred due to retrograde type A dissection related to stent-graft deployment. A proximal landing zone analysis showed frequently elliptical true lumens. The area-derived diameters tended to underestimate the size in highly elliptical lumens, whereas the major axis more closely corresponded to the selected device diameter. CONCLUSIONS: TEVAR for retrograde type A aortic dissection is a feasible strategy with acceptable mid- to long-term outcomes in selected patients. Precise preoperative anatomical assessment and appropriate device sizing are essential to prevent complications. Evaluating the true lumen morphology at the proximal landing zone is critical for optimal device selection.
A Systematic Review and Meta-Analysis of Peak Skin Dose Determination Methods during Standard and Complex Endovascular Aortic Aneurysm Repair Procedures.
Efthymiou FO, Metaxas VI, Pitros CF … +6 more , Antonopoulos CN, Dimitroukas CP, Moulakakis KG, Kakisis JD, Kakkos SK, Panayiotakis GS
Ann Vasc Surg · 2026 Jun · PMID 42335990 · Publisher ↗
BACKGROUND: Endovascular aneurysm repair (EVAR) is performed under real-time fluoroscopic guidance. Complex fenestrated and branched EVAR procedures may result in substantial localized radiation exposure to the patient's...
BACKGROUND: Endovascular aneurysm repair (EVAR) is performed under real-time fluoroscopic guidance. Complex fenestrated and branched EVAR procedures may result in substantial localized radiation exposure to the patient's skin, with peak skin dose (PSD) being the most relevant metric for assessing deterministic radiation risk. Despite advances in dose monitoring technologies, no comprehensive synthesis of PSD during EVAR procedures exists. METHODS: A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, Scopus, and the Cochrane Library were searched without date restrictions for articles reporting PSD during EVAR. Risk-of-bias was assessed using ROBINS-I, and publication bias was evaluated with Egger's test. A random-effects model pooled mean PSD. Subgroup analyses compared PSD by determination method (direct vs. indirect) and EVAR technique (standard vs. complex). RESULTS: Eleven articles comprising 19 study cohorts were included. Direct measurement methods (radiochromic films or thermoluminescent dosimeters) were used in ≈ 57.9% of reported PSD values, indirect methods (dose-area product (DAP) or reference air kerma (RAK) estimations) in ≈ 26.3%, and hybrid approaches in ≈ 15.8%. Reported PSD ranged from 63 mGy to 6600 mGy. Meta-analysis showed that indirect methods yielded significantly higher pooled mean PSD than direct methods (3115 mGy vs. 558 mGy; p < 0.001). No significant difference was observed between standard and complex EVAR (1326 mGy vs. 2719 mGy; p = 0.33). Heterogeneity was substantial (I ≥ 94.9%). CONCLUSION: A substantial discrepancy between indirect and direct PSD measurement methods during EVAR has been revealed. Indirect DAP- or RAK-based estimations yield significantly higher PSD values than direct measurements. No significant difference in PSD was observed between standard and complex EVAR procedures. Future research should prioritize prospective, multi-center studies with standardized, directly validated PSD measurement protocols.
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