Annals Of Vascular Surgery[JOURNAL]
Sun
200 papers
Clinical Practice Guideline for Spontaneous Isolated Superior Mesenteric Artery Dissection (2025 Edition).
Ling J, Sun J, Hou Y … +25 more , Wu M, Yuan P, Hou L, Mo F, Zhuang J, Yu X, Yuan Y, Li W, Zhou W, Liu S, Ye X, Liu C, Sun Y, Lian L, Hu H, Duan C, Zhang H, Ren M, Chen F, Cui M, Deng H, Wang L, Yuan D, Xiong J, Wang W
Ann Vasc Surg · 2026 Jun · PMID 42335989 · Publisher ↗
Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a relatively rare but potentially life-threatening disease. Optimal medical management strategies remain uncertain. Therefore, developing evidence-ba...
Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a relatively rare but potentially life-threatening disease. Optimal medical management strategies remain uncertain. Therefore, developing evidence-based clinical practice guidelines is essential to improve treatments of SISMAD. The guideline adopted approaches informed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology and the European Society of Cardiology (ESC) grading system. Recommendations were formulated according to the quality of evidence, categorized as high (Level A), moderate (Level B), or low (Level C). After reviewing the literature of eight topics, including clinical presentation, imaging evaluation, classification, medical management strategies, and follow-up, the guide writing committee issued 19 recommendations from currently available evidence. Among the 19 recommendations, only a minority were supported by high-quality evidence, underscoring the urgent need for further well-designed clinical studies and prospective research to refine the management of SISMAD.
The role of completion angiography for bypass to tibial and pedal arteries.
Pini R, Acquisti E, Abualhin M … +8 more , Gallitto E, Spath P, Lodato M, Caputo S, Cappiello A, Mattiacci M, Faggioli G, Gargiulo M
Ann Vasc Surg · 2026 Jun · PMID 42335988 · Publisher ↗
INTRODUCTION: Femoro-tibial or pedal bypass (FTPB) for critical limb threating ischemia (CLTI) is a technically demanding intervention. Despite the standardization of several technical and procedural details, the role of...
INTRODUCTION: Femoro-tibial or pedal bypass (FTPB) for critical limb threating ischemia (CLTI) is a technically demanding intervention. Despite the standardization of several technical and procedural details, the role of completion angiography (CA) is still a matter of debate. The present study aims to evaluate the role of CA in FTPB. METHODS: All consecutive patients treated with FTPB were prospectively collected from 2016 to 2024 into a dedicated database evaluating clinical, anatomical, surgical characteristics and medical therapies. Patients considered for the study were treated for CLTI with vein bypasses from the femoral arteries, with distal anastomosis in tibial (posterior/anterior/peroneal) or pedal arteries. The bypasses considered were performed with ex-situ devalvulated greater saphenous vein (GSV) or composite autologous veins and a CA was routinely performed. Primary endpoint was to determine the rate of defects detected by the CA, while secondary outcomes were adjunctive procedures performed to correct them, bypass patency during the follow-up and identification of possible risk factors associated, limb salvage. Follow-up was performed by duplex scan at 6 months and yearly thereafter. Patency rates and survival free from major events were calculated using Kaplan-Meier analysis and compared with the log-rank test. RESULTS: In the study period, a total of 256 bypasses in 238 patients were considered. Patients mean age was 74±8 years and 78% were male, 62% diabetics and 13% in haemodialysis. A composite autologous vein bypass was performed in 18% (46) of cases; the distal anastomosis was performed in 67% to the tibial and 33% to the pedal arteries. At CA, 24 (9%) defects were identified: 14 (50%) vein defects (9-vein stenosis, 4-residual valve), 10 (42%) post-anastomotic stenoses due to clamp injury, and 4 (16%) distal arterial lesions. All the defects were treated intraoperatively, 5 (21%) by surgical revision and 19 (79%) by endovascular angioplasty. The 30-day occlusion rate was 7%, which was attributed to poor outflow, and no occlusions occurred in patients who received defect treatment. The 30-day rates of major amputation and mortality were 4% and 8%, respectively. The mean follow-up was 42±32 months and the 5-year PP of the entire study group was 54±4%. No difference was detected in primary patency between bypass with defect identification and correction and all the other patients: 57±8% vs 54±5%, P=0.67, respectively. Risk factors for the defect identification at CA were the use of composite vein graft and hemodialysis (Odd ratio (OR): 2.1, 95% confidence-interval (CI) 1.3-3.4, P=.04 and OR: 1.7 95%CI 1.2-4.8, P=.04, respectively.) CONCLUSION: CA in FTPB can identify a significant number of defects, most of whom treatable by an endovascular approach. Their presence is associated with composite vein bypass and dialysis, and their identification and treatment allow to obtain a primary patency similar to bypass without defect.
Computed tomography reference diameters of the abdominal aorta in a Portuguese hospital population.
Gouveia E Melo R, Henriques M, Peixoto A … +5 more , Caldeira D, Ministro A, Leitão J, Fernandes E Fernandes R, Pedro LM
Ann Vasc Surg · 2026 Jun · PMID 42331222 · Publisher ↗
INTRODUCTION: Aortic dimensions vary according to age, sex, and population characteristics. This study aimed to establish computed tomography (CT)-based reference diameters for the abdominal aorta in a Portuguese hospita...
INTRODUCTION: Aortic dimensions vary according to age, sex, and population characteristics. This study aimed to establish computed tomography (CT)-based reference diameters for the abdominal aorta in a Portuguese hospital population, providing reference data that may support the assessment of aortic dilatation and future population-specific studies of aneurysm diagnosis and surveillance. METHODS: A single-centre cross-sectional study was conducted using CT examinations performed at a tertiary referral hospital in Portugal during 2018. CT scans were randomly selected using a stratified sampling strategy according to month and time of day. Patients with known aortic disease or CT examinations requested in the context of vascular or cardiac surgery consultations were excluded. Aortic diameters were measured on multiplanar reconstructions using outer-to-outer wall measurements at standardised anatomical locations. Analyses were performed overall and stratified by sex and age group (<50, 50-75, and >75 years). Comparisons were performed using Student's t test and linear regression models, including age-adjusted analyses for sex comparisons. RESULTS: A total of 479 patients were included, of whom 266 (55.5%) were male. Mean age was 64.5 years (SD 17.3). Mean abdominal aortic diameters were 23.71 mm (SD 4.32) at the coeliac level, 22.07 mm (SD 4.08) at the superior mesenteric artery level, and 20.95 mm (SD 4.14) at the renal level. Infrarenal diameters ranged from 18.95 mm (SD 4.05) proximally to 17.72 mm (SD 3.89) distally. Men had significantly larger diameters than women at all anatomical locations (all p < 0.001). Aortic diameter increased significantly with age across all segments (all p < 0.001), with consistent and additive effects of age and sex. CONCLUSION: This study provides CT-based reference values for abdominal aortic diameters in a Portuguese population. Aortic size is strongly influenced by age and sex, supporting the need for population-specific and demographically stratified reference values.
Improving Operative Note Documentation in Vascular Surgery: A Two-Cycle Closed-Loop Audit Following Introduction of Standardised Procedure-Specific Templates.
Mersal M, Amin A, Embaby OM … +3 more , Hamid K, Elsabbagh M, Elboushi A
Ann Vasc Surg · 2026 Jun · PMID 42331221 · Publisher ↗
OBJECTIVE: To evaluate completeness of operative note documentation in a vascular surgery service and to assess whether introduction of standardised procedure-specific templates was associated with improved documentation...
OBJECTIVE: To evaluate completeness of operative note documentation in a vascular surgery service and to assess whether introduction of standardised procedure-specific templates was associated with improved documentation in a repeat audit cycle. METHODS: We conducted a single-centre two-cycle closed-loop audit within a UK vascular surgery department. In Cycle 1, 63 consecutive operative notes from May 2024 were retrospectively reviewed against predefined documentation standards derived from Royal College of Surgeons guidance. Following identification of recurrent omissions, standardised procedure-specific templates were collaboratively developed, disseminated, and introduced at a departmental governance meeting. In Cycle 2, 72 consecutive operative notes from March 2025 were reviewed using the same data collection framework. The primary process measures were documentation rates for four safety-critical fields: indication for surgery, estimated blood loss, distal pulse status, and postoperative plan. Between-cycle differences were compared using Fisher's exact test and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Baseline documentation was incomplete across all four variables. Following template introduction, statistically significant improvements were observed for indication for surgery (43.2% to 79.5%; OR 5.07, 95% CI 2.38-10.80; p < 0.0001) and distal pulse status (19.6% to 65.4%; OR 7.99, 95% CI 3.61-17.68; p < 0.0001). No statistically significant improvement was observed for estimated blood loss (16.3% to 19.2%; OR 1.28, 95% CI 0.52-3.12; p = 0.66) or postoperative plan (39.1% to 44.9%; OR 1.22, 95% CI 0.61-2.42; p = 0.60). CONCLUSIONS: Standardised procedure-specific templates were associated with substantial, statistically significant improvements in two documentation domains. The absence of equivalent improvement in blood loss and postoperative plan recording, confirmed by formal hypothesis testing, indicates that these variables require distinct intervention strategies beyond structured prompting alone. This closed-loop audit supports continued template refinement, targeted behavioural and systems-level interventions, and further re-audit.
Thoracic Endovascular Aortic Repair for the Management of Acute Type B Intramural Hematoma with Ulcer-like Projection Results in Remodeling of Concomitant Retrograde Arch Extension.
McIntosh E, Mustansir F, Wahidi R … +7 more , Dalmia V, Droz N, Kachroo P, Brescia AA, Wanken Z, Ohman JW, Washington University Collaborative for Aortic Research (WashU-CAR)
Ann Vasc Surg · 2026 Jun · PMID 42331220 · Publisher ↗
INTRODUCTION: Aortic intramural hematoma (IMH) has an unpredictable clinical course depending on the extent of disease. Management remains unclear for patients with type B IMH with concomitant type A IMH. We examine our...
INTRODUCTION: Aortic intramural hematoma (IMH) has an unpredictable clinical course depending on the extent of disease. Management remains unclear for patients with type B IMH with concomitant type A IMH. We examine our experience with thoracic endovascular aortic repair (TEVAR) for this patient subset. METHODS: The study design and research was approved by our Institutional Review Board and the need for informed consent was waived. This is a single-institution retrospective study of patients with type B IMH with an ulcer-like projection (ULP) in the descending thoracic aorta, as well as retrograde type A IMH, who underwent TEVAR between 2018-2024. IMH thickness and extent was examined on CTA imaging to assess for resolution and positive aortic remodeling after TEVAR. RESULTS: We identified 65 patients between 2018-2024 treated at our institution for IMH. Of those, 7 patients had a type B IMH with ulcer-like projection with concomitant retrograde arch extension of the IMH, treated with TEVAR. In our series, 5 patients had resolution of the retrograde type A IMH by 5 months, and as early as 3-5 weeks in 2 of those patients. The type B component of IMH had resolved in 5 patients by 10 months, and as early as 11-14 days in 2 patients. One of the 7 patients was lost to follow up. CONCLUSIONS: Early TEVAR for patients with type B IMH with ulcer-like projection with concomitant retrograde ascending aortic or arch IMH, is a management strategy that can promote favorable aortic remodeling, without the need for open ascending aortic repair.
Acute kidney injury is associated with increased mortality following thoracic endovascular aortic repair.
Wahidi R, Brennan L, Elizondo-Benedetto S … +5 more , Mustansir F, Sorber RA, Zayed MA, Ohman JW, Wanken ZJ
Ann Vasc Surg · 2026 Jun · PMID 42331219 · Publisher ↗
OBJECTIVE: Acute kidney injury (AKI) is common following endovascular procedures and has been independently associated with increased hospital length of stay, mortality, and, in patients with severe chronic kidney diseas...
OBJECTIVE: Acute kidney injury (AKI) is common following endovascular procedures and has been independently associated with increased hospital length of stay, mortality, and, in patients with severe chronic kidney disease (CKD), accelerated progression to end-stage renal disease (ESRD) requiring dialysis. Prior studies have often focused on peripheral angiograms and infrarenal endovascular aortic repair (EVAR), with limited contemporary multicenter studies focused on the outcomes of renal function following thoracic endovascular aortic repair (TEVAR). METHODS: We analyzed the SVS-VQI TEVAR registry including patients from 2013-2025. Patients were stratified based on incidence of AKI in the post-operative period, defined as an increase in serum creatinine of either >0.3 mg/dL or 50% from pre-operative baseline. Patients who were dialysis-dependent at the time of TEVAR were excluded from this study. Patient demographics and perioperative variables were compared between the two cohorts utilizing univariate analysis. The primary outcome of this study was 30-day mortality among patients undergoing TEVAR stratified by development of AKI. Secondary outcomes included hospital and ICU length of stay, incidence of aortic-related reinterventions, and new dialysis requirement on hospital discharge. A logistic regression was subsequently performed to develop a risk prediction model utilizing AKI as a binary endpoint, with 70% of the dataset used for training and 30% for testing. RESULTS: A total of 26,702 patients who underwent TEVAR were included, of which 3,347 developed postoperative AKI (13%). A higher proportion of patients with AKI were male (65.8% vs 62.2%, p<0.0001), had higher preoperative creatinine (1.46 mg/dL vs 0.99 mg/dL, p<0.0001), and were more frequently diabetic (17.8% vs 15.6%, p = 0.0011). TEVAR in patients who developed AKI was more frequently performed emergently (35.2% vs 14.7%) and for the indication of acute dissection (36.4% vs 25.7%, both p<0.0001). The development of postoperative AKI was associated with significantly higher 30-day mortality (21.3% vs 4.7%) and length of stay (18.3d vs. 3.6d, both p<0.0001). For patients presenting with acute dissection, AKI development was associated with more distal extent of dissection, decreased true lumen perfusion and postoperative branch patency of all visceral vessels (all p<0.0001). CONCLUSION: AKI following TEVAR is associated with substantially increased 30-day mortality, and is strongly associated with impaired baseline renal function, existing diabetes mellitus, urgent procedures, and aortic dissection.
Underutilization of an Objective Vascular Screening Test in Patients with Diabetic Foot Ulcers.
Suzuki H, Vaughan-Sarrazin M, Ohl M … +5 more , Mecham B, McCoy K, Strief D, Green D, Livorsi DJ
Ann Vasc Surg · 2026 Jun · PMID 42331218 · Publisher ↗
AIMS: While current guidelines recommend ankle-brachial index (ABI) or toe-brachial index (TBI) for all diabetic foot ulcer (DFU) patients due to poor diagnostic accuracy of physical examination, adherence remains unclea...
AIMS: While current guidelines recommend ankle-brachial index (ABI) or toe-brachial index (TBI) for all diabetic foot ulcer (DFU) patients due to poor diagnostic accuracy of physical examination, adherence remains unclear. This study aimed to evaluate the performance and timeliness of ABI/TBI testing among newly diagnosed DFU patients. METHODS: We conducted a retrospective cohort study using Veterans Affairs (VA) data from 1/1/2019 to 12/31/2023. Veterans aged ≥65 years with a new DFU diagnosis were included. ABI/TBI within one year before or after the DFU diagnosis was recorded. Multivariable mixed-effects logistic regression with a facility random intercept evaluated factors associated with ABI/TBI and facility-level variation of vascular screening. RESULTS: Among 57,265 patients, 46.0% completed ABI/TBI. The median time from DFU diagnosis to ABI/TBI was 24 days (IQR 3-92). Patients with complicated DFU (osteomyelitis or gangrene) were more likely to undergo ABI/TBI (74.5% vs. 43.0% for uncomplicated DFU) and had shorter wait times (median 2 days vs. 32 days for uncomplicated DFU), suggesting ABI/TBI was often reserved for complicated DFU patients. There was notable facility-level variation for ABI/TBI (median odds ratio 2.40) after adjustment for patient and facility characteristics, suggesting that systemic barriers may influence vascular screening practices. CONCLUSIONS: Fewer than half of DFU patients received ABI/TBI, and testing was often delayed or reserved for advanced disease. System-level interventions to implement universal ABI/TBI screening for DFU patients are needed.
Intravascular Lithotripsy-Assisted Femoropopliteal Revascularization for Heavily Calcified Chronic Limb-Threatening Ischemia: Midterm Outcomes From a Single-Center Retrospective Study.
Domenico M, Manfredi Agostino M, Chiara F … +5 more , Ettore D, Salvatore A, Alessia V, Felice P, Salvatore B
Ann Vasc Surg · 2026 Jun · PMID 42331217 · Publisher ↗
OBJECTIVE: To evaluate early and midterm outcomes of intravascular lithotripsy (IVL)-assisted endovascular treatment for severely calcified femoropopliteal disease in patients with chronic limb-threatening ischemia (CLTI...
OBJECTIVE: To evaluate early and midterm outcomes of intravascular lithotripsy (IVL)-assisted endovascular treatment for severely calcified femoropopliteal disease in patients with chronic limb-threatening ischemia (CLTI). METHODS: This retrospective, single-center, single-arm study included 43 consecutive Rutherford class 4-6 CLTI patients treated between June 2023 and April 2025. Severe calcification was defined as Peripheral Arterial Calcium Scoring System (PACSS) grade 3 or 4. IVL was used for vessel preparation before drug-coated balloon angioplasty; adjunctive stenting was reserved for residual stenosis, recoil, or flow-limiting dissection. Overall survival, primary patency, and freedom from target-lesion reintervention were estimated using Kaplan-Meier analysis. RESULTS: Mean age was 73.2 ± 9.3 years; 34 patients (79.1%) had diabetes and 21 (48.8%) had chronic kidney disease. Mean lesion length was 25.5 ± 6.0 cm. Chronic total occlusions were present in 27 patients (62.8%), popliteal involvement in 18 (41.9%), and TASC C/D disease in 38 (88.4%). PACSS grade 3 and 4 calcification were present in 19 (44.2%) and 24 (55.8%) patients, respectively. Technical success was achieved in all cases, with final residual stenosis <30%. Bailout stenting was required in 9 patients (20.9%). At 24 months, Kaplan-Meier estimates were 93.0% for overall survival and 90.6% for both primary patency and freedom from target-lesion reintervention. CONCLUSIONS: In this exploratory CLTI cohort, IVL-assisted femoropopliteal revascularization was feasible despite severe calcification and complex anatomy, with selective stenting and encouraging midterm patency and freedom from reintervention.
A Systematic Review of Literature to Assess the Role and Utilization of Palliative Care in Vascular Surgery Patients.
Safaya A, Zil-E-Ali A, Choubey U … +5 more , Chaudhary R, Riarh H, Ahmad A, Aziz F, Aziz F
Ann Vasc Surg · 2026 Jun · PMID 42315031 · Publisher ↗
OBJECTIVE: Vascular surgeons take care of the most medically complex patients, who are at high risk of mortality. Most surgeons are not aware of the full scope of Palliative Care (PC) consultations and underutilize their...
OBJECTIVE: Vascular surgeons take care of the most medically complex patients, who are at high risk of mortality. Most surgeons are not aware of the full scope of Palliative Care (PC) consultations and underutilize their services. The purpose of this study is to assess the utilization, timing, predictors and clinical impact of palliative-care (PC) interventions in adults with high-risk vascular conditions. Additionally, it seeks to identify gaps to help streamline standardized PC pathways within vascular surgery. METHODS: A PRISMA-guided search of 191 targeted studies reporting PC consultations, advance-care planning, hospice referral or symptom-directed management in patients with chronic limb-threatening ischemia (CLTI), major amputation, aortic aneurysm or other vascular emergencies was performed. Reviewers worked independently and screened records, extracted data and appraised risk of bias with ROBINS-I. Ten studies met the criteria and are the subject of this analysis. RESULTS: Ten studies met inclusion criteria. PC utilization was consistently low: 2.7 % after below-knee amputation, 7.4 % among Medicare CLTI cohorts, 7 % in unplanned vascular admissions and 8-12 % after major amputations or inoperable aneurysms. Consultations were typically late, occurring a median 3-17 days before death and sometimes within hours of demise. Predictors of referral included advanced age, frailty, acute limb ischemia, high comorbidity burden and prolonged ICU support, yet many high-risk patients received no PC evaluation. When delivered, PC was associated with reduced in-hospital mortality (OR ≈ 0.25-0.49), lower ICU utilization and higher hospice discharge rates. All studies displayed moderate-to-high risk of bias, chiefly from confounding and selection domains. CONCLUSIONS: Across the vascular surgery spectrum, PC is under-used and introduced too late in care to capitalize on all the benefits. Criteria-driven referral and embedding PC teams into routine vascular care pathways could improve symptom control, align treatment with patient goals and reduce non-beneficial resource use. Standardized protocols and prospective studies are needed to optimize goal-concordant care and establish benchmarks for this high-risk population.
Long-term Outcomes of Surgeon Modified Fenestrated TEVAR at Zone 2 Landing.
Zafer Iscan H, Bogachan Akkaya B, Kulahcioglu E … +5 more , Demir E, Aşkin G, Şenel E, Faruk Çakmak M, Aytekin B
Ann Vasc Surg · 2026 Jun · PMID 42297348 · Publisher ↗
AIM: Surgeon-modified fenestrated stent grafts (SMFSGs) have emerged to overcome limitations related to manufacturing delays, high procedural costs, anatomical constraints, and limited availability of custom-made branche...
AIM: Surgeon-modified fenestrated stent grafts (SMFSGs) have emerged to overcome limitations related to manufacturing delays, high procedural costs, anatomical constraints, and limited availability of custom-made branched or fenestrated endografts. The aim of this study was to evaluate the safety, feasibility, and mid- to long-term follow-up outcomes of the SMFSG technique for zone 2 landing using the Lifetech Ankura™ thoracic endograft. MATERIALS AND METHODS: Between January 2020 and January 2026, 41 consecutive patients with thoracic aortic pathology requiring zone 2 landing and left subclavian artery (LSA) revascularization using SMFSG with the Lifetech Ankura™ thoracic endograft (Lifetech Scientific, Shenzhen, China) were included in the study. No reinforcement sutures were used during graft modification. The primary and secondary endpoints were overall mortality, and aorta-related mortality (ARM), endoleak, patency of LSA, and reinterventions in the follow-up period. RESULTS: The mean age of the patient cohort was 58.2±11.2 (34-85) years. There was no open conversion to surgery and technical success was 100% according to the study definition. Eight patients (19.5%) underwent selective primary balloon-expandable stent placement in the LSA to optimize branch patency. Nine patients (21.95%) underwent the procedure under emergency conditions. The mean intensive care unit period was 14.8±7.1 hours (4-36 hours). The mean length of stay was 3.8±1.4 days (3-6 days). The fenestration procedure took a mean period of 11.3±3.2 minutes (8-18 minutes). The fluoroscopy period was 9.2±4.3 minutes (4-22 minutes). The follow-up period was 51.9±13.6 months (5 - 66 months). Primary and secondary LSA patency rates were 100% and 97.6% for the follow-up period. Two patients experienced Type 1a endoleak and both had TEVAR and Carotico-Subclavian bypass (CSB) at the 12 and 18 month. One patient died at the 28th month due to cardiac causes. There was no aorta related mortality (ARM). CONCLUSION: In this retrospective single-center series, surgeon-modified fenestrated TEVAR using the Lifetech Ankura thoracic endograft was feasible and achieved high technical success with favorable LSA patency and encouraging follow-up outcomes. However, interpretation is limited by the small sample size, heterogeneous pathology, and limited number of late events. Larger comparative studies are needed to better define durability and pathology-specific performance.
Intraoperative optimization of radiocephalic arteriovenous fistula surgery with contemporary techniques.
White NA, de Winter EP, Bulder RMA … +9 more , Urlings TAJ, van der Steenhoven TJ, Eefting D, Jan de Jong W, Specken-Welleweerd JC, Nadery LS, Oliveira-Martens S, Rotmans JI, van der Bogt KEA
Ann Vasc Surg · 2026 Jun · PMID 42297347 · Publisher ↗
RESEARCH PURPOSE: This retrospective study assesses the impact of a standardized intraoperative procedure on radiocephalic arteriovenous fistulas (RCAVFs) outcomes, combining Transit Time Flow Measurement, papaverine adm...
RESEARCH PURPOSE: This retrospective study assesses the impact of a standardized intraoperative procedure on radiocephalic arteriovenous fistulas (RCAVFs) outcomes, combining Transit Time Flow Measurement, papaverine administration, and an external support device. METHODS: Consecutive RCAVF patients were included at The Hague Medical Center between November 2021 and October 2024. Intraoperative flow rates, maturation rates, and (assisted) patency rates at 6 and 12 weeks, and 6 and 12 months were compared to a contemporary control group from the same center. Maturation was defined as venous diameter ≥ 4mm, a flow ≥ 500 mL/min, and a palpable thrill. The number of interventions and per patient costs of interventions and procedures also recorded and compared. RESULTS: The study compared 43 patients in the intervention group with 59 in a control group. The optimized procedure significantly improved intraoperative flow rates (210 ± 89 mL/min vs. 163 ± 85 mL/min, P = 0.008) and maturation rates at 6 weeks (77% vs. 43%, P = 0.002) and 12 weeks (91% vs. 59%, P = 0.003). Males showed higher overall maturation rates (66% vs. 38%, p = 0.03). However, no significant differences were found in primary patency at 12 months, nor in the average number of interventions per patient. There was a trend towards better assisted patency in the optimized patency group at 12 months. The intervention group had significantly higher average costs per patient (€5858.77 vs. €4148.89, p=0.002). CONCLUSION: The optimized RCAVF procedure enhances intraoperative flow and early maturation rates, with the most notable effects in the initial postoperative months. Further research is needed to determine the long-term benefits and cost-effectiveness.
Sarcopenia is an Independent Predictor of All-Cause Death and Major Adverse Cardiovascular Events in Patients with Peripheral Arterial Disease.
Zhang F, Guo Y, Zhao W … +6 more , Zhang L, Diao Y, Chen Z, Li Y, Li H, VIP-PADS Study Collaborators
Ann Vasc Surg · 2026 Jun · PMID 42297346 · Publisher ↗
OBJECTIVE: Peripheral arterial disease (PAD) is a chronic vascular disease with high morbidity, often accompanied by sarcopenia. However, the prognostic value and mechanistic relevance of CT-defined sarcopenia in PAD rem...
OBJECTIVE: Peripheral arterial disease (PAD) is a chronic vascular disease with high morbidity, often accompanied by sarcopenia. However, the prognostic value and mechanistic relevance of CT-defined sarcopenia in PAD remain unclear. This study aims to assess the independent impact of sarcopenia on all-cause mortality and major adverse cardiovascular events in PAD patients, and to determine optimal L3 skeletal muscle index (L3-SMI) cutoffs for risk stratification. METHODS: In this retrospective cohort study, 208 PAD patients were grouped by L3-SMI into sarcopenia (n=110) and non-sarcopenia (n=98). Multivariate Cox regression evaluated associations with mortality and MACE, while restricted cubic spline (RCS) models explored dose-response patterns. Kaplan-Meier and log-rank tests compared survival, and Spearman correlation analyzed functional and metabolic associations. RESULTS: The sarcopenia group exhibited significantly higher age (71.5±9.38 vs. 65.81±10.25 years, p<0.001) , while lower L3-SMI (36.48±5.67 vs. 47.31±7.88 cm/m, p<0.001), lower BMI (22.31±2.96 vs. 25.77±2.72 kg/m, p<0.001), lower albumin (37 vs. 39 g/L, p=0.005), and lower serum phosphate (1.14 vs. 1.23 mmol/L, p=0.009). Over a 36-month median follow-up, sarcopenia was associated with increased all-cause death (27% vs. 14%, p=0.034) and MACE incidence (28% vs. 14%, p=0.024). Multivariate Cox regression revealed that each 1-unit decrease in L3-SMI elevated death risk by 7% (adjusted HR=0.93, 95% CI: 0.88-0.98, p=0.009) and MACE risk by 9% (adjusted HR=0.92, 95% CI: 0.86-0.96, p=0.008). RCS analysis identified nonlinear dose-response relationships: L3-SMI <40.97 cm/m sharply increased death risk (HR=3.3), while L3-SMI <48.78 cm/m significantly amplified MACE risk (HR=7.89). Correlations between L3-SMI and Barthel Index (r=0.56, p<0.001), serum phosphate (r=0.53, p=0.002), and Fontaine stage (r=-0.39, p=0.007) suggested sarcopenia might exacerbate disease progression via metabolic dysregulation, immune suppression, and functional decline. CONCLUSION: CT-defined sarcopenia independently predicts poor outcomes in PAD. L3-SMI thresholds enable early risk stratification and support targeted interventions to improve prognosis. These findings underscore the importance of incorporating body composition assessment into routine risk evaluation for PAD patients.
Letter to the Editor Regarding "Outcomes of Interventions to Salvage the Jailed Profunda Femoris in Recurrent Limb-Threatening Critical Ischemia".
Manenti A, Coppi G, Coppi F … +1 more , Manco G
Ann Vasc Surg · 2026 Jun · PMID 42288247 · Publisher ↗
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Diaphragmatic Paralysis Following Thoracic Outlet Decompression: An Evaluation of Secondary Phrenic Nerve Reconstruction for Salvage.
Kaufman MR, Shah A, Nevitt RT … +2 more , Jarrahy R, Santoro C
Ann Vasc Surg · 2026 Jun · PMID 42288246 · Publisher ↗
BACKGROUND: Thoracic outlet syndrome (TOS) involves the compression of neurovascular structures within the thoracic outlet, defined as a space at the base of the neck, superior to the first rib and posterior to the clavi...
BACKGROUND: Thoracic outlet syndrome (TOS) involves the compression of neurovascular structures within the thoracic outlet, defined as a space at the base of the neck, superior to the first rib and posterior to the clavicle. Surgical management most commonly requires a supraclavicular approach to allow for anterior and middle scalene muscle resection, cervical and first rib resection, and brachial plexus decompression. Pectoralis minor tenotomy and vascular decompression may also be indicated. While these interventions may successfully relieve compression within the thoracic outlet, they carry a risk of iatrogenic phrenic nerve injury (PNI). PNI-induced diaphragm paralysis often results in symptomatic pulmonary dysfunction. Phrenic nerve reconstruction may offer an effective treatment for functional diaphragm salvage after PNI following TOS surgery. METHODS: We performed a retrospective review of 17 patients with PNI following TOS surgery referred for management at a tertiary referral center who underwent phrenic nerve reconstruction to restore functional diaphragm activity. RESULTS: There were 17 patients (10 females and 7 males with a mean age of 47) who were treated for chronic, symptomatic PNI following TOS surgery. Two patients were lost to follow-up. The mean interval from PNI to secondary phrenic nerve reconstruction was 19 months. Following phrenic nerve intervention, 12 of 15 patients (80%) reported improvement, 10 of whom demonstrated partial or complete functional diaphragm recovery on objective analyses. CONCLUSION: Surgical treatment for TOS has demonstrable therapeutic benefits to patients suffering from this disease. However, PNI is a potential complication associated with TOS surgery. Secondary phrenic nerve reconstruction to achieve salvage of diaphragm function can successfully address this risk and reduce or eliminate the morbidity associated with TOS-related PNI.
Treatment of Established Groin Lymphatic Complications after Arterial Surgery: A Systematic Review.
McLoughlin MT, Ghanem YKM, Elkassaby M … +3 more , Gosi G, Masarani N, Walsh SR
Ann Vasc Surg · 2026 Jun · PMID 42285291 · Publisher ↗
OBJECTIVE: To systematically review the effectiveness and safety of interventions for established groin lymphatic complications after arterial vascular surgery. METHODS: PubMed, Embase, and Cochrane CENTRAL were searched...
OBJECTIVE: To systematically review the effectiveness and safety of interventions for established groin lymphatic complications after arterial vascular surgery. METHODS: PubMed, Embase, and Cochrane CENTRAL were searched from inception to May 28, 2025. This review was registered in PROSPERO (CRD420251061708) and conducted according to PRISMA, PRISMA-S, and Synthesis Without Meta-analysis (SWiM) guidance. Eligible studies included adults with established groin lymphorrhea/lymphocutaneous fistula or seroma/lymphocele after arterial exposure in the common femoral or iliofemoral region. Prophylactic studies were excluded. Two reviewers independently screened studies and assessed full texts. Prespecified outcomes were resolution, time to resolution, length of stay, surgical site infection, wound complications, reintervention, and recurrence. Owing to substantial heterogeneity, meta-analysis was not performed. RESULTS: Eighteen retrospective single-centre studies were included; no randomized trials were identified. Reported strategy-family totals were operative control (n=240, including 55 dye-assisted cases), intranodal lymphangiography with glue embolization (n=39), intracavitary or chemical instillation (n=52), negative-pressure wound therapy (n=20), radiotherapy (n=206), and drainage or aspiration alone (n=7). One additional cohort compared nonsurgical with surgical management. Definitions, follow-up windows, and statistical reporting were inconsistent, and arm-level denominators were frequently incomplete. Risk of bias was serious to critical across the evidence base, mainly because of retrospective design, confounding by indication, treatment-selection bias, inconsistent outcome definitions, and incomplete reporting. Using GRADE principles, certainty of evidence was very low across strategies and phenotypes. Across study arms, conduit-directed approaches for external leak and cavity-directed approaches for encapsulated collections often achieved control, but valid comparative inference was not possible. CONCLUSIONS: Evidence is limited to small retrospective series with heterogeneous definitions, serious to critical risk of bias, and very low certainty. Reliable comparisons between interventions cannot currently be made. Standardized phenotype-specific definitions and outcome reporting are needed to support prospective studies and future trials.
Risk Scores for Loss of Secondary Patency and Major Amputation after Successful Thrombectomy of an Infra-Inguinal Arterial Bypass.
Peters AP, Valdez C, Ashraf N … +7 more , Khan N, Hallare J, Darman L, Rodriguez PP, Babrowski T, Bechara CF, Blecha M
Ann Vasc Surg · 2026 Jun · PMID 42285290 · Publisher ↗
OBJECTIVE: The purpose of this study was to utilize VQI data to create internally validated risk scores for two primary outcome events of loss of secondary patency and major lower extremity amputation after successful th...
OBJECTIVE: The purpose of this study was to utilize VQI data to create internally validated risk scores for two primary outcome events of loss of secondary patency and major lower extremity amputation after successful thrombectomy of infra-inguinal arterial bypasses. The goal is to identify modifiable variables which can improve outcomes after successfully recanalizing an occluded infra-inguinal arterial bypass. METHODS: Variables with a multivariable P-value < .05 for the outcomes were included in the risk scores and weighted based on their respective regression beta-coefficient in a point scale. Multivariable significant factors with a beta-coefficient of less than .25 were assigned 1 point, and then a point was added for each rise in beta-coefficient at .25 intervals. A cumulative score was then created for each patient by adding up the points assigned for each significant multivariable factor they possessed. Risk scores were then bundled into groups to allow for cohesion, simplification, enhancement of statistical power and reduced random effects of smaller sample sizes for a given risk score. Area under curve (AUC) analysis was performed for the risk scores in determining the accuracy of association with loss of secondary patency and major amputation. RESULTS: Variables with a statistically significant (P<.05) multivariable association with amputation were : female sex (aOR 1.39); living in a top 20% ADI neighborhood (aOR 1.84); BMI < 20 kg/m (aOR 1.84); multiracial designation (aOR 2.29 relative to white reference); diabetes requiring oral hypoglycemics (aOR 1.86) or insulin (aOR 2.97); anemia (aOR 1.69); tibial/pedal bypass target (aOR 2.93); being selected for anticoagulant at time of initial hospital discharge (aOR 1.61); lack of surveillance imaging in follow up (aOR 2.93); smoking at LTFU (aOR 104.4) and smoking status unknown relative to non-smokers (aOR 24.2); non-ambulatory status at LTFU (aOR 10.50); and re-occluded bypass at LFTU (aOR 2.81). Variables which were protective (P<.05) from amputation on multivariable analysis were being on anticoagulation at the time of LTFU (aOR .67); prior aneurysm repair (aOR .42); and BMI >35 (aOR .53). There was noted to be steep escalation in the frequency of major amputation with rising risk score. At one extreme, no patients with scores < 15 experienced amputation and at the other extreme 77.8% of patients with scores of over 37 suffered amputation. There was a statistically significant (P<.01) rise in amputation rate at each rising risk score bundle. There was an essentially identical rate of amputation in the testing and validation at all risk score bundles with no significant difference in amputation rate at any of the risk score bundles. AUC analysis for the testing cohort achieved a value of .881 for the amputation testing cohort and .896 for the validation cohort. For the loss of secondary patency risk score, again a significant rise in outcome event was noted with rising risk score bundle with patients with scores of 6 and higher experiencing event at over 4 times a higher rate than those with scores less than -2. CONCLUSIONS: Internally validated risk calculators with steep escalation in event rates with progressive scores have been created for the outcomes of major amputation and loss of secondary patency after successful recanalization of an infra-inguinal arterial bypass. Key patient and physician driven modifiable variables in preventing adverse outcomes include smoking cessation, bypass surveillance imaging compliance, single segment vein utilization at original operation, and administration of anticoagulant and antiplatelet medications.
Admission-Based Early Risk Stratification for In-Hospital Mortality in Ruptured Abdominal Aortic Aneurysm: A Pragmatic Clinical Model.
Del Río-Solá MAL, Jimenez-Caja M, Torre-Casaseca C … +3 more , Alvarez-Garcia E, García-Padron C, Flota-Ruiz C
Ann Vasc Surg · 2026 Jun · PMID 42285289 · Publisher ↗
BACKGROUND: To develop and internally validate a pragmatic, admission-based prediction model for in-hospital mortality in patients presenting with ruptured abdominal aortic aneurysm (rAAA), and to assess its performance,...
BACKGROUND: To develop and internally validate a pragmatic, admission-based prediction model for in-hospital mortality in patients presenting with ruptured abdominal aortic aneurysm (rAAA), and to assess its performance, calibration, and clinical utility for early risk stratification. METHODS: This retrospective observational cohort study included consecutive adult patients admitted with rAAA to a tertiary referral university hospital between January 2015 and December 2024. Only variables available at the time of hospital admission were analyzed. Univariable and multivariable logistic regression were used to identify independent predictors of in-hospital mortality. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC), calibration using calibration plots and the Brier score, and internal validation using bootstrap resampling. Clinical utility was evaluated with decision curve analysis. RESULTS: A total of 334 patients with rAAA were included. Overall in-hospital mortality was 65.9% (220/334). Age was independently associated with mortality (adjusted odds ratio [aOR] 1.06 per year), while higher admission hemoglobin levels were protective (aOR 0.73 per-g/dL). Hemodynamic stability at presentation was the strongest independent predictor of survival (aOR 0.24). The admission-based model demonstrated reliable discrimination (AUC 0.74) with good calibration (Brier score 0.19) and minimal optimism after internal validation (optimism-corrected AUC 0.73). Decision curve analysis showed a net clinical benefit across a wide range of clinically relevant threshold probabilities. A simplified admission-based risk score stratified patients into low-, intermediate-, and high-risk groups with observed in-hospital mortality of approximately 11%, 49%, and 77%, respectively. CONCLUSION: An admission-based model using readily available clinical variables provides reliable early prediction of in-hospital mortality in patients with rAAA. By prioritizing simplicity and bedside applicability, this approach may support early risk stratification and decision-making in emergency vascular surgery.
Preoperative Coagulation Indicators Predict Prolonged Mechanical Ventilation in Acute Type A Aortic Dissection.
Li R, Yao P, Wang J … +5 more , Mei J, Liu N, Ma J, Ge Y, Zhu J
Ann Vasc Surg · 2026 Jun · PMID 42276374 · Publisher ↗
BACKGROUND: Preoperative coagulation dysfunction is a common complication among patients with acute type A aortic dissection (ATAAD). However, evidence regarding its association with prolonged mechanical ventilation (PMV...
BACKGROUND: Preoperative coagulation dysfunction is a common complication among patients with acute type A aortic dissection (ATAAD). However, evidence regarding its association with prolonged mechanical ventilation (PMV) following emergency surgery remains limited. METHODS: Clinical data from 793 patients with ATAAD were retrospectively collected. Patients were stratified into two groups according to preoperative coagulation function indicators. Logistic regression and nomogram analyses were conducted to assess the relationship between coagulopathy and PMV in patients with ATAAD. RESULTS: Patients with coagulation dysfunction demonstrated a longer awakening time [9.0 (5.50, 14.0) h vs 7.50 (4.0, 13.0) h, p = 0.015], a higher incidence of PMV [243 (35.5%) vs 28 (25.7%), p = 0.044], a higher incidence of postoperative acute kidney injury [382 (55.8%) vs 39 (35.8%), p < 0.001], and a greater requirement for continuous renal replacement therapy [60 (8.8%) vs 3 (2.8%), p = 0.031]. Multivariable logistic regression analysis indicated that PMV was significantly associated with age, duration of surgery, duration of cardiopulmonary bypass, preoperative lactic acid, creatinine, and fibrin degradation products (FDP). Subgroup analysis further demonstrated that patients with preoperative FDP levels > 15.27 μg/mL experienced poorer early postoperative outcomes. CONCLUSIONS: Preoperative coagulopathy was associated with PMV in patients with ATAAD. These findings underscore the clinical relevance of coagulation dysfunction in preoperative risk stratification for ATAAD.
Impact of Aortic Diameter on Left Ventricular Diastolic Dysfunction Following Endovascular Aortic Repair in Patients with Abdominal Aortic Aneurysm.
Nakanowatari H, Iwai-Takano M, Takano T … +6 more , Fujimiya T, Takahashi K, Endo Y, Fukada Y, Irie Y, Ohira T
Ann Vasc Surg · 2026 Jun · PMID 42276373 · Publisher ↗
BACKGROUND: Endovascular aortic repair (EVAR) is a less invasive treatment for abdominal aortic aneurysm (AAA). It has been reported the relationship between aortic diameter and the cardiovascular dysfunction caused by h...
BACKGROUND: Endovascular aortic repair (EVAR) is a less invasive treatment for abdominal aortic aneurysm (AAA). It has been reported the relationship between aortic diameter and the cardiovascular dysfunction caused by hemodynamic changes after EVAR in animal model. This study explored the relationship between abdominal aortic diameter and cardiovascular dysfunction post-EVAR in AAA patients. METHODS: Eighty-five patients who underwent EVAR (76.0 ± 7.4 years) received contrast-enhanced computed tomography to assess abdominal aortic diameter, echocardiography, and vascular function tests (cardio-ankle vascular index [CAVI]) before and 1 year after EVAR. The patients were categorized as the small (<21.7 mm, N = 42) and large (≥21.7 mm, N = 43) groups based on the median abdominal aortic diameter. We investigated the correlation between abdominal aortic diameters and changes in cardiovascular function. RESULTS: In all patients, pulse pressure and CAVI significantly increased, while E/A decreased post-EVAR (P < 0.05 for each). The left ventricular mass index (LVMI) tended to rise post-EVAR in the small group (87.7 ± 19.2 to 93.5 ± 20.7 g/m, P = 0.059), but not in the large group. When quartiles categorized abdominal aortic diameters, the percentage change of LVMI tended to increase with smaller aortic diameters, and there was a notable difference between quartiles 1 and 4. CONCLUSION: EVAR exacerbates arterial stiffness and LV diastolic dysfunction in patients with AAAs. Additionally, a smaller aortic diameter in these patients may be associated with more significant LV hypertrophy post-EVAR. This highlights the significance of monitoring for LV diastolic dysfunction when performing EVAR in patients with smaller aortic diameters.
Association of Lesion Complexity and Diabetes Mellitus with Target Lesion Failure after Femoropopliteal Atherectomy.
Özkan G, Kılınç Zİ, Kılıçaslan N … +7 more , Tümkaya S, Toz H, Özkan B, Yücel C, El Kılıç H, Satılmış OE, Kavala AA
Ann Vasc Surg · 2026 Jun · PMID 42276372 · Publisher ↗
BACKGROUND: Diabetes mellitus (DM) is associated with adverse outcomes after femoropopliteal endovascular interventions, but diabetic patients often present with greater anatomical complexity and impaired distal outflow,...
BACKGROUND: Diabetes mellitus (DM) is associated with adverse outcomes after femoropopliteal endovascular interventions, but diabetic patients often present with greater anatomical complexity and impaired distal outflow, potentially confounding its relationship with target lesion failure (TLF). METHODS: We retrospectively reviewed 123 consecutive patients who underwent femoropopliteal atherectomy for symptomatic peripheral artery disease between January 2017 and August 2025. All patients received drug-coated balloon angioplasty after atherectomy, and no stents were implanted. The primary end point was TLF, defined as clinically driven target lesion revascularization, duplex ultrasound-proven restenosis, or target vessel occlusion. Multivariable Cox regression, logistic regression for early TLF (≤ 6 months), metabolic sensitivity analyses, stratified interaction testing, and 6-month landmark analysis were performed. RESULTS: TLF occurred in 48.8% of patients. Diabetic patients had worse unadjusted TLF-free survival (log-rank P = 0.045), but DM was not independently associated with overall TLF after adjustment (hazard ratio [HR]: 1.15, 95% confidence interval, 0.72-1.84; P = 0.550). Lesion length ≥ 100 mm (HR: 2.05, P = 0.012), chronic limb-threatening ischemia (HR: 1.80, P = 0.040), and poor tibial runoff (HR: 1.68, P = 0.048) remained independently associated with adverse outcomes. A significant DM × poor runoff interaction was observed (P = 0.029), with TLF occurring in 82.5% of diabetic patients with poor runoff. HbA1c and glucose were not independently associated with TLF in sensitivity analyses. CONCLUSION: DM was not independently associated with TLF after femoropopliteal atherectomy once lesion complexity and distal runoff were considered. Anatomical disease burden and distal hemodynamics may confound the observed association between DM and adverse outcomes.
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