OBJECTIVE: Sarcopenia, defined as loss of skeletal muscle mass and function, predicts adverse surgical outcomes. This study evaluated longitudinal changes in sarcopenia following fenestrated endovascular aortic aneurysm...OBJECTIVE: Sarcopenia, defined as loss of skeletal muscle mass and function, predicts adverse surgical outcomes. This study evaluated longitudinal changes in sarcopenia following fenestrated endovascular aortic aneurysm repair (FEVAR) and their impact on outcomes. METHODS: This retrospective, single centre study included patients who underwent FEVAR for complex abdominal aortic aneurysms between 2007 and 2022. Sarcopenia was defined using skeletal muscle area (SMA) cutoffs of < 144 cm for men and < 92 cm for women, measured from computed tomography scans. The primary outcome was all cause mortality; secondary outcomes included longitudinal changes in SMA, analysed with mixed effects models. RESULTS: This study included 169 patients (median age 74.7 years; 87.6% men) with median follow up of 4.8 years. Pre-operative sarcopenia prevalence was 20.7% (n = 35), which increased to 32.5% (n = 55) post-operatively, with statistically significant muscle loss (-6.6 ± 7.2%; p < .001). Subsequently, sarcopenia rates gradually declined to ∼27% over 3 years (1 year: -3.3 ± 9.2%, p < .001; 2 years: -3.7 ± 8.4%, p < .001; 3 years: -3.8 ± 10.7%, p = .006). Pre-operative sarcopenia did not impact thirty day outcomes or overall survival compared with non-sarcopenic patients at these time points (1 year: 88.4% vs. 95.2%; 3 years: 76.7% vs. 78.6%; 5 years: 55.8% vs. 61.9%, p = .090). Conversely, new or worsened post-FEVAR sarcopenia was associated with poorer survival (1 year: 90.6% vs. 95.2%; 3 years: 73.4% vs. 81.0%; 5 years: 53.1% vs. 64.8%; 7 years: 25.5% vs. 47.4%; 10 years: 2.1% vs. 15.5%, p = .001). Post-operative sarcopenia was a stronger predictor of overall mortality (hazard ratio [HR] 2.00, 95% confidence interval [CI] 1.30 - 3.10; p = .002) compared with pre-operative sarcopenia (HR 1.76, 95% CI 1.06 - 2.93; p = .030). In multivariate analysis, only post-operative sarcopenia remained significant (HR 1.89, 95% CI 1.18 - 3.04; p = .009) and was associated with higher seven year mortality (74.5% vs. 52.6%; p = .020) and ten year mortality (97.9% vs. 84.5%; p = .035). CONCLUSION: In this retrospective observational study, post-operative skeletal muscle loss following FEVAR was significant and was associated with long term mortality. This suggests that FEVAR carries a physiological burden warranting careful post-operative assessment and optimisation. Prospective multicentre studies are needed to establish mechanistic pathways and to determine whether interventions improve outcomes.
OBJECTIVE: A single segment great saphenous vein (GSV) with a diameter ≥ 3.0 mm is widely accepted as the standard conduit for tibial and pedal bypass in chronic limb threatening ischaemia (CLTI) based on studies in Euro...OBJECTIVE: A single segment great saphenous vein (GSV) with a diameter ≥ 3.0 mm is widely accepted as the standard conduit for tibial and pedal bypass in chronic limb threatening ischaemia (CLTI) based on studies in European and American populations. However, this threshold may not be appropriate for Asian patients who generally have smaller body habitus and vein diameter. The aim of this study was to evaluate clinical outcomes and the optimal conduit diameter in Asian patients with CLTI undergoing tibial or pedal bypass. METHODS: Data were analysed from a multicentre retrospective observational study of 1 016 CLTI cases treated with tibial or pedal bypass using autologous vein conduits at seven Japanese centres between 2013 and 2022. Pre-operative vein diameters were assessed by duplex ultrasound (DUS), computed tomography (CT), or both, and were categorised into three groups (< 2.5 mm, 2.5 - 3.0 mm, and ≥ 3.0 mm) for each evaluation. The primary endpoint was primary patency. Secondary endpoints included secondary patency, limb salvage, and wound healing. RESULTS: Among 871 patients (72.0% male; mean age 73 ± 10 years) who received single segment GSV grafts, the three year primary and secondary patency rates were 57.1% and 79.6%, respectively. Limb salvage at 3 years was 90.9% and the twelve month wound healing rate was 83.8%. A DUS evaluated diameter ≥ 2.5 mm and a CT evaluated diameter ≥ 3.0 mm (reflecting a mean difference of 0.30 mm) were significantly associated with improved primary patency after adjustment for patient backgrounds and procedural characteristics. Although approximately 20% of cases had pre-operative diameters < 2.5 mm, these grafts showed comparable three year secondary patency, limb salvage, and wound healing after adjustment. CONCLUSION: DUS and CT evaluated graft diameters were significantly associated with graft patency, but not with limb salvage or wound healing in a Japanese cohort. Further studies of the appropriate graft diameter are needed in Asian patients with CLTI.
OBJECTIVE: To review the relative efficacy and safety of low dose direct oral anticoagulants (DOACs) for extended secondary prevention of venous thromboembolism (VTE). DATA SOURCES: Medline and Scopus databases. REVIEW M...OBJECTIVE: To review the relative efficacy and safety of low dose direct oral anticoagulants (DOACs) for extended secondary prevention of venous thromboembolism (VTE). DATA SOURCES: Medline and Scopus databases. REVIEW METHOD: The databases were searched on 25 October 2025 for randomised controlled trials (RCTs), comparing low dose with therapeutic dose anticoagulation with a DOAC. The study outcomes (including efficacy/recurrent VTE and safety/bleeding events) were expressed as risk ratios (RR) with 95% confidence interval (CI). Certainty of evidence was assessed with the GRADE method. RESULTS: Five RCTs with 8 781 patients were included. Compared with the low dose, therapeutic dose did not reduce the risk of recurrent VTE (RR 0.97, 95% CI 0.70 - 1.34, p = .86, moderate certainty of evidence), pulmonary embolism (RR 1.02, 95% CI 0.66 - 1.60, p = .92, moderate certainty of evidence), or deep vein thrombosis (RR 0.86, 95% CI 0.53 - 1.39, p = .54, moderate certainty of evidence). Therapeutic anticoagulation significantly increased the risk for major bleeding (RR 1.66, 95% CI 1.18 - 2.34, p = .004, moderate certainty of evidence), clinically relevant non-major bleeding (RR 1.34, 95% CI 1.14 - 1.58, p < .001, high certainty of evidence), and any bleeding (RR 1.38, 95% CI 1.13 - 1.68, p = .002, moderate certainty of evidence). There were no subgroup differences between studies including only patients with cancer and those who did not, although a non-significant trend was observed (p = .10, I = 62.4%) for an increased risk of death (RR 1.51, 95% CI 1.03 - 2.19, p = .03, I = 48%) with the therapeutic dose in non-cancer studies. CONCLUSION: Therapeutic doses of DOACs increase the risk of major bleeding and clinically relevant non-major bleeding without decreasing VTE recurrence, making low doses a safer option than therapeutic anticoagulation for extended secondary VTE thromboprophylaxis.
OBJECTIVE: This trial aimed to assess whether custom made three dimensional (3D) printed vascular models improve procedural outcomes when used for pre-operative planning and simulation in endovascular treatment (EVT) of...OBJECTIVE: This trial aimed to assess whether custom made three dimensional (3D) printed vascular models improve procedural outcomes when used for pre-operative planning and simulation in endovascular treatment (EVT) of aorto-iliac-femoropopliteal peripheral artery disease (PAD). METHODS: This single centre, single blind randomised controlled trial (3DPAD-1), registered on ClinicalTrials.gov (Identifier: NCT07000097), enrolled consecutive patients scheduled for EVT between January 2022 and September 2024. Participants were randomised 1 : 1 to standard planning based on computed tomography angiography (CTA) alone (standard group, SG) or CTA plus 3D printed model based planning and simulation (3D model group, 3DMG). The prespecified coprimary endpoints were the cumulative 30 day incidence of peri-operative complications and total procedure duration. Secondary endpoints included technical success, contrast medium volume, radiation exposure, fluoroscopy time, and number of devices used. RESULTS: Of 166 patients screened, 106 were randomised (53 per arm); 99 underwent the allocated intervention (48 in the 3DMG, 51 in the SG). The cumulative incidence of complications was significantly lower in the 3DMG (20.8%) than in the SG (49.0%; p = .006). The univariable logistic model (OR 0.27, 95% CI 0.11 - 0.66; p = .004), the multivariable model (adjusted OR 0.22, 95% CI 0.08 - 0.60; p = .004), and the propensity weighted analyses (Average Treatment Effect OR 0.33, 95% CI 0.13 - 0.86; p = .023; Average Treatment Effect in the Overlap Population OR 0.35, 95% CI 0.14 - 0.79; p = .023) consistently confirmed the protective effect of the 3D model. Procedure duration was significantly shorter in the 3DMG (mean difference -40.3 minutes; p < .001), confirmed in adjusted and weighted models. No significant between group differences were observed in other peri-operative outcomes. CONCLUSION: Custom made 3D printed models significantly reduced peri-operative complications and procedure duration in EVT for PAD, supporting their role in improving procedural planning and efficiency. These findings support the selective adoption of 3D printed models for complex endovascular interventions to enhance procedural efficiency and patient safety.
OBJECTIVE: The aim of this retrospective observational study was to analyse imaging and patient related parameters of splenic artery aneurysms (SAAs) and their impact on SAA growth and rupture. METHODS: The term "aneurys...OBJECTIVE: The aim of this retrospective observational study was to analyse imaging and patient related parameters of splenic artery aneurysms (SAAs) and their impact on SAA growth and rupture. METHODS: The term "aneurysm" was systematically searched for in the radiology reports of 1.9 million abdominal imaging studies conducted in a university hospital district between 2006 and 2020. Clinical data were collected from the medical records, and causes of death from a registry. Computed tomography scans were reviewed for radiological parameters. Multivariate tests were used to analyse factors associated with SAA growth and rupture. RESULTS: Overall, 821 SAAs in 670 patients were identified from 35 378 radiology reports containing the term "aneurysm". The mean SAA diameter ± standard deviation at presentation was 14.1 ± 5.6 mm. Follow up imaging was available for 584 SAAs (71.1%), with a mean follow up of 79.2 ± 54.0 months. Growth was observed in 77 (13.2%) of these SAAs. The mean growth rate was 0.097 ± 0.50 mm/year, and 0.73 ± 1.22 mm/year in growing SAAs. Three SAAs ruptured (0.4%) at a mean size of 32 mm. Aneurysm wall calcification was independently associated with decreased risk of SAA growth or rupture: mild calcification (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.12 - 0.67; p = .004), over one third circular calcification (OR 0.16, 95% CI 0.06 - 0.43; p< .001), and full circumference, i.e., eggshell calcification (OR 0.05, 95% CI 0.02 - 0.16; p < .001). Aneurysm location at the splenic hilum was also associated with decreased growth and rupture risk (OR 0.43, 95% CI 0.22 - 0.85; p = .015), while presence of abdominal aortic aneurysm (AAA) was associated with increased risk (OR 8.08, 95% CI 1.08 - 60.30; p = .042). CONCLUSION: Most SAAs remained stable in size, with only a few ruptures occurring during a mean follow up period of 6 years. Aneurysm wall calcification and SAA location at the splenic hilum were associated with a decreased risk of growth and rupture, while the presence of AAA was associated with increased risk.
OBJECTIVE: Asymptomatic peripheral artery disease (aPAD) may be identified through dedicated vascular assessment (classical aPAD) or incidentally during imaging performed for non-vascular indications (hidden aPAD). Altho...OBJECTIVE: Asymptomatic peripheral artery disease (aPAD) may be identified through dedicated vascular assessment (classical aPAD) or incidentally during imaging performed for non-vascular indications (hidden aPAD). Although classical aPAD has been widely studied, long term outcome data specifically addressing hidden aPAD remain limited. This study aimed to describe the prevalence and 5 year cardiovascular outcomes of hidden aPAD identified on abdominal contrast enhanced computed tomography (CT) in a single centre retrospective cohort. METHODS: This single centre, retrospective, observational study included consecutive patients aged 40-85 years undergoing abdominal contrast enhanced CT. Patients with prior atherosclerotic cardiovascular disease (ASCVD) and who had undergone contrast enhanced CT for ASCVD screening were excluded. Participants were stratified into hidden aPAD and non-PAD groups based on presence or absence of atherosclerotic lesions in the iliac arteries. The primary outcome was major adverse cardiovascular events (MACE) incidence during 5 year follow up. The cumulative event rates were estimated using Kaplan-Meier estimation and compared using a log rank test. Cox regression analysis was performed to identify independent predictors of MACE. RESULTS: This study included 3 022 patients (57.9% male, mean age 69.1 ± 10.3 years, the hidden aPAD n = 52, non-PAD n = 2 970). The incidence of MACE was significantly higher in patients with hidden aPAD than in the non-PAD group (23.1% vs. 2.5%, p <.001). Kaplan-Meier analysis showed markedly lower MACE free survival in the hidden aPAD group (log rank p <.001). Multivariate Cox regression analysis showed that iliac atherosclerotic lesions were independently associated with MACE (hazard ratio 8.17; 95% confidence interval 4.40 - 15.17; p <.001) even without prior ASCVD. CONCLUSION: Patients with hidden aPAD incidentally identified on abdominal contrast enhanced CT without prior ASCVD have increased cardiovascular risk.
OBJECTIVE: Treatment of venous thromboembolism (VTE) with direct oral anticoagulants (DOACs) follows established, agent specific, low molecular weight heparin (LMWH) initiation protocols. However, adherence to these prot...OBJECTIVE: Treatment of venous thromboembolism (VTE) with direct oral anticoagulants (DOACs) follows established, agent specific, low molecular weight heparin (LMWH) initiation protocols. However, adherence to these protocols may be suboptimal in real world practice. This study evaluated the association between protocol adherence and thirty day clinical outcomes in hospitalised patients with VTE receiving DOAC therapy. METHODS: A retrospective cohort study using Taiwan's national hospitalisation database from 2012 to 2022 was conducted. Adults hospitalised for VTE and newly prescribed DOAC were included. Propensity score matching was performed by DOAC type based on LMWH initiation status. RESULTS: Among 29 182 patients, 6 683 received dabigatran/edoxaban and 22 499 received apixaban/rivaroxaban. After matching, 2 135 pairs in the dabigatran/edoxaban cohort and 9 858 pairs in the apixaban/rivaroxaban cohort were analysed. In the dabigatran/edoxaban group, LMWH lead in was not associated with recurrent VTE (2.2% vs. 1.5%; subdistribution hazard ratio [SHR] 1.41, 95% confidence interval [CI] 0.90 - 2.21), major bleeding (0.9% vs. 0.7%; SHR 1.33, 95% CI 0.69 - 2.54), or all cause mortality (5.3% vs. 4.5%; hazard ratio [HR] 1.16, 95% CI 0.89 - 1.53). In the apixaban/rivaroxaban group, LMWH lead in was associated with a higher risk of recurrent VTE (2.6% vs. 1.4%; SHR 1.81, 95% CI 1.48 - 2.23), but not with major bleeding (0.7% vs. 0.6%; SHR 1.18, 95% CI 0.83 - 1.69) or all cause mortality (4.4% vs. 4.2%; HR 1.04, 95% CI 0.91 - 1.19). The effect of LMWH vs. non-LMWH did not differ significantly between the two pharmacological groups. CONCLUSION: In this nationwide observational cohort, initiation with LMWH was not associated with differences in short term thrombotic or bleeding outcomes among dabigatran or edoxaban users. In contrast, among apixaban or rivaroxaban users, LMWH initiation was associated with a higher risk of recurrent VTE without increasing major bleeding. However, the estimates were not significantly different between the two pharmacological groups. Prospective studies and external validation are warranted.