OBJECTIVE: Post-thrombotic syndrome (PTS) is a frequent chronic complication of deep vein thrombosis (DVT), yet predictors of its individual manifestations remain poorly characterised. METHODS: In a multicentre prospecti...OBJECTIVE: Post-thrombotic syndrome (PTS) is a frequent chronic complication of deep vein thrombosis (DVT), yet predictors of its individual manifestations remain poorly characterised. METHODS: In a multicentre prospective cohort of 3 610 adults with a first symptomatic lower limb DVT enrolled in the RIETE registry, PTS manifestations were assessed at 12, 24, and 36 months. Villalta components were dichotomised to enhance reproducibility across centres. Multivariable logistic regression was used to identify independent baseline predictors and early post-diagnosis exposures associated with PTS symptoms, signs, and venous ulceration. RESULTS: At 12 months, 34.7% of patients reported symptoms, 43.2% had signs, and 1.1% developed venous ulcers (increasing to 4.5% at 36 months). Female sex (adjusted odds ratio [aOR] 1.24, 95% confidence interval [CI] 1.07 - 1.44) and younger age (aOR 0.75, 95% CI 0.60 - 0.93 for ≥ 80 years vs. < 80 years) predicted symptoms but not signs or ulcers. Older age was associated with signs and ulcers. Higher body weight and proximal DVT predicted symptoms and signs, while ulcer risk increased in a dose dependent manner with body weight, particularly in men (aOR 4.12, 95% CI 1.18 - 14.3). Elastic stocking use was associated with symptom reporting at 12 months. Thrombolysis and shorter anticoagulation duration were associated with fewer PTS related signs. Associations remained generally consistent over time. CONCLUSION: Predictors differ across PTS domains, suggesting distinct pathophysiologic pathways and highlighting the need for risk stratified follow up and targeted prevention strategies after DVT.
OBJECTIVE: The association between alcohol consumption and peripheral arterial disease (PAD) remains conflicting. Further, although alcohol consumption and smoking are highly correlated habits, interaction between these...OBJECTIVE: The association between alcohol consumption and peripheral arterial disease (PAD) remains conflicting. Further, although alcohol consumption and smoking are highly correlated habits, interaction between these two factors is rarely studied. This study examined these two factors in association with risk of chronic limb threatening ischaemia (CLTI), which is the most severe form of PAD. METHODS: The Singapore Chinese Health Study, a prospective, population based cohort of middle aged and older adults, recruited 63 257 participants between 1993 and 1998. CLTI cases were identified via linkage to the nationwide hospital database to 31 December 2017. Multivariable Cox proportional hazards models were used to evaluate hazard ratio (HR) and 95% confidence interval (CI) for an association with CLTI risk. RESULTS: A total of 1 097 CLTI cases were identified after a median follow up of 20.6 years. Compared with non-drinkers (less than one drink/week), low to moderate alcohol consumption (one to nine drinks/week) was associated with reduced CLTI risk among non-smokers (HR 0.71, 95% CI 0.55 - 0.91), but not among smokers (HR 1.04, 95% CI 0.77 - 1.41) (p for interaction = .055). Conversely, higher alcohol consumption of ten or more drinks/week was linked to increased risk among current smokers (HR 1.48, 95% CI 1.00 - 2.20) and among non-smokers (HR 1.54, 95% CI 0.98 - 2.40), albeit less precisely. In joint analysis, compared with those who neither smoked nor drank alcohol, reduced risk was observed only in non-smokers with one to nine drinks/week (HR 0.71, 95% CI 0.56 - 0.92), while the highest risk was observed in smokers who drank ten or more drinks/week (HR 2.15, 95% CI 1.48 - 3.13). CONCLUSION: Alcohol and smoking may interact to increase the risk of CLTI such that low to moderate alcohol consumption may only be associated with a lower risk in non-smokers but not in smokers.
OBJECTIVE: To define contemporary medium (3 - 5 years) and long term (>5 years) survival and durability outcomes after elective fenestrated and branched endovascular aortic repair for complex abdominal and thoraco-abdomi...OBJECTIVE: To define contemporary medium (3 - 5 years) and long term (>5 years) survival and durability outcomes after elective fenestrated and branched endovascular aortic repair for complex abdominal and thoraco-abdominal aneurysms and to assess the certainty of the available evidence. METHODS: MEDLINE, Embase, and the Cochrane Library were searched from January 2000 to February 2026, supplemented by citation screening. Published Kaplan-Meier time to event data were digitised and reconstructed into individual patient datasets. Pooled survival probabilities were generated using validated methods for meta-analytic methods for survival curves. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework, and risk of bias was assessed with ROBINS-1 (v2). The protocol was registered in the International Prospective Register of Systematic Reviews (CRD42024565664). RESULTS: Twenty four studies comprising 8 886 patients were included. Pooled overall survival was 91.3% (95% confidence interval [CI] 90.7 - 91.9) at 1 year, 73.0% (95% CI 71.9 - 74.0) at 3 years, and 55.4% (95% CI 53.9 - 56.8) at 5 years. Estimated median overall survival was 6.36 years. Based on studies that reported this, at 5 years, freedom from aneurysm related mortality was 96.4% (95% CI 95.3 - 97.2), and freedom from re-intervention was 66.5% (95% CI 64.6 - 68.2). Target vessel patency, based on two studies, was 94.8% (95% CI 93.3 - 96.0). Certainty of evidence was low for overall survival, freedom from aneurysm related mortality and re-intervention, and very low for target vessel patency. CONCLUSION: Elective fenestrated and branched endovascular aortic repair provides durable aneurysm exclusion with low aneurysm related mortality. However, survival beyond 5 years declines substantially. There is a need for more robust survival data and improved tools to support patient selection, shared decision making, and assessment of anticipated benefit when considering prophylactic complex endovascular repair.
OBJECTIVE: This focused update to the European Society for Vascular Surgery (ESVS) clinical practice guidelines (CPGs) on asymptomatic peripheral arterial disease and intermittent claudication (IC) provide revised recomm...OBJECTIVE: This focused update to the European Society for Vascular Surgery (ESVS) clinical practice guidelines (CPGs) on asymptomatic peripheral arterial disease and intermittent claudication (IC) provide revised recommendations on paclitaxel coated devices for endovascular infrainguinal interventions. Recent evidence, particularly from the SWEDEPAD 2 trial, prompted re-evaluation of their efficacy and potential long term risks. As the previously published guidelines were directed towards patients with Rutherford categories 0 - 3, the present update maintains the same scope. METHODS: A narrative systematic review assessed the benefits and risks of paclitaxel coated balloons and stents in infrainguinal revascularisation for IC. The ESVS Guidelines Writing Committee incorporated new randomised trial data into updated recommendations, graded according to the ESVS CPGs recommendation grading system. RESULTS: The updated evidence suggested limited clinical benefit and possible long term harm from paclitaxel coated devices in this population. SWEDEPAD 2 reported no improvement in quality of life (difference in six item Vascular Quality of Life Questionnaire [VascuQoL-6] score at 12 months was -0.02 [95% confidence interval -0.66 - 0.62], indicating no clinically relevant effect) or in reduced re-intervention at 12 months compared with uncoated devices, and indicated a potential excess in the long term all cause mortality rate. These findings corroborate earlier safety concerns raised in a 2018 meta-analysis and in subsequent pooled analyses. Recently published long term efficacy and safety data from some additional pivotal drug coated balloon trials were also considered but reported no or marginal clinical benefits. The update consistently emphasises supervised exercise therapy and best medical therapies as first line treatment. Endovascular revascularisation is recommended only for persistent lifestyle limiting symptoms despite conservative therapy. Paclitaxel coated devices may be considered only for selected cases with re-stenosis following transparent discussion of uncertain long term safety and, at best, modest symptomatic benefit. CONCLUSION: This ESVS focused update integrates emerging evidence to guide contemporary management of IC. Clinicians should carefully balance the limited short term procedural benefits of paclitaxel coated devices against the lack of proven quality of life improvement and the persisting uncertainty regarding long term mortality risk. Management of IC should follow a stepwise approach, prioritising lifestyle modification, exercise therapy, and optimal secondary preventive pharmacotherapy, with revascularisation reserved for compliant patients who remain significantly limited. Emphasis should be placed on conservative management, shared decision making, and continued research to further define the long term safety profile of paclitaxel coated endovascular devices.
OBJECTIVE: Endovascular aortic operations entail significant radiation exposure to healthcare personnel and patients. Therefore, development and implementation of techniques to achieve radiation reduction remains a key o...OBJECTIVE: Endovascular aortic operations entail significant radiation exposure to healthcare personnel and patients. Therefore, development and implementation of techniques to achieve radiation reduction remains a key objective. This paper presents considerations and consensus from a roundtable discussion between physicians with experience in endovascular aortic surgery and medical physicists regarding promising radiation reducing techniques. METHODS: A focused literature review was first performed to identify potentially eligible techniques. Subsequently, the items identified were discussed and a final list was approved by consensus: radiation reduction protocols; simulation training; electromagnetic tracking (EMT), Fiber Optic RealShape (FORS), fusion imaging, and intravascular ultrasound. Three main domains were evaluated for each technique: current status of the technique, potential impact on radiation reduction, and feasibility of implementation. RESULTS: The current status varies from the development to assessment phase, indicating that all techniques are already being used in clinical practice in some form. However, except for radiation reduction protocols, none has yet been widely adopted. All the studied techniques had a substantial (at least potential) impact on radiation reduction. Regarding feasibility and implementation, there is a wide variety among the techniques. Radiation reduction protocols are implemented in almost all hardware and therefore easy to implement, while FORS and EMT require substantial investment and specific hardware, which is not compatible with all vendors. CONCLUSIONS: This multidisciplinary consensus document provides expert driven, evidence based considerations on the current status of six techniques that may play a pivotal role toward achieving the zero radiation goal for endovascular aortic surgery, while balancing their radiation reduction potential against barriers for widespread adoption. Further refinement will come through close multidisciplinary collaboration between surgeons and industry. Educating physicians regarding benefits and limitations of all available modalities will assist with planning better operative approaches, and increasing radiation safety.
OBJECTIVE: Popliteal venous aneurysms (PVAs) are a rare vascular disease that can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). There are limited data on optimal management. This retrospective, single c...OBJECTIVE: Popliteal venous aneurysms (PVAs) are a rare vascular disease that can lead to deep vein thrombosis (DVT) and pulmonary embolism (PE). There are limited data on optimal management. This retrospective, single centre cohort study, conducted over a 25 year period (1998 - 2022), evaluated clinical features, treatment strategies, and outcomes in patients with PVAs. METHODS: Demographics, intra-operative details, and outcomes of all consecutive patients with PVA treated surgically or conservatively were analysed. Primary endpoints were 30 day mortality, long term graft patency, and re-intervention rates. RESULTS: Fifty-four patients (mean age 52.5 ± 18 years; range 15 - 90) were included. Thirty-four of the 54 (63%) patients had symptoms, including PE in eight (15%), DVT in nine (17%), pain in 24 (44%), and palpable mass in seven (13%). Thirty-one (57%) of the PVAs were saccular. Twenty-four (44%) patients underwent surgical repair, 19 of 24 (79%) symptomatic and five of 24 (21%) asymptomatic. The remaining 30 patients (56%) were managed conservatively, including 15 symptomatic and 15 asymptomatic. Tangential aneurysmectomy with lateral venorrhaphy was the most common procedure (19 of 24, 79%), followed by saphenous vein interposition graft in five of 24 (21%). Four (16%) patients experienced early complications, including wound dehiscence (4%), graft thrombosis (4%), and haematoma (8%). During a median follow up of 31 months (range 1 - 134), two patients had recurrent symptomatic PVA, only one requiring surgery. Among symptomatic patients managed conservatively, symptoms resolved in 13, were unchanged in one, and one developed new DVT. Among asymptomatic patients initially treated conservatively (15 of 30), one (3%) developed pain and swelling, which was managed conservatively. The 3 year primary and assisted patency rates were 95 ± 3% and 100%, respectively. Freedom from re-intervention was 97 ± 2%. Five year survival was 94 ± 4%, with no PVA related deaths. CONCLUSIONS: The results support selective operative intervention based on size, symptoms, and thrombus presence, while validating conservative management in low risk patients.
OBJECTIVE: Plain balloon angioplasty (PBA) remains the standard technique for vessel preparation in peripheral artery disease. This prospective, single centre, single blind, parallel group, superiority randomised trial e...OBJECTIVE: Plain balloon angioplasty (PBA) remains the standard technique for vessel preparation in peripheral artery disease. This prospective, single centre, single blind, parallel group, superiority randomised trial enrolled chronic limb threatening ischaemia (CLTI) patients with femoropopliteal (FP) lesions. It evaluated whether AngioSculpt scoring balloon (SB) use, compared with PBA, before Luminor drug coated balloon (DCB) angioplasty in FP lesions and CLTI reduces the need for bailout stenting and improves patency without increasing procedural costs. METHODS: Patients with FP disease and Rutherford category 4 or 5 were randomised to PBA (control) or SB as vessel preparation. Sample size was calculated based on expected bailout stenting rates from previous studies, requiring 39 patients per arm. The primary endpoint was bailout stenting, defined as stent implantation during the index procedure for residual stenosis > 30% or type C dissection (Kobayashi classification). Secondary endpoints included primary patency, defined as duplex ultrasound peak systolic velocity ratio < 2.5 without clinically driven target lesion revascularisation, and procedural cost, defined as the total cost of all balloons and stents used during the index procedure. RESULTS: Eighty-three subjects were enrolled between September 2020 and November 2022 (43 SB, 40 PBA). Mean follow up was 517 ± 272 days. Mean lesion length was 235 ± 134 mm in the SB group and 219 ± 130 mm in the control. Bailout stenting was required in 33% of PBA vs. 5% of SB (p = .003). Overall primary patency was higher in the SB group (91% vs. 70%; p = .035). Procedural costs were €108 lower per patient in the SB cohort (p = .003). CONCLUSIONS: In this study, the use of a SB for vessel preparation prior to DCB angioplasty in CLTI patients with FP lesions significantly reduced the need for bailout stenting and was associated with improved primary patency and lower procedural costs compared with PBA. (ClinicalTrials registration ID: NCT07136883).
OBJECTIVE: Visceral adiposity is a cardiovascular risk factor, but its role in the development of abdominal aortic aneurysm (AAA) remains unclear. This study primarily assessed the association of visceral adiposity index...OBJECTIVE: Visceral adiposity is a cardiovascular risk factor, but its role in the development of abdominal aortic aneurysm (AAA) remains unclear. This study primarily assessed the association of visceral adiposity index (VAI) with AAA incidence, and secondarily evaluated its interaction/joint effects with genetic risk, and potential sex differences. METHODS: This study included 420 069 participants from the UK Biobank. VAI was calculated at baseline (2006 - 2010) using body mass index, waist circumference, triglycerides, and high density lipoprotein cholesterol. Restricted cubic splines (RCS) were applied to examine the association between VAI and the development of AAA, while Cox proportional hazards models estimated adjusted hazard ratios (HRs). Interaction and joint effects of VAI and polygenic risk on AAA risk were also evaluated. RESULTS: During a follow up of median 13.6 years, there were 2 083 cases of AAA. Fully adjusted models showed that each unit/standard deviation increase in VAI was associated with a 12% and 21% higher AAA risk, respectively. Quartile analysis showed adjusted HR (95% CI) of 1.00 (0.84 - 1.18), 1.14 (0.96 - 1.34), and 1.32 (1.12 - 1.55) for Q2 to Q4 compared with Q1 (p for trend < .001). RCS analysis revealed a sex specific pattern: a linear association between VAI and AAA risk in men, and a non-linear association in women. Threshold analysis revealed that in women with VAI < 1.5, AAA risk decreased by 46% per unit VAI increase (HR 0.54, 95% CI 0.31 - 0.94); above this threshold, risk increased by 19% per unit (HR 1.19, 95% CI 1.09 - 1.29). A combination of high VAI (Q4) and high genetic risk conferred a 2.28 fold higher AAA risk (95% CI 1.70 - 3.70) versus low VAI (Q1) and low genetic risk. CONCLUSION: Higher visceral adiposity, particularly in combination with genetic susceptibility, is significantly associated with an increased development of AAA in a sex specific and non-linear manner. These findings suggest its potential value for targeted screening strategies.