OBJECTIVE: Acute and chronic mesenteric ischaemia (AMI and CMI) are associated with high morbidity and mortality. The aim of the study was to evaluate short and mid term outcomes after revascularisation for AMI and CMI a...OBJECTIVE: Acute and chronic mesenteric ischaemia (AMI and CMI) are associated with high morbidity and mortality. The aim of the study was to evaluate short and mid term outcomes after revascularisation for AMI and CMI and to compare endovascular and open surgical approaches. METHODS: This nationwide retrospective observational study used the French National Health Data System (SNDS), a medico-administrative database, primarily intended for evaluation of medical costs and appropriateness of billings, but also containing information on patient risk factors, interventions, and outcomes. The SNDS was used to identify adults in France who between January 2014 and December 2024 underwent a first recorded revascularisation for a diagnosis of AMI or CMI along with their baseline characteristics, comorbidities, and procedural data. The primary outcome was all cause 30 day mortality. Secondary outcomes included 1 and 2 year mortality, and vascular re-interventions. Multivariable Cox proportional hazards models were used to identify factors associated with mortality and re-intervention. RESULTS: A total of 6 228 patients underwent revascularisation for AMI (mean age 69.3 ± 12.8 years; 57.2% men). Endovascular repair was associated with lower 30 day mortality (16.5% vs. 36.7%, p < .001), 1 year and 2 year mortality, compared with open repair. After adjustment, endovascular repair remained associated with reduced 30 day (HR 0.48, 95% CI 0.43 - 0.54), 1 year (HR 0.62, 95% CI 0.57 - 0.67), and 2 year mortality (HR 0.68, 95% CI 0.63 - 0.74). For CMI, 5 016 patients were included (mean age 69.8 ± 12.1 years; 54.1% men). Endovascular repair was associated with lower 30 day mortality (HR 0.39, 95% CI 0.27 - 0.56) but higher re-intervention risk (HR 3.75, 95% CI 2.29 - 6.12). Age > 64 years was associated with higher mortality in both AMI and CMI. CONCLUSION: In this nationwide cohort, endovascular revascularisation was associated with lower 30 day and 1 year mortality in AMI, and lower early mortality in CMI compared with open surgery. These findings support the use of endovascular strategies for mesenteric ischaemia, particularly for high risk patients, while underscoring the need for prospective comparative studies to further investigate long term outcomes.
OBJECTIVE: The association between female sex and mortality after aortic aneurysm repair has been widely identified after both elective and emergency aortic surgery. Increasing evidence exists that this is also valid aft...OBJECTIVE: The association between female sex and mortality after aortic aneurysm repair has been widely identified after both elective and emergency aortic surgery. Increasing evidence exists that this is also valid after complex endovascular aneurysm repair (EVAR). Additionally, an increase in annual hospital volume has shown to improve results and reduce mortality after complex endovascular aortic aneurysm repair (cEVAR). The aim of this study was to evaluate the nationwide peri-operative outcomes of patients who underwent cEVAR within a mandatory quality registry, to assess the effect of sex differences on outcomes and the influence of annual hospital volume on these differences in peri-operative outcomes. METHODS: All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent cEVAR between January 2016 and January 2022 were included. The primary outcome was peri-operative mortality. Secondary outcomes were peri-operative complications including length of stay and the association of female sex with both these outcomes. Furthermore, the effect on mortality differences and hospital volume was assessed to evaluate the influence of hospital volume on mortality among women after cEVAR. RESULTS: A total of 1 150 patients were included: 857 patients undergoing fenestrated EVAR (74.5%) and 293 patients undergoing branched EVAR (25.5%); 925 were male (80.4%) and 225 were female (19.6%). Overall peri-operative mortality rate was 4.7% (n = 54); peri-operative mortality rate for men was 3.8% (n = 35) versus 8.4% (n = 19) in women (odds ratio 2.40, 95% confidence interval 1.25 - 4.51; p = .007). Post-operative complications occurred more frequently in women 40.0% (n = 90) compared with men 30.3% (n = 280) (p = .006). Length of stay in hospital stay was significantly increased in women compared with men (4 vs. 5 days, respectively; p < .001). Mortality rate among women after cEVAR in low volume hospitals (<10 annual procedures) was significantly higher compared with high volume centres; 14.6% vs. 7.1% (odds ratio 2.13, 95% confidence interval 1.12 - 3.99; p = .019). After adjustment of known confounding factors, both sex and hospital volume were significantly associated with mortality in the multivariate analysis. Formal interaction testing between annual hospital volume, female sex and mortality confirmed the observation (Wald χ = 6.40; p = .041) that low volume was significantly associated with mortality, especially in women. CONCLUSION: Real world mandatory quality registry data provide a robust overview on sex specific differences and peri-operative outcomes following complex EVAR in The Netherlands. Women are at risk for impaired survival and worse peri-operative outcomes compared with men after cEVAR. Furthermore, this study identified a protective effect of hospital volume on this association up until 20 cases per year. Patients should be treated in high volume centres to improve survival and to mitigate the sex disadvantage after cEVAR.
Harlianto NI, de Jong PA, Visseren FL
… +7 more, Mali WPTM, Nathoe HM, van Herwaarden JA, Hazenberg CEVB, Ruigrok YM, van Amsterdam WAC, UCC-SMART Study Group
OBJECTIVE: This prospective cohort study hypothesised that a small distal aortic diameter is associated with adverse arterial physiology and when co-existing with atherosclerosis leads to limb events. This study evaluate...OBJECTIVE: This prospective cohort study hypothesised that a small distal aortic diameter is associated with adverse arterial physiology and when co-existing with atherosclerosis leads to limb events. This study evaluated the relationship between distal aortic diameter and major adverse limb events (MALE), major adverse cardiovascular events (MACE), MALE and minor events, and death in patients with established cardiovascular disease. METHODS: Patients were included from the Utrecht Cardiovascular Cohort-Second Manifestations of ARTerial disease cohort. The outer to outer aortic diameter was measured with ultrasound, and diameters > 3 cm were excluded. The relationship between distal aortic diameter and MALE, MACE, and all cause death was reported by quintile, and stratified by sex. The continuous, unbinned values were evaluated using sex stratified multivariable Cox proportional hazard models with restricted cubic splines. RESULTS: The study included 8 463 patients (72.1% men, mean age 60.1 years, aortic diameter range 0.70 - 2.98 cm). In total, 809 major and minor limb events, 571 MALE, 1 731 MACE, and 2 213 deaths occurred (median follow up 10.1 years, interquartile range 5.3, 15.0 years). For men, a U shaped relationship between distal aortic diameter and major and minor lower limb events (lowest quintile hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.09 - 1.83), and MALE (lowest quintile HR 1.39, 95% CI 1.04 - 1.87) was observed. For women, the lower quintile of aortic diameter was associated with major and minor limb events (HR 1.56, 95% CI 1.04 - 2.34), but not MALE (HR 1.11, 95% CI 0.69 - 1.78). The highest quintile was associated with all cause death (HR 1.64, 95% CI 1.27 - 2.12), MACE (HR 1.48, 95% CI 1.08 - 2.01), and vascular death (HR 1.71, 95% CI 1.16 - 2.53). CONCLUSION: Non-aneurysmal distal aortic diameters are associated with major and minor limb events, MALE, and death in patients with established vascular disease, with differences between men and women. The relationship between aortic diameter and limb events is U shaped for men, meaning that both a large diameter and a small diameter are associated with increased risk of events.
OBJECTIVE: Chronic venous disease affects > 40% of adults. The effectiveness of cyanoacrylate closure for the treatment of saphenous vein reflux compared with current global standard modalities remains unclear. The objec...OBJECTIVE: Chronic venous disease affects > 40% of adults. The effectiveness of cyanoacrylate closure for the treatment of saphenous vein reflux compared with current global standard modalities remains unclear. The objective of this study was to assess patient centric and traditional venous outcomes comparing cyanoacrylate closure with surgical stripping and endothermal ablation, two global standards of care. METHODS: VenaSeal Spectrum randomised controlled trials (RCTs) are prospective, global, multicentre, 1:1 randomised studies evaluating the VenaSeal cyanoacrylate closure system for patients with chronic venous disease. Participants were enrolled in 23 centres across four continents. In the first RCT, 106 participants were randomly assigned to receive cyanoacrylate closure or surgical stripping. In the second RCT, 275 participants were randomly assigned to receive cyanoacrylate closure or endothermal ablation. The primary outcomes were patient satisfaction through 30 days using the periprocedural and postprocedural Venous Treatment Satisfaction Questionnaire (VenousTSQ), and proportion of saphenous reflux treated in each target vein. Adverse events were adjudicated by an independent committee and reported through 6 months. Traditional venous outcomes are evaluated as secondary outcomes. RESULTS: In both studies, baseline characteristics were similar between groups. Periprocedural patient satisfaction at 30 days was greater in participants randomised to cyanoacrylate closure compared with surgical stripping (venous treatment satisfaction score 29.3 ± 4.94 vs. 25.0 ± 6.24, p = .001), but postprocedure patient satisfaction at 30 days and proportion of superficial truncal reflux treated were similar. There was no statistical difference detected in the three primary endpoints comparing cyanoacrylate closure and endothermal ablation. Overall adverse event rates were low, with the most common adverse events following cyanoacrylate being mild to moderate hypersensitivity, which was self limiting. CONCLUSION: Cyanoacrylate closure for treatment of saphenous reflux resulted in superior periprocedural patient treatment satisfaction compared with surgical stripping. Patient satisfaction and proportion of superficial reflux treated after cyanoacrylate closure were comparable with endothermal ablation. CLINICAL TRIAL REGISTRATION: https://www. CLINICALTRIALS: gov, unique identifier NCT03820947.
OBJECTIVE: Sex disparities in outcomes following endovascular aortic repair (EVAR) are well documented globally. This study used registry data to evaluate whether these disparities persist within the decentralised German...OBJECTIVE: Sex disparities in outcomes following endovascular aortic repair (EVAR) are well documented globally. This study used registry data to evaluate whether these disparities persist within the decentralised German healthcare system among centres voluntarily participating in quality improvement. METHODS: This retrospective observational study analysed prospectively collected data from the German Society for Vascular Surgery and Vascular Medicine (DGG) quality registry between January 2017 and December 2023. The cohort included all patients undergoing EVAR for intact (asymptomatic or symptomatic) or ruptured abdominal aortic aneurysm. Multivariable logistic regression was employed to identify independent predictors of both in hospital death and failure to rescue. RESULTS: Of 19 266 patients included, 2 576 (13.4%) were women. Compared with men, women were significantly older (median 77 years vs. 74 years), more likely to present with symptomatic (17.1% vs. 11.0%) or ruptured aneurysms (6.3% vs. 4.2%), and had more adverse neck anatomy (< 15 mm; 14.2% vs. 10.5%). Women were less likely to receive statin therapy on admission. Post-operatively, women experienced higher failure to rescue (1.9% vs. 1.0%; p < .001) and in hospital mortality rates (3.3% vs. 1.6%; p < .001). In multivariable analyses, female sex remained independently associated with an increased risk of both in hospital death (odds ratio [OR] 1.853, 95% confidence interval [CI] 1.397 - 2.457) and failure to rescue (OR 1.688, 95% CI 1.183 - 2.409). CONCLUSION: Significant sex based disparities in EVAR management and outcomes persist in Germany, mirroring findings from centralised healthcare systems. Despite treatment in centres dedicated to quality improvement, women face higher mortality and complication rates, suggesting that voluntary quality measures and decentralised structures alone are insufficient to mitigate female patient disadvantage.
OBJECTIVE: This study investigated long term survival following endovascular aortic repair (EVAR) or open surgical repair (OSR) for abdominal aortic aneurysm (AAA), with a relative survival analysis using an age and sex...OBJECTIVE: This study investigated long term survival following endovascular aortic repair (EVAR) or open surgical repair (OSR) for abdominal aortic aneurysm (AAA), with a relative survival analysis using an age and sex matched population cohort. METHODS: This was a retrospective single centre cohort study of patients who underwent AAA repair at a tertiary hospital between June 1998 (OSR from July 2003) and December 2022. Death was obtained from a linked national database, with cause of death identified from electronic hospital records. Maximum aortic diameter and sex were used to estimate the rupture risk over 3 years compared with observed all cause and categorised mortality. Kaplan-Meier probability estimates compared the survival following AAA repair with an age and sex matched New Zealand population cohort. RESULTS: In this study, 1 066 patients underwent EVAR (915 men, 151 women) and 218 patients (169 men, 49 women) underwent OSR. The thirty day mortality rate was 0.84% following EVAR and 6.0% following OSR. The median survival post-EVAR was 7.9 years (95% confidence interval [CI] 7.5 - 8.5), compared with 8.0 years (95% CI 7.0 - 9.7) post-OSR, and 14 years (95% CI 13.2 - 15.2) in an age and sex matched New Zealand population, with survival probability following AAA repair lower by 14% at 3 years and 25% at 5 years compared with the matched cohort. During follow up 673 EVAR patients (63.1%), and 168 OSR patients (77.1%) died, most commonly due to malignancy, respiratory, cardiac, or neurological disease. Aortic related death accounted for 2.8% of the EVAR cohort and 4.8% of OSR deaths. The estimated three year cumulative rupture risk, had repair not been performed, was 5.9% (95% CI 4.4 - 7.7%). CONCLUSION: Over 24 years, patients undergoing AAA repair demonstrated significantly lower medium and long term relative survival compared with an age and sex matched population cohort, with most deaths attributable to non-aortic causes. Long term survival following EVAR and OSR was similar. While contemporary rupture risk appears lower than historically reported, the predominance of competing non-aortic death underscores the importance of individualised patient selection and consideration of projected life expectancy when selecting patients for intervention.
OBJECTIVE: The role of endovascular repair of the ascending aorta remains questionable due to anatomic and technical constraints, particularly at the proximal landing zone. Whether thoracic endovascular aortic repair (TE...OBJECTIVE: The role of endovascular repair of the ascending aorta remains questionable due to anatomic and technical constraints, particularly at the proximal landing zone. Whether thoracic endovascular aortic repair (TEVAR) for the ascending aorta is safe and feasible has not been evaluated previously in a large multicentre study. This study aimed to evaluate the feasibility and safety of endovascular repair of pathologies affecting the ascending aorta. METHODS: An international, multicentre, retrospective study was conducted following the STROBE guidelines including patients who underwent ascending TEVAR (2011 - 2024) for zone 0 aortic pathologies. Primary outcomes were technical success, thirty day death, and re-interventions. Secondary outcomes were survival and re-intervention during follow up analysed using Kaplan-Meier estimates, and post-operative imaging findings, including endoleaks and sac dynamics. RESULTS: Fifty-eight patients (median age 75 years [interquartile range 65, 80]; 26 [45%] women) underwent ascending TEVAR across 17 centres for dissections (n = 18; 31%), non-dissection native pathologies (n = 18; 31%), and post-surgical pseudoaneurysm (n = 22; 38%). Of these, 36% (n = 21) were treated urgently. Technical success was 83% (n = 48), with a thirty day mortality rate of 10% (n = 6) and a re-intervention rate of 12% (n = 7). Median follow up was 11 months. Kaplan-Meier survival at 12 months was 55% (standard error [SE] 0.12) for dissections, 76% (SE 0.10) for non-dissection pathologies, and 77% (SE 0.10) for post-surgical pseudoaneurysms (log rank, p = .34). Freedom from re-intervention at 12 months was 71% (SE 0.13), 94% (SE 0.05), and 70% (SE 0.10), respectively (log rank, p = .27). The estimated re-intervention free survival for the total cohort was 78% (SE 0.06). CONCLUSION: Despite current technical limitations that challenge endovascular repair of the ascending aorta, TEVAR for ascending pathologies may be performed with acceptable mortality and re-intervention rates in selected cases deemed unfit for open repair. Development of dedicated devices might increase the applicability of endovascular repair for ascending aortic pathologies and improve outcomes.