OBJECTIVE: This multicentre, retrospective, comparative, cohort study aimed to evaluate whether three dimensional (3D) printing guidance was associated with procedural efficiency and midterm outcomes of physician modifie...OBJECTIVE: This multicentre, retrospective, comparative, cohort study aimed to evaluate whether three dimensional (3D) printing guidance was associated with procedural efficiency and midterm outcomes of physician modified endovascular graft (PMEG) fenestrated/branched endovascular aortic repair (F/BEVAR) compared with traditional measurement guided planning. METHODS: Consecutive patients undergoing PMEG F/BEVAR at three centres (January 2018 - June 2024) were analysed: 318 with 3D printing guided (PG) and 195 with traditional measurement guided. The primary endpoint was target vessel instability (TVI), a composite of target vessel occlusion, > 70% stenosis, target vessel related re-intervention, or type Ic/III endoleak. Time to event outcomes were assessed using Kaplan-Meier analysis with log rank tests. TVI was evaluated using centre stratified Cox regression and centre adjusted logistic regression with prespecified covariates including procedure year; a sensitivity analysis additionally adjusted for bridging strategy (balloon expandable covered bridging stent [CBE] only vs. non-CBE only). RESULTS: Technical success and 30 day outcomes were similar. PG was associated with shorter EVAR duration (109.8 ± 34.9 vs. 120.9 ± 45.4 minutes; p = .003), shorter fluoroscopy time (73.6 ± 24.9 vs. 85.7 ± 21.4 minutes; p = .001), lower contrast volume (116.0 ± 34.1 vs. 119.1 ± 38.1 mL; p = .029), and lower radiation dose (1 683.4 ± 536.4 vs. 1 900.8 ± 597.3 mGy; p = .001). At a median follow up of 26 months, TVI occurred less frequently in PG (27% vs. 35%; p = .046), with fewer target vessel related endoleaks (6% vs. 10%; p = .034) and target vessel related re-interventions (20% vs. 29%; p = .028). Freedom from TVI was higher in PG (log rank p = .028). In adjusted analyses, PG was associated with a lower TVI hazard (adjusted hazard ratio 0.75, 95% confidence interval [CI] 0.58 - 0.97; p = .030); the logistic model showed a directionally similar association (adjusted odds ratio 0.70, 95% CI 0.48 - 1.03; p = .069). Aortic angulation > 60°, severe abdominal aortic calcification, and dissection pathology were associated with higher TVI risk. CONCLUSION: In this retrospective, multicentre, cohort study, 3D printing guided planning in PMEG F/BEVAR was associated with greater procedural efficiency and favourable midterm target vessel outcomes. The findings should be interpreted as associations, given the non-randomised design.
OBJECTIVE: Routine post-operative admission to the intensive care unit (ICU) is often advocated following fenestrated/branched endovascular repair (F/BEVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdomi...OBJECTIVE: Routine post-operative admission to the intensive care unit (ICU) is often advocated following fenestrated/branched endovascular repair (F/BEVAR) of complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). Given limited ICU resources, identifying pre-operative and intra-operative predictors of major adverse events (MAE) is crucial for optimal resource allocation. METHODS: Consecutive elective F/BEVAR procedures performed between December 2012 and May 2020 were retrospectively analysed. Patients were divided into three groups based on aneurysm extent: CAAA, type 4 TAAA (TAAA4), and type 1 - 3 TAAA (TAAA1-3). MAE were defined according to current Society for Vascular Surgery reporting standards. The primary endpoint was 30 day MAE. Candidate pre- and intra-operative predictors were entered into a least absolute shrinkage and selection operator (LASSO) penalised logistic regression, followed by an unpenalised post-LASSO refit to report odds ratios (OR). RESULTS: A total of 439 patients (129 CAAAs, 193 TAAA4, and 117 TAAA1-3) with 1 694 target arteries were included; 86% had four or more vessels incorporated. Primary technical success was 96%, mean surgical time was 185 ± 68 minutes. MAE occurred in 10% (n = 43), including 4% mortality (n = 16). Most MAE (75%) occurred within 48 hours. Grade 3 spinal cord ischaemia occurred in 2%, which was higher in patients with TAAA1-3 (4%; p = .023). The 30 day re-intervention rate was 8% (3% stent graft related; 3% access related). In the post-LASSO refit, women (OR 3.59, 95% confidence interval [CI] 1.07 - 10.8; p = .03), unplanned additional procedures (OR 2.62, 95% CI 1.18 - 5.75; p = .02), total fluoroscopy time (OR 1.67, 95% CI 1.20 - 2.29; p = .002), and norepinephrine use (OR 3.23, 95% CI 1.46 - 7.14; p = .003) were independently associated with MAE. Model performance showed an area under the receiver operating characteristic curve of 0.78 (95% CI 0.69 - 0.85). CONCLUSION: This study suggests that women undergoing complex surgeries with unplanned additional procedures or extended total fluoroscopy time would benefit the most from close monitoring in the immediate aftermath of F/BEVAR to detect MAE. In contrast, men without these features might be candidates for standard monitoring.
Besutti A, Besutti M, Hentgen B
… +8 more, Hostalrich A, Georg Y, Maurel B, Steinmetz E, Fouilhe L, Settembre N, Rinckenbach S, Association Universitaire de Recherche en Chirurgie Vasculaire (AURC)
OBJECTIVE: The aim of this study was to assess the use and early and midterm outcomes of carotid bypass surgery in a large, multicentre, real world cohort. METHODS: This retrospective multicentre study included consecuti...OBJECTIVE: The aim of this study was to assess the use and early and midterm outcomes of carotid bypass surgery in a large, multicentre, real world cohort. METHODS: This retrospective multicentre study included consecutive patients who underwent carotid bypass surgery in 12 French centres between January 2010 and October 2023. The primary endpoint was the thirty day composite of any stroke and or death. Secondary endpoints included procedure related complications, midterm primary patency, and ipsilateral ischaemic stroke. RESULTS: Four hundred and fifty-nine patients were analysed (mean age 70 years; 80.4% men). Carotid bypass was performed intra-operatively as a bailout during carotid endarterectomy in 51.2% of cases and was scheduled pre-operatively in 48.8% for complex carotid lesions, including re-stenosis, long lesions, associated aneurysms, or post-radiation stenosis. The primary endpoint occurred in 5.8% (27 of 459), including stroke in 4.3% and death in 2.8%; 5.4% of asymptomatic and 6.9% of symptomatic patients experienced the primary endpoint. Prosthetic grafts were used in 69.7% of cases and autologous vein grafts in 30.1%. Use of prosthetic material (odds ratio [OR] 5.35, 95% confidence interval [CI] 1.19 - 24.14; p = .046) and diabetes (OR 2.41, 95% CI 1.01 - 5.73; p = .048) were independently associated with increased risk of thirty day stroke and or death, whereas statin therapy was protective (OR 0.26, 95% CI 0.11 - 0.66; p = .005). During follow up (median 2.7 years, interquartile range 0.8, 5.7), the cumulative Kaplan-Meier estimate of primary patency was 100%, 98.2%, and 97.1% at 1, 3, and 5 years, respectively. CONCLUSION: In this multicentre cohort, carotid bypass surgery was used in selected complex situations and appeared to be associated with a potentially unacceptable excess risk in asymptomatic patients. In symptomatic patients, outcomes slightly exceeded guideline recommended benchmarks but may remain clinically acceptable; accordingly, its use should be restricted to selected cases, primarily as a bailout strategy or when standard revascularisation is unfeasible in those at highest risk of neurological recurrence.
OBJECTIVE: The haemodynamics of non-thrombotic iliac vein lesions are not well understood. While stenosis may change with position, diagnostic testing is commonly conducted in supine. This study aimed to evaluate the imp...OBJECTIVE: The haemodynamics of non-thrombotic iliac vein lesions are not well understood. While stenosis may change with position, diagnostic testing is commonly conducted in supine. This study aimed to evaluate the impact of position on iliac vein stenosis. METHODS: This was an observational cross sectional study, including women aged 16 years and older presenting with symptoms and signs of pelvic venous disease (n = 100). Patients were selected to have > 50% left common iliac vein diameter stenosis while supine. Data were collected on demographics, Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classes, and body mass indices (BMI). Duplex ultrasound was conducted both supine and standing. A stenosis of > 50% diameter reduction was determined by peak vein velocity ratio > 2.5, reverse flow of ipsilateral internal iliac vein (IIV), collaterals, or planimetric measurements. RESULTS: The 100 women were characterised as young (38 ± 12.4 years) and lean (23.8 ± 5.2 kg/m). As chosen, all patients had a > 50% iliac vein diameter stenosis while supine, but only 32 did on standing. Furthermore, reverse flow was noted in the ipsilateral IIV in 83 patients while supine, but in only 32 on standing. There was no difference in any signs and symptoms between the fixed and positional stenoses groups. CONCLUSION: This study revealed a high prevalence of position dependent iliac vein stenosis in two of three patients. Given that diagnostic testing is routinely conducted in supine, and patients experience symptoms during activity, this warrants modification of testing protocols. This study could help guide decisions for stent treatment and reduce overtreatment.
OBJECTIVE: The aim of this study was to characterise thoracic aortic diameters across pre-defined segments in adults undergoing chest computed tomography (CT) during hospitalisation for coronavirus disease 2019 (COVID-19...OBJECTIVE: The aim of this study was to characterise thoracic aortic diameters across pre-defined segments in adults undergoing chest computed tomography (CT) during hospitalisation for coronavirus disease 2019 (COVID-19) in Portugal and to estimate the prevalence of thoracic aortic aneurysm (TAA) and ectasia. METHODS: A retrospective cross sectional analysis of a random sample of adults hospitalised for COVID-19 between March 2020 and December 2021 who underwent chest CT as part of routine care was performed. External aortic diameters were measured at pre-defined thoracic segments using multiplanar reconstructions. Sex and age specific means and standard deviations (SD) were calculated. Median and interquartile range values are presented in the tables. TAA was defined as a segmental diameter ≥ 1.5 times the sex specific mean diameter, and ectasia as > mean + 2 SD. Prevalence estimates were calculated, and logistic regression was used to examine the association between age and TAA. Interobserver variability was assessed. RESULTS: A total of 763 patients were included (mean age 65 ± 18.3 years; 44.2% women). Thoracic aortic diameters progressively decreased from the arch (31 - 28 mm) to the descending thoracic aorta (27 - 23 mm). Men had larger diameters than women across all segments (mean difference 1.7 - 2.7 mm), and aortic size steadily increased with age. The overall prevalence of TAA was 1.4% (n = 11), with a similar prevalence in women (1.5%) and men (1.4%). TAA most frequently occurred in patients ≥ 75 years (2.9%). Thoracic ectasia or aneurysm was identified in 8.7% of patients, with the highest segment specific prevalence in the arch and descending thoracic aorta. Interobserver variability was minimal (< 1 mm). CONCLUSION: This study provides the first CT based thoracic aortic morphometric data in a Portuguese cohort and identified age and sex as key correlates of aortic size. Exploratory estimates of TAA and ectasia prevalence are also reported but should be cautiously interpreted given the small number of aneurysm cases.
OBJECTIVE: This retrospective analysis of prospectively collected observational cohort data aimed to investigate the impact of internal audit using imaging system procedure log analysis on radiation exposure during fenes...OBJECTIVE: This retrospective analysis of prospectively collected observational cohort data aimed to investigate the impact of internal audit using imaging system procedure log analysis on radiation exposure during fenestrated and or branched endovascular aortic repair (FBEVAR). METHODS: Patients who underwent FBEVAR for complex aortic aneurysms by a single operator between January 2016 and January 2024 were analysed. Procedures were performed using a historical hybrid imaging platform (system I, January 2016 - June 2020) and a subsequent platform (system II, July 2021 - January 2024), stratified into phase 1 (pre-optimisation) and phase 2 (post-optimisation) after implementation of audit derived radiation reduction strategies. Procedural log analysis identified contributors to increased radiation dose, prompting optimisation. Endpoints included procedural metrics, air kerma (AK), and dose area product (DAP). RESULTS: Four hundred and ninety-one patients were included (system I: n = 346; system II: n = 145 [phase 1: n = 83; phase 2: n = 62]). The cohort after transition demonstrated greater anatomical complexity. Median AK increased from 0.9 Gy (interquartile range [IQR] 0.6, 1.6) in system I to 1.5 Gy (IQR 1.1, 2.0) in system II phase 1 (p < .001), with DAP increasing from 158 Gy·cm (IQR 111, 229) to 219 Gy·cm (IQR 167, 284) (p = .002). Following optimisation, AK decreased to 0.9 Gy (IQR 0.5, 1.4; p = .098 vs. system I) and DAP to 151 Gy·cm (IQR 101, 229; p = .32 vs. system I). In multivariable analysis, system II phase 1 was independently associated with increased AK and DAP compared with system I (AK: β = +425 mGy; 95% confidence interval 221 - 630; p < .001; DAP: β = +53 Gy·cm; 95% confidence interval 24 - 82; p < .001), whereas no significant differences were observed in phase 2. CONCLUSION: A structured internal audit with targeted workflow and imaging optimisation mitigated radiation dose increases following hybrid platform transition, restoring exposure to baseline levels.