OBJECTIVE: Although endovascular techniques dominate the treatment of abdominal aortic aneurysms (AAAs), open aortic repair (OAR) remains essential for selected patients. As previous research has focused primarily on pro...OBJECTIVE: Although endovascular techniques dominate the treatment of abdominal aortic aneurysms (AAAs), open aortic repair (OAR) remains essential for selected patients. As previous research has focused primarily on procedure specific hospital volume for infrarenal AAA repair, this study evaluated whether hospital volume of cumulated non-cardiac open aortic procedures is associated with in hospital death and peri-operative outcomes after infrarenal OAR for intact AAA (iAAA). METHODS: This study was a retrospective nationwide secondary data analysis based on German hospital episode statistics (diagnosis related group [DRG] data) covering the years 2010 to 2023. All hospitals performing non-cardiac open aortic procedures were included and were stratified into quartiles according to their annual volume of all non-cardiac open aortic procedures. A pre-defined subcohort of cases undergoing open infrarenal repair for iAAA was analysed. The primary outcome was in hospital death; secondary outcomes included acute myocardial infarction, acute kidney injury, acute peripheral ischaemia, and mesenteric thrombosis or embolism. Associations were assessed using multivariable multilevel logistic regression analysis adjusted for age, sex, Elixhauser comorbidity score, and treatment in vascular surgery departments, with random intercepts for hospital and year. RESULTS: Among 100 137 non-cardiac open aortic procedures, 34 100 cases involved infrarenal OAR for iAAA. The overall in hospital mortality rate was 5.9%, ranging from 11.3% in Q1 to 5.2% in Q4. In multivariable analysis, treatment in lower volume hospitals was associated with higher mortality (Q1 vs. Q4: odds ratio [OR] 1.79, 95% confidence interval [CI] 1.30 - 2.47; p < .001). Treatment in vascular surgery departments was associated with reduced mortality (OR 0.83, 95% CI 0.72 - 0.94; p = .005). CONCLUSION: Higher hospital volume of all non-cardiac open aortic procedures was associated with a lower in hospital mortality rate after infrarenal OAR for iAAA. These findings support centralisation efforts and suggest that minimum case volume requirements should consider the overall non-cardiac open aortic caseload rather than infrarenal procedures alone.
OBJECTIVE: While bovine aortic arch (BAA) is the most common aortic arch variant and has been associated with an increased risk of stroke in the general population, limited data exist on the impact of BAA on outcomes fol...OBJECTIVE: While bovine aortic arch (BAA) is the most common aortic arch variant and has been associated with an increased risk of stroke in the general population, limited data exist on the impact of BAA on outcomes following carotid artery stenting (CAS). This study evaluated the association between BAA and post-operative outcomes in patients undergoing CAS. METHODS: A retrospective analysis of the multi-institutional Vascular Quality Initiative database identified all patients undergoing CAS for atherosclerotic carotid stenosis from January 2017 to February 2024. Patients were stratified by the presence of BAA. Procedures included transcarotid artery revascularisation (TCAR) with flow reversal, transfemoral CAS (tfCAS), and transbrachial and transradial CAS (tb/trCAS) using distal embolic protection. The primary outcome was in hospital stroke or death. Secondary outcomes included stroke, death, myocardial infarction (MI), access related complications, and stroke and transient ischaemic attack (TIA). Baseline characteristics were compared, and multivariable logistic regression was performed to adjust for potential confounders. RESULTS: Among 18 254 patients undergoing CAS, 2 037 (11.1%) had BAA. Patients with BAA were more likely to present with symptomatic and left sided carotid stenosis. After adjustment, BAA was not associated with increased odds of post-operative stroke, death, MI, or composite adverse events. Within the BAA cohort, peri-operative outcomes were comparable across TCAR, tfCAS, and tb/trCAS, regardless of symptom status. Independent predictors of in hospital stroke or death included history of congestive heart failure and advanced age. Outcomes did not differ by lesion laterality in patients with BAA. CONCLUSION: In this large, contemporary, multicentre study, BAA was not independently associated with increased peri-operative risk following CAS. In current practice, where access selection is guided by pre-operative imaging and clinical judgement, CAS can be performed with comparable post-operative outcomes in selected patients with BAA.
OBJECTIVE: Major lower limb amputations are most commonly performed for complications of diabetes, peripheral arterial disease (PAD), or trauma. Given the increasing rates of diabetes and PAD globally, this study aimed t...OBJECTIVE: Major lower limb amputations are most commonly performed for complications of diabetes, peripheral arterial disease (PAD), or trauma. Given the increasing rates of diabetes and PAD globally, this study aimed to understand the temporal trends in the incidence of major amputations in contemporary published literature. DATA SOURCES: Medline, Embase, Scopus, and African Journals Online. REVIEW METHODS: A systematic search was conducted for studies reporting the incidence of major amputations, regardless of cause or geography, published since 2008. Studies were included if they reported population level incidence over two or more consecutive or non-consecutive years. Incidence trends were estimated using average annual percentage change in numerator:denominator pairings (referred to as incidence estimates), using log linear or Poisson regression. Meta-analysis of average annual percentage change was performed. If consecutive temporal data were not provided, average annual percentage change was estimated based on annual compound change but was not included in meta-analysis. Average annual percentage change estimates were categorised based on the populations reported in included incidence studies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used for certainty assessment of meta-analysis. RESULTS: Seventy-six studies were included for data extraction, encompassing 88 incidence estimates, with falling incidence reported in 72 of 88 (82%). Three studies were from low and middle income countries, all three of which showed a rising incidence of major amputation. Meta-analysis demonstrated falling incidence of all cause major amputations in the general population (ten studies, average annual percentage change -3.44%, 95% CI -5.17 - -1.67; GRADE certainty analysis - high) and diabetes related major amputations in the diabetes population (19 studies, average annual percentage change -7.13, 95% CI -8.60 - -5.64; GRADE certainty analysis - high). CONCLUSION: Amputation rates are generally reported to be falling in high income countries. Conversely, rates appear to be rising in low and middle income countries. More data are required from low and middle income countries, whilst an understanding of changes resulting in reduced incidence in high income countries may inform practice to reduce major amputation rates in low and middle income countries.
Lemmens CC, Klaassen J, Beck AW
… +8 more, Kölbel T, Schanzer A, Schermerhorn ML, Timaran CH, Wessels B, Schurink GWH, van Herwaarden JA, FORS Learn Registry Study Group
OBJECTIVE: This study describes the first transatlantic multicentre results of catheterisation success rates and radiation reducing effect of Fibre Optic RealShape (FORS) technology in complex endovascular aortic repair...OBJECTIVE: This study describes the first transatlantic multicentre results of catheterisation success rates and radiation reducing effect of Fibre Optic RealShape (FORS) technology in complex endovascular aortic repair (EVAR) procedures. METHODS: Data were derived from the transatlantic, multicenter, prospective observational FORS Learn Registry, executed at seven high-volume international centers specialized in complex endovascular aortic interventions. All target vessel catheterisations during complex EVAR procedures were analysed per protocol, focusing on the technical success of FORS and the impact of FORS on navigation time and radiation exposure, measured by fluoroscopy time (FT), fluoroscopy rate (FR), cumulative air kerma (CAK), and kerma area product (KAP) by comparing successful FORS with conventional catheterisations. RESULTS: During 313 complex EVARs, 812 FORS attempts at 1 037 visceral target catheterisations resulted in an overall technical success of 62.8% (fenestrations 66.2% vs. branches 54.1%; p = .001). Successful FORS catheterisation was significantly faster through fenestrations (5.0 minutes [interquartile range {IQR} 3.0, 7.0] vs. 6.5 minutes [IQR 3.0, 13.0]; p < .001) but not through branches (6.0 minutes [IQR 4.0, 11.0] vs. 7.0 minutes [IQR 4.0, 12.0]; p = .24), compared with conventional catheterisation. Successful FORS use resulted in reduced radiation compared with conventional catheterisations in fenestrations (FT FORS 0.9 minutes [IQR 0.4, 1.9], conventional 4.1 minutes [IQR 1.9, 77], p < .001; FR FORS 21.3% [IQR 10.0, 35.0], conventional 62.1% [IQR 51.7, 71.9], p < .001; CAK FORS 16.5 mGy [IQR 5.0, 48.3], conventional 93.9 mGy [IQR 42.0, 223.8], p < .001; KAP FORS 2.0 Gy·cm [IQR 0.7, 4.7], conventional 7.0 Gy·cm [IQR 2.7, 15.8], p < .001) and branches (FT FORS 1.4 minutes [IQR 0.6, 2.6], conventional 4.1 minutes [IQR 1.8, 7.4], p < .001; FR FORS 21.8% [IQR 12.5, 37.7], conventional 60.6% [IQR 46.1, 68.0], p < .001; CAK FORS 58.0 mGy [IQR 15.1, 132.4], conventional 94.7 mGy [IQR 44.5, 238.5], p < .001; KAP FORS 6.0 Gy·cm [IQR 2.0, 11.6], conventional 6.8 Gy·cm [IQR 3.5, 18.2], p < .004). CONCLUSION: This multicentre study showed the potential of FORS technology to reduce radiation exposure during visceral target catheterisation in complex EVARs with reasonable technical success.
OBJECTIVE: The aim of this study was to evaluate differences in radiation exposure across chronic venous obstruction (CVO) classification groups during endovascular recanalisation and stenting of unilateral iliofemoral l...OBJECTIVE: The aim of this study was to evaluate differences in radiation exposure across chronic venous obstruction (CVO) classification groups during endovascular recanalisation and stenting of unilateral iliofemoral lesions and to identify clinical and procedural factors influencing radiation dose. METHODS: This was a retrospective, single centre cohort study of 133 patients with unilateral iliofemoral CVO who underwent successful endovascular recanalisation and stenting with mobile C arm fluoroscopy between February 2017 and January 2023. Lesions were classified using the Jalaie CVO classification system. Radiation parameters included fluoroscopy time (FT), cumulative air kerma (CAK), kerma area product (KAP), entrance skin dose, and effective dose. Procedure data included total stent length and procedure time. Radiation and procedure parameters were recorded systematically in the institutional database and subsequently analysed across classification groups. Statistical analyses involved Mann-Whitney U test, Pearson and Spearman correlation analyses, and multivariable linear regression. RESULTS: Radiation exposure increased with higher CVO classification. Type III and IV lesions were associated with longer FT and higher CAK and KAP than type I lesions (p < .001). Compared with single stent implantation, use of two or three stents was associated with higher CAK (p < .001 and p = .006, respectively) and KAP (p < .001 and p = .008, respectively). In multivariable analysis, FT was independently predicted by total procedure time (p < .001) and body mass index (BMI) (p = .024). CAK and KAP were independently predicted by total procedure time (p < .001), BMI (p < .001), total stent length (p = .035 and p = .015), and type IV obstruction (p = .020 and p = .034). CONCLUSION: Radiation exposure during unilateral iliofemoral CVO intervention increases with lesion severity. CVO type IV, BMI, total stent length, and procedure time were independently associated with radiation dose.
OBJECTIVE: This retrospective, cohort study aimed to quantitatively evaluate the growth of the proximal landing zone (PLZ), to identify the main predictors influencing the progression of the diameter of the PLZ, and to e...OBJECTIVE: This retrospective, cohort study aimed to quantitatively evaluate the growth of the proximal landing zone (PLZ), to identify the main predictors influencing the progression of the diameter of the PLZ, and to evaluate their influence on the adverse events associated with the PLZ. METHODS: All consecutive patients who underwent a fenestrated, branched, or standard thoracic endovascular aortic repair (TEVAR) and had a PLZ in native aorta (aortic arch and proximal descending aorta), classified as Ishimaru 0 - 4, between April 2018 and January 2022 were included in the study. PLZ diameter changes over time were assessed using longitudinal mixed effects models. Risk factors for PLZ growth were evaluated by uni- and multivariable analyses. Associations between PLZ growth and adverse events were examined using Cox regression. RESULTS: Seventy-six patients were included, with a mean follow up of 24.2 ± 20.7 months. The average PLZ growth was 1.7 mm/year (95% confidence interval [CI] 1.1 - 2.3; p < .001), which was statistically significantly greater than the growth observed in the unstented native aorta proximal to the tip of the endoprosthesis, averaging 0.7 mm/year (95% CI 0.46 - 0.96; p < .001). In the multivariable analysis time (β = 1.7, 95% CI 1.08 - 2.33; p < .001), pre-operative PLZ diameter (β = 0.92, 95% CI 0.78 - 1.1; p < .001), oversizing (β = 0.08, 95% CI 0.02 - 0.14; p = .016), and age (β = -0.06, 95% CI -0.11 - 0.01; p = .015) were identified as significant risk factors for growth. Growth was significantly associated with type Ia endoleak (hazard ratio 1.25, 95% CI 1.1 - 1.4; p < .001) and migration ≥ 10 mm (hazard ratio 1.19, 95% CI 1.07 - 1.33; p = .001). CONCLUSION: Growth of the PLZ after TEVAR exceeds that of the native aorta proximal to the endograft, with progression influenced by both anatomical and procedural factors. Significant PLZ growth is associated with an increased risk of type Ia endoleaks and migration, emphasising the importance of regular follow up and optimised personalised procedure planning.
OBJECTIVE: Endovascular iliofemoral venous stenting has low morbidity; however, in stent re-stenosis (ISR) remains a significant complication that may require re-intervention. This single centre, retrospective study aime...OBJECTIVE: Endovascular iliofemoral venous stenting has low morbidity; however, in stent re-stenosis (ISR) remains a significant complication that may require re-intervention. This single centre, retrospective study aimed to evaluate ISR biopsy findings and risk factors for stent failure in patients with iliofemoral venous stents. METHODS: Eighty-four patients (mean age 45.3 ± 16.0 years) who underwent iliac vein stenting and endovascular biopsies between January 2008 and January 2021 were included. Catheter based venography and endovascular biopsies were performed at 3 - 12 and 12 - 24 months after stenting. Logistic regression and Cox regression analyses were conducted to assess the factors associated with severe ISR (ISR degree ≥ 50%) and stent failure. Stent patency time was estimated using Kaplan-Meier curves. RESULTS: Over a mean follow up of 67.4 ± 43.4 months, stent failure occurred in 27 patients (32.1%), including 10 (11.9%) before the second venographic evaluation. At the first biopsy, 38.1% exhibited fresh or organising thrombus, while 61.9% exhibited old thrombus or diffuse intimal thickening (DIT). At the second biopsy, 28.1% had fresh or organising thrombus and 71.9% had old thrombus or DIT. A prothrombotic state (odds ratio 17.862; p = .003) was the significant risk factor for severe ISR within 12 months after stenting, whereas age > 45 years was protective (odds ratio 0.102; p = .009). Patients with fresh or organising thrombus had a statistically significantly higher incidence of stent failure compared with those with old thrombus or DIT (first: 50.0 vs. 21.2%, p = .008; second: 56.3 vs. 19.5%, p = .010). Jalaie type 3 lesions exhibited statistically significantly greater ISR than Jalaie type 2 at both time points (p = .008 and p = .001). Severe ISR between 12 - 24 months after stenting was the predictor for stent failure (hazard ratio 21.573; p = .001). CONCLUSION: ISR biopsy demonstrating fresh or organising thrombus was associated with a significantly higher risk of stent failure. Early identification of high risk patients can inform risk stratification and post-stenting management strategies.
OBJECTIVE: Despite all the advances in endovascular techniques, carotid endarterectomy (CEA) remains the standard intervention for carotid stenosis. The refinement of intra- and post-operative care increasingly aims to i...OBJECTIVE: Despite all the advances in endovascular techniques, carotid endarterectomy (CEA) remains the standard intervention for carotid stenosis. The refinement of intra- and post-operative care increasingly aims to increasingly minimize the risks associated with this procedure, especially neurological and cardiovascular events. This study aimed to summarise the literature on the benefits and harms of protamine use during CEA. DATA SOURCES: PubMed (MEDLINE), Embase, and Cochrane databases. REVIEW METHODS: MEDLINE, Embase, and Cochrane databases were systematically searched for studies of patients undergoing CEA whose population was partially given protamine. Outcomes included cervical haematomas, stroke, myocardial infarction, and overall mortality rate. Statistical analysis was performed using R Studio version 5.3. Heterogeneity was assessed with the I statistic. RESULTS: Twelve studies, including over 87 000 CEAs, were analysed. Protamine administration significantly reduced the rate of any cervical haematoma (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.39 - 0.60; p < .001) as well as haematomas requiring re-operation (OR 0.48, 95% CI 0.35 - 0.67; p < .001). There was an association with a lower stroke rate after protamine use (OR 0.85, 95% CI 0.74 - 0.97; p = .018). Finally, no difference was identified in terms of mortality (OR 0.95, 95% CI 0.69 - 1.31; p = .77). The GRADE certainty of evidence was rated as very low across all outcomes analysed. CONCLUSION: Protamine may reduce the risks of CEA without increasing adverse outcomes. However, further research is needed given the very low certainty of the available evidence.
OBJECTIVE: Aortic endograft infection (AeGI) is a rare complication following complex endovascular aortic repair (cEVAR). Data on its incidence, risk factors, and outcomes are limited to very small case series. This stud...OBJECTIVE: Aortic endograft infection (AeGI) is a rare complication following complex endovascular aortic repair (cEVAR). Data on its incidence, risk factors, and outcomes are limited to very small case series. This study aimed to retrospectively determine the incidence and risk factors for AeGI after cEVAR and to describe treatment strategies and outcomes in a high volume aortic centre. METHODS: Patients undergoing cEVAR with fenestrated or branched endografts at Uppsala University Hospital, Sweden, between September 2010 and May 2024 were identified retrospectively and crosschecked with the Swedish vascular registry (Swedvasc). AeGI was defined according to the Management of Aortic Graft Infection Collaboration (MAGIC) criteria. Risk factors were assessed using multivariable Cox regression. Outcomes included incidence, microbiology, treatment strategies, survival, and long term infection status. RESULTS: Among 527 patients (542 cEVARs, median follow up 47.4 months), 19 developed MAGIC diagnosed AeGI. The 5 year incidence was 3.87% (3.16% for non-infected aortic pathology and 23.5% for cEVAR treated primary infected aortic pathology [MAA]) adjusting for mortality as a competing risk using the cumulative incidence function. Independent risk factors to develop AeGI were MAA as index pathology (hazard ratio 10.2, 95% confidence interval 3.1 - 33.2) and late aortic related re-interventions (hazard ratio 3.0, 95% confidence interval 1.1 - 7.9). Six patients (32%) had a secondary fistula, associated with poor median survival (4.0 vs. 41.5 months). Treatment strategies were predominantly graft persevering: antimicrobial therapy alone in 11 of 19 (58%) or combined with image guided drainage and or surgical debridement in seven of 19 (37%). At last follow up, remission or cure was achieved in 56%, and treatment failure in 44%, mainly due to AeGI related death. CONCLUSION: AeGI after cEVAR is more common than previously reported. Risk is further increased by MAA as the index pathology and late aortic re-interventions. Prognosis is poor in patients with secondary fistula. Endograft preserving strategies may achieve infection remission and survival in selected patients, not amenable to explantation, without fistula.