OBJECTIVE: This retrospective cohort study assessed the association between aneurysm diameter and one year sac behaviour. METHODS: All endovascular aortic repairs (EVARs) with one year imaging follow up in the Vascular Q...OBJECTIVE: This retrospective cohort study assessed the association between aneurysm diameter and one year sac behaviour. METHODS: All endovascular aortic repairs (EVARs) with one year imaging follow up in the Vascular Quality Initiative (2003 - 2024) were included. Sac behaviour was defined as expansion (≥ 5 mm enlargement), regression (≥ 5 mm shrinkage), or stable (< 5 mm change). Aneurysm diameter was categorised by sex specific thresholds (women/men): < 45/< 50 mm, 45 - 50/50 - 55 mm, 50 - 55/55 - 60 mm, 55 - 60/60 - 65 mm, 60 - 65/65 - 70 mm, and > 65/> 70 mm. Sac behaviour was estimated using multinomial logistic regression, with sac stability and 50 - 55/55 - 60 mm as reference categories. Restricted cubic splines (RCS) were incorporated to explore the continuous relationship. RESULTS: A total of 28 275 patients were included. At one year, 48.5% had sac regression, 45.4% stability, and 6.1% expansion. Using 50 - 55/55 - 60 mm as the diameter reference and sac stability as the outcome reference, adjusted odds ratios (95% confidence interval) for sac regression were 0.40 (0.37 - 0.43) for < 45/< 50 mm, 0.82 (0.77 - 0.86) for 45 - 50/50 - 55 mm, 1.25 (1.17 - 1.33) for 55 - 60/60 - 65 mm, 1.38 (1.29 - 1.48) for 60 - 65/65 - 70 mm, and 1.46 (1.37 - 1.57) for > 65/> 70 mm. Corresponding odds ratios for expansion were 1.92 (1.88 - 1.95), 1.03 (1.02 - 1.04), 1.20 (1.18 - 1.21), 1.43 (1.41 - 1.45), and 1.67 (1.64 - 1.69), respectively. RCS demonstrated that regression increased steeply with diameter up to ∼55 mm, while stability declined progressively. Expansion was most common in small aneurysms and least likely near 55 mm. CONCLUSION: Pre-operative aneurysm diameter showed a non-linear association with one year sac behaviour. Sac regression increased up to ∼55 mm, where the predicted probability of expansion was lowest. Small aneurysms had nearly twofold higher odds of expansion relative to stability. In larger aneurysms, higher odds of expansion reflected lower stability rather than a meaningful rise in absolute expansion risk. Further investigation is needed to clarify the mechanisms underlying sac expansion in small aneurysms. These findings suggest that patients treated at small diameters may require closer surveillance.
OBJECTIVE: Delayed ischaemic stroke (DIS) remains a feared complication following thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), particularly when the left subclavian artery (LSCA) i...OBJECTIVE: Delayed ischaemic stroke (DIS) remains a feared complication following thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), particularly when the left subclavian artery (LSCA) is covered. This study aimed to understand the impact of LSCA revascularisation and other peri-operative factors on delayed stroke risk. METHODS: This was a retrospective cohort study querying the Aortic Trauma Foundation registry to identify patients with BTAI undergoing TEVAR from 2014 to 2025. Patients with DIS after TEVAR were identified, and patient level factors, intra-operative data, and post-operative course variables were analysed. RESULTS: Six hundred and twenty TEVARs for BTAI were identified. The overall DIS rate was 3.1% (19 of 620). LSCA coverage occurred in 32.6% (202 of 620) and was associated with a significantly higher rate of DIS (5.4% vs. 1.9%; p = .017). Adjunctive LSCA revascularisation during or after TEVAR was undertaken in 11.4% (23 of 202) of patients. Among patients requiring LSCA coverage (n = 202), there was no significant difference in the incidence of DIS between those who underwent adjunctive revascularisation (one of 23; 4.3%) and those who did not (10 of 179; 5.6%) (p = .81). Factors associated with DIS included the need for any intra-operative transfusion, mechanical ventilation > 48 hours, and initial post-TEVAR pressor requirement. Traumatic brain injury related factors, age, sex, and TEVAR timing were not identified as being associated with an increased DIS risk. CONCLUSION: LSCA coverage during TEVAR for BTAI is associated with a significant increase in DIS rates. These data do not, however, demonstrate that LSCA revascularisation procedures mitigate the risk of these events in this setting. These findings may be limited by the small number of revascularised patients. Peri-operative physiological indicators emerge as the most reliable predictors of DIS in acute trauma, supporting an individualised approach where global trauma burden is considered a primary driver of neurological outcomes.
OBJECTIVE: Peri-operative myocardial injury (PMI), defined by an asymptomatic increase in troponin levels, has been recognised as a prognostic marker for impaired survival following non-cardiac surgery, with therapy for...OBJECTIVE: Peri-operative myocardial injury (PMI), defined by an asymptomatic increase in troponin levels, has been recognised as a prognostic marker for impaired survival following non-cardiac surgery, with therapy for improvement potentially available. Patients undergoing complex endovascular aneurysm repair (cEVAR) may be at particular risk of PMI owing to their cardiovascular burden. However, due to lack of routine peri-operative troponin monitoring, the incidence proportion and association between PMI and long term mortality following cEVAR remains unclear, with no possibility of applying improvement strategies. METHODS: Pre-operative and consecutive post-operative high sensitivity troponin T (hsTnT) levels were retrospectively analysed from all patients who underwent elective cEVAR in a Dutch tertiary hospital between 2012 and 2022. PMI was defined as the difference between pre- and post-operative troponin concentrations (ΔhsTnT) of ≥ 14 ng/L in the absence of clinical features of myocardial infarction. Primary objectives were the incidence proportion of PMI following cEVAR and its association with 4 year mortality. The study adhered to the STROBE guidelines. RESULTS: A total of 187 patients were included. The median follow up was 56 months. Forty-one patients (21.9%) developed PMI. Coronary artery disease was more prevalent (65.9% vs. 41.8%; p = .018) and American Society of Anesthesiologists (ASA) scores were higher (ASA 4, 13.1% vs. 7.8%; p = .023) in patients with PMI. PMI was independently associated with an increased 4 year mortality rate (adjusted hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.21 - 4.67; p = .013). Pre-operative elevated troponin levels (adjusted HR 2.91, 95% CI 1.41 - 6.33; p = .005) and longer operation time (adjusted HR 1.01, 95% CI 1.00 - 1.01; p = .002) were independently associated with an increased risk of PMI. CONCLUSION: Asymptomatic PMI is relatively common following cEVAR and is associated with impaired midterm survival. Given the high prevalence of cardiovascular comorbidities in patients with PMI, prospective follow up studies should focus on the potential of routine peri-operative hsTnT monitoring for identifying high risk patients who could potentially benefit from enhanced cardiac care.
OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of an innovative, single stage, two target vessel revascularisation endovascular repair strategy, namely single branch and chimney stenting during...OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of an innovative, single stage, two target vessel revascularisation endovascular repair strategy, namely single branch and chimney stenting during thoracic endovascular aortic repair (scTEVAR), for zone 2 aortic pathologies requiring proximal sealing in zone 1. METHODS: This was a retrospective, observational cohort study of consecutive patients who underwent scTEVAR at a tertiary Chinese centre between June 2021 and December 2024. Aortic diameter, centreline distance, tortuosity, and angulation were measured for pre-operative assessment. All procedures adhered to established surgical protocols. Outcomes of interest included technical success, death, stroke, type Ia endoleak, re-intervention, and branch patency. Descriptive statistical analyses were performed using R software. RESULTS: Sixty-six patients (94% men; median age 67 years, interquartile range [IQR] 60, 72) were included. The technical success rate was 91% (60 of 66), with the remaining six patients requiring proximal cuff extension with physician modified fenestration due to intra-operative "sail effect". All additional procedures were successful. Another patient (2%) developed retrograde type A aortic dissection and received emergency surgical repair on the eighth post-operative day. There was no death, stroke, or type Ia endoleak during a median follow up of 22 months (IQR 13, 31). Freedom from re-intervention was 93.8% (95% confidence interval [CI] 88.3 - 99.9%) at both one and three year follow up. The left subclavian artery branch patency rate was 96.8% (95% CI 92.6 - 100.0%) at 1 year and 94.1% (95% CI 87.7 - 100.0%) at 3 years. All left common carotid artery stents remained patent during follow up. CONCLUSION: scTEVAR is a standardised and clinically effective single stage endovascular arch repair strategy for zone 2 aortic pathologies, which enables two target vessel revascularisations and proximal sealing zone extension to zone 1. Peri-operative and 2 year safety and efficacy profiles in anatomically suitable candidates were satisfactory. Studies with improved design on larger cohorts are required to further confirm its durability and safety profiles.
OBJECTIVE: This systematic review aimed to evaluate the clinical effectiveness of duplex ultrasound (DUS) surveillance following infrainguinal revascularisation, both surgical and endovascular, in patients with intermitt...OBJECTIVE: This systematic review aimed to evaluate the clinical effectiveness of duplex ultrasound (DUS) surveillance following infrainguinal revascularisation, both surgical and endovascular, in patients with intermittent claudication (IC) or chronic limb threatening ischaemia (CLTI). DATA SOURCES: Ovid MEDLINE, Embase, and Cochrane Library. REVIEW METHODS: A systematic search of MEDLINE, Embase, and the Cochrane Library was conducted from inception to 1 June 2024, following PRISMA guidelines. Studies were eligible if they reported DUS surveillance protocols after infrainguinal revascularisation and included clinical outcomes such as patency, re-intervention, amputation, or death. Randomised controlled trials (RCTs) and observational studies were included. Risk of bias was assessed using RoB 2 and ROBINS-I tools. Following an a priori methodological plan, meta-analysis was not attempted because studies were not sufficiently comparable. RESULTS: Sixty-one studies were included, with 77% evaluating surgical and 23% evaluating endovascular revascularisation. DUS surveillance following surgery was associated with improved primary assisted patency in 70% of studies and lower amputation rates in several comparative studies. One RCT showed no significant benefit, highlighting heterogeneity. Evidence for endovascular surveillance was limited but promising; two prospective comparative studies demonstrated improved patency, reduced amputations (7 - 10% vs. 35 - 50%), and a lower mortality rate with DUS. Economic analyses reported reduced healthcare costs and amputations with DUS following surgical bypass. However, most studies were observational with moderate to high risk of bias, and DUS protocols varied widely in frequency and duration. In endovascular cohorts, benefits were most evident in studies including longer lesions. Where reported, amputation outcomes are presented separately for CLTI and IC. CONCLUSION: DUS surveillance appears to improve patency and limb salvage following surgical revascularisation and may reduce healthcare costs. Emerging evidence suggests potential benefits in endovascular cases, particularly for long lesions. High quality multicentre RCTs and economic evaluations are needed to determine the optimal surveillance strategy and to inform standardised clinical guidelines.
OBJECTIVE: Varicose veins are highly prevalent and most patients present with great saphenous vein (GSV) reflux. Treatment of truncal venous reflux is the cornerstone in the management of C2 disease. Endovenous laser abl...OBJECTIVE: Varicose veins are highly prevalent and most patients present with great saphenous vein (GSV) reflux. Treatment of truncal venous reflux is the cornerstone in the management of C2 disease. Endovenous laser ablation (EVLA) is widely accepted as the preferred treatment. This study aimed to estimate the long term risk of clinical recurrence in the treated leg after successful EVLA of the GSV. METHODS: This single centre, observational study included patients with C2 varicose veins in whom refluxing GSV was diagnosed. EVLA was performed from 10 - 15 cm below the knee and occlusion was confirmed with duplex after 3 months. Additional treatment after EVLA was always in a staged approach. Clinical recurrence was defined as a patient actively seeking re-treatment at least 6 months after EVLA for symptoms due to varicose veins in the treated leg. Recurrence was identified through electronic health records or, when not documented, by telephonic survey. RESULTS: The study included 543 patients with a median follow up of 6.0 (interquartile range 1.3, 10.3) years. The mean age at treatment was 52.8 ± 13.3 years and 79.2% were women. Clinical recurrence occurred in 210 patients, with an estimated 10 year recurrence rate of 47.6% (95% confidence interval 42.5 - 52.1%). Additional therapy within 6 months following EVLA was associated with a hazard ratio of 1.31 (95% confidence 0.99 - 1.72; p = .055), adjusted for age and sex. CONCLUSION: Clinical recurrence after EVLA of the GSV occurred in approximately half of patients within 10 years of the procedure, exceeding rates reported with concomitant additional treatment and EVLA of the entire refluxing GSV. The association between early additional therapy and a higher recurrence rate suggests that it may indicate an unmet therapeutic need.
OBJECTIVE: Paclitaxel coated balloons have been used to prevent recurrent stenosis in haemodialysis vascular access. Despite the availability of many randomised controlled trials (RCTs), its effectiveness compared with p...OBJECTIVE: Paclitaxel coated balloons have been used to prevent recurrent stenosis in haemodialysis vascular access. Despite the availability of many randomised controlled trials (RCTs), its effectiveness compared with plain balloon angioplasty remains inconclusive. This systematic review and meta-analysis aimed to clarify the effectiveness of paclitaxel coated balloons compared with plain balloon angioplasty for vascular access stenosis based on available randomized controlled trials. DATA SOURCES: Embase.com and Ovid/Medline. REVIEW METHODS: A systematic literature search was performed in Embase.com and Ovid Medline on 02 September 2025 to identify RCTs comparing paclitaxel coated balloons with plain balloons for vascular access stenosis. The primary endpoint was loss of primary patency at 12 months. Risk of bias was assessed with the Cochrane risk of bias tool for randomised trials (RoB 2) and certainty of evidence was assessed with GRADE. The summary treatment effect was estimated by meta-analysis using random effects models with an inverse variance approach based on odds ratios. The meta-analysis was registered with PROSPERO (CRD42024502432) and conducted without external funding. RESULTS: The literature search identified 26 RCTs with 2 930 patients. The overall risk of bias was low in five studies, intermediate in 19 studies, and high in two studies. The odds ratio of primary patency loss after 12 months was 0.54 (95% confidence interval [CI] 0.44 - 0.66; p < .001) in favour of paclitaxel coated balloons, with little between study heterogeneity (I 10%). This resulted in a number needed to treat of seven (95% CI 5 - 10) paclitaxel coated balloon angioplasties to prevent one access related re-intervention. Sensitivity analyses found no impact of variations in study design, risk of bias, or the time point of analysis on the treatment effect of paclitaxel coated balloons. In subgroup analyses, the treatment effect was not significantly different between arteriovenous fistulas and grafts, new and recurrent stenosis, or paclitaxel coated balloon type. The certainty of evidence was high for loss of primary patency and low for vascular access thrombosis and abandonment. CONCLUSION: Paclitaxel coated balloon angioplasty for vascular access stenosis reduces the odds of re-intervention at 1 year compared with plain balloon angioplasty. This meta-analysis provides high certainty evidence to support a strong recommendation to use paclitaxel coated balloons when treating vascular access stenosis.