Guidelines across vascular surgery, cardiology, and radiology specialties recommend appropriate preoperative testing prior to revascularization for claudication. We aimed to identify patient and physician characteristics associated with the absence of preoperative testing before peripheral vascular interventions (PVIs) performed for claudication. Using 100% Medicare fee-for-service claims data, we identified all patients undergoing an index PVI for claudication between 01/2017 and 12/2024. We used CPT codes to identify preoperative testing, which included noninvasive physiologic studies (ABI, pulse volume recordings [PVRs]), near infrared thermography, duplex ultrasound, MRA of the abdomen and pelvis with runoff, CTA of the abdomen and pelvis with runoff, MRA of the lower extremity, or CTA of the lower extremity. Lack of preoperative testing was defined as no preoperative test within 3 months prior to index PVI. We evaluated the associations of patient and physician characteristics with the lack of preoperative testing using multivariable hierarchical logistic regression. We performed sensitivity analyses defining lack of preoperative testing as no testing within 6 and 12 months prior to index PVI. Of 167,406 patients undergoing index PVI for claudication by 3,771 physicians, 27.4% received no preoperative testing. The odds of receiving no preoperative testing significantly increased over time (adjusted odds ratio [aOR] 1.02 per year, 95% confidence interval [95% CI] 1.02-1.03). Patients without preoperative testing were more likely to be age ≤ 64 years (versus age 65-74, aOR 1.06, 95% CI 1.01-1.11), Black (versus White, aOR 1.10, 95% CI 1.05-1.15), or Hispanic (versus White, aOR 1.20, 95% CI 1.11-1.31), and to receive an iliac intervention (aOR 1.29, 95% CI 1.22-1.36). Patients treated by physicians of cardiology (aOR, 1.98; 95% CI, 1.87-2.10), radiology (aOR, 1.20; 95% CI, 1.09-1.33), and other nonvascular surgery specialties (aOR, 1.27; 95% CI, 1.13-1.42) had higher odds of not receiving preoperative testing compared to patients treated by vascular surgeons. Sensitivity analyses using 6 and 12 months as the time cutoff for testing prior to PVI did not substantially change the results. Compliance with society guidelines for preoperative testing prior to outpatient PVI for claudication varies substantially by patient and physician characteristics. Cross-specialty adherence will help ensure patients with claudication receive consistent, evidence-based, high-value care.
Revascularization plays a critical role in chronic limb-threatening ischemia (CLTI) care, aiming to prevent limb loss and improve survival. Revascularization, whether via surgical bypasses or endovascular therapies, plays a major role in saving the limb, prolonging overall patient survival, and improving their quality of life. Our study aims to compare the clinical outcomes of direct revascularization versus indirect revascularization (with or without collaterals) in isolated infrapopliteal percutaneous transluminal angioplasty for the management of CLTI patients with tissue loss. This is a prospective, nonrandomized, comparative clinical study conducted at 2 tertiary centers. The study included all consecutive patients presenting between March 2022 and March 2023 with CLTI due to isolated infrapopliteal arterial occlusive disease or successfully treated proximal femoral lesions with Rutherford stage 5 and 6, and had either critical ischemia/vascularity ankle-brachial index less than 0.4. One hundred and seventeen patients were assessed for eligibility; 17 patients were excluded from the analysis due to failed revascularization to the ankle (n = 17). The remaining 100 patients with technically successful infrapopliteal endovascular treatment with inline flow to the ankle were included (50 in the DR group and 50 in the IR group) and included in the analysis. Limb salvage, however, was significantly higher in the direct group (98%) than in the indirect group without collaterals (74.1%, P = 0.004). Within the indirect group, patients with collateral supply (IR-tc) had higher limb salvage rates (91.3%) than those without collaterals (IR-wc, 74.1%). The optimal strategy for wound revascularization remains controversial. The angiosome model emphasizes restoring blood flow directly to the tibial artery, which supplies the ulcerated foot region, and several studies have demonstrated improved healing and limb salvage with this approach. Conversely, other reports suggest that wound healing is more strongly influenced by factors such as pedal arch integrity, ulcer location and extent, and patient comorbidities. Recently, increasing focus has been placed on the contribution of collateral circulation to revascularization outcomes. Some studies indicate that indirect revascularization (IR), particularly when supported by collateral vessels (IR-tc), may yield results comparable to direct revascularization (DR). Direct revascularization provides highly effective treatment outcomes in CLTI. In the indirect revascularization group, patients without collateral supply to the ischemic area were associated with the poorest outcomes and a higher risk of limb loss.
Previous studies have demonstrated significant changes in arterial stiffness and secondary cardiac effects following endovascular repair of infrarenal or thoracic aortic aneurysms. However, data remain scarce regarding the impact of more extended complex fenestrated and branched endovascular aortic repair (F/BEVAR) for pararenal and thoracoabdominal aortic aneurysms. This study aimed to investigate alterations in arterial stiffness and cardiac function following F/BEVAR. A total of 41 patients undergoing F/BEVAR for pararenal or thoracoabdominal aortic aneurysms were prospectively enrolled. Arterial stiffness was evaluated by measuring the carotid-femoral pulse wave velocity (cfPWV). Cardiac function was assessed by left ventricular global longitudinal strain, left atrial volume index, peak atrial longitudinal strain, left ventricular end-diastolic volume, and N-terminal pro-B-type natriuretic peptide. Measurements were obtained preoperatively and at 1 and 6 months postoperatively. Arterial stiffness increased significantly postoperatively. CfPWV increased from 10.85 ± 2.27 preoperatively to 15.30 ± 3.70 m/s at 1 month (P < 0.001) and remained elevated at 14.54 ± 3.90 m/s (P = 0.22), at 6 months. Ventriculoarterial coupling increased (cfPWV/global longitudinal strain ratio - 0.60 ± 0.23 to - 0.79 ± 0.29 m/s%; P < 0.001). Left atrial volume index increased (30.4 ± 13.7 to 33.1 ± 13.6 ml/m2; P < 0.001), left ventricular end-diastolic volume increased (74.3 ± 21 to 77.1 ± 20.1 mL; P < 0.001), and peak atrial longitudinal strain decreased (30.1 ± 9.7 to 27 ± 8.8%; P = 0.06) at 1 month. N-terminal pro-B-type natriuretic peptide levels increased transiently (341 ± 204 to 1,266 ± 786 pg/mL; P < 0.01) at 1 month follow-up, but seemed to be improved at the second examination. All cardiac markers were elevated at 1-month follow-up and most of them continued to deteriorate at 6 months. A high percentage of aortic coverage seemed to deteriorate the cfPWV measurements. Endovascular repair of complex aortic aneurysms with F/BEVAR is associated with a significant increase in arterial stiffness and measurable changes in cardiac function. Further research is necessary to better understand the potential implications of these extensive endovascular procedures for the cardiac function in the long-term. In view of these findings, long-term cardiovascular monitoring should be considered for patients undergoing extensive endovascular aortic repair.
To describe clinical outcomes associated with the off-label use of the Wrapsody™ Cell-Impermeable Endoprosthesis (CIE) for endovascular popliteal artery aneurysm (PAA) repair. This was a retrospective analysis of patients with PAA treated (September 2021-October 2024) with the WRAPSODY CIE. Clinical outcomes of interest included successful device placement, complete exclusion of the aneurysm at 30 days, aneurysm shrinkage, primary patency, reintervention with secondary patency, and complications. Patients were followed for a range of 4-48 months. Eighteen patients were analyzed (17 males and 1 female). The mean age of patients treated was 73 years. The mean aneurysm length was 6.8 cm. All devices were successfully placed, no major complications were observed. Aneurysm shrinkage was achieved in 8 patients. One patient presented a small type II endoleak from a genicular artery. Early primary patency at 4 months was 100%, late patency at 16 months was 85.7%. One patient underwent endovascular reintervention for acute intrastent thrombosis 12 months postprocedure, without the possibility of recanalization and secondary patency. Another endograft occluded chronically, without symptoms; therefore, the patient was treated with medical therapy. These results indicate that the WRAPSODY CIE used may be a safe and effective intervention for endovascular popliteal artery aneurysm repair and may help physicians optimize care for PAA.
To develop and temporally validate a predictive scoring system (VascGSI Score) for groin surgical site infection (SSI) after vascular surgery. Retrospective cohort study reported per the TRIPOD statement (Collins et al., 2015). A tertiary referral vascular center serving a defined geographic region. From 12,180 femoral-access procedures (2010-2024), 2,156 percutaneous excluded. Of 10,024 with groin incision, 1,282 excluded. Final cohort: 8,742 incisions in 7,218 patients. Derivation 2010-2020 (n = 6,394); temporal validation 2021-2024 (n = 2,348). Groin SSI within 90 days per Centers for Disease Control and Prevention/National Healthcare Safety Network criteria. Twenty-eight a priori candidate predictors. Multiple imputation (multivariate imputation by chained equations, m = 20). Logistic regression with generalized estimating equation confirmation. area under the receiver operating characteristic curve (AUC), calibration, decision curve analysis (5-30%), and net reclassification index/integrated discrimination improvement. Bootstrap (n = 1,000) and temporal validation. Groin SSI occurred in 846/8,742 incisions (9.7%). Ten predictors were retained: diabetes (4 pts), prior femoral exploration/obesity/chronic kidney disease/operative time >180 min/immunosuppression/smoking (3 each), prosthetic graft/chronic limb-threatening ischemia/female sex (2 each). Generalized estimating equation confirmed all predictors (<5% odds ratio change). Derivation AUC 0.831 (0.812-0.850); bootstrap-corrected 0.819. Temporal validation AUC 0.808 (0.778-0.838). Calibration slopes 0.96/0.91. Risk tiers: low (0-6) 3.2%, moderate (7-13) 11.8%, high (14-20) 24.6%, and very high (>20) 41.1%. The VascGSI Score demonstrated good discrimination and calibration in temporal validation. Its incremental value over existing models requires confirmation in multicenter prospective studies before clinical implementation.
Thigh sarcomas (soft-tissue and bone) may encase or invade the femoral vascular axis, historically prompting primary amputation. Contemporary limb-sparing surgery increasingly incorporates planned en bloc vascular resection and reconstruction to secure oncologic margins while preserving limb function. This structured narrative review addresses 3 femoral-axis-specific decision domains in thigh and groin sarcoma surgery: (1) arterial planning, with particular attention to the common femoral bifurcation and profunda femoris artery; (2) selective venous reconstruction versus ligation; and (3) adjunctive factors influencing graft durability, including conduit choice, soft-tissue/lymphatic management, and surveillance. Across contemporary cohorts and meta-analyses, limb salvage is achievable in most patients, but perioperative morbidity remains substantial and is driven primarily by wound/lymphatic complications and graft thrombosis. Current evidence supports mandatory arterial reconstruction after circumferential resection of the femoral axis, while the need for venous reconstruction remains unresolved and should be individualized according to deep venous trunk loss, preoperative patency/collateralization, field hostility, and anticoagulation feasibility. We propose a pragmatic femoral-axis decision framework emphasizing profunda preservation, selective venous reconstruction, proactive wound/coverage planning, and standardized reporting to improve reproducibility and future comparative inference.
Cryopreserved allografts remain a viable option for infrainguinal revascularization in limb salvage when autologous veins are unavailable or prosthetic material is undesirable. Uncertainty persists regarding comparative outcomes by allograft type (arterial vs venous) and clinical indication (infectious vs noninfectious settings). This systematic review and meta-analysis summarizes outcomes and key evidence gaps. A systematic search of studies reporting infrainguinal reconstructions with cryopreserved arterial or venous allografts was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (International Prospective Register of Systematic Reviews: CRD42024579097). Primary outcomes were 1-year primary patency, overall survival, and cumulative major amputation. Random-effects single-arm meta-analyses were performed with subgroup analyses by graft type and infection status. Risk of bias was assessed using Risk Of Bias In Nonrandomized Studies - of Interventions and certainty of evidence using Grading of Recommendation Assessment, Development, and Evaluation (GRADE). Secondary outcomes, including reintervention and graft-related complications, were narratively summarized. Forty-two studies (2,237 patients; 2,170 limbs) were included: 25 were at serious risk of bias and 17 at moderate. Pooled 1-year primary patency was 51.1% (95% confidence interval [CI] 40.9-61.4%), overall survival 85.0% (95% CI 81.1-88.9%), and cumulative major amputation 20.2% (95% CI 15.7-24.7%). Arterial grafts had higher patency (67.6%; 95% CI 54.3-80.9%) than venous (39.6%; 95% CI 30.2-49.0%). Reconstructions for infection had superior patency (70.4%; 95% CI 55.2-85.6%) compared with noninfectious indications (44.2%; 95% CI 32.8-55.5%). GRADE certainty was very low. Cryopreserved allografts enable limb salvage in complex chronic limb-threatening ischemia but show modest 1-year patency and substantial heterogeneity. Arterial conduit and use in infection were associated with superior early patency; robust comparative studies are required to optimize graft selection.
Clinical practice guidelines (CPGs) are often complex and subject to the reader's interpretation. The aim was to develop and validate an artificial intelligence (AI)-driven application for standardized interpretation of CPGs. The application was named "VascLink-AI," reflecting the clinical focus and traceable nature of the tool. A comparative study to benchmark AI performance against established clinical standards. The 2017 European Society of Cardiology/European Society for Vascular Surgery Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases were vectorised into a knowledge graph. A large language model was locked to this graph, returning structured, citation-anchored answers. Performance was tested on 41 committee-answered vignettes. The app's answers and the committee's answers were scored for accuracy, completeness, clarity, relevance, adaptability, and evidence justification by an automated evaluator (GPT-4o) and 2 independent human experts. Inter-rater reliability and consensus scores were compared. A noninferiority analysis was performed. The application achieved high alignment with the expert intent, with composite scores favoring the app for both raters: automated 90.5% versus 77.8%, P < 0.001; human consensus 94.2% versus 86.2%, P < 0.001. Reliability analysis revealed an "agreement gap"; human raters' agreement on committee answers was negligible (Kappa = -0.018), but reached a moderate level on AI answers (Kappa = 0.450). The application was found to be noninferior to the experts across all 12 evaluated metrics (all P < 0.001). This study demonstrates how AI can grow from a general research aid into a traceable, guideline-restricted framework capable of delivering advice that matches human expert interpretation of societal guidelines.
The objective of the present study was to assess the impact of gender on outcomes following endovascular treatment of AIOD, focusing on patency, limb salvage, reintervention rates, and survival. This retrospective cohort study of prospectively collected data included consecutive patients with AIOD who underwent aortoiliac angioplasty between January 2017 and January 2024. Two groups were analyzed: (1) female patients, (2) male patients. Eligible patients presented with critical limb-threatening ischemia or disabling claudication. Regression cox was performed to evaluate the factors related to primary patency, major amputation, and overall survival. Among several factors analyzed, covered versus bare-metal stents and common femoral endarterectomy were evaluated. A total of 108 endovascular procedures were attempted. Technical success was achieved in 103 patients (95.4%), who comprised the study cohort. The female group predominated with 57 patients (55.3%) and the male group with 46 patients (44.7%). Arterial hypertension was the most prevalent comorbidity (79.6%), with higher prevalence at female group than male group (87.7% vs. 69.6%, P = 0.021), followed by dyslipidemia (63.1%), diabetes mellitus (54.4%), and ischemic heart disease (28.2%), with higher prevalence at male group than female group (65.3% vs. 34.5%, P = 0.005). Concomitant common femoral endarterectomy (CFE) was performed in 11 patients (10.7%; 13% male group and 8.8% female group; P = 0.48). The perioperative mortality rate was 11.7%, with no significant differences among groups (P = 0.82). Primary patency at 1,000 days was 80.1% at male group and 78.1% at female group (P = 0.43). Limb salvage rates at 1000 days were 95.5% at male group and 95.5% at female group, P = 0.57. Cox regression analysis identified bare-metal stent use as a predictor of reduced primary patency (HR 15.99, 95% CI 2.07-122.996; P = 0.008). Conversely, CFE was a protective factor for better primary patency (HR 0.123, 95% CI 0.020-0.778; P = 0.026). In conclusion, female and male patients with AIOD submitted to endovascular treatment had similar outcomes regarding patency, limb salvage rates, overall survival, and freedom from target-lesion reintervention. Moreover, covered stent use was associated with higher primary patency and lower reintervention rates compared with bare-metal stents, and concomitant CFE was a protective factor for better primary patency.
The pathogenesis of aortic aneurysm (AA) remains unclear, and there are no effective therapeutic drugs or targets. Circulating plasma proteins are considered biomarkers of AA and potential therapeutic targets for AA. This study aimed to systematically evaluate the causal effects of plasma proteins on AA using a multicohort Mendelian randomization (MR) approach. Protein quantitative trait loci (pQTLs) was obtained from 9 published proteome genome-wide association studies (GWASs) and AA GWAS data from the FinnGen cohort. Independent pQTLs were selected as instrumental variables (IVs). Two-sample MR analysis was performed using inverse-variance weighted, MR-Egger regression, weighted median, weighted mode, and simple mode methods. Heterogeneity and pleiotropy were assessed using Cochran's Q test, I2 statistic, MR-Egger intercept, MR-PRESSO, and Leave-one-out analysis. Steiger filtering was used to test the causal direction. Colocalization analysis and pQTL-expression quantitative trait loci overlap assessment were conducted to validate the findings. Pathway enrichment and drug target analyses were performed to explore the biological and clinical implications of the MR results. A total of 8,285 pQTLs for 4,421 proteins were retained as IVs. Using cis-pQTLs for IVs, MR analysis identified 154 proteins associated with thoracic aortic aneurysm (TAA; 76 protective and 78 risk factors) and 211 proteins with abdominal aortic aneurysm (AAA; 112 protective and 99 risk factors) Using cis-pQTLs combined with trans-pQTLs as IVs, MR analysis identified 236 proteins associated with TAA and 309 proteins with AAA. A subset of these associations survived false discovery rate (FDR) correction (FDR <0.05), representing the most robust findings. Comparison of the TAA and AAA proteomic profiles revealed both shared proteins (e.g., AHSG, MMP7, RARRES2, THBS2, CCL25) and condition-specific proteins (e.g., OVCA2, STAT3, and HPSE for TAA; PLAU, LPA, SERPING1, and SMPDL3A for AAA), reflecting the distinct embryonic origins and pathological drivers of these 2 conditions. Steiger filtering confirmed the expected direction of effect from circulating proteins to AA. Colocalization analysis found evidence of shared causal variants between multiple proteins and AA. Pathway enrichment analysis revealed involvement in stress response, immune regulation, cytokine-cytokine receptor interaction, and metabolic processes. Nearly two-thirds of the associated proteins were classified as druggable or potentially druggable targets. This study identified a large number of potentially novel pathogenic proteins and therapeutic targets for AA, providing important references for elucidating the molecular pathogenesis of AA and advancing drug development. These findings warrant further validation through experimental studies and prospective clinical investigations.
Postsurgical complications following vascular procedures requiring a groin incision are common due to factors such as preexisting comorbidities and are complicated by the frequent use of synthetic grafts. While negative pressure wound therapy and muscle flap coverage are interventions that have been shown to improve vascular graft salvage rates in the groin, use of absorbable antibiotic beads (AABs) may offer another useful adjunct to reduce adverse outcomes. This study evaluated the outcomes in patients receiving AABs during groin reconstruction following vascular procedures at a large tertiary-care hospital. A retrospective review was performed of all patients undergoing vascular surgery in the groin followed by reconstruction by the Plastic and Reconstructive Surgery service from January 2018 to March 2024. Patients were grouped by whether prophylactic AABs were placed during groin reconstruction. Among 63 cases, 20 received AABs. Bivariate analysis showed significantly lower reoperation rates in the AAB group (P = 0.046). Multivariable analysis revealed AAB was associated with a significantly lower odds of composite major complications (P = 0.015), 30-day readmissions (P = 0.012), and reoperation (P = 0.003) following groin reconstruction. AAB use was not a significant predictor for length of stay, composite minor complications, postoperative packed red blood cells transfusions, long-term wound care, or surgical site infection. Use of AABs during groin reconstruction was associated with improved outcomes, including significantly lower rates of reoperations, readmission, and major complications suggesting a potential benefit in managing complex groin wounds.
Elective open abdominal aortic aneurysm (AAA) repair remains associated with substantial postoperative morbidity and prolonged hospital length of stay (LOS). Enhanced recovery after surgery (ERAS) protocols have been increasingly implemented in vascular surgery; however, their impact on clinically relevant outcomes after open AAA repair has not been clearly quantified. We conducted a Preferred Reporting Items for Systematic reviews and Meta-Analyses-compliant systematic review and random-effects meta-analysis evaluating the impact of structured ERAS protocols in elective open AAA repair. Four comparative cohort studies involving 1,142 patients undergoing elective open AAA repair were included (ERAS, n = 556; conventional care, n = 586). Outcomes assessed were postoperative mortality, overall complications, and LOS. The protocol was prospectively registered in PROSPERO (CRD420251283076). Compared with conventional care, ERAS protocols were associated with a significant reduction in postoperative complications (odds ratio 0.59, 95% confidence interval (CI) 0.42-0.86; P = 0.03) and shorter LOS (mean difference -1.32 days, 95% CI -1.89 to -0.75; P < 0.001). No significant difference in postoperative mortality was observed (odds ratio 0.87, 95% CI 0.33-2.30; P = 0.78). Between-study heterogeneity was low for mortality and complications and moderate for LOS. ERAS protocols improve postoperative recovery after elective open AAA repair by reducing complications and LOS without compromising short-term safety. These findings support the integration of structured ERAS pathways into contemporary perioperative management for open AAA surgery.
Chronic limb-threatening ischemia (CLTI) carries a high risk of major amputation. Although the Society for Vascular Surgery (SVS) Wound, Ischemia, and Foot Infection (WIfI) classification provides validated anatomical risk stratification, substantial heterogeneity persists within advanced stages. We evaluated whether integrating systemic physiological biomarkers and Doppler-based ischemia grading appears to improve prediction of major amputation. In this retrospective cohort study, 66 diabetic patients with CLTI (January 2024-January 2026) were analyzed. Baseline SVS WIfI stage, arterial Doppler waveform-based ischemia grade, and admission biomarkers (serum albumin, hemoglobin (Hb), and neutrophil-lymphocyte ratio [NLR]) were recorded. The primary endpoint was major amputation or in-hospital mortality. Predictive performance of an anatomical-only model was compared with a composite model incorporating host reserve biomarkers using multivariable logistic regression and receiver operating characteristic (ROC) analysis. Major amputation occurred in 31 patients (47.0%). WIfI stage strongly predicted outcome (P < 0.001), with 76.3% of stage 4 patients requiring amputation. Doppler-based ischemia grade showed a significant graded association with limb loss (P < 0.001). Patients undergoing major amputation had lower serum albumin (1.94 vs. 2.45 g/dL; P < 0.001), lower Hb (9.15 vs. 10.48 g/dL; P = 0.005), and higher NLR (9.12 vs. 5.46; P = 0.003). Model discrimination improved from area under the ROC curve 0.846 to 0.907 (DeLong test, P = 0.015) with biomarker integration. While SVS WIfI staging remains an important anatomical predictor, the addition of Doppler waveform morphology and systemic physiological markers appears to improve risk stratification, supporting a dual-axis framework integrating anatomical severity and host resilience in CLTI; however, these findings should be considered exploratory and require validation in larger prospective cohorts.
To examine whether adherence to device instructions for use (IFU) impacts outcomes after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) and penetrating aortic ulcer (PAU). This retrospective analysis of the prospective, multicenter Gore Global Registry for Endovascular Aortic Treatment (GREAT) (NCT01658787) included 939 patients treated with GORE® TAG® or Conformable TAG® devices between 2010 and 2016. For the present study, we evaluated 334 elective patients with DTAA or PAU who underwent TEVAR in proximal landing zones 2-4, with 5 years of follow-up (FU). Patients were categorized as treated inside IFU (iIFU) or outside IFU (oIFU). Primary outcomes included survival, aortic-related mortality, serious adverse events (SAEs), and device-/procedure-related complications. Secondary outcomes included endoleak, reintervention (RI), and device integrity. Cox proportional hazards models assessed associations between IFU status and outcomes. Among 334 patients (median age, 71 years; 41% female), 208 (62%) were treated iIFU and 128 (38%) oIFU. The most common deviations were inadequate proximal landing zone (56%) and distal diameter mismatch (47%). Baseline demographics and comorbidities were similar, although coronary heart disease was more prevalent in iIFU patients. Over 5 years, survival (56.1% vs. 62.8%, P = 0.50), aortic-related mortality (4.3% vs. 4.7%, P = 0.90), SAEs (64.3% vs. 61.4%, P = 0.60), and device-/procedure-related SAEs (24.0% vs. 26.7%, P = 0.60) did not differ significantly between iIFU and oIFU groups. Endoleaks were infrequent, with no significant differences by IFU status, though type III endoleaks occurred only in oIFU patients (1.6%). Device migration, fracture, or compression was rare. RIs occurred in 15% of iIFU and 20% of oIFU patients (P = 0.30). Cox analysis demonstrated a significantly increased hazard for "other" RIs in oIFU patients (hazard ratio, 2.38; 95% confidence interval, 1.13-5.02; P = 0.022), whereas risks for device-/procedure-related RIs, endoleaks, or mortality were not significantly different. Elective TEVAR is frequently performed oIFU, largely due to proximal landing zone and distal diameter constraints. In this multicenter registry, oIFU treatment was not associated with significantly worse survival, aortic-related mortality, or major device-related complications over 5 years. However, the increased risk of secondary RIs highlights the need for careful patient selection, structured FU, and further prospective research to define which anatomic deviations can be safely tolerated in clinical practice.
Patients with left ventricular ejection fraction (LVEF) <30% or persistent arrhythmia are often considered at elevated risk for carotid revascularization. While carotid endarterectomy (CEA) remains standard, transcarotid artery revascularization (TCAR) has emerged as a less invasive alternative. Comparative outcomes between these procedures in high-risk cardiac patients remain poorly defined. A retrospective review of a prospectively maintained database identified all CEA and TCAR procedures performed between December 2015 and August 2025. High cardiac risk was defined as LVEF <30% and/or persistent arrhythmia. Baseline demographics, perioperative variables, and outcomes were compared using stratified and survival analyses. Among 2,466 patients, 405 (16.4%) met high-risk criteria (CEA: n=200; TCAR: n=205). Compared with low-risk patients, the high-risk cohort was older (75.4 vs. 71.7 years, p<0.01) and had higher rates of coronary artery disease (64.4% vs. 42.0%, p<0.01) and anticoagulant use (39.4% vs. 5.6%, p<0.01). Blood loss was greater with CEA than TCAR (50 vs. 25 mL, p<0.01) but similar across risk groups. Among high-risk patients, perioperative ipsilateral stroke (2.0% vs. 3.4%), myocardial infarction (4.0% vs. 3.4%), and 30-day mortality (3.0% vs. 2.4%) did not differ between CEA and TCAR. Median follow-up was 20 months after CEA and 11 months after TCAR, with no difference in long-term survival or stroke-free outcomes (Gray's test p=0.35). In patients with severe cardiac comorbidities, CEA and TCAR offer comparable perioperative and long-term results. Both represent safe and durable options for carotid revascularization in this high-risk population.
To compare perioperative and 1-year outcomes of carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TF-CAS) using data from a large multicenter real-world cohort of symptomatic patients treated across community hospital settings. A retrospective analysis was performed on 37,482 symptomatic patients who underwent CEA, TCAR, or TF-CAS within the HCA Healthcare system from 2016 to 2023. Symptomatic status was defined by documented ipsilateral stroke, transient ischemic attack (TIA), or amaurosis fugax. Primary outcomes included 90-day stroke, 30-day all-cause mortality, 30-day myocardial infarction (MI), 30-day wound infection, and 1-year restenosis. Multivariable logistic regression with firth correction was used to assess associations between procedure type and outcomes, adjusting for age, Elixhauser comorbidity index, and antiplatelet therapy. Of the 37,482 patients included in the analysis, 28,021 (74.76%) underwent CEA, 8,603 (22.95%) underwent TF-CAS, and 858 (2.29%) underwent TCAR. The 90-day stroke rates were 2.80% after TCAR, 3.31% after CEA, and 5.96% following TF-CAS (P < 0.0001). Thirty-day mortality was 1.05% after TCAR, 1.07% after CEA, and 3.16% after TF-CAS (P < 0.0001). Rates of MI did not significantly differ across procedure types. No 30-day wound infections occurred in the TCAR group (0/858), compared with 129/28,021 (0.46%) after CEA and 10/8,603 (0.12%) after TF-CAS (P < 0.0001). One-year restenosis rates were low across all modalities; 1.28% after TCAR, 0.85% after CEA, and 0.94% after TF-CAS with no significant adjusted differences between groups (P = 0.35). In this large symptomatic cohort, CEA and TCAR demonstrated similar perioperative safety, while TF-CAS was associated with higher 90-day stroke and 30-day mortality. One-year restenosis rates were low and comparable across all 3 approaches. These findings demonstrate that CEA and TCAR achieve comparably favorable outcomes with low rates of stroke, mortality, and perioperative complications, supporting both as safe and effective options for symptomatic patients. Conversely, TF-CAS was linked to significantly higher stroke risk, underscoring the need for selective use based on anatomy and patient-specific factors. Overall, the results reinforce a personalized, risk-adjusted approach to carotid revascularization.
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To assess the impact of smoking on mortality after interventions for symptomatic carotid stenosis. The Vascular Quality Initiative database was reviewed from 2003 to 2021 to identify patients undergoing interventions for symptomatic carotid artery stenosis with carotid endarterectomy (CEA), transfemoral carotid stenting (TFCAS), or transcarotid artery revascularization (TCAR). Patients were grouped as never, former (quit ≥1 month prior), or active smokers (smoking within 1 month). Propensity matching adjusted for demographics, comorbidities, preoperative medications, and additional risk factors. Primary outcomes were 30-day and 1-year mortality; secondary outcomes included 30-day transient ischemic attack, stroke, and other complications. Multivariate logistic regression identified independent predictors of mortality. We identified 27,693 patients who underwent carotid artery interventions for symptomatic stenosis (CEA = 18,867; TFCAS = 5,388; TCAR = 3,438). After propensity score matching, no significant differences persisted in preoperative demographics and risk factors. After CEA, active smokers exhibited similar rates of 30-day mortality (1.19% vs. 0.89%, P = 0.338), but significantly higher rates of 1-year mortality (5.43% vs. 3.78%, P = 0.005) compared to never smokers. Active smokers also had an increased rate of 1-year mortality compared to former smokers (5.73% vs. 4.57%, P = 0.012). Mortality did not differ by smoking status after TFCAS or TCAR. There was an increased rate of overall complications in former smokers over never smokers undergoing TCAR (8.27% vs. 5.19%, P = 0.041), otherwise no other significant differences were noted in any of the secondary outcomes. On multivariate logistic regression analysis, both active smoking (odds ratio 1.395, 95% confidence interval: 1.11-1.67) and former smoking (odds ratio 1.321, 95% confidence interval: 1.12-1.56) were predictive of 1-year mortality following CEA. Both active and former smoking are independently associated with increased 1-year mortality following CEA for symptomatic carotid artery stenosis, but not after TFCAS or TCAR. Active smoking was associated with higher 1-year mortality than former smoking, highlighting the importance of smoking cessation in patients with carotid disease.
In this meta-analysis, we compared the clinical outcomes and complications of using midline catheters (MCs) versus peripherally inserted central catheters (PICCs) among patients undergoing intravenous therapy (IVT). Our goal was to evaluate the relative risk of complications from MCs and PICCs. We performed an extensive review and meta-analysis of randomized controlled trials (RCTs) and observational investigations. Literature screening was carried out using the electronic databases Embase, Ovid, Cochrane Library, PubMed, and Google Scholar from the day of database establishment till February 26, 2025. Eligible studies included those that compared complication rates among patients using either PICCs or MCs for IVT. Our primary end point was major complications, including catheter-related vein thrombosis (CRVT) and catheter-related bloodstream infection (CRBSI). Among the secondary end points were phlebitis, pain, catheter dislodgement, catheter infiltration, and total complications. All data analyses were conducted using Stata (version 14). The initial screening produced 8,410 articles. Among them, only 11 studies, including 3 RCTs and 8 observational investigations, met our strict inclusion criteria. Based on our meta-analysis, MCs were associated with a significantly higher incidence of CRVT compared to PICCs (incidence rate ratio [IRR], 1.91; 95% confidence interval [CI], 1.13-3.23; P= 0.016; I2= 13.5%), but with a significantly lower incidence of CRBSI (IRR, 0.58; 95% CI, 0.37-0.91; P= 0.018; I2= 0%). Among secondary outcomes, MCs showed a markedly increased risk of infiltration (IRR, 8.41; 95% CI, 2.53-27.93; P= 0.001; I2= 0%) and total complications (IRR, 2.54; 95% CI, 1.29-5.02; P= 0.007; I2= 78.8%). No statistically significant differences were observed between MCs and PICCs in terms of phlebitis (IRR, 2.11; 95% CI, 0.78-5.68; P= 0.14; I2= 0%), dislodgement (IRR, 2.33; 95% CI, 0.58-9.33; P= 0.23; I2= 63.5%), or pain (IRR, 1.76; 95% CI, 0.49-6.38; P= 0.39; I2= 32.7%) CONCLUSION: Our findings suggest that MCs increased the risk of CRVT and reduced the risk of CRBSI relative to PICCs. These findings can help guide future analyses and direct comparative RCTs to further characterize the efficacy and risks of PICCs versus MCs.
Vascular Ehlers-Danlos syndrome (VEDS) vascular type is a rare autosomal dominant disorder caused by pathogenic variants in the COL3A1, resulting in abnormal type III collagen and a high risk of arterial dissection, rupture, and other life-threatening complications at a young age. Diagnosis requires a high index of clinical suspicion and confirmatory genetic testing, which also enables cascade screening and informs prognosis through genotype-phenotype correlations. Management is centered on multidisciplinary care, including vascular surgery, cardiology, and genetics, with baseline head-to-pelvis vascular imaging followed by annual to biannual surveillance. Medical therapy emphasizes strict blood pressure control, typically with beta-blockers and angiotensin receptor blockers, alongside lifestyle modification and avoidance of high-risk medications. Although historically associated with high morbidity, both open and endovascular interventions are increasingly feasible with careful patient selection and meticulous technique, though risks of iatrogenic injury and device-related complications remain substantial. Longitudinal care requires ongoing surveillance and psychosocial support, and pregnancy carries significant maternal risk necessitating specialized management. Advances in genetic characterization and operative strategies have improved outcomes; however, substantial morbidity persists, and future efforts are focused on integrating biologic and ultrastructural markers of tissue integrity to refine risk stratification and enable personalized decision making.