Objective The objective of this study was to apply an artificial intelligence (AI) pipeline for the automatic analysis of follow-up Computed Tomography Angiography (CTA) after Thoracic Endovascular Aortic Repair (TEVAR). Materials and methods A deep-learning network was developed to automatically measure the mean diameters of the proximal (D_LZP) and distal (D_LZD) landing zones, stent length (L), maximum aneurysm diameter (D_MAX), and aneurysm volume. Segmentation accuracy was assessed with the Dice Similarity Coefficient (DSC), and agreement with manual measurements using the Intraclass Correlation Coefficient (ICC). Manual measurements were obtained by an experienced vascular surgeon using dedicated software (EndoSize), based on standardized centerline landmarks. Results The study included 45 TEVAR patients; 3 Computed Tomography (CT) scans (6.6%) were excluded due to segmentation failure, leaving 84 CT scans for analysis (42 preoperative and 42 follow-up). At 1 month and 1 year, D_LZP was 32 ±4.7 mm (ICC 0.86) and 33.41 ±5.8 mm (ICC 0.78), D_LZD 30.15 ±4.54 mm (ICC 0.97) and 31.35 ±4.85 mm (ICC 0.83), while stent length remained stable (∼212 mm, ICC >0.98). D_MAX decreased from 57.4 ±14.8 mm to 55.5 ±13.2 mm (p<0.0001), and aneurysm volume from 68.6 ±86.1 mm3 to 54.3 ±103.7 mm3 (p<0.0001), with a strong correlation between changes in D_MAX and volume (r=0.77, p<0.0001). Conclusion The proposed AI-based pipeline enables reliable and reproducible quantification of stent-graft landing zones after TEVAR. The strong agreement with manual measurements and the detection of significant morphological changes over time support its potential for standardized, objective, and clinically relevant follow-up.
INTRODUCTION:Acute aortic dissection is rare but potentially catastrophic complication of pregnancy. The primary aim of this systematic review was to determine the mortality rates and most common treatment modalities in pregnant patients with type B aortic dissection. The secondary aim was to characterise the presentation of type B aortic dissection during pregnancy. METHODS:The protocol for this review was registered on PROSPERO (CRD420251173789). Electronic databases were searched to the 21st of October 2025. Studies reporting on pregnant or postpartum women diagnosed with an acute type B aortic dissection were included. A random-effects meta-analysis was performed to calculate gestational age at diagnosis, treatment modality and mortality rates. RESULTS:331 records were screened in the initial search. A total of eight studies satisfied the inclusion criteria, evaluating 409 patients. Most patients were diagnosed with a type B aortic dissection during the third trimester (40.3%, 95% CI: 17.2 - 60.9%, I2 = 53.7%). An endovascular approach was followed to treat 39.7% of patients (95% CI: 6.4 - 72.6%, I2 = 80.4%). Average maternal mortality was 8.2% (95% CI: 5.7 - 11.0%) and foetal mortality was 37.8% (95% CI: 20.4 - 56.7%) (I2 = 35.5%). Evidence was low in quality. CONCLUSIONS:Type B aortic dissection in pregnancy is associated with high rates of maternal and foetal mortality. A multidisciplinary approach is required to deliver tailored treatment considering patient presentation, gestational age, and patient choices. Large registry studies are required to better characterise treatment outcomes of type B aortic dissection in pregnancy and to inform future guidelines.
OBJECTIVE:Cerebrospinal fluid drainage (CSFD) is widely used for neuroprotection during thoracic and complex endovascular aortic repair (TEVAR/cEVAR), yet its safety profile remains incompletely defined. This study evaluated the incidence, severity, and risk factors of CSFD-related complications in clinical practice. METHODS:This retrospective single-center study included consecutive patients undergoing TEVAR or complex EVAR with perioperative CSFD between January 2010 and October 2023. The indication for CSFD was based on institutional risk assessment, including extent of aortic coverage, prior aortic repair, and clinical presentation. Primary outcomes were CSFD-associated complications (major, minor, headache). Secondary outcomes included spinal cord ischemia and 30-day mortality. Multivariable logistic regression identified predictors of major complications. RESULTS:A total of 251 patients were included (154 TEVAR, 97 cEVAR); CSFD was applied prophylactically in 239 patients only, therapeutically in 9 patients only, and both prophylactically and therapeutically in 3 patients. Median age was 69 years, and 53.8% had prior aortic surgery. Major CSFD-related complications occurred in 4.4% (11/251), all hemorrhagic, with mortality in 2 patients. Minor complications occurred in 16.7%, and headache in 7.2%. Spinal cord ischemia developed in 4.5% despite prophylactic drainage. In exploratory multivariable analysis, lower BMI was associated with major CSFD-associated complications (OR 0.82, 95% CI 0.69-0.97; p=0.022), while therapeutic CSFD was significant only in univariable analysis. Thirty-day mortality was 8.0%. CONCLUSIONS:CSFD-associated complications were common, with hemorrhagic events accounting for all major complications. These findings emphasize the need for careful patient selection, standardized CSFD management, and close neurological monitoring when CSFD is used during complex endovascular aortic repair.
INTRODUCTION:Frailty is an important predictor of adverse outcomes in vascular surgery, but its prognostic value after lower extremity revascularization for peripheral artery disease (PAD) remains uncertain. This systematic review and meta-analysis evaluated the association between frailty and outcomes after PAD revascularization. METHODS:Methods: PubMed, Embase, and Cochrane Library were searched from inception to May 12, 2026. Studies assessing frailty in patients undergoing peripheral artery surgery (endovascular, open, or hybrid lower extremity revascularization) for PAD were included. Random-effects meta-analyses were performed using odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs). Prespecified subgroup analyses were conducted according to frailty assessment approach (Frailty Index-type vs. Non-Frailty Index tools) and procedural strategy. RESULTS:Nineteen studies comprising 1,638,543 patients were included. Because some studies enrolled mixed PAD populations, only patients undergoing lower extremity revascularization contributed to the pooled analyses. Frailty was associated with increased early mortality (OR 4.74; 95% CI 1.75-12.87), late mortality (HR 1.59; 95% CI 1.07-2.36), and major adverse cardiovascular events (OR 2.56; 95% CI 1.15-5.71), but not with major amputation, major adverse limb events, or postoperative complications. Subgroup analyses demonstrated no significant differences according to frailty assessment approach or procedural strategy. CONCLUSION:Frailty is associated with substantially worse outcomes following lower extremity revascularization for PAD, particularly increased early and late mortality and major adverse cardiovascular events, consistently across different frailty assessment approaches. These findings support routine incorporation of frailty assessment into preoperative evaluation to improve risk stratification, shared decision-making, and perioperative optimization.
BACKGROUND:Splenic artery aneurysm (SAA) management is influenced by clinical presentation, aneurysm type, anatomy, and size. Evidence describing treated urgent and emergency presentations remains limited, particularly in small tertiary-center series. METHODS:We retrospectively reviewed 20 consecutive adults with SAA who underwent intervention at a tertiary center between January 2023 and December 2025. Patients managed by surveillance were not included. Procedures were classified as elective, urgent (symptomatic but hemodynamically stable), or emergency (rupture, active bleeding, or hemodynamic instability). Treatment modality, technical and clinical success, 30-day complications, reintervention, and follow-up were summarized descriptively. Because only five patients received a non-endovascular treatment, multivariable modeling of treatment selection was not considered statistically reliable. RESULTS:The cohort included 18/20 women (90%) and had a median age of 69.5 years (IQR 62.8-74.2; range 34-79). Fourteen/20 aneurysms (70%) were <30 mm, including 13 in the 20-30 mm range and one <20 mm. Seven/20 procedures (35%) were elective, 9/20 (45%) urgent, and 4/20 (20%) emergency. All four emergency cases were treated by splenectomy; 8/9 urgent cases underwent endovascular treatment and one received fibrin sealant/Tisseel, whereas all seven elective cases were treated endovascularly. Technical success was 20/20 (100%) and clinical success 18/20 (90%). Early complications occurred in 5/20 patients (25%): 2/7 elective, 3/9 urgent, and 0/4 emergency. Two patients required reintervention. Follow-up was heterogeneous (mean 21.8 +/- 9.6 months; range 2-32); 16/20 patients had at least 12 months of follow-up. CONCLUSION:In this intervention-only cohort, urgent and emergency presentations accounted for 13/20 procedures (65%) and were managed according to presentation and anatomy, with endovascular therapy predominating in urgent stable patients and splenectomy used in all ruptured emergency cases. The findings describe institutional treatment patterns rather than the appropriateness of intervention thresholds, and longer, standardized follow-up is needed before drawing conclusions about durability.
OBJECTIVE:Endovascular aortic aneurysm repair (EVAR) traditionally relies on iodinated contrast media (ICM), which can be problematic in patients with renal insufficiency or iodine allergy. Carbon dioxide (CO2) has emerged as a valuable alternative to mitigate these risks. This systematic review with meta-analysis aims to evaluate the safety and effectiveness of CO2 angiography in EVAR. METHODS:A literature search was conducted using PubMed, Cochrane Library, Scopus and ISI databases to identify studies published up to May 2026 that assessed CO2 angiography use in EVAR. The primary endpoint of safety was acute kidney injury (AKI) occurrence. Effectiveness was evaluated based on technical success rates. The incidence of acute kidney injury was pooled using a random-effects meta-analysis, with sources of heterogeneity explored via meta-regression. RESULTS:Eight studies involving 1699 patients were included, with 581 undergoing EVAR with CO2 angiography and 1118 receiving ICM. There was no statistical difference regarding AKI between the EVAR cohort assessed with CO2 angiography and the ICM angiography cohort, with an overall AKI risk ratio of 0.65 (95% CI: 0.27-1.56) (I2=0%). CO2 angiography is associated with longer procedural times and higher radiation exposure in some studies. The intraoperative endoleak detection rate was similar or slightly higher in the CO2 group. No significant differences in mortality rates were observed between the groups. CONCLUSIONS:CO2 angiography shows comparable safety and effectiveness to ICM in EVAR procedures. However, risk-reduction of AKI was not statistically different between ICM and CO2.
BACKGROUND:Pelvic venous insufficiency (PVI) may reflect combined iliac outflow obstruction and pelvic venous reflux. This study aimed to compared iliac vein stenting alone versus stenting plus pelvic vein embolization (PVE) in women with PVI secondary to nonthrombotic iliac vein lesions. METHODS:In this prospective randomized two-arm trial, 20 women (18-50 years) with Greiner type 2 pelvic congestion and duplex-confirmed nonthrombotic iliac vein lesions (PSV ratio >2.5) were randomized 1:1 to stent-only (n=10) or stent + embolization (n=10). Embolization targeted pelvic escape pathways using coils and 3% polidocanol. The primary outcome was change in Pelvic Venous Clinical Severity Score (PVCSS). SVP classification and follow-up hemodynamics were recorded. RESULTS:Procedure duration was longer with stent + embolization (2.0 ± 0.41 vs 1.3 ± 0.42 hours; P=0.001). Technical and procedural success were 100% in both groups, with no major adverse events. Sustained clinical improvement was higher with combined therapy (100% vs 50%; P=0.01). SVP normalization to symptom class S0 and varices class V0 occurred more often with combined therapy (both 100% vs 40%; P=0.003). Postoperative PVCSS was lower with combined therapy (4.1 ± 0.74 vs 6.6 ± 2.88; P=0.016), with greater absolute improvement (10.90 ± 1.60 vs 7.10 ± 2.64; P=0.001). Persistent reflux was more frequent after stenting alone (70% vs 0%; P=0.001). CONCLUSIONS:In women with PVI due to nonthrombotic iliac lesions, adding PVE to iliac stenting improved short-term symptom and hemodynamic outcomes, at the cost of longer procedure time.
OBJECTIVES:Despite the recent improvement in female recruitment to randomized controlled medical research trials (RCTs), males continue to predominate in cardiovascular trials due to multiple structural barriers. Scarce data are available on female representation in peripheral artery disease (PAD) trials. This study aimed to analyze the reporting of gender and quantify female enrollment rates in PAD RCTs, the impact of trial funding sources, and geographic factors over two decades. METHODS:A systematic literature search across multiple databases was performed to retrieve PAD RCTs conducted in the United States or Canada from 2001 through June 2021. Extracted data included the trial year, country, geographic region, number of recruitment sites, sample size, sex reporting/composition, follow-up duration, and funding source. A pooled estimate of the female percentages across studies was performed using the random effects meta-analysis with inverse variance pooling. RESULTS:A total of 103 RCTs were included. 98 (95.1%) trials reported their participants' sex. 40 (40.8%) trials were published in 2001-2010, while the rest, 58 (59.2%), were published over the second decade. 75,776 participants were enrolled, 48,120 females, corresponding to an aggregate female enrollment proportion of 63.5%. The random-effects pooled proportion of female participants was 0.30 [95% CI, 0.21-0.40], with substantial heterogeneity. There were no significant differences in overall female proportions across different trial types. Studies that were sponsored by non-NIH, federal, or state governmental agencies demonstrated disproportionately lower rates of female enrollment [8% vs. 35% in NIH, 0.30 industry-sponsored RCTs; P<.01]. CONCLUSIONS:The enrollment of women was disproportionately low in this systematic analysis of PAD clinical trials, regardless of trial purpose, funding source, or geographic site, when compared to men. The analyzed trials occurred for two decades following non-enforceable federal mandates to improve female and minority trial enrollment. As a result, the current purported evidence-based treatment of PAD interventions in women is based upon data disproportionately extrapolated from observations of PAD in men. These findings suggest that the evidence base supporting PAD interventions may have limited generalizability to women as they remain underrepresented among PAD trial participants. A coordinated effort on behalf of investigators, professional societies, industry, and government sponsors is necessary to overcome this research enrollment finding, which calls into question the fidelity of contemporary PAD treatment strategies.
OBJECTIVE:Carotid endarterectomy (CEA) is the established surgical intervention for stroke risk reduction in patients with significant carotid artery stenosis. Partial eversion carotid endarterectomy (PECE) is a modified operative technique using an oblique anterior wall arteriotomy at the carotid bifurcation, preserving the posterior arterial wall and allowing efficient plaque removal without patch closure. This study presents the largest single-center series of PECE, extending our original 2017 report with a further eight years of surgical practice. The 17-year period refers to the span of consecutive practice sampled rather than the duration of follow-up of individual patients; all endpoints are perioperative or early postoperative. The objective was to determine whether the favorable outcomes observed during the developmental phase of the technique were maintained across a subsequent era of mature practice. METHODS:Retrospective analysis of a prospectively maintained clinical database of all consecutive patients undergoing PECE at a single regional vascular center in the United Kingdom between October 2006 and February 2023. All procedures were performed by a single consultant vascular surgeon, for whom PECE was the default technique applied without anatomical preselection to all patients judged to benefit from endarterectomy. Two chronological cohorts were defined: original (2006-2015, n = 352) and extended (2016-2023, n = 173). Demographic data, operative details, 30-day neurologic outcomes, cranial nerve injuries, and duplex-confirmed restenosis rates were recorded. Between-cohort comparisons used the Mann-Whitney U test for continuous variables and Fisher exact test for categorical outcomes; P < .05 was considered significant. Thirty-day outcomes were additionally stratified by indication, and exact 95% confidence intervals (CIs) were calculated for all event rates. RESULTS:A total of 525 patients underwent PECE over 17 years. Median age was 70 years (range, 44-96 years); 60.6% were male. Local anesthesia was used in 99.2% of cases. Median ICA clamping time was 14 minutes (interquartile range [IQR], 11.5-17 minutes) and median operative time was 41 minutes (IQR, 36-43 minutes in the original cohort), remaining stable across both cohorts (P = .81 and P = .72, respectively). The combined 30-day stroke rate was 1.3% (n = 7; 95% CI, 0.54-2.73) and mortality 0.4% (n = 2; 95% CI, 0.05-1.37). Both deaths occurred in patients who had sustained a perioperative stroke; expressed as the number of patients experiencing either outcome, the combined 30-day stroke/death rate was 1.3% (n = 7; 95% CI, 0.54-2.73). Stratified by indication, the 30-day stroke/death rate was 1.41% (6/425; 95% CI, 0.52-3.05) in symptomatic patients, 1.64% (1/61; 95% CI, 0.04-8.80) in asymptomatic patients, and 0% (0/39; 95% CI, 0.00-9.03) in patients undergoing endarterectomy before cardiac surgery. Perioperative transient ischemic attack (TIA) occurred in 1.0% (n = 5), all resolving before discharge. No significant cranial nerve injuries were recorded. No restenosis of 50% or greater was identified during longitudinal duplex surveillance to 24 months in the 185 patients of the original cohort subject to that protocol; among the remaining patients of either cohort, a single duplex scan at 4 to 6 weeks demonstrated no early technical abnormality, a study that cannot exclude subsequent restenosis. Outcomes remained stable across both chronological periods (P > .05 for all endpoints). CONCLUSIONS:PECE is a safe, reproducible, and technically efficient technique for CEA with 30-day outcomes consistently meeting internationally accepted thresholds across 17 years and 525 consecutive procedures. The principal contribution of this updated series is the demonstration that favorable outcomes were maintained over a further eight years of clinical practice, with the addition of 173 cases increasing the total cohort by almost 50%. Extended per-patient surveillance was not undertaken, and the durability of the technique beyond the perioperative period therefore remains to be established. PECE warrants evaluation in prospective multicenter and randomized studies.
OBJECTIVE:Late open conversion (LOC) after endovascular aneurysm repair (EVAR) remains challenging, and an optimal surgical strategy has not yet been established. We evaluated the clinical outcomes and mid- to long-term durability of surgical reconstruction using a standardized strategy for partial explantation in a regional, real-world setting. METHODS:We retrospectively reviewed data from 29 consecutive patients who underwent LOC for noninfectious EVAR failure between July 2013 and December 2025. Clinical outcomes were evaluated using follow-up data available through April 2026. The primary surgical strategy consisted of elective conversion, infrarenal clamping, and partial endograft explantation with "neo-neck" creation whenever feasible. RESULTS:Elective LOC was performed for progressive aneurysm sac enlargement in 27 patients (93.1%); type II endoleak was the predominant preoperative finding (n = 16; 55.2%). The remaining two patients underwent urgent LOC for bilateral endograft limb thrombosis with lower-extremity ischemia (n = 1) or symptomatic sac enlargement with suspected impending rupture (n = 1). Partial explantation was performed in 28 patients (96.6%). The 30-day mortality rate was 6.9% (n = 2). During the median follow-up period of 44 (range, 0-152) months, no late aortic-related events attributable to the retained endograft components were observed. The estimated 5-year overall survival and freedom from aortic-related events were 88.9% and 93.1%, respectively. CONCLUSIONS:The standardized partial explantation strategy was feasible in selected patients undergoing LOC for noninfectious EVAR failure and was associated with acceptable perioperative outcomes and mid- to long-term reconstructive durability even in a low-volume, real-world setting.
OBJECTIVES:Medical therapy alone is widely considered effective for symptomatic low-grade (≤50%) carotid artery stenosis (SxLGS). While mildly stenotic plaques generally carry a lower stroke risk than moderately-to-severely stenotic plaques, advanced imaging has identified high-risk features, such as intraplaque hemorrhage and ulceration, which are associated with an increased stroke risk and necessitate intervention if symptomatic. The evidence regarding symptomatic low-grade carotid stenosis management remains unclear. We aim to investigate patients with (SxLGS) in the VQI database by evaluating postoperative outcomes following carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS). METHODS:This is a retrospective analysis of CEA, TCAR, and TFCAS done for SxLGS patients in the VQI database from 2016 to 2024. Atherosclerotic lesions were only included. The degree of stenosis was classified using duplex ultrasonography as follows: low-grade (LGS) (<50%), moderate-grade (MGS) (50-69%), and severe-grade (SGS) (70-99%). The primary outcomes were in-hospital and one-year stroke and death, comparing the three procedures in each degree of stenosis cohort. Moreover, we conducted a sub-analysis based on procedure type. Kaplan-Meier estimates, along with logistic and Cox regression models, were utilized for the analysis. RESULTS:A total of 2,700 patients with SxLGS (66% CEA, 10% TFCAS, 24% TCAR) were identified. Multivariate analysis revealed that in patients with LGS, TCAR was linked to a lower risk of in-hospital stroke compared to CEA (aOR= 0.44[95% CI:0.21- 0.93];P=0.03) and TFCAS (aOR= 0.28[95% CI:0.11- 0.69];P=0.006). However, there was no significant difference among the three procedures in those with MGS. In SGS, TFCAS was linked to a higher risk of in-hospital stroke/death compared to CEA (aOR= 1.4[95%CI: 1.03-1.85];P=0.03), while TCAR and CEA were comparable (aOR= 1.57[95%CI: 0.76- 3.27];P=0.2). After comparing the three grades of carotid stenosis, we found that LGS was associated with a higher odds of in-hospital stroke/death compared to SGS following CEA (aOR=1.52[95%CI:1.09-2.08];P=0.014) and TFCAS (aOR= 2.13[95% CI: 1.14-4];P=0.018) but not TCAR (aOR= 0.64 [95% CI:0.31-1.28];P=0.208). At one year, TFCAS was associated with the lowest stroke-free survival among patients with LGS. CONCLUSION:In this multi-institutional study, we reviewed outcomes of carotid revascularization in SxLGS patients. TCAR emerged as a superior minimally invasive option, showing a lower rate of stroke/death compared to both CEA and TFCAS. Future studies are required to confirm those findings and refine SxLGS patient selection by including a medical therapy-only arm.
OBJECTIVE:Patients who undergo major lower extremity amputation (MLA) have impaired post-operative mobility. Inpatient rehabilitation (IRF) has demonstrated benefits for patient fitness and freedom from readmission compared to home discharge or skilled nursing facility (SNF) in other disease processes. However, the impact of discharge disposition on one-year mobility and long-term mortality are less well known in an MLA patient cohort. METHODS:Patients with MLA, including below-the-knee (BKA) and above-the-knee (AKA) amputation, within the Vascular Quality Initiative database from 1/2011-1/2025 were included. After excluding those without follow-up data, patients were separated based on discharge disposition: IRF, SNF, or home. Primary outcomes include one-year functional mobility, a composite metric of prosthesis use, ambulation, and physical therapy, and long-term mortality. One-year functional mobility was interrogated using propensity score matched comparisons of in IRF vs. home and IRF vs. SNF. Five-year mortality rates were tested using Kaplan-Meier survival analysis. RESULTS:A total of 12,046 MLA patients were identified: 5,784 (48.0%) were discharged to IRF, 3,200 (26.6%) to SNF, and 3,062 (25.4%) home. Of the matched groups, patients in the IRF group were more likely to use a prosthesis (p<0.001) and had better composite functional mobility (p=0.012) than those in the home or SNF groups. Compared with patients discharged to home, those discharged to IRF were associated with a higher likelihood of one-year prosthesis use (odds ratio [OR]: 1.4, 95% confidence interval [CI]: 1.2-1.6), whereas those discharged to SNF were associated with a lower likelihood of prosthesis use by one year (OR: 0.8, 95% CI: 0.5-0.7). Other factors associated with increased prosthesis use included commercial insurance coverage (OR: 1.3, 95% CI: 1.1-1.5), use of rigid removable dressing (OR: 1.5, 95% CI: 1.2-1.9), and independent ambulation at discharge (OR: 1.4, 95% CI: 1.3-1.7). Also, fixed plaster cast compared with gauge only (OR: 0.5, 95% CI: 0.3-0.8), indication of tissue loss (OR: 0.7, 95% CI: 0.5-0.9), and joint contracture (OR: 0.3, 95% CI: 0.2-0.6) were negatively associated with the ability to walk independently. All-cause mortality was the lowest in patients who were discharged to IRF through five years after index procedure (p<0.001). CONCLUSIONS:Patients who are discharged to IR after MLA had higher functional mobility at one year, reduced all-cause mortality at five years and were more likely to utilize a prosthesis post-amputation. Identified factors that support prosthesis use including inpatient ambulation status may be optimal targets for quality improvement in this patient population.
INTRODUCTION:Trauma induced vascular injuries constitute a significant cause of morbidity and mortality in low- and middle-income countries (LMICs) where access to prompt and specialized care is often limited. Understanding the patterns, management strategies, and outcomes of vascular injuries in these settings is needed to improve care delivery in this setting. This systematic review aims to synthesize current evidence on vascular trauma in LMICs, highlighting injury patterns, treatment approaches, and patient outcomes. METHODS:A systematic search was conducted using databases including PubMed, Scopus, and Embase for studies published between 2000 and 2025. Studies were included if they reported vascular injuries in LMICs and provided data on clinical presentation, management, or outcomes. Data was extracted on patient demographics, injury mechanisms, management strategies, and outcomes following trauma and pooled for meta-analysis using the Mantel-Haenszel method. RESULTS:The literature search yielded 4,189 articles, of which 22 met inclusion criteria, reporting on 2,918 patients with vascular injuries. Injury mechanisms were predominantly penetrating (approximately 50-60%), most commonly due to gunshot and stab wounds, while blunt trauma (about 30-40%) was primarily related to road traffic accidents and falls. The mean age ranged from 26 to 44.8 years, with most patients in their third and fourth decades. Open surgical repair was the dominant approach, while endovascular techniques were increasingly applied in recent years. Total mortality ranged 0-15%, usually linked to polytrauma or thoracic vessel injury. Limb loss varied widely (2.8-59%), highest with delayed presentation (>6-8 hours) and popliteal artery injury. Early revascularization following injury yielded the best outcomes, with limb salvage rates exceeding 90% in several series, though outcomes were poorer in LMICs. Complications were frequent, most common being wound infections (≤23%). CONCLUSION:Despite efforts at surgical and endovascular management of vascular injuries in LMICs, outcomes are often hindered by systemic limitations such as late presentation and limited resources. These results suggest that access to care in limited-resource settings is a significant factor to optimizing vascular trauma outcomes. Future research will focus on studying care access, studying trauma protocols in local hospitals, surveying regional trauma registries, and encouraging cost-effective models of vascular trauma care.
BACKGROUND:Unplanned hospital readmission following vascular surgery remains common and is often related to wound complications, poor communication, and inadequate post-discharge support. We developed a patient-centered smartphone application, the Vascular Surgery Discharge Application (VASDA), and conducted a qualitative and quantitative feasibility study to evaluate patient experiences and perceptions after a variety open lower extremity bypass procedures (LEB). METHODS:A single-center, mixed-methods feasibility study enrolled patients undergoing LEB at discharge and patients were instructed to use VASDA during the 30-day post-discharge period. The application incorporated validated surveys assessing mobility (AM-PAC), pain (PEG scale), and mood (PHQ-2), as well as a wound assessment tool, a real-time messaging platform, and wound photography. Usability was quantified using the System Usability Scale (SUS) and Mobile App Rating Scale (MARS). Semi-structured interviews were conducted to assess patient experience. Interviews were transcribed and analyzed for thematic content. RESULTS:Forty-five patients were enrolled following the study protocol. 82.2% of participants used the application daily for at least 25 of 30 days. Via the smartphone application, patients submitted surveys, wound photographs, and alerts prompted earlier clinical evaluation in 22.7% of participants. The 30-day unplanned readmission rate was 11.1% for the study cohort. AM-PAC returned to baseline by postoperative day 30, while PEG and PHQ-2 improved beyond preoperative baseline. Usability was high (SUS >80; MARS domains ≥4.0). Qualitative analysis identified themes of increased confidence, enhanced communication, early problem identification, increased emotional support, and created a perceived safety net for patients. CONCLUSIONS:The VASDA smartphone application demonstrated high feasibility, acceptability, and adherence rates among patients recovering from open vascular surgery. The application was demonstrated to be effective in identification of post-discharge complications, may assist to lower readmission rates, and aided in early identification of postoperative complications. The VASDA smartphone application demonstrated improved patient communication, confidence, and perceived recovery after discharge.
INTRODUCTION:The aim of this study is to present the 30-day and mid-term outcomes of the off the shelf Covered Endovascular Reconstruction of Iliac Bifurcation (CERIB) technique in patients managed with endovascular repair for aortoiliac aneurysms. METHODS:A single-centre retrospective analysis was conducted including patients with aorto-iliac aneurysms that received the CERIB technique from December 2022 to December 2025. Proximal repair of the aorta was performed either with standard EVAR (endovascular aneurysm repair) or complex EVAR. Mortality, patency, presence of endoleak and reinterventions were analysed at 30-days and during mid-term period. RESULTS:Fifty-nine patients (mean age: 71.6±6, 100% males) were included, receiving 78 CERIB procedures (19 bilaterally). Nineteen patients had previous endovascular aortic repair and half of them (49%; 29/59) received primarily EVAR. The technical success was 100%. Two deaths (3,3%) were recorded in two F/BEVAR patients during 30-day post-op period. The mean follow up was 12±7 months with one cancer related death (1,7%; 1/57). Patency rate was estimated at 98% [standard error; (SE) 2%] at 12 months and remained the same with no further event during follow-up. The freedom from gutter endoleak Ib rate was 96.8% (SE 2.2%) at 6 months and remained the same with no further event. The freedom from re-intervention rate was 93.8% (SE 3%) at 6 months and remained the same with no further event. CONCLUSION:The CERIB technique represents an endovascular procedure for managing complex aorto-iliac pathology, with excellent technical success, favourable patency rates, low early complication and reintervention rates, and durable mid-term outcomes.
BACKGROUND:Femoropopliteal revascularization remains challenged by high restenosis rates, and while paclitaxel-coated balloons (PCB) have demonstrated efficacy, emerging long-term mortality concerns have shifted interest toward sirolimus-coated balloons (SCB) as a mechanistically distinct, cytostatic alternative. This systematic review and meta-analysis aims to comprehensively evaluate their comparative safety and efficacy. METHODS:A systematic search of PubMed, Scopus, Embase, Cochrane Library, ClinicalTrials.gov, and WHO-ICTRP was conducted from inception to June 2026, identifying randomized controlled trials directly comparing SCB vs PCB. Poolable outcomes were meta-analyzed using a random-effects model, with results expressed as risk ratios and 95% confidence intervals; remaining outcomes were narratively synthesized. Methodological quality was assessed using the Cochrane RoB 2 tool, and certainty of evidence was evaluated using the GRADE framework. RESULTS:3 RCTs enrolling 558 participants and two registered trial protocols were included. Narrative synthesis demonstrated similar primary patency (75.1% vs. 76.8%), binary restenosis (18.2% vs. 18.1%), Rutherford classification improvement (88.5% vs. 91.5%), target lesion revascularization (7.3% vs. 6.4%), target vessel revascularization (9.5% vs. 7.3%), hemodynamic improvement (70.6% vs. 70.9%), and major amputation (0.5% vs. 0.5%) between both groups. All-cause mortality (3.9% vs. 2.1%) and major adverse events (41.2% vs. 36.5%) were numerically higher with SCBs in the only trial reporting these endpoints. Meta-analysis demonstrated no significant difference in primary patency (RR = 0.98, 95% CI: 0.88-1.08; p = 0.615; I2 = 0%) or Rutherford classification improvement (RR = 0.98, 95% CI: 0.92-1.05; p = 0.633; I2 = 0%) between SCBs and PCBs. CONCLUSION:Sirolimus-coated balloons demonstrate efficacy and safety comparable to paclitaxel-coated balloons for femoropopliteal artery disease, with no significant differences in primary patency or other clinical outcomes. While preliminary mechanistic findings favor sirolimus, larger studies with longer follow-up are needed to determine whether these biological advantages translate into sustained clinical benefit.
OBJECTIVE:Hypermobile Ehlers-Danlos Syndrome (hEDS) is a rare disorder resulting in joint hypermobility. Thoracic Outlet Syndrome (TOS) is an uncommon compressive disorder affecting neurovascular structures of the upper limb. The coincidence of these syndromes may affect the prognosis of interventions for TOS. The aim of this study was to characterize the presentation, evaluation, and surgical outcomes in patients with hEDS and TOS. METHODS:A retrospective review of clinical encounters from January 2024 to January 2026 was conducted, identifying patients with hEDS and TOS. Medical records were reviewed for demographics, comorbid conditions, medications, allergies, clinical presentation testing, and surgical outcomes. Standardized outcome measures (Quick DASH, Derkash Score) were employed. RESULTS:Approximately 1400 encounters occurred for TOS during the study period. Of these, 28 subjects with hEDS were identified: 2 with venous TOS (VTOS) and 26 with neurogenic TOS (NTOS). The average age at presentation was 35.5 years (range 12-64). Patients were predominantly women, (n=22, 78.6%). TOS etiology included spontaneous onset in 12 (42.8%), repetitive motion injury in 8 (28.6%), accidents in 5 (17.9%), and sports-related in 3 (10.7%). The average number of medical problems listed was 15.8 (range 0-36), medical diagnoses 11.5 (range 0-43), medications 12.4 (range 0-41), allergies 3.5 (range 0-25), and prior surgeries 6.8 (range 0-35). Patients had undergone an average of 4.6 (range 1-18) upper extremity orthopedic procedures. Sixteen patients underwent TOS surgical decompression: 2 VTOS and 14 NTOS. A total of 19 operations were performed. Patients with VTOS underwent one operation each. Of 14 NTOS patients, all underwent first rib resection (FRR); 2 required bilateral FRR, 3 required scalene resections, and 12 underwent pectoralis minor tenotomies. Outcomes were rated as resolved (18.8%), improved (62.5%), unchanged (6.3%), worsened (6.3%), or complicated by venous restenosis (6.3%). The combined endpoint of resolved/improved accounted for 81.3% of surgical cases. Quick DASH scores improved from 69.3 to 44.3 (p=0.019) and Derkash scores improved from 2.0 to 3.06 (p<0.001). CONCLUSION:Patients with hEDS and TOS have a broad spectrum of presentation, this is reflected in the high incidence of significant comorbidities which may affect presentation of upper extremity symptoms, and adversely affect the outcomes of surgery for TOS. Despite the impact of comorbidities, surgical intervention for TOS showed statistically significant improvement in outcomes based on standardized metrics.
OBJECTIVES:Lower extremity angiography interpretation and treatment planning involve complex decision-making. Traditional experiential training is limited by duty hours and concerns about radiation exposure. Expert interpretation processes can be automated bypassing consciousness with heuristics often unintentionally omitted. This study used cognitive task analysis (CTA) to identify and structure the unvoiced expert heuristics used in angiography interpretation and procedure planning. METHODS:A CTA framework was utilized. An environmental analysis was conducted, followed by knowledge elicitation via semi-structured, "think-aloud" interviews with attending vascular surgeons. Experts used angiography videos for stimulated recall to narrate real-time decision-making. Data was transcribed, double-coded, and analyzed using inductive qualitative content analysis, filtering into content units. Thematic analysis was performed within units. RESULTS:Eight interviews reached thematic saturation. The universally emphasized theme was that treatment aggressiveness is dictated by clinical indications, patient comorbidities, and pre-operative imaging, not strictly intraoperative lesion characteristics. Experts reserved conservative algorithms for claudication to preserve bypass targets, while treating chronic limb-threatening ischemia aggressively to achieve inline flow to the foot or specific angiosome. Inductive analysis extracted covert heuristics into a structured angiographic interpretation checklist (image orientation, anatomical survey, dynamic flow assessment). CONCLUSION:Treatment decisions based on angiography, disease severity, and patient comorbidities are complex, relying on expert heuristics often unarticulated to novices. After elucidating the covert cognitive frameworks via CTA, we developed the framework of a curriculum and review exercise to facilitate deliberate practice. The ultimate goal is to enable trainees to safely practice pattern recognition and justify decisions in a low-risk environment, mitigating modern operating room pressures.
OBJECTIVE:Patients with diabetes represent one of the largest subgroups undergoing endovascular revascularization for peripheral artery disease (PAD) and remain at high risk for thrombosis and restenosis. Postprocedural antithrombotic management varies in practice and does not routinely measure platelet response. We evaluated whether thromboelastography with platelet mapping (TEG-PM)-guided thromboprophylaxis was associated with reduced target-vessel thrombosis or clinically significant stenosis. METHODS:We performed a prospective, single-center, sequential cohort study of patients (≥60 years) with diabetes undergoing infrainguinal endovascular revascularization for PAD. In the standard-of-care (SOC) cohort, postoperative thromboprophylaxis was determined by the treating surgeon. In the TEG-PM-guided cohort, serial postoperative TEG-PM measurements informed antiplatelet adjustment to meet prespecified platelet inhibition thresholds (30-86%). The primary outcome was target-vessel thrombosis or clinically significant stenosis at 12 months. RESULTS:Of 164 patients with diabetes, 62 received TEG-PM-guided thromboprophylaxis and 102 received SOC. At 12 months, target-vessel thrombosis or clinically significant stenosis was lower with TEG-PM-guided therapy than SOC (9.7% vs 25.5%; p=0.013). TEG-PM-guided therapy was associated with lower unadjusted hazard of this outcome (HR 0.34; 95% CI 0.14-0.84; p=0.019), although this was not significant after adjustment (HR 0.48; 95% CI 0.19-1.24; p=0.131). Major amputation, all-cause mortality, amputation-free survival, and clinically relevant non-major bleeding did not differ significantly at 12 months. No major bleeding occurred. CONCLUSIONS:TEG-PM-guided thromboprophylaxis was associated with a lower 12-month rate of target-vessel thrombosis or clinically significant stenosis without major bleeding, although this association was attenuated after multivariable adjustment. Future studies should determine whether TEG-PM-guided antiplatelet therapy adjustment improves target-vessel outcomes in patients with diabetes.
BACKGROUND:Endovascular aneurysm repair (EVAR) is often associated with lower short-term mortality than open surgical repair (OSR) in observational studies of ruptured abdominal aortic aneurysm (rAAA), but this apparent benefit may reflect hemodynamic stability, anatomical suitability, and emergency treatment allocation. We aimed to reappraise EVAR-OSR comparisons by examining whether mortality estimates are influenced by treatment-selection bias. METHODS:PubMed, the Cochrane Library, CNKI, and Wanfang Data were searched from inception to May 2026. Comparative rAAA studies reporting extractable mortality data were included. The primary outcome was 30-day mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Risk of bias was assessed with ROBINS-I, and an exploratory subgroup analysis examined operational treatment-selection categories. The protocol was registered in PROSPERO (CRD420261395354). RESULTS:Nine studies were included qualitatively, and six studies involving 1,035 patients were included in the primary meta-analysis of 30-day mortality. EVAR was associated with significantly lower 30-day mortality than OSR (OR 0.59, 95% CI 0.44-0.80; P < 0.001; I2 = 0%). A sensitivity analysis additionally including two studies reporting in-hospital or other non-30-day mortality endpoints showed a consistent association (OR 0.63, 95% CI 0.51-0.77; P < 0.001; I2 = 40%). In an exploratory subgroup analysis, five studies were classified as EVAR-favored and one as unclear; no study met the relatively balanced criteria. The subgroup comparison was underpowered and was interpreted descriptively. CONCLUSIONS:EVAR was associated with lower 30-day mortality than OSR in observational studies of ruptured abdominal aortic aneurysm, but the certainty of evidence is very low because treatment allocation was strongly conditioned by baseline physiology and anatomy. The observed association should be interpreted as selection-sensitive, and future comparative studies require detailed physiological and anatomical adjustment.
