Objectives Remote teaching is nowadays incorporated into vascular surgery education, with its adoption accelerated by COVID-19 pandemic. However, the technical and human factors that determine user satisfaction with this remote learning modality remain poorly characterised. This study aimed to identify the determinants of user satisfaction during remote broadcasts of endovascular procedures. Methods This was a prospective observational multicentre study. Fourteen consecutive endovascular procedures have been broadcasted via the OneViewX system(SparkBioSrl, San Lazzaro-Bologna, Italy) between February 2023 and June 2024. One hundred participants (47 residents, 53 clinical application specialists) attended remotely. Objective transmission metrics (speed, latency, instability, frame-rate) and subjective evaluations (video/audio quality/fluidity, interaction) were recorded. Predefined technical cut-offs and quartile thresholds defined suboptimal performance. The primary endpoint was the participant’s overall educational experience (satisfactory vs. moderate/flawed vs. unsatisfactory). Secondary endpoints included the identification of factors associated with moderate/flawed evaluations. Results Among 182 attendees, 100 questionnaires were returned (69 aortic, 31 peripheral cases). Participants accessed broadcasts via smartphone or personal computers (40 vs.60), with 68 using WiFi and 32 mobile networks. Overall, 85% of participants rated the experience fully satisfactory, 15% moderately satisfactory, and none unsatisfactory. Objective parameters, as speed, latency, instability, and frame rate, were not associated with user satisfaction, even when below technical/lowest performance cut-off values. Subjectively, by 18 responders cases were rated as having flawed video quality, 22 pointed out flawed video fluidity, 12 flawed audio quality, 14 flawed video set-up, 12 reported flawed audio interaction with operators. At univariate analysis, flawed video quality(p=.016); flawed video fluidity(p<.001) and flawed audio interaction ( p<.001) were associated with moderate satisfaction at final evaluation. Logistic regression identified lack in video fluidity as independent predictor(p=.027; odds-ratio =4.85, 95%confidence-interval=1.20–19.64) of moderate satisfactory evaluation. Conclusion Remote digital broadcasting represents a reliable modality for endovascular education and technical support in vascular surgery, using standard digital infrastructure. User satisfaction depended primarily on video fluidity and interactivity rather than objective transmission metrics, suggesting that tele-mentoring systems should prioritize human experience alongside technical performance.
Objectives To characterize central lymphatic anatomy and physiological flow dynamics in healthy volunteers using dynamic contrast-enhanced MR lymphangiography (DCMRL), thereby providing preliminary DCMRL-specific quantitative characterization of central lymphatic anatomy and flow dynamics. Materials and Methods In this prospective single-center study, healthy adult volunteers underwent DCMRL between April 2023 and March 2024. Thoracic duct (TD) morphology, outlet anatomy, length, width, and tortuosity were assessed on contrast-enhanced T1-weighted imaging, with additional width measurements on T2-weighted imaging. Quantitative flow analysis was performed using time-resolved contrast-enhanced sequences. Descriptive statistics, paired and independent t-tests, and Spearman correlation coefficients were applied. Results Sixteen participants (6 male, 10 female; median age 27 years, range 19-44) were included. The thoracic duct (TD) was visualized in all on T2-weighted imaging and in 14 on contrast-enhanced T1-weighted imaging. The cisterna chyli was visible in 13, and the TD outlet was left-sided in 15, with bilateral outlets in one. Fourteen TDs were tubular, with partial duplication in 2. On contrast-enhanced T1-weighted imaging (n=14), mean TD width was 4.43 ± 0.76 mm. On T2-weighted imaging, the corresponding mean TD width was 4.13 ± 0.25 mm. The mean TD length was 232 ± 20 mm, with a tortuosity index of 1.04 ± 0.02. Quantitative flow analysis in 13 participants revealed a steady flow pattern with a mean flow rate of 0.63 ± 0.41 mL/min. Conclusion This prospective study characterizes central lymphatic anatomy and flow physiology in healthy volunteers using DCMRL, highlighting modest physiological variability and a gradual increase in lymphatic contrast propagation, providing preliminary interpretive context for DCMRL interpretation.
Background Infective native aortic aneurysm (INAA) is a rare but life-threatening vascular condition associated with substantial morbidity and mortality. The microbiological spectrum differs geographically, with Salmonella spp. predominating in East Asian populations. In tropical Southeast Asia, Burkholderia pseudomallei represents an additional endemic pathogen whose clinical behaviour in INAA remains poorly characterised. Methods A retrospective observational cohort study was performed involving patients treated for INAA at a tertiary vascular referral centre in Malaysia between January 2018 and December 2024. Patients were categorised into four microbiological groups: culture-negative, Salmonella spp., melioidosis caused by Burkholderia pseudomallei, and other organisms. Baseline demographics, anatomical characteristics, operative strategies, perioperative complications, infection-related complications, reintervention, and survival outcomes were analysed. Results Eighty-six patients were included, comprising 29 culture-negative, 27 Salmonella, 15 B. pseudomallei, and 15 other-organism cases. Melioidosis patients were significantly younger (58 ± 10 years; p=0.041), with the highest prevalence of diabetes mellitus (80.0%; p=0.038), most frequent emergency presentation (86.7%; p=0.049), and highest pre-operative C-reactive protein (median 188 mg/L; p<0.001). Thirty-day mortality was uniformly low across all groups (0 to 6.7%; p=0.62). Persistent post-operative sepsis (33.3%; p=0.047), infection-related complications (46.7%; p=0.049), and aneurysm-related death (26.7%; p=0.044) were highest in the melioidosis group. Kaplan-Meier analysis demonstrated divergence in long-term survival from 24 months onwards: estimated three-year overall survival was 95% (95% CI 76-99%) for Salmonella, 82% (95% CI 64-93%) for culture-negative disease, 67% (95% CI 41-86%) for other organisms, and 50% (95% CI 26-74%) for B. pseudomallei; however, the overall log-rank comparison did not reach conventional statistical significance (p=0.083). Conclusions INAA in tropical Southeast Asia demonstrates a distinct microbiological spectrum dominated by Salmonella spp. and B. pseudomallei. B. pseudomallei-caused INAA appears to represent a clinically high-risk phenotype characterised by severe systemic inflammation, a high rate of late infection-related complications, and worse estimated long-term survival. These survival findings should be interpreted as a clinically important trend that did not reach statistical significance in this cohort.
Objective Although supervised exercise therapy improves walking performance in patients with peripheral artery disease (PAD), little is known about changes in skeletal muscle volume following revascularization. This study aimed to quantitatively assess changes in calf muscle volume before and after revascularization using the computed tomography (CT). Methods Between July 2020 and June 2025, 42 patients (84 limbs) with PAD who underwent revascularization were included. Only patients with unilateral symptomatic disease and a contralateral asymptomatic limb with a normal ankle-brachial index (ABI) were eligible. Calf muscle volume was measured using CT before and 1 month after revascularization. Preoperative muscle atrophy and postoperative muscle volume changes were evaluated by comparing affected and contralateral limbs. Results The mean age was 74.3 ± 8.2 years, and 32 patients (76%) were male. Intermittent claudication was present in 33 cases (79%), and chronic limb-threatening ischemia in 9 cases (21%). The mean ABI was 0.60 ± 0.23 in affected limbs, and 1.01 ± 0.07 in contralateral limbs before treatment. Preoperative mean calf muscle volume was 1078 ± 286 cm3 in affected limbs and 1116 ± 301 cm3 in contralateral limbs, corresponding to a mean atrophic rate of 97 ± 9%. After revascularization, the mean ABI in affected limbs improved to 1.01 ± 0.09, and postoperative mean calf muscle volume increased to1158 ± 302 cm3, corresponding to a mean change of 11 ± 36% (p = .21). The increase in muscle volume was most pronounced after bypass surgery (54% increase, p = .04). No significant changes were observed in muscle volume on contralateral limbs. Conclusions Calf muscle volume showed a nonsignificant trend toward an increase after lower extremity revascularization in patients with PAD. These preliminary findings suggest that revascularization may influence skeletal muscle volume; however, the potential contribution of postoperative edema and the small sample size warrant cautious interpretation.
Objectives The objective of this clinical investigation is to assess the clinical performance and the safety of the drug-coated balloons, Luminor 18 or Luminor 35, in the treatment of arteriovenous fistula stenosis. Methods LUMIFAV was a retrospective, single-center, non-comparative, observational cohort study of adults (≥18 years) treated with paclitaxel-coated balloons between January 2020 and September 2022. Eligible patients had mature upper extremity arteriovenous fistulas, with de novo or recurrent stenosis successfully predilated to ≤30% residual stenosis. The primary endpoint was target lesion primary patency at 6-month follow-up; other endpoints included adverse device effects, mortality, reintervention, access circuit primary patency, and target lesion/vessel revascularization. Analyses included descriptive statistics and Kaplan-Meier estimates. Results Fifty-four patients (78% male; mean age 74 years) were enrolled in the study. Most lesions were juxta-anastomotic (63%); mean lesion length and diameter were 36.9 mm and 2.2 mm, respectively. Pre-dilation was performed in 96%, and 28% underwent post-dilatation. The target lesion primary patency rate at 6 months follow-up was achieved in 78% of patients (38/49; 95% CI [63.0%; 87.8]. No device-related adverse events occurred, and the cumulative mortality rates were 4%, 16%, and 29%, at 30 days, 12 months and 24 months post-index procedure respectively . Main causes were cardiovascular or malignancy. At 30 days, 12 months, and 24 months follow-up the target lesion primary patency rates were 100%, 51% and 26%, respectively; median time to target lesion primary patency failure was 16.2 months. Access circuit primary patency rates were 98%, 54%, 24%, and 15% at 30 days, 6, 12, and 24 months, respectively. Mean time to first reintervention was 6.8 months. Conclusions The Paclitaxel-coated balloons, Luminor 18 and Luminor 35, showed favorable safety and performance for treating arteriovenous fistulas stenosis in hemodialysis patients, supporting their role in maintaining patency without device-related complications and confirming their clinical utility for arteriovenous fistulas management, increasing the delay between re-intervention and maybe, the quality of life for this fragile population.
Background Workflow variation contributes to differences in efficiency, outcomes, and cost. Despite growing interest in standardization, temporal data about perioperative phases are rarely captured systematically. We used an ambient computer vision system to quantify time spent in perioperative workflows across five hospital sites performing high-volume lower extremity interventions. Methods We conducted a retrospective, multisite observational study of perioperative workflows for lower extremity angiographic procedures across five hospitals within a single academic health system. Cases were identified using an ambient computer vision platform that integrates electronic health record data with automated event detection from operating room video. Each case was segmented into standardized perioperative phases, including anesthesia induction, patient preparation, final preparation, active procedure, postoperation, patient exit, room cleanup, and room setup. Phase durations were summarized using medians and interquartile ranges and compared across sites using the Kruskal-Wallis test. Multivariable linear regression models were used to estimate adjusted site level differences, controlling for surgeon, case timing, case classification and operational factors. Results A total of 916 cases were analyzed across five sites. All perioperative phases demonstrated significant intersite variation (p<0.05). The greatest variability was observed in patient preparation (median 9.0-23.0 minutes) and active procedure duration (40.0 – 75.0 minutes). Turnover phases varied substantially, with room cleanup ranging from 10.0 to 25.0 minutes and room setup from 20.0 to 28.5 minutes. Site C demonstrated prolonged preparation and patient exit times, while adjusted analyses revealed shorter active procedural duration relative to the system-wide mean. Sites B and E demonstrated longer adjusted total case durations (+15.1 and +17.9 minutes, respectively), whereas Site C and D demonstrated shorter adjusted total durations (-20.2 and -14.8 minutes). These differences translated into daily operating room time variation of approximately -26 to +27 minutes across sites. Conclusions Perioperative workflows vary substantially across hospital sites, even within the same health system. The greatest differences occurred in patient preparation, active procedure, and turnover phases. These findings suggest that inefficiencies extend beyond procedural performance and are driven in part by modifiable operational processes. Automated workflow analysis provides a scalable approach to identify phase-specific bottlenecks and support targeted improvements in operating room efficiency.
Background Surgical education increasingly relies on simulation and competency-based assessment tools to provide feedback and assess clinical preparedness. This study evaluated inter-rater reliability among attending vascular surgeons scoring resident cadaveric dissections using an Objective Structured Assessment of Technical Skills (OSATS) rubric. Methods Four de-identified cadaveric dissection videos performed by general surgery residents, including two carotid endarterectomies and two femoral endarterectomies, were independently scored by six attending vascular surgeons at a single institution using a standard OSATS rubric. The primary outcome was inter-rater reliability, assessed using intraclass correlation coefficients (ICC), with ICC <0.5 indicating poor reliability, 0.5–0.75 moderate reliability, and >0.75 good reliability. Quality of free-text feedback was assessed as a secondary outcome. Results Surgeons demonstrated substantial variation in scoring practices, with several reviewers identified as outliers for consistently higher or lower scores. Composite inter-rater reliability was poor to moderate, with ICC values ranging from 0.327 to 0.535; no composite score exceeded moderate reliability. Several individual domains demonstrated higher agreement. ICC values were highest for Procedural Flow (0.753 [0.219, 0.980]) and Knowledge of Anatomy (0.747 [0.212, 0.980]), with moderate reliability for Quality of Final Product (0.653 [−0.021, 0.972]) and Knowledge of Procedure Description (0.713 [−0.179, 0.980]). Agreement was lower for Use of Assistant (0.460 [−0.021, 0.949]) and Time and Motion (0.472 [−0.452, 0.957]), while instrument- and tissue-related domains showed near-zero agreement, including Instrument Handling (−0.970) and Respect for Tissue (−1.042). Free-text feedback quality was variable, with one reviewer providing most high-quality comments. Conclusions OSATS-based scoring of cadaveric vascular dissection videos demonstrated modest inter-rater reliability. Reliability was strongest for domains focused on knowledge, anatomy, and procedural steps, and weakest for domains requiring more subjective judgment, such as tissue handling and instrument use. These findings reflect real-world variability in surgical assessment, including “hawk and dove” rating patterns, and suggest that structured scoring alone may not provide dependable entrustment data. Future efforts should emphasize clearer faculty instructions, better-defined scoring anchors, rater training, and improved formative feedback to maximize the utility of competency-based assessment tools.
Objective To evaluate the outcomes after aortic septotomy for the endovascular treatment of aortic dissections. The primary outcomes were septotomy technical success and 30-day mortality. Secondary outcomes were 30-day major systemic complications, overall reinterventions, and overall survival. Methods The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol was prospectively registered on PROSPERO (CRD42025636271). Data sources were Cochrane Library, Embase, MEDLINE. All studies reporting the outcomes of aortic septotomy for the endovascular treatment of aortic dissections were eligible for inclusion. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. A random effects meta-analysis of proportions was conducted. Heterogeneity was assessed with the I2 statistic. Results A total of 15 studies, comprising 132 patients, were included in the review. The majority of patients (94.7%) were treated for chronic post-dissection thoraco-abdominal aortic aneurysm, with the most common procedure being electrocautery aortic septotomy (61.4%). Of these, 119 patients from six studies were included in the quantitative synthesis of outcomes. Regarding primary outcomes, the pooled septotomy technical success rate was 94.7% (I2: 0%), and the pooled 30-day mortality rate was 3.5% (I2: 0%). For secondary outcomes, the pooled rates of 30-day major systemic complications, overall reintervention, and overall survival were 13.4% (I2: 7.6%), 17.6% (I2: 73%), and 93.8% (I2: 44.9%), respectively. Conclusion These results suggest that endovascular aortic septotomy might be a relatively safe procedure that can aid in endograft positioning, enhancing the sealing and potentially improving sustained efficacy of the implant.
Surgical dictum rests on the belief that a careful, conscientious, well-read surgeon may be insulated from error. The cognitive science of decision-making indicates otherwise. In this context, we bring Daniel Kahneman's dual-process framework to a vascular surgical audience and argue that many associated decision-making errors are not failures of knowledge or intelligence but rather predictable failures of cognition. Human judgment operates through two interacting systems. System 1 is the fast, automatic, pattern-based processing that underlies much of what we call surgical expertise. System 2 is the slow, effortful, rule-following analysis required for preoperative risk stratification, evidence-based guideline application, and complex or redo surgical anatomy. A well-trained System 1 is indispensable yet systematically vulnerable to biases such as Representativeness, Anchoring, Availability, Affect, and Confirmation, and we provide relevant surgical scenarios. We challenge the assumption that deliberate System 2 analysis reliably corrects these errors, examining its characteristic failures. For vascular surgeons, familiarity with this framework is a foundational step toward enhanced patient care and safety, more efficient health systems, impactful surgical training, and quality improvement. Diverse and complex surgical teams may provide appropriate external scaffolds to counteract bias. Artificial Intelligence (AI) has the potential to narrow the regulation gaps between System 1 and System 2, leading to improved surgical decision-making. However, a steadfast recognition that current research reporting standards may be insufficiently standardized and that large language and machine-learning models themselves exhibit human-like cognitive biases will be important for using AI to improve care for surgical patients and to optimize training paradigms for future surgeons.
Objective Frailty is increasingly recognized as a key driver of postoperative risk in vascular surgery, yet the comparative accuracy of major frailty indices in patients undergoing aortic surgery remains unclear. We compared the predictive accuracy of the Modified Frailty Index, Risk Analysis Index, Vascular Quality Initiative Frailty Index, and Vascular Quality Initiative Procedure-Based Index in predicting adverse postoperative outcomes in patients undergoing open and endovascular aortic aneurysm repair. Methods In this retrospective single-center cohort study, 131 patients who underwent open or endovascular aortic aneurysm repair between January 1 and December 31, 2023, were included. Frailty scores were calculated retrospectively based on data available at the time of preoperative evaluation. Primary outcomes were 30-day and 60-day hospital readmissions, in-hospital mortality, and 1-year mortality. Secondary outcomes included 30-day stroke, acute kidney injury, myocardial infarction, and reintervention. Statistical associations were evaluated using logistic regression models. Results The cohort's mean age was 70.6 ± 9 years, 31% were female, and pathology included abdominal aortic aneurysm (70%), thoracic aortic aneurysm (11%), thoracoabdominal aortic aneurysm (13%), and aortic dissection (6%). Interventions included endovascular aneurysm repair (34%), thoracic endovascular aortic repair (19%), fenestrated endovascular aortic repair (16%), and open repair (31%). Thirty-day readmission was the only outcome significantly associated with frailty across multiple indices. In the combined, open and endovascular, cohort, the Modified Frailty Index (odds ratio, 2.15; 95% confidence interval, 1.28-3.78; P = .01; area under the curve, 0.71), Risk Analysis Index (odds ratio, 1.09; 95% confidence interval, 1.01-1.18; P = .02; area under the curve, 0.72), and Vascular Quality Initiative Frailty Index (odds ratio, 1.74; 95% confidence interval, 1.25-2.52; P = .002; area under the curve, 0.73) demonstrated significant associations with 30-day readmission. Conclusions In patients undergoing aortic aneurysm repair, frailty indices demonstrated limited predictive value across most postoperative outcomes. Thirty-day readmission was the only outcome consistently associated with frailty scores, with no significant performance differences among the four indices tested. The vascular-specific indices did not outperform generic measures in this cohort, highlighting the need for aortic-specific risk stratification tools.
Background Iliofemoral Deep Vein Thromboses (DVTs) are high-risk blood clots that form in the iliac and femoral veins and carry substantial risk of morbidity, including increased risk of pulmonary embolism and Post-Thrombotic Syndrome. Venous duplex ultrasound (VDUS) is the standard diagnostic tool, but clinically important findings are recorded in free-text reports requiring clinician interpretation, delaying treatment decisions and limiting large-scale quality monitoring. This study evaluates the potential of Large Language Models (LLMs) to automate extraction of clinically relevant structured data from VDUS reports. We hypothesized that open-weight large language models, including computationally efficient distilled variants, could accurately extract clinically actionable DVT features from venous duplex ultrasound reports with performance sufficient to support downstream clinical workflows. Methods In this retrospective study, 1,000 VDUS reports from November 2016 to August 2024 were identified from the electronic medical record (EMR) at a quaternary referral hospital. Four open-weight LLMs, Qwen1.5-72B-Chat-AWQ, DeepSeek-R1-Distill-Qwen-7B, LLaMA-2-13B-Chat-hf, and DeepSeek-R1-Distill-LLaMA-8B, were evaluated on extraction of six clinically relevant fields: presence of iliofemoral DVT, presence of femoral DVT, anatomical laterality, chronicity, extremity, and whether the clot was superficial or deep. Each model also predicted whether the patient would require clinical intervention. Performance was assessed using accuracy, precision, recall, F1 score, and Cohen’s Kappa over a random subset of 100 cases. Results Qwen1.5-72B-Chat-AWQ achieved the highest overall accuracy (96%) and strong F1 Scores across most fields, while LLaMA-2-13B-Chat-hf underperformed across all fields, with 78.6% overall accuracy. The distilled models (DeepSeek-R1-Distill-Qwen-7B and DeepSeek-R1-Distill-LLaMA-8B) performed comparably to Qwen1.5-72B-Chat-AWQ, offering a favorable tradeoff between performance and speed. By processing all 1000 reports in approximately 4 minutes, the distilled models ensure computational efficiency. Although some models achieved perfect recall on extracting iliofemoral DVT, precision for this field was low, indicating a tendency toward overclassification when there are not many positive cases. Conclusions Our study demonstrates that LLMs can enhance the effectiveness of information retrieval from unstructured medical records, specifically with DVT assessment using VDUS reports. Automating this process could streamline referral pathways, accelerate identification of patients with high-risk DVT who may benefit from thrombectomy, reduce chart-review burden, and support real-time data availability for clinical decision-making.
Objective Modified eversion carotid endarterectomy (meCEA) is an alternative to classical patch angioplasty or eversion carotid endarterectomy, in which plaque is everted through a longitudinal arteriotomy over the common carotid artery (CCA) without transection of the internal carotid artery (ICA). Because primary repair of a longitudinal arteriotomy may raise concern for postoperative narrowing, we evaluated postoperative carotid geometry after meCEA in patients with paired preoperative and postoperative computed tomography angiography (CTA). Methods We performed a single-center retrospective review of all meCEA procedures performed between 2009 and 2022. Patients were included in the imaging analysis if both preoperative and postoperative CTA were available. Pre- and postoperative centerline measurements, by two independent observers, were obtained at 1 cm and 2 cm proximal to the ICA ostium within the CCA (CCA1 and CCA2, respectively), the ICA ostium (ICA0), and 1 cm and 2 cm distally within the ICA (ICA1 and ICA2, respectively). Preoperative and postoperative diameters at each arterial segment were compared using paired t-tests. Results Among 480 meCEA procedures performed during the study period, 40 carotid arteries had paired pre-operative and post-operative CTAs available for analysis. Median time to postoperative imaging was 433 days (range, 0 – 1186 days). Mean preoperative diameters were 7.6 mm at CCA2, 8.2 mm at CCA1, 6.8 mm at ICA0, 6.0 mm at ICA1, and 5.2 mm at ICA2. Postoperatively, weighted diameter change was –5.4% at CCA2 (p = 0.36), –10.9% at CCA1 (p = 0.063), -2.1% at ICA0 (p = 0.87), +10.7% at ICA1 (p = 0.23), and +6.1% at ICA2 (p = 0.47). None of these changes reached statistical significance. Conclusions In this selected imaging cohort, meCEA with primary closure was not associated with statistically significant adverse narrowing of the ICA on follow-up imaging. Distal ICA measurements trended upwards, whereas CCA measurements trended downward, but these findings were exploratory and may not be generalizable to the full meCEA population. These data support the interpretation that meCEA does not appear to cause marked adverse ICA narrowing in this selected series; however, standardized imaging surveillance and comparative studies are needed to define long-term geometric and clinical outcomes more clearly.
Objective Acute mesenteric ischemia is a life-threatening cessation of intestinal perfusion associated with high mortality. While revascularization remains the cornerstone of management, the optimal modality of revascularization remains contested. This study aimed to compare the clinical and financial outcomes of open and endovascular revascularization for acute mesenteric ischemia. Methods We conducted a retrospective cohort study using the 2016–2022 Nationwide Readmissions Database. All non-elective adult hospitalizations receiving open or endovascular revascularization for acute mesenteric ischemia were identified using diagnosis and procedure codes from the International Classification of Diseases, 10th Revision. Risk adjustment using entropy balancing followed by multivariable regression examined the association of operative approach with in-hospital mortality, perioperative complications, reoperation, length of stay, and hospitalization costs. Results Of 6,238 patients treated for acute mesenteric ischemia, 1,501 (24.1%) underwent open and 4,737 (75.9%) received endovascular revascularization. The endovascular cohort was older (72 [63–80] vs 70 [61–77] years, P <0.001) with lower overall Elixhauser scores (5 [4-7] vs 6 [4-7], P <0.001). Following risk adjustment, endovascular revascularization was associated with lower odds of mortality (AOR 0.43, 95% CI 0.34–0.55) and bowel resection (AOR 0.46, 95% CI 0.37–0.56) compared to open revascularization. The endovascular cohort was additionally associated with reduced odds of cardiac, respiratory, and infectious complications. Notably, endovascular repair was also linked to lower hospitalization costs, nonhome discharge, and length of stay. Conclusions The present analysis demonstrates endovascular revascularization to be associated with improved clinical outcomes and lower resource utilization compared to open revascularization. Further investigation is warranted to define optimal patient selection and treatment modality in the management of acute mesenteric ischemia.
Objective Chronic venous disease (CVD) is assessed with objective hemodynamic (duplex reflux time) and anatomic (vein diameter) measures, clinical-sign–based scores (CEAP, Venous Clinical Severity Score [VCSS]), and patient-reported instruments (VVSymQ, CIVIQ-20). How these relate, and whether their relationships change as disease advances, is unclear. We examined their cross-sectional concordance overall and by severity. Methods We analyzed pre-procedure data from 305 limbs with great saphenous vein (GSV) reflux (255 patients) before polidocanol endovenous microfoam ablation. Peak GSV reflux time, diameter, rVCSS, VVSymQ, CIVIQ-20, and CEAP class were recorded. Spearman correlations were computed overall, with multivariable adjustment (cluster-robust), and stratified by severity (C1–3 vs C4–6; Fisher r-to-z). Results Peak GSV reflux time did not correlate with any score or with CEAP (all |ρ|≤0.12; all P>.05), at any severity and after adjustment. CEAP class was the strongest independent correlate of every score in multivariable regression (standardized β 0.44–0.66; all P<10-12). GSV diameter correlated weakly in mild disease (CEAP C1–3; ρ 0.22–0.29) but decoupled in advanced disease (CEAP C4–6). Agreement between the two patient-reported instruments fell sharply (VVSymQ–CIVIQ-20 ρ 0.79 vs 0.36; P<.001, surviving multiplicity correction), partly a ceiling effect; the sign-based clinician score (rVCSS) retained moderate correlations with both patient-reported instruments in advanced disease (rVCSS–VVSymQ ρ 0.50, rVCSS–CIVIQ-20 ρ 0.40). Conclusions Objective and subjective assessments of CVD converge in early disease and diverge as it advances. Saphenous reflux time is concurrently uninformative throughout, and vein diameter becomes uninformative in advanced disease; clinical-sign–based staging remains the consistent reference. These cross-sectional data suggest disease burden is better gauged by clinical staging with patient-reported measures than by reflux duration.
Objective To investigate incidences of ipsilateral ischemic stroke (IS) and other outcomes for medically and surgically treated asymptomatic carotid stenosis (ACS). Design Observational, nationwide cohort study. Methods The Swedish vascular registry (Swedvasc) was used to identify patients undergoing carotid intervention, who had a contralateral non-operated ACS (medically treated ACS) as well as patients with surgically treated ACS 2008-2017. Swedvasc was merged with the National stroke register to determine stroke incidence. Hospital records were obtained to determine stroke type and laterality. Primary outcome was ipsilateral ischemic stroke (IS) beyond the perioperative 30-days period. Secondary outcomes included any stroke and all-cause mortality. For surgically treated ACS, perioperative stroke or death and the composite outcome perioperative stroke or death plus late ipsilateral IS were analyzed. Cox regression was used to analyze the influence of clinical risk factors and assess risk differences between groups. Results There were 1 457 patients with medically treated ACS and 1023 patients with surgically treated ACS. Patients with medically treated ACS were almost 5 years older than those with surgically treated ACS. Mean yearly incidences of outcomes for medically and surgically treated ACS were 1.1% and 0.3% for ipsilateral IS, 2.4% and 1.2% for any stroke and 5.6% and 3% for all-cause mortality. Clinical risk factors were not significantly associated with ipsilateral IS in either group, including severity of baseline stenosis (50-69% vs 70-99%). Comparing ipsilateral IS for medically treated ACS with perioperative stroke or death (2.6%) plus late ipsilateral IS for surgically treated ACS resulted in a projected minimum number needed to treat by surgery of 71 to avoid one ipsilateral IS over 5 years. Conclusion Incidences of ipsilateral IS were low for medically treated ACS and very low for surgically treated ACS. The present results suggest that best medical treatment is preferable for the majority of patients with ACS.
Objective Pathological arteriovenous fistulas (AVFs) in the foot have been proposed as a treatable vascular cause of antibiotic-refractory recurrent lower-limb cellulitis, but clinical evidence remains limited. We report clinical phenotype, procedural outcomes, and recurrence-free survival after endovenous laser AVF ablation. Methods This retrospective observational study included 57 consecutive patients who underwent duplex-guided endovenous laser ablation for recurrent lower-limb cellulitis-mimicking inflammatory episodes (January 2015–December 2024). Inclusion criteria were ≥2 prior cellulitis episodes, absence of fever, negative microbiological workup, and duplex-confirmed AVF. The primary outcome was Kaplan–Meier recurrence-free survival. The association between calcium channel blocker (CCB) discontinuation and recurrence was evaluated using Fisher’s exact and log-rank tests. Results Mean age was 73.7±11.2 years (64.0% female). The inflammatory profile at presentation was consistent with a non-infectious mechanism: history of fever in 8.0%, mean WBC 6,501±1,853/μL, median CRP 0.26 mg/dL; all blood cultures were negative. Hypertension was present in 86.0%, with 86.0% receiving CCBs. Recurrence-free survival was 100% at 12 months and 79.3% (95% CI: 57.8–90.6%) at 60 months. All 12 recurrences occurred after 12 months. Among CCB users, the recurrence rate was 3.3% in those whose CCBs were discontinued versus 47.4% in those unchanged (p<0.001); 60-month recurrence-free survival was 100% versus 51.5% (log-rank p=0.003). Conclusions Endovenous laser ablation of pathological AVFs achieved recurrence-free survival in approximately 80% of patients at five years. The presentation consistent with a non-infectious mechanism, exclusively late-onset recurrence, and marked reduction in recurrence with CCB discontinuation support an AVF-driven vascular mechanism. Duplex evaluation for AVFs should be considered in antibiotic-refractory recurrent lower-limb cellulitis.
Objective The association between smoking, socioeconomic status (SES), and outcomes after abdominal aortic aneurysm (AAA) repair remains unclear. Smoking is more prevalent in socioeconomically disadvantaged populations and has been associated with worse outcomes after AAA repair. We evaluated the association between SES and current smoking and explored whether smoking influences the relationship between SES and survival following open AAA repair. Methods A retrospective cohort study of patients undergoing open AAA repair in the Vascular Quality Initiative from 2010 to 2020 was performed. SES was measured using the Area Deprivation Index (ADI) and modeled in quintiles, with higher quintiles indicating greater socioeconomic deprivation. The primary outcome was preoperative current smoking. The secondary exploratory outcome was overall survival and whether inclusion of smoking attenuated the association between SES and survival. Multivariable logistic regression was used to evaluate the association between SES and current smoking. Kaplan–Meier analysis and multivariable Cox proportional hazards regression were used to evaluate survival. Results Among 16,395 patients undergoing open AAA repair, 39.6% were classified as high SES deprivation (ADI quintiles 4–5). Patients with higher deprivation had greater rates of current smoking (48.2% vs 40.7%; P <0.001), greater comorbidity burden, and more frequent symptomatic or ruptured presentation (31.1% vs 27.7%; P <0.001). High deprivation was also associated with higher postoperative complication rates (43.4% vs 41.1%; P = 0.003). In multivariable logistic regression, increasing socioeconomic deprivation demonstrated a graded association with current smoking, with progressively higher odds across ADI quintiles (quintile 5 vs quintile 1: adjusted OR 1.50 [1.36–1.67]; P <0.001). In unadjusted survival analysis, survival did not differ significantly across ADI quintiles (P = 0.105), although worse survival was observed in the most deprived compared with least deprived quintile (P = 0.033). In multivariable Cox regression, SES was not independently associated with survival. Current smoking (HR 1.15 [1.06–1.24]; P <0.001) and urgent presentation (HR 3.95 [3.65–4.27]; P <0.001) were independently associated with mortality. Conclusions Among patients undergoing open AAA repair, socioeconomic deprivation was associated with a greater burden of comorbidities, modifiable risk factors, and postoperative complications, but was not independently associated with poorer survival. Increasing socioeconomic deprivation was strongly associated with current smoking, which was independently associated with mortality. These findings highlight smoking as an important, modifiable risk factor that is disproportionately prevalent among socioeconomically deprived patients.
Objective Percutaneous mechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT) are techniques to restore perfusion to the lower extremity in patients suffering from acute limb ischemia (ALI). We reviewed our institutional experience treating ALI by PMT or CDT over the last 18 years, with emphasis placed on long term limb salvage rates and the required number of trips to the operating room to reestablish perfusion. Methods A single-center retrospective institutional data warehouse review was conducted for patients who were treated for de novo ALI with either PMT or CDT from 2006 to 2024. Patient characteristics and operative outcomes were recorded and analyzed. We identified 133 patients who never had prior treatment for limb ischemia and underwent endovascular treatment only; 27 patients underwent PMT, and 106 patients underwent CDT. Results Patients with ALI treated with PMT had improved freedom from major amputation at three years post-operation compared to CDT (89% vs 76%, P=0.015). In adjusted multivariable analyses, PMT was associated with lower odds of major amputation within three years post-operation compared to CDT patients (OR 0.247, 95% CI 0.063–0.964; P=0.044). The average number of trips to the OR at initial encounter was lower in the PMT group versus the CDT group (1 vs 3; P<0.001). Conclusions In anatomically similar patients with lower extremity acute limb ischemia, PMT was associated with improved freedom from major and minor amputation at three years and fewer trips to the operating room compared with CDT. Prospective, randomized studies are warranted to confirm these findings.
Objective Peripheral artery disease (PAD) is frequently complicated by heart failure (HF), yet the prognostic impact of HF and its phenotypes in patients undergoing endovascular therapy (EVT) remains poorly defined. This study evaluated the 3-year mortality associated with HF and compared outcomes between HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). Design and Methods This multicenter retrospective study included 1,585 patients who underwent EVT for symptomatic PAD between 2018 and 2020. Patients were stratified into non-HF (n = 946) and HF (n = 639) groups; HF was further categorized into HFpEF (EF ≥50%) and HFrEF (EF <40%). The primary outcome was all-cause mortality at 3 years. Results During the 3-year follow-up, all-cause mortality was significantly higher in patients with HF than in those without HF (26.8% vs 8.1%, log-rank p < 0.001). In the overall population, HFrEF was independently associated with increased mortality compared with non-HF patients (adjusted HR 2.07, 95% CI 1.13–3.76; p = 0.017), whereas HFpEF was not. Among patients with HF, HFrEF was associated with higher mortality than HFpEF (38.5% vs 22.8%, p = 0.009), and this remained significant after multivariable adjustment (adjusted HR 1.81, 95% CI 1.16–2.82; p = 0.009). In multivariable analysis, age ≥75 years, chronic limb-threatening ischemia, hemodialysis, serum albumin <3.0 g/dL, and HFrEF were independently associated with all-cause mortality. Conclusion HF phenotype provides important prognostic information in EVT-treated PAD patients. HFrEF was associated with the highest mortality risk, particularly in patients with CLTI.
Objective To evaluate mid-term outcomes of endovascular repair for complex abdominal and Extent IV thoracoabdominal aortic aneurysms (TAAAs) using off-the-shelf branched endografts, comparing the GORE EXCLUDER Thoracoabdominal Branch Endoprosthesis (TAMBE) and the Zenith t-Branch Thoracoabdominal Endovascular Graft (t-Branch). Methods A single-center retrospective analysis was conducted including 44 consecutive patients treated between 2017 and 2025 with either the TAMBE or t-Branch devices for complex abdominal or Extent IV TAAAs. Primary endpoints included target vessel patency, freedom from secondary interventions, and target vessel instability (TVI) defined as a composite of target vessel occlusion, stenosis >50%, type Ic/IIIb-c endoleak, or branch reintervention. Statistical analyses encompassed Kaplan-Meier survival estimates, log-rank tests, and Cox proportional hazards regression to identify factors associated with TVI. Results A total of 44 patients (82% male, mean age 76 ± 7.4 years) were treated for 18 (41%) complex abdominal and 26 (59%) Extent IV TAAAs using off-the-shelf branched devices. TAMBE and t-Branch devices were used in 18 (41%) and 26 (59%) patients, respectively. Technical success was 100% in both cohorts. There were two 30-day deaths, one in the TAMBE cohort of unknown cause and one in the t-Branch cohort secondary to gastrointestinal bleeding. Patient survival at 1, 3, and 5 years was 82.5%, 58%, and 50%, respectively. There were no aortic-related deaths at a mean follow-up of 22±21 months. Secondary interventions were required in 8 (44%) patients with TAMBE and 9 (35%) with t-Branch (P= .35). TVI was significantly more frequent with TAMBE (freedom from TVI at 1, 3 and 5 years was 75%, 66%, and 66% with TAMBE vs. 93%, 87%, and 87% with t-Branch; P=.007). Renal bridging stent length was significantly greater in TAMBE than t-Branch (RRA: 72.1 ± 20.5 vs 50.7 ± 16.0; P = .001; LRA: 72.4 ± 19.2 vs 57.2 ± 15.5; P = .01). Renal bridging stent diameter, a surrogate for target vessel caliber, did not differ between groups (6.4 ± 0.8 vs 6.2 ± 0.9 mm; P = .50). Cox regression identified TAMBE use (HR 3.2; 95% CI 1.4-7.3; P = .006) and longer average renal stent length (>90 mm; HR 2.8; 95% CI 1.2-6.5; P = .017) as independent predictors of TVI.longer average renal stent length (>90 mm; HR 2.8; 95% CI 1.2-6.5; P = .017) as factors associated with TVI; because the TAMBE portal configuration mandates longer renal bridging stents, device type and stent length are closely correlated, and their effects cannot be fully separated in this cohort. Conclusions TAMBE and t-Branch devices are safe for treating complex abdominal and Extent IV TAAAs. Target vessel instability is a concern with off-the-shelf branched devices, particularly TAMBE, given the frequent target vessel occlusions and stenosis. These findings represent an association observed within a limited, single-center, non-randomized cohort and require confirmation in larger multicenter studies.
