Objective The aim of the present study was to report outcomes of inner branches of the Cook Platform in endovascular repair of complex abdominal (cAAAs) and thoracoabdominal aortic aneurysms (TAAAs). Methods All consecutive patients treated at two institutions with F/BEVAR for cAAA or TAAA using stent grafts with inner branches between April 2015 and December 2024 were included. Analysed endpoints included technical success, peri-operative mortality, target vessel patency, freedom from endoleak, target vessel related re-intervention, and target vessel instability (TVI) for vessels addressed with inner branches. Results A total of 108 patients (79 male, mean age 71 ± 8.9 years) with 181 inner branches were analysed. Nineteen (17.6%) patients had a cAAA and 89 (82.4%) patients a TAAA. A stent graft with fenestrations and inner branches was used in 92 (85.2%) patients. Thirty day mortality was 3.7% (4/108). Technical success per inner branch was 98.9% (179/181). Estimated patencies at 1 and 2 years were 95.0% ± 1.7%, and 90.5% ± 2.6%, respectively. Estimated patency at 2 years was lower for the renal arteries compared with the splanchnic arteries (80.4% ± 5.3% vs. 98.9% ± 1.1% respectively, p = .002). Estimated freedom from TVI for vessels treated with inner branches at 1 and 2 years was 93.3% ± 1.5% and 87.6% ± 2.2%, respectively. Estimated freedom from TVI at 2 years was higher for grafts with a combination of fenestrations and inner branches compared with grafts with inner branches only (91.4% ± 3.0% vs. 79.5% ± 6.5%, p = .022). Conclusion Inner branches were associated with excellent technical success rates. Renal arteries were associated with higher occlusion rates at 2 years compared with splanchnic arteries. Grafts with a combination of inner branches and fenestrations might be preferable over grafts with inner branches only, presenting higher patency and lower TVI rates.
OBJECTIVE:This study aimed to assess safety and efficacy of endovascular strategies for management of iliac bifurcation during endovascular aneurysm repair. DATA SOURCES:A systematic search was conducted of PubMed, Web of Science, and Scopus. REVIEW METHODS:A systematic review and Bayesian network meta-analysis were undertaken in accordance with PRISMA 2020 guidelines. Primary endpoints were incidence of iliac related reinterventions and type Ib/Ic endoleaks. Risk of bias was assessed via ROBINS-I tool. Certainty of evidence was evaluated using the GRADE framework. RESULTS:Twenty one studies were included, comprising 6291 patients and 7008 iliac bifurcations. The interventions evaluated were iliac branch devices (IBD), bell bottom technique, coil and cover, internal iliac artery (IIA) coverage with external iliac artery (EIA) extension, and the sandwich technique. IBD emerged as the only treatment reducing reinterventions compared with IIA coverage with EIA extension (risk ratio [RR] 0.46, 95% credible intervals [CrI] 0.15 - 0.93; Certainty of evidence: Moderate). For type Ib/Ic endoleaks, IBD ranked first according to the surface under the cumulative ranking curve (SUCRA) with modest separation from coil and cover (51.91 vs. 45.45) and was associated with a lower risk than bell bottom (RR 0.02, 95% CrI 0.00 - 0.15; Certainty of evidence: High). IBD (RR 0.07, 95% CrI 0.02 - 0.21; Certainty of evidence: Low), IIA coverage with EIA extension (RR 0.11, 95% CrI 0.03 - 0.30; Certainty of evidence: High) and bell bottom (RR 0.01, 95% CrI 0.00 - 0.06; Certainty of evidence: Low) reduced the risk of buttock claudication compared with coil and cover. CONCLUSION:IBD demonstrated fewer iliac related reinterventions than coil and cover, fewer type Ib/Ic endoleaks than bell bottom, and less buttock claudication than coil and cover. Overall, IBD demonstrated the most consistently favourable outcome profile among the evaluated strategies when anatomically suitable.
OBJECTIVE:The Society for Vascular Surgery Wound, Ischemia, and Foot Infection (WIfI) classification is widely used for risk stratification in patients with chronic limb threatening ischaemia. However, its clinical and economic implications within an Asian healthcare setting remain unclear. This study aimed to examine the association of WIfI stages with hospital length of stay (LOS), inpatient costs, major amputation risk, and survival outcomes. METHODS:This was a retrospective analysis of prospectively collected single centre data. Data were accrued from the Singapore General Hospital Vascular Quality Initiative (VQI) registry and the hospital's central billing system. Data were analysed for 1252 patients who underwent lower extremity peripheral vascular interventions (PVI) between January 2019 and December 2024. WIfI stage (1 - 4) was determined at the time of intervention. Clinical outcomes included total and postintervention LOS, complications, major amputation rates, and mortality. Total inpatient costs were assessed in 2024 US dollars. Multivariable linear regression and logistic regression were used to adjust for baseline covariates. Cox proportional hazards and Fine-Gray competing risks regression models evaluated overall survival (OS) and major amputation incidence, respectively. RESULTS:Higher WIfI stages correlated significantly with longer mean total and postintervention LOS, and higher inpatient hospitalisation costs ($25,547.7 in Stage 1 vs. $51,520.2 in Stage 4; p < .001). After multivariable adjustment, each WIfI stage increment was associated with an additional cost of $7637 (95% confidence interval [CI] $5733 - $9541). Stage 4 patients had significantly increased risks of major amputation (subdistribution hazard ratio [SHR] 2.50; 95% CI 1.35 - 4.63) and reduced OS (hazard ratio [HR] 1.38; 95% CI 1.12 - 1.71). CONCLUSION:WIfI classification predicts clinical outcomes and hospitalisation costs in this Asian setting. Higher WIfI stages significantly increase hospital LOS, costs, major amputation risk, and mortality, emphasising the value of the classification for clinical and economic decision making.
OBJECTIVE:The prevalence of abdominal aortic aneurysms (AAA) has increased among older adults. Complex AAAs (cAAA) involving the renovisceral segment pose substantial treatment challenges and require individualised strategies. For elders, evidence to support the best strategy is scarce. This multicentre, registry based, observational cohort study aimed to assess short term outcomes after cAAA repair in patients aged ≥ 80 years, using the Portuguese National Registry of Vascular Procedures. METHODS:Patients with intact cAAA (juxtarenal, pararenal, or complex infrarenal necks outside instructions for use for endovascular aneurysm repair [EVAR]) treated by open repair, fenestrated/branched EVAR (F/BEVAR) or EVAR (proximal neck adjuncts or off label standard EVAR) were included. The primary endpoint was major adverse events (MAEs). Secondary endpoints were textbook outcomes, mortality, failure to rescue, and practice trends. Inverse probability weighting was used to assess outcomes. RESULTS:Among 418 cAAA repairs, 21.5% were octogenarians (OG). They were more often treated by endovascular means (84.4% OG vs. 65.2% non-octogenarians [NOG]; adjusted odds ratio [aOR] 3.12 [95% confidence interval [CI] 1.45 - 6.72]). By 2024, F/BEVAR emerged as the preferred technique in OG (54.5%). Thirty day MAEs and mortality were significantly increased in OG (21.1% vs. 14.0% NOG, aOR 2.88, 95% CI 1.37 - 6.07 and 8.9% vs. 3.0% NOG, aOR 8.80, 95% CI 2.54 - 30.52). Textbook outcomes were less frequent in OG (47.8% vs. 64.0% NOG, aOR 0.37, 95% CI 0.21 - 0.66). Failure to rescue was comparable across age groups. Within octogenarians, open surgical repair (vs. endovascular repair) was associated with increased MAEs. One year survival was lower in OG (65.2% vs. 88.2% NOG, octogenarian aOR for 1 year mortality 6.85, 95% CI 2.90 - 16.15). CONCLUSION:Octogenarians represent a relevant proportion of cAAAs treated in Portugal. Practice favours endovascular repair, with a shift towards F/BEVAR. Despite minimally invasive approaches, octogenarians remain at higher risk of peri-operative complications. The excess peri-operative morbidity and 1 year mortality support concerns regarding patient selection and expected benefit in elders.
OBJECTIVE:Drug repurposing offers a cost effective approach to identify therapies for abdominal aortic aneurysm (AAA), which lacks proven medical treatment. This study assessed associations between long term cumulative drug exposure and AAA events (first time rupture or surgical repair). METHODS:This was a matched nested case-control study using nationwide Danish registries (1996 - 2021). Cases were first time AAA rupture or surgery; controls were individuals with AAA who were event free at the index date and matched 1:20 by sex and birth year. Drug exposure was assessed in defined daily doses at the Anatomical Therapeutic Chemical system chemical subgroup level. Associations were evaluated using log2 transformed unconditional logistic regression, adjusted for comorbidities and socioeconomic status. Identified associations were independently classified into four pre-defined hypothesis generating categories based on plausibility, bias, and relevance to AAA risk. RESULTS:The study included 17 536 cases (mean age 73.8 years; 80.8% male), each matched to approximately 20 controls. Of 181 chemical subgroups analysed, 29 presented significant dose-response associations. Dose doubling of statins and metformin was associated with lower odds of AAA events: odds ratio (OR) 0.93 (95% confidence interval [CI] 0.92 - 0.94) and OR 0.96 (95% CI 0.93 - 0.99), respectively. Additional inverse associations were observed with caries prophylactic agents (OR 0.91, 95% CI 0.84 - 0.99), proton pump inhibitors (OR 0.97, 95% CI 0.96 - 0.98), and antibiotic subgroups. Signals suggesting potential direct effects were observed for several additional drug classes, including antiplatelet agents, β blockers, testosterone inhibitors, non-steroidal anti-inflammatory drugs, and bisphosphonates. Overall, expert review classified 12 associations (41%) as suggestive of a direct or indirect drug effect. The findings suggest a substantial role of chronic infection in AAA pathogenesis. CONCLUSION:These findings identify several dose dependent associations between common medications and risk of AAA events, including signals consistent with protective effects of statins, metformin, and agents used for chronic infections. Chronic infection may represent a mechanistic pathway warranting further investigation.
OBJECTIVE:The aim of this study was to assess long term stent graft durability after thoracic endovascular aortic repair (TEVAR) for blunt traumatic aortic injury (BTAI). Secondary objectives were to evaluate aortic remodelling, to explore anatomic predictors of adverse imaging findings, and to assess imaging modalities and frequency of post-treatment surveillance. METHODS:This was a retrospective, multicentre, imaging based observational study of patients treated with TEVAR for BTAI (2001 - 2021) at four tertiary centres in Sweden. Patients surviving > 1 year were eligible. Inclusion required at least three computed tomography (CT) scans (pre-treatment, early post-treatment, and > 1 year after TEVAR). All CT scans were re-analysed at a single core facility using a pre-defined protocol. TEVAR related adverse findings included endoleak, graft infolding, fracture, collapse, thrombosis, or aneurysm formation. The report was structured according to the STROBE protocol for observational studies. RESULTS:Of 95 treated patients, 43 met the imaging follow up criteria. Most patients were male (86%), median age 42.1 years; ESVS grade II injury predominated (53%). Median follow up was 9.4 years (interquartile range 2.8, 12.7), with a median imaging frequency of 0.7 examinations/year. Adverse imaging findings occurred in nine patients (21%). Aortic dimensions increased significantly over time. From the early post-operative imaging to last follow up, the mean diameter increased by 4.7% (p < .001) at the level of the left subclavian artery, and in the descending aorta 2 cm distal to the stent graft the median diameter increased by 8.3% (p < .001). Aortic length increased in the ascending aorta by 9.5% (p = .037), in the arch by 8.4% (p = .028), and in the descending segment by 2.0% (p = .006). No anatomic variable predicted adverse imaging findings, but bird beak occurred in more than half of the patients and proved to be a dynamic phenomenon, capable of both appearing de novo and spontaneously regressing during follow up. CONCLUSION:In patients surviving the early phase, TEVAR for BTAI demonstrated durable outcome up to 10 years, with low risk of failure in patients with 2 years of uneventful initial follow up. However, progressive aortic remodelling persisted, with significant increases of both aortic diameters and lengths despite the relatively young age of the cohort, underlining the need for continued lifelong surveillance.
Objective It is unclear whether treating multiple diseased tibial arteries at initial revascularisation improves outcomes with chronic limb threatening ischaemia (CLTI). Using data from the Best Endovascular versus Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial this study aimed to compare single arterial intervention (SAI) with multiple arterial intervention (MAI) for infrapopliteal disease. Methods A retrospective, as treated analysis of the endovascular dataset from the BEST-CLI trial was undertaken to compare SAI with MAI. Only patients with multiple tibial vessel arterial occlusive disease with > 50% stenosis were included. Evaluated outcomes included major re-interventions (new bypass, interposition graft, thrombectomy, or thrombolysis), major adverse limb events (MALE)/death, and above ankle amputations. Risk adjusted analysis was performed. Results There were 324 patients included: 224 SAI and 100 MAI. On unadjusted analysis at 3 years, SAI had a higher rate of a major re-intervention (19.2% vs. 5.3%; p = .010) and MALE/death (56.4% vs. 43.6%; p = .030), while there was no difference for above ankle amputation (19.7% vs. 13.1%; p = .14), amputation/death (45.2% vs. 43%; p = .53), or all cause death (37.7% vs. 33.5%, p = .57). SAI and MAI were associated with similar rates of resolution of initial CLTI symptoms (75.9% vs. 86%; p = .60). On risk adjusted analysis, SAI was associated with a higher rate of major re-intervention (odds ratio [OR] 3.14, 95% confidence interval [CI] 1.2 – 8.2; p = .019) than MAI; however, there was no increase in any re-intervention (OR 0.95, 95% CI 0.6 – 1.49; p = .80), MALE/death (OR 1.27, 95% CI 0.86 – 1.89; p = .24), above ankle amputation (OR 1.53, 95% CI 0.74 – 3.19; p = .25), initial CLTI resolution (OR 1.16, 95% CI 0.85 – 1.59; p = .36), or death (OR 1.03, 95% CI 0.64 – 1.63; p = .90). Conclusion In patients with diffuse tibial arterial occlusive disease, treatment of multiple tibial arteries rather than just one at the time of index revascularisation was associated with fewer major re-interventions and should be considered.
Objectives The global burden of peripheral arterial disease (PAD) has increased, contributing to rising rates of lower limb vascular procedures (LLVPs), yet data from Asia remain limited. This retrospective, observational cohort study examined national trends in LLVPs and evaluated post-procedural outcomes, factors associated with these outcomes, and amputation free survival (AFS) following LLVPs. Methods National administrative data were used to retrospectively analyse individuals aged 16 – 100 years from 2012 – 2021. Age–sex standardised LLVP rates were estimated overall, and among populations with diabetes mellitus (DM), end stage renal disease (ESRD), and cardiac disease (CD), including DM–ESRD and DM–CD subpopulations. Trends were assessed using joinpoint regression. Median times to repeat LLVP, minor and major amputation, and all cause mortality were estimated, and Cox regression identified factors associated with AFS and major AFS. Results A total of 20 597 LLVPs were performed in 10 703 unique individuals between 2012 and 2021, 88% of whom had DM. Overall, LLVP rates increased by 3.22% annually (p = .001). Risk attributable to DM increased from 85.8% to 92.4% (p = .004). In 2021, LLVP rates were highest among ESRD (6 072.68 per 100 000) population. Within the DM–ESRD population, ESRD increased LLVP risk by 19 fold. Post-LLVP all cause mortality was 111.86 per 1 000 person years, with a median survival of 22.7 months. AFS and major AFS were 42% and 52% at 3 years. Older age, lower socioeconomic status, poorer cardio–metabolic–renal profile, and higher comorbidity burden were associated with poor outcomes. Conclusion LLVP rates increased nationally, reflecting a growing burden of PAD and were associated with high repeat intervention and mortality rates, particularly among patients with DM and ESRD. Marked ethnic and socioeconomic disparities further underscore the substantial burden of PAD and highlight the need for earlier prevention, improved risk factor control, and targeted strategies to improve long term outcomes.
