BACKGROUND:Clinical practice guidelines (CPGs) are often complex and subject to the reader's interpretation. The aim was to develop and validate an artificial intelligence (AI)-driven application for standardized interpretation of CPGs. The application was named "VascLink-AI," reflecting the clinical focus and traceable nature of the tool. METHODS:A comparative study to benchmark AI performance against established clinical standards. The 2017 European Society of Cardiology/European Society for Vascular Surgery Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases were vectorised into a knowledge graph. A large language model was locked to this graph, returning structured, citation-anchored answers. Performance was tested on 41 committee-answered vignettes. The app's answers and the committee's answers were scored for accuracy, completeness, clarity, relevance, adaptability, and evidence justification by an automated evaluator (GPT-4o) and 2 independent human experts. Inter-rater reliability and consensus scores were compared. A noninferiority analysis was performed. RESULTS:The application achieved high alignment with the expert intent, with composite scores favoring the app for both raters: automated 90.5% versus 77.8%, P < 0.001; human consensus 94.2% versus 86.2%, P < 0.001. Reliability analysis revealed an "agreement gap"; human raters' agreement on committee answers was negligible (Kappa = -0.018), but reached a moderate level on AI answers (Kappa = 0.450). The application was found to be noninferior to the experts across all 12 evaluated metrics (all P < 0.001). CONCLUSION:This study demonstrates how AI can grow from a general research aid into a traceable, guideline-restricted framework capable of delivering advice that matches human expert interpretation of societal guidelines.

BACKGROUND:Although smoking cessation has been shown to improve outcomes after lower extremity revascularization (LER), the impact of cessation duration has not been well-defined. This study investigates the impact of two cessation durations on LER outcomes in patients with chronic limb-threatening ischemia (CLTI). METHODS:The Peripheral Vascular Intervention, Infrainguinal Bypass, and Suprainguinal Bypass modules of the Vascular Quality Initiative were used to identify patients whose first recorded LER occurred between 2016 and 2024 for CLTI. Former smokers (FS) were divided into two groups based on the duration of smoking cessation. Recent FS had quit between 1 and 9 months before LER and 1-year FS had quite between 9 and 21 months to coincide with the standard follow-up period in the Vascular Quality Initiative. FS who quit more than 21 months before surgery were excluded. Two separate propensity score matches based on preoperative variables were performed at a three-to-one ratio, one of current smokers (CS) to recent FS and the other of CS to 1-year FS. Perioperative outcomes were compared along with Kaplan-Meier analysis for 1-year outcomes. RESULTS:There were 42,896 patients (84.7%) who were CS within 1 month of surgery, 4875 (11.4%) recent FS, and 2885 (5.7%) 1-year FS. Both groups of FS were significantly more likely to be older and have more cardiovascular comorbidities and prior revascularization procedures compared with CS. After matching, baseline characteristics were not different. There were no significant differences in perioperative complications between CS and recent FS or 1-year FS. Long-term outcomes were not different between CS and recent FS. However, patients in the 1-year FS group had significantly fewer major amputations compared with CS with no difference in thrombosis, reintervention, or mortality rates. On regression analysis, former smoking between 9 and 21 months was independently associated with lower major amputation compared with current smoking (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.58-0.90). Factors associated with higher major amputation included male sex (HR, 1.23; 95% CI, 1.02-1.48), Black race (HR, 1.52; 95% CI, 1.25-1.86), diabetes (HR, 1.59; 95% CI, 1.28-1.97), and end-stage renal disease (HR, 2.08; 95% CI, 1.61-2.70). CONCLUSIONS:In this study, FS and CS had no difference in perioperative outcomes after LER for CLTI. Smoking cessation for a period of 9 to 21 months before LER, but not less than 9 months, was independently associated with decreased long-term major amputation compared with current smoking. Patients undergoing LER for CLTI may need to sustain smoking cessation for 2 years to begin experiencing measurable benefit with respect to limb salvage.

Background: Premature atherosclerosis (PreAS) is generally defined as a disease affecting those under the age of 50 and has an outsized impact on quality-adjusted life years. We sought to better understand what individuals are at the highest risk for PreAS by examining differences in demographics and comorbidities compared to traditional atherosclerosis (TradAS). Study Design: An Institutional Review Board (IRB) approved retrospective study was conducted using retrospective data from a large regional health system. Patients who received a diagnosis of cerebrovascular disease (CeVD), coronary artery disease (CAD) or peripheral arterial disease (PAD) between 2012 and 2023 were included. Results: The review identified 136,328 patients in which 17,008 or 13% presented with PreAS (diagnosed from age 18 up to, and including, age 50). Rates of comorbidities were as follows (PreAs/TradAS): hypertension 63%/86%, diabetes 29%/35%. hyperlipidemia 45%/67%, chronic kidney disease 15%/26%, tobacco use 52%/60% and substance use 25%/9%. Differences in race, ethnicity and gender were as follows (PreAS/TradAS): White 59%/80%, Black 22%/10% and Latinx 17%/6%; male 51%/55%, and female 49%/45%. Conclusions: Patients with PreAS had lower rates of diseases that typically progress with aging, including hypertension, hyperlipidemia, chronic kidney disease, and diabetes. Tobacco use was less prevalent in the PreAS group and there was a significantly higher rate of illicit substance use in the PreAS population. Race and ethnicity were notably different with Black and Hispanic patients representing a significantly larger proportion of those with PreAS relative to TradAS. Our findings suggest risk factors beyond those classically described may play key roles in causing patients to develop PreAS.

Closed incision negative pressure therapy (ciNPT) with foam dressings has received broad recognition for its ability to support incision healing for a variety of surgical procedures. Over time, these dressings have evolved to include linear and 'area' shapes to better conform to different incision types and surface geometries. To address new studies on these configurations and provide guidance for dressing selection, an international, multidisciplinary panel of experts was convened. The panel reviewed recent publications on ciNPT with reticulated open cell foam (ROCF) dressings, shared their cases and experiences and engaged in roundtable discussions on benefits, drawbacks and technical challenges. Topics were ranked by importance and refined into potential consensus statements. These were shared for anonymous feedback, requiring 80% agreement for consensus. This manuscript establishes 12 consensus statements regarding risk factors supporting the use of ciNPT, conditions supporting preference of linear or area ciNPT dressings and tips for practical application of ciNPT with ROCF dressings. While this consensus panel expands on previous publications to aid clinicians' decision-making, further research is needed to refine recommendations and identify the strengths and limitations of ciNPT. Continued multidisciplinary collaboration will ensure ciNPT remains vital for improving surgical outcomes and patient care.

Atherosclerotic plaques form primarily in the coronary and carotid arteries, the aorta, and peripheral arteries of the lower extremities. Although a common model of atherogenesis across these arteries has evolved over decades, there is limited understanding of important differences in regional atherosclerotic disease. We sought to explore the relation between these disease groups by performing a retrospective study evaluating the temporal pattern of ASCVD patients with a diagnosis of cerebrovascular disease (CeVD), coronary artery disease (CAD), or peripheral arterial disease (PAD). An IRB-approved retrospective chart review was performed on a regional health system database. Records were obtained for all patients from 2012-2023 with ICD-10 diagnosis for CeVD, CAD, and PAD, including subcategory codes. The review identified 119,320 patients older than 50 years at an initial diagnosis. Diagnosis date and demographics were then used to evaluate the incidence and temporal relationship of subsequent disease. Fig 1 shows the distribution of disease by age group. The majority of patients (74%) had CAD. CAD alone was present in 45%, while a combination of CAD with PAD or CeVD (doublets) occurred in 9% and 14%, respectively. In patients with doublets, CAD manifested prior to CeVD in 54% and prior to PVD in 78%. Fig 2 shows the diagnostic sequence of disease in patients with all three diseases (7%; triplets). CAD is the first to manifest in 59% of the patients. CAD is more prevalent than CeVD or PAD in patients with ASCVD. CAD is the dominant disease either alone or in combination with CeVD or PAD. CAD also seems to manifest earlier than CeVD or PAD. This study emphasizes the importance of close management and surveillance of patients that present with CAD as this is a marker for subsequent disease in other vascular beds.Fig 2Triplets by diagnostic sequence.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective:Atherosclerosis underlies the most common etiologies of mortality worldwide, resulting in nearly 10 million deaths annually. In atherosclerosis, inflammation, metabolic factors, and hemodynamics cause the accumulation of extracellular lipids and the formation of plaques in the tunica intima of specific arteries. Atherosclerotic plaques primarily form in the coronary and carotid arteries, the aorta, and the peripheral arteries of the lower extremities. Although a common conceptual model of atherogenesis across these arteries has evolved over decades, there is a limited understanding of the important differences in regional atherosclerotic disease. Methods:This review summarizes clinical studies, meta-analyses, and case reports to compare and contrast the impact, risk, plaque features, and clinical management of carotid, coronary, and femoral atherosclerosis in humans. Results:Common risk factors, such as smoking and diabetes, influence disease risk differently across vascular beds. In addition, biological variables demonstrate a region-specific relationship with disease as peripheral atherosclerosis is most heritable, and male sex increases the risk of coronary and carotid, but not peripheral artery disease. The pathology of atherosclerotic lesions also varies between vascular territories. Specifically, carotid plaques are primarily lipid rich, whereas coronary plaques more commonly include fibrotic components with lipid-rich features, and femoral plaques are predominantly fibrocalcific. Clinically, interventional outcomes are worst in the carotid arteries and response to medical therapies, particularly statins, is not consistent across diseased regions, even within individual patients. Conclusions:Atherosclerosis manifests in site-specific ways with regional differences in susceptibility and treatment response. Despite advances in the scientific understanding and clinical management of atherosclerosis, little is known about the mechanisms determining vessel-specific disease patterns and risk. Further research is needed urgently to delineate factors controlling plaque initiation and progression specific to vascular beds.

BACKGROUND:The introduction of artificial intelligence (AI) has led to groundbreaking advancements across many scientific fields. Machine learning algorithms have enabled AI models to learn, adapt, and solve complex problems in previously unimaginable ways. Natural language processing allows these models to comprehend and respond to inquiries in a natural and humanly understandable way. We sought to investigate the application and performance of an AI chatbot in the diagnosis and management of vascular surgery patients. METHODS:An experimental study to evaluate the performance of GPT-4 AI model across 57 clinical scenarios derived from a textbook in vascular surgery. Specific prompts were devised to address the AI model and task it to identify symptoms, diagnose conditions, and select appropriate therapeutic approaches. Answers were scored, descriptive statistics were produced, and means were compared across topics. The reasoning and evidence used in the cases in which AI performed poorly were critically reviewed. RESULTS:The AI model correctly answered over 65% of the 385 questions. Performance variation between and within 13 vascular surgery topics did not show any statistically significant differences. Analysis of the questions where the model failed by more than 50% suggests a gap in the ability to interpret and process multifaceted medical information. Twenty-seven percent of these errors were attributed to potential lack of understanding of complex clinical scenarios. The AI model also quoted incorrect or outdated information in 14% of cases and showed an inability to comprehend context, nuances, and medical classification systems in 11% of the cases. CONCLUSIONS:GPT-4 demonstrated potential to provide clinically relevant answers for most of the tested scenarios. However, its reasoning must still be carefully analyzed for exactitude and clinical validity. While language models show promise as valuable tools for clinicians, it is essential to recognize their role as supportive mechanisms rather than standalone solutions.

Anterior lumbar interbody fusion (ALIF) is a standard approach for the surgical management of patients with severe degenerative disease at the L4-L5 and lumbosacral (L5-S1) levels. ALIF is performed through retroperitoneal exposure but harbors a small risk of major vascular injury. In this case, we describe an emergent endovascular repair of an external iliac vein injury that occurred during ALIF with long-term follow-up. We discuss specific strategies in the decision making and technique that led to a successful outcome in this case. Endovascular stent grafting is a potential bailout option for serious iliac vein injury.

Background: Antiplatelet monotherapy is recommended after infrainguinal lower extremity bypass (LEB). However, there is a paucity of high-quality data to guide therapy, and antiplatelet therapy is often prescribed in combination with anticoagulation. We therefore aimed to assess the variability in the use of antithrombotic therapy after infrainguinal LEB.Methods: The Vascular Quality Initiative dataset (2015-2021) was retrospectively reviewed to determine discharge patterns of antithrombotic therapy for all patients undergoing infrainguinal LEB. Monotherapy on discharge was defined as either single antiplatelet therapy (SAPT) or sin-gle anticoagulant (SAC). Combination therapy was dual antiplatelet therapy (DAPT), anticoagulant + antiplatelet (ACAP), or triple therapy. Hierarchical multivariable logistic regres-sion with random effects for physician and center was used to identify predictors of combination therapy. Median odds ratios (MOR) were derived to quantify degree of variability in antithrom-botic therapy.Results: There were 29,507 patients undergoing infrainguinal LEB (monotherapy = 10,634 vs. combination therapy = 18,873). SAPT (90.6%) was the most common form of monotherapy, while DAPT (57.7%) and ACAP (34.6%) were the most common combination therapies. Patients undergoing LEB to popliteal targets were more likely to be prescribed monotherapy (SAC or SAPT) than to infra-popliteal targets (60.6% vs. 56.6%, P < 0.001). Combination therapy (DAPT, ACAP, or triple therapy) was more often used in patients with tibial or plantar arteries as the bypass target. Patients undergoing bypass using autogenous vein were more likely to receive monotherapy compared with those receiving other conduits (64.8% vs. 52.9%, P < 0.001), while patients with prosthetic grafts were more likely to receive combination therapy (37.9% vs. 28.2%, P < 0.001). There were no significant differences in postoperative bleeding (P = 0.491) or 30-day mortality (P = 0.302) between the two groups. Prior peripheral vascular interventions (PVI) (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.79-1.99), concomitant PVI (OR: 1.83, 95% CI: 1.66-2.02), prosthetic graft use (OR: 1.74, 95% CI: 1.64-1.85), prior percutaneous coronary intervention (OR: 1.53, 95% CI: 1.43-1.65), plantar distal target (OR:

Background: Median arcuate ligament syndrome (MALS) is a clinical syndrome caused by compression of the celiac artery by the median arcuate ligament that often manifests with nonspecific abdominal pain. Identification of this syndrome is often dependent on imaging of compression and upward bending of the celiac artery by lateral computed tomography angiog-raphy, the so-called "hook sign."The purpose of this study was to assess the relationship of radiologic characteristics of the celiac artery to clinically relevant MALS. Methods: An institutional review board-approved retrospective chart review from 2,000 to 2,021 of 293 patients at a tertiary academic center diagnosed with celiac artery compression (CAC) was performed. Patient demographics and symptoms of 69 patients who were diag-nosed with symptomatic MALS were compared to 224 patients without MALS (but with CAC) per electronic medical record review. Computed tomography angiography images were reviewed and the fold angle (FA) was measured. The presence of a hook sign (defined as a visual FA < 135 & DEG;), as well as stenosis (defined as >50% of luminal narrowing on imaging) were recorded. Wilcoxon rank-sum test and Chi-squared test were used for comparative anal-ysis. Logistic model was run to relate the presence of MALS with comorbidities and radio-graphic findings. Results: Imaging was available in 59 patients (25 males, 34 females) and 157 patients (60 males, 97 females) with and without MALS, respectively. Patients with MALS were more likely to have a more severe FA (120.7 & PLUSMN; 33.6 vs. 134.8 & PLUSMN; 27.9, P = 0.002). Males with MALS were also more likely to have a more severe FA compared with males without MALS (111.1 & PLUSMN; 33.7 vs. 130.4 & PLUSMN; 30.4, P = 0.015). In patients with body mass index (BMI) >25, MALS patients also had narrower FA compared with patients without MALS (112.6 & PLUSMN; 30.5 vs. 131.7 & PLUSMN; 30.3, P = 0.001). The FA was negatively correlated with BMI in patients with CAC. The hook sign and stenosis were associated with diagnosis of MALS (59.3% vs. 28.7%, P < 0.001, and 75.7% vs. 45.2%, P < 0.001, respectively). In logistic regression, pain, stenosis, and a narrow FA were sta-tistically significant predictors of the presence of MALS. Conclusions: The upward deflection of the celiac artery in patients with MALS is more severe compared with patients without MALS. Consistent with prior literature, this bending of the celiac artery is negatively correlated with BMI in patients with and without MALS. When demographic variables and comorbidities are considered, a narrow FA is a statistically significant predictor of MALS. Regardless of MALS diagnosis, a hook sign was associated with narrower FA. While demographics and imaging findings may inform MALS diagnosis, clinicians should not rely on a visual assessment of a hook sign but should quantitatively measure the anatomic bending angle of the celiac artery to assist with the diagnosis and understand the outcomes.

BACKGROUND Median arcuate ligament syndrome (MALS) is a frequent differential diagnosis in patients with post-prandial abdominal symptoms, but diagnosis remains challenging. The aim of this study was to identify characteristics of patients who had MALS compared to non-MALS patients amongst a cohort of patients diagnosed with celiac artery compression (CAC). STUDY DESIGN An IRB approved retrospective chart review (2000-2021) of patients at our institution with a discharge diagnosis of CAC was performed. Medical record review for clinical symptoms and findings consistent with MALS was performed. RESULTS 293 patients with a diagnosis of CAC were identified. 59.7% were female and average age was 63.9 ± 20.2 years. 69 (23.5%) patients with CAC had MALS. There were no significant differences in sex or race between MALS and non-MALS patients, but MALS patients were younger (55.7 vs 68.1, p<0.001). There was no significant difference in gastrointestinal comorbidities between the two groups. Patients with MALS were less likely to have diabetes (12.5% vs. 26.9%), renal disease (4.6% vs 8.2%) and hypertension (41.5% vs. 70.3%), mesenteric atherosclerotic disease (14% vs 61.9%) and peripheral artery disease (15.0% vs 39.7%). CONCLUSION We demonstrate a novel observation that MALS patients tend to have less atherosclerotic characteristics than non-MALS patients with CAC. Patients in our study with MALS were more likely to be younger, female, and presenting with epigastric pain. MALS patients had a significantly lower incidence of diabetes, hypertension, renal disease, mesenteric artery disease and peripheral arterial disease compared to the non-MALS group. An important clinically relevant feature of MALS patients may be their lack of atherosclerotic phenotype compared with non- MALS patients with CAC.

Background/purpose Lack of robust, feasible, and quantitative outcomes impedes Raynaud phenomenon (RP) clinical trials in systemic sclerosis (SSc) patients. Hyperspectral imaging (HSI) non-invasively measures oxygenated and deoxygenated hemoglobin (oxyHb and deoxyHb) concentrations and oxygen saturation (O 2 sat) in the skin and depicts data as oxygenation heatmaps. This study explored the potential role of HSI in quantifying SSc-RP disease severity and activity. Methods Patients with SSc-RP ( n = 13) and healthy control participants (HC; n = 12) were prospectively recruited in the clinic setting. Using a hand-held camera, bilateral hand HSI (HyperMed™, Waltham, MA) was performed in a temperature-controlled room (22 °C). OxyHb, deoxyHb, and O 2 sat values were calculated for 78-mm 2 regions of interest for the ventral fingertips and palm (for normalization). Subjects underwent a cold provocation challenge (gloved hand submersion in 15 °C water bath for 1 min), and repeated HSI was performed at 0, 10, and 20 min. Patients completed two patient-reported outcome (PRO) instruments: the Raynaud Condition Score (RCS) and the Cochin Hand Function Scale (CHFS) for symptom burden assessment. Statistical analyses were performed using the Mann-Whitney U test and a mixed effects model (Stata, College Station, TX). Results Ninety-two percent of participants were women in their 40s. For SSc-RP patients, 69% had limited cutaneous SSc, the mean ± SD SSc duration was 11 ± 5 years, and 38% had prior digital ulcers—none currently. Baseline deoxyHb was higher, and O 2 sat was lower, in SSc patients versus HC ( p < 0.05). SSc patients had a greater decline in oxyHb and O 2 sat from baseline to time 0 (after cold challenge) with distinct rewarming oxyHb, O 2 sat, and deoxyHb trajectories versus HCs ( p < 0.01). There were no significant correlations between oxyHb, deoxyHb, and O 2 sat level changes following cold challenge and RCS or CHFS scores. Conclusion Hyperspectral imaging is a feasible approach for SSc-RP quantification in the clinic setting. The RCS and CHFS values did not correlate with HSI parameters. Our data suggest that HSI technology for the assessment of SSc-RP at baseline and in response to cold provocation is a potential quantitative measure for SSc-RP severity and activity, though longitudinal studies that assess sensitivity to change are needed.

Background: Bleeding is a rare but potentially life-threatening complication of varicose veins. There is paucity of literature about patients with varicose veins that present with bleeding and the effectiveness of vein ablation as therapy to prevent recurrent bleeding. This study compares patients treated with vein ablation for bleeding varicose veins with patients treated for venous symptoms other than bleeding. We hypothesize that vein ablation is safe and effective in preventing recurrence of bleeding from varicose veins. Methods: A retrospective single-centre review of consecutive patients undergoing vein ablation using radiofrequency in an outpatient office was performed. Patients presenting with bleeding were identified. A random (3:1) group of patients undergoing vein ablation for other venous symptoms and no bleeding was selected as a comparative group (control). The medical records were reviewed for patient characteristics and outcomes. A telephone survey inquiring about intensity of symptoms on a numeric rating scale of 0 to 10 prior and after treatment as well as recurrence of bleeding was also conducted. Patient characteristics and outcomes were compared between the two groups. Results: The incidence of patients with bleeding varicose veins was 3.6% (13/362) of all patients undergoing vein ablation at our center. A total of 26 ablations and 60 ablations were performed in patients with bleeding (n = 13) and controls (n = 39), respectively. There was no difference in age and race, but there was a trend for bleeding to occur more commonly in male patients (61.5% vs 33.3%; P = .073). Patients with bleeding from varicose veins were more likely to have congestive heart failure (P = .013) and present with more advanced venous disease based on CEAP classification (P = .005) compared with the control group. There was no difference between the 2 groups in vein closure (P = .246) or complications (P = .299) after vein ablation. With mean follow-up of 2.26 6 1.17 years, 85% of patients (n = 11) remained free from bleeding episodes. One patient with recurrent bleeding required additional vein ablation and the second patient had a concomitant ulcer that was treated with compression therapy. Conclusions: Bleeding from varicose veins is rare and more common in patients with congestive heart failure. Bleeding affects patients with higher CEAP scores. Vein ablation is a safe and effective treatment to prevent the recurrence of bleeding.

A 63-year-old man presented for the treatment of abdominal aortic aneurysm in the setting of bilateral internal iliac artery compromise from prior peripheral arterial disease treatments. The inferior mesenteric artery (IMA) measured 5 mm. Patient underwent coronary artery stenting 6 months prior and experienced left leg claudication. He underwent endovascular aneurysm repair with chimney IMA grafting and a femorofemoral bypass with uneventful recovery. At 1 year, computed tomography angiogram shows no flow in the aneurysm sac, and his left leg claudication resolved. Endovascular aneurysm repair with chimney IMA grafting for colonic perfusion preservation is a reasonable alternative to open surgical repair with IMA reimplantation in high-risk patients.

The prevalence of diabetes mellitus, diabetic foot (DF) disease and, as a result, lower extremity amputation rates remain high in the Caribbean. This study was undertaken to determine whether Caribbean countries have designated individuals that monitor DF disease and whether there are DF protocols consistent with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. Relevant DF health care personnel(s) from the CARICOM and Dutch Caribbean countries were called or sent questionnaires regarding the presence of structured programs to monitor and manage DF problems in the population. All 25 countries (100%) responded. 81% of respondents could not identify any Ministry, Hospital or individual initiatives that monitored the DF. Only 9 (36%) countries had any guidelines in place. Only 3 countries with guidelines in place utilized IWGDF guidelines. Only 6 (24%) countries had podiatrists and 10 (40%) had vascular surgery availability. 7 (28%) countries had the components for a multidisciplinary team. The presence or the appointment of a designated individual and/or a multidisciplinary approach within the countries for DF disease was absent in the majority of respondent countries. Only a minority of countries implemented DF guidelines or had expertise available to organize a DF multidisciplinary team. Vascular surgery and podiatric care were noticeably deficient. These may be critical factors in the variability and reduced success in implementation of strategies for managing DF problems and subsequent amputations amongst these Caribbean countries.