Objective: Complex abdominal aortic aneurysms (cAAA) pose a clinical challenge. The aim of this study was to assess the 30 day mortality and morbidity rates for open aneurysm repair (OAR) and fenestrated or branched endovascular aortic repair (F/B-EVAR), and the effect of hospital volume in patients with asymptomatic cAAA in Switzerland. Methods: Retrospective, cohort study using data from Switzerland's national registry for vascular surgery, Swissvasc, including patients treated from 1 January 2019 to 31 December 2022. All patients with asymptomatic, true, non-infected cAAA were identified. The primary outcome was 30 day mortality and morbidity rates reported using the Clavien-Dindo classification. Outcomes were compared between OAR and F/B-EVAR after propensity score weighting. Results: Of the 461 patients identified, 333 underwent OAR and 128 underwent F/B-EVAR for cAAA. At 30 days, the overall mortality rate was 3.3% after OAR and 3.1% after F/B-EVAR (p = .76). Propensity score weighted analysis indicated similar morbidity rates for both approaches: F/B-EVAR (OR 0.69, 95% CI 0.45- 1.05, p = .055); intestinal ischaemia (1.8% after OAR, 3.1% after F/B-EVAR, p = .47) and renal failure requiring dialysis (1.5% after OAR, 5.5% after F/B-EVAR, p = .024) were associated with highest morbidity and mortality rates. Treatment specific complications with high morbidity were abdominal compartment syndrome and lower limb compartment syndrome following F/B-EVAR. Overall treatment volume was low for most of the hospitals treating cAAA in Switzerland; outliers with increased mortality rates were identified among low volume hospitals. Conclusion: Comparable 30 day mortality and morbidity rates were found between OAR and F/B-EVAR for cAAA in Switzerland; lack of centralisation was also highlighted. Organ specific complications driving death were renal failure, intestinal ischaemia, and limb ischaemia, specifically after F/B-EVAR. Treatment in specialised high volume centres, alongside efforts to reduce peri-procedural kidney injury and mesenteric ischaemia, offers potential to lower morbidity and mortality rates in elective cAAA treatment.

BACKGROUND Mycotic internal iliac artery aneurysms are exceptionally rare and life-threatening, especially when complicated by gastrointestinal fistulization and rupture. CASE REPORT This case report details the multidisciplinary management of an 84-year-old man presenting with a mycotic aneurysm of the left internal iliac artery that ruptured into the neo-sigmoid colon, resulting in severe gastrointestinal bleeding and hemorrhagic shock. Emergency management involved endovascular coil embolization and stent graft placement, stabilizing the patient hemodynamically. Definitive treatment was achieved through open surgical resection of the infected aneurysm and fistula, followed by vascular reconstruction using a bovine pericardial graft. Extensive intraoperative debridement minimized reinfection risk, and targeted antibiotic therapy was administered to control the polymicrobial infection. This case underscores the importance of individualized surgical strategies in managing complex vascular pathologies. The use of a bovine pericardial graft provided a durable reconstruction in an infected field, while collaboration between vascular and colorectal surgeons was critical to addressing the fistulization. The patient had a good recovery, with resolution of the infection and excellent graft function during follow-up. CONCLUSIONS This report highlights the challenges in managing ruptured mycotic aneurysms with gastrointestinal involvement and emphasizes the critical role of timely surgical intervention and an interdisciplinary approach for complex pathologies. Our findings support the integration of endovascular techniques for stabilization and open surgery for definitive treatment, demonstrating how a multidisciplinary approach can optimize outcomes in high-risk patients.

OBJECTIVE:Manuscripts submitted to the European Journal of Vascular and Endovascular Surgery (EJVES) often contain shortcomings in baseline scientific principles and incorrectly applied methodology. Consequently, the editorial team is forced to offer post hoc repair in an attempt to support the authors to improve their manuscripts. This repair could theoretically have been prevented by providing more clear definitions and reporting standards to serve researchers when planning studies and eventually writing their manuscripts. Therefore, the general principles for EJVES publication standards are summarised here. METHODS:These publication standards did not follow a systematic approach but reflect the common opinion of the current Senior and Section Editors team. This team decided to only include recommendations regarding the most common pathologies in vascular surgery in this first edition of reporting standards, namely carotid artery disease, abdominal aortic aneurysm (AAA), peripheral arterial occlusive disease (PAOD), and chronic venous disease. In future editions, the plan is to expand the areas of research. RESULTS:Presented are (1) a common set of minimum but required publication standards applicable to every report, e.g., patient characteristics, study design, treatment environment, selection criteria, core outcomes of interventions such as 30 day death and morbidity, and measures for completeness of data including outcome information, and (2) a common set of minimum publication standards for four vascular areas. CONCLUSION:The editors of the EJVES propose universally accepted definitions and publication standards for carotid artery disease, AAA, PAOD, and chronic venous disease. This will enable the development of a convincing body of evidence to aid future clinical practice guidelines and drive clinical practice in the right direction. These first ever publication and reporting standards for EJVES aim to improve future research in the journal.

therapy ARR Absolute risk reduction ARWMC Age related white matter change AF Atrial fibrillation BA Basilar artery BES Balloon expandable stent BMS Bare metal stent

2 Dimensional 3 Dimensional Image Fusion Artificial Intelligence Artificial Intelligence Fluoroscopy As Low As Reasonably Achievable Air Kerma Automatic Brightness Control Automatic Exposure Control Anterior Posterior Active Personal Dosimeter Cumulative Air Kerma Cone Beam Computed Tomography Computed Tomography Computed Tomography Angiography Dose Area Product Digital Imaging and Communications in Medicine Deoxyribonucleic Acid Detective Quantum Efficiency Diagnostic Reference Level Digital Subtraction Angiography Effective Dose European Basic Safety Standards Directive European Journal of Vascular and Endovascular Surgery Electromagnetic Endovascular Navigation System European Society of Cardiology Entrance Skin Dose European Society for Vascular Surgery European Union European Vascular Surgeons in Training Electron Volt Endovascular Aortic Repair US Food and Drug Administration Fenestrated Endovascular Aortic Repair Field Of View Flat Panel Detector Fiber Optic RealShape Fluoroscopy Time Guideline Committee Guideline Writing Committee Gray “Personal dose equivalent” in soft tissue below body surface International Atomic Energy Agency International Commission on Radiological Protection Instructions For Use Image Intensifier In room Protective Equipment Ionising Radiation Regulations Air Kerma Area Product Kilo Voltage Peak Kilo Voltage Left Anterior Oblique Lifetime Attributable Risk Lower Extremity Peripheral Arterial Disease Lead Free Apron Linear No Threshold Milliamperage Medical Physics Expert Multiplanar Reconstructions National Council on Radiation Protection and Measurements Operator Controlled Imaging Optical Stimulated Luminescence Optically Stimulated Luminescence Dosimeters Lead Personal Protective Equipment PROficiency based StePwise Endovascular Curricular Training programme Peak Skin Dose Quality Assurance Reference Air Kerma Randomised Controlled Trial Radiation Induced Cataract RiboNucleic Acid Region Of Interest Sievert Thoraco-Abdominal Aortic Aneurysm Thoracic Endovascular Aortic Repair Thermoluminescent Dosimeter United Kingdom United Nations Scientific Committee on the Effects of Atomic Radiation Virtual Reality Absorbed dose: The mean energy imparted to matter of mass by ionising radiation. The SI unit for absorbed dose is joule per kilogram and is usually denoted in Gray (Gy). Organ absorbed doses are often quoted. Air kerma (AK): The quotient of the sum of the kinetic energies of all charged particles liberated by uncharged particles in a mass, dm, of air. The AK is measured or calculated at a reference point 15 cm from the isocentre in the direction of the focal spot cumulated from a whole Xray guided procedure. Air kerma area product (KAP, or dose area product, DAP): The KAP is the integral of the air kerma free in air (i.e., in the absence of backscatter) over the area of the Xray beam in a plane perpendicular to the beam axis (usually measured in Gy.cm2). The ICRP now recommends referring to those values as air-air-kerma area product (PKA). C-arm: A fixed or mobile Xray system used for diagnostic imaging and for fluoroscopic guidance during minimally invasive procedures. The name C-arm is derived from the C shaped arm that connects and maintains fixed in space, the Xray source and Xray detector. Collimation: The process of shaping the Xray beam to minimise the radiation field size to the required area of interest using metallic apertures within the Xray source. Computed tomography angiography (CTA): The combination of computed tomography cross sectional imaging with intravenous contrast in order to visualise arterial anatomy and pathology. Cone beam computed tomography (CBCT): A modality, available in modern endovascular operating rooms, that allows rotational acquisition and provides cross sectional imaging of the patient while still on the operating table. Deterministic effects: Deterministic effects of radiation exposure are related to a threshold dose of radiation exposure above which the severity of injury increases with increasing dose. Deterministic effects include harmful tissue reactions and organ dysfunction that result from radiation induced cell death, for example, skin lesions and lens opacities. Diagnostic reference levels (DRLs): Used for medical imaging with ionising radiation to indicate whether, in routine conditions, the patient radiation dose for a specified procedure is unusually high or low for that procedure. DRL values are usually defined as the third quartile of the distribution of the median values of the appropriate DRL quantity observed at each healthcare facility. Digital subtraction angiography (DSA): The acquisition of multiple images in succession within one field of view, with the subsequent digital subtraction of images taken prior to contrast injection, leaving a contrast enhanced image of the vessels, and removing non-vascular structures such as bone. Effective dose: The tissue weighted sum of the equivalent doses in all specified tissues and organs of the body, calculated in Sieverts (Sv). Endovascular operator: Any person carrying out an Xray guided procedure on the vasculature. Endovascular operating room: Any environment where endovascular procedures are carried out with Xray guidance using a C-arm as part of a mobile or fixed imaging system. Endovascular procedure: Any procedure on the vasculature that uses Xray guidance. Entrance skin dose (ESD): The dose absorbed by the skin at the entrance point of the Xray beam measured in Gy. This includes the back scattered radiation from the patient. Equivalent dose: Equivalent dose is the mean absorbed dose in a tissue or organ multiplied by the radiation weighting factor. This weighting factor is 1 for Xrays. Equivalent dose is measured in Sieverts (Sv). European Basic Safety Standards (EBSS) Directive: Describes the standards for protection against the risks associated with exposure to ionising radiation, including radioactive material and natural radiation sources, and also preparedness for the management of emergency exposure situations in the European Union. This is a European Council directive. Filtration: The materials of the Xray tube window and any permanent or variable or adjustable filters that predominantly attenuate the low energetic Xrays in the beam. Fluoroscopy time: The cumulative time spent using fluoroscopy during an endovascular procedure. Gray (Gy): The unit of absorbed radiation dose used to evaluate the amount of energy transferred to matter. One Gy is equivalent to 1 joule/kg. Image intensifier: This component of an imaging system relies on the fact that when Xrays are absorbed in a phosphor screen they convert into light photons. These photons impinge upon a photocathode that emits electrons in proportion to the number of incident Xrays. These photo-electrons are then accelerated across a vacuum in an image intensifier to produce an amplified light image. International Commission on Radiation Protection (ICRP): An independent, international organisation that advances for the public benefit the science of radiological protection, in particular by providing recommendations and guidance on all aspects of protection against ionising radiation. Medical physics expert (MPE): An individual or, if provided for in national legislation, a group of individuals, having the knowledge, training, and experience to act or give advice on matters relating to radiation physics applied to medical exposure, whose competence in this respect is recognised by the competent authority. Peak skin dose (PSD): The dose delivered, by both the primary beam and scatter radiation, at the most irradiated area of the skin. Pulse rate: The number of radiation pulses per second. Radiation exposed worker: Those over the age of 18 years who may be at risk of receiving radiation doses greater than the stipulated public exposure limit of 1 mSv per year of effective dose. Sievert (Sv): The unit used to measure both “effective dose” and “equivalent dose”. For Xrays, 1 Sievert equals 1 Gray (Gy). Stochastic effects: Stochastic effects of radiation exposure are those that occur by chance and, as such, the probability of them occurring, but not the severity, increases with increasing dose. A Linear No Threshold model has been adopted internationally, acknowledging that there is no threshold dose. The development of malignancy is the most common stochastic effect of radiation exposure. The past two decades have witnessed an exponential rise in the number of Xray guided minimally invasive procedures in vascular surgery.1Schanzer A. Steppacher R. Eslami M. Arous E. Messina L. Belkin M. Vascular surgery training trends from 2001–2007: a substantial increase in total procedure volume is driven by escalating endovascular procedure volume and stable open procedure volume.J Vasc Surg. 2009; 49: 1339-1344Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 2Beck A.W. Sedrakyan A. Mao J. Venermo M. Faizer R. Debus S. et al.Variations in abdominal aortic aneurysm care: a report from the International Consortium of Vascular Registries.Circulation. 2016; 134: 1948-1958Crossref PubMed Scopus (169) Google Scholar, 3Suckow B.D. Goodney P.P. Columbo J.A. Kang R. Stone D.H. Sedrakyan A. et al.National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients.J Vasc Surg. 2018; 67 (1690–7)Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar, 4Behrendt C.A. Sigvant B. Kuchenbecker J. Grima M.J. Schermerhorn M. Thomson I.A. et al.Editor's Choice - International variations and sex disparities in the treatment of peripheral arterial occlusive disease: a report from VASCUNET and the International Consortium of Vascular Registries.Eur J Vasc Endovasc Surg. 2020; 60: 873-880Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar With time, many of these endovascular procedures have been validated and have established themselves as the preferred treatment modality based on lower morbidity, mortality, and reduced length of hospital stay, compared with the open surgical alternatives. A large proportion of all vascular interventions are now performed using Xray guided endovascular techniques. Advances in technical expertise, evolving materials technology, and improved imaging capabilities have led to increasingly complex endovascular solutions which are associated with prolonged fluoroscopy times and consequently a rise in radiation exposure to both the patient and the endovascular operating team. There is growing concern regarding the increasing radiation exposure to the patient, and to the whole endovascular team.5Kirkwood M.L. Guild J.B. Arbique G.M. Anderson J.A. Valentine R.J. Timaran C. Surgeon radiation dose during complex endovascular procedures.J Vasc Surg. 2015; 62: 457-463Abstract Full Text Full Text PDF PubMed Google Scholar,6El-Sayed T. Patel A.S. Cho J.S. Kelly J.A. Ludwinski F.E. Saha P. et al.Radiation-induced DNA damage in operators performing endovascular aortic repair.Circulation. 2017; 136: 2406-2416Crossref PubMed Scopus (80) Google Scholar Endovascular operators are key personnel for promoting radiation safety and should work with other key stakeholders in a team approach to protect the patient and all healthcare staff in the endovascular operating room. The risks of radiation exposure are not universally recognised by all, however, because of a poor understanding of key concepts and paucity of educational material directly relevant to vascular surgery.7Mohapatra A. Greenberg R.K. Mastracci T.M. Eagleton M.J. Thornsberry B. Radiation exposure to operating room personnel and patients during endovascular procedures.J Vasc Surg. 2013; 58: 702-709Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar The present guidelines on the subject of radiation safety are the first to be written under the auspices of a vascular surgical society. Their explicit aim is to inform the reader about radiation physics and radiation dosimetry, raising awareness of the risks of ionising radiation and describing the methods available to protect against radiation exposure. Key issues of relevance to radiation protection for endovascular operators and all allied personnel have been outlined, and recommendations provided for best practice. This will no doubt also result in better radiation protection for the patient but a focus on patient radiation protection has been reserved, including during diagnostic procedures that require radiation exposure, for future iterations of the guideline. The guideline was written and approved by 14 members who, as well as vascular surgeons and interventional radiologists, included a radiation protection scientist and a medical physicist. The collated work is based on the best available evidence but also relies on the expert opinion of the aforementioned individuals who, as part of the process of gathering the evidence, identified several areas where future studies would better guide opinion. The reader should note that this document offers guidance and does not aim to dictate standards of care. The grading of each recommendation in these guidelines was agreed by a virtual meeting on 18 February 2022. If there was no unanimous agreement, discussions were held to decide how to reach a consensus. If this failed, then the wording, grade, and level of evidence was secured via a majority vote of the Guidelines Writing Committee (GWC) members. The final version of the guideline was submitted in July 2022. These guidelines will be updated according to future evidence and to the decisions made by the European Society for Vascular Surgery (ESVS) Guidelines Committee (GC). The GWC performed a literature search in Medline (through PubMed), Embase, Clinical Trial databases, and the Cochrane Library up to July 2022. Reference checking and hand search by the GWC added other relevant literature. The GWC selected literature based on the following criteria: (1) Language: English; (2) Level of evidence (Table 1). (3) Sample size: Larger studies were given more weight than smaller studies. (4) Relevant articles published after the search date or in another language were included, but only if they were of paramount importance to this guideline.Table 1Levels of evidence according to European Society of CardiologyLevel of evidence AData derived from multiple randomised clinical trials or meta-analysesLevel of evidence BData derived from a single randomised clinical trial or large non-randomised studiesLevel of evidence CConsensus of opinion of the experts and or small studies, retrospective studies, registries Open table in a new tab The recommendations in the guidelines in this document are based on the European Society of Cardiology (ESC) grading system. For each recommendation, the letter A, B, or C marks the level of current evidence (Table 1). Weighing the level of evidence and expert opinion, every recommendation is subsequently marked as Class I, IIa, IIb, or III (Table 2).Table 2Classes of recommendations according to European Society of CardiologyClasses of recommendationsDefinitionClass IEvidence and or general agreement that a given treatment or procedure is beneficial, useful, effectiveClass IIConflicting evidence and or a divergence of opinion about the usefulness or efficacy of the given treatment or procedure Class IIaWeight of evidence or opinion is in favour of usefulness or efficacy Class IIbUsefulness or efficacy is less well established by evidence or opinionClass IIIEvidence or general agreement that the given treatment or procedure is not useful or effective, and in some cases may be harmful Open table in a new tab It is important to note that for the general aspects of radiation safety, international bodies such as the International Commission on Radiological Protection (ICRP), the American Association of Physicists in Medicine, the European Federation of Organisations for Medicine and the International Atomic Energy Agency (IAEA) regularly carry out a thorough synthesis of available evidence to publish guidance documents and inform legislation pertaining to safety standards. Legislation in this context refers to statutory regulations that form the main legal requirements for the use and control of ionising radiation. These overview documents, rather than individual literature citations, have been used in the present guidelines to inform recommendations where this was thought to be appropriate. The present radiation protection guidelines are unique in that several of the recommendations made are actually based on legislation that derives from physics principles and extensive, irrefutable evidence that is the basis of this legislation. There have been extensive discussions within the GWC and Guidelines Committee as we have not been confronted previously with this issue in other guidelines. The conclusion agreed between all parties involved is that we could not make recommendations for what are legal requirements but that it is important for the guidelines to highlight areas where law “must” be followed. For this reason, we have, by unanimous decision, used the wording that recommendations based on legislation “must” be followed and the level of evidence has been marked as “law”. It must be noted that in some instances these are not “global or universal laws” and that the level of evidence denoted as “law” means law under most jurisdictions. The recommendations that are based on law are automatically Class I or III. This guideline also has several recommendations, where the evidence is based on physics principles and the results of studies are absolute truths even in small series. For example, increasing distance from the source of radiation reduces the amount of exposure. This is a principle of physics. The level of evidence used to make this type of recommendation reflects this concept and each of these recommendations is marked with a footnote as a “physics principle.” The GWC was selected by the ESVS to represent both physicians and scientists with expertise in the management of radiation exposure. The members of the GWC have provided disclosure statements of all relationships that might be perceived as real or potential sources of conflict of interest. The ESVS Guidelines Committee (GC) was responsible for the review and ultimate endorsement of these guidelines. All experts involved in the GWC have approved the final document. The guideline document underwent the formal external expert review process and was reviewed and approved by the ESVS GC. This document has been reviewed in three rounds by 25 reviewers, including vascular surgeons, interventional radiologists, and medical physics experts (MPE). All reviewers approved the final version of this document. Patient and public perceptions of radiation safety pertaining to endovascular surgery were captured. This section was written in partnership with patients and members of the public, to ensure the patient perspective is adequately represented in these guidelines and that medical professionals are aware of these views. The individuals consulted included (1) volunteers from the joint Health Protection Research Unit Public and Community Oversight Committee (https://crth.hpru.nihr.ac.uk/wider-engagement/), from the Scottish Environment Protection Agency, and from the Society and College of Radiographers; and (2) patients who had undergone endovascular procedures at Guy’s and St Thomas’ NHS Foundation Trust. The group was consulted about the guidelines and asked what they understood by the risks of radiation exposure. The patients’ opinions on the information that they would have liked pertaining to radiation exposure prior to their endovascular procedures were sought. We explored whether they would have found this useful despite the many unknowns about the risks associated with low dose radiation exposures. The following was understood by the group. Firstly, endovascular surgery, involving the blood vessels, referred to as minimally invasive procedures (those which use only small incisions, resulting in the need for only a small number of stiches) is used to diagnose and treat problems affecting the blood vessels (vascular disease). Secondly, endovascular surgery requires use of ionising radiation, which is radiation of high enough energy to cause damage to cells, potentially resulting in health effects such as cancer. Diagnosis prior to surgery and surveillance commonly requires computed tomography angiography (CTA) using Xrays. It was explained that the use of ionising radiation is in most countries very tightly controlled through legislation; however, the regulations do not cover all the detailed technical aspects of the use of radiation. As such, it is important that appropriate guidance is provided to ensure that use of radiation for each specific discipline is justified and safe. We explained that these ESVS guidelines have been prepared by physicians and scientists who are members of the GWC, selected by ESVS on the basis of their expertise in relevant areas of vascular surgery and radiation protection. The aims of the Guidelines are to outline for medical professionals the key issues of relevance to protect against exposure to ionising radiation. The Guidelines are written for doctors who perform vascular procedures and all allied personnel to provide recommendations for best practice. The Guidelines cover a range of topics including how to measure radiation exposure, the evidence for radiation effects, the current legislation and how to control exposure of the medical personnel through appropriate use of the equipment in the operating room and personal protection, education, and training, and the requirements for the future. The Guidelines and recommendations are based on the state of the art in terms of scientific evidence (based on the available studies), as reviewed by the committee, and regular updates are anticipated. The group stated that medical practitioners must have a good understanding of patient perceptions and expectations. In recent years information has become easy to find; however, the benefits and risks of health effects associated with ionising radiation are not well understood by the non-specialist, and there is a lot of misinformation. The majority perceived the main risk of radiation exposure to be development of cancer. Further, the real and perceived risk varies greatly depending on the source of radiation and how it is used, as well as on the basis of individual experience. It is generally accepted by the public that imaging involving radiation is an important tool; however, practitioners must ensure that the basic concepts such as what radiation is and why it is being used, as well as the value and risks of the specific procedure are clearly explained to every patient. This can be done both face to face, as part of the consent process, and by providing written literature. Anecdotally, some patients reported that this has not happened. Some patients also do not feel it is appropriate to question their doctor and they may say that they understand information provided when this may not be the case. The group, therefore, stated that generic literature about the procedures should include specific mention of the radiation risks and that the medical practitioner should spend time explaining possible risks to the patient to ensure mutual understanding is reached as far as is practical. This should include a clear explanation to the patient who should be aware that it is acceptable to ask questions. It should also be noted that paediatric exposures are not considered here as endovascular procedures on children are very rare; however, this is something that should perhaps be further considered in future iterations of these Guidelines.Tabled 1Recommendation 1Information regarding the risks of radiation exposure must be provided in plain, easy to understand language to patients before undertaking endovascular procedures.ClassLevelReferencesILawEBSS (2013)8Council Directive 2013/59/EURATOM of 5 December 2013 laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Official Journal of the European Union https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2014:013:0001:0073:EN:PDF.Google Scholar Open table in a new tab The group stated that it was important for physicians to be aware that the use of ionising radiation in general is based on three principles. Firstly, the principle of justification, which requires that use of radiation should do more good than harm. Secondly, the principle of optimisation requires that radiation doses should be kept as low as reasonably achievable. Thirdly, the principle of dose limitation requires that the dose to individuals from planned exposure situations, other than medical exposure of patients, should not exceed the appropriate limits. In contrast to non-medical uses of ionising radiation, which are solely process based, medical uses of radiation also depend on the requirements of the individual patient. When ionising radiation is used for medical purposes, exposure of the patient is carried out on the basis of the principles of justification and optimisation. Dose limitation is not considered relevant because a dose of ionising radiation that is too low is undesirable as the images produced may not be of high enough quality to perform a procedure. Justification of radiation exposure for each procedure ensures that the benefit the patient receives from exposure outweighs the radiation detriment and that associated risks are minimised. Justification is the legal responsibility of the registered healthcare professional (who may or may not be the vascular surgeon). The medical practitioner then takes responsibility to ensure that the patient understands the potential risks and that they understand and agree that the risks are worth taking, after weighing against the benefit of the procedure. If the procedure is justified, optimisation ensures that the procedure is carried out in the best possible way to deliver the best medical goal with the least radiation detriment. In medical settings such as during vascular surgery, where the operator of the imaging equipment is not a radiographer or radiologist, the primary responsibility for ensuring the radiation safety of the patient lies with the medical practitioner. In endovascular surgery, ionising radiation is used only for real time imaging purposes, to allow the surgeon to “see” what they are doing inside the body. As such, in practice, the vascular surgeons themselves have direct responsibility for how much radiation the patient receives as it is the vascular surgeon who directly controls when and how often imaging occurs (through use of a pedal or similar). The doses received by patients undergoing endovascular surgery vary depending on a number of factors including the type and complexity of the procedure. There are only a small number of studies which look explicitly at the doses patients receive, and more work is clearly needed here. In general, as discussed in Chapter 2 and Appendix 2, information about the risks associated with ionising radiation exposure come from information gathered through many years of use of ionising radiation in medical and nuclear settings, as well as from experience following atomic bomb testing and radiation accidents. For the doses experienced by patients, direct “tissue reactions” such as skin burns are rare. However, such effects do occur, and the risks and severity vary on a patient by patient basis. Further research is ongoing to better understand and guard against such effects. The patients and members of the public who have contributed to this chapter suggest that future research focuses more clearly on the patient specific dose levels involved in different procedures and how these vary on a case by case basis, which will facilitate clearer discussions on risk between patients and medical professionals prior to procedures being carried out; how cumulative doses might be recorded and used within the medical profession as a whole (something which is not generally done yet); and on the doses received by the practitioners themselves to underpin appropriate protection. Radiation exposure of the patient who receives specific limited exposure as part of treatment or diagnosis does slightly increase the average risk of late effects such as radiation induced cancer, which depends on cumulative lifetime dose, perhaps up to about 5% for a vascular surgery patient, depending on the type of procedure. However, the combined data from all studies suggest that the risk of developing cancer associated with ionising radiation is very small compared with the overall lifetime risk of all cancers, which is now about 50%. Such a risk is acceptable because it is substantially outweighed by the high risk of early death associated with not having the vascular procedure. Hence the procedure is justified. Patients thought they had very little information about radiation exposure and risks prior to their intervention and universally said they would want more despite some of the exact risks being unknown. Several felt that being empowered with information, either in the form of written information or a dedicated website, would raise their curiosity and make them want to find out more. They thought it essential that they be counselled about the risks of radiation exposure prior to their procedure but that it was unlikely the risks would impact their decision to undergo the procedure. It was

The whole editorial staff of the European Journal of Vascular and Endovascular Surgery (EJVES)1Dick F. Björck M. Inside EJVES - The Team Behind the Scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar wishes you a Happy New Year 2022! For the third time in a row, we live through a turn of the year that is dominated by the COVID 19 pandemic; indeed, the pre-COVID era already seems hard to remember. We have all had to find our individual ways through this global challenge, and we do hope you succeeded in establishing a new and healthy balance for yourself, your family, and friends and but also for the management of your patients2Faggioli G. Chakfé N. Imray C. Maintaining Safe Elective Aneurysm Surgery in the COVID-19 Era.Eur J Vasc Endovasc Surg. 2021; 62: 675-677Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,3Björses K. Blomgren L. Holsti M. Jonsson M. Smidfelt K. Mani K. Editor's Choice – The Impact of Covid-19 on Vascular Procedures in Sweden 2020.Eur J Vasc Endovasc Surg. 2021; 62: 136-137Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and your research.4Björck M. Boyle J. Dick F. The Need of Research Initiatives Amidst and After the Covid-19 Pandemic: A Message from the Editors of the EJVES.Eur J Vasc Endovasc Surg. 2020; 59: 695Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The continued extraordinary global situation also makes the pandemic the formative context of the present EJVES leadership cycle.1Dick F. Björck M. Inside EJVES - The Team Behind the Scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,5Dick F. Björck M. The EJVES is Taking the Next Step Anew.Eur J Vasc Endovasc Surg. 2020; 59: 1-2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar This issue marks the beginning of the third and final year of the present term. To look ahead, we have great pleasure announcing that Mr. Jonathan Boyle from Cambridge has been elected as the next Senior Editor by the EJVES Editorial Board. As Section Editor for Aortic Disease, Jon knows the Journal inside out and is perfectly placed to help lead it to new heights.6Dick F. Björck M. EJVES on the Rise Again, and the Annual Meeting Becomes the ESVS Month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,7Dick F. Björck M. Verhagen H. EJVES in an All-time Hybrid High, and the ESVS Annual Meeting Becomes Hybrid as well.Eur J Vasc Endovasc Surg. 2021; 62: 335-337Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar He will take office from October 2022 in support of Martin Björck, the next Editor in Chief from January 2023. The crucial steps of introducing (a) topical sections, (b) consistent presentation of contents and professional workflows, including a four eye principle in decision making and (c) systematic statistical appraisal1Dick F. Björck M. Inside EJVES - The Team Behind the Scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar were the basis for the current development. The EJVES editors have now broadened their activities towards new, inclusive, and highly successful publication formats (eg. Research letters)1Dick F. Björck M. Inside EJVES - The Team Behind the Scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and interactive platforms (eg. EJVES Vascular Forum)8Vega de Ceniga M. Ricco J.B. Rebirth of an ESVS journal - the new and interactive EJVES vascular Forum.Eur J Vasc Endovasc Surg. 2020; 59: 3-4Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar and have boosted their social media activities again.9Vega de Ceniga M. Chaudhuri A. Learn, connect and interact with the EJVES: EJVES vascular Forum and @EJVES_ESVS.Eur J Vasc Endovasc Surg. 2020; 60: 335-336Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar These conjoint activities resulted in a stunning increase of the Journals 2020 impact factor to 7.069, representing an all time high.7Dick F. Björck M. Verhagen H. EJVES in an All-time Hybrid High, and the ESVS Annual Meeting Becomes Hybrid as well.Eur J Vasc Endovasc Surg. 2021; 62: 335-337Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar This success is completely owing to our fantastic editorial staff1Dick F. Björck M. Inside EJVES - The Team Behind the Scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and our excellent group of external expert reviewers. In 2021, 414 reviewers performed an impressive 2683 expert reviews for the EJVES.10Dick F. Björck M. Acknowledgement of reviewers.Eur J Vasc Endovasc Surg. 2021; 62: 839-841Abstract Full Text Full Text PDF Google Scholar Their enormous contribution cannot be thanked enough, as it is purely driven by enthusiasm and interest, even under the worst of circumstances as during the past two years. In 2022, we will build further on our established base to continue improving our services. We will introduce a new role amongst our staff for ambitious young talents: Assistant Editors. They are expected to support the editorial process of the Journal and to engage in a research project about scientific publishing. During their two year term they will have an unique insight into a leading surgical Journal and may establish a powerful network within the global vascular community. The first Assistant Editor has just been elected, and we are proud to welcome Carlota F. Prendes from Munich to our team! In addition, we are experimenting with a new 'hybrid' publication vehicle, the electronic pdf based flip book. This format reads well on mobile devices, as well as on laptops and iPads, and aims to prepare for a paper free future,7Dick F. Björck M. Verhagen H. EJVES in an All-time Hybrid High, and the ESVS Annual Meeting Becomes Hybrid as well.Eur J Vasc Endovasc Surg. 2021; 62: 335-337Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar without losing the advantages of composed issues with topical associations. It even has obvious advantages over the paper journal; it is easier to navigate both from the Table of Contents to the individual articles, and within them. This option is already available since the October 2021 issue for all who subscribe through a European Society for Vascular Surgery (ESVS) membership individually or through linked national society memberships. We hope for positive feedback on this exciting new publication format. Last but not least, we will also improve our service to authors by reducing their time to publication significantly through online publication of uncorrected proofs of accepted papers.1Dick F. Björck M. Inside EJVES - The Team Behind the Scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar All these measures will set the stage for the next editorial leadership cycle which will start in 2023 with all the characteristic challenges of defending a leading position. As before, the EJVES will strive for the next level by preserving its high scientific and ethical standards whilst developing and pursuing innovative ideas. Two associate editors have ended their terms in December 2021, and we would like to take this opportunity to thank them and acknowledge their great contributions to the Journal. Marianne De Maeseneer (who joined in September 2013) has been responsible, together with Stavros Kakkos, for the venous papers. They have not only developed the 'Blue Department' in general, but also launched a series of key practice guidelines in that field.11Kakkos S.K. Gohel M. Baekgaard N. Bauersachs R. Bellmunt-Montoya S. Black S.A. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis.Eur J Vasc Endovasc Surg. 2021; 61: 9-82Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar,12De Maeseneer M.G. Kakkos S.K. Aherne T. Baekgaard N. Black S. Blomgren L. et al.Editor's choice: European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs.Eur J Vasc Endovasc Surg. 2022; (In Press)https://doi.org/10.1016/j.ejvs.2021.12.024Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar The first ever ESVS Guidelines on Management of Venous Thrombosis11Kakkos S.K. Gohel M. Baekgaard N. Bauersachs R. Bellmunt-Montoya S. Black S.A. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis.Eur J Vasc Endovasc Surg. 2021; 61: 9-82Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar were published in 2021, and the next (February) issue will publish the updated ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs.12De Maeseneer M.G. Kakkos S.K. Aherne T. Baekgaard N. Black S. Blomgren L. et al.Editor's choice: European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs.Eur J Vasc Endovasc Surg. 2022; (In Press)https://doi.org/10.1016/j.ejvs.2021.12.024Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar There has been so much progress, in particular regarding endovenous therapy options, so the updated guidelines are long awaited and appear timely for the ESVS venous Masterclass in January 2022. Eric Verhoeven (who joined in September 2015) has been the journal's well known face of complex endovascular therapies for many years. Attracting and handling research from this dynamic and innovative field is a difficult task. Validity of available evidence is often challenging and at times outdated soon after publication, but there are also ethical and commercial aspects that can turn this area into a minefield. Eric has handled the papers with great care and dedication and built up the journal's reputation for this crucial field. We thank both Marianne and Eric for their enormous contributions and support; their absence will be greatly felt. Fortunately, however, we will soon be able to announce their replacements. All the editorial staff including our rejuvenated editorial board (please see this issue's editorial staff page) will give their best in 2022 to keep serving the needs of our authors, readers and reviewers and to provide the best research and clinical guidance in vascular care. Happy New Year!

ObjectiveA structured and transparent approach is instrumental in translating research evidence to health recommendations and evidence informed clinical decisions. The aim was to conduct an overview and analysis of principles and methodologies for health guideline development.MethodsA literature review on methodologies, strategies, and fundamental steps in the process of guideline development was performed. The clinical practice guideline development process and methodology adopted by the European Society for Vascular Surgery are also presented.ResultsSophisticated methodologies for health guideline development are being applied increasingly by national and international organisations. Their overarching principle is a systematic, structured, transparent, and iterative process that is aimed at making well informed healthcare choices. Critical steps in guideline development include the assessment of the certainty of the body of evidence; evidence to decision frameworks; and guideline reporting. The goal of strength of evidence assessments is to provide well reasoned judgements about the guideline developers’ confidence in study findings, and several evidence hierarchy schemes and evidence rating systems have been described for this purpose. Evidence to decision frameworks help guideline developers and users conceptualise and interpret the construct of the quality of the body of evidence. The most widely used evidence to decision frameworks are those developed by the GRADE Working Group and the WHO-INTEGRATE, and are structured into three distinct components: background; assessment; and conclusions. Health guideline reporting tools are employed to ensure methodological rigour and transparency in guideline development. Such reporting instruments include the AGREE II and RIGHT, with the former being used for guideline development and appraisal, as well as reporting.ConclusionThis guide will help guideline developers/expert panels enhance their methodology, and patients/clinicians/policymakers interpret guideline recommendations and put them in context. This document may be a useful methodological summary for health guideline development by other societies and organisations.

Reference checking and hand search by the GWC members added other relevant literature.A second

Welcome to a hopefully Happy New Year 2021! After a difficult year crammed with unexpected challenges, we hope that we can now all return, slowly but surely, to a new normal in good health and positive spirits. This issue opens the 61st volume of the European Journal of vascular and endovascular surgery (EJVES) and marks the year in the middle of the present leadership cycle.1Dick F. Björck M. The EJVES is taking the next step anew.Eur J Vasc Endovasc Surg. 2020; 59: 1-2Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Following the introduction of a new overall style in 20192Dick F. Kolh P. Introducing the new design of the European journal of vascular and endovascular surgery.Eur J Vasc Endovasc Surg. 2019; 57: 1-3Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, last year was dedicated to restructuring towards more professional workflows. Thereby, dedicated sections were introduced for the Journal's core areas: carotid, aorto-iliac and peripheral artery disease, as well as systematic reviews. A four eye principle in decision making, and systematic statistical appraisal of accepted papers were installed. And a comprehensive style homogenisation of tables and figures was established.2Dick F. Kolh P. Introducing the new design of the European journal of vascular and endovascular surgery.Eur J Vasc Endovasc Surg. 2019; 57: 1-3Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In addition, a new and inclusive publication format, the Research letter, was introduced;3Dick F. Björck M. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar our interactive online open access companion EJVES Vascular Forum was ‘re-invented’;4Vega de Ceniga M. Ricco J.B. Rebirth of an ESVS journal - the new and interactive EJVES vascular Forum.Eur J Vasc Endovasc Surg. 2020; 59: 3-4Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar and both Journals' presence on social media was boosted again.5Vega de Ceniga M. Chaudhuri A. Learn, connect and interact with the EJVES: EJVES vascular Forum and @EJVES_ESVS.Eur J Vasc Endovasc Surg. 2020; 60: 335-336Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In parallel, the production of ESVS clinical guidelines was standardised and enhanced, and, as a consequence, two key practice guidelines (one on the management of acute limb ischaemia6Björck M. Earnshaw J.J. Acosta S. Bastos Gonçalves F. Cochennec F. Debus E.S. et al.Editor's choice - European society for vascular surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia.Eur J Vasc Endovasc Surg. 2020; 59: 173-218Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar and one on vascular graft and endograft infections7Chakfé N. Diener H. Lejay A. Assadian O. Berard X. Caillon J. et al.Editor's choice - European society for vascular surgery (ESVS) 2020 clinical practice guidelines on the management of vascular graft and endograft infections.Eur J Vasc Endovasc Surg. 2020; 59: 339-384Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar) were published in 2020 to follow those published in 2019.8Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.Editor's choice - European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (1191) Google Scholar,9Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guidelines on the management of chronic limb threatening ischaemia.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109Abstract Full Text Full Text PDF PubMed Scopus (503) Google Scholar All these efforts in synergy and with the Journal's impact factor increase to 5.328, have resulted in a record number of submissions to the EJVES in 2020.3Dick F. Björck M. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Despite all the organisational challenges associated with the COVID pandemic10Björck M. Boyle J. Dick F. The need of research initiatives amidst and after the covid-19 pandemic: a message from the editors of the EJVES.Eur J Vasc Endovasc Surg. 2020; 59: 695Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar and the concurrent introduction of a new workflow,1Dick F. Björck M. The EJVES is taking the next step anew.Eur J Vasc Endovasc Surg. 2020; 59: 1-2Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar the EJVES has managed to speed up its editorial processes over the year. Whereas the average time to the first editorial decision stayed at three to four weeks, crucial measures such as ‘time to first online’ and ‘time to final publication’ were reduced by two to three weeks. This is a pleasing outcome for the conjoint efforts to keep the EJVES attractive to our authors. In 2021, we will publish new findings even faster by putting uncorrected proofs of accepted papers online. As is customary at the end of a year, the Editors acknowledged and thanked the journal's reviewers in the last issue for their enormous help to achieve these goals.11Dick F. Björck M. Acknowledgement of reviewers.Eur J Vasc Endovasc Surg. 2020; 60: 795-797Abstract Full Text Full Text PDF Google Scholar In 2020, the EJVES was supported by 417 reviewers who performed a stunning 3281 expert peer reviews for the Journal. This enormous work is purely driven by enthusiasm and interest and is provided on a complimentary basis. This year, the EJVES also wants to acknowledge and thank another crucial group of people for their unremitting hard work which is all too often taken for granted: The editorial and publisher's staff behind the Journal's success (Figure 1, Figure 2, Figure 3). Many are well known clinicians, skilful surgeons and international leaders in their field. Others may be less well known, but all are exquisite scholars and scientists, curious and always striving for knowledge. Without their idealistic commitment, the EJVES would not exist.Figure 2Associate Editors, European Journal of Vascular and Endovascular Surgery. (A) Nabil Chakfé, Associate Editor, France, since September 2015; (B) Arindam Chaudhuri, Associate Editor, United Kingdom, since July 2015; (C) Marianne De Maeseneer, Associate Editor, The Netherlands, since September 2013; (D) Stavros Kakkos, Associate Editor, Greece, since September 2016; (E) Riikka Tulamo, Associate Editor, Finland, since April 2019; (F) Eric Verhoeven, Associate Editor, Germany, since September 2015; (G) Oliver Lyons, incoming Associate Editor, United Kingdom, from January 2021; and (H) Isabelle Van Herzeele, incoming Associate Editor, Belgium, from January 2021.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Publisher's staff, European Journal of Vascular and Endovascular Surgery, Elsevier. (A) Annette Fowler, Administrative Editor; (B) Claire Quick, Journal Manager; (C) Simon Parvin, Language editor; and (C) Ash Allan, Publisher.View Large Image Figure ViewerDownload Hi-res image Download (PPT) First and foremost, we bid farewell to the longest standing Editor of the group, Mark Koelemay who, after more than 10 years in the journal's service, has decided to step down. He led the Systematic reviews section and curated the Journal's correspondence, but above all guided us with his wise yet critical appraisal and unerring advice. His voice will be missed, even if well replaced. Of the other section editors (Fig. 1), Gert De Borst is driving the Carotid section with a lot of enthusiasm after having chaired the Guidelines committee on the Journal's behalf for many years. Jonathan Boyle has taken the Aortic section to even greater heights with an admirable overview of current trends. Joe Mills only joined in 2020 as the first ever EJVES Editor from the US, and already shapes the Peripheral arterial disease section into a hub for seminal analyses. Kevin Mani will take over from Mark after having cared for the randomised trials and having ensured a sound methodology in EJVES publications. In addition, he has assembled and led an excellent group of young clinician statisticians who screen all published papers for analytical consistency and internal validity. The Associate Editors (Fig. 2) process and curate submissions in all other exciting fields of vascular care. Nabil Chakfé, not only a cardiovascular surgeon, but also an inventor and founder of GEPROVAS, screens all basic research submissions for promising translational investigations. Arindam Chaudhuri, social media native, has pushed the EJVES presence in the social media through the roof to reach a much larger community than the subscriber base.5Vega de Ceniga M. Chaudhuri A. Learn, connect and interact with the EJVES: EJVES vascular Forum and @EJVES_ESVS.Eur J Vasc Endovasc Surg. 2020; 60: 335-336Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar He has also embossed many of the Journal's short report formats. Marianne De Maeseneer and Stavros Kakkos have successfully built up the Journal's ‘Blue Department’ to gain support in the phlebology community and launched a series of key guidelines in that field. In addition, Stavros curates the educational contents. Riikka Tulamo has single handedly enforced the style requirements in all publications over the past two years, and thereby shone with incredible diligence, accuracy, and foresight. Finally, Eric Verhoeven has catapulted the EJVES into the realms of endovascular complexities and innovations, tapping his remarkable experience and complex networks. We warmly welcome two incoming Editors (Fig. 2). Oliver Lyons will follow Kevin in caring for methodology and randomised trials; and Isabelle Van Herzeele will take over Research letters, Images and Educational content. Both of them will also support Riikka to get acquainted with the style concepts. A Journal would not exist without a reliable, supportive and swift publishing team (Fig. 3). Many authors will know Annette Fowler, the administrative Editor, who runs the editorial office with unmatched competence and gentleness to process the submissions. All authors who have experienced her quick and accurate replies to whatever issue, will probably be surprised by the fact that she serves not only the EJVES, but four scientific journals! Once a submission is accepted, Claire Quick, the Journal manager, takes over to oversee production. This includes copy and style editing, language editing (perfectly provided for many years by Simon Parvin, former Secretary General of the ESVS and aesthete) and typesetting. With imperturbability, she ensures a perfect result by pre-emptive handling of all pitfalls. Behind this team stands Ash Allan, the Publisher, as the best partner the EJVES could wish for. He supports not only processes with dedication but also the people involved and is an integral part of the EJVES success.3Dick F. Björck M. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Last but not least, the Editors are supported by a dedicated advisory board of eminent clinicians and scientists who are recruited and renewed annually from the very best reviewers.11Dick F. Björck M. Acknowledgement of reviewers.Eur J Vasc Endovasc Surg. 2020; 60: 795-797Abstract Full Text Full Text PDF Google Scholar Members are engaged for three to six years in the Editorial board, and they have a strategic role in the development of the journal, as outlined in the ESVS byelaws. In exceptional cases engagements are prolonged, but never to more than 9 years. We try to rejuvenate a small proportion every year to keep the vascular community involved, and to encourage the best reviewers. We warmly thank all the members who have left the board at the end of last year for their outstanding service and welcome the new Editorial board members! Together we will give our best in 2021 to serve our readers' needs and to provide best research and clinical guidance in vascular care. Happy New Year!

The Swedish Drug Elution Trial in Peripheral Arterial Disease (SWEDEPAD) has reported an interim safety analysis in the New England Journal of Medicine1Nordanstig J. James S. Andersson M. Andersson M. Danielsson P. Gillgren P. et al.Mortality with paclitaxel-coated devices in peripheral artery Disease.N Engl J Med. 2020; Crossref Scopus (89) Google Scholar showing that use of paclitaxel does NOT lead to excess mortality at mean 2.5 years follow up. This is an extremely important and reassuring finding, after the systematic review and meta-analysis by Katsanos et al.2Katsanos K. Spiliopoulos S. Kitrou P. Krokidis M. Karnabatidis D. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials.J Am Heart Assoc. 2018; 7e011245Crossref PubMed Scopus (635) Google Scholar had cast severe doubts on drug eluting technology. Randomised Controlled Trials (RCTs) offer the best methodology to assess the effects of new interventions, but they do have important limitations.3Mani K. Björck M. Alternatives to randomised controlled trials for the poor, the impatient and when evaluating emerging technologies.Eur J Vasc Endovasc Surg. 2019; 57: 598-599Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Selection bias is common, and usually they do not represent the entire population at risk. In addition, RCTs are expensive, and often their results arrive late, so they are sometimes no longer relevant. Observational data may have more obvious limitations, but they can be very representative if collected within systematic registries (‘real world’). A hybrid solution is to randomise patients within population based registries, and the first ever registry based RCT (RRCT) was published in 2013.4Fröbert O. Lagerqvist B. Olivecrona G.K. Omerovic E. Gugnason T. Maeng M. et al.Thrombus aspiration during ST-segment elevation myocardial infarction.N Engl J Med. 2013 Oct 24; 369: 1587-1597Crossref PubMed Scopus (804) Google Scholar SWEDEPAD is the first RRCT within the Swedvasc registry. Its original aim was to find out whether drug elution technology affected amputation rates in patients with chronic limb threatening ischaemia (CLTI), and quality of life (QoL) in patients with intermittent claudication (IC). Based on the sample size calculation the study planned to randomise 3 700 patients, 2 400 with CLTI and 1 300 with IC. When, in December 2018, the Katsanos systematic review2Katsanos K. Spiliopoulos S. Kitrou P. Krokidis M. Karnabatidis D. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials.J Am Heart Assoc. 2018; 7e011245Crossref PubMed Scopus (635) Google Scholar suggested an increased mortality after paclitaxel administration at medium term follow up, inclusion into SWEDEPAD was immediately halted on December 10, 2018. At that time 2 289 patients had been randomised: 1 480 with CLTI, and 809 with IC. Although not pre-planned in the analysis plan, the trial data and safety monitoring committee recommended an interim analysis of all cause mortality as soon as a minimum follow up was reached in a large proportion of the patients. The SWEDEPAD investigators have now found that after a mean follow up of 2.5 years:1Nordanstig J. James S. Andersson M. Andersson M. Danielsson P. Gillgren P. et al.Mortality with paclitaxel-coated devices in peripheral artery Disease.N Engl J Med. 2020; Crossref Scopus (89) Google Scholar as expected in this population, mortality was high, with 574 deaths overall (25%). Of 2 289 randomised patients, 1 457 had been followed for two years, 789 for three years, and 282 for four years. Interestingly, there was no difference in mortality between the treatment groups, either for CLTI or for IC, at any follow up interval. Mortality at the end of follow up was, for drug coated vs. non-drug coated devices, for patients with CLTI 249 [33.4%] vs. 243 [33.1%], and for those with IC 44 [10.9%] vs. 38 [9.4%], respectively. Although the title of the paper (“Mortality with Paclitaxel-coated Devices in Peripheral Artery Disease”)1Nordanstig J. James S. Andersson M. Andersson M. Danielsson P. Gillgren P. et al.Mortality with paclitaxel-coated devices in peripheral artery Disease.N Engl J Med. 2020; Crossref Scopus (89) Google Scholar may suggest otherwise, these results are quite reassuring. In contrast to the Katsanos meta-analysis, which analysed aggregate data of several heterogeneous RCTs (some of them underpowered) with variable follow up,2Katsanos K. Spiliopoulos S. Kitrou P. Krokidis M. Karnabatidis D. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials.J Am Heart Assoc. 2018; 7e011245Crossref PubMed Scopus (635) Google Scholar SWEDEPAD is a large, homogeneous and population based, i.e. representative, RCT. Not even the slightest trend towards an increased mortality among the paclitaxel treated patients was shown. Of note, no other drug than paclitaxel was used in the drug eluting balloons and stents. Furthermore, for mortality not a single patient was lost to follow up in this large study. This is explained by the fact that the same personal identity number that was used in the trial is also used in healthcare and the population registry. The latter captures all deaths in the country with a maximum delay of two weeks and adds this information to Swedvasc through automatic cross matching. Since death is not reported by the treating surgeons or radiologists, the risk of “alternative facts” is minimised. It is important to note that no outcomes other than mortality were reported in this interim analysis. Enrolment into the study has been re-initiated, although the Covid-19 pandemic presently delays the inclusion rate. We look forward to learning about the main outcomes of this study: amputations, re-interventions and QoL, which will inform us whether drug eluting techniques have clinical benefits and risks. In the meantime, we can feel safe using paclitaxel coated devices in the sense that there is not an increased mortality risk. But it remains to be shown whether this treatment has any clinical advantages, and if it is cost effective. This paper adds robust evidence to previous reports from observational data. Behrendt CA et al.5Behrendt C.A. Sedrakyan A. Peters F. Kreutzburg T. Schermerhorn M. Bertges D.J. et al.Editor's choice - long term survival after femoropopliteal artery revascularisation with paclitaxel coated devices: a propensity score matched cohort analysis.Eur J Vasc Endovasc Surg. 2020; 59: 587-596Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar performed two propensity score analyses (sometimes named “the poor man's RCT”) in a large insurance fund database in Germany. They could not identify any increased mortality among patients treated with paclitaxel coated devices, either after intervention in the femoropopliteal,6Heidemann F. Peters F. Kuchenbecker J. Kreutzburg T. Sedrakyan A. Marschall U. et al.Long term outcomes after revascularisations below the knee with paclitaxel coated devices: a propensity score matched cohort analysis.Eur J Vasc Endovasc Surg. 2020; 60: 549-558Abstract Full Text Full Text PDF Scopus (16) Google Scholar or in the below the knee6Heidemann F. Peters F. Kuchenbecker J. Kreutzburg T. Sedrakyan A. Marschall U. et al.Long term outcomes after revascularisations below the knee with paclitaxel coated devices: a propensity score matched cohort analysis.Eur J Vasc Endovasc Surg. 2020; 60: 549-558Abstract Full Text Full Text PDF Scopus (16) Google Scholar segments. The Global CLTI Guidelines7Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guidelines on the management of chronic limb-threatening ischemia. Joint guidelines of the society for vascular surgery; European society for vascular surgery; world federation of vascular societies.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109Abstract Full Text Full Text PDF PubMed Scopus (493) Google Scholar could not give firm recommendations regarding the use of drug eluting devices. Hopefully, we will have more data in future guidelines. In the meantime, vascular surgeons and interventionists will have to lean on personal experience, rule of thumb and budget restrictions, when deciding whether or not to use this technology. At least we need no longer worry that we harm our patients, and the fact that recruitment into the SWEDEPAD trial has restarted is good news for future knowledge.

BACKGROUND:Reliable prediction of the preoperative risk is of crucial importance for patients undergoing aortic repair. In this retrospective cohort study, we evaluated the metabolic equivalent of task (MET) in the preoperative risk assessment with clinical outcome in a cohort of consecutive patients. METHODS:Retrospective analysis of prospectively collected data in a single center unit of 296 patients undergoing open or endovascular aortic repair from 2009 to 2016. The patients were divided into four anatomic main groups (infrarenal (endo: n = 94; open: n = 88), juxta- and para-renal (open n = 84), thoraco-abdominal (open n = 13) and thoracic (endo: n = 11; open: n = 6). Out of these, 276 patients had a preoperative statement of their functional capacity in metabolic units and were evaluated concerning their postoperative outcome including survival, in-hospital mortality, postoperative complications, myocardial infarction and stroke, and the need of later cardiovascular interventions. RESULTS:The median follow-up of the cohort was 10.8 months. Patients with < 4MET had a higher incidence of diabetes mellitus (p = 0.0002), peripheral arterial disease (p < 0.0001), history of smoking (p = 0.003), obesity (p = 0.03) and chronic obstructive pulmonary disease (p = 0.05). Overall in-hospital mortality was 4.4% (13 patients). There was no significant difference in the survival between patients with a functional capacity of more than 4 MET (220 patients, mean survival: 74.5 months) and patients with less than 4 MET (56 patients, mean survival: 65.4 months) (p = 0.64). The mean survival of the infrarenal cohort (n = 169) was 74.3 months with no significant differences between both MET groups (> 4 MET: 131 patients, mean survival 75.5 months; < 4 MET: 38 patients, mean survival 63.6 months. p = 0.35). The subgroup after open surgical technique with less than 4 MET had the lowest mean survival of 38.8 months. In 46 patients with > 4MET (20.9%) perioperative complications occurred compared to the group with < 4MET with 18 patients (32.1%) (p = 0.075). There were no significant differences in both groups in the late cardiovascular interventions (p = 0.91) and major events including stroke and myocardial infarction (p = 0.4) monitored during the follow up period. The risk to miss a potential need for cardiac optimization in patients > 4MET was 7%. CONCLUSION:The functional preoperative evaluation by MET in patients undergoing aortic surgery is a useful surrogate marker of perioperative performance but cannot be seen as a substitute for preoperative cardiopulmonary testing in selected individuals. Trial registration clinicaltrials.gov, registration number NCT03617601 (retrospectively registered).

As every year, Clarivate analytics published the 2020 Journal Citation Report in late June. The European Journal of Vascular and Endovascular Surgery (EJVES) finds itself in an all-time high – again! After last year’s record (5.328),1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar the 2020 EJVES Journal Impact Factor (JIF) further increased by almost 33% and reached a stunning 7.069. In other words, the scientific community cited, on average, every single EJVES paper from 2018 and 2019 more than 7 times during 2020. This reflects an increasing importance1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,2Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar and puts the EJVES into the same league as the leading surgical journals such as, for instance, the BJS (2020 JIF 6.939). Indeed, the EJVES continues to rank among the top 5% of surgical journals (No 9 out of 272), and among the top 10% of peripheral vascular journals (No 7 out of 84).1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,2Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar By comparison, the Journal of Vascular Surgery (JVS) climbed to a 2020 JIF of 4.268 (up 25% from 2019) and ranks 38 in surgery, whilst the Journal of Endovascular Therapy (JEVT) reached a JIF of 3.487 (up 12%) and ranks 58. Therefore, the EJVES seems to have recovered from its recent dip1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar and remains, for the fifth year in a row, the leading journal of vascular and endovascular surgery globally. The rise in JIF has been paralleled by the number of submissions. Between 2016 and 2020, yearly submissions to the EJVES doubled from 847 to 1660, necessitating an increasingly competitive selection process and more professional workflows.3Dick F. Bjorck M. The EJVES is taking the next step anew.Eur J Vasc Endovasc Surg. 2020; 59: 1-2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar As a consequence, the rejection rate of full length articles approached 90% in 2020. All accepted articles, in contrast, were scrutinised (and optimised) by a mean of 3.6 expert peer reviewers completing 8 reviews per article on average – an effort that has not changed over the years despite an ever increasing workload.1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In addition, to ensure selection of the very best submissions, a ‘shared decision making principle’ was introduced within the editorial group,3Dick F. Bjorck M. The EJVES is taking the next step anew.Eur J Vasc Endovasc Surg. 2020; 59: 1-2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar strengthening the importance of every single member of this dedicated team.4Dick F. Bjorck M. Inside EJVES – The team behind the scenes.Eur J Vasc Endovasc Surg. 2021; 61: 1-4Abstract Full Text Full Text PDF Scopus (2) Google Scholar All these experts guarantee the Journal’s quality and credibility by dedicated (and mostly unpaid) work. We owe all of them a great ‘thank you’! As in previous years, half of the 10 papers contributing most to the 2020 EJVES JIF were European Society for Vascular Surgery (ESVS) clinical practice guidelines, reconfirming the success of the core mission of the ESVS and EJVES, i.e. to deliver education and practical guidance for the benefit of all vascular patients. The following guidelines were cited between 87 and 266 times in 2020: The ESVS management guidelines for abdominal aorto-iliac aneurysms (AAA)5Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.Editor's choice - European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (778) Google Scholar; and for carotid disease6Naylor A.R. Ricco J.B. de Borst G.J. Debus S. de Haro J. Halliday A. et al.Editor’s choice - Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (502) Google Scholar; the conjoint European Society of Cardiology (ESC)/ESVS management guidelines for peripheral arterial disease7Aboyans V. Ricco J.B. Bartelink M.L. Bjorck M. Brodmann M. Cohnert T. et al.Editor’s choice - 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 305-368Abstract Full Text Full Text PDF PubMed Scopus (398) Google Scholar; and the conjoint Global Vascular Guidelines for chronic limb threatening disease8Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guidelines on the Management of Chronic Limb-Threatening Ischemia.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109Abstract Full Text Full Text PDF PubMed Scopus (324) Google Scholar; and, last but not least, the ESVS management guidelines for vascular access.9Schmidli J. Widmer M.K. Basile C. de Donato G. Gallieni M. Gibbons C.P. et al.Editor's choice - Vascular access: 2018 clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 757-818Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar Amongst the other half were two Editor’s Choice papers on management of AAA10Ultee K.H.J. Buettner S. Huurman R. Bastos Gonçalves F. Hoeks S.E. Bramer W.M. et al.Editor's choice - Systematic review and meta-analysis of the outcome of treatment for type II endoleak following endovascular aneurysm repair.Eur J Vasc Endovasc Surg. 2018; 56: 794-807Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,11Trenner M. Kuehnl A. Salvermoser M. Reutersberg B. Geisbuesch S. Schmid V. et al.Editor's choice - High annual hospital volume is associated with decreased in hospital mortality and complication rates following treatment of abdominal aortic aneurysms: secondary data analysis of the nationwide German DRG statistics from 2005 to 2013.Eur J Vasc Endovasc Surg. 2018; 55: 185-194Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar; one Vascunet Report on international variation in amputation practice12Behrendt C.A. Sigvant B. Szeberin Z. Beiles B. Eldrup N. Thomson I.A. et al.International variations in amputation practice: a VASCUNET report.Eur J Vasc Endovasc Surg. 2018; 56: 391-399Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar; one systematic review of the importance of frailty in vascular surgery13Wang J. Zou Y. Zhao J. Schneider D.B. Yang Y. Ma Y. et al.The impact of frailty on outcomes of elderly patients after major vascular surgery: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2018; 56: 591-602Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar; and, very pleasantly, one basic research paper.14Wang C. Li Y. Yang M. Zou Y. Liu H. Liang Z. et al.Efficient differentiation of bone marrow mesenchymal stem cells into endothelial cells in vitro.Eur J Vasc Endovasc Surg. 2018; 55: 257-265Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Although we are very happy with the outstanding position that the EJVES has achieved, the success also results in challenges. Scientific publishing is very dynamic and in permanent motion. Most of the work is performed, and financed, by the researchers, their institutions, or by funding bodies. However, publishing scientific reports in a reader friendly way and making them accessible to the medical community requires professional expertise and resources, too. Publisher’s expenses and funding have become a hot political issue recently.15Bjorck M. Dick F. Open access publishing in the EJVES: a hybrid solution for a hybrid specialty (and how 'hybrid' helped the dinosaurs survive).Eur J Vasc Endovasc Surg. 2021; 61: 363-364Abstract Full Text Full Text PDF Scopus (1) Google Scholar Should these expenses be paid by the reader in a classic subscription model, which is still the most common situation today, but may impede fair access to possibly important research results? Or should those who already funded the expensive research also provide for its publication to ensure ‘open access’? Or is ‘open access’ to research findings a societal obligation, and governments should use taxpayer money for that (e.g. Plan S)? Of course, there are different opinions on this crucial issue that will also determine the future of the EJVES. For the time being, the EJVES is a dedicated hybrid journal,15Bjorck M. Dick F. Open access publishing in the EJVES: a hybrid solution for a hybrid specialty (and how 'hybrid' helped the dinosaurs survive).Eur J Vasc Endovasc Surg. 2021; 61: 363-364Abstract Full Text Full Text PDF Scopus (1) Google Scholar allowing both financial models to combine the best of two worlds. As the number of Gold Open Access papers has increased rapidly over the last 2 years, however, open access publishing is most likely the future. A further challenge is that a journal can be regarded as elitist, when a great proportion of the submitted papers gets rejected. Our primary goal is that those involved in vascular care, even if it is challenging to get a paper published, still regard the EJVES as their own scientific journal, where they find the most relevant and up-to-date knowledge to guide clinical practice. To be more inclusive we have not only revamped the EJVES Vascular Forum,16Vega De Ceniga M. Ricco J.B. Rebirth of an ESVS journal - The new and interactive EJVES vascular forum.Eur J Vasc Endovasc Surg. 2020; 59: 3-4Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar but also created various short communication formats: Coup D’Oeil, Jugaar/Innovation and, most recently, Research Letters.3Dick F. Bjorck M. The EJVES is taking the next step anew.Eur J Vasc Endovasc Surg. 2020; 59: 1-2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Regular readers will hopefully agree that these short reports often are very educational and entertaining. Particularly research letters are an ideal inclusive format to present preliminary data, that later need to be confirmed in a larger study, or data on uncommon diseases or situations, in which it is difficult to perform robust clinical trials. Science must not have boundaries, and the EJVES and ESVS are not limited by the geographic borders of Europe.1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,17Bjorck M. Boyle J. Dick F. The need of research initiatives amidst and after the Covid-19 pandemic: a message from the editors of the European Journal of Vascular and Endovascular Surgery.Eur J Vasc Endovasc Surg. 2020; 59: 695-696Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar However, the various (geographic) environments in which we act as vascular surgeons are so diverse in many ways we thought it interesting to invite leaders outside of Europe to present the situation of our speciality in their countries and regions. We hope you have enjoyed our recent ‘Global Tour D’Horizon’ Editorial series. The last 18 months have been tough for all of us personally, socially and professionally. They have certainly been exceptionally challenging for the ESVS as a multinational society. Basically, the whole organisation had to be re-invented. The Academy, responsible for all ESVS educational programmes, has shown its vitality not only by restructuring all courses from ‘hands-on’ to ‘on-line’, but also by merging them seamlessly into comprehensive educational pathways such as “Aorta”, “Peripheral Arterial Disease” or “Venous”. This initiative gives our members an unique opportunity to pick both content and level to match exactly their educational needs. In line with that, the European Vascular Surgeons in Training (EVST), serving the interests of trainees, have used the opportunity to re-define their goals for the coming years.18https://www.esvs.org/membership/evst/, accessed on 16th August 2021.Google Scholar As EVST represents the future of the ESVS, it is reassuring to see the enthusiasm and commitment within this group. Traditionally, the annual general meeting (AGM) has been the cornerstone of ESVS’ activities and income. With no physical meeting over 18 months, financing schemes had to be re-thought as well. The Executive Committee (ExCo) has spent countless hours on brainstorming about creative and sustainable solutions including increased online offers such as podcasts, webinars, masterclasses and last year’s ESVS month.1Dick F. Bjorck M. Haulon S. EJVES on the rise again, and the annual meeting becomes the ESVS month.Eur J Vasc Endovasc Surg. 2020; 60: 333-334Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Luckily, all these activities turned out to be very successful, and a special word of thanks should go to our Office in Bordeaux: their inexhaustible commitment has made the ESVS so much more professional and reliable! However, we all are keen to finally meet face to face again. In early 2021, ExCo took the decision to have at least part of this year’s AGM as a live, on-site happening. After a challenging period of changing regulations at a monthly (sometimes weekly) basis we are truly proud that the AGM will take place in Rotterdam on September 28th-29th. The Programme committee has put together an exceptionally appealing programme with far more interaction and panel discussions than we were used to. In addition, there will be hands-on courses again, organised by the Academy. Obviously, all measures have been taken to comply with local COVID regulations at all times and to guarantee safety for all involved. Please take the opportunity and join in! For those who cannot come to Rotterdam the complete programme will be available online: a true hybrid meeting therefore! Although nobody knows what else the future may bring to our AGMs, it is likely that online participation will remain. Our Rotterdam hybrid meeting adventure is therefore also an important learning experience for our Society that should not be missed! Although the Covid-19 pandemic is not over yet, the vascular community has proven to be resilient to its challenges. We are convinced more than ever that the ESVS core mission of driving science, education and international collaboration, remains crucial in this era of uncertainty.

The authors regret that the name of one of the co-author has been incorrectly spelt. Dr. Melina Vega de Ceniga should have been cited as “Vega de Ceniga M” The authors would like to apologise for any inconvenience caused.

1. According to the EVAR-SCREEN study carried out in the UK, which one of the following statements is correct?A.Compliance to EVAR surveillance varied widely across individual centres.B.Compliance to EVAR surveillance is very good (>80%) across the UK.C.Compliance to EVAR surveillance is very poor (<10%) across the UK.D.There is no need for surveillance after EVAR.E.There should be no difference in surveillance after EVAR compared with open aortic aneurysm repair.

In this issue of the Journal, Schwaneberg et al. present a large retrospective German cohort study which assesses the trends in treatment patterns and comorbidities in patients with lower extremity peripheral artery disease (PAD).1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar The authors demonstrate an increasing number of peripheral vascular interventions (PVI), and fewer major amputations. Of note, these interventions were performed in sicker and older patients, with an increased disease related reimbursement cost. Interestingly, while the estimated incident cases of PAD among the cohort slightly decreased, a significant increase of prevalent PAD cases, numbers of hospitalisations and PVI was observed. The interpretation of these results is a reduction of new cases combined with prolonged periods of chronic disease, through a higher life expectancy and repeated revascularisations. Considering the incidence estimations, the study has a limited observation time and a limited number of people insured by the company, and it remains unclear whether the decrease of incident cases could also be the consequence of fewer people being at risk at the end of the timeframe. It should be remembered that claims data from an insurance database are not truly population based. Even with this limitation in mind, the authors have demonstrated an increasing number of PVI performed to increasingly ill and older patients with rising costs. They have also demonstrated, without doubt, an increasing trend of relevant cardiovascular comorbidities in patients with PAD, such as hypertension, cardiac dysrhythmia, and renal failure. A recent epidemiological study by Song et al.2Song P. Rudan D. Zhu Y. Fowkes F.J.I. Rahimi K. Fowkes F.G.R. et al.Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis.Lancet Glob Health. 2019; 7: e1020-e1030Google Scholar has suggested that in 2015, PAD affected around 236 million people worldwide with a global prevalence of 5.6%. Advanced age, smoking, hypertension, diabetes, and concomitant cardiovascular diseases were confirmed to be associated with a higher risk of PAD in both high income countries (HIC) and low to middle income countries (LMIC), these latter countries representing 73% of global cases. The 236 million PAD cases in 2015 represent a relative increase of 17% from 202 million in 2010. However, this increase did not occur evenly in HIC and LMIC. Across five years, the relative increase was higher in LMIC than in HIC (22.6% vs. 4.5%). It is therefore likely that the observed increase of prevalent cases in the cohort reported by Schwaneberg et al.1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar in a HIC, is at the lower end of the observed prevalence of PAD worldwide, which reinforces their message. The 2017 European Society of Cardiology (ESC) guidelines on the diagnosis and treatment of PAD, in collaboration with the European Society for Vascular Surgery (ESVS), emphasised the need to improve the diagnosis of PAD, with most patients with PAD being asymptomatic or presenting with atypical symptoms, and highlighted the need to assess walking capacity to detect clinically masked PAD.3Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European society for vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 305-388Google Scholar Furthermore, even if asymptomatic, these patients with PAD are at high risk of cardiovascular events and should benefit from preventive strategies and control of risk factors. The ESC/ESVS guidelines recommend ankle brachial index as first line test for PAD screening, duplex ultrasonography being the first imaging method.3Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European society for vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 305-388Google Scholar The observed rise of PVI in the study by Schwaneberg et al.1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar is not unexpected considering the growing number of patients with intermittent claudication and compromised daily life activity despite supervised exercise therapy. It should, however, be emphasised that data from imaging tests should always be analysed with symptoms and haemodynamic data prior to any intervention. In the study by Schwaneberg et al.,1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar among >200,000 hospitalisations, 49.4% occurred in patients with chronic limb threatening ischaemia (CLTI) with a high prevalence of diabetes. To help the clinician, a new classification system (WIfI) has been proposed as the initial assessment of all patients with ischaemic rest pain or wounds.4Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guidelines on the management of chronic limb-threatening ischemia.Eur J Vasc Endovasc Surg. 2019; 58 (S1-S109.e33)Google Scholar WIfI stands for Wound, Ischaemia (based on objective haemodynamic studies) and foot Infection (from local to systemic since the benefit of revascularisation is also dependent upon infection control). The increasing number of PVI together with a decrease in the number of major amputations as observed by Schwaneberg et al.1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar are encouraging and suggest appropriate revascularisation of patients with CLTI together with best medical treatment and risk factor control. The study from Schwaneberg et al.1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar has some obvious shortcomings. It is a post hoc study of health insurance claims data of patients with PAD. It is well known that such registries collected by healthcare providers for billing purposes have a risk of upcoding comorbidities even if data are cross checked by independent physicians as it has been the case in Germany. By contrast, major factors such as smoking may be missed if they do not have any billing impact. The finding of diabetes as a decreasing comorbidity in PAD patients is counterintuitive, given the current epidemics of diabetes and metabolic syndrome that are associated with increased rates of PAD.5Buso G. Aboyans V. Mazzolai L. Lower extremity artery disease in patients with type 2 diabetes.Eur J Prev Cardiol. 2019; 26: 114-124Google Scholar But perhaps most importantly, this study lacks granularity when considering mid and long term outcomes and patient follow up. The reader would have been interested to know more about the fate of these PAD patients after PVI, particularly in the long term.6Sillesen H. Debus S. Dick F. Eiberg J. Halliday A. Haulon S. et al.Long term evaluation should be an integral part of the clinical implementation of new vascular treatments - an ESVS Executive Committee Position Statement.Eur J Vasc Endovasc Surg. 2019; 58: 315-317Google Scholar Unfortunately, stratified information about surveillance outcomes after vein bypass or endovascular treatment is lacking. A consensus document regarding the follow up of patients after revascularisation for PAD has recently been published by the ESC working group on Aorta and Peripheral Vascular Diseases and the ESVS and would complement this registry by recommending a standardised follow up emphasising the importance of multidisciplinary management of these patients with a clinically reasonable and cost effective strategy.7Venermo M. Sprynger M. Desormais I. Björck M. Brodmann M. Cohnert T. et al.Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European society of Cardiology working group on Aorta and peripheral vascular diseases and the European society for vascular Surgery.Eur J Vasc Endovasc Surg. 2019; 58: 641-653Google Scholar However, the efforts of Schwaneberg et al.1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar are to be commended because their study on more than 156,217 patients is a real life and contemporary picture of PAD not limited to highly selected patients as in most randomised studies. In the era of big data, these studies will become more frequent. The major advantages of big data relate to the sheer size of the data sets, their variety and speed of accumulation. There remains, however, a significant risk of selection bias or bias by indication when using big data for comparisons of (non-randomised) diagnostic or therapeutic strategies. A recent study by Perez et al.8Perez M.V. Mahaffey K.W. Hedlin H. Rumsfeld J.S. Garcia A. Ferris T. et al.Large-scale Assessment of a smartwatch to identify atrial fibrillation.N Engl J Med. 2019; 381: 1909-1917Google Scholar reporting the results of a large scale assessment of a smart watch to identify atrial fibrillation in more than 400,000 participants is an example of a large scale pragmatic study using user owned connected devices to assess outcomes, a technology that might also be suitable to assess functional outcomes in patients with PAD. In conclusion, Schwaneberg et al.1Kreutzburg T. Peters F. Rieß H.C. Hischke S. Marschall U. Kriston L. et al.Comorbidity patterns among patients with peripheral arterial occlusive disease in Germany: a trend analysis of health insurance claims data.Eur J Vasc Endovasc Surg. 2020; 59: 59-66Google Scholar reconfirm, in a large scale study, that PAD is an increasing major public health challenge in European HIC countries. Other epidemiological studies have shown that this is also the case elsewhere, particularly in LMIC countries. With the demographic trend towards increased ageing and diabetes, an ever greater increase in the number of patients with PAD is expected in the future, reinforcing the need for an early diagnostic tool. The editors of the European Journal of Vascular and Endovascular Surgery (EJVES) strongly encourage the reporting of high quality data from other countries, allowing us to carefully evaluate the evolution of disease patterns and of the treatments that we offer to our patients.9Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular Surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Google Scholar Corrigendum to "Real Life Lessons in Peripheral Artery Disease – A Priority for Public Healthcare" [Eur J Vasc Endovasc Surg 59 (1) (2020) 5–6]European Journal of Vascular and Endovascular SurgeryVol. 59Issue 4PreviewThe authors regret the following error: Throughout the text, Schwaneberg et al. should read Kreutzburg et al. in relation to reference 1, which is correct. The authors would like to apologise for any inconvenience caused. Full-Text PDF Open Archive

We write this editorial while many are facing the greatest turmoil within healthcare since the Second World War. Covid-19 impacts our patients, ourselves, and our profession in many different ways. For instance, never before have the advantages of minimally invasive possibilities been more obvious. Even major aortic surgery can be performed without a need for intensive care in many cases. Between 1999 and 2013, the proportion of patients who needed less than 48 hours of intensive care after abdominal aortic aneurysm (AAA) repair decreased from 41% to 7%, whereas the use of endovascular aortic repair (EVAR) increased from 7% to 78%.1Gavali H. Mani K. Tegler G. Kawati R. Covaciu L. Wanhainen A. Editor's Choice – prolonged ICU length of stay after AAA repair: analysis of time trends and long term outcome.Eur J Vasc Endovasc Surg. 2017; 54: 157-163Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar EVAR is also established as the first line of treatment for most patients in the updated European Society for Vascular Surgery 2019 AAA Guidelines.2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (1698) Google Scholar Currently, vascular surgeons are overwhelmed by the manifold of clinical challenges posed by the Severe acute respiratory syndrome coronavirus 2 (Sars-cov-2). Managing patients who are sick with Corona virus disease 2019 (Covid-19) is a significant challenge. The management of vascular patients with threats to both life and limb, when resources are limited, while protecting them from Sars-cov-2, has become a new clinical routine for many of our colleagues. Furthermore, personal protection, while working in the clinical environment, has become a high priority. Data suggest that healthcare professionals treating patients with Covid-19 are at a higher risk of developing a more severe infection, and high death tolls among doctors and nurses have been reported from China and Italy. Whereas the exact risks associated with operating on infected patients are still unknown, many surgical societies are issuing preliminary behavioural guidelines recommending full personal protective equipment for all operations (e.g., the UK Intercollegiate General Surgery Guidance on COVID-19). The importance of research, and of the unique research opportunities that this situation presents, must not be overlooked amid these challenges. The consequences of the Covid-19 pandemic will affect vascular surgery worldwide for a long time period, and probably longer than expected now. Many of the postponed elective and semi-acute operations will have to be performed later on, in a secondary overwhelming wave of challenges. Paradoxically, a high death toll among the oldest in our populations may somewhat reduce the need of vascular surgery, and counteract this consequence. There are many unanswered questions, such as: What impact do different stages of Covid-19 have on surgical outcomes? Does type of surgery and anaesthesia affect these outcomes, both in the short and long term? What is the risk for surgeons, nurses, assistants, and anaesthesiologists? What protective measures are effective? What collateral damage (in terms of missed treatment opportunities and options for other patients) does Covid-19 bring, and how can this best be confronted? Scientists must design appropriate studies now to be able to answer such questions later. After all, this will not be the last pandemic affecting the human population and our specialty. According to epidemiologists minor pandemics tend to occur every 20 years, and major ones every 100 years. The easiest, fastest, and probably most effective way to ensure that we will be able to answer these and other questions in the future is to use the already established quality improvement registries, for instance the Vascunet and International Consortium of Vascular Registries collaborations.3Behrendt C.A. Venermo M. Cronenwett J.L. Sedrakyan A. Beck A.W. Eldrup-Jorgensen J. et al.VASCUNET, VQI, and the International Consortium of Vascular Registries – unique collaborations for quality improvement in vascular surgery.Eur J Vasc Endovasc Surg. 2019; 58: 792-793Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar To add the simple pre-operative variable, identifying if the patient is Sars-cov-2 positive or not (or if status is unknown), would already allow later analyses of how the outcome was affected after adjustments for potential confounding.4Mani K. Björck M. Alternatives to randomised controlled trials for the poor, the impatient and when evaluating emerging technologies.Eur J Vasc Endovasc Surg. 2019; 57: 598-599Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar It would also be interesting to add this variable at the postoperative follow up visit, to register if the patient was infected by Sars-cov-2 virus during hospitalisation or afterwards. The great number of patients who may have their procedures postponed as a result of Covid-19 mandates an analysis of the consequences of such delay. Most of the previous "natural history" studies stem from the early or middle 20th century, or are based on small cohorts of patients with severe comorbidities. For instance, we know the (low) risk of rupture among patients with small AAAs with a diameter of 40–54 mm thanks only to the historical work of previous generations of vascular surgeons.5Powell J.T. Brady A.R. Brown L.C. Fowkes F.G. Greenhalgh R.M. et al.United Kingdom Small Aneurysm Trial ParticipantsLong-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms.N Engl J Med. 2002; 346: 1445-1452Crossref PubMed Scopus (554) Google Scholar But there are novel data from the UK AAA screening programme suggesting that contemporary risk of rupture may be even lower,6Oliver-Williams C. Sweeting M.J. Jacomelli J. Summers L. Stevenson A. Lees T. et al.Safety of men with small and medium abdominal aortic aneurysms under surveillance in the NAAASP.Circulation. 2019; 139: 1371-1380Crossref PubMed Scopus (58) Google Scholar and we know very little about the rupture risk above the diameter of 54 mm. Is this observed lower risk explained by changes in medication or smoking habits? The RESCAN study showed that the risk of rupture was twice as high among active smokers,7Sweeting M.J. Thompson S.G. Brown L.C. Powell J.T. RESCAN collaboratorsMeta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms.Br J Surg. 2012; 99: 655-665Crossref PubMed Scopus (409) Google Scholar but can smoking cessation or medication decrease the risk of rupture while awaiting postponed surgery? The current pandemic offers unique scientific opportunities to address such questions. Similarly, what is the risk of deterioration and amputation in different subgroups of patients with chronic limb threatening ischaemia (CLTI)? We know that most patients benefit from an expedited management, but maybe there are subgroups of patients who can be managed less urgently, maybe even without invasive treatment? The global vascular guidelines on the management of CLTI have established the possibly underestimated importance of infection.8Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guidelines on the management of chronic limb-threatening ischemia. Joint guidelines of the society for vascular surgery; European society for vascular surgery; World federation of vascular societies.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109Abstract Full Text Full Text PDF PubMed Scopus (790) Google Scholar Hopefully, the vascular registries have adapted their variables to the WIfI and GLASS classifications, as now may be the time to establish an up to date database to inform future treatment prioritisation. The Covid-19 pandemic presents vascular surgeons with the opportunity to study many fundamental issues facing our specialty. While we did not ask for this turmoil, even the most devastating cyclone has a windless eye. One major drawback of the vascular registries in this particular situation is the fact that most of them only register patients who were operated on. Multicentre international collaborations, merging complete datasets from multiple institutions who could start to collect data on patients whose operations were postponed, could help us to answer these outstanding issues. It is easy to identify the negative aspects of globalisation, when the Covid-19 epidemic spread so quickly. We must remember, however, that the Chinese characterisation of the virus RNA sequence, and the German development of the first polymerase chain reaction diagnostic tool, also spread globally, and much faster. The global scientific community has stood up to the highest standards. Unfortunately, the same cannot be said for the organisation of healthcare. Many hospitals and countries struggle with shortages of drugs, ventilators, and personal protective equipment, putting both patients and staff at risk. Given the regular frequency with which infective epidemics have haunted humanity throughout history, the verdict on those responsible may be harsh. The EJVES is an important player in the vascular scientific community, and we are committed to play our part in this difficult situation. We would like to highlight our fast track publication possibilities to enable fast, yet scientifically sound, communication when indicated. For instance, we recently published an important paper about the paclitaxel debate fast track.9Behrendt C.A. Sedrakyan A. Peters F. Kreutzburg T. Schermerhorn M. Bertges D.J. et al.Long term survival after femoropopliteal artery revascularisation with paclitaxel coated devices: a propensity score matched cohort analysis.Eur J Vasc Endovasc Surg. 2020; 59: 587-596Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar The paper was submitted on 15 November, and despite two major revisions and three review rounds it was accepted for publication on 18 December, and was e-published on 8 January. Another fast track option are Research Letters, introduced early this year. Many important scientific observations can be published in a short version (Research Letters allow a maximum of 800 words, one image or small table, and up to five references). Such short communications can be easily handled and fast tracked when an urgent communication is warranted in the interest of our patients. Take care of your patients, your staff, your families, but also of yourselves in this difficult situation. The secret of winning a war is – in the middle of the fight – to prepare for the next battle. The outcome will depend on how much we are willing to learn from the current challenges.

Dear readers of the European Journal of Vascular and Endovascular Surgery (EJVES), and members of the European Society for Vascular Surgery (ESVS). The editors, editorial board members and publishers involved with the EJVES wish you a very happy, fulfilling and inspiring New Year 2020! We hope you will keep enjoying our company through this year with up to date vascular research, clinical guidance, and continued medical education. At the same time, we encourage you to engage in energetic discussions on our new interactive platform, the EJVES Vascular Forum, which has been renewed to increase our value to the vascular community. The present issue opens the 59th EJVES volume (founded in 1987), and it marks the beginning of a new three year leadership cycle, which has now been synchronised with the calendar year (2020–2022). The regular turnover of senior editors was initiated to ensure a constant inflow of new ideas and visions for the Journal while ensuring a coherent long term vision by providing overlapping successions. Essentially, every ‘Editor-in-Chief-elect’ first serves a three year period as Senior Editor, in order to immerse in the culture and spirit of the Journal before taking over. As the incoming Editor-in-Chief and Senior Editor, we are very grateful for this well tried tradition, as it has offered us the opportunity to work with and learn from the best. The EJVES has accomplished a series of impressive achievements over the past editorial cycles by taking the important steps of mobile access, prioritising practical value and education, establishing a companion open access journal and developing a system of clinical guidelines with global impact.1Björck M. Kolh P. Into the lead: how EJVES became the leading journal in vascular surgery.Eur J Vasc Endovasc Surg. 2017; 54: 273-274Google Scholar, 2Kolh P. Dick F. Halliday A. EJVES: the leading journal in vascular surgery, and one of many highlights for the ESVS annual meeting in valencia.Eur J Vasc Endovasc Surg. 2018; 56: 315-317Google Scholar, 3Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Google Scholar, 4White J. Conte M. Bradbury A. Kolh P. Dick F. Fitridge R. et al.Building a global alliance in vascular surgery.Eur J Vasc Endovasc Surg. 2019; 58: 318-319Google Scholar As a direct consequence, the EJVES has attracted high quality research papers, and it has held, by several metrics including the impact factor, the top ranking position among vascular surgery journals for three years in a row. This development is not an achievement of individuals but became possible through the shared efforts of an outstanding team, including our inspired authors, a visionary editorial board, a dedicated production team, an interested vascular community, a loyal readership, and above all, critical peer reviewers and our excellent Associate Editors. Last year, the EJVES introduced a new style of harmonised reporting standards and recognisable overall appearance of tables and figures5Dick F. Kolh P. Introducing the new design of the European journal of vascular and endovascular surgery.Eur J Vasc Endovasc Surg. 2019; 57: 1-3Google Scholar to prepare for the next step: an integrated workflow behind paper selection, manuscript editing and publication process. Driven by constant striving for the best research in the field,1Björck M. Kolh P. Into the lead: how EJVES became the leading journal in vascular surgery.Eur J Vasc Endovasc Surg. 2017; 54: 273-274Google Scholar, 2Kolh P. Dick F. Halliday A. EJVES: the leading journal in vascular surgery, and one of many highlights for the ESVS annual meeting in valencia.Eur J Vasc Endovasc Surg. 2018; 56: 315-317Google Scholar, 3Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Google Scholar a dedicated style editor was engaged to oversee consistent presentation of contents to improve their comprehensibility and consistency. Thereby, we aim to increase the quality of our publications, the practical value for our readers and the reputation of the Journal.5Dick F. Kolh P. Introducing the new design of the European journal of vascular and endovascular surgery.Eur J Vasc Endovasc Surg. 2019; 57: 1-3Google Scholar This year, the EJVES will take the next steps towards improved professional workflows. With increasing submissions every year1Björck M. Kolh P. Into the lead: how EJVES became the leading journal in vascular surgery.Eur J Vasc Endovasc Surg. 2017; 54: 273-274Google Scholar, 2Kolh P. Dick F. Halliday A. EJVES: the leading journal in vascular surgery, and one of many highlights for the ESVS annual meeting in valencia.Eur J Vasc Endovasc Surg. 2018; 56: 315-317Google Scholar, 3Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Google Scholar the Journal must become more selective. Essentially, management of submissions can be broken down to four steps: (a) Immediate (but fair) rejection of submissions that do not meet the standards, to save resources time and efforts for the Journal, its reviewers and particularly for the submitting authors. (b) Screening of the remainder for the best research using peer review and statistical consultation. (c) Optimisation of formal presentation of accepted papers to ensure consistent style. (d) Approval of the final version by both authors and editors before publication. The importance of this last step has increased with the demand for harmonised style. The EJVES takes several measures to optimise these processes. First, core areas of our Journal, such as carotid, aorto-iliac and peripheral arterial disease, as well as systematic reviews, will be led by dedicated section editors. They will share management of submissions with one of the senior editors, with shared decision making regarding publication after mutual consultation. Although final responsibility will remain with the senior editor, this system is expected to provide improved oversight over the various sections for all involved, and to allow filtering out of substandard (or redundant) submissions quickly, while attracting the best research in the field. In addition, the ‘four eye’ principle will probably enhance impartial assessment and decision making. We aim to start with these four above mentioned sections in April 2020, but more can be added once this new principle has proven its worth. Second, the EJVES has established a group of very knowledgeable clinician statisticians. All of them have a special training in epidemiology and/or statistics and are acknowledged in the Journal's imprint. The editors will consult one of them systematically for all submissions that, after peer review, are likely to be accepted. Thereby we aim to ensure minimum scientific standards regarding study design, data analyses and interpretation. This procedure, already standard in many journals with a high impact factor, should enhance internal and external validity of published papers and therefore, credibility of conclusions and relevance for clinical decision making. Unplanned (ie. completely retrospective) and uncontrolled observations from single centres, or comparisons that are not adjusted for confounding factors, will probably become extinct with time, even though certain imperfections may be balanced by unique datasets or original ideas. We will continue to accompany controversial findings with critical commentaries to put them into perspective. Third, authors will receive enhanced support during writing and revisions by updated instructions for authors detailing all expected items, and by access to the style rulebook. To facilitate submission for evaluation, papers are not expected to comply with all style requirements at first but must do so before being accepted for publication. Therefore, we introduce a ‘provisionally accepted’ stage, after which the style editor liaises with the authors to support style and language editing. The latter is a service that we continue to offer free of charge for all accepted papers. This should make it uncomplicated for authors to submit their work for assessment and will facilitate expeditious online publication after final acceptance. Besides provision of selected high quality original research, educational content and clinical practice guidance remain the mainstays of our society. Our companion open access Journal (formerly EJVES Short Reports) has been specifically revamped to help accomplish this mission. Along with many other exciting functions, the new EJVES Vascular Forum6Vega Ricco Rebirth of an ESVS journal – the new and interactive EJVES vascular Forum.Eur J Vasc Endovasc Surg. 2019; 59: 3-4Google Scholar will accommodate most of our educational content to be freely available and will provide an interactive platform for dynamic opinion formation. In addition, the EJVES has introduced a new exciting format to informally communicate preliminary research findings in our correspondence section, as Research letters to the Editor. More information on this novel publication format will be available soon in the online instructions for authors. Last but not least, clinical practice guidelines have become indispensable to the ESVS and EJVES success, and they are now managed by an independent ESVS guidelines committee that reports directly to the ESVS executive committee. These activities have expanded considerably over recent years, and the ESVS has begun to engage in several intersocietal collaborations2Kolh P. Dick F. Halliday A. EJVES: the leading journal in vascular surgery, and one of many highlights for the ESVS annual meeting in valencia.Eur J Vasc Endovasc Surg. 2018; 56: 315-317Google Scholar, 3Kolh P. Dick F. Sillesen H. EJVES, the leading journal in vascular surgery, is one of the numerous scientific pillars of the ESVS.Eur J Vasc Endovasc Surg. 2019; 58: 311-314Google Scholar, 4White J. Conte M. Bradbury A. Kolh P. Dick F. Fitridge R. et al.Building a global alliance in vascular surgery.Eur J Vasc Endovasc Surg. 2019; 58: 318-319Google Scholar to increase its global and interdisciplinary reach. To support this, Elsevier has agreed to publish guidelines in languages other than English, once they have been translated by national societies (ongoing examples include Japanese, Chinese, Portuguese and Russian translations). The Journal depends on the work of our more than 500 reviewers and our Editorial Board. We want to take this opportunity to thank them all. We decided to increase the size of the Editorial Board by including members from all over the world, to embrace the global scope of the Journal. Those selected for this prestigious recognition are the very best reviewers in terms of quality and workload. This evaluation is based on the editor's assessment of every peer review. Thus, it is not only the paper that is evaluated, but also the review, which may comfort authors who fear that their paper might have been assessed in a biased way. We renew the Editorial board every year, making it possible for those who perform high quality reviews to be selected to the Editorial Board in the future. It remains to be seen whether these initiatives will contribute to a continued success of the Journal. To date, we have seen a steady increase in the number and quality of submissions, and it remains our primary goal to select and curate the best content for our audience. The incoming Editor in Chief and Senior Editor look forward to their new editorial roles and aim to sustain the excellent work of their predecessors. We say goodbye to Philippe Kolh who completes a ten year term at the EJVES as Associate Editor, Senior Editor and Editor-in-Chief. We thank him for all his guidance, enthusiasm and friendship. His legacy of establishing the reliable production of leading clinical guidelines is truly inspiring, and we intend to honour him and those before by taking the next steps with the Journal. We hope you will like the future direction of the EJVES as much as we do, and that its development inspires you to submit your best research to share it with the vascular community. Happy New Year! Martin Björck, Senior EditorView Large Image Figure ViewerDownload Hi-res image Download (PPT)