Background Visceral aneurysms (VAs) are rare dilatations of splanchnic arteries that carry a significant risk of rupture. The role of parietal calcification in the natural progression and rupture risk of these aneurysms remains unclear, with most existing literature focusing on abdominal aortic aneurysms. This study aimed to evaluate the relationship between parietal calcification and VA relative growth rates, aneurysm sac thrombosis, and patient survival. Methods A retrospective analysis of 138 patients diagnosed with VA was conducted at the Hospital das Clínicas, Faculty of Medicine, University of São Paulo. Calcification was assessed via computed tomography and categorized into four types based on circumferential extent. Patients were grouped into low calcification (types 1 and 2) and high calcification (types 3 and 4) categories. The relative growth rate was calculated as the change in aneurysm diameter over time. Kaplan-Meier curves and Cox regression analyses were used to compare survival rates. Results Of the 138 patients, 117 had <50% calcification (types 1 and 2) and 21 had >50% calcification (types 3 and 4). Aneurysm growth was higher in the high-calcification group (0.73 mm/year vs. 0.53 mm/year), although not statistically significant (P = 0.42). A higher prevalence of aneurysm thrombosis was noted in the high-calcification group (33.3% vs. 11.1%, P = 0.002). Kaplan-Meier survival analysis revealed a trend toward better 5- and 10-year survival in patients with higher calcification, but this finding was not statistically significant. Conclusion In this cohort of 138 patients, parietal calcification involving more than 50% of the aneurysm circumference was associated with a significantly higher prevalence of intra-aneurysmal thrombosis and a marked female predominance. A nonsignificant trend toward higher annual growth and toward better long-term survival was also observed in heavily calcified aneurysms. These findings suggest that parietal calcification may represent a morphological feature with prognostic relevance in visceral aneurysms and support the need for further studies to determine its role in risk stratification and management.

INTRODUCTION:Frailty is an important predictor of adverse outcomes in vascular surgery, but its prognostic value after lower extremity revascularization for peripheral artery disease (PAD) remains uncertain. This systematic review and meta-analysis evaluated the association between frailty and outcomes after PAD revascularization. METHODS:Methods: PubMed, Embase, and Cochrane Library were searched from inception to May 12, 2026. Studies assessing frailty in patients undergoing peripheral artery surgery (endovascular, open, or hybrid lower extremity revascularization) for PAD were included. Random-effects meta-analyses were performed using odds ratios (ORs) or hazard ratios (HRs) with 95% confidence intervals (CIs). Prespecified subgroup analyses were conducted according to frailty assessment approach (Frailty Index-type vs. Non-Frailty Index tools) and procedural strategy. RESULTS:Nineteen studies comprising 1,638,543 patients were included. Because some studies enrolled mixed PAD populations, only patients undergoing lower extremity revascularization contributed to the pooled analyses. Frailty was associated with increased early mortality (OR 4.74; 95% CI 1.75-12.87), late mortality (HR 1.59; 95% CI 1.07-2.36), and major adverse cardiovascular events (OR 2.56; 95% CI 1.15-5.71), but not with major amputation, major adverse limb events, or postoperative complications. Subgroup analyses demonstrated no significant differences according to frailty assessment approach or procedural strategy. CONCLUSION:Frailty is associated with substantially worse outcomes following lower extremity revascularization for PAD, particularly increased early and late mortality and major adverse cardiovascular events, consistently across different frailty assessment approaches. These findings support routine incorporation of frailty assessment into preoperative evaluation to improve risk stratification, shared decision-making, and perioperative optimization.

The objective of this study is to compare the early- and late stroke-free survival and stent patency results in patients undergoing carotid artery stenting (CAS), considering the presence or absence of hostile anatomy (HA) for such an endovascular procedure. We conducted a retrospective analysis of 352 CAS procedures from a prospectively collected database. We identified thirty-six CAS patients with HA, and selected 42 matched cases of CAS patients who underwent the procedure under favorable anatomy (FA) as a control group. All procedures were performed by vascular surgeons, with the use of embolic protection devices in 100% of cases. HA parameters were defined as the presence of one or more of the following features: type III aortic arch, aortic arch anatomic variations which could impose technical difficulties, proximal common carotid artery/brachiocephalic trunk stenosis or severe tortuosity, pre-carotid bifurcation stenosis, and severe internal carotid tortuosity/kinking. Both groups had similar clinical characteristics and comorbidities. Previous history of stroke or transient ischemic attack was present in 53% of individuals, with 23% in the prior six months. Intraoperative success rate was 97.2% and 100% for the HA and FA groups, respectively. The 30-day periprocedural ipsilateral disabling stroke rate was 2.8% for the HA group, and 7.1% for the FA group (p = .38). No deaths occurred in the perioperative period. Five-year cumulative freedom from death or ipsilateral neurologic symptoms was 86.0 ± 5.8% for the HA group and 82.5 ± 6.1% for the FA group (p = .93; Fig. 1). Cumulative freedom from stent occlusion in five years was 90.6 ± 5.2% for the HA group, and 96.8 ± 3.2% for the FA group (p = .24). Stent occlusion was not related to neurologic events. Hostile arterial anatomy may pose additional technical challenges in CAS, but its early and late results do not differ from procedures performed under more favorable anatomy.

Background: Splenic artery aneurysms (SAAs) are rare but seem to have higher incidence in patients with portal hypertension (PH). The present article aims to analyze the interference of PH in the natural history of these aneurysms. Methods: This was a retrospective study of data recorded prospectively. Between January 2000 and December 2019, all SAAs patients in follow-up at a tertiary institution were selected for analysis. Primary end point was to analyze the presentation and evolution of SAAs in patients with PH, and secondary was to identify cumulative rates of freedom from rupture, interventions, and survival in this group, during a 10-year follow-up. Results: In total, 96 patients were identified with SAAs, 79 (82.29%) did not have PH and 17 (17.7%) had this comorbidity. Among the demographic characteristics, the patients with SAAs and PH were significantly younger (52 years [standard deviation {SD} 13.3] versus 61.9 years [SD 12.2] [P = 0.05]) and had lower number of pregnancies (1.1 pregnancies [SD 1.2] versus 3.37 pregnancies [SD 2.3] [P = 0.03]). Patients with PH had a higher cumulative rate of surgical intervention throughout follow-up (up to 75.6% in 10 years) when compared to patients without PH, with 36.9% intervention rate in 10 years of follow-up. Patients with PH had larger diameter at diagnosis (35 mm, SD 27.3) compared to patients without PH (22.6 mm, SD 16.1), P = 0.008. However, there were no statistical differences in the relative growth rate, in aneurysmal rupture rate throughout follow-up, as well as in survival over the years, between the groups. Conclusions: The patients with SAAs and PH are significantly younger, have larger SAA diameters at diagnosis and have a higher cumulative rate of surgical intervention throughout followup in 10 years, despite the relative growth rate being similar to that of patients without PH.

Resumo A doença cerebrovascular extracraniana tem sido intensamente investigada em todo o mundo, sendo tema de suma importância para os cirurgiões vasculares. A presente Diretriz foi elaborada pela Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) em sucessão à Diretriz de 2015. As doenças de etiologia não ateroscleróticas não foram incluídas nesse documento. O objetivo desta Diretriz é congregar as evidências mais robustas nessa área para auxiliar os especialistas no processo decisório do tratamento. Foi utilizada a metodologia AGREE II e o sistema da Sociedade Europeia de Cardiologia para as recomendações e níveis de evidências. As recomendações foram graduadas de I a III, e os níveis de evidência classificados em A, B e C. A presente Diretriz foi dividida em 11 capítulos, que tratam dos vários aspectos da doença cerebrovascular extracraniana: diagnóstico, tratamentos e complicações, de forma atualizada e com as recomendações propostas pela SBACV.

Resumo Trombose venosa profunda é uma das principais causas de morbidade hospitalar e ambulatorial, seja em pacientes clínicos, seja em pacientes cirúrgicos, impactando significativamente nas estatísticas de mortalidade, exigindo um diagnóstico rápido para que se institua de forma imediata o tratamento. O presente documento foi preparado e revisado por onze especialistas certificados pela Sociedade Brasileira de Angiologia e Cirurgia Vascular, que buscaram nas principais bases de dados as melhores evidências referentes à abordagem diagnóstica (exame físico, exames de imagem) e terapêutica (heparina, cumarínicos, anticoagulantes orais de ação direita, fibrinolíticos) da doença.

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

To simulate the impact of double antithrombotic therapy (DAT) in patients with stable cardiovascular disease and to identify differences in the response to DAT in different ethnic groups. We prospectively selected individuals with documented coronary artery disease (CAD), cerebrovascular disease (CVD) and/or peripheral artery disease (PAD). All patients were clinically stable, i.e., no acute coronary syndromes, recent stroke, acute or chronic critical limb ischemia. All individuals were on single antiaggregant therapy with acetylsalicylic acid (ASA). Using an individual lifetime benefit and bleeding risk computer model developed by De Vries et al., we simulated the efficacy and safety of introducing DAT with 100 mg ASA once daily plus 2.5 mg rivaroxaban twice daily. The 225 recruited patients were predominantly male (58.7%), with a mean age of 68.9 ± 8.4 years, 73.8% white. CAD was present in 52.9% of the individuals, while CVD and PAD were identified in 25.8% and 61.8%, respectively. Multisite cardiovascular disease was present in 33.3% of patients. In the simulation, patients of all ethnic groups benefited from the DAT strategy. DAT would theoretically provide a 7.6 ± 1.5% absolute cardiovascular risk reduction, with minor increase in absolute major bleeding risk (0.32 ± 0.9%). The number necessary to treat (NNT) and number necessary to harm (NNH) would be 13.6 and 370.2, respectively. There were no significant ethnic differences in terms of absolute cardiovascular risk reduction (7.66 ± 1.5% for whites and 7.59 ± 1.3% for non-whites, respectively; p=0.76). Non-white patients presented a better safety profile. The absolute major bleeding risk increase was 0.05 ± 0.22 for non-whites against 0.42 ± 1.0% for white patients (p<0.001), resulting in different values of NNH of 586 and 293 for non-whites and whites, respectively. DAT appears to have a good risk-benefit for patients with stable cardiovascular disease of all ethnic groups. Non-white individuals appeared to present a better safety profile for DAT in this simulation.

BACKGROUND:Blood donation is a safe process though reactions may still occur. We describe a rare vascular complication in a frequent donor, with improvements in the collection process aimed at avoiding future events. METHODS:A 63-year-old woman presented with local pain and an apparent collection in the left arm 8 days after donation. Duplex ultrasound identified a superficial liquid collection and signs of arteriovenous fistula (AVF) between the cubital vein and an arterial branch. A computed tomography (CT)-angio performed 1 day after ultrasound did not identify signs of AVF, followed by a new duplex which confirmed CT-angio findings. It was assumed that a traumatic AVF evolved with spontaneous thrombosis. In the early follow-up (18 days), a progressive regression of hematoma was observed without any sequelae. RESULTS:Investigation showed a faster whole blood bag collection time (3 min; normal: 5-9 min), and the processed packed red blood cell had a brighter red color than usual. The donor reported local bleeding after needle withdrawal, not observed in previous donations and a bruise forming on the same day. No arterial puncture (AP) was noticed by the collection staff during the procedure. The staff was retrained and actions were taken focusing on more active surveillance of late reactions, highlighting the importance of post-donation information by the donors, regardless of any adverse reaction observed, to detect late complications. CONCLUSION:We described an uncommon AP in a donor that was not identified, leading to an AVF that spontaneously thrombosed.

Deep vein thrombosis is one of the main causes of inpatient and outpatient morbidity, both in medical and surgical patients, significantly impacting mortality statistics and requiring prompt diagnosis so that treatment can be initiated immediately. This document was prepared and reviewed by 11 specialists certified by the Brazilian Society of Angiology and Vascular Surgery, who searched the main databases for the best evidence on the diagnostic (physical examination, imaging) and therapeutic approaches (heparin, coumarins, direct oral anticoagulants, fibrinolytics) to the disease.

Background: The role of thoracic endovascular aortic repair (TEVAR) in the treatment of chronic type B aortic dissection is controversial. Some advocate open surgery, based on the premise that all tears must be treated, and others prefer branched endografts with the same premise. However, TEVAR, with closure of the primary tear in the thorax, has shown good results in some centers. This single-center cohort study was designed to contribute to the knowledge of the long-term evolution (mean, 4.8 years) of the patients submitted to endovascular closure of the proximal intimal tear. Methods: A total of 36 patients with asymptomatic chronic aortic dissection had a successful closure of the primary tear by TEVAR and were followed up for a median time of 57.2 months. Results: In 75% of the cases, there was stabilization or decrease in the maximum diameter. Twenty-five percent had diameter increase in the thoracic or abdominal aorta and indication for one or more additional procedures. One patient refused a second procedure and died from rupture one month after the last evaluation; this was the only case of rupture in the series. One patient died of unrelated cause before having been submitted to a second procedure. Thirty-four patients survived without diameter increase in the follow-up period. Conclusions: Chronic type B aortic dissections can be successfully treated by the coverage of the proximal tear with an endograft. Patients shall be followed carefully, and 25% of them will require one or more additional procedures to achieve a good result.

BACKGROUND:Conflicting results are reported about daytime variation on mortality and cardiac outcomes after non-cardiac surgeries. In this cohort study, we evaluate whether the period of the day in which surgeries are performed may influence all-cause mortality and cardiovascular outcomes in patients undergoing non-cardiac arterial vascular procedures. METHODS:1,267 patients who underwent non-cardiac arterial vascular surgeries between 2012 and 2018 were prospectively included in our cohort and categorized into two groups: morning (7 a.m. to 12 a.m., 79%) and afternoon/night (12:01 p.m. to 6:59 a.m. in the next day, 21%) surgeries. Primary endpoint was all-cause mortality within 30 days and one year. Secondary endpoints were the incidence of perioperative myocardial injury/infarction (PMI), and the incidence of major adverse cardiac events (MACE, including acute myocardial infarction, acute heart failure, arrhythmias, cardiovascular death) at hospital discharge. RESULTS:After adjusting for confounders in the multivariable Cox proportional regression, all-cause mortality rates at 30 days and one year were higher among those who underwent surgery in the afternoon/night (aHR 1.6 [95%CI 1.1-2.3], P = 0.015 and aHR 1.7 [95%CI 1.3-2.2], P < 0.001, respectively). Afternoon/night patients had higher incidence of PMI (aHR 1.4 [95%CI 1.1-1.7], P < 0.001). There was no significant difference in the incidence of MACE (aHR 1.3 [95%CI 0.9-1.7], P = 0.074). CONCLUSIONS:In patients undergoing arterial vascular surgery, being operated in the afternoon/night was independently associated with increased all-cause mortality rates and incidence of perioperative myocardial injury/infarction.

1 Universidade Estadual Paulista “Júlio de Mesquita Filho” – UNESP, Botucatu, SP, Brasil. 2 Universidade de Loyola, Chicago, Illinois, EUA. 3 Universidade Estadual de Campinas – UNICAMP, Campinas, SP, Brasil. 4 Universidade de São Paulo – USP, São Paulo, SP, Brasil. 5 Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brasil. 6 Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, São Paulo, SP, Brasil. 7 Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Rio de Janeiro, RJ, Brasil. 8 Universidade do Estado do Rio de Janeiro – UERJ, Rio de Janeiro, RJ, Brasil. Financial support: None. Conflicts of interest: No conflicts of interest declared concerning the publication of this article. Submitted: August 30, 2021. Accepted: October 04, 2021.

RE-COVERY DVT/PE is a two-phase, international, observational study of anticoagulant therapy in patients with deep vein thrombosis and/or pulmonary embolism (DVT/PE). The objective of the second phase was to compare the safety and effectiveness of dabigatran versus a vitamin K antagonist (VKA) over 1 year of follow-up. Primary safety and effectiveness outcomes were major or clinically relevant nonmajor bleeding events (MBE/CRNMBEs) and symptomatic recurrent venous thromboembolism (VTE) (including deaths related to recurrent VTE). To minimize bias due to unbalanced patient characteristics, only patients in an overlapping range of estimated propensity scores were included (analytic set), and propensity score weighting was applied to compare outcomes. Outcome analysis used an as-treated approach, censoring patients after they stopped or switched their initial anticoagulant. Overall, 3009 patients enrolled from 2016 to 2018 were eligible: 60% were diagnosed with DVT alone, 21% with PE alone, and 19% with DVT plus PE. The analytic set consisted of 2969 patients. The incidence rate in %/year (95% confidence interval [CI]) of MBE/CRNMBEs was 2.63 (1.79–3.74) with dabigatran versus 4.48 (3.23–6.06) with warfarin; hazard ratio 0.63 (95% CI 0.32–1.25). For symptomatic recurrent nonfatal or fatal VTE the incidence rate was 1.53 (0.91–2.42) with dabigatran versus 2.01 (1.21–3.14) with VKAs; hazard ratio 0.78 (95% CI 0.30–2.02). In conclusion, we found lower annualized rates of MBE/CRNMBEs with dabigatran than VKA, although the difference was not statistically significant. Annualized rates of symptomatic VTE or related mortality were similar with dabigatran and VKA. These observational results with 1 year of follow-up reflect those of the randomized clinical trials. Trial registration: ClinicalTrials.gov identifier NCT02596230, first registered November 4, 2015.

Isolated distal deep vein thrombosis (IDDVT) is presumed to be more benign than proximal DVT (PDVT) or pulmonary embolism (PE), suggesting a need for different management approaches. This subgroup analysis of the RE-COVERY DVT/PE global, observational study investigated patient characteristics, hospitalization details, and anticoagulant therapy in patients with IDDVT in real-world settings in 34 countries enrolled from January 2016 to May 2017. Data were analyzed descriptively according to the type and location of the index venous thromboembolism (VTE): IDDVT, PDVTdistal DVT (DDVT), and PE +/- DVT. Of the 6,095 eligible patients, 323 with DVT located outside the lower limb and no PE were excluded. Of the remaining 5,772 patients, 17.6% had IDDVT, 39.9% had PDVT +/- DDVT, and 42.5% had PE +/- DVT. IDDVT patients were younger and had fewer risk factors for VTE than the other groups. Other comorbidities were less frequent in the IDDVT group, except for varicose veins, superficial thrombophlebitis, and venous insufficiency. IDDVT patients were less likely to be diagnosed in an emergency department (22.3 vs. 29.7% for PDVT +/- DDVT and 45.4% for PE +/- DVT) or hospitalized for VTE (29.2 vs. 48.5% for PDVT +/- DDVT and 75.0% for PE +/- DVT). At hospital discharge or 14 days after diagnosis (whichever was later), non-vitamin K antagonist oral anticoagulants were the most commonly used anticoagulants (55.6% for IDDVT, 54.7% for PDVT +/- DDVT, and 52.8% for PE +/- DVT). Although differences in patient characteristics, risk factors, and clinical management were identified, anticoagulant treatment of IDDVT was almost equal to that of PDVT or PE. Prospective studies should investigate whether, in a global perspective, this is an appropriate use of anticoagulants. Trial registration number ClinicalTrials.gov NCT02596230.

RE-COVERY DVT/PE is a multicenter, international, observational study of patients with deep vein thrombosis/pulmonary embolism (DVT/PE), comparing outcomes with dabigatran vs. vitamin K antagonists (VKAs). The main outcomes were International Society on Thrombosis and Haemostasis major or

1 Universidade de São Paulo – USP, Faculdade de Medicina, Hospital das Clínicas, Disciplina de Cirurgia Vascular, São Paulo, SP, Brasil. Financial support: None. Conflicts of interest: No conflicts of interest declared concerning the publication of this article. Submitted: April 17, 2019. Accepted: April 28, 2019. Until recently, medical therapy has always played a secondary role in the management of symptomatic peripheral artery disease, focusing on control of risk factors for atherosclerosis. Strict medical treatment had limited results in avoiding clinical outcomes caused by the evolution of atherosclerotic disease.1,2 However, clinical investigations concluded in the recent years opened new possibilities for medical therapy that goes far beyond the former role of an adjuvant therapy. Some are already a reality incorporated in daily practice, while are still under investigation.

BACKGROUND:New antithrombotic strategies that reduce primary thrombosis and restenosis might improve vascular outcomes in patients with peripheral artery disease (PAD) undergoing arterial angioplasty. The study objective is to evaluate the potential benefit of apixaban plus aspirin compared with standard of care dual antiplatelet therapy (DAPT) in reducing thrombotic restenosis and artery re-occlusion in patients undergoing endovascular infrapopliteal revascularization.STUDY DESIGN:This multicenter, parallel-group, prospective, randomized, open-label, blinded-endpoint adjudication, proof-of-concept, exploratory trial aims to randomize 200 patients 72 hours after successful infrapopliteal angioplasty for critical limb ischemia (CLI). Patients will be randomly assigned in a 1:1 ratio to receive oral apixaban (2.5 mg twice daily) plus aspirin (100 mg once daily) for 12 months or clopidogrel (75 mg daily) for at least 3 months on a background of aspirin (100 mg once daily) for 12 months. The primary endpoint is the composite of target lesion revascularization (TLR), major amputation, or restenosis/occlusion (RAS) in addition to major adverse cardiovascular events - MACE (myocardial infarction, stroke or cardiovascular death) at 12 months. The primary safety endpoint is the composite of major bleeding or clinically relevant non-major bleeding at 12 months.SUMMARY:This study will evaluate the efficacy and safety of apixaban 2.5 mg twice daily plus aspirin compared with DAPT (clopidogrel plus aspirin) in patients with CLI undergoing endovascular infrapopliteal revascularization and might prove the concept of an alternative antithrombotic regimen for these patients to be tested in a future large randomized clinical trial.