AIM:To determine whether achieved sealing length (SL) at the first postoperative computed tomography angiography (CTA) and its subsequent change over time are associated with later endoleak type 1A (EL1A) after infrarenal endovascular aortic repair. Secondary aims were to describe longitudinal remodeling of SL and to assess the association between persistent type 2 endoleak (EL2) and SL trajectories. METHODS:This retrospective study analyzed SL and sealing surface measured on postoperative CTA, using the first postoperative CTA as the reference examination. We examined whether the first postoperative seal, its subsequent change over time, and prior persistent EL2 were associated with later EL1A. Trajectories of ΔSL and Δsealing surface were modeled using spline mixed-effects models. Time to EL1A was analyzed using Cox models with predictors at the first CTA and pre-event change, including a joint baseline-plus-change model. Landmark analyses were used to assess sealing behavior and EL1A risk. Type 2 endoleak was treated as a time-varying exposure, and its association with subsequent EL1A was evaluated using landmark Cox analyses at 12, 24, 36, and 60 months. RESULTS:Among 501 patients, 346 were included in the longitudinal cohort; after a median follow-up time of 56 months (interquartile range, 28-95 months), 73 developed EL2, 39 developed EL1A, and 8 experienced both events. Baseline sealing at the first postoperative CTA and sealing deterioration were independently associated with EL1A in joint models (SL and sealing surface). Type 2 endoleak was associated with differential SL remodeling (interaction P < .001), with progressive divergence after ~24 months. In exploratory landmark analyses, EL2 was associated with higher subsequent EL1A hazard (36-month hazard ratio [HR] = 2.48; P = .030; 60-month HR = 3.14; P = .008), persisting after adjustment for sealing state and change up to the landmark. CONCLUSIONS:Both the first postoperative infrarenal seal and its variation during follow-up were associated with later EL1A. Persistent EL2 was associated with sealing deterioration, whereas its association with subsequent EL1A should be considered exploratory because few patients experienced both events.Clinical ImpactIn infrarenal endovascular aneurysm repair, both the sealing length achieved at the first postoperative computed tomography angiography and its longitudinal change were associated with later type 1A endoleak (EL1A). Persistent type 2 endoleak was associated with less favorable sealing evolution and may identify patients with reduced seal stability and exploratory higher subsequent EL1A risk.

OBJECTIVE:Enhanced Recovery After Surgery (ERAS) protocols represent a multidisciplinary strategy designed to optimize perioperative management and accelerate postoperative recovery. However, their adoption in vascular surgery-particularly in open aortic procedures-remains limited because of procedural complexity and the large number of elements required for implementation. In other surgical specialties, specific perioperative components have been identified as key determinants of outcome improvement, with adherence rates exceeding 70% considered essential to achieve significant clinical benefits. The aim of this study was to identify the core elements within an ERAS protocol for open aortic surgery that most significantly influence outcomes and to evaluate the impact of overall protocol adherence on postoperative results. METHODS:A prospective study was conducted including 206 patients managed under an ERAS protocol (Enhanced Recovery After Vascular Surgery group) between January 2019 and December 2025. Early outcomes assessed included time to discharge, 30-day mortality, postoperative complications, and readmissions. Late outcomes comprised overall survival, freedom from reintervention, and freedom from complications. The relationship between protocol adherence and clinical outcomes was analyzed, as well as the effect of individual protocol components. Based on the proportion of perioperative items applied, six adherence groups were defined (29%, 43%, 57%, 71%, 86%, and 100%), and mean hospital stay and complication rates were compared among them. RESULTS:A protocol adherence above 70% was achieved in 112 patients (54.5%). No statistically significant differences in baseline characteristics or comorbidities were observed between patients with adherence below or above 70%. The mean time to discharge across the six groups was 9.4, 7.8, 8.8, 6.0, 5.1, and 4.0 days, respectively (P < .001). Thirty-day postoperative complications occurred in 18 patients (19.1%) with adherence below 70%, compared with only 2 patients (1.8%) with adherence above 70% (P < .001). No 30-day mortality or readmissions were reported in any group. Follow-up was available for 99.5% of patients, with a mean duration of 44.4 months (standard deviation, 21.4; range, 3-86). Four-year overall survival was 89% in patients with adherence below 70% and 95% in those with adherence ≥70% (P = .029). Linear regression analysis identified preoperative fasting/bowel preparation (B, 2.78; P = .003), delayed removal of the central venous catheter (B, 0.15; P = .054), nasogastric tube (B, 0.23; P = .019), and urinary catheter (B, 0.90; P < .001) as independent predictors of prolonged hospital stay. CONCLUSIONS:Adherence to more than 70% of the ERAS protocol components was associated with a significant improvement in postoperative outcomes and long-term survival, although this adherence level was achieved in just over half of the cohort. Multivariate analysis confirmed the influence of specific perioperative elements on the length of stay. Further multicenter studies are warranted to validate these findings and to assess the reproducibility and generalizability of ERAS pathways in open aortic surgery.

INTRODUCTION:Current diagnostic reference levels (DRLs) for endovascular aortic repair (EVAR), based on iodinated contrast media (ICM) protocols, range from 100 to 200 Gy·cm2. As CO2 is a negative contrast agent requiring digital subtraction angiography (DSA) for visualization, it may be associated with increased radiation exposure. This multicenter study presents the largest prospective data set to date evaluating radiation dose during EVAR using CO2 angiography alone with an automated injector. METHODS:A prospective, multicenter, nationwide, nonrandomized, investigator-initiated observational study of dosimetry recorded during EVAR procedures with CO2 as exclusive contrast medium was conducted. Primary endpoints included dose-area product (DAP) and reference air kerma (Kar) measurements across all participating centers. Secondary objectives focused on evaluating optimization strategies to reduce radiation exposure for both patients and operators at a single investigational site. RESULTS:A total of 293 patients were enrolled across 10 centers, between January 2023 and January 2024, median DAP and Kar were 189 Gy·cm2 (interquartile range [IQR] 107-285) and 626.5 mGy (IQR 145.5-1373.5), respectively, with significant inter-center variability (all p<0.001). Newer angiographic systems demonstrated markedly lower DAP (median: 90 Gy·cm2, IQR 71-153) vs older systems (191 Gy·cm2, IQR 111-409; p<0.001). Through sequential optimization, we achieved progressive dose reductions: 38.5% via low-dose protocols, 52.3% with modern equipment, culminating in a 56% overall reduction (p<0.001) with synchronized CO2-DSA-yielding a final median DAP of 28.5 Gy·cm2. CONCLUSIONS:CO2-guided EVAR exhibits substantial radiation dose variability, driven by angiographic system generation, software, and synchronization protocols. Modern systems with optimized low-dose protocols and CO2-DSA synchronization reduce radiation exposure to levels comparable to ICM-based EVAR.Clinical ImpactThis large multicenter prospective study establishes a reliable radiation dose benchmarks for CO2-guided endovascular aortic repair (EVAR), showing that modern angiographic systems with optimized low-dose protocols and synchronized CO2-digital subtraction angiography achieve median dose-area product values comparable with conventional iodinated contrast media EVAR, thereby dispelling concerns about excessive radiation exposure with CO2-guided EVAR.

Renal artery in-stent restenosis is an uncommon but serious cause of resistant hypertension and flash pulmonary edema. We present the case of a 75-year-old woman with extensive multidistrict atherosclerosis and a history of multiple endovascular procedures, who presented to the emergency department with recurrent pulmonary edema due to uncontrolled hypertension. Despite maximal antihypertensive therapy, her blood pressure remained severely elevated, with evidence of acute kidney injury. Doppler ultrasound revealed restenosis of the right renal artery stent, characterized by a tardus-parvus waveform, along with an atrophic left kidney. The patient underwent successful right renal artery lithotripsy and stenting, resulting in restoration of renal perfusion and subsequent improvement in blood pressure control and pulmonary congestion. In patients with resistant hypertension and recurrent flash pulmonary edema, prompt recognition of renal artery stenosis, the so-called Pickering syndrome, or in-stent restenosis as in the present case, and timely endovascular reintervention can be lifesaving.

Objective: To assess whether baseline abdominal aortic aneurysm (AAA) diameter is associated with long-term durability after elective EVAR, after accounting for relevant anatomic differences. Methods: Consecutive patients undergoing elective EVAR for infrarenal fusiform AAA between 2011 and 2022 at four Italian centers were analyzed. Ruptured, saccular, and adjunctive proximal or distal procedures were excluded. Patients were stratified as AAA ≤ 50 mm or >50 mm. Outcomes included any endoleak, reintervention, aneurysm-related death, sac behavior, and all-cause mortality. Analyses used cumulative incidence functions, Fine–Gray competing-risk models, multivariable Cox regression, and propensity-score matching incorporating key anatomic variables. Results: Among 1505 patients, 499 (33.2%) had AAA ≤ 50 mm. Median follow-up was 49 months. Larger aneurysms showed higher 10-year cumulative incidence of any endoleak (33.9% vs. 15.8%, Gray p < 0.001), type 1a endoleak (16.5% vs. 6.1%, Gray p < 0.001), reintervention (24.7% vs. 16.2%, Gray p < 0.001), and aneurysm-related death (5.4% vs. 2.4%, Gray p = 0.028). In anatomy-adjusted multivariable Cox models, each 1 cm increase in diameter was associated with higher hazards of any endoleak (HR 1.22, 95% CI 1.11–1.34; p < 0.001), type 2 endoleak (HR 1.26, 95% CI 1.12–1.43; p < 0.001), reintervention (HR 1.19, 95% CI 1.07–1.32; p = 0.001), and aneurysm-related mortality (HR 1.46, 95% CI 1.19–1.81; p < 0.001). In propensity-score-matched analyses, AAA ≤ 50 mm was associated with lower hazards of any endoleak, HR 0.39, 95% CI 0.28–0.55; p < 0.001, and reintervention, HR 0.40, 95% CI 0.26–0.62; p < 0.001. Conclusions: Baseline AAA diameter adds prognostic information beyond standard anatomic features and may help tailor post-EVAR surveillance. What is new?: This multicenter real-world study shows that baseline abdominal aortic aneurysm diameter provides continuous prognostic information of clinical outcomes after elective EVAR. Larger preoperative diameter was associated with higher long-term risk of endoleak and reintervention, supporting the use of baseline sac size as one component of individualized post-EVAR surveillance planning.

OBJECTIVE:Patients frequently seek health information and medical advice from chatbots instead of consulting their physicians or referring to credible patient education resources provided by medical societies. A study to evaluate the quality, readability, and clinical appropriateness of ChatGPT generated answers to common vascular surgery questions was designed. METHODS:Sixteen questions, written in a layperson style, were developed covering four major vascular conditions: abdominal aortic aneurysm; carotid stenosis; peripheral arterial occlusive disease; and varicose veins. The questions were categorised across four domains (signs/symptoms, natural history, medical advice, and best treatment) and further grouped for analysis into symptom related and treatment related queries. They were addressed to ChatGPT (gpt-3.5-turbo-0125) in dedicated sessions. Tone, complementarity, urgency, and uncertainty were assessed using adapted QUEST, DISCERN, and urgency scales. The Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) were used to measure readability. The accuracy, comprehensiveness, and clarity of the information was rated on a Likert scale by three board certified vascular surgeons. RESULTS:No significant differences were found in tone or complementarity across disease categories or question types. Urgency did not differ significantly between symptom related and treatment related queries overall; however, urgency varied significantly across subtypes of symptom related questions (p = .03), consistent with inconsistent escalation recommendations. The mean FRE was 32.3 ± 12.1 and FKGL 13.5 ± 2, corresponding to a university level reading requirement. Symptom related responses were more readable than treatment related ones (FRE 38.1 ± 10.3 vs. 26.4 ± 11.4; p = .025). Among the 16 outputs, only seven (44%) were judged clinically appropriate by all reviewers; clarity was rated adequate in 81% of responses, whereas only 50% reached acceptable accuracy and 69% acceptable comprehensiveness. Treatment related answers were particularly weak, with only 25% deemed appropriate. In symptom related questions, misalignment of urgency recommendations emerged as a potential patient safety concern. CONCLUSION:In this specialist evaluation, ChatGPT outputs related to vascular surgery were clear, but mostly clinically inappropriate and inaccurate, and required 13th grade reading skills. The combination of low accuracy and poor accessibility presents a serious patient safety concern for unsupervised patient education. As they stand, generalist large language models cannot provide patient facing information about vascular surgery. A rigorously validated, domain specific, and knowledge locked artificial intelligence system based on curated vascular guidelines may be more appropriate to ensure safety and comprehension.

OBJECTIVES:This study aimed to describe the outcomes of a new custom-made inner-branch device, also suitable as off-the shelf stent graft, for the endovascular repair of complex aortic lesions and to evaluate the results also in narrowed patent aortic lumen (<25 mm) at the level of visceral aorta. METHODS:This multicentre study (2021-2024) included patients treated with this new inner-branched device for complex aortic lesions. Endpoints were: technical success, early (<30 days) mortality, late (>30-days) survival, and freedom from aorta-related mortality (ARM), aortic adverse events, and target visceral vessels (TVVs) patency. RESULTS:This study included 46 patients and 184 target vessels. Technical success was 100%, and no cases of ARM were recorded. Three cases (6.5%) of spinal cord ischaemia (SCI) were registered. Overall 30-day mortality rate was 8.7%. The mean follow-up was 10.5 ± 9 months. Overall survival rate was 97.4% (95% CI, 76-99) at 3 months, 94% (95% CI, 71-98) at 6 months, 85.1% (95% CI, 54-96) at 12 months, and 76% (95% CI, 41-92) at 24 months. Late deaths occurred in 3 patients (8.3%) after a median of 8 months (interquartile range [IQR], 4-12 months). No late ARM, type I or III endoleak were registered. The primary bridge-stent patency was 98.9% (95% CI, 73-99). No late SCI were registered. The subgroup characterized by narrow aortic patent lumen did not showed bridge-stent instability, reintervention, death, and ARM. CONCLUSIONS:Endovascular repair of thoraco-abdominal aortic aneurysms (TAAAs) and complex aortic lesions with this new custom/off-the shelf stent graft was technically safe and effective with promising results both in elective and urgent cases.

BACKGROUND:The CURRENT registry is a prospective, multicenter, real-world investigation designed to evaluate the safety and effectiveness of the Renzan™ stent (Terumo MicroVention Inc., Aliso Viejo, CA, USA) in patients with femoro-popliteal peripheral artery disease (PAD), including complex lesions and chronic limb-threatening ischemia (CLTI). This study reports the interim outcomes at 6 and 12 months. METHODS:A total of 89 patients with symptomatic PAD (Rutherford category IV-V 64.1%) were enrolled across three centers in Tuscany, Italy. All patients underwent endovascular treatment with the Renzan™ dual-layer interwoven nitinol stent. Baseline and follow-up assessments included clinical evaluation and duplex ultrasound imaging. The primary safety endpoint was the composite rate of all-cause death, target lesion revascularization (TLR), and major amputation at 30 days. The primary efficacy endpoint was primary patency at 6 months. Estimated patency and reintervention rates were reported at 12 months using Kaplan-Meier analysis. RESULTS:Technical and procedural success was achieved in 100% of cases. At 30 days, no deaths, TLRs, or major amputations occurred. At 6 months, the composite safety endpoint was met in 94.3% of patients. Primary patency was 100% at 1 and 3 months, 92.0% at 6 months, and declined to 78.7% (95% CI: 55.3-88.1%) at 12 months. Freedom from TLR was 97.2% at 6 months and 78.5% (95% CI: 63.7-88.7%) at 12 months. Exploratory multivariable analysis identified diabetes mellitus, previous peripheral endovascular intervention, and below-the-knee involvement as independent predictors of loss of patency, whereas dual antiplatelet therapy beyond 1 months was associated with a reduced risk of patency loss. CONCLUSIONS:The Renzan™ stent demonstrated excellent early safety and efficacy outcomes in a challenging PAD population, with sustained mid-term patency despite a high proportion of complex lesions. These preliminary results support the use of this new mimetic stent design in real-world clinical settings and warrant further confirmation with longer-term follow-up.

BACKGROUND:The impact of a narrow true lumen (NTL) on the outcomes of fenestrated-branched endovascular repair in patients with postdissection thoracoabdominal aortic aneurysms (PD-TAAAs) is underreported. METHODS:Data from an international, multicenter registry were analyzed, to identify patients treated for PD-TAAAs (2015-2025) at 23 centers. All patients underwent fenestrated-branched endovascular repair using custom or off-the-shelf endografts. NTL was defined by a true lumen diameter <25 mm identified at any aortic level on preoperative computed tomography angiogram. Short-term endpoints compared between NTL and no-NTL patients included technical success, procedural metrics, 30-day mortality, and major adverse events (MAEs). Midterm endpoints included 5-year freedom from aortic adverse events (related mortality, rupture, reintervention, endograft instability) and freedom from target artery instability. RESULTS:Among 544 patients (1705 target vessels), 438 (80%) had an NTL. Device design did not differ between groups (52% branches, 30% fenestrated, and 18% fenestrated-branched combination; P = .053). Patients with an NTL more frequently received bridging stent reinforcement (P < .001), and renal inner branches (P = .038). Septotomy or false lumen occlusion were more often performed in NTLs (27% vs 11%; P = .006). Patients with NTLs had longer operating time (P = .031), fluoroscopy time (P = .007), and a higher dose area product (P = .046). Technical success was 95% in both groups (P = .750). Overall 30-day mortality was 4%, and MAEs occurred in 35%. NTLs did not have a significant impact on MAEs (adjusted odds ratio, 0.84; 95% confidence interval [CI], 0.28-2.76; P = .766). Freedom from any aortic adverse event at 5 years was lower in patents with NTL (73% vs 91%; P = .027), driven primarily by secondary procedures of false lumen embolization (P = .027). Freedom from target vessel instability was 86% ± 4% in the NTL group and 92% ± 4% in the no-NTL group (P = .072). Patients with NTLs had a similar primary patency (97% ± 2% vs 98% ± 2%; P = .380) but lower freedom from target vessel endoleak (89% ± 4% vs 97% ± 3%; P = .006). After adjustment, NTL diameter <10 mm (hazard ratio [HR], 2.45; 95% CI, 1.37-4.36; P = .002) was significantly associated with target artery instability. Use of inner branches (HR, 0.11; 95% CI, 0.02-0.87; P = .035) and bridging stent reinforcement (HR, 0.54; 95% CI, 0.31-0.96; P = .038) were protective. CONCLUSIONS:NTL is the most common anatomic presentation in PD-TAAAs and is associated with more complex procedures, but does not affect technical success, mortality, or MAEs. Patients with an NTL experience a higher rate or reinterventions, primarily false lumen embolization. NTL <10 mm is a risk factor for target vessel instability, and reinforcement of bridging stents may be beneficial in these cases.

This study aimed to prospectively assess the use of the ultrasound signal amplifier in preoperative color Doppler ultrasound (DUS) evaluation of carotid plaques in asymptomatic patients eligible for surgical correction. Between November 2022 and May 2023, 21 patients with asymptomatic carotid stenosis were enrolled. Each patient underwent DUS, contrast-enhanced ultrasound (CEUS), and computed tomography angiography (CTA) during the preoperative workup. Data on demographics, clinical characteristics, risk factors, comorbidities, and therapy were collected. The degree of stenosis was analyzed using North American Symptomatic Carotid Endarterectomy Trial criteria, comparing DUS, CEUS, and CTA with statistical tests. Hemodynamic parameters (peak systolic velocity, end-diastolic velocity, internal carotid artery/common carotid artery ratio) and plaque morphology (juxtaluminal black areas, discrete white areas, and intraplaque neovascularization) were assessed. CEUS examination demonstrated a significantly higher stenosis degree (72%) compared with DUS (68%; P < .001) and differed from CTA (80%; P = .004). Hemodynamic parameters were also higher with CEUS (peak systolic velocity, 321 cm/sec vs 249 cm/sec; end-diastolic velocity, 92 cm/sec vs 88 cm/sec; internal carotid artery/common carotid artery ratio, 4.4 vs 3.8; all P < .001). CEUS examination identified irregular plaque margins more frequently (15 cases vs 8 cases), larger juxtaluminal black areas (17 cases vs 7 cases, mean diameter 3.3 mm vs 2.7 mm), and discrete white areas (6 vs 0). Neovascularization was observed in 10 plaques via CEUS examination. These findings suggest that CEUS examination is a safe, cost-effective, and efficient noninvasive tool for preoperative carotid plaque assessment, offering higher resolution and more detailed plaque characterization compared with DUS. Despite the limited sample size, CEUS examination provides valuable insights into plaque morphology and embolic risk profile. The CEUS examination needs to be validated with larger multicenter cohorts.

OBJECTIVE:This multicentre, retrospective, observational study aimed to identify patients who are suitable for less frequent follow up (FU) checkups after endovascular aneurysm repair (EVAR) through the validation and implementation of the recently updated European Society for Vascular Surgery (ESVS) surveillance algorithm. METHODS:An analysis was performed on consecutive patients who underwent EVAR for abdominal aortic aneurysm (AAA) at four high volume centres that demonstrated adherence to FU for at least five years. Patients were divided into high and low risk of adverse event groups, according to ESVS definitions, and compared. A sub-analysis was conducted for patients categorised as low risk who exhibited sac regression and no evidence of endoleak at the one year FU assessment. RESULTS:Of 596 patients meeting the inclusion criteria, 300 (50.3%) fulfilled the ESVS criteria for classification as low risk. At the five year FU, the rates of rupture (0.7% vs. 3%; p = .031), AAA related death (0.7% vs. 2.4%; p = .089), and re-intervention (9.7% vs. 17.2%; p = .007) were lower in the low risk group. Over the initial five years of FU, 84 patients experienced adverse events such as re-interventions, ruptures, and or AAA related death, with 28 occurring in the ESVS low risk group, indicating that the ESVS protocol has a five year capability of predicting 90.7% of potential adverse events in low risk patients. The sub-analysis of ESVS low risk patients who exhibited sac regression and no evidence of endoleak at one year FU (20.1% of the total cohort) revealed a five year modified ESVS protocol capability of potentially predicting 97.6% of adverse events (three re-interventions recorded). CONCLUSION:The updated ESVS surveillance algorithm provides a consistent prediction of potential adverse events within five years of FU, although refining patient stratification may further improve outcomes. Patients initially classified as low risk and also exhibiting sac regression without endoleaks at one year could be candidates for reduced surveillance.