Total Luminal Volume Predicts Risk after Endovascular Aneurysm Repair

Objective: Large aneurysm diameter represents a well known predictor of late complications after endovascular aneurysm repair (EVAR). However, the role of the thrombus free lumen inside the abdominal aortic aneurysm (AAA) sac is not clear. It was hypothesised that greater luminal volume represents a relevant risk factor for late complications after EVAR. Methods: A retrospective cohort analysis was performed including all patients undergoing EVAR from 2005 to 2016 at a tertiary referral institution. Pre-operative AAA lumen volume was measured in centre lumen line reconstructions and patients were stratified into quartiles according to luminal volume. The primary endpoint was freedom from AAA related complications. Secondary endpoints were freedom from neck events (type 1A endoleak, migration >5 mm or any pre-emptive neck related intervention), iliac related events (type 1B endoleak or pre-emptive iliac related intervention), and overall survival. Results: Four hundred and four patients were included: 101 in the first quartile (Q1; <61 cm3). Patients with higher luminal volumes had wider, shorter, and more angulated proximal necks. There were more ruptured AAAs, more aorto-uni-iliac implanted devices and patients outside neck instructions for use in the 4th quartile. Five year freedo

Comparison of midterm results of endovascular aneurysm repair for ruptured and elective abdominal aortic aneurysms

Objective: Endovascular aneurysm repair (EVAR) became an increasingly preferred modality for abdominal aortic aneurysm (AAA) repair both in elective AAA repair (el-EVAR) and EVAR of a ruptured AAA (r-EVAR) setting. Ruptured AAAs usually have more hostile anatomies and less time for planning. Consequently, more complications may arise after r-EVAR. The purpose of this study was to compare mi-term outcomes between r-EVAR and el-EVAR. Methods: A retrospective cohort analysis of patients undergoing EVAR from 2000 to 2015 at a tertiary institution was performed. Patients with previous aortic surgery, nonatherosclerotic AAA and isolated iliac aneurysms were excluded. In-hospital casualties or patients who were intraoperatively converted to open repair were also excluded. For the midterm outcome analysis, only patients with at least two postoperative examinations (a 30-day computed tomography scan and a second postoperative examination performed 6 months or later) were considered. The primary end point was freedom from aneurysm-related complications (a composite of type I or III endoleak, aneurysm sac growth, migration of more than 5 mm, device integrity failure, AAA-related death, late postimplant rupture, or AAA-related secondary intervention). Freedom from secondary interventions, neck-related events (defined as a composite of type IA endoleak, migration of more than 5 mm, or preemptive neck-related secondary intervention) and late survival were secondary end points. The impact of device instructions for use (IFU) compliance on neck events was also assessed. Results: The study included 565 patients (65 r-EVAR and 500 el-EVAR). Eighty-two patients were treated outside proximal neck IFU, 13 in the r-EVAR group (21.3%) and 69 (14.5%) in the el-EVAR (P =.16). During the index hospitalization, there were more complications (12.3% vs 3.2%; P =.001) and reinterventions (12.3% vs 2.8%; P <.001) in the r-EVAR group. After discharge, median clinical follow-up time was 4.3 years (interquartile range, 2.1-7.0 years) without differences between both groups. Five-year freedom from AAA-related complications was 53.9% in the r-EVAR group and 65.4% in the el-EVAR (P =.21). In multivariable analysis the r-EVAR group was not at increased risk for late complications (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.54-1.61; P =.81). Five-year freedom from neck-related events was 74% in r-EVAR and 82% in the el-EVAR group (P =.345). Patients treated outside neck IFU were at greater risk for neck-related events both in r-EVAR (HR, 6.5; 95% CI, 1.8-22.9; P =.004) and el-EVAR group (HR, 2.6; 95% CI, 1.5-4.5; P <.001). Freedom from secondary interventions at 5 years was 63.0% for r-EVAR and 76.9% for el-EVAR (P =.16). Survival at 5 years was 68.8% in the r-EVAR group and 73.3% in the el-EVAR group (P =.30). Conclusions: Durable and sustainable midterm outcomes were found for both r-EVAR and el-EVAR patients who survived the postoperative period. Patients treated out

Prevention and management of venous thromboembolism. International Consensus Statement. Guidelines according to scientific evidence

This document aims to provide a clear and concise summary of the evidence regarding the efficacy or harm of various methods available to prevent and manage venous thromboembolism (VTE) and to provide recommendations based on such evidence

Recent Advances and Controversial Issues in the Optimal Management of Asymptomatic Carotid Stenosis

Objective: The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of AsxCS patients. Methods: A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis", "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS) and "transcarotid artery revascularization" (TCAR). Areas covered included: i) improvements in best medical treatment (BMT) for AsxCS patients and declining stroke risk, ii) technological advances in surgical/endovascular skills/techniques and outcomes, iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and, iv) the association between cognitive dysfunction and AsxCS. Results: BMT is essential for all AsxCS patients, regardless of whether they will eventually be offered CEA/CAS/TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These include patients with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound, silent infarcts on brain CTA/MRA scans, reduced cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration and intraplaque hemorrhage. Treatment of AsxCS patients should be individualized, taking into consideration individual patient preferences/needs, clinical/imaging characteristics, and cultural/ethnic/social factors. Solid evidence supporting/refuting an association between AsxCS and cognitive dysfunction is lacking. Conclusions: The optimal management of AsxCS patients should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA/CAS/TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs/preference, clinical/imaging characteristics, social/cultural factors and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression/reversal of cognitive dysfunction

European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

peer reviewe

An International, Multispecialty, Expert-Based Delphi Consensus Document on Controversial Issues in the Management of Patients with Asymptomatic and Symptomatic Carotid Stenosis

Objective: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. Methods: Fourteen controversial topics were identified. A 3-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was re-sent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Results: Most experts agreed that: (i) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6 to 4% in SxCS and from 3 to 2% in AsxCS patients, (ii) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less, (iii) 80-99% AsxCS carries a higher risk of stroke compared with 60-79% AsxCS, (iv) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (e.g., plaque features of vulnerability and silent infarctions on brain CT scans), and, (v) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. Conclusions: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research

Fake-news-free evidence-based communication for proper vein-lymphatic disease management

Published scientific evidence demonstrate the current spread of healthcare misinformation in the most popular social networks and unofficial communication channels. Up to 40% of the medical websites were identified reporting inappropriate information, moreover being shared more than 450,000 times in a 5-year-time frame. The phenomenon is particularly spread in infective diseases medicine, oncology and cardiovascular medicine. The present document is the result of a scientific and educational endeavor by a worldwide group of top experts who selected and analyzed the major issues and related evidence-based facts on vein and lymphatic management. A section of this work is entirely dedicated to the patients and therefore written in layman terms, with the aim of improving public vein-lymphatic awareness. The part dedicated to the medical professionals includes a revision of the current literature, summing up the statements that are fully evidence-based in venous and lymphatic disease management, and suggesting future lines of research to fulfill the still unmet needs. The document has been written following an intense digital interaction among dedicated working groups, leading to an institutional project presentation during the Universal Expo in Dubai, in the occasion of the v-WINter 2022 meeting.</p