The latest medical research on Vascular Surgery

Large Vessel Occlusion (LVO) stroke patients with tandem lesions (TLs) have been observed to have worse outcomes when compared to patients with simple isolated intracranial occlusions.

To examine the difference in post-operative functional status at discharge for patients treated with mechanical thrombectomy for an acute LVO stroke based on the presence of a tandem carotid lesion.

This is a retrospective cohort study of 589 patients presenting within the first 24 hours of stroke onset who underwent mechanical thrombectomy. The primary outcome was functional status quantified by modified Rankin Score (mRS) at time of discharge. The secondary outcomes were presence of hemorrhagic conversion, midline shift >5 cm, malignant cerebral edema, reocclusion, Thrombolysis in Cerebral Infarction Scale (TICI), and discharge location.

Patients with tandem occlusions and those with isolated intracranial lesions had similar baseline demographics. However, in patients with TLs, there was a significantly higher NIH stroke scale at admission and a longer time to recanalization. Modified Rankin Score prior to admission was similar for both groups, but was significantly higher in patients with TLs at discharge. The secondary outcomes were similar for hemorrhagic conversion, discharge to hospice, and a TICI scale of 0, but were significantly worse for patients with TLs for in-hospital mortality, midline shift >5 mm, and malignant cerebral edema. The presence of a tandem lesion predicted a higher modified Rankin Score at discharge in univariate regression modeling (β = .45; P-value = .006).

The two groups were similar in baseline characteristics and cardiovascular risk factors, yet patients with tandem carotid lesions experienced more complications during their hospitalization and had greater functional disability at discharge. Patients with a TL had a longer mean time to recanalization, representing a potential explanation for these differences in outcomes.

Non-operative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared to appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of non-operative versus operative management for pediatric uncomplicated acute appendicitis.

A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional non-randomized controlled trial investigating NOM versus surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges (RCC)-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System (PHIS). Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and one-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay (WTP) threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Primary outcome measures included total and incremental mean costs, QALY, DALY, and incremental cost-effectiveness ratios (ICERs).

Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791/patient and yielded an average of 0.884 QALYs while NOM cost an average of $8,044/patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating utilities.

NOM is cost-effective compared to laparoscopic appendectomy for pediatric uncomplicated appendicitis over 1 year.

Although the endovascular management of infrarenal abdominal aortic aneurysms (AAAs) is widely performed, many studies have shown better long-term results with open graft repairing, mostly focusing on the classical open repair with midline access. This study aims to evaluate long-term results comparing EVAR (endovascular aneurysm repair) and surgical open repair with retroperitoneal access associated with ERAS (Enhanced Recovery After Surgery) protocol.

A retrospective analysis of 156 patients treated for AAA between 2015 and 2018 was conducted. Clinical and demographic characteristics of the two groups were homogeneous except for age, which was significantly higher in patients belonging to the EVAR one, and for previous laparotomies. A total of 100 patients (58.7%) underwent open retroperitoneal repair (ORR group), and 56 (42.3%) underwent EVAR. A mean of 51 ± 28 months of follow-up was conducted. This study aims to evaluate long-term survival by comparing EVAR (endovascular aneurysm repair) and surgical open repair with retroperitoneal access associated with ERAS (Enhanced Recovery After Surgery) protocol. Secondary aims evaluate differences between the two techniques regarding late complications, need for re-interventions, and perioperative results.

Freedom from all-cause mortality, calculated with Kaplan-Meier survival curves equalizing the two population with a Covariate Propensity Score, showed significant better survival rates at 1, 3, and 5 years in ORRs then in EVARs. Late complications (>30 days) and need for late re-intervention rates were greater in the EVAR group (6 late re-interventions needed vs 0 in the ORR group).Perioperative results show longer mean length of hospital stay in patients belonging to the ORR group (5 days vs 2) and significantly higher in-hospital-complication rate.

The long-term comparison between EVAR and open retroperitoneal repair shows significantly better late outcomes in the ORR group. The perioperative course appears significantly better in EVARs but anyway good in ORRs when a perioperative protocol as ERAS is applied.In a selected population of young patients fit for surgery, the retroperitoneal surgical approach should be highly taken into account in the therapeutical choice.

Abdominal Aortic Aneurysm (AAA) screening via ultrasound in Caucasian males aged 65 and older has proven cost-effective in metropolitan areas. Evidence suggests that with adequate training, individuals without prior sonography experience can achieve accurate aortic measurements. This study evaluates the capability of junior doctors, after brief training, to conduct reliable AAA ultrasound screenings in a rural hospital setting, addressing the gap in speciality surgical services.

Three junior doctors participated in a 2-hour practical ultrasound training, subsequently performing scans on both inpatients and community volunteers at a regional hospital. The analysis focused on measurement discrepancies within a 5 mm clinically acceptable difference, scanning efficiency, and aneurysm detection accuracy.

A total of 71 participants were included. Among the screenings, 81.7% fell within the clinically acceptable discrepancy range, with 72.7% accuracy in inpatient scans and 95.5% in volunteer scans. Measurement reproducibility improved significantly with the standardisation of ultrasound techniques, and there was excellent agreement among operators in detecting aneurysms. Notably, scanning efficiency improved from the inpatient group to the volunteer group with statistical significance.

Junior doctors demonstrated the ability to efficiently and reproducibly measure the infrarenal aortic diameter at a level comparable to experienced sonographers after only 2 hours of training. A single day of supervised practice is recommended to ensure standardised ultrasound technique. This approach offers a practical, cost-effective supplement to specialist radiology services in rural areas, enhancing access to critical screening procedures without proposing the replacement of professional sonographers.

Diabetes mellitus is a leading cause of renal failure in the US and has been associated with higher mortality when compared to nondiabetic patients. This remains true despite initiation of renal replacement therapy. As such, we were interested in identifying any potential differences in access durability and postoperative outcomes in diabetic patients who receive arteriovenous fistulas versus grafts for hemodialysis.

Diabetic patients undergoing their first arteriovenous (AV) access creation surgery in the Vascular Quality Initiative from January 2011 to January 2022 were included in our study. After exclusions, the study included two groups: those receiving AV fistulas and those receiving AV grafts for hemodialysis. Demographic characteristics were summarized and compared between these two groups using chi-square analysis or unpaired t-test. After propensity score matching was conducted, the effect of procedure type on functional patency, along with secondary outcomes including wound infection were assessed using chi-square analysis.

A total of 20,159 diabetic patients who used their hemodialysis access were included in our study; 16,205 received AV fistulas while 3954 received AV grafts. Patients receiving AV grafts were more likely to be older, female, and have higher pre-operative catheter usage. After propensity score matching, patients who received AV grafts had a shorter time-to-use their conduit (50 vs 166 days, p < 0.0001), however, patients who received AV fistulas were more likely to have longer functional patency use for hemodialysis when compared to those who received AV grafts (mean survival time: 3.3 vs 2.9 years, p < 0.0001). These results were consistent between diabetics with insulin-dependent or insulin-independent diabetes.

Patients diagnosed with diabetes mellitus had an increased risk for significantly inferior clinical outcomes related to newly created AV grafts, including lower rates of mid-term functional patency and higher rates of worse post-operative outcomes when compared to diabetics who received AV fistulas.