The latest medical research on Vascular Surgery
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Request AccessRobotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy.
Journal of theLaparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.
PubMed, Embase and Scopus databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane ROBINS-I tool. Assessed outcomes included intra- and post-operative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random effects model to report odds ratio (OR) and 95% confidence intervals (95% CIs) and continuous data to report mean difference (MD) and 95% CIs.
Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic, 168,335 laparoscopic patients) studies assessed HHR outcomes, while nine (2,384 robotic, 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a non-significantly shorter length of hospital stay (LOS) [MD -0.41 (95% CI -0.87, -0.05)], fewer conversions to open [OR 0.22 (95% CI 0.03, 1.49)], and lower morbidity rates [OR 0.76 (95% CI 0.47, 1.23)]. Robotic HM led to significantly fewer esophageal perforations [OR 0.36 (95% CI 0.15, 0.83)], reinterventions [OR 0.18 (95% CI 0.07, 0.47)] a non-significantly shorter LOS [MD -0.31 (95% CI -0.62, 0.00)]. Both robotic HM and HHR had significantly longer operative times.
Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the two methods, given the low to moderate quality of included studies.
Endovascular Therapy for Vascular Graft Infection After Multiple Bypass Surgeries for Aorto-Iliac Occlusive Disease.
Vascular and Endovascular SurgeryVascular graft infection is a very complex disease. Although complete excision of the infected grafts with extra-anatomic bypass or in situ reconstruction is a general treatment strategy, some concerns including reinfection in the new graft remain.
An 88 year-old man presented to the hospital with abdominal swelling and bleeding. The patient had undergone revascularization for aorto-iliac occlusive disease twice in the past. The first procedure had been performed 15 years previously, with right ilio-femoral bypass grafting for right iliac artery occlusion and stent implantation for left iliac artery stenosis. The second procedure had been performed 10 years previously, with aorta-to-left femoral and left-to-right femoro-femoral bypass grafting because the terminal aorta, the first ilio-femoral bypass graft, and the stent of the left iliac artery had been occluded. The patient was diagnosed with vascular graft infection, and endovascular therapy was selected as the revascularization method prior to graft excision. It was successfully performed using various devices and techniques, followed by graft excision without critical limb ischemia.
This case demonstrates that endovascular therapy prior to graft excision can be an alternative revascularization method for vascular graft infection after bypass surgery for aorto-iliac occlusive disease.
Diagnosis and treatment of venous thromboembolism during pregnancy relate to genetic polymorphism.
VascularPrevious research had shown that age, a positive family history, comorbidities, major surgical operations, gestation, and use of several medications could increase the incidence of venous thromboembolism (VTE). With the development of medical and clinical individualized treatment, many people exposed to above risk factors did not develop VTE, suggested that genetic factors are also involved in the development of VTE. In this review, we aim to summarize VTE diagnosis and treatment in pregnancy women related to gene polymorphism.
A comprehensive electronic search using PubMed, MEDLINE, EMBASE and Web of Science was conducted to find relevant journal articles with key search terms including: "pregnancy OR pregnant," "venous thromboembolism OR VTE," "deep vein thrombosis OR DVT," "pulmonary embolism OR PE," and "genetic OR gene." Prominent publications from establishment of database till present were analysed to achieve a deeper understanding of VTE during pregnancy relate to genetic polymorphism, and the information was then collated to form this review.
The literature review revealed that inherited thrombophilia significantly associated with the development of VTE, especially the factor V Leiden (FVL) and prothrombin gene mutation (PGM). Furthermore, the role of methylenetetrahydrofolate reductase (MTHFR) gene mutation in the development of pregnancy-related VTE remains controversial, further study is required. In the present study, Marburg I polymorphism (G511 E), c.1538 G>A and c.1601 G>A in Factor V (FV), JAK2V617 F mutation were reported as an independent risk factor for VTE, there is no sufficient evidence to confirm the gene mutation is related to VTE during pregnancy, these factors appearing as another promising potential diagnostic marker of VTE during pregnancy. Besides, the dosages of heparin in the treatment of VTE during pregnancy need be adjusted according to gene polymorphism of these population, particularly FVL or PGM carriers, and this area is not studied deeply, it is worth further study.
Inherited thrombophilia significantly associated with the development of VTE, especially the FVL and PGM, however the relation between MTHFR gene mutation and pregnancy-related VTE remains controversial, further study is needed. In addition, the dosages of heparin in the treatment of VTE during pregnancy suggested to adjusted based on gene polymorphism in FVL and PGM, and establish better prediction models is a direction of future research.
Comparison between covered-stents grafting and ligation in the treatment of infected femoral pseudoaneurysm due to intravenous drug abuse.
VascularThe study compared the outcomes between covered-stents grafting (CSG) and ligation of femoral artery (LFA) in the treatment of infected femoral pseudoaneurysm (IFP) caused by intravenous drug injection.
From 1st January 2016 to 30th November 2021, the clinical data of patients with IFP caused by intravenous drug injection who underwent CSG (n = 31, 55.4%) and LFA (n = 25, 45.4%) are retrospectively analyzed. We compared the baseline characteristics and clinical outcomes of the two groups, including early and late mortality and morbidity.
A total of 56 patients were enrolled in the study, comprising 50 (89.3%) men and 6 (10.7%) women, with a mean age of 34.3 years. There was no significant difference observed between the two groups in terms of 30-day mortality (3.2% vs 0%, p = .365) and length of stay (9 [7, 12] vs 11 [8.5, 12.5] days, p = .236). However, group CSG exhibited a lower rate of intermittent claudication (0% vs 32%, p = .001), less blood loss (67.1 ± 22.5 mL vs 177.0 ± 59.8 mL, p < .001), and shorter surgery duration (57.5 ± 9.9 min vs 84.4 ± 22.8 min, p < .001) compared to group LFA. The LFA group were divided into subgroups according to the ligation site. The amputation rate of superficial femoral artery ligation group (0 vs 27.3%, p = .014) was significantly lower than common femoral artery ligation.
Covered-stents grafting may be a preferable treatment to LFA for IFP due to intravenous drug abuse, particularly when the entry tear is located in the common femoral artery.
The Rationale for Using Fixed-Dose Combination Therapy in the Management of Hypertension in Colombia: A Narrative Review.
Cardiovascular DrugsHypertension is a major risk factor for cardiovascular disease and the leading cause of death in Colombia. While the rate of hypertension awareness...
Locally Advanced Adenocarcinoma of the Esophagus: Is Esophagectomy Associated with Improved Overall Survival?
Journal of theEsophagectomy in locally advanced esophageal adenocarcinoma is challenging and carries risk. The value of esophagectomy in locally advanced esophageal adenocarcinoma is not well-defined.
The National Cancer Database was used to identify patients with cT4 esophageal adenocarcinoma from 2004-2020. Multivariable regression was used to identify factors associated with use of esophagectomy. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing esophagectomy were 1:1 propensity score-matched to patients treated non-surgically. Kaplan-Meier analysis was used to compare five-year overall survival (OS).
3,703 patients met inclusion criteria. 541 (15%) underwent esophagectomy, 3,162 (85%) did not. Age ≤ 65 (aOR 1.69, [1.33, 2.14]), white race (aOR 2.98, [2.24, 3.96]), treatment in academic centers (aOR 1.64, [1.33, 2.02]), private insurance (aOR 1.88, [1.50, 2.36]), and tumors <6cm (aOR 1.86, [1.44, 2.40]) were associated with use of esophagectomy. Government/lack of insurance (HR 1.23, [1.12, 1.35]), income <$46,000 (HR 1.11, [1.03, 1.20]), treatment in non-academic centers (HR 1.16, [1.07, 1.25]), CCI ≥ 1 (HR 1.22, [1.12, 1.32]), and tumors ≥ 6 cm (HR 1.20, [1.09, 1.32]) were associated with risk of all-cause mortality. Esophagectomy (HR 0.50, [0.44, 0.56]) and systemic therapy (HR 0.40, [0.37, 0.43]) were associated with decreased risk of all-cause mortality. Patients undergoing esophagectomy had higher rates of 5-year OS (27.4% vs 13.2%, p<0.0001) and longer median OS (24.71 vs. 10.09 months, p<0.0001). Among cT4b patients, those who underwent esophagectomy had higher rates of 5-year OS (24.5% vs 12.3%, p<0.0001) and longer median OS (25.53 vs. 11.01 months, p<0.0001).
In cT4 esophageal adenocarcinoma, esophagectomy is associated with improved rates of 5-year OS compared to non-surgical treatment.
Explant of an infected, endo-trashed IVC filter in an immunosuppressed patient with chronically occluded iliocaval stents.
VascularIn the absence of a contiguous bowel perforation or intraabdominal source, infection of a retained vena cava filter in an occluded IVC has never been described.
To describe a case of an infected IVC filter in a chronically occluded iliocaval segment.
Here we present a case of an immunosuppressed 35-year-old female with chronically occluded iliocaval stents and an extensive staphylococcus hominis infection of a previously endo-trashed Bard Eclipse® filter. Particular attention is paid to supportive imaging in establishing the diagnosis and technical aspects of successful device explant and retroperitoneal debridement.
At 6 months postoperatively, the patient was doing well without evidence of recurrent infection. Her lower extremity edema was controlled with compression alone.
The main objective of this operation was source control with debridement of the infection and removal of the filter and as much of the iliac vein as safely possible. Superinfection of a previously placed iliocaval stents and inferior vena cava filter remains a concern in patients with retroperitoneal infection and chronic iliocaval occlusion. Operative explant and debridement can be safely performed in patients with favorable cardiopulmonary risk.
Assessment of atherosclerotic plaque morphology using contrast-enhanced ultrasound and its impact on primary cardiovascular events following simultaneous carotid endarterectomy and coronary artery bypass grafting.
VascularThe incidence of stroke after on-pump cardiac surgery during the perioperative period can affect up to 2% of patients, and is frequently linked to carotid artery disease. Notably, in patients with significant unilateral carotid artery stenosis of 80%-99%, the risk of stroke reaches 4%. Among individuals undergoing coronary artery bypass grafting (CABG), 3% to 10% exhibit significant carotid artery stenosis. To mitigate the risk of stroke and mortality, patients can undergo either simultaneous or staged carotid endarterectomy and CABG. The aim of this study was to assess whether early postoperative complications, including stroke, following simultaneous CABG/CAE procedures, correlate with morphological attributes of carotid plaque, assessed via contrast-enhanced ultrasound.
A single centre retrospective analysis was performed including 62 patients who underwent simultaneous CABG/CEA between 2019 and 2022. Our study excluded patients who underwent staged carotid endarterectomy and CABG procedures, off-pump CABG, or those necessitating urgent CABG. Our analysis focused on patients meeting elective CABG criteria, diagnosed with symptomatic triple-vessel or left main trunk coronary artery disease (CAD), alongside asymptomatic carotid stenosis (a. carotis internae) exceeding 70% or symptomatic ipsilateral carotid stenosis surpassing 50%. The extent of contralateral carotid artery stenosis was not taken into account. Prior to the CEA/CABG procedure, each patient underwent contrast-enhanced ultrasound to assess atherosclerotic lesions, which were classified using Nakamura et al.'s classification. Among the patients, 37.1% exhibited no neovascularisation within the atherosclerotic plaque, 56.5% showed insignificant neovascularisation, and 6.5% displayed notable neovascularization within the plaque. Our study aimed to establish a connection between the degree of plaque vascularisation identified through contrast-enhanced ultrasound and subsequent postoperative complications.
Upon evaluating postoperative complications occurring within 30 days after the surgery and the plaque morphology identified through contrast-enhanced ultrasound, a statistically significant correlation was observed between a higher grade of plaque vascularisation and the occurrence of ischaemic stroke (r = 0.329, p = .008). Monte Carlo calculations of the Chi-square test indicated a significant association between a higher grade of plaque vascularisation and the presence of peripheral artery disease (χ2 = 15.175, lls = 2, p = .003).
Within 30 days of surgery, a significant correlation exists between the occurrence of ischaemic stroke following carotid endarterectomy subsequent to CABG and the presence of a higher grade plaque vascularisation as identified by contrast-enhanced ultrasound.
Hostile neck anatomy contributes to higher rates of reintervention following endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysm.
VascularRuptured abdominal aortic aneurysms (AAA) presenting with hostile neck anatomy can represent a challenge in surgical decision-making. We hypothesized that, patients who require reinterventions have higher rates of compromised neck anatomy at initial presentation and may indicate a need for altered surveillance paradigm.
Patients presenting with ruptured AAA to a single tertiary care institution from 2014 to 2021 were retrospectively reviewed. Those treated with infrarenal EVAR, with no prior aortic surgeries, and with available pre-operative computed tomography (CT) scans were included. Demographics, timing and type of reintervention, follow-up, and survival were collected. CT scans were assessed for hostile neck anatomy via measurements of diameter, length, angle, taper, bulge, calcification, and thrombus. Demographics, comorbidities, and neck anatomy of those with and without reintervention were compared using Fischer's Exact and Student's T-test. Survival was analyzed via Kaplan-Meier and log-rank test.
Eighty-nine patients were available for analysis, 37 of which met inclusion criteria. Intraoperative death occurred in 3 patients (8.1%) and 1 patient (2.7%) was intraoperatively converted to an open repair. Thirty-day and 1-year survival were 97% and 91%, respectively. The reintervention rate was 30% (n = 10), occurring at a median of 200 days (18-2053 days) after the index operation. All patients requiring reintervention met hostile neck criteria (p = .002) and had a statistically higher number of hostile neck criteria (1.80 vs 0.87, p = .03). Thirty percent (n = 3) of patients that received a reintervention had neck diameter greater than 3 cm, compared to zero patients in the non-reintervention group (p = .022). Proximal reinterventions (n = 5) had statistically higher neck diameters and neck angle compared to the non-reintervention group.
Infrarenal rEVAR is effective at preventing acute mortality despite specific anatomic considerations that may contribute to the higher reintervention rates, and therefore those parameters ought to be considered when following patients in the post-intervention period.
Outcomes of Colectomy and Proctectomy According to Surgeon Training: General vs Colorectal Surgeons.
Journal of theColectomies and proctectomies are commonly performed by both general surgeons (GS) and colorectal surgeons (CRS). The aim of our study was to examine the outcomes of elective colectomy, urgent colectomy, and elective proctectomy according to surgeon training.
Data were obtained from the Vizient database for adults who underwent elective colectomy, urgent colectomy, and elective proctectomy from 2020-2022. Operations performed in the setting of trauma and patients within the database's highest relative expected mortality risk group were excluded. Outcomes were compared according to surgeon's specialty: GS vs. CRS. The primary outcome was in-hospital mortality. The secondary outcome was in-hospital complication rate. Data were analyzed using multivariate logistic regression.
Of 149,516 elective colectomies, 75,711(50.6%) were performed by GS and 73,805(49.4%) by CRS. Compared to elective colectomies performed by CRS, elective colectomies performed by GS had higher rates of complications(4.9% vs. 3.9%, OR1.23, 95%CI 1.17-1.29,p<.01) and mortality(0.5% vs. 0.2%, OR2.06, 95%CI 1.72-2.47,p<.01). Of 71,718 urgent colectomies, 54,680(76.2%) were performed by GS, while 17,038(23.8%) were performed by CRS. Compared to urgent colectomies performed by CRS, urgent colectomies performed by GS were associated with higher rates of complications(12.1% vs. 10.4%, OR1.14, 95%CI 1.08-1.20,p<.01) and mortality (5.1% vs. 2.3%, OR2.08, 95%CI 1.93-2.23,p<.01). Of 43,749 elective proctectomies, 28,458(65.0%) were performed by CRS and 15,291(35.0%) by GS. Compared to proctectomies performed by CRS, those performed by GS were associated with higher rates of complications (5.3% vs. 4.4%, OR1.16, 95%CI 1.06-1.27,p<.01) and mortality(0.3% vs. 0.2%, OR1.49, 95%CI 1.02-2.20,p=.04).
In this nationwide study, colectomies and proctectomies performed by CRS were associated with improved outcomes compared to GS. Hospitals without a CRS on staff should consider prioritizing recruiting CRS specialists.
Incidence of Endoscopic Retrograde Cholangiography after Subtotal Fenestrating and Reconstituting Cholecystectomy.
Journal of theLaparoscopic subtotal cholecystectomy (SC) is used for the difficult cholecystectomy, but published experience with resource utilization for SC is limited. We hypothesized that the need for advanced resources are common after SC.
Retrospective review of laparoscopic cholecystectomies between 2017 and 2021 at a large center. SC cases were identified using a medical record tool. Baseline characteristics were assessed with student's t-test and chi-squared. Primary outcome was ERC within 60-days. Secondary outcomes were reconstituted SC on post-op ERC and length of stay (LOS). Uni- and multivariable logistic regression were used for binary outcomes. Multiple linear regression was used for LOS. Covariates included age, sex, BMI, ASA class.
A total of 1222 laparoscopic cholecystectomies were performed between 2017 and 2021. Of these, 87 (7%) were SC. Male (p<0.001) and older (p<0.001) patients were more likely to undergo SC. Odds of post-op ERC were higher in the SC group (OR 9.79 95% CI 5.90, 16.23 p<0.001). There was no difference in pre-op ERC (17% vs 21% p=0.38). Reconstituting SC had lower odds of post-op ERC (OR 0.12, 0.023-0.58, p=0.009). LOS was 1.81 times higher in the SC group(p=<0.001). Post-op ERC was not associated with LOS (p=.24).
We present one of the largest single-center series of SC. SC patients are more likely to be male, older, have higher ASA class, and have increased LOS. SC should be performed when access to ERC and interventional radiology is available. Absent these adjuncts, reconstituting SC decreases the need for early ERC, but long-term outcomes are unknown.
Access Site Complication Rates Following Peripheral Artery Revascularization in patients With End-Stage Renal Disease: A Comparison of Vascular Closure Devices and Manual Compression.
Vascular and Endovascular SurgeryManual compression (MC) or vascular closure devices (VCDs) are used to achieve hemostasis after percutaneous transluminal angioplasty (PTA). However, limited data on the comparative safety and effectiveness of VCDs vs MC in patients with end-stage renal disease (ESRD) undergoing PTA are available. Accordingly, this study compared the safety and effectiveness of VCD and MC in patients with ESRD undergoing PTA.
This single-center retrospective cohort study included the data of patients with ESRD undergoing peripheral intervention at Chang Gung Memorial Hospital, Taiwan, from January 1, 2019, to June 30, 2022. The patients were divided into VCD and MC groups. The primary endpoint was a composite of puncture site complications, including acute limb ischemia, marked hematoma, pseudoaneurysm, and puncture site bleeding requiring blood transfusion.
We included 264 patients with ESRD undergoing PTA, of whom 60 received a VCD and 204 received MC. The incidence of puncture site complications was 3.3% in the VCD group and 4.4% in the MC group (hazard ratio: .75; 95% confidence interval: .16-3.56 L P = 1.000), indicating no significant between-group difference.
VCDs and MC had comparable safety and effectiveness for hemostasis in patients with ESRD undergoing peripheral intervention.