Vascular Surgery — Weekly Evidence Brief

In peripheral artery disease, intravascular ultrasound (IVUS)-guided drug-coated balloon angioplasty demonstrates superior 24-month outcomes for femoropopliteal artery disease, including higher rates of freedom from clinically driven target lesion revascularization and sustained clinical/hemodynamic improvement, with comparable safety to angiography-guidance 1. Furthermore, malnutrition, quantified by the Prognostic Nutritional Index (PNI), is highly prevalent in patients with chronic limb-threatening ischemia (CLTI) undergoing intervention and is independently associated with significantly worse short- and long-term limb salvage outcomes 2. For complex cases, lower extremity oncovascular reconstructions show promising 1-year patency rates (95% for arterial, 89.4% for venous) and high rates of preserved limb functionality 3. Novel imaging, such as dynamic [18F]FAZA PET/MR, may offer prognostic value in CLTI by assessing changes in tissue microcirculation post-revascularization 4.

Advances in aortic repair include transcatheter electrosurgical septotomy (TEAS), which achieved 100% technical success in optimizing landing zones for post-dissection aortic aneurysms by creating false lumen-free zones and significantly expanding true lumen diameter, potentially reducing secondary interventions 5. However, physician-modified low-profile endografts, while improving deliverability, are associated with significantly higher rates of type I/III and branch-related endoleaks at midterm follow-up compared to standard-profile devices 6. During fenestrated endovascular aortic repair (FEVAR), routine intraoperative plain cone-beam computed tomography (CBCT) can identify and enable immediate correction of over two-thirds of structural defects, primarily involving target vessels, potentially reducing secondary postoperative interventions 7. Preemptive aneurysm sac embolization with biodegradable plugs for infrarenal endovascular aneurysm repair (EVAR) has shown promising 1-year results with sac regression and no endoleaks or reinterventions 8. Regarding timing, urgent thoracic endovascular aortic repair (TEVAR) for intramural hematoma (IMH) is associated with significantly higher perioperative mortality and reintervention rates, especially in symptomatic patients, advocating for stabilization before intervention when possible 9. Additionally, structural helicity in the visceral aortic zone may serve as a predictor for adverse events after TEVAR for Stanford type B aortic dissections 10.

In acute ischemic stroke, adjunctive intra-arterial thrombolysis (IAT) following successful endovascular thrombectomy (EVT) significantly increases the likelihood of achieving an excellent functional outcome at 90 days, particularly in anterior circulation large vessel occlusions, without increasing symptomatic intracranial hemorrhage or mortality 11. Importantly, achieving expanded Thrombolysis in Cerebral Infarction (eTICI) grades 2c-3 after EVT in large ischemic strokes is strongly associated with favorable functional outcomes and lower mortality, highlighting an ideal reperfusion target 12. Beyond recanalization, a comprehensive evaluation of venous outflow, specifically longer washout times of the superficial venous system, independently predicts poor functional outcome, ischemic lesion growth, and hemorrhagic transformation after optimal EVT for anterior large vessel occlusion strokes 13.

For very elderly ischemic stroke patients, EVT is increasingly utilized; while patients aged 90 years and older experience higher odds of poor functional outcome, death, and unsuccessful recanalization compared to younger patients, there is no significant difference in symptomatic intracranial hemorrhage rates, supporting individualized assessment over age-based exclusion 14. Similarly, carotid artery stenting (CAS) in asymptomatic patients aged 80 years or older shows similar composite endpoints (ischemic stroke and all-cause death) at 30 days compared to younger patients, but older patients exhibit significantly worse functional outcomes, necessitating careful patient counseling 15. The management of complex stroke etiologies like tandem occlusions and distal or medium vessel occlusions continues to be refined, with ongoing research guiding optimal endovascular strategies 1617. Furthermore, for ruptured blood blister-like aneurysms, surface-modified flow diverters combined with single antiplatelet therapy and tirofiban bridging show promising high occlusion rates with minimal thromboembolic and hemorrhagic complications 18.

Preoperative risk assessment in vascular surgery faces challenges, as common risk calculators, including the Revised Cardiac Risk Index (RCRI), Vascular Quality Initiative Cardiac Risk Index (VQI-CRI), and NSQIP Surgical Risk Calculator (NSQIP-SRC), demonstrate significant inaccuracies and variability in predicting complications across different vascular procedures, potentially leading to misinformed patient expectations 19. In pulmonary embolism management, a review of intermediate-low risk cases found that catheter-based therapy provided no mortality benefit compared to anticoagulation alone and was associated with a higher 30-day incidence of intracranial hemorrhage, while systemic thrombolysis was linked to universally high mortality and periprocedural bleeding complications 20. These findings suggest that invasive treatments for intermediate-low risk pulmonary embolism should be approached with caution due to limited benefit and increased risks.