Vascular Surgery — Weekly Evidence Brief

Early reintervention within the first postoperative year following endovascular aneurysm repair (EVAR) or fenestrated EVAR (FEVAR) is a critical indicator of adverse long-term outcomes. For EVAR patients, this early reintervention is associated with significantly higher 5-year mortality, reintervention, and rupture rates. Similarly, FEVAR patients with early reintervention face significantly greater reintervention and rupture rates. Risk factors for early EVAR reintervention include younger age, COPD, anemia, and a more distal sealing zone, while for FEVAR, they include female sex, larger aneurysm diameter, and physician-modified endografts 1. Compounding concerns, women with ascending aortic dilation exhibit worse long-term survival, higher all-cause mortality, and a disproportionate number of dissections or ruptures at aortic diameters less than 5 cm, suggesting a need for revised, sex-specific surgical thresholds 2. Novel elastomeric nanofibrillar stent-grafts show promise in preserving aortic compliance and physiological hemodynamics, potentially mitigating adverse remodeling seen with conventional stiff stent-grafts 3. Improving patient adherence to crucial post-EVAR follow-up can be facilitated by educating patients on explicit long-term clinical consequences and implementing protocolized follow-up processes 4.

Standardizing care for acute Type B Aortic Dissections (TBAD) with a protocolized medical therapy significantly reduces disease progression to complicated dissection and the need for aortic surgery during acute admission. This protocolized approach led to increased freedom from aortic surgery at 5 years (75% vs 45%) 5. In the realm of acute ischemic stroke, a primary combined approach to thrombectomy (e.g., aspiration plus stent retriever) demonstrates higher final successful reperfusion rates for medium or distal vessel occlusions compared to either aspiration or stent retriever monotherapy 6. Intriguingly, the utility of 24- to 48-hour infarct volume as a surrogate for clinical outcome in late-window thrombectomy may be limited, as only a small fraction of the clinical benefit of endovascular treatment was explained by infarct volume reduction 7. Furthermore, initiating intravenous thrombolysis in the late time window prior to interhospital transfer for thrombectomy in large vessel occlusion patients is associated with better 3-month functional outcomes and higher recanalization rates, without increasing intracranial hemorrhage 8. Simple, pragmatic equations incorporating ASPECTS, NIHSS scores, and age can also rapidly predict functional independence after endovascular thrombectomy for anterior circulation large vessel occlusion, which can aid in time-sensitive decision-making 9.

Outcomes for lower extremity infrainguinal vein bypass in patients with chronic limb-threatening ischemia (CLTI) have significantly improved over the last two decades. The 1-year major adverse limb event (MALE) or death rate substantially decreased from 37.8% to 21.0% between the PREVENT III and contemporary BEST-CLI cohorts, with major re-interventions also significantly lower. These improvements are attributed to broad advances in cardiovascular risk management, surgical techniques, and postoperative care for CLTI patients 10. For endovascular treatments of lower extremity arterial disease, optimal device selection varies by lesion location and severity. For femoropopliteal lesions in intermittent claudication, atherectomy combined with a drug-coated balloon excels in short-term patency, while covered stents and drug-eluting stents provide superior long-term patency. In infrapopliteal critical limb ischemia, drug-eluting technologies (drug-eluting stents and drug-coated balloons) are superior for both patency and target lesion revascularization at 12 months, with drug-eluting stents potentially linked to a lower major amputation rate 11.

A significant finding challenges current clinical practice: beta-blocker therapy did not reduce a composite adverse outcome over a median of 3.7 years in adults with myocardial infarction (MI) and left ventricular ejection fraction (LVEF) greater than 40% after invasive cardiac care 12. This suggests that current guidelines may need re-evaluation for this specific patient population. For risk stratification in patients undergoing rotational atherectomy for severe coronary artery calcification, the atherogenic index of plasma (AIP) is an independent predictor of long-term adverse outcomes, including cardiovascular death, non-fatal MI, and target vessel revascularization, with a stronger association in elderly patients or those with poor glycemic control 13. In individuals with diabetes, quantitative coronary atherosclerotic plaque burden, rather than myocardial perfusion, serves as a more robust predictor of long-term adverse cardiovascular outcomes 14. Finally, for advanced heart failure patients undergoing Left Ventricular Assist Device (LVAD) implantation, a lower pre-LVAD estimated glomerular filtration rate (eGFR) does not appear to significantly impact myocardial recovery rates 15.