Vascular Surgery — Weekly Evidence Brief

Recent studies shed light on treatment strategies and outcomes for limb ischemia, revealing nuanced benefits and persistent disparities. For acute limb ischemia (ALI), endovascular treatment offers modest benefits in long-term survival, shorter hospital stays, and lower infection rates compared to open surgery, though with an increased risk of intracranial hemorrhage 1. No significant differences in amputation rates were observed. In chronic limb-threatening ischemia (CLTI), significant variations in endovascular practice patterns and patient outcomes exist across specialties, with interventional radiologists showing a lower incidence of major adverse limb events and overall death compared to interventional cardiologists and vascular surgeons 2. Furthermore, while Black and Hispanic patients often present with more advanced disease, disparities in MALE-free survival were mitigated when evidence-based care was provided within a randomized trial setting 3. However, most patients undergoing major lower extremity amputation (MLLA) still do so without prior limb-sparing revascularization or minor amputation, highlighting ongoing gaps in care 4.

Advancements in endovascular thrombectomy (EVT) for stroke continue to refine patient selection and urgency. Unwitnessed stroke onset should not be a barrier to EVT in the extended 6-24 hour time window, as these patients can achieve favorable outcomes comparable to, or even better than, witnessed patients, without increased mortality or hemorrhage risk 5. For M2 segment occlusions, the urgency of EVT appears less critical, with no significant association between time to treatment and functional outcomes or mortality, unlike more proximal large vessel occlusions 6. However, current data suggest no significant benefit for EVT in patients with low NIH Stroke Scale scores (≤5) and anterior circulation large vessel occlusion presenting in the 6-24 hour window, necessitating individualized decisions until further randomized evidence emerges 7. For basilar artery occlusion, tenecteplase and alteplase administered before EVT show comparable functional outcomes, reperfusion success, and hemorrhage rates 8. Identifying risk factors for recurrence in embolic stroke of undetermined source (ESUS) is also crucial, with intracranial nonrelevant stenosis in multiple vessels, paroxysmal atrial fibrillation, and atrial septal aneurysm identified as significant predictors 9.

The landscape of aortic interventions and surgical training is evolving, with a growing emphasis on endovascular techniques and improved risk stratification. Vascular surgery trainees are demonstrating higher levels of autonomy and competence in endovascular aortic cases compared to open procedures upon graduation, highlighting a shift in practice patterns and training needs 10. For open thoracoabdominal aortic aneurysm (TAAA) repair, a new preoperative risk score incorporating factors like TAAA extent II, BMI ≥30, smoking history, and chronic kidney disease can effectively predict spinal cord ischemia 11. In transcarotid artery revascularization (TCAR), post-stent dilation is significantly associated with postoperative hypotension, which can lead to increased ICU utilization, longer hospital stays, and higher mortality 12. Additionally, non-contrast diffusion-weighted MRI with ADC mapping offers a highly accurate alternative for detecting abdominal aortic endoleaks after EVAR, beneficial for patients with renal insufficiency or contrast allergies 13. Furthermore, sex-specific machine learning models show promise in improving predictions of abdominal aortic aneurysm rupture outcomes, addressing previous biases from underrepresentation of female patients 14.

Care for patients with cardiac devices and those undergoing complex cardiac interventions requires careful consideration of unique risks and emerging strategies. Patients with cardiac devices experiencing ST-elevation myocardial infarction (STEMI) are older, more often female, and less likely to achieve the target door-to-balloon time, leading to an increased 5-year all-cause mortality risk 15. For symptomatic lead-related venous stenosis, drug-coated balloon venoplasty offers a safe and effective treatment with a higher long-term success rate and allows for lead retention compared to traditional plain balloon venoplasty 16. In patients undergoing transcatheter aortic valve implantation (TAVI), a simple preoperative Hemoglobin-Geriatric Nutritional Risk Index (H-GNRI) can predict major adverse cardiovascular events 17. Lastly, for severe mitral regurgitation, transcatheter edge-to-edge repair (m-TEER) and surgical repair yield comparable all-cause mortality rates, though surgery is associated with reduced rehospitalization for heart failure and fewer reinterventions 18. Elevated lipoprotein(a) is also identified as a critical risk factor for severe coronary artery disease and adverse long-term cardiovascular outcomes following coronary angiography, highlighting a need for targeted risk-reduction strategies 19.