Society For Vascular Surgery Research Articles

A framework for perioperative care in lower extremity major limb amputation: a consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery

The Society for Vascular Surgery elected an international, multidisciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing major limb amputation due to nonreconstructable chronic limb-threatening ischemia. Structured around the Enhanced Recovery After Surgery (ERAS) core elements, 33 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society Clinical Practice Guidelines for the Management of Varicose Veins of the Lower Extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society Clinical Practice Guidelines for the Management of Varicose Veins of the Lower Extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine

Perspectives on Surgical Leadership: A Panel Discussion at the Society for Clinical Vascular Surgery.

Leadership is a skill that all surgeons are confronted with in some capacity. Surprisingly in the US most training programs do not offer a structured program in leadership and there certainly are no metrics used to assess leadership competency. As a response to this, at The Society for Clinical Vascular Surgery (SCVS) a panel of leaders in vascular surgery both national and international, along with leadership experts discussed some of the salient issues in this space. This document is the result of this discussion and serves as a good framework for understanding needs and current shortcomings of leadership training.

Predictors of Mortality in Ruptured Abdominal Aortic Aneurysms.

Introduction The outcome of a ruptured abdominal aortic aneurysm (AAA) without any interventions is close to uniformly fatal. The Society for Vascular Surgery suggests a door-to-intervention time of less than 90 minutes in a patient with a ruptured AAA. Admission factorsassociated with poor outcomes in ruptured AAAs include hypotension, renal insufficiency, severe anemia, advanced age, and cardiac arrest. Patients who are particularly at high risk for open AAA repair may be candidates for endovascular repair, which may decrease mortality. This study aimed to assess the relationship between systolic blood pressure (SBP) and serum bicarbonate levels in predicting mortality in patients with ruptured AAAs. Methods This retrospective study was performed using the United States Collaborative Network of 57 academic medical centers/healthcare organizations in the TriNetX database. A total of 4,226 patients with ruptured AAAs were identified. Patients were categorized based on SBP of ≤90 mmHg, any SBP, or >90 mmHgand further stratified by bicarbonate levels. Rounded cutoffs of the bicarbonate ranges (<10, 10.01-15; 15.01-20, >20.01) were chosen for interpretative purposes. Mortality outcome was assessed within 90 days after presentation for the ruptured AAA. Results After exclusions, 4,174 patients presented with ruptured AAA between September 30, 2003, and September 30, 2023, in the database. Overall, 90-day mortality in any SPB cohort was 28%. Patients who presented with a ruptured AAA with an SBP ≤ 90 had a 46.3% mortality. Those who presented with a SBP > 90 had a 20.1% mortality. Additionally, as bicarbonate levels decreased, mortality increased within each SBP group. Conclusions Early recognition and intervention are critical for survival in patients with ruptured AAAs. Metabolic acidosis is an important marker of the severity of hemorrhage in these patients. In this large cohort study of ruptured AAAs, mortality increases significantly with hypotension and metabolic acidosis, represented by lower bicarbonate levels. Abnormalities in the serum bicarbonate may be seen before severe changes invital signs in hemorrhaging patients. Early recognition of metabolic acidosis may lead to earlier life-saving interventions in patients with ruptured AAAs.

Outcomes of Carotid Artery Stenting and Endarterectomy in Patients with Prior Contralateral Carotid Revascularization

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are available treatment options for stroke prevention in individuals with severe carotid stenosis. This study aims to compare the early postoperative outcomes in patients who underwent CEA or CAS after prior contralateral carotid revascularization. We conducted a retrospective review of the Society of Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database, identifying patients who had prior carotid artery revascularization followed by a contralateral CEA or CAS between 2017 and 2023. Based on the sequence of the procedures performed, patients were categorized into four groups: 1) patients who had a prior unilateral CEA followed by a contralateral CEA (CEA-CEA); 2) patients who had a prior unilateral CAS followed by a contralateral CEA (CAS-CEA); 3) patients had a prior unilateral CAS followed by a contralateral CAS (CAS-CAS); and 4) patients had a prior unilateral CEA followed by a contralateral CAS (CEA-CAS). Univariate analysis (Pearson χ 2, Wilcoxon rank sum test) and multivariate logistic regression were employed to assess length of stay, rates of in-hospital stroke, myocardial infarction, new-onset arrhythmia, and 30-day mortality. A total of 20,761 patients with a history of prior unilateral carotid revascularization procedures were identified, of which 12,788 underwent contralateral CEA and another 7,973 underwent contralateral CAS. Compared to the CAS-CAS group, patients who underwent CEA followed by contralateral CAS (CEA-CAS group) were associated with higher rates of postoperative in-hospital stroke (1.8% vs. 1%, P = 0.003), new-onset arrhythmia (2% vs. 1.2%, P=0.006), and 30-day mortality (1.3% vs. 0.8%, P = 0.04). On multivariate analysis, preoperative use of statins and beta-blockers was associated with lower odds of in-hospital stroke (OR 0.42; 95% confidence interval [CI] 0.29 - 0.69; P = 0.0002) and new-onset arrhythmia (OR 0.62; 95% CI 0.49 - 0.9; P = 0.01), respectively, after CAS. There were no significant differences in outcomes for CEA-CEA and CAS-CEA groups. Patients with prior CEA undergoing contralateral CAS had higher rates of in-hospital stroke, new-onset arrhythmia, and 30-day mortality. Beta-blockers may reduce postoperative arrhythmia rates in these patients, and established regimens should not be discontinued in the perioperative period; however, further prospective studies are needed to confirm this finding. Optimized medical treatment and appropriate imaging follow-up remain crucial for improvement outcomes.

National registry insights on genetic aortopathies and thoracic endovascular aortic interventions: Presented at the 51st Annual Symposium of the Society for Clinical Vascular Surgery, Scottsdale, AZ, March 16-20, 2024.

National registry insights on genetic aortopathies and thoracic endovascular aortic interventions: Presented at the 51st Annual Symposium of the Society for Clinical Vascular Surgery, Scottsdale, AZ, March 16-20, 2024.

Higher stroke risk after carotid endarterectomy and transcarotid artery revascularization is associated with relative surgeon volume ratio: Presented as a full length oral plenary presentation at the Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, June 19, 2024.

Higher stroke risk after carotid endarterectomy and transcarotid artery revascularization is associated with relative surgeon volume ratio: Presented as a full length oral plenary presentation at the Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, June 19, 2024.

Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia: Presented at the 2024 Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Illinois, June 19-22, 2024.

Proximalization of arterial inflow for treatment of hemodialysis access-induced distal ischemia: Presented at the 2024 Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Illinois, June 19-22, 2024.

Practical guidelines of the International Working Group on the Diabetic Foot, European Society for Vascular Surgery, Society for Vascular Surgery on the prevention and management of diabetes-related foot disease 2023

Diabetes‑related foot disease results in a major global burden for patients and the healthcare system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence‑based guidelines on the prevention and management of diabetes‑related foot disease since 1999. In 2023, all IWGDF Guidelines have been updated, based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In addition, a new guideline on acute Charcot neuro‑osteoarthropathy was created. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification and management of diabetes‑related foot disease, based on the seven IWGDF Guidelines. We also describe the organizational levels to successfully prevent and treat diabetes‑related foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of healthcare professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes‑related lower‑extremity amputations. The burden of foot disease and amputations is increasing at a rapid rate, and comparatively more so in middle to lower income countries. These guidelines also assist in defining standards of prevention and care in the these countries. Authors hope that these updated practical guidelines continue to serve as a reference document to aid healthcare providers in reducing the global burden of diabetes‑related foot disease.

A multi-institutional study from the United States Resident OPerative Experience (ROPE) Consortium examining factors influencing vascular surgery specialization among general surgery residents

ObjectiveThere remains a progressive projected deficit in the vascular surgery (VS) workforce for decades. Despite the expanding integrated VS residency pathway, the fellowship training model remains critical in supporting our future workforce. Therefore, it is imperative to understand the resident and program-specific factors that influence VS specialization among general surgery (GS) residents. MethodsData from the United States Resident OPerative Experience (ROPE) Consortium, which comprises 20 Accreditation Council for Graduate Medical Education-accredited GS residency programs across the United States, were queried for resident demographics and residency program-related details. Logistic regression analysis was used to identify factors associated with VS specialization. ResultsFrom 2010 to 2020, a total of 1343 graduating GS residents were included in the study. Of these, 135 (10.1%) pursued VS fellowship training. Residents pursuing VS were more frequently male (80.7% vs 62.8%; P < .0001) and younger (median age, 32 vs 33 years; P = .03) compared with other GS residents. Racial and ethnic group, underrepresented in medicine status, and international medical graduate status were similar between the VS and non-VS groups. Residency program-level details were also similar between groups, including program type (university vs community-based), region, size, resident volume, dedicated research experience, and National Institutes of Health funding. Dedicated vascular rotations were common among all GS programs (95.4%), and total months spent on a VS rotation (median, 4 vs 4.5 months; P = .11) did not differ among residents pursuing VS and all other residents. The presence of a collocated traditional (5 + 2) VS fellowship (91.1% vs 90.4%; P = .79) or integrated (0 + 5) VS residency (56.3% vs 55.0%; P = .77) were also similar between groups. On multivariate analysis, only male sex (odds ratio, 2.34; 95% confidence interval, 1.50-3.81; P < .001) was associated with pursuing VS fellowship. Factors that did not impact VS specialization included resident age, underrepresented in medicine status, international medical graduate status, program volume, dedicated research experience, or total months spent on a VS rotation. ConclusionsIn this multi-institutional study, we did not find any program-specific factors that influence VS specialization among GS residents. Notably, the presence of a collocated 0 + 5 residency or 5 + 2 fellowship program did not appear to deter GS residents from pursuing a VS fellowship. These data suggest that individual factors, such as mentorship, may be more impactful in recruiting GS residents to the VS specialty.

Influence of Bridging Stent Graft Implantation into the Renal Artery during Complex Endovascular Aortic Procedures on the Renal Resistance Index.

Comparative sonographic examination of the renal resistance index (RRI) can provide evidence of renal artery stenosis. The extent to which the RRI is changed after stent graft implantation is not known. The aim of this study was to investigate the influence of stent graft implantation into non-diseased renal arteries during endovascular treatment of pararenal aortic aneurysms on the RRI. Sonographic examinations of the kidneys were conducted using a GE ultrasound system. The evaluation was performed according to the European Society for Vascular Surgery (ESVS) 2D standard criteria. RRI values were determined in consecutive patients on the day before and after stent graft implantation and compared for each kidney. A total of 32 consecutive patients (73.9 ± 8.2 years, 5 females, 27 males) were treated with a fenestrated or branched aortic stent graft including bridging stent graft implantations into both renal arteries and received pre- and postinterventional examinations. Sonomorphologically, the examined kidneys were inconspicuous. The arborisation of the renal perfusion was preserved pre- and post-implantation. The RRI did not differ (0.66 ± 0.06 versus 0.67 ± 0.07; p = ns). Successful stent graft implantation into non-stenosed renal arteries did not lead to a relevant change in RRI. Therefore, the RRI is a suitable tool for assessing renal perfusion after fenestrated or branched endovascular aortic therapy.

Aortic Outcome after Implementation of a Treatment Strategy for Type B Aortic Dissection Involving the Aortic Arch

ObjectiveTo evaluate outcomes achieved after implementing a treatment strategy for non-A non-B (NANB) (B 1-2 D according to the latest consensus document of the Society of Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) acute aortic dissection (AAD). MethodsThis retrospective observational study adhered to the STROBE checklist. All cases of NANB AAD (B 1-2 D) treated at our Institution between January 2016 and December 2022 were reviewed. Morbidity, mortality, aortic-related reintervention, and remodelling were analysed. ResultsAmong 519 cases of acute aortic syndrome, n=22 (4.2%) patients presented with NANB AAD (B 1-2 D) (n=16,72.7% men, mean age 61.5 years+/14.7). Eleven cases were managed with best medical treatment (BMT) alone. Among them, one patient (9.1%) died suddenly two days after diagnosis for aortic rupture. Frozen elephant trunk procedure (FET) was required in the remaining 11 patients: 7(31.8%) needed emergent operation for risks of impending aortic rupture/retrograde AD extension and 4(26.7%) underwent delayed surgery within a month from initial presentation. Overall, in-hospital mortality was 9.1% with both FET and BMT. At a median follow-up of 40 months (range 2 days-200 months) no other deaths occurred. A statistically significant differences in the rate of FL thrombosis (100% vs 55.5%, p=.033) and a significant positive aortic remodelling in zone 3 (p<.001) and 4 (p=0.038) were reported in operated versus medically managed patients. ConclusionThe best treatment for NANB is not established. We advocate for medical stabilisation with an operative approach that favours open surgery in the acute post dissection period, promotes aortic remodelling and carries acceptable risk in centres where FET is performed routinely.

Influence of Proximal Fixation on Aneurysm Neck Evolution after Endovascular Treatment of Infrarenal Aneurysms

We analyzed the long-term influence of fixation systems on proximal aortic neck (PAN) evolution by comparing 2 late-generation endoprostheses, Endurant (Medtronic Vascular, Minneapolis, Minn) with suprarenal fixation (SRF) and Excluder (W.L Gore & Associates, Flagstaff, Ariz) with infrarenal fixation (IRF). Our retrospective observational study included consecutive patients undergoing endovascular aneurysm repair (EVAR) for aorto-iliac aneurysms (2011-2020). Primary end points: neck enlargement and freedom from significative PAN enlargement (5mm). Secondary end points: neck-related reintervention, endoleaks and graft migration. Results were reported following the Society of Vascular Surgery reporting standards. 139 patients were included (97 in SRF group and 42 in IRF group). A difference in growth at 10mm caudal to lowest renal artery at 2years follow-up was found (mean growth of 1.92±3.38mm in SRF and 0.16±6.86mm in IRF; P<0.001). A tendency to a major growth in SRF at 4years follow-up at the lowest renal artery (1.27±3.36mm vs. 0.63±2.2mm; P=0.06), 5mm distal to lowest renal artery (2.17±3.52mm vs. 0.94±2.76mm; P=0.001) and 10mm distal to lowest renal artery (2.65±3.86mm vs. 1.12±1.5mm; P<0.001) was shown. Freedom from PAN enlargement was 96.65% and 88.20% in SRF and 100% and 94.4% in IRF at 2 and 4years follow-up respectively (log rank 0.041). A greater incidence of type II endoleaks in IRF was observed (40.48% vs. 15.46%; P=0.001). Oversizing >15% showed to be a risk factor of PAN enlargement (odds ratio 6.85; 95% confident interval: 1.67-28.4; P=0.007). A small but significative percentage of patients after EVAR show a progressive PAN enlargement, being significatively greater in SRF, without increasing neck-related complications 4years after graft deployment.

Predicting the future caretakers of traumatic vascular injury management via operative exposure among surgical trainees

BackgroundThe management of vascular trauma requires specialized training and expertise. Although traumatic vascular injury is treated currently by both vascular and trauma surgeons in modern practice, it remains unclear who will inherit the role of managing vascular trauma in the coming decades. In this study, we examined disparities in operative experience in vascular trauma among surgical trainees across different surgical specialties. MethodsAccreditation Council for Graduate Medical Education national operative log reports were collected for graduating vascular surgery residents (VSRs), vascular surgery fellows (VSFs), and general surgery residents (GSRs) from 2012 to 2022. Total operative volume for traumatic vascular injury was examined, as were the five major contributing operative domains (neck, thoracic, abdominal, peripheral, and fasciotomy). ResultsA total of 22,052 GSRs, 334 VSRs, and 1672 VSFs graduated over the 10-year study period. VSR had the highest vascular trauma case volume (24.9 ± 3.9 cases/5 years), followed by VSF (22.1 ± 1.5 cases/2 years) then GSR (2.4 ± 0.3 cases/5 years; P < .001). Thoracic vessel exploration/repair (0.7 cases vs 0.6 cases vs 0.0 cases), abdominal vessel exploration/repair (1.0 cases vs 0.9 cases vs 0.0 cases), neck vessel exploration/repair (4.0 cases vs 3.4 cases vs 0.2 cases), peripheral vessel exploration/repair (12.1 cases vs 9.5 cases vs 1.1 cases), and lower extremity fasciotomy for trauma (7.2 cases vs 7.6 cases vs 1.1 cases) were most frequent among the VSR and VSF groups (P < .001 each). On linear regression analysis, both VSF (+0.5 cases/y; R2 = 0.81; P < .001) and GSR (+0.1 cases/y; R2 = 0.75; P = .001) groups experienced a growth in vascular trauma volume. Contrariwise, vascular trauma volume did not change among graduating VSRs (R2 = 0.13; P = .31). ConclusionsDedicated vascular surgical training provides the highest operative exposure to civilian vascular trauma in the United States.

Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia: Presented at the Forty-eighth Annual Symposium for the Society for Clinical Vascular Surgery, Miami, Fla, March 17, 2021.

Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia: Presented at the Forty-eighth Annual Symposium for the Society for Clinical Vascular Surgery, Miami, Fla, March 17, 2021.

Vascular access on YouTube: Navigating the stream of information for hemodialysis patients

Aim: End-stage renal disease (ESRD) presents significant challenges for patients and healthcare systems. Treatment options include renal transplant, peritoneal dialysis, and hemodialysis, with hemodialysis being the most common, necessitating suitable vascular access like arteriovenous fistula (AVF), graft, or catheter. This study aims to analyze the quality of YouTube videos on vascular access for hemodialysis, using the 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) as a benchmark and employing JAMA, Global Quality, and DISCERN scores. To our knowledge, this is the first study evaluating YouTube content quality on this topic. Material and Methods: A YouTube search for 'arteriovenous fistula' was conducted, analyzing the first 200 videos based on predetermined criteria. Exclusions included videos lacking sound, not in English, off-topic, or duplicates. Data collected included uploader details, upload date, views, comments, likes, and duration. Video accuracy was assessed using the DISCERN tool, JAMA Benchmark Criteria, and Global Quality Scoring System (GQSS). Results: Out of 200 videos, 13 were excluded, leaving 187 for analysis. The interobserver agreement was high (κ=0.967). The videos amassed 12,854,643 views, with a median duration of 5 minutes and a median of 3412 views per video. Most views were for videos with poor DISCERN scores. There was a significant association between DISCERN scores and video characteristics. Videos with higher DISCERN scores had longer durations (p=0.01). However, videos with lower scores received more likes and views (p&lt;0.01). The mean DISCERN score was 33.7, indicating poor quality, with only 18.8% rated as good or excellent. Conclusion: The study underscores the variability in the quality of YouTube content regarding vascular access for hemodialysis. Patients are encouraged to prioritize videos uploaded by healthcare professionals, ensuring both quality and accuracy. Despite limitations, this study contributes to informed decision-making in the context of hemodialysis vascular access.

Circulating CXCL9, monocyte percentage, albumin, and C-reactive protein as a potential, non-invasive, molecular signature of carotid artery disease in 65+ patients with multimorbidity: a pilot study in Age.It.

Carotid endarterectomy (CEA) for the prevention of upcoming vascular and cerebral events is necessary in patients with high-grade stenosis (≥70%). In the framework of the Italian National project Age.It, a pilot study was proposed aiming at the discovery of a molecular signature with predictive potential of carotid stenosis comparing 65+ asymptomatic and symptomatic inpatients. A total of 42 inpatients have been enrolled, including 26 men and 16 women, with a mean age of 74 ± 6 years. Sixteen symptomatic and 26 asymptomatic inpatients with ≥70% carotid stenosis underwent CEA, according to the recommendations of the European Society for Vascular Surgery and the Society for Vascular Surgeons. Plaque biopsies and peripheral blood samples from the same individuals were obtained. Hematobiochemical analyses were conducted on all inpatients, and plasma cytokines/molecules, such as microRNAs (miRs), IL-6, sIL-6Ralpha, sgp130, myostatin (GDF8), follistatin, activin A, CXCL9, FGF21, and fibronectin, were measured using the ELISA standard technique. MiR profiles were obtained in the discovery phase including four symptomatic and four asymptomatic inpatients (both plasma and plaque samples), testing 734 miRs. MiRs emerging from the profiling comparison were validated through RT-qPCR analysis in the total cohort. The two groups of inpatients differ in the expression levels of blood c-miRs-126-5p and -1271-5p (but not in their plaques), which are more expressed in symptomatic subjects. Three cytokines were significant between the two groups: IL-6, GDF8, and CXCL9. Using receiver operating characteristic (ROC) analysis with a machine learning-based approach, the most significant blood molecular signature encompasses albumin, C-reactive protein (CRP), the percentage of monocytes, and CXCL9, allowing for the distinction of the two groups (AUC = 0.83, 95% c.i. [0.85, 0.81], p = 0.0028). The potential of the molecular signature will be tested in a second cohort of monitored patients, allowing the application of a predictive model and the final evaluation of cost/benefit for an assessable screening test.

Reintervention Rate after Treatment with the INCRAFT AAA Ultra–Low-Profile Stent Graft System

ObjectiveThe INCRAFT stent graft system is an ultra-low profile endograft for the exclusion of infrarenal aortic aneurysms. In the market approval studies, an increased rate of device-related complications was observed and the endograft was approved with mandated postmarketing investigations. Our aim was to analyze midterm outcomes of a real-world patient cohort treated with the INCRAFT endograft. MethodsConsecutive patients treated with the INCRAFT endograft between February 2015 and December 2022 at a single institution were included. In accordance with the Society for Vascular Surgery reporting standards, safety endpoints were reported and outcome endpoints included reinterventions, technical success, aortic-related and overall-mortality, endoleak, stent fracture, and endograft migration >5 mm. ResultsEighty patients (85% male) with a mean age of 76 ± 7 years were included. Fifty-two patients (65%) were treated within the endograft’s instruction for use (IFU). Mean aortic diameter was 59 ± 10 mm and 91% of the procedures were performed percutaneously. Mean follow-up was 37 ± 25 months and there was no aortic- or procedure-related mortality. Reinterventions occurred in 25 patients (31%) with a freedom from reintervention at 1, 3 and 5 years of 84%, 66% and 55%. The most frequent reinterventions were limb graft stenting (23%) and type II endoleak embolization (14%). Limb occlusion rate was 9% and in three patients (4%) distal endograft migrations >5 mm occurred. Persisting type II endoleaks were observed in 29% and aneurysm diameter was stable in 41% and had shrunk in 38%. Three type III endoleaks (4%) developed during follow-up and four open conversions (5%) were necessary. No known risk factors, including treatment outside IFU, were predictive for reinterventions. ConclusionTreatment of infrarenal aortic aneurysms with the INCRAFT stent graft system was safe and successful. Nevertheless, a substantial rate of reinterventions was necessary during follow-up to maintain endograft patency and prevent aneurysm growth.

Survey-Based Assessment of the Quality of Reporting Guidelines of Carotid Artery Stenosis

No evaluation of the quality of different carotid guidelines using validated scales has been performed to date. The present study aims to analyze 3 carotid stenosis guidelines, apprizing their quality and reporting using validated tools. A survey-based assessment of the quality of the European Society for Vascular Surgery (ESVS) 2023, European Stroke Organisation (ESO) 2021, and the Society for Vascular Surgery (SVS) 2021 carotid stenosis guidelines, was performed by 43 vascular surgeons, cardiologists, neurologist or interventional radiologists using 2 validated appraisal tools for quality and reporting guidelines, the AGREE II instrument and the RIGHT statement. Using the AGREE II tool, the ESVS, SVS, and ESO guidelines had overall quality scores of 87.3%, 79.4%, and 82.9%, respectively (P=0.001) The ESVS and ESO had better scores in the scope and purpose domain, and the SVS in the clarity of presentation domain. In the RIGHT statement, the ESVS, SVS, and ESO guidelines had overall quality scores of 84.0.7%, 74.3%, and 79.0%, respectively (P=0.001). All 3 guidelines stood out for their methodology for search of evidence and formulating evidence-based recommendations. On the contrary, were negatively evaluated mostly in the cost and resource implications in formulating the recommendations. The 2023 ESVS carotid stenosis guideline was the best evaluated among the 3 guidelines, with scores over 5% higher than the other 2 guidelines. Efforts should be made by guideline writing committees to take the AGREE II and RIGHT statements into account in the development of future guidelines to produce high-quality recommendations.

Frozen Elephant Trunk Procedure for Acute Type a Aortic Dissection: Analysis of Distal Aortic Remodeling According to the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS) Reporting Standard

ObjectiveTo investigate impact of Frozen Elephant Trunk (FET) on long-term distal aortic remodelling in acute AAD according to the latest recommended standards from the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS). MethodsClinical data and imaging of patients undergone FET to treat acute AAD over the last 8 years were retrospectively reviewed. Patients were included if a pre- and post-operative Computed AngioTomographies at least 30-day from surgery was available for comparison. Contrasted postprocessed imaging were analysed with Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA) to analyse long-term positive aortic remodelling, FL thrombosis and aortic expansion according to the SVS/STS recommendations. Secondary endpoints were the rate of in-hospital and long-term mortality, spinal cord ischaemia and aortic-related reinterventions. ResultsOut of 75 patients who underwent FET for type A AAD, n=41(54.6%) were included. Significant positive aortic remodelling was reported in Ishimaru zone 1-4 but not in visceral/infrarenal aorta (p<0.001) and overall rate of FL thrombosis was 95.1% (n=39). Aortic expansion rates were: 4.9% in zones 1-4, 8.3% in zones 5-6 and 15% in zone 7. The rates of in-hospital mortality and long-term mortality were 7.3% (n=3) and 9.7% (n=4) respectively. At a median follow-up of 11 months (range 1-141, reintervention rate was 17.1%. ConclusionsWe report positive aortic remodelling of the distal thoracic aorta in patients who underwent FET for acute AAD according to the SVS/STS reporting standards. The positive effect on the distal aorta is limited to the thoracic segments but not in the visceral aorta.