OBJECTIVE:To provide an updated estimate of the global prevalence of CVD and to comprehensively evaluate risk factors associated with this condition.
BACKGROUND:Chronic Venous Disease (CVD) is an ...important cause of morbidity internationally, but the global burden of this condition is poorly characterised. The burden of CVD must be better characterised to optimise service provision and permit workforce planning to care for patients with different stages of CVD.
METHODS:A systematic search in Ovid MEDLINE and Embase (1946 - 2019) identified 1271 articles. Full-text, English language articles reporting on the epidemiology of CVD in a general adult population were included. Data extraction was performed by two independent reviewers, in accordance with a pre-registered protocol (PROSPEROCRD42019153656). STATA and Review Manager were used for quantitative analysis. A crude, unadjusted pooled prevalence was calculated for each Clinical (C) stage in the Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification and across different geographical regions. Qualitative analysis was performed to evaluate associated risk factors in CVD.
RESULTS:32 articles across 6 continents were identified. 19 studies were included in the overall pooled prevalence for each Clinical (C) stage; pooled estimates wereC0 s9%, C126%, C219%, C38%, C44%, C51%, C60·42%. The prevalence of C2 disease was highest in Western Europe and lowest in the Middle East and Africa. Commonly reported risk factors for CVD includedfemale gender (OR 2·26, 95% CI 2·16–2·36, p < 0.001), increasing age, obesity, prolonged standing, positive family history, parity and Caucasian ethnicity. There was significant heterogeneity across the included studies.
CONCLUSIONS:CVD affects a significant proportion of the population globally however there is significant heterogeneity in existing epidemiological studies.
Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical ...strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR).
A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan–Meier were determined for each group and compared.
Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n = 26) or F-EVAR (n = 33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34–85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86 mm (65–100) and 70 mm (60–80), respectively (p = .008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p = .016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%).
Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.
In the present study, we reviewed the results of secondary iliac branch device (IBD) implantation for patients with a type Ib endoleak after prior fenestrated and/or branched (F/B) or infrarenal ...endovascular aortic aneurysm repair (EVAR) using either brachial access or an “up-and-over” transfemoral technique.
We performed a retrospective, single-center analysis between January 2016 and October 2021 of consecutive patients who had undergone IBD to correct a type Ib endoleak after prior EVAR or F/B-EVAR. The groups were defined by arterial access, which was either brachial (group 1) or transfemoral (group 2). All implanted IBDs had been manufactured by Cook Medical, Inc (Bloomington, IN). The demographics, anatomic features, technical success, and 30-day major adverse events were recorded in accordance with the current Society for Vascular Surgery standards. The survival curves using the Kaplan-Meier method were calculated. Branch instability was a composite end point of any internal iliac artery (IIA) branch-related complication or reintervention indicated to treat endoleak, kink, disconnection, stenosis, occlusion, or rupture.
Overall, 28 patients (93% male; median age, 74 years), who had received 32 IBDs, were included, with 14 patients in each group. The prior endovascular aortic repairs included 23 cases of EVAR and 5 cases of F/B-EVAR, with an interval from the initial repair of 58 months (interquartile range IQR, 48-70 months). The median pre-IBD maximal aneurysm diameter was 63.5 mm (IQR, 59.0-78.0 mm). The baseline characteristics were similar between the two groups, except for pulmonary status. All procedures were performed in a hybrid operative room. The median total operating time, fluoroscopy time, and dose area product was 120 minutes (IQR, 86-167 minutes), 23 minutes (IQR, 15-32 minutes), and 54 Gyċcm2 (IQR, 40-62 Gyċcm2), respectively. The total operating time was shorter for group 2 (P = .006). The technical success rate was 100%, and no early deaths occurred. One 30-day major adverse event, medically treated colonic ischemia, had occurred in one patient in group 2. Aortic-related secondary interventions had been required for seven patients (five in group 1 and two in group 2), including three cases of surgical explantation. The median follow-up was 31 months (IQR, 24-42 months) and 6 months (IQR, 3-10 months) for groups 1 and 2, respectively. For group 1, the 2-year freedom from aortic-related secondary intervention and IIA branch instability was 84.6% (IQR, 67.1%-100%) and 92.3% (IQR, 78.9%-100%), respectively. For group 2, the 6-month freedom from aortic-related secondary intervention and IIA branch instability was 87.5% (IQR, 67.3%-100%) and 91.7% (IQR, 77.3%-100%), respectively.
The results from the present study have shown that secondary implantation of an IBD to correct a distal type I endoleak from a previous aortic stent graft is safe with a high technical success rate. The “up-and-over” technique can be considered an alternative to brachial access for patients with suitable anatomy.
To provide data regarding the etiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR).
Details of patients who had RTAD after TEVAR were ...obtained from the MOTHER Registry supplemented by data from a systematic review of the literature. Univariate analysis and binary logistic regression analysis of patient or technical factors was performed.
In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVAR for aortic dissection (acute P = 0.000212; chronic P = 0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, P < 0.0001) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9894). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a high mortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 10.0 (CI: 4.7-21.9) and 3.4 (CI: 1.3-8.8) for chronic aortic dissection. The incidence of RTAD was not significantly different for endografts with proximal bare stent (2.8%) or nonbare stent (1.9%) (P = 0.1298).
Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD.
Objective Thoracic endovascular aortic repair (TEVAR) of various pathologies has been associated with peri-interventional neurologic complication rates of up to 15%. The objective of this study was ...to determine the influence of the management of the left subclavian artery (LSA) on neurologic complications and to define subgroups that might benefit from LSA revascularization. Methods The Medtronic Thoracic Endovascular Registry (MOTHER; Medtronic, Santa Rosa, Calif), consists of data from five sponsored trials and one institutional series incorporating 1010 patients undergoing TEVAR from 2002 to 2010. Perioperative stroke and spinal cord injury (SCI) rates were described according to the management of the LSA and presenting pathology. Multivariate analysis was performed to determine factors associated with perioperative neurologic complications. Results Of 1002 patients included in the analysis, stroke occurred in 48 (4.8%), and SCI developed in 42 (4.2%) ≤30 days of surgery. The stroke rate was 2.2% in patients with no coverage of the LSA vs 9.1% with coverage alone and 5.1% in patients who underwent LSA revascularization before coverage ( P < .001). This relationship was strongest in the aneurysm group. Coverage of the LSA without revascularization was independently associated with stroke (odds ratio OR, 3.5; 95% confidence interval CI, 1.7-7.1), specifically in the posterior territory (OR, 11.7; 95% CI, 2.5-54.6), as was previous cerebrovascular accident (OR, 7.1; 95% CI, 2.2-23.1; P = .001), whereas a covered LSA was not associated with an increased risk of SCI. Conclusions Coverage of the LSA without revascularization is an important modifiable risk factor for stroke in patients undergoing TEVAR for a thoracic aortic aneurysm. Prior revascularization appears to protect against posterior circulation territory stroke.
Autologous saphenous vein is the preferred conduit for below-the-knee bypasses in patients with critical limb-threatening ischemia. Alternative graft must be considered for patients without ...(autologous saphenous vein). The aim of this article is to evaluate the mid-term performance of arterial allograft (AA) and venous allograft (VA) used as alternative conduits.
This retrospective study included patients with critical limb-threatening ischemia, with or without a history of homolateral femoropopliteal bypass, and no autologous veins were available who underwent infrainguinal arterial reconstructions using VA or AA from 2008 to 2018. Patients undergoing revision operations for infected bypasses were excluded. Primary patency (PP), primary assisted patency, secondary patency, major amputation, and death from any cause were the endpoints. For each event, a set of analyses were performed.
Overall, 111 patients (63 VAs and 48 AAs) were included, with 108 having below-the-knee bypass. The median follow-up time was 27.8 months (15.6-37.4). The difference in PP between the 2 allograft types was significant (P = 0.049), with 65.9% (43.7-81.0), 44.1% (24.2-62.3), and 44.1% (24.2-62.3) in the AA group, respectively, at 6, 12, and 18 months, whereas 55.6% (40.0-68.6), 46.0% (30.6-60.2), and 33.2% (18.2-49.0) in the VA group. The choice of an AA over a VA was an independent factor associated with patency (for PP: hazard ratio HR = 0.43 0.24-0.75, P = 0.003); primary assisted patency: HR = 0.52 (0.30-0.89, P = 0.018; and secondary patency: HR = 0.49 (0.27-0.88), P = 0.016. The allograft type did not affect either the incidence of major amputation or death from any cause (respectively, HR = 1.20 0.49-2.93, and 0.88 0.37-2.14).
The nature of the allograft appears to influence the patency of infrainguinal reconstruction, but not the course of the disease. Performant alternative grafts answering infectious issues are needed.
Diabetes confers a two times excess risk of cardiovascular disease, yet predicting individual risk remains challenging. The effect of total microvascular disease burden on cardiovascular disease risk ...among individuals with diabetes is unknown.
A population-based cohort of patients with type 2 diabetes from the UK Clinical Practice Research Datalink was studied (n=49 027). We used multivariable Cox models to estimate hazard ratios (HRs) for the primary outcome (the time to first major cardiovascular event, which was a composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal ischaemic stroke) associated with cumulative burden of retinopathy, nephropathy, and peripheral neuropathy among individuals with no history of cardiovascular disease at baseline.
During a median follow-up of 5·5 years, 2822 (5·8%) individuals experienced a primary outcome. After adjustment for established risk factors, significant associations were observed for the primary outcome individually for retinopathy (HR 1·39, 95% CI 1·09-1·76), peripheral neuropathy (1·40, 1·19-1·66), and nephropathy (1·35, 1·15-1·58). For individuals with one, two, or three microvascular disease states versus none, the multivariable-adjusted HRs for the primary outcome were 1·32 (95% CI 1·16-1·50), 1·62 (1·42-1·85), and 1·99 (1·70-2·34), respectively. For the primary outcome, measures of risk discrimination showed significant improvement when microvascular disease burden was added to models. In the overall cohort, the net reclassification index for USA and UK guideline risk strata were 0·036 (95% CI 0·017-0·055, p<0·0001) and 0·038 (0·013-0·060, p<0·0001), respectively.
The cumulative burden of microvascular disease significantly affects the risk of future cardiovascular disease among individuals with type 2 diabetes. Given the prevalence of diabetes globally, further work to understand the mechanisms behind this association and strategies to mitigate this excess risk are warranted.
Circulation Foundation.
Organoid techniques provide unique platforms to model brain development and neurological disorders. Whereas several methods for recapitulating corticogenesis have been described, a system modeling ...human medial ganglionic eminence (MGE) development, a critical ventral brain domain producing cortical interneurons and related lineages, has been lacking until recently. Here, we describe the generation of MGE and cortex-specific organoids from human pluripotent stem cells that recapitulate the development of MGE and cortex domains, respectively. Population and single-cell RNA sequencing (RNA-seq) profiling combined with bulk assay for transposase-accessible chromatin with high-throughput sequencing (ATAC-seq) analyses revealed transcriptional and chromatin accessibility dynamics and lineage relationships during MGE and cortical organoid development. Furthermore, MGE and cortical organoids generated physiologically functional neurons and neuronal networks. Finally, fusing region-specific organoids followed by live imaging enabled analysis of human interneuron migration and integration. Together, our study provides a platform for generating domain-specific brain organoids and modeling human interneuron migration and offers deeper insight into molecular dynamics during human brain development.
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•hMGEOs and hCOs recapitulate human brain organization and fetal brain transcriptomes•Transcriptome and chromatin accessibility distinguish hMGEOs and hCOs•hMGEOs and hCOs display activity-dependent and synchronized calcium oscillations•Interneurons migrate from hMGEOs and functionally integrate in hCOs
Xiang and colleagues report a method for generating human medial ganglionic eminence (MGE)-like organoids (hMGEOs) and cortical-like organoids (hCOs), which resemble the developing human MGE and cortex, respectively. By fusing hMGEOs and hCOs, they establish a 3D model to investigate human interneuron migration.
Purpose:
To review the early experience of the use of a bifurcated-fenestrated endograft (Bif-FEVAR) to treat abdominal aortic aneurysms (AAA) in a high-volume aortic center.
Methods:
A retrospective ...single-center analysis was conducted between March 2019 and April 2021 including consecutive patients that underwent Bif-FEVAR. Only patients without a proper infrarenal neck and a distance <70 mm between the lowest target artery and the native or prosthetic aortic bifurcation were considered. All Bif-FEVAR custom-made devices were manufactured by Cook Medical (Inc., Bloomington, Indiana). Demographics, anatomical features, technical success, major adverse events, 30-day mortality, and survival according to Kaplan–Meier were analyzed according to Society for Vascular Surgery standards.
Results:
Overall, 10 patients (100% male with median age 78) were included. The median preoperative maximal aneurysm diameter was 68 mm 51–84. Eight patients were treated for a proximal type I endoleak after endovascular aneurysm repair. A total of 36 fenestrations were planned. The median operative time was 144 min 127–168, with a median fluoro time of 40.5 min 34–54 and a median dose area product of 73 Gy cm2 61–89. Technical success rate was 100%. No patients experienced a major postoperative adverse event. Median follow-up time was 8 months 6–13.
Conclusion:
Bif-FEVAR is technically feasible when there is a short distance below the lowest target artery and the aortic bifurcation, with favorable short-term results.
Clinical Impact
This study assessed the use of an innovative one-piece bifurcated fenestrated stent-graft as a primary procedure or in the treatment of proximal endoleak after standard infrarenal EVAR. We demonstrated these custom-made devices can be used safely with favorable short-term results. One-piece bifurcated fenestrated stent-grafts extend the indications of FEVAR for patients with an unusually short distance between the lowest renal artery and the aorto-iliac bifurcation or the diverter flow of a preexisting bifurcated infrarenal stent-graft.
Background Endovascular treatments of Stanford type B aortic dissection may help to promote aortic remodeling and reduce the incidence of aortic-related complications. The aim of this study was to ...review published literature describing aortic remodeling after endovascular treatment of aortic dissection. Methods A systematic review of the literature was performed which was compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The type of aortic morphology measurements made and the methods used to make them were characterized. The endpoints of interest were the change in these measurements over time. Results After initial screening, 77 articles were identified; 16 of which met the inclusion criteria. Few studies used three-dimensional reconstruction software and none had validated their measurement protocol. True lumen (TL) and false lumen (FL) diameters, areas, and in some cases volumes were measured. Studies assessed the aorta at a variety of different levels and over different periods of follow-up. Acute dissection patients displayed more consistent degree of remodeling (thoracic FL thrombosis in 80% to 90%) than chronic dissection patients (38% to 91%). Less remodeling was seen below the diaphragm in both groups. Conclusions Aortic remodeling after treatment for dissection is described in a highly heterogeneous manner. Despite this there appears to be a greater degree of complete FL resolution in patients with acute dissection than chronic. Factors such as length of aortic coverage and timing of treatment may explain the variation seen in the chronic dissection group. Consensus-based reporting standards are required to synthesize evidence and inform clinical decisions regarding patient selection and operative timing.
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