Vascular Surgery

High-volume-center outcomes for open conversion after failed EVAR highlight risk of non-elective explant

Among 294 open conversions after EVAR, overall 30-day mortality was 10% and major complications occurred in 63%. Non-elective conversions (rupture, infection, aorto-enteric fistula, intraoperative conversion) had much higher 30-day and 90-day mortality than elective cases (19% vs 5%; 25% vs 10%). Non-elective cases required more proximal cross-clamping, more frequent total graft explant, more adjunctive procedures, and greater blood loss and transfusion needs. Elective conversions were mainly for endoleak, occurred later after index EVAR, and had shorter length of stay and fewer major complications than non-elective cases. These data support early referral for planned EVAR explant in failing repairs and concentration of complex non-elective conversions in high-volume aortic centers. 1

In dialysis-dependent CLTI, infrapopliteal bypass with good conduit beats tibial endovascular therapy

In 280 hemodialysis-dependent CLTI limbs undergoing first infrapopliteal intervention, 105 had bypass and 175 had PTA/stenting. Despite more complex GLASS anatomy in the bypass group, perioperative major events were similar between strategies. Adjusted analyses showed bypass reduced two-year major amputation risk and lowered five-year hazards of amputation/death and death versus PTA/stenting. Single-segment great saphenous vein bypass further improved wound healing and reduced major amputation and amputation/death compared with endovascular therapy. These findings support a bypass-first strategy with high-quality vein conduit for suitable dialysis patients with infrapopliteal disease. 2

VQI data show declining smoking cessation after LER despite fewer smokers at baseline

Analysis of over 147,000 LER procedures in VQI found current smokers were common, especially in bypass patients. From 2010 to 2022, the proportion of active smokers undergoing PVI and LEB modestly decreased, but smoking cessation after LER worsened. Suprainguinal and infrainguinal bypass patients were more likely to quit than PVI patients, yet overall cessation remained low. Continued smoking after LER was associated with younger age, male sex, COPD, socioeconomic disadvantage, elective PVI, and claudication. These data underscore the need to embed structured, longitudinal tobacco-cessation interventions into LER care pathways rather than relying on opportunistic counseling. 3

TEG-guided antiplatelet therapy after lower extremity revascularization markedly benefits women

In 443 PAD patients undergoing lower extremity revascularization, TEG-PM–guided antiplatelet adjustment was compared with empiric dual antiplatelet therapy. Women receiving TEG-guided therapy had substantially lower 12-month major amputation rates than men in the same arm, with an estimated 87% relative risk reduction. No sex difference in amputation rates was seen under standard empiric dual therapy, suggesting a sex-specific response to individualized platelet inhibition. TEG-guided therapy reduced thrombotic events overall and improved amputation-free survival in women without obvious sex-specific safety concerns in the abstract. These findings support further evaluation of TEG-guided, sex-aware antiplatelet strategies after limb revascularization, particularly for high-risk women with CLTI or diabetes. 4