Association of women-specific size threshold and mortality in elective abdominal aortic aneurysm repair.

BACKGROUND: It is unclear whether women derive mortality benefit from early repair of abdominal aortic aneurysms (AAA). The aim of this study was to compare short- and mid-term mortality for women treated at small versus large diameters. METHOD: Women receiving elective repair of AAA at small (49-54 mm) and large (≥55 mm) diameters from 2008 to 2022 were extracted from the Swedish National Registry for Vascular Surgery (n = 1642 women). The effect of diameter on 90-day, 1- and 3-year mortality was studied in logistic regression and propensity score models. Age, co-morbidities, smoking and repair modality were considered as confounders. Men (n = 9047) were analysed in parallel. RESULTS: Some 1642 women were analysed, of whom 34% underwent repair at small diameters (versus 52% of men). Women with small (versus large) AAAs were younger (73 versus 75 years, P < 0.001), and 63% of women in both size groups had endovascular repairs (P = 0.120). Mortality was 3.5% (90 days), 7.1% (1 year) and 15.8% (3 years), with no differences between the size strata. There was no consistent association between AAA size and mortality in multivariable models. Sex differences in mortality were almost entirely due to mortality in younger-than-average women versus men (3-year mortality: small AAAs 11.1% versus 7.3%, P < 0.030, or large 14.4% versus 10.7%, P < 0.038). CONCLUSION: Mortality in women is high and unaffected by AAA size at repair. The optimal threshold for women remains undefined. The higher rupture risk in women should not automatically translate into a lower, women-specific threshold.

Multicentric Use of Commercially Available Infrarenal Endografts During Fenestrated Endovascular Aortic Repair: A Feasibility Study.

PURPOSE: This study aimed to assess the feasibility and short-term outcomes of different manufactured proximal and distal stent graft components during fenestrated endovascular aortic repair (FEVAR). MATERIALS AND METHODS: A multicenter retrospective review was conducted at 3 aortic centers, involving all consecutive patients who underwent FEVAR utilizing a customized Dacron-based tubular proximal and a distal bifurcated polytetrafluoreten (PTFE)-based commercially available stent grafts. Primary outcomes were 30 day mortality, major adverse events, and technical and clinical success. Secondary outcomes assessed stent graft migration, occurrence of types I/III endoleak, and reintervention. RESULTS: A total of 23 FEVAR cases across all centers were included in this study. Technical success was achieved in all cases, with a median procedure time of 183 (153-244) minutes. There were no major adverse events, except for 1 transient acute renal failure. The median follow-up period was 23 (17-28) months. All target vessels retained patent with the exception of 1 right renal fenestration that showed signs of kinking at the first follow-up, and despite secondary intervention with relining and distal extension, there was an occlusion afterward and 1 hepatic artery with a separate fenestration. This and 1 successful relining of a superior mesenteric artery kink were the only reinterventions in this cohort. One case of persistent type 1b endoleak was reported in a patient with chronic type B aortic dissection, which resolved with distal extension on the external iliac artery 5 months after the index procedure. No deaths occurred throughout the follow-up with, and there were no signs of stent graft migration or type 3 endoleak. CONCLUSION: The use of commercially available PTFE-based bifurcated stent grafts to extend distally the tubular graft appears to be a feasible approach during FEVAR, with promising short-term outcomes. Further studies are necessary to define the applicability of this solution and evaluate long-term outcomes. CLINICAL IMPACT: This multicentric study on fenestrated endovascular aortic repair (FEVAR) demonstrates the feasibility and good short-term outcomes of utilizing a PTFE-based commercially available stent graft to extend the proximal tubular custom-made fenestrated stent graft. The high technical success rate, absence of major adverse events, and low occurrence of complications such as stent graft migration and endoleaks highlight the potential clinical benefits of this approach with an off-the-shelf distal extension whose delivery system does not cross the fenestrations intraoperatively.

Acute Symptomatic Isolated Abdominal Aortic Dissection - Clinical Characteristics, Outcome, and Sex Differences.

BACKGROUND: Acute isolated abdominal aortic dissection (IAAD) is a rare condition and treatment recommendations are lacking. Most previous studies included both symptomatic and asymptomatic patients. The aims were to determine the proportion of IAAD among patients with acute type B aortic dissection as well as to describe patient characteristics, radiological findings, and frequency of early and late complications and to explore sex differences. METHODS: This was a retrospective cohort study including all patients hospitalized with acute symptomatic IAAD in Stockholm County during 2012-2021. RESULTS: A total of 277 patients with acute type B aortic dissection were identified, of whom 10% (n = 28/277) had acute IAAD. Median age was 56 years and 43% (n = 12/28) were women. Hypertension was diagnosed in 46% (n = 13/28) prior to admission. At onset, abdominal pain was the predominant complaint (93%, n = 26/28) and 93% (n = 26/28) were hypertensive on admission. The suprarenal aorta was involved in 39% (n = 11/28) and at least 1 of the iliac arteries in 50% (n = 14/28). All but 1 patient had uncomplicated IAAD (96%, n = 27/28). One patient presented with aortic rupture, treated with open surgical repair. Among patients with primarily uncomplicated IAAD, 7% eventually developed chronic complications (n = 2/27). Median maximum aortic diameter at 1-year follow-up was 21 mm (interquartile range 17-28). Only 1 patient had an aortic diameter exceeding 30 mm. None of the patients died during follow-up; median follow-up was 3.0 years (interquartile range 2-8). CONCLUSIONS: Early and late complications are rare in patients with acute symptomatic IAAD and a conservative approach with antihypertensive treatment and surveillance in uncomplicated cases seems reasonable.

European Multicentric Experience With Fenestrated-branched ENDOvascular Stent Grafting After Previous FAILed Infrarenal Aortic Repair: The EU-FBENDO-FAIL Registry.

OBJECTIVE: To report the mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR). METHODS: Data from consecutive patients who underwent F-BEVAR for pEVAR or pOAR from 2006 to 2021 from 17 European vascular centers were analyzed. Endpoints included technical success, major adverse events, 30-day mortality, and 5-year estimates of survival, target vessel primary patency, freedom from reinterventions, type I/III endoleaks, and sac growth >5 mm. BACKGROUND: Treatment of a failed previous abdominal aortic aneurysm repair is a complex undertaking. F-BEVAR is becoming an increasingly attractive option, although comparative data are limited regarding associated risk factors, indications for treatment, and various outcomes. RESULTS: There were 526 patients included, 268 pOAR and 258 pEVAR. The median time from previous repair to F-BEVAR was 7 (interquartile range, 4-12) years, 5 (3-8) for pEVAR, and 10 (6-14) for pOAR, P <0.001. Predominant indication for treatment was type Ia endoleak for pEVAR and progression of the disease for pOAR. Technical success was 92.8%, pOAR (92.2%), and pEVAR (93.4%), P =0.58. The 30-day mortality was 6.5% overall, 6.7% for pOAR, and 6.2% for pEVAR, P =0.81. There were 1853 treated target vessels with 5-year estimates of primary patency of 94.4%, pEVAR (95.2%), and pOAR (94.4%), P =0.03. Five-year estimates for freedom from type I/III endoleaks were similar between groups; freedom from reintervention was lower for pEVAR (38.3%) than for pOAR (56.0%), P =0.004. The most common indication for reinterventions was for type I/III endoleaks (37.5%). CONCLUSIONS: Repair of a failed pEVAR or pOARis safe and feasible with comparable technical success and survival rates. While successful treatment can be achieved, significant rates of reintervention should be anticipated, particularly for issues related to instability of target vessels/bridging stents.

The Origin of Thermal Gradient-Induced Voltage in Polyelectrolytes.

Ionic thermoelectric materials can generate large thermal voltages under temperature gradients while also being low-cost and environmentally friendly. Many electrolytes with large Seebeck coefficients are reported in recent years, however, the mechanism of the thermal voltage is remained elusive. In this work, three types of polyelectrolytes are studied with different cations and identified a significant contribution to their thermal voltage originating from a concentration gradient. This conclusion is based on studies of the loss and gain of water upon temperature changes, variations in conductivity with water content and temperature, and the voltages induced by changes in water content. The results are analyzed by the "hopping mode" dynamics of charge transport in electrolytes. The hydration of different cations influences the water concentration gradient, which affects the barrier height and ion-induced potential in the electrodes. This work shows that the hydro-voltage in ionic thermoelectric devices can be one order of magnitude larger than the contribution from thermodiffusion-induced potentials, and becomes the main contributor to energy harvesting when implemented into ionic thermoelectric supercapacitors. Together with the rationalized theoretical discussion, this work clarifies the mechanism of thermal voltages in electrolytes and provides a new path for the development of ionic thermoelectric materials.

The Value of Troponin Measurement in Carotid Revascularization: A Scoping Review.

PURPOSE: Patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS) are at substantially increased risk of short-term and long-term cardiac complications. Still, the role of perioperative troponin in predicting cardiac events remains unclear. The objective was to systematically summarize the existing evidence on the topic and provide directions for further research. MATERIALS AND METHODS: Studies that examined perioperative troponin values and its association with myocardial injury, and/or myocardial infarction (MI), and/or major adverse cardiac events (MACE) and postoperative mortality in exclusively CEA/CAS patients, published in English until March 15, 2022, were retrieved through a systematic search of MEDLINE and Web of Science. The study selection process was independently performed by 2 authors, while the third researcher resolved disagreements. RESULTS: Four studies with 885 participants met the inclusion criteria. Age, chronic kidney disease, presentation of carotid disease, type of closure (primary closure/venous patch/Dacron/polytetrafluoroethylene patch), coronary artery disease, chronic heart failure, and the long-term use of calcium channel blockers represent risk factors for troponin elevation, which occurred in 11% to 15.3%. Myocardial infarction and MACE occurred in 23.5% to 40%, that is, 26.5% of patients with troponin elevation, respectively, during the first 30 postoperative days. Elevated postoperative troponin levels were significantly associated with adverse cardiac events during the long-term surveillance period. The rates of cardiac-related and all-cause mortality were higher in patients with postoperative troponin elevation. CONCLUSION: Troponin measurement could be helpful in the prediction of adverse cardiac events. The predictive role of preoperative troponin, the patient population in whom routine troponin sampling should be used, and a comparison of different treatment methods/anesthesia techniques in carotid patients should be further examined. CLINICAL IMPACT: The present scoping review critically appraises the extent and nature of the existing literature data on the predictive value of troponin on the occurrence of cardiac complications in patients undergoing CEA and CAS. In particular, it provides clinicians with essential insights by systematically summarizing the core evidence and identifying knowledge gaps that may direct future research. This, in turn, may significantly alter the current clinical practice and perhaps even reduce the incidence of cardiac complications in patients undergoing CEA/CAS.

Comparison of Methods for Monitoring Intra-operative Cerebral Perfusion in Patients Undergoing Carotid Endarterectomy with Selective Shunting: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials and Cohort Studies.

OBJECTIVE: This study aimed to analyse the influence of different methods of monitoring cerebral perfusion (MCP) on stroke, death, and use of intraluminal shunt during carotid endarterectomy (CEA). METHODS: A systematic review and network meta-analysis was conducted and registered in the PROSPERO registry (CRD42021246360). Medline, Embase, CENTRAL, and Web of Science were searched. Randomised controlled trials (RCTs) and cohort studies with > 50 participants that compared clinical outcomes for different MCP in patients undergoing CEA were included. Papers reporting one or a combination of two of the following MCPs were included in the analysis: awake testing (AT), near infrared spectroscopy (NIRS), electroencephalography (EEG), somatosensory evoked potential (SSEP), motor evoked potential (MEP), transcranial Doppler (TCD), and stump pressure (SP). A random effects network meta-analysis was performed using a binomial likelihood function with a specified logit link for peri-operative stroke or death and shunting as outcomes. Near infrared spectroscopy was excluded due to the lack of studies that could be used for statistical analysis. RESULTS: Of 1 834 publications, 17 studies (15 cohort studies and two RCTs) including 21 538 participants were incorporated in the quantitative analysis. Electroencephalography was used in the largest number of participants (7 429 participants, six studies), while AT was used in the highest number of studies (10 studies). All monitoring modalities had worse outcomes with respect to stroke or death when compared with AT, with ORs ranging between 1.3 (95% credible interval [CrI] 0.2 - 10.9) for SSEP + MEP and 3.1 (CrI 0.3 - 35.0) for patients monitored with a combination of EEG and TCD. However, the wide CrI indicated that there is no statistically significant difference between the monitoring methods. Patients monitored with a combination of EEG and TCD had the lowest odds of being shunted, while SP had the highest odds of being shunted, also with no statistically significant difference. CONCLUSION: There is a lack of high quality data on this topic in the literature. The present study showed no significant difference between monitoring methods investigated in the network meta-analysis.

Editor's Choice - Nationwide Outcome Analysis of Primary Carotid Endarterectomy in Symptomatic Patients Depending on Closure Technique and Patch Type.

OBJECTIVE: Current European guidelines recommend both eversion carotid endarterectomy (CEA) and conventional CEA with routine patch closure, rather than routine primary closure. Polyester and polytetrafluoroethylene (PTFE) have been used as patch material for a long time. More recently, bovine pericardium has been used; however, there are few studies comparing long term results between bovine pericardium and other patch types. The aim of this study was to investigate the short and long term results after CEA depending on surgical technique and patch material. METHODS: A registry based study on all primary CEAs (n = 9 205) performed for symptomatic carotid artery stenosis in Sweden from July 2008 to December 2019, cross linked with data from the Swedish stroke registry, Riksstroke, and chart review for evaluation of any events occurring during follow up. The primary endpoint was ipsilateral stroke < 30 days. Secondary endpoints included re-operations due to neck haematoma and < 30 day ipsilateral stroke, > 30 day ipsilateral stroke, all stroke > 30 days, and all cause mortality. RESULTS: 2 495 patients underwent eversion CEA and 6 710 conventional CEA for symptomatic carotid stenosis. The most commonly used patch material was Dacron (n = 3 921), followed by PTFE (n = 588) and bovine pericardium (n = 413). A total of 1 788 patients underwent conventional CEA with primary closure. Two hundred and seventy-three patients (3.0%) had a stroke < 30 days. Primary closure was associated with an increased risk of ipsilateral stroke and stroke or death <30 days: odds ratio 1.7 (95% confidence interval [CI] 1.2 - 2.4, p = .002); and 1.5 (95% CI 1.2 - 2.0), respectively. During follow up (median 4.2 years), 592 patients had any form of stroke and 1 492 died. There was no significant difference in long term risk of ipsilateral stroke, all stroke, or death depending on surgical technique or patch material. CONCLUSION: There was an increased risk of ipsilateral stroke < 30 days in patients operated on with primary closure compared with eversion CEA and patch angioplasty. There was no difference between primary closure, different patch types, or eversion after the peri-operative phase.

Editor's Choice - Sex Related Differences in Indication and Procedural Outcomes of Carotid interventions in VASCUNET.

OBJECTIVE: It has been suggested that peri-operative complications after carotid surgery may be higher in women than in men. This assumption may affect the treatment patterns, and it is thus possible that carotid endarterectomy (CEA) is provided to women less often. The aim of the current VASCUNET study was to determine sex related differences in operative risk in routine clinical practice among non-selected patients undergoing carotid revascularisation. METHODS: Data on CEA and carotid artery stenting (CAS) from 14 vascular registries were collected and amalgamated. Comprehensive data were available for 223 626 carotid artery procedures; these were analysed overall and by country. The primary outcome was any stroke and or death within 30 days of carotid revascularisation. Secondary outcomes were stroke, death, or any major cardiac event or haemorrhage leading to re-operation. RESULTS: Of the procedures, 34.8% were done in women. The proportion of CEA for asymptomatic stenosis compared with symptomatic stenosis was significantly higher among women than men (38.4% vs. 36.9%, p < .001). The proportion of octogenarians was higher among women than men who underwent CEA in both asymptomatic (21.2% vs. 19.9%) and symptomatic patients (24.3% vs. 21.4%). In the unadjusted analysis of symptomatic and asymptomatic patients, there were no significant differences between men and women in the rate of post-operative combined stroke and or death, any major cardiac event, or combined death, stroke, and any major cardiac event after CEA. Also, after stenting for asymptomatic or symptomatic carotid stenosis, there were no significant differences between men and women in the rate of post-operative complications. In adjusted analyses, sex was not significantly associated with any of the end points. Higher age and CAS vs. CEA were independently associated with all four end points. CONCLUSION: This study confirmed that, in a large registry among non-selected patients, no significant sex related differences were found in peri-operative complication rates after interventions for carotid stenosis.

Risk for Acute Myocardial Infarction After Ophthalmologic Procedures.

BACKGROUND: Preoperative cardiovascular evaluations are frequently done before ambulatory ophthalmologic procedures. However, whether these procedures can trigger an acute myocardial infarction (AMI) is unknown. OBJECTIVE: To assess the short-term risk for AMI associated with ophthalmologic procedures. DESIGN: Case-crossover design. SETTING: Population-based nationwide study from Norway and Sweden. PARTICIPANTS: First-time patients with AMI, aged 40 years and older, identified via inpatient registries and linked to outpatient surgical procedures in Norway (2008 to 2014) and Sweden (2001 to 2014), respectively. MEASUREMENTS: Using self-matching, for each participant, exposure to ophthalmologic procedures in the 0 to 7 days before AMI diagnosis (hazard period) was compared with an 8-day period 30 days earlier, that is, days 29 to 36 before AMI (control period) to estimate the relative risk for an AMI the week after an ophthalmologic procedure. The odds ratios (ORs) with 95% CIs were calculated, using conditional logistic regression. Only patients who had a procedure of interest during either the hazard or control period were included. RESULTS: For the 806 patients with AMI included in this study, there was a lower likelihood of AMI in the week after an ophthalmologic procedure than during the control week (OR, 0.83; 95% CI, 0.75 to 0.91). Furthermore, there was no evidence of increased risk for AMI when analyses were stratified by surgery subtype, anesthesia (local or general), duration, invasiveness (low, intermediate, or high), patient's age (<65 years or ≥65 years), or comorbidity (none vs. any). LIMITATION: Potential bias from time-varying confounders between the hazard and the control periods. CONCLUSION: Ophthalmologic procedures done in an outpatient setting did not seem to be associated with an increased risk for AMI. PRIMARY FUNDING SOURCE: Central Norway Regional Health Authority and the Swedish Research Council.

Comparison of Early and Mid-Term Outcomes After Fenestrated-Branched Endovascular Aortic Repair in Patients With or Without Prior Infrarenal Repair.

OBJECTIVE: The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair. METHODS: Data from consecutive F-BEVAR (2010-2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency. RESULTS: A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002). CONCLUSIONS: F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term.

Low Incidence of Late Ipsilateral Ischaemic Stroke After Treatment for Symptomatic Carotid Stenosis in Sweden 2008-2017: Increased Risk in the Elderly and After Carotid Stenting.

OBJECTIVE: Carotid stenosis is a major risk factor for stroke and surgical treatment is key in preventing recurrent ischaemic events. Previous randomised trials have demonstrated the net benefit of surgery for significant symptomatic carotid stenosis but, with present day medical treatment, there is limited evidence on the risk of late ipsilateral ischaemic stroke (IS) and its main risk factors. METHOD: Ipsilateral IS after the peri-operative period (≤ 30 days) was investigated in a nationwide, registry based cohort study of patients treated for symptomatic carotid stenosis in Sweden between 2008 - 2017. The Swedish National Registry for Vascular Surgery (Swedvasc) was used to establish the cohort, and the Swedish stroke registry (Riksstroke), combined with hospital records, was used to determine outcome. Stroke of any type and all cause mortality after the peri-operative period were studied as secondary outcomes. Cox regression was used to analyse associations between clinical factors and outcomes. RESULTS: In total, 7 589 patients (mean age 72 ± 8 years, 68% men) were followed for 4.2 ± 2.6 years. Ipsilateral IS occurred in 232 patients corresponding to a yearly incidence of 0.73%. Age above 80 years compared with 65 - 79 years was associated with an increased risk of ipsilateral IS (adjusted HR 1.94, 95% CI 1.43 - 2.65). Carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) was also associated with increased risk (adjusted HR 3.20, 95% CI 2.03 - 5.03). Stroke of any type occurred in 7.7% of patients, and 19.6% of patients died during the follow up period. CONCLUSION: The incidence of ipsilateral IS after treatment for symptomatic carotid stenosis in Sweden 2008-2017 was low, demonstrating the effectiveness and durability of surgery in a real world setting. Only age above 80 years and CAS compared with CEA were associated with increased risk of ipsilateral IS.

Editor's Choice - Structured Computed Tomography Analysis can Identify the Majority of Patients at Risk of Post-Endovascular Aortic Repair Rupture.

OBJECTIVE: The main objective was to report mechanisms and precursors for post-endovascular aneurysm repair (EVAR) rupture. The second was to apply a structured protocol to explore whether these factors were identifiable on follow up computed tomography (CT) prior to rupture. The third objective was to study the incidence, treatment, and outcome of post-EVAR rupture. METHODS: This was a multicentre, retrospective study of patients treated with standard EVAR at five Swedish hospitals from 2008 to 2018. Patients were identified from the Swedvasc registry. Medical records were reviewed up to 2020. Index EVAR and follow up data were recorded. The primary endpoint was post-EVAR rupture. CT at follow up and at post-EVAR rupture were studied, using a structured protocol, to determine rupture mechanisms and identifiable precursors. RESULTS: In 1 805 patients treated by EVAR, 45 post-EVAR ruptures occurred in 43 patients. The cumulative incidence was 2.5% over a mean follow up of 5.2 years. The incidence rate was 4.5/1 000 person years. Median time to post-EVAR rupture was 4.1 years. A further six cases of post-EVAR rupture in five patients found outside the main cohort were included in the analysis of rupture mechanisms only. The rupture mechanism was type IA in 20 of 51 cases (39%), IB in 20 of 51 (39%) and IIIA/B in 11 of 51 (22%). One of these had type IA + IB combined. One patient had an aortoduodenal fistula without another mechanism being identified. Precursors had been noted on CT follow up prior to post-EVAR rupture in 16 of 51 (31%). Retrospectively, using the structured protocol, precursors could be identified in 43 of 51 (84%). In 17 of 27 (63%) cases missed on follow up but retrospectively identifiable, the mechanisms were type IB/III. Overall, the 30 day mortality rate after post-EVAR rupture was 47% (n = 24/51) and the post-operative mortality rate was 21% (n = 7/33). CONCLUSIONS: Most precursors of post-EVAR rupture are underdiagnosed but identifiable before rupture using a structured follow up CT protocol. Precursors of type IB and III failures caused the majority of post-EVAR ruptures.

Carotid Endarterectomy After Intracranial Endovascular Thrombectomy for Acute Ischaemic Stroke in Patients with Carotid Artery Stenosis.

OBJECTIVE: Recent randomised controlled trials demonstrated the benefit of intracranial endovascular thrombectomy (EVT) in acute ischaemic stroke. There is no consensus, however, on how to treat concomitant extracranial carotid artery stenosis after EVT. The aim of this study was to evaluate the outcome in patients treated with carotid endarterectomy (CEA) after EVT, comparing complication rates among patients undergoing CEA for stroke without previous EVT. METHODS: This was a registry study of all patients (n = 3 780) treated with CEA after stroke in Sweden and the capital Helsinki region, Finland, from January 2011 to September 2020. Sixty three patients (1.7%; 0.5% 2011, 4.3% 2019) underwent EVT prior to CEA. The primary outcome was 30 day stroke and death rate. RESULTS: The EVT+CEA group had major stroke as the qualifying neurological event (QNE) in 79%, but just 5.9% had this in the CEA only group (p < .001). Intravenous thrombolysis was administered before EVT in 54% of patients in the EVT+CEA group, but in just 12% in those receiving CEA only (p < .001). The combined stroke and death rate at 30 days for EVT+CEA was 0.0% (95% confidence interval [CI] 0.0 - 5.7). One patient had a post-operative TIA, none had post-operative intracerebral or surgical site haemorrhage. CEA was performed within a median of seven days (interquartile range 4, 15) after QNE, and 75% had CEA ≤14 days from QNE. The main reason to postpone CEA was an infarct larger than one third of the middle cerebral artery territory. The stroke and death rate in patients treated with CEA only was 3.7% (95% CI 3.2 - 4.4), CEA was performed a median of eight days after QNE, and in 79.7% in ≤14 days. The three year survival after EVT+CEA was 93% (95% CI 85 - 100), compared with 87% (95% CI 86 - 88) after CEA only. Cox regression analysis adjusting for age showed no increased all cause mortality after EVT+CEA (HR 1.3, 95% CI 0.6 - 2.7, p = .52). CONCLUSION: These results indicate that CEA is safe to perform after previous successful EVT for acute ischaemic stroke. Results were comparable with those undergoing CEA only, despite the EVT+CEA patients having more severe stroke symptoms prior to surgery, and timing was similar.

Outcomes of descending and thoracoabdominal aortic repair in connective tissue disorder patients.

OBJECTIVES: Open surgical repair (OSR) of descending and thoracoabdominal aortic aneurysms carries risks of mortality and major complications. Patients with connective tissue disorders (CTD) are younger and require safe, efficient treatment with long-term durability. This study provides current outcome data to help inform treatment decisions. METHODS: All OSRs of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) from January 2011 to July 2021 were included in a retrospective cohort study. Primary outcome measures were early and follow-up mortality and reintervention. Secondary outcome measures were major complications. Kaplan-Meier methods were used to estimate reintervention-free survival. RESULTS: A total of 26 OSRs (7 DTAA, 19 TAAA) were performed in 23 patients: 20 (77%) Marfan and 6 (23%) Loeys-Dietz syndrome; median age 43 years. Aortic dissection was present in 100% and 3/26 (12%) were urgent. Early mortality was 1/26 (3.8%). No patient suffered spinal cord ischemia, stroke, vocal cord paralysis, or re-exploration for bleeding. The transient respiratory failure occurred in 19% (5/26) and transient renal replacement therapy in 15% (4/26). Renal function normalized in all patients within 3 months. During follow-up (median 4.6, range 0-11 years) there were no deaths and only one re-intervention on a previously operated aortic segment, resulting in 92% reintervention-free survival at 5 years. CONCLUSIONS: In dedicated units, open surgical DTAA and TAAA repair in patients with CTD can be performed with a very low risk of death, severe complications and, late re-intervention. For CTD patients with reasonable risk, OSR should remain the first line of treatment.

Electrochromic Inorganic Nanostructures with High Chromaticity and Superior Brightness.

The possibility of actively controlling structural colors has recently attracted a lot of attention, in particular for new types of reflective displays (electronic paper). However, it has proven challenging to achieve good image quality in such devices, mainly because many subpixels are necessary and the semitransparent counter electrodes lower the total reflectance. Here we present an inorganic electrochromic nanostructure based on tungsten trioxide, gold, and a thin platinum mirror. The platinum reflector provides a wide color range and makes it possible to "reverse" the device design so that electrolyte and counter electrode can be placed behind the nanostructures with respect to the viewer. Importantly, this makes it possible to maintain high reflectance regardless of how the electrochemical cell is constructed. We show that our nanostructures clearly outperform the latest commercial color e-reader in terms of both color range and brightness.

Estimated glucose disposal rate and risk of stroke and mortality in type 2 diabetes: a nationwide cohort study.

BACKGROUND AND AIMS: Insulin resistance contributes to the development of type 2 diabetes (T2D) and is also a cardiovascular risk factor. The aim of this study was to investigate the potential association between insulin resistance measured by estimated glucose disposal rate (eGDR) and risk of stroke and mortality thereof in people with T2D. MATERIALS AND METHODS: Nationwide population based observational cohort study that included all T2D patients from the Swedish national diabetes registry between 2004 and 2016 with full data on eGDR and categorised as following: < 4, 4-6, 6-8, and ≥ 8 mg/kg/min. We calculated crude incidence rates and 95% confidence intervals (CIs) and used multiple Cox regression to estimate hazard ratios (HRs) to assess the association between the risk of stroke and death, according to the eGDR categories in which the lowest category < 4 (i.e., highest grade of insulin resistance), served as a reference. The relative importance attributed of each factor in the eGDR formula was measured by the R2 (± SE) values calculating the explainable log-likelihoods in the Cox regression. RESULTS: A total of 104 697 T2D individuals, 44.5% women, mean age of 63 years, were included. During a median follow up-time of 5.6 years, 4201 strokes occurred (4.0%). After multivariate adjustment the HRs (95% CI) for stroke in patients with eGDR categories between 4-6, 6-8 and > 8 were: 0.77 (0.69-0.87), 0.68 (0.58-0.80) and 0.60 (0.48-0.76), compared to the reference < 4. Corresponding numbers for the risk of death were: 0.82 (0.70-0.94), 0.75 (0.64-0.88) and 0.68 (0.53-0.89). The attributed relative risk R2 (± SE) for each variable in the eGDR formula and stroke was for: hypertension (0.045 ± 0.0024), HbA1c (0.013 ± 0.0014), and waist (0.006 ± 0.0009), respectively. CONCLUSION: A low eGDR (a measure of insulin resistance) is associated with an increased risk of stroke and death in individuals with T2D. The relative attributed risk was most important for hypertension.

Early and long-term prognosis in patients with and without type 2 diabetes after carotid intervention: a Swedish nationwide propensity score matched cohort study.

OBJECTIVES: To investigate early and long-term outcomes after treatment of carotid artery stenosis in patients with type 2 diabetes (T2D) compared to patients without T2D. DESIGN/METHOD: This observational nationwide population-based retrospective cohort study investigated all T2D patients treated for carotid stenosis registered in the National Swedish Vascular Surgery and the National Diabetes Registries. Data was collected prospectively for all patients after carotid intervention, during 2009-2015. We estimated crude early (within 30-days) hazard ratios (HRs) risk of stroke and death, and long-term HRs risk, adjusted for confounders with 95% confidence intervals (CIs), for stroke and death and major adverse cardiovascular events (MACE) by using inverse probability of treatment weighting matching. RESULTS: A total of 1341 patients with T2D and 4162 patients without T2D were included; 89% treated for symptomatic carotid stenosis, 96% with carotid endarterectomy. There was an increased early risk, HRs (95% CI), for stroke in T2D patients 1.65 (1.17-2.32), whereas risk for early death 1.00 (0.49-2.04) was similar in both groups. During a median follow-up of 4.3 (T2D) and 4.6 (without T2D), with a maximum of 8.0 years; after propensity score matching there was an increased HRs (95% CI) of stroke 1.27 (1.05-1.54) and death 1.27 (1.10-1.47) in T2D patients compared to patients without T2D. Corresponding numbers for MACE were 1.21 (1.08-1.35). CONCLUSIONS: Patients with T2D run an increased risk for stroke, death, and MACE after carotid intervention. They also have an increased perioperative risk for stroke, but not for death.

Deep Femoral Vein Reconstruction for Abdominal Aortic Graft Infections is Associated with Low Aneurysm Related Mortality and a High Rate of Permanent Discontinuation of Antimicrobial Treatment.

OBJECTIVE: Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. METHODS: In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. RESULTS: Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 - 252 months). Mean ± standard deviation operating time was 645 ± 160 minutes, mean blood loss was 6 277 ± 6 525 mL, mean length of intensive care unit stay was 5.3 ± 3.7 days, and mean length of overall hospital stay was 21.2 ± 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n = 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 ± 44.7 months, 20 patients were still alive. CONCLUSION: The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment.

Limb Graft Occlusion Following Endovascular Aneurysm Repair for Infrarenal Abdominal Aortic Aneurysm with the Zenith Alpha, Excluder, and Endurant Devices: a Multicentre Cohort Study.

OBJECTIVE: Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. METHODS: All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) RESULTS: A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (± 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 - 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 - 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 - 16.9) were associated with an increased risk of LGO. CONCLUSION: Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO.