Monte Carlo Dosimetry Validation for X-Ray Guided Endovascular Procedures.

BACKGROUND: Endovascular treatment is continuously gaining ground in vascular surgery procedures. However, current patient radiation dose estimation does not take into account the exact patient morphology and organs' composition. Monte Carlo (MC) simulation can accurately estimate the dose by recreating the irradiation process generated during X-ray-guided interventions. This study aimed to validate the MC simulation models by comparing simulated and measured dose distributions in endovascular aortic aneurysm repair (EVAR) procedures. METHODS: We conducted a clinical study in patients treated for EVAR. Patient dose measurements were taken with passive dosimeters using Optically Stimulated Luminescence technology in 4 specific anatomical points on the skin: xiphoid process, pubic symphysis, right and left iliac crest. Dose measurements were compared to the corresponding simulated doses with the Geant4 Application for Emission Tomography (GATE) and GPU Geant4-based Monte Carlo Simulations (GGEMS) MC simulations softwares. The MC simulation took as input the computed tomography scan of the patient and the parameters of the imaging system (orientation angles, tube voltage, and aluminum filtration) and gives as output the three-dimensional (3D) dose map for each patient and angulation. RESULTS: A good agreement with real doses was found for doses simulated by the MC GATE method (P < 0.0001; r = 0.97; 95% confidence interval [CI] [0.96-0.98]), as well as for doses simulated by the GGEMS method (P < 0.0001; r = 0.96; 95% CI [0.94-0.97]). The mean relative error for all measurements was 5 ± 5% in the MC GATE group and 6 ± 5% in the GGEMS group. Process execution on GGEMS (6 sec) was faster than the GATE MC simulation (5 hr). CONCLUSION: Considering the current imaging settings, this study shows the potential of using the GATE and GGEMS MC simulations platforms to model the 3D dose distributions during EVAR procedures.

Outcomes of Using Balloon-Expandable Covered Stent for Percutaneous Treatment of Access-Site Vascular Injury after Transfemoral Aortic Valve Implantation: A Single Center Experience.

BACKGROUND: Access-site vascular injury (ASVI) remains a challenge for transfemoral transcatheter aortic valve implantation (TAVI). Although surgery is the gold standard, endovascular therapy gains growing acceptance as primary treatment option for ASVI. The aim of this study was to analyze the safety and efficacy of covered balloon-expandable stents (BXSs) placement for ASVI after transfemoral TAVI. METHODS: All patients treated with a covered BXS between January 2018 and December 2020 for access-site related bleeding complications following femoral TAVI were included in this single center retrospective study. Primary measure outcome of this study was the primary patency at 12 months. Technical success, limb clinical worsening and device related complications were additionally analyzed. RESULTS: During the study period, 576 percutaneous femoral TAVIs were performed. Of these, 36 patients (6%) underwent covered stent deployment for a femoral access-site complication (19 men, median age 83 years old). Procedural success was 97%. The median follow-up was 12 months (interquartile range [IQR] = 9.7, range 0-36 months). One patient was lost to follow-up. The primary patency rates at 6 and 12 months were 100% and 95% respectively. No clinical deterioration or stent fracture was described during this period. CONCLUSIONS: Our results suggest that covered BXS deployment is a safe and effective alternative to surgery and may be a promising option for treating ASVI after femoral TAVI.

Vascular Complications Following Transcatheter Aortic Valve Implantation, Using MANTA (Collagen Plug-Based) versus PROSTAR (Suture-Based), from a French Single-Center Retrospective Registry.

TAVI requires a large-bore arteriotomy. Closure is usually performed by the suture system. Some studies report a vascular complication rate of up to 21%. MANTA is a recently developed percutaneous closure system dedicated to large caliber vessels based on an anchoring system. Early studies report a lower rate of vascular complications with MANTA devices. This single-center retrospective study included all patients who underwent femoral TAVI at the Brest University Hospital from 20 November 2019 to 31 March 2021. The primary endpoint is the rate of vascular complications (major and minor) pre and post-TAVI procedure. In total, 264 patients were included. There were no significant differences in vascular complications (major and minor) between the two groups (13.6% in the MANTA group versus 21.2% in the PROSTAR group; p = 0.105), although there was a tendency to have fewer minor vascular complications in the Manta group (12.1% versus 20.5%; p = 0.067). Manta was associated with a lower rate of bleeding complications (3.8% versus 15.2%; p = 0.002), predominantly minor complications with fewer closure failures (4.5% versus 13.6%; p = 0.01), less use of covered stents (4.5% versus 12.9%; p = 0.016), and with no difference in the need for vascular surgery compared to the Prostar group (1.5% versus 2.3%; p = 0.652). On the other hand, Manta was associated with a higher rate of femoral stenosis (4.5% versus 0%; p = 0.013) without clinical significance (1.5% versus 0%; p = 0.156). The Manta and Prostar devices are equivalent in terms of vascular complications. The Manta, compared to the Prostar, is associated with fewer bleeding complications.

Machine Learning and Omics Analysis in Aortic Aneurysm.

Aortic aneurysm is a life-threatening condition and mechanisms underlying its formation and progression are still incompletely understood. Omics approach has brought new insights to identify a broad spectrum of biomarkers and better understand cellular and molecular pathways involved. Omics generate a large amount of data and several studies have highlighted that artificial intelligence (AI) and techniques such as machine learning (ML)/deep learning (DL) can be of use in analyzing such complex datasets. However, only a few studies have so far reported the use of ML/DL for omics analysis in aortic aneurysms. The aim of this study is to summarize recent advances on the use of ML/DL for omics analysis to decipher aortic aneurysm pathophysiology and develop patient-tailored risk prediction models. In the light of current knowledge, we discuss current limits and highlight future directions in the field.

Comprehensive Review of Natural Language Processing (NLP) in Vascular Surgery.

Objective: The use of Natural Language Processing (NLP) has attracted increased interest in healthcare with various potential applications including identification and extraction of health information, development of chatbots and virtual assistants. The aim of this comprehensive literature review was to provide an overview of NLP applications in vascular surgery, identify current limitations, and discuss future perspectives in the field. Data sources: The MEDLINE database was searched on April 2023. Review methods: The database was searched using a combination of keywords to identify studies reporting the use of NLP and chatbots in three main vascular diseases. Keywords used included Natural Language Processing, chatbot, chatGPT, aortic disease, carotid, peripheral artery disease, vascular, and vascular surgery. Results: Given the heterogeneity of study design, techniques, and aims, a comprehensive literature review was performed to provide an overview of NLP applications in vascular surgery. By enabling identification and extraction of information on patients with vascular diseases, such technology could help to analyse data from healthcare information systems to provide feedback on current practice and help in optimising patient care. In addition, chatbots and NLP driven techniques have the potential to be used as virtual assistants for both health professionals and patients. Conclusion: While Artificial Intelligence and NLP technology could be used to enhance care for patients with vascular diseases, many challenges remain including the need to define guidelines and clear consensus on how to evaluate and validate these innovations before their implementation into clinical practice.

Editor's Choice - RANDOMisation Screening for Drug coated or Drug Eluting Device Randomised Trials Among Patients Undergoing Endovascular FemorOPopliteal Procedures (RANDOM-STOP study).

OBJECTIVE: The aim was to assess the proportion of patients undergoing endovascular therapy for femoropopliteal arterial disease (FP) who would be eligible to take part in seven major randomised controlled trials (RCTs) that investigated the efficacy of some of the currently available paclitaxel based (PTX) devices used in this clinical context. Various RCTs have shown a potential clinical benefit from the use of paclitaxel in FP endovascular therapy. Nonetheless, patients enrolled were highly selected and the generalisability of these findings in pragmatic cohorts is unclear. METHODS: Between 1 January and 31 December 2021, all consecutive patients who underwent endovascular procedures for symptomatic FP disease in 16 European centres were retrospectively screened and included in this analysis. The primary outcome measure was individual patient eligibility for inclusion into at least one of the seven RCTs. The reasons for exclusion (clinical and or radiological) as well as in hospital death and morbidity were also reported. RESULTS: A total of 1 567 consecutive patients (959 male, 61%), corresponding to 1 567 lower limbs, were included. Most patients (1 009 patients, 64.39%) were treated for chronic limb threatening ischaemia (CLTI). A total 1 280 patients (81.68%) were not eligible for inclusion in any of the evaluated RCTs. Of them, 741 (47.28%) were excluded for clinical and 1 125 (71.79%) for radiological reasons. CONCLUSION: The analysed RCTs assessing the efficacy or effectiveness of PTX based endovascular therapies do not seem representative of the patient population with FP disease receiving endovascular therapy in routine clinical practice.

Fast dose calculation in x-ray guided interventions by using deep learning.

Objective.Patient dose estimation in x-ray-guided interventions is essential to prevent radiation-induced biological side effects. Current dose monitoring systems estimate the skin dose based in dose metrics such as the reference air kerma. However, these approximations do not take into account the exact patient morphology and organs composition. Furthermore, accurate organ dose estimation has not been proposed for these procedures. Monte Carlo simulation can accurately estimate the dose by recreating the irradiation process generated during the x-ray imaging, but at a high computation time, limiting an intra-operative application. This work presents a fast deep convolutional neural network trained with MC simulations for patient dose estimation during x-ray-guided interventions.Approach.We introduced a modified 3D U-Net that utilizes a patient's CT scan and the numerical values of imaging settings as input to produce a Monte Carlo dose map. To create a dataset of dose maps, we simulated the x-ray irradiation process for the abdominal region using a publicly available dataset of 82 patient CT scans. The simulation involved varying the angulation, position, and tube voltage of the x-ray source for each scan. We additionally conducted a clinical study during endovascular abdominal aortic repairs to validate the reliability of our Monte Carlo simulation dose maps. Dose measurements were taken at four specific anatomical points on the skin and compared to the corresponding simulated doses. The proposed network was trained using a 4-fold cross-validation approach with 65 patients, and evaluating the performance on the remaining 17 patients during testing.Main results.The clinical validation demonstrated a average error within the anatomical points of 5.1%. The network yielded test errors of 11.5 ± 4.6% and 6.2 ± 1.5% for peak and average skin doses, respectively. Furthermore, the mean errors for the abdominal region and pancreas doses were 5.0 ± 1.4% and 13.1 ± 2.7%, respectively.Significance.Our network can accurately predict a personalized 3D dose map considering the current imaging settings. A short computation time was achieved, making our approach a potential solution for dose monitoring and reporting commercial systems.

A comparison of suprarenal and infrarenal fixation and renal volumetric analysis after endovascular aneurysm repair.

OBJECTIVE: Clinical and experimental studies of the stent-graft fixation impact on the renal volume after endovascular abdominal aortic aneurysm repair have focused on glomerular filtration rate, and the results were controversial. The aim of this study was to analyze and compare the impact of the suprarenal (SRF group) and infrarenal (IRF group) stent-graft fixation on the renal volume. METHODS: Between December 2016 and December 2019, all patients treated with endovascular aneurysm repair were retrospectively analyzed. Patients with atrophic or multicystic kidney, renal transplantation, ultrasound examination, or incomplete follow-up were excluded. The renal volume in both groups was extracted with a semiautomatic segmentation from contrast-enhanced computed tomography scan performed before the procedure, at 1 month, and at 12 months of follow-up. A subgroup analysis of the SRF group was performed in order to study the impact of the stent strut position relative to the renal arteries. RESULTS: A total of 63 patients were analyzed (SRF: 32 and IRF: 31). Demographic and anatomic characteristics were similar between the groups. The procedure contrast volume was higher in the IRF group (P = .01). At 12 months, we observed a decrease in the renal volume of 1.4% in the SRF group and 2.3% in the IRF group (P = .86). The SRF subgroup analysis showed only two patients with no stent struts crossing the renal arteries. In the remaining cases, struts crossed one renal artery in 60% of cases (19 patients) and two renal arteries in 34% of cases (11 patients). The renal volume decrease was not correlated with the presence of stent wire struts, crossing a renal artery. CONCLUSIONS: Stent graft with suprarenal fixation seems not to be correlated with renal volume deterioration. A randomized clinical trial with a higher effective and longer follow-up is needed to assess the impact of SRF on renal function.

Common femoral artery endarterectomy by eversion versus prosthetic patch angioplasty: a propensity-matched study.

BACKGROUND: Endarterectomy with prosthetic patch angioplasty is the preferred treatment for common femoral artery occlusive disease. Eversion endarterectomy was described as a promising alternative. the aim of this study was to compare the eversion endarterectomy and patch angioplasty outcomes for patients with de novo femoral bifurcation atherosclerotic lesions. this study was a single-center, retrospective analysis of prospectively collected registry data, non-randomized cohort. Patients treated by eversion endarterectomy and patch angioplasty for de novo femoral bifurcation atheromatous lesions were evaluated. METHODS: Between January 2016 and June 2019, all patients with de novo femoral bifurcation atheromatous lesions with a stenosis ≥70% were included in a prospective single-center database. Patients undergoing eversion endarterectomy and patch angioplasty were propensity-matched by age, sex, preexisting comorbidities, and lesion characteristics. RESULTS: There were 51 eversion endarterectomy and 137 patch angioplasty cases. One-to-one propensity matching yielded 51 pairs of patients. In the matched population, intermittent claudication was the most common clinical presentation (68% for both groups; P=0.83). There was no difference in femoral bifurcation lesion types between the two groups (P=0.11). Univariate analysis found no significant difference between the groups in terms of 30-d morbidity and mortality (10% and 16%; P=0.55). At 24 months, there was no significant difference in primary sustained clinical improvement (72% and 86%; P=0.22), primary patency rate (90% and 98%; P=0.48), and freedom from target lesion revascularization (100% and 98%; P=0.31) between the groups. CONCLUSIONS: This propensity-score analysis did not show any advantage for the EE. The EPPA should be the first line treatment of de novo femoral tripod occlusive disease. Results show that patch angioplasty treatment for de novo femoral bifurcation atheromatous could improve the daily practice with a good clinical improvement and primary patency.

Predictors of Recurrent Venous Thromboembolism or Arterial Thrombotic Events during and after Anticoagulation for a First Venous Thromboembolism.

After first episodes of venous thromboembolism (VTE), patients are at increased risk of recurrent VTE and arterial thrombotic events (ATE) compared with the general population, two disorders that are influenced by anticoagulation. However, risk factors of these conditions occurring during and after anticoagulation are little described. Using cause-specific hazard regression models, we aimed to determine risk factors of the composite outcome recurrent VTE/ATE, and separately recurrent VTE or ATE, during and after anticoagulation in patients with first episodes of VTE from a prospective cohort. Hazard ratios (HRs) are given with 95% confidence intervals (CIs). A total of 2,011 patients treated for at least 3 months were included. A total of 647 patients had recurrent VTE/ATE (incidence: 4.69% per patient-years) during overall follow-up (median: 92 months). Of these events, 173 occurred during anticoagulation (incidence: 3.67% per patient-years). Among patients free of events at the end of anticoagulation, 801 had a post-anticoagulation follow-up ≥3 months; and 95 had recurrent VTE/ATE (incidence: 1.27% per patient-years). After adjustment for confounders, cancer-associated VTE (HR: 2.64, 95% CI: 1.70-4.11) and unprovoked VTE (HR: 1.95, 95% CI: 1.35-2.81) were the identified risk factors of recurrent VTE/ATE during anticoagulation (vs. transient risk factor-related VTE). Risk factors of recurrent VTE/ATE after anticoagulation included 50 to 65 years of age (vs. < 50, HR: 1.99, 95% CI: 1.04-3.81), older than 65 years (vs. < 50, HR: 5.28, 95% CI: 3.03-9.21), and unprovoked VTE (vs. transient risk factor-related VTE, HR: 2.06, 95% CI: 1.27-3.34). Cancer-associated VTE and unprovoked VTE are the main risk factors of recurrent VTE/ATE during anticoagulation, while older age and unprovoked VTE mainly predict the risk of these events after anticoagulation.

Perioperative adverse events in percutaneous versus open brachial access.

OBJECTIVE: The objective of the present study was to compare the incidence of complications at the access site after percutaneous brachial access (PBA) and open brachial access (OBA) in the treatment of peripheral arterial disease. METHODS: From November 2016 to November 2021, all patients who had undergone peripheral artery revascularization with brachial access were included. The primary outcome was the 30-day rate of postoperative complications at the access site. The complications included hematoma, arteriovenous fistula, and pseudoaneurysms that had resulted in prolonged hospitalization and/or reintervention. RESULTS: Overall, 259 procedures with brachial access had been performed (PBA, n = 101; OBA, n = 158). The baseline clinical and demographic characteristics were well-balanced between the two groups. The sheath size was larger for the OBA procedures. Complications had occurred in 11 of 101 patients (11.1%) in the PBA group and 5 of 158 patients (3.2%) in the OBA group (P = .01). The mean duration of the procedure was significantly shorter for the PBA group (73.5 ± 46.5 minutes vs 101.2 ± 60.8 minutes; P = .0001). CONCLUSIONS: For patients who had undergone brachial access for peripheral vascular disease, the rate of access site-related complications was significantly lower for the patients who had undergone open access compared with that for the patients who had undergone percutaneous access.

Treatment of Long Femoropopliteal Lesions With Self-Expanding Interwoven Nitinol Stent: 24 Month Outcomes of the STELLA-SUPERA Trial.

PURPOSE: The performance of self-expanding interwoven nitinol stent (Supera) in femoropopliteal interventions has been proven through trials with short lesions and with relatively low proportion of occlusions. There is limited evidence of Supera stent in long lesions. The aim of this study was to assess the clinical safety and efficiency of the Supera stent in the treatment of long femoropopliteal lesions (Trans-Atlantic Inter-Society Consensus [TASC] C/D) in patients with symptomatic peripheral arterial disease (PAD). METHODS: The STELLA SUPERA (STEnting Long de L'Artère fémorale superficielle par le stent métallique Supera) is a prospective, 2-center, single-arm study. Patients with symptomatic (Rutherford stages 2-6) de novo and TASC C/D lesions of the femoropopliteal segment were treated with Supera stent. The primary endpoint was the primary sustained clinical improvement at 12 months. Follow-up included clinical examination, duplex scan, and biplane X-ray up to 24 months. RESULTS: Between December 2016 and October 2018, 48 symptomatic patients with 49 femoropopliteal lesions (TASC D = 32, 65%) were treated. The mean lesion length was 234 ± 123 mm, and 78% were total occlusion. The mean stented lesion length was 273 ± 127 mm. At 12 and 24 months, the primary sustained clinical improvement rate was 87.2% and 79.7%, respectively. The Rutherford category assessment was significantly improved at 24 months compared with baseline (p=0.02). At 24 months, the primary patency and freedom from target lesion revascularization (TLR) rates were 77.9% and 86.9%, respectively. The ankle-brachial pressure index increased from 0.62 ± 0.15 at baseline to 0.93 ± 0.15 at 24 months (p<0.0001). There were no stent fractures at 24 months. CONCLUSION: The use of Supera stent in long lesions (TASC C/D) is a safe and effective endovascular alternative. These results reinforce the need for randomized clinical trials to assess the value of interwoven stents for long femoropopliteal lesions.

Algorithm of Femoropopliteal Endovascular Treatment.

Background and Objectives: Indications for the endovascular treatment of femoropopliteal lesions have steadily increased over the past decade. Accordingly, the number of devices has also increased, but the choice of the best endovascular treatment remains to be defined. Many devices are now available for physicians. However, in order to obtain a high success rate, it is necessary to respect an algorithm whose choice of device is only one step in the treatment. Materials and Methods: The first step is, therefore, to define the approach according to the lesion to be treated. Anterograde approaches (femoral, radial, or humeral) are distinguished from retrograde approaches depending on the patient's anatomy and surgical history. Secondarily, the lesion will be crossed intraluminally or subintimally using a catheter or an angioplasty balloon. The third step corresponds to the preparation of the artery, which is essential before the implantation of the device. It has a crucial role in reducing the rate of restenosis. Several tools are available and are chosen according to the lesion requiring treatment (stenosis, occlusion). Among them, we find the angioplasty balloon, the atherectomy probes, or intravascular lithotripsy. Finally, the last step corresponds to the choice of the device to be implanted. This is also based on the nature of the lesion, which is considered short, up to 15 cm and complex beyond that. The choice of device will be between bare stents, covered stents, drug-coated balloons, and drug-eluting stents. Currently, drug-eluting stents appear to be the treatment of choice for short lesions, and active devices seem to be the preferred treatment for more complex lesions, although there is a lack of data. Results: In case of failure to cross the lesion, the retrograde approach is a safe and effective alternative. Balloon angioplasty currently remains the reference method for the preparation of the artery, the aim of which is to ensure the intraoperative technical success of the treatment (residual stenosis < 30%), to limit the risk of dissection and, finally, to limit the occurrence of restenosis. Concerning the treatment, the drug-eluting devices seem to present the best results, whether for simple or complex lesions. Conclusions: Endovascular treatment for femoropopliteal lesions needs to be considered upstream of the intervention in order to anticipate the treatment and the choice of devices for each stage.

Fusion Imaging Guidance Does Not Affect Radiation Exposure During Endovascular Procedures for Lower Extremity Arterial Disease: A Randomized Controlled Trial.

PURPOSE: Radiation exposure for vascular interventionalists is still a concern. The aim of this study was to assess the value of advanced imaging guidance on radiation exposure and iodinated contrast volume during endovascular treatment of lower extremity arterial disease (LEAD). MATERIALS AND METHODS: It was a prospective, randomized, monocentric, pilot, single-operator study, conducted from June 2018 to October 2019. Consecutive patients requiring a preoperative computed tomography angiography (CTA) for a symptomatic LEAD and scheduled for an iliac and/or femoropopliteal endovascular repair in a hybrid room were included. Patients were randomly assigned to the use of fusion imaging guidance (Vessel Navigator®, Philips) or not. The primary endpoint was the dose area product (DAP, Gy.cm²). Secondary endpoints were DAP for fluoroscopy, DAP for fluorography, Air Kerma, fluoroscopy time, volume of contrast, and number of digital subtraction angiography (DSA). Data were expressed in median [Q1-Q3]. RESULTS: In all, 64 of the 77 patients enrolled (34 in fusion group, 30 in control group, 82% men, 65.8 years [61-71]) were included. Groups were similar in terms of comorbidities, BMI (26 kg/cm2 [24-28]), but lesion location were not equally distributed (p=0.004). There was no significant difference between the groups regarding DAP (31.6 Gy.cm2 [23.4; 46.9] for fusion group vs 25.6[16.9; 34.0] Gy.cm2; p=0.07), Air Kerma (160 mGy [96;3365] vs 115 mGy [76;201]; p=0.12, fluoroscopy time (560 seconds [326;960] vs 454 seconds [228;1022]; p=0.44), contrast volume (60 ml [42;80] vs 50 ml [40;66]; p=0.10), or operative time (68 minutes [55;90] vs 46 minutes [30;80]; p=0.06). The median number of DSA was 14 [10-18] in the fusion group versus 11 [6-18]; p=0.049. CONCLUSION: Fusion imaging guidance does not affect radiation exposure and contrast volume during endovascular revascularisation of iliac and femoropopliteal occlusive disease in a hybrid room environment.

Risk Factors for Major Adverse Cardiovascular Events and Major Adverse Limb Events after Venous Thromboembolism: A Large Prospective Cohort Study.

BACKGROUND: There is an increased risk of arterial events including major adverse cardiovascular events (MACE) and major adverse limb events (MALE) after venous thromboembolism (VTE). However, their risk factors remain little explored. METHODS: We aimed to determine the risk factors for MACE (acute coronary syndrome/stroke/cardiovascular death) and MALE (limb ischemia/critical limb ischemia/non-traumatic amputation/any limb revascularization) after VTE. Competing risk models (Fine-Gray) were used in a multicenter prospective cohort of 4,940 patients (mean age: 64.6 years and median follow-up: 64 months). RESULTS: MACE occurred in 17.3% of participants (2.35% per patient-years) and MALE in 1.7% (0.27% per patient-years). In multivariable analysis, the identified risk factors for MACE were the age of 50 to 65 years (vs. <50 years, hazard ratio [HR]: 2.00, 95% confidence interval [CI]: 1.38-2.91), age >65 years (vs. <50 years, HR 4.85, 95% CI: 3.35-7.02), pulmonary embolism + deep vein thrombosis (DVT) (vs. isolated-DVT, HR: 1.25, 95% CI: 1.02-1.55), unprovoked-VTE (vs. transient risk factor associated-VTE, HR: 1.29, 95% CI: 1.04-1.59), current tobacco use (vs. never, HR: 1.45, 95% CI: 1.07-1.98), hypertension (HR: 1.61, 95% CI: 1.30-1.98), past history of symptomatic atherosclerosis (HR: 1.52, 95% CI: 1.17-1.98), heart failure (HR: 1.71, 95% CI: 1.21-2.42), atrial fibrillation (HR: 1.55, 95% CI: 1.15-2.08), and vena cava filter insertion (HR: 1.46, 95% CI: 1.03-2.08). The identified risk factors for MALE were the age of 50-65 years (vs. <50 years, HR: 3.49, 95% CI: 1.26-9.65) and atrial fibrillation (HR: 2.37, 95% CI: 1.15-4.89). CONCLUSIONS: Risk factors for MACE and MALE after VTE included some traditional cardiovascular risk factors, patient's comorbidities, and some characteristics of VTE.

Risk Factors of Cardiovascular Death after Venous Thromboembolism: Results from a Prospective Cohort Study.

BACKGROUND: Cardiovascular deaths (CVDTs) are more frequent in patients with venous thromboembolism (VTE) than in the general population; however, risk factors associated with this increased risk of CVDT in patients with VTE are not described. METHODS: To determine the risk factors of CVDT in patients with VTE from a multicenter prospective cohort study, Fine and Gray subdistribution hazard models were conducted. RESULTS: Of the 3,988 included patients, 426 (10.7%) died of CVDT during a median follow-up of 5 years. The risk factors of CVDT after multivariate analyses were: age of 50 to 65 years (vs. <50 years, hazard ratio [HR]: 3.22, 95% confidence interval [CI]: 1.67-6.62), age >65 years (vs. <50 years, HR: 7.60, 95% CI: 3.73-15.52), cancer-associated VTE (vs. transient risk factor-related VTE, HR: 1.73, 95% CI: 1.15-2.61), unprovoked VTE (vs. transient risk factor-related VTE, HR: 1.42, 95% CI: 1.02-2.00), past tobacco use (vs. never, HR: 1.43, 95% CI: 1.06-1.94), current tobacco use (vs. never, HR: 1.87, 95% CI: 1.15-3.01), hypertension (HR: 2.11, 95% CI: 1.51-2.96), chronic heart failure (HR: 2.28, 95% CI: 1.37-3.79), chronic respiratory failure (HR: 1.72, 95% CI: 1.02-2.89), and atrial fibrillation (HR: 1.67, 95% CI: 1.06-2.60). The risk of CVDT was significantly reduced with direct oral anticoagulants (vs. vitamin-K antagonists) and with longer duration of treatment (>3 months). CONCLUSION: Risk factors of CVDT after VTE include some traditional cardiovascular risk factors and other risk factors that are related to characteristics of VTE, and patients' comorbidities.

Anticoagulation for VTE: Impact on the Risk of Major Adverse Cardiovascular Events.

BACKGROUND: It was recently established that patients who developed VTE are at increased risk of major adverse cardiovascular events (MACE) compared with the general population. However, whether the anticoagulation used for VTE influences the risk of MACE remains undescribed. RESEARCH QUESTION: Does the anticoagulant treatment for VTE affect the risk of subsequent MACE? STUDY DESIGN AND METHODS: This study included patients from a large prospective cohort who received only one family of anticoagulant treatment after the acute phase of VTE, including vitamin K antagonist (VKAs) and direct oral anticoagulants (DOACs). MACE included nonfatal acute coronary syndrome, nonfatal stroke, and all-cause death. The secondary outcome, MACE-2, included cardiovascular death instead of all-cause death. Cox proportional and Fine-Gray models served to study the relationship between anticoagulation characteristics and the risk of outcomes. RESULTS: A total of 3,790 patients (47.2% male; mean age, 60.48 years) were included. A total of 1,228 patients (32.4%) were treated for 0 to 3 months (median in overall population, 6 months). Compared with these patients, those treated for 3 to 12 months (hazard ratio [HR], 0.64; 95% CI, 0.54-0.76) or > 12 months (HR, 0.47, 95% CI, 0.39-0.56) had a significant reduced risk of MACE following adjustment for confounders. Findings were similar for MACE-2 (sub-HR for 3-12 months, 0.61 [95% CI, 0.47-0.79]; sub-HR > 12 months, 0.52 [95% CI, 0.39-0.68]). After adjustment for confounders, there was a reduced risk of MACE (HR, 0.53; 95% CI, 0.39-0.71) and MACE-2 (sub-HR, 0.48; 95% CI, 0.29-0.77) in patients treated with DOACs (vs VKAs). INTERPRETATION: Treatment of VTE for > 3 months is associated with a reduced risk of MACE, as is treatment with DOACs vs VKAs. These findings, which may influence the choice of anticoagulation strategies for VTE, need confirmation by randomized clinical trials.

Bare metal stent in the area of drug eluting devices for long femoropopliteal lesions.

The advancement in the endovascular treatment and the introduction of novel techniques allowed treatment of more complex and longer femoropopliteal lesions. However, the optimal treatment modality is still a source of controversy. The use of bare metal stents (BMS) showed good results for long femoropopliteal lesions. In this review, we summarized all available data on the different treatment strategies of long femoro-popliteal lesions using BMS. Nevertheless, RCTs with head-to-head comparison between BMS strategies are still needed to have more clarification on the best strategy for the endovascular treatment of long femoropopliteal occlusive lesions.

Risk factors of arterial thrombotic events after unprovoked venous thromboembolism, and after cancer associated venous thromboembolism: A prospective cohort study.

INTRODUCTION: The increased risk of arterial thrombotic (ATE) after VTE, particularly when they are unprovoked or cancer-associated has been established. However, the risk factors of ATE after these VTE remain unclear. MATERIAL AND METHODS: Using cause-specific hazard regression models, we determined risk factors of ATE (myocardial infarction, ischemic stroke, acute limb ischemia, digestive tract ischemia, or renal ischemia) in 2242 patients with unprovoked VTE and in 914 patients with cancer-associated VTE from a multi-center prospective cohort. RESULTS: Of patients with unprovoked-VTE, 174 developed ATE (7.8%, incidence: 1.26 per 100 patient-years) during follow-up (median: 68 months). Among patients with cancer-associated VTE, 57 developed ATE (6.2%, incidence: 1.98 per 100 patient-years) during follow-up (median: 30 months). After multivariable analysis, the identified risk factors of ATE in patients with unprovoked-VTE were age > 65 years (vs. <50 years, HR 2.59, 95% CI: 1.56-4.29), past history of symptomatic atherosclerosis (HR 2.11, 95% CI: 1.40-3.19), and treatment with low molecule weight heparin (vs. vitamin K antagonists, HR: 2.26, 95% CI: 1.13-4.52). In patients with cancer-associated VTE, the identified risk factors of ATE were: past history of symptomatic atherosclerosis (HR: 3.13, 95% CI: 1.72-5.67), and ongoing anticoagulation at the diagnosis of VTE (HR: 2.77, 95% CI: 1.07-7.22). CONCLUSIONS: The risk of ATE after unprovoked VTE and after cancer-associated VTE, is determined by some classic cardiovascular risk factors and appears to be influenced by anticoagulant treatment introduced for VTE, as well as the presence or absence of ongoing anticoagulation at the diagnosis of VTE.