Benefits of Prehabilitation before Complex Aortic Surgery.

The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.

Does surgical companionship modify the learning curve for fenestrated and branched endovascular aortic repair?

OBJECTIVES: The goal of this study was to describe the learning curve of an operator trained in an aortic centre during the first years of performing fenestrated/branched endovascular aortic repairs independently. METHODS: Patients electively treated with fenestrated/branched stent grafts from January 2013 to March 2020 were included retrospectively. Groups were defined according to the treating operator: experienced operator (group 1), early-career operator (group 2) or both during a 14-month surgical companionship period (group 3). The early-career operator's learning curve was assessed using a cumulative sum analysis. A composite criterion including technical failure, death and/or any major adverse event was evaluated in a logistic regression model. RESULTS: Overall, 437 patients (93% male; median 69 (63, 77) years old) were included (group 1: n = 240; group 2: n = 173; group 3: n = 24). There were significantly more extended thoraco-abdominal aneurysms (extent I, II, III and V) in group 1 compared to group 2 [n = 68 (28%) vs 19 (11%), P<0.001]. The technical success rate was 94% (P=0.874). The 30-day mortality and/or major adverse event rates in juxta-/pararenal aneurysms or extent IV thoraco-abdominal aneurysms were 8.1% in group 1 and 9.7% in group 2 (P = 0.612), whereas they were 10% (group 1) and 0 (group 2) for extended thoraco-abdominal aneurysms (P=0.339). The adjusted cumulative sum analysis highlighted satisfactory results from the beginning of the experience. The operator's experience was not predictive of the composite criterion [adjusted OR 0.77; 95% (0.42, 1.40); P=0.40]. CONCLUSIONS: This study demonstrated favourable outcomes in patients treated with a fenestrated/branched aortic stent graft performed by an early-career operator trained in a high-volume centre from the beginning of independent practice.

Evaluation of Arterial and Venous Allografts in Subinguinal Bypasses.

BACKGROUND: 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. METHODS: 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. RESULTS: 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]). CONCLUSIONS: 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.

Iliac branch device to treat type Ib endoleak with a brachial access or an "up-and-over" transfemoral technique.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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 Gyccm2 (IQR, 40-62 Gyccm2), 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. CONCLUSIONS: 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.

Intraoperative cone beam computed tomography to improve outcomes after infrarenal endovascular aortic repair.

OBJECTIVE: We evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft-related complications and, consequently, reintervention. METHODS: All consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft-related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft-related reinterventions. All-cause and aneurysm-related deaths were also recorded. RESULTS: Overall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft-related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft-related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft-related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47). CONCLUSIONS: To the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft-related complications associated.

Management of Type IA Endoleak After EVAR by Explantation or Custom Made Fenestrated Endovascular Aortic Aneurysm Repair.

OBJECTIVE: 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). METHODS: 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. RESULTS: 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%). CONCLUSION: 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.

Variations in arterial pedal circulation in idiopathic congenital talipes equinovarus: a systematic review.

Variations in pedal circulation in congenital talipes equinovarus (CTEV) are well documented. There is a reported risk of vascular injury to the posterior tibial artery (PTA) during operative procedures for CTEV, potentially leading to necrosis and amputation. The aim of this systematic review was to identify the most common anomalies in arterial pedal circulation in CTEV and to determine the relevance of these to clinical practice. The systematic review was registered on PROSPERO and was carried out according to Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by two independent reviewers. Studies that examined pedal circulation in idiopathic CTEV were included. Articles that studied nonidiopathic CTEV and those not published in English were excluded. Data extracted included patient demographics, imaging modalities, and findings. A total of 14 articles satisfied the inclusion criteria, including 192 patients (279 clubfeet), aged 0-13.5 years, at various stages in their treatment. Imaging modalities included arteriography (n = 5), duplex ultrasound (n = 5), magnetic resonance angiography (n = 2), and direct visualization intraoperatively (n = 2). The dorsalis pedis was most frequently reported as absent (21.5%), and the anterior tibial artery (ATA) was most frequently reported as hypoplastic (18.3%). Where reported (n = 36 feet), 61% of patients were noted to have a dominant supply from the PTA. The most common variation in pedal circulation in CTEV is diminished supply from ATA and dorsalis pedis, although there are documented anomalies in all of the vessels supplying the foot. We therefore recommend routine Doppler ultrasound imaging prior to operative intervention in CTEV.

Global Epidemiology of Chronic Venous Disease: A Systematic Review With Pooled Prevalence Analysis.

OBJECTIVE: To provide an updated estimate of the global prevalence of CVD and to comprehensively evaluate risk factors associated with this condition. BACKGROUND: CVD is an important cause of morbidity internationally, but the global burden of this condition is poorly characterized. The burden of CVD must be better characterized to optimize 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 2 independent reviewers, in accordance with a preregistered protocol (PROSPERO: CRD42019153656). 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 classification and across different geographical regions. Qualitative analysis was performed to evaluate associated risk factors in CVD. RESULTS: Thirty-two articles across 6 continents were identified. Nineteen studies were included in the overall pooled prevalence for each Clinical (C) stage; pooled estimates were: C0 s: 9%, C1: 26%, C2: 19%, C3: 8%, C4: 4%, C5: 1%, C6: 0.42%. The prevalence of C2 disease was highest in Western Europe and lowest in the Middle East and Africa. Commonly reported risk factors for CVD included: female sex (OR 2.26, 95% confidence intervals 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.

Midterm results of endovascular aneurysm sealing to treat abdominal aortic aneurysm.

BACKGROUND: Endovascular aneurysm sealing (EVAS) represents a novel approach to the treatment of abdominal aortic aneurysms. It uses polymer technology to achieve an anatomic seal within the sac of the aneurysm. This cohort study reports the early clinical outcomes, technical refinements, and learning curve during the initial EVAS experience at a single institution. METHODS: Results from 150 consecutive EVAS cases for intact, infrarenal abdominal aortic aneurysms are reported here. These cases were undertaken between March 2013 and July 2015. Preoperative, perioperative, and postoperative data were collected for each patient prospectively. RESULTS: The median age of the cohort was 76.6 years (interquartile range, 70.2-80.9 years), and 87.3% were male. Median aneurysm diameter was 62.0 mm (IQR, 58.0-69.0 mm). Adverse neck morphology was seen in 69 (46.0%) patients, including aneurysm neck length <10 mm (17.3%), neck diameter >32 mm or <18 mm (8.7%), and neck angulation >60 degrees (15.3%). Median follow-up was 687 days (IQR, 463-897 days); 37 patients (24.7%) underwent reintervention. The rates of unresolved endoleak are 1.3% type IA, 0.7% type IB, and 2.7% type I. There were no type III endoleaks. There have been seven secondary ruptures in this cohort; all but one of these patients survived after reintervention. Only one rupture occurred in an aneurysm that had been treated within the manufacturer's instructions for use (IFU). CONCLUSIONS: The rate of unresolved endoleaks is satisfactorily low. The incidence of secondary rupture is of concern; however, when the IFU are adhered to, the rate is very low. The results of this study suggest that working within the IFU yields better clinical results.

Short Stay EVAR is Safe and Cost Effective.

OBJECTIVE: Reducing length of stay (LOS) following surgery offers the potential to improve resource utilisation. Endovascular aneurysm repair (EVAR) is now delivered with a low level of morbidity and as such may be deliverable as a "23 hour stay" intervention. This systematic review aims to assess safety, feasibility and cost effectiveness of a short stay EVAR pathway. METHODS: A database search of Ovid MEDLINE (1996 - April 2018) and Embase (1974 - April 2018) was completed. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. A Newcastle-Ottawa Scale was applied to assess study bias. RESULTS: In total, 570 papers were identified through the literature search, of which 32 abstracts were screened. This led to nine papers being assessed for eligibility. From five suitable studies, 450 (75%) patients were successfully discharged the same or next day after EVAR. Complications most often occurred within 3 hours of surgery, and major complications requiring intensive treatment unit admission occurred within 6 hours. Readmission rates were 0-5% for those discharged early, with no difference in 30 day readmission. Early discharge led to a statistically significant cost saving of £13,360 (LOS four days) to £9844 (LOS one day). CONCLUSION: Selected patients can safely undergo EVAR using a short stay pathway. A period of monitoring 6 h post-operatively for low risk patients would be sufficient. Reducing length of stay after EVAR in the UK from the current median of three days to 1.5 days would free 4361 bed days and lead to a saving of approximately £1,800,000 annually.

Endovascular Versus Open Repair for Chronic Type B Dissection Treatment: A Meta-Analysis.

BACKGROUND: The respective place of endovascular repair (ER) versus open surgery (OS) in thoracic dissecting aneurysm treatment remains debatable. This comprehensive review seeks to compare the outcomes of ER versus OS in chronic type B aortic dissection treatment. METHODS: Embase and Medline searches (2000 to 2017) were performed following PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. Outcomes data extracted comprised (1) early mortality and major complications: stroke, spinal cord ischemia (SCI), dialysis, and respiratory complications; and (2) late survival and reinterventions. Reintervention causes were divided into proximal, adjacent, and distal. Comparative studies allowed comparative meta-analysis. Noncomparative studies were analyzed in pooled proportion meta-analyses for each group. RESULTS: A total of 39 studies were identified after exclusions, of which 4 were comparative. Comparative meta-analysis demonstrated lower early mortality for ER (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.10 to 15.4), stroke (OR, 4.33; 95% CI, 1.02 to 18.35), SCI (OR, 3.3; 95% CI, 0.97 to 11.25), and respiratory complications (OR, 6.88; 95% CI,1.52 to 31.02), but higher reintervention rate (OR, 0.34; 95% CI, 0.16 to 0.69). Midterm survival was similar (OR, 1.19; 95% CI, 0.42 to 3.32). Noncomparative studies demonstrated that most reinterventions were related to the aortic segment distal to primary intervention in both groups (OS 73%, ER 59%). Reintervention procedures were mainly surgical for OS (85%), mainly endovascular for ER (75%). Rupture rates were 1.2% (OS) and 3% (ER). CONCLUSIONS: Endovascular repair is associated with significant early benefits, but this is not sustained at midterm. Reintervention is more frequent, but the OS is not exempt from reintervention or late rupture. Both techniques have their place, but patient selection is key.

Protocol Adaptation of Optical Coherence Tomography in Lower Limb Arteries Revascularization.

In lower limb arteries, assessment of stent apposition and/or the single opening of the diseased artery remains poor since this relies on 2-dimensional angiogram. Extrapolating experience gained with coronary arteries, optical coherence tomography (OCT) could provide 3-dimensional reconstructions of the arterial wall and the stent implanted. A modified protocol of OCT acquisition, which usually includes large amount of iodine contrast flush, is presented here in 3 patients with long and complex occlusion of the superficial femoral artery. Its potential benefits and wider application to improve patient outcomes are discussed.

A Systematic Review of Predictors of Reintervention After EVAR: Guidance for Risk-Stratified Surveillance.

BACKGROUND: Current surveillance protocols after endovascular aneurysm repair (EVAR) are ineffective and costly. Stratifying surveillance by individual risk of reintervention requires an understanding of the factors involved in developing post-EVAR complications. This systematic review assessed risk factors for reintervention after EVAR and proposals for stratified surveillance. METHODS: A systematic search according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting on risk factors predicting reintervention after EVAR and proposals for stratified surveillance. RESULTS: Twenty-nine studies reporting on 39 898 patients met the primary inclusion criteria for reporting predictors of reintervention or aortic complications with or without suggestions for stratified surveillance. Five secondary studies described external validation of risk scores for reintervention or aortic complications. There was great heterogeneity in reporting risk factors identified at the pre-EVAR, intraoperative, and post-EVAR stages of treatment, although large preoperative abdominal aortic aneurysm diameter was the most commonly observed risk factor for reintervention after EVAR. CONCLUSION: Existing data on predictors of post-EVAR complications are generally of poor quality and largely derived from retrospective studies. Few studies describing suggestions for stratified surveillance have been subjected to external validation. There is a need to refine risk prediction for EVAR failure and to conduct prospective comparative studies of personalized surveillance with standard practice.

Systematic Review of Reintervention After Thoracic Endovascular Repair for Chronic Type B Dissection.

This review analyzed the incidence, mechanisms, and risk factors of aortic-related reintervention after endovascular repair of chronic dissections. The systematic review identified 28 studies describing 1,249 patients at median 27 months follow-up (range, 10.3 to 64.4). There were six reinterventions, 0.7 ruptures, and 1.2 surgical conversions per 100 patient-years of follow-up. Stent-related reinterventions were more frequent than nonstent related (80.2% vs 19.8%). Distal false lumen perfusion was the most common complication (40.5%). No individual risk factor-treatment timing, disease extent, covered aorta length, or remodelling-was associated with reintervention. Further investigation based on consistent reporting standards is required.

Early outcomes after left subclavian artery revascularisation in association with thoracic endovascular aortic repair.

Approximately 40-50% of patients undergoing thoracic endovascular aortic repair require left subclavian artery coverage for adequate proximal landing zone. Many of these patients undergo left subclavian artery revascularisation. However, outcomes data for left subclavian artery revascularisation in the context of thoracic endovascular aortic repair remain limited. In this study, 70 left subclavian artery revascularisation procedures, performed on thoracic endovascular aortic repair patients at a tertiary hospital, were retrospectively reviewed. Particular emphasis was placed on revascularisation-related outcomes during staging interval between revascularisation and thoracic endovascular aortic repair. Forty-six (66%) carotid-subclavian bypass, 17 (24%) carotid-carotid-subclavian bypass and 7 (10%) aorto-inominate-carotid-subclavian bypass procedures were performed. There were no strokes or mortalities following left subclavian artery revascularisation procedures alone. Three (10%) minor complications occurred including a seroma, a haematoma and a temporary neuropraxia. Separation of complications following left subclavian artery revascularisation from those of the associated thoracic endovascular aortic repair can be difficult. Early outcomes data from patients who underwent left subclavian artery revascularisation in isolation indicate that the procedure is safe with low complication rates.

Microvascular disease and risk of cardiovascular events among individuals with type 2 diabetes: a population-level cohort study.

BACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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. FUNDING: Circulation Foundation.