The lived experiences and treatment needs of women with opioid use disorder and posttraumatic stress symptoms: A mixed methods study.

INTRODUCTION: Women show a gender-specific risk for co-occurring opioid use disorder (OUD) and posttraumatic stress disorder (PTSD). Expert groups have called for the development of integrated treatments for women with OUD/PTSD, but there remains limited information on such interventions. METHODS: This mixed-methods study interviewed and surveyed 10 women with current or past OUD and co-occurring posttraumatic stress symptoms (PTSS) and 16 providers who work with these women. Interviews and surveys queried patient participants' and providers' experiences of OUD/PTSS and how to best design an integrated, trauma-focused treatment for OUD/PTSD. RESULTS: Patient participants (90 % white, 90 % mothers, Mage = 45.70) met criteria for severe, lifetime OUD and 40 % met a provisional diagnosis for PTSD. Four themes emerged for participants' experiences of OUD/PTSS: 1) numerous stressors; 2) shame; 3) multiple motivations to use opioids; and 4) a cycle of trauma and opioid use. Four themes emerged regarding patient participants' perceptions on the development of an OUD/PTSD treatment: 1) mixed attitudes towards medications for OUD; 2) barriers to treatment (e.g., insufficient treatments and contextual factors); 3) treatment facilitators (e.g., social support); and 4) preferences in treatment (e.g., trauma-focused, gender-focused, family content, ambivalence around group therapy). Providers (Mage = 38.94) were primarily white women (76.5 %). Two themes emerged from their experiences working with women with OUD/PTSS: 1) perceiving women to use opioids to regulate emotions and 2) gender differences in trauma types. Three themes emerged for providers' perceptions on the development of an OUD/PTSD treatment: 1) barriers to treatment (e.g., chaotic lives, contextual factors, family); 2) treatment facilitators (e.g., trust and external motivations); and 3) desired treatment modifications (e.g., stabilization, early skills in therapy, flexibility in therapy, social supports, safety guidelines, and assistance in identifying an index trauma). Most participants (90.0 %) and providers (93.5 %) preferred working on OUD/PTSD symptoms simultaneously rather than separately. CONCLUSIONS: Findings demonstrate the need to modify integrated treatments to meet the preferences of providers and women with OUD/PTSS and OUD/PTSD. Treatments should consider therapeutic content, structure, contextual factors, social support, and PTSD severity to enhance uptake and reach.

Influence of Patient Anatomy on Intraoperative Radiation Exposure and Operation Time during Standard EVAR.

Endovascular aortic repair (EVAR) is the primary treatment for abdominal aortic aneurysms (AAAs). To optimise patient safety during the standard EVAR procedure, we aimed to investigate the influence of patient anatomy on intraoperative radiation exposure and surgical time. This retrospective study comprised 90 patients (mean age 73.4 ± 8.2 years; 92.2% male) with an infrarenal aortic aneurysm who underwent a standard EVAR procedure. The relationships between dose area product, operating time, and anatomical conditions were investigated in preoperative computed tomography angiography using open-source software. Logistic regression analysis indicated that only body mass index (BMI) had predictive value for radiation exposure. The accuracy of the model was 98.67%, with an area under the curve of 0.72. The duration of surgery was significantly correlated with an increased BMI (odds ratio (OR) = 1.183; p < 0.05), the tortuosity of AAAs (OR = 1.124; p < 0.05), and the left common iliac artery (OR = 1.028; p < 0.05). Thus, BMI impacts the prediction of intraoperative radiation exposure more significantly than the anatomical characteristics of the infrarenal aorta and iliac arteries, and the duration of surgery significantly correlates with both BMI and the tortuosity of the infrarenal aorta and iliac arteries.

Sex difference in early mortality after abdominal aortic aneurysm repair.

OBJECTIVE: Although female patients have a lower prevalence of abdominal aortic aneurysm (AAA), they seem to have a worse treatment outcome compared with male patients. Both maximum aneurysm diameter and aortic size index (ASI) are important indicators of the risk of AAA rupture, among which ASI has been shown capable of equalizing sex-related anatomical differences. Our study aimed to investigate whether sex is an independent risk factor for early postoperative mortality and how the diameter or ASI affects the association between sex and mortality. METHODS: We performed a retrospective analysis of patients who enrolled in the AAA registry of the German Society of Vascular Surgery from 2013 to 2019. The patients were treated by either open surgical repair (OSR) or endovascular aneurysm repair (EVAR). The association between sex and 30-day mortality was investigated using logistic regression analysis. The interaction and mediating effects of maximum aneurysm diameter and ASI were investigated to verify their roles in the effect of sex on mortality. The relationships between the diameter (or ASI) and the risk of 30-day mortality in different sexes were demonstrated by the restricted cubic spline. RESULTS: Overall, 23,275 cases were included in our analysis, with 20,130 male (86.5%) and 3139 female (13.5%) patients. Female patients had a smaller maximum aneurysm diameter (OSR, 55.23 ± 10.29 mm vs 58.05 ± 11.28 mm [P < .001]; EVAR, 54.06 ± 9.08 mm vs 56.11 ± 9.38 mm [P < .001]), but a higher ASI (OSR, 3.16 ± 0.71 vs 2.92 ± 0.69 [P < .001]; EVAR, 3.05 ± 0.66 vs 2.80 ± 0.59 [P < .001]) compared with male patients. The 30-day mortality rate was higher for female patients in both OSR (6.6% vs 4.2%; P = .002) and EVAR groups (1.8% vs 0.8%; P < .001). Logistic regression confirmed a significantly higher risk of 30-day mortality for female patients compared with male patients (odds ratio, 1.55; 95% confidence interval, 1.21-1.99; P = .001). No interaction was found between sex and diameter or ASI, but there were mediating effects for diameter and ASI in the effect of sex on 30-day mortality. For female patients, the risk of 30-day mortality linearly increased with the increase of diameter (PNonlinear = .089) or ASI (PNonlinear = .888), whereas the risk for male patients was U-shaped (for diameter, PNonlinear < .001; for ASI, PNonlinear = .020). CONCLUSIONS: Sex is an independent risk factor for 30-day mortality after AAA repair. Both diameter and ASI are mediating factors for the effect of sex on 30-day mortality. The relationship between diameter or ASI and the risk of 30-day mortality is different for male and female patients.

Age and Oversizing Influence Iliac Dilatation after EVAR.

In the past two decades, endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) has become the first line treatment for infrarenal AAA repair in many countries. While short-term results are good, concerns have been raised about long-term durability. Changes in aortoiliac anatomy, especially at the landing zones, could play a role in EVAR failure over time. The current study aimed to determine certain morphological changes in the distal iliac landing zone after EVAR implantation, as well aspossible risk factors associated with iliac sealing failure. In a retrospective analysis of a tertiary single-centre registry, including patients treated with EVAR between January 2008 and July 2018, clinical follow-up data were assessed, and computer tomography (CT) imaging was evaluated regarding morphological changes in the iliac anatomy during follow-up. For clinical analysis all patients with a minimum follow-up of one year were included; for morphological analysis of iliac anatomy all patients with available CT follow-up of a minimum of one year and a minimum of two CT scans were included. Overall, 127 out of 241 treated patients (92.1% male) were included in the clinical follow-up. Complete CT imaging of 99 iliac arteries in 55 patients was available for morphological analysis. Median postoperative follow-up (FU) for these patients was 33 months (IQR 31; min−max: 12−124). Incidence of type 1b endoleak was 3% but iliac limb detachment from the vessel wall was seen in 18.2% of the target vessels. There was a significant difference in oversizing in iliac limbs with detachment (median 13.9%, IQR 23.1) vs. without detachment (median 23.1%, IQR 19.1) (p = 0.034). Iliac arteries at the landing zone showed a significant diameter increase independent of an endoleak presence (overall cohort median diameter increase at one year 23.1 mm; at two years 0 mm; at three years 4.9 mm). Iliac arteries with detachment (median 14.4%; IQR 23.9) showed a significantly higher diameter increase at the landing zone after four years compared to arteries without detachment (median 5.3%; IQR 9) (p = 0.042). Oversizing correlated positively with an iliac diameter increase at the landing zone over time (3 m: p= 0.001; one year: p < 0.001; two years: p < 0.001; three years: p = 0.006). Older patients showed a significantly lower diameter increase at the distal landing zone over time than younger patients in the first two years after EVAR (p < 0.001/r = −0.606 after two years). In the current study, iliac limb oversizing was associated with increased dilatation of the distal landing zone during a three-year follow-up, while iliac limb detachment was observed less often. An older age was inversely associated to the iliac diameter increase. Future studies should clarify the association between stent graft oversizing, age, and changes in the iliac anatomy in order to identify parameters that affect EVAR durability.

Systematic evaluation of imaging techniques and baseline characteristics in patients with suspected vasculitis.

Purpose: To assess the diagnostic value of different imaging modalities in distinguishing systemic vasculitis from other internal and immunological diseases. Methods: This retrospective study included 134 patients with suspected vasculitis who underwent ultrasound, magnetic resonance imaging (MRI), or 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) between 01/2010 and 01/2019, finally consisting of 70 individuals with vasculitis. The main study parameter was the confirmation of the diagnosis using one of the three different imaging modalities, with the adjudicated clinical and histopathological diagnosis as the gold standard. A secondary parameter was the morphological appearance of the vessel affected by vasculitis. Results: Patients with systemic vasculitis had myriad clinical manifestations with joint pain as the most common symptom. We found significant correlations between different imaging findings suggestive of vasculitis and the final adjudicated clinical diagnosis. In this context, on MRI, vessel wall thickening, edema, and diameter differed significantly between vasculitis and non-vasculitis groups (p < 0.05). Ultrasound revealed different findings that may serve as red flags in identifying patients with vasculitis, such as vascular occlusion or halo sign (p = 0.02 vs. non-vasculitis group). Interestingly, comparing maximal standardized uptake values from PET/CT examinations with vessel wall thickening or vessel diameter did not result in significant differences (p > 0.05). Conclusions: We observed significant correlations between different imaging findings suggestive of vasculitis on ultrasound or MRI and the final adjudicated diagnosis. While ultrasound and MRI were considered suitable imaging methods for detecting and discriminating typical vascular changes, 18F-FDG PET/CT requires careful timing and patient selection given its moderate diagnostic accuracy.

Distribution of Mobile Health Applications amongst Patients with Symptomatic Peripheral Arterial Disease in Germany: A Cross-Sectional Survey Study.

BACKGROUND: Broadly available digital and mobile health applications (also known as mHealth) have recently gained increasing attention by the vascular community, but very little is known about the dissemination and acceptance of such technologies in certain target populations. The current study aimed to determine the user behaviour and acceptance of such digital technologies amongst patients with peripheral arterial disease (PAD). METHODS: A cross-sectional survey of consecutively treated inpatients at 12 university institutions, as well as one non-university institution, was conducted. All admitted patients with symptomatic PAD were surveyed for 30 consecutive days within a flexible timeframe between 1 July and 30 September 2021. The factors associated with smartphone use were estimated via backward selection within a logistic regression model with clustered standard errors. RESULTS: A total of 326 patients participated (response rate 96.3%), thereof 102 (34.0%) were treated for intermittent claudication (IC, 29.2% women, 70 years in median) and 198 were treated for chronic limb-threatening ischaemia (CLTI, 29.5% women, 70 years in median). Amongst all of the patients, 46.6% stated that they had not changed their lifestyle and health behaviour since the index diagnosis (four years in median), and 33.1% responded that they were not aware of the reasons for all of their medication orders. Amongst all those surveyed, 66.8% owned a smartphone (IC: 70.6%, CLTI: 64.1%), thereof 27.9% needed regular user support. While 42.5% used smartphone apps, only 15.0% used mobile health applications, and 19.0% owned wearables. One out of five patients agreed that such technologies could help to improve their healthy lifestyle. Only higher age was inversely associated with smartphone possession. CONCLUSIONS: The current survey showed that smartphones are prevalent amongst patients with peripheral arterial disease, but only a small proportion used mobile health applications and a considerable number of patients needed regular user support. Almost half of the patients did not change their lifestyle and one third were not aware of the reasons for their medication orders, emphasising room for improvement. These findings can further help to guide future projects using such applications to identify those target populations that are reachable with digital interventions.

Real-world data of popliteal artery aneurysm treatment: Analysis of the POPART registry.

OBJECTIVE: Popliteal artery aneurysm (PAA) is a rare disease with a prevalence of 0.1% to 1%. Within previous years, endovascular repair (ER) of PAAs has been performed more frequently despite the lack of high-level evidence compared with open surgical repair (OSR). In 2014, the POPART registry was initiated to validate the current treatment options for PAA repair. METHODS: POPART is a multinational multicenter registry of the peri- and postoperative outcomes of ER and OSR for PAAs. Data sets were recorded using the online survey tool SurveyMonkey (available at: https://www.surveymonkey.com/). Regular monitoring and plausibility checks of the data sets are performed to ensure reliability. The aim of the present study was to report the findings from the POPART registry, which includes data from 41 centers. RESULTS: From June 2014 to August 2019, 794 cases had been recorded in the POPART registry. OSR had been performed in 662 patients and ER in 106 patients; 23 patients had been treated conservatively. Of the 106 patients in the primary ER group, 4 had required conversion to OSR. The ER patients were significantly older (ER, median, 71 years; OSR, median, 67 years; P < .05). No other significant differences were present in the demographic data, comorbidities, or aneurysm morphology between the two groups. Of the 662 patients in the OSR group, 50.3% were symptomatic compared with 29.2% of the 106 patients in the ER group (P < .05). Emergency treatment because of acute ischemia, critical ischemia, or rupture was necessary for 149 patients (22.5%) in the OSR group and 11 patients (10.3%) in the ER group. The most frequent postoperative complications were impaired wound healing (OSR, n = 47 [7.1%]; ER, n = 3 [2.8%]; P > .05) and major bleeding (OSR, n = 26 [3.9%]; ER, n = 3 [2.8%]; P > .05). The in-hospital length of stay was significantly longer for the OSR group than for the ER group (median, 10 days; range, 3-65 days; vs median, 7 days; range, 1-73 days). The overall patency for the OSR and ER groups after 12 and 24 months was 83.2% and 44.7% (P < .005) and 74.2% and 29.1% (P < .005), respectively. The outcomes with a prosthetic graft vs an autologous vein were significantly poorer in the OSR group (primary patency, 71.4% vs 88.1% at 12 months). CONCLUSIONS: To evaluate new treatment techniques such as ER for PAAs, real-world data are of essential importance. The present analysis of the first results for the POPART registry shows good perioperative results for endovascular treatment of PAA in asymptomatic patients with good outflow vessels. The perioperative complication rate is low and the postoperative hospital stay is shorter than after OSR. However, the patency rates after 12 and 24 months are low in the ER group compared to patients treated with open repair. More follow-up data is required for further interpretation; the completion of the data sets in the registry is ongoing.

[Therapy of Peripheral Artery Aneurysms]. / Therapie primärer Aneurysmen der Extremitätenarterien.

Peripheral arterial aneurysms are rare vascular pathologies characterised by focal dilatation of at least 1.5-fold relative to the diameter of the native vessel. Primary arterial aneurysms can affect any segment of the arterial trunk. Diagnostic tests include duplex sonography, CT and MR angiography, and digital subtraction angiography. It is essential that the influx and efflux to the aneurysm should be mapped as precisely as possible. The most common type of peripheral arterial aneurysms are popliteal artery aneurysms, which frequently occur with aorta aneurysms. Peripheral arterial aneurysms are more common in patients with connective tissue disease or autoimmune disease (Ehlers-Danlos syndrome, Marfan syndrome, Behçet's disease). The current gold standard for therapy is surgery, although endovascular therapies have also been described. As the condition is rare, there is insufficient evidence to compare these approaches. Results from several register studies and single centre studies in patients with popliteal aneurysms indicate that endovascular therapy can give similar outcomes to open therapy if patients are carefully selected. Nevertheless, open surgery remains the gold standard. Therapy of aneurysms of the extremities must consider individual treatment criteria, such as the morphology of the aneurysm, its anatomical localisation - particularly with respect to mobilise segments, vascular efflux and the patient's general condition.

Development of an Exercise Training Protocol to Investigate Arteriogenesis in a Murine Model of Peripheral Artery Disease.

Exercise is a treatment option in peripheral artery disease (PAD) patients to improve their clinical trajectory, at least in part induced by collateral growth. The ligation of the femoral artery (FAL) in mice is an established model to induce arteriogenesis. We intended to develop an animal model to stimulate collateral growth in mice through exercise. The training intensity assessment consisted of comparing two different training regimens in C57BL/6 mice, a treadmill implementing forced exercise and a free-to-access voluntary running wheel. The mice in the latter group covered a much greater distance than the former pre- and postoperatively. C57BL/6 mice and hypercholesterolemic ApoE-deficient (ApoE-/-) mice were subjected to FAL and had either access to a running wheel or were kept in motion-restricting cages (control) and hind limb perfusion was measured pre- and postoperatively at various times. Perfusion recovery in C57BL/6 mice was similar between the groups. In contrast, ApoE-/- mice showed significant differences between training and control 7 d postoperatively with a significant increase in pericollateral macrophages while the collateral diameter did not differ between training and control groups 21 d after surgery. ApoE-/- mice with running wheel training is a suitable model to simulate exercise induced collateral growth in PAD. This experimental set-up may provide a model for investigating molecular training effects.

Repeated contrast medium application after endovascular aneurysm repair and not the type of endograft fixation seems to have deleterious effect on the renal function.

OBJECTIVE: The influence of endovascular aneurysm repair (EVAR) on renal function is of high concern. The question whether stent graft fixation type plays a significant role in renal outcome after EVAR is still debated. However, other factors, such as repeated contrast medium exposure, should also be considered. METHODS: We performed a two-center, stratified-cohort case control study to evaluate the influence of last-generation abdominal endografts with suprarenal (SR) vs infrarenal (IR) fixation on renal function. RESULTS: From a total of 276 patients, 134 were treated with IR fixation (group A) and 142 with SR fixation (group B) stent grafts. There was no significant difference in intraoperative contrast medium use (mean 120.0 mL group A vs 104.8 mL; P = .087) between the two cohorts. Overall, 11.2% of the patients (31/276) showed a relevant decline (≥20%) of estimated glomerular filtration rate (eGFR) postoperative and 11.5% (31/269) after 12 months. Furthermore, 19/134 (14.2%) patients in group A and 12/142 (8.5%) patients in group B showed a postoperative decrease of eGFR ≥20% (P = .132). Comparing the 12-month follow up, there was also no significant difference between the two groups (group A, n = 18/134; group B, n = 13/135; P = .329). Patients with only one contrast-enhanced computed tomography scan postoperatively (4/102; 3.9%) showed significant less renal deterioration after 12 months compared with the rest of the study collectively (27/166; 16.9%; P = .002). Comparing IR vs SR fixation in these patients, there was no significant difference between the two groups. One patient (1/35; 2.9%) with IR fixation (group A) and 3/67 (4.5%) with SR fixation (group B) showed a decline in eGFR values of ≥20% after 12 months (P = 1.0). CONCLUSIONS: Our study showed no significant difference in renal impairment between SR and IR fixation in EVAR for IR abdominal aortic aneurysm. However, significantly more renal deterioration was observed in patients with increased postoperative contrast medium expose. Therefore, alternatives such as contrast- enhanced duplex ultrasound or magnetic resonance imaging for EVAR surveillance should be considered.

Transfemoral transcatheter aortic valve implantation in a patient with multiple endovascular aortic stents--a case report.

BACKGROUND: In patients undergoing transfemoral transcatheter aortic valve implantation, previous endovascular interventions bear a risk for the valve frame to get stucked to the aortic stents. CASE PRESENTATION: We report on a 75-year-old frail patient with severe aortic stenosis and a rapid increase of an infra-renal aneurysm. He had a history of multiple endovascular interventions on the aorta. Due to his frail preoperative status we decided to perform a transfemoral transcatheter aortic valve implantation in combination with a simultaneous surgical abdominal aneurysm repair. To allow an atraumatic passage of the Edwards SAPIEN 3 valve across the endovascular stents we used a special technique. CONCLUSIONS: The transfemoral approach in patients with previous endovascular stenting can be performed successfully by a partial inflation of the distal balloon.

Technical feasibility of endovascular aortoiliac aneurysm repair combining Anaconda fenestrated and Zenith iliac side-branched stent grafts.

We demonstrate for the first time the technical feasibility of total endovascular aneurysm repair for juxtarenal and pararenal aortoiliac aneurysms by combining the Vascutek Anaconda custom-made fenestrated stent graft with the Cook Zenith iliac side-branched stent graft. Three patients (two male and one female) presented with asymptomatic pararenal aortoiliac aneurysm in the first case and juxtarenal aorto-left iliac aneurysms in the second and third cases. We successfully deployed the Anaconda fenestrated and the iliac side-branched stent graft combined with Atrium Advanta V12 stent grafts for renal, superior mesenteric, and hypogastric arteries. Postoperative computed tomography demonstrated excluded aneurysms with patent renovisceral and hypogastric arteries and no signs of endoleak.