Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis.

BACKGROUND: We investigated the early and midterm efficacy and safety of covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac disease (AID). METHODS: A systematic search on PubMed, Scopus, and Web of Science for articles published by August 2023 was performed. The primary end points were primary patency and secondary patency. RESULTS: Eleven retrospective case series, involving 579 patients, were incorporated in the review with 88.9% of the included lesions being categorized as Trans-Atlantic Inter-Society Consensus (TASC) C or D. The pooled primary patency estimates at 12, 24 and 36 months were 94.4% (95% confidence interval [CI], 89.4-99.7), 84.4% (95% CI, 72.3-98.5) and 83.8% (95% CI, 71.4-98.3) respectively. The mean primary patency time, representing the period during which individuals remained event-free, was 51.9 months (95% CI, 43.6-55.4). The pooled 36 months primary patency for studies with a predominantly claudicant patient population (>75% of patients) was 89.4% (95% CI, 78.5-100.0), compared with 71.5% (95% CI, 45.6-100.0) for studies with a mixed population (50% of patients). The pooled 36 months primary patency for studies with a predominantly TASC D patient population (>82% of patients) was 70.4% (95% CI, 46.4-100.0) compared with 91.0% (95% CI, 79.1-100.0) for studies with a more homogenous cohort. The pooled secondary patency estimates at 12, 24, and 36 months were 98.6% (95% CI, 96.2-100.0), 97% (95% CI, 93.1-100.0), and 97% (95% CI, 93.1-100.0), respectively. The pooled technical success, 30-day mortality and 30-day systemic complications estimates were 95.9% (95% CI, 93.7- 97.4), 1.9% (95% CI, 1.0-3.5), and 6.4% (95% CI, 4.4-9.1), respectively. The pooled intraoperative and postoperative 30-day CERAB-related complications estimates were 7.3% (95% CI, 2.0-23.0) and 4.2% (95% CI, 0.7-21.0), respectively. The pooled major amputation and target lesion reinterventions by the end of follow-up were 1.9% (95% CI, 1.0-3.4) and 13.9% (95% CI, 9.9-19.2), respectively. The pooled access site complication estimate was 11.7% (95% CI, 5.9-21.7). CONCLUSIONS: Although this review has showcased the safety and feasibility of the CERAB technique in treating AID, it has also highlighted the necessity for a close and prolonged follow-up period extending beyond 1 year. Moreover, the favorable secondary patency estimates predominantly attained via endovascular reinterventions emphasize a potentially advantageous characteristic of the CERAB technique, particularly valuable when addressing late-stage AID disease or anatomically complex lesions.

Covered Stents Versus Bare Metal Stents in the Treatment of Aorto-iliac Disease: A Systematic Review and Individual Participant Data Meta-analysis.

OBJECTIVE: To assess the comparative safety and efficacy of covered stents (CS) and bare metal stents (BMS) in the endovascular treatment of aorto-iliac disease in patients with peripheral arterial disease. DATA SOURCES: A systematic review was conducted adhering to the PRISMA 2020 and PRISMA for Individual Participant Data 2015 guidelines. REVIEW METHODS: A search of PubMed, Scopus, and Web of Science for articles published by December 2023 was performed. The primary endpoint was primary patency. Certainty of evidence was assessed via the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. RESULTS: Eleven studies, comprising 1 896 patients and 2 092 lesions, were included. Of these, nine studies reported on patients' clinical status, with 35.5% classified as Rutherford 4 - 6. Overall primary patency for CS and BMS at 48 months was 91.2% (95% confidence interval [CI] 84.1 - 99.0%) (GRADE, moderate) and 83.5% (95% CI 70.9 - 98.3%) (GRADE, low). The one stage individual participant data meta-analyses indicated a significant risk reduction for primary patency loss favouring CS (hazard ratio [HR] 0.58, 95% CI 0.35 - 0.95) (GRADE, very low). The 48 month primary patency for CS and BMS when treating TransAtlantic Inter-Society Consensus (TASC) C and D lesions was 92.4% (95% CI 84.7 - 100%) (GRADE, moderate) and 80.8% (95% CI 64.5 - 100%) (GRADE, low), with CS displaying a decreased risk of patency loss (HR 0.39, 95% CI 0.27 - 0.57) (GRADE, moderate). While statistically non-significant differences were identified between CS and BMS regarding technical success, 30 day mortality rate, intra-operative and immediate post-operative procedure related complications, and major amputation, CS displayed a decreased re-intervention risk (risk ratio 0.59, 95% CI 0.40 - 0.87) (GRADE, low). CONCLUSION: This review has illustrated the improved patency of CS compared with BMS in the treatment of TASC C and D lesions. Caution is advised in interpreting overall primary patency outcomes given the substantial inclusion of TASC C and D lesions in the analysis. Ultimately, both stent types have demonstrated comparable safety profiles.

Long-Term Outcomes of Anatomical and Extra-Anatomical Bypass for the Treatment of Unilateral Iliac Artery Lesions a Systematic Review Aggregated Data and Individual Participant Data Meta-Analysis.

BACKGROUND: We investigated the long-term safety and efficacy of anatomical and extra-anatomical bypass for the treatment of unilateral iliac artery disease. METHODS: A systematic search on PubMed, Scopus and Web of science for articles published by June 2023 was performed. We implemented a 2-stage individual participant data meta-analysis and pooled survival probabilities using the multivariate methodology of DerSimonian and Laird. The primary endpoint was primary patency at 5 and 10 years of follow-up. RESULTS: Ten studies encompassing 1,907 patients were included. The 5- and 10-year pooled patency rates for anatomical bypass were 83.27% (95% confidence interval (CI): 69.99-99.07) and 77.30% (95% CI: 60.32-99.04), respectively, with a mean primary patency time representing the duration individuals remained event-free for 10.08 years (95% CI: 8.05-10.97). The 5- and 10-year pooled primary patency estimates for extra-anatomical bypass were 77.02% (95% CI: 66.79-88.80) and 68.54% (95% CI: 53.32-88.09), respectively, with a mean primary patency time of 9.25 years, (95% CI: 7.21-9.68). Upon 2-stage individual participant data meta-analysis, anatomical bypass displayed a decreased risk for loss of primary patency compared to extra-anatomical bypass, hazard ratio 0.51 (95% CI: 0.30-0.85). The 5- and 10-year secondary patency estimates for anatomical bypass were 96.83% (95% CI: 90.28-100) and 96.13% (95% CI: 88.72-100), respectively. The 5- and 10-year secondary patency estimates for extra-anatomical bypass were 91.39% (95% CI: 84.32-99.04) and 85.05% (95% CI: 74.43-97.18), respectively, with non-statistically significant difference between the 2 groups. The 5- and 10-year survival for patients undergoing anatomical bypass were 67.99% (95% CI: 53.84-85.85) and 41.09% (95% CI: 25.36-66.57), respectively. The 5- and 10-year survival for extra-anatomical bypass were 70.67% (95% CI: 56.76-87.98) and 34.85% (95% CI: 19.76-61.44), respectively. The mean survival time was 6.92 years (95% CI: 5.56-7.89) for the anatomical and 6.78 years (95% CI: 5.31-7.63) for the extra-anatomical groups. The pooled overall 30-day mortality was 2.32% (95% CI: 1.12-3.87) with metaregression analysis displaying a negative association between the year of publication and mortality (ß =-0.0065, P < 0.01). Further analysis displayed a 30-day mortality of 1.29% (95% CI: 0.56-2.26) versus 4.02% (95% CI: 1.78-7.03), (P = 0.02) for studies published after and before the year 2000. Non-statistically significant differences were identified between the 2 groups concerning long-term and 30-day mortality outcomes. CONCLUSIONS: While we have demonstrated favorable long-term primary and secondary patency outcomes for both surgical techniques, anatomical bypass exhibited a reduced risk of primary patency loss potentially reflecting its inherent capacity to circumvent the anticipated disease progression in the distal aorta and the contralateral donor artery. The reduction in perioperative mortality observed in our review, coupled with the anachronistic demographic characteristics and inclusion criteria presented in the existing literature, underscores the imperative necessity for contemporary research.

Endovenous laser ablation (EVLA) 980 nm versus 1470 nm and the impact of fiber type: a systematic review and meta-analysis.

We sought to assess the efficacy and safety of endovenous laser ablation utilizing a 980 nm device versus a 1470 nm device in the treatment of lower limb venous insufficiency. We performed a systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. A research on PubMed, Scopus and Web of science for articles published by January 2024 was conducted. The primary endpoint was great saphenous vein (GSV) and truncal vein occlusion. Eleven studies encompassing 3061 patients and 3193 truncal veins, were included. The 1470 nm device demonstrated superior truncal vein and GSV occlusion outcomes compared to the 980 nm device at the early, one-year, and medium to long-term follow-up intervals. Odds ratios (OR) were 2.79(95%CI:1.31-5.94), 2.22(95%CI:1.21-4.07), and 2.02(95%CI:1.24-3.29) for truncal veins and 2.54(95%CI:1.119-5.41), 2.06(95%CI:1.07-3.95) and 2.04(95%CI:1.25-3.33) for GSV, across the respective intervals. While both devices demonstrated minimal, deep vein thrombosis (DVT), endovenous heat-induced thrombosis (EHIT) ≥ 2, and burn estimates, the 1470 nm device exhibited improved paresthesia, risk ratio (RR), 0.51(95%CI:0.34-0.77) and pain outcomes, standardized mean difference (SMD), -0.62(95%CI:-0.99to-0.25). Subgroup analysis displayed enhanced occlusion outcomes with the 1470 nm device for the six-month and one-year intervals, irrespective of fiber type. Radial fibers were associated with improved paresthesia outcomes (ß=-0.9520,p = 0.03). This review emphasized the enhanced efficacy of the 1470 nm device over the 980 nm device, regardless of fiber type. Radial fibers showed promise for improved paresthesia outcomes, suggesting similar safety profiles for both systems. Conclusive remarks on pain outcomes were impeded by data limitations.

Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for hemorrhoidal disease: a systematic review and meta-analysis.

BACKGROUND: We conducted a systematic review to assess the safety and efficacy of Aluminum potassium sulfate and tannic acid (ALTA) sclerotherapy for the treatment of hemorrhoidal disease. METHODS: Our study was conducted in accordance with the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020. Primary endpoints included overall recurrence and type of recurrence while secondary endpoints included postoperative complications, reintervention, presence of rectal ulcer, rectal stricture, defecation abnormalities and perianal abscess. Α regression analysis, where the percentage of patients with grade II, III and IV hemorrhoidal disease was used as a covariate, was also performed. RESULTS: Twelve studies with 4249 patients met all the inclusion criteria and were eventually included. The crude and pooled estimates of the overall recurrence and complications by the end of follow-up were 10% (95% CI, 6.52%-14.08%) and 5.20% (95% CI, 2.59%-8.52%), respectively. Regression analysis displayed no correlation between recurrence and the grade of hemorrhoid disease II, ß= -0.0012 (95% CI, -0.0074 to 0.0049) (p = .64), grade III ß= -0.0006 (95% CI, -0.0056 to 0.0045) (p = .79) and grade IV ß = 0.0025 (95% CI, -0.0075 to 0.0124). However, a trend suggestive of increased recurrence was observed in patient populations with a higher proportion of grade IV disease. CONCLUSION: ALTA sclerotherapy may be a safe and viable alternative for patients with hemorrhoidal disease. Long-term follow-up and high-quality randomized controlled trials will help define the place of ALTA sclerotherapy in the armamentarium of treatment of hemorrhoids.

A systematic review and meta-analysis of GLASS staging system in the endovascular treatment of chronic limb-threatening ischemia.

OBJECTIVE: The objective of this study was to evaluate the application of the Global Anatomic Staging System (GLASS) in the endovascular treatment of chronic limb-threatening ischemia (CLTI). METHODS: We performed systematic research between June 2019 and February 2022, including articles investigating the relationship of GLASS classification with the outcomes of endovascular interventions in the treatment of CLTI. Data from the included studies were pooled and meta-analyzed. The primary endpoints were limb-based patency (LBP) at 1-year follow-up and immediate technical failure (ITF). Secondary endpoints included major amputation. We performed subgroup analysis between studies that reported on calcium modifier inclusion during GLASS classification and studies that did not. RESULTS: Eleven studies, including 1816 patients (1975 limbs) met the inclusion criteria. The pooled ITF rates for GLASS stages I, II, and III are 5.52% (95% confidence interval [CI], 3.74%-8.07%), 7.39% (95% CI, 5.32%-10.18%), and 21.07% (95% CI, 13.48%-31.39%) respectively. The pooled LBP for GLASS stages I, II, and III are 68.43% (95% CI, 53.44%-80.37%), 41.52% (95% CI, 18.91%-68.37%), and 38.64% (95% CI, 19.83%-61.57%). The relative risk (RR) for ITF regarding composite GLASS I and II stages vs GLASS III is 3.96 (95% CI, 1.96-7.98). The RR for LBP of GLASS I and II versus GLASS stage III is 1.51 (95% CI, 0.86-2.64). Pooled major amputation rates for the composite GLASS I, II and GLASS III stages are 7.62% (95% CI, 5.44%-10.58%) and 15.43% (95% CI, 11.72%-20.05%) respectively, whereas the RR between GLASS I, II, and GLASS III stages is 1.84 (95% CI, 1.18-2.87). CONCLUSIONS: Our study demonstrated that patients with CLTI undergoing endovascular interventions classified as GLASS stage III had almost a four-fold risk increase for ITF and 1.84 times the risk of major amputation compared with stages I and II. Additionally, GLASS classification correctly predicted ITF for all three stages, whereas it failed to predict stage I and II LBP outcomes. Safe conclusions regarding LBP cannot be drawn due to the low quality and small number of the included studies, necessitating further research. Furthermore, we displayed the importance of calcium moderator inclusion in the accurate classification of GLASS.

A systematic review aggregated data and individual participant data meta-analysis of percutaneous endovascular arteriovenous fistula.

OBJECTIVE: To assess the short-term and mid-term safety and efficacy of percutaneous endovascular arteriovenous fistula (pAVF) creation. METHODS: A systematic search was implemented corresponding to the PRISMA 2020 and the PRISMA for individual participant data (IPD) systematic reviews 2015. Aggregated data from the included studies were obtained and meta-analyzed regarding both the overall pAVF efficacy and the comparison of pAVF with surgical AVF (sAVF). We performed a two-stage IPD meta-analysis for studies comparing pAVF and sAVF regarding primary and secondary patency. Primary end points included primary patency, secondary patency, and functional cannulation. RESULTS: Eighteen studies with 1863 patients were included. The overall pAVF, primary patency, secondary patency, functional cannulation and abandonment rates were 54.01% (95% confidence interval [CI], 40.69-66.79), 87.27% (95% CI, 81.53-91.42), 79.94% (95% CI, 65.94-89.13), and 15.58% (95% CI, 7.77-28.79), respectively. The overall pAVF, technical success, maturation, reintervention per person-years and mean time to maturation rates were 97.08% (95% CI, 95.66-98.04), 82.13% (95% CI, 71.64-89.32), 0.80 (95% CI, 0.34-1.47), and 58 days (95% CI, 36.64-92.82), respectively. Secondary patency and pAVF abandonment rates where the only end points were WavelinQ and Ellipsys displayed statistically significant differences of 81.36% (95% CI, 76.15-85.65) versus 92.12% (95% CI, 87.94-94.93) and 32.54% (95% CI, 22.23-44.87) versus 11.13% (95% CI, 4.82-23.65). An IPD meta-analysis of hazard ratios for primary and secondary patency between pAVF and sAVF were 1.27 (95% CI, 0.61-2.67) and 1.25 (95% CI, 0.87-1.80), favoring sAVF. Statistically significant difference between pAVF and sAVF were solely depicted for steal syndrome relative risk of 5.91 (95% CI, 1.12-31.12) and wound infections relative risk of 4.19 (95% CI, 1.04-16.88). Plotting of pAVF smoothed hazard estimate displayed an upsurge in the probability of primary patency failure at 1 month after the intervention. CONCLUSIONS: Although we failed to identify statistically significant differences between pAVF and sAVF regarding any of the primary end points, pAVF displayed a decreased risk for steal syndrome and wound infection. Although both the Ellipsys and WavelinQ devices displayed satisfactory secondary patency rates, Ellipsys demonstrated a statistically significant improved rate compared with WavelinQ. Additionally, and despite the borderline statistically insignificant inferior reintervention rate displayed by WavelinQ, one in three WavelinQ pAVFs resulted in abandonment. The introduction of pAVF as a treatment modality calls for standardized definition adjustment and improvement.

A Systematic Review Network Meta-Analysis and Meta-Regression on Surgical and Endovenous Interventions for the Treatment of Lower Limb Venous Ulcer Disease.

BACKGROUND: Venous leg ulcer (VLU) disease constitutes the most severe form of chronic venous insufficiency. We performed a network meta-analysis and meta-regression to investigate the efficacy and safety of the various available interventions in the treatment of VLU. METHODS: We conducted a systematic research corresponding to the instructions by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for studies reporting on surgical or endovenous interventions for the treatment of VLU. Following data extraction, we performed a Bayesian network meta-analysis and meta-regression. Primary endpoints included VLU healing and recurrence. The secondary endpoint was postintervention complications. RESULTS: Seventeen studies evaluating the impact of compression monotherapy, radiofrequency ablation (RFA), endovenous laser ablation (EVLA), sclerotherapy, and saphenous vein surgery on VLU treatment, consisting of 2156 patients (2186 VLU) were included. When compared to compression monotherapy, RFA was the only treatment displaying a statistically-significant impact on ulcer healing, odds ratio (OR) 5.80 (95% credibility interval (CI): 1.08-35.07), while EVLA, RR 0.06 (95% CI: 0.00-0.57), sclerotherapy, RR 0.07 (95% CI: 0.00-0.68) and RFA, RR 0.12 (95% CI: 0.01-0.91) were the 3 interventions reducing VLU recurrence. EVLA (SUCRA, 69.65) ranked as the most efficient intervention concerning ulcer recurrence reduction. Regarding postintervention complications, EVLA was the only intervention displaying a statistically-significant increased risk compared to compression monotherapy, RR 14.3 (95% CI: 2.03-172.56). Meta-regression analysis exploring the impact of perforator treatment on VLU failed to predict healing, ß = -0.27 (95% CI: -2.55 to 1.85), recurrence, ß = -0.02 (95% CI: -2.96 to 2.75) and complication outcomes, ß = -0.089 (95% CI: -3.13 to 2.85). During sensitivity analysis, RFA and sclerotherapy failed to sustain their effects on ulcer healing and ulcer recurrence, respectively. In addition, sclerotherapy displayed statistically-significant inferior outcomes compared to both EVLA and RFA regarding ulcer recurrence. CONCLUSION: This is the first network meta-analysis examining the effect of various interventions on VLU disease. While we have demonstrated the efficacy of RFA and ELVA in ulcer recurrence prevention, our results regarding the impact of RFA and sclerotherapy on VLU healing and recurrence, respectively, should be interpreted with caution. In addition, this review raises questions concerning the value of surgery and perforator interventions in the treatment of VLU. Further research through randomized controlled trials is required. CLINICAL IMPACT: Our review has revealed the significant efficacy of endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in effectively reducing the incidence of ulcer recurrence when compared to compression monotherapy. These outcomes hold the potential to provide relevant insights to both medical practitioners and patients, thereby informing a more prudent and enlightened decision-making approach. Such informed decisions, aimed at mitigating the recurring occurrence of venous leg ulcers, carry profound significance given the considerable socioeconomic implications associated with this medical condition.

Interventions For the Treatment of Lower Limb Telangiectasias and Reticular Veins: A Systematic Review and Network Meta-Analysis.

OBJECTIVE: To assess the safety and efficacy of available interventions in the treatment of lower limb reticular veins and telangiectasias. DATA SOURCES: An electronic search was performed on Scopus, Embase, and Google scholar. REVIEW METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Following data extraction and processing, a Bayesian network meta-analysis and meta-regression was undertaken. The primary endpoint was telangiectasia and reticular vein clearance. RESULTS: Nineteen studies, 16 randomised controlled trials and three prospective case series, including 1 356 patients and 2 051 procedures, were finally incorporated. All interventions, apart from 0.5% sodium tetradecyl sulphate (STS) and 0.25% STS displayed statistically significantly superior telangiectasia and reticular vein clearance compared with normal saline (N/S), Meta-regression analysis employing the type of the venule treated (telangiectasia or reticular vein) as a covariable, revealed a positive correlation between Nd:YAG 1064 nm laser and telangiectasia clearance (ß = 1.38, 95% CI 0.56 - 2.14). Further exploration unveiled the superiority of Nd:YAG 1064 nm in the treatment of telangiectasias compared with all included interventions except 72% chromated glycerin (CG). STS 0.25% increased the risk of hyperpigmentation compared with all interventions except 0.5% STS, and 1% polidocanol. CG 72% decreased the risk of matting compared with polidocanol foam (risk ratio [RR] 0.14, 95% CI 0.02 - 0.80) and STS (RR 0.31, 95% CI 0.07 - 0.92). Non-statistically significant differences were identified between interventions regarding pain outcomes. CONCLUSION: This network meta-analysis has demonstrated a proportional relationship between sclerosant potency and side effect occurrence in the treatment of telangiectasias and reticular veins and the superiority of laser therapy compared with injection sclerotherapy in treating telangiectasias. The transition of telangiectasia and reticular vein treatment from highly potent detergent solutions to equally effective but milder sclerosants could potentially reduce undesirable adverse events.

Endovenous thermal ablation in the treatment of large great saphenous veins of diameters > 12 mm: A systematic review meta-analysis and meta-regression.

BACKGROUND: We sought to assess the safety and efficacy of endovenous thermal ablation (EVTA) in treating large great saphenous veins (GSV) > 12 mm in diameter. METHODS: We performed a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 for comparative and noncomparative studies depicting EVTA in the treatment of GSV > 12 mm. Primary endpoints included GSV occlusion, technical success, deep vein thrombosis (DVT), and endovenous heat-induced thrombosis (EHIT). We conducted a comparative analysis between GSV > 12 mm and < 12 mm and a meta-regression analysis for two sets of studies, one including the whole dataset, containing treatment arms of comparative studies with GSV < 12 mm and one exclusively for GSV > 12 mm. RESULTS: Seven studies, including 2564 GSV, depicting radiofrequency (RFA) and endovenous laser ablation (EVLA) were included. GSV > 12 mm occlusion, technical success, DVT, and EHIT estimates were 95.9% (95% CI: 93.6-97.8), 99.9% (95% CI: 98.9-100.0), 0.04% (95% CI: 0.0-3.4), and 1.6% (95% CI: 0.3-3.5). Meta-regression revealed a negative association between GSV diameter and occlusion for both the whole dataset (p < 0.01) and the > 12 mm groups (p = 0.04), GSV diameter and technical success for both groups (p < 0.01), (p = 0.016), and GSV diameter and EHIT only for the whole dataset (p = 0.02). The comparative analysis between GSV < 12 mm and GSV > 12 mm displayed an occlusion estimate of OR 1.79 (95% CI: 1.25-2.56) favoring small GSV. CONCLUSION: Whereas we have displayed excellent occlusion and technical success results for the EVTA of GSV > 12 mm, our analysis has illustrated the unfavorable impact of GSV diameter on occlusion, technical success, and EHIT outcomes regardless of the 12 mm threshold. Potential parameter or device adjustments in a diameter-oriented fashion could further enhance outcomes.

Single Branched Endografts for the Preservation of Left Subclavian Artery in the Treatment of Zone II Thoracic Aortic Lesions a Systematic Review and Meta-Analysis.

BACKGROUND: We investigated the safety and feasibility of single branched endografts in the treatment of zone II thoracic endovascular aortic repair (TEVAR). METHODS: We performed a systematic research on Medline, Scopus and EMBASE for articles published up to February 2023. Primary end points included technical success, 30-day mortality, stroke and spinal cord injury (SCI) as well as unassisted left subclavian artery (LSA) branch patency by the end of follow-up. Secondary end points included early 30-day and persistent endoleaks, new onset dissection and reintervention by the end of follow-up. RESULTS: Fourteen studies, three prospective case series and 11 retrospective case series comprised of 727 patients were finally included. The pooled technical success and 30-day mortality rates were 94.86 % (95% confidence interval (CI): 90.95-97.86) and 0.14% (95% CI: 0.00-0.87). The 30-day stroke and SCI rates were 0.45% (95% CI: 0.00-1.39) and 0.08% (95% CI: 0.00-0.99), respectively, while the unassisted LSA branch patency estimate was 99.12% (95% CI: 97.97-99.86). The early 30-day and persistent endoleak rates were 5.19% (95% CI: 2.45-8.65) and 2.57% (95% CI: 0.36-6.02), whereas new onset dissections and reinterventions estimates were 0.94% (95% CI: 0.17-2.11) and 2.40% (95% CI: 0.41-5.42). CONCLUSIONS: While we have displayed the safety and feasibility of single branched endografts in the treatment of zone II thoracic aortic lesions, physicians should be aware of the persistency displayed by early type I endoleaks eventually requiring reintervention. The variations in device and lesion characteristics accompanied by the short-term follow-up presented in our review do not allow for definite conclusions to be drawn, necessitating further research through high-quality randomized controlled trials.

A Systematic Review and Meta-Analysis of Laparoscopic Ligation of the Inferior Mesenteric Artery for the Treatment of Type II Endoleaks.

Objectives: Type II endoleak (T2E), often generated by persistent retrograde flow through the inferior mesenteric artery (IMA) is the most frequent complication following endovascular aortic aneurysm repair (EVAR). T2E treatment revolves around transarterial and translumbar embolization of the feeding artery and/or sac, with mediocre results. The aim of this study is to assess the safety feasibility and efficacy of laparoscopic IMA ligation for the treatment of T2E. Methods: We conducted a systematic electronic research on Medline, Scopus, EMBASE, and Cochrane Library according to Preferred Reporting Items for Systematic Review and Meta-Analysis protocol (PRISMA) for articles published up to February 2022, describing laparoscopic IMA ligation for the treatment of T2E. Publications describing hand assisted or prophylactic IMA ligation were excluded. A metanalysis was performed utilizing both the random and common effects model and the DerSimonian and Laird method. Additionally, we carried out a post hoc power analysis. Results: Fifteen studies, including one prospective case series (CS), five retrospective CS and nine case reports, including 33 patients (91% male) met the inclusion criteria. The mean abdominal aortic aneurysm diameter at the time of diagnosis was 58.8 mm. The mean operational duration was 117.5 minutes. The mean follow-up for the included studies was 17 months. The mean reported time of T2E identification was 9.1 months post-intervention, while the mean reported aneurysmal sac diameter increase at the time of diagnosis was 11.5 mm. T2E type a (T2aE) and type b (T2bE) patterns were 57.6% and 42.4% respectively. Six CS incorporating 24 patients were included in the meta-analysis. The pooled technical success and postoperative mortality rates are 100% (95% CI: 93.13-100), ( I 2 = 0.0%, p = 0.99) (power = 99%) and 0.00% (95% CI: 0.00-6.87) ( I 2 = 0.0%, p = 0.99). The pooled reintervention and conversion to open surgical repair rates are 15.08% (95% CI: 0.79-37.28), ( I 2 = 0.0%, p = 0.66) (power = 13.6%), and 0.69% (95% CI: 0.00-14.80) ( I 2 = 0.0%, p = 0.99) (power = 7.05%) respectively. Conclusions: We demonstrated the safety and feasibility of IMA ligation for the treatment of T2E. Definitive conclusions about its efficacy cannot be drawn due to underpowered results warrantying further research. Identification and proper classification of T2E remain an obstacle affecting treatment outcomes and reintervention rates throughout the entire spectrum of available treatments.

A Systematic Review and Meta-Analysis of Carotid Artery Stenting for the Treatment of Cervical Carotid Artery Dissection.

OBJECTIVE: To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES: Systematic review using Medline, Scopus, EMBASE, and the Cochrane Library. REVIEW METHODS: A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement. Data from the eligible studies were extracted and meta-analysed. Primary endpoints included post-operative mortality, cerebrovascular events (CEs), and modified Rankin Score for neurological disability (mRS) at 90 days. Subgroup analyses were performed between stenting of spontaneous and traumatic CAD, primary stenting vs. stenting after failed medical therapy (FMT), and stenting of CAD in the presence of tandem occlusions vs. stenting of isolated extracranial CAD. RESULTS: Twenty-four studies with 1 224 patients were included. Pooled post-operative mortality, CE, and mRS 0 - 2 rates were 1.71% (95% confidence interval [CI] 0.83 - 2.80), 6.45% (95% CI 2.80 - 11.10), and 76.13% (95% CI 64.15 - 86.50), respectively. The pooled stroke rate was 2.16% (95% CI 0.0 - 6.64). Spontaneous vs. traumatic CAD mortality rates were 3.20% (95% CI 1.80 - 4.88) and 0.00% (95% CI 0.00 - 1.59) while CE rates were 14.26% (95% CI 6.28 - 24.36) and 1.64% (95% CI 0.0 - 6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95% CI 0.0 - 5.63) and 0.0% (95% CI 0.0 - 2.24), while CE rates were 5.02% (95% CI 0.38 - 12.63) and 3.33% (95% CI 0.12 - 9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95% CI 1.76 - 10.83) and 0.23% (95% CI 0.0 - 1.88), respectively, while CE rates were 15.28% (95% CI 6.23 - 26.64) and 1.88% (95% CI 0.23 - 4.51). The methodological index for non-randomised studies score was 8.66 (low). CONCLUSION: Both primary stenting and stenting of spontaneous CAD yielded unfavourable results with respect to stent thrombosis and stroke rates. Conversely, stenting following FMT had acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.

A Systematic Review Aggregated Data and Individual Participant Data meta-Analysis of Spot Stenting in the Treatment of Lower Extremity Peripheral Arterial Disease.

BACKGROUND: The treatment of infrainguinal peripheral arterial disease often involves complex lesions requiring stent implantation. It is common knowledge that stent length is a negative predictor for restenosis. We investigated the efficacy and safety of spot stenting for the treatment of femoropopliteal lesions. METHODS: We carried out a systematic review for articles published by December 2021 regarding spot stenting in the treatment of peripheral arterial disease. Primary endpoints included primary patency (PP) and freedom from target lesion revascularization (TLR) 12 months postoperatively. We performed a meta-analysis of aggregate data for PP, TLR and technical success and a subgroup analysis between devices dedicated to spot stenting and conventional devices. Following the individual participant data (IPD) extraction, we performed a 2 stage time to event IPD meta-analysis for PP and TLR. Plotting of hazard estimates was performed by applying the Epanechnikov Kernel function. RESULTS: Five studies with 818 patients, 965 lesions and a mean lesion length of 169.2 mm were included. Chronic total occlusions comprised 51.7% of the treated lesions while, 80% of the lesions involved the popliteal artery. The pooled PP 12 months post-operatively is 80.72% (95% confidence interval [CI]: 77.67-83.45) (I2 = 36%), 95% prediction interval (PI) (67.94-89.00). The subgroup analysis between devices dedicated to spot stenting and conventional devices produced similar results of 80.93% (95% CI: 77.17-84.19) (I2 = 0%) and 80.30% (95% CI: 74.72-84.90) (I2 = 62%), respectively. The pooled TLR rate is 13.06% (95% CI: 10.69-15.86) (I2 = 53%). The pooled technical success rate is 98.77% (95% CI: 97.50-99.40) (I2 = 18%). The IPD meta-analysis produced statistically significant results favoring spot stenting over long stenting for both primary endpoints. Primary patency hazard ratio (HR) 2.04. (95% CI: 1.25-3.32) (I2 = 0%, t2 = 0). TLR, HR 1.97 (95% CI: 1.02-3.79) (I2 = 0%, t2 = 0). Plotting of hazard estimates produced diametrically opposite courses for the spot and long stenting curves. The hazards cross over at about 6 months, and at about 10 months when long stenting group faces the highest risk for loss of patency, spot stenting hazard reaches near zero values. The curves for TLR portray similar findings. CONCLUSIONS: Spot stenting is a safe and effective strategy for the treatment of femoropopliteal arterial disease with acceptable short and mid-term primary patency and freedom from TLR rates. Long stenting of the femoral artery doubles the risk of patency loss and TLR compared to spot stenting. The risk of patency loss and TLR in femoral artery spot stenting appears 4 months after the intervention and reaches near zero values at 8 months.

Acute leukemia presenting as acute lower limb ischemia.

Objectives: Acute lower limb ischemia (ALLI) is a common vascular emergency. However, ALLI presenting as the initial symptom of acute leukemia (AL) is scarce. Here we present a case of ALLI in the setting of acute myeloid leukemia (AML) while systematically reviewing the current literature to withdraw conclusions about the management, prognosis, and treatment for this atypical presentation of AL. Methods: We conducted a systematic electronic research according to Preferred Reporting Items for Systematic Review and Meta-Analysis protocol (PRISMA) for articles published from January 1981 up to January 2021 concerning ALLI in the setting of acute leukemia (AL). Patients' baseline characteristics were recorded and nine outcomes of interest were studied. Results: Twenty-six individuals, 16 males with a mean age of 46.3 years (±20) were included in this review. The diagnosis included 13 AML patients (50%), 11 acute promyelotic leukemia (APL) (42.3%) and two acute lymphoblastic leukemias (ALL) (7.7%). Treatment varied among nine different regimens. Four patients were treated with chemotherapy alone (15.4%), four with thrombectomy alone (15.4%), and 11 with a combination of chemotherapy and thrombectomy (42.3%). Eight major amputations were recorded (30. 8%). Thirty-day mortality was 35.7%. Forty-eight peripheral thrombotic events were recorded with 12 patients suffering recurrent thrombotic events. Conclusion: ALLI as the presenting symptom of AL is a rare condition that carries significant mortality and amputation rates. Timely diagnosis is crucial concerning short-term survival and limb salvage. APL, despite being the rarest form of AL, represented a significant proportion of the patient population in this review. The role of leukostasis in the disease's progression and the efficacy of leukapheresis as a treatment regimen should be further investigated through case-control studies.

A systematic review and meta-analysis of the streamliner multilayer flow modulator stent for treatment of complex aortic lesions.

OBJECTIVE: We evaluated the safety and efficacy of multilayer flow modulator (MFM) stents (Cardiatis, Isnes, Belgium) for the treatment of complex aortic lesions. METHODS: A systematic electronic research was conducted for studies reported from December 2008 to May 2020. Data extracted from 15 eligible case series (CS) were appropriately pooled and analyzed in a meta-analysis. The patient baseline characteristics were recorded, and 16 outcomes of interest were studied. The primary end points included 30-day all-cause and aneurysm-related mortality, aneurysm-related mortality at 1 year, vessel patency, and any endoleaks, ruptures, reinterventions, and aneurysm exclusion at the end of follow-up. RESULTS: A total of 39 studies (15 CS and 24 case reports), involving 429 patients, met the inclusion criteria. Overall, 436 lesions were treated, and 1521 aortic branches were covered by the multilayer stent. The mean follow-up for the 15 CS with 404 patients was 14.6 months. Compliance with the instructions for use was reported by eight CS, with 75% of the procedures performed within the instructions for use. However, 41% of the patients reported by 12 CS had undergone a previous aortic intervention. The pooled 30-day all-cause and 30-day aneurysm-related mortality rates were 0.56% (95% confidence interval [CI], 0.00%-2.54%) and 0.00% (95% CI, 0.00%-0.80%), respectively. The pooled aneurysm-related mortality at 1 year of follow-up was 5.25% (95% CI, 0.07%-14.91%). The pooled vessel patency at the end of follow-up was 99.12% (95% CI, 97.73%-99.93%). The pooled reintervention and endoleak rates at the end of follow-up were 10.94% (95% CI, 3.64%-20.67%) and 10.70% (95% CI, 4.45%-18.66%), respectively. The crude spinal cord ischemia and renal failure rates were 0.69% and 1.8%, respectively. CONCLUSIONS: The results from the present review and meta-analysis have indicated the safety and efficacy of MFM stents for treating challenging aortic pathologic lesions when used as first-line treatment and within the instructions for use. The almost zero pooled 30-day all-cause and aneurysm-related mortality rates combined with the low crude spinal cord ischemia and renal failure rates indicate the use of MFM stents is a good treatment option for complex aortic lesions in the short- and mid-term periods. The lack of long-term follow-up warrants further research concerning the efficacy of the device in the long term.

Management of the Pediatric Pulseless Supracondylar Humeral Fracture: A Systematic Review and Comparison Study of "Watchful Expectancy Strategy" Versus Surgical Exploration of the Brachial Artery.

BACKGROUND: Pulseless hand after a supracondylar humeral fracture (SHF) in children is well known in the bibliography. Although things are clearer in the management of a "pale pulseless hand," controversy still exists about the "pink pulseless hand" (PPH). METHODS: We reviewed the literature from the electronic database PubMed for studies with main object the vascular injuries after SHF in children and especially the pulseless hand. The primary search terms were "supracondylar humeral fracture" and "vascular injuries". In our final study, 16 articles were gathered and analyzed. RESULTS: We collected 608 pulseless SHFs, regardless of the vascular status, 203 PPHs, and 109 pale pulseless hands. We compared two different strategy methods when the hand remained pulseless after the reduction and fixation of the fracture: (1) the close observation strategy and (2) the surgical exploration of the artery. The close observation strategy was the treatment of choice in PPH, whereas the surgical exploration of the brachial artery was mostly performed in pale pulseless hands. CONCLUSIONS: Closed reduction and fixation of the fracture should be the priority in all pulseless SHFs, both pink and pale. In poorly perfused pale hands, after the reduction and fixation of the fracture, there is a chance that radial pulse may return (we found that this chance is approximately 30%). If not, immediate surgical exploration of the artery is strongly indicated. In well-perfused pink hands, the traditional dogma of "watchful waiting" should not be revisited as long as no signs of deterioration of the vascular status appear. LEVEL OF EVIDENCE: Level I-Systematic review of level I studies.

A critical appraisal of endovascular stent-grafts in the management of abdominal aortic aneurysms.

Endovascular repair of abdominal aortic aneurysms has widely replaced the open surgical repair due to its minimal invasive nature and the accompanying lower perioperative mortality and morbidity. During the past two decades, certain improvements and developments have provided a wide variety of endograft structural designs and geometric patterns, enabling the physician to approach a more patient-specific treatment of AAA. This review presents the currently available aortic endografts and describes the clinical, technical and mechanical characteristics of them.

Vacuum-assisted closure therapy for vascular graft infection (Szilagyi grade III) in the groin-a 10-year multi-center experience.

The aim of the study was to evaluate the benefit of vacuum-assisted closure (VAC) therapy in the management of deep, alloplastic graft infections (Szilagyi grade III) in the groin. From 2000 to 2009, we identified and included in our study 72 deep inguinal infections in 68 patients, involving native as well as synthetic graft or patch material. There were 29 early graft infections (<30 days after implantation) and 43 late infections (≥30 days after implantation). Among these, 17 cases involved native grafts/patches (12 grafts and 5 patches), while 55 cases involved non-native grafts/patches [26 polytetrafluorethylene (PTFE) grafts and 24 Dacron grafts (Haemashield, Meadox Medical, Boston Scientific Corporation, Natick, NY; Gelsoft graft, Vascutek, Inchinnan, Renfrewshire, Scotland, UK; Intervascular, Mahwah, NJ); INVISTA, and 5 Vascu-Guard(™) bovine pericardial patches; Synovis Surgical Innovation]. All patients were treated with multiple wound debridements, graft salvage, sartorius myoplasty, intravenous antibiotics and VAC therapy until thorough surface healing was achieved. Exclusion criteria were an alloplastic graft infection with proximal expansion above the inguinal ligament, blood culture positive for septicaemia or septic anastomotic herald or overt bleeding. Nine months after initiation of therapy, overall, graft/patch salvage was achieved in 61 of 72 (84·7%) cases. Of the native graft/patch group, infected graft material was replaced with an autogenous great saphenous vein graft or patch in four patients (23·5%). In the non-native group, vein or synthetic graft preservation without revision was achieved in 48 of 55 (87·3%) patients. The mean duration of VAC therapy was 16 ± 7·7 days, and postoperative mean hospital stay was 25·3 ± 8·5 days. In 23 of 72 (31·9%) cases, a secondary closure of the wound was achieved; in the other 49 cases, wound healing was achieved by meshed split-thickness skin grafting. Mean wound healing time for all wounds was 24·3 ± 12·5 days. Specific complications during VAC therapy were wound fluid retention in 2 cases and an increased need for analgesics in 12 cases (16·66%). Negative pressure wound therapy (NPWT) has been reported to be useful in the treatment of severe wound infections. Even in the presence of synthetic vascular graft material, NPWT can greatly simplify challenging wound-healing problems leading to wound dehiscence and its sequelae. Our long-term experience demonstrates the safety and effectiveness of VAC therapy in the management of deep graft infections.

Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis.

PURPOSE: Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. METHODS: A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. RESULTS: Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. CONCLUSIONS: Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.