Enhancing identification and treatment of patients with concomitant chronic venous insufficiency and diabetes mellitus. A modified Delphi study from the CODAC (ChrOnic venous disease and Diabetes Advisory Council) group.

BACKGROUND: Chronic venous insufficiency (CVI) and diabetes mellitus (DM) pose significant burdens to patients and healthcare systems. While the two diseases share a number of commonalities in risk factors and pathophysiology, they are often assessed and managed separately. This can lead to a worsening of comorbidities and limitations in a patient's quality of life. This project aims to develop recommendations to enhance the identification and treatment of patients with concomitant CVI and DM. METHODS: Using a modified Delphi method, a panel of experts developed 38 Likert Scale and two multiple choice questions across six key themes. These were used to form an online survey which was disseminated through a convenience sampling approach to CVI and DM healthcare professionals across Europe, Central America, South America, and the Middle East. The threshold for consensus was set at ≥75%. RESULTS: A total of 238 responses were received. 27/38 statements attained >90% agreement, nine of 38 attained between 75-90%, and two failed to meet the threshold (<75%). The awareness around the impact of the two diseases was high, but a gap was highlighted in the identification of patients with concomitant CVI and DM. CONCLUSIONS: The high level of agreement shows that healthcare professionals are aware of the gaps in identification and treatment of patients with concomitant CVI and DM, and of the need to approach this as a combined therapy area. An algorithm is proposed to help the identification of at-risk patients and to provide recommendations on the management of patients with concomitant disease.

Risk Factors, Dynamics, and Clinical Consequences of Aortic Neck Dilatation after Standard Endovascular Aneurysm Repair.

OBJECTIVE: Aortic neck dilatation (AND) occurs after endovascular aneurysm repair (EVAR) with self expanding stent grafts (SESs). Whether it continues, ultimately exceeding the endograft diameter leading to abdominal aortic aneurysm (AAA) rupture, remains uncertain. Dynamics, risk factors, and clinical relevance of AND were investigated after EVAR with standard SESs. METHODS: All intact EVAR patients treated from 2000 to 2015 at a tertiary institution were included. Demographic, anatomical, and device related characteristics were investigated as risk factors for AND. Outer to outer diameters were measured at a single standardised aortic level on reconstructed computed tomography (CT) images. RESULTS: A total of 460 patients were included (median follow up 5.2 years, interquartile range [IQR] 3.0, 7.7 years; CT imaging follow up 3.3 years, IQR 1.3, 5.4). Baseline neck diameter was 24 mm (IQR 22, 26) and increased 11.1% (IQR 1.5%, 21.9%) at last CT imaging. Endograft oversizing was 20.0% (IQR 13.6, 28.0). AND was greater during the first year (5.2% [IQR 0, 11.7]) decreasing subsequently (two to four years to 1.4%/year [IQR 0.0, 4.5%], p ≤ .001) and was associated with suprarenal fixation endografts (t value = 7.9, p < .001) and oversizing (t value = 4.4, p < .001). AND exceeding the endograft was 3.5% (95% CI 2.2% - 4.8%) and 14.4% (95% CI 11.0% - 17.8%) at five and eight years, respectively. Excessive AND was associated with baseline neck diameter (OR 1.2/mm, 95% CI 1.05 - 1.41) while the Excluder endograft had a protective effect (OR 0.15, 95% CI 0.04 - 0.58). Excessive AND was associated with type 1A endoleak (HR 3.3, 95% CI 1.1 - 9.7) and endograft migration > 5 mm (HR 3.1, 95% CI 1.4 - 6.9). CONCLUSION: AND after EVAR with SES is associated with endograft oversizing and radial force but decelerates after the first post-operative year. Baseline aortic neck diameter and suprarenal stent bearing endografts were associated with an increased risk of AND beyond nominal stent graft diameter. However, it remains unclear whether patient selection, differences in endograft radial force or the suprarenal stent are accountable for this difference.

Total Luminal Volume Predicts Risk after Endovascular Aneurysm Repair.

OBJECTIVE: Large aneurysm diameter represents a well known predictor of late complications after endovascular aneurysm repair (EVAR). However, the role of the thrombus free lumen inside the abdominal aortic aneurysm (AAA) sac is not clear. It was hypothesised that greater luminal volume represents a relevant risk factor for late complications after EVAR. METHODS: A retrospective cohort analysis was performed including all patients undergoing EVAR from 2005 to 2016 at a tertiary referral institution. Pre-operative AAA lumen volume was measured in centre lumen line reconstructions and patients were stratified into quartiles according to luminal volume. The primary endpoint was freedom from AAA related complications. Secondary endpoints were freedom from neck events (type 1A endoleak, migration >5 mm or any pre-emptive neck related intervention), iliac related events (type 1B endoleak or pre-emptive iliac related intervention), and overall survival. RESULTS: Four hundred and four patients were included: 101 in the first quartile (Q1; <61 cm3). Patients with higher luminal volumes had wider, shorter, and more angulated proximal necks. There were more ruptured AAAs, more aorto-uni-iliac implanted devices and patients outside neck instructions for use in the 4th quartile. Five year freedom from AAA related complications was 79%, 66%, 58% and 56%, respectively (p = .007). At five years, freedom from neck related events was 86%, 84%, 73%, and 71%, respectively, for the four groups (p = .009), and freedom from iliac related events was 96%, 91%, 88%, and 88%, respectively (p = .335). On multivariable analysis, luminal volume was an independent predictor of late complications (Q4 vs. Q1 - hazard ratio: 1.91, 95% confidence interval 1.01-3.6, p = .046). Overall survival at five years was not affected by lumen volume (p = .75). CONCLUSION: AAA luminal volume represents an important risk factor for AAA related complications. This information may be considered when deciding tailoring surveillance protocols after EVAR. However, larger studies are needed to validate this hypothesis.

Combination of endovascular revascularization and supervised exercise therapy for intermittent claudication: a systematic review and meta-analysis.

BACKGROUND: Peripheral arterial disease is a major health concern in the Western world, often treated with endovascular revascularization (EVR) or supervised exercise therapy (SET). In this systematic review and meta-analysis, we assessed the outcomes after combination treatment of EVR and SET, compared with EVR or SET alone. EVIDENCE ACQUISITION: We performed a systematic search of Embase, Medline, Web of Science, Cochrane Central and Google Scholar. Only randomized controlled trials comparing combination treatment with EVR or SET only, for patients with intermittent claudication due to femoropopliteal or aortoiliac peripheral artery disease, were included. Primary outcome was maximum walking distance (MWD) at 6 and 12 months' follow-up. Secondary outcomes included pain-free walking distance (PFWD), quality of life and adverse events. Pooled estimates of difference in walking distance between EVR plus SET, EVR only and SET only were calculated using random effects models. EVIDENCE SYNTHESIS: Our search yielded 812 articles, of which 7 were finally included in the systematic review. Three studies reported the outcomes of combination treatment versus SET and three more reported the outcomes of combination versus EVR. Follow-up ranged between 6 and 24 months. Combination treatment was associated with a greater MWD at 6 months compared to EVR only or SET only, with a standardized mean difference (SMD) of 0.86 (95% CI: 0.15, 1.57) and 0.41 (95% CI: 0.17, 0.66), respectively. At twelve months no significant difference in maximum walking distance was observed between combination treatment compared to EVR (SMD 0.96 [95% CI: -0.44, 2.37]) or SET (SMD 0.52 [95% CI: -0.17, 1.20]). Compared to EVR only, the combination treatment was associated with a greater PFWD walking distance at 12 months (SMD 0.73 [95% CI 0.01, 1.45]). Most studies reported only minor differences in quality of life in favor of the combination treatment, or no difference at all. CONCLUSIONS: Combination treatment of endovascular revascularization followed by SET shows a greater improvement in maximum walking distance at 6 months' follow-up compared to EVR only or SET only, while this difference was no longer present after 12 months.

Review on management and outcomes of ruptured abdominal aortic aneurysm in women.

Vascular procedures in general, and specifically abdominal aortic aneurysm (AAA) repair, are associated with worse outcomes in female patients. However, how female gender influences outcomes in the setting of aneurysm-rupture remains unclear and may be even more pronounced when compared to elective operations. In this report, the authors aim to review the literature regarding ruptured AAA repair in women. Using the traditional threshold for AAA of 30 mm of maximum diameter, the prevalence in women is lesser than in men. However, the true prevalence may be underestimated due to gender discrepancies in normal aortic diameter. For females, aneurysmal disease seems to manifest later, have more associated comorbidities, and rupture occurs at smaller aortic diameters. This has obvious implications for management. There is still no consensus over the optimal treatment for ruptured AAA in women. They are less frequently treated by endovascular aneurysm repair, possibly due to anatomical restrains. When feasible, endovascular repair shows better outcomes, at least in the short-term, and there is new evidence suggesting a lasting benefit as well. For open repair the results are consensually worse when compared to male counterparts. Finally, despite benefitting of apparently similar healthcare, women have a lower relative survival after rAAA repair when compared to men. Further investigation to determine the reasons of these discrepancies is warranted.