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The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction. [ABSTRACT FROM AUTHOR]

Currently, evidence is lacking for disease specific patient reported outcome measures (PROMs) for use in atherosclerotic carotid artery stenosis (either symptomatic or asymptomatic) submitted to carotid endarterectomy (CEA). This study aimed to obtain expert consensus on the most important items to include in a PROM designed to capture the impact of atherosclerotic carotid artery stenosis and its treatment on health related quality of life. A three round modified Delphi consensus study was performed. A mixed expert Delphi panel of doctors (international panel of dedicated vascular surgeons and neurologists) and patients (either symptomatic or asymptomatic patients meeting criteria for carotid artery revascularisation) was implemented. The aim was to obtain pre-defined consensus on items in four pre-defined domains: generic, quality of life, symptom related, and treatment related. Consensus was reached in rounds two and three with > 70% overall expert agreement. The experts agreed on 23 items (out of 49) which were distributed as follows: five in the generic, six in the quality of life, six in the symptom, and six in the treatment related domain. Interestingly, comparing the items that reached consensus in this study, with the generic and disease specific PROMs previously used in carotid artery disease investigation, the only constant items were "difficulty with walking" and "ability to perform daily activities" included in the symptom domain. Considering the items that reached expert consensus in the additional domains, emphasis was given to the impact of the diagnosis, treatment and follow up, and to fear or concern "about the future" and "about severe stroke". In the treatment domain emphasis was also attained on the side effects, long term patient satisfaction, and on the information provided regarding treatment options. As hard clinical outcomes become increasingly rare, assessment of the impact of CEA becomes increasingly difficult. The consensus reached provides a newly defined disease specific PROM that warrants independent validation in specific populations in the future. [ABSTRACT FROM AUTHOR]

Background: The optimal antithrombotic (antiplatelet or anticoagulant) treatment of patients undergoing extracranial carotid artery interventions is a subject of debate. The aim of this multidisciplinary document was to critically review the recommendations of current guidelines, taking into consideration the results of recendy published studies. Methods:The various antithrombotic strategies reported were evaluated for asymptomatic and symptomatic patients undergoing extracranial carotid artery interventions (endarterectomy, transfemoral carotid artery stenting [CAS] or transcarotid artery revascularization [TCAR]). Based on a critical review, a series of recommendations were formulated by an international expert panel. Results: For asymptomatic patients, we recommend low-dose aspirin (75-100 ing/day) or dopidogrel (75 mg/day) with the primary goal to reduce the risk of myocardial infarction and cardiovascular event rates rather than to reduce the risk of stroke. For symptomatic patients, we recommend dual antiplatelet treatment (DAFT) initiated within 24 h of the index event to reduce the risk of recurrent events. We suggest that following transfemoral CAS or TCAR, patients continue DAFT for 1 month after which a single antiplatelet agent is used. High level of evidence to support anticoagulant treatment for patients with carotid artery disease is lacking. Condusions: The antithrombotic treatment offered to carotid patients should be individualized, taking into account the presence of symptoms, the type of intervention and the goal of the treatment. The duration and type of DAFr (ticagrelor instead of dopidogrel) should be evaluated in future trials. [ABSTRACT FROM AUTHOR]

This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 – 0.85) and mortality rates (OR 0.41; 95% CI 0.31 – 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 – 14 and ≤ 7 vs. 8 – 14 days). Expedited CEA (vs. 3 – 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 – 1.8 vs. 1.8%; 95% CI 1.8 – 2.0, with no statistically significant difference. Expedited CAS (vs. 3 – 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 – 5.50). At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring. [ABSTRACT FROM AUTHOR]

A subset of patients submitted to carotid endarterectomy under regional anesthesia develop intraoperative neurologic deficit during carotid artery crossclamping related to critical cerebral perfusion, which may be owing to low flow or embolic phenomena. This subgroup is deemed prone to worse outcomes, which highlights its clinical relevance. The main aim of this study was to identify clinical and hematological predictors for intraoperative neurologic deficit. The secondary aim was to evaluate the perioperative prognostic value of postcarotid artery crossclamping manifestations of cerebral ischemia. Between January 2012 to January 2020, patients submitted to carotid endarterectomy under regional anesthesia in a tertiary referral center who presented intraoperative neurologic deficit were prospectively and consecutively included. This group constituted 8% of the total carotid endarterectomy performed in the center during this timeframe. The control group of patients was the subsequent patient submitted to carotid endarterectomy without intraoperative neurologic deficit in a 1:1 ratio. Blood samples were collected before surgery (<2 weeks). Propensity score matching was used to identify well-matched pairs of patients. A total of 180 patients were included, with 90 (50% of the cohort and 8% of total carotid endarterectomies) presenting intraoperative neurologic deficit associated to clamping. Mean age was 71.4 ± 9.27 years in the study group and 68.8 ± 8.36 years in the control group. The clinical variables presenting significance after multivariate analysis include: age (adjusted odds ratio: 1.04, 5-95% confidence interval, [1.003–1.078]; P =.034), obesity (adjusted odds ratio: 3.537 [1.445–8.658]; P =.006), lower ipsilateral carotid stenosis grade (adjusted odds ratio: 0.725 [0.525–0.997]; P =.049), and higher contralateral carotid stenosis grade (adjusted odds ratio: 1.266 [1.057–1.516]; P =.010). Red cell distribution width coefficient of variation demonstrated statistical significance in predicting intraoperative neurologic deficit with an adjusted odds ratio of 1.394 (1.076–1.805); P =.012. The 30-day stroke rate was significantly higher in the intraoperative neurologic deficit group, with an adjusted odds ratio of 5.13 (5–95% confidence interval [1.058–24.87]; P =.042) after propensity score matching. Postoperative complications (Clavien-Dindo ≥2) were also associated with intraoperative neurologic deficit (after propensity score matching adjusted odds ratio of 2.748 [5–95% confidence interval, 0.976–7.741]; P =.051). In this study, increased red cell distribution width coefficient of variation demonstrated value to predict intraoperative neurologic deficit. Additionally, age, obesity, a lower degree of ipsilateral carotid stenosis, and a higher degree of contralateral carotid stenosis also demonstrated ability to predict intraoperative neurologic deficit. Moreover, intraoperative neurologic deficit was an independent risk factor for 30-day stroke and postoperative complications Clavien-Dindo ≥2. [ABSTRACT FROM AUTHOR]

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. 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. 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). 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. [ABSTRACT FROM AUTHOR]

Background: Carotid Arterial Disease (CAD) and peripheral arterial disease (PAD) are atherosclerotic diseases. Adipose tissue (AT) and skeletal muscle (SM) are endocrine organs producing polypeptides with vascular effects. The main objective of this study is to characterize the AT and SM in PAD and CAD. It is also an aim to determine their role in central hemodynamics. Methods: A prospective, observational, case–control study is being conducted. The study group includes patients with PAD/CAD, with and without surgical indication. The control group includes subjects without PAD/CAD, with indication for elective non-vascular surgery, in order to allow access to samples of AT and SM. The quantity, histology and endocrine function of AT and SM are being determined. Results: From December 2018 to August 2019, 47 PAD were studied: 33 with Intermittent Claudication (IC) - (28 male; age: 67.24 ± 9.97 years) and 14 Critical Limb Ischemia (CLI) - (seven male; age: 69.21 ± 8.33 years). CLI patients have a lower quantity of SM and higher quantity of visceral and subcutaneous AT, determined on the CT scan, but these differences were not statistically significant. CLI had significant lower SM strength and density [muscle strength right hand: 22.62 ± 8.20 kgf IC vs. 16.38 ± 7.84 kgf CLI, p = 0,02; SM strength left hand: 21.98 ± 8.98 kgf IC vs. 16.37 ± 8.35 kgf CLI, p = 0.04; SM density: 20.44 ± 11.73 Hounsfield Units (HU) IC vs. 9.04 ± 2.47 HU CLI, p = 0.01]. Conclusion: This preliminary data suggests that CLI patients could have a SM dysfunction, inferred from hand grip strength and SM density. These results would be corroborated with the project development. The novelty of this research is the possibility to study the histology features and endocrine markers of AT and SM and to find an association with artery function, arteriosclerosis an atherosclerosis, in human. [ABSTRACT FROM AUTHOR]

Many endografts are currently available for standard endovascular repair of infrarenal abdominal aortic aneurysms. Comparison of long-term outcomes between devices might aid in this decision process, but comparative data are scarce. The purpose of this study was to report long-term clinical outcomes of two commercially available endoprosthesis, the Endurant (Medtronic Vascular, Inc, Minneapolis, Minn) and the Excluder (W. L. Gore & Associates, Flagstaff, Ariz) stent grafts. Patients undergoing standard endovascular repair from July 2004 to December 2011 in a single institution with the Endurant or the Low-Porosity Excluder endografts were eligible. Only patients treated for intact degenerative abdominal infrarenal aneurysms were included. All measurements were performed on center-lumen line reconstructions obtained on dedicated software. The primary end point was primary clinical success, defined as clinical success without the need for an additional or secondary surgical or endovascular procedure. Neck-related events (a composite of type IA endoleak, neck-related secondary intervention, or migration of >5 mm), neck morphology changes, renal function, and overall survival were secondary end points. The study included 277 patients (156 Endurants; 121 Excluders). The median follow-up was 5.8 years (range, 0.1-12.4 years) and did not differ between groups (P =.18). Patients treated with the Endurant stent graft had wider (neck diameter of >28 mm, 27.3% vs 1.7% P <.001]; neck diameter of 27 mm, [interquartile range (IQR), 24-29 mm] for Endurant and 24 mm [IQR, 22-25 mm] for Excluder; P <.001) and more angulated necks (β-angle of >60°, 26.7% vs 12.5%; P =.004). Oversizing was greater in the Endurant group (16% [IQR, 12%-22%] vs 13% [IQR, 8%-17%], respectively; P <.001). Patients were treated outside device instructions for use regarding proximal neck: 16.7% in the Endurant and 17.3% in the Excluder group (P =.720). The 7-year primary clinical success was 54.7% for the Endurant and 58.1% for the Excluder groups (P =.53). Freedom from neck-related events at 7 years was 76.7% for the Endurant and 78.8% for Excluder group (P =.94). The Endurant stent graft (hazard ratio [HR], 2.7; 95% confidence interval [CI], 1.3-5.8; P =.009) was an independent predictor of significant renal function decline. Neck dilatation was greater in Endurant-implanted patients (13% [95% CI, 2%-22%] vs 4% [95% CI, 0%-10%]; P <.001). Overall survival at 7 years was 61.4% in the Endurant and 50.3% (n = 50; standard error, 0.047) in the Excluder group (P =.39). This study reveals that durable and sustainable results can be obtained with either of these late generation devices. This finding suggests that careful planning and a tailored device selection taking into account the patient's anatomy are more relevant determinants than the graft model itself to obtain clinical success. The Endurant endoprosthesis seems to be associated with a higher rate of neck dilatation and faster decrease in the estimated glomerular filtration rate, but further studies with longer follow-up are necessary to determine the clinical relevance of these findings. [ABSTRACT FROM AUTHOR]

Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear. Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response. Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence. The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research. [ABSTRACT FROM AUTHOR]

To gather consensus among European educators about technical procedures that should be included in a future simulation based curriculum in vascular surgery. A three round modified Delphi survey was initiated among 189 key opinion leaders (KOL) from 34 countries across Europe who were identified according to their positions in the European Society for Vascular Surgery, the European Journal of Vascular and Endovascular Surgery , and Union Européenne des Médecins Spécialistes Section and Board of Vascular Surgery. The first round was a brainstorming phase to identify technical procedures that a newly qualified vascular surgeon should be able to perform. The answers were analysed qualitatively. The second round investigated how often the identified procedures are performed, the number of vascular surgeons that should be able to perform these procedures, whether the procedures pose a risk to the patients, and whether simulation based education (SBE) is feasible. In the third round, elimination and re-ranking of procedures were performed. Only procedures that gained more than 70% support were included. An international steering group consisting of open and endovascular surgeons and medical educators governed the process. Response rates in the three rounds were 75% (142/189), 89% (126/142), and 85% (107/126), respectively. In the final prioritised list of 30 technical procedures for SBE, the top five procedures focus on basic open vascular skills, basic endovascular skills, vascular imaging interpretation, femoral endarterectomy, and open peripheral bypass. Twenty-six procedures were eliminated, including peripheral pressure measurement, wound management, open management of complications, major amputations, and highly advanced endovascular skills. The prioritised list of technical procedures from this ESVS supported project could be used to guide planning and development of future SBE programs to meet the needs of vascular surgeons across Europe. [ABSTRACT FROM AUTHOR]

Purpose/Background: Sarcopenia (decrease of muscle mass and function) has been linked with atherosclerosis [1]. The EWGSOP2 updated consensus, uses low muscle strength as the primary indicator of sarcopenia [2]. It is acknowledged that strength is better than mass for predicting adverse outcomes [2]. Handgrip strength (HGS) is a simple assessment to estimate overall muscular strength [3]. and is associated with cardiovascular mortality [4]. Objective: Analyze the relationship between HGS and atherosclerotic disease (carotid artery disease + lower extremity artery disease). Methods: Prospective observation study was conducted from January to December 2019. The clinical and demographic data was recorded. Isometric HGS was measured with an adjustable handheld dynamometer (Jamar The higher value of each arm was used to classify the patient as sarcopenic or non-sarcopenic. Definition of sarcopenia: HGS <30 kgf in men and <20 kgf in women [5]. Results: 94 patients (aged 44–86 years) were analyzed: 64 sarcopenic and 30 non sarcopenic. Groups differed in the prevalence of diabetes and smoking status (Table 1). No differences were found in the carotid parameters analyzed (Table 1). There was, a difference in the prevalence of chronic limb-threatening ischemia (CLTI) in sarcopenic versus non-sarcopenic group (23.44% versus 6.67% p = 0.046). Importantly, binary logistic regression showed that diabetes (p = 0.014), and HGS (p = 0.027) have a significant effect on CLTI (Table 2). Conclusions: No relationship was found between sarcopenia (measured by HGS) and carotid atherosclerosis, differing from other authors [1, 6]. In this study, sarcopenic had a higher incident of diabetes and CLTI. Sarcopenia and diabetes are reciprocally related and may share a similar pathogenetic pathway [7-8, 9]. Table 1 Sarcopenia (n = 64) No Sarcopenia (n = 30) p Age (years) 69.81 ± 8.79 62.6 ± 8.61 p = 0.889 Male 47 (73.44%) 27 (90.00%) p = 0.067 Hypertension 51 (79.69%) 21 (70.00%) p = 0.301 Dyslipidemia 47 (73.43%) 18 (60.00%) p = 0.189 Smoking load (UMA) 24.42 ± 33.14 37.76 ± 31.8 p = 0.748 Smoker/Ex-smoker 33 (51.56%) 24 (80.00%) p = 0.013* Diabetes 28 (43.75%) 7 (23.33%) p = 0.049* Coronary disease 11 (17.19%) 4 (13.33%) p = 0.613 History of stroke 11 (17.19%) 3 (10.00%) p = 0.347 Total cholesterol (mg/dL) 158.16 ± 39.82 159.6 ± 30.72 p = 0.22 LEAD 43 (67.19%) 17 (56.67%) p = 0.275 Claudicants 28 (43.75%) 15 (50.00%) p = 0.615 CLTI 15 (23.44%) 2 (6.67%) p = 0.046* ABI right 0.83 ± 0.24 0.78 ± 0.29 p = 0.287 ABI left 0.81 ± 0.28 0.77 ± 0.23 p = 0.671 Right carotid artery stenosis 50–70 4 (6.25%) 2 (6.67%) p = 0.952 >70% 58 (90.63%) 27 (90.00%) p = 0.702 Light carotid artery stenosis 50–70 3 (4.79%) 1 (3.33%) p = 0.787 >70% 4 (6.25%) 2 (6.67%) p = 0.903 Area right carotid plaque (mm2) 21.22 ± 19.81 20.01 ± 17.04 p = 0.622 Average IMT- right (mm) 0.96 ± 0.41 0.88 ± 0.24 p = 0.159 Area left carotid plaque (mm2) 21.46 ± 18.73 21.47 ± 22.06 p = 0.948 Average IMT- left (mm) 0.93 ± 0.25 0.88 ± 0.29 p = 0.861 Table 2 Independent variables Categories a 95% CI p CLTI Diabetes 1.488 1.34–14.60 0.014 Higher HGS −0.888 0.846–0.990 0.027 [ABSTRACT FROM AUTHOR]

Mechanisms of procedural stroke after carotid endarterectomy (CEA) or carotid artery stenting are surprisingly underresearched. However, understanding the underlying mechanism could (1) assist in balancing the choice for revascularization vs conservative therapy, (2) assist in choosing either open or endovascular techniques, and (3) assist in taking appropriate periprocedural measures to further decrease procedural stroke rate. The purpose of this study was to overview mechanisms of procedural stroke after carotid revascularization and establish reporting standards to facilitate more granular investigation and individual patient data meta-analysis in the future. A systematic review was conducted according to the PRISMA statement. The limited evidence in the literature was heterogeneous and of low quality. Thus, no formal data meta-analysis could be performed. Procedural stroke was classified as hemorrhagic or ischemic; the latter was subclassified as hemodynamic, embolic (carotid embolic or cardioembolic) or carotid occlusion derived, using a combination of clinical inference and imaging data. Most events occurred in the first 24 hours after the procedure and were related to hypoperfusion (pooled incidence 10.2% [95% confidence interval (CI), 3.0-17.5] vs 13.9% [95% CI, 0.0-60.9] after CEA vs carotid artery stenting events, respectively) or atheroembolism (28.9% [95% CI, 10.9-47.0]) vs 34.3 [95% CI, 0.0-91.5]). After the first 24 hours, hemorrhagic stroke (11.6 [95% CI, 5.7-17.4] vs 9.0 [95% CI, 1.3-16.7]) or thrombotic occlusion (18.4 [95% CI, 0.9-35.8] vs 14.8 [95% CI, 0.0-30.5]) became more likely. Although procedural stroke incidence and etiology may have changed over the last decades owing to technical improvements and improvements in perioperative monitoring and quality control, the lack of literature data limits further statements. To simplify and enhance future reporting, procedural stroke analysis and classification should be documented preemptively in research settings. We propose a standardized form enclosing reporting standards for procedural stroke with a systematic approach to inference of the most likely etiology, for prospective use in registries and randomized controlled trials on carotid revascularization. [ABSTRACT FROM AUTHOR]

Endovascular aneurysm repair (EVAR) became an increasingly preferred modality for abdominal aortic aneurysm (AAA) repair both in elective AAA repair (el-EVAR) and EVAR of a ruptured AAA (r-EVAR) setting. Ruptured AAAs usually have more hostile anatomies and less time for planning. Consequently, more complications may arise after r-EVAR. The purpose of this study was to compare mi-term outcomes between r-EVAR and el-EVAR. A retrospective cohort analysis of patients undergoing EVAR from 2000 to 2015 at a tertiary institution was performed. Patients with previous aortic surgery, nonatherosclerotic AAA and isolated iliac aneurysms were excluded. In-hospital casualties or patients who were intraoperatively converted to open repair were also excluded. For the midterm outcome analysis, only patients with at least two postoperative examinations (a 30-day computed tomography scan and a second postoperative examination performed 6 months or later) were considered. The primary end point was freedom from aneurysm-related complications (a composite of type I or III endoleak, aneurysm sac growth, migration of more than 5 mm, device integrity failure, AAA-related death, late postimplant rupture, or AAA-related secondary intervention). Freedom from secondary interventions, neck-related events (defined as a composite of type IA endoleak, migration of more than 5 mm, or preemptive neck-related secondary intervention) and late survival were secondary end points. The impact of device instructions for use (IFU) compliance on neck events was also assessed. The study included 565 patients (65 r-EVAR and 500 el-EVAR). Eighty-two patients were treated outside proximal neck IFU, 13 in the r-EVAR group (21.3%) and 69 (14.5%) in the el-EVAR (P =.16). During the index hospitalization, there were more complications (12.3% vs 3.2%; P =.001) and reinterventions (12.3% vs 2.8%; P <.001) in the r-EVAR group. After discharge, median clinical follow-up time was 4.3 years (interquartile range, 2.1-7.0 years) without differences between both groups. Five-year freedom from AAA-related complications was 53.9% in the r-EVAR group and 65.4% in the el-EVAR (P =.21). In multivariable analysis the r-EVAR group was not at increased risk for late complications (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.54-1.61; P =.81). Five-year freedom from neck-related events was 74% in r-EVAR and 82% in the el-EVAR group (P =.345). Patients treated outside neck IFU were at greater risk for neck-related events both in r-EVAR (HR, 6.5; 95% CI, 1.8-22.9; P =.004) and el-EVAR group (HR, 2.6; 95% CI, 1.5-4.5; P <.001). Freedom from secondary interventions at 5 years was 63.0% for r-EVAR and 76.9% for el-EVAR (P =.16). Survival at 5 years was 68.8% in the r-EVAR group and 73.3% in the el-EVAR group (P =.30). Durable and sustainable midterm outcomes were found for both r-EVAR and el-EVAR patients who survived the postoperative period. Patients treated outside the IFU are at greater risk for late complications. Surveillance protocols may be tailored according to individual anatomy and IFU compliance rather than timing of repair. [ABSTRACT FROM AUTHOR]