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Introduction: The objective of this study is to determine if cardiac damage based on hospital discharge codes is associated with in-hospital outcomes in patients with aortic stenosis (AS)., Methods: We conducted a retrospective cohort study of hospital admissions between 2016 and 2021 with a diagnosis of AS in the National Inpatient Sample (NIS). The cardiac damage stages 0-4 were determined based on hospital discharge codes. Logistic and linear regressions were used to determine the association between cardiac stage and in-hospital mortality, length of stay (LoS) and cost., Results: A total of 2,980,150 hospital admissions were included in the analysis (82.5% conservative management, 11.2% transcatheter aortic valve replacement [TAVR], 6.3% surgical aortic valve replacement [SAVR]). The association between cardiac damage stage and in-hospital outcome was most significant for patients who had SAVR treatment (stage 4 vs. stage 0: mortality OR 27.70 95% CI 17.35-35.17, LoS 7.34 95% CI 6.34-8.35, cost 70,710 95% CI 65,110-76,310) compared to TAVR treatment (stage 4 vs. stage 0: mortality OR 9.15 95% CI 5.52-15.15, LoS 6.27 95% CI 5.63-6.90, cost 28,384 25,084 to 31,684) and conservative treatment (stage 4 vs. stage 0: mortality OR 3.55 95% CI 3.13-4.04, LoS 2.09 95% CI 1.87 to 2.31, cost 6362 95% CI 5642-7083)., Conclusions: Cardiac damage can be evaluated using diagnostic codes in patients with AS and it is associated with in-hospital mortality, LoS and cost, and has more impact on these outcomes in patients treated with SAVR versus those treated with TAVR., (© 2025 Wiley Periodicals LLC.)

Background: Retrograde type A dissection (RTAD) represents a rare but possible lethal complication of thoracic endovascular aortic repair. Intervention is often recommended, but conservative management has been advocated in selected cases., Methods: We performed a systematic review of the literature through MedLine and Cochrane databases over the last 24 years to identify reported cases of RTAD managed conservatively. Primary endpoint was the overall and aortic-related mortality, the morbidity, and the need for intervention during follow-up. The underlining causes and indications for conservative management were also investigated. (Protocol on Prospero Centre for Reviews and Dissemination RD42024542966)., Results: A total of 2,305 papers were identified, and 10 articles were included (20 cases). The reasons for conservative treatment were age (n = 8.40%) and/or haemodynamic stability(n = 16,80%) and/or unfitness for surgery(n = 12,60%). The causes of RTAD were fragile aortic wall in acute type B aortic dissection (TBAD) (n = 10, 50%), Marfan syndrome (n = 2, 10%), use of stents with proximal barbs or bare springs (n = 5, 25%), diameter of the ascending aorta>40 mm (n = 2, 10%), and intraoperative type IA endoleak (n = 2, 10%). Three patients (15%) were lost to follow-up immediately after discharge; one (5%) died in hospital from aortic rupture. At a mean follow-up of 33.5 months (range 9-60), the overall survival was 88.2% (n = 15/17) and aortic-related mortality was 10% (n = 2/20). No complications or interventions during the follow-up period were reported., Conclusions: The mortality rate following RTAD is high, and surgery allows improvement in survival. Conservative management might represent a viable option for selected patients. However, the current evidence is poor and needs to be validated by further and more robust data before such a strategy could be suggested more widely., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Donors with small asymptomatic kidney stones have been increasingly accepted because of organ shortages and advances in endoscopic urology. This study aims to evaluate and compare long-term living-donor kidney transplant outcomes following ex vivo surgical removal versus conservative management of donors' gifted asymptomatic stones., Methods: Between January 2007 and December 2021, 119 kidney transplant recipients received stone-bearing kidneys, divided into the removal group (N = 63) and observation group (N = 56). We evaluated posttransplant stone events, urinary infections, kidney function, delayed graft function, length of hospital stay, and survival outcomes., Results: After a median follow-up of 75.5 mo, the removal group had a 10.9% lower absolute incidence of stone events (7/56 [12.5%] versus 1/63 [1.6%]; hazard ratio, 0.08; 95% confidence interval, 0.01-0.77) and a 14.3% lower absolute incidence of urinary infections (16/56 [28.6%] versus 9/63 [14.3%]; hazard ratio, 0.42; 95% confidence interval, 0.19-0.95) than the observation group. The removal group also showed superior kidney graft function. The 2 groups had comparable length of hospital stay (11.0 versus 12.0 d; P  = 0.297) and exhibited similar delayed graft function incidence (1/56 [1.8%] versus 2/63 [3.2%]; P  = 1.000) and urinary stricture incidence (1/56 [1.8%] versus 3/63 [4.8%]; P  = 0.621). Graft survival ( P  = 0.350) and patient survival ( P  = 0.260) were comparable between 2 groups. Subgroup analyses in recipients who received kidneys with stones <4 mm also reported similar results., Conclusions: Ex vivo surgical removal might outperform conservative management for donors' gifted asymptomatic kidney stones, improving long-term transplant outcomes and reducing stone events without increasing perioperative complications, even for stones <4 mm., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Backgrounds/aims: Central retinal artery occlusion (CRAO) is a vision-devastating emergency. However, widely-acknowledged treatment consensus is lacking and prehospital delays commonly occur. Hence, we aimed to investigate the visual outcomes of conservative treatments (CT), local intra-arterial fibrinolysis (LIF) and hyperbaric oxygen (HBO) therapy for non-arteritic CRAO (NA-CRAO) patients beyond the conventional time window., Methods: This retrospective comparative study included 99 NA-CRAO patients followed up for over 6 months. The subjects were divided into three groups: the CT (50 patients), LIF (10 patients) and HBO group (39 patients). The primary endpoint was the best-corrected visual acuity (BCVA) change at 6 months compared to baseline. The secondary endpoint was the improvement in BCVA at 1 year and final visits., Results: No heterogeneity regarding demographics was identified. However, the HBO group had a more extended time-to-treatment period (median 6.0 days) and more advanced-stage CRAO cases (41 % stage III) than the CT (median 4.0 days, 14 % stage III) and LIF (median 0.6 days, 20 % stage III) groups. Despite this, the HBO group exhibited a significantly greater BCVA and a higher proportion of patients achieving significant vision improvement than those in the CT group at 6-, 12-month and final exams (51.3 % vs. 24.0 %, P < 0.05). The LIF appeared to improve outcomes more than CT over time without significance., Conclusion: Our study provided a concurrent comparison across 3 approaches and demonstrated that HBO therapy beyond the time window remained more effective in improving vision than CT alone for NA-CRAO patients, which had not been proposed by prior studies., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous cholecystostomy (PC) can be used as a bridging therapy for moderately severe acute biliary pancreatitis (MSABP). Currently, there are only a limited number of reports of MSABP using PCs., Aim: To assess the short-term outcomes of early PC in MSABP and factors associated with recurrence and death in MSABP., Methods: Patients who received conservative treatment or PC for acute biliary pancreatitis (ABP) in Liaoning Provincial People's Hospital from January 2017 to July 2022 were collected. A total of 54 patients with MSABP who received early-stage PC and 29 patients who received conservative treatment. The short-term efficacy of PC was evaluated. Depending on whether there is a recurrence, compare the characteristics of the pre-PC and explore the factors of recurrence. Pre-PC features were compared and predictors were discussed, depending on the outcome., Results: After 3 days of PC treatment, patients experienced a reduction in inflammatory markers compared to the conservative group. After PC, patients were divided into non-recurrence ( n = 37) and recurrence ( n = 10) groups, and the results showed that age was an independent correlation affecting ABP recurrence [odds ratio (OR) = 0.937, 95% confidence interval (CI): 0.878-0.999; P = 0.047 < 0.05]. Patient outcomes were divided into non-lethal ( n = 47) and lethal ( n = 7) groups, and Charlson Comorbidity Index (CCI) was a risk factor for mortality (OR = 2.397, 95%CI: 1.139-5.047; P = 0.021 < 0.05). CCI was highly accurate in predicting death in MSABP (area under the curve = 0.86 > 0.7). When the Youden index maximum was 0.565, the cut-off value was 5.5, the sensitivity was 71.4%, and the specificity was 85.1%., Conclusion: PC is an important method in the early years (< 72 hours) of MSABP. Age is a protective factor against recurrence of ABP. High pre-PC CCI is significantly associated with mortality., Competing Interests: Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article., (©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making., Methods: We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR)., Results: Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98-1.11; HR: 1.10, 95% CI: 0.94-1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85-1.12; HR: 0.94, 95% CI: 0.73-1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27-0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57-0.99, p = 0.04; HR: 0.64, 95% CI: 0.49-0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02-2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04-3.56, p = 0.04)., Conclusion: In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Tricuspid transcatheter edge-to-edge repair (T-TEER) has emerged as a treatment option for patients with severe tricuspid regurgitation (TR). However, randomized trials have not shown a survival benefit, possibly because of the inclusion of patients in an early or too advanced disease stage., Objectives: The authors sought to investigate the association between disease stage and outcomes following T-TEER., Methods: In total, 1,885 patients with significant TR were analyzed, including 585 conservatively treated individuals and 1,300 patients who received T-TEER. Patients were evaluated as part of the prospective EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation) registry and grouped into early, intermediate, and advanced disease stage. Disease stage was based on left and right ventricular function, renal function, and natriuretic peptide levels. The stratification was validated in an external cohort. The primary endpoint was 1-year mortality., Results: Overall, 395 patients (21% [395/1,885]) were categorized as early, 1,173 patients (62% [1,173/1,885]) as intermediate, and 317 patients (17% [317/1,885]) as advanced disease stage. In patients with early and advanced disease, mortality did not differ between interventional and conservative treatment (early-stage HR: 0.78; 95% CI: 0.34-1.80; P = 0.54; advanced stage HR: 1.06; 95% CI: 0.71-1.60; P = 0.78). However, mortality was significantly lower in patients undergoing percutaneous treatment with intermediate disease stage (HR: 0.73; 95% CI: 0.52-0.99; P = 0.03)., Conclusions: Compared to medically treated controls, T-TEER was associated with 1-year survival at intermediate stage disease but not at early or advanced disease stages. The timing of T-TEER with regard to disease stages might be crucial to optimize treatment benefits., Competing Interests: Funding Support and Author Disclosures Dr Stolz has received speaker honoraria from Edwards Lifesciences. Dr Kresoja has received travel expenses from Edwards Lifesciences. Dr Rottbauer has received speaker honoraria from Edwards Lifesciences and Abbott. Dr Denti has served as a consultant for InnovHeart, Picardia, HVR, and Approxima; and has received speaker honoraria from Abbott and Edwards Lifesciences. Dr Rassaf has received speaker honoraria and consulting fees from AstraZeneca, Bayer, Pfizer, and Daiichi-Sankyo. Dr Adamo has received consulting fees in the last 3 years from Abbott Structural Heart and Edwards Lifesciences. Dr von Bardeleben has received institutional grants from Abbott Vascular and Edwards Lifesciences; and has served as a speaker for Abbott Vascular and Edwards Lifesciences. Dr Toggweiler has received personal honoraria from Medtronic, Boston Scientific, Biosensors, Abbott Vascular, Medira, Shockwave, Teleflex, atHeart Medical, Cardiac Dimensions, Polares Medical, Amarin, Sanofi, AstraZeneca, ReCor Medical, and Daiichi-Sankyo; has received institutional research grants from Edwards Lifesciences, Boston Scientific, Fumedica, Novartis, and Boehringer Ingelheim; and holds equity in Hi-D Imaging. Dr Metra has received consulting fees in the last 3 years from Abbott Structural Heart, AstraZeneca, Bayer, Boheringer Ingelheim, Edwards Lifesciences, and Roche Diagnostics. Dr Geisler has received speaker honoraria/research grants from AstraZeneca, Bayer, Bristol Myers Squibb/Pfizer, Ferrer/Chiesi, Medtronic, and Edwards Lifesciences; none of them was related to this study. Dr Estévez-Loureiro has received speaker fees from Abbott Vascular, Edwards Lifesciences, Boston Scientific, and Venus Medtech. Dr Luedike has received speaker honoraria and consulting fees from AstraZeneca, Bayer, Pfizer, and Edwards Lifesciences; and has received research honoraria from Edwards Lifesciences. Dr Lauten has a patent with and is a consultant for TricValve licensed to TricValve. Dr Maisano has received grant and/or research institutional support from Abbott, Medtronic, Edwards Lifesciences, Biotronik, Boston Scientific Corporation, NVT, Terumo, and Venus; has received consulting fees and personal and institutional honoraria from Abbott, Medtronic, Edwards Lifesciences, Xeltis, Cardiovalve, Occlufit, Simulands, Mtex, Venus, Squadra, and Valgen; receives royalty income/IP rights from Edwards Lifesciences; and is a shareholder (including share options) of Magenta, Transseptalsolutions, and 4Tech. Dr Praz has received travel expenses from Edwards Lifesciences, Abbott Vascular, Polares Medical, Medira, and Siemens Healthineers. Dr Kessler has received speaker honoraria from Edwards Lifesciences and Abbott. Dr Heitkemper is an employee of Abbott. Dr Peterman is an employee of Abbott. Dr Kalbacher has received personal fees from Abbott Medical, Edwards Lifesciences, and Pi-Cardia Ltd. Dr Rudolph has received research grants from Abbott Medical, Boston Scientific, and Edwards Lifesciences. Dr Iliadis has received consultant fees and travel expenses from Abbott Medical and Edwards Lifesciences. Dr Hausleiter has received research grant support and speaker honoraria from Edwards Lifesciences. Dr Lurz has received institutional grants from Edwards Lifesciences; and has received honoraria from Innoventrics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal management strategy for non-culprit lesions is a subject of ongoing debate. There has been an increasing use of physiology-guidance to assess the extent of occlusion in non-culprit lesions, and hence the need for stenting. Fractional flow reserve (FFR) is commonly used as a technique. This analysis compares FFR versus conservative management in the management of non-culprit lesions in STEMI patients with multivessel disease., Methods: A comprehensive literature search was conducted on databases from inception to May 25, 2024. We conducted a random-effects meta-analysis using RevMan version 5.3.0, employing the Der-Simonian and Laird method to combine the data., Results: The analysis of five RCTs including 3759 patients revealed a significantly lower incidence of major adverse cardiovascular events (composite of all-cause mortality, non-fatal myocardial infarction and the need for repeat revascularization [PCI or CABG]) in the FFR group compared to the conservative management group (RR = 0.65, 95% CI: 0.44-0.96, p = 0.03). The revascularization rates were significantly lower in the FFR group (RR = 0.53, 95% CI: 0.43-0.66, p < 0.00001). Additionally, unplanned hospitalization leading to urgent repeat revascularization and any cause hospitalization were significantly lower in the FFR group (RR = 0.72, 95% CI: 0.56-0.94, p = 0.01), and (RR = 0.62, 95% CI: 0.46-0.84, p = 0.002), respectively. The FFR group had a higher risk of definite stent thrombosis (RR = 2.26, 95% CI: 1.10-4.64, p = 0.03). No significant differences were observed between the two groups in mortality, hospitalization for heart failure, or myocardial infarction. Similarly, bleeding rates, cerebrovascular accidents (CVAs), and contrast-induced nephropathy (CIN) were comparable between both groups., Conclusion: Our findings support FFR-guided PCI to manage non-culprit lesions in STEMI patients with multivessel disease as it is potentially safe, with comparable rates of bleeding, CVAs and CIN. It also improves clinical outcomes, as well as reduces revascularization and hospitalization rates. The risk of stent thrombosis remains a concern, and hence the decision making for FFR-guided complete revascularization should take into account the complexity/risk of the procedure, as well as the patients' individual co-morbidities and preferences., (© 2024 Wiley Periodicals LLC.)

Objectives: To compare the safety and effectiveness of conservative and stent treatment for spontaneous isolated superior mesenteric artery dissection (SISMAD) patients after the failure of initial 3 days' conservative treatment., Methods: All newly diagnosed SISMAD patients between 2013 and 2017 were retrospectively reviewed. After the failure of 3 days' conservative treatment, all patients were recommended for stent treatment, but some patients refused to choose it. Their demographic, radiologic, and clinical data were compared., Results: 57 patients were not improved after initial 3 days' conservative treatment. Among them, 19 patients were chose to receive stent placement and 38 patients were continually treated with conservative treatment. The median follow-up time was 92.0 (range 62.7-120.4) months. There were no bowel ischemia and arterial rupture. No significant difference was observed in clinical complete recovery (Conservative 31/38 vs Stent 12/19, p =.19) and hospitalization time (Conservative 8.3 ± 1.7 days vs Stent 7.2 ± 1.5 days, p =.59) between conservative and stent treatment groups. Significant statistical differences were found in radiological complete remodeling (6/38 vs 16/19, p < .01) and hospitalization expense (8662 ± 2886 China Yuan vs 32,935 ± 11,767 China Yuan, p < .01) between these two groups., Conclusions: Although undergoing the failure of initial 3 days' conservative treatment, continue conservative treatment still is safe and effective for SISMAD patients. Stent placement could be chosen as an alternative treatment, especially for patients potentially with bowel ischemia or arterial rupture., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background:  There is still no guideline or consensus on the treatment of aortic graft infection. This study reported and compared conservative and surgical treatment and different surgical methods for aortic graft infection., Methods:  Data from aortic graft infections treated at our institution between February 2017 and June 2022 were retrospectively analyzed. Clinical data and surgical approaches were evaluated., Results:  This article retrospectively analyzed the treatment and prognosis of 48 patients (43 males) with aortic graft infection. The patients were divided into conservative treatment group ( n  = 15) and surgical treatment group ( n  = 33). During follow-up, the mortality rate of the conservative treatment group was significantly higher than that of the surgical treatment group ( p  < 0.05). The survival curve also showed that the survival time of the surgical treatment group was longer than that of the conservative treatment group ( p  < 0.05). The surgical treatment group included local treatment ( n  = 5), in situ replacement ( n  = 8), and bypass surgery ( n  = 20) groups. There was no significant difference in the mortality rate at 1 month or final follow-up among the local treatment, in situ replacement, and bypass surgery groups., Conclusion:  Surgical treatment is the optimal option for treating aortic graft infections compared to conservative treatment., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Elderly patients are often under-represented in studies about coronary revascularization in acute coronary syndromes (ACS) and undertreated in clinical practice. We sought to evaluate differences in outcomes between an initial invasive or conservative strategy in this subset of patients, METHODS: The analysis was performed following PRISMA guidelines. Randomized controlled trials (RCTs) and adjusted observational studies comparing an invasive and conservative strategy in old patients with ACS were systematically identified. Random or fixed effect model was used accordingly to heterogeneity testing results. Short-term mortality was the primary outcome. 30-day and longer-term re-infarction, MACE and all-cause mortality were secondary endpoints. Sensitivity analysis including RCTs only were performed for the primary endpoint and 1 year mortality and another analysis, stratifying NSTEMI and STEMI studies, was performed for short-term mortality., Results: Invasive management was associated with lower short and long-term mortality (30 days OR 0.64, 95 % CI 0.54-0.76, p < 0.001; 1 year HR 0.60, 95 % CI 0.52-0.78, p < 0.001; Long-term HR 0.62, 95 % CI 0.55-0.71, p < 0.001) compared to a conservative strategy. In the short-term follow-up, the benefit was preserved when differentiating for NSTEMI or STEMI studies but not when considering only RCTs. Major bleedings were more frequent in the invasive group (30 days OR 1.61, 95 % CI 1.39-1.87, p < 0.001). The mean difference in length of stay was not significantly different between the two strategies (mean difference in days 0.14, 95 % CI -0.79 to 1.06, p = 0.77)., Conclusion: An initial invasive strategy might lead to reduced short and long-term mortality in elderly patients presenting with acute coronary syndrome but it is associated with increased bleeding events rate. No difference in hospital stay length was observed. Results were mainly driven by non-randomized studies., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: To investigate the impact of an early coronary revascularization (<24 h) compared with initial conservative strategy on clinical outcomes in diabetic patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) who are in stable condition at hospital admission., Methods and Results: The International Survey of Acute Coronary Syndromes database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Patients with cardiac arrest, haemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using logistic regression and inverse probability of treatment weighting models. Primary outcome measure was all-cause 30-day mortality. Risk ratios (RRs) and odds ratios (ORs) with their 95% confidence intervals (CIs) were employed. Of the 7589 NSTE-ACS patients identified, 2343 were diabetics. The data show a notable reduction in mortality for the elderly (>65 years) undergoing early revascularization compared to those receiving an initial conservative strategy both in the diabetic (3.3% vs. 6.7%; RR: 0.48; 95% CI: 0.28-0.80) and nondiabetic patients (2.7% vs. 4.7%: RR: 0.57; 95% CI: 0.36-0.90). In multivariate analyses, diabetes was a strong independent predictor of mortality in the elderly (OR: 1.43; 95% CI: 1.03-1.99), but not in the younger patients (OR: 1.04; 95% CI: 0.53-2.06)., Conclusion: Early coronary revascularization does not lead to any survival advantage within 30 days from admission in young NSTE-ACS patients who present to hospital in stable conditions with and without diabetes. An early invasive management strategy may be best reserved for the elderly. Factors beyond revascularization are of considerable importance for outcome in elderly diabetic subjects with NSTE-ACS., Clinical Trial Number: ClinicalTrials.gov: NCT01218776., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The benefit of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease and severe aortic stenosis who are undergoing transcatheter aortic-valve implantation (TAVI) remains unclear., Methods: In an international trial, we randomly assigned, in a 1:1 ratio, patients with severe symptomatic aortic stenosis and at least one coronary-artery stenosis with a fractional flow reserve of 0.80 or less or a diameter stenosis of at least 90% either to undergo PCI or to receive conservative treatment, with all patients also undergoing TAVI. The primary end point was a major adverse cardiac event, defined as a composite of death from any cause, myocardial infarction, or urgent revascularization. Safety, including bleeding events and procedural complications, was assessed., Results: A total of 455 patients underwent randomization: 227 to the PCI group and 228 to the conservative-treatment group. The median age of the patients was 82 years (interquartile range, 78 to 85), and the median Society of Thoracic Surgeons-Predicted Risk of Mortality score (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after the procedure) was 3% (interquartile range, 2 to 4). At a median follow-up of 2 years (interquartile range, 1 to 4), a major adverse cardiac event (primary end point) had occurred in 60 patients (26%) in the PCI group and in 81 (36%) in the conservative-treatment group (hazard ratio, 0.71; 95% confidence interval [CI], 0.51 to 0.99; P = 0.04). A bleeding event occurred in 64 patients (28%) in the PCI group and in 45 (20%) in the conservative-treatment group (hazard ratio, 1.51; 95% CI, 1.03 to 2.22). In the PCI group, 7 patients (3%) had PCI procedure-related complications., Conclusions: Among patients with coronary artery disease who were undergoing TAVI, PCI was associated with a lower risk of a composite of death from any cause, myocardial infarction, or urgent revascularization at a median follow-up of 2 years than conservative treatment. (Funded by Boston Scientific and the Danish Heart Foundation; NOTION-3 ClinicalTrials.gov number, NCT03058627.)., (Copyright © 2024 Massachusetts Medical Society.)

Background: Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear., Methods: We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis., Results: A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients., Conclusions: In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.)., (Copyright © 2024 Massachusetts Medical Society.)

Objective: The aim of this study was to assess the utilization of surgical interventions in patients diagnosed with superficial vein thrombosis (SVT) and its potential association with the occurrence of venous thromboembolism (VTE) and bleeding events., Methods: INSIGHTS-SVT, a prospective, non-interventional, multicenter study in Germany, investigated the management and outcomes of patients with acute SVT who received conservative and/or invasive treatments at the discretion of the treating physician., Results: Among the 872 patients with 12-month data, 657 had medical therapy only, and 215 patients underwent vascular surgery (70 within 3 months of SVT diagnosis, 136 between months 4 and 12, and nine had an intervention in both periods). The most commonly performed procedures included endovenous thermal ablation, ligation of the saphenofemoral or saphenopopliteal junction, and vein stripping. The primary outcome of symptomatic VTE was observed in 5.8% of conservatively treated patients and 6.3% of those who underwent surgical intervention. Additionally, the secondary outcome of recurrent or extended SVT was documented in 4.7% of conservatively treated patients and 5.3% of invasively treated patients. Bleeding events occurred in 1.4% of conservatively treated patients and 2.1% of surgically treated patients. These differences were statistically not significant. Furthermore, our analysis indicated a potential protective effect associated with surgical treatments, such as ligation of the saphenofemoral or saphenopopliteal junction, stripping and endovenous thermal ablation, concerning the endpoint of VTE for patients when applied after 3 months from the index SVT event., Conclusions: In line with previous research, our study suggests that surgical interventions are not frequently employed in the management of SVT, although they may be warranted in select cases. Nevertheless, additional research is essential to gain a deeper understanding of the indications, criteria, and benefit of surgical interventions in the treatment of SVT., Competing Interests: Disclosures E.R. has received honoraria for lectures and advisory boards from Bayer, Boehringer Ingelheim, Daiichi-Sankyo, Leo Pharma, and Pfizer. R.B. has received research support from AFNET, CPC, and FADOI; and honoraria from Bayer, BMS, Leo, Pfizer, and Viatris. H.G. has received honoraria for lectures and advisory boards from Aspen, Mylan, Bayer, and Boehringer-Ingelheim. D.P. has received honoraria for consultancy, advisory boards, or lectures by Actelion, Bayer, Biogen, Aspen, Amgen, MSD, Boehringer Ingelheim, Novartis, Daiichi Sankyo, Genzyme, and Zambon. F.L. has received honoraria for lectures or consultancy from Aspen, Bayer, Bristol-Myers Squibb, Daiichi Sankyo, LEO Pharma, Pfizer, Sanofi, and Viatris. U.H. has received research support and honoraria for lectures and advisory boards from Bayer HealthCare Pharmaceuticals, Bristol-Myers-Squibb, Pfizer, Boehringer Ingelheim, Daiichi Sankyo, Leo Pharma, and Aspen. T.N. has received honoraria for consultancy from Medi Bayreuth; and honoraria for presentations from Aspen, Bayer, Bristol-Myers Squibb, and Mylan. A.H. was, at the time of the study, a full-time employee of Aspen Pharma GmbH, Munich, and is now an employee of Amgen GmbH, Germany. A.S. is a full-time employee of Mylan Germany GmbH, Germany., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Whether revascularisation (REV) improves outcomes in patients with three-vessel coronary artery disease (3V-CAD) is uncertain., Aims: Our objective was to evaluate outcomes with REV (percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) versus medical therapy in patients with 3V-CAD., Methods: ISCHEMIA participants with 3V-CAD on coronary computed tomography angiography without prior CABG were included. Outcomes following initial invasive management (INV) with REV (PCI or CABG) versus initial conservative management (CON) with medical therapy alone were evaluated. Regression modelling was used to estimate the outcomes if all participants were to undergo prompt REV versus those assigned to CON. Outcomes were cardiovascular (CV) death/myocardial infarction (MI), death, CV death, and quality of life. Bayesian posterior probability for benefit (Pr [benefit]) for 1 percentage point lower 4-year rates with REV versus CON were evaluated., Results: Among 1,236 participants with 3V-CAD (612 INV/624 CON), REV was associated with lower 4-year CV death/MI (adjusted 4-year difference: -4.4, 95% credible interval [CrI] -8.7 to -0.3 percentage points, Pr [benefit]=94.8%) when compared with CON, with similar results for PCI versus CON (-5.8, 95% CrI: -10.8 to -0.5 percentage points, Pr [benefit]=96.4%) and CABG versus CON (-3.7, 95% CrI: -8.8 to 1.5 percentage points, Pr [benefit]=84.7%). Adjusted 4-year REV versus CON differences were as follows: death -1.2 (95% CrI: -4.7 to 2.2) percentage points, CV death -2.3 (95% CrI: -5.5 to 0.8) percentage points, with similar results for PCI and for CABG. The Pr (benefit) for death with REV (PCI or CABG) versus CON was 49-63%. The adjusted 12-month Seattle Angina Questionnaire-7 summary score differences favoured REV: REV versus CON 4.6 (95% CrI: 2.7-6.4) percentage points; PCI versus CON 3.6 (95% CrI: 1.2-5.8) percentage points and CABG versus CON 4.3 (95% CrI: 1.5-6.9) percentage points with high Pr (benefit)., Conclusions: In participants with 3V-CAD, REV (either PCI or CABG) was associated with a lower 4-year CV death/MI rate and improved quality of life, with similar results for PCI versus CON and CABG versus CON. The differences in all-cause mortality between REV and CON were small with wide confidence intervals. (ClinicalTrials.gov: NCT01471522).

Purpose: The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period., Materials and Methods: Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints., Results: In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen., Conclusions: Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling., Clinical Impact: In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Spontaneous isolated superior mesenteric artery dissection (SISMAD) is a rare vascular disease, the treatment strategies for which remain debated. This retrospective study aimed to compare the outcomes of conservative and endovascular treatments in patients with SISMAD., Materials and Methods: Fifty-eight patients with SISMAD confirmed by computed tomography angiography admitted to our hospital between November 2017 and May 2021 and received confirmed conservative (n=43) or endovascular (n=15) treatment. The patient demographics, imaging analysis, and follow-up results were analyzed and compared., Results: The cohort included 54 males and 4 females with a mean age of 52 years. Abdominal pain was the major complaint (49/58, 84.5%), followed by chest pain (2/58, 3.4%). The mean follow-up was 9.1±7.9 months. The 2 main Sakamoto types were type III (27/58, 46.6%) and type IV (16/58, 27.6%). Most patients in both groups had angle 1 (aortomesenteric angle) and angle 2 (superior mesenteric artery [SMA] course) of over 80°. About 67.3% of patients had long length of dissection (>60 mm). The median distance between the SMA root and the dissection entry site was 1.5 cm, mostly (84.5% of the patients) in the curved segment of the SMA. Telephone follow-ups found that most patients survived pain-free, and none underwent intestinal resection. Only 4 patients, 2 in each group, had recurrent abdominal pain during follow-up and received stenting treatment to achieve complete vascular remodeling. Importantly, we found that the conservative and endovascular therapies achieved similar high remodeling rates (94% and 100%, respectively; p=0.335). The conservative group achieved satisfying vascular remodeling (partial, 35%; complete, 59%), making it as safe and effective a treatment as endovascular therapy., Conclusions: Initial conservative management is safe and effective in patients with SISMAD. A high technical success rate and favorable short-term outcomes were associated with endovascular procedures as secondary interventions. It would be helpful to conduct large-scale, prospective, randomized controlled trials with long-term follow-up for SISMAD., Clinical Impact: 1. This research provided more detail clinical information, such as evaluation of abdominal pain and measurements of SMA angles, which is all relevant to treatment. 2. What's more, the most surprising results of follow-up part shown that conservative treatment could reached the remodeling rate as high as endovascular treatment, which was relatively low in other studies. It helps us share our treatment experience with clinicians. 3. In addition, we get limited knowledge about this rare disease, it's encouraging us to do more researches based on the results we had., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) demonstrated greater health status benefits with an initial invasive strategy, as compared with a conservative one, for patients with chronic coronary disease and moderate or severe ischemia. Whether these benefits vary globally is important to understand to support global adoption of the results., Methods: We analyzed participants' disease-specific health status using the validated 7-item Seattle Angina Questionnaire (SAQ: >5-point differences are clinically important) at baseline and over 1-year follow-up across 37 countries in 6 international regions. The average effect of initial invasive versus conservative strategies on 1-year SAQ scores was estimated using Bayesian proportional odds regression and compared across regions., Results: Considerable regional variation in baseline health status was observed among 4617 participants (mean age=64.4±9.5 years, 24% women), with the mean SAQ summary scores of 67.4±19.5 in Eastern Europe participants (17% of the total), 71.4±15.4 in Asia-Pacific (18%), 74.9±16.7 in Central and South America (10%), 75.5±19.5 in Western Europe (26%), and 78.6±19.2 in North America (28%). One-year improvements in SAQ scores were greater in regions with lower baseline scores with initial invasive management (17.7±20.9 in Eastern Europe and 11.4±19.3 in North America), but similar in the conservative arm. Adjusting for baseline SAQ scores, similar health status benefits of an initial invasive strategy on 1-year SAQ scores were observed (ranging from 2.38 points [95% CI, 0.04-4.50] in North America to 4.66 points [95% CI, 2.46-6.94] in Eastern Europe), with an 88.3% probability that the difference in benefit across regions was <5 points., Conclusions: In patients with chronic coronary disease and moderate or severe ischemia, initial invasive management was associated with a consistent health status benefit across regions, with modest regional variability, supporting the international generalizability of health status benefits from invasive management of chronic coronary disease., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522., Competing Interests: Dr Ikemura received an unrestricted research grant for the Department of Cardiology, Keio University School of Medicine from Bristol Myer Squibb. Dr Spertus discloses providing consultative services on patient-reported outcomes and evidence evaluation to Alnylam, AstraZeneca, Bayer, Merck, Janssen, Bristol Meyers Squibb, Edwards, Kineksia, 4DT Medical, Terumo, Cytokinetics, Imbria, and United Healthcare. He holds research grants from Bristol Meyers Squibb, Abbott Vascular, and Janssen. He owns the copyright to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire and serves on the Board of Directors for Blue Cross Blue Shield of Kansas City. Dr Nguyen is currently supported by the National Heart, Lung, and Blood Institute under Award Number T32HL110837. Dr Reynolds reports grants from National Heart, Lung, and Blood Institute, during the conduct of the study, she received support from Abbott Vascular (donation of optical coherence tomography catheters for an unrelated research study) and Biotelemetry Inc (donation of telemetry monitors for an unrelated research study). Dr Bangalore reports grants from the National Heart, Lung, and Blood Institute, during the conduct of the study; grants and personal fees from Abbott Vascular; personal fees from Biotronik, Pfizer, Amgen, and Reata outside the submitted work. Dr Bhargava reports grants from the National Heart, Lung and Blood Institute, during the conduct of the study. Dr Senior reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study and speaker fees from Bracco, Lantheus Medical Imaging Boston USA, and Philips Healthcare outside the submitted work. A. Elghamaz reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Goodman reports research grant support (eg, steering committee or data and safety monitoring committee) and speaker/consulting honoraria (eg, advisory boards) from Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CSL Behring, CYTE Ltd., Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, HLS Therapeutics, JAMP Pharma, Merck, Novartis, Novo Nordisk A/C, Pendopharm/Pharmascience, Pfizer, Regeneron, Sanofi, Servier, Tolmar Pharmaceuticals, Valeo Pharma; and salary support/honoraria from the Heart and Stroke Foundation of Ontario/University of Toronto (Polo) Chair, Canadian Heart Failure Society, Canadian Heart Research center and MD Primer, Canadian VIGOUR center, Cleveland Clinic Coordinating Center for Clinical Research, Duke Clinical Research Institute, New York University Clinical Coordinating center, PERFUSE Research Institute, TIMI Study Group (Brigham Health). Dr Lopes reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study; other from Bayer and Boehringer Ingelheim; grants and other from Bristol-Myers Squibb; other from Daiichi Sankyo; grants and other from GlaxoSmithKline and Medtronic; other from Merck; grants and other from Pfizer; other from Portola; and grants and other from Sanofi, outside the submitted work. Dr Pracon reports grants from National Heart, Lung, and Blood Institute, during the conduct of the study and research grant honoraria from NYU. Dr Lopez-Sendon reports grants from National Heart, Lung and Blood Institute, during the conduct of the study; other from Bayer, other from Boehringer Ingleheim, grants and other from Bristol-Myers Squibb, other from Daiichi Sankyo, grants and other from Glaxo Smith Kline, grants and other from Medtronic, other from Merck, grants and other from Pfizer, other from Portola, grants and other from Sanofi, outside the submitted work. Dr Maggioni reports grants from the National Heart, Lung, and Blood Institute during the conduct of the study; and personal fees from Bayer, AstraZeneca, Sanofi and Novartis, outside the submitted work. Dr Kohsaka has received grant support paid to the institution and fees from Novartis and AstraZeneca. Dr White has received grant support paid to the institution and fees for serving on Steering Committees of the ODYSSEY trial from Sanofi and Regeneron Pharmaceuticals, the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) and MINT study from the National Institutes of Health, the STRENGTH trial from Omthera Pharmaceuticals, the HEART-FID study from American Regent, the DAL-GENE study from DalCor Pharma UK Inc., the AEGIS-II study from CSL Behring, the CLEAR OUTCOMES study from Esperion Therapeutics Inc, and the SOLIST-WHF and SCOREDS trials from Sanofi Aventis Australia Pty Ltd. Dr Mavromatis reports grants from the National Heart, Lung, and Blood Institute; grants from National Heart, Blood, and Lung Institute (CV Inflammation Reduction Trial and GMCSF in PAD-3 Trial), grants from CSL Behring, St Jude’s Medical, Medtronic, DalCor Pharmaceuticals, AstraZeneca, Novartis, Regeneron, and Member of American College of Cardiology and Society of Cardiovascular Angiography and Interventions. Dr Boden reports grants from the National Heart, Lung, and Blood Institute, during the conduct of the study; grants from Abbvie, grants from Amarin, grants from Amgen, personal fees from Amgen, personal fees from Cleveland Clinic Clinical Coordinating Center, personal fees from Janssen, outside the submitted work. Dr Fatima Rodriguez reports consulting fees from Novartis, NovoNordisk, AstraZeneca, and Health Pals, and research support from the National Institutes of Health, the American Heart Association, and the Doris Duke Foundation. Dr Hochman is PI for the ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) for which, in addition to support by the National Heart, Lung, and Blood Institute grant, devices and medications were provided by Abbott Vascular; Medtronic Inc.; Abbott Laboratories (formerly St. Jude Medical Inc); Royal Philips NV (formerly Volcano Corporation); Arbor Pharmaceuticals, LLC; AstraZeneca Pharmaceuticals, LP; Merck Sharp & Dohme Corp.; Omron Healthcare Inc, and financial donations from Arbor Pharmaceuticals LLC and AstraZeneca Pharmaceuticals LP. She is also the PI for ISCHEMIA-EXTEND. Dr Maron reports grants from National Heart, Lung, and Blood Institute, during the conduct of the study. The other authors report no conflicts.

Background: Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal diabetic foot infection (DFI) treated with either conservative surgery or amputation., Methods: This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all diabetic foot ulcer (DFU) were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups., Results: Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (P = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the reamputation rate for the amputation group was 23.1% (P = 0.2)., Conclusions: The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seem to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to magnetic resonance imaging bone infection signal could be considered to minimize the risk of subsequent surgeries and reamputations., (Copyright © 2024. Published by Elsevier Inc.)

Background: The incidence of fragility fractures of the pelvis is rising. Whereas the treatment for FFP type I, III, and IV is clear, the optimal treatment for FFP type II remains a topic of discussion. Traditionally these fractures have been treated conservatively. However, there is a shift toward early surgical stabilization with percutaneous screw fixation to reduce pain and promote mobility in an already frail patient population. High-quality evidence, however, is lacking. Therefore, a randomized clinical trial was designed to compare conservative management to early percutaneous screw fixation in patients with type II fragility fractures., Methods: This is a monocenter randomized controlled trial. All patients with a FFP type II are screened for inclusion. After obtaining informed consent, patients are randomized between conservative management and surgical stabilization. Conservative management consists of early mobilization under guidance of physiotherapy and analgesics. Patients randomized for surgical treatment are operated on within 72 h using percutaneous screw fixation. The primary endpoint is mobility measured by the DEMMI score. Secondary endpoints are other dimensions of mobility, pain levels, quality of life, mortality, and morbidity. The total follow-up is 1 year. The required sample size is 68., Discussion: The present study aims to give certainty on the potential benefit of surgical treatment. Current literature on this topic remains unclear. According to the volume of FFP at the study hospital, we assume that the number of patients needed for this study is gathered within 2 years., Trial Registration: ClinicalTrials.gov NCT04744350. Registered on February 8, 2021., (© 2024. The Author(s).)

Background: The clinical outcomes and survival of patients with penetrating aortic ulcers (PAU) were evaluated in a tertiary care hospital, comparing those who underwent aortic repair to those treated conservatively. Patients and methods: A retrospective single-centre analysis included all patients that underwent a computed tomography angiography (CT-A) scan with the diagnosis of a PAU between January 2009 and May 2019. "PAU" was identified in 1,493 of 112,506 CT-A scan reports in 576 patients. Clinical and angiomorphological data were collected. The primary outcome was overall survival (OS), with secondary outcomes focusing on identifying risk factors for poor OS. Survival probabilities were analysed by the Kaplan-Meier method using the log-rank test. A Cox hazard model using survival as dependent variable with stepwise backward eliminations based on the likelihood ratios was employed. Results: 315 PAUs were identified in 278 patients. The prevalence in the cohort was 0.8%. The mean age of the patients was 74.4 years, and they were predominantly male (n = 208, 74.8%). The mean ulcer depth was 11.8 mm (range 2-50 mm). Out of the patients, 232 were asymptomatic (83.5%). Among 178 PAUs (56.5%), high-risk factors, such as ulcer depth >10 mm, aortic diameter >40 mm, and ulcer length >20 mm, were observed. Aortic repair was associated with a better mean OS compared to conservatively managed patients (72.6 versus 32.2 months, p = 0.001). The Cox hazard model showed that ulcer depth >1 mm was associated with poor OS (HR 0.67, p = 0.048), while aortic repair was related to a better OS (HR 4.365, p<0.013). Conclusions: Aortic repair is associated with better OS, but this finding should be interpreted with caution because of differences in age and comorbidities between the groups. Further evaluation is warranted through prospective studies with randomized groups. Further assessment for angiomorphological parameters is recommended to identify patients at increased risk for poor OS.

Objectives: Aortic intramural hematoma (IMH) is a rare disease. Thus far, only limited data is available and the indications for conservative and endovascular treatment are not well defined. The aim of this study was to investigate clinical presentation, course, CT imaging features and outcome of patients with type B aortic IMHs., Methods: We included all patients with type B IMHs between 2012 and 2021 in this retrospective monocentric study. Clinical data, localization, thickness of IMHs and the presence of ulcer-like projections (ULPs) was evaluated before and after treatment., Results: Thirty five patients (20 females; 70.3 y ± 11 y) were identified. Almost all IMHs (n = 34) were spontaneous and symptomatic with back pain (n = 34). At the time of diagnosis, TEVAR was deemed indicated in 9 patients, 26 patients were treated primarily conservatively. During the follow-up, in another 16 patients TEVAR was deemed indicated. Endovascularly and conservatively treated patients both showed decrease in thickness after treatment. Patients without ULPs showed more often complete resolution of the IMH than patients with ULPs (endovascularly treated 90.9% (10/11) vs 71.4% (5/7); conservatively treated 71.4% (10/14) vs 33.3% (1/3); P = .207). Complications after TEVAR occurred in 32% and more frequently in patients treated primarily conservatively (37.5% vs 22.2%). No in-hospital mortality was observed during follow-up., Conclusions: Prognosis of IMH seems favourable in both surgically as well as conservatively treated patients. However, it is essential to identify patients at high risk for complications under conservative treatment, who therefore should be treated by TEVAR. In our study, ULPs seem to be an adverse factor for remodeling., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Non-operative management (NOM) of simple appendicitis is becoming an increasingly researched treatment option. This systematic review aims to describe the short and long-term failure rates of NOM and the complication rate of appendicectomy in children with simple appendicitis., Methods: The systematic review was registered a priori (CRD42022322149). Study inclusion criteria are: participants aged ≤ 18 years of age; groups undergoing both NOM and appendicectomy for simple appendicitis; outcomes including one or more of: NOM failure rate at 30 days or 1 year and beyond; study design: RCT or case control study. Four databases were searched and 3 reviewers determined study eligibility and data extraction. Risk of bias was assessed and meta-analysis was performed using Stata., Results: The database search identified 2731 articles, 14 studies met the inclusion criteria; 4 RCTs and 10 case controlled studies. All studies had moderate-serious risk of bias. There were no deaths in either group in any study. Meta-analysis demonstrated a 30 day failure rate of 20 % (95 % CI 11-29 %) and 11 studies reported failure rate at 1 year or beyond at 32 % (95 % CI 25-38 %). Rates of significant complications of appendicectomy was 1 % (95 % CI 0-1 %)., Conclusions: Non-operative management of simple appendicitis in children is safe, with moderate early success. The failure rate increases over time, resulting in eventual appendicectomy in a third of the children diagnosed with appendicitis. These data will enable clinicians to have an informed discussion with children and their parents about their treatment options for simple appendicitis., Level of Evidence: II., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) did not find an overall reduction in cardiovascular events with an initial invasive versus conservative management strategy in chronic coronary disease; however, there were conservative strategy participants who underwent invasive coronary angiography early postrandomization (within 6 months). Identifying factors associated with angiography in conservative strategy participants will inform clinical decision-making in patients with chronic coronary disease., Methods: Factors independently associated with angiography performed within 6 months of randomization were identified using Fine and Gray proportional subdistribution hazard models, including demographics, region of randomization, medical history, risk factor control, symptoms, ischemia severity, coronary anatomy based on protocol-mandated coronary computed tomography angiography, and medication use., Results: Among 2591 conservative strategy participants, angiography within 6 months of randomization occurred in 8.7% (4.7% for a suspected primary end point event, 1.6% for persistent symptoms, and 2.6% due to protocol nonadherence) and was associated with the following baseline characteristics: enrollment in Europe versus Asia (hazard ratio [HR], 1.81 [95% CI, 1.14-2.86]), daily and weekly versus no angina (HR, 5.97 [95% CI, 2.78-12.86] and 2.63 [95% CI, 1.51-4.58], respectively), poor to fair versus good to excellent health status (HR, 2.02 [95% CI, 1.23-3.32]) assessed with Seattle Angina Questionnaire, and new/more frequent angina prerandomization (HR, 1.80 [95% CI, 1.34-2.40]). Baseline low-density lipoprotein cholesterol <70 mg/dL was associated with a lower risk of angiography (HR, 0.65 [95% CI, 0.46-0.91) but not baseline ischemia severity nor the presence of multivessel or proximal left anterior descending artery stenosis >70% on coronary computed tomography angiography., Conclusions: Among ISCHEMIA participants randomized to the conservative strategy, angiography within 6 months of randomization was performed in <10% of patients. It was associated with frequent or increasing baseline angina and poor quality of life but not with objective markers of disease severity. Well-controlled baseline low-density lipoprotein cholesterol was associated with a reduced likelihood of angiography. These findings point to the importance of a comprehensive assessment of symptoms and a review of guideline-directed medical therapy goals when deciding the initial treatment strategy for chronic coronary disease., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522., Competing Interests: Disclosures Dr Pracoń reports grants from the National Heart, Lung, and Blood Institute (NHLBI), during the conduct of the study. Dr Spertus reports grants from the NHLBI, during the conduct of the study; personal fees from Bayer, Novartis, AstraZeneca, Amgen, Janssen, and United Healthcare; grants from the American College of Cardiology; and personal fees from Blue Cross Blue Shield of Kansas City, outside the submitted work. In addition, Dr Spertus has a patent Copyright to the Seattle Angina Questionnaire with royalties paid and Equity in Health Outcomes Sciences. Dr Bangalore reports grants from the NHLBI, during the conduct of the study; grants and personal fees from Abbott; and personal fees from Biotronik, Pfizer, Amgen, and Reata outside the submitted work. Dr Rockhold receives research support from the National Institutes of Health, Patient-Centered Outcomes Research Institute (PCORI), BMS, AstraZeneca, American Regent, the Gates Foundation, and Eidos; consulting fees from Janssen, Clover, Doctor Evidence, Resolve, and Intercept; is on the data safety and monitoring boards (DSMBs) for Lilly, AstraZeneca, Merck, Gilead, Novartis, Icosavax, Sanofi, Union Chimique Belge (UCB), Amgen, Biogen, BMS, Pulmocide, Alkermes, and Diurnal; is the nonprofit chairman of the board (unpaid) of the Frontier Science Foundation; and has stock/stock options in GSK, Clover, Athira, Doctor Evidence, DataVant, Spencer Health Solutions, and Adaptic Health. Dr Mavromatis reports grants from the NHLBI; grants from NHLBI (Cardiovascular Inflammation Reduction Trial and GMCSF in PAD-3 trial [Granulocyte-Macrophage Stimulating Factor (GM-CSF) in Peripheral Arterial Disease (GPAD-3)]); grants from CSL Behring, St Jude’s Medical, Medtronic, DalCor Pharmaceuticals, AstraZeneca, Novartis, and Regeneron; and is a member of the American College of Cardiology and the Society of Cardiovascular Angiography and Interventions. Dr Manjunath reports grants from NHLBI during the conduct of the study. Dr Stone reports grants from NHLBI during the conduct of the study; has received speaker honoraria from Pulnovo and Infraredx; has served as a consultant to Valfix, TherOx, Robocath, HeartFlow, Ablative Solutions, Vectorious, Miracor, Neovasc, Abiomed, Ancora, Elucid Bio, Occlutech, CorFlow, Apollo Therapeutics, Impulse Dynamics, Vascular Dynamics, Shockwave, V-Wave, Cardiomech, Gore, and Amgen; and has equity/options from Ancora, Cagent, Applied Therapeutics, Biostar Family of Funds, SpectraWave, Orchestra Biomed, Aria, Cardiac Success, Valfix, and Xenter. Dr Stone’s daughter is an employee at Medtronic. Dr Stone’s employer, Mount Sinai Hospital, receives research support from Abbott, Bioventrix, Cardiovascular Systems, Inc, Phillips, Biosense-Webster, Shockwave, Vascular Dynamics, and V-Wave. Dr Mancini reports grants from NHLBI, during the conduct of the study; grants and personal fees from Amgen, Sanofi, Boehringer Ingelheim, AstraZeneca, Bayer, Janssen, and Novo Nordisk; grants from Novartis; and grants and personal fees from HLS Therapeutics, outside the submitted work. Dr Boden reports grants from NHLBI, during the conduct of the study; grants from Abbvie, Amarin, and Amgen; and personal fees from Amgen, the Cleveland Clinic Clinical Coordinating Center, and Janssen, outside the submitted work. Dr Newman reports grants from NHLBI, during the conduct of the study. Dr Reynolds reports grants from NHLBI, during the conduct of the study, and receives support from Abbott Vascular (donation of optical coherence tomography catheters for an unrelated research study) and Biotelemetry, Inc (donation of telemetry monitors for an unrelated research study). Dr Hochman is a primary investigator for the ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) for which, in addition to support by NHLBI grant, devices and medications were provided by Abbott Vascular, Medtronic, Inc, Abbott Laboratories (formerly St. Jude Medical, Inc), Royal Philips NV (formerly Volcano Corporation), Arbor Pharmaceuticals LLC, AstraZeneca Pharmaceuticals LP, Merck Sharp & Dohme Corporation, Omron Healthcare, Inc, Sunovion Pharmaceuticals, Inc, Espero BioPharma, and Amgen, Inc, and financial donations from Arbor Pharmaceuticals LLC and AstraZeneca Pharmaceuticals LP. Dr Hochman is also a primary investigator for the ISCHEMIA-EXTEND trial (The International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA] Extended Follow-Up). Dr Maron reports grants from NHLBI, during the conduct of the study. The other authors report no conflicts.

Objective: Assess the effectiveness of sacral neuromodulation (SNM) versus personalized conservative treatment (PCT) in patients with refractory idiopathic slow-transit constipation (STC)., Background: Evidence on SNM for idiopathic STC is conflicting and of suboptimal methodological quality., Methods: The No.2-Trial was a multicenter, open-label, pragmatic, randomized trial performed in 2 Dutch hospitals. Sixty-seven patients with idiopathic STC, a defecation frequency <3 per week and refractory (ie, unresponsive) to maximal conservative (nonoperative) treatment were included. Exclusion criteria included outlet obstruction, rectal prolapse, and previous colon surgery. Patients were randomized (3:2) to SNM (n=41) or PCT (n=26) with randomization minimization between February 21, 2017 and March 12, 2020. In SNM patients, an implantable pulse generator was implanted after a successful 4-week test stimulation. PCT patients received conservative treatment such as laxatives or retrograde colonic irrigation. The primary outcome was treatment success (defined as average defecation frequency ≥3 per week) after 6 months. Secondary outcomes included constipation severity, fatigue, quality of life, and adverse events. Analysis was according to intention-to-treat., Results: After 6 months, 22 (53.7%) patients were successfully treated with SNM versus 1 (3.8%) patient with PCT (odds ratio 36.4, 95% CI 3.4-387.5, P =0.003). At 6 months, SNM patients reported lower constipation severity and fatigue scores ( P <0.001) and improved quality of life compared with PCT ( P <0.001). Eight serious adverse events (6 SNM, 2 PCT) and 78 adverse events (68 SNM, 10 PCT) were reported., Conclusions: SNM is a promising surgical treatment option in a homogeneous group of adults and adolescents with refractory idiopathic STC. No.2-Trial registered at ClinicalTrials.gov NCT02961582., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Teriparatide and denosumab, anti-osteoporosis medications with different mechanisms, have been widely used in the patients with osteoporotic vertebral fracture (OVF) considered as advanced osteoporosis. Teriparatide has been shown to enhance bone formation and fracture healing in OVF, but there are still no sufficient evidences discussing about the role of denosumab in newly developed OVF. In this study, we found the similar radiological deformation and functional outcomes of conservative treatment with teriparatide and denosumab in thoracolumbar (TL) OVF, and teriparatide showed a more frequent incidence of fracture union with paravertebral bone bridge formation compared to denosumab., Introduction: Teriparatide and denosumab have been widely used to treat advanced osteoporosis and prevent subsequent fractures in patients with OVCF. Unlike teriparatide, which is considered to be effective in fracture healing, there is still no clear role and evidence for the effect of denosumab in acute OVCF. This study compared the radiological and functional outcomes of conservative treatment with teriparatide and denosumab in TL-OVF., Methods: This retrospective study enrolled 78 women with mean age of 74.69 ± 7.66 (60-92) years diagnosed as a TL-OVF with no neurological deficits. All patients were treated conservatively with teriparatide (34 of group T, once-daily 20 μg) or denosumab (44 of group D, once-6 months 60 mg) for 6 months. We evaluated the radiological deformation (kyphotic angle, segmental vertebral kyphotic angle, and compression ratio) and the incidence of fracture union with paravertebral bone bridge formation (FUPB) and functional outcomes using the visual analog scale (VAS) and Oswestry Disability Index (ODI) at 0, 3, and 6 months., Results: In the radiological deformation and functional outcomes, there were no significant differences at 0, 3, and 6 months between the two groups (P > 0.05). However, the incidence of FUPB at 6 months was higher in group T (20/34, 58.8%) compared to group D (11/44, 25.0%) (P = 0.004), and teriparatide was the most statistically significant factor for achieving FUPB (OR 4.486, P = 0.012) in multivariable logistic analysis., Conclusions: Teriparatide and denosumab, despite of their different pharmacological mechanisms, showed similar radiological deformation and functional outcomes in the conservative treatment of TL-OVF. However, teriparatide showed a significantly higher incidence of fracture union with paravertebral bone bridge formation., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Objective: To evaluate the anatomical and voice results of conservative management of patients diagnosed with contralateral reactive lesions (CRL) in our voice unit., Methods: A retrospective chart review was conducted of all new adult patients with benign vocal fold lesions with or without CRL, treated in the voice unit at Universidad Católica Clinical Hospital between 2015 and 2019. Patients were divided into two groups, without CRL (group A) and with CRL (group B). Analysis of preoperative and 1 month after surgery videostroboscopy, GRBASI, Voice Handicap Index-10 (VHI-10), Voice Related Quality of Life (VRQOL) surveys and management of CRL was conducted., Results: A total of 62 patients were included, 45 (72.6%) had CRL. When compared, bivariate and multivariate analysis revealed that age was significantly associated as a mild protective factor of presenting a CRL (P < 0.05). No significative differences were found between preoperative group A and B perceptual voice analysis or voice surveys. In terms of CRL management, 30 (66.6%) were injected, conservative management with observation was performed in 12 patients (26.7%) and, three (6.7%) were surgically resected. After 1 month follow-up, 32 (71.1%) had complete CRL resolution, eight (17.8%) had CRL persistence and, five (11.1%) had CRL recurrence. Postoperative vocal outcomes, GRBASI, VHI-10 and VRQOL showed significative improvement as compared with preoperative data for each group. No differences were seen between group A and B in terms of postoperative vocal outcomes., Conclusion: CRL are prevalent, and their management is controversial. On our study 72.6% of BFVL presented with CRL and 93.3% of them were conservatively managed. Improvement in perceptual voice analysis and quality of life surveys were similar in both groups., Competing Interests: Conflict of interest The authors declare no conflict of interests., (Copyright © 2022. Published by Elsevier Inc.)

Background: Carotid near-occlusion (CNO) represents an anatomical-functional condition characterized by severe (more than 90%) internal carotid artery stenosis which can lead to a distal lumen diameter greater or less than 2 mm. CNO can be divided into a less severe subgroup (without lumen full collapse: diameter >2 mm) and a more severe subgroup (with lumen full collapse: diameter <2 mm). The decision for revascularization is still highly debated in Literature. The aim of the present multicenter retrospective study is to analyze the incidence of perioperative (30 days) and follow-up complications in 2 groups of patients with or without distal internal carotid lumen full collapse., Methods: Between January 2011 and March 2023, in 5 Vascular Surgery Units, 67 patients (49 male, 73% and 18 females, 27%) with CNO underwent carotid endarterectomy: 28 (41.7%) with lumen diameter <2 mm and 39 (58.3%) with diameter >2 mm. 19 patients were symptomatic and 48 asymptomatic. The outcomes considered for comparative analysis were: perioperative neurological and cardiac complications, carotid restenosis or occlusion at follow-up. Both groups were homogeneous in terms of risk factors, morphological features and pharmacological treatments., Results: In the group with lumen <2 mm, 3 perioperative major events (10.7%) occurred (1 ischemic stroke, 1 hemorrhagic stroke, 1 myocardial infarction) and 2 (7.1%) at follow-up (average 11 ± 14.5 months; 1 asymptomatic carotid occlusion, 1 hemodynamic restenosis treated with stenting). No event was recorded in the group with lumen >2 mm., Conclusions: According to our results CNO patients show different complication risk according to the presence or not of distal lumen collapse. The later seems to play a significant role in perioperative and follow-up complication rate. These results therefore support a surgical treatment only in patients with CNO without lumen full collapse., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Toxic renal effects of myoglobin following rhabdomyolysis can cause acute kidney injury (AKI) with the necessity of kidney replacement therapy (KRT). Fast elimination of myoglobin seems notable to save kidney function and intensify kidney repair. Clinical data regarding efficacy of KRT in critical care patients with rhabdomyolysis and AKI are limited. This retrospective analysis aimed to identify differences between conservative therapy and different modalities of KRT regarding myoglobin elimination and clinical outcome., Methods: This systematic, retrospective, single-center study analyzed 328 critical care patients with rhabdomyolysis (myoglobin > 1000 µg/l). Median reduction rate of myoglobin after starting KRT was calculated and compared for different modalities. Multivariate logistic regression models were established to identify potential confounder on hospital mortality. Filter lifetime of the various extracorporeal circuits was analyzed by Kaplan-Meier curves., Results: From 328 included patients 171 required KRT. Health condition at admission of this group was more critical compared to patient with conservative therapy. Myoglobin reduction rate did not differ between the groups (KRT 49% [30.8%; 72.2%] vs. conservative treatment (CT) 61% [38.5%; 73.5%]; p = 0.082). Comparison between various extracorporeal procedures concerning mortality showed no significant differences. Hospital mortality was 55.6% among patients with KRT and 18.5% with CT (p < 0.001). Multivariate logistic regression model identified requirement for KRT (OR: 2.163; CI: 1.061-4.407); p = 0.034) and the SOFA Score (OR: 1.111; CI: 1.004-1.228; p = 0.041) as independent predictive factors for hospital mortality. When comparing specific KRT using multivariate regression, no benefit was demonstrated for any treatment modality. Life span of the extracorporeal circuit was shorter with CVVH compared to that of others (log-Rank p = 0.017)., Conclusions: This study emphasizes that AKI requiring KRT following rhabdomyolysis is accompanied by high mortality rate. Differences in myoglobin reduction rate between various KRTs could not be confirmed, but CVVH was associated with reduced filter lifetime compared to other KRTs, which enable myoglobin elimination, too., (© 2024. The Author(s).)

Supracondylar humerus fractures are the most common elbow fractures in children up to 10 years of age. The incidence of associated nerve injuries varies up to 15% depending on the data. Traumatic and iatrogenic lesions mainly affect the ulnar nerve. The regeneration of peripheral nerves is comparatively better in childhood. In the present study, the functional results after surgical and conservative treatment of nerve injuries in children after supracondylar fractures were compared and analyzed for influencing factors. In this retrospective comparative study, clinical data of pediatric nerve injuries following supracondylar humerus fractures treated over a period of 13 years (2008-2021) were analyzed. Children who were treated surgically (neurolysis, autologous reconstruction) due to insufficient clinical/neurophysiological improvement within 6 months after trauma or who were followed up conservatively in case of regression of symptoms within 6 months after trauma were included. All patients underwent multidisciplinary follow-up. 48 patients (26 female/22 male) with nerve injuries were included in this study. All patients had a history of surgical treatment with K- wire fixation due to severe dislocated fractures. The mean age was 7±2 years. The initial symptoms were severe motor deficits in all patients and sensory deficits in 87.5% (n=42). Isolated lesions of the ulnar nerve were most common (n=24, 50%). The nerve was neurolysed in 21 patients and additionally transferred to the volar side in 15. Nerve grafting was performed in 7 children and split repair in 2. Postoperatively, there was a significant improvement in motor function in all patients. Despite comparably severe motor deficits at initial presentation, further 20 children were treated conservatively due to the regression of neurological deficits. They showed comparably good functional results. No serious complications were recorded in either group. The average follow-up time was 377.25±524.87 days. The presented study shows excellent functional results after surgical treatment of pediatric nerve injuries without severe complications. Children with comparatively high-grade lesions at initial presentation have a good chance of complete spontaneous remission even without surgery. For this reason, the indication for surgery in children should be very carefully considered., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objectives: Endovascular treatment (EVT) is an alternative method used to treat isolated dissection of the celiac artery (IDCA). However, only a few mid-term results have been reported. This study aimed to analyze and compare the outcomes of endovascular and non-operative therapies for IDCA., Methods: Data from a cohort of consecutive IDCA patients enrolled in the study hospital between April 2012 and September 2020 were retrospectively reviewed. Demographic information, imaging features, treatment modalities, and follow-up results of celiac artery remodeling and adverse events were collected and analyzed., Results: A total of 87 patients were enrolled in the study. Stents were deployed in 68 patients, and non-operative treatment (blood pressure control and pain management) was continued in the remaining 19 patients who did not receive stenting; among these 19 patients, EVT failed in 6. The mean follow-up period was 37.3 (range, 10-85 months) and 44.0 (range, 9-80 months) months in the EVT and non-operative groups, respectively. During follow-up, the overall complete remodeling (absence of residual dissection with no false lumen or no intramural thrombus) rate was significantly higher in the EVT group than in the non-operative group (87.3% vs 7.1%, p<0.001). The incomplete remodeling (improved true lumen with malabsorption or partial thrombosis of the false lumen) rate was not significantly different between the EVT and non-operative groups (6.3% vs 14.3%; p=0.2984). Meanwhile, the adverse event-free survival rates were 89.0%, 67.0%, and 67.0% at 1, 3, and 5 years, respectively, in the EVT group compared with 39.7% and 29.8% at 1 and 3 years in the non-operative group (p<0.0001)., Conclusions: EVT for IDCA may be considered an effective management option with a favorable clinical success rate, an encouraging complete remodeling rate, and a satisfactory adverse event-free survival rate. However, further evaluation with a long-term follow-up is required., Clinical Impact: Endovascular intervention for isolated dissection of the celiac artery has attracted inadequate attention. In this retrospective study with comparative analysis of endovascular versus conservative therapy for isolated dissection of the celiac artery patients, a better complete remodeling rate and a higher adverse event-free survival rate were observed in the endovascular treatment (EVT) group during follow-up, indicating that EVT could be an effective management option for isolated dissection of the celiac artery., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function., Methods and Results: We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I 2 =31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I 2 =84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding., Conclusion: We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations., Prospero Registration Number: CRD42022306132., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Chyle leak is a pathological extravasation of chyle into the peritoneal cavity after a surgical injury. It is an uncommon complication in colorectal surgery. In most cases, conservative treatment is effective, although it often entails prolonged hospital stays. We present the case of a 60-year-old female with chyle leak after laparoscopic left hemicolectomy with complete mesocolic excision who underwent successful outpatient conservative management. We found no other cases of successful conservative outpatient treatment in the consulted literature. Adequate outpatient management may provide significant benefits by reducing hospital costs and improving patient´s quality of life, while maintaining the possibility of starting adjuvant treatment if indicated.

Background: Different treatment options are discussed for geriatric odontoid fracture. The aim of this study was to compare the treatment options for geriatric odontoid fractures., Methods: Included were patients with the following criteria: age ≥ 65 years, identification of seniors at risk (ISAR score ≥ 2), and odontoid fracture type A/B according to Eysel and Roosen. Three groups were compared: conservative treatment, surgical therapy with ventral screw osteosynthesis or dorsal instrumentation. At a follow-up examination, the range of motion and the trabecular bone fracture healing rate were evaluated. Furthermore, demographic patient data, neurological status, length of stay at the hospital and at the intensive care unit (ICU) as well as the duration of surgery and occurring complications were analyzed., Results: A total of 72 patients were included and 43 patients could be re-examined (range: 2.7 ± 2.1 months). Patients with dorsal instrumentation had a better rotation. Other directions of motion were not significantly different. The trabecular bone fracture healing rate was 78.6%. The patients with dorsal instrumentation were hospitalized significantly longer; however, their duration at the ICU was shortest. There was no significant difference in complications., Conclusion: Geriatric patients with odontoid fracture require individual treatment planning. Dorsal instrumentation may offer some advantages., (© 2023. The Author(s).)

Objective: Several options for the treatment of lower extremity lymphedema (LEL) can be broadly classified into conservative treatment, such as compression garments and decongestive lymphatic therapy, and surgical treatment, such as lymphaticovenular anastomosis (LVA). The purpose of our study was to clarify the superiority of these treatments by comparing the outcomes of LVA with those of conservative treatment for early-stage LEL., Methods: We performed a single-center, retrospective cohort study. The patients with LEL who presented to our department between January 2015 and December 2022 were identified and classified into two groups: conservative treatment and surgical treatment. The LEL indexes, calculated from the four lower extremity circumferences and the body mass index, were compared at the 6-, 12-, and 24-month follow-up between the two groups., Results: Of the 101 patients with LEL, 53 with 72 affected limbs (conservative treatment, 39 patients and 53 affected limbs; surgical treatment, 15 patients and 19 affected limbs) were included in the present analysis. The therapeutic effect for reducing edema, as determined by comparing the corrected LEL index at 12 months (103.7 ± 12.7 vs 91.9 ± 10.7; P = .005) and 24 months (103.1 ± 12.9 vs 83.8 ± 7.2; P < .001), was significantly higher in the surgical treatment group than that in the conservative treatment group. The conservative treatment group showed little change in the corrected LEL index at ≤24 months of follow-up (+3.1%; P = .299). In contrast, the surgical treatment group showed a significant reduction in edema at 24 months according to the corrected LEL index (-16.2%; P = .019)., Conclusions: In early-stage LEL, conservative treatment centered on compression therapy alone only maintained edema (ie, edema did not worsen or improve). In contrast, LVA with compression therapy reduced edema., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Traumatic esophageal injuries are extremely rare and challenging both from a diagnostic and therapeutic point of view. As regards one of their patients, the authors review the etiology and the pathophysiology of esophageal perforations. They present the case of a 36-year-old patient with a penetrating chest trauma. During an acute surgery, the foreign body was removed from the mediastinum, but in the early postoperative period, an oesophageal rupture was recognized. After conservative management, the patient was discharged from the hospital without any complications 82 days after the injury. Considering that the traumatic esophageal rupture is rare and the mortality of these patients is very high, it is important to make a good decision in time. The authors would like to highlight that even in the case of severe penetrating esophageal injury, the right therapeutical decision can lead to complete recovery. Orv Hetil. 2023; 164(43): 1719-1724.

Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: We compared the early and midterm (31, 3-63 months) outcomes of conservative treatment, bare stent treatment (BST), and bare stent-assisted coiling treatment (BSACT) to determine the most effective treatment for patients with symptomatic isolated superior mesenteric artery dissection (SISMAD)., Methods: Consecutive patients with SISMAD admitted to the study hospital between January 2016 and December 2021 were included in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed., Results: A total of 121 patients were included in the study (23 with conservative treatment, 42 with BST, and 56 with BSACT). Symptoms were relieved in 91.3% of conservative patients, whereas all patients (100%) with BST or BSACT had symptom relief (P = 0.035). There was no significant difference in the length of hospital stay between the 2 endovascular treatments (P = 0.9051), but hospital stay was significantly shorter compared to conservative treatment (P < 0.0001). The cumulative rate of complete remodeling was 100% for BSACT versus 46.3% for BST (P < 0.0001) versus 42.9% for conservative patients (P < 0.0001). There were no significant differences between the last 2 groups (P = 0.3925). The prevalence of adverse events for abdominal pain recurrence and aneurysm formation was also significantly lower in the BSACT group at follow-up., Conclusions: BSACT for SISMAD has a preferable early outcome. The cumulative complete remodeling rate and the event-free survival rate are satisfactory at midterm follow-up. BSACT is an effective approach for SISMAD., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The objective of this study is to observe the effect of indwelling needle puncture and irrigation in the conservative treatment of breast abscesses in the non-lactation period. Non-lactating breast abscess patients were treated at the Daping Medical Breast Surgery Clinic, Chongqing. In the Incisive drainage group, 21 patients were treated with conventional incision and drainage. In the Indwelling needle group, 20 patients were treated by puncture and irrigation with a 20 G indwelling needle. The pain VAS scores and wound satisfaction in the Indwelling needle group were significantly lower than those in the Incisive drainage group (P < 0.001), and the cure time and complications were also significantly lower in the Indwelling needle group (P < 0.05). The cure rates of the two groups were similar (P > 0.05). There was a difference in the duration of illness, location, and number of pus cavities between the treatment failure and the treatment recovery (P < 0.05). However, there was no difference in the size of the pus cavity and the maximum amount of pus aspiration (P > 0.05). The indwelling needle can be used as an effective tool for puncture and irrigation of single breast abscess in a non-lactation period, potentially for non-invasive treatment of breast abscesses.

Objective: Abdominal aortic graft and endograft infections (AGIs) are rare complications following aortic surgery. Radical surgery (RS) with resection of the infected graft and reconstruction with extra-anatomical bypass or in situ reconstruction is the preferred therapy. For patients unfit for RS, a semi-conservative (SC), graft preserving strategy is possible. This paper aimed to compare survival and infection outcomes between RS and SC treatment for AGI in a nationwide cohort., Methods: Patients with abdominal AGI related surgery in Sweden between January 1995 and May 2017 were identified. The Management of Aortic Graft Infection Collaboration (MAGIC) criteria were used for the definition of AGI. Multivariable regression was performed to identify factors associated with mortality., Results: One hundred and sixty-nine patients with surgically treated abdominal AGI were identified, comprising 43 SC (14 endografts; 53% with a graft enteric fistula [GEF] in total) and 126 RS (26 endografts; 50% with a GEF in total). The SC cohort was older and had a higher frequency of cardiac comorbidities. There was a non-significant trend towards lower Kaplan-Meier estimated five year survival for SC vs. RS (30.2% vs. 48.4%; p = .066). A non-significant trend was identified towards worse Kaplan-Meier estimated five year survival for SC patients with a GEF vs. without a GEF (21.7% vs. 40.1%; p = .097). There were significantly more recurrent graft infections comparing SC with RS (45.4% vs. 19.3%; p < .001). In a Cox regression model adjusting for confounders, there was no difference in five year survival comparing SC vs. RS (HR 1.0, 95% CI 0.6 - 1.5)., Conclusion: In this national AGI cohort, there was no mortality difference comparing SC and RS for AGI when adjusting for comorbidities. Presence of GEF probably negatively impacts survival outcomes of SC patients. Rates of recurrent infection remain high for SC treated patients., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Conclusive evidence describing the outcomes following different treatment strategies for tension pneumocranium (TP) is lacking. Impact of predisposing conditions like multiple transnasal transsphenoidal (TNTS) procedures, intraoperative cerebrospinal fluid leak, obstructive sleep apnea, continuous positive airway pressure, violent coughing, nose blowing, positive pressure ventilation on TP outcomes is also unknown., Methods: PubMed, Embase, Cochrane, and Google Scholar were searched for articles using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Multivariate logistic regression analysis was done using STATA/ BE ver 17.0., Results: Thirty-five studies with 49 cases of endoscopic TNTS surgeries were included. Tension pneumocephalus was seen in 77.5% (n = 38), tension pneumosella in 7 (14.28%), and tension pneumoventricle in 4 (8.16%). Nonfunctional pituitary adenomas (40.81%) were most common lesions associated with TP. The need of mechanical ventilation was significantly higher in patients who received conservative management (odds ratio, 1.34; confidence interval, 0.65-2.74) (P < 0.01). However, incidence of meningitis or mortality were not influenced by factors like age, gender, pathological diagnosis, initial conservative management or early skull base repair, use of adjuvant radiation, intraoperative cerebrospinal fluid leak, multiple TNTS explorations, or presence of precipitating factors., Conclusions: Nonfunctional pituitary adenomas were the most common lesions associated with TP. Multiple TNTS procedures did not increase incidence of meningitis or mortality. Conservative management increased the need for mechanical ventilation but did not worsen the mortality outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Clinically silent uterine rupture with complete fetal expulsion into the abdominal cavity is an extremely rare complication. Diagnosis can be difficult and the risk to the mother and fetus is high. Conservative management has been described only in a few cases of partial expulsion of the fetus so far., Case Presentation: We present a case of 43-year-old tercigravida with a history of previous laparotomic myomectomy and subsequent cesarean section. The subsequent pregnancy was complicated by uterine wall loosening and rupture at the site of the previous uterine scar after myomectomy and complete fetal expulsion into the abdominal cavity. The diagnosis was made at 24 + 6 weeks of gestation. Considering the absence of clinical symptomatology and the good condition of the fetus, a conservative approach was chosen with intensive monitoring of the maternal and fetal conditions. The pregnancy ended by elective cesarean section and hysterectomy at 28 + 0 weeks of gestation. The postpartum course was uneventful and the newborn was discharged to home care 63 days after delivery., Conclusions: Fetal expulsion into the abdominal cavity after silent uterine rupture of the scarred uterus may be accompanied by minimal symptomatology making early diagnosis difficult. This rare complication must be considered in the differential diagnosis in women after major uterine surgery. In selected cases and under conditions of intensive maternal and fetal monitoring, conservative management may be chosen to reduce the risks associated with prematurity., (© 2023. The Author(s).)

Background: Hemodialysis patients are prone to gastrointestinal bleeding, and Mallory-Weiss syndrome (MWS) is one of the causes. Mallory-Weiss syndrome is often induced by severe vomiting, manifests as upper gastrointestinal bleeding, and is self-limited with a good prognosis. However, mild vomiting in hemodialysis patients can lead to the occurrence of MWS, and the mild early symptoms are easy to misdiagnose, leading to the aggravation of the disease., Case Presentation: In this paper, we report four hemodialysis patients with MWS. All patients displayed symptoms of upper gastrointestinal bleeding. The diagnosis of MWS was confirmed by gastroscopy. One patient had a history of severe vomiting; however, the other three reported histories of mild vomiting. Three patients received the conservative hemostasis treatment, and the gastrointestinal bleeding stopped. One patient underwent the gastroscopic and interventional hemostasis treatments. The conditions of three of the patients improved. Unfortunately, one of the patients died due to the cardia insufficiency., Conclusions: We think that the mild symptoms of MWS are easily covered up by other symptoms. This may lead to delays in diagnosis and treatment. For patients with severe symptoms, gastroscopic hemostasis is still the first choice, and interventional hemostasis can also be considered. For patients with mild symptoms, drug hemostasis is the first consideration., (© 2023. The Author(s).)

Background: The optimal management of patients with spontaneous coronary artery dissection remains debated., Methods: Patients enrolled in the DISCO (Dissezioni Spontanee Coronariche) Registry up to December 2020 were included. The primary end point was major adverse cardiovascular events, a composite of all-cause death, nonfatal myocardial infarction, and repeat percutaneous coronary intervention (PCI). Independent predictors of PCI and medical management were investigated., Results: Among 369 patients, 129 (35%) underwent PCI, whereas 240 (65%) were medically managed. ST-segment-elevation myocardial infarction (68% versus 35%, P <0.001), resuscitated cardiac arrest (9% versus 3%, P <0.001), proximal coronary segment involvement (32% versus 7%, P <0.001), and Thrombolysis in Myocardial Infarction flow 0 to 1 (54% versus 20%, P <0.001) were more frequent in the PCI arm. In-hospital event rates were similar. Between patients treated with PCI and medical therapy, there were no differences in terms of major adverse cardiovascular events at 2 years (13.9% versus 11.7%, P =0.467), all-cause death (0.7% versus 0.4%, P =0.652), myocardial infarction (9.3% versus 8.3%, P =0.921) and repeat PCI (12.4% versus 8.7%, P =0.229). ST-segment-elevation myocardial infarction at presentation (odds ratio [OR], 3.30 [95% CI, 1.56-7.12]; P =0.002), proximal coronary segment involvement (OR, 5.43 [95% CI, 1.98-16.45]; P =0.002), Thrombolysis in Myocardial Infarction flow grade 0 to 1 and 2 (respectively, OR, 3.22 [95% CI, 1.08-9.96]; P =0.038; and OR, 3.98 [95% CI, 1.38-11.80]; P =0.009) and luminal narrowing (OR per 5% increase, 1.13 [95% CI, 1.01-1.28]; P =0.037) were predictors of PCI, whereas the 2B-angiographic subtype predicted medical management (OR, 0.25 [95% CI, 0.07-0.83]; P =0.026)., Conclusions: Clinical presentation and procedural variables drive the choice of the initial therapeutic approach in spontaneous coronary artery dissection. If PCI is needed, it seems to be associated with a similar risk of short-to-mid-term adverse events compared to medical treatment., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT04415762., Competing Interests: Disclosures Dr Porto reports consultant or speaker fees from Biotronik, ABIOMED, Terumo, Philips, Sanofi, Amgen, Daiichi-Sankyo, Astra Zeneca, Bayer, and PIAM, not related to this work. The other authors report no conflicts.

Tracheal perforation is a rare complication of intubation and is associated with high mortality. Here we describe a case of large, full-thickness tracheal perforation from traumatic intubation after an elective procedure. The injury was managed with prolonged intubation that bypassed the site of injury, and the patient was successfully extubated after 11 days. Conservative management of tracheal perforation after traumatic intubation is an option in select patients that avoids need for surgery.

Hepatic subcapsular hematoma and hepatic infarction in labor are mostly secondary to HELLP syndrome and preeclampsia. There are few reported cases with a complicated diagnosis and treatment and high mortality. Here, we present a case of a huge hepatic subcapsular hematoma complicated with hepatic infarction after cesarean section that was secondary to HELLP syndrome and the patient was treated conservatively. Further, we have discussed the diagnosis and treatment of hepatic subcapsular hematoma and hepatic infarction caused by HELLP syndrome., Competing Interests: The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective: The aim of this study was to describe and present the outcomes of a specific treatment protocol for aortic vascular graft and endograft infections (VGEIs) without explantation of the infected graft., Methods: This was a retrospective, observational single centre cohort study carried out between 2012 and 2022 at a tertiary hospital. An aortic VGEI was defined according to the Management of Aortic Graft Infection Collaboration (MAGIC) criteria. Fitness for graft excision was assessed by a multidisciplinary team and included an evaluation of the patient's general condition, septic status, and anatomical complexity. Antimicrobial treatments were individualised. The primary outcome was survival at the last available follow up; secondary outcomes were antimicrobial treatment duration, infection eradication, treatment failure despite antimicrobial treatment, and the development of aortic fistulation., Results: Fifty patients were included in the study, of whom 42 (84%) had had previous endovascular repair. The median patient age was 72 years (range 51 - 82 years) and median duration of treatment with antimicrobials was 18 months (range 1 - 164 months). Kaplan-Meier analysis estimated the 30 day survival to be 98% (95% confidence interval [CI] 96 - 100), the one year survival rate to be 88% (95% CI 83.4 - 92.6), and the three year survival rate to be 79% (95% CI 72.7 - 84.7). Twenty-four (48%) patients were able to discontinue antibiotic treatment after a median of 16 months (range 4 - 81 months). When categorised according to infected graft location, deaths occurred in four (40%) patients with thoracic, two (40%) with paravisceral, seven (30%) with infrarenal VGEIs, and in one (25%) patient with an aorto-iliac VGEI; no (0%) patient with a thoraco-abdominal VGEI died., Conclusion: Identifying the microbiological aetiology in patients with aortic VGEI enables individualised, specific antibiotic treatment, which may be useful in patients with a VGEI excluded from surgery. This single centre retrospective analysis of patients with VGEIs without fistula selected for conservative treatment suggests that conservative management of aortic VGEIs with targeted antibiotic therapy without graft excision is potentially effective, and that antimicrobial treatment will not necessarily be needed indefinitely., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous., Objectives: To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA)., Methods: Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant., Results: Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%)., Conclusions: Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.