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In this trial involving asymptomatic patients with severe carotid stenosis, stenting was noninferior to endarterectomy with regard to the primary composite end point of death, stroke, or myocardial infarction within 30 days or ipsilateral stroke within 1 year after the procedure. Stroke is the fifth leading cause of death and the leading cause of disability among U.S. adults. It affects nearly 800,000 people in the United States annually, resulting in more than 170,000 deaths and causing major disability among the survivors, at a cost estimated to exceed $41 billion annually. 1 Extracranial carotid-artery disease is responsible for up to 20% of these strokes. The Asymptomatic Carotid Atherosclerosis Stenosis (ACAS) and Asymptomatic Carotid Surgery (ACST) trials showed that among asymptomatic patients with carotid-artery stenosis of greater than 60% of the diameter of the artery, the risk of stroke or death was lower when . . .

Repair of Abdominal Aortic Aneurysm This clinical trial compared endovascular with open repair of unruptured abdominal aortic aneurysm. An early survival advantage with endovascular repair was not sustained after 3 years. Aneurysm rupture remains a concern with this type of repair. Each year, 40,000 patients in the United States undergo elective procedures to repair abdominal aortic aneurysms. 1 These procedures result in about 1250 perioperative deaths — more than for any other general or vascular surgical procedure, with the exception of colectomy. 2 Endovascular repair was introduced in the 1990s as a less invasive method than traditional open repair. Randomized trials have shown that endovascular repair reduces perioperative mortality, 3 – 5 but in the United Kingdom Endovascular Aneurysm Repair 1 (EVAR 1) trial 3 and the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, 4 this advantage was lost within 2 years owing to excess late deaths . . .

Abdominal aortic aneurysm (AAA) rupture remains a significant cause of morbidity and mortality, but predictors of continued growth and rupture risk remain limited. The aim of this study was to investigate the relationship between abdominal aortic calcification and AAA growth via a secondary cohort analysis of the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT), a prospective multicenter randomized study. Arterial calcification Agatston scores and maximum transverse diameter were measured in non-contrast computed tomography (CT) scans in patients enrolled in N-TA3CT. Uni- and multi-variable linear regression were used to assess the association of anatomic calcium burden and comorbid conditions with rate of aneurysm growth. Of the 261 randomized patients in the trial, 136 patients met inclusion criteria for analysis. On univariable analysis, baseline calcium score at all assessed anatomic locations- the superior mesenteric artery (spearman correlation coefficient (SCC) -0.20, p  = 0.0176), renal artery (-0.22, p  = 0.0120, infrarenal aorta (-0.26, p  = 0.0020), common iliac artery (-0.19, p  = 0.024), external iliac artery (-0.26, p  = 0.003), and sum of all measured sites (-0.28, p  = 0.001)- was significantly associated with lower AAA diameter growth rates. Of individually measured sites, baseline infrarenal aortic calcification had the strongest negative association with aneurysm growth. Interestingly, infrarenal calcium score was not significantly associated with baseline aneurysm diameter (R 2 0.0001, spearman correlation p  = 0.94), or diabetes status ( p  = 0.59). In a multivariable regression model, factors significantly associated with faster diameter growth included baseline volume and current tobacco use. Factors associated with reduced growth rate included diabetes and baseline infrarenal aorta calcium score thereby establishing aneurysmal calcification as a marker for slower aneurysm growth.

A randomized, multicenter trial that compared endovascular repair with open repair of abdominal aortic aneurysm showed no significant difference between these approaches in overall survival after 8 years.

Objective Endovascular repair is the preferred treatment for aortoiliac aneurysm, with preservation of at least one internal iliac artery recommended. This study aimed to assess pre-endovascular repair anatomical characteristics of aortoiliac aneurysm in patients from the Global Iliac Branch Study (GIBS, NCT05607277) to enhance selection criteria for iliac branch devices (IBD) and improve long-term outcomes. Methods Pre-treatment CT scans of 297 GIBS patients undergoing endovascular aneurysm repair were analyzed. Measurements included total iliac artery length, common iliac artery length, tortuosity index, common iliac artery splay angle, internal iliac artery stenosis, calcification score, and diameters in the device's landing zone. Statistical tests assessed differences in anatomical measurements and IBD-mediated internal iliac artery preservation. Results Left total iliac artery length was shorter than right (6.7 mm, P  = .0019); right common iliac artery less tortuous ( P  = .0145). Males exhibited greater tortuosity in the left total iliac artery ( P  = .0475) and larger diameter in left internal iliac artery's landing zone ( P  = .0453). Preservation was more common on right (158 unilateral, 34 bilateral) than left (105 unilateral, 34 bilateral). There were 192 right-sided and 139 left-sided IBDs, with 318 IBDs in males and 13 in females. Conclusion This study provides comprehensive pre-treatment iliac anatomy analysis in patients undergoing endovascular repair with IBDs, highlighting differences between sides and sexes. These findings could refine patient selection for IBD placement, potentially enhancing outcomes in aortoiliac aneurysm treatment. However, the limited number of females in the study underscores the need for further research to generalize findings across genders.

ObjectiveThe aim of this exploratory study was to compare the performance of carotid artery stenting (CAS) best practices between Intersocietal Accreditation Commission (IAC) accredited facilities and non-accredited facilities certified by the Centers for Medicare and Medicaid Services (CMS).MethodsA random, anonymous survey was sent to CMS and IAC accredited facilities querying facility routine performance of 16 CAS procedure components found in published guidelines and utilised during clinical trials.ResultsThere were 28 responses (response rate=17%). Significant differences were found between the CMS and the IAC facilities for four of 16 procedure measures: determination of modified Rankin Scale score prior to stenting (p=0.012, 95% CI 20% to 80%), accurate measurement of per cent stenosis using electronic callipers (p=0.005, 95% CI 24% to 84%), confirmation of anticoagulation with activated clotting time greater than 250 s prior to crossing the lesion (p=0.03, 95% CI 7% to 69%), and comparison of facility outcomes to accepted benchmarks for stroke and death (p=0.03, 95% CI 7% to 69%). Overall, IAC facilities performed all 16 procedures more frequently (97%) than CMS facilities (66%) (p<0.001, 95% CI 24% to 36%).ConclusionsAlthough the sample size was small, the results demonstrated IAC accredited facilities are more likely to follow best practices, to use quantitative tools to select appropriate patients, and quantitively measure patient-centred clinical outcomes compared with CMS certified facilities. The findings raise the question as to the value of CMS certification versus IAC accreditation as a requirement for reimbursement.

The purpose of this study was to evaluate the prevalence of radiographically detected abdominal wall defects (AWD) after open abdominal aortic aneurysm (AAA) repair and to correlate it with prospectively gathered clinical information. Fine collimation, high-resolution, serial follow-up computed tomography (CT) scans for 99 patients in the control group of the Guidant Ancure device trial were reviewed. CT scans were obtained at 12, 24, 36, 48, and 60 months. AWDs, defined as discontinuity of the fascial layer with protrusion of abdominal contents, were identified. Clinical information regarding AWDs was retrieved from the study registry. The prevalence of AWD exceeds 20% and plateaus at 24 months. Eight patients (8%) had clinical evidence of ventral incisional hernias. One patient underwent repair, but no other patient developed hernia incarceration or intestinal obstruction or required additional procedures related to the AWD. AWDs are radiographic findings occurring frequently after open AAA repair. Radiographic evaluation is more sensitive than clinical observation for detection of ventral hernias. Clinical events and reinterventions related to these radiographic abnormalities are rare.

To the Editor: Lederle and colleagues (May 30 issue) 1 report similar long-term overall survival after endovascular or open surgical repair of infrarenal aortic aneurysms in the Open versus Endovascular Repair (OVER) trial. These results contrast with those from two trials conducted in Europe. 2,3 An important issue is the generalizability of the results. It is noteworthy that a majority (52%) of patients who underwent screening in the OVER trial were excluded because they were ineligible to undergo both procedures. However, no anatomical criteria are provided in the protocol (available with the full text of their article at NEJM.org) except that patients . . .