Current Issue Highlights

Association of preoperative antifibrinolytics with reduced blood transfusions after vascular surgery procedures
August 2026: 84(2):534-543.e3
Objective
Major vascular surgery interventions are critical for treating peripheral artery disease but carry a high risk of intraoperative blood loss with resultant coagulopathy. Blood product transfusions are limited, costly, and associated with an increased risk of myocardial infarction and death. Planned preoperative administration of antifibrinolytic agents (AFAs), aimed at inhibiting intraoperative plasmin-mediated lysis, has become a standard practice for orthopedic, trauma, obstetrics, and cardiac surgery, effectively reducing the perioperative bleeding and transfusion requirements. However, there are limited data that support AFA use in vascular surgery interventions. We hypothesize that preoperative AFA administration in elective major vascular surgical interventions is associated with reduced receipt of blood products.
Methods
We included elective, index major abdominal revascularization procedures (open abdominal aortic aneurysm repair, mesenteric revascularization, and aortoiliac revascularization) and lower extremity revascularization procedures (open bypass) in adult patients across a multihospital health care system (January 2017-June 2024). Preoperative AFA use (tranexamic acid or epsilon-aminocaproic acid) was defined as administration within 60 minutes of the operative start time recorded in anesthesia logs. The primary outcome was total blood product transfusions received (packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate) within 5 postoperative days. Safety outcomes included inhospital seizures, venous thromboembolism events (VTEs; deep venous thrombosis, pulmonary embolism), arterial thrombosis (stroke, bypass thrombosis), and bleeding complications. Multivariable negative binomial regression was used to analyze the association between preoperative AFAs and the number of postoperative blood transfusions with clinically significant covariates selected a priori with variance clustering by surgeon.
Results
Among 674 patients (aged 68.6 ± 10.8 years, male 67.4%, and White 88.1%), 213 (31.6%) received preoperative AFAs. Among treated patients, 36 (16.9%) received blood transfusion by postoperative day 5 at a median of 2 [IQR, 1-2] products per person. After covariate adjustment, preoperative AFA use was significantly associated with fewer blood products transfused by 5 postoperative days (adjusted incident rate ratios [aIRR], 0.57; 95% CI, 0.34-0.98; P =.04). Seizures were only observed among patients who did not receive preoperative AFAs (n = 2). Rates of VTE, bleeding complication, and bypass thrombosis were similar with and without AFA exposure (VTE: n = 2 [0.9%] vs n = 5 [1.1%]; P = .86; bleeding: n = 3 [1.4%] vs n = 6 [1.3%]; P > .9; bypass thrombosis: n = 7 [3.3%] vs n = 11 [2.4%]; P = .7). There were no inhospital strokes.
Conclusions
Overall, preoperative administration of AFAs was associated with a decreased number of transfusions at 5 postoperative days without notable safety concerns after major vascular interventions. These findings suggest a potential benefit of including preoperative AFA administration as the standard of care for patients undergoing major vascular surgery.
Rising hospital costs outpace reimbursement for common vascular procedures
August 2026: 84(2):528-533
Background
Hospitals across the United States have experienced rapidly increasing operating costs since the COVID-19 pandemic, driven by inflation, labor shortages, and rising supply and device expenses. Because vascular surgery care frequently relies on specialized procedural resources and serves a predominantly Medicare population, reimbursement growth may not adequately offset rising hospital costs. This study evaluated trends in hospital costs, reimbursement, and procedural margins for commonly performed vascular procedures within a large tertiary health system.
Methods
Institutional cost accounting data were retrospectively reviewed for five commonly performed vascular procedures performed between 2019 and 2022: arteriovenous fistula creation, arteriovenous graft placement, carotid endarterectomy, endovascular aortic repair, and lower extremity angiography with percutaneous intervention. Financial data were obtained from the STRATA Jazz financial analytics platform and included direct hospital costs, reimbursement, and contribution to indirect (CTI). Financial metrics were standardized per case and compared between the prepandemic baseline year (2019) and the combined postpandemic period (2020-2022). Secondary outcomes included procedural volume, length of stay, and payer mix.
Results
Direct hospital costs increased by approximately 31% to 32% between 2019 and 2022, whereas reimbursement increased by only 20% to 21%, resulting in substantial margin compression. Overall CTI decreased from $1470 per case in 2019 to $1177 during 2020-2022, representing a 20% decline. Outpatient procedures demonstrated a 23% increase in direct costs with a slight decline in reimbursement, resulting in a 25% reduction in CTI. Inpatient procedures demonstrated a 32% increase in direct costs and a 12% decline in CTI per case. Procedure-level analysis demonstrated marked margin deterioration across multiple interventions, including a 67% decline for lower extremity angiography with intervention, a 52% decline for carotid endarterectomy, and conversion of endovascular aortic repair margins from positive to negative by 2022. Procedural volumes, payer mix, and hospital length of stay remained stable throughout the study period.
Conclusions
Direct hospital costs for commonly performed vascular procedures increased substantially from 2019 to 2022 and significantly outpaced reimbursement growth, resulting in progressive erosion of procedural margins across inpatient and outpatient vascular interventions. These findings suggest that structural increases in hospital operating costs, rather than changes in procedural utilization, are driving worsening financial performance. Greater alignment between reimbursement and the true costs of delivering complex vascular care will be necessary to ensure the long-term sustainability of vascular surgery programs.
Quantifying vascular access-associated excess mortality in maintenance hemodialysis patients
August 2026: 84(2):519-526.e1
Objective
Central venous catheters (CVCs) are commonly linked with higher mortality in hemodialysis (HD) patients compared with arteriovenous accesses (AVAs). However, patients with CVCs often have greater comorbidities, complicating causal interpretation. This study aimed to assess the association between vascular access type and survival adjusting for relevant confounders.
Methods
In this retrospective cohort study, data from 146,967 incident HD patients treated between 2016 and 2019 at a large North American dialysis organization (Fresenius Medical Care North America) were analyzed. Multiple analytic strategies were conducted including inverse probability treatment weighted and time-dependent survival analyses.
Results
Among 146,967 incident HD patients, median survival was 1106 days for those initiating with a CVC compared with 1290 days for patients with an AVA, corresponding to a 184-day difference and an 88% restricted mean survival time (RMST) ratio. In the sustained access analysis, median survival was 448 days for CVC-only vs 1226 days for AVA-only patients (RMST difference = 778 days, RMST ratio = 52%). After inverse probability treatment weighting, AVA initiation was associated with a 25% lower mortality risk (hazard ratio: 0.75, 95% confidence interval: 0.73-0.76) and sustained AVA use with a 62% lower risk (hazard ratio: 0.38, 95% confidence interval: 0.36-0.40). Differences in infection-related deaths between the groups were small (8.6%-10.6% of deaths in all comparison groups).
Conclusions
CVC use was associated with higher mortality compared with AVA. Although AVA use remained linked with better survival across analyses, the precise magnitude of any access-related benefit cannot be determined within the constraints of observational data. There are strong indications that the excess risk at least partially reflects differences in baseline health and patient selection rather than a direct causal effect.
Progression of peripheral arterial disease predicts worse outcomes after dialysis access surgery
August 2026: 84(2):510-518
Objective
Peripheral arterial disease (PAD) is highly prevalent among patients requiring hemodialysis access and reflects advanced systemic atherosclerosis. We evaluated whether PAD severity is associated with increased postoperative complications and loss of primary patency following dialysis access creation and performed stratified analyses by access type: arteriovenous fistula (AVF) and arteriovenous graft (AVG).
Methods
We used the Vascular Quality Initiative database from 2011 to 2024, including patients undergoing upper-extremity hemodialysis access creation. PAD status was categorized as no PAD, asymptomatic PAD, claudication, or chronic limb-threatening ischemia (CLTI). Postoperative outcomes included 30-day mortality, prolonged length of stay, bleeding, thrombosis, and steal syndrome. Six-month primary patency was defined as time to first intervention, thrombosis, failure, or abandonment. Multivariable logistic and Cox regression analyses were performed in the overall cohort, followed by subgroup analyses stratified by AVF and AVG.
Results
A total of 78,607 patients were included (25,718 [32.7%] no PAD; 47,771 [60.8%] asymptomatic PAD; 2079 [2.6%] claudication; and 3039 [3.9%] CLTI). In the overall cohort, increasing PAD severity was independently associated with worse postoperative outcomes. Compared with patients without PAD, asymptomatic PAD (adjusted odds ratio [aOR] 1.55; 95% confidence interval [CI], 1.27-1.90; P < .001), claudication (aOR 2.20; 95% CI, 1.52-3.18; P < .001), and CLTI (aOR 3.01; 95% CI, 2.24-4.06; P < .001) were associated with progressively higher odds of 30-day mortality. Asymptomatic PAD (aOR 1.41; 95% CI, 1.16-1.71; P < .001) and CLTI (aOR 2.27; 95% CI, 1.82-2.83; P < .001) were associated with prolonged length of stay. Asymptomatic PAD was also associated with increased odds of postoperative bleeding (aOR 1.30; 95% CI, 1.01-1.69; P = .043). Claudication (aOR 3.57; 95% CI, 1.33-9.59; P = .012) and CLTI (aOR 2.87; 95% CI, 1.21-6.82; P = .017) were associated with increased odds of steal syndrome, whereas PAD severity was not associated with postoperative thrombosis. At 6 months, all PAD stages were strongly associated with loss of primary patency: asymptomatic PAD (adjusted hazard ratio [aHR] 5.09; 95% CI, 3.15-8.22; P < .001), claudication (aHR 4.79; 95% CI, 2.86-8.02; P < .001), and CLTI (aHR 5.05; 95% CI, 3.14-8.10; P < .001). Findings were consistent in analyses stratified by AVF and AVG.
Conclusions
To our knowledge, this is the first study to comprehensively evaluate the impact of PAD and PAD progression on outcomes and patency of dialysis access. PAD severity is independently associated with increased postoperative complications, 30-day mortality, and loss of primary patency following dialysis access creation. Notably, even asymptomatic PAD confers significantly increased risk of mortality and loss of primary patency at 6 months. These findings highlight the importance of incorporating PAD status into preoperative risk stratification and dialysis access planning.
The impact of frailty on enhanced recovery protocol compliance and postoperative outcomes after infrainguinal arterial bypass
August 2026: 84(2):501-509.e2
Objective
The aim of this study was to evaluate the impact of frailty on enhanced recovery protocol (ERP) compliance and the impact of ERP on adverse postoperative outcomes in frail patients undergoing infrainguinal arterial bypass.
Methods
We performed a retrospective single-institution study of patients undergoing infrainguinal arterial bypass (2021-2024). Patients were categorized into three frailty groups using the National Surgical Quality Improvement Program five-item frailty index where F1 is less frail (F1 = 0-1 risk factor; F2 = 2 risk factors; F3 = 3-5 risk factors). The association between frailty and both ERP compliance and postoperative outcomes were analyzed. The χ² and Fisher's exact tests were used for categorical variables while continuous variables were analyzed by Kruskal-Wallis test. Time-to-event outcomes were assessed using Kaplan-Meier survival analysis in the elective intervention cohort, with follow-up truncated at 30 days.
Results
We identified 257 patients and stratified them by frailty (F1 = 32.7%; F2 = 36.6%; F3 = 30.7%). F1 patients were significantly younger (mean age, F1 = 65.0 years; F2 = 71.6 years; F3 = 71.6 years; P < .001) and less likely to present with tissue loss (F1 = 31.0%; F2 = 47.9%; F3 = 62.0%; P < .001). ERP compliance was not associated with frailty (F1 = 57.1%; F2 = 54.8%; F3 = 61.5%; P = .739). Overall, patients who underwent ERP had a significantly shorter median postoperative length of stay compared with non-ERP patients (4.8 vs 7.0 days; P < .001). Within the F3 cohort, ERP compliance was associated with a lower reintervention rate (ERP = 15.0% vs non-ERP = 33.3%; P = .050), lower postoperative length of stay (ERP = 7.9 days vs non-ERP = 9.8 days; P = .016), and a decrease in 30-day mortality (ERP = 2.5% vs non-ERP = 7.7%; P = .298). In a time-to-event analysis of elective procedures, no differences were observed in the 30-day freedom from reintervention, readmission, or mortality rates.
Conclusions
High frailty was not a barrier to the implementation of an ERP, and an ERP was associated with improved postoperative outcomes in highly frail patients.

Latest Articles

Midterm outcomes of off-the-shelf multibranched versus physician-modified endografts for endovascular repair of complex and thoracoabdominal aortic aneurysms: A systematic review and meta-analysis
Journal of Vascular Surgery. August 2026: 84(2):259-275.e1
Background
Custom-manufactured fenestrated-branched endovascular aortic repair devices have demonstrated excellent outcomes for elective repair of complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs). However, for symptomatic or ruptured aneurysms, the manufacturing and shipping time render this option impractical for urgent or emergent repair. To address this clinical need, alternative technologies have been developed, including physician-modified endografts (PMEGs) and off-the-shelf multibranched devices (OTSDs). In this systematic review and meta-analysis, we compare midterm outcomes between OTSDs and PMEGs.
Design/Method
A systematic search was conducted using the MEDLINE, Embase, Scopus, and ClinicalTrials.gov databases through January 1, 2025. Studies with 10 or more patients reporting 1- or 2-year mortality or reintervention after PMEG or OTSD repair of CAAAs or TAAAs were included. Primary outcomes included midterm reintervention and mortality. Secondary outcomes included 30-day mortality, spinal cord ischemia (SCI), and technical success. Subgroup analyses by presentation and aneurysm extent were also performed.
Results
Eighteen studies (11 PMEG, 7 OTSD), including 994 patients (538 PMEGs, 456 OTSDs), were included in the review. One-year reintervention was 11% for PMEG and 12% for OTSD (P = .966), and 2-year reintervention was 15% for PMEG and 13% for OTSD (P = .820). One-year mortality was 9% for PMEG and 8% for OTSD (P = .714), and 2-year mortality was 11% for PMEG and 12% for OTSD (P = .758). Technical success was slightly higher with OTSD (98% vs 96%, P = .03), and SCI occurred more frequently with OTSD (6% vs 0%, P < .0001). Thirty-day mortality was 1% for PMEG and 2% for OTSD (P = .836). Subgroup analyses by presentation and aneurysm extent revealed no differences in primary outcomes.
Conclusions
PMEGs and OTSDs demonstrate acceptable midterm outcomes. However, interpretation of comparative results is limited by substantial differences in aneurysm extent, symptomatic or ruptured presentation, and follow-up duration between the cohorts. Both remain viable strategies, with device selection guided by individual anatomy, urgency, and institutional expertise.
One size does not fit all
Journal of Vascular Surgery. August 2026: 84(2):276-276
The value of the mini-cuff technique in fenestrated/branched endovascular aortic repair: Efficacy validation based on the composite end point of target vessel instability
Journal of Vascular Surgery. August 2026: 84(2):277-288.e2
Objective
To evaluate whether adjunctive mini-cuff use is associated with a reduced risk of postoperative target vessel instability (TVI) after physician-modified endograft (PMEG)-based fenestrated/branched endovascular aortic repair (FB-EVAR).
Methods
This single-center retrospective cohort study included 216 patients with complex aortic diseases treated with PMEG-based FB-EVAR between January 2018 and June 2024. Patients were divided into two groups based on the use of the mini-cuff technique: the FB-EVAR with mini-cuff group (FM group; n = 79) and the FB-EVAR without mini-cuff group (FB group; n = 137). A total of 666 target vessels were analyzed at the branch level, including 193 reconstructed with adjunctive mini-cuff and 473 without mini-cuff. The primary end point was TVI, a composite of target vessel occlusion, >70% stenosis, reintervention, or type Ic/target vessel-related type III endoleak. Time-to-event data were analyzed using Cox proportional hazards regression with robust standard errors to account for within-patient clustering of vessels. Key covariates were prespecified and forced into the multivariable model, including pathology (degenerative vs postdissection), prior aortic endovascular surgery, aneurysm neck-to-sac β-angle of >60°, adverse target vessel condition, and age.
Results
The FM group had a higher prevalence of prior aortic endovascular surgery (48.1% vs 16.1%) and postdissection pathology (65.8% vs 27.7%); at the branch level, adverse anatomical conditions were also more frequent in the FM group (26.4% vs 19.2%). In the unadjusted branch-level analysis, TVI occurred less often with mini-cuffs (10.9% vs 16.3%), although this difference did not attain statistical significance (P = .074). Because mini-cuffs were selectively used in higher-risk anatomies, multivariable adjusted analyses were performed. In the multivariable Cox model with robust standard errors, mini-cuff use was independently associated with a lower hazard of TVI (adjusted hazard ratio, 0.882; 95% confidence interval, 0.802-0.969; P = .009). At 24 months, the Kaplan-Meier-estimated branch-level TVI risk was approximately 20% with mini-cuffs vs 25% without, corresponding with an absolute risk reduction of approximately 5% and an estimated number needed to treat of approximately 21. Perioperative outcomes were similar between the groups.
Conclusions
In this retrospective PMEG-based FB-EVAR cohort, adjunctive mini-cuff use was independently associated with improved midterm target vessel stability without increased perioperative risk. However, given the nonrandomized design and selective use in higher-risk anatomies, residual confounding and selection bias cannot be excluded.