myvascularrotation · field guide

The vascular rotation, within reach.

Twenty-five high-yield tools for bedside classification, hemodynamic interpretation, perioperative risk assessment, intervention planning, infection triage, and surveillance.

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Trial 01 · Aortic

EVAR-1

2004–16

UK Endovascular Aneurysm Repair Trial 1

Primary citations
Lancet 2004;364:843-8; NEJM 2010;362:1863-71; Lancet 2016;388:2366-74.

Question

Is endovascular repair better than open repair for elective AAA ≥5.5 cm?

Design & enrollment

RCT, n=1,252.

Headline result

30-day mortality 1.8% EVAR vs 4.3% open (NEJM 2010 full dataset; earlier interim reported 1.7% vs 4.7%, Lancet 2004).

Why it changed practice

Made EVAR the default for anatomically suitable elective AAA.

One caveat

Early survival advantage eroded over time; EVAR means lifelong surveillance and higher reintervention rates.

Trial 02 · Ruptured AAA

IMPROVE

2014

Immediate Management of Patients with Rupture: Open Versus Endovascular Repair

Question

Endovascular strategy vs open repair for ruptured AAA?

Design & enrollment

Pragmatic RCT, n=613.

Headline result

30-day mortality 35.4% endovascular strategy vs 37.4% open, no significant difference (P=0.62).

Why it changed practice

Supports an endovascular-first strategy where anatomy/logistics allow, without claiming a mortality advantage.

One caveat

Strategy trial with crossover—many endovascular-arm patients received open repair.

Primary citation
BMJ 2014;348:f7661.

Trial 03 · Carotid

NASCET

1991–98

North American Symptomatic Carotid Endarterectomy Trial

Question

Does endarterectomy help symptomatic carotid stenosis?

Design & enrollment

RCT, n=2,885 total (severe 70-99% subgroup n=659).

Headline result

For 70-99% stenosis, 2-year ipsilateral stroke risk 26% medical vs 9% surgical (ARR 17%, P<0.001).

Why it changed practice

Established endarterectomy for symptomatic severe stenosis—the 70% threshold still anchors guidelines.

One caveat

Benefit requires low perioperative risk (trial stroke/death ~5.8%); uses the NASCET stenosis measurement method.

Primary citations
NEJM 1991;325:445-53; NEJM 1998;339:1415-25.

Trial 04 · Carotid

CREST

2010

Carotid Revascularization Endarterectomy versus Stenting Trial

Question

Stenting vs endarterectomy for carotid stenosis?

Design & enrollment

RCT, n=2,502 (symptomatic and asymptomatic).

Headline result

Primary composite 7.2% stenting vs 6.8% endarterectomy, no significant difference (P=0.51); periprocedural stroke higher with stenting (4.1% vs 2.3%), MI higher with surgery (1.1% vs 2.3%); age interaction—stenting better under 70, surgery better over 70.

Why it changed practice

Legitimized stenting as an alternative; age became the key selection criterion.

One caveat

Composite masks the stroke-vs-MI trade-off; rigorously credentialed operators.

Primary citation
NEJM 2010;363:11-23.

Trial 05 · Limb salvage

BEST-CLI

2022

Best Endovascular versus Best Surgical Therapy in CLTI

Question

Bypass vs endovascular for chronic limb-threatening ischemia?

Design & enrollment

Pragmatic RCT, n=1,830 (cohort 1 with adequate saphenous vein n=1,434).

Headline result

Cohort 1 primary composite (major adverse limb event or death) 42.6% surgical vs 57.4% endovascular (HR 0.68, P<0.001); death rates identical between arms.

Why it changed practice

Restored bypass as preferred first-line when adequate vein is available.

One caveat

Benefit driven by fewer reinterventions, not mortality; endovascular techniques have evolved since enrollment.

Primary citation
NEJM 2022 (Farber et al.).

Trial 06 · PAD therapy

VOYAGER PAD

2020

Rivaroxaban 2.5 mg twice daily + aspirin vs aspirin alone after lower-extremity revascularization

Question

Does “vascular dose” rivaroxaban improve outcomes post-revascularization?

Design & enrollment

Double-blind RCT, n=6,564.

Headline result

Primary composite (acute limb ischemia, major amputation, MI, ischemic stroke, CV death) 17.3% vs 19.9% (HR 0.85, P=0.009); TIMI major bleeding 2.65% vs 1.87% (P=0.07, not significant).

Why it changed practice

Made low-dose rivaroxaban + aspirin a guideline-supported strategy post-revascularization.

One caveat

Modest absolute benefit (2.6% ARR) vs a real bleeding signal; high-bleeding-risk patients were excluded.

Primary citation
NEJM 2020 (Bonaca et al.).

Pseudoaneurysm repair triage

Select the location and high-risk findings. The result separates emergency repair, prompt treatment, and the narrow group of access-site lesions that may be observed.

Location and clinical setting

Maximum sac diameter

The 2 cm observation threshold applies only to uncomplicated post-catheterization femoral pseudoaneurysm.

Rupture, active bleeding, expanding hematoma, or hemodynamic instability?

Infection or suspected infected graft/anastomosis?

Examples: fever, cellulitis, drainage, gas, bacteremia, or perigraft inflammatory change.

Rapid growth, significant pain, skin compromise, distal ischemia/embolization, or compressive neurologic symptoms?

Therapeutic anticoagulation must continue?

For femoral access lesions, ongoing anticoagulation lowers the chance of spontaneous thrombosis and favors intervention.

Location guide

Femoral accessObserve only when stable, asymptomatic, <2 cm, and off anticoagulation; otherwise treat.

Visceral / renalTreat pseudoaneurysms promptly regardless of diameter because rupture risk is not size-dependent.

Aortic / anastomoticNeeds aortic or vascular-team repair planning; infection and rupture demand urgent source control.

Cervical / traumaticSymptoms, progression, hemorrhage, embolic events, or threatened perfusion favor open or endovascular repair.

Dialysis accessRepair for growth, infection, pain, skin thinning/erosion, bleeding, thrombosis, or access dysfunction.

Any locationActive bleeding, shock, ischemia, infection, skin loss, or neurologic compression overrides size.

Rutherford chronic ischemia

Choose the most advanced symptom or tissue-loss finding. The result gives the chronic lower-extremity ischemia category and its clinical meaning.

Highest-severity clinical finding

Dialysis access selection & maturation

Choose fistula versus graft using the patient’s ESKD Life-Plan, then check the expected timeline and bedside warning signs for a newly created access.

Decision

Expected dialysis timing

Suitable artery and vein for an autogenous fistula on examination/mapping?

Site choice should also preserve future options and match anticipated dialysis duration, comorbidity, and prior access history.

Fistula versus graft

AV fistulaBest when suitable vessels and time permit: fewer infections and interventions after maturation, but slower and less predictable usability.

AV graftUseful when veins are unsuitable or access is needed sooner; cannulates earlier and has more predictable anatomy, but more infection and thrombosis.

Fistula expectationReview the wound early and evaluate maturation at 4–6 weeks. Some fistulas need several months or a salvage procedure before reliable use.

Standard graft expectationUsually wait at least 2 weeks and until swelling subsides enough to palpate the graft course.

Early-cannulation graftMay be usable sooner, but only according to the specific device instructions and local access-team protocol.

Patient firstKDOQI favors an individualized ESKD Life-Plan—not a universal “fistula first” rule—while preserving future access sites.

References

Clinical criteria and thresholds are keyed from each section to the sources below.

Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. Journal of Vascular Surgery. 1997;26(3):517–538. Clinical classification table and citation.
Society for Vascular Surgery. Endoleaks (Type I–V). Patient and professional reference. SVS.
Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery. 2014;59(1):220–234.e2. doi:10.1016/j.jvs.2013.08.003. Open review with original citation.
Wanhainen A, Van Herzeele I, Bastos Gonçalves F, et al. ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. European Journal of Vascular and Endovascular Surgery. 2024. Guideline update.
Society for Vascular Surgery. Clinical practice guidelines on popliteal artery aneurysms. Guideline summary.
Chaer RA, Abularrage CJ, Coleman DM, et al. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. Journal of Vascular Surgery. 2020;72(1S):3S–39S. Full text.
Naylor AR, Rantner B, Ancetti S, et al. ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. European Journal of Vascular and Endovascular Surgery. 2023;65(1):7–111. Guideline PDF.
Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2020;8(3):342–352. Full text.
Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). European Journal of Vascular and Endovascular Surgery. 2007;33 Suppl 1:S1–S75. doi:10.1016/j.ejvs.2006.09.024. Citation in ACCF/AHA update.
Isselbacher EM, Preventza O, Hamilton Black J III, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation. 2022;146:e334–e482. Full guideline.
Applied Radiology. Chronic mesenteric ischemia: mesenteric artery duplex sonography and the utility of postprandial imaging. 2024. Includes traditional criteria and AbuRahma et al. validation thresholds. Peer-reviewed review.
Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB. The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis. Annals of Internal Medicine. 1995;122:833–838. Criteria summarized in Ultrasound Quarterly review.
Granata A, Fiorini F, Andrulli S, et al. Doppler ultrasound and renal artery stenosis: an overview. Diagnostic review and technical criteria. AORTA review.
Robbin ML, Greene T, Cheung AK, et al. Arteriovenous fistula development in the first 6 weeks after creation. Radiology. 2016;279(2):620–629. KDOQI maturation criteria summarized in the Hemodialysis Fistula Maturation Study. Open full text.
Applied Radiology. US evaluation of arteriovenous fistula complications in the emergency setting. Physical examination and dialysis-access steal findings. Peer-reviewed review.
Zierler RE, Jordan WD, Lal BK, et al. The Society for Vascular Surgery practice guidelines on follow-up after vascular surgery arterial procedures. Journal of Vascular Surgery. 2018;68(1):256–284. Guideline PDF.
Bandyk DF. Surveillance of infrainguinal bypass grafts. Validated duplex velocity criteria. Clinical chapter.
Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of Vascular Surgery. 2018;67(1):2–77.e2. Recommendation summary.
National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NICE guideline NG158. Updated 2023. Two-level DVT Wells score and pathway. NICE recommendations.
American Association for the Surgery of Trauma. Acute Extremity Compartment Syndrome. Clinical signs and pressure criteria. AAST clinical resource.
US Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;322(22):2211–2218. Recommendation summary.
Gornik HL, Aronow HD, Goodney PP, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease. American Heart Association guideline hub.
De Maeseneer MG, Kakkos SK, Aherne T, et al. ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. European Journal of Vascular and Endovascular Surgery. 2022;63(2):184–267. ESVS guideline.
Huber TS, Björck M, Chandra A, et al. Chronic mesenteric ischemia: clinical practice guidelines from the Society for Vascular Surgery. Journal of Vascular Surgery. 2021;73(1S):87S–115S. SVS guideline record.
Bhalla V, Textor SC, Beckman JA, et al. Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association. Hypertension. 2022;79:e128–e143. PubMed record.
Giannakakis S, Galyfos G, Sachmpazidis I, et al. Thrombolysis in peripheral artery disease. Therapeutic Advances in Cardiovascular Disease. 2017;11(4):125–132. Open full text.
Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery. 2012;73(5 Suppl 4):S315–S320. EAST guideline.
DailyMed. Heparin Sodium Injection prescribing information: neutralization with protamine sulfate. US prescribing information.
Hiippala ST, et al. Laboratory assessment of unfractionated heparin with activated clotting time and anti-Xa activity during peripheral arterial angiographic procedures. Diagnostics. 2023;13(8):1489. Open full text.
Gloviczki P, Lawrence PF, Wasan SM, et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2024;12(1):101670. Guideline PDF.
Wiersema AM, et al. ACTION-1: study protocol for ACT-guided heparinization during open abdominal aortic aneurysm repair. Trials. 2021;22:565. Open full text.
Singh K, et al. Peak reflux velocity as an adjunctive duplex marker in lower-limb chronic venous disease. 2020. The study reported 27.4 cm/s as an observational saphenofemoral-junction discriminator, not a treatment-selection threshold. Study record.
Naylor AR, Rantner B, Ancetti S, et al. ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. European Journal of Vascular and Endovascular Surgery. 2023;65(1):7–111. Guideline PDF.
AbuRahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. Journal of Vascular Surgery. 2022;75(1S):4S–22S. Full text.
Setacci C, Chisci E, Setacci F, Iacoponi F, de Donato G. Grading carotid intrastent restenosis: a 6-year follow-up study. Stroke. 2008;39(4):1189–1196. Prospective velocity study.
Szegedi I, et al. Role of carotid duplex in the assessment of carotid artery restenosis after endarterectomy or stenting. Frontiers in Neurology. 2023;14:1226220. Systematic review.
Krawisz A, Carroll B, Secemsky E. Risk-stratification and management of extracranial carotid artery disease. Cardiology Clinics. 2021. Evidence review summarizing AHA/ASA recommendations for symptomatic carotid stenosis and procedure selection. Open review.
Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–1049. doi:10.1161/01.CIR.100.10.1043. Full text.
Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. Journal of the American College of Cardiology. 2024. Full guideline.
Attachaipanich T, Khawaja M, Takahashi EA, et al. Percutaneous coronary intervention and vascular access complications: a contemporary review. 2026. Post-catheterization pseudoaneurysm observation, thrombin injection, and operative indications. Open full text.
Wahlgren CM, Aylwin C, Davenport RA, et al. ESVS 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. European Journal of Vascular and Endovascular Surgery. 2025;69(2):179–237. Open guideline.
Pseudoaneurysmatic complication of an arteriovenous graft in a hemodialysis patient. F1000Research. 2013;2:228. Dialysis-access pseudoaneurysm complications and operative treatment. Open full text.
Kaufman JA, Barnes GD, Chaer RA, et al. Society of Interventional Radiology Clinical Practice Guideline for Inferior Vena Cava Filters in the Treatment of Patients with Venous Thromboembolic Disease. Journal of Vascular and Interventional Radiology. 2020;31(10):1529–1544. doi:10.1016/j.jvir.2020.06.014. Guideline summary and full-text link.
Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery. 2022;17:54. doi:10.1186/s13017-022-00443-x. Open guideline.
National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Patient-centered ESKD Life-Plan, AVF maturation review, and AVG cannulation timing. Guideline PDF.
Chakfé N, Diener H, Lejay A, et al. ESVS 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections. European Journal of Vascular and Endovascular Surgery. 2020;59(3):339–384. doi:10.1016/j.ejvs.2019.10.016. Guideline record.

Post-CEA and post-CAS velocities require reconstruction-specific criteria, morphology, interval comparison, and local vascular-laboratory validation. Near-occlusion, contralateral occlusion, low cardiac output, tandem disease, and technical factors may require different interpretation.

The vascular rotation, within reach.

Three developments worth knowing

SIRONA, three years out

Hydrogel embolic, expanded indication

AI-powered IVUS, cleared

Symptomatic first, percent second.

NASCET in five minutes — the trial that drew the line at 70%.

Twenty minutes of aphasia.

Three developments worth knowing

Large-bore closure, FDA-nodded

PE thrombectomy, published

No-option CLTI, one year out

A ruptured AAA is a clinical diagnosis. Treat it like one.

No winner at 30 days. The recovery decided it.

The back pain that didn't wait.

Three developments worth knowing

Late-breaking PAD trial

New U.S. venous device clearance

Aortoiliac innovation enters a pivotal study

Screening finds the aneurysm. Surveillance manages the risk.

EVAR won the first 30 days. Durability decided the rest of the story.

A prior EVAR is not a lifetime all-clear.

EVAR-1

IMPROVE

NASCET

CREST

BEST-CLI

VOYAGER PAD

Perioperative cardiac risk

Pseudoaneurysm repair triage

Location guide

Rutherford chronic ischemia

Endoleak pattern

SVS WIfI stage

Rutherford acute limb ischemia

Aneurysms

Find the right pathway

AAA screening — USPSTF

Popliteal artery aneurysm

Carotid intervention

Chronic mesenteric ischemia

High-yield guide

CEAP classification

Aortoiliac TASC II

Aortic dissection

IVC filter indications

High-yield guide

Acute mesenteric ischemia

Do not miss

Mesenteric duplex

Renal artery stenosis

Intervention guide

Dialysis access selection & maturation

Fistula versus graft

Vascular surveillance

Two-level Wells DVT score

Acute compartment syndrome

Hard vs soft signs of vascular trauma

Hard signs

Soft signs and screening index

Heparin and protamine dosing

Catheter-directed thrombolysis contraindications

Vascular graft infection

Classification and workup

Varicose vein treatment selection

Where surgery meets innovation.

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