Publications

Hemodialysis is the primary renal replacement therapy in the US for patients with end-stage kidney disease (ESKD). Functioning vascular access, in the form of an arteriovenous fistula (AVF) or graft (AVG), is fundamental to the outcomes for these patients. Over the last decade, changes have occurred in the field of vascular access. Evolving guidelines have placed unprecedented emphasis on individualized access, and rapid innovation-particularly in endovascular technologies-has expanded the toolkit for access creation and maintenance. This narrative review offers vascular medicine providers an in-depth evaluation of contemporary practice relating to hemodialysis access, including a comprehensive review of emerging technologies expected to shape the future of hemodialysis care.

OBJECTIVE: We aimed to conduct a systematic review and study-level meta-analysis of randomized controlled trials and observational studies comparing intravascular ultrasound (IVUS) guidance with angiography guidance for peripheral artery disease (PAD) endovascular revascularization, as current evidence is lacking.

METHODS: We searched Medline, Embase and CENTRAL from inception until November 22, 2025. Trials and observational studies were analyzed separately. We used random-effects as our primary analysis and assessed the certainty of evidence using GRADE. Key outcomes included restenosis, reintervention, major amputation, and mortality.

RESULTS: We included 2 randomized trials (n = 387), and 19 observational studies (n = 1,164,329). According to randomized data, IVUS-guidance likely reduces restenosis compared to angiography-guidance (RR 0.59, 95% CI 0.42 - 0.83; moderate certainty). However, IVUS may not reduce reintervention (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.44 - 1.08, low certainty), or mortality (RR 1.13, 95% 0.37 - 3.42, low certainty), while its effect on major amputation is very uncertain (RR 0.97, 95% 0.14 - 6.73, very low certainty). However, based on observational data, IVUS may reduce restenosis (RR 0.70, 95% CI 0.54 - 0.90, low certainty), reintervention (RR 0.66, 95% CI 0.48 -0.90, low certainty), major amputation (RR 0.83, 95% CI 0.72 - 0.96, low certainty), and mortality (RR 0.88, 95%CI 0.84, 0.93, low certainty).

CONCLUSION: IVUS guidance likely reduces restenosis based on limited randomized evidence. Observational studies suggest potential benefits across several outcomes, although the certainty of evidence is low. Larger randomized trials are required to clarify the potential benefits of IVUS guidance.

BACKGROUND: Pulmonary embolism (PE) remains the third leading cause of cardiovascular-related mortality, and few efforts have been made to study it exclusively through real-world registry data. This research shows demographic and outcomes data from a real-world, PE-specific database, yielding a contemporary examination of PE care in the United States.

METHODS: All data were extracted from the National PERT Consortium registry. This study included consecutive patients diagnosed with PE from October 2015 to June 2024 at 54 US sites. All patients were assigned a PE-specific risk stratification score based on available data. Descriptive statistics were used to analyze the data.

RESULTS: During the study period, 11,612 unique patients were included for analysis, with the majority (73.7%) classified as intermediate risk. Patients tended to be slightly obese (mean body mass index, 31.1 kg/m2) and were more frequently men (51.1%). A patient history of deep vein thrombosis was observed in 1 in 3 patients, and 1 in 4 had a history of malignancy. Patients with high-risk PE underwent intervention more frequently. Furthermore, patients with PE on average spent 4 days in the hospital. When evaluating survival by treatment types, 30-day and 1-year survival in patients who underwent catheter-based intervention were 95.1% and 92.3%, respectively. One-year survival was 67.8% for patients with high-risk PE.

CONCLUSION: Real-world data from the National PERT Consortium database demonstrate current practices in the care of patients with PE. Opportunities exist for better risk stratification and improvement in care across the spectrum of PE.

BACKGROUND: Endovascular treatment of below-the-knee disease in chronic limb-threatening ischemia remains challenging, with limited durability of balloon angioplasty and constraints associated with permanent metallic implants. Drug-eluting resorbable scaffolds (DRS) provide temporary vessel support with local drug delivery followed by bioresorption, representing a promising alternative. However, the optimal clinical scenarios for DRS use remain undefined. This study aimed to establish consensus on DRS use in infrapopliteal revascularization.

METHODS: A multidisciplinary steering committee developed a structured questionnaire addressing lesion characteristics, patient-level clinical factors, and health-system considerations. Using the RAND/UCLA Appropriateness Method and a modified Delphi process, 114 clinical scenarios were evaluated by an international panel of experts in vascular surgery, interventional cardiology, interventional radiology, and vascular medicine. Experts rated each scenario using a 5-point Likert scale. Consensus strength was defined as strong (>80% agreement), partial (60% to 80%), or absent (<60%).

RESULTS: Thirty-five international experts completed the survey. Strong consensus was achieved for 44 scenarios (38.6%), partial consensus for 35 (30.7%), and no consensus for 35 (30.7%). Strong agreement supported DRS use in patients with CLTI (Rutherford 4-6), vessel diameter ≥3 mm, lesions ≤60 mm, and following adequate vessel preparation, particularly in centers with high procedural expertise and advanced imaging capabilities. Partial consensus emerged for longer or moderately complex lesions and certain clinical contexts. Lack of consensus was observed in small-vessel disease, complex bifurcations, long-segment disease requiring multiple scaffolds, thrombotic lesions, and scenarios involving interruption of antiplatelet therapy.

CONCLUSIONS: This consensus defines appropriate clinical scenarios for BTK DRS use, while areas of disagreement identify evidence gaps and research priorities as scaffold technologies evolve.

BACKGROUND: Patients with infrapopliteal peripheral artery disease (PAD) are at elevated risk for amputation and mortality. The comparative efficacy of available endovascular devices for treating infrapopliteal PAD is unknown.

OBJECTIVES: The aim of this study was to compare the efficacy of percutaneous transluminal angioplasty (PTA), bare-metal stents (BMS), drug-coated balloons (DCBs), and drug-eluting stents (DES), including bioresorbable DES, in patients with symptomatic infrapopliteal PAD.

METHODS: Online databases were searched for published randomized controlled trials comparing PTA, BMS, DCB, and DES in patients with infrapopliteal PAD. Random-effects models were used to estimate ORs for binary variables and mean differences (MDs) for continuous variables.

RESULTS: Twenty-one randomized controlled trials comprising 2,958 patients were included (PTA, n = 1,102; BMS, n = 284; DCBs, n = 903; DES, n = 695). Compared with PTA, both DCBs and DES had higher primary patency (DCB OR: 2.66 [95% CI: 1.52-4.64; P = 0.001]; DES OR: 2.41 [95% CI: 1.23-4.73; P = 0.01]) and lower target lesion binary (>50%) restenosis (DCB OR: 0.40 [95% CI: 0.21-0.77; P = 0.006]; DES OR: 0.28 [95% CI: 0.13-0.62; P = 0.002]). DCBs also lowered late lumen loss (MD: 0.34; 95% CI: -0.63 to -0.05; P = 0.02), in-lesion diameter stenosis (MD: -10.04; 95% CI: -19.20 to -0.88; P = 0.03), and clinically driven target lesion revascularization (OR: 0.47; 95% CI: 0.29-0.76; P = 0.002). Conversely, BMS decreased the odds of complete wound healing (OR: 0.41; 95% CI: 0.20-0.85; P = 0.02). No significant differences in amputation or mortality were observed across the 4 comparator groups.

CONCLUSIONS: Compared with PTA, DCBs and DES demonstrated higher primary patency and lower binary restenosis, and DCBs reduced late lumen loss, percentage in-lesion diameter stenosis, and clinically driven target lesion revascularization.

Recent randomized trials have questioned the incremental benefit of intravascular imaging-guided PCI, and the populations most likely to benefit remain uncertain. This study evaluates the long-term outcomes of intravascular imaging-guided PCI and associated factors with greater treatment benefit. Randomized controlled trials (RCTs) comparing PCI guided by intravascular ultrasound (IVUS), optical coherence tomography (OCT), or angiography were systematically identified. The primary outcome was major adverse cardiac events (MACE), defined as a composite of cardiovascular death, target-vessel myocardial infarction, and target-vessel or target-lesion revascularization. Pairwise and network meta-analyses were performed. Subgroup analyses were conducted according to lesion complexity, clinical presentation (acute coronary syndrome [ACS] vs. chronic coronary syndrome [CCS]), and trial region (Asian vs. non-Asian). A total of 23,338 patients from 29 RCTs were included (8,443 IVUS-guided PCI, 5,115 OCT-guided PCI, and 9,780 angiography-guided PCI). Imaging-guided PCI was associated with a significantly lower risk of MACE compared with angiography-guided PCI (HR, 0.74; 95%CI, 0.63-0.87). No significant difference in MACE risk was observed between IVUS- and OCT-guided PCI. The benefit of imaging-guided PCI was greater in trials enrolling patients with complex lesions, ACS, and Asian populations, but a significant interaction was observed only between Asian vs. non-Asian populations (P < 0.01 for interaction). Intravascular imaging-guided PCI was associated with a lower risk of MACE compared with angiography-guided PCI, and its benefit was more consistently observed in trials enrolling patients with Asian populations than non-Asian trials. Further investigation into the benefits of imaging guidance according to patient profiles is warranted. IVUS, intravascular ultrasound; MACE, major adverse cardiovascular events; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; RCT, randomized controlled trial.

BACKGROUND: Percutaneous aspiration thrombectomy is increasingly used as an alternative to surgery for right-sided heart masses, but nationwide data are limited.

METHODS: We analyzed Medicare fee-for-service beneficiaries aged ≥65 years who underwent percutaneous or surgical removal of right-sided heart masses from 2016 to 2021. We examined the temporal change in the number of percutaneous and surgical cases. The association between procedural types and patient characteristics was assessed using a multivariable logistic regression analysis. The primary outcomes were in-hospital and 2-year death. Given baseline differences between groups, we reported overall outcomes from the unadjusted cohort and comparative outcomes after adjustment using propensity score matching.

RESULTS: A total of 831 patients were included (447 percutaneous, 384 surgical), with the proportion of percutaneous cases increasing from 45.8% in 2016 to 65.0% in 2021. Patients with thrombosis (adjusted odds ratio, 3.42 [95% CI, 2.14-5.46]) and infective endocarditis (adjusted odds ratio, 10.08 [95% CI, 5.39-18.85]) were more often treated with percutaneous interventions. In-hospital and 2-year death in the percutaneous group were 11.0% and 43.0%, respectively. In the surgery group, those were 21.1% and 42.9%, respectively. Propensity score matching yielded 221 pairs. In the matched cohort, in-hospital death remained lower with the percutaneous group (10.4% versus 19.5%; P=0.01), while 2-year death was similar (hazard ratio, 1.00 [95% CI, 0.74-1.34]).

CONCLUSIONS: This study from a national database demonstrated that percutaneous intervention for right-sided heart masses has become the predominant strategy compared with surgery. Further trials are required to compare efficacy and safety between these interventions.