Publications by Year: 2026

INTRODUCTION: Over the past decade, the inpatient management of pulmonary embolism has undergone a paradigm shift in response to new evidence and the adoption of catheter-directed reperfusion therapies. However, real-world practice patterns remain poorly characterized.

METHODS: This study used Epic's Cosmos database to analyze admissions for pulmonary embolism in the United States between January 1, 2016, and December 31, 2024. Adult inpatient admissions for pulmonary embolism were identified by International Classification of Diseases, Tenth Revision codes documented in the Admit to Inpatient order. Admissions were stratified by severity using established high-risk criteria to allow for a risk-based comparison of treatment strategies. High-risk criteria included the presence of cardiogenic shock, cardiac arrest, the use of vasopressors, dobutamine, extracorporeal membrane oxygenation, or mechanical ventilation at any point during the admission; the remaining admissions were classified as non-high-risk. Trends in patient characteristics, anticoagulation strategies, reperfusion therapies, and cardiopulmonary support were analyzed across the study period.

RESULTS: This study identified a total of 267,094 hospital admissions for pulmonary embolism (mean [SD] age, 63 [17] years; 51.4% female; 71.1% White) between 2016 and 2024. Of these admissions, 5.5% met one or more high-risk criteria, increasing from 4.3% in 2016 to 5.8% in 2024 (p < 0.001). The proportion of patients receiving unfractionated heparin alone increased across non-high-risk (33.2% to 63.0%) and high-risk cases (53.7% to 66.3%). Among non-high-risk admissions, the utilization of reperfusion therapies nearly doubled (5.2% to 10.3%, p = 0.002), primarily driven by a rise in the use of catheter-directed embolectomy. In high-risk admissions, the overall use of reperfusion therapies remained stable (27%-34%, p = 0.135), while catheter-directed embolectomy emerged as the predominant modality. For hemodynamic support of high-risk admissions, vasopressor/dobutamine utilization increased (53.3% to 72.2%) as mechanical ventilation use declined (54.7% to 32.4%).

CONCLUSIONS: These findings help contextualize the extent to which novel therapies and evolving practice patterns have been integrated into real-world care in the United States. Catheter-directed embolectomy has become the dominant reperfusion strategy for pulmonary embolism, reflecting a major shift in practice.

BACKGROUND: Despite current guidelines recommending physiology- and intravascular imaging-guided percutaneous coronary intervention (PCI) in specific lesion subsets, angiography-guided PCI remains common in practice. The comparative effectiveness of these strategies remains uncertain. We aimed to compare clinical outcomes of PCI guided by intravascular imaging or physiological assessment versus conventional angiography.

METHODS: We conducted a systematic review and network meta-analysis of randomized controlled trials, searching PubMed and EMBASE up to May 31, 2025. Eligible studies compared at least 2 of the following 6 guidance modalities in PCI: angiography, intravascular ultrasound (IVUS), optical coherence tomography/optical frequency domain imaging, fractional flow reserve, angiography-derived fractional flow reserve, and instantaneous wave-free ratio. The primary outcome was trial-defined major adverse cardiovascular events (MACEs). Hazard ratios (HRs) with 95% CIs were pooled using a frequentist random-effects network meta-analysis. Subgroup analyses assessed clinical presentation and guidance objectives such as decision making and procedural optimization.

RESULTS: We identified 43 randomized controlled trials involving 39 291 patients. IVUS-guided PCI (HR, 0.69 [95% CI, 0.60-0.79]), optical coherence tomography/optical frequency domain imaging-guided PCI (HR, 0.75 [95% CI, 0.63-0.90]), and fractional flow reserve-guided PCI (HR, 0.81 [95% CI, 0.70-0.95]) were associated with a lower risk of MACEs compared with angiography-guided PCI. Furthermore, IVUS-guided PCI was associated with a lower risk of MACEs compared with instantaneous wave-free ratio-guided PCI (HR, 0.74 [95% CI, 0.55-1.00]). IVUS-guided PCI reduced the risk of MACE in both acute coronary syndrome and non-acute coronary syndrome patients.

CONCLUSIONS: IVUS- and optical coherence tomography/optical frequency domain imaging-guided PCI were superior to angiography-guided PCI in reducing MACEs. Among the physiology-based approaches, only fractional flow reserve showed a clear benefit.

Carotid artery stenting (CAS) is now established as a less invasive alternative to carotid endarterectomy for patients with carotid artery stenosis. Over the past two decades, stent technologies have undergone significant refinements to improve navigability, conformability, and plaque coverage while aiming to reduce periprocedural complications and enhance long-term durability. Current devices are broadly categorized as open-cell, closed-cell, and dual-layer micromesh stents. Open-cell designs provide excellent flexibility in tortuous anatomy but may be limited by reduced plaque scaffolding. Closed-cell stents improve vessel coverage yet sacrifice some adaptability. Dual-layer micromesh stents combine both principles, seeking to prevent plaque prolapse and distal embolization, with encouraging results from prospective studies and registries. Randomized trials such as CREST and ACT-1 have established the overall noninferiority of CAS compared with carotid endarterectomy, while observational data suggest potential advantages of newer micromesh designs. Nonetheless, clinical outcomes remain closely linked to operator expertise, anatomical complexity, and embolic protection strategies. In contemporary practice, CAS represents a validated treatment option, and individualized stent selection based on device-specific characteristics and patient anatomy is essential to optimize procedural safety and long-term stroke prevention.

Atherosclerosis is a chronic and progressive disease with a long preclinical (asymptomatic) period. The optimal management of patients with preclinical cardiovascular disease (CVD) includes behavioral counselling and lifestyle measures. Weight loss, regular exercise, interventions to modify sleep distubances and control of the modifiable cardiovascular risk factors (smoking, dyslipidemia, hypertension and diabetes mellitus), as well as adoption of a Mediterranean diet including 5 portions of vegetables and fruits per day, are of utmost importance in these patients. Timely initiation of appropriate medical therapy reduces cardiovascular events and disease progression. Medical therapy should be administered: (1) to lower blood pressure <130/80 mmHg in patients with hypertension (and even <120/80 mmHg if tolerated), (2) to reduce glycated hemoglobin values <7.0% (equivalent to <53 mmol/mol), and, (3) to lower low-density lipoprotein cholesterol values <70 mg/dL (1.8 mmol/L) for high-risk individuals and to <55 mg/dL (<1.4 mmol/L) for very high-risk patients. The present narrative review discusses the optimal management of individuals with preclinical cardiovascular disease (CVD), with a focus on carotid artery stenosis.

PURPOSE: To examine the cost implications of intravascular ultrasound (IVUS) in lower extremity deep venous intervention.

MATERIALS AND METHODS: This retrospective cohort study analyzed Medicare claims data from 2016-2021 for beneficiaries aged ≥ 65 years undergoing lower extremity venous interventions. Gamma regression adjusted for demographics and comorbidities assessed cost ratios for IVUS- vs. non-IVUS-guided procedures standardized to duration of follow-up. Rates of rehospitalization for causes attributable to complications of intervention were compared between IVUS and non-IVUS guided procedures by Cox regression. Results are shown as estimates with 95% confidence intervals.

RESULTS: Among 52,610 patients, 42.6% underwent IVUS-guided procedures including stent placement, thrombolysis, or thrombectomy. IVUS use was highest in outpatient settings (75.3%) and ambulatory surgical center/outpatient-based laboratory (ASC/OBL; 86.4%), and lowest inpatient (10.4%). In all settings, IVUS use was associated with cost savings. In the inpatient setting, IVUS guidance was associated with a cost ratio of 0.91 (0.88-0.95) at 90 days, compared to 0.71 (0.6-0.73) in ASC/OBL and 0.73 (0.71-0.76) in hospital-based outpatient settings. Cost savings persisted at one- and three-year follow-up. IVUS guidance was associated with lower one-year complication-related hospitalization in outpatient procedures (HR = 0.73 [0.62-0.86]) and ASC/OBL procedures (HR = 0.78 [0.66-0.91]). Cost savings were present in stenting procedures at 90 days (cost ratio 0.71 [0.69-0.73]), whereas there was cost neutrality in thrombectomy (cost ratio 1.02 [0.97-1.08]) and thrombolysis (cost ratio 0.89 [0.75-1.05]).

CONCLUSIONS: IVUS-guided venous intervention was associated with durable cost savings and reductions in rehospitalization in all procedural settings among procedures involving stent deployment.

Outcomes in chronic limb-threatening ischemia (CLTI) depend on timely revascularization and sustained continuity of specialty care. Although community-level socioeconomic disadvantage is associated with worse outcomes, the impact of individual-level socioeconomic vulnerability on longitudinal outcomes and healthcare utilization after CLTI revascularization remains unclear. We analyzed 333,173 Medicare beneficiaries who underwent CLTI revascularization between 2016 and 2023. Socioeconomic vulnerability was defined by Dual Enrolment (DE) in Medicaid. Outcomes were assessed using Kaplan-Meier analyses and multivariable Cox proportional hazards models. The primary clinical outcome was major amputation. A composite endpoint of major amputation or death was analyzed to contextualize overall disease burden. The study period was stratified into pre-COVID (01/2016-03/2020), COVID (03/2020-12/2021), and post-COVID (12/2021-12/2023) phases. Healthcare utilization was compared between DE and Medicare-only patients. Among included patients, 26.2% were DE. DE patients were younger, more frequently female, and had a higher comorbidity burden. The crude cumulative incidence of the primary outcome was higher in DE patients (80.1% vs. 79.7%; unadjusted HR 1.07, 95%CI 1.06-1.08), but this difference was not significant after adjustment (adjusted HR 1.00, 95%CI 0.99-1.01). DE patients had higher rates of major amputation (17.8% vs. 12.7%; adjusted HR 1.10, 95%CI 1.07-1.12), with no adjusted differences in repeat revascularization or all-cause mortality. During COVID, DE patients had a higher adjusted risk of the primary outcome (HR 1.05, 95%CI 1.02-1.08), whereas risks were similar pre- and post-pandemic. DE identifies CLTI patients at increased risk of limb loss despite similar adjusted survival, highlighting individual-level barriers to care continuity and the need for targeted strategies to reduce preventable amputations.

AIM: The "2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults" is a de novo guideline that provides comprehensive recommendations for the evaluation, management, and follow-up of adult patients (≥18 years of age) with acute pulmonary embolism (acute PE). A key feature of this guideline is the introduction of the AHA/ACC Acute Pulmonary Embolism Clinical Categories, which enhance the precision of severity classification, prognosis assessment, and evidence-based therapeutic decision-making.

METHODS: A comprehensive literature search was conducted from February 2024 to October 2024 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Select key studies published until April 2025 were added by the guideline writing committee as appropriate.

STRUCTURE: The focus of this clinical practice guideline is an evidence-based and patient-centered approach for acute PE evaluation and management of the adult patient. This guideline encompasses the period from the onset of symptoms through clinical follow-up, focusing on risk outcomes assessment, clinical diagnosis of acute PE, appropriate use of adjunctive cardiovascular testing, and management in both the acute and early post-acute phases of PE. It addresses evidence-based diagnostic and management strategies (including pharmacological therapies, advanced interventional therapies, and in-hospital support) for acute PE and associated outcomes.

BACKGROUND: Despite improving abdominal aortic aneurysm (AAA) outcomes in the United States, significant disparities exist. Smaller studies found that women experienced worse outcomes after endovascular aortic aneurysm repair (EVAR), yet few larger analyses have confirmed this. This study aimed to characterize sex-related differences in outcomes among patients who underwent infrarenal EVAR.

METHODS: Medicare fee-for-service beneficiaries ⩾ 66 years old who underwent infrarenal EVAR for intact AAA between January 1, 2011 and December 31, 2019 were included in this retrospective cohort study. The primary outcome was a composite of late aneurysm rupture, aortic reintervention, conversion to open repair, or all-cause mortality. Cox regression and Fine-Gray models were used.

RESULTS: Among 111,381 patients, the mean age was 76.63 ± 6.60 years, 92.88% were White, and 21.19% were women. The maximum follow-up was 3283 days. The hazard of the primary outcome was higher in women in the adjusted model (p = 0.013). When mortality was excluded, the association with sex persisted (p < 0.0010 [adjusted subdistribution model]; p < 0.0010 [adjusted cause-specific model]). Women experienced a lower frequency of postprocedural office visits, but a higher frequency of emergency department visits and hospital readmissions.

CONCLUSION: Women undergoing EVAR had a greater risk of adverse outcomes and unexpected healthcare utilization. Further investigation is warranted to determine the drivers of these outcomes.