Publications by Year: 2026

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.

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.

BACKGROUND: The mainstay of treatment for chronic limb-threatening ischemia (CLTI), late-stage peripheral arterial disease, is prompt revascularization. However, contemporary data on sex differences in CLTI-related endovascular revascularization rates and outcomes remain limited.

METHODS: This retrospective cohort study used a 100% sample of Medicare fee-for-service claims from 2016 to 2023. We identified patients undergoing lower extremity endovascular revascularizations. Male and female sex was the exposure. Population rates of CLTI-related endovascular revascularization were calculated by sex. Baseline characteristics were compared using standardized mean differences. The primary outcome, a composite of major amputation and death, was analyzed using Kaplan-Meier methods and multivariable Cox regression adjusted for demographics, comorbidities, revascularization modality, disease severity, and other mediators. Nondeath outcomes included major amputation, minor amputation, repeat revascularization, and worsening of ambulatory status.

RESULTS: Among 333,173 patients undergoing revascularization for CLTI from 2016 to 2023, 146,644 (44.0%) were female. Females were older (75.7 years vs 73.3 years) and more likely to be Black and from socioeconomically distressed communities. Compared with males, female patients had a lower adjusted risk of mortality or major amputation (hazard ratio [HR], 0.91; 95% CI, 0.90-0.92; P < .0001), major amputation (HR, 0.82; 95% CI, 0.81-0.84; P < .0001), and mortality (HR, 0.93; 95% CI, 0.92-0.94; P < .0001). However, female patients were more likely to experience restriction in ambulatory function after revascularization (HR, 1.06; 95% CI, 1.05-1.08; P < .0001).

CONCLUSIONS: Females underwent CLTI revascularization at lower rates than males and experienced lower risks of mortality and major amputation, with higher rates of ambulatory decline. Continued investigation into modifiable drivers of sex differences can improve the quality of vascular care for both men and women with peripheral arterial disease.

BACKGROUND: Endovascular therapy is a cornerstone for chronic limb-threatening ischaemia (CLTI), yet the optimal device strategy remains uncertain.

AIMS: Our objective was to compare the clinical and economic outcomes between plain balloon angioplasty±bare metal stents (PBA±BMS), drug-coated balloons (DCBs)±BMS, and drug-eluting stents (DES) in a national real-world CLTI cohort.

METHODS: Medicare beneficiaries aged ≥66 years who underwent femoropopliteal revascularisation for CLTI between 2016 and 2023 were included. Patients were grouped by index device. Outcomes included a composite of all-cause mortality or major amputation, as well as major adverse limb events (MALE) and reintervention. Patients were followed from the index procedure until death, loss to follow-up, or the end of the study period. Time-to-event and cost outcomes were analysed using multivariable Cox and gamma regression models, respectively.

RESULTS: Among 108,304 CLTI patients, 52.5% received PBA±BMS, 30.7% DCBs, and 16.8% DES. At 2 years, the composite outcome occurred in 50.54% (PBA±BMS), 43.08% (DCB±BMS), and 43.71% (DES); at 5 years, it occurred in 75.69%, 71.19%, and 71.71%, respectively. Compared with PBA±BMS, DCB±BMS (hazard ratio [HR] 0.92, 95% confidence interval [CI]: 0.90-0.93) and DES (HR 0.93, 95% CI: 0.92-0.95) were associated with a lower risk of the composite outcome. DCBs were associated with reduced major amputation (HR 0.87, 95% CI: 0.84-0.91), mortality (HR 0.93, 95% CI: 0.91-0.94), MALE (HR 0.96, 95% CI: 0.94-0.98), and reintervention (HR 0.97, 95% CI: 0.96-0.99) compared with PBA±BMS. The proportion of BMS use was 10.1% in the PBA±BMS group and 3.1% in the DCB±BMS group.

CONCLUSIONS: In this national CLTI cohort, drug-coated devices were associated with reduced amputation and mortality. Data from this study suggest that DCBs may offer consistent benefit without increased costs.

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.

BACKGROUND: Resistant hypertension is associated with adverse cardiovascular outcomes and mortality. In the past decade, management guidelines have shifted to target lower blood pressures (BP). Current prevalence and prescribing patterns among adults with resistant hypertension are not well characterized.

METHODS: We used data from the National Health and Nutrition Examination Survey from 2003 to 2020. Apparent treatment-resistant hypertension (aTRH) was defined as patients on a diuretic, either with a systolic BP ≥130 or diastolic BP ≥80 mm Hg while on 3 medications or those on ≥4 medications regardless of BP. Medications were identified through pill bottle review.

RESULTS: Of 24 579 adults with hypertension, 1939 had aTRH (42.4% male, 19.9% Black), corresponding to a weighted total of 6 989 821 US patients. Among hypertensive adults, the prevalence of aTRH was 6.41% (95% CI, 5.97%-6.88%) and remained stable over time. Over the study duration, aTRH prevalence among adults on treatment decreased from 17.7% to 12.6%. The overall prevalence of hypertension rose from 50.1% to 54.0%, while the prevalence of uncontrolled BP decreased from 75.0% to 68.7%. Over time, use of 3 drug regimens for aTRH decreased (57.8%-42.9%), while 4 drug regimens increased (34.0%-51.8%). aTRH was most strongly associated with older patients, those of Black race, higher body mass index, and more advanced cardiovascular comorbidities.

CONCLUSION: The prevalence of aTRH has remained stable over the past 2 decades despite the rising incidence of hypertension. Use of multidrug treatment regimens has increased, aligning with national guidelines. However, uncontrolled hypertension remains high.

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.