Publications

OBJECTIVE: Routine imaging surveillance following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is critical for the timely diagnosis of late post-operative complications. Compliance with recommended EVAR surveillance is variable, and disparities in post-EVAR surveillance remain unclear. This study examines variability in EVAR surveillance and emergency health service utilization across several sociodemographic populations.

METHODS: All Medicare fee-for-service beneficiaries who underwent infrarenal EVAR for intact AAA between January 2011 and December 2019 were included. Patients were stratified by several sociodemographic characteristics: age category (66-74, 75-84, >85 years), sex (male, female), race (White, Black, Asian, Other), dual-enrollment in Medicare and Medicaid (dual-enrolled, Medicare-only), and distressed communities index (distressed >80th percentile, non-distressed ≤80th percentile). The following post-operative healthcare utilization metrics were assessed: EVAR-related office visits, imaging studies, emergency department (ED) visits, and hospital readmissions. Annual incidence rates were calculated for each healthcare utilization metric at 2 and 5 years after EVAR and compared across groups using Poisson regression models, adjusting for sociodemographic and hospital characteristics and comorbidities.

RESULTS: In 111,381 Medicare beneficiaries who underwent EVAR, post-operative healthcare utilization varied substantially across sociodemographic groups. After adjustment, annual incidence rates of EVAR-related office visits at 2 years post-EVAR were lower in patients who were >85 years vs 66-75 years (adjusted rate ratio [aRR]: 0.95 [95% confidence interval: 0.93-0.97]), female vs male (0.94 [0.93-0.95]), dual-enrolled vs Medicare-only (0.83 [0.81-0.85]), and residing in distressed vs non-distressed communities (0.95 [0.93-0.96]). Rates of imaging studies were lower in patients who were >85 years (0.98 [0.96-0.99]), dual-enrolled (0.97 [0.95-0.98]), and residing in distressed communities (0.97 [0.96-0.98]). There was higher use of hospital services in patients who were >85 years (ED: aRR 1.37 [1.33-1.41]; Readmission: aRR 1.23 [1.19, 1.28]), female (ED: 1.19 [1.16-1.22]; Readmission: 1.15 [1.12-1.19]), Black (ED: 1.10 [1.05-1.15]; Readmission: 1.15 [1.09-1.22]), dual-enrolled (ED: 1.29 [1.26-1.33]; Readmission: 1.14 [1.09-1.18]), and residing in distressed communities (ED: 1.03 [1.01-1.06]; Readmission 1.02 [0.99-1.05]). At 5 years post-EVAR, similar trends across sociodemographic groups were observed, with the added finding of lower rates of EVAR-related office visits in Black vs White patients.

CONCLUSIONS: Significant variation in post-EVAR healthcare utilization exists among Medicare beneficiaries. Patients who were older age, female sex, Black race, or socioeconomically-disadvantaged had lower rates of EVAR-specific follow up and higher use of emergency health service. Barriers in access to care are apparent, underscoring the need for targeted interventions to enhance post-EVAR surveillance and improve outcomes in these populations.

Pulmonary embolism (PE) is a life-threatening medical condition caused by the thrombotic occlusion of one or more branches of the lung vasculature, which represents the third most common cause of cardiovascular mortality after myocardial infarction and stroke. PE treatment requires a tailored approach based on accurate risk stratification and personalized treatment decision-making. Anticoagulation is the cornerstone of PE management, yet patients at higher clinical risk may require more rapid reperfusion therapies. In recent years, transcatheter treatment has emerged as a valuable option for patients with intermediate-high or high-risk PE who have contraindications to systemic thrombolysis. Recent advancements in catheter-directed therapies, such as catheter-directed thrombolysis (CDT) and catheter-directed mechanical thrombectomy (CDMT), provide minimally invasive options for swift symptom relief and hemodynamic stabilization. This review aims to provide a practical approach for optimal patient selection and management for PE percutaneous therapies, supported by a thorough evaluation of the current evidence base supporting these procedures. A focus on post-procedural management, the prevention of recurrence, and monitoring for long-term complications such as chronic pulmonary hypertension and post-PE syndrome is also specifically tackled.

The clinical presentation and epidemiology of infective endocarditis (IE) have evolved over time. While the cornerstones of IE treatment remain antimicrobial therapy and surgery, percutaneous mechanical aspiration (PMA) has emerged as an option for carefully selected patients as a complementary modality, based on retrospective data, case series, and expert experience. In this comprehensive review, we summarize the proceedings from an inaugural summit dedicated to the discussion of PMA in the global management of IE, consisting of experts across multiple disciplines from diverse geographic regions and care environments. After conceptualizing the 3 major roles of PMA as a bridge to decision, destination therapy, and adjunctive therapy, we then review the clinical scenarios in which PMA might be considered by IE subtype. We discuss patient selection, the rationale for intervention, and the most recent evidence for each. Next, we consider PMA for IE in the larger context of our health care system across 3 domains: clinical collaboration, financial considerations, and academic innovation, emphasizing the importance of interdisciplinary teams and cross-organizational partnerships, reimbursement models, and the need for high-quality research. Finally, we outline what we determined to be the most pressing outstanding questions in this space. In doing so, we propose a national consortium to help organize efforts to move this field forward and share our progress in these endeavors to date. PMA for IE has great promise, but significant work remains if we are to fully realize its potential to safely and effectively improve outcomes for modern endocarditis patients.

OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the safety and feasibility of transradial access for peripheral vascular interventions.

DATA SOURCES: MEDLINE and Embase.

REVIEW METHODS: MEDLINE and Embase databases were searched to June 2023 to identify studies investigating the outcomes of lower extremity, carotid, and visceral artery vascular interventions via transradial vs. transfemoral access. The primary outcome was procedural failure rate. Secondary outcomes were total access site complications, minor and major bleeding, stroke, access vessel occlusion, procedure time, fluoroscopy time, and contrast volume.

RESULTS: Eight randomised controlled trials and 29 observational studies yielded a total of 70 882 patients treated via transradial (n = 2 616) vs. transfemoral access (n = 68 338). The overall failure rate was 2.3 ± 0.7%, and the transradial approach was associated with a statistically significantly higher procedural failure rate than the transfemoral approach (3.9 ± 0.7% vs. 1.0 ± 0.3%; odds ratio [OR] 3.07, 95% confidence interval [CI] 1.84 - 5.12; I2 = 32%; p < .001). Subgroup analysis showed the highest failure rate in lower extremity interventions with 12.4 ± 4.9% for transradial vs. 4.0 ± 1.2% for transfemoral access. Conversely, procedural complications were statistically significantly fewer with transradial access for total access site complications (OR 0.64, 95% CI 0.45 - 0.91; I2 = 36%; p = .010). Minor bleeding was statistically significantly less with the transradial approach (OR 0.52, 95% CI 0.31 - 0.86; I2 = 30%; p = .010), whereas major bleeding and stroke rates were similar. Transradial access had more access vessel occlusion than transfemoral access (1.9% ± 0.5% vs. < 0.1% ± 0.0%; p = .004), although most remained asymptomatic. Procedure time, fluoroscopy time, and contrast volume were all comparable. GRADE certainty was low to moderate in most outcomes.

CONCLUSION: The transradial approach was associated with a higher procedural failure rate. Total access site complications and minor bleeding were lower with the transradial approach, albeit with more frequent access vessel occlusion. Transradial access may be a feasible and safe approach; however, appropriate patient selection is imperative.

Patients with peripheral artery disease (PAD) who undergo lower extremity revascularization (LER) are at high risk for cardiovascular and limb-related ischemic events. The role of antithrombotic therapy is to prevent thrombotic complications, but this requires balancing increased risk of bleeding events. The dual pathway inhibition (DPI) strategy including aspirin and low-dose rivaroxaban after LER has been shown to reduce major adverse cardiovascular and limb-related events without significant differences in major bleeding. There is now a need to implement the broad adoption of DPI therapy in PAD patients who have undergone LER in routine practice.