Publications

PURPOSE: Peripheral arterial disease (PAD) is a major global health burden often requiring endovascular intervention. Complex lesion morphologies such as calcification or long occlusions limit procedural success. Vessel preparation (VP) techniques, including atherectomy and intravascular lithotripsy, are increasingly adopted, but consensus on their definition, purpose, and clinical role is lacking. The main objective was to define VP in endovascular PAD interventions, determine its primary aims, and identify key barriers and enablers for its adoption in clinical practice.

MATERIALS AND METHODS: A modified Delphi process was conducted involving 103 international experts across vascular surgery, interventional radiology, angiology, and cardiology. Two rounds of online surveys and 11 structured interviews were completed, with ≥70% agreement predefined as consensus. Qualitative thematic analysis was used for free-text and interview data.

RESULTS: VP was defined as "the initial step in an endovascular procedure to facilitate subsequent interventions by modifying lesion characteristics" (93% agreement). Six core aims were established: luminal gain, improved vessel compliance, plaque/calcification reduction, enhanced drug delivery, reduced complications, and improved technical success. Barriers included high device costs and insufficient evidence. High-level agreement supported VP use in femoropopliteal and popliteal segments, with intravascular lithotripsy preferred for calcified lesions. Imaging recommendations and modality-specific VP guidance were also developed.

CONCLUSION: This work provides the first international definition and structured aims of VP in PAD. It identifies practical guidance, barriers to adoption, and priorities for future research. Findings will support standardisation in clinical practice, research, and health policy regarding VP technologies in PAD treatment(s).Clinical ImpactThis international consensus provides the first standardised definition, core aims, and practical guidance for vessel preparation in endovascular treatment of peripheral arterial disease (PAD), enabling more consistent clinical practice, research design, and health policy development worldwide.

Rule-based natural language processing (NLP) tools can identify pulmonary embolism (PE) via radiology reports. However, their external validity remains uncertain.In this cross-sectional study, 1,712 hospitalized patients (with and without PE) at Mass General Brigham (MGB) hospitals (2016-2021) were analyzed. Two previously published NLP algorithms were applied to radiology reports to identify PE. Chart review by two physicians was the reference standard. We tested three approaches: (A) NLP applied to all patients; (B) NLP limited to radiology reports of patients with principal or secondary International Classification of Diseases 10th revision (ICD-10) PE discharge codes; and (C) NLP applied to patients with PE discharge codes or a Present-on-Admission (POA) indicator ("Y") for PE. All others were assumed PE-negative in Approaches B and C to minimize NLP false positives. Weighted estimates were derived from the MGB hospitalized cohort (n = 381,642) to calculate F1 scores (as the harmonic mean of sensitivity and positive predictive value [PPV]).In Approach A, both NLP tools showed high sensitivity (82.5%, 93.0%) and specificity (98.9%, 98.7%) but low PPV (60.3%, 59.6%). Approach B improved PPV (95.2%, 94.9%) but reduced sensitivity (74.1%, 76.2%), while Approach C preserved both high sensitivity (82.5%, 93.0%) and PPV (95.6%, 95.8%). Approach C demonstrated the best performance, yielding significantly higher F1 scores for both NLP tools (88.6%, 94.4%) compared with Approach A (69.7%, 72.6%) and Approach B (83.3%, 84.5%) (P < 0.001).The accuracy of PE detection improves when rule-based NLP algorithms are operationalized using administrative claims data in addition to radiology reports.

BACKGROUND: Suboptimal blood pressure (BP) control remains a major cardiovascular disease risk factor. Whether genetically predicted BP independently predicts long-term BP control is unknown. We examined the associations of BP polygenic scores (PGSs) with long-term BP control and treatment-resistant hypertension.

METHODS: We identified 22 456 Mass General Brigham Biobank participants with hypertension. Longitudinal BP control was defined as the percentage of time above-target systolic BP (SBP) ≥130 mm Hg or diastolic BP (DBP) ≥80 mm Hg over 5 years. Using multivariable regression, we assessed the associations of BP PGS with duration above-target BP and lifetime treatment-resistant hypertension incidence. Incremental prognostic utility of BP PGSs was assessed based on the discrimination C-index, Brier score, and net reclassification index. Validation was performed in the population-based UK Biobank cohort using the SBP/DBP ≥140/90 mm Hg threshold.

RESULTS: Among 10 853 (48.3%) were female, the mean SBP/DBP (SD) at index date was 132 (18)/75 (11) mm Hg, and 4126 (18.4%) developed treatment-resistant hypertension over lifetime. In reference to the low (<20th percentile) PGS group, the high (≥80th percentile) BP PGS was associated with 8.01 (95% CI, 6.68%-9.34%) longer duration with above-target SBP and 6.19 (95% CI, 5.05%-7.33%) with high DBP. Each high SBP and DBP PGS conferred 2.36 (95% CI, 2.07-2.68) and 1.75 (95% CI, 1.55-1.99)-fold higher odds of treatment-resistant hypertension. Adding BP PGSs to traditional risk factors improved treatment-resistant hypertension prediction from C-index (95% CI), 0.74 (0.73-0.75) to 0.78 (0.77-0.79). BP PGSs consistently predicted longitudinal BP management to a comparable extent in the UK Biobank.

CONCLUSIONS: Harnessing BP PGSs may inform anticipated trends in BP control to warrant vigilant monitoring and augment prioritization of intensive therapy.

Atherosclerotic renal artery stenosis (RAS) affects nearly 7% of adults over age 65 and is associated with increased cardiovascular and renal morbidity. Although early observational studies suggested benefit from renal artery stenting, subsequent randomized trials failed to show improvement in major clinical endpoints, contributing to substantial declines in procedural use. To characterize contemporary practice, we conducted a retrospective cohort study of Medicare beneficiaries older than 65 years who underwent renal artery stenting for atherosclerotic RAS between 2016 and 2020. Using Medicare claims data, we evaluated baseline characteristics, temporal utilization, and postprocedural outcomes, stratified by race, geographic region, and dual Medicare-Medicaid enrollment status. Among 19,130 patients, the mean age was 76.0 years (±6.4), 59.2% were female, and 90.3% were White; 84.2% had chronic kidney disease and 48.7% had heart failure. Procedural rates declined by 41.1% over the study period. Compared with White patients, Black patients had higher adjusted risks of hypertensive crisis hospitalization (aHR 1.45, 95% CI, 1.24-1.70) and dialysis initiation (aHR 1.78, 95% CI, 1.39-2.27); patients of Other races also had greater risk of dialysis initiation (aHR 1.98, 95% CI, 1.50-2.63). Patients in the South experienced higher unadjusted cardiovascular event rates (50.0%) but similar adjusted mortality compared with those in the Northeast (aHR 1.09, 95% CI, 0.98-1.21). Dual enrollment was associated with increased all-cause mortality (aHR 1.31, 95% CI, 1.20-1.43). In conclusion, renal artery stenting rates continued to decline in recent years, and contemporary recipients constitute an older, comorbid population with substantial cardiovascular risk. Outcomes differed markedly by race, socioeconomic status, and geography, highlighting the need for improved risk stratification and prospective evaluation of stenting in high-risk cohorts.

AIMS: Multidisciplinary pulmonary embolism response teams (PERTs) are being established in hospitals worldwide to address the increasing complexity in acute PE management. To identify recent trends in PERT decisions regarding advanced treatment of acute severe PE.

METHODS AND RESULTS: We analysed data from the prospective multicentre PERT™ Consortium registry (years 2018-2024), focusing on catheter-directed treatment (CDT) and including systemic thrombolysis, surgical embolectomy, and extracorporeal membrane oxygenation (ECMO). An age-, sex-, and PE risk-matched population from the US Nationwide Inpatient Sample (NIS) was used for comparison. Among 11 436 patients enrolled at 51 sites (median age, 65 years; 13.7% high-risk and 62.5% intermediate-risk PE), 2639 (23.1%) underwent CDT. Of those, 140 (5.3%) underwent catheter-directed thrombolysis without ultrasound, 851 (32.2%) ultrasound-assisted catheter thrombolysis, and 1534 (58.1%) mechanical thrombectomy/aspiration. Systemic thrombolysis was used in 5.6%, surgical embolectomy in 1.1%, and ECMO in 1.6% of all patients. Trends of CDT increased over time (+0.36% quarterly by linear regression; P = 0.002), with increase in mechanical thrombectomy (+0.83%; P < 0.001) and decrease in catheter-directed thrombolysis (-0.4%; P = 0.001). Matching 10 883 patients from the PERT™ Consortium registry to the NIS population, we found a 22% (95% CI, 21-23%) standardized mean difference in CDT use, 1.3% (0.6-2.0%) lower in-hospital mortality, and 0.75 (0.2-1.3) fewer days of hospital stay among PERT™ Consortium registry patients.

CONCLUSION: In a national quality assurance database of patients with PE included in the PERT registry, the use of catheter-directed treatment increased over time. Compared with a nationwide NIS sample, these patients had lower in-hospital mortality and shorter hospital length of stay.

BACKGROUND: Radiation-induced atherosclerosis represents an underestimated clinical entity.

CASE SUMMARY: We report on 2 cases of patients with upper-limb ischemia due to subclavian artery lesions. Both patients had radiation therapy due to cancer more than 15 years before symptom onset and no other signs of atherosclerosis. Angiography and intravascular ultrasound were performed in both cases, and lesions were treated with angioplasty and stent placement in the first patient, whereas intravascular lithotripsy was necessary in the second patient due to severe calcification and balloon underexpansion.

DISCUSSION & TAKE-HOME MESSAGES: Intravascular ultrasound helps to accurately assess lesion characteristics, size the balloon and stent devices, and judge the effectiveness of the endovascular therapy. Since radiotherapy is linked to accelerated atherosclerosis, such patients may benefit from clinical and imaging surveillance by duplex ultrasound.

Carotid artery revascularization plays an important role in stroke prevention among patients with carotid stenosis. While carotid endarterectomy has been the mainstay of revascularization in those with moderate to severe stenosis, the evolution of carotid artery stenting and the recent expansion of Medicare coverage have impacted utilization trends and guideline recommendations. We aim to review currently available data on revascularization techniques, discuss important factors influencing treatment decisions, and explore future directions of carotid stenosis management.

PURPOSE OF REVIEW: This review provides a practical, evidence-based summary of the physiology, major trial data and clinical role of renal denervation in the treatment of hypertension.

RECENT FINDINGS: The cornerstone of hypertension therapy remains anti-hypertensive medications although this strategy has significant limitations with poor rates of blood pressure control for most patients. Renal denervation was designed to bypass concerns about medication adherence and provide an "always-on" treatment. Recent trial data and meta-analyses are presented demonstrating a modest, although heterogeneous, response to renal denervation which led to the treatment's recent FDA approval. Improvements in catheter design and renal artery treatment strategy may underlie the improved clinical response to denervation in more recent trials.

SUMMARY: Hypertension centers involving multi-disciplinary care teams are equipped to provide patients with advanced diagnostic testing for secondary hypertension, comprehensive non-invasive management strategies and invasive renal denervation to address hypertension. Early referral for patients with uncontrolled hypertension can provide patients with nuanced conservative and interventional options which have the potential to improve hypertension related morbidity and mortality. Future studies are needed to identify which patients are most likely to respond to renal denervation.

Head-to-head research comparing invasive revascularization strategies for chronic limb-threatening ischemia (CLTI) is sparse, partly due to challenges in conducting randomized controlled trials in the CLTI space. These include the expense of head-to-head trials, optimizing patient selection criteria for real-world applicability, and identifying optimal study end points. The Vascular InterVentional Advances (VIVA) Foundation, a 501(c)(3) not-for-profit organization, convened a Vascular Leaders Forum to initiate an open, multispecialty collaborative discussion of these challenges and ways to optimize the design of medical device trials in CLTI. This article summarizes the current landscape of clinical studies of CLTI revascularization strategies and options for designing comparative trials proposed by representatives from vascular surgery, interventional cardiology, interventional radiology, vascular medicine, podiatry, the U.S. Food and Drug Administration, and a medical device manufacturer. Four broad areas to optimize comparative trials of CLTI interventions were identified. First, primary end points should be carefully chosen with attention to clinical, patient-centric, imaging, and hierarchical considerations; standardization; and inclusion of guideline-directed medical therapy. Second, broader eligibility criteria can expand and hasten enrollment and are important for gathering evidence on outcomes in medically complex patients often encountered in real-world practice. Third, extending the primary end point timing to 12 months with additional follow-up out to 24 to 60 months would accommodate a longer period of device evaluation and the ability to enrich clinical end-point rates. Finally, innovative pragmatic trial designs and statistical methodologies are needed to conduct comprehensive, cost effective, relevant trials with sufficient statistical power and without prohibitively large sample sizes and study durations.

Care for patients with chronic limb-threatening ischemia (CLTI) is complex, and it is most effective when conducted with collaboration across multiple specialties. A recent upward trend in major limb amputation among patients with CLTI warrants a renewed effort to optimize care for this multifaceted condition. The Vascular InterVentional Advances (VIVA) Foundation, a not-for-profit 501(c)(3) organization, convened a Vascular Leaders Forum in 2024 to initiate an open, multispecialty discussion about the state of CLTI care in the United States and current challenges around delivery and access to such care. The forum comprised representatives from vascular surgery, interventional cardiology, interventional radiology, vascular medicine, podiatry, regulators, medical device manufacturers, patient advocacy, and the CLTI and CLTI caregiver population. This article explores the central themes of challenges in CLTI care and ways in which collaboration across specialties and care settings could improve CLTI outcomes. In summary, it was recommended that integrated CLTI care teams extend beyond vascular surgery, interventional cardiology, and interventional radiology to include vascular medicine, podiatry, wound care, diabetology, and dietetics. Meeting the increasing demand for CLTI revascularization will require these teams to span tertiary care hospitals, community hospitals, outpatient revascularization clinics, and primary care settings.