Publications

BACKGROUND AND AIMS: Radial access site for percutaneous coronary intervention (PCI) is recommended by clinical practice guidelines because of superior outcomes compared with femoral access site. Historically, the adoption of radial access site in the USA has lagged behind much of the rest of the world, but contemporary data on access site selection across the spectrum of clinical presentations and its association with outcomes are lacking.

METHODS: A retrospective cohort study from the National Cardiovascular Data Registry's CathPCI Registry was conducted including PCIs performed between 1 January 2013 and 30 June 2022. The comparative safety of radial vs femoral access site for PCI was evaluated with instrumental variable analysis, a technique that can be used to support causal inference, exploiting operator variation in access site preferences as the instrumental variable.

RESULTS: Overall, 6 658 479 PCI procedures were performed during the study period, of which 40.4% (n = 2 690 355) were performed via radial access site, increasing from 20.3% in 2013 to 57.5% in 2022. This increase was seen in all geographic regions and across the full spectrum of presentations, with the largest relative increase seen in patients with ST-elevation myocardial infarction. Overall, 2 420 805 PCIs met inclusion criteria for the comparative safety analysis. In instrumental variable analyses, radial access site was associated with lower in-hospital mortality [absolute risk difference (ARD) -.15%, 95% confidence interval (CI) -.20 to -.10], major access site bleeding (ARD -.64%, 95% CI -.68 to -.60), and other major vascular complications (ARD -.21%, 95% CI -.23 to -.18) but a higher risk of ischaemic stroke (ARD .05%, 95% CI .03-.08). There was no association with the falsification endpoint of gastrointestinal or genitourinary bleeding (ARD .00%, 95% CI -.03-.03).

CONCLUSIONS: Over the past decade, use of radial access site for PCI has increased 2.8-fold in the USA and now represents the dominant form of access site across all procedural indications. Based on instrumental variable analyses, PCI with radial access site had lower rates of in-hospital mortality, major access site bleeding, and other major vascular complications compared with femoral access site but a slightly higher risk of ischaemic stroke in contemporary practice.

BACKGROUND: Patients with both peripheral artery disease (PAD) and coronary artery disease are at heightened risk for adverse cardiovascular outcomes. Although long-term risk has been well documented, contemporary in-hospital outcomes for patients with PAD presenting with acute myocardial infarction (AMI) are less well characterized.

METHODS: We analyzed 493 740 AMI hospitalizations from 670 US sites in the NCDR (National Cardiovascular Data Registry) Chest Pain-MI Registry between January 2019 and March 2023. Primary outcomes were in-hospital mortality and major bleeding; secondary end points included cardiac arrest, cardiogenic shock, heart failure, stroke, and new dialysis initiation. Subgroup analyses were conducted by age, sex, race, AMI type, revascularization status, and extent of coronary disease. We used the NCDR validated risk model for multivariable adjustment.

RESULTS: PAD was present in 36 274 patients with AMI (7.4%). In-hospital mortality was significantly higher in patients with PAD compared with those without (8.23% versus 4.87%; adjusted odds ratio [aOR], 1.25 [95% CI, 1.19-1.31]). Increased mortality persisted across age groups (<65 years: aOR, 1.42; ≥65 years: aOR, 1.18) and AMI type (non-ST-segment-elevation MI: aOR, 1.14; ST-segment-elevation MI: aOR, 1.46), with significant interactions by both age and AMI type. Among revascularized patients, mortality was elevated in those with PAD (aOR, 1.49). PAD was associated with increased rates of major bleeding (aOR, 1.23), particularly among revascularized patients (aOR, 1.31), as well as cardiac arrest, shock, heart failure, stroke, and new dialysis.

CONCLUSIONS: PAD was independently associated with markedly worse in-hospital outcomes in AMI, highlighting the need for risk mitigation strategies in this high-risk population.

INTRODUCTION: National guidelines recommend forearm arteriovenous fistulas (AVFs) over upper arm AVFs as the initial permanent vascular access for hemodialysis if consistent with the end-stage kidney disease (ESKD) Life-Plan, but comparative outcomes are underexplored. Our objective was to assess longitudinal outcomes of forearm versus upper arm AVFs in patients with advanced kidney disease.

METHODS: Using multicenter data from three prospective studies (Hemodialysis Fistula Maturation [HFM] Study; PATENCY-1; and PATENCY-2), we conducted a cohort study of 1,516 patients who underwent upper extremity AVF creation (2014-2019). Demographic factors, comorbidities, procedural details, and 3 years of longitudinal follow-up were captured. Outcomes included primary, primary-assisted, and secondary patency at 3 years, successful AVF use, and access-related hand ischemia (ARHI) interventions. Forearm versus upper arm AVF outcomes were compared using Cox regression and logistic regression models. Subgroup analyses included outcomes stratified by site volume using model interaction terms.

RESULTS: The study population included 1,059 forearm AVFs and 457 upper arm AVFs; mean (SD) age was 56.2 (13.4) years and 25.2% were female. The overall primary, primary-assisted, and secondary patency at 3 years was 26.2% (95% CI 23.6% to 29.1%), 57.6% (54.6% to 60.9%), and 66.5% (63.6% to 69.5%), respectively, with no significant differences between forearm and upper arm AVFs. Successful AVF use at 12 months was also similar between forearm (66.1%) and upper arm AVFs (70.0%) (OR 1.02, 95% CI [0.71-1.48], p=0.91). Forearm AVFs had lower risk of ARHI interventions (HR 0.36, 95% CI [0.18-0.71], p=0.003) compared to upper arm AVFs. Subgroup analyses showed that compared to upper arm AVFs, patients who received forearm AVFs at low volume sites (≤30 access creations per year) were at higher risk for loss of primary-assisted (HR 2.03, 95% CI [1.21-3.41], p<0.001) and secondary patency (HR 2.53, 95% CI [1.33-4.83], p <0.001). Patients receiving forearm AVFs at low volume sites also had lower AVF use at 12 months (OR 0.52, 95% CI [0.21-1.31], p value of interaction =0.03).

CONCLUSIONS: Although forearm AVFs demonstrate similar long-term patency and usability to upper arm AVFs, they are associated with lower rates of ARHI. However, outcomes for forearm AVFs appear to have associations with institutional volume-significantly poorer results are seen at low-volume centers. System-level efforts are needed to improve outcomes for forearm AVFs, which serve as a critical lifeline for ESKD patients.

OBJECTIVE: Socioeconomic disparities are known to contribute to adverse outcomes after surgery; however, the role of individual wealth and neighborhood environment on both follow-up and outcomes following EVAR are not well understood.

METHODS: We included all fee-for-service Medicare beneficiaries ≥66 years who underwent infrarenal EVAR with a bifurcated endograft for intact AAA from 2011-2019. Patients were divided into cohorts using dual enrollment in Medicare/Medicaid (vs. Medicare only) as a measure of individual wealth and residence in a distressed community (vs. non-distressed community) as a measure of regional wealth (as defined by the Distressed Community Index, DCI). The primary outcome was the composite of late aneurysm rupture, aortic reintervention, conversion to open repair, or all-cause mortality at 9 years. The cumulative incidence of the primary composite outcome was determined using Kaplan Meier methods and compared across groups using log-rank tests.

RESULTS: Of 111,381 patients who underwent EVAR, 9,991 (9.0%) were dual-enrolled in Medicare/Medicaid, and 22,902 (21%) lived in distressed communities. A higher incidence of the primary outcome was observed in dual-enrolled vs. Medicare-only patients (83% vs 72%, hazard ratio (HR) 1.42[95% Confidence interval (CI) 1.38, 1.47] p<.01) and in those living in distressed vs. non-distressed communities (75% vs 72%, HR 1.09[1.06,1.11] p<.01). After adjustment for comorbidities and other disparity measures, the association between dual enrollment or DCI and the primary outcome was attenuated but remained significant (aHR 1.19 [95%CI 1.15, 1.23], aHR 1.03 [95%CI 1.00,1.05], respectively). When mortality was removed from the primary outcome, the relationships between dual enrollment or DCI and the composite outcome were no longer significant after adjustment (aHR 1.02, [0.93, 1.13], aHR 0.95, [0.89, 1.05]). Among EVAR-specific secondary outcomes, rates of 9-year all-cause mortality and late rupture were higher in dual-enrolled vs. Medicare-only patients, and mortality rates were higher in distressed vs. non-distressed patients. In addition, both dual-enrolled and residents of distressed communities had lower rates of EVAR-related office visits and AAA-related imaging in follow-up and higher rates of emergency department visits.

CONCLUSION: Among Medicare beneficiaries who underwent EVAR for AAA, socioeconomically disadvantaged beneficiaries had a higher incidence of the primary composite outcome, driven primarily by higher all-cause mortality. This study highlights the need for interventions targeted at improving access to appropriate disease surveillance and management of comorbidities for patients who are most vulnerable.

BACKGROUND: The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial reported the superiority of surgical bypass compared with endovascular intervention for the treatment of chronic limb-threatening ischemia (CLTI) in patients deemed suitable for either; however, the generalizability of these findings to the broader CLTI population is in question. Herein, we analyzed perioperative (30-day) outcomes from the National Surgical Quality Improvement Project (NSQIP) for CLTI interventions.

METHODS: The NSQIP-Vascular targeted database was queried from 2014 to 2019, contemporaneous with BEST-CLI, for patients undergoing CLTI intervention. Surgical bypass groups included saphenous vein (OPEN-GSV) or alternative conduit (OPEN-Other) and were compared to the endovascular (intervention group) (ENDO). Inverse Probability weighting with regression adjustment assessed 30-day outcomes including perioperative death (POD), major amputation, major adverse limb events (MALE, major reintervention and/or amputation), composite MALE or POD, and major adverse cardiovascular events (MACE, myocardial infarction, or stroke). Results were provided as risk ratio (RR).

RESULTS: Of the total cohort, 6780 (34.1%) were in the OPEN-GSV group, 4201 (21.1%) in OPEN-Other, and 8887 (44.7%) in ENDO. Compared to OPEN-GSV, ENDO exhibited a higher risk for major amputation (RR, 1.38; P = .002), higher risk of MALE (RR, 1.23; P = .004), lower risk of MACE (RR, 0.48; P < .001), and similar risk for all other outcomes. Compared to OPEN-Other, ENDO exhibited a lower risk of MACE (RR, 0.49; P < .001) and POD (RR, 0.76; P = .040) and was similar for all other outcomes.

CONCLUSIONS: These data demonstrate a higher rate of early amputation and MALE among those who underwent ENDO vs OPEN-GSV. Conversely, early limb events were similar between ENDO and OPEN-Other. Both OPEN-GSV and OPEN-Other were associated with a higher risk of 30-day MACE. OPEN-Other was associated with a higher risk of MACE. These data highlight the importance of patient selection to optimize overall patient outcomes in CLTI.