Patterns of Care and Outcomes of Ambulatory Endovascular Interventions in Lower Extremity Peripheral Arterial Disease.

Lower extremity endovascular intervention (LE-EVI) is gaining popularity as the primary treatment modality for patients with symptomatic peripheral artery disease refractory to noninvasive management. We examined the contemporary patterns of care, regional variation, and outcomes of ambulatory LE-EVI in the United States. The National Ambulatory Surgery Sample was analyzed to identify 266,563 records with peripheral artery disease and LE-EVI between January 1, 2016 and December 31, 2017. The mean age of the study cohort was 68.9 years and 40.5% were women. The majority of the endovascular interventions were performed at large (58.1%), urban teaching (64.1%), private not-for-profit (76.8%) centers, and the southern region accounted for most cases (43%). Periprocedural major adverse renal and cardiovascular events and other complications were 0.5% and 3.3%, respectively. Most patients (97.6%) were discharged home after the procedure. Age, female gender, uncontrolled hypertension, ischemic heart disease, heart failure, arrhythmia, chronic kidney disease, malnutrition, non-Medicare insurance, private for-profit, urban teaching facilities, and southern and midwest regions were associated with higher odds of major adverse renal and cardiovascular events. The mean charges per patient encounter were $56,500, with significant differences across various patient and facility characteristics. In conclusion, our study demonstrates the use, patterns of care, financial aspect, and overall safety of ambulatory LE-EVIs in a real-world setting.

Risk profiles, access to care, and outcomes in Hispanics hospitalized for lower extremity peripheral artery disease.

OBJECTIVE: Previous studies have shown that Hispanics have worse clinical outcomes for lower extremity peripheral artery disease (PAD) than non-Hispanic White (NHWs). Using a national database, this study aimed to document the contemporary burden of PAD in Hispanics by evaluating their risk profiles, access to care, and outcomes compared with NHWs. METHODS: Hospitalizations of Hispanics and NHWs with a primary diagnosis of PAD were identified using 2011-2017 National Inpatient Sample data. Patient sociodemographic characteristics, comorbidities, whether the admission was through the emergency department (ED) or elective, length of stay, and costs accrued were compared by ethnicity. Temporal trends in revascularizations, amputations, and ED admissions by year were evaluated with the Cochran-Mantel-Haenszel test and stratified by ethnicity. Data were combined across years and multivariable logistic regression was used to evaluate the association of ethnicity with inpatient revascularization, amputation, and mortality, adjusting for sociodemographic and cardiovascular risk factors. RESULTS: From 2011 to 2017, there were a total of 1,018,220 PAD hospitalizations among Hispanics (13.9%) and NHWs (86.1%) between 2011 and 2017. Hispanics were more often low income and uninsured and presented with higher burden of comorbidities including diabetes, renal failure, prior amputations, and chronic limb-threatening ischemia compared with NHWs. Most Hispanics were admitted via the ED compared with NHWs (58.0% vs 36.7%; d = 0.48), and median length of stay was almost a day longer (4.5 days vs 3.7 days). Hispanic ethnicity was associated with lower odds of surgical (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.57-0.67) and endovascular revascularization (OR, 0.94; 95% CI, 0.89-0.996) and mortality (OR, 0.83; 95% CI, 0.75-0.93), but higher odds of minor (OR, 1.25; 95% CI, 1.20-1.31) and major (OR, 1.08; 95% CI, 1.03-1.14) amputation. CONCLUSIONS: Two tiers of health care consumption for inpatient PAD care and outcomes manifested among Hispanics and NHWs. First, Hispanics with PAD had a more vulnerable socioeconomic profile and presented with more severe PAD than NHWs. Second, they sought care more disproportionately through the ED and underwent more amputations than NHWs. To eradicate these inequities in PAD care and risk, strategies that improve access to outpatient care and expand health care coverage, as well as targeted management of risk factors in these vulnerable minority groups are needed.

Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism.

Background: There is significant debate on whether large-bore thrombectomy (LBT) or catheter-directed thrombolysis (CDT) is superior for the treatment of intermediate- and high-risk pulmonary embolism (PE) while employing an early invasive strategy through endovascular therapies. Methods: Between 2018 and 2021, 147 patients who presented to our institution with acute intermediate- or high-risk PE and had undergone PE Response Team-guided endovascular intervention with either LBT (Inari FlowTriever) or CDT (EKOSonic) were retrospectively reviewed. Data on the patients' clinical characteristics, comorbidities, serum biomarkers, hemodynamics, and imaging characteristics were obtained. The primary outcome was all-cause mortality; the secondary outcomes were all-cause readmission, readmission for PE, and length of stay in the intensive care unit and hospital. The safety outcome of procedure-related bleeding was evaluated. Kaplan-Meier curves were used to estimate the cumulative event rate. Multivariate Cox-proportional hazard regression and inverse propensity weighting were used to adjust for confounders. Results: The median age of the patients was 63 (IQR, 53-73) years, and 48.3% of the patients were women. Patients in the LBT group had a higher PE Severity Index score (LBT vs CDT: median, 132 vs 108; P = .015) and greater prevalence of malignancy (LBT vs CDT: median, 22.7% vs 6%; P = .011). After propensity matching for baseline characteristics, there was no significant difference in all-cause mortality (LBT vs CDT: median, 15.8% vs 9.1%; hazard ratio, 0.64; 95% CI, 0.21-1.98; P = .442) for up to 1 year. The secondary outcomes or safety end points were also similar between the 2 interventions. An exploratory analysis showed elevated PE Severity Index scores, lower systolic blood pressures, and higher lactic acid levels to be associated with an increased risk of early death at 30 days. Conclusions: In this retrospective cohort study, there was no significant difference in the cumulative event rate of all-cause mortality between LBT and CDT. Further studies are needed to evaluate the use of LBT versus CDT versus noninvasive therapy to understand outcomes and appropriate patient selection among those with intermediate- and high-risk PE.

Patient-level and external factors in the use of drug-coated balloons and drug-eluting stents in femoropopliteal endovascular interventions.

OBJECTIVE: Drug-coated balloons (DCB) and drug-eluting stents (DES) have been rapidly adopted for femoropopliteal endovascular interventions due to their favorable patency rates. It is unclear whether choice of using drug coated devices versus bare metal stents (BMS) or plain balloon angioplasty (POBA) as primary treatment in femoropopliteal disease is mostly associated with patient-level factors, safety concerns, or by operator preferences. This study sought to evaluate factors associated with their use in a contemporary dataset. METHODS: All femoropopliteal lesions treated with endovascular interventions between 2016 and 2019 from the Vascular Quality Initiative registry were included. For each procedure, a primary treatment was identified based on the following hierarchy: DES > DCB > BMS > POBA. A hierarchical logistic regression model predicting DCB or DES use included patient-level characteristics, key events (period after Centers for Medicare and Medicaid Services reimbursement change, January 2018 [vs before] and period after Katsanos meta-analysis December 2018 [vs before]), and random effects for site and operator. Operator-level variability for DCB and DES use was summarized with an adjusted median odds ratio (MOR). RESULTS: A total of 57,753 femoropopliteal endovascular procedures were included. Poor functional status (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.90-0.94), prior anticoagulant use (OR, 0.92; 95% CI, 0.87-0.97), higher Rutherford classification (OR, 0.86; 95% CI, 0.84-0.88), chronic kidney disease stage 4 or 5 (OR, 0.92; 95% CI, 0.86-0.98), and the period after the Katsanos meta-analysis publication (OR, 0.3; 95% CI, 0.29-0.32) were associated with a lower odds of DCB or DES use; whereas female sex (OR, 1.12; 95% CI,1.08-1.17), prior lesion treatment (OR, 1.17; 95% CI, 1.11-1.22), diabetes (OR, 1.07; 95% CI, 1.02-1.12), Trans-Atlantic Inter-Society Consensus class B (OR, 1.16; 95% CI, 1.09-1.24) and C (OR, 1.2; 95% CI, 1.12-1.28), and the period after the Centers for Medicare and Medicaid Services reimbursement change (OR, 1.08; 95% CI, 1.03-1.14) were associated with a higher odds of DCB or DES use. Significant variability in use was found across operators (adjusted MOR, 2.70; 95% CI, 2.55-2.85) and centers (adjusted MOR, 2.89; 95% CI, 2.50-3.27). CONCLUSIONS: DCB or DES use in femoropopliteal disease demonstrates wide variability across operators and is linked strongly with external factors, followed by anatomic lesion characteristics and a history of previous interventions. Future work needs to focus on tailoring DCB or DES use to patient and lesion characteristics and to develop appropriate use guidelines integrating these factors.

Team-Based Care in Patients with Chronic Limb-Threatening Ischemia.

PURPOSE OF REVIEW: Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach. RECENT FINDINGS: Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.

Impact of the COVID-19 pandemic on interventional cardiology training in the United States.

OBJECTIVES: We sought to determine the effect of COVID-19 related reduction in elective cardiac procedures and acute coronary syndrome presentations on interventional cardiology (IC) training. BACKGROUND: The COVID-19 pandemic has significantly disrupted healthcare in the United States, including cardiovascular services. The impact of COVID-19 on IC fellow training in the United States has not been assessed. METHODS: The Society for Cardiovascular Angiography and Interventions (SCAI) surveyed IC fellows training in both accredited and advanced non-accredited programs, as well as their program directors (PD). RESULTS: Responses were received from 135 IC fellows and 152 PD. All respondents noted reductions in procedural volumes beginning in March 2020. At that time, only 43% of IC fellows had performed >250 PCI. If restrictions were lifted by May 15, 2020 78% of IC fellows believed they would perform >250 PCI, but fell to only 70% if restrictions persisted until the end of the academic year. 49% of IC fellows felt that their procedural competency was impaired by COVID-19, while 97% of PD believed that IC fellows would be procedurally competent at the end of their training. Most IC fellows (65%) noted increased stress at work and at home, and many felt that job searches and/or existing offers were adversely affected by the pandemic. CONCLUSION: The COVID-19 pandemic has substantially affected IC training in the United States, with many fellows at risk of not satisfying current program procedural requirements. These observations support a move to review current IC program requirements and develop mitigation strategies to supplement gaps in education related to reduced procedural volume.

Extension of Adrenocortical Carcinoma into the Right Atrium.

Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignant neoplasm which can produce intravascular extension into the inferior vena cava (IVC) rarely extend into the right atrium (RA). We report a case of a male patient with large ACC with extension into the IVC and RA. Computed tomography showed a large right adrenal mass with contiguous tumor thrombus extending into IVC and RA with extension to the level of tricuspid valve. Patient underwent combined cardiac and abdominal surgical intervention on cardiopulmonary bypass with removal of the mass.