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COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.

Purpose: The purpose of this review and meta-analysis is to determine the clinical outcome differences between patients with chronic limb-threatening ischemia who underwent direct versus indirect angiosome revascularization using either the surgical or endovascular approach.Materials and Methods: The data sources used for article selection included PubMed, Embase/Medline, Cochrane reviews, and Web of Science (All studies were in English and included up to September 2023). All articles included were comparative in design, including retrospective, prospective, and randomized controlled trials that compared the clinical outcomes between direct and indirect angiosome-guided revascularization in chronic limb-threatening ischemia. A random-effects model was used to determine the measure of association between direct revascularization and amputation-free survival, wound healing, and overall survival. Publication bias was assessed with both Begg’s and Egger’s test, and heterogeneity was calculated using an I2.Results: Data from 9 articles were analyzed and reported in this review. Direct revascularization was associated with improved amputation-free survival (odds ratio [OR]=2.632, confidence interval [CI]: 1.625, 4.265), binary wound healing (OR=2.262, CI: 1.518, 3.372), and overall survival (OR=1.757, CI: 1.176, 2.625). Time until wound healed was not associated with either direct or indirect revascularization (Standard Mean Difference [SMD]=−2.15, p=0.11). There was a low risk of bias across all studies according to the RoB 2.0 tool.Conclusion: Direct revascularization is associated with improved amputation-free survival, overall survival, and wound healing in chronic limb-threatening ischemic patients compared to the indirect approach.Clinical Impact Preservation of the lower extremity is critical for preventing mortality and maintaining independence. The benefit of angiosome-guided revascularization for chronic limb-threatening ischemia remains controversial. The authors of this article aim to review the current literature and compare direct and indirect angiosome-guided intervention for preserving the lower extremity. Current findings suggest direct angiosome-guided intervention reduces amputation rates and improves survival; however, many trials neglect to address the multifactorial approach needed in wound care management.

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Introduction:COVID-19 infection disproportionally impacts non-Whites with higher morbidity and mortality. However, differences by race and ethnicity in COVID-19 patients with concomitant STEMI have not been previously described.Methods:The North American COVID-19 STEMI (NACMI) registry is a prospective, observational registry enrolling COVID-19 patients with concomitant STEMI from 64 centers in Canada and the United States from March 2020 to December 2021. We compared clinical characteristics, treatment strategies, and in-hospital mortality risks by race/ethnicity.Results:Among 679 STEMI patients with concomitant COVID-19, 54.5% were White, 14.3% Black, 19.4% Hispanic/Latinx, and 11.8% Asian/Indigenous/Other. Blacks had the highest prevalence of current smokers, and Whites had the lowest prevalence of diabetes. The rate of high-risk features including cardiac arrest, cardiogenic shock, and inotropic support was comparable between the groups. Presence of infiltrates and cardiomegaly was higher in Blacks and Hispanic/Latinx; whereas, COVID-19 severity was similar in the groups. Blacks and Hispanic/Latinx and Blacks were more likely to not have coronary angiography performed. Among patients that underwent angiography, Whites and Hispanic/Latinx were more likely to be treated with primary PCI. In-hospital mortality was highest in Hispanic/Latinx (38%) and the Asian/Indigenous/Other group (Table).Conclusions:Despite no difference in high-risk features in patients with COVID-19 and STEMI, there was a significant difference in in-hospital mortality between Whites and non-Whites with highest risk in Hispanic/Latinx and Asian/Indigenous/Other. Further research in needed to explore discrepant outcomes in racial/ethnic minorities in this patient population and the role of discrepant management.

Purpose:To investigate the impact on restenosis rates of deep injury to the adventitial layer during directional atherectomy. Methods:Between 2007 and 2010, 116 consecutive patients (mean age 69.6 years; 56 men) with symptomatic femoropopliteal stenoses were treated with directional atherectomy at a single center. All patients had claudication and TASC A/B lesions in the superficial femoral or popliteal arteries. Histopathology analysis of atherectomy specimens was performed to identify adventitial injury. Clinical follow-up included physical examination and duplex ultrasound scans at 3, 6, and 12 months in all patients. The primary endpoint was the duplex-documented 1-year rate of restenosis, which was determined by a peak systolic velocity ratio <2.4. Patients were dichotomized by the presence or absence of adventitial or medial cuts as evaluated by histopathology. Results:Adventitial injury were identified in 62 (53%) of patients. There were no differences in baseline demographic and clinical features (p>0.05), lesion length (58.7±12.8 vs 56.2±13.6 mm, p=0.40), or vessel runoff (1.9±0.6 vs 2.0±0.6, p=0.37) between patients with and without adventitial injury, respectively. The overall 1-year incidence of restenosis was 57%, but the rate was significantly higher (p<0.0001) in patients with adventitial or medial injury (97%, 60/62) as compared with those without (11%, 6/54). Conclusion:Lack of adventitial injury after atherectomy for femoropopliteal stenosis is strongly related to patency at 1 year.

Varicose veins are a common manifestation of chronic venous disease and affect approximately 25% of adults in the western hemisphere. The historical standard treatment has been surgery, with high ligation and stripping, combined with phlebectomies. In the past decade, alternative treatments such as endovenous ablation of the great saphenous vein (GSV) with laser, radiofrequency ablation, and ultrasonography-guided foam sclerotherapy have gained popularity. Performed as office-based procedures using tumescent local anesthesia, the new minimally invasive techniques have been shown in numerous studies to obliterate the GSV, eliminate reflux, and improve symptoms safely and effectively.

COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.

Introduction:To assess the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKA) in very elderly patients with atrial fibrillation (AF) undergoing transcatheter aortic valve replacement (TAVR). Two efficacy outcomes were used: all-cause mortality and thromboembolic events (defined as stroke and/or transient ischemic attack and/or systemic embolism and/or valve thromboses) and one safety outcome: life-threatening or major bleeding events. There is a discrepancy between the results of previous studies on the appropriate anticoagulation regimen in patients with AF with CHA2DS2Vasc score≥2 undergoing TAVRMethods:A systematic review of Medline, Cochrane, and Embase was done to find all studies in which the previously described outcomes in AF patients undergoing TAVR were compared according to their use of DOACs vs. VKA.Results:Six studies with a total 3,631 participants, mean follow-up 19±9.4 months (male: 30.3%, mean ages were 82.8±1.1 years and 82.2±1.5 years for the DOAC and the VKA groups, respectively) were included in our analysis. No significant differences were found between the DOAC and VKA group in all-cause mortality (Risk Ratio [RR] 1.06, 95% Confidence Interval [CI] 0.84-1.35) or life-threatening or major bleeding events (RR 1.02, 95% CI 0.83-1.25). A significant increase in risk of thromboembolic events was found in the DOAC group (RR 1.23, 95% CI 1.05-1.44).Conclusions:VKA should be preferred over DOACs in very elderly patients with AF who undergo TAVR, given the significantly increased risk in thromboembolic events seen with DOACs and the lack of significant difference in all-cause mortality and bleeding. RCTs are needed to confirm or refute our findings.

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Introduction:The rate and significance of microembolic events during carotid endarterectomy (CEA) and carotid artery stenting (CAS) remain unclear. We evaluated pre-procedural, intra-procedural and post-procedural microembolic signals (MES) rates in patients treated electively with CEA and transfemoral CAS with distal filter protection monitoring MES continuously with transcranial Doppler (TCD). The goal of the study was to determine if symptomatic patients i.e., patient with the previous history of stroke, TIA, amaurosis fugax and diplopia had more MES during the procedures compared to asymptomatic patients.Methods:Fifty-six patients (mean age 71?9 years; 35 men, 21 women) with significant carotid stenosis underwent successful TCD monitoring during the elective revascularization procedure (34 CEAs and 22 CASs). While 31 patients had a previous history of symptomatic embolic events, 25 patients did not report any history of symptoms. Ipsilateral MES were segregated into a total of 9 phases of pre-procedure, intra-procedure and post-procedure and the data were analyzed with IBM SPSS software. Cognitive function was assessed with Mini-Mental State Examination 2nd edition questioner.Results:Higher MES were determined during power injection phase, post-dilation phase and post-procedure in symptomatic patients (respectively, n=11?10, n=3.1?2, n=4.8?4.6) compared to asymptomatic patients (respectively, n=2.4?2.7, n=1.1?1.8, n=1.3?1.6) during CAS (respectively, p=0.022, p=0.047, and p=0.044). There were more MES detected during internal carotid artery clamping in patients with symptoms (n=14.6?22) compared to the asymptomatic patient (n=2.1?3.4) in the CEA group (p=0.05). No significant difference in cognitive function in pre and post procedure periods was found in CEA and CAS groups.Conclusions:Although TCD recordings demonstrated a significant increase of MES during some phases of the transfemoral CAS using distal filter protection in patients with symptoms, higher MES were recorded during internal carotid artery clamping in patients with symptoms compared to patients without symptoms during CEA. Interestingly, no difference was found in cognitive function in pre and post procedure periods in both groups.

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