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Chronic limb-threatening ischemia (CLTI) carries a significant risk of limb loss and thus demands urgent attention. Calcified atherosclerotic disease affecting the infra-popliteal (IP) arteries poses a formidable challenge for effective revascularization due to the narrow vessel diameter and the common presence of extensively calcified, long occlusive lesions. Intravascular lithotripsy (IVL) is an endovascular treatment that induces microfractures in the medial calcifications of blood vessels, thereby facilitating the clearance of calcified obstructive arterial lesions. This review assesses the growing body of evidence from multiple prospective studies that have investigated the role of IVL in the treatment of peripheral arterial disease (PAD) involving the IP segment. The clinical efficacy of IVL has been extensively studied and validated in various trials and real-world experiences. These studies consistently demonstrate IVL's ability to achieve vessel preparation, with excellent procedural success rates and low rates of major adverse events. Moreover, IVL has shown remarkable versatility, proving effective across a wide spectrum of PAD, including iliac artery disease, femoropopliteal disease and IP calcified disease. The available results from existing literature are encouraging and demonstrates safety and efficacy of the technology in treating calcified PAD. Additional studies on a larger scale are needed to better understand its long-term effects.

Background: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO)., Methods: A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts., Results: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib)., Conclusions: Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Arteriovenous fistula (AVF) is the optimal form of vascular access for most haemodialysis dependant patients; however, it is prone to the formation of stenoses that compromise utility and longevity. Whilst there are many factors influencing the development of these stenoses, pathological flow-related phenomena may also incite the formation of intimal hyperplasia, and hence a stenosis. Repeated CFD-derived resistance was calculated for six patient who had a radiocephalic AVF, treated with an interwoven nitinol stent around the juxta-anastomotic region to address access dysfunction. A three-dimensional freehand ultrasound system was used to obtain patient-specific flow profiles and geometries, before performing CFD simulations to replicate the flow phenomena in the AVF, which enabled the calculation of CFD-derived resistance. We presented six patient cases who were examined before and after treatment and our results showed a 77% decrease in resistance, recorded after a surgical intervention to address access dysfunction. Problematic AVFs were found to have high resistance, particularly in the venous segment. AVFs with no reported clinical problems, and clinical patency, had low resistance in the venous segment. There did not appear to be any relationship with clinical problems/patency and resistance values in the arterial segment. Identifying changes in resistance along the circuit allowed stenoses to be identified, independent to that determined using standard sonographic criteria. Our exploratory study reveals thatCFD-derived resistance is a promising metric that allows for non-invasive identification of diseased AVFs. The pipeline analysis enabled regular surveillance of AVF to be studied to aid with surgical planning and outcome, further exhibiting its clinical utility., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The arteriovenous fistula (AVF) is commonly faced with stenosis at the juxta-anastomotic (JXA) region of the vein. Implantation of a flexible nitinol stent across the stenosed JXA has led to the retention of functioning AVFs leading to the resulting AVF geometry being distinctly altered, thereby affecting the haemodynamic environment within it. In this study, large eddy simulations of the flow field within a patient-specific AVF geometry before and after stent implantation were conducted to detail the change in flow features. Although the diseased AVF had much lower flow rates, adverse flow features, such as recirculation zones and swirling flow at the anastomosis, and jet flow at the stenosis site were present. Larger velocity fluctuations (leading to higher turbulent kinetic energy) stemming from these flow features were apparent in the diseased AVF compared to the stented AVF. The unsteadiness at the stenosis created large regions of wall shear stress (WSS) fluctuations downstream of the stenosis site that were not as apparent in the stented AVF geometry. The larger pressure drop across the diseased vein, compared to the stented vein, was primarily caused by the constriction at the stenosis, potentially causing the lower flow rate. Furthermore, the WSS fluctuations in the diseased AVF could lead to further disease progression downstream of the stenosis. The change in bulk flow unsteadiness, pressure drop, and WSS behaviour confirms that the haemodynamic environment of the diseased AVF has substantially improved following the flexible stent implantation., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process., Competing Interests: Funding Support and Author Disclosures Dr Li has served on the advisory board for Boston Scientific, Inari Medical, and Medtronic; and as a consultant for Abbott Vascular, Endovascular Engineering, and Philips. Dr Varcoe has served as a consultant for Abbott Vascular, Intact Medical, Shockwave, Intervene, Surmodics, and Boston Scientific; and on the advisory board for Abbott Vascular and Intact Medical. Dr Manzi has served as a consultant for Abbott Vascular, Bard/BD, Boston Scientific, Angiodroid, Cook, and Terumo. Dr Kum has served as a consultant for Abbott Vascular, Boston Scientific, and LimFlow. Dr Iida has reported that he has no relationships relevant to the contents of this paper to disclose. Dr Schmidt has received consulting and speaker honoraria from Abbott Vascular, Boston Scientific, Bard/BD, Cook, Cordis, Intact Vascular, Medtronic, Reflow, and Upstream Peripheral. Dr Shishehbor has served on the global advisory board for Abbott Vascular, Medtronic, Terumo, Phillips, Boston Scientific, ANT, and Inquis Medical., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

This review details the utility of intravascular ultrasound (IVUS) for the management of peripheral artery and venous disease. The purpose of this document is to provide an update in the use of IVUS in peripheral arterial and venous pathology and demonstrate the use of IVUS as a practical diagnostic imaging procedure to evaluate and treat peripheral vascular disorders. IVUS, a diagnostic tool that relies on sound waves to produce precise images of the vessel being evaluated, was originally introduced to the medical community for the purposes of peripheral artery imaging, though it was quickly adapted for coronary interventions with positive outcomes. The utility of IVUS includes vessel measurement, pre- and post-procedural planning, treatment optimisation, and detection of thrombus, dissection or calcium severity. While angiography remains the standard imaging approach during peripheral intervention, multiple observational studies and small prospective trials have shown that in comparison, IVUS provides more accurate imaging detail, which may improve procedural outcomes. IVUS can also address limitations of angiography, including the need to administer contrast medium and eliminate the ambiguity associated with other forms of imaging. This review provides contemporary examples of where IVUS is being used during peripheral intervention as well as representative imaging to serve as a resource for the practising clinician.

Aims: COVID-19 had a devastating impact on patients with severe aortic stenosis (AS). Like many cardiac procedures, transcatheter aortic valve replacement (TAVR) services were suspended during the first wave of COVID-19. We took the opportunity to evaluate the clinical outcomes and identify any delays at different stages of the TAVR pathway during the COVID-19 pandemic., Methods: Prospectively collected data on 210 consecutive TAVR patients between March 2019 and March 2021 were analysed. We compared the clinical outcomes and 30-day mortality rates of TAVR cases pre-pandemic and during the pandemic. We also looked to identify any time lags from the initial referral to respective stages of the TAVR workup., Results: A total of 134 patients underwent TAVR prior to the national lockdown (March 2019-March 2020), compared to 76 patients during COVID-19 (April 2020-April 2021). Success rates of TAVR were similar (99% prior to the pandemic and 97.4% during COVID-19). The 30-day survival rates were 98.6% and 94.7%, respectively. Median length of stay post TAVR was 2 days during COVID-19 and 2.5 days prior to the pandemic (p = 0.064). Patients were seen quicker in clinic (median of 33 days) during COVID-19, compared to 51 days before COVID-19 (p = 0.044). No significant difference in times from referral to discussion at TAVR multidisciplinary team (MDT) meetings, CT Aortogram and TAVR implantation, in both groups., Conclusions: Reconfiguring the patient pathway during COVID-19 allowed TAVR to be performed safely, with a similar success rate and no excess complications or increased 30-day mortality. There proved to be no delay in the respective stages of patient TAVR workup, during the pandemic., Competing Interests: Conflicts of interest None declared., (Copyright © 2022 Hellenic Society of Cardiology. All rights reserved.)

Background: There has been growing use of intravascular ultrasound (IVUS) during lower extremity arterial and venous revascularization. Observational data suggest that the use of IVUS can improve periprocedural and long-term outcomes, but largescale prospective data remain limited. Consensus opinion regarding the appropriate use of IVUS during peripheral intervention is needed., Objectives: The purpose of this consensus document is to provide guidance on the appropriate use of IVUS in various phases of peripheral arterial and venous interventions., Methods: A 12-member writing committee was convened to derive consensus regarding the appropriate clinical scenarios for use of peripheral IVUS. The group iteratively created a 72-question survey representing 12 lower extremity arterial interventional scenarios. Separately, a 40-question survey representing 8 iliofemoral venous interventional scenarios was constructed. Clinical scenarios were categorized by interventional phases: preintervention, intraprocedure, and postintervention optimization. Thirty international vascular experts (15 for each survey) anonymously completed the survey instrument. Results were categorized by appropriateness using the median value and disseminated to the voting panel to reevaluate for any disagreement., Results: Consensus opinion concluded that IVUS use may be appropriate during the preintervention phase for evaluating the etiology of vessel occlusion and plaque morphology in the iliac and femoropopliteal arteries. IVUS was otherwise rated as appropriate during iliac and femoropopliteal revascularization in most other preintervention scenarios, as well as intraprocedural and postprocedural optimization phases. IVUS was rated appropriate in all interventional phases for the tibial arteries. For iliofemoral venous interventions, IVUS was rated as appropriate in all interventional phases., Conclusions: Expert consensus can help define clinical procedural scenarios in which peripheral IVUS may have value during lower extremity arterial and venous intervention while additional prospective data are collected., Competing Interests: Funding Support and Author Disclosures Dr Secemsky is funded in part by National Institutes of Health/National Heart, Lung, and Blood Institute grant K23HL150290. This review was funded in part by unrestricted educational grants from Boston Scientific and Philips IGT. These companies have not seen or participated in the creation of this manuscript, including no contribution in the writing of the manuscript, significant edits, or the decision whether to submit. Dr Secemsky is a consultant and Speakers Bureau and/or advisory board member for Abbott, Bayer, Becton, Dickinson and Company, Boston Scientific, Cook, Cardiovascular Systems, Inc., Endovascular Engineering, Inari, Janssen, Medtronic, Philips, and VentureMed; has received grants to the institution from the National Institutes of Health/National Heart, Lung, and Blood Institute (K23HL150290), the U.S. Food and Drug Administration, Harvard Medical School (Shore Faculty Development Award), AstraZeneca, BD, Boston Scientific, Cook, Cardiovascular Systems, Inc., Laminate Medical, Medtronic, and Philips. Dr Kohi is a board member at VIVA Physicians; and is a global principal investigator of the ELEGANCE (Drug-Eluting Registry: Real-World Treatment of Lesions in the Peripheral Vasculature) registry with Boston Scientific but is not being personally compensated. Dr Rosenfield is a consultant and scientific advisory board member for Angiodynamics, Boston Scientific, Contego, InspireMD, Magneto, Mayo Clinic, Neptune Medical, Philips, Summa Therapeutics, Surmodics, Thrombolex, and Truvic; has received grants to the institution from the National Institutes of Health and Boston Scientific; holds equity in Accolade, Access Vascular, Althea Medical, Contego, Cruzar Systems, Embolitech, Endospan, JanaCare, Magneto, Orchestra, PQ Bypass, Shockwave, Thrombolex, Truvic, and Valcare; and is a board member for the National PERT Consortium, a not-for-profit 501(c)(3) organization dedicated to advancing treatment and improving outcomes in pulmonary embolism. Dr Lichtenberg has received honoraria for lectures from Cagent Vascular, CR Bard, Boston Scientific, AB Medica, Philips, Terumo, Biotronik, Veryan, and Medtronic; has received honoraria for advisory board activities from Cagent Vascular, Biotronik, Veryan, Boston Scientific, Philips, Soundbite, Limflow, Covellus, and Medtronic; has participated in clinical trials for Cagent Vascular, Biotronik, CR Bard, Verya, Boston Scientific, LimFlow, Terumo, and Philips; and has received research funding from Cagent Vascular, Biotronik, Boston Scientific, Veryan, plusMedica, Philips, and CR Bard. Dr Meissner has served as a consultant for Cook Medical for a project using a Delphi consensus panel for venous stenting; Dr Varcoe consults for Medtronic, Abbott, BD Bard, Philips Healthcare, Intervene, and Surmodics; Dr Holden is a medical advisory board member for Medtronic, Gore, and Boston Scientific; and is a clinical investigator for Bard/BD, Boston Scientific, Cagent Medical, Cook Medical, Endologix, Endospan, Gore Medical, Intact Vascular, Medtronic, Philips, Reflow Medical, Shockwave Medical, and TriReme Medical. Dr Jaff is a part-time employee at Boston Scientific; is a consultant at Glide Healthcare; and holds equity investments in R3 Vascular, Nectero, Vactronix, and EFemoral. Dr Chalyan is an employee at Philips IGT. Dr Clair discloses his involvement with Boston Scientific, Elastimed, Endologix, and Medtronic and clarifies that he does not receive any income from these relationships, as all the income goes to the organization by which he is employed; and serves as a data and safety monitoring board member for Bard/Becton, Dickinson and Company and Boston Scientific (all income goes to the medical group). Dr Hawkins is a consultant at Baim; and conducts institutional research at Behring, Hemostemix, and the National Institutes of Health/National Heart, Lung, and Blood Institute. Dr Parikh is an advisory board member for Abbott, Boston Scientific, Medtronic, Philips, and Cordis; has conducted research for Abbott, Boston Scientific (data and safety monitoring board), Shockwave, Surmodics, TriReme, Veryan Medical, Acotec, and MedAlliance; and is a consultant for Abiomed, Canon, Inari, Penumbra, and Terumo. Dr Mosarla has reported that she has no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The ACURATE neo™ is a novel, second-generation self-expanding supra-annular transcatheter heart valve (THV). The objective of this multi-centre registry is to assess the safety, clinical utility, and impact of 'learning-curve-experience' (LCE) on transcatheter aortic valve replacement outcomes in the United Kingdom (UK) and Ireland., Methods: We prospectively collected data from seven ACURATE neo™ THV implanting centres (n = 484) between February 2016 and November 2020. We compared mortality rates and outcomes in the LCE group (n = 120) compared to next successive 120 cases., Results: The mean age of the cohort was 81.9(SD: 6.1) years and the majority were in the moderate risk category (EuroSCORE-II):3.3(SD: 3). The 97.5% of cases were performed under local anesthetic. The valve was successfully deployed in 98.8% of cases. The survival rate at 30 days was 97.9%. The incidence of stroke was 2.5%. Life threatening bleeding occurred in 0.6% of cases and vascular access complications occurred in 21 (4.3%) patients. Implantation-related conduction abnormalities occurred in 8.3% but only 5.6% required a PPM. The successful valve deployment occurred in 96% of the patients in the LCE group compared to 100% in the other group (p = 0.04; OR-2[CI 1.7-2.3]). The mortality rates at 30 days (1.7% vs. 1.7%) and 1 year (1.9% vs. 2.7%) were comparable between the two groups., Conclusions: This study represents the largest published UK and Ireland real-world experience of the ACURATE neo™ valve. The procedural success rates and safety outcomes were excellent and endorse its utility in clinical practice. The LCE appears to have an impact on the successful valve deployment but without translating into short-term or long-term outcomes., (© 2021 Wiley Periodicals LLC.)

Introduction: Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of chronic venous disease. Approximately 40% of patients with VLU present with the underlying deep venous disease (DVD). Although the data are scarce, these deep venous disease-related VLU (DRV) are thought to have higher recurrence rates and a substantial economic burden. The objective of this study was to assess the economic burden of DRV across Australia, France, Germany, Italy, Spain, the UK, and the USA., Methods: A comprehensive literature review was undertaken to identify publications documenting the incidence and prevalence of VLU and DRV, medical resource utilization, and associated costs of DRV. Findings from this literature review were used to estimate the economic burden of illness, including direct medical costs over a 12-month interval following initial presentation of a newly formed DRV., Results: Total annual incidence of new or recurrent DRV in Australia, France, Germany, Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000, 253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019. Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated annual direct medical costs for patients managed conservatively in these geographies total ~ $10.73 billion (USD) or $5527 per person per year., Conclusion: The availability of published data on the costs of VLU care varies widely across countries considered in this analysis. Although country-specific VLU practice patterns vary, there is a uniform pattern of high-cost care.