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Background: We aimed to describe patient and limb outcomes in the decade after endovascular revascularization for chronic lower-extremity peripheral artery disease (PAD). Methods: We assessed outcomes in patients having endovascular revascularization of the superficial femoral artery in two centers between 2003 and 2011 and followed for a median 9.3 (25–75%: 6.8, 11.1) years. Outcomes included death, myocardial infarction, stroke, repeat limb revascularizations, and amputations. We used competing risks analysis with clustering by patient to determine the hazard ratios (HR) and 95% CI for patients, and procedural characteristics for cause of death, cardiovascular events, and major adverse limb events (MALE). Results: There were 253 index limb revascularizations in 202 patients followed for a median 9.3 years. Patients had intensive medical treatment with 90% on statins and 80% on beta-blockers. During follow up there were 57 (28%) cardiovascular deaths and 62 (31%) noncardiovascular deaths. Of the 253 limbs, 227 (90%) were free of MALE over follow up and 93 (37%) had MALE or minor repeat revascularization. In multivariable models, cardiovascular death significantly associated with critical limb ischemia (HR = 3.21, 95% CI = 1.84, 5.61) and noncardiovascular death with chronic kidney disease (HR = 2.69, 95% CI = 1.68, 4.30), and smoking (HR = 2.75, 95% CI = 1.01, 7.52). MALE or minor repeat revascularization associated with critical limb ischemia (HR = 1.43, 95% CI = 0.84, 2.43), smoking (HR = 2.49, 95% CI = 1.26, 4.90), and lesion length > 200 mm (HR = 1.51, 95% CI = 0.98, 2.33). Conclusions: Among patients with intensive medical therapy, the risk of noncardiovascular death was high and similar to cardiovascular death. Endovascular intervention can have acceptable long-term results. Future studies should evaluate strategies to reduce both cardiovascular and noncardiovascular deaths. [ABSTRACT FROM AUTHOR]

Key Points: Question: What is the blood pressure–lowering effect of ultrasound renal denervation compared with a sham procedure in patients with hypertension without the confounding influence of antihypertensive medications? Findings: In this sham-controlled, randomized (2:1) clinical trial including 224 patients withdrawn from antihypertensive medications, ultrasound renal denervation achieved clinically relevant reductions in daytime ambulatory systolic blood pressure (baseline-adjusted between-group difference, −6.3 mm Hg) as well as improvement for 6 of 7 secondary blood pressure outcomes compared with the sham procedure at 2 months. No major adverse events were reported in either group. Meaning: Ultrasound renal denervation lowered daytime ambulatory systolic blood pressure among patients with hypertension. Importance: Two initial sham-controlled trials demonstrated that ultrasound renal denervation decreases blood pressure (BP) in patients with mild to moderate hypertension and hypertension that is resistant to treatment. Objective: To study the efficacy and safety of ultrasound renal denervation without the confounding influence of antihypertensive medications in patients with hypertension. Design, Setting, and Participants: Sham-controlled, randomized clinical trial with patients and outcome assessors blinded to treatment assignment that was conducted between January 14, 2019, and March 25, 2022, at 37 centers in the US and 24 centers in Europe, with randomization stratified by center. Patients aged 18 years to 75 years with hypertension (seated office systolic BP [SBP] ≥140 mm Hg and diastolic BP [DBP] ≥90 mm Hg despite taking up to 2 antihypertensive medications) were eligible if they had an ambulatory SBP/DBP of 135/85 mm Hg or greater and an SBP/DBP less than 170/105 mm Hg after a 4-week washout of their medications. Patients with an estimated glomerular filtration rate of 40 mL/min/1.73 m2 or greater and with suitable renal artery anatomy were randomized 2:1 to undergo ultrasound renal denervation or a sham procedure. Patients were to abstain from antihypertensive medications until the 2-month follow-up unless prespecified BP criteria were exceeded and were associated with clinical symptoms. Interventions: Ultrasound renal denervation vs a sham procedure. Main Outcomes and Measures: The primary efficacy outcome was the mean change in daytime ambulatory SBP at 2 months. The primary safety composite outcome of major adverse events included death, kidney failure, and major embolic, vascular, cardiovascular, cerebrovascular, and hypertensive events at 30 days and renal artery stenosis greater than 70% detected at 6 months. The secondary outcomes included mean change in 24-hour ambulatory SBP, home SBP, office SBP, and all DBP parameters at 2 months. Results: Among 1038 eligible patients, 150 were randomized to ultrasound renal denervation and 74 to a sham procedure (mean age, 55 years [SD, 9.3 years]; 28.6% female; and 16.1% self-identified as Black or African American). The reduction in daytime ambulatory SBP was greater with ultrasound renal denervation (mean, −7.9 mm Hg [SD, 11.6 mm Hg]) vs the sham procedure (mean, −1.8 mm Hg [SD, 9.5 mm Hg]) (baseline-adjusted between-group difference, −6.3 mm Hg [95% CI, −9.3 to −3.2 mm Hg], P <.001), with a consistent effect of ultrasound renal denervation throughout the 24-hour circadian cycle. Among 7 secondary BP outcomes, 6 were significantly improved with ultrasound renal denervation vs the sham procedure. No major adverse events were reported in either group. Conclusions and Relevance: In patients with hypertension, ultrasound renal denervation reduced daytime ambulatory SBP at 2 months in the absence of antihypertensive medications vs a sham procedure without postprocedural major adverse events. Trial Registration: ClinicalTrials.gov Identifier: NCT03614260 This sham-controlled, randomized clinical trial compares the efficacy and safety of ultrasound renal denervation vs a sham procedure without the confounding influence of antihypertensive medications in adults with hypertension. [ABSTRACT FROM AUTHOR]

Pulmonary embolism (PE) is one of the most common causes of cardiovascular (CV) mortality worldwide. Owing to the associated morbidity and mortality with other treatment modalities, including systemic thrombolysis, a discernible change in the era of acute pulmonary embolism management has been reported. Catheter-directed thrombectomy using the FlowTriever system (Inari Medical; Irvine, CA, USA) was shown to reduce endpoints of interest in patients with acute intermediate-high risk PE and was associated with rapid hemodynamic improvement. In this report, we describe our experience with three cases of patients presenting with submassive PE, whereby immediate pulmonary artery pressure improvement was evident in all cases after successful mechanical thrombectomy. Our experience supports the use of FlowTriever mechanical thrombectomy for the treatment of submassive PE in clinical practice, with a call for further research to establish associated benefits. [ABSTRACT FROM AUTHOR]

Background: Quiescent‐interval slice‐selective (QISS) magnetic resonance angiography (MRA) is a non‐contrast alternative for the pre‐procedural assessment of patients with peripheral artery disease (PAD). However, the feasibility of pre‐procedural stent size estimation using QISS MRA would merit investigation. Purpose To evaluate the feasibility of QISS MRA for pre‐procedural stent size estimation in PAD patients compared to computed tomography angiography (CTA). Study Type: Retrospective. Subjects: Thirty‐three PAD patients (68 ± 9 years, 18 men, 15 women). Field Strength/Sequence: Two‐dimensional balanced steady‐state free precession QISS MRA at 1.5 T and 3 T. Assessment All patients received QISS MRA and CTA of the lower extremity run‐off followed by interventional digital subtraction angiography (DSA). Stenotic lesion length and diameter were quantified (AMF and AVS with 3 and 13 years of experience in cardiovascular imaging, respectively) to estimate the dimensions of the stent necessary to restore blood flow in the treated arteries. Measured dimensions were adjusted to the closest stent size available. Statistical Tests: The Friedman test with subsequent pairwise Wilcoxon signed‐rank test was used to compare the estimated stent dimensions between QISS MRA, CTA, and the physical stent size used for intervention. Intra‐class correlation (ICC) analysis was performed to assess inter‐reader agreement. Significant differences were considered at P < 0.05. Results: No significant difference was observed between estimated stent diameter by QISS MRA or CTA compared to physical stent diameter (8.9 ± 2.9 mm, 8.8 ± 3.0 mm, and 8.8 ± 3.8 mm, respectively; χ2 = 1.45, P = 0.483). There was a significant underestimation of stent length for both QISS MRA and CTA, compared to physical stent length (45.8 ± 27.8 mm, 46.4 ± 29.3 mm, and 50.4 ± 34.0 mm, respectively; χ2 = 11.96) which could be corrected when measurements were adjusted to the next available stent length (χ2 = 2.38, P = 0.303). Inter‐reader assessment showed good to excellent agreement between the readers (all ICC ≥0.81). Data Conclusion: QISS MRA represents a reliable method for pre‐procedural lesion assessment and stent diameter and length estimation in PAD patients. Level of Evidence: 3 Technical Efficacy: Stage 2 [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is the third most common cause of cardiovascular disease after myocardial infarction and stroke. Population-based studies estimate that up to 94,000 new cases of pulmonary embolism (PE) occur in the United States annually with an increasing incidence with age. Mortality from PE is the greatest in the first 24 hours, with a decreased survival extending out 3 months. Thus, acute PE is a potentially fatal illness if not recognized and treated in a timely manner. Contemporary management includes systemic anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. This article reviews current clinical evidence and societal guidelines for the use of systemic and catheter-directed thrombolysis for treatment of acute PE. [ABSTRACT FROM AUTHOR]

The coexistence of coronavirus disease 2019 (COVID-19) and pulmonary embolism (PE), two life-threatening illnesses, in the same patient presents a unique challenge. Guidelines have delineated how best to diagnose and manage patients with PE. However, the unique aspects of COVID-19 confound both the diagnosis and treatment of PE, and therefore require modification of established algorithms. Important considerations include adjustment of diagnostic modalities, incorporation of the prothrombotic contribution of COVID-19, management of two critical cardiorespiratory illnesses in the same patient, and protecting patients and health-care workers while providing optimal care. The benefits of a team-based approach for decision-making and coordination of care, such as that offered by pulmonary embolism response teams (PERTs), have become more evident in this crisis. The importance of careful follow-up care also is underscored for patients with these two diseases with long-term effects. This position paper from the PERT Consortium specifically addresses issues related to the diagnosis and management of PE in patients with COVID-19. [ABSTRACT FROM AUTHOR]

Objectives This study sought to evaluate the image quality and diagnostic accuracy of noncontrast quiescent-interval single-shot (QISS) magnetic resonance angiography (MRA) versus iodine-contrast computed tomography angiography (CTA) in patients with peripheral artery disease (PAD), with invasive digital subtraction angiography (DSA) as the reference standard. Background QISS is a recently introduced noncontrast MRA technique. Although the diagnostic accuracy of QISS is reportedly similar to that of contrast-enhanced MRA, its performance compared with contrast-enhanced CTA, the most frequently used noninvasive modality for evaluation of PAD, is unknown. Methods Thirty patients (66 ± 7 years of age) with PAD underwent lower extremity CTA with third-generation dual-source dual-energy CT and 1.5-T MRA using a prototype noncontrast QISS sequence. DSA was performed within 50 days. The abdominal aorta and lower extremity run-off were imaged. Eighteen arterial segments were analyzed. Subjective image quality (3-point Likert scale) and stenosis (5-point grading) were evaluated by 2 observers and compared using the Mann–Whitney U and chi-square tests, respectively. Sensitivity and specificity of MRA and CTA for >50% stenosis detection were compared using the McNemar-test. Results Of 540 segments, 15 (2.8%) and 42 (7.8%) inconclusive segments were excluded from MRA and CTA analysis, respectively (p = 0.0006). The DSA results were available for 410 of the remaining segments. Overall subjective image quality was rated similarly with QISS-MRA (2.52 [95% confidence interval: 2.46 to 2.57]) and CTA (2.49 [95% confidence interval: 2.43 to 2.55]; p = 0.5062). The sensitivity and specificity of MRA for >50% stenosis were 84.9% and 97.2%, respectively, similar to those of CTA (87.3% and 95.4%, respectively). Interobserver agreement for stenosis detection was excellent for MRA (κ > 0.81) and CTA (κ > 0.81). Conclusions Noncontrast QISS-MRA provides high diagnostic accuracy compared with DSA, while being less prone to image artifacts than CTA. QISS better visualizes heavily calcified segments with impaired flow. QISS-MRA obviates the need for contrast administration in PAD patients. [ABSTRACT FROM AUTHOR]

Hypertensive heart disease is the leading cause of mortality and morbidity in the United States. Despite widespread availability of medical therapy, it remains a challenge to treat. Autonomic nervous system imbalance resulting in overactivity of the sympathetic nervous system is integral to the development of hypertension and ultimately the development of hypertensive heart disease. Although the results with renal sympathetic denervation so far have been encouraging, optimism has recently been tempered with the broadcast alert from Medtronic, the sponsor of Symplicity HTN-3, that the trial did not meet its primary efficacy endpoint. The principal focus of this article is to review the developments in renal sympathetic denervation for the treatment of resistant hypertension. [ABSTRACT FROM AUTHOR]

Hypertensive patients with clinical blood pressure (BP) uncontrolled on ≥3 antihypertensive medications (ie, apparent treatment-resistant hypertension [aTRH]) comprise ≈28% to 30% of all uncontrolled patients in the United States. However, the proportion receiving these medications in optimal doses is unknown; aTRH is used because treatment adherence and measurement artifacts were not available in electronic record data from our >200 community-based clinics Outpatient Quality Improvement Network. This study sought to define the proportion of uncontrolled hypertensives with aTRH on optimal regimens and clinical factors associated with optimal therapy. During 2007-2010, 468 877 hypertensive patients met inclusion criteria. BP <140/<90 mmHg defined control. Multivariable logistic regression was used to assess variables independently associated with optimal therapy (prescription of diuretic and ≥2 other BP medications at ≥50% of maximum recommended hypertension doses). Among 468 877 hypertensives, 147 635 (31.5%) were uncontrolled; among uncontrolled hypertensives, 44684 were prescribed ≥3 BP medications (30.3%), of whom 22 189 (15.0%) were prescribed optimal therapy. Clinical factors independently associated with optimal BP therapy included black race (odds ratio, 1.40 [95% confidence interval, 1.32-1.49]), chronic kidney disease (1.31 [1.25-1.38]), diabetes mellitus (1.30 [1.24-1.37]), and coronary heart disease risk equivalent status (1.29 [1.14-1.46]). Clinicians more often prescribe optimal therapy for aTRH when cardiovascular risk is greater and treatment goals lower. Approximately 1 in 7 of all uncontrolled hypertensives and 1 in 2 with uncontrolled aTRH are prescribed ≥3 BP medications in optimal regimens. Prescribing more optimal pharmacotherapy for uncontrolled hypertensives including aTRH, confirmed with out-of-office BE could improve hypertension control. [ABSTRACT FROM AUTHOR]

Patients with critical limb ischemia have higher rates of death and amputation after revascularization compared to patients with intermittent claudication. However, the differences in patency after percutaneous revascularization of the superficial femoral artery are uncertain and impact the long-term risk of amputation and function in critical limb ischemia. We identified 171 limbs from 136 consecutive patients who had angioplasty and/or stenting for superficial femoral artery stenoses or occlusions from July 2003 through June 2007. Patients were followed for primary and secondary patency, death and amputation up to 2.5 years, and 111 claudicants were retrospectively compared to the 25 patients with critical limb ischemia. Successful percutaneous revascularization occurred in 128 of 142 limbs (90%) with claudication versus 25 of 29 limbs (86%) with critical limb ischemia (p = 0.51). Overall secondary patency at 2.5 years was 91% for claudication and 88% for critical limb ischemia. In Cox proportional hazards models, percutaneous revascularization for critical limb ischemia had similar long-term primary patency (adjusted hazard ratio = 1.1, 95% CI = 0.4, 2.6; p = 0.89) and secondary patency (adjusted hazard ratio = 1.1, 95% CI = 0.2, 6.0; p = 0.95) to revascularization for claudication. Patients with critical limb ischemia had higher mortality and death rates compared to claudicants, with prior statin use associated with less death (p = 0.034) and amputation (p = 0.010), and prior clopidogrel use associated with less amputation (p = 0.034). In conclusion, percutaneous superficial femoral artery revascularization is associated with similar long-term durability in both groups. Intensive treatment of atherosclerosis risk factors and surveillance for restenosis likely contribute to improving the long-term outcomes of both manifestations of peripheral artery disease. [ABSTRACT FROM AUTHOR]

Abstract: Massive pulmonary embolism carries a high mortality rate as a result of right ventricular failure. In addition to anticoagulation, systemic thrombolysis is the standard first line of therapy for patients with life-threatening massive pulmonary embolism. Surgical embolectomy is often considered in patients with contraindications to receiving systemic thrombolysis or when thrombolysis has failed. Surgical embolectomy is not without inherent risk and limitations.Although there is a paucity of large clinical trials, available data suggests catheter-based treatment of massive pulmonary embolism restores hemodynamic stability and thus is an alternative to surgical therapy. [Copyright &y& Elsevier]

Inadequate balloon occlusion while measuring pulmonary artery wedge pressure (PAWP) during right heart catheterization (RHC) may lead to inaccurate measures and clinically relevant misdiagnosis of disease. Following the 6th World Symposium on Pulmonary Hypertension (PH) recommendations, we instituted a standard of care clinical protocol at the Medical University of South Carolina that required obtaining a PAWP saturation (sat) to confirm complete occlusion whenever initially measured PAWP is >15 mmHg. We sought to determine: 1) The difference between initial and lowest reported PAWP 2) The frequency in which this practice leads to a change in PH classification 3) The overall success rate in obtaining a PAWP sat. After IRB approval, investigators not performing the RHC procedure prospectively collected demographic, echocardiographic and hemodynamic data. Subjects undergoing routine post-transplant RHC were excluded. After the initial PAWP measurement (as determined by the RHC operator), a PAWP sat was drawn to confirm occlusion (defined as >90% or within 5% of the systemic arterial oxygen saturation). If the PAWP sat did not confirm occlusion, the balloon was deflated and up to two additional attempts were made to re-measure the PAWP and confirm with a PAWP sat. PAWP were recorded at the same point in the respiratory cycle with each attempt. Repeated measures were compared using Signed Rank Test. We enrolled 75 subjects (age 58.3 +/- 13.3 years, 60% men, 59% with LVEF <50%) who underwent RHC in our institution from September 2019 to March 2020 and had a PAWP > 15 mmHg. Despite apparent confirmation of PAWP position by fluoroscopy and/or typical hemodynamic waveforms, an occlusive PAWP sat was unable to be confirmed in 39 (52%) of subjects during the first attempt. In these subjects, the mean difference between initial and lowest PAWP was -4.1 +/- 7.7 mmHg (p<0.001) and PVR increased from 3.2 +/- 2.3 to 4.5 +/- 4.6 Wood Units (p<0.001). Twelve of the 39 subjects (31%) had a difference =/> 5 mmHg. Three of the 4 subjects referred for PH with preserved EF were ultimately reclassified as having pre-capillary PH. Eight of the 16 referred for advanced heart failure evaluation were re-classified as combined post- and pre-capillary PH with PVR > 3 WU, which then required vasodilator testing. With additional attempts, a PAWP sat was confirmed in 83% of subjects. There were no observed complications during additional PAWP attempts. The practice of requiring a PAWP sat resulted in significantly lower PAWP, higher PVR and clinically relevant disease reclassification. A PAWP sat is a simple and safe technique to verify an elevated PAWP during RHC. [ABSTRACT FROM AUTHOR]

The article describes the case of a 52-year or male patient presenting with hemoptysis and progressive dyspnea on exertion after radiofrequency ablation due to paroxysmal atrial fibrillation. The patient underwent computed tomagraphy (CT) angiography, real-time 3dimensional (3D) transesophageal echocardiography (TEE) and recanalized the left-lower pulmonary vein then stented. The article discusses using real-time 3D TEE for flush occluded pulmonary vein not seen on 2D TEE or angiography.