Search

BACKGROUND: The benefit of catheter-directed therapy (CDT) for submassive pulmonary embolism (sPE) has been the subject of debate. We sought to determine the short- and long-term mortality and outcomes of CDT compared with anticoagulation for patients with sPE. METHODS: We performed a single healthcare network, multihospital, retrospective cohort study of hospitalizations for sPE from 2012 to 2019. sPE was defined as the presence of right heart strain or elevated biomarkers (troponin I or B-type natriuretic peptide). Patients with massive PE and those who had undergone systemic thrombolysis were excluded. The sPE groups included therapeutic anticoagulation alone or anticoagulation plus CDT (ie, thrombolysis or suction thrombectomy). The primary outcome was mortality at 1, 3, and 5 years. The other measured outcomes included PE-related death, short term mortality (30 days and 3 and 6 months), 30-day treatment-related complications (eg, bleeding, transfusion, stroke), chronic thromboembolic pulmonary hypertension, and 6-minute walk test at 1 year. After 1:1 nearest-neighbor propensity score matching, Kaplan-Meier survival plots were generated, and the treatment groups were compared using log-rank testing. We used Cox multivariate analysis to evaluate the outcomes after clustering at the hospital level, generating matched hazard ratios (mHRs) with associated 95% confidence intervals (CIs). RESULTS: Of 6746 sPE hospitalizations, the patients who had received CDT were younger (age, 58.9 ± 15.5 years vs 61.5 ± 17.4 years; P = .004), were more frequently White (92.5% vs 85.7%; P < .001), and had presented with a higher mean heart rate (104.6 bpm vs 94.9 bpm; P < .001), lower median systolic blood pressure (129 mm Hg vs 135 mm Hg; P < .001), and a greater incidence of right heart strain (79.2% vs 20.3%; P < .001). A total of 470 patients were matched, with 235 in the CDT group and 235 in the anticoagulation-only group. CDT was associated with a lower risk of mortality compared with anticoagulation at 1 year (7.6% vs 9.8%; mHR, 0.77; 95% CI, 0.65–0.92; P = .004), 3 years (11.1% vs 16.6%; mHR, 0.64; 95% CI, 0.55–0.73; P < .001), and 5 years (14.5% vs 19.1%; mHR, 0.71; 95% CI, 0.66–0.77; P < .001). Anticoagulation alone resulted in a greater incidence of PE-related deaths at 1, 3, and 5 years. The mortality at 30 days and 3 months was similar; however, CDT had resulted in better survival at 6 months (mHR, 0.81; 95% CI, 0.68–0.97; P = .02). No differences were found between the two groups in the incidence of bleeding complications at 30 days, development of chronic thromboembolic pulmonary hypertension, or the mean walking distance at 1 year. CONCLUSIONS: CDT plus anticoagulation for sPE was associated with improved long-term survival compared with anticoagulation alone, with a lower incidence of PE-related death and a low complication rate. CDT should be considered for select patients with sPE given its survival benefit. (J Vase Surg Venous Lymphat Disord 2023;11:70–81.)

This position paper, written by members of International Union of Angiology (IUA) Youth Committee and senior experts, shows an overview of therapeutical approaches for patients with chronic limb-threatening ischemia (CLTI) and absence of 'standard' solutions for revascularization. The aim was to demonstrate the accurate management of the 'no-option' CLTI patient including the wound treatment and the rehabilitation, considering always the goal of the increase of quality of life of the patients.

The COVID-19 (coronavirus disease 2019) pandemic has led to a rapid expansion in the use of telemedicine across all medical fields but has also exposed telehealth care disparities with differing access to technology across racial and ethnic groups. The objective of our study was to investigate the effects of telehealth on vascular visit compliance and to explore the effects of sociodemographic factors on vascular surgery outpatient telehealth usage during the COVID-19 pandemic.Consecutive patients who had undergone an outpatient vascular surgery evaluation between February 24, 2020 (the launch of our telemedicine program) and December 31, 2020, were reviewed. The baseline demographic and outcomes were obtained from the electronic medical records. Telehealth and in-person evaluations were defined according to the patient's index visit during the study period. Medical visit compliance was established on completion of the telehealth or in-person encounter. We used χA total of 23,553 outpatient visits had been scheduled for 10,587 patients during the study period. Of the outpatient visits, 1559 had been scheduled telehealth encounters compared with 21,994 scheduled in-person encounters. Of the scheduled outpatient encounters, 13,900 medical visits (59.0%) had been completed: 1183 telehealth visits and 12,717 in-person visits. The mean travel distance saved for the telehealth visits was 22.1 ± 27.1 miles, and the mean travel time saved was 46.3 ± 41.47 minutes. We noted no sociodemographic differences between the patients scheduled for telehealth vs in-person visits. We found a trend toward a lower proportion of African-American patients in the telehealth group vs the in-person group (7.8% vs 10.6%; P = .116), without statistical significance. A significantly higher rate of medical visit completion was found for the telehealth group compared with the in-person group (79.5% vs 59.4%; P .001). Among the patients scheduled for an outpatient medical visit, a scheduled telemedicine evaluation (vs in-person) was associated with 2.3 times the odds of completing the medical visit (odds ratio, 2.31; 95% confidence interval, 2.05-2.61), adjusting for age, sex, race, ethnicity, language, and the distance between the patient's home zip code and the outpatient vascular center's zip code. Selecting for scheduled telemedicine visits, African-American race was associated with a decreased odds of telemedicine usage (odds ratio, 0.73; 95% confidence interval, 0.59-0.90) after adjusting for age, sex, ethnicity, language, and visit type.Use of the vascular surgery outpatient telehealth evaluation appeared to improve medical visit completion in our region with apparent sociodemographic disparities. Further studies are needed to confirm whether telemedicine expansion has improved access to care in other geographic areas.

Extension of an iliofemoral thrombosis into the inferior vena cava (IVC), or from the IVC descending into the iliofemoral segments, can confer significant morbidity and mortality. Interventional management of acute deep vein thrombosis (DVT) has been controversial, but there is little doubt that certain subpopulations benefit, such as those with symptomatic IVC thrombosis. When considering an intervention, caval involvement introduces technical difficulties due to its larger diameter, high thrombus burden, bilateral limb clot extension and need for dual access. The frequent coexistence of an IVC filter increases the complexity even more. This review summarises the current indications and treatment modalities available for the management of acute DVT involving the vena cava.