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Background After an acute coronary syndrome event, secondary prevention is critical but remains suboptimal in underserved populations. Project Rationale Structural barriers, neighborhood deprivation, and clinical inertia create an implementation gap in lipid management, disproportionately affecting vulnerable patients. Project Summary LIICA (Lankenau Initiative to Improve Cardiovascular Access) is a multidisciplinary quality improvement program using the Area Deprivation Index to identify high-risk patients and enroll them in a coordinated pathway led by an advanced practice provider, interventional cardiologist, nurse navigator, community health worker (CHW), and pharmacists. The primary outcome was low-density lipoprotein cholesterol management; secondary outcomes included hemoglobin A1c, Duke Activity Status Index, blood pressure, sleep, anxiety, weight, body mass index, social needs resources, and hospital use. In this pilot cohort at 1 year, achievement of low-density lipoprotein cholesterol <55 mg/dL increased from 6.1% to 58.2%, mean hemoglobin A1c fell from 7.1% to 6.4%, Duke Activity Status Index and anxiety improved, and there were 0% second acute coronary syndrome events. Weight, body mass index, sleep, and blood pressure remained stable. CHWs provided substantial resources. Take-Home Message A multidisciplinary, CHW-led navigation model closes the lipid management implementation gap in high-deprivation populations, converting guideline targets into real-world outcomes.
PURPOSE:Patients with pedal artery occlusive disease have limited options when presenting with chronic limb-threatening ischemia (CLTI). Serration angioplasty (SA) has demonstrated less recoil and improved freedom from reintervention compared with plain old balloon angioplasty within the tibial vessels. We aimed to identify the technical feasibility and clinical outcomes of SA within the pedal (inframalleolar) vasculature in patients with CLTI. MATERIALS AND METHODS:Patient with SA of the pedal vasculature for CLTI from January 01, 2021 to March 31, 2023 were included in this multicenter retrospective study. Pedal vessels were defined as any inframalleolar vessel distal to the talocrural joint. Patient demographics, anatomic and technical details, acute procedural outcomes, and outcomes at the most recent follow-up were collected for analysis. The primary endpoint was technical success, defined as SA with <50% residual target vessel stenosis. Secondary endpoints included freedom from vessel injury, amputation-free survival, clinically-driven target lesion revascularization (CD-TLR), composite major adverse limb events (MALEs), wound healing rate, and improvement in wound, ischemia, and foot infection (WIfI) clinical stage at the most recent follow-up. RESULTS:Of the identified 45 patients managed with pedal SA, median pre-intervention Rutherford classification was 5, and 91.9% of patients had concomitant below-the-knee tibial artery intervention. The most commonly treated artery was the dorsalis pedis (59.2%), with a median diameter SA of 2.5 mm. Residual stenosis was <50% in 93.3% of cases and <30% in 82.2%. Freedom from vessel injury was 93.3% (1 immediate occlusion and 2 bail-out stents). Six-month freedom from major amputation was 93.3%, freedom from pedal CD-TLR was 93.3%, and freedom from MALE was 80.0%. At a median follow-up of 163 days, 48.7% of patients had complete wound healing, with the total frequency of either healed or improving wounds of 79.5%. CONCLUSION:Serration angioplasty of the inframalleolar vasculature in patients with CLTI had high rates of technical success with a low incidence of vessel injury. At a median follow-up of 5.4 months, wound healing was ahead of previously published studies on inframalleolar intervention.Clinical ImpactThis represents the largest series of a specialty balloon used to treat pedal occlusive disease in chronic limb-threatening ischemia patients. As the rate of pedal intervention increases, using new technology to safely achieve luminal gain is crucial for both short- and long-term limb salvage.
AIMS:Heart failure (HF) with preserved (HFpEF) and mildly reduced (HFmrEF) ejection fraction are prevalent, yet frequently underdiagnosed syndromes associated with high morbidity and mortality, impaired quality of life, and escalating healthcare expenditures. Although guideline-directed medications like SGLT2 inhibitors have been shown to reduce the risk of hospitalization and cardiovascular death, their use remains limited and substantial residual risk persists. This trial aims to evaluate the safety and performance of a novel left-atrium-to-coronary-sinus shunt (Edwards APTURE transcatheter shunt system) in HFpEF and HFmrEF patients. METHODS:ALT-FLOW II is a prospective multi-centre, randomized, sham-controlled, double-blinded (patient and assessor) trial. Approximately 100 symptomatic HF patients aged ≥18 years with left ventricular ejection fraction >40% and exercise pulmonary capillary wedge pressure (PCWP) ≥25 mm Hg with a PCWP to right atrial pressure gradient ≥8 mm Hg will be randomized 1:1 to the APTURE shunt vs sham control. Key exclusion criteria include severe HF, significant valvular disease, and more than mild right ventricular dysfunction. The primary endpoints are the safety of the APTURE device at 30 days and change in workload-corrected PCWP normalized to bodyweight at 6 months. Secondary endpoints include changes in patient-reported outcomes, and hemodynamic and echocardiographic parameters through 5 years. The trial will also explore the impact of the device on short-term cardiac remodelling and intra-cardiac flow patterns using multi-modality imaging. CONCLUSIONS:The ALT-FLOW II trial will evaluate the safety and performance of the APTURE system in symptomatic HFpEF and HFmrEF patients with elevated left atrial pressure.
Guidelines were developed for aortic evaluation based on a patient's health status, comorbidities, and the aneurysm's maximum diameter. The arrival of the endovascular aneurysm repair (EVAR) technique and its more advanced permutations introduced new variables to managing abdominal aortic aneurysm (AAA) and aortic dissection. For patients who present de novo for treatment of AAA or aortic dissection without any prior imaging available, the entire aorta (including the thoracic portion) should be assessed to fully characterize the anatomy. Preoperative imaging has one primary focus: to determine the need and feasibility for surgery based on anatomy, pathology extent, and rate of growth. Following both open and endovascular repair, surveillance imaging is needed. This is particularly true for EVAR due to its higher rate of complications that require reintervention. Successful therapy results in an aneurysm or dissection that remains stable or decreases in size with preserved branch vessel flow, as documented on surveillance imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Background: Syringe service programs (SSPs) provide health-promoting and preventative care for people who use drugs (PWUDs) and can reduce the risk of overdose and infectious diseases. SSPs are predominantly located in urban areas. Purpose: This study aims to (1) assess the number of syringes distributed and the services utilized at an SSP in Pennsylvania, and (2) assess the number of participants traveling to the SSP from other counties, and the rurality of each county. Methods: A convenience sample of individuals utilizing SSP services over 2 years was used. Data collected at the visits were analyzed to assess the volume of syringe distribution, the percentage of participants utilizing secondary services, the distance participants traveled, and the rurality of where participants traveled from. Results: A total of 8,632 individuals accessed SSP services and were included in the analysis. A total of 518 participants who were accessing the SSP traveled from neighboring or distant counties to access services. The average number of miles traveled per participant residing outside the county was 73. Conclusions: In Pennsylvania, PWUDs residing in rural communities travel, on average, more than 70 miles to access harm reduction services provided at SSPs. Through advocacy for policy change, nurses can aid in SSP expansion across Pennsylvania and other rural settings to allow for more accessible and equitable healthcare resources for rural PWUDs. Implications: Nurses should advocate for improved access to harm reduction services, including SSPs, for PWUD, both in rural Pennsylvania and other rural regions in the United States.
