OBJECTIVES:The provision of renal replacement therapy for the end stage kidney disease (ESKD) patient is lifesaving therapy. Surgically created arteriovenous access (SAA) is the most utilized modality. Positive remodeling may occur following SAA leading to high flow vascular access (HFVA). The impact of long-term exposure to HFVA on cardiovascular structural remodeling is not well understood. Accordingly, this study describes the echocardiographic changes observed in HFVA following SAA creation METHODS: This single-center retrospective study included all patients with HFVA, defined as volume flow (Qa) > 2000 ml/min, over a 10-year period. Electronic medical records were reviewed to extract demographic, clinical, and echocardiographic data before and after SAA creation at serial intervals. Changes in echocardiographic parameters were compared using paired analyses. Univariable and multivariable Cox regression models assessed mortality, ventricular dilatation, and dysfunction. RESULTS:201 patients were included, with an average age of 57 years and a median Qa of 2338 ml/min (2189, 2787). The cohort comprised of 31% females and 68% Black American patients. SAA were predominantly in the upper arm (87%), brachial-basilic (42%) and autogenous (89%). Significant echocardiographic changes were observed over time: Left atrial volume and left ventricular (LV) end-diastolic volume worsened after 6 months. At 1-3 years, most remaining parameters worsened significantly, and notably the right ventricle (RV) systolic pressure (. LV ejection fraction (LVEF) significantly decreased after 5 years (p<0.01), and LV mass index did not change significantly (p=0.34). RV and LV dilation and dysfunction were significant at 1-3 years. Most importantly, any degree of RV dilatation (HR 2.83; p 0.007) or RV systolic dysfunction (HR 2.36; p 0.017) was independently associated with early mortality. CONCLUSION:In patients with HFVA, cardiac remodeling was observed as early as 6 months. After 1-3 years' timeline, HFVA exposure was associated with progressive decline of key echocardiographic parameters related to heart failure. These findings underscore the importance of routine surveillance of the vascular access circuit and cardiac structures to detect early remodeling. Close monitoring of worsening RV parameters is essential, as it independently correlates with early mortality risk.
OBJECTIVE:Transcatheter arterialization of the deep veins (TADV) is a novel therapy for no-option chronic limb-threatening ischemia (CLTI) that delivers oxygenated blood to the foot via the venous system and has demonstrated favorable limb salvage outcomes in several studies, including the PROMISE II trial. The present study characterizes circuit maturation in the PROMISE II cohort by examining its longitudinal hemodynamic development and associated wound healing, with the goal of better defining the mechanism of action of TADV. METHODS:PROMISE II (NCT03970538) was a prospective, multicenter study on TADV in patients with no-option CLTI due to "desert foot" arterial anatomy. The objective was to evaluate longitudinal changes following TADV including hemodynamics from duplex ultrasound, distal perfusion, and wound healing over time. Clinical outcomes, perfusion metrics, and serial duplex ultrasound data were collected through 1 year using standardized protocols. Duplex studies evaluated volume flow and spectral Doppler parameters across the TADV circuit. Distal perfusion was assessed using toe-brachial index (TBI) and toe pressures. Duplex-derived waveforms were categorized as low- or high-resistance, and longitudinal hemodynamic changes were analyzed. Circuit maturation was assessed using characteristics such as waveform achieving high-resistance configuration and decreased acceleration time indicating vascular remodeling. RESULTS:A total of 105 patients from PROMISE II were included in the analysis. Limb salvage was 68.7% at 1 year. Among patients with adjudicated wound data, 75.5% were healed/healing at 1 year; patients with worsening status decreased from 52.6% to 14.3%, while complete healing increased to 46.9%. Circuits transitioned from low- to high-resistance waveforms (7.9% at baseline, 24.6% at 3 months, 37.7% at 6 months, 81.1% at 1 year, p<0.0001). At 1 year, in patients with high-resistance circuits, healed/healing wound status was 86.7%, TBI ≥0.3 was 57.1%, and toe pressure ≥40 mmHg was 78.3% indicating greater distal perfusion. CONCLUSIONS:TADV promotes limb salvage through staged hemodynamic maturation demonstrated with duplex, microvascular remodeling, sustaining perfusion, and supporting its durable benefit in no-option CLTI.
OBJECTIVE:Depression affects 20% to 37% of patients with peripheral artery disease, frequently requiring serotonergic antidepressants while receiving antiplatelet therapy concomitantly after vascular intervention. As platelets depend entirely on the serotonin transporter for serotonin uptake, serotonergic agents may alter platelet function in this setting. Hence, we aimed to determine whether serotonergic antidepressant exposure is associated with longitudinal instability in adenosine diphosphate (ADP)-mediated platelet inhibition. METHODS:In this retrospective cohort study of prospectively enrolled patients with peripheral artery disease undergoing lower-extremity revascularization (December 2020-2025) at a single US tertiary care center, serial thromboelastography with platelet mapping data (December 2020-2025) were used to construct consecutive-visit pairs. The primary outcome was visit-to-visit variability in ADP-mediated platelet inhibition, defined as log-transformed absolute change between consecutive measurements, capturing larger visit-to-visit change regardless of direction. Serotonergic antidepressant exposure (such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, or trazodone) was evaluated both as active exposure at the current assessment within each consecutive measurement pair and as a four-level transition variable: stable nonexposure ((0→0), reference), initiation (0→1, exposure onset between two sequential assessments), discontinuation (1→0), and stable exposure (1→1). Associations were estimated using adjusted linear mixed-effects model. Prespecified exploratory analyses were performed in the chronic limb-threatening ischemia subgroup. RESULTS:Among 514 enrolled cases, 330 contributing 896 consecutive-visit pairs were included; 307 patients contributed 838 consecutive-visit pairs in the complete case-adjusted analysis. Active serotonergic exposure was not independently associated with greater longitudinal variability in platelet inhibition [β = .135; 95% confidence interval (CI), -0.901 to 0.360; P = .240]. However, serotonergic initiation was associated with increased variability compared with stable nonexposure (β = .571, 95% CI, 0.144-0.998; P = .009), persisting after adjustment for psychiatric diagnosis burden. Discontinuation showed a borderline association (β = .405; P = .05); stable exposure was not associated with greater variability (β = .105; P = .40). Ticagrelor use was independently associated with lower variability in primary adjusted models (β = -.521; 95% CI, -0.901 to -0.141; P = .008). In exploratory chronic climb-threatening ischemia analyses, initiation was associated with a 19.7 percentage point mean upward shift in ADP-mediated platelet inhibition (95% CI, 3.9-35.6; P = .015) and higher odds of entering a high-inhibition range previously linked to bleeding risk (odds ratio, 7.61; 95% CI, 1.32-43.96; P = .023). CONCLUSIONS:Serotonergic antidepressant initiation, rather than stable ongoing therapy, was associated with increased instability in ADP-mediated platelet inhibition after lower-extremity revascularization. These findings identify the peri-initiation window with implications for medication reconciliation in vascular surgery patients and raise the hypothesis that background P2Y12 regimen consistency may modulate the magnitude of serotonergic medication-induced platelet instability.
BACKGROUND:Single-segment great saphenous vein (GSV) grafts are the conduits of choice for infra-inguinal bypasses (IIB) performed for chronic limb-threatening ischemia (CLTI). GSV has been used in three different configurations: reversed, in situ, and non-reversed. In this large multi-institutional study, we aimed to compare outcomes of IIBs performed utilizing different GSV configurations in a real-world experience. METHODS:We queried Vascular Quality Initiative (VQI)-Medicare-Linked database for all IIBs performed for occlusive disease presenting with CLTI between 2011 and 2019. All bypasses were performed with single-segment GSV. The primary outcome was amputation-free survival (AFS). The secondary outcomes included overall survival (OS), limb salvage (LS), and freedom from reintervention (FFR). LS was defined as freedom from major amputation. All outcomes were analyzed at one and five years. Kaplan-Meier survival estimates and Cox regression were used for the analyses. RESULTS:The study included three cohorts of IIBs including reversed (N=3,003, 53.0%), in situ (N=1,344, 23.7%), and non-reversed (N=1,322, 23.3%) GSV configurations. Five-year AFS was 39.8%, 39.5%, and 42.4%, in reversed, in situ, and non-reversed cohorts, respectively (P=0.126). After adjusting for potential confounders, in situ and non-reversed configurations were not associated with increased hazards of major amputation/death at one year compared with reversed configuration (adjusted Hazards Ratio [aHR]=0.96, 95% Confidence Interval [CI], 0.83-1.13; P=0.652 and aHR=0.94, 95% CI, 0.81-1.08; P=0.375, respectively). Additionally, in situ and non-reversed configurations were not associated with increased hazards of major amputation/death at five years compared with reversed (aHR=1.06, 95% CI, 0.96-1.17; P=0.255 and aHR=0.93, 95% CI, 0.84-1.02; P=0.129, respectively). Non-reversed configuration was associated with decreased hazards of death (aHR=0.82, 95% CI, 0.73-0.93; P=0.002) and major amputation/death (aHR=0.87, 95% CI, 0.78-0.97; P=0.016) compared with in situ configuration at five years. GSV configuration was not associated with reintervention. CONCLUSIONS:In this large multi-institutional study comparing three GSV configurations for lower extremity bypass, long-term limb-related outcomes were largely comparable across configurations. Although non-reversed configuration was associated with lower hazards of death and major amputation/death compared with in situ configuration at five years, this difference was primarily driven by mortality and may reflect differences in patient selection. Overall, all three GSV configurations represent acceptable and durable options for infrainguinal bypass, with conduit selection guided by surgeon preference, conduit availability, and patient anatomy.
OBJECTIVE:Medical management of peripheral artery disease (PAD) consists of antiplatelet therapy, cholesterol reduction, blood pressure control, and anticoagulation. These medications lead to lower mortality, improved quality of life, and fewer adverse limb events in patients with PAD. However, few studies have examined medication adherence rates, the factors that influence them, and the subsequent effect on outcomes. METHODS:We identified all patients who underwent lower extremity endovascular revascularization for PAD between May 2022 and November 2024. Pharmacy dispensing reports were utilized to calculate the proportion of days covered for 90 days postoperatively for antiplatelet agents, anticoagulants, statins, antihypertensives, insulin, and other antihyperglycemic agents. We evaluated the factors associated with nonadherence (defined as composite proportion of days covered of <80%) and the association between nonadherence and reintervention, minor and major amputation, and 90-day mortality. RESULTS:Our study population included 405 patients, of which 45% were female, 39% Hispanic, 18% current smokers, 22% had claudication, and 78% had chronic limb-threatening ischemia (CLTI). Nonadherence rates ranged from 21.7% for sulfonylureas to 54.1% for short-acting insulin. In our sample, 62% met the criteria for composite adherence. Patients with CLTI had 45% lower composite medication adherence compared with that for claudicants (87.7% vs 78.1%; P = .046). Moreover, 97 patients underwent reintervention (24%), 68 (17%) underwent minor amputation, 39 (10%) underwent major amputation, 149 (37%) were readmitted within 90 days, and 16 (4%) died within 90 days. While no difference was noted in mortality (P = .90) between adherent and nonadherent patients, medication adherence was associated with a 61% lower risk of death-censored reintervention (subdistribution hazard ratio [sHR], 0.39; 95% confidence interval [CI], 0.27-0.58, P < .001), 56% lower risk of death-censored major amputation (sHR, 0.44; 95% CI, 0.23-0.84; P = .01), and 45% lower risk of death-censored minor amputation (sHR, 0.55; 95% CI, 0.34-0.90; P = .02). Patients on dialysis had a higher risk of minor amputation (P = .007), and patients with CLTI had higher risks of reintervention (P = .017) and minor amputation (P = .032). Insurance status and area deprivation index were not associated with composite adherence. CONCLUSIONS:Medication nonadherence significantly increases the risks of reintervention and major/minor amputation following lower extremity endovascular revascularization. A significant proportion of patients are nonadherent to their medications following revascularization. Patients with CLTI comprise a high-risk group for nonadherence, with high rates of reintervention and amputation. Notably, traditionally accepted risk factors such as area deprivation index and insurance were not associated with adherence, suggesting that significant work is warranted to understand the reasons why patients are nonadherent to medications.
OBJECTIVE:Current carotid revascularization paradigms are primarily stenosis-based, with optimized medical therapy alone generally recommended for symptomatic patients with (≤50%) mild-to-moderate degree of stenosis (MMDS) and no routine recommendation for revascularization, despite evidence of potentially high-risk plaque features beyond stenosis. We aimed to contrast clinical presentation, prevalence of vulnerable plaque features, and postrevascularization outcomes among symptomatic patients with MMDS and high-degree stenosis (HDS > 50%) across three stroke centers. METHODS:We performed a retrospective multicenter case-control study of symptomatic patients with MMDS vs HDS who underwent carotid revascularization from January 2016 to February 2026. Carotid revascularization procedures included were endarterectomy, transfemoral stenting, and transcarotid revascularization. MMDS was defined as ≤50% stenosis on all available preoperative cross-sectional imaging using North American Symptomatic Carotid Endarterectomy Trial criteria and the European Society for Vascular Surgery 2023 Clinical Practice Guidelines. Patients with any imaging study showing >50% stenosis were classified as HDS. Baseline characteristics, symptom phenotype, preoperative medications, imaging findings, vulnerable plaque features on magnetic resonance angiography with vessel wall imaging, and 30-day and long-term outcomes were compared. Composite outcomes included ipsilateral stroke, transient ischemic attack, myocardial infarction, and death. RESULTS:Among 800 symptomatic patients, 87 (10.9%) had MMDS and 713 (89.1%) had HDS. Patients with MMDS were more frequently male (MMDS: 85.1% vs HDS: 68.0%; P < .01) and more commonly presented with cerebral infarction (MMDS: 59.8% vs HDS: 48.4%; P = .04), whereas transient ischemic attack were trending more frequently in patients with HDS (MMDS: 23.0% vs HDS: 33.5%; P = .05). Neurologic severity was similar by the National Institutes of Health Stroke Scale at admission (MMDS: 3.00 ± 3.54 vs HDS: 4.34 ± 5.78; P = .27), National Institutes of Health Stroke Scale at discharge (MMDS: 1.60 ± 2.20 vs HDS: 2.02 ± 3.64; P = .80), modified Rankin Scale at discharge (MMDS: 0.87 ± 1.25 vs HDS: 0.81 ± 1.09; P = .43), and Age, Blood pressure, Clinical features, Duration of symptoms, and Diabetes score (MMDS: 3.83 ± 1.53 vs HDS: 3.47 ± 1.43; P = .31). Patients with MMDS had higher rates of intraplaque hemorrhage (MMDS: 64.0% vs HDS: 29.4%; P < .01), ulceration (MMDS: 30.0% vs HDS: 13.0%; P < .01), and overall vulnerable plaque features other than stenosis (MMDS: 80.0% vs HDS: 39.4%; P < .01). Thirty-day composite outcomes were similar (MMDS: 5.7% vs HDS: 3.7%; P = .39), as were long-term (3.3 ± 2.6 years) composite outcomes (MMDS: 17.2% vs HDS: 25.0%; P = .11). In a sensitivity analysis excluding patients with 50% stenosis, the <50% stenosis subgroup (n = 44) demonstrated findings consistent with the primary analysis, presenting significantly more commonly in males [MDS: 84.1% vs moderate-to-high degree stenosis (MHDS): 69.0%; P = .03], with higher rate of cerebral infarction as their presenting symptom (MDS: 65.9% vs MHDS: 48.7%; P = .03), and vulnerable plaque features (MDS: 84.6% vs MHDS: 42.3%; P <.01), without differences in 30-day or long-term outcomes. CONCLUSIONS:In our series of consecutive revascularized patients with symptomatic carotid disease, compared with HDS, MMDS were more likely to present with cerebral infarction, and had a higher prevalence of vulnerable plaque features on cross-sectional imaging despite lower luminal vessel stenosis. There were similar 30-day and long-term postrevascularization outcomes. In symptomatic patients with MMDS, magnetic resonance angiography with vessel wall imaging plaque characterization may represent an important diagnostic step in the evaluation of patients with higher risk for recurrence of a subsequent neurovascular event. Prospective studies are needed to determine whether vulnerable plaque features, rather than vessel stenosis alone, should guide risk stratification and treatment selection in this population.
Background:Individuals with chronic kidney disease (CKD) have twice the risk of peripheral arterial disease (PAD) and are more susceptible to arterial calcification. Diagnosing arterial abnormalities involves a combination of clinical assessment and noninvasive tests. The ankle-brachial index (ABI) is a cost-effective method for assessing arterial abnormalities and predicting mortality. Continuous Doppler ultrasound is the gold standard for ABI assessment due to its greater accuracy, and point-of-care ultrasound (POCUS) enables bedside measurement of this index. Objectives:To analyze the prevalence of arterial abnormalities in individuals undergoing hemodialysis using POCUS. Methods:We conducted an observational, analytical, cross-sectional study of 85 patients on hemodialysis, using a clinical and sociodemographic questionnaire and calculating the ABI. The primary outcome was the analysis of the presence of arterial abnormalities through the measurement of ABI using the POCUS method.. Results:The prevalence of ABI results suggestive of PAD and arterial calcification was 24.7% and 22.4%, respectively. Diabetes mellitus (p = 0.02) and advanced age (p = 0.01) were identified as the main risk factors for PAD. Conclusions:The POCUS-assisted assessment identified a prevalence of 24.7% for PAD and 22.4% for arterial calcification among patients with CKD. Advanced age and diabetes mellitus were the main risk factors associated with PAD. The data suggest that POCUS is an innovative approach for the bedside diagnosis of arterial abnormalities in patients on hemodialysis.
Background:To date, the COVID-19 pandemic constitutes the greatest health care challenge of the century. Its central pathophysiology involves an infectious respiratory disease caused by the SARS-CoV-2 virus with potential in the most severe cases to provoke cardiovascular complications, including venous thromboembolism (VTE). Objectives:This study describes the clinical and laboratory characteristics of hospitalized patients with VTE confirmed during a COVID-19 infection. Methods:This is an observational, longitudinal, and retrospective analytical study based on review of the medical records of patients admitted to three tertiary centers in the capital of Pará state, Brazil, with VTE diagnosed by imaging. Epidemiological and laboratory data were collected retrospectively at each health center, covering the period starting when the first case of COVID-19 was recorded and ending in July 2021. Results:VTE cases were recorded in 1.30% of medical records, with percentages varying from 0.60% to 2.25% at the different centers. Mean age, C-reactive protein, D-dimer, body mass index, and length of hospital stay were 46.35 years, 143.23 mg/L, 4.12 µg/mL, 27.65 kg/m2, and 50.18 days, respectively. No significant correlations (p < 0.05) were observed between presence of VTE and any of variables studied. Conclusions:There appeared to be associations between some of the variables tested, but it was not possible to confirm any causal relationships. It is possible that epidemiological associations between COVID-19 and VTE could be measured and better explained by possible confounding factors, such as simultaneous coinfections, preexisting health conditions, and others.
Severe renal trauma is a rare and potentially life-threatening condition that requires rapid and individualized management. Selective embolization has proven to be an effective and minimally invasive option for hemorrhage control and renal function preservation. We present two cases of severe renal trauma, one blunt and one penetrating, successfully treated with superselective embolization. In the first case, microcoils were used for segmental branch occlusion; in the second, cyanoacrylate glue (Hystoacryl + Lipiodol, 33%) was applied. Both patients achieved hemodynamic stabilization, laboratory recovery, and preserved renal function without complications. Endovascular management proved to be a safe and decisive treatment, avoiding nephrectomy and reinforcing the essential role of interventional radiology in the management of high-complexity renal trauma.
OBJECTIVE:To perform a systematic review and meta-analysis evaluating the prognostic utility of the Global Limb Anatomical Staging System (GLASS) classification in patients with chronic limb-threatening ischemia, and to determine which intervention, endovascular or open bypass, is associated with superior outcomes in patients classified as GLASS III. METHODS:We conducted a systematic review and meta-analysis using PubMed, Scopus, and Cochrane Central from inception through October 2025. Outcomes compared across GLASS stages included immediate technical success (ITS) of endovascular procedures, overall survival, amputation-free survival, limb salvage, freedom from major adverse limb events (MALE), and limb-based patency (LBP). For patients with GLASS III disease, we directly compared endovascular vs surgical bypass revascularization for overall survival, freedom from MALE, and limb salvage. RESULTS:We included 17 studies in the meta-analysis, comprising 5290 patients and 5492 limbs: 945 (17.2%) GLASS I, 1431 (26.1%) GLASS II, and 3116 (56.7%) GLASS III. Compared with GLASS I, GLASS II presented a significantly higher hazard for LBP failure [hazard ratio (HR), 1.53; 95% confidence interval (CI), 1.06-2.20; P = .032] and major amputation (endovascular only; HR, 1.45; 95% CI, 1.13-1.86). When comparing GLASS III with GLASS I, GLASS III had significantly higher hazard for mortality (HR, 1.28; 95% CI, 1.06-1.56; P = .021), MALE (HR, 1.36; 95% CI, 1.02-1.83; P = .042), and LBP failure (HR, 2.23; 95% CI, 1.56-3.19; P = .003). GLASS I presented a significantly higher ITS rate compared with GLASS II [risk ratio (RR), 1.03; 95% CI, 1.01-1.05; P = .016] and GLASS III (RR, 1.24; 95% CI, 1.09-1.41; P = .005). GLASS II also showed a significantly higher ITS rate compared with GLASS III (RR, 1.20; 95% CI, 1.04-1.38; P = .017). No other comparisons across GLASS stages were statistically significant. Among patients classified as GLASS III, we found an increased hazard of MALE in the endovascular group compared with open bypass surgery (HR, 1.88; 95% CI, 1.35-2.61; P = .015). No significant differences were identified between endovascular and surgical bypass revascularization for other outcomes. CONCLUSIONS:This meta-analysis demonstrates that increasing GLASS anatomical severity is associated with progressively lower ITS following endovascular intervention and increased hazard of LBP failure across all revascularization strategies in patients with chronic limb-threatening ischemia. Patients classified as GLASS I, with low complexity anatomies, had a lower mortality and MALE hazard compared with those with high-complexity disease (GLASS III). Among patients classified as GLASS III, endovascular therapy is associated with an increased hazard for MALE compared with bypass surgery.
OBJECTIVE:Delphi consensus guidelines recommend utilization of dual antiplatelet therapy (DAPT) following fenestrated and branched endovascular aortic repair (F/BEVAR) for target vessel (TV) patency. Limited data supports this recommendation with little known about the impact on bleeding events and optimal treatment duration. This study assesses TV occlusion and bleeding complications based on antithrombotic regimens following F/BEVAR. METHODS:Patients who underwent F/BEVAR for treatment of thoracoabdominal aortic aneurysms at a single institution from 2012 to 2024 were assessed. Discharge regimens were maintained for 3-months, long-term regimens were assessed at 6-months and included single antiplatelet therapy (SAPT), DAPT, and anticoagulation (AC) plus SAPT. TV occlusion and bleeding events within 3-months were assessed with univariate analysis. Long-term outcomes including TV occlusion, bleeding events, reintervention, and survival were compared with Kaplan-Meier analysis. Multivariate Cox regression analysis was performed for TV occlusion, bleeding events, and survival. RESULTS:A total of 235 patients were included; 53% were discharged on SAPT, 28% on DAPT, and 19% on AC plus SAPT. During the study period, there were 35 TV occlusions (3.8%)-including 31 branches (6.1%), four fenestrations (1.0%), 29 renal (6.4%), and five mesenteric targets (1.1%). In total, nine TV occlusions (26%) occurred in the setting of documented cessation and/or noncompliance with prescribed antiplatelet medication regimens. TV occlusion within 3-months did not differ by discharge regimen. In time-to-event analysis, TV occlusions were similar based on discharge (P = .30) and long-term regimens (P = .62). At 1-year, 3.4%, 2.5%, and 0% of patients discharged on SAPT, DAPT, and AC plus SAPT had TV occlusions. In subgroup analysis, there were differences in TV occlusion by type of SAPT prescribed at discharge; 1-year (Aspirin, 2.1% vs Plavix, 17.1%; P < .001). In adjusted analysis, renal targets [hazard ratio (HR), 7.5; 95% confidence interval (CI), 2.9-19.3] and branch configurations (HR, 8.3; 95% CI, 2.9-23.9) were associated with increased risk for TV occlusion, but medication regimens were not. In total, 41 patients (17%) experienced 51 bleeding events. The majority of bleeding events were minor (73%) and gastrointestinal bleeds (57%). Bleeding events by long-term regimen did not differ in time-to-event analysis (P = .07). However, in adjusted analysis, long-term AC plus SAPT was associated with increased risk of bleeding complications (HR, 3.1; 95% CI, 1.3-7.6) and decreased long-term survival (HR, 2.2; 95% CI, 1.1-4.3) compared with SAPT, whereas DAPT was not. CONCLUSIONS:DAPT was not associated with a significant reduction in TV occlusion following F/BEVAR. However, complete cessation of antithrombotic medications increases risk for TV occlusion, highlighting the critical importance of continued adherence to antiplatelet therapy. Bleeding complications are more common with long-term AC plus SAPT, but not DAPT. Randomized control trials are needed to further delineate optimal antithrombotic medication regimens given the high-risk comorbidity profile of patients treated and associated impact of TV occlusion and bleeding events on patient outcomes.
OBJECTIVE:We aimed to conduct a systematic review and study-level meta-analysis of randomized controlled trials and observational studies comparing intravascular ultrasound (IVUS) guidance with angiography guidance for peripheral artery disease (PAD) endovascular revascularization, as current evidence is lacking. METHODS:We searched Medline, Embase, and CENTRAL from inception until November 22, 2025. Trials and observational studies were analyzed separately. We used random-effects as our primary analysis and assessed the certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation. Key outcomes included restenosis, reintervention, major amputation, and mortality. RESULTS:We included two randomized trials (n = 387), and 19 observational studies (n = 1,164,329). According to randomized data, IVUS-guidance likely reduces restenosis compared with angiography-guidance [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.42-0.83; moderate certainty]. However, IVUS may not reduce reintervention (RR, 0.68; 95% CI, 0.44-1.08; low certainty), or mortality (RR, 1.13; 95% CI, 0.37-3.42; low certainty), whereas its effect on major amputation is very uncertain (RR, 0.97; 95% CI, 0.14-6.73; very low certainty). However, based on observational data, IVUS may reduce restenosis (RR, 0.70; 95% CI, 0.54-0.90; low certainty), reintervention (RR, 0.66; 95% CI, 0.48-0.90; low certainty), major amputation (RR, 0.83; 95% CI, 0.72-0.96; low certainty), and mortality (RR, 0.88; 95% CI, 0.84-0.93; low certainty). CONCLUSIONS:IVUS guidance likely reduces restenosis based on limited randomized evidence. Observational studies suggest potential benefits across several outcomes, although the certainty of evidence is low. Larger randomized trials are required to clarify the potential benefits of IVUS guidance.
