Endovascular Treatment of Resistant and Uncontrolled Hypertension Therapies on the Horizon

The treatment of resistant hypertension has undergone remarkable advancements in recent years. Endovascular radio frequency renal sympathetic denervation (RSD) has shown initial success in treating resistant hypertension by targeting the connection between the brain and renal sympathetic nerves. However, the encouraging results of first-generation RSD have been tempered by important procedural limitations and a need for long-term results of safety and efficacy. In an effort to build on early clinical success, several second-generation RSD technologies are now being developed that may improve procedural safety and efficacy. Preliminary evidence for some of the latest technologies is now available. In this review, we summarize the current evidence in support of RSD and consider unique features of several new technologies that are likely to refine the endovascular treatment of resistant hypertension

Acute Outcomes for the Full US Cohort of the FLASH Mechanical Thrombectomy Registry in Pulmonary Embolism

Background Evidence supporting interventional pulmonary embolism (PE) treatment is needed. Aims We aimed to evaluate the acute safety and effectiveness of mechanical thrombectomy for intermediate- and high-risk PE in a large real-world population. Methods FLASH is a multicentre, prospective registry enrolling up to 1,000 US and European PE patients treated with mechanical thrombectomy using the FlowTriever System. The primary safety endpoint is a major adverse event composite including device-related death and major bleeding at 48 hours, and intraprocedural adverse events. Acute mortality and 48-hour outcomes are reported. Multivariate regression analysed characteristics associated with pulmonary artery pressure and dyspnoea improvement. Results Among 800 patients in the full US cohort, 76.7% had intermediate-high risk PE, 7.9% had high-risk PE, and 32.1% had thrombolytic contraindications. Major adverse events occurred in 1.8% of patients. All-cause mortality was 0.3% at 48-hour follow-up and 0.8% at 30-day follow-up, with no device-related deaths. Immediate haemodynamic improvements included a 7.6 mmHg mean drop in mean pulmonary artery pressure (-23.0%; p Conclusions Mechanical thrombectomy with the FlowTriever System demonstrates a favourable safety profile, improvements in haemodynamics and functional outcomes, and low 30-day mortality for intermediate- and high-risk PE

Relationship of Beam Angulation and Radiation Exposure in the Cardiac Catheterization Laboratory

ObjectivesThe aim of this study was to analyze the relationship between beam angulation and air kerma in a modern cardiac catheterization laboratory.BackgroundRecent reports have identified the merits of reducing radiation scatter, an important determinant of radiation dose in the catheterization laboratory. Radiation scatter is poorly characterized in the context of catheterization laboratories using modern digital equipment. Understanding the principles of dosimetry may reduce the radiation exposure to patients, providers, and medical staff.MethodsProspectively captured radiation data were extracted from a database of 1,975 diagnostic catheterizations (DCs) and 755 percutaneous coronary interventions (PCIs), which included 138,342 fluoroscopic and 35,440 acquisition (cine) sequences. Fluoroscopy and acquisition modes were categorized into tertiles based on the total air kerma measured at a standard reference point. Radiation maps were modeled according to the relative proportion of exposure in each projection.ResultsMedian air kerma during DCs and PCIs was 677 and 2,188 mGy, respectively. Fluoroscopy contributed to 66.3% of total dose during PCIs compared with 39.7% during DCs (p < 0.001). Fluoroscopy was more sensitive to changes in angulation with a rapid increase in total air kerma on small increases in beam angulation. Complex spatial maps were created to study the impact of angulation and other covariates on total air kerma. Besides beam angulation, body surface area was the strongest predictor of the total air kerma.ConclusionsThis study uniquely describes radiation dosimetry using contemporary equipment in a real-world setting. Extreme angulations were associated with high air kerma values. Fluoroscopy compared with acquisition was more sensitive to changes in angulation, with relatively larger increases in total air kerma with small increases in steepness of the angulation

Comparison of anticoagulation versus mechanical thrombectomy for the treatment of iliofemoral deep vein thrombosis

Objective:To compare the comparative effects of treatment with contemporary mechanical thrombectomy or anticoagulation on Villalta scores and post thrombotic syndrome incidence through 12 months in iliofemoral deep vein thrombosis. Methods:Patients with deep vein thrombosis in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) randomized trial and the ClotTriever Outcomes (CLOUT) registry were included in this analysis. Both studies evaluated the effects of thrombus removal on the incidence of post thrombotic syndrome. Patients with bilateral deep vein thrombosis, isolated femoral-popliteal deep vein thrombosis, symptom duration \u3e4 weeks, or incomplete case data for matching covariates were excluded. Propensity scores were used to match patients 1:1 that received anticoagulation (from ATTRACT) to those treated with mechanical thrombectomy (from CLOUT) using nearest neighbor matching on 9 baseline covariates, including age, body mass index, leg treated, provoked deep vein thrombosis, prior venous thromboembolism, race, sex, Villalta score, and symptom duration. Clinical outcomes, including Villalta score and post thrombotic syndrome, were assessed. Logistic regression was used to estimate the likelihood of developing post thrombotic syndrome at 12 months. Results:A total of 164 pairs were matched, with no significant differences in baseline characteristics after matching. There were fewer patients with any post thrombotic syndrome at 6 months (19% vs 46%, p\u3c.001) and 12 months (17% vs 38%, p\u3c.001) in the mechanical thrombectomy treatment group. Modeling revealed that after adjusting for baseline Villalta scores, patients treated with anticoagulation had significantly higher odds of developing any post thrombotic syndrome (OR=3.1, 95% CI [1.5 to 6.2], p=.002) or moderate to severe post thrombotic syndrome (OR=3.1, 95% CI [1.1 to 8.4], p=.027) at 12 months compared with those treated with mechanical thrombectomy. Mean Villalta scores were lower through 12 months among those receiving mechanical thrombectomy vs anticoagulation (3.3 vs 6.3 at 30 days, 2.5 vs 5.5 at 6 months, and 2.6 vs 4.9 at 12 months, p\u3c.001 for all). Conclusions:Mechanical thrombectomy treatment of iliofemoral deep vein thrombosis was associated with significantly lower Villalta scores and reduced incidence of post thrombotic syndrome through 12 months compared with treatment using anticoagulation. Results from currently enrolling clinical trials will further clarify the role of these therapies in the prevention of post thrombotic syndrome following an acute deep vein thrombosis event