The interventional management of symptomatic carotid disease (ie, endarterectomy, angioplasty/stenting, or transcarotid artery revascularization) has traditionally involved correcting the area of arterial narrowing, guid...The interventional management of symptomatic carotid disease (ie, endarterectomy, angioplasty/stenting, or transcarotid artery revascularization) has traditionally involved correcting the area of arterial narrowing, guided by stenosis severity combined with medical therapy, and has been recommended by the 2021 American Heart Association Secondary Stroke Prevention Guidelines. Despite this traditional practice, advances in medical therapy show promise in reducing recurrent stroke without the need for interventional procedures in the setting of low-to-intermediate-risk carotid lesions. We review current evidence for the nonoperative management of symptomatic carotid disease, focusing on markers of plaque vulnerability, risk calculators, and the efficacy of intensive medical therapy. The objective of this review was to illustrate that medical management of symptomatic carotid disease may be a reasonable alternative to surgical intervention in select patients. High-risk features such as intraplaque hemorrhage, a large lipid-rich necrotic core, a thin fibrous cap, plaque ulceration, vessel wall enhancement, and microembolic activity found on transcranial Doppler ultrasound strongly predict recurrent ischemic events and favor revascularization. In contrast, their absence supports medical management. Risk stratification tools such as the Carotid Artery Risk score and PLAQUE Radiology Scoring system have demonstrated potential utility for identifying low-risk patients who are good candidates for medical therapy. Guideline-directed medical therapy uses antiplatelet agents, intensive lipid-lowering therapy, blood pressure control, diabetes management, and structured lifestyle interventions. Contemporary clinical trials such as the Second European Carotid Surgery Trial and CASCOM are evaluating the comparative effectiveness of revascularization versus intensive medical therapy, with interim data suggesting comparable outcomes in appropriately selected patients. In the modern era, medical management of symptomatic carotid stenosis is safe and effective for patients lacking high-risk plaque features. Integration of imaging biomarkers, validated risk calculators, and structured risk factor modification programs offers a precision-medicine approach that may redefine treatment algorithms and aid in patient management.
Carotid duplex ultrasound emerged in the 1970s, and in the subsequent decade it leapt rapidly from the bench to the bedside. While duplex velocity criteria were initially validated against carotid angiograms with good fi...Carotid duplex ultrasound emerged in the 1970s, and in the subsequent decade it leapt rapidly from the bench to the bedside. While duplex velocity criteria were initially validated against carotid angiograms with good fidelity, the methods of measurement employed by pivotal carotid trials in the 1990s necessitated a revalidation of existing classification schemes. Today, there is significant variation in the criteria used by vascular laboratories, with early efforts towards standardization correlating poorly with other imaging modalities. The new Intersocietal Accreditation Commission modified consensus criteria revised in 2023 represent the newest effort to standardize duplex criteria based on traditional as well as more clinically relevant metrics. In the modern era, duplex ultrasound has shown benefit in screening asymptomatic groups at high risk for carotid stenosis such as those with numerous atherosclerotic risk factors, high-risk patients undergoing coronary artery bypass grafting, and those with lower extremity peripheral arterial disease. Carotid duplex also serves as a practical method of surveilling patients for restenosis after carotid endarterectomy and carotid artery stenting, with recent studies guiding modified velocity criteria in this population. Characterization of plaque morphology continues to evolve and may predict plaques at high risk of becoming symptomatic, and those which may respond poorly to carotid stenting. Even with the emergence of higher spatial resolution modalities such as CT and MR angiography, carotid duplex continues to play a critical role in the current diagnosis and treatment of carotid disease.
Atherosclerosis is a chronic and progressive disease with a long preclinical (asymptomatic) period. The optimal management of patients with preclinical cardiovascular disease (CVD) includes behavioral counselling and lif...Atherosclerosis is a chronic and progressive disease with a long preclinical (asymptomatic) period. The optimal management of patients with preclinical cardiovascular disease (CVD) includes behavioral counselling and lifestyle measures. Weight loss, regular exercise, interventions to modify sleep distubances and control of the modifiable cardiovascular risk factors (smoking, dyslipidemia, hypertension and diabetes mellitus), as well as adoption of a Mediterranean diet including 5 portions of vegetables and fruits per day, are of utmost importance in these patients. Timely initiation of appropriate medical therapy reduces cardiovascular events and disease progression. Medical therapy should be administered: (1) to lower blood pressure <130/80 mmHg in patients with hypertension (and even <120/80 mmHg if tolerated), (2) to reduce glycated hemoglobin values <7.0% (equivalent to <53 mmol/mol), and, (3) to lower low-density lipoprotein cholesterol values <70 mg/dL (1.8 mmol/L) for high-risk individuals and to <55 mg/dL (<1.4 mmol/L) for very high-risk patients. The present narrative review discusses the optimal management of individuals with preclinical cardiovascular disease (CVD), with a focus on carotid artery stenosis.
The prevalence of carotid artery stenosis is expected to increase as the population ages. Patients with carotid disease face an elevated risk of cerebrovascular and cardiovascular (CV) complications, including stroke, tr...The prevalence of carotid artery stenosis is expected to increase as the population ages. Patients with carotid disease face an elevated risk of cerebrovascular and cardiovascular (CV) complications, including stroke, transient ischemic attack, myocardial infarction, and CV death. Recommended lifestyle modifications emphasize adherence to a Mediterranean-style diet, regular physical activity, and smoking cessation, with pharmacologic support such as varenicline or combination nicotine replacement therapy as appropriate. Core medical therapies include low-dose aspirin monotherapy (or a P2Y12 receptor antagonist in cases of aspirin allergy or intolerance), high-intensity statin therapy, and blood pressure control. Patients with diabetes should be managed per current guidelines, with preference for SGLT2 inhibitors and GLP-1 receptor agonists due to their CV benefits.
Transcarotid artery revascularization is increasingly prevalent, but relies on fluoroscopic guidance for placement of carotid stents. With increasing awareness about the hazards of radiation exposure, we aimed to explore...Transcarotid artery revascularization is increasingly prevalent, but relies on fluoroscopic guidance for placement of carotid stents. With increasing awareness about the hazards of radiation exposure, we aimed to explore the prior literature regarding alternative and adjunct imaging methods in carotid stenting. These have included fusion with preoperative computed tomography angiography, fully contrast-sparing procedures with preoperative magnetic resonance angiography and fusion using plain fluoroscopy, and ultrasound-assisted transfemoral carotid stenting. All methods demonstrated excellent technical results but have achieved very limited adoption. We also reviewed literature on the use of ultrasound-guided stent and device deployment in other vascular beds, including inferior vena cava (IVC) filter placement, endovascular aneurysm repair, and peripheral arterial stenting, suggesting that ultrasound is a feasible method for intraoperative guidance. However, with lack of widespread adoption, further modifications may be required to improve usability in the operative setting. Finally, our group explored a novel frontier in ultrasound-guided transcarotid stenting, using preoperative computed tomography angiography imaging in conjunction with live ultrasound imaging. Fusion of the live and preoperative imaging allows the user to see the exact location of their ultrasound imaging plane superimposed on a 3-dimensional model of the carotid, taking significant uncertainty out of real-time ultrasound imaging. This novel registration technology may significantly improve the ability of surgeons to use ultrasound in the deployment of carotid stents, thereby reducing radiation exposure in the procedure. In addition, the same technology may be extrapolated to other areas of vascular pathology in the future.
Holden-Wingate CE, Holden-Wingate LR, Hussain A
… +8 more, Kotturu NRK, Montano D, Appah-Sampong A, Tran A, Salomon BJ, Ozaki CK, Hentschel DM, Hussain MA
Semin Vasc Surg
· 2025 Dec · PMID 41386915
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More than 800,000 people live with end-stage kidney disease (ESKD) in the United States, and the incidence continues to rise. Further, the treatment landscape is evolving due to increasing prevalence of risk factors, suc...More than 800,000 people live with end-stage kidney disease (ESKD) in the United States, and the incidence continues to rise. Further, the treatment landscape is evolving due to increasing prevalence of risk factors, such as diabetes and the aging United States population. More than ever, the creation and management of hemodialysis accesses require a multidisciplinary, team-based approach to provide care effectively. However, there is limited available research on the effects of multidisciplinary team (MDT)-based care in arteriovenous (AV) access outcomes and there remains no widely accepted standard regarding the composition and function of the required processes within an MDT. This manuscript provides an overview of the current literature on MDTs in AV access care, utilizing 5 specific examples where an MDT would be especially pertinent for optimizing patient care and outcomes. Our findings suggest a benefit from initiating an MDT model in AV access care and highlight potential improvements in catheter-free days and patient and provider satisfaction.
The diagnosis and treatment of fibromuscular dysplasia (FMD) is challenging due to its heterogeneous clinical presentations and variable vascular involvement. Although there has been an increase in published research fro...The diagnosis and treatment of fibromuscular dysplasia (FMD) is challenging due to its heterogeneous clinical presentations and variable vascular involvement. Although there has been an increase in published research from large international registries to aid in the care of patients with FMD, the complexity of disease management necessitates multidisciplinary collaboration to optimize patient outcomes. Multidisciplinary teams, often including vascular medicine specialists, vascular surgeons, primary care providers, cardiologists, nephrologists, neurologists, noninvasive vascular laboratory, radiology, interventionalists, cardiovascular genetic counselors, pharmacists, and mental health care providers, collaborate using team-based models composed of coordinated visits for comprehensive and efficient evaluation, systematic imaging, and individualized management. Patient advocacy organizations also play a key role in the care of patients. Clinical care coordinators are instrumental in reinforcing individualized care plans and patient education. Vascular care centers are strongly encouraged to adopt such multidisciplinary, team-based care models using structured workflows, care coordination, and patient-centered approaches to advance FMD knowledge and care.
Lymphedema is a chronic, progressive condition characterized by the accumulation of protein-rich interstitial fluid due to impaired lymphatic transport. It significantly impairs quality of life and presents complex diagn...Lymphedema is a chronic, progressive condition characterized by the accumulation of protein-rich interstitial fluid due to impaired lymphatic transport. It significantly impairs quality of life and presents complex diagnostic and therapeutic challenges. Despite its prevalence, lymphedema remains underdiagnosed and undertreated, in part due to limited provider education and a lack of access to coordinated care. For this reason, a multidisciplinary approach to lymphedema management is crucial. Early diagnosis is critical and requires collaboration across primary care, oncology, vascular medicine, radiology, lymphatic therapy, and surgery. There are increasing imaging techniques available, but require unique skill sets to perform and interpret. Similarly, there are growing surgical treatment options, but conservative therapy remains the mainstay for most patients. A structured, collaborative model is essential for high-quality, patient-centered lymphedema care. Establishing multidisciplinary lymphedema centers can enhance outcomes, reduce delays, and promote innovation in treatment strategies.
Thrombotic lower extremity venous disease is associated with significant diagnostic and therapeutic complexity. Not only do venous occlusion and upstream venous hypertension lead to symptoms for patients, but their seque...Thrombotic lower extremity venous disease is associated with significant diagnostic and therapeutic complexity. Not only do venous occlusion and upstream venous hypertension lead to symptoms for patients, but their sequelae, including venous reflux, lymphedema, and wound formation, contribute to significant morbidity for patients and are difficult to separate from one another. Therapeutically, much of the complexity in the management of these patients stems from the fact that each individual management strategy may treat some, but not all, of the pathophysiology and associated symptoms. Given the complexity in diagnosing and managing the treatment of these patients, a multidisciplinary, multimodal approach is thus necessary to provide patients optimal and durable symptom relief in most cases. A multidisciplinary team composed of interventional radiologists and/or vascular surgeons, vascular medicine and hematology physicians, wound care providers, pelvic pain specialists, lymphedema therapists, and others, has the power to comprehensively diagnose and treat patients, improve patient access, decrease health care utilization and costs, and afford numerous other benefits to patients with thrombotic lower extremity venous disease.
Shared decision making is a cornerstone of person-centered care, yet its integration into the management of patients with lower extremity peripheral arterial disease (PAD) remains limited. Effective and responsive commun...Shared decision making is a cornerstone of person-centered care, yet its integration into the management of patients with lower extremity peripheral arterial disease (PAD) remains limited. Effective and responsive communication is critical for shared decision making. This study explored patients' experiences of patient-clinician communication in PAD care to identify barriers and opportunities for improvement through a secondary qualitative analysis of semi-structured interviews with 16 patients with PAD. The following 3 key themes were identified: (1) the challenge of being in tune, where patients emphasized the need to feel heard and acknowledged, with technical jargon and unempathetic interactions often causing disengagement; (2) sound and logic explanations, underscoring the importance of clear, relatable, and personalized communication to build trust; and (3) limited time and fragmented care, highlighting the negative impact of rushed consultations and fragmented care on communication and trust. Patients valued approachable clinicians; the use of visual aids; and consistent, meaningful interactions. These findings revealed significant barriers to effective communication at patient, clinician, and system levels, challenging shared decision making in PAD care.
Optimal care of peripheral arterial disease and chronic limb threatening ischemia hinges upon multispecialty collaboration. A comprehensive team should include vascular specialists, Primary Care Providers (PCPs), podiatr...Optimal care of peripheral arterial disease and chronic limb threatening ischemia hinges upon multispecialty collaboration. A comprehensive team should include vascular specialists, Primary Care Providers (PCPs), podiatry/orthopedics, plastic surgery, infectious disease, endocrinology, social work and rehabilitation professionals, among others. Special attention should be paid to the unique considerations of underrepresented patient populations, such as minorities and geriatric patients, in managing their associated risks.
Individuals with peripheral artery disease (PAD) often have risk factors including, but not limited to, multiple comorbidities, lower extremity wounds, limb amputation, and poor quality of life. PAD has been shaped by ad...Individuals with peripheral artery disease (PAD) often have risk factors including, but not limited to, multiple comorbidities, lower extremity wounds, limb amputation, and poor quality of life. PAD has been shaped by advancements in medical technology, evolving treatment paradigms, and a growing focus on patient-reported health status and patient-centered outcomes. Collaborative care models with multidisciplinary teams including primary care physicians and vascular medicine, vascular surgery, interventional radiology, interventional cardiology, physical therapy, podiatry, infectious diseases, endocrinology, pain management, and mental health specialists continue to evolve. Because individuals with PAD have multiple comorbidities, a team-based approach has been recommended by societal guidelines to ensure optimal medical, social, and possibly interventional options. This article will review the importance of a multidisciplinary team approach for individuals with PAD.
Fenestrated and branched technology for endovascular aortic repair of the thoracoabdominal aorta and aortic arch has evolved significantly over the last decade. The spectrum of these devices is largely available outside...Fenestrated and branched technology for endovascular aortic repair of the thoracoabdominal aorta and aortic arch has evolved significantly over the last decade. The spectrum of these devices is largely available outside the United States (US), while patient-specific company manufactured devices are limited to ten sites in the US, with ongoing expanding use of market-approved off-the-shelf devices. The necessary environment for appropriate education to ensure safe dissemination of these technologies is limited, and the current centralization of both device availability and skillsets affects trainee education. In order to refine their endovascular treatment algorithm and planning/implantation skillsets at these multidisciplinary aortic centers, senior-level surgical trainees and early-to-mid career surgeons have looked transatlantic to gain exposure to this technology. This international aortic training is available as both formal and informal super-fellowships but limited in number. Significant clinical and professional benefits can ensue from such an experience, however there are challenges that must be overcome. Herein, we describe the right candidate, ideal program and mentor, goals of the fellowship, and funding opportunities for a US-based, senior-level surgical trainee or early-to-mid career vascular or cardiothoracic surgeon interested in a nonaccredited aortic super-fellowship abroad.
BACKGROUND: Multidisciplinary aortic teams (MAT) are integral to the management of aortic pathology. This study quantifies the effects of MAT implementation on aortic case volumes, practice patterns and surgical producti...BACKGROUND: Multidisciplinary aortic teams (MAT) are integral to the management of aortic pathology. This study quantifies the effects of MAT implementation on aortic case volumes, practice patterns and surgical productivity at a single academic institution. METHODS: Patients receiving aortic procedures were identified using CPT codes. Three time periods were defined: 2 years prior to MAT (2018), the first year with MAT (2020), and 2 years post implementation of MAT (2022). Full MAT was defined as having aortic-focused providers from cardiothoracic surgery, vascular surgery, cardiology and genetics. RESULTS: Total aortic case volume increased over 300 over the study period. Increased volume was seen for both cardiothoracic and vascular cases with a significant increase in the proportion of ascending aortic replacements as well as thoracic endografting (P < .01). Patients receiving multiple procedures significantly increased from 2018 to 2020 (70.3% vs. 84.9%) as well as mean number of procedures per patient (1.98 vs. 2.42, both P < .05). While the number of patients receiving genetic testing and followed by the institutional cardiology team remained constant during the study period, the number of patients receiving joint cardiothoracic and vascular evaluation increased significantly (23.8% 2018 vs 41.1% 2020, P = .02). Overall procedural RVUs increased from 6.8k in 2018 to 21.1k in 2022 (310% increase). CONCLUSIONS: Implementation of MAT correlated with increased aortic case volumes for cardiothoracic and vascular surgeons as well as increased overall productivity. These data suggest that robust multidisciplinary involvement is crucial to expand complex aortic volume and develop comprehensive treatment plans for patients with thoracoabdominal pathology.
Patients presenting with complex carotid artery disorders require diligent care and decision making to achieve positive outcomes. With advancements in endovascular techniques and the ongoing need for surgical interventio...Patients presenting with complex carotid artery disorders require diligent care and decision making to achieve positive outcomes. With advancements in endovascular techniques and the ongoing need for surgical intervention in some patients, multiple specialties share in the responsibility of treating these patients. At the Cleveland Clinic, a multidisciplinary, team-based approach to caring for complex carotid disorders has been established to provide patients with comprehensive care. Collaboration at the Cleveland Clinic is accomplished, in part, by means of structured multidisciplinary discussions. Monthly, a carotid-focused conference is held to review complex patients and reinforce concepts of complex disease among several specialties, including vascular surgery, neurology, neurosurgery and interventional neuroradiology. Furthermore, quarterly conferences review outcomes for stroke, myocardial infarction, and death for each of the specialties. The accredited vascular ultrasound laboratory assists in maintaining accurate detection of carotid disease, while providing an educational component for both vascular laboratory technicians and those interpreting the results. A team-based approach to managing complex carotid disorders has proven to be beneficial for both patients and physicians. Discussion among departments encourages thoughtfulness in developing care plans and has routed patients to providers who are best suited to address their disease process.
Vascular surgeons are often responsible for navigating treatment decisions when caring for older adults. Care for these patients is informed by the surgeon's assessment of the patient's decision-making capacity, use of a...Vascular surgeons are often responsible for navigating treatment decisions when caring for older adults. Care for these patients is informed by the surgeon's assessment of the patient's decision-making capacity, use of advance care planning, and understanding of futility. Having difficult conversations with patients and their families is supported by strategies that promote empathic communication and shared decision making with older adults with serious illness due to, and associated with, vascular disease. These strategies include avoiding the cognitive trap, using heads-up and headline statements, best case and worst case to manage uncertainty, and better conversations to provide informed consent.
Chronic venous insufficiency (CVI) develops as a consequence of valvular incompetence or venous obstruction over time and can significantly impair quality of life. Its prevalence and burden are highest among older adults...Chronic venous insufficiency (CVI) develops as a consequence of valvular incompetence or venous obstruction over time and can significantly impair quality of life. Its prevalence and burden are highest among older adults, as the physiological changes of aging predispose to the onset and progression of CVI. We present an overview of the evaluation and management of CVI in older adults, with a focus on superficial venous disease. Current treatment modalities for superficial venous disease and their outcomes in older adults are discussed.
The rate of end-stage kidney disease (ESKD) is steadily rising in the United States, and older adults (ie, 65 years and older) represent the fastest-growing segment in need of hemodialysis. This demographic shift present...The rate of end-stage kidney disease (ESKD) is steadily rising in the United States, and older adults (ie, 65 years and older) represent the fastest-growing segment in need of hemodialysis. This demographic shift presents unique challenges due to age-related comorbidities, frailty, and increased procedural risks. Despite these challenges, there is limited guidance for risk stratification and management of renal replacement therapy in older patients with ESKD. The authors provide a review of current literature and tools to characterize high-risk older patients with ESKD, focusing on the following three key considerations when planning for permanent hemodialysis access placement: vascular anatomy, frailty, and ESKD Life-Plan considerations. Within this population of older patients, consideration of areas of focus for the history and physical examination, preoperative vascular imaging studies, hemodialysis access type, timing of access placement, type of anesthesia used, and multidisciplinary teams are discussed. Our findings suggest that applying a systematic approach to care that incorporates these key considerations may present a route for improving outcomes in this vulnerable population; however, further research is needed.