Journal of medical Internet researchYong Fang, Wenxiao Wu, Dili Chen, Zhili Jiang, Mingyue Zhang, Fanghong Dong, Xinyue Xiang, Lihua Huang
BACKGROUND: Medication nonadherence after percutaneous coronary intervention (PCI) remains a major barrier to secondary prevention. Prior SMS text messaging interventions have shown inconsistent results, often limited to reminders without addressing behavioral or psychological determinants. OBJECTIVE: This study aimed to evaluate the effectiveness of a theory-informed, WeChat-based messaging intervention for improving medication adherence and patient-reported outcomes after PCI. METHODS: A nonrandomized quasi-experimental parallel-group study was conducted from July 2022 to March 2023 at a tertiary hospital in Hangzhou, China. Patients were allocated by ward admission to the intervention or control group. The intervention comprised 12-week WeChat-based medication reminders and theory-informed messages mapped to capability, opportunity, and motivation-behavior model domains and behavior change techniques. The primary outcome was medication adherence measured using the 8-item Morisky Medication Adherence Scale (MMAS-8); secondary outcomes were medication beliefs, self-efficacy, and disease-specific health status measured using the Beliefs About Medicines Questionnaire (BMQ)-Specific, Self-Efficacy for Appropriate Medication Use Scale, and Seattle Angina Questionnaire (SAQ), respectively. Outcomes were assessed at baseline and 12 weeks by blinded assessors and analyzed using baseline-adjusted analysis of covariance based on the observed outcome data for all 92 participants. Sensitivity analyses included a per-protocol analysis restricted to the 87 participants who completed the full assigned care protocol and a difference-in-differences analysis comparing changes from baseline to 12 weeks between groups. RESULTS: Of 180 patients screened, 92 (51.1%) were enrolled, of whom all completed the 12-week outcome assessment and 87 (94.6%) completed the full assigned care protocol. At 12 weeks, medication adherence was higher in the intervention group than in the control group (adjusted mean MMAS-8 score 7.40, SE 0.05 vs 6.22, SE 0.10; adjusted mean difference 1.18, 95% CI 0.96-1.40; P<.001). Secondary outcomes generally favored the intervention, including the BMQ necessity (adjusted mean difference 1.62, 95% CI 1.06-2.17) and concerns (adjusted mean difference -3.25, 95% CI -3.87 to -2.63) subscales, medication self-efficacy (adjusted mean difference 4.04, 95% CI 3.21-4.87), and the SAQ summary score (adjusted mean difference 6.13, 95% CI 4.72-7.53; P<.001 in all cases). SAQ treatment satisfaction did not differ significantly between groups (adjusted mean difference 0.40, 95% CI -2.02 to 2.82; P=.74). Both the per-protocol and difference-in-differences sensitivity analyses yielded findings consistent with the primary analysis, supporting the robustness of the results. CONCLUSIONS: A theory-informed, WeChat-based messaging intervention was associated with improvements in medication adherence, medication beliefs, self-efficacy, and disease-specific health status after PCI. Larger, adequately powered randomized trials with longer follow-up are needed to confirm these findings.
BMJ case reportsNisha Rajan, Kiruthika Asokan, Venkatesh Karthik, Pediredla Karunakar
Moyamoya disease (MMD) is a progressive cerebrovascular disorder characterised by distal internal carotid artery (ICA) stenosis and compensatory collateral vessel formation. Psychiatric manifestations are rare, particularly in children. We report the case of an early adolescent with previously diagnosed MMD who developed acute-onset psychosis following a febrile illness associated with headache and vomiting. Symptoms included auditory hallucinations, persecutory delusions, emotional lability and Fregoli syndrome, a rare condition in which different strangers are believed to be a familiar person in disguise. Neuroimaging revealed bilateral ICA narrowing with extensive collateral networks. Infectious, autoimmune and metabolic evaluations were unremarkable. The patient underwent superior temporal artery-middle cerebral artery bypass with encephalo-duro-arterio-myo-synangiosis. Psychotic symptoms resolved after surgery, and he returned to baseline functioning within 1 month. This case highlights the importance of considering cerebrovascular aetiologies in abrupt-onset childhood psychosis, even in the absence of major neurological deficits.
Deutsche medizinische Wochenschrift (1946)Isabel Horn, Tanja Rudolph
Aortic valve diseases are among the most common structural heart diseases in adults. Aortic stenosis (AS), in particular, poses a growing challenge due to demographic trends, as it continues to be underdiagnosed.The current 2025 ESC/EACTS guidelines mark a paradigm shift: for the first time, early intervention is recommended for selected asymptomatic patients. At the same time, various AI tools support early patient screening.Also new, with a Class IIb recommendation, is that TAVI may be considered for patients with a bicuspid aortic valve and increased surgical risk, provided the anatomy is suitable.In addition to that the age limit for TAVI implantation has been lowered to 70 years for patients with suitable anatomy and a tricuspid aortic valve (Class IA recommendation). Another point is that concerning the choice between SAVR and TAVI the importance of the interdisciplinary heart team, taking into account anatomy, comorbidities, and lifestyle considerations was highlighted.Patients with severe aortic valve stenosis should be referred by their primary care cardiologist to a cardiac center so that an interdisciplinary cardiac team can determine the best possible treatment option for the patient.Concerning screening of patients with valvular heart disease artificial intelligence is playing an increasingly important role. Tools such as the digital stethoscope and ECG-based screening help improve patient screening.
Deutsche medizinische Wochenschrift (1946)Ander Arteagoitia, Philipp Lurz, Marc Adrian Rogmann
Mitral valve disease ranks among the most frequent valvular conditions and carries significant morbidity and mortality if left untreated. This review addresses anatomy, the Carpentier classification, and echocardiographic severity grading, as well as current management of primary and secondary mitral regurgitation (MR) and mitral stenosis. Transcatheter therapies, including edge-to-edge repair and transcatheter mitral valve replacement, receive particular attention and are discussed in the context of four clinical cases from a specialized valve center.
European stroke journalZilin Xu, Yuanyuan Liu, Yanbo Huang, Yuzhang Bei, Yong He, Yanling Li, Hao Wang, Lingling Meng, Le Gao, Yan Li, Yuhang Cao, Lan Liu, Jinyue Li, Xunming Ji, Chu…
BACKGROUND: Endovascular therapy is the standard of care for eligible patients with acute ischemic stroke due to LVO. However, nearly half of patients remain functionally dependent even after successful reperfusion. Albumin is a biologically plausible adjunctive cerebroprotective therapy and has shown neuroprotective effects in preclinical studies, but the clinical benefit of albumin combined with EVT remains uncertain. STUDY DESIGN: Albumin for patients with acute large vessel occlusive stroke undergoing endovascular therapy-2 (ARISE-2) is an investigator-initiated, prospective, multicenter, randomised, open-label, controlled trial with blinded endpoint assessment (PROBE design). Eligible participants will be randomly assigned in a 1:1 ratio to receive either EVT plus intravenous 25% albumin at 0.5 g/kg (maximum dose, 37.5 g) initiated within 60 min after randomisation and then repeated once daily on days 2-4, or EVT alone. The initial target sample size is 1192 participants (596 per group). A prespecified adaptive sample size re-estimation will be performed after approximately 50% of participants have completed the 90-day follow-up, allowing the total sample size to be increased, but not reduced, to a maximum of 1788 participants. This trial aims to evaluate the efficacy and safety of albumin administered in combination with EVT in patients with acute ischemic stroke caused by anterior circulation LVO. STUDY ENDPOINTS: The primary outcome is a favourable functional outcome at 90 days, defined as a mRS score of 0-2, or return to the premorbid mRS for participants with a prestroke mRS score of 3-4. SUMMARY: The ARISE-2 trial is designed to evaluate the efficacy and safety of moderate-dose albumin combined with EVT in participants with acute ischemic stroke caused by anterior circulation LVO. The trial will provide evidence on whether albumin can improve functional outcomes as an adjunctive cerebroprotective strategy in patients undergoing reperfusion therapy. TRIAL REGISTRATION: ClinicalTrials.gov: NCT07263308.
Abnormal oxygenation may influence thrombosis, but evidence in catheterized critically ill patients remains limited. We examined whether the first arterial partial pressure of oxygen (PaO2) measured within 24 hours after qualifying invasive venous catheter insertion was associated with documented acute upper-body deep or central venous thrombosis during hospitalization. This retrospective observational cohort study used the Medical Information Mart for Intensive Care IV database, version 2.2 (MIMIC-IV v2.2) (2008-2019). Adult intensive care unit admissions were included when a qualifying invasive venous catheter was present and an arterial PaO2 measurement was obtained after insertion, within 24 hours, and while the catheter remained in situ. PaO2 was analyzed continuously and categorically (≤80, 81-100, and >100 mmHg). Logistic regression models sequentially adjusted for patient characteristics, laboratory measurements, catheter characteristics, measurement timing, inspired oxygen concentration, respiratory support, and non-respiratory organ dysfunction. Multiple imputation addressed missing covariate data, and patient-clustered robust standard errors accounted for repeated admissions. The cohort included 11,277 hospital admissions from 10,789 patients; 195 admissions (1.73%) had the primary outcome. In the unadjusted model, higher PaO2 was associated with lower odds of the outcome (odds ratio [OR] per 10-mmHg increase, 0.970; 95% confidence interval [CI], 0.952-0.987), but this association attenuated after adjustment. In the fully adjusted model, PaO2 was not associated with the outcome (OR, 1.008; 95% CI, 0.989-1.027; P = 0.430). Most secondary analyses supported the primary result, although the 60-minute sensitivity analysis yielded adjustment-dependent estimates. In the complete cohort, a single early post-insertion PaO2 measurement was not independently associated with documented acute upper-body deep or central venous thrombosis. These findings do not support PaO2-based thrombosis risk stratification or modification of oxygen therapy for thrombosis prevention. Future studies should incorporate repeated oxygenation measurements and accurately timed, imaging-confirmed thrombotic outcomes.
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of CardiologyJasmine M Marquard, Rasmus P Beske, Christian Hassager, Lisette O Jensen, Hans Eiskjær, Norman Mangner, Amin Polzin, P Christian Schulze, Carsten Skurk, Peter …
BACKGROUND: The prognostic impact of multivessel coronary anatomy and complexity in infarct-related cardiogenic shock (CS) is insufficiently characterised. AIMS: We sought to investigate the prognostic value of baseline and residual SYNTAX scores and their influence on the effect of microaxial flow pump (mAFP) support in multivessel disease (MVD) and infarct-related CS. METHODS: In this secondary analysis of the DanGer Shock trial, MVD was defined as ≥1 non-culprit stenosis ≥70% or an isolated left main (LM) culprit lesion. Baseline SYNTAX scores were categorised as low (≤22), intermediate (23-32), or high (>32). Patients with an isolated LM culprit lesion were analysed separately. The primary outcome was 180-day all-cause mortality. RESULTS: Of 355 patients included in DanGer Shock, 256 patients had MVD; 211 had an available baseline SYNTAX score, with 26% of these in the low, 47% in the intermediate, and 27% in the high baseline SYNTAX groups. In all, 35 patients had an isolated LM culprit lesion. A high baseline SYNTAX score was associated with higher odds of 180-day all-cause mortality compared with low and intermediate baseline SYNTAX scores (adjusted odds ratio [OR] 3.12, 95% confidence interval [CI]: 1.17-8.69). A higher baseline SYNTAX score was associated with a higher residual SYNTAX score (p<0.001). The residual SYNTAX score independently predicted 180-day all-cause mortality. The mAFP effect was not modified by the baseline SYNTAX group (p for interaction=0.31). In patients with an isolated LM culprit lesion, mAFP use was associated with lower odds of 180-day all-cause mortality compared with standard care alone (adjusted OR 0.17, 95% CI: 0.03-0.99). CONCLUSIONS: Baseline and residual SYNTAX scores independently predicted 180-day mortality. The mAFP effect was not modified by SYNTAX measures. In the isolated left main subgroup, a hypothesis-generating signal towards a clinical benefit with mAFP use was observed.
European journal of trauma and emergency surgery : official publication of the European Trauma SocietyMustafa Yıldız, Muhammed Köroğlu, Mustafa Ertuğrul Karabaş, İpek Balıkçı Çiçek, Thomas Stevenson, Ahmet Harma
OBJECTIVE: Segmental bone transport offers biological reconstruction and limb preservation for extensive lower-extremity long-bone defects, but treatment often involves prolonged external fixation, planned stages, and unplanned reoperations. We evaluated reconstructive and functional outcomes and examined the association between cumulative operative burden and final patient-reported function. METHODS: This retrospective single-centre study screened 44 patients treated between January 2012 and March 2023. Thirty-six patients, representing 37 reconstructed long bones, had complete final outcome ascertainment. ASAMI bone outcome was reported per reconstructed bone (n = 37); limb preservation and all functional and multivariable analyses were patient-level (n = 36). Outcomes included limb preservation, ASAMI bone and functional results, the Lower Extremity Functional Scale (LEFS), the Karlström-Olerud score, healing indices, treatment-related events, and the cumulative number of formal operations. Multivariable linear regression, bootstrap resampling, sensitivity analyses, and exploratory receiver operating characteristic analysis were performed. RESULTS: Mean defect length was 10.32 ± 4.67 cm and the mean defect-to-bone length ratio was 26.3% ± 12.4%. Patients underwent a mean of 8.08 ± 4.21 operations (median, 7; range, 3-18). Mean follow-up after external-fixator removal was 5.69 ± 3.62 years. Limb preservation was achieved in 35 of 36 patients (97.2%). Combined excellent/good ASAMI bone and functional outcomes were 75.7% and 77.8%, respectively. Pin-site infection occurred in 17 patients and accounted for 32 fixation-element events; premature consolidation occurred in 11 patients and accounted for 18 episodes. After adjustment for age, defect length, and consolidation index, each additional operation was associated with a 1.94-point lower LEFS (β=-1.94, 95% CI - 3.12 to - 0.76; p=.002). Excluding the patient who underwent below-knee amputation and had an LEFS of 0 did not materially alter this association (n = 35; β=-1.86, 95% CI - 2.85 to - 0.86; p<.001). Older age was also independently associated with lower LEFS (β=-0.46 points/year; p=.006). Follow-up duration was not associated with LEFS and did not alter the principal association. Exploratory ROC analysis for LEFS < 40 yielded an AUC of 0.846 (bootstrap 95% CI 0.689-0.968); the internally derived ≥ 11-operation threshold was regarded as hypothesis-generating. CONCLUSION: Segmental bone transport achieved high limb preservation and largely favourable ASAMI outcomes despite a substantial treatment burden. A greater cumulative number of operations was associated with lower final LEFS. Operation count should be interpreted as a summary marker of case complexity and the treatment course, not as evidence that repeated surgery alone caused poorer function.
Current cardiology reportsValentina Jaramillo Restrepo, Sunil V Rao
PURPOSE OF REVIEW: The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for managing patients with acute coronary syndromes (ACS) is the first major update since the 2013-2015 ST-elevation myocardial infarction (STEMI) and non-ST elevated myocardial infarction (NSTEMI) guidelines. It brings both conditions together into a single framework. This review covers the most important new and revised recommendations and points out where evidence is still lacking. RECENT FINDINGS: New findings show that several significant updates are based on recent large-scale trials. The use of bivalirudin with high-dose infusion after percutaneous coronary intervention (PCI) is now given a Class I recommendation for primary PCI in the case of STEMI, as a result of the BRIGHT-4 trial. Complete revascularization is also now recommended as Class I for stable STEMI patients who have multivessel disease, according to the COMPLETE trial. For a selected group of patients with refractory cardiogenic shock resulting from a myocardial infarction, the percutaneous microaxial flow pump has received a new Class IIa recommendation from the DanGer Shock trial, while the intra-aortic balloon pump and extracorporeal membrane oxygenation are classified as Class III for routine use. Intracoronary imaging (intravascular ultrasound and optical coherence tomography) is now given a Class I recommendation for complex PCI, based on the data of the RENOVATE-COMPLEX-PCI, OCTOBER, and OCTIVUS trials. The guidelines also suggest specific low-density lipoprotein cholesterol (LDL-C) targets, and non-statin drugs should be added if the LDL-C level remains above 70 mg/dL even when maximum statin therapy is used. Regarding antiplatelet therapy, ticagrelor or prasugrel is now preferred to clopidogrel in the case of ACS-PCI, and it is formally recommended to switch to P2Y12 monotherapy at one month in patients at high risk for bleeding as an alternative to standard DAPT. The updates indicate a shift towards more potent antiplatelet therapy at hospital presentation, use of radial access when feasible, more use of imaging-guided PCI, stricter lipid targets, and more refined antiplatelet approaches at the time of discharge. That said, significant gaps in the evidence still exist. It has not yet become clear whether physiology-guided revascularization of non-culprit arteries in patients with STEMI or NSTEMI is better than angiography-guided PCI-a question that is currently being investigated in the randomized COMPLETE-2 trial. The optimal time to provide mechanical circulatory supper in cases of cardiogenic shock remains uncertain. The recent neutral findings from intracoronary imaging studies such as OPTIMAL and IVUS-CHIP might alter the existing Class I recommendation. Lastly, new data from the HOST-EXAM, and SMART CHOICE 3, studies suggest that P2Y12 monotherapy may be better than aspirin for the long-term prevention of major adverse cardiovascular events, and this could influence future guideline recommendations for long term antiplatelet therapies in the chronic phase.
BACKGROUND: Timely creation of arteriovenous (AV) access before hemodialysis initiation is recommended to reduce catheter-related complications and improve clinical outcomes. However, predialysis AV access preparation remains suboptimal in Thailand despite guideline recommendations and expanded hemodialysis services. Evidence comparing perspectives among professional groups involved in the AV access care pathway is limited. This exploratory regional study compared the perspectives of nephrologists, vascular surgeons, and dialysis nurses in Upper Northern Thailand and identified supportive strategies that providers considered relevant to improving timely AV access preparation. METHODS: We conducted a cross-sectional convergent mixed-methods study using a self-administered survey among nephrologists, vascular surgeons, and dialysis nurses practicing in hospitals and dialysis clinics across Upper Northern Thailand from February to April 2025. Likert-scale responses were summarized and compared across professional groups, and brief open-ended responses were analyzed thematically. Quantitative and qualitative findings were integrated during interpretation. RESULTS: A total of 113 providers participated, including 78 nurses, 19 surgeons, and 16 nephrologists. Integration of the quantitative and qualitative findings identified five priority barriers: limited patient understanding, late presentation, procedural waiting times, insurance or reimbursement constraints, and clinical suitability concerns. Although the broad barrier patterns were shared, the emphasis placed on particular barriers varied across professional groups. Four supportive strategies were consistently endorsed: predictable financial coverage and reimbursement mechanisms, a dedicated vascular access coordinator, electronic referral and longitudinal follow-up systems, and proactive, stage-aligned AV access planning guidelines. Qualitative responses provided context by showing that providers associated these shared strategies with different role-related considerations, including patient preparation, referral coordination, procedural feasibility, and timing of care. CONCLUSIONS: Providers in this regional study identified shared priorities for improving timely predialysis AV access preparation, while differing in the meanings and considerations they associated with those priorities. These context-specific, hypothesis-generating findings may inform locally adapted service improvement and future evaluation of the proposed strategies.
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of CardiologyTuomas T Rissanen, Simon Eccleshall, Florian Krackhardt, Kris Bogaerts, Tanios Akiki, Carlo Briguori, Guillaume Cayla, Nick Cruden, Alexander W den Hartog, Phi…
BACKGROUND: Drug-eluting stents (DES) are the current mainstay of percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients. However, drug-coated balloons may be an alternative that reduces reliance on prolonged courses of antiplatelet therapy. AIMS: The SELUTION DeNovo trial randomised 3,323 PCI candidates 1:1 to treatment with either sirolimus-eluting balloons (SEBs) and provisional stenting or systematic DES implantation. We report on a prespecified subgroup of HBR patients. METHODS: A total of 522 enrolled patients met the Academic Research Consortium-HBR criteria. At 1 year, we assessed target vessel failure (TVF; a composite of cardiac death, target vessel myocardial infarction and clinically driven target vessel revascularisation), major bleeding (Bleeding Academic Research Consortium [BARC] 3-5) and net adverse clinical events (NACE; a composite of TVF and BARC 3-5 bleeding). Antithrombotic treatment was prescribed according to current guidelines and local practice. RESULTS: Altogether, 269 and 253 patients were identified as HBR in the SEB strategy and DES strategy arms, respectively. In the SEB arm, 17.1% of patients had bailout stenting. Overall, 67% of patients were discharged on oral anticoagulants. At 1 year, TVF occurred in 4.9% of the SEB arm vs 7.9% of the DES arm (absolute risk difference [RD] -3.05%, 95% confidence interval [CI]: -7.27 to 1.17). BARC 3-5 bleeding occurred in 2.3% vs 3.2% (absolute RD -0.91%, 95% CI: -3.71 to 1.89) and NACE in 6.8% vs 10.7% (absolute RD -3.94%, 95% CI: -8.80 to 0.92) in the SEB and DES arms, respectively. While the proportion of patients on dual antiplatelet therapy and single antiplatelet therapy did not differ significantly between the two groups during follow-up, all antiplatelet medication was stopped in 7.7% vs 2.5% at 30 days (p=0.005) and in 27.8% vs 14.9% of patients at 6 months (p<0.001) in the SEB and DES arms, respectively. CONCLUSIONS: Although this subset analysis is not powered for definitive conclusions, our data suggest that an SEB strategy with minimal stenting appears to be a safe and effective alternative to systematic DES implantation for HBR patients.
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of CardiologyAsahi Oshima, Pruthvi C Revaiah, Nozomu Kanehama, Adrian Wlodarczak, Helge Möllmann, Raul Moreno, Milosz Dziarmaga, Manel Sabaté, Jacek Legutko, Marc Silvestri…
BACKGROUND: The European Association of Percutaneous Cardiovascular Interventions (EAPCI)-endorsed algorithm for defining device success has not yet been prospectively tested against standardised quantitative coronary angiography (QCA) by a core lab. AIMS: We sought to assess whether visually evaluated device success by the operator at the end of percutaneous coronary intervention (PCI) aligns with the EAPCI-endorsed standardised definition adjudicated by the core lab and to evaluate its association with clinical outcomes. METHODS: This prespecified analysis of the Multivessel TALENT trial included 1,548 patients with three-vessel disease randomised to treatment with either Supraflex Cruz or SYNERGY stents. PCI was attempted in 4,052 lesions. The core lab assessed post-PCI residual in-stent percentage diameter stenosis (%DS) by QCA (target <20%) and exploratory delta (Δ) angiography-derived fractional flow reserve (angio-FFR) across the stent(s) (target <0.05). Device success was evaluated using the site-reported data (visual evaluation of in-stent %DS), core lab QCA, core lab angio-FFR, and combined core lab QCA+angio-FFR. The lesion-oriented composite endpoint (LOCE; comprising cardiovascular death, target vessel myocardial infarction, or target lesion revascularisation) was assessed at 1 year. RESULTS: Site-reported device success was 97.4%. Core lab definitions yielded lower rates: 93.8% for Δangio-FFR <0.05, 88.0% for residual %DS <20%, and 83.2% for QCA+angio-FFR (all p<0.001 vs site report after Bonferroni correction). Lesions not meeting QCA-based device success had a higher incidence of LOCE than those meeting the definition (12.0% vs 9.1%; log-rank p=0.041). Device success and LOCE rates did not differ between the two stents for any definition. CONCLUSIONS: In this prespecified lesion-level substudy, standardised assessment using the EAPCI device success algorithm with core lab QCA reclassified a substantial proportion of operator-adjudicated successes and identified lesions at higher 1-year LOCE risk. (ClinicalTrials.gov: NCT04390672).
Clinical oral investigationsVrbanić Vrankić, A Berišić, L Šimunović, I Lapić, S Želalić, I Šutej
OBJECTIVES: To determine whether serum amyloid A (SAA) is detectable in saliva of patients with internal carotid artery (ICA) stenosis and to investigate the relationship between salivary and serum SAA levels across the perioperative period of carotid endarterectomy (CEA). MATERIALS AND METHODS: Six patients with asymptomatic ICA stenosis (60-99%) undergoing CEA were enrolled. Periodontal status was assessed at enrolment and used to characterise the cohort and document potential oral inflammatory confounding of salivary SAA. Salivary and serum SAA, C-reactive protein (CRP), and lipid parameters were measured before CEA, on postoperative day 2, and 30-45 days postoperatively using enzyme-linked immunosorbent assay (ELISA) and standard laboratory methods. RESULTS: SAA was detectable in all saliva samples. Serum SAA increased after surgery and did not decline at follow-up, whereas salivary SAA showed a progressive decline (repeated measures ANOVA: F(2,4) = 25.01, p = 0.005). A strong negative correlation was observed between changes in serum and salivary SAA (Pearson's r = - 0.976, p = 0.004). CONCLUSIONS: In this small pilot cohort, SAA was detectable in all saliva samples, and salivary concentrations decreased across the perioperative time points while serum SAA did not show a parallel decline. The observed inverse serum-saliva association should be interpreted cautiously given the very small sample size, absence of a control group, and potential oral and sampling confounders. These findings support the feasibility of measuring salivary SAA in this clinical setting and warrant confirmation in larger controlled studies.
Although drug-coated balloons (DCBs) are increasingly used in acute coronary syndrome (ACS), evidence regarding mid-term clinical outcomes after DCB angioplasty remains limited. Real-world data evaluating whether intravascular ultrasound (IVUS)-guided lesion preparation is associated with improved outcomes compared with angiography-guided intervention are scarce, particularly in patients with complex coronary lesions. This study compares clinical outcomes associated with IVUS versus coronary angiography (CAG) guidance for DCB angioplasty in patients with ACS, focusing on major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) within the prespecified 24-month observation window. This retrospective study included 229 patients with ACS treated with DCB angioplasty between October 2017 and June 2025. Patients were categorized into IVUS-guided (n = 122) and CAG-guided (n = 107) groups according to the imaging strategy used during the procedure. Inverse probability of treatment weighting (IPTW) was applied to adjust for baseline confounders. The primary endpoints were MACE and NACE occurring within the prespecified 24-month observation window after DCB angioplasty. Secondary outcomes included individual clinical events, procedural characteristics, length of stay, and biochemical parameters assessed at predefined follow-up time points. After IPTW adjustment, baseline characteristics were balanced between groups. Procedural parameters, including DCB diameter, number of DCBs deployed, and bailout stenting rate, were comparable (all P > .05). Within the prespecified 24-month observation window, MACE occurred less frequently in the IVUS group than in the CAG group (8.2% vs 17.8%; IPTW P = .038). Major bleeding was also lower in the IVUS group (1.6% vs 11.2%; IPTW P = .015), contributing to a lower incidence of NACE (9.8% vs 26.2%; IPTW P = .001). IVUS guidance was additionally associated with a shorter hospital stay (4.2 vs 5.8 days; P < .001), while biochemical parameters remained comparable during follow-up. In patients with ACS treated with DCB, IVUS‑guided angioplasty was associated with significantly lower MACE and improved NACE outcomes during follow-up compared with angiography‑guided therapy alone. This benefit was largely attributable to an improved safety profile (e.g., fewer bleeding events). The associations remained consistent across subgroups, suggesting that IVUS‑guided lesion preparation may offer clinical value in this population and warrants further investigation.
BMC neurologyPablo Albiña-Palmarola, Noel P Schechtman, Andrés Gallardo, Ali Khanafer, Michio Fujimoto, Ivan Lylyk, Kamran Hajiyev, Hans Henkes
BACKGROUND: Non-ischemic cerebral enhancing (NICE) lesions are rare delayed inflammatory brain lesions reported after flow-diverter (FD) treatment of intracranial aneurysms. We systematically reviewed their reported incidence, clinical and imaging characteristics, diagnostic findings, management, and outcomes. METHODS: We performed a PROSPERO-registered systematic review. MEDLINE, Embase, Scopus, and Cochrane CENTRAL were searched for reports of delayed NICE lesions after FD treatment of intracranial aneurysms that were not better explained by infarction or alternative causes. Two reviewers independently screened studies and extracted data. Findings were synthesized narratively because heterogeneity precluded meta-analysis. RESULTS: Twenty-two studies met inclusion criteria; seven reported incidence data. One multicenter survey provided the only FD-specific denominator (12 NICE cases among 1201 FD-treated aneurysms; 1.0%), but the true incidence remains uncertain. Other estimates, using all aneurysm endovascular procedures as denominators, ranged from 0.05% to 1.3%. Overall, 40 unique FD-associated NICE patients were identified. Among cases with available individual data, median age was 54 years; all patients with reported sex were women, and all aneurysms with reported location involved the anterior circulation. NICE lesions appeared after a median of 73 days, most often with headache, focal deficits, or seizures, and as multifocal, predominantly ipsilateral enhancing lesions with edema on MRI. Brain biopsy was performed in six patients and identified hydrophilic polymer or other foreign material in four; in one additional case, device-coating detachment was observed directly. Both coated and uncoated FDs were represented, although the source component was usually undetermined. Systemic corticosteroids were administered in 22/24 cases with treatment data. Radiologic improvement or resolution occurred in 12/25, recurrent or fluctuating activity in 11/25, and 19/23 patients with reported functional outcomes were asymptomatic or independent at last follow-up. CONCLUSIONS: Reported NICE lesions after flow diversion appear uncommon, but the true incidence remains uncertain. The available evidence supports a foreign-body inflammatory mechanism potentially related to hydrophilic coatings or other materials within the endovascular construct, without establishing a single culprit device. Corticosteroid-associated improvement is common, but relapsing or fluctuating courses require prolonged clinical and imaging follow-up. TRIAL REGISTRATION: PROSPERO CRD420251186127.
To investigate the predictive value of non-high-density lipoprotein cholesterol (non-HDL-C) and remnant cholesterol (remnant-C) for the progression of non-culprit coronary lesions with quantitative flow ratio ≤ 0.80. A total of 214 patients with coronary artery disease undergoing percutaneous coronary intervention from January 2022 to March 2024 were consecutively enrolled, with 321 non-culprit lesions. All patients completed at least 24 months of clinical follow-up. Based on follow-up quantitative coronary angiography assessment, patients were divided into lesion progression and non-progression groups. Baseline clinical data, laboratory parameters, and coronary angiography characteristics were collected. Univariate and multivariate logistic regression analyses were performed to assess the independent predictive value of non-HDL-C and remnant-C for lesion progression. Predictive performance was compared using receiver operating characteristic curves, and subgroup analyses were conducted. During follow-up, 62 patients (29.0%) experienced non-culprit lesion progression. The median angiographic follow-up interval was 14.2 months (interquartile range, 10.8-18.1; range, 6.1-23.8) overall and did not differ significantly between the progression and non-progression groups (14.6 vs 14.0 months, P = .47). Multivariable logistic regression showed that, after adjustment for prespecified clinical covariates, both non-HDL-C (odds ratio = 1.68, 95% confidence interval: 1.22-2.31, P = .001) and remnant-C (odds ratio = 1.52, 95% confidence interval: 1.24-1.86, P < .001) were independently associated with lesion progression. The apparent areas under the curves were 0.72 for non-HDL-C and 0.70 for remnant-C; after adding clinical variables, the apparent areas under the curves were 0.84 and 0.83, respectively. Numerically larger effect estimates were observed in patients with diabetes mellitus, multivessel disease, and renal dysfunction, but all interaction P values were >.05. Non-HDL-C and remnant-C are independent predictors of progression of non-culprit coronary lesions with quantitative flow ratio ≤ 0.80. Combining them with traditional risk factors significantly improves predictive performance, offering clinical value for high-risk patient identification and secondary prevention optimization.
LaeknabladidKristjana Lind Olafsdottir, Luis Gisli Rabelo, Boðvar Pall Asgeirsson, Matthildur Maria Magnusdottir, Sigurdur Ragnarsson, Tomas Gudbjartsson
INTRODUCTION: Most studies comparing Off-pump and On-pump coronary artery bypass grafting (CABG) have primarily focused on short-term outcomes. The aim of this study was therefore to evaluate and compare long-term complications and survival between these surgical approaches. MATERIAL AND METHODS: This retrospective study included 2337 patients who underwent primary isolated CABG in Iceland between 2001-2021; 397 (17,0%) performed Off-Pump and 1940 (83,0%) On-Pump. The complications stroke, myocardial infarction (MI), percutaneous coronary intervention (PCI), repeat CABG and death; combined as major adverse cardiovascular and cerebrovascular events (MACCE), were compared between the groups after 1:1 propensity score matching (377 pairs). Long-term survival and MACCE-free survival were estimated using the Kaplan-Meier method and multivariable Cox regression. RESULTS: Before matching, patients in the On-Pump group had more extensive coronary artery disease and were more often operated on acutely. At 10-year follow-up, the cumulative incidence of PCI (14.0% in the Off-Pump group vs. 10.2% in the On-Pump group, p=0.110), MI (9.0% vs. 8.0%, p=0.784), stroke (4.6% vs. 6.8%, p=0.090) and repeat CABG (0.9% vs. 0.0%, p=0.090) were comparable between groups in the matched cohort. MACCE-free survival (71.0% in the Off-Pump group vs. 71.4% in the On-Pump group, p=0.74) and overall survival (78.5% vs. 73.2%, p=0.095) at 10 years was also comparable between groups. Furthermore, multivariate analysis showed similar overall survival for both surgical techniques (HR: 0.81; 95%-CI: 0.60-1.09; p=0,156). CONCLUSIONS: The long-term outcomes following CABG in Iceland are favorable for both Off-pump and On-pump procedures, both in terms of survival and long-term complications.
Liver international : official journal of the International Association for the Study of the LiverFuquan Liu, Kan Zhang, Yu Zhang, Quanwei He, Mingming Meng, Xuemei Ma, Bing Zhu, Yifan Wu, Linjing An, Yifan Lv, Fuhuang Lin, Ke Zhang, Bowen Liu, Xiujuan Chan…
BACKGROUND/AIMS: International guidelines recommend initiating transjugular intrahepatic portosystemic shunt (TIPS) placement with an 8-mm stent. However, there is an evident lack of randomized controlled trials evaluating TIPS diameters < 8 mm in cirrhotic patients with a relatively small liver. The aim of this study was to determine whether 7 mm-covered TIPS, compared with 8-mm stents, could achieve comparable shunt function with a lower incidence of hepatic encephalopathy (HE). METHODS: In this multicenter randomized controlled trial, patients with cirrhosis and relatively small liver were randomized 1:1 to receive TIPS with a 7-mm (n = 92) or 8-mm (n = 92) covered stent to prevent variceal rebleeding. The primary endpoint was the incidence of overt HE after randomization. All-cause rebleeding, orthotopic liver transplantation (OLT)-free survival and a composite of these outcomes, were designated as secondary endpoints. RESULTS: Among the 184 enrolled patients, the predominant etiologies of liver cirrhosis were hepatitis B virus infection (56.0%) and alcohol-related liver disease (20.7%). Over a median follow-up of 26.5 months, overt HE occurred in 19 patients (20.7%) in the 7-mm group and 33 patients (35.9%) in the 8-mm group. The 2-year cumulative incidence of overt HE was significantly lower in the 7-mm group than in the 8-mm group (21.4% vs. 37.2%, p = 0.02). Stent diameter, post-TIPS portosystemic pressure gradient, pre-covert HE and MELD-Na score were identified as independent risk factors for overt HE. The rates of shunt dysfunction were statistically similar between groups (8.7% vs. 8.7%, p = 1.0), as were 2-year rebleeding rates (10.9% vs. 9.8%, p = 0.81) and OLT-free survival rates (91.3% vs. 88.0%, p = 0.82). CONCLUSIONS: A 7-mm covered TIPS demonstrated comparable shunt function to an 8-mm covered stents, with a significantly lower risk of overt HE. These findings support consideration of 7-mm TIPS stents for preventing variceal rebleeding in cirrhotic patients with a small liver who are undergoing TIPS. TRAIL REGISTRATION: ClinicalTrials.gov, NCT02541825.
Haemodialysis patients face a markedly elevated risk of foot lesions because of coexisting diabetes mellitus (DM), peripheral arterial disease (PAD) and uremia-related impairment of wound healing. Structured outpatient strategies and the optimal place of basic fibroblast growth factor (bFGF) within a stepwise algorithm remain poorly defined. To report complete healing and its durability in haemodialysis patients treated with bFGF for foot lesions, and to propose a stepwise limb-salvage algorithm with prespecified escalation criteria in which bFGF precedes dehydrated human amnion/chorion membrane (dHACM) or surgery. Retrospective observational case series of 20 haemodialysis patients receiving bFGF (trafermin; Fiblast Spray) for foot lesions across three outpatient wound-care programmes. Wound status was documented by area, depth, tissue exposure and WIfI classification; perfusion was assessed in every patient by toe-brachial and ankle-brachial indices, duplex ultrasonography and angiography, independently of any pre-existing recorded diagnosis. Complete healing was defined a priori as 100% re-epithelialization confirmed on two consecutive visits at least 2 weeks apart. Tier entry criteria and escalation triggers were prespecified, using a wound-area reduction below 50% at 4 weeks as the principal threshold. The broader haemodialysis population (n = 212) served as contextual comparator. Mean age was 75.0 ± 7.3 years (range, 59-92); there were six men and 14 women. DM was present in 15 patients (75.0%) and registry-recorded PAD in 8 (40.0%), against 56.6% and 17.9% in the broader population; objective testing identified hemodynamically significant PAD in 12 patients (60.0%), all of whom were revascularized. Mean baseline wound area was 5.5 ± 3.4 cm (2), and WIfI stages 1-4 comprised 5, 8, 6 and 1 patients. Twelve patients (60.0%) were managed with bFGF alone, five (25.0%) required dHACM and three (15.0%) required surgery. Complete healing was achieved in 18 of 20 patients (90.0%) at a mean of 8.9 ± 4.4 weeks, with no amputation of any level. Over a median follow-up of 13.0 months (range, 6-28), recurrence at the same site occurred in two patients (10.0%); amputation-free survival at 12 months was 100% and overall survival 95%. The bFGF-treated cohort carried a disproportionate burden of DM and PAD, supporting targeted early biologic intervention in this highest-risk subgroup. Within a stepwise algorithm combining objective perfusion assessment with prespecified escalation criteria, 90% of wounds healed completely without amputation, providing a practical limb-salvage framework for this vulnerable population.
Physiotherapy research international : the journal for researchers and clinicians in physical therapyNeha Thakare, Manish Prannath Shukla, Vaibhav Kapre
BACKGROUND & PURPOSE: Patients with diabetes mellitus undergoing coronary artery bypass grafting (CABG) with saphenous vein harvesting are at increased risk of impaired lower extremity perfusion and wound-related complications. Buerger-Allen exercises have been proposed to improve peripheral circulation; however, evidence supporting their effectiveness following CABG remains limited. This study evaluated the effect of Buerger-Allen exercises as an adjunct to phase I cardiac rehabilitation on lower extremity perfusion and wound healing in diabetic patients undergoing CABG. METHODS: A randomized controlled trial was conducted involving 60 diabetic patients undergoing CABG with saphenous vein harvesting. Participants were randomly allocated to an intervention group receiving standard phase I cardiac rehabilitation plus Buerger-Allen exercises (n = 30) or a control group receiving standard rehabilitation alone (n = 30). The primary outcome was ankle-brachial index (ABI). Secondary outcomes included wound healing disturbances and peripheral ankle swelling. Postoperative ABI was analyzed using two-way repeated-measures ANOVA, whereas categorical outcomes were analyzed using Fisher's exact test or the Chi-squared test. RESULTS: A significant effect of time on ABI was observed (p = 0.004), whereas neither the group effect (p = 0.754) nor the group × time interaction (p = 0.711) was statistically significant. An earlier resolution of mild wound-related pain was observed on postoperative day 3 in the intervention group (p = 0.038); however, no between-group differences were present on postoperative day 5. No intervention-related adverse events were reported. DISCUSSION: Buerger-Allen exercises were safe and feasible during early postoperative rehabilitation but did not provide additional improvement in lower extremity perfusion beyond standard rehabilitation during the 5-day postoperative period. The isolated improvement in wound-related pain should be interpreted cautiously. CONCLUSION: Buerger-Allen exercises did not significantly improve the primary outcome of lower extremity perfusion following CABG. Although they appeared safe and were associated with transient improvement in wound-related pain, further adequately powered studies with longer follow-up are required to determine whether clinically meaningful benefits exist. TRIAL REGISTRATION: This study was prospectively registered in the Clinical Trial Registry India (CTRI/2023/10/058535).
Physiotherapy research international : the journal for researchers and clinicians in physical therapyKinga Balla, Karl K Haase, Alexander Wick
BACKGROUND AND PURPOSE: Early mobilisation after myocardial infarction (MI) is strongly recommended. However, evidence regarding the benefits of structured physiotherapy during the acute in-hospital phase remains limited. This controlled clinical trial (CCT) aimed to evaluate whether an intensive early physiotherapy programme could improve health-related quality of life (HRQoL) and psychological well-being. METHODS: This CCT included 172 adults hospitalised after MI and treated with primary percutaneous coronary intervention (PCI). The participants were quasi-randomly allocated (1:1) to the intervention or control group based on the hospital room number. They received either an intensive physiotherapy programme (daily supervised mobilisation, education and graded activity) or standard medical care and an informational flyer. Primary outcomes included HRQoL (MacNew) and psychological well-being (Hospital Anxiety and Depression Scale, HADS-D). Clinically important changes were evaluated using the standardised response mean (SRM, which reflects the clinical relevance of observed changes), and the minimal clinically important difference (MCID, the smallest change in an outcome perceived as important by patients). Statistical analysis was conducted to assess group-by-time and pre-post interaction effects. RESULTS: Clinical significance metrics: The intervention group showed less deterioration in overall HRQoL (SRM: 0.04 vs. 0.1) and an enhancement in the MacNew emotional subscale (SRM: 0.22 vs. 0.09) compared with the control group. The HADS-D improved to a greater extent in the intervention group, exceeding the MCID (1.7 points). There were no statistically significant interaction effects between groups by time (interaction factor group * factor time; HRQoL p = 0.68 and anxiety/depression p = 0.15) or between the time points (pre-post, main effect factor time; HRQoL p = 0.35 and anxiety/depression p = 0.4). DISCUSSION: Clinically, intensive early in-hospital physiotherapy may lead to improved psychological outcomes and an attenuation of HRQoL decline. Although the change in HADS-D in the intervention group did not reach statistical significance, it exceeded the MCID, indicating a clinically meaningful improvement from the patients' perspective. The implementation of structured early mobilisation protocols may provide clinically relevant benefits during the acute post-PCI hospitalisation period and warrants further investigation. TRAIL REGISTRATION: Ethical approval was first submitted in January 2023, then resubmitted after minor revision in March 2023, and was then accepted on 15 March 2023 (Reg.Nr. K-2023-001).
Journal of clinical apheresisAmber P Sanchez, Dan Norman Nicodemus Perez, Yeon Su Han, Janice Park, Marian Cabandong, Jerel Lee S Malong
Peripheral intravenous catheters (PIVCs) are the preferred vascular access for apheresis; however, veins that initially appear suitable may develop venous spasms, resulting in poor inlet flow and frequent pressure alarms. Ports used for apheresis can also experience inlet pressure alarms due to catheter or venous occlusion. When conservative measures failed, we implemented a novel double-draw technique in which a second draw line was connected via a four-way stopcock and male-to-male adapter to the initial draw access (either a PIVC or port) to improve inlet flow. The double-draw technique was performed in 26 procedures (therapeutic plasma exchange [TPE], n = 10 and lipoprotein apheresis [LA], n = 16) in 8 patients. During TPE, median negative inlet pressure improved from -179 mmHg (IQR -218 to -69) with single-draw access to -71 mmHg (IQR -78 to -62) following placement of a second draw line (p = 0.0162). Inlet flow rate during TPE improved from median 47 mL/min (IQR, 40-58 mL/min) with single-draw access to 70 mL/min (IQR, 60-75 mL/min) (p = 0.008). During LA, median negative inlet pressure improved from -136 mmHg (IQR -193 to -109) to -59 mmHg (IQR -66 to -47) (p < 0.0001). Median inlet flow rate during LA improved from 70 mL/min (IQR 59-71 mL/min) with single-draw access to median 80 mL/min (IQR 70-80 mL/min) (p = 0.023). Overall 25 of 26 procedures (96.2%) demonstrated an improvement in inlet pressure following implementation of the double-draw technique. All procedures were completed successfully without abandonment of the original access site. The double-draw technique is a novel option for managing inlet pressure alarms during apheresis when conservative measures fail.
Pharmacoepidemiology and drug safetyByeong Yeob Choi
BACKGROUND: In observational pharmacoepidemiology, estimating average treatment effects (ATEs) is often challenging due to a lack of practical positivity. In highly selective clinical settings, certain patients almost always or never receive treatment, causing ATE estimators to rely on unstable extrapolation. Incremental propensity score interventions (IPSIs) offer a stochastic alternative by shifting each patient's probability of treatment, providing a more clinically realistic framework that circumvents positivity violations. METHODS: We illustrate the IPSI approach, including key identification results and inferential procedures. Using observational data from a cohort of 996 patients undergoing percutaneous coronary intervention (PCI), we evaluated the effect of shifting each patient's probability of receiving abciximab by a predetermined amount on six-month mortality. Propensity scores (PSs) and outcome predictions were estimated using a machine learning ensemble (Super Learner) with 10-fold sample splitting. RESULTS: The ATE estimate suggested that abciximab administration reduced the 6-month mortality risk by 5.9 percentage points compared with PCI alone (risk difference = -0.059, 95% CI: -0.104 to -0.015). However, the practical interpretability of the ATE estimate may be limited because it implicitly assumes that patients with a near-certain probability of treatment could realistically be assigned to withhold abciximab. In contrast, shifting each patient's treatment propensity by odds ratios ranging from 0.1 to 10 showed that 6-month mortality would be significantly reduced under a strong treatment policy promoting abciximab administration. CONCLUSIONS: IPSIs provide a robust and practical alternative to conventional causal inference methods in pharmacoepidemiology settings where treatment assignment is highly selective and the strict positivity is violated.
Patients admitted to the intensive care unit with shock do not automatically need to have an arterial catheter inserted immediately. This is the main take-away point from the Early Versus Deferred Arterial Catheterization in Critically Ill Patients With Acute Circulatory Failure (EVERDAC) trial, which found that slightly fewer patients died in a group randomly assigned to not have an arterial catheter inserted unless it was truly needed, compared with putting one in immediately. This result easily met the trial's predefined criterion for noninferiority of deferring arterial catheterization, and it challenges our standard practice.
Anticancer researchAngela M Mercurio, Alexandra M Arguello, Mikaela H Sullivan, Thanh P Ho, Steven I Robinson, Brittany L Siontis, Katie N Lee, Meng X Welliver, Matthew T Houdek
BACKGROUND/AIM: Ewing sarcoma (ES) is a rare tumor, but one of the most common primary bone tumors of the foot and ankle. The aim of this study was to review long-term outcomes of ES of the foot or ankle. PATIENTS AND METHODS: We reviewed 21 patients (16 male, 5 female, mean age 20±14 years) treated for ES of the foot or ankle. Local control consisted of surgical resection alone (n=16), surgery with radiotherapy (n=1), or definitive radiotherapy (n=4). Of the patients who underwent surgical resection, 11 underwent amputation and 6 underwent limb salvage. RESULTS: The 5-, and 10-year disease-specific survival rates were 65%, and 46%, respectively. Patients who presented with metastatic disease were not at increased risk of death due to disease [hazard ratio (HR)=2.45, p=0.14] but were more likely to be treated with definitive radiotherapy [odds ratio (OR)=22.5, p=0.01]. Patients with tumors arising in the hind-foot had the worst 5-year overall survival (16%, p=0.003). There was no difference in the 5-year Musculoskeletal Tumor Society Score comparing patients who underwent a primary amputation or limb salvage (79% vs. 78%, p=0.14). CONCLUSION: Ewing sarcoma of the foot and ankle demonstrates poor survival in patients with tumors arising in the hindfoot. The results of this study indicate that decision between surgery and radiotherapy is based on the patient's status. In patients who undergo primary limb salvage, the majority retain their limb at long-term follow-up.
Nursing openJieyu Wang, Si Deng, Hui Hu, Ya Feng, Xiaoling Dong, Jing Zhang, Jiao Yang, Li Geng, Yilan Liu, Yaling Wang
BACKGROUND: Midline catheters (MCs) are increasingly utilized as an alternative to peripheral and central venous catheters. However, the lack of standardized protocols for tip location and confirmation methods remains a significant barrier to patient safety and clinical decision-making. AIM: This scoping review aimed to systematically map the current evidence and evolving clinical practices regarding MC tip placement, specifically exploring tip location standards, confirmation methods and associated clinical characteristics. DESIGN: Scoping review. REVIEW METHODS: The scoping review was conducted following the Arksey and O'Malley framework and PRISMA-ScR reporting guidelines. Two independent reviewers conducted screening and data extraction, with descriptive methods used for synthesis. DATA SOURCES: Eleven databases (platforms) were searched from inception to 31 August 2026: the Cochrane Library, PubMed, EMBASE, Web of Science, Scopus, ProQuest, CINAHL, CNKI, Wanfang Data, SinoMed and VIP databases. RESULTS: Out of 762 initial records, 41 publications met eligibility criteria. North American guidelines strictly restrict MC tips to the peripheral axilla, whereas European consensus advocates for deeper placement into the thoracic axillary or subclavian veins. Tip confirmation practices are heterogeneous. Methods range from external anatomical measurement to ultrasound guidance and post-procedural radiography. A significant limitation identified is the reduced reliability of ultrasound for tip visualization in patients with morbid obesity, often necessitating alternative confirmation or resulting in indeterminate placement. The quality and comparability of outcome data across studies were limited by inconsistent tip location definitions, heterogeneous patient populations and variable follow-up durations. CONCLUSION: This review highlights substantial heterogeneity in clinical practice and guideline recommendations. The association between tip position and catheter-related complications is multifactorial. This scoping review identifies that current evidence is inadequate to support a clear preference for any single midline catheter tip-positioning strategy. These findings set an agenda for future research to inform standardized, evidence-based midline catheter practice guidelines. IMPLICATIONS FOR THE PROFESSION: Clinical nurses and vascular access specialists should be aware of divergent international guideline suggestions for midline catheter tip positioning. Consensus-based definitions for implantation depth and target veins, together with consistent anatomical terminology, are needed to support cross-study comparison. Optimized multimodal tip-confirmation workflows may reduce unnecessary X-ray use and improve safety, supported by targeted education and interprofessional collaboration. Future prospective cohort studies and comparative trials are needed to evaluate the relationship between tip location, confirmation strategies and patient-important clinical outcomes. IMPACT: This scoping review synthesizes existing international literature on midline catheter tip-related practices and exposes inconsistencies across guideline documents. It draws attention to key unresolved clinical questions and provides clear directions for subsequent primary research. The findings may support the development of future consensus statements and help reduce practice variation in midline catheter care. REPORTING METHOD: PRISMA-ScR. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. REVIEW PROTOCOL REGISTRATION: https://osf.io/fn8vz/overview.
NefrologiaIván Zamora, María Antonieta Azancot, Mercedes Pérez-Lafuente, Xavier Faner, Natalia Ramos Terrades, Carla González Junyent, Juan León-Román, Marvin García Rey…
INTRODUCTION: Juxta-anastomotic venous stenosis is a frequent cause of dysfunction in native arteriovenous fistula (AVFs), compromising both maturation and long-term patency. Endovascular treatment has emerged as a minimally invasive alternative to surgical revision. We evaluated short-term patency and functionality outcomes and temporal patterns following endovascular treatment of juxta-anastomotic venous stenosis. MATERIALS AND METHODS: We conducted a retrospective single-center observational study including adult patients with native AVFs who underwent endovascular treatment for juxta-anastomotic venous stenosis between January 2020, and June 2024. Analyses were performed at the patient level using the first (index) intervention. Assisted primary patency was assessed using Kaplan-Meier survival analysis. Exploratory associations with 6-month failure were evaluated using penalized logistic regression. RESULTS: Fifty patients were included. Median age was 72 years [IQR: 65-76], and 72% of patients were male, with a high burden of cardiovascular comorbidity. At intervention, 72% were on hemodialysis and 28% were followed in advanced chronic kidney disease (ACKD). Delayed AVF maturation accounted for 46% of cases. The median time from AVF creation to stenosis detection was 112.5 days (IQR 60.5-511), indicating heterogeneous temporal presentation. Stenosis was detected significantly earlier in AVFs treated for delayed maturation compared with established accesses (median 68.5 vs 388.5 days; p=0.001). Conventional balloon angioplasty was performed in 98% of index procedures, with selective use of cutting balloons and drug-coated balloons. During 6-months of follow-up, 8 access failures occurred. Kaplan-Meier estimates of assisted primary patency were 90% at 90 days (95% CI 0.78-0.96) and 84% at 180 days (95% CI 0.71-0.92). Functional success at 6-months was 90% of patients. CONCLUSIONS: In this single-center retrospective cohort, endovascular treatment was associated with high short-term assisted primary patency and functional success. These results represent real-world descriptive data and require confirmation in prospective studies with longer follow-up and comparative designs. .
Yonsei medical journalKina Jeon, Hyeongsu Kim, Chul Kim, Kunsei Lee, Bora Lee, Ho Jin Jeong, Sung Hea Kim, Kyeong Eun Uhm
PURPOSE: Cardiac rehabilitation (CR) is central to tertiary prevention after acute myocardial infarction (AMI), but the prognostic impact of different education and therapy patterns in Asian real world practice is uncertain. MATERIALS AND METHODS: Using Korean National Health Insurance Service claims (2018-2022), we identified patients aged ≥40 years hospitalized for AMI who underwent thrombolysis, percutaneous coronary intervention, or coronary artery bypass grafting. CR exposure was classified into six groups by structured education and the number of supervised therapy sessions, and outcomes over 2 years included all cause readmission, readmission and emergency room (ER) visits for MI or unstable angina (UA), all cause mortality, repeat revascularization, and stroke. Multivariable Cox models estimated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: Among 92968 patients, 85.5% received no CR, 3.2% had education only, and 11.3% received any therapy. Education only participants had the lowest crude rates of mortality, cardiovascular readmission, and repeat revascularization. All CR exposed groups showed lower all cause mortality, with the greatest benefit in education plus ≥4 therapy sessions (HR 0.257, 95% CI 0.123-0.539) and ≥4 therapy sessions without education (HR 0.291, 95% CI 0.203-0.417). Education focused CR was additionally associated with lower cardiovascular readmission and repeat revascularization, whereas readmission and ER visits varied across therapy intensive groups. CONCLUSION: In this nationwide Korean AMI cohort, CR participation, especially with education, was associated with substantial mortality reduction, suggesting structured education as a pragmatic cornerstone of tertiary prevention, with supervised therapy providing incremental benefit when available.
Emergency medicine Australasia : EMAGiles Barrington, Lauren E Thurlow, Sarah Wiggs, Sundy Ni-Yen Yang, Suzanne Bumpstead, Bibesh Pokhrel, Viet Tran, Diana Egerton-Warburton, Lisa Kuhn
Peripheral intravenous catheters (PIVCs) are the most frequently inserted invasive device in acute care, yet up to 52% remain unused, exposing patients to avoidable risks and increasing healthcare costs. Despite growing awareness of inappropriate PIVC use, unnecessary insertion persists, driven by cultural and organisational norms and risk-averse practices. Interventions to reduce PIVC use have been implemented, but their effectiveness and sustainability have not been systematically synthesised. A systematic review was conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD420251033201). Searches of CINAHL, MEDLINE, Scopus, and Web of Science identified studies reporting interventions to reduce PIVC insertion, unused PIVCs, and common complications. Data were extracted for intervention characteristics and PIVC outcomes. Implementation strategies were mapped to Consolidated Framework for Implementation Research domains for summative analysis. Random-effects meta-analysis was performed when appropriate. Twelve studies were included from emergency departments and inpatient settings across high-income countries. Most reported reductions in PIVC insertion and unused catheters, with improvements in secondary outcomes including phlebitis and bloodstream infections. Sustainability of practice change was demonstrated in two multi-year follow-up studies. Interventions showed a significant trend for increasing complexity over time, with recent strategies incorporating multi-modal, theory-informed approaches. Meta-analysis showed substantial heterogeneity, limiting pooled estimate interpretation, while methodological limitations restricted causal inference. Multi-modal interventions addressing behavioural, organisational, and contextual determinants appear most effective for reducing PIVC insertion rates and unnecessary PIVC use. Future research should evaluate sustainability, cost-effectiveness, and scalability using implementation science frameworks.
Clinical interventions in agingQin Sun, Jing Yu, Aiai Li, Wei Zhang, Yan Zhong, Zhi Zeng, Dongze Li, Zhi Wan
BACKGROUND: Acute kidney injury (AKI) is a frequent complication in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI), significantly increasing mortality. The Huaxi Fall Risk Assessment (H-FRA) scale, a multidimensional bedside tool, may indirectly reflect AKI risk through factors like impaired mobility and systemic vulnerability. This study investigated the association between H-FRA and AKI in AMI patients. METHODS: This multicenter retrospective cohort study utilized data from 2,883 AMI patients treated with PCI across seven Chinese tertiary hospitals (January 2017 - February 2019). Patients were stratified into low, intermediate, and high fall-risk groups based on H-FRA tertiles at admission. Baseline serum creatinine was the first value measured upon admission. Multivariable logistic regression adjusted for confounders (age, sex, comorbidities, lab values). Predictive performance was assessed using receiver operating characteristic (ROC) curve analysis, sensitivity and specificity. RESULTS: AKI incidence significantly increased across H-FRA groups (low-risk: 4.8%, intermediate-risk: 18.3%, high-risk: 41.3%, p < 0.001). After adjustment, high H-FRA risk was independently associated with AKI (adjusted odds ratio [OR] 2.12, 95% confidence interval [CI] 1.24-3.92, p < 0.001). Each 1-point H-FRA increase raised AKI risk by 30% (OR 1.30, 95% CI 1.14-1.48, p < 0.001). The H-FRA demonstrated moderate predictive performance (area under the curve [AUC] 0.731, 95% CI 0.714-0.748, p < 0.0001). CONCLUSION: The H-FRA is independently associated with AKI in patients with AMI. The H-FRA may serve as a useful and simple bedside tool for identifying AMI patients at increased risk of AKI. However further prospective validation is required.
Rhode Island medical journal (2013)Marie Nicole Hamel, John J Lee, Sun Ho Ahn
Phlegmasia cerulea dolens (PCD) is a rare but serious complication of extensive venous thromboembolism (VTE) that can lead to limb ischemia and significant morbidity if not treated promptly. We describe a 69-year-old man with metastatic non-small cell lung cancer and hemorrhagic brain metastases who developed rapidly progressive PCD despite recent negative imaging and an existing inferior vena cava filter. He presented with bilateral lower extremity discoloration, absent Doppler signals, and signs of end-organ involvement. The patient underwent urgent mechanical thrombectomy with rapid clinical improvement and restoration of venous flow. This case highlights how quickly PCD can develop in high-risk patients and supports thrombectomy as a useful option for the resolution of extensive VTE and PCD.
Brain and behaviorJing Bian, Junfeng Xu, Xiuyun Li, Xianhui Ding, Yapeng Guo, Ke Yang, Xianjun Huang, Shoucai Zhao, Zhiming Zhou, Zibao Li
BACKGROUND AND PURPOSE: The C-reactive protein-triglyceride-glucose index (CTI), capturing insulin resistance (IR) and systemic inflammation, is related to stroke prognosis in general, but has not yet been studied with respect to functional outcomes after endovascular thrombectomy (EVT). METHODS: A retrospective analysis was carried out on individuals with acute ischemic stroke (AIS) experiencing EVT (September 2018-December 2024). CTI is measured as: 0.412 × Ln (C-reactive protein) (mg/L) + Ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)]/2. The endpoint was unfavorable functional outcomes, characterized by a modified Rankin Scale (mRS) score of 3-6 at 90-day follow-up. Restricted cubic splines (RCS) and logistic regression (LR) analysis were utilized to estimate the link between the CTI and clinical outcomes. RESULTS: Among 813 patients, a high CTI level was significantly correlated with unfavorable functional outcome (p < 0.05). Compared with patients in the lowest quartile (Q1) of CTI, those in the highest CTI quartile (Q4) demonstrated an increased likelihood of unfavorable outcome (adjusted odds ratio [aOR] of 2.04, 95% confidence interval (95% CI) of 1.17-3.54). RCS modeling, after adjustment for significant variables identified in the univariate analysis, confirmed that there was no nonlinear connection between CTI levels and the probability of unfavorable functional recovery. Stratified analysis indicated that these associations were more significant among elderly and non-smoking patients. CONCLUSION: The CTI is an independent indicator of functional outcomes in individuals with AIS undergoing EVT, underlining its potential clinical value as a readily accessible marker for risk stratification and individualized prognostic assessment.
Critical care nurseNaomi Ragsdale, Wendy Simpson, W Frank Peacock
BACKGROUND: Central line [catheter]-associated bloodstream infections (CLABSIs) represent a significant mortality risk. LOCAL PROBLEM: Due to a significant increase in CLABSI rate, a new CLABSI prevention bundle strategy was evaluated to determine whether it changed the CLABSI rate. METHODS: A before and after quality improvement project was performed in an 18-bed intensive care unit from March 1, 2021, to March 1, 2025. A CLABSI prevention bundle was implemented; CLABSI rates were compared for 1 year before to 3 years after intervention implementation. Additionally, clinician satisfaction surveys were collected. INTERVENTIONS: The implemented bundle consisted of (1) replacement of disposable stethoscopes with touch-free, aseptic stethoscope diaphragm cover dispensers (DiskCover System, AseptiScope, Inc) in each intensive care unit room, and (2) requiring a chlorhexidine-impregnated dressing for all central catheters, with standardization and reeducation of bedside staff on central catheter dressing changes. RESULTS: Of 5226 intensive care unit patients, the mean CLABSI rate was 4.42 (95% CI, 2.93-5.91) infections per 1000 patient central catheter days during the year before implementation, which decreased to 0.70 (95% CI, -1.21 to 2.61) in the 3 years after implementation. Clinicians reported the new strategy was easy to use and superior to disposable stethoscopes. CONCLUSION: A CLABSI bundle that included touch-free, aseptic stethoscope hygiene barriers and chlorhexidine-impregnated dressings was highly effective at decreasing the CLABSI rate.
European journal of gastroenterology & hepatologyXiongtao Ma, Xinyan Yu, Qingping Wu, Yu Chen, Ting Jiang, Lei Wang, Qinghua Tao
BACKGROUND: This study aimed to evaluate whether transjugular intrahepatic portosystemic shunt (TIPS) combined with embolization could further improve efficacy for patients with decompensated liver cirrhosis complicated with esophageal and gastric variceal bleeding. METHODS: We searched PubMed, Web of Science, Embase, and Cochrane Library, for all relevant randomized controlled trials and cohort studies up to March 2025. Statistical results were evaluated using risk ratios and 95% confidence intervals (CIs). RESULTS: A total of 14 studies involving 3079 patients were included. The statistical results showed that the rebleeding rate in the TIPS combined with embolization group was lower than that in the TIPS alone group (risk ratios = 0.67; 95% CI = 0.57-0.79; P < 0.001), and the same result was observed only in the subgroup of patients with gastric variceal bleeding (risk ratios = 0.50; 95% CI = 0.34-0.74; P < 0.001). There was no significant difference between the groups in patients with isolated esophageal variceal bleeding (risk ratios = 0.83; 95% CI = 0.51-1.35; P = 0.46). In addition, the incidence of hepatic encephalopathy in the TIPS combined with embolization group was also lower than that in the TIPS alone group (risk ratios = 0.82; 95% CI = 0.73-0.91; P < 0.001), but there was no significant difference in survival rate (risk ratios = 1.00; 95% CI = 0.97-1.03; P = 0.94). CONCLUSION: Compared with TIPS alone, the combined treatment showed a trend toward lower rebleeding and hepatic encephalopathy, yet survival appeared similar between the two groups.
Annals of medicineSeonghyeon Bu, Jaehyuk Jang, Sang Hyun Kim, Jaeho Byeon, Kwan Yong Lee, Gyu-Chul Oh, Sungmin Lim, Eun Ho Choo, Ik Jun Choi, Byung-Hee Hwang, Chan Joon Kim, Mah…
BACKGROUND: The clinical effects of dual antiplatelet therapy de-escalation after acute myocardial infarction may differ by age. We evaluated whether the efficacy and safety of de-escalation from ticagrelor to clopidogrel differed by age in stabilized patients after percutaneous coronary intervention (PCI). PATIENTS AND METHODS: This was a prespecified secondary analysis of the TALOS-AMI randomized trial. Patients event-free 1 month after PCI receiving aspirin-ticagrelor were randomly allocated to de-escalation (aspirin-clopidogrel) or continuation (aspirin-ticagrelor). The primary net clinical endpoint was a composite of major adverse cardiovascular events (cardiovascular death, myocardial infarction, stroke) and Bleeding Academic Research Consortium types 2, 3, or 5 bleeding at 1 year. RESULTS: We included 2697 participants (mean age 60.0 ± 11.4 years; 16.8% women). Among patients aged <75 years (n = 2376), de-escalation reduced the primary net clinical endpoint (4.1% vs. 7.2%; adjusted hazard ratio (aHR), 0.54 [95% CI, 0.38-0.77]) and bleeding (2.8% vs. 4.9%; aHR, 0.54 [0.35-0.82]). Among patients aged ≥75 years, no significant differences were observed for the primary endpoint (6.4% vs. 11.6%; aHR0.54 [0.25-1.17]) or bleeding (3.2% vs. 7.9%; aHR, 0.41 [0.15-1.15]). Interaction testing showed no treatment effect modification by age for the primary endpoint (p for interaction = 0.978), MACE (p = 0.585), or BARC bleeding (p = 0.597). Among patients aged ≥75 years, 14/18 bleeding events occurred within 180 days. CONCLUSIONS: Among stabilized, event-free patients 1 month after PCI, no significant age-treatment interaction was observed; therefore, the efficacy and safety of de-escalation in older adults (≥75 years) remain uncertain. UNLABELLED: Trial registration: ClinicalTrials.gov (NCT02018055).
Journal of the American Heart AssociationYingjian Pei, Na Li, Guitao Zhang, Wenbo Li, Yinghua Zhou, Shujuan Li
BACKGROUND: Although carotid atherosclerosis is a recognized risk factor, the relationship between plaque characteristics and clinical outcomes after cardiac surgery remains unclear. METHODS: We retrospectively studied 1087 patients undergoing coronary artery bypass graft-containing cardiac surgery between January 2023 and January 2024. Preoperative carotid ultrasound was used to assign Carotid Plaque-Reporting and Data System (Plaque-RADS) grades 1 to 4. The primary outcome was in-hospital ischemic stroke. Given the low number of events, associations were evaluated using Firth penalized logistic regression with limited covariate adjustment. RESULTS: In-hospital ischemic stroke occurred in 14 patients (1.3%). Stroke incidence increased across Plaque-RADS grades from 0% in grade 1 to 0.6%, 2.0%, and 6.3% in grades 2, 3, and 4, respectively (P=0.011). Higher Plaque-RADS grade was associated with greater odds of in-hospital ischemic stroke after adjustment for age, sex, surgical procedure, operative time, and aortic atherosclerotic burden (odds ratio per 1-grade increase, 4.31 [95% CI, 1.72-11.43]; P=0.002). The association was directionally similar among patients with carotid stenosis <50%. In exploratory discrimination analyses, the model including both stenosis and Plaque-RADS had the highest numerical area under the receiver operating characteristic curve, although the incremental gain over either individual parameter was modest. CONCLUSIONS: Higher ultrasound-based Plaque-RADS grade was associated with in-hospital ischemic stroke after coronary artery bypass graft-containing cardiac surgery. Plaque-RADS may provide complementary risk information. These findings should be considered hypothesis generating and require validation in larger prospective cohorts.
Journal of the American Heart AssociationJorge Chavez, Gabriela Tirado-Conte, Yusuke Kobari, Lluis Asmarats, Alberto Berenguer, Alba Abril Molina, Jose Ramón Lopez-Minguez, Ander Regueiro, Antonio Gom…
BACKGROUND: Most evidence for transcatheter aortic valve replacement (TAVR) for valve-in-valve procedures comes from balloon-expandable and supra-annular self-expanding valves. However, data on intra-annular self-expanding valves remain limited. The objectives of this registry were to evaluate the short- and midterm outcomes of ViV-TAVR using the intra-annular self-expanding valve Navitor platform in a real-world setting. METHODS: The NAViV (Navitor Valve-in-Valve) registry is a retrospective, multicenter study that included 200 patients who underwent valve-in-valve TAVR with the Portico/Navitor systems. The primary end point was 30-day device success. Secondary outcomes included intraprocedural technical success, early safety, and all-cause death and major adverse events at 2 years. RESULTS: The cohort had a high-risk profile and a high prevalence of small surgical bioprostheses (internal diameter ≤21 mm in 86% of the patients). Technical success was achieved in 96%, with an in-hospital mortality rate of 2% and early safety at 30 days of 84%. Mean residual gradients after TAVR were low (14 [interquartile range, 10-20] mm Hg), and residual significant aortic regurgitation was rare (1%). Device success was 73.5%, with high residual gradients (≥20 mm Hg) being the main reason for device failure. Two-year survival and major adverse events were 85.6% and 69.8%, respectively; with low residual gradients and baseline significant AR being independently associated with higher survival. CONCLUSIONS: Valve-in-valve TAVR using the Portico/Navitor intra-annular self-expanding valve demonstrates a favorable procedural safety profile, sustained valve performance, and encouraging midterm survival in intermediate- and high-risk populations. Larger and comparative studies are warranted to confirm these findings.
BMJ case reportsPerya Abbasoglu, Volkan Gider, Eyüp Deniz, Pelin Basım
The surgical management of breast cancer in patients with coronary artery disease presents significant challenges, requiring a balance between oncological treatment and cardiovascular stability. A woman in her 70s was diagnosed with breast cancer after imaging identified a right breast lesion confirmed as papillary ductal carcinoma in situ on tru-cut biopsy. Following discussion at the multidisciplinary team (MDT) meeting, the consensus recommendation was mastectomy with sentinel lymph node biopsy. During the preoperative anaesthesia evaluation, cardiology consultation was obtained, and coronary angiography revealed severe stenosis of the left anterior descending and right coronary arteries. Given the patient's cardiovascular status, an MDT decision was made to perform simultaneous off-pump coronary artery bypass grafting and mastectomy using a beating-heart technique. This case highlights the challenges of managing complex comorbidities in patients with cancer and demonstrates the role of MDT collaboration in achieving optimal surgical outcomes.
Journal of the American Heart AssociationHao-Jie Lei, Guang-Ren Huang, Xing-Ning Mao, Zhong Qin, Xiao Qin, Jing Chen, Hai-Ying Zhang, Zi-San Zeng, Qian-Hui Tang
BACKGROUND: The periaortic microenvironment visible on routine computed tomography angiography remains incompletely characterized in type B aortic dissection (TBAD). We evaluated computed tomography angiography-based periaortic adipose tissue (PAAT) phenotypes associated with prevalent TBAD and explored a prespecified Tear Risk Index for post-thoracic endovascular aortic repair aortic dilation. METHODS: This retrospective case-control study included 100 patients with TBAD undergoing primary thoracic endovascular aortic repair and 50 normal controls frequency matched by age and sex. Deep learning-assisted, radiologist-reviewed segmentation quantified multilayer PAAT and aortic morphology. Interreader reproducibility was assessed using intraclass correlation coefficients and Bland-Altman analyses. Group comparisons, receiver operating characteristic analyses, and adjusted logistic regression were performed. RESULTS: Compared with controls, patients with TBAD had larger aortic volume and higher 3-mm PAAT volume, fat attenuation index, and fragmentation index. Aortic volume showed an area under the curve of 0.966 (95% CI, 0.941-0.991); corresponding values for 3-mm PAAT volume, fat attenuation index, and fragmentation index were 0.614, 0.819, and 0.716, respectively. Interreader intraclass correlation coefficients for selected 3-mm PAAT measures ranged from 0.822 to 0.907. Principal TBAD-control PAAT findings remained supported after false discovery rate correction, whereas post-thoracic endovascular aortic repair PAAT differences were not robust. Tear Risk Index showed limited exploratory discrimination for dilation status. CONCLUSIONS: Selected 3-mm PAAT measures characterize a reproducible computed tomography angiography-based imaging phenotype associated with prevalent TBAD and may complement conventional aortic morphology. These findings are hypothesis generating, and Tear Risk Index should not be used as a standalone clinical predictor.
Journal of the American Heart AssociationSefa Sural, Claudiu Ungureanu, Abdullah Yıldırım, Vedat Aslan, Barış Düzel, Ahmet S Gürbüz, Niyazi Görmüş, Mehmet K Karaca, Özerdem Özçalışkan, Cüneyt Kocaş, E…
BACKGROUND: The optimal revascularization strategy for isolated left anterior descending artery chronic total occlusion (CTO) remains uncertain, with limited comparative data between CTO percutaneous coronary intervention (CTO-PCI) and coronary artery bypass grafting (CABG). METHODS: The RITUAL (Revascularization of Isolated Chronic Total Occlusion of the Left Anterior Descending Artery) study was a retrospective, multicenter analysis conducted at 4 centers including patients who underwent revascularization for isolated left anterior descending artery CTO between January 2017 and January 2023. Lesion complexity was assessed using the Japanese Chronic Total Occlusion score. The primary end point was technical and procedural success. Secondary end points included 3-year major adverse cardiac and cerebrovascular events and a periprocedural composite safety outcome. Multivariable Cox regression and restricted cubic spline analyses were performed. RESULTS: Among 2382 patients treated with CTO-PCI and 5850 surgical patients screened, 297 eligible patients (184 CTO-PCI, 113 CABG) were analyzed. Baseline characteristics were comparable. Adjusted procedural success favored CTO-PCI (88.6% versus 83.2%; adjusted hazard ratio [HR], 1.33 [95% CI, 1.01-1.75]; P=0.043), while technical success was similar. CABG was associated with higher rates of acute kidney injury and blood transfusion. At 3 years, all-cause death and major adverse cardiac and cerebrovascular events were comparable. However, adjusted periprocedural composite safety outcomes were lower with CTO-PCI (20.7% versus 35.4%; adjusted HR, 0.63 [95% CI, 0.40-0.99]; P=0.047). Increasing Japanese Chronic Total Occlusion score was linearly associated with higher major adverse cardiac and cerebrovascular event risk (P=0.007), and among patients with a Japanese Chronic Total Occlusion score <3, periprocedural composite safety outcomes favored CTO-PCI. CONCLUSIONS: In isolated left anterior descending artery CTO, no significant differences in 3-year clinical outcomes were observed between CABG and CTO-PCI, although CABG was associated with higher in-hospital complications and CTO-PCI with more favorable periprocedural composite safety outcomes, particularly in less complex lesions. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT07373678.