PURPOSE:The procedure time of endovascular treatment (EVT) for lower extremity artery disease (LEAD) may increase as its application expands to more complex lesions. Given this trend and the growing importance of radiation protection, this study investigated the association between annual institutional EVT volume and radiation exposure in patients with LEAD. METHODS:Data from 1638 cases of EVT for LEAD were collected from 167 institutions between April 2020 and March 2022. The locations of treated vascular lesions were classified into 3 anatomical segments: aortoiliac (AI), femoropopliteal (FP), and below-the-knee (BTK) regions. Institutions were categorized as a high-volume group (≥147 EVT cases/year) or low-volume group (<147 EVT cases/year). Propensity score matching was performed using the following covariates: age, sex, body mass index, number of digital angiography and digital subtraction angiography acquisitions, the presence of chronic total occlusion, and fluoroscopy dose rates. The primary endpoints were air kerma at the entrance reference point (Ka,r), air kerma area product (PKA), and fluoroscopy time (FT). RESULTS:Fluoroscopy time was significantly shorter in all regions in the high-volume group (AI: 21.0 vs 33.8 minutes, P = .043; FP: 20.3 vs 28.2 minutes, P = .022; BTK: 30.6 vs 34.9 minutes, P = .009). No significant differences were observed in Ka,r or PKA in any regions between the groups. CONCLUSION:In EVT for LEAD, FT was significantly shorter in high-volume institutions, whereas cumulative radiation dose metrics did not differ significantly. These findings suggest that radiation exposure is influenced by multiple technical and patient-related factors. Optimizing radiation exposure therefore requires not only reducing FT but also implementing comprehensive dose management strategies, including standardization of imaging protocols, equipment settings, and education in radiation techniques.Clinical ImpactThis study demonstrates that institutions performing a higher annual volume of endovascular treatments (EVT) for lower extremity artery disease achieve significantly shorter fluoroscopy times compared with lower-volume centers, although no significant differences were observed in radiation dose indicators such as Ka,r and PKA. These findings highlight that procedural efficiency gained through institutional experience does not necessarily translate into reduced radiation exposure, as total dose is influenced by multiple factors including imaging conditions, equipment parameters, and patient characteristics. From a clinical perspective, this underscores the importance of comprehensive dose management strategies that extend beyond reducing fluoroscopy time, incorporating the standardization of imaging protocols, optimization of device settings, and continuous education on radiation safety. The present results provide new evidence to guide radiation protection practices in EVT and support the establishment of cross-institutional benchmarks for safer and more effective patient care.
PURPOSE:To report the first application of the Leak-Loop Technique (LLT) that combines controlled endoleak and dual guidewire loop stabilization to address cerebral perfusion maintenance and endograft malpositioning during in situ fenestrated thoracic endovascular arch repair (fTEVAR) under urgent resource-limited setting. CASE REPORT:A 52-year-old man presented with acute progressive chest pain. Computed tomographic angiography identified an extensive subacute intramural haematoma (IMH) with penetrating atherosclerotic ulcer (PAU). In the absence of open surgical infrastructure and a customized device, in situ fTEVAR using the LLT was performed. Dual U-shaped guidewire loops created via same-sheath snare capture at each carotid access site anchored the proximal endograft and prevented rotational displacement during deployment. A pre-positioned balloon inflated at zone 0 prior to endograft deployment created a controlled gutter between the balloon shaft and aortic wall, maintaining antegrade supra-aortic branch perfusion throughout the fenestration interval. Sequential in situ fenestration and supra-aortic branch reconstruction were completed without complications. At 6-month follow-up, all branch stents were patent and the endograft was stable without endoleak. CONCLUSIONS:The LLT maintained cerebral perfusion through a self-limited controlled gutter and prevented endograft malpositioning during in situ arch fTEVAR for extensive subacute IMH with PAU. Six-month branch patency supports technical feasibility pending prospective validation.Clinical ImpactThe Leak-Loop Technique provides a reproducible, fully endovascular solution to cerebral perfusion maintenance and endograft malpositioning during in situ fenestrated thoracic endovascular arch repair (fTEVAR) using only commercially available equipment, making it particularly applicable in urgent or resource-limited settings where custom devices and open surgical infrastructure are unavailable. The 6-month outcomes suggest its potential as a viable approach in this challenging clinical scenario pending prospective validation.
BACKGROUND:Although current revascularization paradigms emphasize direct inline flow through the target arterial pathway (TAP), the prognostic importance of distal pedal connectivity in this anatomical setting remains uncertain. METHODS:Clinical, anatomical, procedural, and follow-up characteristics were analyzed. Kaplan-Meier methods were used for time-to-event analyses, and multivariable logistic regression identified independent predictors of major amputation. RESULTS:During follow-up, major amputation occurred in 29 limbs (25.7%). After multivariable adjustment, increasing Wound, Ischemia, and foot Infection (WIfI) stage was independently associated with a higher risk of major amputation (adjusted odds ratio [OR] 4.47, 95% confidence interval [CI], 2.11-9.45; P < .001), whereas each additional patent deep pedal arch was independently associated with a lower risk of limb loss (adjusted OR 0.23, 95% CI, 0.10-0.53; P < .001). Kaplan-Meier estimates demonstrated significantly better limb salvage in limbs with preserved pedal arch integrity (log-rank P = .003). At 12 months, estimated amputation-free survival was 68.1%, whereas freedom from major adverse limb event among revascularized limbs was 79.7%. CONCLUSIONS:In patients with isolated peroneal artery runoff, distal pedal connectivity, reflected by pedal arch integrity, and clinical severity are the principal independent predictors of limb salvage. The peroneal-based global limb anatomic staging system classification improves anatomical stratification in this selected anatomical population but does not provide independent prognostic information beyond WIfI stage and distal pedal connectivity. These findings support the systematic assessment of distal pedal circulation when planning revascularization in this challenging anatomical subgroup.Clinical ImpactIn patients with chronic limb-threatening ischemia and isolated peroneal artery runoff, revascularization planning should extend beyond proximal anatomical complexity and include systematic assessment of distal pedal circulation. This study demonstrates that pedal arch integrity provides clinically relevant prognostic information for limb salvage, while WIfI stage remains a major determinant of amputation risk. Although application of the original GLASS framework using the peroneal artery as the target arterial pathway improves anatomical stratification, it does not independently predict limb loss. These findings support integrating clinical severity and distal pedal connectivity into treatment planning and prognostic assessment in this challenging anatomical subgroup.
BACKGROUND:Optimal proximal landing zone selection in thoracic endovascular aortic repair (TEVAR) for acute and subacute Stanford type B aortic dissection remains controversial. This meta-analysis compared zone 2 versus zone 3 deployment with respect to perioperative and mid-term outcomes. METHODS:This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed and Scopus were systematically searched up to August 1, 2025. Eligible studies included adult patients with acute or subacute type B aortic dissection undergoing TEVAR with proximal landing in zone 2 or zone 3. Random-effects meta-analyses were performed using odds ratios (ORs) with 95% CIs. Heterogeneity was assessed using I2, and sensitivity analyses included leave-one-out and fixed-effect comparisons. RESULTS:Four studies comprising 907 patients (393 zone 2, 514 zone 3) were included. There was no significant difference in 30-day mortality between groups (OR = 0.94, 95% CI, 0.64-1.39; I2 = 0%). Zone 2 repair was associated with increased spinal cord ischemia in the common-effect model (OR = 2.29, 95% CI, 1.20-4.02), while the random-effects model showed a non-significant but consistent trend (OR = 2.96, 95% CI, 0.61-14.38). The risk of stroke showed a similar trend favoring zone 3 (OR = 2.05, 95% CI, 1.08-3.87). Reintervention rates were higher in zone 2 in the common-effect model (OR = 1.91, 95% CI, 1.24-2.95) but were not robust in sensitivity analysis. Endoleak outcomes showed substantial heterogeneity (I2 = 81.5%), precluding reliable pooling. Other complications and retrograde type A dissection showed no consistent differences between groups. CONCLUSION:Zone 2 TEVAR is associated with a potential increase in neurologic and reintervention-related complications, while mortality remains comparable. The evidence is limited by heterogeneity and small study numbers.Clinical ImpactThese findings support a more individualized approach to proximal landing-zone selection during TEVAR for acute and subacute type B aortic dissection. Zone 3 deployment may be preferable when anatomically feasible, given its potential association with lower rates of spinal cord ischemia and stroke. When zone 2 coverage is necessary, clinicians should carefully weigh the neurologic risks against the anatomical and procedural benefits. The study highlights the importance of incorporating spinal cord protection strategies and meticulous patient selection. Its innovation lies in directly synthesizing comparative evidence on proximal landing zones while testing the robustness of observed differences through sensitivity analyses. These findings may help inform procedural planning while underscoring the need for larger prospective comparative studies.
OBJECTIVE:To evaluate the efficacy and safety of a novel single-use peripheral intravascular ultrasound (IVUS) system in a porcine model. METHODS:Six healthy white pigs were randomized into 2 groups. The Efficacy Valuation Group (group A, self-controlled, n = 3) underwent imaging before and after stent implantation with both the test device (automated pullback) and a control IVUS system (manual pullback). The Safety Evaluation Group (group B, n = 3) was imaged with the test device only for safety and pathological evaluation. Endpoints included mean stent cross-sectional area (MSA), stent length, measurement agreement, image quality, device usability, vital signs, adverse events, and vascular safety. RESULTS:For the primary endpoint, the 95% confidence intervals (CIs) for the relative difference in MSA between devices fell within the prespecified ±10% equivalence margin at both low-speed (2.010%-4.649%) and high-speed (0.844%-6.968%) pullback, as confirmed by two one-sided tests (TOST). A prespecified subgroup analysis by vessel type (arterial vs venous) confirmed consistent equivalence within each subgroup. The 95% limits of agreement for MSA were within ±1.5 mm2 for both speeds. Stent length measurements correlated excellently with digital subtraction angiography (r = .997, P < .0001). Lumen measurements showed good inter-device agreement. Both systems achieved a 100% image-quality excellence rate. Operators rated the test device significantly higher for overall usability (4.8 ± 0.4 vs 4.5 ± 0.5, P < .05). All animals remained hemodynamically stable with no device-related adverse events, and pathological examination revealed no significant vascular injury. It should be noted that key study limitations include the comparison of automated versus manual pullback, potential data clustering from multiple measurements per animal, and the use of a healthy animal model that does not replicate human atherosclerotic disease. CONCLUSION:In a porcine model, the novel high-frequency automated-pullback IVUS system demonstrated imaging efficacy noninferior to a control device, with a favorable safety profile and no observed complications. These preclinical findings support its further clinical investigation for peripheral vascular interventions.Clinical ImpactThis preclinical study demonstrates that a novel peripheral IVUS system, featuring a higher-frequency transducer (30 MHz) and automated pullback, achieves imaging efficacy and acute safety comparable to a control device in a porcine model. The higher-frequency design may improve resolution, and automated pullback enables standardized, operator-independent measurements. These features could enhance procedural planning for complex interventions. The system clearly visualized vessel microstructures, supporting more precise device selection with the potential to improve outcomes in precision vascular medicine. Future clinical studies are warranted to translate these advancements into clinical benefits for patients with atherosclerotic arterial or relevant venous diseases.
BACKGROUND/OBJECTIVE:Acute mesenteric ischaemia (AMI) is a multidisciplinary emergency, requiring the involvement of different medical specialties for successful management. Endovascular aspiration thrombectomy (EAT) has entered the field leading to the possibility of treating acute arterial occlusions with a minimally invasive approach. The aim of the study was to provide contemporary data on results after use of EAT in AMI patients. METHODS:The study was a retrospective, observational, multicentre study conducted in 10 Italian centres. Patients with AMI, undergoing EAT of the superior mesenteric artery (SMA) with the Penumbra Indigo system (Penumbra Inc., Alameda, CA, USA) from January 1, 2020 to December 31, 2024 were enrolled. Technical success and mortality were the primary outcomes. Secondary outcomes included perioperative complications and length of stay in the hospital and intensive care unit (ICU). RESULTS:Forty-eight consecutive AMI patients undergoing EAT were enrolled in the study. The median age of the study population was 80 years (interquartile range [IQR] = 68-86), and 52% were male. The median time from emergency acceptance up to referral for definitive treatment was 1 hour (IQR = 1-5), with 77% of patients presenting to the hospital less than 6 hours from onset of symptoms. Overall, 29 patients (60%) received only EAT at presentation, whereas 19 patients (39%) received a combined general surgical procedure at the same time of endovascular intervention. Technical success of EAT was achieved in 44 cases (92%). Thirty-one patients (64%) required ICU stay, with a median duration of 1.5 days. Severe postoperative complications (i.e. Clavien-Dindo scale >3) occurred in 28 patients (58%), and the average duration of hospital stay was 10 days. The overall rate of 90-day mortality was 46% (n = 22); of these, 19 deaths occurred in the first 30 days and 3 additional events occurred between 30 and 60 days after index presentation. On multivariable analysis, a procedure longer than 90 minutes (odds ratio [OR] 6.3; 95% confidence interval [CI], 1.0-37.2; P = .041) and Clavien-Dindo score greater than 3 (OR 19.5; 95% CI, 3.2-115.5; P = <.001) resulted as independent factors for mortality. CONCLUSIONS:The application of the Penumbra Indigo system for EAT of the SMA in AMI cases may provide an effective total endovascular procedure for its solution, providing high technical success rates. However, mortality rates are still high, owing to the severity of illness and comorbid status of patients, with most death events occurring in the first 30 days.Clinical ImpactThe results of this study demonstrate that endovascular aspiration thrombectomy of the superior mesenteric artery for treatment of acute mesenteric ischemia may provide a safe and effective procedure for this condition. However, mortality rates are still high, owing to the severity of illness and comorbid status of patients, with most death events occurring in the first 30 days. Longer procedures and severe postoperative adverse events were also identified to be associated with higher odds of death, thereby highlighting potential bundles for improving care.
PURPOSE:Fiber Optic RealShape (FORS) is a novel technology using light instead of X-rays to visualize guidewire and catheters during endovascular procedures. A 3D-Hub allows visualization of conventional catheters when used in combination with the FORS guidewire. This study evaluates the FORS performance and radiation exposure during visceral target vessel (TV) catheterization in complex endovascular aortic repair (cEVAR). MATERIALS AND METHODS:Single-centre data were retrieved from the prospective FORS Learn Registry cohort study. The primary outcome was FORS technical success, defined as successful catheterization using FORS without reverting to a conventional guidewire. Secondary outcomes included catheterization and fluoroscopy time, Dose Area Product (DAP) and Air Kerma (AK), compared across technical success, technical failure and conventional catheterizations using analysis of variance (ANOVA) with post hoc testing. RESULTS:Between December 2020 and December 2023, 96 patients underwent cEVAR. In total 319 visceral targets were catheterized, including 176 FORS attempts with a technical success rate of 63.6%. This success rate decreased in TVs with versus without ostial stenosis (21.7% vs 69.9%, P < .001) or with versus without calcification (14.3% vs 67.9%, P < .001), and increased with versus without the use of the 3D-Hub (80.6% vs 60.0%, P = .039). Type of TV, stent graft configuration or prior TV stent did not affect technical success rates. Radiation exposure was significantly lower during successful FORS catheterizations (fluoroscopy time 1.7 ± 2.1 min; DAP 3.7 ± 8.5 Gy∙cm2; AK 30.8 ± 55.9 mGy) compared to FORS technical failures (fluoroscopy time 6.5 ± 4.3 min, P < .001; DAP 8.8 ± 6.4 Gy∙cm2, P = .030; AK 126.5 ± 116.5 mGy, P < .001) and conventional catheterizations (fluoroscopy time 6.2 ± 9.2 min, P < .001; DAP 9.4 ± 20.25 Gy∙cm2, P = .003; AK 111.5 ± 151.1 mGy, P < .001). No significant differences occurred between technically failed and conventional catheterizations. Catheterization time was shortest with FORS technical success (6.5 ± 5.0 min) compared to conventional catheterizations (9.7 ± 13.5 min, P = .015), followed by technical failure (14.3 ± 6.9 min, P < .001). CONCLUSION:Fiber Optic RealShape has an acceptable technical success rate in visceral TV catheterization during cEVAR, which has improved following the 3D-Hub implementation. Successful FORS catheterization results in reduced radiation exposure and catheterization time. When reversion to conventional catheterization is required, outcomes remain comparable to primary conventional procedures, supporting initial FORS use in all catheterizations to minimize radiation. Continued device and software development is essential to optimize FORS performance.Clinical ImpactFiber Optic RealShape (FORS) is a new technology that enables visualization of exclusive FORS-guidewires and catheters using light pulses instead of radiation. This study shows acceptable technical success rates with reduced radiation exposure compared to technically unsuccessful FORS and primary conventional catheterizations of visceral target vessels during complex endovascular aortic repair. These findings support the clinical benefit of initially attempting catheterization with FORS, as it results in reduced radiation exposure, even in case of reversion to conventional devices, without compromising patient outcomes. Additionally, the technical success rates improved significantly following the implementation of the 3D Hub.
OBJECTIVE:To investigate the short- and long-term event-free survival (EFS) in patients with chronic kidney disease (CKD) undergoing carotid artery stenting (CAS) for the treatment of symptomatic carotid artery stenosis. METHOD:The single-center retrospective study included 1363 patients, who were categorized into CKD stages 2, 3, 4, and 5 based on their glomerular filtration rate. The primary endpoint was long-term EFS from the occurrence of stroke, myocardial infarction (MI), or death within a 10-year follow-up period. Secondary outcomes included perioperative major adverse events, such as any stroke, MI, death, or transient ischemic attacks (TIAs) occurring within 30 days after CAS. RESULTS:Perioperative event rates were 1.8%, 3.0%, 10.3%, and 8.7% across the 4 cohorts. The estimated rates of EFS were 96.1% versus 86.7% versus 78.4% versus 63.5% at 3 years, 91.0% versus 80.2% versus 65.2% versus 49.5% at 5 years and 78.0% versus 70.4% versus 54.8% versus 36.3% at 10 years. Kaplan-Meier analysis reported that the long-term EFS did not differ between patients with stage 2 and stage 3 CKD (107.79 months 95% confidence interval [CI]: 104.64, 110.95 vs 97.20 months, 95% CI, 90.71-103.69), whereas EFS was lower in patients with stage 4 and stage 5 CKD (67.04 months, 95% CI, 61.15-72.93 vs 58.56 months, 95% CI, 48.20-68.91) (log-rank P < .001). CONCLUSION:Patients with stage 2 to 3 CKD benefited from long-term EFS following invasive CAS. In contrast, those with stage 4 to 5 CKD exhibited poor long-term EFS or reduced life expectancy limiting the prevention of events over a 10-year follow-up period. Cautious consideration of the potential benefits was necessary when planning CAS even in symptomatic cases.Clinical ImpactThis study provided real-world 10-year follow-up evidence to refine CAS decision-making for symptomatic carotid stenosis patients with CKD. Clinicians could stratify candidates by CKD stages: stage 2-3 patients were recommended for CAS to gain satisfying long-term event-free survival, while for stage 4-5 patients, cautious, individualized benefit-risk assessment was required before intervention. The innovation lied in its large-sample, stage-stratified long-term outcome data filling the relevant gap in Chinese CKD population, guiding clinicians to avoid over-treatment for advanced CKD patients with limited life expectancy.
PURPOSE:To compare the efficacy and safety of transradial (TR) versus transfemoral (TF) access in peripheral arterial angioplasty and stenting, providing evidence to guide clinical decision-making in endovascular interventions. METHODS:A systematic review and meta-analysis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and cohort studies comparing TR and TF approaches in patients with peripheral artery disease (PAD) were included. Databases (PubMed, Embase, and Cochrane Library) were searched up to May 10, 2025. Risk of bias was assessed using the Cochrane tool, and RevMan 5.3 was used for statistical analysis. Outcomes included technical success, fluoroscopy time, hospital stay, minor/major bleeding, and access site complications. RESULTS:Seventeen studies (13 210 patients) were analyzed. No significant difference was found in technical success (odds ratio [OR] = 1.48, P = .36, 95% CI, 0.64, 3.54). However, TR access was associated with a shorter hospital stay (mean difference = -0.09 days, P = .01, 95% CI, -0.16, -0.02) and a trend toward fewer access site complications (OR = 0.49, P = .07, 95% CI, 0.23, 1.06), with significant reduction in lower extremity interventions (P < .01). Transradial also showed lower bleeding risks, with a trend in minor bleeding (P = .09) and significant reduction in major bleeding (P = .03). CONCLUSION:Transradial access for peripheral angioplasty and stenting offers advantages over TF, including reduced hospital stay, fewer complications, and lower bleeding risks. As TR techniques advance, TR may become the preferred approach, particularly when TF access is not feasible.Clinical ImpactThis study provides clinically relevant evidence supporting transradial (TR) access as a practical alternative to transfemoral (TF) access for peripheral arterial interventions. TR access showed fewer access-site complications, shorter hospitalization, and a trend toward reduced bleeding, suggesting benefits for both patient recovery and healthcare resource use. Although TF access remains preferable in certain femoropopliteal interventions, the growing availability of TR-specific devices and robotic technologies may further expand the role of TR access. These findings can guide access-site selection and improve procedural safety in clinical practice.
BACKGROUND:Femoral artery pseudoaneurysm (FAP) is a recognized complication following endovascular therapy (EVT). Routine ultrasound surveillance has been criticized for inflating reported FAP incidence (surveillance bias). We hypothesized that ultrasound could be repurposed from passive surveillance to an active "confirmation and rescue" strategy to detect and correct incomplete hemostasis immediately. METHODS AND RESULTS:We retrospectively analyzed 1002 consecutive patients undergoing femoral access EVT for lower extremity artery disease. The hemostasis protocol consisted of manual compression followed by immediate bedside Doppler ultrasound. If residual flow or hematoma expansion was detected, rescue compression was performed until hemostasis was confirmed. A mandatory follow-up ultrasound was performed the next morning. The overall FAP incidence was 1.0% (10/1002), which was within the lower range of rates reported in prior EVT series. Of the 10 cases, 8 were detected on next-morning ultrasound and 2 (0.2%) presented as delayed events at 5 and 39 days. Thrombin injection was required in 3 cases; the remaining 7 were managed by compression alone. No patient required surgical repair. CONCLUSIONS:Immediate ultrasound confirmation with rescue compression was associated with a low FAP incidence in a high-risk EVT population. Most events were managed without surgery, suggesting a potential practical advantage over passive surveillance alone.Clinical ImpactThis study describes a practical hemostasis protocol that repurposes bedside ultrasound from passive next-day surveillance to active immediate confirmation with rescue compression after femoral access endovascular therapy. Over 60% of puncture sites required additional compression that standard manual compression alone would not have objectively identified, yet the overall pseudoaneurysm rate was 1.0%, with no surgical repairs. This protocol requires no specialized equipment beyond a standard duplex ultrasound and may be implementable in catheterization laboratories where such ultrasound is available, offering a potentially practical approach to hemostasis assessment in peripheral endovascular practice.
INTRODUCTION:Endovascular repair has increasingly been adopted as a less-invasive alternative to open surgery for popliteal artery aneurysms, yet its long-term durability remains debated. Since the last comprehensive review in 2015, substantial new data with extended follow-up have emerged. This systematic review aimed to evaluate long-term outcomes after endovascular popliteal artery aneurysm repair (EPAR) and summarise contemporary evidence published between 2014 and 2025. METHODS:In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Web of Science, and Scopus were searched from January 2014 to November 2025. Studies including ≥10 adult patients undergoing EPAR with covered stent grafts and reporting follow-up of ≥3 years were eligible. Pooled Kaplan-Meier estimates were generated for long-term primary patency (primary outcome), as well as secondary patency, primary-assisted patency, overall survival, and freedom from reintervention where reported. Risk of bias was assessed using ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions), and certainty of evidence was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation). RESULTS:Eleven retrospective cohort studies were included, comprising 929 patients and 993 treated limbs. The weighted mean age was 72.8 years, and 95.8% of patients were male. Bilateral disease was present in 24.5% of patients, and 28.9% were symptomatic at presentation. Endovascular repair was associated with high technical success (>98%) and low perioperative morbidity. Pooled Kaplan-Meier estimates for primary patency at 1, 3, 5, 10, and 15 years were 84.5%, 72.1%, 64.4%, 51.2%, and 47.3%, respectively. At 15 years, secondary patency and primary-assisted patency were 59.5% and 46.7%, respectively, while overall survival was 35.5%. Freedom from reintervention was 74.3% at 5 years. All studies were judged to be at serious risk of bias, and certainty of evidence was very low for all outcomes. CONCLUSION:EPAR is a feasible and safe option for popliteal artery aneurysms, providing good midterm patency with acceptable survival and reintervention rates in appropriately selected patients. Patency declines beyond 10 years; however, interpretation is limited by retrospective study design, low certainty of evidence, small number of studies with extended follow-up, and the use of earlier-generation devices and techniques. Therefore, prospective studies with standardised long-term outcome reports are needed.Clinical ImpactThis updated long-term analysis demonstrates that endovascular popliteal artery aneurysm repair (EVPAR) provides acceptable durability, with sustained secondary patency and limb preservation up to 15 years. Although primary patency declines over time, reinterventions effectively maintain graft function in selected patients. These findings reinforce EVPAR as a viable option in appropriately selected individuals, particularly those at high surgical risk or with favorable anatomy. Importantly, the study highlights the need for structured long-term surveillance and careful patient selection to optimize outcomes. Clinicians should balance minimally invasive benefits against the risk of late occlusion and tailor follow-up strategies accordingly.
PURPOSE:To analyse predictors of aortic complications (ACs) and outcomes of patients admitted for acute type B intramural haematoma (IMH-B). METHODS:A retrospective analysis of data of patients diagnosed with acute IMH-B from 7 French tertiary centres between December 2003 and December 2019 was conducted. Baseline demographics, initial anatomical features, indication and treatment modality during the acute phase including either thoracic endovascular aortic repair (TEVAR) and optimal medical therapy (OMT) or OMT alone were recorded. The primary endpoint was the occurrence of any AC during follow-up, defined as a composite criterion including aortic rupture, ulcer-like projection, aortic dissection or aneurysmal degeneration. Secondary endpoints included freedom from all-cause mortality and from aortic-related intervention. RESULTS:Eighty-one patients (52% male, median age 72 [62-77]) were included. Medical therapy initiated during the acute phase included more than 2 antihypertensive drugs in 39 (48%) patients. Nine patients (11%) underwent urgent (<24 hours) TEVAR for frank or impending rupture. Fourteen (19%) underwent TEVAR within 30 days for OMT failure. Of these, 8 were AC-related including 6 patients treated for rapid aortic growth. The overall 30-day mortality was 4.9% (n = 4), 2 patients died after TEVAR. The median follow-up was 34 months (7-53). Overall, 43 ACs occurred at a median time of 6 months (1-36). The 1- and 3-year estimate survival and freedom from AC were 88% (81-96) and 86% (78-95), and 60% (50-73) and 53% (42-67), respectively. By Cox regression analysis, previous aortic surgery (hazard ratio [HR] = 3.5 [1.2-10.3]; P = .025) and the maximum aortic true lumen diameter at admission (HR [per 1 mm increment] = 1.07 [1.02-1.13]; P = .009) were predictors of AC. CONCLUSION:After acute type B IMH, ACs are most prevalent within the first year, mandating close early clinical and imaging follow-up. Larger presenting aortic lumen maximum diameter is associated with increased likelihood of AC.Clinical ImpactIntramural haematoma (IMH) is a rare condition. While invasive treatment with thoracic stent-grafts has become the standard of care for complicated cases, treatment indications during the acute phase remain a matter of debate, and the natural history of the condition is not fully understood. This study, which included 81 patients with type B IMH (IMH-B), suggests that a presenting aortic lumen diameter greater than 27 mm and a history of aortic surgery are predictive for the risk of ACs after acute IMH-B, mandating closer imaging and clinical monitoring.
Despite significant progress in revascularization techniques, the vascular approach itself can still be a challenge in complex polyvascular disease. In this case report, we describe the feasibility of a potentially underutilized alternative vascular approach in a patient with multiple arterial occlusions who presented to our hospital with acute multivessel thromboses and chronic occlusions of the distal aorta and subclavian arteries, which rendered noninvasive blood pressure measurements unreliable. The patient also exhibited signs of heart failure with a severely reduced ejection fraction, likely due to ongoing ischemia, as the ventricles had not yet remodeled. To overcome the anatomical limitations safely, we used superficial temporal artery access for coronary angiography - an approach first described, to the best of our knowledge, by Csavajda et al. In addition, this access enabled angiography of the aorta and its branches, visualization of collateral flow, and invasive intra-aortic blood pressure measurement. Together with the possibility to better titrate medical therapy, this additional diagnostic information allowed us to plan aortocoronary bypass surgery with appropriate graft selection and ultimately contributed to improved patient outcomes.Clinical Impact:In complex polyvascular patients with multiple arterial occlusions, when standard femoral and radial access sites are not feasible and peripheral blood pressure measurements are unreliable, an alternative vascular approach through the superficial temporal artery for coronary angiography, aortography, and invasive blood pressure measurement can be safely utilized to improve diagnostic accuracy, therapeutic planning, and clinical outcomes. This illustrative case highlights the usefulness and safety of this vascular approach and demonstrates additional technical possibilities that can be achieved through its use.
Endovascular aortic repair (EVAR) has emerged as a popular option for minimally invasive treatment of abdominal and thoracic aortic aneurysms, offering advantages over traditional open surgical methods by reducing immediate postoperative morbidity and mortality. Although the endovascular repair option is attractive, it can potentially increase patient risks associated with x-ray exposure during the procedure, as significant levels of ionizing radiation are generated during preoperative diagnostic angiography, perioperative device placement, and lifelong follow-up imaging. For treatment of complex aortic aneurysms involving visceral vessels, radiation exposure during fenestrated stent-graft repair is typically double that of conventional unfenestrated stent-graft delivery and placement, which puts patients and clinicians at risk of reaching lifetime radiation limits and potentially developing cancer. To address this issue, a novel electromagnetic (EMAG) system has been developed and studied to potentially reduce radiation overexposure during the procedures by expediting a key step of the process, namely cannulation of fenestrations. The solenoid electromagnetic EMAG system embedded surrounding the ostia of the fenestrations attracts the magnetized tip of either a guidewire or catheter into a side branch, rapidly and selectively cannulating branch vessels in the aorta. The EMAG prototype was designed and fabricated with selective design requirements. A comparative study between the EMAG system and a standard guidewire demonstrated that the average time to cannulate with the EMAG system was 5.73 ± 2.67 seconds, which was significantly less than the average time taken to cannulate with the standard guidewire (34.37 ± 39.91 seconds, P < .01). In addition, the feasibility of the EMAG device was evaluated by characterizing its attraction force, dislodging force, and temperature rise. This device has the potential to reduce radiation exposure during EVAR procedures, offering a promising approach to improve patient safety in an increasingly common procedure.Clinical ImpactThe findings of this study demonstrate the feasibility of the EMAG system as a novel approach for assisting branch-vessel cannulation during fenestrated endovascular aortic repair. By advancing this technology through further preclinical and clinical studies, the EMAG system has the potential to improve workflow, enhance procedural consistency, reduce fluoroscopy dependence, and contribute to safer and more efficient complex endovascular interventions.
Background: Flow diversion (FD) requires perfect vessel wall apposition to optimize aneurysm occlusion rates and minimize complications. Objective: To elucidate the safety of an off-label technique using the Comaneci device for augmenting vessel wall apposition of distally deployed flow-diverting stents. Methods: Over a 20-month period, all FD cases for the treatment of aneurysms beyond the internal carotid artery terminus performed by the senior author were reviewed. Patient demographics, case characteristics, and procedural outcomes were collected and analyzed for cases involving both distal aneurysms and the use of the Comaneci device to augment vessel wall apposition. Results: Of 58 FD cases of distal aneurysms, the Comaneci device was required for vessel wall apposition in 16 cases (27%). Of these cases, the average patient age was 68.8 ± 8.4 years, and 13 (81%) were female. Average aneurysm size was 3.3 ± 1.1 mm. Comaneci device deployment and retrieval was successful in all (100%) cases. Procedures had an average fluoroscopy time of 38 ± 20.9 minutes, average contrast use of 37.9 ± 9.9 mL, and average radiation exposure of 1182 ± 458.3 mGy. Conclusion: This study demonstrates the safety and feasibility of a previously described technique for augmenting stent stenosis in proximal anterior circulation applied in distal anterior circulation aneurysms. Clinical Impact Incomplete vessel wall apposition of flow-diverting stents increases the risk of thromboembolic complications, in-stent stenosis, and treatment failure. In the distal circulation, techniques for improving apposition are limited due to anatomical tortuosity and vessel size. This series demonstrates the use of the Comaneci device as a safe and effective method for augmenting flow diverter apposition beyond the internal carotid artery terminus. This technique maintains endoluminal flow throughout remodeling, requires no exchange of the existing 0.027” microcatheter, and minimizes device burden, making it an efficient technique for clinicians.
Introduction: Acute limb ischemia (ALI) is a vascular emergency requiring prompt revascularization to prevent limb loss and death. Endovascular thrombectomy (ET) and catheter-directed thrombolysis (CDT) are the most commonly used strategies. Despite their increasing use, comparative effectiveness and safety remain unclear. This study aims to compare the clinical outcomes between ET and CDT in patients with ALI. Methods: This systematic review and meta-analysis followed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) 2020 guidelines and was registered in PROSPERO (CRD42024590036). A comprehensive literature search in scientific databases was conducted up to December 2024. Studies comparing ET and CDT in adult patients with ALI were included. Data were pooled using random- or fixed-effects models depending on heterogeneity. Sensitivity and publication bias analyses were performed. Results: Five retrospective studies with 495 patients (ET: 256; CDT: 206) were analyzed. No significant differences were observed between groups in terms of technical success (risk ratio [RR]=0.72, p=0.40), clinical success (RR=1.01, p=0.78), or limb salvage (RR=1.00, p=0.94). ET was associated with a longer procedure duration (mean difference [MD]=57.80 minutes, p=0.03) but shorter hospital stays (MD=−1.86 days, p=0.04). Major complications were lower in the ET group, the difference was not statistically significant (RR=0.63, p=0.15). Cost reporting was heterogeneous, suggesting a potential trade-off in which ET has higher upfront costs but shorter hospitalization. Conclusion: ET and CDT demonstrated comparable effectiveness in revascularization outcomes for ALI. ET may offer added benefits by reducing complication rates and shortening recovery time. The choice between interventions should take patient-specific factors into account. Clinical Impact This study supports the use of endovascular thrombectomy (ET) as an effective alternative to catheter-directed thrombolysis (CDT) due to its favorable safety profile, demonstrated by lower rates of major complications and shorter hospital stays. ET may be particularly suitable in patients with a high bleeding risk. However, individual patient anatomy and comorbidities remain critical determinants in treatment selection. Institutional factors and cost-effectiveness considerations also play important roles in determining the choice of intervention. Overall, both techniques ET and CDT are effective revascularization strategies for restoring arterial perfusion in acute limb ischemia.
BACKGROUND:The Barthel Index (BI) is a reliable tool for assessing the level of independence in activities of daily living (ADLs). Current risk stratification for chronic limb-threatening ischemia (CLTI) primarily focuses on anatomical severity and comorbidities, with less emphasis on functional status. Although several studies have examined its prognostic utility in patients with CLTI, the association between BI at admission and wound healing outcomes remains unclear, particularly in the context of multidisciplinary treatment strategies. METHODS:This retrospective single-center study included 187 patients (220 limbs) with CLTI and tissue loss who underwent endovascular treatment (EVT). Patients were stratified into 4 groups according to their BI at admission: total independence (TI, BI ≥ 85), partial independence (PI, BI: 61-84), partial assistance (PA, BI: 41-60), and total assistance (TA, BI: ≤ 40). The primary endpoint was wound healing rate, and secondary analyses examined major amputation and ADL recovery. RESULTS:Baseline disease severity and treatment characteristics were comparable among the 4 groups. Most patients showed functional improvement during hospitalization, except those with high baseline BI who already maintained good independence. However, patients in the TA group exhibited significantly lower 1-year wound healing rates compared with PA, PI, and TI groups. Major amputations were also more frequent in the TA group. Multivariable Cox regression analysis identified BI ≤ 40 at admission as an independent negative predictor of wound healing, suggesting limited responsiveness to standardized multidisciplinary care, including EVT and rehabilitation, in these patients. CONCLUSIONS:A lower BI at admission was associated with delayed wound healing and a higher risk of major amputation despite appropriate EVT. These findings highlight the clinical value of incorporating functional assessment into current risk stratification frameworks. Barthel Index assessment at admission is a simple and reliable prognostic indicator for patients with CLTI and may aid in early risk stratification and optimization of treatment strategies, including the consideration of the intensity of revascularization and rehabilitation efforts.Clinical ImpactThis study demonstrates that the Barthel Index, a simple and readily available measure of functional status, provides clinically meaningful prognostic information in patients with chronic limb-threatening ischemia beyond conventional assessments of disease severity. A low Barthel Index at admission identifies patients who remain at high risk for delayed wound healing and major amputation despite guideline-based multidisciplinary treatment, including endovascular revascularization. Incorporating the Barthel Index into the initial evaluation improves risk stratification, facilitates individualized treatment planning, optimizes rehabilitation and resource allocation, and supports shared decision-making.
