INTRODUCTION: Revascularisation of chronic juxtarenal aortic occlusions can present a complex challenge. While open repair remains the gold standard, endovascular therapy is increasingly used in high- risk patients. The role of catheter- directed thrombolysis (CDT) in chronic aortic occlusions remains unclear and might be underestimated in patients unfit for open revascularisation. METHODS: We conducted a narrative review of PubMed/MEDLINE and Embase for English- language studies from January 1, 2000, to January 31, 2025. Using MeSH and free- text terms for thrombolysis (e.g., catheter- directed thrombolysis, fibrinolysis, urokinase, tissue plasminogen activator) and chronic aortic/aroilial occlusion (including juxtarenal/infrarrenal anatomy), we included native chronic aortic or aortoiliac occlusions treated with CDT in revascularisation studies reporting technical and/or clinical outcomes. Case reports (<5 patients) were excluded. Outcomes assessed included technical success (thrombus reduction enabling definitive endovascular therapy), patency, and major complications. RESULTS: Five retrospective series were included, comprising 54 patients treated with CDT (urokinase or tPA) before endovascular aortoiliac revascularisation. All studies used CDT as an adjunct to endovascular revascularisation. Technical success rates ranged from 80 - 100%, with no 30- day mortality and low complication rates. Reported primary patency after definitive endovascular reconstruction was generally 85 - 100% at 1 year (83% at 18 months in one series), with limited longer- term follow- up. CONCLUSION: CDT may serve as a useful adjunct in the endovascular treatment of chronic juxtarenal aortic occlusions, particularly in high- risk patients. However, further prospective studies are needed to define its long- term efficacy and safety.
INTRODUCTION: Major lower limb amputation is often the last resort procedure for patients with advanced peripheral artery disease and is associated with substantial mortality. Preoperative biomarkers such as haemoglobin and albumin may provide valuable prognostic information by reflecting oxygen-carrying capacity, nutritional status and systemic inflammation. This study aimed to evaluate the association between preoperative haemoglobin and albumin levels and survival among patients undergoing major lower-limb amputation. METHODS: A retrospective single-centre study was conducted, including all patients who underwent major lower limb amputation between June 2016 and December 2023 at a tertiary vascular surgery centre. Preoperative haemoglobin and albumin levels were collected from medical records. Patients were stratified according to survival status during follow-up. Independent samples t-tests were used to compare mean values between groups. Cox proportional hazards regression was performed to identify independent predictors of mortality, adjusting for relevant comorbidities. RESULTS: A total of 585 patients were included (mean age 72±12 years; 66% male), with 61% of patients undergoing transfemoral amputation. During follow-up, 66 patients (11.3%) died. Mean preoperative haemoglobin and albumin levels were significantly higher among survivors (haemoglobin: 10.46 vs 10.06 g/dL p = 0.015; albumin: 3.25 vs 2.94 g/dL p = 0.019. In multivariable Cox regression analysis, cerebrovascular disease (HR 1.50 p = 0.003, congestive heart failure (HR 1.53 p = 0.007), atrial fibrillation (HR 1.49 p = 0.008), and haemoglobin (HR 0.93 per g/dL p = 0.048) were independently associated with mortality. As albumin levels were available for only 99 patients, albumin was analysed separately and showed a strong association with improved survival in univariable analysis. (HR 0.488 p = 0.001). CONCLUSION: Preoperative haemoglobin is an independent predictor of survival following major lower limb amputation, underscoring the importance of preoperative optimisation and risk stratification. Although albumin demonstrated a significant protective association in univariate analysis, further multivariable validation is required. Incorporating these biomarkers into perioperative assessment protocols may improve the identification of high-risk patients and guide targeted interventions.
Atherosclerotic renal artery stenosis (RAS) is a well-known cause of secondary hypertension and progressive renal insufficiency. In patients with a solitary functioning kidney, it is uncommon but high-risk, posing a dilemma between revascularization and medical management. Revascularization is usually reserved for selected high-risk cases. We report a 54-year-old woman with hypertension, prior ischemic heart disease, superficially invasive squamous cell carcinoma of the cervix, and a solitary functional kidney, who was admitted with acute renal failure and recurrent episodes of flash pulmonary edema. CT angiography revealed occlusion of the left renal artery and severe stenosis of the right. Angioplasty and stent placement in the left renal artery restored blood flow, leading to recovery of renal function and adequate blood pressure control. Renal revascularization can improve blood pressure, renal function, and cardiovascular profile. Despite trials such as STAR, ASTRAL, and CORAL not showing overall benefit over medical therapy, international guidelines recommend considering revascularization in selected high-risk patients. This case illustrates that endovascular revascularization can be effective in patients with a solitary kidney and severe RAS, emphasizing the importance of a multidisciplinary, individualized approach to optimize clinical outcomes.
INTRODUCTION: Medical registries are key tools for monitoring healthcare quality. In 2019, the Portuguese Society of Angiology and Vascular Surgery (SPACV) launched the Registo Nacional de Procedimentos Vasculares (RNPV), to collect nationwide data on vascular surgical procedures within the Portuguese healthcare network. The initial chapter focused on abdominal aortic aneurysms (AAAs) and has been in existence for five years. The value of interpreting such data is directly tied to its validity and completeness. Therefore, we aim to present the findings of the first internal validation of the RNPV- AAA module. METHODS: Four of the 20 institutions included in the RNPV were visited by three independent validators. Data from procedures performed between 2021- 2022 for AAA were evaluated. Registry data from 27 variables of 15 randomly selected cases per centre were compared with data from individual patient records for internal validation. The primary endpoint was internal validity. Secondary endpoints were data discrepancy and missing data. RESULTS: Sixty AAA cases across 4 institutions, totalling 405 data fields per centre and 1620 data fields across all cases, were compared with the original registration. An internal validity of 96.0% was observed. Overall, 1.1% data fields were missing, and 3.0% of data discrepancies were observed. Baseline characteristics (4.6%) presented the highest rate of mismatch, followed by procedure- related (3.6%) and outcome data (1.4%). Mismatch was more common in continuous data, with 15.0% mismatch in pre- operative creatinine and 16.7% in the largest aortic diameter. Follow- up data (not included in this internal validation) were missing in up to 54% of patients. CONCLUSION: The first validation of the RNPV- AAA chapter revealed reassuring results with a high degree of correspondence. Although conducted across a comprehensive set of variables, the missingness in long- term data remains noteworthy. Continuous data are more likely to be related to mismatched records, though the clinical implications are uncertain. Further external validation is anticipated.
INTRODUCTION: Covered Endovascular Aortic Repair (CERAB) has previously been shown to be a viable treatment option for patients with aortiliac occlusive disease. However, data reporting on the technique is still scarce, and durability remains a concern. The aim of this study was to conduct a descriptive analysis of our experience and to evaluate the outcomes of CERAB over the last 10 years. METHODS: A retrospective, single- centre cohort study was conducted. From April 2015 to February 2025, we included all consecutive patients who underwent CERAB for aortiliac occlusive disease. Outcomes were defined as primary patency rate, freedom from clinically driven target lesion revascularisation, and amputation- free survival at 12 and 36 months. Major adverse events were defined as a composite of myocardial infarction, stroke, bowel ischemia, respiratory insufficiency, acute limb ischemia or access- related complications. RESULTS: A total of 23 patients (65%)(65%) male) were included, with a mean age of 60.7 years (±10.2)(±10.2) . The most common clinical presentation was Rutherford classification grade 5 chronic ischemia (44%)(44%) , and the majority (87%)(87%) had Transatlantic Inter- Society Consensus II (TASC II) D lesions. Technical success was achieved in 100%100% of cases. Major adverse events at 30 days were observed in 39%39% , with access- related complications the most common (17%)(17%) . The median hospital stay was six days (range 3.0- 15), and 30- day mortality occurred in one case. The median follow- up was 27 months (4.6- 62.1). The primary patency rate was 84%84% and 77%77% at 12 and 36 months, respectively. The target lesion revascularisation freedom rate was 85%85% at 12 and 36 months, while the major amputation- free survival rate was 89%89% at the same time points. CONCLUSION: The CERAB technique appears to be a feasible option for patients with extensive aortiliac occlusive disease, including TASC II D lesions, demonstrating high technical success. Despite the small sample size, good mid- term outcomes were observed in a clinical and anatomically complex group of patients.
Background: The anatomical complexity of the aortic arch poses significant challenges to its repair, particularly in high-risk patients. The introduction of branched endografts, specifically designed to overcome these challenges, has revolutionized this field as demonstrated in the present case-report. Report: A 60-year-old male, with a prior history of smoking and neurosyphilis, was referenced to our outpatient clinic due to a CT finding of a 66mm aortic arch aneurysm with complex anatomical features, including a short brachiocephalic trunk and narrow iliac arteries. Thus, a staged hybrid approach was meticulously planned. The patient was initially submitted to a left carotid-subclavian bypass, followed by a right subclavian-carotid bypass. Later, an endoconduit was constructed using two GORE-Viabahn® stent grafts (11x100mm), deployed in the left common and external iliac arteries, facilitating subsequent TEVAR. Finally, the aneurysm was excluded using a custom-made Terumo-Relay® double inner-branched endograft (46x32x270mm) deployed in zone 0, with two inner branches for the brachiocephalic trunk (BCT)/right subclavian artery (RSA) and left common carotid artery (LCCA). The inner branches were catheterized via trans-carotid (left) and trans-axillary (right) accesses. An iliac extension GORE-Excluder® (16x12x100mm) to the BCT/RSA and a GORE-Viabahn® stent graft (7x75mm) to the LCCA were deployed. An additional extension endograft (34x30x150mm) was deployed to complete distal exclusion. The left subclavian artery was subsequently occluded using a vascular plug. Postoperatively, the patient experienced a minor posterior circulation stroke, with full recovery within two weeks. Six-month follow-up imaging showed patency of the endografts with complete exclusion of the aneurysm and no evidence of endoleaks. The patient remained asymptomatic, with no further vascular or neurological events. Conclusion: This case highlights the feasibility of a staged hybrid approach for complex aortic arch aneurysms in patients with challenging anatomy. The use of a custom-made endograft and careful preoperative planning proved critical to the success of the procedure.
Background: Aneurysmal sac growth is a major concern after endovascular aortic repair (EVAR) and the main reason for reintervention. Despite timely diagnosis and intervention, some cases of persistent sac growth warrant further investigation, namely for less frequent etiologies. Report: We report the case of a 68-year-old male patient referred to the Vascular Surgery outpatient clinic due to an asymptomatic 71mm infrarenal abdominal aortic aneurysm. He has a history of heavy smoking habits, severe chronic obstructive pulmonary disease and a previous prostatectomy and local radiotherapy. Due to favorable anatomy and a high surgical risk for open repair, he underwent an aorto-bi-iliac EVAR in 2019. One year follow-up showed no endoleaks nor sac growth. In 2024, due to a significant sac diameter growth to 91mm, an urgent CT angiogram showed loss of proximal sealing and type II endoleak. Based on these findings, a custom-made fenestrated cuff was designed and implanted. Despite adequate sealing, with no evidence of target vessel complications, the patient was admitted in the emergency room 5 months after the reintervention with de novo abdominal and lumbar pain along with frank leukocytosis and an increase in C-reactive protein levels. Urgent CT angiography showed a 105mm diameter sac and periaortic densification, with apparent type II endoleak. The patient was put empirically on meropenem and linezolide. An urgent open conversion was performed with graft preservation and thrombus removal, and sac wrapping. Mycoplasma hominis was isolated from the aneurysm sac and thrombus and the patient was discharged on levofloxacin and doxycycline. One month follow-up showed no signs of recurrence. Discussion: In the absence of clear sources of endoleak, infection may be the cause for over 20% of occult sac growth. In frail patients such as this case, sac evacuation and wrapping may be an alternative approach to graft explantation.
BACKGROUND: Although the traditional standard of care for aortic arch aneurysms is open surgical arch replacement, this approach usually requires sternotomy, cardiopulmonary bypass and hypothermic arrest. Even among the subset of patients fit for open surgery, it is associated with a pooled mortality and stroke rate of around 5%. Nowadays, a multidisciplinary team of vascular and cardiac surgeons is mandatory to determine the best, individualised treatment for each patient. CASE REPORT: A 70-year-old male was incidentally diagnosed with an asymptomatic saccular aortic arch aneurysm. After a discussion with vascular and cardiac teams, a total endovascular arch repair was decided. Percutaneous access was obtained to the right femoral and axillary arteries, the left brachial artery, and the left femoral vein. Only the left carotid artery was surgically exposed. A Cook custom-made three-inner-branched stent graft was deployed under temporary inferior vena cava occlusion. Two anterograde branches for the innominate trunk (bridged with a 12 mm-diameter iliac limb) and the left carotid artery (bridged with a 6 mm Bentley Begraft balloon-expandable covered stent), and a retrograde branch with a preloaded catheter for the left subclavian artery (bridged with a 10 mm Gore Viabahn self-expandable covered stent, relined with a 10 mm Bentley Begraft due to a kink) were implanted. The procedure was successfully completed, and the patient was discharged after three days. Computed tomography angiography at three months demonstrated aneurysm exclusion, patency of the three supra-aortic branches and absence of cerebral ischemic lesions. CONCLUSION: In the elective setting, a triple-branch custom-made device enables total endovascular arch repair without the need for surgical revascularisation, thereby reducing invasiveness and morbidity, even in non-high-risk patients with suitable anatomy. A third branch also allows upper-extremity access for future visceral branch endovascular interventions.
Introduction Spinal cord ischemia (SCI) is an infrequent distressing complication following thoraco-abdominal (TAAA) and complex abdominal aortic aneurysm (CAAA) repair. Prior studies showed controversial results regarding risk factors and preventive measures. We aim to analyze the incidence of SCI after endovascular treatment of complex aortic aneurysms in our center and perform a descriptive analysis. Methods Single-center retrospective study conducted in a tertiary care center including all patients with a TAAA or CAAA who underwent endovascular repair using a fenestrated/branched endograft from June 2010 to February 2025. Patient characteristics, peri-procedural and follow-up data were obtained. SCI was defined according to the Society for Vascular Surgery reporting standards as new-onset motor or sensitive deficits after endovascular treatment. Results 145 patients (91% male, mean age 71±6 years) were included, of which 59 (41%) had degenerative TAAAs (types I-V) and 57 (39%) CAAAs. Mean aneurysm diameter was 66±14mm. A prophylactic cerebrospinal fluid drainage (CSFD) was preoperatively placed in 61 patients (42%). Total incidence of SCI was 8% (12/145): minimal sensory deficits in 33% (4/12), paraparesis in 8% (1/12) and paraplegia in 59% (7/12). Most patients (83%, 10/12) presented with delayed SCI. After symptom onset, 58% of patients (n=7) required rescue CSFD. Regarding patients with grade 3 SCI (n=7), a complete recovery was observed in 3 patients, 1 patient experienced partial recovery and 3 did not recover. No differences concerning prior aortic surgery, internal iliac artery patency, procedural staging or preoperative CSFD placement were found between SCI and no-SCI patients. Conclusion In this study, SCI manifested mostly as a delayed event. Prophylactic CSFD may prevent permanent injury. The small sample size could hinder the investigation of more robust findings. Despite several risk factors and preventive measures having been identified, the best preventive approach is still lacking. Further studies are required to prevent this devastating complication.
INTRODUCTION: Subintimal angioplasty is an endovascular technique used to recanalize occluded segments in the arterial bed that cannot be crossed via an intraluminal path. However, there is still limited data regarding the clinical outcome of subintimal angioplasty. The aim of this study is to evaluate the impact of subintimal angioplasty in femoro-popliteal lesions. METHODS: This is a retrospective, single-centre, comparative study. From January 2023 to February 2025, all patients with chronic lower limb ischemia due to femoro-popliteal arterial lesions who underwent endovascular treatment as a first revascularisation procedure were considered. Patients were grouped according to the cross-lesion pathway: the subintimal cross-lesion group (S group) and the intraluminal cross-lesion group (L group). Both groups were compared with respect to the atherosclerotic disease pattern, and the primary endpoints were the rates of reintervention and amputation. RESULTS: The study included 95 patients, of whom 10% (n = 9) presented with intermittent claudication and 90% (n = 85) with chronic limb-threatening ischaemia. The median follow-up time was nine months. The S group included 30% (n = 28) of the patients and L group included 70% (n = 67). The median femoro-popliteal GLASS classification was 4 in both groups, but this GLASS stage was more common in S group (p = 0.004). Severe calcification (p < 0.001) and bailout stenting (p < 0.001) were more common in the S group. Regarding the primary endpoints, no statistically significant differences were found between groups in rates of reintervention (p = 0.95) and amputation (p = 0.26) at 12 months of follow-up. CONCLUSION: Our results suggest that the clinical outcomes of subintimal angioplasty are similar to those of intraluminal angioplasty, with comparable limb outcomes in patients with femoro-popliteal lesions. These findings may support adopting a lower threshold for subintimal crossing in calcified and complex lesions, as it can achieve good results with comparable outcomes to the intraluminal angioplasty.
Background: Around 40-60% of abdominal aorta aneurysm (AAA) patients are deemed to be outside the instructions for use (IFU) for endovascular aneurysm repair (EVAR) because of hostile anatomy. Short and angulated necks pose a serious risk of type IA endoleak due to the difficulty in achieving proper proximal fixation and endograft seal. Report: A 72-year-old male with a history of dyslipidemia and smoking was admitted to the vascular ward with a diagnosis of an AAA with 85-mm in diameter. The patient had recently undergone a Hartmann procedure for transmural ischemic colitis. Despite suboptimal anatomy for EVAR, including a short proximal neck (13 mm) and severe infrarenal angulation (90°), endovascular repair with the Endurant II stent graft was performed, using the reverse slider technique. The procedure was technically successful, with angiography confirming proper graft fixation and aneurysm exclusion. Follow-up Computed Tomography Angiography at one month demonstrated correct positioning of the endograft with no evidence of endoleak. Conclusion: The reverse slider technique allows proximal sealing in short and angulated neck aneurysms. It involves the repeated rotation of the external slider in the reverse direction, accompanied by gradual deployment of the suprarenal stent, allowing the proximal edge of the endograft to gradually expand, progressively approaching the contralateral side of the aortic wall.
INTRODUCTION: Secondary implantation of iliac branch devices (IBDs) after endovascular aortic repair (EVAR) for type Ib endoleak poses unique technical challenges due to altered aortoiliac anatomy and prior femoral access. Selecting an optimal access strategy is critical to minimize complications and ensure procedural success. This review summarizes contemporary transfemoral and upper extremity access techniques, with a focus on modern endovascular solutions that facilitate safe and effective reinterventions. METHODS: A narrative review of the literature published between 2010 and 2025 was conducted using PubMed, focusing on studies reporting technical strategies, outcomes, and complications of secondary IBD implantation after EVAR. Only original research, including technical notes, was included. RESULTS: Across the reviewed studies, upper extremity access was associated with neurologic events, longer operative times, and higher access-site complication rates. Transfemoral "up-and-over" techniques consistently demonstrated technical success rates over 95%, shorter procedural times, and reduced complication rates. Steerable sheath systems enable complete IBD implantation from a single femoral access, with promising safety and efficacy. Technical refinements, including special attention to the prior graft bifurcation and meticulous technique, appear to be key elements to optimising immediate and late outcomes. CONCLUSION: Transfemoral strategies, particularly "up-and-over" techniques using steerable sheaths, appear to be safe and effective alternatives to upper-extremity access for secondary IBD implantation following EVAR. Access strategy should be tailored to patient anatomy and prior graft configuration, with emphasis on minimising vascular trauma, neurologic risk, and procedural complexity.
BACKGROUND: Popliteal Artery Entrapment Syndrome (PAES) is an uncommon but important cause of lower limb ischemia affecting young, active individuals without traditional atherosclerotic risk factors. The condition has an estimated prevalence of 0.17–3.5% in the general population and accounts for approximately 3–5% of claudication cases in patients under 40 years without atherosclerotic risk factors. PAES results from abnormal anatomical relationships between the popliteal artery and surrounding structures, causing compression and intermittent claudication. Early diagnosis is crucial to prevent complications such as thrombosis, aneurysm formation, or irreversible ischemia. CASE REPORT: A 36-year-old previously healthy male presented with right lower-limb claudication, limiting walking to less than 100 metres. Physical examination revealed absent right distal pulses, and Doppler ultrasound showed a peak systolic velocity of 400 cm/s in the right popliteal artery, corresponding to 90–99% stenosis. Magnetic resonance angiography confirmed type 3 PAES with sub-occlusive popliteal artery stenosis. Surgical treatment comprised myotomy of the lateral accessory head of the medial gastrocnemius muscle and popliteal artery interposition grafting from P1 to P3 using the contralateral inverted great saphenous vein via a posterior approach. The patient recovered uneventfully, with restored distal pulses, and remained symptom-free at one-year follow-up. CONCLUSION: This case highlights the importance of considering PAES in young patients presenting with claudication without atherosclerotic risk factors. Successful surgical management demonstrates that timely intervention yields excellent functional outcomes. The case emphasises the need for greater PAES awareness among healthcare providers, as early recognition and intervention improve patient outcomes and reduce the long-term burden of undiagnosed vascular disease.
