Objective To share the diagnosis and treatment outcomes of brucellar aortoiliac aneurysms (BIAAs) from two large vascular surgery centres in China, and to describe the clinical characteristics and prognosis of different treatment regimens. Methods A retrospective analysis was performed on the demographic, clinical, and follow up data of 15 patients with BIAAs admitted to the Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, and Beijing Hospital between May 2019 and June 2025. Results Among the 15 patients, 14 were men and one was a woman; 12 had a history of contact with sheep or their faeces. Lumbar/abdominal pain and fever were the most common clinical manifestations. The positive rate of Brucella Rose Bengal Test (RBT) was 100% (15 of 15), the positive rate of blood culture was 40% (6 of 15), and the positive rate of intra-operative tissue culture was 11% (1 of 9). All 15 patients completed follow up with a mean follow up duration of 32.93 ± 22.61 months, and the survival rate was 93% (14 of 15). Five patients who received endovascular treatment had a good prognosis, five patients who underwent open surgery achieved satisfactory curative effects, one patient who received conservative treatment remained stable, and four patients who received endovascular treatment developed severe complications and infection recurrence, among whom one died despite rescue efforts. Conclusion BIAAs are clinically rare and highly dangerous. Open surgery based on anti-Brucella therapy remains the preferred radical treatment option in clinical practice, and endovascular treatment can be used as an alternative in specific emergency cases. It should be noted that this study had a small sample size, and the comparison of different treatment methods was mainly descriptive, with certain limitations.
Introduction The use of retrograde branches during endovascular aortic arch repair in chronic dissections has been associated with endograft lumen compression in the distal arch true lumen. This results in a functional pseudocoarctation, which carries a risk of cardiac failure. Technique This exemplar case presents a patient treated with a three-branch arch endograft for an anastomotic false aneurysm and a residual chronic arch dissection extending to the supra-aortic trunks. To overcome device compression, a kissing angioplasty of the endograft and the left common carotid artery branch was performed after achieving wire access to the left subclavian artery. This manoeuvre successfully disrupted the distal arch lamella while securing the left common carotid artery bridging stent and maintaining access to the left subclavian artery. Discussion This technique is now routinely performed in all patients presenting with chronic aortic dissections. In the authors’ limited recent experience with short-term follow up, no instances of cardiac failure secondary to endograft lumen narrowing have been observed since implementing this manoeuvre. It appears to be a feasible and effective method for overcoming endograft lumen compression and its associated complications.
Introduction Type II endoleaks (T2ELs) are a common finding after endovascular aortic repair (EVAR), often caused by retrograde flow from the inferior mesenteric artery (IMA). Although transarterial embolisation is standard, laparoscopic IMA ligation may provide a definitive alternative in selected cases. Indocyanine green fluorescence angiography (ICG-FA) adds real time vascular visualisation, helping the identification and confirmation of successful ligation. This report illustrates the potential benefit of Indocyanine green guided laparoscopic IMA clipping for managing T2ELs. Technique The case of a 69 year old man with an abdominal aortic aneurysm who underwent emergency EVAR for a ruptured left iliac artery aneurysm is presented. At two year follow up, computed tomography angiography revealed a persistent T2EL originating from the IMA, resulting in abdominal aortic aneurysm growth. Given the aneurysm’s progression, laparoscopic IMA clipping using ICG-FA was performed. The IMA was identified, and ICG-FA was used to confirm its precise location before applying ligation clips to occlude the vessel. Successful exclusion was further confirmed with repeated ICG-FA. Post-operative recovery was uneventful, and no endoleaks were detected on follow up imaging (computed tomography angiography). Discussion ICG-FA laparoscopic clipping of the IMA may offer a safe and effective treatment option in selected cases for persistent T2ELs after EVAR. Compared with endovascular options, it allows direct exclusion of the inflow vessel with real time visual confirmation. ICG-FA can provide real time functional imaging of vascular perfusion, enabling intra-operative identification of the IMA and objective confirmation of successful vessel occlusion. Its integration is practical, widely accessible, and may increase the safety and confidence of laparoscopic IMA ligation in selected patients.
Introduction Extracranial internal carotid artery pseudoaneurysms are well recognised; however, those large enough to cause airway or oesophageal compression are exceedingly rare. Surgical management of complicated lesions remains difficult and is often accompanied by significant potential for adverse events. Report Two patients were diagnosed with extracranial internal carotid artery pseudoaneurysm presenting with airway and oesophageal compression. Both were successfully treated by surgical excision and revascularisation of the internal carotid artery. Post-operative recovery was uneventful in both patients, with no complications observed. Discussion Extracranial internal carotid artery pseudoaneurysm should be detected and treated early in cases of rapid progression or when complications are present. Surgical excision of the pseudoaneurysm combined with revascularisation provides a definitive solution to the lesion and represents a relatively safe approach.
Background Thoracic endovascular aortic repair (TEVAR) is widely used for thoracic aortic diseases, most commonly with a proximal landing in Ishimaru zone 3. When an adequate proximal sealing zone is lacking, extension into zone 2 is required, often necessitating left subclavian artery (LSA) revascularisation. The Castor single branched stent graft provides a fully endovascular solution for zone 2 TEVAR by incorporating an antegrade branch for the LSA. This study reports a single centre Western experience with this device. Method A retrospective analysis was conducted on 15 consecutive patients undergoing elective zone 2 TEVAR with the Castor single branched stent graft between July 2023 and December 2025. Indications included thoracic aortic aneurysm, subacute or chronic Stanford type B dissection, and penetrating aortic ulcer. The primary endpoint was technical success, defined as accurate deployment without type I or III endoleak and with preserved LSA patency. Secondary endpoints included clinical success, access related complications, intensive care unit (ICU) and hospital stays, re-intervention, and death. Follow up consisted of serial computed tomography angiography. Results The mean age was 63.9 ± 11 years, and 87% of patients were men. Technical and clinical success were achieved in 14 patients (93%). One patient required adjunctive covered stenting of the LSA for incomplete branch expansion. There were no access related complications or 30 day deaths. Mean ICU and hospital stays were 1.2 ± 0.6 days and 15.3 ± 9.6 days, respectively. Over a mean follow up of 13.5 ± 8.4 months, all LSA branches remained patent, with no endoleak, device migration, or re-intervention. Conclusion Zone 2 TEVAR using the Castor single branched stent graft appears feasible, safe, and effective in a Western population. In this small elective series, LSA branch patency was maintained and no device related re-intervention occurred during available follow up. Larger studies with longer follow up are needed to assess durability and longer term outcomes.
Objective To evaluate the ethics of introducing the Endo-Bentall (a novel high risk procedure) in the context of compassionate care and to make practical recommendations to support its incorporation into practice. Methods A seven step ethical framework was systematically applied to three clinical vignettes involving the Endo-Bentall procedure. Ethical issues identified across cases were synthesised and used to develop practical recommendations for clinical practice. Results Decision making regarding the Endo-Bentall procedure is challenging in the absence of robust outcome data. Patients amenable to treatment represent a highly heterogeneous population, with a high degree of variability in procedural risk, likelihood of technical success, consequences of failure, and uncertainty of long term durability. Despite this, ethical justification may be achievable in carefully selected cases where anticipated benefits proportionately outweigh risks, particularly in the context of otherwise limited therapeutic alternatives. Conclusion Ethical implementation of the Endo-Bentall procedure is possible in select patients. However, structured safeguards are necessary. These include enhanced informed consent processes with explicit disclosure of the learning curve, limited validation, and unknown long term outcomes; mitigation of potential conflicts of interest through independent or external case review; formal oversight mechanisms despite its classification as compassionate or innovative care; and integration within a learning health system framework with ongoing data reporting and outcome monitoring.
Introduction:Visceral artery aneurysms (VAAs) and isolated mesenteric and renal artery dissections (IMAD and IRAD) are uncommon conditions with unclear natural histories and uncertainties due to the lack of level 1 evidence guiding optimal management. This study was part of the European Visceral Artery Revascularisation (EVisAR; ClinicalTrial.gov NCT06913530) study initiative. A single round, international, cross sectional online survey, in compliance with the Checklist for Reporting of Survey Studies (CROSS), was conducted to assess current heterogeneity for the management of VAAs, IMAD, and IRAD across Europe. Method:EVisAR physicians were invited and surveyed with questions on caseload, diagnostic pathways, treatment indications and strategies, and follow up protocols. Responses were analysed descriptively, and inter-physician agreement was estimated with the Fleiss κ method. Results:A total of 54 physicians completed the survey (of 107 invited); 98% were vascular surgeons from 12 European countries and one from Australia. Institutional caseloads were low (fewer than ten cases/year) for both conditions. Aneurysm size thresholds for intervention varied depending on the location, with 2 - 3 cm being common for several arteries and an agreement for a 3 cm threshold for renal and splenic artery aneurysms (74% and 65%, respectively). Endovascular intervention was the preferred approach for VAAs and dissections (98%). Initial IMAD management largely depended on clinical status and most frequently included triple medication (antihypertensive, anticoagulant, and antiplatelet, 68%), fasting (63%), monitoring of biomarkers for intestinal ischaemia (89%), and a second scan at one to three days (63%). Overall agreement on management was moderate for VAA (κ = 0 .41) and IMAD and IRAD (κ = 0.40). For both, the lowest agreement was observed for follow up indications (κ = 0.03 and κ = 0.32, respectively). Conclusions:Current management shows substantial heterogeneity and a lack of consensus, particularly concerning long term surveillance and specific therapeutic approaches, although endovascular interventions seem to be the preferred strategy. These findings underscore the urgent need for high quality data and support the ongoing need for the EVisAR study.
Introduction: Carotid free floating thrombus is a rare vascular condition associated with a high risk of early cerebral embolisation. It may occur in the absence of significant carotid stenosis, which complicates therapeutic decision making. Owing to its rarity, optimal management remains controversial, with both medical and surgical strategies described. Report: A 66 year old woman presented with transient right upper limb paraesthesia consistent with a transient ischaemic attack. Computed tomography angiography and duplex ultrasound revealed a mobile free floating thrombus measuring 16–18 mm in the proximal left internal carotid artery, without associated stenosis, plaque ulceration, or dissection. Neurovascular imaging demonstrated a patent circle of Willis and normal intracranial perfusion. Given the thrombus mobility and recent neurological symptoms, urgent surgical thrombectomy was performed under general anaesthesia with cerebral monitoring. The thrombus was removed en bloc without complications. Post-operatively, the patient was treated with anticoagulant and statin therapy. At one year follow up, she remained asymptomatic, with imaging confirming sustained carotid patency and no recurrent thrombus. Discussion: This case highlights that carotid free floating thrombus can present without underlying carotid stenosis and still pose a significant embolic risk. Thrombus morphology, clinical presentation, and cerebrovascular anatomy are key factors guiding management. In selected symptomatic patients with favourable collateral circulation, urgent surgical thrombectomy may represent a safe and effective therapeutic option. Careful post-operative antithrombotic management and imaging surveillance remain important components of overall care.
Introduction:Venous thoracic outlet syndrome (vTOS) results from compression of the axillary or subclavian vein and may present with acute upper limb deep vein thrombosis. Catheter directed thrombolysis followed by decompression is widely performed but carries bleeding risk and may delay definitive surgery. Mechanical thrombectomy offers a lysis free alternative. This study aimed to assess early outcomes of mechanical thrombectomy followed by urgent surgical decompression in vTOS patients. Method:This paper reports a retrospective single centre case series of patients with vTOS treated with Penumbra Indigo (Penumbra Inc., California, USA) mechanical thrombectomy followed by urgent surgical decompression between January 2025 and February 2026. Results:Four patients (ages 17, 27, 42, and 35 years) underwent successful thrombectomy between one and 21 days after the deep vein thrombosis but within one and six days from referral, followed by first rib decompression within zero to four days. All patients achieved full resolution of symptoms and technical success, evident on follow up venograms, with restoration of central venous flow and no major complications. Conclusion:Early experience suggests that mechanical thrombectomy followed by urgent decompression is feasible and safe in selected patients with acute vTOS. Larger studies with longer follow up are required.
Introduction:Femoropopliteal bypass surgery (FPBS) is a standard surgical procedure but is still associated with complications, especially surgical site infections and groin seromas. This feasibility study aimed to investigate whether endoscopic, robot assisted surgery enabled FPBS with minimal surgical trauma and without a groin incision. Method:The da Vinci single port (SP) system (Intuitive Surgical, Sunnyvale, USA) was used to perform the novel technique of endoscopic FPBS on fresh frozen cadavers. For this novel technique, a 4 cm incision was made in the distal third of the medial thigh for supragenicular exposure of the proximal femoral artery. Thereafter, an end to side anastomosis between the common femoral artery and a polytetrafluoroethylene (PTFE) graft was performed endoscopically with the da Vinci SP system. Success of the procedure was defined by completion of the proximal bypass anastomosis and the avoidance of injuries to anatomic key structures. First evaluation of the technique was performed by assessment with a slightly modified Northwestern Objective Microanastomosis Assessment Tool (NOMAT) score. Results:Two proximal bypass anastomoses were successfully sutured without injury to the five pre-defined key anatomic structures. Skin to skin complete duration of the intervention including removal of the robotic system was 105 minutes and 92 minutes, respectively. The modified NOMAT score representing the efficiency of surgical handling and quality of the anastomosis was 29 of 45 and 37 of 45, respectively. Conclusion:The current study demonstrates that endoscopic, robot assisted FPBS was feasible within an acceptable timeframe and without injury to key anatomic structures. Further clinical development of endoscopic FPBS could enable minimally invasive bypass surgery including the advantages of conventional surgery but avoiding its limitations.
Introduction:This case report presents a 49 year old man with chronic limb threatening ischaemia (CLTI) and seronegative rheumatoid arthritis who presented with ischaemic foot ulcers, rest pain, and severely impaired pedal circulation. Imaging revealed occlusions of the dorsalis pedis, common plantar, and medial plantar arteries, with no visualised perfusion around the foot wounds, classifying the case as no option CLTI in which conventional revascularisation was deemed unfeasible. Report:The lateral plantar artery was barely visualised and measured 0.4 mm in diameter, initially considered too small for bypass. As a bridging strategy in an initially deemed no option situation, viscosity intervention using Rheocarna (Kaneka Medix Corporation, Osaka, Japan), a selective apheresis system designed to reduce low density lipoprotein cholesterol and fibrinogen via double plasma filtration, was initiated with the expectation that it would improve rest pain and wound condition, and potentially sufficiently enhance pedal microcirculation to enable bypass surgery. Following this intervention, the patient exhibited improvements in wound size, rest pain, and circulatory status. Notably, ultrasound revealed an increase in diameter of the lateral plantar artery to 0.8 mm, after which bypass to this artery became technically feasible. Discussion:The combined approach of pre-operative viscosity intervention and subsequent pedal bypass surgery resulted in marked improvement in pedal perfusion and complete wound healing. The patient regained ambulatory function and returned to daily life. This case highlights the potential of viscosity intervention with Rheocarna as an adjunctive pre-operative strategy to convert no option CLTI into operable cases by optimising pedal circulation status.
Introduction:Non-anastomotic rupture of a vascular prosthesis is an extremely rare complication in the late post-operative period. Modern gelatine coated woven Dacron grafts have demonstrated excellent long term durability and resistance to intrinsic degeneration. However, they remain susceptible to physical damage resulting from sustained mechanical irritation by surrounding hard tissues. A life threatening case of graft perforation caused by direct contact with a remnant calcified aortic wall 11 years after abdominal aortic aneurysm repair is reported. Report:An 82 year old man, who had undergone bifurcated graft replacement (18 × 10 mm) (Gelsoft, Terumo Corporation, Tokyo, Japan) for abdominal aortic aneurysm 11 years earlier, presented to the emergency department with sudden abdominal pain and haemorrhagic shock. Contrast enhanced computed tomography revealed contrast extravasation into a new pseudo-aneurysm surrounding the right graft limb. Emergency exploratory laparotomy was performed. Intra-operative findings identified a pinhole perforation on the body of the right graft limb, distinct from the anastomotic sites. The perforation was in direct contact with a sharp, calcified lesion on the dorsal aspect of the remnant aneurysm wall that had been used for wrapping during the initial surgery. The defect was successfully repaired with direct sutures, and the surrounding sharp calcification was debrided. The patient was discharged on post-operative day 15 without complications. Discussion:The mechanism of injury was attributed to physical fraying of polyester fibres caused by repeated mechanical friction against the sharp calcified intima over a decade. Previous experimental studies support that pulsatile contact with hard tissues can physically disrupt woven Dacron fibres. Sharp calcified lesions should be removed, or cushioning material should be interposed between the graft and the aortic wall during the initial repair. This case highlights the need for long term morphological surveillance to assess the spatial relationship between the graft and calcified remnants, even in the very late post-operative phase.
Introduction: The study investigates the effectiveness of a newly developed halloysite coated haemostatic gauze (haemostatic gauze (HG), SpeedM) compared with kaolin coated QuikClot Combat Gauze (CG) in a standardised lethal porcine model of arterial haemorrhage. The study aimed to evaluate halloysite's potential as a novel haemostatic agent for traumatic bleeding treatment. Method: Twenty-one anticoagulated pigs underwent a standardised femoral artery injury under anaesthesia. The animals were randomised to treatment with either HG (n = 10) or CG (n = 11). After a five minute compression at 200 mmHg, haemostatic performance was assessed based on primary haemostasis, need for secondary application, haemodynamic stability, and survival over a sixty minute observation period after returning to baseline. Results: Both products achieved primary haemostasis under controlled conditions. Secondary application defined as primary failure was needed in 10% of HG (n = 1) and 18% of CG (n = 2) but without fatality. The mortality rate owing to unstoppable bleeding defined as final failure was lower in the HG group (10%, n = 1) than in the CG group (27%, n = 3). One death occurred in each group before a mean arterial pressure ≥60 mmHg was reached. The other two of the three CG fatalities occurred at a mean arterial pressure >60 mmHg. Conclusion: Although no statistically significant differences were observed between HG and CG regarding mortality (p = .59) or re-application rates (p = 1.0), the unique physicochemical properties of halloysite may warrant further investigation in future adequately powered studies.
Introduction:Endovascular aortic repair (EVAR) is the standard of care for abdominal aortic aneurysms owing to its minimally invasive nature and favourable peri-operative outcomes. However, reliance on iodinated contrast media (ICM), including unnecessarily high volumes, raises concerns regarding contrast induced nephropathy, particularly in patients with pre-existing renal impairment. This study describes simple, pragmatic, and cost effective strategies to minimise ICM use during EVAR and presents an institutional experience. Technique:Three contrast injection strategies were applied, designated the wet protocol (ICM only), mixed protocol (ICM + carbon dioxide [CO2]), and dry protocol (CO2 only). Key strategies included meticulous pre-operative planning using C-arm optimisation and bony landmarks, automated contrast injector systems for controlled (specifically 'low volume, high rate') ICM delivery, and selective adoption of CO2 angiography using the CO2mmander II System (AngioAdvancements, Fort Myers, FL, USA). Discussion:An exemplar analysis was undertaken of 150 patients (98 men and 52 women, mean age 76 ± 7 years) who underwent infrarenal EVAR between March 2017 and June 2025 by author A.C., applying these contrast protocols. These were used accordingly: wet protocol (n = 120), mixed protocol (n = 26), and dry protocol (n = 4). The median ICM volume used in the wet protocol was 36 mL (interquartile range 18 mL), and 16 mL (interquartile range 18.5 mL) in the mixed protocol. A significant improvement in post-EVAR estimated glomerular filtration rate was noted for the wet protocol (p < 0.001, paired t test), whereas for the mixed protocol, the improvement was marginal (p = 0.053, paired t test). Such approaches reduce contrast dose overall and are particularly valuable for patients at risk of contrast induced nephropathy, supporting safer and more individualised EVAR practice. This experience demonstrates that these pragmatic techniques significantly reduce ICM use without compromising technical success or safety. Application of CO2 angiography is dependent on access to appropriate injection systems. Such considerations can be applied to the operative workflow at the time of multidisciplinary peri-operative discussion.
Introduction:Branched thoracic endovascular aneurysm repair has become an increasingly common intervention since the advent of custom made and now off the shelf devices. This report describes the use of a sequential double deployment of the Gore TAG Thoracic Branch Endoprosthesis (TBE; WL Gore and Associates, Flagstaff, AZ, USA) to exclude a left common carotid artery aneurysm (LCCAA) due to large vessel vasculitis (LVV). Report:A 39 year old man (smoker, schizophrenic, known antiphospholipid syndrome, and previous deep vein thromboses) presented with a 45 mm LCCAA eight months after resection of a left carotid bulb aneurysm (using a reversed great saphenous vein, which had later occluded). Special investigations and multidisciplinary discussion highlighted the suspicion of LVV involving the arch outflow, and thus an endovascular treatment approach was selected. Sequential dual TBE devices were deployed for branch thoracic endovascular aneurysm repair from Ishimaru zone 3 to zone 0C with coil embolisation of the LCCAA. Successful exclusion of the LCCAA and maintenance of arch branch patency were achieved. Following referral to a tertiary rheumatology centre, the post-operative phase was particularly complicated by a haemorrhagic stroke, which was successfully treated by neurosurgical intervention. The patient continues to be stable at four months and is maintained on long term immunosuppressant, antiplatelet, lipid lowering, and anticoagulant therapy. Discussion:The use of an off the shelf device like the TBE allows modular totally endovascular arch reconstruction, facilitated here by the permissive effect of the left carotid outflow already being sacrificed. Endovascular options may provide an initial solution for treating aortic arch branch vessel aneurysms, thus reducing the morbidity and mortality of open surgical arch reconstructions, but an overall multidisciplinary approach is mandated for the management of such patients with long term follow up.
Objective:Anastomotic false aneurysms can form due to damaged polypropylene sutures (PS). This study aimed to examine whether pinching PS with modern less traumatic vascular instruments affects their tensile strength (TS). Methods:Fifteen pairs each of 3-0 Prolene and 4-0 and 5-0 Optilene, as well as 18 pairs each of 6-0 and 7-0 Surgipro II PS were tested. Half of the sutures were compressed with a Jacobson Micro Needle Holder (NH) and half with DeBakey atraumatic tissue forceps (TF) for two seconds using a standardised pressure force of 40.8 ± 5.0 g. The pressure was based on the mean pinch force produced by a total of six experienced vascular surgical consultants. The same unpaired numbers of these PS served as references. Samples were tested for breakage on a traction device with a tensile force sensor. The TS was calculated for each sample and compared with the reference. Two sets of sutures of each size, containing five NH and TF compressions on each set, were examined for possible surface damages with optical tomography. Results:A statistically significant TS decrease was detected only after NH compression of 6-0 (p = 0.003) and 7-0 (p < 0.001) PS. On optical tomography, the extent of post-compression changes increased with decreasing diameter; the changes were similar throughout the corresponding size and instrument groups. Surfaces compressed with an NH were evenly deformed and rough, with multiple cortex damages. PS pinched with TF were unevenly deformed. The visually detectable surface damage was less extensive compared with what was observed after NH compressions. Conclusion:Pinching of the tested PS led to structural deformations and superficial cortex damage. Compressions of 6-0 and 7-0 PS with an NH led to significant TS reduction.
Introduction:Whether endovenous thermal ablation (EVTA) can be performed soon after the diagnosis of superficial venous thrombosis (SVT) in patients with chronic venous insufficiency (CVI) remains uncertain. This study assessed the safety and clinical benefit of early EVTA performed under anticoagulation. Method:Consecutive CVI patients with acute SVT (symptom onset ≤14 days) who underwent endovenous laser ablation (EVLA), radiofrequency ablation (RFA), or endovenous microwave ablation (EMA) between January 2022 and March 2025 were identified. All received peri-procedural anticoagulation. Co-primary endpoints were technical success (first post-procedural duplex) and clinical improvement (change in Venous Clinical Severity Score [VCSS] to six months). Secondary endpoints included immediate pain relief (numerical rating scale [NRS] at rest and movement to discharge), Venous Insufficiency Epidemiological and Economic Study-Quality of Life (VEINES-QoL) change to six months, and complications (including deep vein thrombosis [DVT] and pulmonary embolism [PE]) and recurrence. Results:The study analysed 255 patients (262 limbs) with a median follow up of 14 months. Mean procedure duration was 54.3 ± 22.1 minutes. Complications were uncommon: DVT 1.2% (3 of 262), minor bleeding 0.78% (2 of 255); there was no PE, re-operation, or infection. Pain improved substantially (NRS decreased by 2.59 points at rest and 4.15 points with movement). Clinical severity and QoL also improved (VCSS decreased by 5.73 ± 1.78 points; VEINES-QoL increased by 12.87 ± 1.92 points). Outcomes and complication rates did not differ between EVLA, RFA, and EMA. Conclusion:In this cohort, early EVTA under anticoagulation appeared feasible and was associated with low thrombotic and bleeding complication rates and clinically meaningful improvements in pain, clinical severity, and quality of life. Given the non-controlled design, findings should be interpreted as hypothesis generating and warrant confirmation in comparative prospective studies.
