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.
