Background The role of incompetent perforating veins (IPVs) in varicose veins is controversial. There are different views on the mechanism of "incompetence" and, hence, the importance of IPVs. Those following CHIVA and "haemodynamic surgery" principles suggest higher velocities in the deep veins cause blood to flow inwards due to the Venturi effect. The senior author of this case has previously proposed that increased pressure by muscle activity forces blood out of any IPV, a phenomenon called "active" reflux. This case report appears to show active reflux in an isolated IPV using infrared thermography.Methods A 34-year-old lady presented with a tender lower leg varicose vein due to an isolated IPV. She was placed supine and still for 10 minutes, then performed 10 plantar- and dorsi-flexions. Next, she stood up and stood still for 10 minutes. Her leg was monitored throughout using an infra-red camera (IFC).Results Immediately on lying, the IFC showed the vein, indicating blood flowing out of the IPV from the warm deep compartment into the colder superficial compartment (passive/diastolic or gravitational reflux). Over 10 minutes, the signal reduced significantly, suggesting no more blood was being pumped out through the IPV. During 10 plantar- and dorsi-flexions, the signal returned strongly, indicating blood being pumped out of the IPV once again. On standing, the signal was strong initially, but after 10 min of standing still, the signal had faded, indicating a lack of passive (gravitational) reflux in the IPV.Conclusion This case suggests that reflux through this IPV is due to muscle activity and not by passive reflux due to gravity. This could explain why IPVs can cause fasciocutaneous damage and/or varicose veins in the lower limb. If correct, failure to identify and treat IPVs during varicose vein surgery would mean that the procedure would be inadequate.
Objective To map the applications and outcomes of robotic technologies in aortic and aortoiliac procedures, including robot-assisted laparoscopic surgery, endovascular procedures, and micro-robotics. Methods PubMed was searched up to October 4, 2026, for primary studies including at least 3 patients treated with robotic or robot-assisted interventions for aortic or aortoiliac disease, following PRISMA-ScR guidelines. Case reports and two-patient series were summarized separately. Results Fifteen observational studies (552 patients) were included. Robot-assisted laparoscopic surgery (9 studies; 494 patients) was mainly applied to aortoiliac occlusive disease (385 procedures), with robotic proximal aortic anastomosis and open distal anastomoses, and less frequently to aneurysm repair. Conversion rates ranged from 0% to 20%, graft patency from 89% to 100% at up to 48 months, and hospital stay from 4 to 8 days. Robot-assisted endovascular procedures (5 studies; 49 patients) were mostly applied to single procedural steps. Robotic target vessel cannulation succeeded in 81% of vessels, and robotic gate cannulation achieved a shorter catheter path length than manual cannulation (35.7 vs 74.1 cm; P = 0.019), but longer cannulation time. Robotic arch navigation was associated with fewer cerebral high-intensity transient signals (median 0 vs 2; P = 0.018), and operator radiation dose at the shielded console was 96.5% lower than at the procedure table. No robot-related complications were reported. Micro-robotic sac puncture for type II endoleak embolization (1 study; 9 patients) succeeded in all cases. Conclusion Robotic technologies are a promising and feasible option for selected patients undergoing aortic procedures at experienced centers. Robot-assisted laparoscopic surgery showed acceptable conversion rates and favorable mid-term patency, while endovascular robotics improved technical and surrogate endpoints. As current evidence is limited to small observational series, prospective comparative studies are needed to define the clinical benefit of robotics compared with open and endovascular repair.
Background Splenomesenteric artery aneurysms are a rare clinical entity occurring in <1% of the population, where the splenic artery originates from the superior mesenteric artery (SMA). These aneurysms carry a high risk of rupture due to exposure to high-flow hemodynamic stress near the SMA origin. Case Presentation A 76-year-old female was incidentally diagnosed with a 1.6 cm saccular splenomesenteric aneurysm during investigation for sepsis. The patient underwent successful endovascular exclusion using a combination of a microvascular plug and coil embolisation to address the aneurysm ‘front’ and ‘back’ doors, while a covered stent was deployed in the SMA to prevent coil prolapse and preserve mesenteric perfusion. Follow-up at 3 months confirmed successful exclusion with preserved visceral flow. Discussion Due to the rarity of this anatomical variant, documented in less than 60 cases in English literature, no standardised treatment algorithm exists. This study adds to the literature by demonstrating procedural innovation, refining management strategies and advocating for early intervention for such conditions.
Introduction Primary vascular leiomyosarcomas (PVLs) are rare, aggressive tumors arising from the smooth muscle cells of large veins, most commonly the inferior vena cava (IVC). Fewer than 500 cases have been reported worldwide, and outcomes remain poor without complete surgical resection. Treatment often requires complex venous and multivisceral reconstruction, but data on operative strategies and outcomes remain limited. Methods We reviewed four cases of IVC PVL resected at our institution between 2020 and 2023. Each case involved a distinct anatomic segment of the IVC, requiring individualized approaches to resection and vascular reconstruction. Results Patient 1 underwent infrarenal IVC resection with en bloc removal of bilateral renal veins and right renal artery, followed by complex reconstruction using cryopreserved cadaveric vein grafts to preserve bilateral renal function. Patients 2 and 3 presented with pararenal and suprarenal IVC tumors, respectively, and underwent en bloc resection with patch venoplasty using bovine pericardium, avoiding luminal narrowing and preserving caval flow. Patient 4 had a large pararenal IVC tumor with suprarenal atriocaval extension requiring cardiopulmonary bypass and patch venoplasty. She subsequently developed two recurrences, the second requiring thoracoabdominal exposure and interposition IVC bypass with a biologic tube graft. All patients recovered well postoperatively, with patent reconstructions and preserved organ function on surveillance imaging. At follow-up ranging from 12 months to 3 years, three patients remained disease-free, while one experienced recurrence managed with repeat resection. Conclusions IVC leiomyosarcomas present unique surgical challenges requiring patient-specific operative strategies. Complete resection with negative margins remains the cornerstone of treatment, with vascular reconstruction essential to preserve renal function and venous return. This series contributes to the limited literature by demonstrating the feasibility of both standard (patch venoplasty) and complex (renal vein preservation, interposition grafting) reconstructions, highlighting the importance of individualized, multidisciplinary operative planning to optimize outcomes.
AimThis study aimed to evaluate the prevalence, anatomical variations, and branching patterns of the renal arteries using multiphasic computed tomography angiography (CTA), based on the modified classification proposed by Cases et al (2017). Understanding renal artery variations is essential for preoperative planning, renal transplantation, endovascular procedures, and urological interventions.Materials and MethodsA retrospective analysis was conducted on 1220 abdominal CTA studies performed between March 2020 and June 2024. Fourteen cases were excluded according to predetermined exclusion criteria, resulting in 1206 studies being included in the final analysis (700 males, 520 females). All examinations were performed using a 128-slice CT scanner (Siemens SOMATOM; syngo CT VC 40). CTA protocols included 5-mm acquisition and 1-mm reconstruction, with administration of 100-120 mL of iodinated contrast at 5-6 mL/s via an 18G antecubital cannula. Post-processing involved multiplanar reformation, volume rendering, and 3D reconstruction. Two experienced radiologists independently reviewed all studies. Renal arteries were categorized into Types A-E and Patterns I-V. "Early division" (Types B and E) and "polar branches" (Types C and D) were further grouped for analytical purposes.ResultsAmong 1206 CTA studies, Type A (normal hilar artery) was the most common in both kidneys, with a slightly higher prevalence on the right (74.29%) than on the left (67.99%). Polar branches were more frequent in the left kidney, whereas early divisions were more common in the right kidney. Pattern 1 was predominant bilaterally (RK: 85.73%; LK: 77.61%), followed by Pattern 2. Significant differences were observed between the kidneys in the distribution of Types A, C, D, and Patterns 1 and 2.ConclusionCTA provides excellent visualization of renal artery variations, enabling precise classification and improving surgical, interventional, and transplant planning. Recognition of these anatomical differences is essential for minimizing procedural complications.
