We present a rare case of a 59-year-old man who developed a progressively enlarging pseudoaneurysm at the level of the left renal artery owing to an infection with Streptococcus pneumoniae, clinically manifesting as worsening pain, new-onset chills, and febrile episodes. This report underscores the complexities associated with the management of mycotic pseudoaneurysm, highlighting the necessity of prompt diagnosis, thorough preoperative evaluation, and individualized surgical intervention to optimize patient outcomes in these challenging cases.

OBJECTIVE:The VOYAGER PAD trial demonstrated the benefit of low-dose dual pathway inhibition (LD-DPI) with aspirin and low-dose rivaroxaban in select populations, yet the balance between bleeding and limb-related outcomes in real-world practice remains unclear. We aimed to compare outcomes among patients on differing antithrombotic regimens after lower extremity revascularization for chronic limb-threatening ischemia (CLTI). METHODS:All patients with available medication data undergoing first-time lower extremity revascularization for CLTI between 2005 and 2022 at a single institution were included. Patients were stratified by discharge medication regimen, including single antiplatelet therapy (SAPT; further stratified into aspirin monotherapy [SAPTasa] and P2y12 inhibitor monotherapy [SAPTp2y]), prolonged (>90 days) dual antiplatelet therapy (DAPT), LD-DPI, standard DPI (SAPT + full-dose anticoagulation), and triple therapy (TT; DAPT + anticoagulation at any dose). Primary outcomes included gastrointestinal bleeding (GIB), any bleeding complication (bleeding necessitating transfusion of ≥2 units within 48 hours, bleeding leading to surgical intervention, or intracranial hemorrhage), stroke, myocardial infarction (MI), acute limb ischemia, primary patency, major adverse limb events (MALE), and mortality. Outcomes were analyzed with Kaplan-Meier and Cox regression analyses. RESULTS:Overall, 1286 patients were included: 402 SAPTasa, 85 SAPTp2y, 359 DAPT, 35 LD-DPI, 257 DPI, and 148 TT. Baseline demographics varied, with SAPTasa and TT having the lowest and highest respective rates of coronary artery disease (49% vs 60%), hypertension (84% vs 95%), and atrial fibrillation (11% vs 60%) (all P < .05). Kaplan-Meier estimates showed significant differences between groups in 3-year rates of GIB (1.5% [SAPTasa] vs 2.6% [SAPTp2y] vs 8.8% [DAPT] vs 10% [LD-DPI] vs 10% [DPI] vs 15% [TT]), any bleeding complication (3.2% vs 2.6% vs 5.8% vs 7.8% vs 14% vs 21%), and death (37% vs 38% vs 38% vs 44% vs 43% vs 57%) (all P ≤ .001). No differences were noted in rates of MI, stroke, primary patency, or MALE. After adjustment, compared with SAPTasa, DAPT, DPI, and TT were associated with increasingly higher hazard of GIB (DAPT: hazard ratio [HR], 3.75; 95% confidence interval [CI], 1.60-8.76; DPI: HR, 5.48; 95% CI, 2.11-14.2; and TT: HR, 8.65; 95% CI, 3.07-24.3) and DPI and TT with higher hazard of any bleeding complication (HR, 5.07; 95% CI, 2.22-11.6; and HR, 9.65; 95% CI, 3.99-23.3). Compared with SAPTasa, TT had 40% higher hazard of mortality (HR, 1.40; 95% CI, 1.01-1.95). CONCLUSIONS:Escalation of antithrombotic therapy beyond SAPT after first-time lower extremity revascularization for CLTI is associated with higher bleeding risk, and TT with lower survival, possibly reflecting the vulnerability of frailer patients less able to tolerate bleeding complications. No differences were observed in MI, stroke, patency, or MALE, underscoring the challenge of balancing limb-related outcomes with bleeding risk. Careful monitoring, individualized risk stratification, and shared decision-making remain essential. Larger studies are needed to further define the relative efficacy and safety of intensified antithrombotic regimens.

OBJECTIVE:Both standard and low-profile endografts have been used for physician-modified endografts (PMEGs) to treat complex aortic aneurysms; however, recent data from a 2025 multi-institutional analysis suggest that low-profile devices are associated with type IIIc endoleak rates as high as 15% at the 20-month follow-up. Early demonstrations of PMEG modifications, including fenestration reinforcement with polytetrafluoroethylene (PTFE) cuffs, have proposed a possible remedy to these elevated endoleak rates. This analysis evaluates a single center's experience with PTFE cuff reinforcement for PMEG fenestrations. METHODS:All PMEGs performed at our institution between 2016 and 2025 were retrospectively reviewed. Each PMEG included fenestrations that were individually reinforced with a PTFE cuff and an embolization coil, secured with a running locking Ethibond suture. Primary outcomes included target vessel-related (type Ic and IIIc) endoleaks and endoleak-related reintervention. Outcomes were analyzed on both per-patient and per-fenestration bases. Bridging stent type (iCAST vs VBX) was also evaluated as a potential modifier of outcomes, with secondary outcomes including stent patency and target vessel instability. Rates of endoleak at 1 month and beyond were reported using Kaplan-Meier estimates. RESULTS:Overall, 229 PMEGs (100% low profile; 861 PTFE cuffs) were included in our analysis with a median follow-up of 1.3 years. The median age was 76 years and patients were primarily White (89%) and male (72%). The majority of cases were done electively (82%) for juxtarenal aneurysms (65%). The median aneurysm diameter at time of repair was 62 mm, and 80% included four or more target vessel fenestrations. Through 2 years, 26% (n = 42) of patients underwent an aneurysm- or PMEG-associated reintervention; of these, nearly one-half (n = 21 [15% of all patients]) were endoleak related. The most common indication for endoleak-related reintervention was sac expansion from type II endoleaks (8.9%). Type Ic and IIIc endoleaks occurred in 2.2% and 1.1% of patients, respectively. Bridging stents included 358 iCAST and 489 VBX. Stent distribution differed significantly by vessel, yet no significant differences were observed in 2-year patency (98% vs 99%), stent-related stenosis/occlusion (2.1% vs 2.0%), or reintervention rates (1.0% vs 1.3%) (all P > .05). On a per-fenestration basis, type Ic and IIIc endoleaks occurred in 0.6% and 0.1% of fenestrations, respectively, with no difference based on stent type (iCAST, 0.7% vs VBX, 0.8%; P = .23). Overall, freedom from target vessel instability at 2 years was >98% across all groups and vessels, without any difference in bridging stent type (98.3% vs 98.6%; P = .82). CONCLUSIONS:PMEG modification with individual fenestration reinforcement using a PTFE cuff and an embolization coil demonstrates effective fenestration sealing with notably low rates of target vessel-related endoleaks. Bridging stent choice does not appear to be a primary determinant of target vessel instability, endoleaks, or reinterventions, potentially underscoring the importance of fenestration modifications over stent platform differences. These findings suggest the value of using this technique for PMEG customization in low-profile devices.

A subset of patients with chronic limb-threatening ischemia (CLTI) lack viable options for traditional arterial revascularization - often termed "no-option" patients - and have historically faced primary major amputation as the default treatment. Deep venous arterialization (DVA) has emerged as a potential limb salvage strategy for this challenging population, involving the creation of an arteriovenous fistula to deliver oxygenated blood via the venous system to the ischemic foot. The approval of the LimFlow System by the United States Food and Drug Administration (FDA) in 2023, following the PROMISE II trial, has generated considerable interest in this approach. Prospective studies report 6-month amputation-free survival of 66% and limb salvage of 76% after percutaneous DVA. However, real-world Medicare data demonstrate substantially inferior outcomes, with 6-month amputation-free survival of only 42% and 1-year amputation-free survival of 33%. This discrepancy likely reflects differences in patient selection, operator experience, and institutional resources between clinical trials and routine practice. Outcomes are particularly poor in dialysis-dependent patients. Critical evidence gaps remain, including the absence of randomized controlled trials comparing DVA to intensive wound care alone, limited patient-reported outcome data, and undefined cost-effectiveness. Despite an evolving evidence base, DVA represents a promising treatment for carefully selected no-option patients at centers capable of providing comprehensive wound care, close surveillance, and timely reintervention.