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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "General Surgery".

Deadline for manuscript submissions: closed (25 November 2025) | Viewed by 9043

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Dr. Giovanni Coppi

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Department of Vascular and Thoracic Surgery, Bozen Central Hospital, 39100 Bozen, Italy
Interests: vascular surgery; vascular medicine; surgery; aneurysm; stents; endovascular surgery; angioplasty; thoracic surgery; aortic diseases; carotid arteries

Special Issue Information

Dear Colleagues,

Carotid revascularization remains an important part of the everyday practice of a vascular surgery unit. Although much studied with several scientific publications, there are still parts of this topic that remain debated and are not clarified by the most recent guidelines.

The scope of the Special Issue is trying to, according to your personal experience and a thorough review of the literature, shed some light on the more controversial aspects of carotid revascularization. In particular regarding the use of carotid artery stenting in recently symptomatic stenosis, the treatment of tandem intracranial and extracranial carotid stenosis in patients with acute stroke or carotid revascularization after intravenous thrombolysis.

I hope you find this proposal intriguing and could help us write an interesting issue.

Dr. Giovanni Coppi
Guest Editor

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Keywords

stroke
carotid artery stenosis
carotid artery stenting
carotid endarterectomy
occlusion

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Published Papers (7 papers)

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Research

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15 pages, 851 KB

Open AccessArticle

Multicentre Retrospective Cohort Study on Current Practices in Treatment of Patients Presenting with Non-A Non-B Aortic Dissection and Factors Predicting the Need for Intervention and Mortality

by Ottavia Borghese, Gabriel Lopez-Pena, Athanasios Saratzis, Tryfon Vainas, Alice Lopes, Blandine Maurel and Tara Mastracci

J. Clin. Med. 2026, 15(1), 211; https://doi.org/10.3390/jcm15010211 - 27 Dec 2025

Viewed by 651

Abstract

Objectives: Non-A Non-B (NANB) aortic dissections (ADs) are uncommon. Because of their rarity, their therapeutic pathway is not yet standardized, and anatomic or goal-directed treatments are not reported in current practices. We reviewed the treatment strategies of NANB AD across Europe, aiming to identify factors associated with increased mortality and the need for intervention, outlining optimal management pathways for future care. Methods: This multicentre cohort study was carried out in four European aortic centres, retrospectively including patients affected by NANB AD over the last 10 years. Patients’ anatomical clinical and treatment data were collected with the aim of investigating the factors associated with their need for intervention and increased mortality, comparing the characteristics of those requiring surgery with those who responded to medical treatment alone. Results: Thirty-eight NANB patients (26, 68.4% men; mean age 60.6 ± 12.87) were included. The primary entry tear was identified in Ishimaru zone 1 or 2 in most cases (24, 63.2%) and the dissection extended distally to the ilio-femoral arteries in half of the patients (21, 55.3%). Surgical repair was indicated in 21 (55.3%) cases within 90 days of acute onset for end-organ ischemia, impending aortic rupture, or retrograde extension of the dissection (including 11 emergent/urgent operations), with most patients requiring surgery within 15 days of acute onset (17, 44.7%). The mean aortic diameter among patients requiring surgery was significantly higher in both zone 1 (7 37 IQR 3 versus 34 IQR 7, p = 0.043) and 2 (36 IQR 6 versus 32.5 IQR 7, p = 0.044) when compared with patients who underwent medical treatment alone. An increased in-hospital mortality rate was noted among patients with indication for surgery after medical treatment (0% versus 30.8%, p = 0.023). Conclusions: This cohort provides an additional description of clinical aspects and current practices in the treatment of NANB in Europe. Most patients of this series had an indication for surgery within two weeks of acute onset, demonstrating a frequently complicated course; moreover, this raises questions surrounding the most appropriate timing for interventional management. Although a diameter threshold was not identified, the baseline enlarged aortic diameter in zones 1 and 2 seemed to be associated with a need for early intervention. Further study is needed to fully refine the indications for treatment in NANB patients; this will support the study of the independent risk factors for increased mortality risk and complications among this group, and will allow the identification of subgroups of patients that may benefit from more aggressive treatment from acute onset. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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11 pages, 1339 KB

Open AccessArticle

Innovative Use of Bleomycin Electrosclerotherapy (BEST) for High-Flow Arteriovenous Malformations in the Head District: Preliminary Results of Two Cases

by Linda Latini, Sandra Bracco, Samuele Cioni, Sara Leonini, Flavia Cascino and Paolo Gennaro

J. Clin. Med. 2025, 14(7), 2516; https://doi.org/10.3390/jcm14072516 - 7 Apr 2025

Cited by 5 | Viewed by 2313

Abstract

Background: According to the ISSVA 2018 classification, arteriovenous malformations (AVMs) are high-flow vascular malformations, distinct from low-flow lesions. About 60% of extracranial AVMs occur in the head and neck, making their management a focus of maxillofacial surgery. Due to their complexity, precise diagnosis and careful treatment planning are crucial for optimal aesthetics and structural preservation. The standard approach combines embolization with surgical resection, though Bleomycin electrosclerotherapy (BEST) has recently gained recognition. Methods: From July 2023 to December 2024, a total of 16 patients with vascular malformations were treated with bleomycin electrosclerotherapy at the Azienda Ospedaliera Universitaria Senese (AOUS). Among them, two patients were affected by arteriovenous malformations. These two patients underwent this treatment to avoid more invasive and demolitive procedures, considering the anatomical region involved. Both patients had previously been treated at other hospitals, experiencing subsequent lesion recurrence. Preoperative evaluation included angiographic and ultrasound studies. The patients underwent electrosclerotherapy sessions and were closely monitored during follow-up. The uniqueness of this innovative approach lies in the use of fractionated doses of bleomycin for each treatment session, compared to the standard protocols described in the literature. Results: BEST has demonstrated efficacy in the treatment of high-flow AVMs by delivering bleomycin into the interstitial tissue and subsequently applying electroporation so the drug’s effects can be precisely localized and amplified. The macroscopically evident results, patient satisfaction, and, most importantly, the objective ultrasound flow data demonstrate the effectiveness of this treatment. Conclusions: Arteriovenous malformations (AVMs) pose treatment challenges due to their variability and lack of standardized guidelines. This study explores electrosclerotherapy with bleomycin in two head and neck AVM cases, using fractionated doses to enhance safety and efficacy. The findings support its potential as a minimally invasive alternative, warranting further research on broader applications. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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Review

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9 pages, 1574 KB

Open AccessReview

Retropharyngeal Internal Carotid Artery Stenosis: A Case-Based Narrative Review

by Chiara Caruso, Paolo Verlato, Omar Odeh, Roberta Munao, Alessandro Rossi, Besjona Puta, Massimiliano Martelli and Alberto Maria Settembrini

J. Clin. Med. 2026, 15(7), 2683; https://doi.org/10.3390/jcm15072683 - 2 Apr 2026

Viewed by 658

Abstract

Introduction: The retropharyngeal carotid artery (RCA) is a rare anatomical variant where the carotid artery resides in the retropharyngeal space. The co-occurrence of RCA and significant atherosclerotic stenosis of the carotid bifurcation is even rarer. Recognizing this anatomy is crucial because of the increased risk of adverse events during procedures such as intubation or oropharyngeal surgery. Furthermore, differentiating between the fixed and dynamic forms is essential for guiding appropriate diagnostic and therapeutic strategies. A scoping review was undertaken, and two cases of RCA and significant internal carotid artery stenosis requiring a surgical approach were presented. Materials and Methods: EMBASE and OVID were systematically searched for studies reporting data on RCA and significant internal carotid artery stenosis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) was followed, and we presented two case reports of RCA and significant internal carotid artery stenosis requiring surgical treatment, treated at the Division of Vascular Surgery, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy. Results and Discussion: Among the 22 papers identified by the scoping review, 6 case reports were ultimately included in the analysis, supplemented by our two cases. The review and the added cases highlight significant heterogeneity in the clinical presentation and management of RCA with stenosis. Therapeutic options include carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR). Also, the diagnostic with dynamic 3D-CT angiography during swallowing would be important in some symptomatic cases to document mechanical compression by the hyoid bone or thyroid cartilage (dynamic RCA), which standard static imaging failed to detect. Conclusions: Due to the rarity of the condition, no high-level evidence (RCTs) exists. Treatment decisions are based on the qualitative assessment of anatomical risk and isolated case reports. Standard interventions (CEA and TF-CAS) are generally considered high-risk. The final management choice must be individualized based on technical feasibility, neurological risk, and the determination of whether the pathology is fixed or dynamically compressive. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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21 pages, 564 KB

Open AccessReview

Early (<6 Days) Extracranial Carotid Revascularization After Intravenous Thrombolysis for Stroke: A Scoping Review

by Giovanni Coppi, Luiz Felippe Milazzo, Marco Damiano Pipitone, Giovanni Zambello, Francesco Zaraca and Reinhold Perkmann

J. Clin. Med. 2026, 15(3), 1174; https://doi.org/10.3390/jcm15031174 - 2 Feb 2026

Viewed by 589

Abstract

Background: Current guidelines recommend delaying extracranial carotid revascularization for at least 6–7 days after intravenous thrombolysis (IVT). However, evidence remains inconclusive, and patients with minimal or no brain lesions may benefit from earlier intervention. Objective: This scoping review evaluates outcomes of carotid revascularization performed within six days of IVT in patients with small strokes or no imaging-detected lesions. Design: We searched Medline, EMBASE, and Cochrane CENTRAL for studies published between 2005 and 2025 reporting carotid revascularization after IVT. Primary outcomes included perioperative ischemic stroke, symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial bleeding (aICB), and wound complications. Data on timing, imaging findings (CT/MRI), and stroke severity (NIHSS or modified Rankin scale) were extracted. The review followed PRISMA-ScR guidelines. Results: Seventeen studies (1459 patients) were included; 97.6% underwent carotid endarterectomy (CEA) and 2.4% carotid artery stenting (CAS). Data for procedures within six days post-IVT were available for 402 patients, with some treated within 24–72 h. Mean NIHSS at admission was 10.2 ± 2.8. Brain lesion characterization was poor and only used as an exclusion criterion. Thirty-day ischemic stroke incidence was 2.5%, while combined sICH/aICB was 4.0%, with symptomatic cases at 2.5%. Most hemorrhages occurred in patients operated within 48–72 h from IVT and in patients with higher NIHSS. CAS carried higher sICH risk than CEA (8.6% vs. 1.9%). Overall mortality was 1.1%; wound complications occurred in 3.7%. Conclusions: The available literature provides limited characterization of brain lesion extent. Neurological complications after CEA are rare, mainly limited to patients operated within 48–72 h from IVT. Further research is needed to optimize treatment in this patient group, although delaying CEA only to 48–72 h seems reasonable in case of low NIHSS. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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Other

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15 pages, 3315 KB

Open AccessCase Report

Microsurgical Management of Carotid Body Tumors: An Educational Neurosurgical Perspective with Video Demonstrations

by Abdullah Keles, Ufuk Erginoglu, Yerkebulan Serikanov, Yannick Canton Kessely, Sima Sayyahmelli, Oyku Ozturk, Nafiye Sanlier, Behman Demir, Maryam Sabah Al-Jebur, Umid Sulaimanov and Mustafa Kemal Baskaya

J. Clin. Med. 2026, 15(7), 2508; https://doi.org/10.3390/jcm15072508 - 25 Mar 2026

Viewed by 1878

Abstract

Background/Objectives: Carotid body paragangliomas, commonly referred to as Carotid Body Tumors (CBTs), are rare, highly vascular paragangliomas arising at the carotid bifurcation and pose significant surgical challenges due to their proximity to critical neurovascular structures. Optimal management remains debated, particularly for large or complex lesions. This study aims to present a structured neurosurgical operative workflow as an educational and practical resource to help young surgeons understand operative decision-making and technical execution from a neurosurgical perspective. Methods: We retrospectively reviewed patients diagnosed with CBTs and identified three cases that underwent microsurgical resection by a single neurosurgeon. Clinical presentation, radiographic findings, operative strategies, intraoperative microsurgical techniques, and postoperative outcomes were analyzed. Surgical procedures for all three cases are further illustrated with technical video demonstrations highlighting meticulous microsurgical techniques performed by a single neurosurgeon. Results: All three patients presented with either incidental or slowly progressive neck masses, with imaging demonstrating classic splaying of the internal and external carotid arteries. One patient exhibited elevated catecholamine metabolites, while another had a familial history of paragangliomas. Preoperative embolization was successfully performed in all three cases. Complete tumor resection was achieved in each patient. One patient developed post-embolization embolic ischemic changes with transient neurological deficits that were resolved within several hours. No permanent cranial nerve deficits, vascular injuries, or tumor recurrences were observed. Pathology confirmed paraganglioma in all cases. Conclusions: Surgical resection remains an effective treatment for CBTs, which are commonly managed by vascular or head and neck surgeons. This case series illustrates the technical feasibility of CBT resection using a comprehensive neurosurgical strategy that integrates endovascular preparation, cerebral perfusion assessment, and meticulous microsurgical technique. Rather than proposing novel surgical innovation, this report aims to provide a structured operative framework and detailed video-based illustration of complex carotid bifurcation management from a neurosurgical perspective. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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20 pages, 786 KB

Open AccessSystematic Review

Clinical Applications of Indocyanine Green Fluorescence Imaging in Vascular Malformations: A Systematic Review

by Carlos Delgado-Miguel, Javier Arredondo-Montero, Julio César Moreno-Alfonso, Marta Rodríguez Ruiz, Isabella Garavis Montagut, Paloma Triana Junco, Miriam Miguel-Ferrero, Mercedes Díaz, Francisco Hernández-Oliveros and Juan Carlos López-Gutiérrez

J. Clin. Med. 2026, 15(5), 1834; https://doi.org/10.3390/jcm15051834 - 27 Feb 2026

Cited by 1 | Viewed by 798

Abstract

Background/Objectives: The use of near-infrared fluorescence (NIRF) imaging with indocyanine green (ICG) has gained increasing attention in the management of vascular malformations, offering real-time visualization of vascular and lymphatic structures that may improve surgical precision and outcomes. Methods: A systematic review was conducted in accordance with PRISMA guidelines, searching PubMed, Web of Science, CINAHL, and EMBASE databases for studies evaluating the intraoperative use of ICG in vascular malformations, which was prospectively registered in PROSPERO (CRD420251131951). Two independent reviewers screened all records based on predefined eligibility criteria. Extracted data included study design, patient characteristics, ICG administration protocols, clinical applications, and perioperative outcomes. Results: A total of 33 studies comprising 433 patients treated between 2014 and 2025 were included for qualitative synthesis. Nineteen (57.6%) were case reports, seven (21.2%) retrospective descriptive studies, two (6.1%) retrospective comparative studies, three (9.1%) prospective comparative trials, and two (6.1%) prospective descriptive studies. Clinical indications for ICG included capillary and venous malformations (5 studies), arteriovenous malformations (9 studies), and lymphatic malformations (19 studies). Quality assessment with the MINORS tool showed that most studies scored < 17, while only seven reached 18–24, reflecting higher methodological quality. Conclusions: Intraoperative ICG fluorescence imaging represents a promising adjunct in the treatment of vascular malformations, providing real-time visualization that may facilitate lesion delineation, guide resection, and support minimally invasive techniques such as lymphaticovenous anastomosis. However, current evidence is largely descriptive, with very limited comparative outcome data, and high-quality studies are needed to determine whether these technical advantages translate into improved long-term clinical outcomes. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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8 pages, 8481 KB

Open AccessCase Report

Limb Salvage in Patients with Concomitant Advanced Malignancy

by Jolyn Hui Qing Pang and Nick Zhi Peng Ng

J. Clin. Med. 2025, 14(5), 1642; https://doi.org/10.3390/jcm14051642 - 28 Feb 2025

Viewed by 1209

Abstract

Background: We are experiencing an increasing number of patients presenting with advanced malignancy who are also presenting with chronic limb threatening ischemia. Method: With advancements in medicine and surgery, we are suggesting a shift in mindset of how we treat this group of patients and proposing a more holistic approach for treatment options. Result: In this original article, we highlight our approach in managing such patients and suggest an algorithm. Conclusions: We hope that our article brings awareness and assists vascular surgeons in managing such cases, resulting in improved quality of life for these patients. Full article

(This article belongs to the Special Issue Vascular Surgery: Current Advances and Future Directions)

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