Journal of Vascular Diseases

Background: Self-expanding transcatheter heart valves (SEVs) are often used to treat Sievers type 1 bicuspid aortic valve (BAV) stenosis. It remains unclear, however, if different SEVs yield similar outcomes in BAV stenosis, a class effect, or if the unique design features of different SEVs produce disparate clinical results. Objectives: This is a “proof-of-concept” study that compares procedural and clinical outcomes of Acurate neo2 and Evolut Pro/Pro+/Fx platforms in Sievers type 1 BAV stenosis. Methods: The CLASS effect is a retrospective, multicenter registry that enrolls patients with raphe-type 1 BAV stenosis undergoing TAVI at 29 international centers, who received Acurate neo2 and Evolut Pro/Pro+/Fx devices. An inverse probability of treatment weighting (IPTW) analysis was performed to adjust for baseline imbalances. Primary endpoints included VARC-3 technical success, 30-day device success, and early safety according to VARC-3. Results: Among 389 eligible patients, 155 and 234 patients were treated with Acurate neo2 and Evolut platforms, respectively. A higher rate of technical success was observed in the Evolut group (Acurate neo2 vs. Evolut: 93.4% vs. 97.1%, OR 0.41, 95% CI 0.19–0.83, and p = 0.017). At 30 days, device success was comparable (90.1% vs. 89.4%, OR 1.09, 95% CI 0.68–1.75, and p = 0.733), whereas Acurate neo2 was associated with a higher rate of early safety (84.1% vs. 70.4%, OR 2.22, 95% CI 1.56–3.17, and p < 0.001), which was mainly driven by a lower risk of new permanent pacemaker implantation (PPI) (6.3% vs. 19.5%, OR 0.28, 95% CI 0.16–0.46, and p < 0.001). Conclusions: Acurate neo2 and Evolut Pro/Pro+/Fx platforms provide similarly effective procedural and short-term outcomes in Sievers type 1 BAV stenosis. However, Evolut was associated with a higher technical success, while Acurate neo2 demonstrated a lower incidence of new PPI. Full article

Objectives: This study aimed to identify factors associated with mean arterial pressure and pulse pressure, while considering non-modifiable factors. Methods: This study was a retrospective cross-sectional analysis of adults with lower limb loss and no history of a major adverse cardiovascular event. Participants completed self-reported medical histories and outcome measures, including a report of pain extent per body diagrams and physical activity per the General Practice Physical Activity Questionnaire. During an onsite clinical evaluation, participants underwent a resting vital sign assessment by a physiatrist and/or physical therapist. Forward stepwise logistic regression models were run to identify the factors associated with elevated mean arterial pressure (i.e., >100 mmHg) and wide pulse pressures (i.e., >60 mmHg). Results: Of 206 participants (aged 54.5 ± 14.1 years; 74.3% male; 72.8% White; 42.2%; dysvascular etiology), n = 107 (51.9%) presented with an elevated mean arterial pressure and n = 52 (25.2%) had a wide pulse pressure. Forty-two participants (20.4%) presented to the clinic with both conditions. A mean arterial pressure > 100 mmHg was associated with upper extremity pain presence [odds ratio (OR) = 2.62, 95% confidence interval (CI) = 1.26–5.45, p = 0.010] and increasing heart rate (OR = 1.02, CI = 1.00–1.04, p = 0.033). A pulse pressure > 60 mmHg was associated with advancing age (OR = 1.07, 95%CI = 1.04–1.10, p < 0.001) and a lower physical activity level (OR = 1.50, 95%CI = 1.07–2.11, p = 0.017). Conclusions: Over 50% of adults with lower limb loss and no history of major adverse cardiovascular events have an elevated mean arterial pressure and/or wide pulse pressure, suggesting maladaptive cardiovascular changes. Factors associated with elevated mean arterial pressure and/or wide pulse pressure may suggest underlying cardiovascular disease and sympathetic overactivity, warranting a further evaluation of cardiovascular risk. Full article

Background: Despite level-A evidence demonstrating superior long-term survival with bilateral internal mammary artery (BIMA) grafting, its global utilization remains dismally low (<10–15%), largely due to historical concerns over deep sternal wound infections (DSWI) and technical complexity. This underutilization persists even as multi-arterial grafting (MAG) adoption stagnates, with recent North American data showing only 16% of coronary artery bypass grafting CABG procedures utilize more than one arterial conduit. Objective: This review synthesizes contemporary evidence demonstrating that modern surgical refinements—particularly skeletonized “no-touch” harvesting—have effectively mitigated these concerns, enabling wider BIMA application. Methods & Results: Over two decades of institutional experience confirm that skeletonized harvesting preserves sternal perfusion and minimizes DSWI risk, even in high-risk patients. Propensity-matched analyses show significant survival benefits of BIMA grafting across age and comorbidity strata (8-year survival: 67.1% BIMA vs. 58.2% single internal mammary artery (SIMA), p < 0.05), rendering previous contraindications relative rather than absolute. Long-term outcomes demonstrate superior 10-year survival for in situ BIMA compared with SIMA (86.1% vs. 78.6%, p < 0.05). Advanced configurations such as sequential skeletonized grafting are safe and further enhance outcomes. In single-vessel left anterior descending artery (LAD) disease, skeletonized left internal mammary artery (LIMA) continues to outperform percutaneous coronary intervention (PCI), underscoring the unmatched durability of arterial conduits. Conclusions: The technical evolution of conduit harvesting has resolved the “BIMA paradox”. Contemporary evidence supports BIMA grafting as a standard of care for a broad CABG population, offering a durable, lifelong solution for coronary artery disease and warranting renewed guideline emphasis on multi-arterial revascularization. Full article

Intramural hematoma (IMH) is an infrequent but clinically significant complication of percutaneous coronary intervention (PCI), characterized by blood accumulation within the medial layer, causing true lumen compression and impaired coronary flow. Often under-recognized on angiography, the use of intravascular imaging has enhanced diagnostic accuracy and facilitated timely management. This review outlines the pathophysiology and mechanisms of iatrogenic IMH during PCI, clinical presentations, and contemporary strategies for detection and treatment. Illustrative case examples highlight practical considerations. We discuss the roles of intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared imaging in diagnosis; summarize interventional approaches including stenting, cutting/scoring balloons, and drug-coated balloons; and propose a pragmatic clinical management algorithm. This reinforces that early identification of PCI-related IMH coupled with imaging-directed therapy significantly improves procedural accuracy and correlates with more favorable long-term vascular outcomes. Full article

Subarachnoid hemorrhage (SAH) is a life-threatening cerebrovascular event with high mortality and long-term morbidity. While clinical grading scales such as Hunt and Hess or the World Federation of Neurological Surgeons (WFNS) score aid in prognosis, their accuracy implies a neurological assessment that can be confounded in sedated patients, highlighting the need for objective biomarkers. Biomarkers offer an alternative approach for risk stratification. This review examines the prognostic value of the glucose/potassium ratio (GPR) in patients with aneurysmal SAH and its potential integration into future predictive models. A literature review of retrospective studies assessing the association between GPR and clinical outcomes in SAH was conducted. Evidence on the pathophysiological basis of stress-induced hyperglycemia and hypokalemia in SAH is presented, along with findings from five key clinical studies evaluating GPR in relation to mortality, vasospasm, delayed cerebral ischemia, and functional outcomes. Elevated GPR levels were consistently associated with poor short- and long-term outcomes in SAH patients. Studies reported significant correlations between GPR and 30-day mortality, poor Glasgow Outcome Scale (GOS) scores, increased incidence of cerebral vasospasm, and higher rates of rebleeding. The optimal GPR cutoff for predicting adverse outcomes was greater than 37 mg/dL, with multivariate analyses confirming GPR as an independent prognostic factor. GPR is a promising, cost-effective biomarker that integrates two stress-response parameters (glucose and potassium), both of which are independently associated with SAH prognosis. Its incorporation into future predictive models may enhance early risk stratification and guide clinical decision-making. Further prospective studies are warranted to validate its utility and standardize its clinical application. Full article

Background/Objectives: Chronic venous disease is a very common disease. Recent studies suggest a potential link between this condition and cardiovascular disease or mortality. Common pathophysiological features include endothelial injury, hypercoagulability, and systemic inflammation. Conservative management of chronic venous disease includes compression therapy and pharmacological treatment. However, there is some controversy regarding the exact place of pharmacological treatment in the management of this condition. We conducted the VeinHeart Survey to gather information on the management of patients with chronic venous disease referred to vascular specialists in Italy. Methods: The present survey involved 78 Italian phlebologists, angiologists, and vascular surgeons, with data from a total of 1621 patients. Results: Drug therapies prescribed by vascular specialists participating in this survey included: glycosaminoglycans, topical phlebotonics, systemic phlebotonics, and supplements. The most commonly prescribed medications were glycosaminoglycans, both at the first visit and at follow-up. The meantime since the first visit was 56.4 days. Both symptoms and signs improved at follow-up. The most improved signs at follow-up were edema and venous ulcer healing. The prevalence of CEAP classes C3 and C4 also showed a decrease at the follow-up visit. Conclusions: The findings of this survey provide a picture of the state of the art of current pharmacological treatments prescribed by expert clinicians in the management of patients with chronic venous disease in Italy. This may offer some useful insights for the optimization of current therapeutic options, in order to improve the clinical management of this disease. Full article

Objectives: The field of view on abdominal CT includes the lower portion of the heart and thoracic aorta. Notably, triple rule-out (TRO) abnormalities [acute myocardial infarction (AMI), acute aortic syndrome (AAS), and pulmonary thromboembolism (PE)] may be overlooked on abdominal CT. The purpose of this paper is to evaluate the frequency of overlooked TRO abnormalities on abdominal CT in patients presenting with nonspecific abdominal pain. Methods: We retrospectively identified 913 patients from January 2017 to June 2018 in whom enhanced abdominal CT was performed due to nonspecific abdominal pain. Two chest radiologists retrospectively assessed the abdominal CT, focusing on whether TRO abnormalities were overlooked. Results: Upon retrospective review, there were 0.5% TRO abnormalities (four AMI and one AAS) not described on abdominal CT. A majority (71.4%) of the TRO abnormalities were overlooked on the initial CT report. Conclusions: Radiologists should routinely assess the lower chest on abdominal CT to avoid overlooked TRO abnormalities. Full article

Chronic venous insufficiency (CVI) is a common peripheral vascular condition characterised by the retrograde blood flow in the lower extremities and its consequences such as oedema and other complications. Clinical severity of CVI is assessed according to the CEAP (Clinical, Etiological, Anatomic, and Physiopathologic) classification, which recognises seven grades of increasing clinical severity (C₀–C₆). Compression therapy aims to accelerate vein, lymph, and microcirculation flow and therefore reduce chronic nonbacterial inflammation and oedema of the extremities. In accordance with the elasticity and stiffness, compression bandages and garments are divided into short-stretch and long-stretch compression materials. Compression therapy is applicable in all stages of CVI. Moreover, compression therapy in conjunction with physical therapy and lifestyle modifications is more effective in reducing oedema, preventing venous distension, and reducing venous wall tension, all while improving calf muscle pump function. Physical therapy in CVI treatment combines everyday lifestyle modifications, physical activity, medical exercise, sports activity, hydrotherapy, and electrotherapy. Therefore, physical therapy is used either for prevention or either for therapeutic purposes in CVI. For grades CEAP C₀–C_2, preventive measures consist of education and counselling, medical exercise and general fitness, and sports and physical activities. However, for therapy in grades CEAP C₃–C₆, medical exercise and a specific rehabilitation programme, manual lymphatic drainage and massage, balneotherapy, and electrotherapy are recommended. Full article

Alzheimer’s disease (AD), epilepsy, and vascular dementia (VaD) are highly prevalent neurological diseases and lead global drivers of morbidity. While these conditions have been historically treated as distinct entities, they now appear to share convergent molecular and cellular processes that drive disease initiation and progression. This narrative review collates evidence from studies published from 2000 to 2025 to investigate overlapping mechanisms and therapeutic opportunities for the three conditions. Five interconnected mechanisms, excitotoxicity, neuroinflammation, oxidative stress, mitochondrial dysfunction, and vascular impairment, were identified as key driving processes resulting in self-sustaining cycles leading to neuronal injury, cognitive impairment, and seizure susceptibility. Clinically, this is represented by shared cognitive, behavioral, and functional impairments, and often, seizures can be overlooked during the dementia process. Therapeutic strategies which may be useful across diseases could include anti-inflammatory treatments, mitochondrial stabilizers, vascular health treatments, and protein aggregation changes. Important translational gaps also exist for practice particularly in the biomarker space and trials that allow intervention across diseases. Each of these conditions, in essence, represent the same inter-relationships at the level of pathophysiology and provides opportunities for multi-targeted treatment approaches and integrated research trajectories to ease the worldwide burden of neurodegenerative disorder. Full article

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease, is an autosomal dominant vascular disorder caused most commonly by pathogenic variants in the ENG and ACVRL1/ALK1 genes. It is characterized by mucocutaneous telangiectasias and arteriovenous malformations (AVMs) in various organs, leading to recurrent epistaxis, gastrointestinal bleeding, and iron deficiency anemia. Diagnosis relies on the Curaçao Criteria, which include recurrent nosebleeds, characteristic telangiectasias, visceral AVMs, and family history. This review aims to present current therapeutic approaches and emerging treatment strategies for HHT. Traditional surgical and laser-based methods are increasingly complemented or replaced by targeted pharmacological interventions. Antiangiogenic agents such as bevacizumab and thalidomide have demonstrated efficacy in reducing bleeding frequency and transfusion requirements, although adverse effects may limit long-term use. Novel therapies under investigation target molecular pathways involved in vascular remodeling, including tyrosine kinase inhibitors (sorafenib, nintedanib), anti-ANGPT2 antibodies, and modulators of BMP9/ALK1 signaling (tacrolimus, sirolimus). Preclinical and early clinical studies suggest that these agents may provide disease-modifying benefits. Continued research should focus on optimizing treatment efficacy, reducing toxicity, and developing individualized therapeutic regimens based on genetic and clinical characteristics. Full article

Background: Hypertension remains a leading cause of cardiovascular morbidity and mortality, disproportionately affecting low- and middle-income countries (LMICs), where healthcare access and awareness are limited. Excessive sodium intake, often from discretionary salt used in cooking, contributes significantly to this burden. Salt substitutes, typically formulated by partially replacing sodium chloride with potassium chloride or other minerals, offer a cost-effective dietary intervention to lower blood pressure (BP) and reduce cardiovascular risk, particularly in resource-constrained settings. Objective: This review examines the efficacy of low-sodium salt substitutes (LSSS) in reducing blood pressure (BP) and its effects on cardiovascular (CV) outcomes, safety concerns, and challenges to their implementation in LMICs. Methods: We conducted a comprehensive narrative review of studies published between 1994 and 2024 using PubMed, Embase, and Scopus databases. Eligible studies included randomized controlled trials, systematic reviews, observational studies, and implementation research that evaluated the effects of LSSS on BP, CV outcomes, safety, and feasibility in LMIC contexts. Thematic synthesis was used to summarize the findings. Key Findings: Salt substitutes consistently lowered systolic and diastolic BP across diverse populations, with mean reductions ranging from 3 to 5 mmHg. Trials have also demonstrated reductions in stroke incidence, CV events, and all-cause mortality. However, the benefits were mostly derived from studies conducted in China and other upper-middle-income settings. Safety concerns (particularly hyperkalemia in individuals with chronic kidney disease or RAAS inhibitors) warrant targeted risk screening and public education. Implementation barriers in LMICs include cost, limited availability, poor awareness, and a lack of regulatory oversight. Conclusions: Salt substitutes present a promising, scalable strategy to reduce BP and CV disease burden in LMICs. However, their adoption must be context-specific, culturally sensitive, and supported by government subsidies, regulatory frameworks, and educational campaigns. Future trials should evaluate the long-term safety and cost-effectiveness in underrepresented LMIC populations to guide equitable public health interventions. Full article

Background: Orthostatic hypotension (OH) is identified by a significant decrease in blood pressure upon standing from a seated or supine position. A reduction in systolic blood pressure of 20 mmHg within three minutes of standing meets the criteria for clinical diagnosis. We hypothesized that venous outflow obstruction from jugular valvular dysfunction or extrinsic compression of the left brachiocephalic vein may cause OH. Improving venous return and reducing venous congestion of the autonomic pathways through endovascular intervention could alleviate symptoms. Methods: This retrospective review included six male patients (aged 63–87) with medically refractory OH who underwent venograms revealing jugular, brachiocephalic, or subclavian vein stenosis. Patients were treated with balloon angioplasty and/or stenting. Blood pressure was measured in supine, seated, and standing positions before and immediately after the procedure, with multiple readings per position (total n = 117 for supine-standing comparisons). Statistical analysis used Welch’s t-test to compare pre- and post-procedural systolic blood pressure disparities. Results: The patients showed improved post-procedural blood pressure and reduced OH symptoms. The average supine-standing systolic disparity decreased from 38.68 mmHg preoperatively to 24.61 mmHg postoperatively (p = 0.024). The seated-standing disparity was insignificant, possibly due to autonomic compensation. Patients also reported relief from associated symptoms like headaches, tinnitus, and vertigo. Conclusions: These findings suggest venous outflow obstruction may contribute to OH, and venoplasty/stenting can mitigate symptoms, potentially reducing reliance on medications with adverse effects. Further studies should explore the role of Venous Outflow Obstruction Disorders in neurological conditions. Full article

Chronic type B aortic dissection (cTBAD) is a challenging condition frequently complicated by persistent false lumen (FL) perfusion, leading to aneurysmal degeneration. Despite significant advances in thoracic endovascular aortic repair (TEVAR), long-term management remains challenging because of continuous FL backflow from distal re-entry tears and progressive aortic dilatation. We present the first documented case of FL exclusion using a custom-made false lumen occlusion device (FLOD). A 77-year-old male who had undergone TEVAR in 2017 underwent computed tomography angiography (CTA) in 2025, with the results revealing aneurysmal degeneration of the descending thoracic aorta (maximum diameter 58.5 mm) and two distal re-entry tears with substantial FL perfusion. Following multidisciplinary evaluation, the patient underwent endovascular reintervention with proximal stent graft extension and the deployment of a custom FLOD into the FL via femoral access. Completion angiography confirmed proper FL exclusion with preservation of visceral artery patency. Transesophageal echocardiography demonstrated rapid FL thrombosis. The patient was discharged on postoperative day 5 in good condition without complications. This case highlights that combining endograft extension with a dedicated FLOD is a safe and effective strategy for selected patients with complex cTBAD anatomy. Full article

Background: Cardiovascular disease (CVD) is the leading cause of mortality in chronic kidney disease (CKD), driven by mechanisms distinct from the general population. Fibroblast Growth Factor 23 (FGF-23), a phosphaturic hormone elevated early in CKD, has been mechanistically linked to left ventricular hypertrophy, vascular dysfunction, and disordered mineral metabolism. This study examines the associations between FGF-23 and key renal, mineral, and cardiovascular parameters and its utility in risk stratification. Methods: We conducted a cross-sectional study of 60 adults with CKD stages 1–5. Serum FGF-23 was quantified using ELISA, alongside measures of iPTH, phosphorus, calcium, and eGFR (Estimated Glomerular Filtration Rate). Cardiovascular evaluation included transthoracic echocardiography and carotid intima-media thickness (CIMT). Associations were analyzed using Spearman correlations, ROC analysis, and multivariable logistic regression. Results: FGF-23 levels were significantly associated with declining eGFR (r = –0.288; p < 0.05), elevated iPTH (Intact Parathyroid Hormone) (r = 0.361; p < 0.05), and serum phosphorus (r = 0.335; p < 0.05). Patients with structural cardiac abnormalities (left atrial enlargement or left ventricular hypertrophy) exhibited higher FGF-23 concentrations (154 vs. 128 pg/mL; p = 0.027). FGF-23 alone predicted high cardiovascular risk with moderate accuracy (AUC 0.70; sensitivity 76%; specificity 67%). A composite model including iPTH and eGFR improved discriminatory power (AUC 0.76). Conclusions: FGF-23 correlates with subclinical cardiovascular remodeling and key mineral abnormalities in CKD. Its integration with iPTH and eGFR enhances cardiovascular risk stratification, supporting its potential as a multidimensional biomarker in early CKD. However, the cross-sectional design and modest correlation strengths limit causal inference and generalizability of the findings. Full article

An ascending aortic aneurysm is a localized dilation of the ascending aorta, which poses a high risk of aortic dissection or rupture, with surgery recommended at diameters > 5.5 cm. However, events also occur at smaller sizes, suggesting additional factors—such as stenosis—may significantly influence aneurysm severity. To investigate this, a computational fluid dynamics (CFD) analysis was conducted using a patient-specific ascending aortic model (aneurysm diameter: 5.28 cm) under three aortic stenosis severities: mild, moderate, and severe. Results showed that the severe stenosis condition led to the formation of prominent recirculation zones and increased peak velocities, 2.36 m·s⁻¹ compared to 1.53 m·s⁻¹ for moderate stenosis and 1.37 m·s⁻¹ for mild stenosis. A significantly increased pressure loss coefficient was observed for the severe case. Additionally, the wall shear stress (WSS) distribution exhibited higher values along the anterior region and lower values along the posterior region. Peak WSS values were recorded at 43.46 Pa in the severe stenosis model, compared to 21.98 Pa and 13.87 Pa for the moderate and mild cases, respectively. Velocity distribution and helicity analyses demonstrate that increasing stenosis severity amplifies jet-induced flow disturbances, contributing to larger recirculation zones and greater helicity heterogeneity in the ascending aorta. Meanwhile, WSS results indicate that greater stenosis severity is also associated with elevated WSS magnitude and heterogeneity in the ascending aorta, with severe cases exhibiting the highest value. These findings highlight the need to incorporate hemodynamic metrics, alongside traditional diameter-based criteria, into rupture risk assessment frameworks. Full article

Background: Giant cell arteritis (GCA) is a systemic granulomatous vasculitis affecting large and medium-sized arteries, predominantly in individuals over 50 years. While it traditionally involves cranial branches of the external carotid artery, particularly the temporal arteries, growing evidence underscores frequent extracranial involvement, especially in the supra-aortic trunks. Objective: We aimed to critically review the diagnostic utility of extended Color Doppler Ultrasound (CDUS) in GCA, with a focus on vertebrobasilar involvement and current international imaging guidelines. Methods: Taking inspiration from a representative case of extracranial GCA with vertebrobasilar ischemic events, the current literature and international recommendations (e.g., EULAR, ACR, BSR and SIR) were reviewed. Results: Diagnostic accuracy significantly improves when CDUS is extended to include carotid, vertebral, subclavian and axillary arteries. Elevated inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) correlate with large-vessel involvement and support the use of extended scanning protocols. International guidelines vary in their emphasis on extended CDUS, but consensus is growing toward ultrasound imaging-first strategies in expert hands. Conclusion: Extended CDUS is a sensitive, non-invasive first-line diagnostic tool for GCA. In patients with symptoms of the posterior cerebral circulation and elevated inflammatory indices, early comprehensive vascular imaging reduces diagnostic delay and may obviate the need for temporal artery biopsy. Full article

Background: Acute aortic occlusion (AAO) is a rare but life-threatening condition which can present with a spectrum of symptoms, ranging from mild cramping pain in the lower extremities (with or without sensory loss) to more dramatic motor loss and paraplegia. Once a diagnosis has been established, the treatment remains ambiguous, especially in a resource-limited setting. Treatment ranges from direct vascular intervention to systemic or directed thrombolysis—however, there is a lack of published literature on systemic thrombolysis, and thereby, consensus guidelines are nonexistent. Additionally, systemic thrombolysis bears a risk of hemorrhagic complications; however, the risk of death due to AAO is up to 57 times greater than the risk of intracerebral hemorrhage from systemic thrombolysis. Methods: This case report explores the prompt diagnosis of an acute aortic occlusion causing bilateral acute lower extremity ischemia in a sixty-three-year-old female patient treated with systemic thrombolysis. Results: The patient received 100 mg of tPA (without a bolus dose, over a two-hour period) in the Emergency Department (similar to that which is administered for the full-dose pulmonary embolism protocol). One hour after administration, the patient had restored flow to the bilateral lower extremities verified using bedside color-flow Doppler, with a drastic improvement in her symptoms. Two days after systemic thrombolysis, a repeat CTA showed evidence of complete resolution of her aortic clot. Her condition was complicated by a brief episode of retroperitoneal bleeding (presenting with flank pain) while on a heparin drip after admission (day two), which was resolved through discontinuation of the heparin drip and a two-unit blood transfusion. Conclusion: The patient was discharged with full function of the lower extremities on day six without anticoagulation. At her 2-week follow-up appointment, she was noted to be ambulatory without any neurodeficit, with a persistently restored arterial flow to the lower extremity. The application of systemic tPA could be paramount in the treatment of AAO in the setting of ischemic limb pathology, particularly at rural hospitals and healthcare centers where urgent direct vascular intervention may not be possible. Full article

Introduction: Isolated true subclavian artery aneurysm (SAA) is a rare form of peripheral arterial aneurysm that poses significant anatomical challenges to endovascular repair, especially in cases requiring planned vertebral artery (VA) sacrifice. The Balloon Occlusion Test (BOT) is a critical preoperative tool for evaluating collateral circulation before VA embolization. Case Report: A 74-year-old male was admitted with a pulsatile mass in the left supraclavicular fossa, and a 65 mm aneurysm of the intrathoracic segment of the left subclavian artery (LSA) involving critical arterial branches was diagnosed by computed tomography angiography. Due to his comorbidities, the patient was judged unfit for an open surgical repair of the aneurysm, and a two-stage endovascular subclavian aneurysm repair (EVSAR) was planned. The first step included embolization of the internal mammary artery and thyrocervical trunk, followed by BOT of the left VA, which confirmed an adequate perfusion of the posterior cerebral and cerebellar circulation that allowed safe VA embolization. The second step included zone 2 thoracic endograft placement (TEVAR) with LSA coverage and vascular plug occlusion of the proximal segment of the LSA and the axillary artery. Postoperative monitoring revealed no neurological deficit, and the patient was discharged home without complications. Follow-up imaging up to 24 months confirmed complete aneurysm exclusion and significant sac shrinkage. Conclusions: EVSAR with thoracic endograft and VA sacrifice, preceded by BOT, may be a safe and effective minimally invasive approach for the treatment of intrathoracic SAA. Full article

Background/Objectives: Unruptured intracranial aneurysms (UIAs) carry a risk of subarachnoid hemorrhage (SAH), which has a high mortality rate of up to 45% and significant long-term disability among survivors. Traditional surgical clipping and endovascular treatment (EVT) are widely used, but both have limitations: EVT shows higher recurrence and retreatment rates, while open clipping poses higher procedural risks. Minimally invasive craniotomy (MIC) techniques are emerging as a promising third option, offering potential benefits in terms of safety, durability, and recovery. This study aims to compare MIC and EVT for UIAs to evaluate their relative efficacy, safety, and long-term outcomes. Methods: A systematic literature review was conducted using PubMed and Scopus. Inclusion criteria encompassed original, peer-reviewed studies reporting clinical outcomes of UIA treatments. Data extracted included study characteristics, treatment modality, complication rates, recurrence, retreatment, and patient outcomes. Results: MIC demonstrated low complication rates (1.6–5.88%), for which the percentage was significantly lower than that for stent-assisted coiling (37%) and flow diversion (17%), while maintaining similar efficacy to traditional clipping. New EVT techniques such as WEB devices showed less procedural risks (0.7%) but higher retreatment rates. Conclusions: This review shows that while traditional craniotomy for aneurysm clipping carries higher perioperative risk than EVT, most studies have failed to compare long-term recurrences. MIC has significantly lower perioperative complications rates, comparable to EVT, and provides the same durability with improved cosmetic results. MIC should be considered when selecting patients as an alternative to EVT, particularly for unruptured anterior circulation aneurysms. Further prospective studies are needed to guide treatment decisions. Full article