Journal of Vascular Diseases

Background: Pancreatic Ductal Adenocarcinoma (PDAC) is one of the most common malignancies associated with thrombotic events. While there is research present on various techniques of portal vein reconstruction, there is limited published data on the techniques and/or considerations of reconstruction in the setting of complete portal vein occlusion. We therefore sought to analyze and present our experience of this clinical scenario. Methods: This was a retrospective analysis of a prospectively collected database. All patients who underwent portal vein resection and/or reconstruction during a pancreatic resection were included. Post-operatively, all patients underwent a contrast-enhanced CT scan on post-operative day 1 to assess for any portal vein thrombus. Results: Pancreatic resection with portal vein reconstruction was performed in 183 patients. Complete PV occlusion was seen in 12 patients at the time of surgery. In those patients with an occluded PV, reconstruction options included primary repair with end-end anastomosis (n = 2) or use of an interposition graft (n = 9). Interposition graft conduits included the left renal vein (n = 6), tubularized bovine pericardium (n = 3), and femoral vein (n = 1). Post-operative portal vein thrombus was seen in 4/12 patients. The majority of patients (n = 7) were discharged on therapeutic anticoagulation, 4 were discharged on an antiplatelet, and 1 patient received neither. Conclusions: Based on our series, we would recommend attempting PV reconstruction in these patients with an interposition graft (with autologous left renal vein or bovine pericardium). We believe that with this technique, the post-operative thrombosis risk is similar to PV reconstructions in non-occluded patients. Full article

Background and aim: Low-density lipoprotein cholesterol (LDL-C) is an important and well-established modifiable risk factor for cardiovascular disease, including peripheral artery disease (PAD). We aimed at evaluating the lipid profile at admission in PAD patients with an indication for invasive treatment. Methods: Among patients with PAD diagnosis admitted to the vascular surgery department, those receiving statins and those with LDL-C values in the recommended target (<55 mg/dL) were identified. The correlation of LDL-C values with different clinical variables was investigated. Results: Of the 399 patients, 259 (65%) were on statin therapy. According to multivariate linear regression analysis, diabetes (p = 0.004), previous CAD history (p < 0.001), and statin therapy (p < 0.001) were independently associated with LDL-C levels. Patients with LDL-C < 55 mg/dL at admission were 89 (22% of the overall cohort). Among these patients, diabetes (48.3% versus 35.8%, p = 0.036), CAD history (52.8% versus 30%, p < 0.001), and statin use (91% versus 57.4%, p < 0.001) were more frequent as compared with patients not at target. Conclusion: Despite the very high cardiovascular risk of our group, the rate of statin prescription was very low and far from ideal. Only a small percentage of patients achieved target LDL-C values. Patients with coexistent diabetes and CAD had lower LDL-C values, suggesting management by specialists with greater attention to lipid profile and pointing out an urgent need for information on cardiovascular disease management. Full article

Aortic aneurysm is a vascular disease with a complex pathogenesis which is usually asymptomatic but can lead to high mortality with sudden rupture. This review comprehensively examines the molecular mechanisms of aortic aneurysms in the context of extracellular matrix destruction, smooth muscle cell apoptosis, chronic inflammation, oxidative stress, genetic mutations, and epigenetic regulations. In addition, the potential of molecular biomarkers in diagnosis and prognosis and targeted treatment strategies are evaluated. Animal models and translational findings form the basis for establishing a bridge between preclinical and clinical applications. This study aims to provide insight into the integration of molecular findings into clinical practice in light of the current literature and to guide future research. Full article

Background/Objectives: Radial artery occlusion (RAO) following hemostasis after coronary procedures is the most common complication, with a highly variable incidence (1–33%). While it is well established that the patent hemostasis technique reduces RAO rates, it remains unclear which device should be preferred. The wide variety of available radial hemostasis devices makes it necessary to identify those associated with a lower incidence of complications. Methods: Literature from 2016 to 2021 was reviewed through a systematic search in PubMed, CINAHL, Cochrane, and Embase databases. Only randomized controlled trials (RCTs) involving adult patients undergoing percutaneous transradial coronary procedures were included. Devices considered included pneumatic compression devices, manual compression, elastic bandages, and hemostatic dressings. The review process followed PRISMA guidelines. Two random-effects frequentist network meta-analyses were conducted to compare the effects of 16 and 9 radial hemostasis devices on RAO incidence at 24 h and 30 days after the procedure. Results: A total of 17 RCTs were included. The network meta-analysis (NMA) showed a protective effect at the 24 h endpoint for both double-balloon devices and pneumatic compression devices adjusted to mean arterial pressure. At the 30-day endpoint, significant differences were observed among pneumatic compression, chitosan-based PADs, mechanical compression devices, and adjustable elastic bandages. Conclusions: Although some treatments with specific devices significantly differ from the reference treatment, the limited availability of data to assess RAO at 30 days and a certain heterogeneity between devices indicate the need for further investigation. Full article

Late ruptures of abdominal aortic aneurysms post-endovascular aneurysm repair present a significant risk, occurring in about 0.9% of cases. The typical timeframe leading to rupture is roughly 37 months, with the primary factors often linked to endoleaks, especially types I and III, which sustain pressure within the aneurysm sac. The approaches to managing late ruptures consist of endovascular approaches, open surgical interventions, and conservative care, each customised to the patient’s specific characteristics. When feasible endovascular repair is favoured, additional stent grafts are deployed to seal endoleaks and offer lower perioperative mortality rates compared to those for open surgery. Open repair is considered when endovascular solutions fail or are not feasible. Conservative management with active monitoring and supportive treatment can be considered for haemodynamically stable non-surgical patients. Endovascular repair methods like fenestrated/branched EVAR (F/BEVAR) and parallel grafting (PGEVAR) are effective for complicated anatomies and show high technical success with reduced morbidity compared to that with open repairs. Chimney techniques and physician-modified endografts may help regain and broaden the sealing zone. Limb extensions with or without embolisation, interposition endografting, and whole-body relining are helpful options for type IB and type 3–5 endoleaks. Open surgical repair carries a higher perioperative mortality but may be essential in preventing death due to rupture following failed EVAR. The choice depends on the patient’s clinical stability and fitness for surgery in the absence of a viable endovascular alternative. This article discusses the available options for treating late rupture after EVAR, emphasising the importance of individualised treatment plans and the need for rigorous postoperative surveillance to prevent such complications. Full article

Patients with End-Stage Renal Disease (ESRD) represent a very fragile population, presenting with higher rates of complications and morbidity following vascular interventions. This study aims to analyze post-operative outcomes, such as mortality, readmissions, and amputations, in patients with Peripheral Arterial Disease (PAD) and ESRD on dialysis. Methods: A retrospective cohort study was conducted of patients with PAD and ESRD on dialysis who underwent vascular interventions between 2015 and 2017. This study focused on post-operative outcomes, including mortality, readmissions, and amputations. The data were analyzed to identify patterns and correlations. Results: This study found that patients with PAD and ESRD have long hospital stays, high amputation rates, high readmission rates, and treatment failure. Above-knee amputation (AKA) and female gender were associated with higher mortality rates, while prior stroke was associated with higher odds of readmissions. Conclusions: This study highlights the need for further studies with larger patient populations to identify independent predictors of negative outcomes. The findings suggest that specific factors, such as AKA, female gender, and prior stroke, significantly impact post-operative outcomes in this patient population. Full article

Objectives: This study investigates the effects of cluster set resistance training (RT) on heart rate variability (HRV) parameters in young, healthy individuals. Methods: This trial was registered in the Brazilian Clinical Trials Registry (ReBEC) under the identification number RBR-9857xj3 on 7 December 2024. Sixteen participants (seven female, 25 ± 2 years old) performed both cluster set and traditional RT protocols with equal relative intensity (85% 10RM), volume load (4 × 10 repetitions), and rest intervals (120 s). Cluster set configuration involved the introduction of a shorter rest interval between a cluster of sets [4 × (2 × 5) with 90 s inter-set rest and 30 s intra-set rest]. HRV parameters (RMSSD, HFnu, SD1, LFnu, LF/HF ratio, and SD2) were assessed before and 30 min post-exercise. The rating of perceived exertion (RPE) was assessed immediately after RT protocols. Results: The traditional RT protocol led to a significant reduction in parasympathetic activity (RMSSD, HFnu, SD1) and an increase in sympathetic activity (LFnu, LF/HF ratio, and SD2) (p < 0.05), whereas the cluster set RT protocol did not alter HRV parameters. Additionally, RPE was significantly higher (p < 0.001) in the traditional RT protocol. Conclusion: This study suggests that the cluster set may have a less pronounced impact on HRV parameters 30 min post-exercise compared to traditional sets. These findings can guide exercise physiologists in designing resistance training programs for clinical populations by prescribing protocols that minimize cardiac autonomic stress. Full article

Peripheral artery disease (PAD) is a chronic progressive accumulation of atherosclerotic lesions with varying degrees of arterial obstruction determining ischemic symptoms of the involved extremities. PAD is associated with decreased bioavailable nitric oxide due to endothelial cell dysfunction and the development and progression of vascular arterial stiffening (VAS). Atherosclerosis also plays an essential role in the development and progression of vascular arterial stiffening (VAS), which is associated with endothelial cell activation and dysfunction that results in a proinflammatory endothelium with a decreased ability to produce bioavailable nitric oxide (NO). NO is one of three gasotransmitters, along with carbon monoxide and hydrogen sulfide, that promotes vasodilation. NO plays a crucial role in the regulation of PAD, and a deficiency in its bioavailability is strongly linked to the development of atherosclerosis, VAS, and PAD. A decreased arterial patency may also occur due to a reduction in the elasticity or diameter of the vessel wall due to the progressive nature of VAS and atherosclerosis in PAD. Progressive atherosclerosis and VAS promote narrowing over time, which leads to impairment of vasorelaxation and extremity blood flow. This narrative review examines how atherosclerosis, aging and hypertension, metabolic syndrome and type 2 diabetes, tobacco smoking, and endothelial cell activation and dysfunction with decreased NO and VAS with its increased damaging pulsatile pulse pressure result in microvessel remodeling. Further, the role of ischemia and ischemia–reperfusion injury is discussed and how it contributes to ischemic skeletal muscle remodeling, ischemic neuropathy, and pain perception in PAD. Full article

Background: Stroke is a major cause of morbidity and mortality worldwide, with distinct pathophysiological mechanisms between ischemic stroke (IS) and hemorrhagic stroke (HS). Hematological parameters, such as lymphocyte and erythrocyte count, have been implicated in stroke prognosis, but their predictive value remains uncertain. Objective: To evaluate the association between hematological biomarkers and stroke subtypes (ischemic stroke and hemorrhagic stroke), and transient ischemic attack. Methods: This cross-sectional study analyzed clinical, metabolic, and hematological parameters in patients with stroke. Logistic regression models, adjusted for age, gender, and ethnicity, were applied to assess the association between lymphocyte and erythrocyte counts and stroke subtypes. Results: Lymphopenia was significantly associated with higher odds of hemorrhagic stroke (HS) in both the TIA–HS (OR 1.15, 95% CI: 1.05–1.26, p = 0.004) and the IS–HS models (OR 1.11, 95% CI: 1.03–1.20, p = 0.009). Additionally, erythrocyte count was significantly associated with increased odds of conversion from IS to HS (OR 3.97, 95% CI: 1.45–10.89, p = 0.007). The lymphocyte-to-monocyte ratio (LMR) was significantly different between IS and HS (OR = 1.38, 95% CI: 1.07–1.78, p = 0.014), while no significant association was found between TIA and HS (p = 0.399). Conclusions: Hematological parameters varied among stroke subtypes, with lymphopenia associated with hemorrhagic stroke and erythrocyte count differing between IS and HS. While these findings may aid in stroke characterization, further studies are needed to confirm their clinical relevance. Full article

Background: Varicose veins (VVs) of the lower limbs, characterized by palpable, dilated, and tortuous veins, affect 2–73% of the global population. Artificial intelligence (AI) offers significant potential to enhance healthcare efficiency and decision-making, particularly in managing VVs through improved risk factor identification, diagnosis, and treatment planning. Objective: This abstract explores the role of AI in VV management, focusing on its applications in risk detection, image analysis, treatment planning, and surgical interventions, while addressing challenges to its widespread adoption. Methods: AI leverages advanced techniques such as computer vision and deep learning to analyze patient data, including medical history, symptoms, physical examinations, and imaging (e.g., ultrasounds, venography). It identifies patterns in large datasets to support personalized treatment plans, early risk detection, and disease severity assessment. Results: AI demonstrates promise in automating VV detection and classification, assessing disease severity, and aiding treatment planning. It enhances surgical interventions through preoperative planning, intraoperative navigation, and recurrence risk prediction. However, its adoption is limited by a lack of large-scale studies, concerns over accuracy, and the need for regulatory and ethical oversight. Conclusion: AI has the potential to revolutionize VV management by improving diagnosis, treatment precision, and patient outcomes. Further research, validation, and integration are critical to overcoming current limitations and fully realizing AI’s capabilities in clinical practice. Full article

The aging of the global population over recent decades has resulted in an increased prevalence of hypertension in older adults. Hypertension develops with increasing age primarily due to a disastrous feedback loop of increased arterial stiffness and maladaptive hemodynamics; this is compounded by age-related changes in physiology. The risk of adverse hypertension-related outcomes concurrently increases with age, and optimal blood pressure (BP) control in older adults thus becomes increasingly important each year. The results of several randomized clinical trials (RCTs) evaluating antihypertension strategies in older adults have concluded that the potential benefits of intensive BP management outweigh the risks of harm. However, the exclusion of frail, multimorbid, and institutionalized individuals limits the generalizability of such findings to the broader population of older patients with hypertension. Secondary analyses and external studies have continued to support intensive BP control strategies in older adults with frailty or sarcopenia. Therefore, based on available evidence, clinicians should continue practicing intensive BP control strategies in the older population, yet careful consideration of functional status, life expectancy, medication side effects, polypharmacy, and multimorbidity must take place to avoid unnecessary harm. Strategies must then be tailored to accommodate modifiers such as frailty and sarcopenia in older adults with hypertension. Knowledge gaps underscore the need for future studies evaluating BP management in older adults that incorporate greater proportions of multimorbid and institutionalized individuals with frailty, assess personalization of treatment, and identify subgroups in which optimal BP levels exist or the permissibility of higher BP levels is safer than BP reduction. Full article

Background: Vascular Ehlers–Danlos syndrome (vEDS) is a rare connective tissue disorder characterized by collagen type III deficiency, predisposing to spontaneous arterial, uterine, and intestinal ruptures. While intestinal complications are recognized in vEDS, intestinal failure (IF) secondary to these complications is a rare and potentially life-threatening occurrence. This study aimed to describe the clinical presentation, surgical management, and outcomes of pediatric patients with IF secondary to vEDS and to provide a comprehensive review of the limited existing literature on this challenging clinical scenario. Methods: This study comprises a case series of pediatric patients with IF due to vEDS complications and a comprehensive literature review. Clinical data were collected from medical records, including age at diagnosis, surgical history, complications, nutritional status, and long-term outcomes. A literature review was performed to identify studies reporting gastrointestinal complications, surgical outcomes in pediatric vEDS patients, and cases of intestinal failure. Results: Two pediatric patients with vEDS and IF were included. Both patients experienced intestinal perforations and surgical complications and required long-term parenteral nutrition (PN). One patient required PN for 18 months before achieving enteral autonomy, while the other remains dependent. The literature review included four articles and revealed a high risk of complications, including anastomotic leaks, fistulae, and recurrent perforations, in patients with vEDS undergoing intestinal surgery. Delayed diagnosis of vEDS was common. Conclusions: Intestinal complications in pediatric patients with vEDS can lead to severe short bowel syndrome and long-term PN dependence. Early diagnosis and a multidisciplinary approach are crucial for optimizing patient care and minimizing complications. Full article

Cerebral microbleeds (CMBs) are increasingly detected in patients with aortic and cardiac diseases following transcatheter aortic valve implantation (TAVI), thoracic endovascular aortic repair (TEVAR), or cardiac surgery. CMBs can be observed in magnetic resonance imaging (MRI) when susceptibility-weighted imaging (SWI) or T2*-Gradient-Echo (GRE) sequences are used. Differential diagnosis of CMBs from other causes, such as cerebral amyloid angiopathy (CAA), is crucial because of its clinical implications, particularly for anticoagulation management. A literature search was conducted using publicly available online databases to identify relevant studies for this review. The selection criteria focused on publications utilizing MRI with T2*-GRE or SWI sequences to detect CMBs in patients following cardiac or endovascular procedures. The extracted data included study characteristics, lesion distribution, and associated clinical factors. Ten studies were included in this review, with 50% analyzing a prospective cohort. Cerebral T2*-GRE or SWI hypointensities after cardiac and vascular procedures often showed a lobar distribution, thus complicating the differential diagnosis with “probable” CAA. However, CMBs seem predominantly located in subcortical white matter (SWM), unlike CAA, and commonly not associated with other alterations. Furthermore, CMBs seem to correlate with prolonged procedural duration, especially in the case of cardiopulmonary bypass, and anticoagulation therapy. Regarding etiology, various hypotheses have been proposed, with the most widely accepted being microhemorrhagic. CMBs are a common finding following cardiac procedures, either surgical or endovascular. Their distribution patterns may aid in differentiating from CAA-related lesions, with important implications for anticoagulation strategies. Identifying and characterizing these lesions is essential for optimizing postoperative management. Full article

Background/Objectives: Cerebrovascular reactivity (CVR) and time shift (TS) are vascular-related parameters that reflect cerebral perfusion and may be associated with the risk of developing stroke in patients with asymptomatic carotid artery stenosis (ACAS). We investigated CVR and TS in patients with ACAS using resting-state magnetic resonance imaging based on blood-oxygen-level-dependent contrast (BOLD-MRI). Methods: We included twenty patients with severe unilateral ACAS and twenty age-matched controls. Individual CVR maps were obtained through a voxel-wise regression of the MRI signal, using the global signal filtered in a specific frequency range (0.02–0.04 Hz) as the regressor. A recursive cross-correlation method provided individual TS maps through the BOLD low-frequency fluctuation. CVR and TS values were obtained for the territories irrigated by the main cerebral arteries (anterior, middle, and posterior) separated into proximal, intermediary, and distal regions. Results: Compared to controls, ACAS patients presented reduced CVR and increased TS in the distal parts of the brain vascular territories. Individual CVR and TS values varied more within the patient group than controls. Such individual variability may help identify patients eligible for intervention better than the stenosis grade. Conclusions: CVR and TS may indicate subtle hemodynamic changes and assist in identifying regions at higher risk of neuronal damage or ischemic stroke on an individual basis, aiding in the stratification of patients with ACAS based on their risk of progressing to stroke. Full article

Background: The superficial temporal artery (STA) typically bifurcates into frontal and parietal branches in the temporal region. This study describes a rare anatomical variation identified during a cadaveric dissection where the STA presented an early cervical bifurcation. Methods: A cadaveric dissection was performed on a 58-year-old Caucasian female specimen injected with synthetic polymers. The STA was meticulously dissected, and anatomical findings were documented through photographs and measurements. Results: An unusual cervical bifurcation of the STA was observed. The frontal and parietal branches originated at the level of the posterior belly of the digastric muscle, ascending separately. The anterior branch, identified as the frontal branch, coursed below the facial nerve and stylomastoid artery, reaching the temporal line without further branching after giving the transverse facial artery as the only collateral branch. The posterior parietal branch extended posteriorly to the external acoustic meatus, compensating for the absence of the posterior auricular artery. This anatomical variation might influence surgical approaches to the head and neck region, particularly in parotid and reconstructive surgeries. Discussion: Variations in STA anatomy can significantly impact clinical practices, including reconstructive surgery, vascular interventions, and esthetic procedures. Imaging techniques, though useful, may not detect such rare variants. Cadaveric dissection remains a crucial tool for detailed anatomical assessment. Conclusions: This study highlights the importance of recognizing the STA’s vascular variations for safe surgical planning and improving patient outcomes. Further studies correlating imaging findings with cadaveric dissections are recommended. Full article

Background: Endovascular aortic aneurysm repair (EVAR) is a commonly used treatment for abdominal aortic aneurysms (AAAs), but anatomical complexities limit its application in certain cases. Objective: This study evaluates the mid-term outcomes, referring to a follow-up period with a mean of 29.9 ± 24.1 months (approximately 1–5 years), of a novel double-barrel technique that employs overlapping tubular stent grafts to address these challenges. Methods: A retrospective analysis was conducted on seven patients treated with this technique from May 2014 to February 2023. Patients had narrow and short proximal necks, inadequate landing zones, or required re-do procedures. Results: The double-barrel technique achieved technical success in 85.7% of cases with zero mortality. Patients had an average hospital stay of 11.9 ± 10.0 days and attended follow-up for a mean of 29.9 ± 24.1 months. Minimal complications and no significant adverse events were reported. Conclusions: These findings suggest that the double-barrel technique is a cost-effective and viable alternative for anatomically complex cases where standard EVAR is unsuitable. While promising mid-term outcomes were observed, further studies with larger cohorts are necessary to confirm its long-term effectiveness and broader applicability. Full article

Background: Mycotic aneurysms of the subclavian artery are infrequent and pose significant diagnostic challenges, particularly in the context of recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The concomitant presence of upper extremity deep vein thrombosis (UEDVT) further complicates the management of bleeding risk and the necessity for anticoagulation therapy. Methods: This report discusses a 75-year-old male patient with a medical history of lung and skin cancer undergoing immunotherapy who presented with a swollen and painful right arm. Ultrasound examination identified deep vein thrombosis in the right axillary and basilic veins, and blood cultures confirmed MRSA infection. Subsequent imaging revealed bilateral subclavian artery aneurysms with contained ruptures involving previously placed stent grafts. Emergent endovascular interventions were performed to prevent catastrophic hemorrhage. Results: Despite the initial interventions, concerns regarding infected stent grafts persisted due to ongoing MRSA bacteremia and the presence of an endoleak. The complexity of balancing anticoagulation for DVT with the risk of aneurysm rupture necessitated the patient’s transfer to a tertiary care center for potential open surgical debridement. Conclusions: This case underscores the diagnostic and therapeutic challenges associated with the simultaneous occurrence of vascular infection, thrombosis, and aneurysmal pathology. Although emergency endovascular repair provided temporary hemostatic control, definitive management may require graft removal if stent infection is confirmed. Optimal care in such complex clinical scenarios demands a multidisciplinary approach and may necessitate advanced surgical interventions. Full article

Median Arcuate Ligament Syndrome, also known as Dunbar’s syndrome, is a rare condition caused by stenosis of the celiac artery (CAS) through the fibrous arch connecting the diaphragmatic branches. It manifests as postprandial abdominal pain, nausea, vomiting, weight loss and increased epigastric tenderness. The condition most commonly affects young females without coexisting vascular comorbidities. Diagnosis is difficult due to the non-specific symptoms, often overlapping with other gastrointestinal diseases. Standard investigations include duplex ultrasound, computed tomography angiography (CTA) and contrast-enhanced magnetic resonance imaging (CE-MRA). Treatment mainly consists of surgical release of the arch ligament, which can be performed by open, laparoscopic or robotic methods. Surgery is often supported by celiac truncal stenting for residual stenosis, which significantly improves vascular flow. Alternative approaches include visceral plexus blocks and novel hybrid techniques, such as a combination of ligament release and endovascular treatment of the celiac trunk. In severe cases, vascular by-passes are recommended. The aim of this paper is to discuss the clinical manifestations, diagnostic possibilities, therapeutic options and directions for further research on MALS from the perspective of a vascular surgeon. It emphasizes the need for a multidisciplinary approach, including collaboration between the surgeon, radiologist, gastroenterologist and psychologist, which enables comprehensive disease management and improved quality of life for patients. In addition, the need for further development of diagnostic and therapeutic methods for early diagnosis and effective treatment was pointed out. Full article

Renal artery stenosis (RAS) is a vascular condition characterized by narrowing of one or both renal arteries, leading to reduced blood flow to the kidneys, activation of the renin–angiotensin–aldosterone system (RAAS), and subsequent renovascular hypertension. Overactivation of the same cascade potentiates the production of angiotensin II, which induces systemic vasoconstriction, increases sodium and water retention via aldosterone, and activates the sympathetic nervous system. Angiotensin II is also implicated in endothelial dysfunction, oxidative stress, and chronic inflammation, thus impairing vascular remodeling and arterial stiffness, all of which serve to accelerate cardiovascular complications, such as left ventricular hypertrophy, heart failure, and myocardial infarction. RAS is usually due in at least 90% of cases to atherosclerosis, which typically affects older people with diabetes and smoking as risk factors. There are two types of RAS: unilateral and bilateral. Bilateral RAS is commonly associated with flash pulmonary edema, a life-threatening emergency condition in which alveolar space flooding can occur within minutes. RAS typically remains asymptomatic until the late stage with complications of hypertension, ischemic nephropathy, or chronic kidney disease. FMD tends to create structural abnormalities of the artery, whereas atherosclerosis causes plaque formation and endothelial dysfunction of the artery. Epidemiological surveys have revealed that the prevalence of RAS ranges from 4% to 53% and is especially high among patients with hypertension, cardiovascular disease, or CKD. Diagnosis is based on clinical suspicion and supported by imaging studies, including Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography. Early detection also relies on certain laboratory biomarkers, especially in identifying high-risk patients. These markers would include increased plasma renin activity, elevated aldosterone-renin ratio, and inflammatory markers, including C-reactive protein and endothelin-1. Treatment would also involve pharmacological approaches, including RAAS inhibitors, beta-blockers, and statins, and interventional treatments, including angioplasty and stenting in patients with severe forms of the disease. However, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) Trial showed that most patients would likely require medical therapy, and that intervention should be reserved for those with uncontrolled hypertension, progressive renal dysfunction, or recurrent episodes of pulmonary edema. Other emerging therapies include drug-eluting balloons, bioresorbable stents, and gene-editing techniques, all of which have shown great promise in the few studies that have been conducted, although further evaluation is needed. Despite these advances, there are still gaps in knowledge regarding patient stratification, biomarker validation, and the development of personalized treatment strategies. This article reviews the complexities of RAAS and its systemic impact on cardiovascular and renal health. Future research can therefore focus on improving early diagnosis, optimizing patient selection for intervention, and developing new therapies to slow disease progression and mitigate complications. Full article