Search Results (86)

Ischemia–reperfusion is a rapidly evolving cascade that involves a variety of metabolic shifts whose precise timing and sequential order are still poorly understood. Clarifying these dynamics is critical for understanding the core injury trajectory of stroke and for refining time-delimited therapeutic interventions. More broadly, continuous in situ monitoring of the middle-cerebral-artery occlusion process at the system level has not yet been achieved. Here, we report the first single-subject high-resolution spatiotemporal resolution metabolic maps of the ultra-early phase of ischemic stroke in a rodent model. Matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) imaging mapped a metabolic abnormality area in the ischemic hemisphere that propagates from the striatum to the cortex. Microdialysis probes were then stereotaxically implanted within this metabolic abnormality area, capturing 10,429 metabolites that resolved into 16 temporally distinct trajectories aligned with probe insertion, ischemic injury, and reperfusion injury. Analysis of specific metabolic pathways mainly revealed that the delayed clearance of metabolic waste (urea and tryptamine) during early reperfusion, the transient attenuation of the citrate-to-oxaloacetate buffering gradient within the TCA cycle, and the accumulation of extracellular branched-chain amino acids all play crucial roles in shaping the injury trajectory. Simultaneously, the depletion of cellular repair mechanisms (pyrimidine synthesis) in the early phase of reperfusion also warrants our attention. These findings provide novel insights into the molecular basis and mechanisms of ischemia–reperfusion and offer a comprehensive resource for further investigation. Full article

Objective: Stent-assisted treatments for intracranial aneurysms, including stent-assisted coiling (SAC) and flow diversion (FD), are associated with an increased thrombotic risk despite dual antiplatelet therapy (DAPT). Recently, intravenous prophylactic protocols incorporating glycoprotein IIb/IIIa antagonists, adapted from cardiology practices, have been introduced. This study evaluates the safety and efficacy of prophylactic low-dose intra-arterial Eptifibatide for cerebral aneurysm management using SAC or FD. Methods: This single-center, single-arm, retrospective study included 99 patients who underwent endovascular treatment with stent-assisted coiling (SAC) or flow diversion (FD) between 2017 and 2023. All patients were initiated on dual antiplatelet therapy (DAPT) 7 days prior to the procedure. Prophylactic intra-arterial Eptifibatide (2–3 mg) was administered intra-procedurally, immediately after stent deployment. Complications were recorded and categorized as periprocedural (occurring during or within 24 h of the procedure) or postprocedural (occurring between 24 and 72 h after the procedure), and included both thrombotic and hemorrhagic events. Results: Among the 99 patients (mean age 57.0 ± 10.8 years), periprocedural complications included three cases of ischemic-related neurological deficits, with no evidence of stent thrombosis or intracranial branch occlusion. All deficits were resolved within 48 h. An additional two patients developed ischemic-related neurological deficits post-procedural. One patient fully recovered following a short rehabilitation period, while the other was left with mild permanent deficits. Overall, any complications following Eptifibatide administration were observed in 5.1% of patients. No hemorrhagic complications were recorded. Conclusions: Prophylactic low-dose intra-arterial Eptifibatide demonstrated a favorable safety profile, potentially reducing thrombotic complications without substantially increasing hemorrhagic risk. Full article

Background and Clinical Significance: Tandem pathology at the dominant-hemisphere middle cerebral artery (MCA)—combining a wide-neck bifurcation aneurysm that shares the neck with both M2 origins and a short dorsal M1 fusiform dilation embedded in the lenticulostriate belt—compresses the therapeutic margin and complicates device-first pathways. We aimed to describe an anatomy-led, microscope-only sequence designed to secure an immediate branch-definitive result at the fork and to remodel dorsal M1 without perforator compromise, and to place these decisions within a pragmatic perioperative framework. Case Presentation: A 37-year-old right-handed man with reproducible, load-sensitive cortical association and capsulostriate signs underwent high-fidelity digital subtraction angiography (DSA) with 3D rotational reconstructions. Through a left pterional approach, vein-respecting Sylvian dissection achieved gravity relaxation. Reconstruction proceeded in sequence: a fenestrated straight clip across the bifurcation neck with the superior M2 encircled to preserve both M2 ostia, followed by a short longitudinal clip parallel to M1 to reshape the fusiform segment while keeping each lenticulostriate mouth visible and free. Temporary occlusion windows were brief (bifurcation 2 min 30 s; M1 < 2 min). No neuronavigation, intraoperative fluorescence, micro-Doppler, or intraoperative angiography was used. No perioperative antiplatelets or systemic anticoagulation were administered and venous thromboembolism prophylaxis followed institutional practice. The bifurcation dome collapsed immediately with round, mobile M2 orifices, and dorsal M1 regained near-cylindrical geometry with patent perforator ostia under direct inspection. Emergence was neurologically intact, headaches abated, and preoperative micro-asymmetries resolved without new deficits. The early course was uncomplicated. Non-contrast CT at three months showed structurally preserved dominant-hemisphere parenchyma without infarction or hemorrhage. Lumen confirmation was scheduled at 12 months. Conclusions: In dominant-hemisphere tandem MCA disease, staged, perforator-sparing clip reconstruction can restore physiologic branch and perforator behavior while avoiding prolonged antiplatelet exposure and device-related branch uncertainty. A future-facing pathway pairs subtle clinical latency metrics with high-fidelity angiography, reports outcomes in branch- and perforator-centric terms, and, where available, incorporates patient-specific hemodynamic simulation and noninvasive lumen surveillance to guide timing, technique, and follow-up. Full article

Endovascular repair of thoracoabdominal aortic aneurysms (TAAAs) requires multidisciplinary expertise to minimize mortality and disabling complications. Despite satisfactory outcomes with this approach being common knowledge, extensive aortic coverage occurring in fenestrated/branched endovascular aortic repair (F/B-EVAR) carries a non-negligible risk of spinal cord ischemia (SCI). Recently, many authors have proposed different endovascular strategies to mitigate the risk of SCI; however, the real effectiveness of these maneuvers is not universally recognized due to a lack of standardized protocols among individual centers. Several adjuncts have been proposed to obtain staged occlusion of segmental aortic branches to promote spinal cord preconditioning. These strategies include proximal thoracic aortic repair (PTAR), temporary aneurysm sac perfusion (TASP), and minimally invasive staged segmental artery coil embolization (MIS²ACE). The present paper aims to provide an overview of the most advanced staging strategies used in high-volume aortic centers, pointing out that it takes meticulous preoperative planning to face every clinical scenario. Full article

Background: Adult moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular disorder for which surgical revascularization is the primary treatment. The standard direct superficial temporal artery–middle cerebral artery (STA-MCA) bypass uses the frontal and/or parietal branch of the STA as the donor. However, in some patients, conventional STA-MCA bypass may be suboptimal because of a large mismatch in caliber between the STA branch and the recipient artery, increasing the risk of cerebral hyperperfusion. This study aimed to investigate the impact of a modified STA-MCA bypass on MMD treatment. Methods: We retrospectively reviewed adult cases of MMD at our institution (2012–2025) for patients who underwent modified direct STA-MCA bypass using a small side branch of the STA as the donor artery. Surgical techniques and clinical outcomes of these cases were analyzed descriptively. Results: Five cases (five hemispheres in four patients) underwent side-branch STA-MCA bypass. All procedures were completed successfully, with 100% graft patency confirmed by intraoperative indocyanine green angiography, and a mild increase in cerebral blood flow confirmed by postoperative single-photon emission computed tomography. No patients developed postoperative cerebral hyperperfusion syndrome or wound healing complications. Clinically, all patients experienced a stable or improved neurological status, with no reported new ischemic or hemorrhagic events during follow-up. Conclusions: In this small feasibility series, the side-branch STA–MCA bypass was technically feasible and safe, with no cerebral hyperperfusion syndrome observed. Any risk-mitigating effect on hyperperfusion remains theoretical and requires confirmation in comparative studies. 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

This is a single-center study about upward facing in branched endovascular aortic repair. Background: The evolution of branched endovascular aortic repair (BEVAR) has introduced upward-facing branches as a novel approach to facilitate exclusive transfemoral access in complex aortic aneurysm repair. This study evaluates the feasibility, safety, and early outcomes of custom-made BEVAR devices incorporating upward-facing branches in patients with cranially oriented renal arteries. The investigation further aims to analyze the technical success and mid-term outcomes related to these novel devices, as well as to identify any challenges or complications specific to the use of upward-facing branches in clinical practice. Methods: We retrospectively analyzed 17 patients treated at a single center between January 2020 and December 2024 using custom-made Cook Medical branched stent grafts with at least one upward-facing branch. Demographics, comorbidities, target vessel details, bridging stent graft (BSG) configurations, and procedure-related complications were collected. The primary endpoints were technical success and branch patency. Secondary endpoints included short- and mid-term branch-related complications. Results: The cohort had a mean age of 70 years, with hypertension (88%) and coronary artery disease (47%) being common comorbidities. Technical success was achieved in 100% of cases. The left renal artery was the most frequently targeted vessel (63.2%). Most upward-facing branches were bridged using a combination of balloon-expandable and self-expandable stents. One patient (5.9%) experienced a renal bleeding complication requiring embolization. There were no cases of primary stent occlusion or dislocation. At a mean follow-up of 14 months, one asymptomatic occlusion of an upward-facing branch was detected in computed tomography angiography. No further upward-facing branch-related complications occurred, and 1-year follow-up was available in 41.2% of patients. Conclusions: In our single-center study including 17 patients, upward-facing branches in BEVAR demonstrate high technical success and a low complication rate, offering a promising alternative to traditional access strategies. These findings support broader adoption in select anatomical scenarios, pending larger comparative studies and longer-term data collection. Full article

Background/Objectives: Radial artery access (RAA) is widely used for catheter-based procedures due to its safety and convenience, but complex regional pain syndrome (CRPS) remains a rare, underrecognized complication—particularly in women. CRPS manifests as prolonged, severe pain and autonomic symptoms, often associated with nerve irritation near the carpal tunnel. This study aimed to evaluate whether modifying the puncture site to a high radial artery puncture (HRAP) reduces the risk of CRPS in patients undergoing transarterial micro-embolization (TAME) for frozen shoulder. Methods: We retrospectively reviewed 97 patients (47 women and 50 men) who underwent transarterial micro-embolization (TAME) via conventional RAA for frozen shoulder between February and June 2019. The occurrence of CRPS and vascular complications was recorded. All punctures were ultrasound-guided. Results: Among women treated via conventional RAA, five developed CRPS and one had radial artery occlusion. CRPS symptoms included intense puncture site pain (mean duration was 47 days), which severely impaired daily function. No complications occurred in men. Following the adoption of HRAP, no cases of CRPS, prolonged pain, or vascular complications were observed in the consecutive 101 women treated. Conclusions: Our findings suggest HRAP reduces CRPS risk by avoiding superficial nerve branches and targeting deeper arterial segments with fewer sensory structures. This ultrasound-guided modification is simple, does not require additional training, and may be widely applicable in both musculoskeletal and cardiovascular interventions. HRAP may help minimize neuropathic complications in broader patient populations. Full article

Purpose: To systematically review the evidence regarding the characteristics of Optical Coherence Tomography Angiography (OCTA) in acute retinal arterial occlusion (RAO), with a particular focus on vascular alterations across the superficial and deep capillary plexuses, choroid, and peripapillary regions. Methods: A comprehensive literature search was performed across PubMed, Web of Science, Scopus, EMBASE, Google Scholar, and the Cochrane Database up to April 2025. The search terms included “Optical coherence tomography angiography,” “OCTA,” “Retinal arterial occlusion,” “Central retinal artery occlusion,” and “Branch retinal artery occlusion.” Studies were included if they evaluated the role of OCTA in diagnosing or assessing acute RAO. Case reports, conference abstracts, and non-English articles were excluded. Two reviewers independently conducted the study selection and data extraction. The methodological quality of the included studies was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. Results: The initial search yielded 457 articles, from which 10 studies were ultimately included in the final analysis after a rigorous screening process excluding duplicates, non-English publications, and ineligible articles based on title, abstract, or full-text review. The included studies consistently demonstrated that OCTA is a valuable, noninvasive modality for evaluating microvascular changes in RAO. Key OCTA findings in acute RAO include significant perfusion deficits and reduced vessel density in both the superficial capillary plexus (SCP) and deep capillary plexus (DCP). Several studies noted more pronounced involvement of the SCP compared to the DCP. OCTA parameters, such as vessel density in the macular region, have been found to correlate with visual acuity, suggesting a prognostic value. While findings regarding the foveal avascular zone (FAZ) were mixed, the peripapillary area frequently showed reduced vessel density. Conclusion: Acute RAO is an ocular emergency that causes microvascular ischemic changes detectable by OCTA. This review establishes OCTA as a significant noninvasive tool for diagnosing, monitoring, and prognosticating RAO. It effectively visualizes perfusion deficits that correlate with clinical outcomes. However, limitations such as susceptibility to motion artifacts, segmentation errors, and the lack of standardized normative data must be considered. Future standardization of OCTA protocols and analysis is essential to enhance its clinical application in managing RAO. Full article

Background/Objective: Bridging stent optimal choice in fenestrated and branched endovascular aortic repair (f/bEVAR) is under investigation. This systematic review and meta-analysis studied the outcomes of the BeGraft peripheral and peripheral PLUS as bridging stents in f/bEVAR. Methods: The methodology was pre-registered to the PROSPERO (CRD420251007695). Following the PRISMA guidelines and PICO model, the PubMed, Cochrane and Embase databases were searched for observational studies and randomized control trials, in English, from 2015 to 2025, reporting on f/bEVAR patients using the second-generation BeGraft peripheral or the BeGraft peripheral PLUS balloon expandable covered stent (BECS; Bentley InnoMed, Hechingen, Germany) for bridging. The ROBINS-I assessed the risk of bias and GRADE the quality of evidence. Target vessel technical success, occlusion/stenosis, endoleak Ic/IIIc, reintervention and instability during follow-up were primary outcomes, assessed using proportional meta-analysis. Results: Among 1266 studies, eight were included (1986 target vessels; 1791 bridged via BeGraft); all retrospective, except one. The ROBINS-I showed that seven were at serious risk of bias. According to GRADE, the quality of evidence was “very low” for primary outcomes. Target vessel technical success was 99% (95% CI 98–100%; I² = 12%). The mean follow-up was 20.2 months. Target-vessel instability was 3% (95% CI 2–5%; I² = 44%), occlusion/stenosis was 1% (95% CI 1–4%; I² = 8%) and endoleak Ic/IIIc was 1% (95% CI 0–3%; I² = 0%). The estimated target-vessel reintervention was 2% (95% CI 2–4%; I² = 12%). Celiac trunk, superior mesenteric and renal artery instability were 1% (95% CI 0–16%; I² = 0%;), 1% (95% CI 0–5%; I² = 14%) and 4% (95% CI 2–7%; I² = 40%), respectively. Conclusions: The BeGraft peripheral and peripheral PLUS BECS performed with high technical success and low instability when used for bridging in f/bEVAR. Cautious interpretation is required due to the very low quality of evidence. Full article

Background: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remains a complex procedure that requires advanced operator skills and dedicated devices. Despite increased success rates in experienced centers, the in-hospital complications of CTO PCI remain notably high. Female patients undergoing CTO PCI are reported to experience higher rates of complications; however, the underlying mechanisms remain inadequately defined. Methods: We prospectively enrolled consecutive patients undergoing CTO PCI at our university-affiliated tertiary care center over 4 years (2018–2021), aiming to elucidate sex-based disparities in in-hospital complications. In addition, we investigated the impact of angiographic femoral artery metrics on in-hospital complications. Results: Among 271 patients who underwent antegrade or retrograde CTO PCI, 222 (81.9%) were men and 49 (18.9%) women. Female patients were significantly older (67 ± 11 vs. 72 ± 12 years; p = 0.005) and had a comparable lesion complexity. Women exhibited smaller femoral artery diameters, more side branches at the puncture area and higher bifurcations. In-hospital complications occurred more frequently in women compared to men (16.3% vs. 6.8%; p = 0.044). Female sex independently predicted in-hospital complications (OR = 2.92; CI 1.07 to 7.60; p = 0.024), yet lost significance after adjustment for femoral artery characteristics. Maximal femoral artery diameter (OR = 0.30, 95% CI: 0.17 to 0.50, p < 0.001) and side-branch density (OR = 2.45, 95% CI: 1.26 to 5.20, p = 0.012) independently predicted in-hospital complications. Conclusions: Female patients undergoing CTO PCI are at increased risk for procedural complications, likely driven by femoral artery anatomical differences. Detailed pre-procedural assessment of femoral artery metrics may improve patient selection, procedural planning, and outcomes, particularly among women. Full article

Background: Acute mesenteric ischemia (AMI) is a potentially life-threatening condition that requires prompt diagnosis and treatment. The presence of air within the arterial lumen, particularly in the abdomen, is an uncommon finding with varied etiologies. This case report presents a unique instance of AMI with air in the superior mesenteric artery (SMA), highlighting the complexities in diagnosis and management. Case presentation: An 89-year-old male with a history of smoking, hypertension, dyslipidemia, and atrial fibrillation presented with chest pain and underwent coronary angiography for suspected anterior ST-elevation myocardial infarction (STEMI). Following successful thromboaspiration and admission to the coronary care unit, he developed severe abdominal pain. A contrast-enhanced computed tomography (CECT) scan revealed a thromboembolic occlusion in the SMA, along with air filling in the SMA and its branches. An endovascular thrombectomy was performed, but the patient died the next day due to complications related to AMI and metabolic acidosis. Conclusions: This case underscores the challenges in diagnosing and managing AMI, particularly when accompanied by unusual imaging findings such as air within the SMA. The presence of air in the arterial system raises questions about its origin and clinical significance in the context of AMI. Further research is needed to understand the mechanisms and implications of this rare phenomenon, which may have implications for refining diagnostic and therapeutic strategies for AMI. Full article

Moyamoya angiopathy (MMA) is a cerebrovascular disease determining chronic progressive steno-occlusion of the supraclinoid internal carotid arteries and their main branches. The pathogenesis of MMA remains largely unknown. Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating disease of the central nervous system characterized by the progressive accumulation of focal demyelinating lesions, whose pathophysiology has been theorized but still incompletely understood. Beyond misdiagnoses due to mimicking features among the two disorders, MS coexisting with MMA have been previously, rarely, reported. Herein, we present two other cases of patients with MMA with a concomitant, previously missed, diagnosis of MS and discuss their overlapping features as a hint for a potentially shared pathophysiology. The finding of typical angiographic features enables MMA diagnosis, yet it does not allow us to rule out other potentially concomitant disorders affecting the CNS. The association may be easily missed if the clinical/neuroradiological picture is not carefully assessed. Cerebral spinal fluid analysis and spine neuroimaging should be suggested in all MMA patients with atypical MRI lesions. Full article

(1) Background: Renal artery occlusion after F/B EVAR for abdominal aortic aneurysm is a serious complication that may require re-intervention, and understanding the hemodynamic mechanisms by which it occurs is essential to optimize the surgical procedure. (2) Methods: We used computational fluid dynamics (CFD) to analyze the impact of various parameters on blood flow. Theoretical vascular models were constructed based on the common dimensions and angles of aortic stents and branch arteries in clinical practice. Actual case models were constructed from CT image data of six patients treated with F/B-EVAR. Data were collected for analysis after simulation and calculation by FLUENT software. (3) Results: Theoretical model simulations showed that a larger tilt angle of the branch stent, smaller branch entry depth, and larger branch stent diameter were beneficial for blood flow. In the case models, a significant difference in the tilt angle of the renal artery stents was observed between the high- and low-flow groups, while the differences in entry depth and branch stent diameter were not significant. Occluded renal arteries had lower WSS values than patent ones. (4) Conclusions: This study offers valuable guidance for optimizing stent placement in F/B EVAR to mitigate renal artery occlusion risk. Full article

Background: Tandem Lesions (TLs) or Tandem Occlusions (TOs) are characterized by simultaneous high-grade stenosis or occlusion of the proximal extracranial internal carotid artery and the intracranial terminal internal carotid artery or its branches. These lesions can result in stroke and pose significant challenges to endovascular treatment. This study introduces and evaluates the “T-Top technique” as an innovative approach to address TLs, assessing its safety and technical efficacy. Methods: Data from acute ischemic stroke (AIS) patients treated with the T-Top technique between September 2022 and September 2023 were retrospectively analyzed. The technique involves using the pusher wire of a stent retriever as a microwire to guide a monorail angioplastic balloon to the extracranial carotid stenosis, performing angioplasty simultaneously with stent retriever anchorage. Clinical outcomes, procedural data, and safety were assessed. Results: Successful reperfusion (mTICI > 2b) was achieved in 91% of cases, with a median groin puncture to final recanalization time of 50 min. Favorable clinical outcomes (mRS < 3) were observed in 69% of patients, with a low mortality rate of 6% after 90 days. Conclusions: The T-Top technique offers a rapid and reliable strategy for TL treatment, improving reperfusion rates and clinical outcomes. Further studies are warranted to validate its efficacy in larger cohorts. This technique holds promise for enhancing endovascular treatment outcomes in patients with Tandem Lesions. Full article