Search Results (109)

Excimer Laser Coronary Atherectomy (ELCA) has re-emerged as a valuable adjunctive modality in percutaneous coronary intervention (PCI), particularly in the context of increasingly complex coronary anatomy and rising procedural expectations. By delivering pulsed ultraviolet energy at 308 nm through flexible fiber-optic catheters, ELCA enables precise photochemical, photothermal, and photomechanical ablation of atherosclerotic, fibrotic, calcified, and thrombotic tissue while minimizing thermal injury to surrounding structures. Recent technical refinements, simplified catheter designs, and improved safety profiles have enhanced its feasibility and utility across a range of challenging lesion subsets. This review summarizes the fundamental principles underlying excimer laser–tissue interaction, discusses available equipment and key procedural considerations, and examines the expanding clinical evidence supporting ELCA in contemporary practice. Data from observational studies and multicenter registries suggest that ELCA may enhance device crossability, restore coronary flow, and reduce distal embolization in thrombus-rich lesions, particularly during primary PCI. In device-uncrossable lesions, ELCA facilitates plaque modification and improves procedural success, including in chronic total occlusions. Furthermore, ELCA—especially when performed with simultaneous contrast injection—has demonstrated efficacy in treating stent underexpansion refractory to high-pressure balloon dilation, improving minimal stent area and enabling optimal post-dilatation. As lesion complexity continues to increase, ELCA is gaining recognition as an important tool within the interventional armamentarium. While generally safe in experienced hands, ELCA carries a risk of procedural complications that must be carefully considered. Ongoing investigations are expected to further define its optimal use and reinforce its relevance in modern interventional cardiology. Full article

Background/Objectives: To evaluate the efficacy of balloon occlusion trans-arterial hepatic radioembolization with Yttrium-90 (b-TARE) in optimizing dose activity in patients with large or multifocal Hepatocellular Carcinoma (HCC) lesions with heterogeneous macroaggregate distribution by retrospectively comparing outcomes with a similar cohort treated with standard TARE. Methods: This single-center restrospective study included sixty-three consecutive patients with unresectable HCC treated with TARE, of whom 24/63 had balloon-occluded TARE and 39/63 had standard TARE. Both cohorts included large or multifocal HCC lesions characterized by heterogeneous macroaggregate distribution, also in relation to the angiosome framework. The impact of b-TARE was analyzed using 2D and 3D dosimetry with dedicated software on post-procedural SPECT-CT. Dosimetric b-TARE results were retrospectively compared with standard TARE. Results: Both 2D and 3D SPECT-CT analyses demonstrated a better dosimetry profile in the b-TARE group. Concerning 2D evaluation, the activity intensity peak was significantly higher in the b-TARE group compared to the TARE group (998.6 ± 394.9 vs. 578.8 ± 313.3, p = 0.004). Regarding 3D dose analysis, the mean intra-lesion dose administered was significantly higher in the b-TARE group (162.7 ± 54.3 Gy vs. 111.2 ± 44.5 Gy, p = 0.01). There was no increase in significant complications or in the mean dose delivered to the normal liver in the b-TARE group. Conclusions: The employment of balloon occlusion in TARE was associated with a higher activity intensity peak and lesion absorbed dose on voxel-based dosimetry, compared to standard TARE, in patients with heterogeneous HCC and uneven macroaggregate distribution, without increasing mean non-tumoral liver dose. Full article

Background: Severe (FIGO grade 3b & c) placenta accreta spectrum (PAS) is potentially a life-threatening condition due to catastrophic haemorrhage at delivery. Consequently, interventional radiology (IR) techniques are often employed to prevent massive blood loss, but this is not always readily available, is costly, and can cause significant morbidity, including distal limb ischaemia due to thrombus formation. We believe that internal iliac ligation under direct vision is a safe option to control bleeding. We sought to evaluate the short- and long-term outcomes relating to this technique compared to IR. Methods: This is a mixed-methods cohort study of women with severe PAS who underwent hysterectomy with either surgical devascularisation, as part of the Soleymani and Collins (SAC) technique, or IR insertion of internal iliac balloon catheters, in a UK tertiary referral centre for PAS between 2011 and 2022. Only women with intraoperative diagnosis of very severe PAS (FIGO stage 3b & c) were included in this study. Results: Of the 22 women invited to participate in the long-term component of the study, 59% agreed. Women in the surgical devascularisation group experienced no adverse short or late sequelae related to internal iliac arterial ligation. Pelvic devascularisation (11 patients, 41%) demonstrated a reduction in median estimated blood loss, 1600 millilitres vs. 2500 millilitres in the IR balloon catheter group (p = 0.04). Conclusions: We have demonstrated that the SAC technique for surgical devascularisation is a safe method for achieving haemorrhage control during caesarean hysterectomy for severe PAS. It also appears to be at least as effective at haemorrhage control as IR balloon occlusion of the internal iliac vessels. Full article

ST-segment elevation myocardial infarction (STEMI) represents a time-critical medical emergency where complete coronary artery occlusion initiates progressive myocardial necrosis. The fundamental principle of modern STEMI care—“Time is Muscle”—establishes that ischemic duration directly determines infarct size and clinical outcomes. Each minute of delay correlates with increased mortality, larger infarcts, and a higher risk of heart failure development. Total ischemic time encompasses both patient-mediated delays (often the largest component) and system-related delays, each influenced by distinct factors requiring targeted interventions. This comprehensive review analyzes the components of total ischemic time, quantifies the clinical consequences of delay, and evaluates evidence-based mitigation strategies. We examine the evolution from fibrinolysis to primary percutaneous coronary intervention and the resulting logistical challenges. System-level interventions—including public awareness campaigns, regionalized STEMI networks, pre-hospital ECG acquisition, and standardized hospital protocols—have dramatically reduced treatment times. However, persistent disparities based on geography, presentation timing, sex, race, and age remain problematic. Emerging technologies, particularly artificial intelligence for ECG interpretation, offer promise for further time reduction. Full article

Some studies report better outcomes in cell therapy for myocardial infarction (MI) with repeated administrations. We aimed to elucidate the potential differences in terms of cardiac function and protein expression after one or three doses of cardiosphere-derived cells (CDCs) in a porcine MI model. CDCs were isolated from swine cardiac explants, cultured in cardiomyocyte growth medium (CGM), and prepared for administration. Pigs surviving a 90 min balloon occlusion of the mid-left anterior descending coronary artery (LAD) were randomly allocated to receive vehicle (CON), one (D1), or three (D3) doses of 30 × 10⁶ CDCs via the infarct-related coronary artery. Cardiac function was assessed with magnetic resonance at baseline and 10 weeks. Programmed electrical stimulation to study arrhythmogenicity was performed at 10 weeks. High-throughput quantitative proteomic analysis of infarcted tissue was performed to identify biological processes based on protein abundance changes between groups. No significant differences were found between the three groups for any cardiac function parameter at 10 weeks. No increase in ventricular tachycardia inducibility was seen in treated groups. However, gene ontology and topological analyses revealed potentially beneficial molecular adaptations. Upregulation of GYS1, AGL, and GBE1 indicated an increase in glycogen biosynthesis and energy availability, while an increase in ANK2, along with hub proteins ALB and TRAP1, suggested cardioprotective effects. Furthermore, the increase in remodeling-related proteins, including EPHA4, PODN, and ALPK3, pointed to favorable structural adaptation following infarction. In conclusion, the intracoronary administration of single or repeated doses of 30 × 10⁶ CDCs to a porcine reperfused MI model shows only slight differential improvement in both cardiac function and protein profile in this experimental setting, thus presenting limited translational potential. Full article

Background: Coronary imaging is increasingly used in chronic total occlusion percutaneous coronary intervention (CTO-PCI), but the impact of different imaging strategies on procedural decisions and outcomes remains unclear. Methods: We retrospectively analyzed 171 consecutive patients undergoing CTO-PCI, stratified by imaging strategy into four groups: angiography-only (n = 48), IVUS-guided (n = 42), CT-guided (n = 40) and CT + IVUS-guided (n = 41). Procedural and in-hospital clinical outcomes were compared. A multivariable logistic regression identified predictors of intense debulking techniques (defined as the use of rotational atherectomy or intravascular lithotripsy). Results: Imaging guidance was associated with progressively longer procedural (p < 0.001) and fluoroscopic time (p = 0.007). Similarly, an increased number of guidewires (p = 0.005) and balloons (p = 0.003) was used in the imaging groups, with the CT + IVUS groups showing the highest features. Regarding stenting characteristics, higher stent length and diameter (p = 0.01) were observed in the imaging groups. In patients with J-CTO score > 2, procedural success rates significantly increased with the use of coronary imaging (p = 0.01). Multivariable analysis showed that both J-CTO score (OR 2.0; 95% CI 1.3–3.0; p = 0.001) and imaging strategies (OR 1.6; 95% CI 1.02–2.4; p = 0.04) independently predicted the use of intense debulking techniques. Importantly, no significant differences were observed in in-hospital complications across groups. Conclusions: The use of coronary imaging, particularly the combination of IVUS and CT, is associated with more complex CTO lesions and led to increased procedural time, fluoroscopic time and more extensive stenting, as well as higher debulking usage. In complex CTO cases, coronary imaging was associated with higher procedural success rates. Imaging strategies independently predicted the need for advanced lesion preparation, beyond anatomical complexity, without compromising safety. Despite higher procedural demands, coronary imaging enables a more tailored and successful approach to CTO-PCI, particularly in complex cases. These findings underscore the pivotal role of multimodal imaging in the procedural planning and optimization of CTO-PCI. Full article

Objectives: Atherectomy use for the treatment of femoropopliteal lesions has significantly increased. This study aimed to assess the clinical benefits of percutaneous atherectomy (PA) over balloon angioplasty and/or stenting (PTA ± stent) for femoropopliteal arterial disease using a nationwide prospective multicenter registry. Methods: Using data from the Damoeum registry of the Korean Society for Vascular Surgery, we identified patients with revascularization due to lower-extremity arterial disease. After excluding patients who underwent open and hybrid revascularization, we compared the clinical outcomes of the patients in the PA group versus the PTA ± stent group. We investigated the target lesion patency and functional and safety outcomes during the follow-up. Results: A total of 424 patients were included in the final analysis: 90 in the PA group and 334 in the PTA ± stent group. There were 344 men and 79 women (mean age: 71.1 years). The preprocedural ankle–brachial index (ABI) was significantly increased in both groups (p = 0.015). When we compared 90 patients of the PA group and 270 patients of the matched PTA ± stent cohort (1:3 propensity-matched cohort), the overall 1-year primary patency rate was not significantly different (83.8% vs. 80.0%; p = 0.895). However, the PA group showed a significantly lower risk of occlusion compared with the PTA ± stent group during the follow-up (adjusted HR: 0.01; p < 0.001). Overall mortality was similar in the two groups (p = 0.695). Conclusions: The use of atherectomy was not associated with improvement in target lesion patency. However, the use of atherectomy devices demonstrated a significant reduction in target lesion occlusion during the follow-up. Full article

Background: The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for control of noncompressible torso hemorrhage remains controversial. We aimed to utilize a novel and transparent/interpretable artificial intelligence (AI) method called Optimal Policy Trees (OPTs) to improve the appropriate use and decrease the misuse of REBOA in hemodynamically unstable blunt trauma patients. Methods: We trained and then validated OPTs that “prescribe” REBOA in a 50:50 split on all hemorrhagic shock blunt trauma patients in the 2010–2019 ACS-TQIP database based on rates of survival. Hemorrhagic shock was defined as a systolic blood pressure ≤90 on arrival or a transfusion requirement of ≥4 units of blood in the first 4 h of presentation. The expected 24 h mortality rate following OPT prescription was compared to the observed 24 h mortality rate in patients who were or were not treated with REBOA. Results: Out of 4.5 million patients, 100,615 were included, and 803 underwent REBOA. REBOA patients had a higher rate of pelvic fracture, femur fracture, hemothorax, pneumothorax, and thoracic aorta injury (p < 0.001). The 24 h mortality rate for the REBOA vs. non-REBOA group was 47% vs. 21%, respectively (p < 0.001). OPTs resulted in an 18% reduction in 24 h mortality for REBOA and a 0.8% reduction in non-REBOA patients. We specifically divert the misuse of REBOA by recommending against REBOA in cases where it leads to worse outcomes. Conclusions: This proof-of-concept study shows that interpretable AI models can improve mortality in unstable blunt trauma patients by optimizing the use and decreasing the misuse of REBOA. To date, these models have been used to predict outcomes, but their groundbreaking use will be in prescribing interventions and changing outcomes. Full article

Background: The STEMI/NSTEMI classification guides management and quality metrics for acute myocardial infarction (AMI). We examined whether the final cath-lab diagnosis of STEMI versus NSTEMI correlates more closely with door-to-balloon (D2B) time than with either ST-segment elevation (STE) on pre-angiogram ECG or a culprit lesion with TIMI 0-1 flow. Methods: This retrospective study analyzed 410 patients with AMI from the DOMI-ARIGATO database who underwent coronary angiography. For each patient, we recorded FDx coded by the interventional cardiologist, D2B < 120 min versus > 120 min, STE criteria (Fourth Universal Definition), and angiographic TIMI 0-1 culprit. Predictors of FDx-STE discordance were evaluated with multivariable logistic regression. Results: Among 410 angiographed AMI patients (mean age 63 ± 13; 71% male), 165 (40.2%) received an FDx-STEMI and 245 (59.8%) an FDx-NSTEMI. D2B time showed 94% agreement with FDx (160/165 FDx-STEMI treated < 120 min; 225/245 FDx-NSTEMI treated > 120 min), exceeding concordance for STE (82%; p < 0.001) and TIMI 0-1 flow (75%; p < 0.001). FDx and STE diverged in 75 patients (18%): 60 rapidly treated STE-negative cases were labelled STEMI, whereas 15 delayed STE-positive cases were labelled NSTEMI. In regression analysis, D2B < 120 min remained the sole independent predictor of discordance (adjusted OR 6.7, 95% CI 3.5–13.8). Conclusions: In this registry, the cath-lab label “STEMI” showed the strongest correlation with meeting a 120 min benchmark, exceeding correlations for STE or angiographic occlusion. These findings suggest that quality-metric compliance, rather than electrocardiographic or anatomic criteria, predominantly drives final diagnosis. 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

Objectives: We sought to document interim methodologic improvements and preliminary results for pulmonary suffusion. Methods: A Phase I/II trial of thoracoscopic lung suffusion for resectable sarcoma and colorectal carcinoma metastases followed a pilot study on oligometastatic lung malignancy at a comprehensive cancer center. Primary-specific chemotherapy doses (cisplatin, oxaliplatin, doxorubicin, or gemcitabine) suffused unilaterally for 30 min were escalated to amplify regional deliveries three-fold. Drug delivery was measured with tissue, blood samples, and ⁹⁹Tc; pulmonary function tests and clinical adverse events (AEs) assessed safety and tolerance. Results: From 2008–2025, 31 ECOG 0–2 patients (10 male) aged 33–75 years had unilateral lung suffusion (16 right, 14 left, 1 aborted, and 8 sides selected randomly). Vascular occlusion intolerance was immediate or delayed (25 min) in two cases. Two catheter-positioning grade 3 AEs occurred: hypotension with troponin leak (1) and atrial fibrillation (1). Patients averaged 1.3 ± 1.2 metastasectomies (17 sub-lobar, 8 lobar resections, and 2 intentional open cytoreductive metastasectomies). Hospitalizations were brief (1–4 days) except for 6–7 day stays in the only two open cases and one doxorubicin (grade 4 hypoxic respiratory failure) case. Ninety-day survival was 100%, and the Phase I delivery goal of 12.75 mg/m² 65 (15% systemic) was achieved for oxaliplatin. Lung function was preserved according to ⁹⁹Tc differentials within 6.1 ± 7.1% of the predicted reductions at 30 days. Sampling delays, tracer discordances, and atypical pharmacokinetics reduced tissue drug detections. Recent pulmonary artery snaring cases (two) demonstrated in-flow control more stable than that of balloon occlusions. Conclusions: Suffusion for metastatic malignancies appears safe and warrants further investigation. 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: An aberrant internal carotid artery (aICA) in the middle ear is a rare vascular anomaly with potentially catastrophic consequences if injured during otologic procedures. Given its rarity, standardized treatment recommendations are lacking. This study aims to present four cases of aICA bleeding, systematically review the literature, and evaluate the outcomes of conservative and interventional management. Methods: A retrospective review of four patients treated for intraoperative aICA hemorrhage at two tertiary referral centers was performed. A systematic review was conducted following PRISMA guidelines. Neurologic and otologic outcomes, hemostasis, and complications were analyzed. Results: Two patients were treated conservatively with external auditory canal packing, while two required endovascular coil embolization due to pseudoaneurysm formation or persistent bleeding. One patient suffered a stroke due to traumatic ICA occlusion. The systematic review identified 20 additional cases. Conservative treatment alone sufficed in 37.5% of cases, whereas 62.5% required vessel occlusion via coiling, balloon occlusion, or stenting. Neurologic complications occurred in 25% of patients, while otologic outcomes varied widely and were inconsistently reported. Conclusions: Initial external auditory canal packing and a CT angiogram should be recommended for all patients. Initial conservative management may be appropriate for cases with early hemostasis if close monitoring is ensured. Endovascular treatment is often necessary, particularly in cases of pseudoaneurysm or rebleeding. 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

The HepACAGA (Hepatic Arteriography and C-arm CT-Guided Ablation) technique, which integrates C-arm CT guidance with transcatheter C-arm CT hepatic arteriography (C-arm CTHA), significantly improves liver tumor ablation outcomes by enhancing tumor visualization, navigation, and the intraprocedural assessment of ablation margins. The two key advantages of using C-arm CT over conventional CT for image guidance are firstly that the entire procedure can be performed in the angiography suite, eliminating the need for patient transfer between the angiography suite (catheterization) and CT-room (ablation), and secondly, that integrated C-arm needle guidance software can greatly reduce the difficulty of needle placement. Beyond these advantages, the HepACAGA technique offers additional benefits across four domains: (1) the direct conversion of ablation to intra-arterial liver-directed therapies (e.g., radioembolization or chemoembolization) upon the intraprocedural detection of disease progression; (2) the direct combination of ablation with intra-arterial treatments or portal vein embolization in one session; (3) the enhanced ablation effect through heat sink effect reduction with adjunct bland embolization or balloon occlusion; and (4) the immediate hemorrhage control through direct embolization. This pictorial essay demonstrates the advantages of combining C-arm CT guidance with real-time C-arm CTHA in the percutaneous thermal ablation of liver tumors, with clinical cases illustrating each of the aforementioned four key domains. Full article