Search Results (926)

Introduction: Major retroperitoneal arterial bleeding may remain clinically difficult to recognize when vital signs are initially stable. Case presentation: We report the case of a 67-year-old man who developed progressive abdominal and right groin pain radiating to the ipsilateral flank, accompanied by two episodes of vomiting and an early hemoglobin (Hb) and hematocrit decline on the first postoperative day after right-sided direct anterior total hip arthroplasty (THA). Despite the absence of hemodynamic instability, computed tomography angiography (CTA) demonstrated active contrast extravasation from the right external iliac artery (EIA) with a large retroperitoneal hematoma. CTA localized the bleeding source and enabled immediate endovascular treatment planning. Subsequent angiography confirmed active extravasation from the right EIA, and a covered stent–graft was deployed through ultrasound-guided superficial femoral artery access, achieving complete exclusion of the bleeding source with preserved arterial patency. The subsequent Hb nadir and transfusion were interpreted as reflecting preceding retroperitoneal blood loss rather than persistent bleeding, because follow-up CTA showed a stable hematoma without active extravasation. The patient was discharged in stable condition, and 1-month duplex ultrasound and following 3-month CTA confirmed stent–graft patency. Discussion: This case highlights the diagnostic mismatch that may occur between substantial retroperitoneal blood loss and initially reassuring hemodynamic findings. When progressive abdominal or groin symptoms are accompanied by a serial, otherwise unexplained Hb decline, CTA may be more informative than DUS for suspected deep pelvic bleeding because it can identify active extravasation, define hematoma extent, assess alternative abdominopelvic causes, and support treatment planning. In anatomically suitable lesions, covered stent–graft repair can rapidly control hemorrhage while preserving EIA patency. Conclusions: Stable vital signs do not exclude major retroperitoneal arterial bleeding after direct anterior THA. Progressive abdominal or groin pain with early postoperative Hb decline should raise suspicion for occult vascular injury, for which CTA can provide rapid diagnosis and guide immediate endovascular management. Full article

Background: Carotid free-floating thrombus (CFFT) is an uncommon but clinically significant cause of transient ischemic attack and ischemic stroke, carrying a substantial risk of recurrent cerebral embolization. Despite advances in vascular imaging, the optimal management of CFFT remains controversial because available recommendations are largely based on retrospective studies, case series, and expert opinion. The present study reports a single-center experience with CFFT and provides an updated narrative review of current diagnostic and therapeutic strategies, with particular attention to the timing of intervention. Methods: A retrospective review of patients diagnosed with CFFT and managed at our institution over a 20-year period was performed. Clinical presentation, imaging findings, treatment strategy, and outcomes were analyzed. In parallel, a narrative review of the contemporary literature was conducted to summarize current evidence regarding medical management, carotid endarterectomy, endovascular techniques, hybrid approaches, and emerging concepts related to thrombus composition and maturation. Results: Five patients with symptomatic CFFT were identified. Four patients underwent carotid thromboendarterectomy, whereas one patient was managed medically with anticoagulation and antiplatelet therapy, resulting in complete thrombus resolution. Two patients experienced neurological deterioration while receiving initial anticoagulation and subsequently required urgent surgical intervention. No postoperative strokes occurred after carotid endarterectomy. Review of the literature confirmed that anticoagulation remains the cornerstone of initial therapy and achieves thrombus resolution in a substantial proportion of patients. However, recurrent neurological events continue to occur under medical treatment, while the indications and timing of invasive intervention remain poorly defined. Recent advances in high-resolution magnetic resonance imaging and optical coherence tomography suggest that thrombus age and composition may become important determinants of future treatment selection. Conclusions: CFFT represents a rare but potentially unstable vascular condition for which high-quality evidence is still lacking. Initial anticoagulation remains the most widely accepted treatment strategy, while carotid endarterectomy, endovascular thrombectomy, carotid artery stenting, and hybrid procedures may be appropriate in selected patients. Future management algorithms may ultimately move beyond a one-size-fits-all approach by incorporating thrombus biology, imaging characteristics, and individual patient risk profiles. Although this concept remains preliminary, advances in thrombus characterization may provide the foundation for more personalized treatment strategies as further clinical evidence becomes available. Full article

Background: The Contour Neurovascular System (CNS) has been established as an effective treatment for wide-neck intracranial bifurcation aneurysms. However, its post-intervention hemodynamic impact remains insufficiently understood. In silico studies investigating the associated hemodynamic changes are limited and rarely consider post-interventional configurations. Methods: Five intracranial aneurysms treated with the CNS were retrospectively analyzed using both pre-interventional and 24 h post-interventional imaging data. CNS-associated morphological changes were assessed, and virtual CNS deployment was performed in pre- and post-interventional configurations. Consequently, 20 high-fidelity, image-based blood flow simulations were performed to evaluate six flow- and shear-related parameters. Results: All cases exhibited an increase in ostium area between pre- and post-interventional configurations (118.7% ± 52.4%), whereas no relevant geometric differences were observed in the surrounding vessels. Hemodynamic analyses revealed that morphological differences were associated with variations in flow characteristics. In particular, most post-interventional configurations showed higher intra-aneurysmal velocities independent of device implantation, although CNS deployment consistently reduced all investigated parameters (reduction in intra-aneurysmal velocity—pre-interventional with CNS: −83.5% ± 14.0%; post-interventional with CNS: −72.4% ± 19.4%). Conclusions: In this exploratory study, the observed CNS-associated morphological differences were accompanied by variations in aneurysmal hemodynamics, potentially influencing the estimated treatment effect. Although validation in larger cohorts is required, these findings highlight the potential value of 3D-DSA follow-up imaging for a more comprehensive assessment of CNS-associated changes and outcomes. Full article

Endovascular aneurysm repair (EVAR) has become a widely adopted treatment for abdominal aortic aneurysms, offering lower perioperative morbidity and mortality than open surgical repair. Nevertheless, long-term imaging surveillance remains essential because procedure-related complications may occur years after treatment. Among these, endoleaks represent the most frequent and clinically relevant finding, particularly Type II endoleaks, which are sustained by retrograde collateral perfusion and may be associated with persistent aneurysm sac filling and sac enlargement. Computed tomography angiography (CTA) remains the reference standard for anatomical assessment after EVAR, providing detailed evaluation of endograft integrity, aneurysm sac morphology, and vascular anatomy. However, repeated CTA examinations involve cumulative radiation exposure and iodinated contrast administration and may be limited in the detection of low-flow or intermittent endoleaks. Contrast-enhanced ultrasound (CEUS) provides real-time hemodynamic assessment, improves detection of slow-flow endoleaks, and avoids both ionizing radiation and nephrotoxic contrast agents. Nevertheless, CEUS may be affected by operator dependency and limited anatomical overview. CT–ultrasound fusion imaging combines pre-acquired CTA datasets with real-time ultrasound through spatial co-registration and probe tracking, enabling simultaneous evaluation of vascular anatomy and flow dynamics. This narrative review critically synthesizes current evidence regarding CTA, CEUS, and CT–ultrasound fusion imaging in post-EVAR surveillance, with particular emphasis on the incremental clinical value of fusion imaging beyond standalone CTA and CEUS. Particular attention is devoted to diagnostic performance, technical implementation, clinical applicability, current limitations, and future perspectives of CT–CEUS fusion imaging. Full article

Background: Arteriovenous fistula is an abnormal connection between an artery and a vein. Post-traumatic fistulas are uncommon and usually occur after penetrating injuries, including gunshot wounds. Cervical arteriovenous fistulas are particularly rare and may coexist with a pseudoaneurysm, creating diagnostic and therapeutic challenges because of the proximity of major vascular, neurological, and aerodigestive structures. In hemodynamically stable patients, the limited external appearance of the wound may underestimate the extent of internal vascular injury; therefore, imaging is central to diagnosis and treatment planning. Case Presentation: We report the case of a 49-year-old man who presented to the emergency department with a gunshot wound to the left side of the neck. Computed tomography angiography (CTA) demonstrated a vascular injury adjacent to the left common carotid artery (LCCA), and further evaluation revealed an arteriovenous fistula (AVF) between the LCCA and the left internal jugular vein (LIJV), coexisting with a pseudoaneurysm of the LCCA. Doppler ultrasonography (DUS) identified an arterial wall defect and extrinsic compression of the LCCA by the hematoma. Selective digital subtraction angiography (DSA) confirmed an AVF between the LCCA and the LIJV, coexisting with an LCCA pseudoaneurysm. A covered stent-graft was implanted and completion angiography confirmed exclusion of both lesions with preserved patency of the LCCA. Discussion: This case demonstrates the complementary value of CTA, DUS and DSA in penetrating neck trauma. CTA provided rapid cross-sectional assessment of the injury trajectory and associated lesions, DUS added information on the arterial wall and local hemodynamic consequences, and DSA confirmed arteriovenous shunting while enabling immediate endovascular treatment. Conclusions: In hemodynamically stable patients with penetrating neck trauma, CTA should be considered when the wound trajectory approaches major vessels, even in the absence of active external bleeding. DUS and DSA may provide complementary information for lesion characterization and procedural planning. Covered stent-graft implantation may be a feasible reconstructive option in carefully selected patients. Full article

Objective: Giant thrombosed intracranial aneurysms (GTIAs) are aneurysmal dilatations containing partial or complete intraluminal thrombus. Representing approximately 2–5% of intracranial aneurysms, GTIAs present diagnostic and therapeutic challenges. Optimal management remains controversial and may involve microsurgical, endovascular, or hybrid strategies. Methods: A systematic review was performed in accordance with PRISMA guidelines using PubMed and Embase to identify relevant studies published between January 2000 and August 2025. Eligible studies reported clinical, anatomical, or treatment-related data for patients with GTIAs. Extracted variables included patient demographics, aneurysm characteristics, treatment modality, and outcomes. Data were standardized and analyzed using Python. Complication and recurrence rates were pooled in subsets of studies reporting explicit event counts; comparisons between treatment modalities were assessed using chi-square analysis. Results: In total, 101 studies including 536 patients met our criteria. Mean patient age was 50.2 years. Most aneurysms arose from the anterior circulation (88.2%) involving the internal carotid artery (46.6%) and middle cerebral artery (39.9%). The unweighted mean aneurysm diameter was 39.0 mm, with a patient-weighted mean of 24.3 mm. Hybrid treatment strategies were most frequently reported (62.7%), followed by endovascular (23.3%) and microsurgical (14.0%) approaches. Among studies reporting explicit counts, the pooled complication rate was 17.0% and the recurrence rate was 21.0%. Complication rates did not differ significantly between treatment modalities (p = 0.48), whereas recurrence differed significantly (p = 0.00013). Conclusions: Management of GTIAs remains heterogeneous, with increasing reliance on multimodal and hybrid treatment strategies. However, inconsistent outcome reporting and the predominance of retrospective studies limit definitive comparisons between treatment modalities. Full article

Thoracic endovascular aortic repair (TEVAR) is one of the main treatments, together with open aortic repair, for thoracic aortic aneurysm. This procedure is associated with low procedural morbidity and mortality and provides satisfactory mid-term results. However, identifying the optimal location for device deployment before the operation remains essential. In previous studies, computer simulations were used to examine the hemodynamic stress linked to different areas of the arch, pinpointing regions unsuitable for TEVAR delivery. Computational fluid dynamics (CFD) simulations suggest that zone 3 poses the most challenges for delivering endograft in type III arches, as it is considered a hostile region from biomechanical and hemodynamic perspectives. Morphologically, type III aortic arch shows a more pronounced curvature and a lower position of the arch, resulting in increased separation between the ascending and descending aorta. However, these studies utilized 3D geometrical models reconstructed from computed tomography angiography scans. Still, the flow boundary conditions were based on existing data rather than the specific hemodynamic characteristics of the patient. To bridge this gap, the present study uses MRI flow wave data to compute displacement forces (DFs) for each proximal landing zone. We found that zones 0 and 3 exhibited a high magnitude of displacement forces. Still, only zone 3 was identified as the most hemodynamically stressed area when the force was normalized for the lumen area. Furthermore, there was a significant discontinuity in the upward components of DFs between zone 2 and zone 3. The patient-specific assessment of displacement forces enabled us to identify suboptimal areas for TEVAR delivery, suggesting that personalized computer simulations could greatly enhance preoperative planning for TEVAR procedures. Full article

Background: Intermittent claudication is one of the most common symptoms of peripheral arterial disease. The Walking Impairment Questionnaire (WIQ) is frequently used to assess patients suffering from intermittent claudication as it measures walking distance, speed, and ability to climb stairs. Although the questionnaire has been translated and employed in different countries, no validated Polish version is available yet. The aim of this study was to translate and validate the Polish version of the WIQ. Methods: One hundred patients with IC who qualified for endovascular treatment were enrolled. WIQ translation and clinical validation was performed. The correlations among the WIQ, the two quality of life questionnaires (VascuQol-25 and SF-36), and objective walking distances in a 6-minute walking test (6 MWT) were calculated to determine the validity. Results: Correlations were observed among all WIQ domains, as well as between the total WIQ score and both initial claudication distance (InCD) and maximum walking distance (MWD), across all domains and 6 MWT parameters. The WIQ correlated with all domains of both VascuQol and SF-36. Test–retest reliability, as measured using the ICC, was 0.90. The internal consistency determined using Cronbach’s alpha was 0.94 for the total WIQ score. Conclusions: This study demonstrates that the Polish version of the WIQ, using the European metric system, is a reliable and clinically relevant tool for assessing walking impairment in patients with intermittent claudication. Full article

Background/Objective: The modified Fisher scale classifies intraventricular hemorrhage (IVH) as present or absent, potentially obscuring meaningful vasospasm risk differences. This study aimed to identify the IVH burden threshold, measured by the Graeb scale, at which symptomatic vasospasm risk increases after aneurysmal subarachnoid hemorrhage (SAH) and whether this association differs by treatment modality. Methods: This retrospective single-center study included aneurysmal SAH patients undergoing microsurgical clipping or endovascular coiling between 2015 and 2025. IVH was graded using the original Graeb scale (range, 0–12) and categorized as no IVH (0), grades 1–3, 4–7, or ≥8. The outcome was symptomatic vasospasm. Multivariate logistic regression and exploratory subgroup analyses were performed. Results: Among the 307 patients analyzed (clipping, n = 224; coiling, n = 83), symptomatic vasospasm occurred in 63 (20.5%). On multivariate analysis, an IVH Graeb score ≥ 4 was the only independent predictor of symptomatic vasospasm (odds ratio, 4.32; 95% confidence interval, 2.10–8.87; p < 0.001). Exploratory subgroup analysis showed the clipping-coiling difference was most pronounced in Graeb 4–7 (18.2% vs. 62.5%; p = 0.008), with no significant differences in remaining categories. However, the treatment × Graeb-category interaction was non-significant (p = 0.066). Conclusions: An IVH Graeb score ≥ 4 independently predicted symptomatic vasospasm after aneurysmal SAH. The treatment-specific divergence observed in the Graeb 4–7 subgroup was exploratory and hypothesis-generating, suggesting that early cerebrospinal fluid diversion may warrant particular consideration when endovascular coiling is performed in patients with moderate IVH. Full article

A 64-year-old woman presented with recurrent abdominal pain and rapid weight loss of 10 kg. Five years prior, an abdominal endovascular aneurysm repair (EVAR) was performed, followed by an open repair with proximal graft interposition due to an endoleak type IA two years ago. Laboratory tests revealed only moderately elevated infection markers (CrP 66 mg/L, WBC 14 GPt/L). ¹⁸F-FDG PET/CT showed a hypermetabolic peri-aortic mass initially suspected to be inflammatory. However, the patient did not exhibit signs of fever. Because of the equivocal constellation, a fine-needle biopsy was conducted, revealing malignant cells. The patient underwent complete tumor resection including aortic replacement. Histopathology confirmed the diagnosis of an angiosarcoma. The treatment was then supplemented with chemotherapy using doxorubicin and ifosfamide. Full article

Background/Objectives: Endovascular embolization of ruptured intracranial arterial aneurysms has become the first-choice treatment due to its minimal invasiveness, rapid patient recovery, and lower complication rate. The aim of this study was to analyze putative risk factors of unfavorable outcomes of ruptured intracranial aneurysms after coil embolization and the recanalization rate. Methods: This case series included adult patients with ruptured intracranial aneurysms who underwent endovascular embolization during the study period of 2007–2023. In total, 1080 patients with ruptured intracranial aneurysms treated using endovascular coiling participated in this study. Results: During the first year after the initial intervention, repeated embolization was performed for 50 patients (5.5%). Treatment outcome was assessed using the modified Rankin Scale, and neuroradiological follow-up was conducted during a five-year period on 672 patients. During the period from one to five years, re-embolization was performed in 11 (1.5%) cases, of which only three occurred during the last 3 years of follow-up. Conclusions: Endovascular embolization is a safe method for the treatment of ruptured intracranial aneurysms, with a low complication rate and good clinical outcome. Higher risk for repeated aneurysm embolization is associated with male sex, alcohol consumption, smoking, hyperlipidemia, aneurysm size, diabetes, aneurysm location, and obliteration rate. This study showed that aneurysms in which recanalization is not observed within 2 years after coil embolization remain stable during a follow-up period of 5 years, except in the case of large aneurysms and low obliteration rates. Full article

Background & Objectives: Endovascular embolization has matured into a sophisticated, precision-guided discipline that is central to the management of complex neurovascular pathologies. This review synthesizes contemporary treatment strategies, evaluating the advanced material characteristics of conventional inert liquid polymers, specifically non-adhesive ethylene vinyl alcohol (EVOH) copolymers and adhesive cyanoacrylates, alongside their targeted clinical applications in brain arteriovenous malformations (bAVMs), dural arteriovenous fistulas (dAVFs), hypervascular intracranial tumors, and chronic subdural hematomas (CSDHs). Furthermore, it examines the critical material and hemodynamic constraints that limit these agents in cerebral aneurysm repair. Methods: A comprehensive literature synthesis through 3 July 2026 was integrated with peer-reviewed clinical illustrations to evaluate both procedural mechanics and the necessity of post-procedural physiological management. Review Findings: Embolization serves a critical dual role: as a definitive curative therapy and as an essential preoperative or radiosurgical adjunct. As demonstrated by recent clinical validations, technical angiographic success must be closely coupled with vigilant neurocritical oversight to manage profound, localized hemodynamic shifts. While these conventional methods represent established clinical practice, the field is evolving away from inert mechanical occlusion toward a highly integrated approach. The convergence of stimuli-responsive “smart” hydrogels and endovascular robotics is being evaluated for potential roles in transforming these interventions into dynamic, bioactive platforms capable of modulating disease-specific mechanisms, such as Rat Sarcoma-Mitogen-Activated Protein Kinase (RAS-MAPK) and Bone Morphogenetic Protein (BMP) signaling in bAVMs or the Von Hippel-Lindau/Vascular Endothelial Growth Factor (VHL/VEGF) axis in hypervascular tumors. This review further analyzes landmark data, including the Squid Trial For the Embolization of the Middle Meningeal Artery for Treatment of Chronic Subdural Hematoma (STEM) trial for CSDH, providing a synthesis for translating these advanced material sciences into standardized, multidisciplinary neurointerventional care. Full article

Background/Objectives: Spinal dural arteriovenous fistulas (sDAVFs) are the most common spinal vascular malformation and a treatable cause of progressive myelopathy, yet diagnosis and optimal management remain challenging. This study presents a nine-year institutional experience using a multidisciplinary treatment algorithm that prioritizes endovascular embolization, with surgery reserved for unsuccessful or contraindicated cases. Methods: We retrospectively analyzed 15 patients treated between 2015 and 2023, all diagnosed by MRI and confirmed by digital subtraction angiography. Endovascular embolization was attempted as the initial treatment modality in all patients using contemporary liquid embolic agents. Results: Three patients (20%) subsequently required surgical disconnection following unsuccessful or incomplete embolization. Lesions ranged from Th5 to L5, and most patients presented with varying degrees of motor deficits, gait disturbance, paresthesias, or sphincter dysfunction. Neurological improvement occurred in all but one patient, and no treatment-related complications were observed. Prior embolization attempts aided intraoperative localization in surgically treated cases, facilitating precise fistula identification. Conclusions: These findings demonstrate the feasibility and favorable outcomes of a multidisciplinary, stepwise treatment strategy in this single-center experience. Endovascular embolization served as the initial treatment modality, while surgical disconnection provided an effective complementary option in selected cases where embolization was unsuccessful or incomplete. Full article

Glioblastoma (GBM) is the most common and aggressive primary brain tumor, characterized by poor prognosis and a median survival of 12–18 months despite standard therapies such as surgery, radiation, and temozolomide chemotherapy. Its high cellular heterogeneity, along with complex mechanisms of therapy resistance, presents significant challenges for effective treatment. Conventional systemic chemotherapy is limited by the blood–brain barrier (BBB), systemic toxicity, and insufficient drug penetration into the tumor microenvironment. Emerging therapeutic strategies aim to overcome these barriers through novel chemotherapeutic agents, targeted therapies, immunotherapies, and smart drug delivery systems. Endovascular drug delivery, particularly super-selective intra-arterial cerebral infusion (SSIACI), offers a minimally invasive approach to directly target the tumor vasculature, potentially increasing drug concentration at the tumor site while reducing systemic exposure. Complementary techniques, such as MR-guided focused ultrasound, hyperosmotic disruption, and nanoparticle-based carriers, are being explored to enhance BBB penetration and retention of therapeutics within the tumor. Ongoing clinical trials and translational studies provide insights into optimizing these approaches, with future directions focused on precision medicine, biomarker-driven patient selection, and combination therapies. Integrating endovascular strategies with innovative chemotherapies and immunotherapies may transform GBM management, but further research is required to establish their efficacy and safety in clinical practice. Full article

This case demonstrates the efficacy and feasibility of visceral–renal debranching with endovascular repair for the treatment of a distal stent graft-induced new entry (dSINE) that occurred 47 months after a frozen elephant trunk procedure in a patient with chronic aortic dissection type B. There were no perioperative complications. Postoperative computed tomography scans confirmed sealing dSINE and the patency of visceral and renal arteries. Full article