Search Results (191)

Introduction: Kawasaki disease (KD) is an acute systemic vasculitis and the leading cause of acquired pediatric heart disease in high-income countries. Coronary artery aneurysms (CAA) represent the most severe complication and drive long-term cardiovascular risk. Despite improved outcomes with early intravenous immunoglobulin therapy, follow-up strategies remain heterogeneous, particularly for patients showing CAA regression. Dynamic risk stratification based on coronary Z-scores has been proposed, but long-term real-world data are still needed to optimize surveillance. Methods: We conducted a single-center, retrospective study including pediatric patients (age 1 month–18 years) with KD complicated by CAA, followed at Bambino Gesù Children’s Hospital (Rome) between 1999 and 2024. Coronary involvement was assessed using Boston Z-scores of the right coronary artery, left main coronary artery, and left anterior descending artery. CAA severity over time was analyzed using a composite MAX SCORE (highest Z-score among coronary branches) along with the 1-YEAR MAX SCORE (highest MAX SCORE reached within the 1 year of disease). The distribution and timing of cardiac computed tomography angiography (CCTA) and exercise stress testing (EST) during follow-up were analyzed in relation to coronary severity. Results: Among 502 KD patients, 122 (24.3%) developed CAA; 113 were included in the analysis. Mean age at diagnosis was 24.6 months (M/F 3.5:1). Multivessel involvement was observed in 72%, most frequently affecting the left anterior descending artery. Long-term follow-up ≥10 years was available for 31.9% of patients. Most changes in coronary severity occurred within the first year after disease onset, with complete CAA regression in 76.1% of patients. Conversely, 53% of patients affected by giant aneurysms at 12 months showed persistent severe disease at last follow-up. EST (164 tests in 40 patients) was almost universally negative for inducible ischemia (163/164), whereas CCTA (47 exams in 35 patients) was preferentially performed early and in higher-risk patients. Test prescription correlated more closely with 1-YEAR MAX SCORE than with contemporaneous severity. Echocardiography showed systematic differences compared with CCTA for right coronary and left anterior descending artery Z-scores. Discussion: In our experience, early coronary status was closely associated with the intensity of long-term surveillance strategies in KD. The 1-YEAR MAX SCORE was associated with subsequent patterns of coronary evolution, and the continuous 1-year Maximum Z-score showed good discriminatory ability for persistent CAA on ROC analysis, pending external validation. While the low rate of positive findings on EST raises questions about its diagnostic yield in real-world practice, CCTA provided detailed anatomical characterization. Overall, these findings suggest that early coronary severity may help inform individualized, severity-driven follow-up strategies, warranting confirmation in prospective multicenter studies. Full article

Background: The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) of the left main coronary artery remains uncertain because this lesion involves a large myocardial territory and requires a careful balance between ischemic protection and bleeding risk. This review aimed to provide an updated, left-main-focused synthesis of the evidence on DAPT duration after PCI and to clarify how treatment should be individualized according to clinical presentation, lesion complexity, procedural strategy, intravascular imaging, and validated ischemic and bleeding risk scores. Methods: This narrative review with a structured literature search examined studies published from January 2010 through May 2026 in PubMed/MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar. From 248 identified records, 62 studies met the eligibility criteria and were included in the qualitative synthesis, comprising 38 randomized controlled trials and 24 observational studies or pooled analyses. The review prioritized direct left-main-specific evidence while also incorporating broader PCI studies with left-main subgroups and indirect contextual evidence relevant to antiplatelet decision-making. Independent screening, duplicate data extraction, and qualitative risk-of-bias assessment were performed, but the review was not prospectively registered, and no meta-analysis was conducted. Results: The available evidence supports an individualized rather than fixed DAPT strategy after left main PCI. In stable patients with anatomically simple left main lesions and acceptable bleeding risk, 6–12 months of DAPT appears generally sufficient, whereas patients with acute coronary syndromes, two-stent distal bifurcation strategies, high thrombotic burden, or other high-ischemic-risk features may derive greater benefit from extending therapy beyond 12 months when bleeding risk is low. Contemporary guideline recommendations are broadly aligned with this risk-adapted approach, and recent trials further refine decision-making: PARTHENOPE provided randomized support for risk-score-guided personalization of DAPT duration, whereas NEO-MINDSET cautioned against immediate aspirin withdrawal after PCI in acute coronary syndromes. Intravascular imaging, especially IVUS and OCT, improves procedural optimization and may help contextualize post-PCI thrombotic risk, although current data do not validate imaging findings alone as a stand-alone criterion for abbreviated DAPT. Conclusions: DAPT duration after left main PCI should be individualized by integrating clinical presentation, lesion and procedural complexity, intravascular imaging, and validated ischemic and bleeding risk tools. A personalized, risk-adapted strategy currently offers the most appropriate framework for balancing ischemic benefit against bleeding harm in this high-risk population. Full article

Background/Objectives: Myocardial perfusion PET/CT, e.g., using Rb-82, enables the measurement of absolute myocardial blood flow (MBF) and, hence, the blood flow reserve, which plays a crucial role in the diagnosis of coronary artery disease. However, the values might depend on the observer’s analysis and, thus, depend on the observer’s experience. We investigated the inter-observer reliability of MBF measurements in Rb-82-PET/CT. Methods: Thirty consecutive patients who underwent Rb-82-PET/CT for suspected myocardial ischemia were analyzed. Stress conditions were simulated using 400 µg Regadenoson. MBF was measured using Corridor 4DM software. Myocardial flow reserve (MFR) is the ratio of absolute flow measurements under stress and rest conditions. Four different physicians with different levels of experience (two senior physicians and two residents) measured the MBF. The experience of the two residents was one year of experience and no previous experience, respectively. Intraclass correlation coefficients (ICC) were calculated for MBF and MFR in the three main vascular territories as well as in the whole left ventricle. Additionally, the left ventricular ejection fraction (EF) was determined. Results: The evaluation of MBF showed an excellent correlation between all observers, indicated by a low inter-observer variability. Comparing the two different levels of experience, senior physicians showed a slightly higher accordance in MBF assessment (ICC ranging from 0.9 to 0.98) than the residents (ICC ranging from 0.86 to 0.94). The MFR calculations showed a slightly lower reliability due to the accumulation of variability in rest and stress measurements (ICC between 0.78 and 0.81), still indicating a good reliability. The EF calculations also showed a good reliability among the different observers (ICC 0.83). Conclusions: Measurement of MBF, MFR and EF in Rb-82-PET/CT is highly robust with a very low inter-observer variability. A slightly higher inter-observer reliability was found for more experienced physicians. Full article

Background: No consensus guideline exists for double-lumen tube (DLT) size selection, which conventionally relies on height, sex, and chest radiography. Computed tomography (CT) has been proposed to refine sizing, particularly in women and patients of small stature. We examined whether high-resolution CT (HRCT) measurement of the trachea and main bronchi improves DLT size selection beyond a height- and sex-based estimate in patients undergoing minimally invasive coronary artery bypass (MICS-CABG). The aim of this study was to determine whether HRCT measurement of the trachea and main bronchi improves DLT size selection beyond a height- and sex-based estimate in patients undergoing MICS-CABG. Methods: A total of 140 patients were retrospectively analyzed who had undergone MICS-CABG and had HRCT within 30 days of surgery. Tracheal anteroposterior and transverse diameters and left and right main bronchus diameters were measured in lung, mediastinal, and bronchial windows (mean of six readings by two observers). The DLT size used was related to each parameter through Spearman correlation; the agreement between the height/sex estimate and the size used was determined using Cohen’s kappa; discrimination for a larger tube (≥39 Fr) was evaluated through receiver operating characteristic analysis; and the incremental value of imaging was assessed using leave-one-out cross-validation. Results: In total, 82.1% of patients were male (mean age 59.7 ± 10 years; height 171.7 ± 7.3 cm). The height- and sex-based estimates correlated most strongly with the size used (ρ = 0.885, p < 0.001), followed by height alone (ρ = 0.844, p < 0.001); the best imaging measure, the lung-window left main bronchus diameter, was weaker (ρ = 0.503, p < 0.001), and body mass index showed no association (ρ = −0.008, p = 0.926). The estimate matched the size used exactly in 85.7% of patients and was within one size for all patients (linear-weighted κ = 0.831). Height best discriminated a larger tube (AUC = 0.969). Adding the bronchial diameter to height and sex did not improve cross-validated prediction (exact match 80.7% with and without; AUC 0.972 versus 0.973). The mediastinal window yielded systematically larger calibers than the lung and bronchial windows. Conclusions: HRCT airway measurement did not improve the prediction of the double-lumen tube size selected in routine practice beyond a simple height- and sex-based formula. Because the reference standard was the size clinicians actually placed rather than an independently validated optimum, these data argue against routine preoperative HRCT undertaken solely to predict tube size; they do not exclude a benefit of HRCT when selection is judged against clinical outcomes. CT remains valuable when abnormal airway anatomy is suspected. Full article

Coronary in-stent restenosis (ISR) remains a major contributor to repeat revascularisation despite advances in drug-eluting stent (DES) technology. Its persistence reflects a complex and heterogeneous interplay among mechanical, biological, and procedural factors, and understanding the dominant mechanism in each case is fundamental to effective treatment selection. This narrative review provides a contemporary, mechanism-guided approach to the practical management of coronary ISR. We summarise the definition, incidence, and classification of ISR—including the Mehran, Waksman, and SCAI 2023 time-based frameworks—and outline patient-related, procedural, anatomical, and stent-related risk factors. The pathophysiology of neointimal hyperplasia and neoatherosclerosis is discussed with reference to its clinical implications. Intracoronary imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is central to ISR characterisation and treatment planning. Current international guidelines support imaging use in ISR management, though it is important to recognise that this recommendation is based largely on observational and surrogate-endpoint data rather than ISR-specific randomised trials demonstrating reductions in hard clinical outcomes, and practical barriers including cost, availability, and operator expertise must be acknowledged. Evidence-based treatment strategies—including drug-coated balloons (DCB), repeat DES implantation, lesion-modifying therapies, vascular brachytherapy, and coronary artery bypass grafting—are reviewed critically with reference to contemporary trial data and their specific clinical applicability. The choice between DCB and repeat DES is addressed with greater nuance, accounting for ISR type (BMS-ISR versus DES-ISR), lesion pattern, stent layering, and bleeding risk. Management considerations in complex subsets—chronic total occlusion ISR, left main ISR, saphenous vein graft ISR, and recurrent ISR—are also addressed. We propose a practical, substrate-driven management framework aligned with the 2024 ESC, 2021 ACC/AHA/SCAI, and 2018 JCS/JSCVS guidelines. Future research priorities include ISR-specific randomised trials with hard clinical endpoints, prospective validation of imaging-guided treatment algorithms, head-to-head comparisons of DCB platforms, and investigation of pharmacological strategies targeting neoatherosclerosis progression. Full article

Background/Objectives: Despite advances in heart failure (HF) pharmacotherapy, novel treatments are needed for its main subtypes: preserved (HFpEF), mildly reduced (HFmrEF), and reduced (HFrEF) ejection fraction. Glucagon-like peptide-1 (GLP-1) based therapies have shown cardioprotective effects. We conducted a systematic review and meta-analysis (Prospero Registration Number CRD42024606997) assessing the efficacy of GLP-1 based therapies (GLP-1 receptor agonists including tirzepatide) across the spectrum of left ventricular ejection fraction on cardiovascular (CV) outcomes. Methods: The PubMed, Embase, Scopus and trial registries were searched until December 2025 for randomised controlled trials (RCTs) involving adults with HF treated with GLP-1 based therapies. Outcomes included heart failure hospitalisations (HFH), CV, and all-cause mortality. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Subgroup analyses were performed by HF subtype, age, coronary artery disease (CAD) presence, and GLP-1 based therapeutic agent. Results: Fourteen RCTs (15,180 participants), at low risk of bias, were included. These agents significantly reduced HFH (RR: 0.84, 95% CI: 0.71–0.99), especially in HFpEF patients with stable CAD (RR: 0.61, 95% CI: 0.46–0.79). Limited data suggested benefits for exenatide in HFmrEF patients (RR: 0.67, 95% CI: 0.47–0.95). CV mortality was reduced in HFrEF patients <65 years old (RR: 0.71, 95% CI: 0.54–0.95). Benefit was seen in composites of HFH and CV mortality for HFpEF (RR: 0.67, 95% CI: 0.54–0.83). Conclusions: GLP-1 based therapies may reduce HFH in HFpEF and possibly lower CV mortality in younger HFrEF patients, suggesting phenotype-specific effects. Full article

Aim: We aimed to provide a structured ex vivo protocol for cardiopulmonary micro-CT that combines gelatin–barium sulfate (gelatin–BaSO₄) contrast medium with agar embedding in neonatal canine cardiopulmonary specimens. Materials and Methods: Heart–lung specimens from 23 puppies that died shortly after birth were collected, stored at −20 °C, and then slowly thawed prior to imaging. Before perfusion, body mass and heart–lung complex mass were recorded. Body mass ranged from 140 to 951 g, and heart–lung complex mass ranged from 1.2 to 51.2 g. The cranial and caudal venae cavae, the brachiocephalic trunk, and the left subclavian artery were ligated. A catheter was introduced into the thoracic aorta. Contrast was prepared by dissolving porcine gelatin in hot water and mixing with a commercial BaSO₄ suspension. The mixture was maintained at a warm temperature to remain free-flowing and was delivered at low pressure until uniform opacification of the coronary and pulmonary arteries was observed. After in situ gelation, the organs were embedded in warm agar and sealed to limit motion and dehydration. Scans were performed on a benchtop system (120 kV, ~83 µA, ~1200 projections, ~2 s exposures; voxel ~40 µm). Reconstruction was performed in XMReconstructor, with post-processing in Falcon and RadiAnt. The reconstructed micro-CT datasets were reviewed anatomically by a medical cardiologist and a veterinary cardiologist, whereas vascular filling was evaluated semi-quantitatively by three observers with expertise in veterinary anatomy and cardiology. Results: In all specimens examined, the main coronary artery course was assessable. Conclusions: The gelatin–BaSO₄ contrast medium combined with agar immobilization provides a simple, lead-free, and affordable approach for structured cardiopulmonary micro-CT in very small post-mortem specimens. In the examined specimens, the workflow provided visually consistent low-pressure vascular opacification without gross evidence of vessel rupture or motion-related acquisition failure under the conditions of this study. Practical mitigations included temperature/viscosity control, avoidance of phosphate buffers, container sealing, and minimization of particle aggregation, bubbles, and dehydration. The protocol may complement conventional autopsy in very small post-mortem specimens in similar ex vivo research settings. Full article

Background and Objectives: Pericoronary adipose tissue (PCAT) attenuation measured on coronary CT angiography is a promising imaging biomarker of coronary inflammation; however, absolute values may be influenced by technical and inter-individual variability, and a standardized methodology for measurement has not been established. Our study aimed to evaluate the association between PCAT attenuation and CAC burden while comparing absolute attenuation values with normalized values to minimize these sources of variability. Materials and Methods: Two hundred patients undergoing cardiac CT were included and stratified into four CAC categories (0, 1–99, 100–299, ≥300). PCAT attenuation was measured at multiple locations on two main levels: aortic root level and four-chamber view level. Relative PCAT attenuation was calculated by subtracting subcutaneous fat attenuation from raw PCAT values. Group comparisons were performed using ANOVA or Kruskal–Wallis tests, and multivariable linear regression models were adjusted for age, sex, and body mass index. Results: In univariate analysis, relative PCAT attenuation differed significantly across CAC categories at the aortic-level right coronary artery (RCA) site (p = 0.007). In multivariable analysis, higher CAC categories were associated with increased relative PCAT attenuation at the aortic RCA (β = 8.56, p = 0.015 for CAC 100–299; β = 10.68, p = 0.005 for CAC ≥300), while associations at the left main coronary artery (LMCA) showed significance in low and moderate CAC categories (β = 6.91, p = 0.047 for CAC 1–99 and β = 8.57, p = 0.016 for CAC 100–299). No significant associations were observed between CAC and raw PCAT attenuation at the aortic level, while isolated and inconsistent findings were observed in other territories. Conclusions: Relative PCAT attenuation is independently associated with CAC severity and normalized values may reduce technical and biological variability, potentially enhancing the sensitivity and robustness of this CT-based biomarker. Full article

Background: Kounis syndrome is an acute coronary syndrome triggered by hypersensitivity reactions, which may result in coronary vasospasm, thrombosis, or stent-related complications. Case Summary: A 64-year-old male smoker with dyslipidemia and recently diagnosed urothelial carcinoma presented with exertional angina and underwent coronary angiography. Percutaneous coronary intervention was performed for a critical proximal–mid left anterior descending artery lesion using a drug-eluting stent. Immediately after stent deployment, the patient developed diffuse multivessel coronary vasospasm involving the left main stem, left anterior descending, and left circumflex arteries, accompanied by slow-flow/no-reflow phenomena and subsequent acute in-stent thrombosis. The clinical course rapidly progressed to ventricular arrhythmias and cardiogenic collapse. Despite transient return of spontaneous circulation after cardiopulmonary resuscitation, the patient developed fatal asystole during a repeat angiographic attempt. No cutaneous or respiratory allergic manifestations were observed. The abrupt onset of diffuse coronary dysfunction immediately following contrast exposure was suggestive of suspected Kounis syndrome, although mechanical causes and chemotherapy-related vasospasm could not be entirely excluded. Conclusions: Diffuse coronary vasospasm with multivessel dysfunction occurring abruptly after contrast exposure should raise suspicion for Kounis syndrome, even in the absence of overt allergic manifestations. Early recognition is essential to avoid misattribution to procedural complications and may be particularly important in patients with malignancy undergoing invasive coronary procedures. Full article

Post-infarction ventricular septal defect (VSD) represents a rare but frequently fatal mechanical complication of ST-elevation myocardial infarction (STEMI), associated with high morbidity and mortality despite advances in reperfusion strategies. The optimal timing of surgical repair remains a matter of ongoing debate, particularly in patients presenting with hemodynamic instability and evolving right ventricular failure. Two main strategies have been proposed: an early surgical approach aimed at preventing progressive hemodynamic deterioration and right ventricular dysfunction, and a delayed strategy that allows for infarct maturation and fibrotic remodeling of the septal margins, thereby facilitating more secure patch anchoring and reducing the risk of residual shunting. We report the case of a 39-year-old male with multiple cardiovascular risk factors who presented to the emergency department after seven days of persistent chest pain and was diagnosed with an inferior STEMI. Urgent percutaneous coronary intervention was performed, with successful stent implantation in the right coronary artery. Seven days later, transthoracic echocardiography identified an inferior post-infarction ventricular septal defect. In the context of clinical deterioration characterized by progressive right ventricular failure, urgent surgical repair was undertaken. The postoperative course was complicated by severe pulmonary hypertension and refractory cardiogenic shock, necessitating veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for five days. The patient was subsequently weaned successfully from mechanical circulatory support and discharged on postoperative day 12. At one- and three-month follow-up, he remained asymptomatic, with significant recovery of left ventricular ejection fraction. This case underscores the critical importance of timely surgical intervention in post-infarction VSD, particularly in the setting of right ventricular failure, and highlights the essential role of temporary mechanical circulatory support in the management of severe postoperative cardiogenic shock. Full article

Coronary artery calcification, present in 20–30% of percutaneous coronary interventions (PCI), significantly impairs procedural success. Conventional angiography detects calcification in fewer than half of affected cases, while intravascular imaging—though precise—requires lesion crossability that cannot be guaranteed in up to 20% of severely calcified lesions. Cardiac CT (CCT) addresses both constraints by providing comprehensive, three-dimensional calcium characterization before the procedure begins, independent of wire crossability. This review details how specific CCT-derived parameters translate into procedural decisions. Calcium arc, depth, density, and longitudinal distribution each carry distinct implications for device selection: superficial high-density calcium favors atherectomy, while deep concentric patterns are better addressed by intravascular lithotripsy. Validated scoring systems—including the ABCD score—enable objective pre-procedural risk stratification. For chronic total occlusions, bifurcation lesions, ostial stenoses, and very long calcified segments, CCT provides lesion-specific information that supports stepwise strategy selection, equipment preparation, and anticipation of combined modification approaches. Importantly, CCT also identifies anatomical configurations—such as left main bifurcations or tortuous calcified segments—where specific device-related risks warrant particular caution. CCT and intravascular imaging serve complementary roles: CCT defines the strategic framework before the procedure, while intravascular imaging guides real-time execution and optimization. Limitations include operator-dependent interpretation, the absence of standardized protocols for translating calcium morphology into device selection, and the need to validate established Hounsfield unit thresholds in emerging photon-counting CT systems. Prospective randomized evidence comparing CCT-guided and intravascular imaging-guided strategies remains limited but is anticipated from ongoing trials. Full article

Coronary artery disease (CAD) often coexists with severe aortic stenosis (AS) in patients undergoing transcatheter aortic valve implantation (TAVI), posing a complex diagnostic and therapeutic challenge. As TAVI is increasingly used for younger, lower-risk patients, managing CAD is becoming a personalized, long-term clinical concern. This narrative review summarizes the current evidence on coronary assessment and revascularization strategies in individuals with severe AS. Invasive coronary angiography remains the leading method for anatomical coronary imaging, but coronary computed tomography angiography is emerging as a reliable alternative that may reduce unnecessary invasive procedures in certain patients. The routine performance of PCI before TAVI is under increasing scrutiny, and available data support a more selective approach based on lesion significance, CAD complexity, procedural timing, and anticipated need for future coronary access. Significant uncertainties remain concerning the physiological evaluation of lesions, the timing and completeness of revascularization, and the treatment of left main or multivessel disease. Additional phenotype-specific and longitudinal studies are needed to improve management algorithms for this population. Full article

Background/Objectives: Fractional flow reserve (FFR) is the reference standard for assessing the functional significance of intermediate coronary stenoses and guiding revascularization. Although a universal ischemic threshold is applied to all epicardial vessels, potential physiological differences between coronary territories remain insufficiently explored. The aim of this study was to evaluate whether the functional significance of intermediate coronary stenoses differs according to coronary artery and to assess the clinical outcomes of FFR-guided deferral across coronary territories. Methods: This single-center retrospective study included patients who underwent single-vessel FFR assessment for angiographically intermediate lesions between 2019 and 2022. Patients with left main disease or multivessel physiological assessment were excluded. Clinical characteristics, FFR values, and long-term outcomes were analyzed according to the investigated coronary artery. Major adverse cardiovascular events (MACE) were defined as a composite of death, myocardial infarction, and urgent revascularization. Results: A total of 310 patients (corresponding to 310 coronary arteries) were included: 211 LAD, 68 RCA, and 31 LCX lesions. Overall, 18.7% of lesions had a positive FFR (≤0.80). The only variable identified in univariable analysis as being associated with FFR positivity was the coronary artery evaluated (p < 0.001). Positive FFR values were observed in 24.6% of LAD lesions, compared with 8.8% in the RCA and none in the LCX. Among patients with negative FFR for whom revascularization was deferred, five-year MACE-free survival was similar across coronary territories (p = 0.12). Conclusions: The functional significance of intermediate coronary stenoses varies according to the coronary territory, with LAD lesions more frequently reaching ischemic thresholds. However, deferral of revascularization based on negative FFR is associated with favorable long-term outcomes across all vessels, supporting a vessel-specific physiological interpretation of coronary stenoses. Full article

Background: Acute type A aortic dissection (ATAAD) is a life-threatening condition that may be complicated by malperfusion, particularly in patients with prior aortic interventions such as Thoracic Endovascular Aortic Repair (TEVAR). Management becomes increasingly complex when the dissection involves supra-aortic branches and compromises previously placed stents. Methods: We report the case of a 58-year-old male presenting with ATAAD and left lower limb paralysis, with a history of prior TEVAR. Imaging demonstrated an entry tear in the ascending aorta with extension into the distal left main and supra-aortic branches, resulting in a dissection flap obstructing the proximal end of the TEVAR stent. The patient underwent emergency surgical intervention including a Bentall procedure, coronary artery bypass grafting (CABG), and deployment of a small Ascyrus Medical Dissection Stent (AMDS) distally within the TEVAR stent. Pre-operatively, the patient had severe lower limb ischemia due to near-complete obstruction of distal flow. Results: Following surgical intervention, there was restoration of true lumen perfusion with resolution of malperfusion. The patient was successfully weaned from cardiopulmonary bypass, extubated on post-operative day 4, and discharged on day 7 with stable hemodynamics and intact bilateral lower limb perfusion. Post-operative computed tomography (CT) demonstrated a well-seated AMDS with no evidence of ongoing false lumen perfusion. At 30-day follow-up, there was no clinical or biochemical evidence of organ malperfusion. Conclusions: The use of an AMDS deployed within a pre-existing TEVAR stent may represent an effective strategy for managing complex ATAAD with malperfusion, particularly in cases requiring combined surgical interventions. Full article