Search Results (31)

Background/Objectives: Intermittent ureteropelvic junction obstruction (UPJO), classically termed Dietl’s crisis, may be missed when imaging is obtained outside symptomatic periods. The challenge is amplified in duplicated collecting systems, where the obstructed moiety may not be recognized on screening ultrasonography. Case Presentation: A 14-year-old boy presented with recurrent severe right flank pain triggered by heavy fluid intake, associated with nausea and vomiting and separated by symptom-free intervals. An initial renal ultrasound performed between attacks was normal. One week later, the same pain pattern recurred together with a febrile urinary tract infection. Computed tomography urography (CTU) demonstrated an incomplete right duplex collecting system with a bifid ureter, marked hydronephrosis of the lower moiety, delayed contrast excretion, and focal narrowing at the lower-moiety ureteropelvic junction adjacent to one crossing artery and one crossing vein. Diuretic ^99mTc-mercaptoacetyltriglycine (MAG3) renography documented obstructive drainage, with a post-furosemide drainage half-time (T1/2) > 20 min, differential renal function of 51% on the right, and split moiety function of 31% (upper) and 20% (lower). The patient underwent transperitoneal robot-assisted dismembered Anderson–Hynes pyeloplasty of the lower moiety with the reconstructed ureteropelvic junction repositioned anterior to the crossing vessels; a 6 Fr × 26 cm double-J stent was placed and subsequently removed at 4 weeks postoperatively. Total skin-to-skin operative time was 75 min, estimated blood loss < 100 mL, and the postoperative course was uneventful. At early 3-month follow-up, the patient remained free of Dietl-type episodes, and ultrasonography showed marked reduction in lower-moiety hydronephrosis. Selective postoperative CTU, obtained because of the unusual bifid anatomy, demonstrated patent drainage. Conclusions: A normal interval ultrasound should not exclude intermittent UPJO when the history is stereotypical, and cross-sectional plus functional imaging is decisive when duplex anatomy and crossing vessels coexist. Full article

Background: While recent literature emphasizes the predictive value of composite inflammatory and nutritional indices for vascular outcomes, this study evaluates the actual predictive capacity of preoperative indices (PNI, GNRI, SII, NLR, PLR) for de novo arteriovenous fistula (AVF) maturation and 1-year primary patency. Methods: We retrospectively analyzed 945 end-stage renal disease patients who underwent strictly radio-cephalic autologous AVF creation. Preoperative indices were calculated from routine parameters. Diagnostic accuracy for predicting 1-year patency loss was assessed using receiver operating characteristic (ROC) curves, and a multivariate logistic regression model was constructed to adjust for baseline anatomical and clinical variables. Targeted subgroup analyses evaluated high-risk populations, including those with diabetes, coronary, and peripheral artery disease. Results: The 1-year primary and secondary patency rates were 73.3% and 93.1%, respectively. In contrast to prevalent reports, no significant differences in preoperative PNI, GNRI, NLR, PLR, or SII scores existed between patients with patent and thrombosed fistulas (p > 0.05). ROC analyses showed no predictive utility (AUC: 0.476–0.518). Crucially, multivariate logistic regression revealed that preoperative arterial (OR: 0.58, p < 0.001) and venous diameters (OR: 0.51, p < 0.001) were the strongest independent predictors of AVF failure, whereas all systemic biomarkers lacked independent predictive significance. Subgroup analyses confirmed these indices failed to predict AVF outcomes even in high-risk settings with severe endothelial dysfunction. Conclusions: Preoperative composite nutritional and inflammatory indices do not independently predict AVF maturation or long-term patency when adjusted for local anatomy. Local anatomical features and hemodynamics heavily dominate vascular outcomes, indicating that systemic biomarkers have limited standalone clinical utility for guiding preoperative vascular access planning. Full article

Background: Interventional cardiology is increasingly being reshaped by rapid progress in non-invasive cardiovascular imaging. Coronary computed tomography angiography (CTCA), once used mainly to exclude obstructive coronary artery disease (CAD), is now being adopted as a broader planning instrument before percutaneous coronary intervention (PCI). Its ability to generate high-resolution three-dimensional visualization of the coronary tree, together with functional assessment through CT-derived fractional flow reserve (FFR-CT) and more advanced plaque analysis supported by artificial intelligence (AI), has expanded its relevance from diagnosis alone to strategic procedural preparation. In this setting, CTCA can help refine lesion assessment, anticipate technical complexity, and support better procedural and clinical outcomes. Technological Advancements: The value of CTCA for both diagnosis and risk stratification has increased substantially with recent technical innovation. Among the most important developments is the maturation of FFR-CT, which enables non-invasive physiological interrogation of coronary stenoses using computational modeling. At the same time, artificial intelligence and deep learning tools are reshaping the CTCA workflow by improving automation, facilitating plaque analysis, and highlighting adverse plaque characteristics such as positive remodeling, spotty calcification, and the napkin-ring sign. Clinical Applications: In modern catheterization practice, CTCA is increasingly used to address anatomically demanding scenarios. Its role is particularly valuable in chronic total occlusion (CTO) intervention, where it can delineate occlusion length, stump characteristics, vessel course, and collateral anatomy before the procedure. Its usefulness also extends beyond CTO PCI by supporting vessel sizing, stent planning, and anticipation of lesion preparation requirements in complex coronary disease. Challenges: Despite these advantages, several barriers continue to limit wider implementation, including blooming from heavy calcification, radiation burden, contrast-related renal concerns, and the practical difficulty of embedding CTCA-based planning into routine workflows. Conclusions: CTCA is becoming an increasingly important adjunct in PCI planning because it can combine anatomical definition, physiological interpretation, and plaque-level information before invasive treatment is undertaken. Overall, this review emphasizes CTCA not only as a diagnostic modality, but also as a practical pre-procedural roadmap that can guide lesion selection, stent planning, calcium modification strategies, and overall PCI strategy. Full article

Background: Retroperitoneal surgical corridors, particularly in robotic-assisted partial nephrectomy and donor surgery, require precise knowledge of hilar vascular orientation. The typically described Vein–Artery–Pelvis (VAP) anatomy is often assumed, yet its reliability is poorly quantified. Therefore, the purpose of the present study is to provide a comprehensive radioanatomical map of hilar architecture to enhance surgical safety and predictability. Methods: Contrast-enhanced computed tomography (CT) scans of the abdomen from 200 patients (104 males and 96 females) were evaluated. The anterior-to-posterior sequence of hilar structures, the frequency of early vascular branching, and the presence of accessory vessels were documented and stratified by sex and laterality. Results: The conventional VAP sequence was observed in a minority of cases, occurring in only 32.6% (131 sides). The map identified 37 distinct sequence variants. The most common variants included VAPA (9.0%), AVAP (7.8%), and VAAP (7.0%). Adherence to typical VAP anatomy was significantly lower in males (27.9%) than in females (37.7%). Arterial complexity, characterized by early branching or accessory vessels, was present in 43.2% of sides, with a significantly higher occurrence in males and on the right side. Venous mapping revealed a marked lateral disparity; accessory veins were predominantly right-sided (12.5%), whereas early venous branching was predominantly a left-sided feature (30.0%). Conclusions: Renal hilar architecture demonstrates substantial variability, with the classical VAP configuration representing a minority arrangement. These findings highlight the importance of individualized preoperative imaging assessment and may help anticipate anatomical complexity in retroperitoneal surgery. Full article

Background: This study aims to evaluate the prevalence, spectrum, and coexistence of anatomical variations in the major branches of the abdominal aorta using Multidetector Computed Tomography (MDCT) angiography, with a specific emphasis on analyzing sex-related differences in a large-scale cohort. Methods: A retrospective analysis was conducted on 1174 patients (63.8% male, 36.2% female; mean age 60.54) who underwent abdominal CT angiography between January 2023 and June 2024. Images were acquired using a 128-slice MDCT scanner and reconstructed for detailed vascular assessment. Statistical comparisons between genders were performed using Chi-square and Fisher–Freeman–Halton tests, with p < 0.05 considered significant. Results: The celiac trunk (93.3%), superior mesenteric artery (SMA) (97.1%), and inferior mesenteric artery (IMA) (98.5%) predominantly showed classical patterns. However, significant sex-related differences were identified. Females exhibited significantly higher rates of classical patterns for the celiac trunk (96.2% vs. 91.7%), IMA (99.1% vs. 98.1%), right hepatic artery (RHA) (91.5% vs. 82.6%), and left hepatic artery (LHA) (95.8% vs. 85.4%). Conversely, males showed a higher prevalence of complex variations, including replaced/accessory hepatic arteries and the absence of the common hepatic artery. The number of right and left renal arteries was similar between sexes and did not show a significant difference, while horseshoe kidney was detected only in males. Conclusions: Abdominal vascular structures adhere to classical anatomy more frequently in females, while males exhibit greater morphological variability. These findings emphasize the necessity of gender-specific preoperative vascular mapping to optimize surgical outcomes and reduce morbidity. Full article

Background/Objectives: For centuries, humans have employed animal models to progress biomedical science, to understand pathological and biological processes, and to develop and test drugs, vaccines, and surgical techniques. In the field of urology, Sampaio and his colleagues from Brazil were the pioneers in proposing that the porcine model is the most accurate representation of the human kidney. We aim to describe the relevant urinary anatomy of female Landrace pigs based on endoscopy and computed tomography (CT) scans and compare differences between the urinary anatomy of pigs and humans. Methods: Four white Landrace female pigs were used for the study: two for CT imaging and two for endoscopic assessment. CT-urograms were performed using a 64-channel tomography machine with 0.625 mm thick slices. For the endoscopic procedure, the intravaginal urethral meatus was cannulated using a cystoscope, followed by complete urethrocystoscopy. The ureteric orifices were then cannulated, and a retrograde pyelogram was performed, followed by ureterorenoscopy. The analyses were performed using SPSS (Version 28), and simulated data was created using R (version 3.5.0), with the significance set at p ≤ 0.05. The data obtained from two pigs was used to simulate an empirical data with 500 observations, using the mean and standard deviations from our n = 2 to produce a random normal distribution. Results: CT and endoscopic findings showed two multirenculate multipapillate kidneys, each receiving blood supply from a single renal artery that is further divided into cranial and caudal branches. The delayed phase of the urogram showed distal ureters passing posterior to the bladder and emptying into the bladder at the base. Urethroscopy revealed an intravaginal urethral meatus ventral to the anus, positioned midway between the mucocutaneous junction of the vulva and the cervix. Endoscopic view of the bladder neck showing patulous ureteric orifices at the bladder neck with no distinct interureteric ridge or trigone. Retrograde pyelogram showed a Group B drainage pattern in both pigs. Conclusions: While there are numerous similarities between the urinary systems of humans and pigs, there are important subtle differences that urologists and researchers need to be mindful of before using the porcine model for urological research and training. Full article

Background/Objectives: Progress in diagnostic and therapeutic strategies has resulted in an increasing prevalence of adults with congenital heart disease (ACHD), including those involving genetically determined syndromes. This study aimed to characterize prevalence, congenital phenotypes, heart failure (HF) stages, comorbidity burden, and current medical management of ACHD and concomitant genetically determined syndromes enrolled in a prospective HF-focused registry. Methods: The PATHFINDER-CHD Registry is a German-based (est. 2022) multicenter observational registry. This web-based platform consecutively tracks ACHD patients across the heart failure spectrum, including those with current or prior HF, as well as those at high structural or functional risk. HF stage was classified using a modified ACC/AHA scheme adapted for CHD; functional capacity was graded according to the Perloff classification. Baseline demographics, CHD anatomy, prior surgical/interventional treatment, cardiac and extracardiac comorbidities, and medication were collected from medical records. Results: Among 1987 enrolled ACHD, 107 (5.4%) had a genetic syndrome (n = 65, 60.7% women; mean age 33.5 ± 9.4 years; range 18–68). Most common syndromes were trisomy 21 (n = 49; 45.8%) and 22q11.2 deletion (n = 27; 25.2%); 31 patients (30.0) had rarer syndromes. Predominant CHD diagnoses were atrioventricular septal defect (n = 42, 39.3%), tetralogy of Fallot (n = 19, 17.8%), and pulmonary atresia with ventricular septal defect (n = 7, 6.5%). A systemic left ventricle was present in 102 (95.3%); 40 (37.4%) had primarily cyanotic CHD, and 7 (6.5%) an Eisenmenger physiology. Most patients (n = 71; 66.4%) had undergone definite surgical repair; 25 patients (23.3%) had at least one catheter intervention, including transcatheter valve implantation in 17 cases (15.9%). HF stage was mainly B (n = 30, 28.0%) or C (n = 75, 70.1%). Perloff functional class I/II was present in 97 (90.7%). Leading cardiac comorbidities included intrinsic aortopathy (n = 49, 45.8%), pulmonary arterial hypertension (n = 12, 11.2%), and arrhythmias (n = 10, 9.3%). Frequent extracardiac comorbidities were thyroid dysfunction (n = 34, 31.8%), kidney disease (n = 16, 15.0%), hyperuricemia (n = 13, 12.1%), and depression (n = 15, 14.0%). Pharmacotherapy was used in 66 patients (61.7%). Beta-blockers (n = 25, 23.4%) were common, while ACEi/ARB (n = 9, 8.4%), diuretics (n = 10, 9.3%), MRAs (n = 8, 7.5%), and SGLT2 inhibitors (n = 3; 2.8%) were infrequently prescribed; no patient received ARNI or digitalis. For targeted treatment of pulmonary arterial hypertension, phosphodiesterase-5 inhibitors (n = 7, 6.5%), endothelin receptor antagonists (n = 6, 5.6%), or prostacyclin analogues (n = 1, 0.9%) were used. As oral anticoagulants, vitamin K antagonists or direct oral anticoagulants (DOACs) were prescribed in 17 cases (15.9%). Forty-one patients (38.3%) received thyroid hormone replacement. Conclusions: Syndromic ACHD constitute a small but clinically high-risk subgroup within an HF-oriented registry, marked by complex CHD, substantial cardio–extracardiac multimorbidity (notably aortopathy, PAH, thyroid disease, renal dysfunction, depression), and low utilization of contemporary HF therapies. These data support specialized, interdisciplinary, longitudinal care pathways and prospective studies addressing outcomes and evidence-based HF management in syndromic ACHD. Full article

Background: Intentional occlusion of the internal iliac artery (IIA) during endovascular repair of aorto-iliac aneurysms may predispose patients to pelvic ischemic complications such as gluteal claudication, erectile dysfunction, and bowel ischemia. Iliac branch devices (IBDs) have been developed to preserve hypogastric perfusion. E-Liac (Artivion/Jotec) is one of the latest modular IBDs yet reports on mid-term performance are limited to small single-center cohorts with short follow-up. The CAMpania PugliA bRanch IliaC (CAMPARI) study is a multicenter investigation of E-Liac outcomes. Methods: A retrospective observational cohort study was conducted across five Italian vascular centers. All consecutive patients undergoing E-Liac implantation for aorto-iliac or isolated iliac aneurysms between January 2015 and December 2024 were identified from prospectively maintained registries. Inclusion criteria comprised elective or urgent endovascular repair of aorto-iliac aneurysms in which an adequate distal sealing zone was not available without covering the IIA and suitability for the E-Liac device according to its instructions for use (IFU). Patients with a life expectancy < 1 year or hostile anatomy incompatible with the IFU were excluded. The primary end point was freedom from branch instability (occlusion/stenosis, kinking, or detachment of the bridging stent). Secondary end points included freedom from any endoleak, freedom from device-related reintervention, freedom from gluteal claudication, aneurysm-related and all-cause mortality, acute renal failure, and sac regression > 5 mm. Results: A total of 69 consecutive patients (68 male, 1 female, median age 72.0 years) received 74 E-Liac devices, including 5 bilateral implantations. The mean infrarenal aortic diameter was 45 mm and the mean CIA diameter 34 mm; 14 patients (20.0%) had a concomitant IIA aneurysm (>20 mm). Concomitant fenestrated or branched aortic repair was performed in 23% of procedures. Two patients received a standalone IBD without implantation of a proximal aortic endograft. Technical success was achieved in 71/74 cases (96.0%); three failures occurred due to inability to catheterize the IIA. Distal landing was in the main IIA trunk in 58 cases and in the posterior branch in 13 cases. Over a median follow-up of 18 (6; 36) months, there were four branch instability events (5.4%): three occlusions and one bridging stent detachment. Seven patients (9.5%) developed endoleaks (one type Ib, two type II, two type IIIa, and two type IIIc). Five patients (6.8%) required reintervention, and five (6.8%) reported gluteal claudication. There were seven all-cause deaths (10%), none within 30 days or related to aneurysm rupture; causes included COVID-19 pneumonia, acute coronary syndrome, melanoma, gastric cancer, and stroke. No acute renal or respiratory failure occurred. Kaplan–Meier analysis showed 92% (95% CI 77–100) freedom from branch instability in the main-trunk group and 89% (60–100) in the posterior-branch group (log-rank p = 0.69). Freedom from any endoleak at 48 months was 87% (95% CI 75–95), and freedom from reintervention was 93% (95% CI 83–98). Conclusions: In this multicenter cohort, the E-Liac branched endograft demonstrated high technical success and favorable early–mid-term outcomes. Preservation of hypogastric perfusion using E-Liac was associated with low rates of branch instability, endoleak, and reintervention, with no 30-day mortality or aneurysm-related deaths. These findings support the safety and efficacy of E-Liac for aorto-iliac aneurysm management, although larger prospective studies with longer follow-up are needed. Full article

Pararenal abdominal aortic aneurysm/pseudoaneurysms (PAAA/PAAP) are rare, high-risk complex aortic lesions involving the renal arteries. Management includes open surgical repair (OSR), endovascular aortic repair (EVAR), or hybrid repair, each with specific advantages and limitations. A review of the literature was performed to assess treatment strategies and outcomes for PAAA and PAAP. A PubMed search using relevant MeSH terms identified 184 articles published in the last five years. After applying inclusion and exclusion criteria, 34 studies comprising 6460 patients with complex AAA/AAP were included for analysis. Treatment strategies were predominantly endovascular (79.4%), followed by open (5.8%) and hybrid approaches (2.9%) (11.7% have used EVAR or OSR in the same study). To emphasize difficulties in the management of this pathology, a case report of a large PAAP involving both renal arteries and occluded celiac trunk with retrograde flow from patent superior mesenteric artery (SMA) is presented. Given the complex anatomy and high surgical risk, hybrid treatment was chosen consisting of bilateral ilio-renal Dacron bypasses followed by ChEVAR (chimney stenting of the SMA), with favorable postoperative recovery. The management of PAAP requires an individualized, anatomy- and risk-adapted approach. Open surgical repair remains preferable for younger, low-risk patients for superior long-term durability, whereas endovascular repair offers lower perioperative morbidity in high-risk cohorts. Optimal outcomes are dependent on high-volume centers with multidisciplinary expertise. Full article

Background: The treatment of thoraco-abdominal aortic aneurysms (TAAAs) and chronic type B aortic dissections (TAAD), is technically challenging. Traditional open surgery repair carries high morbidity and mortality rates, while endovascular repair is limited by anatomical constraints. This study investigates the safety and effectiveness of a hybrid approach in high-risk patients with TAA disease and complex renal and hypogastric anatomy. Methods: This was a retrospective single-center study, including all consecutive patients with TAAA and TAAD with complex renal and/or hypogastric artery anatomy treated with a hybrid approach between 2020 and 2024 in a high-volume aortic center. Primary endpoint was technical success. Secondary endpoints were early complications, overall and aortic-related mortality, aortic-related reintervention, the incidence of endoleaks, and the target vessel (TV) patency and TV instability at 30-day and during follow-up. Results: During the study period, a total of 92 patients with TAAA or TAAD were treated at our institution. Five high-risk patients (5.4%) with complex renal/hypogastric artery anatomy underwent open renal debranching and hypogastric revascularization followed by staged endovascular repair with custom-made double fenestrated/branched device. Technical success was achieved in all cases with no intra-operative mortality. No spinal cord ischemia or 30-day mortality occurred. Target vessel patency at 30 days was 90%. At a median follow-up of 38 months (IQR 26–49 months), there were no cases of aortic-related death. Conclusions: Hybrid repair is a feasible and effective option for managing complex TAAA and TAAD in high-risk patients. Larger studies with longer follow-up are needed to better define the clinical role of this approach. Full article

The renal vessels are known to exhibit variations in different populations. The present retrospective cross-sectional study aimed to evaluate the radiological anatomy of renal arteries and veins in the Omani population. Computed tomography angiography scans were used to assess diameter, laterality, and vascular branching patterns in adults (aged ≥ 18 years) who underwent contrast-enhanced CT angiography of the abdomen and pelvis between 1 January 2023, and 31 December 2024. Normal CT angiograms of cases performed for vascular pathology screening, renal transplant workup, or trauma evaluation with normal findings were included. Measurements included diameters, anatomical course, and vascular variations in the renal arteries and veins. Accessory renal arteries were defined as any additional arteries arising from the aorta supplying the kidney, regardless of the entry point. The mean diameters of the right and left renal arteries were significantly higher in males (p = 0.020 and 0.026, respectively). The right renal vein was significantly larger in females (p = 0.020). Accessory renal arteries were identified in 24.22% (n = 31 patients), including two cases with unilateral double accessory arteries. The right and left RA diameters were 4.51 ± 0.91 mm and 4.95 ± 0.98 mm, respectively, both significantly larger in males (p = 0.020 and 0.026). Supernumerary renal veins were observed in 21 patients; retroaortic and circumaortic left RVs were found in seven and one case(s), respectively. Venous variations were present in 17.2% of the Omani subjects. The findings may enhance preoperative planning, especially in renal transplantation and urologic surgery, by increasing awareness of anatomical variants. This region-specific dataset supports the development of optimized imaging protocols and surgical strategies for better patient care. Full article

Background: The presence of multiple renal arteries (MRAs) is a common anatomical variant in living kidney donors. While MRAs are not considered a contraindication to donation, it remains uncertain whether leaving the donor with a kidney containing MRAs affects long-term outcomes. This study aimed to evaluate renal and clinical outcomes in donors based on the vascular anatomy of the remnant kidney. Methods: We conducted a retrospective cohort study of living kidney donors who underwent nephrectomy at our institution between 2011 and 2016. Donors were categorized according to the vascular anatomy of the remaining kidney: single renal artery (SRA) vs. multiple renal arteries (MRAs). Data on renal function, hypertension, diabetes mellitus, and cardiovascular events were collected at baseline and follow-up. The primary outcome was long-term renal function, which was measured by the estimated glomerular filtration rate (eGFR). Secondary outcomes included clinical comorbidities and postoperative complications. Results: Among 190 donors, 132 had a remaining kidney with a single artery and 58 had MRAs. Over a median follow-up of 89.5 months (SRA) and 74.5 months (MRA), there were no significant differences in eGFR (SRA: 66 mL/min vs. MRA: 65 mL/min, p = 0.60), serum creatinine (p = 0.86), or the incidence of hypertension (31.8% vs. 34.5%, p = 0.35). Rates of diabetes mellitus and cardiovascular events were similarly low and comparable between groups. Conclusions: Living kidney donors left with a remnant kidney containing multiple renal arteries have similar long-term renal function and clinical outcomes as those with a single renal artery. These findings support the feasibility of MRA retention in donor selection and contribute to evidence-based surgical planning and donor counseling. 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

The sympathetic division of the autonomic nervous system plays a crucial role in maintaining homeostasis, but its overactivity is implicated in various pathological conditions, including hypertension, hyperglycaemia, heart failure, and rheumatoid arthritis. Traditional pharmacotherapies often face limitations such as side effects and poor patient adherence, thus prompting the exploration of device-based multi-organ denervation as a therapeutic strategy. Crucially, this procedure can potentially offer therapeutic benefits throughout the 24 h circadian cycle, described as an “always-on” effect independent of medication compliance and pharmacokinetics. In this comprehensive review, we evaluate the evidence behind targeted multi-organ sympathetic denervation by considering the anatomy and function of the autonomic nervous system, examining the evidence linking sympathetic nervous system overactivity to various cardiometabolic and inflammatory conditions and exploring denervation studies within the literature. So far, renal denervation, developed in 2010, has shown promise in reducing blood pressure and may have broader applications for conditions including arrhythmias, glucose metabolism disorders, heart failure, chronic kidney disease and obstructive sleep apnoea. We review the existing literature surrounding the denervation of other organ systems including the hepatic and splenic arteries, as well as the pulmonary artery and carotid body, which may provide additional physiological benefits and enhance therapeutic effects if carried out simultaneously. Furthermore, we highlight the challenges and future directions for implementing multi-organ sympathetic ablation, emphasising the need for further clinical trials to establish optimal procedural technique, efficacy and safety. Full article

Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed. Full article