To in-vitro compare different material properties of two balloon-expandable covered-stents, VBX (W.L. Gore & Associates, Flagstaff, AZ, USA) and iCover (iVascular, Barcelona, Spain), as bridging stents in fenestrated aortic endoprosthesis. Four experiments were designed to evaluate a total of 12 stents (6 VBX 6x59 mm and 6 iCover 6x57 mm). Visibility of the stents was evaluated by computed tomography (CT) comparing Hounsfield units (HU) of the radiopaque marks of the balloon, the first and second stent crown and the whole crimped and expanded stent. Material assessment was analyzed performing three experiments: 1) evaluation of the diameter in three different zones, the percentage of stent shortening and its integrity after the expansion and flaring inside a 6-mm-diameter handmade fenestration; 2) evaluation of the residual lumen area of the stent with a 90° angulation; 3) water permeability test; measuring the water entry pressure and the integral water leakage at 120 mmHg. All models underwent a CT scan immersed in a 37 °C water bath and analyzed in the workstation Osirix Imaging Software v 3.8.1, 32 bit (Pixmeo, Geneva, Switzerland) by two different observers. In the crimped configuration, both stents showed statistically significant differences in radiopacity. iCover was more radiopaque than VBX for the entire stent as well as for the first and second stent crowns (4935.23 vs. 2574.39 HU; 723.81 vs. 262.63 HU; and 535.94 vs. 259.02 HU, respectively; P<0.001). For the expanded stent, iCover appeared to be more radiopaque than VBX; 1662.61 vs. 930.71 HU, P<0.001. However, VBX balloons had more intense radiopaque marks than iCover; 1454.89 vs. 1107.79 HU, P<0.001. The expansion into the fenestration did not show significant differences in the diameters after flaring, but VBX presented a greater shortening percentage; 8.32% vs. 2.57%, P<0.001. The reduction in the total area at 90º was 12% iCover vs. 19% VBX, P=0.152. The water entry pressure was 120 mmHg for both. The integral water leakage at 120 mmHg was 0 in both cases. VBX and iCover stents showed similar properties that demonstrate their competence in in-vitro conditions.
Endovascular techniques have been proposed as an alternative to open repair for lesions of the femoral bifurcation and origin of the deep femoral artery (DFA). Debulking prior to drug-coated balloon angioplasty might improve the technical success and patency. We report the case of a 51-year-old woman with resting foot pain, bilateral femoropopliteal occlusion, and thrombosis of the right DFA, with severe, diffuse, and heavily calcified atherosclerosis. Under locoregional anesthesia, the DFA lesion was recanalized and a ByCross rotational atherectomy system (ByCross Atherectomy Catheter©, Plusmedica) was used in combination with a drug-eluting balloon (DEB) angioplasty (IN.PACT Admiral©, Medtronic). Successful re-establishment of DFA patency was achieved with no evidence of residual stenosis, recoil or flow-limiting dissections. No periprocedural issues or complications related to the use of the ByCross device were observed. The day after the procedure, the patient was discharged on dual oral antiplatelet therapy. After six months of follow-up the duplex ultrasound demonstrated patency without hemodynamic restenosis. The treatment of DFA atherosclerotic disease with ByCross rotational atherectomy has not been previously reported. ByCross rotational atherectomy followed by paclitaxel-coated balloon angioplasty of the DFA appears to be useful in patients at high risk for open repair with severely calcified arterial disease.
Over the past decade, drug-coated balloons (DCBs) delivering paclitaxel have become widely used for the treatment of peripheral artery disease (PAD). The safety and efficacy of various DCBs have been extensively studied, but differences in device design and drug delivery matrices may influence outcomes. The publication aim was to report long-term safety and efficacy data of the Passeo-18 Lux DCB for the treatment of symptomatic PAD due to stenosis, restenosis or occlusion of the femoral and/or popliteal arteries. Three hundred and two patients were randomized 1:1 and assigned to the Passeo-18 Lux DCB (study device) group or to the IN.PACT Admiral DCB (control device) group for testing of noninferiority. An efficacy endpoint was freedom from clinically-driven target lesion revascularization (CD-TLR) at 36 months. In terms of safety, a composite endpoint of freedom from device-/procedure-related death at 30 days post-index procedure, - major target limb amputation and clinically-driven target vessel revascularization (CD-TVR) at 36 months was investigated. At 36 months, freedom from CD-TLR-was achieved in 119 out of 128 patients in the IN.PACT Admiral group (93.0%) and in 116 out of 127 patients in the Passeo-18 Lux group (91.3%). The null hypothesis of inferiority was rejected with a P value of 0.0095, confirming the non-inferiority of Passeo-18 Lux compared to IN.PACT Admiral in terms of efficacy. Both treatment groups demonstrated sustained clinical improvement, as shown by the evolution of the Rutherford Clinical Category (RCC). At 36 months, the mean change in target limb RCC class compared to baseline was -2.5 in both groups, indicating comparable and significant clinical improvement over time. The Passeo-18 Lux and the IN.PACT Admiral DCBs demonstrate comparable results with excellent effectiveness and safety through 36 months for femoropopliteal interventions.
To perform a systematic review and meta-analysis of studies reporting the incidence of post-dissection aneurysms and need for secondary interventions after surgery for acute type A aortic dissections (ATAAD). Following PRISMA guidelines, MEDLINE and CENTRAL databases were searched from inception to June 2023 for longitudinal studies reporting post-dissection aneurysmal formation and secondary interventions after surgery for ATAAD. The main outcome was the incidence of post-dissection aneurysms. Secondary outcomes included the incidence of post-dissection suture-line complications and secondary interventions related to aneurysmal complications. Additionally, the overall and aortic-related mortality during follow-up were pooled. One hundred and twenty-eight studies were included. The pooled calculated incidence of post-dissection aneurysmal formation after surgery for ATAAD was 10.24% (95% CI: 8.03-12.66). On sensitivity analysis considering only studies assessed having low risk of bias, incidence of post-dissection aneurysms increased to 24.9% (95% CI: 17.9-33.3). The incidence of suture line complications was 1.59% (95% CI: 0.98-22.30) and the incidence of late secondary interventions related to aortic aneurysmal complications was 12.00% (95% CI 10.12-14.00). Lastly, the calculated overall mortality was 17.53% (95% CI 14.71-20.53) and the aortic-related mortality was 1.59% (95% CI 1.08-2.18). The incidence of post-dissection aneurysmal formation in patients after previous surgery for acute type A aortic dissection in primarily untreated segments remains frequent. The reporting of this long-term issue has been broadly adopted in the aortic literature. Further studies are needed to assess the initial surgical strategy and its extent as well as a stringent follow-up protocol on early detection and intervention in these patients.
Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for various thoracic aortic pathologies, including blunt thoracic aortic injury, aneurysms, and dissections. Involvement of Ishimaru Zone 2 occurs in up to 60% of TEVAR cases requiring extension across the distal aortic arch and left subclavian artery (LSA). Coverage of the LSA without revascularization increases the risk of complications such as upper extremity ischemia, stroke, and spinal cord injury. Therefore, the preservation of LSA perfusion during TEVAR is essential. Cervical debranching remains an effective alternative to preserve flow to the LSA, but it poses risks of bleeding, infection, and nerve injury. Similarly, although technically feasible, other endovascular approaches, such as parallel grafts, in situ fenestrations and physician-modified endografts, may lead to added risk of stent-graft complications and are considered off-label indications. To address these challenges, the Gore Thoracic Branch Endoprosthesis® (TBE; W.L. Gore & Associates, Flagstaff, AZ, USA) has emerged as an off-the-shelf thoracic branch stent-graft for the treatment of distal aortic arch lesions that require extension of the proximal seal into Zone 2 while enabling LSA incorporation. Recent literature has reinforced its promising results across different clinical scenarios. This article outlines the technical considerations of the Gore TBE® and provides a contemporary narrative review of its clinical outcomes.
Intravesical instillation of bacillus Calmette-Guérin (BCG) is currently the gold standard for treating non-muscle-invasive bladder cancer (NMIBC). Vascular complications following bladder instillations, including the development of mycotic aneurysms, are extremely rare. This study aims to report six cases of mycotic aneurysm following intravesical BCG instillations and to review the relevant literature. We present a case series of six patients with mycobacterial aortic infections related to BCG treatment, managed at our hospital between 2017 and 2023, following the PROCESS (Preferred Reporting of Case Series in Surgery) guidelines. Additionally, a literature review was conducted using major international databases (PubMed, Scopus, and EMBASE). A total of 74 patients with aortic lesions following intravesical BCG instillation have been reported in the literature. All patients were male (74/74), with a mean age of 72±7 years. The demographic characteristics in our series were similar. In five of our six cases (83.3%), the infection involved the thoracic or thoracoabdominal aorta. The mean time from the first BCG instillation to the development of a mycotic aneurysm was 15±2 months in the literature, whereas in our experience it was 26 months. Overall, open surgical repair was the definitive treatment in 71.6% of patients, whereas in our series the rate was 83.3%. Major postoperative complications included bleeding (2.7%), multi-organ failure (4%), and reinfection (4%). The overall 30-day mortality rate was 9.4%, in our series was 16.6% (one case). All surviving patients initiated multidrug antitubercular therapy. Although extremely rare, mycotic aneurysms related to intravesical BCG instillation can develop months to years after treatment. Diagnosis requires a high index of suspicion due to nonspecific symptoms. Both prosthetic and biological grafts yielded favorable outcomes regarding early mortality and morbidity. Postoperative multidrug antitubercular therapy appears essential following surgical repair.
In many low-income and middle-income countries, access to specialised surgical care is limited by infrastructure gaps, workforce shortages and weak financing, leading to unmet needs and cross-border inequities. The African Network of Medical Excellence (ANME) was created as a public-non-government organisation partnership to strengthen national health systems through specialised centres of excellence providing free, high-quality care. This paper outlines the design, implementation and outcomes of the ANME Regional Programme (RP), a coordinated cross-border referral system.The RP operates through formal agreements with Ministries of Health, structured referral pathways, specialist outreach missions, and full coverage of patient travel, accommodation, surgery, follow-up and essential medicines. Two ANME hospitals-the Salam Centre for Cardiac Surgery in Sudan and the Children's Surgical Hospital in Uganda-serve as regional hubs. By December 2024, 190 screening and follow-up missions had reached over 16 000 patients across 28 countries, with 2024 receiving specialised surgical care.Outcomes confirm the feasibility and safety of this model. At the Salam Centre, early postoperative mortality among RP-referred patients was lower than that of host-country patients (1.8% vs 2.9%), reflecting effective case selection and continuity of care. At the Children's Surgical Hospital in Uganda, early implementation of the paediatric RP addressed major unmet needs for complex congenital conditions, with no postoperative deaths reported.The ANME regional programme demonstrates how a not-for-profit, government-supported referral system can expand equitable access to specialised care, strengthen local capacity and support sustainable, rights-based health system development. Its approach offers transferable lessons for regional collaboration in other resource-limited settings.
The CURRENT registry is a prospective, multicenter, real-world investigation designed to evaluate the safety and effectiveness of the Renzan™ stent (Terumo MicroVention Inc., Aliso Viejo, CA, USA) in patients with femoro-popliteal peripheral artery disease (PAD), including complex lesions and chronic limb-threatening ischemia (CLTI). This study reports the interim outcomes at 6 and 12 months. A total of 89 patients with symptomatic PAD (Rutherford category IV-V 64.1%) were enrolled across three centers in Tuscany, Italy. All patients underwent endovascular treatment with the Renzan™ dual-layer interwoven nitinol stent. Baseline and follow-up assessments included clinical evaluation and duplex ultrasound imaging. The primary safety endpoint was the composite rate of all-cause death, target lesion revascularization (TLR), and major amputation at 30 days. The primary efficacy endpoint was primary patency at 6 months. Estimated patency and reintervention rates were reported at 12 months using Kaplan-Meier analysis. Technical and procedural success was achieved in 100% of cases. At 30 days, no deaths, TLRs, or major amputations occurred. At 6 months, the composite safety endpoint was met in 94.3% of patients. Primary patency was 100% at 1 and 3 months, 92.0% at 6 months, and declined to 78.7% (95% CI: 55.3-88.1%) at 12 months. Freedom from TLR was 97.2% at 6 months and 78.5% (95% CI: 63.7-88.7%) at 12 months. Exploratory multivariable analysis identified diabetes mellitus, previous peripheral endovascular intervention, and below-the-knee involvement as independent predictors of loss of patency, whereas dual antiplatelet therapy beyond 1 months was associated with a reduced risk of patency loss. The Renzan™ stent demonstrated excellent early safety and efficacy outcomes in a challenging PAD population, with sustained mid-term patency despite a high proportion of complex lesions. These preliminary results support the use of this new mimetic stent design in real-world clinical settings and warrant further confirmation with longer-term follow-up.
Intravascular ultrasound (IVUS) is a catheter-based imaging technique that utilizes high-frequency sound waves to produce real-time, cross-sectional images of the vessel lumen. IVUS is a well-known endovascular imaging tool for peripheral and aortic procedures, with potential benefit also during branched endovascular aortic repair (BEVAR) METHODS: We conducted a single-center retrospective observational study, including 47 patients undergoing elective BEVAR procedure from 2020 to 2024. Exclusion criteria were acute dissection, frank rupture. Two groups were compared: an IVUS-guided group, with routine IVUS for BEVAR procedure guidance, as intraoperative tool for post - implant bridging stent quality control; a NON-IVUS-guided group underwent standard BEVAR procedures without IVUS use. Primary endpoints are technical success of IVUS assessment for each target vessel, incidence of intraoperative branch instability detected by IVUS, and absence of IVUS-related adverse events. Secondary endpoints are procedural metrics, rate of intraoperative revisions prompted by IVUS findings, and postoperative outcomes such as branch instability requiring reintervention, as confirmed by follow-up imaging. There were 27 BEVAR (nine type I-III, 11 type IV, seven post-dissection TAAAs) in IVUS group and 20 (seven type I-III, eight type IV, five post-dissection TAAAs) in NON-IVUS group. Overall, there were no differences in operative time (median procedure time 310 vs. 318 min; P=0.89) and Xray exposure (47.3 vs. 47.5 mGy, P=0.99) between the two groups. There was a significant reduction of contrast volume for the main graft deployment phase (P=0.021) and X-ray reduction during the bridging stent phase (P=0.012); 76 TVVs were treated in group NON-IVUS group and over 103 bridged target vessels in IVUS group, the number of branch instability as kinking or compression identified with IVUS and not with angiography was 22%; this required additional unplanned reinforcement with stent reinforcement in 16% of the cases. This study suggests that IVUS is a safe and potentially valuable adjunctive imaging technology for intra-operative detection of TVV instability and highly sensitive in the identification of morphological defects, reducing Xray exposure or contrast volume for selected steps of the procedure. Long term investigations on larger cohorts are required to validate these promising results.
The aim of the study is to review the literature available about in-situ fenestration (ISF) techniques and their applicability to "zone 2" TEVAR for the revascularization of left subclavian artery (LSA), and retrospectively analyze a cohort of patients submitted to this type of endovascular approach in a single center. It is a single-center, retrospective, physician-initiated cohort study of patients treated in our institution from November 2023 to May 2024. Inclusion criteria were isolated left subclavian artery revascularization for elective or urgent/emergent 'zone 2' TEVAR. The primary outcome was the technical feasibility and the technical success of the procedure. Secondary outcomes were perioperative complications and follow-up. During the study period, 7 patients (all men; mean age of 73 + 9 [62-83] years) received ISNF for LSA revascularization, urgently in 4 patients (57%). In all cases (100%), it was possible to obtain the technical success with correct ISNF and exclusion of the aortic pathology. In the first two cases (28%), the procedure highlighted focal dissection of the axillary artery, necessitating PTA and stenting to properly restore the flow. No perioperative major adverse event occurred within 30 days. No patient underwent reoperation for aortic pathology; all patients are still alive today. Overall, postoperative CTA showed regular follow-up of the aortic pathology. Our initial case series analysis, in agreement with the current literature, suggests that ISNF for LSA revascularization in TEVAR provides encouraging midterm results and seems to be feasible and effective. ISF using the Ankura™ device showed promising outcomes.
The left subclavian artery (LSA) and vertebral arteries (VAs) undergo complex embryological development, resulting in a wide spectrum of anatomical variants. These variations are of significant clinical relevance due to their potential impact on cerebral, spinal, and upper limb perfusion, as well as their influence on surgical and endovascular decision-making. A comprehensive review of the available literature was performed focusing on the embryology, anatomical variants, and clinical implications of LSA and VA anomalies. Relevant anatomical, radiological, surgical, and endovascular studies were analyzed to identify common variants, their prevalence, and associated procedural risks. The LSA typically arises as the third branch of the aortic arch, while the VAs develop from longitudinal anastomoses of the cervical intersegmental arteries. Variants such as aberrant LSA, bovine arch configuration, isolated LSA, and anomalous origins of the VAs are well documented. These anomalies may significantly complicate open aortic arch surgery, thoracic endovascular aortic repair (TEVAR), coronary artery bypass grafting, and cervical or cranial interventions. Failure to recognize these variants preoperatively may lead to inadequate cerebral or spinal cord perfusion and increase the risk of iatrogenic injury. Anatomical variants of the LSA and VAs are common and clinically important. Accurate preoperative identification using advanced imaging is essential to optimize surgical and endovascular planning, reduce procedural complications, and ensure adequate organ perfusion. Tailored strategies should be adopted when managing patients with these vascular anomalies to improve outcomes and procedural safety.
Secure distal anastomosis is the critical determinant of success in total arch replacement (TAR). We aimed to examine the outcomes of a turn-up technique for TAR and introduced a modified turn up method with graft like frill-necked lizard for distal anastomosis, which provides secure anastomosis under excellent visualization, regardless of underlying pathology or the use of a frozen elephant trunk (FET). We retrospectively evaluated 228 consecutive patients who underwent TAR for 119 thoracic aortic aneurysms (TAA) and 109 acute aortic dissections (AAD) between January 2013 and January 2024. We initially used the turn-up method for distal anastomosis. More recently, we have adopted a modified turn-up method with a frill-necked graft. We evaluated overall surgical outcomes of TAR and performed a comparative analysis between patients with TAA and AAD. Circulatory arrest time during distal anastomosis with the modified turn-up technique was compared with that of the conventional turn-up technique. For all patients, the operation, cardiopulmonary bypass, aortic cross-clamp, and lower body circulatory arrest times were 376.2±81.7, 229.3±56.1, 148.6±47.1, and 52.4±16.5 minutes. The circulatory arrest times required for distal anastomosis were 53.1±15.9 and 51.6±17.2 minutes in the TAA and AAD groups. The overall 30-day mortality was 3.1%. The permanent neurological dysfunction rate was 5.7%. Spinal cord complications included three cases of paraparesis; there was no case of paraplegia. Kaplan-Meier survival analysis showed an overall 5-year survival rate of 87.6%. Circulatory arrest time was significantly shorter in the modified turn-up group compared with the conventional turn-up group (34.4 ± 9.4 min vs. 53.9 ± 16.1 min, P<0.01). The turn-up technique provides secure distal anastomosis regardless of the pathology or FET use and the frill-necked graft facilitates distal anastomosis.
Custom-made endografts are effective for aneurysms involving visceral or supra-aortic vessels but unsuitable in emergencies due to production delays. Off-the-shelf devices expand repair options yet often face anatomical limitations. Recently, alternative approaches - in-situ fenestration (ISF) and physician-modified endografts (PMEG) - have emerged to address complex aortic pathologies when standard devices are impractical. This study aimed to describe the results of ISF and PMEG techniques and compare their outcomes, with a focus on target vessels (TV). Single-center, retrospective, observational study. Consecutive patients treated with ISF or PMEG for thoracic or complex abdominal aortic pathologies from January 2021 to December 2024 were included. Forty-eight patients were included, with 28 (58.3%) undergoing ISF and 20 (41.7%) PMEG. A total of 69 TVs were treated, which were bridged using ISF in 34 (49.3%) cases and PMEG in 35 (50.7%). The procedure-related technical success was 95.8% (96.4% ISF vs. 95% PMEG, P=0.807). The TV-related technical success was 98.5% (100% ISF vs. 97.1% PMEG, P=0.321). Systemic complications were lower in the ISF group (absolute risk reduction 29.3%, P=0.017). At one-year, estimated freedom from aorta-related mortality was 92.3% for ISF vs. 100% for PMEG (P=0.165), and freedom from reintervention was 80% vs. 83.5% (P=0.662). Competing risk analysis showed similar one-year TV-related reintervention and TV instability incidences. ISF demonstrated lower systemic complication rates compared to PMEG, despite involving a significant period of TV ischemia, and achieved early similar TV-related outcomes despite the lack of fenestration reinforcement.
The primary objective of this systematic review and meta-analysis was to assess the incidence and prognosis of sac regression following endovascular aneurysm repair (EVAR), focusing on mortality (all-cause and aneurysm-related), aneurysm rupture, endoleaks, and secondary interventions. A systematic literature search was performed across PubMed, Scopus, Web of Science, and Google Scholar up to December 2024. Randomized trials, cohort studies, and case-control studies involving patients who underwent standard EVAR for abdominal aortic aneurysms (AAA) were included. The studies were included only if they compared patients with sac regression versus those without during follow-up. The Newcastle-Ottawa Scale (NOS) was used for quality assessment. The data were synthesized using a random-effects model to calculate relative risks (RR) for outcomes of interest. A total of 18 observational studies involving 25,984 patients were included. Sac regression was reported in 12,195 patients (46.9% [95% CI: 46.3%, 47.5%]), although with varying definitions of shrinkage through studies. Pooled analyses showed that sac regression was significantly associated with reduced all-cause mortality (RR=0.68 [95% CI: 0.59, 0.78], P<0.001) and aneurysm rupture (RR=0.38 [95% CI: 0.15, 0.97], P=0.044). Sac regression also correlated with lower rates of endoleaks (RR=0.45 [95% CI: 0.33, 0.62], P<0.001) and secondary interventions (RR=0.40 [95% CI: 0.31, 0.52], P<0.001). Aneurysm sac regression is a valuable prognostic marker after EVAR. It is associated with better clinical outcomes, including reduced mortality and complications. Standardizing the definition and assessment of sac regression is essential for more consistent findings. Further prospective studies and randomized trials are needed to confirm these results and better understand the mechanisms behind sac regression.
Acute limb ischemia (ALI) is one of the most common arterial emergencies and is associated with a high risk of limb loss, morbidity, and mortality. Among endovascular techniques, catheter-directed thrombolysis (CDT) is the most widely used, though it presents limitations related to slow thrombus resolution and bleeding risk. Pharmacomechanical thrombectomy (PMT) has emerged as a faster and potentially more effective alternative. However, the comparative efficacy and safety of these two modalities remain a matter of debate. A systematic review and meta-analysis was conducted by searching PubMed and EMBASE databases to identify studies directly comparing PMT and CDT. Outcomes assessed included technical success, procedural complications, primary patency, limb salvage, and survival. Pooled analyses were performed using a random-effects model (OR; 95% CI). Four retrospective observational studies met the inclusion criteria, comprising a total of 607 patients (163 treated with PMT and 444 with CDT). Baseline demographics, comorbidities, and clinical limb presentation were similar, although more recent studies reported a higher prevalence of IIB Rutherford class ischemia in the PMT group. No differences were found in technical success OR 0.69 (95% CI: 0.16-3.03, P=0.62). At 30 days, there were no significant differences in limb loss rate OR 1.22 (95% CI: 0.66-2.27, P=0.52) and mortality OR 1.17 (95% CI: 0.59-2.31, P=0.65). At 12 months, no differences were observed in primary patency OR 1.84 (95% CI: 0.57-5.96, P=0.31), freedom from limb loss OR 1.20 (95% CI: 0.59-2.45, P=0.62), or freedom from all-cause death OR 1.53 (95% CI: 0.74-3.13, P=0.25). Adverse events such as distal embolization and acute kidney injury occurred more frequently in PMT group, with OR 2.09 (95% CI: 1.22-3.59, P=0.007) and OR 4.77 (95% CI: 1.85-12.30, P=0.001), respectively. Bleeding complications were slightly lower in the PMT group but did not reach statistical significance (P=0.67). Hospital stay was significantly shorter in the PMT group (MD -1.27 days; 95% CI: -1.84 to -0.70, P<0.001). PMT and CDT appear to provide comparable early and mid-term outcomes in the treatment of ALI. While PMT was associated with more periprocedural complications, it may offer advantages in selected cases requiring rapid revascularization. No clear superiority emerged between the two approaches. Considering the current limited evidence base, further high-quality prospective studies are warranted to define the optimal endovascular strategy and assess long-term effectiveness.
Patients with congenitally corrected transposition of the great arteries (CCTGA) have a heterogenous anatomy due to the altered ventricular topology and associated malformations, leading to a diverse range of management options. Crucially the dichotomous decision of whether to continue with the right ventricle as the systemic ventricle or to perform complex inflow and outflow re-routing surgery, restoring the left ventricle to its role as the systemic ventricle will determine the patient's future care. Using the protocol of a tertiary cardiac surgery centre we describe how cardiac MRI provides a uniquely accurate combination of anatomical and functional data about the complex native cardiac and extra-cardiac anatomy prior to operation. MRI provides a non-invasive and non-ionising modality without the limitations of echocardiography 'acoustic windows'. We describe how to assess CCTGA from infancy to adulthood including the patency of the venous baffle pathways, re-routed outflow pathway and residual lesions/complications in post-operative patients. MRI also allows the study of tissue characterisation in our aging congenital heart disease population and is well-established in the lifelong surveillance and assessment of the systemic right ventricle across the world.
Pulmonary embolism (PE) is one of the leading causes of cardiovascular mortality in the United States. Even in those patients who get treatment in the acute phase, they are at risk of developing pulmonary hypertension, recurrent PE, which can lead to functional impairment and decreased survival. Interventional therapies for PE are reserved for unstable patients with high-risk PE or stable patients at high risk for decompensation. Several large-bore devices are currently approved for the treatment of PE and can provide expeditious thrombus removal without the need for lytic agents. Here, we review some of the large-bore catheter devices available for the treatment of acute PE.
Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for most descending thoracic aortic pathologies. In Zone 2 procedures, intentional coverage of the left subclavian artery (LSA) is frequently required to achieve an adequate proximal seal, but this carries a risk of stroke, spinal cord ischemia, and upper extremity ischemia. Preventive LSA revascularization is therefore recommended in current guidelines, although the level of supporting evidence remains limited. This narrative review summarizes the indications, timing strategies, techniques, and outcomes of surgical LSA debranching in combination with Zone 2 TEVAR. Both carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) restore antegrade flow to the LSA. Patency rates are excellent for both techniques, with CSB being favored in many tertiary centers due to lower rates of local nerve injury. Timing remains debated: staged approaches are increasingly adopted in elective cases, as simultaneous debranching and TEVAR have been associated with higher perioperative stroke rates. However, overall stroke risk appears more strongly related to the TEVAR procedure itself than to the revascularization technique. Surgical debranching offers long-term durability and versatility, especially in complex arch anatomy, and avoids endoleak-related complications. Endovascular alternatives, however, reduce local surgical morbidity and allow minimally invasive management under sedation, with comparable long-term survival. In conclusion, surgical LSA debranching remains a cornerstone adjunct to Zone 2 TEVAR, balancing durability and neurological protection against higher local complication rates. Further studies are required to refine patient selection, compare surgical and endovascular strategies, and strengthen the evidence base for current recommendations.
Acute pulmonary embolism (PE) remains a leading cause of cardiovascular mortality worldwide. Effective management hinges on accurate risk stratification - classifying patients as high, intermediate, or low risk - to guide reperfusion strategies. This review evaluates the contemporary role of systemic thrombolysis, with a focus on the balance between rapid hemodynamic restoration and the risk of catastrophic hemorrhage. For high-risk PE characterized by hemodynamic instability, systemic thrombolysis remains the gold standard, offering a significant survival benefit that outweighs bleeding risks. Conversely, in intermediate-risk PE, it has been demonstrated that while full-dose thrombolysis prevents hemodynamic decompensation, it is associated with a significant increase in major bleeding and intracranial hemorrhage. Consequently, current guidelines generally support a "rescue thrombolysis" strategy rather than routine, up-front administration in this population. Encouragingly, recent small studies appear to demonstrate reduced-dose protocols that maintain efficacy while minimizing risk of major bleeding. While the acute effects of thrombolysis on hemodynamics are clear, there is conflicting evidence regarding the impact of thrombolysis on long-term sequelae such as chronic thromboembolic pulmonary hypertension (CTEPH). Ultimately, clinical decision-making must prioritize immediate hemodynamic risk while carefully evaluating contraindications to minimize adverse outcomes.
This report describes the second-generation unibody Cratos single-branched stent-graft for left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR). The Cratos device represents the second-generation evolution of the Castor single-branched stent-graft, featuring an outer unibody branch configuration that allows simultaneous exclusion of the primary entry tear and revascularization of the LSA. It incorporates an adjustable proximal stent segment that optimizes sealing and reduces the risk of bird-beak formation at the proximal landing zone, while a reinforced branch-main body junction enhances fatigue resistance and long-term durability. We reported 2 patients presented with TBAD extending to the distal aortic arch, with the primary entry tear located just distal to the LSA zone 3. Both were successfully treated with the Cratos single-branched stent-graft, achieving complete exclusion of the entry tear and preservation of LSA flow without endoleak or neurological complications during follow-up. The Cratos single-branched stent-graft provides a safe and effective option for one-stage endovascular repair of aortic arch pathologies requiring zone 2 landing. Long-term follow-up and larger studies are warranted to confirm these promising early outcomes.