INTRODUCTION: Major lower limb amputation is often the last resort procedure for patients with advanced peripheral artery disease and is associated with substantial mortality. Preoperative biomarkers such as haemoglobin and albumin may provide valuable prognostic information by reflecting oxygen-carrying capacity, nutritional status and systemic inflammation. This study aimed to evaluate the association between preoperative haemoglobin and albumin levels and survival among patients undergoing major lower-limb amputation. METHODS: A retrospective single-centre study was conducted, including all patients who underwent major lower limb amputation between June 2016 and December 2023 at a tertiary vascular surgery centre. Preoperative haemoglobin and albumin levels were collected from medical records. Patients were stratified according to survival status during follow-up. Independent samples t-tests were used to compare mean values between groups. Cox proportional hazards regression was performed to identify independent predictors of mortality, adjusting for relevant comorbidities. RESULTS: A total of 585 patients were included (mean age 72±12 years; 66% male), with 61% of patients undergoing transfemoral amputation. During follow-up, 66 patients (11.3%) died. Mean preoperative haemoglobin and albumin levels were significantly higher among survivors (haemoglobin: 10.46 vs 10.06 g/dL p = 0.015; albumin: 3.25 vs 2.94 g/dL p = 0.019. In multivariable Cox regression analysis, cerebrovascular disease (HR 1.50 p = 0.003, congestive heart failure (HR 1.53 p = 0.007), atrial fibrillation (HR 1.49 p = 0.008), and haemoglobin (HR 0.93 per g/dL p = 0.048) were independently associated with mortality. As albumin levels were available for only 99 patients, albumin was analysed separately and showed a strong association with improved survival in univariable analysis. (HR 0.488 p = 0.001). CONCLUSION: Preoperative haemoglobin is an independent predictor of survival following major lower limb amputation, underscoring the importance of preoperative optimisation and risk stratification. Although albumin demonstrated a significant protective association in univariate analysis, further multivariable validation is required. Incorporating these biomarkers into perioperative assessment protocols may improve the identification of high-risk patients and guide targeted interventions.

INTRODUCTION: Revascularisation of chronic juxtarenal aortic occlusions can present a complex challenge. While open repair remains the gold standard, endovascular therapy is increasingly used in high- risk patients. The role of catheter- directed thrombolysis (CDT) in chronic aortic occlusions remains unclear and might be underestimated in patients unfit for open revascularisation. METHODS: We conducted a narrative review of PubMed/MEDLINE and Embase for English- language studies from January 1, 2000, to January 31, 2025. Using MeSH and free- text terms for thrombolysis (e.g., catheter- directed thrombolysis, fibrinolysis, urokinase, tissue plasminogen activator) and chronic aortic/aroilial occlusion (including juxtarenal/infrarrenal anatomy), we included native chronic aortic or aortoiliac occlusions treated with CDT in revascularisation studies reporting technical and/or clinical outcomes. Case reports (<5 patients) were excluded. Outcomes assessed included technical success (thrombus reduction enabling definitive endovascular therapy), patency, and major complications. RESULTS: Five retrospective series were included, comprising 54 patients treated with CDT (urokinase or tPA) before endovascular aortoiliac revascularisation. All studies used CDT as an adjunct to endovascular revascularisation. Technical success rates ranged from 80 - 100%, with no 30- day mortality and low complication rates. Reported primary patency after definitive endovascular reconstruction was generally 85 - 100% at 1 year (83% at 18 months in one series), with limited longer- term follow- up. CONCLUSION: CDT may serve as a useful adjunct in the endovascular treatment of chronic juxtarenal aortic occlusions, particularly in high- risk patients. However, further prospective studies are needed to define its long- term efficacy and safety.

INTRODUCTION: Covered Endovascular Aortic Repair (CERAB) has previously been shown to be a viable treatment option for patients with aortiliac occlusive disease. However, data reporting on the technique is still scarce, and durability remains a concern. The aim of this study was to conduct a descriptive analysis of our experience and to evaluate the outcomes of CERAB over the last 10 years. METHODS: A retrospective, single- centre cohort study was conducted. From April 2015 to February 2025, we included all consecutive patients who underwent CERAB for aortiliac occlusive disease. Outcomes were defined as primary patency rate, freedom from clinically driven target lesion revascularisation, and amputation- free survival at 12 and 36 months. Major adverse events were defined as a composite of myocardial infarction, stroke, bowel ischemia, respiratory insufficiency, acute limb ischemia or access- related complications. RESULTS: A total of 23 patients (65%)(65%) male) were included, with a mean age of 60.7 years (±10.2)(±10.2) . The most common clinical presentation was Rutherford classification grade 5 chronic ischemia (44%)(44%) , and the majority (87%)(87%) had Transatlantic Inter- Society Consensus II (TASC II) D lesions. Technical success was achieved in 100%100% of cases. Major adverse events at 30 days were observed in 39%39% , with access- related complications the most common (17%)(17%) . The median hospital stay was six days (range 3.0- 15), and 30- day mortality occurred in one case. The median follow- up was 27 months (4.6- 62.1). The primary patency rate was 84%84% and 77%77% at 12 and 36 months, respectively. The target lesion revascularisation freedom rate was 85%85% at 12 and 36 months, while the major amputation- free survival rate was 89%89% at the same time points. CONCLUSION: The CERAB technique appears to be a feasible option for patients with extensive aortiliac occlusive disease, including TASC II D lesions, demonstrating high technical success. Despite the small sample size, good mid- term outcomes were observed in a clinical and anatomically complex group of patients.

Background: Aneurysmal sac growth is a major concern after endovascular aortic repair (EVAR) and the main reason for reintervention. Despite timely diagnosis and intervention, some cases of persistent sac growth warrant further investigation, namely for less frequent etiologies.   Report: We report the case of a 68-year-old male patient referred to the Vascular Surgery outpatient clinic due to an asymptomatic 71mm infrarenal abdominal aortic aneurysm. He has a history of heavy smoking habits, severe chronic obstructive pulmonary disease and a previous prostatectomy and local radiotherapy. Due to favorable anatomy and a high surgical risk for open repair, he underwent an aorto-bi-iliac EVAR in 2019. One year follow-up showed no endoleaks nor sac growth. In 2024, due to a significant sac diameter growth to 91mm, an urgent CT angiogram showed loss of proximal sealing and type II endoleak. Based on these findings, a custom-made fenestrated cuff was designed and implanted. Despite adequate sealing, with no evidence of target vessel complications, the patient was admitted in the emergency room 5 months after the reintervention with de novo abdominal and lumbar pain along with frank leukocytosis and an increase in C-reactive protein levels. Urgent CT angiography showed a 105mm diameter sac and periaortic densification, with apparent type II endoleak. The patient was put empirically on meropenem and linezolide. An urgent open conversion was performed with graft preservation and thrombus removal, and sac wrapping. Mycoplasma hominis was isolated from the aneurysm sac and thrombus and the patient was discharged on levofloxacin and doxycycline. One month follow-up showed no signs of recurrence.   Discussion: In the absence of clear sources of endoleak, infection may be the cause for over 20% of occult sac growth. In frail patients such as this case, sac evacuation and wrapping may be an alternative approach to graft explantation.

Background: The anatomical complexity of the aortic arch poses significant challenges to its repair, particularly in high-risk patients. The introduction of branched endografts, specifically designed to overcome these challenges, has revolutionized this field as demonstrated in the present case-report.   Report: A 60-year-old male, with a prior history of smoking and neurosyphilis, was referenced to our outpatient clinic due to a CT finding of a 66mm aortic arch aneurysm with complex anatomical features, including a short brachiocephalic trunk and narrow iliac arteries. Thus, a staged hybrid approach was meticulously planned. The patient was initially submitted to a left carotid-subclavian bypass, followed by a right subclavian-carotid bypass. Later, an endoconduit was constructed using two GORE-Viabahn® stent grafts (11x100mm), deployed in the left common and external iliac arteries, facilitating subsequent TEVAR. Finally, the aneurysm was excluded using a custom-made Terumo-Relay® double inner-branched endograft (46x32x270mm) deployed in zone 0, with two inner branches for the brachiocephalic trunk (BCT)/right subclavian artery (RSA) and left common carotid artery (LCCA). The inner branches were catheterized via trans-carotid (left) and trans-axillary (right) accesses. An iliac extension GORE-Excluder® (16x12x100mm) to the BCT/RSA and a GORE-Viabahn® stent graft (7x75mm) to the LCCA were deployed. An additional extension endograft (34x30x150mm) was deployed to complete distal exclusion. The left subclavian artery was subsequently occluded using a vascular plug. Postoperatively, the patient experienced a minor posterior circulation stroke, with full recovery within two weeks. Six-month follow-up imaging showed patency of the endografts with complete exclusion of the aneurysm and no evidence of endoleaks. The patient remained asymptomatic, with no further vascular or neurological events.   Conclusion: This case highlights the feasibility of a staged hybrid approach for complex aortic arch aneurysms in patients with challenging anatomy. The use of a custom-made endograft and careful preoperative planning proved critical to the success of the procedure.

Atherosclerotic renal artery stenosis (RAS) is a well-known cause of secondary hypertension and progressive renal insufficiency. In patients with a solitary functioning kidney, it is uncommon but high-risk, posing a dilemma between revascularization and medical management. Revascularization is usually reserved for selected high-risk cases. We report a 54-year-old woman with hypertension, prior ischemic heart disease, superficially invasive squamous cell carcinoma of the cervix, and a solitary functional kidney, who was admitted with acute renal failure and recurrent episodes of flash pulmonary edema. CT angiography revealed occlusion of the left renal artery and severe stenosis of the right. Angioplasty and stent placement in the left renal artery restored blood flow, leading to recovery of renal function and adequate blood pressure control. Renal revascularization can improve blood pressure, renal function, and cardiovascular profile. Despite trials such as STAR, ASTRAL, and CORAL not showing overall benefit over medical therapy, international guidelines recommend considering revascularization in selected high-risk patients. This case illustrates that endovascular revascularization can be effective in patients with a solitary kidney and severe RAS, emphasizing the importance of a multidisciplinary, individualized approach to optimize clinical outcomes.