When a peripheral arterial stenosis/occlusion can be crossed by a guidewire, but no device can follow over it, to have proficiency in bailout strategies which allow device crossing can be beneficial. Limited information is available on these bailout manoeuvres. This article aims to provide a comprehensive pictorial review of various bailout techniques, equipping operators with an algorithm to apply in specific scenarios, to eventually improve procedural success rates.

The aim of this study was to determine whether the on-site availability of treatment options (carotid endarterectomy CEA, carotid artery stenting CAS) was associated with patient and hospital characteristics, medical management and outcome. This study is a pre-planned sub study of the Integration and Spatial Analysis of Regional, Site-specific, and patient-level factors for Improving Quality of treatment for carotid artery stenosis (ISAR-IQ) project, which analysed data from the nationwide German statutory quality assurance carotid database. Hospitals were categorized according to on-site availability of: CEA-only, CAS-only, and both CEA and CAS centre. Primary outcome event was any in-hospital perioperative stroke or death. The multivariable regression analysis was adjusted for age, sex, American Society of Anesthesiologists Physical Status (ASA stage), symptomatic status, antiplatelet therapy, ipsilateral and contralateral degree of stenosis, pre- and post-procedural assessment by a specialist in neurology, and hospital volume. A total of 201,330 patients undergoing CAS or CEA for asymptomatic or symptomatic carotid stenosis between 2012 and 2018 were included. 74% were treated in hospitals that offer both methods, 24% in CEA-only centres and 2.5% in CAS-only centres. The median annual number of cases for CEA and CAS was 44 and 7, respectively, in centres that offered both compared to 16 and 6 in centres that performed either CEA or CAS, respectively. The overall stroke and death rate until hospital discharge was 2.1%. In centres providing both CEA and CAS, the stroke and death rates were 2.0% for CEA and 2.4% for CAS. These figures were 2.0% in centres providing CEA-only and 3.0% for CAS-only centres. The multivariable regression analysis showed significant higher perioperative stroke or death rate in the CEA-only group (adjusted Odds Ratio aOR=1.12, 95%-confidence interval (CI) 1.03-1.21) and CAS-only group (aOR=1.26, 95%-CI 1.04-1.52) versus the combined CEA and CAS group. Centres providing both CEA and CAS had a lower risk of perioperative stroke and death than centres performing CEA-only or CAS-only. The minimum volume recommendations of the national guideline were not achieved in the median by CEA-only and CAS-only centres. This could be a starting point for public health measures to increase guideline conformity and treatment quality.

To evaluate the short-term outcomes of a novel, customized multibranched G-Branch endograft for the treatment of thoraco-abdominal aortic aneurysm (TAAA) and juxta/pararenal abdominal aortic aneurysm (J/PAAA). Between July 2023 and May 2025, 50 patients (mean age 72 years; 45 men) were treated with implantation of a customized G-Branch endograft (Lifetech Scientific, Shenzhen, China) at four European regional vascular centres. The mean aneurysm diameter was 65.7 mm (range, 55-90 mm). Depending on the size and extent of the aortic pathology, 19 patients had J/PAAA and 31 had TAAA. Three patients had concomitant common iliac artery aneurysms, and one patient had a concomitant arch aneurysm. All patients underwent either an elective one-stage repair (30 patients, 60%) or a staged repair (20 patients, 40%) according to the local protocol of each centre. Multicentre outcome data were prospectively collected and retrospectively analysed. Perioperative results were assessed before discharge and during follow-ups at 1, 6, and 12 months. Technical success was achieved in 96% (48/50) of patients. In-hospital mortality was 4% (2/50). Early perioperative complications occurred in six patients (11%), with no spinal cord ischemia. Over a mean follow-up of 7 months (range, 1-23 months), two patient (4%) required an unplanned late reintervention with branch extension or relining due to a type Ic and IIIb endoleaks, respectively. Of the 198 target vessels, all remained patent, yielding an overall freedom from branch instability of 99%. No patients died due to aneurysm- or procedure-related causes; one patient died 8 months postoperatively due to a major stroke. All remaining 47 patients were doing well at the last follow-up. Our preliminary experience with the G-Branch endograft appears safe and yields high technical success with encouraging short-term outcomes for the endovascular repair of J/PAAA and TAAA. Continued patient surveillance and extended follow-up are essential to confirm these results.

Coral reef atherosclerosis of the renovisceral aorta leads to end-organ and extremity malperfusion due to ischaemia and/or embolic events. Those mostly female patients typically present with renovascular hypertension, chronic mesenteric ischaemia, and symmetric peripheral artery disease of all stages, including critical limb ischaemia. Mortality and morbidity are high in open surgery. Here we describe step by step the individually designed endovascular solutions with multiple arterial accesses using stentgrafts and open stents in 8 consecutive patients. All patients survived, acute renal failure occurred in 1 case, otherwise uneventful inhospital courses. Patients were followed over 25 (7-56) months with durable results. Endovascular treatment of coral reef aorta leading to aortic stenosis or occlusion in the renovisceral segment is feasible in most cases using multiple arterial accesses with good functional results, low mortality and morbidity and durable results.

Bilateral symptoms of peripheral artery disease may be rarely caused by isolated atherosclerotic aortic stenosis or short occlusion. Standard therapies have been open surgery, balloon angioplasty and implantation of selfexpanding stents and stentgrafts. In this retrospective study 54 consecutive patients were treated under local anaesthesia with a balloon-expandable endograft. Endpoints were safety, ankle-brachial and toe-brachial index (ABI, TBI), walking distance, clinical stage and re-interventions at long-term. There were 36 women and 18 men, mean age 68 years; 48 patients suffered from claudication, 6 patients had rest pain with skin lesions in 3 cases. The technical success rate was 100%. There was an immediate average improvement of ABI from 0.76 +/- 0.26 at rest before intervention to 0.88 +/- 0.31 at rest after stentgraft implantation into the aortic stenosis. TBI improved from 0.48 +/- 0.17 to 0.58 +/- 23 at rest. Mean follow-up was 1 to 8 years (mean 4.46) years. Average walking distance improved from 124 m to 612 m. Of the 6 patients with rest pain or skin lesions all except 1 patient improved to at least claudication stage with a painfree walking distance over 200 m. No complications such as aortic rupture, dissection or peripheral embolisation occurred, 2 patients needed surgical revision of their calcified common femoral arteries at the access sites. Three patients developed at long-term recurrent stenosis due to the compression of stentgrafts by the calcified plaque burden which was solved by balloon angioplasty or implantation of an additional aortic stentgraft. Endovascular treatment of aortic stenosis or occlusion is feasible under local anaesthesia with good functional results, very low mortality and morbidity and durable results.

Lipedema is a chronic disease characterized by the disproportionate and symptomatic accumulation of fat in the lower limbs and arms. Women with lipedema experience heaviness, fatigue and pain, leading to impairments in daily activities and reduced quality of life. Conservative treatment mainly focuses on lifestyle modifications, along with compression therapy and manual lymphatic drainage. Exercise training could also play a pivotal role in the management of lipedema. The aim of this systematic review was to explore the effectiveness of exercise training in women with lipedema. A comprehensive literature search was conducted in Embase, MEDLINE, Cochrane CENTRAL, Web of Science, CINAHL on June 23, 2025. The main outcomes were pain, fatigue and other symptoms, quality of life, anthropometric characteristics, lower limb volumes and/or circumference, and functional performance. The search strategy identified 523 studies, of which six were included in this review. Studies included 115 women with lipedema. Exercise training seems to improve pain and other symptoms, quality of life, limb volumes and/or circumference, and functional performance. The effects seem to be greater when combined with ongoing compression therapy. However, the effects of exercise training on the different outcomes varied among the studies, probably related to the high heterogeneity, different training approaches, and small sample sizes. Exercise training might be a promising therapeutic care option in women with lipedema, and the effects seem to be greater when combined with ongoing compression therapy. Appropriately designed and adequately powered studies are needed to further explore the benefits of exercise in these patients. (PROSPERO Registration No.: CRD42024604164).

Peripheral artery disease (PAD) is a growing health problem, with symptoms ranging from intermittent claudication to chronic limb-threatening ischemia (CLTI). Balloon angioplasty in below-the-knee (BTK) PAD lesions is the mainstay treatment procedure but still a challenging one, given the heterogeneity in the patient population, multivessel and multilevel involvement, small-vessel size, long lesions (up to 40 cm), calcium burden, and lower flow rates with or without impaired runoff. The technical success of balloon angioplasty is often subverted by flow-limiting dissections, recoil with early restenosis. This review will explore current guidelines, revascularization anatomical planning, interventional approaches, and possible solutions to avoid the feared dissection, recoil and restenosis that our patients currently face.

Duplex ultrasound assessment with the patient standing is standard for diagnosing chronic venous insufficiency (CVI). However, assessments are often performed with patients in tilted or supine positions due to age or physical limitations. This study aimed to evaluate the influence of the patient's positioning on venous diameters and venous valve function. Monocentric, prospective cohort study in 30 patients with CVI of the great saphenous vein (GSV). 18 contralateral limbs without GSV insufficiency were defined as the control group. With duplex ultrasound, we measured GSV diameters at different anatomic points. Moreover, we analyzed the occurrence of venous reflux (>0.5s) with the patient in a lying position (0°), on the tilting table in 30° and 70° positions, and with the patient standing (90°). A linear relationship was found between patient inclination and diameters in varicose GSVs. Average diameters in limbs with CVI increased from lying to standing by 39-42%, while average diameters in healthy GSVs increased by 20-23%. In ≥97% of the patients, pathological venous reflux findings observed in the standing position were also detected in the 70° tilted position, with no statistically significant differences between these two positions. For duplex ultrasound examination of the GSV in cases of suspected CVI, it can be recommended to position the patient on a table tilted at 70°. This position provides results comparable to those obtained in the standing position while enhancing patient safety and examiner comfort.

Atherosclerotic cardiovascular disease (ASCVD) encompasses a diverse range of disease manifestations including coronary, lower extremity peripheral (PAD), carotid, or extensive (e.g., polyvascular) arterial disease. However, a paucity of data exists with regard to the prevalence, shared risk factors, and rate of prescribed secondary preventive medications in different ASCVD subgroups. We sought to investigate this from a population-based perspective using data derived from the contemporary Hamburg City Health Study (HCHS). In the population-based HCHS participants between 45 and 74 years were recruited at random. In the current cross-sectional analysis of the first 10,000 participants enrolled between February 2016 and November 2018, participants were stratified by the arterial vascular bed affected by atherosclerosis, e.g., carotid artery disease, lower extremity PAD, or coronary artery disease, as well as a combination of at least two entities (polyvascular disease). Baseline characteristics including risk factor profiles, prescribed preventive medications as well as cardiovascular risk scores (ESC SCORE 2, Stroke score) were compared. A total of 6,324 individuals with complete cardiovascular screening data were included. Overall, 2,258 (35.7%), 732 (11.6%) and 174 (2.8%) participants were diagnosed with isolated carotid artery disease, lower extremity PAD, or coronary artery disease, respectively. In 739 (11.7%) participants polyvascular disease was noted. Across the subgroups, different patterns of risk factor profiles were documented. Participants with polyvascular disease were the oldest, most often unemployed, diabetic, and current smokers. Individuals with coronary artery disease or polyvascular disease were noted to have the highest cardiovascular risk scores and highest rates of prescribed preventive medications. In this contemporary population-based analysis, different risk factor profiles, cardiovascular risk scores and prescribed secondary preventive medications were noted according to the diseased vascular bed. Our findings suggest differences between best medical treatment which could be targeted to improve cardiovascular event rates in patients with ASCVD.

Atherectomy-assisted endovascular revascularization has emerged as a promising treatment tool with high technical success rates in complex and calcified peripheral artery disease (PAD). Our aim was to evaluate sex-specific differences in patients undergoing atherectomy-assisted endovascular revascularization. Consecutive patients with symptomatic PAD, undergoing rotational atherectomy were included in a prospective single-centre registry. Demographic and clinical data and lesion localization were recorded in men and women. The primary safety endpoint was vessel perforation and peripheral embolization. Secondary endpoints were clinically driven target lesion revascularization (CD-TLR) and mortality rates during follow-up. Overall, 632 patients (847 lesions, median length = 18.0 cm) were analysed (244 women and 388 men). Median age was 78.0 (69.0-84.0) years. Women were older than men (p<.001), while CLTI, diabetes and BTK lesions were more common in men (65.4% versus 58.2%, p<.05, 53.1% versus 38.5%, p=.004, and 35.9% vs. 21.6%, p<.0001, respectively). Lesion length and complexity by TASC were similar in men and women, while men showed higher calcification by PACSS (p=.03). High procedural success rates (99.5%) and low complications rates were observed. Women received less stents than men in the femoropopliteal segment (p=.03). Complication rates were similar between men and women (1.3% versus 2.5%, p=.28 for perforation and 1.5% versus 2.9%, p=.25 for embolization). CD-TLR and mortality rates were similar in men and women. Our study confirms the safety and effectiveness of front cutting rotational atherectomy in men and women presenting with complex and symptomatic PAD. Patient safety was present in men and women, whereas CD-TLR rates were relatively low in both sexes.

Bridging Stent Grafts (BSG) are an essential element of fenestrated and branched endovascular aortic repair (FEVAR and BEVAR respectively). Until CE marking of a dedicated stent in late 2024, a variety of BSG were used. The aim of this study was to evaluate the outcomes of the iCover stent graft in this application. We retrospectively analysed 22 consecutive patients treated at our institution with FEVAR and BEVAR between 05/2023 and 09/2024. The primary endpoint is a composite of target vessel (TV) technical success and freedom from target vessel instability (TVI) in the early and short-/mid-term phase. Secondary endpoints consisted of early, short- and mid-term clinical outcomes. Ninety-seven iCover stent grafts were used to bridge 90 target vessels: 23 for the coeliac arteries (CA), 23 for the superior mesenteric artery (SMA) and 50 for the renal arteries (RA); one iCover stent could not be implanted. The underlying aortic pathology was juxtarenal and pararenal aneurysm (12/22; 54,5%), penetrating aortic ulcer (PAU) (2/22; 9%), type Ia endoleak following infrarenal EVAR (3/22; 13,6%), chronic type B aortic dissection with aneurysmal degeneration (1/22; 4,5%), Safi type IV (3/22; 13.6%) and Safi type V (1/22; 4.5%) thoraco-abdominal aortic aneurysm (TAAA). The mean aneurysm diameter was 60,5 mm (+/- 10,6 mm). Four (18,2%) patients underwent urgent procedures. The median follow-up was 291,5 days (IQR 63-425,2). 3 patients (13,6%) died from non-aneurysm-related causes. Assisted primary TV technical success was 98,88% (89/90). One non-iCover related loss of TV was excluded from mid-term analysis. The TV patency was 98,88% (89/90) in the early phase and 98,87% (88/89) at mid-term follow-up. Cumulative freedom from TVI was 92,13% (82/89). The iCover is effective and safe to use as a BSG in fenestrated endovascular aortic repair. Our results align with the available literature, but further studies are needed to validate iCover as BGS, especially in BEVAR.

Peripheral Artery Disease (PAD) is a significant global health concern, leading to morbidity through progressive stenosis and eventually occlusion of the lower extremity arterial vasculature. Advanced imaging modalities play a major role in diagnosing PAD, in planning endovascular as well as surgical interventions, and in monitoring post-treatment outcomes. This review highlights the current major imaging techniques, including duplex ultrasound, computed tomography angiography (CTA) and magnetic resonance angiography (MRA). It provides insights into their applications, advantages, limitations and the importance of individualized imaging strategies for optimizing patient outcomes.

Peripheral artery disease (PAD) remains under-recognised. Low awareness among the public, patients and healthcare professionals (HCPs) contributes to delayed diagnosis and poorer outcomes. This rapid review applied the Model of Pathways to Treatment (MPT) to synthesise behavioural and system-level factors shaping the diagnostic pathway and identifies evidence gaps to inform intervention and service redesign. Databases (CINAHL, PubMed, PsycINFO) were searched (January 2001-July 2024) for qualitative, quantitative or mixed-methods studies exploring PAD diagnosis from the perspective of patients, at-risk public or HCPs. Eligible studies examined events, behaviours or timings linked to PAD diagnosis. Quality was assessed using the Mixed Methods Appraisal Tool and findings synthesised using the MPT. Twenty-one studies (13 quantitative, 7 qualitative, 1 mixed method) were included. Mapping to the MPT revealed modifiable, multifactorial barriers across the diagnostic pathway from symptom appraisal to pre-treatment. At the patient level, symptom misattribution, normalisation, competing priorities, fear and financial concerns delayed help-seeking. At the provider level, HCPs often lacked training, confidence or incentives to assess PAD, with underuse of tools including the ankle-brachial index. At the system level, referral delays were linked to unclear pathways and limited feedback from vascular services. Only one study explored variations in diagnosis timeline by population or setting. Although PAD is under diagnosed and associated with poor outcomes, few studies have examined the behavioural and structural factors delaying diagnosis. This review identifies missed opportunities along the diagnostic pathway and highlights targets for future research and intervention across patient, HCP and system levels.

Type II endoleaks (T2EL) remain the most common complication after endovascular aneurysm repair (EVAR). Aneurysm sac regression is a predictor for better treatment outcomes compared to sac stability and growth. T2EL are associated with aneurysm sac regression and prophylactic embolization of the sac or side branches may result in lower T2EL incidence. This review aims to assess the current evidence on whether prophylactic treatment strategies provide improved clinical outcomes after EVAR. A systematic search was performed of the Scopus, PubMed and Web of Science databases. Original studies reporting prophylactic embolization to prevent endoleaks were included and a meta-analysis was performed on important clinical outcome parameters; T2EL incidence, sac remodelling and T2EL related reinterventions. A total of 1,870 publications were identified. After screening and quality assessment by two reviewers, data were extracted from 29 studies and analysed. T2EL incidence was significantly lower in the embolization group; odds ratio 0.29 [0.19-0.45, 95% confidence interval] at 6 months, 0.20 [0.13-0.31] at 12 months and 0.28 [0.14-0.55] at 24 months. Sac growth was significantly lower in the embolization group with odds ratios of 0.08 [0.01-0.59], 0.16 [0.05-0.53] and 0.24 [0.11-0.52] at 6, 12 and 24 months, respectively. Sac shrinkage was significantly higher in the embolization group with odds ratios of 0.42 [0.28-0.63], 0.49 [0.32-0.77] and 0.28 [0.16-0.50] at 6, 12 and 24 months, respectively. Reintervention rates were lower in the embolization group, although not statistically significant. The results from this review and meta-analysis show that prophylactic embolization, either through non-selective sac filling or selective side branch embolization, result in better clinical outcomes at 6, 12 and 24 months. Prophylactic embolization seems promising in increasing sac regression rates and reducing T2EL incidence, but more data about other clinical outcome parameters is required.

Over the last years, the discussion about gender equality has reached surgery. Among all the different aspects being discussed, the question of the necessity of implementing a women's quota arises regularly. In 2022 a questionnaire was answered by members of the German Society for Vascular Surgery and Vascular Medicine. Relevant career and family-life related demographic aspects as well as their personal opinion on the need for a women's quota were evaluated. 540 vascular surgeons participated in the survey. Significantly more male surgeons were in a committed relationship. Significantly more partners of female colleagues had full-time jobs, and significantly less women stated that they were the main earners in the relationship. Male surgeons had significantly more children. In general, men held higher positions and significantly more male surgeons were enrolled as head of department. Significantly more women favoured a women's quota for e.g. head of department positions, senior surgeon positions, scientific committees and scientific panels at scientific conferences. Regarding the level of such a quota, 43% of participating female surgeons and 19.5% of males suggested a 50% quota, whereas 59% of male and 30% of female surgeons did not see the need of a women's quota at all. The present survey shows the imbalance between men and women in vascular surgery in Germany in terms of career development and family life. Persistent disadvantages for women were shown. Women's quotas could be helpful, but are certainly no reasonable "stand-alone-approach": a general change of mindset is needed here.

Open thoracoabdominal aortic aneurysm (TAAA) repair for Crawford extent II aneurysms carries substantial risks. This study compares outcomes of open TAAA repair following prior thoracic endovascular aortic repair (TEVAR) with conventional open extent II repair. A retrospective analysis of 91 patients (2006-2024) divided into prior TEVAR (n=29) and conventional repair Crawford extent II repair without previous TEVAR (n=62). Primary endpoints included mortality and complications; secondary endpoints assessed survival and reinterventions. This study was designed according to STROBE criteria. The prior TEVAR group (n=29) had a mean age of 61.5±10.7 years and 72.4% were male, while the conventional extent II repair group (n=62) had a mean age of 63.2±9.8 years and 69.4% were male. Prior TEVAR patients underwent open repair for extent II (13.8%), III (58.6%), or IV (27.6%) aneurysms. In-hospital mortality was lower in the prior TEVAR group (6.9% vs. 25.8%, p =.07), as were rates of spinal cord ischemia (3.4% vs. 8.1%, p =.55), acute kidney injury (24.1% vs. 35.5%, p =.28), and massive transfusion (24.1% vs. 30.6%, p =.54). Pulmonary complications occurred less frequently after TEVAR (69.0% vs. 82.3%, p =.25). Kaplan-Meier analysis revealed no significant survival difference (log-rank p=.05), with 5-year survival rates of 94% (prior TEVAR) and 61% (conventional). Aortic reintervention rates were also similar (10.5% vs. 18.8%, p=.69). Open TAAA repair following prior TEVAR may offer clinically meaningful advantages over conventional open type II repair with acceptable survival rates; however, these findings should be interpreted cautiously given the study's retrospective design and small sample size. Staged hybrid approach could be a viable strategy for managing complex aortic pathologies.

Coral reef aorta (CRA) is a rare and therapeutically challenging condition characterized by heavily calcified paravisceral aortic stenosis, leading to severe clinical manifestations. Open surgery is associated with substantial perioperative morbidity and mortality, while standard endovascular approaches often face technical limitations. This multicentre study aimed to evaluate the feasibility and safety of intravascular lithotripsy (IVL) combined with aortic and/or reno-visceral vessel (RVV) stenting for the treatment of paravisceral CRA. Patients with paravisceral CRA treated with IVL between 2021 and 2025 across six vascular centres were retrospectively analysed. The primary endpoint was technical success. Secondary endpoints included IVL-related complications, perioperative mortality, freedom from reintervention, clinical improvement, and aortic lumen gain at the site of maximum stenosis. A total of 16 patients were included. Presenting symptoms were claudication (n=15), renal failure (n=9), mesenteric ischemia (n=4), and cardiac failure (n=2). IVL alone was performed in 3 patients (18.8%), while 13 patients (81.2%) underwent adjunctive aortic and/or RVV stenting. Technical success was achieved in all cases. There were no IVL-related complications or perioperative deaths. All patients demonstrated clinical improvement and significant aortic lumen gain. During a median follow-up of 5 (1-11.5) months, two elective reinterventions were required. No patients were lost to follow-up. In our cohort, IVL combined with aortic and/or RVV stenting appeared to be a feasible and safe endovascular strategy for the management of paravisceral CRA. The approach offers high technical success with low perioperative morbidity, mortality, and reintervention rates.

Optimal pharmacotherapy is a cornerstone for the treatment of patients with symptomatic peripheral artery disease (PAD). Our aim was to evaluate the impact of adjunct medical therapy, including lipid-lowering and antiplatelet treatment in patients undergoing open or endovascular revascularization due to common femoral artery occlusive disease (CFAOD). Consecutive patients undergoing either endovascular or open revascularization due to CFAOD were analyzed. Pharmacotherapy before and after treatment was registered and its impact on the following post-procedural outcomes: (i) all-cause mortality and (ii) major adverse limb events (MALE), including major amputation and clinically driven target lesion revascularization (CD-TLR), were systematically analyzed. Patients undergoing endovascular therapy (n=225) were older and exhibited more comorbidities such as diabetes mellitus and heart failure and had more frequently chronic limb threatening ischemia (CLTI) compared to those undergoing open repair (n=662). During 1.73 (0.9-3.3) years of follow-up, 96 (10.8%) deaths and 118 (13.3%) MALE occurred. After endovascular therapy, more patients received clopidogrel (70.2% versus 41.5%) and statins (92.0% versus 74.9%), (p<.001 for both). By multivariable analysis, statin perscription was associated with lower death rates (Odds Ratio (OR)= 0.43, 95%CI=0.25-0.73, p<.002), whereas clopidogrel was associated with lower MALE rates (OR=0.65, 95%CI=0.43-0.97, p=.04). These effects were primarily driven by patients undergoing open repair (effect of statins) and by patients with chronic limb threatening ischemia (effect of clopidogrel). Statin and clopidogrel treatment are important components of the post-procedural treatment of patients with PAD undergoing revascularisation due to CFAOD. Especially statins need to be prescribed based on current national and international guidelines independent of the revascularization type in every patient to reduce death rates.