Scielo RSS http://scielo.pt/rss.php?pid=1646-706X20250004&lang=pt vol. 21 num. 4 lang. pt http://scielo.pt/img/en/fbpelogp.gif http://scielo.pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400156&lng=pt&nrm=iso&tlng=pt http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400157&lng=pt&nrm=iso&tlng=pt Abstract Introduction: Subintimal angioplasty is an endovascular technique used to recanalize occluded segments in the arterial bed that cannot be crossed via an intra-luminal path. However, there is still limited data regarding the clinical outcome of subintimal angioplasty. The aim of this study is to evaluate the impact of subintimal angioplasty in femoro-popliteal lesions. Methods: This is a retrospective, single-centre, comparative study. From January 2023 to February 2025, all patients with chronic lower limb ischemia due to femoro-popliteal arterial lesions who underwent endovascular treatment as a first revascularisation procedure were considered. Patients were grouped according to the cross-lesion pathway: the subintimal cross-lesion group (S group) and the intra-luminal cross-lesion group (L group). Both groups were compared with respect to the atherosclerotic disease pattern, and the primary endpoints were the rates of reintervention and amputation. Results: The study included 95 patients, of whom 10% (n = 9) presented with intermittent claudication and 90% (n = 85) with chronic limb-threatening ischaemia. The median follow-up time was nine months. The S group included 30% (n = 28) of the patients and L group included 70% (n = 67). The median femoro-popliteal GLASS classification was 4 in both groups, but this GLASS stage was more common in S group (p = 0.004). Severe calcification (p < 0.001) and bailout stenting (p < 0.001) were more common in the S group. Regarding the primary endpoints, no statistically significant differences were found between groups in rates of reintervention (p = 0.95) and amputation (p = 0.26) at 12 months of follow-up. Conclusion: Our results suggest that the clinical outcomes of subintimal angioplasty are similar to those of intra-luminal angioplasty, with comparable limb outcomes in patients with femoro-popliteal lesions. These findings may support adopting a lower threshold for subintimal crossing in calcified and complex lesions, as it can achieve good results with comparable outcomes to the intra-luminal angioplasty. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400163&lng=pt&nrm=iso&tlng=pt Abstract Introduction: Spinal cord ischaemia (SCI) is a rare, distressing complication following thoraco-abdominal (TAAA) and complex abdominal aortic aneurysm (CAAA) repair. Prior studies have reported conflicting findings on risk factors and preventive measures. We aim to analyse the incidence of SCI following endovascular treatment of complex aortic aneurysms at our centre and to provide a descriptive analysis. Methods: Single-centre retrospective study conducted in a tertiary care centre, including all patients with a TAAA or CAAA who underwent endovascular repair using a fenestrated/branched endograft from June 2010 to February 2025. Patient characteristics, peri-procedural and follow-up data were obtained. SCI was defined according to the Society for Vascular Surgery reporting standards as new-onset motor or sensitive deficits after endovascular treatment. Results: 145 patients (91% male, mean age 71 ± 6 years) were included, of which 59 (41%) had degenerative TAAAs (types I-V) and 57 (39%) CAAAs. Mean aneurysm diameter was 66 ± 14 mm. A prophylactic cerebrospinal fluid drainage (CSFD) was preoperatively placed in 61 patients (42%). The total incidence of SCI was 8% (12/145). Among the affected patients, minimal sensory deficits were noted in 33% (4/12), paraparesis in 8% (1/12) and complete paraplegia in 58% (7/12). Most patients (83%, 10/12) presented with delayed SCI. After symptom onset, all but one patient without prophylactic drainage (58%) underwent rescue CSFD. Regarding patients with complete paraplegia (n = 7), a complete recovery was observed in three patients, one patient experienced partial recovery, and three did not recover. No differences concerning prior aortic surgery, internal iliac artery patency, procedural staging or preoperative CSFD placement were found between SCI and no-SCI patients. Conclusion: In this study, SCI manifested mostly as a delayed event. Prophylactic CSFD may prevent permanent injury. The small sample size could hinder the investigation of more robust findings. Despite several risk factors and preventive measures having been identified, the most effective preventive approach remains lacking. Further studies are required to prevent this devastating complication. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400171&lng=pt&nrm=iso&tlng=pt Abstract Introduction: Secondary implantation of iliac branch devices (IBDs) after endovascular aortic repair (EVAR) for type Ib endoleak poses unique technical challenges due to altered aortoiliac anatomy and prior femoral access. Selecting an optimal access strategy is critical to minimize complications and ensure procedural success. This review summarizes contemporary transfemoral and upper extremity access techniques, with a focus on modern endovascular solutions that facilitate safe and effective reinterventions. Methods: A narrative review of the literature published between 2010 and 2025 was conducted using PubMed, focusing on studies reporting technical strategies, outcomes, and complications of secondary IBD implantation after EVAR. Only original research, including technical notes, was included. Results: Across the reviewed studies, upper extremity access was associated with neurologic events, longer operative times, and higher access-site complication rates. Transfemoral “up-and-over” techniques consistently demonstrated technical success rates over 95%, shorter procedural times, and reduced complication rates. Steerable sheath systems enable complete IBD implantation from a single femoral access, with promising safety and efficacy. Technical refinements, including special attention to the prior graft bifurcation and meticulous technique, appear to be key elements to optimising immediate and late outcomes. Conclusion: Transfemoral strategies, particularly “up-and-over” techniques using steerable sheaths, appear to be safe and effective alternatives to upper-extremity access for secondary IBD implantation following EVAR. Access strategy should be tailored to patient anatomy and prior graft configuration, with emphasis on minimising vascular trauma, neurologic risk, and procedural complexity. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400176&lng=pt&nrm=iso&tlng=pt Abstract Background: Popliteal Artery Entrapment Syndrome (PAES) is an uncommon but important cause of lower limb ischemia affecting young, active individuals without traditional atherosclerotic risk factors. The condition has an estimated prevalence of 0.17 - 3.5% in the general population and accounts for approximately 3 - 5% of claudication cases in patients under 40 years without atherosclerotic risk factors. PAES results from abnormal anatomical relationships between the popliteal artery and surrounding structures, causing compression and intermittent claudication. Early diagnosis is crucial to prevent complications such as thrombosis, aneurysm formation, or irreversible ischemia. Case report: A 36-year-old previously healthy male presented with right lower-limb claudication, limiting walking to less than 100 metres. Physical examination revealed absent right distal pulses, and Doppler ultrasound showed a peak systolic velocity of 400 cm/s in the right popliteal artery, corresponding to 90-99% stenosis. Magnetic resonance angiography confirmed type 3 PAES with sub-occlusive popliteal artery stenosis. Surgical treatment comprised myotomy of the lateral accessory head of the medial gastrocnemius muscle and popliteal artery interposition grafting from P1 to P3 using the contralateral inverted great saphenous vein via a posterior approach. The patient recovered uneventfully, with restored distal pulses, and remained symptom-free at one-year follow-up. Conclusion: This case highlights the importance of considering PAES in young patients presenting with claudication without atherosclerotic risk factors. Successful surgical management demonstrates that timely intervention yields excellent functional outcomes. The case emphasises the need for greater PAES awareness among healthcare providers, as early recognition and intervention improve patient outcomes and reduce the long-term burden of undiagnosed vascular disease. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400180&lng=pt&nrm=iso&tlng=pt Abstract Background: Around 40% to 60% of patients with abdominal aortic aneurysm (AAA) are deemed outside the instructions for use for endovascular aneurysm repair (EVAR) because of hostile anatomy. Short and angulated necks pose a serious risk of type Ia endoleak due to difficulty achieving adequate proximal fixation and endograft seal. Report: A 72-year-old male with a history of dyslipidaemia and smoking was admitted to the vascular ward with a diagnosis of an AAA measuring 85 mm in diameter. The patient had recently undergone a Hartmann procedure for transmural ischemic colitis. Despite suboptimal anatomy for EVAR, including a short proximal neck (13 mm) and severe infrarenal angulation (90°), endovascular repair with the Endurant II stent graft was performed, using the reverse slider technique. The procedure was technically successful, with angiography confirming proper graft fixation and aneurysm exclusion. Follow-up computed tomography angiography at one month demonstrated correct endograft positioning with no evidence of endoleak. Conclusion: The reverse slider technique allows proximal sealing in short and angulated neck aneurysms. It involves repeatedly rotating the external slider in the reverse direction while gradually deploying the suprarenal stent, allowing the proximal edge of the endograft to expand and progressively approach the contralateral aortic wall. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400183&lng=pt&nrm=iso&tlng=pt Abstract Background: Although the traditional standard of care for aortic arch aneurysms is open surgical arch replacement, this approach usually requires sternotomy, cardiopulmonary bypass and hypothermic arrest. Even among the subset of patients fit for open surgery, it is associated with a pooled mortality and stroke rate of around 5%. Nowadays, a multidisciplinary team of vascular and cardiac surgeons is mandatory to determine the best, individualised treatment for each patient. Case report: A 70-year-old male was incidentally diagnosed with an asymptomatic saccular aortic arch aneurysm. After a discussion with vascular and cardiac teams, a total endovascular arch repair was decided. Percutaneous access was obtained to the right femoral and axillary arteries, the left brachial artery, and the left femoral vein. Only the left carotid artery was surgically exposed. A Cook® custom-made three-inner-branched stent graft was deployed under temporary inferior vena cava occlusion. Two anterograde branches for the innominate trunk (bridged with a 12 mm-diameter iliac limb) and the left carotid artery (bridged with a 6 mm Bentley Begraft® balloon-expandable covered stent), and a retrograde branch with a preloaded catheter for the left subclavian artery (bridged with a 10 mm Gore Viabahn® self-expandable covered stent, relined with a 10 mm Bentley Begraft due to a kink) were implanted. The procedure was successfully completed, and the patient was discharged after three days. Computed tomography angiography at three months demonstrated aneurysm exclusion, patency of the three supra-aortic branches and absence of cerebral ischemic lesions. Conclusion: In the elective setting, a triple-branch custom-made device enables total endovascular arch repair without the need for surgical revascularisation, thereby reducing invasiveness and morbidity, even in non-high-risk patients with suitable anatomy. A third branch also allows upper-extremity access for future visceral branch endovascular interventions. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400187&lng=pt&nrm=iso&tlng=pt Abstract Background: Although the traditional standard of care for aortic arch aneurysms is open surgical arch replacement, this approach usually requires sternotomy, cardiopulmonary bypass and hypothermic arrest. Even among the subset of patients fit for open surgery, it is associated with a pooled mortality and stroke rate of around 5%. Nowadays, a multidisciplinary team of vascular and cardiac surgeons is mandatory to determine the best, individualised treatment for each patient. Case report: A 70-year-old male was incidentally diagnosed with an asymptomatic saccular aortic arch aneurysm. After a discussion with vascular and cardiac teams, a total endovascular arch repair was decided. Percutaneous access was obtained to the right femoral and axillary arteries, the left brachial artery, and the left femoral vein. Only the left carotid artery was surgically exposed. A Cook® custom-made three-inner-branched stent graft was deployed under temporary inferior vena cava occlusion. Two anterograde branches for the innominate trunk (bridged with a 12 mm-diameter iliac limb) and the left carotid artery (bridged with a 6 mm Bentley Begraft® balloon-expandable covered stent), and a retrograde branch with a preloaded catheter for the left subclavian artery (bridged with a 10 mm Gore Viabahn® self-expandable covered stent, relined with a 10 mm Bentley Begraft due to a kink) were implanted. The procedure was successfully completed, and the patient was discharged after three days. Computed tomography angiography at three months demonstrated aneurysm exclusion, patency of the three supra-aortic branches and absence of cerebral ischemic lesions. Conclusion: In the elective setting, a triple-branch custom-made device enables total endovascular arch repair without the need for surgical revascularisation, thereby reducing invasiveness and morbidity, even in non-high-risk patients with suitable anatomy. A third branch also allows upper-extremity access for future visceral branch endovascular interventions. http://scielo.pt/scielo.php?script=sci_arttext&pid=S1646-706X2025000400188&lng=pt&nrm=iso&tlng=pt Abstract Background: Although the traditional standard of care for aortic arch aneurysms is open surgical arch replacement, this approach usually requires sternotomy, cardiopulmonary bypass and hypothermic arrest. Even among the subset of patients fit for open surgery, it is associated with a pooled mortality and stroke rate of around 5%. Nowadays, a multidisciplinary team of vascular and cardiac surgeons is mandatory to determine the best, individualised treatment for each patient. Case report: A 70-year-old male was incidentally diagnosed with an asymptomatic saccular aortic arch aneurysm. After a discussion with vascular and cardiac teams, a total endovascular arch repair was decided. Percutaneous access was obtained to the right femoral and axillary arteries, the left brachial artery, and the left femoral vein. Only the left carotid artery was surgically exposed. A Cook® custom-made three-inner-branched stent graft was deployed under temporary inferior vena cava occlusion. Two anterograde branches for the innominate trunk (bridged with a 12 mm-diameter iliac limb) and the left carotid artery (bridged with a 6 mm Bentley Begraft® balloon-expandable covered stent), and a retrograde branch with a preloaded catheter for the left subclavian artery (bridged with a 10 mm Gore Viabahn® self-expandable covered stent, relined with a 10 mm Bentley Begraft due to a kink) were implanted. The procedure was successfully completed, and the patient was discharged after three days. Computed tomography angiography at three months demonstrated aneurysm exclusion, patency of the three supra-aortic branches and absence of cerebral ischemic lesions. Conclusion: In the elective setting, a triple-branch custom-made device enables total endovascular arch repair without the need for surgical revascularisation, thereby reducing invasiveness and morbidity, even in non-high-risk patients with suitable anatomy. A third branch also allows upper-extremity access for future visceral branch endovascular interventions.