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Background:
Peripheral Arterial Disease (PAD) remains a significant burden in vascular medicine, often compli-cated by heavily calcified lesions and in-stent occlusions. A novel laser atherectomy (LA) system is a 355 nm solid-state laser designed to deliver precise, non-thermal photoablation of plaque—in-cluding dense calcium while minimizing vessel trauma. This case series presents initial clinical ex-perience using this LA system in patients with symptomatic PAD, including native and in-stent le-sions.

Methods:
Ten patients (Rutherford class 2–5) with moderate to severe calcification femoro-popliteal and in-frapopliteal lesions underwent endovascular treatment with this novel LA system between March and April 2025. Following LA, adjunctive therapy including drug-coated balloon (DCB) angioplasty or provisional stenting was performed based on intra-procedural assessment. Outcomes evaluated included technical feasibility, procedural safety, and short-term patency.

Results:
A total of 12 lesions in 10 patients (mean age 69 ± 9 years) were successfully treated (100% tech-nical success rate). DCB angioplasty was also performed in all cases; stent implantation was re-quired in two cases (16%). The LA proved to be effective in all treated lesions, especially in heavily calcified lesions and in-stent lesions. There were no procedure- or device-related complications. The 6-month results, including target lesion patency rates, will be presented at the USGG Con-gress.

Conclusions:
This novel LA system shows promising acute results in treatment of complex PAD lesions, includ-ing heavily calcified lesions and in-stent occlusions. In most lesions additional stentplacement could be avoided. Further studies are needed to assess durability and long-term outcomes.

Das Popliteale Arterielle Entrapment Syndrom (PAES) ist eine seltene muskuläre Fehlbildung in der Fossa Poplitea mit Kompression der A. poplitea. Die Erstbeschreibung erfolgte durch T Anderson Stewart (J Anat Physiol 13: 162, 1879). Es werden 6 anatomische und eine funktionelle Form unterschieden. Die Therapie ist überwiegend chirurgisch mit einer Spaltung des aberranten Anteils des M. gastrocnemius mit oder ohne simultane Gefäßrekonstruktion. Über das Rezidiv nach chirurgischer Therapie sind keine Studien publiziert. Wir berichten unsere Erfahrungen über die chirurgische Therapie des Rezidiv-Entrapment.

Retrospektive Analyse von Patienten, die einen Zweiteingriff nach Operation eines PAES auf der ipsilateralen Seite erhalten haben.

Im Zeitraum 2/03-5/24 wurden 10 Rezidiv-Eingriffe an 5 Patienten durchgeführt 2 Pat wurden bilateral operiert, davon 1 Patientin mehrfach. 4 männliche Patienten, medianes Alter bei Erstoperation: 28.2a (16.5-40), medianes Alter bei Rezidivoperation 30.5a (17-43). Das mediane Intervall zwischen den Eingriffen lag bei 6 Monaten (0.1-229). Der Ersteingriff bestand in 50% in einer alleinigen Myotomie des M. gastrocnemius, in den übrigen Fällen wurde neben der Myotomie auch eine Gefäßrekonstruktion mit V. saphena magna (VSM) durchgeführt. Bei 2 Patienten bestand ein „funktionelles“ Entrapment. Bei der Rezidivoperation wurde in 70% eine extraanatomische Bypassrekonstruktion durchgeführt (ispilaterale VSM: 4, contralaterale VSM: 2, alloplastisch: 1), und in 30% eine partielle Resektion des M. gastrocnemius. Das mediane Follow-up nach Rezidiveingriff betrug 5.8 Jahre (0.7-22), wobei in 3 Fällen neuerliche Beschwerden auftraten. Therapie: 2x Bypassrevision, 1x konservativ. In einem Fall von funktionellem Entrapment musste eine Major-Amputation durchgeführt werden.

Das Rezidiv nach PAES ist außerordentlich selten. Frührezidive (< 6 Monate) sind meist durch technische Faktoren bei der Erstoperation bedingt. Spätrezidive (> 1 Jahr) werden meist durch Verschluß der Gefäßrekonstruktion hervorgerufen. Das funktionelle Entrapment stellt dabei hohe Anforderungen an die Diagnostik und Therapie, und ist mit schlechten Langzeitergebnissen vergesellschaftet.

The endovascular treatment of anastomotic lesions in femoropopliteal and tibial bypass grafts remains a challenging clinical scenario. The aim of this analysis is to evaluate the performance of the VIABAHN endoprosthesis with a heparin bioactive surface for the treatment of bypass anastomotic stenosis (BAS).

This is a single-center, single-arm, retrospective study. Consecutive patients treated with the Viabahn stent graft for BAS between December 2021 and December 2024 were included in this study. The primary endpoint was the primary patency of the treated grafts. Secondary patency, freedom from target lesion revascularization (TLR), mortality, and major amputation rates were additionally analyzed.

A total of 33 patients were included in this study. The majority presented with acute limb ischemia (n=19, 59%), 13% with claudication, and 28% with chronic limb-threatening ischemia (CLTI). A prosthetic bypass was treated in 29 cases. Surgical bypass thrombectomy prior to Viabahn deployment was performed in 29 patients (91%). The median hospital stay was 11 days (range: 9 to 21). Intensive care treatment was required in 31% of the patients, while in-hospital morbidity and mortality rates were 34% and 9%, respectively. The primary patency at 3, 6, and 12 months was 55%, 49%, and 33%, respectively. The secondary patency at 12 months was 42%, while freedom from TLR was 43%. Finally, the survival rate at 12 months was 80%, and freedom from amputation was 89%.

In this study, the use of the Viabahn stent graft for BAS was associated with low bypass graft patency rates, an increased risk for TLR, and acceptable amputation and survival rates at 12 months.

There is a widely accepted dogma that patients with CLTI and peripheral ulcers need a continuous vascular pathway down to the foot for successful wound healing. Nevertheless, in patients with concomitant common femoral / profunda artery stenosis and femoropopliteal occlusion it is sometimes decided to leave the femoropopliteal occlusion untreated and only perform profundoplasty +/- iliac artery stenting. The aim of this study was to evaluate the outcome in these patients.

Retrospective analysis of consecutive patients.

Between 2014 and 2023 33 limbs in 30 patients with CLTI received profundoplasty (+/- iliac stenting) without treatment of the femoropopliteal occlusion. The decision not to treat the femoropopliteal occlusion was the lack of an adequate vein for bypass surgery in 5, patient morbidity in 7, small lesion not justifying extensive surgery in 7, very good collateralization from the profunda artery in 3, unsuccessful attempt of femoropopliteal recanalization in 3 patients. In 9 patient no clear reason for the decision could be discerned. Nearly all patients were in WIfI stage 2. No patient was lost to follow-up.

12 limbs in 11 patients (36%) needed femoropopliteal revascularization because of wound progression (8 bypass surgery, 4 endovascular) and 1 patient (3%) had major amputation. The strategy to not treat the femoropopliteal occlusion thus failed in 13 (39%) of limbs. In all 20 limbs that did not require femoropopliteal revascularization, complete wound healing was documented. One year after profundoplasty 4/12 patients with femoropopliteal revascularization but only 2/18 patient without femoropopliteal revascularization had died.

In approx. two thirds of our patients with limited wounds the strategy to only perform profundoplasty and leave the femoropopliteal occlusion untreated was successful. Even though our data do not allow us to identify patient characteristics, that predict wound healing despite incomplete revascularization, they do suggest that in some patients a staged approach, performing only profundaplasty and perform bypass surgery only in case of failure of wound healing, may be recommendable.

Access site complications influence short-term survival and outcomes in patients undergoing percutaneous femoral artery access. While ultrasound-guided (USG) puncture is a reliable method to reduce such complications, USG closure-device deployment remains rarely utilised in access site management.

A systematic literature search was conducted to assess the safety and efficacy of USG-closure compared to vascular closure device deployment without ultrasound guidance, referred to as conventional closure (CC). All studies reporting on USG-closure in transfemoral arterial interventions were eligible, and those directly comparing USG to CC were included.

Overall, 2,738 patients receiving USG-closure were included: 1,025 for introducer sheaths measuring 12 fr or larger and 1,713 for introducer sheaths smaller than 12 fr. The incidence of access complications was 5.7% (0.8 to 21.6%) for large sheath procedures and 2.6% (0.9 to 4.7%) for small sheath procedures. The meta-analysis, which included 2,339 patients who received USG-closure and 1,175 who underwent CC, showed that USG-closure was associated with reduced access site complications compared to CC (OR 0.49, 95% CI 0.37 – 0.65, P <.001). This was consistently seen for both small sheath (OR 0.45, 95% CI 0.28 – 0.75, P =.002) and large sheath procedures (OR 0.50, 95% CI 0.37 – 0.71, P <.001). Additionally, major complications (OR 0.26, 95% CI 0.10 – 0.63, P =.003) and bleeding complications (OR 0.50, 95% CI 0.33 – 0.76, P =.001) were significantly less with USG-closure.

USG vessel closure of the femoral artery appeared to be associated with a lower rate of overall and major access site complications compared to CC techniques. Bleeding events occurred less frequently following USG vascular closure device deployment.

A German single center retrospective registry with more than 300 patients. The aim was to show a superior result of rotational-atherectomy against POBA

The Bycross device is a unique , new developped atherectomy device, which is usuable in
thrombotic, calcified aswell as neointimal lesions, designed for debulkig of the iliac, femoral or
popliteal region. No capital eqipment is required, it is a single use handheld. No filter has been used, with a 1 percent
embolizationrate so far.

We have treated in our center over 365 patients mainly with total occlusions, up to 25 cm, always
followed by a angioplasty with DCB (Paclitaxel or Serolimus)technology.
The promising results show a 98 percent success-rate, an improvement in the Rutherford scale
between 2-4 .
Only 4 patients had to be treated for re-occluion within up to 12 month in the followed up patients.
Bycross is a safe, novel atherectomy-device

A total of 365 lesions were treated. Clinical follow-up was available
at 12.7±10.2 months for (91%) patients. Lesions were mostly identified in the
femoropopliteal segments. #
Bycross is a safe, novel atherectomy-device. A longer follow up is needed, aswell as a greater patient
population for future presentation of reliable results.

A patent bypass graft doesn't guarantee effective limb salvage, as patients may develop progressive below-the-knee (BTK) arterial disease despite maintained graft patency. We observed patients with chronic limb-threatening ischemia (CLTI) who, despite patent femoro-popliteal bypass grafts, presented with persistent ischemic symptoms. This study evaluated the safety and efficacy of using patent bypass grafts as access routes for endovascular intervention in BTK and pedal lesions.

Between January 2022 and December 2024, six patients (4 male, 2 female; mean age 72 years) with advanced peripheral arterial disease (Rutherford categories 4–6) were enrolled. All had significant comorbidities and presented with symptomatic BTK and pedal artery disease despite patent infrainguinal bypass grafts.
Preprocedural evaluation included ankle-brachial index measurement, duplex ultrasonography, and angiography. Endovascular revascularization was performed using either a retrograde "up-and-over" approach (n=4) or antegrade access via the patent bypass graft (n=2). The intervention comprised vessel recanalization, lesion preparation using low-profile rotational atherectomy, and prolonged balloon angioplasty. The primary endpoint was achieving at least one-vessel runoff to the foot.

Technical success was achieved in all cases, with successful restoration of direct vessel runoff to the foot. All patients experienced resolution of rest pain and significant symptomatic improvement. Minor amputations were performed in three patients, with one requiring a Syme amputation. No major adverse cardiovascular events occurred during 30-day follow-up. One patient developed a puncture site hematoma, which resolved with conservative management. At six-month follow-up, primary patency was 83.3%, and limb salvage was achieved in all patients.

This study demonstrates that combining existing surgical bypasses with advanced endovascular techniques offers a viable treatment option for patients with patent grafts but progressive BTK disease. Strategic use of patent bypass grafts as access conduits for BTK/pedal interventions may optimize outcomes in this challenging population. A holistic approach incorporating both open and endovascular modalities appears essential in managing complex PAD patients.

Superior mesenteric artery (SMA) origin varies. In case of SMA lesions, such as aneurysms or acute thrombotic occlusions, stable placement of the sheath is needed. Due to the variety of the angulation of the SMA or the presence of severe atherosclerotic disease in the supra-aortic vessels, transfemoral access is preferable. Aim of the present study was the evaluation the safety and feasibility of the use of steerable sheaths from the groin for complex SMA lesions.

Between January 2023 and January 2025, 3 patients with upward oriented origin of the SMA, presented with saccular 3cm aneurysm of the inferior pancreaticodudodenalis artery (n:1) and acute thrombotic occlusion of the SMA (n:2). Due to the cranial
In all cases, a steerable sheath Oscor (NXT Med GmbH) was used. The insertion side was the right common femoral artery.

The cannulation and position of the sheath at the orifice of the SMA was safe and fast. No additional catheter was necessary and the position of the sheath was stable allowing the successful treatment of the 3 entities. We used for the aneurysm 3D coils and for the acute occlusions the Penumbra Lightning aspiration system. The patients had an uneventful course and no other issues were observed in the 6-month of follow up.

Transfemoral cannulation and endovascular treatment of SMA lesions over steerable sheaths is safe and feasible. Avoidance of transcubital access is beneficial minimizing the risk of strokes.