Gianmarco de Donato

Computed tomography angiography (CTA) is the reference imaging modality for diagnosis, endovascular planning, and surveillance of abdominal aortic aneurysms (AAAs), but conventional assessment remains time-consuming, operator-dependent, and limited by complex anatomy. This narrative review examines the role of artificial intelligence (AI) in three-dimensional aortic CTA segmentation for AAA management. The narrative synthesis drew on literature identified through PubMed/MEDLINE, Scopus and the Cochrane Library, with the original search covering January 2000 to July 2026. Ten primary studies from the existing bibliography were characterized in a study-level table, and reported Dice coefficients were displayed for nine studies. Current evidence indicates that AI-based segmentation, particularly using convolutional neural networks, U-Net-derived models, and nnU-Net frameworks, can improve the speed and reproducibility of aortic lumen, wall, thrombus, branch vessel, endograft, and aneurysm sac delineation. These techniques may support more accurate morphometric measurements, device sizing, procedural planning, quantitative surveillance, and the development of advanced imaging biomarkers. However, available studies remain heterogeneous in datasets, anatomical evaluation, imaging protocols, validation strategies, and reported performance metrics, limiting direct comparison and clinical generalizability. AI-assisted 3D segmentation represents a promising tool for transforming CTA from descriptive imaging into quantitative decision support, but robust multicenter validation, workflow integration, and expert supervision remain essential before widespread clinical adoption.

Background: In a significant proportion of carotid interventions, carotid graft replacement is required to achieve a successful outcome either as a primary method or as a bailout solution. Whether carotid grafting should be performed, the indications for its use, and other technical aspects remain insufficiently addressed in the literature. An exhaustive mapping of the sparse and heterogeneous evidence available in the literature may provide a more comprehensive understanding of this topic. Objective: This scoping review aims to examine and summarize the scientific evidence on the indications, graft types, and outcomes of graft interposition during elective and emergency carotid interventions. Methods: This scoping review will be conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines for reporting. Peer-reviewed papers written in English will be identified through searches of the following databases: PubMed (MEDLINE), Embase, Scopus, and Web of Science. The web-based systematic review platform Rayyan will be used for deduplication and study screening. The review will encompass the following clinical scenarios: elective carotid endarterectomy, emergent carotid endarterectomy, carotid artery restenosis, carotid artery trauma, carotid artery aneurysm, carotid artery dissection, carotid patch infection, radiation-induced carotid fibrosis, and carotid body tumors. All study designs (randomized controlled trials, observational studies, and case series) will be considered. Non-English studies, animal studies, cadaveric or anatomical-only reports, and purely technical notes without clinical data will be excluded. Data regarding extracranial-to-intracranial bypass will be excluded. Study selection based on title and abstract screening (first stage), full-text review (second stage), and data extraction (third stage) will be performed by a group of researchers, whereby each paper will be reviewed by at least 2 researchers. Any conflict regarding the inclusion or exclusion of a study and the data extraction will be resolved by discussion between the researchers who evaluated the papers; a third researcher will be involved if consensus is not reached. Data synthesis will be performed with the aim of clearly presenting the indications, graft types, and outcomes of graft interposition during carotid interventions. Results: The search strategy was finalized in July 2026. Preliminary searches of PubMed (MEDLINE), PROSPERO, and JBI Evidence Synthesis databases identified no published or registered systematic or scoping reviews specifically addressing carotid interposition grafting across elective and emergent carotid interventions. As of September 2026, formal database searches and study selection had not yet begun and were scheduled to start in October 2026. Data extraction and evidence synthesis are expected to be completed by spring 2027, and submission of the final scoping review is planned for summer 2027. Conclusions: Our scoping review will seek to provide an overview of the available evidence and identify research gaps regarding the role of graft interposition during elective and emergent carotid interventions.

Purpose: To describe the ECO-PLUG technique, a standardised ultrasound-guided workflow for percutaneous femoral access and plug-based closure, and to report its feasibility and clinical performance in patients undergoing peripheral artery revascularization procedures. Technique: The ECO-PLUG protocol incorporates continuous ultrasound guidance throughout all procedural phases: femoral access, closure device deployment, and post-procedural haemostasis verification. Five predefined checkpoints (C1-C5) structure the workflow from pre-access mapping to early and delayed ultrasound follow-up. Key elements include in-plane puncture, ultrasound-guided plug deployment with a modified retract manoeuvre, and systematic colour-Doppler assessment at 0 and 3 to 5 minutes after closure. Results: A total of 200 elective endovascular procedures using 6F/8F femoral access were analysed. Anatomical complexity was common, including moderate-to-severe anterior wall calcification (55%), arterial depth >35 mm (24%), and bifurcation variants (22%). Immediate haemostasis was achieved in 98% of cases, while 2% required prolonged compression or manual conversion. Access-related complications occurred in 4% of patients, including pseudoaneurysms (1.5%) and haematomas. No arterial occlusions or surgical conversions were observed. Conclusions: The ECO-PLUG protocol demonstrates acceptable haemostasis efficacy and a favourable access-site safety profile across anatomically complex settings, supporting its potential as a structured image-guided closure strategy. Prospective comparative studies are needed to validate these preliminary findings. Clinical Impact: The ECO-PLUG protocol introduces the first formally structured, checkpoint-based ultrasound workflow integrating continuous imaging guidance across all phases of percutaneous femoral closure, from pre-access mapping through plug deployment and hemostasis verification. Unlike conventional approaches, where ultrasound use is typically limited to arterial puncture alone, ECO-PLUG extends real-time sonographic control to anchor positioning and collagen release, reducing operator dependency in anatomically complex cases. With 98% immediate hemostasis and no arterial occlusions or surgical conversions across 200 consecutive procedures, including patients with heavy calcification, deep vessels, and bifurcation variants, this protocol offers clinicians a reproducible, teachable standard applicable across varying experience levels.

Carotid artery stenting (CAS) is an established revascularization option for patients with carotid disease at high surgical risk. Periprocedural cerebral embolization remains a clinical concern, and plaque prolapse, the extrusion of atherosclerotic material through the stent struts into the lumen, has emerged as an actionable mechanism directly linked to embolic events and adverse neurological outcomes. This narrative review provides a structured, practice-oriented framework addressing one specific question: how can plaque prolapse be prevented during CAS? Drawing on prospective registries, comparative cohort studies and intravascular imaging analyses based on optical coherence tomography (OCT) and intravascular ultrasound (IVUS), we discuss the main determinants of prolapse risk, plaque morphology, procedural variables and device selection, converging on dual-layer micromesh stent (DLMS) technology as the most advanced device-based solution available. Pooled clinical data indicate a 30-day stroke rate of approximately 1.4% when DLMSs are used in combination with embolic protection, and OCT studies confirm reduced prolapse compared with single-layer stents. Prevention requires an integrated strategy combining lesion-specific characterisation, optimised technique and tailored device selection, while standardised imaging definitions and adequately powered randomised trials with hard clinical endpoints remain research priorities.

Article: Ad-interim 6- and 12-month results from a prospective multicenter investigation on Renzan Stent in the treatment of patients with femoro-popliteal disease in Tuscany (CURRENT Registry) - The Journal of Cardiovascular Surgery 2026 Apr 22 - Minerva Medica - Journals

Purpose: The algorithm of treatment for dysfunctional haemodialysis vascular access (VA) varies significantly between centres, and the role of stent-grafts is not yet standardised. A multidisciplinary panel of European experts on VA was convened, with the aim of finding consensus on stent-graft strategies in symptomatic dysfunctional VA using a modified Delphi approach. Methods: A modified 3-round Delphi study was conducted with a panel of 12 European experts from high-volume dialysis access practices across multiple specialties (5 vascular surgeons, 5 interventional radiologists, 1 transplant surgeon and 1 nephrologist). Round 1 involved semi-structured interviews to identify key parameters. Round 2 assessed extent of expert agreement to the statements or if neutral. Round 3 allowed experts to revise responses after viewing anonymised panel results. To highlight gradations of consensus, a grading system (A–D) was applied based on agreement or disagreement, with consensus defined as ≥75% agreement. Results: Each expert voted on the 57 statements on treatment considerations relating to optimal stent-graft utilisation; patient background; vascular occlusive pathology; considerations specific to the graft-venous anastomosis, cephalic arch and thoracic central vein stenoses; general treatment considerations with stent-grafts; and a summary treatment algorithm by anatomical location. The analysis revealed strong consensus across multiple domains, with 81% of statements (46/57) achieving ≥75% agreement. An expert panel consensus (≥75% agreement) on the use of stent-graft was found for the treatment of graft-venous anastomosis, recurrent restenosis in the central venous system, in-stent stenosis in previously-placed bare metal stents, and restenosis of the cannulation zone if to be abandoned. All 12 experts completed 3 rounds (100% retention). Response stability was high with only 3 experts adjusting 11 responses (1.6%) between rounds regarding 9 statements that changed the overall consensus level of the panel. Conclusions: Based on the elevated strength and high consistency of this international multidisciplinary expert-based Delphi consensus, most of the statements might guide the current stent-graft strategies of dysfunctional VA, including practical recommendations on best practice using stent-grafts.

Purpose: The purpose of the study is to evaluate the early and long-term technical and clinical outcomes of endovascular treatment for central venous stenosis (CVS) and occlusion (CVO) in hemodialysis patients, and to describe procedural strategies aiming at optimizing vascular access preservation. Materials and Methods: A retrospective single-center analysis was performed including all patients with an upper-limb arteriovenous access undergoing endovascular revascularization for symptomatic CVS/CVO between January 2020 and December 2024. Indications comprised severe venous congestion, prolonged bleeding after dialysis, poor access maturation, and inadequate dialysis efficiency. Diagnosis was established by duplex ultrasound and computed tomography angiography; digital subtraction angiography was used when noninvasive imaging was inconclusive. Procedural details, device use, and perioperative outcomes were recorded. Primary outcome was primary patency; secondary outcomes included technical success, procedural safety, cumulative (secondary) patency, and freedom from reintervention. Results: Forty-four patients (mean age 65.8±16.2 years; 59.1% male) were treated, 50% for complete occlusions. The most frequent lesion site was the brachiocephalic vein (70.4%). High-pressure balloon angioplasty was performed in 93.2% of cases, and stents were implanted in 45.5% (mostly self-expanding nitinol). Technical success was achieved in 93.2% with no perioperative complications. Over a median follow-up of 36.7±32.2 months, 20 patients (45.5%) underwent reintervention for restenosis (34.1%) or reocclusion (11.4%); 30% of reinterventions revealed stent fractures. Kaplan–Meier analysis showed primary patency rates of 85.5% at 6 months, 69.9% at 12 months, and 58.7% at 18 months. Cumulative patency was 88.4% at 6 months, 80.9% at 12 and 24 months, 74.8% at 36 months, and 69.1% at 60 months. Prior ipsilateral central venous catheter placement was associated with reduced freedom from reintervention. Conclusions: Endovascular revascularization of CVS/CVO in hemodialysis patients is safe and offers high technical success. While primary patency declines over time, cumulative patency remains favorable, underscoring the role of timely reinterventions and structured surveillance in prolonging access life. Clinical Impact: This study reinforces endovascular revascularization as a safe and effective first-line strategy for managing central venous stenosis and occlusion in hemodialysis patients, allowing immediate reuse of the vascular access and avoiding dialysis interruption. The data highlight that long-term success depends less on a single “perfect” procedure and more on structured surveillance and timely reintervention. Prior ipsilateral central venous catheter placement emerges as a key predictor of failure, underscoring the need to minimize catheter use and promote early AVF creation. From a practical standpoint, selective primary stenting in long or recoil-prone lesions and careful attention to stent durability can meaningfully prolong access lifespan in this fragile population.

Background: Acute infrainguinal bypass graft occlusion is a critical vascular emergency that threatens limb viability and challenges both surgical and endovascular management. Despite progress in revascularization strategies, outcomes remain suboptimal, and consensus on the optimal treatment approach is lacking. Methods: This narrative review summarizes current evidence on the epidemiology, etiology, diagnosis, and treatment of acute infrainguinal graft occlusion. Particular attention is given to the evolving role of catheter-directed thrombolysis and mechanical thrombectomy, as well as to prevention strategies based on structured surveillance and medical optimization. Results: Infrainguinal bypass failure is influenced by technical, anatomical, and systemic factors, with distinct mechanisms affecting vein and prosthetic grafts. While surgical thrombectomy remains a viable option in selected cases, endovascular techniques have gained prominence due to their minimally invasive nature and promising short-term outcomes. Prevention of occlusion through duplex surveillance and best medical therapy is crucial to preserving graft patency and reducing major amputation risk. Conclusions: Management of acute graft occlusion requires timely diagnosis and a tailored, multidisciplinary approach. Although endovascular therapies have expanded treatment options, further prospective studies are needed to define optimal strategies and improve long-term outcomes in this high-risk population.

Introduction: The profunda femoral artery (PFA) puncture is generally fraught with risk of bleeding and iatrogenic damage, leading to possible impaired flow in such a valuable artery. However, the PFA represents a potential retrograde path to the common femoral artery (CFA) due to its usual good size and convenient location. Since endovascular treatment of the CFA and its bifurcation is gaining popularity, this study intends to report the use of PFA access in complex revascularizations. Materials and Methods: This is a retrospective multicenter registry on PFA retrograde approaches, including 15 cases in which this access was used during challenging recanalizations of iliac and femoral chronic total occlusions (CTO). This access was performed as a bailout in 11 cases (73.3%). The puncture’s technical success and the diseased segments’ recanalization were achieved in all cases. Hemostasis was done by intraluminal balloon inflation (9/15, 60%), external manual compression (4/15, 26.7%), or closure device deployment (2/15, 13.3%). No complications related to the access were noted. Conclusion: This series represents the largest cohort of patients who underwent retrograde PFA puncture for iliac and femoral CTO crossing. It shows how different clinical and anatomical settings may suit this endovascular approach, making it a safe alternative that vascular specialists should be aware of. Clinical Impact: Retrograde puncture of the profunda femoral artery (PFA) could represent a strategic approach during complex iliac and femoral endovascular revascularizations and total endovascular femoral reconstruction. This article presents 15 cases of PFA retrograde puncture and conveys technical tips for performing this maneuver correctly and avoiding potential risks at the level of this vessel. Surgeons and interventionalists should be aware of this possibility, especially with the increasing number of total endovascular treatments of the femoral bifurcation.