Bibhas Amatya

Failure of true‐lumen re‐entry after subintimal wire passage is a well‐recognized limitation of endovascular treatment for external iliac artery (EIA) chronic total occlusions (CTO). We report a 73‐year‐old woman with severe limb ischemia and a prior failed endovascular attempt who underwent hybrid left common femoral artery (CFA) endarterectomy with patch angioplasty, followed by trans‐patch retrograde access and dedicated device‐assisted re‐entry (Outback Elite) after antegrade and retrograde wires repeatedly tracked subintimally without reaching the true lumen. Controlled re‐entry preserved hypogastric artery flow and allowed drug‐eluting stent reconstruction of the EIA. At 12‐month follow‐up, ABI improved from 0.36 to 0.50, and TBI improved to 0.37. Duplex ultrasound at 6‐month follow‐up confirmed patency of the reconstructed segment without evidence of hemodynamically significant restenosis. This technical report illustrates the use of an endarterectomized CFA as a retrograde re‐entry platform and reviews contemporary strategies for managing subintimal crossing failure in iliac CTOs.

Study Design: Retrospective cohort study.Purpose: To compare three cervical sarcopenia metrics and frailty as preoperative predictors of unfavorable postoperative outcomes following surgical fixation of odontoid fractures.Overview of Literature: Sarcopenia is increasingly recognized as an indicator of physiologic vulnerability in spine surgery and thoracolumbar trauma. However, its prognostic significance in odontoid fractures remains unclear, and no previous study has directly compared cervical sarcopenia measurement sites in this population.Methods: Adult patients who underwent surgical fixation of traumatic odontoid fractures at a single level I trauma center were retrospectively reviewed. Sarcopenia was quantified on perioperative computed tomography using sternocleidomastoid, prevertebral, and paraspinal cross-sectional area normalized to the C3 vertebral body area. Frailty was assessed using the 5-factor modified frailty index (mFI-5), with hypertension status confirmed through a review of prescribed medications. Associations with postoperative outcomes were evaluated using threshold-based analyses, intercorrelation testing, subgroup analysis of combined low-sarcopenia/high-frailty patients, and an exploratory Combined Sarcopenia-Frailty Score.Results: This study included 61 patients (mean age, 61.7 years; 50.8% female). The three sarcopenia metrics were only modestly intercorrelated (Spearman rho, 0.34–0.47), with 46.7%–53.3% overlap among patients in the most sarcopenic quartiles. No individual sarcopenia or mFI-5 threshold independently predicted postoperative outcomes. However, patients in the most sarcopenic quartile on any cervical metric with an mFI-5 ≥2 (n=11) experienced higher rates of mortality, urinary tract infection, pneumonia, and nonunion. In exploratory receiver operating characteristic analysis, the Combined Sarcopenia-Frailty Score exhibited moderate discrimination for significant adverse events, with an area under the curve of 0.73 and an optimal threshold of ≥9.Conclusions: Cervical sarcopenia and frailty were not independently associated with adverse outcomes following odontoid fracture fixation. However, their combination identified patients at substantially higher risk for mortality, complications, and nonunion, supporting a potential role for combined preoperative risk stratification (Level of Evidence: level III).

Patients undergoing surgery for spinal metastases often have limited physiologic reserve. Although hypoalbuminemia is a recognized risk marker, its graded association with short-term postoperative outcomes and discharge disposition has not been well defined in large national cohorts. We evaluated the relationship between preoperative serum albumin and early postoperative outcomes following surgery for spinal metastases. Adults undergoing surgery for metastatic extradural spinal tumors (laminectomy or tumor excision with or without fusion) were identified in ACS-NSQIP (2010-2022). Hypoalbuminemia was defined as albumin < 3.5 g/dL and stratified as mild (3.0-3.49), moderate (2.5-2.99), or severe (< 2.5). Primary outcomes were any 30-day complication, 30-day mortality, and non-home discharge. Multivariable logistic regression adjusted for demographic, clinical, and operative factors. Exploratory machine-learning models assessed discrimination and variable importance. Among 4,126 patients, 1,534 (37.2%) were hypoalbuminemic. Hypoalbuminemia was associated with higher rates of complications, mortality, non-home discharge, and longer hospitalization (all p < 0.001), with outcomes worsening stepwise across albumin strata. After adjustment, hypoalbuminemia independently predicted complications (OR 1.52), mortality (OR 2.73), and non-home discharge (OR 1.89) (all p < 0.001). Albumin ranked among the most influential predictors in machine-learning models. Preoperative hypoalbuminemia shows a dose-dependent, independent association with early morbidity, mortality, and post-acute care needs after surgery for spinal metastases, supporting its use in perioperative risk stratification and care planning.

Background: Major vascular injuries during orthopedic procedures such as open reduction and internal fixation (ORIF) of acetabular fractures are rare but potentially fatal. The iliac veins are particularly vulnerable during anterior approaches due to their close proximity to the pelvic brim. Purpose: To describe the management of an iatrogenic external iliac vein injury sustained during acetabular ORIF via a modified Stoppa approach and to highlight the role of endovascular techniques as a rescue strategy. Research Design: Descriptive case study and literature review. Study Sample: Single patient undergoing acetabular ORIF complicated by intraoperative external iliac vein injury. Data Collection and/or Analysis: Intraoperative findings, management strategy, and postoperative outcomes were systematically documented. A narrative review of the contemporary literature on endovascular management of iliac and inferior vena cava injuries was performed. Results: The injury resulted in sudden, massive hemorrhage that could not be controlled through open exposure due to limited visualization and significant bleeding risk. An intraoperative endovascular approach was therefore adopted. Sequential deployment of aortic cuff stent-grafts via femoral access achieved rapid hemostasis while preserving venous patency. Postoperative imaging confirmed patent stents without evidence of extravasation. Conclusions: Endovascular stent grafting represents a viable and potentially life-saving alternative to open repair for major iliac venous injuries, particularly in anatomically challenging settings. This paper demonstrates the importance of preoperative vascular preparedness and the integration of endovascular rescue strategies into orthopedic trauma surgery.

Brain metastases (BMs) increasingly represent a significant cause of morbidity and mortality in cancer patients. The efficacy of systemic therapies for BMs, in contrast to extracranial metastases (EMs), remains limited secondary to a host of challenges. These include insufficient drug delivery due to the blood–brain barrier and blood-tumor barrier, the unique immunological milieu in the tumor microenvironment and cerebrospinal fluid, the diversity of immunogenomic landscapes in BMs across genetically distinct malignancies, the branching evolution of BM from EMs, and the challenges in longitudinally obtaining information regarding clinically actionable genetic alterations in BMs for precision oncology. These complex, long-standing challenges require treatment strategies that address multiple problems concurrently, as represented by the potential of focused ultrasound (FUS) for enhancing effectiveness of several existing BM-specific management strategies. Beyond historically investigated applications of FUS for BMs, including thermoablation and histotripsy, new frontiers include enhanced drug delivery of systemic therapies, plasma sono-liquid biopsy of BM-derived factors, radiosensitization, and immunomodulation. These applications, as discussed here, enable multiple combinatorial opportunities of FUS with targeted- and/or immunotherapies for BMs. With multiple ultrasound delivery platforms (including MR-guided, neuro-navigation-guided, and implantable devices) being investigated in neuro-oncology trials worldwide, this review provides strategies for designing and optimizing future research efforts.

Cerebral cavernous malformations (CCMs) are clusters of dilated, thin-walled vascular channels that pose significant neurological risks, particularly in pediatric patients. While stereotactic radiosurgery (SRS) has been explored as a non-invasive treatment modality, its safety and efficacy in children remain incompletely defined. We conducted a systematic review and meta-analysis of single-arm proportions after SRS for pediatric CCMs. PubMed and the Cochrane Library were searched; four retrospective cohort studies met inclusion criteria. Random-effects pooled proportions were calculated for key outcomes. Post-SRS seizure proportion (three studies; n = 73) was 0.23 (95% CI, 0.11–0.37; I² = 23.7%; p = 0.27). A lesion-volume decrease was observed in 0.34 (0.18–0.67; I² = 82.1%; p = 0.0037). Post-SRS hemorrhage proportion (four studies) was 0.22 (0.09–0.52; I² = 76.1%; p = 0.0058). Adverse radiation effects (AREs) were uncommon but variably reported. Findings suggest that radiosurgery may provide benefit in selected pediatric CCMs, though small sample sizes and study heterogeneity warrant cautious interpretation.

Chronic mesenteric ischemia (CMI) secondary to extensive paravisceral atherosclerosis is a rare but challenging vascular condition, often presenting with postprandial abdominal pain, weight loss, and claudication due to impaired blood flow. While surgical bypass is a standard treatment, it carries significant risks, particularly in patients with severe calcified vascular disease. Advances in endovascular techniques, including intravascular lithotripsy, offer less invasive alternatives for select cases. We describe the application of IVL in a patient with near‐total paravisceral aortic occlusion involving the origins of the superior mesenteric, celiac, and bilateral renal arteries. A multidisciplinary endovascular‐first approach integrated IVL, angioplasty, and embolic protection, abolishing the translesional gradient and restoring visceral and renal perfusion. One‐year follow‐up confirmed durable patency and symptom resolution. To contextualize this case, we reviewed published reports of IVL in visceral and paravisceral disease, which collectively demonstrate high technical success, symptomatic improvement, and acceptable short‐term safety, though long‐term durability data remain limited. This case illustrates the effective use of endovascular lithotripsy for extensive paravisceral atherosclerosis causing CMI. This paper adds to emerging evidence supporting the role of IVL in complex mesenteric and paravisceral interventions.

Dipankar Mukherjee and Bibhas Amatya. Vasc Specialist Int 2025;41:. https://doi.org/10.5758/vsi.250041

Background: Endovascular procedures requiring large bore access, such as Transcatheter Aortic Valve Replacement (TAVR), Thoracic Endovascular Aortic Repair (TEVAR), and Endovascular Aneurysm Repair (EVAR), have become increasingly common. Despite advancements, complications from these procedures pose clinical challenges, especially in elderly and frail patients. The clinical objective of this paper is to demonstrate the complexities and innovative management strategies for complications that arise from large bore access. Case Report: This report presents two cases illustrating percutaneous management of complications arising from large bore access during endovascular interventions. The first case involves a 74-year-old Asian female with a history of type A aortic dissection, who underwent TEVAR using a Gore TBE endograft. Post-procedure, the patient developed hemorrhagic shock due to disruption of the right external iliac artery. Interventions included upsizing the left femoral artery sheath, CODA balloon inflation in the distal aorta, and deployment of multiple VBX stents. The second case features a 24-year-old Caucasian female with a large pseudoaneurysm at the cannulation site in the aortic arch following a heart transplant. Successful TEVAR was performed to exclude the pseudoaneurysm. Closure of the right femoral artery access using 6 French ProGlide sutures was complicated, requiring balloon angioplasty to create an opening in the common femoral artery. Conclusions: These cases highlight the challenges and innovative strategies in managing complications associated with large bore access during endovascular procedures. Insights gained from these experiences contribute to the armamentarium of interventionists, offering valuable guidance in addressing similar scenarios.