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Highlights • Revascularization for PAD has been characterized by the adaptation of technologies from the treatment of CAD, with few therapies specifically developed for PAD. • In light of recent increases in all-cause mortality driven by endovascular PAD interventions that employ elution of antiproliferative agents, this review highlights the unmet need to address underlying local inflammation and proposes an alternative therapeutic approach. • Development of next-generation PAD-specific endovascular interventions will benefit from integration of specialized immunotherapies that target macrophage polarization and focus on vessel healing., Summary Peripheral artery disease (PAD) has a significant impact on human health, affecting 200 million people globally. Advanced PAD severely diminishes quality of life, affecting mobility, and in its most severe form leads to limb amputation and death. Treatment of PAD is among the least effective of all endovascular procedures in terms of long-term efficacy. Chronic inflammation is a key driver of PAD; however, stents and coated balloons eluting antiproliferative drugs are most commonly used. As a result, neither stents nor coated balloons produce durable clinical outcomes in the superficial femoral artery, and both have recently been associated with significantly increased mortality. This review summarizes the most common clinical approaches and limitations to treating PAD and highlights the necessity to address the underlying causes of inflammation, identifying macrophages as a novel therapeutic target in the next generation of endovascular PAD intervention., Central Illustration

Iatrogenic complications may manifest in a variety of ways. We present the case of an 86-year-old woman who underwent a percutaneous coronary intervention with a drug-eluting stent for non–ST-segment elevation myocardial infarction followed by leadless pacemaker placement through a femoral approach. Her post-procedure course was complicated by new onset high-output heart failure secondary to iatrogenic arteriovenous fistula formation, requiring covered stent placement. (Level of Difficulty: Advanced.), Graphical abstract

A 55-year-old male was admitted with numbness in the left foot and intermittent claudication. Doppler ultrasound and digital subtraction angiography presented chronic total occlusion in the ostial of left superficial femoral artery and reperfusion flow at one-third below from collateral channels of deep femoral artery. Thus, we decided to perform an endovascular intervention for this patient. First, we used contralateral transfemoral approach technique, but the microwire could not reach to the occluded superficial femoral artery lesion. Then, we approached the chronic total occlusion lesion retrogradely. A wire was passed successfully from the popliteal artery to ostial superficial femoral artery. Finally, 2 stents were implanted. This case highlights that popliteal retrograde approach is effective and safe for total occlusion of superficial femoral artery.

An 84-year-old man was admitted to the authors’ hospital for the treatment of intermittent claudication. Angiography revealed an exophytic calcified nodules in the distal superficial femoral artery. Angioscopy also revealed abundant exophytic atherosclerotic calcification. Histology confirmed the diagnosis. (Level of Difficulty: Beginner.), Graphical abstract

This article is a technical review of the common techniques used in the treatment of lower-limb occlusive arterial disease associated with diabetes. The techniques described here reflect the author’s own practice and are methods that the author finds helpful in avoiding complications and in making the technical aspects of the procedures easier. Keywords: Diabetes, Foot ulcer, Ischemia, Endovascular treatment, Angioplasty, Stenting, Retrograde access, Subintimal, Intraluminal, Pedal arch, Perfusion

Introduction Peripheral Arterial Disease (PAD) in diabetic patients is a significant cause of Morbility. Long arterial occlusion in patient previously treated can require unusual and complex solution. Herein we report a case of complicated bypass in diabetic patient with history of bypass for bilateral popliteal aneurysm. Presentation of case A 51-year-old male, smoker, with hypertension and diabetes mellitus was referred to our hospital for rest pain in left limb and peripheral cyanosis. Ultrasound doppler (US) showed an occlusion after common femoral artery with patency of Anterior-tibial artery (ATA) two centimeters after the origin. The unavailability of adequate autologous conduit necessitated an alternative solution and was chosen a composite femoro-anterior tibial artery bypass with successive ATA angioplasty to ensure the patency of graft. Discussion The autogenous vein is the preferred conduit in below-knee vascular reconstructions but in redo-procedures in the absence of vein, synthetic or biologic vascular prostheses must be considered as graft material. In these cases tibial angioplasty can improve the outflow and the patency. Conclusion Composite Femoro-ATA bypass with tibial angioplasty is an alternative technique for critically ischemic legs with limited autologous vein material. In our experience this approach was safe and effective., Highlights • Damage of microcirculation can be due to major amputation with an incidence of 30.7%. • Long arterial occlusion in patient previously treated can require complex solution. • In this case we have chosen a composite femoro-anterior tibial artery bypass. • Composite Fem-ATA bypass with tibial angioplasty is an alternative technique in CLI.

Shockwave intravascular lithotripsy for the treatment of peripheral arterial disease is routinely performed via femoral artery access. In patients with complex femoropopliteal disease, this traditional approach is not feasible. To address this situation, we used an exclusive pedal access approach along with other adjunctive treatments, resulting in a successful outcome. (Level of Difficulty: Advanced.), Graphical abstract, Shockwave intravascular lithotripsy for the treatment of peripheral arterial disease is routinely performed via femoral artery access. In patients…

The incidence of venous and arterial thromboembolic complications in COVID-19 patients is significant. The vast majority of COVID-19 patients spend their quarantine at home in a self-isolation condition. The occurrence of Acute limb ischaemia (ALI) is a dangerous event that needs prompt diagnosis and management with time-dependent recanalization outcomes. We present a case series of three COVID-19 patients who suffered from ALI that occurred during home self-isolation, and that were diagnosed and treated with a significant time-delay due to COVID-19 social implications.

A patient with occlusion of the left superficial femoral artery (SFA) underwent endovascular intervention. Six-month follow-up angiography revealed aneurysmal dilatation of the previously stented artery. This finding may be a result of maladaptive vascular remodeling or arterial injury resulting in aneurysmal dilatation secondary to subintimal crossing, atherectomy, and paclitaxel therapies. (Level of Difficulty: Beginner.), Graphical abstract

Orbital atherectomy is a commonly used procedure for peripheral arterial disease. Crown entrapment is a rare but potentially dangerous complication of orbital atherectomy. We describe a case of crown entrapment by markedly excessive atheromatous intimal tissue attachment to the device and an innovative retrieval technique that may minimize vascular injury. (Level of Difficulty: Beginner.), Graphical abstract

Objectives To evaluate the clinical outcomes and perioperative complications associated with complete percutaneous decannulation of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) with the MANTA closure device. Methods This is a retrospective analysis of a single surgeon consecutive series of 14 patients at a single center who underwent decannulation from VA-ECMO, 10 of whom underwent a percutaneous method of femoral cannula removal. Results After a mean duration of VA-ECMO support of 7.4 ± 3.8 days, all 10 patients, with arterial cannulas ranging in size from 17 to 21 Fr, underwent percutaneous decannulation with the MANTA closure device, with immediate hemostasis. One patient had acute lower limb ischemia that was recognized intraoperatively and successfully treated with suction embolectomy. Two patients had a pseudoaneurysm at the distal perfusion catheter site recognized on perioperative imaging studies, one resolving with observation and the other necessitating thrombin injection. One patient had a hematoma that resolved with observation. Conclusions Percutaneous decannulation from VA-ECMO using the MANTA large-bore vascular closure device is feasible and results in immediate hemostasis with excellent angiographic results.