Endovascular Coarctoplasty (CoAP) with stenting is the treatment of choice in Coarctation of Aorta (CoA). Literature on the harms or benefits of CoAP in Eisenmenger's syndrome (ES) is scarce. There is the hypothetical possibility of an increase in right-to-left intracardiac shunting once the coarctation is relieved. We report a 17-year-old male adolescent who presented with secondary hypertension, cyanosis, and lower limb claudication. He was diagnosed as a case of ventricular septal defect (VSD), patent ductus arteriosus (PDA), and CoA with associated ES. He underwent successful balloon CoAP with no clinical or invasive hemodynamic deterioration. At one-year follow-up, there was no clinical or echocardiographic evidence of complications from ES or restenosis. This case highlights that CoA with ES can be safely managed by CoAP with good long-term results. The proposed pathophysiology for the uneventful procedure is an extension of our understanding of the 'shunt dynamics' in cyanotic spells in patients with congenital cyanotic heart diseases.

Peripheral artery disease (PAD) is highly prevalent in older adults. PAD is associated with cognitive impairment; however the underlying mechanisms are unclear. The brain's metabolic needs rapidly change in response to neuronal activity requiring adjustment of regional cerebral blood flow, termed neurovascular coupling (NVC). The microvascular endothelium contributes to NVC responses. Patients with PAD have endothelial dysfunction that may extend to the cerebral circulation, impairing NVC and cognitive function. The present study examined NVC responses to cognitive stimulation using Transcranial Doppler Ultrasonography (TCD) in older adults with PAD. Participants underwent bilateral TCD in the middle cerebral arteries during four recordings; baseline and tasks from Addenbrooke's-III Cognitive Examination and Digit Span. Mean absolute change in cerebral blood velocity (CBv) was measured at two time points (25-30s; 30-40s) from a 20s baseline. Nineteen patients with intermittent claudication and 20 age-matched controls (mean: 68.4 [8.1] years; female: 12) were included. CBv increased on all cognitive tasks, however no significant differences were observed between patients (range: 0.9-7.4 cm/s) and controls (range: 1.1-6.9 cm/s). Patients with PAD had significantly poorer working memory and global cognitive function. Older adults with PAD had similar NVC responses to age-matched controls. The lack of differences may be due to the low prevalence of cognitive impairment, disease severity, small sample size, or the relatively simple cognitive paradigms. Future studies examining NVC in patients with PAD during tasks with higher cognitive load, and in more advanced disease stages, are needed to further understand whether impaired NVC contributes to PAD-related cognitive impairment.

Peripheral arterial disease (PAD) is associated with impaired physical performance beyond walking limitation, including reduced muscle strength, impaired balance, and increased risk of falls. We performed a systematic review and exploratory meta-analysis following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) 2020 guidelines to evaluate the association between PAD severity and functional outcomes. Twelve studies involving 2083 patients with PAD were included. Study-level associations between clinical characteristics (ankle-brachial index [ABI], claudication, smoking, and statin use) and functional outcomes (balance performance, Timed Up-and-Go Test, Short Physical Performance Battery, 6-minute walk distance, and handgrip strength) were examined using Spearman's correlation and random-effects meta-regression. Claudication was associated with poorer balance, greater fear of falling, and slower Timed Up-and-Go performance, while smoking correlated with lower handgrip strength and increased fear of falling. Higher ABI values were associated with better walking performance, and meta-regression demonstrated significant associations between lower ABI and slower gait speed and poorer lower-extremity function. These findings suggest that greater PAD severity is associated with impaired balance, muscle weakness, and reduced functional mobility. Early functional assessment and targeted rehabilitation strategies, including balance and strength training, may help reduce frailty and fall risk in patients with PAD.

Takayasu's arteritis is a chronic large-vessel vasculitis that can lead to progressive arterial stenosis and occlusion, resulting in significant ischemic complications. We report the case of a 41-year-old woman with hypertension and a history of Takayasu's arteritis diagnosed at 12 years of age who presented with worsening left upper extremity claudication. Computed tomography angiography demonstrated complete occlusion of the left subclavian and axillary arteries. Given the severity of symptoms and extent of arterial disease, a carotid-to-mid humeral bypass using a polytetrafluoroethylene graft was performed. The procedure resulted in complete resolution of ischemic symptoms and restoration of functional capacity. Long-term follow-up demonstrated sustained graft patency and excellent limb preservation. This case highlights the challenges associated with the diagnosis and long-term management of Takayasu's arteritis. Although immunosuppressive therapy remains the mainstay of treatment during active disease, surgical revascularization can provide durable symptom relief and excellent outcomes in selected patients with advanced occlusive lesions.

ObjectiveThe primary goal of surgery for lumbar spinal stenosis is to achieve adequate neural decompression while preserving spinal stability. This study evaluated the clinical and radiological outcomes of the window technique, which partially preserves the posterior osteoligamentous structures, and assessed its association with postoperative instability and reoperation rates.MethodsThis single-centre retrospective study included 134 patients with lumbar spinal stenosis who underwent decompression exclusively using the window technique. Patients were categorized according to the number of decompressed levels (single-, two-, and three-level). Clinical outcomes included preoperative and postoperative Visual Analog Scale (VAS) leg pain scores and walking distance before the onset of neurogenic claudication. Radiological instability was evaluated using flexion-extension radiographs. Non-parametric statistical tests were used for data analysis.ResultsThe median age of the patients was 64 years, and 73 (54.5%) were female. Decompression was performed at one level in 85 patients, two levels in 32 patients, and three levels in 17 patients. Follow-up exceeded four years in 32.1% of the patients. The mean VAS leg pain score decreased significantly from 7.6 ± 0.9 preoperatively to 2.2 ± 0.9 postoperatively (p < 0.001), although postoperative scores differed significantly among the decompression-level groups (p < 0.001). The mean distance to the onset of neurogenic claudication was 80.2 ± 34.6 m preoperatively, whereas all patients were able to walk more than 500 m without neurogenic claudication at the six-month follow-up. Grade I postoperative iatrogenic spondylolisthesis developed in four patients, three of whom required revision surgery.ConclusionsThe window technique was associated with favorable clinical outcomes and low rates of postoperative instability and reoperation in selected patients with lumbar spinal stenosis without preoperative radiological instability. These findings suggest that the technique may provide adequate neural decompression while preserving postoperative spinal stability in selected patients.

Background/Objectives: Lumbar magnetic resonance imaging (MRI) is widely overused in low back pain. We assessed the appropriateness of lumbar MRI requests against three international guidelines and two independent large language model (LLM)-based artificial intelligence (AI) assessments, related appropriateness to diagnostic yield, and derived a simple decision rule to identify imaging likely to change management. Methods: In this single-centre retrospective study, 147 consecutive adults undergoing lumbar MRI for low back pain were analysed. Each request was classified using pre-imaging clinical variables according to operationalised ACR, NICE and ACP criteria and by two blinded LLM assessments (Claude, Anthropic; ChatGPT, OpenAI). The reference outcome was a management-changing MRI (subsequent surgery or interventional procedure); a four-item decision rule was derived by exhaustive search over clinical criteria optimising the Youden index. Results: Depending on the instrument, 57.8-72.1% of requests were inappropriate (ACR 66.0%; NICE 72.1%; ACP 66.0%; AI 57.8-64.6%). Agreement between instruments was substantial to near-perfect (κ 0.69-0.94; inter-AI κ 0.77). Red flags or neurological warning features were present in only 5.4%. MRI changed management in 33.3% overall-58.1-80.5% of appropriate versus 15.1-16.8% of inappropriate requests. A rule of four criteria-red flag or neurological warning feature, neurogenic claudication, purely radicular pain, or pre-imaging consideration of surgery/intervention-predicted management-changing MRI with 84% sensitivity and 81% specificity (Youden 0.64, versus 0.50-0.59 for the guidelines) and would have reduced imaging volume by 59.2%. Conclusions: Roughly two-thirds of lumbar MRI requests were guideline-inappropriate and rarely altered management. In this exploratory derivation cohort, a simple four-item rule showed promising predictive performance, but its apparent numerical advantage over existing guideline logic was not statistically confirmed and requires independent prospective validation; two blinded LLM assessments showed substantial agreement with guideline judgements, supporting further evaluation of LLM-based pre-order screening in independently validated settings.

Background: To evaluate the ability of atherectomy combined with scoring and drug coated balloon (DCB) angioplasty for the treatment of atherosclerotic common femoral artery (CFA) disease. Patients and methods: This dual-center retrospective study analyzed data from consecutive patients who underwent atherectomy-assisted endovascular revascularization followed by scoring and DCB angioplasty and if required stent placement in the CFA. The primary endpoints included target-lesion revascularization (TLR) and improvement in clinical symptoms as measured by Rutherford categories (RC). Lesion calcification was evaluated using the Peripheral Arterial Calcification Scoring System (PACSS). Results: Of 111 patients, 64 (57.7%) had lifestyle limiting claudication, whereas 47 (42.3%) had chronic limb-threatening ischemia (CLTI). Mean age was 71.9 ± 7.8 years, 45 (40.5%) were female and 32 (28.8%) had diabetes mellitus. CFA median lesion length was 3.2 (2.4-3.7cm) and median lesion calcification by PACSS was 3.0 (3.0-3.0), whereas 13 (11.7%) were chronic total occlusions. Atherectomy was performed in 46 (41.4%) patients using the Phoenix and in 65 (58.6%) patients using the Jetstream atherectomy device with low complication rates (zero perforations and 4 (3.6%) distal embolizations). Bail-out stenting was necessary in 6 (5.4%) patients. During median follow-up of 2.0 (1.5-2.2) years, TLR was necessary in 9 (8.1%) patients, whereas RC improvement of ≥2 categories was noticed in 79 (71.2%) patients. Severe calcification PACSS four was associated with higher TLR rates (p < .001). Conclusions: Atherectomy- and scoring balloon assisted lesion preparation combined with DCB resulted in a low rate of bail-out stenting, low TLR and clinically acceptable RC improvement rates in CFAD patients. Long-term prospective trials are warranted.

Background: Severe arterial calcification poses a major challenge to endovascular therapy (EVT) in peripheral artery disease (PAD). Orbital atherectomy (OAS) is used to modify plaque and enhance luminal gain, potentially improving EVT outcomes, but long-term evidence remains limited. Patients and methods: This retrospective single-center study assessed the mid-term outcomes of OAS in heavily calcified infrainguinal disease. We included symptomatic PAD patients (Rutherford 2-6) with ≥70% stenosis undergoing OAS for above- and below-the-knee (BTK) arterial lesions. Results: From 2018 to 2023, 78 patients underwent EVT for 83 infrainguinal lesions with OAS. Most were male (84.6%; 66/78) and had significant cardiovascular risk factors. Lesions were located in the femoropopliteal (FP) segment in 28.9% (24/83) and in BTK in 71.1% (59/83). Chronic limb threatening ischemia (CLTI) was significantly more frequent in BTK disease (13.0% [3/23] vs. 76.4% [42/55], p < .001). Mean lesion length was 101.8 ± 72.9 mm in FP and 133.0 ± 102.7 mm in BTK lesions, with chronic total occlusions in 25.0% (6/24) and 49.2% (29/59), respectively. One-year freedom from target lesion revascularization was 90.5% ± 6.5% for FP and 73.1% ± 7.7% for BTK lesions. One-year survival was 95.7% ± 4.3% in claudicants and 62.4% ± 7.8% CLTI patients (logrank p = .001). Major limb amputation occurred in .0% (0/22) of FP and 4.4% (2/45) of BTK cases at 30 days. Conclusions: OAS demonstrated feasibility in this highly selected cohort; however, its comparative efficacy remains uncertain.