Vertebral artery dissection (VAD) can cause posterior-circulation ischemia after cervical manipulation; postpartum physiological changes may increase vascular vulnerability. A 30-year-old woman, nine months postpartum, developed an abrupt occipital headache, vertigo, nausea, and gait imbalance during a commercial neck massage. On examination, she had truncal ataxia and gait instability without focal limb weakness. We obtained 1.5-T MRI (diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC), T1-weighted imaging (T1), T2-weighted imaging (T2), fluid-attenuated inversion recovery (FLAIR), T2*/susceptibility-weighted imaging (SWI), and postcontrast 3D T1), time-of-flight magnetic resonance angiography (TOF-MRA), and computed tomography angiography (CTA). Imaging showed a right VAD with an intramural hematoma and luminal irregularity, right posterior inferior cerebellar artery (PICA) occlusion, and right-predominant cerebellar infarcts. A posterior fossa developmental venous anomaly (DVA) drained adjacent to the outlets of the fourth ventricle. Cerebellar swelling produced triventricular hydrocephalus with transependymal flow and early tonsillar descent. After multidisciplinary discussion, we initiated antithrombotic therapy, provided supportive care and a short course of corticosteroids for vasogenic edema, and preserved the DVA drainage. Neurosurgery placed an external ventricular drain for obstructive hydrocephalus; serial imaging documented regression of the edema and normalization of the ventricles. The patient improved but retained mild truncal ataxia at follow-up. Prompt vascular imaging should be obtained for acute posterior head or neck pain with neurologic signs after cervical manipulation. CSF diversion and edema control should be prioritized when posterior fossa mass effect arises, and DVA drainage should be preserved to avoid venous infarction.

Acute mesenteric ischemia remains one of the most lethal abdominal emergencies, particularly when bowel necrosis has already occurred at the time of diagnosis. Embolic occlusion of the superior mesenteric artery is most commonly associated with atrial fibrillation. Although hyperthyroidism is a recognized trigger for atrial fibrillation, widespread systemic arterial embolization in this setting is rarely reported. We describe a 77-year-old woman with biochemical thyrotoxicosis and new-onset atrial fibrillation who developed simultaneous superior mesenteric and peripheral arterial occlusions, resulting in near-total small bowel necrosis that was not surgically survivable. Her rapid clinical deterioration underscores the aggressive nature of embolic mesenteric ischemia and the narrow window available for intervention.

Malignancy-associated hypercoagulability may cause arterial thrombotic events and acute limb ischemia. When combined with diabetic vasculopathy, rapid progression to gangrene and severe infection may occur. We report a patient with type 2 diabetes who developed acute limb ischemia and progressive diabetic foot gangrene. Despite prior endovascular therapy, severe infection with necrotizing soft tissue infection and osteomyelitis developed. A staged limb-salvage approach involving aggressive debridement, removal of infected bone, pedicled flap reconstruction, antimicrobial therapy, anticoagulation, metabolic optimization, and offloading resulted in successful wound closure and functional recovery. Subsequent investigation revealed pancreatic acinar cell carcinoma, and the patient later received systemic therapy and radiofrequency ablation for liver metastasis. This case highlights the complex interaction between advanced peripheral arterial disease, severe diabetic foot infection, and pancreatic acinar cell carcinoma (ACC)-associated hypercoagulability. Successful limb salvage was achieved through an integrated multidisciplinary strategy combining vascular intervention, aggressive surgical source control, staged reconstruction, antimicrobial therapy, anticoagulation, metabolic optimization, and oncologic management. Although causality between ACC-associated hypercoagulability and acute limb ischemia cannot be definitively established, this case demonstrates that durable wound healing and functional limb preservation can still be achieved in highly complex patients when treatment is coordinated within a staged, multidisciplinary framework.

Peripheral arterial thromboembolic disease is a key cause of limb-threatening ischemia. Clot composition analysis may offer insights into thrombus etiology and aid in treatment decisions. This review aims to synthesize the current available literature on the histopathological evaluation of thrombi retrieved from peripheral arterial interventions for acute limb-threatening events. The objective of this study is to systematically review the current evidence on histopathological and qualitative analysis of thrombi retrieved during peripheral arterial interventions for acute limb-threatening ischemic events and to evaluate whether clot composition has demonstrated diagnostic or therapeutic impact. A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered with PROSPERO (CRD420251016001). The major databases PubMed, Embase, and Cochrane CENTRAL were searched. Studies involving histological and/or qualitative analysis of clots ("thrombi") retrieved from patients with peripheral arterial thromboembolic events were included. A total of 1,943 records were identified. Ultimately, five studies met the inclusion criteria and were analyzed qualitatively. Studies demonstrated limited but varied histopathological approaches including mass spectrometry, scanning electron microscopy, and biochemical assays. No consistent diagnostic or treatment impact was identified. Data were limited and prevented quantitative analysis. There is a significant lack of data on histopathological analysis of thrombi retrieved during peripheral arterial thromboembolectomy. Despite promising developments in cardiac and neurovascular fields, current evidence does not support routine clot composition analysis in peripheral vascular surgery. Further research is needed to define its translational role and value to the domain of vascular surgery.

Peripheral artery disease (PAD) is a major global health challenge, affecting more than 200 million people worldwide and an estimated 8 to 12 million in the United States. Its clinical spectrum ranges from intermittent claudication to chronic limb-threatening ischemia and acute limb ischemia. Accurate vascular imaging is essential for diagnosis, risk stratification, treatment planning, and postprocedural surveillance, guiding management from conservative therapy to endovascular or surgical revascularization. In this review, we aim to summarize the contemporary imaging pathways in PAD, focusing on noninvasive methods-duplex ultrasound (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA)-and invasive strategies such as digital subtraction angiography (DSA) with adjunct intravascular imaging. DUS, with high sensitivity for detecting ≥50% stenosis, is a cost-effective, radiation-free first-line modality, though operator dependence and acoustic shadowing may limit accuracy in heavily calcified vessels. CTA offers rapid, high-resolution anatomical assessment but requires ionizing radiation and iodinated contrast. MRA provides excellent soft-tissue contrast without radiation, with noncontrast techniques such as quiescent-interval single-shot (QISS) mitigating gadolinium-related concerns in renal dysfunction. As of now, DSA remains the gold standard, with intravascular modalities including intravascular ultrasound and optical coherence tomography improving lesion characterization and optimizing endovascular therapy. Angioscopy and near-infrared spectroscopy contribute additional structural or lipid-content insights. Emerging technologies-photon-counting computed tomography (CT), photoacoustic imaging, and artificial intelligence-augmented analysis-promise enhanced resolution, reduced artifact burden, and improved physiological and molecular assessment. Current American College of Cardiology/American Heart Association and ESC guidelines endorse DUS as the initial diagnostic test, with CTA or MRA selected according to renal function, calcification severity, and revascularization planning needs. Tailoring imaging strategies to patient-specific characteristics enables more precise intervention, reduces amputation risk, and advances personalized PAD care.

Acute limb ischemia is a severe complication of acute type A aortic dissection (ATAAD). The optimal management strategy remains debated and is dependent on the clinical context. Herein, we report the case of a 58-year-old man with ATAAD complicated by right lower limb malperfusion. During the aortic root replacement, regional oxygen saturation (rSO2) of the lower extremities was monitored using near-infrared spectroscopy, which demonstrated an early decline in right limb rSO2. To achieve prompt reperfusion, a femoro-femoral external shunt from the left to the right common femoral artery was established, serving as a bridge for definitive femoro-femoral bypass. The postoperative course was uneventful, without any evidence of reperfusion syndrome or neurological deficits. Thus, in certain cases, an external shunt may provide an effective bridging strategy for limb ischemia, and a decrease in rSO2 may serve as an early indicator for immediate reperfusion.

Severe rheumatic mitral stenosis with atrial fibrillation creates a highly thrombogenic left atrial substrate, particularly when anticoagulation is inadequate. Coronary embolism may present as ST-elevation myocardial infarction (STEMI) and can mask simultaneous systemic arterial embolization.