Alsabbagh, Yaman

Purpose: Supervised walking exercise is a critical component of rehabilitation for patients with peripheral artery disease (PAD); however, various barriers could limit participation in such programs, highlighting the need for accessible exercise strategies that may facilitate a gradual transition to more intensive physical activity while improving vascular function and walking performance in this population. We examined the hypothesis that static muscular stretching would improve microvascular function and walking ability in patients with PAD. Methods: Thirty-six PAD patients, classified as Fontaine Stage II or III, were randomized into stretching or non-stretching groups. The stretching group performed daily calf stretching using an ankle dorsiflexion splint for 30 minutes, 5 days a week, for 4 weeks. The six-minute walk test (6MWT) and a vascular occlusion test were used to assess changes in walking ability and calf microvascular function before and after the intervention. Results: Microvascular hyperemic reperfusion significantly increased in the treatment group (4958±1111 to 5749±1459 %*s, p=0.034), with no change observed in the control group (5502±1231 to 5022±1160 %*s, p=0.155). 6MWT total walking distance increased in all participants (260±88 to 285±85 m, p=0.004). A moderate but non-significant correlation was observed between the changes in 6MWT and total walking distance and reperfusion index in the treatment group (r=0.45, p=0.26). Conclusions: Static muscular stretching improves microvascular perfusion in the calf muscles, which may contribute to improvement in walking ability in patients with PAD. This low-cost and time-saving intervention may serve as a gradual transition to traditional supervised walking exercise rehabilitation, especially in patients with severely impaired walking ability.

Background: Patients with abdominal aortic aneurysms (AAA) often have comorbidities that make them poor candidates for open surgical repair (OSR). Endovascular aortic aneurysm repair (EVAR) circumvents the morbidity associated with OSR of AAA. Candidacy for EVAR is impacted by multiple factors, including the quality and size of vascular access vessels and involvement of visceral arteries, as seen in paravisceral abdominal aortic aneurysms (PVAAA). Additional challenges, such as obesity, can complicate vascular access during EVAR. PVAAA may be better suited for fenestrated EVAR (FEVAR) using a physician-modified endograft (PMEG). Materials and Methods: In this report, we describe the case of a 64-year-old female patient with a complex PVAAA in the setting of significant aortoiliac occlusive disease (AIOD) with intermittent claudication. We describe a successful staged FEVAR technique in which vascular access challenges were first addressed by recanalization of the iliac system with femoral conduit (FC) creation, followed by successful FEVAR using bilateral FC for deployment of the PMEG. Conclusion: Patients with PAAA have unique and complex pathology that are clinically challenging to address. It is not uncommon that these patients also have co-morbid conditions that make them less-than ideal candidates for open repair. Patients may also have other conditions such as AIOD which make EVAR complex. Staged approach with iliac recanalization and femoral conduit creation followed by FEVAR with PMEG is an effective treatment option for high-risk complex patients and can help avoid common complications such as groin infection and delay in FEVAR which may result in a catastrophic event such as interval AAA rupture.

Vascular surgery has evolved from durable yet invasive open reconstructions to less traumatic endovascular techniques. While endovascular repair reduces perioperative morbidity, it introduces durability challenges and the need for lifelong surveillance. Laparoscopic surgery bridged some gaps but was hindered by steep learning curves and technical limitations. Robotic-assisted surgery represents a “third revolution”, combining the durability of open repair with the recovery and ergonomic benefits of minimally invasive approaches through enhanced 3D visualization, wristed instrumentation, and tremor filtration. This review synthesizes current evidence on robotic applications in vascular surgery, including aortic, visceral, venous, and endovascular interventions. Feasibility of robotic vascular surgery has been demonstrated in over 1500 patients across aortic, visceral, venous, and decompression procedures. Reported outcomes include pooled conversion rates of ~5%, 30-day mortality of 1–3%, and long-term patency rates exceeding 90% in aortoiliac occlusive disease. Similarly favorable outcomes have been observed in AAA repair, visceral artery aneurysm repair, IVC reconstructions, renal vein transpositions, and minimally invasive decompression procedures such as median arcuate ligament and thoracic outlet syndromes. Endovascular robotics enhances catheter navigation precision and reduces operator radiation exposure by 85–95%, with multiple series demonstrating consistent benefit compared to manual techniques. Despite these advantages, adoption is limited by high costs, lack of dedicated vascular instruments, absent haptic feedback on most platforms, and the need for standardized training. Most available evidence is observational and from high-volume centers, highlighting the need for multicenter randomized trials. Future directions include AI-enabled planning and augmented-reality navigation, which are the most feasible near-term technologies since they rely largely on software integration with existing systems. Other advances such as microsurgical robotics, soft-robotic platforms, and telesurgery remain longer-term developments requiring new hardware and regulatory pathways. Overcoming barriers through collaborative innovation, structured training, and robust evidence generation is essential for robotics to become a new standard in vascular care.

Objective: To evaluate the efficacy of regional anesthesia (RA) in enabling arteriovenous fistula (AVF) creation in patients with small-caliber veins who would typically receive arteriovenous grafts (AVG), and to compare access outcomes between AVF and AVG cohorts. Methods: We conducted a retrospective analysis of a prospectively maintained database from 2018 through 2024 involving patients with chronic kidney disease (CKD) requiring access creation. Eligible patients were those aged 18 years or older with inadequate veins for AVF creation based on initial ultrasound vein mapping. All patients underwent RA prior to the access creation and had a repeated intraoperative vein mapping at least 30 min after RA. Patients whose veins were sufficiently dilated and met the criteria for AVF creation underwent AVF formation; otherwise, an AVG was created. Outcomes included access maturation, patency rates, access failure, abandonment, and mortality. Statistical analysis was performed using R software, with significance set at p < 0.05. Results: Of the 106 patients, 67 (63.2%) underwent AVF creation post-RA due to sufficient vein dilation, while 39 (36.8%) received AVGs. Baseline vein diameters and comorbidities were comparable between groups. AVF maturation was achieved in 83.6% of AVF patients, with longer times to successful cannulation compared to AVG (median 187.0 vs 80.0 days, p = 0.037). Kaplan-Meier analysis revealed no difference in primary patency ( p = 0.97), but AVF patients had superior primary assisted ( p = 0.015) and secondary patency ( p = 0.033), and lower access failure rates ( p = 0.034) compared to AVG patients. Access abandonment and mortality rates did not differ significantly between groups. Conclusions: RA-induced venodilation enables the use of veins previously deemed inadequate for AVF creation, leading to improved access outcomes compared to AVG placement. Implementing RA may increase AVF utilization and enhance patient outcomes in hemodialysis access surgery.

Background: Patients with no-option chronic limb-threatening ischemia (NoCLTI), lacking suitable distal arteries for conventional revascularization, face major limb amputation. The 1-year mortality rate after major amputation is 48.3%, increasing to 70.9% in 3 years. Open deep venous arterialization (DVA) offers a promising alternative for limb salvage, achievable through open, endovascular, or hybrid approaches. We aim to provide a comprehensive, step-by-step guide to performing open DVA in NoCLTI patients, addressing preoperative and postoperative considerations as well as the technical details of the procedure. Methods: Patient selection for open DVA focuses on individuals with NoCLTI at high risk for amputation. Preoperative assessments include evaluating risk factors, determining limb threat severity using the Wound, Ischemia, and foot Infection (WIfI) score, and mapping anatomical patterns via the Global Limb Anatomic Staging System (GLASS). The procedure involves identifying the target artery using Doppler ultrasound, performing microdissection to expose the artery and vein, ligating proximal vein branches, and creating a side-to-side anastomosis. Venous valves are disrupted with a valvulotome to allow antegrade flow. A proximal bypass graft may be applied if necessary. Results: Postoperatively, patients are monitored for 2–4 days with frequent Doppler assessments. Anticoagulation therapy begins with a heparin drip, transitioning to oral agents and/or dual antiplatelet therapy. Wound care includes deferred debridement for 2–4 weeks and may involve negative-pressure therapy. Follow-up involves weekly visits for the first month, and then at 3 months, and every 6 months thereafter, with surveillance using transcutaneous oxygen measurement, the toe–brachial index, and arterial duplex ultrasound. Conclusions: Open DVA represents a viable limb salvage option for patients with NoCLTI, potentially avoiding major amputations and improving quality of life. Success depends on careful patient selection, a meticulous surgical technique, and comprehensive postoperative care.

We present an 81-year-old male with an extensive past medical history and an enlarging abdominal aortic aneurysm (AAA). Axial imaging showed dense aortoiliac calcification with a complete occlusion of the right common iliac and high-grade stenosis of the left common iliac artery (CIA). Shockwave Intravascular Lithotripsy and the pave-and-crack technique utilizing an endoconduit were used to dilate the left external iliac artery and the CIA to facilitate placement of an aortic stent graft and exclude the patient’s AAA. This method gives surgeons the ability to treat patients with AAAs endovascularly, despite a heavily diseased and/or diminutive iliac anatomy. We also present a contemporary literature review of the utilization of the pave-and-crack technique as well as tips and tricks of how we do it.

Abdominal aortic aneurysm (AAA) is a significant vascular condition characterized by the dilation of the abdominal aorta, presenting a substantial risk of rupture and associated high mortality rates. Current management strategies primarily rely on aneurysm diameter and growth rates to predict rupture risk and determine the timing of surgical intervention. However, this approach has limitations, as ruptures can occur in smaller AAAs below surgical thresholds, and many large AAAs remain stable without intervention. This review highlights the need for more precise and individualized assessment tools that integrate biomechanical parameters such as wall stress, wall strength, and hemodynamic factors. Advancements in imaging modalities like ultrasound elastography, computed tomography (CT) angiography, and magnetic resonance imaging (MRI), combined with artificial intelligence, offer enhanced capabilities to assess biomechanical indices and predict rupture risk more accurately. Incorporating these technologies can lead to personalized medicine approaches, improving decision-making regarding the timing of interventions. Additionally, emerging treatments focusing on targeted delivery of therapeutics to weakened areas of the aortic wall, such as nanoparticle-based drug delivery, stem cell therapy, and gene editing techniques like CRISPR-Cas9, show promise in strengthening the aortic wall and halting aneurysm progression. By validating advanced screening modalities and developing targeted treatments, the future management of AAA aims to reduce unnecessary surgeries, prevent ruptures, and significantly improve patient outcomes.

Introduction: Peripheral arterial disease (PAD) is caused by a lack of blood flow to the musculature relative to its metabolism which results in pain. PAD impacts up to 20% of patients around the world. PAD involves macrovascular and microvascular dysfunction. Near-infrared spectroscopy (NIRS) measures muscle oxygenation levels and assesses microvascular function. The standard of care for diagnosing PAD is the ankle-brachial index (ABI), which assesses macrovascular disease, and the 6-minute walk test (6MWT), which measures gait speed and claudication. NIRS has the potential to monitor progression of PAD. Hypothesis: NIRS measurement of muscle oxygenation, during a standard test of vascular occlusion and post-occlusive hyperemia, the vascular occlusion test (VOT), is predictive of PAD severity as determined by ABI and 6MWT. Methods: We studied 24 patients diagnosed with PAD. The mean age of the patients was 71.3 years, including 54% (n=13) males and 46% (n=11) females. The VOT consisted of rest, occlusion, and reperfusion phases each lasting 5 min (15 min total). Muscle oxygen saturation levels were recorded at 2 hertz. For every patient, 6 features were extracted from the VOT data using computational methods. The VOT features from 15 patients were used to train function-fitting neural network models to predict ABI and 6MWT Continuous Distance. The models were then used to predict ABI and 6MWT Continuous Distance from the VOT features of 9 test patients not used in the training, Results: For patients in the test set, the ABI and 6MWT Continuous Distance predicted by the models differed from the actual measurements by 14%±13% and 15%±17%, respectively (Figure 1). For patients in the training set, the ABI and 6MWT Continuous Distance predicted by the models differed from the actual measurements by 0±0% and 12%±11%, respectively (Figure 1). Conclusion: The VOT has the potential to predict the ABI and 6MWT Continuous Distance of patients diagnosed with PAD, suggesting that the VOT can be automated and used to monitor the severity of PAD. With more data from both healthy patients and PAD patients, and improvement of the model, we anticipate that the VOT will complement ABI and 6MWT in the diagnosis and monitoring of PAD.

Introduction: Peripheral artery disease (PAD), an atherosclerotic disease of the peripheral arteries, also results in microvascular dysfunction. PAD patients are recommended to undergo supervised walking and medical management; however, compliance with supervised walking programs is limited due to inconvenience and pain, necessitating alternative non-pharmacological interventions. We have shown that daily muscle stretching improved microvascular function in aged rats. This prompted us to study the effect of daily muscle stretching on microvascular function of the calf muscles in PAD patients. Methods: A randomized, single-blinded study was conducted on 24 PAD patients. Patients were assigned to either stretching or placebo stretching using a dorsiflexion splint (Image 1) for 30 min/day, 5 days/wk for 4 wks. Calf muscle oxygen saturation (smO 2 ) was recorded using near-infrared spectroscopy during the six-minute walking test (6MWT) before (Visit 1) and after (Visit 2) stretching or placebo stretching. The percentage decrease in smO 2 (from baseline) at minute 1 (Δ1) and minute 2 (Δ2) of the 6MWT was determined. Two-way ANOVA was used to compare Δ1 and Δ2 between the stretching and placebo stretching groups. Results: The mean age of the patients was 74.1±11.4 yrs with 52% (13/23) males. There was no significant difference in the changes in smO 2 during the 6MWT at either minute 1 (Δ1: 44.1±7.3% vs 27.1±7.0%, p=0.12) or minute 2 (Δ2: 78.7±8.2% vs 58.1±7.9%, p=0.08) between the stretching group and placebo stretching group at Visit 1. In contrast, at Visit 2, there was a significantly greater change in smO 2 at minute 2 (D2: 83.1±8.2% vs 51.3±7.9%, p=0.008) in the stretching group compared to the placebo stretching group with a trend towards a statistically greater change in smO 2 at minute 1 (Δ1: 39.0±7.3% vs 20.4±7.0%, p=0.06) (Image 2). Conclusion: Daily stretching of the calf muscles for 4 weeks is associated with increased oxygen extraction by the calf muscles during walking.