Two-dimensional perfusion angiography permits direct visualization of redistribution of flow in hepatocellular carcinoma during b-TACE.

OBJECTIVES: To demonstrate in vivo redistribution of the blood flow towards HCC's lesions by utilizing two-dimensional perfusion angiography in b-TACE procedures. MATERIAL AND METHODS: In total, 30 patients with 35 HCC nodules treated in the period between January 2019 and November 2021. For each patient, a post-processing software leading to a two-dimensional perfusion angiography was applied on each angiography performed via balloon microcatheter, before and after inflation. On the colour map obtained, reflecting the evolution of contrast intensity change over time, five regions of interests (ROIs) were assessed: one on the tumour (ROI-t), two in the immediate peritumoural healthy liver parenchyma (ROI-ihl) and two in the peripheral healthy liver parenchyma (ROI-phl). The results have been interpreted with a novel in silico model that simulates the hemodynamics of the hepatic arterial system. RESULTS: Among the ROIs drawn inside the same segment of target lesion, the time-to-peak of the ROI-t and of the ROI-ihl have a significantly higher mean value when the balloon was inflated compared with the ROIs obtained with deflated balloon (10.33 ± 3.66 s vs 8.87 ± 2.60 s (p = 0.015) for ROI-t; 10.50 ± 3.65 s vs 9.23 ± 2.70 s (p = 0.047) for ROI-ihl). The in silico model prediction time-to-peak delays when balloon was inflated, match with those observed in vivo. The numerical flow analysis shows how time-to-peak delays are caused by the obstruction of the balloon-occluded artery and the opening of intra-hepatic collateral. CONCLUSION: The measurements identify predictively the flow redistribution in the hepatic arteries during b-TACE, supporting a proper positioning of the balloon microcatheter.

CIRSE Standards of Practice on Management of Endoleaks Following Endovascular Aneurysm Repair.

BACKGROUND: Endoleaks represent the most common complication after EVAR. Some types are associated with ongoing risk of aneurysm rupture and necessitate long-term surveillance and secondary interventions. PURPOSE: This document, as with all CIRSE Standards of Practice documents, will recommend a reasonable approach to best practices of managing endoleaks. This will include imaging diagnosis, surveillance, indications for intervention, endovascular treatments and their outcomes. Our purpose is to provide recommendations based on up-to-date evidence, updating the guidelines previously published on this topic in 2013. METHODS: The writing group was established by the CIRSE Standards of Practice Committee and consisted of clinicians with internationally recognised expertise in endoleak management. The writing group reviewed the existing literature performing a pragmatic evidence search using PubMed to select publications in English and relating to human subjects up to 2023. The final recommendations were formulated through consensus. RESULTS: Endoleaks may compromise durability of the aortic repair, and long-term imaging surveillance is necessary for early detection and correct classification to guide potential re-intervention. The majority of endoleaks that require treatment can be managed using endovascular techniques. This Standards of Practice document provides up-to-date recommendations for the safe management of endoleaks.

Strongly enhanced light-matter coupling of monolayer WS2 from a bound state in the continuum.

Exciton-polaritons derived from the strong light-matter interaction of an optical bound state in the continuum with an excitonic resonance can inherit an ultralong radiative lifetime and significant nonlinearities, but their realization in two-dimensional semiconductors remains challenging at room temperature. Here we show strong light-matter interaction enhancement and large exciton-polariton nonlinearities at room temperature by coupling monolayer tungsten disulfide excitons to a topologically protected bound state in the continuum moulded by a one-dimensional photonic crystal, and optimizing for the electric-field strength at the monolayer position through Bloch surface wave confinement. By a structured optimization approach, the coupling with the active material is maximized here in a fully open architecture, allowing to achieve a 100 meV photonic bandgap with the bound state in the continuum in a local energy minimum and a Rabi splitting of 70 meV, which results in very high cooperativity. Our architecture paves the way to a class of polariton devices based on topologically protected and highly interacting bound states in the continuum.

Rydberg polaritons in ReS2 crystals.

Rhenium disulfide belongs to group VII transition metal dichalcogenides (TMDs) with attractive properties such as exceptionally high refractive index and remarkable oscillator strength, large in-plane birefringence, and good chemical stability. Unlike most other TMDs, the peculiar optical properties of rhenium disulfide persist from bulk to the monolayer, making this material potentially suitable for applications in optical devices. In this work, we demonstrate with unprecedented clarity the strong coupling between cavity modes and excited states, which results in a strong polariton interaction, showing the interest of these materials as a solid-state counterpart of Rydberg atomic systems. Moreover, we definitively clarify the nature of important spectral features, shedding light on some controversial aspects or incomplete interpretations and demonstrating that their origin is due to the interesting combination of the very high refractive index and the large oscillator strength expressed by these TMDs.

Role of CT and MR imaging in the assessment of suspected spondylodiscitis and planning of needle biopsy.

PURPOSE: Our aim was to assess the role of computed tomography (CT) or magnetic resonance imaging (MRI) in the assessment of spondylodiscitis, identifying the best target structures for biopsy to increase the likelihood of positive cultures. MATERIALS AND METHODS: This study was approved by our Institutional Review Board, and requirement for specific consent form was waived. In this retrospective single Institution study, we evaluated clinical and imaging records of 60 patients who underwent spine biopsy for suspected spondylodiscitis from January 2016 to May 2021. CT and MRI sensitivity and inter-reader agreement were assessed according to the phase of spondylodiscitis, defined as acute, subacute or chronic. Inter-reader agreement for the diagnosis and identification of spondylodiscitis phase was assessed using K statistics. Univariate logistic regression analysis was performed to assess any relationship between MRI/CT findings, spondylodiscitis phase and positive cultures. RESULTS: Sixty patients (48 males) with mean age 59, 2 ± 29 were enrolled in this study. MRI showed higher sensitivity (96% vs 65% of CT) in the diagnosis and good inter-reader agreement (k = 0.8) in the identification of the acute and subacute phase of spondylodiscitis, and moderate inter-reader agreement (k = 0.7) and lower sensitivity (80% vs 95% of CT) for the chronic phase. Univariate analysis showed as MRI-specific findings such as extensive hyperintensity of vertebral body and/or disc on Short Tau Inversion Recovery-T2w images, paravertebral collections, preserved or augmented disc height and presence of a vertebral fractures were mainly found in the acute/subacute phase and was a predictor for positive cultures (p < 0.05). CONCLUSION: MRI and CT are both able to identify the different phases of spondylodiscitis, although MRI is more sensitive in the acute phase. Findings such as extensive hyperintensity of the disc/vertebral body, fractures and paravertebral collections, represent the main targets for biopsy related to a positive culture.

Cone-Beam CT-Guided Transarterial Tagging of Endophytic Renal Tumors with Indocyanine Green for Robot-Assisted Partial Nephrectomy.

PURPOSE: To evaluate the safety, efficacy, and clinical impact of preoperative cone-beam computed tomography (CT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and ethiodized oil in patients undergoing robot-assisted partial nephrectomy (RAPN) using near-infrared fluorescence imaging (NIR-FI). MATERIALS AND METHODS: Patients with renal endophytic tumors eligible for RAPN and transarterial embolization with ICG and ethiodized oil were prospectively enrolled. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as ethiodized oil accumulation in the nodule, was classified as poor, moderate, good, or optimal on the basis of postembolization cone-beam CT. Surgical visibility of the tumors during RAPN with the use of NIR-FI was classified as follows: (a) not visible, (b) visible with poorly defined margins, and (c) visible with well-defined margins. RESULTS: Forty-one patients underwent preoperative selective embolization. Technical success was 100%. Ethiodized oil accumulation on cone-beam CT was poor in 2 (4.9%), moderate in 6 (14.6%), good in 25 (61.0%), and optimal in 8 (19.5%) of 41 patients. During RAPN with NIR-FI, tumors were visible with well-defined margins in 26 (63.4%), visible with blurred margins in 14 (34.1%), and not visible in 1 (2.4%) of 41 cases. There were no adverse events following endovascular embolization. CONCLUSIONS: Preoperative transarterial superselective embolization of endophytic renal tumors with ICG and ethodized oil in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Percutaneous spine biopsy under cone beam computed tomography guidance for spondylodiscitis: Time is diagnosis.

BACKGROUND AND PURPOSE: Percutaneous spine biopsies for spondylodiscitis have been long discussed due to the low microbiologic yield. This retrospective study evaluated factors of cone beam computed tomography-guided spine biopsies that may affect microbiologic yield. METHODS: We retrospectively reviewed percutaneous spine biopsies under cone beam computed tomography for spondylodiscitis performed from January 2015-December 2020. Clinical and technical features such as the time from initial symptoms to biopsy, level biopsied, biopsy needle type/gauge, technical approach, radiation dose, technical success and microbiologic yield were recorded. Pre-procedure magnetic resonance imaging findings were also recorded such as the number of vertebral bodies involved, and disc morphology. Univariate logistic regression analysis and Receiver operating characteristic analysis were performed to assess any relationship between relevant factors and positive cultures. RESULTS: A total of 50 patients underwent cone beam computed tomography-guided biopsies for spondylodiscitis, with resulted positive cultures in 18 patients (36%). The mean time from the initial referral of spinal symptoms to procedure in the positive culture group was the most influential finding for positive cultures (odds ratio 56.3, p < 0.001). Among magnetic resonance imaging findings, thin or degenerated intervertebral disc was a negative factor for positive cultures (odds ratio 0.09, p = 0.006). Univariate analysis showed that percutaneous approach (transpedicular vs posterolateral/interlaminar) needle size (11-13 g vs 16-18G, odds ratio 1.2, p = 0.7) and site of biopsy (disc vs bone vs disc plus endplate) did not significantly affect the microbiologic yield of spine biopsy. CONCLUSION: Percutaneous cone beam computed tomography-guided biopsy for spondylodiscitis is a reliable and safe technique and its microbiologic yield may increase if biopsy is performed within the acute phase of infection.

Use of Phil Embolic Agent for Bleeding in Non-Neurological Interventions.

OBJECTIVE: To evaluate the safety and efficacy of the Phil liquid embolic agent in non-neurological embolization procedures. M&M: Thirty-five patients with a mean age of 62.5 years underwent percutaneous embolization using Phil for the treatment of visceral arterial bleedings in 20/35 patients (including three gluteal, one bladder, two superior mesenteric, three epigastric, one deep femoral, five internal iliac, four intercostal, and one lingual arteries), splanchnic pseudoaneurysms in 11/35 patients (including three hepatic, five splenic, and three renal arteries), pancreatic bleeding metastasis in 1/35 patient, and gastric bleeding varices in 3/35 patients. Phil is composed of a non-adhesive copolymer dissolved in DMSO (Anhydrous Dimethyl Sulfoxide) with different viscosity. Procedures were performed slowly under continuous fluoroscopic guidance to avoid embolization of non-target vessels. RESULTS: Clinical success was obtained with a single intervention in 34 cases (97.15%), while a repeated procedure was required in one case (2.85%). No technical complications nor non-target embolization occurred. A case of post-embolic syndrome was noted (2.85%) in one patient. DMSO administration-related pain was successfully controlled by medical therapy. CONCLUSION: Phil can be considered a safe and effective embolic agent for the treatment of non-neurologic bleeding.

Balloon occluded TACE (B-TACE) vs DEM-TACE for HCC: a single center retrospective case control study.

BACKGROUND: To compare oncological results and safety profile of balloon micro-catheter trans-arterial chemoembolization (b-TACE) and drug-eluting-microsphere (DEM-TACE) in patients with hepatocellular-carcinoma (HCC). METHODS: This is a case-control, retrospective, single-center study. Between January-2015/March-2019, 149 patients (131 males [87.9%]) with 226 HCC were treated, 22 patients (35 HCC; 19 [86.4%] males) with b-TACE and 127 with DEM-TACE (191 HCC, 112 [88.2%] males). Embolization protocol was standardized (sequential 100 ± 25 and 200 ± 25 µm microspheres). Results were evaluated by modified-response-evaluation-criteria-in-solid-tumor [mRECIST] at 1, 3-6 and 9-12 months and time to recurrence after complete response [TTR] at 1 years. Cox's regression weighted with tumor dimensions was performed. Adverse events (AEs) were recorded. RESULTS: mRECIST oncological response at all time points (1, 3-6 and 9-12 months) for both treatments were similar, with the exception of Objective response rate at 9-12 months. Objective response at 1 and 3-6 months between b-TACE vs DEM-TACE [23/35 (65.7%) vs 119/191 (62.3%), 21/29 (72.4%) vs 78/136 (57.4%) (p > 0.05), respectively]. On the contrary, at 9-12 months, it was significantly higher in b-TACE subgroup than DEM-TACE (15/19 [78.9%] vs 48/89 [53.9%], p = 0.05). TTR for complete response at 1 year had a better trend for b-TACE vs DEM-TACE (278.0 days [196.0-342.0] vs 219.0 days [161.0-238.0], OR 0.68 [0.4-1.0], p = 0.10). The use of balloon micro-catheter reduced the relative risk of the event of recurrence by 0.63 [CI95% 0.38-1.04]; p = 0.07). No significant differences were found in AEs rate. CONCLUSION: b-TACE showed a trend of better oncological response over DEM-TACE with and longer TTR with a similar adverse events rate, in patients presenting with larger tumors.

Direct percutaneous embolization of aneurysm sac: a safe and effective procedure to treat post-EVAR type II endoleaks.

PURPOSE: To report safety and effectiveness of type II endoleak embolization, with percutaneous direct aneurysm sac puncture. MATERIALS AND METHODS: Fifty patients, 31 male (mean age 55 ± 5), with post-EVAR type-II endoleak underwent direct percutaneous sac puncture for embolization. Procedures were performed, under local anesthesia. Sac puncture was done using a 20G needle under rotational angiography guidance. A coaxial system (4 Fr catheter + 2.7 microcatheter) was used to navigate the sac. During the follow-up period, all patients underwent contrast-enhanced ultrasound (CEUS) at 6 and 12 months. RESULTS: Technical success, with complete exclusion of the aneurysm sac, was achieved in all cases. Time of procedure varied between 36 and 68 min (mean 51.36 min). Mean fluoroscopy time was 16.7 min. A posterior left access was used in 41 cases, posterior right access in 6 cases, and an anterior approach in 3. In 19 cases (38%), one or more feeding vessels were visualized and embolized. Sac embolization was done using Onyx plus micro-coils in 31 cases (62%) and Onyx alone in 19 cases (38%). Mean amount of Onyx was 6 ml. No complications, correlated with the direct percutaneous sac puncture, or to Onyx injection occurred. After 1-year follow-up, sac shrinkage occurred in 34 cases (68%), while in 16 patients (32%) sac size remained stable without evidence of sac perfusion. CONCLUSION: Percutaneous direct sac embolization using Onyx in combination or not with microcoils represents a safe and valid technique to solve post-EVAR type II endoleaks.

Current assessment and management of endoleaks after advanced EVAR: new devices, new endoleaks?

INTRODUCTION: In recent years there has been an increasing application of advanced EVAR techniques to tackle complex clinical and anatomical scenarios. In a bid to overcome the limitations of the traditional stent-grafts, newer EVAR endografts and techniques have been developed and introduced into clinical practice, permitting endovascular management of difficult infrarenal, juxta-renal and thoracoabdominal aneurysms for which previously there was no endovascular solution. As a consequence, we are now confronted with unique patterns of endoleak requiring customized clinical-radiological assessment and treatment. Despite the increasing body of evidence regarding new EVAR techniques and related endoleaks, current guidelines do not specifically address these issues. OBJECTIVES: Our review aims to assess risk factors, development, and management strategies of these endoleaks, in the most recent infrarenal EVAR devices and in more complex fenestrated EVAR (FEVAR) and Chimney EVAR (Ch-EVAR). EXPERT OPINION: Most new devices have demonstrated types of endoleaks that need specific imaging and treatment, as in EVAS, FEVAR, and ChEVAR. Knowledge of specific stent-graft characteristics and the nature of endoleaks associated with the various procedures facilitates the application of relevant useful imaging. In addition, it should aid development of a customized and practically relevant approach to patient management during intervention and follow-up.

Computed Tomography Angiography findings can predict massive bleeding in head and neck tumours.

PURPOSE: The aim of our study was to assess CT angiography findings of head and neck tumours in predicting carotid blow out syndrome (CBS). METHOD: We retrospectively reviewed the records of patients with head and neck cancer who underwent invasive angiography for CBS at our Institution from July 2013-2019. All routine CT angiography scans were assessed for the following findings with a univariate logistic regression analysis: 1) 360 ° involvement of the suspect artery by the tumour; 2) tissue or tumour necrosis, which was defined as an hypodense area with lack of contrast enhancement in the soft tissues of the neck or tumour mass, adjacent to the suspected vessel; 3) calibre reduction of the culprit artery; 5) jugular vein infiltration. T stage was also included in the analysis. RESULTS: A total of 24 patients who underwent routine CT angiogram neck and embolization for CBS were included in this study. Univariate logistic regression showed as 360 ° involvement of target vessel may significantly increase the risk of bleeding (OR 11.6, CI: 1.4-91.5; p = 0.01), along with T stage (OR 14.0, p = 0.03). Tumour necrosis and calibre vessel reduction were quite influential, but not significantly (i.e. tumour necrosis OR 5.0 95 % CI: 0.8-31.0, p = 0.08). Contingency table analysis found 360 ° vessel involvement with the highest sensitivity and PPV in predicting bleeding (87.5 % and 82.35 %, respectively). CONCLUSIONS: CT angiography imaging findings have the potential to identify patients with head and neck cancer at higher risk of bleeding.

Intra-procedural dual phase cone beam computed tomography has a better diagnostic accuracy over pre-procedural MRI and MDCT in detection and characterization of HCC in cirrhotic patients undergoing TACE procedure.

PURPOSE: This study was directed to compare diagnostic accuracy of dual-phase cone beam computed tomography (DP-CBCT) vs pre-procedural second line imaging modality (SLIM [multidetector computed tomography and magnetic resonance imaging]) to detect and characterize hepatocellular carcinoma (HCC) in cirrhotic patients with indication for trans-arterial chemoembolization (TACE). METHODS: This is a single centre, retrospective, and observational study. Exclusion criteria were not-assisted DP-CBCT TACE, and unavailable follow-up SLIM. We evaluated 280 consecutive patients (January/2015-Febraury/2019). Seventy-two patients were eligible. Three radiologists in consensus reviewed: pre-procedural SLIM, DP-CBCT, and SLIM at follow-up, with 4 months of interval between each reading. Hyper-vascular foci (HVF) were detected and characterized. Diameter was recorded. Radiological behaviour, according to LI-RADS criteria, of HFV throughout follow-up time was the reference standard. Diagnostic accuracy was calculated for pre-procedural SLIM and DP-CBCT and evaluated through receiver operating characteristic curve. HVF only visible on DP-CBCT (defined as occult) were analysed. Tumour diameters were compared. RESULTS: Median time between pre-procedural SLIM and DP-CBCT and between DP-CBCT and definitive radiological diagnosis of HVF were 46.0 days (95%CI 36.5-55.0) and 30.5 days (95%CI 29.0-33.0), respectively. DP-CBCT had a better diagnostic performance than pre-examination SLIM (sensitivity 99%vs78%; specificity 89%vs85%; PPV 99%vs99%; NPV 92%vs30%; and accuracy 94%vs79%). DP-CBCT diagnosed 63 occult HVF. Occult HCC were 54/243 (22.2%). Six were occult angiomas. Three were false positive. Mean diameter was significantly higher in DP-CBCT vs pre-procedural SLIM (+7.5% [95%CI 3.7-11.3], p < 0.05). CONCLUSIONS: DP-CBCT has a better diagnostic accuracy and NPV than pre-procedural SLIM in cirrhotic patients with indication for TACE.

Provisional Stenting Using the Zilver PTX Drug-Eluting Stent After Drug-Coated Balloon Angioplasty: Initial Experience From the Double Drug Dose "3D" Study.

Purpose: To explore the provisional use of a drug-eluting stent (DES) after suboptimal drug-coated balloon (DCB) angioplasty in complex, calcified femoropopliteal lesions. Materials and Methods: A prospective, single-center, investigator-initiated pilot study enrolled 15 patients (mean age 71.3 years; 9 men) with symptomatic stenosis (n=6) or occlusion (n=9) of the native superficial femoral and/or proximal popliteal arteries who experienced suboptimal DCB dilation despite postdilation. Lesion characteristics were evaluated with computed tomography angiography and duplex ultrasound confirmed by intravascular ultrasound. Follow-up included clinical and imaging evaluations as well as blood tests to monitor inflammatory markers. Endpoints included systemic inflammation, acute/chronic thrombosis, aneurysm formation, and mortality. Results: Provisional stenting was required for residual stenosis >50% in 4 cases and flow-limiting dissection in 11. Provisional spot stenting was done using the Zilver PTX DES. Clinical improvement was observed in all cases. After 24-month follow-up all patients were alive and in good clinical condition. One- and 2-year primary patency rates were 93.3% and 92.9%, respectively; secondary patency was 100%. Restenosis required reintervention in 2 cases. No local or systemic complications or toxicity were observed due to the use of a double dose of paclitaxel. No significant increase in any inflammation marker was observed in the perioperative period, and no aneurysm formation was seen over 24 months of follow-up. Conclusion: Combined DCB plus DES therapy seems to be safe and correlated with high primary patency following suboptimal angioplasty. Larger studies are required to confirm the safety and efficacy of this approach.

Balloon-Occluded Transcatheter Arterial Chemoembolization (b-TACE) for Hepatocellular Carcinoma Performed with Polyethylene-Glycol Epirubicin-Loaded Drug-Eluting Embolics: Safety and Preliminary Results.

PURPOSE: To report technical success, safety profile and oncological results of balloon-occluded transcatheter arterial chemoembolization using a balloon micro-catheter and epirubicin-loaded polyethylene-glycol (PEG) microsphere (100 ± 25 µm and 200 ± 50 µm) in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: This is a single-centre, single-arm, retrospective study with 6-month follow-up. Twenty-two patients (Child-Pugh A 68% [15/22], B in 32% [7/22]; age 67.05 ± 14 years) with 29 HCC were treated in 24 procedures. Technical success is defined: ability to place the balloon micro-catheter within the required vascular segment, balloon-occluded arterial stump pressure drops and assessment of microsphere deposition. Laboratory assessment pre/post-procedural and complications were analysed, respectively, according to Common Terminology Criteria for Adverse Events (CTCAEv5) and CIRSE system. Postembolization syndrome (PES) was defined as fever and/or nausea and/or pain onset. Oncological results were evaluated using m-RECIST criteria with CT/MRI imaging at 1 and 3-6 months. In partial responder patients, pre/post-procedural tumour volume was compared. RESULTS: Pre-planned feeder was reached in all cases. Pressure drop average was 51.1 ± 21.6 mmHg. Exclusive target embolization was achieved in 14/24 procedures (58.3%). Laboratory test modifications were all grade 1. 4/24 adverse events occurred (17%): pseudo-aneurysm of the feeder (grade 3), liver abscess (grade 2) and 2 asymptomatic segmentary biliary tree dilatations (grade 2). PES occurred in 8/24 (33%). The complete response at 1 and 3-6 months was 44.8% (13/29) and 52.9% (9/17), respectively. The partial response at 1 and 3-6 months was 55% (16/29) and 4/17 (23.5%), respectively. Among partial responder patients, the average percentage of tumour volume reduction was 64.9 ± 27.3%. CONCLUSION: Epirubicin-loaded PEG microsphere b-TACE is technically feasible, safe and effective procedure for HCC treatment.

Updated Clinical and Radiological Classification of Lower Limb Atherosclerotic Disease.

Lower limb atherosclerotic disease has classically been classified as acute or chronic; however, this is an evolving process that has a wide spectrum of clinical and imaging aspects. Owing to the evolvement of endovascular and imaging techniques, we have now garnered new information regarding the pathophysiology and behavior of atherosclerotic disease, also in response to endovascular and surgical techniques. Clinical presentation can actually be classified according to the time of presentation, ranging from acute (<2 weeks) and subacute (from 2 weeks to 3 months) to chronic (over 3 months) and acute/subacute on underlying chronic disease. Imaging characteristics such as the presence of thrombus, number of collaterals, and target vessel wall features may help in defining the correct type of atherosclerotic lesion, triggering the appropriate treatment strategy. Clinical and imaging characteristics of those different stages are complex and not systematically addressed by current guidelines, that do not show any specific recommendations for imaging pathways/characteristics or treatment. This review illustrates the clinical and imaging characteristics of the different stages of lower limb atherosclerotic disease and related treatment options.

Current Status of Distal Embolization in Femoropopliteal Endovascular Interventions.

The application of advanced endovascular techniques in very complex femoropopliteal atherosclerotic lesions has shown to expose patients to a higher risk of distal embolization (DE). This complication can affect both the short- and long-term outcomes, leading to worsening ischemia, early minor/major amputation, and longer hospital stay. Recently, there has been an increasing body of evidence on pathophysiology and clinical-radiological management of DE that however has not been systematically addressed by guidelines. The aim of this review was to analyze the current evidence outlining definition and classification, risk assessment, prevention, and management strategies of DE in femoropopliteal endovascular interventions.