The physician-modified endograft technique is becoming widely accepted as an alternative to standard fenestrated endovascular aortic repair. We report a streamlined workflow based on a bifurcation endograft, using the punch card and the Hungaroring reinforcement, two novel additions to the armamentarium that might contribute to the safety and durability of such repairs. A cohort of 11 patients was treated with 43 vessels incorporated. The clinical success rate was 100%. No major adverse event or death was recorded at 30 days. The punch card and the novel reinforcement technique might improve the safety and durability of such repairs.

Background and Objectives: Pulmonary sequestration (PS) is a rare congenital lung malformation. In adults, intralobar disease with recurrent infection or hemoptysis predominates. Cross-sectional imaging (CTA/MRA) is central to mapping the aberrant systemic supply; catheter angiography is used when noninvasive imaging is inconclusive or when an endovascular procedure is planned. We aimed to synthesize adult PS cases treated with endovascular or hybrid approaches and to summarize case selection, techniques, and outcomes. Methods: We conducted a PRISMA-2020-informed systematic review. We searched PubMed and Scopus from 1 January 2000 to 31 May 2025. Two reviewers extracted data independently; due to heterogeneity, we performed a narrative synthesis and a JBI-adapted qualitative risk-of-bias appraisal. Eligible studies enrolled adults (≥18 years) with imaging-confirmed PS treated with embolization, stent-graft exclusion, or hybrid therapy; prespecified outcomes included technical and clinical success, complications, recurrence, and re-intervention. The review was not registered. Results: Of 93 records screened, 41 publications reporting 48 adults were included. Twenty-five patients were managed endovascularly and 23 with hybrid therapy. Intralobar sequestration predominated (36/48); feeding arteries most often arose from the descending thoracic aorta (28/48). Complications were reported in 10 cases, mostly minor; three embolization cases required re-intervention. Conclusions: Endovascular therapy is useful for selected anatomies and urgent bleeding control, while hybrid strategies may benefit large, complex, or aneurysmal feeding arteries. The evidence base is limited to small case reports/series with heterogeneous outcome definitions and follow-up, precluding quantitative synthesis. Standardized outcome definitions, structured follow-up, and prospective registries are needed.

Nephroprotective imaging in peripheral arterial disease (PAD) is often crucial. We compared the diagnostic performance of non-contrast Quiescent-interval single-shot magnetic resonance angiography (QISS MRA) and carbon-dioxide digital subtraction angiography (CO2 DSA) in chronic lower extremity PAD patients. A 19-segment lower extremity arterial model was used to assess the degree of stenosis (none, 70%) and the image quality (5-point Likert scale: 1-non-diagnostic, 5-excellent image quality). Intra-class correlation coefficient (ICC) was calculated for inter-rater reliability. Diagnostic accuracy and interpretability were evaluated using CO2 DSA as a reference standard. 523 segments were evaluated in 28 patients (11 male, mean age: 71 ± 9 years). Median and interquartile range of subjective image quality parameters for QISS MRA were significantly better compared to CO2 DSA for all regions: (aortoiliac: 4 [4–5] vs. 3 [3–4]; femoropopliteal: 4 [4–5] vs. 4 [3–4]; tibioperoneal: 4 [3–5] vs. 3 [2–3]; all regions: 4 [4–5] vs. 3 [3–4], all p < 0.001). QISS MRA out-performed CO2 DSA regarding interpretability (98.3% vs. 86.0%, p < 0.001). Diagnostic accuracy parameters of QISS MRA for the detection of obstructive luminal stenosis (70%<) as compared to CO2 DSA were as follows: sensitivity 82.6%, specificity 96.9%, positive predictive value 89.1%, negative predictive value 94.8%. Regarding the degree of stenosis, interobserver variability for all regions was 0.97 for QISS MRA and 0.82 for CO2 DSA. QISS MRA proved to be superior to CO2 DSA regarding subjective image quality and interpretability for the imaging of chronic lower extremity PAD.

The aim was to evaluate the outcome of stenting in patients with isolated distal internal carotid artery (ICA) stenosis or post-surgical restenosis, as no data are currently available in the literature. Sixty-six patients (men, N = 53; median age: 66 [IQR, 61–73] years) with ≥50% distal ICA (re)stenosis were included in this single-center retrospective study. The narrowest part of the (re)stenosis was at least 20 mm from the bifurcation in all patients. Patients were divided into two etiological groups, atherosclerotic (AS, N = 40) and post-surgical restenotic (RES, N = 26). Postprocedural neurological events were observed in two patients (5%) in the AS group and in two patients (7.7%) in the RES group. The median follow-up time was 40 (IQR, 18–86) months. Three patients (7.5%) in the AS group had an in-stent restenosis (ISR) ≥ 50%, but none in the RES group. Three patients (7.5%) in the AS group and seven patients (26.9%) in the RES group died. None of the deaths in the RES group were directly related to stenting itself. The early neurological complication rate of stenting due to distal ICA (re)stenoses is acceptable. However, the mid-term mortality rate of stenting for distal ICA post-surgical restenoses is high, indicating the vulnerability of this subgroup.

Background/Objectives: Virtual non-contrast (VNC) images derived from dual-energy CTA (DE-CTA) could potentially replace true non-contrast (TNC) scans while reducing radiation exposure. This study evaluated the image quality of VNC compared to TNC for assessing native arteries and bypass grafts in patients with peripheral arterial disease (PAD). Methods: We retrospectively analyzed 175 patients (111 men, 64 women, mean age: 69.3 ± 9.5 years) with PAD who underwent lower extremity DE-CTA. Mean attenuation and image noise values of TNC and VNC images were measured in native arteries and bypass grafts at six arterial levels, from the aorta to the popliteal arteries, using circular regions of interest (ROI). Signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) were calculated. Three independent radiologists evaluated the subjective image quality of VNC images compared to baseline TNC scans for overall quality (4-point Likert scale), and for residual contrast medium (CM), calcium subtractions, and bypass graft visualization (3-point Likert scales). Radiation dose parameters (DLP, CTDIvol) were recorded to estimate effective dose values (ED) and the potential radiation dose reduction. Differences between TNC and VNC measurements and radiation dose parameters were compared using a paired t-test. Interobserver agreement was assessed with Gwet’s AC2. Results: VNC attenuation and noise values were significantly lower across all native arterial levels (p < 0.05, mean difference: 4.7 HU–10.8 HU) and generally lower at all bypass regions (mean difference: 2.2 HU–13.8 HU). Mean image quality scores were 3.03 (overall quality), 2.99 (residual contrast), 2.04 (subtracted calcifications), and 3.0 (graft visualization). Inter-reader agreement was excellent for each assessment (AC2 ≥ 0.81). The estimated radiation dose reduction was 36.8% (p < 0.0001). Conclusions: VNC reconstructions demonstrated comparable image quality to TNC in a PAD assessment and offer substantial radiation dose reduction, supporting their potential as a promising alternative in clinical practice. Further prospective studies and optimization of reconstruction algorithms remain essential to confirm diagnostic accuracy and address remaining technical limitations.

Objective: Three-dimensional models are increasingly used to facilitate the positioning of fenestrations on a physician-modified endograft (PMEG) during the fenestrated endovascular aortic repair (FEVAR) of complex abdominal aortic aneurysms (CAAA). The punch card technique was developed to eliminate the 3D printing workflow while preserving the benefits of having a 3D model. The objective of the current study is to evaluate the performance of the purpose-built software EndoDraft compared to manual punch card design. Methods: An experimental study was performed to compare software-assisted and manual punch card creation. Fenestration data of readily available procedural plans were used for patients who underwent elective FEVAR for CAAA from May 2023 to September 2024. Time needed to complete punch card planning was recorded as well as inaccuracies of the manual technique were evaluated by measuring the vertical and circumferential position of the fenestrations on the punch card. Results: A total of 76 punch cards and 288 fenestrations were made based on 38 patients’ fenestration data. Preparation time was 233.0 ± 40.3 seconds for the manual group, whereas 63.2 ± 21.5 seconds for the software-aided group (p<0.001). Longitudinal imprecision of the manual punch card was 0.8 ± 0.6 mm for the celiac axis (CA), 1.0 ± 0.6 mm for the superior mesenteric artery (SMA), 0.8 ± 0.5 mm for the right renal artery (RRen), whereas 1.0 ± 0.6 mm for the left renal artery (LRen). Circumferential errors of the same fenestrations were 0.4 ± 0.4 mm for the CA, 0.4 ± 0.4 mm for the SMA, 0.6 ± 0.5 mm for the RRen, and 0.5 ± 0.4 mm for the LRen. No significant difference between the completion time recorded at the beginning and at the end of the software’s learning curve was detected (77.8 ± 29.4 s vs 55.8 ± 18.5 s, p=0.15). Conclusions: The software-assisted design of the punch card is associated with higher precision and a vast improvement in speed compared to the manual technique during PMEG planning for the endovascular treatment of CAAAs. The purpose-built EndoDraft tool was made freely available in an online repository offering a more streamlined workflow. Clinical Impact: EndoDraft® could meaningfully streamline the PMEG-FEVAR workflow by replacing manual punch-card drafting with rapid, software-generated, proportionally scaled templates that are produced in about one minute rather than several minutes, while reducing the small but measurable positioning errors inherent to hand drawing. For clinicians, this means a more reproducible planning step, less cognitive load and “ruler time” during preparation, and a workflow that is easier to standardize across operators with a short learning curve. The key innovation is purpose-built automation with integrated 2D/virtual 3D visualization and direct PDF output, made freely available to support wider adoption.