The arteriovenous fistula (AVF) is the preferred hemodialysis access type because it has better patency rates and fewer complications than other access types. However, primary failure remains a common problem impeding AVF maturation and adding to patients’ morbidity and mortality. Juxta-anastomotic (or inflow) stenosis is the most common reason leading to primary failure, and percutaneous transluminal angioplasty continues to be the gold-standard treatment with excellent success rates. Intimal hyperplasia (IH) has been traditionally blamed as the main pathophysiologic culprit, but new evidence raises doubts regarding the contribution of IH alone to primary failure. We report a 64-year-old man with a 2-stage brachiobasilic AVF that was complicated by failure 4 months after creation. An angiogram showed multiple juxta-anastomotic and midfistula stenotic lesions. Percutaneous transluminal angioplasty was successful in assisting maturation and subsequently cannulating the AVF for hemodialysis treatment. We failed to identify the underlying cause of stenosis because biopsy specimens from fistula tissue obtained at the time of transposition revealed no occlusive IH. This case emphasizes the need for additional research on factors contributing to AVF failure besides IH and highlights the need for more therapeutic options to reduce AVF failure rate.

Researchers from Bengbu Medical University and Tongling People's Hospital developed a risk stratification model for arteriovenous fistula (AVF) re-failure following percutaneous transluminal angioplasty (PTA) using intraoperative digital subtraction angiography (DSA) variables. The retrospective study analyzed 243 patients treated with Mustang™ balloons, employing Fine-Gray subdistribution hazard models with death and kidney transplantation as competing events. The analysis revealed that lesion length demonstrated a strong non-linear association with re-failure, with subdistribution hazard ratios varying significantly across lengths: 0.25 at 1 centimeter, 1.46 at 2 centimeters, and 4.31 at 3 centimeters. During follow-up, 42.4 percent of patients experienced re-failure. The final model achieved an optimism-corrected C-index of 0.79 at one year and 0.80 at two years, with lesion length carrying nearly all discriminative ability. Notably, traditional systemic markers including age, diabetes, and coronary artery calcium score showed no significant association. This finding is clinically significant as it provides a cost-effective, resource-appropriate alternative for risk stratification in resource-limited settings without requiring additional testing.

Peripheral arterial disease, a condition characterized by reduced blood supply to the lower legs due to arterial blockages, affects numerous individuals and can result in serious complications including pain, infection, and amputation. While initial treatment typically involves medication and lifestyle modifications such as smoking cessation and exercise programs, some patients require surgical intervention. Drug-eluting balloon angioplasty, which coats blood vessels with chemotherapy agents like paclitaxel during the procedure, has emerged as a promising alternative to traditional plain balloon angioplasty. A comprehensive review analyzing 31 randomized clinical trials involving 5,292 participants compared these two approaches for treating lower leg peripheral arterial disease in both thigh and leg arteries above and below the knee. The analysis revealed that drug-eluting balloons demonstrated superior outcomes in reducing the need for repeat treatments on the same artery, preventing restenosis, and minimizing late lumen loss. However, no significant differences were observed between the two techniques regarding amputation rates, amputation-free survival, mortality, ankle-brachial index changes, quality of life scores, or walking ability. These findings suggest that while drug-eluting balloons offer technical advantages in preventing vessel renarrowing, they do not translate into meaningful improvements in patient-centered outcomes.

Orbital atherectomy represents a significant advancement in treating severe coronary artery disease, particularly when conventional methods prove ineffective against calcified arterial blockages. This catheter-based procedure employs a specialized rotating device that precisely abrades hardened plaque deposits into microscopic particles, allowing them to pass safely through the bloodstream without obstruction. Unlike standard angioplasty, which relies on balloon pressure, orbital atherectomy effectively softens calcified plaque, preparing arteries for subsequent stent placement and ensuring optimal long-term outcomes. The technique is specifically designed for patients with severely calcified vessels where traditional approaches fail to adequately address blockages. Understanding arterial disease progression is crucial for patient care, as plaque accumulates gradually from cholesterol and fats before calcifying into bone-like structures resistant to conventional treatment. Early detection of peripheral artery disease through symptoms like leg discomfort during activity, cold extremities, and slow-healing wounds enables timely intervention. For patients with advanced calcification, orbital atherectomy offers a superior treatment pathway compared to standard angioplasty, combining precision with effectiveness to restore proper blood flow and maintain cardiovascular health.

This case report documents the successful application of bioresorbable scaffold technology in treating a patient with chronic limb ischemia, a condition characterized by severely reduced blood flow to the extremities. The clinical team implanted a bioresorbable scaffold—a temporary support structure designed to gradually dissolve as the body heals—to restore vascular function and improve tissue perfusion. Bioresorbable scaffolds represent an advancement over traditional permanent stents, as they provide initial mechanical support while eventually being absorbed by the body, theoretically reducing long-term complications such as chronic inflammation and restenosis. This case demonstrates the potential of bioresorbable scaffold technology to address the challenging clinical problem of chronic limb ischemia, where treatment options are often limited. The successful outcome underscores the importance of exploring innovative interventional approaches for peripheral vascular disease, offering hope for patients with this serious condition who face risks of amputation and disability without effective revascularization.

# Professional Summary Researchers conducted the SUCCESS PTA real-world single-arm study to evaluate sirolimus-eluting balloons as a treatment for peripheral artery disease. This open-access study, published in August 2026 in CVIR Endovascular, investigated the efficacy and safety of this innovative drug-coated balloon technology in clinical practice beyond controlled trial settings. Sirolimus-eluting balloons represent an advancement in interventional cardiology, combining mechanical angioplasty with controlled drug delivery to reduce restenosis rates. The real-world nature of the SUCCESS PTA study provided valuable data on how the technology performs across diverse patient populations and clinical scenarios, rather than in strictly controlled environments. The findings from this trial contribute important evidence regarding the sirolimus-eluting balloon's effectiveness in preventing vessel re-narrowing and improving long-term outcomes for peripheral artery disease patients. This research matters significantly to interventional cardiologists and vascular specialists seeking evidence-based alternatives to traditional balloon angioplasty and stenting approaches, potentially improving treatment options and patient outcomes in peripheral vascular interventions.

Surface vibration analysis using HAVSE demonstrated physiologically coherent patterns in isolated perianastomotic and outflow stenoses but limited discriminatory performance in multifocal or central venous disease, supporting further device development and validation in larger studies that incorporate Doppler ultrasound correlations and standardized acquisition protocols.

Compared with PTA, DCBs and DES demonstrated higher primary patency and lower binary restenosis, and DCBs reduced late lumen loss, percentage in-lesion diameter stenosis, and clinically driven target lesion revascularization.

Arteriovenous fistulas (AVF) dysfunction due to recurrent stenosis can compromise effective renal replacement therapy in patients with end-stage kidney disease (ESKD). Timely salvage of failing AVFs is therefore essential. This retrospective study aims to evaluate the 1-year outcomes of interwoven nitinol stent placement for treatment of dysfunctional forearm arteriovenous fistulas (AVFs) due to juxta-anastomotic (JAS) stenosis in patients with end-stage kidney disease.

Kidney function may modify the comparative effectiveness in limb ischemia. Surgery is associated with fewer limb reinterventions regardless of kidney function. In advanced kidney disease, higher death risk offsets surgery’s limb benefit. Treatment decisions should account for competing risk of death.

The available evidence on atherectomy in peripheral artery disease remains heterogeneous and, in part, conflicting. Randomized controlled trials across different device platforms and anatomical segments have consistently confirmed its ability for lumen gain without barotrauma, resulting in lower dissection rates and lower rates of bail-out stenting, but also failed to demonstrate its superiority over balloon angioplasty, drug-coated balloons, or contemporary stent-based strategies with respect to long-term patency, freedom from reintervention, or limb-related outcomes. Procedure-specific risks, including distal embolization and health-economic considerations, do not support the routine use of atherectomy but rather its anatomy-driven use in selected segments and lesion morphologies and patients with adequate distal run-off (Fig. 4). Its responsible use requires careful integration of available evidence, operator expertise, and consideration of alternative technologies. Future research focusing on morphology-guided patient selection and imaging-supported strategies is essential to better define its optimal role in contemporary endovascular practice.

Arteriovenous (AV) fistulas, the preferred vascular access for hemodialysis, fail to mature in up to 60% of patients with kidney failure. This high failure rate is often attributed to adverse hemodynamic conditions, yet the exact mechanisms remain poorly understood. This review explores the application of computational fluid dynamics and machine learning to elucidate these mechanisms and predict clinical outcomes. Computational fluid dynamic models have been instrumental in characterizing the complex interplay between AV fistula geometry, such as anastomotic angle and curvature, and hemodynamic parameters, such as wall shear stress and oscillatory shear index. These studies consistently link disturbed flow patterns, including low wall shear stress and high oscillatory shear index, to regions prone to neointimal hyperplasia and stenosis. Concurrently, machine learning models have demonstrated significant promise in predicting AV fistula maturation, stenosis, and failure by leveraging diverse data sources, including clinical characteristics, ultrasound imaging, and acoustic bruit analysis.

The role of oxidative stress in AVF formation may appear to be a double-edged sword, but its positive effects are often overlooked. On the one hand, much evidence points to the negative effects of oxidative stress on AVF maturation by causing endothelial dysfunction and stimulating the proliferation and migration of smooth muscle cells and fibroblasts. On the other hand, the massive production of oxidative stress in the early stage of AVF formation also plays an undeniably important role in AVF outward remodeling and maturation. Perhaps the research on AVF should go deeper into the change law of oxidative stress in the whole process to understand the changing role of oxidative stress generation in different stages from maturation to inward remodeling of AVF. Likewise, research should delve into the outcomes of modulating antioxidant stress at different time points.

Researchers have proposed an innovative theoretical framework combining quaternion-based recurrent neural networks (QRNNs) with machine learning to address limitations in superficial femoral artery (SFA) assessment and restenosis prediction. The superficial femoral artery is highly susceptible to atherosclerotic disease, with restenosis rates exceeding 30–50% following endovascular intervention. Current diagnostic methods, including two-dimensional angiography and duplex ultrasound, fail to capture the complex three-dimensional spatiotemporal dynamics of vessel remodeling during physiological motion. The proposed integrated pipeline combines 3D convolutional neural network encoders for feature extraction, QRNN cores for temporal modeling using Hamilton product operations, and conditional generative adversarial networks for synthetic geometry generation. Quaternions provide singularity-free representations of 3D rotations, enabling superior fidelity in modeling dynamic vessel behavior compared to Euclidean approximations. A multi-objective loss function balances quaternion prediction accuracy, geometric feature errors, and probability calibration. Once validated, this framework could enable predictive 3D vessel remodeling modeling, personalized intervention planning, and quantitative risk stratification for peripheral artery disease, potentially transforming management of this condition affecting over 200 million individuals globally.

Central venous occlusion (CVO) affects 25–40% of hemodialysis patients, causing significant complications including vascular access dysfunction. This condition stems from prolonged catheter use and elevated blood flow from vascular accesses, which promote venous intimal hyperplasia. Standard symptoms include facial and limb edema and access failure. While endovascular treatment is the first-line management strategy, some rigid occlusions resist conventional recanalization techniques. The sharp recanalization technique (SRT), first described by Ferral in 1996, offers an alternative approach for failed conventional interventions. SRT employs specialized instruments including stiff guidewires, Chiba and Colapinto needles, transjugular hepatic puncture needles, transseptal puncture systems, or radiofrequency and laser technology to traverse impassable occlusions. This case report documents a 68-year-old hemodialysis patient with right brachiocephalic venous trunk occlusion who failed conventional antegrade crossing attempts using standard catheters and guidewires. SRT proved effective for successful recanalization, demonstrating its clinical value when conventional endovascular methods are exhausted, thereby preserving vascular access and alleviating debilitating symptoms.

Compared with PTA, DCBs and DES demonstrated higher primary patency and lower binary restenosis, and DCBs reduced late lumen loss, percentage in-lesion diameter stenosis, and clinically driven target lesion revascularization.

Lower extremity peripheral artery disease (PAD) is associated with considerable morbidity, diminished quality of life, and mortality; reducing the risk of cardiovascular events is the primary goal of medical treatment. Intermittent claudication is the most common symptom of PAD; treatment aims to improve ambulatory function through smoking cessation, medical therapy, exercise, and (selective) revascularization. Chronic limb-threatening ischaemia is associated with increased amputation risk and mortality; treatment is based on effective revascularization, which aims to relieve pain, heal wounds, and preserve limb function. Advances in endovascular technologies and open surgical approaches have created a growing range of revascularization options for PAD, although their outcomes are highly dependent on the anatomical pattern of disease. Active areas of investigation in PAD include cell-based and gene-based therapies, tissue-engineered vascular conduits, and drug-eluting, biomimetic, and bioresorbable scaffolds.

This clinical trial, sponsored by DK Medical Technology (Suzhou) Co., Ltd., evaluates scoring balloon and high-pressure balloon techniques for treating arteriovenous graft stenosis in hemodialysis patients. The study enrolled patients aged 18–80 years with mature AVGs and target lesions in the return vein or venous anastomosis showing ≥50% stenosis combined with clinical indicators such as elevated venous pressure, increased puncture difficulty, or reduced blood flow. Primary and restenotic lesions measuring 4.0–8.0mm in reference diameter and up to 80mm total length were included. The trial excluded patients with central vein stenosis, prior stent placement, severe calcification, acute thrombosis, recent percutaneous transluminal angioplasty treatment, or planned kidney transplantation. This research addresses a critical clinical challenge in vascular access maintenance, as stenosis is a leading cause of dialysis access failure. The findings will inform optimal balloon angioplasty strategies for preserving AVG function and reducing intervention frequency in hemodialysis populations.

Discussion on managing complex peripheral artery disease, particularly in the femoropopliteal region, and a relevant case study to highlight specific challenges.

Researchers have demonstrated a novel approach to treating complex femoropopliteal arterial lesions using rotational atherectomy accessed through the retrograde popliteal route without embolic protection devices. This technique addresses challenging calcified or fibrotic blockages in the femoral-popliteal artery segment, which supplies blood to the leg. The retrograde popliteal access approach—entering from behind the knee rather than traditional antegrade methods—provides improved angles and maneuverability for the rotational atherectomy device, which mechanically abrades plaque buildup. Notably, the procedure was performed without embolic protection filters, suggesting adequate safety despite potential debris generation. This advancement published in CVIR Endovascular represents a significant technical innovation in peripheral arterial interventions. The findings matter because they expand treatment options for complex lesions previously difficult to manage, potentially improving outcomes for patients with peripheral artery disease while potentially reducing procedural complexity and cost by eliminating embolic protection requirements.