Chronic limb-threatening ischemia represents the most severe form of peripheral artery disease and is associated with high risks of limb loss and mortality. It is closely associated with below-the-knee arterial disease, with substantial overlap between the two conditions, particularly in patients with diabetes. Endovascular treatment plays a central role in restoring distal tibial and pedal perfusion, which is critical for wound healing and limb salvage. However, it remains technically challenging due to small vessel size, diffuse disease, and heavy calcification, which limit luminal expansion and predispose to recoil, dissection, and restenosis. Procedural success requires a structured approach integrating access strategy, guidewire crossing, and subsequent treatment. Crossing strategies, including subintimal tracking, retrograde tibio-pedal access, and bidirectional techniques such as controlled antegrade and retrograde tracking, are often required in complex lesions. Plain balloon angioplasty remains the most broadly applicable treatment, whereas drug-coated balloons show inconsistent benefit. Drug-eluting stents provide favorable outcomes in selected short focal lesions, whereas other technologies have more limited evidence. Overall, treatment should be individualized based on lesion characteristics and clinical context.

<b>Purpose</b><br/>This study aims to investigate the clinical outcomes and safety of a standardized two-session catheter-directed ethanol sclerotherapy protocol for peritoneal inclusion cysts. <br/><b>Materials and Methods</b><br/>Between November 2020 and July 2025, six women (median age, 32.5 years) with symptomatic peritoneal inclusion cysts underwent ethanol sclerotherapy. After complete drainage using an 8.5-Fr or 10.2-Fr pigtail catheter, two sessions of sclerotherapy were performed on consecutive days. In each session, 99.5% ethanol (50% of the aspirated volume, up to 150 mL) was instilled and retained for 20 minutes. Follow-up ultrasound was performed at 1, 3, and 6 months. Technical success was defined as successful completion of both sessions with a 20-minute ethanol retention time, and clinical success was defined as symptom improvement with a >50% decrease in cyst diameter at 3 months. <br/><b>Results</b><br/>Technical success was achieved in all cases (6/6, 100%). The median maximum cyst diameter significantly decreased from 14.0 cm (range, 6.0 to 20.0 cm) to 5.25 cm (range, 2.0 to 8.0 cm) at the follow-up within 1 month (p = 0.03). Clinical success was achieved in all cases at 3 months (6/6, 100%). No residual cysts were visualized on follow-up ultrasound at 6 months in all patients (6/6, 100%). Anti-Müllerian hormone levels measured in four patients showed heterogeneous changes, precluding definitive conclusions regarding the impact on ovarian reserve. No major complications occurred. <br/><b>Conclusion</b><br/>Two-session catheter-directed ethanol sclerotherapy appears to be a safe and effective minimally invasive alternative to surgery for peritoneal inclusion cysts, providing a high rate of complete resolution.

Pyrrolizidine alkaloid–induced hepatic sinusoidal obstruction syndrome (PA-HSOS) is highly prevalent in Asia, primarily due to the widespread use of traditional herbal medicines containing hepatotoxic pyrrolizidine alkaloids. This condition poses significant clinical challenges, including diagnostic difficulties and limited therapeutic options, frequently leading to severe liver damage and portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) treatment has emerged as a key intervention for managing complications associated with PA-HSOS, such as refractory ascites and variceal bleeding, by reducing portal pressure and supporting liver function recovery. However, TIPS has not been widely accepted as a salvage therapy for severe PA-HSOS unresponsive to anticoagulation therapy, mainly due to concerns about post-TIPS complications, particularly hepatic encephalopathy. Consequently, careful patient selection and risk stratification are critical. This review synthesizes the current evidence on PA-HSOS in Asia, evaluates the clinical utility of TIPS, and discusses strategies to optimize outcomes while minimizing adverse effects. Specifically, we review the epidemiology, pathophysiology, and diagnostic advancement of PA-HSOS, with a particular focus on the evolving role of TIPS in its management.

Current percutaneous treatment strategies for acute limb ischemia (ALI) include catheterdirected thrombolysis (CDT) and mechanical thrombectomy. However, about 20% of these patients can have contraindications to thrombolytic therapy. Mechanical thrombectomy is the only option in such patients except for surgical candidates. Manual aspiration thrombectomy using a large-bore aspiration catheter is a preferred first option. However, this technique is sometimes insufficient when the thrombi burden is significant with the risk of distal embolization. In this case report, we would like to introduce a case with acute limb ischemia successfully treated with stentassisted thrombectomy when contraindicated for thrombolysis and failed simple aspiration thrombectomy alone.