A technique for recanalization of femoral and popliteal arterial occlusions by intentional subintimal dissection is described. Recanalization with this technique was attempted in 71 occlusions of the femoro-popliteal segment with a mean length of 11.4 cm. Primary technical success was achieved in 54 (76%) cases, with complications occurring in 4 (5.6%). Of 44 successful cases reviewed at a mean follow up of 6 months, 37 (84%) were either asymptomatic or improved. The technique has proved to be an effective method of treating occlusions of the femoral and popliteal arteries with an acceptable complication rate. It may allow successful angioplasty where the standard intraluminal method fails, particularly when reconstructive surgery is the only option.

Graft-related endoleaks appear to be the predominant causes of late aneurysm rupture. Quality of and compliance with post-EVAR surveillance are important factors in late rupture; a large proportion of late ruptures are amenable to endovascular treatment.

In the ongoing evolution of a categorization system for endoleak, the authors propose the term endotension to define persistent or recurrent pressurization of the aortic aneurysm sac after endovascular repair. Endotension is evidence that the aneurysm remains at risk of rupture and should, therefore, be considered an indication for secondary intervention. Management strategies and a grading system for endotension are offered.

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Localized "hot spots" of MMP hyperactivity could lead to focal weakening of the aneurysm wall and rupture at relatively low levels of intraluminal pressure. These data suggest that tensile strength of the sac is just as important as intrasac tension in determining the risk of rupture. Moreover, these observations may explain why some small aneurysms rupture and larger aneurysms do not. Assessment of rupture risk based on computation or measurement of wall stress may be subject to error and inaccuracy due to variations in wall tensile strength.