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Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. A multi-institutional Greek study of late ruptures after EVAR between 2008 – 2022 was performed. Primary outcomes were intra-operative and in hospital death. A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 – 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p =.21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 – 39.1; p <.001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 – 32.40; p =.010) and in hospital death (OR 9.53, 95% CI 2.79 – 32.58; p <.001). These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended. [ABSTRACT FROM AUTHOR]

Secondary aortoduodenal fistulae (SADF) are uncommon but life-threatening conditions that occur as complications of aortic reconstructive surgery. Data on the mortality and morbidity of procedures associated with SADF remain scarce. Comprehensive literature search was conducted on the MedLine, Scopus, Embase, and Web of Knowledge databases for cases of SADF. Data regarding patient demographics, fistula anatomy and treatment interventions performed were extracted for further analysis. The study pool consisted of 127 case reports, 28 case series and 1 retrospective study published between 1973 and 2021. A total of 189 patients were operated for SADF. Among the 189 patients, 141 patients (74.6%) had aortic graft excision, 26 (13.8%) aortic primary repair, and 22 (11.6%) EVAR. Although patients undergoing EVAR were older with higher Charlson Comorbidity Index, compared with patients who had graft excision and primary aortic repair these differences were not statistically significant (P =.12 and P =.22, respectively). Primary bowel repair was performed in 145 patients (76.7%), duodenectomy in 25 (13.2%), and no bowel repair in 19 (10.1%). Additional omentoplasty was performed in 65 patients (34.6%). Mortality was comparable with respect to the type of aortic and bowel repair, with no statistically significant differences recorded (P =.54 and P =.77, respectively). Omentoplasty significantly decreased the risk of death (odds ratio, 0.4; 95% confidence interval, 0.2-0.8, P =.01). Optimal operative management should address both the aortic and duodenal defects and be complemented with appropriate reconstructive procedures. Endovascular aortic approaches seem feasible in carefully select patients in whom duodenal repair may be omitted. [ABSTRACT FROM AUTHOR]

Foreign body ingestion is not uncommon, but in most patients the object passes without sequelae. In very few patients, the ingested foreign objects may perforate the gastrointestinal tract, causing potentially life-threatening complications. Pointed ingested objects such as toothpicks are the most common. Vascular perforation due to toothpick ingestion has rarely been reported. We present a patient with lower gastrointestinal bleeding secondary to simultaneous perforation of the sigmoid colon and the right iliac limb of an aortobiiliac endograft by an ingested toothpick. This arterioenteric fistula was treated in two stages. First as a bridging operation, a stent graft was inserted into the ipsilateral limb of the previous aortoiliac endograft to control the bleeding. Second, the aortoiliac endograft was removed, the aorta was oversewn, and an extra-anatomic axillobifemoral bypass restored the flow to the lower limbs. The colon perforation was treated with a proximal temporary loop colostomy. To our knowledge, this the first case of aortoiliac endograft-enteric fistula after endovascular abdominal aortic aneurysm repair caused by this extraordinary mechanism. [Copyright &y& Elsevier]

The multilayer stents are occasionally used for the treatment of complicated aortic aneurysms, including thoracoabdominal aneurysms. No aneurysm-related mortality among patients treated with this technique has been described in the literature to date. We describe a case of rupture of an aortic aneurysm previously treated with a multilayer stent. [Copyright &y& Elsevier]

Tennis is a popular, safe sport that exposes amateur or professional players to minimal risk of injury. Most of this risk is related to musculoskeletal injuries, and vascular trauma is extremely rare. We present a case of a 68-year-old man in whom intermittent claudication developed after his right groin was struck by a tennis ball. The patient sought medical evaluation 2 months after the accident, and a subtotal occlusion of his right common femoral artery was disclosed by angiography and treated by endarterectomy. [Copyright &y& Elsevier]

Background Treatment of superficial femoral artery (SFA) lesions remains challenging. We conducted a network meta-analysis of randomized controlled trials aiming to explore the efficacy of treatment modalities for SFA “de novo” lesions. Methods Eleven treatments for SFA occlusive disease were recognized. We used primary patency and binary restenosis at 12-month follow-up as proxies of efficacy for the treatment of SFA lesions. Results A total of 33 studies (66 study arms; 4659 patients) were deemed eligible. In terms of primary patency, odds ratios (ORs) with 95% confidence intervals (CIs) were statistically significantly higher in drug-eluting stent (DES; OR, 10.05; 95% CI, 3.22-31.39), femoropopliteal bypass surgery (BPS; OR, 7.15; 95% CI, 2.27-22.51), covered stent (CS; OR, 3.56; 95% CI, 1.33-9.53), and nitinol stent (NS; OR, 2.83; 95% CI, 1.42-5.51) compared with balloon angioplasty (BA). The rank order from higher to lower primary patency in the multidimensional scaling was DES, BPS, NS, CS, drug-coated balloon, percutaneous transluminal angioplasty with brachytherapy, stainless steel stent, cryoplasty (CR), and BA. Combination therapy of NS with CR and drug-coated balloon were the two most effective treatments, followed by NS, CS, percutaneous transluminal angioplasty with brachytherapy, cutting balloon, stainless steel stent, BA, and CR in terms of multidimensional scaling values for binary restenosis. Conclusions DES has shown encouraging results in terms of primary patency for SFA lesions, whereas BPS still maintains its role as a principal intervention. On the contrary, BA and CR appear to be less effective treatment options. [ABSTRACT FROM AUTHOR]

Background: Despite the increasing numbers of female medical students, surgery remains male-dominated.Purpose: To highlight the principal career obstacles experienced by aspiring female surgeons.Methods: A narrative review of literature on the position and career barriers of female surgeons has been conducted, using the MEDLINE and EMBASE databases.Main Findings: Implicit and even explicit biases against female surgeons remain prevalent, negatively impacting their training performance and overall professional trajectory. Female surgeons are globally underrepresented in leadership positions and senior academic rankings, especially that of a full professor. They feel hampered by lack of effective mentorship, whose value for a successful career has been acknowledged by all medical students, surgeons and surgical leaders. Their work-life imbalance is sometimes expressed as lower likelihood than their male contemporaries of getting married or having children and may be attributed to their conventional association with the role of caretaker, their personal desire to accommodate occupational and family duties and the inadequate implementation of parental leave and childcare policies. Female surgeons' "infertility" may be further explained by direct and indirect pregnancy-related difficulties. Female surgeons are also financially undercompensated compared to their male contemporaries. Finally, specialty-specific challenges should not be overlooked.Conclusions: While encouraging steps have been made, women in surgery feel still hindered by various obstacles. The qualitative, interview-based nature of current literature requires more meticulous studies on these barriers with a more quantitative and objective approach. Attenuation of gender imbalance in surgical specialties requires further changes in mentality and more targeted modifications in relevant policies. [ABSTRACT FROM AUTHOR]