暂无摘要。

Infected abdominal aortic aneurysms (AAAs) make up a small minority of AAAs yet are characterized by a high fatality rate, largely attributed to their increased risk of aneurysm rupture. This case details a rare presentation of a 56-year-old man that developed Proteus mirabilis bacteremia secondary to a perineal abscess and subsequently experienced a 3 cm growth of his previously stable AAA over an 8 day period. This case underscores the importance of maintaining a heightened suspicion for infected aortic aneurysms in sick patients and highlights the critical role of surgical management in achieving source control.

BACKGROUND: Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI following abdominal surgery is from the gastrointestinal and urologic literature. These data have been extrapolated to vascular surgery, especially with regards to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.
METHODS: This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone non-elective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.
RESULTS: A total of 123 patients met study criteria with an overall POI rate of 8.9% (n=11). Patients who developed a POI had significantly lower BMIs (24.3 kg/m2 versus 27.1 kg/m2, P=.003), were more likely to undergo a transperitoneal approach (81.8% versus 42.0%, P=.022), midline laparotomy (81.8% versus 37.5%, P=.008), longer total clamp times (151.6 minutes versus 97.7 minutes, P=.018), larger amounts of intraoperative crystalloid infusion (3495 mL versus 2628 mL, P=.029), and were more likely to return to the operating room (27.3% versus 3.6%, P=.016). Proximal clamp site was not associated with POI (P=.463). POI patients also had higher rates of post-operative vasopressor use (100% versus 61.1%, P=.014) and larger amounts of oral morphine equivalents in the first 3 post-operative days (488.0 mg + 216.0 versus 203.8 mg + 29.6 P=.016). Patients who developed POI had longer lengths of stay (12.5 days versus 7.6 days, P<.001), longer duration of NGT decompression (5.9 days versus 2.2 days, P<.001), and a longer period of time before diet tolerance (9.1 days versus 3.7 days, P<.001). Of those that developed a POI (n=11), 4 (36.4%) required total parental nutrition during the admission.
CONCLUSIONS: POI is a morbid complication amongst patients undergoing elective open AAA surgery that significantly prolongs hospital stay. Patients at risk for developing a POI are those with lower BMIs, had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, post-operative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important peri-operative opportunities to reduce the prevalence of POI.

BACKGROUND: Although renal artery aneurysms (RAAs) are rare and often asymptomatic with slow growth, their natural progression and optimal management are not well understood. Treatment recommendations for RAAs do exist; however, they are supported by limited data.
METHODS: A retrospective cohort study was conducted to explore the management of patients diagnosed with an RAA at our institution from January 1st, 2013, to December 31st, 2020. Patients were identified through a search of our radiological database, followed by a comprehensive chart review for further assessment. Data collection encompassed patient and aneurysm characteristics, the rationale for initial imaging, treatment, surveillance, and all-cause mortality.
RESULTS: One hundred eighty-five patients were diagnosed with or treated for RAAs at our center during this timeframe, with most aneurysms having been discovered incidentally. Average aneurysm size was 1.40 cm (±0.05). Of those treated, the mean size was 2.38 cm (±0.24). Among aneurysms larger than 3 cm in size, comprising 3.24% of the total cases, 83.3% underwent treatment procedures. Only 20% of women of childbearing age received treatment for their aneurysms. There was one instance of aneurysm rupture, with no associated mortality or significant morbidity.
CONCLUSIONS: Our institution\'s management of RAAs over the period of the study generally aligned with guidelines. One potential area of improvement is more proactive intervention for women of childbearing age.

OBJECTIVE: To evaluate the current evidence and literature on treatment options for proximal hamstring injuries.
RESULTS: Patients with 3-tendon complete tears with greater than 2 cm of retraction have worse outcomes and higher complication rates compared to those with less severe injuries. Endoscopic and open proximal hamstring repair both have favorable patient reported outcomes at 5-year follow up. Proximal hamstring repair in patients who are male, with isolated semimembranosus injury, and have proximal hamstring free tendon rupture are more likely to have earlier return to sports. The Parisian Hamstring Avulsion Score (PHAS) is a validated patient-reported outcome measure to predict return to sports. Proximal hamstring injuries may occur in both elite and recreational athletes and may present with varying degrees of chronicity and severity. Injuries occur most commonly during forceful eccentric contraction of the hamstrings and often present with ischial tuberosity tenderness, ecchymosis, and hamstring weakness. Treatment decision-making is dictated by the tendons involved and chronicity. Many proximal hamstring injuries can be successfully treated with non-surgical measures. However, operative treatment of appropriately indicated proximal hamstring tendon injuries can result in significantly better functional outcomes and faster and more reliable return to sports compared to nonoperative treatment. Both endoscopic and open surgical repair techniques show high satisfaction levels and excellent patient-reported outcomes at short- and mid-term follow-up. Postoperative rehabilitation protocols vary across the literature and ongoing study is needed to clarify the optimal program, though emphasis on eccentric hamstring strengthening may be beneficial.

BACKGROUND: Late open conversion (LOC) following endovascular aneurysm repair (EVAR) is a rare complication with a high morbidity and mortality and is often proposed as the last line of treatment after failure of endovascular reintervention of any type. This study aimed to highlights the limitations of EVAR follow-up imaging in characterizing endoleaks, which may contribute to the failure of endovascular reinterventions and lead to LOC.
METHODS: This retrospective cohort study recruited all EVAR implanted in Amiens University Hospital (France) between January 2008 and December 2022. Elective LOC was defined as surgical conversion >1 month after EVAR. The primary endpoint was the rate of wrong categorization of endoleaks by follow-up exams before LOC. Secondary endpoints were the morbidity and the mortality associated with LOC.
RESULTS: Seven hundred eight EVARs were performed in our institution, 30 required elective LOC. Twenty-five of them were treated for sac enlargement due to an endoleak (83.3%) (all types). Wrong categorization of the endoleak was noted in 13 patients (52.2%). Twelve of these recategorizations involved the preoperative diagnosis of a type II endoleaks (92.3%). The change in categorization in 7 out of 12 cases (58%) was in favor of a type I endoleak, other recategorization included 1 type III (8%) and 4 type IV (33%). One patient died during the 30-day postoperative period and 7 patients (28%) presented a major complication; the median length of stay was 13 days (interquartile range 9-21).
CONCLUSIONS: Routine follow-up examinations such as angioscanner and contrast Doppler ultrasound appear to be limited in their ability to categorize the type of persistent endoleak, which may increase the number of patients requiring LOC. New precision diagnostic imaging techniques, such as dynamic examinations, need to be developed to limit the need for LOC.

OBJECTIVE: Although the medical field has made significant progress, there has been little improvement in the survival rate of patients with ruptured abdominal aortic aneurysms (rAAAs). We implemented a protocol consisting of five strategies in the management of rAAA patients who underwent open repair surgery.
METHODS: The protocol comprised the following strategies: intentional hypotension <70 mmHg, lung first and kidney last policy (restricted fluid resuscitation and permissive oligoanuria), immediate postoperative extubation, free-water intake with active ambulation, and open abdomen with the routine second-look operation. The study included 13 patients (11 male) with a mean age of 75.5 ± 7.4 (range: 58-87) years who underwent the procedure from 2016 to 2018, with a mean follow-up of 40.1 ± 9.04 months. Five deteriorating to hemodynamic shock and decreased consciousness requiring intubation and ventilation prior to surgery were observed. Two of these patients required preoperative cardiopulmonary resuscitation (CPR).
RESULTS: All patients regained consciousness after surgery, including the two patients who required cardiopulmonary resuscitation. Immediate postoperative extubation was performed in nine patients, but two (22.2%) of them needed re-intubation due to ventilation/perfusion mismatch. Four patients underwent continuous renal replacement therapy, with three of them having anuria for up to 48 h after surgery. Two of these patients made a full recovery. Daily ambulation was carried out for a mean of 4.77 ± 3.5 (range 1-13) days with an open abdomen, during which no significant events were reported. Four cases of colon ischemia/necrosis were identified in the second-look operation, with two patients requiring Hartman\'s procedure and the other two undergoing left colon partial resection. There were two in-hospital mortalities (15.4%).
CONCLUSIONS: A protocol-based approach, through multidisciplinary team consensus and the development of optimal surgical strategies, could improve clinical outcomes for patients undergoing emergency surgery for rAAA. Further studies with larger sample sizes are needed to refine the protocols.

OBJECTIVE: Prior literature has found worse outcomes for female patients after endovascular repair of abdominal aortic aneurysm and mixed findings after thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysm. However, the influence of sex on outcomes after TEVAR for acute type B aortic dissection (aTBAD) is not fully elucidated.
METHODS: We identified patients who underwent TEVAR for aTBAD (<30 days) in the Vascular Quality Initiative from 2014 to 2022. We excluded patients with an entry tear or stent seal within the ascending aorta or aortic arch and patients with an unknown proximal tear location. Included patients were stratified by biological sex, and we analyzed perioperative outcomes and 5-year mortality with multivariable logistic regression and Cox regression analysis, respectively. Furthermore, we analyzed adjusted variables for interaction with female sex.
RESULTS: We included 1626 patients, 33% of whom were female. At presentation, female patients were significantly older (65 [interquartile range: 54, 75] years vs 56 [interquartile range: 49, 68] years; P = .01). Regarding indications for repair, female patients had higher rates of pain (85% vs 80%; P = .02) and lower rates of malperfusion (23% vs 35%; P < .001), specifically mesenteric, renal, and lower limb malperfusion. Female patients had a lower proportion of proximal repairs in zone 2 (39% vs 48%; P < .01). After TEVAR for aTBAD, female sex was associated with comparable odds of perioperative mortality to males (8.1 vs 9.2%; adjusted odds ratio [aOR]: 0.79 [95% confidence interval (CI): 0.51-1.20]). Regarding perioperative complications, female sex was associated with lower odds for cardiac complications (2.3% vs 4.7%; aOR: 0.52 [95% CI: 0.26-0.97]), but all other complications were comparable between sexes. Compared with male sex, female sex was associated with similar risk for 5-year mortality (26% vs 23%; adjusted hazard ratio: 1.01 [95% CI: 0.77-1.32]). On testing variables for interaction with sex, female sex was associated with lower perioperative and 5-year mortality at older ages relative to males (aOR: 0.96 [0.93-0.99] | adjusted hazard ratio: 0.97 [0.95-0.99]) and higher odds of perioperative mortality when mesenteric malperfusion was present (OR: 2.71 [1.04-6.96]).
CONCLUSIONS: Female patients were older, less likely to have complicated dissection, and had more distal proximal landing zones. After TEVAR for aTBAD, female sex was associated with similar perioperative and 5-year mortality to male sex, but lower odds of in-hospital cardiac complications. Interaction analysis showed that females were at additional risk for perioperative mortality when mesenteric ischemia was present. These data suggest that TEVAR for aTBAD overall has a similar safety profile in females as it does for males.

OBJECTIVE: The results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results.
OBJECTIVE: There is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols.
METHODS: This was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review.
RESULTS: Four hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07).
CONCLUSIONS: This study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes.
METHODS: III; retrospective comparative, non-randomized.

We report the case of a 77-year-old woman presenting with an asymptomatic internal carotid artery (ICA) aneurysm arising at the skull base. The distal right extracranial ICA aneurysm presented as a challenging case due to difficulty in obtaining adequate surgical exposure and preserving the facial nerves present near the ICA aneurysm. Transcervical open repair with a team of vascular and otolaryngology surgeons was completed successfully. In this report, we detail the operative steps needed to complete this exposure and our perioperative management.