Resolution of Posterior Nutcracker Syndrome through Left Renal Vein Ligation: A Case Report

This case report presents the clinical course of a 54-year-old male patient diagnosed with posterior Nutcracker Syndrome (NCS). The patient experienced recurrent episodes of macroscopic hematuria and severe left flank pain. He was diagnosed with retro-aortic left renal vein (RLRV), an unusual congenital abnormality, which can result in the compression of the left renal vein between the aorta and the vertebra. Initial attempts at conservative management and endovascular interventions were unsuccessful. An open surgical intervention was ultimately performed. The surgery involved ligation of the left renal vein. Postoperatively, the patient experienced marked improvement in symptoms, with complete resolution of hematuria and pain. Furthermore, renal function remained stable, and no kidney-related complications were reported. This case suggests that, in certain situations where endovascular intervention and transposition of LRV or re-implantation of the left gonadal vein are not feasible, ligation of the LRV may provide a safe and practical treatment option for patients with posterior NCS. Future research is needed to validate these findings

Resultados inmediatos de la reparación endovascular de los aneurismas de aorta abdominal con cuello aórtico no favorable

Estudi retrospectiu de pacients tractats d'aneurisma d'aorta abdominal, mitjançant reparaci

The ARIA trial protocol: a randomised controlled trial to assess the clinical, technical, and cost-effectiveness of a cloud-based, ARtificially Intelligent image fusion system in comparison to standard treatment to guide endovascular Aortic aneurysm repair

BackgroundEndovascular repair of aortic aneurysmal disease is established due to perceived advantages in patient survival, reduced postoperative complications, and shorter hospital lengths of stay. High spatial and contrast resolution 3D CT angiography images are used to plan the procedures and inform device selection and manufacture, but in standard care, the surgery is performed using image-guidance from 2D X-ray fluoroscopy with injection of nephrotoxic contrast material to visualise the blood vessels. This study aims to assess the benefit to patients, practitioners, and the health service of a novel image fusion medical device (Cydar EV), which allows this high-resolution 3D information to be available to operators at the time of surgery.MethodsThe trial is a multi-centre, open label, two-armed randomised controlled clinical trial of 340 patient, randomised 1:1 to either standard treatment in endovascular aneurysm repair or treatment using Cydar EV, a CE-marked medical device comprising of cloud computing, augmented intelligence, and computer vision. The primary outcome is procedural time, with secondary outcomes of procedural efficiency, technical effectiveness, patient outcomes, and cost-effectiveness. Patients with a clinical diagnosis of AAA or TAAA suitable for endovascular repair and able to provide written informed consent will be invited to participate.DiscussionThis trial is the first randomised controlled trial evaluating advanced image fusion technology in endovascular aortic surgery and is well placed to evaluate the effect of this technology on patient outcomes and cost to the NHS.Trial registrationISRCTN13832085. Dec. 3, 202

Μετα-ανάλυση των αποτελεσμάτων ενδαγγειακής αποκατάστασης ανευρύσματος κοιλιακής αορτής σε ασθενείς με εχθρική και φιλική ανατομία αυχένα

Ολοένα αυξανόμενος αριθμός ανευρυσμάτων κοιλιακής αορτής με μη ευνοϊκή ανατομία αυχένα αντιμετωπίζονται με κλασική ενδαγγειακή αποκατάσταση. Η ασφάλεια και αποτελεσματικότητα της πρακτικής αυτής είναι αμφίβολη. Μέθοδος: Πραγματοποιήσαμε μια συστηματική ανασκόπηση της βιβλιογραφίας για να ανιχνεύσουμε όλες τις μελέτες που συγκρίνουν τα αποτελέσματα της ενδαγγειακής αποκατάστασης ανευρύσματος κοιλιακής αορτής (endovascular aortic aneurysm repair-EVAR) σε ασθενείς με εχθρική και φιλική υπονεφρική ανατομία. Ως εχθρικός αυχένας ορίστηκαν οι συνθήκες που δεν ήταν συμβατές με τις οδηγίες χρήσης των ενδομοσχευμάτων που χρησιμοποιήθηκαν. Τα αποτελέσματα των μελετών αθροίστηκαν και αναλύθηκαν χρησιμοποιώντας στατιστικές δοκιμασίες (fixed or random effects models). Αποτελέσματα: Αναγνωρίστηκαν επτά μη τυχαιοποιημένες μελέτες και ένας συνολικός αριθμός 1559 ασθενών (ομάδα εχθρικής ανατομίας: 714 ασθενείς, ομάδα φιλικής ανατομίας: 845 ασθενείς) συμπεριλήφθηκε στην ανάλυση. Ασθενείς με εχθρική ανατομία χρειάστηκαν αυξημένο αριθμό συμπληρωματικών επεμβάσεων σε σύγκριση με ασθενείς με φιλική ανατομία, ώστε να επιτευχθεί στεγανοποίηση του κεντρικού αυχένα (αναλογία πιθανοτήτων-odds ratio [OR] 3.050, διάστημα εμπιστοσύνης-confidence interval [CI] 95% 1.884-4.938). Παρόλο που ασθενείς με μη ευνοϊκή ανατομία αυχένα είχαν αυξημένο κίνδυνο να αναπτύξουν νοσηρότητα στις 30 ημέρες (OR 2.278, 95% CI 1.025-5.063), δε βρέθηκαν σημαντικές διαφορές στη συχνότητα ενδοδιαφυγής τύπου Ι ή επανεπέμβασης 30 ημέρες από την αποκατάσταση του ανευρύσματος (OR 2.467 και 1.082, 95% CI 0.562-10.823 και 0.096-12.186 αντιστοίχως). Ασθενείς με εχθρική ανατομία είχαν τετραπλάσιο κίνδυνο εμφάνισης ενδοδιαφυγής τύπου Ι (OR 4.563, 95% CI 1.430-14.558) και εννεαπλάσιο κίνδυνο να εμφανίσουν θνητότητα σχετιζόμενη με το ανεύρυσμα ένα χρόνο μετά την αποκατάσταση (OR 9.378, 95% CI 1.595-55.137). Συμπεράσματα: Δεν υπάρχουν επαρκή στοιχεία που να υποστηρίζουν την ασφαλή χρήση EVAR σε ασθενής με εχθρική ανατομία αυχένα. Από την ανάλυση της παρούσης μελέτης προκύπτει ότι EVAR θα πρέπει να χρησιμοποιείται με προσοχή στους ασθενείς αυτούς.An increasing number of abdominal aortic aneurysms (AAA) with unfavorable proximal neck anatomy are treated with standard endograft devices. Skepticism exists with regard to safety and efficacy of this practice. Methods A systematic review of the literature was undertaken to identify all studies comparing the outcomes of endovascular aneurysm repair (EVAR) in patients with hostile and friendly infra-renal neck anatomy. Hostile neck conditions were considered those that were not consistent with the instructions for use of the endograft devices used in the selected studies. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random effects models. Results Seven observational studies reporting on 1559 patients (hostile anatomy group, 714 patients; friendly anatomy group, 845 patients) were included. Patients with hostile anatomy required an increased number of adjunctive procedures to achieve proximal seal as compared to patients with friendly anatomy (OR = 3.050, 95% CI 1.884-4.938). Even though patients with unfavorable neck anatomy had an increased risk of developing 30-day morbidity (OR = 2.278, 95% CI 1.025-5.063), no significant differences in the incidence of type I endoleak and re-intervention rates within 30-days of treatment between the two groups were identified (OR = 2.467, 95% CI 0.562-10.823; OR = 1.082, 95% CI 0.096-12.186; p = 0.949, respectively). Patients with hostile anatomy had a four-fold increased risk of developing type I endoleak (OR = 4.563, 95% CI 1.430-14.558) and a nine-fold increased risk of aneurysm-related mortality within one year of treatment (OR = 9.378, 95% CI 1.595-55.137). Conclusions Insufficient high level evidence for or against applying standard EVAR in patients with hostile neck anatomy exists. Our analysis suggests EVAR is cautiously used in patients with anatomic neck constraints

Global impact of the first coronavirus disease 2019 (COVID-19) pandemic wave on vascular services

This online structured survey has demonstrated the global impact of the COVID-19 pandemic on vascular services. The majority of centres have documented marked reductions in operating and services provided to vascular patients. In the months during recovery from the resource restrictions imposed during the pandemic peaks, there will be a significant vascular disease burden awaiting surgeons. One of the most affected specialtie

Documenting the Recovery of Vascular Services in European Centres Following the Initial COVID-19 Pandemic Peak: Results from a Multicentre Collaborative Study

Objective: To document the recovery of vascular services in Europe following the first COVID-19 pandemic peak. Methods: An online structured vascular service survey with repeated data entry between 23 March and 9 August 2020 was carried out. Unit level data were collected using repeated questionnaires addressing modifications to vascular services during the first peak (March - May 2020, "period 1"), and then again between May and June ("period 2") and June and July 2020 ("period 3"). The duration of each period was similar. From 2 June, as reductions in cases began to be reported, centres were first asked if they were in a region still affected by rising cases, or if they had passed the peak of the first wave. These centres were asked additional questions about adaptations made to their standard pathways to permit elective surgery to resume. Results: The impact of the pandemic continued to be felt well after countries' first peak was thought to have passed in 2020. Aneurysm screening had not returned to normal in 21.7% of centres. Carotid surgery was still offered on a case by case basis in 33.8% of centres, and only 52.9% of centres had returned to their normal aneurysm threshold for surgery. Half of centres (49.4%) believed their management of lower limb ischaemia continued to be negatively affected by the pandemic. Reduced operating theatre capacity continued in 45.5% of centres. Twenty per cent of responding centres documented a backlog of at least 20 aortic repairs. At least one negative swab and 14 days of isolation were the most common strategies used for permitting safe elective surgery to recommence. Conclusion: Centres reported a broad return of services approaching pre-pandemic "normal" by July 2020. Many introduced protocols to manage peri-operative COVID-19 risk. Backlogs in cases were reported for all major vascular surgeries