Nonatherosclerotic extrinsic compression from para-articular cysts is a rare but clinically important cause of claudication. We report the case of a 50-year-old man who presented with left calf claudication and absence of distal left dorsalis pedis artery pulse after exertion. A duplex ultrasound study revealed a popliteal fossa cyst that doubled in size under exertion (from 3.2 to 7.2 mm), leading to an extrinsic compression of the popliteal artery. Magnetic resonance imaging scans confirmed a possible articular origin of the cyst. Dense adhesions surrounding the lesion led to the reconstruction of both the left popliteal artery and left popliteal vein. This case highlights the importance of implementing exercise during duplex ultrasound study of lower limbs to identify rare exercise-induced enlargement of popliteal cysts causing popliteal artery stenosis, which may subsequently require complex multivessel surgical management.

e16386 Background: Locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) combined with hepatic arteries invasion is usually considered unresectable. This study explores a new procedure with preoperative segmental hepatic arteries embolization and hepatic artery resection and evaluate its safety. Methods: All LA-PDAC patients received neoadjuvant chemotherapy and had stable or partially remission tumors as assessed by CT imaging. Before surgery, all patients underwent preoperative segmental hepatic arteries embolization, include right hepatic artery (RHA), left hepatic artery (LHA) and left gastric artery (LGA). Results: Pancreaticoduodenectomy was performed in 8 patients and distal pancreatectomy in 2 patients, combined with hepatic artery resection. No perioperative deaths occurred, and all patients achieved R0 resection. Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were normal after hepatic arterial embolization. The average peak values of ALT and AST after surgery were 734.7 and 805.5 respectively, and the average time for ALT and AST levels to return to normal was 8.5 days. Two patients had localized hepatic ischemia after surgery, but no patient had liver abscess. Conclusions: The novel surgical approach of radical pancreatic cancer resection combined with preoperative hepatic artery embolization and hepatic artery resection is feasible and safe for LA-PDAC patients with hepatic artery invasion. This study provides evidence supporting the potential use of this procedure in such cases.

BACKGROUND:En bloc resection of adjacent structures, including major vessels, is often required to achieve negative margins in retroperitoneal sarcoma (RPS). However, the effect of vascular involvement and different reconstruction techniques in patients undergoing vascular resection remains unclear. This study investigated the morbidity, mortality, and long-term survival of patients who underwent an aggressive surgical approach with vascular resection for RPS. METHODS:We analyzed a prospectively maintained database of patients who underwent surgical resection (with or without vascular resection) for RPS between 2015 and 2020. The primary endpoint was long-term overall survival (OS). FINDINGS:The study population comprised 252 patients. Postoperative morbidity, mortality, and OS did not differ significantly between the vascular and no vascular resection groups. Among patients with vascular involvement, those who underwent aggressive surgical approach with vascular resection had a significantly higher OS (66.3 months vs. 25.6 months) compared to those who underwent palliative resection, without an increase in mortality or complication rate. No significant differences were observed in postoperative morbidity, 30-day mortality, or estimated median OS between patients who underwent primary repair and reconstruction. CONCLUSIONS:In patients with RPS with vascular involvement, an aggressive surgical approach with vascular resection achieved optimal clinical outcomes. Vascular reconstruction techniques had no impact on clinical outcomes.

Non-traumatic lower limb ischemic diseases are extremely rare among young people. Clinically, they are mainly seen in the form of popliteal artery entrapment syndrome (PAES). In addition, with the prevalence of COVID-19 infection, more and more studies report that COVID-19 infection may lead to arteriovenous thrombosis, which could cause lower limb ischemia. This case reported that a 31-year-old male amateur football player who developed intermittent claudication after recovering from COVID-19. After 2 months of consultation, he was ultimately diagnosed with PAES. As is well known, PAES is mostly caused by long-term compression of the popliteal artery by abnormal anatomical structures, resulting in thickening of the vascular outer membrane and progression of the disease until intimal damage and thrombosis, leading to lower limb ischemia. During the progression of the disease, there may be multiple factors that accelerate its progression. Therefore, combined with the patient's clinical history and related studies on confirmed thrombosis caused by COVID-19, we can infer that COVID-19 could accelerate the occurrence of PAES.

Abstract Background and aim Surgery is the mainstay of treatment and completeness of surgical resection is critical to achieve local control for retroperitoneal sarcoma (RPS). En-bloc resection of adjacent organs, including major abdominal vessels, is often required to achieve negative margins. The aim of this review was to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with vascular resection in patients with retroperitoneal sarcoma (RPS). Methods We searched PubMed, the Cochrane Library, and EMBASE for relevant studies published from inception up to August 1, 2022. We performed a systematic review of the available studies to assess the safety and long-term survival results of vascular resection for RPS. Results We identified a total of 23 studies for our review. Overall postoperative in-hospital or 30-day mortality rate of patients with primary iliocaval leiomyosarcoma was 3% (11/359), and the major complication rate was 13%. The recurrence-free survival (RFS) rates after the follow-up period varied between 15% and 52%, and the 5-year overall survival (OS) rates ranged from 25 to 78%. Overall postoperative in-hospital or 30-day mortality rate of patients with RPSs receiving vascular resection was 3%, and the major complication rate was 27%. The RFS rates after the follow-up period were 18–86%, and the 5-year OS rates varied between 50% and 73%. There were no significant differences in the rates of RFS (HR: 0.97; 95% CI: 0.74–1.19; p = 0.945) and OS (HR: 1.01; 95% CI: 0.66–1.36; p = 0.774) between the extended resection group and tumour resection alone group. Conclusions With adequate preparation and proper management, for patients with RPSs involving major vessels, aggressive surgical approach with vascular resection can achieve R0/R1 resection and improve survival.

PURPOSE:This study aimed to analyze the experience of our center and assess the efficacy of sac filling with fibrin sealant (FS) and gentamicin after endovascular aortic repair (EVAR) in patients with Brucella-related aorto-iliac artery aneurysms. MATERIALS AND METHODS:All patients who received sac filling with FS and gentamicin after EVAR for Brucella-related aorto-iliac artery aneurysms between March 2019 and September 2022 were reviewed. Before and after sac filling with FS and gentamicin, aneurysm sac thrombosis and endoleak were evaluated using a preloaded catheter to monitor immediate repair outcome. Short- to mid-term outcomes were assessed by the incidence of vascular graft infection (VGI), all-cause mortality, maximum aneurysm diameter, aneurysm sac thrombosis, and other adverse events. RESULTS:There were 14 patients with Brucella-related aorto-iliac artery aneurysms who underwent sac filling with FS and gentamicin after EVAR. Perioperative death due to myocardial infarction in 1 patient resulted in a postoperative all-cause mortality rate of 7.1% (1/14). All patients received anti-Brucella drugs for a median of 6.0 (range: 3-12) months postoperatively. During a median follow-up period of 15.0 (range 0.5-36) months, the absolute and sagittal maximum diameters of the aorto-iliac aneurysm sac were significantly smaller than preoperation (from 46.3 ± 17.0 to 27.2 ± 16.3 mm, P<.001, and from 39.2 ± 13.1 to 24.0 ± 13.8 mm, P<.001). Two of these patients had a postoperative disappearance of the pseudoaneurysm. One patient was reintervened for bilateral femoral artery bypass surgery. Except for sac filling with gentamicin, all patients received anti-brucella medication for a median of 6.0 (range: 3-12) months. There were no allergic reactions, nephrotoxicity, endoleak, recurrence, VGI, aorta-related or infection-related deaths during the perioperative period and follow-up. CONCLUSIONS:Sac filling with FS and gentamicin adjunctive to EVAR, with targeted drug delivery to the sites of Brucella-related aorto-iliac artery aneurysm infection lesions, may be an effective solution to control pseudoaneurysm infection and rupture.Clinical ImpactPrevious Brucella-associated aorto-iliac artery aneurysms have been limited to case reports. This study significantly increased the number of Brucella-associated aorto-iliac aneurysms by 19.7% (14/71) and extended the follow-up to 3 years. In this retrospective study of 14 patients with Brucella-associated aorto-iliac aneurysms treated endovascularly with fibrin sealant and gentamicin for sac filling and targeted administration to infection-related aneurysms, there were no aneurysm-related deaths or infection-related complications and may be an effective solution for controlling aneurysm infection and rupture. And, this approach is an attractive treatment for moving away from long-term dependence on antibiotics but still needs further evaluation.

Background: Venous thromboembolism (VTE) is a common postoperative complication; however, the incidence and risk stratification of postoperative VTE in patients with retroperitoneal tumor remains unclear. The authors aim to quantify the incidence, identify risk factors, and determine the outcomes of VTE in patients undergoing retroperitoneal tumor surgery. Methods: The authors retrospectively reviewed the characteristics, perioperative outcomes, and overall survival (OS) of patients (VTE and non-VTE) who underwent retroperitoneal tumor surgery between 2015 and 2020. Perioperative and oncologic outcomes were compared using propensity-matching and Cox analyses. Results: Of 1223 patients with retroperitoneal tumor surgery, 2.1% had VTE. Age [odds ratio (OR) 1.140, 95% CI: 1.053-1.239, P=0.004], recurrence (OR 1.851, 95% CI: 1.241-2.761, P=0.003), and vascular resection (OR 2.036, 95% CI: 1.054-3.934, P=0.034) were independent risk factors, with significant between-group differences regarding age, recurrence, sarcoma, organ resection, vascular resection, and operation time. No between-group differences in 30-day all-cause mortality (8 vs. 4%, OR 0.657, 95% CI: 0.375-1.151, P=0.427) and major complications (12 vs. 8%, OR 0.775, 95% CI: 0.483-1.244, P=0.572) were observed. Mean hospitalization duration (20.1 vs. 22.9 days, OR 1.153, 95% CI: 1.022-1.386, P=0.033) and ICU stay (3.2 vs. 5.5 days, OR 1.193, 95% CI: 1.034-1.347, P=0.012) were shorter in non-VTE versus VTE, respectively, with inferior OS (hazard ratio 2.090, 95% CI: 1.014-4.308, P=0.046) in VTE. Conclusions: Age, recurrence, and vascular resection are positively associated with VTE, which is associated with inferior OS.

ABSTRACT BACKGROUND Agenesis of the inferior vena cava (IVC) is an extremely rare congenital malformation. Although IVC dysplasia can present with symptoms, because of the low prevalence of this disease, it is often omitted from routine examination. Most reports on this topic have described the absence of the IVC; the absence of both a deep venous system and the IVC is even rarer. Chronic venous hypertension and varicosities leading to venous ulcers have been reported in patients with absent IVC that could be surgically bypassed; however, the absence of iliofemoral veins precluded any bypass procedure in the present patient. CASE PRESENTATION The authors report a case of IVC below renal vein hypoplasia in a 5-year-old girl who presented bilaterally with venous stasis dermatitis and ulcers in the lower extremity limb area. Ultrasonography revealed no clear IVC and iliofemoral venous system under the renal venous plane. Magnetic resonance venography subsequently confirmed the same findings. The patient’s ulcers were healed by compression therapy and routine wound care. CONCLUSIONS This is a rare case of venous ulcer in a pediatric patient stemming from congenital IVC malformation. With this case, the authors demonstrate the etiology of the appearance of venous ulcers in children.

From the Department of Vascular Surgery, West China Hospital, Chengdu, China [email protected]. Disclosure: The authors declare no conflict of interest.

Objective:To analyze and summarize the short and long-term results of open surgical repair (OSR) of abdominal aortic aneurysm (AAA) with hostile neck.Methods:The clinical data of AAA patients with hostile neck who underwent OSR from June 2017 to September 2019 in the Division of Vascular Surgery, West China Hospital of Sichuan University were retrospectively analyzed. A total of 21 patients were included, with a mean age of (64.33±12.46) years, 12 male patients, and 10 impending ruptures. The primary outcome was 30-day mortality, secondary outcomes included 3-year overall survival and reintervention rate.Results:Among 21 patients, 15 were short neck or pararenal aneurysms, 3 were large-neck AAAs, and 9 were AAAs with severe neck angulation. The aneurysm diameter of the patients was (66.54±17.34) mm. Three underwent renal artery reconstruction, and 2 underwent renal artery angioplasty. The median length of stay was 16 (12,19) days. The 30-day postoperative mortality rate was 4.76% (1/21), and the patient died of severe pulmonary infection. During a median follow-up of 40 (40, 67) months, 2 patients died of cardiovascular events. The 3-year overall survival rate was 85.71% (18/21). No aortic-related reintervention or death was observed during follow-up.Conclusion:OSR of AAA with hostile neck is safe and effective. Although there is a short-term risk of postoperative pulmonary complications, the long-term results are stable with a low risk of reintervention and mortalit.

Significant pancreatic islet dysfunction and loss shortly after transplantation to the liver limit the widespread implementation of this procedure in the clinic. Nonimmune factors such as reactive oxygen species and inflammation have been considered as the primary driving force for graft failure. The adipokine adiponectin plays potent roles against inflammation and oxidative stress. Previous studies have demonstrated that systemic administration of adiponectin significantly prevented islet loss and enhanced islet function at post‐transplantation period. In vitro studies indicate that adiponectin protects islets from hypoxia/reoxygenation injury, oxidative stress as well as TNF‐α‐induced injury. By applying adenovirus mediated transfection, we now engineered islet cells to express exogenous adiponectin gene prior to islet transplantation. Adenovirus‐mediated adiponectin transfer to a syngeneic suboptimal islet graft transplanted under kidney capsule markedly prevented inflammation, preserved islet graft mass and improved islet transplant outcomes. These results suggest that adenovirus‐mediated adiponectin gene therapy would be a beneficial clinical engineering approach for islet preservation in islet transplantation.

BACKGROUND:Definitive evidence to guide clinical practice on the principles of surgery for retroperitoneal sarcomas (RPSs) is still lacking. This study aims to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with contiguous organ resection in patients with RPS, the association between surgical resection margins and survival outcomes, and the role of surgery in recurrent RPS. METHODS:We searched PubMed, the Cochrane Library, and EMBASE for relevant randomised trials and observational studies published from inception up to May 1, 2021. Prospective or retrospective studies, published in the English language, providing outcome data with surgical treatment in patients with RPS were selected. The primary outcome was overall survival (OS). FINDINGS:In total, 47 articles were analysed. There were no significant differences in the rates of OS (HR: 0.93; 95% CI: 0.83-1.03; P = 0.574) and recurrence-free survival (HR: 1.00; 95% CI: 0.74-1.27; P = 0.945) between the extended resection group and the tumour resection alone group. Organ resection did not increase postoperative mortality (OR: 1.00; 95% CI: 0.55-1.81; P = 0.997) but had a relatively higher complication rate (OR: 2.24, 95% CI: 0.94-5.34; P = 0.068). OS was higher in R0 than in R1 resection (HR: 1.34; 95% CI: 1.23-1.44; P < 0.001) and in R1 resection than in R2 resection (HR: 1.86; 95% CI: 1.35-2.36; P < 0.001). OS was also higher in R2 resection than in no surgery (HR: 1.26; 95% CI: 1.07-1.45; P < 0.001), however, subgroup analysis showed that the pooled HR in the trials reporting primary RPS was similar between the two groups (HR, 1.14; 95% CI, 0.87-1.42; P = 0.42). Surgical treatment achieves a significantly higher OS rate than does conservative treatment (HR: 2.42; 95% CI: 1.21-3.64; P < 0.001) for recurrent RPS. CONCLUSIONS:For primary RPS, curative-intent en bloc resection should be aimed, and adjacent organs with evidence of direct invasion must be resected to avoid R2 resection. For recurrent RPS, surgical resection should be considered as a priority. Incomplete resection remains to have a survival benefit in select patients with unresectable recurrent RPS.

Covered stent has become one of the mainstream therapies for aortoiliac obstructive disease (AIOD), with a higher patency rate than bare metal stent. Covered balloon-expandable (CBE) stent can be placed more accurately with higher a radial support force, while covered self-expanding (CSE) stent has greater elasticity and higher trackability. However, there is no level I evidence regarding the comparison safety and efficacy between the CSE stent and CBE stent in AIOD to date. Therefore, this study aims to compare the efficacy and safety of CBE stent (BARD®LIFESTREAM™) and CSE stent (GORE® VIABAHN™) in AIOD. This trial is a prospective, single-center, parallel, noninferiority, randomized controlled trial. A total of 106 patients will be enrolled and these patients will be randomized to either the CBE stent group or the CSE stent group. The primary end point of the study is the occurrence of target lesion revascularization (TLR) at 12 months after the intervention. To our knowledge, the ballooN sElf cOver steNt AorToiliAc occuLusive (NEONATAL) trial is the first RCT to compare CBE and CSE stent in AIOD patients. The main aim is to compare the TLR of the target lesion between CBE stent and CSE stent at 12 months post-procedure. The results of clinical trials may contribute to establishing a strategic guideline for choosing the optimal type of covered stent in the treatment of AIOD patients. Chinese Clinical Trials Registry ChiCTR2100046734. Registered on 27 May 2021

探讨团队学习的教学方法应用在血管外科轮转住院医师显微技术培训中的效果.实践表明,应用团队学习教学方法对在血管外科轮转的住院医师进行显微技术的培训,有助于住院医师发挥主观能动性,从而增强他们学习显微外科技术的兴趣,提高他们的操作技能.

Objective To summarize our hospital's single-center experience of and reflections on the treatment of chronic limb-threatening ischemia (CLTI) of lower limbs combined with diabetes in the past 5 years. Methods We retrospectively analyzed cases of lower limb CLTI combined with diabetes diagnosed at our hospital from March 2017 to June 2021. The baseline data, surgical information, and follow-up results of the patients were collected. The primary outcome indicator was the patency rate of lower limb target artery within 1 year post-op, and the secondary indicators were the reoperation rate within 1 year post-op and the amputation rate within 1 year post-op. Results A total of 89 patients with lower limb CLTI combined with diabetes were included in the study. A total of 85 patients underwent percutaneous transluminal angioplasty and the operation of 7 patients ended in failure, with the operation success rate reaching 91.76% (78/85). Three patients underwent femoral popliteal artery bypass grafting with artificial blood vessels and one patient underwent iliac femoral artery bypass grafting with artificial blood vessels, with the success rate of the operations reachign 100% (4/4). Among 78 patients who successfully underwent percutaneous transluminal angioplasty, the median follow-up time was 33 months (13, 64). Two patients died within one year after operation, with the post-op one-year survival rate being 97.44% (76/78). The post-op 1-year reoperation rate was 19.23% (15/78), the 1-year target vascular patency rate (deaths not included) was 85.53% (65/76), and the 1-year amputation rate was 3.85% (3/78). Among the patients who underwent bypass surgery, the follow-up period was 13-48 months. No thrombosis in or re-occlusion of the artificial blood vessels were observed during the follow-up period, and the artificial blood vessels remained unoccluded. Conclusion Transluminal angioplasty has a relatively ideal rate of postoperative vascular patency. In addition, it is a minimally invasive procedure involving low perioperative risks and is performed under local anesthesia. Therefore, it can be used as the preferred treatment for patients with CLTI. On the other hand, bypass surgery has good long-term patency rate, but it involves higher perioperative risks and the procedure is more invasive. Therefore, bypass surgery can be used as an alternative when transluminal angioplasty ends in failure.

Background Wide-spread concerns have been raised about possible bias in published surgical non-inferiority trials. Therefore, we performed a comprehensive bibliometric analysis to identify the existence of bias, and provided recommendations for future non-inferiority trials. Methods Databases including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched (last update on 27 April 2020) to include published phase II and phase III non-inferiority surgical trials. We collected general information and parameters associated with trial design. The association between extracted factors and establishment of non-inferiority was then analyzed. Results A total of 347 trials were included in this study. Only 13 (3.7%) trials reported the pre-specified non-inferiority margin in registration, and 99 (28.5%) trials justified margin selection in ultimate trial publications. A significant association was found between industry funding and increased odds of achieving non-inferiority [odds ratio (OR): 1.17, 95% confidence interval (CI): 1.06 to 1.30, P=0.001]. Moreover, trials which had been presented in conferences were less likely to claim non-inferiority (OR: 0.83, 95% CI: 0.69 to 0.99, P=0.035). Conclusions Our study was the first quantitative analysis revealing the presence of biases in findings of existing surgical non-inferiority trials, which could possibly mislead surgeons’ clinical decision making. We suggest improving reporting of detailed study design especially funding sources as well as margin justification for future trials. We also encourage conference presentation of ongoing trials prior to the ultimate publication.

目的 对比破裂腹主动脉瘤腔内修复术与传统开放手术(OSR)治疗破裂腹主动脉瘤的临床疗效.方法 收集2009年1月至2015年12月于四川大学华西医院收治的71例破裂腹主动脉瘤患者的临床资料.根据治疗方式的不同将患者分为腹主动脉瘤腔内修复术(EVAR)组(n=30)和OSR组(n=41).比较两组患者的术前临床特征、手术情况和随访结果.结果 两组患者的年龄、性别、吸烟情况、休克、糖尿病、原发性高血压、冠心病、心力衰竭、心脏瓣膜病、周围血管疾病、慢性阻塞性肺疾病、慢性肾功能不全、昏迷、瘤颈长度、瘤体最大直径、瘤颈角度比较,差异均有统计学意义(P<0.05).EVAR组患者的手术持续时间短于OSR组患者,术中输血量和补液量均明显少于OSR组患者,差异均有统计学意义(P<0.05).术后,两组患者的总体重症监护室(ICU)观察时间比较,差异有统计学意义(P<0.05).EVAR组患者的围手术期病死率明显低于OSR组患者,差异有统计学意义(P<0.01).EVAR组患者的再干预率为16.67％,高于OSR组患者的2.44％,差异有统计学意义(P<0.05).两组患者术后1、3、6、12个月的生存率比较,差异无统计学意义(P>0.05).结论 EVAR治疗破裂腹主动脉瘤的手术时间更短,术后ICU观察时间更短,长期疗效与OSR类似,值得临床推广应用.

目的 探讨80岁及以上腹主动脉瘤(AAA)患者腔内覆膜支架修复术(EVAR)后短期及远期生存情况的危险因素.方法 收集2011年9月至2019年1月四川大学华西医院收治的175例行EVAR的80岁及以上AAA患者临床资料.首要短期结局指标为30 d病死率.采用多因素Logistic及Cox比例风险回归模型确定短期及远期结局的独立危险因素.结果 175例80岁及以上AAA患者EVAR后30 d病死率为3.43％(6/175).单因素分析结果显示,合并充血性心力衰竭和慢性肾脏病4～5期与80岁及以上AAA患者EVAR后30 d病死可能有关(P<0.05);多因素分析结果显示,合并充血性心力衰竭和慢性肾脏病4～5期均是80岁及以上AAA患者EVAR后30 d病死的独立危险因素(P<0.05).单因素分析结果显示,年龄、冠状动脉支架植入、充血性心力衰竭、心律不齐、动脉瘤最大直径均与80岁及以上AAA患者EVAR后的远期生存情况可能有关(P<0.05);将单因素分析中差异有统计学意义的因素作为自变量,将术后远期预后情况作为因变量纳入Cox风险比例回归模型进行分析,结果显示,80岁及以上、合并充血性心力衰竭、心律不齐、动脉瘤最大直径均是80岁及以上AAA患者EVAR后远期生存情况的独立危险因素(P<0.05).结论 对于术前合并充血性心力衰竭及慢性肾脏病4～5期的80岁及以上AAA患者,需适当提高其AAA腔内干预指征.高龄、充血性心力衰竭、心律不齐和动脉瘤最大直径均是80岁及以上AAA患者EVAR后远期生存情况的独立危险因素,应加强对此类患者的随访及心脑血管风险管理.

腹主动脉瘤是常见的主动脉疾病,目前尚无有效的药物保守治疗可抑制腹主动脉瘤扩大及破裂.因此,治疗方式多限于外科手术或腔内修复术.腹主动脉瘤动物模型对于深入研究腹主动脉瘤的发病机制、疾病进展及评价相关治疗方案具有重要意义.通过腹主动脉瘤疾病模型中动物种类的选择对不同的腹主动脉瘤建模方法进行研究.本文针对不同腹主动脉瘤建模方法的进展进行综述.