OBJECTIVE:Primarily to evaluate the area of neck coverage and secondarily, technical and clinical outcomes of the GORE® EXCLUDER® Conformable AAA Endoprosthesis (EXCC), designed to treat patients with significant angulation of the aortic neck, in routine clinical treatment of patients with abdominal aortic aneurysm (AAA). DESIGN:A prospective, multicentre, observational cohort study. MATERIALS AND METHODS:Patients aged >55 years with a nonruptured infrarenal AAA requiring treatment, were enrolled into the registry from June 2019 to December 2021. Baseline clinical, procedural, and follow-up data were collected pre-, peri-, and postoperatively at 3 and 12-months. CT images were assessed using a strict protocol at a core laboratory. The primary outcome was the estimated percentage of the total aortic neck that remained uncovered by the graft assessed on the first follow-up CT scan. RESULTS:One hundred five patients with AAA underwent endovascular aneurysm repair (EVAR) with the EXCC device in 13 UK study centers (mean age 77.5 years, 14/105 female, 7/105 symptomatic). One hundred two participants with available CT scans were placed into group A-beta angulation <60° and aortic neck >10 mm (51/102); group B-beta angulation <90° and >60° and aortic neck >15 mm (37/102); and group C-those outside of instructions for use (14/102). The primary outcome of median percentage of neck that remained uncovered after EVAR was 5.1% [IQR 1.9-12.4]; 4.8% in group A, 6.0% in group B, and 3.8% in group C. Overall technical success was 96% (97.9%, 100%, and 84.6% in group A, B, and C, respectively). One-year overall and aneurysm related mortality was 9.1% and 0%. Four patients required re-intervention for proximal neck complications (including 2/14 patients in group C). CONCLUSION:The EXCC device can be accurately placed even in patients with significant angulation of the aortic neck. Clinical outcomes are acceptable to 1 year; however, physicians should exercise caution when treating patients where the graft is placed outside the instructions for use.Clinical ImpactThis prospective registry assessed the performance of a novel device with greater conformability, and angulation control of the delivery system to treat abdominal aortic aneurysm (AAA) with up to 90° neck angulation within instructions for use (IFU). In 105 patients, the primary outcome of estimated median percentage of uncovered aortic neck was 5.1% [IQR 1.9-12.4]. In patients with anatomy conforming to IFU, there was no difference in the percentage of neck that was uncovered in angulated (>60°) versus nonangulated patients (0-60°) and no early type 1a endoleak. This suggests excellent apposition of the graft to the aortic wall despite significant angulation of the aortic neck. Clinical outcomes were acceptable to 1 year.

Background Standardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres. Methods Consensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies. Results Three consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital. Conclusions This consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.

Journal Article Management of aortic graft infection using biological neoaortic reconstruction: mid-term outcomes Get access Simon Glasgow, Simon Glasgow Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Ashwin Sivaharan, Ashwin Sivaharan Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Prakash Saha, Prakash Saha Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Hany Zayed, Hany Zayed Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Tommaso Donati, Tommaso Donati Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Dan Taylor, Dan Taylor Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Oliver T A Lyons, Oliver T A Lyons Department of Vascular Surgery, Christchurch Hospital, Christchurch, New ZealandUniversity of Otago, Dunedin, New Zealand Search for other works by this author on: Oxford Academic Google Scholar Nicholas Price, Nicholas Price Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Rachel E Bell, Rachel E Bell Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Search for other works by this author on: Oxford Academic Google Scholar Morad Sallam Morad Sallam Department of Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK Correspondence to: Morad Sallam, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK (e-mail: morad.sallam@gstt.nhs.uk) Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, znad159, https://doi.org/10.1093/bjs/znad159 Published: 26 July 2023 Article history Received: 03 December 2022 Revision received: 03 May 2023 Accepted: 05 May 2023 Published: 26 July 2023

Supplementary Table from An Exercise-Induced Metabolic Shield in Distant Organs Blocks Cancer Progression and Metastatic Dissemination

Fibrosis is associated with dramatic changes in extracellular matrix (ECM) architecture of unknown etiology. Here we exploit keloid scars as a paradigm to understand fibrotic ECM organization. We reveal that keloid patient fibroblasts uniquely produce a globally aligned ECM network in 2-D culture as observed in scar tissue. ECM anisotropy develops after rapid initiation of a fibroblast supracellular actin network, suggesting that cell alignment initiates ECM patterning. Keloid fibroblasts produce elevated levels of IL-6, and autocrine IL-6 production is both necessary and sufficient to induce cell and ECM alignment, as evidenced by ligand stimulation of normal dermal fibroblasts and treatment of keloid fibroblasts with the function blocking IL-6 receptor monoclonal antibody, tocilizumab. Downstream of IL-6, supracellular organization of keloid fibroblasts is controlled by activation of cell-cell adhesion. Adhesion formation inhibits contact-induced cellular overlap leading to nematic organization of cells and an alignment of focal adhesions. Keloid fibroblasts placed on isotropic ECM align the pre-existing matrix, suggesting that focal adhesion alignment leads to active anisotropic remodeling. These results show that IL-6-induced fibroblast cooperativity can control the development of a nematic ECM, highlighting both IL-6 signaling and cell-cell adhesions as potential therapeutic targets to inhibit this common feature of fibrosis.

BACKGROUND:Loop diuretics are commonly used for patients with heart failure (HF) but it remains unknown if one loop diuretic is clinically superior.HYPOTHESIS:Biomarkers and proteomics provide insight to how different loop diuretics may differentially affect outcomes.METHODS:Blood and urine were collected from outpatients with HF who were taking torsemide or furosemide for >30 days. Differences were assessed in cardiac, renal, and inflammatory biomarkers and soluble protein panels using the Olink Cardiovascular III and inflammation panels.RESULTS:Of 78 subjects, 55 (71%) were treated with furosemide and 23 (29%) with torsemide, and 25 provided a urine sample (15 treated with furosemide, 10 with torsemide). Patients taking torsemide were older (68 vs 64 years) with a lower mean eGFR (46 vs 54 ml/min/1.73 m2 ), a higher proportion were women (39% vs 24%) and Black (43% vs 27%). In plasma, levels of hs-cTnT, NT-proBNP, and hsCRP were not significantly different between groups. In urine, there were significant differences in urinary albumin, β-2M, and NGAL, with higher levels in the torsemide-treated patients. Of 184 proteins testing in Olink panels, in plasma, 156 (85%) were higher in patients taking torsemide but none were significantly different after correcting for false discovery.CONCLUSIONS:We show differences in urinary biomarkers but few differences in plasma biomarkers among HF patients on different loop diuretics. Olink technology can detect differences in plasma protein levels from multiple biologic domains. These findings raise the importance of defining differences in mechanisms of action of each diuretic in an appropriately powered study.

Advocacy interventions for survivors of domestic violence are well established and supported by evidence in some community and healthcare settings. Survivors of domestic violence identified in emergency departments have important differences, and it is not clear whether evidence can be applied to this population. We conducted an inclusive systematic review of controlled studies evaluating the effectiveness of advocacy workers for adult survivors identified in emergency departments. We identified five studies, all with substantial methodological flaws. The outcome measures were very varied. No study reported harm from advocacy. Most reported benefits from referrals to advocacy workers. Despite weak evidence, referral to advocacy workers for survivors of domestic violence is not harmful and offers benefits.

Patient-derived cell (PDC) models are a tool that bridge the gap between conventional cancer lines that do not faithfully replicate clinical responses and costly and time-consuming patient derived xenograft (PDX) models. Imagen Therapeutics is establishing the world’s largest biobank of PDC models for both patient diagnostic (PredictRx) and biopharma drug development (PredictTx) studies that show a high degree of correlation between PDC and patient drug response. Through our research, we have established unique culture conditions that specifically select for cancer stem cells, and these have been characterized using both 2-D and 3-D short-term high content image (HCI)-based analysis. To better understand the genomic and phenotypic profiles of these models we analyzed Next Generation Sequencing data and phenotypic cell killing using a panel of FDA-approved agents. Our results showed that mRNA expression of several known cancer stem cell markers were upregulated in our PDCs in addition to multidrug resistance (MDR) genes. Drug resistance in the phenotypic assay was then correlated with stemness and MDR expression profiles. Finally, sequential PDCs (models developed from same patient at different stages in disease progression), in addition to PDCs developed from the same patient at multiple lesion sites, were compared in terms of genomic sequencing and drug responses. Together our data supports the premise that PDCs recapitulate the cancer stem cell population and are a useful platform with which to interrogate drug responses in a variety of different cancer types. Citation Format: Gareth J. Griffiths, Abbie Dodd, Olivia Nee, Tilly Thuringer, Subir Singh, Rachel Howard-Jones, Yuen Ngan Fan, Albert Bezman, Rachel Bell, Ido Sloma, Chris Noakes, Dominic I. James. Establishment and characterization of patient-derived cancer cell models for pharmaceutical drug screening [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 191.

Abstract Exercise prevents cancer incidence and recurrence, yet the underlying mechanism behind this relationship remains mostly unknown. Here we report that exercise induces the metabolic reprogramming of internal organs that increases nutrient demand and protects against metastatic colonization by limiting nutrient availability to the tumor, generating an exercise-induced metabolic shield. Proteomic and ex vivo metabolic capacity analyses of murine internal organs revealed that exercise induces catabolic processes, glucose uptake, mitochondrial activity, and GLUT expression. Proteomic analysis of routinely active human subject plasma demonstrated increased carbohydrate utilization following exercise. Epidemiologic data from a 20-year prospective study of a large human cohort of initially cancer-free participants revealed that exercise prior to cancer initiation had a modest impact on cancer incidence in low metastatic stages but significantly reduced the likelihood of highly metastatic cancer. In three models of melanoma in mice, exercise prior to cancer injection significantly protected against metastases in distant organs. The protective effects of exercise were dependent on mTOR activity, and inhibition of the mTOR pathway with rapamycin treatment ex vivo reversed the exercise-induced metabolic shield. Under limited glucose conditions, active stroma consumed significantly more glucose at the expense of the tumor. Collectively, these data suggest a clash between the metabolic plasticity of cancer and exercise-induced metabolic reprogramming of the stroma, raising an opportunity to block metastasis by challenging the metabolic needs of the tumor. Significance: Exercise protects against cancer progression and metastasis by inducing a high nutrient demand in internal organs, indicating that reducing nutrient availability to tumor cells represents a potential strategy to prevent metastasis. See related commentary by Zerhouni and Piskounova, p. 4124

OBJECTIVE:Use of colour duplex ultrasound (CDUS) and computed tomography angiography (CTA) for infrarenal endovascular aortic aneurysm repair (EVAR) surveillance differs in internationally published guidelines. This study aimed firstly to compare CDUS detection of significant sac abnormalities with CTA. Secondly, a sensitivity analysis was conducted to compare financial estimates of the, predominantly CDUS based, local and Society of Vascular Surgery (SVS) protocols, the risk stratified European Society of Vascular Surgery (ESVS) protocol, and the CTA based National Institute of Health and Care Excellence (NICE) protocol. METHODS:Agreement between CDUS and CTA was assessed for detection of significant sac abnormalities. Surveillance protocols were extrapolated from published guidelines and applied to infrarenal EVAR patients active on local surveillance at a large, single centre. Surveillance intensity was dependent on presence of endoleak and subsequent risk of treatment failure in accordance with surveillance recommendations. Estimates for each surveillance protocol were inclusive of a range of published incidences of endoleak, contrast associated acute kidney injury (AKI), and excess hospital bed days, and estimated for a hypothetical five year surveillance period. RESULTS:The kappa coefficient between CDUS and CTA for detecting sac abnormalities was 0.68. Maximum five year surveillance cost estimates for the 289 active EVAR patients were £272 359 for SVS, £230 708 for ESVS, £643 802 for NICE, and £266 777 for local protocols, or £1 270, £1 076, £3 003, and £1 244 per patient. Differences in endoleak incidence accounted for a 1.1 to 1.4 fold increase in costs. AKI incidence accounted for a 3.3 to 6.2 fold increase in costs. CONCLUSION:A combined CTA and CDUS EVAR surveillance protocol, with CTA reserved for early seal assessment and confirmatory purposes, provides an economical approach without compromising detection of sac abnormalities. AKI, as opposed to direct imaging costs, accounted for the largest differences in surveillance cost estimates.

Background: Because of their direct patient contact, healthcare workers (HCW) face an unprecedented risk of exposure to COVID-19. The aim of this study was to examine incidence of COVID-19 disease among asymptomatic HCW and community participants in Northern Virginia during 6 months of follow-up. Methods: This is a prospective cohort study that enrolled healthy HCW and residents who never had a symptomatic COVID-19 infection prior to enrolment from the community in Northern Virginia from April to November 2020. All participants were invited to enrol in study, and they were followed at 2-, and 6-months intervals. Participants were evaluated by commercial chemiluminescence SARS-CoV-2 serology assays as part of regional health system and public health surveillance program to monitor the spread of COVID-19 disease. Findings: Of a total of 1,819 asymptomatic HCW enrolled, 1,473 (96%) had data at two-months interval, and 1,323 (73%) participants had data at 6-months interval. At baseline, 21 (1.15%) were found to have prior COVID-19 exposure. At two-months interval, COVID-19 rate was 2.8% and at six months follow-up, the overall incidence rate increased to 4.8%, but was as high as 7.9% among those who belong to the youngest age group (20-29 years). Seroconversion rates in HCW were comparable to the seropositive rates in the Northern Virginia community. The overall incidence of COVID-19 in the community was 4.5%, but the estimate was higher among Hispanic ethnicity (incidence rate = 15.3%) potentially reflecting different socio-economic factors among the community participants and the HCW group. Using cross-sectional logistic regression and spatio-temporal mixed effects models, significant factors that influence the transmission rate among HCW include age, race/ethnicity, resident ZIP-code, and household exposure, but not direct patient contact. Interpretation: In Northern Virginia, the seropositive rate of COVID-19 disease among HCW was compa-rable to that in the community. (C) 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Myofibroblasts, renowned for their contractility and extracellular matrix production, are widely considered the key effector cells for nearly all scars resulting from tissue repair processes, ranging from normal scars to extreme fibrosis. For example, it is often assumed that myofibroblasts underpin the characteristics of keloid scars, which are debilitating pathological skin scars lacking effective treatments because of a poor understanding of the disease mechanisms. Here, we present primary and published transcriptional and histological evidence that myofibroblasts are not consistently present in primary keloid lesions, and when alpha-smooth muscle actin (αSMA)-positive cells are detected, they are not greater in number or expressing more αSMA than in normal or hypertrophic scars. In conclusion, keloid scars do not appear to require αSMA-positive myofibroblasts; continuing to consider keloids on a quantitative spectrum with normal or hypertrophic scars, with αSMA serving as a biomarker of disease severity, is hindering advancement of understanding and therapy development.

Abstract Background/Aims IgG4 related disease (IgG4-RD) is a rare immune-mediated condition, increasingly being recognised as a multi-organ disorder. It is a relatively new entity and the precise prevalence is not known. It is a chronic fibro-inflammatory condition with raised circulating levels of immunoglobulin G4 and accumulation of plasma cells and fibrosis in the affected tissue. We report a retrospective observational study of patients with IgG4 related disease (IgG4-RD). Methods We conducted a retrospective observational study of patients seen at Guy’s and St Thomas’ NHS Foundation Trust Hospitals, London, UK. The data collected was analysed for clinical presentation, laboratory markers of inflammation, immunoglobulin subsets, autoantibody profiles, imaging and histopathology and compared to the 2019 ACR/EULAR criteria to determine a confirmed diagnosis of IgG4-RD. Data was also collected post standard-of-care treatment, including patient clinical outcomes and possible improvement. Results The study included a multi-ethnic cohort of 83 patients with multi-organ involvement. Fifty-nine of the eighty-three patients were classified as confirmed IgG4-RD (71%). Seventy one patients had biopsies of which 49 of the 59 (91%) confirmed IgG4-RD patients had biopsies consistent with IgG4-RD. Fifty patients underwent PET-CT scanning of which uptake was seen in 76% of those with confirmed IgG4-RD (26/34). Immunoglobulin IgG subclass analysis showed significantly higher IgG4 levels in the confirmed IgG4-RD group as compared to possible IgG4. Treatments were with corticosteroids and immunosuppressants such as azathioprine, methotrexate, mycophenolate, cyclophosphamide and rituximab. P167 Table 1:IgG4 levels and inflammatory markers for pre and post treatment groupsPre-RxPost-Rxp-valueCRPmean29 mg/l9 mg/l0.0298*Range0-300 mg/l1-70 mg/lESRmean35 mm/hr17 mm/hr0.0002*Range2-131 mm/hr1-74 mm/hrSerum IgG4mean4.9 g/L2.83 g/L0.0001*Range0.1-24.2 g/L0.02-13.3 g/L Conclusion IgG4-RD is a fibro-inflammatory disorder involving multiple organs. If not treated adequately may develop severe organ damage. It often responds to corticosteroids but may require other immunosuppressive therapy. Treatment with biologics such as B cell depletion therapy results are encouraging. Disclosure S. Sangle: None. N.T. Morton: None. A. Casian: None. L. Nel: None. J. Hanna: None. A. Fernando: None. R. Bell: None. P. Taylor: None. J. Pattison: None. T. O'Brien: None. D. D'Cruz: None.

Almost half of the human microRNAs (miRNAs) are encoded in clusters. Although transcribed as a single unit, the levels of individual mature miRNAs often differ. The mechanisms underlying differential biogenesis of clustered miRNAs and the resulting physiological implications are mostly unknown. In this study, we report that the melanoma master transcription regulator MITF regulates the differential expression of the 99a/let-7c/125b-2 cluster by altering the distribution of RNA polymerase II along the cluster. We discovered that MITF interacts with TRIM28, a known inhibitor of RNA polymerase II transcription elongation, at the mIR-let-7c region, resulting in the pausing of RNA polymerase II activity and causing an elevation in mIR-let-7c expression; low levels of RNA polymerase II occupation over miR-99a and miR-125b-2 regions decreases their biogenesis. Furthermore, we showed that this differential expression affects the phenotypic state of melanoma cells. RNA-sequencing analysis of proliferative melanoma cells that express miR-99a and miR-125b mimics revealed a transcriptomic shift toward an invasive phenotype. Conversely, expression of a mIR-let-7c mimic in invasive melanoma cells induced a shift to a more proliferative state. We confirmed direct target genes of these miRNAs, including FGFR3, BAP1, Bcl2, TGFBR1, and CDKN1A. Our study demonstrates an MITF-governed biogenesis mechanism that results in differential expression of clustered 99a/let-7c/125b-2 miRNAs that control melanoma progression.

Splenic artery aneurysms (SAA) are a rare and life-threatening pathology. Ruptured SAA has a mortality rate of up to 25%, with increased rates of rupture in pregnancy, pseudoaneurysm, liver transplantation, portal hypertension, symptomatic SAA and diameter >2 cm. Management of SAA in pregnant women is poorly described in the literature, making treatment of these patients difficult. Furthermore, careful consideration of complications for both the mother and the foetus need to be taken into account. This case report demonstrates that conservative management with monthly surveillance MRI can be used as viable treatment option of an asymptomatic 17 mm splenic artery aneurysm in a pregnant woman.

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The objective was to report and to evaluate the midterm outcomes of aortic infections in a high-volume center using a multidisciplinary team standardized management protocol. A retrospective analysis was conducted of prospectively collected data of 40 aortic infection cases (primary mycotic aneurysm or infected aortic grafts) managed between 2014 and 2019. All patients were managed as part of a multidisciplinary dedicated aortic infection service by complete resection of infected aortic segment or infected graft with in situ reconstruction using biologic graft. All patients completed a minimum of 3 months postoperative antimicrobial treatment. Curative state was defined by clinical assessment, normal inflammatory markers (white blood cell count, C-reactive protein), and resolution of uptake on positron emission tomography scan (maximum standardized uptake <4) at least 1 month after completion of antimicrobial treatment. Since 2015 at our center, 40 aortic infection (primary or after explantation) reconstructions have been performed with no intraoperative mortality (2.5% at 30 days and 17.5% at 6 months). Overall survival was 75% (mean follow-up, 26 months). All cases were reconstructed with in situ biologic grafts (19 bovine, 18 autologous vein, 2 bovine-vein combinations, and 1 cadaveric allografts), including 6 thoracic, 4 thoracoabdominal, and 30 abdominal. Median age at time of reconstruction was 70 years (range, 40-84 years) in a predominantly male (33) cohort. There were 14 (35%) patients who presented with primary infected (mycotic) aneurysms, 4 (29%) of which underwent immediate open intended-curative reconstruction; 10 (71%) were temporized with endovascular stenting followed by open reconstruction. The remaining 26 (65%) cases represented secondary infection of 11 (28%) endovascular stent grafts and 15 (38%) previous open graft repairs. Sixteen (40%) cases of aortoenteric fistulization were identified. Eight (80%) deaths were related to complications of surgery, initial infection, or reinfection, and two were from unrelated causes. Median time to death was 44 days (interquartile range, 39-186 days), and no significant difference was found between mortality in bovine vs autologous vein reconstructions on log-rank (Mantel-Cox) testing (P = .33). Twenty-six patients (65%) have reached a curative state to date. Reinfection occurred in three (8%) cases, two of which had undergone further intervention with additional stenting or intra-abdominal surgery. The most common cause of initial infection was an aortoenteric fistula, identified in 16 (40%) cases. Complete excision of infected aortic graft or native aorta combined with biologic neoaorta reconstruction is technically challenging but can be curative without the need of long-term antimicrobials. In our experience a multidisciplinary team approach and dedicated service seem to improve outcomes.

Intramural haematoma (IMH) describes the presence of blood within the aortic wall, and is associated with a significant morbidity and mortality. Early diagnosis is essential for institution of medical, and sometimes surgical, management. Neurological complications have rarely been described during the initial presentation of IMH, or other forms of acute aortic syndrome. We describe a 56-year-old man who presented with sudden onset chest pain and left leg weakness and numbness, and the loss of right leg pain and temperature sensation. CT Angiography showed a Type A intramural haematoma extending from the ascending to the infra-renal aorta. He was managed successfully with cerebrospinal fluid drainage and thoracic endografting to cover the intimal entry lesion. His neurological symptoms improved and he remained well at 3 years with minor residual neurological deficits. Spinal cord infarction is a rare but documented complication of acute aortic syndrome; Brown–Séquard syndrome typically results from a traumatic injury. To the best of our knowledge, this is the first report of IMH presenting with Brown–Séquard syndrome. This case highlights the need to consider acute aortic syndromes in a patient presenting with chest pain and acute neurological symptoms.