Internal modulation of proteolysis in vascular extracellular matrix remodeling: role of ADAM metallopeptidase with thrombospondin type 1 motif 5 in the development of intracranial aneurysm rupture.

Intracranial aneurysms (IAs) are common cerebrovascular diseases that carry a high mortality rate, and the mechanisms that contribute to IA formation and rupture have not been elucidated. ADAMTS-5 (ADAM Metallopeptidase with Thrombospondin Type 1 Motif 5) is a secreted proteinase involved in matrix degradation and ECM (extracellular matrix) remodeling processes, and we hypothesized that the dysregulation of ADAMTS-5 could play a role in the pathophysiology of IA. Immunofluorescence revealed that the ADAMTS-5 levels were decreased in human and murine IA samples. The administration of recombinant protein ADAMTS-5 significantly reduced the incidence of aneurysm rupture in the experimental model of IA. IA artery tissue was collected and utilized for histology, immunostaining, and specific gene expression analysis. Additionally, the IA arteries in ADAMTS-5-administered mice showed reduced elastic fiber destruction, proteoglycan accumulation, macrophage infiltration, inflammatory response, and apoptosis. To further verify the role of ADAMTS-5 in cerebral vessels, a specific ADAMTS-5 inhibitor was used on another model animal, zebrafish, and intracranial hemorrhage was observed in zebrafish embryos. In conclusion, our findings indicate that ADAMTS-5 is downregulated in human IA, and compensatory ADAMTS-5 administration inhibits IA development and rupture with potentially important implications for treating this cerebrovascular disease.

Cerebellar Arteriovenous Malformation Rupture Despite Apparent Angiographic Obliteration.

BACKGROUND: Arteriovenous malformations (AVMs) can occur in all regions of the brain and spinal cord, with clinical consequences and risks varying by location. Delayed AVM rupture despite digital subtraction angiography-confirmed obliteration post-radiation is exceedingly rare. CASE DESCRIPTION: To our knowledge, we present the first documented case of delayed hemorrhage associated with a cerebellar AVM 5 years after linear accelerator-based radiation in a man aged 31 years despite apparent angiographic obliteration. CONCLUSIONS: Intracranial hemorrhage after radiosurgery in digital subtraction angiography-confirmed obliterated AVMs is rare, with limited understanding of risk factors, appropriate preventative management, and mechanisms of occurrence. This case serves to demonstrate the need for greater awareness of this rare complication, as well as the need for appropriate surveillance and management strategies.

Unilateral twin tubal pregnancy: a case report and review of the literature.

BACKGROUND: Unilateral twin tubal pregnancy is an extremely rare condition, occurring in 1/20.000-250.000 pregnancies and represents a major health risk for reproductive-aged women, leading to even life-threatening complications. AIM: We present a case of a 31-year-old woman with unilateral twin tubal pregnancy, treated with methotrexate and then surgically because of failure, followed by review of the literature. METHODS: Researches for relevant data were conducted utilizing multiple databases, including PubMed and Ovid. RESULTS: The most common type of twin ectopic pregnancy is the heterotopic (1/7000 pregnancies) in which in which both ectopic and intrauterine pregnancy occur simultaneously. Expectant, medical and surgical therapy have similar success rates in correctly selected patients. Two prospective randomized trials did not identify any statistically significant differences between groups receiving MTX as a single dose or in multiple doses. Among the 106 cases reported in literature, methotrexate was tried just in 4 patients (3 unilateral and 1 bilateral) before ours. Details are reported in the table 1. CONCLUSION: The recent shift in the treatment of singleton ectopic pregnancies to the less invasive medical therapy might apply even in the case of twin implants.

Stent grafts in patients with carotid blowout syndrome: Outcome and antiplatelet therapy in preventive versus emergency cases.

BACKGROUND: Carotid blowout syndrome due to tumor infiltration, fistulas, and therapy-related necrosis can occur as late as years after the treatment. Reporting our experiences with preventive and acute treatment with stent grafts and discussing different ways of antiplatelet therapy. METHODS: We reviewed all patients between 2010 and 2016 who underwent stent graft placement and analyzed outcome, complications, and antiplatelet regime. RESULTS: Seventeen patients were treated in 24 sessions (n = 7 threatened, n = 5 imminent, and n = 12 acute bleeding). The antiplatelet regime covered the entire range from aspirin only to loading doses of aspirin/clopidogrel, perioperative heparin, and aspirin/clopidogrel for 12 months followed by lifelong aspirin. Rare complications were not associated with the preprocedural or periprocedural but were associated with the postprocedural antiplatelet regime. CONCLUSION: Most complications of stent graft implantations due to a carotid blowout syndrome occur postprocedurally: rare thrombotic events are linked to not taking a medication and frequent rebleedings may be reduced by an earlier reduction of dual-antiplatelet to mono-antiplatelet therapy.

Large gastric intramural hematoma mimicking a visceral artery aneurysm: a case report.

BACKGROUND: Gastric hematoma is a rare disorder. Here we report a case of a large gastric intramural hematoma mimicking an impending rupture of a visceral artery aneurysm. CASE PRESENTATION: A 60-year-old Japanese woman complained of left flank pain. Computed tomography with intravenously administered contrast agent showed a solid mass of 5 × 5 × 8 centimeter in the left middle abdominal quadrant. On completion of computed tomography, the working diagnosis was an impending rupture of an aneurysm located in a branch of the superior mesenteric artery. Transcatheter arterial embolization was performed, but angiography of the superior mesenteric artery and the inferior mesenteric artery did not indicate extravasation of the contrast agent and we did not observe any aneurysmal structure. We decided to perform surgery. The operational findings revealed that the mass was a gastric intramural hematoma. CONCLUSION: On encountering an intra-abdominal mass found to be attached to a gastric wall, a gastric intramural hematoma should be considered.

Splenic Rupture in Children With Portal Hypertension.

INTRODUCTION: Massive splenomegaly from portal hypertension (PHTN) in children raises the specter of splenic rupture; however, the incidence, etiology, and risk of rupture have not been studied, nor have existing practices to reduce risk. We therefore performed an international survey to describe the splenic rupture cases in PHTN and to describe the existing empirical practice among hepatologists. METHODS: A questionnaire was constructed to elicit cases of splenic rupture and collect hepatologists' common practices for prevention of splenic rupture. Pediatric hepatologists working in selected tertiary academic centers in the United States, Canada, and the United Kingdom were contacted. RESULTS: Hepatologists from 30 of 35 centers who met the inclusion criteria replied to the survey. Thirteen cases of splenic rupture were described of which 11 resulted from trauma. In the opinion of the practitioners, high-risk activities were football, hockey, and wrestling. Sixty-one percent recommended total restriction from high-risk activities. Seventy-four percent stated that platelet count had no effect on this decision and 61% advised a spleen guard for certain activities. CONCLUSIONS: Splenic rupture in patients with PHTN and splenomegaly seems to be rare. The reported splenic rupture cases were mostly related to falling (and not to participation in sports). There was general agreement among hepatologists about restricting high impact sports. There was variation in recommendations regarding the use of a spleen guard. The authors recommend use of spleen guards in children with splenomegaly from PHTN for physical activities with risk of fall or blunt abdominal trauma.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the review first published in 2014. OBJECTIVES: This review aims to compare the clinical outcomes of percutaneous access with surgical cut-down femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR). SEARCH METHODS: For this update the Cochrane Vascular Information Specialist (CIS) searched their Specialised Register (last searched October 2016) and CENTRAL (2016, Issue 9). We also searched clinical trials registries and checked the reference lists of relevant retrieved articles. SELECTION CRITERIA: We considered only randomised controlled trials. The primary intervention was a totally percutaneous endovascular repair. We considered all device types. We compared this against surgical cut-down femoral artery access endovascular repair. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for a ruptured abdominal aortic aneurysm and those reporting aorto-uni-iliac repairs. DATA COLLECTION AND ANALYSIS: Two review authors independently collected all data. Owing to the small number of trials identified we did not conduct any formal sensitivity analysis. Heterogeneity was not significant for any outcome. MAIN RESULTS: Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology.We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence).There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence).Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence).We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups. AUTHORS' CONCLUSIONS: This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.

[Spontaneous Tendon Ruptures in the Rheumatoid Hand]. / Spontánní slachové ruptury v oblasti revmatické ruky.

A spontaneous tendon rupture is a direct consequence of rheumatoid inflammation and can appear without any noticeable impact, often during sleep. The patient then presents with inability to flex or extend metacarpophalageal or interphalangeal joints. Multiple ruptures resulting in impaired function of several fingers can also occur and markedly limit the hand's grip strength. A tear may arise from either mechanical injury to the tendon along its course over bone or connective tissues, or by biochemical action of lysosomal enzymes, released during the inflammation process, on the connective tissue of the tendon. Ischaemic damage to a part of the tendon due to constriction of vessels supplying the peritenonium is found in hypertrophic peri-tenosynovitis. Spontaneous ruptures can be prevented, in the first place, by early synovectomy and then by a number of prophylactic procedures on soft tissues and carpal bones, which can stop or at least slow down the development of severe axial deformities of the wrist and hand. Simple end-to-end suture of the stumps is usually not possible; tendon repair surgery using free grafts or, more often, intact tendon transfer is necessary. In the flexor part, transfer of the superficial flexor tendon to a stump of the deep flexor tendon is frequently performed; a free graft can also be used at a two-stage tendon reconstruction. The repair of flexor tendons is technically more demanding and the results are less satisfactory compared to repair surgery on the extensor tendon. Key words: rheumatoid arthritis, metacarpophalageal joint, interphalangeal joint, tendon rupture.

A Splenic Epithelial Cyst: Increased Size, Exacerbation of Symptoms, and Elevated Levels of Serum Carcinogenic Antigen 19-9 after 6-year Follow-up.

A 58-year-old man, who had presented with a large cyst between the pancreatic tail and splenic hilum 6 years previously, was referred to our hospital with exacerbation of abdominal distention. Computed tomography revealed a well-demarcated, unilocular cyst, with a beak sign for the pancreas, without wall thickening or nodules suggestive of a non-neoplastic cyst. Compared with 6 years previously, the cyst had increased in size from 14.7 cm to 19.5 cm, and the serum carcinogenic antigen 19-9 level had increased from 635 U/mL to 1,918 U/mL. To prevent spontaneous rupture, laparotomy was performed, and the cyst was pathologically diagnosed as a splenic epithelial cyst.

Gene therapy strategies to improve strength and quality of flexor tendon healing.

INTRODUCTION: Rupture of the repair and adhesion around a tendon are two major problems after tendon surgery. Novel biological therapies which enhance healing and reduce adhesions are goals of many investigations. Gene therapy offers a new and promising approach to tackle these difficult problems. In the past decade, we sought to develop methods to augment tendon healing and reduce tendon adhesion through gene therapy. AREAS COVERED: This review discusses the methods and results of adeno-associated viral (AAV) type 2 vector gene therapy to increase tendon healing strength and reduce adhesions in a chicken model. Micro-RNA related gene therapy is also discussed. We also developed a controlled release system, which incorporates nanoparticles to deliver micro-RNAs to regulate tendon healing. EXPERT OPINION: We obtained promising results of enhancement of tendon healing strength in a chicken model using AAV2-mediated gene transfer. AAV2-mediated micro-RNA transfer also limited adhesions around the tendon. Controlled release systems incorporating nanoparticles have ideally delivered genes to the healing tendons and resulted in a moderate (but incomplete) reduction of adhesions. It remains to be determined what the best doses are and what other factors are in play in adhesion formation. These are two targets in our future investigations.

Is there still a place for Achilles tendon lengthening?

Patients with diabetes and ankle equinus are at particularly high risk for forefoot ulceration because of the development of high forefoot pressures. Stiffness in the triceps surae muscles and tendons are thought to be largely responsible for equinus in patients with diabetes and underpins the surgical rationale for Achilles tendon lengthening (ATL) procedures to alleviate this deformity and reduce ulcer risk. The established/traditional surgical approach is the triple hemisection along the length of the Achilles tendon. Although the percutaneous approach has been successful in achieving increases in ankle dorsiflexion >30°, the tendon rupture risk has led to some surgeons looking at alternative approaches. The gastrocnemius aponeurosis may be considered as an alternative because of the Achilles tendon's poor blood supply. ATL procedures are a balance between achieving adequate tendon lengthening and minimizing tendon rupture risk during or after surgery. After ATL surgery, the first 7 days should involve reduced loading and protected range of motion to avoid rupture, after which gradual reintroduction to loading should be encouraged to increase tendon strength. In summary, there is a moderate level of evidence to support surgical intervention for ankle joint equinus in patients with diabetes and forefoot ulceration that is non-responsive to other conservative treatments. Areas of caution for ATL procedures include the risk for overcorrection, tendon rupture and the tendon's poor blood supply. Further prospective randomized control trials are required to confirm the benefits of ATL procedures over conservative care and the most optimal anatomical sites for surgical intervention.

The clinical value of surgeons' efforts of preventing intraoperative tumor rupture in stage I clear cell carcinoma of the ovary: A Korean multicenter study.

OBJECTIVE: To demonstrate the survival impact of intraoperative tumor rupture in women with stage I clear cell carcinoma (CCC) of the ovary. METHODS: A total of 193 patients with stage I CCC of the ovary who had undergone a complete staging operation followed by ≥three cycles of adjuvant platinum-based chemotherapy, were retrospectively reviewed. Survival analysis was performed and compared between three stage groups: IA/IB, IC1, and IC2/IC3. RESULTS: There were 70, 51, and 72 women with ovarian CCC in stages IA/IB, IC1, and IC2/IC3, respectively. Intraoperative tumor rupture occurred in 69 (35.8%) patients. Gross endometriosis (p=0.020) and significant peritumoral adhesion (p<0.001) were associated with intraoperative tumor rupture. However, neither laparoscopic approach nor large tumor size >10cm were associated with intraoperative tumor rupture. Patients with stage IC2/IC3 compared to those with stage IC1, had poorer progression-free survival (PFS) (5-year PFS, 68.5% versus 91.7%; p=0.010) and overall survival (OS) (5-year OS, 81.1% versus 95.4%; p=0.027). However, there was no significant difference between patients with stages IA/IB and IC1 CCC in PFS (5-year PFS 88.8% versus 91.7%; p=0.291) and OS (5-year OS 94.6% versus 95.4%; p=0.444). Stage IC2/IC3 was the only independent poor prognostic factor for OS (hazard ratio, 3.50; 95% confidence interval, 1.31 to 9.36). CONCLUSION: Surgical spillage of tumor cells does not appear to have a negative impact on survival outcomes of women with stage I ovarian CCC who received ≥three cycles of adjuvant platinum-based chemotherapy.

[A Case of Malignant Lymphoma of the Spleen Infiltrating the Diaphragm Treated with Splenectomy].

A 67-year-old man was treated for diabetes mellitus by his family doctor. A splenic tumor was suspected based on his pain in the left side of the abdomen. He was admitted to our hospital for close inspection and medical treatment. Abdominal CT and MRI scans showed a tumor, 10 cm in diameter, in the spleen. An opaque boundary with the diaphragm was also observed. On PET-CT, accumulations of FDG were observed in the left supraclavicular fossa and the left axilla. The serum levels of LDH and sIL-2R were elevated, and therefore a diagnosis of malignant lymphoma was suspected. Due to the risk of splenic rupture, a splenectomy was performed. After pathological examination, the patient was diagnosed with diffuse large B-cell malignant lymphoma. He is currently being treated with chemotherapy at another medical institute. Splenic rupture occurs in some cases of splenic malignant lymphoma, although the number of reported cases is low. In some of the cases, splenic rupture occurred during treatment of the malignant lymphoma. There is no specific way to measure the risk of splenic rupture; however, performing a prophylactic splenectomy is one option in cases where tumor cells have extended to the capsula lienis, similar to that in our patient.

Medical and neurologic complications of the current management strategy of angiographically negative nontraumatic subarachnoid hemorrhage patients.

PURPOSE: Common management of angionegative subarachnoid hemorrhage includes mandatory intensive care unit stay for up to 14 days with strict bedrest, constant neurologic serial examination, invasive arterial and central line monitoring, and aneurysm rupture precautions. We evaluated the frequency of neurologic and nonneurologic complications in this patient population. METHODS: This was a retrospective chart review from July 2008 to 2011. Adult patients with International Classification of Diseases, Ninth Revision code for nontraumatic subarachnoid hemorrhage who had angiograms and cranial cat scans (CTs) were evaluated as the first screening measure. Negative screening angiograms constituted our study population and were divided into 2 groups (aneurysmal or perimesencephalic) based on the CT blood pattern. RESULTS: Fifty-one patients met the study criteria (aneurysmal CT, n = 26; perimesencephalic CT pattern, n = 25). There were no incidences of rebleeding or mortality, and patients were discharged after a mean of 15.24 hospital days and a mean of 11 bedrest days. Seventeen patients (65%) in the aneurysmal group developed at least 1 nonneurologic complication compared with 2 patients (8%) in the perimesencephalic group (P = .001). Eleven patients in the aneurysmal group (42.3%) developed at least 1 neurologic complication compared with 1 patient (4%) in the perimesecephalic group (P = .001). CONCLUSION: Based on our results, we propose admission to the medical floor for patients with World Federation of Neurosurgical Societies score 1 to 3, perimesencephalic CT pattern, and no hydrocephalus.

Hemodynamic analysis and treatment of an enlarging extrahepatic portal aneurysm: report of a case.

Aneurysms in the portal venous system are relatively rare. We report the case of an extrahepatic portal venous aneurysm, detected incidentally by ultrasonography. The patient, a 75-year-old woman, was initially observed over 18 months, during which time, the aneurysm grew from 36 mm × 32 mm to 51 mm × 37 mm in size, without symptoms. Hemodynamic analysis employing computational flow dynamics technique showed obvious turbulence in the aneurysm, and the wall shear stress (WSS) against that part of the aneurysmal wall was greater than in other sites. To prevent complications such as spontaneous rupture and portal vein thrombosis, the aneurysm was resected, with reconstruction of the portal trunk. While careful follow-up is sufficient for most portal venous aneurysms, its enlargement could indicate possible spontaneous rupture. The increased WSS against part of the aneurysmal wall most likely accounts for the aneurysm enlargement in this case.

Comparative analysis of laparoscopy versus laparotomy in the management of ovarian cyst during pregnancy.

AIM: The aim of the present study was to evaluate the surgical and obstetric results of laparoscopy versus laparotomy in the management of ovarian cyst during pregnancy. MATERIAL AND METHODS: Sixty-nine eligible patients who met our criteria were randomly divided into the laparoscopy group (n = 33) and the laparotomy group (n = 36). The two groups were compared for their surgical and obstetric outcomes and the extent of pelvic adhesion discovered in later cesarean section (CS). RESULTS: The laparoscopy group had less blood loss (43 ± 15 vs 51 ± 13 mL, P = 0.02), shorter postoperative hospital stay (2.9 ± 0.5 vs 5.8 ± 0.6 days, P < 0.001), and lower postoperative pain score (2.7 ± 1.2 vs 5.9 ± 1.5, P < 0.001) compared with the laparotomy group. The operative time, neonates' Apgar scores and birthweights between the two groups showed no significant differences (P > 0.05). Sixteen patients in the laparoscopy group, and 15 patients in the laparotomy group underwent cesarean section. The filmy and dense type adhesion rate was significantly different between the laparoscopy group and the laparotomy group (6.25% vs 53.3%, and 0% vs 20%, respectively). CONCLUSIONS: The present results suggest that laparoscopy is a better choice than laparotomy for ovarian cyst during pregnancy, with less blood loss, less postoperative pain and less postoperative hospital stay. It offers a faster recovery, results in less pelvic adhesion and does not affect the fetus; however, studies encompassing larger numbers of cases are needed.

Totally percutaneous versus standard femoral artery access for elective bifurcated abdominal endovascular aneurysm repair.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. More recently endovascular aneurysm repairs (EVARs) have become a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in patients with, for example, groin scarring or arterial calcification. OBJECTIVES: This review aims to compare the clinical outcomes of percutaneous access with standard femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR). SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched July 2013), CENTRAL (2013, Issue 6) and clinical trials databases. Reference lists of retrieved articles were checked. SELECTION CRITERIA: Only randomised controlled trials were considered. The primary intervention was a totally percutaneous endovascular repair. All device types were considered. This was compared against standard femoral artery endovascular repair. Only studies investigating elective repairs were considered. Studies reporting emergency surgery for a ruptured abdominal aortic aneurysm (rAAA) and those reporting aorto-uni-iliac repairs were excluded. DATA COLLECTION AND ANALYSIS: All data were collected independently by two review authors. Owing to the small number of trials identified, no formal assessment of heterogeneity or sensitivity analysis was conducted. MAIN RESULTS: Only one trial met the inclusion criteria, involving a total of 30 participants, 15 undergoing the percutaneous technique and 15 treated by the standard femoral cut-down approach. There were no significant differences between the two groups at baseline.No mortality or failure of aneurysm exclusion was observed in either group. Three wound infections occurred in the standard femoral cut-down group, whereas none were observed in the percutaneous group. This was not statistically significant. Only one major complication was observed in the study, a conversion to the cut-down technique in the percutaneous access group. No long-term outcomes were reported. One episode of a bleeding complication was reported in the percutaneous group. Significant differences were detected in surgery time (percutaneous 86.7 ± 27 minutes versus conventional 107.8 ± 38.5 minutes; P < 0.05).The included study had a small sample size and failed to report adequately the method of randomisation, allocation concealment and the pre-selected outcomes. AUTHORS' CONCLUSIONS: Only one small study was identified, which did not provide adequate evidence to determine the efficacy and safety of the percutaneous approach compared with endovascular aneurysm repairs. This review has identified a clear need for further research into this potentially beneficial technique. One ongoing study was identified in the search, which may provide an improved evidence base in the future.