Anxiety, depression, and body image among infertile women with and without polycystic ovary syndrome.

STUDY QUESTION: In women undergoing fertility treatment, do those with polycystic ovary syndrome (PCOS) have a higher prevalence of symptoms of anxiety and depression and lower body appreciation than women without PCOS? SUMMARY ANSWER: Having PCOS was not associated with symptoms of anxiety and depression but was associated with somewhat lower body appreciation. WHAT IS KNOWN ALREADY: PCOS has been associated with a higher chance to develop mental health problems, like anxiety, and body image concerns. The International Guidelines on PCOS recommend that all women with PCOS should routinely be screened for anxiety and depressive disorders. In most studies in this field, the comparison group included healthy women without fertility problems. STUDY DESIGN, SIZE, DURATION: We conducted a cross-sectional survey study between May 2021 and July 2023, using an online questionnaire. We informed women about this study at fertility clinics in the Netherlands through posters and leaflets and on the websites of the Dutch patient organizations Freya and Stichting PCOS. PARTICIPANTS/MATERIALS, SETTING, METHODS: This study included women with infertility, with and without PCOS, who were undergoing fertility treatment. Women completed two assessment tools: the Hospital Anxiety and Depression Scale (HADS) and the Body Appreciation Scale-2 (BAS-2). Primary outcomes were clinically relevant symptoms of anxiety (score ≥ 11) and depression (score ≥ 11), and BAS-2 scores. Secondary outcomes were mean anxiety and depression scores and anxiety and depression scores of 8 and higher. Dichotomous outcomes and continuous outcomes were analysed using logistic and linear regression analyses adjusted for age, BMI, and duration of infertility. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 1025 women currently undergoing infertility treatment participated, of whom 502 (49.0%) had PCOS and 523 (51.0%) had other infertility diagnoses. We found self-reported clinically relevant symptoms of anxiety in 33.1% of women with PCOS and in 31.0% of women with other infertility diagnoses (adjusted OR: 0.99, 95% CI 0.74-1.31). Clinically relevant symptoms of depression were reported in 15.5% of women with PCOS versus 14.5% of women with other infertility diagnoses (adjusted OR: 1.04, 95% CI 0.71-1.50). Women with PCOS reported slightly less body appreciation (adjusted mean difference: -1.34, 95% CI -2.32 to -0.36). LIMITATIONS, REASONS FOR CAUTION: Results are based on self-report and may have been affected by sampling bias. WIDER IMPLICATIONS OF THE FINDINGS: Although guidelines recommend screening women with PCOS, feelings of anxiety and depression can be present in any woman undergoing fertility treatments. We advise fertility clinics to be aware of women's mental health issues and to offer support accordingly, as a part of routine care. STUDY FUNDING/COMPETING INTEREST(S): This study did not receive specific funding. All authors report no conflict of interest related to the current research. TRIAL REGISTRATION NUMBER: This study was pre-registered at OSF: https://osf.io/qbeav.

Assessing the quality of cardiac rehabilitation programs by measuring adherence to the Australian quality indicators.

BACKGROUND: Every year, over 65,000 Australians experience an acute coronary syndrome (ACS) and around one-third occur in people with prior coronary heart disease. Cardiac rehabilitation (CR) aims to prevent a repeat ACS by supporting patients' return to an active and fulfilling lifestyle. CR programs are efficacious, but audits of clinical practice show variability of program delivery, which may compromise patient outcomes. Core components, quality indicators and accreditation of programs have been introduced internationally to increase program standardisation. With Australian quality indicators (QIs) for cardiac rehabilitation recently introduced, we aimed to conduct a survey in one state of Australia to assess the extent to which programs adhere to the measurement of QIs comparing country, metropolitan, telephone and face to face programs. METHODS: A cross- sectional survey design with face validity testing was used to formulate questions to evaluate cardiac rehabilitation program and personnel characteristics and QI adherence. Between October 2020- December 2021, 23 cardiac rehabilitation programs across country and metropolitan areas were invited to participate. Quality improvement was defined as adherence to the Australian Quality Indicators, and we developed an objective score to calculate program performance categorised by quartiles. Significance of CR completion and time to enrolment between program type (telephone versus face to face) and location (country versus metropolitan were compared using Pearson's Chi-square and Mann-Whitney U tests. RESULTS: Among the 23 CR programs, 15 were country and 8 metropolitan-based and 22 were face to face and 1 telephone-based. Median wait time from discharge was 27.0 days, (interquartile range 19.3-46.0) across all programs and country completions of enrolled were 76.9% versus metropolitan 56.5%, p < 0.001 and telephone versus face to face 92.9% versus 59.6% p < 0.001. Pre-program QI adherence was higher than post program for depression, medication adherence, health-related quality of life and comprehensive re-assessment. Seventy four percent of programs were ranked at a medium level of performance (mean score: 11.4/16, SD ± 0.79). CONCLUSIONS: A survey of 23 cardiac rehabilitation programs, showed variability in adherence to measurement of the Australian Cardiovascular and Rehabilitation Association and Australian Heart Foundation Cardiac Rehabilitation Quality Indicators. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ANZCTR), ACTRN12621000222842 , registered 03/03/2021.

A model for perception-based identification of sensitive skin.

BACKGROUND: With high prevalence of sensitive skin (SS), lack of strong evidence on pathomechanisms, consensus on associated symptoms, proof of existence of 'general' SS and tools to recruit subjects, this topic attracts increasing attention of research. OBJECTIVE: To create a model for selecting subjects in studies on SS by identifying a complete set of self-reported SS characteristics and factors discriminatively describing it. METHODS: A survey (n = 3058) was conducted, comprising questions regarding socio-demographics, atopy, skin characteristics, personal care, degree of self-assessed SS and subjective and objective reactions to endogenous and exogenous factors. Exploratory factor analysis on 481 questionnaires was performed to identify underlying dimensions and multivariate logistic regression to find contributing variables to the likelihood of reporting SS. RESULTS: The prevalence of SS was found to be 41%, and 56% of SS subjects reports a concomitant atopic condition. The most discriminative were the eliciting factors toiletries and emotions, and not specific skin symptoms in general. CONCLUSION: Triggers of different origins seem to elicit SS, it is not defined by concomitant skin diseases only, suggesting existence of 'general' SS. A multifactorial questionnaire could be a better diagnostic than a one-dimensional provocative test.

Urodynamic changes in mice with experimental autoimmune encephalomyelitis correlate with neurological impairment.

AIMS: Neurogenic bladder dysfunction is a major issue in Multiple Sclerosis (MS). High intravesical pressure should be treated early. Available therapies are insufficient and there is need for drug development and investigation of pathogenesis. Experimental Autoimmune Encephalomyelitis (EAE) in rodents is a well validated model to study MS. Previous research has shown that these animals develop urinary symptoms. However, from clinical studies, we know that symptoms do not necessarily reflect changes in bladder pressure. This paper aims to provide a complete overview of urodynamic changes in a model for detrusor overactivity in MS. METHODS: Female C57Bl/6J mice, injected with MOG35-55 and control mice, injected with vehicle (Complete Freund's adjuvant), were monitored daily for neurologic symptoms. Within 1 month after symptom development, mice were used for cystometry or histology of the bladder. RESULTS: Increasing disease score correlated with increased micturition frequency, basal pressure, and average pressure, and with a decrease in functional bladder capacity, voiding amplitude, and maximum pressure. CONCLUSIONS: This paper provides a detailed description of bladder function in C57Bl/6J mice with Myelin Oligodendrocyte Glycoprotein peptide (MOG35-55 ) induced EAE. This EAE model induces detrusor overactivity in close relationship to neurological impairment. EAE in mice is a suitable model to study detrusor overactivity in MS. Neurourol. Urodynam. 35:450-456, 2016. © 2015 Wiley Periodicals, Inc.

Aortic Dissection Limited to Abdominal Aorta: an Underrecognized Entity?

BACKGROUND: Aortic dissection limited to the abdominal aorta is a rare clinical entity with non-specific clinical features. Optimal treatment, as well as natural history and progression of the disease, remain unclear. In 1992 we -reported 5 cases of isolated abdominal aortic dissection (IAAD) and in the present paper we update our series with 5 additional patients. A concise literature review is also provided. METHODS: Between 1992 and 2014, we diagnosed 5 patients with IAAD (4 men, mean age 60.6 years, range 45-77). No patient presented with acute onset of symptoms. One patient was diagnosed with a periumbilical bruit, and diagnosis was made with magnetic resonance (MR)-angiography. Other diagnoses were incidental findings on computed tomographic (CT) scanning. Dissection was located infrarenally in four cases and at the celiac trunk in one case. RESULTS: All cases were treated conservatively with hypertension control and close follow-up. Follow-up period ranged from 10 months to 20 years and was performed yearly by CT- or MR-angiography and blood pressure monitoring. All patients remained symptom-free, all dissection lengths remained stable. Slowly increasing post-dissection aneurysmal dilatation was encountered in two patients. We combined results of these five new patients with five previously diagnosed and reported patients at our center. Treatment was surgical in only one out of 10 patients. There was no disease-related mortality during follow-up. CONCLUSIONS: Based on our case series, IAAD remains a rare clinical condition with relative benign clinical course. Treatment was almost exclusively conservative. Recent publications state IAAD might be underrecognized and under-diagnosed compared to thoracic aortic dissections.

Preclose Percutaneous Endurant™ Endografting with the Proglide™ Device: a Safe and Feasible Combination.

BACKGROUND: Endovascular repair of abdominal aortic aneurysms has been revolutionized over the last two decades. Opening the doors for a percutaneous approach by avoiding surgical exposure of the vascular access site. The goal of this report is to analyze the feasibility and efficacy of using Perclose Proglide™ through a preclose technique in a percutaneous approach to Endurant™ endografting for Asymptomatisch infrarenal aortic aneurysms in an elective setting. METHODS: Between April 2011 and April 2014, 45 consecutive patients underwent percutaneous endovascular aortic aneurysm repair (PEVAR) for an asymptomatic infrarenal aortic aneurysm. Closure of percutaneous access sites was ensured with Perclose Proglide in a "preclose" technique. Data were collected in a prospective maintained database with a follow-up period of one month. Patient demographics, aneurysmal characteristics, procedural details and complications were recorded. RESULTS: A total of 170 Proglide devices were used to close 85 access sites. Adequate hemostasis was obtained in 96.5 percent (82 of 85 access sites). Conversion to a femoral cutdown was necessary in 2.4% (2 of 85 access sites). The mean hospitalization was 2.6 days and 86.7 percent of patients were discharged within 2 days. The incidence of post-procedural access-related complications was 2.2%. CONCLUSIONS: PEVAR using the Perclose Proglide in preclosing 14Fr to 20Fr access sites for Endurant endografting in the treatment of asymptomatic infrarenal aortic aneurysms is feasible and effective. Moreover, the percutaneous approach allows for procedures to be performed under local anesthesia, while providing a low risk for access-related complications and a relatively short hospitalization.

GHS-R1a signaling in the DMH and VMH contributes to food anticipatory activity.

BACKGROUND: Rats that have restricted access to food at a fixed time point of the circadian phase display high levels of food anticipatory activity (FAA). The orexigenic hormone ghrelin has been implicated in the regulation of FAA. However, it is not known via which brain area ghrelin exerts this effect. Growth hormone secretagogue receptor 1a (GHS-R1a) is highly expressed in the hypothalamus, including the dorsomedial hypothalamus (DMH) and the ventromedial hypothalamus (VMH). These two hypothalamic areas have been reported to play a role in FAA. AIM OF THE STUDY: To examine the role of GHS-R1a signaling in the DMH and VMH in FAA. DESIGN: Adeno-associated virus expressing a shRNA directed against GHS-R1a was used to establish local knockdown of GHS-R1a in the DMH and VMH in rats. Rats were subsequently subjected to a restricted feeding schedule (RFS). RESULTS: Under ad libitum conditions, knockdown of GHS-R1a in the VMH increased food intake and body weight gain. In addition, GHS-R1a knockdown in VMH and DMH reduced body temperature and running wheel activity (RWA). When rats were subjected to a RFS, the main effect of GHS-R1a knockdown in both DMH and VMH was a decrease in RWA and an attenuation of body weight loss. Rats with knockdown of GHS-R1a in DMH and VMH showed a delay in onset of FAA. In addition, GHS-R1a knockdown in DMH resulted in a reduction of FAA amplitude. CONCLUSION: This is the first study to investigate the effect of local hypothalamic knockdown of GHS-R1a on FAA. Our results implicate hypothalamic GHS-R1a signaling in the regulation of FAA. Nevertheless, some FAA remained, suggesting that a distributed network of brain areas and signaling pathways is involved in the development of FAA.

Differences in mortality, risk factors, and complications after open and endovascular repair of ruptured abdominal aortic aneurysms.

OBJECTIVE/BACKGROUND: Endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) has faced resistance owing to the marginal evidence of benefit over open surgical repair (OSR). This study aims to determine the impact of treatment modality on early mortality after rAAA, and to assess differences in postoperative complications and long-term survival. METHODS: Patients treated between January 2000 and June 2013 were identified. The primary endpoint was early mortality. Secondary endpoints were postoperative complications and long-term survival. Independent risk factors for early mortality were calculated using multivariate logistic regression. Survival estimates were obtained by means of Kaplan-Meier curves. RESULTS: Two hundred and twenty-one patients were treated (age 72 ± 8 years, 90% male), 83 (38%) by EVAR and 138 (62%) by OSR. There were no differences between groups at the time of admission. Early mortality was significantly lower for EVAR compared with OSR (odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.21-0.97). Similarly, EVAR was associated with a threefold risk reduction in major complications (OR: 0.33, 95%CI: 0.15-0.71). Hemoglobin level <11 mg/dL was predictive of early death for patients in both groups. Age greater than 75 years and the presence of shock were significant risk factors for early death after OSR, but not after EVAR. The early survival benefit of EVAR over OSR persisted for up to 3 years. CONCLUSION: This study shows an early mortality benefit after EVAR, which persists over the mid-term. It also suggests different prognostic significance for preoperative variables according to the type of repair. Age and the presence of shock were risk factors for early death after OSR, while hemoglobin level on admission was a risk factor for both groups. This information may contribute to repair-specific risk prediction and improved patient selection.

Increased incidence of squamous cell carcinoma of the skin after long-term treatment with azathioprine in patients with auto-immune inflammatory rheumatic diseases.

BACKGROUND: Auto-immune inflammatory rheumatic diseases (AIRD) are often successfully treated with the immunosuppressant azathioprine for years. Treatment with azathioprine has been proven to increase the risk of non-melanoma skin cancer (NMSC) in transplant patients and possibly in patients with inflammatory bowel disease as well. Little is known about the risk of NMSC in AIRD patients treated with azathioprine. OBJECTIVES: The aim of this study is to determine the incidence of NMSC in patients with AIRD treated with azathioprine for at least 1 year, as compared with the general Dutch population. METHODS: Data were extracted from a historical cohort of patients with AIRD in a tertiary care centre. We compared the incidence to an age-matched control population and analysed risk factors for NMSC with univariate logistic regression. RESULTS: Fifty-nine patients were analysed. No patients were diagnosed with basal cell carcinoma and four patients with a single squamous cell carcinoma (SCC). Patients with SCC had a higher cumulative dose of azathioprine (≥ 500 g: OR 30.0 [95% CI 2.6-345.1]) and longer treatment duration (≥ 11 years: OR 13.5 [95% CI 1.3-143.6]). The risk of SCC compared with the general Dutch population was increased (standardized incidence ratio of 16.0 [95% CI 0.3-31.7]). CONCLUSIONS: In this cohort of patients with AIRD treated with azathioprine for at least 1 year, the risk of SCC was increased, as compared with the general population. An individual cumulative dose of at least 500 g azathioprine and a treatment duration of at least 11 years were quantified as risk factors.

Electromechanical abdominal massage and colonic function in individuals with a spinal cord injury and chronic bowel problems.

STUDY DESIGN: A prospective intervention of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with spinal cord injury (SCI). OBJECTIVES: To evaluate the effects of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with SCI and chronic bowel problems. This easy-to-use apparatus can be applied by the patients at home without the help of a therapist. SETTING: Homes of community-living individuals. METHODS: Twenty-one subjects with SCI were instructed to use the massage apparatus daily for 20 min during a 10-week period. Compliance, effects, side effects and user satisfaction were assessed using questionnaires. RESULTS: Fifteen subjects completed the 10-week period. Although some characteristics of defecation changed positively for some of the subjects (time to result, amount, consistency), none felt better or more confident after using the massage device. In addition, some individuals experienced negative side effects (predominantly pain or discomfort). The overall satisfaction with the device is ambiguous, with half of the group judging the device as insufficient and the other half as at least adequate. CONCLUSION: The use of an electromechanical massage device does not improve bowel function in most individuals with SCI who have chronic bowel problems. Why some subjects benefit and others do not should be investigated in future studies.

Malignant Pleural Mesothelioma : Rationale for a New TNM Classification.

BACKGROUND: Malignant pleural mesothelioma (MPM) is a rare but aggressive thoracic malignancy with a poor prognosis. In this regard, a well-defined staging system is of utmost importance in order to correctly diagnose and assign an appropriate treatment to the patient. METHODS: The current TNM-staging system (7th edition) enables to either clinically or pathologically stage the severity of the disease according to extension of the tumor (T), number of nodes (N) and presence of metastases (M). Patients with stage I-III are considered for surgery, while palliative treatment is indicated for stage IV patients according to the current classification. RESULTS: Despite its widespread use, the validity of this staging system is questioned due to the low prevalence, histological variety and retrospective nature of the previous study design. In addition, the role of specific treatment modalities including surgery, has yet to be determined, especially for treatment of early-stage disease. In this regard, the International Association for the Study of Lung Cancer (IASLC) initiated the multi-centre, prospective "Mesothelioma Staging Project" in order to address limitations of the 7th edition and to optimize the staging system in accordance to current needs. CONCLUSIONS: An improved staging system will contribute to the design of prospective multi-institutional clinical trials investigating novel treatment strategies for mesothelioma. In this way comparison of outcome between different medical centres also becomes feasible.

Modifiable risk factors and self-reported health after percutaneous coronary intervention - with and without a history of atrial fibrillation.

AIMS: Atrial fibrillation (AF) and coronary artery disease (CAD) have several common risk factors, and 10-15% of patients with AF undergo percutaneous coronary intervention (PCI). Little is known about changes over time in modifiable risk factors and self-reported health in patients with and without a history of AF after PCI. Therefore, the aims were to determine and compare changes in modifiable risk factors and self-reported health in patients with and without a history of AF after PCI. METHODS AND RESULTS: CONCARDPCI, a prospective multicentre cohort study including patients after PCI, was conducted at seven high-volume PCI centres in Norway and Denmark (N=3417). Of these, 408 had a history of AF. Data collection was conducted at the index admission and at 2-, 6- and 12 months after discharge. Self-reported health was assessed with RAND-12 and the Myocardial Infarction Dimensional Assessment Scale (MIDAS). Patients with a history of AF reported a poorer health at baseline. However, the physical (p=0.012) and mental (p<0.001) health improved over time in both groups. The patients with a history of AF reported more emotional reactions (p=0.029) and insecurities (p=0.015). The proportion of smokers increased from 2- to 12 months in patients with a history of AF (p=0.041), however, decreased in patients without AF from baseline to 6 months (p<0.001). CONCLUSION: An intensified focus on lifestyle interventions is needed to improve modifiable risk factors and self-reported health in patients with and without a history of AF after PCI.

The clinical benefit of blood transfusion: a hypothetical experiment based on a nationwide survey of severe maternal morbidity.

BACKGROUND: It is beyond doubt that blood transfusion services have added to the decline in maternal mortality in high-resource countries. To quantify the clinical benefit of red blood cell (RBC) transfusion in obstetric care, we performed a hypothetical experimental study using data from a prospective nationwide cohort of women giving birth in the Netherlands. STUDY DESIGN AND METHODS: Data were abstracted from a nationwide cohort study on severe maternal morbidity, including obstetric haemorrhage requiring 4 or more units of RBC, to obtain an observed and a hypothetical control group consisting of the same women. In the hypothetical control group, we simulated a situation where RBC transfusion was unavailable and estimated how many of these women would have died in that situation. A questionnaire survey asked experts in major (obstetric) haemorrhage to choose a critical minimal number of RBC transfusions at which a woman with obstetric haemorrhage would have died if RBC transfusion was not available. Maternal mortality rate per 100,000 maternities [maternal mortality ratios (MMR)] and relative risk were calculated for the observed and hypothetical group. RESULTS: The observed MMR was 13 per 100,000 maternities. According to 47 responding experts, the median number of RBC units without which a woman would have most probably died was nine, resulting in a hypothetical MMR of 87 per 100,000 maternities (relative risk 6·5; 95% confidence interval 4·2-10·0). CONCLUSIONS: It can be expected that unavailability of RBC transfusion in obstetric care increases the risk of maternal death 6.5-fold. Blood transfusion thus largely contributes to the decline of MMR and would also be an important pillar of improving quality of care in resource-poor settings.

Elevated preoperative serum interleukin-6 level is predictive for worse postoperative outcome after soft tissue sarcoma surgery.

BACKGROUND: The pro-inflammatory cytokine interleukin-6 (IL-6) plays a role in cancer development and progression, but research into the predictive value of IL-6 on postoperative outcome in soft tissue sarcoma (STS) is scarce. The purpose of this study is to investigate the predictive value of serum IL-6 level for the achievement of assumed (post)operative outcome after STS surgery, the so-called textbook outcome. METHODS: Preoperative IL-6 serum levels were collected in all patients with a STS at first presentation between February 2020 and November 2021. Textbook outcome was defined as a R0 resection, no complications, no blood transfusions, no reoperation within the postoperative period, no prolonged hospital stay, no hospital readmission within 90-days, and no mortality within 90-days. Factors associated with textbook outcome were determined by multivariable analysis. RESULTS: Among 118 patients with primary, non-metastatic STS, 35.6% achieved a textbook outcome. Univariate analysis showed that smaller tumor size (p = 0.026), lower tumor grade (p = 0.006), normal hemoglobin (Hb, p = 0.044), normal white blood cell (WBC) count (p = 0.018), normal C-reactive protein (CRP) serum level (p = 0.002) and normal IL-6 serum level (p = 1.5 × 10-5) were associated with achieving textbook outcome after surgery. Multivariable analysis showed that elevated IL-6 serum level (p = 0.012) was significantly associated with not achieving a textbook outcome. CONCLUSIONS: Increased IL-6 serum level is predictive for not achieving a textbook outcome after surgery for primary, non-metastatic STS.

Incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infection in European hospitals: the COMBACTE-NET ARTHR-IS multi-centre study.

BACKGROUND: The aim of this study was to estimate the incidence, associated disease burden and healthcare utilization due to Staphylococcus aureus prosthetic joint infections (SA-PJI) after primary hip and knee arthroplasty in European centres. METHODS: This study was conducted in patients who underwent primary hip and knee arthroplasty in 19 European hospitals between 2014 and 2016. The global incidence of PJI and SA-PJI was calculated. The associated disease burden was measured indirectly as infection-related mortality plus loss of function. For healthcare utilization, number and duration of hospitalizations, number and type of surgical procedures, duration of antibiotic treatments, and number of outpatient visits were collected. Subgroup and regression analyses were used to evaluate the impact of SA-PJI on healthcare utilization, controlling for confounding variables. RESULTS: The incidence of PJI caused by any micro-organism was 1.41%, and 0.40% for SA-PJI. Among SA-PJI, 20.7% were due to MRSA with substantial regional differences, and were more frequent in partial hip arthroplasty (PHA). Related deaths and loss of function occurred in 7.0% and 10.2% of SA-PJI cases, respectively, and were higher in patients with PHA. Compared with patients without PJI, patients with SA-PJI had a mean of 1.4 more readmissions, 25.1 more days of hospitalization, underwent 1.8 more surgical procedures, and had 5.4 more outpatient visits, controlling for confounding variables. Healthcare utilization was higher in patients who failed surgical treatment of SA-PJI. CONCLUSIONS: This study confirmed that the SA-PJI burden is high, especially in PHA, and provided a solid basis for planning interventions to prevent SA-PJI.

Treatment of post-implantation aneurysm growth by laparoscopic sac fenestration: long-term results.

OBJECTIVES: Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. METHODS: The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. RESULTS: Follow-up had a median length of 6.6 (range 0.6-8.6) years. During this time, only three patients successfully achieved durable aneurysm shrinkage (n = 2) or stability (n = 1). The remaining patients suffered persistent (n = 2) or recurrent sac growth (n = 3), all regarded as failure of fenestration. A total of six additional interventions were performed, comprising open conversion (n = 2), relining (n = 1) and implantation of iliac extensions (n = 3). All additional interventions were successful at arresting further sac growth during the remainder of follow-up. CONCLUSIONS: Despite being a less invasive alternative to conversion and open repair, the long-term outcome of sac fenestration is unpredictable and additional major procedures were often necessary to arrest sac growth.

Spontaneous ilio-iliac arteriovenous fistula due to an iliac artery aneurysm: a case-report.

A spontaneous arterio-venous ilioiliac fistula (AVF) caused by an iliac artery aneurysm (IAA) is a rare complication. We present the case of a 75-year-old man with previous aortic surgery 11 years before who was admitted at the Emergency Department for acute gluteal pain. He was suspected for a hip problem because of cup loosening on X-ray. A lumbar CT-scan to rule out nerve compression showed an aneurysm of the left common and internal iliac artery that was ruptured into the iliac vein. The AVF was treated endovascularly under local anesthesia by a sandwich technique (covered stent at the venous side and coils at the arterial side) with good results. The case demonstrates that lifelong follow-up of a patient with previous aortic surgery is mandatory.