Sultan AlSheikh

Background: Renal artery aneurysms (RAAs) are uncommon visceral arterial lesions whose management depends on symptoms, patient-specific rupture risk, and arterial anatomy. Markedly high origin renovisceral arteries may further complicate endovascular access and reconstruction. This report describes the management of a symptomatic RAA in a young woman with multifocal aneurysmal disease and unusual renovisceral arterial origins at the 11th and 12th thoracic vertebral levels (T11–T12). Case presentation: A 35-year-old woman presented with intermittent right loin pain. Computed tomography angiography demonstrated multiple right renal artery aneurysms, the largest measuring 1.7 cm, together with a 0.6-cm left renal artery aneurysm and a 0.67-cm superior mesenteric artery aneurysmal dilatation. The celiac trunk, superior mesenteric artery, and both renal arteries originated unusually high at the T11–T12 level. An initial trial of right renal artery stenting through right brachial access was technically difficult. Selective angiography after difficult cannulation demonstrated contrast extravasation from a minute right renal artery perforation. The patient remained hemodynamically stable; heparin was reversed with protamine, and repeat angiography 5 min later demonstrated complete sealing without further extravasation. The procedure was therefore aborted with close inpatient observation. Definitive treatment was achieved by ligation of the right renal artery aneurysmal segment and a retrocaval aorta-to-right renal artery bypass using a reversed great saphenous vein graft. At six months, the graft remained patent with preserved renal perfusion and no recurrence of the presenting symptom. Conclusions: This case demonstrates how extreme renovisceral anatomical variation, multifocal aneurysmal disease, and adverse arterial characteristics can limit the feasibility of endovascular treatment. In selected patients in whom secure endovascular access or renal branch preservation cannot be achieved, open reconstruction remains an effective renal-preserving option. Long-term surveillance is important because of the remaining untreated aneurysmal lesions and the limited duration of follow-up in this report.

Background: Carotid endarterectomy (CEA) plays a critical role in stroke prevention, but assessing a patient’s preoperative physiological reserve remains challenging. This study aimed to evaluate the impact of sarcopenia and preoperative albumin on postoperative management outcomes and resource utilization in CEA patients with a high prevalence of metabolic comorbidities. Methods: This retrospective cohort study evaluated 67 patients who underwent elective or urgent CEA between January 2015 and June 2025. Sarcopenia was quantified using the Masseter Muscle Index (MMI) derived from routine preoperative head and neck computed tomography (CT) scans. Multivariable regression models were used to assess the relationships between the MMI, serum albumin levels, and surgical outcomes. Results: The cohort had a mean age of 66.8 years and demonstrated a significant metabolic burden, with a high prevalence of diabetes (71.6%) and an average body mass index (BMI) of 28.15 kg/m². Despite this predominantly overweight demographic, the MMI revealed underlying frailty and showed a strong inverse relationship with hospital resource utilization. A one-unit increase in the MMI significantly reduced total hospital length of stay (LOS) by 14.40 days (p = 0.001) and ICU LOS by 6.91 days (p < 0.001). Emergency surgery was the only independent predictor of mortality (OR 16.61, p = 0.047), while neither the MMI nor albumin significantly predicted short-term adverse clinical events. Conclusions: In a patient population where a higher BMI may mask underlying frailty, opportunistic screening for sarcopenia using routine preoperative CT scans provides important prognostic value. In this cohort study, a lower MMI showed an association with prolonged hospital and ICU stays; while it did not independently predict short-term mortality, its potential utility in forecasting resource utilization warrants further investigation in larger, prospective cohorts.

Introduction: Phlebolith is a term that refers to round‐shaped calcified thrombi commonly located in the pelvic region. The occurrence of dense, linear calcifications or phlebolith‐like formations within the soft tissues of the lower extremities, particularly in the superficial femoral, greater saphenous, or popliteal veins, is rare. Patient Concerns: This study presents the case of a 73‐year‐old woman who was being evaluated for postmenopausal bleeding. During the patient’s diagnostic workup, an incidental linear‐shaped phlebolith was discovered. She had a positive history of deep vein thrombosis (DVT) for 36 years following her previous vaginal delivery. Diagnosis: Upon further examination and imaging, the patient was found to have a chronic calcified thrombus in the iliofemoral, popliteal, great saphenous, and superficial femoral veins, which was initially reported as a foreign body in the femoral vein on computed tomography (CT). Interventions and Outcomes: Conservative management was undertaken, with no worsening of her condition upon further follow‐up. Conclusion: This study showcased a rare form of a radiographically visible calcified thrombus in the veins of the lower extremities of our patient. Calcified venous thrombosis in the lower extremities is rare, as previously documented cases of venous calcifications have been observed in the pelvis with round shapes or as phleboliths. The common presentations differ from those in our case, making it important to consider such cases when formulating a differential diagnosis. While the precise mechanisms behind the formation of calcified thrombi remain unclear, this study emphasizes the significance of further exploration and future case studies to shed light on this enigmatic phenomenon.

Background/Objectives: Since thoracic endovascular aortic repair (TEVAR) and endovascular aneurysm repair (EVAR) are increasingly utilized, examining their outcomes and safety in real-world scenarios is crucial. This study investigated the management and outcomes of TEVAR and EVAR as alternatives to traditional open surgical repair for managing aortic pathologies. Methods: This was a retrospective cohort study. We analyzed the data from 59 consecutive patients who underwent TEVAR or EVAR between 2015 and 2022 at a single tertiary care center. The primary outcome was survival, and secondary outcomes were complications assessment, including re-intervention and occurrence of endoleaks. Results: TEVAR accounted for 47.5% of cases (n = 28), while EVAR comprised 52.5% (n = 31). Patients were mostly 61–70 years old (23.7%) and male (91.5%). Surgery indications differed, with aneurysmal repair being the prevalent indication for EVAR (90.3%, n = 28) and trauma being the main indication for TEVAR (67.9%, n = 19). Regarding the primary outcome, 11 patients (18.6%) died for various reasons; of those, 2 patients (3.4%) were determined to have died from vascular-related issues. Most patients (81.4%, n = 48) did not experience intraoperative complications. The most common intraoperative complications were endoleaks and access failure, each affecting 5.1% (n = 3) of patients. Re-intervention was necessary in 16.9% (n = 10) of cases, with endoleaks being the major indication (60%). Emergency intervention was more frequent in the TEVAR group (p = 0.013), resulting in significantly longer hospitalization (p = 0.012). Conclusions: Despite limitations, our analysis indicates a good safety profile with high success rates and a low incidence of adverse health outcomes and mortality in TEVAR/EVAR procedures. Nevertheless, the results emphasize the ongoing concern of endograft leaks, necessitating re-interventions.

Considering the absence of integrated vascular surgery residency programs in Saudi Arabia, and the need for planning training pathways, we aim to identify how many medical students are interested in vascular surgery, and the factors affecting students’ opinions on pursuing vascular surgery. Materials and Methods: A cross-sectional study was conducted using an online questionnaire that was distributed to medical students nationwide via social media and email. Data were collected from 13 February 2022 to 1 March 2022. Results: A total of 408 students participated. Among them, 152 students were interested in general surgery, of which 103 were considering vascular surgery as a possible future fellowship. However, only 29 out of 408 (7.1%) students picked vascular surgery as their 1st choice. The main motivating factors for students to pursue vascular surgery as a career were: an interest in vascular cases (cardiovascular science), the use of emerging technologies, and the endovascular capabilities of vascular surgeons. The negative factors were simply a preference for another specialty, followed by a lack of experience in vascular surgery. Conclusion: This study reveals that only 7.1% of students consider vascular surgery their first choice. Both the lack of vascular surgeons and students’ experience in vascular surgery affected awareness levels. Interaction with vascular surgeons through virtual rotations for under-served medical schools and the introduction of vascular sciences within the cardiology blocks during basic science years are recommended strategies.

Background: although liver injuries are one of the most critical complications of abdominal trauma, choosing when to operate on these injuries is challenging for surgeons worldwide. Methods: We conducted a retrospective analysis of liver injury cases at our institution from 2016 to 2022 to describe the operative and nonoperative management (NOM) outcomes in patients with traumatic liver injuries. Baseline patient characteristics, liver injury details, treatments, and outcomes were analyzed. Results: Data from 45 patients (male, 77.8%) were analyzed. The mean age was 29.3 years. Blunt trauma was the most common injury mechanism (86.7%), whereas penetrating injuries were 8.9% of cases. Conservative management was associated with 18.9% of complications. The overall complication rate was 26.7%; delirium and sepsis were the most common (13.3%), followed by acute renal failure (4.4%), pneumonia, biliary leaks, and meningitis/seizures. Conclusions: Notwithstanding its limitations, this retrospective analysis demonstrated that NOM can serve as a safe and effective strategy for hemodynamically stable patients with liver trauma, irrespective of the patient’s injury grade. Nevertheless, careful patient selection and monitoring are crucial. Further investigations are necessary to thoroughly evaluate the management of traumatic liver injuries, particularly in the context of multiorgan injuries.

Background: The level of awareness of peripheral artery disease (PAD) in Saudi Arabia, especially among populations at high risk, is not currently well known. Therefore, our objective was to assess the existing level of awareness among patients who are at high risk of PAD, as well as their comprehension of the disease. Method: An interview-based cross-sectional study included 1035 participants with risk factors for PAD and collected data on demographics and knowledge domains related to PAD. Results: The statistical analysis was performed using t-tests and ANOVA. Overall, participants exhibited poor knowledge, with a mean score of 5.7 out of 26. The highest scores were observed in the risk factor and preventive measure domains, with means of 1.8 out of 7 and 1.8 out of 6, respectively. The factors associated with higher knowledge scores included older age, male gender, higher education, healthcare profession, interviews in vascular settings, previous awareness of PAD, and prior cardio-cerebrovascular interventions. Conclusion: This study underscores the inadequate knowledge of PAD among high-risk individuals. Targeted educational initiatives are essential to bridge this knowledge gap, potentially reducing the burden of PAD-related complications and improving patient outcomes. Efforts should focus on raising awareness about PAD, particularly among high-risk populations.

Background: This study aimed to compare the outcomes of the percutaneous femoral access and open surgical cutdown access approaches in patients undergoing thoracic/abdominal endovascular aortic repair. Methods: We retrospectively reviewed the medical records of 59 patients who underwent a thoracic/abdominal endovascular aortic repair at a single tertiary care hospital between 2015 and 2022. Based on their femoral access type, the patients were categorized into the “percutaneous” or “cutdown” groups. Using a computerized sheet, relevant patient data (including demographic information and patient risk factors) were collected. The operative duration, complication rates, mortality rates, intensive care unit admission and stay durations, and total hospital stay were compared between the two groups. The primary outcomes were differences in the postoperative morbidity and mortality associated with the two approaches. Results: The cutdown and percutaneous groups comprised 24 (41%) and 35 (59%) patients, respectively. The two groups displayed comparable demographic and clinical characteristics (p > 0.05). However, the vascular anatomy differed with the common femoral artery diameter being larger in the percutaneous group compared to the cutdown group (9.63 ± 1.81 mm vs. 8.49 ± 1.54 mm, p = 0.028). The ratio of the sheath diameter to the common femoral artery diameter was significantly lower in the percutaneous group than in the cutdown group (0.73 ± 0.16 vs. 0.85 ± 0.20, p = 0.027). A ratio of ≥0.74 was associated with a higher risk of complications (odds ratio, 12.0; 95% confidence interval, 1.4–102.2; p = 0.023) and mortality (odds ratio, 5.79; 95% confidence interval, 1.13–29.6; p = 0.035). Additionally, the operative duration was significantly shorter in the percutaneous group than in the cutdown group (141.43 ± 97.05 min vs. 218.46 ± 126.31 min, p = 0.001). Compared to the cutdown group, the percutaneous group experienced a shorter total hospital stay (21.54 ± 21.49 days vs. 11.60 ± 12.09 days, p = 0.022) and lower intensive care unit-admission rates (66.7% vs. 40%, p = 0.044). Conclusion: The percutaneous approach is a viable and more time-efficient alternative to the traditional cutdown method for delivering vascular endografts. It is associated with a significantly shorter operative duration and briefer hospital stays. Additionally, the ratio of the sheath diameter to the common femoral artery diameter can help surgeons preoperatively predict and anticipate the risks of complications and mortality. Future in-depth research is necessary to better understand the association between this ratio and postoperative outcomes and complications.

Rationale: The autosomal dominant condition known as neurofibromatosis type 1 (NF-1) is characterized by café au lait macules and neurofibromatosis. Aneurysms in renal arteries are rare. Renal artery aneurysm (RAA) can be successfully treated with endovascular procedures; however, successful cases in NF-1 adults have not been reported. Patient concerns: Here, we report the case of a 30-year-old female suffering from NF-1. The patient presented to the emergency department with complaints of chronic, poorly controlled hypertension. A left RAA was found om the computed tomography angiography (CTA). Diagnoses: A left renal artery aneurysm was diagnosed using CTA during workup for secondary hypertension. Interventions: Selective angiographym of the left renal artery confirmed a fusiform aneurysm of the distal renal artery. A self-expandable covered stent was placed, and a completion angiogram demonstrated good aneurysm sealing and contrast flow to the left kidney. Outcomes: The patient’s blood pressure improved after the procedure. Her medications were lowered to almost half of their baseline doses, and hydralazine was discontinued. On the follow-up visit after 4 months, the patient reported his home-measured systolic blood pressure to be less than 120 mm Hg. A repeated CTA of the abdomen showed post-left RAA repair with a covered stent and interval improvement of the left kidney. Lessons: RAA caused by NF-1 are manageable and feasible with endovascular intervention.

Although the effects of obstructive sleep apnea (OSA) on the cardiovascular outcomes of coronary artery disease (CAD) have been well-established, its significance on the occurrence of peripheral arterial disease (PAD) remains debatable. Prompt diagnosis and treatment of OSA would help reduce cardiovascular comorbidities. Our study aimed to assess the relationship between OSA and PAD and report any statistical association between the two conditions. Here, we investigated the prevalence and association of OSA in PAD based on related articles from PubMed, Embase, and the Cochrane Library. All databases were systematically searched from January 2000 to December 2020. A total of 238 articles deemed relevant were assessed for eligibility, of which seven articles were selected for the systematic review. Seven prospective cohorts were qualified for inclusion, which included 26,881 male and 34,403 female patients (N = 61,284). The retrieved articles described OSA severity based on the apnea-hypopnea index and reported increased OSA prevalence in PAD patients. The Epworth sleepiness scale showed no association between OSA severity, poor ankle-brachial index values, and increased daytime sleepiness. The prevalence of OSA increased in patients with PAD. Further research and prospective clinical trials are required to establish strong associations between OSA and PAD to make appropriate changes in patient management algorithms and improve their outcomes.