To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

An 81-year-old man underwent an aortobifemoral bypass graft because of a ruptured abdominal aortic aneurysm. His postoperative recovery was complicated by unilateral lower limb paralysis caused by perioperative ischemia of the lumbosacral plexus. Ischemic lumbosacral plexopathy is an uncommon complication after infrarenal aortic surgery with serious morbidity.Despite a good surgical technique and knowledge of the vascularization of the spinal cord, its occurrence remains unpredictable.An 81-year-old man was urgently referred to the emergency services by his treating physician because of acute abdominal pain, mainly in the left flank. On admission, he was pale and suffered from hypotension (blood pressure 50/30 mm Hg). A computerized tomography (CT) was performed, which showed a ruptured juxtarenal abdominal aortic aneurysm. The patient was rushed to the operating room, where an aortobifemoral bypass was performed. There was a suprarenal clamp time of 25 minutes. As nefroprotection rescuvolin (folic acid) and lysomucil (acetylcysteine) were given. There were no important periods of hypotension perioperatively, despite the need for massive transfusion (2 L of autotransfusion, 8 units of packed cells, 4 units of fresh frozen plasma, and 2 pools of thrombocytes, perioperatively). The patient was extubated the same day. The next morning, he complained of hypoesthesia and paresis of his right leg. We also noticed rising of his serum creatinine and urea levels and a potassium level of 6.5 mmol/L (3.5-5.1 mmol/L). Glucose and insulin were started to correct the potassium level, and a subclavian dialysis catheter was used for dialysis. After a few days, potassium, creatinine, and urea levels normalized and all therapies were stopped, but the paralysis and paresthesia of the right limb remained. A CT scan of the brain ruled out any central etiology and an electromyogram (EMG) confirmed peripheral pathology (combined drop foot and plantar flexion paralysis) and our diagnosis of ischemic lumbar plexopathy. Magnetic resonance imaging (MRI) of the lumbar spine 3 weeks postoperative was negative. When the patient was discharged, limited mobilization was possible with aid. DiscussionLower limb paralysis following aortoiliac procedures is a known but rare complication. The overall neurologic risk of endovascular and open infrarenal abdominal aortic surgery ranges between 0% and 1%. 1 The risk is higher for emergency cases (1.4-2%) than for elective cases 2 (0.1-0.2%) and consists of central cord, lumbosacral, and peripheral nerve From the Department of Vascular and Thoracic Surgery, AZ Groeninge Kortrijk, Belgium.

An 85-year-old patient presented with a giant pseudo-aneurysm in the groin fifteen years after placement of an aortobifemoral graft (ABG). The pseudo-aneurysm was expanding rapidly. To prevent massive haemorrhage an inflatable balloon was inserted into the native distal aorta. The balloon was inserted via the contralateral groin. After inflation, the pseudo-aneurysm was safely excluded by the interposition of a new prosthetic segment between the left prosthetic branch of the ABG and the common femoral artery. This technique, which has been used for more than 50 years in several other indications, is an elegant method to minimise blood loss in the treatment of large pseudoaneurysms of the groin.

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